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Wang S, Fu S, Li R, Guo Z, Wang Y, Sun W, Sun D. Construction and validation of nomogram prognostic model for predicting survival in hepatoblastoma patients: a population-based study. Updates Surg 2024; 76:1223-1234. [PMID: 38795309 DOI: 10.1007/s13304-024-01814-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 03/04/2024] [Indexed: 05/27/2024]
Abstract
For patients with hepatoblastoma (HB), current staging system is not accurate in predicting survival outcomes. The aim of this study was to develop two accurate survival prediction models to guide clinical decision making. A retrospective analysis of 424 HB patients was performed from 2004 to 2015 using the Surveillance, Epidemiology and End Results (SEER) database. Univariate and multivariate Cox regression analysis was used to screen for variables. The identified variables were used to build survival prediction model. The performance of the nomogram models was assessed based on the concordance index (C-index), calibration plot, and receiver operating characteristic (ROC) curve. The Cox regression analysis identified six variables affecting overall survival (OS) in HB patients, including race, tumor size, lymph node involvement, distant metastases, surgery and chemotherapy. And the Cox regression analysis identified five variables including race, lymph node involvement, distant metastases, surgery, and chemotherapy that affect cancer-specific survival (CCS) in HB patients. In the training cohort, the C-index of the nomogram in predicting the OS was 0.791 [95% confidence intervals (95% CI) 0.717-0.865], CSS was 0.805(95% CI 0.728-0.882). In the validation cohort, the C-index of the nomogram in predicting the OS was 0.712 (95% CI 0.511-0.913), the CSS was 0.751 (95% CI 0.566-0.936). In the training cohort, the area under the receiver operator characteristics curve (AUC) values of the nomogram in prediction of the 1-, 3-, and 5-year OS were 0.842 (95% CI 0.739-0.944), 0.759 (95% CI 0.670-0.849), and 0.770 (95% CI 0.686-0.852), respectively. In the validation cohort, the AUC values for prediction of the 1-, 3-, and 5-year OS were 0.920 (95% CI 0.806-1.034), 0.863 (95% CI 0.750-0.976), and 0.844 (95% CI 0.721-0.967), respectively. Two nomogram models were developed and validated in this study which provided accurate prediction of the OS and CSS in HB patients. The constructed models can be used for predicting survival outcomes and guide treatment for HB patients.
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Affiliation(s)
- Song Wang
- Department of Pediatric Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Siqi Fu
- Department of Pediatric Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Rui Li
- Department of Pediatric Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Zheng Guo
- Department of Pediatric Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Yuchao Wang
- Department of Pediatric Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Wei Sun
- Department of Pediatric Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Daqing Sun
- Department of Pediatric Surgery, Tianjin Medical University General Hospital, Tianjin, China.
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Maxwell R, Häberle B, Kappler R, von Schweinitz D, Rassner M, von Frowein J, Schmid I. Hepatoblastoma Relapse-Findings from the German HB99 Trial and the German Liver Tumor Registry. Cancers (Basel) 2024; 16:696. [PMID: 38398087 PMCID: PMC10886809 DOI: 10.3390/cancers16040696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/19/2023] [Accepted: 01/25/2024] [Indexed: 02/25/2024] Open
Abstract
Survival rates for HB patients have improved; however, outcomes for patients who relapse remain poor. A retrospective review of information gathered for the HB99 study and the German Liver Tumor Registry identified 25 relapse patients (6.9%, 25/362). The median time from initial diagnosis to first relapse was 13 months (range: 5-66 months). Two patients relapsed >36 months after initial diagnosis. A total of 68% (17/25) of relapses were metastatic, 24% local, and 8% combined. 67% of local relapses were alive at the last follow-up, in contrast to 53% of metastatic and 0% of combined relapses. At the last follow-up, 73% (8/11) of patients with lung relapses were still alive (0/4 with peritoneal, 1/2 with CNS involvement). A total of 20% of the patients had AFP-negative relapses, 64% of the relapse patients achieved a second complete remission, 69% were still in complete second remission at the last follow-up (median FU of 66 months), and 83% (5/6) of irinotecan-naïve patients who received relapse treatment including irinotecan were in second complete remission at the last follow-up. The 3-year overall survival/event-free survival from relapse was 63%/48% respectively. There is a good chance that HB patients will achieve a second remission despite a first relapse. However, patients who suffer further relapses tend to have a poorer prognosis.
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Affiliation(s)
- Rebecca Maxwell
- Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, Lindwurmstraße 4, 80337 Munich, Germany; (R.M.); (M.R.); (J.v.F.)
| | - Beate Häberle
- Department of Pediatric Surgery, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 80337 Munich, Germany; (B.H.); (R.K.); (D.v.S.)
| | - Roland Kappler
- Department of Pediatric Surgery, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 80337 Munich, Germany; (B.H.); (R.K.); (D.v.S.)
| | - Dietrich von Schweinitz
- Department of Pediatric Surgery, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 80337 Munich, Germany; (B.H.); (R.K.); (D.v.S.)
| | - Mark Rassner
- Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, Lindwurmstraße 4, 80337 Munich, Germany; (R.M.); (M.R.); (J.v.F.)
| | - Julia von Frowein
- Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, Lindwurmstraße 4, 80337 Munich, Germany; (R.M.); (M.R.); (J.v.F.)
| | - Irene Schmid
- Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, Lindwurmstraße 4, 80337 Munich, Germany; (R.M.); (M.R.); (J.v.F.)
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Somers KM, Tabbouche RB, Bondoc A, Towbin AJ, Ranganathan S, Tiao G, Geller JI. Retreatment with Cisplatin May Provide a Survival Advantage for Children with Relapsed/Refractory Hepatoblastoma: An Institutional Experience. Cancers (Basel) 2023; 15:3921. [PMID: 37568737 PMCID: PMC10416880 DOI: 10.3390/cancers15153921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/15/2023] [Accepted: 06/23/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Hepatoblastoma (HB) is the most common liver malignancy in children. There is no standard of care for management of relapsed/refractory HB (rrHB) and reports in the literature are limited. OBJECTIVE To describe presenting features, biology, treatment strategies, and outcomes for pediatric patients with relapsed/refractory hepatoblastoma. METHODS An IRB-approved retrospective institutional review of patients with rrHB who presented for consultation and/or care from 2000-2019. Clinical, radiographic, and histologic data were collected from all patients. RESULTS Thirty subjects were identified with a median age of 19.5 months (range 3-169 months) at initial diagnosis and 32.5 months (range 12-194 months) at time of first relapse. 63% of subjects were male, 70% Caucasian, and 13% were born premature. Three subjects had a known cancer predisposition syndrome. Eight patients had refractory disease while 22 patients had relapsed disease. Average time from initial diagnosis to relapse or progression was 12.5 months. Average alpha-fetoprotein (AFP) at initial diagnosis was 601,203 ng/mL (range 121-2,287,251 ng/mL). Average AFP at relapse was 12,261 ng/mL (range 2.8-201,000 ng/mL). For patients with tumor sequencing (n = 17), the most common mutations were in CTNNB1 (13) and NRF2 (4). First relapse sites were lungs (n = 12), liver (n = 11) and both (n = 6). More than one relapse/progression occurred in 47% of subjects; 6 had ≥3 relapses. Pathology in patients with multiply relapsed disease was less differentiated including descriptions of small cell undifferentiated (n = 3), pleomorphic (n = 1), transitional liver cell tumor (n = 2) and HB with carcinoma features (n = 1). All subjects underwent surgical resection of site of relapsed disease with 7 subjects requiring liver transplantation. Overall survival was 50%. Survival was associated with use of cisplatin at relapse (78.6% with vs. 25% without, p = 0.012). The most common late effect was ototoxicity with at least mild sensorineural hearing loss found in 80% of subjects; 54% required hearing aids. CONCLUSIONS Retreatment with cisplatin at the time of relapse may provide an advantage for some patients with hepatoblastoma. Multiply relapsed disease was not uncommon and not associated with a worse prognosis. Careful attention should be paid to cumulative therapy-induced toxicity while concurrently aiming to improve cure.
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Affiliation(s)
- Katherine M. Somers
- Division of Pediatric Hematology/Oncology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Rachel Bernstein Tabbouche
- Division of Pediatric Hematology/Oncology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Alexander Bondoc
- Department of Pediatric and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA; (A.B.); (G.T.)
| | - Alexander J. Towbin
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA;
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Sarangarajan Ranganathan
- Department of Pathology and Laboratory Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA;
| | - Greg Tiao
- Department of Pediatric and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA; (A.B.); (G.T.)
| | - James I. Geller
- Division of Pediatric Hematology/Oncology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
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Sharma K, Agarwala S, Kandasamy D, Jana M, Sharma R, Dhua A, Jain V, Bhatnagar V. Role of Diffusion Weighted MRI (DW-MR) in Detection of Satellite Lesions Not Detected with Multiphase CT Scans in Hepatoblastoma and Its Implications for Management. Indian J Pediatr 2022; 89:968-974. [PMID: 34997528 DOI: 10.1007/s12098-021-04016-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 10/18/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To evaluate the role of diffusion-weighted magnetic resonance imaging (DW-MR) in hepatoblastoma as compared to multiphase contrast enhanced computed tomography (CECT) scans for detection of satellite lesions. METHODS In this prospective study on new cases of hepatoblastoma, multiphase CECT scans and DW-MR were performed before initiation of chemotherapy. Results of interpretation were compared for detection of satellite lesions. PRETEXT grouping and risk categorization was done according to SIOPEL based on CECT scan. RESULTS Nine boys and 1 girl with hepatoblastoma, with median age of 11.5 mo were included. All patients were stratified as high-risk group with 2 (20%) in PRETEXT II and 8 (80%) in PRETEXT III. In 2 of 10 (20%) patients, additional satellite lesions were detected on DW-MR, which upgraded their stage. One of the two patients had one satellite lesion identified on CECT, while additional seven satellite lesions were identified on DW-MR imaging. For the other patient, CECT showed no satellite lesion while DW-MR detected six satellite lesions. CONCLUSION MRI has become the gold standard investigation for evaluation of hepatoblastoma. DW-MR, which is a contrast free technique, is a better tool for assessment of satellite lesions which are usually missed on CECT. This would help in proper staging, planning of management and prognostication.
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Affiliation(s)
- Kanika Sharma
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India.,Department of Pediatric Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Sandeep Agarwala
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | | | - Manisha Jana
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Anjan Dhua
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Vishesh Jain
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Veereshwar Bhatnagar
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India.,Department of Pediatric Surgery, Sharda University, School of Medical Sciences & Research, Greater Noida, Uttar Pradesh, India
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Li X, Wang Z, Zhang D, Zhao D, Ye J, Duan W, Duan L, Liu Q. Repeat hepatectomy for pediatric recurrent chemotherapy-resistant hepatoblastoma: a report of 18 cases. J Cancer Res Clin Oncol 2022:10.1007/s00432-022-04291-9. [PMID: 36038674 DOI: 10.1007/s00432-022-04291-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/14/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIMS Repeat hepatectomy for adult recurrent hepatocellular carcinoma significantly prolongs the overall survival, but repeat hepatectomy for pediatric recurrent hepatoblastoma (HB) is rarely reported, and the outcomes are warranted to be investigated. METHODS All patients between May 2015 and December 2020 with recurrent HB after intended surgical cure were retrospectively evaluated. Clinicopathologic features, surgical details and outcomes were analyzed during a median following-up of 24 months after repeat hepatectomy. Survival analysis was performed using the Kaplan-Meier estimate. RESULTS A total of 18 patients of recurrent HB undergoing repeat hepatectomy with radical cure intention were included. There were 11 males and 7 females. The median age was 29 months (range 5-87 months) at first hepatectomy, and the median time to the recurrence from the first hepatectomy was 7 months. The operating time of the repeat hepatectomy was 5.0 h (range 3.5-9.0 h) and the mean blood loss was 592 ml (range 50-3200 ml). Radical resection (R0) was achieved in 12 patients (66.7%), with a postoperative hospital stay of 7.9 ± 1.8 days. No serious postoperative complications or mortality occurred. The overall survival (OS) rate was 55.6% (10/18) and the event-free survival (EFS) rate was 33.3% (6/18). Those with no lung metastases, not high-risk stratification, and achieving R0 hepatectomy, anatomic hepatectomy had longer OS rate (all P < 0.05) after repeat hepatectomy. Two of three patients with re-recurrence HB undergoing salvage liver transplantation were alive with a tumor-free survival. CONCLUSIONS Repeat hepatectomy for recurrent HB can be carried out safely. However, only a highly selected subgroup of patients might actually benefit from this procedure.
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Affiliation(s)
- Xiaoran Li
- Postgraduate Base of the PLA Rocket Force Medical Center, Jinzhou Medical University, Jinzhou, 121001, Liaoning Province, China
- Department of Hepatobiliary Surgery, PLA Rocket Force Medical Center, Beijing, 100088, China
| | - Zheng Wang
- Department of Surgery, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Dongpo Zhang
- Department of Surgery, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Di Zhao
- Department of Hepatobiliary Surgery, PLA Rocket Force Medical Center, Beijing, 100088, China
| | - Jindong Ye
- Department of Hepatobiliary Surgery, PLA Rocket Force Medical Center, Beijing, 100088, China
| | - Weihong Duan
- Department of Hepatobiliary Surgery, PLA Rocket Force Medical Center, Beijing, 100088, China
| | - Liuxin Duan
- Department of Hepatobiliary Surgery, PLA Rocket Force Medical Center, Beijing, 100088, China.
| | - Quanda Liu
- Postgraduate Base of the PLA Rocket Force Medical Center, Jinzhou Medical University, Jinzhou, 121001, Liaoning Province, China.
- Department of Hepatobiliary Surgery, PLA Rocket Force Medical Center, Beijing, 100088, China.
- Department of Surgery, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China.
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Treatment optimization for recurrent hepatoblastoma: retrospective study from a hepatoblastoma cohort in Southern China. Pediatr Surg Int 2022; 38:1031-1039. [PMID: 35435487 DOI: 10.1007/s00383-022-05126-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE The present study aimed to explore the clinical characteristics and optimal treatments of RHB patients. METHODS We retrospectively collected 42 RHB cases and 161 primary HB (PHB) cases. Clinical characteristics were compared between RHB and PHB patients. The risk factors related to overall survival (OS) and progression-free survival (PFS) in RHB patients were explored by COX regression analysis. Patients were further divided into curable and refractory subgroup by treatments. Propensity score match (PSM) analysis was performed to match recurrent curable patients from 145 curable PHB patients from the same cohort. PFS was further compared between 34 pairs of primary and recurrent curative HB patients. RESULTS Recurrence treatment and number of relapsed tumors were significantly related with both OS and PFS of RHB patients (p < 0.05). Chemotherapy regimen alteration was also risk factor of PFS for RHB (HR = 4.26; 95% CI = 1.54-11.78; p = 0.005). RHB patients underwent curable treatment had better prognosis, compared with recurrent refractory subgroup (p < 0.001). Matched curable PHB patients demonstrated no significant difference of 3-year PFS with curable RHB patients (p = 0.540). CONCLUSION Curable RHB patients might get benefit from surgery or ablation with similar prognosis with primary curable HB patients.
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Chen ST, Han ZY, Ling P, Yu XL, Cheng ZG, Liu FY, Jiang H, Yu J. Percutaneous thermal ablation versus open liver resection for recurrent hepatoblastoma: a retrospective study. Int J Hyperthermia 2021; 38:1086-1091. [PMID: 34286633 DOI: 10.1080/02656736.2021.1941310] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The survival of children with recurrent hepatoblastoma (RHB) is still unsatisfactory and the treatment for relapsed patients is challenging. PURPOSE To compare short-term results between open liver resection (OLR) and percutaneous thermal ablation (TA) in the treatment of RHB and provide evidence to support the treatment options for such patients. METHODS A retrospective data of 21 patients with RHB in two Chinese centers were analyzed from January 2013 to May 2019. The baseline indicators and clinical effect of the two groups of children were compared. RESULTS There was no statistical difference in baseline indicators between the two groups of children, and complete remission (CR) was achieved after comprehensive treatment. The median follow-up time was 30 months (IQR 38.5 months) in the TA group, and 23 months (IQR 21.7 months) in OLR group (p = .57). The 2-year OS rates were 92.3% in the percutaneous TA group and 87.5% in the OLR group (p = .68, HR = 1.6, 95% confidence interval [CI]: 0.2-12.4). The 2-year EFS rates were 66.7%, in the TA group and 50.0% in the OLR group (p = .51, HR = 0.6, 95% CI: 0.2-2.6). Compared with the OLR group, TA group had shorter operation time (3.5 ± 1.8 vs. 0.5 ± 0.1, p < .001) and postoperative hospitalization time (11.8 ± 3.0 vs. 9.5 ± 6.8 d, p = .045). No major complications occurred in both groups. CONCLUSIONS Ultrasound-guided percutaneous TA for RHB is a safe and effect treatment option for children. It has comparable effect with surgery within 2 years after treatment. Particularly, due to its minimally invasive advantage, it needs shorter operation and hospitalization time. Percutaneous ablation may be an alternative minimally invasive treatment for RHB children.
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Affiliation(s)
- Si-Tong Chen
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing, PR China
| | - Zhi-Yu Han
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing, PR China
| | - Ping Ling
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing, PR China
| | - Xiao-Ling Yu
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing, PR China
| | - Zhi-Gang Cheng
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing, PR China
| | - Fang-Yi Liu
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing, PR China
| | - Hong Jiang
- Department of Pediatric Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China
| | - Jie Yu
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing, PR China
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Liu L, Cui Z, Zhang J, Wang J, Gu S, Ma J, Chen H, Hang L, Yang J, Shi Y. Knockdown of NRAGE Impairs Homologous Recombination Repair and Sensitizes Hepatoblastoma Cells to Ionizing Radiation. Cancer Biother Radiopharm 2020; 35:41-49. [PMID: 31916845 DOI: 10.1089/cbr.2019.2968] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: NRAGE (neurotrophin receptor-interacting melanoma antigen-encoding gene homolog) has a complex role and regulates cell growth in different tumor cells. Although NRAGE was been discovered for more than 10 years ago, the function of NRAGE in hepatoblastoma (HB) cells is currently unknown. Materials and Methods: The expression of NRAGE was detected by reverse transcription-quantitative polymerase chain reaction assay or western blotting assay. Cellular apoptosis was analyzed to estimate the effect of NRAGE under radiation. The ability of clonogenic capacity was evaluated to confirm the influence of proliferation for NRAGE by radiation. The immunofluorescence assay was used to further study the expression of NRAGE under radiation. A nude mouse tumor xenograft model was constructed to confirm the effect of NRAGE deficiency under radiation conditions in vivo. Results: The authors determined that deletion of NRAGE significantly inhibited HB cell proliferation in vitro and in vivo, and NRAGE knockdown apparently sensitized HB cells to ionizing radiation (IR). Further mechanistic studies revealed that NRAGE plays a critical role in homologous recombination by inhibiting the expression of RNF8 (ring finger protein 8) and BARD1 (BRCA1 associated RING domain 1) and the recruitment of RAD51. Conclusions: The authors demonstrated that downregulation of NRAGE sensitizes HB cell lines to IR in vitro and in vivo. It provides a promising therapeutic strategy for HB patients by specifically targeting NRAGE.
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Affiliation(s)
- Li Liu
- Department of Clinical Laboratory, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Zhongqi Cui
- Department of Clinical Laboratory Medicine, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China
| | - Jie Zhang
- Department of Clinical Laboratory Medicine, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China
| | - Jing Wang
- Department of Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Song Gu
- Department of Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Ji Ma
- Department of Laboratory Clinical Medicine, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Hao Chen
- Department of Clinical Laboratory, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Liang Hang
- Department of Clinical Laboratory, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Jin Yang
- Department of Laboratory, Xigaze People's Hospital of Tibet, Xizang, China
| | - Yi Shi
- Department of Clinical Laboratory, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
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Luo Z, Cao P. Long noncoding RNA PVT1 promotes hepatoblastoma cell proliferation through activating STAT3. Cancer Manag Res 2019; 11:8517-8527. [PMID: 31572006 PMCID: PMC6759231 DOI: 10.2147/cmar.s213707] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 07/15/2019] [Indexed: 12/29/2022] Open
Abstract
Background Hepatoblastoma is the most common liver malignancy in children. The long noncoding RNA (IncRNA) PVT1 plays oncogenic roles in human cancers; however, its regulation and function in hepatoblastoma remain poorly understood. Purpose This study was designed to investigate the regulation and function of PVT1 in hepatoblastoma. Methods PVT1 expression was compared between human hepatoblastoma tissues and adjacent non-tumor tissues, and then analyzed using Kaplan-Meier method. The proliferation of hepatoblastoma cells was determined by BrdU incorporation assay. The tumor xenograft model was used to assess tumor proliferation in vivo. The gene expression level was measured by qRT-pCR, Western blot and immunohistochemistry analyses. Results Compared with normal counterparts, PVT1 is upregulated in human hepatoblastoma tissues as well as in hepatoblastoma cell lines. Additionally, PVT1 promotes the proliferation of hepatoblastoma cells in vitro and accelerates tumor growth in xenograft model in vivo. Mechanistically, PVT1 promotes the activation of the signal transducer and activator of transcription 3 (STAT3), which leads to the transcriptional activation of downstream targets involved in cell cycle progression, and moreover,STAT3 inhibition with the selective inhibitor stattic abolishes PVT1 pro-proliferative role in hepatoblastoma cells. Conclusion PVT1 promotes hepatoblastoma cell proliferation through activating STAT3-induced cell cycle progression, which may implicate PVT1 as a potential therapeutic target for hepatoblastoma treatment.
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Affiliation(s)
- Zhenqin Luo
- Oncology Department, The Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, People's Republic of China
| | - Peiguo Cao
- Oncology Department, The Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, People's Republic of China
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Cui R, Yu J, Gu Y, Cao F, Liu FY, Dong LN, Liang P. Microwave ablation assisted by three-dimensional visualization system as local therapy for relapsed hepatoblastoma: a small pilot study. Abdom Radiol (NY) 2019; 44:2909-2915. [PMID: 31089779 DOI: 10.1007/s00261-019-02011-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE We aimed to explore the feasibility of microwave ablation (MWA) assisted by three-dimensional visualization system for relapsed HB in children. METHODS From August 2014 to February 2017, five patients with relapsed HB were enrolled. A total of 12 liver tumors were treated with MWA assisted by a three-dimensional visualization system. Follow-up data were obtained in all patients. The residual liver volume, local tumor progression, new intrahepatic tumors, survival outcome, and complications were analyzed. RESULTS All tumors were completely ablated in a single session. The mean ablation time per tumor was 9.7 ± 8.6 min, and the median ablation/liver volume ratio was 2.37%. No local tumor progression was observed during a follow-up period of 9-39 months. All patients were still alive at the end of the follow-up. The median progression-free survival time after ablation was 9 months, and the median survival time after ablation was 12 months. No other complications were observed except for fever. CONCLUSIONS MWA assisted by three-dimensional visualization system appears to be a safe and feasible local treatment for recurrent HB in pediatric patients.
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Affiliation(s)
- Rui Cui
- Department of Interventional Ultrasound, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Jie Yu
- Department of Interventional Ultrasound, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Ying Gu
- Department of Laser Medicine, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Feng Cao
- Department of Cardiology, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Feng-Yong Liu
- Department of Interventional Radiology, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Li-Nan Dong
- Department of Interventional Ultrasound, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Ping Liang
- Department of Interventional Ultrasound, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China.
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Ginsenoside Rg1 impairs homologous recombination repair by targeting CtBP-interacting protein and sensitizes hepatoblastoma cells to DNA damage. Anticancer Drugs 2019; 29:756-766. [PMID: 29952772 DOI: 10.1097/cad.0000000000000646] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The ginsenoside Rg1, the primary pharmacologically active ingredient of the traditional Chinese herb ginseng, is widely used in the clinical treatment of diseases of the immune and nervous systems. Recent studies have shown that it also has an antitumor effect. In this study, we explored the effects of Rg1 on hepatoblastoma (HB) and its underlying mechanisms. We demonstrated that Rg1 significantly inhibited HB cell growth both in vivo and in vitro. Mechanistic studies revealed that Rg1 impaired homologous recombination and triggered double-strand breaks in HB cells by directly targeting CtBP-interacting protein (CtIP), a key double-strand break repair factor, which is highly expressed in HB tissues. Moreover, we also demonstrated that Rg1 sensitized HB cells to DNA-damaging agents both in vitro and in vivo. In conclusion, our data not only demonstrate the potential clinical application of Rg1 as a novel chemotherapeutic candidate but also offer a mechanism-based therapeutic option by which DNA-damaging agents can be used in combination with Rg1 to target HB.
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Uchida H, Sakamoto S, Sasaki K, Takeda M, Hirata Y, Fukuda A, Hishiki T, Irie R, Nakazawa A, Miyazaki O, Nosaka S, Kasahara M. Surgical treatment strategy for advanced hepatoblastoma: Resection versus transplantation. Pediatr Blood Cancer 2018; 65:e27383. [PMID: 30084209 DOI: 10.1002/pbc.27383] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/26/2018] [Accepted: 07/03/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Excellent outcomes of the extreme procedure of liver resection (LR) for advanced hepatoblastoma (HB) have been achieved in recent reports. However, liver transplantation (LT) remains the only surgical treatment for patients with unresectable HB. The aim of this study was to evaluate our retrospective data for cases of advanced HB necessitating surgical intervention and analyze the prognostic factors of recurrence by comparing patients with tumors resected by LR and LT. PATIENTS AND METHODS We retrospectively reviewed 24 children with PRETEXT II/III/IV tumors that required consideration for LT between August 2011 and September 2016. RESULT The staging at the time of the diagnosis was PRETEXT II/III/IV in 1/13/10 patients, respectively, while the preoperative staging after neoadjuvant chemotherapy was POSTTEXT II/III/IV in 5/17/2 patients. Among those 24 patients, complete resection of the primary tumor was achieved with LT in 12 patients and LR in 12 patients. A high serum level of alpha-fetoprotein (AFP) at the time of surgery, no significant decrease in the rate of change of AFP, and low tumor shrinkage rate were related to the risk of tumor recurrence, and patients with tumors resected by LR with those risks had a higher recurrence rate than those without them. The overall survival was higher in patients with tumors resected by LT (100%) than in patients with tumors resected by LR. CONCLUSION Patients with advanced HB with a poor response to chemotherapy should definitively be prioritized for primary LT, given the possibility of vascular invasion and microscopic residual tumor.
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Affiliation(s)
- Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kengo Sasaki
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Masahiro Takeda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Yoshihiro Hirata
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Tomoro Hishiki
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Rie Irie
- Division of Clinical Pathology, National Center for Child Health and Development, Tokyo, Japan
| | - Atsuko Nakazawa
- Division of Clinical Pathology, National Center for Child Health and Development, Tokyo, Japan
| | - Osamu Miyazaki
- Division of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Shunsuke Nosaka
- Division of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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Zhang F, Zhang CM, Li S, Wang KK, Guo BB, Fu Y, Liu LY, Zhang Y, Jiang HY, Wu CJ. Low dosage of arsenic trioxide inhibits vasculogenic mimicry in hepatoblastoma without cell apoptosis. Mol Med Rep 2017; 17:1573-1582. [PMID: 29138840 PMCID: PMC5780096 DOI: 10.3892/mmr.2017.8046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 10/12/2017] [Indexed: 01/03/2023] Open
Abstract
Hepatoblastoma (HB) is the most common type of pediatric liver malignancy, which predominantly occurs in young children (aged <5 years), and continues to be a therapeutic challenge in terms of metastasis and drug resistance. As a new pattern of tumor blood supply, vasculogenic mimicry (VM) is a channel structure lined by tumor cells rather than endothelial cells, which contribute to angiogenesis. VM occurs in a variety of solid tumor types, including liver cancer, such as hepatocellular carcinoma. The aim of the present study was to elucidate the effect of arsenic trioxide (As2O3) on VM. In vitro experiments identified that HB cell line HepG2 cells form typical VM structures on Matrigel, and the structures were markedly damaged by As2O3 at a low concentration before the cell viability significantly decreased. The western blot results indicated that As2O3 downregulated the expression level of VM-associated proteins prior to the appearance of apoptotic proteins. In vivo, VM has been observed in xenografts of HB mouse models and identified by periodic acid-Schiff+/CD105− channels lined by HepG2 cells without necrotic cells. As2O3 (2 mg/kg) markedly depresses tumor growth without causing serious adverse reactions by decreasing the number of VM channels via inhibiting the expression level of VM-associated proteins. Thus, the present data strongly indicate that low dosage As2O3 reduces the formation of VM in HB cell line HepG2 cells, independent of cell apoptosis in vivo and in vitro, and may represent as a candidate drug for HB targeting VM.
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Affiliation(s)
- Feng Zhang
- Department of Ultrasonography, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Chun-Mei Zhang
- Department of Ultrasonography, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Shu Li
- Department of Cardiovascular, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Kun-Kun Wang
- Department of Ultrasonography, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Bin-Bin Guo
- Department of Ultrasonography, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Yao Fu
- Department of Ultrasonography, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Lu-Yang Liu
- Department of Ultrasonography, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Yu Zhang
- Department of Ultrasonography, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Hai-Yu Jiang
- Department of Ultrasonography, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Chang-Jun Wu
- Department of Ultrasonography, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
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Pugmire BS, Towbin AJ. Magnetic resonance imaging of primary pediatric liver tumors. Pediatr Radiol 2016; 46:764-77. [PMID: 27229495 DOI: 10.1007/s00247-016-3612-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 02/28/2016] [Accepted: 03/15/2016] [Indexed: 12/31/2022]
Abstract
Although primary hepatic neoplasms are less common than other intra-abdominal tumors in children, these neoplasms are a significant source of morbidity and mortality in the pediatric population. MRI is increasingly relied upon in the diagnostic evaluation of these lesions, both before and after treatment, and familiarity with the MRI findings associated with these neoplasms is a must for pediatric radiologists. Advances in MRI technology, particularly the advent of hepatocyte-specific gadolinium-based MRI contrast agents, have allowed for accurate characterization of several types of hepatic neoplasms on the basis of imaging appearance. In this review, we provide an overview of the approach to imaging hepatic neoplasms in children using MRI, including a sample imaging protocol. We also discuss the relevant clinical features and MRI findings of the most clinically relevant entities, including their appearance on post-contrast imaging using hepatocyte-specific gadolinium-based MRI contrast agents.
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Affiliation(s)
- Brian S Pugmire
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC-5031, Cincinnati, OH, 45255, USA
| | - Alexander J Towbin
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC-5031, Cincinnati, OH, 45255, USA.
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Rikhi RR, Spady KK, Hoffman RI, Bateman MS, Bateman M, Howard LE. Hepatoblastoma: A Need for Cell Lines and Tissue Banks to Develop Targeted Drug Therapies. Front Pediatr 2016; 4:22. [PMID: 27047905 PMCID: PMC4800278 DOI: 10.3389/fped.2016.00022] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 03/07/2016] [Indexed: 12/11/2022] Open
Abstract
Limited research exists regarding the most aggressive forms of hepatoblastoma. Cell lines of the rare subtypes of hepatoblastoma with poor prognosis are not only difficult to attain but also challenging to characterize histologically. A community-driven approach to educating parents and families, regarding the need for donated tissue, is necessary for scientists to have access to resources for murine models and drug discovery. Herein, we describe the currently available resources, existing gaps in research, and the path to move forward for uniform cure of hepatoblastoma.
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Affiliation(s)
- Rishi Raj Rikhi
- Children's Cancer Therapy Development Institute , Beaverton, OR , USA
| | - Kimberlee K Spady
- Faculty of the 2015 Pediatric Cancer Biology Nanocourse, Children's Cancer Therapy Development Institute , Fort Collins, CO , USA
| | - Ruth I Hoffman
- Faculty of the 2015 Pediatric Cancer Biology Nanocourse, Children's Cancer Therapy Development Institute , Fort Collins, CO , USA
| | - Michael S Bateman
- Faculty of the 2015 Pediatric Cancer Biology Nanocourse, Children's Cancer Therapy Development Institute , Fort Collins, CO , USA
| | - Max Bateman
- Faculty of the 2015 Pediatric Cancer Biology Nanocourse, Children's Cancer Therapy Development Institute , Fort Collins, CO , USA
| | - Lisa Easom Howard
- Faculty of the 2015 Pediatric Cancer Biology Nanocourse, Children's Cancer Therapy Development Institute , Fort Collins, CO , USA
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The role of BH3-mimetic drugs in the treatment of pediatric hepatoblastoma. Int J Mol Sci 2015; 16:4190-208. [PMID: 25690034 PMCID: PMC4346952 DOI: 10.3390/ijms16024190] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 02/01/2015] [Accepted: 02/09/2015] [Indexed: 12/20/2022] Open
Abstract
Pediatric hepatoblastoma (HB) is commonly treated by neoadjuvant chemotherapy and surgical tumor resection according to international multicenter trial protocols. Complete tumor resection is essential and survival rates up to 95% have now been achieved in those tumors classified as standard-risk HB. Drug resistance and occurrence of metastases remain the major challenges in the treatment of HB, especially in high-risk tumors. These conditions urgently require the development of alternative therapeutic strategies. One of those alternatives is the modulation of apoptosis in HB cells. HBs regularly overexpress anti-apoptotic proteins of the Bcl-family in comparison to healthy liver tissue. This fact may contribute to the development of chemoresistance of HB cells. Synthetic small inhibitory molecules with BH3-mimetic effects, such as ABT-737 and obatoclax, enhance the susceptibility of tumor cells to different cytotoxic drugs and thereby affect initiator proteins of the apoptosis cascade via the intrinsic pathway. Besides additive effects on HB cell viability when used in combination with cytotoxic drugs, BH3-mimetics also play a role in preventing metastasation by reducing adhesion and inhibiting cell migration abilities. Presumably, including additive BH3-mimetic drugs into existing therapeutic regimens in HB patients might allow dose reduction of established cytotoxic drugs and thereby associated immanent side effects, while maintaining the antitumor activity. Furthermore, reduction of tumor growth and inhibition of tumor cell dissemination may facilitate complete surgical tumor resection, which is mandatory in this tumor type resulting in improved survival rates in high-risk HB. Currently, there are phase I and phase II clinical trials in several cancer entities using this potential target. This paper reviews the available literature regarding the use of BH3-mimetic drugs as single agents or in combination with chemotherapy in various malignancies and focuses on results in HB cells.
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Zhang YT, Feng LH, Zhong XD, Wang LZ, Chang J. Vincristine and irinotecan in children with relapsed hepatoblastoma: a single-institution experience. Pediatr Hematol Oncol 2015; 32:18-25. [PMID: 24852330 DOI: 10.3109/08880018.2014.909913] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE This study was to determine the efficacy of vincristine and irinotecan in children with relapsed hepatoblastoma (HB). METHODS A total of 10 patients with relapsed HB were enrolled. Three patients were excluded. Patients received irinotecan 50 mg/m(2)/day, day 1-5 and vincristine 1.5 mg/m(2)/day, day 1, repeated every 3 weeks. The maximum cycles were eight. Reevaluation of tumor was performed every two cycles. The primary outcome was the rate of complete resection. Secondary outcomes were event-free survival (EFS) and overall survival (OS). RESULTS Of the seven patients assessable for response, one patient with normal AFP level showed a progressive disease and withdrew. He finally died 6 months later. Four had PR, all of them underwent a second surgery and achieved complete resection. Two patients had SD, one patient relapsed 6 months after orthotopic liver transplantation and died, the other one undergoing surgery had micro margin positive, he relapsed again but alive. The rate of complete resection was 71.4% (including orthotopic liver transplantation). The 2-year EFS and OS for the whole group were 57.1% (95% CI, 12.7% to 34.2%) and 71.4% (95% CI, 16.39% to 37.4%), respectively. CONCLUSIONS The combination of irinotecan and vincristine has a significant antitumor activity and acceptable toxicity in children with relapsed HB.
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Affiliation(s)
- Yu-tong Zhang
- 1Department of Pediatric Hematology and Oncology, the First Hospital of Jilin University, Changchun, Jilin, China
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Shah R, Tran HC, Randolph L, Mascarenhas L, Venkatramani R. Hepatoblastoma in a 15-month-old female with trisomy 13. Am J Med Genet A 2013; 164A:472-5. [DOI: 10.1002/ajmg.a.36271] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Accepted: 09/03/2013] [Indexed: 12/19/2022]
Affiliation(s)
- Rachana Shah
- Division of Hematology and Oncology; Children's Hospital Los Angeles; Los Angeles California
| | - Hung Chi Tran
- Division of Hematology and Oncology; Children's Hospital Los Angeles; Los Angeles California
- Department of Pediatrics; Keck School of Medicine; University of Southern California; Los Angeles California
| | - Linda Randolph
- Department of Pediatrics; Keck School of Medicine; University of Southern California; Los Angeles California
- Division of Medical Genetics; Children's Hospital Los Angeles; Los Angeles California
| | - Leo Mascarenhas
- Division of Hematology and Oncology; Children's Hospital Los Angeles; Los Angeles California
- Department of Pediatrics; Keck School of Medicine; University of Southern California; Los Angeles California
| | - Rajkumar Venkatramani
- Division of Hematology and Oncology; Children's Hospital Los Angeles; Los Angeles California
- Department of Pediatrics; Keck School of Medicine; University of Southern California; Los Angeles California
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