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Carey SS, Huang J, Myers JR, Mostafavi R, Orr BA, Dhanda SK, Michalik LH, Tatevossian RG, Klimo P, Boop F, Lu C, Sioson E, Zhou X, Nichols KE, Merchant TE, Ellison DW, Robinson GW, Onar-Thomas A, Gajjar A, Upadhyaya SA. Outcomes for children with recurrent/refractory atypical teratoid rhabdoid tumor: A single-institution study with molecular correlation. Pediatr Blood Cancer 2024; 71:e31208. [PMID: 39034595 PMCID: PMC11343675 DOI: 10.1002/pbc.31208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 06/09/2024] [Accepted: 07/04/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Survival data for recurrent pediatric atypical teratoid rhabdoid tumor (ATRT) and its association to molecular groups are extremely limited. METHODS Single-institution retrospective study of 64 children less than 21 years old with recurrent or treatment-refractory (progressive disease [PD]) ATRT treated at St. Jude Hospital from January 2000 to December 2020. Demographic, clinicopathologic, treatment, molecular grouping (SHH, TYR, and MYC) and germline data were collected. Progression-free survival (PFS2: time from PD to subsequent first progression) and overall survival (OSpostPD: time from PD to death/last follow-up) were estimated by Kaplan-Meier analysis. RESULTS Median age at and time from initial diagnosis to PD were 2.1 years (range: 0.5-17.9 years) and 5.4 months (range: 0.5-125.6 months), respectively. Only five of 64 children (7.8%) are alive at median follow-up of 10.9 (range: 4.2-18.1) years from PD. The 2/5-year PFS2 and OSpostPD were 3.1% (±1.8%)/1.6% (±1.1%) and 20.3% (±4.8%)/7.3% (±3.5%), respectively. Children with TYR group (n = 10) had a better OSpostPD compared to those with MYC (n = 11) (2-year survival estimates: 60.0% ± 14.3% vs. 18.2% ± 9.5%; p = .019), or those with SHH (n = 21; 4.8% ± 3.3%; p = .014). In univariate analyses, OSpostPD was better with older age at diagnosis (p = .037), female gender (p = .008), and metastatic site of PD compared to local or combined sites of PD (p < .001). Two-year OSpostPD for patients receiving any salvage therapy (n = 39) post PD was 33.3% ± 7.3%. CONCLUSIONS Children with recurrent/refractory ATRT have dismal outcomes. Older age at diagnosis, female gender, TYR group, and metastatic site of PD were associated with relatively longer survival in our study.
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Affiliation(s)
- Steven S. Carey
- Department of Hospitalist Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Jie Huang
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Jason R. Myers
- Center for Applied Bioinformatics, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Roya Mostafavi
- Division of Genetics, Le Bonheur Children’s Hospital, Memphis, TN, USA
| | - Brent A. Orr
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | | | - Layna H. Michalik
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Ruth G. Tatevossian
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Paul Klimo
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Frederick Boop
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Congyu Lu
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Edgar Sioson
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Xin Zhou
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Kim E. Nichols
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Thomas E. Merchant
- Department of Radiation Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - David W. Ellison
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Giles W. Robinson
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Arzu Onar-Thomas
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Amar Gajjar
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Santhosh A. Upadhyaya
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
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Donzé C, Revon-Rivière G, Pondrom M, Verschuur A, Leblond P, André N. Retrospective experience of children with relapsed brain tumors treated with oral combination of axitinib and metronomic etoposide. Pediatr Blood Cancer 2024; 71:e31076. [PMID: 38778441 DOI: 10.1002/pbc.31076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/28/2024] [Accepted: 05/02/2024] [Indexed: 05/25/2024]
Abstract
Metronomic chemotherapy-based combinations have received interest for relapsed/refractory malignancies. Preclinical and clinical studies showed activity of metronomic etoposide and axitinib. We report our retrospective experience in six children treated with axitinib and metronomic etoposide for refractory/relapsed brain tumors as an "off-label" combination. Three patients with medulloblastoma experienced partial response; one patient with atypical teratoid rhabdoid tumor (ATRT) displays an ongoing stable disease (12 months); two patients with medulloblastoma had progressive disease. Grade 3-4 toxicities were observed in two patients (thrombocytopenia, anemia, diarrhea, fatigue). The axitinib-etoposide combination shows signals of efficacy in heavily pretreated patients with relapsed/refractory brain tumors. These results were based on real-world observation and will need formal evaluation in a phase I/II trial.
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Affiliation(s)
- Caroline Donzé
- Department of Pediatric Hematology, Immunology and Oncology, APHM, La Timone Children's Hospital, Marseille, France
| | - Gabriel Revon-Rivière
- Department of Pediatric Hematology, Immunology and Oncology, APHM, La Timone Children's Hospital, Marseille, France
- REMAP4KIDS, CNRS, INSERM, CRCM, Aix Marseille University, Marseille, France
| | - Morgane Pondrom
- Department of Pediatric Hemato-Oncology, Nice University Hospital, Nice, France
| | - Arnauld Verschuur
- Department of Pediatric Hematology, Immunology and Oncology, APHM, La Timone Children's Hospital, Marseille, France
- REMAP4KIDS, CNRS, INSERM, CRCM, Aix Marseille University, Marseille, France
| | - Pierre Leblond
- Department of Pediatric Oncology, Institute of Pediatric Hematology and Oncology, Lyon, France
| | - Nicolas André
- Department of Pediatric Hematology, Immunology and Oncology, APHM, La Timone Children's Hospital, Marseille, France
- REMAP4KIDS, CNRS, INSERM, CRCM, Aix Marseille University, Marseille, France
- Metronomic Global Health Initiative, Marseille, France
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Mak LS, Li X, Chan WYK, Leung AWK, Cheuk DKL, Yuen LYP, So JCC, Ha SY, Liu APY. Case report: Therapy-related myeloid neoplasms in three pediatric cases with medulloblastoma. Front Oncol 2024; 14:1364199. [PMID: 38595820 PMCID: PMC11002154 DOI: 10.3389/fonc.2024.1364199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 03/13/2024] [Indexed: 04/11/2024] Open
Abstract
Introduction Medulloblastoma is the most common malignant brain tumor in children, often requiring intensive multimodal therapy, including chemotherapy with alkylating agents. However, therapy-related complications, such as therapy-related myeloid neoplasms (t-MNs), can arise, particularly in patients with genetic predisposition syndromes. This case report presents three pediatric cases of medulloblastoma with subsequent development of t-MNs, highlighting the potential role of genetic predisposition and the importance of surveillance for hematological abnormalities in long-term survivors. Case presentation We describe three cases of pediatric medulloblastoma who developed t-MNs after receiving chemotherapy, including alkylating agents. Two of the patients had underlying genetic predisposition syndromes (TP53 pathologic variants). The latency period between initial diagnosis of medulloblastoma and the development of secondary cancer varied among the cases, ranging from 17 to 65 months. The three cases eventually succumbed from secondary malignancy, therapy-related complications and progression of primary disease, respectively. Conclusions This report highlights the potential association between genetic predisposition syndromes and the development of therapy-related myeloid neoplasms in pediatric medulloblastoma survivors. It underscores the importance of surveillance for hematological abnormalities among such patients.
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Affiliation(s)
- Li Shun Mak
- Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital, Hong Kong, Hong Kong SAR, China
- Department of Pediatrics and Adolescent Medicine, Hong Kong Children’s Hospital, Hong Kong, Hong Kong SAR, China
| | - Xiuling Li
- Department of Pathology, Hong Kong Children’s Hospital, Hong Kong, Hong Kong SAR, China
| | - Wilson Y. K. Chan
- Department of Pediatrics and Adolescent Medicine, Hong Kong Children’s Hospital, Hong Kong, Hong Kong SAR, China
| | - Alex W. K. Leung
- Department of Pediatrics and Adolescent Medicine, Hong Kong Children’s Hospital, Hong Kong, Hong Kong SAR, China
| | - Daniel K. L. Cheuk
- Department of Pediatrics and Adolescent Medicine, Hong Kong Children’s Hospital, Hong Kong, Hong Kong SAR, China
| | - Liz Y. P. Yuen
- Department of Pathology, Hong Kong Children’s Hospital, Hong Kong, Hong Kong SAR, China
| | - Jason C. C. So
- Department of Pathology, Hong Kong Children’s Hospital, Hong Kong, Hong Kong SAR, China
| | - Shau Yin Ha
- Department of Pediatrics and Adolescent Medicine, Hong Kong Children’s Hospital, Hong Kong, Hong Kong SAR, China
| | - Anthony P. Y. Liu
- Department of Pediatrics and Adolescent Medicine, Hong Kong Children’s Hospital, Hong Kong, Hong Kong SAR, China
- Department of Paediatrics and Adolescent Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
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André N, Deley MCL, Léguillette C, Probst A, Willems L, Travers R, Aerts I, Faure-Conter C, Revond-Riviere G, Min V, Geoerger B, Chastagner P, Entz-Werlé N, Leblond P. METRO-PD1: Phase 1 study of nivolumab in combination with metronomic chemotherapy in children and adolescents with relapsing/refractory solid tumors. Eur J Cancer 2024; 198:113525. [PMID: 38199147 DOI: 10.1016/j.ejca.2024.113525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/23/2023] [Accepted: 01/02/2024] [Indexed: 01/12/2024]
Abstract
BACKGROUND This multicenter Phase I study (NCT03585465) evaluated nivolumab in combination with 3 metronomic chemotherapy (MC) regimens in children with refractory/relapsing solid tumors. OBJECTIVES To evaluate the feasibility and safety of the three regimens METHODS: Patients aged < 18 years were enrolled. Nivolumab was combined with cyclophosphamide and vinblastine (arm A), capecitabine (arm B), or cyclophosphamide, vinblastine and capecitabine (arm C). Arm A and B were allocated sequentially. Arm C opened only if A and B were deemed safe. Dose-limiting toxicities (DLTs) were evaluated over the first two cycles. Patients were evaluable if they received > 2 cycles and > 70% of the planned dose. POPULATION Sixteen patients were enrolled, 3 in arm A, 6 in arm B, and 7 in arm C. Median age was 11.5 years (range, 5-19). Patients previously received a median of 3.5 (range, 1-4) lines of systemic treatment, 14 patients had surgery and 11 had radiotherapy. RESULTS Median number of cycles was 2 (1-24), median treatment duration was 56 days (18-714). In arm C, median number of cycles was 4 with median treatment duration of 95 days. No DLT was observed. Grade 3 adverse events (AE) and serious AE were observed in 8 patients (50%) and 1 patient (6%), respectively, over the first 2 cycles. No grade 4 AE occurred. The 6-month PFS and OS were 12% and 44%, respectively, in the whole population. Prolonged stable disease was observed in a high-grade glioma and an atypical teratoid rhabdoid tumor. CONCLUSION Arm C appears safe. A randomized phase II trial evaluating the addition of nivolumab to the triple MC is ongoing.
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Affiliation(s)
- Nicolas André
- Marseille-La Timone University Hospital, Oncologie pédiatrique, Marseille, France; CRCM INSERM U1068 SMARTc Aix Marseille University, France; Metronomics Global Health Initiative, France.
| | | | | | - Alicia Probst
- Oscar Lambret Comprehensive Cancer Center, Department of Clinical Research, Lille, France
| | - Leen Willems
- Department Pediatric Hematology and Oncology, UZ Ghent, Belgium
| | - Romain Travers
- Centre François Baclesse, Centre de Traitement des Données du Cancéropôle Nord-Ouest, Caen, France
| | - Isabelle Aerts
- Institut Curie, PSL Research University, Oncology Center SIREDO, Paris, France
| | | | - Gabriel Revond-Riviere
- Marseille-La Timone University Hospital, Oncologie pédiatrique, Marseille, France; CRCM INSERM U1068 SMARTc Aix Marseille University, France
| | - Victoria Min
- Marseille-La Timone University Hospital, Oncologie pédiatrique, Marseille, France
| | - Birgit Geoerger
- Gustave Roussy Cancer Campus, Department of Pediatric and Adolescent Oncology, INSERM U1015, Université Paris-Saclay, Villejuif, France
| | - Pascal Chastagner
- Nancy University Hospital, Service d'hémato-oncologie pédiatrique, Nancy, France
| | - Natascha Entz-Werlé
- Strasbourg University Hospital, Pédiatrie Onco-Hématologie - Pédiatrie III, Strasbourg, France; UMR CNRS 7021 - Université de Strasbourg, Laboratoire de Bioimagerie et Pathologies, Equipe signalisation tumorale et cibles thérapeutiques, Faculté de Pharmacie, Illkirch, France
| | - Pierre Leblond
- Centre Léon Bérard, IHOPe, Lyon, France; Oscar Lambret Comprehensive Cancer Center, Pediatric Oncology Unit, Lille, France
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Mushtaq N, Ul Ain R, Hamid SA, Bouffet E. Evolution of Systemic Therapy in Medulloblastoma Including Irradiation-Sparing Approaches. Diagnostics (Basel) 2023; 13:3680. [PMID: 38132264 PMCID: PMC10743079 DOI: 10.3390/diagnostics13243680] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023] Open
Abstract
The management of medulloblastoma in children has dramatically changed over the past four decades, with the development of chemotherapy protocols aiming at improving survival and reducing long-term toxicities of high-dose craniospinal radiotherapy. While the staging and treatment of medulloblastoma were until recently based on the modified Chang's system, recent advances in the molecular biology of medulloblastoma have revolutionized approaches in the management of this increasingly complex disease. The evolution of systemic therapies is described in this review.
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Affiliation(s)
- Naureen Mushtaq
- Division of Pediatric Oncology, Department of Oncology, Aga Khan University, Karachi 74800, Pakistan;
| | - Rahat Ul Ain
- Department of Pediatric Hematology/Oncology & Bone Marrow Transplant, University of Child Health Sciences, Children’s Hospital, Lahore 54600, Pakistan;
| | - Syed Ahmer Hamid
- Department of Pediatric Hematology and Oncology, Indus Hospital & Health Network, Karachi 74800, Pakistan;
| | - Eric Bouffet
- Global Neuro-Oncology Program, Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, St. Jude Global, Memphis, TN 38105, USA
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André N, Bailey S, Peyrl A. Successfully targeting the cancer system with metronomics for medulloblastoma. Trends Cancer 2023; 9:989-991. [PMID: 37940401 DOI: 10.1016/j.trecan.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 10/17/2023] [Accepted: 10/20/2023] [Indexed: 11/10/2023]
Abstract
The prognosis of the patients with medulloblastoma who relapse after initial treatment including radiotherapy remains dismal. A recent study by Peyrl et al. in JAMA Oncology suggests that the metronomic multidrug combination used in the medulloblastoma European multitarget metronomic antiangiogenic trial (MEMMAT) given at relapse can improve long-term survival.
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Affiliation(s)
- Nicolas André
- Department of Pediatric Oncology, Timone Hospital, Assistance Publique Hôpitaux de Marseille (AP-HM), Marseille, France; Reverse Molecular Pharmacology in Pediatric Oncology, Centre de Recherche en Cancérologie de Marseille (CRCM), Aix-Marseille Université, Centre National de la Recherche Scientifique (CNRS), Institut National de la Santé et de la Recherche Médicale (INSERM), Marseille, France; Metronomics Global Health Initiative, Marseille, France.
| | - Simon Bailey
- Great North Children's Hospital, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK; Wolfson Childhood Cancer Research Centre, Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne NE1 7RU, UK
| | - Andreas Peyrl
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria
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Massimino M, Vennarini S, Buttarelli FR, Antonelli M, Colombo F, Minasi S, Pecori E, Ferroli P, Giussani C, Schiariti M, Schiavello E, Biassoni V, Erbetta A, Chiapparini L, Nigro O, Boschetti L, Gianno F, Miele E, Modena P, De Cecco L, Pollo B, Barretta F. Optimizing reirradiation for relapsed medulloblastoma: identifying the ideal patient and tumor profiles. J Neurooncol 2023; 163:577-586. [PMID: 37326761 DOI: 10.1007/s11060-023-04361-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/01/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND First-line therapies for medulloblastoma(MBL) are obtaining higher survival-rates while decreasing late-effects, but treatment at relapse is not standardized. We report here the experience with MBL re-irradiation(re-RT), its timing and outcome in different clinical settings and tumor groups. METHODS Patient's staging/treatment at diagnosis, histotypes/molecular subgroups, relapse site/s, re-treatments outcome are reported. RESULTS 25 patients were included, with a median age of 11.4 years; 8 had metastases. According to 2016-2021 WHO-classification, 14 had SHH subgroup tumors(six TP53 mutated,one + MYC,one + NMYC amplification), 11 non-WNT/non-SHH (two with MYC/MYCN amplification).Thirteen had received HART-CSI, 11 standard-CSI, one HFRT; all post-radiation chemotherapy(CT), 16 also pre-RT. Median time to relapse (local-LR in nine, distant-DR in 14, LR + DR in two) was 26 months. Fourteen patients were re-operated, in five cases excising single DR-sites, thereafter three received CT, two after re-RT; out of 11 patients not re-operated, four had re-RT as first treatment and seven after CT. Re-RT was administered at median 32 months after first RT: focally in 20 cases, craniospinal-CSI in five. Median post-relapse-PFS/after re-RT was 16.7/8.2 months, while overall survival-OS was 35.1/23.9 months, respectively. Metastatic status both at diagnosis/relapse negatively affected outcome and re-surgery was prognostically favorable. PD after re-RT was however significantly more frequent in SHH (with a suggestive association with TP53 mutation, p = 0.050). We did not observe any influence of biological subgroups on PFS from recurrence while SHH showed apparently worse OS compared to non-WNT/non-SHH group. CONCLUSIONS Re-surgery + reRT can prolong survival; a substantial fraction of patients with worse outcome belongs to the SHH-subgroup.
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Affiliation(s)
- Maura Massimino
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, 20133, Italy.
| | - Sabina Vennarini
- Pediatric Radiotherapy, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Manila Antonelli
- Department of Radiological, Oncological and Anatomo-Pathological Sciences, Sapienza University, Rome, Italy
| | - Francesca Colombo
- Pediatric Radiotherapy, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Simone Minasi
- Department of Radiological, Oncological and Anatomo-Pathological Sciences, Sapienza University, Rome, Italy
| | - Emilia Pecori
- Pediatric Radiotherapy, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Paolo Ferroli
- Neurosurgery Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Carlo Giussani
- Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Marco Schiariti
- Neurosurgery Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Elisabetta Schiavello
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, 20133, Italy
| | - Veronica Biassoni
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, 20133, Italy
| | - Alessandra Erbetta
- Neuroradiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | | | - Olga Nigro
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, 20133, Italy
| | - Luna Boschetti
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, 20133, Italy
| | - Francesca Gianno
- Department of Radiological, Oncological and Anatomo-Pathological Sciences, Sapienza University, Rome, Italy
| | - Evelina Miele
- Department of Pediatric Onco-Hematology and Transfusion Medicine (EM), Ospedale Pediatrico Bambino Gesù, Roma, Italy
| | | | - Loris De Cecco
- Integrated Biology Platform, Department of Applied Research and Technology Development, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Bianca Pollo
- Neuropathology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesco Barretta
- Department of Clinical Epidemiology and Trial Organization, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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