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Biassoni V, Schiavello E, Gandola L, Pecori E, Poggi G, Spreafico F, Terenziani M, Meazza C, Podda M, Ferrari A, Luksch R, Casanova M, Puma N, Chiaravalli S, Bergamaschi L, Cefalo G, Simonetti F, Gattuso G, Seregni EC, Pallotti F, Gianno F, Diletto B, Barretta F, Massimino M. Secreting Germ Cell Tumors of the Central Nervous System: A Long-Term Follow-up Experience. Cancers (Basel) 2020; 12:cancers12092688. [PMID: 32967085 PMCID: PMC7565315 DOI: 10.3390/cancers12092688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 09/13/2020] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Due to the rarity of nongerminomatous germ cell tumors (NGGCT) with non-standard treatment as yet, we report retrospectively our 30 year experience with chemotherapy followed by craniospinal irradiation (CSI), plus a boost of whole ventricular irradiation (WVI)/tumor bed (TB), tailored to pre-radiation chemotherapy response. METHODS Between 1988 and 2016, 28 patients received four cycles of PEB (cisplatin/etoposide/bleomycin), then CSI, and two further PEB cycles. Between 1988 and1994, CSI was 25.5 Gy for patients in complete remission (CR), 30 Gy if in partial remission (PR) or metastatic, with a boost to TB up to 45-54 Gy. In the period of 1995-2010, the boost included WVI and any extra-ventricular tumor sites up to 45 Gy. After 2010, CSI was reduced to 25.5 Gy for all non-metastatic patients, and a boost was given only to TB up to 40.5/45.5 Gy, depending on patients' CR/PR status. After 2003, patients with alfafetoprotein (αFP) > 1000 ng/mL received intensified treatment, also including autologous stem cell transplantation. RESULTS Among 28 patients (23 males; median age 12 years, 6 metastatic), 25 responded to PEB, and three progressed (PD) after one to four cycles; 26 received radiotherapy obtaining 13 CR, 7 PR and 5 stable disease (SD), 1 PD; 6 (21%) died (5 for disease, 1 for pneumonia while in CR). Five-year overall survival (OS) and progression-free survival (PFS) were both 81%; 10 year OS and PFS 81% and 76%, respectively (median follow-up 11 years). CONCLUSIONS Survival for children with NGGCT, independently from disease extent, was encouraging. Further studies should elucidate which patients could benefit from reduced volume and dose irradiation.
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Affiliation(s)
- Veronica Biassoni
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (E.S.); (F.S.); (M.T.); (C.M.); (M.P.); (A.F.); (R.L.); (M.C.); (N.P.); (S.C.); (L.B.); (F.S.); (G.G.); (M.M.)
- Correspondence: ; Tel.: +39-0223902590; Fax: +39-0223902648
| | - Elisabetta Schiavello
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (E.S.); (F.S.); (M.T.); (C.M.); (M.P.); (A.F.); (R.L.); (M.C.); (N.P.); (S.C.); (L.B.); (F.S.); (G.G.); (M.M.)
| | - Lorenza Gandola
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (L.G.); (E.P.); (B.D.)
| | - Emilia Pecori
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (L.G.); (E.P.); (B.D.)
| | - Geraldina Poggi
- Neuro-Oncological Unit and Neuropsychological Rehabilitation Unit Scientific Institute, IRCCS E. Medea, Bosisio Parini, 23842 Lecco, Italy;
| | - Filippo Spreafico
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (E.S.); (F.S.); (M.T.); (C.M.); (M.P.); (A.F.); (R.L.); (M.C.); (N.P.); (S.C.); (L.B.); (F.S.); (G.G.); (M.M.)
| | - Monica Terenziani
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (E.S.); (F.S.); (M.T.); (C.M.); (M.P.); (A.F.); (R.L.); (M.C.); (N.P.); (S.C.); (L.B.); (F.S.); (G.G.); (M.M.)
| | - Cristina Meazza
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (E.S.); (F.S.); (M.T.); (C.M.); (M.P.); (A.F.); (R.L.); (M.C.); (N.P.); (S.C.); (L.B.); (F.S.); (G.G.); (M.M.)
| | - Marta Podda
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (E.S.); (F.S.); (M.T.); (C.M.); (M.P.); (A.F.); (R.L.); (M.C.); (N.P.); (S.C.); (L.B.); (F.S.); (G.G.); (M.M.)
| | - Andrea Ferrari
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (E.S.); (F.S.); (M.T.); (C.M.); (M.P.); (A.F.); (R.L.); (M.C.); (N.P.); (S.C.); (L.B.); (F.S.); (G.G.); (M.M.)
| | - Roberto Luksch
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (E.S.); (F.S.); (M.T.); (C.M.); (M.P.); (A.F.); (R.L.); (M.C.); (N.P.); (S.C.); (L.B.); (F.S.); (G.G.); (M.M.)
| | - Michela Casanova
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (E.S.); (F.S.); (M.T.); (C.M.); (M.P.); (A.F.); (R.L.); (M.C.); (N.P.); (S.C.); (L.B.); (F.S.); (G.G.); (M.M.)
| | - Nadia Puma
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (E.S.); (F.S.); (M.T.); (C.M.); (M.P.); (A.F.); (R.L.); (M.C.); (N.P.); (S.C.); (L.B.); (F.S.); (G.G.); (M.M.)
| | - Stefano Chiaravalli
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (E.S.); (F.S.); (M.T.); (C.M.); (M.P.); (A.F.); (R.L.); (M.C.); (N.P.); (S.C.); (L.B.); (F.S.); (G.G.); (M.M.)
| | - Luca Bergamaschi
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (E.S.); (F.S.); (M.T.); (C.M.); (M.P.); (A.F.); (R.L.); (M.C.); (N.P.); (S.C.); (L.B.); (F.S.); (G.G.); (M.M.)
| | - Graziella Cefalo
- Department of Pediatrics, University of Milan, San Paolo Hospital, Santi Paolo e Carlo ASST, 20121 Milan, Italy;
| | - Fabio Simonetti
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (E.S.); (F.S.); (M.T.); (C.M.); (M.P.); (A.F.); (R.L.); (M.C.); (N.P.); (S.C.); (L.B.); (F.S.); (G.G.); (M.M.)
| | - Giovanna Gattuso
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (E.S.); (F.S.); (M.T.); (C.M.); (M.P.); (A.F.); (R.L.); (M.C.); (N.P.); (S.C.); (L.B.); (F.S.); (G.G.); (M.M.)
| | - Ettore Cesare Seregni
- Nuclear Medicine Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (E.C.S.); (F.P.)
| | - Federica Pallotti
- Nuclear Medicine Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (E.C.S.); (F.P.)
| | - Francesca Gianno
- Department of Radiological, Oncological and Anatomo-Pathological Sciences, University Sapienza of Rome, 00161 Rome, Italy;
| | - Barbara Diletto
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (L.G.); (E.P.); (B.D.)
| | - Francesco Barretta
- Clinical Epidemiology and Trial Organization Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy;
| | - Maura Massimino
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (E.S.); (F.S.); (M.T.); (C.M.); (M.P.); (A.F.); (R.L.); (M.C.); (N.P.); (S.C.); (L.B.); (F.S.); (G.G.); (M.M.)
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Calaminus G, Frappaz D, Kortmann RD, Krefeld B, Saran F, Pietsch T, Vasiljevic A, Garre ML, Ricardi U, Mann JR, Göbel U, Alapetite C, Murray MJ, Nicholson JC. Outcome of patients with intracranial non-germinomatous germ cell tumors-lessons from the SIOP-CNS-GCT-96 trial. Neuro Oncol 2018; 19:1661-1672. [PMID: 29048505 DOI: 10.1093/neuonc/nox122] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Following promising results to increase survival and reduce treatment burden in intracranial non-germinomatous germ cell tumors (NGGCTs), we conducted a European study using dose-intense chemotherapy followed by risk-adapted radiotherapy. Methods All patients received 4 courses of cisplatin/etoposide/ifosfamide. Non-metastatic patients then received focal radiotherapy only (54 Gy); metastatic patients received 30 Gy craniospinal radiotherapy with 24 Gy boost to primary tumor and macroscopic metastatic sites. Results Patients with localized malignant NGGCT (n = 116) demonstrated 5-year progression-free survival (PFS) and overall survival (OS) of 0.72 ± 0.04 and 0.82 ± 0.04, respectively. Primary tumor sites were: 67 pineal, 35 suprasellar, 5 bifocal, 9 others. One patient died postsurgery in clinical remission; 3 patients progressed during treatment and 27 (23%) relapsed afterward. Fourteen were local, 6 combined, and 7 distant relapses (outside radiation field). Seventeen of the 27 relapsed patients died of disease. Patients with metastatic disease (n = 33) demonstrated 5-year PFS and OS of 0.68 ± 0.09 and 0.75 ± 0.08, respectively; 1 patient died following progression on treatment and 9 (27%) relapsed afterward (5 local, 1 combined, 3 distant). Only one metastatic patient with recurrence was salvaged. Multivariate analysis identified diagnostic alpha-fetoprotein level (serum and/or cerebrospinal fluid level >1000 ng/mL, 19/149 patients, of whom 11 relapsed; P < 0.0003) and residual disease following treatment, including after second-look surgery (n = 52/145 evaluable patients, 26 relapsed; P = 0.0002) as significant prognostic indicators in this cohort. Conclusion In localized malignant NGGCT, craniospinal radiotherapy could be avoided without increased relapses outside the radiotherapy field. Chemotherapy and craniospinal radiotherapy remain the gold standard for metastatic disease.
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Affiliation(s)
- Gabriele Calaminus
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Didier Frappaz
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Rolf Dieter Kortmann
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Barbara Krefeld
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Frank Saran
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Torsten Pietsch
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Alexandre Vasiljevic
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Maria Luisa Garre
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Umberto Ricardi
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Jillian R Mann
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Ulrich Göbel
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Claire Alapetite
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Matthew J Murray
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - James C Nicholson
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
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