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Ma J, Chen T, Zhang J, Cao W, Gao G, Yu X, Wang H. Enhanced outcomes in residual or recurrent craniopharyngioma: evaluating combined gamma knife and phosphorus-32 brachytherapy. Clin Transl Oncol 2024:10.1007/s12094-024-03435-2. [PMID: 38488982 DOI: 10.1007/s12094-024-03435-2] [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: 01/03/2024] [Accepted: 03/02/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Managing residual and recurrent craniopharyngioma effectively is crucial for improving patient outcomes. This study evaluates the combined use of gamma knife and phosphorus-32 brachytherapy, offering insights into alternative, less invasive treatment strategies. METHODS We conducted a retrospective analysis of 97 patients treated from 2010 to 2016 for residual and recurrent craniopharyngioma using gamma knife and phosphorus-32 brachytherapy. We classified these patients into three groups: superficial solid (Group A), simple cystic (Group B), and mixed cystic-solid (Group C). We assessed the treatment's effectiveness by the tumor control rates and evaluated safety by monitoring vision, endocrine function improvements, and complication rates. RESULTS The treatment achieved complete and adequate control rates of 49.5% and 87.6%, respectively. We observed improvements in vision or visual fields in 55.1% of the patients. The morbidity rate was 15.5%. The study found no significant differences in tumor control rates among the various lesion types. CONCLUSION The combination of gamma knife and phosphorus-32 brachytherapy presents a viable, minimally invasive alternative for treating residual and recurrent craniopharyngioma. It offers high tumor control and functional improvement rates, suggesting its potential as a preferred strategy in some instances.
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Affiliation(s)
- Jie Ma
- PLA Medical School, Beijing, 100853, People's Republic of China
- Department of Neurosurgery, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, People's Republic of China
| | - Tao Chen
- State Key Laboratory of Industrial Control Technology, Zhejiang University, Hangzhou, 310027, People's Republic of China
| | - Jianning Zhang
- Department of Neurosurgery, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, People's Republic of China
| | - Weidong Cao
- Department of Neurosurgery, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, People's Republic of China
| | - Gan Gao
- PLA Medical School, Beijing, 100853, People's Republic of China
- Department of Neurosurgery, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, People's Republic of China
| | - Xinguang Yu
- Department of Neurosurgery, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, People's Republic of China.
| | - Hongwei Wang
- Department of Neurosurgery, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, People's Republic of China.
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Massimi L, Palombi D, Musarra A, Bianchi F, Frassanito P, Tamburrini G, Di Rocco C. Adamantinomatous craniopharyngioma: evolution in the management. Childs Nerv Syst 2023; 39:2613-2632. [PMID: 37728836 PMCID: PMC10613147 DOI: 10.1007/s00381-023-06143-4] [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: 07/26/2023] [Accepted: 08/31/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND In spite of the continuous progresses in pediatric neurosurgery, adamantinomatous craniopharyngioma (AC) remains a challenging tumor due to its proximity to optic pathways, pituitary gland, hypothalamus, and Willis' circle, which can result in significant endocrine, cognitive, and neurological morbidity after treatment with subsequent impact on the patient's quality of life (QoL). The relevance that QoL has today explains the changes in the management of AC observed over the time. The goal of the present article is to provide a historical background, to show the milestones in the changes of the AC treatment, and to analyze the current main options to manage such a challenging tumor. MATERIAL AND METHODS The pertinent literature has been reviewed. Moreover, a comparison between the past and recent personal series is reported. RESULTS Three main eras have been identified. The first (named Cushing era) was characterized by the need to realize a harmless surgery and to define the best way to approach AC; the second (microscope era) was characterized by a tremendous technical and technological development, with remarkable results in term of safe tumor resection and control but relatively poor QoL outcomes; and the third one (current period) is characterized by an increasing integration between surgery and adjuvant treatments, with relatively minor tumor control but significant improvement of QoL (comparable overall survival). The authors' experience reflects these changes. Two groups of children were compared: 52 cases (mean follow-up: 17.5 years) belong to the historical series (group 1, 1985-2003, aggressive surgical management) and 41 (mean follow-up: 8.5 years) to the current one (Group 2, 2004-2021, integrated management). No significant differences between the two groups were detected about recurrence rate, surgical mortality, and overall survival. However, Group 2 showed significant lower rates of postoperative panhypopituitarism, obesity, and visual deterioration. CONCLUSIONS Radical surgery allows for a good AC control with a low rate of recurrence but high risk of permanent morbidity. Despite the greater number of recurrences and surgeries, the more conservative policy, based on a combination of treatments, seems to provide the same tumor control with a better QoL. The advances in trans-nasal and trans-ventricular endoscopy, in proton therapy and in the management of the AC cyst are the main factors that allowed such an improvement.
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Affiliation(s)
- Luca Massimi
- Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy.
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Davide Palombi
- Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Alessandra Musarra
- Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Federico Bianchi
- Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Paolo Frassanito
- Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Gianpiero Tamburrini
- Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
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Prognostic Factors and Treatment Impact on Overall Survival in Adult Craniopharyngioma. World Neurosurg 2023; 173:e132-e139. [PMID: 36773809 DOI: 10.1016/j.wneu.2023.02.020] [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: 12/13/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVE To examine the demographics, tumor characteristics, treatments, and clinical outcomes of a large adult craniopharyngioma population. METHODS The 2004-2018 National Cancer Database was queried to investigate adult patients with craniopharyngioma. Univariable and multivariable Cox hazard ratio analysis was conducted to analyze the overall survival (OS) impact of demographic and clinical variables. RESULTS A total of 666 adult patients with craniopharyngioma were identified with a mean age of 51 years (standard deviation 16 years). On multivariable analysis, independent of demographic and clinical variables, increased age, uninsured status, Medicaid, Medicare, Charlson-Deyo Comorbidity Index of 2, and tumor size greater than 40 mm were independently associated with worse OS. There was no significant difference in survival between histologic subtypes. Gross total resection (GTR) (hazard ratio [HR] 0.602, 95% confidence interval [CI] 0.384-0.942, P = 0.026) and subtotal resection (STR) with adjuvant radiotherapy (HR 0.316, 95% CI 0.140-0.710, P = 0.005) were independently associated with improved OS. GTR with radiotherapy trended towards improved OS (HR 0.601, 95% CI 0.334-1.083, P =0.090), but STR alone and radiotherapy alone demonstrated no significant difference in survival compared with no treatment on multivariable analysis. Kaplan-Meier survival models demonstrated improved survival with GTR, GTR + radiation therapy, and STR + radiation therapy. Patients undergoing endoscopic resection had significantly lower GTR rates and greater rates of adjuvant radiotherapy compared with open approaches but no difference in OS. CONCLUSION Adult patients with craniopharyngioma who underwent GTR or STR with adjuvant radiotherapy had significantly improved overall survival. Endoscopic approaches had lower rates of GTR but no difference in OS.
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Salmon MK, Kshirsagar RS, Eide JG. Craniopharyngioma surgery for rhinologists. Curr Opin Otolaryngol Head Neck Surg 2023; 31:45-52. [PMID: 36730658 DOI: 10.1097/moo.0000000000000856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Craniopharyngiomas are rare tumors that that present with loss of pituitary function in most cases. They present in a bimodal age distribution and the most common treatment paradigms include gross total resection or subtotal resection followed by radiation. Endoscopic transnasal access to intradural tumors has become increasingly common due to improvements in equipment, increased familiarity with the surgical corridor and anatomy, and reconstruction techniques. As such, rhinologists play an increasingly important role in the management of craniopharyngiomas. RECENT FINDINGS Recent years have highlighted our growing experience with pediatric endonasal skull base surgery. Prior concerns including sphenoid pneumatization, midfacial growth restrictions, and intercarotid space limitations have been studied more extensively. It has been found that there are no increased complications with lack of sphenoid pneumatization, no changes to midfacial growth with endonasal techniques, and the inter-carotid distance is stable after around age 5. Advances in surgical and skull base reconstruction techniques and intraoperative monitoring have reduced the risks of complications from surgery. SUMMARY Rhinologists play an important role in craniopharyngioma surgery. The approach to and reconstruction after tumor removal are vital portions of the procedure that allow for resection and prevent postsurgical complications.
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Affiliation(s)
- Mandy K Salmon
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Rijul S Kshirsagar
- Department of Head and Neck Surgery, Kaiser Permanente Redwood City Medical Center, Redwood City, California
| | - Jacob G Eide
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan, USA
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Kamogawa M, Shuto T, Matsunaga S. Effects of two different radiotherapies for craniopharyngiomas using stereotactic radiosurgery/ stereotactic radiotherapy or fractionated stereotactic radiotherapy. Surg Neurol Int 2022; 13:563. [PMID: 36600746 PMCID: PMC9805634 DOI: 10.25259/sni_802_2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/21/2022] [Indexed: 12/05/2022] Open
Abstract
Background Numerous studies have reported about good tumor control with both stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (FSRT) for residual and recurrent craniopharyngiomas, but no studies have reported on the appropriate use of different types of radiation modalities. This study aimed to report the outcomes of SRS/stereotactic radiotherapy (SRT) or FSRT and compare tumor control in a single center. Methods From 2014 when TrueBeamTM STx with Novalis was introduced in our hospital to 2021, 21 patients underwent SRS/SRT or FSRT with gamma knife surgery (GKS) and Novalis. We have selected the radiation modalities considering mainly the distance of the optic nerve and chiasm. Imaging and clinical follow-up data were sent and reviewed. Results The mean age was 52 years and there were 11 men. Of the 21 total patients, three experienced SRS (GKS, 50% isodose 12-15 Gy), five underwent SRT (GKS or Novalis, 19.5-24 Gy 3 fractions), and 13 patients underwent FSRT (Novalis, 54 Gy 30 fractions). The median follow-up was 32.6 (range 17-44) months after SRS/SRT and 34.0 (range 4-61) months after FSRT. In the SRS/SRT group, the mean tumor volume decreased from 1.103 to 0.131 cm3 (P < 0.01), and in the FSRT group, from 3.015 to 1.012 cm3 (P < 0.01). No radiation-induced optic neuropathy and other acute toxicity occurred. Conclusion Craniopharyngioma can be expected to have very good tumor control by selecting SRS/SRT or FSRT depending on the distance between the optic nerve and the tumor.
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Affiliation(s)
- Misaki Kamogawa
- Corresponding author: Misaki Kamogawa, Department of Neurosurgery, Yokohama Rosai Hospital, Yokohama, Japan.
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Hong CS, Omay SB. The Role of Surgical Approaches in the Multi-Modal Management of Adult Craniopharyngiomas. Curr Oncol 2022; 29:1408-1421. [PMID: 35323318 PMCID: PMC8947636 DOI: 10.3390/curroncol29030118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 02/15/2022] [Accepted: 02/18/2022] [Indexed: 11/16/2022] Open
Abstract
Craniopharyngiomas are rare, benign primary brain tumors that arise from remnants of the craniopharyngeal duct epithelium within the sellar and suprasellar region. Despite their benign biology, they may cause significant morbidity, secondary to involvement of nearby eloquent neural structures, such as the pituitary gland, hypothalamus, and optic apparatus. Historically, aggressive surgical resection was the treatment goal to minimize risk of tumor recurrence via open transcranial midline, anterolateral, and lateral approaches, but could lead to clinical sequela of visual, endocrine, and hypothalamic dysfunction. However, recent advances in the endoscopic endonasal approach over the last decade have mostly supplanted transcranial surgery as the optimal surgical approach for these tumors. With viable options for adjuvant radiation therapy, targeted medical treatment, and alternative minimally invasive surgical approaches, the management paradigm for craniopharyngiomas has shifted from aggressive open resection to more minimally invasive but maximally safe resection, emphasizing quality of life issues, particularly in regards to visual, endocrine, and hypothalamic function. This review provides an update on current multi-modal approaches for craniopharyngiomas, highlighting the modern surgical treatment paradigm for this disease entity.
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Henderson F, Schwartz TH. Update on management of craniopharyngiomas. J Neurooncol 2021; 156:97-108. [PMID: 34807341 DOI: 10.1007/s11060-021-03906-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 11/17/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE/INTRODUCTION Craniopharyngiomas are locally-aggressive tumors arising along the hypothalamic-pituitary axis. Treatment is nuanced as a result of their proximity and adherence to vital neurovascular structures and responsiveness to surgery, radiation and, in some cases, chemotherapy. METHODS We reviewed the literature discussing the current state of knowledge regarding craniopharyngioma biology and therapy. RESULTS Recent advances in endoscopic endonasal surgery (EEA) have made surgery a safer and more effective option. While cure may be achieved with gross total resection (GTR), when felt to be too risky, a subtotal resection followed by radiation is often a more prudent strategy, particularly in children with hypothalamic invasion. Data on long-term outcome are mostly derived from older studies in which a craniotomy, rather than EEA, was performed. Long-term EEA outcome studies are lacking. Enhanced knowledge of the biological basis of papillary CPs has led to novel medical treatments for BRAFv600E variants that appear to be effective. CONCLUSION Endoscopic technology has improved surgical results for craniopharyngiomas and expanded the indications for the transsphenoidal approach. The goal of CP surgery goal is maximal safe resection to achieve cure, but subtotal resection and radiation may be equally effective. Early diagnosis of specific variants will facilitate enrollment in promising medical trials.
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Affiliation(s)
- Fraser Henderson
- Department of Neurological Surgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, 525 East 68th St, Box #99, New York, NY, 10065, USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, 525 East 68th St, Box #99, New York, NY, 10065, USA.
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Pikis S, Mantziaris G, Lavezzo K, Dabhi N, Sheehan J. Stereotactic radiosurgery for craniopharyngiomas. Acta Neurochir (Wien) 2021; 163:3201-3207. [PMID: 34518903 DOI: 10.1007/s00701-021-04990-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/25/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The management of craniopharyngiomas is challenging, usually requiring multidisciplinary care. We evaluated the long-term clinical and radiologic outcomes of Gamma Knife radiosurgery (GKRS) for craniopharyngiomas. METHODS This retrospective study involved patients managed with GKRS for a craniopharyngioma during the period of 1989 to 2019. Patient clinical and radiologic data, tumor characteristics, and procedural details were analyzed. RESULTS Thirty-eight consecutive patients (24 males; mean patient age at GKRS = 30.82 years [SD ± 20.45 years]) were treated with GKRS for craniopharyngioma. Overall survival rates at 5 and 10 years were 84.1% and 80.1%, respectively. Progression-free survival at 5 years was 48.1%, and, at 10 years, it was 29.8%. Risk factors for post-GKRS clinical deterioration were increasing number of isocenters used (p = 0.04 (HR1.32, CI 1-1.73)), increasing margin dose [p = 0.02 (HR1.52, CI 1.31-1.84)], and maximum dose > 35 Gy [p = 0.002 (HR1.35, CI 1.11-1.63)]. CONCLUSION Stereotactic radiosurgery (SRS) appears a safe and effective management option in selected craniopharyngioma patients. Increasing margin dose and maximum dose > 35 Gy are associated with an increased risk for post-SRS neurologic deficit. Further, well-designed studies are necessary to determine the optimal timing and SRS parameters and to identify which patients with craniopharyngioma will benefit the most from SRS.
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Affiliation(s)
- Stylianos Pikis
- Department of Neurological Surgery, University of Virginia Health System, Box 800212, Charlottesville, VA, 22908, USA
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Karen Lavezzo
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Nisha Dabhi
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Box 800212, Charlottesville, VA, 22908, USA.
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Albano L, Losa M, Barzaghi LR, Niranjan A, Siddiqui Z, Flickinger JC, Lunsford LD, Mortini P. Gamma Knife Radiosurgery for Pituitary Tumors: A Systematic Review and Meta-Analysis. Cancers (Basel) 2021; 13:cancers13194998. [PMID: 34638482 PMCID: PMC8508565 DOI: 10.3390/cancers13194998] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 09/27/2021] [Accepted: 10/03/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Pituitary tumors represent approximately 10–15% of all brain neoplasms. Gamma Knife, the most commonly used stereotactic radiosurgery technique worldwide, plays an important role in the treatment of several pituitary neoplasm. It is currently used in cases of residual or recurrent tumors after surgery or as primary treatment when surgery is contraindicated. Its goals are long-term tumor control, preservation of visual function, and, for secreting pituitary adenomas, endocrine remission. Several retrospective case-series (level of evidence IV) on Gamma Knife for pituitary tumors have been published describing encouraging outcomes; only one systematic review and meta-analysis on non-functioning pituitary adenoma has been recently reported. We provide a systematic review of the literature and meta-analysis from the last two decades on Gamma Knife radiosurgery for several pituitary tumors with the aim of describing and confirming safety and effectiveness of this technique. Abstract To describe and evaluate outcomes of Gamma Knife radiosurgery (GK) for the treatment of pituitary tumors over the past twenty years, a systematic review and meta-analysis according to PRISMA statement was performed. Articles counting more than 30 patients were included. A weighted random effects models was used to calculate pooled outcome estimates. From 459 abstract reviews, 52 retrospective studies were included. Among them, 18 reported on non-functioning pituitary adenomas (NFPA), 13 on growth hormone (GH)-secreting adenomas, six on adrenocorticotropic hormone (ACTH)-secreting adenomas, four on prolactin hormone (PRL)-secreting adenomas, and 11 on craniopharyngiomas. Overall tumor control and five-year progression free survival (PFS) estimate after one GK procedure for NFPA was 93% (95% CI 89–97%) and 95% (95% CI 91–99%), respectively. In case of secreting pituitary adenomas, overall remission (cure without need for medication) estimates were 45% (95% CI 35–54%) for GH-secreting adenomas, 64% (95% CI 0.52–0.75%) for ACTH-secreting adenomas and 34% (95% CI: 19–48%) for PRL-secreting adenomas. The pooled analysis for overall tumor control and five-year PFS estimate after GK for craniopharyngioma was 74% (95% CI 67–81%) and 70% (95% CI: 64–76%), respectively. This meta-analysis confirms and quantifies safety and effectiveness of GK for pituitary tumors.
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Affiliation(s)
- Luigi Albano
- Departments of Neurosurgery and Gamma Knife Radiosurgery, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, 20132 Milan, Italy; (L.R.B.); (P.M.)
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, 20132 Milan, Italy
- Correspondence: (L.A.); (M.L.); Tel.: +390226432396 (L.A. & M.L.)
| | - Marco Losa
- Departments of Neurosurgery and Gamma Knife Radiosurgery, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, 20132 Milan, Italy; (L.R.B.); (P.M.)
- Correspondence: (L.A.); (M.L.); Tel.: +390226432396 (L.A. & M.L.)
| | - Lina Raffaella Barzaghi
- Departments of Neurosurgery and Gamma Knife Radiosurgery, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, 20132 Milan, Italy; (L.R.B.); (P.M.)
| | - Ajay Niranjan
- Departments of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (A.N.); (L.D.L.)
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (Z.S.); (J.C.F.)
| | - Zaid Siddiqui
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (Z.S.); (J.C.F.)
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - John C. Flickinger
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (Z.S.); (J.C.F.)
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Lawrence Dade Lunsford
- Departments of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (A.N.); (L.D.L.)
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (Z.S.); (J.C.F.)
| | - Pietro Mortini
- Departments of Neurosurgery and Gamma Knife Radiosurgery, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, 20132 Milan, Italy; (L.R.B.); (P.M.)
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