1
|
Schupper AJ, Patel S, Steinberger JM, Germano IM. The role of minimally invasive surgery within a multidisciplinary approach for patients with metastatic spine disease over a decade: A systematic review. Neuro Oncol 2024; 26:417-428. [PMID: 37988270 PMCID: PMC10912012 DOI: 10.1093/neuonc/noad206] [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: 07/18/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Metastatic spine disease (MSD) occurs commonly in cancer patients causing pain, spinal instability, devastating neurological compromise, and decreased quality of life. Oncological patients are often medically complex and frail, precluding them form invasive procedures. To address this issue, minimally invasive spinal surgery (MISS) techniques are desirable. The aim of this study is to review published peer-reviewed literature and ongoing clinical trials to provide current state of the art. METHODS A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, assessing MISS in MSD patients for the period 2013-2023. Innovations under development were assessed by querying and reviewing data from currently enrolling U.S. registered clinical trials. RESULTS From 3,696 articles, 50 studies on 3,196 patients focused on spinal oncology MISS. The most commonly reported techniques were vertebral augmentation (VA), percutaneous spinal instrumentation, and radiofrequency ablation (RFA). Surgical instrumentation/stabilization techniques were reported in 10/50 articles for a total of 410 patients. The majority of studies focused on pain as a primary outcome measure, with 28/50 studies reporting a significant improvement in pain following intervention. In the United States, 13 therapeutic trials are currently recruiting MSD patients. Their main focus includes radiosurgery, VA and/or RFA, and laser interstitial thermal therapy. CONCLUSIONS Due to their medical complexity and increased fragility, MSD patients may benefit from minimally invasive approaches. These strategies are effective at mitigating pain and preventing neurological deterioration, while providing other advantages including ease to start/resume systemic/radiotherapy treatment(s).
Collapse
Affiliation(s)
- Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shrey Patel
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jeremy M Steinberger
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Isabelle M Germano
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| |
Collapse
|
2
|
Li J, Wang X, Li Y, Cao Q, Bu Y, Cao H, Wang X. Pathological Clinical Analysis and Imaging Manifestations for Spinal Bone Tumors Based on Cement Injection. Appl Bionics Biomech 2022; 2022:2105332. [PMID: 35510043 PMCID: PMC9061064 DOI: 10.1155/2022/2105332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/08/2022] [Accepted: 04/12/2022] [Indexed: 11/17/2022] Open
Abstract
In order to explore the imaging manifestations and pathological characteristics of spine tumors, this article explores the clinical diagnosis and treatment methods through multi-sample case analysis with the support of imaging, and proposes a targeted treatment method that uses a special PVP needle with a beveled puncture surface for puncture. Moreover, this article uses the supporting PVP syringe for bone cement injection, develops a health status questionnaire, and adopts a scoring method for comprehensive assessment. The purpose of this article is to show that through the combination of preoperative radiotherapy and postoperative bracing, bone cement injection to treat vertebral tumors can immediately obtain satisfactory pain relief. Finally, through case analysis and image performance, we can see that the method proposed in this article has a certain effect.
Collapse
Affiliation(s)
- Jie Li
- Department of Spine, Second Hospital of Tangshan, Tangshan, Hebei, China 063000
| | - Xu Wang
- Department of Spine, Second Hospital of Tangshan, Tangshan, Hebei, China 063000
| | - Yongmin Li
- Department of Spine, Second Hospital of Tangshan, Tangshan, Hebei, China 063000
| | - Qinhui Cao
- Department of Spine, Second Hospital of Tangshan, Tangshan, Hebei, China 063000
| | - Yi Bu
- Department of Spine, Second Hospital of Tangshan, Tangshan, Hebei, China 063000
| | - Hengcong Cao
- Department of Spine, Second Hospital of Tangshan, Tangshan, Hebei, China 063000
| | - Xiaoqiang Wang
- Department of Neurosurgery, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China 200000
| |
Collapse
|
3
|
Sullivan PZ, Niu T, Abinader JF, Syed S, Sampath P, Telfeian A, Fridley J, Klinge P, Camara J, Oyelese A, Gokaslan ZL. Evolution of surgical treatment of metastatic spine tumors. J Neurooncol 2022; 157:277-283. [PMID: 35306618 DOI: 10.1007/s11060-022-03982-0] [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: 12/31/2021] [Accepted: 03/04/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE The treatment of cancer has transformed over the past 40 years, with medical oncologists, radiation oncologists and surgeons working together to prolong survival times and minimize treatment related morbidity. With each advancement, the risk-benefit scale has been calibrated to provide an accurate assessment of surgical hazard. The goal of this review is to look back at how the role of surgery has evolved with each new medical advance, and to explore the role of surgeons in the future of cancer care. METHODS A literature review was conducted, highlighting the key papers guiding surgical management of spinal metastatic lesions. CONCLUSION The roles of surgery, medical therapy, and radiation have evolved over the past 40 years, with new advances requiring complex multidisciplinary care.
Collapse
Affiliation(s)
- Patricia Zadnik Sullivan
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA.
| | - Tianyi Niu
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA
| | - Jose Fernandez Abinader
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA
| | - Sohail Syed
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA
| | - Prakash Sampath
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA
| | - Albert Telfeian
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA
| | - Jared Fridley
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA
| | - Petra Klinge
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA
| | - Joaquin Camara
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA
| | - Adetokunbo Oyelese
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA
| |
Collapse
|
4
|
Sciubba DM, Pennington Z, Colman MW, Goodwin CR, Laufer I, Patt JC, Redmond KJ, Saylor P, Shin JH, Schwab JH, Schoenfeld AJ. Spinal metastases 2021: a review of the current state of the art and future directions. Spine J 2021; 21:1414-1429. [PMID: 33887454 DOI: 10.1016/j.spinee.2021.04.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/07/2021] [Accepted: 04/12/2021] [Indexed: 02/03/2023]
Abstract
Spinal metastases are an increasing societal health burden secondary to improvements in systemic therapy. Estimates indicate that 100,000 or more people have symptomatic spine metastases requiring management. While open surgery and external beam radiotherapy have been the pillars of treatment, there is growing interest in more minimally invasive technologies (eg separation surgery) and non-operative interventions (eg percutaneous cementoplasty, stereotactic radiosurgery). The great expansion of these alternatives to open surgery and the prevalence of adjuvant therapeutic options means that treatment decision making is now complex and reliant upon multidisciplinary collaboration. To help facilitate construction of care plans that meet patient goals and expectations, clinical decision aids and prognostic scores have been developed. These have been shown to have superior predictive value relative to more classic prediction models and may become an increasingly important aspect of the clinical practice of spinal oncology. Here we overview current therapeutic advances in the management of spine metastases and highlight emerging areas for research. Given the rapid advancements in surgical technologies and adjuvants, the field is likely to undergo further transformative changes in the coming decade.
Collapse
Affiliation(s)
- Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY 11030, USA.
| | - Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| | - Matthew W Colman
- Department of Orthopaedic Surgery, Rush University School of Medicine, Chicago, IL USA
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Ilya Laufer
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Joshua C Patt
- Department of Orthopaedic Surgery, Atrium Musculoskeletal Institute, Levine Cancer Institute, Carolinas Medical Center - Atrium Health, Charlotte, NC 28204, USA
| | - Kristin J Redmond
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Philip Saylor
- Department of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard medical School, Boston, MD 02115, USA
| | | |
Collapse
|
5
|
Park BJ, Seaman SC, Noeller JL, Smith MC, Hasan DM, Yasin H, Hitchon PW. Metastatic Renal Cell Carcinoma to the Spine: Outcomes and Morbidity: Single-Center Experience. World Neurosurg 2021; 154:e398-e405. [PMID: 34280537 DOI: 10.1016/j.wneu.2021.07.041] [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: 06/08/2021] [Accepted: 07/09/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Renal cell carcinoma with metastases to the spine (RCCMS) requires a multidisciplinary approach. We reviewed our institutional experience with RCCMS patients undergoing spinal surgery in order to identify factors that may affect clinical outcomes, survival, and complications. METHODS Patients with RCCMS who underwent operative intervention from 2007 to 2020 were reviewed retrospectively. RESULTS Forty-four patients with the diagnosis of RCCMS were identified. Pain was the most common symptom, and neurologic dysfunction was present in one third of cases. Thoracic spine was the most common location (N = 27), followed by the lumbar (N = 12) and cervical (N = 5) regions. The overall survival from diagnosis of renal cell carcinoma was 25 (2 - 194) months and 8 (0.3 - 92) months after spinal surgery. Gender, age, spinal level, postoperative radiation, and nephrectomy had no bearing on survival. Survival for patients with a Tokuhashi score of 0 - 8, 9 - 11, and 12 - 15 was 6.5 (1.5 - 23.5), 8.9 (0.3 - 91.6), and 23.4 (2.5 - 66) months, respectively (P = 0.03). The postoperative American Spinal Cord Injury Association score of E (hazard ratio 0.109 [95% confidence interval 0.022 - 0.534, P = 0.006) also bore a significant influence on survival. There was a total of 10 complications in 7 of 44 (16%) patients. CONCLUSIONS Median postoperative survival of patients with RCCMS was 8 (0.3 - 92) months. Higher Tokuhashi score and ASIA E score at follow-up correlated with improved overall survival. Complication rate was 16%. Spinal surgery in RCCMS is indicated for the preservation of function and prevention of neurologic deterioration. Multimodality therapy with improved chemotherapy and stereotactic spinal radiation is expected to impact quality and length of survival positively.
Collapse
Affiliation(s)
- Brian J Park
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Scott C Seaman
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Jennifer L Noeller
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mark C Smith
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - David M Hasan
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Hesham Yasin
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Patrick W Hitchon
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
| |
Collapse
|
6
|
Chakravarthy VB, Applewhite MK, Krishnaney AA. Ethics of Decision-Making in Metastatic Spinal Disease. World Neurosurg 2021; 148:1-3. [PMID: 33418119 DOI: 10.1016/j.wneu.2020.12.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 12/25/2020] [Indexed: 10/22/2022]
Affiliation(s)
| | - Megan K Applewhite
- Alden March Bioethics Institute and Department of Surgery, Albany Medical College, Albany, New York, USA; Department of Surgery, Albany Medical Center, Albany, New York, USA
| | | |
Collapse
|
7
|
Bastos DCA, Vega RA, Traylor JI, Ghia AJ, Li J, Oro M, Bishop AJ, Yeboa DN, Amini B, Kumar VA, Rao G, Rhines LD, Tatsui CE. Spinal laser interstitial thermal therapy: single-center experience and outcomes in the first 120 cases. J Neurosurg Spine 2020:1-10. [PMID: 33307530 DOI: 10.3171/2020.7.spine20661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to present the results of a consecutive series of 120 cases treated with spinal laser interstitial thermal therapy (sLITT) to manage epidural spinal cord compression (ESCC) from metastatic tumors. METHODS The electronic records of patients treated from 2013 to 2019 were analyzed retrospectively. Data collected included demographic, pathology, clinical, operative, and imaging findings; degree of epidural compression before and after sLITT; length of hospital stay; complications; and duration before subsequent oncological treatment. Independent-sample t-tests were used to compare means between pre- and post-sLITT treatments. Survival was estimated by the Kaplan-Meier method. Multivariate logistic regression was used to analyze predictive factors for local recurrence and neurological complications. RESULTS There were 110 patients who underwent 120 sLITT procedures. Spinal levels treated included 5 cervical, 8 lumbar, and 107 thoracic. The pre-sLITT Frankel grades were E (91.7%), D (6.7%), and C (1.7%). The preoperative ESCC grade was 1c or higher in 92% of cases. Metastases were most common from renal cell carcinoma (39%), followed by non-small cell lung carcinoma (10.8%) and other tumors (35%). The most common location of ESCC was in the vertebral body (88.3%), followed by paraspinal/foraminal (7.5%) and posterior elements (4.2%). Adjuvant radiotherapy (spinal stereotactic radiosurgery or conventional external beam radiation therapy) was performed in 87 cases (72.5%), whereas 33 procedures (27.5%) were performed as salvage after radiotherapy options were exhausted. sLITT was performed without need for spinal stabilization in 87 cases (72.5%). Post-sLITT Frankel grades were E (85%), D (10%), C (4.2%), and B (0.8%); treatment was associated with a median decrease of 2 ESCC grades. The local control rate at 1 year was 81.7%. Local control failure occurred in 25 cases (20.8%). The median progression-free survival was not reached, and overall survival was 14 months. Tumor location in the paraspinal region and salvage treatment were independent predictors of local recurrence, with hazard ratios of 6.3 and 3.3, respectively (p = 0.01). Complications were observed in 22 cases (18.3%). sLITT procedures performed in the lumbar and cervical spine had hazard ratios for neurological complications of 15.4 and 17.1 (p < 0.01), respectively, relative to the thoracic spine. CONCLUSIONS sLITT is safe and provides effective local control for high-grade ESCC from vertebral metastases in the thoracic spine, particularly when combined with adjuvant radiotherapy. The authors propose considering sLITT as an alternative to open surgery in selected patients with spinal metastases.
Collapse
Affiliation(s)
| | - Rafael A Vega
- 4Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | | - Behrang Amini
- 3Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas; and
| | - Vinodh A Kumar
- 3Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas; and
| | | | | | | |
Collapse
|
8
|
Di Perna G, Cofano F, Mantovani C, Badellino S, Marengo N, Ajello M, Comite LM, Palmieri G, Tartara F, Zenga F, Ricardi U, Garbossa D. Separation surgery for metastatic epidural spinal cord compression: A qualitative review. J Bone Oncol 2020; 25:100320. [PMID: 33088700 PMCID: PMC7559860 DOI: 10.1016/j.jbo.2020.100320] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 02/07/2023] Open
Abstract
Separation surgery is a new concept for metastatic spinal cord compression treatment. Stereotactic radiosurgery increased local control, overcoming radio-resistance’s idea. The surgery goal shifted towards creating targets for radiations avoiding cord damages. Minimal invasive strategies could allow quick return to systemic therapies.
Introduction The new concept of separation surgery has changed the surgical paradigms for the treatment of metastatic epidural spinal cord compression (MESCC), shifting from aggressive cytoreductive surgery towards less invasive surgery with the aim to achieve circumferential separation of the spinal cord and create a safe target for high dose Stereotactic Body Radiation Therapy (SBRT), which turned out to be the real game-changer for disease’s local control. Discussion In this review a qualitative analysis of the English literature has been performed according to the rating of evidence, with the aim to underline the increasingly role of the concept of separation surgery in MESCC treatment. A review of the main steps in the evolution of both radiotherapy and surgery fields have been described, highlighting the important results deriving from their integration. Conclusion Compared with more aggressive surgical approaches, the concept of separation surgery together with the advancements of radiotherapy and the use of SBRT for the treatment of MESCC showed promising results in order to achieve a valuable local control while reducing surgical related morbidities and complications.
Collapse
Key Words
- CTV, Clinical tumor volume
- Carbon fiber/PEEK cement
- ECOG PS, Eastern Cooperative Oncology Group Performance Status Scale
- ESCC, Epidural Spinal Cord Compression
- Epidural spinal cord compression
- GTV, Gross tumor volume
- KPS, Karnofsky Performance Status
- LC, Local Control
- LITT, Laser Interstitial Thermal Therapy
- MAS, Minimal Access Spine
- MESCC, Metastatic Epidural Spinal Cord Compression
- MIS techniques
- MIS, Minimally Invasive Surgical
- NSCLC, Non-Small Cell Lung Cancer
- NSE, Neurologic Stability Epidural compression
- PEEK, Polyetheretherketone
- PLL, Posterior Longitudinal Ligament
- PMMA, Poly-Methyl-Methacrylate
- PRV, Spinal cord planning risk volume
- PTV, Planning target volume
- SBRT, Stereotactic Body Radiation Therapy
- SINS, Spinal Instability Neoplastic Score
- SRS, Stereotactic Radiosurgery
- SS, Separation Surgery
- Separation surgery
- Spinal metastases
- Stereotactic body radiation therapy
- cEBRT, conventional External Beam Radiation Therapy
Collapse
Affiliation(s)
- Giuseppe Di Perna
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Fabio Cofano
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
- Spine Surgery, Humanitas Gradenigo, Turin, Italy
- Corresponding author at: Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Via Cherasco 15, 10126 Turin, Italy.
| | - Cristina Mantovani
- Radiation Oncology Unit, Department of Oncology, University of Turin and Città della Salute e della Scienza Hospital, Via Genova 3, 10126 Turin, Italy
| | - Serena Badellino
- Radiation Oncology Unit, Department of Oncology, University of Turin and Città della Salute e della Scienza Hospital, Via Genova 3, 10126 Turin, Italy
| | - Nicola Marengo
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Marco Ajello
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Ludovico Maria Comite
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Giuseppe Palmieri
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Fulvio Tartara
- Neurosurgery Unit, Istituto Clinico Città Studi, Milan, Italy
| | - Francesco Zenga
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Umberto Ricardi
- Radiation Oncology Unit, Department of Oncology, University of Turin and Città della Salute e della Scienza Hospital, Via Genova 3, 10126 Turin, Italy
| | - Diego Garbossa
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| |
Collapse
|