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Nemir J, Maric LS, Trbojevic T, Zarkovic K, Jadrijević-Cvrlje F. Papillary tumor of the pineal region in pediatric patient – A case report. Surg Neurol Int 2022; 13:488. [DOI: 10.25259/sni_867_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 09/24/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Papillary tumor of the pineal region (PTPR) represents a rare and histologically distinct subgroup of tumors originating in the pineal region. Few pediatric cases have been reported so far in the literature; therefore, clinical data are scarce.
Case Description:
We describe a case of PTPR in a 9-year-old girl who presented with a 5-month history of excessive appetite and weight gain. The patient underwent neuroimaging procedures and total gross surgical resection with postoperative adjuvant local radiotherapy, which from our experience was the best treatment choice as an attempt to avoid local recurrence. During 78-month follow-up, the patient from our study manifested no disease recurrence.
Conclusion:
PTPR should be included in the differential diagnosis of pineal region masses.
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Affiliation(s)
- Jakob Nemir
- Department of Neurosurgery, University Hospital Center Zagreb, Zagreb, Croatia
| | - Lorna Stemberger Maric
- Department of Pediatric Infectious Diseases, University Hospital for Infectious Diseases, Dr. Fran Mihaljevic, Zagreb, Croatia
| | - Tena Trbojevic
- Department of Pediatrics, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Kamelija Zarkovic
- Department of Pathology, Clinical Medical Centre Zagreb, Zagreb, Croatia
| | - Filip Jadrijević-Cvrlje
- Department of Pediatrics, Division of Hematology and Oncology, Children’s Hospital Zagreb, Zagreb, Croatia
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2
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Pineal Gland Tumors: A Review. Cancers (Basel) 2021; 13:cancers13071547. [PMID: 33801639 PMCID: PMC8036741 DOI: 10.3390/cancers13071547] [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: 02/11/2021] [Revised: 03/24/2021] [Accepted: 03/26/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Pineal neoplasms are tumors with different and variable morphological, histological, and radiological characteristics and, consequently different diagnosis and management. Due to their rarity, pineal tumors may be misdiagnosed. Pineal tumors, are divided into germ cell tumors, pineal parenchymal tumors and tumors that derive from adjacent structures. In this review, we report the clinical relevance of the main pineal gland tumors, underlining the importance of studying the triggering causes of pineal region carcinogenesis, to realize appropriate diagnosis and, consequently, better clinical management. Abstract The pineal gland is a small, pinecone-shaped endocrine gland that participates in the biological rhythm regulation of vertebrates. The recognized major product of the pineal gland is melatonin—a multifunctional endogenous indoleamine. Accumulating evidence suggests that the pineal gland is important for preserving ideal health conditions in vertebrate. Tumors of the pineal region account for approximately 3–11% of pediatric brain neoplasms but fewer than 1% of brain neoplasms in adults. It is fundamental to expand advanced imaging techniques together with both clinical and laboratory knowledge, to help to differentiate among pineal neoplasms and thus facilitate accurate primary diagnoses and proper therapeutic interventions. In this review, we report the gross anatomy of the pineal gland and its functional significance and discuss the clinical relevance of pineal gland tumors, underlining the importance of identifying the leading causes of pineal region masses.
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Yamaki VN, Solla DJF, Ribeiro RR, da Silva SA, Teixeira MJ, Figueiredo EG. Papillary Tumor of the Pineal Region: Systematic Review and Analysis of Prognostic Factors. Neurosurgery 2020; 85:E420-E429. [PMID: 30989225 DOI: 10.1093/neuros/nyz062] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 02/08/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinical outcomes and biological behavior of papillary tumors of the pineal region (PTPR) are still under investigation. The best therapeutic strategy has not been defined. OBJECTIVE To perform a comprehensive patient-level analysis of all PTPR cases and identify their clinical features, treatment options, and prognostic factors. METHODS A search of the medical databases for case series and reports on PTPRs from January 2003 to June 2017 was performed. Data addressing PTPR's clinical presentation, imaging, treatment, and histological features were. Variables associated with the primary outcome of 36-mo survival were identified through Cox regression models. RESULTS The initial search yielded 1164 studies, of which 71 were included (60 case reports and 11 case series), containing 177 patients (mean age 33.0 ± 15.3 yr and 53.2% male). Intracranial hypertension and hydrocephalus prevailed as the clinical picture. Surgery was performed on 82.0% and gross total resection (GTR) was achieved on 71.4%. A total of 56.8% recurred after a median 29 mo (quartiles 10.5-45.5). The 36-mo survival rate was 83.5% (95% confidence interval [CI] 76.2-89.2%). Good functional outcomes (Glasgow Outcome Scale 4/5) were observed in 60.0%. The variables of interest were inconsistently reported and the multivariable analysis final sample was 133 patients. After adjustment for age, tumor size (each additional centimeter, hazard ratio [HR] 1.99, 95% CI 1.12-3.53, P = .019) and surgical treatment (HR 0.16, 95% CI 0.05-0.45, P = .001) were associated with 36-mo survival. CONCLUSION Tumor size and surgery are associated with improvement in 36-mo survival. We did not observe any significant benefits from GTR or adjuvant treatments.
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Affiliation(s)
- Vitor Nagai Yamaki
- Department of Neurosurgery, School of Medicine, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Renan Ribeiro Ribeiro
- Department of Pathology, School of Medicine, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Saul Almeida da Silva
- Department of Neurosurgery, School of Medicine, Universidade de Sao Paulo, Sao Paulo, Brazil
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Biswas R, Kumari K, Haresh KP, Gupta S, Halder A, Rath GK. Papillary Tumor of the Pineal Region in an Adolescent. Indian J Med Paediatr Oncol 2019. [DOI: 10.4103/ijmpo.ijmpo_251_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Rituparna Biswas
- Department of Radiation Oncology, Dr. B. R. A. IRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Kalpana Kumari
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - K P Haresh
- Department of Radiation Oncology, Dr. B. R. A. IRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Subhash Gupta
- Department of Radiation Oncology, Dr. B. R. A. IRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Anirban Halder
- Department of Radiation Oncology, VMMC and Safdarjung Hospital, New Delhi, India
| | - G K Rath
- Department of Radiation Oncology, Dr. B. R. A. IRCH, All India Institute of Medical Sciences, New Delhi, India
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Braun M, Tomasik B, Bieńkowski M, Wiśniewski K, Kupnicka DJ, Jaskólski D, Papierz W, Fijuth J, Kordek R. Recurrent Pineocytomalike Papillary Tumor of The Pineal Region: A Case Report and Literature Review. World Neurosurg 2018; 120:1-14. [PMID: 30165231 DOI: 10.1016/j.wneu.2018.08.125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 08/17/2018] [Accepted: 08/18/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Papillary tumors of the pineal region (PTPRs) are malignant World Health Organization grade II/III tumors; however, they may perfectly mimic benign tumors (e.g., pineocytomas [World Health Organization grade I]). CASE DESCRIPTION We present a case of a 28-year-old man with a 35-mm tumor of the pineal region. Considering the typical radiological and pathologic presentation, the tumor was first diagnosed as pineocytoma. However, despite first total resection, the tumor recurred after 7 years. The recurrent neoplasm was composed mainly of papillary structures with low-grade atypical cells positive for CKAE1/AE3 and CK18. This categorization led to the final diagnosis of PTPR. The patient underwent adjuvant radiotherapy, which vastly improved his neurologic condition and resulted in significant tumor regression. CONCLUSIONS This case exemplifies that PTPRs can perfectly mimic pineocytomas and simple staining for cytokeratins may warrant correct diagnosis and better treatment.
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Affiliation(s)
- Marcin Braun
- Department of Pathology, Chair of Oncology, Medical University of Lodz, Lodz, Poland; Postgraduate School of Molecular Medicine, Medical University of Warsaw, Warsaw, Poland.
| | - Bartłomiej Tomasik
- Postgraduate School of Molecular Medicine, Medical University of Warsaw, Warsaw, Poland; Department of Biostatistics and Translational Medicine, Medical University of Lodz, Lodz, Poland; Department of Radiation Oncology, Medical University of Lodz, Lodz, Poland
| | - Michał Bieńkowski
- Department of Pathomorphology, Medical University of Gdansk, Gdansk, Poland
| | - Karol Wiśniewski
- Department of Neurosurgery and Neurooncology, Barlicki University Hospital, Medical University of Lodz, Lodz, Poland
| | | | - Dariusz Jaskólski
- Department of Neurosurgery and Neurooncology, Barlicki University Hospital, Medical University of Lodz, Lodz, Poland
| | - Wielisław Papierz
- Department of Pathomorphology, Medical University of Lodz, Lodz, Poland
| | - Jacek Fijuth
- Department of Radiation Oncology, Medical University of Lodz, Lodz, Poland
| | - Radzislaw Kordek
- Department of Pathology, Chair of Oncology, Medical University of Lodz, Lodz, Poland
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6
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Aggarwal SK, Agarwal P, Sahu RN. Papillary tumor of pineal region with an unusual clinical presentation: Case report and review of the literature. Asian J Neurosurg 2016; 11:78-9. [PMID: 26889301 PMCID: PMC4732264 DOI: 10.4103/1793-5482.172592] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Papillary tumor of the pineal region (PTPR) is a newly described entity, which has been recently included in the World Health Organization classification of central nervous system tumors. We report an unusual presentation of PTPR in a 17-year-old girl, which was extending into the third ventricle, along with a detailed description of morphological and immunohistochemical characteristics of PTPRs. The diagnosis of PTPR was established on immunohistopathological examination.
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Affiliation(s)
| | - Preeti Agarwal
- Department of Pathology, SGPGIMS, Lucknow, Uttar Pradesh, India
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7
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Edson MA, Fuller GN, Allen PK, Levine NB, Ghia AJ, Mahajan A, Brown PD, DeMonte F, Li J. Outcomes After Surgery and Radiotherapy for Papillary Tumor of the Pineal Region. World Neurosurg 2015; 84:76-81. [PMID: 25749579 DOI: 10.1016/j.wneu.2015.02.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 02/23/2015] [Accepted: 02/24/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Papillary tumor of the pineal region (PTPR) is a rare neuroectodermal tumor that was first described in 2003 and formally codified by the World Health Organization in 2007. Limited reports suggest surgical resection is the mainstay of treatment; however, the role of multimodality therapy is not well defined. We evaluated our institutional experience in the treatment of PTPR. METHODS A retrospective review of 8 patients with pathologically confirmed PTPR diagnosed between 1999 and 2013 was performed. RESULTS The median age at diagnosis was 37 years (range, 25-56 years). After a median follow-up period of 60 months (range, 10-170 months), 7 of 8 patients were still living. All patients underwent maximum safe surgical resection; 5 received adjuvant radiation (63%). Overall and progression-free survival 5 years after diagnosis were 100% and 51%, respectively. Progression-free survival 5 years after completion of adjuvant radiotherapy was 64%. Crude recurrence rates for patients receiving adjuvant radiotherapy (n = 5) and patients not receiving adjuvant radiotherapy (n = 3) were 20% and 67%, respectively. Crude recurrence rate after gross total resection (GTR) and no adjuvant radiotherapy (n = 2) was 100% versus 0% when adjuvant radiotherapy was administered after GTR (n = 2). After subtotal resection, 3 patients received adjuvant radiotherapy; 1 of these patients had out-of-field recurrence at 46 months (crude recurrence rate 33%). In all cases, salvage with radiation at the time of recurrence was effective. CONCLUSIONS Our institutional experience confirms a recent multicenter retrospective series showing excellent survival but high risk of local recurrence for PTPR. Our findings suggest that radiotherapy provides durable local control, particularly when administered in the adjuvant setting after GTR.
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Affiliation(s)
- Mark A Edson
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gregory N Fuller
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pamela K Allen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicholas B Levine
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Amol J Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Anita Mahajan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Paul D Brown
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Franco DeMonte
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
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Papillary Tumor of the Pineal Region: MR Signal Intensity Correlated to Histopathology. Case Rep Neurol Med 2015; 2015:315095. [PMID: 25688307 PMCID: PMC4320939 DOI: 10.1155/2015/315095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 01/06/2015] [Indexed: 11/17/2022] Open
Abstract
Tumors of the pineal region are rare and can be challenging to differentiate by imaging. Papillary tumor of the pineal region (PTPR) was recently recognized as a neoplasm in the World Health Organization (WHO) 2007 classification, arising from specialized ependymocytes in the subcommissural organ, which is located in the pineal region. It is a rare histological type of pineal tumor with only a few cases reported. Here, we describe a case of histologically confirmed PTPR in a 17-year-old man who presented with a headache. A literature review was performed to clarify the clinical, radiological, and pathological features of PTPR. Pineal neoplasms do not have pathognomonic imaging findings; however, we discuss T1 hyperintensity, which is a key for imaging diagnosis according to recent reports. In particular, if the hyperintensity in T1 is not due to fat, calcification, melanin, or hemorrhage in a mass of the posterior commissure or pineal region, the diagnosis of a PTPR may be suggested, as observed in this case.
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Vandergriff C, Opatowsky M, O'Rourke B, Layton K. Papillary tumor of the pineal region. Proc (Bayl Univ Med Cent) 2012; 25:78-9. [PMID: 22275792 DOI: 10.1080/08998280.2012.11928791] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Presented is a patient with papillary tumor of the pineal region (PTPR), an uncommon and recently recognized neoplasm. As its name implies, PTPR does not arise from the pineal gland itself. The cell of origin is thought to be the specialized ependymocytes of the subcommissural organ. Primary tumors of the pineal region include pineal parenchymal neoplasms, germ cell neoplasms, and tumors arising from adjacent structures, including meningiomas, astrocytomas, and ependymomas. Like other masses in this location, PTPR often leads to obstructive hydrocephalus. Due to the relative paucity of reported cases of PTPR, its natural history is unknown.
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Affiliation(s)
- Clayton Vandergriff
- Departments of Radiology (Vandergriff), Neuroradiology (Opatowsky, O'Rourke), and Interventional Neuroradiology (Layton), Baylor University Medical Center at Dallas
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11
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Histopathologic and Ultrastructural Features and Claudin Expression in Papillary Tumors of the Pineal Region. Am J Surg Pathol 2012; 36:916-28. [DOI: 10.1097/pas.0b013e31824b7114] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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12
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El Majdoub F, Blau T, Hoevels M, Bührle C, Deckert M, Treuer H, Sturm V, Maarouf M. Papillary tumors of the pineal region: a novel therapeutic option-stereotactic 125iodine brachytherapy. J Neurooncol 2012; 109:99-104. [PMID: 22528796 DOI: 10.1007/s11060-012-0870-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Accepted: 03/31/2012] [Indexed: 11/30/2022]
Abstract
We evaluated the efficacy of interstitial brachytherapy (IBT) using (125)Iodine ((125)I) seeds for treatment of papillary tumors of the pineal region. Between September 2003 and September 2010, four patients (M/F = 2/2; median age, 57.3 years; range 29.2-69.1 years) with papillary tumors of the pineal region underwent IBT using (125)I seeds. Before brachytherapy two patients underwent endoscopic ventriculo-cisternotomy, because of occlusive hydrocephalus, and subsequent microsurgical resection was performed on one; three patients were primarily treated with IBT. Median tumor volume was 3.3 ml (range 1.6-4 ml), the tumor surface dose ranged between 50 and 65 Gy. For three patients the seeds were implanted permanently whereas one patient received temporary implants (28 days). The median follow-up time was 53.6 months (range 13-103.4 months). After brachytherapy, follow-up MR images revealed complete remission in one patient, partial remission in two, and stable disease in the remaining patient. Neurological status improved in all patients (reduced headache and nausea/vomiting for four patients; improvement of oculomotor dysfunction for two of three patients partially and for one of three patients completely). Neither treatment-related morbidity nor mortality was observed. Our results are indicative of good local control of papillary tumors of the pineal region after IBT, without treatment-related morbidity.
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Affiliation(s)
- Faycal El Majdoub
- Department of Stereotaxy and Functional Neurosurgery, University Hospital of Cologne, Kerpenerstrasse 62, 50937, Cologne, Germany.
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Four-year clinical and neuroradiological follow-up of a papillary tumor of the pineal region. Neurol Sci 2011; 33:931-5. [PMID: 22124853 DOI: 10.1007/s10072-011-0860-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Accepted: 11/11/2011] [Indexed: 10/15/2022]
Abstract
Papillary tumor of the pineal region (PTPR) is a rare variety of CNS neoplasms and, since its first definition in 2003, only 64 cases have been described. PTPR is a primary neoplasm morphologically characterized by papillary structure staining for cytokeratin, transthyretin, neurone-specific enolase and S-100 protein. We report on a case of about 4 years' clinical history and neuroradiological follow-up of PTPR, in a 47-year-old Indian patient, with the aim of increasing the knowledge of its natural history. We describe through CT and MRI scans the natural evolution of this neoplasm, enhancing changes and morphologic structures involved, together with the final surgical treatment and pathological details. A mean growth rate average was calculated for this kind of lesion. In conclusion, the inexorable progressive growing nature of this tumor leads us to advocate an aggressive attitude among neurosurgeons and radiotherapists, with a precocious surgical approach when the suspicion rises.
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Poulgrain K, Gurgo R, Winter C, Ong B, Lau Q. Papillary tumour of the pineal region. J Clin Neurosci 2011; 18:1007-17. [PMID: 21658955 DOI: 10.1016/j.jocn.2010.12.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Revised: 12/15/2010] [Accepted: 12/19/2010] [Indexed: 11/18/2022]
Abstract
Papillary tumour of the pineal region (PTRR) is one of the new tumour entities to be included in the latest World Health Organization classification of central nervous system tumours. We report two illustrative patients, a 25-year-old female who presented following a head injury sustained from a fall due to gait disturbances, and a 42-year-old man who presented with headaches. Histology of both cases showed distinct papillary growth patterns with lining of the papillae by multi-layered cuboidal to columnar cells, prominent perivascular rosette and focal true rosette formation. Immunohistochemistry exhibited strong cytokeratin immunoreactivity in addition to CD56, focal S100, glial fibrillary acidic protein and neuron specific enolase positivity which supported a diagnosis of PTPR in both patients. Postoperatively, both patients underwent courses of adjuvant radiation therapy. One patient reported local recurrence of the tumour 23 months after surgery. While PTPR may have been misdiagnosed in the past, clear and consistent characteristics are beginning to be elucidated in the published reports and literature, which have been reviewed. As a relatively new distinct clinicopathological entity, prognostic data are limited and guidelines for treatment protocols are still being investigated in view of its propensity for local recurrence.
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Affiliation(s)
- Katherine Poulgrain
- School of Medicine, University of Queensland, St. Lucia, Queensland, Australia
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Gutenberg A, Brandis A, Hong B, Gunawan B, Enders C, Schaefer IM, Burger R, Ostertag H, Gaab M, Krauss JK, Füzesi L. Common molecular cytogenetic pathway in papillary tumors of the pineal region (PTPR). Brain Pathol 2011; 21:672-7. [PMID: 21470326 DOI: 10.1111/j.1750-3639.2011.00493.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Primary papillary tumors of the central nervous system and particularly the pineal region are rare. Papillary tumor of the pineal region (PTPR) is a recently described neoplasm that has been formally recognized in the 2007 World Health Organization Classification of Tumors of the Nervous System. Because of their rarity, further pheno- and genotypical observations as well as therapeutic experience are necessary to differentiate PTPR from other primary or secondary papillary tumors of this region. We herein present three cases of PTPR characterized by local recurrence in two of them. Primary and recurrent tumors were analyzed by immunohistochemistry and comparative genomic hybridization (CGH). From our results clonal chromosomal aberrations can be postulated which seem to be a feasible tool to differentiate PTPRs from other primary or secondary papillary tumors of this region.
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Affiliation(s)
- Angelika Gutenberg
- Departments of Neurosurgery Pathology, Georg August University Göttingen, Germany.
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