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Goyal-Honavar A, Pateriya V, Chauhan S, Sadashiva N, Vazhayil V, Konar S, Beniwal M, Ar P, Arimappamagan A, B J, Natesan P. Factors Influencing Long-Term Outcomes of Single-Session Gamma Knife Radiosurgery in Large-Volume Meningiomas >10 cc. Stereotact Funct Neurosurg 2024; 102:109-119. [PMID: 38432224 DOI: 10.1159/000536409] [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: 11/08/2023] [Accepted: 01/15/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Meningiomas are the most common primary intracranial tumour. Gamma knife radiosurgery (GKRS) is a frequently employed non-invasive method of treatment, with good remission rates and low morbidity in literature. However, the role of GKRS in the management of "large" meningiomas is unclear, with reported outcomes that vary by centre. We aimed to assess the factors that influence long-term outcomes following GKRS in meningiomas >10 cc in volume. METHODS A retrospectively analysed all patients with meningiomas exceeding 10 cc in volume who underwent GKRS between January 2006 and December 2021 at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru. Demographic, clinical, radiological, and follow-up data were acquired, and factors associated with progression following GKRS were assessed. RESULTS The cohort comprised 76 patients 29 males (38.2%) and 47 females (61.8%) with a mean age of 46.3 ± 11.02 years. Thirty-nine patients had been previously operated (51.3%). Meningiomas were most frequently located in the parasagittal region (26 tumours, 34.2%) and sphenopetroclival region (23 tumours, 30.3%), with mean lesion volume of 12.55 ± 5.22 cc, ranging 10.3 cc-25 cc. The mean dose administered to the tumour margin was 12.5 Gy ± 1.2 Gy (range 6-15 Gy). The median duration of clinical follow-up was 48 months, over which period radiological progression occurred in 14 cases (20%), with unchanged tumour volume in 20 cases (28.6%) and reduction in size of the tumour in 36 cases (51.4%). Progression-free survival after GKRS was 72% at 5 years, was significantly poorer among meningiomas with tumour volume >14 cc (log-rank test p = 0.045), tumours presenting with limb motor deficits (log-rank test p = 0.012), and tumours that underwent prior Simpson grade 3 or 4 excision (log-rank test p = 0.032). CONCLUSIONS Meningiomas >10 cc in volume appear to display a high rate of progression and subsequent need for surgery following GKRS. Primary surgical resection, when not contraindicated, may be considered with GKRS serving an adjuvant role, especially in tumours exceeding 14 cc in volume, and presenting with limb motor deficits. Long-term clinical and radiological follow-up is essential following GKRS as the response of large meningiomas may be unpredictable.
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Affiliation(s)
- Abhijit Goyal-Honavar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
| | - Vibhor Pateriya
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
| | - Sonal Chauhan
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
| | - Nishanth Sadashiva
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
| | - Vikas Vazhayil
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
| | - Subhas Konar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
| | - Manish Beniwal
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
| | - Prabhuraj Ar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
| | - Arivazhagan Arimappamagan
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
| | - Jeeva B
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
| | - Ponnusamy Natesan
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
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Matani H, Abel S, Yu A, Karlovits SM, Wegner RE. Trends in the use of radiation for meningioma across the United States. Radiat Oncol J 2022; 40:29-36. [PMID: 35368198 PMCID: PMC8984135 DOI: 10.3857/roj.2021.00563] [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: 06/04/2021] [Accepted: 12/21/2021] [Indexed: 11/17/2022] Open
Abstract
Purpose Meningiomas are tumors originating from arachnoid cap cells on the surface of the brain or spinal cord. Treatment differs by grade but can consist of observation, surgery, radiation therapy or both. We utilized the National Cancer Database (NCDB) to compare trends in the use stereotactic radiosurgery (SRS) and external beam radiation therapy (EBRT) in the management of meningioma. Materials and Methods We queried the NCDB from 2004–2015 for meningioma patients (grade 1–3) treated with radiation therapy, either SRS or EBRT. Multivariable logistic regression was used to identify predictors of each treatment and to generate a propensity score. Propensity adjusted Kaplan-Meier survival curve analysis and multivariable Cox hazards ratios were used to identify predictors of survival. Results We identified 5,406 patients with meningioma meeting above criteria with 45%, 44%, and 11% having World Health Organization (WHO) grade 1, 2, and 3 disease, respectively. Median follow up was 43 months. Predictors for SRS were grade 1 disease, distance from treatment facility, and histology. The only predictor of EBRT was grade 3 disease. Treatment year, histology, race and female sex were associated with improved survival. Five- and 10-year survival rates were 89.2% versus 72.6% (p < 0.0001) and 80.3% versus 61.4% (p = 0.29) for SRS and EBRT respectively. After propensity matching 226 pairs were generated. For SRS, 5-year survival was not significantly improved at 88.2% compared with EBRT (p = 0.056). Conclusion In the present analysis, predictors of SRS utilization in management of meningioma include WHO grade 1 disease, distance from treatment facility and histology whereas conventional EBRT utilization was associated with grade 2 and 3 disease. Future studies need to be performed in order to optimize management of atypical and malignant meningioma.
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Affiliation(s)
- Hirsch Matani
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
- Correspondence: Hirsch Matani Division of Radiation Oncology, Allegheny Health Network Cancer Institute, 2580 Haymaker Rd, Pittsburgh, PA 15212, USA. Tel: +1-412-359-3400 E-mail:
| | - Stephen Abel
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Alexander Yu
- Division of Neurosurgery, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Stephen M. Karlovits
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Rodney E. Wegner
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
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Ganz JC. Meningiomas. PROGRESS IN BRAIN RESEARCH 2022; 268:163-190. [PMID: 35074079 DOI: 10.1016/bs.pbr.2021.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Meningiomas arise in various locations. Convexity tumors are relatively simple to remove. Skull base tumors and tumors adjacent to the major cerebral veins and venous sinuses can be very difficult to extirpate. Attempts at radical resection can lead to serious morbidity. The combination of bulk reduction using microsurgery followed by GKNS gives greatly improved survival and very low morbidity. With smaller tumors, GKNS may be used as the primary treatment. Increasing numbers of asymptomatic meningiomas are demonstrated either as an unexpected finding or as a residual or recurrent tumor after surgery. In all of these situations, GKNS gives a better result than observation or reoperation.
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Affiliation(s)
- Jeremy C Ganz
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
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Stereotactic radiosurgery training patterns across neurosurgical programs: a multi-national survey. J Neurooncol 2021; 151:325-330. [PMID: 33394260 DOI: 10.1007/s11060-020-03670-x] [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: 10/26/2020] [Accepted: 11/30/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The field of neurosurgery has witnessed a dramatic increase in the use of stereotactic radiosurgery (SRS) as a modality to treat various cranial and spinal pathologies. However, studies have consistently demonstrated disparities in SRS training. Accordingly, the present study represents a cross-sectional analysis of current SRS training and practice patterns. METHODS An online survey was utilized to collect data from participants. Two-sided t-tests were used in order to compare frequency tables for statistically significant differences between groups. Qualitative analyses were performed by modified thematic analyses, employing open and axial coding. RESULTS A total of 67 participants completed the online survey (16.4% response rate). The majority of participants were neurosurgery attendings (58.2%), followed by neurosurgery residents (25.4%). The majority of participants reported that resident exposure to SRS was gained primarily through non-SRS focused rotations (52.2%). The survey found that exposure to tumor cases was most frequent, followed by functional, vascular, and spine indications. The majority of participants (49.3%) indicate that residents are not competent or exhibit a low level of competency in SRS at the completion of neurosurgical residency. Qualitative analyses demonstrated that respondents believe SRS is a critical modality in current cranial neurosurgical care and that increased training is needed. CONCLUSIONS This study provides a multi-national analysis of SRS residency training and practice patterns, and aims to stimulate improvement in SRS in training worldwide. Enhanced resident training in SRS must include wider exposure to vascular, neoplastic, functional and pediatric indications for SRS.
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Ding K, Romiyo P, Ng E, Udawatta M, Dejam D, Phillips HW, Sun MZ, Yang I. A systematic analysis of stereotactic radiosurgery surveys for residents in neurosurgery training programs. J Neurol Sci 2020; 417:116867. [PMID: 32423574 DOI: 10.1016/j.jns.2020.116867] [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: 03/18/2020] [Accepted: 04/26/2020] [Indexed: 10/24/2022]
Abstract
OBJECT The use of stereotactic radiosurgery (SRS) has increased. SRS training has not risen congruently. Neurosurgeons have conducted surveys and advocated implementation of widespread, standardized radiosurgery training. Here we analyze the SRS surveys conducted throughout the past decade. METHODS This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic literature review. A broad search of the literature was conducted in October 2018 through the PubMed, Scopus, Embase, and Web of Science databases. This study included surveys evaluating SRS training in neurosurgery and excluded those regarding other specialties. RESULTS An overview of surveys showed that neurosurgery residents possess gaps in SRS knowledge and procedural competency that have persisted through the past decade. There is an overwhelming sentiment that current radiosurgery training is not adequate to prepare residents for future practice. Our recommendation is for residency programs to integrate formal SRS training electives, with a movement towards creating more options for extended SRS fellowships post-residency. CONCLUSIONS We present data from SRS competency and current training surveys. Although resident SRS training still lags behind other subspecialties, we see indications for growth. To keep up with the role of SRS in neurosurgery, residencies need more formalized SRS rotations.
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Affiliation(s)
- Kevin Ding
- Departments of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Prasanth Romiyo
- Departments of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Edwin Ng
- Departments of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Methma Udawatta
- Departments of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Dillon Dejam
- Departments of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - H Westley Phillips
- Departments of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Matthew Z Sun
- Departments of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Isaac Yang
- Departments of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA; Office of the Patient Experience, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA; Radiation Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA; Head and Neck Surgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA; UCLA Jonsson Comprehensive Cancer Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA; Department of Neurosurgery at Harbor-UCLA Medical Center, Torrance, CA, USA; Los Angeles Biomedical Research Institute (LA BioMed) at Harbor-UCLA Medical Center, Torrance, CA, USA.
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Park CK, Jung NY, Chang WS, Jung HH, Chang JW. Gamma Knife Radiosurgery for Postoperative Remnant Meningioma: Analysis of Recurrence Factors According to World Health Organization Grade. World Neurosurg 2019; 132:e399-e402. [DOI: 10.1016/j.wneu.2019.08.136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/19/2019] [Accepted: 08/22/2019] [Indexed: 10/26/2022]
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Image-Guided Robotic Radiosurgery for Treatment of Recurrent Grade II and III Meningiomas. A Single-Center Study. World Neurosurg 2019; 131:e96-e107. [PMID: 31306844 DOI: 10.1016/j.wneu.2019.07.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 07/05/2019] [Accepted: 07/06/2019] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) has been increasingly applied for malignant meningiomas as an alternative to conventionally fractioned radiation therapy. We performed a retrospective analysis of an institutional patient cohort with malignant meningiomas treated by image-guided SRS. METHODS All patients with atypical or anaplastic meningiomas who were treated by SRS using CyberKnife (CK) were identified. Local failure and regional and/or distant recurrences were evaluated together with toxicity and overall survival. RESULTS We identified 127 treated lesions (105 atypical and 22 anaplastic) in 35 patients. The mean time interval between the last surgery and subsequent CK-SRS was 30.8 ± 24.5 months. Most lesions (83.5%) were treated using single-fraction CK-SRS. The median planning target volume of all 127 lesions was 1.71 cm3 (range, 0.06-22.5 cm3). The median follow-up period was 23 months (range, 2.1-60.3 months). The estimated local control rates were 97%, 77%, and 67% at 12, 36, and 60 months, respectively, in atypical meningiomas and 66% each at 12 and 24 months in anaplastic meningiomas. The regional progression-free survival was 93%, 73%, and 59% at 12, 36, and 60 months, respectively, in atypical lesions and 93% and 46% at 12 and 24 months in anaplastic lesions. The estimated distant tumor progression-free interval in atypical lesions was 80%, 44%, and 44% at 12, 36, and 60 months, respectively, and 49% and 24% at 12 and 24 months, respectively, in anaplastic lesions. Age was identified as a risk factor for local failure. CONCLUSIONS Although the real boundaries of efficacy of SRS have to be further evaluated in a prospective trial, it seems that aggressive treatment by high-dose single or multisession SRS of recurring malignant meningiomas provides satisfactory local control rates.
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Albert A, Lee A, Vijayakumar S, Kanakamedala M, Allbright R, Schreiber D. Adjuvant treatment of meningioma with stereotactic radiation surgery and hypofractionated stereotactic radiation surgery: Patterns of care and survival in a large, hospital database. Adv Radiat Oncol 2018; 3:280-287. [PMID: 30202797 PMCID: PMC6128035 DOI: 10.1016/j.adro.2018.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 04/13/2018] [Accepted: 04/16/2018] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVES Stereotactic radiation surgery (SRS) and hypofractionated stereotactic radiation surgery (HF-SRS) have become an alternative to external beam radiation therapy (EBRT) in the adjuvant treatment of meningiomas. The purpose of this study was to identify national treatment patterns and survival outcomes for meningiomas on the basis of radiation treatment modality in the adjuvant setting. METHODS AND MATERIALS The National Cancer Database was queried for patients with meningioma diagnosed between 2010 and 2012. World Health Organization grade I disease with subtotal resection and all cases of grade II disease regardless of the extent of the resection were included. Logistic regression was used to determine factors that were associated with receipt of SRS/HF-SRS compared with EBRT. Cox regression was used to determine covariables associated with differences in overall survival (OS). RESULTS A total of 802 patients met the inclusion criteria of which 173 patients received SRS/HF-SRS (22%) and 629 patients (78%) received EBRT. The 3-year OS rate was 97.3% for the SRS/HF-SRS group and 93.4% for the EBRT group (P = .018). On subgroup analysis by grade, for grade I the 3-year OS rate was 98.3% for the SRS/HF-SRS group versus 96.7% for the EBRT group (P = .117). For grade II disease, the 3-year OS rate was 94.4% in the SRS/HF-SRS group versus 92.4% in the EBRT group (P = .199). On multivariable analysis, World Health Organization grade II histology (odds ratio [OR]: 0.34; 95% confidence interval [CI], 0.21-0.56; P < .001) and gross total resection (OR: 0.29; 95% CI, 0.15-0.57; P < .001) were associated with a decreased likelihood of receiving SRS/HF-SRS but private insurance (OR: 8.89; 95% CI, 1.15-68.47; P = .036) and Medicare (OR: 10.03; 95% CI, 1.28-78.69; P = .028) were associated with an increased likelihood of receiving SRS/HF-SRS. Year of diagnosis was not associated with receipt of SRS/HF-SRS. The multivariable Cox regression demonstrated a trend toward improved OS for treatment with SRS/HF-SRS (hazard ratio: 0.24; 95% CI, 0.06-1.03; P = .055). CONCLUSIONS SRS and HF-SRS are associated with similar survival as EBRT; however, SRS/HF-SRS is used infrequently and usage has not increased over time.
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Affiliation(s)
- Ashley Albert
- Department of Radiation Oncology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Anna Lee
- Department of Radiation Oncology, SUNY Downstate Medical Center, Brooklyn, New York
- Department of Veterans Affairs, New York Harbor Healthcare System, Brooklyn, New York
| | - Srinivasan Vijayakumar
- Department of Radiation Oncology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Madhava Kanakamedala
- Department of Radiation Oncology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Robert Allbright
- Department of Radiation Oncology, University of Mississippi Medical Center, Jackson, Mississippi
| | - David Schreiber
- Department of Radiation Oncology, SUNY Downstate Medical Center, Brooklyn, New York
- Summit Medical Group at MD Anderson Cancer Center, Berkeley Heights, New Jersey
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Samuel N, Philteos J, Alotaibi NM, Ahuja C, Mansouri A, Kulkarni AV. Canadian Neurosurgery Educators' Views on Stereotactic Radiosurgery in Residency Training. World Neurosurg 2018; 112:e208-e215. [PMID: 29331746 DOI: 10.1016/j.wneu.2018.01.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 01/02/2018] [Accepted: 01/04/2018] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Despite the increasing prominence of stereotactic radiosurgery (SRS) in treating intracranial and spinal pathologies, there is currently a dearth of exposure to this modality in the neurosurgical residency. To address this gap, the aim of this study is to assess neurosurgery educators' views regarding the current state of SRS exposure, and to identify potential approaches to improve residency education in this domain. METHODS Qualitative thematic analysis and constructivist grounded theory methodology were employed. Semistructured telephone-based interviews were conducted with current or past residency program directors, as well as current departmental chairs across neurosurgical departments in Canada. Interviews were transcribed and subjected to thematic analysis using open and axial coding. RESULTS Of the 34 eligible participants, the overall response rate was 41.1% (14/34), with a 35.3% participation rate (12/34). Participants represented 9 of the 12 Canadian institutions surveyed. The majority of participants were current program directors (n = 8), followed by past program directors (n = 2), and departmental chairs (n = 2). Most respondents 75% (9/12) view an increasing role for SRS in neurosurgery. Unanimously, respondents endorse greater exposure to SRS during residency through formal residency rotations and engagement in interdisciplinary tumor boards to facilitate involvement in clinical decision-making. CONCLUSIONS This is the first study to systematically collate neurosurgery educators' views on SRS in residency in Canada and demonstrates recognition of the discordance between SRS in practice and residency training. Neurosurgery educators broadly endorse increased exposure to this modality. Future work is needed to delineate the requirements necessary to achieve adequate competency in SRS.
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Affiliation(s)
- Nardin Samuel
- MD/PhD Program, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Justine Philteos
- Undergraduate Medical Program, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Naif M Alotaibi
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Ahuja
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alireza Mansouri
- Division of Neurology and Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Abhaya V Kulkarni
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Masalha W, Heiland DH, Franco P, Delev D, Haaker JG, Schnell O, Scheiwe C, Grauvogel J. Atypical meningioma: progression-free survival in 161 cases treated at our institution with surgery versus surgery and radiotherapy. J Neurooncol 2017; 136:147-154. [DOI: 10.1007/s11060-017-2634-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 10/06/2017] [Indexed: 11/28/2022]
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