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Ogawa T, Nishimura K, Takahashi Y, Iwami K, Yasumura T, Yo K, Okamoto H, Inukai D, Sano R, Watanabe T, Kakizaki H. Incisionless facial resection for Kadish stage C olfactory neuroblastoma: Transcaruncular approach with combined endonasal and skull base surgery. Clin Case Rep 2020; 8:1494-1501. [PMID: 32884782 PMCID: PMC7455426 DOI: 10.1002/ccr3.2906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/02/2020] [Accepted: 04/10/2020] [Indexed: 11/25/2022] Open
Abstract
This case report describes resection without facial incision for aggressive Kadish stage C olfactory neuroblastoma (ONB). We performed resection via transcaruncular approach with combined endonasal and skull base surgery. This multidisciplinary team surgical approach is expected to lead to a new strategy for this type of tumor in the future.
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Affiliation(s)
- Tetsuya Ogawa
- Department of OtorhinolaryngologyAichi Medical UniversityAichiJapan
| | | | - Yasuhiro Takahashi
- Department of OculoplasticOrbital & Lacrimal SurgeryAichi Medical UniversityAichiJapan
| | - Kenichiro Iwami
- Department of NeurosurgeryAichi Medical UniversityAichiJapan
| | - Tsuneo Yasumura
- Department of Plastic surgeryAichi Medical UniversityAichiJapan
| | - Kinga Yo
- Department of OtorhinolaryngologyAichi Medical UniversityAichiJapan
| | - Hiroki Okamoto
- Department of OtorhinolaryngologyAichi Medical UniversityAichiJapan
| | - Daisuke Inukai
- Department of OtorhinolaryngologyAichi Medical UniversityAichiJapan
| | - Rui Sano
- Department of OtorhinolaryngologyAichi Medical UniversityAichiJapan
| | | | - Hirohiko Kakizaki
- Department of OculoplasticOrbital & Lacrimal SurgeryAichi Medical UniversityAichiJapan
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Wertz A, Hollon T, Marentette LJ, Sullivan SE, McHugh JB, McKean EL. Surgical Treatment of Olfactory Neuroblastoma: Major Complication Rates, Progression Free and Overall Survival. J Neurol Surg B Skull Base 2017; 79:151-155. [PMID: 29868319 DOI: 10.1055/s-0037-1605593] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 06/21/2017] [Indexed: 10/19/2022] Open
Abstract
Objective We aimed to compare major complication rates in patients undergoing open versus endoscopic resection of olfactory neuroblastoma (ONB) and to determine the prognostic utility of the Kadish staging and Hyams grading systems with respect to progression-free survival (PFS) and overall survival (OS). Methods It is a retrospective review of experience in treating ONB at a single tertiary care hospital from 1987 through 2015. Major complications were defined as cerebrospinal fluid (CSF) leak, meningitis, osteomyelitis, tracheostomy, and severe neurologic injury. Results Forty-one patients were included. An open approach was used in 34 (83%), endoscopic in 6 (15%), and combined in 1 (2%) case. Rates of major complications by surgical approach were 17% after endoscopic versus 31% after open ( p = 0.65). There was no significant difference in PFS or OS based on Kadish B versus C (PFS, p = 0.28; OS, p = 0.11) or Hyams grade 1 and 2 versus Hyams grade 3 and 4 (PFS, p = 0.53; OS, p = 0.38). Conclusions There was no significant difference in major complications between open and endoscopic approaches for the treatment of ONB. Patient stratification using the Kadish staging and Hyams grading systems did not show significant differences in PFS or OS. Further research is needed to determine if a different staging system would better predict patient outcomes.
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Affiliation(s)
- Aileen Wertz
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan, United States
| | - Todd Hollon
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan, United States
| | - Lawrence J Marentette
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan, United States.,Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan, United States.,Section of Oral and Maxillofacial Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, United States
| | - Stephen E Sullivan
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan, United States
| | - Jonathan B McHugh
- Department of Pathology, University of Michigan Health System, Ann Arbor, Michigan, United States
| | - Erin L McKean
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan, United States.,Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan, United States
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Xiong L, Zeng XL, Guo CK, Liu AW, Huang L. Optimal treatment and prognostic factors for esthesioneuroblastoma: retrospective analysis of 187 Chinese patients. BMC Cancer 2017; 17:254. [PMID: 28399835 PMCID: PMC5387340 DOI: 10.1186/s12885-017-3247-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 03/30/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The standard treatment for esthesioneuroblastoma, a rare malignant nasal vault neoplasm, is not established. METHODS We retrospectively assessed the clinicopathological features, prognostic factors and treatment methods for 187 patients with esthesioneuroblastoma treated in China between 1981 and 2015. Overall survival (OS) and disease-free survival (DFS) were evaluated using the Kaplan-Meier method and log-rank tests. RESULTS Twenty-three (12.3%), 48 (25.7%) and 113 (60.4%) patients had Kadish stage A, B and C esthesioneuroblastoma; 3 (1.6%) had unknown stage. Overall, 117 (62.6%) patients received surgery and combined radiotherapy with or without chemotherapy; 35 (18.7%) received radiotherapy with or without chemotherapy; 32 (17.1%) received surgery alone; and 3 (1.6%) received palliative treatment. Three-year OS and DFS for the entire cohort were 66.7% and 57.5%, respectively. Three-year OS for stage A, B and C were 91.3%, 91.2% and 49.5% (P < 0.0001). Three-year OS was 16.7% and 66.7% for patients with and without distant metastasis (P < 0.0001). Surgery and combined radiotherapy with or without chemotherapy led to better OS and DFS than other treatment modes (both P < 0.0001). Univariate and multivariate analysis showed distant metastasis (hazard ratio [HR] = 2.162, 95% confidence interval [CI] = 1.145, 4.082, P = 0.017) and not receiving a combined modality treatment (HR = 2.391, 95% CI = 1.356, 4.218, P = 0.003) were independent prognostic factors for poor OS and DFS. CONCLUSIONS This study indicates surgery and combined radiotherapy may currently be the optimal treatment for esthesioneuroblastoma.
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Affiliation(s)
- Le Xiong
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, 1 Minde Road, Nanchang, Jiangxi Province, 330006, China
| | - Xiao-Li Zeng
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, 1 Minde Road, Nanchang, Jiangxi Province, 330006, China
| | - Chang-Kuo Guo
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, 1 Minde Road, Nanchang, Jiangxi Province, 330006, China
| | - An-Wen Liu
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, 1 Minde Road, Nanchang, Jiangxi Province, 330006, China.
| | - Long Huang
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, 1 Minde Road, Nanchang, Jiangxi Province, 330006, China.
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Abstract
Esthesioneuroblastoma is a rare malignant tumor of neuroectodermal origin. It usually presents with nonspecific symptoms, such as nasal obstruction, epistaxis, and pain, but has an aggressive course if the treatment is delayed. The authors report a case of esthesioneuroblastoma in a 47-year-old woman, treated with extensive surgical resection, radiotherapy, and chemotherapy. Despite intensive treatment, the patient developed a local recurrence with systemic metastasis and succumbed 4 months later.
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Manthuruthil C, Lewis J, McLean C, Batra PS, Barnett SL. Endoscopic Endonasal Management of Olfactory Neuroblastoma: A Retrospective Analysis of 10 Patients with Quality-of-Life Measures. World Neurosurg 2016; 90:1-5. [PMID: 26899467 DOI: 10.1016/j.wneu.2016.02.035] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 02/02/2016] [Accepted: 02/03/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Anterior craniofacial resection has served as the traditional surgical treatment of olfactory neuroblastoma (ON). With the development of extended endonasal approaches, the opportunity exists for using minimal access techniques for management of select tumors. This study assesses the impact of endoscopic resection on ON and patient outcomes and quality of life. METHODS A retrospective review identified 10 patients with ON (3 women, 7 men; mean age 49.1 years) who underwent endoscopic resection during the period 2010-2013. Modified Kadish staging divided the cohort into 3 stage B patients (30%), 5 stage C patients (50%), and 2 stage D patients (20%). Outcome measures included extent of resection, complications, recurrence, and preoperative and postoperative Sino-Nasal Outcome Test-20 scores. RESULTS Gross total resection was achieved in all patients, with negative margins in 9 patients. One patient had negative frozen section pathology but was noted to have a positive posterior dural margin on final pathology. There was a 20% complication rate (pneumocephalus, ethmoid meningoencephalocele). Neoadjuvant chemotherapy and radiation were performed in 2 patients (Kadish stage C and D). Adjuvant chemotherapy and radiation were performed in 5 patients (4 Kadish stage C and 1 stage D). Postoperative radiation alone was administered in 3 patients (Kadish stage B). Analysis of postoperative Sino-Nasal Outcome Test-20 scores demonstrated no significant change relative to preoperative Sino-Nasal Outcome Test-20 scores. At the most recent follow-up examination, there was no evidence of recurrent disease in patients who underwent endoscopic resection. One patient (Kadish stage D) died during the follow-up period. Mean follow-up duration was 21.1 months. CONCLUSIONS This series adds to the growing body of literature that suggests equivalent or improved outcomes of purely endonasal resection for select patients. Given the advanced Kadish stage of most of our patients, longer follow-up is required to determine the full applicability of purely endoscopic approaches to the treatment of ON.
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Affiliation(s)
- Christine Manthuruthil
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jeremy Lewis
- Department of Neurological Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Caitlin McLean
- Department of Otolaryngology-Head and Neck Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Pete S Batra
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush Center for Skull Base and Pituitary Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Samuel L Barnett
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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Komotar RJ, Starke RM, Raper DMS, Anand VK, Schwartz TH. Endoscopic endonasal compared with anterior craniofacial and combined cranionasal resection of esthesioneuroblastomas. World Neurosurg 2012; 80:148-59. [PMID: 23228365 DOI: 10.1016/j.wneu.2012.12.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2011] [Revised: 08/19/2012] [Accepted: 12/06/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Esthesioneuroblastomas represent a surgical challenge because of their anatomical location, the necessity of achieving negative margins, and the often-cosmetically disfiguring transfacial approaches needed. Recently, expanded endonasal endoscopic approaches have been developed, either alone or in combination with a craniotomy. We conducted a systematic review of case series and case reports to compare outcomes between these various surgical approaches. METHODS A MEDLINE search was conducted of the modern literature (1985-2010) to identify open and endoscopic surgical series. Tumor and patient characteristics, Kadish stage, extent of resection, and progression-free and overall survival were recorded and analyzed by approach. Kaplan-Meier analysis was used to assess overall survival and progression-free survival. RESULTS Forty-seven studies comprising 453 patients were included. The endoscopic cohort had a greater proportion of Kadish Stage A tumors compared with the craniofacial group. Gross total resection was achieved in 98.1% of patients who underwent an endoscopic approach compared with 81.3% for the craniofacial and 100% for the cranionasal cohorts. Local recurrence occurred in 8.0% of patients in the endoscopic group compared with 22.1% in the craniofacial and 16.7% in the cranionasal cohorts. CONCLUSION In well-selected cases, cranionasal and endonasal approaches can be safe and effective. An ongoing evaluation of the benefits and limitations are necessary to better define the ideal patient population and patient-specific risk factors for the use of these minimal access techniques.
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Affiliation(s)
- Ricardo J Komotar
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
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Aggressive olfactory neuroblastoma invading the oral cavity: report of a rare case and review of the literature. J Oral Maxillofac Surg 2012; 70:e252-7. [PMID: 22374068 DOI: 10.1016/j.joms.2011.11.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Revised: 11/17/2011] [Accepted: 11/17/2011] [Indexed: 11/23/2022]
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Komotar RJ, Starke RM, Raper DMS, Anand VK, Schwartz TH. Endoscopic skull base surgery: a comprehensive comparison with open transcranial approaches. Br J Neurosurg 2012; 26:637-48. [PMID: 22324437 DOI: 10.3109/02688697.2012.654837] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Little data exists comparing endoscopic endonasal approaches to pathology of the anterior skull base with more traditional transcranial and transsphenoidal microscopic approaches. In order to more fully characterize the role of endoscopy in the management of pathology of the anterior cranial base, we conducted a systematic review of case series and case reports documenting surgical and clinical outcomes. We found that for craniopharyngiomas, clival chordomas, esthesioneuroblastomas and giant pituitary adenomas, the endonasal endoscopic approach can result in equivalent or higher rates of gross total resection than open approaches. For meningiomas, however, open transcranial approaches are still able to achieve higher rates of total resection. CSF leak rates are higher for patients undergoing endoscopic surgery for meningiomas and craniopharyngiomas, but not for chordomas, esthesioneuroblastomas or giant pituitary adenomas. In certain patients, the endonasal endoscopic approach may be a safe and effective alternative for the treatment of a wide variety of skull base pathology, particularly those with small midline tumours.
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Affiliation(s)
- Ricardo J Komotar
- Department of Neurological Surgery, University of Miami, Miami, FL, USA
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Rao AJ, Gultekin SH, Neuwelt EA, Cintrón-Colón HR, Ragel BT. Late occurrence of drop metastasis to the spine in a case of esthesioneuroblastoma. J Neurosurg Spine 2011; 15:571-5. [DOI: 10.3171/2011.6.spine11157] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Esthesioneuroblastoma is an aggressive neuroectodermal tumor that originates from the olfactory mucosa and often recurs locally. Distant metastasis of esthesioneuroblastoma has been described, but there are few reports of drop metastasis to the spinal cord. Here, we report a case of multiple drop metastases to the cervical, thoracic, and lumbar regions of the spinal cord that occurred 18 years after resection and radiotherapy of the original anterior cranial fossa lesion. There was no evidence of local recurrence. The symptomatic lesion was treated with resection and adjuvant chemotherapy. The options available for treatment of this disease are summarized with a review of the few reported cases of spinal metastasis of esthesioneuroblastoma.
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Affiliation(s)
| | | | - Edward A. Neuwelt
- 1Departments of Neurological Surgery,
- 3Neurology, Oregon Health & Science University, Portland, Oregon
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Dimou J, Mitchell RA, Tsui A, Kavar B, Kaye AH. Metastatic olfactory neuroblastoma invading a radiation-induced meningioma. J Clin Neurosci 2011; 18:1249-51. [PMID: 21752653 DOI: 10.1016/j.jocn.2011.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Revised: 01/31/2011] [Accepted: 01/31/2011] [Indexed: 11/28/2022]
Abstract
Olfactory neuroblastomas are malignant, neuroectodermal nasal tumours. We describe a 62-year-old patient with a recurrent olfactory neuroblastoma invading a radiation-induced meningioma. Given the temporal and spatial relationship between the primary lesion and the described recurrence, this was due to metastatic rather than direct contiguous spread, fulfilling all the criteria for true tumour-to-tumour metastasis. To our knowledge, this is the first description of an olfactory neuroblastoma metastasising to a meningioma.
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Affiliation(s)
- James Dimou
- Department of Neurosurgery, The Royal Melbourne Hospital, Parkville, Victoria, Australia.
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Nabili V, Kelly DF, Fatemi N, St John M, Calcaterra TC, Abemayor E. Transnasal, transfacial, anterior skull base resection of olfactory neuroblastoma. Am J Otolaryngol 2011; 32:279-85. [PMID: 20728963 DOI: 10.1016/j.amjoto.2010.05.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Accepted: 05/17/2010] [Indexed: 11/18/2022]
Abstract
PURPOSE Using a transnasal, transfacial, anterior skull base approach, we have removed olfactory neuroblastomas (OFN) obviating the need for a frontal craniotomy. The objectives were to present our surgical approach in achieving clear margins, to assess patient survival, and to recommend eligibility criteria. MATERIALS AND METHODS A retrospective chart review was done to identify patients diagnosed with OFN who underwent this surgical approach. Thirteen patients were identified who underwent our pictorially described approach. Postoperative assessment of pathologic margins, patient survival, and limitations of surgical approach was determined. RESULTS Of the 13 patients, 12 (92%) had clear postsurgical margins. One patient had residual intracranial disease due to coagulopathy preventing further resection. Twelve patients remain alive with 10 patients remaining disease-free (follow-up ranging from 11 to 64 months). Three patients presented with recurrent disease initially, with 2 having had subsequent repeat local and regional recurrences, respectively; one of whom died recently of the re-recurrent disease. One patient had a postoperative cerebrospinal fluid leak repaired via the original surgical approach. CONCLUSIONS Although craniofacial resection remains an accepted approach for surgical treatment of OFN, we have adopted a transnasal, transfacial approach eliminating the need for a frontal craniotomy. This approach allows for adequate exposure of the cribriform plate, dura, and anterior skull base. Our technique minimizes dural defects and prevents many craniotomy-associated complications, including frontal lobe retraction. Long-term follow-up is needed to compare survival using this approach; however, our results to date are quite promising.
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Affiliation(s)
- Vishad Nabili
- Divisions of Head and Neck Surgery, David Geffen School of Medicine at UCLA, University of California-Los Angeles, 10833 LeConte Avenue, Los Angeles, CA 90095, USA.
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Smee RI, Broadley K, Williams JR, Meagher NS, Bridger GP. Retained role of surgery for olfactory neuroblastoma. Head Neck 2010; 33:1486-92. [PMID: 21928422 DOI: 10.1002/hed.21644] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Revised: 08/29/2010] [Accepted: 09/06/2010] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Olfactory neuroblastoma is a rare paranasal sinus malignancy. The traditional approach was craniofacial resection (CFR) and then postoperative radiotherapy until 1998. This review will chart development of a new protocol. METHODS This ethics-approved audit evaluated the number of new patients diagnosed with olfactory neuroblastoma, with information relating to patient, disease, and treatment factors noted. RESULTS There were 24 eligible patients, 16 men, 8 women, 7 Kadish stage B, 17 stage C. The planned treatment was: chemotherapy (cisplatin/etoposide) and determine treatment dependent on response in 6 patients, surgery and radiotherapy in 16 patients, and single-modality treatment only (surgery, radiotherapy 1) in 2 patients. Surgery to radiotherapy occurred in 17 patients. With salvage treatment ultimate local control was 79%. CONCLUSIONS There was a higher local control in those patients who had surgery; abandoning this may carry a higher risk of local failure. The use of response to chemotherapy to determine local treatment remains experimental.
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Affiliation(s)
- Robert I Smee
- Department of Radiation Oncology, The Prince of Wales Cancer Centre, Randwick, New South Wales, Australia.
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Kane AJ, Sughrue ME, Rutkowski MJ, Aranda D, Mills SA, Buencamino R, Fang S, Barani IJ, Parsa AT. Posttreatment prognosis of patients with esthesioneuroblastoma. J Neurosurg 2010; 113:340-51. [PMID: 20345216 DOI: 10.3171/2010.2.jns091897] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT There is no Class I evidence to guide the appropriate management of esthesioneuroblastoma (EN). Most data currently guiding treatment come from small- or modest-sized series gathered at individual centers that have concluded that surgery with radiotherapy is the preferred treatment. In this study, the authors summarize the published literature on treatment outcomes in patients with EN. The objective was to ascertain what variables predict prognosis in these patients and to determine the relative effect of different therapies. METHODS The authors identified 205 published studies containing treatment outcomes for surgery, radiotherapy, chemotherapy, or multimodal treatment. Using Kaplan-Meier analysis, the survival of patients who received surgery was compared with that in those who received surgery and radiotherapy. Additionally, Kadish staging was compared with low- and high-grade Hyams criteria to assess for subgroup prognostic significance in survival differences. RESULTS Nine hundred fifty-six patients met the inclusion criteria, with a median follow-up time of 3 years. Kaplan-Meier analysis demonstrated no difference in survival between patients who underwent surgery alone and those who underwent surgery plus radiotherapy at 5 years (78 vs 75%) or 10 years (67 vs 61%, respectively) (p = 0.3). Univariate analysis demonstrated worse survival in cases involving Kadish Grade C tumors, Hyams Grade 3 and 4 tumors, and in patients older than 65 years of age. Multivariate analysis demonstrated that Hyams Grade 3 and 4 lesions carried significant risk (proportional hazard = 4.83, p < 0.001) with 5- and 10-year survival of 47 and 31%. CONCLUSIONS A biopsy should always be obtained in cases suspected of EN because histology is a strong prognostic indicator and will help guide appropriate treatment. Unimodal surgery and combined surgery/radiotherapy appear to be of equivalent efficacy with respect to survival in patients with EN. Chemotherapy should be considered in high-grade EN.
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Affiliation(s)
- Ari J Kane
- Department of Neurological Surgery, University of California, San Francisco, California 94143, USA
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