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Kakodkar P, Houlihan LM, Preul M, Bermingham N, Lim C. Primary and metastatic paraganglioma of the cranial vault. Br J Neurosurg 2023; 37:967-975. [PMID: 33739182 DOI: 10.1080/02688697.2021.1902477] [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: 01/19/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
AIM Primary paragangliomas (PGs) are extra-adrenal neuroendocrine tumours that are extremely rare. Multiple lesions in the central nervous system raise suspicion of a metastatic process. Lack of consensus on their management warrants the categorization of existing literature to evaluate management options. METHODS A systematic review of the medical literature on paraganglioma within the cranial vault was completed in accordance with PRISMA guidelines using the Medline database. Tumour physical measures, management parameters, and immunohistochemistry of all documented cases of primary and secondary paraganglioma within the cranial vault were descriptively compared. This review was augmented by comparison with our centre's case of a 48-year-old man diagnosed with metastatic PG originating in the cauda equina and seeding in the cerebellum. Histological parameters within the literature was also established. RESULTS The systematic literature review yielded published 52 papers. Most prevalent primary intracranial PGs (n = 37) were in the sellar region (78%, n = 23) and the cerebellum (21%, n = 6). The highest progression free survival was seen in primary sellar PGs (87.5% by 34.5 months) and cerebellar PGs (100% by 35.7 months) when treated with adjuvant radiotherapy with subtotal resection or gross total resection, respectively. Contrasting, the most frequent intracranial PGs metastases (n = 15) occurred in the cerebellum (36%, n = 6), and the cerebral parenchyma (29%, n = 4). Their recurrence rate was between 4 and 10% and these metastasized PG in the cerebellum are slow growing (8.9 years, range: 3-22 years). Adjuvant radiotherapy with Gross Total Resection resulted in the optimum progression-free survival (100% up to 48 months) for the patient with PGs metastasis to the cerebellum. CONCLUSION Metastatic PGs tend to be slow-growing and are clinically silent tumours. Diagnosed patients should undergo regular surveillance neuroradiological assessment, regardless of symptomatology, for metastases along the complete neural axis. We recommend operative management with GTR and adjunct RT in these patients.
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Affiliation(s)
- Pramath Kakodkar
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Lena Mary Houlihan
- Department of Neurosurgery, Cork University Hospital, Cork, Ireland
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Mark Preul
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Niamh Bermingham
- Department of Neuropathology, Cork University Hospital, Cork, Ireland
| | - Chris Lim
- Department of Neurosurgery, Cork University Hospital, Cork, Ireland
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Pellerino A, Verdijk RM, Nichelli L, Andratschke NH, Idbaih A, Goldbrunner R. Diagnosis and Treatment of Peripheral and Cranial Nerve Tumors with Expert Recommendations: An EUropean Network for RAre CANcers (EURACAN) Initiative. Cancers (Basel) 2023; 15:cancers15071930. [PMID: 37046591 PMCID: PMC10093509 DOI: 10.3390/cancers15071930] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 03/12/2023] [Accepted: 03/21/2023] [Indexed: 04/14/2023] Open
Abstract
The 2021 WHO classification of the CNS Tumors identifies as "Peripheral nerve sheath tumors" (PNST) some entities with specific clinical and anatomical characteristics, histological and molecular markers, imaging findings, and aggressiveness. The Task Force has reviewed the evidence of diagnostic and therapeutic interventions, which is particularly low due to the rarity, and drawn recommendations accordingly. Tumor diagnosis is primarily based on hematoxylin and eosin-stained sections and immunohistochemistry. Molecular analysis is not essential to establish the histological nature of these tumors, although genetic analyses on DNA extracted from PNST (neurofibromas/schwannomas) is required to diagnose mosaic forms of NF1 and SPS. MRI is the gold-standard to delineate the extension with respect to adjacent structures. Gross-total resection is the first choice, and can be curative in benign lesions; however, the extent of resection must be balanced with preservation of nerve functioning. Radiotherapy can be omitted in benign tumors after complete resection and in NF-related tumors, due to the theoretic risk of secondary malignancies in a tumor-suppressor syndrome. Systemic therapy should be considered in incomplete resected plexiform neurofibromas/MPNSTs. MEK inhibitor selumetinib can be used in NF1 children ≥2 years with inoperable/symptomatic plexiform neurofibromas, while anthracycline-based treatment is the first choice for unresectable/locally advanced/metastatic MPNST. Clinical trials on other MEK1-2 inhibitors alone or in combination with mTOR inhibitors are under investigation in plexiform neurofibromas and MPNST, respectively.
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Affiliation(s)
- Alessia Pellerino
- Division of Neuro-Oncology, Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital, 10126 Turin, Italy
| | - Robert M Verdijk
- Department of Pathology, Section Ophthalmic Pathology, Erasmus MC University Medical Center Rotterdam, 3015 Rotterdam, The Netherlands
- Department of Pathology, Leiden University Medical Center, 2333 Leiden, The Netherlands
| | - Lucia Nichelli
- Department of Neuroradiology, Sorbonne Université, 75005 Paris, France
- Assistance Publique-Hôpitaux de Paris, 75610 Paris, France
- Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, 75013 Paris, France
| | - Nicolaus H Andratschke
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, 8006 Zurich, Switzerland
| | - Ahmed Idbaih
- AP-HP, Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, Sorbonne Université, 75005 Paris, France
- Inserm, CNRS, UMR S 1127, Institut du Cerveau-Paris Brain Institute, 75013 Paris, France
- ICM, Service de Neurologie 2-Mazarin, 75013 Paris, France
| | - Roland Goldbrunner
- Center for Neurosurgery, Department of General Neurosurgery, University of Cologne, 50923 Cologne, Germany
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Primary Paraganglioma of the Spine: A Systematic Review of Clinical Features and Surgical Management in Cauda Equina vs Non-Cauda Equina Lesions. World Neurosurg 2022; 161:190-197.e20. [PMID: 35123022 DOI: 10.1016/j.wneu.2022.01.110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Primary spine paragangliomas are rare tumors. Surgical resection plays a role, but aggressive lesions are challenging. We reviewed the literature on primary spine paragangliomas. METHODS PubMed, Scopus, Web of Science, and Cochrane were searched upon the PRISMA guidelines to include studies on primary spine paragangliomas. Clinical-radiological features, treatments, and outcomes were analyzed and compared between cauda-equina vs non-cauda-equina tumors. RESULTS We included 143 studies comprising 334 patients. Median age was 46 years (range, 6-85). The most frequent symptoms were lower-back (64.1%) and radicular (53.9%) pain, and sympathetic in 18 patients (5.4%). Cauda-equina paragangliomas (84.1%) had frequently lumbar (49.1%) or lumbosacral (29%) locations. Non-cauda-equina tumors were mostly in the thoracic (11.4%), thoracolumbar (5.1%), and cervical (3.6%) spine. Median tumor diameter was 2.5cm (range, 0.5-13.0). Surgical resection (98.5%) was preferred over biopsy (1.5%). Decompressive laminectomy (53%) and spine fusion (6.9%) were also performed. Adjuvant radiotherapy was delivered in 39 patients (11.7%) with aggressive tumors. Post-treatment symptomatic improvement was described in 86.2% cases. Median follow-up was 19.5 months (range, 0.1-468.0), and 23 patients (3.9%) had tumor recurrences. No significant differences were found between cauda-equina vs non-cauda-equina tumors. CONCLUSION Surgical resection is effective and safe in treating primary spine paragangliomas; however, adjuvant treatments may be needed for aggressive lesions.
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Liu Y, Wei T. Micturition-triggered severe headache associated with bladder paraganglioma: A case report. Cephalalgia 2021; 42:166-169. [PMID: 34407652 DOI: 10.1177/03331024211036155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Paragangliomas are rare neuroendocrine tumors, especially in the bladder. Although many paragangliomas are non-functional, functioning paragangliomas present with many non-specific signs and symptoms, such as hypertension and headache, complicating their diagnosis. Here, we report a case of micturition-induced severe headache associated with a bladder paraganglioma.Case description: This report describes a severe headache disorder triggered by micturition and associated with a bladder paraganglioma in a middle-aged woman. Her pain occurred consistently after micturition, beginning from the left side of the nose and gradually extended to the forehead and the parietal and occipital regions. The headaches lasted 5-10 min. Removal of the paraganglioma completely eliminated the patient's pain syndrome. CONCLUSION This case elucidates the association between micturition-triggered headaches and bladder paragangliomas. The presence of a post-micturition severe headache should suggest the possibility of a bladder paraganglioma.
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Affiliation(s)
- Yonghui Liu
- Department of Encephalopathy, the First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Tianlu Wei
- Department of Encephalopathy, the First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
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Apostolidis L, Schrader J, Jann H, Rinke A, Krug S. Leptomeningeal Carcinomatosis: A Clinical Dilemma in Neuroendocrine Neoplasms. BIOLOGY 2021; 10:biology10040277. [PMID: 33800581 PMCID: PMC8066280 DOI: 10.3390/biology10040277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/21/2021] [Accepted: 03/26/2021] [Indexed: 11/16/2022]
Abstract
Central nervous system (CNS) involvement by paraneoplastic syndromes, brain metastases, or leptomeningeal carcinomatosis (LC) in patients with neuroendocrine neoplasms (NEN) has only been described in individual case reports. We evaluated patients with LC in four neuroendocrine tumor (NET) centers (Halle/Saale, Hamburg, Heidelberg, and Marburg) and characterized them clinically. In the study, 17 patients with a LC were defined with respect to diagnosis, clinic, and therapy. The prognosis of a LC is very poor, with 10 months in median overall survival (mOS). This is reflected by an even worse course in neuroendocrine carcinoma (NEC) G3 Ki-67 >55%, with a mOS of 2 months. Motor and sensory deficits together with vigilance abnormalities were common symptoms. In most cases, targeted radiation or temozolomide therapy was used against the LC. LC appears to be similarly devastating to brain metastases in NEN patients. Therefore, the indication for CNS imaging should be discussed in certain cases.
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Affiliation(s)
- Leonidas Apostolidis
- Department of Medical Oncology, National Center for Tumor Diseases, University Hospital Heidelberg, 69120 Heidelberg, Germany;
| | - Jörg Schrader
- I. Medical Department—Gastroenterology and Hepatology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
| | - Henning Jann
- Department of Gastroenterology and Hepatology, Charité—University Medical Center Berlin, Campus Virchow Klinikum and Charité Mitte, Augustenburger Platz 1, 13353 Berlin, Germany;
| | - Anja Rinke
- Department of Gastroenterology and Endocrinology, University Hospital Marburg, Baldinger Strasse, 35043 Marburg, Germany
- Correspondence: (A.R.); (S.K.); Tel.: +49-0345-557-2661 (S.K.); Fax: +49-0345-557-2253 (S.K.)
| | - Sebastian Krug
- Clinic for Internal Medicine I, Martin-Luther University Halle/Wittenberg, Ernst-Grube-Straße 40, 06120 Halle, Germany
- Correspondence: (A.R.); (S.K.); Tel.: +49-0345-557-2661 (S.K.); Fax: +49-0345-557-2253 (S.K.)
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Kitagawa T, Ohtonari T, Yamamoto J, Nishihara N, Nishigaki M, Takekoshi K. Longest survival by the combination of radiation-therapy and resection in patient with metastatic spinal paragangliomas from primary-neck lesion with succinate dehydrogenase subunit B (SDHB) mutation. Endocr J 2021; 68:81-86. [PMID: 32863293 DOI: 10.1507/endocrj.ej20-0292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Metastatic paraganglioma (MPG) of the spine is a rare condition, with no established management. Herein, we report the longest survival case of a primary neck tumor that caused spinal MPG with a succinate dehydrogenase subunit B (SDHB) mutation (c.470delT, p.L157X) which could have promoted its malignancy. This male patient initially presented with a left neck PG which was diagnosed by a biopsy when he was 54 years-old. Simultaneously performed additional examinations revealed the spinal metastatic tumors on the T5-7 vertebrae and L3 vertebra-sacrum. These primary neck and metastatic spinal tumors' growths were once suppressed under the radiation therapy. Nineteen years later, he developed acute progressive paraparesis due to a mass located at the T2-3 level, tightly compressing the spinal cord, and protruding into the left thoracic cavity. We resected the maximum possible area of tumor in the spinal canal, confirmed MPG by histological examination, and then, we administered radiation therapy of 40 Gy in 20 fractions. Eventually, the patient was able to walk unaided with no evidential tumor recurrence for 3 years after treatment. Generally, clinical feature of MPG with SDHB mutation from abdominal lesion is thought to be poor prognosis. However, our case suggests the possibility of long-term control of spinal MPG with the adequate combination of radiation therapy and resection if metastatic lesions from primary-neck lesion with an SDHB mutation are remained to spine.
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Affiliation(s)
- Takehiro Kitagawa
- Department of Neurosurgery, University of Occupational and Environmental Health, Kitakyushu, Fukuoka 807-8555, Japan
- Department of Spinal Surgery, Brain Attack Center, Ota Memorial Hospital, Fukuyama, Hiroshima 720-0825, Japan
| | - Tatsuya Ohtonari
- Department of Spinal Surgery, Brain Attack Center, Ota Memorial Hospital, Fukuyama, Hiroshima 720-0825, Japan
| | - Junkoh Yamamoto
- Department of Neurosurgery, University of Occupational and Environmental Health, Kitakyushu, Fukuoka 807-8555, Japan
| | - Nobuharu Nishihara
- Department of Spinal Surgery, Brain Attack Center, Ota Memorial Hospital, Fukuyama, Hiroshima 720-0825, Japan
| | - Masakazu Nishigaki
- Department of Nursing, Human Health Sciences, Kyoto University, Kyoto, Kyoto 606-8507, Japan
| | - Kazuhiro Takekoshi
- Division of Sports Medicine/Laboratory Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8577, Japan
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Honeyman SI, Warr W, Curran OE, Demetriades AK. Paraganglioma of the Lumbar Spine: A case report and literature review. Neurochirurgie 2019; 65:387-392. [PMID: 31247160 DOI: 10.1016/j.neuchi.2019.05.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/11/2019] [Accepted: 05/30/2019] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Lumbar paragangliomas are rare, vascular, neuroendocrine tumors. They are notoriously difficult to diagnose radiologically and can prove challenging to manage intraoperatively, if capable of catecholamine secretion. CASE REPORT We report the case of a 45-year-old man, who presented with a lumbar spinal paraganglioma. The patient described a 2-year history of worsening lower back pain and sciatica. Neurological examination was normal. MRI revealed a lesion at L3, with prominent vessels, compressing the cauda equina. Gross total resection (GTR) of the tumor was performed. The patient recovered well, with relief of pain and no neurological deficit. DISCUSSION A literature search of lumbar paraganglioma cases, from January 1970 to April 2018 was carried out. Results of this review highlighted the importance of inclusion of paraganglioma as a differential diagnosis in lumbar spinal tumor and also the requirement for preoperative investigations to determine any potential secretory activity. CONCLUSIONS Lumbar paraganglioma behavior is most commonly benign and rates of recurrence are low after GTR. However, long-term postoperative follow-up is crucial, due to findings of late metastatic recurrence.
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Affiliation(s)
- S I Honeyman
- University of Oxford Medical School, Green Templeton College, 43 Woodstock Road, Oxford, OX2 6HG, UK.
| | - W Warr
- University of Oxford Medical School, Green Templeton College, 43 Woodstock Road, Oxford, OX2 6HG, UK
| | - O E Curran
- Department of Neuropathology, Western General Hospital, Crewe Road South, Edinburgh, EH4 2XU, UK
| | - A K Demetriades
- Department of Neurosurgery, Western General Hospital, Crewe Road South, Edinburgh, EH4 2XU, UK
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Remarkable efficacy of temozolomide for relapsed spinal myxopapillary ependymoma with multiple recurrence and cerebrospinal dissemination: a case report and literature review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:421-425. [PMID: 29270703 DOI: 10.1007/s00586-017-5413-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 11/16/2017] [Accepted: 11/26/2017] [Indexed: 12/17/2022]
Abstract
PURPOSE Myxopapillary ependymomas are intradural tumors which grow from the terminal filum of the spinal cord. Although they are classified as WHO grade I, they sometimes cause cerebrospinal fluid dissemination or local recurrence. In this report, we describe a case in that temozolomide (TMZ) showed remarkable efficacy on a recurrent spinal myxopapillary ependymoma. CASE REPORT A 26-year-old female underwent resection of an intradural myxopapillary ependymoma at L5 initially. Although an en bloc total resection, including the capsule, could be achieved, she needed two additional tumor resection surgeries with postoperative radiotherapy at L4 and at L3 (2 and 6 years after the initial surgery, respectively). Moreover, 4 years after the initial surgery, a disseminated metastatic tumor occurred at T11/12 and local radiotherapy was not effective. After the third surgery, an aggressive adjuvant therapy was necessary because there was a high risk of another recurrence. Therefore, TMZ was administered for 1 year. After 6 months of TMZ treatment, remarkably, the disseminated metastatic tumor at T11/12 had disappeared completely. Presently, 6 years after finishing the TMZ treatment, the follow-up MRI has shown no recurrence in the brain and whole spine. CONCLUSIONS TMZ is usually used in the treatment of glioblastoma and, recently, it has been reported to be effective for the lower grade spinal gliomas including spinal intramedullary ependymomas. However, for myxopapillary ependymomas, there has been no report that TMZ is effective. According to our results, TMZ could be one of the possible candidates for adjuvant therapy in multiple recurrent myxopapillary ependymomas.
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Nayar G, Ejikeme T, Chongsathidkiet P, Elsamadicy AA, Blackwell KL, Clarke JM, Lad SP, Fecci PE. Leptomeningeal disease: current diagnostic and therapeutic strategies. Oncotarget 2017; 8:73312-73328. [PMID: 29069871 PMCID: PMC5641214 DOI: 10.18632/oncotarget.20272] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 07/20/2017] [Indexed: 12/28/2022] Open
Abstract
Leptomeningeal disease has become increasingly prevalent as novel therapeutic interventions extend the survival of cancer patients. Although a majority of leptomeningeal spread occurs secondary to breast cancer, lung cancer, and melanoma, a wide variety of malignancies have been reported as primary sources. Symptoms on presentation are equally diverse, often involving a combination of neurological deficits with the possibility of obstructive hydrocephalus. Diagnosis is definitively made via cerebrospinal fluid cytology for malignant cells, but neuro-imaging with high quality T1-weighted magnetic resonance imaging can aid diagnosis and localization. While leptomeningeal disease is still a terminal, late-stage complication, a variety of treatment modalities, such as intrathecal chemotherapeutics and radiation therapy, have improved median survival from 4–6 weeks to 3–6 months. Positive prognosticative factors for survival include younger age, high performance scores, and controlled systemic disease. In looking to the future, diagnostics that improve early detection and chemotherapeutics tailored to the primary malignancy will likely be the most significant advances in improving survival.
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Affiliation(s)
- Gautam Nayar
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Tiffany Ejikeme
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Pakawat Chongsathidkiet
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Pathology, Duke University Medical Center, Durham, NC, USA
| | - Aladine A Elsamadicy
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Kimberly L Blackwell
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey M Clarke
- Division of Medical Oncology, Duke University Medical Center, Durham, NC, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Peter E Fecci
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,Department of Pathology, Duke University Medical Center, Durham, NC, USA
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