Publications by authors named "Mark H Bilsky"

137 Publications

Introduction. Treatment of spinal cord and spinal axial tumors.

Neurosurg Focus 2021 05;50(5):E1

5Department of Oncology, Queen's University, Kingston, Ontario, Canada.

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http://dx.doi.org/10.3171/2021.2.FOCUS21113DOI Listing
May 2021

Short-segment cement-augmented fixation in open separation surgery of metastatic epidural spinal cord compression: initial experience.

Neurosurg Focus 2021 05;50(5):E11

1Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center; and.

Objective: High-grade metastatic epidural spinal cord compression from radioresistant tumor histologies is often treated with separation surgery and adjuvant stereotactic body radiation therapy. Historically, long-segment fixation is performed during separation surgery with posterior transpedicular fixation of a minimum of 2 spinal levels superior and inferior to the decompression. Previous experience with minimal access surgery techniques and percutaneous stabilization have highlighted reduced morbidity as an advantage to the use of shorter fixation constructs. Cement augmentation of pedicle screws is an attractive option for enhanced stabilization while performing shorter fixation. Herein, the authors describe their initial experience of open separation surgery using short-segment cement-augmented pedicle screw fixation for spinal reconstruction.

Methods: The authors performed a retrospective chart review of patients undergoing open (i.e., nonpercutaneous, minimal access surgery) separation surgery for high-grade epidural spinal cord compression using cement-augmented pedicle screws at single levels adjacent to the decompression level(s). Patient demographics, treatment data, operative complications, and short-term radiographic outcomes were evaluated.

Results: Overall, 44 patients met inclusion criteria with radiographic follow-up at a mean of 8.5 months. Involved levels included 19 thoracic, 5 thoracolumbar, and 20 lumbar. Cement augmentation through fenestrated pedicle screws was performed in 30 patients, and a vertebroplasty-type approach was used in the remaining 14 patients to augment screw purchase. One (2%) patient required an operative revision for a hardware complication. Three (7%) nonoperative radiographic hardware complications occurred, including 1 pathologic fracture at the index level causing progressive kyphosis and 2 incidences of haloing around a single screw. There were 2 wound complications that were managed conservatively without operative intervention. No cement-related complications occurred.

Conclusions: Open posterolateral decompression utilizing short-segment cement-augmented pedicle screws is a viable alternative to long-segment instrumentation for reconstruction following separation surgery for metastatic spine tumors. Studies with longer follow-up are needed to determine the rates of delayed complications and the durability of these outcomes.
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http://dx.doi.org/10.3171/2021.2.FOCUS217DOI Listing
May 2021

Improvement in Quality of Life Following Surgical Resection of Benign Intradural Extramedullary Tumors: A Prospective Evaluation of Patient-Reported Outcomes.

Neurosurgery 2021 04;88(5):989-995

Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.

Background: Historically, symptomatic, benign intradural extramedullary (IDEM) spine tumors have been managed with surgical resection. However, minimal robust data regarding patient-reported outcomes (PROs) following treatment of symptomatic lesions exists. Moreover, there are increasing reports of radiosurgical management of these lesions without robust health-related quality of life data.

Objective: To prospectively analyze PROs among patients with benign IDEM spine tumors undergoing surgical resection to define the symptomatic efficacy of surgery.

Methods: Prospective, single-center observational cohort study of patients with benign IDEM spine tumors undergoing open surgical resection. Pre- and postoperative Brief Pain Index (BPI) and MD Anderson Symptom Inventory (MDASI) questionnaires were used to quantitatively assess their symptom control after surgical intervention. Matched pairs were analyzed with the Wilcoxon signed-rank test.

Results: A total of 57 patients met inclusion criteria with both pre- and postoperative PROs. There were 35 schwannomas, 18 meningiomas, 2 neurofibromas, 1 paraganglioma, and 1 mixed schwannoma/neurofibroma. Most patients were American Spinal Injury Association Impairment (ASIA) E (93%) with high-grade spinal cord compression (77%), and underwent either a 2 or 3 level laminectomy (84%). Surgical resection resulted in statistically significant improvement in all 3 composite BPI constructs of pain-severity, pain-interference, and overall patient pain experience (P < .0001). Surgical resection resulted in statistically significant improvements in all composite scores for the MDASI core symptom severity, spine tumor, and disease interference constructs (P < .01). Three patients (5%) had postoperative complications requiring surgical interventions (2 wound revisions and 1 ventriculo-peritoneal shunt).

Conclusion: Surgical resection of IDEM spine tumors provides rapid, significant, and durable improvement in PROs.
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http://dx.doi.org/10.1093/neuros/nyaa561DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8046588PMC
April 2021

The spinal distribution of metastatic renal cell carcinoma: Support for locoregional rather than arterial hematogenous mode of early bony dissemination.

Urol Oncol 2021 03 7;39(3):196.e9-196.e14. Epub 2021 Jan 7.

Department of Neurological Surgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY. Electronic address:

Background: Quantifying the degree to which spinal involvement of metastatic renal cell carcinoma (mRCC) is a locoregional phenomenon vs. a hematogenous, bone-specific affinity has implications for prognosis and antimetastatic therapy.

Objective: To investigate the distribution of spinal metastasis in mRCC and to explore relationships between clinical factors and patterns of spinal spread.

Methods: Patients with mRCC and spinal involvement from June 2005 to November 2018 were identified. Clinical and biologic features including primary tumor size and degree of spinal and nonbony metastatic involvement were collected. Spinal distributions were evaluated by the permutation test, with the null hypothesis that metastases are distributed uniformly across levels.

Results: One hundred patients with 685 spinal levels involved by mRCC were evaluated. A nonuniform spatial distribution was observed across the cohort (P < 0.001); a preponderance of thoracolumbar involvement was noted with the mode at L3. No significant deviation in metastatic distribution from uniform was observed in right- or left-sided tumors, subgroups of distant or local metastases, or histology. Patients with smaller tumors (<4 cm) and local spread had distribution of spinal metastases not significantly different from uniform (P = 0.292 and P = 0.126, respectively).

Conclusions: These data support a dominant locoregional as opposed to arterial hematogenous mechanism for early spinal dissemination of mRCC. Characterizations of the biologic molecular features contributing to osseous tropism and aggressive tumor biology (as seen in the subset of outlier patients with small tumors who appear to have more uniform spread), have implications for surveillance and are an area of active investigation.
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http://dx.doi.org/10.1016/j.urolonc.2020.12.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8237695PMC
March 2021

Phase 3 Multi-Center, Prospective, Randomized Trial Comparing Single-Dose 24 Gy Radiation Therapy to a 3-Fraction SBRT Regimen in the Treatment of Oligometastatic Cancer.

Int J Radiat Oncol Biol Phys 2021 Jul 8;110(3):672-679. Epub 2021 Jan 8.

Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.

Purpose: This prospective phase 3 randomized trial was designed to test whether ultra high single-dose radiation therapy (24 Gy SDRT) improves local control of oligometastatic lesions compared to a standard hypofractionated stereotactic body radiation therapy regimen (3 × 9 Gy SBRT). The secondary endpoint was to assess the associated toxicity and the impact of ablation on clinical patterns of metastatic progression.

Methods And Materials: Between November 2010 and September 2015, 117 patients with 154 oligometastatic lesions (≤5/patient) were randomized in a 1:1 ratio to receive 24 Gy SDRT or 3 × 9 Gy SBRT. Local control within the irradiated field and the state of metastatic spread were assessed by periodic whole-body positron emission tomography/computed tomography and/or magnetic resonance imaging. Median follow-up was 52 months.

Results: A total of 59 patients with 77 lesions were randomized to 24 Gy SDRT and 58 patients with 77 lesions to 3 × 9 Gy SBRT. The cumulative incidence of local recurrence for SDRT-treated lesions was 2.7% (95% confidence interval [CI], 0%-6.5%) and 5.8% (95% CI, 0.2%-11.5%) at years 2 and 3, respectively, compared with 9.1% (95% CI, 2.6%-15.6%) and 22% (95% CI, 11.9%-32.1%) for SBRT-treated lesions (P = .0048). The 2- and 3-year cumulative incidences of distant metastatic progression in the SDRT patients were 5.3% (95% CI, 0%-11.1%), compared with 10.7% (95% CI, 2.5%-18.8%) and 22.5% (95% CI, 11.1%-33.9%), respectively, for the SBRT patients (P = .010). No differences in toxicity were observed.

Conclusions: The study confirms SDRT as a superior ablative treatment, indicating that effective ablation of oligometastatic lesions is associated with significant mitigation of distant metastatic progression.
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http://dx.doi.org/10.1016/j.ijrobp.2021.01.004DOI Listing
July 2021

Robotic Resection of a Nerve Sheath Tumor Via a Retroperitoneal Approach.

Oper Neurosurg (Hagerstown) 2021 01;20(2):E85-E90

Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York.

Background: Resection of large nerve sheath tumors in the lumbar spine using minimally invasive approaches is challenging, as approaches to tumors in this region may require facetectomy or partial resection of adjacent ribs for access to the involved neuroforamen and instrumentation across the involved joint to prevent subsequent kyphotic deformity.

Objective: To describe a robot-assisted retroperitoneal approach for resection of a lumbar nerve sheath tumor, obviating the need for facetectomy and instrumentation. The operation is described, together with intraoperative images and an annotated video, in the context of a schwannoma arising from the right L1 root.

Methods: The operation was performed by a urologic surgeon and a neurosurgeon. The patient was placed in lateral position, and the da Vinci Xi robot was used for retroperitoneal access via 5 ports along the right flank. Ultrasound was used to localize the tumor within the psoas. The tumor capsule was defined and released. Encountered nerves were stimulated, allowing small sensory nerves to be identified and safely divided. The tumor was traced into the right L1-L2 neuroforamen and removed.

Results: Complete en bloc resection of the tumor was achieved, including the paraspinal and foraminal components, without any removal of bone and without violation of the dura.

Conclusion: In selected patients, a robot-assisted retroperitoneal approach represents a minimally invasive alternative to traditional approaches for resection of lumbar nerve sheath tumors. This approach obviates the need for bone removal and instrumented spinal fusion. Interdisciplinary collaboration, as well as use of adjunctive technologies, including intraoperative ultrasound and neurophysiologic monitoring, is advised.
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http://dx.doi.org/10.1093/ons/opaa329DOI Listing
January 2021

Editorial. Spinal laser interstitial thermal therapy: a great idea without a great application.

J Neurosurg Spine 2020 Dec 11:1-3. Epub 2020 Dec 11.

2Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.

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http://dx.doi.org/10.3171/2020.7.SPINE201214DOI Listing
December 2020

The importance of multidisciplinary care for spine metastases: initial tumor management.

Neurooncol Pract 2020 Nov 18;7(Suppl 1):i25-i32. Epub 2020 Nov 18.

Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York.

Spine metastases are very common in cancer patients often requiring urgent assessment and the initiation of therapy. Treatment paradigms have changed exponentially over the past decade with the evolution and integration of stereotactic body radiotherapy, minimally invasive spine techniques, and systemic options including biologics and checkpoint inhibitors. These advances necessitate multidisciplinary assessments and interventions to optimize outcomes. The NOMS framework provides a mechanism for all practitioners to evaluate the 4 sentinel assessments required to make decisions in patients with spine metastases: Neurologic, Oncologic, Mechanical Stability, and Systemic disease. The NOMS framework is continuously updated with the integration of newer technologies and evidence-based medicine as they become available. This paper presents the current iteration of NOMS with a focus on the role of medical and neuro-oncologists in the assessment and treatment of metastatic spine tumors.
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http://dx.doi.org/10.1093/nop/npaa056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7705527PMC
November 2020

Survival Trends After Surgery for Spinal Metastatic Tumors: 20-Year Cancer Center Experience.

Neurosurgery 2021 01;88(2):402-412

Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York.

Background: Over the last 2 decades, advances in systemic therapy have increased the expected overall survival for patients with cancer. It is unclear whether the same survival benefit has been conferred to patients requiring surgery for metastatic spinal disease.

Objective: To examine trends in postoperative survival over a 20-yr period for patients surgically treated for spinal metastatic disease.

Methods: Data were obtained for 1515 patients who underwent surgery for metastatic epidural spinal cord compression or tumor-related mechanical instability. Postoperative overall survival was calculated for all included patients using Kaplan-Meier methodology from date of surgery until death or last follow-up for those who were censored. Trends were analyzed using Cox proportional hazards modeling.

Results: Patients with renal, breast, lung, and colon cancers experienced a statistically significant improvement in survival over time based on the year of surgery (40%-100% improvement over the study period), whereas the overall survival trend for the entire cohort did not reach statistical significance (P = .12, median survival 0.71 yr, 95% CI 0.63-0.78). Patients presenting with synchronous metastatic disease had better survival compared to those presenting with metachronous disease (median overall survival: 0.94 vs 0.63 yr, respectively; log-rank P-value = .00001).

Conclusion: The postoperative survival among patients with spinal metastases has improved over the past 20 yr, particularly in patients with kidney, breast, lung, and colon tumors metastatic to the spine. The observed survival improvement emphasizes the need for long-term outcome consideration in treatment decisions for patients undergoing surgery for spinal metastatic tumors.
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http://dx.doi.org/10.1093/neuros/nyaa380DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7803433PMC
January 2021

Hypofractionated spinal stereotactic body radiation therapy for high-grade epidural disease.

J Neurosurg Spine 2020 Jul 24:1-8. Epub 2020 Jul 24.

2Radiation Oncology.

Objective: To characterize the clinical outcomes when stereotactic body radiation therapy (SBRT) alone is used to treat high-grade epidural disease without prior surgical decompression, the authors conducted a retrospective cohort study of patients treated at the Memorial Sloan Kettering Cancer Center between 2014 and 2018. The authors report locoregional failure (LRF) for a cohort of 31 cases treated with hypofractionated SBRT alone for grade 2 epidural spinal cord compression (ESCC) with radioresistant primary cancer histology.

Methods: High-grade epidural disease was defined as grade 2 ESCC, which is notable for radiographic deformation of the spinal cord by metastatic disease. Kaplan-Meier survival curves and cumulative incidence functions were generated to examine the survival and incidence experiences of the sample level with respect to overall survival, LRF, and subsequent requirement of vertebral same-level surgery (SLS) due to tumor progression or fracture. Associations with dosimetric analysis were also examined.

Results: Twenty-nine patients undergoing 31 episodes of hypofractionated SBRT alone for grade 2 ESCC between 2014 and 2018 were identified. The 1-year and 2-year cumulative incidences of LRF were 10.4% (95% CI 0-21.9) and 22.0% (95% CI 5.5-38.4), respectively. The median survival was 9.81 months (95% CI 8.12-18.54). The 1-year cumulative incidence of SLS was 6.8% (95% CI 0-16.0) and the 2-year incidence of SLS was 14.5% (95% CI 0.6-28.4). All patients who progressed to requiring surgery had index lesions at the thoracic apex (T5-7).

Conclusions: In carefully selected patients, treatment of grade 2 ESCC disease with hypofractionated SBRT alone offers a 1-year cumulative incidence of LRF similar to that in low-grade ESCC and postseparation surgery adjuvant hypofractionated SBRT. Use of SBRT alone has a favorable safety profile and a low cumulative incidence of progressive disease requiring open surgical intervention (14.5%).
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http://dx.doi.org/10.3171/2020.4.SPINE20118DOI Listing
July 2020

The Role of Minimal Access Surgery in the Treatment of Spinal Metastatic Tumors.

Global Spine J 2020 Apr 28;10(2 Suppl):79S-87S. Epub 2020 May 28.

Memorial Sloan Kettering Cancer Center, New York, NY, USA.

Study Design: Literature review.

Objective: To provide an overview of the recent advances in minimal access surgery (MAS) for spinal metastases.

Methods: Literature review.

Results: Experience gained from MAS in the trauma, degenerative and deformity settings has paved the road for MAS techniques for spinal cancer. Current MAS techniques for the treatment of spinal metastases include percutaneous instrumentation, mini-open approaches for decompression and tumor resection with or without tubular/expandable retractors and thoracoscopy/endoscopy. Cancer care requires a multidisciplinary effort and adherence to treatment algorithms facilitates decision making, ultimately improving patient outcomes. Specific algorithms exist to help guide decisions for MAS for extradural spinal metastases. One major paradigm shift has been the implementation of percutaneous stabilization for treatment of neoplastic spinal instability. Percutaneous stabilization can be enhanced with cement augmentation for increased durability and pain palliation. Unlike osteoporotic fractures, kyphoplasty and vertebroplasty are known to be effective therapies for symptomatic pathologic compression fractures as supported by high level evidence. The integration of systemic body radiation therapy for spinal metastases has eliminated the need for aggressive tumor resection allowing implementation of MAS epidural tumor decompression via tubular or expandable retractors and preliminary data exist regarding laser interstitial thermal therapy and radiofrequency ablation for tumor control. Neuronavigation and robotic systems offer increased precision, facilitating the role of MAS for spinal metastases.

Conclusions: MAS has a significant role in the treatment of spinal metastases. This review highlights the current utilization of minimally invasive surgical strategies for treatment of spinal metastases.
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http://dx.doi.org/10.1177/2192568219895265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263343PMC
April 2020

Does the SORG algorithm generalize to a contemporary cohort of patients with spinal metastases on external validation?

Spine J 2020 10 16;20(10):1646-1652. Epub 2020 May 16.

Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.

Background Context: The SORG machine-learning algorithms were previously developed for preoperative prediction of overall survival in spinal metastatic disease. On sub-group analysis of a previous external validation, these algorithms were found to have diminished performance on patients treated after 2010.

Purpose: The purpose of this study was to assess the performance of these algorithms on a large contemporary cohort of consecutive spinal metastatic disease patients.

Study Design/setting: Retrospective study performed at a tertiary care referral center.

Patient Sample: Patients of 18 years and older treated with surgery for metastatic spinal disease between 2014 and 2016.

Outcome Measures: Ninety-day and one-year mortality.

Methods: Baseline patient and tumor characteristics of the validation cohort were compared to the development cohort using bivariate logistic regression. Performance of the SORG algorithms on external validation in the contemporary cohort was assessed with discrimination (c-statistic and receiver operating curve), calibration (calibration plot, intercept, and slope), overall performance (Brier score compared to the null-model Brier score), and decision curve analysis.

Results: Overall, 200 patients were included with 90-day and 1-year mortality rates of 55 (27.6%) and 124 (62.9%), respectively. The contemporary external validation cohort and the developmental cohort differed significantly on primary tumor histology, presence of visceral metastases, American Spinal Injury Association impairment scale, and preoperative laboratory values. The SORG algorithms for 90-day and 1-year mortality retained good discriminative ability (c-statistic of 0.81 [95% confidence interval [CI], 0.74-0.87] and 0.84 [95% CI, 0.77-0.89]), overall performance, and decision curve analysis. The algorithm for 90-day mortality showed almost perfect calibration reflected in an overall calibration intercept of -0.07 (95% CI: -0.50, 0.35). The 1-year mortality algorithm underestimated mortality mainly for the lowest predicted probabilities with an overall intercept of 0.57 (95% CI: 0.18, 0.96).

Conclusions: The SORG algorithms for survival in spinal metastatic disease generalized well to a contemporary cohort of consecutively treated patients from an external institutional. Further validation in international cohorts and large, prospective multi-institutional trials is required to confirm or refute the findings presented here. The open-access algorithms are available here: https://sorg-apps.shinyapps.io/spinemetssurvival/.
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http://dx.doi.org/10.1016/j.spinee.2020.05.003DOI Listing
October 2020

Full endoscopic resection of a lumbar osteoblastoma: technical note.

J Neurosurg Spine 2020 Apr 3:1-4. Epub 2020 Apr 3.

Departments of1Neurological Surgery and.

Osteoblastomas are a rare, benign primary bone tumor accounting for 1% of all primary bone tumors, with 40% occurring within the spine. Gross-total resection (GTR) is curative, although depending on location, this can require destabilization of the spine and necessitate instrumented fixation. Through the use of minimally invasive, muscle-sparing approaches, these lesions can be resected while maintaining structural integrity of the spine. The authors present a case report and technical note of a single patient describing the use of a purely endoscopic technique to resect a right L5 superior articulating process osteoblastoma in a 45-year-old woman. The patient underwent an image-guided endoscopic resection of her superior articulating facet osteoblastoma. Intraoperative CT demonstrated GTR. On postoperative examination, she remained neurologically intact with resolution of her pain. At follow-up, she remained pain free. Resection of lumbar osteoblastoma through a fully endoscopic approach was a safe and effective technique in this patient. This technique allowed for GTR without compromising spinal structural integrity, thus eliminating the need for instrumented fixation.
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http://dx.doi.org/10.3171/2020.2.SPINE191091DOI Listing
April 2020

Neurosurg Clin N Am 2020 04 5;31(2):xi-xii. Epub 2020 Feb 5.

Neuro Advanced Care Unit, Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, C707, New York, NY 10065, USA. Electronic address:

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http://dx.doi.org/10.1016/j.nec.2020.01.001DOI Listing
April 2020

Surgical Management of Intramedullary Spinal Cord Tumors.

Neurosurg Clin N Am 2020 Apr 31;31(2):237-249. Epub 2020 Jan 31.

Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; Department of Neurological Surgery, Weill Cornell Medical College, 525 E. 68th St, New York, NY 10065, USA.

Intramedullary spinal cord tumors (IMSCT) comprise a rare subset of CNS tumors that have distinct management strategies based on histopathology. These tumors often present challenges in regards to optimal timing for surgery, invasiveness, and recurrence. Advances in microsurgical techniques and technological adjuncts have improved extent of resection and outcomes with IMSCT. Furthermore, adjuvant therapies including targeted immunotherapies and image-guided radiation therapy have witnessed rapid development over the past decade, further improving survival for many of these patients. In this review, we provide an overview of types, epidemiology, imaging characteristics, surgical management strategies, and future areas of research for IMSCT.
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http://dx.doi.org/10.1016/j.nec.2019.12.004DOI Listing
April 2020

Hybrid Therapy for Spinal Metastases.

Neurosurg Clin N Am 2020 Apr 24;31(2):191-200. Epub 2020 Jan 24.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. Electronic address:

The combination of separation surgery and stereotactic body radiotherapy optimizes the treatment of metastatic spine tumors. The integration of SBRT into treatment paradigms produces superb local control rates and consequently has diminished the role of surgery from principle treatment to one of adjuvant therapy. Under this paradigm, hybrid therapy for the treatment of metastatic spine tumors employs separation surgery to decompress the spinal cord and stabilize the spine while creating a safe target for ablative SBRT. Hybrid therapy is well tolerated, allows an early return to systemic therapy, and provides durable, local tumor control compared with more aggressive traditional approaches.
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http://dx.doi.org/10.1016/j.nec.2019.11.001DOI Listing
April 2020

Neurologic, Oncologic, Mechanical, and Systemic and Other Decision Frameworks for Spinal Disease.

Neurosurg Clin N Am 2020 Apr 6;31(2):151-166. Epub 2020 Feb 6.

Memorial Sloan Kettering Cancer Center, 1275 York Avenue, c705, New York, NY 10021, USA. Electronic address:

The incidence of metastatic spinal disease is increasing as systemic treatment options are improving and concurrently increasing the life expectancy of patients, and the interventions are becoming increasingly complex. Treatment decisions are also complicated by the increasing armamentarium of surgical treatment options. Decision-making frameworks such as NOMS (neurologic, oncologic, mechanical, and systemic) help guide practitioners in their decision making and provide a structure that would be readily adaptable to the evolving landscape of systemic, surgical, and radiation treatments. This article describes these decision-making frameworks, discusses their relative benefits and shortcomings, and details our approach to treating these complex patients.
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http://dx.doi.org/10.1016/j.nec.2019.11.005DOI Listing
April 2020

Long-term outcomes of high-dose single-fraction radiosurgery for chordomas of the spine and sacrum.

J Neurosurg Spine 2019 Oct 18:1-10. Epub 2019 Oct 18.

2Neurosurgery.

Objective: The current treatment of chordomas is associated with significant morbidity, high rates of local recurrence, and the potential for metastases. Stereotactic radiosurgery (SRS) as a primary treatment could reduce the need for en bloc resection to achieve wide or marginal margins. Spinal SRS outcomes support the exploration of SRS's role in the durable control of these conventionally radioresistant tumors. The goal of the study was to evaluate outcomes of patients with primary chordomas treated with spinal SRS alone or in combination with surgery.

Methods: Clinical records were reviewed for outcomes of patients with primary chordomas of the mobile spine and sacrum who underwent single-fraction SRS between 2006 and 2017. Radiographic local recurrence-free survival (LRFS), overall survival (OS), symptom response, and toxicity were assessed in relation to the extent of surgery.

Results: In total, 35 patients with de novo chordomas of the mobile spine (n = 17) and sacrum (n = 18) received SRS and had a median post-SRS follow-up duration of 38.8 months (range 2.0-122.9 months). The median planning target volume dose was a 24-Gy single fraction (range 18-24 Gy). Overall, 12 patients (34%) underwent definitive SRS and 23 patients (66%) underwent surgery and either neoadjuvant or postoperative adjuvant SRS. Definitive SRS was selectively used to treat both sacral (n = 7) and mobile spine (n = 5) chordomas. Surgical strategies for the mobile spine were either intralesional, gross-total resection (n = 5) or separation surgery (n = 7) and for the sacrum en bloc sacrectomy (n = 11). The 3- and 5-year LRFS rates were 86.2% and 80.5%, respectively. Among 32 patients (91%) receiving 24-Gy radiation doses, the 3- and 5-year LRFS rates were 96.3% and 89.9%, respectively. The 3- and 5-year OS rates were 90.0% and 84.3%, respectively. The symptom response rate to treatment was 88% for pain and radiculopathy. The extent or type of surgery was not associated with LRFS, OS, or symptom response rates (p > 0.05), but en bloc resection was associated with higher surgical toxicity, as measured using the Common Terminology Criteria for Adverse Events (version 5.0) classification tool, than epidural decompression and curettage/intralesional resection (p = 0.03). The long-term rate of toxicity ≥ grade 2 was 31%, including 20% grade 3 tissue necrosis, recurrent laryngeal nerve palsy, myelopathy, fracture, and secondary malignancy.

Conclusions: High-dose spinal SRS offers the chance for durable radiological control and effective symptom relief with acceptable toxicity in patients with primary chordomas as either a definitive or adjuvant therapy.
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http://dx.doi.org/10.3171/2019.7.SPINE19515DOI Listing
October 2019

Treatment of dedifferentiated chordoma: a retrospective study from a large volume cancer center.

J Neurooncol 2019 Sep 23;144(2):369-376. Epub 2019 Jul 23.

Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Box 22, New York, NY, 10065, USA.

Objective: Dedifferentiated chordomas (DC) are genetically and clinically distinct from conventional chordomas (CC), exhibiting frequent SMARCB1 alterations and a more aggressive clinical course. We compared treatment and outcomes of DC and CC patients in a retrospective cohort study from a single, large-volume cancer center.

Methods: Overall, 11 DC patients were identified from 1994 to 2017 along with a cohort of 68 historical control patients with CC treated during the same time frame. Clinical variables and outcomes were collected from the medical record and Wilcoxon rank sum or Fisher exact tests were used to make comparisons between the two groups. Kaplan-Meier survival analysis and log-rank tests were used to compare DC and CC overall survival.

Results: DC demonstrated a bimodal age distribution at presentation (36% age 0-24; 64% age > 50). DC patients more commonly presented with metastatic disease than CC patients (36% vs. 3% p = 0.000). DC patients had significantly shorter time to local treatment failure after radiation therapy (11.1 months vs. 34.1 months, p = 0.000). The rate of distant metastasis following treatment was significantly higher in DC compared to CC (57% vs. 5%, p = 0.000). The median overall survival after diagnosis for DC was 20 months (95% CI 0-48 months) compared to 155 months (95% CI 94-216 months) for CC (p = 0.007).

Conclusion: DC patients exhibit significantly higher rates of both synchronous and metachronous metastases, as well as shorter overall survival rates compared to conventional chordoma. The relatively poor survival outcomes with conventional therapies indicate the need to study targeted therapies for the treatment of DC.
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http://dx.doi.org/10.1007/s11060-019-03239-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7594172PMC
September 2019

Adjacent level fracture incidence in single fraction high dose spinal radiosurgery.

Ann Transl Med 2019 May;7(10):211

Department of Surgery, Neurological Divisiony, Memorial Sloan Kettering Cancer Center, New York, NY, USA.

Background: Vertebral body compression fracture (VCF) is a complication following spinal stereotactic radiosurgery (SRS). However, the incidence of VCF in vertebrae adjacent to the level of SRS is unknown. This study aimed to determine the incidence of adjacent level VCF (adjVCF) following spinal SRS.

Methods: A retrospective review of 239 lesions treated with single-fraction SRS from 2011-2014 was performed. Clinical and pathologic factors were collected including evaluation of VCFs in adjacent levels to SRS site. In patients with adjVCFs, dose-volume histograms for adjacent-level endplates were calculated. Cox regression analysis was performed to determine any association among clinical factors and adjVCF occurrence.

Results: Median follow-up was 14.7 months. Twenty-six adjVCFs occurred (10.8%). Of the adjVCFs, 19 had metastases following SRS, and seven did not (2.9% of total treatments). Median time to fracture post-SRS was 13.5 months. In adjVCFs, median of the mean dose to adjacent level fractured endplate was 23.3 Gy, and median of the mean dose of sixteen non-fractured endplates immediately adjacent to the SRS site was 19.1 Gy. Age, gender, and histology were not associated with adjVCF.

Conclusions: AdjVCF after spinal SRS occurs at a rate of 2.9%, when excluding metastatic sites of disease. Adjacent level endplates should be investigated as an organ at risk during SRS planning.
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http://dx.doi.org/10.21037/atm.2019.04.68DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6595213PMC
May 2019

Image guidance in spine tumor surgery.

Neurosurg Rev 2020 Jun 1;43(3):1007-1017. Epub 2019 Jun 1.

Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.

Beginning with basic stereotactic operative methods in neurosurgery, intraoperative navigation and image guidance systems have since become the norm in that field. Following the introduction of image guidance into spinal surgery, there has been a dramatic increase in its utilization across disciplines and pathologies. Spine tumor surgery encompasses a wide range of complex surgical techniques and treatment strategies. Similarly to deformity correction and trauma surgery, spine navigation holds potential to improve outcomes and optimize surgical technique for spinal tumors. Recent data demonstrate the applicability of neuro-navigation in the field of spinal oncology, particularly for spinal stabilization, maximizing extent of resection and integration of minimally invasive therapies. The rapid introduction of new, less invasive, and ablative surgical techniques in spine oncology coupled with the rising incidence of spinal metastatic disease make it imperative for spine surgeons to be familiar with the indications for and limitations of imaging guidance. Herein, we provide a practical, current concepts narrative review on the use of spinal navigation in three areas of spinal oncology: (a) extent of tumor resection, (b) spinal column stabilization, and (c) focal ablation techniques.
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http://dx.doi.org/10.1007/s10143-019-01123-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6885094PMC
June 2020

Outcome analysis of surgery for symptomatic spinal metastases in long-term cancer survivors.

J Neurosurg Spine 2019 Apr 26:1-6. Epub 2019 Apr 26.

Departments of1Neurosurgery.

OBJECTIVEAs patients with metastatic cancer live longer, an increased emphasis is placed on long-term therapeutic outcomes. The current study evaluates outcomes of long-term cancer survivors following surgery for spinal metastases.METHODSThe study population included patients surgically treated at a tertiary cancer center between January 2010 and December 2015 who survived at least 24 months postoperatively. A retrospective chart and imaging review was performed to collect data regarding patient demographics; tumor histology; type and extent of spinal intervention; radiation data, including treatment dose and field; long-term sequelae, including local tumor control; and reoperations, repeat irradiation, or postoperative kyphoplasty at a previously treated level.RESULTSEighty-eight patients were identified, of whom 44 were male, with a mean age of 61 years. The mean clinical follow-up for the cohort was 44.6 months (range 24.2-88.3 months). Open posterolateral decompression and stabilization was performed in 67 patients and percutaneous minimally invasive surgery in 21. In the total cohort, 84% received postoperative adjuvant radiation and 27% were operated on for progression following radiation. Posttreatment local tumor progression was identified in 10 patients (11%) at the index treatment level and 5 additional patients had a marginal failure; all of these patients were treated with repeat irradiation with 5 patients requiring a reoperation. In total, at least 1 additional surgical intervention was performed at the index level in 20 (23%) of the 88 patients: 11 for hardware failure, 5 for progression of disease, 3 for wound complications, and 1 for postoperative hematoma. Most reoperations (85%) were delayed at more than 3 months from the index surgery. Wound infections or dehiscence requiring additional surgical intervention occurred in 3 patients, all of which occurred more than a year postoperatively. Kyphoplasty at a previously operated level was performed in 3 cases due to progressive fractures.CONCLUSIONSDurable tumor control can be achieved in long-term cancer survivors surgically treated for symptomatic spinal metastases with limited complications. Complications observed after long-term follow-up include local tumor recurrence/progression, marginal tumor control failures, early or late hardware complications, late wound complications, and progressive spinal instability or deformity.
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http://dx.doi.org/10.3171/2019.2.SPINE181306DOI Listing
April 2019

Advances in the treatment of metastatic spine tumors: the future is not what it used to be.

J Neurosurg Spine 2019 03;30(3):299-307

An improved understanding of tumor biology, the ability to target tumor drivers, and the ability to harness the immune system have dramatically improved the expected survival of patients diagnosed with cancer. However, many patients continue to develop spine metastases that require local treatment with radiotherapy and surgery. Fortunately, the evolution of radiation delivery and operative techniques permits durable tumor control with a decreased risk of treatment-related toxicity and a greater emphasis on restoration of quality of life and daily function. Stereotactic body radiotherapy allows delivery of ablative radiation doses to the majority of spine tumors, reducing the need for surgery. Among patients who still require surgery for decompression of the spinal cord or spinal column stabilization, minimal access approaches and targeted tumor excision and ablation techniques minimize the surgical risk and facilitate postoperative recovery. Growing interdisciplinary collaboration among scientists and clinicians will further elucidate the synergistic possibilities among systemic, radiation, and surgical interventions for patients with spinal tumors and will bring many closer to curative therapies.
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http://dx.doi.org/10.3171/2018.11.SPINE18709DOI Listing
March 2019

Spinal Instability Neoplastic Score component validation using patient-reported outcomes.

J Neurosurg Spine 2019 01 18:1-7. Epub 2019 Jan 18.

Departments of1Neurological Surgery and.

OBJECTIVE: The Spinal Instability Neoplastic Score (SINS) correlates with preoperative disability and response to stabilization, with patients with higher scores experiencing greater relief after surgery. However, there is a paucity of data demonstrating the extent to which each component contributes to preoperative clinical status and response to stabilization surgery. The objectives of this study were 2-fold. First, to determine how SINS components correlate with pre- and postoperative patient-reported outcomes (PROs). Second, to determine whether patients with higher SINS (10-12) in the "indeterminate" group respond differently to surgery compared to patients with lower SINS (7-9). METHODS: SINS and PROs were prospectively collected in 131 patients undergoing stabilization surgery for metastatic spinal disease. Association of SINS components and their individual scores with preoperative symptom burden and PRO symptom change after surgery was analyzed using the Spearman rank correlation coefficient (rho) and the Kruskal-Wallis test. SINS and association with preoperative PRO scores and mean differences in post- and preoperative PRO scores were compared for 2 SINS categories within the indeterminate group (7-9 vs 10-12) using the Wilcoxon 2-sample test and Wilcoxon signed-rank test. RESULTS: The presence of mechanical pain, followed by metastatic location, correlated most strongly with preoperative functional disability measures and lower disability PRO scores following surgical stabilization. Blastic rather than lytic bone lesions demonstrated stronger association with pain reduction following stabilization. Following surgery, patients with SINS 10-12 demonstrated markedly greater improvement in pain and disability PRO scores nearly across the board compared to patients with SINS 7-9. CONCLUSIONS: The presence of mechanical pain has the strongest correlation with preoperative disability and improvement in pain and disability PRO scores after surgery. Radiographic components of SINS also correlate with preoperative symptom severity and postoperative PRO, supporting their utilization in evaluation of spinal instability. Among patients with indeterminate SINS, patients with higher scores experience greater reduction in pain and disability PRO scores following surgical stabilization, suggesting that the indeterminate-SINS group includes distinct populations.
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http://dx.doi.org/10.3171/2018.9.SPINE18147DOI Listing
January 2019

A NOMS Framework Solution.

Int J Radiat Oncol Biol Phys 2019 01 12;103(1):17-18. Epub 2018 Dec 12.

Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York.

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http://dx.doi.org/10.1016/j.ijrobp.2018.09.026DOI Listing
January 2019

Utility of Cement Augmentation via Percutaneous Fenestrated Pedicle Screws for Stabilization of Cancer-Related Spinal Instability.

Oper Neurosurg (Hagerstown) 2019 05;16(5):593-599

Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York.

Background: Cancer patients experience pathological fractures and the typical poor bone quality frequently complicates stabilization. Methods for overcoming screw failure include utilization of fenestrated screws that permit the injection of bone cement into the vertebral body to augment fixation.

Objective: To evaluate the safety and efficacy of cement augmentation via fenestrated screws.

Methods: A retrospective chart review of patients with neoplastic spinal instability who underwent percutaneous instrumented stabilization with cement augmentation using fenestrated pedicle screws. Patient demographic and treatment data and intraoperative and postoperative complications were evaluated by chart review and radiographic evaluation. Prospectively collected patient reported outcomes (PRO) were evaluated at short (2- <6 mo) and long term (6-12 mo).

Results: Cement augmentation was performed in 216 fenestrated pedicle screws in 53 patients. Three patients required reoperation. One patient had an asymptomatic screw fracture at 6 mo postoperatively that did not require intervention. No cases of lucency around the pedicle screws, rod fractures, or cement extravasation into the spinal canal were observed. Eight cases of asymptomatic, radiographically-detected venous extravasation were found. Systemic complications included a pulmonary cement embolism, a lower extremity deep vein thrombosis, and a postoperative mortality secondary to pulmonary failure from widespread metastatic pulmonary infiltration. Significant improvement in PRO measures was found in short- and long-term analysis.

Conclusion: Cement augmentation of pedicle screws is an effective method to enhance the durability of spinal constructs in the cancer population. Risks include cement extravasation into draining blood vessels, but risk of clinically significant extravasation appears to be exceedingly low.
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http://dx.doi.org/10.1093/ons/opy186DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7311793PMC
May 2019

Change in the cross-sectional area of the thecal sac following balloon kyphoplasty for pathological vertebral compression fractures prior to spine stereotactic radiosurgery.

J Neurosurg Spine 2018 10;30(1):111-118

Departments of2Neurosurgery and.

OBJECTIVEPercutaneous vertebral augmentation procedures such as vertebroplasty and kyphoplasty are often performed in cancer patients to relieve mechanical axial-load pain due to pathological collapse deformities. The collapsed vertebrae in these patients can be associated with varying degrees of spinal canal compromise that can be worsened by kyphoplasty. In this study the authors evaluated changes to the spinal canal, in particular the cross-sectional area of the thecal sac, following balloon kyphoplasty (BKP) prior to stereotactic radiosurgery (SRS).METHODSThe authors retrospectively reviewed the records of all patients with symptomatic vertebral compression fractures caused by metastatic disease who underwent kyphoplasty prior to single-fraction SRS. The pre-BKP cross-sectional image, usually MRI, was compared to the post-BKP CT myelogram required for radiation treatment planning. The cross-sectional area of the thecal sac was calculated pre- and postkyphoplasty, and intraprocedural CT imaging was reviewed for epidural displacement of bone fragments, tumor, or polymethylmethacrylate (PMMA) extravasation. The postkyphoplasty imaging was also evaluated for evidence of fracture progression or fracture reduction.RESULTSAmong 30 consecutive patients, 41 vertebral levels were treated with kyphoplasty, and 24% (10/41) of the augmented levels showed a decreased cross-sectional area of the thecal sac. All 10 of these vertebral levels had preexisting epidural disease and destruction of the posterior vertebral body cortex. No bone fragments were displaced posteriorly. Minor epidural PMMA extravasation occurred in 20% (8/41) of the augmented levels but was present in only 1 of the 10 vertebral segments that showed a decreased cross-sectional area of the thecal sac postkyphoplasty.CONCLUSIONSIn patients with preexisting epidural disease and destruction of the posterior vertebral body cortex who are undergoing BKP for pathological fractures, there is an increased risk of further mass effect upon the thecal sac and the potential to alter the SRS treatment planning.
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http://dx.doi.org/10.3171/2018.6.SPINE18206DOI Listing
October 2018

Survival, local control, and health-related quality of life in patients with oligometastatic and polymetastatic spinal tumors: A multicenter, international study.

Cancer 2019 03 29;125(5):770-778. Epub 2018 Nov 29.

Research Department, AOSpine International, Davos, Switzerland.

Background: The treatment of oligometastatic (≤5 metastases) spinal disease has trended toward ablative therapies, yet to the authors' knowledge little is known regarding the prognosis of patients presenting with oligometastatic spinal disease and the value of this approach. The objective of the current study was to compare the survival and clinical outcomes of patients with cancer with oligometastatic spinal disease with those of patients with polymetastatic (>5 metastases) disease.

Methods: The current study was an international, multicenter, prospective study. Patients who were admitted to a participating spine center with a diagnosis of spinal metastases and who underwent surgical intervention and/or radiotherapy between August 2013 and May 2017 were included. Data collected included demographics, overall survival, local control, and treatment information including surgical, radiotherapy, and systemic therapy details. Health-related quality of life (HRQOL) measures included the EuroQOL 5 dimensions 3-level questionnaire (EQ-5D-3L), the 36-Item Short Form Health Survey (SF-36v2), and the Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ).

Results: Of the 393 patients included in the current study, 215 presented with oligometastatic disease and 178 presented with polymetastatic disease. A significant survival advantage of 90.1% versus 77.3% at 3 months and 77.0% versus 65.1% at 6 months from the time of treatment was found for patients presenting with oligometastatic disease compared with those with polymetastatic disease. It is important to note that both groups experienced significant improvements in multiple HRQOL measures at 6 months after treatment, with no differences in these outcome measures noted between the 2 groups.

Conclusions: The treatment of oligometastatic disease appears to offer a significant survival advantage compared with polymetastatic disease, regardless of treatment choice. HRQOL measures were found to improve in both groups, demonstrating a palliative benefit for all treated patients.
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http://dx.doi.org/10.1002/cncr.31870DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8020734PMC
March 2019

Minimal Access Surgery for Spinal Metastases: Prospective Evaluation of a Treatment Algorithm Using Patient-Reported Outcomes.

World Neurosurg 2018 Dec 4;120:e889-e901. Epub 2018 Sep 4.

Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Neurological Surgery, Weill Cornell Medical College, New York, New York, USA. Electronic address:

Background: Minimal access surgery (MAS) allows for an early return to systemic and radiation therapy in patients with cancer, leading to its increasing usage in the treatment of spinal metastases. Systematic examination of surgical indications resulted in the development of an algorithm for implementation of MAS in the treatment of spinal metastases. The objective of the present study was to evaluate a spine tumor MAS treatment algorithm using patient-reported outcomes for patients with cancer undergoing treatment of spinal metastases.

Methods: We performed a prospective cohort study of patients who had undergone spinal percutaneous instrumented stabilization with the addition of MAS spinal cord or nerve root decompression and/or kyphoplasty when indicated at a tertiary cancer center from December 2013 to August 2016. Validated patient-reported outcome measures, including the Brief Pain Inventory and the MD Anderson Symptom Inventory-spine module, were used. The patient-reported outcome measures were collected and compared at baseline, 3 months, and long-term follow-up (range, 4.5-12 months).

Results: A total of 51 patients were included. MAS resulted in a statistically significant decrease in the severity of pain and improved activity, ability to work, and enjoyment of life (P < 0.001). The improvement was reported at the short- and long-term follow-up points.

Conclusions: We present our treatment algorithm for MAS implementation in the treatment of thoracolumbar spinal metastases. Prospectively collected data have demonstrated that using this algorithm, MAS surgery for the treatment of spinal metastases results in significant decreases in pain severity and symptom interference with daily activities.
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http://dx.doi.org/10.1016/j.wneu.2018.08.182DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6786494PMC
December 2018
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