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Spinal Cord Astrocytomas

  • Mirza Pojskić
  • Kenan I. Arnautović
Chapter

Abstract

Astrocytomas are the most common intramedullary tumors in children and occur secondary to ependymomas in adults. Astrocytomas in adults have better prognoses then their pediatric counterparts. For the purpose of this chapter, we concentrated mostly on low-grade astrocytomas in adults. Term “Low grade” Astrocytomas is usually reserved for WHO I and II tumors. The most common symptoms are pain, gait ataxia, motor weakness, sensory deficits, dysesthesias, and sphincter problems. Astrocytomas often take up contrast homogeneously on T1-weighted spinal MRI. On axial scans, astrocytomas are often eccentric and may transgress the pia mater to grow exophytically. The ideal goal of treatment should be radical gross total resection of tumor using microsurgical techniques with obligatory intraoperative neuromonitoring while preserving and improving normal neurological function. Surgical technique has been described in detail with accompanying video. The extent of surgical resection shows a significant association with survival and reduction of the risk of disease progression. Specific surgical aspects and complications have been discussed. The strongest predicting factor of functional outcome is the preoperative neurological condition. Median overall survival for low grade spinal astrocytomas was reported between 91 and 156 months (7.58–13 years) whereas pathologic grade is the strongest prognostic factor of overall survival and progression free survival. Recurrence, malignant transformation and role of adjuvant treatment have been discussed.

Keywords

Spinal cord astrocytoma Low grade astrocytoma Pilocytic astrocytoma Surgical technique 

Supplementary material

Video 13.1.

Microsurgical resection of a spinal cord astrocytoma of the thoracic spine (MPG 521892 kb)

References

  1. 1.
    Benes V, Barsa P, Suchomel P. Prognostic factors in intramedullary astrocytomas: a literature review. Eur Spine J. 2009;18(10):1397–422.  https://doi.org/10.1007/s00586-009-1076-8.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Raco A, Esposito V, Lenzi J, Piccirilli M, Delfini R, Cantore G. Long-term follow-up of intramedullary spinal cord tumors: a series of 202 cases. Neurosurgery. 2005;56(5):972–81. discussion 972–981PubMedGoogle Scholar
  3. 3.
    Samii JKM. Surgery of spinal tumors. Berlin: Springer; 2007.  https://doi.org/10.1007/978-3-540-44715-3.CrossRefGoogle Scholar
  4. 4.
    Adams H, Avendaño J, Raza SM, Gokaslan ZL, Jallo GI, Quiñones-Hinojosa A. Prognostic factors and survival in primary malignant astrocytomas of the spinal cord: a population-based analysis from 1973 to 2007. Spine (Phila Pa 1976). 2012;37(12):E727–35.  https://doi.org/10.1097/BRS.0b013e31824584c0.CrossRefGoogle Scholar
  5. 5.
    Louis DN, Perry A, Reifenberger G, von Deimling A, Figarella-Branger D, Cavenee WK, Ohgaki H, Wiestler OD, Kleihues P, Ellison DW. The 2016 World Health Organization Classification of Tumors of the Central Nervous System: a summary. Acta Neuropathol. 2016;131(6):803–20.  https://doi.org/10.1007/s00401-016-1545-1.CrossRefGoogle Scholar
  6. 6.
    Banan R, Hartmann C. The new WHO 2016 classification of brain tumors-what neurosurgeons need to know. Acta Neurochir. 2017;159(3):403–18.  https://doi.org/10.1007/s00701-016-3062-3.PubMedCrossRefGoogle Scholar
  7. 7.
    Houten JK, Cooper PR. Spinal cord astrocytomas: presentation, management and outcome. J Neurooncol. 2000;47(3):219–24.PubMedCrossRefGoogle Scholar
  8. 8.
    Epstein FJ, Farmer JP, Freed D. Adult intramedullary astrocytomas of the spinal cord. J Neurosurg. 1992;77(3):355–9.  https://doi.org/10.3171/jns.1992.77.3.0355.PubMedCrossRefGoogle Scholar
  9. 9.
    Minehan KJ, Shaw EG, Scheithauer BW, Davis DL, Onofrio BM. Spinal cord astrocytoma: pathological and treatment considerations. J Neurosurg. 1995;83(4):590–5.  https://doi.org/10.3171/jns.1995.83.4.0590.PubMedCrossRefGoogle Scholar
  10. 10.
    Ryu SJ, Kim JY, Kim KH, Park JY, Kuh SU, Chin DK, Kim KS, Cho YE, Kim SH. A retrospective observational study on the treatment outcomes of 26 patients with spinal cord astrocytoma including two cases of malignant transformation. Eur Spine J. 2016;25(12):4067–79.  https://doi.org/10.1007/s00586-016-4475-7.PubMedCrossRefGoogle Scholar
  11. 11.
    Yang S, Yang X, Hong G. Surgical treatment of one hundred seventy-four intramedullary spinal cord tumors. Spine (Phila Pa 1976). 2009;34(24):2705–10.  https://doi.org/10.1097/BRS.0b013e3181b43484.CrossRefGoogle Scholar
  12. 12.
    Ellezam B, Theeler BJ, Walbert T, Mammoser AG, Horbinski C, Kleinschmidt-DeMasters BK, Perry A, Puduvalli V, Fuller GN, Bruner JM, Aldape KD. Low rate of R132H IDH1 mutation in infratentorial and spinal cord grade II and III diffuse gliomas. Acta Neuropathol. 2012;124(3):449–51.  https://doi.org/10.1007/s00401-012-1011-7.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Gessi M, Gielen GH, Dreschmann V, Waha A, Pietsch T. High frequency of H3F3A (K27M) mutations characterizes pediatric and adult high-grade gliomas of the spinal cord. Acta Neuropathol. 2015;130(3):435–7.  https://doi.org/10.1007/s00401-015-1463-7.PubMedCrossRefGoogle Scholar
  14. 14.
    Harraher CD, Vogel H, Steinberg GK. Spinal pilocytic astrocytoma in an elderly patient. World Neurosurg. 2013;79(5–6):799.E797–9.  https://doi.org/10.1016/j.wneu.2011.10.033.CrossRefGoogle Scholar
  15. 15.
    Ida CM, Lambert SR, Rodriguez FJ, Voss JS, Mc Cann BE, Seys AR, Halling KC, Collins VP, Giannini C. BRAF alterations are frequent in cerebellar low-grade astrocytomas with diffuse growth pattern. J Neuropathol Exp Neurol. 2012;71(7):631–9.  https://doi.org/10.1097/NEN.0b013e31825c448a.PubMedCrossRefGoogle Scholar
  16. 16.
    Horbinski C, Hamilton RL, Nikiforov Y, Pollack IF. Association of molecular alterations, including BRAF, with biology and outcome in pilocytic astrocytomas. Acta Neuropathol. 2010;119(5):641–9.  https://doi.org/10.1007/s00401-009-0634-9.PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Zadnik PL, Gokaslan ZL, Burger PC, Bettegowda C. Spinal cord tumours: advances in genetics and their implications for treatment. Nat Rev Neurol. 2013;9(5):257–66.  https://doi.org/10.1038/nrneurol.2013.48.PubMedPubMedCentralCrossRefGoogle Scholar
  18. 18.
    Babu R, Karikari IO, Owens TR, Bagley CA. Spinal cord astrocytomas: a modern 20-year experience at a single institution. Spine (Phila Pa 1976). 2014;39(7):533–40.  https://doi.org/10.1097/BRS.0000000000000190.CrossRefGoogle Scholar
  19. 19.
    Robinson CG, Prayson RA, Hahn JF, Kalfas IH, Whitfield MD, Lee SY, Suh JH. Long-term survival and functional status of patients with low-grade astrocytoma of spinal cord. Int J Radiat Oncol Biol Phys. 2005;63(1):91–100.  https://doi.org/10.1016/j.ijrobp.2005.01.009.PubMedCrossRefGoogle Scholar
  20. 20.
    Kim MS, Chung CK, Choe G, Kim IH, Kim HJ. Intramedullary spinal cord astrocytoma in adults: postoperative outcome. J Neurooncol. 2001;52(1):85–94.PubMedCrossRefGoogle Scholar
  21. 21.
    Abdel-Wahab M, Etuk B, Palermo J, Shirato H, Kresl J, Yapicier O, Walker G, Scheithauer BW, Shaw E, Lee C, Curran W, Thomas T, Markoe A. Spinal cord gliomas: A multi-institutional retrospective analysis. Int J Radiat Oncol Biol Phys. 2006;64(4):1060–71.  https://doi.org/10.1016/j.ijrobp.2005.09.038.PubMedCrossRefGoogle Scholar
  22. 22.
    Samii M, Klekamp J. Surgical results of 100 intramedullary tumors in relation to accompanying syringomyelia. Neurosurgery. 1994;35(5):865–73. discussion 873CrossRefGoogle Scholar
  23. 23.
    Nakamura M, Chiba K, Ishii K, Ogawa Y, Takaishi H, Matsumoto M, Toyama Y. Surgical outcomes of spinal cord astrocytomas. Spinal Cord. 2006;44(12):740–5.  https://doi.org/10.1038/sj.sc.3101932.PubMedCrossRefGoogle Scholar
  24. 24.
    Nakamura M, Ishii K, Watanabe K, Tsuji T, Takaishi H, Matsumoto M, Toyama Y, Chiba K. Surgical treatment of intramedullary spinal cord tumors: prognosis and complications. Spinal Cord. 2008;46(4):282–6.  https://doi.org/10.1038/sj.sc.3102130.PubMedCrossRefGoogle Scholar
  25. 25.
    Abd-El-Barr MM, Huang KT, Chi JH. Infiltrating spinal cord astrocytomas: Epidemiology, diagnosis, treatments and future directions. J Clin Neurosci. 2016;29:15–20.  https://doi.org/10.1016/j.jocn.2015.10.048.PubMedCrossRefGoogle Scholar
  26. 26.
    Parker F, Campello C, Lejeune JP, David P, Herbrecht A, Aghakhani N, Messerer M. Intramedullary astrocytomas: A French retrospective multicenter study. Neurochirurgie. 2017;  https://doi.org/10.1016/j.neuchi.2016.09.007.PubMedCrossRefGoogle Scholar
  27. 27.
    Fakhreddine MH, Mahajan A, Penas-Prado M, Weinberg J, McCutcheon IE, Puduvalli V, Brown PD. Treatment, prognostic factors, and outcomes in spinal cord astrocytomas. Neuro Oncol. 2013;15(4):406–12.  https://doi.org/10.1093/neuonc/nos309.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Huddart R, Traish D, Ashley S, Moore A, Brada M. Management of spinal astrocytoma with conservative surgery and radiotherapy. Br J Neurosurg. 1993;7(5):473–81.PubMedCrossRefGoogle Scholar
  29. 29.
    Jyothirmayi R, Madhavan J, Nair MK, Rajan B. Conservative surgery and radiotherapy in the treatment of spinal cord astrocytoma. J Neurooncol. 1997;33(3):205–11.PubMedCrossRefGoogle Scholar
  30. 30.
    Zhao M, Shi B, Chen T, Zhang Y, Geng T, Qiao L, Zhang M, He L, Zuo H, Wang G. Axial MR diffusion tensor imaging and tractography in clinical diagnosed and pathology confirmed cervical spinal cord astrocytoma. J Neurol Sci. 2017;375:43–51.  https://doi.org/10.1016/j.jns.2017.01.044.PubMedCrossRefGoogle Scholar
  31. 31.
    Klekamp J. Treatment of intramedullary tumors: analysis of surgical morbidity and long-term results. J Neurosurg Spine. 2013;19(1):12–26.  https://doi.org/10.3171/2013.3.SPINE121063.PubMedCrossRefGoogle Scholar
  32. 32.
    Kim WH, Yoon SH, Kim CY, Kim KJ, Lee MM, Choe G, Kim IA, Kim JH, Kim YJ, Kim HJ. Temozolomide for malignant primary spinal cord glioma: an experience of six cases and a literature review. J Neurooncol. 2011;101(2):247–54.  https://doi.org/10.1007/s11060-010-0249-y.PubMedCrossRefGoogle Scholar
  33. 33.
    Minehan KJ, Brown PD, Scheithauer BW, Krauss WE, Wright MP. Prognosis and treatment of spinal cord astrocytoma. Int J Radiat Oncol Biol Phys. 2009;73(3):727–33.  https://doi.org/10.1016/j.ijrobp.2008.04.060.PubMedCrossRefGoogle Scholar
  34. 34.
    Rodrigues GB, Waldron JN, Wong CS, Laperriere NJ. A retrospective analysis of 52 cases of spinal cord glioma managed with radiation therapy. Int J Radiat Oncol Biol Phys. 2000;48(3):837–42.PubMedCrossRefGoogle Scholar
  35. 35.
    Lee HK, Chang EL, Fuller GN, Aldape KD, Atkinson GJ, Levy LB, McCutcheon IE, Maor MH. The prognostic value of neurologic function in astrocytic spinal cord glioma. Neuro Oncol. 2003;5(3):208–13.  https://doi.org/10.1215/S1152851702000595.PubMedPubMedCentralCrossRefGoogle Scholar
  36. 36.
    Sandalcioglu IE, Gasser T, Asgari S, Lazorisak A, Engelhorn T, Egelhof T, Stolke D, Wiedemayer H. Functional outcome after surgical treatment of intramedullary spinal cord tumors: experience with 78 patients. Spinal Cord. 2005;43(1):34–41.  https://doi.org/10.1038/sj.sc.3101668.PubMedCrossRefGoogle Scholar
  37. 37.
    Ardeshiri A, Chen B, Hütter BO, Oezkan N, Wanke I, Sure U, Sandalcioglu IE. Intramedullary spinal cord astrocytomas: the influence of localization and tumor extension on resectability and functional outcome. Acta Neurochir. 2013;155(7):1203–7.  https://doi.org/10.1007/s00701-013-1762-5.PubMedCrossRefGoogle Scholar
  38. 38.
    Innocenzi G, Salvati M, Cervoni L, Delfini R, Cantore G. Prognostic factors in intramedullary astrocytomas. Clin Neurol Neurosurg. 1997;99(1):1–5.PubMedCrossRefGoogle Scholar
  39. 39.
    McGirt MJ, Goldstein IM, Chaichana KL, Tobias ME, Kothbauer KF, Jallo GI. Extent of surgical resection of malignant astrocytomas of the spinal cord: outcome analysis of 35 patients. Neurosurgery. 2008;63(1):55–60.; discussion 60–51.  https://doi.org/10.1227/01.NEU.0000335070.37943.09.PubMedCrossRefGoogle Scholar
  40. 40.
    Karikari IO, Nimjee SM, Hodges TR, Cutrell E, Hughes BD, Powers CJ, Mehta AI, Hardin C, Bagley CA, Isaacs RE, Haglund MM, Friedman AH. Impact of tumor histology on resectability and neurological outcome in primary intramedullary spinal cord tumors: a single-center experience with 102 patients. Neurosurgery. 2015;76(Suppl 1):S4–13; discussion S13.  https://doi.org/10.1227/01.neu.0000462073.71915.12.PubMedCrossRefGoogle Scholar
  41. 41.
    Seki T, Hida K, Yano S, Aoyama T, Koyanagi I, Sasamori T, Hamauch S, Houkin K. Clinical factors for prognosis and treatment guidance of spinal cord astrocytoma. Asian Spine J. 2016;10(4):748–54.  https://doi.org/10.4184/asj.2016.10.4.748.PubMedPubMedCentralCrossRefGoogle Scholar
  42. 42.
    Arnautovic KI, Kovacevic M. CSF-related complications after intradural spinal tumor surgery: utility of an autologous fat graft. Med Arch. 2016;70(6):460–5.  https://doi.org/10.5455/medarh.2016.70.460-465.PubMedPubMedCentralCrossRefGoogle Scholar
  43. 43.
    Garcés-Ambrossi GL, McGirt MJ, Mehta VA, Sciubba DM, Witham TF, Bydon A, Wolinksy JP, Jallo GI, Gokaslan ZL. Factors associated with progression-free survival and long-term neurological outcome after resection of intramedullary spinal cord tumors: analysis of 101 consecutive cases. J Neurosurg Spine. 2009;11(5):591–9.  https://doi.org/10.3171/2009.4.SPINE08159.PubMedCrossRefGoogle Scholar
  44. 44.
    Eroes CA, Zausinger S, Kreth FW, Goldbrunner R, Tonn JC. Intramedullary low grade astrocytoma and ependymoma. Surgical results and predicting factors for clinical outcome. Acta Neurochir. 2010;152(4):611–8.  https://doi.org/10.1007/s00701-009-0577-x.PubMedCrossRefGoogle Scholar
  45. 45.
    Pojskić M, Arnautović K. Prone position for intracranial procedures. In: Arthur A, Foley K, Hamm CW, editors. Perioperative considerations and positioning for neurosurgical procedures. New York: Springer; 2018.Google Scholar
  46. 46.
    Kwee MM, Ho YH, Rozen WM. The prone position during surgery and its complications: a systematic review and evidence-based guidelines. Int Surg. 2015;100(2):292–303.  https://doi.org/10.9738/INTSURG-D-13-00256.1.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Matjasko J, Petrozza P, Cohen M, Steinberg P. Anesthesia and surgery in the seated position: analysis of 554 cases. Neurosurgery. 1985;17(5):695–702.PubMedCrossRefGoogle Scholar
  48. 48.
    Bharti N, Bala I. Kinking of endotracheal tube during posterior fossa surgery. Indian J Anaesth. 2010;54(2):172–3.  https://doi.org/10.4103/0019-5049.63629.PubMedPubMedCentralCrossRefGoogle Scholar
  49. 49.
    Lonjaret L, Lairez O, Minville V, Geeraerts T. Optimal perioperative management of arterial blood pressure. Integr Blood Press Control. 2014;7:49–59.  https://doi.org/10.2147/IBPC.S45292.PubMedPubMedCentralCrossRefGoogle Scholar
  50. 50.
    Biais M, Bernard O, Ha JC, Degryse C, Sztark F. Abilities of pulse pressure variations and stroke volume variations to predict fluid responsiveness in prone position during scoliosis surgery. Br J Anaesth. 2010;104(4):407–13.  https://doi.org/10.1093/bja/aeq031.PubMedCrossRefGoogle Scholar
  51. 51.
    Dutton RP. Controlled hypotension for spinal surgery. Eur Spine J. 2004;13(Suppl 1):S66–71.  https://doi.org/10.1007/s00586-004-0756-7.PubMedPubMedCentralCrossRefGoogle Scholar
  52. 52.
    Bonsanto MM, Metzner R, Aschoff A, Tronnier V, Kunze S, Wirtz CR. 3D ultrasound navigation in syrinx surgery - a feasibility study. Acta Neurochir. 2005;147(5):533–40.; discussion 540–531.  https://doi.org/10.1007/s00701-005-0505-7.PubMedCrossRefGoogle Scholar
  53. 53.
    Kolstad F, Rygh OM, Selbekk T, Unsgaard G, Nygaard OP. Three-dimensional ultrasonography navigation in spinal cord tumor surgery. Technical note. J Neurosurg Spine. 2006;5(3):264–70.  https://doi.org/10.3171/spi.2006.5.3.264.PubMedCrossRefGoogle Scholar
  54. 54.
    Shamov T, Eftimov T, Kaprelyan A, Enchev Y. Ultrasound-based neuronavigation and spinal cord tumour surgery - marriage of convenience or notified incompatibility? Turk Neurosurg. 2013;23(3):329–35.  https://doi.org/10.5137/1019-5149.JTN.6639-12.2.PubMedCrossRefGoogle Scholar
  55. 55.
    Ivanov M, Budu A, Sims-Williams H, Poeata I. Using Intraoperative Ultrasonography for Spinal Cord Tumor Surgery. World Neurosurg. 2017;97:104–11.  https://doi.org/10.1016/j.wneu.2016.09.097.PubMedCrossRefGoogle Scholar
  56. 56.
    Brotchi J. Intramedullary astrocytomas surgery in adult patients: the rationale for cautious surgery. World Neurosurg. 2013;80(5):e139–40.  https://doi.org/10.1016/j.wneu.2011.12.065.PubMedCrossRefGoogle Scholar
  57. 57.
    Sala F, Palandri G, Basso E, Lanteri P, Deletis V, Faccioli F, Bricolo A. Motor evoked potential monitoring improves outcome after surgery for intramedullary spinal cord tumors: a historical control study. Neurosurgery. 2006;58(6):1129–43.; discussion 1129–1143.  https://doi.org/10.1227/01.NEU.0000215948.97195.58.PubMedCrossRefGoogle Scholar
  58. 58.
    Matsuyama Y, Sakai Y, Katayama Y, Imagama S, Ito Z, Wakao N, Sato K, Kamiya M, Yukawa Y, Kanemura T, Yanase M, Ishiguro N. Surgical results of intramedullary spinal cord tumor with spinal cord monitoring to guide extent of resection. J Neurosurg Spine. 2009;10(5):404–13.  https://doi.org/10.3171/2009.2.SPINE08698.PubMedCrossRefGoogle Scholar
  59. 59.
    Jin SH, Chung CK, Kim CH, Choi YD, Kwak G, Kim BE. Multimodal intraoperative monitoring during intramedullary spinal cord tumor surgery. Acta Neurochir. 2015;157(12):2149–55.  https://doi.org/10.1007/s00701-015-2598-y.PubMedCrossRefGoogle Scholar
  60. 60.
    Eicker SO, Floeth FW, Kamp M, Steiger HJ, Hänggi D. The impact of fluorescence guidance on spinal intradural tumour surgery. Eur Spine J. 2013;22(6):1394–401.  https://doi.org/10.1007/s00586-013-2657-0.PubMedPubMedCentralCrossRefGoogle Scholar
  61. 61.
    Acerbi F, Cavallo C, Schebesch KM, Akcakaya MO, de Laurentis C, Hamamcioglu MK, Broggi M, Brawanski A, Falco J, Cordella R, Ferroli P, Kiris T, Höhne J. Fluorescein-guided resection of intramedullary spinal cord tumors: results from a preliminary, multicentric, retrospective study. World Neurosurg. 2017;  https://doi.org/10.1016/j.wneu.2017.09.061.PubMedCrossRefGoogle Scholar
  62. 62.
    Wiedemayer H, Sandalcioglu IE, Aalders M, Floerke M, Stolke D. Reconstruction of the laminar roof with miniplates for a posterior approach in intraspinal surgery: technical considerations and critical evaluation of follow-up results. Spine (Phila Pa 1976). 2004;29(16):E333–42.CrossRefGoogle Scholar
  63. 63.
    McGirt MJ, Garcés-Ambrossi GL, Parker SL, Sciubba DM, Bydon A, Wolinksy JP, Gokaslan ZL, Jallo G, Witham TF. Short-term progressive spinal deformity following laminoplasty versus laminectomy for resection of intradural spinal tumors: analysis of 238 patients. Neurosurgery. 2010;66(5):1005–12.  https://doi.org/10.1227/01.NEU.0000367721.73220.C9.PubMedCrossRefGoogle Scholar
  64. 64.
    Harrop JS, Ganju A, Groff M, Bilsky M. Primary intramedullary tumors of the spinal cord. Spine (Phila Pa 1976). 2009;34(22 Suppl):S69–77.  https://doi.org/10.1097/BRS.0b013e3181b95c6f.CrossRefGoogle Scholar
  65. 65.
    Brotchi J. Surgical treatment of intramedullary tumors. Experience with 316 cases. Bull Mem Acad R Med Belg. 2004;159(5–6):335–9. discussion 339–341PubMedGoogle Scholar
  66. 66.
    Xiao R, Abdullah KG, Miller JA, Lubelski D, Steinmetz MP, Shin JH, Krishnaney AA, Mroz TE, Benzel EC. Molecular and clinical prognostic factors for favorable outcome following surgical resection of adult intramedullary spinal cord astrocytomas. Clin Neurol Neurosurg. 2016;144:82–7.  https://doi.org/10.1016/j.clineuro.2016.03.009.PubMedCrossRefGoogle Scholar
  67. 67.
    Jallo GI, Danish S, Velasquez L, Epstein F. Intramedullary low-grade astrocytomas: long-term outcome following radical surgery. J Neurooncol. 2001;53(1):61–6.PubMedCrossRefGoogle Scholar
  68. 68.
    Wong AP, Dahdaleh NS, Fessler RG, Melkonian SC, Lin Y, Smith ZA, Lam SK. Risk factors and long-term survival in adult patients with primary malignant spinal cord astrocytomas. J Neurooncol. 2013;115(3):493–503.  https://doi.org/10.1007/s11060-013-1296-y.PubMedCrossRefGoogle Scholar
  69. 69.
    Sandler HM, Papadopoulos SM, Thornton AF, Ross DA. Spinal cord astrocytomas: results of therapy. Neurosurgery. 1992;30(4):490–3.PubMedGoogle Scholar
  70. 70.
    Santi M, Mena H, Wong K, Koeller K, Olsen C, Rushing EJ. Spinal cord malignant astrocytomas. Clinicopathologic features in 36 cases. Cancer. 2003;98(3):554–61.  https://doi.org/10.1002/cncr.11514.PubMedCrossRefGoogle Scholar
  71. 71.
    Chamberlain MC. Temozolomide for recurrent low-grade spinal cord gliomas in adults. Cancer. 2008;113(5):1019–24.  https://doi.org/10.1002/cncr.23677.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Mirza Pojskić
    • 1
  • Kenan I. Arnautović
    • 2
    • 3
  1. 1.Department of NeurosurgeryUniversity of MarburgMarburgGermany
  2. 2.Semmes MurpheyMemphisUSA
  3. 3.Department of NeurosurgeryUniversity of Tennessee Health Science CenterMemphisUSA

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