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Dennis T. Lockney, Timothy Shub, Benjamin Hopkins, Natalie A. Lockney, Nelson Moussazadeh, Eric Lis, Yoshiya Yamada, Adam M. Schmitt, Daniel S. Higginson, Ilya Laufer and Mark Bilsky

while still achieving appropriate tumor control and preventing disease progression. 31 We report on a single-institution series of 12 patients who underwent intralesional resection with separation surgery followed by adjuvant SBRT. Methods IRB approval was obtained. We identified 22 patients with a histologically confirmed diagnosis of chordoma in the mobile spine who underwent resection followed by SBRT at Memorial Sloan Kettering Cancer Center (MSKCC) from 2004 to 2016. Patients who underwent spinal SBRT within 4 months following surgery were included

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Berkeley G. Bate, Nickalus R. Khan, Brent Y. Kimball, Kyle Gabrick and Jason Weaver

growth ( Fig. 1 ). Those with high-grade ESCC and/or mechanical instability undergo debulking and instrumentation, or “separation surgery,” to create a tumor-free margin around the thecal sac and to stabilize the spine. 6 , 18 High-dose SRS may be used as the primary therapy if a safe margin exists between the spinal cord and tumor on initial imaging, eliminating the need for surgery. FIG. 1. Grading of ESCC. Left: Grade 0 is disease confined to bone, Grade 1a disease involves the epidural space but does not compress the dura, Grade 1b disease compresses the

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Charles Fisher and Juliet Batke

(separation surgery) and then administering high-dose SRS to the remaining tumor, thus providing a means of potentially achieving local control while minimizing surgical insult and cord toxicity. The study has a strong rationale and clear purpose: to determine local recurrence rate after separation surgery and SRS. The study design is a retrospective case series involving a relatively large consecutive patient cohort treated at a specialized cancer center between 2002 and 2011. The study design is reasonable for the research question, given the complexity of the patient

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Claudio E. Tatsui, R. Jason Stafford, Jing Li, Jonathan N. Sellin, Behrang Amini, Ganesh Rao, Dima Suki, Amol J. Ghia, Paul Brown, Sun-Ho Lee, Charles E. Cowles, Jeffrey S. Weinberg and Laurence D. Rhines

attain tumoricidal radiation dosing in the epidural compartment and lead to treatment failure. 9 The judicious use of cEBRT, surgery, and SSRS optimized to minimize morbidity in the management of malignant spinal cord compression was popularized by Bilsky et al. in their proposed neurologic, oncologic, mechanical, and systemic (NOMS) decision framework. 4 , 22 These authors coined the term “separation surgery” to describe an operation intended to stabilize the spine and remove the epidural tumor adjacent to the dura mater, rather than one aimed at gross

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Ilya Laufer, J. Bryan Iorgulescu, Talia Chapman, Eric Lis, Weiji Shi, Zhigang Zhang, Brett W. Cox, Yoshiya Yamada and Mark H. Bilsky

potentially to reduce the aggressiveness of tumor resection due to the expectation that residual tumor can be controlled with cytotoxic doses of radiation that spare the spinal cord. 23 , 25–27 Moulding et al. 23 previously reported a pilot study from our institution involving 21 patients who underwent “separation surgery” in which the thecal sac was decompressed by limited posterolateral tumor resection and posterior segmental instrumentation. This limited tumor resection was followed by postoperative single-fraction SRS, with doses ranging from 18 to 24 Gy. The overall

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James P. Caruso, Or Cohen-Inbar, Mark H. Bilsky, Peter C. Gerszten and Jason P. Sheehan

extramedullary paraspinal melanoma metastases. In our experience, intramedullary metastases, or metastases that demonstrate leptomeningeal spread, are not suitable candidates for traditional surgical or radiosurgical intervention. We provide a conceptual overview of recent developments in melanoma immunotherapy, and we devote particular attention to the application of the concept of “separation surgery” and stereotactic radiosurgery (SRS) to treat extramedullary metastatic spinal melanoma. Immunotherapy Introduction to Melanoma Immunotherapy The FDA approvals of

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The evolution of surgical management for vertebral column tumors

JNSPG 75th Anniversary Invited Review Article

Jared Fridley and Ziya L. Gokaslan

widespread adoption at many institutions. Under the NOMS framework, patients who should be considered for surgery are those who have high-grade spinal cord compression and/or spinal instability ( Fig. 2 ). The high rate of local tumor control with SRS led to the concept of “separation surgery” in patients with high-grade metastatic epidural spinal cord compression. 46 The goal of separation surgery is to limit the amount of tumor resection needed by creating a tumor-free margin around the thecal sac and using postoperative SRS for the remaining spinal tumor. By minimizing

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Dhiego Chaves de Almeida Bastos, Richard George Everson, Bruno Fernandes de Oliveira Santos, Ahmed Habib, Rafael A. Vega, Marilou Oro, Ganesh Rao, Jing Li, Amol J. Ghia, Andrew J. Bishop, Debra Nana Yeboa, Behrang Amini, Laurence D. Rhines and Claudio Esteves Tatsui

traditional resistance of certain tumor types to cEBRT, and providing exceptional rates of tumor control. 3 , 7 , 20 However, in cases of high-grade ESCC, proximity to the spinal cord results in reduced radiation doses to the epidural space in order to minimize toxicity. In such cases, Bilsky et al., recommended a more limited surgical decompression aimed at reconstituting the subarachnoid space around the spinal cord (separation surgery) to allow a margin for the safe delivery of a cytotoxic dose of radiation to the remaining tumor while respecting the spinal cord toxicity

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Farideh Nejat, Zohreh Habibi, Mehrdad Goudarzi, Mahdi Souraki Azad, Ehsan Moradi, Vahid Heidari, Maliheh Kadivar, Zahra Ebrahim Soltani and Leila Kouchakzadeh

C raniopagus represents one of the rarest and most complex anomalies in pediatric neurosurgery. Survival depends on the type and extent of joining and the presence or absence of associated anomalies. The greatest risks to conjoined twins are related to anesthesia and surgical intervention. 2 , 17 One of the most important and terrifying issues for the parents, the medical team, and especially for twins who undergo separation surgery at an older age is the death of one of the twins, which can predispose the other one to death from disseminated coagulopathy

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Chunzi Jenny Jin, John Berry-Candelario, Anne S. Reiner, Ilya Laufer, Daniel S. Higginson, Adam M. Schmitt, Eric Lis, Ori Barzilai, Patrick Boland, Yoshiya Yamada and Mark H. Bilsky

candidates for en bloc resection to achieve wide or marginal margins due to high-grade spinal cord or cauda equina compression or bilateral vertebral artery involvement. Mobile spine surgical strategies were either curettage, gross-total resection, or separation surgery. The surgical approach to sacral tumors was en bloc sacrectomy with the goal of achieving wide margins. Titanium implants were used for reconstruction in all mobile spine cases and were used selectively following sacrectomy. Data Sources Hospital electronic medical records provided the following data: age