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Omidele OO, Connors C, Wainganker N, Badani K, Sfakianos J, Mehrazin R, Jayaratna I. Prognostic factors and treatment impact on overall survival in patients with renal neuroendocrine tumour. BJUI COMPASS 2024; 5:576-584. [PMID: 38873350 PMCID: PMC11168774 DOI: 10.1002/bco2.341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/24/2024] [Accepted: 01/28/2024] [Indexed: 06/15/2024] Open
Abstract
Background Renal neuroendocrine neoplasms (R-NEN) are exceptionally rare tumours characterized by high mortality rates. Objective The objective of this study is to analyse prognostic factors and treatment impact on overall survival in patients with R-NEN. Design setting and participants We identified all patients with R-NEN in the National Cancer Database (NCDB) from 2004 to 2019 and identified prognostic factors for improved survival. Results and limitations Of 542 R-NEN cases, 166 (31%) were neuroendocrine tumour grade 1 (NET-G1), 14 (3%) were neuroendocrine tumour grade 2 (NET-G2), 169 (31%) were neuroendocrine carcinoma (NEC-NOS), 18 (3%) were large cell neuroendocrine carcinoma (LC-NEC) and 175 (32%) were small cell neuroendocrine carcinoma (SC-NEC). Median overall survival for all patients in the study was 44.88 months (SE, 4.265; 95% CI, 27.57-62.19). Median overall survival was 7.89 months (SE 0.67; 95% CI, 6.58-9.20) for patients without surgical intervention and 136.61 months (SE 16.44; 95% CI, 104.38-168.84, p < 0.001) for patients who underwent surgery. Increased age (HR, 1.05; 95% CI, 1.03-1.06; p < 0.001), T4 stage disease (HR, 3.17; 95% CI, 1.96-5.1; p < 0.001), NEC-NOS histology (HR, 2.82; 95% CI, 1.64-4.86; p < 0.001), LC-NEC histology (HR, 2.73; 95% CI, 1.04-7.17; p = 0.041) and SC-NEC histology (HR, 5.17; 95% CI, 2.95-9.05; p < 0.001) were all positive predictors of worsening overall survival. The main limitation of the study is its retrospective design. Conclusion R-NEN is an aggressive tumour characterized by high mortality rates. Surgery continues to be the mainstay of treatment and has shown to provide a survival benefit for most patients. Patient Summary R-NEN is composed of several tumour histologies that differ based on their aggressiveness with NEC-NOS and SC-NEC being the most lethal. Surgery, predominantly through minimally invasive approaches, is the mainstay of treatment and has a clear survival benefit.
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Affiliation(s)
- Olamide O. Omidele
- Department of UrologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Christopher Connors
- Department of UrologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Nikhil Wainganker
- Department of UrologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Ketan Badani
- Department of UrologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - John Sfakianos
- Department of UrologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Reza Mehrazin
- Department of UrologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Isuru Jayaratna
- Department of UrologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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2
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Sarswat S, Singhal A, Sharma A, Yadav R. Primary Small Cell Carcinoma of the Kidney: A Case Study with Emphasis on Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography Findings. Indian J Nucl Med 2024; 39:55-58. [PMID: 38817728 PMCID: PMC11135375 DOI: 10.4103/ijnm.ijnm_139_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/18/2023] [Indexed: 06/01/2024] Open
Abstract
Small cell carcinoma (SCC) of the kidney is included in extrapulmonary SCC which is a group of extremely rare but highly aggressive cancers. There have been only a few case reports and small retrospective series in the literature describing the malignancy in kidneys. Most of the published reports describe the entity as a variant mixed with other tumor subtypes such as urothelial carcinoma, adenocarcinoma, and squamous cell carcinoma. Pure-form SCC in kidneys is exceedingly rare. Fluorodeoxyglucose positron emission tomography-computed tomography plays an essential role in the accurate staging evaluation of this cancer.
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Affiliation(s)
| | | | - Aparna Sharma
- Department of Medical Oncology, NCI, AIIMS, Delhi, India
| | - Rajni Yadav
- Department of Pathology, AIIMS, Delhi, India
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3
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Kasajima A, Pfarr N, von Werder A, Schwamborn K, Gschwend J, Din NU, Esposito I, Weichert W, Pavel M, Agaimy A, Klöppel G. Renal neuroendocrine tumors: clinical and molecular pathology with an emphasis on frequent association with ectopic Cushing syndrome. Virchows Arch 2023; 483:465-476. [PMID: 37405461 PMCID: PMC10611615 DOI: 10.1007/s00428-023-03596-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/21/2023] [Accepted: 06/29/2023] [Indexed: 07/06/2023]
Abstract
Renal neuroendocrine tumors (RenNETs) are rare malignancies with largely unknown biology, hormone expression, and genetic abnormalities. This study aims to improve our understanding of the RenNETs with emphasis of functional, hormonal, and genetic features. Surgically resected RenNETs (N = 13) were retrieved, and immunohistochemistry and next-generation sequencing (NGS) were performed in all cases. In addition, all published RenNETs were systematically reviewed. Our cohort (4 men and 9 women, mean age 42, mean tumor size 7.6 cm) included 2 patients with Cushing syndrome (CS). WHO grade (23% G1, 54% G2, and 23% G3) and tumor progression did not correlate. CS-associated RenNETs (CS-RenNETs) showed a solid and eosinophilic histology and stained for ACTH, while the remaining non-functioning tumors had a trabecular pattern and expressed variably hormones somatostatin (91%), pancreatic polypeptide (63%), glucagon (54%), and serotonin (18%). The transcription factors ISL1 and SATB2 were expressed in all non-functioning, but not in CS-RenNETs. NGS revealed no pathogenic alterations or gene fusions. In the literature review (N = 194), 15 (8%) of the patients had hormonal syndromes, in which CS being the most frequent (7/15). Large tumor size and presence of metastasis were associated with shorter patients' survival (p < 0.01). RenNETs present as large tumors with metastases. CS-RenNETs differ through ACTH production and solid-eosinophilic histology from the non-functioning trabecular RenNETs that produce pancreas-related hormones and express ISL1 and SATB2. MEN1 or DAXX/ARTX abnormalities and fusion genes are not detected in RenNETs, indicating a distinct yet unknown molecular pathogenesis.
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Affiliation(s)
- Atsuko Kasajima
- Department of Pathology, Technical University Munich, Trogerstr. 18, 81675, Munich, Germany.
| | - Nicole Pfarr
- Department of Pathology, Technical University Munich, Trogerstr. 18, 81675, Munich, Germany
| | - Alexander von Werder
- Department of Internal Medicine II, Technical University Munich, Munich, Germany
| | - Kristina Schwamborn
- Department of Pathology, Technical University Munich, Trogerstr. 18, 81675, Munich, Germany
| | - Jürgen Gschwend
- Department of Urology, Technical University Munich, Munich, Germany
| | - Nasir Ud Din
- Section of Histopathology, Department of Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Irene Esposito
- Institute of Pathology, Heinrich-Heine University and University Hospital Düsseldorf, Düsseldorf, Germany
| | - Wilko Weichert
- Department of Pathology, Technical University Munich, Trogerstr. 18, 81675, Munich, Germany
| | - Marianne Pavel
- Department of Internal Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Abbas Agaimy
- Department of Pathology, University Hospital Erlangen, Erlangen, Germany
| | - Günter Klöppel
- Department of Pathology, Technical University Munich, Trogerstr. 18, 81675, Munich, Germany
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4
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Kumari N, Verma R, Agrawal V, Singh UP. Primary Renal Well-Differentiated Neuroendocrine Tumors: Analyis of Six Cases from a Tertiary Care Center in North India with Review of Literature. Int J Surg Pathol 2023; 31:982-992. [PMID: 35903907 DOI: 10.1177/10668969221113494] [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] [Indexed: 11/16/2022]
Abstract
Well-differentiated renal neuroendocrine tumors are rare tumors. As their biologic behavior is not fully known, there is a need to know more about these cases. We performed a retrospective chart review of all the cases diagnosed with renal neuroendocrine tumors from January 2016 to December 2020 (five years) in order to understand their clinical features, morphological characteristics and outcome. We included six cases with mean age of 46.2 years (4 males) in our study. All patients underwent radical nephrectomy. Histologically all showed tumor disposed in nests and trabeculae and majority of the tumors belonged to well-differentiated neuroendocrine tumor Grade 1 (WHO criteria of gastoroenteropancreatic neuroendocrine neoplasms). Lymph node metastasis was seen in two cases at the time of clinical presentation. All the tumors were diffusely positive for neuroendocrine tumor markers (synaptophysin, chromogranin, NSE, CD56). Follow-up data was available in all cases with an average follow-up of two years and neither has shown evidence of metastasis or relapse till last follow-up. Role of morphological patterns and immunohistochemical markers is highlighted with the importance of including Ki-67 index in grading them to better understand their outcome.
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Affiliation(s)
- Neha Kumari
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, India
| | - Ritu Verma
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, India
| | - Vinita Agrawal
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, India
| | - Uday Pratap Singh
- Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, India
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5
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Yang D, Tang W, Wu T, Zhao Z, Liang G. Well‑differentiated neuroendocrine tumor of the right kidney: A case report. Oncol Lett 2023; 25:243. [PMID: 37153061 PMCID: PMC10161357 DOI: 10.3892/ol.2023.13829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 03/10/2023] [Indexed: 05/09/2023] Open
Abstract
Neuroendocrine tumors (NETs) are tumors originating from neuroendocrine cells and peptidergic neurons. Primary renal well-differentiated NETs (WDNETs) are rare and only sporadic cases have been reported worldwide. In November 2021, a 45-year-old female patient was admitted to The Affiliated Hospital of Zunyi Medical University (Zunyi, China) with right-sided lumbago. Abdominal computed tomography revealed a 44×34×70-mm mass in the right kidney. Following a complete examination, a laparoscopic partial nephrectomy of the right kidney was performed under general anesthesia. The postoperative pathology indicated a well-differentiated NET of the right kidney. There was no tumor recurrence or metastasis during the 1-year follow-up period. WDNETs are rare, their clinical and imaging findings are not specific, and their diagnosis depends on immunohistochemical analysis. The degree of malignancy is low and the prognosis is positive. Surgical resection is often the first choice, and long-term follow-up is required.
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Affiliation(s)
- Denghao Yang
- Department of Urology, The Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou 563000, P.R. China
| | - Wen Tang
- Department of Urology, The Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou 563000, P.R. China
| | - Tao Wu
- Department of Urology, The Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou 563000, P.R. China
- Correspondence to: Dr Tao Wu, Department of Urology, The Affiliated Hospital of Zunyi Medical University, 145 Dalian Road, Huichuan, Zunyi, Guizhou 563000, P.R. China, E-mail:
| | - Zeju Zhao
- Department of Urology, The Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou 563000, P.R. China
| | - Guobiao Liang
- Department of Urology, The Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou 563000, P.R. China
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Paisey SA, Weerasuriya S, Palmer K, White BE, Srirajaskanthan R, Chandrakumaran K, Ramage JK. Primary renal neuroendocrine neoplasms: A systematic literature review, report of four local cases, and original survival analysis of 63 patients from a national registry 2012-2018. J Neuroendocrinol 2022; 34:e13215. [PMID: 36524462 DOI: 10.1111/jne.13215] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 10/02/2022] [Accepted: 10/13/2022] [Indexed: 11/13/2022]
Abstract
Primary renal neuroendocrine neoplasms (NEN) are rare. We aimed to conduct a systematic review, present local cases, and analyse data from the England's National Cancer Registration and Analysis Service (NCRAS) to provide comprehensive evidence on clinical experience, incidence, and survival to better characterize these tumours. First, a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method; second, a synthesis of local cases; and, finally, a retrospective population-based cohort analysis of renal NEN recorded between 2012 and 2018 on NCRAS were performed. Kaplan-Meier estimator was used to calculate overall survival and Cox proportional hazard regression to identify prognostic factors. Systematic review identified 48 articles and the evidence was summarized and presented. We reported data from four local cases presenting with abdominal and back pain but without carcinoid syndrome. In population-based analysis, we identified 63 cases of renal NEN between 2012 and 2018 from the registry. Age-standardized incidence was 0.09-0.32 per million with a median age of 64 years (interquartile range = 48-72 years). Survival was worse in males and those aged 64 years and over. Five-year survival for renal neuroendocrine tumours (NET) was 69.8% (95% confidence interval = 66.6-72.7) and neuroendocrine carcinomas (NEC) was 38.4% (95% confidence interval = 34.6-42.0). No independent predictive factor was identified in the multivariable analyses. We have given a systematic review of evidence, published local experience, and reported incidence and survival of renal NEN in England for the first time. We have provided clinicians with evidence on diagnosis and proposed a treatment algorithm of theses rare tumours. The incidence and median age of presentation in England is similar to other published series. Renal NET has better survival than renal NEC as expected. A uniform classification system would reduce inconsistencies in reporting and standardize treatment decisions for this neoplasia.
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Affiliation(s)
- Sangeeta A Paisey
- Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
- King's Health Partners ENETS Centre of Excellence, London, UK
| | | | - Kieran Palmer
- Barts Cancer Centre, St Bartholomew's Hospital, London, UK
| | | | | | | | - John K Ramage
- Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
- King's Health Partners ENETS Centre of Excellence, London, UK
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7
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Neuroendocrine Neoplasms of the Female Genitourinary Tract: A Comprehensive Overview. Cancers (Basel) 2022; 14:cancers14133218. [PMID: 35804996 PMCID: PMC9264819 DOI: 10.3390/cancers14133218] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 06/25/2022] [Accepted: 06/27/2022] [Indexed: 11/30/2022] Open
Abstract
Simple Summary Primary neuroendocrine neoplasms (NENs) are a rare, heterogeneous group of tumors that include well-differentiated neuroendocrine tumors, poorly differentiated neuroendocrine carcinoma, and paraganglioma. NENs in the urinary tract are observed in <0.05% of individuals, in whom the bladder is the most common site. In this review, we described the epidemiology, pathogenesis, imaging, staging, and management of the genitourinary NENs. Abstract Primary neuroendocrine neoplasms are a rare heterogeneous group of tumors that include well-differentiated neuroendocrine tumors, poorly differentiated neuroendocrine carcinoma, and paraganglioma. An extensive literature search was used to compile the data regarding epidemiology, pathogenesis, imaging features, and management of the urinary system NENs. We also included the updated staging of the NENs at various locations of the urinary system.
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8
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Deacon MJ, Harvey H, Shah C, Khan A. A Rare Case of a Large Primary Renal Neuroendocrine Tumour: A Case Report and Brief Review of Literature. Cureus 2021; 13:e19743. [PMID: 34812336 PMCID: PMC8604431 DOI: 10.7759/cureus.19743] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 11/05/2022] Open
Abstract
Primary renal neuroendocrine tumours are very rare clinical entities, and as such, relatively little is known about their clinical progression. Here, we outline the case of a young female patient presenting with abdominal pain and a large 14 cm right renal mass. Initial radiological studies demonstrated localised disease, but during surgical resection, widespread liver metastasis was identified. Histological analysis revealed a grade 2, well-differentiated neuroendocrine tumour pT3a. Whilst surgical resection remains the gold standard for localised disease, further work is required to understand the pathogenesis, prognostic indicators and treatment following metastatic spread. The poor prognosis seen in primary renal neuroendocrine neoplasia highlights the importance of further directed research in this area.
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Affiliation(s)
| | - Hannah Harvey
- Urology Department, King's College Hospital, London, GBR
| | - Chirag Shah
- Pathology Department, King's College Hospital, London, GBR
| | - Azhar Khan
- Urology Department, King's College Hospital, London, GBR
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9
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Single institutional experience on primary neuroendocrine neoplasms of the kidney: a rare distinct entity. Hum Pathol 2021; 114:36-43. [PMID: 33891968 DOI: 10.1016/j.humpath.2021.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/01/2021] [Accepted: 04/06/2021] [Indexed: 01/12/2023]
Abstract
Primary pure renal neuroendocrine neoplasms (R-NENs) are a distinct and rare entity. Not much is known about the histopathology and biologic behavior of these tumors. We attempted to review the clinicopathologic aspects of these neoplasms encountered at our institution. We performed a retrospective chart review to identify primary pure (not admixed with any other tumor component) R-NENs from institutional Cancer Registry database. Pathologic review of the diagnostic archival slides was done for detailed assessment of the histologic features. R-NENs were classified according to the current WHO system for gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs). Eight pure R-NEN cases were identified, all unifocal, and most (6/8) involved the right kidney. Three patients had poorly differentiated neuroendocrine carcinoma (NEC), and five had well-differentiated neuroendocrine tumor (NET). All tumors were located near the renal hilum, stained diffusely with synaptophysin, variably with chromogranin, and were negative for renal site-specific marker PAX8 or for markers of renal cell carcinoma. We identified two distinct patterns of growth: one of sheets with interspersed rosettes and the other of large nests with low proliferative crowded centers and peripheral cells with higher proliferation and prominent palisading. Based on Ki-67 proliferative index, the tumors were classifiable into WHO grade 1 or grade 2 (based on GEP-NEN). All three NECs characteristically showed cytologic features intermediate between classic large and small cell type. This is the first comprehensive clinicopathologic study involving the rare group of R-NEN. Classifying and grading them according to the GEP-NEN system is of prognostic significance.
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Yi Z, Liu R, Hu J, He T, Wang Z, Li Y, Zu X. Clinicopathologic Features and Survival Outcomes for Primary Renal Neuroendocrine Neoplasms. Clin Genitourin Cancer 2021; 19:155-161. [DOI: 10.1016/j.clgc.2020.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/27/2020] [Accepted: 10/30/2020] [Indexed: 12/17/2022]
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Chiapponi C, Lürssen N, Cremer B, Wahba R, Drebber U, Faust M, Schmidt M, Stippel DL. Peptide receptor radionuclide therapy as a two-step strategy for initially unresectable liver disease from neuroendocrine tumors: a single-center experience. Endocrine 2020; 70:187-193. [PMID: 32419082 DOI: 10.1007/s12020-020-02341-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/04/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE In this study, we describe our experience with peptide receptor radionuclide therapy (PRRT) for initially unresectable liver disease as a two-steps therapeutic strategy, first in neoadjuvant intention before surgery and then later on in case of disease relapse. METHODS We performed a retrospective evaluation of four cases of unresectable liver metastases of NET of different origins treated with neoadjuvant Lu-177-DotaTATE for conversion into resectability first and as rechallenging treatment after disease relapse. RESULTS After treatment with Lu-177-DotaTAE, resectability was reached in three of four cases. In one case, SIRT was additionally performed preoperatively. Relapse occurred in three of four cases after 32, 34, and 37 months, respectively, and was managed with Re-PRRT-treatment. CONCLUSION Although more data are needed, our retrospective study suggests that treatment with Lu-177-DotaTATE is an important adjunct to surgery not only in neoadjuvant intention but also for treating disease relapse. A register study might deliver more evidence for supporting this strategy.
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Affiliation(s)
- Costanza Chiapponi
- Department for General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
| | - Nadine Lürssen
- Department for General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Birgit Cremer
- Department for Hemato-Oncology, University Hospital of Cologne, Univeristy of Cologne, Cologne, Germany
| | - Roger Wahba
- Department for General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Uta Drebber
- Department for Pathology, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Michael Faust
- Polyclinic for Endocrinology, Diabetes and Preventive Medicine, University Hospital of Cologne, Univeristy of Cologne, Cologne, Germany
| | - Matthias Schmidt
- Department of Nuclear Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Dirk L Stippel
- Department for General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
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