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Rimbach H, Linxweiler M, Körner S, Smola S, Linxweiler B, Speicher S, Helfrich J, Solomayer EF, Wagner M, Schick B, Kühn JP. Prediction of lymph node status in patients with surgically treated head and neck squamous cell carcinoma via neck lavage cytology: A pilot study. Cancer Cytopathol 2024; 132:285-296. [PMID: 38329321 DOI: 10.1002/cncy.22800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/09/2023] [Accepted: 12/11/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Neck dissection is a standardized surgical procedure for patients with head and neck squamous cell carcinoma (HNSCC) and plays a critical role in the choice of adjuvant treatment based on histopathological findings. Saline irrigation is routinely performed at the end of surgery. However, this irrigant is not used for diagnostic purposes. METHODS Intraoperative irrigation of the neck dissection wound was performed in 56 patients with HNSCC (N = 93 neck dissections), and the cytological suspension obtained was processed via the liquid-based cytology (LBC) technique, Papanicolaou staining, and immunocytochemical staining. Microscopic preparations were screened for the presence of tumor cells and classified as positive, borderline, or negative. These results were correlated with the histopathological and clinical data. RESULTS Neck lavage LBC demonstrated high diagnostic value in detecting lymph node metastases (N+) with extracapsular spread (ECS), with a specificity, sensitivity, negative predictive value, and positive predictive value of 93.1%, 100%, 100%, and 80%, respectively. Tumor cells were detected in 4.8% of N- cases, 20% of N+ cases without ECS, and 100% of N+ cases with ECS. Receiver operating characteristic curve analysis showed an area under the curve of 0.8429 for the prediction of N+ (p < .0001) and 0.9658 for the prediction of N+ with ECS (p < .0001). CONCLUSIONS Differential lavage cytology can provide valid and rapid information on the lymph node status in patients with HNSCC and showed an excellent correlation with histopathology. Thus, neck lavage LBC may facilitate faster and more reasonable planning of adjuvant treatment and help improve the therapeutic management of patients with HNSCC.
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Affiliation(s)
- Hugo Rimbach
- Department of Otorhinolaryngology, Saarland University, Homburg/Saar, Germany
| | | | - Sandrina Körner
- Department of Otorhinolaryngology, Saarland University, Homburg/Saar, Germany
| | - Sigrun Smola
- Institute of Virology, Saarland University, Homburg/Saar, Germany
| | | | - Stefanie Speicher
- Department of Otorhinolaryngology, Saarland University, Homburg/Saar, Germany
| | - Johanna Helfrich
- Department of Otorhinolaryngology, Saarland University, Homburg/Saar, Germany
| | | | - Mathias Wagner
- Department of Pathology, Saarland University, Homburg/Saar, Germany
| | - Bernhard Schick
- Department of Otorhinolaryngology, Saarland University, Homburg/Saar, Germany
| | - Jan Philipp Kühn
- Department of Otorhinolaryngology, Saarland University, Homburg/Saar, Germany
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Roth S, Linxweiler M, Rehner J, Schmartz GP, Becker SL, Kühn JP. Auritidibacter ignavus, an Emerging Pathogen Associated with Chronic Ear Infections. Emerg Infect Dis 2024; 30. [PMID: 38146955 PMCID: PMC10756363 DOI: 10.3201/eid3001.230385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
We describe detection of the previously rarely reported gram-positive bacterium Auritidibacter ignavus in 3 cases of chronic ear infections in Germany. In all 3 cases, the patients had refractory otorrhea. Although their additional symptoms varied, all patients had an ear canal stenosis and A. ignavus detected in microbiologic swab specimens. A correct identification of A. ignavus in the clinical microbiology laboratory is hampered by the inability to identify it by using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Also, the bacterium might easily be overlooked because of its morphologic similarity to bacterial species of the resident skin flora. We conclude that a high index of suspicion is warranted to identify A. ignavus and that it should be particularly considered in patients with chronic external otitis who do not respond clinically to quinolone ear drop therapy.
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Kühn JP, Speicher S, Linxweiler B, Körner S, Rimbach H, Wagner M, Solomayer EF, Schick B, Linxweiler M. Dual Sec62/Ki67 immunocytochemistry of liquid-based cytological preparations represents a highly valid biomarker for non-invasive detection of head and neck squamous cell carcinomas. Cytopathology 2024; 35:113-121. [PMID: 37787092 DOI: 10.1111/cyt.13310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Head and neck squamous cell carcinomas (HNSCC) are frequently diagnosed in advanced stages, which limits therapeutic options and results in persistently poor patient outcomes. The aim of this study was to use liquid-based swab cytology (LBC) in combination with dual immunocytochemical detection of migration and proliferation markers Sec62 and Ki67 in order to allow non-invasive early detection of HNSCC as well as to analyse the diagnostic validity of this method for predicting the malignancy of suspicious oral lesions. METHODS 104 HNSCC patients and 28 control patients, including healthy patients (n = 17), papilloma (n = 1) and leukoplakia patients (n = 10), were included in this study. For all patients, an LBC swab followed by simultaneous immunocytochemical detection of Sec62 and Ki67 was performed. Immunocytochemical as well as cytopathological results were correlated with histological diagnoses and clinical findings. RESULTS All HNSCC patients (100%) showed dual Sec62/Ki67 positivity, and all control patients except for the papilloma patient were negative for Sec62/Ki67 (96.4%), resulting in a 100% sensitivity and 96.4% specificity of Sec62/Ki67 dual stain for non-invasive detection of HNSCC. The positive predictive value was 99% and the negative predictive value was 100%. Sec62 expression levels showed a positive correlation with tumour de-differentiation (p = 0.0489). CONCLUSION Simultaneous immunocytochemical detection of Sec62/Ki67 using LBC represents a promising non-invasive and easy-to-apply tool for the early detection of HNSCC in routine clinical practice. This novel technique can help to avoid incisional biopsies and reduce the frequency with which general anaesthesia is used in diagnostic procedures in patients with suspicious oral lesions.
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Affiliation(s)
- Jan Philipp Kühn
- Department of Otorhinolaryngology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Stefanie Speicher
- Department of Otorhinolaryngology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Barbara Linxweiler
- Department of Gynecology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Sandrina Körner
- Department of Otorhinolaryngology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Hugo Rimbach
- Department of Otorhinolaryngology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Mathias Wagner
- Department of Pathology, Saarland University Medical Center, Homburg/Saar, Germany
| | | | - Bernhard Schick
- Department of Otorhinolaryngology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Maximilian Linxweiler
- Department of Otorhinolaryngology, Saarland University Medical Center, Homburg/Saar, Germany
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Linxweiler M, Schneider M, Körner S, Knebel M, Brust LA, Braun FL, Wemmert S, Wagner M, Hecht M, Schick B, Kühn JP. Expression of 3q Oncogene SEC62 Predicts Survival in Head and Neck Squamous Cell Carcinoma Patients Treated with Primary Chemoradiation. Cancers (Basel) 2023; 16:98. [PMID: 38201525 PMCID: PMC10778380 DOI: 10.3390/cancers16010098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/19/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
Primary chemoradiotherapy (CRT) is an established treatment option for locally advanced head and neck squamous cell carcinomas (HNSCC) usually combining intensity modified radiotherapy with concurrent platinum-based chemotherapy. Though the majority of patients can be cured with this regimen, treatment response is highly heterogeneous and can hardly be predicted. SEC62 represents a metastasis stimulating oncogene that is frequently overexpressed in various cancer entities and is associated with poor outcome. Its role in HNSCC patients undergoing CRT has not been investigated so far. A total of 127 HNSCC patients treated with primary CRT were included in this study. The median follow-up was 5.4 years. Pretherapeutic tissue samples of the primary tumors were used for immunohistochemistry targeting SEC62. SEC62 expression, clinical and histopathological parameters, as well as patient outcome, were correlated in univariate and multivariate survival analyses. High SEC62 expression correlated with a significantly shorter overall survival (p = 0.015) and advanced lymph node metastases (p = 0.024). Further significant predictors of poor overall and progression-free survival included response to therapy (RECIST1.1), nodal status, distant metastases, tobacco consumption, recurrence of disease, and UICC stage. In a multivariate Cox hazard proportional regression analysis, only SEC62 expression (p = 0.046) and response to therapy (p < 0.0001) maintained statistical significance as independent predictors of the patients' overall survival. This study identified SEC62 as an independent prognostic biomarker in HNSCC patients treated with primary CRT. The role of SEC62 as a potential therapeutic target and its interaction with radiation-induced molecular alterations in head and neck cancer cells should further be investigated.
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Affiliation(s)
- Maximilian Linxweiler
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, D-66421 Homburg, Germany; (M.S.); (S.K.); (M.K.); (L.A.B.); (S.W.); (B.S.); (J.P.K.)
| | - Matthias Schneider
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, D-66421 Homburg, Germany; (M.S.); (S.K.); (M.K.); (L.A.B.); (S.W.); (B.S.); (J.P.K.)
| | - Sandrina Körner
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, D-66421 Homburg, Germany; (M.S.); (S.K.); (M.K.); (L.A.B.); (S.W.); (B.S.); (J.P.K.)
| | - Moritz Knebel
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, D-66421 Homburg, Germany; (M.S.); (S.K.); (M.K.); (L.A.B.); (S.W.); (B.S.); (J.P.K.)
| | - Lukas Alexander Brust
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, D-66421 Homburg, Germany; (M.S.); (S.K.); (M.K.); (L.A.B.); (S.W.); (B.S.); (J.P.K.)
| | - Felix Leon Braun
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, D-66421 Homburg, Germany; (M.S.); (S.K.); (M.K.); (L.A.B.); (S.W.); (B.S.); (J.P.K.)
| | - Silke Wemmert
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, D-66421 Homburg, Germany; (M.S.); (S.K.); (M.K.); (L.A.B.); (S.W.); (B.S.); (J.P.K.)
| | - Mathias Wagner
- Department of General and Surgical Pathology, Saarland University Medical Center, D-66421 Homburg, Germany;
| | - Markus Hecht
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Center, D-66421 Homburg, Germany;
| | - Bernhard Schick
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, D-66421 Homburg, Germany; (M.S.); (S.K.); (M.K.); (L.A.B.); (S.W.); (B.S.); (J.P.K.)
| | - Jan Philipp Kühn
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, D-66421 Homburg, Germany; (M.S.); (S.K.); (M.K.); (L.A.B.); (S.W.); (B.S.); (J.P.K.)
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Trennheuser S, Reith W, Kühn JP, Morris LGT, Bozzato A, Naumann A, Schick B, Yilmaz U, Linxweiler M. Transorbital embolization of cavernous sinus dural arterio-venous malformations with surgical exposure and catheterization of the superior ophthalmic vein. Interv Neuroradiol 2023; 29:715-724. [PMID: 35758285 PMCID: PMC10680959 DOI: 10.1177/15910199221110967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/11/2022] [Accepted: 06/14/2022] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Cavernous sinus dural arterio-venous malformations (dAVF) represent a pathologic connection between branches of the internal and/or external carotid artery and the cavernous sinus. Standard endovascular approaches for dAVF treatment are transvenous embolization through the inferior petrosal sinus or the facial vein and transarterial embolization. These approaches are not always successful or feasible, and alternative techniques are required. Here, we present a case series of a minimally invasive transorbital approach with surgical exposure and catheterization of the superior ophthalmic vein for transvenous fistula coiling. METHODS 14 patients with dAVFs (Barrow Type B to D) that were treated at a tertiary care medical center over a period of 13 years were included in the study. Patients with persisting dAVF associated symptoms were selected for this approach when conventional endovascular interventions were not successful or not feasible. The surgical procedure was performed under general anaesthesia. RESULTS A successful transorbital approach was performed in all 14 cases. In 12 of 14 patients a catheter assisted successful embolization of the fistula was performed using platinum coils with no relevant residual fistula flow. In two cases, a spontaneous thrombosis of the fistula during the surgical procedure required no further embolization. No postoperative therapy-associated complications were observed. CONCLUSION The described approach is an effective method to embolize dAVFs in selected cases when catheter assisted transvenous and/or transarterial embolization is not successful or not feasible. In this case series we demonstrate an excellent success rate with no therapy-associated major complications.
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Affiliation(s)
- Sophie Trennheuser
- Department of Otorhinolaryngology, Head and Neck Surgery; Saarland University Medical Center, Homburg/Saar, Germany
| | - Wolfgang Reith
- Department of Diagnostic and Interventional Neuroradiology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Jan Philipp Kühn
- Department of Otorhinolaryngology, Head and Neck Surgery; Saarland University Medical Center, Homburg/Saar, Germany
| | - Luc G T Morris
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Alessandro Bozzato
- Department of Otorhinolaryngology, Head and Neck Surgery; Saarland University Medical Center, Homburg/Saar, Germany
| | - Andreas Naumann
- Department of Otorhinolaryngology, plastic surgery and special pain therapy, Bremen Mitte Hospital, Bremen, Germany
| | - Bernhard Schick
- Department of Otorhinolaryngology, Head and Neck Surgery; Saarland University Medical Center, Homburg/Saar, Germany
| | - Umut Yilmaz
- Department of Diagnostic and Interventional Neuroradiology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Maximilian Linxweiler
- Department of Otorhinolaryngology, Head and Neck Surgery; Saarland University Medical Center, Homburg/Saar, Germany
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Kromrey ML, Oswald S, Becher D, Bartel J, Schulze J, Paland H, Ittermann T, Hadlich S, Kühn JP, Mouchantat S. Intracerebral gadolinium deposition following blood-brain barrier disturbance in two different mouse models. Sci Rep 2023; 13:10164. [PMID: 37349374 PMCID: PMC10287697 DOI: 10.1038/s41598-023-36991-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 06/14/2023] [Indexed: 06/24/2023] Open
Abstract
To evaluate the influence of the blood-brain barrier on neuronal gadolinium deposition in a mouse model after multiple intravenous applications of the linear contrast agent gadodiamide. The prospective study held 54 mice divided into three groups: healthy mice (A), mice with iatrogenic induced disturbance of the blood-brain barrier by glioblastoma (B) or cerebral infarction (C). In each group 9 animals received 10 iv-injections of gadodiamide (1.2 mmol/kg) every 48 h followed by plain T1-weighted brain MRI. A final MRI was performed 5 days after the last contrast injection. Remaining mice underwent MRI in the same time intervals without contrast application (control group). Signal intensities of thalamus, pallidum, pons, dentate nucleus, and globus pallidus-to-thalamus and dentate nucleus-to-pons ratios, were determined. Gadodiamide complex and total gadolinium amount were quantified after the last MR examination via LC-MS/MS and ICP-MS. Dentate nucleus-to-pons and globus pallidus-to-thalamus SI ratios showed no significant increase over time within all mice groups receiving gadodiamide, as well as compared to the control groups at last MR examination. Comparing healthy mice with group B and C after repetitive contrast administration, a significant SI increase could only be detected for glioblastoma mice in globus pallidus-to-thalamus ratio (p = 0.033), infarction mice showed no significant SI alteration. Tissue analysis revealed significantly higher gadolinium levels in glioblastoma group compared to healthy (p = 0.013) and infarction mice (p = 0.029). Multiple application of the linear contrast agent gadodiamide leads to cerebral gadolinium deposition without imaging correlate in MRI.
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Affiliation(s)
- M L Kromrey
- Department of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany.
| | - S Oswald
- Institute of Pharmacology and Toxicology, Rostock University Medical Center, Rostock, Germany
| | - D Becher
- Department of Microbial Proteomics, Institute of Microbiology, University of Greifswald, Greifswald, Germany
| | - J Bartel
- Department of Microbial Proteomics, Institute of Microbiology, University of Greifswald, Greifswald, Germany
| | - J Schulze
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - H Paland
- Department of Pharmacology/C_DAT, University Medicine Greifswald, Greifswald, Germany
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - T Ittermann
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - S Hadlich
- Department of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
| | - J P Kühn
- Department of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
- Institute and Policlinic of Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - S Mouchantat
- Department of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
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Knebel M, Körner S, Kühn JP, Wemmert S, Brust L, Smola S, Wagner M, Bohle RM, Morris LGT, Pandey A, Schick B, Linxweiler M. Prognostic impact of intra- and peritumoral immune cell subpopulations in head and neck squamous cell carcinomas - comprehensive analysis of the TCGA-HNSC cohort and immunohistochemical validation on 101 patients. Front Immunol 2023; 14:1172768. [PMID: 37383237 PMCID: PMC10294051 DOI: 10.3389/fimmu.2023.1172768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/31/2023] [Indexed: 06/30/2023] Open
Abstract
Background Due to the expanding role of immune checkpoint inhibition in the treatment of head and neck squamous cell carcinoma, understanding immunological processes in the tumor microevironment (TME) has strong translational importance. Though analytical methods for a comprehensive analysis of the immunological TME have constantly improved and expanded over the past years the prognostic relevance of immune cell composition in head and neck cancer TME largely remains ambiguous with most studies focusing on one or a small subset of immune cells. Methods The overall survival (OS) of the TCGA-HNSC patient cohort comprising 513 head and neck cancer patients was correlated with a total of 29 different immune metrics including a wide spectrum of immune cell subpopulations as well as immune checkpoint receptors and cytokines using RNAseq based immune deconvolution analyses. The most significant predictors of survival among these 29 immune metrics were validated on a separate HNSCC patient cohort (n=101) using immunohistochemistry: CD3, CD20+CXCR5, CD4+CXCR5, Foxp3 and CD68. Results Overall immune infiltration irrespective of immune cell composition showed no significant correlation with the patients' overall survival in the TCGA-HNSC cohort. However, when focusing on different immune cell subpopulations, naïve B cells (p=0.0006), follicular T-helper cells (p<0.0001), macrophages (p=0.0042), regulatory T cells (p=0.0306), lymphocytes (p=0.0001), and cytotoxic T cells (p=0.0242) were identified as highly significant predictors of improved patient survival. Using immunohistochemical detection of these immune cells in a second independent validation cohort of 101 HNSCC patients, we confirmed the prognostic relevance of follicular T helper cells, cytotoxic T cells and lymphocytes. In multivariable analysis, HPV negativity and advanced UICC stages were identified as additional prognostic biomarkers associated with poor outcome. Conclusion Our study highlights the prognostic relevance of the immunological tumor environment in head and neck cancer and demonstrates that a more detailed analysis of immune cell composition and immune cell subtypes is necessary to accurately prognosticate. We observed the highest prognostic relevance for lymphocytes, cytotoxic T cells, and follicular T helper cells, suggesting further investigations focusing on these specific immune cell subpopulations not only as predictors of patient prognosis but also as promising targets of new immunotherapeutic strategies.
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Affiliation(s)
- Moritz Knebel
- Department of Otorhinolaryngology, Saarland University Medical Center, Homburg, Saar, Germany
| | - Sandrina Körner
- Department of Otorhinolaryngology, Saarland University Medical Center, Homburg, Saar, Germany
| | - Jan Philipp Kühn
- Department of Otorhinolaryngology, Saarland University Medical Center, Homburg, Saar, Germany
| | - Silke Wemmert
- Department of Otorhinolaryngology, Saarland University Medical Center, Homburg, Saar, Germany
| | - Lukas Brust
- Department of Otorhinolaryngology, Saarland University Medical Center, Homburg, Saar, Germany
| | - Sigrun Smola
- Institute of Virology, Saarland University Medical Center, Homburg, Saar, Germany
| | - Mathias Wagner
- Department of General and Surgical Pathology, Saarland University Medical Center, Homburg, Saar, Germany
| | - Rainer M. Bohle
- Department of General and Surgical Pathology, Saarland University Medical Center, Homburg, Saar, Germany
| | - Luc G. T. Morris
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY, United States
| | - Abhinav Pandey
- Weill Cornell School of Medical Sciences, New York City, NY, United States
| | - Bernhard Schick
- Department of Otorhinolaryngology, Saarland University Medical Center, Homburg, Saar, Germany
| | - Maximilian Linxweiler
- Department of Otorhinolaryngology, Saarland University Medical Center, Homburg, Saar, Germany
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Danisman Z, Linxweiler M, Kühn JP, Linxweiler B, Solomayer EF, Wagner M, Wagenpfeil G, Schick B, Berndt S. Differential nasal swab cytology represents a valuable tool for therapy monitoring but not prediction of therapy response in chronic rhinosinusitis with nasal polyps treated with Dupilumab. Front Immunol 2023; 14:1127576. [PMID: 37180133 PMCID: PMC10173305 DOI: 10.3389/fimmu.2023.1127576] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/22/2023] [Indexed: 05/15/2023] Open
Abstract
Introduction Chronic Rhinosinusitis with nasal polyps (CRSwNP) is a common chronic disease with a high impact on patients' quality of life. If conservative and surgical guideline treatment cannot sufficiently control disease burden, biologicals can be considered as a comparably new treatment option that has revolutionized CRSwNP therapy since the first approval of Dupilumab in 2019. With the aim to select patients who benefit from this new treatment and to find a marker for therapy monitoring, we investigated the cellular composition of nasal mucous membranes and inflammatory cells of patients suffering from CRSwNP and undergoing Dupilumab therapy using non-invasive nasal swab cytology. Methods Twenty CRSwNP patients with the indication for Dupilumab therapy have been included in this prospective clinical study. In total, five study visits were conducted with ambulatory nasal differential cytology using nasal swabs starting with the beginning of therapy and followed by visits every 3 months for 12 months. First, these cytology samples were stained with the May-Grunwald-Giemsa method (MGG) and the percentage of ciliated cells, mucinous cells, eosinophil cells, neutrophil cells, and lymphocytes was analyzed. Secondly, an immunocytochemical (ICC) ECP-staining was performed to detect eosinophil granulocytes. Additionally, during each study visit the nasal polyp score, SNOT20 questionnaire, olfactometry, the total IgE concentration in peripheral blood as well as the eosinophil cell count in peripheral blood were recorded. The change of parameters was evaluated over one year and the correlation between clinical effectiveness and nasal differential cytology was analyzed. Results In both MGG (p<0.0001) and ICC analysis (p<0.001) a significant decrease of eosinophils was seen under Dupilumab treatment. When patients were divided into a Eo-low- (<21%) and Eo-high- (≥21%) group according to the percentage eosinophils in nasal swab catology in the first study visit, the Eo-high-group showed a greater change of eosinophils over time (Δ17.82) compared to the Eo-low-group (Δ10.67) but, however, no better response to therapy. The polyp score, SNOT20 questionnaire, and total IgE concentration in peripheral blood showed a significant decrease during the observation period (p<0.0001). Discussion Nasal swab cytology as an easy-to-apply diagnostic method allows detection and quantification of the different cell populations within the nasal mucosa at a given time. The nasal differential cytology showed a significant decrease of eosinophils during Dupilumab therapy and can therefore be used as non-invasvive method for monitoring therapy success of this cost intensive therapy and potentially can allow an optimized individual therapy planning and management for CRSwNP patients. Since the validity of initial nasal swab eosinophil cell count as a predictive biomarker for therapy response was limited in our study, additional studies including larger number of participants will be necessary to further evaluate the potential benefits for clinical practice of this new diagnostic method.
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Affiliation(s)
- Zeynep Danisman
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarlandy University Medical Center, Homburg, Germany
| | - Maximilian Linxweiler
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarlandy University Medical Center, Homburg, Germany
| | - Jan Philipp Kühn
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarlandy University Medical Center, Homburg, Germany
| | - Barbara Linxweiler
- Department of Gynecology and Obstetrics, Saarland University Medical Center, Homburg, Germany
| | - Erich-Franz Solomayer
- Department of Gynecology and Obstetrics, Saarland University Medical Center, Homburg, Germany
| | - Mathias Wagner
- Department of General and Surgical Pathology, Saarland University Medical Center, Homburg, Germany
| | - Gudrun Wagenpfeil
- Department of Medical Biometry, Epidemiology and Medical Informations, Saarland University, Homburg, Germany
| | - Bernhard Schick
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarlandy University Medical Center, Homburg, Germany
| | - Sabrina Berndt
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarlandy University Medical Center, Homburg, Germany
- *Correspondence: Sabrina Berndt,
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Linxweiler M, Reith W, Wagner M, Kühn JP, Schick B. Schwannoma of the Hypoglossal Nerve Mimicking Carotid Body Paraganglioma. Diagnostics (Basel) 2022; 12:diagnostics12092122. [PMID: 36140522 PMCID: PMC9498050 DOI: 10.3390/diagnostics12092122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 08/24/2022] [Accepted: 08/30/2022] [Indexed: 11/16/2022] Open
Abstract
Carotid body paragangliomas (CBPs) clinically present as highly vascularized cervical masses with a pathognomonic localization at the carotid artery bifurcation. Following ultrasonography and MRI/CT imaging, surgical resection with optional preoperative embolization is considered as the treatment of choice in most cases. We herein present the case of a 60-year-old female with characteristic clinical signs and imaging findings of a right-sided CBP who finally went to surgical treatment. Intraoperatively, the tumor showed an adherent growth to the hypoglossal nerve that had to be partially resected, resulting in a postoperative nerve palsy. Histological examination of the resected tumor revealed the unexpected diagnosis of a hypoglossal nerve schwannoma. To the best of our knowledge, we herein present the third case reported in the literature of a unilateral hypoglossal schwannoma located at the carotid bifurcation mimicking clinical symptoms, imaging and intraoperative findings of a CBP.
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Affiliation(s)
- Maximilian Linxweiler
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, 66421 Homburg, Saar, Germany
- Correspondence: ; Tel.: +49-6841-1622928
| | - Wolfgang Reith
- Department of Diagnostic and Interventional Neuroradiology, Saarland University Medical Center, 66421 Homburg, Saar, Germany
| | - Mathias Wagner
- Department of General and Surgical Pathology, Saarland University Medical Center, 66421 Homburg, Saar, Germany
| | - Jan Philipp Kühn
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, 66421 Homburg, Saar, Germany
| | - Bernhard Schick
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, 66421 Homburg, Saar, Germany
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Kühn JP, Bochen F, Körner S, Schick B, Wagner M, Smola S, Berkó-Göttel B, Morris LGT, Wang J, Bozzato A, Linxweiler M. Podoplanin expression in lymph node metastases of head and neck cancer and cancer of unknown primary patients. Int J Biol Markers 2022; 37:280-288. [PMID: 35880270 DOI: 10.1177/03936155221105524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Head and neck squamous cell carcinomas (HNSCCs) are cancers with generally poor prognosis. Outcomes have not improved in decades, with more than half of the patients presenting with lymph node metastases at the time of diagnosis. A unique subtype of HNSCC, cancer of unknown primary of the head and neck (HNCUP) is associated with a poor outcome. Increased expression of the D2-40 gene (podoplanin) has been described for several human malignancies and has been associated with increased metastatic potential of cancer cells. METHODS In order to examine the role of podoplanin in lymph node metastasis of HNSCC generally and HNCUP specifically, we evaluated the prognostic impact of podoplanin expression in HNSCC- (n = 68) and HNCUP-associated lymph node metastases (n = 30). The expression of podoplanin was analyzed by immunohistochemical staining of lymph node tissue samples and correlated with clinical and histopathological data. RESULTS We found a non-significant tendency towards a higher podoplanin expression in HNCUP compared to HNSCC lymph node metastases and a significant correlation between a high podoplanin expression and advanced node-stage classification. Podoplanin expression had no significant impact on overall survival for both groups and did not correlate with human papillomavirus tumor status. CONCLUSION Taken together, our results suggest that upregulation of podoplanin may be associated with a stimulation of lymphatic metastasis in head and neck cancer.
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Affiliation(s)
- Jan Philipp Kühn
- Department of Otorhinolaryngology, Head and Neck Surgery, 39072Saarland University Medical Center, Homburg, Germany
| | - Florian Bochen
- Department of Otorhinolaryngology, Head and Neck Surgery, 39072Saarland University Medical Center, Homburg, Germany
| | - Sandrina Körner
- Department of Otorhinolaryngology, Head and Neck Surgery, 39072Saarland University Medical Center, Homburg, Germany
| | - Bernhard Schick
- Department of Otorhinolaryngology, Head and Neck Surgery, 39072Saarland University Medical Center, Homburg, Germany
| | - Mathias Wagner
- Department of General and Surgical Pathology, Saarland University Medical Center, Homburg, Germany
| | - Sigrun Smola
- Institute of Virology, Saarland University Medical Center, Homburg, Germany
| | | | - Luc G T Morris
- Department of Surgery, 5803Memorial Sloan Kettering Cancer Center, New York City, NY, USA.,Human Oncology and Pathogenesis Program, 39072Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Jingming Wang
- Human Oncology and Pathogenesis Program, 39072Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Alessandro Bozzato
- Department of Otorhinolaryngology, Head and Neck Surgery, 39072Saarland University Medical Center, Homburg, Germany
| | - Maximilian Linxweiler
- Department of Otorhinolaryngology, Head and Neck Surgery, 39072Saarland University Medical Center, Homburg, Germany
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Linxweiler M, Kühn JP, Neubert C, Khreish F, Balensiefer B, Wagner M, Schick B. Complete remission of an early-stage laryngeal cancer under combined pembrolizumab and chemotherapy treatment of a synchronous lung adenocarcinoma. J Otolaryngol Head Neck Surg 2022; 51:21. [PMID: 35578359 PMCID: PMC9109389 DOI: 10.1186/s40463-022-00572-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 03/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anti-PD1-Checkpoint inhibition (CI) is an established treatment of recurrent and/or metastatic head and neck cancer. A potential benefit from CI in early-stage disease that is usually treated by radiation or surgery has not been investigated so far and is currently not addressed in clinical trials. CASE PRESENTATION A 58-year-old man was diagnosed with a cT2 supraglottic laryngeal cancer and a synchronous metastasized adenocarcinoma of the lung. As the patient refused any treatment of his laryngeal cancer, he received combined immune-chemotherapy according to the KEYNOTE-189 protocol. After 4 cycles of pembrolizumab/carboplatin/pemetrexed, the patient showed a complete remission of his laryngeal cancer with a clear shrinkage of the mediastinal and hilar lung cancer metastases. After 21 cycles of maintenance therapy, the lung adenocarcinoma shows a stable disease status with no signs of any residual or recurrent laryngeal cancer. CONCLUSIONS Anti-PD1-CI may be a treatment option also for early-stage HNSCC with excellent functional outcome when established therapies are not available.
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Affiliation(s)
- Maximilian Linxweiler
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Kirrbergerstr. 100, Building 6, 66421, Homburg/Saar, Germany.
| | - Jan Philipp Kühn
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Kirrbergerstr. 100, Building 6, 66421, Homburg/Saar, Germany
| | - Christian Neubert
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Kirrbergerstr. 100, Building 6, 66421, Homburg/Saar, Germany
| | - Fadi Khreish
- Department of Nuclear Medicine, Saarland University Medical Center, Homburg/Saar, Germany
| | - Benedikt Balensiefer
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Mathias Wagner
- Department of General and Surgical Pathology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Bernhard Schick
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Kirrbergerstr. 100, Building 6, 66421, Homburg/Saar, Germany
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12
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Linxweiler M, Körner S, Wemmert S, Rimbach H, Helfrich J, Linxweiler B, Takacs ZF, Solomayer EF, Wagner M, Morris LGT, Schick B, Kühn JP. Cytology-based Cancer Surgery of the Head and Neck (CyCaS-HN): a prospective, randomized, controlled clinical trial. Eur Arch Otorhinolaryngol 2022; 279:4505-4514. [PMID: 35305137 PMCID: PMC9363327 DOI: 10.1007/s00405-022-07333-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/28/2022] [Indexed: 11/29/2022]
Abstract
Purpose Liquid-based cytology (LBC) is routinely used in gynecology but is rarely applied in head and neck oncology though many suspicious lesions are easily accessible. While several studies have evaluated the potential use of LBC for early detection and molecular characterization of head and neck squamous cell carcinomas (HNSCCs), no study investigated its potential role in surgical management and therapy planning so far. Methods Twenty-five patients with cT1-2 squamous cell carcinomas of the oral cavity and oropharynx were prospectively enrolled in this study and were randomized to two treatment arms: in the control arm, a diagnostic panendoscopy with incisional biopsy was followed by a second operation with transoral tumor resection ± neck dissection and tracheostomy. In the intervention arm, patients underwent LBC diagnostics and in case of a positive result received one single operation with panendoscopy and incisional biopsy for confirmation of LBC result by rapid section histology followed by transoral tumor resection ± neck dissection and tracheostomy in the same session. Results Time between clinical diagnosis and definitive surgical treatment was significantly shorter in the intervention group compared with the control group (p < 0.0001). Additionally, time of hospitalization (p < 0.0001) and cumulative operation time (p = 0.062) were shorter in the intervention group. No significant differences in overall, progression-free, and disease-specific survival were observed. Conclusion Cytology-based cancer surgery is a promising therapeutic strategy that can potentially be considered for a well-defined group of early-stage HNSCC patients and help to avoid repetitive general anesthesia, shorten the diagnosis-to-treatment interval and spare operation as well as hospitalization time.
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Affiliation(s)
- Maximilian Linxweiler
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Kirrbergerstr. 100, building 6, 66421, Homburg, Germany.
| | - Sandrina Körner
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Kirrbergerstr. 100, building 6, 66421, Homburg, Germany
| | - Silke Wemmert
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Kirrbergerstr. 100, building 6, 66421, Homburg, Germany
| | - Hugo Rimbach
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Kirrbergerstr. 100, building 6, 66421, Homburg, Germany
| | - Johanna Helfrich
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Kirrbergerstr. 100, building 6, 66421, Homburg, Germany
| | - Barbara Linxweiler
- Department of Gynecology, Obstetrics and Reproductive Medicine, Saarland University Medical Center, Homburg, Germany
| | - Zoltan Ferenc Takacs
- Department of Gynecology, Obstetrics and Reproductive Medicine, Saarland University Medical Center, Homburg, Germany
| | - Erich Franz Solomayer
- Department of Gynecology, Obstetrics and Reproductive Medicine, Saarland University Medical Center, Homburg, Germany
| | - Mathias Wagner
- Department of General and Surgical Pathology, Saarland University Medical Center, Homburg, Germany
| | - Luc G T Morris
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY, USA.,Immunogenomics and Precision Oncology Platform, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Bernhard Schick
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Kirrbergerstr. 100, building 6, 66421, Homburg, Germany
| | - Jan Philipp Kühn
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Kirrbergerstr. 100, building 6, 66421, Homburg, Germany
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13
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Kühn JP, Linsler S, Nourkami-Tutdibi N, Meyer S, Becker SL, Yilmaz U, Schick B, Bozzato A, Kulas P. [Pott's Puffy Tumor: a need for interdisciplinary diagnosis and treatment. German Version]. HNO 2022; 70:550-556. [PMID: 35260911 PMCID: PMC9242906 DOI: 10.1007/s00106-021-01133-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2021] [Indexed: 11/29/2022]
Abstract
Der Pott-Puffy-Tumor (PPT) stellt als bakterielle Infektion des Sinus frontalis mit subperiostaler und intrakranieller Abszessbildung eine seltene Erkrankung in der Pädiatrie dar. Nachfolgend präsentieren wir vier Fälle eines PPT, die bei zwei Kindern (6 und 9 Jahre) und bei zwei jungen Erwachsenen (17 und 19 Jahre) auftraten. Alle Patienten wurden interdisziplinär von einem Team aus Neurochirurgie, Pädiatrie, HNO-Heilkunde, Neuroradiologie und Mikrobiologie betreut. Die Antibiotikabehandlung wurde in einem Fall mit einer endoskopischen Nasennebenhöhlenoperation (FESS) und in den anderen drei Fällen zusätzlich mit einem offenen transkraniellen Zugang zur Drainage der intrakraniellen Abszessbildung kombiniert. Da der PPT im Kindesalter mit dem Befund einer intrakraniellen Abszessbildung einhergehen kann, ist eine enge interdisziplinäre Zusammenarbeit für eine erfolgreiche Behandlung dieser seltenen Erkrankung erforderlich.
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Affiliation(s)
- Jan Philipp Kühn
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum des Saarlandes, Kirrberger Straße, 66421, Homburg, Deutschland.
| | - Stefan Linsler
- Klinik für Neurochirurgie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Nasenien Nourkami-Tutdibi
- Klinik für Allgemeine Pädiatrie und Neonatologie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Sascha Meyer
- Klinik für Allgemeine Pädiatrie und Neonatologie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Sören L Becker
- Institut für Medizinische Mikrobiologie und Hygiene, Institute für Infektionsmedizin, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Umut Yilmaz
- Klinik für diagnostische und interventionelle Neuroradiologie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Bernhard Schick
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum des Saarlandes, Kirrberger Straße, 66421, Homburg, Deutschland
| | - Alessandro Bozzato
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum des Saarlandes, Kirrberger Straße, 66421, Homburg, Deutschland
| | - Philipp Kulas
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum des Saarlandes, Kirrberger Straße, 66421, Homburg, Deutschland
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Seppelt D, Ittermann T, Kromrey ML, Kolb C, vWahsen C, Heiss P, Völzke H, Hoffmann RT, Kühn JP. Simple diameter measurement as predictor of liver volume and liver parenchymal disease. Sci Rep 2022; 12:1257. [PMID: 35075169 PMCID: PMC8786943 DOI: 10.1038/s41598-022-04825-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 12/20/2021] [Indexed: 11/12/2022] Open
Abstract
To investigate the accuracy of liver diameters for estimation of liver size and to evaluate their application as tool for assessment of parenchymal liver disease. In the course of a population-based study, (SHIP) one thousand nine hundred thirty-nine volunteers underwent magnetic resonance imaging (MRI) of the liver including 3D gradient echo MRI sequences. Maximum liver diameters were measured in cranio-caudal (CC), anterior–posterior (AP), medial–lateral (ML) orientation. Diameters were compared with true liver volume assessed by liver segmentation. Additionally, age-dependent reference values for diameters were defined. Finally, accuracy of liver diameters was assessed to discriminate volunteers with healthy livers and participants with parenchymal changes, measured by MRI and laboratory. Reference values of liver diameters within the healthy population (n = 886) were defined as follows (mean ± standard deviation, confidence interval CI in cm): CC 17.2 ± 2, CI 13.6/21.2; AP 15.8 ± 1.9, CI 12.6/19.8; ML 19.7 ± 2.3, CI 15.8/24.6. There was a poor correlation using linear regression between liver diameter and true liver volume; CC 0.393, AP 0.359; ML 0.137. The AP direction shows the best correlation to discriminate between healthy and pathologic liver changes; AUC 0.78; p < 0.001, CC AUC 0.53; p < 0.001 and ML AUC 0.52; p = 0.008. Measurement of liver diameter, especially in the anterior–posterior direction is a simple option to detect chronic liver disease but less suitable for prediction of liver volume.
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Affiliation(s)
- D Seppelt
- Institute and Policlinic for Diagnostic and Interventional Radiology, University Hospital Carl-Gustav-Carus, TU Dresden, Dresden, Germany.
| | - T Ittermann
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - M L Kromrey
- Department of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - C Kolb
- Institute and Policlinic for Diagnostic and Interventional Radiology, University Hospital Carl-Gustav-Carus, TU Dresden, Dresden, Germany
| | - C vWahsen
- Department of Diagnostic Radiology, University Medical Center Regensburg, Regensburg, Germany
| | - P Heiss
- Department of Diagnostic Radiology, University Medical Center Regensburg, Regensburg, Germany
| | - H Völzke
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - R T Hoffmann
- Institute and Policlinic for Diagnostic and Interventional Radiology, University Hospital Carl-Gustav-Carus, TU Dresden, Dresden, Germany
| | - J P Kühn
- Institute and Policlinic for Diagnostic and Interventional Radiology, University Hospital Carl-Gustav-Carus, TU Dresden, Dresden, Germany
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Kühn JP, Schmid W, Körner S, Bochen F, Wemmert S, Rimbach H, Smola S, Radosa JC, Wagner M, Morris LG, Bozzato V, Bozzato A, Schick B, Linxweiler M. HPV Status as Prognostic Biomarker in Head and Neck Cancer-Which Method Fits the Best for Outcome Prediction? Cancers (Basel) 2021; 13:cancers13184730. [PMID: 34572957 PMCID: PMC8469433 DOI: 10.3390/cancers13184730] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/11/2021] [Accepted: 09/20/2021] [Indexed: 01/22/2023] Open
Abstract
The incidence of human papillomavirus (HPV)-related head and neck cancer (HNSCC) is rising globally, presenting challenges for optimized clinical management. To date, it remains unclear which biomarker best reflects HPV-driven carcinogenesis, a process that is associated with better therapeutic response and outcome compared to tobacco/alcohol-induced cancers. Six potential HPV surrogate biomarkers were analyzed using FFPE tissue samples from 153 HNSCC patients (n = 78 oropharyngeal cancer (OPSCC), n = 35 laryngeal cancer, n = 23 hypopharyngeal cancer, n = 17 oral cavity cancer): p16, CyclinD1, pRb, dual immunohistochemical staining of p16 and Ki67, HPV-DNA-PCR, and HPV-DNA-in situ hybridization (ISH). Biomarkers were analyzed for correlation with one another, tumor subsite, and patient survival. P16-IHC alone showed the best performance for discriminating between good (high expression) vs poor outcome (low expression; p = 0.0030) in OPSCC patients. Additionally, HPV-DNA-ISH (p = 0.0039), HPV-DNA-PCR (p = 0.0113), and p16-Ki67 dual stain (p = 0.0047) were significantly associated with prognosis in uni- and multivariable analysis for oropharyngeal cancer. In the non-OPSCC group, however, none of the aforementioned surrogate markers was prognostic. Taken together, P16-IHC as a single biomarker displays the best diagnostic accuracy for prognosis stratification in OPSCC patients with a direct detection of HPV-DNA by PCR or ISH as well as p16-Ki67 dual stain as potential alternatives.
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Affiliation(s)
- Jan Philipp Kühn
- Department of Otorhinolaryngology, Saarland University Medical Center, D-66421 Homburg, Germany; (J.P.K.); (W.S.); (S.K.); (F.B.); (S.W.); (H.R.); (V.B.); (A.B.); (B.S.)
| | - Wendelin Schmid
- Department of Otorhinolaryngology, Saarland University Medical Center, D-66421 Homburg, Germany; (J.P.K.); (W.S.); (S.K.); (F.B.); (S.W.); (H.R.); (V.B.); (A.B.); (B.S.)
| | - Sandrina Körner
- Department of Otorhinolaryngology, Saarland University Medical Center, D-66421 Homburg, Germany; (J.P.K.); (W.S.); (S.K.); (F.B.); (S.W.); (H.R.); (V.B.); (A.B.); (B.S.)
| | - Florian Bochen
- Department of Otorhinolaryngology, Saarland University Medical Center, D-66421 Homburg, Germany; (J.P.K.); (W.S.); (S.K.); (F.B.); (S.W.); (H.R.); (V.B.); (A.B.); (B.S.)
| | - Silke Wemmert
- Department of Otorhinolaryngology, Saarland University Medical Center, D-66421 Homburg, Germany; (J.P.K.); (W.S.); (S.K.); (F.B.); (S.W.); (H.R.); (V.B.); (A.B.); (B.S.)
| | - Hugo Rimbach
- Department of Otorhinolaryngology, Saarland University Medical Center, D-66421 Homburg, Germany; (J.P.K.); (W.S.); (S.K.); (F.B.); (S.W.); (H.R.); (V.B.); (A.B.); (B.S.)
| | - Sigrun Smola
- Institute of Virology, Saarland University Medical Center, D-66421 Homburg, Germany;
| | - Julia Caroline Radosa
- Department of Gynecology and Obstetrics, Saarland University Medical Center, D-66421 Homburg, Germany;
| | - Mathias Wagner
- Department of General and Surgical Pathology, Saarland University Medical Center, D-66421 Homburg, Germany;
| | - Luc G.T. Morris
- Immunogenomics and Precision Oncology Platform, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA;
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Victoria Bozzato
- Department of Otorhinolaryngology, Saarland University Medical Center, D-66421 Homburg, Germany; (J.P.K.); (W.S.); (S.K.); (F.B.); (S.W.); (H.R.); (V.B.); (A.B.); (B.S.)
| | - Alessandro Bozzato
- Department of Otorhinolaryngology, Saarland University Medical Center, D-66421 Homburg, Germany; (J.P.K.); (W.S.); (S.K.); (F.B.); (S.W.); (H.R.); (V.B.); (A.B.); (B.S.)
| | - Bernhard Schick
- Department of Otorhinolaryngology, Saarland University Medical Center, D-66421 Homburg, Germany; (J.P.K.); (W.S.); (S.K.); (F.B.); (S.W.); (H.R.); (V.B.); (A.B.); (B.S.)
| | - Maximilian Linxweiler
- Department of Otorhinolaryngology, Saarland University Medical Center, D-66421 Homburg, Germany; (J.P.K.); (W.S.); (S.K.); (F.B.); (S.W.); (H.R.); (V.B.); (A.B.); (B.S.)
- Correspondence: ; Tel.: +49-6841-1622928
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16
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Kühn JP, Wagner M, Bozzato A, Linxweiler M. Multiple schwannomas of the facial nerve mimicking cervical lymphoma: a case report. J Med Case Rep 2021; 15:436. [PMID: 34412684 PMCID: PMC8377860 DOI: 10.1186/s13256-021-03006-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 07/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In this report, we describe the first case in literature of a patient with multiple schwannomas of the marginal mandibular branch of the facial nerve. CASE PRESENTATION A Caucasian patient presented with a sudden onset of left lower facial nerve palsy House-Brackmann score III for 1 month. Computed tomography imaging was performed to exclude a cerebral event and revealed multiple tumors within the left parotid gland. Duplex ultrasound and magnetic resonance imaging scans delineated multiple, hypoechoic tumors, round in shape and well defined without a hilar structure along the left mandible. For histological verification, a left-side partial parotidectomy and extirpation of an intraparotideal node was performed with use of a nerve-integrity monitor. Histomorphological analysis of the resected tissue revealed a benign schwannoma. Facial nerve function remained unchanged since the operation. The size of the nonresected tumors is currently monitored regularly by ultrasonography. Fibromatosis has been excluded. CONCLUSIONS If multiple tumors occur in the parotid gland and the angle of the jaw, schwannomas need to be considered as a differential diagnosis. To plan the right diagnostic surgical intervention and prevent nerve damage, a thorough ultrasound examination is essential in preoperative diagnostic work-up for any suspicious lesion of the parotid gland and jaw region.
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Affiliation(s)
- Jan Philipp Kühn
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Kirrbergerstr. 100, building 6, 66421, Homburg, Germany.
| | - Mathias Wagner
- Department of General and Surgical Pathology, Saarland University Medical Center, 66421, Homburg, Germany
| | - Alessandro Bozzato
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Kirrbergerstr. 100, building 6, 66421, Homburg, Germany
| | - Maximilian Linxweiler
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Kirrbergerstr. 100, building 6, 66421, Homburg, Germany
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Kühn JP, Vogt T, Schick B. [A cervical inflammation and signs of sepsis]. HNO 2021; 69:501-503. [PMID: 32876718 DOI: 10.1007/s00106-020-00936-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- J P Kühn
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum des Saarlandes, Kirrberger Straße, 66421, Homburg, Deutschland.
| | - T Vogt
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - B Schick
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum des Saarlandes, Kirrberger Straße, 66421, Homburg, Deutschland
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Blum SFU, Ittermann T, Kromrey ML, Dreyer CM, Seppelt D, Hoffmann RT, Völzke H, Kühn JP. Long-term outcome of incidental cystic liver tumors in the general population. Sci Rep 2021; 11:11661. [PMID: 34083637 PMCID: PMC8175727 DOI: 10.1038/s41598-021-91140-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/20/2021] [Indexed: 11/29/2022] Open
Abstract
Aim of this study was to investigate frequency, incidence and risk factors of liver cysts in the general population in a longitudinal survey. Cyst frequency was investigated in 607 adult volunteers (288 women, 319 men, mean age 55 years) using strong T2-weighted magnetic resonance imaging. Risk factors were investigated for occurrence, frequency and size of cystic lesions at baseline. Incidence and physiological growing of the lesions were observed in a 5-years follow-up. At baseline, 431 volunteers had 1,479 cysts (71.0%). The mean number of cysts per person was 3.4 ± 9.0. The mean size of cysts was 13.1 ± 11.7 mm. Women had a higher number of cysts than men (p = 0.026). Older and male volunteers demonstrated a higher cyst frequency (p = 0.002 and p = 0.025). Per one-year increase in age the chance for a liver cyst increased by 2%. Four-hundred seventeen volunteers had cysts in the follow-up, in 24.6% new lesions had occurred. Lesion size significantly increased in follow-up (p < 0.001). Age and male sex were associated with the occurrence of at least one liver cyst. Women had a higher average number of cysts. Cystic lesion progression is a physiological phenomenon in the long-term follow-up.
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Affiliation(s)
- S F U Blum
- Institute and Polyclinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
| | - T Ittermann
- Institute of Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - M L Kromrey
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - C M Dreyer
- Institute and Polyclinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - D Seppelt
- Institute and Polyclinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - R T Hoffmann
- Institute and Polyclinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - H Völzke
- Institute of Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - J P Kühn
- Institute and Polyclinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
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Müller CSL, Pföhler C, Wahl M, Bochen F, Körner S, Kühn JP, Bozzato A, Schick B, Linxweiler M. Expression of SEC62 Oncogene in Benign, Malignant and Borderline Melanocytic Tumors-Unmasking the Wolf in Sheep's Clothing? Cancers (Basel) 2021; 13:cancers13071645. [PMID: 33915997 PMCID: PMC8036965 DOI: 10.3390/cancers13071645] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 01/09/2023] Open
Abstract
Simple Summary Amplification and overexpression of the SEC62 oncogene was reported in a variety of human cancers and was associated with poor prognosis as well as lymph node and distant metastases. In this study, SEC62 expression was analyzed in benign, borderline, and malignant melanocytic lesions of 209 patients. We found the highest expression in Spitz nevi, followed by melanoma metastases, primary melanoma, congenital nevi, and blue nevi. In melanoma patients, high Sec62 levels correlated with shorter overall and progression-free survival. Significantly higher Sec62 levels were found in melanomas with lymph node and distant metastases compared with those without. Taken together, these data suggest a relevant role of SEC62 as a metastasis-stimulating oncogene in melanoma development, which represents a promising therapeutic target. Abstract SEC62 oncogene located at chromosomal region 3q26 encodes for a transmembrane protein of the endoplasmic reticulum (ER) and is expressed at high levels in numerous human malignancies. SEC62 overexpression has been associated with worse prognosis and high risk for lymphatic and distant metastases in head and neck cancer, cervical cancer, hepatocellular cancer, and lung cancer. However, its role in the development and tumor biology of melanocytic lesions has not been investigated so far. An immunohistochemical study including 209 patients with melanocytic lesions (malignant melanoma (MM), n = 93; melanoma metastases (MET), n = 28; Spitz nevi (SN), n = 29; blue nevi (BN), n = 21; congenital nevi (CN), n = 38) was conducted and SEC62 expression was correlated with clinical data including patient survival and histopathological characteristics. SN showed the highest SEC62 expression levels followed by MET, MM, CN, and BN. High SEC62 expression correlated with a shorter overall and progression-free survival in MM patients. Additionally, high Sec62 levels correlated significantly with higher tumor size (T stage), the presence of tumor ulceration, and the presence of lymph node as well as distant metastases. Strikingly, SEC62 expression showed a strong correlation with Clark level. Taken together, these data demonstrate that SEC62 is a promising prognostic marker in MM and has the potential to predict biological behavior and clinical aggressiveness of melanocytic lesions.
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Affiliation(s)
- Cornelia S. L. Müller
- Department of Dermatology, Venerology and Allergology, Saarland University Medical Center, D-66421 Homburg, Germany; (C.S.L.M.); (C.P.); (M.W.)
| | - Claudia Pföhler
- Department of Dermatology, Venerology and Allergology, Saarland University Medical Center, D-66421 Homburg, Germany; (C.S.L.M.); (C.P.); (M.W.)
| | - Maria Wahl
- Department of Dermatology, Venerology and Allergology, Saarland University Medical Center, D-66421 Homburg, Germany; (C.S.L.M.); (C.P.); (M.W.)
| | - Florian Bochen
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, D-66421 Homburg, Germany; (F.B.); (S.K.); (J.P.K.); (A.B.); (B.S.)
| | - Sandrina Körner
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, D-66421 Homburg, Germany; (F.B.); (S.K.); (J.P.K.); (A.B.); (B.S.)
| | - Jan Philipp Kühn
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, D-66421 Homburg, Germany; (F.B.); (S.K.); (J.P.K.); (A.B.); (B.S.)
| | - Alessandro Bozzato
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, D-66421 Homburg, Germany; (F.B.); (S.K.); (J.P.K.); (A.B.); (B.S.)
| | - Bernhard Schick
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, D-66421 Homburg, Germany; (F.B.); (S.K.); (J.P.K.); (A.B.); (B.S.)
| | - Maximilian Linxweiler
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, D-66421 Homburg, Germany; (F.B.); (S.K.); (J.P.K.); (A.B.); (B.S.)
- Correspondence: ; Tel.: +49-6841-162-2928
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Abstract
CLINICAL ISSUE Percutaneous transhepatic biliary and gall bladder interventions play an important role in the diagnosis and therapy of biliary tract diseases. PERFORMANCE With technical success rates up to 99% as well as complications rates up to a maximum of 26% they showed good results. Indications were opacification of the biliary tree as well as treatment of biliary system pathologies, such as drainage and stents. ACHIEVEMENTS Interventions were used if endoscopic approaches are not possible or exploited. We describe the current state of knowledge and the range for percutaneous biliary/gall bladder interventions and give an overview of technical approaches for fundamental interventional procedures, including percutaneous transhepatic biliary drainage. PRACTICAL RECOMMENDATIONS Percutaneous transhepatic biliary and gall bladder interventions are safe and effective treatments for benign and malignant stenosis, postoperative complications and risk patients with cholecystitis.
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Affiliation(s)
- C Radosa
- Institut und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Carl-Gustav-Carus, TU Dresden, Fetscherstraße 74, Haus 27, 01307, Dresden, Deutschland.
| | - F Schaab
- Institut und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Carl-Gustav-Carus, TU Dresden, Fetscherstraße 74, Haus 27, 01307, Dresden, Deutschland
| | - T Hofmockel
- Institut und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Carl-Gustav-Carus, TU Dresden, Fetscherstraße 74, Haus 27, 01307, Dresden, Deutschland
| | - J P Kühn
- Institut und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Carl-Gustav-Carus, TU Dresden, Fetscherstraße 74, Haus 27, 01307, Dresden, Deutschland.,Institut für Diagnostische und Interventionelle Radiologie, Universitätsmedizin Greifswald, Greifswald, Deutschland
| | - R T Hoffmann
- Institut und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Carl-Gustav-Carus, TU Dresden, Fetscherstraße 74, Haus 27, 01307, Dresden, Deutschland
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Seppelt D, Kolb C, Kühn JP, Speiser U, Radosa CG, Hoberück S, Hoffmann RT, Platzek I. Comparison of sequential and high-pitch-spiral coronary CT-angiography: image quality and radiation exposure. Int J Cardiovasc Imaging 2019; 35:1379-1386. [PMID: 30850908 DOI: 10.1007/s10554-019-01568-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 02/21/2019] [Indexed: 12/28/2022]
Abstract
New protocols for coronary computed tomography angiography (CCTA) could lower the radiation dose for patients but influence the image quality. To compare image quality and radiation exposure in step-and-shoot CCTA and high-pitch spiral CCTA. Fifty-nine pairs of patients matched for weight, height, sex and heart rate were included in this study (74 m, 44 f, average age 60 years, age range 29-94 years). Step-and-shoot CCTA and high-pitch spiral CCTA was performed on a third generation dual-source CT in equally sized patient groups. The signal-to-noise ratio (SNR) in the ascending aorta and the coronary arteries were determined for each dataset. Image quality was rated using a five-point scale. We used the t-test for paired samples to compare SNR and effective dose, and the Wilcoxon test to compare image quality scores. Mean effective dose for the step-and-shoot protocol (4.15 ± 3.07 mSv) was significantly higher in comparison to the high-pitch spiral protocol (1.2 ± 0.69 mSv; p < 0.0001). Mean SNR was higher with the step-and-shoot protocol compared to the high-pitch spiral protocol in the aorta, in the left main and peripheral coronary arteries (p < 0.01), in the proximal right coronary artery (p = 0.027). Image quality scores were significantly better for the step-and-shoot protocol (p = 0.0003). Step-and-shoot CCTA has significantly better SNR and overall image quality compared to high-pitch spiral CCTA, but with a mean effective dose more than thrice as high.
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Affiliation(s)
- D Seppelt
- Institute and Policlinic for Diagnostic and Interventional Radiology, Dresden University Hospital, Carl-Gustav-Carus University, Fetscherstraße 74, 01307, Dresden, Germany.
| | - C Kolb
- Institute and Policlinic for Diagnostic and Interventional Radiology, Dresden University Hospital, Carl-Gustav-Carus University, Fetscherstraße 74, 01307, Dresden, Germany
| | - J P Kühn
- Institute and Policlinic for Diagnostic and Interventional Radiology, Dresden University Hospital, Carl-Gustav-Carus University, Fetscherstraße 74, 01307, Dresden, Germany
| | - U Speiser
- Department of Cardiology, Heart Centre Dresden University Hospital, Fetscherstraße 76, 01307, Dresden, Germany
| | - C G Radosa
- Institute and Policlinic for Diagnostic and Interventional Radiology, Dresden University Hospital, Carl-Gustav-Carus University, Fetscherstraße 74, 01307, Dresden, Germany
| | - S Hoberück
- Department of Nuclear Medicine, Dresden University Hospital, Fetscherstraße 74, 01307, Dresden, Germany
| | - R T Hoffmann
- Institute and Policlinic for Diagnostic and Interventional Radiology, Dresden University Hospital, Carl-Gustav-Carus University, Fetscherstraße 74, 01307, Dresden, Germany
| | - I Platzek
- Institute and Policlinic for Diagnostic and Interventional Radiology, Dresden University Hospital, Carl-Gustav-Carus University, Fetscherstraße 74, 01307, Dresden, Germany
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Linxweiler M, Kühn JP, Wagner M, Al Kadah B, Schick B. Reduction of post-operative pain after tonsillectomy by a local mucosal flap - a prospective, randomized, controlled clinical trial on 100 adult patients. Acta Otolaryngol 2018; 138:913-920. [PMID: 30354838 DOI: 10.1080/00016489.2018.1497807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Tonsillectomy is one of the most frequent operations in otorhinolaryngology being associated with intense post-operative pain and an impairment of swallowing and speech. AIMS To determine whether wound sealing with a local mucosal flap can improve patient rehabilitation. MATERIALS AND METHODS The study was designed as a prospective, randomized, monocentric, controlled clinical trial including 100 patients. Patients were operated on using either conventional extracapsular tonsillectomy (n = 50) or a modified technique with a local mucosal flap prepared from the posterior surface of the tonsil (n = 50). Number of requested pain medications, local oedema, patient-reported pain level, post-operative haemorrhage, impairment of speech, swallowing and general condition were assessed. The study was registered at the German Clinical Trials Register. RESULTS The mucosal flap technique significantly reduced post-operative pain [2.94 (intervention group) vs. 4.61 (control group) in an numerical analogue scale, p < .001] and the number of pain medications [6 (intervention group) vs. 1 (control group), p < .001]. CONCLUSIONS Wound sealing with a local mucosal flap can reduce post-operative pain in tonsillectomy patients and is recommended whenever anatomically feasible. SIGNIFICANCE This new tonsillectomy technique can help to reduce post-operative pain and thereby improve the patients' post-operative rehabilitation.
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Affiliation(s)
- Maximilian Linxweiler
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Centre, Homburg, Germany
| | - Jan Philipp Kühn
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Centre, Homburg, Germany
| | - Mathias Wagner
- Department of General and Surgical Pathology, Saarland University Medical Center, Homburg, Germany
| | - Basel Al Kadah
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Centre, Homburg, Germany
| | - Bernhard Schick
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Centre, Homburg, Germany
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23
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Bochen F, Balensiefer B, Körner S, Bittenbring JT, Neumann F, Koch A, Bumm K, Marx A, Wemmert S, Papaspyrou G, Zuschlag D, Kühn JP, Al Kadah B, Schick B, Linxweiler M. Vitamin D deficiency in head and neck cancer patients - prevalence, prognostic value and impact on immune function. Oncoimmunology 2018; 7:e1476817. [PMID: 30228945 PMCID: PMC6140588 DOI: 10.1080/2162402x.2018.1476817] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 01/17/2023] Open
Abstract
Vitamin D deficiency is frequently observed in human cancer patients and a prognostic relevance could be shown for some entities. Additionally, it is known that vitamin D can stimulate the patients' antitumor immunity. However, valid epidemiological data for head and neck squamous cell carcinoma (HNSCC) patients are sparse and functional studies on a possible connection between vitamin D and the patients' immune system are missing. 25-OH vitamin D serum levels were analyzed in 231 HNSCC patients and 232 healthy controls and correlated with clinical data and patient survival. Intra- and peritumoral infiltration with T-cell, NK-cell and macrophage populations was analyzed in 102 HNSCC patients by immunohistochemistry. In 11 HNSCC patients, NK-cells were isolated before and after vitamin D substitution and analyzed for their cytotoxic activity directed against a HNSCC cell line. Vitamin D serum levels were significantly lower in HNSCC patients compared with healthy controls. Low vitamin D levels were associated with lymphatic metastasis and a negative HPV status and were a significant predictor of poor overall survival. HNSCC patients with severe vitamin D deficiency showed significantly altered intra- and peritumoral immune cell infiltrate levels. After vitamin D substitution, the patients' NK cells showed a significant rise in cytotoxic activity. Taken together, we could show that Vitamin D deficiency is highly prevalent in HNSCC patients and is a predictor of poor survival. Vitamin D substitution used as an adjuvant in immune therapies such as cetuximab and nivolumab treatment could support antitumorigenic immune responses, thus contributing to the improvement of the patients' prognosis in the context of a multimodal therapy.
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Affiliation(s)
- Florian Bochen
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Homburg, Germany
| | - Benedikt Balensiefer
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Homburg, Germany
| | - Sandrina Körner
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Homburg, Germany
| | - Jörg Thomas Bittenbring
- Department of Hematology, Oncology, Rheumatology and Clinical Immunology, Saarland University Medical Center, Homburg, Germany
| | - Frank Neumann
- Department of Hematology, Oncology, Rheumatology and Clinical Immunology, Saarland University Medical Center, Homburg, Germany
| | - Armand Koch
- Department of Otorhinolaryngology, Zitha Hospital, Luxemburg-City, Luxemburg
| | - Klaus Bumm
- Department of Otorhinolaryngology, Head and Neck Surgery, Caritas Hospital, Saarbrücken, Germany
| | - Anke Marx
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Homburg, Germany
| | - Silke Wemmert
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Homburg, Germany
| | - Georgios Papaspyrou
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Homburg, Germany
| | - David Zuschlag
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Homburg, Germany
| | - Jan Philipp Kühn
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Homburg, Germany
| | - Basel Al Kadah
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Homburg, Germany
| | - Bernhard Schick
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Homburg, Germany
| | - Maximilian Linxweiler
- Department of Otorhinolaryngology, Head and Neck Surgery, Saarland University Medical Center, Homburg, Germany
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Stecher SS, Simon P, Friesecke S, Glitsch A, Kühn JP, Lerch MM, Mayerle J. Delayed severe bleeding complications after treatment of pancreatic fluid collections with lumen-apposing metal stents. Gut 2017; 66:1871-1872. [PMID: 28082319 DOI: 10.1136/gutjnl-2016-313562] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 12/20/2016] [Accepted: 12/21/2016] [Indexed: 01/10/2023]
Affiliation(s)
- S S Stecher
- Department of Medicine B, University Medicine, Ernst-Moritz-Arndt-University, Greifswald, Germany
| | - P Simon
- Department of Medicine A, University Medicine, Ernst-Moritz-Arndt-University, Greifswald, Germany
| | - S Friesecke
- Department of Medicine B, University Medicine, Ernst-Moritz-Arndt-University, Greifswald, Germany
| | - A Glitsch
- Department of General Surgery, University Medicine, Ernst-Moritz-Arndt-University, Greifswald, Germany
| | - J P Kühn
- Institute of Radiology, University Medicine, Ernst-Moritz-Arndt-University, Greifswald, Germany
| | - M M Lerch
- Department of Medicine A, University Medicine, Ernst-Moritz-Arndt-University, Greifswald, Germany
| | - J Mayerle
- Medizinische Klinik und Poliklinik II, Klinikum der LMU, München-Grosshadern, Munich, Germany
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Kromrey ML, Göhler A, Friedrich N, Kindermann K, Hadlich S, Puls D, Steinmetz I, Kühn JP. Monitoring of abdominal Staphylococcus aureus infection using magnetic resonance imaging: a murine animal model for hepatic and renal abscesses. Eur J Clin Microbiol Infect Dis 2016; 36:373-378. [PMID: 27778120 DOI: 10.1007/s10096-016-2811-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 10/09/2016] [Indexed: 11/30/2022]
Abstract
To establish a routine workflow for in vivo magnetic resonance imaging (MRI) of mice infected with bacterial biosafety level 2 pathogens and to generate a mouse model for systemic infection with Staphylococcus aureus suitable for monitoring by MRI. A self-contained acrylic glass animal bed complying with biosafety level 2 requirements was constructed. After intravenous infection with 105 colony-forming units (CFU) (n = 3), 106 CFU (n = 11) or 107 CFU (n = 6) of S. aureus strain Newman, female Balb/c mice were whole-body scanned by 7T MRI. Abdominal infections such as abscesses were visualized using a standard T2-weighted scan. Infection monitoring was performed for each animal by measurements at 1, 3, and 7 days after infection. Intravenous pathogen application led to a dose-dependent decrease in survival probability (p = 0.03). In the group with the highest infectious dose the 7-day survival rate was 33 %. An intermediate S. aureus dose showed a survival rate of 80 %, whereas at the lowest infection dose, none of the animals died. All animals with the highest infection dose exhibited hepatic abscesses 4 days after inoculation, 80 % developed renal abscesses on the 3rd day. Mice obtaining the intermediate S. aureus load reached a plateau at day 4 with 72 % liver and 60 % renal abscess probability. No abscesses were observed in other abdominal organs at any time point. The implemented experimental setup provides a suitable and reliable in vivo MRI method to study murine abdominal infection models using BSL-2 pathogen. Systemic Staphylococcus aureus infection leads to a dose-dependent development of hepatic and renal abscesses.
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Affiliation(s)
- M L Kromrey
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany.
| | - A Göhler
- Friedrich Loeffler Institute of Medical Microbiology, University Greifswald, Greifswald, Germany
| | - N Friedrich
- Institute for Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany.,Research Centre for Prevention and Health, Glostrup University Hospital, Glostrup, Denmark
| | - K Kindermann
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - S Hadlich
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - D Puls
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - I Steinmetz
- Friedrich Loeffler Institute of Medical Microbiology, University Greifswald, Greifswald, Germany
| | - J P Kühn
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
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Mensel B, Grotz A, Kühn JP, Hegenscheid K, Lorbeer R, Hosten N. Analyse der Gefäßdurchmesser sowie der Stenoseprävalenz der Becken-Bein-Arterien in einer Normalbevölkerung. ROFO-FORTSCHR RONTG 2014. [DOI: 10.1055/s-0034-1372905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Kühn JP, Hegenscheid K, Behnrdt PO, Völzke H, Hosten N, Mensel B. Quantifizierung des Leberfett- und Lebereisengehaltes mit der Magnetresonanztomografie: Einsatz in einer populationsbasierten Studie. ROFO-FORTSCHR RONTG 2013. [DOI: 10.1055/s-0033-1346323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Kühn JP, Mensel B, Hosten N, Völzke H, Hegenscheid K. Diagnostische Genauigkeit von Ultraschall in der Diagnostik der Fettlebererkrankung: Eine MRT Korrelationsstudie. ROFO-FORTSCHR RONTG 2013. [DOI: 10.1055/s-0033-1346325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Kühn JP, Hernando D, Reeder SB, Hosten N. Stellenwert der Multispektralen Fettkorrektur für eine akkurate Bestimmung von Lebereisen und Leberfett in Chemical Shift Gradienten-Echo-Sequenzen. ROFO-FORTSCHR RONTG 2012. [DOI: 10.1055/s-0032-1311351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Mensel B, Kühn JP, Hegenscheid K, Langner S, Puls R, Hosten N. Durchmesserbestimmung der Aorta und des Trunkus pulmonalis im Rahmen epidemiologischer Forschung- benötigen wir Gadolinium und orthogonale Rekonstruktionen? ROFO-FORTSCHR RONTG 2012. [DOI: 10.1055/s-0032-1311053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Mensel B, Hoene A, Kühn JP, v. Bernstorff W, Rosenberg C, Traeger T, Hosten N, Puls R. Endovascular Aortic Repair: Talent versus Endurant- Hält der Herausforderer was er verspricht? ROFO-FORTSCHR RONTG 2012. [DOI: 10.1055/s-0032-1311018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Kühn JP, Mensel B, Behrndt PO, Hegenscheid K, Hosten N, Puls R. Quantifizierung der Lipomatosis pancreatis in der Magnetresonanztomographie und Bestimmung potentieller klinischer Korrelate in einer populationsbasierten Studie. ROFO-FORTSCHR RONTG 2012. [DOI: 10.1055/s-0032-1311352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Puls R, Hegenscheid K, Bülow R, Laquar R, Otto M, Langner S, Kirsch M, Seipel R, Kühn JP, Mensel B, Hosten N. Populationsbasierte Ganzkörper-Magnetresonanztomographie. Fortlaufende prospektive, epidemiologische Bevölkerungsstudie - „Study of Health in Pomerania” (SHIP). ROFO-FORTSCHR RONTG 2012. [DOI: 10.1055/s-0032-1311308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Puls R, Rosenberg C, Kühn JP, Traeger T, Mensel B, Hoene A. [Thoracic aortic interventions]. ROFO-FORTSCHR RONTG 2011; 184:15-23. [PMID: 22198828 DOI: 10.1055/s-0031-1281935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
The treatment of thoracic aortic diseases has undergone a paradigm shift due to the introduction and further development of interventional techniques in recent years. Thoracic endovascular aortic repair (TEVAR) of the descending aorta has significantly lower mortality and complication rates compared to open repair. Meanwhile this endovascular approach is the first option for the treatment of the majority of thoracic aortic diseases.
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Affiliation(s)
- R Puls
- Institut für Diagnostische Radiologie und Neuroradiologie, Universitätsmedizin der Ernst-Moritz-Arndt-Universität Greifswald, Greifswald.
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Kühn JP, Hegenscheid K, Bühlow R, Evert M, Seipel R, Kirsch M, Hosten N, Puls R. Nicht invasive Quantifizierung des Leberfettgehaltes unter Verwendung der T2* korrigierten DIXON-MRT. ROFO-FORTSCHR RONTG 2011. [DOI: 10.1055/s-0031-1279260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Puls R, Hegenscheid K, Kühn JP, Bülow R, Otto M, Hosten N. Klinisch relevante Zufallsbefunde in der Ganzkörper-MRT. ROFO-FORTSCHR RONTG 2011. [DOI: 10.1055/s-0031-1279253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Kühn JP, Langner S, Soltesz S, Hosten N. MRT-gestützte abdominelle Biopsien an einem Hochfeld-3T Gerät mit großer Magnetöffnung: Umsetzung, Handhabung und Nadelartefakte. ROFO-FORTSCHR RONTG 2010. [DOI: 10.1055/s-0030-1252880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kühn JP, Hadlich S, Brunch K, Hosten N. Kontrastmittelreaktionen: Anzeichen, Erscheinung und Akutbehandlung. ROFO-FORTSCHR RONTG 2010. [DOI: 10.1055/s-0030-1252980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Hegenscheid K, Kühn JP, Völzke H, Biffar R, Hosten N, Puls R. Whole-body magnetic resonance imaging of healthy volunteers: pilot study results from the population-based SHIP study. ROFO-FORTSCHR RONTG 2009; 181:748-59. [PMID: 19598074 DOI: 10.1055/s-0028-1109510] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE Approximately 4000 volunteers will undergo whole-body magnetic resonance imaging (WB-MRI) within the next 3 years in the population-based Study of Health in Pomerania (SHIP). Here we present a pilot study conducted (a) to determine the feasibility of adding a WB-MRI protocol to a large-scale population-based study, (b) to evaluate the reliability of standardized MRI interpretation, and (c) to establish an approach for handling pathological findings. MATERIALS AND METHODS The institutional review board approved the study, and oral and written informed consent was obtained from each participant. Two hundred healthy volunteers (99 women, 101 men; mean age 48.3 years) underwent a standardized WB-MRI protocol. The protocol was supplemented by contrast-enhanced cardiac MRI and magnetic resonance (MR) angiography in 61 men (60.4%) and cardiac MRI and MR mammography in 44 women (44.4%). MR scans were evaluated independently by two readers. Abnormalities were discussed by an advisory board and classified according to the need for further clinical work-up. RESULTS One hundred ninety-four (97.0%) WB-MRI examinations were successfully completed in a mean scan time per subject of 90 minutes. There were 431 pathological findings in 176 (88%) of the participants. Of those 45 (10.4%) required further clinical work-up and 386 (89.6%) characterized as benign lesions did not. The interobserver agreement for the detection of pathological findings was excellent (kappa = 0.799). CONCLUSION The preliminary results presented here indicate that a large prospective, population-based study using WB-MRI is feasible and that the results of image analysis are reproducible. A variety of positive findings provide valuable information regarding disease prevalence in a general adult population.
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Affiliation(s)
- K Hegenscheid
- Institut für Diagnostische Radiologie und Neuroradiologie, Universitätsklinikum der Ernst-Moritz-Arndt-Universität Greifswald
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Kühn JP, Hadlich S. Physikochemische Eigenschaften von MRT-Kontrastmitteln. ROFO-FORTSCHR RONTG 2009. [DOI: 10.1055/s-0029-1221672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Hegenscheid K, Kühn JP, Ungerer S, Völzke H, Hosten N, Puls R. Zufallsbefunde einer Ganzkörper-Magnetresonanztomographie-Untersuchung im Rahmen des Prä-Tests einer prospektiven, epidemiologischen Bevölkerungsstudie – Study of Health in Pomerania (SHIP). ROFO-FORTSCHR RONTG 2009. [DOI: 10.1055/s-0029-1221309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Kühn JP, Hegenscheid K, Puls R. [Ruptured visceral artery aneurysm as the initial symptomatic manifestation of panarteritis nodosa]. ROFO-FORTSCHR RONTG 2009; 180:922-4. [PMID: 19238643 DOI: 10.1055/s-2008-1027684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Otto S, Kühn JP, Wallaschofski H, Puls R. [Neuroendocrine tumors of the gastro-pancreatic system--also extraluminal]. ROFO-FORTSCHR RONTG 2008; 180:1131-3. [PMID: 18925539 DOI: 10.1055/s-2008-1027821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- S Otto
- Ernst-Moritz-Arndt-Universität, F.- Sauerbruchstrasse, 17489 Greifswald, Germany.
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Kühn JP, Puls R, Hosten N. [Native MRT diagnosis of transplantation dysfunction--the acute graft reaction]. ROFO-FORTSCHR RONTG 2008; 180:669-72. [PMID: 18484517 DOI: 10.1055/s-2008-1027435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Kühn JP, Puls R, Maier S, Hosten N. PTCD mit transhepatischem Zugang über die Gallenblase - Entlastung einer sekundären Duodenalstumpfinsuffizienz nach Gastrektomie. ROFO-FORTSCHR RONTG 2007; 179:860-2. [PMID: 17599289 DOI: 10.1055/s-2007-963233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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