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Kratzer W, Güthle M, Dobler F, Seufferlein T, Graeter T, Schmidberger J, Barth TFE, Klaus J. Comparison of superb microvascular imaging (SMI) quantified with ImageJ to quantified contrast-enhanced ultrasound (qCEUS) in liver metastases-a pilot study. Quant Imaging Med Surg 2022; 12:1762-1774. [PMID: 35284256 PMCID: PMC8899953 DOI: 10.21037/qims-21-383] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 04/07/2021] [Accepted: 10/12/2021] [Indexed: 07/28/2023]
Abstract
BACKGROUND The aim of the study was to compare methods for the assessment of vascularisation of liver metastases (LM) between superb microvascular imaging (SMI), contrast-enhanced ultrasound, and microvascular density (MVD). METHODS SMI results were quantified as the vascularisation quotient (VQ), based on a grey-scale analysis with ImageJ image software. Those results were compared to contrast-enhanced ultrasonography (CEUS) values, calculated with VueBox®. MVD was measured with an anti-CD34 antibody. RESULTS This study included 13 patients with LM. The VQ showed a strong correlation with the quantified parameters of contrast-enhanced ultrasound. The parameters of quantified contrast-enhanced ultrasound compared with quantified SMI showed the following statistical correlations: peak enhancement (PE), in arbitrary unit (a.u.) (r=0.72104, P=0.0054), PE in Decibel (dB) (r=0.65918, P=0.00141), Wash-in- Area Under the Curve (WiAUC) in a.u. (r=0.63604, P=0.00194), Wash-in Perfusion-Index (WiPI) in a.u. (r=0.73337, P=0.0043), Wash-in Perfusion-Index (WiPI) in dB (r=0.65642, P=0.0194), Wash-in-Rate (WiR) in a.u. (r=0.7304, P=0.0036) and Wash-in-Rate (WiR) in dB (r=0.82897, P=0.0005). CONCLUSIONS Comparison of the two methods, SMI and contrast-enhanced ultrasound (CEUS), for quantitative assessment of vascularisation of LM showed good correlation. The contrast-independent Doppler technique SMI can qualitatively assess the vascularisation of LM.
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Affiliation(s)
- Wolfgang Kratzer
- Department of Internal Medicine I, University Hospital Ulm, Ulm, Germany
| | - Melanie Güthle
- Department of Internal Medicine I, University Hospital Ulm, Ulm, Germany
| | - Felix Dobler
- Department of Internal Medicine I, University Hospital Ulm, Ulm, Germany
| | - Thomas Seufferlein
- Department of Internal Medicine I, University Hospital Ulm, Ulm, Germany
| | - Tilmann Graeter
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
| | | | - Thomas FE Barth
- Institute of Pathology, University Hospital Ulm, Ulm, Germany
| | - Jochen Klaus
- Department of Internal Medicine I, University Hospital Ulm, Ulm, Germany
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Ettrich TJ, Sturm N, Güthle M, Hüttner FJ, Perkhofer L. Pancreatic Cancer: Current Multimodality Treatment Options and the Future Impact of Molecular Biological Profiling. Visc Med 2022; 38:20-29. [PMID: 35295894 PMCID: PMC8874237 DOI: 10.1159/000521631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 08/04/2021] [Accepted: 12/19/2021] [Indexed: 02/03/2023] Open
Abstract
Background Pancreatic cancer (PDAC) - even if deemed resectable - has still a dismal prognosis and is the seventh leading cause of global cancer-related death with rising incidence worldwide. Summary Surgical resection at best in combination with adjuvant systemic chemotherapy is the only potentially curative treatment. Surgical treatment has substantially improved over the last years with significantly reduced perioperative morbidity and mortality. Even when deemed radiologically resectable, the majority of PDAC is likely to have micrometastases, leaving most PDAC patients with an advanced stage. Recent 5-year overall survival was up to 46% in patients eligible for surgery with intensified adjuvant chemotherapy. Eligible for curative surgery are about one-third of the patients, and only 20% of these patients have the option for cure with surgery and adjuvant chemotherapy. Standards of care in treating PDAC patients include various mostly combinational chemotherapy approaches in the advanced and adjuvant setting. Moreover, first targeted therapies for individualizing treatment, e.g., specific subgroups like BRCA1/2 germline mutated patients, were established lately. Neoadjuvant concepts are currently part of research. This review focuses on current and future multimodal treatment options of PDAC and the impact of molecular profiling for individualizing treatment. Key Messages State of the art in pancreatic cancer therapy is multimodal and includes novel strategies to allow molecular defined subgroup-specific treatment.
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Affiliation(s)
- Thomas J. Ettrich
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany,*Thomas J. Ettrich,
| | - Niklas Sturm
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Melanie Güthle
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Felix J. Hüttner
- Department of General and Visceral Surgery, Ulm University Hospital, Ulm, Germany
| | - Lukas Perkhofer
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
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Schranz T, Klaus J, Kratzer W, Schmidberger J, Güthle M. A comparison of spleen size measured by ultrasound in a random population sample and a matched sample of patients at a university hospital, and the determination of normal values and influencing factors. Z Gastroenterol 2021; 59:438-445. [PMID: 33752244 DOI: 10.1055/a-1404-4097] [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] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES This study aimed to compare spleen sizes in a hospital and a population sample using ultrasound and define normal values and factors influencing spleen size. METHODS Both samples' spleen sizes (n = 1520) were measured using ultrasound under the same conditions. Blood counts and other laboratory parameters were determined under the same conditions in both samples. RESULTS In the hospital sample (n = 760), the mean spleen size was 114.7 mm, and in the population sample (n = 760), it was 99.1 mm. In both, spleen size in men was significantly higher than in women (p < 0.0001) and influenced by body height, weight, and BMI (body mass index) (p < 0.0001). In the hospital sample, there was a correlation with higher values for ALT (p = 0.0160), AST (p = 0.0394), AP (p = 0.0482), and ferritin (p = 0.0008) and lower values for HDL (p = 0.0091) and thrombocytes (p < 0.0001). In the multivariate analysis, higher values for AP (p = 0.0059) and lower values for hemoglobin (p = 0.0014) and thrombocytes (p = 0.0001) were found. Stratified for sex (men, women), spleen size increased with higher values for ALT (p = 0.0116, p = 0.0113), AST (p = 0.0014, p = 0.0113), and AP (p = 0.0001, p = 0.0012), and with lower values of hemoglobin (p = 0.0057, p = 0.0016), thrombocytes (p < 0.0001, p = 0.0003), and albumin (p = 0.0029, p = 0.0432). In women, there was a discordant correlation with red blood cells (p = 0.0005) and a concordant correlation with GGT (p = 0.0241), and in men discordant correlations with cholesterol (p = 0.0010) and HDL (p = 0.0404). CONCLUSIONS The already proven impact of anthropometric data on spleen size was confirmed. The role of laboratory values should be further analyzed.
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Affiliation(s)
| | - Jochen Klaus
- Klinik für Innere Medizin I, Universitätsklinikum Ulm, Ulm
| | | | | | - Melanie Güthle
- Klinik für Innere Medizin I, Universitätsklinikum Ulm, Ulm
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Ettrich TJ, Perkhofer L, Decker T, Hofheinz RD, Heinemann V, Hoffmann T, Hebart HF, Herrmann T, Hannig CV, Büchner-Steudel P, Güthle M, Hermann PC, Berger AW, Seufferlein T. Nintedanib plus mFOLFOX6 as second-line treatment of metastatic, chemorefractory colorectal cancer: The randomised, placebo-controlled, phase II TRICC-C study (AIO-KRK-0111). Int J Cancer 2020; 148:1428-1437. [PMID: 32930387 DOI: 10.1002/ijc.33296] [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] [Received: 03/12/2020] [Revised: 06/26/2020] [Accepted: 07/23/2020] [Indexed: 11/10/2022]
Abstract
Nintedanib is a triple angiokinase inhibitor of vascular endothelial growth factor receptor 1-3, fibroblast growth factor receptor 1-3 and platelet-derived growth factor receptor-a/-b. Thereby, it targets angiogenic escape mechanisms. The trial TyRosine kinase Inhibitor for the treatment of Chemorefractory Colorectal Cancer (TRICC-C) trial evaluates the addition of nintedanib to mFOLFOX6 (fluorouracil, folinic acid and oxaliplatin) in patients with metastatic colorectal cancer (mCRC). TRICC-C is a randomised controlled, double-blinded, phase II trial in mCRC patients that received a first-line non-oxaliplatin containing chemotherapy. Patients received mFOLFOX6 + nintedanib (F + N) (2 × 200 mg p.o./d, d1-d14) or mFOLFOX6 + placebo (F + P), in a 1:1 ratio. Primary endpoint was median progression free survival (mPFS) and secondary overall response rate (ORR), overall survival (OS) and safety. Fifty-three patients (27 F + N; 26 F + P) were randomised between 12/2012 and 5/2016 (scheduled n = 180). The trial was terminated prematurely due to slow accrual. The trial did not reach its primary endpoint but mPFS, median overall survival (mOS) and disease control rate (DCR) were numerically higher in the F + N arm compared to the F + P arm; however, the difference was not significant (mPFS: F + P: 4.6 months vs F + N: 8.1 months; HR 0.65; 95% CI 0.32-1.30; P = .2156; mOS: F + P: 9.9 months vs F + N: 17.1 months; HR 1.03, 95% CI 0.48-2.23; P = .9387; DCR: F + P: 50% vs F + N: 66,7%; P = .2709). Toxicity was moderate and only different for neutropenia (F + P: 11.5%, F + N: 19.2%) and gastrointestinal disorders (F + P: 65.4%, F + N: 84.6%). Final results show safety and a nonsignificant trend towards improved PFS and DCR for the combination of mFOLFOX6 + nintedanib in the second-line therapy of mCRC.
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Affiliation(s)
- Thomas J Ettrich
- Department of Internal Medicine I, Ulm University, Ulm, Delaware, USA
| | - Lukas Perkhofer
- Department of Internal Medicine I, Ulm University, Ulm, Delaware, USA
| | - Thomas Decker
- Private Practice, Onkologie Ravensburg, Ravensburg, Germany
| | | | - Volker Heinemann
- Department of Medical Oncology and Comprehensive Cancer Center, Ludwig Maximilians University, Munich, Germany
| | | | - Holger F Hebart
- Medizinische Klinik, Klinikum Schwäbisch Gmünd, Stauferklinik, Mutlangen, Baden-Württemberg, Germany
| | - Thomas Herrmann
- Medizinische Klinik, Westküstenklinikum Heide, Heide, Schleswig-Holstein, Germany
| | - Carla V Hannig
- Private Practice, Schwerpunktpraxis Hämatologie/Onkologie, Bottrop, Germany
| | | | - Melanie Güthle
- Department of Internal Medicine I, Ulm University, Ulm, Delaware, USA
| | - Patrick C Hermann
- Department of Internal Medicine I, Ulm University, Ulm, Delaware, USA
| | - Andreas W Berger
- Department of Internal Medicine I, Ulm University, Ulm, Delaware, USA
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Abstract
Background Gastrointestinal malignancies have both a high incidence rate and a high mortality rate. Immuno-oncological treatment approaches are becoming increasingly established in the treatment of gastrointestinal cancers. Summary In this review, we give an overview of the types and effects of immunotherapies. We focus on recent studies on immunotherapies with special attention to immune checkpoint inhibition in carcinomas of the esophagus and stomach, the hepato-pancreatico-biliary system, and the colorectum including the anal channel in the metastatic setting, and we show their achievements but also their limitations. In an outlook, we discuss new approaches in immunotherapy like CAR T-cell therapy and oncolytic viruses. Key Messages Gastrointestinal cancers show overall moderate response rates to immunotherapy. Nevertheless, subgroups such as DNA mismatch repair-deficient or microsatellite-instable tumors particularly benefit from the immune checkpoint blockade. Further studies are ongoing.
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Affiliation(s)
- Melanie Güthle
- Internal Medicine I, University Hospital of Ulm, Ulm, Germany
| | - Thomas Ettrich
- Internal Medicine I, University Hospital of Ulm, Ulm, Germany
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Ettrich T, Berger A, Decker T, Hofheinz R, Heinemann V, Hoffmann T, Hebart H, Herrmann T, Hannig CV, Büchner-Steudel P, Bartholomäus H, Güthle M, Perkhofer L, Seufferlein T. TRICC-C: Nintedanib vs. placebo in patients receiving mFOLFOX6 for metastatic, chemorefractory colorectal cancer: Final results from the randomized phase II trial of the AIO. Ann Oncol 2018. [DOI: 10.1093/annonc/mdy281.110] [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: 11/13/2022] Open
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Ettrich TJ, Perkhofer L, von Wichert G, Gress TM, Michl P, Hebart HF, Büchner-Steudel P, Geissler M, Muche R, Danner B, Kächele V, Berger AW, Güthle M, Seufferlein T. DocOx (AIO-PK0106): a phase II trial of docetaxel and oxaliplatin as a second line systemic therapy in patients with advanced pancreatic ductal adenocarcinoma. BMC Cancer 2016; 16:21. [PMID: 26772812 PMCID: PMC4714522 DOI: 10.1186/s12885-016-2052-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [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: 07/28/2015] [Accepted: 01/06/2016] [Indexed: 12/18/2022] Open
Abstract
Background The current study was conducted to examine the activity of a docetaxel/oxaliplatin (DocOx) combination as second line treatment for advanced pancreatic ductal adenocarcinoma (Trial registration: NCT00690300. Registered June 2, 2008) Methods DocOx is a prospective, multi-center, single arm, phase II trial using docetaxel (75 mg/m2, 60 min, d 1) and oxaliplatin (80 mg/m2, 120 min, d 2) in 21-day cycles. The treatment period was scheduled for up to 8 cycles. Primary endpoint was tumor response according to RECIST 1.0. Secondary endpoints were progression free survival, overall survival, safety/toxicity, quality of life and clinical benefit. Results Data represent the intention to treat analysis of 44 patients with chemorefractory pancreatic cancer enrolled between 2008 and 2012 at five institutions in Germany. The primary endpoint of tumor response was achieved in 15.9 % of the patients (7 partial remissions, no complete remission), with a disease control rate of 48 % after the first two treatment cycles. Median progression free survival (PFS) was 1.82 months (CI 95 % 1.5–3.96 months) and median overall survival (OS) was 10.1 months (CI 95 % 5.1–14.1 months). Conclusions This single-arm trial demonstrates that the combination of docetaxel and oxaliplatin yields promising results for the treatment of advanced pancreatic ductal adenocarcinoma patients. Selected patients had particular benefit from this treatment as indicated by long PFS and OS times. Even after 8 cycles of treatment with DocOx a partial response was observed in 2 patients and stable disease was observed in another 6 patients. The data obtained with the DocOx protocol compare well with other second line protocols such as OFF (oxaliplatin, 5-FU, leucovorin). The DocOx regimen could be an interesting option for patients who received gemcitabine as first line treatment for metastatic pancreatic cancer. Electronic supplementary material The online version of this article (doi:10.1186/s12885-016-2052-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | - Goetz von Wichert
- Department of Internal Medicine, Schön-Klinik Hamburg-Eilbeck, Hamburg, Germany.
| | - Thomas M Gress
- Department of Gastroenterology, Endocrinology, Metabolism and Infectiology, Philipps University of Marburg, Marburg, Germany.
| | - Patrick Michl
- Department of Internal Medicine I, Martin-Luther-University, Halle (Saale), Germany.
| | - Holger F Hebart
- Department of Internal Medicine, Stauferklinikum Schwaebisch-Gmuend, Mutlangen, Germany.
| | - Petra Büchner-Steudel
- Department of Internal Medicine I, Martin-Luther-University, Halle (Saale), Germany.
| | - Michael Geissler
- Department of Internal Medicine, Oncology/Hematology, Gastroenterology, Esslingen Hospital, Esslingen, Germany.
| | - Rainer Muche
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany.
| | - Bettina Danner
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany.
| | | | - Andreas W Berger
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, D-89081, Ulm, Germany.
| | - Melanie Güthle
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, D-89081, Ulm, Germany.
| | - Thomas Seufferlein
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, D-89081, Ulm, Germany.
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Ettrich T, Perkofer L, Berger A, Güthle M, Behl S, Zipprich A, Wörns M, Waldschmidt D, Belle S, Michl P, Seufferlein T, Dollinger M. 2363 Sorafenib plus Doxorubicin versus Sorafenib alone for advanced hepatocellular carcinoma (Soradox trial): final results of a prospective, randomized, open-label, multicenter phase IIb trial. Eur J Cancer 2015. [DOI: 10.1016/s0959-8049(16)31279-5] [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: 10/22/2022]
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Güthle M, Friesen C, Hofheinz R, Muche R, Ettrich T, Perkhofer L, Berger A, Seufferlein T. Eine Phase I/II-Studie zur Therapie mit D,L-Methadon in der Behandlung von Patienten mit histologisch gesicherten chemorefraktären kolorektalen Karzinomen. Z Gastroenterol 2015. [DOI: 10.1055/s-0035-1559240] [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] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Russell R, Perkhofer L, Liebau S, Lin Q, Lechel A, Feld FM, Hessmann E, Gaedcke J, Güthle M, Zenke M, Hartmann D, von Figura G, Weissinger SE, Rudolph KL, Möller P, Lennerz JK, Seufferlein T, Wagner M, Kleger A. Loss of ATM accelerates pancreatic cancer formation and epithelial-mesenchymal transition. Nat Commun 2015; 6:7677. [PMID: 26220524 PMCID: PMC4532798 DOI: 10.1038/ncomms8677] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 05/30/2015] [Indexed: 12/12/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is associated with accumulation of particular oncogenic mutations and recent genetic sequencing studies have identified ataxia telangiectasia-mutated (ATM) mutations in PDAC cohorts. Here we report that conditional deletion of ATM in a mouse model of PDAC induces a greater number of proliferative precursor lesions coupled with a pronounced fibrotic reaction. ATM-targeted mice display altered TGFβ-superfamily signalling and enhanced epithelial-to-mesenchymal transition (EMT) coupled with shortened survival. Notably, our mouse model recapitulates many features of more aggressive human PDAC subtypes. Particularly, we report that low expression of ATM predicts EMT, a gene signature specific for Bmp4 signalling and poor prognosis in human PDAC. Our data suggest an intimate link between ATM expression and pancreatic cancer progression in mice and men.
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Affiliation(s)
- Ronan Russell
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, Ulm 89081, Germany
| | - Lukas Perkhofer
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, Ulm 89081, Germany
| | - Stefan Liebau
- Institute of Neuroanatomy, Eberhard Karls University Tuebingen, Oesterbergstr. 3, Tuebingen 72074, Germany
| | - Qiong Lin
- Department of Cell Biology, Institute for Biomedical Engineering, Medical Faculty, RWTH Aachen University, Pauwelstr. 30, Aachen 52074, Germany
| | - André Lechel
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, Ulm 89081, Germany
| | - Fenja M Feld
- Institute of Pathology, Ulm University, Albert-Einstein-Allee 23, Ulm 89081, Germany
| | - Elisabeth Hessmann
- Department of Gastroenterology II, University Medical Center Goettingen, Robert-Koch-Str. 40, Goettingen 37075, Germany
| | - Jochen Gaedcke
- Department of Surgery, University Medical Center Goettingen, Robert-Koch-Str. 40, Goettingen 37075, Germany
| | - Melanie Güthle
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, Ulm 89081, Germany
| | - Martin Zenke
- Department of Cell Biology, Institute for Biomedical Engineering, Medical Faculty, RWTH Aachen University, Pauwelstr. 30, Aachen 52074, Germany
| | - Daniel Hartmann
- Department of Surgery, Technische Universität München, Ismaninger Str. 22, Munich 81675, Germany
| | - Guido von Figura
- II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, Munich 81675, Germany
| | | | - Karl-Lenhard Rudolph
- Leibniz Institute for Age Research - Fritz Lipmann Institute e.V., Beutenbergstr. 11, Jena 07745, Germany
| | - Peter Möller
- Institute of Pathology, Ulm University, Albert-Einstein-Allee 23, Ulm 89081, Germany
| | - Jochen K Lennerz
- Institute of Pathology, Ulm University, Albert-Einstein-Allee 23, Ulm 89081, Germany
| | - Thomas Seufferlein
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, Ulm 89081, Germany
| | - Martin Wagner
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, Ulm 89081, Germany
| | - Alexander Kleger
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, Ulm 89081, Germany
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Abstract
BACKGROUND The incidence of hepatocellular carcinoma (HCC) has increased over the past decades as a result of alcoholic liver disease, the metabolic syndrome and the increasing incidence of viral hepatitis B and C. OBJECTIVES An evaluation of the epidemiology of HCC, presentation and discussion of the risk factors for the development of HCC. MATERIAL AND METHODS This study was based on a literature review, analysis of the statistics of the World Health Organization (WHO), discussion of current basic research and expert recommendations. RESULTS The results show that HCC already represents the fifth most common malignancy in men and the ninth most common malignancy in women, and the incidence is still rising. The pronounced regional differences in prevalence and underlying risk factors are mainly, but not exclusively, due to the prevalence of chronic viral hepatitis B. CONCLUSION Hepatocellular carcinoma is a major medical problem. Primary prevention measures and suitable screening algorithms are gaining more and more importance.
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Affiliation(s)
- M Güthle
- Zentrum für Innere Medizin, Klinik für Innere Medizin I, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland
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