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Scheyda-Yoo K, Hofer U, Várnai-Händel A, Maus MKH, Dumoulin FL. [Rapid growth and malignant transformation of a mucinous cystic neoplasm during pregnancy - a case report]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024. [PMID: 38657617 DOI: 10.1055/a-2239-7898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND Mucinous-cystic neoplasms (MCN) account for 10% of all pancreatic cystic lesions. They are found almost exclusively in females. MCN have an ovarian-like stroma and often estrogen and progesterone receptors. During pregnancy, they can massively increase in size and transform into malignancy. CASE REPORT We report on a 29-year-old woman in whom a 35mm cyst in the pancreatic tail had been diagnosed several years ago. After workup the lesions had been classified as a pseudocyst. During pregnancy, the cyst massively increased in size and finally was resected. Histology showed a mucinous-cystic neoplasia with focal malignant transformation. CONCLUSION Cystic neoplasms of the pancreas require a differentiated management. While overtreatment should be avoided, malignant transformation always merits consideration - in particular if the cystic lesion is located in the pancreatic tail. Women with suspected MCN or cystic pancreatic lesions of uncertain etiology should be informed about the (rare) risk of a malignant transformation of an MCN and should be closely monitored during pregnancy.
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Affiliation(s)
- Katharina Scheyda-Yoo
- Abteilung für Innere Medizin, Gemeinschaftskrankenhaus St Elisabeth St Petrus St Johannes gGmbH, Bonn, Germany
| | - Ulrich Hofer
- Abteilung für Radiologie, Interventionelle Radiologie und Neuroradiologie, Gemeinschaftskrankenhaus St Elisabeth St Petrus St Johannes gGmbH, Bonn, Germany
| | | | - Martin K-H Maus
- Funktionelle OGI Chirurgie, Evangelisches Krankenhaus Kalk, Koln, Germany
| | - Franz Ludwig Dumoulin
- Abteilung für Innere Medizin, Gemeinschaftskrankenhaus St Elisabeth St Petrus St Johannes gGmbH, Bonn, Germany
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Suzuki T, Sugiura T, Okazaki J, Okaniwa A, Yoshida Y. Pancreatic serous cystic neoplasms with spontaneous hemorrhage in a young woman: A case report. Int J Surg Case Rep 2024; 115:109309. [PMID: 38286083 PMCID: PMC10839250 DOI: 10.1016/j.ijscr.2024.109309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 01/31/2024] Open
Abstract
INTRODUCTION Pancreatic serous cystic neoplasm (SCN) is usually benign and is often managed using imaging surveillance if asymptomatic. It has a higher incidence in females but is rare in younger age groups. Acute hemorrhagic complications associated with SCN are infrequent. Whether asymptomatic SCN can cause acute hemorrhage, especially in women of childbearing age, is not well-established. PRESENTATION OF CASE A 30-year-old Japanese female, who was six months postpartum and under surveillance for asymptomatic pancreatic SCN, presented to the emergency department with gradually worsening left lateral abdominal pain. Regular ultrasound revealed no change in SCN size; however, no imaging surveillance had been conducted over the past two years. She had pain in the entire abdomen, which intensified around the navel and elicited guarding. Abdominal contrast-enhanced computed tomography revealed a cystic mass in the pancreatic tail with a contrast blush within the cyst and an adjacent retroperitoneal hematoma. Endovascular embolization was performed to control the hemorrhage. The patient had an uneventful medical recovery and was discharged five days after embolization. Five months after discharge, she underwent laparoscopic distal pancreatectomy and splenectomy as an elective surgery and was discharged uneventfully. DISCUSSION Even with periodic imaging surveillance, pancreatic SCN can suddenly cause spontaneous hemorrhage. Clinicians should be aware that pancreatic SCN can potentially cause life-threatening complications, including spontaneous hemorrhage. CONCLUSION We report a case of an unexpected complication with spontaneous hemorrhage in a young woman who was under imaging surveillance for pancreatic SCN. The patient was successfully treated with angioembolization and planned laparoscopic surgery.
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Affiliation(s)
- Toshinao Suzuki
- Department of Anesthesiology, Kimitsu Chuo Hospital, 1010 Sakurai, Kisarazu, Chiba 292-8535, Japan.
| | - Takahiro Sugiura
- Department of Anesthesiology, Kimitsu Chuo Hospital, 1010 Sakurai, Kisarazu, Chiba 292-8535, Japan.
| | - Junko Okazaki
- Department of Anesthesiology, Kimitsu Chuo Hospital, 1010 Sakurai, Kisarazu, Chiba 292-8535, Japan
| | - Akira Okaniwa
- Department of Surgery, Kimitsu Chuo Hospital, 1010 Sakurai, Kisarazu, Chiba 292-8535, Japan
| | - Yu Yoshida
- Department of Gastroenterology, Kimitsu Chuo Hospital, 1010 Sakurai, Kisarazu, Chiba 292-8535, Japan
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Al Shamousi K, Al-Busafi SA, Kashoob M, Al Zadjali A, Al Kaabi H. Mucinous Cystic Neoplasm of the Pancreas in Pregnancy: A Case Report. Cureus 2023; 15:e50446. [PMID: 38222172 PMCID: PMC10785736 DOI: 10.7759/cureus.50446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2023] [Indexed: 01/16/2024] Open
Abstract
Mucinous cystic neoplasms (MCNs) of the pancreas are rare epithelial neoplasms, characterized by an inner epithelial layer and an ovarian-type sub-epithelial stroma. These lesions are typically benign but can pose challenges during pregnancy due to their rapid growth potential, associated risk of malignant transformation, and complications such as pancreatitis. We present a case of a 39-year-old pregnant female with a history of recurrent acute pancreatitis, diagnosed with an MCN during pregnancy. Diagnostic procedures were deferred until after delivery, followed by successful distal pancreatectomy. This case underscores the importance of individualized management strategies in pregnant patients with pancreatic MCNs, balancing the need for timely intervention with maternal and fetal safety. Long-term follow-up is generally unnecessary for MCNs without associated invasive carcinoma, emphasizing the favorable prognosis of these lesions following complete surgical resection.
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Affiliation(s)
| | - Said A Al-Busafi
- Gastroenterology, Sultan Qaboos University Hospital, Muscat, OMN
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Alomair AA, Almohaimeed RA, Alsaud JS, Alotaibi DF, Alharbi OT. Mucinous Cystic Neoplasm of the Pancreas in a Pregnant Woman: A Case Report and Review of the Literature. Cureus 2023; 15:e37787. [PMID: 37214006 PMCID: PMC10195075 DOI: 10.7759/cureus.37787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2023] [Indexed: 05/23/2023] Open
Abstract
Mucinous cystic neoplasms of the pancreas are rare tumors that represent 10% of cystic pancreatic tumors. They are potentially sex hormone-sensitive. However, mucinous cystic neoplasms occurring during pregnancy are relatively uncommon. A 33-year-old woman in her ninth week of gestation was referred to us due to abdominal pain for two months. Magnetic resonance imaging revealed a well-defined unilocular cystic lesion at the tail of the pancreas, measuring 7x6.4 cm. The patient underwent tumor resection with distal pancreatectomy and splenectomy during the second trimester to prevent the potential risk of rupture of the neoplasm, rapid growth, and/or intrauterine growth restriction. Histopathological examination revealed a mucinous cystadenoma with no atypia or malignancy. The patient completely recovered from the surgery and had a healthy full-term baby. This case shows the benefit of performing the surgery during the second trimester compared to the potential risk of delaying the surgery.
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Dhamor D, Irrinki S, Naik A, Kurdia KC, Rastogi P, Gupta P, Kapoor VK. Pregnancy-associated mucinous cystic neoplasms of the pancreas - A systematic review. Am J Surg 2023; 225:630-638. [PMID: 36424200 DOI: 10.1016/j.amjsurg.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 11/02/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Mucinous cystic neoplasms (MCN) are mucin-producing epithelial cell tumors of pancreas. They consist of an ovarian-type stroma expressing estrogen and progesterone receptors. Pregnancy-associated MCNs are presumed to be larger in size and more aggressive without any concrete evidence. OBJECTIVE and Data Sources: Systematic review of published literature using PubMed and Google Scholar databases. Original articles including case reports and series published between 1970&2021 were included wherein MCN was diagnosed during pregnancy/within one-year post-partum. Thirty-three publications having 36 cases, adding one of our own patient were analyzed in this review. RESULT Median age at presentation was 32 years. Only three (9%) patients were asymptomatic. Mean size of MCN was 135 mm. Ten patients (27%) reported an increase in size during pregnancy. Most tumors involved body and tail of pancreas (60%). Distal pancreatectomy with splenectomy was the most common resection performed (57%). No foetal mortality was reported to date. CONCLUSION Pregnancy may cause a rapid increase in size of MCN. Decision-making is more complex and needs a fine balance between optimal oncological and obstetric outcomes.
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Affiliation(s)
- Devesh Dhamor
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Santhosh Irrinki
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anil Naik
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kailash Chand Kurdia
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
| | - Pulkit Rastogi
- Department of Haematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Gupta
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vinay K Kapoor
- Department of Hepato-pancreato-biliary (HPB) Surgery, Mahatma Gandhi Medical College and Hospital (MGMCH), Jaipur, India
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Fogliati A, Garancini M, Uggeri F, Braga M, Gianotti L. Pancreatic Cystic Neoplasms and Pregnancy: A Systematic Review of Surgical Cases and a Case Report of a Fully Laparoscopic Distal Pancreatectomy. Surg Laparosc Endosc Percutan Tech 2021; 32:133-139. [PMID: 34882616 PMCID: PMC9907686 DOI: 10.1097/sle.0000000000001023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/28/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Mucinous cystic neoplasms and solid pseudopapillary neoplasms are the most common pancreatic tumors occurring in women of fertile age and in pregnant women. The aim of this study is to provide an updated literature review on this association and to present a fully laparoscopic resection of a pregnancy-associated pancreatic cystic neoplasm. MATERIALS AND METHODS A systematic literature review was performed using PubMed (MEDLINE), Scopus, Ovid, ISI Web of Science, and Google Scholar for searching. The syntax was (pancr*) AND (cyst*) AND (pregn*) AND (tumor). Only English-language articles describing pancreatic surgical resections were included. RESULTS Forty-seven case reports were included. The mean age of the patients was 29.6±5.3. Nine patients (20%) required emergency surgery, 4 (9%) due to cyst rupture, and 5 (11%) due to hemorrhage. Four patients (9%) suffered a miscarriage, and 2 (5%) opted for pregnancy termination; the rest of the women delivered a healthy newborn (86%, n=36). Thirty percent (n=14) of the resected neoplasms were malignant, and among mucinous cystic lesions, this raised to 45% (n=11). All patients diagnosed during the third trimester were resected postpartum, whereas 26/34 (76%) of patients diagnosed during the first 2 trimesters underwent surgery before delivery. CONCLUSIONS The most worrisome complications in pregnancy-associated pancreatic cysts are bleeding or rupture. Mucinous cystic neoplasm has a tendency to grow during pregnancy. A postpartum resection was generally preferred when the cystic neoplasm was diagnosed during the third trimester. This report is the first to describe a fully laparoscopic pancreatic resection.
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Affiliation(s)
| | - Mattia Garancini
- Department of Surgery, San Gerardo University Hospital, Monza, Italy
| | - Fabio Uggeri
- School of Medicine and Surgery, Milano-Bicocca University, Milan
- Department of Surgery, San Gerardo University Hospital, Monza, Italy
| | - Marco Braga
- School of Medicine and Surgery, Milano-Bicocca University, Milan
- Department of Surgery, San Gerardo University Hospital, Monza, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, Milano-Bicocca University, Milan
- Department of Surgery, San Gerardo University Hospital, Monza, Italy
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Lee YJ, Kim SW, Kim Y. Ovarian mass combined with pancreatic neoplasm in pregnancy: A rare case report and literature review. J Obstet Gynaecol Res 2021; 48:244-250. [PMID: 34729873 DOI: 10.1111/jog.15085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 09/22/2021] [Accepted: 10/17/2021] [Indexed: 01/18/2023]
Abstract
A 35-year-old woman presented with abdominal discomfort at 26 weeks gestation. The magnetic resonance imaging demonstrated a huge unilocular cystic mass with mural nodules originated from body and tail of pancreas. There was also a cystic mass in the left ovary with suppressed intensity on fat saturated image. One week later, she complained of worsening left lower abdominal pain and dyspnea as a new symptom. Hence, distal pancreatectomy with splenectomy and left ovarian cystectomy were performed. The huge cystic mass of pancreas was compressing the diaphragm, and left tubo-ovarian torsion was observed. This is the second case wherein an MCN of the pancreas with mature cystic teratoma of the ovary caused different symptoms. The management of MCNs in pregnant women should consider multiple aspects such as the malignancy potential of imaging findings, severity of symptoms, and fetal well-being.
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Affiliation(s)
- Young Joo Lee
- Department of Obstetrics and Gynecology, Kyung Hee Medical Center, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - So-Woon Kim
- Department of Pathology, Kyung Hee Medical Center, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Youngsun Kim
- Department of Obstetrics and Gynecology, Kyung Hee Medical Center, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
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Kośnik A, Stadnik A, Szczepankiewicz B, Patkowski W, Wójcicki M. Spontaneous rupture of a mucinous cystic neoplasm of the liver resulting in a huge biloma in a pregnant woman: A case report. World J Clin Cases 2021; 9:9114-9121. [PMID: 34786394 PMCID: PMC8567505 DOI: 10.12998/wjcc.v9.i30.9114] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 07/26/2021] [Accepted: 09/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Mucinous cystic neoplasm of the liver (MCN-L) and intraductal papillary neoplasm of the bile duct (IPN-B) are two different types of mucin-producing bile duct tumour that may complicate the course of pregnancy. To the best of our knowledge, we describe herein the first case of MCN-L with spontaneous rupture during pregnancy necessitating complex surgical treatment.
CASE SUMMARY A 24-year-old woman was initially admitted to another hospital in October 2018 with signs of jaundice (serum bilirubin level 12 mg/dL) and upper abdominal pain radiating to the left shoulder. Initial magnetic resonance imaging (MRI) of the abdominal cavity revealed a multilocular cystic tumour of the liver hilum (37 mm × 40 mm in diameter) located between segments 3 and 4 of the left liver lobe. Six weeks later (December 2018), the patient was found to be 12 wk pregnant and was referred to our institution for further diagnostics and treatment. At admission, a soft, palpable, and tender mass in the left upper abdomen was found. It was determined via MRI (with no intravenous contrast in view of the first-trimester pregnancy) to be a large collection of fluid (19 cm × 17 cm × 10 cm) located close to the liver hilum and below the left liver lobe. The patient did not undergo any diagnostic or therapeutic procedures nor did they have any abdominal trauma in the preceding weeks. The fluid collection proved to be of biliary origin following percutaneous drainage. Therefore, we concluded this was a spontaneous rupture of an MCN-L with the formation of a biloma. The MRI study also revealed the previously found cystic tumour of the liver hilum communicating with the left hepatic duct, which, together with left hepatic duct dilatation, suggested the diagnosis of IPN-B. The follow-up MRI with intravenous gadolinium contrast performed in the second trimester of pregnancy (week 14) showed, in turn, some features of MCN-L, including enhancement of the internal septations within the cystic liver mass. A precise preoperative differential diagnosis between IPN-B and MCN-L was therefore not possible. The patient was submitted to surgery in the second trimester of pregnancy (week 18). Surgery included a cholecystectomy, left hepatectomy, and concomitant resection of the extrahepatic bile ducts followed by anastomosis of the right hepatic duct with the Roux limb of the jejunum. The post-operative period was uneventful and the patient was discharged 8 days after surgery. The histopathological examination of the resected specimen revealed a final diagnosis of MCN-L with low-grade dysplasia and epithelium surrounded by ovarian-type stromal tissue. The patient delivered a healthy baby girl and both remain well at present, after 2 years of follow-up since surgery.
CONCLUSION The differential diagnosis and management of MCN-L and IPN-B may be very challenging, particularly in the setting of pregnancy. When indications for surgery are obvious, the final diagnosis is based on histopathological examination, with ovarian-type stroma being pathognomonic for MCN-L. We believe that the growth of this subepithelial stroma secondary to the high levels of sex hormones produced during pregnancy might have been the main causative factor leading to the tumour rupture with the formation of a biloma in our patient.
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Affiliation(s)
- Artur Kośnik
- Liver and Internal Medicine Unit, Medical University of Warsaw, Warsaw 02-097, Poland
| | - Anna Stadnik
- Department of Radiology, Medical University of Warsaw, Warsaw 02-097, Poland
| | | | - Waldemar Patkowski
- Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw 02-097, Poland
| | - Maciej Wójcicki
- Liver and Internal Medicine Unit, Medical University of Warsaw, Warsaw 02-097, Poland
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Farahmandi S, Elessawy M, Bauerschlag DO, Pecks U, Abdullazade S, Beckmann JH, Heilmann T, Rumpf AL, Maass N, Jansen P, Winkler V. Mucinous Cystic Neoplasm of Pancreas in a Pregnant Woman Presenting with Severe Anemia and Gastric Bleeding: Case Report and Review of the Literature. Healthcare (Basel) 2021; 9:healthcare9050540. [PMID: 34066323 PMCID: PMC8148137 DOI: 10.3390/healthcare9050540] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/16/2021] [Accepted: 04/23/2021] [Indexed: 12/28/2022] Open
Abstract
Mucinous cystic neoplasms of the pancreas are uncommon and especially their occurrence during pregnancy is an extremely rare event which necessitates an individualized and interdisciplinary management. A 33-year old woman was referred to our department during her third trimester of pregnancy (34th week of gestation) with severe anemia and tarry stools. Based on gastroscopic findings, our interdisciplinary team suspected a gastrointestinal stromal tumor and therefore indicated a prompt delivery via cesarean section completed with an oncological resection of the neoplasm. Histological examination subsequently showed a mucinous cystic neoplasm of the pancreas with no evidence of malignancy. To review the prevalence of mucinous cystic neoplasms and to discuss diagnosis and treatment during pregnancy. Moreover, we critically value the indication of preterm delivery and the oncological procedure in the perspective of outcome for mother and infant. A bleeding gastrointestinal tumor during pregnancy represents a life-threatening risk for mother and infant and requires an immediate interdisciplinary treatment. The urgency and radicality of the therapy should be adapted according to individual findings. As our patient's tumor was suspected of having a malignant progression, an extensive surgical intervention was necessary.
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Affiliation(s)
- Susan Farahmandi
- Department of Gynecology and Obstetrics, Campus Kiel, University Medical Center UKSH, Arnold-Heller-Straße 3, Haus C, 24105 Kiel, Germany; (S.F.); (M.E.); (D.O.B.); (U.P.); (T.H.); (A.-L.R.); (N.M.); (P.J.)
| | - Mohamed Elessawy
- Department of Gynecology and Obstetrics, Campus Kiel, University Medical Center UKSH, Arnold-Heller-Straße 3, Haus C, 24105 Kiel, Germany; (S.F.); (M.E.); (D.O.B.); (U.P.); (T.H.); (A.-L.R.); (N.M.); (P.J.)
| | - Dirk O. Bauerschlag
- Department of Gynecology and Obstetrics, Campus Kiel, University Medical Center UKSH, Arnold-Heller-Straße 3, Haus C, 24105 Kiel, Germany; (S.F.); (M.E.); (D.O.B.); (U.P.); (T.H.); (A.-L.R.); (N.M.); (P.J.)
| | - Ulrich Pecks
- Department of Gynecology and Obstetrics, Campus Kiel, University Medical Center UKSH, Arnold-Heller-Straße 3, Haus C, 24105 Kiel, Germany; (S.F.); (M.E.); (D.O.B.); (U.P.); (T.H.); (A.-L.R.); (N.M.); (P.J.)
| | - Samir Abdullazade
- Department of Pathology, Campus Kiel, University Medical Center UKSH, Arnold-Heller-Straße 3, Haus U33, 24105 Kiel, Germany;
| | - Jan Henrik Beckmann
- Department of General, Abdominal, Thoracic, Transplantation and Pediatric Surgery, Campus Kiel, University Medical Center UKSH, Arnold-Heller-Straße 3, Haus U33, 24105 Kiel, Germany;
| | - Thorsten Heilmann
- Department of Gynecology and Obstetrics, Campus Kiel, University Medical Center UKSH, Arnold-Heller-Straße 3, Haus C, 24105 Kiel, Germany; (S.F.); (M.E.); (D.O.B.); (U.P.); (T.H.); (A.-L.R.); (N.M.); (P.J.)
| | - Anna-Lena Rumpf
- Department of Gynecology and Obstetrics, Campus Kiel, University Medical Center UKSH, Arnold-Heller-Straße 3, Haus C, 24105 Kiel, Germany; (S.F.); (M.E.); (D.O.B.); (U.P.); (T.H.); (A.-L.R.); (N.M.); (P.J.)
| | - Nicolai Maass
- Department of Gynecology and Obstetrics, Campus Kiel, University Medical Center UKSH, Arnold-Heller-Straße 3, Haus C, 24105 Kiel, Germany; (S.F.); (M.E.); (D.O.B.); (U.P.); (T.H.); (A.-L.R.); (N.M.); (P.J.)
| | - Peer Jansen
- Department of Gynecology and Obstetrics, Campus Kiel, University Medical Center UKSH, Arnold-Heller-Straße 3, Haus C, 24105 Kiel, Germany; (S.F.); (M.E.); (D.O.B.); (U.P.); (T.H.); (A.-L.R.); (N.M.); (P.J.)
| | - Vincent Winkler
- Department of Gynecology and Obstetrics, Campus Kiel, University Medical Center UKSH, Arnold-Heller-Straße 3, Haus C, 24105 Kiel, Germany; (S.F.); (M.E.); (D.O.B.); (U.P.); (T.H.); (A.-L.R.); (N.M.); (P.J.)
- Correspondence: ; Tel.: +49-431-500-21401
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