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Koh ES, Dabsha A, Rahouma M, Zappi K, Srinivasan Y, Hickner A, Kutler DI. Succinate dehydrogenase mutations in head and neck paragangliomas: A systematic review and meta-analysis of individual patients' data. Head Neck 2024; 46:1795-1808. [PMID: 38273766 DOI: 10.1002/hed.27652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/03/2024] [Accepted: 01/12/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Head and neck paragangliomas (HNPs) have been associated with gene mutations in the succinate dehydrogenase (SDH) complex, but the clinical significance remains unclear. We sought to explore the demographics, clinical characteristics, treatment methods, and outcomes of SDH-mutated HNPs. METHODS Databases were systematically searched. Pooled event ratio and relative 95% confidence intervals were calculated for dichotomous outcomes. Meta-regression was performed. Cochran's Q test and I2 test assessed heterogeneity. Funnel plot and Egger's regression test assessed publication bias. RESULTS Forty-two studies with 8849 patients were included. Meta-regression revealed a significant correlation between multifocality and SDHD mutations (0.03 ± 0.006, p < 0.0001) and between distant metastases and SDHB mutations (0.06 ± 0.023, p = 0.008). There was no correlation between sex, age, tumor size, or familial occurrences and SDH-related mutations. CONCLUSION Multifocality of HNPs correlates with the SDHD mutational subtype, and metastases correlate with the SDHB subtype. Knowledge of HNP phenotypes associated with SDH-related mutations has the potential to influence the management approach to such HNPs.
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Affiliation(s)
- Elizabeth S Koh
- Department of Otolaryngology - Head & Neck Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Anas Dabsha
- Department of Otolaryngology - Head & Neck Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Kyle Zappi
- Department of Otolaryngology - Head & Neck Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Yashes Srinivasan
- Department of Otolaryngology - Head & Neck Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Andy Hickner
- Samuel J. Wood Library, Weill Cornell Medicine, New York, New York, USA
| | - David I Kutler
- Department of Otolaryngology - Head & Neck Surgery, Weill Cornell Medicine, New York, New York, USA
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Palade DO, Severin F, Vrinceanu D, Hainarosie R, Maniu A, Ahmed H, Manole F, Mocanu F, Voiosu C. Laryngeal Paraganglioma-A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:198. [PMID: 38399485 PMCID: PMC10890263 DOI: 10.3390/medicina60020198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 01/14/2024] [Accepted: 01/21/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: Paragangliomas of the head and neck are rare neuroendocrine tumors originating from the paraganglia, which might be sympathetic or parasympathetic. Laryngeal paragangliomas are the rarest subtype of these tumors, with only 1.41% of all paragangliomas, arising from the supraglottic or subglottic paraganglia of the larynx. The vast majority of them are benign, but there are some cases in which they turn out to be malignant, and the only way to know with certainty the difference between them is when we identify distant metastases. The aim of this article is to share our experience with a rare case of laryngeal paraganglioma and review the clinical characteristics, methods of diagnostic, necessary investigation prior to the operation, and surgical management of this type of tumor. Materials and Methods: We present the case of a 68-year-old female patient, a non-smoker, who accused dysphagia, dysphonia, foreign body sensation, chronic cough, and hoarseness for six months. We performed a tracheostomy prior to biopsy to secure the airways in case of bleeding and then took a few biopsy samples. The histopathological exam revealed the presence of a laryngeal paraganglioma. An enhanced CT scan was performed in order to describe the localization, size, and invasion of the tumor. We also measured the vanillylmandelic acid from the urine to determine if the tumor produced catecholamines alongside a full cardiology and endocrinology examinations. In order to prevent massive bleeding during the operation, chemoembolization was attempted before surgery, but it was unsuccessful due to an anatomical variation of the left superior thyroid artery. She underwent surgery, first through transoral endoscopic microsurgery; however, we decided to undertake an external approach because of poor bleeding control, even though we had ligated both the superior thyroid artery and the external carotid artery, with a thyrotomy and laryngofissure achieving the complete resection of the tumor. Results: The patient was discharged 10 postoperative days later, with the recommendation of introducing food step-by-step from liquids to solids. She was decannulated after 30 days, with no complications regarding breathing, phonation, or deglutition. Twelve months after the surgery, we did not identify any local relapses of distant metastases. Conclusions: Laryngeal paragangliomas are rare neuroendocrine tumors that arise from the laryngeal paraganglia. Surgery is the best treatment option available, and it can be done by either an external approach or by transoral endoscopy. Enhanced CT or MRI, as well as full cardiological and endocrinological evaluation are mandatory prior to the operation. Measuring the catecholamines levels show the if the tumor is secretory. Controlling the bleeding poses the biggest challenge in performing the resection of the tumor, especially when a transoral endoscopic approach is chosen. Further standardized follow-up guidelines are required in the future.
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Affiliation(s)
- Dragos Octavian Palade
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (D.O.P.); (F.S.); (H.A.)
| | - Florentina Severin
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (D.O.P.); (F.S.); (H.A.)
| | - Daniela Vrinceanu
- ENT Department, Faculty of Medicine, “Carol Davilla” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (D.V.); (R.H.); (C.V.)
| | - Razvan Hainarosie
- ENT Department, Faculty of Medicine, “Carol Davilla” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (D.V.); (R.H.); (C.V.)
| | - Alma Maniu
- Department of Otolaryngology, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400347 Cluj, Romania;
| | - Huzafa Ahmed
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (D.O.P.); (F.S.); (H.A.)
| | - Felicia Manole
- Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Florin Mocanu
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (D.O.P.); (F.S.); (H.A.)
| | - Catalina Voiosu
- ENT Department, Faculty of Medicine, “Carol Davilla” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (D.V.); (R.H.); (C.V.)
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Guha A, Vicha A, Zelinka T, Kana M, Musil Z, Pacak K, Betka J, Chovanec M, Plzak J, Boucek J. High incidence of occult familial SDHD cases amongst Czech patients with head and neck paragangliomas. Front Endocrinol (Lausanne) 2023; 14:1278175. [PMID: 38144572 PMCID: PMC10739302 DOI: 10.3389/fendo.2023.1278175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/06/2023] [Indexed: 12/26/2023] Open
Abstract
Introduction Head and neck paragangliomas (HNPGLs) are rare neuroendocrine tumors, which are mostly benign in nature. Amongst all genes, Succinate Dehydrogenase Subunit D (SDHD) is the most commonly mutated in familial HNPGLs. In about 30% of HNPGLs, germline mutations in SDHD can also occur in the absence of positive family history, thus giving rise to "occult familial" cases. Our aim was to evaluate the pattern of SDHD germline mutations in Czech patients with HNPGLs. Materials and methods We analyzed a total of 105 patients with HNPGLs from the Otorhinolaryngology departments of 2 tertiary centers between 2006 - 2021. All underwent complex diagnostic work-up and were also consented for genetic analysis. Results Eighty patients aged 13-76 years were included; around 60% with multiple PGLs were males. Carotid body tumor was the most frequently diagnosed tumor. Germline SDHD mutation was found in only 12% of the Czech patients; approximately 78% of those harboring the mutation had negative family history. The mutation traits had higher affiliation for multiple tumors with nearly 70% patients of ≤ 40 years of age. Conclusion An SDHD mutation variant was shared amongst unrelated patients but no founder-effect was established. Our findings confirmed that the pattern of SDHD mutation distribution amongst HNPGLs in Czech Republic differs from most studies worldwide.
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Affiliation(s)
- Anasuya Guha
- Department of Otorhinolaryngology, Charles University, 3 Faculty of Medicine and University Hospital Kralovske Vinohrady, Prague, Czechia
| | - Ales Vicha
- Department of Pediatric Hematology and Oncology, Charles University, 2 Faculty of Medicine and University Hospital Motol, Prague, Czechia
| | - Tomas Zelinka
- 3 Department of Medicine, Department of Endocrinology and Metabolsim of the 1 Faculty of Medicine and General University Hospital in Prague, Prague, Czechia
| | - Martin Kana
- Department of Otorhinolaryngology and Head and Neck Surgery, Charles University, 1 Faculty of Medicine and University Hospital Motol, Prague, Czechia
| | - Zdenek Musil
- Institute of Biology and Medical Genetics of the 1 Faculty of Medicine and General University Hospital in Prague, Prague, Czechia
| | - Karel Pacak
- Section of Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Jan Betka
- Department of Otorhinolaryngology and Head and Neck Surgery, Charles University, 1 Faculty of Medicine and University Hospital Motol, Prague, Czechia
| | - Martin Chovanec
- Department of Otorhinolaryngology, Charles University, 3 Faculty of Medicine and University Hospital Kralovske Vinohrady, Prague, Czechia
| | - Jan Plzak
- Department of Otorhinolaryngology and Head and Neck Surgery, Charles University, 1 Faculty of Medicine and University Hospital Motol, Prague, Czechia
| | - Jan Boucek
- Department of Otorhinolaryngology and Head and Neck Surgery, Charles University, 1 Faculty of Medicine and University Hospital Motol, Prague, Czechia
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Targeted metabolomics detects a putatively diagnostic signature in plasma and dried blood spots from head and neck paraganglioma patients. Oncogenesis 2023; 12:10. [PMID: 36841802 PMCID: PMC9968333 DOI: 10.1038/s41389-023-00456-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 02/10/2023] [Accepted: 02/14/2023] [Indexed: 02/27/2023] Open
Abstract
Head and neck paragangliomas (HNPGLs), rare chemoresistant tumors curable only with surgery, are strongly influenced by genetic predisposition, hence patients and relatives require lifetime follow-up with MRI and/or PET-CT because of de novo disease risk. This entails exposure to electromagnetic/ionizing radiation, costs, and organizational challenges, because patients and relatives are scattered far from reference centers. Simplified first-line screening strategies are needed. We employed flow injection analysis tandem mass spectrometry, as used in newborn metabolic screening, to compare the plasma metabolic profile of HNPGL patients (59 samples, 56 cases) and healthy controls (24 samples, 24 cases). Principal Component Analysis (PCA) and Partial Least Discriminant Analysis (PLS-DA) highlighted a distinctive HNPGL signature, likely reflecting the anaplerotic conversion of the TCA cycle to glutaminolysis and catabolism of branched amino acids, DNA damage and deoxyadenosine (dAdo) accumulation, impairment of fatty acid oxidation, switch towards the Warburg effect and proinflammatory lysophosphatidylcholines (LPCs) signaling. Statistical analysis of the metabolites that most impacted on PLS-DA was extended to 10 acoustic neuroma and 2 cholesteatoma patients, confirming significant differences relative to the HNPGL plasma metabolomic profile. The best confusion matrix from the ROC curve built on 2 metabolites, dAdo and C26:0-LPC, provided specificity of 94.29% and sensitivity of 89.29%, with positive and negative predictive values of 96.2% and 84.6%, respectively. Analysis of dAdo and C26:0-LPC levels in dried venous and capillary blood confirmed that dAdo, likely deriving from 2'-deoxy-ATP accumulated in HNPGL cells following endogenous genotoxic damage, efficiently discriminated HNPGL patients from healthy controls and acoustic neuroma/cholesteatoma patients on easily manageable dried blood spots.
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5
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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] [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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Richter S, Qiu B, Ghering M, Kunath C, Constantinescu G, Luths C, Pamporaki C, Bechmann N, Meuter L, Kwapiszewska A, Deutschbein T, Nölting S, Peitzsch M, Robledo M, Prejbisz A, Pacak K, Gudziol V, Timmers HJLM, Eisenhofer G. Head/neck paragangliomas: focus on tumor location, mutational status and plasma methoxytyramine. Endocr Relat Cancer 2022; 29:213-224. [PMID: 35171114 PMCID: PMC8942340 DOI: 10.1530/erc-21-0359] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 02/16/2022] [Indexed: 11/08/2022]
Abstract
Head and neck paragangliomas (HNPGLs) are tumors of parasympathetic origin that occur at variable locations and are often secondary to germline mutations in succinate dehydrogenase (SDH) subunit genes. Occasionally, these tumors produce catecholamines. Here, we assessed whether different locations of HNPGLs relate to the presence of SDHx mutations, catecholamine production and other presentations. In this multicenter study, we collected clinical and biochemical data from 244 patients with HNPGLs and 71 patients without HNPGLs. We clarified that jugulotympanic HNPGLs have distinct features. In particular, 88% of jugulotympanic HNPGLs arose in women, among whom only 24% occurred due to SDHx mutations compared to 55% in men. Jugulotympanic HNPGLs were also rarely bilateral, were of a smaller size and were less often metastatic compared to carotid body and vagal HNPGLs. Furthermore, we showed that plasma concentrations of methoxytyramine (MTY) were higher (P < 0.0001) in patients with HNPGL than without HNPGL, whereas plasma normetanephrine did not differ. Only 3.7% of patients showed strong increases in plasma normetanephrine. Plasma MTY was positively related to tumor size but did not relate to the presence of SDHx mutations or tumor location. Our findings confirm that increases in plasma MTY represent the main catecholamine-related biochemical feature of patients with HNPGLs. We expect that more sensitive analytical methods will make biochemical testing of HNPGLs more practical in the future and enable more than the current 30% of patients to be identified with dopamine-producing HNPGLs. The sex-dependent differences in the development of HNPGLs may have relevance to the diagnosis, management and outcomes of these tumors.
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Affiliation(s)
- Susan Richter
- Institute for Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Correspondence should be addressed to S Richter:
| | - Bei Qiu
- Institute for Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Mirthe Ghering
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Carola Kunath
- Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Georgiana Constantinescu
- Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Charlotte Luths
- Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Christina Pamporaki
- Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Nicole Bechmann
- Institute for Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Leah Meuter
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Timo Deutschbein
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
- Medicover Oldenburg MVZ, Oldenburg, Germany
| | - Svenja Nölting
- Medizinische Klinik and Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
- Department for Endocrinology, Diabetology and Clinical Nutrition, UniversitätsSpital Zürich, Zurich, Switzerland
| | - Mirko Peitzsch
- Institute for Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Mercedes Robledo
- Hereditary Endocrine Cancer Group, CNIO, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Madrid, Spain
| | | | - Karel Pacak
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Volker Gudziol
- Department of Otorhinolaryngology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Hals-Chirurgie, Plastische Operationen, Städtisches Klinikum Dresden, Akademisches Lehrkrankenhaus der Technischen Universität Dresden, Dresden, Germany
| | - Henri J L M Timmers
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Graeme Eisenhofer
- Institute for Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Hudler P, Urbancic M. The Role of VHL in the Development of von Hippel-Lindau Disease and Erythrocytosis. Genes (Basel) 2022; 13:genes13020362. [PMID: 35205407 PMCID: PMC8871608 DOI: 10.3390/genes13020362] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 12/20/2022] Open
Abstract
Von Hippel-Lindau disease (VHL disease or VHL syndrome) is a familial multisystem neoplastic syndrome stemming from germline disease-associated variants of the VHL tumor suppressor gene on chromosome 3. VHL is involved, through the EPO-VHL-HIF signaling axis, in oxygen sensing and adaptive response to hypoxia, as well as in numerous HIF-independent pathways. The diverse roles of VHL confirm its implication in several crucial cellular processes. VHL variations have been associated with the development of VHL disease and erythrocytosis. The association between genotypes and phenotypes still remains ambiguous for the majority of mutations. It appears that there is a distinction between erythrocytosis-causing VHL variations and VHL variations causing VHL disease with tumor development. Understanding the pathogenic effects of VHL variants might better predict the prognosis and optimize management of the patient.
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Affiliation(s)
- Petra Hudler
- Medical Centre for Molecular Biology, Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia;
| | - Mojca Urbancic
- Eye Hospital, University Medical Centre Ljubljana, Grabloviceva ulica 46, 1000 Ljubljana, Slovenia
- Correspondence:
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Reply. J Vasc Surg 2021; 75:386-387. [PMID: 34949388 DOI: 10.1016/j.jvs.2021.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 09/17/2021] [Indexed: 11/23/2022]
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9
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Head and Neck Paragangliomas in the Czech Republic: Management at the Otorhinolaryngology Department. Diagnostics (Basel) 2021; 12:diagnostics12010028. [PMID: 35054195 PMCID: PMC8775065 DOI: 10.3390/diagnostics12010028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/16/2021] [Accepted: 12/20/2021] [Indexed: 11/28/2022] Open
Abstract
Head and neck paragangliomas (HNPGLs) are rare neuroendocrine tumors, comprising only 3% of all head and neck tumors. Early diagnosis forms an integral part of the management of these tumors. The two main aims of any treatment approach are long-term tumor control and minimal cranial nerve morbidity. The scope of this article is to present our case series of HNPGLs to stress most important clinical aspects of their presentation as well as critical issues of their complex management. Thirty patients with suspected HNPGLs were referred to our otorhinolaryngology clinic for surgical consultation between 2016–2020. We assessed the demographical pattern, clinicoradiological correlation, as well as type and outcome of treatment. A total of 42 non-secretory tumors were diagnosed—16.7% were incidental findings and 97% patients had benign tumors. Six patients had multiple tumors. Jugular paragangliomas were the most commonly treated tumors. Tumor control was achieved in nearly 96% of operated patients with minimal cranial nerve morbidity. Surgery is curative in most cases and should be considered as frontline treatment modality in experienced hands for younger patients, hereditary and secretory tumors. Cranial nerve dysfunction associated with tumor encasement is a negative prognostic factor for both surgery and radiotherapy. Multifocal tumors and metastasis are difficult to treat, even with early detection using genetic analysis. Detecting malignancy in HNPGLs is challenging due to the lack of histomorphological criteria; therefore, limited lymph node dissection should be considered, even in the absence of clinical and radiological signs of metastasis in carotid body, vagal, and jugular paragangliomas.
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Steinman JR, Thomas MH, McCartney CR, Padia SH. A novel pathogenic variant in MAX-Associated pheochromocytoma. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY CASE REPORTS 2021. [DOI: 10.1016/j.jecr.2021.100101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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11
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Ryder SJ, Love AJ, Duncan EL, Pattison DA. PET detectives: Molecular imaging for phaeochromocytomas and paragangliomas in the genomics era. Clin Endocrinol (Oxf) 2021; 95:13-28. [PMID: 33296100 DOI: 10.1111/cen.14375] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/15/2020] [Accepted: 11/20/2020] [Indexed: 01/26/2023]
Abstract
Phaeochromocytomas and paragangliomas (PPGLs) are rare tumours that arise from the adrenal medulla or extra-adrenal sympathetic or parasympathetic paraganglia. Recent advances in genetics have greatly enhanced understanding of the pathogenesis and molecular physiology of PPGL. Concomitantly, advances in molecular imaging mean four techniques are now available for use in PPGLs: [123 I]-MIBG coupled with SPECT/CT; [18 F]- FDG, [68 Ga]-DOTATATE and [18 F]-FDOPA coupled with PET/CT. Each modality relies on unique cellular uptake mechanisms that are contingent upon the tumour's molecular behaviour-which, in turn, is determined by the tumour's genetic profile. This genotype-phenotype correlation means the appropriate choice of radiotracer may depend on the known (or suspected) underlying genetic mutation, in addition to the clinical indication for the scan-whether confirming diagnosis, staging disease, surveillance or determining eligibility for radionuclide therapy. Given these rapid recent changes in genetic understanding and molecular imaging options, many clinicians find it challenging to choose the most appropriate scan for an individual with PPGL. To this end, recent guidelines published by the European Association of Nuclear Medicine and the Society of Nuclear Medicine and Molecular Imaging (EANM/SNMMI) have detailed the preferred radiotracer choices for individuals with PPGL based on their genotype and/or clinical presentation, providing timely clarity in this rapidly moving field. The current review summarizes the implications of the genotype-phenotype relationship of PPGL, specifically relating this to the performance of molecular imaging modalities, to inform and enable practising endocrinologists to provide tailored, personalized care for individuals with PPGL.
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Affiliation(s)
- Simon J Ryder
- Department of Endocrinology and Diabetes, Royal Brisbane and Women's Hospital, Herston, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Amanda J Love
- Department of Endocrinology and Diabetes, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Emma L Duncan
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Professor of Clinical Endocrinology, Department of Twin Research & Genetic Epidemiology, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- The Department of Endocrinology, St Thomas' Hospital, Guy's and St Thomas' NHS Trust, London, UK
| | - David A Pattison
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Department of Nuclear Medicine & Specialised PET Services, Royal Brisbane and Women's Hospital, Herston, Australia
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Guha A, Vicha A, Zelinka T, Musil Z, Chovanec M. Genetic Variants in Patients with Multiple Head and Neck Paragangliomas: Dilemma in Management. Biomedicines 2021; 9:biomedicines9060626. [PMID: 34072806 PMCID: PMC8226913 DOI: 10.3390/biomedicines9060626] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/24/2021] [Accepted: 05/27/2021] [Indexed: 11/16/2022] Open
Abstract
Multiple head and neck paragangliomas (HNPGLs) are neuroendocrine tumors of a mostly benign nature that can be associated with a syndrome, precipitated by the presence of a germline mutation. Familial forms of the disease are usually seen with mutations of SDHx genes, especially the SDHD gene. SDHB mutations are predisposed to malignant tumors. We found 6 patients with multiple tumors amongst 30 patients with HNPGLs during the period of 2016 to 2021. We discuss the phenotypic and genetic patterns in our patients with multiple HNPGLs and explore the management possibilities related to the disease. Fifty percent of our patients had incidental findings of HNPGLs. Twenty-one biochemically silent tumors were found. Four patients had germline mutations, and only one had a positive family history. Three out of five underwent surgery without permanent complications. Preventative measures (genetic counselling and tumor surveillance) represent the gold standard in effectively controlling the disease in index patients and their relatives. In terms of treatment, apart from surgical and radiotherapeutic interventions, new therapeutic measures such as gene targeted therapy have contributed very sparsely. With the lack of standardized protocols, management of patients with multiple HNPGLs still remains very challenging, especially in those with sporadic or malignant forms of the disease.
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Affiliation(s)
- Anasuya Guha
- Department of Otorhinolaryngology, 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, 100 34 Prague, Czech Republic;
- Correspondence:
| | - Ales Vicha
- Department of Pediatric Hematology and Oncology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, 150 06 Prague, Czech Republic;
| | - Tomas Zelinka
- Department of Internal Medicine, 1st Faculty of Medicine, Charles University and General University Hospital, 128 08 Prague, Czech Republic;
| | - Zdenek Musil
- Department of Biology and Medical Genetics, 1st Faculty of Medicine, Charles University and General University Hospital, 128 00 Prague, Czech Republic;
| | - Martin Chovanec
- Department of Otorhinolaryngology, 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, 100 34 Prague, Czech Republic;
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Li L, Xu H, Chen X, Yu Z, Zhou J, Mydlarz WK, London NR. Management of Multiple Head and Neck Paragangliomas With Assistance of a 3-D Model. EAR, NOSE & THROAT JOURNAL 2021; 102:362-368. [PMID: 33829883 DOI: 10.1177/01455613211009441] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Extirpation of multiple head and neck paragangliomas carries challenge due to close anatomic relationships with critical neurovascular bundles. OBJECTIVES This study aims to assess whether the application of 3-D models can assist with surgical planning and treatment of these paragangliomas, decrease surgically related morbidity and mortality. METHODS Fourteen patients undergoing surgical resection of multiple head and neck paragangliomas were enrolled in this study. A preoperative 3-D model was created based on radiologic data, and relevant critical anatomic relationships were preoperatively assessed and intraoperatively validated. RESULTS All 14 patients presented with multiple head and neck paragangliomas, including bilateral carotid body tumors (CBT, n = 9), concurrent CBT with glomus jugulare tumors (GJT, n = 4), and multiple vagal paragangliomas (n = 1). Ten patients underwent genomic analysis and all harbored succinate dehydrogenase complex subunit D (SDHD) mutations. Under guidance of the 3-D model, the internal carotid artery (ICA) was circumferentially encased by tumor on 5 of the operated sides, in 4 (80%) of which the tumor was successfully dissected out from the ICA, whereas ICA reconstruction was required on one side (20%). Following removal of CBT, anterior rerouting of the facial nerve was avoided in 3 (75%) of 4 patients during the extirpation of GJT with assistance of a 3-D model. Two patients developed permanent postoperative vocal cord paralysis. There was no vessel rupture or mortality in this study cohort. CONCLUSION The 3-D model is beneficial for establishment of a preoperative strategy, as well as planning and guiding the intraoperative procedure for resection of multiple head and neck paragangliomas.
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Affiliation(s)
- Lifeng Li
- Department of Otolaryngology-Head and Neck Surgery, 117902Beijing Tongren Hospital, Capital Medical University, China
| | - Hongbo Xu
- Department of Otolaryngology-Head and Neck Surgery, 117902Beijing Tongren Hospital, Capital Medical University, China
| | - Xiaohong Chen
- Department of Otolaryngology-Head and Neck Surgery, 117902Beijing Tongren Hospital, Capital Medical University, China
| | - Zhenya Yu
- Department of Vascular Surgery, 117902Beijing Tongren Hospital, Capital Medical University, China
| | - Jing Zhou
- Department of Otolaryngology-Head and Neck Surgery, 117902Beijing Tongren Hospital, Capital Medical University, China
| | - Wojciech K Mydlarz
- Department of Otolaryngology-Head and Neck Surgery, 1500Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Nyall R London
- Department of Otolaryngology-Head and Neck Surgery, 1500Johns Hopkins School of Medicine, Baltimore, MD, USA
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Lekovic GP, Mehta GU, Maxwell AK, Peng KA, Brackmann DE. Radiation-Induced Malignant Peripheral Nerve Sheath Tumor of the Vagus Nerve Following Radiation Treatment of Cervical Paraganglioma. J Neurol Surg Rep 2021; 81:e66-e70. [PMID: 33403195 PMCID: PMC7775188 DOI: 10.1055/s-0040-1718408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 09/02/2020] [Indexed: 12/02/2022] Open
Abstract
Radiation-induced sarcoma is a known but rare complication of radiation treatment for skull base paraganglioma. We present the cases of a female patient with multiple paraganglioma syndrome treated with external beam radiation treatment who presented 4 years later with a malignant peripheral nerve sheath tumor of the vagus nerve.
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Affiliation(s)
- Gregory P Lekovic
- Division of Neurosurgery, House Institute, Los Angeles, California, United States
| | - Gautam U Mehta
- Division of Neurosurgery, House Institute, Los Angeles, California, United States
| | - Anne K Maxwell
- Division of Neurotology, House Institute, Los Angeles, California, United States
| | - Kevin A Peng
- Division of Neurotology, House Institute, Los Angeles, California, United States
| | - Derald E Brackmann
- Division of Neurotology, House Institute, Los Angeles, California, United States
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Snezhkina AV, Fedorova MS, Pavlov VS, Kalinin DV, Golovyuk AL, Pudova EA, Guvatova ZG, Melnikova NV, Dmitriev AA, Razmakhaev GS, Poloznikov AA, Alekseeva GS, Kaprin AD, Krasnov GS, Kudryavtseva AV. Mutation Frequency in Main Susceptibility Genes Among Patients With Head and Neck Paragangliomas. Front Genet 2020; 11:614908. [PMID: 33391357 PMCID: PMC7775293 DOI: 10.3389/fgene.2020.614908] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/26/2020] [Indexed: 11/13/2022] Open
Abstract
Head and neck paragangliomas (HNPGLs) are rare neuroendocrine tumors that have a high degree of heritability and are predominantly associated with mutations in ten genes, such as SDHx, SDHAF2, VHL, RET, NF1, TMEM127, MAX, FH, MEN2, and SLC25A11. Elucidating the mutation prevalence is crucial for the development of genetic testing. In this study, we identified pathogenic/likely pathogenic variants in the main susceptibility genes in 102 Russian patients with HNPGLs (82 carotid and 23 vagal paragangliomas) using whole exome sequencing. Pathogenic/likely pathogenic variants were detected in 43% (44/102) of patients. We identified the following variant distribution of the tested genes: SDHA (1%), SDHB (10%), SDHC (5%), SDHD (24.5%), and RET (5%). SDHD variants were observed in the majority of the patients with bilateral/multiple paragangliomas. Thus, among Russian patients with HNPGLs the most frequently mutated gene was SDHD followed by SDHB, SDHC, RET, and SDHA.
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Affiliation(s)
| | - Maria S Fedorova
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, Moscow, Russia
| | - Vladislav S Pavlov
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, Moscow, Russia
| | - Dmitry V Kalinin
- Vishnevsky Institute of Surgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - Alexander L Golovyuk
- Vishnevsky Institute of Surgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - Elena A Pudova
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, Moscow, Russia
| | - Zulfiya G Guvatova
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, Moscow, Russia
| | - Nataliya V Melnikova
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, Moscow, Russia
| | - Alexey A Dmitriev
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, Moscow, Russia
| | - George S Razmakhaev
- National Medical Research Radiological Center, Ministry of Health of the Russian Federation, Moscow, Russia
| | - Andrey A Poloznikov
- National Medical Research Radiological Center, Ministry of Health of the Russian Federation, Moscow, Russia
| | - Galina S Alekseeva
- National Medical Research Radiological Center, Ministry of Health of the Russian Federation, Moscow, Russia
| | - Andrey D Kaprin
- National Medical Research Radiological Center, Ministry of Health of the Russian Federation, Moscow, Russia
| | - George S Krasnov
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, Moscow, Russia
| | - Anna V Kudryavtseva
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, Moscow, Russia
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Majewska A, Budny B, Ziemnicka K, Ruchała M, Wierzbicka M. Head and Neck Paragangliomas-A Genetic Overview. Int J Mol Sci 2020; 21:ijms21207669. [PMID: 33081307 PMCID: PMC7589036 DOI: 10.3390/ijms21207669] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 12/17/2022] Open
Abstract
Pheochromocytomas (PCC) and paragangliomas (PGL) are rare neuroendocrine tumors. Head and neck paragangliomas (HNPGL) can be categorized into carotid body tumors, which are the most common, as well as jugular, tympanic, and vagal paraganglioma. A review of the current literature was conducted to consolidate knowledge concerning PGL mutations, familial occurrence, and the practical application of this information. Available scientific databases were searched using the keywords head and neck paraganglioma and genetics, and 274 articles in PubMed and 1183 in ScienceDirect were found. From these articles, those concerning genetic changes in HNPGLs were selected. The aim of this review is to describe the known genetic changes and their practical applications. We found that the etiology of the tumors in question is based on genetic changes in the form of either germinal or somatic mutations. 40% of PCC and PGL have a predisposing germline mutation (including VHL, SDHB, SDHD, RET, NF1, THEM127, MAX, SDHC, SDHA, SDHAF2, HIF2A, HRAS, KIF1B, PHD2, and FH). Approximately 25–30% of cases are due to somatic mutations, such as RET, VHL, NF1, MAX, and HIF2A. The tumors were divided into three main clusters by the Cancer Genome Atlas (TCGA); namely, the pseudohypoxia group, the Wnt signaling group, and the kinase signaling group. The review also discusses genetic syndromes, epigenetic changes, and new testing technologies such as next-generation sequencing (NGS).
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Affiliation(s)
- Anna Majewska
- Department of Otolaryngology, Head and Neck Surgery, Poznan University of Medical Sciences, 60-355 Poznań, Poland;
- Correspondence:
| | - Bartłomiej Budny
- Department of Endocrinology, Metabolism and Internal Diseases, Poznan University of Medical Sciences, 60-355 Poznań, Poland; (B.B.); (K.Z.); (M.R.)
| | - Katarzyna Ziemnicka
- Department of Endocrinology, Metabolism and Internal Diseases, Poznan University of Medical Sciences, 60-355 Poznań, Poland; (B.B.); (K.Z.); (M.R.)
| | - Marek Ruchała
- Department of Endocrinology, Metabolism and Internal Diseases, Poznan University of Medical Sciences, 60-355 Poznań, Poland; (B.B.); (K.Z.); (M.R.)
| | - Małgorzata Wierzbicka
- Department of Otolaryngology, Head and Neck Surgery, Poznan University of Medical Sciences, 60-355 Poznań, Poland;
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Stütz B, Korbonits M, Kothbauer K, Müller W, Fischli S. Identification of a TMEM127 variant in a patient with paraganglioma and acromegaly. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200119. [PMID: 33416299 PMCID: PMC7576664 DOI: 10.1530/edm-20-0119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 09/03/2020] [Indexed: 02/03/2023] Open
Abstract
SUMMARY The coincidence of a pheochromocytoma or paraganglioma and a pituitary adenoma in the same patient is a rare condition. In the last few years SDHx and MAX mutations have been identified and discussed as a potential causal connection in cases of coincidence. We describe a case of a middle-aged female patient which presented with acromegaly, a growth hormone-secreting pituitary adenoma and a symptomatic neck paraganglioma. The patient was cured by surgery from both the pituitary tumour and the paraganglioma and is well after ten years follow-up. Due to the unusual coexistence of two neuroendocrine tumours, further molecular genetic testing was performed which revealed a variant in the TMEM127 gene (c245-10C>G). LEARNING POINTS Pheochromocytoma/paraganglioma and coexisting functioning pituitary adenoma are a very rare condition. An appropriate treatment of each tumour entity with a multi-disciplinary approach and regular follow-up is needed. The possibility of a hereditary disease should be considered and genetic workup is recommended. Genetic testing should focus primarily on the genes with mutations related to pheochromocytomas and paragangliomas. Next-generation sequencing with multi-gene panel testing is the currently suggested strategy. Genes associated with paragangliomas and pituitary adenomas are SDHA, SDHB, SDHC, SDHD, SDHAF2, MAX and MEN1, while case reports with VHL, RET and NF1 may represent coincidences. Variants of uncertain significance may need ongoing vigilance, in case novel data become available of these variants.
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Affiliation(s)
- Beryl Stütz
- Department of Endocrinology, Diabetes and Clinical Nutrition, Luzerner Kantonsspital, Luzern, Switzerland
| | - Marta Korbonits
- Department of Endocrinology, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Karl Kothbauer
- Department of Neurosurgery, Luzerner Kantonsspital, Luzern, Switzerland
| | - Werner Müller
- Department of Otorhinolarnygology, Head and Neck Surgery, Luzerner Kantonsspital, Luzern, Switzerland
| | - Stefan Fischli
- Department of Endocrinology, Diabetes and Clinical Nutrition, Luzerner Kantonsspital, Luzern, Switzerland
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Current Approach of Functioning Head and Neck Paragangliomas: Case Report of a Young Patient with Multiple Asynchronous Tumors. Case Rep Endocrinol 2020; 2020:6827109. [PMID: 32082649 PMCID: PMC7019207 DOI: 10.1155/2020/6827109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 12/10/2019] [Accepted: 01/11/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction. Pheochromocytomas (Pheo) and paragangliomas (PGL) are rare neuroendocrine tumors arising from chromaffin cells of the adrenal medulla and from the extra-adrenal autonomic paraganglia, respectively. Only 1–3% of head and neck PGL (HNPGL) show elevated catecholamines, and at least 30% of Pheo and PGL (PCPG) are associated with genetic syndromes caused by germline mutations in tumor suppressor genes and proto-oncogenes. Clinical Case. A 33-year-old man with a past medical history of resection of an abdominal PGL at the age of eleven underwent a CT scan after a mild traumatic brain injury revealing an incidental brain tumor. The diagnosis of a functioning PGL was made, and further testing was undertaken with a PET-CT with 68Ga-DOTATATE, SPECT-CT 131-MIBG, and genetic testing. Discussion and Conclusion. The usual clinical presentation of functioning PCPG includes paroxistic hypertension, headache, and diaphoresis, sometimes with a suggestive family history in 30–40% of cases. Only 20% of PGL are located in head and neck, of which only 1–3% will show elevated catecholamines. Metastatic disease is present in up to 50% of cases, usually associated with a hereditary germline mutation. However, different phenotypes can be observed depending on such germline mutations. Genetic testing is important in patients with PCPG since 31% will present a germline mutation. In this particular patient, an SDHB gene mutation was revealed, which can drastically influence the follow-up plan and the genetic counsel offered. A multidisciplinary approach is mandatory for every patient presenting with PCPG.SDHB gene mutation was revealed, which can drastically influence the follow-up plan and the genetic counsel offered. A multidisciplinary approach is mandatory for every patient presenting with PCPG.
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Rissardo J, Caprara AF. Head-and-neck paragangliomas. FORMOSAN JOURNAL OF SURGERY 2020. [DOI: 10.4103/fjs.fjs_105_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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