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Small adrenal incidentaloma becoming an aggressive adrenocortical carcinoma in a patient carrying a germline APC variant
Nadia Gagnon @1 . Pascale Boily1 . Catherine Alguire1 . Gilles Corbeil1 . Irina Bancos2 . Mathieu Latour3 . Catherine Beauregard1 . Katia Caceres1 . Zaki El Haffaf4 . Fred Saad5 . Harold J. Olney6 . Isabelle Bourdeau1,4
Received: 25 September 2019 / Accepted: 17 January 2020 @ Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract
Purpose Recent guidelines on adrenal incidentalomas suggested in patients with an indeterminate adrenal mass and no significant hormone excess that follow up with a repeat noncontrast CT or MRI after 6-12 months may be an option. Methods We report the case of a 32-year-old woman who presented with a 2.9 x 1.9 cm left adrenal incidentaloma that was stable in size for 4 years. Ten years later the left adrenal mass was a stage IV adrenocortical carcinoma (ACC).
Results In 2006, a 32-year-old French Canadian woman was referred to endocrinology for a left 2.9 x 1.9 cm incidentally discovered adrenal mass (31 HU). She had normal hormonal investigation. The patient was followed with adrenal imaging and hormonal investigation yearly for 4 years and the lesion stayed stable in size over the 4 years. Ten years later, in 2016, the patient presented with renal colic. Urological CT unexpectedly revealed that the left adrenal mass was now measuring 9×8.2 cm and 2 new hepatic lesions were found. Biochemical workup demonstrated hypercorticism and hyperan- drogenemia: plasma cortisol after 1 mg overnight DST of 476 nmol/L and DHEA-S of 14.0 umol/L (N 0.9-6.5). Twenty- four hour urine steroid profiling was consistent with an adrenocortical carcinoma (ACC) co-secreting cortisol, androgens and glucocorticoid precursors. The diagnosis of ACC with hepatic ACC metastases was confirmed at histology. Following genetic analysis, germline heterozygous variant of uncertain significance (VUS) was identified in the exon 16 of the APC gene (c.2414G> A, p.Arg805Gln). Immunohistochemical staining’s of the ACC was positive for IGF-2 and cytoplasmic/ nuclear ß-catenin staining.
Conclusions This case illustrates that (1) small adrenal incidentaloma stable in size may evolve to ACC and (2) better genetic characterization of these patients may eventually give clues on this unusual evolution.
Keywords Adrenal incidentaloma · Adrenocortical carcinoma · APC gene
Abbreviations
ACC adrenocortical carcinoma
DST dexamethasone suppression test
HBP high blood pressure
| CT | computed tomography |
| HU | Hounsfield unit |
| LCMS | liquid chromatography and mass spectrometry |
| MRI | magnetic resonance imaging |
| PET | positron emission tomography |
| N | normal |
Supplementary information The online version of this article (https:// doi.org/10.1007/s12020-020-02209-4) contains supplementary material, which is available to authorized users.
☒ Isabelle Bourdeau isabelle.bourdeau@umontreal.ca
1 Division of Endocrinology, Department of Medicine, Research Center, Centre hospitalier de l’Université de Montréal (CHUM), Montreal, QC, Canada
2 Division of Endocrinology, Metabolism, Nutrition and Diabetes, Mayo Clinic, Rochester, MN, USA
3 Division of Pathology, Department of Medicine, Research Cente, Centre hospitalier de l’Université de Montréal (CHUM),
Montreal, QC, Canada
4 Division of Genetics, Department of Medicine, Centre hospitalier de l’Université de Montréal (CHUM), Montreal, QC, Canada
5 Division of Urology, Department of Surgery, Research Center, Centre hospitalier de l’Université de Montréal (CHUM), Montreal, QC, Canada
6 Division of Medical Oncology, Department of Medicine, Research Center, Centre hospitalier de l’Université de Montréal (CHUM), Montreal, QC, Canada
Introduction
Although adrenal incidentalomas are frequent, large pro- spective studies on their natural history to inform the management are lacking and several controversies still remain. Further evaluation of their hormonal secretion and surveillance of their growth incur both additional cost and health risk, including exposure to ionizing radiation from computed tomography (CT). Recent guidelines were pub- lished by the European Society of Endocrinology (ESE) in collaboration with the European Network for the Study of Adrenal Tumors (ENSAT) on management of the adrenal incidentaloma [1]. In patients with an indeterminate adrenal mass opting not to undergo adrenalectomy, the authors suggest a repeat unenhanced CT or magnetic resonance imaging (MRI) after 6-12 months to exclude significant growth. Guidelines recommend surgical resection if the lesion enlarges by more than 20% during this period and additional imaging after 6-12 months if there is growth below this threshold. The rational of the authors is based on the principle that either primary adrenal malignancies or adrenal metastases are likely to increase in size over this time period; lack of growth may be taken as an indicator of benign disease in radiologically indeterminate lesions. Based on these recommendations, we may conclude that if there is no growth no follow up is required.
We report the case of a 32-year-old woman who pre- sented with a 2.9 x 1.9 cm left adrenal incidentaloma that was stable in size for 4 years. Ten years later, the left adrenal mass progressed to a stage IV adrenal cortical carcinoma (ACC).
Case
A 42-year-old French Canadian woman was referred to our adrenal tumor clinic 10 years after the discovery of a left adrenal incidentaloma. Her past medical history was positive for episodes of urolithiasis, irritable bowel syndrome, and fibromyalgia. Her father died of colon cancer at the age of 66 years and her paternal grandfather died of brain cancer at 67 years old. The adrenal incidentaloma was first noticed on an unenhanced CT performed for abdominal pain, in December 2005, when the patient was 32 years old (Fig. 1). In 2006, she was referred to endocrinology for a left oval adrenal mass of 2.9 × 1.9 cm with 31 Hounsfield units (HU) on an unenhanced CT. Her physical exam indicated no signs of primary hyper- aldosteronism, overt Cushing syndrome or androgen excess. Evaluation for hormonal excess was negative including a 1 mg overnight dexamethasone suppression test (DST) (cortisol 33 nmol/L, Normal (N): < 50 nmol/L) (Table 1).
In January 2007, the left adrenal mass was measured at 2.4 × 2.0 cm and was isointense in T2 with few hyperintense areas on MRI. There was no loss of signal in the out of
A
(a)
B:2.02cm
Périmètre 30.6 mm
May. 27.5 HU Dev 17.3
2.71cm
NG (Sines S)
(b)
B:1.97cm
A:2.43cm
T2 TSE AM
12 de 35
(c)
P
117 de 456
phase imaging. The washout was described as fast and the overall uptake homogenous. The right adrenal gland was normal. In June 2007, a third unenhanced abdominal CT performed for follow-up showed a stable adrenal lesion of 2.5 × 2.0 cm with 20 HU (Fig. 1).
In 2009, there was a fourth follow-up in endocrinology and a second hormonal evaluation. Her physical exam was again negative for overt hormonal excess. At this time, cortisol after
| 06-2006 | 09-2009* | 08-2015 | 03-2016 | |
|---|---|---|---|---|
| 1 mg dexamethasone suppression test (DST) (Cortisol nmol/L, <50) | 33 | 110/63 | 476 | 654 |
| 24 h urine collection of cortisol (<120 nmol/day) | 93 | 97 | 425 | 327 |
| ACTH (2-10 pmol/L) | 0.8 | 1.5 | ||
| Midnight salivary cortisol (<7 nmol/L) | 13,2/12,3 | |||
| Aldosterone/Renin (pmol/L/ng/L) (Ratio, N < 144) | – | – | 94/3 (31.3) | - |
| DHEA-S (0.8-11.3 mol/L) | 3.6 | – | – | 14 |
| Androstenedione (1.6-9.2 nmol/L) | 44.3 | |||
| Total testosterone (0-2.9 nmol/L) | 5.7 | |||
| Free testosterone (<11.0 nmol/L) | 5.1 | |||
| 17-Hydroxyprogesterone (<9.0 nmol/L) | 6.0 | 11.1 |
Abnormal results are shown in bold and normal reference values in parentheses
*On oral birth control
1 mg overnight DST administration was abnormal (cortisol 110 nmol/L), but thought to be a false positive due to con- comitant oral contraceptive therapy. On repeat of 1 mg overnight DST 6 weeks off oral contraceptive therapy was almost normal (cortisol 63 nmol/L). A 24 h urine collection for cortisol was normal at 97 nmol/d (N <120). A fourth unenhanced abdominal CT showed a left adrenal mass of 2.5 × 1.8 cm with 23 HU, dictated as a benign lesion by the radiologist, evoking that the lesion was stable in size for 4 years supporting the diagnosis of adenoma. During the first 4 years, no positron emission tomography (PET) scan was done. Unfortunately, the patient was lost to follow-up.
In February 2016, the patient presented to the emergency department with renal colic and an enhanced abdominal CT showed that the left adrenal lesion was enlarged to 9 x 8.2 cm, with a necrotic center, few calcifications and 2 new hepatic lesions (Fig. 1). The hormonal investigation revealed the absence of suppression to the 1 mg overnight DST (cortisol 476 nmol/L). The 24 h urine collection of cortisol was elevated at 425 nmol/d (N <120). Three samples of midnight salivary cortisol were completed and were slightly abnormal: 7.7 nmol/L, 7.6 nmol/L, and 8.0 nmol/L (N <7.0). She was admitted to endocrinology and the investigation suggested co-secretion of cortisol and androgens. In addi- tion, steroid profiling was performed in a sample from 24 h urine, by high-resolution accurate-mass mass spectrometry as described by Hines et al. and demonstrated elevated androgens (ANDROS, ETIO, DHEA, 16a-DHEA-S), pre- cursors (5PT, 5PD, PD, 17HP, and THS), and cortisol with glucocorticoid metabolites (Fig. 2) [2]. In March 2016, a PET scan demonstrated a left adrenal lesion highly meta- bolic with a maximal SUV of 13.7 and no distant uptake. A first thoracic CT performed in March 2016 demonstrated no evidence of metastatic lesions, but on follow-up in June 2016, small bilateral pulmonary nodules suspicious for metastases were described.
Treatment and outcome
Adrenalectomy was performed in April 2016 with pathology reporting an ACC of 12× 8 ×7 cm, with a mitotic index of 20/50 in some regions and vascular invasion. The Aubert score was 6/7 and the Ki67 was elevated at 30%. Mitotane was initiated in June 2016 along with hydrocortisone. In July 2016, after noticing growth of the hepatic lesions on both CT and MRI, a liver biopsy was performed and con- firmed ACC metastases and thus stage IV ACC. Che- motherapy with etoposide, doxorubicin and cisplatin was introduced in August 2016. Unfortunately, the patient did not tolerate mitotane and chemotherapy and declined any further treatment. Following cessation of therapy, disease progressed rapidly with enlargement of the liver metastases and the development of several lung metastases.
Genetic counseling and multigene panel analysis
Taking into account the patient’s family history of colon cancer in her father and brain tumor in her paternal grand- father she was referred to the genetic clinic. The patient gave written informed consent for further genetic investi- gations. A multigene panel (Invitae, San Francisco, CA) was offered to the patient. After signing an informed con- sent, the following genes were analyzed for sequence changes and exonic deletions/duplications including APC, ATM, BMPR1A, BRCA1, BRC2, BRIP1, CDH1, CHEK2, EPCAM, MEN1, MLH1, MSH2, MSH6, MUTYH, PALB2, PMS2, PTEN, RAD51C, RAD51D, SMAD4, STK11, and TP53 genes. Although, no mutations were found in the leukocyte DNA of the patient, a variant of uncertain sig- nificance (VUS) was identified in the exon 16 of the APC gene (c.2414G> A, p.Arg805Gln) (NM_000038.5). This missense change is present in population databases with low frequency (rs200593940, ExAC 0.000825%). Algorithms
(a)
| Abbreviation | Common name | Healthy ranges, mean (SD) (ul, 24 hour urine collection) | Patient measurements (ul, 24 hour urine collection) |
|---|---|---|---|
| ANDROS | Androsterone | 1715 (1336) | 7314 |
| ETIO | Etiocholanolone | 1994 (1624) | 13743 |
| DHEA | Dehydroepiandrosterone | 132 (148) | 16850 |
| 16a-OH-DHEA | 16a-hydroxyDHEA | 558 (148) | 6490 |
| 5-PT | Pregnenetriol | 87 (91) | 9007 |
| 5-PD | Pregnenediol | 111(130) | 570 |
| THB | Tetrahydrocorticosterone | 124 (72) | <20 |
| THDOC | Tetrahydro-11- deoxycorticosterone | 23 (29) | 93 |
| PD | Pregnanediol | 594 (1421) | 1419 |
| 17HP | 17-hydroxypregnanolone | 191 (243) | 814 |
| PT | Pregnanetriol | 619 (417) | 2054 |
| PTONE | Pregnane-triolone | 43 (71) | 31 |
| THS | Tetrahydro-11- deoxycortisol | 90 (51) | 12479 |
| Cortisol | Cortisol | 75 (37) | 475 |
| 6ß-OH-Cortisol | 6ß-hydroxycortisol | 121 (68) | 1348 |
| THF | Tetrahydrocortisol | 1550 (824) | 6745 |
| 5a-THF | 5a-tetrahydrocortisol | 931 (758) | 1241 |
| B-cortol | B-cortol | 383 (278) | 1370 |
| 11ß-OH-ANDRO | 11ß-hydroxy-androsterone | 820 (502) | 1847 |
| 11ß-OH-ETIO | 11ß-hydroxy- etiocholanolone | 511 (374) | 2261 |
| Cortisone | Cortisone | 125 (83) | 451 |
| THE | Tetrahydrocortisone | 3021 (1996) | 8917 |
| a-cortolone | a-cortolone | 1468 (733) | 3013 |
| B-cortolone | B-cortolone | 690 (446) | 1785 |
| 11-oxo-ETIO | 11-oxo-etiocholanolone | 698 (386) | 1716 |
(b)
(c)
ANDROS
ETIO
DHEA
Control
16a-DHEA
Asn
Arg
His
5-PT
AATCGACAT
5-PD
THB
THDOC
PD
Leukocyte DNA
17HP
Biomarkers
Patient
PT
PT-ONE
Asn
Arg/Gln
His
THS
AATCGACAT
Cortisol
6b-OH-Cortisol
THF
5a-THF
Leukocyte DNA
b-Cortol
Patient
11b-OH-ANDRO
11b-OH-ETIO
Asn
Arg/Gln
His
Cortisone
A A TCGACAT
THE
a-Cortolone
b-Cortolone
11-OXO-ETIO
Tumor FFPE DNA
-5
0
5
10
developed to predict the effect of missense changes on protein structure and function do not reach consensus on the potential impact of this missense change: disease causing (Mutation Taster) [3], probably pathogenic (UMD-Pre- dictor) [4], deleterious (PredictSNP) [5], uncertain sig- nificance (Clin Var NCBI database), or neutral (Provean) [6]. However, the c.2414G > A, p.Arg805Gln variant was not reported previously in patients with APC-related disease so it remains for now a VUS.
Immunohistochemical analysis (IHC) of the ACC for IGF-2, beta-catenin, and TP53 proteins
Original and new hematoxylin and eosin slides of the ACC tumor were reviewed by an experienced pathologist (M.L.) to confirm the diagnosis of ACC and to determine the Weiss score. ß-catenin, IGF-2, and TP53 stainings were performed on 3-mm-thick sections of deparaffinized tissue and anti- gens were retrieved. The slides were incubated with mouse monoclonal antibodies (Ventana BenchMark system) against ß-catenin (clone b-catenin 1, 1:200 dilution) (Dako), IGF-2 protein (clone SIF2, 1:100 dilution) (Millipore), and
controls, blue represents lower values than healthy controls. Cortisol and glucocorticoid metabolites, steroid precursors (5PT, 5PD and THS, PD, 17HP), and androgens are significantly elevated. c Sanger sequencing chromatograms showing germline variant in exon 16 of APC gene (NM_000038.5) c.2414G>A, p.Arg805Gln in leukocyte and tumoral FFPE DNA of the patient. The normal sequence allele is retained in the ACC FFPE DNA
TP53 (clone Pab1801, 1:50 dilution) (Leica). External positive controls were performed. The ACC tumor immu- nochemistry was scored semi quantitatively as 0 (negative), 1+ (focally or weakly positive), 2+ (moderate staining), 3+ (diffuse strong staining), or 4+ (intense diffuse staining). In our patient, IHC analysis showed perinuclear in a dot-like pattern for IGF-2 (2+). There were both diffuse membra- nous cytoplasmic staining for ß-catenin (3+) and nuclear staining (Fig. 3). TP53 nuclear staining was positive in <20% of the tumoral cells suggesting a wild-type state of TP53 gene in the tumor.
Mutational analysis of APC and CTNNB1 genes in tumoral DNA
After giving her written informed consent, tumoral tissue of the patient was analyzed for the c.2414G > A, p.Arg805Gln APC genetic alteration (rs200593940) mutation and the CTNNB1 gene. Exon numbering is based on the NCBI references sequences NM_000038.5 and NM_001904.3, respectively. Tumoral DNA was extracted from frozen ACC tissues and microdissected formalin-fixed paraffin embedded
(a)
(b)
(c)
(d)
(e)
(f)
as described previously. APC exon 16 and beta-catenin exon 3 were amplified by a polymerase chain reaction and directly sequenced using the Applied Biosystems 3730xl DNA ana- lyzer (Mcgill University and Genome Québec Innovation Centre, Québec, Canada). All the primers that were used are described in Supplemental Table 1. There were no beta- catenin mutations. As expected the germline heterozygote APC c.2414G > A, p.Arg805Gln variant was identified. There was no loss of heterozygosity (LOH) because the wild-type allele was retained in the ACC tissue. To exclude another genetic event in the APC gene, we sequenced the whole APC cDNA and no pathogenic mutations were found. Only one missense benign variant (c.5465T>A, p.Val1822Asp) and six polymorphisms were identified (Supplemental Table 2). In addition, we found the presence of the coding exon 9a iso- form that miss 303 nucleotides from 5’ end of coding exon 9. This isoform, with coding exon 9 partially deleted, is in-frame and conduct to a functional protein (NP_001341832.1) as described previously [7-9].
Discussion
Although adrenal incidentalomas are frequent, large pro- spective studies on their management are lacking and several controversies remain. In 2016, the ESE in collaboration with the ENSAT published a clinical practice Guideline for the management of adrenal incidentalomas (1). At the time of initial detection, they recommend aiming to establish if the adrenal mass is benign or malignant, primarily with the use of an unenhanced abdominal CT. This guideline suggests that if the adrenal lesion is indeterminate on noncontrast CT with no
hormone excess, and depending on individual circumstances and suspicion for malignancy, three options should be con- sidered: (1) surgery, (2) immediate additional imaging with another modality and (3) repeat unenhanced CT or MRI after 6-12 months to exclude significant growth. Lack of growth over a period of 6-12 months makes a malignant mass highly unlikely. Following this recommendation, it would have been acceptable to stop the follow-up imaging for the patient reported here after the MRI performed one year after initial imaging showing no growth and neither worrisome features. In addition, based on these recommendations choosing another modality of imaging as PET imaging, in the initial investigation, would have also been an option; however, PET imaging was not widely used for this indication in our center at that time and was not performed.
Exceptional cases of malignant adrenal tumor without significant growth for several years were previously described [10, 11]. In 2015, a retrospective study of a cohort of 422 ACC evaluated the radiographic characteristics of adrenal mass preceding the diagnosis of ACC [10]. Twenty patients with a prior adrenal tumor were identified and in all cases where an initial unenhanced CT was available, the attenuation exceeded 11 HU (12-67 HU). Two of them had initial imaging characteristics suggestive of a benign lesion, but on contrast-enhanced CT. Five lesions were <2 cm in diameter and all were homogeneous. The growth pattern was variable with some lesions showing long-term stability in size, between 7 months and 2 years in 4 patients and more than 4 years in 2 patients. Similarly, in our case the adrenal lesion was stable in size for 4 years with imaging completed annually that confirmed the absence of growth and underline that no growth may be falsely reassuring.
In the above mentioned study while 8 out of 20 patients had clinical evidence of hormone excess at diagnosis of ACC, initial endocrine workup was not available for any of these patients [10]. In this case, we confirmed the absence of hormone excess at the initial diagnosis of the adrenal incidentaloma and at 4 years of follow-up while co- secretion of cortisol and androgens was demonstrated at diagnosis of ACC. The use of urinary steroid metabolite profiling is an emerging technique that can help to distin- guish benign from malignant adrenal tumors [12, 13]. This method has shown a sensitivity and specificity of 90% in a cohort of 102 adrenocortical adenoma patients and 45 ACC patients [12]. More recently, plasma steroid metabolome profiling identified a diagnostic signature including six steroids for male and female patients with positive pre- dictive values of 92% and 96% and negative predictive values of 90% and 86%, respectively [14].
In a more recent study, Ozsari et al. reviewed data of 439 patients with ACC. Among them, twenty-five patients had imaging prior diagnosis of ACC; 5 had normal adrenal glands and 20 had preexisting adrenal lesions [11]. On the first available images, the median mass size was 2.8 cm (range 0-9) with median precontrast density of 36 HU (17-43). The longest time between the identification of the initial adrenal lesion and the diagnosis of ACC was of 90 months. In our case, the diagnosis of ACC was made 124 months after the initial diagnosis of the adrenal incidentaloma.
Recent data on CT criteria for discriminating adrenal adenomas and ACC, has shown that HU >13.9 allows a sensitivity of 100%, but a lower specificity of 68% [15]. In 2016, a meta-analysis on the imaging for the diagnosis of malignancy in incidentally discovered adrenal mass, also reported that CT density >10 HU has high sensitivity for detection of adrenal malignancy [16]. In our case, this was the only clue to a malignant evolution since HU varying between 20 and 31. Recently in 2017, the case of a 71-year-old man with an adrenal adenoma, who developed a carcinoma 14 years later, with subsequent metastases and death was reported [17]. In this case, the initial CT showed a right adrenal lesion of 1.7 cm, homogenous with density between 7.9 and 13 HU which was stable in size for 5 years of follow- up before being diagnosed as ACC 8 years later. In this case, like in our patient, unfortunately the diagnosis of ACC was made at stage IV, which is associated with a poor 5-year overall survival of 10-15%.
We identified in this case a germline APC VUS. APC mutations are found in familial adenomatous polyposis char- acterized by numerous adenomatous polyps throughout the colon and rectum; however, this patient had no abnormalities detected at colonoscopy. APC mutations lead to activation of Wnt/ß-catenin signaling, which plays a major role in adreno- cortical tumorigenesis. Using immunohistochemical analysis, we demonstrated ß-catenin accumulation revealing Wnt/
B-catenin pathway activation in the ACC cells of the patient while no somatic ß-catenin mutations were identified. The significance of this germline APC VUS remains to be deter- mined. Previous associations of ACC and APC mutations were described. In 2010, Gaujoux et al. found a silent het- erozygous somatic mutation in 1 out of 20 sporadic cases of ACC [18]. Moreover, in 2014, Assié et al. reported 2% of somatic APC mutations in a cohort of 45 ACC [19]. In 2018, Shiroky et al. described the case of a 24-year-old woman carrying a pathogenic germline APC mutation that developed a nonsecreting ACC [20]. As opposed to our case, the ACC significantly increased in size, from 1 cm to 3.5 cm, in the first 5 years of follow-up. Previous studies reported overall lower survival rate in ACC patients presenting alterations in APC/ CTNNB1 in comparison to those without mutation [21, 22].
In conclusion, rare cases of adrenal tumors, without sig- nificant growth for several years, may be malignant. Thus, long-term stability of a small adrenal lesion does not exclude the diagnosis of ACC. It is important to consider all features of different types of imaging and follow-up imaging should be individualized particularly in young patients with unde- termined small adrenal incidentaloma. Moreover, this case is illustrating that a nonsecreting adrenal lesion may become functional over the years. Finally, better genetic character- ization of these patients may eventually provide clues on this unusual evolution of an adrenal incidentaloma.
Author contributions We thank the patient who kindly consents that we report her case. We thank Dr. Serge Nolet for technical assistance for leukocyte DNA. N.G. and I. Bourdeau contributed to literature search and writing of the manuscript. I. Bourdeau designed the study. I. Bancos provided the metabolomic profile. G.C. and K.C. contributed to technical laboratory work. I.B and all other co-authors contributed towards patient care and finalizing the draft.
Funding This research was supported in part by a salary grant to I. Bourdeau from Fonds de Recherche du Québec-Santé (FRQ-S) and the generous financial support from Fondation McAbbie for the laboratory work.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of interest.
Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent The authors confirm that written informed consent was obtained from the patient for publication of the submitted article and the accompanying images.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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