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Ziele: Das Ziel dieser offiziellen Leitlinie, die von der Deutschen Gesellschaft für Gynäkologie und Geburtshilfe (DGGG) und der Deutschen Krebsgesellschaft (DKG) publiziert und koordiniert wurde, ist es, die Früherkennung, Diagnostik, Therapie und Nachsorge des Mammakarzinoms zu optimieren.
Methoden: Der Aktualisierungsprozess der S3-Leitlinie aus 2012 basierte zum einen auf der Adaptation identifizierter Quellleitlinien und zum anderen auf Evidenzübersichten, die nach Entwicklung von PICO-(Patients/Interventions/Control/Outcome-)Fragen, systematischer Recherche in Literaturdatenbanken sowie Selektion und Bewertung der gefundenen Literatur angefertigt wurden. In den interdisziplinären Arbeitsgruppen wurden auf dieser Grundlage Vorschläge für Empfehlungen und Statements erarbeitet, die im Rahmen von strukturierten Konsensusverfahren modifiziert und graduiert wurden.
Empfehlungen: Der Teil 1 dieser Kurzversion der Leitlinie zeigt Empfehlungen zur Früherkennung, Diagnostik und Nachsorge des Mammakarzinoms: Der Stellenwert des Mammografie-Screenings wird in der aktualisierten Leitlinienversion bestätigt und bildet damit die Grundlage der Früherkennung. Neben den konventionellen Methoden der Karzinomdiagnostik wird die Computertomografie (CT) zum Staging bei höherem Rückfallrisiko empfohlen. Die Nachsorgekonzepte beinhalten Untersuchungsintervalle für die körperliche Untersuchung, Ultraschall und Mammografie, während weiterführende Gerätediagnostik und Tumormarkerbestimmungen bei der metastasierten Erkrankung Anwendung finden.
Purpose: The aim of this official guideline coordinated and published by the German Society for Gynecology and Obstetrics (DGGG) and the German Cancer Society (DKG) was to optimize the screening, diagnosis, therapy and follow-up care of breast cancer.
Methods: The process of updating the S3 guideline dating from 2012 was based on the adaptation of identified source guidelines which were combined with reviews of evidence compiled using PICO (Patients/Interventions/Control/Outcome) questions and the results of a systematic search of literature databases and the selection and evaluation of the identified literature. The interdisciplinary working groups took the identified materials as their starting point to develop recommendations and statements which were modified and graded in a structured consensus procedure.
Recommendations: Part 1 of this short version of the guideline presents recommendations for the screening, diagnosis and follow-up care of breast cancer. The importance of mammography for screening is confirmed in this updated version of the guideline and forms the basis for all screening. In addition to the conventional methods used to diagnose breast cancer, computed tomography (CT) is recommended for staging in women with a higher risk of recurrence. The follow-up concept includes suggested intervals between physical, ultrasound and mammography examinations, additional high-tech diagnostic procedures, and the determination of tumor markers for the evaluation of metastatic disease.
(1) Background: Patients with locally advanced head and neck squamous cell carcinoma (HNSCC) who are biologically at high risk for the development of loco–regional recurrences after postoperative radiotherapy (PORT) but at intermediate risk according to clinical risk factors may benefit from additional concurrent chemotherapy. In this matched-pair study, we aimed to identify a corresponding predictive gene signature. (2) Methods: Gene expression analysis was performed on a multicenter retrospective cohort of 221 patients that were treated with postoperative radiochemotherapy (PORT-C) and 283 patients who were treated with PORT alone. Propensity score analysis was used to identify matched patient pairs from both cohorts. From differential gene expression analysis and Cox regression, a predictive gene signature was identified. (3) Results: 108 matched patient pairs were selected. We identified a 2-metagene signature that stratified patients into risk groups in both cohorts. The comparison of the high-risk patients between the two types of treatment showed higher loco–regional control (LRC) after treatment with PORT-C (p < 0.001), which was confirmed by a significant interaction term in Cox regression (p = 0.027), i.e., the 2-metagene signature was indicative for the type of treatment. (4) Conclusion: We have identified a novel gene signature that may be helpful to identify patients with high-risk HNSCC amongst those at intermediate clinical risk treated with PORT, who may benefit from additional concurrent chemotherapy.
Mathematische Basiskompetenzen gelten als wichtiger Prädiktor für die schulische Mathematikleistung. Ebenso offenbaren Studien eine prädiktive Wirkung des selbstregulierten Lernens auf die akademische Leistung. Die Ergebnisse mehrerer Studien zeigen, dass Kinder mit Migrationshintergrund im deutschen Schulsystem schlechter abschneiden. Schon in der Grundschule weisen diese Kinder im Fach Mathematik schlechtere Leistungen auf als ihre Mitschüler[innen] ohne Migrationshintergrund. Vermutlich kann dieser Umstand mit schlechteren Ausgangsbedingungen im mathematischen Vorwissen begründet werden. Darüber hinaus spielen auch mangelnde Sprachfähigkeiten in der Unterrichtssprache eine wichtige Rolle. Daher sollten die fehlenden Kompetenzen im Anfangsunterricht entwicklungsorientiert aufgebaut werden. Zusätzlich sollten auch Methoden zum selbstregulierten Lernen frühzeitig vermittelt werden, da diese Fähigkeit die Übertragung fachlicher Förderungen auf weiterführende Inhalte erleichtert und eine Voraussetzung für die gelingende Umsetzung verschiedener Unterrichtsmethoden darstellt. In der Praxis werden entsprechende Konzepte bislang allerdings nur vereinzelt umgesetzt.
In der vorliegenden Studie sollten daher die Lernvoraussetzungen von Kindern mit Migrationshintergrund in den mathematischen Basiskompetenzen und im selbstregulierten Lernen überprüft werden. Im Anschluss hieran sollte erprobt werden, ob sich die Kombination aus einem Training zur Förderung mathematischer Basiskompetenzen sowie einem Programm zur Förderung selbstregulierten Lernens als Unterrichtskonzept für den Anfangsunterricht mit Kindern mit Migrationshintergrund eignet und hiermit die Disparitäten in den Lernvoraussetzungen der migrierten Kinder ausgeglichen werden können. Hierfür wurde das ursprünglich für den vorschulischen Einsatz konzipierte Trainingsprogramm „Mengen, zählen, Zahlen“ (MZZ, Krajewski, Nieding & Schneider 2007) sowie ein von Otto (2007) ausgearbeitetes Konzept mit selbstregulativen Inhalten (SRL) für den unterrichtsintegrierten Einsatz im Erstunterricht adaptiert. Für die Teilnahme an der Studie konnten 30 Grundschulklassen rekrutiert werden. 517 Schüler[innen] wurden klassenweise einer von drei Versuchsbedingungen zugeordnet: (1) Der ersten Experimentalgruppe, in der die Trainingskombination in der Reihenfolge erst SRL, dann MZZ durchgeführt wurde (EGSRL+MZZ) oder (2) der zweiten Experimentalgruppe, die die Trainingskombination in der umgekehrten Reihenfolge (EGMZZ+SRL) erhielt oder (3) der Kontrollgruppe (KG), in der der reguläre Mathematikunterricht erfolgte. Die Durchführung der Trainingskombination wurde von den jeweiligen Mathematiklehrkräften vorgenommen. Vor der Implementierung der Trainingsprogramme erfolgte eine Erfassung der mathematischen Basiskompetenzen, der Fähigkeiten im selbstregulierten Lernen sowie der Fähigkeiten im Wortverständnis. Zur Überprüfung der Wirksamkeit wurden im Anschluss an die Durchführung der Trainingskombination diese Fähigkeiten erneut erhoben. Zudem wurde die Transferwirkung auf die Fähigkeiten im Basisrechnen untersucht. Ein halbes Jahr später erfolgte eine Follow-up-Untersuchung, bei der abermals die Fähigkeiten im selbstregulierten Lernen sowie der Transfer auf das Basisrechnen und die curriculare Mathematikleitung erfasst wurden.
Die Ergebnisse offenbarten für Kinder mit Migrationshintergrund ein schlechteres Vorwissen in den mathematischen Basiskompetenzen. Hinsichtlich der Fähigkeiten im selbstregulierten Lernen konnten keine Unterschiede gefunden werden. Die Ergebnisse des Posttests konnten einen größeren Kompetenzzuwachs in den mathematischen Basiskompetenzen bei den Kindern mit Migrationshintergrund der ersten Experimentalgruppe (EGSRL+MZZ) im Vergleich zu den Kindern mit Migrationshintergrund der Kontrollgruppe nachweisen. Zudem zeigten sich positive Transfereffekte auf das Basisrechnen. Transfereffekte auf die curriculare Mathematikleistung wurden bei den Kindern mit Migrationshintergrund dagegen nicht ersichtlich. Hinsichtlich der Fähigkeiten im selbstregulierten Lernen ließen sich bei den Kindern mit Migrationshintergrund keine Trainingseffekte aufdecken. In Bezug auf die Kompensation der lückenhaften Lernvoraussetzungen in den mathematischen Basiskompetenzen bei Kindern mit Migrationshintergrund konnte für die erste Experimentalgruppe (EGSRL+MZZ) ein höherer Lernzuwachs bei Kindern nicht deutscher Herkunft festgestellt werden. Bei der zweiten Experimentalgruppe (EGMZZ+SRL) zeigten sich zwar keine Unterschiede zwischen Kindern mit und ohne Migrationshintergrund, doch es offenbarte sich, dass Kinder mit deutscher Muttersprache von der Trainingskombination im Hinblick auf ihre mathematischen Basiskompetenzen mehr profitieren. Die Ergebnisse verweisen auf die Bedeutung der sprachlichen Fähigkeiten bei der entwicklungsorientierten Förderung mathematischer Kompetenzen und werden vor dem Hintergrund einer Ausarbeitung zu einem flächendeckend einsetzbaren Unterrichtskonzept diskutiert.
Glioblastoma is one of the deadliest malignancies and is virtually incurable. Accumulating evidence indicates that a small population of cells with a stem-like phenotype is the major culprit of tumor recurrence. Enhanced DNA repair capacity and expression of stemness marker genes are the main characteristics of these cells. Elimination of this population might delay or prevent tumor recurrence following radiochemotherapy. The aim of this study was to analyze whether interference with the Hedgehog signaling (Hh) pathway or combined Hh/Notch blockade using small-molecule inhibitors can efficiently target these cancer stem cells and sensitize them to therapy. Using tumor sphere lines and primary patient-derived glioma cultures we demonstrate that the Hh pathway inhibitor GANT61 (GANT) and the arsenic trioxide (ATO)-mediated Hh/Notch inhibition are capable to synergistically induce cell death in combination with the natural anticancer agent (−)-Gossypol (Gos). Only ATO in combination with Gos also strongly decreased stemness marker expression and prevented sphere formation and recovery. These synergistic effects were associated with distinct proteomic changes indicating diminished DNA repair and markedly reduced stemness. Finally, using an organotypic brain slice transplantation model, we show that combined ATO/Gos treatment elicits strong growth inhibition or even complete elimination of tumors. Collectively, our data show for the first time that ATO and Gos, two drugs that can be used in the clinic, represent a promising targeted therapy approach for the synergistic elimination of glioma stem-like cells.
Purpose: Dexamethasone (Dex) is the most common corticosteroid to treat edema in glioblastoma (GBM) patients. Recent studies identified the addition of Dex to radiation therapy (RT) to be associated with poor survival. Independently, Tumor Treating Fields (TTFields) provides a novel anti-cancer modality for patients with primary and recurrent GBM. Whether Dex influences the efficacy of TTFields, however, remains elusive. Methods: Human GBM cell lines MZ54 and U251 were treated with RT or TTFields in combination with Dex and the effects on cell counts and cell death were determined via flow cytometry. We further performed a retrospective analysis of GBM patients with TTFields treatment +/- concomitant Dex and analysed its impact on progression-free (PFS) and overall survival (OS). Results: The addition of Dex significantly reduced the efficacy of RT in U251, but not in MZ54 cells. TTFields (200 kHz/250 kHz) induced massive cell death in both cell lines. Concomitant treatment of TTFields and Dex did not reduce the overall efficacy of TTFields. Further, in our retrospective clinical analysis, we found that the addition of Dex to TTFields therapy did not influence PFS nor OS. Conclusion: Our translational investigation indicates that the efficacy of TTFields therapy in patients with GBM and GBM cell lines is not affected by the addition of Dex.
MRI-detection rate and incidence of lumbar bleeding sources in 190 patients with non-aneurysmal SAH
(2017)
Background: Up to 15% of all spontaneous subarachnoid hemorrhages (SAH) have a non-aneurysmal SAH (NASAH). The evaluation of SAH patients with negative digital subtraction angiography (DSA) is sometimes a diagnostic challenge. Our goal in this study was to reassess the yield of standard MR-imaging of the complete spinal axis to rule out spinal bleeding sources in patients with NASAH.
Methods: We retrospectively analyzed the spinal MRI findings in 190 patients with spontaneous NASAH, containing perimesencephalic (PM) and non-perimesencephalic (NPM) SAH, diagnosed by computer tomography (CT) and/or lumbar puncture (LP), and negative 2nd DSA.
Results: 190 NASAH patients were included in the study, divided into PM-SAH (n = 87; 46%) and NPM-SAH (n = 103; 54%). Overall, 23 (22%) patients had a CT negative SAH, diagnosed by positive LP. MR-imaging of the spinal axis detected two patients with lumbar ependymoma (n = 2; 1,05%). Both patients complained of radicular sciatic pain. The detection rate raised up to 25%, if only patients with radicular sciatic pain received an MRI.
Conclusion: Routine radiological investigation of the complete spinal axis in NASAH patients is expensive and can not be recommended for standard procedure. However, patients with clinical signs of low-back/sciatic pain should be worked up for a spinal pathology.
Background: The prognostic factors and outcome of aneurysms appear to be dependent on its locations. Therefore, we compared left- and right- sided aneurysms in patients with aneurysmal subarachnoid hemorrhage (SAH) in terms of differences in outcome and prognostic factors.
Methods: Patients with SAH were entered into a prospectively collected database. A total of 509 patients with aneurysmal subarachnoid hemorrhage were retrospectively selected and stratified in two groups depending on side of ruptured aneurysm (right n = 284 vs. left n = 225). Midline aneurysms of the basilar and anterior communicating arteries were excluded from the analysis. Outcomes were assessed using the modified Rankin Scale (mRS; favorable (mRS 0–2) vs. unfavorable (mRS 3–6)) six months after SAH.
Results: We did not identify any differences in outcome depending on left- and right-sided ruptured aneurysms. In both groups, the significant negative predictive factors included clinical admission status (WFNS IV+V), Fisher 3- bleeding pattern in CT, the occurrence of delayed cerebral ischemia (DCI), early hydrocephalus and later shunt-dependence. The side of the ruptured aneurysm does not seem to influence patients´ outcome. Interestingly, the aneurysm side predicts the side of infarction, with a significant influence on patients´ outcome in case of left-sided infarctions. In addition, the in multivariate analysis side of aneurysm was an independent predictor for the side of cerebral infarctions.
Conclusion: The side of the ruptured aneurysms (right or left) did not influence patients’ outcome. However, the aneurysm-side predicts the side of delayed infarctions and outcome appear to be worse in patients with left-sided infarctions.
Short- and long-term effects of rehabilitation after perimesencephalic subarachnoid hemorrhage
(2021)
n about 25% of patients with spontaneous subarachnoid hemorrhage (SAH), a bleeding source cannot be identified during radiological diagnostics. Generally, the outcome of perimesencephalic or prepontine (PM) SAH is known to be significantly better than after non-PM SAH. Data about long-term follow-up concerning physical and mental health are scarce, so this study is reports on long-term results. We measured the influence of PM SAH on a quality-of-life modified Rankin (mRs) scale after six months. For long-term follow-up, a SF-36 questionnaire was used. Questionnaires were sent out between 18 and 168 months after ictus. In 37 patients, a long-term follow-up was available (up to 14 years after SAH). Data detected with the SF-36 questionnaire are compared to reference applicability to the standard population. In total, 37 patients were included for further analysis and divided in 2 subgroups; 13 patients (35%) received subsequent rehabilitation after clinical stay and 24 (65%) did not. In the short-term outcome, a significant improvement from discharge until follow-up was identified in patients with subsequent rehabilitation, but not in the matched pair group without rehabilitation. When PM SAH was compared to the standard population, a reduction in quality of life was identified in physical items (role limitations because of physical health problems, physical functioning) as well as in psychological items (role limitations because of emotional problems). Subsequent rehabilitation on PM SAH patients probably leads to an increase in independence and better mRs. While better mRs was shown at discharge in patients without subsequent rehabilitation, the mRs of rehabilitants was nearly identical after rehabilitation. Patients with good mRs also reached high levels of health-related quality of life (HRQoL) without rehabilitation. Thus, subsequent rehabilitation needs to be encouraged on an individual basis. Indication criteria for subsequent rehabilitation should be defined in further studies to improve patient treatment and efficiency in health care.
Background: The surgical treatment of giant olfactory groove meningiomas (OGMs) with marked perilesional brain oedema is still a surgical challenge. After tumour resection, increase of brain oedema may occur causing dramatic neurological deterioration and even death of the patient. The objective of this paper is to describe surgical features of a two-step staged resection of these tumours performed to counter increase of postoperative brain oedema.
Methods: This two-step staged resection procedure was carried out in a consecutive series of 19 patients harbouring giant OGMs. As first step, a bifrontal craniectomy was performed followed by a right-sided interhemispherical approach. About 80% of the tumour mass was resected leaving behind a shell-shaped tumour remnant. In the second step, carried out after the patients’ recovery from the first surgery and decline of oedema, the remaining part of the tumour was removed completely followed by duro- and cranioplasty.
Results: Ten patients recovered quickly from first surgery and the second operation was performed after a mean of 12.4 days. In eight patients, the second operation was carried out later between day 25 and 68 due to surgery-related complications, development of a trigeminal zoster, or to a persisting frontal brain oedema. Mean follow-up was 49.3 months and all but one patient had a good outcome regardless of surgery-related complications.
Conclusions: Our results suggest that a two-step staged resection of giant OGMs minimizes the increase of postoperative brain oedema as far as possible and translates into lower morbidity and mortality.