Resident, University Medical Center Hamburg-Eppendorf (Germany), Neurosurgery
PhD, Medical School Hannover (Germany), Surgery (2021)
MD, Semmelweis University Budapest (Hungary) & University of Oxford (UK) (2020)
Michelle Monje-Deisseroth, Postdoctoral Faculty Sponsor
A Multicenter, Propensity Score-Matched Assessment of Endoscopic Versus Microscopic Approaches in the Management of Pituitary Adenomas.
BACKGROUND: There is considerable controversy as to which of the 2 operating modalities (microsurgical or endoscopic transnasal surgery) currently used to resect pituitary adenomas (PAs) is the safest and most effective intervention.OBJECTIVE: To compare rates of clinical outcomes of patients with PAs who underwent resection by either microsurgical or endoscopic transnasal surgery.METHODS: To independently assess the outcomes of each modality type, we sought to isolate endoscopic and microscopic PA surgeries with a 1:1 tight-caliper (0.01) propensity score-matched analysis using a multicenter, neurosurgery-specific database. Surgeries were performed between 2017 and 2020, with data collected retrospectively from 12 international institutions on 4 continents. Matching was based on age, previous neurological deficit, American Society of Anesthesiologists (ASA) score, tumor functionality, tumor size, and Knosp score. Univariate and multivariate analyses were performed.RESULTS: Among a pool of 2826 patients, propensity score matching resulted in 600 patients from 9 surgery centers being analyzed. Multivariate analysis showed that microscopic surgery had a 1.91 odds ratio (OR) (P = .03) of gross total resection (GTR) and shorter operative duration (P < .01). However, microscopic surgery also had a 7.82 OR (P < .01) for intensive care unit stay, 2.08 OR (P < .01) for intraoperative cerebrospinal fluid (CSF) leak, 2.47 OR (P = .02) for postoperative syndrome of inappropriate antidiuretic hormone secretion (SIADH), and was an independent predictor for longer postoperative stay (beta = 2.01, P < .01). Overall, no differences in postoperative complications or 3- to 6-month outcomes were seen by surgical approach.CONCLUSION: Our international, multicenter matched analysis suggests microscopic approaches for pituitary tumor resection may offer better GTR rates, albeit with increased intensive care unit stay, CSF leak, SIADH, and hospital utilization. Better prospective studies can further validate these findings as matching patients for outcome analysis remains challenging. These results may provide insight into surgical benchmarks at different centers, offer room for further registry studies, and identify best practices.
View details for DOI 10.1227/neu.0000000000002497
View details for PubMedID 37057921
Targeted anticonvulsive treatment of IDH-wildtype glioblastoma based on DNA methylation subclasses.
View details for DOI 10.1093/neuonc/noad014
View details for PubMedID 36860191
Impact of the SARS-CoV-2 pandemic on the survival of patients with high-grade glioma and best practice recommendations.
2023; 13 (1): 2766
The severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) has changed the clinical day-to-day practice. The aim of this study was to evaluate the impact of the pandemic on patients with high-grade glioma (HGG) as well as to derive best practice recommendations. We compared a multi-institutional cohort with HGG (n = 251) from 03/2020 to 05/2020 (n = 119) to a historical cohort from 03/2019 to 05/2019 (n = 132). The endpoints were outcome (progression-free survival (PFS) and overall survival (OS)) as well as patterns of care and time intervals between treatment steps. The median OS for WHO grade 4 gliomas was 12 months in 2019 (95% Confidence Interval 9.7-14.3 months), and not reached in 2020 (p = .026). There were no other significant differences in the Kaplan-Meier estimates for OS and PFS between cohorts of 2019 and 2020, neither did stratification by WHO grade reveal any significant differences for OS, PFS or for patterns of care. The time interval between cranial magnetic resonance imaging (cMRI) and biopsy was significantly longer in 2020 cohort (11 versus 21 days, p = .031). Median follow-up was 10 months (range 0-30 months). Despite necessary disease containment policies, it is crucial to ensure that patients with HGG are treated in line with the recent guidelines and standard of care (SOC) algorithms. Therefore, we strongly suggest pursuing no changes to SOC treatment, a timely diagnosis and treatment with short time intervals between first symptoms, initial diagnosis, and treatment, as well as a guideline-based cMRI follow-up.
View details for DOI 10.1038/s41598-023-29790-8
View details for PubMedID 36797335
View details for PubMedCentralID PMC9933015
DNA methylation subclasses predict the benefit from gross total tumor resection in IDH-wildtype glioblastoma patients.
2023; 25 (2): 315-325
DNA methylation-based tumor classification allows an enhanced distinction into subgroups of glioblastoma. However, the clinical benefit of DNA methylation-based stratification of glioblastomas remains inconclusive.Multicentric cohort study including 430 patients with newly diagnosed glioblastoma subjected to global DNA methylation profiling. Outcome measures included overall survival (OS), progression-free survival (PFS), prognostic relevance of EOR and MGMT promoter methylation status as well as a surgical benefit for recurrent glioblastoma.345 patients (80.2%) fulfilled the inclusion criteria and 305 patients received combined adjuvant therapy. DNA methylation subclasses RTK I, RTK II, and mesenchymal (MES) revealed no significant survival differences (RTK I: Ref.; RTK II: HR 0.9 [95% CI, 0.64-1.28]; p = 0.56; MES: 0.69 [0.47-1.02]; p = 0.06). Patients with RTK I (GTR/near GTR: Ref.; PR: HR 2.87 [95% CI, 1.36-6.08]; p < 0.01) or RTK II (GTR/near GTR: Ref.; PR: HR 5.09 [95% CI, 2.80-9.26]; p < 0.01) tumors who underwent gross-total resection (GTR) or near GTR had a longer OS and PFS than partially resected patients. The MES subclass showed no survival benefit for a maximized EOR (GTR/near GTR: Ref.; PR: HR 1.45 [95% CI, 0.68-3.09]; p = 0.33). Therapy response predictive value of MGMT promoter methylation was evident for RTK I (HR 0.37 [95% CI, 0.19-0.71]; p < 0.01) and RTK II (HR 0.56 [95% CI, 0.34-0.91]; p = 0.02) but not the MES subclass (HR 0.52 [95% CI, 0.27-1.02]; p = 0.06). For local recurrence (n = 112), re-resection conveyed a progression-to-overall survival (POS) benefit (p < 0.01), which was evident in RTK I (p = 0.03) and RTK II (p < 0.01) tumors, but not in MES tumors (p = 0.33).We demonstrate a survival benefit from maximized EOR for newly diagnosed and recurrent glioblastomas of the RTK I and RTK II but not the MES subclass. Hence, it needs to be debated whether the MES subclass should be treated with maximal surgical resection, especially when located in eloquent areas and at time of recurrence.
View details for DOI 10.1093/neuonc/noac177
View details for PubMedID 35868257
View details for PubMedCentralID PMC9925709
Epigenetic profiling reveals a strong association between lack of 5-ALA fluorescence and EGFR amplification in IDH -wildtype glioblastoma
View details for DOI 10.1093/nop/npad025
DNA methylation subclass receptor tyrosine kinase II (RTK II) is predictive for seizure development in glioblastoma patients.
2022; 24 (11): 1886-1897
Seizures can present at any time before or after the diagnosis of a glioma. Roughly, 25%-30% of glioblastoma (GBM) patients initially present with seizures, and an additional 30% develop seizures during the course of the disease. Early studies failed to show an effect of general administration of antiepileptic drugs for glioblastoma patients, since they were unable to stratify patients into high- or low-risk seizure groups.111 patients, who underwent surgery for a GBM, were included. Genome-wide DNA methylation profiling was performed, before methylation subclasses and copy number changes inferred from methylation data were correlated with clinical characteristics. Independently, global gene expression was analyzed in GBM methylation subclasses from TCGA datasets (n = 68).Receptor tyrosine Kinase (RTK) II GBM showed a significantly higher incidence of seizures than RTK I and mesenchymal (MES) GBM (P < .01). Accordingly, RNA expression datasets revealed an upregulation of genes involved in neurotransmitter synapses and vesicle transport in RTK II glioblastomas. In a multivariate analysis, temporal location (P = .02, OR 5.69) and RTK II (P = .03, OR 5.01) were most predictive for preoperative seizures. During postoperative follow-up, only RTK II remained significantly associated with the development of seizures (P < .01, OR 8.23). Consequently, the need for antiepileptic medication and its increase due to treatment failure was highly associated with the RTK II methylation subclass (P < .01).Our study shows a strong correlation of RTK II glioblastomas with preoperative and long-term seizures. These results underline the benefit of molecular glioblastoma profiling with important implications for postoperative seizure control.
View details for DOI 10.1093/neuonc/noac108
View details for PubMedID 35511473
View details for PubMedCentralID PMC9629427
The Comprehensive Complication Index (CCI) as a Measure of Postoperative Morbidity and Neurological Outcome after Elective Intracranial Surgery.
Journal of neurological surgery. Part A, Central European neurosurgery
The Comprehensive Complication Index (CCI) is a numerical scale based on the Clavien-Dindo classification (CDC) and both are widely used to assess outcome. However, the CCI had not been described for neurosurgical procedures.We aimed to investigate the value of the CCI to predict outcome in patients who underwent elective intracranial surgery.Prospective cohort study including patients who underwent elective intracranial surgery. Complications were graded using CDC, and the CCI was calculated daily. Neurological outcome was assessed using mRS, NANO, NIHSS, and KPS.Of 294 patients who underwent an elective intracranial procedure, 211 (71.8%) patients underwent a craniotomy, while 28 (9.5%) patients had a burr hole procedure and 55 (18.7%) patients a transsphenoidal approach. A higher blood loss was the only significant predictor for a higher CCI (OR 1.09, 95% CI 1.00-1.12, P < 0.01). Patients with a higher CCI had a longer LOS (mean: 5.4 versus 10.9 days, P < 0.01) and ICU stay (mean: 0.8 versus 2.4 days, P < 0.01). Daily CCI revealed a risk for complications after craniotomies until postoperative day (POD) 7. In patients who underwent brain tumor surgery, the resection of meningiomas and metastasis showed a similar developmental course of CCI. A significantly higher CCI was observed in patients who had a neurological deterioration at discharge ( P < 0.01).CCI is a valid scale to measure outcome after intracranial procedures and correlates with neurological outcome. Risk for adverse events after craniotomy is at highest until postoperative day 7.
View details for DOI 10.1055/a-1962-0636
View details for PubMedID 36252766
Single-Center Experience Using a 3D4K Digital Operating Scope System for Aneurysm Surgery.
Operative neurosurgery (Hagerstown, Md.)
2022; 22 (6): 433-439
In recent years, 3D4K exoscope systems (EXs) have been introduced to microneurosurgery and reported to be an alternative to conventional operating microscopes (OMs). This study reviews our single-center experience using an 3D4K EX in intracranial aneurysm surgery.To investigate the applicability of a novel 3D4K EX for intracranial aneurysm surgery.A retrospective analysis of patients who underwent microsurgical repair of incidentally or ruptured cerebral aneurysms between August 2018 and August 2020 was performed. Patient and aneurysm characteristics and technical features, including 3-dimensional indocyanine green fluorescence, were evaluated. Data on surgery duration were statically assessed for a time trend and comparability with the OM cohort.Overall, we collected 185 aneurysm cases in which the exoscope was used in 44 cases. The mean duration of surgery using the EX was in similar range to those using the OM (165.5 ± 45.8 minutes vs 160.5 ± 39.2 minutes, P > .05). Routine postoperative computed tomography angiography showed comparable rates of complete aneurysm occlusion (95.5% vs 92.2%, P > .05) and postoperative complications (9.1% vs 9.7%, P > .05). There was no necessity to revert to the OM from the EX. Three-dimensional indocyanine green fluorescence was used in all procedures without any malfunction.The 3D4K EX for vascular microsurgical cases proved to be as useful as the OM. Because of the ease of use and comparable surgical results, the EX has the potential to become an accepted and additional visualization tool in vascular microsurgery next to the OM.
View details for DOI 10.1227/ons.0000000000000150
View details for PubMedID 35383707
Enhancing Safety in Epilepsy Surgery (EASINESS): Study Protocol for a Retrospective, Multicenter, Open Registry.
Frontiers in neurology
2021; 12: 782666
Introduction: Optimizing patient safety and quality improvement is increasingly important in surgery. Benchmarks and clinical quality registries are being developed to assess the best achievable results for several surgical procedures and reduce unwarranted variation between different centers. However, there is no clinical database from international centers for establishing standardized reference values of patients undergoing surgery for mesial temporal lobe epilepsy. Design: The Enhancing Safety in Epilepsy Surgery (EASINESS) study is a retrospectively conducted, multicenter, open registry. All patients undergoing mesial temporal lobe epilepsy surgery in participating centers between January 2015 and December 2019 are included in this study. The patient characteristics, preoperative diagnostic tools, surgical data, postoperative complications, and long-term seizure outcomes are recorded. Outcomes: The collected data will be used for establishing standardized reference values ("benchmarks") for this type of surgical procedure. The primary endpoints include seizure outcomes according to the International League Against Epilepsy (ILAE) classification and defined postoperative complications. Discussion: The EASINESS will define robust and standardized outcome references after amygdalohippocampectomy for temporal lobe epilepsy. After the successful definition of benchmarks from an international cohort of renowned centers, these data will serve as reference values for the evaluation of novel surgical techniques and comparisons among centers for future clinical trials. Clinical trial registration: This study is indexed at clinicaltrials.gov (NT 04952298).
View details for DOI 10.3389/fneur.2021.782666
View details for PubMedID 34966349
View details for PubMedCentralID PMC8710656
Impact of acute kidney injury after extended liver resections.
HPB : the official journal of the International Hepato Pancreato Biliary Association
2021; 23 (7): 1000-1007
Complex liver resection is a risk factor for the development of AKI, which is associated with increased morbidity and mortality. Aim of this study was to assess risk factors for acute kidney injury (AKI) and its impact on outcome for patients undergoing complex liver surgery.AKI was defined according to the KDIGO criteria. Primary endpoint was the occurrence of AKI after liver resection. Secondary endpoints were complications and mortality.Overall, 146 patients undergoing extended liver resection were included in the study. The incidence of AKI was 21%. The incidence of chronic kidney disease (CKD) and hepatocellular carcinoma were significantly higher in patients with AKI. In the AKI group, the proportion of extended right hepatectomies was the highest (53%), followed by ALPPS (43%). Increased intraoperative blood loss, increased postoperative complications and perioperative mortality was associated with AKI. Besides age and CKD, ALPPS was an independent risk factor for postoperative AKI. A small future liver remnant seemed to increase the risk of AKI in patients undergoing ALPPS.Following extended liver resection, AKI is associated with an increased morbidity and mortality. ALPPS is a major independent risk factor for the development of AKI and a sufficient future liver remnant could avoid postoperative AKI.
View details for DOI 10.1016/j.hpb.2020.10.015
View details for PubMedID 33191106
The clinical relevance of the Hippo pathway in pancreatic ductal adenocarcinoma.
Journal of cancer research and clinical oncology
2021; 147 (2): 373-391
The Hippo pathway has broadened in cancer research in the past decade and revealed itself to be an important driver for tumorigenesis and metastatic spread. In this study, we investigated the clinical relevance of the Hippo pathway with regard to metastatic invasion, patients' outcome and histopathological features.Protein expression of components of the Hippo pathway were analyzed by immunohistochemistry (IHC) using paraffin-embedded tissue from 103 patients who had been diagnosed with pancreatic ductal adenocarcinoma and had undergone surgery. Results were correlated with clinicopathological data, disease-free and overall survival.Immunohistochemistry studies in pancreatic tumour tissues revealed a significant upregulation of MST1, MST2, pLATS, pYAP and 14-3-3, representing the active Hippo pathway, in non-metastasized patients (p < 0.01). In turn, the pathway is more inactive in metastasized patients and relating liver metastases as LATS1, LATS2, YAP, transcriptional factors TEAD2 and TEAD3 were upregulated in these patients (p < 0.01). A higher pYAP expression was associated with a favorable OS and DFS.The Hippo pathway is inactive in metastasized patients releasing the pro-metastatic and proliferative potential of the pathway. Furthermore, our study underlines the prognostic relevance of the Hippo pathway as a shift in the balance towards the inactive pathway predicts an unfavorable OS and DFS.
View details for DOI 10.1007/s00432-020-03427-z
View details for PubMedID 33098447
View details for PubMedCentralID PMC7817599
Association of subcellular localization of TEAD transcription factors with outcome and progression in pancreatic ductal adenocarcinoma.
Pancreatology : official journal of the International Association of Pancreatology (IAP) ... [et al.]
2021; 21 (1): 170-179
Transcriptional enhanced associated domain (TEAD) transcription factors are nuclear effectors of several oncogenic signalling pathways including Hippo, WNT, TGF-ß and EGFR pathways that interact with various cancer genes. The subcellular localization of TEAD regulates the functional output of these pathways affecting tumour progression and patient outcome. However, the impact of the TEAD family on pancreatic ductal adenocarcinoma (PDAC) and its clinical progression remain elusive.A cohort of 81 PDAC patients who had undergone surgery was established. Cytoplasmic and nuclear localization of TEAD1, TEAD2, TEAD3 and TEAD4 was evaluated with the immunoreactive score (IRS) by immunohistochemistry (IHC) using paraffin-embedded tissue. Results were correlated with clinicopathological data, disease-free and overall survival.Nuclear staining of all four TEADs was increased in pancreatic cancer tissue. Patients suffering from metastatic disease at time of surgery showed a strong nuclear staining of TEAD2 and TEAD3 (p < 0.05). Furthermore, a nuclear > cytoplasmic ratio of TEAD2 and TEAD3 was associated with a shorter overall survival and TEAD2 emerged as an independent prognostic factor for disease-free survival.Our study underlines the importance of TEAD transcription factors in PDAC as a nuclear localization was found to be associated with metastatic disease and an unfavourable prognosis after surgical resection.
View details for DOI 10.1016/j.pan.2020.12.003
View details for PubMedID 33317954
Establishing a student-run free clinic in a major city in Northern Europe: a 1-year experience from Hamburg, Germany.
Journal of public health (Oxford, England)
2020; 42 (4): 793-798
Student-Run Free Clinics (SRFCs) have been an integral part of US medical schools since the 1960s and provide health care to underserved populations. In 2018, we established an SRFC in Hamburg, Germany, a major city in Northern Europe. The aim of this study was to describe the central problems and to investigate the usefulness of an SRFC in a country with free access to medical care, such as Germany.All consecutive patients treated at the SRFC Hamburg between February 2018 and March 2019 that consented to this study were analyzed regarding clinical characteristics, diagnosis, readmission rate and country of origin.Between February 2018 and March 2019, 229 patients were treated at the SRFC in Hamburg. The patients came from 33 different countries with a majority (n = 206, 90%) from countries inside the European Union. The most common reasons for visiting the SRFC were infections (23.2%), acute or chronic wounds (13.5%) and fractures (6.3%).Our multicultural patients suffer mainly from infections and traumatological and dermatological diseases. We find similarities to published Canadian SRFC patient cohorts but differences in diseases and treatment modalities compared to US SRFCs. Importantly, we demonstrate the relevance and necessity of the SRFC in a major city in Northern Europe.
View details for DOI 10.1093/pubmed/fdz165
View details for PubMedID 31840742
View details for PubMedCentralID PMC7685854
Involvement of Medical Students During the Coronavirus Disease 2019 Pandemic: A Cross-Sectional Survey Study.
2020; 12 (8): e10147
The coronavirus disease 2019 (COVID-19) pandemic affects the education of medical students around the world and countries have had differing responses in dealing with this dynamic situation. The role of medical students in fighting this pandemic is controversial and it is yet to be elucidated how they can best be of service. The aim of this study is to evaluate the working fields of volunteering students and the impact of the pandemic on final year students from a student's perspective.An anonymous online survey was conducted amongst 219 medical students from Hamburg (Germany), using an institutional online data collection program.A total of 137 questionnaires (63.5%) were completed. Of these, 97 participants were students from academic year three to five (70.8%) and 40 students were in the final year of medical school (29.2%). Of the 97 students from academic year three to five, 68 students (70.1%) signed up for voluntary duties during the pandemic. Interestingly, only 25.0% of the students were called for voluntary work in hospitals or health authorities. Final year students had already been working in hospitals since before the outbreak, with 35.0% of them assisting doctors in the treatment of COVID-19 positive patients during their placements. Using a 5-Point Likert Scale, the students who volunteered self-assessed their work as more useful and received more gratitude than final year students (p<0.01).The majority of medical students are willing to make a significant contribution in the response to COVID-19 and do not wish to be overlooked. Furthermore, the current pandemic offers novel educational opportunities for medical students.
View details for DOI 10.7759/cureus.10147
View details for PubMedID 33014645
View details for PubMedCentralID PMC7526758
Significance of unphosphorylated and phosphorylated heat shock protein 27 as a prognostic biomarker in pancreatic ductal adenocarcinoma.
Journal of cancer research and clinical oncology
2020; 146 (5): 1125-1137
Few studies reported about the potential of unphosphorylated heat shock protein 27 (HSP27) and phosphorylated heat shock protein 27 (pHSP27) as a predictor for survival and gemcitabine resistance in pancreatic ductal adenocarcinoma (PDAC). In this study, we analysed the expression patterns of pHSP27 and HSP27 in a patient population after surgery and correlated the immunohistochemical results with clinicopathological data and long-term outcome of the patients.HSP27 and pHSP27 (Ser-15, Ser-78 and Ser-82) protein expression were analysed by immunohistochemistry using the immunoreactive score (IRS) from paraffin-embedded tissue of 106 patients with PDAC who underwent surgery. Immunohistochemical results were correlated with clinicopathological data, disease-free (DFS) and overall survival (OS).HSP27 expression was significantly lower in patients with a shorter OS (p = 0.006) and DFS (p < 0.0001). A higher HSP27 expression was associated with a better response to gemcitabine in the resected, non-metastasised patients group (p = 0.001). Furthermore, HSP27 was downregulated in patients suffering from metastases at time of surgery (p < 0.001) and in undifferentiated tumours (p = 0.007). In contrast, pHSP27-Ser15, -Ser78 and -Ser82 were not associated with any survival data of the study population.HSP27 seems to be a strong indicator for the prediction of OS and DFS. Moreover, HSP27 could play a role in the formation and migration of liver metastases of PDAC.
View details for DOI 10.1007/s00432-020-03175-0
View details for PubMedID 32200459
View details for PubMedCentralID PMC7142055