TY - JOUR A1 - Kimpel, Otilia A1 - Schindler, Paul A1 - Schmidt-Pennington, Laura A1 - Altieri, Barbara A1 - Megerle, Felix A1 - Haak, Harm A1 - Pittaway, James A1 - Dischinger, Ulrich A1 - Quinkler, Marcus A1 - Mai, Knut A1 - Kroiss, Matthias A1 - Polat, Bülent A1 - Fassnacht, Martin T1 - Efficacy and safety of radiation therapy in advanced adrenocortical carcinoma JF - British Journal of Cancer N2 - Background International guidelines emphasise the role of radiotherapy (RT) for the management of advanced adrenocortical carcinoma (ACC). However, the evidence for this recommendation is very low. Methods We retrospectively analysed all patients who received RT for advanced ACC in five European centres since 2000. Primary endpoint: time to progression of the treated lesion (tTTP). Secondary endpoints: best objective response, progression-free survival (PFS), overall survival (OS), adverse events, and the establishment of predictive factors by Cox analyses. Results In total, 132 tumoural lesions of 80 patients were treated with conventional RT (cRT) of 50–60 Gy (n = 20) or 20–49 Gy (n = 69), stereotactic body RT of 35–50 Gy (SBRT) (n = 36), or brachytherapy of 12–25 Gy (BT) (n = 7). Best objective lesional response was complete (n = 6), partial (n = 52), stable disease (n = 60), progressive disease (n = 14). Median tTTP was 7.6 months (1.0–148.6). In comparison to cRT\(_{20-49Gy}\), tTTP was significantly longer for cRT\(_{50-60Gy}\) (multivariate adjusted HR 0.10; 95% CI 0.03–0.33; p < 0.001) and SBRT (HR 0.31; 95% CI 0.12–0.80; p = 0.016), but not for BT (HR 0.66; 95% CI 0.22–1.99; p = 0.46). Toxicity was generally mild and moderate with three grade 3 events. No convincing predictive factors could be established. Conclusions This largest published study on RT in advanced ACC provides clear evidence that RT is effective in ACC. KW - adrenal tumours KW - adrenocortical carcinoma (ACC) KW - radiotherapy (RT) Y1 - 2023 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-324411 VL - 128 IS - 4 ER - TY - JOUR A1 - Detomas, Mario A1 - Ritzel, Katrin A1 - Nasi-Kordhishti, Isabella A1 - Wolfsberger, Stefan A1 - Quinkler, Marcus A1 - Losa, Marco A1 - Tröger, Viola A1 - Kroiss, Matthias A1 - Fassnacht, Martin A1 - Vila, Greisa A1 - Honegger, Jürgen Bernd A1 - Reincke, Martin A1 - Deutschbein, Timo T1 - Outcome of CRH stimulation test and overnight 8 mg dexamethasone suppression test in 469 patients with ACTH-dependent Cushing’s syndrome JF - Frontiers in Endocrinology N2 - Objective To evaluate diagnostic accuracy of the corticotropin-releasing hormone (CRH) stimulation test and the overnight 8 mg dexamethasone suppression test (DST) for the differentiation of Cushing’s disease (CD) and ectopic Cushing’s syndrome (ECS). Methods Retrospective study in 6 European centers. Inclusion criteria: patients with a) overt adrenocorticotropin (ACTH)-dependent Cushing’s syndrome at the time of dynamic testing, b) histopathological confirmed tumors and/or c) postoperative biochemical remission and/or adrenal insufficiency. Optimal cut-offs were calculated via receiver operating characteristic (ROC) analysis using CD as reference. Results 469 patients were analyzed [78% females; median age 43 years (IQR 19)]. CRH test and overnight 8 mg DST were performed in 420 [CD, n=394 (94%); ECS, n=26 (6%)] and 237 patients [228 CD (96%), 9 ECS (4%)]. Both tests were performed in 205 patients (44%). The post-CRH %-increase at 30 minutes of both ACTH (cut-off ≥31%, sensitivity 83%, specificity 85%, AUC 0.81) and cortisol (cut-off ≥12%, sensitivity 82%, specificity 89%, AUC 0.86) discriminated best between CD and ECS. A test duration of >60 minutes did not improve diagnostic performance of the CRH test. The optimal cortisol cut-off for the %-suppression during the 8 mg DST was ≥55% (sensitivity 80%, specificity 78%, AUC 0.75). Conclusion The CRH test has equivalent sensitivity but higher specificity than the 8 mg DST and is therefore the test of first choice. The diagnostic outcome of ACTH and cortisol is well comparable, however, sampling beyond 60 minutes post-CRH does not provide diagnostic benefits. KW - ACTH KW - Cushing's disease KW - Cushing’s syndrome KW - CRH stimulation test KW - diagnosis KW - ectopic KW - endogenous hypercortisolism KW - high dose dexamethasone suppression test Y1 - 2022 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-289450 SN - 1664-2392 VL - 13 ER - TY - JOUR A1 - Monteagudo, María A1 - Martínez, Paula A1 - Leandro-García, Luis J. A1 - Martínez-Montes, Ángel M. A1 - Calsina, Bruna A1 - Pulgarín-Alfaro, Marta A1 - Díaz-Talavera, Alberto A1 - Mellid, Sara A1 - Letón, Rocío A1 - Gil, Eduardo A1 - Pérez-Martínez, Manuel A1 - Megías, Diego A1 - Torres-Ruiz, Raúl A1 - Rodriguez-Perales, Sandra A1 - González, Patricia A1 - Caleiras, Eduardo A1 - Jiménez-Villa, Scherezade A1 - Roncador, Giovanna A1 - Álvarez-Escolá, Cristina A1 - Regojo, Rita M. A1 - Calatayud, María A1 - Guadalix, Sonsoles A1 - Currás-Freixes, Maria A1 - Rapizzi, Elena A1 - Canu, Letizia A1 - Nölting, Svenja A1 - Remde, Hanna A1 - Fassnacht, Martin A1 - Bechmann, Nicole A1 - Eisenhofer, Graeme A1 - Mannelli, Massimo A1 - Beuschlein, Felix A1 - Quinkler, Marcus A1 - Rodríguez-Antona, Cristina A1 - Cascón, Alberto A1 - Blasco, María A. A1 - Montero-Conde, Cristina A1 - Robledo, Mercedes T1 - Analysis of telomere maintenance related genes reveals NOP10 as a new metastatic-risk marker in pheochromocytoma/paraganglioma JF - Cancers N2 - One of the main problems we face with PPGL is the lack of molecular markers capable of predicting the development of metastases in patients. Telomere-related genes, such as TERT and ATRX, have been recently described in PPGL, supporting the association between the activation of immortalization mechanisms and disease progression. However, the contribution of other genes involving telomere preservation machinery has not been previously investigated. In this work, we aimed to analyze the prognostic value of a comprehensive set of genes involved in telomere maintenance. For this study, we collected 165 PPGL samples (97 non-metastatic/63 metastatic), genetically characterized, in which the expression of 29 genes of interest was studied by NGS. Three of the 29 genes studied, TERT, ATRX and NOP10, showed differential expression between metastatic and non-metastatic cases, and alterations in these genes were associated with a shorter time to progression, independent of SDHB-status. We studied telomere length by Q-FISH in patient samples and in an in vitro model. NOP10 overexpressing tumors displayed an intermediate-length telomere phenotype without ALT, and in vitro results suggest that NOP10 has a role in telomerase-dependent telomere maintenance. We also propose the implementation of NOP10 IHC to better stratify PPGL patients. KW - pheochromocytoma KW - paraganglioma KW - PPGL KW - telomeres KW - prognostic biomarker KW - ALT KW - TERT KW - ATRX KW - NOP10 Y1 - 2021 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-246321 SN - 2072-6694 VL - 13 IS - 19 ER - TY - JOUR A1 - Basile, Vittoria A1 - Puglisi, Soraya A1 - Altieri, Barbara A1 - Canu, Letizia A1 - Libè, Rossella A1 - Ceccato, Filippo A1 - Beuschlein, Felix A1 - Quinkler, Marcus A1 - Calabrese, Anna A1 - Perotti, Paola A1 - Berchialla, Paola A1 - Dischinger, Ulrich A1 - Megerle, Felix A1 - Baudin, Eric A1 - Bourdeau, Isabelle A1 - Lacroix, André A1 - Loli, Paola A1 - Berruti, Alfredo A1 - Kastelan, Darko A1 - Haak, Harm R. A1 - Fassnacht, Martin A1 - Terzolo, Massimo T1 - What is the optimal duration of adjuvant mitotane therapy in adrenocortical carcinoma? An unanswered question JF - Journal of Personalized Medicine N2 - A relevant issue on the treatment of adrenocortical carcinoma (ACC) concerns the optimal duration of adjuvant mitotane treatment. We tried to address this question, assessing whether a correlation exists between the duration of adjuvant mitotane treatment and recurrence-free survival (RFS) of patients with ACC. We conducted a multicenter retrospective analysis on 154 ACC patients treated for ≥12 months with adjuvant mitotane after radical surgery and who were free of disease at the mitotane stop. During a median follow-up of 38 months, 19 patients (12.3%) experienced recurrence. We calculated the RFS after mitotane (RFSAM), from the landmark time-point of mitotane discontinuation, to overcome immortal time bias. We found a wide variability in the duration of adjuvant mitotane treatment among different centers and also among patients cared for at the same center, reflecting heterogeneous practice. We did not find any survival advantage in patients treated for longer than 24 months. Moreover, the relationship between treatment duration and the frequency of ACC recurrence was not linear after stratifying our patients in tertiles of length of adjuvant treatment. In conclusion, the present findings do not support the concept that extending adjuvant mitotane treatment over two years is beneficial for ACC patients with low to moderate risk of recurrence. KW - mitotane KW - adjuvant treatment KW - adrenocortical cancer KW - recurrence KW - recurrence free survival KW - timing Y1 - 2021 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-236507 SN - 2075-4426 VL - 11 IS - 4 ER - TY - JOUR A1 - Altieri, Barbara A1 - Sbiera, Silviu A1 - Herterich, Sabine A1 - De Francia, Silvia A1 - Della Casa, Silvia A1 - Calabrese, Anna A1 - Pontecorvi, Alfredo A1 - Quinkler, Marcus A1 - Kienitz, Tina A1 - Mannelli, Massimo A1 - Canu, Letizia A1 - Angelousi, Anna A1 - Chortis, Vasileios A1 - Kroiss, Matthias A1 - Terzolo, Massimo A1 - Fassnacht, Martin A1 - Ronchi, Cristina L. T1 - Effects of Germline CYP2W1*6 and CYP2B6*6 Single Nucleotide Polymorphisms on Mitotane Treatment in Adrenocortical Carcinoma: A Multicenter ENSAT Study JF - Cancers N2 - Mitotane is the only approved drug for advanced adrenocortical carcinoma (ACC) and no biomarkers are available to predict attainment of therapeutic plasma concentrations and clinical response. Aim of the study was to evaluate the suitability of cytochrome P450(CYP)2W1 and CYP2B6 single nucleotide polymorphisms (SNPs) as biomarkers. A multicenter cohort study including 182 ACC patients (F/M = 121/61) treated with mitotane monotherapy after radical resection (group A, n = 103) or in not completely resectable, recurrent or advanced disease (group B, n = 79) was performed. CYP2W1*2, CYP2W1*6, CYP2B6*6 and CYP2B6 rs4803419 were genotyped in germline DNA. Mitotane blood levels were measured regularly. Response to therapy was evaluated as time to progression (TTP) and disease control rate (DCR). Among investigated SNPs, CYP2W1*6 and CYP2B6*6 correlated with mitotane treatment only in group B. Patients with CYP2W1*6 (n = 21) achieved less frequently therapeutic mitotane levels (>14 mg/L) than those with wild type (WT) allele (76.2% vs 51.7%, p = 0.051) and experienced shorter TTP (HR = 2.10, p = 0.019) and lower DCR (chi-square = 6.948, p = 0.008). By contrast, 55% of patients with CYP2B6*6 vs. 28.2% WT (p = 0.016) achieved therapeutic range. Combined, a higher rate of patients with CYP2W1*6WT+CYP2B6*6 (60.6%) achieved mitotane therapeutic range (p = 0.034). In not completely resectable, recurrent or advanced ACC, CYP2W1*6 SNP was associated with a reduced probability to reach mitotane therapeutic range and lower response rates, whereas CYP2B6*6 correlated with higher mitotane levels. The association of these SNPs may predict individual response to mitotane. KW - adrenocortical carcinoma KW - mitotane KW - CYP2W1 KW - CYP2B6 KW - SNP KW - biomarker KW - predictive marker Y1 - 2020 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-200565 SN - 2072-6694 VL - 12 IS - 2 ER - TY - JOUR A1 - Zopf, Kathrin A1 - Frey, Kathrin R. A1 - Kienitz, Tina A1 - Ventz, Manfred A1 - Bauer, Britta A1 - Quinkler, Marcus T1 - \(Bcl\)I polymorphism of the glucocorticoid receptor and adrenal crisis in primary adrenal insufficiency JF - Endocrine Connections N2 - Context: Patients with primary adrenal insufficiency (PAI) or congenital adrenal hyperplasia (CAH) are at a high risk of adrenal crisis (AC). Glucocorticoid sensitivity is at least partially genetically determined by polymorphisms of the glucocorticoid receptor (GR). Objectives: To determine if a number of intercurrent illnesses and AC are associated with the GR gene polymorphism \(Bcl\)I in patients with PAI and CAH. Design and patients: This prospective, longitudinal study over 37.7 ± 10.1 months included 47 PAI and 25 CAH patients. During the study period, intercurrent illness episodes and AC were documented. Results: The study period covered 223 patient years in which 21 AC occurred (9.4 AC/100 pat years). There were no significant differences between \(Bcl\)I polymorphisms (CC (n=29), CG (n=34) and GG (n=9)) regarding BMI, hydrocortisone equivalent daily dose and blood pressure. We did not find a difference in the number of intercurrent illnesses/patient year among \(Bcl\)I polymorphisms (CC (1.5±1.4/pat year), CG (1.2±1.2/pat year) and GG (1.6±2.2/pat year)). The occurrence of AC was not significantly different among the homozygous (GG) genotype (32.5 AC/100 pat years), the CC genotype (6.7 AC/100 pat years) and the CG genotype (4.9 AC/100 pat years). Concomitant hypothyroidism was the highest in the GG genotype group (5/9), compared to others (CC (11/29) and CG (11/34)). Conclusions: Although sample sizes were relatively small and results should be interpreted with caution, this study suggests that the GR gene polymorphism \(Bcl\)I may not be associated with the frequencies of intercurrent illnesses and AC. KW - medicine KW - adrenal crisis KW - adrenal insufficiency KW - cortisol KW - hydrocortisone KW - polyglandular autoimmune syndrome Y1 - 2017 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-173276 VL - 6 IS - 8 ER - TY - JOUR A1 - Baur, Johannes A1 - Büntemeyer, Tjark-Ole A1 - Megerle, Felix A1 - Deutschbein, Timo A1 - Spitzweg, Christine A1 - Quinkler, Marcus A1 - Nawroth, Peter A1 - Kroiss, Matthias A1 - Germer, Christoph-Thomas A1 - Fassnacht, Martin A1 - Steger, Ulrich T1 - Outcome after resection of Adrenocortical Carcinoma liver metastases: a retrospective study JF - BMC Cancer N2 - Background: Metastatic Adrenocortical Carcinoma (ACC) is a rare malignancy with a poor 5-year-survival rate (<15%). A surgical approach is recommended in selected patients if complete resection of distant metastasis can be achieved. To date there are only limited data on the outcome after surgical resection of hepatic metastases of ACC. Methods: A retrospective analysis of the German Adrenocortical Carcinoma Registry was conducted. Patients with liver metastases of ACC but without extrahepatic metastases or incomplete tumour resection were included. Results: Seventy-seven patients fulfilled these criteria. Forty-three patients underwent resection of liver metastases of ACC. Complete tumour resection (R0) could be achieved in 30 (69.8%). Median overall survival after liver resection was 76.1 months in comparison to 10.1 months in the 34 remaining patients with unresected liver metastases (p < 0.001). However, disease free survival after liver resection was only 9.1 months. Neither resection status (R0/R1) nor extent of liver resection were significant predictive factors for overall survival. Patients with a time interval to the first metastasis/recurrence (TTFR) of greater than 12 months or solitary liver metastases showed significantly prolonged survival. Conclusions: Liver resection in the case of ACC liver metastases can achieve long term survival with a median overall survival of more than 5 years, but disease free survival is short despite metastasectomy. Time to recurrence and single versus multiple metastases are predictive factors for the outcome. KW - Adrenocortical Carcinoma KW - liver resection KW - retrospective study KW - prognosis KW - survival analysis Y1 - 2017 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-159409 VL - 17 IS - 522 ER - TY - JOUR A1 - Mitchell, Anna L. A1 - Macarthur, Katie D. R. A1 - Gan, Earn H. A1 - Baggott, Lucy E. A1 - Wolff, Anette S. B. A1 - Skinningsrud, Beate A1 - Platt, Hazel A1 - Short, Andrea A1 - Lobell, Anna A1 - Kampe, Olle A1 - Bensing, Sophie A1 - Betterle, Corrado A1 - Kasperlik-Zaluska, Anna A1 - Zurawek, Magdalena A1 - Fichna, Marta A1 - Kockum, Ingrid A1 - Eriksson, Gabriel Nordling A1 - Ekwall, Olov A1 - Wahlberg, Jeanette A1 - Dahlqvist, Per A1 - Hulting, Anna-Lena A1 - Penna-Martinez, Marissa A1 - Meyer, Gesine A1 - Kahles, Heinrich A1 - Badenhoop, Klaus A1 - Hahner, Stephanie A1 - Quinkler, Marcus A1 - Falorni, Alberto A1 - Phipps-Green, Amanda A1 - Merriman, Tony R. A1 - Ollier, William A1 - Cordell, Heather J. A1 - Undlien, Dag A1 - Czarnocka, Barbara A1 - Husebye, Eystein A1 - Pearce, Simon H. S. T1 - Association of Autoimmune Addison's Disease with Alleles of STAT4 and GATA3 in European Cohorts JF - PLOS ONE N2 - Background: Gene variants known to contribute to Autoimmune Addison's disease (AAD) susceptibility include those at the MHC, MICA, CIITA, CTLA4, PTPN22, CYP27B1, NLRP-1 and CD274 loci. The majority of the genetic component to disease susceptibility has yet to be accounted for. Aim: To investigate the role of 19 candidate genes in AAD susceptibility in six European case-control cohorts. Methods: A sequential association study design was employed with genotyping using Sequenom iPlex technology. In phase one, 85 SNPs in 19 genes were genotyped in UK and Norwegian AAD cohorts (691 AAD, 715 controls). In phase two, 21 SNPs in 11 genes were genotyped in German, Swedish, Italian and Polish cohorts (1264 AAD, 1221 controls). In phase three, to explore association of GATA3 polymorphisms with AAD and to determine if this association extended to other autoimmune conditions, 15 SNPs in GATA3 were studied in UK and Norwegian AAD cohorts, 1195 type 1 diabetes patients from Norway, 650 rheumatoid arthritis patients from New Zealand and in 283 UK Graves' disease patients. Meta-analysis was used to compare genotype frequencies between the participating centres, allowing for heterogeneity. Results: We report significant association with alleles of two STAT4 markers in AAD cohorts (rs4274624: P = 0.00016; rs10931481: P = 0.0007). In addition, nominal association of AAD with alleles at GATA3 was found in 3 patient cohorts and supported by meta-analysis. Association of AAD with CYP27B1 alleles was also confirmed, which replicates previous published data. Finally, nominal association was found at SNPs in both the NF-kappa B1 and IL23A genes in the UK and Italian cohorts respectively. Conclusions: Variants in the STAT4 gene, previously associated with other autoimmune conditions, confer susceptibility to AAD. Additionally, we report association of GATA3 variants with AAD: this adds to the recent report of association of GATA3 variants with rheumatoid arthritis. KW - Graves disease KW - identical twins KW - hashimotos-thyroiditis KW - population KW - gene KW - polymorphism KW - susceptibility KW - prevalence KW - haplotype KW - rheumatoid arthritis Y1 - 2014 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-117105 VL - 9 IS - 3 ER - TY - JOUR A1 - Quinkler, Marcus A1 - Beuschlein, Felix A1 - Hahner, Stefanie A1 - Meyer, Gesine A1 - Schöfl, Christof A1 - Stalla, Günter K. T1 - Adrenal Cortical Insufficiency-a Life Threatening Illness With Multiple Etiologies JF - Deutsches Ärzteblatt International N2 - Background: The clinical signs of adrenal cortical insufficiency (incidence, ca. 25 per million per year; prevalence, ca. 400 per million) are nonspecific, and misdiagnoses are therefore common. Glucocorticoid substitution therapy has been in use for 50 years but is not a wholly adequate treatment. Our understanding of this disease remains incomplete in many ways. Methods: We selectively searched the Medline database for publications on adrenal cortical insufficiency, with particular attention to studies from the year 2000 onward (search terms: "adrenal insufficiency" or "Addison's disease" or "hypopituitarism"). Results: Hydrocortisone substitution therapy is often given in doses of 10-25 mg/day, timed according to the circadian rhythm. Gastrointestinal and other, febrile infections account for 30-50% of life-threatening adrenocortical crises. Such crises affect 8 of 100 persons with adrenal cortical insufficiency per year and must be treated by the immediate administration of glucocorticoids and fluids. When persons with adrenal cortical insufficiency are acutely ill or are otherwise under unusual stress, they may need additional amounts of hydrocortisone, often in the range of 5-10 mg but occasionally as high as 200 mg. The sustained administration of excessive amounts of steroid can shorten patients' lives by several years. Inappropriate substitution therapy can cause other major medical conditions, such as metabolic syndrome and osteoporosis. Conclusion: Important measures for the prevention of adrenocortical crises include improved care by treating physicians, education of patients and their families, the provision of emergency identifying documents, and the prescription of glucocorticoid emergency kits. KW - short term KW - subjective health-status KW - modified-release hydrocortisone KW - glucocorticoid replacement regimens KW - Addisons disease KW - therapeutic management KW - hypopituitary patients KW - premature mortality KW - circadian therapy KW - adult patients Y1 - 2013 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-131662 VL - 110 ER - TY - JOUR A1 - Johanssen, Sarah A1 - Hahner, Stefanie A1 - Saeger, Wolfgang A1 - Quinkler, Marcus A1 - Beuschlein, Felix A1 - Dralle, Henning A1 - Haaf, Michaela A1 - Kroiss, Matthias A1 - Jurowich, Christian A1 - Langer, Peter A1 - Oelkers, Wolfgang A1 - Spahn, Martin A1 - Willenberg, Holger S. A1 - Maeder, Uwe A1 - Allolio, Bruno A1 - Fassnacht, Martin T1 - Deficits in the Management of Patients With Adrenocortical Carcinoma in Germany N2 - Background: Adrenocortical carcinoma (ACC) is a rare tumor with a poor prognosis. Often, the physicians who first treat patients with ACC have no prior experience with the disease. The aim of our study was to evaluate the quality of medical care for patients with ACC in Germany. Methods: Data from the German ACC registry were analyzed with regard to the patients’ preoperative diagnostic evaluation, histopathological reporting, and clinical followup. The findings were compared with the recommendations of the European Network for the Study of Adrenal Tumors (ENSAT). Results: Data were analyzed from 387 patients who had been given an initial diagnosis of ACC in the years 1998 to 2009. 21% of them underwent no hormonal evaluation before surgery, and 59% underwent an inadequate hormonal evaluation. This exposed the patients to unnecessary perioperative risks and impaired their follow-up. 48% did not undergo CT scanning of the chest, even though the lungs are the most frequent site of metastases of ACC. For 13% of the patients, the diagnosis of ACC was later revised by a reference pathologist. For 11% of the patients, the histopathology report contained no information about resection status, even though this is an important determinant of further treatment and prognosis. Optimal management requires re-staging at three-month intervals, yet some patients underwent re-staging only after a longer delay, or not at all. Conclusion: We have identified significant deficits in the care of patients with ACC in Germany. We suspect that the situation is similar for other rare diseases. The prerequisite to better care is close and early cooperation of the treating physicians with specialized centers. Y1 - 2010 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-85897 ER -