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. 2025 Nov 7;21:651. doi: 10.1186/s12917-025-05096-x

Successful surgical removal of a retroperitoneal paraganglioma in the celiac artery trifurcation in a dog

Kyosuke Takeuchi 1, Kenji Hosoya 1,✉, Ryo Owaki 2, Ryohei Kinoshita 1, Sangho Kim 1, Masahiro Okumura 2
PMCID: PMC12598821  PMID: 41204159

Abstract

Background

Paraganglioma (PGL) is a general term for tumors that originate in the paraganglia in dogs, most commonly reported in the carotid and aortic bodies. Reports on surgical treatment are rare because these tumors develop near large blood vessels, and their prognosis remains unclear. In dogs, the indications for and safety of surgical procedures involving the celiac artery (CA) root and the dissection of its major branches have not been established. To the best of our knowledge, this is the first reported case of CA root involvement in canine PGL.

Case presentation

Surgery was performed on day 84 to remove a PGL tumor. The mass was firmly attached to the left lobe of the pancreas, portal vein, CA, and cranial mesenteric artery (CMA). Therefore, a combined resection was performed, including the spleen, left lobe of the pancreas, and left hepatic lymph nodes. Among the main branches of the CA, the splenic and left gastric arteries could not be separated and were transected. Consequently, the stomach wall became ischemic, and reduced pulsation of the left gastric and omental arteries was observed. To maintain blood supply, the common hepatic artery was preserved. After normalization of the stomach wall color, the CMA was separated from the mass, and the tumor was removed. Pathological examination confirmed that the mass was a PGL, with no metastasis to the hepatic lymph nodes. A computed tomography scan on day 265 revealed that blood flow in the common hepatic artery, portal vein, and left gastric region was well maintained. As of day 279, there was no evidence of metastasis or recurrence, and the patient remained in good condition.

Conclusions

In this case, the main branches of the CA, except for the common hepatic artery, were transected to remove the mass; however, the patient was discharged without serious complications. This is attributable to recovery of blood flow from collateral routes. Considering this blood flow recovery and that intraoperative gastric ischemia was temporary, complete ligation of the CA root may be acceptable in some cases. Additionally, the prognosis for PGL was favorable when complete resection was achieved.

Keywords: Paraganglioma, Celiac artery, Cranial mesenteric artery, Prognosis, Surgical resection, Collateral circulation

Background

Paraganglioma (PGL) is a general term used to describe neuroendocrine tumors originating in the paraganglia [1]. These tumors can arise in multiple areas throughout the body, including the adrenal medulla, the aortic, carotid, and vagus nerve bodies, the abdominal cavity, and the retroperitoneum. They are classified based on their development as having either sympathetic or parasympathetic origins [1, 2]. Paraganglia are collections of neuroendocrine cells that differentiate from neural crest cells during fetal life and form in close proximity to the autonomic nervous system. Pheochromocytomas are neuroendocrine tumors that originate from the sympathetic cystic ganglia in the adrenal medulla but are distinct from paragangliomas. Paragangliomas, by definition, are neuroendocrine tumors of paraganglionic origin that arise outside the adrenal medulla [1, 2]. Canine paragangliomas mainly develop from the aortic and carotid bodies, which are parasympathetic in origin. These tumors are referred to as heart-based and carotid body tumors, respectively [2]. In contrast, paragangliomas originating in the retroperitoneal cavity are rare compared with those in the head and neck, which is the primary location of sympathetic paragangliomas in humans [3–6]. A retrospective study by Gombert et al. [7] using computed tomography (CT) reported that canine retroperitoneal paragangliomas form along the aorta, consistent with their origin in humans.

Due to the lack of surgical cases of dogs with retroperitoneal paragangliomas treated with surgical resection without resection of major vessels, information regarding prognosis is limited [8, 9]. The celiac artery (CA) is the first artery to branch off the abdominal aorta and is typically divided into three main branches: The common hepatic, left gastric, and splenic arteries. The CA supplies the liver, gallbladder, pancreas, stomach, spleen, and omentum. Anatomically, the CA is continuous with the anterior mesenteric artery (cranial mesenteric artery [CMA]) via the gastroduodenal artery. Because collateral blood vessels form after separation of the CA root in humans, combined resection of the CA is sometimes performed as an extended procedure for CA injury or pancreatic cancer [10, 11]. However, in dogs, the indications for and safety of resecting the CA root and its main branches, excluding the splenic artery, remain unknown. In this study, we describe a case in which combined resection of the main CA branches, excluding the common hepatic artery, was performed for a retroperitoneal paraganglioma that developed between the CA, CMA, posterior vena cava, and portal vein, resulting in a favorable long-term prognosis.

Case presentation

A mixed-breed female dog, 11 years old and weighing 7.2 kg, was brought to a referral veterinarian because the owner recognized increased thirst in the dog. Ultrasonography revealed an intra-abdominal mass of unknown origin; therefore, a CT scan was performed at another facility. Based on the CT results, the referral veterinarian suspected a pancreatic tumor with hepatic lymph node metastasis, and the dog was subsequently referred to the Hokkaido University Veterinary Teaching Hospital (HUVTH) for consultation. Upon examination at HUVTH, the patient exhibited no symptoms, including polydipsia, and was in good general condition. The CT image (Fig. 1) provided by the referral veterinarian was reviewed at HUVTH. The mass (38 × 27 × 35 mm) compressed the portal vein ventrally, positioned between the CA, CMA, and portal vein, and exhibited marked contrast enhancement in the arterial phase. Additionally, the mass was in contact with the surface of the pancreas, but signs of infiltration into the pancreatic parenchyma were absent. The hepatic lymph nodes were not enlarged, and the contrast pattern was normal. We thus determined the absence of lymph node metastasis. Furthermore, no distant metastases were observed. The mass demonstrated marked enhancement in the arterial phase and was located in the midline adjacent to major vessels, suggesting a provisional diagnosis of retroperitoneal paraganglioma rather than pancreatic tumor. Surgical removal of the mass was considered high-risk due to its location. Retrospective studies have suggested that toceranib phosphate may be clinically useful for treating canine paraganglioma [12–14]. Therefore, to reduce the volume of the mass, a preoperative trial using toceranib (Palladia®, Zoetis Japan, Tokyo) was initiated at 2.8 mg/kg orally once daily on a Monday/Wednesday/Friday schedule. An ultrasound examination was performed on day 36. Although no apparent change was observed in the maximum short diameter of the mass, the patient developed acute right forelimb lameness for several days following toceranib phosphate administration, with gradual progression. Orthopedic and neurological examinations revealed no abnormalities, suggesting an adverse event related to toceranib; therefore, the dose was reduced to 2.1 mg/kg on a Monday/Wednesday/Friday schedule, and the patient was monitored. Four days after the dose reduction, the lameness resolved; therefore, toceranib was continued at 2.1 mg/kg on the same schedule, and a CT scan was performed 1 month later to assess the treatment effect. On day 64, the animal remained in good general condition, with no clinical signs observed.

Fig. 1.

Fig. 1

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Three-dimensional reconstruction of the CT scan images: front (a) and right (b) view. CA: celiac artery, CMA: Cranial mesenteric artery, PV: portal vein; CT: computed tomography

Although CT images showed no evidence of distant metastasis, the mass size had apparently increased (48 × 34 × 43 mm). Although the tumor may have grown because the dose of toceranib was reduced to 2.1 mg/kg, surgical therapy was performed after consultation with the owner, and the administration of toceranib was discontinued. The metanephrine fraction of the patient was measured, revealing metanephrine/creatinine and normetanephrine/creatinine levels of 106.3 and 251.6, respectively. Because endocrine testing was performed after the toceranib trial and not at the time of diagnosis, it cannot be ruled out that excessive hormone secretion may have been suppressed by the administration of toceranib, but the endocrine test results suggested that the mass was a non-functional paraganglioma. Consequently, preoperative sympathetic nerve-blocking agents were not administered, and surgery proceeded.

Operative record

On day 82, a laparotomy was performed to remove the mass. Fentanyl 5 µg/kg (Fentanyl Citrate; Daiichi Sankyo Company, Limited, Tokyo, Japan) was administered intravenously as pre-anesthesia medication. Anesthesia was induced by intravenous administration of propofol 10 mg/kg (Propofol Mylan; Mylan Seiyaku, Tokyo, Japan). After endotracheal intubation, anesthesia was maintained with mechanical ventilation using isoflurane (IsoFlo; Zoetis, Parsippany, NJ, USA) and pure oxygen (0.5 L/min) and air (0.5 L/min). For local anesthesia, a paravertebral block at the T8-9, T9-10, and T10-11 levels was performed with levobupivacaine 2 mg/kg (Maruishi Pharmaceutical, Osaka, Japan). For intraoperative and postoperative pain management, fentanyl 5–20 µg/kg/h (Fentanyl Citrate; Daiichi Sankyo Company, Limited, Tokyo, Japan) was provided at a constant infusion rate. For bradycardia during surgery, atropine (Mitsubishi Tanabe Pharma Co., Osaka, Japan) was administered intravenously, and for hypotension, dopamine 5.0 µg/kg/min (Teva Takeda Pharma Ltd., Nagoya, Japan), noradrenaline 0.1–0.4 µg/kg/min (Alfresa Pharma Corp., Osaka, Japan), and vasopressin 1 IU/kg/min (Daiichi Sankyo Company, Limited, Tokyo, Japan) were provided at a constant infusion rate. As an antibiotic, cefazolin 20 mg/kg (Nichi-Iko Pharmaceutical Co., Ltd.) was administered intravenously and re-administered every 90–120 min until the end of surgery.

After positioning the animal in dorsal recumbency, the abdomen was opened using a Mercedes incision. The omentum, including the pancreas, was retracted cranially, the mesentery shared by the transverse colon and duodenum was divided, and the colon was retracted caudally to access the tumor. The tumor compressed the main portal vein trunk ventrally and was centered at the confluence of the portal and gastrosplenic veins. The left lobe of the pancreas was firmly adhered to the ventral aspect of the mass. Dissecting the pancreas from the mass was challenging; therefore, the pancreatic branch to the gastric and splenic veins was ligated with 3 − 0 polyglactin 910 (Johnson & Johnson K.K., Tokyo, Japan), transected, and partially resected using the guillotine method with 3 − 0 polydioxanone (Johnson & Johnson K.K.; Fig. 2). The main trunk of the portal vein was adherent to the mass but was carefully dissected from the mass head, allowing separation of the main trunk of the portal vein from the mass capsule without damage. The capsule structure surrounding the lymph node was preserved because the left hepatic lymph node was located on the ventral surface of the mass near the main trunk of the portal vein. The inflow and outflow vessels were ligated and transected en bloc, and the subsequent procedure was performed with the mass still attached laterally. The gastric and splenic veins adhered to the mass at their junction with the main portal vein; therefore, they were ligated with 2 − 0 nylon (Matsuda Medical Industry Co., Ltd., Tokyo, Japan) and transected. Next, the arterial system was addressed. The left gastric and splenic arteries, which were intertwined within the tumor, could not be preserved. Consequently, the left gastric artery was transected proximally between the tumor and the stomach. The hepatic artery was selectively preserved at the base of the celiac artery on the tumor side, whereas the splenic artery was ligated and transected along with the left gastric artery (Fig. 3). After ligating and transecting the left gastric and splenic arteries, the stomach wall was examined (Fig. 4). The stomach wall became ischemic, the arterial pulse was diminished, and the veins appeared congested. Based on these findings, it was determined that transection of the common hepatic artery would likely result in gastric ischemia, and preservation of the CMA was uncertain. Therefore, the common hepatic artery was preserved, the mass was dissected from the celiac artery, and the omentum was included in the resection. After the gastric wall color normalized, the blood vessels directly supplying the mass from the CMA were ligated and transected, and the mass was removed through the space between the portal vein and the abdominal aorta (Fig. 5).

Fig. 2.

Fig. 2

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Three-dimensional reconstruction from CT images. a A full view of the abdomen to visualize the position of the mass with regards to the surrounding organs. b Left lobe of the pancreas was cut using the guillotine method. b´ Actual surgical photograph corresponding to Fig. 2b. c The gastric and splenic veins that join the main portal vein trunk were ligated. c´ Actual surgical photograph corresponding to Fig. 2c. GSV: gastrosplenic vein, PV: portal vein, SP: spleen, PANC: pancreas, GB: gall bladder.

Fig. 3.

Fig. 3

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Three-dimensional reconstruction generated from preoperative CT scans. AO: aorta, CA: celiac artery, CHA: common hepatic artery, CMA: cranial mesenteric artery, LGA: left gastric artery, SA: splenic artery, red dotted line: ligature site

Fig. 4.

Fig. 4

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Changes in blood flow in the stomach wall. a Before separation of the left gastric artery and left splenic artery. b After separation of the left gastric artery and left splenic artery. CO: colon, PV: portal vein, ST: stomach

Fig. 5.

Fig. 5

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Macroscopic findings of the abdominal cavity after removal of the mass. CO: colon, PV: portal vein, ST: stomach

The tumor, left lobe of the pancreas, spleen, and left hepatic lymph nodes were excised (Fig. 6). After confirming hemostasis, a 6-Fr feeding catheter (Atom Medical Corporation, Saitama, Japan) was placed in the proximal jejunum as an enterostomy tube for early postoperative nutritional management, and a closed suction drain (MEDCON Corporation, Osaka, Japan) was positioned in the abdominal cavity. The wound was closed according to standard practice, completing the surgery. During intraoperative anesthesia management, no sudden blood pressure fluctuations or arrhythmias occurred due to mass manipulation, and neither sympatholytic nor antiarrhythmic drugs were administered.

Fig. 6.

Fig. 6

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Macroscopic findings of the excised mass. PANC: PANC: pancreas, SP: spleen

Postoperative course

Histopathological examination confirmed paraganglioma. The tumor was surrounded by a capsule-like structure, and there was no evidence of invasion beyond the capsule, with complete margins. Additionally, no metastatic lesions were resected in the spleen or liver lymph nodes. One day after surgery, the patient was conscious, and vital signs were stable. However, the patient presented with anorexia, and ultrasound examination revealed a moderate fluid accumulation in the stomach. Blood tests showed increased lipase activity ([LIPA] v-lip-p: 632 IU/L; reference range: 10–160 U/L) and elevated liver enzyme levels (alanine aminotransferase [ALT]: >1,000 IU/L). These findings suggested acute pancreatitis [15–17]. Therefore, oral feeding was not initiated, and the patient was instead fed liquid food (Gastrointestinal Support Low-Fat Liquid, Royal Canin Japan, Tokyo, Japan) via a jejunal tube. Three days after surgery, gastric stagnation improved, but the dog exhibited mild lethargy. A blood test revealed a decreased platelet count (144 × 10³/µL). Ultrasound examination identified a mixed echogenic lesion compressing the stomach from the body to the pyloric region, with no detectable blood flow. To further investigate the lesion pressing on the stomach, a CT scan was performed without anesthesia to assess blood flow in the preserved common hepatic artery and portal vein, the presence of collateral vessels in the left gastric region, and the possibility of infected foci such as liver abscesses. CT images showed that the lesion compressing the stomach was not connected to surrounding tissues, and no blood flow was detected within it. Therefore, it was concluded to be a postoperative blood clot. Blood flow was preserved in the common hepatic artery and portal vein. Additionally, blood was found to flow into the left gastric artery, separated from the mass, via the hepatic artery and right gastric artery, before returning to the left gastric region (Figs. 7 and 8). No other abnormalities were observed. Although lipase activity remained elevated, there were no clinical signs of pancreatitis, and liver enzyme levels normalized seven days after surgery. The blood clot gradually decreased in size, the patient's appetite improved, and the patient was discharged 27 days postoperatively. Subsequent follow-up examinations were conducted at intervals of approximately 1–3 months in collaboration with the referring doctor. CT scans performed at our hospital on postoperative days 265 and 729 showed no evidence of metastasis or recurrence, indicating good recovery.

Fig. 7.

Fig. 7

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Left view of the three-dimensional image constructed from the postoperative CT image. Of the celiac axis, the hepatic artery can be selectively preserved. AO: aorta, CA: celiac artery, CHA: common hepatic artery, CMA: Cranial mesenteric artery, LK: left kidney, PV: portal vein, CVC:caudal vena cava

Fig. 8.

Fig. 8

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Three-dimensional reconstruction generated from postoperative CT scans of the lesser curvature of the stomach. AO: aorta, CA: celiac artery, Car: cardia, CHA: common hepatic artery, CMA: Cranial mesenteric artery, GDA: gastroduodenal artery, LGA: left gastric artery, RK: right kidney, PANC; pancreas

Discussion and conclusions

In humans, retroperitoneal paragangliomas are resistant to chemotherapy and radiotherapy; therefore, curative surgery is considered the primary therapeutic option [6, 18, 19]. Many cases of retroperitoneal paragangliomas present with various clinical symptoms, such as hypertension, abdominal pain, headache, and nausea, which are associated with catecholamine hypersecretion. Preoperative treatment with sympatholytic drugs is generally performed [20]. In dogs, catecholamine hypersecretion is rarely observed in retroperitoneal paragangliomas [21]. In this case, no specific signs suggesting catecholamine hypersecretion were observed in the perioperative period. However, endocrine tests for this case were performed after the toceranib trial, whereas they should have been conducted at the time of diagnosis prior to treatment. Gombert et al. [7] reported high urinary catecholamine levels in a patient with retroperitoneal pheochromocytoma who presented with hypertension. Clinical information on peritoneal paragangliomas in dogs is lacking, and the incidence of clinically problematic catecholamine excess is unclear. In addition, clinical manifestations associated with excessive catecholamine secretion are generally considered unclear and intermittent [22, 23]. Endocrinological tests for pheochromocytoma in dogs have been used to assess plasma and urinary catecholamines and their metabolites, revealing that measurement of the urinary metanephrine fraction is particularly useful for diagnosis [24, 25]. Therefore, endocrine testing may provide information to determine the necessity of medical therapy in paraganglioma patients. However, owing to the lack of evidence regarding the clinical characteristic of canine paragangliomas, monitoring for catecholamine secretion should be a precautionary measure. Retroperitoneal paragangliomas develop along the aorta, potentially making surgical resection high-risk. In this case, the mass was located in a high-risk area; thus, a toceranib trial was performed preoperatively to possibly reduce the volume of the mass. A CT scan performed 2 months after toceranib administration revealed an increase in mass size; therefore, the toceranib trial was discontinued and surgical resection was performed. However, since adverse events related to toceranib occurred in this case, the drug was administered a lower dose for 1 month.

In this case, the mass was located between the CA and CMA and was closely attached to the root of the CA; therefore, iatrogenic damage to the CA and combined resection of the mass were anticipated. Appleby et al. [26] used collateral blood flow from the CMA as an extended operation for patients with gastric cancer and described a surgical technique involving total gastrectomy with transection at the root of the CA and combined splenopancreatic resection [26]. In the procedure by Appleby et al. [26], the primary issue was complications caused by blood flow disorders in the hepatobiliary system after surgery; therefore, it is now rarely performed for gastric cancer. Currently, a modified version of this procedure, which preserves the entire stomach, is being explored as an extended approach for patients with pancreatic cancer [11].

To the best of our knowledge, no surgical procedure involving CA dissection has been reported in dogs. However, in a study by Keskitalo et al. [27], the CA was rendered completely ischemic for 3 h, and the subjects were divided into two groups: One in which collateral blood flow from the CMA was preserved and another in which it was blocked. The study examined changes in CA blood pressure, collateral blood flow from the CMA, and histopathological findings in the organs supplied by the CA following ischemia. In both groups, the findings suggested that the stomach and liver were more susceptible to the effects of impaired blood flow than other organs. In the group with preserved collateral blood flow, gastric mucosal edema, peritoneal inflammation, and degenerative and necrotic changes in the liver were observed in approximately half of the cases. However, because the duration of CA ischemia was 3 h, and in the group with preserved collateral blood flow, the collateral blood flow from the CMA and CA blood pressure increased over time, it remains unclear whether permanent CA ischemia would exacerbate ischemic damage to the liver and stomach. Hoosgod et al. [28] and Becker et al. [29] investigated the effects of isolating the main branches of the CA (splenic, left gastric, and common hepatic arteries) on gastric blood flow in dogs. Hoosgod et al. [28] reported that after transection of the splenic, short gastric, and left gastric omental arteries, blood flow in the right gastric omental artery increased, suggesting compensation for the blood supply to the left gastric region, which was originally perfused by the short and left gastric omental arteries. Becker et al. [29] reported that when only the right gastric artery was preserved, while the common hepatic and splenic arteries were intact, blood flow in the muscular layer of the gastric fundus was reduced by approximately 40%. In this case, the splenic, left gastric, short gastric, and left and right gastric omental arteries were divided, resulting in a greater number of blocked gastric arteries compared with those reported by Hoosgod et al. [28] and Becker et al. [29]. Blood flow from the celiac artery was supplied via the right gastric artery from the common hepatic artery, raising concerns about compromised blood flow in the left gastric region. Intraoperatively, no notable macroscopic changes in the gastric wall were observed when the short gastric, and left and right gastric omental arteries were transected. However, after transection of the left gastric artery, the stomach wall became ischemic, and arterial pulsation decreased. Furthermore, because preservation of the CMA was uncertain, we decided to selectively preserve the common hepatic artery. In actual surgery, it is important to understand the vascular anatomy of each individual case beforehand, simulate the risk of vascular damage during tumor resection, and evaluate the predicted discrete collateral blood flow following actual vascular transection during surgery. Incidentally, the ischemic changes in the stomach wall after left gastric and splenic artery dissection improved over time during surgery, possibly due to transient alterations in the stomach wall following arterial blockage or increased collateral blood flow from the CMA. Furthermore, we could not rule out the suitability of CA dissection.

The gastric stagnation observed on the day after surgery was likely due to a temporary decrease in gastric motility. Possible causes of this decrease in motility include postoperative peritonitis, gastric wall edema due to vascular transection, and pancreatitis. Ischemic gastritis, however, is a rare and highly fatal disease that occurs in humans due to surgical ligation of major arteries or veins or embolism caused by sepsis or shock [30]. In this case, gastric stagnation improved three days after surgery, making ischemic gastritis unlikely, and it did not develop into a clinical concern. Additionally, ALT and LIPA levels were markedly increased on the first postoperative day; however, postoperative imaging showed no abnormalities. Elevated ALT and LIPA levels may reflect damage caused by ischemia, even if the collateral circulation of the hepatobiliary system and residual pancreas was preserved on postoperative imaging. It has been reported that in patients with ischemic hepatitis and liver failure caused by occlusion of the celiac artery or mesenteric artery, liver enzyme levels decrease several days after hepatic blood flow is restored by surgical reconstruction or stent placement [31, 32]. In this case, liver enzyme levels also returned to normal levels seven days after surgery. Although no abnormalities were found upon CT scanning, it was performed three days after surgery, such that hepatic blood flow may have had recovered during that time. ALT levels normalized by postoperative day 7, and pancreatitis was managed with supportive care, making these findings clinically acceptable.

In humans, surgical techniques involving preoperative embolization have been reported to promote collateral blood flow, thereby preventing blood flow disorders in the stomach and biliary system following CA dissection [33]. Additionally, techniques that preserve the left gastric artery by assessing the branching pattern of the CA and the localization of the mass have been described [34]. In this case, no severe postoperative complications occurred. However, the safety and indications for multiple CA system dissections, including surgical procedures, should be carefully considered to prevent blood flow disorders in dogs.

In humans, retroperitoneal paragangliomas exhibit greater malignancy than pheochromocytomas and other paragangliomas [35, 36], with metastases frequently occurring in regional and distant lymph nodes, the liver, bone, and lungs, and a maximum reported metastasis rate of 66% [3, 37, 38]. In dogs, metastatic lesion formation has been suggested in a few cases [39, 40]. However, in other reported cases, metastatic lesions have not been detected, and no recurrence or metastasis has been reported following treatment when surgical resection was relatively straightforward [8, 9].

In this case, histopathological examination revealed no invasion into adjacent organs or lymph node metastasis, and the patient remained well 729 days postoperatively. Therefore, surgical therapy may achieve a long-term prognosis in paragangliomas without metastasis or invasion, but further cases are needed to confirm this indication. 

Acknowledgements

We would like to thank Editage (www.editage.jp) for English language editing.

Abbreviations

PGL

Paraganglioma

CA

Celiac artery

CMA

Cranial mesenteric artery

CT

Computed tomography

PV

Portal vein

GDA

Gastroduodenal artery

LGA

Left gastric artery

RK

Right kidney

PANC

Pancreas

AO

Aorta

Car

Cardia

CHA

Common hepatic artery

GSV

Gastrosplenic vein

SP

Spleen

Authors’ contributions

KT contributed to the treatment of cases and the writing of the manuscript. KH contributed to the treatment of cases, writing, and editing of the manuscript. MO, RK, RO, and SK contributed to the treatment of the cases in an adjunct role. All authors read and approved of the final manuscript.

Funding

This study did not receive any funding.

Data availability

All data generated or analyzed during this study are included in this published article.

Declarations

Ethics approval and consent to participate

The patient’s owner has consented to the release of clinical information by signing a written informed consent form.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Data Availability Statement

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