{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T05:41:17Z","timestamp":1791438077302,"version":"4.3.3"},"reference-count":20,"publisher":"Springer Science and Business Media LLC","issue":"7","license":[{"start":{"date-parts":[[2021,1,13]],"date-time":"2021-01-13T00:00:00Z","timestamp":1610496000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2021,1,13]],"date-time":"2021-01-13T00:00:00Z","timestamp":1610496000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"name":"Projekt DEAL"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Cancer Immunol Immunother"],"published-print":{"date-parts":[[2021,7]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Merkel cell carcinoma (MCC) is a rare and aggressive neuroendocrine cutaneous malignancy with poor prognosis. In Europe, approved systemic therapies are limited to the PD-L1\u00a0inhibitor avelumab. For avelumab-refractory patients, efficient and safe treatment options are lacking.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>At three different sites in Germany, clinical and molecular data of patients with metastatic MCC being refractory to the PD-L1 inhibitor avelumab and who were later on treated with combined IPI\/NIVO were retrospectively collected and evaluated.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Five patients treated at three different academic sites in Germany were enrolled. Three out of five patients investigated for this report responded to combined IPI\/NIVO according to RECIST 1.1. Combined immunotherapy was well tolerated without any grade II or III immune-related adverse events. Two out of three responders to IPI\/NIVO received platinum-based chemotherapy in between avelumab and combined immunotherapy.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>In this small retrospective study, we observed a high response rate and durable responses to subsequent combined immunotherapy with IPI\/NIVO in avelumab-refractory metastatic MCC patients. In conclusion, our data suggest a promising activity of second- or third-line PD-1- plus CTLA-4-blockade in patients with anti-PD-L1-refractory MCC.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00262-020-02832-0","type":"journal-article","created":{"date-parts":[[2021,1,13]],"date-time":"2021-01-13T19:56:58Z","timestamp":1610567818000},"page":"2087-2093","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":43,"title":["Activity of ipilimumab plus nivolumab in avelumab-refractory Merkel cell carcinoma"],"prefix":"10.1007","volume":"70","author":[{"given":"Valerie","family":"Glutsch","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hermann","family":"Kneitz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anja","family":"Gesierich","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthias","family":"Goebeler","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sebastian","family":"Haferkamp","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J\u00fcrgen C.","family":"Becker","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Selma","family":"Ugurel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8859-4103","authenticated-orcid":false,"given":"Bastian","family":"Schilling","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2021,1,13]]},"reference":[{"issue":"11","key":"2832_CR1","doi-asserted-by":"publisher","first-page":"3564","DOI":"10.1245\/s10434-016-5266-4","volume":"23","author":"KL Harms","year":"2016","unstructured":"Harms KL, Healy MA, Nghiem P, Sober AJ, Johnson TM, Bichakjian CK, Wong SL (2016) Analysis of prognostic factors from 9387 Merkel Cell carcinoma cases forms the basis for the new 8th edition AJCC staging system. Ann Surg Oncol 23(11):3564\u20133571. https:\/\/doi.org\/10.1245\/s10434-016-5266-4","journal-title":"Ann Surg Oncol"},{"key":"2832_CR2","doi-asserted-by":"publisher","first-page":"17077","DOI":"10.1038\/nrdp.2017.77","volume":"3","author":"JC Becker","year":"2017","unstructured":"Becker JC, Stang A, DeCaprio JA, Cerroni L, Lebbe C, Veness M, Nghiem P (2017) Merkel cell carcinoma. Nat Rev Dis Primers 3:17077. https:\/\/doi.org\/10.1038\/nrdp.2017.77","journal-title":"Nat Rev Dis Primers"},{"issue":"10","key":"2832_CR3","doi-asserted-by":"publisher","first-page":"1374","DOI":"10.1016\/S1470-2045(16)30364-3","volume":"17","author":"HL Kaufman","year":"2016","unstructured":"Kaufman HL, Russell J, Hamid O, Bhatia S, Terheyden P, D\u2019Angelo SP, Shih KC, Lebbe C, Linette GP, Milella M, Brownell I, Lewis KD, Lorch JH, Chin K, Mahnke L, von Heydebreck A, Cuillerot JM, Nghiem P (2016) Avelumab in patients with chemotherapy-refractory metastatic Merkel cell carcinoma: a multicentre, single-group, open-label, phase 2 trial. Lancet Oncol 17(10):1374\u20131385. https:\/\/doi.org\/10.1016\/S1470-2045(16)30364-3","journal-title":"Lancet Oncol"},{"issue":"26","key":"2832_CR4","doi-asserted-by":"publisher","first-page":"2542","DOI":"10.1056\/NEJMoa1603702","volume":"374","author":"PT Nghiem","year":"2016","unstructured":"Nghiem PT, Bhatia S, Lipson EJ, Kudchadkar RR, Miller NJ, Annamalai L, Berry S, Chartash EK, Daud A, Fling SP, Friedlander PA, Kluger HM, Kohrt HE, Lundgren L, Margolin K, Mitchell A, Olencki T, Pardoll DM, Reddy SA, Shantha EM, Sharfman WH, Sharon E, Shemanski LR, Shinohara MM, Sunshine JC, Taube JM, Thompson JA, Townson SM, Yearley JH, Topalian SL, Cheever MA (2016) PD-1 blockade with pembrolizumab in advanced Merkel-cell carcinoma. N Engl J Med 374(26):2542\u20132552. https:\/\/doi.org\/10.1056\/NEJMoa1603702","journal-title":"N Engl J Med"},{"issue":"9","key":"2832_CR5","doi-asserted-by":"publisher","first-page":"693","DOI":"10.1200\/JCO.18.01896","volume":"37","author":"P Nghiem","year":"2019","unstructured":"Nghiem P, Bhatia S, Lipson EJ, Sharfman WH, Kudchadkar RR, Brohl AS, Friedlander PA, Daud A, Kluger HM, Reddy SA, Boulmay BC, Riker AI, Burgess MA, Hanks BA, Olencki T, Margolin K, Lundgren LM, Soni A, Ramchurren N, Church C, Park SY, Shinohara MM, Salim B, Taube JM, Bird SR, Ibrahim N, Fling SP, Homet Moreno B, Sharon E, Cheever MA, Topalian SL (2019) Durable tumor regression and overall survival in patients with advanced Merkel cell carcinoma receiving pembrolizumab as first-line therapy. J Clin Oncol 37(9):693\u2013702. https:\/\/doi.org\/10.1200\/JCO.18.01896","journal-title":"J Clin Oncol"},{"issue":"9","key":"2832_CR6","doi-asserted-by":"publisher","first-page":"e180077","DOI":"10.1001\/jamaoncol.2018.0077","volume":"4","author":"SP D\u2019Angelo","year":"2018","unstructured":"D\u2019Angelo SP, Russell J, Lebb\u00e9 C, Chmielowski B, Gambichler T, Grob J-J, Kiecker F, Rabinowits G, Terheyden P, Zwiener I, Bajars M, Hennessy M, Kaufman HL (2018) Efficacy and safety of first-line avelumab treatment in patients with stage IV metastatic merkel cell carcinoma: a preplanned interim analysis of a clinical trial. JAMA Oncol 4(9):e180077\u2013e180077. https:\/\/doi.org\/10.1001\/jamaoncol.2018.0077","journal-title":"JAMA Oncol"},{"issue":"1","key":"2832_CR7","doi-asserted-by":"publisher","first-page":"170","DOI":"10.1186\/s40425-019-0661-6","volume":"7","author":"J LoPiccolo","year":"2019","unstructured":"LoPiccolo J, Schollenberger MD, Dakhil S, Rosner S, Ali O, Sharfman WH, Silk AW, Bhatia S, Lipson EJ (2019) Rescue therapy for patients with anti-PD-1-refractory Merkel cell carcinoma: a multicenter, retrospective case series. J Immunother Cancer 7(1):170. https:\/\/doi.org\/10.1186\/s40425-019-0661-6","journal-title":"J Immunother Cancer"},{"issue":"14","key":"2832_CR8","doi-asserted-by":"publisher","first-page":"1263","DOI":"10.2217\/fon-2017-0072","volume":"13","author":"P Nghiem","year":"2017","unstructured":"Nghiem P, Kaufman HL, Bharmal M, Mahnke L, Phatak H, Becker JC (2017) Systematic literature review of efficacy, safety and tolerability outcomes of chemotherapy regimens in patients with metastatic Merkel cell carcinoma. Future Oncol 13(14):1263\u20131279. https:\/\/doi.org\/10.2217\/fon-2017-0072","journal-title":"Future Oncol"},{"issue":"10","key":"2832_CR9","doi-asserted-by":"publisher","first-page":"1667","DOI":"10.1093\/annonc\/mdz230","volume":"30","author":"V Glutsch","year":"2019","unstructured":"Glutsch V, Kneitz H, Goebeler M, Gesierich A, Schilling B (2019) Breaking avelumab resistance with combined ipilimumab and nivolumab in metastatic Merkel cell carcinoma? Ann Oncol 30(10):1667\u20131668. https:\/\/doi.org\/10.1093\/annonc\/mdz230","journal-title":"Ann Oncol"},{"issue":"5866","key":"2832_CR10","doi-asserted-by":"publisher","first-page":"1096","DOI":"10.1126\/science.1152586","volume":"319","author":"H Feng","year":"2008","unstructured":"Feng H, Shuda M, Chang Y, Moore PS (2008) Clonal integration of a polyomavirus in human Merkel cell carcinoma. Science 319(5866):1096\u20131100. https:\/\/doi.org\/10.1126\/science.1152586","journal-title":"Science"},{"issue":"24","key":"2832_CR11","doi-asserted-by":"publisher","first-page":"5228","DOI":"10.1158\/0008-5472.CAN-15-1877","volume":"75","author":"SQ Wong","year":"2015","unstructured":"Wong SQ, Waldeck K, Vergara IA, Schroder J, Madore J, Wilmott JS, Colebatch AJ, De Paoli-Iseppi R, Li J, Lupat R, Semple T, Arnau GM, Fellowes A, Leonard JH, Hruby G, Mann GJ, Thompson JF, Cullinane C, Johnston M, Shackleton M, Sandhu S, Bowtell DD, Johnstone RW, Fox SB, McArthur GA, Papenfuss AT, Scolyer RA, Gill AJ, Hicks RJ, Tothill RW (2015) UV-associated mutations underlie the etiology of mcv-negative Merkel cell carcinomas. Cancer Res 75(24):5228\u20135234. https:\/\/doi.org\/10.1158\/0008-5472.CAN-15-1877","journal-title":"Cancer Res"},{"issue":"18","key":"2832_CR12","doi-asserted-by":"publisher","first-page":"3720","DOI":"10.1158\/0008-5472.CAN-15-0702","volume":"75","author":"PW Harms","year":"2015","unstructured":"Harms PW, Vats P, Verhaegen ME, Robinson DR, Wu YM, Dhanasekaran SM, Palanisamy N, Siddiqui J, Cao X, Su F, Wang R, Xiao H, Kunju LP, Mehra R, Tomlins SA, Fullen DR, Bichakjian CK, Johnson TM, Dlugosz AA, Chinnaiyan AM (2015) The distinctive mutational spectra of polyomavirus-negative Merkel cell carcinoma. Cancer Res 75(18):3720\u20133727. https:\/\/doi.org\/10.1158\/0008-5472.CAN-15-0702","journal-title":"Cancer Res"},{"issue":"6257","key":"2832_CR13","doi-asserted-by":"publisher","first-page":"207","DOI":"10.1126\/science.aad0095","volume":"350","author":"EM Van Allen","year":"2015","unstructured":"Van Allen EM, Miao D, Schilling B, Shukla SA, Blank C, Zimmer L, Sucker A, Hillen U, Foppen MH, Goldinger SM, Utikal J, Hassel JC, Weide B, Kaehler KC, Loquai C, Mohr P, Gutzmer R, Dummer R, Gabriel S, Wu CJ, Schadendorf D, Garraway LA (2015) Genomic correlates of response to CTLA-4 blockade in metastatic melanoma. Science 350(6257):207\u2013211. https:\/\/doi.org\/10.1126\/science.aad0095","journal-title":"Science"},{"key":"2832_CR14","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.20.00201","author":"SL Topalian","year":"2020","unstructured":"Topalian SL, Bhatia S, Amin A, Kudchadkar RR, Sharfman WH, Lebbe C, Delord JP, Dunn LA, Shinohara MM, Kulikauskas R, Chung CH, Martens UM, Ferris RL, Stein JE, Engle EL, Devriese LA, Lao CD, Gu J, Li B, Chen T, Barrows A, Horvath A, Taube JM, Nghiem P (2020) Neoadjuvant nivolumab for patients with resectable Merkel cell carcinoma in the checkmate 358 trial. J Clin Oncol. https:\/\/doi.org\/10.1200\/JCO.20.00201","journal-title":"J Clin Oncol"},{"key":"2832_CR15","doi-asserted-by":"publisher","DOI":"10.1136\/jitc-2020-000674","author":"SP D'Angelo","year":"2020","unstructured":"D\u2019Angelo SP, Bhatia S, Brohl AS, Hamid O, Mehnert JM, Terheyden P, Shih KC, Brownell I, Lebbe C, Lewis KD, Linette GP, Milella M, Georges S, Shah P, Ellers-Lenz B, Bajars M, Guzel G, Nghiem PT (2020) Avelumab in patients with previously treated metastatic Merkel cell carcinoma: long-term data and biomarker analyses from the single-arm phase 2 JAVELIN Merkel 200 trial. J Immunother Cancer. https:\/\/doi.org\/10.1136\/jitc-2020-000674","journal-title":"J Immunother Cancer"},{"issue":"12","key":"2832_CR16","doi-asserted-by":"publisher","first-page":"1916","DOI":"10.1038\/s41591-019-0654-5","volume":"25","author":"D Liu","year":"2019","unstructured":"Liu D, Schilling B, Liu D, Sucker A, Livingstone E, Jerby-Amon L, Zimmer L, Gutzmer R, Satzger I, Loquai C, Grabbe S, Vokes N, Margolis CA, Conway J, He MX, Elmarakeby H, Dietlein F, Miao D, Tracy A, Gogas H, Goldinger SM, Utikal J, Blank CU, Rauschenberg R, von Bubnoff D, Krackhardt A, Weide B, Haferkamp S, Kiecker F, Izar B, Garraway L, Regev A, Flaherty K, Paschen A, Van Allen EM, Schadendorf D (2019) Integrative molecular and clinical modeling of clinical outcomes to PD1 blockade in patients with metastatic melanoma. Nat Med 25(12):1916\u20131927. https:\/\/doi.org\/10.1038\/s41591-019-0654-5","journal-title":"Nat Med"},{"issue":"1","key":"2832_CR17","doi-asserted-by":"publisher","first-page":"3868","DOI":"10.1038\/s41467-018-06300-3","volume":"9","author":"KG Paulson","year":"2018","unstructured":"Paulson KG, Voillet V, McAfee MS, Hunter DS, Wagener FD, Perdicchio M, Valente WJ, Koelle SJ, Church CD, Vandeven N, Thomas H, Colunga AG, Iyer JG, Yee C, Kulikauskas R, Koelle DM, Pierce RH, Bielas JH, Greenberg PD, Bhatia S, Gottardo R, Nghiem P, Chapuis AG (2018) Acquired cancer resistance to combination immunotherapy from transcriptional loss of class I HLA. Nat Commun 9(1):3868. https:\/\/doi.org\/10.1038\/s41467-018-06300-3","journal-title":"Nat Commun"},{"key":"2832_CR18","doi-asserted-by":"publisher","DOI":"10.1002\/ijc.33038","author":"D Caracciolo","year":"2020","unstructured":"Caracciolo D, Riillo C, Arbitrio M, Di Martino MT, Tagliaferri P, Tassone P (2020) Error-prone DNA repair pathways as determinants of immunotherapy activity: an emerging scenario for cancer treatment. Int J Cancer. https:\/\/doi.org\/10.1002\/ijc.33038","journal-title":"Int J Cancer"},{"issue":"1","key":"2832_CR19","doi-asserted-by":"publisher","first-page":"23","DOI":"10.1056\/NEJMoa1504030","volume":"373","author":"J Larkin","year":"2015","unstructured":"Larkin J, Chiarion-Sileni V, Gonzalez R, Grob JJ, Cowey CL, Lao CD, Schadendorf D, Dummer R, Smylie M, Rutkowski P, Ferrucci PF, Hill A, Wagstaff J, Carlino MS, Haanen JB, Maio M, Marquez-Rodas I, McArthur GA, Ascierto PA, Long GV, Callahan MK, Postow MA, Grossmann K, Sznol M, Dreno B, Bastholt L, Yang A, Rollin LM, Horak C, Hodi FS, Wolchok JD (2015) Combined Nivolumab and Ipilimumab or Monotherapy in Untreated Melanoma. N Engl J Med 373(1):23\u201334. https:\/\/doi.org\/10.1056\/NEJMoa1504030","journal-title":"N Engl J Med"},{"issue":"7","key":"2832_CR20","doi-asserted-by":"publisher","first-page":"948","DOI":"10.1016\/S1470-2045(19)30151-2","volume":"20","author":"EA Rozeman","year":"2019","unstructured":"Rozeman EA, Menzies AM, van Akkooi ACJ, Adhikari C, Bierman C, van de Wiel BA, Scolyer RA, Krijgsman O, Sikorska K, Eriksson H, Broeks A, van Thienen JV, Guminski AD, Acosta AT, Ter Meulen S, Koenen AM, Bosch LJW, Shannon K, Pronk LM, Gonzalez M, Ch\u2019ng S, Grijpink-Ongering LG, Stretch J, Heijmink S, van Tinteren H, Haanen J, Nieweg OE, Klop WMC, Zuur CL, Saw RPM, van Houdt WJ, Peeper DS, Spillane AJ, Hansson J, Schumacher TN, Long GV, Blank CU (2019) Identification of the optimal combination dosing schedule of neoadjuvant ipilimumab plus nivolumab in macroscopic stage III melanoma (OpACIN-neo): a multicentre, phase 2, randomised, controlled trial. Lancet Oncol 20(7):948\u2013960. https:\/\/doi.org\/10.1016\/S1470-2045(19)30151-2","journal-title":"Lancet Oncol"}],"container-title":["Cancer Immunology, Immunotherapy"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00262-020-02832-0.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s00262-020-02832-0\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00262-020-02832-0.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,6,11]],"date-time":"2021-06-11T11:08:01Z","timestamp":1623409681000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s00262-020-02832-0"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,1,13]]},"references-count":20,"journal-issue":{"issue":"7","published-print":{"date-parts":[[2021,7]]}},"alternative-id":["2832"],"URL":"https:\/\/doi.org\/10.1007\/s00262-020-02832-0","relation":{},"ISSN":["0340-7004","1432-0851"],"issn-type":[{"value":"0340-7004","type":"print"},{"value":"1432-0851","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,1,13]]},"assertion":[{"value":"28 September 2020","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"14 December 2020","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"13 January 2021","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Compliance with ethical standards"}},{"value":"<i>Valerie Glutsch<\/i> has received honoraria from Bristol-Myers Squibb (BMS) and reports travel support from Novartis, Pierre Fabre Pharmaceuticals, BMS, Merck Sharp and Dohme (MSD) and Sanofi Genzyme; outside the submitted work. <i>Anja Gesierich<\/i> reports advisory roles for BMS, MSD Sharp and Dohme, Novartis, Roche, Pierre Fabre Pharmaceuticals, Pfizer and Sanofi Genzyme, has received honoraria from BMS, MSD Sharp and Dohme, Novartis and Roche, and travel support from BMS, MSD Sharp and Dohme, Novartis, Roche and Pierre Fabre Pharmaceuticals; outside of the submitted work. <i>Sebastian Haferkamp<\/i> is on the advisory board or has received honoraria and travel support from Amgen, Bristol-Myers Squibb, Merck Sharp and Dohme, Novartis, Pierre Fabre, Roche, and Sanofi; outside the submitted work. <i>Selma Ugurel<\/i> declares research support from Bristol-Myers Squibb and Merck Serono; speakers and advisory board honoraria from Bristol-Myers Squibb, Merck Sharp and Dohme, Merck Serono, Novartis and Roche, and travel support from Bristol-Myers Squibb, and Merck Sharp and Dohme. <i>J\u00fcrgen C. Becker<\/i> has received speaker\u2019s bureau honoraria from Amgen, Pfizer, MerckSerono, Recordati and Sanofi, is a paid consultant\/advisory board member\/DSMB member for Boehringer Ingelheim, eTheRNA, InProTher, MerckSerono, Pfizer, 4SC, and Sanofi\/Regeneron. His group receives research grants from Bristol-Myers Squibb, Merck Serono, HTG, IQVIA, and Alcedis. <i>Bastian Schilling<\/i> has received personal honoraria from Bristol-Myers Squibb, Merck Sharpe and Dome, Novartis, Pfizer\/EMD Serono, Pierre Fabre and Roche; has an advisory role for Bristol-Myers Squibb, Merck Sharpe and Dome, Novartis, Pierre Fabre and Roche; and has received research funding from Bristol-Myers Squibb, Merck Sharpe and Dome, and Pierre Fabre, all paid to the institute. The other authors declare no potential conflicts of interest.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}},{"value":"Due to the retrospective nature of the study and the collection of anonymous patient data, informed consent was waived by the Ethics Committee of the University Hospital W\u00fcrzburg.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval"}},{"value":"Not applicable.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent to participate"}},{"value":"Publication of patient photos was approved by written consent.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}}]}}