Endoscopic Management of a Rare Nasal Septal Chondrosarcoma: A Case Report and Literature Review

Endoscopic Management of a Rare Nasal Septal Chondrosarcoma: A Case Report and Literature Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Endoscopic Management of a Rare Nasal Septal Chondrosarcoma: A Case Report and Literature Review JIHENE AYARI, MEZRI SAMEH, TASNIME FEHRI, TLILI KARIMA This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6634464/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Chondrosarcomas are malignant cartilaginous tumors, rarely occurring in the head and neck region. Nasal septal chondrosarcomas are exceptionally uncommon, presenting diagnostic and therapeutic challenges due to their rarity and nonspecific symptoms. Case Presentation: We report a case of a 59-year-old male with a history of type II diabetes mellitus and previous tobacco use, presenting with rotatory vertigo and headaches. Imaging revealed a calcified mass originating from the posterior nasal septum, extending into the nasal cavities and right maxillary sinus. Endoscopic resection was performed, and histopathological analysis confirmed a grade I chondrosarcoma. A second surgery ensured complete excision. Follow-up imaging showed no recurrence. Conclusion: This case underscores the importance of considering chondrosarcoma in differential diagnoses of nasal masses and highlights the efficacy of endoscopic surgical approaches in managing such rare tumors. Oncology Chondrosarcoma Nasal septum Endoscopic surgery Rare tumors Case report Figures Figure 1 Figure 2 Figure 3 Introduction Chondrosarcomas are malignant tumors originating from cartilaginous tissue, accounting for approximately 0.1% of head and neck neoplasms [ 1 ]. Within this subset, nasal septal chondrosarcomas are exceedingly rare, with limited cases documented in the literature [ 2 ]. Due to their rarity and nonspecific clinical presentations, they pose significant diagnostic challenges. This report discusses a rare case of nasal septal chondrosarcoma, detailing the diagnostic process and successful endoscopic management. Case Report A 59-year-old male with a medical history of type II diabetes mellitus, managed with insulin, and a history of tobacco use (ceased 20 years prior), presented with a five-month history of rotatory vertigo and headaches. There were no other associated symptoms. Nasal endoscopy revealed a right choanal obstruction. Vestibular and neurological examinations were unremarkable. A computed tomography (CT) scan, performed to investigate persistent headaches, identified a 26×21 mm calcified mass originating from the posterior bony part of the nasal septum, extending bilaterally into the nasal cavities, causing right choanal obstruction, and involving the medial wall of the right maxillary sinus. Magnetic resonance imaging (MRI) suggested a chondrosarcoma without loco-regional extension. The patient underwent endoscopic surgical resection under general anesthesia. Intraoperative findings included a large tumor originating from the posterior nasal septum, extending into both nasal cavities and obstructing the right nasal cavity. Surgical procedures included resection of the lower and upper parts of the nasal septum, excision of the tumor up to the lower corner and medial wall of the right maxillary sinus, left middle and inferior turbinectomy, right inferior turbinectomy, and right middle maxillectomy. Histopathological examination confirmed a grade I chondrosarcoma, characterized by well-differentiated chondroid territories with medium cellularity and slight atypia, infiltrating the bone. Surgical margins were positive, necessitating a second surgery. The subsequent procedure involved revision of the postero-superior wall of the nasal septum with milling of the vomer, right middle turbinectomy, and excision of the inter-sinuso-nasal wall and the right maxillary sinus. Histological analysis post-second surgery showed nonspecific inflammatory changes with no residual tumor. A thoraco-abdomino-pelvic CT scan revealed no secondary lesions. Follow-up MRI of the facial skeleton, performed three months post-surgery, showed no evidence of recurrence. Discussion Nasal septal chondrosarcomas are rare entities, with limited cases reported, making standardized management protocols scarce [ 2 ]. Clinical presentations are often nonspecific, including nasal obstruction, headaches, and facial pain, leading to potential diagnostic delays [ 3 ]. Imaging modalities like CT and MRI are crucial for assessing the lesion's extent and planning surgical intervention [ 4 ]. Surgical resection with negative margins remains the primary treatment modality. Endoscopic approaches offer advantages such as reduced morbidity and better visualization, especially for tumors confined to the nasal cavity [ 5 ]. In this case, the endoscopic approach facilitated complete tumor excision with preservation of surrounding structures. The role of adjuvant radiotherapy in low-grade chondrosarcomas is controversial and generally reserved for cases with positive margins or unresectable tumors [ 6 ]. Chemotherapy is typically ineffective and not routinely employed [ 1 ]. Regular follow-up with imaging is essential due to the risk of recurrence, even in low-grade tumors. In this patient, no recurrence was observed during the three-month postoperative period. Conclusion This case highlights the importance of considering chondrosarcoma in patients presenting with persistent nasal symptoms and the efficacy of endoscopic surgical approaches in managing such rare tumors. Early diagnosis and complete surgical excision are critical for favorable outcomes. Declarations Patient Consent: Written informed consent was obtained from the patient for publication of this case report and accompanying images. Conflict of Interest: The authors declare no conflicts of interest. Funding: No funding was received for this study. References Gelderblom H, Hogendoorn PCW, Dijkstra SD et al (2008) The clinical approach towards chondrosarcoma. Oncologist 13(3):320–329 Khajavi M, Khoshsirat S, Zangane A (2020) Chondrosarcoma of the nasal septum: Case report. J Otorhinolaryngol Facial Plast Surg 6(1):1–5 Aziz A, Mohamed MAM, Khan MH (2022) A huge chondrosarcoma of the nasal septum. Cureus 14(7):e27532 Sahu PK, Goyal L, Bothra J et al (2020) Chondrosarcoma of nasal cavity: a rare entity. Indian J Surg Oncol 11(Suppl 2):288–292 Mikhailov V et al (2022) Endoscopic endonasal removal of nasal cavity chondrosarcoma extending to the base of the skull: a case report. Precision Cancer Med 5:1–5 Uhl M, Welzel T, Oelmann J et al (2014) Carbon ion therapy for advanced or recurrent skull base chondrosarcoma and chordoma. Radiother Oncol 111(3):321–327 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6634464","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":454659675,"identity":"ec9bfffe-e3dd-4c90-836d-52e83e9019e6","order_by":0,"name":"JIHENE AYARI","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIiWNgGAWjYBACxmYeBOfABxtStRyckcYgwcDADGQm4NOEpIWZhxgtzO28Bx8XVDDIGxw/+/CwTcK2OgaJ/KMbGH/cweMwvmTjGWcYDDecSTc4nJNwW4JBIpntBkPCM3x+MZPmbWNg3HAgjeFw7g+4lsP4tJj/5v3HYL/h/DOGwxYJxGkxY+ZtYEjccANoCwORWoyleY5JJM+88YzhYE/Cbck2nsdmNxLScGsx7D9j+Jmnxsa273wa84cfCbf5+dkTn934YINHSwOYkmBQOAAVYQMRCTg1MDDIwxkNeFSNglEwCkbByAYA28dSnEY04NAAAAAASUVORK5CYII=","orcid":"","institution":"university tunis el manar","correspondingAuthor":true,"prefix":"","firstName":"JIHENE","middleName":"","lastName":"AYARI","suffix":""},{"id":454659676,"identity":"5563886f-b73e-46e4-a6c6-ada70de1b046","order_by":1,"name":"MEZRI SAMEH","email":"","orcid":"","institution":"university tunis elmanar","correspondingAuthor":false,"prefix":"","firstName":"MEZRI","middleName":"","lastName":"SAMEH","suffix":""},{"id":454661936,"identity":"74b237bf-a059-4a66-ae54-0d845e3eea54","order_by":2,"name":"TASNIME FEHRI","email":"","orcid":"","institution":"university tunis elmanar","correspondingAuthor":false,"prefix":"","firstName":"TASNIME","middleName":"","lastName":"FEHRI","suffix":""},{"id":454662006,"identity":"c86dd186-853a-46df-8f63-60ee5ef14876","order_by":3,"name":"TLILI KARIMA","email":"","orcid":"","institution":"university tunis elmanar","correspondingAuthor":false,"prefix":"","firstName":"TLILI","middleName":"","lastName":"KARIMA","suffix":""}],"badges":[],"createdAt":"2025-05-10 11:18:40","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6634464/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6634464/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82609972,"identity":"c2f1d8af-da4a-41f6-9ced-e8a038666f8a","added_by":"auto","created_at":"2025-05-13 10:35:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":78950,"visible":true,"origin":"","legend":"\u003cp\u003eAxial CT scan showing a well-defined, predominantly calcified mass originating from the posterior nasal septum, expanding bilaterally into the nasal cavities and causing right choanal obstruction. The lesion shows heterogeneous density and involvement of the medial wall of the right maxillary sinus.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6634464/v1/c0e376e7b4f311d469ce002a.png"},{"id":82609266,"identity":"2f46eb68-b991-465e-81fc-f0e41368e18c","added_by":"auto","created_at":"2025-05-13 10:27:39","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":233209,"visible":true,"origin":"","legend":"\u003cp\u003eAxial MRI (T2-weighted) image showing a heterogeneous tissue mass arising from the posterior nasal septum with bilateral expansion. No evidence of loco-regional invasion is noted.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6634464/v1/830c0541c3672291ca7b76b8.png"},{"id":82609270,"identity":"aeeace4c-1543-4645-9fcd-0d97ab7564e9","added_by":"auto","created_at":"2025-05-13 10:27:39","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":340086,"visible":true,"origin":"","legend":"\u003cp\u003eHistological section (Hematoxylin \u0026amp; Eosin stain, 40× magnification) illustrating low-grade chondrosarcoma characterized by hyaline cartilage matrix, moderate cellularity, and slight nuclear atypia without mitotic activity.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6634464/v1/087029f9e79819fa52eb19d8.png"},{"id":82609975,"identity":"ea344e89-9375-4a59-90a7-f1e51b65573f","added_by":"auto","created_at":"2025-05-13 10:35:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1102368,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6634464/v1/10f581d0-9dbf-4fa9-afb6-0e40d35d0944.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eEndoscopic Management of a Rare Nasal Septal Chondrosarcoma: A Case Report and Literature Review\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChondrosarcomas are malignant tumors originating from cartilaginous tissue, accounting for approximately 0.1% of head and neck neoplasms [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Within this subset, nasal septal chondrosarcomas are exceedingly rare, with limited cases documented in the literature [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Due to their rarity and nonspecific clinical presentations, they pose significant diagnostic challenges. This report discusses a rare case of nasal septal chondrosarcoma, detailing the diagnostic process and successful endoscopic management.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eA 59-year-old male with a medical history of type II diabetes mellitus, managed with insulin, and a history of tobacco use (ceased 20 years prior), presented with a five-month history of rotatory vertigo and headaches. There were no other associated symptoms. Nasal endoscopy revealed a right choanal obstruction. Vestibular and neurological examinations were unremarkable.\u003c/p\u003e \u003cp\u003eA computed tomography (CT) scan, performed to investigate persistent headaches, identified a 26\u0026times;21 mm calcified mass originating from the posterior bony part of the nasal septum, extending bilaterally into the nasal cavities, causing right choanal obstruction, and involving the medial wall of the right maxillary sinus. Magnetic resonance imaging (MRI) suggested a chondrosarcoma without loco-regional extension.\u003c/p\u003e \u003cp\u003eThe patient underwent endoscopic surgical resection under general anesthesia. Intraoperative findings included a large tumor originating from the posterior nasal septum, extending into both nasal cavities and obstructing the right nasal cavity. Surgical procedures included resection of the lower and upper parts of the nasal septum, excision of the tumor up to the lower corner and medial wall of the right maxillary sinus, left middle and inferior turbinectomy, right inferior turbinectomy, and right middle maxillectomy.\u003c/p\u003e \u003cp\u003eHistopathological examination confirmed a grade I chondrosarcoma, characterized by well-differentiated chondroid territories with medium cellularity and slight atypia, infiltrating the bone. Surgical margins were positive, necessitating a second surgery. The subsequent procedure involved revision of the postero-superior wall of the nasal septum with milling of the vomer, right middle turbinectomy, and excision of the inter-sinuso-nasal wall and the right maxillary sinus. Histological analysis post-second surgery showed nonspecific inflammatory changes with no residual tumor.\u003c/p\u003e \u003cp\u003eA thoraco-abdomino-pelvic CT scan revealed no secondary lesions. Follow-up MRI of the facial skeleton, performed three months post-surgery, showed no evidence of recurrence.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eNasal septal chondrosarcomas are rare entities, with limited cases reported, making standardized management protocols scarce [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Clinical presentations are often nonspecific, including nasal obstruction, headaches, and facial pain, leading to potential diagnostic delays [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Imaging modalities like CT and MRI are crucial for assessing the lesion's extent and planning surgical intervention [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSurgical resection with negative margins remains the primary treatment modality. Endoscopic approaches offer advantages such as reduced morbidity and better visualization, especially for tumors confined to the nasal cavity [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In this case, the endoscopic approach facilitated complete tumor excision with preservation of surrounding structures.\u003c/p\u003e \u003cp\u003eThe role of adjuvant radiotherapy in low-grade chondrosarcomas is controversial and generally reserved for cases with positive margins or unresectable tumors [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Chemotherapy is typically ineffective and not routinely employed [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegular follow-up with imaging is essential due to the risk of recurrence, even in low-grade tumors. In this patient, no recurrence was observed during the three-month postoperative period.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case highlights the importance of considering chondrosarcoma in patients presenting with persistent nasal symptoms and the efficacy of endoscopic surgical approaches in managing such rare tumors. Early diagnosis and complete surgical excision are critical for favorable outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003ePatient Consent:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGelderblom H, Hogendoorn PCW, Dijkstra SD et al (2008) The clinical approach towards chondrosarcoma. Oncologist 13(3):320\u0026ndash;329\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhajavi M, Khoshsirat S, Zangane A (2020) Chondrosarcoma of the nasal septum: Case report. J Otorhinolaryngol Facial Plast Surg 6(1):1\u0026ndash;5\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAziz A, Mohamed MAM, Khan MH (2022) A huge chondrosarcoma of the nasal septum. Cureus 14(7):e27532\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSahu PK, Goyal L, Bothra J et al (2020) Chondrosarcoma of nasal cavity: a rare entity. Indian J Surg Oncol 11(Suppl 2):288\u0026ndash;292\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMikhailov V et al (2022) Endoscopic endonasal removal of nasal cavity chondrosarcoma extending to the base of the skull: a case report. Precision Cancer Med 5:1\u0026ndash;5\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUhl M, Welzel T, Oelmann J et al (2014) Carbon ion therapy for advanced or recurrent skull base chondrosarcoma and chordoma. Radiother Oncol 111(3):321\u0026ndash;327\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"MILITARY HOSPITAL TUNIS","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Chondrosarcoma, Nasal septum, Endoscopic surgery, Rare tumors, Case report","lastPublishedDoi":"10.21203/rs.3.rs-6634464/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6634464/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction: Chondrosarcomas are malignant cartilaginous tumors, rarely occurring in the head and neck region. Nasal septal chondrosarcomas are exceptionally uncommon, presenting diagnostic and therapeutic challenges due to their rarity and nonspecific symptoms.\u003c/p\u003e \u003cp\u003eCase Presentation: We report a case of a 59-year-old male with a history of type II diabetes mellitus and previous tobacco use, presenting with rotatory vertigo and headaches. Imaging revealed a calcified mass originating from the posterior nasal septum, extending into the nasal cavities and right maxillary sinus. Endoscopic resection was performed, and histopathological analysis confirmed a grade I chondrosarcoma. A second surgery ensured complete excision. Follow-up imaging showed no recurrence.\u003c/p\u003e \u003cp\u003eConclusion: This case underscores the importance of considering chondrosarcoma in differential diagnoses of nasal masses and highlights the efficacy of endoscopic surgical approaches in managing such rare tumors.\u003c/p\u003e","manuscriptTitle":"Endoscopic Management of a Rare Nasal Septal Chondrosarcoma: A Case Report and Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-13 10:27:34","doi":"10.21203/rs.3.rs-6634464/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0e4a40f8-dabc-4592-82c3-e76511b518b2","owner":[],"postedDate":"May 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":48343653,"name":"Oncology"}],"tags":[],"updatedAt":"2025-05-13T10:27:35+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-13 10:27:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6634464","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6634464","identity":"rs-6634464","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}