Skip to main content
Erschienen in: Annals of Surgical Oncology 7/2013

01.07.2013 | Endocrine Tumors

Prophylactic Central Neck Dissection in Differentiated Thyroid Cancer: An Assessment of the Evidence

verfasst von: David E. Gyorki, MD, Brian Untch, MD, R. Michael Tuttle, MD, Ashok R. Shaha, MD

Erschienen in: Annals of Surgical Oncology | Ausgabe 7/2013

Einloggen, um Zugang zu erhalten

Abstract

An area of ongoing controversy in the management of patients with differentiated thyroid cancer is the role of prophylactic central neck dissection (pCND). This review describes the natural history of differentiated thyroid cancer and provides the limited data regarding the role of routine pCND. An evidence-based analysis was performed of the rationale for routine pCND was performed, including reduced rates of central neck recurrence, reduced morbidity with secondary central neck lymphadenectomy, improved rates of postoperative athyroglobulinemia, and improved stratification of radioactive iodine (RAI) dosage. A critical appraisal of the available literature demonstrates insufficient evidence to indicate that this extra procedure performed routinely leads to improvement in clinically meaningful end points.
Literatur
1.
2.
Zurück zum Zitat Davies L, Welch HG. Increasing incidence of thyroid cancer in the United States, 1973–2002. JAMA. 2006;295:2164–7.PubMedCrossRef Davies L, Welch HG. Increasing incidence of thyroid cancer in the United States, 1973–2002. JAMA. 2006;295:2164–7.PubMedCrossRef
3.
Zurück zum Zitat Howlader NA, Krapcho M, Neyman N, et al., eds. SEER cancer statistics review, 1975–2009 (vintage 2009 populations). Bethesda, MD: National Cancer Institute; 2011. Howlader NA, Krapcho M, Neyman N, et al., eds. SEER cancer statistics review, 1975–2009 (vintage 2009 populations). Bethesda, MD: National Cancer Institute; 2011.
4.
Zurück zum Zitat Carling T, Carty SE, Ciarleglio MM, et al. American Thyroid Association design and feasibility of a prospective randomized controlled trial of prophylactic central lymph node dissection for papillary thyroid carcinoma. Thyroid. 2012;22:237–44.PubMedCrossRef Carling T, Carty SE, Ciarleglio MM, et al. American Thyroid Association design and feasibility of a prospective randomized controlled trial of prophylactic central lymph node dissection for papillary thyroid carcinoma. Thyroid. 2012;22:237–44.PubMedCrossRef
5.
Zurück zum Zitat Cooper DS, Doherty GM, Haugen BR, et al. Management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2006;16:109–42.PubMedCrossRef Cooper DS, Doherty GM, Haugen BR, et al. Management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2006;16:109–42.PubMedCrossRef
6.
Zurück zum Zitat Cooper DS, Doherty GM, Haugen BR, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009;19:1167–214.PubMedCrossRef Cooper DS, Doherty GM, Haugen BR, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009;19:1167–214.PubMedCrossRef
7.
Zurück zum Zitat Noguchi M, Yamada H, Ohta N, et al. Regional lymph node metastases in well-differentiated thyroid carcinoma. Int Surg. 1987;72:100–3.PubMed Noguchi M, Yamada H, Ohta N, et al. Regional lymph node metastases in well-differentiated thyroid carcinoma. Int Surg. 1987;72:100–3.PubMed
8.
Zurück zum Zitat Randolph G, Duh QY, Heller KS, et al. The prognostic significance of nodal metastases from papillary thyroid carcinoma can be stratified based on the size and number of metastatic lymph nodes, as well as the presence of extranodal extension. ATA Surgical Affairs Committee’s Taskforce on Thyroid Cancer Nodal Surgery. Thyroid. 2012;22:1144–52.PubMedCrossRef Randolph G, Duh QY, Heller KS, et al. The prognostic significance of nodal metastases from papillary thyroid carcinoma can be stratified based on the size and number of metastatic lymph nodes, as well as the presence of extranodal extension. ATA Surgical Affairs Committee’s Taskforce on Thyroid Cancer Nodal Surgery. Thyroid. 2012;22:1144–52.PubMedCrossRef
9.
Zurück zum Zitat Humphrey RW, Brockway-Lunardi LM, Bonk DT, et al. Opportunities and challenges in the development of experimental drug combinations for cancer. J Natl Cancer Inst. 2011;103:1222–6.PubMedCrossRef Humphrey RW, Brockway-Lunardi LM, Bonk DT, et al. Opportunities and challenges in the development of experimental drug combinations for cancer. J Natl Cancer Inst. 2011;103:1222–6.PubMedCrossRef
10.
Zurück zum Zitat Monchik JM, Simon CJ, Caragacianu DL, et al. Does failure to perform prophylactic level VI node dissection leave persistent disease detectable by ultrasonography in patients with low-risk papillary carcinoma of the thyroid? Surgery. 2009;146:1182–7.PubMedCrossRef Monchik JM, Simon CJ, Caragacianu DL, et al. Does failure to perform prophylactic level VI node dissection leave persistent disease detectable by ultrasonography in patients with low-risk papillary carcinoma of the thyroid? Surgery. 2009;146:1182–7.PubMedCrossRef
11.
Zurück zum Zitat Ito Y, Uruno T, Nakano K, et al. An observation trial without surgical treatment in patients with papillary microcarcinoma of the thyroid. Thyroid. 2003;13:381–7.PubMedCrossRef Ito Y, Uruno T, Nakano K, et al. An observation trial without surgical treatment in patients with papillary microcarcinoma of the thyroid. Thyroid. 2003;13:381–7.PubMedCrossRef
12.
Zurück zum Zitat Ito Y, Miyauchi A, Inoue H, et al. An observational trial for papillary thyroid microcarcinoma in Japanese patients. World J Surg. 2010;34:28–35.PubMedCrossRef Ito Y, Miyauchi A, Inoue H, et al. An observational trial for papillary thyroid microcarcinoma in Japanese patients. World J Surg. 2010;34:28–35.PubMedCrossRef
13.
Zurück zum Zitat Ricarte-Filho J, Ganly I, Rivera M, et al. Papillary thyroid carcinomas with cervical lymph node metastases can be stratified into clinically relevant prognostic categories using oncogenic BRAF, the number of nodal metastases, and extra-nodal extension. Thyroid. 2012;22:575–84.PubMedCrossRef Ricarte-Filho J, Ganly I, Rivera M, et al. Papillary thyroid carcinomas with cervical lymph node metastases can be stratified into clinically relevant prognostic categories using oncogenic BRAF, the number of nodal metastases, and extra-nodal extension. Thyroid. 2012;22:575–84.PubMedCrossRef
14.
Zurück zum Zitat Podnos YD, Smith D, Wagman LD, Ellenhorn JD. The implication of lymph node metastasis on survival in patients with well-differentiated thyroid cancer. Am Surg. 2005;71:731–4.PubMed Podnos YD, Smith D, Wagman LD, Ellenhorn JD. The implication of lymph node metastasis on survival in patients with well-differentiated thyroid cancer. Am Surg. 2005;71:731–4.PubMed
15.
Zurück zum Zitat Zaydfudim V, Feurer ID, Griffin MR, Phay JE. The impact of lymph node involvement on survival in patients with papillary and follicular thyroid carcinoma. Surgery. 2008;144:1070–7.PubMedCrossRef Zaydfudim V, Feurer ID, Griffin MR, Phay JE. The impact of lymph node involvement on survival in patients with papillary and follicular thyroid carcinoma. Surgery. 2008;144:1070–7.PubMedCrossRef
16.
Zurück zum Zitat Carty SE, Cooper DS, Doherty GM, et al. Consensus statement on the terminology and classification of central neck dissection for thyroid cancer. Thyroid. 2009;19:1153–8.PubMedCrossRef Carty SE, Cooper DS, Doherty GM, et al. Consensus statement on the terminology and classification of central neck dissection for thyroid cancer. Thyroid. 2009;19:1153–8.PubMedCrossRef
17.
Zurück zum Zitat Tang JY, Spaunhurst KM, Chlebowski RT, et al. Menopausal hormone therapy and risks of melanoma and nonmelanoma skin cancers: women’s health initiative randomized trials. J Natl Cancer Inst. 2011;103:1469–75.PubMedCrossRef Tang JY, Spaunhurst KM, Chlebowski RT, et al. Menopausal hormone therapy and risks of melanoma and nonmelanoma skin cancers: women’s health initiative randomized trials. J Natl Cancer Inst. 2011;103:1469–75.PubMedCrossRef
18.
Zurück zum Zitat Gemsenjager E, Perren A, Seifert B, et al. Lymph node surgery in papillary thyroid carcinoma. J Am Coll Surg. 2003;197:182–90.PubMedCrossRef Gemsenjager E, Perren A, Seifert B, et al. Lymph node surgery in papillary thyroid carcinoma. J Am Coll Surg. 2003;197:182–90.PubMedCrossRef
19.
Zurück zum Zitat Hughes DT, White ML, Miller BS, et al. Influence of prophylactic central lymph node dissection on postoperative thyroglobulin levels and radioiodine treatment in papillary thyroid cancer. Surgery. 2010;148:1100–6.PubMedCrossRef Hughes DT, White ML, Miller BS, et al. Influence of prophylactic central lymph node dissection on postoperative thyroglobulin levels and radioiodine treatment in papillary thyroid cancer. Surgery. 2010;148:1100–6.PubMedCrossRef
20.
Zurück zum Zitat Moo TA, McGill J, Allendorf J, et al. Impact of prophylactic central neck lymph node dissection on early recurrence in papillary thyroid carcinoma. World J Surg. 2010;34:1187–91.PubMedCrossRef Moo TA, McGill J, Allendorf J, et al. Impact of prophylactic central neck lymph node dissection on early recurrence in papillary thyroid carcinoma. World J Surg. 2010;34:1187–91.PubMedCrossRef
21.
Zurück zum Zitat Moreno MA, Edeiken-Monroe BS, Siegel ER, et al. In papillary thyroid cancer, preoperative central neck ultrasound detects only macroscopic surgical disease, but negative findings predict excellent long-term regional control and survival. Thyroid. 2012;22:347–55.PubMedCrossRef Moreno MA, Edeiken-Monroe BS, Siegel ER, et al. In papillary thyroid cancer, preoperative central neck ultrasound detects only macroscopic surgical disease, but negative findings predict excellent long-term regional control and survival. Thyroid. 2012;22:347–55.PubMedCrossRef
22.
Zurück zum Zitat Roh JL, Kim JM, Park CI. Central lymph node metastasis of unilateral papillary thyroid carcinoma: patterns and factors predictive of nodal metastasis, morbidity, and recurrence. Ann Surg Oncol. 2011;18:2245–50.PubMedCrossRef Roh JL, Kim JM, Park CI. Central lymph node metastasis of unilateral papillary thyroid carcinoma: patterns and factors predictive of nodal metastasis, morbidity, and recurrence. Ann Surg Oncol. 2011;18:2245–50.PubMedCrossRef
23.
Zurück zum Zitat Sywak M, Cornford L, Roach P, et al. Routine ipsilateral level VI lymphadenectomy reduces postoperative thyroglobulin levels in papillary thyroid cancer. Surgery. 2006;140:1000–5.PubMedCrossRef Sywak M, Cornford L, Roach P, et al. Routine ipsilateral level VI lymphadenectomy reduces postoperative thyroglobulin levels in papillary thyroid cancer. Surgery. 2006;140:1000–5.PubMedCrossRef
24.
Zurück zum Zitat Voit CA, van Akkooi AC, Eggermont AM, et al. Fine needle aspiration cytology of palpable and nonpalpable lymph nodes to detect metastatic melanoma. J Natl Cancer Inst. 2011;103:1771–7.PubMedCrossRef Voit CA, van Akkooi AC, Eggermont AM, et al. Fine needle aspiration cytology of palpable and nonpalpable lymph nodes to detect metastatic melanoma. J Natl Cancer Inst. 2011;103:1771–7.PubMedCrossRef
25.
26.
Zurück zum Zitat Gethins M. International Cancer Conference: targeted therapies boom expected in 3–5 years. J Natl Cancer Inst. 2011;103:1491–3.PubMedCrossRef Gethins M. International Cancer Conference: targeted therapies boom expected in 3–5 years. J Natl Cancer Inst. 2011;103:1491–3.PubMedCrossRef
27.
Zurück zum Zitat Friedman R. Nano dot technology enters clinical trials. J Natl Cancer Inst. 2011;103:1428–9.PubMedCrossRef Friedman R. Nano dot technology enters clinical trials. J Natl Cancer Inst. 2011;103:1428–9.PubMedCrossRef
28.
Zurück zum Zitat Segal K, Friedental R, Lubin E, et al. Papillary carcinoma of the thyroid. Otolaryngol Head Neck Surg. 1995;113:356–63.PubMedCrossRef Segal K, Friedental R, Lubin E, et al. Papillary carcinoma of the thyroid. Otolaryngol Head Neck Surg. 1995;113:356–63.PubMedCrossRef
29.
Zurück zum Zitat Simon D, Goretzki PE, Witte J, Roher HD. Incidence of regional recurrence guiding radicality in differentiated thyroid carcinoma. World J Surg. 1996;20:860–6.PubMedCrossRef Simon D, Goretzki PE, Witte J, Roher HD. Incidence of regional recurrence guiding radicality in differentiated thyroid carcinoma. World J Surg. 1996;20:860–6.PubMedCrossRef
30.
Zurück zum Zitat Kim MK, Mandel SH, Baloch Z, et al. Morbidity following central compartment reoperation for recurrent or persistent thyroid cancer. Arch Otolaryngol Head Neck Surg. 2004;130:1214–6.PubMedCrossRef Kim MK, Mandel SH, Baloch Z, et al. Morbidity following central compartment reoperation for recurrent or persistent thyroid cancer. Arch Otolaryngol Head Neck Surg. 2004;130:1214–6.PubMedCrossRef
31.
Zurück zum Zitat Moley JF, Lairmore TC, Doherty GM, et al. Preservation of the recurrent laryngeal nerves in thyroid and parathyroid reoperations. Surgery. 1999;126:673–7.PubMedCrossRef Moley JF, Lairmore TC, Doherty GM, et al. Preservation of the recurrent laryngeal nerves in thyroid and parathyroid reoperations. Surgery. 1999;126:673–7.PubMedCrossRef
32.
Zurück zum Zitat Shen WT, Ogawa L, Ruan D, et al. Central neck lymph node dissection for papillary thyroid cancer: comparison of complication and recurrence rates in 295 initial dissections and reoperations. Arch Surg. 2010;145:272–5.PubMedCrossRef Shen WT, Ogawa L, Ruan D, et al. Central neck lymph node dissection for papillary thyroid cancer: comparison of complication and recurrence rates in 295 initial dissections and reoperations. Arch Surg. 2010;145:272–5.PubMedCrossRef
33.
Zurück zum Zitat Alvarado R, Sywak MS, Delbridge L, Sidhu SB. Central lymph node dissection as a secondary procedure for papillary thyroid cancer: is there added morbidity? Surgery. 2009;145:514–8.PubMedCrossRef Alvarado R, Sywak MS, Delbridge L, Sidhu SB. Central lymph node dissection as a secondary procedure for papillary thyroid cancer: is there added morbidity? Surgery. 2009;145:514–8.PubMedCrossRef
34.
Zurück zum Zitat Kouvaraki MA, Shapiro SE, Fornage BD, et al. Role of preoperative ultrasonography in the surgical management of patients with thyroid cancer. Surgery. 2003;134:946–54.PubMedCrossRef Kouvaraki MA, Shapiro SE, Fornage BD, et al. Role of preoperative ultrasonography in the surgical management of patients with thyroid cancer. Surgery. 2003;134:946–54.PubMedCrossRef
35.
Zurück zum Zitat Popadich A, Levin O, Lee JC, et al. A multicenter cohort study of total thyroidectomy and routine central lymph node dissection for cN0 papillary thyroid cancer. Surgery. 2011;150:1048–57.PubMedCrossRef Popadich A, Levin O, Lee JC, et al. A multicenter cohort study of total thyroidectomy and routine central lymph node dissection for cN0 papillary thyroid cancer. Surgery. 2011;150:1048–57.PubMedCrossRef
36.
Zurück zum Zitat Yoo D, Ajmal S, Gowda S, et al. Level VI lymph node dissection does not decrease radioiodine uptake in patients undergoing radioiodine ablation for differentiated thyroid cancer. World J Surg. 2012;36:1255–61.PubMedCrossRef Yoo D, Ajmal S, Gowda S, et al. Level VI lymph node dissection does not decrease radioiodine uptake in patients undergoing radioiodine ablation for differentiated thyroid cancer. World J Surg. 2012;36:1255–61.PubMedCrossRef
37.
Zurück zum Zitat Tuttle RM, Lopez N, Leboeuf R, et al. Radioactive iodine administered for thyroid remnant ablation following recombinant human thyroid stimulating hormone preparation also has an important adjuvant therapy function. Thyroid. 2010;20:257–63.PubMedCrossRef Tuttle RM, Lopez N, Leboeuf R, et al. Radioactive iodine administered for thyroid remnant ablation following recombinant human thyroid stimulating hormone preparation also has an important adjuvant therapy function. Thyroid. 2010;20:257–63.PubMedCrossRef
38.
Zurück zum Zitat Tuttle RM, Tala H, Shah J, et al. Estimating risk of recurrence in differentiated thyroid cancer after total thyroidectomy and radioactive iodine remnant ablation: using response to therapy variables to modify the initial risk estimates predicted by the new American Thyroid Association staging system. Thyroid. 2010;20:1341–9.PubMedCrossRef Tuttle RM, Tala H, Shah J, et al. Estimating risk of recurrence in differentiated thyroid cancer after total thyroidectomy and radioactive iodine remnant ablation: using response to therapy variables to modify the initial risk estimates predicted by the new American Thyroid Association staging system. Thyroid. 2010;20:1341–9.PubMedCrossRef
39.
Zurück zum Zitat Sawka AM, Thabane L, Parlea L, et al. Second primary malignancy risk after radioactive iodine treatment for thyroid cancer: a systematic review and meta-analysis. Thyroid. 2009;19:451–7.PubMedCrossRef Sawka AM, Thabane L, Parlea L, et al. Second primary malignancy risk after radioactive iodine treatment for thyroid cancer: a systematic review and meta-analysis. Thyroid. 2009;19:451–7.PubMedCrossRef
40.
Zurück zum Zitat Iyer NG, Morris LG, Tuttle RM, et al. Rising incidence of second cancers in patients with low-risk (T1N0) thyroid cancer who receive radioactive iodine therapy. Cancer. 2011;117:4439–46.PubMedCrossRef Iyer NG, Morris LG, Tuttle RM, et al. Rising incidence of second cancers in patients with low-risk (T1N0) thyroid cancer who receive radioactive iodine therapy. Cancer. 2011;117:4439–46.PubMedCrossRef
41.
Zurück zum Zitat Alexander C, Bader JB, Schaefer A, et al. Intermediate and long-term side effects of high-dose radioiodine therapy for thyroid carcinoma. J Nucl Med. 1998;39:1551–4.PubMed Alexander C, Bader JB, Schaefer A, et al. Intermediate and long-term side effects of high-dose radioiodine therapy for thyroid carcinoma. J Nucl Med. 1998;39:1551–4.PubMed
42.
Zurück zum Zitat Almeida JP, Sanabria AE, Lima EN, Kowalski LP. Late side effects of radioactive iodine on salivary gland function in patients with thyroid cancer. Head Neck. 2011;33:686–90.PubMedCrossRef Almeida JP, Sanabria AE, Lima EN, Kowalski LP. Late side effects of radioactive iodine on salivary gland function in patients with thyroid cancer. Head Neck. 2011;33:686–90.PubMedCrossRef
Metadaten
Titel
Prophylactic Central Neck Dissection in Differentiated Thyroid Cancer: An Assessment of the Evidence
verfasst von
David E. Gyorki, MD
Brian Untch, MD
R. Michael Tuttle, MD
Ashok R. Shaha, MD
Publikationsdatum
01.07.2013
Verlag
Springer-Verlag
Erschienen in
Annals of Surgical Oncology / Ausgabe 7/2013
Print ISSN: 1068-9265
Elektronische ISSN: 1534-4681
DOI
https://doi.org/10.1245/s10434-013-2897-6

Weitere Artikel der Ausgabe 7/2013

Annals of Surgical Oncology 7/2013 Zur Ausgabe

Häusliche Gewalt in der orthopädischen Notaufnahme oft nicht erkannt

28.05.2024 Häusliche Gewalt Nachrichten

In der Notaufnahme wird die Chance, Opfer von häuslicher Gewalt zu identifizieren, von Orthopäden und Orthopädinnen offenbar zu wenig genutzt. Darauf deuten die Ergebnisse einer Fragebogenstudie an der Sahlgrenska-Universität in Schweden hin.

Fehlerkultur in der Medizin – Offenheit zählt!

28.05.2024 Fehlerkultur Podcast

Darüber reden und aus Fehlern lernen, sollte das Motto in der Medizin lauten. Und zwar nicht nur im Sinne der Patientensicherheit. Eine negative Fehlerkultur kann auch die Behandelnden ernsthaft krank machen, warnt Prof. Dr. Reinhard Strametz. Ein Plädoyer und ein Leitfaden für den offenen Umgang mit kritischen Ereignissen in Medizin und Pflege.

Mehr Frauen im OP – weniger postoperative Komplikationen

21.05.2024 Allgemeine Chirurgie Nachrichten

Ein Frauenanteil von mindestens einem Drittel im ärztlichen Op.-Team war in einer großen retrospektiven Studie aus Kanada mit einer signifikanten Reduktion der postoperativen Morbidität assoziiert.

TAVI versus Klappenchirurgie: Neue Vergleichsstudie sorgt für Erstaunen

21.05.2024 TAVI Nachrichten

Bei schwerer Aortenstenose und obstruktiver KHK empfehlen die Leitlinien derzeit eine chirurgische Kombi-Behandlung aus Klappenersatz plus Bypass-OP. Diese Empfehlung wird allerdings jetzt durch eine aktuelle Studie infrage gestellt – mit überraschender Deutlichkeit.

Update Chirurgie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

S3-Leitlinie „Diagnostik und Therapie des Karpaltunnelsyndroms“

Karpaltunnelsyndrom BDC Leitlinien Webinare
CME: 2 Punkte

Das Karpaltunnelsyndrom ist die häufigste Kompressionsneuropathie peripherer Nerven. Obwohl die Anamnese mit dem nächtlichen Einschlafen der Hand (Brachialgia parästhetica nocturna) sehr typisch ist, ist eine klinisch-neurologische Untersuchung und Elektroneurografie in manchen Fällen auch eine Neurosonografie erforderlich. Im Anfangsstadium sind konservative Maßnahmen (Handgelenksschiene, Ergotherapie) empfehlenswert. Bei nicht Ansprechen der konservativen Therapie oder Auftreten von neurologischen Ausfällen ist eine Dekompression des N. medianus am Karpaltunnel indiziert.

Prof. Dr. med. Gregor Antoniadis
Berufsverband der Deutschen Chirurgie e.V.

S2e-Leitlinie „Distale Radiusfraktur“

Radiusfraktur BDC Leitlinien Webinare
CME: 2 Punkte

Das Webinar beschäftigt sich mit Fragen und Antworten zu Diagnostik und Klassifikation sowie Möglichkeiten des Ausschlusses von Zusatzverletzungen. Die Referenten erläutern, welche Frakturen konservativ behandelt werden können und wie. Das Webinar beantwortet die Frage nach aktuellen operativen Therapiekonzepten: Welcher Zugang, welches Osteosynthesematerial? Auf was muss bei der Nachbehandlung der distalen Radiusfraktur geachtet werden?

PD Dr. med. Oliver Pieske
Dr. med. Benjamin Meyknecht
Berufsverband der Deutschen Chirurgie e.V.

S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“

Appendizitis BDC Leitlinien Webinare
CME: 2 Punkte

Inhalte des Webinars zur S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“ sind die Darstellung des Projektes und des Erstellungswegs zur S1-Leitlinie, die Erläuterung der klinischen Relevanz der Klassifikation EAES 2015, die wissenschaftliche Begründung der wichtigsten Empfehlungen und die Darstellung stadiengerechter Therapieoptionen.

Dr. med. Mihailo Andric
Berufsverband der Deutschen Chirurgie e.V.