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1.
Arkh Patol ; 83(1): 49-52, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33512128

RESUMO

BACKGROUND AND AIM: Histopathological Evaluation of surgical margins of a resected tumour specimen can give an insight about the extent of tumour spread. Errors in proper identification and orientation of resected tumour margins can lead to treatment failure and poor prognosis. Inking of resected margins is the most reliable and safe method. The aim of this study is to systematically review the studies which compares various materials used for inking of surgically resected specimen. MATERIALS AND METHODS: Articles searched from PubMed, Cochrane, Google search, manual search using key words - inking, tissue marking dyes, surgical margin, tumour margin, surgical pathology, grossing, gross specimens and back references of the articles, yielded three articles. Three articles with a total sample size of 1325 and compares properties of India ink, Acrylic colours and Tissue Marking Dyes were considered in this review. RESULTS: Both India ink and acrylic colours are good with respect to the Ease of application, visibility on paraffin wax blocks, Visibility on naked eye examination of slides and Visibility on microscope. Acrylic colours have less drying time than India ink. India ink do not result in contamination of tissue processing fluids, Interference with cellular and nuclear details and penetration in to tissues when compared with acrylic colours. CONCLUSION: India Ink will continue to dominate as the best surgical ink when comparing all the parameters till newer studies are available for acrylic colours or other dyes. Acrylic colours have the potential to be widely used as a tissue marking dyes except for the few disadvantages.


Assuntos
Neoplasias , Patologia Cirúrgica , Corantes , Humanos , Tinta
2.
Pathologe ; 42(1): 116-124, 2021 Feb.
Artigo em Alemão | MEDLINE | ID: mdl-33346872

RESUMO

Primary vaginal carcinoma is rare. There are two pathogenetic pathways, one associated with HPV high-risk infection and another one with inactivation of p53. Vaginal Paget's disease is rare and mostly associated with vulvar disease or represents intravaginal spread of associated locoregional cancer. Diagnostic vaginal biopsies should be examined by step sections on H&E. Sentinel lymph nodes should be processed completely using ultrastaging. Morphology-based prognostic factors with good clinical evidence are tumour stage and lymph node status. Molecular markers are not currently relevant for treatment decision and prognosis.


Assuntos
Carcinoma in Situ , Patologia Cirúrgica , Neoplasias Vaginais , Neoplasias Vulvares , Feminino , Humanos , Estadiamento de Neoplasias , Prognóstico , Biópsia de Linfonodo Sentinela , Neoplasias Vaginais/diagnóstico , Neoplasias Vaginais/patologia , Neoplasias Vulvares/diagnóstico , Neoplasias Vulvares/patologia
4.
Arch Pathol Lab Med ; 144(10): 1162-1163, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-33002155
5.
Am J Clin Pathol ; 154(6): 724-730, 2020 11 04.
Artigo em Inglês | MEDLINE | ID: mdl-32915188

RESUMO

OBJECTIVES: To determine the impact of the coronavirus disease 2019 (COVID-19) pandemic on our service, pre-, and postgraduate education and discuss the measures taken to ensure continued provision of quality service as well as education during the mandatory lockdown. METHODS: Measures taken to protect staff from infection and minimize virus transmission within the department as well as measures taken to allow smooth provision of quality service and uninterrupted pre- and postgraduate education were analyzed. Data were collected regarding case volumes (histology, cytology, and frozen sections) and case complexity during the lockdown and analyzed. RESULTS: Staggered rota was introduced for all staff. Strict social distancing measures were implemented. Staff was extensively counseled regarding the importance of protective measures. Pre- and postgraduate education, which was temporarily suspended, was quickly resumed using online teaching ensuring continuation of academic activities. The volume of cases decreased during the lockdown but complexity increased even more. CONCLUSIONS: Immediate and effective measures were taken to protect staff from infection and ensure smooth provision of quality services. Measures were quickly taken to ensure resumption of pre- and postgraduate academic activities. The volume of cases decreased but complexity increased. There is fear among faculty and staff regarding the future.


Assuntos
Infecções por Coronavirus , Pandemias , Patologia Cirúrgica , Pneumonia Viral , Betacoronavirus , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Humanos , Exposição Ocupacional/prevenção & controle , Saúde do Trabalhador , Paquistão , Pandemias/prevenção & controle , Patologia Cirúrgica/educação , Patologia Cirúrgica/organização & administração , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão
6.
Ann Diagn Pathol ; 48: 151560, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32645559

RESUMO

The coronavirus disease 2019 (COVID-19) pandemic has dramatically changed the world over the past weeks, with already 8,25 million infections and 445,000 deaths worldwide, leading to an unprecedented international global effort to contain the virus and prevent its spread. The emergence of novel respiratory viruses such as the SARS-CoV-2 creates dramatic challenges to the healthcare services, including surgical pathology laboratories, despite their extensive daily experience in dealing with biological and chemical hazards. Here, we cover important aspects on the knowledge on COVID-19 gathered during the first six months of the pandemic and address relevant issues on human biological sample handling in the Anatomic Pathology laboratory in the context of COVID-19 global threat. In addition, we detail our strategy to minimize the risk of contamination upon exposure to the different biological products received in the laboratory, which can be of general interest to other laboratories worldwide. Our approach has enabled a safe work environment for laboratory staff, while ensuring the maintenance of high quality standards of the work performed. In times of uncertainty and given the lack of specific guidelines directed at Anatomic Pathology services to better deal with the global COVID-19 public-health emergency, it is essential to share with the community rigorous methodologies that will enable us to better cope with probable novel waves of COVID-19 infection and other viruses that will possibly arise in the near future.


Assuntos
Infecções por Coronavirus , Controle de Infecções/métodos , Laboratórios Hospitalares/normas , Pandemias , Patologia Cirúrgica/métodos , Pneumonia Viral , Manejo de Espécimes/métodos , Betacoronavirus , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Humanos , Controle de Infecções/normas , Pandemias/prevenção & controle , Serviço Hospitalar de Patologia/normas , Patologia Cirúrgica/normas , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Portugal , Manejo de Espécimes/normas
8.
Mod Pathol ; 33(11): 2115-2127, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32572154

RESUMO

Remote digital pathology allows healthcare systems to maintain pathology operations during public health emergencies. Existing Clinical Laboratory Improvement Amendments regulations require pathologists to electronically verify patient reports from a certified facility. During the 2019 pandemic of COVID-19 disease, caused by the SAR-CoV-2 virus, this requirement potentially exposes pathologists, their colleagues, and household members to the risk of becoming infected. Relaxation of government enforcement of this regulation allows pathologists to review and report pathology specimens from a remote, non-CLIA certified facility. The availability of digital pathology systems can facilitate remote microscopic diagnosis, although formal comprehensive (case-based) validation of remote digital diagnosis has not been reported. All glass slides representing routine clinical signout workload in surgical pathology subspecialties at Memorial Sloan Kettering Cancer Center were scanned on an Aperio GT450 at ×40 equivalent resolution (0.26 µm/pixel). Twelve pathologists from nine surgical pathology subspecialties remotely reviewed and reported complete pathology cases using a digital pathology system from a non-CLIA certified facility through a secure connection. Whole slide images were integrated to and launched within the laboratory information system to a custom vendor-agnostic, whole slide image viewer. Remote signouts utilized consumer-grade computers and monitors (monitor size, 13.3-42 in.; resolution, 1280 × 800-3840 × 2160 pixels) connecting to an institution clinical workstation via secure virtual private network. Pathologists subsequently reviewed all corresponding glass slides using a light microscope within the CLIA-certified department. Intraobserver concordance metrics included reporting elements of top-line diagnosis, margin status, lymphovascular and/or perineural invasion, pathology stage, and ancillary testing. The median whole slide image file size was 1.3 GB; scan time/slide averaged 90 s; and scanned tissue area averaged 612 mm2. Signout sessions included a total of 108 cases, comprised of 254 individual parts and 1196 slides. Major diagnostic equivalency was 100% between digital and glass slide diagnoses; and overall concordance was 98.8% (251/254). This study reports validation of primary diagnostic review and reporting of complete pathology cases from a remote site during a public health emergency. Our experience shows high (100%) intraobserver digital to glass slide major diagnostic concordance when reporting from a remote site. This randomized, prospective study successfully validated remote use of a digital pathology system including operational feasibility supporting remote review and reporting of pathology specimens, and evaluation of remote access performance and usability for remote signout.


Assuntos
Infecções por Coronavirus , Pandemias , Patologia Cirúrgica , Pneumonia Viral , Telepatologia , Betacoronavirus , Humanos , Processamento de Imagem Assistida por Computador/métodos , Patologia Cirúrgica/instrumentação , Patologia Cirúrgica/métodos , Patologia Cirúrgica/organização & administração , Telepatologia/instrumentação , Telepatologia/métodos , Telepatologia/organização & administração , Fluxo de Trabalho
11.
Rev. colomb. obstet. ginecol ; 71(2): 103-114, abr.-jun. 2020. tab, graf
Artigo em Espanhol | LILACS | ID: biblio-1126322

RESUMO

RESUMEN Objetivo: determinar la prevalencia del compro miso ganglionar de pacientes con cáncer de endometrio y hacer una exploración de los factores asociados a la invasión ganglionar. Materiales y métodos: estudio de prevalencia con análisis exploratorio. Se incluyeron pacientes con cáncer de endometrio llevadas a histerectomía abdominal total más salpingooforectomía bilateral y linfadenectomía pélvica, con o sin linfadenectomía paraaórtica en siete centros de oncología de Colombia, en el periodo 2009-2016. Se excluyeron pacientes con radioterapia o quimioterapia previa, diagnóstico histológico de tumores neuroendocrinos, carcinosarcomas, tumores sincrónicos o metacrónicos. Muestreo no probabilístico. Tamaño muestral n = 290. Variables medidas: sociodemográficas, clínicas e histopatológicas y compromiso ganglionar pélvico o paraaórtico. Se presenta la prevalencia de periodo; el análisis exploratorio se realizó por medio de odds ratio (OR) crudo y el ajustado mediante un modelo multivariado (regresión logística no condicional). Resultados: se obtuvieron 467 casos de los cuales se excluyeron 163 por no presentar la totalidad de las variables, se estudiaron 304 pacientes. La prevalencia del compromiso ganglionar fue del 15,8 % (48/304). Los factores asociados al compromiso ganglionar en el análisis crudo y ajustado fueron la invasión linfovascular (OR ajustado = 9,32; IC 95 %: 4,27-21,15) e invasión miometrial (OR ajustado = 3.95; IC 95 %: 1,29-14,98). Conclusión: el 15 % de las pacientes sometidas a linfadenectomía tienen compromiso ganglionar. Se deben evaluar alternativas diagnósticas menos invasivas que la cirugía radical para establecer la invasión ganglionar.


ABSTRACT Objective: To determine the prevalence of lymph node involvement in patients with endometrial cancer and to explore factors associated with lymph node invasion. Materials and methods: Prevalence study with exploratory analysis. The study included patients with endometrial cancer who underwent total abdominal hysterectomy plus bilateral salpyingooophorectomy and pelvic lymphadenectomy with or without para-aortic lymphadenectomy in seven oncology centers in Colombia between 2009 and 2016. Patients who had received prior radiotherapy or chemotherapy, with a histological diagnosis of neuroendocrine tumors, carcinosarcomas or synchronous or metachronous lesions were excluded. Non-probabilistic sampling. Sample size n=290. Measured variables: sociodemographic, clinical and histopathological, and pelvic or para-aortic lymph node involvement. The prevalence for the period is presented. The exploratory analysis was conducted using crude odds ratio (OR) and adjusted OR by means of a multivariate model (unconditional logistic regression). Results: Overall, 467 cases were retrieved. Of them, 163 were excluded because of non-availability of all the variables. In total, 304 patients were studied. The prevalence of lymph node involvement was 15.8 % (48/304). In the crude and adjusted analysis, factors associated with lymph node involvement were lymphovascular invasion (adjusted OR: 9.32; 95 % CI 4.27-21.15) and myometrial invasion (adjusted OR: 3.95; 95 % CI 1.29-14.98). Conclusion: Of the patients undergoing lymphadenectomy, 15 % have lymph node involvement. Less invasive diagnostic options than radical surgery to ascertain lymph node invasion should be assessed.


Assuntos
Neoplasias do Endométrio , Patologia Cirúrgica , Linfonodos
12.
Arch Pathol Lab Med ; 144(10): 1262-1270, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-32142368

RESUMO

CONTEXT.­: The use of neoadjuvant therapy in the management of early-stage invasive breast cancer is increasing. Residual Cancer Burden and other similar tools use pathologic characteristics of post-neoadjuvant therapy breast tumors to determine long-term outcome. However, there are no standardized guidelines for the pathologic evaluation of these specimens in the routine clinical setting. OBJECTIVE.­: To assess current practices among Canadian pathologists and pathology assistants with regard to the processing and reporting of post-neoadjuvant therapy breast specimens. DESIGN.­: An electronic survey was distributed to pathologists and pathology assistants across Canada. RESULTS.­: Sixty-three responses were obtained. A total of 48% (15 of 31) of surveyed pathologists reported familiarity with the Residual Cancer Burden tool. A total of 40% (25 of 63) of respondents reported a lack of routine use of specimen photography, and 35% (22 of 63) reported a lack of routine use of grossing diagrams. There was significant variation with respect to tumor bed sampling; the most common method was to submit 1 block per centimeter of tumor (20 of 63; 32%). There was also significant variation in the method of measuring residual tumor; the most common method was to measure the largest cross-section of residual tumor (16 of 32; 50%). CONCLUSIONS.­: There is a need for standardization of the evaluation of post-neoadjuvant therapy breast specimens in the routine clinical setting in Canada. We recommend the routine use of specimen mapping, submitting the largest cross section of tumor bed in toto, reporting tumor size as per American Joint Committee on Cancer and Residual Cancer Burden guidelines, and routinely including measurements of residual tumor cellularity and in situ disease in the final pathology report as per Residual Cancer Burden guidelines.


Assuntos
Neoplasias da Mama/patologia , Mama/patologia , Patologia Cirúrgica/normas , Manejo de Espécimes/normas , Neoplasias da Mama/tratamento farmacológico , Canadá , Quimioterapia Adjuvante , Feminino , Humanos , Terapia Neoadjuvante/métodos
13.
Arch Pathol Lab Med ; 144(10): 1245-1253, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-32057275

RESUMO

CONTEXT.­: The adoption of digital capture of pathology slides as whole slide images (WSI) for educational and research applications has proven utility. OBJECTIVE.­: To compare pathologists' primary diagnoses derived from WSI versus the standard microscope. Because WSIs differ in format and method of observation compared with the current standard glass slide microscopy, this study is critical to potential clinical adoption of digital pathology. DESIGN.­: The study enrolled a total of 2045 cases enriched for more difficult diagnostic categories and represented as 5849 slides were curated and provided for diagnosis by a team of 19 reading pathologists separately as WSI or as glass slides viewed by light microscope. Cases were reviewed by each pathologist in both modalities in randomized order with a minimum 31-day washout between modality reads for each case. Each diagnosis was compared with the original clinical reference diagnosis by an independent central adjudication review. RESULTS.­: The overall major discrepancy rates were 3.64% for WSI review and 3.20% for manual slide review diagnosis methods, a difference of 0.44% (95% CI, -0.15 to 1.03). The time to review a case averaged 5.20 minutes for WSI and 4.95 minutes for glass slides. There was no specific subset of diagnostic category that showed higher rates of modality-specific discrepancy, though some categories showed greater discrepancy than others in both modalities. CONCLUSIONS.­: WSIs are noninferior to traditional glass slides for primary diagnosis in anatomic pathology.


Assuntos
Interpretação de Imagem Assistida por Computador/métodos , Microscopia/métodos , Patologia Cirúrgica/métodos , Método Duplo-Cego , Humanos , Variações Dependentes do Observador , Reprodutibilidade dos Testes
15.
Arch Pathol Lab Med ; 144(9): 1067-1074, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32023089

RESUMO

CONTEXT.­: The concept of critical diagnoses in anatomic pathology is relatively recent and rigorous study of the issue is quite limited. The College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology issued a consensus statement in 2012. There has been no multi-institutional study of communication policies since then. OBJECTIVE.­: To survey the policies of anatomic pathology laboratories regarding communication of critical values. DESIGN.­: A survey of the Association of Directors of Anatomic and Surgical Pathology membership was performed using a 14-question electronic survey tool. RESULTS.­: Responses were received from 38 institutions. Thirty-five of 38 (92%) had a policy on anatomic pathology critical values. Twenty-five of 38 (66%) respondents had read the College of American Pathologists/Association of Directors of Anatomic and Surgical Pathology consensus statement. Twelve of 38 (32%) institutions divided critical values into 2 categories, of which 9 used the College of American Pathologists/Association of Directors of Anatomic and Surgical Pathology terminology; 24 used only a single term, of which 11 used critical value. There was substantial variation in the diagnoses that were considered critical. A direct phone call to the responsible provider was uniformly considered an acceptable means of communication; all other methods had mixed or low support. The most common time frame was same day; many laboratories did not specify a timeframe. Most laboratories document date, time, and person to whom the result was communicated in the final report or an addendum report. Eighteen of 38 (47%) laboratories report an auditing mechanism for communication. CONCLUSIONS.­: Policies for communication of critical/urgent/significant, unexpected results in anatomic pathology are the norm. However, there remains significant variation between institutions in the details of these policies.


Assuntos
Comunicação , Patologia Cirúrgica/métodos , Consenso , Humanos
16.
Arch Pathol Lab Med ; 144(3): 275-276, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32101057

RESUMO

This special section includes 4 articles as the proceedings of the Fifth Princeton Integrated Pathology Symposium (PIPS): Genitourinary Pathology, and an update on neuroendocrine tumor of the prostate. The symposium took place at the Princeton Medical Center, Plainsboro, New Jersey, on Sunday April 15, 2018. We hope again that this collection of outstanding reviews will serve as a handy reference for your daily practice.


Assuntos
Patologia/métodos , Próstata/patologia , Neoplasias da Próstata/patologia , Humanos , Masculino , Patologia Clínica/métodos , Patologia Molecular/métodos , Patologia Cirúrgica/métodos , Próstata/metabolismo , Próstata/cirurgia , Neoplasias da Próstata/genética , Neoplasias da Próstata/cirurgia
18.
J Clin Pathol ; 73(8): 503-506, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31806732

RESUMO

BACKGROUND: Digital pathology is now used for primary diagnostic work as well as teaching, research and consultation. In our multisite institution service reorganisation led to histopathology being located in a separate hospital from some surgical specialities. We implemented remotely supervised specimen sampling and frozen section diagnosis using digital pathology. In this study we assessed the concordance of glass and digital slide diagnosis using this system. METHODS: We reviewed cases from the first 2 years of digital frozen section reporting at our institution. Cases with potential digital to glass slide discordance were reviewed by three experienced thoracic histopathologists. The reasons for discordance were determined and common themes identified. We also reviewed critical incidents relating to digital pathology during the study period. RESULTS: The study population comprised 211 cases. Frozen section to final diagnosis concordance between digital and glass slide diagnosis was found in 196 (92.6%) cases. The 15 potentially discordant cases were reviewed. Intraobserver concordance between glass and digital slide review ranged from 9/15 to 12/15 cases across the three pathologists. Glass slide review diagnosis showed better concordance with ground truth in two cases; digital slide review was more accurate in two cases. One relevant critical incident was identified during the study period. DISCUSSION: This is the largest study to examine digital pathology for thoracic frozen section diagnosis and shows that this is a safe and feasible alternative to glass slide diagnosis. Discordance between digital and glass slide diagnoses were unrelated to the processes of whole slide imaging and digital microscopy.


Assuntos
Secções Congeladas/métodos , Patologia Cirúrgica/métodos , Manejo de Espécimes/métodos , Telepatologia/métodos , Neoplasias Torácicas/patologia , Estudos de Viabilidade , Secções Congeladas/normas , Humanos , Cuidados Intraoperatórios/métodos , Microscopia/métodos , Microscopia/normas , Patologia Cirúrgica/normas , Tecnologia de Sensoriamento Remoto/métodos , Tecnologia de Sensoriamento Remoto/normas , Sensibilidade e Especificidade , Telepatologia/normas , Neoplasias Torácicas/cirurgia
19.
Histopathology ; 76(1): 171-177, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31846526

RESUMO

Surgical pathology forms the cornerstone of modern oncological medicine, owing to the wealth of clinically relevant information that can be obtained from tissue morphology. Although several ancillary testing modalities have been added to surgical pathology, the way in which we view and interpret tissue morphology has remained largely unchanged since the inception of our profession. In this review, we discuss new technological advances that promise to transform the way in which we access tissue morphology and how we use it to guide patient care.


Assuntos
Inteligência Artificial/tendências , Doenças dos Genitais Femininos/patologia , Patologia Cirúrgica/tendências , Medicina de Precisão/tendências , Feminino , Humanos
20.
Cancer Cytopathol ; 128(1): 29-35, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31722125

RESUMO

BACKGROUND: Risk stratification is a critical element for the successful implementation of cytopathology reporting systems. To the authors' knowledge, there are limited prior studies regarding risk stratification for The Papanicolaou Society of Cytopathology System for Reporting Pancreaticobiliary Cytology (PSCPC). In the current study, the authors reported on a single-institution experience on 3-year prospective PSCPC regarding risk of malignancy (ROM) and the overall risk of malignancy (OROM). METHODS: A computerized search was performed from August 2014 to December 2017 for all pancreatic fine-needle aspiration (FNA) samples. Pathology from surgical resections and biopsies and relevant radiologic and clinical follow-up data were collected. The ROM and the OROM were calculated. The OROM was based on the total number of FNA samples in each category. RESULTS: A total of 1017 pancreatic FNA cases were identified, with surgical and/or clinical follow-up data available for 548 cases. The cytopathologic diagnoses included 242 nondiagnostic (category I), 162 benign (category II), 142 atypical (category III), 20 neoplastic-benign (category IV: benign), 133 neoplastic-other (category IV: other), 28 suspicious (category V), and 290 malignant (category VI) cases. A total of 364 malignancies were documented in 11 cases, 4 cases, 36 cases, 0 cases, 36 cases, 21 cases, and 255 cases, respectively, from categories I, II, III, IV: benign, IV:other, V, and VI. The ROM was 25%, 17.4%, 41.8%, 0%, 34.3% (95.2%), 95.5%, and 99.6%, respectively, and the OROM was 4.5%, 2.5%, 25.3%, 0%, 27.1% (83.3%), 75%, and 87.9%, respectively, for categories I, II, III, IV: benign, IV: other (with high-grade dysplasia), V, and VI. CONCLUSIONS: The true ROM for PSCPC is likely between the ROM and OROM for the benign and indeterminate categories. In the neoplastic-other category (category IV: other), identifying high-grade dysplasia is important for its association with malignancy and a higher ROM.


Assuntos
Pâncreas/patologia , Neoplasias Pancreáticas/diagnóstico , Lesões Pré-Cancerosas/diagnóstico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Aspiração por Agulha Fina Guiada por Ultrassom Endoscópico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Estadiamento de Neoplasias , Pâncreas/diagnóstico por imagem , Pâncreas/cirurgia , Pancreatectomia , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/cirurgia , Patologia Clínica , Patologia Cirúrgica , Lesões Pré-Cancerosas/patologia , Lesões Pré-Cancerosas/cirurgia , Estudos Prospectivos , Medição de Risco/métodos , Sociedades Médicas , Adulto Jovem
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