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Pulmonary Medicine 2016. Endobronchial ultrasound (EBUS) is a procedure that provides access to the mediastinal staging; however, EBUS cannot be used to stage all of the nodes in the... (Meta-Analysis)
Meta-Analysis Review
. Endobronchial ultrasound (EBUS) is a procedure that provides access to the mediastinal staging; however, EBUS cannot be used to stage all of the nodes in the mediastinum. In these cases, endoscopic ultrasound (EUS) is used for complete staging. . To provide a synthesis of the evidence on the diagnostic performance of EBUS + EUS in patients undergoing mediastinal staging. . Systematic review and meta-analysis to evaluate the diagnostic yield of EBUS + EUS compared with surgical staging. Two researchers performed the literature search, quality assessments, data extractions, and analyses. We produced a meta-analysis including sensitivity, specificity, and likelihood ratio analysis. . Twelve primary studies (1515 patients) were included; two were randomized controlled trials (RCTs) and ten were prospective trials. The pooled sensitivity for combined EBUS + EUS was 87% (CI 84-89%) and the specificity was 99% (CI 98-100%). For EBUS + EUS performed with a single bronchoscope group, the sensitivity improved to 88% (CI 83.1-91.4%) and specificity improved to 100% (CI 99-100%). . EBUS + EUS is a highly accurate and safe procedure. The combined procedure should be considered in selected patients with lymphadenopathy noted at stations that are not traditionally accessible with conventional EBUS.
Topics: Bronchoscopy; Endosonography; Humans; Lung Neoplasms; Lymphatic Metastasis; Mediastinum; Neoplasm Staging; Reproducibility of Results; Sensitivity and Specificity
PubMed: 27818796
DOI: 10.1155/2016/1024709 -
Medicine Jun 2015Optimal management of clinical stage IIIA (N2) non-small cell lung cancer (NSCLC) is controversial. This study is a systematic review and meta-analysis of published... (Meta-Analysis)
Meta-Analysis Review
Is There a Survival Benefit in Patients With Stage IIIA (N2) Non-small Cell Lung Cancer Receiving Neoadjuvant Chemotherapy and/or Radiotherapy Prior to Surgical Resection: A Systematic Review and Meta-analysis.
Optimal management of clinical stage IIIA (N2) non-small cell lung cancer (NSCLC) is controversial. This study is a systematic review and meta-analysis of published randomized control trials of multimodality management strategies for NSCLC. We conducted a comprehensive literature search of the Pubmed, Embase, Medline, and CENTRAL databases for relevant studies comparing patients with stage IIIA (N2) NSCLC undergoing surgery alone, chemotherapy and/or radiotherapy alone, or surgical resection after neoadjuvant treatment with chemotherapy and/or radiotherapy. We estimated hazard ratios, odds ratios (ORs), and 95% confidence intervals (CIs) for survival data. Seven trials involving 1049 patients were included in this study. There was no significant difference in overall survival (OS) or progression-free survival (PFS) in stage IIIA (N2) NSCLC patients who received neoadjuvant chemotherapy or chemoradiotherapy prior to surgical resection compared to those who received neoadjuvant chemotherapy or chemoradiotherapy prior to radical radiotherapy. There was a significant increase in pathological complete remission in the mediastinal lymph nodes in stage IIIA (N2) NSCLC patients who received neoadjuvant chemoradiotherapy prior to surgical resection compared to those who received neoadjuvant chemotherapy (OR 3.61; 95% CI 1.07-12.15; P = 0.04), but no difference in tumor downstaging, OS, or PFS. Neoadjuvant chemotherapy and/or radiotherapy prior to surgical resection do not appear to be clinically superior to neoadjuvant chemotherapy and/or radiotherapy prior to definitive radiotherapy in IIIA (N2) NSCLC patients. Neoadjuvant chemoradiotherapy does not improve survival compared to neoadjuvant chemotherapy alone.
Topics: Carcinoma, Non-Small-Cell Lung; Chemotherapy, Adjuvant; Disease-Free Survival; Humans; Lung Neoplasms; Neoadjuvant Therapy; Neoplasm Staging; Pneumonectomy; Preoperative Care; Radiotherapy, Adjuvant; Survival Rate; Treatment Outcome
PubMed: 26061306
DOI: 10.1097/MD.0000000000000879 -
Urology Journal Apr 2015There are many recent observational studies on testicular microlithiasis (TM) and risk of testicular cancer. Whether TM increases the risk of testicular cancer is still... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
There are many recent observational studies on testicular microlithiasis (TM) and risk of testicular cancer. Whether TM increases the risk of testicular cancer is still inconclusive. The objective of this updated meta-analysis was to synthesize evidence from clinical observational studies that evaluated the association between TM and testicular cancer.
MATERIALS AND METHODS
We identified eligible studies by searching the PubMed, Embase and Cochrane Library before March 2014. Adjusted relative risks (RR) with 95% confidence interval (CI) were calculated using random-or fixed-model.
RESULTS
A total of 14 studies involving 35,578 participants were included in the meta-analysis. On the basis of the Newcastle Ottawa Scale systematic review, eleven studies were identified as relatively high-quality. TM was strong association with an increased incidence of testicular cancer (RR = 12.70, 95% CI: 8.18-19.71, P < .001), with significant evidence of heterogeneity among these studies (P for heterogeneity < .001, I2 = 82.1%). The subgroup and sensitivity analysis confirmed the stability of the results and no publication bias was detected.
CONCLUSION
The present meta-analysis suggests that TM is significantly associated with risk of testicular cancer. More researches are warranted to clarify an understanding of the association between TM and risk of testicular cancer.
Topics: Calculi; Global Health; Humans; Incidence; Male; Neoplasms, Germ Cell and Embryonal; Risk Factors; Testicular Diseases; Testicular Neoplasms
PubMed: 25923148
DOI: No ID Found -
The Cochrane Database of Systematic... Nov 2014A major determinant of treatment offered to patients with non-small cell lung cancer (NSCLC) is their intrathoracic (mediastinal) nodal status. If the disease has not... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
A major determinant of treatment offered to patients with non-small cell lung cancer (NSCLC) is their intrathoracic (mediastinal) nodal status. If the disease has not spread to the ipsilateral mediastinal nodes, subcarinal (N2) nodes, or both, and the patient is otherwise considered fit for surgery, resection is often the treatment of choice. Planning the optimal treatment is therefore critically dependent on accurate staging of the disease. PET-CT (positron emission tomography-computed tomography) is a non-invasive staging method of the mediastinum, which is increasingly available and used by lung cancer multidisciplinary teams. Although the non-invasive nature of PET-CT constitutes one of its major advantages, PET-CT may be suboptimal in detecting malignancy in normal-sized lymph nodes and in ruling out malignancy in patients with coexisting inflammatory or infectious diseases.
OBJECTIVES
To determine the diagnostic accuracy of integrated PET-CT for mediastinal staging of patients with suspected or confirmed NSCLC that is potentially suitable for treatment with curative intent.
SEARCH METHODS
We searched the following databases up to 30 April 2013: The Cochrane Library, MEDLINE via OvidSP (from 1946), Embase via OvidSP (from 1974), PreMEDLINE via OvidSP, OpenGrey, ProQuest Dissertations & Theses, and the trials register www.clinicaltrials.gov. There were no language or publication status restrictions on the search. We also contacted researchers in the field, checked reference lists, and conducted citation searches (with an end-date of 9 July 2013) of relevant studies.
SELECTION CRITERIA
Prospective or retrospective cross-sectional studies that assessed the diagnostic accuracy of integrated PET-CT for diagnosing N2 disease in patients with suspected resectable NSCLC. The studies must have used pathology as the reference standard and reported participants as the unit of analysis.
DATA COLLECTION AND ANALYSIS
Two authors independently extracted data pertaining to the study characteristics and the number of true and false positives and true and false negatives for the index test, and they independently assessed the quality of the included studies using QUADAS-2. We calculated sensitivity and specificity with 95% confidence intervals (CI) for each study and performed two main analyses based on the criteria for test positivity employed: Activity > background or SUVmax ≥ 2.5 (SUVmax = maximum standardised uptake value), where we fitted a summary receiver operating characteristic (ROC) curve using a hierarchical summary ROC (HSROC) model for each subset of studies. We identified the average operating point on the SROC curve and computed the average sensitivities and specificities. We checked for heterogeneity and examined the robustness of the meta-analyses through sensitivity analyses.
MAIN RESULTS
We included 45 studies, and based on the criteria for PET-CT positivity, we categorised the included studies into three groups: Activity > background (18 studies, N = 2823, prevalence of N2 and N3 nodes = 679/2328), SUVmax ≥ 2.5 (12 studies, N = 1656, prevalence of N2 and N3 nodes = 465/1656), and Other/mixed (15 studies, N = 1616, prevalence of N2 to N3 nodes = 400/1616). None of the studies reported (any) adverse events. Under-reporting generally hampered the quality assessment of the studies, and in 30/45 studies, the applicability of the study populations was of high or unclear concern.The summary sensitivity and specificity estimates for the 'Activity > background PET-CT positivity criterion were 77.4% (95% CI 65.3 to 86.1) and 90.1% (95% CI 85.3 to 93.5), respectively, but the accuracy estimates of these studies in ROC space showed a wide prediction region. This indicated high between-study heterogeneity and a relatively large 95% confidence region around the summary value of sensitivity and specificity, denoting a lack of precision. Sensitivity analyses suggested that the overall estimate of sensitivity was especially susceptible to selection bias; reference standard bias; clear definition of test positivity; and to a lesser extent, index test bias and commercial funding bias, with lower combined estimates of sensitivity observed for all the low 'Risk of bias' studies compared with the full analysis.The summary sensitivity and specificity estimates for the SUVmax ≥ 2.5 PET-CT positivity criterion were 81.3% (95% CI 70.2 to 88.9) and 79.4% (95% CI 70 to 86.5), respectively.In this group, the accuracy estimates of these studies in ROC space also showed a very wide prediction region. This indicated very high between-study heterogeneity, and there was a relatively large 95% confidence region around the summary value of sensitivity and specificity, denoting a clear lack of precision. Sensitivity analyses suggested that both overall accuracy estimates were marginally sensitive to flow and timing bias and commercial funding bias, which both lead to slightly lower estimates of sensitivity and specificity.Heterogeneity analyses showed that the accuracy estimates were significantly influenced by country of study origin, percentage of participants with adenocarcinoma, (¹⁸F)-2-fluoro-deoxy-D-glucose (FDG) dose, type of PET-CT scanner, and study size, but not by study design, consecutive recruitment, attenuation correction, year of publication, or tuberculosis incidence rate per 100,000 population.
AUTHORS' CONCLUSIONS
This review has shown that accuracy of PET-CT is insufficient to allow management based on PET-CT alone. The findings therefore support National Institute for Health and Care (formally 'clinical') Excellence (NICE) guidance on this topic, where PET-CT is used to guide clinicians in the next step: either a biopsy or where negative and nodes are small, directly to surgery. The apparent difference between the two main makes of PET-CT scanner is important and may influence the treatment decision in some circumstances. The differences in PET-CT accuracy estimates between scanner makes, NSCLC subtypes, FDG dose, and country of study origin, along with the general variability of results, suggest that all large centres should actively monitor their accuracy. This is so that they can make reliable decisions based on their own results and identify the populations in which PET-CT is of most use or potentially little value.
Topics: Carcinoma, Non-Small-Cell Lung; Cross-Sectional Studies; Humans; Lung Neoplasms; Lymph Nodes; Lymphatic Metastasis; Mediastinum; Multimodal Imaging; Positron-Emission Tomography; Prospective Studies; Retrospective Studies; Tomography, X-Ray Computed
PubMed: 25393718
DOI: 10.1002/14651858.CD009519.pub2 -
PloS One 2014This systematic review and meta-analysis aimed to evaluate the overall survival, local recurrence, distant metastasis, and complications of mediastinal lymph node... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
This systematic review and meta-analysis aimed to evaluate the overall survival, local recurrence, distant metastasis, and complications of mediastinal lymph node dissection (MLND) versus mediastinal lymph node sampling (MLNS) in stage I-IIIA non-small cell lung cancer (NSCLC) patients.
METHODS
A systematic search of published literature was conducted using the main databases (MEDLINE, PubMed, EMBASE, and Cochrane databases) to identify relevant randomized controlled trials that compared MLND vs. MLNS in NSCLC patients. Methodological quality of included randomized controlled trials was assessed according to the criteria from the Cochrane Handbook for Systematic Review of Interventions (Version 5.1.0). Meta-analysis was performed using The Cochrane Collaboration's Review Manager 5.3. The results of the meta-analysis were expressed as hazard ratio (HR) or risk ratio (RR), with their corresponding 95% confidence interval (CI).
RESULTS
We included results reported from six randomized controlled trials, with a total of 1,791 patients included in the primary meta-analysis. Compared to MLNS in NSCLC patients, there was no statistically significant difference in MLND on overall survival (HR = 0.77, 95% CI 0.55 to 1.08; P = 0.13). In addition, the results indicated that local recurrence rate (RR = 0.93, 95% CI 0.68 to 1.28; P = 0.67), distant metastasis rate (RR = 0.88, 95% CI 0.74 to 1.04; P = 0.15), and total complications rate (RR = 1.10, 95% CI 0.67 to 1.79; P = 0.72) were similar, no significant difference found between the two groups.
CONCLUSIONS
Results for overall survival, local recurrence rate, and distant metastasis rate were similar between MLND and MLNS in early stage NSCLC patients. There was no evidence that MLND increased complications compared with MLNS. Whether or not MLND is superior to MLNS for stage II-IIIA remains to be determined.
Topics: Carcinoma, Non-Small-Cell Lung; Humans; Lung Neoplasms; Lymph Node Excision; Mediastinum; Neoplasm Staging
PubMed: 25296033
DOI: 10.1371/journal.pone.0109979 -
Respirology (Carlton, Vic.) Aug 2014Intrathoracic lymph node metastases in patients with extrathoracic malignancies are a common clinical manifestation. Several studies evaluating intrathoracic lymph node... (Meta-Analysis)
Meta-Analysis Review
Endobronchial ultrasound-guided transbronchial needle biopsy for the diagnosis of intrathoracic lymph node metastases from extrathoracic malignancies: a meta-analysis and systematic review.
Intrathoracic lymph node metastases in patients with extrathoracic malignancies are a common clinical manifestation. Several studies evaluating intrathoracic lymph node metastases in patients with extrathoracic malignancy by using the endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) have been reported. The objective of this meta-analysis is to investigate the diagnostic value of EBUS-TBNA for diagnosing intrathoracic lymph node metastases in patients with extrathoracic malignancies. We systematically searched Cochrane Library, Medline and Embase for relevant studies published prior to May 2013. Studies specifically designed to evaluate the diagnostic accuracy of EBUS-TBNA for intrathoracic lymph node metastases in patients with an extrathoracic malignancy were selected. Diagnostic accuracy meta-analysis was conducted by pooling estimates of sensitivity, specificity, negative likelihood ratio (NLR), positive likelihood ratio (PLR) and diagnostic odds ratios (DOR) derived from a summary receiver operating characteristic (SROC) analysis of the original studies. Six studies were included, which provided a dataset of 533 patients. EBUS-TBNA pooled estimates had 0.85 sensitivity (95% confidence interval (CI): 0.80-0.89), 0.99 specificity (95% CI: 0.95-1.00), PLR 28.63 (95% CI: 11.51-71.22) and NLR 0.16 (95% CI: 0.12-0.21). The overall DOR was 179.77 (95% CI: 66.29-487.50). The area under the SROC curve and the diagnostic accuracy were 0.9247 and 0.8588, respectively. Evidence gathered from studies of moderate quality reveals a high degree of diagnostic accuracy of EBUS-TBNA for diagnosing intrathoracic lymph node metastases in patients with extrathoracic malignancies.
Topics: Adult; Aged; Aged, 80 and over; Biopsy, Needle; Bronchoscopy; Endosonography; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; ROC Curve; Reproducibility of Results; Sensitivity and Specificity; Thoracic Neoplasms
PubMed: 24935652
DOI: 10.1111/resp.12335 -
Journal of Cardiothoracic Surgery May 2014For patients with superficial esophageal carcinoma, ESD was one of treatment modalities to remove the lesion safely and effectively. We perform this meta-analysis to... (Meta-Analysis)
Meta-Analysis Review
AIM
For patients with superficial esophageal carcinoma, ESD was one of treatment modalities to remove the lesion safely and effectively. We perform this meta-analysis to determine the efficacy and incidence of complication of ESD for patients with superficial esophageal carcinoma.
METHOD
Articles were searched in MEDLINE (PubMed and Ovid), Cochrane Database of Systemic Reviews, Google scholar, and Web of Science. Two reviewers independently searched and extracted data. Meta-analysis of the efficacy of ESD was analyzed by calculating pooled en bloc and R0 resection rate. Incidence of complications such as perforation, stenosis and mediastinal emphysema was also calculated. Pooling was conducted using either fixed-effects model or random-effects model depending on the heterogeneity across studies.
RESULTS
21 studies (1152 patients and 1240 lesions) were included in this analysis. The pooled en bloc resection rate was 99% (95% CI 99%-100%). Stratified by tumor size, en bloc resection rates did not show any significant difference. The pooled R0 resection rate was 90% (95% CI 87%-93%). The pooled R0 resection rate was 85% (95% CI, 80%-90%) for large tumor and 92% (95% CI, 87%-93%) for small tumor (p < 0.001). Stenosis served as the most common reported complication with pooled incidence of 5% (95% CI 3-8%), followed by perforation (1%, 95% CI 0-1%) and mediastinal emphysema (0% CI 0-1%). The incidence of postoperative stenosis decreased significantly after 2011 (2%, 95% CI 0-3%) compared with that before 2011 (9%, 95% CI 3-8%) (p < 0.001).
CONCLUSION
ESD was an efficient modality for treating superficial esophageal carcinoma, with perfect en bloc and R0 resection rate and low complication rate. The most common complication of ESD was stenosis. Although recurrence rate was low, patients should be maintained in a scheduled surveillance program.
Topics: Dissection; Esophageal Neoplasms; Esophagoscopy; Global Health; Humans; Incidence; Intestinal Mucosa; Neoplasm Recurrence, Local; Postoperative Complications; Treatment Outcome
PubMed: 24885614
DOI: 10.1186/1749-8090-9-78 -
Cancer Control : Journal of the Moffitt... Apr 2014The preferred treatment for locally aggressive lung cancers is triple modality therapy with concurrent and induction chemotherapy with radiation therapy followed by... (Review)
Review
BACKGROUND
The preferred treatment for locally aggressive lung cancers is triple modality therapy with concurrent and induction chemotherapy with radiation therapy followed by surgery. Patients with locally advanced T4 Pancoast tumors with spine involvement, without mediastinal N2 lymph node involvement and without distant metastases, are appropriate candidates for complete resection with subsequent spine reconstruction. This review addresses the questions of whether triple modality therapy with complete en bloc resection of locally advanced Pancoast tumors offers an advantage in terms of overall survival and complication rates compared with other therapeutic modalities or therapies with incomplete resection.
METHODS
A comprehensive literature search was conducted using common medical databases. Inclusion and exclusion criteria for the articles were prospectively defined. The articles were independently reviewed and a consensus decision was made about each article. Selected papers were graded by level of evidence.
RESULTS
A total of 1,001 abstracts and 93 articles fulfilled the criteria; from these studies, 14 were included in this systematic review. No level 1 study was found in this search. Four level 2 studies and 10 level 3 retrospective case series were found. The overall 5-year survival rate reported in these studies ranged from 37% to 59% and the mortality rate ranged from 0% to 6.9%.
CONCLUSIONS
Evidence suggests that triple modality therapy with complete resection of locally advanced Pancoast tumors with involvement of the spine offers an advantage over other therapeutic modalities or therapies with incomplete resections.
Topics: Combined Modality Therapy; Humans; Lymphatic Metastasis; Pancoast Syndrome; Prognosis; Prospective Studies; Spinal Neoplasms; Survival Rate
PubMed: 24667403
DOI: 10.1177/107327481402100209 -
Journal of Thoracic Oncology : Official... Aug 2011Accurate clinical staging of mediastinal lymph nodes (MLNs) of patients with non-small cell lung cancer (NSCLC) is important in determining therapeutic options and... (Review)
Review
Diagnostic performance of integrated positron emission tomography/computed tomography for mediastinal lymph node staging in non-small cell lung cancer: a bivariate systematic review and meta-analysis.
INTRODUCTION
Accurate clinical staging of mediastinal lymph nodes (MLNs) of patients with non-small cell lung cancer (NSCLC) is important in determining therapeutic options and prognoses. Integrated positron emission tomography and computed tomography (PET/CT) scanning is becoming widely used for MLN staging in patients with NSCLC. We performed a bivariate meta-analysis to determine the pooled sensitivity (SEN) and specificity (SPE) of this imaging modality.
METHODS
The PubMed/MEDLINE, Embase, and SpringerLink databases were searched for articles related to PET/CT for MLN staging in patients with NSCLC. SEN and SPE were calculated for every study. Hierarchical summary receiver operating characteristic curves were used to summarize overall test performance and assess study quality. Potential between-study heterogeneity was explored by subgroup analyses.
RESULTS
Fourteen of 330 initially identified reports were included in the meta-analysis. When we did not consider the unit of analysis, the pooled weighted SEN and SPE were 0.73 (95% confidence interval [CI]: 0.65-0.79) and 0.92 (95% CI: 0.88-0.94), respectively. In the patient-based data analysis, the pooled weighted SEN was 0.76 (95% CI: 0.65-0.84) and the pooled weighted SPE was 0.88 (95% CI: 0.82-0.92). In the MLN-based data analysis, the pooled SEN was 0.68 (95% CI: 0.56-0.78) and the pooled SPE was 0.95 (95% CI: 0.91-0.97).
CONCLUSIONS
Integrated PET/CT is a relatively accurate noninvasive imaging technique, with excellent specificity for MLN staging in patients with NSCLC. Nevertheless, current evidence suggests that we should not depend on the results of PET/CT completely for MLN staging in patients with NSCLC.
Topics: Carcinoma, Non-Small-Cell Lung; Fluorodeoxyglucose F18; Humans; Lung Neoplasms; Lymph Nodes; Mediastinum; Meta-Analysis as Topic; Neoplasm Staging; Positron-Emission Tomography; Prognosis; Radiopharmaceuticals; Tomography, X-Ray Computed
PubMed: 21642874
DOI: 10.1097/JTO.0b013e31821d4384 -
Cancer Control : Journal of the Moffitt... Apr 2011Central compartment lymph node dissection is a common adjunct to thyroidectomy in the treatment of papillary thyroid cancer. The indications, surgical technique,... (Review)
Review
BACKGROUND
Central compartment lymph node dissection is a common adjunct to thyroidectomy in the treatment of papillary thyroid cancer. The indications, surgical technique, potential benefits, and operative risks of this procedure should be clearly defined in order to provide optimal care to these patients.
METHODS
A systematic review of the literature and an analysis of evidence-based recommendations were performed regarding central neck node dissection for patients with papillary thyroid carcinoma.
RESULTS
Cervical nodal metastasis in papillary thyroid cancer is a common occurrence. The presence of metastasis is associated with increased recurrence rates and may decrease survival. Detection of central and lateral neck nodal metastasis preoperatively with clinical examination and cervical ultrasound is important in determining the appropriate initial surgical management. Level VI neck dissection and central neck dissection are terms often used interchangeably to describe surgical excision of all lymph nodes from the hyoid bone to the sternal notch between the carotid arteries, but the addition of the superior mediastinal lymph nodes in compartment VII should be included in the central neck dissection. Due to improved recurrence rates and survival, therapeutic central neck dissection is recommended for all patients with nodal involvement detected pre- or intraoperatively. Prophylactic central neck dissection in patients without detectable nodal disease remains a controversial topic due to a lack of definitive evidence of improved recurrence rates or survival and the possibility of higher complication rates compared to total thyroidectomy alone. Reoperative central nodal dissection can be a challenging procedure with increased complication rates but with good outcomes in experienced centers.
CONCLUSIONS
Central neck lymph node dissection plays an important role in the appropriate treatment of papillary thyroid cancer at initial presentation and in cases of recurrent disease. Surgeons caring for this group of patients should have familiarity and skill with this procedure.
Topics: Carcinoma; Carcinoma, Papillary; Humans; Lymphatic Metastasis; Neck Dissection; Reoperation; Thyroid Cancer, Papillary; Thyroid Neoplasms
PubMed: 21451450
DOI: 10.1177/107327481101800202