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#4909431 by Rapa22 [Power User] at 30/11/2018 - 21:44:16 GMT Rep. + Rep. -

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Il asteptam ! :love:

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O echipa de agen?i secre?i israelieni �ncearca sa dea de urma criminalului de
razboi, Adolf Eichmann (Ben Kingsley), coordonatorul nazist al Holocaust-ului din
timpul celui de-al Doilea Razboi Mondial.

Romania o arde in engleza !

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@TopSecret, it's good to kown.
Este bine de stiut.
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Multumesc.

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Tumorile de cavum

Autor: Pavaloiu Giorgiana , publicat la 04-07-2014

Tumorile de cavum
Cancerul de cavum se refera la cancerul de nazofaringe (rinofaringe). Cancerul de
cavum este un cancer rar comparativ cu alte tipuri de cancere (s�n, colon, prostata
etc); este un cancer mai frecvent �nt�lnit �n Asia si Africa de Nord, �n Statele
Unite ale Americii, �n schimb, este relativ rar (aproximativ 2900 de persoane
diagnosticate �n fiecare an). [1]
Anatomie
Faringele este organul la nivelul caruia calea respiratorie se �ncruciseaza cu
calea digestiva. Rinofaringele reprezinta etajul superior al faringelui, are o
forma cuboidala si este constituit din 6 pereti: 2 pereti laterali, unde se gasesc
orificiile faringiene ale trompei lui Eustachio si fosetele Rosenmuller, un perete
inferior, locul de comunicare cu bucofaringele, un perete anterior, prin care
comunica cu fosele nazale, un perete posterior si un perete superior, unde se
gaseste amigdala faringiana Lushka [2].

Factori de risc
Fumatul
Fumatul reprezinta unul din principalii factori de risc pentru cancerele de cap si
g�t (printre care si carcinomul nazofaringian). Fumatul pasiv creste, de asemenea,
riscul de carcinom nazofaringian.

Alcoolul
Consumul cronic de alcool creste riscul de aparitie al cancerului de nazofaringe.
Exista un risc �nca si mai mare �n cazul sunt prezenti ambii factori de risc:
alcool si fumatul; acest risc este �nsa mai mic dec�t �n cazul altor tipuri de
cancere de cap si g�t.

Alti factori de risc

etnia: cancerul de cavum este mai frecvent la asiatici
sexul: barbatii au risc de doua mai mare de a dezvolta cancer de nazofaringe dec�t
femeile
expunerea la Epstein Barr: virusul care determina mononucleoza infectioasa (clasic,
boala sarutului) este asociat cu cancerul de nazofaringe
dieta: consumul cronic de carne si peste cre?te riscul de a dezvolta cancer de
cavum
factori de mediu: expunerea la fumul de tigara (fumatul pasiv) si praf cresc riscul
de apari?ie al cancerului de cavum
marijuana: s-a demonstrat ca marijuana este asociata cu acest tip de cancer [1]

Clasificare

�n rinofaringe se pot dezvolta mai multe tipuri de tumori maligne, �nsa tipul cel
mai frecvent este carcinomul nazofaringian scuamos nediferentiat. Potrivit OMS,
tumorile de cavum se �mpart �n 3 mari categorii:

carcinom nazofaringian nediferentiat

carcinom nazofaringian scuamos keratinizant
carcinom nazofaringian scuamos non-keratinizant
Histologic, au fost descrise mai multe tipuri de tumori de cavum:

1. Limfoepiteliomul este o tumora care deriva din tesutul adenoid de la acest

nivel, radiosensibila, cu o evolutie lenta. Se prezinta ca o tumora vegetanta,
moale, uneori ulcerata. De obicei, limfoepitelomul determina adenopatii cervicale
bilaterale, chiar �n stadiile incipiente, de regula nu determina metastaze osoase.
2. Carcinomul apare de obicei la adult, dupa v�rsta de 40 de ani, are o evolutie
rapida, si se poate manifesta initial prin adenopatii cervicale. Poate ulcera si
determina s�ngerari la nivelul rinofaringelui.

3. Sarcomul apare ca o tumora neteda, regulata si dura; poate aparea la orice

v�rsta. Spre deosebire de carcinom, evolueaza mai rapid, nu determina (de obicei)
adenopatii si nu ulcereaza.

4. Limfocitomul deriva din vegetatiile adenoide la acest nivel, apare de regula la

pacientii tineri si are o evolutie rapida. Se prezinta ca o tumora vegetanta,
moale, neulcerata, �nsotita de adenopatii cervicale bilaterale.

5. Tumorile conjunctive (sarcomul si limfocitomul) se aseamana din punct de vedere

histologic cu limfoepiteliomul dar sunt mai rar �nt�lnite.

Simptome si semne
adenopatii cervicale nedureroase
obstruc?ie nazala
otite medii recurente
afectari ale nervilor cranieni II (manifestari oculare), VIII (manifestari auditive
si vestibulare), IX si XII (tulburari de deglutitie)
cefalee

�n perioada de debut, simptomatologia este nespecifica si se instaleaza lent, ceea

ce face ca diagnosticul sa fie pus de cele mai multe ori tardiv. Tumora de cavum se
manifesta mai degraba prin semne si simptome de vecinatate, prin interceptarea
structurilor din jur: simptome auriculare, oculare, rinofaringiene etc.

�n perioada de stare, tumora de cavum se manifesta �n principiu prin aceleasi

simptome �nsa mai pregnant: se accentueaza obstructia nazala, hipoacuzia devine
bilaterala, durerea se intensifica etc. Tumora se poate extinde �n toate
directiile: superior, spre baza craniului (unde poate intercepta nervii cranieni si
poate mima simptomatolgia data de o tumora cerebrala) ; lateral, spre peretii
laterali ai faringelui (cu aparitia otalgiei si a trismusului, contractia
masterilor) ; inferior, spre valul palatin (determin�nd tulburari de deglutitie si
fonatie), anterior, spre globii oculari (cu aparitia exoftalmiei, protruzia
globilor oculari).

Rinoscopia
�n perioada de debut, la rinoscopia anterioara nu se deceleaza nicio leziune la
nivelul nazofaringelui. �n perioada de stare, c�nd tumora �ncepe sa creasca �n
dimensiuni, se poate decela o formatiune tumorala moale, vegetanta, nedureroasa (�n
cazul limfoepiteliomului). La palpare, se pot gasi adenopatii cervicale dure,
fixate, nedureroase, uni sau bilaterale.

Diagnosticul pozitiv

Diagnosticul tumorii de cavum se bazeaza pe biopsie si examen histopatologic, ca �n

cazul oricarei tumori. Pe l�nga examenul histopatologic, trebuie efectuat un bilant
care sa cuprinda :

examinare ORL : rinoscopie anterioara, rinoscopie posterioara, otoscopie, palpare

cervicala
examen neuro-oftalmologic si audiologic
RMN cervicofacial cu contrast, CT cervicofacial cu contrast, PET-CT
CT toracic cu contrast, scintigrafie osoasa, CT cerebral, bilant hepatic, ecografie
hepatica (�n cautarea unor metastaze)
teste pentru depistarea virusului Epstein Barr

Pot fi necesare si alte investigatii �n functie de pacient (pentru depistarea unor

metastaze la distanta etc).

Clasificare TNM

T1- tumora limitata la nazofaringe

T2: extindere spre orofaringe, fose nazale

T3- invazii osoase, invazia sinusurilor

T4- extensie intracraniana, orbita, fosa infratemporala etc

Adenopatii

N1- adenopatie de maximum 6 cm diametru

N2- adenopatii bilaterala de maximum 6 cm diametru

N3- 3a- adenopatii de peste 6cm, 3b- adenopatii subclaviculare

Metastaze

M0- fara metastaze

M1- cu metastaze la distanta

Diagnostic diferential
fibrom nazofaringian (nu este asociat �n general cu adenopatii, nu s�ngereaza)
polip Killian
vegeta?ii adenoide hipertrofice
tuberculoza, goma sifilitica

Tratament

Tratamentul standard pentru pacientii cu carcinom nazofaringian cuprinde [3]:

1. Radioterapie
2. Radioterapie urmata de chimioterapie
3. Chirurgie- mai rar, �n cazul adenopatiilor metastatice reziduale
4. Chimioterapie- �n stadiul metastatic (metastaze la distanta)
Chimioterapia combinata cu radioterapia �n doze mari reprezinta tratamentul de
prima intentie pentru carcinomul nazofaringian. Tratamentul chirurgical este
indicat atunci c�nd adenopatiile nu regreseaza complet la radioterapie. Doza si
c�mpul de radioterapie variaza �n functie de pacient (dimensiunea si localizarea
tumorii si a adenopatiilor). Majoritatea cazurilor sunt tratate prin radioterapie
externa �nsa �n unele situatii se pot folosi implante intracavitare sau
interstitiale sau se poate recurge la radioterapie stereotactica.

Radioterapia cu intensitate modulata (IMRT- intensity modulated radiation therapy)

determina mai putin reactii adverse dec�t radioterapia bi- sau tridimensionala
conventionala; studiile au aratat ca IMRT este asociata cu o mai calitate a vietii
mai buna (inciden?a xerostomiei, de exemplu, este mai mica �n cazul IMRT) [5].

Carcinomul nazofaringian stadiu I:

1. radioterapie in doze mari cu inten?ie curativa

2. radioterapie profilactica �n teritoriul de drenaj limfatic al tumorii

Carcinomul nazofaringian stadiu II:

1. chemoiradiere urmata de chimioterapie adjuvanta

2. radioterapie �n doze mari cu inten?ie curativa ?i radioterapie profilactica �n

teritoriul de drenaj limfatic al tumorii

Carcinomul nazofaringian stadiu III:

1. tratament combinat radioterapie-chimioterapie

2. radioterapie fractionata

3. tratament chirurgical �n caz de adenopatii restante

Exista si alte optiuni de tratament �n curs de evaluare, cum ar fi chimioterapia
neoadjuvanta. Chimioterapia neoadjuvanta este folosita pentru a micsora tumorile de
cavum cu scopul de a creste rata de succes a radioterapiei. Chimioterapia
neoadjuvanta presupune ca se aplica �naintea altor metode de tratament, este
diferita asadar de chimioterapia adjuvanta care se aplica dupa un alt tratament
(radioterapie sau tratament chirurgical).

S-a urmarit eficacitatea tratamentului combinat radioterapie- chimioterapie

(cisplatin, epirubicina, bleomicina) comparativ cu tratamentul radioterapic
(monoterapie) �n doua studii clinice prospective [4] si s-a demonstrat ca rata de
supravietuire este mai mare �n cazul primului grup, adica in cazul tratamentului
combinat chimioterapie-radioterapie.

Exista si alte studii �n curs de desfasurare care urmaresc eficacitatea unor scheme
de tratament: chimioterapie administrata �naintea radioterapiei, chimioterapie
administrata concomitent cu radioterapia si chimioterapie adjuvanta dupa
tratamentul radioterapic.

Carcinomul nazofaringian stadiu IV:

1. chemoiradiere urmata de chimioterapie adjuvanta

2. radioterapie frac?ionata

3. tratament chirurgical �n cazul adenopatiilor metastatice

4. chimioterapie

Exista mai multe studii �n curs de desfasurare care urmaresc eficacitatea

chimioterapiei neoadjuvante sau tratamentul combinat radioterapie-chimioterapie.

Un studiu clinic randomizat realizat pe 65 de pacienti cu carcinom nazofaringian

stadiu III si IV, tratati fie prin chemoiradiere (monoterapie) fie prin
chimioterapie neoadjuvanta (docetaxel, cisplatin), a demonstrat ca rata de
supravietuire la 3 ani a fost mai mare �n cazul grupului supus chimioterapiei
neoadjuvante comparativ cu grupul control (94, 1% versus 67, 7%) [4].

Carcinomul nazofaringian recidivat

Tratamentul standard al cancerului recidivat:

1. pacientii cu tumora de cavum recidivata pot fi retratati cu doze moderate de

radioterapie: IMRT, radioterapie stereotactica, radioterapie intracavitara sau
intesti?iala
2. tratament chirurgical �n cazul bolii reziduale doar la pacien?i atent
selectiona?i (indicatii limitate)

3. �n cazul pacientilor cu boala recidivata sau metastatica care nu preteaza la

radioterapie sau chirurgie, se recomanda chimioterapia

Prognostic

Factorii care influenteaza prognosticul unui pacient cu tumora de cavum sunt:

dimensiunea tumorii: cu c�t tumora are o dimensiune mai mare la momentul

diagnosticului cu at�t prognosticul este mai prost
stadiul tumorii: un stadiu mai avansat este, de asemenea, asociat cu un prognostic
mai slab
prezen?a adenopatiilor metastatice: asociata cu un prognostic mai prost

Alti factori care influenteaza prognosticul sunt: v�rsta, statusul imun al

pacientului, intervalul de timp lung �ntre diagnostic si �nceperea radioterapiei,
sarcina, recidiva, anumite tipuri de Epstein Barr, excizia incompleta a
ganglionilor metastatici [3].

Cancerul de cavum se refera la cancerul de nazofaringe (rinofaringe). Cancerul de

cavum este un cancer rar comparativ cu alte tipuri de cancere (san, colon, prostata
etc); este un cancer mai frecvent intalnit in Asia si Africa de Nord, in Statele
Unite ale Americii, in schimb, este relativ rar (aproximativ 2900 de persoane
diagnosticate in fiecare an). [1]

Anatomie
Faringele este organul la nivelul caruia calea respiratorie se incruciseaza cu
calea digestiva. Rinofaringele reprezinta etajul superior al faringelui, are o
forma cuboidala si este constituit din 6 pereti: 2 pereti laterali, unde se gasesc
orificiile faringiene ale trompei lui Eustachio si fosetele Rosenmuller, un perete
inferior, locul de comunicare cu bucofaringele, un perete anterior, prin care
comunica cu fosele nazale, un perete posterior si un perete superior, unde se
gaseste amigdala faringiana Lushka [2].

Factori de risc
Fumatul
Fumatul reprezinta unul din principalii factori de risc pentru cancerele de cap si
gat (printre care si carcinomul nazofaringian). Fumatul pasiv creste, de asemenea,
riscul de carcinom nazofaringian.

Alcoolul
Consumul cronic de alcool creste riscul de aparitie al cancerului de nazofaringe.
Exista un risc inca si mai mare in cazul sunt prezenti ambii factori de risc:
alcool si fumatul; acest risc este insa mai mic decat in cazul altor tipuri de
cancere de cap si gat.

Alti factori de risc

etnia: cancerul de cavum este mai frecvent la asiatici
sexul: barbatii au risc de doua mai mare de a dezvolta cancer de nazofaringe decat
femeile
expunerea la Epstein Barr: virusul care determina mononucleoza infectioasa (clasic,
boala sarutului) este asociat cu cancerul de nazofaringe
dieta: consumul cronic de carne si peste creste riscul de a dezvolta cancer de
cavum
factori de mediu: expunerea la fumul de tigara (fumatul pasiv) si praf cresc riscul
de aparitie al cancerului de cavum
marijuana: s-a demonstrat ca marijuana este asociata cu acest tip de cancer [1]

Clasificare

In rinofaringe se pot dezvolta mai multe tipuri de tumori maligne, insa tipul cel
mai frecvent este carcinomul nazofaringian scuamos nediferentiat. Potrivit OMS,
tumorile de cavum se impart in 3 mari categorii:

carcinom nazofaringian nediferentiat

carcinom nazofaringian scuamos keratinizant
carcinom nazofaringian scuamos non-keratinizant
Histologic, au fost descrise mai multe tipuri de tumori de cavum:

1. Limfoepiteliomul este o tumora care deriva din tesutul adenoid de la acest

nivel, radiosensibila, cu o evolutie lenta. Se prezinta ca o tumora vegetanta,
moale, uneori ulcerata. De obicei, limfoepitelomul determina adenopatii cervicale
bilaterale, chiar in stadiile incipiente, de regula nu determina metastaze osoase.

2. Carcinomul apare de obicei la adult, dupa varsta de 40 de ani, are o evolutie

rapida, si se poate manifesta initial prin adenopatii cervicale. Poate ulcera si
determina sangerari la nivelul rinofaringelui.

3. Sarcomul apare ca o tumora neteda, regulata si dura; poate aparea la orice

varsta. Spre deosebire de carcinom, evolueaza mai rapid, nu determina (de obicei)
adenopatii si nu ulcereaza.

4. Limfocitomul deriva din vegetatiile adenoide la acest nivel, apare de regula la

pacientii tineri si are o evolutie rapida. Se prezinta ca o tumora vegetanta,
moale, neulcerata, insotita de adenopatii cervicale bilaterale.
5. Tumorile conjunctive (sarcomul si limfocitomul) se aseamana din punct de vedere
histologic cu limfoepiteliomul dar sunt mai rar intalnite.

Simptome si semne
adenopatii cervicale nedureroase
obstructie nazala
otite medii recurente
afectari ale nervilor cranieni II (manifestari oculare), VIII (manifestari auditive
si vestibulare), IX si XII (tulburari de deglutitie)
cefalee

In perioada de debut, simptomatologia este nespecifica si se instaleaza lent, ceea

ce face ca diagnosticul sa fie pus de cele mai multe ori tardiv. Tumora de cavum se
manifesta mai degraba prin semne si simptome de vecinatate, prin interceptarea
structurilor din jur: simptome auriculare, oculare, rinofaringiene etc.

In perioada de stare, tumora de cavum se manifesta in principiu prin aceleasi

simptome insa mai pregnant: se accentueaza obstructia nazala, hipoacuzia devine
bilaterala, durerea se intensifica etc. Tumora se poate extinde in toate
directiile: superior, spre baza craniului (unde poate intercepta nervii cranieni si
poate mima simptomatolgia data de o tumora cerebrala) ; lateral, spre peretii
laterali ai faringelui (cu aparitia otalgiei si a trismusului, contractia
masterilor) ; inferior, spre valul palatin (determinand tulburari de deglutitie si
fonatie), anterior, spre globii oculari (cu aparitia exoftalmiei, protruzia
globilor oculari).

Rinoscopia
In perioada de debut, la rinoscopia anterioara nu se deceleaza nicio leziune la
nivelul nazofaringelui. In perioada de stare, cand tumora incepe sa creasca in
dimensiuni, se poate decela o formatiune tumorala moale, vegetanta, nedureroasa (in
cazul limfoepiteliomului). La palpare, se pot gasi adenopatii cervicale dure,
fixate, nedureroase, uni sau bilaterale.

Diagnosticul pozitiv

Diagnosticul tumorii de cavum se bazeaza pe biopsie si examen histopatologic, ca in

cazul oricarei tumori. Pe langa examenul histopatologic, trebuie efectuat un bilant
care sa cuprinda :

examinare ORL : rinoscopie anterioara, rinoscopie posterioara, otoscopie, palpare

cervicala
examen neuro-oftalmologic si audiologic
RMN cervicofacial cu contrast, CT cervicofacial cu contrast, PET-CT
CT toracic cu contrast, scintigrafie osoasa, CT cerebral, bilant hepatic, ecografie
hepatica (in cautarea unor metastaze)
teste pentru depistarea virusului Epstein Barr
Pot fi necesare si alte investigatii in functie de pacient (pentru depistarea unor
metastaze la distanta etc).

Clasificare TNM

T1- tumora limitata la nazofaringe

T2: extindere spre orofaringe, fose nazale

T3- invazii osoase, invazia sinusurilor

T4- extensie intracraniana, orbita, fosa infratemporala etc

Adenopatii

N1- adenopatie de maximum 6 cm diametru

N2- adenopatii bilaterala de maximum 6 cm diametru

N3- 3a- adenopatii de peste 6cm, 3b- adenopatii subclaviculare

Metastaze

M0- fara metastaze

M1- cu metastaze la distanta

Diagnostic diferential

fibrom nazofaringian (nu este asociat in general cu adenopatii, nu sangereaza)

polip Killian
vegetatii adenoide hipertrofice
tuberculoza, goma sifilitica

Tratament

Tratamentul standard pentru pacientii cu carcinom nazofaringian cuprinde [3]:

1. Radioterapie
2. Radioterapie urmata de chimioterapie
3. Chirurgie- mai rar, in cazul adenopatiilor metastatice reziduale
4. Chimioterapie- in stadiul metastatic (metastaze la distanta)
Chimioterapia combinata cu radioterapia in doze mari reprezinta tratamentul de
prima intentie pentru carcinomul nazofaringian. Tratamentul chirurgical este
indicat atunci cand adenopatiile nu regreseaza complet la radioterapie. Doza si
campul de radioterapie variaza in functie de pacient (dimensiunea si localizarea
tumorii si a adenopatiilor). Majoritatea cazurilor sunt tratate prin radioterapie
externa insa in unele situatii se pot folosi implante intracavitare sau
interstitiale sau se poate recurge la radioterapie stereotactica.

Radioterapia cu intensitate modulata (IMRT- intensity modulated radiation therapy)

determina mai putin reactii adverse decat radioterapia bi- sau tridimensionala
conventionala; studiile au aratat ca IMRT este asociata cu o mai calitate a vietii
mai buna (incidenta xerostomiei, de exemplu, este mai mica in cazul IMRT) [5].

Carcinomul nazofaringian stadiu I:

1. radioterapie in doze mari cu intentie curativa

2. radioterapie profilactica in teritoriul de drenaj limfatic al tumorii

Carcinomul nazofaringian stadiu II:

1. chemoiradiere urmata de chimioterapie adjuvanta

2. radioterapie in doze mari cu intentie curativa si radioterapie profilactica in

teritoriul de drenaj limfatic al tumorii

Carcinomul nazofaringian stadiu III:

1. tratament combinat radioterapie-chimioterapie

2. radioterapie fractionata

3. tratament chirurgical in caz de adenopatii restante

Exista si alte optiuni de tratament in curs de evaluare, cum ar fi chimioterapia

neoadjuvanta. Chimioterapia neoadjuvanta este folosita pentru a micsora tumorile de
cavum cu scopul de a creste rata de succes a radioterapiei. Chimioterapia
neoadjuvanta presupune ca se aplica inaintea altor metode de tratament, este
diferita asadar de chimioterapia adjuvanta care se aplica dupa un alt tratament
(radioterapie sau tratament chirurgical).

S-a urmarit eficacitatea tratamentului combinat radioterapie- chimioterapie

(cisplatin, epirubicina, bleomicina) comparativ cu tratamentul radioterapic
(monoterapie) in doua studii clinice prospective [4] si s-a demonstrat ca rata de
supravietuire este mai mare in cazul primului grup, adica in cazul tratamentului
combinat chimioterapie-radioterapie.
Exista si alte studii in curs de desfasurare care urmaresc eficacitatea unor scheme
de tratament: chimioterapie administrata inaintea radioterapiei, chimioterapie
administrata concomitent cu radioterapia si chimioterapie adjuvanta dupa
tratamentul radioterapic.

Carcinomul nazofaringian stadiu IV:

1. chemoiradiere urmata de chimioterapie adjuvanta

2. radioterapie fractionata

3. tratament chirurgical in cazul adenopatiilor metastatice

4. chimioterapie

Exista mai multe studii in curs de desfasurare care urmaresc eficacitatea

chimioterapiei neoadjuvante sau tratamentul combinat radioterapie-chimioterapie.

Un studiu clinic randomizat realizat pe 65 de pacienti cu carcinom nazofaringian

stadiu III si IV, tratati fie prin chemoiradiere (monoterapie) fie prin
chimioterapie neoadjuvanta (docetaxel, cisplatin), a demonstrat ca rata de
supravietuire la 3 ani a fost mai mare in cazul grupului supus chimioterapiei
neoadjuvante comparativ cu grupul control (94, 1% versus 67, 7%) [4].

Carcinomul nazofaringian recidivat

Tratamentul standard al cancerului recidivat:

1. pacientii cu tumora de cavum recidivata pot fi retratati cu doze moderate de

radioterapie: IMRT, radioterapie stereotactica, radioterapie intracavitara sau
intestitiala

2. tratament chirurgical in cazul bolii reziduale doar la pacienti atent

selectionati (indicatii limitate)

3. in cazul pacientilor cu boala recidivata sau metastatica care nu preteaza la

radioterapie sau chirurgie, se recomanda chimioterapia

Prognostic

Factorii care influenteaza prognosticul unui pacient cu tumora de cavum sunt:

dimensiunea tumorii: cu cat tumora are o dimensiune mai mare la momentul

diagnosticului cu atat prognosticul este mai prost
stadiul tumorii: un stadiu mai avansat este, de asemenea, asociat cu un prognostic
mai slab
prezenta adenopatiilor metastatice: asociata cu un prognostic mai prost

Alti factori care influenteaza prognosticul sunt: varsta, statusul imun al

pacientului, intervalul de timp lung intre diagnostic si inceperea radioterapiei,
sarcina, recidiva, anumite tipuri de Epstein Barr, excizia incompleta a
ganglionilor metastatici [3].

Publicat la 04-07-2014 | Vizite: 15483 | bibliografie

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MANUAL OF TEMPORALBONE DISSECTION

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MANUAL OF TEMPORALBONE DISSECTION
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