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Точность эндосонографии в предоперационном cТ и сN-стадировании рака желудка: результаты ретроспективного исследования
Точность эндосонографии в предоперационном cТ и сN-стадировании рака желудка: результаты ретроспективного исследования
Бугаёв В.Е., Неред С.Н., Стилиди И.С. Точность эндосонографии в предоперационном cТ и сN-стадировании рака желудка: результаты ретроспективного исследования. Современная Онкология. 2025;27(3):220–224. DOI: 10.26442/18151434.2025.3.203378
© ООО «КОНСИЛИУМ МЕДИКУМ», 2025 г.
© ООО «КОНСИЛИУМ МЕДИКУМ», 2025 г.
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Аннотация
Оптимальная тактика лечения пациентов с ранними и местно-распространенными формами рака желудка (РЖ) напрямую зависит от стадии TNM, что определяет важность точного предоперационного стадирования. В соответствии с международными рекомендациями, комбинация гастроскопии и эндоскопического ультразвукового исследования (эндоУЗИ) – неотъемлемая часть стандартного протокола обследования.
Цель. Оценить точность эндоУЗИ в предоперационном определении стадии T и N при РЖ.
Материалы и методы. В исследование включены 174 больных РЖ, получившие хирургическое лечение без предшествующей химиотерапии. Всем пациентам проводилось стадирование с помощью гастроскопии с эндоУЗИ и компьютерной томографии. После радикальной резекции желудка патоморфологическая стадия T (pT) и стадия N (pN) сравнивались с предоперационной стадией, определенной по данным эндоУЗИ (uT-стадия и uN-стадия).
Результаты. Чувствительность эндоУЗИ варьировалась от 24 при опухолях T4 до 63,9% при стадии T2. Специфичность менялась от 65,9 для T2 до 92,4% для T4. Точность составила 70,52% для опухолей T1, 65,32% при T2, 72,99% при T3 и 81,03% при T4. Правильная оценка стадии T достигнута в 66,7% случаев при T1a, в 50% случаев при T1b, в 32,9% случаев при T2, в 44,7% случаев при T3 и 33,3% случаев при T4a. У пациентов со стадией T2, где наблюдалась наибольшая частота неправильного стадирования, недооценка стадии T произошла в 30% случаев, переоценка – в 37,1% случаев. Для N-стадирования эндоУЗИ показало чувствительность 23,5%, специфичность 89,6% и точность 63,79%.
Заключение. ЭндоУЗИ – обязательная часть первичного стадирования больных РЖ. Для любой стадии T эндоУЗИ чаще переоценивает стадию, чем недооценивает истинную степень инвазии опухоли. Точность диагностики зависит от гистологических особенностей опухоли, например диффузного и перстневидноклеточного рака. Диагностическая ценность эндоУЗИ при N-стадировании низкая.
Ключевые слова: рак желудка, эндосонография, неоадъювантная химиотерапия, стадии TNM, стадирование опухоли
Aim. Assess the accuracy of EUS in assessing the T and N stage in gastric cancer.
Materials and methods. Patients with gastric cancer who received surgical treatment without prior chemotherapy were included in the study. All patients were staged by gastroscopy with EUS and CT scan. Following radical gastric resection, the pathological T-stage (pT) and N-stage (pN) were compared with preoperative stage (uT-stage and uN-stage).
Results. 174 patients were included in the study. The sensitivity of EUS ranged from 24 (for T4) to 63.9% (for T2). Specificity ranged from 65.9 (for T2) to 92.4% (for T4). Accuracy was 70.52, 65.32, 72.99 and 81.03% for T1, T2, T3 and T4 respectively. The T-stage was determined correctly in 66.7% of cases with T1a, in 50% of cases with T1b, in 32.9% of cases with T2, in 44.7% of cases with T3, and in 33.3% of cases with T4a. In patients with T2 tumors, where the greatest frequency of misstaging was observed, underestimation of the T-stage occurred in 30% of cases, overestimation – in 37.1% of cases. For N-staging, EUS has a sensitivity of 23.5%, specificity of 89.6% and an accuracy of 63.79%.
Conclusion. EUS is mandatory part of the initial staging of patients with gastric cancer. For any T-stage, EUS often overestimated the stage rather than underestimated the true extent of tumor invasion. The accuracy of diagnosis is influenced by histological features of the tumor, such as the diffuse type and signet-ring cell carcinoma. Diagnostic value of EUS in N-staging is low.
Keywords: gastric cancer, endosonography, neoadjuvant chemotherapy, TNM stages, tumor staging
Цель. Оценить точность эндоУЗИ в предоперационном определении стадии T и N при РЖ.
Материалы и методы. В исследование включены 174 больных РЖ, получившие хирургическое лечение без предшествующей химиотерапии. Всем пациентам проводилось стадирование с помощью гастроскопии с эндоУЗИ и компьютерной томографии. После радикальной резекции желудка патоморфологическая стадия T (pT) и стадия N (pN) сравнивались с предоперационной стадией, определенной по данным эндоУЗИ (uT-стадия и uN-стадия).
Результаты. Чувствительность эндоУЗИ варьировалась от 24 при опухолях T4 до 63,9% при стадии T2. Специфичность менялась от 65,9 для T2 до 92,4% для T4. Точность составила 70,52% для опухолей T1, 65,32% при T2, 72,99% при T3 и 81,03% при T4. Правильная оценка стадии T достигнута в 66,7% случаев при T1a, в 50% случаев при T1b, в 32,9% случаев при T2, в 44,7% случаев при T3 и 33,3% случаев при T4a. У пациентов со стадией T2, где наблюдалась наибольшая частота неправильного стадирования, недооценка стадии T произошла в 30% случаев, переоценка – в 37,1% случаев. Для N-стадирования эндоУЗИ показало чувствительность 23,5%, специфичность 89,6% и точность 63,79%.
Заключение. ЭндоУЗИ – обязательная часть первичного стадирования больных РЖ. Для любой стадии T эндоУЗИ чаще переоценивает стадию, чем недооценивает истинную степень инвазии опухоли. Точность диагностики зависит от гистологических особенностей опухоли, например диффузного и перстневидноклеточного рака. Диагностическая ценность эндоУЗИ при N-стадировании низкая.
Ключевые слова: рак желудка, эндосонография, неоадъювантная химиотерапия, стадии TNM, стадирование опухоли
________________________________________________
Aim. Assess the accuracy of EUS in assessing the T and N stage in gastric cancer.
Materials and methods. Patients with gastric cancer who received surgical treatment without prior chemotherapy were included in the study. All patients were staged by gastroscopy with EUS and CT scan. Following radical gastric resection, the pathological T-stage (pT) and N-stage (pN) were compared with preoperative stage (uT-stage and uN-stage).
Results. 174 patients were included in the study. The sensitivity of EUS ranged from 24 (for T4) to 63.9% (for T2). Specificity ranged from 65.9 (for T2) to 92.4% (for T4). Accuracy was 70.52, 65.32, 72.99 and 81.03% for T1, T2, T3 and T4 respectively. The T-stage was determined correctly in 66.7% of cases with T1a, in 50% of cases with T1b, in 32.9% of cases with T2, in 44.7% of cases with T3, and in 33.3% of cases with T4a. In patients with T2 tumors, where the greatest frequency of misstaging was observed, underestimation of the T-stage occurred in 30% of cases, overestimation – in 37.1% of cases. For N-staging, EUS has a sensitivity of 23.5%, specificity of 89.6% and an accuracy of 63.79%.
Conclusion. EUS is mandatory part of the initial staging of patients with gastric cancer. For any T-stage, EUS often overestimated the stage rather than underestimated the true extent of tumor invasion. The accuracy of diagnosis is influenced by histological features of the tumor, such as the diffuse type and signet-ring cell carcinoma. Diagnostic value of EUS in N-staging is low.
Keywords: gastric cancer, endosonography, neoadjuvant chemotherapy, TNM stages, tumor staging
Полный текст
Список литературы
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3. Ajani JA, D'Amico TA, Bentrem DJ, et al. Gastric Cancer, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2022;20(2):167-92. DOI:10.6004/jnccn.2022.0008
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5. Al-Batran SE, Homann N, Pauligk C, et al. Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4): a randomised, phase 2/3 trial. Lancet. 2019;393(10184):1948-57. DOI:10.1016/S0140-6736(18)32557-1
6. Shi D, Xi X. Factors Affecting the Accuracy of Endoscopic Ultrasonography in the Diagnosis of Early Gastric Cancer Invasion Depth: A Meta-analysis. Gastroenterol Res Pract. 2019;2019:8241381. DOI:10.1155/2019/8241381
7. Yokota T, Kunii Y, Teshima S, et al. Signet ring cell carcinoma of the stomach: a clinicopathological comparison with the other histological types. Tohoku J Exp Med. 1998;186(2):121-30. DOI:10.1620/tjem.186.121
8. Caletti G, Fusaroli P. The rediscovery of endoscopic ultrasound (EUS) in gastric cancer staging. Endoscopy. 2012;44(6):553-5. DOI:10.1055/s-0032-1309770
9. Cardoso R, Coburn N, Seevaratnam R, et al. A systematic review and meta-analysis of the utility of EUS for preoperative staging for gastric cancer. Gastric Cancer. 2012;15(Suppl. 1):19-26. DOI:10.1007/s10120-011-0115-4
10. Mocellin S, Pasquali S. Diagnostic accuracy of endoscopic ultrasonography (EUS) for the preoperative locoregional staging of primary gastric cancer. Cochrane Database Syst Rev. 2015;2015(2):CD009944. DOI:10.1002/14651858.CD009944.pub2
11. Yoshida S, Tanaka S, Kunihiro K, et al. Diagnostic ability of high-frequency ultrasound probe sonography in staging early gastric cancer, especially for submucosal invasion. Abdom Imaging. 2005;30(5):518-23. DOI:10.1007/s00261-004-0287-z
12. Kim GH, Park DY, Kida M, et al. Accuracy of high-frequency catheter-based endoscopic ultrasonography according to the indications for endoscopic treatment of early gastric cancer. J Gastroenterol Hepatol. 2010;25(3):506-11. DOI:10.1111/j.1440-1746.2009.06111.x
13. Kim JH, Song KS, Youn YH, et al. Clinicopathologic factors influence accurate endosonographic assessment for early gastric cancer. Gastrointest Endosc. 2007;66(5):901-8. DOI:10.1016/j.gie.2007.06.012
14. Lee KG, Shin CI, Kim SG, et al. Can endoscopic ultrasonography (EUS) improve the accuracy of clinical T staging by computed tomography (CT) for gastric cancer? Eur J Surg Oncol. 2021;47(8):1969-75. DOI:10.1016/j.ejso.2021.02.031
15. Tokunaga M, Sato Y, Nakagawa M, et al. Perioperative chemotherapy for locally advanced gastric cancer in Japan: current and future perspectives. Surg Today. 2020;50(1):30-7. DOI:10.1007/s00595-019-01896-5
16. Yokota T, Kunii Y, Teshima S, et al. Signet ring cell carcinoma of the stomach: a clinicopathological comparison with the other histological types. Tohoku J Exp Med. 1998;186(2):121-30. DOI:10.1620/tjem.186.121
17. Adachi Y, Mori M, Enjoji M, Sugimachi K. Microvascular architecture of early gastric carcinoma. Microvascular-histopathologic correlates. Cancer. 1993;72(1):32-6. DOI:10.1002/1097-0142(19930701)72:1<32::aid-cncr2820720108>3.0.co;2-6
18. Kim J, Kim SG, Chung H, et al. Clinical efficacy of endoscopic ultrasonography for decision of treatment strategy of gastric cancer. Surg Endosc. 2018;32(9):3789-97. DOI:10.1007/s00464-018-6104-5
19. Kuroki K, Oka S, Tanaka S, et al. Clinical significance of endoscopic ultrasonography in diagnosing invasion depth of early gastric cancer prior to endoscopic submucosal dissection. Gastric Cancer. 2021;24(1):145-55. DOI:10.1007/s10120-020-01100-5
20. Tsendsuren T, Jun SM, Mian XH. Usefulness of endoscopic ultrasonography in preoperative TNM staging of gastric cancer. World J Gastroenterol. 2006;12(1):43-7. DOI:10.3748/wjg.v12.i1.43
21. Kelly S, Harris KM, Berry E, et al. A systematic review of the staging performance of endoscopic ultrasound in gastro-oesophageal carcinoma. Gut. 2001;49(4):534-9. DOI:10.1136/gut.49.4.534
22. Chang KJ, Katz KD, Durbin TE, et al. Endoscopic ultrasound-guided fine-needle aspiration. Gastrointest Endosc. 1994;40(6):694-9.
2. Lordick F, Carneiro F, Cascinu S, et al. Gastric cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol. 2022;33(10):1005-20. DOI:10.1016/j.annonc.2022.07.004
3. Ajani JA, D'Amico TA, Bentrem DJ, et al. Gastric Cancer, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2022;20(2):167-92. DOI:10.6004/jnccn.2022.0008
4. Besova NS, Kalinin AE, Nered SN, et al. Gastric cancer: Russian clinical guidelines. Journal of Modern Oncology. 2021;23(4):541-71 (in Russian). DOI:10.26442/18151434.2021.4.201239
5. Al-Batran SE, Homann N, Pauligk C, et al. Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4): a randomised, phase 2/3 trial. Lancet. 2019;393(10184):1948-57. DOI:10.1016/S0140-6736(18)32557-1
6. Shi D, Xi X. Factors Affecting the Accuracy of Endoscopic Ultrasonography in the Diagnosis of Early Gastric Cancer Invasion Depth: A Meta-analysis. Gastroenterol Res Pract. 2019;2019:8241381. DOI:10.1155/2019/8241381
7. Yokota T, Kunii Y, Teshima S, et al. Signet ring cell carcinoma of the stomach: a clinicopathological comparison with the other histological types. Tohoku J Exp Med. 1998;186(2):121-30. DOI:10.1620/tjem.186.121
8. Caletti G, Fusaroli P. The rediscovery of endoscopic ultrasound (EUS) in gastric cancer staging. Endoscopy. 2012;44(6):553-5. DOI:10.1055/s-0032-1309770
9. Cardoso R, Coburn N, Seevaratnam R, et al. A systematic review and meta-analysis of the utility of EUS for preoperative staging for gastric cancer. Gastric Cancer. 2012;15(Suppl. 1):19-26. DOI:10.1007/s10120-011-0115-4
10. Mocellin S, Pasquali S. Diagnostic accuracy of endoscopic ultrasonography (EUS) for the preoperative locoregional staging of primary gastric cancer. Cochrane Database Syst Rev. 2015;2015(2):CD009944. DOI:10.1002/14651858.CD009944.pub2
11. Yoshida S, Tanaka S, Kunihiro K, et al. Diagnostic ability of high-frequency ultrasound probe sonography in staging early gastric cancer, especially for submucosal invasion. Abdom Imaging. 2005;30(5):518-23. DOI:10.1007/s00261-004-0287-z
12. Kim GH, Park DY, Kida M, et al. Accuracy of high-frequency catheter-based endoscopic ultrasonography according to the indications for endoscopic treatment of early gastric cancer. J Gastroenterol Hepatol. 2010;25(3):506-11. DOI:10.1111/j.1440-1746.2009.06111.x
13. Kim JH, Song KS, Youn YH, et al. Clinicopathologic factors influence accurate endosonographic assessment for early gastric cancer. Gastrointest Endosc. 2007;66(5):901-8. DOI:10.1016/j.gie.2007.06.012
14. Lee KG, Shin CI, Kim SG, et al. Can endoscopic ultrasonography (EUS) improve the accuracy of clinical T staging by computed tomography (CT) for gastric cancer? Eur J Surg Oncol. 2021;47(8):1969-75. DOI:10.1016/j.ejso.2021.02.031
15. Tokunaga M, Sato Y, Nakagawa M, et al. Perioperative chemotherapy for locally advanced gastric cancer in Japan: current and future perspectives. Surg Today. 2020;50(1):30-7. DOI:10.1007/s00595-019-01896-5
16. Yokota T, Kunii Y, Teshima S, et al. Signet ring cell carcinoma of the stomach: a clinicopathological comparison with the other histological types. Tohoku J Exp Med. 1998;186(2):121-30. DOI:10.1620/tjem.186.121
17. Adachi Y, Mori M, Enjoji M, Sugimachi K. Microvascular architecture of early gastric carcinoma. Microvascular-histopathologic correlates. Cancer. 1993;72(1):32-6. DOI:10.1002/1097-0142(19930701)72:1<32::aid-cncr2820720108>3.0.co;2-6
18. Kim J, Kim SG, Chung H, et al. Clinical efficacy of endoscopic ultrasonography for decision of treatment strategy of gastric cancer. Surg Endosc. 2018;32(9):3789-97. DOI:10.1007/s00464-018-6104-5
19. Kuroki K, Oka S, Tanaka S, et al. Clinical significance of endoscopic ultrasonography in diagnosing invasion depth of early gastric cancer prior to endoscopic submucosal dissection. Gastric Cancer. 2021;24(1):145-55. DOI:10.1007/s10120-020-01100-5
20. Tsendsuren T, Jun SM, Mian XH. Usefulness of endoscopic ultrasonography in preoperative TNM staging of gastric cancer. World J Gastroenterol. 2006;12(1):43-7. DOI:10.3748/wjg.v12.i1.43
21. Kelly S, Harris KM, Berry E, et al. A systematic review of the staging performance of endoscopic ultrasound in gastro-oesophageal carcinoma. Gut. 2001;49(4):534-9. DOI:10.1136/gut.49.4.534
22. Chang KJ, Katz KD, Durbin TE, et al. Endoscopic ultrasound-guided fine-needle aspiration. Gastrointest Endosc. 1994;40(6):694-9.
2. Lordick F, Carneiro F, Cascinu S, et al. Gastric cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol. 2022;33(10):1005-20. DOI:10.1016/j.annonc.2022.07.004
3. Ajani JA, D'Amico TA, Bentrem DJ, et al. Gastric Cancer, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2022;20(2):167-92. DOI:10.6004/jnccn.2022.0008
4. Бесова Н.С., Калинин А.Е., Неред С.Н., и др. Рак желудка. Современная онкология. 2021;23(4):541-71 [Besova NS, Kalinin AE, Nered SN, et al. Gastric cancer: Russian clinical guidelines. Journal of Modern Oncology. 2021;23(4):541-71 (in Russian)]. DOI:10.26442/18151434.2021.4.201239
5. Al-Batran SE, Homann N, Pauligk C, et al. Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4): a randomised, phase 2/3 trial. Lancet. 2019;393(10184):1948-57. DOI:10.1016/S0140-6736(18)32557-1
6. Shi D, Xi X. Factors Affecting the Accuracy of Endoscopic Ultrasonography in the Diagnosis of Early Gastric Cancer Invasion Depth: A Meta-analysis. Gastroenterol Res Pract. 2019;2019:8241381. DOI:10.1155/2019/8241381
7. Yokota T, Kunii Y, Teshima S, et al. Signet ring cell carcinoma of the stomach: a clinicopathological comparison with the other histological types. Tohoku J Exp Med. 1998;186(2):121-30. DOI:10.1620/tjem.186.121
8. Caletti G, Fusaroli P. The rediscovery of endoscopic ultrasound (EUS) in gastric cancer staging. Endoscopy. 2012;44(6):553-5. DOI:10.1055/s-0032-1309770
9. Cardoso R, Coburn N, Seevaratnam R, et al. A systematic review and meta-analysis of the utility of EUS for preoperative staging for gastric cancer. Gastric Cancer. 2012;15(Suppl. 1):19-26. DOI:10.1007/s10120-011-0115-4
10. Mocellin S, Pasquali S. Diagnostic accuracy of endoscopic ultrasonography (EUS) for the preoperative locoregional staging of primary gastric cancer. Cochrane Database Syst Rev. 2015;2015(2):CD009944. DOI:10.1002/14651858.CD009944.pub2
11. Yoshida S, Tanaka S, Kunihiro K, et al. Diagnostic ability of high-frequency ultrasound probe sonography in staging early gastric cancer, especially for submucosal invasion. Abdom Imaging. 2005;30(5):518-23. DOI:10.1007/s00261-004-0287-z
12. Kim GH, Park DY, Kida M, et al. Accuracy of high-frequency catheter-based endoscopic ultrasonography according to the indications for endoscopic treatment of early gastric cancer. J Gastroenterol Hepatol. 2010;25(3):506-11. DOI:10.1111/j.1440-1746.2009.06111.x
13. Kim JH, Song KS, Youn YH, et al. Clinicopathologic factors influence accurate endosonographic assessment for early gastric cancer. Gastrointest Endosc. 2007;66(5):901-8. DOI:10.1016/j.gie.2007.06.012
14. Lee KG, Shin CI, Kim SG, et al. Can endoscopic ultrasonography (EUS) improve the accuracy of clinical T staging by computed tomography (CT) for gastric cancer? Eur J Surg Oncol. 2021;47(8):1969-75. DOI:10.1016/j.ejso.2021.02.031
15. Tokunaga M, Sato Y, Nakagawa M, et al. Perioperative chemotherapy for locally advanced gastric cancer in Japan: current and future perspectives. Surg Today. 2020;50(1):30-7. DOI:10.1007/s00595-019-01896-5
16. Yokota T, Kunii Y, Teshima S, et al. Signet ring cell carcinoma of the stomach: a clinicopathological comparison with the other histological types. Tohoku J Exp Med. 1998;186(2):121-30. DOI:10.1620/tjem.186.121
17. Adachi Y, Mori M, Enjoji M, Sugimachi K. Microvascular architecture of early gastric carcinoma. Microvascular-histopathologic correlates. Cancer. 1993;72(1):32-6. DOI:10.1002/1097-0142(19930701)72:1<32::aid-cncr2820720108>3.0.co;2-6
18. Kim J, Kim SG, Chung H, et al. Clinical efficacy of endoscopic ultrasonography for decision of treatment strategy of gastric cancer. Surg Endosc. 2018;32(9):3789-97. DOI:10.1007/s00464-018-6104-5
19. Kuroki K, Oka S, Tanaka S, et al. Clinical significance of endoscopic ultrasonography in diagnosing invasion depth of early gastric cancer prior to endoscopic submucosal dissection. Gastric Cancer. 2021;24(1):145-55. DOI:10.1007/s10120-020-01100-5
20. Tsendsuren T, Jun SM, Mian XH. Usefulness of endoscopic ultrasonography in preoperative TNM staging of gastric cancer. World J Gastroenterol. 2006;12(1):43-7. DOI:10.3748/wjg.v12.i1.43
21. Kelly S, Harris KM, Berry E, et al. A systematic review of the staging performance of endoscopic ultrasound in gastro-oesophageal carcinoma. Gut. 2001;49(4):534-9. DOI:10.1136/gut.49.4.534
22. Chang KJ, Katz KD, Durbin TE, et al. Endoscopic ultrasound-guided fine-needle aspiration. Gastrointest Endosc. 1994;40(6):694-9.
________________________________________________
2. Lordick F, Carneiro F, Cascinu S, et al. Gastric cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol. 2022;33(10):1005-20. DOI:10.1016/j.annonc.2022.07.004
3. Ajani JA, D'Amico TA, Bentrem DJ, et al. Gastric Cancer, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2022;20(2):167-92. DOI:10.6004/jnccn.2022.0008
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Авторы
В.Е. Бугаёв*1, С.Н. Неред1,2, И.С. Стилиди1
1ФГБУ «Национальный медицинский исследовательский центр онкологии им. Н.Н. Блохина» Минздрава России, Москва, Россия;
2ФГБОУ ДПО «Российская медицинская академия непрерывного профессионального образования» Минздрава России, Москва, Россия
*vladbugaev@mail.ru
1Blokhin National Medical Research Center of Oncology, Moscow, Russia;
2Russian Medical Academy of Continuous Professional Education, Moscow, Russia
*vladbugaev@mail.ru
1ФГБУ «Национальный медицинский исследовательский центр онкологии им. Н.Н. Блохина» Минздрава России, Москва, Россия;
2ФГБОУ ДПО «Российская медицинская академия непрерывного профессионального образования» Минздрава России, Москва, Россия
*vladbugaev@mail.ru
________________________________________________
1Blokhin National Medical Research Center of Oncology, Moscow, Russia;
2Russian Medical Academy of Continuous Professional Education, Moscow, Russia
*vladbugaev@mail.ru
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