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Bakkar S, Chorti A, Papavramidis T, AlHalaseh M, Aljarrah Q, Donatini G, Miccoli P. Verifying the oncologic rationale of prophylactic central compartment neck dissection in the management of papillary thyroid carcinoma using a pathologic spectrum of nodal metastases characteristics. A Prospective Comparative study. Endocrine 2025:10.1007/s12020-025-04209-8. [PMID: 40024949 DOI: 10.1007/s12020-025-04209-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2024] [Accepted: 02/20/2025] [Indexed: 03/04/2025]
Abstract
BACKGROUND Disease-free survival is the main outcome of interest considered when assessing the effectiveness of surgical management of papillary thyroid carcinoma (PTC). Specific characteristics of nodal metastases have been demonstrated to impact the risk of recurrence. OBJECTIVE Verify the oncologic rationale of prophylactic central compartment neck dissection (pCCND) in the management of PTC by comparing the pathologic spectrum of lymph nodes in patient's undergoing pCCND vs. therapeutic CCND (tCCND). METHODS Between May 2017 and October 2018, 257 patients underwent total thyroidectomy for PTC. pCCND was performed for clinically uninvolved nodes, and tCCND for clinically apparent nodal disease. Harvested metastatic nodes from each group were compared in terms of number, size, and the presence of extranodal extension. Cut-off values for the size and number were 2 mm and 5, respectively. Patients were followed until October 2023. RESULTS 78 patients underwent tCCND. Whereas pCCND was performed in 179 patients. The mean number of nodes harvested in tCCND was 14 (9-31), and 9 (5-24) in pCCND (p < 0.0001). Node positivity was 84.6, and 37.4%, respectively (p < 0.0001). ≥5 metastatic nodes were harvested in 66.6% of tCCND vs. 7.5% of pCCND (p < 0.0001). 73% of tCCND had a metastatic node ≥2 mm in size vs. 2.5% of pCCND (p < 0.0001). Extranodal extension occurred in 25% of tCCND vs. 2.5% of pCCND (p = 0.01). Recurrence rate was 3.8% in tCCND vs. none in pCCND (p = 0.008). CONCLUSION Clinically inapparent nodal disease has a pathological spectrum with insignificant impact on disease recurrence. Therefore, pCCND does not seem to be oncologically meaningful.
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Affiliation(s)
- Sohail Bakkar
- Department of General and Specialized Surgery, Faculty of Medicine, The Hashemite University, Zarqa, Jordan.
| | - Angeliki Chorti
- 1st Propaedeutic Surgical Department, University Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki (AUTH), Thessaloniki, Greece
| | - Theodosis Papavramidis
- 1st Propaedeutic Surgical Department, University Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki (AUTH), Thessaloniki, Greece
| | - Mais AlHalaseh
- Nuclear Medicine Department, MEDRAY Center, Amman, Jordan
| | - Qusai Aljarrah
- Department of General Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Gianluca Donatini
- Department of General and Endocrine Surgery, University of Poitiers, CHU Poitiers, Poitiers, France
| | - Paolo Miccoli
- Department of Surgical, Medical, Pathology, and Critical Care, The University of Pisa, Pisa, Italy
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Ruiz-García C, Rodrigáñez Riesco L, Mateos-Serrano B, Bernáldez Millán R, Del Palacio Muñoz AJ, Gavilán J, Parra Ramírez P, Martín-Rojas Marcos P, Lisbona Catalán A, Lecumberri B, Álvarez-Escolá C, Castro A. Disease-free survival and response to therapy of clinically node- negative Papillary Thyroid Cancer treated without central neck dissection: Retrospective study of 321 patients. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2024; 75:224-230. [PMID: 38346491 DOI: 10.1016/j.otoeng.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/12/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND AND OBJECTIVE Nodal metastases in the central compartment are frequent in papillary thyroid cancer (PTC). However, they are mostly micrometastases with no impact on survival and their relevance on the risk of locoregional relapse is controversial. There is no consensus regarding optimal management of the central neck in patients with PTC cN0. In our center, we do not perform prophylactic central neck dissection (pCND). The objective of this study is to review our long-term results and compare them with the most recent literature. PATIENTS AND METHODS Retrospective review of patients with PTC who underwent total thyroidectomy (TT) without CND between 2005 and 2017. Primary result was disease-free survival in the neck (DFS). RESULTS 321 patients were identified, mostly T1-T2 tumors (94.1%). Median follow-up was 90 months. DFS in the central compartment was excellent (96.1% at 10 year's follow-up). 19 patients had cervical recurrence, of which 15 underwent salvage surgery. On their last visit, including salvage surgery when appropriate, 77% of patients had excellent response, 18.7% had indeterminate response, 3.1% had biochemically incomplete response and 1.2% had morphologically incomplete response. Recurrent laryngeal nerve (RLN) paralysis after TT was transient in 4.7% of patients and permanent in 0.9% of patients. There were no RLN paralysis after salvage surgery. Permanent hypoparathyroidism occurred in 3.4% of patients. Only one patient had hypoparathyroidism after salvage surgery and it was permanent. CONCLUSIONS Based on long-term results and low rate of complications associated with salvage surgery in our experience, we consider routine pCND is not justified.
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Affiliation(s)
- Carmen Ruiz-García
- Otorhinolaryngology Department, Hospital Universitario La Paz, Madrid, Spain
| | | | | | | | | | - Javier Gavilán
- Otorhinolaryngology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Paola Parra Ramírez
- Endocrinology and Nutrition Department, Hospital Universitario La Paz, Madrid, Spain
| | | | | | - Beatriz Lecumberri
- Endocrinology and Nutrition Department, Hospital Universitario La Paz, Madrid, Spain
| | | | - Alejandro Castro
- Otorhinolaryngology Department, Hospital Universitario La Paz, Madrid, Spain.
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Baud G, Chereau N, De Ponthaud C, Santucci N, Sebag F, Goudet P. Scope of prophylactic lymph node dissection in the surgical treatment of differentiated thyroid cancer. Recommendations of the AFCE (Association francophone de chirurgie endocrinienne) with the SFE (Société française d'endocrinologie) and the SFMN (Société française de médecine nucléaire). J Visc Surg 2023; 160:S84-S87. [PMID: 37127470 DOI: 10.1016/j.jviscsurg.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Prophylactic lymph node dissection is considered only for papillary cancers. It is not indicated for vesicular cancers or oncocytic cancers, nor should it entail a secondary surgical intervention in the event of an incidental discovery of papillary cancer on a thyroidectomy specimen. Prophylactic lymph node dissection means a cervical lymph node dissection in the absence of any pre- or intraoperative evidence (biological, cytological, histological, clinical or ultrasound) of lymph node metastases. There is currently no evidence in the literature that prophylactic central dissection improves overall survival, which is similar for N0 and NX patients. Yet although prophylactic lymph node dissection is not justified by overall survival, it does seem to reduce the risk of locoregional recurrence in the case of micro-N1, and it allows occult metastases to be detected and a tumour to be reclassified. This enables patients at risk of recurrence to be more surely identified and therapeutic strategy and follow-up adapted accordingly. Prophylactic homolateral central lymph node dissection is warranted for papillary cancers with largest ultrasound diameter 4cm and above and/or with intraoperative macroscopic evidence of perithyroid tissue invasion. The benefits and risks of lymph node dissection must be assessed and discussed on a case-by-case basis. Only a central lymph node dissection homolateral to the tumour is recommended, except for bilateral or isthmic cancers, for which a prophylactic bilateral central lymph node dissection may be considered. This bilateral lymph node dissection incurs an increased risk of complications (parathyroids, recurrent laryngeal nerve). Prophylactic lateral lymph node dissection is not recommended.
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Affiliation(s)
- Grégory Baud
- General and Endocrine Surgery Department, University Hospital Center of Lille, Lille, France.
| | - Nathalie Chereau
- Digestive and Endocrine Surgery Department, University Hospital Center Pitié Salpêtrière, Paris, France
| | - Charles De Ponthaud
- Digestive and Endocrine Surgery Department, University Hospital Center Pitié Salpêtrière, Paris, France
| | - Nicolas Santucci
- Department of Endocrine and Metabolic Surgery, University Hospital Center of Dijon Bourgogne, Dijon, France
| | - Fréderic Sebag
- Endocrine and Metabolic General Surgery Department, University Hospital of Marseille Conception, Marseille, France
| | - Pierre Goudet
- Department of Endocrine and Metabolic Surgery, University Hospital Center of Dijon Bourgogne, Dijon, France
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Wang J, Sheng X, Dai Y, Zhang J, Song L, Guo Y. The Application Value of the Central Lymph Node Metastasis Risk Assessment Model in Papillary Thyroid Microcarcinoma of Stage cN0: A Study of 828 Patients. Front Endocrinol (Lausanne) 2022; 13:843573. [PMID: 35360071 PMCID: PMC8960455 DOI: 10.3389/fendo.2022.843573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 02/08/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The aim of this study is to build a risk assessment system for central lymph node metastasis (CLNM) in papillary thyroid microcarcinoma (PTMC) of stage cN0 and to explore its application value in clinical practice. METHODS A total of 500 patients with PTMC who underwent thyroid operation from 2013 to 2015 in Ningbo First Hospital were selected as the model group. Independent risk factors related to CLNM in PTMC were analyzed and determined, and a risk assessment system for CLNM was preliminarily established. Furthermore, the clinicopathological data from 328 PTMC patients with the same conditions as the model group from 2016 to 2017 were further collected as the validation group to verify the diagnostic value of the risk assessment system. RESULTS The risk assessment system was based on the score rating (score ≤ 5 was classified as low risk, 6-8 was classified as medium risk, and ≥9 was classified as high-risk). The area under the receiver operating characteristic curve (ROC) was 0.687 (95% CI: 0.635-0.783). According to the risk assessment system, 328 PTMC patients in the validation group were scored. Among the low-risk group, the moderate-risk group, and the high-group, 96.8%, 58.1%, and 43.2% were the CLNM (-) patients, and 3.1%, 41.9%, and 65.8% were CLNM (+) patients, respectively. The area under ROC was 0.837 (95% CI: 0.778-0.869). CONCLUSIONS The risk assessment system in this study is of diagnostic value and can provide a theoretical foundation for intraoperative decision-making of prophylactic central neck dissection (pCND).
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Affiliation(s)
- Jinqiu Wang
- Department of Thyroid and Breast Surgery, Ningbo First Hospital, Ningbo, China
| | - Xianneng Sheng
- Department of Thyroid and Breast Surgery, Ningbo First Hospital, Ningbo, China
| | - Yongping Dai
- Department of Thyroid and Breast Surgery, Ningbo First Hospital, Ningbo, China
| | - Jiabo Zhang
- Department of Thyroid and Breast Surgery, Ningbo First Hospital, Ningbo, China
| | - Lihua Song
- School of Medicine, Ningbo University, Ningbo, China
| | - Yu Guo
- Department of Thyroid and Breast Surgery, Ningbo First Hospital, Ningbo, China
- *Correspondence: Yu Guo,
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Salem FA, Bergenfelz A, Nordenström E, Almquist M. Central lymph node dissection and permanent hypoparathyroidism after total thyroidectomy for papillary thyroid cancer: population-based study. Br J Surg 2021; 108:684-690. [PMID: 34157088 DOI: 10.1002/bjs.12028] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/24/2020] [Accepted: 08/03/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND Papillary thyroid cancer is treated with total/near-total thyroidectomy (TT) with or without central lymph node dissection (CLND), depending on risk factors and tumour size. Balancing the risk of disease recurrence and surgical morbidity remains a challenge. A population-based nationwide study was undertaken to evaluate the risk of permanent hypoparathyroidism associated with CLND. METHOD Data on patients with stage pT1-3 papillary thyroid cancer, who underwent TT with or without CLND between 1 July 2004 and 30 June 2014 were retrieved from the Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal Surgery. Drug use was ascertained by cross-linking with the Swedish Prescribed Drug Register. Permanent hypoparathyroidism was defined as treatment with active D vitamin or oral calcium drugs for more than 6 months after surgery. Data were analysed separately for all patients and those who underwent TT + CLND. Univariable and multivariable logistic regression analyses were done, yielding odds ratios (ORs) with 95 per cent confidence intervals. RESULTS A total of 722 patients were included in the study. Permanent hypoparathyroidism was more common in the TT + CLND group than the TT group: 30 of 265 patients (6·6 per cent) versus six of 457 (2·3 per cent) (P = 0·011). In multivariable logistic regression analysis, CLND was a risk factor for permanent hypoparathyroidism (OR 3·74, 95 per cent c.i. 1·46 to 9·59, based on use of combined therapy 6 months after surgery). In patients who had TT + CLND, node negativity was associated with a risk of permanent hypoparathyroidism (OR 3·08, 1·31 to 7·25). CONCLUSION CLND is an independent risk factor for permanent hypoparathyroidism. Node negativity is associated with a higher risk of permanent hypoparathyroidism.
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Affiliation(s)
- F A Salem
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - A Bergenfelz
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - E Nordenström
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - M Almquist
- Department of Clinical Sciences, Lund University, Lund, Sweden
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High-Dose RAI Therapy Justified by Pathological N1a Disease Revealed by Prophylactic Central Neck Dissection for cN0 Papillary Thyroid Cancer Patients: Is it Superior to Low-Dose RAI Therapy? World J Surg 2019; 43:1256-1263. [PMID: 30684002 DOI: 10.1007/s00268-019-04924-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE One of the presumed advantages of prophylactic central neck dissection (pCND) is offering staging basis for more aggressive radioactive iodine (RAI) therapy, which postulates the necessity of high dose for treatment efficacy. The present study aims to compare the effectiveness between low-dose and high-dose RAI in a select cohort of cN0 papillary thyroid cancer (PTC) patients with pathological N1a (pN1a) disease revealed by pCND in terms of ablation rate and response to therapy. The frequency of short-term adverse effects between the two groups was also compared. PATIENTS AND METHODS From January 2014 to April 2016, cN0 PTC patients with pN1a disease revealed by pCND in our hospital were retrospectively reviewed. Patients with other indications for high-dose RAI, such as the presence of extrathyroidal extension, vascular invasion or suspicions of distant metastasis, were excluded. For the included patients, high dose (3700 MBq) was administered between January 2014 and August 2015 and low dose (1110 MBq) between August 2015 and April 2016. Ablation assessment was performed 6 months after RAI therapy. Response evaluation after RAI therapy was performed after 46.3 ± 9.5 months for high-dose group and 29.1 ± 2.6 months for low-dose group. All patients were also evaluated for short-term adverse effects 24 and 72 hours after RAI administration. RESULTS A total of 84 patients were enrolled. Among them, 42 were in the high-dose group and the other 42 in the low-dose group. There was no significant difference in ablation rate (P = 0.7707) and response to RAI therapy (P = 0.6454) between the two groups. Twenty-four hours after RAI administration, neck pain and swelling (33.3% VS. 11.9%; P = 0.0372) and gastrointestinal discomfort (45.2% vs. 21.4%; P = 0.0373) were significantly more frequent in the high-dose group. CONCLUSION High-dose RAI therapy, with higher frequency of short-term adverse effects, appears to be not superior to low-dose RAI therapy for cN0 PTC patients with pN1a disease revealed by pCND to achieve better response to therapy. Further randomized studies with larger series of patients and longer follow-up duration, especially with the low-dose group, are needed to validate our results.
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Gonçalves Filho J, Zafereo ME, Ahmad FI, Nixon IJ, Shaha AR, Vander Poorten V, Sanabria A, Hefetz AK, Robbins KT, Kamani D, Randolph GW, Coca-Pelaz A, Simo R, Rinaldo A, Angelos P, Ferlito A, Kowalski LP. Decision making for the central compartment in differentiated thyroid cancer. Eur J Surg Oncol 2018; 44:1671-1678. [PMID: 30145001 DOI: 10.1016/j.ejso.2018.08.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/15/2018] [Accepted: 08/03/2018] [Indexed: 12/17/2022] Open
Abstract
The central compartment is a common site for nodal spread from differentiated thyroid carcinoma, often occurring in patients without clinical or ultrasonographic (US) evidence of neck lymph node metastasis (cN0). However, the role of elective central compartment neck dissection (CND) among patients with DTC remains controversial. We performed a systematic literature review, also including review of international guidelines, with discussion of anatomic and technical aspects, as well as risks and benefits of performing elective CND. The recent literature does not uniformly support or refute elective CND in patients with DTC, and therefore an individualized approach is warranted which considers individual surgeon experience, including individual recurrence and complication rates. Patients (especially older males) with large tumors (>4 cm) and extrathyroidal extension are more likely to benefit from elective CND, but elective CND also increases risk for hypoparathyroidism and recurrent nerve injury, especially when operated by low-volume surgeons. Individual surgeons who perform elective CND must ensure the number of central compartment dissections needed to prevent one recurrence (number needed to treat) is not disproportionate to their individual number of central compartment dissections per related complication (number needed to harm).
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Affiliation(s)
- João Gonçalves Filho
- Head and Neck Surgery and Otorhinolaryngology Department, A C Camargo Cancer Center, Sao Paulo, Brazil
| | - Mark E Zafereo
- Department of Head and Neck Surgery, MD Anderson Cancer Center, Houston, TX, USA.
| | - Faisal I Ahmad
- Department of Head and Neck Surgery, MD Anderson Cancer Center, Houston, TX, USA
| | - Iain J Nixon
- Consultant Otorhinolaryngologist Head and Neck Surgeon NHS Lothian/ Edinburgh University, UK
| | - Ashok R Shaha
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vincent Vander Poorten
- Otorhinolaryngology-Head and Neck Surgery and Department of Oncology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Alvaro Sanabria
- Head and Neck Surgeon, Department of Surgery, School of Medicine, Universidad de Antioquia-Fundacion Colombiana de Cancerologia-Clinica Vida, Medellin, Colombia
| | - Avi Khafif Hefetz
- ARM Center for Advanced Otolaryngology Head and Neck Surgery, Assura Medical Center, Tel Aviv, Israel
| | - K Thomas Robbins
- Division of Otolaryngology - Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Dipti Kamani
- Division of General Otolaryngology and Thyroid and Parathyroid Endocrine Surgery, Mass. Eye and Ear, Boston, MA, USA
| | - Gregory W Randolph
- Division of General Otolaryngology and Thyroid and Parathyroid Endocrine Surgery, Mass. Eye and Ear, Boston, MA, USA
| | - Andres Coca-Pelaz
- Department of Otolaryngology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Ricard Simo
- Consultant Otorhinolaryngologist Head and Neck Surgeon Head and Neck Cancer Unit Guy's and St Thomas' Hospital NHS Foundation Trust London, London, UK
| | | | - Peter Angelos
- Professor of Surgery, Chief of Endocrine Surgery, University of Chicago Medicine, Chicago IL, USA
| | - Alfio Ferlito
- Formerly Director of the Department of Surgical Sciences and Chairman of the ENT Clinic at the University of Udine School of Medicine, Udine, Italy
| | - Luiz P Kowalski
- Head and Neck Surgery and Otorhinolaryngology Department, A C Camargo Cancer Center, Sao Paulo, Brazil
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Clinical response to radioactive iodine therapy for prophylactic central neck dissection is not superior to total thyroidectomy alone in cN0 patients with papillary thyroid cancer. Nucl Med Commun 2017; 38:1036-1040. [DOI: 10.1097/mnm.0000000000000756] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Soydal Ç, Özkan E, Küçük NÖ, Kir KM. Effect of the application of prophylactic central compartment lymph node dissectionon radioiodine ablation doses in patients with papillary thyroid carcinoma. Turk J Med Sci 2016; 46:1078-82. [PMID: 27513407 DOI: 10.3906/sag-1505-40] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 10/05/2015] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND/AIM The aim of this study was to document the effect of the application of prophylactic central compartment dissection on radioiodine ablation activities for papillary thyroid carcinoma. MATERIALS AND METHODS This retrospective study included 452 (383 females, 69 males; mean age = 46.69 years, min-max: 13-71) patients who received ablative radioiodine activity between April 2010 and December 2014. The histopathological reports of thyroidectomy and the administered radioiodine activity were evaluated. Frequencies of prophylactic central compartment dissection according to T stage of the primary tumor, detection rate of lymph node metastases, and its effect on radioiodine ablation activities were calculated. RESULTS Prophylactic central compartment dissection was applied for a total of 252 (56%) patients. The T stages of these patients were T1a, T1b, T2, and T3 in 85 (34%), 106 (42%), 41 (16%), and 20 (8%) cases, respectively. The administered radioiodine ablation activity was affected by central compartment lymph node metastases in 112 (44%) patients. While 32 (29%) of these patients had papillary microcarcinoma (T1a), 48 (43%), 20 (18%), and 12 (11%) of them had T1b, T2, and T3 tumors, respectively. CONCLUSION The application of prophylactic central compartment dissection affects the radioiodine ablation activity in approximately half of patients. This effect is more prominent in T1 stage tumors.
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Affiliation(s)
- Çiğdem Soydal
- Department of Nuclear Medicine, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Elgin Özkan
- Department of Nuclear Medicine, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Nuriye Özlem Küçük
- Department of Nuclear Medicine, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Kemal Metin Kir
- Department of Nuclear Medicine, Faculty of Medicine, Ankara University, Ankara, Turkey
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