Axillary dissection in primary breast cancer: variations of the surgical technique and influence on morbidity
Identifieur interne : 002B50 ( Pmc/Checkpoint ); précédent : 002B49; suivant : 002B51Axillary dissection in primary breast cancer: variations of the surgical technique and influence on morbidity
Auteurs : Sebastian Wojcinski [Allemagne] ; Sirin Nuengsri [Allemagne] ; Peter Hillemanns [Allemagne] ; Werner Schmidt [Allemagne] ; Mustafa Deryal [Allemagne] ; Kubilay Ertan [Allemagne] ; Friedrich Degenhardt [Allemagne]Source :
- Cancer Management and Research [ 1179-1322 ] ; 2012.
Abstract
Lymphedema of the arm is the most common and impairing complication after breast cancer surgery with axillary lymph node dissection (ALND). Our prospective study evaluated the effect of two different surgical techniques for ALND on postoperative morbidity. Patients were scheduled to undergo ALND. Patients in group 1 (n = 17) underwent the most common and standard technique of ALND, which uses sharp dissection of the tissue and subsequent electro-coagulation of bleedings. Patients in group 2 (n = 17) underwent a modified standard technique of ALND with clamping and ligatures of all resection margins. Postoperative wound secretion was quantified and patients were followed up for 6 months to assess long-term morbidity. The variations in surgical technique had no significant influence on the outcome variables. However, patients in group 2 showed a tendency to less wound secretion (713 versus 802 mL;
Url:
DOI: 10.2147/CMAR.S30207
PubMed: 22570566
PubMed Central: 3346198
Affiliations:
- Allemagne
- Bade-Wurtemberg, Basse-Saxe, District de Karlsruhe, Sarre (Land)
- Hanovre, Karlsruhe, Sarrebruck
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Hospital, Department of Obstetrics/Gynecology, Leverkusen, Germany</nlm:aff><country xml:lang="fr">Allemagne</country><wicri:regionArea>Leverkusen Hospital, Department of Obstetrics/Gynecology, Leverkusen</wicri:regionArea><wicri:noRegion>Leverkusen</wicri:noRegion><wicri:noRegion>Leverkusen</wicri:noRegion><wicri:noRegion>Leverkusen</wicri:noRegion></affiliation></author><author><name sortKey="Degenhardt, Friedrich" sort="Degenhardt, Friedrich" uniqKey="Degenhardt F" first="Friedrich" last="Degenhardt">Friedrich Degenhardt</name><affiliation wicri:level="1"><nlm:aff id="af1-cmar-4-121">Franziskus Hospital, Department of Obstetrics/Gynecology, Bielefeld, Germany</nlm:aff><country xml:lang="fr">Allemagne</country><wicri:regionArea>Franziskus Hospital, Department of Obstetrics/Gynecology, Bielefeld</wicri:regionArea><wicri:noRegion>Bielefeld</wicri:noRegion><wicri:noRegion>Bielefeld</wicri:noRegion><wicri:noRegion>Bielefeld</wicri:noRegion></affiliation></author></analytic><series><title level="j">Cancer Management and Research</title><idno type="eISSN">1179-1322</idno><imprint><date when="2012">2012</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Lymphedema of the arm is the most common and impairing complication after breast cancer surgery with axillary lymph node dissection (ALND). Our prospective study evaluated the effect of two different surgical techniques for ALND on postoperative morbidity. Patients were scheduled to undergo ALND. Patients in group 1 (n = 17) underwent the most common and standard technique of ALND, which uses sharp dissection of the tissue and subsequent electro-coagulation of bleedings. Patients in group 2 (n = 17) underwent a modified standard technique of ALND with clamping and ligatures of all resection margins. Postoperative wound secretion was quantified and patients were followed up for 6 months to assess long-term morbidity. The variations in surgical technique had no significant influence on the outcome variables. However, patients in group 2 showed a tendency to less wound secretion (713 versus 802 mL; <italic>P</italic> = nonsignificant), a decreased rate of immediate postoperative seromas (11.8 versus 23.5%; <italic>P</italic> = nonsignificant) and less lymphedema after 3 months (29.4 versus 41.2%; <italic>P</italic> = nonsignificant). Moreover, the number of resected lymph nodes correlated with the total amount of drained fluid (<italic>P</italic> = 0.006), the duration of the drain (<italic>P</italic> = 0.015), and the risk for the development of lymphedema after 3 months (<italic>P</italic> = 0.016). The described variations in surgical technique had no influence on the outcomes of the patients. The number of resected axillary lymph nodes remains the most important risk factor for treatment-related morbidity. Therefore, a well-balanced choice of the extent of the axillary dissection should be the surgeon’s main concern.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Wang, Z" uniqKey="Wang Z">Z Wang</name></author><author><name sortKey="Wu, Lc" uniqKey="Wu L">LC Wu</name></author><author><name sortKey="Chen, Jq" uniqKey="Chen J">JQ Chen</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Schijven, Mp" uniqKey="Schijven M">MP Schijven</name></author><author><name sortKey="Vingerhoets, Aj" uniqKey="Vingerhoets A">AJ Vingerhoets</name></author><author><name sortKey="Rutten, Hj" uniqKey="Rutten H">HJ Rutten</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mathew, J" uniqKey="Mathew J">J Mathew</name></author><author><name sortKey="Barthelmes, L" uniqKey="Barthelmes L">L Barthelmes</name></author><author><name sortKey="Neminathan, S" uniqKey="Neminathan S">S 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Bonnema</name></author><author><name sortKey="Ligtenstein, Da" uniqKey="Ligtenstein D">DA Ligtenstein</name></author><author><name sortKey="Wiggers, T" uniqKey="Wiggers T">T Wiggers</name></author><author><name sortKey="Van Geel, An" uniqKey="Van Geel A">AN van Geel</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Tsai, Rj" uniqKey="Tsai R">RJ Tsai</name></author><author><name sortKey="Dennis, Lk" uniqKey="Dennis L">LK Dennis</name></author><author><name sortKey="Lynch, Cf" uniqKey="Lynch C">CF Lynch</name></author><author><name sortKey="Snetselaar, Lg" uniqKey="Snetselaar L">LG Snetselaar</name></author><author><name sortKey="Zamba, Gk" uniqKey="Zamba G">GK Zamba</name></author><author><name sortKey="Scott Conner, C" uniqKey="Scott Conner C">C Scott-Conner</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Erickson, Vs" uniqKey="Erickson V">VS Erickson</name></author><author><name sortKey="Pearson, Ml" 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Cancer Manag Res</journal-id><journal-id journal-id-type="iso-abbrev">Cancer Manag Res</journal-id><journal-title-group><journal-title>Cancer Management and Research</journal-title></journal-title-group><issn pub-type="epub">1179-1322</issn><publisher><publisher-name>Dove Medical Press</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">22570566</article-id><article-id pub-id-type="pmc">3346198</article-id><article-id pub-id-type="doi">10.2147/CMAR.S30207</article-id><article-id pub-id-type="publisher-id">cmar-4-121</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Research</subject></subj-group></article-categories><title-group><article-title>Axillary dissection in primary breast cancer: variations of the surgical technique and influence on morbidity</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Wojcinski</surname><given-names>Sebastian</given-names></name><xref ref-type="aff" rid="af1-cmar-4-121">1</xref><xref ref-type="author-notes" rid="fn1-cmar-4-121">*</xref><xref ref-type="corresp" rid="c1-cmar-4-121"></xref></contrib><contrib contrib-type="author"><name><surname>Nuengsri</surname><given-names>Sirin</given-names></name><xref ref-type="aff" rid="af2-cmar-4-121">2</xref><xref ref-type="author-notes" rid="fn1-cmar-4-121">*</xref></contrib><contrib contrib-type="author"><name><surname>Hillemanns</surname><given-names>Peter</given-names></name><xref ref-type="aff" rid="af3-cmar-4-121">3</xref></contrib><contrib contrib-type="author"><name><surname>Schmidt</surname><given-names>Werner</given-names></name><xref ref-type="aff" rid="af4-cmar-4-121">4</xref></contrib><contrib contrib-type="author"><name><surname>Deryal</surname><given-names>Mustafa</given-names></name><xref ref-type="aff" rid="af5-cmar-4-121">5</xref></contrib><contrib contrib-type="author"><name><surname>Ertan</surname><given-names>Kubilay</given-names></name><xref ref-type="aff" rid="af6-cmar-4-121">6</xref></contrib><contrib contrib-type="author"><name><surname>Degenhardt</surname><given-names>Friedrich</given-names></name><xref ref-type="aff" rid="af1-cmar-4-121">1</xref></contrib></contrib-group><aff id="af1-cmar-4-121"><label>1</label>Franziskus Hospital, Department of Obstetrics/Gynecology, Bielefeld, Germany</aff><aff id="af2-cmar-4-121"><label>2</label>Karlsruhe Hospital, Department of Internal Medicine, Karlsruhe, Germany</aff><aff id="af3-cmar-4-121"><label>3</label>Hannover Medical School, Department of Obstetrics/Gynecology, Hannover, Germany</aff><aff id="af4-cmar-4-121"><label>4</label>University Hospital of Saarland, Department of Obstetrics/Gynecology, Homburg/Saar, Germany</aff><aff id="af5-cmar-4-121"><label>5</label>Caritas Hospital Saarbrücken St Theresia, Department of Obstetrics/Gynecology, Saarbrücken, Germany</aff><aff id="af6-cmar-4-121"><label>6</label>Leverkusen Hospital, Department of Obstetrics/Gynecology, Leverkusen, Germany</aff><author-notes><corresp id="c1-cmar-4-121">Correspondence: Sebastian Wojcinski, Franziskus Hospital, Department of Obstetrics/Gynecology, Kisker Str 27, 33615 Bielefeld, Germany, Tel +49 521 589 1501; +49 521 589 71505, Fax +49 521 589 1504, Email <email>s@wojcinski.de</email></corresp><fn id="fn1-cmar-4-121"><label>*</label><p>The first two authors contributed equally to this manuscript</p></fn></author-notes><pub-date pub-type="collection"><year>2012</year></pub-date><pub-date pub-type="epub"><day>27</day><month>4</month><year>2012</year></pub-date><volume>4</volume><fpage>121</fpage><lpage>127</lpage><permissions><copyright-statement>© 2012 Wojcinski et al, publisher and licensee Dove Medical Press Ltd.</copyright-statement><copyright-year>2012</copyright-year><license><license-p>This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.</license-p></license></permissions><abstract><p>Lymphedema of the arm is the most common and impairing complication after breast cancer surgery with axillary lymph node dissection (ALND). Our prospective study evaluated the effect of two different surgical techniques for ALND on postoperative morbidity. Patients were scheduled to undergo ALND. Patients in group 1 (n = 17) underwent the most common and standard technique of ALND, which uses sharp dissection of the tissue and subsequent electro-coagulation of bleedings. Patients in group 2 (n = 17) underwent a modified standard technique of ALND with clamping and ligatures of all resection margins. Postoperative wound secretion was quantified and patients were followed up for 6 months to assess long-term morbidity. The variations in surgical technique had no significant influence on the outcome variables. However, patients in group 2 showed a tendency to less wound secretion (713 versus 802 mL; <italic>P</italic> = nonsignificant), a decreased rate of immediate postoperative seromas (11.8 versus 23.5%; <italic>P</italic> = nonsignificant) and less lymphedema after 3 months (29.4 versus 41.2%; <italic>P</italic> = nonsignificant). Moreover, the number of resected lymph nodes correlated with the total amount of drained fluid (<italic>P</italic> = 0.006), the duration of the drain (<italic>P</italic> = 0.015), and the risk for the development of lymphedema after 3 months (<italic>P</italic> = 0.016). The described variations in surgical technique had no influence on the outcomes of the patients. The number of resected axillary lymph nodes remains the most important risk factor for treatment-related morbidity. Therefore, a well-balanced choice of the extent of the axillary dissection should be the surgeon’s main concern.</p></abstract><kwd-group><kwd>breast cancer</kwd><kwd>axillary dissection</kwd><kwd>lymphedema</kwd><kwd>morbidity</kwd></kwd-group></article-meta></front><floats-group><fig id="f1-cmar-4-121" position="float"><label>Figure 1</label><caption><p>Comparison of the amount of drained fluid drained from the axilla between group 1 (surgery based on cutting and coagulation) and group 2 (surgery based on clamping and ligatures).</p><p><bold>Note:</bold> The difference between the groups was not statistically significant.</p></caption><graphic xlink:href="cmar-4-121f1"></graphic></fig><fig id="f2-cmar-4-121" position="float"><label>Figure 2</label><caption><p>Positive correlation between the number of resected LNs and the total amount of fluid drained from the axilla (<italic>P</italic> = 0.006; <bold>A</bold>) and a positive correlation between the number of resected LNs and the duration of the drain (<italic>P</italic> = 0.015; <bold>B</bold>).</p><p><bold>Abbreviation:</bold> LNs, lymph nodes.</p></caption><graphic xlink:href="cmar-4-121f2"></graphic></fig><fig id="f3-cmar-4-121" position="float"><label>Figure 3</label><caption><p>Positive correlation between the number of resected LNs and the protein concentration in the drained fluid (<italic>P</italic> = 0.054; <bold>A</bold>) and a positive correlation between the number of resected LNs and hemoglobin in the drained fluid (<italic>P</italic> = 0.045; <bold>B</bold>).</p><p><bold>Abbreviation:</bold> LNs, lymph nodes.</p></caption><graphic xlink:href="cmar-4-121f3"></graphic></fig><table-wrap id="t1-cmar-4-121" position="float"><label>Table 1</label><caption><p>Group comparison (mean ± standard deviation, range, or rate)</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" valign="top" rowspan="1" colspan="1"></th><th align="left" valign="top" rowspan="1" colspan="1">Group 1 (cutting and coagulation)<break></break>(n = 17)</th><th align="left" valign="top" rowspan="1" colspan="1">Group 2 (clamping and ligation)<break></break>(n = 17)</th></tr></thead><tbody><tr><td align="left" valign="top" rowspan="1" colspan="1">Age (years)</td><td align="left" valign="top" rowspan="1" colspan="1">59.4 ± 12.4 (45–84)</td><td align="left" valign="top" rowspan="1" colspan="1">60.3 ± 12.1 (39–83)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">BMI (kg/m²)</td><td align="left" valign="top" rowspan="1" colspan="1">25.0 ± 2.0 (21–40)</td><td align="left" valign="top" rowspan="1" colspan="1">28.2 ± 5.2 (19–39)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Blood pressure preoperative (systolic/diastolic, mmHg)</td><td align="left" valign="top" rowspan="1" colspan="1">129 ± 14/76 ± 11 (100–170/55–95)</td><td align="left" valign="top" rowspan="1" colspan="1">127 ± 16/75 ± 11 (80–155/60–100)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">BCT (%, n)</td><td align="left" valign="top" rowspan="1" colspan="1">64.7% (11/17)</td><td align="left" valign="top" rowspan="1" colspan="1">64.7% (11/17)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Total duration of surgery (min)</td><td align="left" valign="top" rowspan="1" colspan="1">117 ± 36</td><td align="left" valign="top" rowspan="1" colspan="1">127 ± 54</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">pT1 (%, n)</td><td align="left" valign="top" rowspan="1" colspan="1">35.3% (6/17)</td><td align="left" valign="top" rowspan="1" colspan="1">52.9% (9/17)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">pT2 (%, n)</td><td align="left" valign="top" rowspan="1" colspan="1">58.8% (10/17)</td><td align="left" valign="top" rowspan="1" colspan="1">41.2% (7/17)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">pT3/pT4 (%, n)</td><td align="left" valign="top" rowspan="1" colspan="1">5.9% (1/17)</td><td align="left" valign="top" rowspan="1" colspan="1">5.9% (1/17)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">CT (%, n)</td><td align="left" valign="top" rowspan="1" colspan="1">76.5% (13/17)</td><td align="left" valign="top" rowspan="1" colspan="1">76.5% (13/17)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">RT if BCT (%, n)</td><td align="left" valign="top" rowspan="1" colspan="1">100% (11/11)</td><td align="left" valign="top" rowspan="1" colspan="1">100% (11/11)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">PMRT (%, n)</td><td align="left" valign="top" rowspan="1" colspan="1">33.3% (2/6)</td><td align="left" valign="top" rowspan="1" colspan="1">33.3% (2/6)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">ET if HR+ (%, n)</td><td align="left" valign="top" rowspan="1" colspan="1">100% (13/13)</td><td align="left" valign="top" rowspan="1" colspan="1">100% (14/14)</td></tr></tbody></table><table-wrap-foot><fn id="tfn1-cmar-4-121"><p><bold>Note:</bold> Differences between group 1 and group 2 are statistically not significant.</p></fn><fn id="tfn2-cmar-4-121"><p><bold>Abbreviations:</bold> BCT, breast-conserving therapy; CT, chemotherapy; ET, endocrine therapy; HR+, hormone responsive; PMRT, postmastectomy radiation therapy; pT, pathologic tumor stage; RT, radiation therapy.</p></fn></table-wrap-foot></table-wrap><table-wrap id="t2-cmar-4-121" position="float"><label>Table 2</label><caption><p>Comparison of the outcome variables between group 1 and group 2 (mean ± standard deviation, range, or rate)</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" valign="top" rowspan="1" colspan="1"></th><th align="left" valign="top" rowspan="1" colspan="1">Group 1 (cutting and coagulation)<break></break>(n = 17)</th><th align="left" valign="top" rowspan="1" colspan="1">Group 2 (clamping and ligation)<break></break>(n = 17)</th></tr></thead><tbody><tr><td align="left" valign="top" rowspan="1" colspan="1">Total number of resected lymph nodes (n)</td><td align="left" valign="top" rowspan="1" colspan="1">11.1 ± 6.4</td><td align="left" valign="top" rowspan="1" colspan="1">13.6 ± 5.7</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Number of resected lymph nodes level I (n)</td><td align="left" valign="top" rowspan="1" colspan="1">6.8 ± 4.5</td><td align="left" valign="top" rowspan="1" colspan="1">9.8 ± 4.1</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Number of resected lymph nodes level II (n)</td><td align="left" valign="top" rowspan="1" colspan="1">3.4 ± 2.5</td><td align="left" valign="top" rowspan="1" colspan="1">3.0 ± 2.8</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Number of resected lymph nodes level III (n)</td><td align="left" valign="top" rowspan="1" colspan="1">0.9 ± 1.7</td><td align="left" valign="top" rowspan="1" colspan="1">0.8 ± 1.0</td></tr><tr><td colspan="3" align="left" valign="top" rowspan="1"><bold>Primary outcome variables</bold></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Total amount of drained fluid (mL)</td><td align="left" valign="top" rowspan="1" colspan="1">803 ± 546 (160–1480)</td><td align="left" valign="top" rowspan="1" colspan="1">712 ± 382 (110–2270)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Duration of suction drain (days)</td><td align="left" valign="top" rowspan="1" colspan="1">10.1 ± 4.0 (5–14)</td><td align="left" valign="top" rowspan="1" colspan="1">9.5 ± 3.9 (4–19)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Immediate seroma after removal of suction drain (%)</td><td align="left" valign="top" rowspan="1" colspan="1">23.5</td><td align="left" valign="top" rowspan="1" colspan="1">11.8</td></tr><tr><td colspan="3" align="left" valign="top" rowspan="1"><bold>Secondary outcome variables</bold></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Lymphedema after 3 months (%, n)</td><td align="left" valign="top" rowspan="1" colspan="1">41.2 (7/17)</td><td align="left" valign="top" rowspan="1" colspan="1">29.4 (5/17)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Lymphedema after 6 months (%, n)</td><td align="left" valign="top" rowspan="1" colspan="1">47.1 (8/17)</td><td align="left" valign="top" rowspan="1" colspan="1">47.1 (8/17)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Other morbidity concerning the axillary region after 3 and 6 months (%, n)</td><td align="left" valign="top" rowspan="1" colspan="1">0 (0/17)</td><td align="left" valign="top" rowspan="1" colspan="1">0 (0/17)</td></tr><tr><td colspan="3" align="left" valign="top" rowspan="1"><bold>Additional data</bold></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Total protein content of drained fluid (g/L)</td><td align="left" valign="top" rowspan="1" colspan="1">41.3 ± 7.3 (25–52)</td><td align="left" valign="top" rowspan="1" colspan="1">43.2 ± 8.1 (30–59)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Hemoglobin content of drained fluid (g/dL)</td><td align="left" valign="top" rowspan="1" colspan="1">2.4 ± 1.3 (0.3–4.6)</td><td align="left" valign="top" rowspan="1" colspan="1">2.7 ± 1.8 (0.5–6.1)</td></tr></tbody></table><table-wrap-foot><fn id="tfn3-cmar-4-121"><p><bold>Note:</bold> Differences between group 1 and group 2 are statistically not significant.</p></fn></table-wrap-foot></table-wrap></floats-group></pmc><affiliations><list><country><li>Allemagne</li></country><region><li>Bade-Wurtemberg</li><li>Basse-Saxe</li><li>District de Karlsruhe</li><li>Sarre (Land)</li></region><settlement><li>Hanovre</li><li>Karlsruhe</li><li>Sarrebruck</li></settlement></list><tree><country name="Allemagne"><noRegion><name sortKey="Wojcinski, Sebastian" sort="Wojcinski, Sebastian" uniqKey="Wojcinski S" first="Sebastian" last="Wojcinski">Sebastian Wojcinski</name></noRegion><name sortKey="Degenhardt, Friedrich" sort="Degenhardt, Friedrich" uniqKey="Degenhardt F" first="Friedrich" last="Degenhardt">Friedrich Degenhardt</name><name sortKey="Deryal, Mustafa" sort="Deryal, Mustafa" uniqKey="Deryal M" first="Mustafa" last="Deryal">Mustafa Deryal</name><name sortKey="Ertan, Kubilay" sort="Ertan, Kubilay" uniqKey="Ertan K" first="Kubilay" last="Ertan">Kubilay Ertan</name><name sortKey="Hillemanns, Peter" sort="Hillemanns, Peter" uniqKey="Hillemanns P" first="Peter" last="Hillemanns">Peter Hillemanns</name><name sortKey="Nuengsri, Sirin" sort="Nuengsri, Sirin" uniqKey="Nuengsri S" first="Sirin" last="Nuengsri">Sirin Nuengsri</name><name sortKey="Schmidt, Werner" sort="Schmidt, Werner" uniqKey="Schmidt W" first="Werner" last="Schmidt">Werner Schmidt</name></country></tree></affiliations></record>Pour manipuler ce document sous Unix (Dilib)
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