Skip to main content
SpringerLink
Log in

Making the Diagnosis of Myositis: Lung Biopsy and Interpretation

  • Chapter
  • First Online:
Managing Myositis

  • 908 Accesses

Abstract

Myositis-associated lung disease occurs in up to 80% of myositis patients. It has to be distinguished from idiopathic or secondary lung diseases such as infection or aspiration. Histologically, myositis-associated interstitial lung disease shows either an acute lung injury pattern such as diffuse alveolar damage (clinically corresponding to sudden onset and rapidly progressing disease) or chronic fibrosing lung disease (clinically corresponding to insidious onset and slowly progressing disease). Histopathologic features are typically not pathognomonic and require multidisciplinary discussion to arrive at the best possible diagnosis. Acute lung injury patterns usually portend a worse prognosis than chronic lung disease. Diffuse fibrosing lung disease in myositis patients usually carries a better prognosis than idiopathic forms of the same histologic pattern.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 159.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Hallowell RW, Ascherman DP, Danoff SK. Pulmonary manifestations of polymyositis/dermatomyositis. Semin Respir Crit Care Med. 2014;35(2):239–48.

    Article  PubMed  Google Scholar 

  2. Marie I, Menard JF, Hachulla E, et al. Infectious complications in polymyositis and dermatomyositis: a series of 279 patients. Semin Arthritis Rheum. 2011;41(1):48–60.

    Article  PubMed  Google Scholar 

  3. Marie I, Hachulla E, Cherin P, et al. Opportunistic infections in polymyositis and dermatomyositis. Arthritis Rheum. 2005;53(2):155–65.

    Article  PubMed  Google Scholar 

  4. Hadjinicolaou AV, Nisar MK, Bhagat S, Parfrey H, Chilvers ER, Ostor AJ. Non-infectious pulmonary complications of newer biological agents for rheumatic diseases—a systematic literature review. Rheumatology (Oxford). 2011;50(12):2297–305.

    Article  Google Scholar 

  5. Schwarz MI, Sutarik JM, Nick JA, Leff JA, Emlen JW, Tuder RM. Pulmonary capillaritis and diffuse alveolar hemorrhage. A primary manifestation of polymyositis. Am J Respir Crit Care Med. 1995;151(6):2037–40.

    Article  CAS  PubMed  Google Scholar 

  6. Lee CS, Chen TL, Tzen CY, et al. Idiopathic inflammatory myopathy with diffuse alveolar damage. Clin Rheumatol. 2002;21(5):391–6.

    Article  PubMed  Google Scholar 

  7. Tazelaar H, Viggiano R, Pickersgill J, Colby T. Interstitial lung disease in polymyositis and dermatomyositis. Clinical features and prognosis as correlated with histologic findings. Am Rev Respir Dis. 1990;141(3):727–33.

    Article  CAS  PubMed  Google Scholar 

  8. Douglas WW, Tazelaar HD, Hartman TE, et al. Polymyositis-dermatomyositis-associated interstitial lung disease. Am J Respir Crit Care Med. 2001;164(7):1182–5.

    Article  CAS  PubMed  Google Scholar 

  9. Schwarz MI, Matthay RA, Sahn SA, Stanford RE, Marmorstein BL, Scheinhorn DJ. Interstitial lung disease in polymyositis and dermatomyositis: analysis of six cases and review of the literature. Medicine (Baltimore). 1976;55(1):89–104.

    Article  CAS  Google Scholar 

  10. Cottin V, Thivolet-Bejui F, Reynaud-Gaubert M, et al. Interstitial lung disease in amyopathic dermatomyositis, dermatomyositis and polymyositis. Eur Respir J. 2003;22(2):245–50.

    Article  CAS  PubMed  Google Scholar 

  11. Selva-O’Callaghan A, Labrador-Horrillo M, Munoz-Gall X, et al. Polymyositis/dermatomyositis-associated lung disease: analysis of a series of 81 patients. Lupus. 2005;14(7):534–42.

    Article  PubMed  Google Scholar 

  12. Sauter JL, Butnor KJ. Expanding the spectrum of pulmonary histopathologic manifestations of anti-synthetase syndrome: anti-EJ-associated acute fibrinous and organizing pneumonia. Histopathology. 2014;65:581–2.

    Article  PubMed  Google Scholar 

  13. Kang EH, Lee EB, Shin KC, et al. Interstitial lung disease in patients with polymyositis, dermatomyositis and amyopathic dermatomyositis. Rheumatology (Oxford). 2005;44(10):1282–6.

    Article  CAS  Google Scholar 

  14. Bunch TW, Tancredi RG, Lie JT. Pulmonary hypertension in polymyositis. Chest. 1981;79(1):105–7.

    Article  CAS  PubMed  Google Scholar 

  15. Travis WD, Costabel U, Hansell DM, et al. An official American Thoracic Society/European Respiratory Society statement: update of the international multidisciplinary classification of the idiopathic interstitial pneumonias. Am J Respir Crit Care Med. 2013;188(6):733–48.

    Google Scholar 

  16. Hervier B, Devilliers H, Stanciu R, et al. Hierarchical cluster and survival analyses of antisynthetase syndrome: phenotype and outcome are correlated with anti-tRNA synthetase antibody specificity. Autoimmun Rev. 2012;12(2):210–7.

    Article  CAS  PubMed  Google Scholar 

  17. Koreeda Y, Higashimoto I, Yamamoto M, et al. Clinical and pathological findings of interstitial lung disease patients with anti-aminoacyl-tRNA synthetase autoantibodies. Intern Med. 2010;49(5):361–9.

    Article  PubMed  Google Scholar 

  18. Chen IJ, Jan Wu YJ, Lin CW, et al. Interstitial lung disease in polymyositis and dermatomyositis. Clin Rheumatol. 2009;28(6):639–46.

    Article  PubMed  Google Scholar 

  19. Flaherty KR, Colby TV, Travis WD, et al. Fibroblastic foci in usual interstitial pneumonia: idiopathic versus collagen vascular disease. Am J Respir Crit Care Med. 2003;167(10):1410–5.

    Article  PubMed  Google Scholar 

  20. Song JW, Do K-H, Kim M-Y, Jang SJ, Colby TV, Kim DS. Pathologic and radiologic differences between idiopathic and collagen vascular disease-related usual interstitial pneumonia. Chest. 2009;136:23–30.

    Article  PubMed  Google Scholar 

  21. Yousem SA, Colby TV, Carrington CB. Lung biopsy in rheumatoid arthritis. Am Rev Respir Dis. 1985;131(5):770–7.

    CAS  PubMed  Google Scholar 

  22. Yousem SA, Colby TV, Carrington CB. Follicular bronchitis/bronchiolitis. Hum Pathol. 1985;16(7):700–6.

    Article  CAS  PubMed  Google Scholar 

  23. Pego-Reigosa JM, Medeiros DA, Isenberg DA. Respiratory manifestations of systemic lupus erythematosus: old and new concepts. Best Pract Res Clin Rheumatol. 2009;23(4):469–80.

    Article  PubMed  Google Scholar 

  24. Enomoto N, Suda T, Kato M, et al. Quantitative analysis of fibroblastic foci in usual interstitial pneumonia. Chest. 2006;130(1):22–9.

    Article  PubMed  Google Scholar 

  25. Kwak JJ, Chang JE, Lee J, Cho YJ, Sung SH. Chronic eosinophilic pneumonia associated with an initiation of rheumatoid arthritis. Clin Rheumatol. 2003;22(3):240–3.

    Article  PubMed  Google Scholar 

  26. Lettieri CJ, Veerappan GR, Parker JM, et al. Discordance between general and pulmonary pathologists in the diagnosis of interstitial lung disease. Respir Med. 2005;99(11):1425–30.

    Article  PubMed  Google Scholar 

  27. Flaherty KR, King TE Jr, Raghu G, et al. Idiopathic interstitial pneumonia: what is the effect of a multidisciplinary approach to diagnosis? Am J Respir Crit Care Med. 2004;170(8):904–10.

    Article  PubMed  Google Scholar 

  28. Raghu G, Collard HR, Egan JJ, et al. An official ATS/ERS/JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management. Am J Respir Crit Care Med. 2011;183(6):788–824.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Hamaguchi Y, Fujimoto M, Matsushita T, et al. Common and distinct clinical features in adult patients with anti-aminoacyl-tRNA synthetase antibodies: heterogeneity within the syndrome. PLoS One. 2013;8(4):e60442.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Lega JC, Cottin V, Fabien N, Thivolet-Bejui F, Cordier JF. Interstitial lung disease associated with anti-PM/Scl or anti-aminoacyl-tRNA synthetase autoantibodies: a similar condition? J Rheumatol. 2010;37(5):1000–9.

    Article  CAS  PubMed  Google Scholar 

  31. Tansley SL, Betteridge ZE, Gunawardena H, et al. Anti-MDA5 autoantibodies in juvenile dermatomyositis identify a distinct clinical phenotype: a prospective cohort study. Arthritis Res Ther. 2014;16(4):R138.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  32. Gossez M, Levesque M, Khouatra C, Cottin V, Garnier L, Fabien N. Interstitial lung disease in an adult patient with dermatomyositis and anti-NXP2 autoantibody. Eur Respir Rev. 2015;24(136):370–2.

    Article  PubMed  Google Scholar 

  33. Alshehri A, Choksi R, Bucelli R, Pestronk A. Myopathy with anti-HMGCR antibodies: perimysium and myofiber pathology. Neurol Neuroimmunol Neuroinflamm. 2015;2(4):e124.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Satoh M, Tanaka S, Ceribelli A, Calise SJ, Chan EK. A comprehensive overview on myositis-specific antibodies: new and old biomarkers in idiopathic inflammatory myopathy. Clin Rev Allergy Immunol. 2017;52(1):1–19.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Solomon J, Swigris JJ, Brown KK. Myositis-related interstitial lung disease and antisynthetase syndrome. J Bras Pneumol. 2011;37(1):100–9.

    Article  PubMed  Google Scholar 

  36. Yousem SA, Gibson K, Kaminski N, Oddis CV, Ascherman DP. The pulmonary histopathologic manifestations of the anti-Jo-1 tRNA synthetase syndrome. Mod Pathol. 2010;23(6):874–80.

    Article  CAS  PubMed  Google Scholar 

  37. Schneider F, Aggarwal R, Bi D, Gibson K, Oddis C, Yousem SA. The pulmonary histopathology of anti-KS transfer RNA synthetase syndrome. Arch Pathol Lab Med. 2015;139(1):122–5.

    Article  PubMed  Google Scholar 

  38. Lega JC, Reynaud Q, Belot A, Fabien N, Durieu I, Cottin V. Idiopathic inflammatory myopathies and the lung. Eur Respir Rev. 2015;24(136):216–38.

    Article  PubMed  Google Scholar 

  39. Schneider F, Yousem SA, Bi D, Gibson KF, Oddis CV, Aggarwal R. Pulmonary pathologic manifestations of anti-glycyl-tRNA synthetase (anti-EJ)-related inflammatory myopathy. J Clin Pathol. 2014;67(8):678–83.

    Article  PubMed  Google Scholar 

  40. Sauter JL, Butnor KJ. Expanding the spectrum of pulmonary histopathological manifestations of anti-synthetase syndrome: anti-EJ-associated acute fibrinous and organizing pneumonia. Histopathology. 2014;65(4):581–2.

    Article  PubMed  Google Scholar 

  41. Yousem SA, Schneider F, Bi D, Oddis CV, Gibson K, Aggarwal R. The pulmonary histopathologic manifestations of the anti-PL7/antithreonyl transfer RNA synthetase syndrome. Hum Pathol. 2014;45(6):1199–204.

    Article  CAS  PubMed  Google Scholar 

  42. Hervier B, Wallaert B, Hachulla E, et al. Clinical manifestations of anti-synthetase syndrome positive for anti-alanyl-tRNA synthetase (anti-PL12) antibodies: a retrospective study of 17 cases. Rheumatology. 2010;49(5):972–6.

    Article  CAS  PubMed  Google Scholar 

  43. Johnson C, Pinal-Fernandez I, Parikh R, et al. Assessment of mortality in autoimmune myositis with and without associated interstitial lung disease. Lung. 2016;194(5):733–7.

    Article  CAS  PubMed  Google Scholar 

  44. Marie I, Hachulla E, Cherin P, et al. Interstitial lung disease in polymyositis and dermatomyositis. Arthritis Rheum. 2002;47(6):614–22.

    Article  CAS  PubMed  Google Scholar 

  45. Debray MP, Borie R, Revel MP, et al. Interstitial lung disease in anti-synthetase syndrome: initial and follow-up CT findings. Eur J Radiol. 2015;84(3):516–23.

    Article  PubMed  Google Scholar 

  46. Sato S, Kuwana M, Fujita T, Suzuki Y. Anti-CADM-140/MDA5 autoantibody titer correlates with disease activity and predicts disease outcome in patients with dermatomyositis and rapidly progressive interstitial lung disease. Mod Rheumatol. 2013;23(3):496–502.

    Article  CAS  PubMed  Google Scholar 

  47. Chen Z, Cao M, Plana MN, et al. Utility of anti-melanoma differentiation-associated gene 5 antibody measurement in identifying patients with dermatomyositis and a high risk for developing rapidly progressive interstitial lung disease: a review of the literature and a meta-analysis. Arthritis Care Res (Hoboken). 2013;65(8):1316–24.

    Article  CAS  Google Scholar 

  48. Tanizawa K, Handa T, Nakashima R, et al. HRCT features of interstitial lung disease in dermatomyositis with anti-CADM-140 antibody. Respir Med. 2011;105(9):1380–7.

    Article  PubMed  Google Scholar 

  49. Nagata K, Tomii K, Nanjo S, Kubota M, Tachikawa R, Nishio M. Four cases of interstitial pneumonia associated with amyopathic dermatomyositis characterized by the anti-CADM-140 antibody. Nihon Kokyuki Gakkai Zasshi. 2011;49(1):30–6.

    PubMed  Google Scholar 

  50. Suzuki A, Kondoh Y, Taniguchi H, et al. Lung histopathological pattern in a survivor with rapidly progressive interstitial lung disease and anti-melanoma differentiation-associated gene 5 antibody-positive clinically amyopathic dermatomyositis. Respir Med Case Rep. 2016;19:5–8.

    PubMed  PubMed Central  Google Scholar 

  51. Kuroda H, Morinaga H, Satoh C, Miyata A, Sunami K. Clinical study of 10 cases of acute or subacute interstitial pneumonia associated with dermatomyositis. Mod Rheumatol. 2003;13(4):313–8.

    Article  PubMed  Google Scholar 

  52. Marie I, Hatron PY, Dominique S, Cherin P, Mouthon L, Menard JF. Short-term and long-term outcomes of interstitial lung disease in polymyositis and dermatomyositis: a series of 107 patients. Arthritis Rheum. 2011;63(11):3439–47.

    Article  CAS  PubMed  Google Scholar 

  53. Schneider F, Yousem SA, Oddis CV, Aggarwal R. Pulmonary pathologic manifestations of anti-alanyl-tRNA synthetase (anti-PL-12)-related inflammatory myopathy. Arch Pathol Lab Med. 2018;142(2):191–7.

    Article  CAS  Google Scholar 

  54. Park JH, Kim DS, Park I-N, et al. Prognosis of fibrotic interstitial pneumonia. Idiopathic versus collagen vascular disease-related subtypes. Am J Respir Crit Care Med. 2007;175:705–11.

    Article  PubMed  Google Scholar 

  55. Aggarwal R, McBurney C, Schneider F, et al. Myositis-associated usual interstitial pneumonia has a better survival than idiopathic pulmonary fibrosis. Rheumatology (Oxford). 2017;56(3):384–9.

    Google Scholar 

  56. Tanizawa K, Handa T, Nakashima R, et al. The long-term outcome of interstitial lung disease with anti-aminoacyl-tRNA synthetase antibodies. Respir Med. 2017;127:57–64.

    Article  PubMed  Google Scholar 

  57. Colombat M, Mal H, Groussard O, et al. Pulmonary vascular lesions in end-stage idiopathic pulmonary fibrosis: histopathologic study on lung explant specimens and correlations with pulmonary hemodynamics. Hum Pathol. 2007;38(1):60–5.

    Article  CAS  PubMed  Google Scholar 

  58. Takahashi K, Taniguchi H, Ando M, et al. Mean pulmonary arterial pressure as a prognostic indicator in connective tissue disease associated with interstitial lung disease: a retrospective cohort study. BMC Pulm Med. 2016;16(1):55.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Tanizawa K, Handa T, Nakashima R, et al. The prognostic value of HRCT in myositis-associated interstitial lung disease. Respir Med. 2013;107(5):745–52.

    Article  PubMed  Google Scholar 

  60. Flaherty KR, Thwaite EL, Kazerooni EA, et al. Radiological versus histological diagnosis in UIP and NSIP: survival implications. Thorax. 2003;58(2):143–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  61. Raj R, Raparia K, Lynch DA, Brown KK. Surgical lung biopsy for interstitial lung diseases. Chest. 2017;151(5):1131–40.

    Article  PubMed  Google Scholar 

  62. Lindley SW, Gillies EM, Hassell LA. Communicating diagnostic uncertainty in surgical pathology reports: disparities between sender and receiver. Pathol Res Pract. 2014;210(10):628–33.

    Article  PubMed  Google Scholar 

  63. Anzidei M, Porfiri A, Andrani F, et al. Imaging-guided chest biopsies: techniques and clinical results. Insights Imaging. 2017;8(4):419–28.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Aubry MC, Myers JL, Douglas WW, et al. Primary pulmonary carcinoma in patients with idiopathic pulmonary fibrosis. Mayo Clin Proc. 2002;77(8):763–70.

    Article  PubMed  Google Scholar 

  65. Barrena S, Almeida J, Del Carmen Garcia-Macias M, et al. Flow cytometry immunophenotyping of fine-needle aspiration specimens: utility in the diagnosis and classification of non-Hodgkin lymphomas. Histopathology. 2011;58(6):906–18.

    Article  PubMed  Google Scholar 

  66. Fibla JJ, Brunelli A, Allen MS, et al. Microbiology specimens obtained at the time of surgical lung biopsy for interstitial lung disease: clinical yield and cost analysis. Eur J Cardiothorac Surg. 2012;41(1):36–8.

    PubMed  Google Scholar 

  67. Gao JW, Rizzo S, Ma LH, et al. Pulmonary ground-glass opacity: computed tomography features, histopathology and molecular pathology. Transl Lung Cancer Res. 2017;6(1):68–75.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  68. Afify A, Davila RM. Pulmonary fine needle aspiration biopsy. Assessing the negative diagnosis. Acta Cytol. 1999;43(4):601–4.

    Article  CAS  PubMed  Google Scholar 

  69. Heerink WJ, de Bock GH, de Jonge GJ, Groen HJ, Vliegenthart R, Oudkerk M. Complication rates of CT-guided transthoracic lung biopsy: meta-analysis. Eur Radiol. 2017;27(1):138–48.

    Article  CAS  PubMed  Google Scholar 

  70. Leslie KO, Gruden JF, Parish JM, Scholand MB. Transbronchial biopsy interpretation in the patient with diffuse parenchymal lung disease. Arch Pathol Lab Med. 2007;131(3):407–23.

    PubMed  Google Scholar 

  71. Drakopanagiotakis F, Paschalaki K, Abu-Hijleh M, et al. Cryptogenic and secondary organizing pneumonia: clinical presentation, radiographic findings, treatment response, and prognosis. Chest. 2011;139(4):893–900.

    Article  PubMed  Google Scholar 

  72. Tomassetti S, Cavazza A, Colby TV, et al. Transbronchial biopsy is useful in predicting UIP pattern. Respir Res. 2012;13:96.

    Article  PubMed  PubMed Central  Google Scholar 

  73. Berbescu EA, Katzenstein AL, Snow JL, Zisman DA. Transbronchial biopsy in usual interstitial pneumonia. Chest. 2006;129(5):1126–31.

    Article  PubMed  Google Scholar 

  74. Lentz RJ, Argento AC, Colby TV, Rickman OB, Maldonado F. Transbronchial cryobiopsy for diffuse parenchymal lung disease: a state-of-the-art review of procedural techniques, current evidence, and future challenges. J Thorac Dis. 2017;9(7):2186–203.

    Article  PubMed  PubMed Central  Google Scholar 

  75. Colby TV, Tomassetti S, Cavazza A, Dubini A, Poletti V. Transbronchial cryobiopsy in diffuse lung disease: update for the pathologist. Arch Pathol Lab Med. 2017;141(7):891–900.

    Article  CAS  PubMed  Google Scholar 

  76. Monaghan H, Wells AU, Colby TV, du Bois RM, Hansell DM, Nicholson AG. Prognostic implications of histologic patterns in multiple surgical lung biopsies from patients with idiopathic interstitial pneumonias. Chest. 2004;125(2):522–6.

    Article  PubMed  Google Scholar 

  77. Flaherty KR, Travis WD, Colby TV, et al. Histopathologic variability in usual and nonspecific interstitial pneumonias. Am J Respir Crit Care Med. 2001;164(9):1722–7.

    Article  CAS  PubMed  Google Scholar 

  78. Kwon KY, Myers JL, Swensen SJ, Colby TV. Middle lobe syndrome: a clinicopathological study of 21 patients. Hum Pathol. 1995;26(3):302–7.

    Article  CAS  PubMed  Google Scholar 

  79. Hutchinson JP, Fogarty AW, McKeever TM, Hubbard RB. In-hospital mortality after surgical lung biopsy for interstitial lung disease in the United States. 2000 to 2011. Am J Respir Crit Care Med. 2016;193(10):1161–7.

    Article  CAS  PubMed  Google Scholar 

  80. Raj R, Brown KK. Mortality related to surgical lung biopsy in patients with interstitial lung disease. The devil is in the denominator. Am J Respir Crit Care Med. 2016;193(10):1082–4.

    Article  CAS  PubMed  Google Scholar 

  81. Durheim MT, Kim S, Gulack BC, et al. Mortality and respiratory failure after thoracoscopic lung biopsy for interstitial lung disease. Ann Thorac Surg. 2017;104(2):465–70.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Emory University School of Medicine, Emory University Hospital, Department of Pathology and Laboratory Medicine, Atlanta, GA, USA

    Frank Schneider

  2. The Permanente Medical Group, Kaiser Permanente Medical Center, Department of Rheumatology, Oakland, CA, USA

    Patty Chen

Authors
  1. Frank Schneider
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Patty Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Frank Schneider .

Editor information

Editors and Affiliations

  1. Division of Rheumatology and Clinical Immunology, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA

    Rohit Aggarwal

  2. Division of Rheumatology and Clinical Immunology, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA

    Chester V. Oddis

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Schneider, F., Chen, P. (2020). Making the Diagnosis of Myositis: Lung Biopsy and Interpretation. In: Aggarwal, R., Oddis, C. (eds) Managing Myositis. Springer, Cham. https://doi.org/10.1007/978-3-030-15820-0_15

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-15820-0_15

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-15819-4

  • Online ISBN: 978-3-030-15820-0

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation