Abstract
Biologically-based modeling of spontaneous and radiation-induced carcinogenesis has a history spanning several decades. Such models are important conceptual and quantitative tools, particularly useful whenever cancer risks must be estimated under exposure situations for which no data yet exist, e.g., for novel and prospective radiotherapy protocols. Direct extrapolation from existing data is often not possible due to complex differences between the data sets, but quantitative models can accommodate such extrapolation. Many carcinogenesis models can be characterized as short-term, in that they focus on those processes occurring during and shortly after irradiation. The main advantage of this class of models is that they provide a detailed initial dose response for short-term endpoints which are used as surrogates for carcinogenesis. The main disadvantage is that the possibly substantial modulations of the magnitude and shape of this initial dose response during the lengthy period between irradiation and manifestation of typical solid tumors are not considered. In contrast with the short-term models, another class of biologically-motivated models can be characterized as long-term, in the sense that they track carcinogenesis mechanisms throughout the entire human life span. The main advantages of long-term models are: (1) modulation of the radiation dose response during the long latency period between exposure and diagnosis of cancer is included; and (2) extensive data on spontaneous cancers can be used to help determine the adjustable parameters needed to estimate cancer risks. The main disadvantage is that the early radiation response is typically treated in a less-mechanistic manner than in the short-term models. Here we review some short- and long-term model examples and the carcinogenesis mechanisms which they incorporate. We also discuss an example of unification of both model classes, focusing on application of such formalisms for quantifying radiotherapy-induced second cancer risks.
This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsReferences
Almog N, Henke V, Flores L et al (2006) Prolonged dormancy of human liposarcoma is associated with impaired tumor angiogenesis. Faseb J 20:947–949
Anonymous (2004) Cancer survivors: living longer, and now, better. Lancet 364:2153–2154
Armitage P (1985) Multistage models of carcinogenesis. Environ Health Perspect 63:195–201
Armitage P, Doll R (1954) The age distribution of cancer and a multi-stage theory of carcinogenesis. Br J Cancer VIII:1–12
BEIR VII Report, Phase 2 (2005) Health risks from exposure to low levels of ionizing radiation. The National Academic Press, Washington
Bennett WR, Crew TE, Slack JM et al (2003) Structural-proliferative units and organ growth: effects of insulin-like growth factor 2 on the growth of colon and skin. Development 130:1079–1088
Bennett J, Little MP, Richardson S (2004) Flexible dose-response models for Japanese atomic bomb survivor data: Bayesian estimation and prediction of cancer risk. Radiat Environ Biophys 43:233–245
Bockmuhl U, Petersen I (2002) DNA ploidy and chromosomal alterations in head and neck squamous cell carcinoma. Virchows Arch 441:541–550
Boice JD Jr, Blettner M, Kleinerman RA et al (1987) Radiation dose and leukemia risk in patients treated for cancer of the cervix. J Natl Cancer Inst 79:1295–1311
Boice JD Jr, Engholm G, Kleinerman RA et al (1988) Radiation dose and second cancer risk in patients treated for cancer of the cervix. Radiat Res 116:3–55
Borthwick DW, Shahbazian M, Krantz QT et al (2001) Evidence for stem-cell niches in the tracheal epithelium. Am J Respir Cell Mol Biol 24:662–670
Brash DE (2006) Roles of the transcription factor p53 in keratinocyte carcinomas. Br J Dermatol 154(Suppl 1):8–10
Brash DE, Zhang W, Grossman D et al (2005) Colonization of adjacent stem cell compartments by mutant keratinocytes. Semin Cancer Biol 15:97–102
Brem SS, Gullino PM, Medina D (1977) Angiogenesis: a marker for neoplastic transformation of mammary papillary hyperplasia. Science 195:880–882
Brenner DJ, Hahnfeldt P, Amundson SA et al (1996) Interpretation of inverse dose-rate effects for mutagenesis by sparsely ionizing radiation. Int J Radiat Biol 70:447–458
Brenner DJ, Curtis RE, Hall EJ et al (2000) Second malignancies in prostate carcinoma patients after radiotherapy compared with surgery. Cancer 88:398–406
Brenner DJ, Shuryak I, Russo S et al (2007) Reducing second breast cancers: a potential role for prophylactic mammary irradiation. J Clin Oncol 25:4868–4872
Brunet A, Rando TA (2007) Ageing: from stem to stern. Nature 449:288–291
Calabrese P, Tavare S, Shibata D (2004) Pretumor progression: clonal evolution of human stem cell populations. Am J Pathol 164:1337–1346
Carlson ME, Conboy IM (2007) Loss of stem cell regenerative capacity within aged niches. Aging Cell 6:371–382
Chaturvedi AK, Engels EA, Gilbert ES et al (2007) Second cancers among 104,760 survivors of cervical cancer: evaluation of long-term risk. J Natl Cancer Inst 99:1634–1643
Cook PJ, Doll R, Fellingham SA (1969) A mathematical model for the age distribution of cancer in man. Int J Cancer 4:93–112
Croizat H, Frindel E, Tubiana M (1980) The effect of partial body irradiation on haemopoietic stem cell migration. Cell Tissue Kinet 13:319–325
Curtis SB (1986) Lethal and potentially lethal lesions induced by radiation—a unified repair model. Radiat Res 106:252–270
Curtis RE, Boice JD Jr, Stovall M et al (1994) Relationship of leukemia risk to radiation dose following cancer of the uterine corpus. J Natl Cancer Inst 86:1315–1324
Curtis SB, Luebeck EG, Hazelton WD et al (2001) The role of promotion in carcinogenesis from protracted high-LET exposure. Phys Med 17(Suppl 1):157–160
Curtis R, Freedman D, Ron E et al (2006) New malignancies among cancer survivors: SEER Cancer Registries, 1973–2000. National Cancer Institute, Bethesda
Dale RG (1986) The application of the linear-quadratic model to fractionated radiotherapy when there is incomplete normal tissue recovery between fractions, and possible implications for treatments involving multiple fractions per day. Br J Radiol 59:919–927
Dasu A, Toma-Dasu I, Olofsson J et al (2005) The use of risk estimation models for the induction of secondary cancers following radiotherapy. Acta Oncol 44:339–347
Feitelson MA, Pan J, Lian Z (2004) Early molecular and genetic determinants of primary liver malignancy. Surg Clin North Am 84:339–354
Finley JC, Reid BJ, Odze RD et al (2006) Chromosomal instability in Barrett’s esophagus is related to telomere shortening. Cancer Epidemiol Biomarkers Prev 15:1451–1457
Fliedner TM (1998) The role of blood stem cells in hematopoietic cell renewal. Stem Cells 16(Suppl 1):13–29
Fliedner TM, Graessle D, Paulsen C et al (2002) Structure and function of bone marrow hemopoiesis: mechanisms of response to ionizing radiation exposure. Cancer Biother Radiopharm 17:405–426
Fuchs E, Tumbar T, Guasch G (2004) Socializing with the neighbors: stem cells and their niche. Cell 116:769–778
Ghazizadeh S, Taichman LB (2005) Organization of stem cells and their progeny in human epidermis. J Invest Dermatol 124:367–372
Gray LH (1957) Radiobiology and cancer. Nature 179:991–994
Hahnfeldt P, Hlatky L (1996) Resensitization due to redistribution of cells in the phases of the cell cycle during arbitrary radiation protocols. Radiat Res 145:134–143
Hahnfeldt P, Hlatky L (1998) Cell resensitization during protracted dosing of heterogeneous cell populations. Radiat Res 150:681–687
Hall EJ, Wuu CS (2003) Radiation-induced second cancers: the impact of 3D-CRT and IMRT. Int J Radiat Oncol Biol Phys 56:83–88
Hanks GE (1964) In vivo migration of colony-forming units from shielded bone marrow in the irradiated mouse. Nature 203:1393–1395
Harding C, Pompei F, Lee EE et al (2008) Cancer suppression at old age. Cancer Res 68:4465–4478
Heidenreich WF, Hoogenveen R (2001) Limits of applicability for the deterministic approximation of the two-step clonal expansion model. Risk Anal 21:103–105
Heidenreich WF, Paretzke HG (2001) The two-stage clonal expansion model as an example of a biologically based model of radiation-induced cancer. Radiat Res 156:678–681
Heidenreich WF, Jacob P, Paretzke HG et al (1999) Two-step model for the risk of fatal and incidental lung tumors in rats exposed to radon. Radiat Res 151:209–217
Heidenreich WF, Luebeck EG, Hazelton WD et al (2002) Multistage models and the incidence of cancer in the cohort of atomic bomb survivors. Radiat Res 158:607–614
Heidenreich WF, Cullings HM, Funamoto S et al (2007) Promoting action of radiation in the atomic bomb survivor carcinogenesis data? Radiat Res 168:750–756
Hlatky L, Hahnfeldt P, Tsionou C et al (1996) Vascular endothelial growth factor: environmental controls and effects in angiogenesis. Br J Cancer Suppl 27:S151–S156
Hodgson DC, Koh ES, Tran TH et al (2007) Individualized estimates of second cancer risks after contemporary radiation therapy for Hodgkin lymphoma. Cancer 110:2576–2586
Hofmann W, Crawford-Brown DJ, Fakir H et al (2006) Modeling lung cancer incidence in rats following exposure to radon progeny. Radiat Prot Dosimetry 122:345–348
Inskip PD, Kleinerman RA, Stovall M et al (1993) Leukemia, lymphoma, and multiple myeloma after pelvic radiotherapy for benign disease. Radiat Res 135:108–124
Ivanov VK, Gorski AI, Tsyb AF et al (2004) Solid cancer incidence among the Chernobyl emergency workers residing in Russia: estimation of radiation risks. Radiat Environ Biophys 43:35–42
Knudson AG Jr (1971) Mutation and cancer: statistical study of retinoblastoma. Proc Natl Acad Sci U S A 68:820–823
Koh ES, Tran TH, Heydarian M et al (2007) A comparison of mantle versus involved-field radiotherapy for Hodgkin’s lymphoma: reduction in normal tissue dose and second cancer risk. Radiat Oncol 2:13
Kohle C, Schwarz M, Bock KW (2008) Promotion of hepatocarcinogenesis in humans and animal models. Arch Toxicol 82:623–631
Komarova NL, Cheng P (2006) Epithelial tissue architecture protects against cancer. Math Biosci 200:90–117
Kopp-Schneider A, Portier CJ (1991) Distinguishing between models of carcinogenesis: the role of clonal expansion. Fundam Appl Toxicol 17:601–613
Lange CS, Mayer PJ, Reddy NM (1997) Tests of the double-strand break, lethal-potentially lethal and repair-misrepair models for mammalian cell survival using data for survival as a function of delayed-plating interval for log-phase Chinese hamster V79 cells. Radiat Res 148:285–292
Leedham SJ, Wright NA (2008) Expansion of a mutated clone—from stem cell to tumour. J Clin Pathol 61(2):164–171
Leedham SJ, Schier S, Thliveris AT et al (2005) From gene mutations to tumours–stem cells in gastrointestinal carcinogenesis. Cell Prolif 38:387–405
Li L, Xie T (2005) Stem cell niche: structure and function. Annu Rev Cell Dev Biol 21:605–631
Lindsay KA, Wheldon EG, Deehan C et al (2001) Radiation carcinogenesis modelling for risk of treatment-related second tumours following radiotherapy. Br J Radiol 74:529–536
Little MP (2001) Comparison of the risks of cancer incidence and mortality following radiation therapy for benign and malignant disease with the cancer risks observed in the Japanese A-bomb survivors. Int J Radiat Biol 77:431–464
Little MP (2007) A multi-compartment cell repopulation model allowing for inter-compartmental migration following radiation exposure, applied to leukaemia. J Theor Biol 245:83–97
Little MP, Li G (2007) Stochastic modelling of colon cancer: is there a role for genomic instability? Carcinogenesis 28:479–487
Little MP, Wright EG (2003) A stochastic carcinogenesis model incorporating genomic instability fitted to colon cancer data. Math Biosci 183:111–134
Little MP, Weiss HA, Boice JD Jr et al (1999) Risks of leukemia in Japanese atomic bomb survivors, in women treated for cervical cancer, and in patients treated for ankylosing spondylitis. Radiat Res 152:280–292
Luebeck EG, Hazelton WD (2002) Multistage carcinogenesis and radiation. J Radiol Prot 22:A43–A49
Luebeck EG, Moolgavkar SH (2002) Multistage carcinogenesis and the incidence of colorectal cancer. Proc Natl Acad Sci U S A 99:15095–15100
Maley CC (2007) Multistage carcinogenesis in Barrett’s esophagus. Cancer Lett 245:22–32
Maley CC, Reid BJ (2005) Natural selection in neoplastic progression of Barrett’s esophagus. Semin Cancer Biol 15:474–483
McDonald SA, Preston SL, Greaves LC et al (2006) Clonal expansion in the human gut: mitochondrial DNA mutations show us the way. Cell Cycle 5:808–811
Mebust M, Crawford-Brown D, Hofmann W et al (2002) Testing extrapolation of a biologically based exposure-response model from in vitro to in vivo conditions. Regul Toxicol Pharmacol 35:72–79
Meza R, Jeon J, Moolgavkar SH et al (2008) Age-specific incidence of cancer: phases, transitions, and biological implications. Proc Natl Acad Sci U S A 105:16284–16289
Michor F, Iwasa Y, Komarova NL et al (2003a) Local regulation of homeostasis favors chromosomal instability. Curr Biol 13:581–584
Michor F, Frank SA, May RM et al (2003b) Somatic selection for and against cancer. J Theor Biol 225:377–382
Michor F, Iwasa Y, Rajagopalan H et al (2004) Linear model of colon cancer initiation. Cell Cycle 3:358–362
Michor F, Iwasa Y, Lengauer C et al (2005) Dynamics of colorectal cancer. Semin Cancer Biol 15:484–493
Midorikawa Y, Makuuchi M, Tang W et al (2007) Microarray-based analysis for hepatocellular carcinoma: from gene expression profiling to new challenges. World J Gastroenterol 13:1487–1492
Moolgavkar SH (1978) The multistage theory of carcinogenesis and the age distribution of cancer in man. J Natl Cancer Inst 61:49–52
Moolgavkar S (1980) Multistage models for carcinogenesis. J Natl Cancer Inst 65:215–216
Moolgavkar SH (1983) Model for human carcinogenesis: action of environmental agents. Environ Health Perspect 50:285–291
Moolgavkar SH (1986) Carcinogenesis modeling: from molecular biology to epidemiology. Annu Rev Public Health 7:151–169
Moolgavkar SH, Knudson AG Jr (1981) Mutation and cancer: a model for human carcinogenesis. J Natl Cancer Inst 66:1037–1052
Naumov GN, Bender E, Zurakowski D et al (2006) A model of human tumor dormancy: an angiogenic switch from the nonangiogenic phenotype. J Natl Cancer Inst 98:316–325
NCRP Report 136 (2001) Evaluation of the linear-nonthreshold dose-response model for ionizing radiation. The National Academic Press, Washington
Neglia JP, Robison LL, Stovall M et al (2006) New primary neoplasms of the central nervous system in survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. J Natl Cancer Inst 98:1528–1537
Nguyen LN, Ang KK (2002) Radiotherapy for cancer of the head and neck: altered fractionation regimens. Lancet Oncol 3:693–701
Nilsson P, Thames HD, Joiner MC (1990) A generalized formulation of the ‘incomplete-repair’ model for cell survival and tissue response to fractionated low dose-rate irradiation. Int J Radiat Biol 57:127–142
Nishimura M, Furumoto H, Kato T et al (2000) Microsatellite instability is a late event in the carcinogenesis of uterine cervical cancer. Gynecol Oncol 79:201–206
Nordling CO (1953) A new theory on the cancer inducing mechanism. Br J Cancer 7:68–72
Nowak MA, Komarova NL, Sengupta A et al (2002) The role of chromosomal instability in tumor initiation. Proc Natl Acad Sci U S A 99:16226–16231
Nowak MA, Michor F, Iwasa Y (2006) Genetic instability and clonal expansion. J Theor Biol 241:26–32
Ohtaki M, Niwa O (2001) A mathematical model of radiation carcinogenesis with induction of genomic instability and cell death. Radiat Res 156:672–677
Ottolenghi A, Ballarini F, Merzagora M (1999) Modelling radiation-induced biological lesions: from initial energy depositions to chromosome aberrations. Radiat Environ Biophys 38:1–13
Perez-Ordonez B, Beauchemin M, Jordan RC (2006) Molecular biology of squamous cell carcinoma of the head and neck. J Clin Pathol 59:445–453
Pierce DA, Mendelsohn ML (1999) A model for radiation-related cancer suggested by atomic bomb survivor data. Radiat Res 152:642–654
Pierce DA, Vaeth M (2003) Age-time patterns of cancer to be anticipated from exposure to general mutagens. Biostatistics 4:231–248
Pompei F, Wilson R (2002) A quantitative model of cellular senescence influence on cancer and longevity. Toxicol Ind Health 18:365–376
Pompei F, Polkanov M, Wilson R (2001) Age distribution of cancer in mice: the incidence turnover at old age. Toxicol Ind Health 17:7–16
Potten CS, Booth C (2002) Keratinocyte stem cells: a commentary. J Invest Dermatol 119:888–899
Radivoyevitch T, Kozubek S, Sachs RK (2001) Biologically based risk estimation for radiation-induced CML. Inferences from BCR and ABL geometric distributions. Radiat Environ Biophys 40:1–9
Ritter G, Wilson R, Pompei F et al (2003) The multistage model of cancer development: some implications. Toxicol Ind Health 19:125–145
Ron E (2006) Childhood cancer—treatment at a cost. J Natl Cancer Inst 98:1510–1511
Ronckers CM, Sigurdson AJ, Stovall M et al (2006) Thyroid cancer in childhood cancer survivors: a detailed evaluation of radiation dose response and its modifiers. Radiat Res 166:618–628
Rossi HH, Kellerer AM (1986) The dose rate dependence of oncogenic transformation by neutrons may be due to variation of response during the cell cycle. Int J Radiat Biol Relat Stud Phys Chem Med 50:353–361
Rusyn I, Peters JM, Cunningham ML (2006) Modes of action and species-specific effects of di-(2-ethylhexyl)phthalate in the liver. Crit Rev Toxicol 36:459–479
Sachs RK, Brenner DJ (2005) Solid tumor risks after high doses of ionizing radiation. Proc Natl Acad Sci U S A 102:13040–13045
Sachs RK, Chan M, Hlatky L et al (2005) Modeling intercellular interactions during carcinogenesis. Radiat Res 164:324–331
Sachs RK, Shuryak I, Brenner D et al (2007) Second cancers after fractionated radiotherapy: stochastic population dynamics effects. J Theor Biol 249:518–531
Schneider U, Kaser-Hotz B (2005) Radiation risk estimates after radiotherapy: application of the organ equivalent dose concept to plateau dose-response relationships. Radiat Environ Biophys 44:235–239
Schneider U, Walsh L (2008) Cancer risk estimates from the combined Japanese A-bomb and Hodgkin cohorts for doses relevant to radiotherapy. Radiat Environ Biophys 47:253–263
Schollnberger H, Mitchel RE, Crawford-Brown DJ et al (2002) Nonlinear dose-response relationships and inducible cellular defence mechanisms. J Radiol Prot 22:A21–A25
Sharpless NE, DePinho RA (2007) How stem cells age and why this makes us grow old. Nat Rev Mol Cell Biol 8:703–713
Shaw IC, Jones HB (1994) Mechanisms of non-genotoxic carcinogenesis. Trends Pharmacol Sci 15:89–93
Shuryak I, Sachs RK, Hlatky L et al (2006) Radiation-induced leukemia at doses relevant to radiation therapy: modeling mechanisms and estimating risks. J Natl Cancer Inst 98:1794–1806
Shuryak I, Hahnfeldt P, Hlatky L, Sachs RK, Brenner DJ (2009a) A new view of radiation-induced cancer: integrating short- and long-term processes. Part I: approach. Radiat Environ Biophys 48(3):263–274 (Erratum in: Radiat Environ Biophys 50(4):607–608)
Shuryak I, Hahnfeldt P, Hlatky L, Sachs RK, Brenner DJ (2009b) A new view of radiation-induced cancer: integrating short- and long-term processes. Part II: second cancer risk estimation. Radiat Environ Biophys 48(3):275–286 (Erratum in: Radiat Environ Biophys 50(4):607–608)
Slack JM (2000) Stem cells in epithelial tissues. Science 287:1431–1433
Sontag W (1997) A discrete cell survival model including repair after high dose-rate of ionizing radiation. Int J Radiat Biol 71:129–144
Spiess PE, Czerniak B (2006) Dual-track pathway of bladder carcinogenesis: practical implications. Arch Pathol Lab Med 130:844–852
Stewart RD (2001) Two-lesion kinetic model of double-strand break rejoining and cell killing. Radiat Res 156:365–378
Tahara E (2004) Genetic pathways of two types of gastric cancer. IARC Sci Publ 157:327–349
Tamura G (2006) Alterations of tumor suppressor and tumor-related genes in the development and progression of gastric cancer. World J Gastroenterol 12:192–198
Thames HD (1985) An ‘incomplete-repair’ model for survival after fractionated and continuous irradiations. Int J Radiat Biol Relat Stud Phys Chem Med 47:319–339
Thomlinson RH, Gray LH (1955) The histological structure of some human lung cancers and the possible implications for radiotherapy. Br J Cancer 9:539–549
Tobias CA (1985) The repair-misrepair model in radiobiology: comparison to other models. Radiat Res Suppl 8:S77–S95
Travis LB, Andersson M, Gospodarowicz M et al (2000) Treatment-associated leukemia following testicular cancer. J Natl Cancer Inst 92:1165–1171
Travis LB, Gospodarowicz M, Curtis RE et al (2002) Lung cancer following chemotherapy and radiotherapy for Hodgkin’s disease. J Natl Cancer Inst 94:182–192
Travis LB, Hill DA, Dores GM et al (2003) Breast cancer following radiotherapy and chemotherapy among young women with Hodgkin disease. JAMA 290:465–475
Trosko JE (2006) From adult stem cells to cancer stem cells: Oct-4 Gene, cell–cell communication, and hormones during tumor promotion. Ann N Y Acad Sci 1089:36–58
Upton AC (2003) The state of the art in the 1990’s: NCRP Report No. 136 on the scientific bases for linearity in the dose-response relationship for ionizing radiation. Health Phys 85:15–22
Weiss HA, Darby SC, Fearn T et al (1995) Leukemia mortality after X-ray treatment for ankylosing spondylitis. Radiat Res 142:1–11
Wheldon EG, Lindsay KA, Wheldon TE (2000) The dose-response relationship for cancer incidence in a two-stage radiation carcinogenesis model incorporating cellular repopulation. Int J Radiat Biol 76:699–710
Yakovlev A, Polig E (1996) A diversity of responses displayed by a stochastic model of radiation carcinogenesis allowing for cell death. Math Biosci 132:1–33
Yamasaki H, Mesnil M, Nakazawa H (1992) Interaction and distinction of genotoxic and non-genotoxic events in carcinogenesis. Toxicol Lett 64–65 Spec No:597–604
Zaider M, Wuu CS (1995) The effects of sublethal damage recovery and cell cycle progression on the survival probability of cells exposed to radioactive sources. Br J Radiol 68:58–63
Zelefsky MJ, Fuks Z, Hunt M et al (2002) High-dose intensity modulated radiation therapy for prostate cancer: early toxicity and biochemical outcome in 772 patients. Int J Radiat Oncol Biol Phys 53:1111–1116
Zhang W, Remenyik E, Zelterman D et al (2001) Escaping the stem cell compartment: sustained UVB exposure allows p53-mutant keratinocytes to colonize adjacent epidermal proliferating units without incurring additional mutations. Proc Natl Acad Sci U S A 98:13948–13953
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2014 Springer-Verlag Berlin Heidelberg
About this chapter
Cite this chapter
Brenner, D.J., Shuryak, I., Sachs, R.K. (2014). Radiotherapy-Induced Carcinogenesis and Leukemogenesis: Mechanisms and Quantitative Modeling. In: Rubin, P., Constine, L., Marks, L. (eds) ALERT - Adverse Late Effects of Cancer Treatment. Medical Radiology(). Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-540-72314-1_14
Download citation
DOI: https://doi.org/10.1007/978-3-540-72314-1_14
Published:
Publisher Name: Springer, Berlin, Heidelberg
Print ISBN: 978-3-540-72313-4
Online ISBN: 978-3-540-72314-1
eBook Packages: MedicineMedicine (R0)