Información de la revista
Vol. 99. Núm. 8.
Páginas 608-620 (octubre 2008)
Compartir
Compartir
Descargar PDF
Más opciones de artículo
Vol. 99. Núm. 8.
Páginas 608-620 (octubre 2008)
Advances in dermatology
Acceso a texto completo
Genotypic Analysis in Primary Cutaneous Lymphomas Using the Standardized Biomed-2 Polymerase Chain Reaction Protocols
Aplicación de los Protocolos de PCR Biomed-2 en el Análisis Genotípico de los Linfomas Cutáneos Primarios
Visitas
7107
F. Gallardoa,
Autor para correspondencia
FGallardo@imas.imim.es

Correspondence: Servicio de Dermatología, Hospital del Mar, IMAS, Passeig Marítim, 25-29, 08003 Barcelona, Spain.
, B. Bellosillob, S. Serranob, R.M. Pujola
a Servicio de Dermatología, Servicio de Patología, Hospital del Mar, IMAS, Barcelona, Spain
b Laboratorio de Biología Molecular, Servicio de Patología, Hospital del Mar, IMAS, Barcelona, Spain
Este artículo ha recibido
Información del artículo
Abstract

The European Biomedicine and Health (BIOMED-2) Concerted Action Project BMH4-CT98-3936 has defined standardized protocols for polymerase chain reaction (PCR) amplification of different loci of the T-cell receptor (TCR) and immunoglobulin (Ig) genes with a view to achieving greater sensitivity and specificity in the assessment of clonality of lymphoid neoplasms. To assess T-cell clonality, analysis of TCRβ gene and TCRδ rearrangements (useful in cases of Tγδ+ cell neoplasms) is proposed alongside that of TCRγ. For analysis of B-cell clonality, along with the framework (FR) III segment of the IgH gene, other segments are studied (FRI, FRII) in addition to Igγ and Igκ genes or incomplete DJ rearrangements of the IgH gene and the κ deleting element. The results of the amplification are read using automatic reading systems (GeneScan) or using a heteroduplex system.

Key words:
cutaneous lymphoma
gene rearrangement
clonality
polymerase chain reaction
BIOMED-2
GeneScan
Resumen

El proyecto europeo BIOMED-2 Concerted Action BMH4-CT98-3936 describe protocolos estandarizados de amplificación por reacción en cadena de la polimerasa (PCR) de los diferentes loci de los genes del receptor de la célula T (TCR) e inmunoglobulinas (Ig) con el objetivo de obtener una mayor sensibilidad y especificidad en el estudio de clonalidad de las neoplasias linfoides. En el estudio de clonalidad T, además del TCRγ se propone el estudio adicional de los reordenamientos del gen TCRβ y del locus TCRδ (útil en casos de neoplasias de células Tγδ+). En el estudio de clonalidad B, junto al segmento FRIII del gen IgH se diseña el estudio de otros segmentos (FRI, FRII), así como de los genes Igλ e Igκ o reordenamientos incompletos DJ del gen IgH y κde (kappa deleting element). La lectura de los resultados de la amplificación se realiza mediante sistemas automatizados de lectura (GeneScan) o mediante el sistema heterodúplex.

Palabras clave:
linfoma cutáneo
reordenamiento genético
clonalidad
reacción en cadena de la polimerasa
BIOMED-2
GeneScan
El Texto completo está disponible en PDF
References
[1.]
K.J. Trainor, M.J. Brisco, J.H. Wan, S. Neoh, S. Grist, A.A. Morley.
Gene rearrangement in B- and T-lymphoproliferative disease detected by the polymerase chain reaction.
Blood, 78 (1991), pp. 192-196
[2.]
M. Volkenandt, R. Wienecke, M. Tiemann.
Detection of monoclonal lymphoid cells populations by polymerase chain reaction technology.
Dermatol Clin, 12 (1994), pp. 341-349
[3.]
N.S. Penneys, C. Leonardi.
Polymerase chain reaction: relevance for dermatopathology.
J Cutan Pathol, 18 (1991), pp. 3-7
[4.]
K.P. McCarthy, J.P. Sloane, J.H.S. Kabarowski, E. Matutes, L.M. Wiedemann.
A simplified method of detection of clonal rearrangements of the T-cell receptor-gamma chain gene.
Diagn Mol Pathol, 1 (1992), pp. 173-179
[5.]
K.P. McCarthy, J.P. Sloane, J.H. Kabarowski, E. Matutes, L.M. Wiedemann.
The rapid detection of clonal T-cell proliferations in patients with lymphoid disorders.
Am J Pathol, 138 (1991), pp. 821-828
[6.]
A. Bourguin, R. Tung, N. Galili, J. Sklar.
Rapid, non radioactive detection of clonal T-cell receptor gene rearrangements in lymphoid neoplasms.
Proc Natl Acad Sci USA, 87 (1990), pp. 8536-8540
[7.]
N. Curco, O. Servitje, M. Llucia, J. Bertran, A. Limon, M. Carmona, et al.
Genotypic analysis of cutaneous T-cell lymphoma: a comparative study of Southern blot analysis with polymerase chain reaction amplification of the T-cell receptor-gamma gene.
Br J Dermatol, 137 (1997), pp. 673-679
[8.]
E. Dippel, C. Assaf, M. Hummel, H.J. Schrag, H. Stein, S. Goerdt, et al.
Clonal T-cell receptor gamma-chain gene rearrangement by PCR-based GeneScan analysis in advanced cutaneous T-cell lymphoma: a critical evaluation.
[9.]
S.R. Lessin, A.H. Rook, G. Rovera.
Molecular diagnosis of cutaneous T-cell lymphoma: polymerase chain reaction amplification of T-cell antigen receptor beta-chain gene rearrangements.
J Invest Dermatol, 96 (1991), pp. 299-302
[10.]
P. Algara, C. Soria, P. Martínez, L. Sánchez, R. Villuendas, P. García, et al.
Value of PCR detection of TCR gamma gene rearrangement in the diagnosis of cutaneous lymphocytic infiltrates.
Diagn Mol Pathol, 3 (1994), pp. 275-282
[11.]
H. Bachelez, L. Bioul, B. Flageul, M. Baccard, I. Moulon-guet-Michau, O. Verola, et al.
Detection of clonal T-cell receptor gamma gene rearrangements with the use of the polymerase chain reaction in cutaneous lesions of mycosis fungoides and Sézary syndrome.
Arch Dermatol, 131 (1995), pp. 1027-1031
[12.]
G.S. Wood, R.M. Tung, A.C. Haeffner, C.F. Crooks, S. Liao, R. Orozco, et al.
Detection of clonal T-cell receptor gamma gene rearrangements in early mycosis fungoides/Sézary syndrome by polymerase chain reaction and denaturing gradient gel electrophoresis (PCR/DGGE).
J Invest Dermatol, 103 (1994), pp. 34-41
[13.]
J. Guitart, K. Kaul.
A new polymerase chain reaction-based method for the detection of T-cell clonality in patients with possible cutaneous T-cell lymphoma.
Arch Dermatol, 135 (1999), pp. 158-162
[14.]
G.S. Wood, A.Z. Uluer.
Polymerase chain reaction/denaturing gradient gel electrophoresis (PCR-DGGE).
Am J Dermatopathol, 21 (1999), pp. 547-551
[15.]
J.J. van Dongen, A.W. Langerak, M. Bruggemann, P.AS. Evans, M. Hummel, F.L. Lavender, et al.
Design and standardization of PCR primers and protocols for detection of clonal immunoglobulin and T-cell receptor gene recombinations in suspect lymphoproliferations: report of the BIOMED-2 Concerted Action BMH4-CT98-3936.
Leukemia, 17 (2003), pp. 2257-2317
[16.]
P.A. Evans, C.h. Pott, P.J. Groenen, G. Salles, F. Davis, F. Berger, et al.
Significantly improved PCR-based clonality testing in B-cell malignancies by use of multiple immunoglobulin gene targets. Report of the BIOMED-2 Concerted Action BHM4-CT98-3936.
Leukemia, 21 (2007), pp. 207-214
[17.]
S. Tonegawa.
Somatic generation of antibody diversity.
Nature, 302 (1983), pp. 575-581
[18.]
M.M. Davis, P.J. Bjorkman.
T-cell antigen receptor genes and T-cell recognition.
Nature, 334 (1988), pp. 395-402
[19.]
R. Kuppers, U. Klein, M.L. Hansmann, K. Rajewsky.
Cellular origin of human B-cell lymphomas.
N Engl J Med, 341 (1999), pp. 1520-1529
[20.]
D.N. Slack, K.P. McCarthy, L.M. Wiedemann, J.P. Sloane.
Evaluation of sensitivity, specificity and reproducibility of an optimised method for detecting clonal rearrangements of immunoglobulin and T-cell receptor genes in formalin-fixed, paraffin-embedded sections.
Diagn Mol Pathol, 2 (1993), pp. 223-232
[21.]
M. Kneba, I. Bolz, B. Linke, W. Hiddemann.
Analysis of rearranged T-cell receptor beta-chain genes by polymerase chain reaction (PCR) DNA sequencing and automated high resolution PCR fragment analysis.
Blood, 86 (1995), pp. 3930-3937
[22.]
U. Scheller, M. Muche, W. Sterry, A. Lukowsky.
Detection of clonal T cells in cutaneous T cell lymphoma by polymerase chain reaction: comparison of mutation detection enhancement-polyacrylamide gel electrophoresis, temperature gradient gel electrophoresis and fragment analysis of sequencing gels.
Electrophoresis, 19 (1998), pp. 653-658
[23.]
A. Lukowsky, S. Richter, K. Dijkstal, W. Sterry, M. Muche.
A T-cell receptor gamma polymerase chain reaction assay using capillary electrophoresis for the diagnosis of cutaneous T-cell lymphomas.
Diagn Mol Pathol, 11 (2002), pp. 59-66
[24.]
C. Assaf, M. Hummel, E. Dippel, S. Goerdt, H.H. Müller, I. Anagnostopoulos, et al.
High detection rate of T-cell receptor beta chain rearrangement in T-cell lymphoproliferations by family specific polymerase chain reaction in combination with the GeneScan technique and DNA sequencing.
Blood, 96 (2000), pp. 640-646
[25.]
R. Gutzmer, S. Mommert, P. Kiehl, M. Wittmann, A. Kapp, T. Werfel.
Detection of clonal T cell receptor gamma gene rearrangements in cutaneous T cell lymphoma by LightCyclerpolymerase chain reaction.
J Invest Dermatol, 116 (2001), pp. 926-932
[26.]
C. Costa, F. Gallardo, R. Pujol, B. Espinet, B. Bellosillo, T. Estrach, et al.
Comparative analysis of TCR-gamma gene rearrangements by Genescan and polyacrylamide gelelectrophoresis in cutaneous T-cell lymphoma.
Acta Derm Venereol, 84 (2004), pp. 6-11
[27.]
B. Linke, I. Bolz, A. Fayyazi, M. von Hofen, C. Pott, J. Bertram, et al.
Automated high resolution PCR fragment analysis for identification of clonally rearranged immunoglobulin heavy chain genes.
Leukemia, 11 (1997), pp. 1055-1062
[28.]
B. Gleissner, J. Maurer, A. Sindram, R. Reinhard, E. Thiel.
Comparison of ethidium bromide-stained agarose gel electrophoresis and automated fragment analysis for evaluation of IgH gene products.
Leuk Res, 25 (2001), pp. 769-774
[29.]
M. Bottaro, E. Berti, A. Biondi, N. Migone, L. Crosti.
Heteroduplex analysis of T-cell receptor gamma gene rearrangements for diagnosis and monitoring of cutaneous T-cell lymphomas.
Blood, 83 (1994), pp. 3271-3278
[30.]
I. Theodorou, M.H. Delfau-Laure, C. Bigorgne, C. Lahet, G. Cochet, M. Bagot, et al.
Cutaneous T-cell infiltrates: analysis of T-cell receptor gamma gene rearrangement by polymerase chain reaction and denaturing gradient gel electrophoresis.
Blood, 86 (1995), pp. 305-310
[31.]
S. Kohler, C.D. Jones, R.A. Warnke, J.L. Zehnder.
PCRheteroduplex analysis of T-cell receptor gamma gene rearrangement in paraffin-embedded skin biopsies.
Am J Dermatopathol, 22 (2000), pp. 321-327
[32.]
K.S. Elenitoba-Johnson, S.D. Bohling, R.S. Mitchell, M.S. Brown, R.S. Robetorye.
PCR analysis of the immunoglobulin heavy chain gene in polyclonal processes can yield pseudoclonal bands as an artifact of low B cell number.
J Mol Diagn, 2 (2000), pp. 92-96
[33.]
M.J. García, B. Martínez-Delgado, J.J. Granizo, J. Benítez, C. Rivas.
IgH, TCR gamma, and TCR beta gene rearrangement in 80 B-and T-Cell Non-Hodgkin's lymphomas: study of the association between proliferation and the so-called aberrant patterns.
Diagn Mol Pathol, 10 (2001), pp. 69-77
[34.]
R. Ponti, M.T. Fierro, P. Quaglino, B. Lisa, F.C. Paola, O. Michela, et al.
TCR-Chain Gene Rearrangement by PCR-Based GeneScan: Diagnostic Accuracy Improvement and Clonal Heterogeneity Analysis in Multiple Cutaneous T-Cell Lymphoma Samples.
J Invest Dermatol, 128 (2008), pp. 1030-1038
[35.]
R. Ponti, P. Quaglino, M. Novelli, M.T. Fierro, A. Comessatti, A. Peroni, et al.
T-cell receptor gamma gene rearrangement by multiplex polymerase chain reaction/heteroduplex analysis in patients with cutaneous T-cell lymphoma (mycosis fungoides/Sézary syndrome) and benign inflammatory disease: correlation with clinical, histological and immunophenotypical findings.
Br J Dermatol, 153 (2005), pp. 565-573
[36.]
L.J. Medeiros, J. Carr.
Overview of the role of molecular methods in the diagnosis of malignant lymphomas.
Arch Pathol Lab Med, 123 (1999), pp. 1189-1207
[37.]
E. Hodges, M.T. Krishna, C. Pickard, J.L. Smith.
Diagnostic role of tests for T cell receptor genes.
J Clin Pathol, 56 (2003), pp. 1-11
[38.]
S.M. Morgan, E. Hodges, T. Mitchell, S. Harris, S. Whittaker, J. Smith.
Molecular analysis of T-cell receptor beta genes in cutaneous T-cell lymphoma reveal Jbeta1 bias.
J Invest Dermatol, 126 (2006), pp. 1893-1899
[39.]
J.A. Plaza, C. Morrison, C.M. Magro.
Assessment of TCRbeta clonality in a diverse group of cutaneous T-Cell infiltrates.
J Cutan Pathol, 35 (2008), pp. 358-365
[40.]
M. Chen, A. Deng, A.N. Crowson, M. Srinivasan, K.H. Yearsley, S. Jewell, et al.
Assessment of T-cell Clonality via T-cell Receptor-gamma Rearrangements in Cutaneous T-cell-Dominant Infiltrates Using Polymerase Chain Reaction and Single-stranded DNA Conformational Polymorphism Assay.
Appl Immunohistochem Mol Morphol, 12 (2004), pp. 373-379
[41.]
S. Cherny, S. Mraz, L. Su, J. Harvell, S. Kholer.
Heteroduplex analysis of T-cell receptor gamma gene rearrangement as an adjuvant diagnostic tool in skin biopsies for erythroderma.
J Cutan Pathol, 28 (2001), pp. 351-355
[42.]
Y. Sandberg, F. Heule, K. Lam, P.J. Lugtenburg, I.L. Wolvers-Tettero, J.J. van Dongen, et al.
Molecular immunoglobulin/T-cell receptor clonality analysis in cutaneous lymphoproliferations. Experience with the BIOMED-2 standardized polymerase chain reaction protocol.
Haematologica, 88 (2003), pp. 659-670
[43.]
D.S. Harrington, S.W. Braddock, K.S. Blocher, D.D. Weisenburger, W. Sanger, J.O. Armitage.
Lymphomatoid papulosis and progression to T cell lymphoma: an immunophenotypic and genotypic analysis.
J Am Acad Dermatol, 21 (1989), pp. 951-957
[44.]
L.M. Weiss, G.S. Wood, M. Trela, R.A. Warnke, J. Sklar.
Clonal T-cell populations in lymphomatoid papulosis. Evidence of a lymphoproliferative origin for a clinically benign disease.
N Engl J Med, 315 (1986), pp. 475-479
[45.]
R.A. El-Azhary, L.E. Gibson, P.J. Kurtin, M.R. Pittelkow, S.A. Muller.
Lymphomatoid papulosis: a clinical and histopathologic review of 53 cases with leukocyte immunophenotyping, DNA flow cytometry, and T-cell receptor rearrangement studies.
J Am Acad Dermatol, 30 (1994), pp. 210-218
[46.]
J. Greisser, G. Palmedo, C. Sander, H. Kutzner, D.V. Kazakov, M. Roos, et al.
Detection of clonal rearrangement of T-cell receptor genes in the diagnosis of primary cutaneous CD30 lymphoproliferative disorders.
J Cutan Pathol, 33 (2006), pp. 711-715
[47.]
L.M. Weiss, G.S. Wood, L.W. Ellisen, T.C. Reynolds, J. Sklar.
Clonal T-cell populations in pityriasis lichenoides et varioliformis acuta (Mucha-Habermann disease).
Am J Pathol, 126 (1987), pp. 417-421
[48.]
K.B. Gordon, J. Guitart, T. Kuzel, D. Salard, O. Bakouche, P. Domer, et al.
Pseudo-mycosis fungoides in a patient taking clonazepam and fluoxetine.
J Am Acad Dermatol, 34 (1996), pp. 304-306
[49.]
J. Guitart, C. Magro.
Cutaneous T-cell lymphoid dyscrasia: a unifying term for idiopathic chronic dermatoses with persistent T-cell clones.
Arch Dermatol, 143 (2007), pp. 921-932
[50.]
A. Kikuchi, W. Naka, T. Harada, K. Sakuraoka, R. Harada, T. Nishikawa.
Parapsoriasis in plaque: its potential for progression to malignant lymphoma.
J Am Acad Dermatol, 29 (1993), pp. 419-422
[51.]
A.C. Haeffner, B.R. Smoller, K. Zepter, G.S. Wood.
Differentiation and clonality of lesional lymphocytes in small plaque parapsoriasis.
Arch Dermatol, 131 (1995), pp. 321-324
[52.]
M. Muche, A. Lukowsky, J. Heim, M. Friedrich, H. Audring, W. Sterry.
Demonstration of frequent occurrence of clonal T cells in the peripheral blood but not in the skin of patients with small plaque parapsoriasis.
Blood, 94 (1999), pp. 1409-1417
[53.]
S. Stachowitz, M. Mempel, C. Schmöckel, R. von Spanyl, D. Abeck.
Variable course of patients with plaque psoriasis: lack of transformation into tumours mycosis fungoides.
Blood, 95 (2000), pp. 3635-3636
[54.]
C.D. Klemke, E. Dippel, A. Dembinski, N. Ponitz, C. Assaf, M. Hummel, et al.
Clonal T cell receptor -chain gene rearrangement by PCR-based GeneScan analysis in the skin and blood of patients with parapsoriasis and early stage mycosis fungoides.
J Pathol, 197 (2002), pp. 348-354
[55.]
N. Pimpinelli, E.A. Olsen, M. Santucci, E. Vonderheid, A.C. Haefner, S. Stevens, et al.
Defining early mycosis fungoides.
J Am Acad Dermatol, 53 (2005), pp. 1053-1063
[56.]
C. Costa, F. Gallardo, B. Bellosillo, B. Espinet, R. Pujol, C. Barranco, et al.
Analysis of T-cell receptor gamma gene rearrangements by PCR-Genescan and PCR-polyacrylamide gel electrophoresis in early-stage mycosis fungoides/ largeplaque parapsoriasis.
Dermatology, 207 (2003), pp. 418-419
[57.]
F. Gallardo, C. Costa, B. Bellosillo, F. Sole, T. Estrach, O. Servitje, et al.
Lymphomatoid papulosis associated with mycosis fungoides: clinicopathological and molecular studies of 12 cases.
Acta Derm Venereol, 84 (2004), pp. 463-468
[58.]
T. Basarab, E.A. Fraser-Andrews, G. Orchard, S. Whittaker, R. Russel-Jones.
Lymphomatoid papulosis in association with mycosis fungoides: A study of 15 cases.
Br J Dermatol, 139 (1998), pp. 630-638
[59.]
M.H. Delfau-Larue, L. Laroche, J. Wechsler, E. Lepage, C. Lahet, M. Asso-Bonnet, et al.
Diagnostic value of dominant Tcell clones in peripheral blood in 363 patients presenting consecutively with a clinical suspicion of cutaneous lymphoma.
Blood, 96 (2000), pp. 2987-2992
[60.]
N. Cordel, B. Lenormand, P. Courville, M.F. Helot, J. Benichou, P. Joly, et al.
Usefulness of cutaneous T-cell clonality analysis for the diagnosis of cutaneous T-cell lymphoma in patients with erythroderma.
Arch Pathol Lab Med, 129 (2005), pp. 372-376
[61.]
M. Muche, A. Lukowsky, K. Asadullah, S. Gellerich, W. Sterry.
Demonstration of frequent occurrence of clonal T-cells in the peripheral blood of patients with primary cutaneous T-cell lymphoma.
Blood, 4 (1997), pp. 1636-1642
[62.]
K. Amara, M. Trimeche, S. Ziadi, B. Sriha, M. Mokni, S. Korbi.
PCR-based clonality analysis of B-cell lymphomas in paraffin-embedded tissues: diagnostic value of immunoglobulin kappa and lambda light chain gene rearrangement investigation.
Pathol Res Pract, 202 (2006), pp. 425-431
[63.]
J. Hughes, S. Weston, B. Bennetts, M. Prasad, R. Angulo, R. Jaworskit, et al.
The application of a PCR technique for the detection of immunoglobulin heavy chain gene rearrangements in fresh or paraffin-embedded skin tissue.
Pathology, 33 (2001), pp. 222-225
[64.]
M.A. Hoeve, A.D. Krol, K. Philippo, P.W. Derksen, R.A. Veenendaal, E. Schuuring, et al.
Limitations of clonality analysis of B cell proliferations using CDR3 polymerase chain reaction.
Mol Pathol, 53 (2000), pp. 194-200
[65.]
M. Alaibac, A. Belloni-Fortina, M. Mori, B. Pigozzi, A. Peserico, N. Pimpinelli.
Immunoglobulin heavy chain variable region family expression in primary cutaneous follicle centre cell lymphomas.
Br J Dermatol, 144 (2001), pp. 862-865
[66.]
A. Bouloc, M.H. Delfau-Larue, B. Lenormand, F. Meunier, J. Wechsler, E. Thomine, et al.
Polymerase chain reaction analysis of immunoglobulin gene rearrangement in cutaneous lymphoid hyperplasias. French Study Group for Cutaneous Lymphomas.
Arch Dermatol, 135 (1999), pp. 168-172
[67.]
L. Cerroni, S. Signoretti, G. Höfler, G. Annessi, B. Putz, E. Lackinger, et al.
Primary cutaneous marginal zone B-cell lymphoma: a recently described entity of low-grade malignant cutaneous B-cell lymphoma.
Am J Surg Pathol, 21 (1997), pp. 1307-1315
[68.]
F. Child, A.J. Woolford, E. Calonje, R. Russell-Jones, S.J. Whittaker.
Molecular analysis of the immunoglobulin heavy chain gene in the diagnosis of primary cutaneous B cell lymphoma.
J Invest Dermatol, 117 (2001), pp. 984-989
[69.]
J.H. Ritter, M.R. Wick, P.N. Adesokan, J.F. Fitzgibbon, X. Zhu, P.A. Humphrey.
Assessment of clonality in cutaneous lymphoid infiltrates by polymerase chain reaction analysis of immunoglobulin heavy chain gene rearrangement.
Am J Clin Pathol, 108 (1997), pp. 60-68
[70.]
S. Signoretti, M. Murphy, P. Puddu, J.F. DeCoteau, T. Faraggiana, M.E. Kadin, et al.
Clonality of cutaneous B-cell infiltrates determined by microdissection and immunoglobulin gene rearrangement.
Diagn Mol Pathol, 8 (1999), pp. 176-182
[71.]
A. Lukowsky, M. Marchwat, W. Sterry, S. Gellrich.
Evaluation of B-cell clonality in archival skin biopsy samples of cutaneous B-cell lymphoma by immunoglobulin heavy chain gene polymerase chain reaction.
Leuk Lymphoma, 47 (2006), pp. 487-493

This study was partly funded by the FIS 03/394 grant from the Spanish Ministry of Health and Consumer Affairs.

Copyright © 2008. Academia Española de Dermatología y Venereología and Elsevier España, S.L.
Descargar PDF
Idiomas
Actas Dermo-Sifiliográficas
Opciones de artículo
Herramientas
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?