Share This Article:

Epidemiology of Cancer in Systemic Sclerosis—Systematic Review and Meta-Analysis of Cancer Incidence, Predictors and Mortality*

Abstract Full-Text HTML Download Download as PDF (Size:777KB) PP. 231-245
DOI: 10.4236/ojra.2013.34037    3,328 Downloads   5,206 Views  


Objectives: The study was conducted to improve our understanding of the epidemiology of cancer in systemic sclerosis (SSc) by evaluating the incidence, prevalence, relative risk of overall and site-specific malignancies, predictors and cancer-attributable mortality. Methods: MEDLINE, CINAHL, EMBASE and Cochrane Library (inception-May 2012) were searched. Estimates were combined using a random effects model. Consistency was evaluated using the I2 statistic. Results: 4876 citations were searched to identify 60 articles. The average incidence of malignancy in SSc was 14 cases/1000 person-years; the prevalence ranged between 4%-22%. Cancer was the leading cause of non-SSc related deaths with a mean of 38%. Overall SIR for all-site malignancy risk was 1.85 (95%CI 1.52, 2.25; I276%). There was a greater risk of lung (SIR 4.69, 95%CI 2.84, 7.75; I293%) and haematological (SIR 2.58, CI 95% 1.75, 3.81; I20%) malignancies, including non-Hodgkins lymphoma (SIR 2.55, 95%CI 1.40, 4.67; I20%). SSc patients were at a higher risk of leukemia (SIR 2.79, 95%CI 1.22, 6.37; I20%), malignant melanoma (SIR 2.92, 95%CI 1.76, 4.83; I235%), liver (SIR 4.75, 95%CI 3.09, 7.31; I20%), cervical (SIR 2.28, 95%CI 1.26, 4.09; I254%) and oropharyngeal (SIR 5.0, 95%CI 2.18, 11.47; I258%) cancers. Risk factors include a-RNAP I/III seropositivity, male sex, and late onset SSc. Smoking and longstanding interstitial lung disease increase the risk of lung cancer; Barretts esophagus and a positive family history of breast cancer, respectively, increase the risk of esophageal adenocarcinoma and breast cancer. Conclusions: SSc patients have a two-fold increase in all-site malignancy, and greater risk of lung and haematological malignancies that contribute significantly to mortality. Vigilance should be considered in SSc patients with risk factors for cancer.

Conflicts of Interest

The authors declare no conflicts of interest.

Cite this paper

T. Nevskaya, S. Chandran, A. Roos, C. Pasarikovski, A. Kron, C. Chau and S. Johnson, "Epidemiology of Cancer in Systemic Sclerosis—Systematic Review and Meta-Analysis of Cancer Incidence, Predictors and Mortality*," Open Journal of Rheumatology and Autoimmune Diseases, Vol. 3 No. 4, 2013, pp. 231-245. doi: 10.4236/ojra.2013.34037.


[1] S. Jacobsen, P. Halberg and S. Ullman, “Mortality and Causes of Death of 344 Danish Patients with Systemic Sclerosis (Scleroderma),” British Journal of Rheumatology, Vol. 37, No. 7, 1998, pp. 750-755.
[2] R. Hesselstrand, A. Scheja and A. Akesson, “Mortality and Causes of Death in a Swedish Series of Systemic Sclerosis Patients,” Annals of the Rheumatic Diseases, Vol. 57, 1998, pp. 682-686.
[3] L. Scussel-Lonzetti, F. Joyal, J. P. Raynauld, A. Roussin, E. Rich, J. R. Goulet et al., “Predicting Mortality in Systemic Sclerosis: Analysis of a Cohort of 309 French Canadian Patients with Emphasis on Features at Diagnosis as Predictive Factors for Survival,” Medicine, Vol. 81, No. 2, 2002, pp. 154-167.
[4] S. Chatterjee, G. W. Dombi, R. K. Severson and M. D. Mayes, “Risk of Malignancy in Scleroderma: A Population-Based Cohort Study,” Arthritis & Rheumatism, Vol. 52, No. 8, 2005, pp. 2415-2424.
[5] K. A. Black, P. J. Zilko, R. L. Dawkins, B. K. Armstrong and G. L. Mastaglia, “Cancer in Connective Tissue Disease,” Arthritis & Rheumatism, Vol. 25, No. 9, 1983, pp. 1130-1133.
[6] C. T. Derk, M. Rasheed, C. M. Artlett and C. A. Jimenez, “A Cohort Study of Cancer Incidence in Systemic Sclerosis,” Journal of Rheumatology, Vol. 33, No. 6, 2006, pp. 1113-1116.
[7] A. B. Olesen, C. Svaerke, D. K. Farkas and H. T. Sorensen, “Systemic Sclerosis and the Risk of Cancer: A Nationwide Population-Based Cohort Study,” British Journal of Rheumatology, Vol. 163, No. 4, 2010, pp. 800-806.
[8] K. Y. Kang, H. W. Yim, I. J. Kim, J. U. Yoon, J. H. Ju, H. Y. Kim et al., “Incidence of Cancer among Patients with Systemic Sclerosis in Korea: Results from a Single Centre,” Scandinavian Journal of Rheumatology, Vol. 38, No. 4, 2009, pp. 299-303.
[9] A. D. Roumm and T. A. Medsger, “Cancer and Systemic Sclerosis. An Epidemiologic Study,” Arthritis & Rheumatism, Vol. 28, No. 12, 1985, pp. 1336-1340.
[10] A. K. Rosenthal, J. K. McLaughlin, G. Gridley and O. Nyrén, “Incidence of Cancer among Patients with Systemic Sclerosis,” Cancer, Vol. 76, No. 5, 1995, pp. 910-914.<910::AID-CNCR2820760528>3.0.CO;2-T
[11] M. Abu-Shakra, F. Guillemin and P. Lee, “Cancer in Systemic Sclerosis,” Arthritis & Rheumatism, Vol. 36, No. 4, 1993, pp. 460-464.
[12] C. L. Hill, A. M. Nguyen, D. Roder and P. Roberts-Thomson, “Risk of Cancer in Patients with Scleroderma: A Population Based Cohort Study,” Annals of the Rheumatic Diseases, Vol. 62, No. 8, 2003, pp. 728-731.
[13] K. Siau, C. J. Laversuch, P. Creamer and K. P. O’Rourke, “Malignancy in Scleroderma Patients from South West England: A Population-Based Cohort Study,” Rheumatology International, Vol. 31, No. 5, 2011, pp. 641-645.
[14] Y. Fuse, J. Masuyama, T. Yoshio, A. Mimori, A. Takeda, S. Minota et al., “Progressive Systemic Sclerosis (PSS) and Cancer—Increasing Coincidence Rate of Cancer in 67 PSS Patients,” Ryumachi, Vol. 35, No. 1, 1995, pp. 25-31.
[15] M. A. Omair, V. Phumethum and S. R. Johnson, “Long-Term Safety and Effectiveness of Tumour Necrosis Factor Inhibitors in Systemic Sclerosis Patients with Inflammatory Arthritis,” Clinical and Experimental Rheumatology, Vol. 30, No. Suppl 71, 2012, pp. S55-S59.
[16] R. A. Nash, P. A. McSweeney, L. J. Crofford, M. Abidi, C. S. Chen, J. D. Godwin et al., “High-Dose Immunosuppressive Therapy and Autologous Hematopoietic Cell Transplantation for Severe Systemic Sclerosis: Long-Term Follow-Up of the US Multicenter Pilot Study,” Blood, Vol. 110, No. 4, 2007, pp. 1388-1396.
[17] M. Bonifazi, I. Tramacere, G. Pomponio, B. Gabrielli, E. V. Avvedimento, C. La Vecchia et al., “Systemic Sclerosis (Scleroderma) and Cancer Risk: Systematic Review and Meta-Analysis of Observational Studies,” Rheumatology (Oxford), Vol. 52, No. 1, 2013, pp. 143-154.
[18] M. Higuchi, T. Horiuchi, N. Ishibashi, S. Yoshizawa, Y. Niho and K. Nagasawa, “Anticentromere Antibody as a Risk Factor for Cancer in Patients with Systemic Sclerosis,” Clinical Rheumatology, Vol. 19, No. 2, 2000, pp. 123-126.
[19] P. Airo, A. Ceribelli, I. Cavazzana, M. Taraborelli, S. Zingarelli and F. Franceschini, “Malignancies in Italian Patients with Systemic Sclerosis Positive for Anti-RNA Polymerase III Antibodies,” Journal of Rheumatology, Vol. 38, No. 7, 2011, pp. 1329-1334.
[20] E. K. Pontifex, C. L. Hill and P. Roberts-Thomson, “Risk Factors for Lung Cancer in Patients with Scleroderma: A Nested Case-Control Study,” Annals of the Rheumatic Diseases, Vol. 66, No. 4, 2007, pp. 551-553.
[21] T. Y. Lu, C. L. Hill, E. K. Pontifex and P. J. Roberts-Thomson, “Breast Cancer and Systemic Sclerosis: A Clinical Description of 21 Patients in a Population-Based Cohort Study,” Rheumatology International, Vol. 28, No. 9, 2008, pp. 895-899.
[22] C. T. Derk, “Associations of Breast Cancer Development in Patients with Systemic Sclerosis: An Exploratory Study,” Clinical Rheumatology, Vol. 26, No. 10, 2007, pp. 1615-1619.
[23] The PRISMA Statement.
[24] A. K. Rosenthal, J. K. McLaughlin, M. S. Linet and I. Perrson, “Scleroderma and Malignancy: An Epidemiological Study,” Annals of the Rheumatic Diseases, Vol. 52, No. 7, 1993, pp. 531-533.
[25] P. Hissaria, S. Lester, P. Hakendorf, R. Woodman, K. Patterson, C. Hill, et al., “Survival in Scleroderma: Results from the Population-Based South Australian Register,” Internal Medicine Journal, Vol. 41, No. 5, 2011, pp. 381-390.
[26] L. Czirják, G. Kumánovics, C. Varjú, Z. Nagy, A. Pákozdi, Z. Szekanecz et al., “Survival and Causes of Death in 366 Hungarian Patients with Systemic Sclerosis,” Annals of the Rheumatic Diseases, Vol. 67, No. 1, 2008, pp. 59-63.
[27] E. Thomas, D. Symmons, D. Brewster, R. Black, G. Macfarlane, “National Study of Cause-Specific Mortality in Rheumatoid Arthritis, Juvenile Chronic Arthritis, and Other Rheumatic Conditions: A 20-Year-Follow-Up Study,” Journal of Rheumatology, Vol. 30, No. 5, 2003, pp. 958-965.
[28] P. G. Vlachoyiannopoulos, U. G. Dafni, I. Pakas, M. Spyropoulou-Vlachou, C. Stavropoulos-Giokas and H. M. Moutsopoulos, “Systemic Scleroderma in Greece: Low Mortality and Strong Linkage with HLADRB1* 1104 Allele,” Annals of the Rheumatic Diseases, Vol. 59, No. 5, 2000, pp. 359-367.
[29] C. T. Derk, C. M. Artlett and S. A. Jimenez, “Morbidity and Mortality of Patients Diagnosed with Systemic Sclerosis after the Age of 75: A Nested Case-Control Study,” Clinical Rheumatology, Vol. 25, No. 6, 2006, pp. 831-834.
[30] C. T. Derk, L. I. Sakkas, M. Rasheed, C. Artlett and S. A. Jimenez, “Autoantibodies in Patients with Systemic Sclerosis and Cancer: A Case-Control Study,” Journal of Rheumatology, Vol. 30, No. 9, 2003, pp. 1994-1996.
[31] C. T. Derk, M. Rasheed, J. R. Spiegel and S. A. Jimenez, “Increased Incidence of Carcinoma of the Tongue in Patients with Systemic Sclerosis,” Journal of Rheumatology, Vol. 32, No. 4, 2005, pp. 637-641.
[32] E. Szekanecz, S. Szamosi, L. Gergely, P. Keszthelyi, Z. Szekanecz and G. Szucs, “Incidence of Lymphoma in Systemic Sclerosis: A Retrospective Analysis of 218 Hungarian Patients with Systemic Sclerosis,” Clinical Rheumatology, Vol. 27, No. 9, 2008, pp. 1163-1166.
[33] D. Launay, R. Le Berre, P. Y. Hatron, J. P. Peyrat, E. Hachulla, B. Devulder and M. Hebbar, “Association between Systemic Sclerosis and Breast Cancer: Eight New Cases and Review of the Literature,” Clinical Rheumatology, Vol. 23, No. 6, 2004, pp. 516-522.
[34] M. C. Segel, W. L. Campbell, T. A. Medsger Jr. and A. D. Roumm, “Systemic Sclerosis (Scleroderma) and Esophageal Adenocarcinoma: Is Increased Patient Screening Necessary?” Gastroenterology, Vol. 89, No. 3, 1985, pp. 485-488.
[35] S. Vettori, S. Staibano, M. Mascolo, G. Ilardi and G. Valentini, “Non-Hodgkin’s Lymphoma in Systemic Sclerosis: Case and Literature Review,” Clinical Rheumatology, Vol. 29, No. 1, 2010, pp. 1-6.
[36] E. Retetto, O. Cerrato, N. Spotorno and A. Sorbi, “Clinical Study of the Incidence of Malignant Neoplasms in Some Autoimmune Diseases,” Reumatismo, Vol. 26, No. 2, 1974, pp. 102-108.
[37] X. Kyndt, M. Hebbar, V. Queyrel, E. Hachulla, P. Y. Hatron and B. Devulder, “Systemic Scleroderma and Cancer. Search for Predictive Factors of Cancer in 123 Patients with Scleroderma,” La Revue de Médecine Intern, Vol. 18, No. 7, 1997, pp. 528-532.
[38] J. Kim, S. K. Park, K. W. Moon, E. Y. Lee, J. Y. Lee, Y. W. Song, et al., “The Prognostic Factors of Systemic Sclerosis for Survival among Koreans,” Clinical Rheumatology, Vol. 29, No. 3, 2010, pp. 297-302.
[39] F. Sakauchi, M. Mori, O. Ishikawa and H. Endo, “The Association of Systemic Sclerosis with Malignant Neoplasms,” Nihon Rinsho Meneki Gakkai Kaishi (Japanese Journal of Clinical Immunology), Vol. 27, No. 6, 2004, pp. 402-406.
[40] M. Peters-Golden, R. A. Wise, M. Hochberg, M. B. Stevens and F. M. Wigley, “Incidence of Lung Cancer in Systemic Sclerosis,” The Journal of Rheumatology, Vol. 12, No. 6, 1985, pp. 1136-1139.
[41] A. A. Shah, A. Rosen, L. Hummers, F. Wigley and L. Casciola-Rosen, “Close Temporal Relationship between Onset of Cancer and Scleroderma in Patients with RNA Polymerase I/III Antibodies,” Arthritis & Rheumatism, Vol. 62, No. 9, 2010, pp. 2787-2795.
[42] M. Nikpour, P. Hissaria, J. Byron, J. Sahhar, M. Micallef, W. Paspaliaris, et al., “Prevalence, Correlates and Clinical Usefulness of Antibodies to RNA Polymerase III in Systemic Sclerosis: A Cross-Sectional Analysis of Data from an Australian Cohort,” Arthritis Research & Therapy, Vol. 13, No. 6, 2011, p. R211.
[43] C. F. Kuo, S. F. Luo, K. H. Yu, I. J. Chou, W. Y. Tseng, H. C. Chang, et al., “Cancer Risk among Patients with Systemic Sclerosis: A Nationwide Population Study in Taiwan,” Scandinavian Journal of Rheumatology, Vol. 41, No. 1, 2012, pp. 44-49.
[44] M. Hudson, A. Sharma, J. Bernstein and M. Baron, Canadian Scleroderma Research Group, “Validity of Self-Reported Comorbidities in Systemic Sclerosis,” Journal of Rheumatology, Vol. 36, No. 7, 2009, pp. 1477-1480.
[45] E. Thomas, D. H. Brewster, R. J. Black and G. J. Macfarlane, “Risk of Malignancy among Patients with Rheumatic Conditions,” International Journal of Cancer, Vol. 88, No. 3, 2000 pp. 497-502.<497::AID-IJC27>3.0.CO;2-J
[46] J. Wipff, R. Coriat, M. Masciocchi, P. Caramaschi, C. T. Derk, E. Hachulla, et al., “Outcomes of Barrett’s Oesophagus Related to Systemic Sclerosis: A 3-Year EULAR Scleroderma Trials and Research Prospective Follow-Up Study,” Rheumatology (Oxford), Vol. 50, No. 8, 2011, pp. 1440-1444.
[47] A. R. Villa, A. Kraus, A. Jiménez-Corona, S. Sandino, A. Velázquez-González, J. Granados, et al., “Malignant Neoplasms in Autoimmune Rheumatic Diseases: Examination of the Risk of Developing a Malignancy among Five Different Rheumatic Diseases in One Institution,” Journal of Clinical Rheumatology, Vol. 6, No. 4, 2000, pp. 176-183.
[48] C. F. Kuo, L. C. See, K. H. Yu, I. J. Chou, W. Y. Tseng, H. C. Chang, et al., “Epidemiology and Mortality of Systemic Sclerosis: A Nationwide Population Study in Tai-wan,” Scandinavian Journal of Rheumatology, Vol. 40, No. 5, 2011, pp. 373-378.
[49] P. Lee, P. Langevitz, C. A. Alderdice, M. Aubrey, P. A. Baer, M. Baron, et al., “Mortality in Systemic Sclerosis (Scleroderma),” Quarterly Journal of Medicine, Vol. 82, 1992, pp. 139-148.
[50] A. J. Tyndall, B. Bannert, M. Vonk, P. Airò, F. Cozzi, P. E. Carreira, et al., “Causes and Risk Factors for Death in Systemic Sclerosis: A Study from the EULAR Scleroderma Trials and Research (EUSTAR) Database,” Annals of the Rheumatic Diseases, Vol. 69, No. 10, 2010, pp. 1809-1815.
[51] C. Bond, K. D. Pile, J. D. McNeil, M. J. Ahern, M. D. Smith, L. G. Cleland, et al., “South Australian Scleroderma Register: Analysis of Deceased Patients,” Pathology, Vol. 30, No. 4, 1998, pp. 386-390.
[52] B. E. Joven, R. Almodovar, L. Carmona and P. E. Carreira, “Survival, Causes of Death, and Risk Factors Associated with Mortality in Spanish Systemic Sclerosis Patients: Results from a Single University Hospital,” Seminars in Arthritis and Rheumatism, Vol. 39, No. 4, 2010, pp. 285-293.
[53] E. Hachulla, P. Carpentier, V. Gressin, E. Diot, Y. Allanore, J. Sibilia, et al., “Risk Factors for Death and the 3-Year Survival of Patients with Systemic Sclerosis: The French ItinérAIR-Sclérodermie Study,” Rheumatology (Oxford), Vol. 48, No. 3, 2009, pp. 304-308.
[54] L. Chung, E. Krishnan and E. F. Chakravarty, “Hospitalizations and Mortality in Systemic Sclerosis: Results from the Nationwide Inpatient Sample,” Rheumatology, Vol. 46, No. 12, 2007, pp. 1808-1813.
[55] S. Chwiesko, S. Sierakowski and O. Kowal-Bielecka, “Causes of Death of Patients with Systemic Sclerosis,” Polski Merkuriusz Lekarski, Vol. 21, No. 124, 2006, pp. 341-344.
[56] S. Vettori, G. Cuomo, G. Abignano, M. Iudici and G. Valentini, “Survival and Death Causes in 251 Systemic Sclerosis Patients from a Single Italian Center,” Reumatismo, Vol. 62, No. 3, 2010, pp. 202-209.
[57] C. C. Mok, C. L. Kwok, L. Y. Ho, P. T. Chan and S. F. Yip, “Life Expectancy, Standardized Mortality Ratios, and Causes of Death in Six Rheumatic Diseases in Hong Kong, China,” Arthritis & Rheumatism, Vol. 63, No. 5, 2011, pp. 1182-1189.
[58] A. Hashimoto, S. Tejima, T. Tono, M. Suzuki, S. Tanaka, T. Matsui, et al., “Predictors of Survival and Causes of Death in Japanese Patients with Systemic Sclerosis,” The Journal of Rheumatology, Vol. 38, No. 9, 2011, pp. 1931-1939.
[59] K. Nishioka, I. Katayama, H. Kondo, H. Shinkai, H. Ueki, K. Tamaki, et al., “Epidemiological Analysis of Prognosis of 496 Japanese Patients with Progressive Systemic Sclerosis (SSc). Scleroderma Research Committee Japan,” Journal of Dermatology, Vol. 23, No. 10, 1996, pp. 677-682.
[60] V. D. Steen and T. A. Medsger, “Changes in Causes of Death in Systemic Sclerosis, 1972-2002,” Annals of the Rheumatic Diseases, Vol. 66, No. 7, 2007, pp. 940-944.
[61] C. Ferri, G. Valentini, F. Cozzi, M. Sebastiani, C. Michelassi, G. La Montagna, et al., “Systemic Sclerosis: Demographic, Clinical, and Serologic Features and Survival in 1012 Italian Patients,” Medicine, Vol. 81, No. 2, 2002, pp. 139-153.
[62] S. M. Gadalla, S. Amr, P. Langenberg, M. Baumgarten, W. F. Davidson, C. Schairer, et al., “Breast Cancer Risk in Elderly Women with Systemic Autoimmune Rheumatic Diseases: A Population-Based Casecontrol Study,” British Journal of Cancer, Vol. 100, No. 5, 2009, pp. 817-821.
[63] L. M. Brown, G. Gridley, D. Check and O. Landgren, “Risk of Multiple Myeloma and Monoclonal Gammopathy of Undetermined Significance among White and Black Male United States Veterans with Prior Autoimmune, Infectious, Inflammatory, and Allergic Disorders,” Blood, Vol. 111, No. 7, 2008, pp. 3388-3394.
[64] A. M. Landgren, O. Landgren, G. Gridley, G. M. Dores, M. S. Linet and L. M. Morton, “Autoimmune Disease and Subsequent Risk of Developing Alimentary Tract Cancers among 4.5 Million US Male Veterans,” Cancer, Vol. 117, No. 6, 2011, pp. 1163-1171.
[65] L. A. Anderson and E. A. Engels, “Autoimmune Conditions and Hairy Cell Leukemia: An Exploratory Case control Study,” Journal of Hematology and Oncology, Vol. 3, 2010, p. 35.
[66] L. A. Anderson, S. Gadalla, L. M. Morton, O. Landgren, R. Pfeiffer, J. L. Warren, et al., “Population-Based Study of Autoimmune Conditions and the Risk of Specific Lymphoid Malignancies,” International Journal of Cancer, Vol. 125, No. 2, 2009, pp. 398-405.
[67] S. Y. Kristinsson, J. Koshiol, M. Bjorkholm, L. R. Goldin, M. L. McMaster, I. Turesson, et al., “Immunerelated and Inflammatory Conditions and Risk of Lymphoplasmacytic Lymphoma or Waldenstrom Macroglobulinemia,” Journal of the National Cancer Institute, Vol. 102, No. 8, 2010, pp. 557-567.
[68] L. Mellemkjaer, R. M. Pfeiffer, E. A. Engels, G. Gridley, W. Wheeler, K. Hemminki, et al., “Autoimmune Disease in Individuals and Close Family Members and Susceptibility to Non-Hodgkin’s Lymphoma,” Arthritis & Rheumatism, Vol. 58, No. 3, 2008, pp. 657-666.
[69] National Cancer Institute. Detroit Registry. Metropolitan Detroit Cancer Surveillance System.
[70] V. Artinian and P. A. Kvale, “Cancer and Interstitial Lung Disease,” Current Opinion in Pulmonary Medicine, Vol. 10, No. 5, 2004, pp. 425-434.
[71] G. Rittner, G. Schwanitz, M. P. Baur, C. M. Black, K. I. Welsh, P. Kühnl, et al., “Family Studies in Scleroderma (Systemic Sclerosis) Demonstrating an HLA-Linked Increased Chromosomal Breakage Rate in Cultured Lymphocytes,” Human Genetics, Vol. 81, No. 1, 1988, pp. 64-70.
[72] C. M. Artlett, C. M. Black, D. C. Briggs, C. Stephens and K. I. Welsh, “DNA Allelic Alterations within VNTR Loci of Scleroderma Families,” British Journal of Rheumatology, Vol. 35, No. 12, 1996, pp. 1216-1222.
[73] L. I. Sakkas, D. F. Moore and N. C. Akritidis, “Cancer in Families with Systemic Sclerosis,” American Journal of the Medical Sciences, Vol. 310, No. 6, 1995, pp. 223-225.
[74] M. Zuber, “Positive Antinuclear Antibodies in Malignancies,” Annals of the Rheumatic Diseases, Vol. 51, No. 4, 1992, pp. 573-574.
[75] F. F. Madrid and M. Maroun, “Serologic Laboratory Findings in Malignancy,” Rheumatic Disease Clinics of North America, Vol. 37, No. 4, 2011, pp. 507-525.

comments powered by Disqus

Copyright © 2018 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.