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Pelvic Nephroureterectomy for Renal Cell Carcinoma in an Ectopic Kidney

Pelvic Nephroureterectomy for Renal Cell Carcinoma in an Ectopic Kidney Hindawi Publishing Corporation Case Reports in Oncological Medicine Volume 2012, Article ID 350916, 4 pages doi:10.1155/2012/350916 Case Report Pelvic Nephroureterectomy for Renal Cell Carcinoma in an Ectopic Kidney 1, 2 1, 2 1, 2 1, 2 Kevin G. Baldie, Usama A. Al-Qassab, Chad W. Ritenour, Muta M. Issa, 1, 2, 3 1, 2, 3, 4 Adeboye O. Osunkoya, and John A. Petros Atlanta Veterans Affairs Medical Center, 1670 Clairmont Road NE, Decatur, GA 30033, USA Department of Urology, Emory University School of Medicine, Clinic B, 1365 Clifton Road, Atlanta, GA 30322, USA Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA 30322, USA Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA Correspondence should be addressed to John A. Petros, jpetros@emory.edu Received 31 July 2012; Accepted 26 September 2012 Academic Editors: C. Gennatas, E. Itakura, and Y. Niibe Copyright © 2012 Kevin G. Baldie et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. We present a case of an ectopic renal tumor in a 61-year-old morbidly obese man with a pelvic kidney found after presenting with hematuria and irritative voiding symptoms. The mass, along with the ectopic kidney and ureter, was radically resected through an open operation that involved removing both them and the renal vessels from the underlying iliac vessels. Pathological analysis demonstrated an 8.3 cm papillary renal cell carcinoma (RCC) with oncocytic features, Fuhrman nuclear grade 3, with angiolymphatic invasion and negative margins. The patient has been recurrence-free for over four years since tumor resection. 1. Introduction urinary tract symptoms. The remainder of the review of systems was unremarkable. He initially went to an outside Renal ectopia is a rare condition involving a failure of the hospital after his symptoms were refractory to antibiotic mature kidney to reach its normal location within the renal management where he was found on noncontrast CT to fossa. This congenital anomaly comprises about 0.001% of have a large left renal mass arising from an ectopic pelvic all autopsies. Pelvic, iliac, abdominal, thoracic, contralateral, kidney. Mercaptoacetyltriglycine-3 (MAG3) renography was and crossed ectopic kidneys can occur. Apart from the performed at our institution following referral, showing an development of hydronephrosis and urolithiasis, the ectopic essentially nonfunctional left kidney and delayed perfusion, kidney is no more susceptible to disease than the normally uptake, and excretion in the contralateral kidney. Two weeks positioned kidney [1]. Nevertheless, when considering surgi- later, the patient was further worked up with a complete cal resection, particularly with the intent to remove a tumor, history and physical, labs, and abdominal MRI with and an accurate understanding of the surrounding anatomy is without contrast. Physical exam and labs were unremarkable crucial in order to avoid causing both unnecessary damage except for a creatinine of 2.2. MRI showed an 8.6 cm to blood vessels and leaving remnants of tumor within the centrally necrotic, peripherally enhancing solid mass in patient. the superior-interpolar region of the ectopic left kidney worrisome for renal malignancy. The superior margin of the mass rested anterior to the left common iliac vessels (Figure 1). Two anomalous renal arteries supplied the 2. Case Report kidney, with the proximal artery branching off of the distal The patient presented as a 61 year old morbidly obese male aorta and the distal artery branching of the left common with a history of chronic kidney disease describing three iliac artery (Figure 2). The left renal vein drained into the months of gross, painless hematuria and irritative lower left internal iliac vein (Figure 3). 2 Case Reports in Oncological Medicine Figure 3: Venous Phase T1-weighted MRI image (transverse view) showing anomalous venous drainage from ectopic left kidney and mass (star). Left renal vein (short arrow) draining into left internal iliac vein (long arrow). visualization. The sigmoid colon was medially displaced and Figure 1: T2-weighted MRI image (coronal view) showing orien- the left colon mobilized medially in order to better access the tation of mass (star) to major vessels. Normal kidney (diamond). retroperitoneum. A renal artery was draped over the anterior Aorta (short arrow). IVC (long arrow). Note that aortic bifurcation portion of the kidney, originating from the left common occurs at level of superior pole of ectopic left kidney. iliac artery. The renal vein took a medial course to reach the left common iliac vein. The kidney was carefully dissected superiorly and inferiorly until the ureter was visualized and tagged. The tumor and kidney were fibrotically adhered to the left common iliac artery, and dissection was done in the midst of confirming palpable lower extremity pulses before and after this stage in the operation. The left renal artery and vein were transected with good hemostasis. The ureter was then clipped distally to the level of the intramural ureter, transected and removed from the pelvis along with the remainder of the specimen (Figure 4)prior to irrigation and layered closure of the peritoneum and abdominal wall. There were no intraoperative complications and the patient tolerated the procedure well. After a low grade Figure 2: Arterial Phase T1-weighted MRI image (transverse view) fever self-resolved on postoperative day three, the patient showing anomalous arterial supply to ectopic left kidney and progressed as expected and was discharged from the hospital mass (star). Proximal left renal artery (short arrow) branching off on postoperative day seven shortly following removal of distal aorta. Distal left renal artery (long arrow) branching off left his urethral catheter. Pathology revealed an 8.3 cm papil- common iliac artery. lary renal cell carcinoma (RCC) with oncocytic features, Fuhrman nuclear grade 3, with angiolymphatic invasion and negative ureteral, renal vein, and renal artery margins The patient was thoroughly discussed at our institution’s (Figure 5). The patient was followed up with yearly imaging weekly genitourinary (GU) preoperative conference with and, although he was eventually placed on hemodialysis due all urology physicians present and, after weighing the risks to end stage renal disease, he has been recurrence-free for and benefits, the decision was made for definitive surgical over four years since tumor resection. management. The following week, the patient underwent an open transperitoneal radical left pelvic nephroureterectomy. Cystourethroscopy at the onset of the procedure was done 3. Discussion to ensure patency of the contralateral ureteral orifice. A midline incision was made from the level of the pubic There is a dearth in the literature discussing renal malignancy symphysis to the xiphoid. The space of Retzius was developed in the ectopic pelvic kidney [2, 3]. The advent of improved bilaterally until there was visualization of the external iliac imaging studies has allowed for a higher incidence in vessels. After entering the peritoneum and transecting and the identification of ectopic kidneys, including those with ligating the proximal and distal urachus, the bladder was malignancy. Despite this fact, these patients can still be dissected down to the level of the vas deferens to aid in misdiagnosed, particularly with atypical presentations as in Case Reports in Oncological Medicine 3 is normally completed by the eighth week of gestation. Improper migration of the kidney and ipsilateral ureter can result from uterine bud maldevelopment, defective metanephric tissue that fails to induce ascent, genetic abnormalities, and maternal disease or teratogenesis. Ectopic kidney disease can be associated with anomalies of the vertebral column, lower gastrointestinal tract, genital tract, or spinal cord and meninges. Genital abnormalities are the most prominent. For women, these include bicornuate or unicornuate uterus, rudimentary or absent uterus and vagina, and duplication of the vagina. For men, undescended testes, urethral duplication, and hypospadias can occur [1]. The pattern of the renal vascular network is dependent on the position of the ectopic kidney and is completely anomalous. More inferiorly situated ectopic kidneys may be supplied by one or two main renal arteries arising from the distal aorta, aortic bifurcation, and the common or external iliac arteries. The inferior mesenteric arteries can also provide blood supply to these kidneys [1]. Figure 4: Coronal cut of pelvic/ectopic kidney showing a fairly well circumscribed 8.3 × 6.9 × 6.8 cm reddish-brown markedly RCC accounts for 80% of all renal malignancies. In hemorrhagic mass (star), consistent with papillary renal cell 2007, over 51,000 new diagnoses were reported in the carcinoma. Other structures include normal renal parenchyma United States. According to the 2004 WHO Histological (diamond), ureter (narrow arrow), and left renal artery (thick Classification of RCC, clear cell RCC is the most common arrow). type, consisting of 75% of all RCC’s. This is followed by papillary (10%), chromophobe (5%), hereditary can- cer syndromes (5%), and unclassified lesions (4%) [4]. A number of rarer histologic subtypes exists, including multilocular cystic RCC, collecting duct carcinoma, muci- nous tubular and spindle cell carcinoma, neuroblastoma- associated RCC, and Xp 11.2 translocation-TFE3 carcinoma, with each making up <1% of RCC [5]. Radiographically, papillary RCC’s typically appear hypovascular and homo- geneous with limited contrast enhancement on contrast- enhanced CT, although larger tumors may show hetero- geneity due to necrosis, hemorrhage, and calcification [1, 5]. This report describes a case of successful surgical man- agement of a pelvic kidney with cancer. Imaging was carefully Figure 5: Papillary renal cell carcinoma with oncocytic features analyzed to determine the orientation of the tumor, kidney, (hematoxylin and eosin stain, high magnification). Note distinct renal vessels, and collecting system, and their association papillae with eosinophilic cytoplasm (bottom arrow), with fibrovas- with the underlying major vascular structures enabling the cular core (top arrow). surgeons to avoid significant blood loss during dissection of the effected tissue. Negative margins were acquired and close clinical and radiographic follow-up confirmed appropriate surgical technique while helping ensure long-term patient this case. To our knowledge, this is the first case report success. demonstrating the radical removal of an ectopic pelvic kidney as a result of high grade papillary carcinoma with long term success. References Ectopic kidney disease is a relatively rare congenital disorder, occurring in about one in 900 autopsies. The [1] A. J. Wein, L. R. Kavoussi, and M. F. Campbell, Campbell-Walsh incidence of pelvic kidneys is between one in 2100 and Urology, Elsevier Saunders, Philadelphia, Pa, USA, 2012. one in 3000 autopsies. Embryologically, the uterine bud [2] N. M. Cinman, Z. Okeke, and A. D. Smith, “Pelvic kidney: ascends from the Wolffian duct toward the urogenital associated diseases and treatment,” Journal of Endourology, vol. ridge by the fourth week of gestation, acquiring a cap of 21, no. 8, pp. 836–842, 2007. metanephric blastema by the fifth week. Both the uterine [3] N. Mahmoudnejad, A. Danesh, and H. Abdi, “Renal cell bud and developing metanephric blastema migrate cra- carcinoma in presacral pelvic kidney,” Journal of the Pakistan nially and rotate medially along its long axis. This process Medical Association, vol. 59, no. 7, pp. 482–483, 2009. 4 Case Reports in Oncological Medicine [4] A.Lopez-Beltran,M.Scarpelli,R.Montironi, andZ.Kirkali, “2004 WHO classification of the renal tumors of the adults,” European Urology, vol. 49, no. 5, pp. 798–805, 2006. [5] S.R.Prasad, P. A. Humphrey,J.R.Catenaetal., “Common and uncommon histologic subtypes of renal cell carcinoma: imaging spectrum with pathologic correlation,” Radiographics, vol. 26, no. 6, pp. 1795–1806, 2006. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Case Reports in Oncological Medicine Hindawi Publishing Corporation

Pelvic Nephroureterectomy for Renal Cell Carcinoma in an Ectopic Kidney

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Copyright © 2012 Kevin G. Baldie et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract

Hindawi Publishing Corporation Case Reports in Oncological Medicine Volume 2012, Article ID 350916, 4 pages doi:10.1155/2012/350916 Case Report Pelvic Nephroureterectomy for Renal Cell Carcinoma in an Ectopic Kidney 1, 2 1, 2 1, 2 1, 2 Kevin G. Baldie, Usama A. Al-Qassab, Chad W. Ritenour, Muta M. Issa, 1, 2, 3 1, 2, 3, 4 Adeboye O. Osunkoya, and John A. Petros Atlanta Veterans Affairs Medical Center, 1670 Clairmont Road NE, Decatur, GA 30033, USA Department of Urology, Emory University School of Medicine, Clinic B, 1365 Clifton Road, Atlanta, GA 30322, USA Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA 30322, USA Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA Correspondence should be addressed to John A. Petros, jpetros@emory.edu Received 31 July 2012; Accepted 26 September 2012 Academic Editors: C. Gennatas, E. Itakura, and Y. Niibe Copyright © 2012 Kevin G. Baldie et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. We present a case of an ectopic renal tumor in a 61-year-old morbidly obese man with a pelvic kidney found after presenting with hematuria and irritative voiding symptoms. The mass, along with the ectopic kidney and ureter, was radically resected through an open operation that involved removing both them and the renal vessels from the underlying iliac vessels. Pathological analysis demonstrated an 8.3 cm papillary renal cell carcinoma (RCC) with oncocytic features, Fuhrman nuclear grade 3, with angiolymphatic invasion and negative margins. The patient has been recurrence-free for over four years since tumor resection. 1. Introduction urinary tract symptoms. The remainder of the review of systems was unremarkable. He initially went to an outside Renal ectopia is a rare condition involving a failure of the hospital after his symptoms were refractory to antibiotic mature kidney to reach its normal location within the renal management where he was found on noncontrast CT to fossa. This congenital anomaly comprises about 0.001% of have a large left renal mass arising from an ectopic pelvic all autopsies. Pelvic, iliac, abdominal, thoracic, contralateral, kidney. Mercaptoacetyltriglycine-3 (MAG3) renography was and crossed ectopic kidneys can occur. Apart from the performed at our institution following referral, showing an development of hydronephrosis and urolithiasis, the ectopic essentially nonfunctional left kidney and delayed perfusion, kidney is no more susceptible to disease than the normally uptake, and excretion in the contralateral kidney. Two weeks positioned kidney [1]. Nevertheless, when considering surgi- later, the patient was further worked up with a complete cal resection, particularly with the intent to remove a tumor, history and physical, labs, and abdominal MRI with and an accurate understanding of the surrounding anatomy is without contrast. Physical exam and labs were unremarkable crucial in order to avoid causing both unnecessary damage except for a creatinine of 2.2. MRI showed an 8.6 cm to blood vessels and leaving remnants of tumor within the centrally necrotic, peripherally enhancing solid mass in patient. the superior-interpolar region of the ectopic left kidney worrisome for renal malignancy. The superior margin of the mass rested anterior to the left common iliac vessels (Figure 1). Two anomalous renal arteries supplied the 2. Case Report kidney, with the proximal artery branching off of the distal The patient presented as a 61 year old morbidly obese male aorta and the distal artery branching of the left common with a history of chronic kidney disease describing three iliac artery (Figure 2). The left renal vein drained into the months of gross, painless hematuria and irritative lower left internal iliac vein (Figure 3). 2 Case Reports in Oncological Medicine Figure 3: Venous Phase T1-weighted MRI image (transverse view) showing anomalous venous drainage from ectopic left kidney and mass (star). Left renal vein (short arrow) draining into left internal iliac vein (long arrow). visualization. The sigmoid colon was medially displaced and Figure 1: T2-weighted MRI image (coronal view) showing orien- the left colon mobilized medially in order to better access the tation of mass (star) to major vessels. Normal kidney (diamond). retroperitoneum. A renal artery was draped over the anterior Aorta (short arrow). IVC (long arrow). Note that aortic bifurcation portion of the kidney, originating from the left common occurs at level of superior pole of ectopic left kidney. iliac artery. The renal vein took a medial course to reach the left common iliac vein. The kidney was carefully dissected superiorly and inferiorly until the ureter was visualized and tagged. The tumor and kidney were fibrotically adhered to the left common iliac artery, and dissection was done in the midst of confirming palpable lower extremity pulses before and after this stage in the operation. The left renal artery and vein were transected with good hemostasis. The ureter was then clipped distally to the level of the intramural ureter, transected and removed from the pelvis along with the remainder of the specimen (Figure 4)prior to irrigation and layered closure of the peritoneum and abdominal wall. There were no intraoperative complications and the patient tolerated the procedure well. After a low grade Figure 2: Arterial Phase T1-weighted MRI image (transverse view) fever self-resolved on postoperative day three, the patient showing anomalous arterial supply to ectopic left kidney and progressed as expected and was discharged from the hospital mass (star). Proximal left renal artery (short arrow) branching off on postoperative day seven shortly following removal of distal aorta. Distal left renal artery (long arrow) branching off left his urethral catheter. Pathology revealed an 8.3 cm papil- common iliac artery. lary renal cell carcinoma (RCC) with oncocytic features, Fuhrman nuclear grade 3, with angiolymphatic invasion and negative ureteral, renal vein, and renal artery margins The patient was thoroughly discussed at our institution’s (Figure 5). The patient was followed up with yearly imaging weekly genitourinary (GU) preoperative conference with and, although he was eventually placed on hemodialysis due all urology physicians present and, after weighing the risks to end stage renal disease, he has been recurrence-free for and benefits, the decision was made for definitive surgical over four years since tumor resection. management. The following week, the patient underwent an open transperitoneal radical left pelvic nephroureterectomy. Cystourethroscopy at the onset of the procedure was done 3. Discussion to ensure patency of the contralateral ureteral orifice. A midline incision was made from the level of the pubic There is a dearth in the literature discussing renal malignancy symphysis to the xiphoid. The space of Retzius was developed in the ectopic pelvic kidney [2, 3]. The advent of improved bilaterally until there was visualization of the external iliac imaging studies has allowed for a higher incidence in vessels. After entering the peritoneum and transecting and the identification of ectopic kidneys, including those with ligating the proximal and distal urachus, the bladder was malignancy. Despite this fact, these patients can still be dissected down to the level of the vas deferens to aid in misdiagnosed, particularly with atypical presentations as in Case Reports in Oncological Medicine 3 is normally completed by the eighth week of gestation. Improper migration of the kidney and ipsilateral ureter can result from uterine bud maldevelopment, defective metanephric tissue that fails to induce ascent, genetic abnormalities, and maternal disease or teratogenesis. Ectopic kidney disease can be associated with anomalies of the vertebral column, lower gastrointestinal tract, genital tract, or spinal cord and meninges. Genital abnormalities are the most prominent. For women, these include bicornuate or unicornuate uterus, rudimentary or absent uterus and vagina, and duplication of the vagina. For men, undescended testes, urethral duplication, and hypospadias can occur [1]. The pattern of the renal vascular network is dependent on the position of the ectopic kidney and is completely anomalous. More inferiorly situated ectopic kidneys may be supplied by one or two main renal arteries arising from the distal aorta, aortic bifurcation, and the common or external iliac arteries. The inferior mesenteric arteries can also provide blood supply to these kidneys [1]. Figure 4: Coronal cut of pelvic/ectopic kidney showing a fairly well circumscribed 8.3 × 6.9 × 6.8 cm reddish-brown markedly RCC accounts for 80% of all renal malignancies. In hemorrhagic mass (star), consistent with papillary renal cell 2007, over 51,000 new diagnoses were reported in the carcinoma. Other structures include normal renal parenchyma United States. According to the 2004 WHO Histological (diamond), ureter (narrow arrow), and left renal artery (thick Classification of RCC, clear cell RCC is the most common arrow). type, consisting of 75% of all RCC’s. This is followed by papillary (10%), chromophobe (5%), hereditary can- cer syndromes (5%), and unclassified lesions (4%) [4]. A number of rarer histologic subtypes exists, including multilocular cystic RCC, collecting duct carcinoma, muci- nous tubular and spindle cell carcinoma, neuroblastoma- associated RCC, and Xp 11.2 translocation-TFE3 carcinoma, with each making up <1% of RCC [5]. Radiographically, papillary RCC’s typically appear hypovascular and homo- geneous with limited contrast enhancement on contrast- enhanced CT, although larger tumors may show hetero- geneity due to necrosis, hemorrhage, and calcification [1, 5]. This report describes a case of successful surgical man- agement of a pelvic kidney with cancer. Imaging was carefully Figure 5: Papillary renal cell carcinoma with oncocytic features analyzed to determine the orientation of the tumor, kidney, (hematoxylin and eosin stain, high magnification). Note distinct renal vessels, and collecting system, and their association papillae with eosinophilic cytoplasm (bottom arrow), with fibrovas- with the underlying major vascular structures enabling the cular core (top arrow). surgeons to avoid significant blood loss during dissection of the effected tissue. Negative margins were acquired and close clinical and radiographic follow-up confirmed appropriate surgical technique while helping ensure long-term patient this case. To our knowledge, this is the first case report success. demonstrating the radical removal of an ectopic pelvic kidney as a result of high grade papillary carcinoma with long term success. References Ectopic kidney disease is a relatively rare congenital disorder, occurring in about one in 900 autopsies. The [1] A. J. Wein, L. R. Kavoussi, and M. F. Campbell, Campbell-Walsh incidence of pelvic kidneys is between one in 2100 and Urology, Elsevier Saunders, Philadelphia, Pa, USA, 2012. one in 3000 autopsies. Embryologically, the uterine bud [2] N. M. Cinman, Z. Okeke, and A. D. Smith, “Pelvic kidney: ascends from the Wolffian duct toward the urogenital associated diseases and treatment,” Journal of Endourology, vol. ridge by the fourth week of gestation, acquiring a cap of 21, no. 8, pp. 836–842, 2007. metanephric blastema by the fifth week. Both the uterine [3] N. Mahmoudnejad, A. Danesh, and H. Abdi, “Renal cell bud and developing metanephric blastema migrate cra- carcinoma in presacral pelvic kidney,” Journal of the Pakistan nially and rotate medially along its long axis. This process Medical Association, vol. 59, no. 7, pp. 482–483, 2009. 4 Case Reports in Oncological Medicine [4] A.Lopez-Beltran,M.Scarpelli,R.Montironi, andZ.Kirkali, “2004 WHO classification of the renal tumors of the adults,” European Urology, vol. 49, no. 5, pp. 798–805, 2006. [5] S.R.Prasad, P. A. Humphrey,J.R.Catenaetal., “Common and uncommon histologic subtypes of renal cell carcinoma: imaging spectrum with pathologic correlation,” Radiographics, vol. 26, no. 6, pp. 1795–1806, 2006. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

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Case Reports in Oncological Medicine – Hindawi Publishing Corporation

Published: Oct 22, 2012

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