Mediastinal Metastasis 10 Years after Primary Renal Cell Carcinoma
—A Report of a Case and a Review

Abstract

Late recurrence of renal cell carcinoma (RCC), arbitrarily defined, as >10 years post-nephrectomy, is rare. Here we review 43 reports comprising 467 cases. Metastasis occurred between few months and 45 years. We report a new case with a 10-year interval to metastasis.

Share and Cite:

Rifat, M. , Rifat, U. , Al-Safi, K. and Annab, H. (2016) Mediastinal Metastasis 10 Years after Primary Renal Cell Carcinoma
—A Report of a Case and a Review. Open Journal of Urology, 6, 127-137. doi: 10.4236/oju.2016.68022.

Received 20 June 2016; accepted 8 August 2016; published 11 August 2016

1. Introduction

The incidence of late recurrence of metastatic RCC is 11% in patients surviving for 10 years after the initial diagnosis [1] . T-stage, grade and sarcomatoid differentiation independently dictate the risk of tumor recurrence. Recurrences (distant and/or local) could represent more than half of the cases [2] . The mean and median time to recurrence varies from series to series (Table 1) [1] - [43] . It ranges from few months to decades [24] .

Late recurrence of renal cell carcinoma (RCC), arbitrarily defined, as >10 years post-nephrectomy, is rare [24] . Here we review previous cases and report one new case.

2. Methods

Table 1. A review of 467 cases: all the studies were of level of evidence 5 [1] - [43] .

*Two recurrences occurred, with interval of 3 and 19 years after primary RCC; RCC: renal cell carcinoma; NR: no recurrence; Y: years; N/A: not available.

comprising 467 cases (Table 1).

We describe one new case.

3. Report of Case

The patient is a seventy-four-year old female from Iraq. There is a history of long-standing hypertension and atrial fibrillation and was put on warfarin since 2005. She had cholecystectomy then right radical nephrectomy for renal cell carcinoma in 2006. She had CVA in 2009 without residuals.

She presented recently with cough and shortness of breath for one-month duration. Her cough was severe and more at night. It was productive of small brownish sputum, which became yellowish later. There was orthopnea too. There is bilateral lower limbs swelling and shortness of breath, which was not related to exertion. There was no weight loss or night sweats.

Chest X-ray showed Right mediastinal versus paramediastinal well defined opacity, congested perihilar vessels, and mild bilateral pleural effusion (Figure 1).

Serum creatinine was normal. CT-scan with contrast enhancement (Figures 2-4) showed a large heterogeneously enhancing solid lesion with irregular central necrosis measuring about 6.7 cm seen in the right side of mediastinum located posterior to the superior vena cava and the aortic arch. It was superior to the right pulmonary artery and i lateral to the trachea. There is no evidence of hilar or mediastinal lymph node enlargement. There is collapse consolidation of the lower lung lobes seen with air bronchogram and right-sided pleural effusion. A small left-sided pleural effusion with atelectasis of the basal lung tissue is also noted. The rest of lung fields are clear. A small cystic nodule measuring about 1 cm is seen in the right lobe of thyroid gland. Chest wall and rib cage are unremarkable.

Bone Scan showed multiple abnormal areas of increased radiotracer uptake involving skull, both shoulder joints, right 5th rib anteriorly, several ribs anteriorly at costo-chondral junction, lower lumbar spine, proximal end of right humerus, sternum, bilateral sterno-clavicular joints, and both knee joints. Right kidney is not visualized

Figure 1. Chest X-ray showed right mediastinal versus paramediastinal well defined opacity, congested perihilar vessels, and mild bilateral pleural effusion.

Figure 2. CT-scan with contrast enhancement showed a large heterogeneously enhancing solid lesion with irregular central necrosis measuring about 6.7 cm seen in the right side of mediastinum located posterior to the superior vena cava and the aortic arch. It was superior to the right pulmonary artery and i lateral to the trachea. There is no evidence of hilar or mediastinal lymph node enlargement. There is collapse consolidation of the lower lung lobes seen with air bronchogram and right- sided pleural effusion. A small left-sided pleural effusion with atelectasis of the basal lung tissue is also noted. The rest of lung fields are clear.

Figure 3. CT-scan with contrast enhancement showed a large heterogeneously enhancing solid lesion with irregular central necrosis measuring about 6.7 cm seen in the right side of mediastinum located posterior to the superior vena cava and the aortic arch. It was superior to the right pulmonary artery and i lateral to the trachea. There is no evidence of hilar or mediastinal lymph node enlargement. There is collapse consolidation of the lower lung lobes seen with air bronchogram and right- sided pleural effusion. A small left-sided pleural effusion with atelectasis of the basal lung tissue is also noted. The rest of lung fields are clear.

Figure 4. CT-scan with contrast enhancement showed a large heterogeneously enhancing solid lesion with irregular central necrosis measuring about 6.7 cm seen in the right side of mediastinum located posterior to the superior vena cava and the aortic arch. It was superior to the right pulmonary artery and i lateral to the trachea. There is no evidence of hilar or mediastinal lymph node enlargement. There is collapse consolidation of the lower lung lobes seen with air bronchogram and right-sided pleural effusion. A small left-sided pleural effusion with atelectasis of the basal lung tissue is also noted. The rest of lung fields are clear.

(Rt. Nephrectomy). There is high target to soft tissue uptake ratio throughout the skeleton, with increased uptake along both lower limbs. Appearances are consistent with metabolic bone disease, pulmonary hypertrophic osteoarthpathy secondary to intra thoracic mass, renal osteodystrophy and osteoporosis. There was no scinti- graphic evidence of bone metastasis.

US abdomen and pelvis findings: The liver showed normal echogenieity and echotcxture, no visible focal lesions or megaly. Right nephrectomy and cholecystectomy were obvious.

The right renal bed shows no masses. The left kidney shows increased parenchymal echogenicity with lobulated contour, it measures 9.6 cm-length, no stones, masses, or hydronephrosis. Small right-sided plural effusion is noted. The visualized portions of the pancreas and retroperitoneal area appeared normal. The spleen has normal sonographic appearances. The urinary bladder has no luminal defects. The uterus shows no masses and the pelvis shows no cysts or masses.

ECG showed atrial fibrillation. ECHO showed left and right atrium enlargement. Ejection fraction was 65%.

Under ultrasound guidance aspiration of about 300 cc of bloody right pleural effusion was performed. There was segmental collapse of right lower lobe. The cytology was negative for malignant cells.

CT-guided Truecut needle biopsy from that mass was taken and the specimen sent for histopathology. No pneumothorax occurred and there was only lung contusion.

The histopathological diagnosis was compatible with metastatic renal cell carcinoma. Figure 5(a) and Figure 5(b) show renal cell carcinoma―low and high power view (magnification × 40 and × 400 respectively) showing optically clear cytoplasm and sharp cell membranes.

Figure 6 shows Pancytokeratin (AE1/AE3)―showing positive cytoplasmic staining―Ventana Benchmark― high power view (magnification × 400).

Figure 7 shows CD10 (CALLA)―showing membrane staining of tumor cells―Ventana Benchmark―high power view (magnification × 400).

Figure 8 shows Vimetin immunohistochemical stain showing positive cytoplasmic staining of tumor cells (Ventana Benchmark)―high power view (magnification × 400).

(a) (b)

Figure 5. Shows renal cell carcinoma―low and high power view (magnification × 40 and × 400 respectively) showing optically clear cytoplasm and sharp cell membranes.

Figure 6. Shows pancytokeratin (AE1/AE3)―showing positive cytoplasmic staining―Ventana Benchmark―high power view (magnification × 400).

She was put on Sutant (Sunitinib) 50 mg orally 1 × 1 for 4 weeks then another cycle for 4 weeks with 2 weeks interval in between.

4. Discussion

Renal cell carcinoma (RCC) is the most common renal malignancy (approximately 90% of cases) with high metastatic potential. Most of these tumors are incidentally discovered at abdominal imaging and usually carry a better prognosis owing to early-stage disease. Approximately 20% of patients will go on to develop metastatic disease within the first 3 to 5 years after treatment of the primary tumor. Sites of metastases include the lungs, liver, bone, and brain, contra lateral kidney renal fossa, rectum and stomach [6] [27] [31] [35] [37] [39] .

Brain metastasis occurs in 3.9% - 24% of patients with renal cell carcinoma (RCC), with an average interval from nephrectomy to brain metastasis of 1 to 3 years. A few cases have been reported where brain metastasis occurred following a delay of 15 to 20 years after a nephrectomy for RCC [4] [9] [10] [16] .

Figure 7. CD10 (CALLA)―showing membrane staining of tumor cells―Ventana Benchmark―high power view (magnification × 400).

Figure 8. Vimetin immunohistochemical stain showing positive cytoplasmic staining of tumor cells (Ventana Benchmark)―high power view (magnification × 400).

Thyroid and salivary glands metastasis was reported at 10 and 19 years after nephrectomy for renal cell carcinoma [5] [13] - [15] [20] [28] . Also falx metastasis was described 20 years afterward right nephrectomy for renal cell carcinoma. Dural metastases after renal cell carcinoma are very rare [7] .

Metastatic non-colorectal cancer of the anal canal is a rare entity. To date, only four cases have been described in the literature. It can present as a hemorrhoid [8] .

A rare case of RCC metastasis in the parotid gland was described eleven years after the initial diagnosis [11] . Metastasis of renal cell carcinoma to the buccal mucosa occurred 19 years after radical nephrectomy [17] .

Walter and Gellespie reported the longest known clinical disease-free interval of 36 years in 1960 [24] . However, Helene Tapper et al. [24] reported the 45-year interval between nephrectomy and clinical recurrence of RCC. It appears to be the longest on record [24] . McNichols et al. reported a recurrence rate of 11% in a series of 506 patients. This estimate is based on 18 late recurrences in 158 patients who were followed over a period of 24 to 37 years. Since most of the patients (348) in this series died from other causes, the actual recurrence rate may be less than 11% [24] .

This report presents a mediastinal mass consistent with metastatic RCC 10 years after successful treatment of the primary RCC. Clearly, this is rare, but the case serves to remind the need for vigilance in dealing with cases having a history of previous malignancy. The case presented confirms the possibility that this rare event may present even 10 or more years after nephrectomy has been performed.

Renal cell carcinoma contains glycogen, making it PAS-positive and diastase-negative.

Additionally, RCC shows immunohistochemically positive staining with keratin and vimentin and CEA negativity, supporting the diagnosis of metastatic RCC.

It is well known that solitary metastasis and a greater interval between the primary treatments to the appearance of the metastasis are favorable prognostic factors in RCC [14] .

We offered adjuvant treatment (Sunitinib), because of patient’s poor general condition. Treatment was well tolerated. Sunitinib is an oral inhibitor of tyrosine kinases, including vascular endothelial growth factor receptor and platelet-derived growth factor receptor, and has been associated with higher response rates and longer progression-free survival in patients with metastatic RCC as compared to interferon and might also show activity in the adjuvant and neoadjuvant setting [3] .

RCC patients require long-term follow-up, to assist in early detection of metastasis and early treatment.

NOTES

*Corresponding author.

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1] Chawla, A., Mishra, D., Bansal, R. and Chundra, M. (2013) Rare Sites of Delayed Metastasis in Renal Cell Carcinoma. BMJ Case Reports, 2013, bcr2013009971.
http://dx.doi.org/10.1136/bcr-2013-009971
[2] Sameh, W.M., Hashad, M.M., Eid, A.A., Abou Yousif, T.A. and Mohammed, A. (2012) Recurrence Pattern in Patients with Locally Advanced Renal Cell Carcinoma: The Implications of Clinicopathological Variables. Arab Journal of Urology, 10, 131-137.
http://dx.doi.org/10.1016/j.aju.2011.12.007
[3] Fokt, R.-M., Templeton, A., Gillessen, S., Ohlschlegel, C., et al. (2009) Prostatic Metastasis of Renal Cell Carcinoma Successfully Treated with Sunitinib. Urologia Internationalis, 83, 122-124.
http://dx.doi.org/10.1159/000224882
[4] Choi, W.H., Koh, Y.-C., Song, S.W., Roh, H.G. and Lim, S.-D. (2013) Extremely Delayed Brain Metastasis from Renal Cell Carcinoma. Brain Tumor Research and Treatment, 1, 99-102.
http://dx.doi.org/10.14791/btrt.2013.1.2.99
[5] Pickhardt, P.J. and Pickard, R.H. (2003) Sonography of Delayed Thyroid Metastasis from Renal Cell Carcinoma with Jugular Vein Extension. AJR, 181, 272-274.
http://dx.doi.org/10.2214/ajr.181.1.1810272
[6] Kolokythas, A., Weiskopf, S., Singh, M. and Cabay, R.J. (2015) Renal Cell Carcinoma: Delayed Metachronous Metastases to Parotid and Cerebellum. Journal of Oral and Maxillofascial Surgery, 73, 1296-1303.
http://dx.doi.org/10.1016/j.joms.2015.01.017
[7] Montano, N., Puca, A., Pierconti, F. and Larocca, L.M. (2007) Extremely Delayed Falx Metastasis from Renal Cell Carcinoma. Neurology, 68, 1541.
http://dx.doi.org/10.1212/01.wnl.0000261253.45209.97
[8] Davies, J.R.L., Smith, G., Cornaby, A.J., Thomas, T. and Lamparelli, M.J. (2015) Delayed Recurrence of Renal Cell Carcinoma Presenting as a Haemorrhoid. Journal of Surgical Case Reports, 3, rjv022.
[9] Bademci, G. (2008) Extremely Delayed Renal Cell Carcinoma Metastasis Mimicking Convexity Meningioma. Turkish Neurosurgery, 18, 400-403.
http://dx.doi.org/10.4321/s1130-14732008000600008
[10] Roser, F., Rosahl, S.K. and Samii, M. (2002) Single Cerebral Metastasis 3 and 19 Years after Primary Renal Cell Carcinoma: Case Report and Review of the Literature. Journal of Neurology, Neurosurgery, and Psychiatry, 72, 257-258.
http://dx.doi.org/10.1136/jnnp.72.2.257
[11] Hosn-Centenero, S.A., Coll-Anglada, M., Pradillos-Garcés, A. and Salinas-Duffo, D. (2014) STUDYA Rare Case of Renal Cell Carcinoma Metastasis in the Parotid Gland Eleven Years after the Initial Diagnosis. Acta Otorrinolaringológica Espanola, 65, 375-377.
http://dx.doi.org/10.1016/j.otorri.2013.03.005
[12] Citgez, B., Uludag, M., Gurbulak, E.K., Ozguven, B.Y., et al. (2011) Thyroid Metastasis of Renal Cell Carcinoma. World Journal of Endocrine Surgery, 3, 93-95.
http://dx.doi.org/10.5005/jp-journals-10002-1066
[13] Shi, J.-L., Zhou, J.-Q. and Li, J.-P. (2015) Renal Clear Cell Carcinoma with Thyroid and Parotid Metastases: A Case Report. Oncology Letters, 10, 2617-2619.
http://dx.doi.org/10.3892/ol.2015.3549
[14] Gogüs, O.A., Kilic, O., Tulunay, O., Tulunay, O. and Bedük, Y. (2004) Solitary Metastasis of Renal Cell Carcinoma to the Parotid Gland 10 Years after Radical Nephrectomy. International Journal of Urology, 11, 894-896.
http://dx.doi.org/10.1111/j.1442-2042.2004.00902.x
[15] Moudouni, S.M., Tligui, M., Doublet, J.D., Haab, F., Gattegno, B. and Thibault, P. (2006) Late Metastasis of Renal Cell Carcinoma to the Submaxillary Gland 10 Years after Radical Nephrectomy. International Journal of Urology, 13, 431-432.
http://dx.doi.org/10.1111/j.1442-2042.2006.01318.x
[16] Sadatomo, T., Yuki, K., Migita, K., Taniguchi, E., Kodama, Y. and Kurisu, K. (2005) Solitary Brain Metastasis from Renal Cell Carcinoma 15 Years after Nephrectomy. Neurologia Medico-Chirurgica (Tokyo), 45, 423-427.
http://dx.doi.org/10.2176/nmc.45.423
[17] Gil-Julio, H., Vázquez-Alonso, F., Fernández-Sánchez, A.J., Puche-Sanz, I., Flores-Martín, J.F. and Cózar, J.M. (2012) Metastasis of Renal Cell Carcinoma to the Buccal Mucosa 19 Years after Radical Nephrectomy. Case Reports in Oncological Medicine, 2012, Article ID: 823042.
http://dx.doi.org/10.1155/2012/823042
[18] Kadrian, D. and Tan, L. (2004) Single Choroid Plexus Metastasis 16 Years after Nephrectomy for Renal Cell Carcinoma: Case Report and Review of the Literature. Journal of Clinical Neuroscience, 11, 88-91.
http://dx.doi.org/10.1016/j.jocn.2002.09.002
[19] Macedo-Alves, D., Koca, P., Soares, V., Gouveia, P., Honavar, M. and Taveira-Gomes, A. (2015) Thyroid Metastasis from Renal Cell Carcinoma—A Case Report after 9 Years. International Journal of Surgery Case Reports, 16, 59-63.
http://dx.doi.org/10.1016/j.ijscr.2015.09.004
[20] Kihara, M., Yokomise, H. and Yamauchi, A. (2004) Metastasis of Renal Cell Carcinoma to the Thyroid Gland 19 Years after Nephrectomy. Auris Nasus Larynx, 31, 95-100.
http://dx.doi.org/10.1016/j.anl.2003.09.002
[21] De Jesus, C.M.N., Casafus, F.A.S. and Agostinho, A.D. (2008) Surgical Treatment of Renal Cell Carcinoma Recurrence at the Renal Fossa Following Radical Nephrectomy. Sao Paulo Medical Journal, 126, 194-196.
http://dx.doi.org/10.1590/S1516-31802008000300011
[22] Adamy, A., Chong, K.T., Chade, D., Costaras, J., Russo, G., Kaag, M.G., Bernstein, M., Motzer, R.J. and Russo, P. (2011) Clinical Characteristics and Outcomes of Patients with Recurrence 5 Years after Nephrectomy for Localized Renal Cell Carcinoma. The Journal of Urology, 185, 433-438.
http://dx.doi.org/10.1016/j.juro.2010.09.100
[23] Park, Y.H., Baik, K.D., Lee, Y.J., Ku, J.H., et al. (2012) Late Recurrence of Renal Cell Carcinoma > 5 Years after Surgery: Clinicopathological Characteristics and Prognosis. BJU International, 110, E553-E558.
http://dx.doi.org/10.1111/j.1464-410X.2012.11246.x
[24] Tapper, H., Klein, H., Rubenstein, W., Intriere, L., Choi, Y. and Kazam, E. (1997) Recurrent Renal Cell Carcinoma after 45 Years. Clinical Imaging, 21, 273-275.
http://dx.doi.org/10.1016/S0899-7071(96)00042-3
[25] Miah, M.S., White, S.J., Oommen, G., Birney, E. and Majumdar, S. (2010) Late Simultaneous Metastasis of Renal Cell Carcinoma to the Submandibular and Thyroid Glands Seven Years after Radical Nephrectomy. International Journal of Otolaryngology, 2010, Article ID: 698014.
http://dx.doi.org/10.1155/2010/698014
[26] Saidi, R.F. and Remine, S.G. (2007) Isolated Gastric Metastasis from Renal Cell Carcinoma 10 Years after Radical Nephrectomy. Journal of Gastroenterology and Hepatology, 22, 140-144.
http://dx.doi.org/10.1111/j.1440-1746.2006.04335.x
[27] Sugasawa, H., Ichikura, T., Ono, S., Tsujimoto, H., et al. (2010) Isolated Gastric Metastasis from Renal Cell Carcinoma 19 Years after Radical Nephrectomy. International Journal of Clinical Oncology, 15, 196-200.
http://dx.doi.org/10.1007/s10147-010-0025-1
[28] Wilkinson, L., Tervit, G. and Bloxham, C. (2008) Metastatic Renal Cell Carcinoma to the Thyroid Gland Presenting 17 Years after Nephrectomy. Diagnostic Histopathology, 14, 408-410.
http://dx.doi.org/10.1016/j.mpdhp.2008.06.013
[29] Chin, C.J., Franklin, J.H., Moussa, M. and Chin, J.L. (2011) Metastasis from Renal Cell Carcinoma to the Thyroid 12 Years after Nephrectomy. Canadian Medical Association Journal, 183, 1398-1399.
http://dx.doi.org/10.1503/cmaj.092152
[30] Fuente Bartolomé, M., Osorio Silla, I., Gutiérrez Samaniego, M., Martinez Pueyo, J.I. and de La Cruz Vigo, F. (2014) Metastasis en tiroides de carcinoma renal de células claras. Endocrinología y Nutrición, 61, 296-297.
http://dx.doi.org/10.1016/j.endonu.2013.12.002
[31] Takashi, M., Hibi, H., Ohmura, M., Sate, K., Sakata, T. and Ando, M. (1997) Renal Fossa Recurrence of a Renal Cell Carcinoma 13 Years after Nephrectomy: A Case Report. International Journal of Urology, 4, 508-511.
http://dx.doi.org/10.1111/j.1442-2042.1997.tb00294.x
[32] Brookman-May, S., May, M., Shariat, S.F., Xylinas, E., et al. (2013) Features Associated with Recurrence beyond 5 Years after Nephrectomy and Nephron-Sparing Surgery for Renal Cell Carcinoma: Development and Internal Validation of a Risk Model (PRELANE Score) to Predict Late Recurrence Based on a Large Multicenter Database (CORONA/SATURN Project). European Urology, 64, 472-477.
http://dx.doi.org/10.1016/j.eururo.2012.06.030
[33] Miyao, N., Naito, S., Ozono, S., Shinohara, N., et al. (2011) Late Recurrence of Renal Cell Carcinoma: Retrospective and Collaborative Study of the Japanese Society of Renal Cancer. Urology, 77, 379-384.
http://dx.doi.org/10.1016/j.urology.2010.07.462
[34] Heckl, S., Braun, K., Debus, J. and Kunze, S. (2003) Cerebral Metastasis after Primary Renal Cell Carcinoma. Journal of Neurology, Neurosurgery & Psychiatry, 74, 141.
http://dx.doi.org/10.1136/jnnp.74.1.141
[35] Bradham, R.R., Wannamaker, C.C. and Pratt-Thomas, H.R. (1973) Renal Cell Carcinoma Metastases 25 Years after Nephrectomy. JAMA, 223, 921-922.
http://dx.doi.org/10.1001/jama.1973.03220080051019
[36] Lee, J.G., Kim, J.S., Kim, H.J., Kim, S.T., et al. (2002) Simultaneous Duodenal and Colon Masses as Late Presentation of Metastatic Renal Cell Carcinoma. The Korean Journal of Internal Medicine, 17, 143-146.
http://dx.doi.org/10.3904/kjim.2002.17.2.143
[37] Sotiropoulos, G.C., Lang, H., Liu, C., Brokalaki, E.I., et al. (2005) Surgical Treatment of Pancreatic Metastases of Renal Cell Carcinoma. Journal of the Pancreas, 6, 339-343.
[38] Namikawa, T., Iwabu, J., Kitagawa, H., Okabayashi, T., et al. (2012) Solitary Gastric Metastasis from a Renal Cell Carcinoma, Presenting 23 Years after Radical Nephrectomy. Endoscopy, 44, E177-E178.
http://dx.doi.org/10.1055/s-0031-1291751
[39] Dellon, E.S. and Gangarosa, L.M. (2006) Hematochezia Due to a Renal Cell Carcinoma Metastasis to the Rectum: A Case Report and Review of the Literature. Revista de Gastroenterología de México, 71, 316-318.
[40] Pezzoli, A., Matarese, V., Boccia, S., Simone, L. and Gullini, S. (2007) Gastrointestinal Bleeding from Gastric Metastasis of Renal Cell Carcinoma, Treated by Endoscopic Polypectomy. Endoscopy, 39, E52.
http://dx.doi.org/10.1055/s-2006-945127
[41] Riviello, C., Tanini, I., Cipriani, G., Pantaleo, P., et al. (2006) Unusual Gastric and Pancreatic Metastatic Renal Cell Carcinoma Presentation 10 Years after Surgery and Immunotherapy: A Case Report and a Review of Literature. World Journal of Gastroenterology, 12, 5234-5236.
[42] Costa, T.N., Takeda, F.R., Ribeiro Jr., U. and Cecconello, I. (2014) Palliative Laparoscopic Resection of Renal Cell Carcinoma Metastatic to the Stomach: Report of a Case. World Journal of Surgical Oncology, 12, 394.
http://dx.doi.org/10.1186/1477-7819-12-394
[43] Chang, W.-T., Chai, C.-Y. and Lee, K.-T. (2004) Unusual Upper Gastro-Intestinal Bleeding Due to Late Metastasis from Renal Cell Carcinoma: A Case Report. The Kaohsiung Journal of Medical Sciences, 20, 137-141.
http://dx.doi.org/10.1016/S1607-551X(09)70098-1

Copyright © 2024 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.