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Insulin and insulin-like activity in tumor tissue and plasma of a patient with a fibrosarcoma associated with hypoglycemia
Insulin and Insulin-like Activity in Tumor Tissue and Plasma of a Patient with a Fibrosarcoma Associated with Hypoglycemia By CARLOSSUBAUSTE, ROLANDOCALDER~N,LUIS A. LLERENA AND ENRIQUECARRIOX insulin was not detected in significant concentration. A normal level of ILA and insulin was found in plasma. There was no significant blood glucose response to intravenous tolbutamide as seen in patients with insulin-producing tumors.
In a patient with a large fibrosarcoma and associated hypoglycemia, assays for insulin-like activity (ILA) were performed on extract of tumor tissue and plasma. A significant level of ILA was found in the extract of tumor tissue while
T
HE CAUSE OF HYPOGLYCEMIA which occms in some patients with tumors of nonpancreatic origin continues to be a subject of considerable discussion. Ten reports are available presently which indicate that extracts of tumors from these patients contained an insulin-like substance manifesting stimulatory activity either in the isolated rat diaphragm or epididymal fat ‘lo An elevation of the level of insulin-like activity in serum was pad systems. level of insulin-likcl found in only 1 of these 10 patients. l1 This elevated activity returned into the normal range after resection of the fibrosarcoma. Alt elevated level of plasma insulin determined by an immunoassay has been reported in only 1 patient with hypoglycemia due to a large fibrosarcoma.‘” An extremely high level of serum insulin returned to normal levels after reduction of the size of the tumor by radiotherapy, concomitant with disappearance of hypoglycemia. Tumor tissue was not available for assay. Manv case reports have been published to indicate that insulin-like activitv or insulin was not found in significant amounts in extracts of tumor tisslle’:’ or in exccssive amounts in plasma. The patient with a large fibrosarcoma and associated hypcg:ycemia described below is reported, since results of immunoassay of insulin of plasma, of extract of tumor tissue, and of pancreas are available. Assays for insulin-likr, activity (ILA) on extract of tumor tissue and plasma were also performed. L4 significant level of ILA was found in the extract of tumor tissue, while insulin was not detected in significant concentration. A normal level of ILA and insulin was found in plasma. There was no significant blo#od glucose response to intravenous tolbutamide as seen in patients with insulin-producing tumors.“” CASE REPORT S. Xl. G., a 56 year old widowed housewife, 1961.
complaining
of a tumor
in the thyroid.
From the Dq~artment of Endocrinology, “Cayetano Heredin,” Lima, Peru. Received for publication Apr. 20. 1965.
was seen for the first time in December, present since childhood and enlarging in
Hospital
Loayx,
and Faczrldad
de
Medicinc~
881
\IETAIXXJSXI,VOL. 11. No. 8 (Accuse). 1965
882 the
SUBAUSTE,
last
10 years.
The physical fusely.
The
Dyspnea,
examination thyroid
palpitation disclosed
was enlarged
and
CALDERbN,
loss of weight
an undernourished
were
patient
and firm in consistency.
The
LLERENA,
additional
who
CARRION
complaints.
was perspiring
pulsr
rate was
heart was not enlarged. The second sound at the pulmonic area was accentuated. 1 systolic murmur could be heard over the precordium. Abdominal examination a large fixed tumor mass filling the left upper quadrant and flank. Laboratory Studies. Complete blood count and urinalysis were
normal.
lS8.
proThe
A grade revealed
Erythrocytr
sedimentation rate was 26 mm./hour. A serologic test for syphilis was negative. Levels of fasting blood glucose were 96 and 102 mg./100 ml. ( Folin-Wu). Blood urea nitrogen was 24 and 14 mg./ltMl ml., and serum calcium 9 mg./IOO ml. Liver function tests were within normal limits. Serum albumin was 4.6 Gm./lOO ml. and globulin 2.77 Gm./lOO ml. A radioactive iodine uptake was 63 per cent at 24 hours. An electrocardiogram showed sinus tachycardia and isolated ventricular extrasystoles. An x-ray of the chest showed an elevation of the left hemidiaphragm. Two months later a chest film disclosed a mild left pleural effusion. The patient received antithyroid therapy and on May 8, 1962, was performed for a multinodular goiter. Following operation administered in a dosage of 2 grains/day.
a subtotal thyroidectomy desiccated thyroid was
A series of radiologic studies was performed in December, intervals through 1962. Xlray of the abdomen disclosed a large
1961, tumor
quadrant and left flank which was irregularly large tumor in the left upper hypochondrium
and repeated at in the left upper
calcified. Pneumoperitoneum attached to the diaphragm.
showed a Intravenous
pyelography showed downward displacement of the left kidney by the tumor. Gastrointestinal x-rays disclosed displacement of the stomach to the right and forward, and downward displacement of the splenic flexure of the colon and of jejunal segments. During and following hospitalization the patient had numerous hypoglycemic crises in the early
morning
hours
and postprandially.
Withdrawal
of thyroid
medication
did not
relieve the symptoms. An intravenous tolbutamide test gave the following results: fasting 40 mg./lCtO ml., 20 min. 44 mg./lOO ml., 40 min. 38 mg./lOO ml., 60 min. 36 mg./lOO ml., 80 min. 36 mg./lOO ml. (Folin-Wu). An intravenous glucose tolerance test employing 40 Gm. of glucose gave the following results: fasting 31 mg./lOO ml., 15 min. 140 mg./ 100 ml., 30 min. 99 mg./lOO ml., 45 min. 83 mg./lOO ml., and 60 min. 61 mg./lOO ml. ( Somogyi-Nelson). On December 13, 1962, the patient was transferred to the Surgical A huge retroperitoneal mass was found. A Department for an abdominal exploration. biopsy specimen was taken but removal of the tumor was not possible. The pancreas was normal to palpation. A biopsy specimen of the pancreas was taken and was reported as normal. The biopsy specimen of the tumor was reported as showing a sarcoma with a low grade of malignancy. Assays for insulin-like activity (ILA) by the method of Renold et al.15 and insulin assays by the method of Yalow and Bersonls were performed through the courtesy of Dr. L. Power and Dr. John C. Floyd, Jr., Department of Internal Medicine (Division of Endocrinology and Metabolism, The Metabolic Research Unit), University of Michigan, Ann Arbor, A sample of fasting plasma (blood sugar 77 mg./lOO ml., Folin-Wu) taken before the operation contained 96 PU ILA/ml., and 10 FLU insulin/ml. Assay for ILA on acid alcohol extract of tumor tissue gave a concentration of 0.024 units/Gm. Insulin assay of the same extract gave a value of 0.001 units insulin/Gm. An acid alcohol extract of pancreatic tissue gave a level of 1.95 units insulin/Gm. Postoperatively the hypoglycemic crises persisted. On January 3, 1963, another intravenous tolbutamide test gave the following results: fasting 41 mg./lOO ml., 20 min. 30 mg./lOO ml., 40 min. 35 mg./lOO ml., 66 mm. 42 mg./106 ml., and 80 min. 46 mg./lOO ml. ( Somogyi-Nelson). Following initiation of radiotherapy, there was shrinkage of the tumor mass. Hypeglycemic episodes persisted between 5 and 7 a.m. but with lesser frequency. On February 26th the patient requested to be discharged from the hospital.
INSL~LIN,
ILA IN TUMOR
8X3
AND HYI’OC~LYCE:SlIA
Thr~ low level of insulin in serum and absence of inslllin in tumor tissllfx not suggest that this patient’s tumor secretes insulin.‘” Nor do these results indicate that there is release of a factor from tumor tissue which stimulates excessive insulin secretion from the pancreas. The srlbnormal hypoglycemic response to tolbutamide is additional evidence against excessivcx pancreatic activity unless the islets of Langerhans were releasing insulin at maximum capacity already. This is unlikelv in view of the low level of insulin in plasma and the normal concentration of insulin in pancreatic tissue. T~v data obtained with the assay for ILA suggest release from tumor tissue of a factor with insulin-like activity which does not react antigenically like insulin. Plasma level of ILA was not elevated. There is no proof that the ILA assav& in tllmor extract is the cause of the hvpoglvcemia although this is an attracti\fc, hypothesis. Excessive glucose consuhptio;, by tumor tissue cannot be r~llc~d otlt with the data at hand, although this seems a less likely cause for hypeglycemia. The findings reported here do not disclose the cause of hypogl!. cemia in this patient but can be added to the accllmulation of data, so f’al scanty, obtained in patients with similar tumors associated with hypoglycemia. do
REFERENCES 1. Ailgllst. J. T., verc
nonpancnaatic srllin
2.
and
Hiatt,
hypoglycemia activity.
H.
H.:
secondary
fibrosarcoma New
Eng.
Scto
with J.
a in-
hlrd.
2.58: 17, 1958. hlillrr. I>. R., Bolinger, R. I>.. Janigall, I).. Crockett, J. E., and Friesen. S. R.: Hypoglycemia dllc> to nonpancrratic mesodermal tumors. port of two cases. Ann. Surg. 684.
ReISO:
19.59.
3. \‘olk. B. I\‘.. Goldner, ht. G.. and B.: Spontaneous hypoWainfc,ld, glycemia with abdominal spindle-cell Sarcoma. Geriatrics 15:473, 1960. ,a. \\‘hitncy, J. E., and Massey, C. G.: Appar~~nt insulin activity in fibrosarassociated with spontaneous c,oma hypoglycunia. J. Clin. Endocrinol. & Vetah. 21:.541, 1961. 5. S~honf~ld, A., Bahhott, D., and Glmder~1, IL: Hypoglycemia and polycythcmia associated with primary hepntomas. New Eng. J. Med. 265:231, 1961. 6. ‘I’ranqllada. R. E., Bender, A. B., and Heigclman, P. M.: Hypoglycemia associatetl with carcinoma of tile ~YWU~~ ;tnd syndrome of testicldar feminization. Ntw Eng. J. hlrd. 266:1302,
1962. 7. Gonzalez, Shnider, cinema
F. hl., B. I.:
Gold, G. I,.. Gastrointestinal
and or-
an d concomitant hypoglycrmia. Ann. Int. Med. 58: 149, 1963. 8. Perkoff, G. T., and Simons, E. I,.: Hypoglycemia in a patient witll a fibrous tumor. Studies of the mochanism of the hypoglycemia. Med. 112:389, 1963.
Arch.
Int.
9. Firld. 1. B., Keen, H., Johnson. J., and Herring, B.: Inslllin-like activity of nonpancreatic
tumors
associated
hypoglycemia. J. Clin. Metal,. 2.3: 1229, 1963.
with
Endoc,rinol.
10. BoshelI, B. R., Kirschenfeld, J. J., SotcVs, I’. S.: Extrapancreatic sulin-secreting tumor. New Eng. Med. “70:338, 1964. 11. Whitnq~, J. E., and Heller, B. I.: creased insulin-like activity of the rum in a patient with hypoglycemia associated roprritoneal fibrosarcoma. Med. 30:633, 1961.
& an11 illJ. IIIse-
spontancotls with a retAmer. J.
12. Oleesky, S., Bailey, I.. Samols, E., ;IIKI Bilkus, I).: A fibrosarcoma with hypoglyc~aemia and a high srrun-ilrsr&n Ic~rl. Lanc~ct 2:378. 1962. 13. Steinlie.
J., Soeldner,
J. S., and
R~~c~l~l.
884
SUBAUSTE, CALDERbN,
A. E.: Insulin-like activity of extract from large sarcomatous tumor associated with hypoglycemia. J. Clin. Invest. 41: 1403, 1962. 14. Fajans, S. S., Schneider, J. hsl., Schteingart, D. E., and Corm, J. W.: The diagnostic value of sodium tolbutamide in hypoglycemic states. J. Clin. Endocrinol. & Metab. 21:371, 1961. 15. Renold.
A. E., Martin,
D. B., Dagenais,
Y. M., Steinke, and Sheps, M. small quantities
LLERENA,
J., Nickerson, R. J., C.: Measurement of of insulin-like ac-
tivity using rat adipose tissue. I. A proposed procedure. J. Clin. Invest. 39: 1487, 1960. 16. Ya!ow, R. S., and Berson, S. A.: Immunoassay of endogenous plasma insulin in man. J, Clin. Invest. 39: 1157,
1960.
Carlos Subauste, M.D., Associate Profe.ssor of Medicine, Universidad Peruana Cayetano Heredia, and Assistant Physician, Hospital Loayza, Lima, Perti. Roland0 Caledrdn, M.D., Assistant Professor of Medicine, Universidad Peruana Cayetano Heredia, and Endocrinologist, Hospital Loaysa, Lima, Perk L. Albert0 Llerena, M.D., Assistant Professor of Medicine, Universidad Peruana Cayetano Heredia and Assistant in Medicine, Hospital Loayza, Lima, Perk Enrique
Carridn,
CARRION
M.D., Assistant, Department Hospital Loayza, Lima, Perk
of Medicine,
In a patient with a large fibrosarcoma and associated hypoglycemia, assays for insulin-like activity (ILA) were performed on extract of tumor tissue and plasma. A significant level of ILA was found in the extract of tumor tissue while
T
HE CAUSE OF HYPOGLYCEMIA which occms in some patients with tumors of nonpancreatic origin continues to be a subject of considerable discussion. Ten reports are available presently which indicate that extracts of tumors from these patients contained an insulin-like substance manifesting stimulatory activity either in the isolated rat diaphragm or epididymal fat ‘lo An elevation of the level of insulin-like activity in serum was pad systems. level of insulin-likcl found in only 1 of these 10 patients. l1 This elevated activity returned into the normal range after resection of the fibrosarcoma. Alt elevated level of plasma insulin determined by an immunoassay has been reported in only 1 patient with hypoglycemia due to a large fibrosarcoma.‘” An extremely high level of serum insulin returned to normal levels after reduction of the size of the tumor by radiotherapy, concomitant with disappearance of hypoglycemia. Tumor tissue was not available for assay. Manv case reports have been published to indicate that insulin-like activitv or insulin was not found in significant amounts in extracts of tumor tisslle’:’ or in exccssive amounts in plasma. The patient with a large fibrosarcoma and associated hypcg:ycemia described below is reported, since results of immunoassay of insulin of plasma, of extract of tumor tissue, and of pancreas are available. Assays for insulin-likr, activity (ILA) on extract of tumor tissue and plasma were also performed. L4 significant level of ILA was found in the extract of tumor tissue, while insulin was not detected in significant concentration. A normal level of ILA and insulin was found in plasma. There was no significant blo#od glucose response to intravenous tolbutamide as seen in patients with insulin-producing tumors.“” CASE REPORT S. Xl. G., a 56 year old widowed housewife, 1961.
complaining
of a tumor
in the thyroid.
From the Dq~artment of Endocrinology, “Cayetano Heredin,” Lima, Peru. Received for publication Apr. 20. 1965.
was seen for the first time in December, present since childhood and enlarging in
Hospital
Loayx,
and Faczrldad
de
Medicinc~
881
\IETAIXXJSXI,VOL. 11. No. 8 (Accuse). 1965
882 the
SUBAUSTE,
last
10 years.
The physical fusely.
The
Dyspnea,
examination thyroid
palpitation disclosed
was enlarged
and
CALDERbN,
loss of weight
an undernourished
were
patient
and firm in consistency.
The
LLERENA,
additional
who
CARRION
complaints.
was perspiring
pulsr
rate was
heart was not enlarged. The second sound at the pulmonic area was accentuated. 1 systolic murmur could be heard over the precordium. Abdominal examination a large fixed tumor mass filling the left upper quadrant and flank. Laboratory Studies. Complete blood count and urinalysis were
normal.
lS8.
proThe
A grade revealed
Erythrocytr
sedimentation rate was 26 mm./hour. A serologic test for syphilis was negative. Levels of fasting blood glucose were 96 and 102 mg./100 ml. ( Folin-Wu). Blood urea nitrogen was 24 and 14 mg./ltMl ml., and serum calcium 9 mg./IOO ml. Liver function tests were within normal limits. Serum albumin was 4.6 Gm./lOO ml. and globulin 2.77 Gm./lOO ml. A radioactive iodine uptake was 63 per cent at 24 hours. An electrocardiogram showed sinus tachycardia and isolated ventricular extrasystoles. An x-ray of the chest showed an elevation of the left hemidiaphragm. Two months later a chest film disclosed a mild left pleural effusion. The patient received antithyroid therapy and on May 8, 1962, was performed for a multinodular goiter. Following operation administered in a dosage of 2 grains/day.
a subtotal thyroidectomy desiccated thyroid was
A series of radiologic studies was performed in December, intervals through 1962. Xlray of the abdomen disclosed a large
1961, tumor
quadrant and left flank which was irregularly large tumor in the left upper hypochondrium
and repeated at in the left upper
calcified. Pneumoperitoneum attached to the diaphragm.
showed a Intravenous
pyelography showed downward displacement of the left kidney by the tumor. Gastrointestinal x-rays disclosed displacement of the stomach to the right and forward, and downward displacement of the splenic flexure of the colon and of jejunal segments. During and following hospitalization the patient had numerous hypoglycemic crises in the early
morning
hours
and postprandially.
Withdrawal
of thyroid
medication
did not
relieve the symptoms. An intravenous tolbutamide test gave the following results: fasting 40 mg./lCtO ml., 20 min. 44 mg./lOO ml., 40 min. 38 mg./lOO ml., 60 min. 36 mg./lOO ml., 80 min. 36 mg./lOO ml. (Folin-Wu). An intravenous glucose tolerance test employing 40 Gm. of glucose gave the following results: fasting 31 mg./lOO ml., 15 min. 140 mg./ 100 ml., 30 min. 99 mg./lOO ml., 45 min. 83 mg./lOO ml., and 60 min. 61 mg./lOO ml. ( Somogyi-Nelson). On December 13, 1962, the patient was transferred to the Surgical A huge retroperitoneal mass was found. A Department for an abdominal exploration. biopsy specimen was taken but removal of the tumor was not possible. The pancreas was normal to palpation. A biopsy specimen of the pancreas was taken and was reported as normal. The biopsy specimen of the tumor was reported as showing a sarcoma with a low grade of malignancy. Assays for insulin-like activity (ILA) by the method of Renold et al.15 and insulin assays by the method of Yalow and Bersonls were performed through the courtesy of Dr. L. Power and Dr. John C. Floyd, Jr., Department of Internal Medicine (Division of Endocrinology and Metabolism, The Metabolic Research Unit), University of Michigan, Ann Arbor, A sample of fasting plasma (blood sugar 77 mg./lOO ml., Folin-Wu) taken before the operation contained 96 PU ILA/ml., and 10 FLU insulin/ml. Assay for ILA on acid alcohol extract of tumor tissue gave a concentration of 0.024 units/Gm. Insulin assay of the same extract gave a value of 0.001 units insulin/Gm. An acid alcohol extract of pancreatic tissue gave a level of 1.95 units insulin/Gm. Postoperatively the hypoglycemic crises persisted. On January 3, 1963, another intravenous tolbutamide test gave the following results: fasting 41 mg./lOO ml., 20 min. 30 mg./lOO ml., 40 min. 35 mg./lOO ml., 66 mm. 42 mg./106 ml., and 80 min. 46 mg./lOO ml. ( Somogyi-Nelson). Following initiation of radiotherapy, there was shrinkage of the tumor mass. Hypeglycemic episodes persisted between 5 and 7 a.m. but with lesser frequency. On February 26th the patient requested to be discharged from the hospital.
INSL~LIN,
ILA IN TUMOR
8X3
AND HYI’OC~LYCE:SlIA
Thr~ low level of insulin in serum and absence of inslllin in tumor tissllfx not suggest that this patient’s tumor secretes insulin.‘” Nor do these results indicate that there is release of a factor from tumor tissue which stimulates excessive insulin secretion from the pancreas. The srlbnormal hypoglycemic response to tolbutamide is additional evidence against excessivcx pancreatic activity unless the islets of Langerhans were releasing insulin at maximum capacity already. This is unlikelv in view of the low level of insulin in plasma and the normal concentration of insulin in pancreatic tissue. T~v data obtained with the assay for ILA suggest release from tumor tissue of a factor with insulin-like activity which does not react antigenically like insulin. Plasma level of ILA was not elevated. There is no proof that the ILA assav& in tllmor extract is the cause of the hvpoglvcemia although this is an attracti\fc, hypothesis. Excessive glucose consuhptio;, by tumor tissue cannot be r~llc~d otlt with the data at hand, although this seems a less likely cause for hypeglycemia. The findings reported here do not disclose the cause of hypogl!. cemia in this patient but can be added to the accllmulation of data, so f’al scanty, obtained in patients with similar tumors associated with hypoglycemia. do
REFERENCES 1. Ailgllst. J. T., verc
nonpancnaatic srllin
2.
and
Hiatt,
hypoglycemia activity.
H.
H.:
secondary
fibrosarcoma New
Eng.
Scto
with J.
a in-
hlrd.
2.58: 17, 1958. hlillrr. I>. R., Bolinger, R. I>.. Janigall, I).. Crockett, J. E., and Friesen. S. R.: Hypoglycemia dllc> to nonpancrratic mesodermal tumors. port of two cases. Ann. Surg. 684.
ReISO:
19.59.
3. \‘olk. B. I\‘.. Goldner, ht. G.. and B.: Spontaneous hypoWainfc,ld, glycemia with abdominal spindle-cell Sarcoma. Geriatrics 15:473, 1960. ,a. \\‘hitncy, J. E., and Massey, C. G.: Appar~~nt insulin activity in fibrosarassociated with spontaneous c,oma hypoglycunia. J. Clin. Endocrinol. & Vetah. 21:.541, 1961. 5. S~honf~ld, A., Bahhott, D., and Glmder~1, IL: Hypoglycemia and polycythcmia associated with primary hepntomas. New Eng. J. Med. 265:231, 1961. 6. ‘I’ranqllada. R. E., Bender, A. B., and Heigclman, P. M.: Hypoglycemia associatetl with carcinoma of tile ~YWU~~ ;tnd syndrome of testicldar feminization. Ntw Eng. J. hlrd. 266:1302,
1962. 7. Gonzalez, Shnider, cinema
F. hl., B. I.:
Gold, G. I,.. Gastrointestinal
and or-
an d concomitant hypoglycrmia. Ann. Int. Med. 58: 149, 1963. 8. Perkoff, G. T., and Simons, E. I,.: Hypoglycemia in a patient witll a fibrous tumor. Studies of the mochanism of the hypoglycemia. Med. 112:389, 1963.
Arch.
Int.
9. Firld. 1. B., Keen, H., Johnson. J., and Herring, B.: Inslllin-like activity of nonpancreatic
tumors
associated
hypoglycemia. J. Clin. Metal,. 2.3: 1229, 1963.
with
Endoc,rinol.
10. BoshelI, B. R., Kirschenfeld, J. J., SotcVs, I’. S.: Extrapancreatic sulin-secreting tumor. New Eng. Med. “70:338, 1964. 11. Whitnq~, J. E., and Heller, B. I.: creased insulin-like activity of the rum in a patient with hypoglycemia associated roprritoneal fibrosarcoma. Med. 30:633, 1961.
& an11 illJ. IIIse-
spontancotls with a retAmer. J.
12. Oleesky, S., Bailey, I.. Samols, E., ;IIKI Bilkus, I).: A fibrosarcoma with hypoglyc~aemia and a high srrun-ilrsr&n Ic~rl. Lanc~ct 2:378. 1962. 13. Steinlie.
J., Soeldner,
J. S., and
R~~c~l~l.
884
SUBAUSTE, CALDERbN,
A. E.: Insulin-like activity of extract from large sarcomatous tumor associated with hypoglycemia. J. Clin. Invest. 41: 1403, 1962. 14. Fajans, S. S., Schneider, J. hsl., Schteingart, D. E., and Corm, J. W.: The diagnostic value of sodium tolbutamide in hypoglycemic states. J. Clin. Endocrinol. & Metab. 21:371, 1961. 15. Renold.
A. E., Martin,
D. B., Dagenais,
Y. M., Steinke, and Sheps, M. small quantities
LLERENA,
J., Nickerson, R. J., C.: Measurement of of insulin-like ac-
tivity using rat adipose tissue. I. A proposed procedure. J. Clin. Invest. 39: 1487, 1960. 16. Ya!ow, R. S., and Berson, S. A.: Immunoassay of endogenous plasma insulin in man. J, Clin. Invest. 39: 1157,
1960.
Carlos Subauste, M.D., Associate Profe.ssor of Medicine, Universidad Peruana Cayetano Heredia, and Assistant Physician, Hospital Loayza, Lima, Perti. Roland0 Caledrdn, M.D., Assistant Professor of Medicine, Universidad Peruana Cayetano Heredia, and Endocrinologist, Hospital Loaysa, Lima, Perk L. Albert0 Llerena, M.D., Assistant Professor of Medicine, Universidad Peruana Cayetano Heredia and Assistant in Medicine, Hospital Loayza, Lima, Perk Enrique
Carridn,
CARRION
M.D., Assistant, Department Hospital Loayza, Lima, Perk
of Medicine,