- Email: [email protected]
Renal failure secondary to angiomyolipoma case of forme-fruste tuberous sclerosis
CASE REPORTS
RENAL
FAILURE
SECONDARY
Case of Forme-Fruste WILLIAM MARTIN THOMAS
L. THELMO, LEFKOWITZ,
TO ANGIOMYOLIPOMA
Tuberous Sclerosis M.D. M.D.
A. SEEMAYER,
M.D.
From the Department of Pathology, Westchester County Medical Center, Valhalla, New York, and the Pathology Institute, McGill University, Montreal, Quebec, Canada
ABSTRACT -A fifty-f our- y ear-old woman without the clinical features of tuberous sclerosis underwent nephrectomy at age thirty-three years for angiomyolipoma, and twenty-one years later severe renal failure deueloped. At necropsy the remaining kidney had extensive angiomyolipomatous involvement; not until the brain was examined was the diagnosis of tuberous sclerosis made. To date, this would appear to be the third case without clinical tuberous sclerosis in which renal involvement was the sole clinical expression of tuberous sclerosis, and the seventh reported instance of renal failure due to renal angiomyolipomatous hamartomatous transformation.
Classic tuberous sclerosis usually presents in infancy, childhood, or early adulthood with seimental deficiency, hypopigmented zures, macules, and adenoma sebaceum.’ The disease incidence has been estimated to range from one in 50,000 to 100,000 live births. Since earlier descriptions, however, an increasing number of incomplete variants, forme frustes, have been described; many were unrecognized until late in life. The association of clinically apparent tuberous sclerosis with bilateral renal involvement and renal failure has been the subject of scant attention.2-4 In recent years 2 patients have been described who lacked the classic cutaneous and central nervous system manifestations of tuberous sclerosis and yet had severe renal, involvement progressing to uremia.4*5 This report describes a patient without clinical features of tuberous sclerosis who underwent nephrectomy at age thirty-three years for angiomyolipoma and in whom severe renal failure developed twenty-one years later. At necropsy extensive angiomyolipomatous transformation of the remaining kidney and cerebral and cerebel-
UROLOGY
/ APRIL1978 / VOLUMEXI
NUMBER4
lar subependymal gliomas were discovered. This would appear to be the seventh reported instance of renal failure due to renal angiomyolipomatous hamartomatous transformation and only the third in which the renal involvement was the sole clinical expression of tuberous sclerosis. Case Report A fifty-four-year-old white female of normal intelligence was admitted for evaluation of severe anemia and azotemia. Twenty-one years previously she had been investigated for persistent left flank pain following trauma. At that time hemoglobin was 11.5 Cm. and blood urea nitrogen 23 mg./lOO ml. Intravenous pyelography disclosed a large mass within the left kidney. The right kidney appeared enlarged but demonstrated relatively normal function. A left nephrectomy was performed which revealed a renal tumor variously interpreted as a “liposarcoma” and “perithelial myosarcoma,” arising in an angiolipoma. Bone survey disclosed mottled areas of demineralization of the pelvis and spine
389
FIGURE 1. (A) Right kidney weighing 875 Cm. almost totally replaced by vascular fatty tumor with small hematoma in upper pole from previous biopsy; renal capsule is still intact. (B) Microscopy of right kidney showing residual renal parenchyma with scattered fatty tissue and confluent large area of angiomyolipomatous tissue. (Hematoxylin and eosin, original magni$cation x 64.) (C) Coronal section of cerebrum showing tuberous sclerotic nodule in anterior horn of ventricle. (D) Microscopy of tuberous sclerotic nodule in ventricle showing extensive calcified spherules and astrocytic elements. (Hematoxylin and eosin, original magnification X 64.) and nodular sclerotic foci in the bones of the hands, feet, and skull. Skull radiographs revealed calcification of the pineal gland and the Postoperatively the left renal choroid plexus. bed was irradiated with a total dose of 2,000 rads. She remained asymptomatic for the ensuing twenty-one years. At age fifty-two symptoms of anemia and azotemia developed. The latter, not further investigated, was attributed to recurrent pyelonephritis. The anemia was treated with transfusions over the next two years. On final admission, the blood pressure was 130/60 mm. Hg. A mass was palpated in the right upper quadrant. Hematocrit was 25; blood urea nitrogen was 270 mg. and creatinine 14 mg./lOO ml. Urinalysis revealed a specific gravity of 1.015, 2 plus protein, and unremarkable sediment.
Cystoscopy and retrograde pyelography revealed a nonobstructed enlarged right kidney. Open renal biopsy disclosed immature fat and benign mesenchymal elements. Four days postbiopsy the patient died of renal failure. Necropsy failed to reveal skin changes of tuberous sclerosis. The Ieft renal fossa contained no residual tumor. The right kidney was enlarged, 19 by 11 by 6 cm., yellow-gray and soft. A small hematoma was identified at the surgical biopsy site (Fig. 1A). The calyces, pelvis, and ureter were dilated. Small islands of pale tan parenchyma were interspersed among the dominant angiomyolipomatous mass. Histologically, the kidney was largely replaced by a mixture of fat, smooth muscle, and blood vessels of varying degrees of maturity with only scant islands of residual atrophic renal parenchyma (Fig. 1B). Fat cells varied from mature adult cells to
UROLOGY
I
APRIL 1978 / VOLUME
XI NUMBER 4
TABLEI.
Reported
cases of tuberous
sclerosis (T.S.) with renal failure
Reference
Clinical Evidence of T.S.
Age and Sex
1910"
Yes
28,M
Bilateral tumors presented in uremia; family history suggestive of T. S.
Cerebral T. S. bilateral angiomyolipoma
Golji, 1S613
Yes
. . .
One patient in mental institution with T.S. died of uremia
Bilateral angiomyolipoma
Schnitzer,
No
62,F
Nephrectomy 15 years previously for “benign tumor”; presented with uremia
Cerebral T. S. lesions; renal angiomyolipoma
Yes
31,F
Presented with uremia; treated with bilateral nephrectomy and allotransplantation
Bilateral angiomyolipoma and clear cell tumors
Anderson and Tannen, 1969
Yes
19,F
Presented age I4 months with enlarged kidneys; slow progression to uremia by age 19 years; bilateral cystic replacement of kidneys; treated with chronic hemodialysis
Biopsy one kidney consistent with angiomyolipoma
Chonko et al., 19744
No
22,F
Presented with uremia of 3 months’ duration; bilateral renal masses on x-ray and angiography; therapy - hemoclialysis
Biopsy - consistent with renal angiomyolipoma
Present case, 1975
No
55, F
Nephrectomy 21 years previously for angiomyolipoma; gradual onset of uremia
Angiomyolipoma of remaining kidney; cerebral glial nodules
Kirpicznik,
19635
Jochimsen, Braunstein, Najarian, 1969i2
and
bizarre lipoblasts. Blood vessels were of irregular size and shape with eccentric lumens and thick muscular walls. Identical hamartomatous tissue was observed in the lungs and liver. The brain weighed 1,300 Gm. The meninges were focally thickened. Coronal sections displayed multiple zones of effacement of gray matter by well-demarcated firm yellow-white plaques in both the cerebrum and cerebellum. The ventricular system was striking due to multiple nodular granular tuberosities with a subependymal distribution (Fig. 1C and D). Histologically, the cerebral nodules and subventricular plaques were composed of nodules of astrocytes and many gemistocytes. There was neither necrosis nor endothelial proliferation although calcified spherules were dispersed among the nodules. Similar tumors were observed in the cerebellum.
UROLOGY
/ APRIL1978 / VOLUMEXI
NUMBER4
Clinical Data
Pathology
Comment Tuberous sclerosis was first described in feeble-minded French children with extensive cutaneous lesions and uncontrollable epilepsy.6 Adenoma sebaceum and peculiar large sclerotic plaques of the cerebral cortex were considered characteristic. Primitive renal tumors, although also noted, were thought to be merely coincidental and unrelated. In 1942 Moolten’ proposed a unifying concept that tuberous sclerosis represented a “congenital developmental anomaly characterized by the occurrence of tumour-like malformations in various organs.” Although the most striking involvement occurred in ectodermal derived tissue, namely, brain, skin, retina, organs of mesodermal origin, that is the heart and kidneys, were also affected. The term “tuberous
391
sclerosis complex” was suggested to embrace the resultant variable clinicopathologic constellation. The renal hamartomas consist of mixtures of adipose tissue, smooth muscle, fibrous tissue, and blood vessels. The variable dominance of one element over another has been responsible for multiple designations such as angiomyolipoma, angiomyoma, angiolipoma, and angiofibromyolipoma. Presently, it is common knowledge that angiomyolipomas may be quite cellular and bizarre, and yet, pursue a benign course. This feature has only recently been appreciated. * The association of renal angiomyolipomas with tuberous sclerosis is controversial. Some authors consider them to represent a distinct component of tuberous sclerosis,9 while others believe there is a variable relationship between the tw~.“‘~ Nevertheless when the renal lesion is associated with tuberous sclerosis, it is usually bilateral, multiple, and asymptomatic, of little clinical consequence. In fact Golji,3 in reviewing 47 cases of tuberous sclerosis with renal tumors, concluded that the mere presence of tumor is insufficient indication for surgery since they rarely produce renal failure. Only 1 in 9 necropsied patients had renal failure. Indeed, extensive renal involvement with angiomyolipomatosis producing renal failure is rare as a recent review substantiated.4 Renal failure has been observed in tuberous sclerosis from age nineteen to sixty-two years, yet many of these patients were known to have clinical tuberous sclerosis with multiple organ involvement. Our case is but the seventh reported and only the third in which tuberous sclerosis was unsuspected (Table I). Moreover, it is of considerable interest considering the temporal relationships. Following unilateral nephrectomy for angiomyolipoma, over two decades elapsed before the remaining kidney was sufficiently involved to produce clinically overt renal failure, even though the remaining kidney was enlarged at the time of initial nephrectomy. Obviously, sufficient functional parenchyma was present at the time, however, over the years a constant loss of parenchyma followed. Presently, more instances of incomplete clinical expression of tuberous sclerosis are being
392
described in patients without classic cutaneous lesions and with minimal or absent manifestations of the central nervous system. The patient’s only clinical manifestation of tuberous sclerosis was unilateral renal angiomyolipomatosis, yet autopsy revealed a more extensive expression of the disease in multiple organs systems. This suggests that through long-term clinical observation and eventual necropsy a more precise significance can be ascribed to the patient with unilateral renal angiomyolipomatosis. In retrospect, our patient was noted to have an enlarged contralateral kidney at the time of initial nephrectomy. Since it is our impression that the incidence of bilaterality of this hamartomatous transformation is significant, perhaps these patients warrant more thorough investigation, including renal angiography. Since renal involvement is not always complete but may be partial in extent, surgical resection of the involved portion of kidney might be considered in the future evaluation of these patients. Valhalla, New York 10595 (DR. THELMO) References 1. Roth JC, and Epstein C: Infantile spasm and hypopigmented macules early manifestation of tuberous sclerosis, Arch. Neurol. 25: 547 (1971). 2. Anderson D, and Tannen R: Tuberous sclerosis and chronic renal failure, Am. J. Med. 47: 163 (1969). 3. Golji H: Tuberous sclerosis and renal neoplasms, J. Urol. 85: 919 (1961). 4. Chonko AM, Weiss SM, Stein JH, and Ferris TF: Renal involvement in tuberous sclerosis, Am. J. Med. 56: 124 (1974). 5. Schnitzer B: Tuberous sclerosis complex, Arch. Pathol. 76: 626 (1963). 6. Boumeville DM: Contribution a l’etude de l’idiotie, Arch. Neurol. 1: 69 (1880). 7. Moolten SE: Hamartial nature of the tuberous sclerosis complex and its bearing on the tumor problem, Arch. Intern. Med. 69: 589 (1912). 8. Price EB, and Mostofi FK: Symptomatic angiomyolipoma of the kidney, Cancer 18: 761 (1965). 9. Corssett AD, Jr: Roentgenographic findings in the renal lesion of tuberous sclerosis, Am. J. Roentgenol. 98: 739 (1966). 10. McQueeney AJ, Dahlen GA, and Gebhart WF: Cystic hamartoma (angiomyolipoma) of the kidney simulating renal carcinoma, J. Urol. 92: 98 (lQ64). 11. Kirpicznik J: Ein fall von Tuberoser Sklerose und Gleichzeitigen multiplen Nierengeschwulsten, Virchows Arch. Pathol. Anat. 292: 358 (1910). 12. Jochimsen PR, Braunstein PM, and Najarian JS: Renal allotransplantation for bilateral renal tumors, J.A.M.A. 210: 1721 (1969).
UROLOGY
/
APRIL 1978
/
VOLUME XI
NUMBER4
RENAL
FAILURE
SECONDARY
Case of Forme-Fruste WILLIAM MARTIN THOMAS
L. THELMO, LEFKOWITZ,
TO ANGIOMYOLIPOMA
Tuberous Sclerosis M.D. M.D.
A. SEEMAYER,
M.D.
From the Department of Pathology, Westchester County Medical Center, Valhalla, New York, and the Pathology Institute, McGill University, Montreal, Quebec, Canada
ABSTRACT -A fifty-f our- y ear-old woman without the clinical features of tuberous sclerosis underwent nephrectomy at age thirty-three years for angiomyolipoma, and twenty-one years later severe renal failure deueloped. At necropsy the remaining kidney had extensive angiomyolipomatous involvement; not until the brain was examined was the diagnosis of tuberous sclerosis made. To date, this would appear to be the third case without clinical tuberous sclerosis in which renal involvement was the sole clinical expression of tuberous sclerosis, and the seventh reported instance of renal failure due to renal angiomyolipomatous hamartomatous transformation.
Classic tuberous sclerosis usually presents in infancy, childhood, or early adulthood with seimental deficiency, hypopigmented zures, macules, and adenoma sebaceum.’ The disease incidence has been estimated to range from one in 50,000 to 100,000 live births. Since earlier descriptions, however, an increasing number of incomplete variants, forme frustes, have been described; many were unrecognized until late in life. The association of clinically apparent tuberous sclerosis with bilateral renal involvement and renal failure has been the subject of scant attention.2-4 In recent years 2 patients have been described who lacked the classic cutaneous and central nervous system manifestations of tuberous sclerosis and yet had severe renal, involvement progressing to uremia.4*5 This report describes a patient without clinical features of tuberous sclerosis who underwent nephrectomy at age thirty-three years for angiomyolipoma and in whom severe renal failure developed twenty-one years later. At necropsy extensive angiomyolipomatous transformation of the remaining kidney and cerebral and cerebel-
UROLOGY
/ APRIL1978 / VOLUMEXI
NUMBER4
lar subependymal gliomas were discovered. This would appear to be the seventh reported instance of renal failure due to renal angiomyolipomatous hamartomatous transformation and only the third in which the renal involvement was the sole clinical expression of tuberous sclerosis. Case Report A fifty-four-year-old white female of normal intelligence was admitted for evaluation of severe anemia and azotemia. Twenty-one years previously she had been investigated for persistent left flank pain following trauma. At that time hemoglobin was 11.5 Cm. and blood urea nitrogen 23 mg./lOO ml. Intravenous pyelography disclosed a large mass within the left kidney. The right kidney appeared enlarged but demonstrated relatively normal function. A left nephrectomy was performed which revealed a renal tumor variously interpreted as a “liposarcoma” and “perithelial myosarcoma,” arising in an angiolipoma. Bone survey disclosed mottled areas of demineralization of the pelvis and spine
389
FIGURE 1. (A) Right kidney weighing 875 Cm. almost totally replaced by vascular fatty tumor with small hematoma in upper pole from previous biopsy; renal capsule is still intact. (B) Microscopy of right kidney showing residual renal parenchyma with scattered fatty tissue and confluent large area of angiomyolipomatous tissue. (Hematoxylin and eosin, original magni$cation x 64.) (C) Coronal section of cerebrum showing tuberous sclerotic nodule in anterior horn of ventricle. (D) Microscopy of tuberous sclerotic nodule in ventricle showing extensive calcified spherules and astrocytic elements. (Hematoxylin and eosin, original magnification X 64.) and nodular sclerotic foci in the bones of the hands, feet, and skull. Skull radiographs revealed calcification of the pineal gland and the Postoperatively the left renal choroid plexus. bed was irradiated with a total dose of 2,000 rads. She remained asymptomatic for the ensuing twenty-one years. At age fifty-two symptoms of anemia and azotemia developed. The latter, not further investigated, was attributed to recurrent pyelonephritis. The anemia was treated with transfusions over the next two years. On final admission, the blood pressure was 130/60 mm. Hg. A mass was palpated in the right upper quadrant. Hematocrit was 25; blood urea nitrogen was 270 mg. and creatinine 14 mg./lOO ml. Urinalysis revealed a specific gravity of 1.015, 2 plus protein, and unremarkable sediment.
Cystoscopy and retrograde pyelography revealed a nonobstructed enlarged right kidney. Open renal biopsy disclosed immature fat and benign mesenchymal elements. Four days postbiopsy the patient died of renal failure. Necropsy failed to reveal skin changes of tuberous sclerosis. The Ieft renal fossa contained no residual tumor. The right kidney was enlarged, 19 by 11 by 6 cm., yellow-gray and soft. A small hematoma was identified at the surgical biopsy site (Fig. 1A). The calyces, pelvis, and ureter were dilated. Small islands of pale tan parenchyma were interspersed among the dominant angiomyolipomatous mass. Histologically, the kidney was largely replaced by a mixture of fat, smooth muscle, and blood vessels of varying degrees of maturity with only scant islands of residual atrophic renal parenchyma (Fig. 1B). Fat cells varied from mature adult cells to
UROLOGY
I
APRIL 1978 / VOLUME
XI NUMBER 4
TABLEI.
Reported
cases of tuberous
sclerosis (T.S.) with renal failure
Reference
Clinical Evidence of T.S.
Age and Sex
1910"
Yes
28,M
Bilateral tumors presented in uremia; family history suggestive of T. S.
Cerebral T. S. bilateral angiomyolipoma
Golji, 1S613
Yes
. . .
One patient in mental institution with T.S. died of uremia
Bilateral angiomyolipoma
Schnitzer,
No
62,F
Nephrectomy 15 years previously for “benign tumor”; presented with uremia
Cerebral T. S. lesions; renal angiomyolipoma
Yes
31,F
Presented with uremia; treated with bilateral nephrectomy and allotransplantation
Bilateral angiomyolipoma and clear cell tumors
Anderson and Tannen, 1969
Yes
19,F
Presented age I4 months with enlarged kidneys; slow progression to uremia by age 19 years; bilateral cystic replacement of kidneys; treated with chronic hemodialysis
Biopsy one kidney consistent with angiomyolipoma
Chonko et al., 19744
No
22,F
Presented with uremia of 3 months’ duration; bilateral renal masses on x-ray and angiography; therapy - hemoclialysis
Biopsy - consistent with renal angiomyolipoma
Present case, 1975
No
55, F
Nephrectomy 21 years previously for angiomyolipoma; gradual onset of uremia
Angiomyolipoma of remaining kidney; cerebral glial nodules
Kirpicznik,
19635
Jochimsen, Braunstein, Najarian, 1969i2
and
bizarre lipoblasts. Blood vessels were of irregular size and shape with eccentric lumens and thick muscular walls. Identical hamartomatous tissue was observed in the lungs and liver. The brain weighed 1,300 Gm. The meninges were focally thickened. Coronal sections displayed multiple zones of effacement of gray matter by well-demarcated firm yellow-white plaques in both the cerebrum and cerebellum. The ventricular system was striking due to multiple nodular granular tuberosities with a subependymal distribution (Fig. 1C and D). Histologically, the cerebral nodules and subventricular plaques were composed of nodules of astrocytes and many gemistocytes. There was neither necrosis nor endothelial proliferation although calcified spherules were dispersed among the nodules. Similar tumors were observed in the cerebellum.
UROLOGY
/ APRIL1978 / VOLUMEXI
NUMBER4
Clinical Data
Pathology
Comment Tuberous sclerosis was first described in feeble-minded French children with extensive cutaneous lesions and uncontrollable epilepsy.6 Adenoma sebaceum and peculiar large sclerotic plaques of the cerebral cortex were considered characteristic. Primitive renal tumors, although also noted, were thought to be merely coincidental and unrelated. In 1942 Moolten’ proposed a unifying concept that tuberous sclerosis represented a “congenital developmental anomaly characterized by the occurrence of tumour-like malformations in various organs.” Although the most striking involvement occurred in ectodermal derived tissue, namely, brain, skin, retina, organs of mesodermal origin, that is the heart and kidneys, were also affected. The term “tuberous
391
sclerosis complex” was suggested to embrace the resultant variable clinicopathologic constellation. The renal hamartomas consist of mixtures of adipose tissue, smooth muscle, fibrous tissue, and blood vessels. The variable dominance of one element over another has been responsible for multiple designations such as angiomyolipoma, angiomyoma, angiolipoma, and angiofibromyolipoma. Presently, it is common knowledge that angiomyolipomas may be quite cellular and bizarre, and yet, pursue a benign course. This feature has only recently been appreciated. * The association of renal angiomyolipomas with tuberous sclerosis is controversial. Some authors consider them to represent a distinct component of tuberous sclerosis,9 while others believe there is a variable relationship between the tw~.“‘~ Nevertheless when the renal lesion is associated with tuberous sclerosis, it is usually bilateral, multiple, and asymptomatic, of little clinical consequence. In fact Golji,3 in reviewing 47 cases of tuberous sclerosis with renal tumors, concluded that the mere presence of tumor is insufficient indication for surgery since they rarely produce renal failure. Only 1 in 9 necropsied patients had renal failure. Indeed, extensive renal involvement with angiomyolipomatosis producing renal failure is rare as a recent review substantiated.4 Renal failure has been observed in tuberous sclerosis from age nineteen to sixty-two years, yet many of these patients were known to have clinical tuberous sclerosis with multiple organ involvement. Our case is but the seventh reported and only the third in which tuberous sclerosis was unsuspected (Table I). Moreover, it is of considerable interest considering the temporal relationships. Following unilateral nephrectomy for angiomyolipoma, over two decades elapsed before the remaining kidney was sufficiently involved to produce clinically overt renal failure, even though the remaining kidney was enlarged at the time of initial nephrectomy. Obviously, sufficient functional parenchyma was present at the time, however, over the years a constant loss of parenchyma followed. Presently, more instances of incomplete clinical expression of tuberous sclerosis are being
392
described in patients without classic cutaneous lesions and with minimal or absent manifestations of the central nervous system. The patient’s only clinical manifestation of tuberous sclerosis was unilateral renal angiomyolipomatosis, yet autopsy revealed a more extensive expression of the disease in multiple organs systems. This suggests that through long-term clinical observation and eventual necropsy a more precise significance can be ascribed to the patient with unilateral renal angiomyolipomatosis. In retrospect, our patient was noted to have an enlarged contralateral kidney at the time of initial nephrectomy. Since it is our impression that the incidence of bilaterality of this hamartomatous transformation is significant, perhaps these patients warrant more thorough investigation, including renal angiography. Since renal involvement is not always complete but may be partial in extent, surgical resection of the involved portion of kidney might be considered in the future evaluation of these patients. Valhalla, New York 10595 (DR. THELMO) References 1. Roth JC, and Epstein C: Infantile spasm and hypopigmented macules early manifestation of tuberous sclerosis, Arch. Neurol. 25: 547 (1971). 2. Anderson D, and Tannen R: Tuberous sclerosis and chronic renal failure, Am. J. Med. 47: 163 (1969). 3. Golji H: Tuberous sclerosis and renal neoplasms, J. Urol. 85: 919 (1961). 4. Chonko AM, Weiss SM, Stein JH, and Ferris TF: Renal involvement in tuberous sclerosis, Am. J. Med. 56: 124 (1974). 5. Schnitzer B: Tuberous sclerosis complex, Arch. Pathol. 76: 626 (1963). 6. Boumeville DM: Contribution a l’etude de l’idiotie, Arch. Neurol. 1: 69 (1880). 7. Moolten SE: Hamartial nature of the tuberous sclerosis complex and its bearing on the tumor problem, Arch. Intern. Med. 69: 589 (1912). 8. Price EB, and Mostofi FK: Symptomatic angiomyolipoma of the kidney, Cancer 18: 761 (1965). 9. Corssett AD, Jr: Roentgenographic findings in the renal lesion of tuberous sclerosis, Am. J. Roentgenol. 98: 739 (1966). 10. McQueeney AJ, Dahlen GA, and Gebhart WF: Cystic hamartoma (angiomyolipoma) of the kidney simulating renal carcinoma, J. Urol. 92: 98 (lQ64). 11. Kirpicznik J: Ein fall von Tuberoser Sklerose und Gleichzeitigen multiplen Nierengeschwulsten, Virchows Arch. Pathol. Anat. 292: 358 (1910). 12. Jochimsen PR, Braunstein PM, and Najarian JS: Renal allotransplantation for bilateral renal tumors, J.A.M.A. 210: 1721 (1969).
UROLOGY
/
APRIL 1978
/
VOLUME XI
NUMBER4