Tag: CLINICAL FEATURES

Interstitial Cystitis

INTERSTITIAL CYSTITIS


INTERSTITIAL CYSTITIS (HUNNER’S ULCER, ELUSIVE ULCER)

  • Inflammation of bladder mucosa is cystitis.
  • The characteristic linear bleeding ulcer is caused by splitting of mucosa when the bladder is distended under anaesthesia
  • Severe fibrosis along with inflammation of urinary bladder due to pancystitis results in small thimble bladder.
  • Ulceration of the mucosa occurs in fundus of bladder.
  • Mast cells are often seen in the mucosa, lamina propria, and muscularis propria in interstitial cystitis.
  • Decrease bladder capacity 30- 60 ml

CLINICAL FEATURES-

  • Increase frequency
  • Initial symptom- increase frequency and pain is relieved by micturition and aggrevated by distension of bladder due to decrease bladder capacity
  • Haematuria

INVESTIGATIONS-

  • Cystoscopy and biopsy confirms diagnosis

TREATMENT-

  • Hydrostatic dilatation
  • Instillation of dimethyl sulphoxide
  • Ranitine instillation
  • Ileocystoplasty or caecocystoplasty increases bladder capacity

Exam Important

  • Inflammation of bladder mucosa is cystitis.
  • The characteristic linear bleeding ulcer is caused by splitting of mucosa when the bladder is distended under anaesthesia
  • Severe fibrosis along with inflammation of urinary bladder due to pancystitis results in small thimble bladder.
  • Ulceration of the mucosa occurs in fundus of bladder.
  • Mast cells are often seen in the mucosa, lamina propria, and muscularis propria in interstitial cystitis.
  • Decrease bladder capacity 30- 60 ml
Don’t Forget to Solve all the previous Year Question asked on INTERSTITIAL CYSTITIS

Module Below Start Quiz

Interstitial Cystitis

Interstitial Cystitis

Q. 1 Cells involved in interstitial cystitis?

 A

Lymphocytes

 B

Neutrophils

 C

Macrophages

 D

Mast cells

Q. 1

Cells involved in interstitial cystitis?

 A

Lymphocytes

 B

Neutrophils

 C

Macrophages

 D

Mast cells

Ans. D

Explanation:

Ans. is ‘d’ i.e., Mast cells

  • Mast cells are often seen in the mucosa, lamina propria, and muscularis propria in interstitial cystitis.

Quiz In Between



Acute Prostatitis

ACUTE PROSTATITIS


ACUTE PROSTATITIS

  • Inflammation of prostate can be Acute or Chronic.

ETIOLOGY-

  • MC organism- E. Coli > staphylococcus aureus > staphylococcus albus
  • Instrumentation
  • Ascending and descending infection from below and above into infected urine into prostatic ducts
  • Haematogenous

CLINICAL FEATURES-

  • High grade fever, chills and rigors
  • Retention of urine
  • Perineal heaviness, pain on defaecation and micturition
  • Enlarged, tender and boggy protate- rectal examination
  • Catherization and prostatic massage is contraindicated  

INVESTIGATIONS-

  • USG abdomen 

TREATMENT-

  • IV fluids, antipyretics
  • Antibiotics- TMP- SMX, ciprofloxacin or norfloxacin (2- 3 weeks)
COMPLICATIONS
  • Seminal vasculitis

Exam Important

ETIOLOGY-

  • MC organism- E. Coli > staphylococcus aureus > staphylococcus albus
  • Instrumentation
  • Ascending and descending infection from below and above into infected urine into prostatic ducts
COMPLICATIONS
  • Seminal vasculitis
Don’t Forget to Solve all the previous Year Question asked on ACUTE PROSTATITIS

Module Below Start Quiz

Acute Prostatitis

Acute Prostatitis

Q. 1 Complication which commonly accompanies acute prostatitis –

 A

Epididymitis

 B

Orchitis

 C

Seminal vesiculitis

 D

Sterility

Q. 1

Complication which commonly accompanies acute prostatitis –

 A

Epididymitis

 B

Orchitis

 C

Seminal vesiculitis

 D

Sterility

Ans. C

Explanation:

Ans. is ‘c’ i.e., Seminal vesiculitis 

Quiz In Between



Paraphimosis

PARAPHIMOSIS


PARAPHIMOSIS

  • Inability to place back the retracted prepucial skin over the glans.
  • The retracted skin acts like a tight ring constricting proximal to the corona and prepuceal skin resulting in venous congestion.
  • Congestion results n glans swelling, oedematous with severe pain and tenderness.
  • Glans will undergo necrosis or gangrenous change.

ETIOLOGY

  • Catherization
  • After sexual intercourse

CLINICAL FEATURES-

  • Severe pain
  • Swelling and oedema

TREATMENT-

  • Sedation
  • Injection hyluronidase (250 units in 10- 15 ml of saline injected into constricting ring reduces oedema and paraphimosis also gets reduced)
  • Dorsal slit is given for reduction which is followed by circumcision later.

Exam Important

  • Inability to place back the retracted prepucial skin over the glans.
  • The retracted skin acts like a tight ring constricting proximal to the corona and prepuceal skin resulting in venous congestion.
  • Congestion results n glans swelling, oedematous with severe pain and tenderness.
  • Glans will undergo necrosis or gangrenous change.

TREATMENT-

  • Sedation
  • Injection hyluronidase (250 units in 10- 15 ml of saline injected into constricting ring reduces oedema and paraphimosis also gets reduced)
  • Dorsal slit is given for reduction which is followed by circumcision later.
Don’t Forget to Solve all the previous Year Question asked on PARAPHIMOSIS

Module Below Start Quiz

Paraphimosis

Paraphimosis

Q. 1 Not true about paraphimosis is –

 A

Iatrogenic

 B

Seen in Diabetes mellitus

 C

Gangrene of glans

 D

Circumcision is the t/t

Q. 1

Not true about paraphimosis is –

 A

Iatrogenic

 B

Seen in Diabetes mellitus

 C

Gangrene of glans

 D

Circumcision is the t/t

Ans. B

Explanation:

Ans is ‘b’ ie Seen in Diabetes mellitns 

  • Diabetes mellitus has no role in paraphimosis.

Paraphimosis

  • Etiology: When a prepuce is forcibly retracted over the glans penis, it may get stuck behind the glans. This condition is k/a paraphimosis.
  • Pathology –>

This constricting band of phimotic prepuce causes obstruction to the venous flow, which lead to edema and congestion of the glans.

The glans swells leading to more difficulty in retracting back the prepuce.

In neglected cases gangrene may result.

  • Treatment —>
  • Ice bags, gentle manual compression and injection of a solution of hyaluronidase in normal saline may help to reduce the swelling.
  • If conservative method fails then the pt. can be t/t by circumcision*.

A dorsal slit of the prepuce under local anaesthetic may be enough in an emergency

  • It is uncommon for the urethra to be compressed, so the micturition is normally not affected.

Q. 2 About Paraphimosis true is :

 A

Catheter induced

 B

Circumcision is treatment

 C

Hyaluronidase inj

 D

All of the above

Q. 2

About Paraphimosis true is :

 A

Catheter induced

 B

Circumcision is treatment

 C

Hyaluronidase inj

 D

All of the above

Ans. D

Explanation:

Ans. is ‘d’ i.e. All of the above 
Paraphimosis may be produced when during catheterization the prepuce is forcibly retracted over gland penis. 

Quiz In Between



Peyronie’s Disease

PEYRONIE’S DISEASE


PEYRONIE’S DISEASE (PENILE FIBROMATOSIS/ INDURATION- PENIS PLASTICA)

  • It is a development of fibrous tissue plaque on the covering of corpus cavernosum involving tunica albuginea which may later calcify or ossify.
  • Palmar fibromatosis + plantar fibromatosis + penile fibromatosis = superficial fibromatosis

ETIOLOGY

  • Associated with-

a) Dupuytren’s contracture (plamar fibromatosis)

b) Retroperitoneal fibrosis

c) Plantar facitis

  • Trauma
  • Venereal disease

CLINICAL FEATURES-

  • Painful erection, curvature of penis and poor erection distal to involved area
  • Palpable induration or mass present on dorsolateral aspect of the penis
  • Later erectile dysfunction, penile shortening
  • Indurated plaque in the penis
  • Spontaneous regression occurs in 50% of the cases.

 

TREATMENT-

  1. Drugs- steroids, Vitamin E, tsmoxifen, terfenadine and fexafenadine (not very effective)
  2. Intralesional injection- verapamil
  3. Surgery-

a) Excision and placation to opposite side- fitzpatric

b) Multiple incisions over fibrous plaque and temporal fascia bridging- Gelhard’s operation

Exam Important

ETIOLOGY

  • Associated with-

a) Dupuytren’s contracture (plamar fibromatosis)

b) Retroperitoneal fibrosis

c) Plantar facitis

  • Trauma
  • Venereal disease

CLINICAL FEATURES-

  • Painful erection, curvature of penis and poor erection distal to involved area
  • Palpable induration or mass present on dorsolateral aspect of the penis
  • Later erectile dysfunction, penile shortening
  • Indurated plaque in the penis
  • Spontaneous regression occurs in 50% of the cases.

TREATMENT-

  1. Drugs- steroids, Vitamin E, tsmoxifen, terfenadine and fexafenadine (not very effective)
  2. Intralesional injection- verapamil
  3. Surgery-

a) Excision and placation to opposite side- fitzpatric

b) Multiple incisions over fibrous plaque and temporal fascia bridging- Gelhard’s operation

Don’t Forget to Solve all the previous Year Question asked on PEYRONIE’S DISEASE

Module Below Start Quiz

Peyronie’s Disease

Peyronie disease

Q. 1

The following statements are true about Peyronie’s disease except –

 A Pt. presents with complaints of painful erection

 B

Condition affects adolescent males

 C

The condition can be associated with Dupuytren’s contracture of the tendon of the hand.

 D

Spontaneous regression occurs in 50% of the cases.

Q. 1

The following statements are true about Peyronie’s disease except –

 A

Pt. presents with complaints of painful erection

 B

Condition affects adolescent males

 C

The condition can be associated with Dupuytren’s contracture of the tendon of the hand.

 D

Spontaneous regression occurs in 50% of the cases.

Ans. B

Explanation:

Ans is (b) i.e. Condition affects adolescent males

  • Peyronie’s disease is usually seen over 40 years of age
  • Important points about Peyronie’s disease
  • It is also k/a penile fibromatosis
  • It is due to fibrous plaques in one or both corpus cavernosum.They may later calcify or ossify.
  • Fibrous plaques lead to pain and curvature of the penis on erection
  • Palpable induration or mass appears usually on the dorsolateral aspect of the penis.
  • Palmar fibromatosis (Dupuytren’s contracture), plantar fibromatosis and penile fibromatosis (Peyronie’s ds.) are components of the same pathological process called superficial fibromatosis.
  • The aetilogy is uncertain, but it may be a result of past trauma.
  • Treatment is difficult but some cases may show spontaneous regression. Medical treatments are often ineffective.
  • If the penile deformity is distressing, Nesbitt’s operation can be performed to straighten the penis

Q. 2

All are true about Peyronie’s disease except ‑

 A Self limiting

 B

Medical treatment is effective

 C

Association with Dupytren’s contracture

 D

Calcified plaques

Q. 2

All are true about Peyronie’s disease except ‑

 A

Self limiting

 B

Medical treatment is effective

 C

Association with Dupytren’s contracture

 D

Calcified plaques

Ans. B

Explanation:

Ans. is `b’ i.e., Medical treatment is effective 


Q. 3

Peyronie’s disease affects the –

 A

Breast

 B

Vagina

 C

Scrotum

 D

Penis

Q. 3

Peyronie’s disease affects the –

 A

Breast

 B

Vagina

 C

Scrotum

 D

Penis

Ans. D

Explanation:

Ans. is ‘d’ i.e., Penis 

Quiz In Between



Carcinoma Of Penis

CARCINOMA OF PENIS


CARCINOMA OF PENIS

  • MC type – SCC

ETIOLOGY-

  1. Premalignant lesions-
  • Genital warts- Bushke- Lowenstein tumour is a giant penile condyloma (verrucous carcinoma of penis)
  • Erythroplasia of Queyrat or Paget’s disease of penis- precancerous lesion
  • Leukoplakia of glans
  • Bowen’s disease- small eczematous plaque
  • Chronic balanoposthitis, phimosis (50%), Balanitis xerotica obliterans
  • Condyloma auminata (HPV)
  • Most important carcinogens- HPV (16, 18, 31, 33)
  • Poor hygiene

PATHOLOGY-

  1. Infiltrating type- pre-existing leukoplakia
  2. Papilliferous type
  3. Ulcerative type- glans penis MC site. 80% are low grade tumours

SPREAD-

  1. Lymphatics-
  • Spreads to horizontal group of inguinal lymph nodes and are nodular, hard, fixed which suggests metstasis.
  • Carcinoma from shaft of penis spreads to external iliac LN
  • Initernal and paraaortic LN get enlarged

2. Blood spread is rare

3. Death may occur due to erosions of femoral vessels by iguinal LN.

CLINICAL FEATURES-

  • Occurs in 6th decade
  • Neonatal circumcision helps in immunity against carcinoma penis, HIV or STD.
  • MC orginates from glans > sulcus > prepuce > shaft
  • Foul smelling discharge is common
  • In adults, recent onset of phimosis
  • Haematuria, pain while passing urine- advanced tumours
  • On examination, fungation and induration, everted edge
  • Pain, oedema, tenderness, redness present on infection
  • Urethra is rarely involved as it is protected by tough Buck’s fascia

 

INVESTIGATIONS-

  • Incisional biopsy for grade and depth of invasion and wedge biopsy for SCC
  • Senitel LN biopsy (Cabana sentinel LN)
  • USG- assessment of depth
  • MRI- IOC for staging in CA penis

STAGING-

  1. Stage 1- Confined to glans or prepuce
  2. Stage 2- involving penile shaft or copora cavernosa
  3. Stage 3- Operable inguinal LN metastasis
  4. Stage 4- inoperable inguinal LN metastasis Or advanced spread

TNM STAGING 

TREATMENT-

  • Surgery is the TOC
  • Ca in situ- topical 5- FU cream, Nd- YAG laser, radiotherapy + follow up
  • Ca in situ
  • Young’s operation- for glans involvement without extending into proximal part of shaft
  • Total amputation with perineal urethrostomy- if shaft is involved
  • Piersey Gold operation- total amputation + total scrotectomy + total orchidectomy
  • Laser ablation- stage T1 tumour
  • Enlarged inguinal node- block dissection

Exam Important

  • MC type – SCC

ETIOLOGY-

  1. Premalignant lesions-
  • Genital warts- Bushke- Lowenstein tumour is a giant penile condyloma (verrucous carcinoma of penis)
  • Erythroplasia of Queyrat or Paget’s disease of penis- precancerous lesion
  • Leukoplakia of glans
  • Bowen’s disease- small eczematous plaque
  • Chronic balanoposthitis, phimosis (50%), Balanitis xerotica obliterans
  • Condyloma auminata (HPV)
  • Most important carcinogens- HPV (16, 18, 31, 33)
  • Poor hygiene

SPREAD-

1. Lymphatics-

  • Spreads to horizontal group of inguinal lymph nodes and are nodular, hard, fixed which suggests metstasis.
  • Carcinoma from shaft of penis spreads to external iliac LN
  • Initernal and paraaortic LN get enlarged

2. Blood spread is rare

3. Death may occur due to erosions of femoral vessels by iguinal LN. 

CLINICAL FEATURES-

  • Occurs in 6th decade
  • Neonatal circumcision helps in immunity against carcinoma penis, HIV or STD.
  • MC orginates from glans > sulcus > prepuce > shaft
  • Foul smelling discharge is common
  • In adults, recent onset of phimosis
  • Haematuria, pain while passing urine- advanced tumours
  • On examination, fungation and induration, everted edge
  • Pain, oedema, tenderness, redness present on infection
  • Urethra is rarely involved as it is protected by tough Buck’s fascia

TREATMENT-

  • Surgery is the TOC
  • Ca in situ- topical 5- FU cream, Nd- YAG laser, radiotherapy + follow up
  • Ca in situ
  • Young’s operation- for glans involvement without extending into proximal part of shaft
  • Total amputation with perineal urethrostomy- if shaft is involved
  • Piersey Gold operation- total amputation + total scrotectomy + total orchidectomy
  • Laser ablation- stage T1 tumour
  • Enlarged inguinal node- block dissection
Don’t Forget to Solve all the previous Year Question asked on CARCINOMA OF PENIS

Module Below Start Quiz

Carcinoma Of Penis

Carcinoma Penis

Q. 1 Carcinoma penis is rarest among –

 A

Americans

 B

Indians

 C

Swedes

 D

Jews

Q. 1

Carcinoma penis is rarest among –

 A

Americans

 B

Indians

 C

Swedes

 D

Jews

Ans. D

Explanation:

Ans. is `d’ i.e., Jews

Carcinoma of penis

  • Penile cancer is a malignant growth found on the skin or in the tissue of penis.
  • Circumcision confers protection hence, this cancer is extremely rare among jews and moslems and is correspondingly more common in populations in which circumcision is not routinely practiced. Predisposing factors : – 

 Smoking    

  • Infection with HPV16 and HPV- 18
  • Presence of pre-cancerous lesion —> Bowen disease.

Q. 2 Not true about carcinoma penis is –

 A

Erythroplasia of Queret is a precancerous condition

 B

40% of pts are under 40 year of age

 C

Circumcision if done any time before puberty provides 100% protection against carcinoma penis

 D

More than 50% pt. have inguinal 1.n enlargement when they present

Q. 2

Not true about carcinoma penis is –

 A

Erythroplasia of Queret is a precancerous condition

 B

40% of pts are under 40 year of age

 C

Circumcision if done any time before puberty provides 100% protection against carcinoma penis

 D

More than 50% pt. have inguinal 1.n enlargement when they present

Ans. C

Explanation:

Ans. ie ‘c’ ie Circumcision if done any time before puberty provides 100% protection 

  • The circumcision that is done soon after birth in infancy gives almost complete immunity against Ca penis; but that done later in life does not have the same effect, so Muslims circumcised between the ages of 4 and 9 years are still liable to the disease.
  • About Ca Penis

Most common histological type is –> sq. cell Ca (98%)

Erythroplasia of Queret is precancerous condition. It’s the in-situ form of Ca Penis.

[Carcinoma in situ of the penis is called Erythroplasia of Queyrat if it involves the glans penis, prepuce or penile shaft, and is called Bowen’s disease if it involves the remainder of the genitalia or perinea! region” – Cambell’s Urology 8/e, p 2950]

  • Premalignant lesions of Ca Penis

a.          Penile cutaneous horn
b.          Balanitis xerotica obliterans
c.          Leukoplakia
d.          Viral (Human papilloma virus) related Dermatologic lesion

– Condyloma acuminata (also k/a genital warts)

– Bowenoid papulori

  • The one etiological factor most commonly associated with penile carcinoma is poor hygine.
  • Clinical features
  • Age – Penile Ca occurs most commonly in the sixth decade of life, but its presentation in younger age group is not uncommon (“40% of pts are under 40 years of age” – Bailey)
  • Most common complaint at presentation is the lesion itself. Pain is rare.
  • Most common site of involvement (% from Cambell’s Urology 8/e, p 2953)

Glans

—>

-48%

Prepuce

—>

-21%

Both Glans & Prepuce

-4

9%

Coronal sulcus

 

-6%

Shaft

—>

-2%

  • Lymph node involvement

More than 50% of patients present with enlarged inguinal lymph nodes (but half of these are reactive enlargement d/t sepsis).

–  The presence and the extent of metastasis to the inguinal region is the most important prognostic factor for survival in patients with Ca Penis.

  • Distant metastasis is infrequent
  • Diagnosis is made by biopsy of lesion.
  • Treatment is discussed ahead.

Q. 3

Cause of death in Carcinoma penis is usually –

 A Metastasis to lung

 B

Metastasis to liver

 C

Erosion of Femoral blood vessels

 D

Urinary obstruction

Q. 3

Cause of death in Carcinoma penis is usually –

 A

Metastasis to lung

 B

Metastasis to liver

 C

Erosion of Femoral blood vessels

 D

Urinary obstruction

Ans. C

Explanation:

Ans. is ‘c’ i.e., Erosion of femoral blood vessels 

Inguinal lymph nodes erode the skin of the groin and the death of the patient may be due to involvement of the femoral or external iliac artery with torrential haemorrhage.

Quiz In Between


Q. 4 What is true about carcinoma penis – 

 A

Metastasis is rare

 B

Occurs more commonly in circumcised male

 C

Arises from corona of glans

 D

Pain is frequent

Q. 4

What is true about carcinoma penis – 

 A

Metastasis is rare

 B

Occurs more commonly in circumcised male

 C

Arises from corona of glans

 D

Pain is frequent

Ans. C

Explanation:

Ans. is ‘c’ i.e., Arises from corona of glans 

  • As already mentioned persons circumcised at birth or soon after are immune to Ca Penis.
  • Metastasis to lymph nodes is quite common. Distant metastasis occurs in less than 10% of pts.
  • MC site is glans penis
  • Pain is infrequent
  • Bailey writes – “There is little or no pain”

Q. 5

Features of carcinoma penis are all EXCEPT:

March 2013

 A

Circumcision soon after birth provides total immunity

 B

Pagets disease is not a premalignant disease

 C

Metastasis to inguinal nodes

 D

Surgery is treatment of choice

Q. 5

Features of carcinoma penis are all EXCEPT:
March 2013

 A

Circumcision soon after birth provides total immunity

 B

Pagets disease is not a premalignant disease

 C

Metastasis to inguinal nodes

 D

Surgery is treatment of choice

Ans. B

Explanation:

Ans. B i.e. Pagets disease is not a premalignant disease

Quiz In Between


Q. 6

Features of carcinoma penis include all except:
March 2007

 A

Metastasize to inguinal lymph nodes

 B

Surgery is the treatment of choice

 C

Hypospadias is a premalignant lesion

 D

Circumcision provides protection

Q. 6

Features of carcinoma penis include all except:
March 2007

 A

Metastasize to inguinal lymph nodes

 B

Surgery is the treatment of choice

 C

Hypospadias is a premalignant lesion

 D

Circumcision provides protection

Ans. C

Explanation:

Ans. C: Hypospadias is a premalignant lesion

Following as risk factors for penile cancer:

Human papillomavirus (HPV) infection, smoking, smegma, phimosis, treatment of psoriasis, age, and AIDS. The other etiologic factor most commonly associated with penile carcinoma is poor hygiene. Lichen sclerosus (also known as balanitis xerotica obliterans) may also be a risk factor.

Symptoms

Redness, irritation and a sore or a lump on the penis.

Pathology

  • Precancerous Dermatologic Lesions
  • Carcinoma in Situ (Bowen Disease, Erythroplasia of Queyrat)
  • Invasive Carcinoma of the Penis

A Squamous cell carcinoma usually originating in the glans or foreskin is by far the most common type, occurring in 9 out of 10 cases.

Staging

The stages are assessed as follows:

  • Stage I – Cancer has only affected the glans and/or foreskin.
  • Stage II – Cancer has spread to the shaft of the penis.
  • Stage III – Cancer has affected the penis and surrounding lymph nodes.
  • Stage IV – Cancer has moved beyond the groin area to other parts of the body.
  • Recurrent – Cancer that has returned after treatment.

The most common treatment is one of five types of surgery:

  • Wide local excision – The tumor and some surrounding healthy tissue are removed
  • Microsurgery – Surgery performed with a microscope is used to remove the tumor and as little healthy tissue as possible
  • Laser surgery – laser light is used to burn or cut away cancerous cells
  • Circumcision – cancerous foreskin is removed
  • Amputation (penectomy) – a partial or total removal of the penis, and possibly the associated lymph nodes. This is the most common and effective treatment.

Radiation therapy is usually used adjuvantly with surgery to reduce the risk of recurrence.

With earlier stages of penile cancer, a combination of topical chemotherapy and less invasive surgery may be used. More advanced stages of penile cancer usually require a combination of surgery, radiation and chemotherapy.


Q. 7 All of the following are features of carcinoma penis Except:        
March 2005

 A

Surgery is the treatment of choice

 B

Balanoposthitis may be a predisposing factor

 C

Metastaizes to inguinal nodes

 D

Histologically a transitional cell carcinoma

Q. 7

All of the following are features of carcinoma penis Except:        
March 2005

 A

Surgery is the treatment of choice

 B

Balanoposthitis may be a predisposing factor

 C

Metastaizes to inguinal nodes

 D

Histologically a transitional cell carcinoma

Ans. D

Explanation:

Ans. D: Histologically a transitional cell carcinoma

Penile squamous cell carcinoma, the most common penile malignancy, behaves similarly to squamous cell carcinoma in other parts of the skin.

Chronic balanoposthitis is known to be a contributory factor for penile carcinoma.

Metastasis, which is possible with this type of carcinoma, is often lethal.

Quiz In Between



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