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Dominicis ED, Marella GL, Giuga G, Ceccobelli G, Savino L, Tavone AM. Autopsy findings of fatal retroperitoneal hemorrhage after traumatic rupture of bilateral renal angiomyolipoma. Autops Case Rep 2024; 14:e2024482. [PMID: 38562647 PMCID: PMC10984609 DOI: 10.4322/acr.2024.482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/28/2024] [Indexed: 04/04/2024]
Abstract
The present work reports the autopsy findings of a unique case characterized by fatal retroperitoneal hemorrhage following the traumatic rupture of bilateral renal angiomyolipomas. Renal angiomyolipomas are generally benign tumors with an unpredictable clinical course, ranging from asymptomatic to sudden rupture and hemorrhagic shock. They may be associated with genetic disorders such as tuberous sclerosis complex. The case under investigation is unprecedented in the medical literature due to its bilateral nature and fatal outcome. Autopsy analysis revealed an extensive retroperitoneal hemorrhage originating from bilateral ruptured tumors. Microscopic examination found features consistent with bilateral renal angiomyolipoma. Circumstantial information identified a traffic accident before the death, considering it as the cause of the tumors' traumatic rupture. In this case, due to the severity of the situation, immediate medical measures-such as fluid resuscitation, coagulopathy correction, and surgical treatment, which are usually lifesaving-could not be performed. This led to the patient being declared dead at the scene of the crash.
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Affiliation(s)
| | - Gian Luca Marella
- University of Rome Tor Vergata, Department of Surgical Sciences, Rome, Italy
| | - Gabriele Giuga
- University of Rome Tor Vergata, Department of Biomedicine and Prevention, Rome, Italy
| | - Giulia Ceccobelli
- University of Rome Tor Vergata, Department of Biomedicine and Prevention, Rome, Italy
| | - Luca Savino
- University of Rome Tor Vergata, Department of Biomedicine and Prevention, Rome, Italy
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Cong X, Zhang J, Xu X, Zhang M, Chen Y. Renal epithelioid angiomyolipoma: magnetic resonance imaging characteristics. Abdom Radiol (NY) 2018. [PMID: 29525877 DOI: 10.1007/s00261-018-1548-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The aim of the study was to analyze MR imaging features of renal epithelioid angiomyolipoma (EAML). METHODS This study included 17 patients with histopathologically confirmed renal EAML who underwent renal MRI scanning before radical or partial nephrectomy. MR images were retrospectively reviewed and correlated with pathological findings. RESULT Fifteen lesions (88.2%) appeared as round or oval. The tumor-kidney interface was round in 14 lesions (82.4%). Fifteen tumors (88.2%) presented mainly isointensity on T1WI, and eleven tumors (64.7%) presented mainly hypointensity on T2WI. Twelve lesions (70.6%) showed restricted diffusion on DWI, and the mean ADC value was 1.23 ± 0.28 × 10-3mm2/s. Minimal fat component was identified as loss of signal intensity on opposed-phase MR images in 6 cases (35.3%). Sixteen lesions (100%) demonstrated inhomogeneous enhancement, and 7 of 16 masses (43.8%) showed reticular enhancement. Rapid wash-in and wash-out enhancement was seen in 13 masses (81.3%). In the corticomedullary phase, the mass showed markedly enhancement in 14 cases (87.5%). The irregular vessels and hemorrhage were detected in 4 cases (23.5%) and 7 cases (41.2%), respectively. One patient (5.9%) had a lymph node involvement at initial diagnosis, and showed distant metastasis after operation. In the immunohistochemical analysis, 15 tumors (88.2%) were positive for melanocytic marker (HMB45 or Melan-A), and all cases (100%) were negative for epithelial-associated markers (CK or AE1/AE3). CONCLUSION The presence of hypointensity on T2WI, restricted diffusion on DWI, round tumor-kidney interface, reticular, and marked enhancement (rapid wash-in and wash-out) should further raise suspicion for renal EAML. The diagnosis may be confirmed by pathological analysis.
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Affiliation(s)
- Xinying Cong
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
- China Rehabilitation Research Center, Beijing, 100068, China
| | - Jin Zhang
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Xiaojuan Xu
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Miaomiao Zhang
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Yan Chen
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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Jinzaki M, Silverman SG, Akita H, Mikami S, Oya M. Diagnosis of Renal Angiomyolipomas: Classic, Fat-Poor, and Epithelioid Types. Semin Ultrasound CT MR 2016; 38:37-46. [PMID: 28237279 DOI: 10.1053/j.sult.2016.11.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
With the increasing discovery of small renal masses with cross-sectional imaging, there has been the concomitant rise in their treatment. With the intent of early curative surgery for a presumed renal cell carcinoma, many renal masses are being resected at surgery without a confirmed diagnosis. Many of them are benign, and some are angiomyolipomas. The diagnosis of renal angiomyolipoma using imaging is, therefore, is as important as ever. Although most, if not all angiomyolipomas with abundant fat are diagnosed readily, some have too little fat to be detected with imaging. This article reviews the current classification, imaging pitfalls, and diagnosis of angiomyolipoma with an emphasis on the fat-poor types. Proper imaging technique, a thorough search for fat, and the appropriate use of percutanoeus biopsy are all needed to eliminate the unnecessary treatment of these benign neoplasms.
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Affiliation(s)
- Masahiro Jinzaki
- Department of Diagnostic Radiology, Keio University School of Medicine, Tokyo, Japan.
| | | | - Hirotaka Akita
- Department of Diagnostic Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Shuji Mikami
- Department of Diagnostic Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Mototsugu Oya
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
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Kobari Y, Takagi T, Kondo T, Tachibana H, Iida S, Nishina Y, Omae K, Morita S, Yamamoto T, Iizuka J, Nagashima Y, Tanabe K. Fat-poor angiomyolipoma with cyst-like changes mimicking a cystic renal cell carcinoma: a case report. World J Surg Oncol 2015; 13:251. [PMID: 26282684 PMCID: PMC4539965 DOI: 10.1186/s12957-015-0677-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 08/09/2015] [Indexed: 01/22/2023] Open
Abstract
Angiomyolipoma is a common benign renal tumor. It is typically composed of adipose tissue and hence is easily diagnosed by using imaging methods such as ultrasonography, computed tomography, and magnetic resonance imaging. However, it is difficult to differentiate an atypical angiomyolipoma such as a fat-poor angiomyolipoma from a malignant tumor by using these imaging methods. We report a case of a fat-poor angiomyolipoma with cyst-like changes in a 35-year-old man. The angiomyolipoma was initially suspected to be a cystic renal cell carcinoma according to preoperative imaging studies. A 5-cm cystic tumor with an enhanced septal wall and exophytic formation was present in the middle section of the left kidney. The patient underwent partial nephrectomy. Pathological findings showed necrosis and hematoma in almost the entire lesion, with a small amount of adipose and muscle tissue. Finally, a fat-poor angiomyolipoma was diagnosed.
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Affiliation(s)
- Yuki Kobari
- Department of Urology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Toshio Takagi
- Department of Urology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Tsunenori Kondo
- Department of Urology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Hidekazu Tachibana
- Department of Urology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Shoichi Iida
- Department of Urology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Yu Nishina
- Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, Tokyo, Japan.
| | - Kenji Omae
- Department of Urology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Satoru Morita
- Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, Tokyo, Japan.
| | - Tomoko Yamamoto
- Department of Surgical Pathology, Tokyo Women's Medical University, Tokyo, Japan.
| | - Junpei Iizuka
- Department of Urology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Yoji Nagashima
- Department of Surgical Pathology, Tokyo Women's Medical University, Tokyo, Japan.
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
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Jinzaki M, Silverman SG, Akita H, Nagashima Y, Mikami S, Oya M. Renal angiomyolipoma: a radiological classification and update on recent developments in diagnosis and management. ACTA ACUST UNITED AC 2015; 39:588-604. [PMID: 24504542 PMCID: PMC4040184 DOI: 10.1007/s00261-014-0083-3] [Citation(s) in RCA: 213] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Angiomyolipoma is the most common benign solid renal neoplasm observed in clinical practice. Once thought to be a hamartoma and almost always diagnosed by the imaged-based detection of fat, angiomyolipomas are now known to consist of a heterogeneous group of neoplasms. Although all are considered perivascular epithelioid cell tumors, many display different pathology, imaging features, and clinical behavior. The importance of understanding this group of neoplasms is emphasized by the fact that many types of angiomyolipoma contain little to no fat, and despite being benign, sometimes escape a pre-operative diagnosis. These types of angiomyolipomas can all be considered when encountering a renal mass that is both hyperattenuating relative to renal parenchyma on unenhanced CT and T2-hypointense, features that reflect their predominant smooth muscle component. We review recent developments and provide a radiological classification of angiomyolipomas that helps physicians understand the various types and learn how to both diagnose and manage them.
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Affiliation(s)
- Masahiro Jinzaki
- Department of Diagnostic Radiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan,
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Schieda N, Kielar AZ, Al Dandan O, McInnes MDF, Flood TA. Ten uncommon and unusual variants of renal angiomyolipoma (AML): radiologic-pathologic correlation. Clin Radiol 2014; 70:206-20. [PMID: 25468637 DOI: 10.1016/j.crad.2014.10.001] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Revised: 09/26/2014] [Accepted: 10/06/2014] [Indexed: 12/22/2022]
Abstract
Classic (triphasic) renal angiomyolipoma (AML) is currently classified as a neoplasm of perivascular epithelioid cells. For diagnosis of AML, the use of thin-section non-contrast enhanced CT (NECT) improves diagnostic accuracy; however, identifying gross fat within a very small AML is challenging and often better performed with chemical-shift MRI. Although the presence of gross intra-tumoural fat is essentially diagnostic of AML; co-existing intra-tumoural fat and calcification may represent renal cell carcinoma (RCC). Differentiating AML from retroperitoneal sarcoma can be difficult when AML is large; the feeding vessel and claw signs are suggestive imaging findings. AML can haemorrhage, with intra-tumoural aneurysm size >5 mm a more specific predictor of future haemorrhage than tumor size >4 cm. Diagnosis of AML in the setting of acute haemorrhage is complex; comparison studies or follow-up imaging may be required. Not all AML contain gross fat and imaging features of AML without visible fat overlap with RCC; however, homogeneity, hyperdensity at NECT, low T2-weighted signal intensity and, microscopic fat are suggestive features. Patients with tuberous sclerosis often demonstrate a combination of classic and minimal fat AML, but are also at a slightly increased risk for RCC and should be imaged cautiously. Several rare pathological variants of AML exist including AML with epithelial cysts and epithelioid AML, which have distinct imaging characteristics. Classic AML, although benign, can be locally invasive and the rare epithelioid AML can be frankly malignant. The purpose of this review is to highlight the imaging manifestations of 10 uncommon and unusual variants of AML using pathological correlation.
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Affiliation(s)
- N Schieda
- Department of Radiology, The Ottawa Hospital, The University of Ottawa, Civic Campus C1 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada.
| | - A Z Kielar
- Department of Radiology, The Ottawa Hospital, The University of Ottawa, Civic Campus C1 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada
| | - O Al Dandan
- Department of Radiology, King Fahad Hospital, University of Dammam, Al Aqrabiyah, Al Khobar 31952, Saudi Arabia
| | - M D F McInnes
- Department of Radiology, The Ottawa Hospital, The University of Ottawa, Civic Campus C1 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada
| | - T A Flood
- Division of Anatomical Pathology, The Ottawa Hospital, The University of Ottawa, 501 Smyth Road, 4th Floor CCW, Room 4278, Ottawa, Ontario K1Y 4E9, Canada
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Jinzaki M, Silverman SG, Akita H, Nagashima Y, Mikami S, Oya M. Renal angiomyolipoma: a radiological classification and update on recent developments in diagnosis and management. ABDOMINAL IMAGING 2014. [PMID: 24504542 DOI: 10.1007/s00261-014-0083-3.pubmedpmid:24504542;pubmedcentralpmcid:pmc4040184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Angiomyolipoma is the most common benign solid renal neoplasm observed in clinical practice. Once thought to be a hamartoma and almost always diagnosed by the imaged-based detection of fat, angiomyolipomas are now known to consist of a heterogeneous group of neoplasms. Although all are considered perivascular epithelioid cell tumors, many display different pathology, imaging features, and clinical behavior. The importance of understanding this group of neoplasms is emphasized by the fact that many types of angiomyolipoma contain little to no fat, and despite being benign, sometimes escape a pre-operative diagnosis. These types of angiomyolipomas can all be considered when encountering a renal mass that is both hyperattenuating relative to renal parenchyma on unenhanced CT and T2-hypointense, features that reflect their predominant smooth muscle component. We review recent developments and provide a radiological classification of angiomyolipomas that helps physicians understand the various types and learn how to both diagnose and manage them.
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Affiliation(s)
- Masahiro Jinzaki
- Department of Diagnostic Radiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan,
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Bishay VL, Crino PB, Wein AJ, Malkowicz SB, Trerotola SO, Soulen MC, Stavropoulos SW. Embolization of giant renal angiomyolipomas: technique and results. J Vasc Interv Radiol 2010; 21:67-72. [PMID: 20123192 DOI: 10.1016/j.jvir.2009.09.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2009] [Revised: 09/11/2009] [Accepted: 09/27/2009] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To evaluate the efficacy and safety of prophylactic embolization of angiomyolipomas (AMLs) larger than 10 cm. MATERIALS AND METHODS Sixteen patients (mean age, 41.2 years; 14 women and two men) underwent embolization for 23 AMLs larger than 10 cm. All lesions were embolized by using microcatheters with ethanol and ethiodized oil mixed to a ratio of 7(ethanol) to 3(ethiodized oil). Data collected included pre- and posttreatment AML size, creatinine level, technical success, volume of embolic material used, clinical success, and complications. RESULTS The mean AML size before treatment was 15 cm (range, 10-25 cm). Ten of the 16 patients (62%) had all their AMLs treated in one session, whereas six (38%) required multiple sessions. A mean volume of 8.6 mL of the ethanol-ethiodized oil mixture (range, 2-20 mL) was administered per lesion. Patients were followed up for a mean of 29 months (range, 1-80 months). No patient had an increase of 0.2 mg/dL (17.7 mumol/L) or greater in mean serum creatinine level during the follow-up period. Two of the 16 patients (12%) required repeat embolization due to AML regrowth (n = 1) or reperfusion (n = 1) seen at surveillance imaging. One of the 16 patients (6.2%) had an AML hemorrhage 59 months after AML embolization. CONCLUSIONS Embolization of giant renal AMLs to decrease the risk of bleeding can be done safely without loss of renal function. Although recurrence was infrequent, additional treatment may be necessary and giant renal AMLs should be followed up with serial imaging studies.
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Affiliation(s)
- Vivian L Bishay
- Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Yamakado K, Tanaka N, Nakagawa T, Kobayashi S, Yanagawa M, Takeda K. Renal angiomyolipoma: relationships between tumor size, aneurysm formation, and rupture. Radiology 2002; 225:78-82. [PMID: 12354988 DOI: 10.1148/radiol.2251011477] [Citation(s) in RCA: 271] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE To evaluate the relationships between tumor size, aneurysm formation, and spontaneous rupture in renal angiomyolipomas. MATERIALS AND METHODS Twenty-three patients with renal angiomyolipoma were examined with angiography and computed tomography (CT). The single largest lesion in each kidney was evaluated. Tumor size was measured at CT, and aneurysm size was measured at renal angiography. Tumor and aneurysm sizes were compared between the group with ruptured angiomyolipoma and the group with unruptured angiomyolipoma. Multiple regression analysis was performed to identify factors affecting rupture. RESULTS Twenty-nine kidneys with angiomyolipoma were identified. Eight angiomyolipomas were hemorrhagic; the remaining 21 were not hemorrhagic. Tumor size was larger than 4 cm and aneurysm size was 5 mm or larger in all hemorrhagic lesions. There were significant differences in mean tumor size (11.4 cm +/- 5.5 [SD] vs 5.0 cm +/- 3.1, P <.02) and mean aneurysm size (13.3 mm +/- 6.2 vs 2.4 mm +/- 2.9, P <.02) between the ruptured and unruptured tumor groups. When tumor size of 4 cm or larger and aneurysm size of 5 mm or larger were used as predictors of rupture, sensitivity and specificity, respectively, were 100% and 38% with the former criterion and 100% and 86% with the latter criterion. Multiple regression analysis indicated that aneurysm size was the most important factor linked to rupture. CONCLUSION Aneurysm formation appears to be related to tumor size, and large aneurysms confer a higher probability of rupture.
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Affiliation(s)
- Koichiro Yamakado
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan.
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Peh WC, Yip KH, Tam PC. Spontaneous renal pseudoaneurysm rupture presenting as acute intraabdominal haemorrhage. Br J Radiol 1997; 70:1188-90. [PMID: 9536914 DOI: 10.1259/bjr.70.839.9536914] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
A 39-year-old man with a known history of end-stage renal disease presented with hypovolaemic shock and acute abdominal pain. Blood-stained peritoneal fluid was present. Right perirenal and extensive mesenteric haematomas were seen at laparotomy and CT. Right renal arteriography demonstrated a small renal artery pseudoaneurysm, and embolization was performed. The patient later developed intractable sepsis and died despite nephrectomy and drainage of the infected haematomas. Although there is an increasing trend towards conservative management of spontaneously ruptured kidneys from benign causes, embolization followed by early surgery should be considered in cases of extensive intraabdominal haemorrhage.
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Affiliation(s)
- W C Peh
- Department of Diagnostic Radiology, University of Hong Kong, Queen Mary Hospital, Hong Kong
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Ooi GC, Ngan N. Case quiz. Spontaneous rupture of a renal tumour with a perinephric haematoma. AUSTRALASIAN RADIOLOGY 1997; 41:79-81. [PMID: 9125080 DOI: 10.1111/j.1440-1673.1997.tb00478.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- G C Ooi
- Department of Diagnostic Radiology, University of Hong Kong, Queen Mary Hospital
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