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Pulmonary Adenocarcinoma Occurring 5 Years after Resection of a Primary Pancreatic Adenocarcinoma: A Relevant Differential Diagnosis

Pulmonary Adenocarcinoma Occurring 5 Years after Resection of a Primary Pancreatic... Hindawi Publishing Corporation Case Reports in Oncological Medicine Volume 2014, Article ID 841907, 4 pages http://dx.doi.org/10.1155/2014/841907 Case Report Pulmonary Adenocarcinoma Occurring 5 Years after Resection of a Primary Pancreatic Adenocarcinoma: A Relevant Differential Diagnosis 1 1 1 2 3 R. F. Falkenstern-Ge, M. Wohlleber, M. Kimmich, K. Huettl, G. Friedel, 2 1 G. Ott, and M. Kohlhäufl Division of Pulmonology, Klinik Schillerhoehe, Center for Pulmonology and or Th acic Surgery, Teaching Hospital of the University of Tuebingen, Solitude Straße 18, Gerlingen, 70839 Stuttgart, Germany Division of Clinical Pathology, Robert Bosch Krankenhaus, Teaching Hospital of the University of Tuebingen, Auerbachstraße 110, 70376 Stuttgart, Germany Division of Thoracic Surgery, Klinik Schillerhoehe, Center for Pulmonology and Thoracic Surgery, Teaching Hospital of the University of Tuebingen, Solitude Straße 18, Gerlingen, 70839 Stuttgart, Germany Correspondence should be addressed to R. F. Falkenstern-Ge; rogerfalkenstern@yahoo.de Received 11 November 2013; Accepted 15 January 2014; Published 23 February 2014 Academic Editors: K. Aogi, A. Goodman, and Y. Yokoyama Copyright © 2014 R. F. Falkenstern-Ge et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Ductal adenocarcinoma of the pancreas is a lethal disease. Surgical extirpation only oeff rs the slim chance for long-term survival in localized disease. We report on a 73 year old female patient who initially underwent successful resection of pancreatic adenocarcinoma in May 2005. She was treated with adjuvant chemotherapy with gemcitabine. In October 2010 the patient noticed increasing dyspnea with haemoptysis. She was soon referred to our center. After the diagnosis of pulmonary adenocarcinoma with widespread metastasis, she was treated with systemic chemotherapy. For a period of next three years, she was treated with different chemotherapy regimens due to repeated episodes of tumor progression. To the best of our knowledge aer ft reviewing the literature, this case represents an unusually clinical course with metachronous pulmonary adenocarcinoma arising aer ft treatment of a primary pancreatic cancer aer ft a long latency period. 1. Main Article dyspnea with haemoptysis. Contrast-enhanced tomography revealed a major pulmonary mass in the right upper lobe with The patient had undergone distal pancreatectomy with portal contralateral metastases (Figure 1(a)). Macroscopic histologic vein resection for pancreatic body cancer in early May 2005. workup revealed tumor nodule measured 1.3 cm in maximum diameter and it was sharply demarcated. Histological exam- At the time of pancreatectomy, the cancer was confined ination revealed a well-differentiated adenocarcinoma with to the organ and had not invaded the portal-splenic vein lepidic, papillary, and acinar growth patterns and intracellular junction.Toensureanadequatesurgicalmargin, subto- and extracellular mucin production. A curative tumor resec- tal distal pancreatectomy was performed. Histopathological tion was not feasible. First line systemic chemotherapy with examination revealed an invasive well-differentiated ductal carboplatin and pemetrexed was initiated. Aeft r vfi e months, adenocarcinoma of the pancreas. Adjuvant chemotherapy stable disease was achieved (Figure 1(b)). with gemcitabine was administered. All follow-up reevalua- tions showed no signs of tumor recurrence, and external lab- During the next 3 years, different chemotherapy agents were required due to repeated episodes of tumor pro- oratory tests did not show elevated CA 19-9 levels. In October 2010, she was referred to our center due to the increasing gression. Aeft r the second/third and fourth line therapy 2 Case Reports in Oncological Medicine (a) (b) (c) Figure 1: Contrast-enhanced tomography revealed a major pulmonary mass within the right upper lobe (arrow) (a). Stable disease was achieved under first line therapy with carboplatin and pemetrexed (b). CT-evaluation revealed tumor progression of the pulmonary mass and metastases, huge pleural effusion due to pleural carcinosis of the right side (c). including erlotinib, gemcitabine, and vinorelbine, systemic pattern, favored the diagnosis of a primary mucinous adeno- chemotherapy was na fi lly stopped due to low overall perfor- carcinoma of the lung. mance and the declining clinical condition of the patient. The most recent contrast-enhanced thoracic tomography 2. Discussion revealed severe tumor progression of the pulmonary mass and metastases (Figure 1(c)). In order to optimize current We report a patient who successfully underwent Whipple supportive care, we inserted drainage pleurX-catheter due to pancreatectomy for pancreatic body cancer in early May the huge pleural effusion with pleural carcinosis of the right 2005. In October 2010, she was diagnosed with metachronous lung. pulmonary adenocarcinoma. The tumor cells showed a strong expression of CK7, but Schwarze et al. and colleagues described 3 patients with no positive reactions for CK20, NapsinA, TTF-1, or MUC2 metachronous cancers of the lung and pancreas. In those on immunohistochemistry (Figures 2(a)–2(c)). Notably, anti- cases, the patients were reported to develop the secondary MUC1 staining displayed a nonspecicfi weak partial mem- cancer aer ft 16–66 months [ 1]. The time frame of our patient branous reaction in the tumor cells (Figure 3). Most primary with 65 months represents one of the longest intervals mucinous adenocarcinoms of the lung neither express TTF- documented in patients, who developed late metachronous 1 nor NapsinA, and therefore were not helpful markers in secondary lung carcinoma aer ft pancreatic cancer. the present case. Considering the previous diagnosis of a The prognosis of patients with locally advanced pancre- moderately differentiated adenocarcinoma of the pancreas atic cancer is extremely dismal. Only few patients survive with “classical” ductal growth, the conventional morphology forlongerperiods of time,eveniftreated by pancreatectomy of thepulmonary tumor, especially theinpartlepidic growth combined with blood vessel resection, extended lymph node Case Reports in Oncological Medicine 3 (a) Figure 3: Anti-MUC1 staining shows a nonspecific weak partial membranous reaction in the tumor cells. case represents the rfi st documentation of such a long latency between a primary pancreatic carcinoma and a secondary metachronous pulmonary adenocarcinoma. Gemcitabine has been the standard treatment modality for more than 15 years for advanced pancreatic cancer. New combination chemotherapy regimens (e.g., FOLFIRI- (b) NOX, nab-paclitaxel plus gemcitabine) achieved a significant survival benefit compared to gemcitabine alone [ 7]. Our patient also received the standard adjuvant chemotherapy with gemcitabine after the tumor resection 5 years ago. The synergistic activity of pemetrexed with platinum agents in non-small cell lung cancer (NSCLC) and the renal safety of carboplatin suggest a very balanced benefit/risk profile for this combination in elderly patients. A multicenter single-arm phase II Study from Gervais et al. suggested that the combination of pemetrexed-carboplatin could be a valuable treatment option in elderly patients. Neutropenia (c) remained the most common toxicity. Stable disease rate was Figure 2: (a) HE-staining of the tumor clearly demonstrates a achieved at 42.9%. Grade 3/4 toxicities related to study drugs lepidic growth pattern (×50). (b) eTh tumor cells display a strong were asthenia 16.1%, anorexia 4.8%, diarrhea 3.2%, neu- expression of CK7. (c) eTh tumor cells are negative for TTF-1 on tropenia 51.6%, leucopenia 30.7%, thrombocytopenia 29%, immunohistochemistry (note positive internal control). and anemia 19.4%. In advanced NSCLC, pemetrexed use is restricted to nonsquamous histology [8]. In conclusion, we report on a patient who survived two different epithelial cancers for an unusually long period dissection, and adjuvant therapy such as chemotherapy and of more than 8 years. eTh time interval between the two radiation therapy [2, 3]. cancers represents extreme long latency interval in a docu- Initially, the pulmonary tumor was suspected to represent mented patient who was diagnosed with late metachronous late metastasis of the previously resected pancreatic carci- pulmonary adenocarcinoma after resection of a primary noma. eTh incidence of pulmonary metastasis in that cancer pancreatic cancer. is relatively low with only a percentage of 6.4% reported before [4, 5]. In our patient, the initial pancreaticoduodenec- Conflict of Interests tomy was performed as a curative intent and the lymph nodes were free of metastasis. All follow-up evaluations were The authors indicated no potential conflict of interests. performedwithinaregulartimeframe.Notumor recurrence was detected. On the other hand, survival aeft r Whipple’s surgery is References often short, and median overall survival times of 23.9 months weregivenintheliteratureforpatientswithpancreaticcancer [1] R. E. Schwarz, P. G. Chu, and F. W. Grannis Jr., “Pancreatic tumors in patients with lung malignancies: A spectrum of that underwent resection [6]. We suppose that our obser- clinicopathologic considerations,” Southern Medical Journal, vation has clinical significance as it suggests that contrary vol. 97, no. 9, pp. 811–815, 2004. to current practice, surveillance of patients also beyond 5 years after pancreatic resections might be important to pick [2] S. C. Mayo, H. Nathan, J. L. Cameron et al., “Conditional up those patients who fall into this categorical group. This survival in patients with pancreatic ductal adenocarcinoma 4 Case Reports in Oncological Medicine resected with curative intent,” Cancer, vol. 118, no. 10, pp. 2674– [3] K. C. Conlon, D. S. Klimstra, and M. F. Brennan, “Long-term survival aeft r curative resection for pancreatic ductal adenocar- cinoma: Clinicopathologic analysis of 5-year survivors,” Annals of Surgery,vol.223,no. 3, pp.273–279,1996. [4] S.Emoto,H.Kamachi,M.Taharaetal.,“Acaseoflung metastasis occurring 6 years aer ft pancreaticoduodenectomy for pancreas cancer,” Journal of Japan Surgical Association,vol. 71, no. 4, pp. 1034–1038, 2010. [5] C. Sperti, C. Pasquali, A. Piccoli, and S. Pedrazzoli, “Recurrence aer ft resection for ductal adenocarcinoma of the pancreas,” World Journal of Surgery,vol.21, no.2,pp. 195–200, 1997. [6] M.H.Katz, H. Wang,J.B.Flemingetal.,“Long-termsurvival aer ft multidisciplinary management of resected pancreatic ade- nocarcinoma,” Annals of Surgical Oncology,vol.16, no.4,pp. 836–847, 2009. [7] L. Faloppi, K. Andrikou, and S. Cascinu, “Cetuximab : still an option in the treatment of pancreatic cancer?” Expert Opinion on Biological Therapy ,vol.13, no.5,pp. 791–801, 2013. [8] R. Gervais, G. Robinet, C. Clement- Duchene et al., “Peme- trexed and carboplatin, an active option in first- line treatment of elderly patients with advanced non- small cell lung cancer (NSCLC): a phase II trial,” Lung Cancer,vol.80, no.2,pp. 185– 190, 2013. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Case Reports in Oncological Medicine Hindawi Publishing Corporation

Pulmonary Adenocarcinoma Occurring 5 Years after Resection of a Primary Pancreatic Adenocarcinoma: A Relevant Differential Diagnosis

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Copyright © 2014 R. F. Falkenstern-Ge et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract

Hindawi Publishing Corporation Case Reports in Oncological Medicine Volume 2014, Article ID 841907, 4 pages http://dx.doi.org/10.1155/2014/841907 Case Report Pulmonary Adenocarcinoma Occurring 5 Years after Resection of a Primary Pancreatic Adenocarcinoma: A Relevant Differential Diagnosis 1 1 1 2 3 R. F. Falkenstern-Ge, M. Wohlleber, M. Kimmich, K. Huettl, G. Friedel, 2 1 G. Ott, and M. Kohlhäufl Division of Pulmonology, Klinik Schillerhoehe, Center for Pulmonology and or Th acic Surgery, Teaching Hospital of the University of Tuebingen, Solitude Straße 18, Gerlingen, 70839 Stuttgart, Germany Division of Clinical Pathology, Robert Bosch Krankenhaus, Teaching Hospital of the University of Tuebingen, Auerbachstraße 110, 70376 Stuttgart, Germany Division of Thoracic Surgery, Klinik Schillerhoehe, Center for Pulmonology and Thoracic Surgery, Teaching Hospital of the University of Tuebingen, Solitude Straße 18, Gerlingen, 70839 Stuttgart, Germany Correspondence should be addressed to R. F. Falkenstern-Ge; rogerfalkenstern@yahoo.de Received 11 November 2013; Accepted 15 January 2014; Published 23 February 2014 Academic Editors: K. Aogi, A. Goodman, and Y. Yokoyama Copyright © 2014 R. F. Falkenstern-Ge et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Ductal adenocarcinoma of the pancreas is a lethal disease. Surgical extirpation only oeff rs the slim chance for long-term survival in localized disease. We report on a 73 year old female patient who initially underwent successful resection of pancreatic adenocarcinoma in May 2005. She was treated with adjuvant chemotherapy with gemcitabine. In October 2010 the patient noticed increasing dyspnea with haemoptysis. She was soon referred to our center. After the diagnosis of pulmonary adenocarcinoma with widespread metastasis, she was treated with systemic chemotherapy. For a period of next three years, she was treated with different chemotherapy regimens due to repeated episodes of tumor progression. To the best of our knowledge aer ft reviewing the literature, this case represents an unusually clinical course with metachronous pulmonary adenocarcinoma arising aer ft treatment of a primary pancreatic cancer aer ft a long latency period. 1. Main Article dyspnea with haemoptysis. Contrast-enhanced tomography revealed a major pulmonary mass in the right upper lobe with The patient had undergone distal pancreatectomy with portal contralateral metastases (Figure 1(a)). Macroscopic histologic vein resection for pancreatic body cancer in early May 2005. workup revealed tumor nodule measured 1.3 cm in maximum diameter and it was sharply demarcated. Histological exam- At the time of pancreatectomy, the cancer was confined ination revealed a well-differentiated adenocarcinoma with to the organ and had not invaded the portal-splenic vein lepidic, papillary, and acinar growth patterns and intracellular junction.Toensureanadequatesurgicalmargin, subto- and extracellular mucin production. A curative tumor resec- tal distal pancreatectomy was performed. Histopathological tion was not feasible. First line systemic chemotherapy with examination revealed an invasive well-differentiated ductal carboplatin and pemetrexed was initiated. Aeft r vfi e months, adenocarcinoma of the pancreas. Adjuvant chemotherapy stable disease was achieved (Figure 1(b)). with gemcitabine was administered. All follow-up reevalua- tions showed no signs of tumor recurrence, and external lab- During the next 3 years, different chemotherapy agents were required due to repeated episodes of tumor pro- oratory tests did not show elevated CA 19-9 levels. In October 2010, she was referred to our center due to the increasing gression. Aeft r the second/third and fourth line therapy 2 Case Reports in Oncological Medicine (a) (b) (c) Figure 1: Contrast-enhanced tomography revealed a major pulmonary mass within the right upper lobe (arrow) (a). Stable disease was achieved under first line therapy with carboplatin and pemetrexed (b). CT-evaluation revealed tumor progression of the pulmonary mass and metastases, huge pleural effusion due to pleural carcinosis of the right side (c). including erlotinib, gemcitabine, and vinorelbine, systemic pattern, favored the diagnosis of a primary mucinous adeno- chemotherapy was na fi lly stopped due to low overall perfor- carcinoma of the lung. mance and the declining clinical condition of the patient. The most recent contrast-enhanced thoracic tomography 2. Discussion revealed severe tumor progression of the pulmonary mass and metastases (Figure 1(c)). In order to optimize current We report a patient who successfully underwent Whipple supportive care, we inserted drainage pleurX-catheter due to pancreatectomy for pancreatic body cancer in early May the huge pleural effusion with pleural carcinosis of the right 2005. In October 2010, she was diagnosed with metachronous lung. pulmonary adenocarcinoma. The tumor cells showed a strong expression of CK7, but Schwarze et al. and colleagues described 3 patients with no positive reactions for CK20, NapsinA, TTF-1, or MUC2 metachronous cancers of the lung and pancreas. In those on immunohistochemistry (Figures 2(a)–2(c)). Notably, anti- cases, the patients were reported to develop the secondary MUC1 staining displayed a nonspecicfi weak partial mem- cancer aer ft 16–66 months [ 1]. The time frame of our patient branous reaction in the tumor cells (Figure 3). Most primary with 65 months represents one of the longest intervals mucinous adenocarcinoms of the lung neither express TTF- documented in patients, who developed late metachronous 1 nor NapsinA, and therefore were not helpful markers in secondary lung carcinoma aer ft pancreatic cancer. the present case. Considering the previous diagnosis of a The prognosis of patients with locally advanced pancre- moderately differentiated adenocarcinoma of the pancreas atic cancer is extremely dismal. Only few patients survive with “classical” ductal growth, the conventional morphology forlongerperiods of time,eveniftreated by pancreatectomy of thepulmonary tumor, especially theinpartlepidic growth combined with blood vessel resection, extended lymph node Case Reports in Oncological Medicine 3 (a) Figure 3: Anti-MUC1 staining shows a nonspecific weak partial membranous reaction in the tumor cells. case represents the rfi st documentation of such a long latency between a primary pancreatic carcinoma and a secondary metachronous pulmonary adenocarcinoma. Gemcitabine has been the standard treatment modality for more than 15 years for advanced pancreatic cancer. New combination chemotherapy regimens (e.g., FOLFIRI- (b) NOX, nab-paclitaxel plus gemcitabine) achieved a significant survival benefit compared to gemcitabine alone [ 7]. Our patient also received the standard adjuvant chemotherapy with gemcitabine after the tumor resection 5 years ago. The synergistic activity of pemetrexed with platinum agents in non-small cell lung cancer (NSCLC) and the renal safety of carboplatin suggest a very balanced benefit/risk profile for this combination in elderly patients. A multicenter single-arm phase II Study from Gervais et al. suggested that the combination of pemetrexed-carboplatin could be a valuable treatment option in elderly patients. Neutropenia (c) remained the most common toxicity. Stable disease rate was Figure 2: (a) HE-staining of the tumor clearly demonstrates a achieved at 42.9%. Grade 3/4 toxicities related to study drugs lepidic growth pattern (×50). (b) eTh tumor cells display a strong were asthenia 16.1%, anorexia 4.8%, diarrhea 3.2%, neu- expression of CK7. (c) eTh tumor cells are negative for TTF-1 on tropenia 51.6%, leucopenia 30.7%, thrombocytopenia 29%, immunohistochemistry (note positive internal control). and anemia 19.4%. In advanced NSCLC, pemetrexed use is restricted to nonsquamous histology [8]. In conclusion, we report on a patient who survived two different epithelial cancers for an unusually long period dissection, and adjuvant therapy such as chemotherapy and of more than 8 years. eTh time interval between the two radiation therapy [2, 3]. cancers represents extreme long latency interval in a docu- Initially, the pulmonary tumor was suspected to represent mented patient who was diagnosed with late metachronous late metastasis of the previously resected pancreatic carci- pulmonary adenocarcinoma after resection of a primary noma. eTh incidence of pulmonary metastasis in that cancer pancreatic cancer. is relatively low with only a percentage of 6.4% reported before [4, 5]. In our patient, the initial pancreaticoduodenec- Conflict of Interests tomy was performed as a curative intent and the lymph nodes were free of metastasis. All follow-up evaluations were The authors indicated no potential conflict of interests. performedwithinaregulartimeframe.Notumor recurrence was detected. On the other hand, survival aeft r Whipple’s surgery is References often short, and median overall survival times of 23.9 months weregivenintheliteratureforpatientswithpancreaticcancer [1] R. E. Schwarz, P. G. Chu, and F. W. Grannis Jr., “Pancreatic tumors in patients with lung malignancies: A spectrum of that underwent resection [6]. We suppose that our obser- clinicopathologic considerations,” Southern Medical Journal, vation has clinical significance as it suggests that contrary vol. 97, no. 9, pp. 811–815, 2004. to current practice, surveillance of patients also beyond 5 years after pancreatic resections might be important to pick [2] S. C. Mayo, H. Nathan, J. L. Cameron et al., “Conditional up those patients who fall into this categorical group. This survival in patients with pancreatic ductal adenocarcinoma 4 Case Reports in Oncological Medicine resected with curative intent,” Cancer, vol. 118, no. 10, pp. 2674– [3] K. C. Conlon, D. S. Klimstra, and M. F. Brennan, “Long-term survival aeft r curative resection for pancreatic ductal adenocar- cinoma: Clinicopathologic analysis of 5-year survivors,” Annals of Surgery,vol.223,no. 3, pp.273–279,1996. [4] S.Emoto,H.Kamachi,M.Taharaetal.,“Acaseoflung metastasis occurring 6 years aer ft pancreaticoduodenectomy for pancreas cancer,” Journal of Japan Surgical Association,vol. 71, no. 4, pp. 1034–1038, 2010. [5] C. Sperti, C. Pasquali, A. Piccoli, and S. Pedrazzoli, “Recurrence aer ft resection for ductal adenocarcinoma of the pancreas,” World Journal of Surgery,vol.21, no.2,pp. 195–200, 1997. [6] M.H.Katz, H. Wang,J.B.Flemingetal.,“Long-termsurvival aer ft multidisciplinary management of resected pancreatic ade- nocarcinoma,” Annals of Surgical Oncology,vol.16, no.4,pp. 836–847, 2009. [7] L. Faloppi, K. Andrikou, and S. Cascinu, “Cetuximab : still an option in the treatment of pancreatic cancer?” Expert Opinion on Biological Therapy ,vol.13, no.5,pp. 791–801, 2013. [8] R. Gervais, G. Robinet, C. Clement- Duchene et al., “Peme- trexed and carboplatin, an active option in first- line treatment of elderly patients with advanced non- small cell lung cancer (NSCLC): a phase II trial,” Lung Cancer,vol.80, no.2,pp. 185– 190, 2013. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Journal

Case Reports in Oncological MedicineHindawi Publishing Corporation

Published: Feb 23, 2014

References