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UROEPITHELIAL TUMORS TERRENCE C. DEMOS, MD DEPARTMENT OF RADIOLOGY LOYOLA UNIVERSITY MEDICAL CENTER. UROEPITHELIAL TUMORS INCIDENCE. URINARY BLADDER (94% OF ALL UROEPITHELIAL TUMORS) RENAL PELVIS (5% OF ALL UROTHELIAL TUMORS) URETER

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Uroepithelial tumors terrence c demos md department of radiology loyola university medical center l.jpg

UROEPITHELIAL TUMORS

TERRENCE C. DEMOS, MD

DEPARTMENT OF RADIOLOGY

LOYOLA UNIVERSITY MEDICAL CENTER


Uroepithelial tumors incidence l.jpg
UROEPITHELIAL TUMORS INCIDENCE

  • URINARY BLADDER(94% OF ALL UROEPITHELIAL TUMORS)

  • RENAL PELVIS

    • (5% OF ALL UROTHELIAL TUMORS)

  • URETER

  • (1% OF ALL UROTHELIAL TUMORS)


  • Uroepithelial tumors incidence3 l.jpg
    UROEPITHELIAL TUMORSINCIDENCE

    • URINARY BLADDER

    • (50 THOUSAND NEW CASES BLADDER CA/YEAR IN USA) M:F 3:1

    • RENAL CELL CARCINOMA OF KIDNEY

      • (15,000 THOUSAND NEW CASES/YEAR IN USA)


    Uroepithelial tumors risk factors l.jpg
    UROEPITHELIAL TUMORSRISK FACTORS

    • SMOKING

    • ANALGESICS

      • PHENACETIN

      • CYCLOPHOSPHAMIDE

  • OCCUPATIONAL CARCINOGENS

    • COAL, ASPHALT, TAR, PETROCHEMICALS, PLASTICS

  • PAPILLARY NECROSIS

  • FAMILIAL CANCER SYNDROMES

    • HEREDITARY NONPOLYPOSIS COLORECTAL CANCER (LYNCHII)


  • Uroepithelial tumors l.jpg
    UROEPITHELIAL TUMORS

    COLLECTING SYSTEM DEVELOPES FROM FETAL MESONEPHROS

    UROEPITHELIAL CA: TRANSITIONAL CELL OR SQUAMOUS CARCINOMA DERIVED FROM

    • MESODERM

    • EPITHELIAL TISSUE

      RENAL PARENCHYMA DEVELOPES FROM METANEPHRIC BLASTEMA

      RENAL CELL CA: ADENOCARCINOMA

      DERIVED FROM

    • TUBULAR EPITHELIUM


    Uroepithelial tumors6 l.jpg
    UROEPITHELIAL TUMORS

    • 90% TRANSITIONAL CELL

    • 9% SQUAMOUS CELL

    • >1%

      • ADENOCARCINOMA

      • SARCOMA

      • UNDIFFERENTIATED

      • BENIGN MESODERMAL


    Uroepithelial tumor transitional squamous and sarcoma elements l.jpg
    UROEPITHELIAL TUMORTRANSITIONAL, SQUAMOUS, AND SARCOMA ELEMENTS



    Transitional cell carcinoma l.jpg
    TRANSITIONAL CELL CARCINOMA

    CLASSIFICATION

    PAPILLARY

    NONPAPILLARY


    Transitional cell carcinoma10 l.jpg
    TRANSITIONAL CELL CARCINOMA

    • PAPILLARY TYPE 80%

      • 50% ARE INFILTRATIVE MALIGNANCIES

  • NONPAPILLARY TYPE 20%

    • ALL CONSIDERED TO BE MALIGNANT


  • Papillary carcinoma invasive versus noninvasive l.jpg
    PAPILLARY CARCINOMAINVASIVE VERSUS NONINVASIVE


    Nonpapillary flat carcinoma invasive versus noninvasive l.jpg
    NONPAPILLARY (FLAT) CARCINOMAINVASIVE VERSUS NONINVASIVE


    Transitional cell tumors l.jpg
    TRANSITIONAL CELL TUMORS

    • PATHOLOGIC CLASSIFICATION RANGE

      • WELL DIFFERENTIATED PAPILLOMA (GRADE 1)

      • MALIGNANCY

        RANGES FROM LOW-GRADE AND SUPERFICIAL

        TO HIGH-GRADE AND INVASIVE


    Uroepithelial tumors imaging modalities l.jpg
    UROEPITHELIAL TUMORSIMAGING MODALITIES

    • EXCRETORY UROGRAM

    • SONOGRAPHY

    • RETROGRADE PYELOGRAM

    • COMPUTED TOMOGRAPHY

    • ANGIOGRAPHY


    Transitional cell tumors15 l.jpg
    TRANSITIONAL CELL TUMORS

    GROSS APPEARANCE ON IMAGING STUDIES

    • SINGLE LESION

      • SMALL AND PAPILLARY TO BULKY AND SESSILE

    • MULTIPLE DISCRETE LESIONS

    • DIFFUSE AND CONFLUENT LESIONS



    Uroepithelial tumors17 l.jpg
    UROEPITHELIAL TUMORS

    • PAPILLARY TYPE

    • STIPPLED APPEARANCE


    Transitional cell ca papillary type stippled appearance l.jpg
    TRANSITIONAL CELL CAPAPILLARY TYPESTIPPLED APPEARANCE


    Transitional cell carcinoma19 l.jpg
    TRANSITIONAL CELL CARCINOMA

    • TENDENCY TO BE MULTICENTRIC AND BILATERAL

    • BILATERAL IN UP TO 10% OF PATIENTS

      • (SYNCHRONOUS OR METACHRONOUS)

    • UP TO 1/2 OF PATIENTS WITH CA URETER OR PELVIS WILL DEVELOP BLADDER CARCINOMA



    Transitional cell carcinoma prognosis l.jpg
    TRANSITIONAL CELL CARCINOMA PROGNOSIS

    • PATIENTS WITH A RENAL PELVIC PAPILLOMA

      • 1/4 WILL DEVELOP A CARCINOMA

  • PATIENTS WITH MULTIPLE PAPILLOMAS

    • 1/2 WILL DEVELOP A CARCINOMA

  • PATIENTS WITH BLADDER/URETER TRANSITIONAL NEOPLASM

    • 1/3 ALREADY HAVE ANOTHER BLADDER TCC



  • Squamous tumors l.jpg
    SQUAMOUS TUMORS

    • ASSOCIATED WITH INFECTION AND STONES, LEUKOPLAKIA

    • SQUAMOUS METAPLASIA OF TRANSITIONAL EPITHELIUM

    • MOST ARE SOLITARY

    • CAN BE PAPILLARY OR SESSILE

    • HIGHLY INVASIVE

    • OVERALL, POOR PROGNOSIS


    Hematuria squamous carcinoma l.jpg
    HEMATURIASQUAMOUS CARCINOMA

    INITIAL CT

    CT 8 MONTHS LATER


    Squamous tumors25 l.jpg
    SQUAMOUS TUMORS

    • DIFFICULT TO RECOGNIZE DUE TO UNDERLYING DISEASE

      • INFECTION

      • STONES

  • OFTEN INVASIVE OR METASTATIC AT TIME OF DIAGNOSIS

  • PREDOMINENTLY EXTRALUMINAL

  • MAY APPEAR AS URETERAL STRICTURE




  • Uroepithelial tumors imaging l.jpg

    UROEPITHELIAL TUMORSIMAGING

    COLLECTING SYSTEM

    CALYCES

    INFUNDIBULI

    PELVIS

    URETERS

    BLADDER


    Uroepithelial tumors29 l.jpg
    UROEPITHELIAL TUMORS

    • RENAL PELVIS





    Hematuria l.jpg
    HEMATURIA

    IVP 1YEAR LATER

    TWO RETROGRADES

    INITIAL IVP



    Transitional cell ca papillary type stippled appearance35 l.jpg
    TRANSITIONAL CELL CAPAPILLARY TYPESTIPPLED APPEARANCE


    Renal sinus fat opacified calyx tumor l.jpg
    RENAL SINUSFAT, OPACIFIED CALYX, TUMOR


    48 year old woman persistent abdominal pain l.jpg
    48-YEAR-OLD WOMAN PERSISTENT ABDOMINAL PAIN

    CT ONE YEAR LATER


    Ct 10 mm versus 5 mm collimation l.jpg
    CT10 mm VERSUS 5 mm COLLIMATION


    Transitional cell ca pelvis ct and angiography l.jpg
    TRANSITIONAL CELL CA PELVISCT AND ANGIOGRAPHY



    Transitional cell ca l.jpg
    TRANSITIONAL CELL CA

    CT

    IVP

    RETROGRADE


    Transitional cell ca lower pole calyx l.jpg
    TRANSITIONAL CELL CALOWER POLE CALYX


    Transitional cell carcinoma ct ivp retrograde pyelogram l.jpg
    TRANSITIONAL CELL CARCINOMACT, IVP, RETROGRADE PYELOGRAM


    Transitional cell carcinoma dilated calyx l.jpg
    TRANSITIONAL CELL CARCINOMA DILATED CALYX

    IVP

    RETROGRADE


    Transitional cell ca amputated calyx l.jpg
    TRANSITIONAL CELL CAAMPUTATED CALYX


    Slide46 l.jpg

    HEMATURIA

    70/M

    IVP

    CT 1 YEAR LATER


    Transitional cell carcinoma papillary type with stippling l.jpg
    TRANSITIONAL CELL CARCINOMAPAPILLARY TYPE WITH STIPPLING




    Gross hematuria distal ureteral ca l.jpg
    GROSS HEMATURIADISTAL URETERAL CA


    Uroepithelial tumors51 l.jpg
    UROEPITHELIAL TUMORS

    • BERGMAN SIGN

      (RETROGRADE PYELOGRAM)

    • GOBLET SIGN

      • (EXCRETORY UROGRAM)



    Hematuria 52 year old man l.jpg
    HEMATURIA 52-YEAR-OLD MAN

    IVP

    IVP 1YEAR LATER


    Transitional cell carcinoma irregular distal ureter stricture l.jpg
    TRANSITIONAL CELL CARCINOMAIRREGULAR DISTAL URETER STRICTURE



    Voluminous renal pelvis 84 year old woman l.jpg
    VOLUMINOUS RENAL PELVIS84-YEAR-OLD WOMAN


    Atrophic kidney distal ureteral tumor l.jpg
    ATROPHIC KIDNEYDISTAL URETERAL TUMOR


    Atrophic kidney distal ureter transitional cell ca l.jpg
    ATROPHIC KIDNEYDISTAL URETER TRANSITIONAL CELL CA


    Atrophic kidney distal ureter transitional cell ca59 l.jpg
    ATROPHIC KIDNEYDISTAL URETER TRANSITIONALCELL CA


    Pseudoureterocele versus simple ureterocele l.jpg
    PSEUDOURETEROCELEVERSUS SIMPLE URETEROCELE



    Urinary bladder carcinoma l.jpg
    URINARY BLADDER CARCINOMA

    • M:F- 4:1

    • MOST COMMON AFTER 5TH DECADE OF LIFE

    • 12,000 DEATHS AND 50,OOO NEW CASES ANNUALLY

    • MEN 4TH LEADING, WOMEN 10TH LEADING CAUSE OF DEATH

    • EXCRETORY UROGRAPHY INSENSITIVE FOR DIAGNOSIS

      • BUT OPTIMIZE TECHNIQUE AND SCRUTINIZE BLADDER

    • CYSTOSCOPY




    Bowel gas etched in white neoplasm with no white halo l.jpg
    BOWEL GAS ETCHED IN WHITENEOPLASM WITH NO WHITE HALO




    Uroepithelial tumors68 l.jpg
    UROEPITHELIAL TUMORS

    • TUMOR CALCIFICATION

    • TRANSITIONAL CELL CARCINOMA

    • SQUAMOUS CARCINOMA

    • URACHAL CARCINOMA



    Urachal carcinoma l.jpg
    URACHAL CARCINOMA

    SQUAMOUS CARCINOMA


    Cytitis glandularis with pelvic lipomatosis l.jpg
    CYTITIS GLANDULARISWITH PELVIC LIPOMATOSIS



    Two men with hematuria l.jpg
    TWO MEN WITH HEMATURIA

    LITTRE GLANDS

    TRANSITIONAL CA



    Uroepithelial neoplams tnm staging l.jpg
    UROEPITHELIAL NEOPLAMSTNM STAGING

    • T1INVASION OF SUBEPITHELIAL CONNECTIVE TISSUE

    • T2INVASION OF MUSCULARIS

    • T3INVASION THRU MUSCULARIS INTO

      • PERIPELVIC FAT OR KIDNEY PARENCHYMA BY PELVIC LESION

      • INVASION OF PERIURETERIC FAT BY URETERAL LESION

  • T4INVASION INTO PERINEPHRIC FAT OR ADJACENT ORGANS

  • N

  • M


  • Uroepithelial neoplams tnm staging76 l.jpg
    UROEPITHELIAL NEOPLAMSTNM STAGING

    T1 AND T2 (INVASION OF MUSCULARIS)

    • T1 AND T2 OFTEN NOT DIFFERENTIATED BY IMAGING STUDIES

  • T3 INVASION THRU MUSCULARIS INTO

    • PERIPELVIC FAT OR KIDNEY PARENCHYMA BY PELVIC LESION

    • INVASION OF PERIURETERIC FAT BY URETERAL LESION

      • INFILTRATION OF FAT NOT SPECIFIC FOR TUMOR INVASION

  • T4 INVASION INTO PERINEPHRIC FAT OR ADJACENT ORGANS

    • TUMOR ABUTTING BUT NOT INVADING MAY NOT BE DIFFERENTIATED BY IMAGING STUDIES

  • NFALSE POSITIVE AND FALSE NEGATIVE LYMPH NODES

    • LARGE NODES WITHOUT TUMOR AND SMALL NODES WITH TUMOR


  • Invasion of the renal vein l.jpg
    INVASION OF THE RENAL VEIN

    • RENAL CELL CARCINOMA

    • RENAL PELVIS TRANSITIONAL CELL CA

    • ANGIOMYOLIPOMA



    Hematuria 57 m l.jpg
    HEMATURIA 57/M

    IVP & CT

    9 MONTHS LATER

    INITIAL CT





    D d of a filling defect collecting system or ureter l.jpg
    D.D. OF A FILLING DEFECT COLLECTING SYSTEM OR URETER

    • STONE

    • BLOOD CLOT

    • NEOPLASM

    • GAS BUBBLE

    • CROSSING VESSEL

    • PERISTALSIS

    • PYELITIS / URETERITIS CYSTICA

    • INFECTION / NECROTIC DEBRIS

    • FUNGUS BALL

    • LEUKOPLAKIA, MALAKOPLAKIA

    • SLOUGHED PAPILLA, ABERRANT PAPILLA




    Gross hematuria ureteral stone l.jpg
    GROSS HEMATURIAURETERAL STONE


    Gross hematuria stippled ureteral lesion l.jpg
    GROSS HEMATURIASTIPPLED URETERAL LESION


    Detection of stones l.jpg
    DETECTION OF STONES

    • EXCRETORY UROGRAM

      • DETECTS 75% OF ALL CALCULI

  • CT

    • DECTECTS >98% OF ALL CALCULI

  • SONOGRAPHY

    • SENSTIVE FOR RENAL PELVIS AND PROXIMAL URETERAL CALCULI

    • INSENSTIVE FOR DISTAL URETERAL CALCULI


  • Renal stone sonography l.jpg
    RENAL STONESONOGRAPHY




    Blood clot diagnosis of hematomas l.jpg
    BLOOD CLOTDIAGNOSIS OF HEMATOMAS

    • RADIOGRAPHS AND EXCRETORY UROGRAMS

      • NONSPECIFIC MASS EFFECT

  • COMPUTED TOMOGRAPY

    • ACUTE HEMORRHAGE HAS HIGH ATTENUATION

    • LATER, HEMATOMA APPEARS AS LOW DENSITY CYST

  • MAGNETIC RESONANCE IMAGING

    • MOST SENSITIVE FOR DIAGNOSING HEMATOMA

      • IN ACUTE, INTERMEDIATE, AND LATE STAGES OF EVOLUTION




  • Crossing blood vessels l.jpg
    CROSSING BLOOD VESSELS

    • EXCRETORY UROGRAM

      • SMOOTH FILLING DEFECT

        • PERIPHERAL IF VIEW IN PROFILE

        • CENTRAL IF VIEWED ENFACE

      • INCONSTANT SHAPE

  • CONFIRM DIAGNOSIS

    • CT ANGIO

    • MR ANGIO



  • Ureteritis pyelitis cystica l.jpg
    URETERITIS, PYELITIS CYSTICA

    • SUBEPITHELIAL FLUID CONTAINING CYSTS

    • USUALLY SMALL BUT RANGE FROM 1-20 MM

    • ASSOCIATED WITH CHRONIC INFECTION

    • PERSISTENT OR PERMANENT

    • MAY BE ASSOCIATED WITH CYSTITIS CYSTICA



    Immune suppressed patient transplanted kidney infected urine l.jpg
    IMMUNE SUPPRESSED PATIENTTRANSPLANTED KIDNEYINFECTED URINE


    Urinary tract infection fungal infection l.jpg
    URINARY TRACT INFECTION FUNGAL INFECTION

    • HISTORY OF PATIENT SHOULD BE OBTAINED

    • BACTERIAL URINARY TRACT INFECTIONS CAN PRODUCE DEBRIS CAUSING FILLING DEFECTS.

    • FUNGAL INFECTION CAN PRODUCE FUNGUS BALLS

      • CANDIDA ALBICANS MOST COMMON

        • IMMUNOCOMPRIMISED OR DEBILITATED PATIENTS



    Leukoplakia l.jpg
    LEUKOPLAKIA

    • SQUAMOUS METAPLASIA OF TRANSITIONAL CELLS WITH PROLIFERATION & ATYPIA OF SQUAMOUS EPITHELIAL LAYER………PREMALIGNANT

    • CHOLESTEATOMA……..MASS OF SHED MATRIAL

    • IMAGING OF PYELOCALYCEAL SYSTEM AND URETER

      • FOCAL OR WIDESPREAD IRREGULAR MARGINS

      • IRREGULAR INTRALUMINAL MASS

      • STONE DISEASE IN 1/2

      • CHRONIC INFECTION IS COMMON

      • CARCINOMA IN UP TO 1/4



    Malakoplakia of bladder l.jpg
    MALAKOPLAKIA OF BLADDER

    MICHAELIS-GUTMANN BODIES


    Malakoplakia l.jpg
    MALAKOPLAKIA

    • GRANULOMATOUS RESPONSE TO E. COLI INFECTION

    • MACROPHAGES CONTAIN CYTOPLASMIC INCLUSION BODIES CALLED MICHAELIS-GUTMANN BODIES

    • AFFECTS ARE PART OF GU TRACT, BUT MOST COMMON IN BLADDER

    • IMAGING SHOWS MULTIPLE IRREGULAR FILLING DEFECTS

    • LOWER URINARY TRACT….GOOD PROGNOSIS

    • DIFFUSE, MULTIFOCAL OR RENAL TX PATIENT…. POOR PROGNOSIS

    • NO MALIGNANT POTENTIAL



    Papillary necrosis excretory urogram and retrograde pyelogram l.jpg
    PAPILLARY NECROSISEXCRETORY UROGRAM AND RETROGRADE PYELOGRAM

    • EARLY: SMALL, IRREGULAR COLLECTIONS OF CONTRAST IN PAPILLAE

    • LATE: IRREGULAR DILATION OF CALYCES

      • FILLING DEFECTS

      • SLOUGHED PAPILLA IN CALYX, RENAL PELVIS, OR URETER

    • SLOUGHED PAPILLAE THAT CALCIFY HAVE PERIPHERAL CALCIFICATION….DIFFERENT THAN STONES

    • THE CONTOUR OF THE KIDNEY MAY BE WAVY DUE TO SELECTIVE ATROPHY OF CORTEX OVERLYING THE MEDULLARY SEGMENTS OF THE KIDNEY

    • ETIOLOGY: ANALGESICS, DIABETES, INFECTION with OSTRUCTION

      TUBERCULOSIS, SS DISEASE



    Uroepithelial tumors109 l.jpg
    UROEPITHELIAL TUMORS

    • RETROGRADE PYELOGRAM




    Urethral pseudodiverticuli l.jpg
    URETHRAL PSEUDODIVERTICULI

    RISK OF MALIGNANCY


    Ureteral pseudodiverticuli l.jpg
    URETERAL PSEUDODIVERTICULI

    • SMALL (2-5 MM) OUTPOUCHINGS

    • HYPERPLASIA OF TRANSITIONAL EPITHELIUM

    • RELATED TO CHRONIC INFECTION

    • ASSOCIATED WITH TRANSITIONAL CELL CA

      • HAVE PRECEDED MALIGNANCY BY 2-10 YEARS

      • PATIENTS MUST BE CLOSELY MONITORED



    Uroepithelial tumors115 l.jpg
    UROEPITHELIAL TUMORS

    • EXCRETORY UROGRAM


    Excretory urogram renal pelvis l.jpg
    EXCRETORY UROGRAMRENAL PELVIS

    • FILLING DEFECT

      • SINGLE OR MULTILPLE FILLING DEFECTS

      • SESSILE OR FLAT

      • SMOOTH, IRREGULAR, STIPPLED SURFACE

  • COLLECTING SYSTEM

    • DILATED CALYX

    • DILATED COLLECTING SYSTEM

    • AMPUTATED CALYX OR INFUNDIBULUM

    • ATROPHIC KIDNEY

    • NONFUNCTIONING KIDNEY

  • NEPHROGRAM

    • DEFECT DUE TO TUMOR INVASION OR COLLECTING SYSTEM OBSTRUCTION

    • MASS LIKE DEFECT


  • Excretory urogram ureter l.jpg
    EXCRETORY UROGRAMURETER

    • CALIBER OF URETER

      • NORMAL CALIBER

      • DILATED PROXIMAL TO LESION

        • WITH DILATED COLLECTING SYSTEM

        • WITHOUT DILATED COLLECTING SYSTEM

      • NARROWED AT SITE OF LESION

  • URETER AT SITE OF LESION

    • GOBLET SIGN (BERGMAN SIGN)

    • STRICTURE

      • SMOOTH AND CIRCUMFERENTIAL

      • ECCENTRIC

      • IRREGULAR

  • MULTIPLE LESIONS


  • Uroepithelial tumors118 l.jpg
    UROEPITHELIAL TUMORS

    • COMPUTED TOMOGRAPHY


    Computed tomography l.jpg
    COMPUTED TOMOGRAPHY

    • SCANNING SEQUENCES

      • UNENHANCED

      • CORTICOMEDULLARY PHASE

      • NEPHROGRAPHIC PHASE

      • DELAYED

        • OPACIFY COLLECTING SYSTEM, URETER AND BLADDER

  • APPROPRIATE COLLIMATION


  • Computed tomography120 l.jpg
    COMPUTED TOMOGRAPHY

    • FINDINGS SIMILAR TO EXCRETORY UROGRAPHY

    • NEED DELAYED SCANNING TO OPACIFY COLLECTING SYSTEM

    • NEED THIN COLLIMATION TO SHOW SMALL LESIONS

    • CT AFTER IVP IS VALUABLE TO DIFFERENTIATE TUMOR FROM

      • CROSSING VESSEL, STONE, PERIPELVIC FAT OR MASS

  • STAGING



  • Angiography l.jpg
    ANGIOGRAPHY

    • UROEPITHELIAL NEOPLASMS ARE HYPOVASCULAR

      • LARGE TUMOR VESSELS ARE RARE

      • TUMOR VESSELS MAY BE SUBTLE OR ABSENT

  • ABNORMAL VESSELS, WHEN PRESENT

    • CAN BE IDENTICAL TO NONMALIGNANT DISEASE

    • BE IDENTICAL TO POORLY VASCULARIZED RENAL CELL CA


  • Benign uroepithelial neoplasms l.jpg
    BENIGN UROEPITHELIAL NEOPLASMS

    • MESODERMAL NEOPLASMS

      • SMOOTH MUSCLE

      • NEURAL

      • VASCULAR

  • PAPILLOMA GRADE 1

    • CONSIDERED TO BE MALIGNANCY

  • INVERTED PAPILLOMA

    • RARE, ALMOST EXCLUSIVELY IN MEN

  • FIBROEPITHELIAL POLYPS


  • Fibroepithelial polyp l.jpg
    FIBROEPITHELIAL POLYP

    • FIBROUS TISSUE, SMOOTH MUSCLE, VESSELS, NERVE CELLS COVERED BY UROEPITHELIUM

    • MOST ARISE IN URETER

    • ELONGATED AND THIN, FINGER LIKE DISTAL BRANCHES

    • HIGHLY MOBILE


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