Monday, November 10, 2014

Oncocytoma: A Benign Kidney Tumor Often Confused for Cancer

Upwards of 15-20% of kidney tumors may be benign lesions. While physicians and surgeons can use patient information, radiographic imaging and biopsy to provide information, the definitive diagnosis of cancer or benign tumor is established only after the tumor has been removed. For instance, smaller tumors, female sex and age are associated with benign tumors - younger women are nearly twice as likely as age-matched men to have benign masses.[1-5] While certain characteristics are indicative of benign tumors (i.e. fat always indicates an angiomyolipoma), many other benign tumors – like oncocytoma – can appear similar to renal cell carcinoma (RCC) on CT scan and biopsy.

This blog will review oncocytoma, one of the most common benign tumors of the kidney.


Epidemiology and Etiology

Renal oncocytoma is one of the most common of benign renal masses, accounting for 3-7% of kidney tumors.[6] Oncocytomas appear as enhancing renal masses and are often indistinguishable from clear-cell RCC on CT scans (see Diagnosis below). Both oncocytomas and clear-cell RCC pick up contrast material and enhance brightly. However, oncocytoma is a distinct entity from RCC with unique cell of origin and cytogenetic abnormalities.[7-8]

Oncocytomas are more common in older patients with small, incidentally discovered renal masses. [4,9] Generally, they are more common in men than women (2:1 ratio), present in the 4th to 6th decade of life and can present bilaterally, multifocally or recur in 6-13% of cases.[10] Patients with the rare, Birt-Hogg-Dubé, genetic syndrome can present with oncocytomatosis – the presence of multiple oncocytomas in both kidneys. [11] Oncocytomas are benign tumors and rare case reports of metastatic oncocytoma represent either malignant degeneration, coexistence of RCC or pseudometastases (not really metastatic disease).[12]


Diagnosis

In general, oncocytoma appear similar to RCC on imaging. However, a number of characteristic radiographic findings are common in oncocytoma:
  • On CT scan, bright, rapidly-enhancing pattern and a central stellate scar [13]
  • On angiography, a spoke wheel pattern of feeding arteries may be present
  • On MRI, a well-defined capsule, central stellate scar, and distinctive pattern on T1 and T2 images may indicate oncocytoma.[14,15]
The similar appearance of clear-cell RCC and oncocytoma on contrast-enhanced CT scan.
The Houndsfield Unit (HU) -based enhancement patterns for clear-cell RCC and oncocytoma are overlapping on CT scan. [13]




Renal biopsy has a limited role in the diagnosis of oncocytoma, particularly because it can be difficult to distinguish from chromophobe RCC (see our blog entry on Renal Cell Carcinoma: Implications of Histology for more information about chromophobe RCC), the eosinophilic-variant of clear-cell RCC (a rare and potentially aggressive form of kidney cancer) and may be co-exist with RCC in 7-32% of cases. However, surgical series indicate that if oncocytoma is present with RCC in the same tumor, the tumor is often low-grade and indolent (benign-behaving).[16]


Histology and Pathology

Oncocytomas appear grossly as tan, homogenous tumors with a distinct border (composed of a well-formed pseudocapsule) and typically have a central stellate scar. Microscopically, cells are derived from distal tubules, are rounded and highly-eosinophlic (pink) due to an abundance of mitochondria (the energy producing portion of the cell). As stated above, it can extremely difficult to distinguish oncocytoma from chromophobe RCC or the eosinophilic-variant of clear-cell RCC under the microscope. Cells are typically arranged in a nested pattern and can demonstrate perinephric extension, pleomorphism (variability in size and shape), prominent nucleoli and atypia, making the distinction between RCC difficult.[17,18] On a percutaneous renal biopsy, where only a portion of tumor is present and cellular architecture is incomplete, distinguishing oncocytoma from RCC can be extremely challenging.


From pathologyatlas.com

To distinguish ococytoma from RCC, a number of features can be examined. Chromosomal abnormalities associated with RCC are not present in oncocytoma, and oncocytoma will commonly present with loss of chromosome 1p, loss of Y- or 14q- and rearrangements of 11q13. [7,8] Hale's colloidal iron stain has traditionally been used to identify oncoctyoma, however can have nonspecific staining patterns leading to difficult interpretation.[19] One of the distinguishing cellular features of oncocytoma is uniform, round mitochondria with lamellar cristae – in chromphobe RCC, mitochondria are variable in size and shape with tubulocystic cristae; and in eosinophilic-variant of clear-cell RCC, mitochondria are pleomorphic and have attenuated cristae.[20] Researchers at Johns Hopkins are taking advantage of differences in mitochondria among oncocytoma and RCC to come up with a better, preoperative diagnostic test to distinguish oncocytoma before a sending a patient to surgery.


Electron micropscopy of oncocytoma with uniform, round mitochondria (left) and chromophobe RCC with the pale area around the nucleus is predominantly occupied by microvesicles and irregular mitochondria (right).[20]

Management

Most often oncocytoma are clinically assumed to be RCC and have the same management strategies available including active surveillance, radical nephrectomy (for large tumors of uncertain etiology) and nephron-sparing surgeries including partial nephrectomy and thermal ablation. Oncocytomas under active surveillance can demonstrate rapid growth and are often the fastest growing tumors in active surveillance studies! Therefore, growth rate is not able to distinguish oncocytoma from RCC during periods of AS.[21,22] When the diagnosis of oncocytoma is known or highly-suspected, nephron-sparing approaches should be employed due to the benign nature of these lesions. At Johns Hopkins, partial nephrectomy is preferred to thermal ablation as a definitive diagnosis can be made from analysis of the tumor rather than biopsy specimens.



This blog is adapted from the Handbook of Urology, Chapter 24: Angiomyolipoma, Oncocytoma and Retroperitoneal Fibrosis, by Phillip M. Pierorazio, MD; Edited by John Kellogg Parsons, John B. Eifler, and Misop Han available from Wiley.


 








  1. Kutikov A, Fossett LK, Ramchandani P, et al.: Incidence of benign pathologic findings at partial nephrectomy for solitary renal mass presumed to be renal cell carcinoma on preoperative imaging. Urology 2006; 68(4): 737-40.
  2. Kouba E, Smith A, McRackan D, Wallen EM, Pruthi RS: Watchful waiting for solid renal masses: insight into the natural history and results of delayed intervention. J Urol 2007; 177(2): 466-70; discussion 470.
  3. Pierorazio PM, Murphy AM, Benson MC, McKiernan JM: Gender discrepancies in the diagnosis of renal cortical tumors. World J Urol 2007; 25(1): 81-5.
  4. Cao Y, Paner GP, Perry KT, Flanigan RC, Campbell SC, Picken MM: Renal neoplasms in younger adults: analysis of 112 tumors from a single institution according to the new 2004 World Health Organization classification and 2002 American Joint Committee on Cancer Staging System. Arch Pathol Lab Med 2005; 129(4): 487-91.
  5. Snyder ME, Bach A, Kattan MW, Raj GV, Reuter VE, Russo P: Incidence of benign lesions for clinically localized renal masses smaller than 7 cm in radiological diameter: influence of sex. J Urol 2006; 176(6 Pt 1): 2391-5; discussion 2395-6.
  6. Morra MN, Das S: Renal oncocytoma: a review of histogenesis, histopathology, diagnosis and treatment. J Urol 1993; 150(2 Pt 1): 295-302.
  7. Lindgren V, Paner GP, Omeroglu A, et al.: Cytogenetic analysis of a series of 13 renal oncocytomas. J Urol 2004; 171(2 Pt 1): 602-4.
  8. Paner GP, Lindgren V, Jacobson K, et al.: High incidence of chromosome 1 abnormalities in a series of 27 renal oncocytomas: cytogenetic and fluorescence in situ hybridization studies. Arch Pathol Lab Med 2007; 131(1): 81-5.
  9. Skolarus TA, Serrano MF, Berger DA, et al.: The distribution of histological subtypes of renal tumors by decade of life using the 2004 WHO classification. J Urol 2008; 179(2): 439-43; discussion 443-4.
  10. Minor LD, Picken MM, Campbell SC: Benign renal tumors. AUA Update 2003; 22: 170-175.
  11. Al-Saleem T, Cairns P, Dulaimi EA, Feder M, Testa JR, Uzzo RG: The genetics of renal oncocytosis: a possible model for neoplastic progression. Cancer Genet Cytogenet 2004; 152(1): 23-8.
  12. Oxley JD, Sullivan J, Mitchelmore A, Gillatt DA: Metastatic renal oncocytoma. J Clin Pathol 2007; 60(6): 720-2.
  13. Pierorazio PM1, Hyams ES, Tsai S, Feng Z, Trock BJ, Mullins JK, Johnson PT, Fishman EK, Allaf ME. Multiphasic enhancement patterns of small renal masses (≤4 cm) on preoperative computed tomography: utility for distinguishing subtypes of renal cell carcinoma, angiomyolipoma, and oncocytoma. Urology. 2013 Jun;81(6):1265-71. doi: 10.1016/j.urology.2012.12.049. Epub 2013 Apr 17.
  14. Licht MR: Renal adenoma and oncocytoma. Semin Urol Oncol 1995; 13(4): 262-6.
  15. Harmon WJ, King BF, Lieber MM: Renal oncocytoma: magnetic resonance imaging characteristics. J Urol 1996; 155(3): 863-7.
  16. Ginzburg S, Uzzo R, Al-Saleem T, Dulaimi E, Walton J, Corcoran A, Plimack E, Mehrazin R, Tomaszewski J, Viterbo R, Chen DY, Greenberg R, Smaldone M, Kutikov A. Coexisting hybrid malignancy in a solitary sporadic solid benign renal mass: implications for treating patients following renal biopsy. J Urol. 2014 Feb;191(2):296-300. doi: 10.1016/j.juro.2013.07.059. Epub 2013 Jul 27.
  17. Amin MB, Crotty TB, Tickoo SK, Farrow GM: Renal oncocytoma: a reappraisal of morphologic features with clinicopathologic findings in 80 cases. Am J Surg Pathol 1997; 21(1): 1-12.
  18. Perez-Ordonez B, Hamed G, Campbell S, et al.: Renal oncocytoma: a clinicopathologic study of 70 cases. Am J Surg Pathol 1997; 21(8): 871-83.
  19. Leroy X, Moukassa D, Copin MC, Saint F, Mazeman E, Gosselin B: Utility of cytokeratin 7 for distinguishing chromophobe renal cell carcinoma from renal oncocytoma. Eur Urol 2000; 37(4): 484-7.
  20. Tickoo SK, Lee MW, Eble JN, Amin M, Christopherson T, Zarbo RJ, Amin MB. Ultrastructural observations on mitochondria and microvesicles in renal oncocytoma, chromophobe renal cell carcinoma, and eosinophilic variant of conventional (clear cell) renal cell carcinoma. Am J Surg Pathol. 2000 Sep;24(9):1247-56.
  21. Kawaguchi S, Fernandes KA, Finelli A, Robinette M, Fleshner N, Jewett MA: Most renal oncocytomas appear to grow: observations of tumor kinetics with active surveillance. J Urol 2011; 186(4): 1218-22.
  22. Siu W, Hafez KS, Johnston WK, 3rd, Wolf JS, Jr.: Growth rates of renal cell carcinoma and oncocytoma under surveillance are similar. Urol Oncol 2007; 25(2): 115-9.

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  13. I will like to share my testimony to you all.i got married to my husband about three year ago we start having problems after two years of the marriage, like we stop sleeping on the same bed, fighting about little things he always comes home late at night, drinking too much and sleeping with other women outside, i have never love any man in my life except him, he is the father of my two children and I don't want to loose him because we have worked so hard together to become what we are and have today, few months ago he now decided to live me and the kids, being a single mother can be hard sometimes and so I have nobody to turn to, I was heart broken.i called my mom and explain every thing to her, my mother told me about Dr Ehighaloa, how he helped her solve the problems between her and my dad, my dad always snow at night, if he is sleeping at night, his snowing will even wake our neighbors, it became a big problem in my hood, that led to the brake up between my parents, I was surprise when my mom told me that Dr Ehighaloa had helped him stop his snowing, and brought them together, i was surprise about it because they have been without each other for three and half years and it was like a miracle how they came back to each other, and how my dad stop snoring, that was how i was directed to Dr Ehighaloa, and explain everything to him, so he promise me not to worry that he will cast a spell and make things come back to how we where so much in love again and that it was another lady that cast a spell on him, that was controlling my husband, he told me that my problem will be solved within 30 hours if I believe I said yes, So he cast a spell for me and after 29 hours my love came back asking me to forgive him.i Am so happy now, so that why I decided to share my experience and testimony with every body that have such problems contact him email. drehighaloaspelltemple@gmail.com you can as well call him on his number +2348134548904 or wathsapp him on +2348144661207
    PENIS ENLARGEMENT
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    At the process these are the things he told me he can do for any person who is interested .. contact him on his private email and explain what you want him to do for you i assure you he shall help,His email is drehighaloaspelltemple@gmail.com or http://drehighaloaspelltemple.webs.com/

    ReplyDelete
  14. hello everyone i am Ashley Walters from Jamaica penis enlargement and erectile dysfunction has been a problem to me for more than 7 years,my wife always get disappointed with me when ever we have sex in bed,i don’t last for up to two minute,during sex, i have taking different medication but to no solution,then i went on the net for a solution on how to enlarge my penis and i got contact of DR HARRY who help in cure erection and ejaculation problem with his product and also help to enlarge penis,i got in touch with him through is email drharrysolution@gmail.com or website http://drharrysolutio.wixsite.com/dr-harry ,he replied me and gave me steps to follow and i got his herbal product. which i took for just 2 weeks and my premature ejaculation is now normal and my erection is hard and my
    penis got bigger up to 10 inches and 6.5 girth than before and now i can last long in bed. now 10.5 inches long on erection and off course very large round. I am very happy for this Penis Enlargement experience no side problem . He can help with all kinds of cure you may need as follows:
    Penis Enlargement
    Low sperm count
    Weak Erection
    Love spell
    Herpes spell
    HIV spell
    Pregnancy spell
    Marriage for spell
    cancer
    watering sperm
    womb fertilization
    penis erection
    witch craft attack
    s t d diseases
    internal heat
    rashes
    low sperm count
    dairy
    long time sickness
    kidney,heart,lungs,problem
    with doctor,DR HARRY you are in safe hands your healing is assured
    Email:drharrysolution@gmail.com or website http://drharrysolutio.wixsite.com/dr-harry .. you can for whatsapp number: +2348143240563 thanks

    ReplyDelete
  15. Greetings to the general public, i want to tell about how i was cured of HIV/AIDS disease by a Doctor called Dr EHI. I was browsing through the Internet searching for remedy on HIV and i saw comments of people talking about how Doctor EHI cured them. I Was scared because i never believed in the Internet but i was convince to give him a try because i having no hope of been cured of HIV/AIDS so i decided to contact him with his email that was listed on the comment (dr.ehispelltemple1@gmail.com) when i contacted him he gave me hope and send a Herbal medicine to me that i took and it seriously worked for me, am a free person now without problem, my HIV result came out negative. I pray for you Dr EHI God will give you everlasting life, you shall not die before your time for being a sincere and grate men. Am so happy, you can also contact him if you have any problem Email: dr.ehispelltemple1@gmail.com

    ReplyDelete
  16. Grateful on how DR KOBA miraculously help me on my penis enlargement which i have suffered for so long and since then i have never witness any form of insult from my woman, before now she always says lot of bad words to me, that i am not a full man, but now she is after sex and it has gotten to a point when i am tired as we have sex from 12AM Till 5AM and still asked for more, but i am very happy that after i meant with DR KOBA my life turned around, if you having issues of quick ejaculation, slow erection problem, and cumming on time. all you have to do is to contact DR KOBA and have your issues resolved for ever and have a happy sex life, with your partner or spouse. because today i am a living testimony of DR KOBA wonder cream action. waste no more time and write to him on his email:drkobaherbalsolutionhome@gmail.com or his what app number:+2349037387574 or his website:https://drkobaherbalsoluti.wixsite.com/dr-koba

    ReplyDelete
  17. I'm Dorothy Saltzman, From Texas, USA. but curently Reside in Germany. It's no longer Rumors that the Acquired Immune Deficiency Syndrome ALS And Herpes Virus is increasing Day by Day. The fear is that many people living with the sickness are scared of saying it because of the stigma that comes along with it. I 'm bold enough among many others to state that there is now a Potent Cure to this sickness but many are unaware of it. I discovered that I was infected with ALS virus 3months Ago, After a Herbal Medical Check-Up. My Doctor EHI, told me and I was shocked, confused and felt like my World has crumbled. I was dying slowly due to the Announcement of my Medical Practitioner but he assured me that I could leave a normal life if I took my Medications (as there was no Medically known Cure to Herpes). I went from Churches to Churches but soon found that my Case needed urgent Attention as I was growing lean due to fear of dying anytime soon. In a bid to look for a lasting solution to my Predicament, I sought for solutions from the Voodoo World. I went online and searched for every Powerful Trad-medical Practitioner that I could Severe, cos I heard that the African Voodoo Priests had a cure to the Herpes Syndrome. It was after a little time searching the Web that I came across one Dr EHI (A Powerful African Voodoo Priest), Who offered to help me at a Monetary fee. I had to comply as this was my Final bus-stop to receiving a perfect healing. My last resolve was to take my life by myself, should this plan Fail. At last it worked out well. He gave me some steps to follow and I meticulously carried out all his Instructions. Last month, to be precise, I went back to the hospital to conduct another test and to my Amazement, the Results showed that " I am NEGATIVE". You can free yourself of this Herpes virus by consulting this great African Voodoo Priest via this e-mail:(drehicurehome123@gmail.com) or call and whats-app him on +2349030589283 He will help you and his Herbal Medication is Sure. He has the Cure on all this Disease/Virus as He told me and it listed. GENITAL WARTS/ PREGNANCY. EPILEPSY. GENPILENCIN, HIV/AIDS, MADNESS, WEAK ERECTION, WATERY SPERM, TUBERCULOUSES, PENIS ENLARGEMENT, PREGNANCY, DIABETICS, STROKE, EXPANDS OF PENIS BREAST H.P.V TYPE 1 TYPE 2 TYPE 3 AND TYPE 4. TYPE 5, HUMAN PAPAILOMA VIRUS, HERPES, SYPHILIS, BREAST CANCER, HEPATITIS A B and C, HIGH BLOOD PRESSURE, AND BODY BOILS, BODY ODDUR, AND BODY DISEASES , THANK TO YOU ALL FOR YOUR TIME OF READING MY TESTIMONY AND MOST ESPECIALLY YOU Dr EHI. I PRAY TO GOD TO NEVER LET ME AND MY FAMILY FORGET YOU IN OUR LIFE

    Why go the Expensive Treatment? when Dr. EHI is there to help you get rid of that
    Incurable Disease with his Herbs and Healing Oil. I contracted Genital Herpes 2 years ago, I saw this Awesome Testimonies you can view on google during my research for Herpes Cure from an article made by Alexander Millin and Lancelot Morgan, How they but got Cured from HIV/HERPES VIRUS Respectively. They also dropped the Contact Address of this Great Man: drehicurehome123@gmail.com Advising that if anyone need help to Cure any Incurable Disease or Viral Infection that he should Contact This Great Man. I contacted him, thank God I did. I'm still in shock that the Herbal Treatment he sent to me actually Works. It seems so simple, and in a lots of ways I guess its simple. But the important thing is that I have been 100% herpes free for full two years now and it's all thanks to you Dr. Ehi You'hv given me my life back, I'll forever remain Grateful,. you can email me for assistant on: drehicurehome123@gmail.com. Please Once you are cured let others know about it no need hiding it. Together We fight to become healthy.
    Dr. EHI Root/Herbs and Healing-Oil has been used to cured Home and Abroad
    REVELATION22.2
    GENESIS1:29

    ReplyDelete
  18. +1(310) 220-0075 men clinic penis enlargement herbal cream in Africa by (DR.BEN).

    This is the only Male Penis Enlargement Cream has been used by men around the world supplement that has been PROVEN to-enlarge your penis – safely, quickly, and importantly – PERMANENTLY.Full BEN Penis Enlargement Cream when used will Increase in penis length by 1-5 inches Increase in penis width by 20%helps in preventing Premature Ejaculation.Achieved longer, rock hard erections All gains in penis length and width are 100% permanent Full BEN Penis Enlargement Cream is also:100% Herbal, 100% Safest with no side effect and its of two types I have the one for enlargement and for reduction and your advised to use it by message 100% Satisfaction and Money Back Guarantee. DR. BEN, About my products i have herbal cream and oil 100% Permanent Guaranteed resulting it on your body where you feel you want to reduce or enlarge which will help you to be strong and you get the desirable size you want-within 3-5 days and when you get your desirable size you are advised to stop using it and the results you gain will remain permanent We also do deliveries all over Nigeria, and worldwide so i would like to know first when do you need the product.for more information call Dr. BEN +1(310) 220-0075 email; benherbaltemple@gmail.com Via: Webs http://benherbaltemple.webs.com/ for more information call +1(310) 220-0075





    +1(310) 220-0075 men clinic penis enlargement herbal cream in Africa by (DR.BEN).

    This is the only Male Penis Enlargement Cream has been used by men around the world supplement that has been PROVEN to-enlarge your penis – safely, quickly, and importantly – PERMANENTLY.Full BEN Penis Enlargement Cream when used will Increase in penis length by 1-5 inches Increase in penis width by 20%helps in preventing Premature Ejaculation.Achieved longer, rock hard erections All gains in penis length and width are 100% permanent Full BEN Penis Enlargement Cream is also:100% Herbal, 100% Safest with no side effect and its of two types I have the one for enlargement and for reduction and your advised to use it by message 100% Satisfaction and Money Back Guarantee. DR. BEN, About my products i have herbal cream and oil 100% Permanent Guaranteed resulting it on your body where you feel you want to reduce or enlarge which will help you to be strong and you get the desirable size you want-within 3-5 days and when you get your desirable size you are advised to stop using it and the results you gain will remain permanent We also do deliveries all over Nigeria, and worldwide so i would like to know first when do you need the product.for more information call Dr. BEN +1(310) 220-0075 email; benherbaltemple@gmail.com Via: Webs http://benherbaltemple.webs.com/ for more information call +1(310) 220-0075

    ReplyDelete
  19. The ureteral stents by Manish Medi innovation are made of soft plastic which is used to remove kidney stones. It is an effective method of handling urinary blockage and popularly used by specialists.
    http://www.manishmediinnovation.net/ureteral-stent/

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  20. I am a spell caster called Dr Ajayi Ololo, I was the chief priest to this great temple called OLOLO at the age of 18years, and now i am almost 60 years old man. I am telling this to the world to make them know that this temple has been in existence for years now and we have been durable and truthful to all. Our work here is helping anybody to getting there heart desire, Over here in this temple we grant anything you want us to do for you and when you come to this temple you must see result of our work. NOTE: TO THE ONES THAT HAS BEEN DECEIVED BY THOSE ONLINE SCAMMERS, DO NOT COMPARE THIS GREAT TEMPLE WITH ANY OTHER SPELL CASTER THAT HAS RIPPED YOU OFF YOUR MONEY BY CLAMMING TO BE SPELL CASTERS. THEY ARE ALL FAKE AND SCAMMERS ONLINE THERE TO RIP WERE THEY DID NOT SOW, COME TO OLOLO SPELL CASTING TEMPLE AND GET YOUR HEART DESIRE WITHOUT STRESS. In this temple, we work with the spirits in the spiritual realm and they tell us how to solve any problem that you are facing and also i will want you to NOTE: THAT THIS SPELL CASTING DO NOT HAVE ANY SIDE EFFECT ON ANYONE, BUT JUST TO GET YOUR HEART DESIRE AND BE HAPPY. I Dr Ajayi Ololo urge you all that has the following problem 1.} We heal barrenness in women and disturbing menstruation 2.} Get you marriage to the lover of your choice 3.} Guarantee you win the troubling court cases & divorce no matter how what stage 4.} Ensure success in work and business 5.} Mental illness & bewitched 6.} Can?t sleep at night or walking at night 7.} Recover stolen property and whereabouts of people that hurt you. 8.} Bring supernatural luck into 9.} Extreme protection for those doing dangerous jobs like security guards, Bank manager, cash transporters, To mention but a few.11. Get your scam money back 12.} Bring back lost lover, even if lost for a long time 13.} Remove bad spells from homes, business & customer attraction etc. 14.} Get promotion you have desired for a long time at work or in your career.16.} Remove the black spot that keeps on taking your money away 17. Find out why you are not progressing in life and the solution 18.} Eliminate in family fights 19.} Ensure excellent school grades even for children with mental disabilities 20.} Stop your marriage or relationship from breaking apart 21.} I destroy and can send back the Nikolos if requested 22.} . COME HERE AND SOLVE ALL YOUR PROBLEMS HERE AND GET ALL YOUR HEART DESIRES HERE WITHOUT ANY-SIDE EFFECT ON IT. ANY KIND OF PROBLEM YOU ARE FACING IN LIFE SEND YOUR EMAILS TO: ajayiololo@yahoo.com . to get it solved in the next 5 to 6 hours.

    THE ONLY TEMPLE WERE YOU CAN GET YOUR EX-LOVER BACK AND MANY MORE!!. Anyone that require the help of our services should kindly send an email to the following email address: ajayiololo@yahoo.com .

    ReplyDelete
  21. TAKE IT OR LEAVE WE STILL REMAIN THE ONLY TRUE EXISTING SPELL CASTER ON EARTH.
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    ReplyDelete
  22. Thank God for the good works of Dr Henry Bude who has really been the mentor of my marital happiness. I had penis erection and enlargement problems which affected my marriage so badly. My penis was very small measuring just about 4 inches, i also masturbated a lot when i was teen and it affected my penis and caused erectile dysfunction which almost cost me my 3 months old marriage. I saw comments about Dr Henry when i was searching online for help, and i called him on +234810063964 and explained my problems to him , he encouraged me and told me about his herbal medicines which he said was powerful enough to cure my weak erection and enlarge my penis. I purchased the herbal medicines and used them as directed and the experience was awesome. For just within few days of use i started noticing good results of my penis enlarging and also responding to erections and now i can proudly say to the entire world that my weak penis erection has been cured by the herbal medicines which was sent to me by Dr Henry Bude. The herbal medicines worked and i now measure up to 9 inches long when fully erect. And if you are reading this message and you want to get rid of that penis problems disturbing your reproduction or relationship, i need to let you know that you shouldn't lost the hopes of been able to satisfy your woman someday, just contact Dr Henry Bude right now also directly on his Email: dr.henrybude@gmail.com and calls/whatsapp on +2348100663964

    ReplyDelete
  23. Hello everyone am Laurens from USA. I have been doing some research on how to increase my length and growth of my penis I came across some few comments about Dr MANBELA, PENIS Enlargement cream some weeks ago, though I had really wanted my PENIS to grow large, I never thought of having it as great as it is now, I am now very good in sex , am really amazed on the fast results archived within 3 weeks of using the Enlargement cream since I purchased 1 for myself, now and i believe my friend will love it more now, am very happy for this , Enlargement experience and so grateful to the Dr and his Penis enlargement cream, hip's curve, Brest bombs Enlargement. contacts via: Manbelaspelltemple1@gmail.com or add him up through is whatsapp number +2348100929597. contact him now , he is such a honest man. once again thanks Dr. MANBELA am very grateful.

    ReplyDelete
  24. I would like to let all know that the size of your Penis really matters in your relationship or marriage. I got married to my wife about 1 month after we met on a photo studio, we lived happily for the first 3 months of our marriage until i and my wife started having quarrels at home because i couldn't satisfy her on bed with my little penis. Actually my penis was very small, it measured about 4.5 inch long on erection and i am 39 years old. My wife said it was forbidden by the women of this world. My wife started sleeping with other men outside. Sometimes i will return from work without finding my wife at home and whenever i call or ask her where she was, she will always snub at me and sometimes just tell me to go get a larger dick. All this continued for a long time and it hurt me so much that i was at the edge of breaking up on the marriage till when i read about a doctor called DR.Moses Buba. online. I never thought i could smile and be in a happy marriage again if not for the help of DR.Moses Buba. I got the doctors Emails:(buba.herbalmiraclemedicine@gmail.com ) on the internet and i emailed him, and he got back to me with some encouraging words, he got me some herbs cream which i use for just 8 days and i began to feel the enlargement of my penis, and without surgery. This went on for a little period of about 10 days and to my surprise my wife keeps screaming that she love my big dick now. Now my wife no longer cheat on me, and my penis is now about 10.5 inches long on erection and off course very large round. And now my wife uses breasts, hips and bums enlargement. I and my wife are very happy for the help rendered to me by DR.Moses Buba, and i want to say a big thanks to Doctor for the help. You can contact the Doctor now on his Email:( buba.herbalmiraclemedicine@gmail.com ) Am thankful to the doctor for helping me.
    ,,,.,

    ReplyDelete
  25. https://www.google.as/url?sa=t&rct=j&q=&esrc=s&source=web&cd=69&cad=rja&uact=8&ved=0ahUKEwjatrG18bLUAhXMMyYKHU0hBqo4PBAWCFkwCA&url=http%3A%2F%2Ftruedemocracyparty.net%2F2013%2F11%2Fgarlic-the-natural-cure-8-scientific-studies-that-prove-garlic-kills-cancer-dead-dead-dead%2F&usg=AFQjCNEcA72bwsl9J13plMi-hYrue-K6eg

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  26. So amazing i am little bit ashamed to share this marvelous story about a great Dr Oboite who helped me to enlarge my small penis size and my weak erection through his herbal medicine and cream,i was passing through many heart broke because i have a very small penis about 3 inches i was so are shame of my self i could not satisfy my wife in bed,my marriage was really breaking, my wife was about to divorce me and i needed help urgently,i have used all type of drugs but none work for me,so one faithful day as i was browsing through the internet i saw few comments on a forum about how Mr Paul Kern from France testified how Dr Oboite helped him to enlarge his penis and also cured his weak erection,i contacted him through his email droboiteherbalcurehome@gmail.come he replied and gave me steps to follow and i did just as he said ,and he sent me the herbal medicine and cream to me through the DHL service and i receive it within 3 days and i used the herbal medicine and the cream for just one week to my greatest surprise my penis that was just 3 inches got enlarge to 10 inches long and fully strong,wow my wife love me more then before i am so happy that i can satisfy her very well now in bed ,,i even last longer than before thank you so much Dr Oboite for making me a real man again ..so if you are out there having similar problems please contact him now on his email droboiteherbalcurehome@gmail.come or whatsapp him or call him through his phone number +2348054265852.

    ReplyDelete
  27. My name is Hector Colin,i just want to share my testimony with the world on how Doctor Trust Help me to enlarge my pines. Please read my good news carefully and i am sure it will affect your life positively on how you will also enlarge your pines,because i know some many people out there also need his help!

    I came across so many comments about Dr Trust Penis Enlargement Medicine some weeks ago, though I had really wanted my penis to be large, long and thick,because i was not able to have sex with my wife..It was really affecting our marriage and my wife was about to divorce me. I had about 3.7cm – 3.2 inches before. Am really amazed on the fast results archived within 14 days of using Dr. Trust Penis Enlargement Medicine. It work and now I have got 22.87cm – 10.5 inches now. And my wife love it more now, i began to feel the enlargement of my penis, This went on for a little period of about 5 days and to my surprise my wife keeps screaming that she love my big dick now. And my penis is now 10.5 inches long on erection and off course very large round. I am very happy for this Penis Enlargement experience. He can help with all kinds of cure you may need as flows:

    Pines Enlargement
    Low sperm count
    Weak Erection
    Love spell
    Herpes spell
    HIV spell
    Pregnancy spell
    Marriage for spell
    cancer
    watering sperm
    womb fertilization
    penis erection
    witch craft attack
    s t d diseases
    internal heat
    rashes
    low sperm count
    dairy
    long time sickness
    kidney,heart,lungs,problem
    with doctor,Dr. Trust you are in safe hands your healing is assured

    Email:Ultimatecurecenter@yahoo.com
    Web site: https://ultimatecurecenter.wixsite.com/dr-trust
    Call or WhatApp him +2348156885231

    ReplyDelete


  28. It is a pleasure to testify of the good works of Dr.Voodoo in my life, few months ago I started searching online for solution to my insatiable sexual life, not been able to last long in bed made my wife cheat on me several times till I came across a testimony of (ASHLEY CLARK) on how Dr.Voodoo helped him enlarge his penis and how he could last longer then he used to after using his medicine so I summoned courage to contact him through the phone number that I got in his testimony (+2348135790702) quickly I did! Soon I got a reply from him and also words of encouragement, after which he sent me some liquid that I should use and in three weeks I could tell of the difference when ever I made love to a woman, life has been at it best ever since I meet Dr.Voodoo, his work are magnificent. You can talk with him on email (voodoospell10@gmail.com) or call (+2348135790702) for more information or whatsapp with him......

    ReplyDelete

  29. Sometimes when i read people comment about how they break up or separate with their ex and how they want him or she back get me worried because i was once like you guys, it all started when my ex went on holiday in Germany he met a lady there who my husband eventually fall in love with and forget he has me and the kids here in united states. My ex stop calling me and wanted not to come back to me again i was totally depress and hopeless when i found about his lover in Germany, it was a good friend of mine who directed me to high Dr. Todd that he can cast a spell to bring him back and love me alone forever. I contacted high Dr. Todd and behold my ex husband came back to me begging and kneeling for my forgiveness. You can contact him now if you want your ex back::manifestspellcast@yahoo.com or mnifestspellcast@gmail.com..Thank you high Dr. Todd

    ReplyDelete