Letter to the Editor
Mixed epithelial and stromal tumor of the kidney
Tumor mixto epitelial-estromal renal
M.E. Martínez-Corrala,
, J.J. Núñez-Oteroa, V. Toucedo-Caamañoa, S.M. García-Acuñab, R. García-Figueirasc, C. García-Freirea
Corresponding author
a Servicio de Urología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
b Servicio de Anatomía Patológica, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
c Servicio de Radiodiagnóstico, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
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Old male patient with histol. Proven urothelial cancer of the bladder pT2high grade, and biopsy proven multifocal high grade UTUC.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">A)</span> Histophatological specimen en-block removal of the right kidney, ureter, bladder, prostate and membranous part of the urethra (because of the prostatic urethra involvement in conjunction with high grade urothelial cancer). <span class="elsevierStyleItalic">B)</span> Aproxx15 cm. Of the colon and 20 cm. Of the terminal ileum is used for neobladder reconstructions <span class="elsevierStyleItalic">C)</span> Configuration of the orthotopic ileo-coecal pouch with appendix as a substitute for the missing membranous urethra (white arrow-appendix). <span class="elsevierStyleItalic">D)</span> Reconstruction of the appendico-urethral anastomosis end to end with absorbable 5.0 maxon interrupted sutures (appendix-white arrow, bulbar urethra-black arrow). <span class="elsevierStyleItalic">E)</span> Postoperative cystogram<span class="elsevierStyleItalic">. F)</span> Because of the stricture recurrence in the site of the anastomosis, Memokath stent (white arrow) was placed (which made patient to be completely incontinent), therefore in the same setting was AMS 800 implanted concomitantly. <span class="elsevierStyleItalic">G)</span> Measurement of the retrograde leak point pressure (AMS 800 was activated, RLPP > 45 mm/H<span class="elsevierStyleInf">2</span>O, cuff is closed-black arrow.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Weibl, G. Ameli, C.H. Plank, W. Huebner" "autores" => array:4 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Weibl" ] 1 => array:2 [ "nombre" => "G." "apellidos" => "Ameli" ] 2 => array:2 [ "nombre" => "C.H." "apellidos" => "Plank" ] 3 => array:2 [ "nombre" => "W." 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"apellidos" => "Martínez-Corral" "email" => array:1 [ 0 => "memartinezc92@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J.J." "apellidos" => "Núñez-Otero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "V." "apellidos" => "Toucedo-Caamaño" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "S.M." "apellidos" => "García-Acuña" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "R." "apellidos" => "García-Figueiras" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "C." "apellidos" => "García-Freire" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Urología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tumor mixto epitelial-estromal renal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1499 "Ancho" => 1500 "Tamanyo" => 537131 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(a) Voluminous cystic lesion (asterisk) dependent on the interpolar region of the left kidney (LK); (b) left partial nephrectomy and excision of the large cystic mass showing renorrhaphy with interrupted 2-0 Vicryl™ suture and Hem-o-Lock®, and application of a TachoSil® patch (white arrow); (c) tumor lesion with solid–cystic areas; (d) hematoxylin and eosin stain, 20×. A neoplastic lesion made up of epithelial and stromal components can be seen.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Mixed epithelial and stromal tumors (MEST) of renal origin were first described by Michal and Syrucek in 1998.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> They are grouped, along with adult cystic nephroma, within mixed epithelial and mesenchymal tumors, according to the 2016 World Health Organization classification of renal tumors.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Below, we describe the case of a 46-year-old male who presented to the emergency department for progressive abdominal distention. A computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast showed a heterogeneous lesion initially suspicious for angiomyolipoma with signs of progressive bleeding. Given our suspicion of a retroperitoneal tumor lesion and the difficulty in characterizing the lesion, abdominal magnetic resonance imaging (MRI) was performed, revealing the presence of a large cystic mass initially interpreted as a retroperitoneal teratoma (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In view of these findings, it was decided to perform a left partial nephrectomy and excision of the large cystic mass. A mixed tumor lesion with solid–cystic areas was macroscopically identified. The definitive anatomopathological study identified a biphasic tumor made up of epithelial and stromal components (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The patient is currently asymptomatic after 16 months of follow-up with no signs of recurrence or distant metastasis in subsequent imaging studies.</p><p id="par0025" class="elsevierStylePara elsevierViewall">MEST of the kidney is a rare entity of unknown etiology. It accounts for about 0.20%–0.28% of all renal neoplasms and should be considered within the differential diagnosis of kidney tumors.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It occurs most frequently in women aged between 36–80 (mean age 46 years, female:male ratio of 6:1<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>).</p><p id="par0030" class="elsevierStylePara elsevierViewall">Although it is usually benign without recurrence or metastasis,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> some cases of malignant sarcomatoid or carcinomatoid behavior have been described<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> and malignant transformation can be observed in both components: the epithelial and the stromal.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In cases with clinical manifestation, it usually presents as a palpable abdominal mass, macroscopic hematuria, lumbar pain or urinary tract infection.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However, approximately 25% of MEST are asymptomatic and diagnosed incidentally.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The diagnosis is often based on the CT imaging diagnostic tool, where it presents a diverse appearance; it may sometimes mimic cystic nephroma and multilocular cystic renal cell carcinoma.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Due to the difficulty to establish an accurate preoperative diagnosis of MEST in the absence of typical radiological features,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> histopathological and immunohistochemical examination is mandatory to obtain a definitive postoperative diagnosis.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Macroscopically, it is a complex neoplasm composed of a mixture of solid and cystic elements,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> well circumscribed, with a size that ranges from a few centimeters to large masses. In terms of histopathologic features, they reveal a biphasic growth pattern comprising stromal elements with epithelial components.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The immunohistochemical profile of the stromal component demonstrates positivity for desmin, vimentin, smooth muscle actin, caldesmon, estrogen and progesterone receptors, as well as CD10. The expression of estrogen and progesterone receptors in the stromal component reflects the influence of hormones in the development of this type of tumor. The epithelial component usually expresses cytokeratins (especially CK7), GATA3 and PAX8.</p><p id="par0060" class="elsevierStylePara elsevierViewall">When feasible, nephron-sparing surgery<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> is the standard treatment and these tumors have a favorable prognosis.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Since certain cases with malignant behavior have been described, continuous postoperative follow-up<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> may be advisable in order to rule out possible malignant transformations in a subset of these patients.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Martínez-Corral ME, Núñez-Otero JJ, Toucedo-Caamaño V, García-Acuña SM, García-Figueiras R, García-Freire C. Tumor mixto epitelialestromal renal. Actas Urol Esp. 2021;45:412–415.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1500 "Ancho" => 1500 "Tamanyo" => 245088 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) Axial contrast-enhanced abdominopelvic CT scan (portal phase) showing a complex and heterogeneous mass which originated in the left kidney (red arrows) with areas of macroscopic fat (white arrows), a large cystic portion (asterisk) and small foci of calcification (arrowhead); (b) coronal plane reconstructed image of the same case showing a septum in the most caudal portion of the cystic component (red arrowheads); (c and d) T2-weighted MR images without (c) and with (d) fat saturation showing the displacement of the left kidney (LK) and the cystic (asterisk) and fat (red arrows) components of the mass. The fat elements produce signal loss in the MRI sequence with fat saturation (d).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1499 "Ancho" => 1500 "Tamanyo" => 537131 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(a) Voluminous cystic lesion (asterisk) dependent on the interpolar region of the left kidney (LK); (b) left partial nephrectomy and excision of the large cystic mass showing renorrhaphy with interrupted 2-0 Vicryl™ suture and Hem-o-Lock®, and application of a TachoSil® patch (white arrow); (c) tumor lesion with solid–cystic areas; (d) hematoxylin and eosin stain, 20×. A neoplastic lesion made up of epithelial and stromal components can be seen.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Benign mixed epithelial and stromal tumor of the kidney" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Michal" 1 => "M. 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