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CASE REPORT
Metanephric Adenoma: clinical, imaging, and Histological findings
Fábio César Miranda TorricelliI,
Corresponding author
fabio_torri@yahoo.com.br

Tel.: 55 11 5533-4900
, Giovanni Scala MarchiniI, Rodrigo Sousa Madeira CamposII, Antônio Otero GilIII
I Urologic Surgeon, Urology Department, Faculdade de Medicina da Universidade de Sao, Sao Paulo - SP – Brazil.
II Urologic Surgeon, Urology Department, Hospital do Servidor Público Estadual, Sao Paulo - SP – Brasil.
III Urology - Instituto Dante Pazanezzi, Sao Paulo, São Paulo, Brazil.
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">Metanephric adenoma &#40;MA&#41;&#44; also designated nephronogenic nephroma or renal epithelial tumor resembling immature nephron&#44; has just been recently recognized as a special type of benign renal epithelial tumor&#46; Only few reports are found in the literature regarding this rare renal tumor&#46; The purpose of this paper is to describe our clinical&#44; imaging and histological &#47; immunohistochemical observations of MA diagnosed in two patients and compare these data to previous information reported in medical databases&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">Case Report</span><p id="para20" class="elsevierStylePara elsevierViewall">The first case refers to a 70-years-old female patient&#44; who except by systemic arterial hypertension was completely healthy&#46; During routine examinations&#44; a mass of 4&#46;5 cm located on the lower third of her right kidney was incidentally found&#46; At that time&#44; the patient presented only low-grade fever and weakness for about two weeks&#46; Abdominal ultrassonography &#40;USG&#41; showed hypoechoec mass with solid aspect and irregular limits&#46; It was heterogeneous and exofitic&#44; containing septation and cystic areas in its interior&#46; Magnetic resonance imaging &#40;MRI&#41; showed a solid mass 5&#46;2 cm for its higher dimension located in right kidney with same hemorrhagic foci and no sign of peri-renal invasion &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1</a>&#41;&#46; Also&#44; simple renal cysts were evidenced&#46; The patient was submitted to a successful partial nephrectomy by open surgery&#44; evolving uneventfully&#46; Pathologic examination of surgical specimen revealed a firm lesion of light brown tissue with reticulated central area and clear delimitation from the adjacent parenchyma&#46; Microscopic evaluation showed no cellular atypical or mitotic activity&#46; Peri-renal adipose tissue was free from neoplasic invasion&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><p id="para30" class="elsevierStylePara elsevierViewall">The second patient was a 23-year-old man with no previous heath problem&#44; who presented with flank pain for one month&#46; Abdominal USG showed a 4&#215;4 cm nodular&#44; solid and heterogenic lesion with hyperecogenic areas and exofitic characteristics in the lower third of right renal parenchyma&#46; Computed tomography &#40;CT&#41; confirmed the presence of a 4 cm expansive tumoral formation with intermediate attenuation and minimum venous contrast enhancing at that anatomic site &#40;<a class="elsevierStyleCrossRef" href="#fig2">Figure 2</a>&#41;&#46; Partial nephrectomy was again the therapeutic choice&#46; The patient evolved well but an arterial-venous fistula clinically manifested by hematuria was diagnosed in post-operative &#40;PO&#41; day five&#46; The fistula was successfully embolized by arteriography and no other complications occurred&#46; Immunohistochemical study employing incubation of histological cuts with mono and polyclonal antibodies &#40;panels&#41; showed a profile focally and positive to WT-1&#44; EMA and CK7&#46;</p><elsevierMultimedia ident="fig2"></elsevierMultimedia><p id="para40" class="elsevierStylePara elsevierViewall">Both patients are free of neoplasic disease with no signs of recurrence after 2 years of follow up&#46;</p></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">DISCUSSION</span><p id="para50" class="elsevierStylePara elsevierViewall">MA is a renal tumor with benign behavior&#46; The classification is based on a combination of histological&#44; immunohistochemical&#44; and genetic features&#46; Most small MA tumors are well circumscribed&#44; firm&#44; and white&#59; larger tumors may be hemorrhagic and softer&#46;</p><p id="para60" class="elsevierStylePara elsevierViewall">The cytology of a few cases has been described<a class="elsevierStyleCrossRef" href="#bib1">1</a> and is composed of tight&#44; short papillae and loose sheets of cells with scant cytoplasm&#44; round nuclei&#44; fine chromatin and rare small nucleoli&#46; By analyzing all described findings at immunohistochemical and lectin histochemical studies&#44; MA has shown reactivity for keratin &#40;CK7 is the most common&#41;&#44; CD 57&#44; vimentin&#44; S-100 protein&#44; EMA&#44; lysozyme&#44; a-1-antitrypsin&#44; PNA&#44; DBA&#44; SBA and WT-1&#46;<a class="elsevierStyleCrossRef" href="#bib2">2</a> It seems that&#44; despite the variability&#44; CK7 focally positive is a rule&#46; In our second case&#44; immunohistochemic examination revealed WT-1&#44; EMA and CK7 locally positive&#46;</p><p id="para70" class="elsevierStylePara elsevierViewall">Unlike renal adenoma&#44; which is by definition &#60;5 mm in diameter&#44; MA can grow to a large size&#46; The diameter of MA ranges from 6 to 200 mm<span class="elsevierStyleSup">2</span>&#46; Our findings were renal tumors of 40 and 45 mm&#46; All MA reported&#44; except one&#44;<a class="elsevierStyleCrossRef" href="#bib3">3</a> behaved in a benign way with no metastatic findings or local recurrence after surgical removal&#44; showing no evidence of cellular atypical or mitotic activity&#46;<a class="elsevierStyleCrossRef" href="#bib2">2</a> Similar fact was observed for our two patients&#46; For their special findings in MA variants&#44; some authors deserve brief comment&#46; In 2000&#44; Renshaw et al <a class="elsevierStyleCrossRef" href="#bib3">3</a> presented the only reported case of a metastatic disease from a typical MA occurring in a 7 year old child&#44; but no death related to the tumor has been demonstrated&#46;</p><p id="para80" class="elsevierStylePara elsevierViewall">Clinical manifestations related to MA are very unspecific and sometimes even absent&#44; being the majority of these renal tumors incidentally found&#46;<a class="elsevierStyleCrossRef" href="#bib4">4</a> In 1995&#44; four of eight cases reported by Nonomura et al<a class="elsevierStyleCrossRef" href="#bib5">5</a> were found with no signs or symptoms and two presented only a tumoral mass&#46; In the same year&#44; Jones et al<a class="elsevierStyleCrossRef" href="#bib6">6</a> reported one tumor found only at autopsy and six tumors discovered during other pathological investigation&#46; When present&#44; signs and symptoms include abdominal or flank pain&#44; hematuria&#44; palpable mass&#44; hypertension and fever&#46; Our cases presented some of these clinical findings&#46;</p><p id="para90" class="elsevierStylePara elsevierViewall">At present there are only few reports regarding the imaging findings of MA&#46; Some authors found adenomas to be hyperechoic at USG&#46;<a class="elsevierStyleCrossRefs" href="#bib7">7&#44;8</a> MA has been described to show enhancement on contrast CT&#44; but angiography reveals neither neovascularization nor tumor staining&#46; <a class="elsevierStyleCrossRefs" href="#bib7">7&#44;8</a> On both T1- and T2-weighted MR images&#44; the tumor is represented as an isointense mass&#46;<a class="elsevierStyleCrossRefs" href="#bib5">5&#44;7</a> On the imaging findings of MA&#44; hypovascularity and frequent calcification may be rather characteristic&#46; Bastide et al<a class="elsevierStyleCrossRef" href="#bib9">9</a> reported their imaging findings in nine patients&#44; describing MA as a lesion with no vascular flow on color Doppler USG&#44; presence of calcifications&#44; and minimal enhancement in contrast CT&#46; It is possible to realize that MA has same common findings&#44; however none is so specific neither can exclude malignity&#46;</p><p id="para100" class="elsevierStylePara elsevierViewall">Most reports describe total nephrectomy as gold standard treatment for MA&#44; but partial nephrectomy must be considered a good option&#46; Nowadays&#44; it is known that partial nephrectomy is indicated even to malignant tumors and even large masses &#40;bigger than 4 cm&#41; can be ressected without prejudice to the oncological results&#46; In 2000&#44; Kosugi et al&#46;<a class="elsevierStyleCrossRef" href="#bib10">10</a> performed partial nephrectomy for a 32 years old female patient who presented with a right renal MA of 1&#46;5 cm at abdominal USG examination at a routine medical check up&#46; Our two patients were also treated with partial nephrectomy&#44; procedure with better renal function preservation&#44; without compromising the patient&#39;s survival&#46; Further advance in reducing patient morbidity may be achieved by laparoscopic nephrectomy as reported by Ebine et al&#46;<a class="elsevierStyleCrossRef" href="#bib11">11</a> in 2004 for MA treatment in a 31 years old female patient with a left renal mass of 4&#46;5 cm detected incidentally during an abdominal ultrasound examination&#46; Three years latter&#44; Kumar et al<a class="elsevierStyleCrossRef" href="#bib12">12</a> reported a laparoscopic partial nephrectomy as treatment for MA in a 47-year-old patient&#46; In the biggest MA series reported&#44; Bastide et al<a class="elsevierStyleCrossRef" href="#bib9">9</a> performed four radical and five partial nephrectomies&#46; In this paper&#44; authors suggest a preoperative diagnostic biopsy&#44; a partial nephrectomy or active surveillance&#46; We believe&#44; that biopsy should be reserved to cases where patient refuse or does not have clinical conditions for surgery or less invasive procedure shall be tried&#44; such as cryotherapy&#46;</p><p id="para110" class="elsevierStylePara elsevierViewall">It is possible to realize that MA treatment has evolved as well as others renal tumors approach&#44; and partial nephrectomy should be remembered as an option &#40;<a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl1"></elsevierMultimedia></span></span>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">kosugi&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Open partial nephrectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ebine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Laparoscopic total nephrectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">kumar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Laparoscopic partial nephrectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Batisde&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">4 partial and 5 total nephrectomies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">MA treatment evolution</p>"
        ]
      ]
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      "titulo" => "REFERENCES"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "cebibsec10"
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                      "autores" => array:1 [
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                    1 => array:1 [
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                      "autores" => array:1 [
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                      "autores" => array:1 [
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                            3 => """
                              N Kakkad \n
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Article information
ISSN: 18075932
Original language: English
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es en pt

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