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Clinical report
Retroperitoneal perivascular epithelioid cell tumor in a 47-years old woman
Tumor retroperitoneal perivascular de células epitelioides en una mujer de 47 años de edad
Minguez Ojeda César1,
Corresponding author
cesar.minguez.1994@gmail.com

Corresponding author.
, Lorca Álvaro Javier1, López-Rodríguez Mónica A.2, Andreu Arnanz Ana2, Tagalos Muñoz Ana Cristina1, Gómez Dos Santos Victoria1, Burgos Revilla Francisco Javier1
1 Department of Urology, Hospital Universitario Ramón y Cajal, Madrid, Spain
2 Department of Internal Medicine, Hospital Universitario Ramón y Cajal, Madrid, Spain
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clear cell &#40;&#8220;sugar&#8221;&#41; tumor &#40;CCST&#41; of the lungs and extrapulmonar sites&#46; It was described the association between tuberous sclerosis complex &#40;TSC&#41; and some PEComas&#46;<a class="elsevierStyleCrossRef" href="#bb0015"><span class="elsevierStyleSup">3</span></a></p><p id="p0015" class="elsevierStylePara elsevierViewall">They tend to appear in middle-aged patients and have a marked female predominance &#40;ratio 7&#58;1 female-to-male&#41;&#46; Clinical features depend on the size and location of the tumour&#46;<a class="elsevierStyleCrossRef" href="#bb0020"><span class="elsevierStyleSup">4</span></a> More than 40&#37; occur in the gynecologic tract&#44; but 20-30&#37; are found in the retroperitoneum&#44; soft tissues and skin&#46;<a class="elsevierStyleCrossRef" href="#bb0025"><span class="elsevierStyleSup">5</span></a></p></span><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0030">Case report</span><p id="p0020" class="elsevierStylePara elsevierViewall">A 47-year-old woman with a personal history of an acoustic neuroma&#44; uterine fibroids and pulmonary lymphangioleiomyomatosis presented a 1-year history of intermittent pain in the left upper quadrant of abdomen&#46; Computed tomography revealed a left retroperitoneal mass of 10cm in maximum diameter&#46; Surgical resection of the mass was performed by laparoscopic in another medical center&#46; The pathological anatomy showed a retroperitoneal tumour compatible with PEComa&#46;</p><p id="p0025" class="elsevierStylePara elsevierViewall">During follow-up&#44; a possible para-aortic tumour recurrence and a lymphadenopathy suspected of malignancy were observed &#40;<a class="elsevierStyleCrossRef" href="#f0005">Fig&#46; 1</a>&#41;&#46; A PET-CT scan demonstrated a doubtful uptake in the retroperitoneal lesion &#40;<a class="elsevierStyleCrossRef" href="#f0010">Fig&#46; 2</a>&#41;&#46; In view of a possible tumour recurrence&#44; the patient was assessed in conjunction with Internal Medicine&#46; She had three major criteria for tuberous sclerosis &#40;acoustic neurinoma&#44; pulmonary lymphangioleiomyomatosis and retroperitoenal PEComa&#41; and it was decided to start treatment with m-TOR inhibitors &#40;sirolimus 2mg daily&#41;&#46; Sirolimus levels are monitored every two months&#46; After 3 months&#44; a follow-up CT scan showed radiological improvement of the lesions with a decrease in the size of the mediastinal and retroperitoneal adenopathies described&#46; &#40;<a class="elsevierStyleCrossRef" href="#f0015">Fig&#46; 3</a>&#41;&#46; At the present time&#44; the patient has no signs of recurrence in control imaging tests and continues treatment with sirolimus&#44; very well tolerated and without relevant adverse effects&#46;</p><elsevierMultimedia ident="f0005"></elsevierMultimedia><elsevierMultimedia ident="f0010"></elsevierMultimedia><elsevierMultimedia ident="f0015"></elsevierMultimedia></span><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0035">Discussion</span><p id="p0030" class="elsevierStylePara elsevierViewall">PEComas are composed of large polygonal epitheloid cells with granular eosinophilic cytoplasm&#46; The immunohistochemistry of PEComas is characterized by being positive for smooth muscle markers as actin &#40;80&#37; of cases&#41; and melanocytic markers&#44; most often HMB-45 &#40;90&#37; of cases&#41;&#46; Another marker such as desmin and S-100 protein are less often expressed&#46;</p><p id="p0035" class="elsevierStylePara elsevierViewall">PEComas often show alterations of the TSC genes caused by mutations of the TSC1 &#40;9q34&#41; or TSC2 &#40;16p13&#46;3&#41; gene&#46; TSC genes have an important role in the regulation of the mammalian target of rapamycin &#40;m-TOR&#41; pathway and it has been found that PEComas with TSC mutation have this pathway deregulated &#40;leading to m-TORC1 hyperactivation&#41;&#46;</p><p id="p0040" class="elsevierStylePara elsevierViewall">Initially&#44; these tumours were considered benign&#46; However&#44; as knowledge has advanced&#44; multiple cases have been reported with local or metastatic spread at the time of diagnosis&#46; Local recurrence occurs in 10-15&#37; of patients and distance metastases in 20&#37; &#40;mostly to liver&#44; lungs and bone&#41;&#46; Overall&#44; 10&#37; of PEComa patients end up dying from their disease&#46; The aggressive behaviour of PEComas is associated with tumour size greater than 5 cm&#44; infiltrative growth pattern&#44; high cellularity&#44; high nuclear grade&#44; mitotic activity and necrosis and vascular invasion&#46;</p><p id="p0045" class="elsevierStylePara elsevierViewall">At present&#44; the only treatment that seems to improve the survival of these patients is surgery&#46; Performing a R0 surgical resection manages to maintain tumour-free recurrence for several years in some patients&#46; Due to the dysregulation of m-TOR pathway by mutation of TSC genes&#44; it has been shown that sirolimus &#40;and others m-TOR inhibitors such as temsirolimus and everolimus&#41; has efficacy in renal AMLs and pulmonary LAM&#46; Recently&#44; some patients with malignant metastatic PEComas have been treated with sirolimus showing benefits but clinical trials are on going to evaluate the efficacy of this therapeuthic approach of PEComas&#46;</p></span><span id="s0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0040">Conclusion</span><p id="p0050" class="elsevierStylePara elsevierViewall">PEComas are rare tumors with perivascular disposition&#46; They are most common in women and their location is in the retropertineum&#44; uterus and abdomen&#47;pelvis&#46; Most PEComas are benign but it is important to know the aggressiveness factors of the tumor because a significant proportion of these tumors are malignant with an aggressive clinical course with metastases&#46; At this moment&#44; the only curative treatment is surgery&#46; But as in the case of our patient&#44; targeted therapies against mutations of TSC genes &#40;like m-TOR inhibitors&#41; are showing great results for the treatment of these tumours</p></span><span id="s0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0045">Statements</span><p id="p0055" class="elsevierStylePara elsevierViewall">The authors have no relevant financial or non-financial interests to disclose&#46;</p></span><span id="s0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0050">Competing interests</span><p id="p0060" class="elsevierStylePara elsevierViewall">The authors declare no competing interests&#46;</p></span><span id="s0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0055">Informed consent</span><p id="p0065" class="elsevierStylePara elsevierViewall">All patients included in this study have individually signed the informed consent form allowing the use of personal and medical data&#46;</p></span></span>"
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        "resumen" => "<span id="as0010" class="elsevierStyleSection elsevierViewall"><p id="sp0025" class="elsevierStyleSimplePara elsevierViewall">Los tumores de c&#233;lulas epitelioides perivasculares &#40;PEComa&#41; son neoplasias raras definidas como tumores mesenquimales con histolog&#237;a e inmunohistoqu&#237;mica distintivas&#46; Suelen aparecer en pacientes de mediana edad y principalmente en mujeres&#46; Las c&#233;lulas tumorales muestran una asociaci&#243;n con las paredes de los vasos sangu&#237;neos&#46; La mayor&#237;a de los PEComas son benignos&#44; aunque una proporci&#243;n de estos tumores se comporta de forma agresiva&#46; Se presenta el caso de una mujer de 47 a&#241;os con una masa retroperitoneal y resecci&#243;n laparosc&#243;pica cuya anatom&#237;a patol&#243;gica mostr&#243; un tumor retroperitoneal compatible con PEComa&#46; Describimos las principales caracter&#237;sticas de los PEComas as&#237; como su abordaje terap&#233;utico&#46;</p></span>"
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                            4 => "Franco Bonett"
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                      "doi" => "10.1007/s00428-007-0509-1"
                      "Revista" => array:6 [
                        "tituloSerie" => "Virchows Arch"
                        "fecha" => "2008"
                        "volumen" => "452"
                        "paginaInicial" => "119"
                        "paginaFinal" => "132"
                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18080139"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Perivascular epithelioid cell neoplasms&#58; pathology and pathogenesis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46;L&#46; Folpe"
                            1 => "D&#46;J&#46; Kwiatkowski"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.humpath.2009.05.011"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hum Pathol"
                        "fecha" => "2010"
                        "volumen" => "41"
                        "paginaInicial" => "1"
                        "paginaFinal" => "15"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19604538"
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                  "referenciaCompleta" => "Guido Martignoni&#44; Maurizio Pea&#44; Daniela Reghellin&#44; Giuseppe Zamboni&#44; Franco Bonetti Perivascular epithelioid cell tumor &#40;PEComa&#41; in the genitourinary tract&#46; Adv Anat Pathol&#46; 2007&#59;14&#58;36&#8211;41&#46;"
                ]
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            ]
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                      "titulo" => "Renal epithelioid angiomyolipoma with atypia&#58; a series of40 cases with emphasis on clinic pathologic prognostic indicators of malignancy"
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                          "autores" => array:6 [
                            0 => "Fadi Brimo"
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                            2 => "Charles Guo"
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                            4 => "Matthieu Latour"
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                      "doi" => "10.1097/PAS.0b013e3181d90370"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Surg Pathol"
                        "fecha" => "2010"
                        "volumen" => "34"
                        "paginaInicial" => "715"
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                  "referenciaCompleta" => "Andrew J&#46; Wagner&#44; Izabela Malinowska-Kolodziej&#44; Jeffrey A&#46; Morgan&#44; Wei Qin&#44; Christopher D&#46;M&#46; Fletcher&#44; Natalie Vena&#44; Azra H&#46; Ligon&#44; Cristina R&#46; Antonescu&#44; Nikhil H&#46; Ramaiya&#44; George D&#46; Demetri&#44; David J&#46; Kwiatkowski&#44; Robert G&#46; Maki&#46; Clinical activity of mTOR inhibition with sirolimus in malignant perivascular epithelioid cell tumors&#58; targeting the pathogenic activation of mTORC1 in tumors&#46; J Clin Oncol&#46; 2010&#59;28&#58;835&#8211;840"
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ISSN: 26039249
Original language: English
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