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Reconstruction by minimum intensity projection in coronal plane (B). Voluminous exophytic mass (white arrow in A) depending on the upper calyceal system of the left kidney (white arrows in B), with well-defined margins and heterogeneous density alternating decreased uptake areas suggestive of cystic-necrotic content with other areas of solid enhancement. Note the extrinsic compression of the kidney caused by the extrarenal component of the mass (black arrows).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Mixed epithelial and stromal tumour (MEST) of the kidney is a rare neoplasm with just over 150 cases described in the literature.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> The 2016 WHO classification of renal tumours included this entity in the family of mixed epithelial and stromal tumours.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This tumour predominantly affects perimenopausal women, with very few cases in men. Most patients had a history of taking oral oestrogens. The typical presentation includes symptoms such as haematuria, flank or lumbar pain and palpable mass, although it has been detected as an incidental finding in up to 25% of cases.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Macroscopically, they are usually solitary tumours and arise from the central portion of the renal pelvis, with cystic and solid components in different proportions. Histologically, there are two cell lines; the epithelial, which forms the wall of the cysts, and the stromal, spindle cells that form the solid portion and resemble the ovarian stroma. They usually have receptors for oestrogen and progesterone.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> It generally has a benign clinical and histological behavior.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The imaging findings of MEST are non-specific, and often lend themselves to differential diagnosis with other malignant cystic renal neoplasms. The definitive management and diagnosis of these patients is usually surgical.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> Extremely rare cases of malignant sarcoma associated with MEST have been reported, with local recurrence after nephrectomy.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We report a case of MEST with sarcomatoid degeneration and subsequent recurrence in the form of abdominal metastases after surgery.</p><p id="par0020" class="elsevierStylePara elsevierViewall">A 51-year-old woman presents to our emergency department with fever and pain in the left costovertebral angle. As a personal history of interest, she was diagnosed 6 months earlier with a spontaneous retroperitoneal haematoma that required selective embolization. The patient reported that the pain had been present for several weeks, associated in the last few hours with fever and nausea, with no other symptoms. Physical examination revealed a positive left costovertebral angle percussion and a palpable mass in the left flank. In view of the findings and history, an abdominal ultrasound was requested, which revealed a large mass, predominantly solid in nature, with a marked exophytic growth, which was dependent on the left kidney.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In view of these findings, the study was completed by abdominal-pelvic computed tomography (CT) with intravenous contrast, which confirmed the presence of a renal mass highly suspicious of neoplasm with solid and cystic areas (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). This tumour appeared to depend on the upper calyceal system and herniated towards the upper infundibulum and renal pelvis, producing occupation and obstruction at this level. The extension work-up was negative.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The patient underwent radical nephrectomy surgery, which facilitated a complete macroscopic resection, with free margins in the histopathological study, which showed findings compatible with a mixed renal epithelial-stromal tumour, with a benign cystic epithelial and mesenchymal component corresponding to a moderately differentiated spindle cell stromal sarcoma. In addition, the sarcomatoid component had immunohistochemical characteristics that made it impossible to discern between sarcomatoid dedifferentiation of the stromal component of MEST and other primary sarcomas.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The first control CT scan 6 months later showed multiple nodules located in the left side of the abdomen, mainly retroperitoneal, compatible with locoregional recurrence. Subsequently, ultrasound-guided biopsy of one of the lesions confirmed the sarcomatoid nature and recurrence of renal stromal sarcoma. The patient is currently undergoing chemotherapy treatment and is still undergoing oncological follow-up.</p><p id="par0040" class="elsevierStylePara elsevierViewall">There are only 18 published cases of malignant MESTs,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and these mainly focus on histological features, with little emphasis on imaging features due to the lack of typical signs. Due to the rarity of this neoplasm, it is difficult to determine whether these sarcomas represent a true malignant transformation of MEST or a sarcoma trapped between cystic changes.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">On CT scan, benign MEST shows as a well-defined multiseptated mass with cystic and solid components in variable proportions, which may herniate into the renal pelvis. Behaviour under iodinated contrast is variable depending on the stromal component, with more intense enhancement in more cellular areas and minimal in fibrotic areas. Malignant MEST usually has similar radiological features to the one described in our case, with larger heterogeneous solid areas and marked enhancement. Similarly, the imaging appearance is not specific, and the lack of typical radiological signs makes accurate diagnosis difficult.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0050" class="elsevierStylePara elsevierViewall">The guidelines of the Ethics Committee of the County of Granada were followed in the preparation of this work. Informed consent was obtained from the patient for the publication of the images.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0055" class="elsevierStylePara elsevierViewall">No funding has been received in relation to this study.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 305 "Ancho" => 755 "Tamanyo" => 45433 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Axial CT images of abdomen and pelvis with intravenous contrast in nephrographic phase (A). Reconstruction by minimum intensity projection in coronal plane (B). Voluminous exophytic mass (white arrow in A) depending on the upper calyceal system of the left kidney (white arrows in B), with well-defined margins and heterogeneous density alternating decreased uptake areas suggestive of cystic-necrotic content with other areas of solid enhancement. Note the extrinsic compression of the kidney caused by the extrarenal component of the mass (black arrows).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "L.C. Chu" 1 => "R.H. Hruban" 2 => "K.M. Horton" 3 => "E.K. 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Vol. 162. Issue 12.
Pages 618-619 (June 2024)
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Vol. 162. Issue 12.
Pages 618-619 (June 2024)
Letter to the Editor
Mixed epithelial stromal tumor of the kidney with malignant transformation
Tumor mixto epitelial y estromal de riñón con transformación maligna
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