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Metanephric Adenoma–Epithelial Wilms Tumor Overlap Lesions

An Analysis of BRAF Status

Wobker, Sara E. MD, MPH*,†; Matoso, Andres MD; Pratilas, Christine A. MD§; Mangray, Shamlal MB, BS; Zheng, Gang MD, PhD; Lin, Ming-Tseh MD, PhD; Debeljak, Marija PhD; Epstein, Jonathan I. MD‡,§; Argani, Pedram MD‡,§

The American Journal of Surgical Pathology: September 2019 - Volume 43 - Issue 9 - p 1157–1169
doi: 10.1097/PAS.0000000000001240
Original Articles

Metanephric adenoma (MA) has historically been considered to represent a differentiated form of epithelial Wilms tumor (WT), based in part upon cases that morphologically overlap these 2 neoplasms. More recently, BRAF V600E mutations have been demonstrated in the majority of MAs but not in unselected or even epithelial-predominant WTs, suggesting 2 genetically distinct entities. However, no prior study has examined BRAF status in neoplasms with overlapping histologic features of epithelial WT and MA. We studied a cohort of 11 such overlapping lesions, 2 of which we considered morphologically to be otherwise typical MAs with unusually prominent mitotic activity and 9 of which we classified as epithelial WTs with areas resembling MA. Both mitotically active MAs demonstrated the BRAF V600E mutation. While the majority (5/9) of epithelial WTs with areas resembling MA were negative for BRAF V600E mutation, 4 such cases were positive. Two BRAF V600E mutation-positive WTs occurred in children. One case in a 6-year-old male was morphologically similar to the BRAF V600E mutation-positive adult cases and subsequently metastasized to the lungs; remarkably, the metastases then completely resolved on Braf targeted therapy. A second occurred in a 3-year-old girl whose posttherapy nephrectomy specimen’s tumor was encapsulated and mitotically active like a typical WT, but also had more differentiated areas resembling MA. Immunohistochemistry for Braf V600E paralleled the molecular findings, demonstrating immunoreactivity in both the WT and MA-like areas of all 4 of these neoplasms. In summary, we demonstrate that BRAF V600E mutations are not entirely restricted to typical MA, as they may be seen in MAs showing mitotic activity along with a subset of epithelial-predominant WTs in adults and children that have foci which overlap morphologically with MA.

Departments of *Pathology and Laboratory Medicine

Urology, University of North Carolina, Chapel Hill, NC

Departments of Pathology

§Oncology, Johns Hopkins University School of Medicine, Baltimore, MD

Department of Pathology, Nationwide Children’s Hospital, Columbus, OH

Conflicts of Interest and Source of Funding: Supported in part by the Dahan Fund (P.A.) and Joey’s Wings (P.A.). The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Correspondence: Pedram Argani, MD, The Johns Hopkins Hospital, Surgical Pathology, Weinberg Building, Room 2242, 401 N. Broadway, Baltimore, MD 21231-2410 (e-mail:

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