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Adenomatous Polyp Of The Bladder: A Rare Cause Of Hematuria in Young Men
0022-5347 /81/1264-0549$02.00/0
THE
Vol. 126, October Printed in U.S.A.
JOURNAL OF UROLOGY
Copyright© 1981 by The Williams & Wilkins Co.
ADENOMATOUS POLYP OF THE BLADDER: A RARE CAUSE OF HEMATURIA IN YOUNG MEN JONATHAN RUBIN, OM P. KHANNA
AND
IVAN DAMJANOV
From the Departments of Pathology, Laboratory Medicine and Urology, Hahnemann Medical College and Hospital, Philadelphia, Pennsylvania
ABSTRACT
A 26-year-old black man presented with gross hematuria and was found to have a papillary lesion of the trigone of the bladder. The lesion proved to be an adenomatous polyp with prostatic-type epithelium. This type of neoplasia ordinarily is found in the prostatic urethra and has not been reported previously in the bladder. Adenomatous polyps are benign tumors and should be considered in the differential diagnosis of hematuria in young men. Polypoid or papillary lesions of the male urethra lined with cuboidal epithelium are rare tumors that may cause hematuria in young male subjects. 1- 4 These adenomatous polyps with prostatic-type epithelium previously have been found exclusively in the prostatic urethra. 2 We report a case of adenomatous polyp of the bladder to show that tumors lined by prostatictype epithelium may, although rarely, arise in other parts of the urinary tract besides the urethra.
and the base was fulgurated. The patient was in good health and had no urinary tract symptoms 2 years after the resection. Macroscopic findings. The specimen consisted of multiple fragments of irregular, grayish-tan soft tissue. The largest fragment measured 1.6 X 1.4 X 0.8 cm. and appeared polypoid with surface ulceration. Microscopic findings. The specimen consisted of a polypoid mass with a fibrovascular connective tissue stalk. Numerous
A, histologic appearance of bladder tumor. H & E, reduced from Xl20. B, high magnification of neoplastic epithelium. Note that epithelial lining is in 2 layers and that luminal cells have cuboidal shape. Reduced from x320. CASE REPORT
A 26-year-old black man was hospitalized in October 1978 with a 3-week history of gross hematuria and dysuria. The patient had no symptoms of bladder outlet obstruction. He had suffered a bladder infection 1 year earlier and had been treated with penicillin for syphilis in 1971. The external genitalia were normal. Rectal examination revealed a firm, slightly enlarged prostate. An excretory urogram revealed normal kidneys, collecting system and bladder. During cystoscopy a moderately large papillary lesion was seen arising from the right side of the trigone of the bladder. The area surrounding the base of the tumor was edematous but the remainder of the bladder and urethra appeared normal. The tumor was resected in fragments
branching papillary projections were covered for the most part by a 2-layered epithelium (part A of figure). The outer layer consisted of tall columnar cells with basal nuclei and eosinophilic cytoplasm, while the inner layer was composed of flattened or low cuboidal cells (part B of figure). Flattened epithelium with a single layer of columnar or cuboidal cells and occasional epithelial stratification suggesting squamous metaplasia was seen focally. No transitional epithelium was found in any of the fragments. Glands resembling prostatic acini extended deeply into the fibrovascular stroma (part A of figure). Numerous glands contained eosinophilic, homogeneous material, reminiscent of corpora amylacea. DISCUSSION
Ectopic prostatic tissue in the male urethra is a significant and perhaps the most common cause of gross hematuria in
Accepted for publication December 5, 1981. 549
550
RUBIN, KHANNA AND DAMJANOV
young men. 1 In 68 cases of papillary or polypoid tumors of the urethra, which were composed of ectopic prostatic tissue, the mean patient age was 35 years and microscopic or gross hematuria occurred in all but 3 patients. 1 Dysuria and urinary frequency were common. These lesions had histochemical staining characteristics identical to those of normal prostatic tissue: they contained acid phosphatase and exhibited no epithelial mucin. 1- 5 These lesions may arise from evaginations of glandular epithelium, which forms the anlage of the embryonic prostate and ordinarily invaginates during development to form the ducts and the acini of the prostate. 5 The submucosal glands of the prostatic urethra also have been suggested as the origin of the ectopic prostatic tissue. 4 To our knowledge this case is the first documented example of an adenomatous polyp with prostatic-type epithelium occurring in the bladder. As reported for similar lesions of the urethra the tumor was recognized after it caused gross hematuria in a young man. The histopathologic features of this bladder tumor correlated closely with the reported characteristics of the urethral lesions. 1- 4 The papillary fronds had a fibrovascular core, covered with epithelium similar to that of the prostate. Extension of glands into the fibrovascular stroma, mimicking prostatic acini, as well as the presence of corpora amylacea heightened the similarity to prostatic tissue. There are isolated reports of ectopic prostatic tissue occurring in the bladder wall. Goodale reported on a submucosal cystadenoma of the bladder, which he thought had developed from ectopic prostatic glands. 6 Gutierrez and Nesbit described a case of ectopic tissue, microscopically identical to prostatic tissue, occurring in the wall of the bladder in the area of the interur-
eteral ridge. 7 They proposed that the ectopic prostatic tissue in the bladder was related either to the subcervical glands of Albarran at the bladder neck or the subtrigonal glands. Therefore, ectopic prostatic tissue arising from the subtrigonal glands is a possible explanation for the trigonal location of the adenomatous polyp in the present case. Urethral adenomatous polyps with prostatic-type epithelium invariably have proved to be benign. 1- 4 In the large series reported by Butterick and associates simple fulguration was effective and no recurrences or malignant transformation was observed. 1 However, there were 2 recurrences in the series reported by Mostofi and Price." The disease in our patient also had a benign course despite the atypical location of the tumor. REFERENCES
1. Butterick, J. D., Schnitzer, B. and Abell, M. R.: Ectopic prostatic tissue in urethra: a clinicopathological entity and a significant cause of hematuria. J. Urol., 105: 97, 1971. 2. Mostofi, F. K. and Price, E. B., Jr.: Tumors of the male genital system. In: Atlas of Tumor Pathology. Washington, D. C.: Armed Forces Institute of Pathology, 2nd series, fasc. 8, 1973. 3. Craig, J. R. and Hart, W. R.: Benign polyps with prostatic-type epithelium of the urethra. Amer. J. Clin. Path., 63: 343, 1975. 4. Murad, T. M., Robinson, L. H. and Bueschen, A. J.: Villous polyps of the urethra: a report of two cases. Hum. Path., 10: 478, 1979. 5. Nesbit, R. M.: The genesis of benign polyps in the prostatic urethra. J. Urol., 87: 416, 1962. 6. Goodale, R. H.: Cystadenoma of the bladder from aberrant prostatic gland. Arch. Path., 6: 210, 1928. 7. Gutierrez, J. and Nesbit, R. M.: Ectopic prostatic tissue in bladder. J. Urol., 98: 474, 1967.
THE
Vol. 126, October Printed in U.S.A.
JOURNAL OF UROLOGY
Copyright© 1981 by The Williams & Wilkins Co.
ADENOMATOUS POLYP OF THE BLADDER: A RARE CAUSE OF HEMATURIA IN YOUNG MEN JONATHAN RUBIN, OM P. KHANNA
AND
IVAN DAMJANOV
From the Departments of Pathology, Laboratory Medicine and Urology, Hahnemann Medical College and Hospital, Philadelphia, Pennsylvania
ABSTRACT
A 26-year-old black man presented with gross hematuria and was found to have a papillary lesion of the trigone of the bladder. The lesion proved to be an adenomatous polyp with prostatic-type epithelium. This type of neoplasia ordinarily is found in the prostatic urethra and has not been reported previously in the bladder. Adenomatous polyps are benign tumors and should be considered in the differential diagnosis of hematuria in young men. Polypoid or papillary lesions of the male urethra lined with cuboidal epithelium are rare tumors that may cause hematuria in young male subjects. 1- 4 These adenomatous polyps with prostatic-type epithelium previously have been found exclusively in the prostatic urethra. 2 We report a case of adenomatous polyp of the bladder to show that tumors lined by prostatictype epithelium may, although rarely, arise in other parts of the urinary tract besides the urethra.
and the base was fulgurated. The patient was in good health and had no urinary tract symptoms 2 years after the resection. Macroscopic findings. The specimen consisted of multiple fragments of irregular, grayish-tan soft tissue. The largest fragment measured 1.6 X 1.4 X 0.8 cm. and appeared polypoid with surface ulceration. Microscopic findings. The specimen consisted of a polypoid mass with a fibrovascular connective tissue stalk. Numerous
A, histologic appearance of bladder tumor. H & E, reduced from Xl20. B, high magnification of neoplastic epithelium. Note that epithelial lining is in 2 layers and that luminal cells have cuboidal shape. Reduced from x320. CASE REPORT
A 26-year-old black man was hospitalized in October 1978 with a 3-week history of gross hematuria and dysuria. The patient had no symptoms of bladder outlet obstruction. He had suffered a bladder infection 1 year earlier and had been treated with penicillin for syphilis in 1971. The external genitalia were normal. Rectal examination revealed a firm, slightly enlarged prostate. An excretory urogram revealed normal kidneys, collecting system and bladder. During cystoscopy a moderately large papillary lesion was seen arising from the right side of the trigone of the bladder. The area surrounding the base of the tumor was edematous but the remainder of the bladder and urethra appeared normal. The tumor was resected in fragments
branching papillary projections were covered for the most part by a 2-layered epithelium (part A of figure). The outer layer consisted of tall columnar cells with basal nuclei and eosinophilic cytoplasm, while the inner layer was composed of flattened or low cuboidal cells (part B of figure). Flattened epithelium with a single layer of columnar or cuboidal cells and occasional epithelial stratification suggesting squamous metaplasia was seen focally. No transitional epithelium was found in any of the fragments. Glands resembling prostatic acini extended deeply into the fibrovascular stroma (part A of figure). Numerous glands contained eosinophilic, homogeneous material, reminiscent of corpora amylacea. DISCUSSION
Ectopic prostatic tissue in the male urethra is a significant and perhaps the most common cause of gross hematuria in
Accepted for publication December 5, 1981. 549
550
RUBIN, KHANNA AND DAMJANOV
young men. 1 In 68 cases of papillary or polypoid tumors of the urethra, which were composed of ectopic prostatic tissue, the mean patient age was 35 years and microscopic or gross hematuria occurred in all but 3 patients. 1 Dysuria and urinary frequency were common. These lesions had histochemical staining characteristics identical to those of normal prostatic tissue: they contained acid phosphatase and exhibited no epithelial mucin. 1- 5 These lesions may arise from evaginations of glandular epithelium, which forms the anlage of the embryonic prostate and ordinarily invaginates during development to form the ducts and the acini of the prostate. 5 The submucosal glands of the prostatic urethra also have been suggested as the origin of the ectopic prostatic tissue. 4 To our knowledge this case is the first documented example of an adenomatous polyp with prostatic-type epithelium occurring in the bladder. As reported for similar lesions of the urethra the tumor was recognized after it caused gross hematuria in a young man. The histopathologic features of this bladder tumor correlated closely with the reported characteristics of the urethral lesions. 1- 4 The papillary fronds had a fibrovascular core, covered with epithelium similar to that of the prostate. Extension of glands into the fibrovascular stroma, mimicking prostatic acini, as well as the presence of corpora amylacea heightened the similarity to prostatic tissue. There are isolated reports of ectopic prostatic tissue occurring in the bladder wall. Goodale reported on a submucosal cystadenoma of the bladder, which he thought had developed from ectopic prostatic glands. 6 Gutierrez and Nesbit described a case of ectopic tissue, microscopically identical to prostatic tissue, occurring in the wall of the bladder in the area of the interur-
eteral ridge. 7 They proposed that the ectopic prostatic tissue in the bladder was related either to the subcervical glands of Albarran at the bladder neck or the subtrigonal glands. Therefore, ectopic prostatic tissue arising from the subtrigonal glands is a possible explanation for the trigonal location of the adenomatous polyp in the present case. Urethral adenomatous polyps with prostatic-type epithelium invariably have proved to be benign. 1- 4 In the large series reported by Butterick and associates simple fulguration was effective and no recurrences or malignant transformation was observed. 1 However, there were 2 recurrences in the series reported by Mostofi and Price." The disease in our patient also had a benign course despite the atypical location of the tumor. REFERENCES
1. Butterick, J. D., Schnitzer, B. and Abell, M. R.: Ectopic prostatic tissue in urethra: a clinicopathological entity and a significant cause of hematuria. J. Urol., 105: 97, 1971. 2. Mostofi, F. K. and Price, E. B., Jr.: Tumors of the male genital system. In: Atlas of Tumor Pathology. Washington, D. C.: Armed Forces Institute of Pathology, 2nd series, fasc. 8, 1973. 3. Craig, J. R. and Hart, W. R.: Benign polyps with prostatic-type epithelium of the urethra. Amer. J. Clin. Path., 63: 343, 1975. 4. Murad, T. M., Robinson, L. H. and Bueschen, A. J.: Villous polyps of the urethra: a report of two cases. Hum. Path., 10: 478, 1979. 5. Nesbit, R. M.: The genesis of benign polyps in the prostatic urethra. J. Urol., 87: 416, 1962. 6. Goodale, R. H.: Cystadenoma of the bladder from aberrant prostatic gland. Arch. Path., 6: 210, 1928. 7. Gutierrez, J. and Nesbit, R. M.: Ectopic prostatic tissue in bladder. J. Urol., 98: 474, 1967.