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INverted papilloma of bladder
INVERTED EDWARD
J. PIENKOS,
FRANCISCO VICTOR
PAPILLOMA
M.D.
R. JABLOKOW,
M.D.
of Urology and Pathology,
Hines Veterans Administration Hines, Illinois
ABSTRACT-A sented.
case of inverted
papilloma
Hospital,
of the urinary bladder in a forty-six-year-old
The lesion is rare but may be easily misdiagnosed
Inverted papilloma of the urinary bladder is a rare lesion. Since the first reported case by Potts and Hirst’ in 1963, only one additional case has appeared in the literature .2 We present one other case to promote awareness of this entity as a benign neoplasm of the bladder. Its histologic characteristics could easily be mistaken for those of malignant growths. Case Report A forty-six-year-old white man with a chief complaint of gross hematuria with the passage of blood clots for three days was admitted to the hospital. Additional history included nocturia of three to four times, hypogastric pain, and occasional chills and fever. He denied he smoked cigarettes, but he took diphenylhydantoin, 100 mg. three times a day, for a convulsive disorder and chloropropamide, 250 mg. every morning, for adult-onset diabetes. Physical examination revealed a moderately obese man. His liver was palpable 3 cm. below the right costal margin. The right testicle was slightly tender on rectal examination. Essential positive laboratory findings included a urinalysis which showed numerous red blood cells and a fasting serum glucose of 175 mg. per 100 ml. Subsequent three-hour glucose tolerance test revealed a diabetic curve. A complete blood count was normal without evidence of anemia. All other blood tests were within normal range. An intravenous pyelogram failed to demonstrate any abnormality of the kidneys, collecting examination of system, or bladde r. Cytologic urine yielded inflammatory and red blood cells,
178
BLADDER
M.D.
IGLESIAS,
From the Departments
OF
as transitional-cell
man is pre-
carcinoma.
but a cystogram demonstrated a definite mass (Fig. 1). On cystoscopy, the bladder was essentially normal except for a mass which appeared to be 1 cm. in diameter, pedunculated, and avascular. It was located in the trigone distal to the left ureteral orifice. The mass floated in the bladder currents and was easily moved by the cystoscope. Biopsy was reported as transitional-cell carcinoma, Grade II. Subsequently the patient underwent transurethral resection of the bladder tumor and biopsy of the base. The tumor grossly measured 1.5 by 1.5 by 1 cm. It appeared polypoid with a smooth external surface which, when cut, was gray in color. Its microscopic appearance was of a papillomatous lesion that had an “inverted” configuration not unlike inverted papillomas of the upper respiratory passages (Fig. 2A). The tumor consisted of anastomosing groups and cords of cells that had connection to the overlying transitional epithelium suggesting invagination (Fig. 2B). The cells had transitional appearance and were similar to the overlying mucosal cells. However, the cells were more compact and had a smaller amount of cytoplasm. The nuclei were elongated with small variation in size. No mitotic activity was seen. The stroma was scanty. The original bladder biopsy was reexamined. It revealed a histologic appearance similar to the main tumor. Comment Inverted papilloma of bladder was first defined as a distinct entity by Potts and Hirstl who de-
UROLOGY
/
AUGUST
1973
/
VOLUME
II, NUMBER
2
FIGURE 1. Cystogram illustrating irregular polypoid lesion protruding into bladder lumen. scribed a pedunculated bladder tumor arising just inside the bladder neck. Although hematuria was conspicuously absent in their case, Assor and Taylor2 reported a similar tumor with hematuria as a presenting symptom, as it was in our patient. All three of these lesions were located at or near the trigone. Potts has postulated that the origin of this tumor was the downward proliferation of cells from subtrigonal glands. The lesion later becomes pedunculated by a process of extrusion. Chronic inflammation is considered to stimulate downward proliferation of transitional-cell epithelium giving rise to pyelitis-ureteritiscystitis cystica or glandularis. Although more common at the bladder base, it may occur anywhere in the urothelial tract. This is borne out by case reports of Trites3 who mentioned 3 histologically similar cases of inverted papillomas occurring in the prostatic urethra and by Price4 who had seen one occurring in the renal pelvis. Although all papillary growths of the bladder are considered to be carcinoma because of the tendency to recur, no such recurrence to date has been reported when this entity was treated with transurethral resection and fulguration of the base. Many of these tumors may have been misdiagnosed as transitional-cell carcinoma of the bladder because of the pat ologists’ unfamiliarity of cases at the Armed with this entity. In a revie Forces Institute of Path01% gy, Price5 stated that
UROLOGY
I
AUGUST
1973
/
VOLUME
II, NUMBER
2
FIGURE 2. Microscopic sections stomosing cords of (A) transitional gestuig “inverted” growth, and (B) of epithelial cells. he had seen approximately arising in the bladder.5
revealing epithet&m high-power
13 additional
anasugview
cases
Hines, Illinois 60141 (DR. PIENKOS) References 1. 2. 3. 4. 5.
POTTS, I. F., and HIRST, E.: Inverted papilloma of the bladder, J. Urol. 90: 175 (1963). of the ASSOR, D., and TAYLOR, J.N.: Inverted papilloma bladder, ibid. 104: 715 (1970). TRITES, A. E. W.: Inverted urothelial papilloma; report of two cases, Ibid. 101: 216 (1969). communication, March 5, PRICE, E. B., JR.: Personal 1972. IDEM: Diseases of the lower urinary tract, presented at Annual Meeting of American Society of Clinical Pathologists, Chicago, Illinois, September, 1969.
179
J. PIENKOS,
FRANCISCO VICTOR
PAPILLOMA
M.D.
R. JABLOKOW,
M.D.
of Urology and Pathology,
Hines Veterans Administration Hines, Illinois
ABSTRACT-A sented.
case of inverted
papilloma
Hospital,
of the urinary bladder in a forty-six-year-old
The lesion is rare but may be easily misdiagnosed
Inverted papilloma of the urinary bladder is a rare lesion. Since the first reported case by Potts and Hirst’ in 1963, only one additional case has appeared in the literature .2 We present one other case to promote awareness of this entity as a benign neoplasm of the bladder. Its histologic characteristics could easily be mistaken for those of malignant growths. Case Report A forty-six-year-old white man with a chief complaint of gross hematuria with the passage of blood clots for three days was admitted to the hospital. Additional history included nocturia of three to four times, hypogastric pain, and occasional chills and fever. He denied he smoked cigarettes, but he took diphenylhydantoin, 100 mg. three times a day, for a convulsive disorder and chloropropamide, 250 mg. every morning, for adult-onset diabetes. Physical examination revealed a moderately obese man. His liver was palpable 3 cm. below the right costal margin. The right testicle was slightly tender on rectal examination. Essential positive laboratory findings included a urinalysis which showed numerous red blood cells and a fasting serum glucose of 175 mg. per 100 ml. Subsequent three-hour glucose tolerance test revealed a diabetic curve. A complete blood count was normal without evidence of anemia. All other blood tests were within normal range. An intravenous pyelogram failed to demonstrate any abnormality of the kidneys, collecting examination of system, or bladde r. Cytologic urine yielded inflammatory and red blood cells,
178
BLADDER
M.D.
IGLESIAS,
From the Departments
OF
as transitional-cell
man is pre-
carcinoma.
but a cystogram demonstrated a definite mass (Fig. 1). On cystoscopy, the bladder was essentially normal except for a mass which appeared to be 1 cm. in diameter, pedunculated, and avascular. It was located in the trigone distal to the left ureteral orifice. The mass floated in the bladder currents and was easily moved by the cystoscope. Biopsy was reported as transitional-cell carcinoma, Grade II. Subsequently the patient underwent transurethral resection of the bladder tumor and biopsy of the base. The tumor grossly measured 1.5 by 1.5 by 1 cm. It appeared polypoid with a smooth external surface which, when cut, was gray in color. Its microscopic appearance was of a papillomatous lesion that had an “inverted” configuration not unlike inverted papillomas of the upper respiratory passages (Fig. 2A). The tumor consisted of anastomosing groups and cords of cells that had connection to the overlying transitional epithelium suggesting invagination (Fig. 2B). The cells had transitional appearance and were similar to the overlying mucosal cells. However, the cells were more compact and had a smaller amount of cytoplasm. The nuclei were elongated with small variation in size. No mitotic activity was seen. The stroma was scanty. The original bladder biopsy was reexamined. It revealed a histologic appearance similar to the main tumor. Comment Inverted papilloma of bladder was first defined as a distinct entity by Potts and Hirstl who de-
UROLOGY
/
AUGUST
1973
/
VOLUME
II, NUMBER
2
FIGURE 1. Cystogram illustrating irregular polypoid lesion protruding into bladder lumen. scribed a pedunculated bladder tumor arising just inside the bladder neck. Although hematuria was conspicuously absent in their case, Assor and Taylor2 reported a similar tumor with hematuria as a presenting symptom, as it was in our patient. All three of these lesions were located at or near the trigone. Potts has postulated that the origin of this tumor was the downward proliferation of cells from subtrigonal glands. The lesion later becomes pedunculated by a process of extrusion. Chronic inflammation is considered to stimulate downward proliferation of transitional-cell epithelium giving rise to pyelitis-ureteritiscystitis cystica or glandularis. Although more common at the bladder base, it may occur anywhere in the urothelial tract. This is borne out by case reports of Trites3 who mentioned 3 histologically similar cases of inverted papillomas occurring in the prostatic urethra and by Price4 who had seen one occurring in the renal pelvis. Although all papillary growths of the bladder are considered to be carcinoma because of the tendency to recur, no such recurrence to date has been reported when this entity was treated with transurethral resection and fulguration of the base. Many of these tumors may have been misdiagnosed as transitional-cell carcinoma of the bladder because of the pat ologists’ unfamiliarity of cases at the Armed with this entity. In a revie Forces Institute of Path01% gy, Price5 stated that
UROLOGY
I
AUGUST
1973
/
VOLUME
II, NUMBER
2
FIGURE 2. Microscopic sections stomosing cords of (A) transitional gestuig “inverted” growth, and (B) of epithelial cells. he had seen approximately arising in the bladder.5
revealing epithet&m high-power
13 additional
anasugview
cases
Hines, Illinois 60141 (DR. PIENKOS) References 1. 2. 3. 4. 5.
POTTS, I. F., and HIRST, E.: Inverted papilloma of the bladder, J. Urol. 90: 175 (1963). of the ASSOR, D., and TAYLOR, J.N.: Inverted papilloma bladder, ibid. 104: 715 (1970). TRITES, A. E. W.: Inverted urothelial papilloma; report of two cases, Ibid. 101: 216 (1969). communication, March 5, PRICE, E. B., JR.: Personal 1972. IDEM: Diseases of the lower urinary tract, presented at Annual Meeting of American Society of Clinical Pathologists, Chicago, Illinois, September, 1969.
179