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“Phantom Bladder”: Is This an Unusual Entity?
354
LETTERS TO THE EDITOR
study. In the absence of such measures, as in the reported case, no definite conclusions can be drawn from the study. Respectfully, Alphonse Pfau Hadassah University Hospital Jerusalem, Israel
Reply by authors. The modifications of split renal function studies and renal vein renin measurement described by Doctor Pfau have been reported to increase the sensitivity for detecting renal ischemia. However, at the time our patient was studied we did not have the laboratory facilities to perform a urea infusion or to measure inulin or para-aminohippuric acid. As we stated in the report, "These studies of renal function ... do not support the concept of secondary hyperreninemia as a causal factor in the hypertension associated with a renal arteriovenous fistula". We did not exclude the possibility that modifications of either split renal function studies or renal vein renin may have demonstrated an ischemic pattern. Experimentally, we have been able to demonstrate in dogs a dramatic increase in renin generation distal to a renal arteriovenous fistula and pathologic evidence of renal ischemia in one animal but without the animals suffering systemic hypertension. 1 These animal studies lend further support to our hypothesis that mechanisms other than increased renin productions are operative in the hypertension associated with renal arteriovenous fistula. 1. Moore, M. A. and Tyras, D.: Increased renin generation from experimental renal arteriovenous fistula. Kidney Int., 10: 534, 1976. RE: INCREASED ACTIVITY IN A RENAL CELL CARCINOMA IMAGED USING 2,3-DIMERCAPTOSUCCINIC ACID
Sidney J. Pion, Edward V. Staab and Peter S. Stevens J. Ural., 116: 512, 1976
To the Editor. The authors have reported an unusual case in which 9 9mTc dimercaptosuccinic acid (DMSA) uptake was seen in the renal tumor area on the late image. It has been our experience that in cases of chronic renal failure the vertebral column, iliac bone and the residual part of renal tissues are well visualized on the very late image using 9 9mTc DMSA (see figure). Although Handmaker and associates stated that the static image in patients with severe chronic renal diseases and renal failure frequently needed to be delayed 6 to 10 hours after injection to allow for sufficient blood clearance to permit renal imaging, 1 9 9mTc DMSA would hardly accumulate in the kidney where the number of functioning nephrons is decreased severely because of the preferential accumulation of DMSA in the renal cortex. Therefore, even though they did not mention whether the right kidney was replaced by renal tumor, I would like to suggest the possibility that in the case of severe renal impairment, 99mTc DMSA may, as seen on a late image, accumulate in hypervascular tissues such as bone and incidentally occurring hypervascular tumors (as experienced by Pion and associates). While 99mTc DMSA produces a good static renal image on the late phase (2 to 4 hours post-injection), with the early image (20 to 50 seconds post-injection), a dynamic vascular pool can be visualized in the renal cortex, thus representing a nuclear angiography with 9!lmTc compounds. We have reported that a 99mTc DMSA renal scintigram combining early and late images was useful in differentiating renal space-occupying lesions detected by excretory urography in 19 patients (10 solitary renal cysts, 6 renal cell carcinomas, 2 renal pelvic tumors and 1 renal cell carcinoma with a solitary renal cyst).2 In the case of a solitary renal cyst the cold area was revealed in the early and late images with almost 100 per cent diagnostic accuracy. In the case of the renal cell carcinoma 9 9mTc DMSA uptake was seen in the early image and the cold area was observed in the late image in accordance with the pathological lesion. However, 9 9mTc DMSA uptake was not seen in the early image in which the renal cell carcinoma had advanced to the stage of necrotic lesions and tumor thrombi. In the case of renal pelvic tumor, tumor invasion to the adjacent renal parenchyma produced a cold area on the scintigram even when abnormal vessels could not be detected with a renal angiogram. A final diagnosis of renal space-occupying lesions cannot be made with renal scintigram alone. However, a 9 9mTc DMSA renal
9 9mTc DMSA renal scintigram (8 hours after injection) in 46-yearold man with polycystic kidneys. Blood urea nitrogen was 90.0 mg. per 100 ml., serum creatinine 8.6 mg. per 100 ml. and creatinine clearance 6.8 ml. per minute.
scintigram consisting of early and late images and the renal angiogram are most useful tools for detecting the character of spaceoccupying lesions. Respectfully, J uichi Kawamura Kyoto University Kyoto 606, Japan 1. Handmaker, H., Young, B. W. and Lowenstein, J. M.: Clinical experience with 9 9mTc-DMSA (dimercaptosuccinic acid), a new renal-imaging agent. J. Nucl. Med., 16: 28, 1975. 2. Kawamura, J., Hosokawa, S., Hayashi, T. and Yoshida, 0.: An assessment to differentiate renal space-occupying lesions by using 99mTc-DMSA renal scintigram consisting of both early and late images. Acta Urol. Jap., 22: 219, 1976. "PHANTOM BLADDER": IS THIS AN UNUSUAL ENTITY?
To the Editor. The "phantom limb", the term used for an extremity that has been removed but is considered by the patient to be present, is a phenomenon well known in the surgical world. Absence of an organ, such as a kidney, stomach or lung, has not, to my knowledge, produced symptoms of a "phantom organ". I recently saw a patient with what is believed to be a "phantom bladder". A 60-year-old woman had had recurrent bladder tumors treated initially by multiple transurethral resections. Since the tumors progressed despite resections, 6,000 rads by a linear accelerator were administered during a 4-month period. The lesions responded poorly and the pain became so excruciating that a total cystectomy, partial vaginectomy and pelvic node dissection were done. An ileal loop was created for ureteral drainage. These procedures were done by Dr. Donald Skinner, of the University of California, Los Angeles, who referred the patient to me for followup. The patient's hospital course was complicated by 2 myocardial infarctions and subsequent pulmonary and peripheral edema. On discharge from the hospital the patient was doing well. Furosemide had been given for the edema while the patient was at the University of California, Los Angeles. This drug produced a severe, intense urge to void from a bladder that had been removed. Other diuretics as well as smaller doses of furosemide were tried and a similar intense desire to void was felt by the patient. Variations of dosage and combinations of diuretics also were tried without relief of distress. Furosemide functions by inhibiting adenosine triphosphatase in the renal tubular system. I do not know
355
LETTERS TO THE EDITOR
of, nor can I find in the literature, an explanation of a scientific nature for the "phantom bladder" in this patient. I would urge that other such observations be reported. Respectfully, John A. Arcadi Department of Surgery (Urology) Presbyterian Hospital and Department of Biology Whittier College Whittier, California 90608 SECONDARY INVOLVEMENT OF THE BLADDER BY DIRECT EXTENSION OF CERVICAL CANCER
To the Editor. It is rare for primary neoplasms of other organs to metastasize to the bladder but secondary involvement of the bladder frequently occurs by direct extension of a primary neoplasm arising in a contiguous organ, such as the bowel, uterus, ovary, prostate, urethra, ureter and, especially, the cervix. 1 Because of this direct involvement from cervical cancer cystoscopic examination is part of the diagnostic procedure performed by the urologist in patients with cancer of the cervix. According to the International Federation of Gynecology and Obstetrics, the presence of a bullous edema or ridges and furrows in the bladder wall should be interpreted as signs of submucous involvement of the bladder and does not allot the disease to stage IV classification. 2 To document bladder invasion and, thus, to allot the disease to stage IV it is necessary to determine clinical involvement of the mucosa of the bladder or to take a biopsy when cytological findings show malignant cells. However, some urologists customarily resect and fulgurate any tumor found in the bladder at the time of cystoscopic examination, including submucosal involvement from cervical carcinoma. This practice should be avoided since 1) biopsy, when indicated, is sufficient to obtain the necessary information and 2) resection and fulguration increase fistula formation by removing the uninvolved bladder mucosa, causing the patient to have severe cystitis and contracted bladder if she undergoes subsequent radiotherapy." Locally advanced carcinoma of the cervix is neither uncommon nor incurable. Million and associates treated with radiotherapy 53 patients who had stage IV carcinoma of the cervix with bladder invasion. The 5-year survival rate was 30 per cent, with only 2 vesicovaginal fistulas developing during treatment and none developing after completion of treatment. The urologist who understands the purpose of cystoscopic examination and the adequacy of biopsy, when indicated, in patients with cancer of the cervix will not resect and fulgurate those patients who have submucosal involvement of the bladder. Respectfully, Won K. Tak Tufts-New England Medical Center Boston, Massachusetts 02111 1. Campbell, M. F. and Harrison, J. H.: Urology, 3rd ed. Philadelphia: W. B. Saunders Co., p. 1027, 1970. 2. Kottmeier, H. L.: Annual Report on the Results of Treatment in Carcinoma of the Uterus, Vagina, and Ovary. Stockholm: Radiumhemmet, 1976. 3. Bloedorn, F. G.: Carcinoma of the bladder. In: Textbook of Radiotherapy, 2nd ed. Edited by G. H. Fletcher. Philadelphia: Lea & Febiger, p. 724, 1973. 4. Million, R. R., Rutledge, F. and Fletcher, G. H.: Stage IV carcinoma of the cervix with bladder invasion. Amer. J. Obst. Gynec., U3: 239, 1972.
inside the endoscopic sheath rather than through external. urethrotomy. It is interesting to observe the same disease presenting and treated so differently in 2 separate countries. I am certain that fewer people in the United States than in developing countries will allow a ureteral stone to pass spontaneously. Patients at the Clinic would not tolerate the colic and extraction under screen resorted to more quickly there than in Kuwait. The sized stone is more likely to reimpact in the urethra passed successfully down the ureter. If the cases are treated only by trained urologists then endo. scopic extraction as described in the article by Paulk and associates would be a justified procedure. However, these authors do admit that the stone must be small enough to go inside the sheath, otherwise mucosa! damage of the urethra will ensue. Even if the stone is only slightly larger than the sheath any procedure other than external urethrotomy will surely be injurious. The temptation of an apparently minor extraction (endoscopic or otherwise) in the hands of a casualty officer is particularly harmful. We believe that we have contributed to a diminution in stricture incidence in developing countries by advising external urethrotomy as a primary procedure in impacted penile urethral stones. Respectfully, Hessein A. Amin Sabah Hospital Kuwait 1. Amin, H. A.: Urethral calculi. Brit. J. Urol., 45: 192, 1973. RE: PROSTATIC CARUNCLE: A URETHRAL PAPILLARY TUMOR DERIVED FROM PROLAPSE OF THE PROSTATIC DUCT
Sanshin Hara and Akio Horie
J. Urol., 117: 303-305, 1977 To the Editor. I wish to register a protest against the use of the term "caruncle" in connection with prostatic lesions. Herbut stated that a caruncle is "a clinical rather than a pathologic entity". The term connotes "tissue that arises in the terminal portion of the female urethra". 1 Certainly, there is no clinical comparison between the lesions described by the authors and caruncles seen in women. The lesions in the male subjects described contain prostatic acini in lobular pattern; some even corpora amylacea. Engorged vascular capillaries and an infiltration by lymphocytes are present. In female subjects caruncles usually are exquisitely tender inflammatory masses truding from the meatus and covered by squamous overlying dilated capillaries engorged with blood, sometimes thrombotic. Rarely, a few Skene's gland extensions may be included. While anatomically the female urethra is the homologue of the posterior urethra in the male subject, the masses in the 2 sexes are quite different. The consensus is that a caruncle is a clinica.1 entity presenting at the external urethral meatus of the female urethra. If men had a similar lesion at the meatus then the term "caruncle" may be properly used. The lesions in pos-terior urethra of the male subject deserve terms that are descriptive of their makeup, such as polyps, papillomas, carcinoma, prolapse and so forth. Respectfully, Meyer M. Melicow Columbia University College of Physicians and Surgeons New York, New York 10032 1. Herbut, P.A.: Urological Pathology. Philadelphia: Lea & Febiger,
RE: URETHRAL CALCULI
Stephen C. Paulk, Ansar U. Khan, R. S. Malek and Laurence F. Greene J. Urol., 116: 436-439, 1976
To the Editor. These authors refer to our series' and to 2 differences: 1) presentation-acute retention being uncommon in their experience and 2) management-they extract penile urethral stones
p. 96, 1952.
Reply by authors. For the term "caruncle" there is no original meaning indicating the female urethra. According to Dorland's Illustrated Medical Dictionary a caruncle is a small fleshy eminence, whether normal or abnormal. As for clinical entity of the term prostatic caruncle should be used as a clinicopathological entity, not as a pure histopathological one. The term is based on a similarity between morphogenesis of female urethral caruncles and that of prostatic caruncles. Descriptive terms for the lesions, such as papillomas and so forth might sometimes be confused neoplasms, not in reality.
LETTERS TO THE EDITOR
study. In the absence of such measures, as in the reported case, no definite conclusions can be drawn from the study. Respectfully, Alphonse Pfau Hadassah University Hospital Jerusalem, Israel
Reply by authors. The modifications of split renal function studies and renal vein renin measurement described by Doctor Pfau have been reported to increase the sensitivity for detecting renal ischemia. However, at the time our patient was studied we did not have the laboratory facilities to perform a urea infusion or to measure inulin or para-aminohippuric acid. As we stated in the report, "These studies of renal function ... do not support the concept of secondary hyperreninemia as a causal factor in the hypertension associated with a renal arteriovenous fistula". We did not exclude the possibility that modifications of either split renal function studies or renal vein renin may have demonstrated an ischemic pattern. Experimentally, we have been able to demonstrate in dogs a dramatic increase in renin generation distal to a renal arteriovenous fistula and pathologic evidence of renal ischemia in one animal but without the animals suffering systemic hypertension. 1 These animal studies lend further support to our hypothesis that mechanisms other than increased renin productions are operative in the hypertension associated with renal arteriovenous fistula. 1. Moore, M. A. and Tyras, D.: Increased renin generation from experimental renal arteriovenous fistula. Kidney Int., 10: 534, 1976. RE: INCREASED ACTIVITY IN A RENAL CELL CARCINOMA IMAGED USING 2,3-DIMERCAPTOSUCCINIC ACID
Sidney J. Pion, Edward V. Staab and Peter S. Stevens J. Ural., 116: 512, 1976
To the Editor. The authors have reported an unusual case in which 9 9mTc dimercaptosuccinic acid (DMSA) uptake was seen in the renal tumor area on the late image. It has been our experience that in cases of chronic renal failure the vertebral column, iliac bone and the residual part of renal tissues are well visualized on the very late image using 9 9mTc DMSA (see figure). Although Handmaker and associates stated that the static image in patients with severe chronic renal diseases and renal failure frequently needed to be delayed 6 to 10 hours after injection to allow for sufficient blood clearance to permit renal imaging, 1 9 9mTc DMSA would hardly accumulate in the kidney where the number of functioning nephrons is decreased severely because of the preferential accumulation of DMSA in the renal cortex. Therefore, even though they did not mention whether the right kidney was replaced by renal tumor, I would like to suggest the possibility that in the case of severe renal impairment, 99mTc DMSA may, as seen on a late image, accumulate in hypervascular tissues such as bone and incidentally occurring hypervascular tumors (as experienced by Pion and associates). While 99mTc DMSA produces a good static renal image on the late phase (2 to 4 hours post-injection), with the early image (20 to 50 seconds post-injection), a dynamic vascular pool can be visualized in the renal cortex, thus representing a nuclear angiography with 9!lmTc compounds. We have reported that a 99mTc DMSA renal scintigram combining early and late images was useful in differentiating renal space-occupying lesions detected by excretory urography in 19 patients (10 solitary renal cysts, 6 renal cell carcinomas, 2 renal pelvic tumors and 1 renal cell carcinoma with a solitary renal cyst).2 In the case of a solitary renal cyst the cold area was revealed in the early and late images with almost 100 per cent diagnostic accuracy. In the case of the renal cell carcinoma 9 9mTc DMSA uptake was seen in the early image and the cold area was observed in the late image in accordance with the pathological lesion. However, 9 9mTc DMSA uptake was not seen in the early image in which the renal cell carcinoma had advanced to the stage of necrotic lesions and tumor thrombi. In the case of renal pelvic tumor, tumor invasion to the adjacent renal parenchyma produced a cold area on the scintigram even when abnormal vessels could not be detected with a renal angiogram. A final diagnosis of renal space-occupying lesions cannot be made with renal scintigram alone. However, a 9 9mTc DMSA renal
9 9mTc DMSA renal scintigram (8 hours after injection) in 46-yearold man with polycystic kidneys. Blood urea nitrogen was 90.0 mg. per 100 ml., serum creatinine 8.6 mg. per 100 ml. and creatinine clearance 6.8 ml. per minute.
scintigram consisting of early and late images and the renal angiogram are most useful tools for detecting the character of spaceoccupying lesions. Respectfully, J uichi Kawamura Kyoto University Kyoto 606, Japan 1. Handmaker, H., Young, B. W. and Lowenstein, J. M.: Clinical experience with 9 9mTc-DMSA (dimercaptosuccinic acid), a new renal-imaging agent. J. Nucl. Med., 16: 28, 1975. 2. Kawamura, J., Hosokawa, S., Hayashi, T. and Yoshida, 0.: An assessment to differentiate renal space-occupying lesions by using 99mTc-DMSA renal scintigram consisting of both early and late images. Acta Urol. Jap., 22: 219, 1976. "PHANTOM BLADDER": IS THIS AN UNUSUAL ENTITY?
To the Editor. The "phantom limb", the term used for an extremity that has been removed but is considered by the patient to be present, is a phenomenon well known in the surgical world. Absence of an organ, such as a kidney, stomach or lung, has not, to my knowledge, produced symptoms of a "phantom organ". I recently saw a patient with what is believed to be a "phantom bladder". A 60-year-old woman had had recurrent bladder tumors treated initially by multiple transurethral resections. Since the tumors progressed despite resections, 6,000 rads by a linear accelerator were administered during a 4-month period. The lesions responded poorly and the pain became so excruciating that a total cystectomy, partial vaginectomy and pelvic node dissection were done. An ileal loop was created for ureteral drainage. These procedures were done by Dr. Donald Skinner, of the University of California, Los Angeles, who referred the patient to me for followup. The patient's hospital course was complicated by 2 myocardial infarctions and subsequent pulmonary and peripheral edema. On discharge from the hospital the patient was doing well. Furosemide had been given for the edema while the patient was at the University of California, Los Angeles. This drug produced a severe, intense urge to void from a bladder that had been removed. Other diuretics as well as smaller doses of furosemide were tried and a similar intense desire to void was felt by the patient. Variations of dosage and combinations of diuretics also were tried without relief of distress. Furosemide functions by inhibiting adenosine triphosphatase in the renal tubular system. I do not know
355
LETTERS TO THE EDITOR
of, nor can I find in the literature, an explanation of a scientific nature for the "phantom bladder" in this patient. I would urge that other such observations be reported. Respectfully, John A. Arcadi Department of Surgery (Urology) Presbyterian Hospital and Department of Biology Whittier College Whittier, California 90608 SECONDARY INVOLVEMENT OF THE BLADDER BY DIRECT EXTENSION OF CERVICAL CANCER
To the Editor. It is rare for primary neoplasms of other organs to metastasize to the bladder but secondary involvement of the bladder frequently occurs by direct extension of a primary neoplasm arising in a contiguous organ, such as the bowel, uterus, ovary, prostate, urethra, ureter and, especially, the cervix. 1 Because of this direct involvement from cervical cancer cystoscopic examination is part of the diagnostic procedure performed by the urologist in patients with cancer of the cervix. According to the International Federation of Gynecology and Obstetrics, the presence of a bullous edema or ridges and furrows in the bladder wall should be interpreted as signs of submucous involvement of the bladder and does not allot the disease to stage IV classification. 2 To document bladder invasion and, thus, to allot the disease to stage IV it is necessary to determine clinical involvement of the mucosa of the bladder or to take a biopsy when cytological findings show malignant cells. However, some urologists customarily resect and fulgurate any tumor found in the bladder at the time of cystoscopic examination, including submucosal involvement from cervical carcinoma. This practice should be avoided since 1) biopsy, when indicated, is sufficient to obtain the necessary information and 2) resection and fulguration increase fistula formation by removing the uninvolved bladder mucosa, causing the patient to have severe cystitis and contracted bladder if she undergoes subsequent radiotherapy." Locally advanced carcinoma of the cervix is neither uncommon nor incurable. Million and associates treated with radiotherapy 53 patients who had stage IV carcinoma of the cervix with bladder invasion. The 5-year survival rate was 30 per cent, with only 2 vesicovaginal fistulas developing during treatment and none developing after completion of treatment. The urologist who understands the purpose of cystoscopic examination and the adequacy of biopsy, when indicated, in patients with cancer of the cervix will not resect and fulgurate those patients who have submucosal involvement of the bladder. Respectfully, Won K. Tak Tufts-New England Medical Center Boston, Massachusetts 02111 1. Campbell, M. F. and Harrison, J. H.: Urology, 3rd ed. Philadelphia: W. B. Saunders Co., p. 1027, 1970. 2. Kottmeier, H. L.: Annual Report on the Results of Treatment in Carcinoma of the Uterus, Vagina, and Ovary. Stockholm: Radiumhemmet, 1976. 3. Bloedorn, F. G.: Carcinoma of the bladder. In: Textbook of Radiotherapy, 2nd ed. Edited by G. H. Fletcher. Philadelphia: Lea & Febiger, p. 724, 1973. 4. Million, R. R., Rutledge, F. and Fletcher, G. H.: Stage IV carcinoma of the cervix with bladder invasion. Amer. J. Obst. Gynec., U3: 239, 1972.
inside the endoscopic sheath rather than through external. urethrotomy. It is interesting to observe the same disease presenting and treated so differently in 2 separate countries. I am certain that fewer people in the United States than in developing countries will allow a ureteral stone to pass spontaneously. Patients at the Clinic would not tolerate the colic and extraction under screen resorted to more quickly there than in Kuwait. The sized stone is more likely to reimpact in the urethra passed successfully down the ureter. If the cases are treated only by trained urologists then endo. scopic extraction as described in the article by Paulk and associates would be a justified procedure. However, these authors do admit that the stone must be small enough to go inside the sheath, otherwise mucosa! damage of the urethra will ensue. Even if the stone is only slightly larger than the sheath any procedure other than external urethrotomy will surely be injurious. The temptation of an apparently minor extraction (endoscopic or otherwise) in the hands of a casualty officer is particularly harmful. We believe that we have contributed to a diminution in stricture incidence in developing countries by advising external urethrotomy as a primary procedure in impacted penile urethral stones. Respectfully, Hessein A. Amin Sabah Hospital Kuwait 1. Amin, H. A.: Urethral calculi. Brit. J. Urol., 45: 192, 1973. RE: PROSTATIC CARUNCLE: A URETHRAL PAPILLARY TUMOR DERIVED FROM PROLAPSE OF THE PROSTATIC DUCT
Sanshin Hara and Akio Horie
J. Urol., 117: 303-305, 1977 To the Editor. I wish to register a protest against the use of the term "caruncle" in connection with prostatic lesions. Herbut stated that a caruncle is "a clinical rather than a pathologic entity". The term connotes "tissue that arises in the terminal portion of the female urethra". 1 Certainly, there is no clinical comparison between the lesions described by the authors and caruncles seen in women. The lesions in the male subjects described contain prostatic acini in lobular pattern; some even corpora amylacea. Engorged vascular capillaries and an infiltration by lymphocytes are present. In female subjects caruncles usually are exquisitely tender inflammatory masses truding from the meatus and covered by squamous overlying dilated capillaries engorged with blood, sometimes thrombotic. Rarely, a few Skene's gland extensions may be included. While anatomically the female urethra is the homologue of the posterior urethra in the male subject, the masses in the 2 sexes are quite different. The consensus is that a caruncle is a clinica.1 entity presenting at the external urethral meatus of the female urethra. If men had a similar lesion at the meatus then the term "caruncle" may be properly used. The lesions in pos-terior urethra of the male subject deserve terms that are descriptive of their makeup, such as polyps, papillomas, carcinoma, prolapse and so forth. Respectfully, Meyer M. Melicow Columbia University College of Physicians and Surgeons New York, New York 10032 1. Herbut, P.A.: Urological Pathology. Philadelphia: Lea & Febiger,
RE: URETHRAL CALCULI
Stephen C. Paulk, Ansar U. Khan, R. S. Malek and Laurence F. Greene J. Urol., 116: 436-439, 1976
To the Editor. These authors refer to our series' and to 2 differences: 1) presentation-acute retention being uncommon in their experience and 2) management-they extract penile urethral stones
p. 96, 1952.
Reply by authors. For the term "caruncle" there is no original meaning indicating the female urethra. According to Dorland's Illustrated Medical Dictionary a caruncle is a small fleshy eminence, whether normal or abnormal. As for clinical entity of the term prostatic caruncle should be used as a clinicopathological entity, not as a pure histopathological one. The term is based on a similarity between morphogenesis of female urethral caruncles and that of prostatic caruncles. Descriptive terms for the lesions, such as papillomas and so forth might sometimes be confused neoplasms, not in reality.