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Plasma Cell Granuloma of the Bladder: A Case Report
0022-5347/94/1523-0956$03. 00/0
THE JOURNAL OF UROLOGY Copyright© 1994 by AMERICAN UROLOGICAL AssoCIATION, INC.
Vol. 152, 956-957, September 1994 Printed in U.S.A.
PLASMA CELL GRANULOMA OF THE BLADDER: A CASE REPORT HIROSHI MAEDA, SHINGO YAMAMOTO, YOSHIHIRO YAMADA
AND
HIROTAKA MORI
From the Departments of Urology and Pathology, Saiseikai Noe Hospital, Osaka, Japan
ABSTRACT
Plasma cell granuloma of the lung has been reported often but extrapulmonary cases are rare. A case of plasma cell granuloma of the bladder involving the omentum is reported. Transurethral biopsy of the bladder did not aid in diagnosis because the lesion was deeply seated, and differential diagnosis with hematoxylin and eosin staining was difficult due to atypical plasma cells. Immunohistochemistry established the final diagnosis. KEY WORDS: granuloma, plasma cell; bladder; diagnosis, differential
Plasma cell granuloma is a rare nonneoplastic mass of unknown etiology that occurs most commonly as a solitary coin lesion in the lung. Extrapulmonary plasma cell granu loma is more unusual. We report a case of such a lesion involving the bladder and the omentum. CASE REPORT
A 49-year-old woman presented with a 5-month history of recurring bladder irritability and colic in the right lower abdomen. Except for elective abortion 10 years previously, she had no history of urinary tract infection, instrumenta tion, trauma or other urological problems. Physical examina tion revealed a painless, firm pelvic mass, palpable per vagi nam above the bladder neck. Urinalysis was normal and urinary cytology was negative. White blood count, C-reactive protein and erythrocyte sedimentation rate were moderately elevated. Other laboratory findings were within normal lim its. Excretory urography showed normal upper urinary tracts and a filling defect of the bladder. Cystoscopy revealed a broad based mass arising near the bladder dome that was covered with edematous mucosa (fig. 1). Computerized to mography confirmed a heterogeneous lesion 4 cm. in diame ter in the anterior wall that seemed to be continuous with the bowel. No pelvic lymphadenopathy was demonstrated (fig. 2). A barium enema and fibercolonoscopy were normal, and transurethral biopsy of the mass showed only inflammation. Because primary bladder cancer was ruled out, we performed partial cystectomy. Exploration of the abdomen revealed that the mass was firm and adherent to the greater omentum. The mass, includAccepted for publication December 22, 1993.
Fm. 2. Computerized tomography shows heterogeneously dense mass in anterior wall of bladder (arrows).
ing a part of omentum, was resected en bloc. Other organs were normal. Convalescence was uneventful and the patient was discharged from the hospital 32 days postoperatively. Followup cystoscopy and excretory urography showed a slight deformity of the bladder but no evidence of recurrence 8 months later. Grossly, the resected specimen measured 5 X 5 X 4 cm. and the lesion consisted of poorly defined, white-yellowish tissue of a rather firm consistency with necrotic foci. It was separated from the bladder wall and the mucosa was edem atous (fig. 3). Microscopy showed that the tumor was not encapsulated and that it was located chiefly in the perivesical adipose tissue, partially involving the deep muscular layer. The lesion was comprised mainly of plasma cells and occa sional atypical multinucleated plasma cells (fig. 4). Other inflammatory cells were present including lymphocytes and a few histiocytes without atypia. The bladder epithelium could be identified. Edema and inflammatory cell infiltrates were noted in the lamina pro pria but the cells were mostly lymphocytes. There was no fistula formation between the mucosa and the tumor.
IIIJIIUIIIIIIUU-1 Fm. 1. Broad based tumor is covered with edematous mucosa
Fm. 3 Cut surface of mass removed by partial cystectomy with 2 cm. margin of normal surrounding bladder wall and greater omen tum adherent to tumor (arrows). 956
957
PLASMA CELL GRANULOIVIA OF BLADDER
FIG. 4. A, aggregates of inflammatory cells, predominantly plasma cells. Reduced from X 100. B, high power view demonstrates plasma cells with atypia. Reduced from X400.
FIG. 5. Immunohistochemical stain shows positive reaction for kappa (A) and lambda (B) chains. Reduced from X400
Michaelis-Gutmann bodies were not seen, cytokeratin and Ziehl-Neelsen carbolfuchsin staining were negative, and pe riodic acid, Schiff and Grocott-Gomori methenamine silver nitrate staining showed no fungi. Kappa and lambda chains were recognized in the plasma cells, which showed polyclonal proliferation (fig. 5). On the basis of these findings this lesion was diagnosed as a plasma cell granuloma of the bladder. DISCUSSION
Plasma cell granuloma is a rare, benign tumor that was first described in detail by Bahadori and Liebow. 1 Histolog ically, it consists of a proliferation of mature, well differenti ated plasma cells and reticuloendothelial cells in a stroma of granulation tissue. The disease occurs in the lung as a mostly asymptomatic solitary coin lesion with no characteristic find ings.2 The etiology of this lesion is thought to be infectious or immunological but it has not been identified yet. Extrapul monary plasma cell granulomas are rare but they have been reported in the stomach, pancreas, tonsil, liver, thyroid, ret roperitoneum, 4th ventricle, spinal cord meninges, intracra nial structures, kidney and heart. 3 To our knowledge only 1 other report of plasma cell gran uloma of the bladder exists in the literature. Jufe et al de scribed a case similar to ours, including patient age and chief complaint, and no hematuria. 4 Because no history of urinary infection existed in either case, the lesion may not be of infectious origin. In our case transurethral resection did not contribute to the diagnosis because the lesion was deeply seated. In the case of Jufe et al the lesion was also deep, which may be characteristic of this condition. The differential diagnosis of a submucosal bladder mass is broad, including cancer, endometriosis and inflammatory le sions. In our case carcinoma and endometriosis were ruled out based on the absence of epithelial cells and negative cytokeratin staining. A few histiocytes were seen but they
showed no atypia. Since there was no evidence of the tumoral proliferation of other mesenchymal cells, sarcoma could be excluded. The patient had no history of urogenital infection, peritonitis or bowel inflammation, such as diverticulitis or Crohn's disease. The tumor was localized and it did not communicate with the peritoneal cavity or the bladder lu men. These findings eliminated a nonspecific infectious ori gin, while negative periodic acid, Schiff and Grocott-Gomori methenamine silver nitrate staining excluded fungal infec tion. The rarity of histiocytes and the absence of Michaelis Gutmann bodies ruled out malacoplakia. Furthermore, the absence of tubercles and epithelioid cells, and the negative Ziehl-Neelsen carbolfuchsin staining excluded tuberculosis. Differential diagnosis from extramedullary plasmacytoma of the bladder was difficult with hematoxylin and eosin stain ing. However, the presence of polyclonal plasma cells that was demonstrated by irnmunohistochemistry established the final diagnosis of plasma cell granuloma of the bladder. In conclusion, it is important for clinicians to be aware of plasma cell granuloma in the differential diagnosis of sub mucosal tumor of the bladder. Immunohistochemistry has a definitive role in differentiating plasma cell granuloma from extramedullary plasmacytoma. Keiko Zen and Seiko Ogura provided technical assistance. REFERENCES 1. Bahadori, M. and Liebow, A. A.: Plasma cell granulomas of the lung. Cancer, 31: 191, 1973. 2. Spencer, H.: The pulmonary plasma cell/histiocytoma complex. Histopathology, 8: 903, 1984. 3. Chou, P., Gonzalez-Crussi, F., Cole, R. and Reddy, V. B.: Plasma cell granuloma of the heart. Cancer, 62: 1409, 1988. 4. Jufe, R., Molinolo, A. A., Fefer, S. A. and Meiss, R. P.: Plasma cell granuloma of the bladder: a case report. J. Urol., 131: 1175, 1984.
THE JOURNAL OF UROLOGY Copyright© 1994 by AMERICAN UROLOGICAL AssoCIATION, INC.
Vol. 152, 956-957, September 1994 Printed in U.S.A.
PLASMA CELL GRANULOMA OF THE BLADDER: A CASE REPORT HIROSHI MAEDA, SHINGO YAMAMOTO, YOSHIHIRO YAMADA
AND
HIROTAKA MORI
From the Departments of Urology and Pathology, Saiseikai Noe Hospital, Osaka, Japan
ABSTRACT
Plasma cell granuloma of the lung has been reported often but extrapulmonary cases are rare. A case of plasma cell granuloma of the bladder involving the omentum is reported. Transurethral biopsy of the bladder did not aid in diagnosis because the lesion was deeply seated, and differential diagnosis with hematoxylin and eosin staining was difficult due to atypical plasma cells. Immunohistochemistry established the final diagnosis. KEY WORDS: granuloma, plasma cell; bladder; diagnosis, differential
Plasma cell granuloma is a rare nonneoplastic mass of unknown etiology that occurs most commonly as a solitary coin lesion in the lung. Extrapulmonary plasma cell granu loma is more unusual. We report a case of such a lesion involving the bladder and the omentum. CASE REPORT
A 49-year-old woman presented with a 5-month history of recurring bladder irritability and colic in the right lower abdomen. Except for elective abortion 10 years previously, she had no history of urinary tract infection, instrumenta tion, trauma or other urological problems. Physical examina tion revealed a painless, firm pelvic mass, palpable per vagi nam above the bladder neck. Urinalysis was normal and urinary cytology was negative. White blood count, C-reactive protein and erythrocyte sedimentation rate were moderately elevated. Other laboratory findings were within normal lim its. Excretory urography showed normal upper urinary tracts and a filling defect of the bladder. Cystoscopy revealed a broad based mass arising near the bladder dome that was covered with edematous mucosa (fig. 1). Computerized to mography confirmed a heterogeneous lesion 4 cm. in diame ter in the anterior wall that seemed to be continuous with the bowel. No pelvic lymphadenopathy was demonstrated (fig. 2). A barium enema and fibercolonoscopy were normal, and transurethral biopsy of the mass showed only inflammation. Because primary bladder cancer was ruled out, we performed partial cystectomy. Exploration of the abdomen revealed that the mass was firm and adherent to the greater omentum. The mass, includAccepted for publication December 22, 1993.
Fm. 2. Computerized tomography shows heterogeneously dense mass in anterior wall of bladder (arrows).
ing a part of omentum, was resected en bloc. Other organs were normal. Convalescence was uneventful and the patient was discharged from the hospital 32 days postoperatively. Followup cystoscopy and excretory urography showed a slight deformity of the bladder but no evidence of recurrence 8 months later. Grossly, the resected specimen measured 5 X 5 X 4 cm. and the lesion consisted of poorly defined, white-yellowish tissue of a rather firm consistency with necrotic foci. It was separated from the bladder wall and the mucosa was edem atous (fig. 3). Microscopy showed that the tumor was not encapsulated and that it was located chiefly in the perivesical adipose tissue, partially involving the deep muscular layer. The lesion was comprised mainly of plasma cells and occa sional atypical multinucleated plasma cells (fig. 4). Other inflammatory cells were present including lymphocytes and a few histiocytes without atypia. The bladder epithelium could be identified. Edema and inflammatory cell infiltrates were noted in the lamina pro pria but the cells were mostly lymphocytes. There was no fistula formation between the mucosa and the tumor.
IIIJIIUIIIIIIUU-1 Fm. 1. Broad based tumor is covered with edematous mucosa
Fm. 3 Cut surface of mass removed by partial cystectomy with 2 cm. margin of normal surrounding bladder wall and greater omen tum adherent to tumor (arrows). 956
957
PLASMA CELL GRANULOIVIA OF BLADDER
FIG. 4. A, aggregates of inflammatory cells, predominantly plasma cells. Reduced from X 100. B, high power view demonstrates plasma cells with atypia. Reduced from X400.
FIG. 5. Immunohistochemical stain shows positive reaction for kappa (A) and lambda (B) chains. Reduced from X400
Michaelis-Gutmann bodies were not seen, cytokeratin and Ziehl-Neelsen carbolfuchsin staining were negative, and pe riodic acid, Schiff and Grocott-Gomori methenamine silver nitrate staining showed no fungi. Kappa and lambda chains were recognized in the plasma cells, which showed polyclonal proliferation (fig. 5). On the basis of these findings this lesion was diagnosed as a plasma cell granuloma of the bladder. DISCUSSION
Plasma cell granuloma is a rare, benign tumor that was first described in detail by Bahadori and Liebow. 1 Histolog ically, it consists of a proliferation of mature, well differenti ated plasma cells and reticuloendothelial cells in a stroma of granulation tissue. The disease occurs in the lung as a mostly asymptomatic solitary coin lesion with no characteristic find ings.2 The etiology of this lesion is thought to be infectious or immunological but it has not been identified yet. Extrapul monary plasma cell granulomas are rare but they have been reported in the stomach, pancreas, tonsil, liver, thyroid, ret roperitoneum, 4th ventricle, spinal cord meninges, intracra nial structures, kidney and heart. 3 To our knowledge only 1 other report of plasma cell gran uloma of the bladder exists in the literature. Jufe et al de scribed a case similar to ours, including patient age and chief complaint, and no hematuria. 4 Because no history of urinary infection existed in either case, the lesion may not be of infectious origin. In our case transurethral resection did not contribute to the diagnosis because the lesion was deeply seated. In the case of Jufe et al the lesion was also deep, which may be characteristic of this condition. The differential diagnosis of a submucosal bladder mass is broad, including cancer, endometriosis and inflammatory le sions. In our case carcinoma and endometriosis were ruled out based on the absence of epithelial cells and negative cytokeratin staining. A few histiocytes were seen but they
showed no atypia. Since there was no evidence of the tumoral proliferation of other mesenchymal cells, sarcoma could be excluded. The patient had no history of urogenital infection, peritonitis or bowel inflammation, such as diverticulitis or Crohn's disease. The tumor was localized and it did not communicate with the peritoneal cavity or the bladder lu men. These findings eliminated a nonspecific infectious ori gin, while negative periodic acid, Schiff and Grocott-Gomori methenamine silver nitrate staining excluded fungal infec tion. The rarity of histiocytes and the absence of Michaelis Gutmann bodies ruled out malacoplakia. Furthermore, the absence of tubercles and epithelioid cells, and the negative Ziehl-Neelsen carbolfuchsin staining excluded tuberculosis. Differential diagnosis from extramedullary plasmacytoma of the bladder was difficult with hematoxylin and eosin stain ing. However, the presence of polyclonal plasma cells that was demonstrated by irnmunohistochemistry established the final diagnosis of plasma cell granuloma of the bladder. In conclusion, it is important for clinicians to be aware of plasma cell granuloma in the differential diagnosis of sub mucosal tumor of the bladder. Immunohistochemistry has a definitive role in differentiating plasma cell granuloma from extramedullary plasmacytoma. Keiko Zen and Seiko Ogura provided technical assistance. REFERENCES 1. Bahadori, M. and Liebow, A. A.: Plasma cell granulomas of the lung. Cancer, 31: 191, 1973. 2. Spencer, H.: The pulmonary plasma cell/histiocytoma complex. Histopathology, 8: 903, 1984. 3. Chou, P., Gonzalez-Crussi, F., Cole, R. and Reddy, V. B.: Plasma cell granuloma of the heart. Cancer, 62: 1409, 1988. 4. Jufe, R., Molinolo, A. A., Fefer, S. A. and Meiss, R. P.: Plasma cell granuloma of the bladder: a case report. J. Urol., 131: 1175, 1984.