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Presented by Jonathan Epstein, M.D. and prepared by Amy Duffield, M.D., Ph.D.
Case 1: A 48 year old male was noted to have a mass following work-up for gross hematuria.
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1. Question
Week 348: Case 1
A 48 year old male was noted to have a mass following work-up for gross hematuria.images/4_14_08 1A.jpg
images/4_14_08 1B.jpg
images/4_14_08 1C.jpg
images/4_14_08 1D.jpg
images/4_14_08 1E.jpgCorrect
Answer: Benign inverted urothelial papilloma
Histology: The surface of this lesion has a smooth appearance without papillary fronds. Beneath the overlying urothelium there are anastomosing columns of urothelium set in a myxoid background without an inflammatory reaction. Cytologically, the lesion lacks urothelial atypia and is composed of bland urothelium many of which have nuclear grooves. Mitotic figures are difficult to appreciate. In areas there is somewhat of peripheral palisading of the urothelium along the outer borders of the columns with central streaming of the nuclei parallel to the columns. Occasional cysts are identified filled with colloid material.
Discussion: These findings are classic for benign inverted urothelial papilloma. All of the variance of papillary urothelial neoplasms may have an inverted growth pattern. This includes PULMP with an inverted growth patterns as well as low and high grade noninvasive papillary urothelial carcinomas with inverted growth pattern. One can distinguish benign inverted urothelial papilloma from carcinomas with an inverted growth pattern quite readily based on cytologic atypia in carcinomas. The distinction between a PUNLMP with an inverted growth pattern versus a benign inverted urothelial papilloma is mainly based on architecture. A PUNLMP with an inverted growth pattern typically shows some exophytic papillary fronds characteristic of a PUNLMP although rarely one can have a PUNLMP with a pure inverted growth pattern. In either case, the inverted urothelial nests in a PUNLMP with an inverted pattern are large and round in contrast to the thin anastomosing columns seen in benign inverted urothelial papilloma. The distinction between a PUNLMP with an inverted growth pattern and a benign inverted urothelial papilloma has clinical implications. PUNLMP is associated with an increased risk of recurrence and patients need to be followed for life with follow-up cystoscopy and urine cytology. Benign inverted urothelial papillomas once excised do not recur and are not associated with an increase risk of other urothelial neoplasms. Consequently, patients with benign inverted urothelial papilloma do not need life long surveillance of their urothelial tract.
Incorrect
Answer: Benign inverted urothelial papilloma
Histology: The surface of this lesion has a smooth appearance without papillary fronds. Beneath the overlying urothelium there are anastomosing columns of urothelium set in a myxoid background without an inflammatory reaction. Cytologically, the lesion lacks urothelial atypia and is composed of bland urothelium many of which have nuclear grooves. Mitotic figures are difficult to appreciate. In areas there is somewhat of peripheral palisading of the urothelium along the outer borders of the columns with central streaming of the nuclei parallel to the columns. Occasional cysts are identified filled with colloid material.
Discussion: These findings are classic for benign inverted urothelial papilloma. All of the variance of papillary urothelial neoplasms may have an inverted growth pattern. This includes PULMP with an inverted growth patterns as well as low and high grade noninvasive papillary urothelial carcinomas with inverted growth pattern. One can distinguish benign inverted urothelial papilloma from carcinomas with an inverted growth pattern quite readily based on cytologic atypia in carcinomas. The distinction between a PUNLMP with an inverted growth pattern versus a benign inverted urothelial papilloma is mainly based on architecture. A PUNLMP with an inverted growth pattern typically shows some exophytic papillary fronds characteristic of a PUNLMP although rarely one can have a PUNLMP with a pure inverted growth pattern. In either case, the inverted urothelial nests in a PUNLMP with an inverted pattern are large and round in contrast to the thin anastomosing columns seen in benign inverted urothelial papilloma. The distinction between a PUNLMP with an inverted growth pattern and a benign inverted urothelial papilloma has clinical implications. PUNLMP is associated with an increased risk of recurrence and patients need to be followed for life with follow-up cystoscopy and urine cytology. Benign inverted urothelial papillomas once excised do not recur and are not associated with an increase risk of other urothelial neoplasms. Consequently, patients with benign inverted urothelial papilloma do not need life long surveillance of their urothelial tract.
