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Year : 2020  |  Volume : 63  |  Issue : 1  |  Page : 96-97
Glandular-type inverted papilloma of urinary bladder – Report of a unique case with immunohistochemistry


1 Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

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Date of Web Publication31-Jan-2020
 

   Abstract 


Inverted papilloma of urothelium is a rare benign tumour accounting for 1–2% of all the urothelial lesions. Morphologically, these are of two main subtypes – trabecular and glandular, of which the former subtype is most frequently encountered compared to the latter. The glandular subtype closely mimics cystitis glandularis and urothelial carcinoma with inverted growth pattern. We discuss a case of a 27-year-old male presenting with hematuria. On cystoscopy, he was found to have a bladder mass which was diagnosed as glandular-type of inverted papilloma on histopathology. The image illustrates the histopathology for easy identification and early diagnosis of this rare entity.

Keywords: Glandular subtype, hematuria, inverted papilloma

How to cite this article:
Sundaram A, Gupta K, Singla S, Singh SK. Glandular-type inverted papilloma of urinary bladder – Report of a unique case with immunohistochemistry. Indian J Pathol Microbiol 2020;63:96-7

How to cite this URL:
Sundaram A, Gupta K, Singla S, Singh SK. Glandular-type inverted papilloma of urinary bladder – Report of a unique case with immunohistochemistry. Indian J Pathol Microbiol [serial online] 2020 [cited 2020 Feb 17];63:96-7. Available from: http://www.ijpmonline.org/text.asp?2020/63/1/96/277385





   Introduction Top


Inverted papilloma (IP) is a rare benign tumour arising from the urothelial epithelium of the urinary bladder accounting for about 2.2% of all the urothelial lesions.[1] The two common types are 'classical' trabecular type and glandular type which differ histomorphologically. The clinical features are usually not specific since the urothelial carcinoma also presents with similar features of hematuria and other urinary symptoms. Although the IPs are considered benign, they seem to have multiplicity and low recurrence rate with uncertain malignant potential.


   Case Report Top


A 27-year-old man presented with painless gross hematuria and increased frequency of micturition of 2 months duration. A computed tomography (CT) scan was advised which revealed a single polypoidal mass measuring 2 × 1.2 × 1 cm in the lateral wall of urinary bladder. The patient underwent transurethral resection of bladder tumour (TURBT). Endoscopically, the tumour appeared pedunculated with a smooth surface. The TURBT chips were submitted for histopathological evaluation.

On gross examination, the resected specimen comprised of multiple irregular greyish white tissue pieces measuring about 2 ml in volume. Histopathologically, these tissue bits revealed a polypoid and proliferative tumour with inward growth into the lamina propria [Figure 1]a and [Figure 1]b. The tumour was arranged in closely placed interconnected glands with minimal intervening stroma. Occasional glands showed luminal eosinophilic secretions. The tumour cells were relatively monomorphic to mildly pleomorphic with bland nuclear morphology. There was no atypia, hyperchromasia, mitosis, surrounding desmoplastic reaction or inflammation. The cells demonstrated strong cytoplasmic positivity for CK7, focal weak positivity for CK20, cytoplasmic positivity for beta-catenin and strong nuclear positivity for GATA3, thereby confirming its urothelial origin [Figure 2]a [Figure 2]b [Figure 2]c [Figure 2]d.
Figure 1: (a) Tumour with inward growth pattern arranged as closely placed glands (H and E, ×200 magnification), (b) Occasional luminal eosinophilic secretions within these glandular structures (H and E, ×400 magnification)

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Figure 2: Immunohistochemistry panel showing (a) strong cytoplasmic positivity for CK7, (b) weak focal positivity for CK20, (c) cytoplasmic positivity for beta-catenin and (d) nuclear positivity for GATA3 (×400 magnification)

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   Discussion Top


IP was described first by Paschkis in 1927 which had a distinct inverted polypoid epithelial architecture situated in the urinary bladder.[2] Initially it was termed as Brunnian adenoma. Although few studies have related it to smoking, the histogenesis is uncertain. Cummings[3] and Matz et al.[4] described it as a hyperplastic reaction of the Brunn's cell nests secondary to chronic inflammation or irritative agents. IP has a broad age range, although males of sixth and seventh decades are commonly affected. The presenting symptoms are painless gross hematuria and irritative voiding manifestations. The common site of involvement is the trigone and the bladder neck followed by lateral wall of the bladder and distal ureter. One case of glandular type IP has been reported in prostatic urethra.[5] The characteristic gross appearance described is non-invasive, non-papillary, sessile or pedunculated lesions of urothelium with smooth surface. Microscopically, these represent trabecular or glandular types, of which the former appears as a thin cord like inter-communicating structures with downward growth. The glandular type has morphological overlap with cystitis glandularis and grows as nests of mature urothelium arranged in pseudoglandular or true glandular structures with goblet cells. Immunohistochemistry has a limited role in diagnosis of IPs, however, these are important to differentiate them from urothelial carcinomas. In a study by Jones et al., none of 15 cases in their cohort revealed positivity for CK20 and Ki67.[6] CK7 and GATA3 suggest its urothelial origin. Molecular studies can show rare deletions at chromosome 9 and 17, FGFR mutations and low rate of loss of heterozygosity.

The preoperative diagnosis of IP is difficult. There are no specific radiological findings for IP. Transurethral resection is the gold standard treatment for IP. Cystoscopic follow up is recommended since they have low rates of recurrence (1–7%) and malignancy (1.5%).


   Conclusion Top


To conclude, glandular type IPs are rare benign tumours of the urinary tract presenting commonly in elderly men with lower urinary tract symptoms. Histologically, they show an inverted growth pattern having glandular arrangement with minimal cytological atypia. Post-transurethral resection, cystoscopy is recommended for follow up.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Darras J, Inderadjaja N, Vossaert P. Synchronous inverted papilloma of bladder and renal pelvis. Urology 2005;65:798.  Back to cited text no. 1
    
2.
Paschkis R. Ueber adenome der Harnblase. Z Urol Chir 1927;21:315-21.  Back to cited text no. 2
    
3.
Cummings R. Inverted papilloma of the bladder. J Pathol 1974;112:225-7.  Back to cited text no. 3
    
4.
Matz LR, Wishard VA, Goodman MA. Inverted urothelial papilloma. Pathology 1974;6:37-44.  Back to cited text no. 4
    
5.
Lopez JI, Ereno C. Glandular-type inverted papilloma of the prostatic urethra. Arch Anat Cytol Pathol 1997;45:227-9.  Back to cited text no. 5
    
6.
Jones TD, Zhang S, Lopez-Beltran A, Eble JN, Sung MT, MacLennan GT, et al. Urothelial carcinoma with an inverted growth pattern can be distinguished from inverted papilloma by fluorescence in situ hybridization, immunohistochemistry, and morphologic analysis. Am J Surg Pathol 2007;31:1861-7.  Back to cited text no. 6
    

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Correspondence Address:
Kirti Gupta
Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_456_18

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