Inverted urothelial papilloma of the upper urinary tract: description of two cases with systematic literature review

Abstract

Background: Inverted urothelial papilloma (IUP) of the upper urinary tract is an uncommon benign tumour that occasionally presents as a polypoid mass causing urinary obstruction. Histologically, IUP is characterised by a proliferating urothelium arranged in cords and trabeculae, in continuity with overlying intact epithelium, and extending into the lamina propria in a non-invasive, endophytic manner. Cytological atypia is minimal or absent. Top differential diagnoses include urothelial carcinoma with inverted growth pattern and florid ureteritis cystica. Although urothelial carcinomas of the upper urinary tract with prominent inverted growth pattern commonly harbour microsatellite instability, the role of the mutator phenotype pathway in IUP development is still unclear. The aim of this study was to describe two additional cases of IUP of the upper urinary tract, along with an extensive literature review.

Case presentation: We observed two polypoid tumours originating in the renal pelvis and the distal ureter, respectively. Both patients, a 76-year-old woman and a 56-year-old man, underwent surgery because of the increased likelihood of malignancy. Histology was consistent with IUP and patients are alive and asymptomatic after long-term follow-up (6 years for the renal pelvis lesion and 5 years for the ureter lesion). The tumours retained the expression of the mismatch-repair protein MLH1, MSH2, and PMS2 whereas loss of MSH6 was found in both cases.

Conclusions: When completely resected, IUP does not require rigorous surveillance protocols, such as those for urothelial carcinoma and exophytic urothelial papilloma. It is therefore important for the surgical pathologist to be aware of this rare entity in order to ensure correct patient management.

Keywords: Inverted urothelial papilloma; Microsatellite instability; Molecular markers; Upper urinary tract.

Fig. 1

Histological features of two cases of IUP of the upper urinary tract. Sessile polypoid tumour of the renal pelvis consisting of anastomosing trabeculae and cords growing downward into the lamina propria, with prominent peripheral palisading in the trabeculae (Case 1: a, b). Pedunculated polypoid IUP of the distal ureter characterized by microcyst formation and foci of squamous metaplasia (Case 2: c, d)

Fig. 2

Immunohistochemical results in two cases of IUP pf the upper urinary tract. Both cases were negative for CK20 immunostaining (Case 1: a; Case 2: c) and showed low Ki-67 labelling index (< 1%) (Case 2: b; Case 2: d)

Fig. 3

Expression of the mismatch-repair proteins in two cases of IUP of the upper urinary tract (Case 1: a-d; Case 2: e-h). Nuclear staining for MLH1 (a, e), MSH2 (b, f), PMS2 (c, g) was observed in both cases, whereas the tumours showed loss of MSH6 expression (d, h)