Young Teenage Male with Macroscopic Hematuria

Specimen Type:



A 15-year-old boy with macroscopic hematuria underwent a cystoscopy with bladder biopsy. Visualization by endoscopy shows a solitary exophytic papillary lesion (fig 4.1). At gross description, the lesion is received as multiple portions, in aggregate 2 cm x 1.5 cm x 0.3 cm. Representative cross-sections were submitted.

Pathologic Features:

Sections revealed a complex papillary proliferation of urothelium. The urothelium presents normal thickness in some focal areas but in general is greater than 7 layers (fig 4.2). Superficial (umbrella) cells are absent (fig 4.3). Nuclei are uniform in shape and spacing; the chromatin texture is finely granular, without significant nucleolar enlargement (fig 4.4). Mitotic figures are rare.

Papilloma: The WHO criteria for papilloma include five strict features:

  • lesion less than 2 cm in greatest dimension; (2) solitary (3) papillae consist of delicate fibrovascular cores lined by less than 7 layers of urothelium; (4) without mitotic figures or any significant cytologic atypia. Mild nuclear atypia is occasionally present; intact superficial (umbrella) cell layer; and (5) patients are less than 50 years of age.
  • Papilloma is uncommon, representing less than 3 % of papillary urothelial tumors. Urothelial papilloma does not have the capacity to invade or metastasize. However, it is neoplastic, with a small but significant potential for recurrence.

Polypoid cystitis: Although classically described as being associated with indwelling catheters, this lesion may arise as a reaction to any inflammatory insult to the urinary mucosa. This lesion appears as either an area of friable mucosa irregularity, thin finger-like papillae (Papillary cystitis), or edematous and broad-based papillae (Polypoid cystitis). Abundant chronic inflammation is present within the stoma accompanied by prominent and often ectatic blood vessels.

Papillary urothelial hyperplasia: Flat or papillary urothelial hyperplasia consists of a markedly thickened mucosa with few or no significant cytological abnormalities.

Differential Diagnosis:

Considering patient’s age, papilloma enters the major differential diagnosis (fig 4.5).

  • Polypoid cystitis
  • Papillary urothelial hyperplasia


Non-Invasive Grade 1 (OF 3) Papillary Urothelial Carcinoma (Who 1973 Classification).

Key Features:

  • Age: Usually > 50 years*
  • Size: Usually > 2 cm
  • Sex ratio (Male:female): 3:1
  • Microscopic findings:
    • Well-formed papillae: Present
    • Thickness of urothelium: Usually > 7 layers
    • Superficial umbrella cells: Usually present, may be absent
    • Cytology
      • Nuclear enlargement: slight to modetrate
      • Nuclear hyperchromasia: Slight
      • Chromatin: Slighty coarse or granular
      • Nucleolar enlargement: May be present
    • Mitotic figures: Rare
    • Stromal invasion: Uncommon

* In the case presented here, the patient is 15- year-old. Based on histological findings (urothelium greater than 7 layers (despite normal thickness present in some areas) and absence of superficial umbrella cells)), the diagnosis of urothelial carcinoma is retained.

  • Transitional cell carcinoma of the bladder occurs rarely during the first two decades of life. The malignancy is usually low grade and noninvasive, with a law recurrence rate
  • Transurethral resection and fulguration is the treatment of choice, and the prognosis is excellent
  Papilloma Grade I Carcinoma
Age (y) Younger (usually <50) Older (usually >50)
Sex (Male:female) 2:1 3:1
Size Small, usually <2cm Larger
Microscopic findings    
-Well-formed papillae Present Present
-Thicknes of Urothelium < 7 layers Usually > 7 layers
-Superficial umbrella cells Present Usually present
-Nuclear enlargement Rare or none Slight to moderate
-Nuclear hyperchromasia Rare or none Slight
-Chromatin Fine granular Slight coarse or granular
-Chromatin Absent May be present
Mitotic figures None Rare
Stromal Invasion Absent Uncommon


  1. Hoenig DM, McRae S, Chen SC, et al. Transitional cell carcinoma of the bladder in the pediatric patient. J Urol. 1996; 156(1):203-5.
  2. Bostwick DG, Ramnani D, Cheng L. Diagnosis and grading of bladder cancer and associated lesions. Urol Clin North Am. 1999; 26(3):493-507.
  3. Cheng L, Darson M, Cheville JC, et al. Urothelial papilloma of the bladder. Clinical and biologic implications. Cancer. 1999; 86(10):2098-101.
  4. Cheng L, Neumann RM, Bostwick DG. Papillary urothelial neoplasms of low malignant potential. Clinical and biologic implications. Cancer. 1999; 86(10):2102-8.
  5. Mc Kenney JK, Amin MB, Young RH. Urothelial (Transitionnal Cell) Papilloma of the urinary bladder: A clinicopathologic study of 26 cases. Mod Pathol. 2003; 16(7):623-9.