Evaluation of atypical urine cytology progression to malignancy

Benign-appearing urothelial tissue fragments in noninstrumented voided urine specimens are associated with low rates of urothelial neoplasia

BACKGROUND

The presence of urothelial tissue fragments (UTF) in voided urine (VU) is often considered an abnormal finding that may be associated with the presence of urothelial papillary neoplasms. In the current study, the authors reviewed VU specimens containing benign-appearing UTF (BUTF) to determine the associated rate of urothelial neoplasia at the study institution.

METHODS

A retrospective search of the electronic pathology database system over a 5-year period (2009-2013) revealed 1131 VU specimens containing UTF. Of these, 459 cases (40.6%) did not have a recent history of instrumentation. Fifteen cases were excluded because the slides were not available for review. In the remaining 444 cases, 274 cases (61.7%) had BUTF. A total of 170 cases (38.3%) had UTF with atypical cytologic features and were therefore excluded.

RESULTS

Of the 274 cases, 29 (10.6%) had follow-up surgical pathology specimens available. The overall rate of urothelial neoplasia on follow-up was 3.6% for low-grade urothelial neoplasia (10 cases) and 0.7% for high-grade urothelial carcinoma (2 cases). Forty-five cases (16.4%) were determined to have urinary tract stones on follow-up.

CONCLUSIONS

The presence of BUTF in VU specimens requires careful examination of the medical history because their presence may be explained by recent instrumentation. If recent instrumentation is not identified, the etiology of BUTF is not usually determined; in the current study, BUTF were found to be associated with urinary tract stones in 16.4% of cases. They also present a low risk of low-grade urothelial neoplasia (3.6%) and high-grade urothelial carcinoma (0.7%) when compared with the overall benign category at the study institution (2.3% [P =.15] and 0.7%, respectively).

What should not be reported as atypia in urine cytology

The term "atypia," although not well characterized, is widely used in diagnostic surgical and cytopathology. Because there are no guidelines regarding when to use this term, in the majority of cases, it is used as a "wastebasket." This definitely applies to urine cytology, where the reported rate of atypia ranges from 1.9% to 23%. This review lists a number of cytomorphologic findings in urine cytology that are associated with known and specific causes. Urine specimens in which the morphologic changes can be attributed to particular etiologic factors should no longer be classified as "atypical." These include urine specimens showing reactive umbrella cells or seminal vesicle cells, reactive changes due to stones, cytologic changes characteristic of infectious processes or therapy effect, instrumented urines with pseudopapillary clusters, and urinary diversion specimens.

Diagnosis of upper tract urothelial carcinoma-a comparative study of urinary cytology and surgical biopsy

INTRODUCTION

Upper tract urothelial carcinoma (UTUC) is defined as urothelial carcinoma (UC) arising in the renal pelvis and ureter. Upper tract (UT) cytology and biopsy evaluation can be technically challenging. The aim of the study is to evaluate the diagnostic modality and sensitivity of urine cytology and ureteroscopic biopsy for the diagnosis of UTUC.

MATERIAL AND METHODS

All patients with UTUC who underwent radical nephroureterectomy or ureterectomy with preoperative cytology and/or biopsy from January 1, 2000 to September 30, 2011 at our institution were included in this study. The sensitivity of each diagnostic modality was calculated with respect to tumor grade, stage, and size.

RESULTS

A total of 143 cytology specimens and 54 biopsies from 65 patients were evaluated. For low-grade UTUC, the sensitivities for biopsy, lower tract cytology, and UT cytology were 68.4%, 27.3%, and 37.5%, respectively. These numbers were 82.9%, 40.7%, and 80.6% for high-grade UTUC. By combining the UT cytology and biopsy, the diagnostic sensitivities were increased to 87.5% for low-grade UTUC and 100% for high-grade UTUC. The consistency of tumor grade between biopsy and surgical specimen were 63.2% for low-grade UTUC and 68.6% for high-grade UTUC.

CONCLUSIONS

Both UT cytology and biopsy showed higher sensitivity in detecting high-grade UTUC versus low-grade UTUC. The sensitivities of UT cytology and ureteroscopic biopsy in detecting high-grade UTUC were comparable. The sensitivity was greatly improved when these diagnostic modalities were combined. As expected, the selective UT cytology evaluation had superior sensitivity in detecting UTUC than did the lower tract cytology sampling.

Atypical urine cytology and the Johns Hopkins Hospital template: the University of Chicago experience

INTRODUCTION

The rate of atypical diagnoses in urine cytology can be high depending on the screening population. Unlike thyroid and cervical cytology, there is a lack of standardized criteria to stratify them into more clinically meaningful categories.

MATERIALS AND METHODS

A set of diagnostic criteria described by Johns Hopkins Hospital (JHH) provided a tool to divide atypical urine specimens into those that were low risk and those likely to be predictive of high-grade urothelial carcinoma (HGUC). In this study, the JHH template was applied to a cohort of atypical urine cytology specimens from the University of Chicago (U of C) to compare it to existing U of C terminology and determine whether it should be formally adopted.

RESULTS

Sixty-eight percent of patients classified as atypical urothelial cells, favor high-grade lesion (AUC-H) were diagnosed with HGUC during the study. Correlation was noted between the JHH diagnostic categories and the U of C diagnostic categories, with 49% of patients reclassified as AUC-H being diagnosed with atypical urothelial cells, suspicious for neoplasia and 83% of cases of patients reclassified as atypical urothelial cells of unknown significance being diagnosed as atypical, urothelial cells. The JHH category of AUC-H had a higher positive predictive value for HGUC than the U of C category atypical urothelial cells, suspicious for neoplasm did (69% versus 58%, p = 0.0087). Unlike the JHH study, AUC-H showed higher correlation with HGUC in the hematuria group (90%) than in the surveillance group (66%).

CONCLUSIONS

JHH criteria demonstrated a higher rate of predicting HGUC than U of C diagnostic categories, supporting the adoption of these criteria at U of C.

Significance of atypical category in voided urine specimens prepared by liquid-based technology: Experience of a single institution

INTRODUCTION

The goal of this study was to evaluate the clinical significance of atypical cytology in voided urine samples. We also studied any differences in outcome that may exist between the patients being surveyed versus high risk for urothelial carcinoma (UC).

MATERIALS AND METHODS

This was a retrospective study of all voided urine specimens with "atypical" cytology over a 10-year period. The patients were categorized into those with and without a prior diagnosis of UC as the "surveillance" and "de novo" (DG) groups. Follow-up was obtained. Clinical impact and outcomes of the 2 groups were compared.

RESULTS

In this study, 5.7% of voided urine specimens were atypical. Mean age of patients in years, male/female ratio, and time to diagnosis in days was 59 versus 71, 23:15 versus 22:1, and 95 versus 43 in the DG and surveillance group, respectively. Rate of progression to UC was similar in both groups. High-grade UC was significantly higher in the DG.

CONCLUSIONS

Approximately 20% of patients in the DG were subsequently diagnosed with UC. The common causes for the atypical diagnosis that did not progress to UC were stones and benign prostatic hyperplasia. In the absence of an etiology for the atypia, further investigations are warranted.