Adequacy in voided urine cytology specimens: The role of volume and a repeat void upon predictive values for high-grade urothelial carcinoma

A comparison between conventional and the Paris systems of reporting urinary cytopathology with a literature update

INTRODUCTION

Owing to certain inherent limitations of earlier reporting systems, "The Paris System for Reporting Urinary Cytology (TPS)" was implemented in 2015 to standardize reporting urine cytology with more stringent cytomorphologic criteria. We share our post-TPS experience, comparing it with the conventional system (CS).

AIM

To assess and compare the cyto-histopathologic/cystoscopic agreement between the conventional and the Paris systems (CS and TPS) for reporting urine cytology.

MATERIALS AND METHODS

It is a cross-sectional study involving urine samples from 170 patients divided into two groups (CS and TPS). Of the 170 cases, 85 were reported according to the CS, and 85 were reported according to TPS with all the relevant clinical, radiologic, and cystoscopic findings. Using the kappa statistics, both groups were statistically analyzed for sensitivity, specificity, predictive values, and agreement.

RESULTS

The sensitivity and specificity for high-grade urothelial carcinoma (HGUC) as per TPS were 83.33% and 94.59%, respectively, while they were 73.47% and 80.56% for the conventional system. The agreement for HGUC with TPS was 87.06% with a kappa value of 0.7416, while it was 76.5% with a kappa value of 0.53 for the CS. Implementing the TPS minimized usage of the atypical urothelial cells (AUC) category, increasing the clarity in detecting HGUC.

CONCLUSION

TPS provides better agreement with histopathology than the CS for diagnosing HGUC, which is attributable to stringent TPS criteria that prompt cytopathologists to look more diligently for morphologic and numeric criteria.

Urine cytology in the detection of renal cell carcinomas - a territory-wide multi-institutional retrospective review of more than 2 decades

INTRODUCTION

Compared with urothelial lesions of the upper urinary tract, the diagnostic performance of urine cytology in detection of renal cell carcinomas is underreported. This study aims to establish the role of urine cytology in the assessment of renal carcinomas by a multi-institute review of urine cytology from nephrectomy confirmed renal cell carcinomas, referenced against renal urothelial and squamous cell carcinomas.

METHODS

Records of nephrectomy performed from the 1990s to 2020s at three hospitals were retrieved and matched to urine cytology specimens collected within 1 year prior. Patient demographics, specimen descriptors, and histology and staging parameters were reviewed and compared against cytologic diagnoses.

RESULTS

There were 1147 cases of urine cytology matched with renal cell carcinomas, with 666 renal urothelial/squamous carcinomas for comparison. The detection rate for urothelial/squamous (atypia or above [C3+]: 63.1%; suspicious or above [C4+]: 24.0%) were higher than renal cell carcinoma (C3+: 13.1%; C4+: 1.5%) (p < 0.001). The positive rate for upper tract urine exceeded other collection methods at 45.0% (C3+) and 10.0% (C4+) (p < .01). Other factors associated with increased positive rates were male sex, collecting duct carcinoma histology, nuclear grade, and renal/sinus involvement (p < .05). Multivariate analysis revealed additional positive correlations with presence of sarcomatoid tumor cells, lymphovascular invasion, and perinephric fat involvement (p < .05). Larger lesion size and higher urine volume did not improve detection rates (p < .05).

CONCLUSIONS

The detection rate of renal cell carcinomas is suboptimal compared with urothelial carcinomas, although urine samples collected from cystoscopy or percutaneous nephrostomy significantly outperformed voided urine specimens.

Utility and performance of cell blocks in urine cytology: Experience at three teaching hospitals

BACKGROUND

The use of cell block (CB) preparation is underused in urine cytology (UC) and varies among hospitals. In addition to confirming a diagnosis, CBs can be useful in cases of metastatic disease, diagnoses requiring immunohistochemical (IHC) staining, and for ancillary studies. The role of this study is to examine the performance of CBs for UC at three affiliated teaching hospitals.

MATERIALS AND METHODS

A retrospective review of UC cases with a CB was conducted at a county hospital, Veterans Affairs hospital, and tertiary university-based hospital. For each specimen, patient demographics, specimen type, volume, original diagnosis, and IHC stains were recorded. Each case was reviewed for diagnosis based on ThinPrep alone, diagnosis based on ThinPrep and CB, utility of CB for diagnosis, and CB cellularity.

RESULTS

A total of 250 UC specimens with CB from 186 patients was identified. Bladder washes were the most common (72.1%). IHC stains were performed on 17.2% of cases. On blinded review, CB preparation was deemed useful in 61.2% of cases, with the highest rate for suspicious for high-grade urothelial carcinoma (SHGUC) cases (87.0%). The diagnosis based on ThinPrep review changed with incorporation of CB in 13.2% of cases, with the highest rate for SHGUC cases (43.5%).

CONCLUSIONS

The results demonstrate that use of CB in UC confirms the final diagnosis in more than one-half of cases and changes the diagnosis in a subset of cases. Use of CB was most helpful in the SHGUC category. Further evaluation of the types of cases in which CB are prepared is warranted.

Iodinated Contrast Medium Affects Urine Cytology Assessment: A Prospective, Single-Blind Study and Its Impact on Urological Practice

During endoscopic procedures for suspected urothelial tumors of the upper urinary tract, radiographic imaging using an iodinated contrast medium is often required. However, following ureteropyelography, we detected changes in cytology characteristics not correlating with real cytology findings in naive urine. The aim of our study was to assess cytology changes between naive and postcontrast urine according to The Paris System of cytology classification. Methods: We prospectively assessed urine samples from 89 patients (23 patients with histologically proven urothelial cancer and 66 healthy volunteers). The absence of malignancy was demonstrated by CT urography and/or ureteroscopy. The study was single blind (expert cytopathologist) and naïve Paris system for urine cytology assessment was used. Furthermore, additional cytological parameters were analyzed (e.g., specimen cellularity, degree of cytolysis, cytoplasm and nucleus color, chromatin and nucleo-cytoplasmic ratio). Results: Our study showed statistically significant differences when comparing naïve and postcontrast urine in healthy volunteers (only 51 % concordance, p = 0.001) versus malignant urine specimens (82 % concordance). The most important differences were in the shift from The Paris System category 2 (negative) to 1 (non-diagnostic) and from category 2 (negative) to 3 (atypia). Other significant changes were found in the assessment of specimen cellularity (p = 0.0003), degree of cytolysis (p = 0.001), cytoplasm color (p = 0.003), hyperchromasia (p = 0.001), course chromatin (p = 0.002), nucleo-cytoplasmatic ratio (p = 0.001) and nuclear borders’ irregularity (p = 0.01). Conclusion: Our unique study found crucial changes in the cytological assessment of naive and postcontrast urine and we confirm that postcontrast urine is more often assessed as abnormal, suspect or non-diagnostic. Therefore, before urine collection for cytology, the clinician should avoid administration of iodinated contrast into the urinary tract.

The Paris System for reporting urinary cytology improves the negative predictive value of high-grade urothelial carcinoma

Background

The Paris System (TPS) for reporting urinary cytology differs from conventional systems (CS) in that it focuses on the diagnosis of high-grade urothelial carcinoma (HGUC). This study investigated the impact of TPS implementation on the diagnostic accuracy of HGUC by comparing it with our institutional CS.

Methods

A total of 649 patients who underwent transurethral resection of bladder tumor (TURBT) between January 2009 and December 2020 were included in this study. Our institution adopted TPS to report urinary cytology in February 2020. The diagnostic accuracy of HGUC in preoperative urinary cytology was compared with the presence or absence of HGUC in resected specimens of TURBT before and after TPS implementation.

Results

After implementing TPS in urinary cytology, 89 patients were reviewed and compared with 560 patients whose urinary cytology was diagnosed by CS. TPS and CS for detecting HGUC had 56.0% and 58.2% sensitivity, 97.8% and 91.2% specificity, and 93.3% and 87.9% positive predictive values, respectively. There were no significant differences between TPS and CS in terms of sensitivity, specificity, and positive predictive value for HGUC (P = 0.83, 0.21, 1.00). On the other hand, the negative predictive value for HGUC using TPS was 80.0%, which was significantly higher than that of CS (66.4%, P = 0.04) The multivariate logistic regression analysis indicated that not using TPS was one of the independent predictive factors associated with false-negative results for HGUC (odds ratio, 2.26; 95% confidence interval, 1.08–4.77; P = 0.03).

Conclusion

In instances where urinary cytology is reported as negative for HGUC by TPS, there is a low probability of HGUC, indicating that TPS has a potential diagnostic benefit.

Clinician's commentary: Atypia in urinary tract cytology specimens

At the 18th International Congress of Cytology in Paris in 2013, the "Paris Group" created standardized reporting system/criteria for urine cytopathology. This reporting system provided evidence-based criteria for all the urine cytopathologic diagnosis in aims to avoid atypia being used a "waste basket." The addition of standard classification system greatly helps minimizing atypia diagnosis; however, clinicians, specifically, urologist, are still left without a clear set of guidelines for how to approach atypia. Prospective collaborate work with cytopathologists and urologist can help solve the dreaded atypia cytology pathological report and provide a framework and guidelines on management, providing better care to our patients.

Effect of the Paris system for reporting urinary cytology with histologic follow-up

BACKGROUND

The Paris system (TPS) for Reporting Urinary Cytology provides a standardized reporting system whose main focus is the diagnosis of high-grade urothelial carcinoma (HGUC). We conducted a study to see the impact of The Paris System on our cytologic diagnoses with associated histology.

MATERIALS AND METHODS

We reviewed our pathology database regarding urinary specimens in the year before implementation of The Paris System and the year after. We gathered the data regarding cytologic diagnosis and concurrent/subsequent histology.

RESULTS

Over a 1-year period from 2016-2017, 486 urine cytology specimens were identified before implementation of The Paris System and diagnosed as follows: 83% benign/negative, 10% atypical, 2% suspicious, 5% HGUC, 0.2% low grade urothelial neoplasm (LGUN), and 0.2% unsatisfactory. Over a next 1-year period from 2017 to 2018, 602 specimens used TPS and diagnosed as follows: 85% negative for HGUC, 6% atypical, 3% suspicious, 4% HGUC, 0.17% LGUN, and 2% unsatisfactory. Although, not listed as a standardized category in The Paris System, our institution used "Negative for high-grade, cannot rule out low-grade urothelial neoplasm (NHL)" as a subcategory of Negative for HGUC. 4% of the cases fell into this category. Focusing on the Atypical category before TPS, histology was available in 15/49 (31%) cases. Of these, 40% had HGUC. Regarding the Atypical category after TPS, histology was available in 21/36 (58%) cases. Of these, 52% were HGUC. For the NHL category, concurrent histology was available in 13/26 (50%) cases. Of these, 67% were low grade urothelial neoplasms.

CONCLUSION

Our study showed that TPS lowered the rate of Atypical from 10% to 6%. After the implementation of TPS, Atypical corresponded to a higher rate of high-grade urothelial carcinoma. Also, the NHL subcategory had a high positive predictive value for diagnosing low grade urothelial neoplasms.

The Usefulness of 4 Immunoperoxidase Stains Applied to Urinary Cytology Samples in the Pathologic Stage of Urothelial Carcinoma: A Study With Histologic Correlation

BACKGROUND

Currently, the golden rule for the diagnosis of urothelial carcinoma is biopsy and cystoscopy, unfortionally both are costly, invasive, and uncomfortable. While most urothelial cancers are noninvasive at presentation, it is necessary to find a highly sensitive, noninvasive way to diagnose in its earlier stages, Cytology with immunostaining is a noninvasive, reliable method that might play a role in detecting the earlier stages before its progression and accurate correlation with different stages of these tumors.

AIM

This study aimed to reach an accurate level in the staging of urothelial carcinoma using CD44, ProExC, Laminin, and Fascin on urinary cytology.

DESIGN

We include a total of 180 urinary cytology specimens with their surgical biopsies' counterparts, the staging of the surgical specimens were done according to AJCC2017TNM classification, while their counterpart urinary samples were centrifuged and the sediment was used for H&E and immunocytochemical staining with CD44, ProExC, Laminin, and Fascin.

RESULTS

The diagnosis of Ta-stage tumors was done according to the following immunohistochemical (IHC) profile [positive (+ve) CD44, negative (-ve) proExC, -ve Laminin, and -ve Fascin] with 100% sensitivity, 100% specificity. The diagnosis of Tis stage tumors was done according to IHC profile [-ve CD44, +ve proExC, -ve Laminin, and -ve Fascin] with 100% sensitivity, 93% specificity. The diagnosis of T1 stage tumors according to IHC profile [-ve CD44, +ve proExC, +ve Laminin, and -ve Fascin] with 100% sensitivity, 97% specificity, The diagnosis of T2 and T3 stage tumors was done according to IHC profile [-ve CD44, +ve proExC, +ve Laminin and weak to moderate +ve Fascin] with 100% sensitivity, 92% specificity, while the diagnosis of T4 stage tumors according to the IHC profile [-ve CD44, +ve proExC, +ve Laminin, and intense +ve Fascin] with 100% sensitivity, 100% specificity.

CONCLUSION

Using (CD44, ProExC, Laminin, and Fascin) on urinary cytology is a simple, reliable, and noninvasive method for the staging of urothelial carcinoma with 99% total accuracy.

Urinary tract cytology: a cytologic-histopathologic correlation with The Paris System, an institutional study

INTRODUCTION

Urothelial carcinoma (UC) requires lifelong monitoring, commonly through urinary cytology and cystoscopy. Urine cytology has a relatively high sensitivity for detecting high-grade urothelial carcinoma (HGUC); however, its sensitivity for low-grade urothelial neoplasm (LGUN) is significantly lower with wide interobserver variability. The Paris System (TPS) was proposed to create standardized diagnostic categories with defined cytomorphologic criteria. We attempt to evaluate diagnostic efficacy of identifying UC using TPS through cytologic-histologic correlation.

MATERIALS AND METHODS

A retrospective search identified 170 cases of urine cytology cases with concurrent biopsies collected during a 2-year time period at University of Rochester Medical Center. Patient age, sex, smoking history, prior malignancy diagnoses, cystoscopy findings, specimen collection method, UroVysion results, and 1-year follow-up of surgical pathology cases were included.

RESULTS

Cytologic-histologic correlation was identified in 59% of cases, with 18% true positives and 41% true negatives. Discordant results were identified in 41% of cases; of these, 4% were false positives, 11% false negatives, 12% potential sampling bias, and 14% were low-grade urothelial carcinoma (LGUC). The analysis of this 2-year study finds a positive predictive value of urine cytology for HGUC to be 81%, a negative predictive value of 79%, a sensitivity of 61%, a specificity of 91%, and an accuracy of 79%.

CONCLUSIONS

Our results support TPS's ability to improve the reliability and accuracy of interpretations in urine cytology for HGUC. Nevertheless, additional studies are essential to improve the diagnostic accuracy of LGUN, and urine adequacy, in order to improve patient care and early detection, while identifying potential sampling bias.

Outcome analysis and negative predictive value of the "unsatisfactory/nondiagnostic" category of The Paris System for Reporting Urinary Cytology

INTRODUCTION

The Paris System (TPS) for Reporting Urinary Cytology (UCyto) was published in 2016, but to date, no study addressing the unsatisfactory (UNSAT) category has been published. We aimed to identify the negative predictive value (NPV) for UNSAT UCyto after the implementation of TPS at our institution.

METHOD

For the period from January 1, 2017, to December 31, 2019, we identified all cases with UNSAT diagnosis on UCyto specimens and available cytologic and/or surgical pathology follow-up within 6 months from the UNSAT diagnosis. Cases were deemed true negative (TN) if the follow-up was "negative for high-grade urothelial carcinoma" (NHGUC). Information regarding previous medical history, clinical indications, and specimen type were tabulated and analyzed.

RESULTS

From 6348 UCyto specimens, there were 230 (3.6%) UNSAT diagnoses made on 209 patients (112 [53.6%] men and 97 [46.4%] women) with a median age of 64 years. Of these, 116 UCyto specimens from 106 patients, which had cytologic and/or surgical pathology follow-up within 6 months, were further studied. Most UNSAT UCyto specimens were bladder washing/barbotage (BW/BB), and the most common indication for UCyto was cancer surveillance. The main cause of UNSAT UCyto was low cellularity. There were 5 false-negative (FN) results for high-grade urothelial carcinoma (HGUC), which corresponds to an overall NPV of 84.4%. NPV was highest for patients with UCyto for hematuria, and for patients with BW/BB as UCyto specimen type.

CONCLUSIONS

Our results show that UNSAT diagnoses have a lower NPV than that typical of NHGUC diagnoses, and should be managed accordingly.

Developing a Machine Learning Algorithm for Identifying Abnormal Urothelial Cells: A Feasibility Study

INTRODUCTION

Urine cytology plays an important role in diagnosing urothelial carcinoma (UC). However, urine cytology interpretation is subjective and difficult. Morphogo (ALAB, Boston, MA, USA), equipped with automatic acquisition and scanning, optical focusing, and automatic classification with convolutional neural network has been developed for bone marrow aspirate smear analysis of hematopoietic diseases. The goal of this preliminary study was to determine the feasibility of developing a machine learning algorithm on Morphogo for identifying abnormal urothelial cells in urine cytology slides.

METHODS

Thirty-seven achieved abnormal urine cytology slides from cases with the diagnosis of atypical urothelial cells and above (suspicions or positive for UC) were obtained from 1 hospital. A pathologist (J.R.) reviewed the slides and manually selected and annotated representative cells to feed into Morphogo with following categories: benign (urothelial cells, squamous cells, degenerated cells, and inflammatory cells), atypical cells, and suspicious cells. Initial validation of the algorithm was performed on a subset of the original 37 cases. Urine samples from additional 12 unknown cases with various histological diagnoses (6 cases of high-grade urothelial carcinoma (HGUC), 1 case of low-grade urothelial carcinoma (LGUC), 1 case of prostate adenocarcinoma, 1 case of renal cell carcinoma, and 4 cases of non-neoplastic conditions) were collected from another hospital for initial blind testing.

RESULTS

A total of 1,910 benign and 1,978 abnormal (atypical and suspicious) cells from 37 slides were annotated for developing and training of the algorithm. This algorithm was validated on 27 slides that resulted in identification of at least 1 abnormal cell per slide, with a total of 200 abnormal cells, and an average of 7.4 cells per slide. Of the 12 unknown cases tested, the original cytology was positive for tumor cells in 2 HGUC samples. Morphogo was abnormal (atypical or suspicious) for 6 samples from patients with UC, including one with LGUC and one with prostate adenocarcinoma.

CONCLUSION

Morphogo machine learning algorithm is capable of identifying abnormal urothelial cells. Further validation studies with a larger number of urine samples will be needed to determine if it can be used to assist the cytological diagnosis of UC.

Clinical Validation of a Urine Test (Uromonitor-V2®) for the Surveillance of Non-Muscle-Invasive Bladder Cancer Patients

The costly and burdensome nature of the current follow-up methods in non-muscle-invasive bladder cancer (NMIBC) drives the development of new methods that may alternate with regular cystoscopy and urine cytology. The Uromonitor-V2^® is a new urine-based assay in the detection of hotspot mutations in three genes (TERT, FGFR3, and KRAS) for evaluation of disease recurrence. The aim of this study was to investigate the Uromonitor-V2^®’s performance in detecting NMIBC recurrence and compare it with urine cytology. From February 2018 to September 2019 patients were enrolled. All subjects underwent a standard-of-care (SOC) cystoscopy, either as part of their follow-up for NMIBC or for a nonmalignant urological pathology. Urine cytology was performed in NMIBC patients. Out of the 105 patients enrolled, 97 were eligible for the study. Twenty patients presented nonmalignant lesions, 29 had a history of NMIBC with disease recurrence, and 49 had a history of NMIBC without recurrence. In NMIBC, the Uromonitor-V2^® displayed a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 93.1%, 85.4%, 79.4%, and 95.3%, respectively. Urine cytology was available for 52 patients, and the sensitivity, specificity, PPV, and NPV were 26.3%, 90.9%, 62.5%, and 68.2%, respectively. With its high NPV of 95.3%, the Uromonitor-V2^® revealed promising properties for the follow-up of patients with NMIBC.

Cell blocks in urine cytopathology: do they add value to the diagnosis? A pilot study

INTRODUCTION

The utility of cell block (CB) preparation is well established in cytopathology. Despite 23.3% of College of American Pathologists-accredited laboratories using CB with liquid-based preparations on urine cytology (UC) cases, there are very few studies on their performance. To determine their usefulness, we conducted a retrospective review of UC cases that received CB.

MATERIALS AND METHODS

We identified 27 UC cases with ThinPrep (TP) and CB preparation between 2016 and 2020 at our institution. Clinical history and follow-up data were compiled. A blinded review of TP alone, and TP together with CB, was performed by 2 pathologists and 2 cytotechnologists. Diagnoses were rendered in accordance with The Paris System for Reporting Urine Cytology.

RESULTS

Blood and acute inflammation were common background elements in cases that received CB preparation. In total, CB upgraded the diagnosis in 7 of 27 cases (26%). The maximum utility of CB preparation was seen in indeterminate cases where 60% (6 of 10) were upgraded, including 71% (5 of 7) of atypical urothelial cells (AUC) and 30% (1 of 3) of suspicious for high-grade urothelial carcinoma (HGUC). One case (1 of 12, 8%) diagnosed as negative for HGUC on TP was diagnosed as low-grade urothelial neoplasia on CB.

CONCLUSIONS

Our results demonstrate that adjunct use of CB preparation aids in a definitive diagnosis on AUC category and may be helpful in cases with cell clusters or tissue fragments, or cases suspicious for HGUC. Further correlation studies are warranted in this area to expand our knowledge about the utility of CBs in urine cytology.

The Paris system of Reporting Urinary Cytology: Strengths and opportunities

The Paris system for reporting urinary cytopathology (TPS) was created to address inherent weaknesses inherent in the practice of urinary cytopathology. While urothelial cytology has always performed well at finding high grade, genetically unstable urothelial carcinoma, it performs poorly when it comes to detecting low-grade urothelial neoplasia. TPS intends to improve the utility of urothelial cytology by focusing on what is important, high-grade urothelial carcinoma. This article is a snapshot of the current state of TPS as it heads into its second edition. Successes are described and further developments are considered.

A review of urinary cytology in the setting of upper tract urothelial carcinoma

Urothelial carcinomas of the upper urinary tract (UUT) are uncommon. Cytological examination of voided urine or washings from the UUT has been part of the standard workup for upper tract urothelial carcinoma (UTUC); however, its value remains controversial. The lack of uniform terminology and specific diagnostic criteria could also have contributed to the inferior performance of urinary cytology for detecting UTUC. The Paris System for Reporting Urinary Cytology (TPS) has provided a standardized reporting system for urinary cytology specimens with clearly defined cytomorphologic diagnostic criteria and found acceptance on an international level after its implementation in 2016. Recent studies have shown that TPS has led to improved diagnostic performance of urinary cytology; however, most of these studies had focused on the evaluation of lower urinary tract cytology specimens. Only a limited number of new research studies have analyzed the effect of TPS when applied to UUT cytology specimens. In the present report, we have summarized the current understanding and utility of UTUC, including its molecular biology, and reviewed the current literature.

Interobserver reproducibility of The Paris System of Reporting Urine Cytology on cytocentrifuged samples

BACKGROUND

The Paris System of Reporting Urine Cytology aims to screen samples for HGUC and to provide a universally acceptable reporting format for urine cytology specimens. However, studies detailing the reproducibility of this system, especially on cyto-centrifuge preparations, are lacking.

METHODS

149 voided urine samples received in Department of Pathology were reviewed independently by five cytopathologists. To estimate the overall agreement, Gwet's AC and AC1statistics between each pair of raters were used. To measure the random error component, polychoric correlations were used. To assess the systematic error, Friedman test was used.

RESULTS

There was moderately good inter-rater agreement between the raters. Gwets AC2 ranged between 0.67 and 0.89 for the classification of the cases once the sample was found adequate for assessment, while the Gwet's AC1 ranged between 0.61 and 0.94 in assessing for adequacy. There were significant systematic differences between raters in their thresholds for the different categories as well as in differentiating between an adequate and inadequate sample (P value by Friedman test <.001). The association between pathologists was moderately high (polychoric correlations ranging from 0.67 to 0.93). In the majority (108 of 149, 72.5%) of the cases, the range of differences between raters were of one category or less, suggesting satisfactory agreement, but having large disagreements in minority.

CONCLUSION

The interobserver reproducibility for the Paris System is moderately good, and is suitable for adoption. It is limited by the lack of agreement as to what constitutes an adequate specimen and differing threshold for categorizing the lesions in differing groups.

Diagnostic Utility of UroVysion Combined With Conventional Urinary Cytology for Urothelial Carcinoma of the Upper Urinary Tract

OBJECTIVES

We prospectively evaluated the utility of UroVysion in urothelial carcinomas of the upper urinary tract (UCUUTs).

METHODS

Ninety patients who received nephroureterectomy for UCUUT were enrolled. We performed urinary cytology and UroVysion before nephroureterectomy. We also performed the assays on 23 volunteers without a history of urothelial carcinoma.

RESULTS

Seventy-five high-grade urothelial carcinomas (HGUCs), 10 low-grade urothelial carcinomas, and five other conditions were enrolled. Sensitivity, specificity, positive predictive value, and negative predictive value for HGUC detection by urinary cytology were 28.0%, 100.0%, 100.0%, and 31.6%, respectively; for detection by fluorescence in situ hybridization, these values were 60.0%, 84.0%, 93.8%, and 41.2%, respectively. UroVysion detected the only deletion of 9p21 in eight of 23 samples negative for HGUC by urinary cytology and in three of 23 volunteers.

CONCLUSIONS

Combining urinary cytology and UroVysion can improve the diagnostic accuracy of UCUUT. Caution is advised in diagnosing UCUUT based only on deletion of 9p21.

Determination of appropriate urine volume cutoff values for voided urine specimens to assess adequacy

INTRODUCTION

Incorporating urine volume into adequacy assessment was recommended by The Paris System for Reporting Urinary Cytology. The concept was relatively new, however, and supportive studies were sparse. We accordingly aimed to determine the role of urine volume in adequacy assessment and cutoff values for urine samples using ThinPrep (Hologic, Inc, MA) processing.

MATERIAL AND METHODS

Archived consecutive urine cytology cases (n = 2117) were analyzed. Patient age, sex, collection method, urine volume and fixative (CytoLyt, Hologic, Inc) added, adequacy and diagnoses were documented. Adequate samples were defined as samples with >50 well-preserved, well-visualized urothelial cells. Diagnoses of suspicious and positive for high-grade urothelial carcinoma were combined for analysis. Statistical analysis was performed using IBM SPSS Statistics for Windows.

RESULTS

There was a correlation between urine volume and the unsatisfactory/less than optimal cellularity versus satisfactory samples (P ≤ 0.001) in voided urine specimens. A minimum of 10 mL of fresh voided urine was found to be a reasonable cutoff to achieve sufficient cellularity. Cutoff values of 30 mL for voided urine for the high-risk diagnosis were associated with the highest χ² statistic, although this was not statistically significant.

CONCLUSIONS

Urine volume was justified as an adequacy criterion in voided urine. Although 10 mL of fresh voided urine might achieve sufficient cellularity, higher volume (≥30 mL) is recommended in order to maximize the chance of detecting a high-risk diagnosis. Nevertheless, the presence of high-grade urothelial carcinoma can still be detected in low-volume (<20 mL) specimens. Hence, correlation of clinical information with voided urine volume cutoff values for individual cases might also be beneficial.

Noninvasive diagnostic imaging using machine-learning analysis of nanoresolution images of cell surfaces: Detection of bladder cancer

We report an approach in diagnostic imaging based on nanoscale-resolution scanning of surfaces of cells collected from body fluids using a recent modality of atomic force microscopy (AFM), subresonance tapping, and machine-leaning analysis. The surface parameters, which are typically used in engineering to describe surfaces, are used to classify cells. The method is applied to the detection of bladder cancer, which is one of the most common human malignancies and the most expensive cancer to treat. The frequent visual examinations of bladder (cytoscopy) required for follow-up are not only uncomfortable for the patient but a serious cost for the health care system. Our method addresses an unmet need in noninvasive and accurate detection of bladder cancer, which may eliminate unnecessary and expensive cystoscopies. The method, which evaluates cells collected from urine, shows 94% diagnostic accuracy when examining five cells per patient's urine sample. It is a statistically significant improvement (P < 0.05) in diagnostic accuracy compared with the currently used clinical standard, cystoscopy, as verified on 43 control and 25 bladder cancer patients.

Clinical and cytopathological factors affecting the cellularity of urinary cell blocks and the implication for diagnosis and follow-up of urinary bladder urothelial carcinoma

OBJECTIVE

The methodology of cell blocks (CBs) has long been an integrated part of cytology. However, there are very few data on CBs derived from urine. Their main disadvantage is a lack of cellularity, which limits their broader clinical applicability. Factors affecting cellular adequacy in urine remain unclear. We assessed the impact of basic clinical and cytopathological factors on the adequacy of cellularity in urinary CBs.

METHODS

Freshly voided urine was collected from 401 consecutive individuals. Of these, 167 patients were diagnosed with urothelial carcinoma. The remaining 234 patients had various benign urological conditions. Papanicolaou classes were determined and CBs produced. Cellular adequacy was assigned to each CB (acellular, hypocellular, moderate cellularity, high cellularity), and moderately and highly cellular CBs were considered as adequate. Several factors were analysed to find any correlation with the adequacy of the cellularity.

RESULTS

In univariate analysis, seven factors significantly correlated with the adequacy of the CBs. In the multivariate model, positive sediment (OR = 3.7), female sex (OR = 2.7), positive urinary cytology (OR = 2.6) and positive leucocyturia (OR = 2.1) were independent predictors of adequate cellularity. Positive predictive value and negative predictive value of the model were 65.0% and 77.7%, respectively.

CONCLUSIONS

We determined four clinical and cytopathological factors which independently predict adequate cellularity in urinary CBs. Based on these results, several clinical situations have been proposed, in which the highest probability of adequate cellularity in urinary CBs can be achieved.

The Paris System for Reporting Urinary Cytology: early review of the literature reveals successes and rare shortcomings

The Paris System for Reporting Urinary Cytology (TPS) provides recommendations for the diagnosis of urinary tract cytology (UTC) specimens and has found acceptance on an international level. Since the official release of TPS in 2016, numerous research studies have been published analyzing its impact. This review summarizes the studies published since the release of TPS, highlighting areas in which TPS has performed well and other areas in which TPS may need improvement.

Paris Interobserver Reproducibility Study (PIRST)

OBJECTIVES

In concert with the 2015 publication of The Paris System for Urinary Cytopathology (TPS), a Web-based interobserver study, co-sponsored by the American Society of Cytopathology (ASC) and International Academy of Cytology (IAC), was performed to determine diagnostic agreement among volunteer participants and with the TPS author consensus.

MATERIAL AND METHODS

Participants at various levels of training and certification were recruited through national and international cytopathology professional societies. Although the survey was open to all comers, potential participants were screened by two basic cytopathology questions. Information was collected on the level of training, practice patterns, and experience. Study participants evaluated 85 images (previously unpublished) chosen from the TPS atlas. These images spanned all diagnostic categories.

RESULTS

Of the 1993 attempts to access the survey, 1313 participants correctly answered the qualifying questions and were included in the survey. Respondents were concentrated in the United States, although many participants came from other countries. The majority of respondents were board-certified in anatomic pathology with cytopathology certification. A smaller number were cytotechnologists. Board-certified cytopathologists and specialist cytotechnologists outperformed other certifications. Practice type (academics versus non-academic), and country (US versus international) were not major factors in concordance. Diagnostic categories with the best agreement were Negative for High-Grade Urothelial Carcinoma (NHGUC; 71%), Low-Grade Urothelial Neoplasm (LGUN; 62%), and High-Grade Urothelial Carcinoma (HGUC; 57%). Indeterminate categories showed low concordance.

CONCLUSIONS

The NHGUC, LGUN, and HGUC were most correlated with diagnostic agreement among observers. This study can serve as a baseline for future comparisons.

Increased accuracy of a novel mRNA-based urine test for bladder cancer surveillance

OBJECTIVES

To evaluate the diagnostic accuracy of the Xpert Bladder Cancer (BC) Monitor, compared with cystoscopy and cytology in the oncological follow-up of non-muscle-invasive bladder cancer (NMIBC).

MATERIAL AND METHODS

A total of 140 patients with a history of NMIBC undergoing routine surveillance at our institution were enrolled prospectively in this study (ISRCTN study registry number 37210907). Urine cytology was evaluated according to the Paris classification system. In addition, urinary specimens were analysed using the Xpert BC Monitor, which measures five target mRNAs (ABL1, CRH, IGF2, UPK1B, ANXA10) using real-time PCR. Descriptive analysis, diagnostic accuracy including sensitivity, specificity, positive (PPV) and negative predictive value (NPV), receiver-operating characteristic curve, and area under the curve (AUC) were calculated.

RESULTS

The overall sensitivity (0.84) and NPV (0.93) of the Xpert BC Monitor were significantly superior to those of bladder washing cytology (0.33 and 0.76; P < 0.001). Subgroup analyses confirmed the high sensitivity of the Xpert BC Monitor even in low-grade (0.77) and pTa (0.82) disease compared with barbotage cytology (low-grade: 0.13; pTa: 0.21). The overall specificity of the Xpert BC Monitor and barbotage cytology was similar (0.91 vs 0.94; P = 0.41). Combining the Xpert BC Monitor with barbotage cytology (AUC = 0.85) did not enhance diagnostic performance compared with the performance of the Xpert BC Monitor alone (AUC = 0.87).

CONCLUSION

In this study, we report for the first time that the Xpert BC Monitor, a new mRNA-based urine test, outperforms cytology with regard to sensitivity and NPV, even in low-grade and pTa tumours, with no reduction of specificity.

Adequacy of voided urine specimens prepared by ThinPrep and evaluated using The Paris System for Reporting Urinary Cytology

INTRODUCTION

The Paris System for Reporting Urinary Cytology (TPS) currently includes a volume recommendation for voided urine specimens of 30 mL based on observations of performance with BD SurePath preparation system. Given that many labs use the Hologic ThinPrep methods for voided urines, an analysis of data acquired with this system is undertaken in this study.

MATERIALS AND METHODS

We identified a total of 744 voided urine specimens. All specimens were processed fresh by ThinPrep at a large academic center that had incorporated a tiered urine cytology reporting template prior to TPS. To determine the optimum binary cutoff thresholds for voided urine volume, the fraction of high-risk cytologic diagnoses-suspicious for high-grade urothelial carcinoma (SHGUC) or worse-was compared below and above various volumes cutpoints.

RESULTS

The cytology diagnosis was inadequate in 1.5%, negative for high-grade urothelial carcinoma in 64%, atypical urothelial cells in 14.2% SHGUC in 6.6%, high-grade urothelial carcinoma (HGUC) in 11.3%, low-grade urothelial neoplasm in 1.9%, and other malignancies in 0.5%. High-risk cytology was diagnosed in 19.1% of specimens ≥25 mL and in 13.5% of specimens <25 mL (P = 0.090). Volume of ≥25 mL was associated with the optimum cutoff for diagnosing SHGUC or HGUC.

CONCLUSIONS

A specimen volume of ≥25 mL is associated with higher rates of diagnosis of HGUC or SHGUC in voided urine specimens processed by ThinPrep. This is similar to the 30 mL cutoff determined for SurePath preparation that was incorporated into TPS and may provide helpful information for ThinPrep labs that are in the process of adopting TPS.

A review of the Paris system for reporting urinary cytology

After the 2013 International Congress of Cytology in Paris, consensus groups were formed to establish an international reporting system for urinary tract (UT) specimens. The recommended guidelines, known as The Paris System (TPS) for Reporting Urinary Cytology, focus on reducing the rate of unnecessary indeterminate diagnoses while maintaining the excellent performance UT cytology has for identifying high-grade urothelial carcinoma. This review highlights the major features of TPS.

The Paris System for Reporting Urinary Cytology: The Quest to Develop a Standardized Terminology

The main purpose of urine cytology is to detect high-grade urothelial carcinoma. With this principle in mind, The Paris System (TPS) Working Group, composed of cytopathologists, surgical pathologists, and urologists, has proposed and published a standardized reporting system that includes specific diagnostic categories and cytomorphologic criteria for the reliable diagnosis of high-grade urothelial carcinoma. This paper outlines the essential elements of TPS and the process that led to the formation and rationale of the reporting system. TPS Working Group, organized at the 2013 International Congress of Cytology, conceived a standardized platform on which to base cytologic interpretation of urine samples. The widespread dissemination of this approach to cytologic examination and reporting of urologic samples and the scheme's universal acceptance by pathologists and urologists is critical for its success. For urologists, understanding the diagnostic criteria, their clinical implications, and limitations of TPS is essential if they are to utilize urine cytology and noninvasive ancillary tests in a thoughtful and practical manner. This is the first international/inclusive attempt at standardizing urinary cytology. The success of TPS will depend on the pathology and urology communities working collectively to improve this seminal paradigm shift, and optimize the impact on patient care.

The Paris System for Reporting Urinary Cytology: The Quest to Develop a Standardized Terminology

The main purpose of urine cytology is to detect high-grade urothelial carcinoma (HGUC). With this principle in mind, The Paris System (TPS) Working Group, composed of cytopathologists, surgical pathologists, and urologists, has proposed and published a standardized reporting system that includes specific diagnostic categories and cytomorphologic criteria for the reliable diagnosis of HGUC. This paper outlines the essential elements of TPS and the process that led to the formation and rationale of the reporting system. The Paris System Working Group, organized at the 2013 International Congress of Cytology, conceived a standardized platform on which to base cytologic interpretation of urine samples. The widespread dissemination of this approach to cytologic examination and reporting of urologic samples and the scheme's universal acceptance by pathologists and urologists is critical for its success. For urologists, understanding the diagnostic criteria, their clinical implications, and the limitations of TPS is essential if they are to utilize urine cytology and noninvasive ancillary tests in a thoughtful and practical manner. This is the first international/inclusive attempt at standardizing urinary cytology. The success of TPS will depend on the pathology and urology communities working collectively to improve this seminal paradigm shift, and optimize the impact on patient care.

The Paris System for Reporting Urinary Cytology: the quest to develop a standardized terminology

The main purpose of urine cytology is to detect high-grade urothelial carcinoma (HGUC). With this principle in mind, The Paris System (TPS) Working Group, composed of cytopathologists, surgical pathologists, and urologists, has proposed and published a standardized reporting system that includes specific diagnostic categories and cytomorphologic criteria for the reliable diagnosis of HGUC. This paper outlines the essential elements of TPS and the process that led to the formation and rationale of the reporting system. The Paris System Working Group, organized at the 2013 International Congress of Cytology, conceived a standardized platform on which to base cytologic interpretation of urine samples. The widespread dissemination of this approach to cytologic examination and reporting of urologic samples and the scheme's universal acceptance by pathologists and urologists is critical for its success. For urologists, understanding the diagnostic criteria, their clinical implications, and the limitations of TPS is essential if they are to utilize urine cytology and noninvasive ancillary tests in a thoughtful and practical manner. This is the first international/inclusive attempt at standardizing urinary cytology. The success of TPS will depend on the pathology and urology communities working collectively to improve this seminal paradigm shift, and optimize the impact on patient care.

A specimen volume of ≥80 mL improves cytologic sensitivity for malignant ascites: a retrospective analysis of 2665 cases

INTRODUCTION

Although paracentesis simultaneously allows cytologic evaluation of peritoneal fluid and symptomatic relief, its utility is limited by a paltry 50% to 60% sensitivity for malignancy. Specimen volume has recently been shown to affect cytologic diagnosis in other body fluids, but its role has never been examined in ascites. This study evaluates how specimen volume impacts cytologic diagnosis of malignant ascites.

MATERIALS AND METHODS

We identified 2665 consecutive paracentesis specimens with documented numeric volumes collected at our institution between 1994 and 2013. We separated the cases into 10 bins of roughly equivalent sample size and compared the percentage of cases that received malignant diagnoses across each cutoff volume. When follow-up pathology was available, we also compared the sensitivity of cytology with the gold standard of surgical pathology.

RESULTS

The peritoneal fluids had a mean volume of 760.2 mL (range: 1-10,000). Just 11.3% of specimens with volumes <80 mL were diagnosed as malignant, while 20.1% were malignant at volumes ≥80 mL (P < 0.001, OR = 0.51, 95% CI = 0.39-0.64). Lower volume specimens also had more indeterminate and nondiagnostic results. Cytologic sensitivity increased from 56.7% for specimens <80 mL to 75.4% for volumes ≥80 mL (P = 0.03, OR = 0.43, 95% CI = 0.19-0.94).

CONCLUSIONS

A specimen volume of ≥80 mL is associated with increased cytologic sensitivity for malignant ascites and a higher rate of malignant diagnoses. The disparate sensitivity at lower volumes likely stems from inadequate sampling of larger specimens. Although fluids should not be summarily rejected based on volume, a specimen volume of ≥80 mL minimizes the influence of specimen size on diagnostic adequacy in paracentesis specimens.