Significance of urinary cytology in the early detection of transitional cell cancer of the upper urinary tract

UroVysionTM Fluorescence In Situ Hybridization in Urological Cancers: A Narrative Review and Future Perspectives

UroVysionTM is a fluorescence in situ hybridization assay that was developed for the detection of bladder cancer (UC accounted for 90%) in urine specimens. It consists of fluorescently labeled DNA probes to the pericentromeric regions of chromosomes 3, 7, 17 and to the 9p21 band location of the P16 tumor suppressor gene, which was approved by the Food and Drug Administration (FDA) in 2001 and 2005, respectively, for urine detection in patients with suspected bladder cancer and postoperative recurrence monitoring. Furthermore, recent studies also demonstrated that U-FISH was useful for assessing superficial bladder cancer patients’ response to Bacillus Calmette–Guérin therapy and in detecting upper tract urothelial carcinoma. Therefore, positive U-FISH was well known to urologists as a molecular cytogenetic technique for the detection of UC. However, with the continuous enrichment of clinical studies at home and abroad, U-FISH has shown a broader application space in the detection of various urinary primary tumors and even metastatic tumors. This review focuses on summarizing the research status of U-FISH in UC, non-urothelial carcinoma and metastatic tumor, so as to strengthen urologists’ more comprehensive understanding of the application value of U-FISH and better complete the accurate diagnosis and treatment of urological cancers.

Can Endoscopic Appearance, Selective Cytology, and Pathological Sampling During Ureteroscopy Accurately Predict Tumor Grade of Upper-Tract Urothelial Carcinoma?

OBJECTIVE

This study examined the reliability of the various parameters obtained in diagnostic ureteroscopy for upper-tract urothelial carcinoma (UTUC) in predicting the degree of differentiation in the final pathological report after radical nephroureterectomy (RNU).

METHODS

We conducted a retrospective review of patients undergoing RNU at a single tertiary hospital between 2000 and 2020. Only patients who underwent preoperative diagnostic ureteroscopy (URS) were included. The results of urine selective cytology, endoscopic appearance of the tumor, and biopsy taken during ureteroscopy were compared to the final pathological report.

RESULTS

In total, 111 patients underwent RNU. A preliminary URS was performed in 54. According to endoscopic appearance, 40% of the "solid"-looking tumors were high grade (HG), while 52% of those with a papillary appearance were low grade (LG). Positive cytology predicted HG tumors in 86% of cases. However, 42% of patients with negative cytology had HG disease. The biopsies acquired during URS showed that HG disease findings matched the final pathology in 75% of cases. However, 25% of patients noted as being HG, based on URS biopsies, were noted to have LG disease based on nephroureterectomy biopsies. Full analyses revealed that 40% of the cases diagnosed as LG based on the URS biopsies actually had HG disease.

CONCLUSIONS

Direct tumor observation of papillary lesions, negative cytology, and biopsies indicating LG disease are of low predictive value for classifying the actual degree of tumor differentiation. No single test can accurately rule out HG disease. In light of the rising use of neo-adjuvant chemotherapy in UTUC, a reliable predictive model should be developed that accurately discriminates between HG and LG disease.

A comprehensive comparison of fluorescence in situ hybridization and cytology for the detection of upper urinary tract urothelial carcinoma: A systematic review and meta-analysis

OBJECTIVE

To compare the relative effectiveness of fluorescence in situ hybridization (FISH) and cytology in diagnosing upper urinary tract urothelial carcinoma (UUT-UC) and to evaluate the advantages and potential deficiencies of FISH analysis.

METHODS

We performed a complete systematic review based on studies from PubMed/Medline, Embase, Web of Science, Ovid, Web of Knowledge, and Cochrane Library. We identified 2031 patients with strict criteria in 14 individual studies between January 2005 to November 2017 in accordance to preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines, we summarized the test performance using bivariate random effects models.

RESULTS

FISH was superior to cytology in terms of pooled sensitivities (84.0%, 95% confidence interval [CI] 74.4-90.5% vs 40.0%, 95% CI 33.6-46.7%). FISH and cytology were similar to each other in terms of pooled specificities, which were 89.5% (95% CI 85.3-92.6%) for FISH and 95.9% (95% CI 91.2-98.1%) for cytology.

CONCLUSION

We confirm the superiority of FISH over cytology in terms of sensitivity and find similar diagnostic outcomes between them based on systematic analysis. Therefore, we demonstrate that FISH is extremely sensitive while still very reliable with a relatively low error rate for diagnosing UUT-UC.

Negative pathology of ureteral carcinoma significantly delaying the diagnosis of the primary tumor of osteoblastic metastases: A case report and review of the literature

Ureteral urothelial carcinoma (UC) is a rare malignant tumor. The most common clinical manifestations of ureteral UC are hematuria, increased urinary frequency, dysuria and pain. The diagnosis of ureteral UC is made via radiography, endoscopy and pathology. Although osteoblastic destruction is usually observed in metastasis of prostate cancer, UC can also be a reason for osteoblastic metastasis. The present study reports the case of a 66-year-old man presenting with osteoblastic metastases, in which the primary tumor was finally diagnosed as a ureteral UC. However, the lack of pathological evidence significantly delayed the diagnosis of the primary tumor (>6 months), even though the results of radiographic examination, and the type and mode of bone metastases significantly suggested a ureteral UC. The case reveals that a suitable screening test should be recommended for patients at high risk due to the possibility of a negative pathology result for ureteral UC. Additionally, a more efficient diagnostic method is required. Moreover, the possibility of new diagnostic criterion that do not rely on the pathology of primary foci in ureteral UC should be considered in future.

Effect of contrast media on urinary cytopathology specimens

INTRODUCTION

Urological dogma dictates that washings collected from the urinary tract for cytological assessment must be performed without interference from contrast agents that may alter cellular integrity and diagnostic interpretation. In practice, the initial contrast used to outline the upper tracts is commonly discarded with subsequent saline washings sent for cytology. We hypothesize that contrast washings do not affect the morphology of urothelial carcinoma cells or the integrity of cytology interpretation.

METHODS

Samples obtained from (1) human bladder cell lines; (2) urine from a human xenograft bladder cancer model using UC-3 cells; and (3) patients with urothelial carcinoma were subjected to various experimental solutions (water, saline, urine, and dilutions of contrast media) for different exposure times. After exposure to various different solutions, samples underwent cytological analysis to assess morphologic and degenerative changes.

RESULTS

No cytological differences were seen when cells were exposed to ionic, hyperosmolar, or non-ionic low-osmolar contrast agents for any exposures up to five minutes. Cells exposed to mixtures of contrast agents and urine also demonstrated no evidence of degenerative change. Cells exposed to water for greater than one minute demonstrated significant hydropic degeneration impacting cytological interpretation. At 40 minutes or later, all reagents caused severe degeneration when evaluating urine samples from the mouse bladder cancer model and from patients undergoing urothelial carcinoma.

CONCLUSIONS

Commonly used contrast agents have no effect on urinary cytology up to five minutes. Contrast washings of the urinary tract should not be discarded and can be sent for cytological diagnosis if fixed within this time period.

Prospective evaluation of FISH for detecting upper tract urothelial carcinoma in voided urine specimens

The aim of the present study was to estimate the diagnostic value of fluorescence in situ hybridization (FISH) analysis of tumor cells in voided urine specimens for detecting upper tract urothelial carcinoma (UTUC). Cytology and FISH analyses were conducted on voided urine collected in the morning from 125 patients with suspected UTUC. During follow-up, ureteroscopy with biopsy and histopathology were used to confirm the presence of tumors. The average follow-up time was 23.8 months (range, 6-36 months). A total of 8 patients who could not be contacted until the last follow-up were excluded from the study. Of the remaining 117 patients, 19 were histologically demonstrated to have UTUC, of whom, 3 patients had stage pTis disease, 6 had stage pTa disease, 5 had stage pT1 disease and 5 had stage pT2 disease (7 G1, 8 G2 and 4 G3). The overall sensitivity of FISH to detect UTUCs in voided urine specimens was 84.21% (16/19), whereas that of cytology was 42.11% (8/19) (P<0.05). The overall specificity of FISH to detect UTUCs in voided urine specimens was 89.80% (88/98), compared with 94.90% (93/98) of cytology (P>0.05). The positive predictive value (PPV) and negative predictive value of FISH were 80.00% (16/20) and 97.78% (88/90), respectively, whereas those of cytology were 100.00% (8/8) (P>0.05) and 90.29% (93/103) (P>0.05), respectively. The present data indicated that FISH was a method capable of detecting UTUCs in voided urine specimens with good sensitivity and specificity, although it exhibited a high rate of false positivity and low PPV.

Diagnostic Utility of Selective Upper Tract Urinary Cytology: A Systematic Review and Meta-analysis of the Literature

The diagnosis of upper tract urothelial carcinoma (UTUC) can be a challenging diagnostic pursuit. To date, there is no large-scale study assessing the statistical utility (eg, sensitivity and specificity) of selective cytology. Herein, we systematically reviewed and meta-analyzed the published literature to evaluate the efficacy of selective cytology for the detection of UTUC in patients with a suspicious clinical profile Selective cytology confers a high specificity but marginal sensitivity for the detection of UTUC. The sensitivity is greater for high-grade UTUC lesions. The statistical assessment of its utility is limited by the heterogeneity and bias of previous studies.

The Johns Hopkins Hospital template for urologic cytology samples: part I-creating the template

BACKGROUND

The most important indicator for urologic surgeons at The Johns Hopkins Hospital to have a patient undergo cystoscopy is a cytologic diagnosis of high-grade urothelial carcinoma. The template was designed to standardize diagnostic categories so clinicians can manage their patients uniformly. The template was based in part on the Bethesda System for cervical cytology.

METHODS

According to the template, reactive/inflammatory changes were included in the negative group (no urothelial atypia or malignancy identified). The category atypical urothelial cells of undetermined significance (AUC-US) was akin to atypical squamous cells of undetermined significance (ASC-US), as was the category of atypical urothelial cells, favor high-grade carcinoma (AUC-H). The categories high-grade urothelial carcinoma (HGUC) and low-grade urothelial carcinoma also were added.

RESULTS

The Pathology Data System at the Johns Hopkins Hospital was searched for cases that met the following criteria over a period from July 1, 2007 to June 30, 2009: all cytologic specimens from the urinary tract and all surgical specimens with a diagnosis of HGUC, regardless of invasion status. All cytologic specimens were then matched with biopsies during the same period, and all surgical specimens from patients who had a cytologic diagnosis of AUC-US or AUC-H were retrieved for 18 months after the end of the 2-year study period. Greater than 50% of patients who had biopsy-confirmed HGUC had a preceding cytologic diagnosis of AUC-H or HGUC. When patients with AUC-US were added to the analysis, 80% of patients with HGUC had at least 1 abnormal urinary cytology result. Of those patients who had a diagnosis of AUC-H, 38% had urothelial cancer discovered at biopsy compared with only 10% of those with an AUC-US diagnosis.

CONCLUSIONS

The authors concluded that their template is effective in targeting those patients who need to undergo cystoscopy.

The Johns Hopkins Hospital template for urologic cytology samples: parts II and III: improving the predictability of indeterminate results in urinary cytologic samples: an outcomes and cytomorphologic study

BACKGROUND

Urine cytology represents a major portion of testing volume in many cytopathology laboratories.

METHODS

The authors previously reported a template designed to standardize urothelial diagnostic categories to enable clinicians to uniformly manage their patients. In this study, they examined the common cytomorphologic features observed in specimens diagnosed with atypical urothelial cells, cannot exclude high-grade urothelial carcinoma (AUC-H), which prove most predictive of high-grade urothelial carcinoma (HGUC).

RESULTS

The most common morphologic features observed in the AUC-H specimens were hyperchromasia, irregular nuclear borders, increased nucleus-to-cytoplasm ratio, and anisonucleosis. Of the 58 patients who had specimens diagnosed with AUC-H, 95% ultimately were diagnosed with HGUC on follow-up biopsy over the study period. The small number of patients who had AUC-H with non-HGUC follow-up did not allow for a statistical comparison to determine the predictive ability of the selected criteria for HGUC. Next, the authors used the same features to examine a subset of urine samples that were diagnosed with atypical urothelial cells of unknown significance (AUC-US) in an attempt to improve the predictive value of this clinically frustrating category. A blind review was performed of 290 urine specimens from 217 patients. In contrast to the AUC-H specimen cohort, the majority of specimens with AUC-US did not contain atypical cells with the 4 common morphologic features. All 4 features significantly predicted HGUC in surveillance patients, but not in patients with hematuria.

CONCLUSIONS

Hyperchromasia was the strongest predictor of HGUC by far in patients who were undergoing surveillance (odds ratio, 9.81). Hyperchromasia remained statistically significant in multivariate analysis, indicating its predictive strength even in the absence of other features.

Urinary cytology has a poor performance for predicting invasive or high-grade upper-tract urothelial carcinoma

OBJECTIVE

• To evaluate the diagnostic accuracy of urine cytology for detecting aggressive disease in a multi-institutional cohort of patients undergoing extirpative surgery for upper-tract urothelial carcinoma (UTUC).

METHODS

• We reviewed the records of 326 patients with urinary cytology data who underwent a radical nephroureterectomy or distal ureterectomy without concurrent or previous bladder cancer. • We assessed the association of cytology (positive, negative and atypical) with final pathology. Sensitivity and positive predictive value (PPV) of a positive (± atypical) cytology for high-grade and muscle-invasive UTUC was calculated.

RESULTS

• On final pathology, 53% of patients had non-muscle invasive disease (pTa, pTis, pT1) and 47% had invasive disease (≥ pT2). Low-grade and high-grade cancers were present in 33% and 67% of patients, respectively. • Positive, atypical and negative urine cytology was noted in 40%, 40% and 20% of cases. Positive urinary cytology had sensitivity and PPV of 56% and 54% for high-grade and 62% and 44% for muscle-invasive UTUC. • Inclusion of atypical cytology with positive cytology improved the sensitivity and PPV for high-grade (74% and 63%) and muscle-invasive (77% and 45%) UTUC. Restricting analysis to patients with selective ureteral cytologies further improved the diagnostic accuracy when compared with bladder specimens (PPV > 85% for high-grade and muscle-invasive UTUC).

CONCLUSIONS

• In this cohort of patients with UTUC treated with radical surgery, urine cytology in isolation lacked performance characteristics to accurately predict muscle-invasive or high-grade disease. • Improved surrogate markers for pathological grade and stage are necessary, particularly when considering endoscopic modalities for UTUC.

[Diagnostic procedures in upper urinary tract urothelial carcinoma]

Upper urinary tract transitional cell carcinomas represent 5-6% of all urothelial carcinomas. Macroscopic hematuria is the most common symptom. The diagnostic algorithm contains medical history, clinical investigation, cystoscopy, urinary cytology, ultrasound and intravenous urography. When suspected, a complementary retrograde pyeloureterography with collecting selective urinary cytology is conducted. When radiological findings are doubted or when conservative treatment is planned, an ureterorenoscopy for biopsy of the suspected area is indicated. Computed tomography and magnetic resonance tomography is used to define the local extension of invasive tumors and to detect metastases. The use of urinary markers in the diagnosis of upper urinary tract urothelial carcinoma has to be evaluated in prospective trials.

Fluorescence in situ hybridization for detecting upper urinary tract tumors--a preliminary report

OBJECTIVES

To evaluate fluorescence in situ hybridization (FISH) in voided urine specimens and selective upper urinary tract washings obtained from patients with suspected transitional cell cancer of the upper urinary tract (UT-TCC).

METHODS

A total of 16 patients with suspected UT-TCC were included in the study. All patients underwent urinary tract imaging. Endoscopy was also performed. Voided urine specimens from all patients and ureteral washings were subjected to cytologic examination and FISH analysis (UroVysion probe set). If indicated, surgery (nephroureterectomy or ureterectomy) was performed.

RESULTS

Of the 16 patients, 9 (56.25%) were diagnosed with UT-TCC. None of the remaining patients was diagnosed with UT-TCC after a mean follow-up of 21.3 months (median 20, range 11 to 36). For FISH analysis, the sensitivity was 87.5% and specificity 80%. FISH analysis was not possible in 1 patient with UT-TCC because of an insufficient number of cells. For cytology, the sensitivity was 60% and specificity 80%. In patients with UT-TCC, the cytologic findings were inconclusive (atypia of uncertain significance) in 4 patients (44.4%). In contrast to the cytology findings, all results of the FISH analysis of the upper urinary tract washings matched those of the voided urine samples.

CONCLUSIONS

Our preliminary data suggest that FISH analysis of voided urine might be a useful ancillary test in the detection of UT-TCC with excellent sensitivity and specificity. If confirmed in larger studies, FISH might contribute to a more reliable and less-invasive diagnostic approach to UT-TCC.

Management of patients with upper urinary tract transitional cell carcinoma

Multiple therapeutic options are available for the management of patients with upper urinary tract transitional cell carcinoma (TCC). Radical nephroureterectomy with an ipsilateral bladder cuff is the gold-standard therapy for upper-tract cancers. However, less invasive alternatives have a role in the treatment of this disease. Endoscopic management of upper-tract TCC is a reasonable strategy for patients with anatomic or functional solitary kidneys, bilateral upper-tract TCC, baseline renal insufficiency, and significant comorbid diseases. Select patients with a normal contralateral kidney who have small, low-grade lesions might also be candidates for endoscopic ablation. Distal ureterectomy is an option for patients with high-grade, invasive, or bulky tumors of the distal ureter not amenable to endoscopic management. In appropriately selected patients, outcomes following distal ureterectomy are similar to that of radical nephroureterectomy. Bladder cancer is a common occurrence following the management of upper-tract TCC. Currently, there are no variables that consistently predict which patients will develop intravesical recurrences. As such, surveillance with cystoscopy and cytology following surgical management of upper-tract TCC is essential. Extrapolating from data on bladder TCC, both regional lymphadenectomy and neoadjuvant chemotherapy regimens are likely to be beneficial for patients with upper-tract TCC, particularly in the setting of bulky disease.

[Urinary cytology. Possibilities, limitations and the future]

Even now, 60 years after the fundamental studies on oncological urinary cytology carried out by Papanicolaou and Marschall and the subsequent integration of the test they devised into the diagnostic investigations applied in the diagnosis of urothelial carcinoma, urinary cytology still maintains its place in the diagnosis of primary and recurrent tumours of the urinary tract. Newer diagnostic techniques involving urine-bound tumour markers have not so far achieved such high levels of acceptance as their method. It is possible, certainly, that a combination of these newer methods with cytological testing, or with other innovative diagnostic methods, such as photodynamic techniques, could prove very promising in the future and might overcome the limitations of urinary cytology.

Comparison of ureteral washing and biopsy specimens in the community setting

BACKGROUND

Ureteral lesions can be difficult to diagnose. The value of ureteral biopsy in addition to ureteral washings has not been defined clearly.

METHODS

All ureteral washings and biopsies with follow-up that were performed at a single institution were reviewed.

RESULTS

In total, 39 patients underwent ureteral washing, ureteral biopsy, or both and had follow-up: Eighteen patients had urothelial tumors at follow-up (14 high-grade carcinomas, 3 low-grade carcinomas, and 1 papillary urothelial neoplasm of low malignant potential). The sensitivity was 79% for washings and 71% for biopsies (P = 1.0), for a combined sensitivity of 100%. Biopsies often were scant, and cell blocks from biopsies and washings often were of value.

CONCLUSIONS

Ureteral washings and biopsies had similar sensitivity and appeared to be complementary. Cell blocks often are useful for both specimen types.

Ureteroscopic Resection of Upper-Tract Transitional-Cell Carcinoma

Technological advances have increased the applicability of endoscopic treatment for upper-tract transitional-cell carcinoma (TCC). Percutaneous and ureteroscopic tumor resection have become reasonable treatment options for patients with anatomically or functionally solitary kidneys, bilateral upper-tract tumors, significant renal insufficiency, or comorbid disease that would preclude standard open surgery. This approach also is being used increasingly on those with a normal contralateral kidney in whom nephroureterectomy and en bloc removal of the ipsilateral ureteral orifice and surrounding bladder cuff is considered the standard therapy. This paper reviews the current role of ureteroscopic management of upper-tract TCC.

Abnormal selective cytology results predict recurrence of upper-tract transitional-cell carcinoma treated with ureteroscopic laser ablation

BACKGROUND AND PURPOSE

Endoscopic management of transitional-cell carcinoma (TCC) of the upper urinary tract remains associated with a significant rate of recurrence. We evaluated the impact of selective upper-tract cytology findings on tumor recurrence and renal salvage rate after ureteroscopic laser tumor ablation.

PATIENTS AND METHODS

From 1993 though 2003, 38 patients with upper-tract TCC underwent ureteroscopic laser tumor ablation. Cytology specimens were collected from the upper urinary tract prior to ablation. "Abnormal cytology" was defined as the presence of malignant or atypical cells. Patients with abnormal cytology results were compared with patients with those having negative findings for tumor recurrence and renal salvage rates using the X (2) test.

RESULTS

Of the 38 patients, 26 (68.4%) experienced at least one recurrence at a mean follow-up of 37.2 months. Pretreatment upper-tract cytology results were available in 34 of these patients: 17 (50%) were negative, and 17 were abnormal. Sixteen of the patients (94.1%) with abnormal cytology results had tumor recurrence after ablation, compared with 8 of the 17 (47.1%) with negative cytology findings (P = 0.0026). Twelve patients (31.5%) underwent nephroureterectomy during follow-up: 8 of the 17 (47.1%) with abnormal cytology, and 4 of the 17 (23.5%) with negative cytology (P = 0.15).

CONCLUSION

Abnormal selective cytology results were associated with a significantly higher rate of tumor recurrence and a trend toward increased renal loss in patients with upper-tract TCC treated with ureteroscopic ablation. These findings suggest a prognostic value for upper-tract cytology analysis in patients undergoing endoscopic therapy.

Transitional cell carcinoma of the ureter and renal pelvis

Transitional cell carcinoma (TCC) of ureter and renal pelvis is relatively uncommon. Smoking, occupational carcinogens, analgesic abuse, Balkan nephropathy are the risk factors. Cytogenetic studies revealed that the most frequent aberration is the partial or complete loss of chromosome 9. Approximately 20-50% of patients with upper urinary tract (UUT) TCC have bladder cancer at some point on their course, whereas the incidence of UUT TCC after primary bladder cancer is 0.7-4%. Excretory urography and retrograde pyelography are the conventional diagnostic tools; however, ureteropyeloscopy combined with cytology and biopsy is more accurate. Grade and stage of the disease have the most significant impact on survival. Nephroureterectomy with bladder cuff excision has been the mainstay of treatment. Local resection may be appropriate for distal ureteral lesions especially when the disease is low grade and stage. Advances in endourology have made it possible to treat many tumors conservatively. Ureteroscopic and to a certain extent percutaneous surgical approaches are widely used today especially in patients with low grade, low stage disease. Endoscopic close surveillance is mandatory for these patients. Adjuvant topical therapies appear to be safe but confirmation of any benefits awaits the results of further large studies. More recently, laparoscopic techniques have become a viable alternative to open surgery, but long term cancer control data are lacking. Aggressive surgical resection does not affect the outcome of patients with advanced disease. Adjuvant radiotherapy is ineffective, and systemic chemotherapy results in a low complete response rate for patients with metastases.

Transitional cell carcinoma of the renal pelvis the diagnostic role of pelvic washings

One hundred renal pelvic washings were reviewed blindly for 12 cytologic features. Of 52 washings with tissue confirmation, the cytologic diagnosis suggestive of or positive for transitional cell carcinoma (TCC) was made in 36 cases; 11 were negative, and 5 were unsatisfactory. Of 36 positive washings, histology confirmed the TCC diagnosis in 35 but revealed only reactive changes in 1. Of 11 negative washings, 9 were histologically negative for TCC, and 2 were positive for high-grade TCC. Among 48 washings without tissue confirmation, 33 were negative for TCC or showed reactive changes, 12 were negative for high-grade dysplasia or malignancy, but low-grade TCC could not be ruled out, 1 was suggestive of malignancy, and 2 were unsatisfactory. Clinical follow-up revealed no TCC. Predictive cytologic features of high-grade TCC were high nuclear/cytoplasmic ratio, isolated cells, anisonucleosis, nuclear hyperchromasia, and coarse chromatin; for low-grade they were presence of more than 5 papillary groups, cellular overlapping, anisonucleosis, and hyperchromasia. The sensitivity and specificity for the cytologic diagnosis were 89% and 97% for high-grade TCC and 100% and 78% for low-grade TCC, respectively. Renal pelvic washings can be used to accurately diagnose TCC of the renal pelvis. The positive predictive value for high-grade TCC is 93%, but for low-grade tumors it is 43%.

Detection of upper urinary tract transitional cell carcinoma with ImmunoCyt: a preliminary report

OBJECTIVES

To assess the clinical performance of ImmunoCyt in the detection of upper urinary tract transitional cell carcinoma (UT-TCC). This newly developed immunocytochemical test detects three cellular markers specific for TCC.

METHODS

Thirty-seven patients with symptoms and/or findings on imaging suggestive of UT tumors were prospectively evaluated. All patients underwent a standard cytologic evaluation and ImmunoCyt testing of voided urine, as well as imaging studies. Urine samples were also obtained from the UT of 32 patients by ureteral catheterization and tested by cytologic analysis and ImmunoCyt.

RESULTS

Sixteen patients had UT-TCC as documented by the final histologic evaluation. The sensitivity of testing the voided urine from 37 patients was 50% for cytologic analysis, 75% for ImmunoCyt, and 87% for both methods combined. The cytologic evaluation detected no G1, 1 (17%) of 6 G2, and 7 (100%) of 7 G3 tumors. ImmunoCyt detected 1 (33%) of 3 G1, 6 (100%) of 6 G2, and 5 (71%) of 7 G3 tumors. The sensitivity in the 32 urine samples obtained from the UT was 82% for cytologic analysis, 91% for ImmunoCyt, and 100% for both methods combined. Cytologic analysis detected all G2 and G3 (100% sensitivity) and no G1 tumors. ImmunoCyt detected 2 (100% sensitivity) of 2 G1, 4 (100%) of 4 G2, and 4 (80%) of 5 G3 tumors. The test specificity, calculated in 21 patients free of TCC, was 100% for cytologic analysis in voided and ureteral urine specimens and 95% and 100% for ImmunoCyt in voided and ureteral urine samples, respectively.

CONCLUSIONS

The results of this preliminary study show that ImmunoCyt complements cytologic analysis in detecting UT-TCC, mainly because of its high sensitivity to low-grade TCC. The combination of cytologic testing and ImmunoCyt gives 100% sensitivity in detecting UT-TCC in UT urine samples.

Upper-tract transitional cell carcinoma

Advances in ureteroscopic techniques have made it possible to treat many upper-tract tumors conservatively. Such treatment has demonstrated acceptable survival and renal preservation in high-risk patients, particularly those with a solitary kidney, bilateral tumors, poor renal function, or prohibitive operative risk. It is also preferred in patients with grade I TCC, particularly when located in the distal ureter. For patients with regionally extensive upper-tract urothelial neoplasms, use of endourologic techniques should be considered to control hemorrhage, relieve obstruction, and preserve as much functioning renal tissue as possible. Success with small, solitary, low-grade tumors allows the application of this technique to patients with a normal contralateral kidney on an elective basis. Adjuvant BCG or mitomycin C therapy appears to be safe, but confirmation of any benefits awaits the results of larger trials. Benign neoplasms can occur in the upper urinary tract and should be distinguished from TCC, thus avoiding more radical treatment for a benign lesion. Endoscopic surveillance should be maintained because recurrences can develop without radiographic evidence.

Ureteroscopic biopsy: technique and specimen preparation

Because tissue samples obtained ureteroscopically are small, the techniques for biopsy and for handling and processing the samples are crucial. Our aim is to describe the biopsy technique in great detail so other centers can reproduce it. Patients were evaluated by retrograde ureteropyelography and ureteroscopy for diagnosis. The entire collecting system was examined using a combination of small-diameter rigid and flexible ureteroscopes. Samples were retrieved by aspiration, saline lavage, or, when possible, biopsy of visible tumor by a basket or cup forceps. Multiple samples were obtained from all patients. Fresh specimens were hand delivered to the cytopathology laboratory, where they were evaluated with the cytospin technique. A cell block was prepared whenever there was any visible tissue in the sample. Since we have practiced this technique of handling specimens, our ability to diagnose and grade upper tract neoplasms ureteroscopically has improved markedly. Use of this technique can improve the diagnostic accuracy of ureteroscopic biopsy.

Transitional cell carcinoma of the upper urinary tract: Our experience with regard to diagnosis

Transitional cell carcinoma of the upper urinary tract is rare and presents quite interesting diagnostic and therapeutic problems. Available case studies, in accordance with literature on the subject, show how diagnosis relies on the combination of several data obtained from both traditional radiological methods and complementary tests. The importance of urography and retrograde ureteropyelography in providing morphological information is therefore fundamental and should be emphasised. It is advisable, however, to combine these data with those from urinary cytology, ultrasonography and to a lesser extent from CT scan, to be more sure of the nature and the extent of the disease.

The management of clinically unconfirmed positive urinary cytology

An aggressive evaluation of extravesical sites of disease in patients with clinically unconfirmed positive urinary cytology findings is indicated only in previously untreated asymptomatic or symptomatic patients (group 1) and in those with a complete response to intravesical therapy who are without evidence of disease for 1 year (group 4). Patients who have positive urinary cytology findings immediately after complete transurethral resection of bladder tumors or intravesical therapy will almost always have recurrent bladder transitional cell carcinoma and do not require aggressive extravesical evaluation initially. Transurethral resection prostate biopsy between the 5 and 7 o'clock positions along the entire length of the prostatic urethra is the technique of choice for detecting transitional cell carcinoma of the prostate, since other less invasive techniques frequently underestimate the extent of disease. In the absence of radiographic disease, bilateral ureteral lavage cytology is the technique of choice to identify the upper tract as the source of a positive urinary cytology result. Rigid and flexible ureteropyeloscopy should be performed only in the presence of radiographic or cytological evidence of upper tract transitional cell carcinoma, or in patients with a history of upper tract disease who have suspected relapse on the basis of a positive urinary cytology result.

Ureteroscopic cytologic diagnosis of upper tract lesions

The definitive diagnosis of upper urinary tract lesions often relies on providing adequate tissue samples for cytopathologic review. Uretreopyeloscopy allows direct examination of these lesions and enables tissue sampling under visual control. A retrospective analysis of 11 patients with 13 abnormal upper tracts was performed, comparing sampling techniques performed under endoscopic vision (brush biopsy, fine-needle aspiration [FNA], and forceps biopsy) with standard retrograde catheter lavage. Forceps biopsy was the most accurate of the direct vision sampling methods (100%), although it provided adequate tissue only 56% of the time. Direct vision brush biopsy and FNA were better than forceps biopsy at providing adequate tissue but were less accurate, at 83% and 89%, respectively. Surprisingly, retrograde catheter lavage was superior to direct vision sampling methods. These results may be attributable to patient selection bias in that five of seven upper tracts found to have malignancy had multifocal disease. One patient developed a distal ureteral stricture from instrumentation that was managed successfully with an endoureterotomy.

Pyelovenous lymphatic migration of transitional cell carcinoma following flexible ureterorenoscopy

Ureterorenoscopy has enhanced the diagnosis and treatment of upper urinary tract disorders. However, the irrigation necessary for visualization and distention of the lumen may increase renal pelvic pressure, resulting in pyelovenous lymphatic backflow. We report a case of renal pelvic transitional cell carcinoma that may have migrated to submucosal venous and lymphatic spaces during flexible ureterorenoscopy.

Development of upper tract carcinoma after cystectomy for bladder carcinoma

Two hundred twenty patients who underwent a radical cystectomy and en bloc pelvic lymph node dissection with urinary diversion were reviewed to define the incidence of upper tract carcinoma developing after cystectomy. Each patient was followed for at least five years or until death. In 5 of 220 (2.4%) upper tract lesions developed, with a disease-free interval from cystectomy of twenty-two to fifty-four months. All patients died within two to twenty-seven months of diagnosis. Common pathologic features included the presence of high-grade multifocal lesions or carcinoma in situ (CIS) in the cystectomy specimen, tumor invasion of the intramural ureter, and positive findings on urethrectomy specimens. Although the incidence of this disease process is low, heightened surveillance of the upper urinary tracts would seem appropriate in patients displaying these pathologic features.

Papillary transitional-cell carcinoma of the upper urinary tract: a cytological review

Urinary cytology is a well-accepted diagnostic procedure for bladder carcinomas but it is utilized less frequently for diagnosis of upper urinary tract tumors. Accurate diagnosis depends on a suitable specimen as well as knowledge of diagnostic traps. This review article with several case studies emphasizes the various techniques used to obtain optimal samples, correct interpretative criteria, and diagnostic pitfalls. Technological advances for objective grading and predicting the biological behavior of tumors are also discussed.

Routine excretory urography in follow-up of superficial transitional cell carcinoma of bladder

To determine cost-effective guidelines for the follow-up of patients with superficial transitional cell carcinoma of the bladder (STCCAB), we reviewed clinical histories, pathology reports, and intravenous pyelography results in 84 patients with Stage Ta or T1 disease. In 4 patients (4.8%) subsequent upper tract tumors developed with an average interval from initial presentation to the development of upper tract disease of 5.4 years. Three of these patients were treated successfully. We recommend upper tract surveillance in this group of patients with intravenous pyelography at diagnosis and every twenty-four months thereafter, or selection of those patients who are at high risk for development of upper tract disease (i.e., ureteral-vesical reflux) with voiding cystourethrography one month following each resection of tumors near a ureteral orifice. Refluxing patients should then either undergo surgical repair of their reflux or yearly pyelography.

Transitional cell carcinoma of upper urinary tract: some prognostic indicators

Thirty cases of transitional cell carcinoma were reviewed over a twenty-year period. The incidence of bladder tumor recurrence was no different in those who had complete or incomplete nephroureterectomy. Grade and stage correlated well with survival. Intravenous urogram findings at presentation were important prognostic indicators.

Impact of endourology on diagnosis and management of upper urinary tract urothelial cancer

The technique of transurethral ureteropyeloscopy was used in 43 patients with upper urinary tract urothelial tumors. Diagnosis was confirmed in 19 of 22 renal pelvic tumors (86 per cent) and 19 of 21 ureteral tumors (90 per cent). The major complication rate in this series is low (7 per cent) and did not appear to influence unfavorably subsequent management or outcome. A total of 21 patients underwent conservative endourological management of the upper tract tumor. The local recurrence rate was 20 per cent (1 of 8) for renal pelvic tumors and 15 per cent for distal ureteral tumors (2 of 13). The technique of ureteropyeloscopy should be added to the standard diagnostic regimen for the investigation of upper tract filling defects and conservative endourological techniques can be used safely for management of selected cases of upper tract urothelial tumor.

Primary carcinoma in situ of the ureter: a case report

A case of primary carcinoma in situ of the right ureter without a history of bladder tumors is presented. Cytological investigation of the right ureteral urine specimens revealed malignant cells and computerized tomography showed focal thickening of the upper portion of the right ureter. The patient underwent right nephroureterectomy, including excision of a bladder cuff. The diagnostic role of exfoliative urinary cytology is emphasized.

Upper urinary tract transitional cell cancer after radical cystectomy for bladder cancer

We studied 425 patients who had undergone radical cystectomy for transitional cell cancer of the bladder and were followed for 5 years or more, or until death. Upper urinary tract urothelial cancer developed in 14 patients (3.3 per cent), 3 of whom had bilateral disease: 2 synchronous and 1 asynchronous. The interval between cystectomy and emergence of the upper tract tumor ranged from 8 to 100 months (mean 40 months). There was a declining incidence of upper tract cancer relative to cystectomy P stage for carcinoma in situ (9.1 per cent), papillary stages O and A (3.6 per cent), stages B1, C and D1 (2.6 per cent) and no residual cancer (0 per cent). Of the 14 patients 8 (57 per cent) had features of multifocal carcinoma in situ in the cystectomy specimens. In 4 of the 14 patients (29 per cent) ipsilateral disease developed when the distal ureteral margins were involved with cancer at cystectomy. Only 3 of the 14 patients (21.4 per cent), all with stage I disease, were alive at the time of this report.

Transitional cell carcinoma of the kidney

This paper presents 14 personal patients with transitional cell carcinoma of the kidney who were managed over a period of 13 years. Emphasis is placed on the diagnostic features, the great variety of radiological appearances of this neoplasm and the value of preoperative cytological examination of urine. In three patients the tumour started in the mucosa of peripheral calyces, and did not involve the surgical renal pelvis; this added to the diagnostic difficulty, and led to delay in diagnosis and treatment in one patient. The possibility that this tumour may be more common in Australia because of the high incidence of analgesic nephropathy is raised.

Systematic mapping of nephroureterectomy specimens removed for urothelial cancer: pathological findings and clinical correlations

The nature and extent of mucosal alterations in 30 consecutive surgical specimens removed for urothelial neoplasia were evaluated by systematic mapping. The findings correlated with pertinent pathological, cytological and clinical data. Generally, the grade of the principal neoplasm paralleled the degree of epithelial disturbance in the grossly normal urothelium, high grade carcinomas being associated consistently with severe changes and low grade cancers with hyperplasia only. Cytological studies reflected accurately the grade of the principal neoplasm, and the presence of concomitant contiguous and remote mucosal abnormalities.