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Zhao J, Shen Y, Guo M, Matin SF, Hansel DE, Guo CC. Diagnostic accuracy of upper tract urothelial carcinoma using biopsy, urinary cytology, and nephroureterectomy specimens: A tertiary cancer center experience. Am J Clin Pathol 2024:aqae065. [PMID: 38860463 DOI: 10.1093/ajcp/aqae065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/06/2024] [Indexed: 06/12/2024] Open
Abstract
OBJECTIVES We studied the diagnostic accuracy and discordance of upper tract urothelial carcinoma (UTUC) by comparing biopsy and urinary cytology with matched nephroureterectomy specimens. METHODS Sixty-nine patients with UTUC without neoadjuvant treatment were retrospectively identified who had matched biopsy and nephroureterectomy specimens. Twenty patients had concurrent upper tract cytology. H&E and cytology slides were re-reviewed. Statistical analysis was performed. RESULTS Patients included 48 men and 21 women with a mean age of 69 years. A concordant grade between biopsy and surgical specimen was present in 49 (71%) patients. The mean size of biopsy specimens in the discordant group was significantly smaller than that in the concordant group. Invasion was evaluated in 48 biopsy cases that had adequate subepithelial tissue, and 33 of them were diagnosed with concordant invasion status. Mean tumor size in both tumor grade and invasion discordant groups was significantly larger than that in the concordant group. High-grade urothelial carcinoma was detected in 84% of cases using urinary cytology. CONCLUSIONS Our study demonstrates the diagnostic challenges of UTUC on small biopsy specimens. Biopsy specimen size and tumor size are significantly associated with the diagnostic discordance. Upper tract cytology showed high diagnostic accuracy and should be complementary to the biopsy.
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Affiliation(s)
- Jianping Zhao
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, US
| | - Yuan Shen
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, US
| | - Ming Guo
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, US
| | - Surena F Matin
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, US
| | - Donna E Hansel
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, US
| | - Charles C Guo
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, US
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Gravestock P, Cullum D, Somani B, Veeratterapillay R. Diagnosing upper tract urothelial carcinoma: A review of the role of diagnostic ureteroscopy and novel developments over last two decades. Asian J Urol 2024; 11:242-252. [PMID: 38680592 PMCID: PMC11053284 DOI: 10.1016/j.ajur.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 08/13/2022] [Indexed: 11/29/2022] Open
Abstract
Objective The role of ureteroscopy in the diagnosis of upper tract urothelial carcinoma is yet to be fully determined. We aimed to provide an up to date evaluation of its role and the emerging technologies in the field. Methods A literature search of the last two decades (from 24th May, 2001 to 24th May, 2021) was carried out identifying 147 papers for potential inclusion within this narrative review. Results Diagnostic ureteroscopy is undeniably useful in its ability to visualise and biopsy indeterminate lesions, and to risk stratify malignant lesions that may be suitable for kidney sparing surgery. However, an increased risk of intravesical recurrence following nephroureterectomy when a prior diagnostic ureteroscopy has been performed, inadequate sampling at biopsy, complications from the procedure, and difficult ureteric access are all potential drawbacks. Furthermore, whilst generally an accurate diagnostic procedure, it risks missing carcinoma in-situ lesions. Despite this, evidence shows that routine use of ureteroscopy changes the management of patients in a large proportion of cases, preventing unnecessary surgery or facilitating kidney sparing surgery. The overall rate of complications is low, and improved biopsy techniques and the use of tissue biomarkers for improved staging and grading are encouraging. The risks of delays to definitive management and post-ureteroscopy intravesical recurrence do not seem to affect survival, and trials are in progress to determine whether intravesical therapy can mitigate the latter. Further promising techniques are being investigated to improve shortcomings, particularly in relation to improved diagnosis of carcinoma in situ and preoperative staging. Conclusion Ureteroscopy has a role in the diagnosis of upper tract malignancy, though whether it should be used routinely is yet to be determined.
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Affiliation(s)
- Paul Gravestock
- Urology Department, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Daniel Cullum
- Urology Department, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Bhaskar Somani
- Department of Urology, University Hospital Southampton, Southampton, UK
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Jia L, Rood T, Kirkpatrick J, Sarode V. Utility of The Paris System (TPS) for upper urinary tract cytopathology: correlation with histology follow-up and UroVysion fluorescence in situ hybridization (FISH) analysis. J Am Soc Cytopathol 2024; 13:149-155. [PMID: 38341300 DOI: 10.1016/j.jasc.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/24/2023] [Accepted: 12/28/2023] [Indexed: 02/12/2024]
Abstract
INTRODUCTION The Paris System (TPS) provides a uniform reporting system of urine cytology based on well-defined cytologic criteria. Due to their rarity, there are limited data on the utility of TPS in upper urinary tract (UUT) lesions and follow-up histology of cases with abnormal cytology. We aimed to evaluate the utility of TPS for UUT lesions by correlating the cytologic diagnoses using TPS criteria with subsequent histology. Additionally, the diagnostic utility of UroVysion (Abbott) fluorescence in situ hybridization (FISH) was assessed. MATERIALS AND METHODS A total of 148 UUT cytology specimens were retrospectively identified (2018-2022). Cytologic interpretation was performed using TPS, and then correlated with the findings of concurrent or subsequent histologic specimens. The performance of UroVysion FISH was analyzed. Sensitivity and specificity, positive predictive value (PPV) and negative predictive value (NPV) for detecting high-grade urothelial carcinoma (HGUC) were determined. RESULTS Among 83 patients who had concurrent or subsequent histologic specimens, cyto-histologic discrepancy was seen in 7 cases (8.4%). The sensitivity, specificity, PPV, and NPV using TPS criteria for detecting HGUC were 87%, and 92%, 96.4%, and 73%, respectively. UroVysion FISH was performed in 21 patients with atypical cytologic findings. The sensitivity and specificity of UroVysion for detecting HGUC was 75% and 86%, respectively, while PPV and NPV were 86% and 75%, respectively. CONCLUSIONS In our experience, the application of TPS criteria for reporting upper urinary cytology was reliable at detecting UUT lesions, especially HGUC. UroVysion FISH was a valuable ancillary test for detecting HGUC of UUT.
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Affiliation(s)
- Liwei Jia
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Tricia Rood
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - James Kirkpatrick
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Venetia Sarode
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas
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Carmona O, Kleinmann N, Zilberman DE, Dotan ZA, Shvero A. Do Urine Cytology and FISH Analysis Have a Role in the Follow-Up Protocol of Upper Tract Urothelial Carcinoma? Clin Genitourin Cancer 2024; 22:98-105. [PMID: 37996271 DOI: 10.1016/j.clgc.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 10/24/2023] [Accepted: 10/29/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Current guidelines recommend a stringent follow-up regimen that includes interval cystoureteronephscopy, CT urography, and selective urine cytology sampling for upper tract urothelial carcinoma (UTUC) patients undergoing endoscopic treatment and management. There are no recommendations regarding FISH analysis. Our purpose was to assess the efficacy of cytology and FISH as part of the follow-up protocol and its significance to clinical decision-making in this scenario. METHODS The medical records of all patients who managed endoscopically for UTUC at our institute between 2014 and 2022 were retrospectively analyzed. Demographic and clinical data, histology, cytology, and FISH results were collected. FISH analysis was considered malignant according to Paris criteria. RESULTS During the study period, 62 patients underwent 561 ureteroscopies as part of the treatment and follow-up regimen of low-grade UTUC. Urine from the affected upper tract was sampled for cytology in 377 procedures, and FISH analyses were performed in 273. In 75.4% of FISH analyses, the result was different from the cytology results: FISH found malignant aberrations in 15.5% of cases where cytology was benign. Furthermore, FISH classified all the cells defined as atypical via cytology as either benign or malignant. In only one case (0.17%), the urinary cytology report changed the follow-up regimen. CONCLUSION Cytology may be omitted from the follow-up protocol of low-grade UTUC. In the handful of cases cytology does assist the diagnosis of UTUC, there is an additional benefit to performing FISH analysis, particularly when cellular atypia is reported in the cytology results.
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Affiliation(s)
- Orel Carmona
- The Department of Urology, Sheba Medical Center, Ramat Gan, Israel; The School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Nir Kleinmann
- The Department of Urology, Sheba Medical Center, Ramat Gan, Israel; The School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dorit E Zilberman
- The Department of Urology, Sheba Medical Center, Ramat Gan, Israel; The School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zohar A Dotan
- The Department of Urology, Sheba Medical Center, Ramat Gan, Israel; The School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Asaf Shvero
- The Department of Urology, Sheba Medical Center, Ramat Gan, Israel; The School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Chan KH, Shu T, Al Shaarani M, Cen P. Complete Pathologic Response With Pembrolizumab and Enfortumab Vedotin in Urothelial Carcinoma of the Upper Urinary Tract. J Investig Med High Impact Case Rep 2024; 12:23247096241257333. [PMID: 38804541 PMCID: PMC11135087 DOI: 10.1177/23247096241257333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/02/2024] [Accepted: 05/09/2024] [Indexed: 05/29/2024] Open
Abstract
Urothelial carcinoma of the upper urinary tract (UTUC) presents a significant clinical challenge, often requiring aggressive surgical intervention for optimal management. We present a case of an 84-year-old woman with recurrent high-grade papillary UTUC of the left renal pelvis, refractory to prior endourologic interventions, who underwent neoadjuvant treatment with pembrolizumab and enfortumab vedotin (Pembro/EV) due to contraindications to cisplatin therapy. Following a favorable response to neoadjuvant therapy, the patient underwent laparoscopic left radical nephroureterectomy, achieving a pathologic complete response. We discuss the utility of Pembro/EV in the perioperative management of patients with UTUC, particularly in those ineligible for cisplatin-based therapy. In addition, we highlight the potential role of somatic mutation testing and the integration of novel therapeutic agents such as olaparib in personalized treatment strategies for UTUC. This case underscores the importance of exploring innovative treatment approaches and optimizing patient selection for kidney preservation strategies in the management of UTUC. Further research and clinical trials are warranted to elucidate the full therapeutic potential of Pembro/EV and other emerging therapies in this setting.
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Affiliation(s)
- Kok Hoe Chan
- University of Texas Health Science Center at Houston, USA
| | - Tung Shu
- University of Texas Health Science Center at Houston, USA
| | | | - Putao Cen
- University of Texas Health Science Center at Houston, USA
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Maeda K, Nakano Y, Shigemura K, Fujisawa M. Urinary tract infections after retrograde pyelography and prophylactic antibiotics. J Infect Chemother 2023; 29:1132-1136. [PMID: 37611743 DOI: 10.1016/j.jiac.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/02/2023] [Accepted: 08/15/2023] [Indexed: 08/25/2023]
Abstract
INTRODUCTION Retrograde pyelography (RP) is performed for examination of upper urinary tract cancers and hydronephrosis. Although urinary tract infections (UTI) are known to be complicated by the examination, there are few reports on the frequency of occurrence and prophylactic antibiotics. METHODS The incidence of UTI and febrile UTI (f-UTI) and patient background information were compared in 388 patients who underwent RP at our hospital from January 2018 to December 2022. We also examined the administration of pre-RP antibiotics. RESULTS Of the 388 patients who underwent RP, 27 (6.9%) had UTI and 17 (4.4%) had f-UTI. Of the 27 UTI cases, 25 (92.6%) were pyelonephritis; 20 (74.0%) were hospitalized and 2 (7.4%) presented with septic shock and were managed in the intensive care unit. When comparing the background of patients with UTI, no significant differences were found in the present study, but when limited to the 17 cases of f-UTI, the presence of hydronephrosis before RP and not prescribing antibiotics before RP were associated with significantly higher incidence of f-UTI (p = 0.019, p = 0.036, respectively). Especially for patients without pyuria and bacteriuria before RP, prescribing antibiotics before RP resulted in 0 cases of f-UTI (p = 0.020). CONCLUSION This retrospective study showed that the presence of hydronephrosis before RP and not prescribing prophylactic antibiotics before RP are risk factors for f-UTI.
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Affiliation(s)
- Koki Maeda
- Department of Urology, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Yuzo Nakano
- Department of Urology, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Katsumi Shigemura
- Department of Urology, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan; Department of Medical Innovation Engineering, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-cho, Chuo-ku, Kobe, Japan.
| | - Masato Fujisawa
- Department of Urology, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
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Sydén F, Baard J, Bultitude M, Keeley FX, Rouprêt M, Thomas K, Axelsson TA, Jaremko G, Jung H, Malm C, Proietti S, Osther PJS, Brehmer M. Consultation on UTUC II Stockholm 2022: diagnostics, prognostication, and follow-up-where are we today? World J Urol 2023; 41:3395-3403. [PMID: 37540248 PMCID: PMC10693525 DOI: 10.1007/s00345-023-04530-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/07/2023] [Indexed: 08/05/2023] Open
Abstract
PURPOSE To summarise the current knowledge regarding diagnostics, prognostication and follow-up in upper tract urothelial carcinoma (UTUC). METHODS A scoping review combined with expert opinion was applied to provide an overview of the current research field. Based on the published literature and the experts' own experience and opinions, consensus was reached through presentations and discussions at the meeting Consultation on UTUC II in Stockholm 2022. RESULTS The strongest prognostic factors in UTUC are tumour grade and stage. They are correlated, and grade is used for indirect staging. The diagnostic examinations should include multiphase computed tomography urography (CTU) with corticomedullary phase, and urethrocystoscopy with cytology. If there is no clear diagnosis for clinical decision-making, ureterorenoscopy (URS) with focal cytology and biopsies should be performed. Both WHO classification systems (1973/1999 and 2004/2016) should be used. Novel biomarker tests are not yet widespread nor recommended for the detection of UTUC. Long-term, regular follow-up, including URS in patients who have had organ-sparing treatment, is important to check for tumour recurrences, intravesical recurrences, metastases and progression of the tumour. CONCLUSION Proper diagnostics with correct grading of UTUC are necessary for appropriate treatment decisions. The diagnostics should include CTU with corticomedullary phase, urine or bladder cytology, URS with focal barbotage cytology, and biopsies when needed for proper diagnosis and risk stratification. Regular, long-term follow-ups are fundamental, due to the high rate of recurrence and risk of progression.
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Affiliation(s)
- Filip Sydén
- Department of Urology, Stockholm South General Hospital, Stockholm, Sweden
| | - Joyce Baard
- Department of Urology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Matthew Bultitude
- Guy's and St. Thomas' NHS Foundation Trust, Urology Centre/Stone Unit, Guy's and St. Thomas' Hospital, London, UK
| | | | - Morgan Rouprêt
- Sorbonne University, Pitié Salpétrière Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Kay Thomas
- Guy's and St. Thomas' NHS Foundation Trust, Urology Centre/Stone Unit, Guy's and St. Thomas' Hospital, London, UK
| | | | - Georg Jaremko
- Department of Oncology and Pathology, Karolinska Institute, Stockholm, Sweden
| | - Helene Jung
- Department of Urology, Lillebaelt Hospital, University Hospital of Southern Denmark, Vejle, Denmark
| | - Camilla Malm
- Department of Urology, Stockholm South General Hospital, Stockholm, Sweden
| | | | - Palle Jørn Sloth Osther
- Department of Urology, Lillebaelt Hospital, University Hospital of Southern Denmark, Vejle, Denmark
| | - Marianne Brehmer
- Department of Urology, Stockholm South General Hospital, Stockholm, Sweden.
- Department of Clinical Sciences Karolinska Institute, Stockholm, Sweden.
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Malm C, Jaremko G, Brehmer M. S-phase - an independent prognostic marker in upper tract urothelial carcinoma. Scand J Urol 2022; 56:397-403. [PMID: 35971571 DOI: 10.1080/21681805.2022.2107065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To evaluate S-phase fraction as a predictor of invasiveness and cancer-specific survival in upper tract urothelial carcinoma (UTUC). PATIENTS AND METHODS One hundred and fifteen patients having undergone radical nephroureterectomy were analysed with histology in radical nephroureterectomy specimens as reference test and S-phase fraction as index test. Ploidy and S-phase were determined using flow cytometry. Differences in S-phase fraction were calculated between stages, grades (WHO 1999 and 2004 classifications), ploidy and patients that died of UTUC and those who did not. Five- and 10-year-cancer-specific survivals were calculated. Areas under the ROC curve (AUCs) of S-phase fraction in relation to tumour stage and to death from UTUC were measured. Multiple Cox regression was performed. RESULTS Independent prognostic markers of death from UTUC were S-phase fraction and stage. Correlation between S-phase fraction and risk of dying from UTUC was strong, with a 17% greater risk of death from UTUC with every 1% increase in S-phase fraction, hazard ratio = 1.17, 95% CI = 1.10-1.25, p < 0.001, Spearman's rho ρ = 0.65. AUCs for S-phase fraction as predictors of stage and death from UTUC were 0.8 (95% CI = 0.705-0.894) and 0.77 (95% CI = 0.67-0.87), respectively. Cancer-specific survival was statistically significantly different between stages, ploidy and WHO 1999 grades, but not between WHO 2004 grades. This was also reflected in S-phase fraction, which differed in LG-G1 compared with LG-G2 and in HG-G2 compared with HG-G3. CONCLUSION S-phase fraction was a good test for predicting both invasiveness and cancer-specific survival. Using both WHO 1999 and 2004 classifications, rather than one system alone, had a higher predictive value of cancer-specific survival.
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Affiliation(s)
- Camilla Malm
- Department of Oncology/Pathology, Karolinska Institute, Stockholm, Sweden.,Stockholm South General Hospital, Stockholm, Sweden
| | - Georg Jaremko
- Department of Oncology/Pathology, Karolinska Institute, Stockholm, Sweden
| | - Marianne Brehmer
- Department of Clinical Sciences, Danderyd Hospital-Karolinska Institute, Stockholm, Sweden
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Chien AL, Chua KJ, Doppalapudi SK, Ghodoussipour S. The role of endoscopic management and adjuvant topical therapy for upper tract urothelial cancer. FRONTIERS IN UROLOGY 2022; 2:916259. [PMID: 38855025 PMCID: PMC11160966 DOI: 10.3389/fruro.2022.916259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
Upper tract urothelial carcinoma (UTUC) has traditionally been managed with radical nephroureterectomy, and while this approach remains the gold standard for high-risk disease, endoscopic, kidney-sparing management has increasingly been adopted for low-risk disease as it preserves kidney function without compromising oncologic outcomes. Ureteroscopy and percutaneous renal access not only provide diagnoses by tumor visualization and biopsy, but also enable treatment with electrocautery or laser ablation. Several modalities exist for laser ablative treatments including thulium:YAG, neodymium:YAG, holmium:YAG, and combinations of the preceding. Furthermore, due to high recurrence rates after endoscopic management, adjuvant intracavitary instillation of various agents such as mitomycin C and bacillus Calmette-Guerin have been used given benefits seen in non-muscle invasive urothelial bladder cancer. Other formulations also being studied include gemcitabine, anthracyclines, and immunotherapies. More recently, Jelmyto, a mitomycin reverse thermal gel, has been developed to allow for adequate drug delivery time and potency since urine flow could otherwise dilute and washout topical therapy. In this article, the authors review techniques, indications, best practices, and areas of current investigation in endoscopic management and adjuvant topical therapy for UTUC.
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Affiliation(s)
- Austin L. Chien
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
- Division of Urology, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Kevin J. Chua
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
- Division of Urology, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Sai Krishnaraya Doppalapudi
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
- Division of Urology, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Saum Ghodoussipour
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
- Division of Urology, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
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Zhao H, Jiao B, Liu K, Luo Z, Ding Z, Lai S, Ren J, Zhang G. Intravesical recurrence factors and outcome after radical nephroureterectomy for upper tract urothelial carcinoma: Multivariate analysis with propensity score matching. Front Oncol 2022; 12:984014. [PMID: 36059684 PMCID: PMC9433701 DOI: 10.3389/fonc.2022.984014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 07/29/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe risk factors for intravesical recurrence (IVR) after radical nephroureterectomy (RNU) in patients with upper tract urothelial carcinoma (UTUC) remain inconsistent and unclear. Thus, the risk factors of IVR after RNU and the prognostic significance of the risk indicators were explored herein.MethodsWe retrospectively analyzed UTUC patients upon RNU in our center from January 2009 to December 2019. After propensity score matching, 139 patients were included in this study. Univariate and multivariate Cox proportional hazard regressions were used to estimate the hazard ratio and 95% confidence intervals. Overall survival (OS), cancer-specific survival (CSS) and recurrence-free survival (RFS) were measured using the Kaplan–Meier curve with a log-rank test. A P-value < 0.05 was considered statistically significant.ResultsWe included 139 patients with a median follow-up of 42 months, of which 48 patients had an intravesical recurrence. Multivariate Cox regression analysis showed cytological abnormalities in urine (HR=3.101, P=0.002), hydronephrosis (HR=1.852, P=0.042), adjuvant chemotherapy (HR=0.242, P<0.001), and previous history of bladder cancer (HR=5.51, P<0.001) were independent risk factors for IVR. As for clinical outcomes, OS and CSS suggested disadvantages in patients with IVR compared with patients without recurrence (P=0.042 for OS, P<0.0001 for CSS), OS of patients with abnormal urine cytology and OS and CSS of patients receiving adjuvant chemotherapy did not present clinical significance, and other risk factors all affected the clinical outcome.ConclusionIn this propensity-score matching study, cytological abnormality of urine, hydronephrosis, adjuvant chemotherapy and previous history of bladder cancer were shown to be independent risk factors for IVR. Moreover, risk factors also influence clinical outcomes, thereby rendering it necessary to adopt more active postoperative surveillance and treatment strategies for these patients, which may help improve treatment outcomes.
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Affiliation(s)
- Hang Zhao
- Department of Urology, China-Japan Friendship Hospital, Beijing, China
- China-Japan Friendship School Clinical Medicine, Peking University, Beijing, China
| | - Binbin Jiao
- Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Kunpeng Liu
- Beijing Laboratory of Biomedical Materials, State Key Laboratory of Organic-Inorganic Composite Materials, College of Life Science and Technology, Beijing University of Chemical Technology, Beijing, China
| | - Zhenkai Luo
- Graduate School of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhenshan Ding
- Department of Urology, China-Japan Friendship Hospital, Beijing, China
| | - Shicong Lai
- Department of Urology, Peking University People’s Hospital, Beijing, China
| | - Jian Ren
- Department of Urology, China-Japan Friendship Hospital, Beijing, China
- *Correspondence: Guan Zhang, ; Jian Ren,
| | - Guan Zhang
- Department of Urology, China-Japan Friendship Hospital, Beijing, China
- China-Japan Friendship School Clinical Medicine, Peking University, Beijing, China
- *Correspondence: Guan Zhang, ; Jian Ren,
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Klein JT, John A, Bohnert L, Enderle MD, Linzenbold W, Bolenz C. Improving the Quality of Human Upper Urinary Tract Specimens by Cryobiopsy. Front Oncol 2022; 12:810367. [PMID: 35223492 PMCID: PMC8881114 DOI: 10.3389/fonc.2022.810367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 01/05/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe quality of histopathological specimens obtained from the upper urinary tract with conventional flexible ureterorenoscopic biopsy needs to be improved. We investigated the feasibility and biopsy quality of specimens obtained by cryobiopsy, compared with standard ureterorenoscopic biopsy techniques in a human ex vivo model.Materials and MethodsHuman ureters obtained from nephrectomy specimens (N=12) were dissected and canulated with an ureteral access sheath. Ureterorenoscopic biopsies were randomly obtained from different sites of the renal pelvic caliceal system using different types of instruments. The performance of two newly developed flexible cryoprobes with outer diameters of 1.1 mm (CB11) and 0.9 mm (CB09) was compared with that of the biopsy forceps(FB) and Bigopsy®(BiG) and two different Dormia baskets N‐Gage (NG) and Zero‐Tip (ZT). We assessed the feasibility of the various biopsy techniques based on the number of biopsy attempts needed to obtain macroscopically discernible biopsies. The specimens were examined histopathologically for size, biopsy quality, presence of various artifact types, and representativeness.ResultsBiopsies taken with the cryoprobes showed a higher biopsy quality than biopsies taken with the comparative instruments. The CB11 provided significantly larger biopsies than forceps biopsies and also than biopsies with ZT. The CB09 was able to collect larger samples when compared with the FB and BiG biopsy forceps. There were no significant differences in artifact area, except for the CB11 cryoprobe compared with the NG. To clarify the results a subdivision of larger or smaller than 20% artifact area was performed. A significant difference was found between CB11 and the forceps biopsies, as well as between CB11 and NG and ZT in favor of the cryoprobe. The representation of the histopathological sample was also determined. Biopsies taken with CB11 were more representative compared with forceps biopsies BiG and FB and basket biopsies NG and ZT.ConclusionsIn a standardized comparative ex vivo setting, larger biopsies were obtained by using the cryobiopsy technique with the CB11 probe. Qualitatively, cryobiopsy specimens were overlaid by fewer artifacts and a higher biopsy quality was achieved in histopathologic examination compared with standard instrumentation. Further stepwise development will transfer the promising cryobiopsy technique into the clinical setting.
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Affiliation(s)
- Jan T. Klein
- Department of Urology, University of Ulm, Ulm, Germany
| | - Axel John
- Department of Urology, University of Ulm, Ulm, Germany
| | - Lars Bohnert
- Department of Urology, University of Ulm, Ulm, Germany
| | - Markus D. Enderle
- Department of Research and Basic Technologies, Erbe Elektromedizin GmbH, Tuebingen, Germany
| | - Walter Linzenbold
- Department of Research and Basic Technologies, Erbe Elektromedizin GmbH, Tuebingen, Germany
| | - Christian Bolenz
- Department of Urology, University of Ulm, Ulm, Germany
- *Correspondence: Christian Bolenz,
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12
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Pierconti F, Martini M, Fiorentino V, Cenci T, Racioppi M, Foschi N, Di Gianfrancesco L, Sacco E, Rossi E, Larocca LM, Bassi PF. Upper urothelial tract high-grade carcinoma: comparison of urine cytology and DNA methylation analysis in urinary samples. Hum Pathol 2021; 118:42-48. [PMID: 34582934 DOI: 10.1016/j.humpath.2021.09.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 09/13/2021] [Accepted: 09/16/2021] [Indexed: 10/20/2022]
Abstract
Numerous studies showed that bladder urothelial carcinoma and upper urothelial tract carcinoma (UTUC) display clinical and genomic similarities. In order to analyze that the same panel of biomarkers used in the diagnosis of bladder urothelial carcinoma could be suitable for early detection of UTUC, we performed a retrospective study in which we analyzed Bladder EpiCheck scores in the urinary samples obtained by selective ureteral catheterization in a high-grade UTUC cohort, correlating the results with urinary cytology and diagnostic urethral biopsies. The present study represents a retrospective analysis of 82 patients with clinically localized high-grade UTUC (60 renal pelvis UTUC, 22 ureter UTUC) who had undergone a radical nephroureterectomy (RNU) at our Urology department from June 2018 to November 2020. Before any surgical procedure, one sample of urine, obtained by selective ureteral catheterization, was collected for each patient for cytological examination, and the remaining material was stored for the Bladder EpiCheck test. Our results showed that the sensitivity of the methylation test for high-grade UTUC was about 97.4%, significantly higher than the sensitivity of urinary cytology either considering the HGUC cytological diagnosis or including in the positive cases the SHGUC cytological diagnosis (97.4% versus 59% or 70.5%). The methylation analysis of urinary samples may represent a valid tool in the diagnostic process of patients with suspected UTUC. In cases with a difficult clinical decision after upper urinary tract biopsy and cytology, the methylation test could assist in the clinical management of UTUC patients.
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Affiliation(s)
- Francesco Pierconti
- Department of Pathology, Insitute of Pathology, Università Cattolica Del S. Cuore, Fondazione Policlinico "A. Gemelli", Rome, 00138, Italy.
| | - Maurizio Martini
- Department of Pathology, Insitute of Pathology, Università Cattolica Del S. Cuore, Fondazione Policlinico "A. Gemelli", Rome, 00138, Italy
| | - Vincenzo Fiorentino
- Department of Pathology, Insitute of Pathology, Università Cattolica Del S. Cuore, Fondazione Policlinico "A. Gemelli", Rome, 00138, Italy
| | - Tonia Cenci
- Department of Pathology, Insitute of Pathology, Università Cattolica Del S. Cuore, Fondazione Policlinico "A. Gemelli", Rome, 00138, Italy
| | - Marco Racioppi
- Department of Urology, Insitute of Urology, Università Cattolica Del S. Cuore, Fondazione Policlinico "A. Gemelli", Rome, 00138, Italy
| | - Nazario Foschi
- Department of Urology, Insitute of Urology, Università Cattolica Del S. Cuore, Fondazione Policlinico "A. Gemelli", Rome, 00138, Italy
| | - Luca Di Gianfrancesco
- Department of Urology, Insitute of Urology, Università Cattolica Del S. Cuore, Fondazione Policlinico "A. Gemelli", Rome, 00138, Italy
| | - Emilio Sacco
- Department of Urology, Insitute of Urology, Università Cattolica Del S. Cuore, Fondazione Policlinico "A. Gemelli", Rome, 00138, Italy
| | - Ernesto Rossi
- Department of Oncology, Università Cattolica Del S. Cuore, Fondazione Policlinico "A. Gemelli", Rome, 00138, Italy
| | - Luigi M Larocca
- Department of Pathology, Insitute of Pathology, Università Cattolica Del S. Cuore, Fondazione Policlinico "A. Gemelli", Rome, 00138, Italy
| | - Pier Francesco Bassi
- Department of Urology, Insitute of Urology, Università Cattolica Del S. Cuore, Fondazione Policlinico "A. Gemelli", Rome, 00138, Italy
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13
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Territo A, Gallioli A, Meneghetti I, Fontana M, Huguet J, Palou J, Breda A. Diagnostic ureteroscopy for upper tract urothelial carcinoma: friend or foe? Arab J Urol 2021; 19:46-58. [PMID: 33763248 PMCID: PMC7954478 DOI: 10.1080/2090598x.2021.1883810] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction The European Association of Urology guidelines recommend offering kidney-sparing surgery (KSS) as a primary treatment option to patients with low-risk tumours. Cystoscopy, urinary cytology, and computed tomography urography (CTU) do not always allow correct disease staging and grading, and sometimes there is even a lack of certainty regarding the diagnosis of UTUC. Diagnostic ureteroscopy (d-URS) may therefore be of crucial importance within the diagnostic framework and fundamental in establishing the appropriate therapeutic approach. Evidence acquisition and synthesis A systematic review of the literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Risk of bias was assessed using Risk of Bias in Non-randomized Studies of interventions (ROBINS-I). Overall, from 3791 identified records, 186 full-text articles were assessed for eligibility. Finally, after a quantitative review of the selected literature, with the full agreement of all authors, 62 studies were considered relevant for this review. Results CTU has a sensitivity and specificity for UTUC of 92% and 95% respectively, but is not able to detect small or flat lesions with adequate accuracy. The sensitivity of voided urinary cytology for UTUC is around 67–76% and ranges from 43% to 78% for selective ureteric urine collection. As no technique offers a diagnosis of certainty, d-URS can allow an increase in diagnostic accuracy. In the present review the pros and cons of d-URS were analysed. This technique may provide additional information in the selection of patients suitable for neoadjuvant chemotherapy or KSS, distinguishing between normal tissue and low- and high-grade UTUC thanks to the emerging technologies. Conclusions Information obtainable from d-URS and ureteroscopic-guided biopsy can prove extremely valuable when the diagnosis of UTUC is doubtful or KSS is being considered. Notwithstanding concerns remain regarding the potential risk of bladder recurrence, cancer dissemination, and/or delay in radical treatment. Abbreviations: CLE: confocal laser endomicroscopy; CSS: cancer-specific survival; CTU: CT urography; d-URS: diagnostic ureteroscopy; EAU: European Association of Urology; HR: hazard ratio; IMAGE1S: Storz professional imaging enhancement system; IVR: intravesical recurrence; KSS: kidney-sparing surgery; MFS: Metastasis-free survival; NAC: neoadjuvant chemotherapy; NBI: narrow-band imaging; OCT: optical coherence tomography; RFS: Recurrence-free survival; RNU: radical nephroureterectomy; ROBINS-I: Risk of Bias in Non-randomized Studies of interventions; URS(-GB): Ureteroscopy(-guided biopsy); UTUC: upper tract urothelial carcinoma; UUT: upper urinary tract
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Affiliation(s)
- Angelo Territo
- Urology Department, Fundació Puigvert, Autonomous University of Barcelona, Barcelona, Spain
| | - Andrea Gallioli
- Urology Department, Fundació Puigvert, Autonomous University of Barcelona, Barcelona, Spain
| | - Iacopo Meneghetti
- Urology Department, Fundació Puigvert, Autonomous University of Barcelona, Barcelona, Spain
| | - Matteo Fontana
- Urology Department, Fundació Puigvert, Autonomous University of Barcelona, Barcelona, Spain
| | - Jordi Huguet
- Urology Department, Fundació Puigvert, Autonomous University of Barcelona, Barcelona, Spain
| | - Joan Palou
- Urology Department, Fundació Puigvert, Autonomous University of Barcelona, Barcelona, Spain
| | - Alberto Breda
- Urology Department, Fundació Puigvert, Autonomous University of Barcelona, Barcelona, Spain
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14
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Li R. Patient Evaluation and Diagnosis – Screening, Evaluation, and Workup. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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15
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Compérat EM, Al-Ahmadie H. Pathology. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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16
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Ma R, Xia H, Qiu M, Tao L, Lu M, Huang R, Lu J, Ma L. A Diagnostic Nomogram of Pathologic Grade for Preoperative Risk Stratification in Upper Tract Urothelial Carcinoma. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2020; 14:1179554920927662. [PMID: 33100833 PMCID: PMC7551492 DOI: 10.1177/1179554920927662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 04/23/2020] [Indexed: 01/13/2023]
Abstract
Background: To develop a novel nomogram to improve the preoperative diagnosis of
pathological grade of upper tract urothelial carcinoma (UTUC). Methods: Retrospective study was conducted with 245 patients with UTUC treated by
radical nephroureterectomy from 2002 to 2016. Of the cohort, 57.6% received
ureteroscopic (URS) biopsy and 35.9% received urine cytology examination.
Preoperative clinical characteristics and examination results were
collected. Final pathological grade was diagnosed by postoperative
pathology. Univariable and multivariable binary logistic regressions were
applied to establish a preoperative predictive model for tumor grade, and
significant factors were included in the nomogram. The area under curve
(AUC) was used to show the predictive efficacy, and the calibration plot was
drawn for validation. Results: Of the 245 patients, 72.7% were diagnosed with pathological high-grade
disease. Age (odds ratio [OR] = 1.03, P = .039), sessile
(OR = 3.86, P = .021), positive urinary cytology
(OR = 6.87, P = .035), and biopsy high-grade result
(OR = 10.85, P < .001) were independent predictors for
pathological high-grade disease. The predictive nomogram containing these
factors achieved an AUC of 0.78, which was significantly better than URS
biopsy alone (AUC = 0.62, P = .003) in the whole cohort. In
the URS biopsy subgroup, the nomogram achieved an AUC of 0.79, better than
biopsy alone (AUC = 0.76), but was not statistically significant
(P = .431). When the cutoff value of the nomogram was
set at 0.64, the sensitivity of detecting a high-grade lesion versus
low-grade lesion was 80.3%, better than that of URS biopsy alone
(sensitivity = 65.7%). Conclusions: Advanced age, sessile, positive urinary cytology, and biopsy high-grade were
independent predictors of pathological high-grade disease in patients with
UTUC. A nomogram containing these factors can improve diagnostic accuracy,
potentially reducing the risk of “undergrading” by URS biopsy.
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Affiliation(s)
- Runzhuo Ma
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Haizhui Xia
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Min Qiu
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Liyuan Tao
- Department of Biostatistics, Peking University Third Hospital, Beijing, China
| | - Min Lu
- Department of Pathology, Peking University Third Hospital, Beijing, China
| | - Rui Huang
- Department of Oncological Surgery, Peking University Cancer Hospital & Institute, Beijing, China.,Department of Molecular and Cellular Biology, Beckman Research Institute, City of Hope, Duarte, CA, USA
| | - Jian Lu
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, Beijing, China
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17
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Zhang ML, Miki Y, Hang JF, Vohra M, Peyton S, McIntire PJ, VandenBussche CJ, Vohra P. A review of upper urinary tract cytology performance before and after the implementation of The Paris System. Cancer Cytopathol 2020; 129:264-274. [PMID: 32897658 DOI: 10.1002/cncy.22343] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 12/22/2022]
Abstract
Urinary cytology (UC) is one of the primary diagnostic modalities used for the screening and surveillance of urothelial carcinoma. Despite its widespread use, UC has suffered from a lack of standardized or reproducible criteria and wide interobserver variability, particularly of the designation of atypical urothelial cells. The Paris System for Reporting Urinary Cytology (TPS), published in 2016, aimed to provide a standardized approach for evaluating UC by creating diagnostic categories with specific cytomorphologic criteria. Recent studies have primarily investigated the application of TPS on lower urinary tract specimens and have mostly shown that TPS implementation has improved the performance of UC specimens. Only a few studies have reported the impact of TPS on upper urinary tract (UUT) cytology. Additionally, there is uncertainty as to which cytological features are most predictive of high-grade urothelial carcinoma (HGUC) in the UUT. This review summarizes the literature regarding the utility and performance of UUT cytology and highlights findings before and after the implementation of TPS.
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Affiliation(s)
- M Lisa Zhang
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Yurina Miki
- Department of Cellular Pathology, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jen-Fan Hang
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Manjiv Vohra
- Environmental Chemical Corp, Burlingame, California
| | - Stephen Peyton
- QML Pathology, Anatomical Pathology, Brisbane, Queensland, Australia
| | - Patrick J McIntire
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | | | - Poonam Vohra
- Department of Anatomic Pathology, University of California, San Francisco, California
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18
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Freund JE, Duivenvoorden MJC, Sikma BT, Vernooij RWM, Savci-Heijink CD, Legemate JD, de Reijke TM. The Diagnostic Yield and Concordance of Ureterorenoscopic Biopsies for Grading of Upper Tract Urothelial Carcinoma: A Dutch Nationwide Analysis. J Endourol 2020; 34:907-913. [PMID: 32483982 DOI: 10.1089/end.2020.0246] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objectives: To evaluate the diagnostic yield and concordance of upper tract urothelial carcinoma (UTUC) grading between ureterorenoscopic biopsies and surgical resections. Materials and Methods: The nationwide Dutch Pathology Registry (nationwide network and registry of histo- and cytopathology in the Netherlands [PALGA]) was searched for UTUC-positive renal units (RUs) with histopathology excerpts from ureterorenoscopic biopsies and surgical resections, matched for laterality and localization of the tumor, from 2011 until 2018. The positive predictive value (concordance) of the biopsy grade with regard to the final grade according to the World Health Organization (WHO) 2004 classification was calculated. Results: A total of 1002 UTUC-positive rental units were included, of which 776 UTUC-positive RUs were graded according to the WHO 2004 classification in the ureterorenoscopic biopsy, the localization-matched surgical resection, or in both. The diagnostic yield of biopsies for a classifying diagnosis was 89% with a sensitivity for UTUC of 84%. In case of UTUC, the diagnostic yield for biopsy-based grading and staging was 97% and 72%, respectively. The concordance of high-grade biopsies with regard to the final histopathology was 97% and 62% for low-grade biopsies. Upgrading to final high grade occurred in 33% of the low-grade biopsies. Downgrading to final low grade occurred in 2% of high-grade biopsies. Conclusions: This is the first study to portray the limitations of ureterorenoscopic biopsies for UTUC in a nationwide cohort. The diagnostic yield of ureterorenoscopic biopsies for a classifying diagnosis is suboptimal, but the diagnostic yield for grading according to the WHO 2004 classification is high. Yet, a worrisome amount of ureterorenoscopic biopsies are upgraded with regard to the surgical resection. Consequently, one-third of patients, who qualify for kidney-sparing treatment according to one of the criteria recommended for risk stratification, might be stratified incorrectly. These findings stress the importance of a timely and stringent ureterorenoscopic follow-up after kidney-sparing surgery and highlight the need for improvements in the diagnostic approach to optimize the risk stratification.
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Affiliation(s)
- Jan Erik Freund
- Department of Urology and Amsterdam University Medical Centers, University of Amsterdam, The Netherlands.,Department of Pathology, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Mylène J C Duivenvoorden
- Department of Urology and Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Boukje T Sikma
- Department of Urology and Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Robin W M Vernooij
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | | | - Jaap D Legemate
- Department of Urology and Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Theo M de Reijke
- Department of Urology and Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
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19
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Subiela JD, Territo A, Mercadé A, Balañà J, Aumatell J, Calderon J, Gallioli A, González-Padilla DA, Gaya JM, Palou J, Breda A. Diagnostic accuracy of ureteroscopic biopsy in predicting stage and grade at final pathology in upper tract urothelial carcinoma: Systematic review and meta-analysis. Eur J Surg Oncol 2020; 46:1989-1997. [PMID: 32674841 DOI: 10.1016/j.ejso.2020.06.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/21/2020] [Accepted: 06/14/2020] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To assess the accuracy of ureteroscopic (URS) biopsies in predicting stage and grade at final pathology in upper tract urothelial carcinoma (UTUC). MATERIALS AND METHODS The meta-analysis was performed in accordance with the PRISMA statement. Studies providing data on tumor stage and grade at URS biopsy and surgical specimens were included. The negative predictive value (NPV) implies concordance between the absence of subepithelial connective tissue invasion or the presence of low-grade tumors at URS biopsy and the absence of a muscle-invasive disease in the final pathology. RESULTS A total of 23 studies were included (3547 patients). The stage-to-stage match between URS biopsy/final pathology showed a positive predictive value (PPV) for cT1+/muscle-invasive disease of 94% (95% CI: 84%-100%) and a NPV for cTa-Tis/non-muscle-invasive disease of 60% (95% CI: 52%-68%). The grade-to-grade match between URS biopsy/final pathology was 66% (95% CI: 55%-77%) for low-grade (cLG/pLG) tumors and 97% (95% CI: 94%-98%) for high-grade (cHG/pHG) tumors. The PPV for cHG/muscle-invasive disease was 60% (95% CI: 54%-66%) and the NPV for cLG/non-muscle-invasive disease was 77% (95% CI: 73%-82%). The undergrading and understaging rates were 32% (95%CI: 25%-38%) and 46% (95% CI: 38%-54%), respectively. CONCLUSIONS There is a substantial correlation between tumor grade at URS biopsy and the final pathology. The identification of cHG tumors and subepithelial connective tissue invasion (cT1+) in URS biopsy showed a moderate and a strong correlation with invasive UTUC, respectively. Nevertheless, a certain risk of undergrading and understaging should be assumed.
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Affiliation(s)
- José Daniel Subiela
- Oncology Urology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Carrer de Cartagena 340-350, 08025, Barcelona, Spain.
| | - Angelo Territo
- Oncology Urology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Carrer de Cartagena 340-350, 08025, Barcelona, Spain.
| | - Asier Mercadé
- Oncology Urology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Carrer de Cartagena 340-350, 08025, Barcelona, Spain.
| | - Josep Balañà
- Oncology Urology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Carrer de Cartagena 340-350, 08025, Barcelona, Spain.
| | - Julia Aumatell
- Oncology Urology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Carrer de Cartagena 340-350, 08025, Barcelona, Spain.
| | - Julio Calderon
- Oncology Urology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Carrer de Cartagena 340-350, 08025, Barcelona, Spain.
| | - Andrea Gallioli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Urology, Department of Clinical Sciences and Community Health, University of Milan, Via della Commenda, 10, 20122, Milan, Italy.
| | | | - Josep Maria Gaya
- Oncology Urology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Carrer de Cartagena 340-350, 08025, Barcelona, Spain.
| | - Joan Palou
- Oncology Urology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Carrer de Cartagena 340-350, 08025, Barcelona, Spain.
| | - Alberto Breda
- Oncology Urology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Carrer de Cartagena 340-350, 08025, Barcelona, Spain.
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20
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Honda Y, Nakamura Y, Teishima J, Goto K, Higaki T, Narita K, Akagi M, Terada H, Kaichi Y, Fujii S, Hayashi T, Matsubara A, Sentani K, Yasui W, Iida M, Awai K. Clinical staging of upper urinary tract urothelial carcinoma for T staging: Review and pictorial essay. Int J Urol 2019; 26:1024-1032. [PMID: 31379021 DOI: 10.1111/iju.14068] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 06/18/2019] [Indexed: 12/17/2022]
Abstract
Upper urinary tract urothelial carcinoma is staged using the TNM classification of malignant tumors. Preoperative TNM is important for treatment planning. Computed tomography urography is now widely used for clinical survey of upper urinary tract carcinoma because of its diagnostic accuracy. Computed tomography urography is recommended as the first-line imaging procedure in several guidelines. Several reports stated that computed tomography urography is also useful for staging. However, no educational and practical reviews detailing the T staging of upper urinary tract urothelial carcinomas using imaging are available. We discuss the scanning protocol, T staging using computed tomography urography, limitations, magnetic resonance imaging, computed tomography comparison and pitfalls in imaging of upper urinary tract urothelial carcinoma. A recent study reported the high diagnostic accuracy of computed tomography urography with respect to T3 or higher stage tumors. To date, images that show a Tis-T2 stage have not been reported, but various studies are ongoing. Although magnetic resonance imaging has lower spatial resolution than computed tomography urography, magnetic resonance imaging can be carried out without radiation exposure or contrast agents. Magnetic resonance imaging also offers the unique ability of diffusion-weighted imaging without contrast agent use. Some researchers reported that diffusion-weighted imaging is useful not only for detecting lesions, but for predicting the T stage and tumor grade. We recommend the appropriate use of computed tomography and magnetic resonance while considering the limitations of each modality and the pitfalls in upper urinary tract urothelial carcinoma imaging.
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Affiliation(s)
- Yukiko Honda
- Department of Diagnostic Radiology, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuko Nakamura
- Department of Diagnostic Radiology, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Jun Teishima
- Department of Urology, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Keisuke Goto
- Department of Urology, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Toru Higaki
- Department of Diagnostic Radiology, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Keigo Narita
- Department of Diagnostic Radiology, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Motonori Akagi
- Department of Diagnostic Radiology, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroaki Terada
- Department of Diagnostic Radiology, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yoko Kaichi
- Department of Diagnostic Radiology, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinsuke Fujii
- Department of Urology, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tetsutaro Hayashi
- Department of Urology, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akio Matsubara
- Department of Urology, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazuhiro Sentani
- Department of Molecular Pathology, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Wataru Yasui
- Department of Molecular Pathology, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Makoto Iida
- Department of Diagnostic Radiology, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazuo Awai
- Department of Diagnostic Radiology, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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21
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Malm C, Grahn A, Jaremko G, Tribukait B, Brehmer M. Predicting invasiveness and disease-specific survival in upper tract urothelial carcinoma: identifying relevant clinical tumour characteristics. World J Urol 2019; 37:2335-2342. [PMID: 31016451 PMCID: PMC6825649 DOI: 10.1007/s00345-019-02760-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 04/04/2019] [Indexed: 12/31/2022] Open
Abstract
PURPOSE The aim of this prospective study was to identify the tumour characteristics that are associated with invasiveness and those that are relevant for disease-specific survival (DSS) in upper tract urothelial carcinoma, UTUC. METHODS From a prospective consecutive cohort of patients with suspicion of UTUC, those who were diagnosed with UTUC using URS prior to rNU between 2005 and 2012 were included. Tumour characteristics were analysed for prediction of invasiveness and association with DSS. Stages were categorised as superficial (pTa-1 and CIS only) or invasive (≥ pT2). Tumours were graded according to WHO 1999 classification. DSS was analysed regarding possible association with stage, grade, size, multifocality, location, ploidy and rate of proliferation. Associations were tested using Fisher's exact test, Pearson Chi-square or Cox's regression. Kaplan-Meier survival curves were constructed. RESULTS Forty-five consecutive patients were included, and 43 of them were included in the final analyses because their rNU specimens were available for reassessment. The only tumour characteristics that were significantly associated with stage were tumour grade (P < 0.001), DNA ploidy (P = 0.045) and rate of proliferation (P = 0.004). No association with stage was noted for size, multifocality or location. Grade, stage and rate of proliferation were associated with DSS. CONCLUSIONS Grade, DNA ploidy and S-phase fraction were the only tumour characteristics associated with stage in our study. However, DNA ploidy was not associated with DSS. The prognostic factors that we identified were tumour grade, stage, and S-phase fraction.
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Affiliation(s)
- Camilla Malm
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden.,Department of Urology, Stockholm South General Hospital, Stockholm, Sweden
| | - Alexandra Grahn
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden.,Division of Urology, Karolinska University Hospital, Stockholm, Sweden
| | - Georg Jaremko
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Pathology and Cytology, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Bernhard Tribukait
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Marianne Brehmer
- Division of Urology, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
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Clinical utility and concordance of upper urinary tract cytology and biopsy in predicting clinicopathological features of upper urinary tract urothelial carcinoma. Hum Pathol 2019; 86:76-84. [DOI: 10.1016/j.humpath.2018.11.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/16/2018] [Accepted: 11/23/2018] [Indexed: 10/27/2022]
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Fojecki G, Magnusson A, Traxer O, Baard J, Osther PJS, Jaremko G, Seitz C, Knoll T, Giusti G, Brehmer M. Consultation on UTUC, Stockholm 2018 aspects of diagnosis of upper tract urothelial carcinoma. World J Urol 2019; 37:2271-2278. [PMID: 30915526 PMCID: PMC6825655 DOI: 10.1007/s00345-019-02732-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/13/2019] [Indexed: 02/07/2023] Open
Abstract
Purpose To summarize knowledge on upper urinary tract carcinoma (UTUC) regarding diagnostic procedures, risk factors and prognostic markers. Methods A scoping review approach was applied to search literature in Pubmed, Web of Science, and Embase. Consensus was reached through discussions at Consultation on UTUC in Stockholm, September 2018. Results Tumor stage and grade are the most important prognostic factors. CT urography (CTU) including corticomedullary phase is the preferred imaging modality. A clear tumor on CTU in combination with high-grade UTUC in urine cytology identifies high-risk UTUC, and in some cases indirect staging can be obtained. Bladder urine cytology has limited sensitivity, and in most cases ureterorenoscopy (URS) with in situ samples for cytology and histopathology are mandatory for exact diagnosis. Image-enhancing techniques, Image S1 and narrow-band imaging, may improve tumor detection at URS. Direct confocal laser endomicroscopy may help to define grade during URS. There is strong correlation between stage and grade, accordingly correct grading is crucial. The correlation is more pronounced using the 1999 WHO than the 2004 classification: however, the 1999 system risks greater interobserver variability. Using both systems is advisable. A number of tissue-based molecular markers have been studied. None has proven ready for use in clinical practice. Conclusions Correct grading and staging of UTUC are mandatory for adequate treatment decisions. Optimal diagnostic workup should include CTU with corticomedullary phase, URS with in situ cytology and biopsies. Both WHO classification systems (1999 and 2004) should be used to decrease risk of undergrading or overtreatment.
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Affiliation(s)
- Grzegorz Fojecki
- Department of Urology, Hospital of Southern Jutland, Sønderborg, Denmark
| | | | | | - Joyce Baard
- Department of Urology, Amsterdam UMC, University of Amsterdam, Amsterdam, Holland
| | - Palle Jörn Sloth Osther
- Urological Research Center, Lillebaelt Hospital, University of Southern Denmark, Vejle, Denmark
| | - Georg Jaremko
- Department of Clinical Pathology and Cytology, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Christian Seitz
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Thomas Knoll
- Department of Urology, Teaching Hospital University Tuebingen, Sindelfingen, Germany
| | - Guido Giusti
- Department of Urology, IRCCS San Raffaele Hospital, Ville Turro Division, Milan, Italy
| | - Marianne Brehmer
- Division of Urology, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
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[Biopsy techniques in the upper urinary tract for the diagnosis of urothelial carcinoma: systematic review]. Urologe A 2019; 58:14-21. [PMID: 30617531 DOI: 10.1007/s00120-018-0829-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The diagnostic accuracy of ureteroscopic biopsies in the upper urinary tract is limited by technical difficulties during extraction and small sample size. OBJECTIVES To evaluate the impact of different techniques and instruments on the histopathologic quality and diagnostic yield of extracted samples as well as the predictive value of clinical grading and staging on final pathologic stage at radical nephroureterectomy. MATERIALS AND METHODS For this systematic review, we searched PubMed and Embase databases for original publications and meeting abstracts according to the PRISMA guidelines. RESULTS Overall, we included 23 studies which comprised a total of 1547 biopsies for the investigation of diagnostic yield and 778 patients for the assessment of grade and stage concordance. We found that the median diagnostic yields of big retrograde 2F [french] forceps, antegrade 3F forceps and baskets in combination with forceps were 92% (range 83-100), 72% (50-90) and 91% (78-94), respectively. Median rates of grade concordance and upgrading across all techniques ranged between 78-89% and 5-16%, respectively, without relevant differences. CONCLUSIONS The choice of biopsy technique affects the ability to diagnose upper tract urothelial carcinoma. The correct determination of pathologic grading is comparable between different techniques. The combination of biopsy forceps and baskets during ureterorenoscopy seems to achieve optimal diagnostic accuracy.
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Breda A, Territo A, Sanguedolce F, Basile G, Subiela JD, Reyes HV, Ferrer OM, Gaya JM, Palou J. Comparison of biopsy devices in upper tract urothelial carcinoma. World J Urol 2018; 37:1899-1905. [PMID: 30560298 DOI: 10.1007/s00345-018-2586-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 11/27/2018] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION A correct characterization of upper tract urothelial carcinoma (UTUC) lesions is fundamental to appropriately select patients suitable for endoscopic management. We analyzed the diagnostic yield of three different biopsy tools for the histology evaluation of the UTUC. Furthermore, the concordance between biopsy grading and final UTUC pathology results at specimen (i.e., after ureterectomy or radical nephroureterectomy-RNU) was evaluated. MATERIALS AND METHODS Three different devices were evaluated: 3F biopsy forceps, 6F BIGopsy® Backloading biopsy forceps and the 2.2F Nitinol Basket. Data were collected between January 2015 and October 2017 and retrospectively analyzed. Univariate and multivariate logistic regression analyses were performed to identify the variables related to diagnosis. RESULTS A total of 302 biopsies were taken: lesions could be characterized in 236 (78.2%) specimens by the pathologist. Positive biopsies for UTUC were found in 140 specimens. In 66 biopsies (21.8%), the quality of the tissue sampled was inadequate for a histological characterization; of these, 55 (83.3%) were taken using 3F forceps and 11 (16.7%) using BIGopsy forceps. No inadequate specimen arose using the 2.2F Nitinol Basket. Among 28 patients who underwent distal ureterectomy or RNU, the tumor was upgraded to high grade in 9 (32%), while in 19 (68%) the grading was confirmed. CONCLUSION In comparison to 3F forceps, the BIGopsy forceps showed to be more accurate in obtaining sufficient specimen for pathologic examination. In papillary lesions, the 2.2F Nitinol basket achieves a final histology characterization in 100% of the cases. For tumor < 2 cm, there is a high concordance between URS biopsy grade and final pathology (distal ureterectomy or RNU).
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Affiliation(s)
- Alberto Breda
- Department of Urology, Fundació Puigvert, Autonomous University of Barcelona, 08035, Barcelona, Spain.
| | - Angelo Territo
- Department of Urology, Fundació Puigvert, Autonomous University of Barcelona, 08035, Barcelona, Spain
| | - Francesco Sanguedolce
- Department of Urology, Fundació Puigvert, Autonomous University of Barcelona, 08035, Barcelona, Spain
| | - Giuseppe Basile
- Department of Urology, Fundació Puigvert, Autonomous University of Barcelona, 08035, Barcelona, Spain
| | - Jose D Subiela
- Department of Urology, Fundació Puigvert, Autonomous University of Barcelona, 08035, Barcelona, Spain
| | - Helena Vila Reyes
- Department of Urology, Fundació Puigvert, Autonomous University of Barcelona, 08035, Barcelona, Spain
| | - Olga Mayordomo Ferrer
- Department of Urology, Fundació Puigvert, Autonomous University of Barcelona, 08035, Barcelona, Spain
| | - Jose M Gaya
- Department of Urology, Fundació Puigvert, Autonomous University of Barcelona, 08035, Barcelona, Spain
| | - Joan Palou
- Department of Urology, Fundació Puigvert, Autonomous University of Barcelona, 08035, Barcelona, Spain
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Akita H, Kikuchi E, Hayakawa N, Mikami S, Sugiura H, Oya M, Jinzaki M. Performance of diffusion-weighted MRI post-CT urography for the diagnosis of upper tract urothelial carcinoma: Comparison with selective urine cytology sampling. Clin Imaging 2018; 52:208-215. [DOI: 10.1016/j.clinimag.2018.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 07/13/2018] [Accepted: 08/14/2018] [Indexed: 01/03/2023]
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Klein JT, Berger F, Linzenbold W, Jäger L, Enderle MD, Bösmüller H, Mundhenk J, Schwentner C, Bolenz C. Cryobiopsy in the Upper Urinary Tract: Preclinical Evaluation of a Novel Device. Urology 2018; 123:273-279. [PMID: 30312669 DOI: 10.1016/j.urology.2018.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/21/2018] [Accepted: 10/02/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To develop a novel device for cryobiopsy of the upper urinary tract (UUT) and to evaluate its feasibility in a standardized preclinical setting. MATERIALS AND METHODS Flexible cryoprobes (diameter 0.9 mm; cooling agent CO2) were developed and used to extract biopsies in porcine UUTs. Cryosamples obtained by ureterorenoscopy were systematically compared with biopsy specimens obtained with standard of care devices in terms of physical characteristics (deflection angle and irrigation flow rates) and histologic criteria (assessability). RESULTS Irrigation flow rates were significantly higher with introduced BIGopsy (2.8 ± 0.1) compared with standard forceps (0.94 ± 0.06; P < .001) and cryoprobe (1.1 ± 0.1; P < .001). Angular deflection was significantly reduced by the inserted cryoprobe (130.7° ± 1.2° vs 166.9° ± 1.1° [BIGopsy] or 161.4° ± 1.9° [standard forceps]; both P < .001). Significantly larger UUT tissue samples were obtained by the cryoprobe (mean specimen area 7.5 ± 2.5 vs 4.6 ± 2.5 mm² [BIGopsy] or 1.4 ± 1.4 mm² [standard forceps]; both P < .001). No crush artifacts were observed in cryosamples. Superior histologic assessability scores were achieved in samples obtained by the cryoprobe (mean 2.8 ± 0.8) and BIGopsy (2.3 ± 1.9) when compared with standard forceps (0.4 ± 0.9; P < .001). CONCLUSION Cryobiopsy in the UUT is feasible and represents a viable new option to improve the diagnostic accuracy of histopathologic evaluation. Larger and more representative tissue samples can be obtained using a cryoprobe and artifacts may be avoided. Further optimization of the probe will reduce possible restrictions of ureterorenoscopy handling when the device is inserted.
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Affiliation(s)
| | | | | | | | | | - Hans Bösmüller
- Institute of Pathology and Neuropathology, University of Tübingen, Tübingen, Germany
| | - Jens Mundhenk
- Department of Urology, Diakonie Hospital, Stuttgart, Germany
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28
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Lama DJ, Safiullah S, Patel RM, Lee TK, Balani JP, Zhang L, Okhunov Z, Margulis V, Savage SJ, Uchio E, Landman J. Multi-institutional Evaluation of Upper Urinary Tract Biopsy Using Backloaded Cup Biopsy Forceps, a Nitinol Basket, and Standard Cup Biopsy Forceps. Urology 2018; 117:89-94. [PMID: 29630955 DOI: 10.1016/j.urology.2018.03.040] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Revised: 03/09/2018] [Accepted: 03/22/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To compare the performance of 3 contemporary ureteroscopic biopsy devices for the histopathologic diagnosis of upper tract urothelial carcinoma (UTUC). METHODS We retrospectively reviewed 145 patients who underwent 182 urothelial biopsies using 2.4F backloaded cup biopsy forceps, a nitinol basket, or 3F standard cup biopsy forceps at 3 tertiary academic centers between 2011 and 2016. Experienced genitourinary pathologists provided an assessment of each specimen without knowledge of the device used for biopsy. For patients who underwent nephroureterectomy without neoadjuvant chemotherapy within 3 months of biopsy-proven UTUC diagnosis, the biopsy grade was compared with both the grade and stage of the surgical specimen. RESULTS Biopsy utilization varied among the 3 institutions (P <.0001). Significant variabilities in specimen size (P = .001), the presence of intact urothelium (P = .008), and crush artifact (P = .028) were found among the biopsy devices. The quality of specimens from backloaded cup forceps was rated similarly to the nitinol basket (P >.05) and was favored over standard cup forceps specimens. Grade concordance was not affected by specimen size (P >.05), morphology (P >.1), or location (P >.5). No difference existed among the devices in the rate of acquiring a grade concordant biopsy; however, the backloaded cup forceps provided concordant biopsies that could be distinguished as low- and high-grade (P = .02). CONCLUSION The backloaded cup forceps and nitinol basket obtained a higher quality urothelial specimen compared with standard cup forceps. Ureteroscopic biopsy device selection did not significantly impact the accuracy of the histologic diagnosis of UTUC.
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Affiliation(s)
- Daniel J Lama
- Department of Urology, University of California, Irvine (UCI) Medical Center, Orange, CA.
| | - Shoaib Safiullah
- Division of Urology, Department of Surgery, University of Missouri (MU), Columbia, MO
| | - Roshan M Patel
- Department of Urology, University of California, Irvine (UCI) Medical Center, Orange, CA
| | - Thomas K Lee
- Department of Pathology, University of California, Irvine (UCI) Medical Center, Orange, CA
| | - Jyoti P Balani
- Department of Pathology, University of Texas Southwestern Medical Center (UTSW), Dallas, TX
| | - Lishi Zhang
- Department of Urology, University of California, Irvine (UCI) Medical Center, Orange, CA
| | - Zhamshid Okhunov
- Department of Urology, University of California, Irvine (UCI) Medical Center, Orange, CA
| | - Vitaly Margulis
- Department of Urology, University of Texas Southwestern Medical Center (UTSW), Dallas, TX
| | - Stephen J Savage
- Department of Urology, Medical University of South Carolina (MUSC), Charleston, SC
| | - Edward Uchio
- Department of Urology, University of California, Irvine (UCI) Medical Center, Orange, CA
| | - Jaime Landman
- Department of Urology, University of California, Irvine (UCI) Medical Center, Orange, CA
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Abstract
A select group of patients with upper tract urothelial carcinoma (UTUC) may meet indications for endoscopic management. Strategies for disease management are provided, based on a comprehensive review of the data using PubMed and Medline databases and marrying this with our experience with endoscopic management of UTUC. Endoscopic management of UTUC via retrograde or antegrade approaches is a viable treatment option for appropriately selected patients with low-risk UTUC, including those with low-grade, low-volume, and solitary tumors. However, recurrence risk limits these procedures to compliant patients under a vigilant surveillance program. Efficacious adjuvant therapies are needed to reduce local recurrences.
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Affiliation(s)
- Firas G Petros
- Department of Urology, UT MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Roger Li
- Department of Urology, UT MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Surena F Matin
- Department of Urology, UT MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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30
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Liem EI, Freund JE, Baard J, de Bruin DM, Laguna Pes MP, Savci-Heijink CD, van Leeuwen TG, de Reijke TM, de la Rosette JJ. Confocal Laser Endomicroscopy for the Diagnosis of Urothelial Carcinoma in the Bladder and the Upper Urinary Tract: Protocols for Two Prospective Explorative Studies. JMIR Res Protoc 2018; 7:e34. [PMID: 29415874 PMCID: PMC5822038 DOI: 10.2196/resprot.8862] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 11/08/2017] [Accepted: 11/13/2017] [Indexed: 12/23/2022] Open
Abstract
Background Visual confirmation of a suspicious lesion in the urinary tract is a major corner stone in diagnosing urothelial carcinoma. However, during cystoscopy (for bladder tumors) and ureterorenoscopy (for tumors of the upper urinary tract) no real-time histopathologic information can be obtained. Confocal laser endomicroscopy (CLE) is an optical imaging technique that allows for in vivo high-resolution imaging and may allow real-time tumor grading of urothelial lesions. Objective The primary objective of both studies is to develop descriptive criteria for in vivo CLE images of urothelial carcinoma (low-grade, high-grade, carcinoma in situ) and normal urothelium by comparing CLE images with corresponding histopathology. Methods In these two prospective clinical trials, CLE imaging will be performed of suspicious lesions and normal tissue in the urinary tract during surgery, prior to resection or biopsy. In the bladder study, CLE will be performed in 60 patients using the Cystoflex UHD-R probe. In the upper urinary tract study, CLE will be performed in 25 patients during ureterorenoscopy, who will undergo radical treatment (nephroureterectomy or segmental ureter resection) thereafter. All CLE images will be analyzed frame by frame by three independent, blinded observers. Histopathology and CLE-based diagnosis of the lesions will be evaluated. Both studies comply with the IDEAL stage 2b recommendations. Results Presently, recruitment of patients is ongoing in both studies. Results and outcomes are expected in 2018. Conclusions For development of CLE-based diagnosis of urothelial carcinoma in the bladder and the upper urinary tract, a structured conduct of research is required. This study will provide more insight in tissue-specific CLE criteria for real-time tumor grading of urothelial carcinoma. Trial Registration Confocal Laser Endomicroscopy: ClinicalTrials.gov NCT03013894; https://clinicaltrials.gov /ct2/show/NCT03013894?term=NCT03013894&rank=1 (Archived by WebCite at http://www.webcitation.org/6wiPZ378I); and Dutch Central Committee on Research Involving Human Subjects NL55537.018.15; https://www.toetsingonline.nl /to/ccmo_search.nsf/fABRpop?readform&unids=6B72AE6EB0FC3C2FC125821F001B45C6 (Archived by WebCite at http://www.webcitation.org/6wwJQvqWh). Confocal Laser Endomicroscopy in the upper urinary tract: ClinicalTrials.gov NCT03013920; https://clinicaltrials.gov/ct2/show/NCT03013920? term=NCT03013920&rank=1 (Archived by WebCite at http://www.webcitation.org/6wiPkjyt0); and Dutch Central Committee on Research Involving Human Subjects NL52989.018.16; https://www.toetsingonline.nl/to/ccmo_search.nsf/fABRpop?readform&unids=D27C9C3E5755CFECC12581690016779F (Archived by WebCite at http://www.webcitation.org/6wvy8R44C).
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Affiliation(s)
- Esmee Iml Liem
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Jan Erik Freund
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Joyce Baard
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - D Martijn de Bruin
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.,Department of Biomedical Engineering & Physics, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - M Pilar Laguna Pes
- Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - C Dilara Savci-Heijink
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Ton G van Leeuwen
- Department of Biomedical Engineering & Physics, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Theo M de Reijke
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
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31
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Zhang ML, Rosenthal DL, VandenBussche CJ. Upper urinary tract washings outperform voided urine specimens to detect upper tract high-grade urothelial carcinoma. Diagn Cytopathol 2017; 45:700-704. [DOI: 10.1002/dc.23746] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/19/2017] [Accepted: 05/08/2017] [Indexed: 11/05/2022]
Affiliation(s)
- M. Lisa Zhang
- Department of Pathology; The Johns Hopkins University School of Medicine; Baltimore Maryland
- Department of Pathology; Massachusetts General Hospital; Boston Massachusetts
| | - Dorothy L. Rosenthal
- Department of Pathology; The Johns Hopkins University School of Medicine; Baltimore Maryland
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32
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Malm C, Grahn A, Jaremko G, Tribukait B, Brehmer M. Diagnostic accuracy of upper tract urothelial carcinoma: how samples are collected matters. Scand J Urol 2017; 51:137-145. [DOI: 10.1080/21681805.2017.1295102] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Camilla Malm
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Alexandra Grahn
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Georg Jaremko
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Bernhard Tribukait
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Marianne Brehmer
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
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33
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Mandalapu RS, Remzi M, de Reijke TM, Margulis V, Palou J, Kapoor A, Yossepowitch O, Coleman J, Traxer O, Anderson JK, Catto J, de la Rosette J, O'Brien T, Zlotta A, Matin SF. Update of the ICUD-SIU consultation on upper tract urothelial carcinoma 2016: treatment of low-risk upper tract urothelial carcinoma. World J Urol 2017; 35:355-365. [PMID: 27233780 PMCID: PMC5554604 DOI: 10.1007/s00345-016-1859-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 05/17/2016] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION The conservative management of upper tract urothelial carcinoma (UTUC) has historically been offered to patients with imperative indications. The recent International Consultation on Urologic Diseases (ICUD) publication on UTUC stratified treatment allocations based on high- and low-risk groups. This report updates the conservative management of the low-risk group. METHODS The ICUD for low-risk UTUC working group performed a thorough review of the literature with an assessment of the level of evidence and grade of recommendation for a variety of published studies in this disease space. We update these publications and provide a summary of that original report. RESULTS There are no prospective randomized controlled studies to support surgical management guidelines. A risk-stratified approach based on clinical, endoscopic, and biopsy assessment allows selection of patients who could benefit from kidney-preserving procedures with oncological outcomes potentially similar to radical nephroureterectomy with bladder cuff excision, with the added benefit of renal function preservation. These treatments are aided by the development of high-definition flexible digital URS, multi-biopsies with the aid of access sheaths and other tools, and promising developments in the use of adjuvant topical therapy. CONCLUSIONS Recent developments in imaging, minimally invasive techniques, multimodality approaches, and adjuvant topical regimens and bladder cancer prevention raise the hope for improved risk stratification and may greatly improve the endoscopic treatment for low-risk UTUC.
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Affiliation(s)
| | | | | | - Vitaly Margulis
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - J Palou
- Fundacio Puigvert, Barcelona, Spain
| | - A Kapoor
- McMaster University, Hamilton, ON, Canada
| | | | - Jonathan Coleman
- Department of Urology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Olivier Traxer
- Hôpital Tenon, Université Pierre et Marie Curie Paris 6, Paris, France
| | - J Kyle Anderson
- University of Minnesota Medical Center, Minneapolis, MN, USA
| | - James Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | | | | | | | - Surena F Matin
- Department of Urology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1373, Houston, TX, 77030, USA.
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Soria F, Shariat SF, Lerner SP, Fritsche HM, Rink M, Kassouf W, Spiess PE, Lotan Y, Ye D, Fernández MI, Kikuchi E, Chade DC, Babjuk M, Grollman AP, Thalmann GN. Epidemiology, diagnosis, preoperative evaluation and prognostic assessment of upper-tract urothelial carcinoma (UTUC). World J Urol 2017; 35:379-387. [PMID: 27604375 DOI: 10.1007/s00345-016-1928-x] [Citation(s) in RCA: 233] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 08/27/2016] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Upper-tract urothelial carcinoma (UTUC) is a relatively uncommon disease with limited available evidence on specific topics. The purpose of this article was to review the previous literature to summarize the current knowledge about UTUC epidemiology, diagnosis, preoperative evaluation and prognostic assessment. METHODS Using MEDLINE, a non-systematic review was performed including articles between January 2000 and February 2016. English language original articles, reviews and editorials were selected based on their clinical relevance. RESULTS UTUC accounts for 5-10 % of all urothelial cancers, with an increasing incidence. UTUC and bladder cancer share some common risk factors, even if they are two different entities regarding practical, biological and clinical characteristics. Aristolochic acid plays an important role in UTUC pathogenesis in certain regions. It is further estimated that approximately 10 % of UTUC are part of the hereditary non-polyposis colorectal cancer spectrum disease. UTUC diagnosis remains mainly based on imaging and endoscopy, but development of new technologies is rapidly changing the diagnosis algorithm. To help the decision-making process regarding surgical treatment, extent of lymphadenectomy and selection of neoadjuvant systemic therapies, predictive tools based on preoperative patient and tumor characteristics have been developed. CONCLUSIONS Awareness regarding epidemiology, diagnosis, preoperative evaluation and prognostic assessment changes is essential to correctly diagnose and manage UTUC patients, thereby potentially improving their outcomes.
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Affiliation(s)
- Francesco Soria
- Department of Urology, Medical University of Vienna, Vienna, Austria
- Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, Turin, Italy
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria
- Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Urology, Weill Cornell Medical College, New York, NY, USA
| | - Seth P Lerner
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
| | - Hans-Martin Fritsche
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
| | - Michael Rink
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wassim Kassouf
- Department of Surgery (Urology), McGill University, Montreal, QC, Canada
| | - Philippe E Spiess
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Dingwei Ye
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China
| | | | - Eiji Kikuchi
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Daher C Chade
- Urology Department, University of Sao Paulo Medical School and Institute of Cancer, São Paulo, Brazil
| | - Marko Babjuk
- Department of Urology, Faculty Hospital Motol, Second Faculty of Medicine, Charles University in Praha, Prague, Czech Republic
| | - Arthur P Grollman
- Department of Pharmacological Sciences and Department of Medicine, Stony Brook University, Stony Brook, NY, USA
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Abstract
Upper tract urothelial carcinoma (UTUC) is a rare condition and recommendations based on a high level of evidence for diagnosis, treatment and follow-up monitoring are lacking. Current decision-making is often based on evidence from trials investigating urothelial carcinoma of the lower tract. Radical nephroureterectomy has been the standard of care for UTUC but kidney-sparing treatment using endoscopic approaches has been established for a select patient group with low-grade and low-stage disease. Optimal treatment choice requires correct tumour characterization. According to available recommendations, diagnostic work-up of UTUC includes evaluation by CT urography or MRI urography, cystoscopy and urine cytology. Ureterorenoscopy and lesion biopsy are grade C recommendations in patients with suspected UTUC. When kidney-sparing treatment is planned, ureterorenoscopy and biopsy should be considered and are the procedures of choice in most cases. These diagnostics have limitations and their accuracy varies in defining tumour characteristics and predicting grade and stage. Urinary tests have higher sensitivity than cytology for detection of lower tract urothelial carcinoma but evidence of their benefit in UTUCs is lacking. New optical and image enhancement techniques are being developed to facilitate real-time diagnostics with increased accuracy. A new diagnostic algorithm for patients with suspected UTUC that integrates the diagnosis, treatment and clinical risk stratification is required.
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Khene ZE, Mathieu R, Kammerer-Jacquet SF, Seisen T, Roupret M, Shariat SF, Peyronnet B, Bensalah K. Risk stratification for kidney sparing procedure in upper tract urothelial carcinoma. Transl Androl Urol 2016; 5:711-719. [PMID: 27785428 PMCID: PMC5071190 DOI: 10.21037/tau.2016.09.05] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Risk stratification for kidney sparing procedures (KSP) to treat upper tract urothelial carcinoma (UTUC) is a major issue. A non-systematic Medline/PubMed literature search was performed using the terms “upper tract urothelial carcinoma” with different combinations of keywords to review the current knowledge on this topic. Original articles, reviews and editorials in English language were selected based on their clinical relevance. Available techniques for KSP include segmental ureterectomy and endoscopic resection through a percutaneous or flexible ureteroscopic access. These approaches were traditionally restricted to patients with imperative indications. Current recommendations suggest that selected patients with normal contralateral kidney should also be candidates for such treatments. Modern imaging and endoscopy have improved to accurately stage and grade the tumor while various prognostic clinical factors and biomarkers have been proposed to identify tumor with aggressive features and worse outcomes. Several predictive models using different combinations of such baseline characteristics may help clinicians in clinical decision making. However, risk-adapted based approach that has been proposed in recent guidelines to identify patients who are more likely to benefit from KSP only relies on few clinical and pathological factors. Despite growing understanding of the disease, treatment of UTUC remains challenging. Further efforts and collaborative multicenter studies are mandatory to improve risk stratification to decide and promote optimal KSP in UTUC. These efforts should focus on the integration of promising biomarkers and predictive tools in clinical decision making.
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Affiliation(s)
| | - Romain Mathieu
- Department of Urology, Rennes University Hospital, Rennes, France
| | - Solène-Florence Kammerer-Jacquet
- Department of Urology, Rennes University Hospital, Rennes, France;; Department of Pathology, Rennes University Hospital, Rennes, France
| | - Thomas Seisen
- Academic Department of Urology, Pitié-Salpêtrière University Hospital, Paris, France; ; GRC 5, ONCOTYPE-Uro, University Institute of Oncology, UMPC University Paris 6, Paris, France
| | - Morgan Roupret
- Academic Department of Urology, Pitié-Salpêtrière University Hospital, Paris, France; ; GRC 5, ONCOTYPE-Uro, University Institute of Oncology, UMPC University Paris 6, Paris, France
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria; ; Department of Urology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA; ; Department of Urology, Weill Cornell Medical College, New York, NY, USA; ; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
| | - Benoit Peyronnet
- Department of Urology, Rennes University Hospital, Rennes, France
| | - Karim Bensalah
- Department of Urology, Rennes University Hospital, Rennes, France
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Potretzke AM, Knight BA, Vetter JM, Anderson BG, Hardi AC, Bhayani SB, Figenshau RS. Diagnostic Utility of Selective Upper Tract Urinary Cytology: A Systematic Review and Meta-analysis of the Literature. Urology 2016; 96:35-43. [PMID: 27151340 DOI: 10.1016/j.urology.2016.04.030] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 04/18/2016] [Accepted: 04/26/2016] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Aaron M Potretzke
- Division of Urology, Washington University School of Medicine, Saint Louis, MO.
| | - B Alexander Knight
- Division of Urology, Washington University School of Medicine, Saint Louis, MO
| | - Joel M Vetter
- Division of Urology, Washington University School of Medicine, Saint Louis, MO
| | - Barrett G Anderson
- Division of Urology, Washington University School of Medicine, Saint Louis, MO
| | - Angela C Hardi
- Division of Urology, Washington University School of Medicine, Saint Louis, MO
| | - Sam B Bhayani
- Division of Urology, Washington University School of Medicine, Saint Louis, MO
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Investigating upper urinary tract urothelial carcinomas: a single-centre 10-year experience. World J Urol 2016; 35:131-138. [PMID: 27129575 PMCID: PMC5233745 DOI: 10.1007/s00345-016-1820-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 03/23/2016] [Indexed: 10/29/2022] Open
Abstract
OBJECTIVES Evidence of the accuracy of predictive tests in confirming the presence and grade of upper urinary tract urothelial carcinomas (UUTUC) is limited. We present the largest series evaluating the diagnostic value of pre- and intra-operative parameters in the detection of UUTUC. MATERIALS AND METHODS We retrospectively analysed records of patients who underwent diagnostic ureteroscopy between 2005 and 2014 for suspected UUTUC. Pre-operative workup included voided urine cytology and CT imaging. Intra-operative assessments involved ureteroscopy to directly visualise suspicious lesions, and where possible selective cytology and biopsy. Primary outcomes were the visualisation of UUTUC and histopathological confirmation of tumour. RESULTS Hundred out of 160 (63 %) patients presenting with suspected upper tract malignancy had UUTUC. Voided and selective urine cytology and CT individually predicted UUTUC with a sensitivity/specificity of 63/67, 76/73, and 95/26 %, respectively. Forty out of 48 (83 %) patients who had abnormal CT and abnormal voided urine cytology had UUTUC, while 100 % of those with normal CT and normal voided cytology (investigated for ongoing symptoms) were normal. Comparing endoscopic biopsy to nephroureterectomy specimen grade, 19 (46 %), 18 (44 %), and 4 (10 %) were identical, upgraded, and downgraded, respectively. CONCLUSION Pre-operative investigations can predict UUTUCs. When these investigations were normal, the risk of UUTUC is negligible. In selective patients with abnormal investigations, ureteroscopy should be performed to confirm and predict the grade of UUTUC, in order to guide future management. Selective cytology is unlikely to significantly contribute to the diagnostic workup of UUTUC.
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Glass R, Cocker R, Rosen L, Coutsouvelis C, Chau K, Slim F, Brenkert R, Sheikh-Fayyaz S, Farmer P, Das K. The impact of subdividing the “atypical” category for urinary cytology on patient management. Diagn Cytopathol 2016; 44:477-82. [DOI: 10.1002/dc.23468] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 12/10/2015] [Accepted: 02/22/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Ryan Glass
- Department of Pathology; Staten Island University Hospital; New York New York
| | - Rubina Cocker
- Department of Pathology; Hofstra North Shore LIJ School of Medicine; New York New York
| | - Lisa Rosen
- North Shore-LIJ Health System; Feinstein Institute for Medical Research; New York New York
| | | | - Karen Chau
- Department of Pathology; Hofstra North Shore LIJ School of Medicine; New York New York
| | - Farah Slim
- Department of Pathology; Hofstra North Shore LIJ School of Medicine; New York New York
| | - Ryan Brenkert
- Department of Pathology; Hofstra North Shore LIJ School of Medicine; New York New York
| | - Silvat Sheikh-Fayyaz
- Department of Pathology; Hofstra North Shore LIJ School of Medicine; New York New York
| | - Peter Farmer
- Department of Pathology; Hofstra North Shore LIJ School of Medicine; New York New York
| | - Kasturi Das
- Department of Pathology; Hofstra North Shore LIJ School of Medicine; New York New York
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Malta F, Lenos M, Leotsakos I, Katafigiotis I, Gakiopoulou H, Constantinides C, Mikou P. Audit of cytology of upper urinary tract. Cytopathology 2016; 27:369-73. [PMID: 26916255 DOI: 10.1111/cyt.12310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Cytology is an essential tool for the investigation of urinary tract malignancy. In this audit, we aimed to assess our laboratory performance in the diagnosis of upper urinary tract malignancy and to use the information provided to improve our service. METHODS We retrieved cytology reports of upper urinary tract specimens from two periods, re-evaluated the cases, compared the reports with histology data and estimated the sensitivity, specificity and positive predictive value (PPV). In the time interval between the two periods, we adopted new terminology, established better communication with clinicians and gained experience in the field. Finally, the data from the two periods were compared. RESULTS In phase A, we estimated a sensitivity of 73%, specificity of 86% and PPV of 84.6%. As a result of the cytological re-evaluation, correlation with histology and clinical follow-up, plus communication with the clinicians during the audit, we established new terminology and a new request form. A three tiered grading system of atypia (mild, moderate and severe) was replaced by a two tiered grading system. The first category "atypia probably benign" corresponded to "mild atypia" while the second category "atypia, not otherwise specified" corresponded to "moderate atypia". The cases diagnosed as "severe atypia" were reclassified as "suspicious for malignancy". In phase B, the sensitivity, specificity and PPV were 75%, 89% and 90%, respectively. CONCLUSIONS Our laboratory performance is in concordance with reported data and has been improved through this study. The audit process is extremely valuable for the identification of problems, for taking action and, finally, for the improvement of the clinical cytology service in the field of upper urinary tract malignancy.
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Affiliation(s)
- F Malta
- Cytopathology Department, Laiko Hospital, Athens, Greece
| | - M Lenos
- Cytopathology Department, Laiko Hospital, Athens, Greece
| | - I Leotsakos
- 1st University Urology Clinic, Athens Medical School, Laiko Hospital, Athens, Greece
| | - I Katafigiotis
- 1st University Urology Clinic, Athens Medical School, Laiko Hospital, Athens, Greece
| | - H Gakiopoulou
- 1st Histopathology Department, Athens Medical School, Laiko Hospital, Athens, Greece
| | - C Constantinides
- 1st University Urology Clinic, Athens Medical School, Laiko Hospital, Athens, Greece
| | - P Mikou
- Cytopathology Department, Laiko Hospital, Athens, Greece.
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The Forgotten Complication of Recurrent Nephrolithiasis: "Squamous Cell Carcinoma of the Renal Pelvis"-A Case and Review of the Literature. Case Rep Urol 2015; 2015:298317. [PMID: 26579326 PMCID: PMC4633549 DOI: 10.1155/2015/298317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/09/2015] [Accepted: 10/13/2015] [Indexed: 11/18/2022] Open
Abstract
Squamous cell carcinoma (SCC) of the renal pelvis is an aggressive tumor with insidious onset of unspecific symptoms and advanced stages at diagnosis. It is a rare entity, accounting for 0.5–8% of renal tumors. In this paper, we describe the case of a patient with a history of recurrent nephrolithiasis that presented with an aggressive form of SCC of the renal pelvis with rapid relapse after resection.
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Chen L, He H, Zarka MA, Zhou M, Magi-Galluzzi C. Upper tract urinary cytology to detect upper tract urothelial carcinoma: Using the Johns Hopkins Hospital template and evaluation of its feasibility. Cytojournal 2015; 12:17. [PMID: 26288652 PMCID: PMC4527050 DOI: 10.4103/1742-6413.161608] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 06/10/2015] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Primary upper urinary tract (UT) urothelial carcinoma (UC) is rare. UT washing cytology is often used during UT surveillance. The Johns Hopkins Hospital template (JHHT) is primarily designed to use on lower tract urine cytology and the data on applying JHHT on UT cytology is limited. We herein study the value of UT cytology in detecting UTUC using JHHT in a cohort. MATERIALS AND METHODS One hundred UT cytologic specimens were retrieved from our database during a 10-year period (2001-2011). For each patient, the cytology specimen with the highest degree of abnormality was selected. Histologic sections of these cases were also studied. RESULTS Seventy-six cases of UT cytology had histologic follow-up by either serial (>2) endoscopic biopsies or nephroureterectomy or ureterectomy. Among them, the cytologic diagnosis of positive or suspicious for high-grade UC (HGUC) was made in 15 cases; suspicious for low-grade UC (LGUC) in 3 cases; atypical urothelial cells (AUCs) of undetermined significance in 19 cases; and negative in 39 cases. Of the 15 cases with diagnosis of positive for HGUC or AUC-HGUC (AUC-H), 10 had histologically confirmed HGUC, 1 had LGUC, and 4 had benign histology. All 3 cases of cytologically suspicious for LGUC had LGUC on concomitant histology. Among the 19 washings with AUCs with unknown significance, 7 were LGUC, 1 was HGUC, and 11 were benign on histology. Six of 39 cases with negative cytology had UC (3 low-grade and 3 high-grade) on histology. Combining positive and AUC-H for UC diagnoses, sensitivity, and specificity for detecting HGUC were 71.4% and 91.9%, while for LGUC were 21.4% and 100%, respectively. CONCLUSIONS UT washing cytology has high specificity for detecting UC, especially HGUC. Using JHHT on UT washing cytology is feasible, but the category of LGUC may need modification.
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Affiliation(s)
- Longwen Chen
- Address: Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, AZ, USA
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Huiying He
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Pathology, Peking University, Health Science Center, Beijing, China
| | - Matthew A. Zarka
- Address: Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Ming Zhou
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Pathology, New York University Langone Medical Center, New York, NY, USA
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43
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Lucca I, Leow JJ, Shariat SF, Chang SL. Diagnosis and Management of Upper Tract Urothelial Carcinoma. Hematol Oncol Clin North Am 2015; 29:271-88, ix. [DOI: 10.1016/j.hoc.2014.10.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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44
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Tai YS, Chiang IN, Huang CY, Tai HC, Pu YS. Effectiveness of different diagnostic tools for upper urinary tract urothelial carcinoma. UROLOGICAL SCIENCE 2015. [DOI: 10.1016/j.urols.2014.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Sverrisson EF, Kim T, Espiritu PN, Sexton WJ, Pow-Sang JM, Dhillon J, Spiess PE. The merits of cytology in the workup for upper tract urothelial carcinoma - a contemporary review of a perplexing issue. Int Braz J Urol 2015; 40:493-8. [PMID: 25251966 DOI: 10.1590/s1677-5538.ibju.2014.04.07] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 03/05/2014] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The importance of upper tract cytology for evaluating tumors is unclear. We correlated upper tract cytology with histologic findings in patients who underwent nephroureterectomy for upper tract urothelial carcinoma (UTUC) at a single tertiary care referral center. MATERIALS AND METHODS 137 patients underwent nephroureterectomy between 2004 and 2012. 18 patients were excluded (benign tumors, atrophic kidneys with the remaining 119 patients serving as our study population). Upper tract cytology from the renal pelvis and/or ureter were retrospectively reviewed and analyzed with final pathology data in the remaining patients with UTUC. RESULTS 57% (68/119) had preoperative upper tract cytology collected. 73% (50/68) patients had abnormal cytology (positive, suspicious) with a sensitivity of 74% (which increased to 90% if atypical included), specificity of 50% and a positive predictive value of 98%. High grade tumors were more common than expected (77% high grade vs. 20% low grade). Abnormal cytology did not predict T stage or tumor grade. Interestingly, positive upper tract cytology was found in all of the UTUC CIS specimen. CONCLUSIONS Upper tract cytology has been utilized to support the diagnosis of upper tract urothelial carcinoma. Our data demonstrates that abnormal cytology correlates well with the presence of disease but does not predict staging or grading in these respective patients.
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Affiliation(s)
- E F Sverrisson
- Genitourinary Oncology Program, Moffitt Cancer Center, Tampa, FL, USA
| | - T Kim
- Genitourinary Oncology Program, Moffitt Cancer Center, Tampa, FL, USA
| | - P N Espiritu
- Genitourinary Oncology Program, Moffitt Cancer Center, Tampa, FL, USA
| | - W J Sexton
- Genitourinary Oncology Program, Moffitt Cancer Center, Tampa, FL, USA
| | - J M Pow-Sang
- Genitourinary Oncology Program, Moffitt Cancer Center, Tampa, FL, USA
| | - J Dhillon
- Genitourinary Oncology Program, Moffitt Cancer Center, Tampa, FL, USA
| | - P E Spiess
- Genitourinary Oncology Program, Moffitt Cancer Center, Tampa, FL, USA
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Carcinoma in situ is significantly underdetected by prenephroureterectomy ureteroscopy in the management of upper tract urothelial cancers. BIOMED RESEARCH INTERNATIONAL 2015; 2015:547586. [PMID: 25654112 PMCID: PMC4310489 DOI: 10.1155/2015/547586] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Revised: 10/05/2014] [Accepted: 10/14/2014] [Indexed: 11/18/2022]
Abstract
Objective. Diagnostic reliability of prenephroureterectomy ureteroscopy (PNU) for the detection of upper tract carcinoma in situ (CIS) remains unproven in particular and underreported in general. Methods. Patients who underwent radical nephroureterectomy (RNU) in a large multicentre retrospective study for upper tract transitional cell carcinoma (UT-TCC) between January 2002 and December 2013 were identified from our hospitals databases. PNU appearances, stage, and grade of ureteroscopic biopsy were compared with final histology results of RNU to assess the diagnostic reliability of PNU for carcinoma in situ (CIS). Results. Three hundred patients underwent RNU for UT-TCC. 106 (106/300; 35.3%) of the cohort had PNU using white light with biopsies taken in most (92/106; 86.7%). Postnephroureterectomy histology of the cohort showed CIS in 65 (65/300; 21.6%) patients. Thirty nine of patients with CIS (39/65; 60%) had prenephroureterectomy ureteroscopy biopsies. Out of ten patients with CIS on ureteroscopic biopsies, six did not show CIS on final histopathology (6/10; 60%). Moreover, grading and staging on PNU biopsies of obvious tumours showed a significant nonconcordance with final histopathology of RNU specimen (P = 0.02). Overall survival was also shorter in patients with CIS compared with those without; this showed strong statistical significance (P = 0.004). Conclusions. There is a high incidence of CIS in upper tract with significant underdetection and discordance rate between the histopathology of biopsy samples obtained by white light PNU and resected specimen of radical nephroureterectomy. The presence of concomitant CIS and high stage disease in the upper tract TCC carried a poor prognosis following radical nephroureterectomy.
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Wang L, Pambuccian SE, Wojcik EM, Barkan GA. Diagnosis of upper tract urothelial carcinoma-a comparative study of urinary cytology and surgical biopsy. J Am Soc Cytopathol 2015; 4:3-9. [PMID: 31051670 DOI: 10.1016/j.jasc.2014.09.203] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 09/02/2014] [Accepted: 09/03/2014] [Indexed: 06/09/2023]
Abstract
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.
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Affiliation(s)
- Lu Wang
- Department of Pathology and Lab Medicine, Loyola University Medical Center, 2160 W. 1st Avenue, Maywood, Illinois
| | - Stefan E Pambuccian
- Department of Pathology and Lab Medicine, Loyola University Medical Center, 2160 W. 1st Avenue, Maywood, Illinois
| | - Eva M Wojcik
- Department of Pathology and Lab Medicine, Loyola University Medical Center, 2160 W. 1st Avenue, Maywood, Illinois
| | - Güliz A Barkan
- Department of Pathology and Lab Medicine, Loyola University Medical Center, 2160 W. 1st Avenue, Maywood, Illinois.
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Chau K, Rosen L, Coutsouvelis C, Fenelus M, Brenkert R, Klein M, Stone G, Raab S, Aziz M, Cocker R. Accuracy and risk of malignancy for diagnostic categories in urine cytology at a large tertiary institution. Cancer Cytopathol 2014; 123:10-8. [PMID: 25388289 DOI: 10.1002/cncy.21477] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 07/17/2014] [Accepted: 07/29/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND At a high-volume center, it became necessary to provide benchmarks for the accuracy and risk of malignancy per urine cytology diagnostic category. The additive sensitivity for the determination of the residual risk of disease was calculated with the goal of determining the performance of cytology and optimal triage, including the number of urine samples, before the detection of malignancy in surveillance patients. METHODS A 2-year laboratory information system-based search was conducted, and it yielded 587 subjects (695 biopsy and cytology pairs) with histological follow-up. The sensitivity and specificity of cytology for urothelial malignancy, the risk of malignancy per diagnostic category, the additive sensitivity, and the time for conversion from a negative initial cytology result to a positive cytology result were examined. RESULTS The overall average sensitivity and specificity of cytology were 48.9% and 83.0%, respectively. The additive sensitivity increased with each subsequent cytology and peaked with the third cytology. A median conversion time of 22.2 months from a negative initial cytology result to a positive cytology result and a decline in predictive positive cytology after the fourth cytology were noted. Subcategorization of the atypical category failed to show statistical significance in predicting outcomes of biopsy. Surveillance subjects, as compared to primary subjects, showed a higher sensitivity for the detection of high and low grade cancers. CONCLUSIONS The findings suggest that atypia favoring malignancy is being appropriately flagged. However, further definition of the atypical category is needed to increase specificity with a better qualitative or quantitative morphological algorithm. This study provides a risk of malignancy for each category for benchmarking and clinical triage. The data suggest that follow-up should include at least 4 consecutive urine specimens over a period of 22.2 months.
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Affiliation(s)
- Karen Chau
- Department of Cytopathology, North Shore-LIJ Health System, Lake Success, New York
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50
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Mazzucchelli R, Scarpelli M, Galosi A, Di Primio R, Lopez-Beltran A, Cheng L, Montironi R. Pathology of Upper Tract Urothelial Carcinoma with Emphasis on Staging. Int J Immunopathol Pharmacol 2014; 27:509-16. [DOI: 10.1177/039463201402700406] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The first two authors contributed equally to this work Classification of upper tract urothelial preneoplastic and neoplastic lesions mirrors that of the urinary bladder, with all lesions of the bladder urothelium being possible in the upper tract and vice versa. There are three major groups of non-invasive urothelial neoplasms: flat, papillary, and inverted. These three groups share a similar morphological spectrum of intraurothelial changes, ranging from hyperplasia to dysplasia to carcinoma in situ. However, they differ in terms of architectural growth pattern compared to the surrounding non-neoplastic mucosal surface. Infiltrating urothelial carcinoma is defined as a urothelial tumor that invades beyond the basement membrane. Unlike in non-invasive papillary urothelial neoplasms (pTa), the role of histologic grade in pT1 and higher stage tumors has been suggested to be of only relative importance. The vast majority of tumors of the upper urinary tract are urothelial carcinoma. More commonly seen, however, are foci of squamous differentiation and, less frequently, glandular differentiation. Pure urothelial carcinomas also display a wide range of variant morphologies, and recognition of these morphologies is important for diagnosis, classification, and prognosis.
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Affiliation(s)
- R. Mazzucchelli
- Section of Pathological Anatomy, Polytechnic University of the Marche Region, School of Medicine, United Hospitals, Ancona, Italy
| | - M. Scarpelli
- Section of Pathological Anatomy, Polytechnic University of the Marche Region, School of Medicine, United Hospitals, Ancona, Italy
| | - A.B. Galosi
- Division of Urology, “Murri” General Hospital, Fermo ASUR Marche, Fermo, Italy
| | - R. Di Primio
- Department of Clinical and Molecular Sciences, Polytechnic University of the Marche Region, School of Medicine, Ancona, Italy
| | - A. Lopez-Beltran
- Department of Surgery, Cordoba University Medical School, Cordoba, Spain
| | - L. Cheng
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - R. Montironi
- Section of Pathological Anatomy, Polytechnic University of the Marche Region, School of Medicine, United Hospitals, Ancona, Italy
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