Diagnostic value of voided urine and bladder barbotage cytology in detecting transitional cell carcinoma of the urinary tract

Contemporary management of upper tract urothelial cell carcinoma

Upper tract urothelial cell carcinoma (UTUCC), formerly known as transitional cell carcinoma of the upper urinary tract, is a rare oncologic disease in Western countries. Thus its disease process and its management are not as well defined as other urologic cancers. We are reviewing the current evidence based literature available to develop a plan for the treatment of UTUCC. A PubMed search was completed using the key words “upper tract urothelial cell carcinoma”, “epidemiology”, “risk factor”, “treatment” and “prognosis”. Six hundred fifty two articles were found. We narrowed our search to articles published between January 2004 and June 2016 for a more contemporary review of the topic. Four hundred seventy articles were then available for review. Further detailed search was performed for relevance on the topic and hundred one articles were selected for the review. Many risk factors have been found to be associated with the development of UTUCC, including tobacco use. Patients are often asymptomatic and may only present with microscopic or gross hematuria. Tumor grade and stage are pivotal in determining the treatment options for UTUCC. Advancements in endoscopic techniques have aided in the diagnosis, grading and treatment of this disease. Treatment options include topical therapy, with combinations of methotrexate, vinblastine, doxorubicin and cisplatin or gemcitibine or cisplatin, endoscopic resection, segmental ureterectomy and ureteral implantation, and nephroureterectomy, including bladder cuff. Treatment recommendations depend on tumor grade and stage, renal function, tumor location and the patient’s prognosis. There are currently no tissue or blood-based biomarkers available to accurately monitor the disease. Further studies of gene expression and biomarkers may hopefully improve the management of this disease. Although rare in many countries, UTUCC is becoming more prevalent due to exposure to carcinogenic herbal remedies and other identifiable risk factors. Numerous treatment modalities, both surgical and chemotherapeutic, have been utilized to treat both low and high grade UTUCC tumors. Additional clinical trials are necessary to further develop methods for screening, treatment, and surveillance to improve management.

Evidence-based adequacy criteria for urinary bladder barbotage cytology

INTRODUCTION

Adequacy criteria are well established in some areas of cytopathology to prevent false negative diagnoses. To date, no such criteria have been proposed and validated for urinary tract specimens. Our aim was to determine a cellularity cutoff point that significantly affects the sensitivity of detecting high-grade or in situ urothelial carcinoma (HGUC or UCIS) in bladder barbotage/washing specimens.

MATERIALS AND METHODS

Bladder barbotage specimens collected in liquid-based media were selected. Specimens diagnosed as "positive for HGUC" (with histologic confirmation) composed the study group, with negative cases as control specimens. Samples were serially diluted and ThinPrep slides of decreasing cellularity were made and reviewed for diagnosis and cellularity. In a retrospective validation study, we identified cases with a "negative for malignancy" bladder barbotage/washing and a surgical pathology diagnosis of UCIS or HGUC (ie, false negative cytology). Cellularity was assessed.

RESULTS

A distinct difference in sensitivity was noted at a cutoff point of 2644 (20 per 10 high-power fields) urothelial cells. Sensitivities increased for atypical or higher (68.3% versus 100%) and HGUC (43.3% versus 88.0%) after application of this cutoff point with high statistical significance (P = 0.001 and 0.0001, respectively). For the retrospective review, cases below the cutoff point were reclassified as unsatisfactory, and sensitivity rose from 76.3% to 84.8% (P = 0.0027).

CONCLUSIONS

Our results indicate that, in the absence of atypical or malignant cells, an adequate bladder barbotage specimen should have a minimum of 2644 (20 per 10 high-power fields) well-visualized, well-preserved urothelial cells to increase the positive predictive value of this test.

A Comparison Between ThinPrep Monolayer and Cytospin Cytology for the Detection of Bladder Cancer

Purpose

The sensitivity of urine cytology is higher for carcinoma in situ and poorly differentiated tumors in bladder cancer, while being fairly low for low-grade or well-differentiated tumors. Development of a sensitive diagnostic test to detect bladder carcinoma would significantly facilitate patient management and allow earlier treatment of this disease. This study compared ThinPrep urine cytology (Cytyc Co.) and conventional Cytospin urine cytology (Shandon Scientific Ltd.) in the diagnosis of bladder cancer.

Materials and Methods

From January 2002 to December 2010, ThinPrep cytology and conventional urine Cytospin cytologic examination of bladder washings were performed in 3,085 subjects suspected of having bladder cancer and in 379 patients with follow-up after transurethral resection of bladder tumor (TUR-BT). The sensitivity and specificity of the urine ThinPrep test was compared with that of conventional Cytospin cytology according to tumor number, size, pathological stage, grade, and recurrence.

Results

Of 3,085 subjects, bladder cancer was confirmed by TUR-BT in 379 subjects. The overall sensitivity of ThinPrep and Cytospin cytology was 60.9% and 59.9% in patients suspected of having bladder cancer, respectively. The overall specificity of ThinPrep and Cytospin cytology was 94.8% and 95.3% in patients suspected of having bladder cancer, respectively. The sensitivity of ThinPrep and Cytospin cytology was increased with increasing number, size, pathological stage, and grade, but there was no significant difference between the two tests.

Conclusions

These results suggest that ThinPrep cytology has no advantage in the diagnosis of bladder cancer of a low grade or low stage.

Utility of urine cytology in the workup of asymptomatic microscopic hematuria in low-risk patients

OBJECTIVES

To evaluate performance and cost-effectiveness of voided cytology in patients with pure asymptomatic microscopic hematuria (AMH). Although voided cytology has been validated for use in patients with a history of urothelial carcinoma (UC), its use in low-risk patients with AMH is controversial.

METHODS

A total of 200 consecutive low-risk patients (median age, 64 years) with AMH were referred to the urology clinic between 2005 and 2007. All underwent cystoscopy, upper tract imaging, and voided urinary cytology. Results of voided cytology were classified as positive, atypical, or negative. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and costs were calculated.

RESULTS

None had positive cytology, 23 (11.5%) had atypical cytology, and 177 (88.5%) had negative urinary cytology. Of 200 patients, 8 (4%) were found to have low-grade UC of bladder via cystoscopy; the cytology was negative in 4 patients and atypical in 4. Of 8, 4 were Ta and 4 were pT1 tumors. There was no upper urinary tract or renal malignancy identified. If atypical cytology was considered as positive, the sensitivity, specificity, PPV, and NPV of cytology were 50%, 90%, 17%, and 98%, respectively. If atypical cytology was considered as negative, the sensitivity, specificity, PPV, and NPV of cytology were 0%, 100%, 0%, and 96%, respectively. Cost of performing urinary cytology was estimated at $262.50 per patient.

CONCLUSIONS

Although this study supports evaluating patients with AMH because a significant percentage of patients will have UC, voided urine cytology added a significant cost without any diagnostic benefit in the work-up of low-risk patients with AMH.

Urine cytology and urine-based markers for bladder urothelial carcinoma detection and monitoring: developments and future prospects

Bladder cancer is currently diagnosed using cystoscopy and cytology in patients with suspicious signs and symptoms. These tests are also used to monitor patients with a history of bladder cancer. The recurrence rate for bladder cancer is high, thus necessitating long-term follow-up. Urine cytology has a high sensitivity and specificity for the detection of high-grade urothelial carcinoma, but lacks the sensitivity to detect low-grade tumors. Recently, multiple noninvasive urine-based bladder cancer tests have been developed. Many markers (BTA stat®, BTA TRAK®, ImmunoCyt™, NMP22® and UroVysion™) have already been approved by the US FDA for bladder cancer surveillance, while other markers are still undergoing development, preclinical and clinical investigation. An ideal bladder cancer test would be noninvasive, highly sensitive and specific, inexpensive, easy to perform and yield highly reproducible results. Many of the tests reviewed herein meet some, but not all, of these criteria.

Current bladder cancer tests: unnecessary or beneficial?

Bladder cancer is currently diagnosed using cystoscopy and cytology in patients with suspicious signs and symptoms. These same tests are used to monitor patients with a history of bladder cancer for recurrence. The recurrence rate for bladder cancer is high, thus necessitating long-term follow-up. Urine cytology requires an experienced cytopathologist and is costly. It has high specificity, but low sensitivity for low-grade bladder tumors. Recently many non-invasive bladder cancer tests, utilizing markers found in the urine, have been developed. The FDA has approved several of these for the use is bladder cancer diagnosis, and many others are undergoing development and investigation. An ideal bladder cancer test would be non-invasive, highly sensitive and specific, inexpensive, easy to perform, and yield highly reproducible results. Many of the tests reviewed meet some, but not all, of these criteria.