Conventional liquid-based techniques versus Cytyc Thinprep processing of urinary samples: a qualitative approach

Comparison of conventional and liquid-based cytology using The Paris System for Reporting Urinary Cytology

BACKGROUND

This retrospective study was conducted to compare the conventional cytospin method and ThinPrep liquid-based urinary cytology in diagnosing bladder cancer using The Paris System (TPS) of classification.

METHODS

We retrieved files for 2020, at the Cytopathology Department of Laiko Hospital, of urinary cases diagnosed according to TPS. Cytospin and ThinPrep slides were separately reviewed and new diagnoses were rendered, then compared with the original diagnosis and histology when available. Risk of high-grade malignancy (ROHM) for each TPS category was assessed, along with accuracy parameters of each method and their combination.

RESULTS

The study material comprised 100 cases of void urinary cytology classified as 20 high-grade urothelial carcinoma (HGUC = TPS5) cases, 20 of suspicion for HGUC (SHGUC = TPS4), 25 of atypical urothelial cells (AUC = TPS3), and 35 of negative for HGUC (NHGUC = TPS2). A single inadequate (TPS1) case and 4 of low-grade urothelial neoplasm (TPS6) were excluded as small in number. The ROHM was 95% for HGUC, 55% for SHGUC, 28% for AUC and 5.7% for NHGUC. Agreement with the original diagnosis was 86% for cytospin and 82% for ThinPrep. No significant differences were observed among the two techniques or their combination regarding sensitivity and specificity, with a mild advantage for cytospin. Interobserver reproducibility and repeatability were high.

CONCLUSION

No significant differences were found concerning sensitivity and specificity between cytospin and ThinPrep when applying TPS criteria. TPS is a reliable classification scheme for either conventional/cytospin or liquid-based cytology, or their combination.

Fluorescence Emitted by Papanicolaou-Stained Urothelial Cells Improves Sensitivity of Urinary Conventional Cytology for Detection of Urothelial Tumors

Background

Urinary conventional cytology (UCCy) is easy to perform, but its low sensitivity, especially for low-grade urothelial neoplasms (LGUNs), limits its indications in the management of patients at risk of bladder cancer. The authors aim at obtaining a complementary test that would effectively increase the sensitivity of UCCy on voided urines by analyzing fluorescence of Papanicolaou-stained urothelial cells with no change of method in slide preparation.

Methods

In this retrospective study of 155 patients, 91 Papanicolaou-stained voided urines were considered satisfactory under fluorescence microscopy (FMi). The results of FMi were compared with UCCy (using transmission microscopy) and correlated to cystoscopy, histology and follow-up data.

Results

The results are given for all patients and for two groups of them according to the patients’ main complaints (group 1: 33 patients followed up for a previously treated bladder tumor; group 2: 58 patients with persistent urinary symptoms). Overall negative predictive value (NPV) and sensitivity of FMi were 100% vs. 73.7% and 64.3% respectively for UCCy (P = 0.0001). Sensitivity of FMi for LGUN was unexpectedly high with a value of 100% vs. 46.2% for UCCy (P = 0.0002). FMi was significantly superior to UCCy for detecting urothelial tumors in every group of patients and would allow a better characterization of atypical urothelial cells (AUCs) defined by the Paris System for Reporting Urine Cytology (TPS).

Conclusions

Because of its sensitivity and NPV of 100%, FMi could complement UCCy to screen voided urines allowing a better detection of primary urothelial tumors or early recurrences of previously treated urothelial carcinoma. Moreover, this “dual screening” would allow completing efficiently cystoscopy to detect flat dysplasia, carcinoma in situ (CIS) and extra bladder carcinoma.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

SurePath® LBC improves the diagnostic accuracy of intrahepatic and hilar cholangiocarcinoma

INTRODUCTION

The current study aimed to compare cytology using SurePath^® (SP)-LBC and biliary tissue histology (BTH) for the diagnosis of biliary disease.

METHODS

Between January 2014 and December 2016, 57 patients underwent endoscopic retrograde cholangiopancreatography for the diagnosis of biliary disease. Biliary cytological samples were processed using SP-LBC and subsequently BTH was performed. A final diagnosis was confirmed by surgery (23 malignant cases) and clinical follow-up (34 benign and malignant cases): 18 extrahepatic cholangiocarcinoma; 17 intrahepatic/hilar cholangiocarcinoma (intra/H-CC); eight other malignant disease; and 14 benign biliary disease. The diagnoses made using SP-LBC and BTH were classified into four categories: (1) benign; (2) indeterminate; (3) suspicious for malignancy/malignant; and (4) inadequate. In addition, diagnostic accuracy was compared between SP-LBC and BTH.

RESULTS

Although 23% (13/57) of BTH samples were classified as inadequate, all SP-LBC cases were classified as adequate. Among 43 malignant cases, 11 normal, four indeterminate and 28 suspicious for malignancy/malignant were found using SP-LBC (26%, 9% and 65%, respectively), in contrast to 10 inadequate, nine normal, 10 indeterminate and 14 suspicious for malignancy/malignant observed using BTH (23%, 21%, 23%, and 33%, respectively). The identification of malignant cells was strikingly different between SP-LBC and BTH. Furthermore, limited to intra/H-CC, accuracy was significantly higher using SP-LBC than using BTH (P < .001).

CONCLUSIONS

SP-LBC of the biliary tract is a useful and reliable method for diagnosing biliary malignant disease and has an advantage over BTH for detecting malignant cells and accurately diagnosing intra/H-CC.

A Modified Direct-Smear Processing Technique Employing Two-Step Centrifugation/Fixation Is Useful for Detecting High-Grade Urothelial Carcinoma

OBJECTIVE

To demonstrate the usefulness of a direct-smear processing technique employing two-step centrifugation/fixation processing (TSCFP) in the cytoscreening of high-grade urothelial carcinoma (HGUC).

STUDY DESIGN

Using the T24 HGUC cell line, we compared the cell yield and the morphological preservation of preparations concurrently processed by direct-smear, SurePath, ThinPrep, and TSCFP techniques. A total of 287 urine cytology cases subjected to TSCFP over a period of 6 years were reviewed and reclassified according to the Paris System for Reporting Urinary Cytology (PSRUC) and correlated with histology results.

RESULTS

TSCFP of T24 cells demonstrated good cell yield with a recovery rate of about 70%. Diagnostic features of HGUC, such as a high nuclear/cytoplasmic ratio and irregular/hyperchromatic chromatin, were better discovered in TSCFP smears than in smears prepared with the other methods. Cytological evaluation of 287 voided urine specimens revealed that the rate of unsatisfactory preparations was quite low (0.30%) and the overall sensitivity, specificity, and positive and negative predictive values for urothelial carcinoma were 0.719, 0.923, 0.973, and 0.462, respectively.

CONCLUSION

TSCFP was able to provide adequate preparations for detecting HGUC in urine cytology and could be considered as a promising processing method according to the principal purpose of PSRUC.

The combined application of urinary liquid-based cytology with fluorescence in situ hybridization and p16/Ki-67 dual immunostaining is valuable for improving the early diagnosis of upper tract urothelial carcinomas

OBJECTIVES

To evaluate the diagnostic values of urine liquid-based cytology (LBC), fluorescence in situ hybridization (FISH), and p16/Ki-67 dual immunostaining in the detection of upper tract urothelial carcinomas (UTUCs).

METHODS

Sixty-one patients with UTUCs were retrospectively analyzed. All patients were diagnosed both by urine cytology and by FISH, and histologically confirmed as UTUCs. Thirty-two patients had been stained with p16/Ki-67 dual labeling.

RESULTS

The sensitivities for low-grade UTUCs (LGUTUCs) and high-grade UTUCs (HGUTUCs) were 33.3% and 67.4% by LBC, 60% and 69.6% by FISH, and 12.5% and 66.7% by p16/Ki-67 dual labeling, respectively.

CONCLUSIONS

Our results indicated that LBC was more suitable to identify HGUTUCs, FISH was highly valuable for predicting LGUTUCs, and p16/Ki-67 dual labeling was useful for distinguishing HGUTUCs from LGUTUCs. The combined application of these methods may improve the sensitivity or accuracy in the detection or diagnosis of UTUCs.

Ultrasensitive electrochemical immunosensor based on dual signal amplification process for p16(INK4a) cervical cancer detection in clinical samples

The p16(INK4a) (p16) is a cyclin-dependent kinase inhibitor, which has been evaluated in several studies as a diagnostic marker of cervical cancer. Immunostaining using p16 specific antibody has confirmed an over-expression of p16 protein in cervical cancer cells and its association with disease progression. This article reports an ultrasensitive electrochemical immunosensor for specific detection of p16 and demonstrates its performance for detection of solubilized p16 protein in cell lysates obtained from patients. Sandwich-based immunoreaction couple with double signal amplification strategy based on catalytic enlargement of particle tag was used for high sensitivity and specificity. The conditions were optimized to create an immunoassay protocol. Disposable screen-printed electrode modified with capture antibodies (Ab1) was selected for further implementation towards point-of-care diagnostics. Small gold nanoparticles (15 nm diameter) conjugated with detection antibodies (Ab2) were found to better serve as a detection label due to limited interference with antigen-antibody interaction. Double signal enhancement was performed by sequential depositions of gold and silver layers. This gave the sensitivity of 1.78 μA mL(ng GST-p16)(-1) cm(-2) and detection limit of 1.3 ng mL(-1) for GST-p16 protein which is equivalent to 0.49 ng mL(-1) for p16 protein and 28 cells for HeLa cervical cancer cells. In addition to purified protein, the proposed immunosensor effectively detected elevated p16 level in cervical swab samples obtained from 10 patients with positive result from standard Pap smear test, indicating that an electrochemical immunosensors hold an excellent promise for detection of cervical cancer in clinical setting.

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.

Overview of nongynecological samples prepared with liquid-based cytology medium

OBJECTIVE

Liquid-based cytology of nongynecological specimens is commonly used in cytology laboratories throughout the world and various processing methods, such as ThinPrep and SurePath, have been reported. The cytological features and performance of liquid-based cytology for various cytology specimens, including body cavity fluids, urine, brushing specimens and fine-needle aspiration of various lesions, were reviewed and compared with the experience of our laboratory and the literature published in PubMed.

STUDY DESIGN

The parameters for the evaluation of liquid-based cytology and conventional smears were described in the various types of specimens. Criteria for the interpretation of nongynecological liquid-based cytology were highlighted to show differences in cell morphology, background and artifacts.

RESULTS

The interpretation requires familiarity with the appearance of liquid-based cytology in the various types of preparations to avoid misdiagnosis.

CONCLUSIONS

Cell blocks can be prepared with specimens preserved in a liquid-based cytology medium and immunocytochemical stains and molecular testing can be successfully performed. These are important adjuncts in order to reach a definitive diagnosis.

A novel precision-engineered microfiltration device for capture and characterisation of bladder cancer cells in urine

BACKGROUND

Sensitivity of standard urine cytology for detecting urothelial carcinoma of the bladder (UCB) is low, attributable largely to its inability to process entire samples, paucicellularity and presence of background cells.

OBJECTIVE

Evaluate performance and practical applicability of a novel portable microfiltration device for capture, enumeration and characterisation of exfoliated tumour cells in urine, and compare it with standard urine cytology for UCB detection.

METHODS

A total of 54 urine and bladder wash samples from patients undergoing surveillance for UCB were prospectively evaluated by standard and microfilter-based urine cytology. Head-to-head comparison of quality and performance metrics, and cost effectiveness was conducted for both methodologies.

RESULTS

Five samples were paucicellular by standard cytology; no samples processed by microfilter cytology were paucicellular. Standard cytology had 33.3% more samples with background cells that limited evaluation (p<0.001). Microfilter cytology was more concordant (κ=50.4%) than standard cytology (κ=33.5%) with true UCB diagnosis. Sensitivity, specificity and accuracy were higher for microfilter cytology compared to standard cytology (53.3%/100%/79.2% versus 40%/95.8%/69.9%, respectively). Microfilter-captured cells were amenable to downstream on-chip molecular analyses. A 40 ml sample was processed in under 4 min by microfilter cytology compared to 5.5 min by standard cytology. Median microfilter cytology processing and set-up costs were approximately 63% cheaper and 80 times lower than standard cytology, respectively.

CONCLUSIONS

The microfiltration device represents a novel non-invasive UCB detection system that is economical, rapid, versatile and has potentially better quality and performance metrics than routine urine cytology, the current standard-of-care.

Liquid-based urine cytology as a tool for detection of human papillomavirus, Mycoplasma spp., and Ureaplasma spp. in men

Liquid-based urine cytology (LB-URC) was evaluated for cytological diagnosis and detection of human papillomavirus (HPV), Mycoplasma, and Ureaplasma. Midstream urine samples were collected from 141 male patients with urethritis and 154 controls without urethritis, and sediment cells were preserved in liquid-based cytology solution. Urethral swabs from urethritis patients were tested for the presence of Neisseria gonorrhoeae and Chlamydia trachomatis. Papanicolaou tests were performed for cytological evaluation. HPV, Mycoplasma, and Ureaplasma genomes were determined by PCR-based methods, and localization of HPV DNA in urothelial cells was examined by in situ hybridization (ISH). The β-globin gene was positive in 97.9% of LB-URC samples from urethritis patients and in 97.4% of control samples, suggesting that high-quality cellular DNA was obtained from the LB-URC samples. HPV DNA was detected in 29 (21.0%) urethritis cases and in five (3.3%) controls (P < 0.05). HPV type 16 (HPV 16) was most commonly found in urethritis patients. Cytological evaluations could be performed for 92.1% of urethritis patients and 64.3% of controls. Morphological changes suggestive of HPV infection were seen in 20.7% of the HPV-positive samples, and ISH demonstrated the presence of HPV DNA in both squamous and urothelial cells in HPV-positive samples. Mycoplasma genitalium, Mycoplasma hominis, Ureaplasma parvum, and Ureaplasma urealyticum were detected in 14.5%, 10.9%, 6.5%, and 12.3% of urethritis patients, respectively. The prevalence rates of these microorganisms (except Ureaplasma parvum) were significantly higher in urethritis cases than controls (P < 0.05). LB-URC is applicable for detection of HPV, Mycoplasma, and Ureaplasma. HPV infection occurs in urothelial cells, especially in gonococcal urethritis.

Comparison of ThinPrep preparations to other preparation types in gastrointestinal cytology: observations from the College of American Pathologists Interlaboratory Comparison Program in Nongynecologic Cytology

CONTEXT

Differences in participant responses for ThinPrep (TP) and non-ThinPrep (NTP) preparations for gastrointestinal cytology challenges, which circulated in the College of American Pathologists Interlaboratory Comparison Program in Nongynecologic Cytology (CAP NGC), may help to identify performance variations between preparation types.

OBJECTIVE

To compare the performance of TP-prepared slides of gastrointestinal exfoliative cytology specimens to that of NTP preparations in the CAP NGC program.

DESIGN

Participant responses between 2000 and 2007 were evaluated for esophageal wash/brush, gastric wash/brush, and biliary tract brush specimens with a reference diagnosis of adenocarcinoma, squamous cell carcinoma, carcinoid, or spindle cell neoplasm. ThinPrep challenges were compared with NTP preparations (conventional smears, cytospins) for discordant responses.

RESULTS

In all, 6023 pathologist responses and 3825 cytotechnologist responses were reviewed. Non-ThinPrep preparations comprised 93% (n = 11 588) of the challenges, while 7% (n = 912) were TP material. A match for a "positive/suspicious" diagnosis was seen in 88.5% of NTP and 95.9% of TP preparations (P < .001). These results were statistically significant when the specific reference diagnosis was adenocarcinoma (P < .001). Overall performance of cytotechnologists was not different from that of pathologists (89.2% versus 89.0%; P = .75). Cytotechnologists had better performance for detecting squamous cell carcinoma (96.3% versus 92.6%; P < .001), while pathologists had better performance for detecting spindle cell neoplasm (79.7% versus 42.9%; P < .001).

CONCLUSIONS

ThinPrep preparations performed significantly better than NTP preparations in gastrointestinal cytology specimens circulated in an interlaboratory comparison program. Performance varied by reference interpretation, with the best performance for the interpretation of adenocarcinoma. Cytotechnologists and pathologists performed at the same level overall, but with differences for the diagnosis of spindle cell neoplasm and squamous carcinoma.

Do Liquid-Based Preparations of Urinary Cytology Perform Differently Than Classically Prepared Cases? Observations From the College of American Pathologists Interlaboratory Comparison Program in Nongynecologic Cytology

Context.—The cytomorphology of liquid-based preparations in urine cytology is different than classic slide preparations.

Objectives.—To compare the performance of liquid-based preparation specimens to classically prepared urine specimens with a malignant diagnosis in the College of American Pathologists Interlaboratory Comparison Program in Nongynecologic Cytology.

Design.—Participant responses between 2000 and 2007 for urine specimens with a reference diagnosis of high-grade urothelial carcinoma/carcinoma in situ/dysplasia (HGUCA), squamous cell carcinoma, or adenocarcinoma were evaluated. ThinPrep and SurePath challenges were compared with classic preparations (smears, cytospins) for discordant responses.

Results.—There were 18 288 pathologist, 11 957 cytotechnologist, and 8086 “laboratory” responses available. Classic preparations comprised 90% (n = 34 551) of urine challenges; 9% (n = 3295) were ThinPrep and 1% (n = 485) were SurePath. Concordance to the general category of “positive-malignant” was seen in 92% of classic preparations, 96.5% of ThinPrep, and 94.6% of SurePath challenges (P &lt; .001). These results were statistically different for the exact reference interpretation of HGUCA (P &lt; .001) but not for adenocarcinoma (P = .22). Cytotechnologists demonstrate statistically better performance for the general category of “positive-malignant” compared with pathologists for all urinary slide types and for the exact reference interpretation of HGUCA (94% versus 91.1%; P &lt; .001) but not adenocarcinoma (96.3% versus 95.8%; P = .77) or squamous cell carcinoma (93.6% versus 87.7%; P = .07).

Conclusions.—Liquid-based preparations performed significantly better in urinary cytology challenges when evaluating malignant categories in the College of American Pathologists interlaboratory comparison program. The liquid-based preparation challenges also performed better for the exact reference interpretation of HGUCA, but no difference was observed for adenocarcinoma challenges. Cytotechnologists perform better than pathologists for all slide types, as well as those demonstrating HGUCA. These results suggest that liquid-based preparations facilitate a more accurate diagnosis than conventional preparations.

High-grade urothelial carcinoma: comparison of SurePath liquid-based processing with cytospin processing

There is limited literature available comparing SurePath (SP) with conventional cytospins (CS) for urine cytology specimens, especially urothelial carcinoma. In this study, urinary tract cytology cases of high-grade urothelial carcinoma were assessed on SP and CS slides. Also, the morphologic differences of high-grade urothelial carcinoma between SP and CS were evaluated on a total of 35 cases of high-grade urothelial carcinoma. SP showed that the tumor cells tend to present as three-dimensional groups and have a smaller cell size than CS. In terms of nuclear features, SP and CS were found to be comparable in morphologic assessment of the tumor cells, with CS providing a slightly better visualization.

The reliability of nipple aspirate and ductal lavage in women at increased risk for breast cancer--a potential tool for breast cancer risk assessment and biomarker evaluation

PURPOSE

Ductal lavage, a technique used to sample epithelial cells from breast ducts, has potential use in risk assessment and biomarker evaluation among women at increased risk for breast cancer. However, little is known about the reliability of the procedure.

METHODS

We evaluated the reliability of nipple aspirate (NAF) and ductal lavage at two time points 6 months apart in women at increased risk for breast cancer. Eligible women had a 5-year Gail risk >or=1.66% or lifetime risk of >20%, and/or a family history or personal history of breast cancer. All ducts that produced NAF were cannulated. The kappa statistic was used to evaluate reliability of NAF production, cellular yield, and cytologic diagnosis.

RESULTS

Sixty-nine women (mean age, 47 years) were enrolled over 35 months. Forty-seven returned for a second visit. At baseline, 65% of premenopausal and 41% of postmenopausal women produced NAF (P = 0.05), of which 72% underwent successful lavage of at least one duct. Samples of inadequate cellular material for diagnosis were significantly more likely in postmenopausal women than in premenopausal women (P = 0.04). Of the women who returned for a second visit, 18 of 24 who produced NAF had at least one duct successfully cannulated. Twenty-four ducts in 14 women were lavaged twice. Among these ducts, cellular yield for the two time points was inconsistent (kappa = 0.33 +/- 0.13), and only fair cytologic agreement was observed (kappa = 0.32 +/- 0.15). Ductal lavage was associated with moderate discomfort.

CONCLUSION

Currently, the use of ductal lavage is limited by technical challenges in duct cannulation, inconsistent NAF production, a high rate of inadequate cellular material for diagnosis, fair cytologic reproducibility, and low participant return rates.