Urine cytology discrepancies: frequency, causes, and outcomes

Impact of implementing the first edition of the Paris system for reporting: A systematic review and meta-analysis

Urine cytology is a noninvasive, widely used diagnostic tool for screening and surveillance of genitourinary tract neoplasms. However, the absence of unified terminology and clear objective morphological criteria limits the clinical benefit of urine cytology. The Paris System for Reporting Urine Cytology (TPS) was developed with the goal of standardizing reporting and improving urine cytology performance in detecting high-grade malignancy (HGM). We aimed to evaluate potential effects of TPS on improving urine cytology diagnostic performance and clinical utility by conducting a systematic review and meta-analysis. We searched six electronic databases to identify cross-sectional and cohort studies written in English assessing the accuracy of urine cytology in detecting genitourinary tract malignancies of patients under surveillance or with clinical suspicion of malignancy from January 2004 to December 2022. We extracted relevant data from eligible studies to calculate relative distribution of cytology diagnostic categories; ratio of atypical to HGM cytology diagnosis; and risk of HGM (ROHGM) and HGM likelihood ratio (HGM-LR) associated with cytology diagnostic categories. We used a generalized linear mixed model with logit transformation to combine proportions and multilevel mixed-effect logistic regression to pool diagnostic accuracy measurements. We performed meta-regression to evaluate any significant difference between TPS and non-TPS cohorts. We included 64 studies for 99,796 combined total cytology samples, across 31 TPS and 49 non-TPS cohorts. Pooled relative distribution [95% confidence interval (CI)] of negative for high-grade urothelial carcinoma (NHGUC)/negative for malignancy (NM); atypical urothelial cells (AUC); suspicious for high-grade urothelial carcinoma (SHGUC)/suspicious for malignancy (SM); low-grade urothelial neoplasm (LGUN); and HGM categories among satisfactory cytology cases were 83.8% (80.3%-86.9%), 8.0% (6.0%-10.6%), 2.2% (1.4%-3.3%), 0.01% (0.0%-0.1%), and 4.2% (3.2%-5.5%) in TPS versus 80.8% (76.8-2.7%), 11.3% (8.6%-14.7%), 1.8% (1.2%-2.7%), 0.01% (0.0%-0.1%), and 3.3% (2.5%-4.3%) in non-TPS cohorts. Adopting TPS classification resulted in a significant increase in the frequency of NHGUC and a reduction in AUC cytology diagnoses, respectively. The AUC/HGM ratio in TPS cohort was 2.0, which showed a statistically significant difference from the atypical/HGM ratio of 4.1 in non-TPS cohort (p-value: 0.01). Moreover, the summary rate (95% CI) of LGUN called AUC on cytology significantly decreased to 20.8% (14.9%-28.3%) in the TPS compared with 34.1% (26.4%-42.8%) in non-TPS cohorts. The pooled ROHGM (95% CI) was 20.4% (6.2%-50.0%) in nondiagnostic (NDX), 15.5% (9.6%-24.2%) in NHGUC, 40.2% (30.9%-50.2%) in AUC, 80.8% (72.9%-86.8%) in SHGUC, 15.1% (5.7%-34.3%) in LGUN, and 91.4% (87.3%-94.3%) in HGM categories in TPS studies. NHGUC, AUC, SHGUC, and HGM categories were associated with HGM-LR (95% CI) of 0.2 (0.1-0.3), 0.9 (0.6-1.3), 6.9 (2.4-19.9), and 16.8 (8.3-33.8). Our results suggest that TPS 1.0 has reduced the relative frequency of AUC diagnosis, AUC/HGM ratio, and the frequency of LGUNs diagnosed as AUC on cytology. Adopting this classification has improved the clinical utility of SHGUC and HGM cytology diagnoses in ruling in high-grade lesions. However, an NHGUC diagnosis does not reliably rule out the presence of a high-grade lesion.

Implementation of The Paris System for Reporting Urine Cytology improves diagnostic accuracy of selective upper urinary tract cytology

BACKGROUND

The Paris System for Reporting Urine Cytology (TPS) recommends diagnostic criteria for urinary tract cytology, focusing primarily on the detection of high-grade urothelial carcinoma (HGUC) in the lower urinary tract. The second edition of TPS (TPS 2.0), published in 2022, extends these recommendations to the upper urinary tract (UUT); however, there is a lack of comprehensive data on this subject.

METHODS

In total, 223 consecutive UUT cytology specimens from 137 patients were retrieved and reclassified according to TPS 2.0 criteria and were compared with the original diagnosis based on the conventional system (CS). Histologic follow-up within a 3-month period was conducted for 43 patients.

RESULTS

Histologic follow-up revealed 30 HGUCs, five low-grade urothelial carcinomas (LGUCs), and eight nonneoplastic fibrotic tissues. The risk of high-grade malignancy for each TPS diagnostic category was 16.7% for nondiagnostic/unsatisfactory, 2.3% for negative for HGUC (NHGUC), 42.1% for atypical urothelial cells, 50.0% for suspicious for HGUC (SHGUC), and 81.8% for HGUC. In all five cases of histologically diagnosed LGUC, the cytologic diagnosis was NHGUC. When SHGUC/HGUC was considered positive, the diagnostic accuracy of TPS had 63% sensitivity, 95% specificity, a 90% negative predictive value, and a 79% positive predictive value, which were better than those of CS. In addition, the TPS indices did not differ significantly between the specimens obtained before and after the application of contrast reagents.

CONCLUSIONS

TPS implementation improved the accuracy of UUT cytology in predicting histologic HGUC, which was unaffected by the application of contrast reagents. These data indicate the usefulness of TPS for UUT cytology in routine clinical settings.

Examining longitudinal markers of bladder cancer recurrence through a semiautonomous machine learning system for quantifying specimen atypia from urine cytology

BACKGROUND

Urine cytology is generally considered the primary approach for screening for recurrence of bladder cancer. However, it is currently unclear how best to use cytological examinations for assessment and early detection of recurrence, beyond identifying a positive finding that requires more invasive methods to confirm recurrence and decide on therapeutic options. Because screening programs are frequent, and can be burdensome, finding quantitative means to reduce this burden for patients, cytopathologists, and urologists is an important endeavor and can improve both the efficiency and reliability of findings. Additionally, identifying ways to risk-stratify patients is crucial for improving quality of life while reducing the risk of future recurrence or progression of the cancer.

METHODS

In this study, a computational machine learning tool, AutoParis-X, was leveraged to extract imaging features from urine cytology examinations longitudinally to study the predictive potential of urine cytology for assessing recurrence risk. This study examined how the significance of imaging predictors changes over time before and after surgery to determine which predictors and time periods are most relevant for assessing recurrence risk.

RESULTS

Results indicate that imaging predictors extracted using AutoParis-X can predict recurrence as well or better than traditional cytological/histological assessments alone and that the predictiveness of these features is variable across time, with key differences in overall specimen atypia identified immediately before tumor recurrence.

CONCLUSIONS

Further research will clarify how computational methods can be effectively used in high-volume screening programs to improve recurrence detection and complement traditional modes of assessment.

Deep Learning-Based Screening of Urothelial Carcinoma in Whole Slide Images of Liquid-Based Cytology Urine Specimens

Urinary cytology is a useful, essential diagnostic method in routine urological clinical practice. Liquid-based cytology (LBC) for urothelial carcinoma screening is commonly used in the routine clinical cytodiagnosis because of its high cellular yields. Since conventional screening processes by cytoscreeners and cytopathologists using microscopes is limited in terms of human resources, it is important to integrate new deep learning methods that can automatically and rapidly diagnose a large amount of specimens without delay. The goal of this study was to investigate the use of deep learning models for the classification of urine LBC whole-slide images (WSIs) into neoplastic and non-neoplastic (negative). We trained deep learning models using 786 WSIs by transfer learning, fully supervised, and weakly supervised learning approaches. We evaluated the trained models on two test sets, one of which was representative of the clinical distribution of neoplastic cases, with a combined total of 750 WSIs, achieving an area under the curve for diagnosis in the range of 0.984-0.990 by the best model, demonstrating the promising potential use of our model for aiding urine cytodiagnostic processes.

Large-scale longitudinal comparison of urine cytological classification systems reveals potential early adoption of The Paris System criteria

INTRODUCTION

Urine cytology is used to screen for urothelial carcinoma in patients with hematuria or risk factors (eg, smoking, industrial dye exposure) and is an essential clinical triage and longitudinal monitoring tool for patients with known bladder cancer. However, urine cytology is semisubjective and thus susceptible to issues including specimen quality, interobserver variability, and "hedging" towards equivocal ("atypical") diagnoses. These factors limit the predictive value of urine cytology and increase reliance on invasive procedures (cystoscopy). The Paris System for Reporting Urine Cytology (TPS) was formulated to provide more quantitative/reproducible endpoints with well-defined criteria for urothelial atypia. TPS is often compared to other assessment techniques to justify its adoption. TPS results in decreased use of the atypical category and better reproducibility. Previous reports comparing diagnoses pre- and post-TPS have not considered temporal differences between diagnoses made under prior systems and TPS. By aggregating across time, studies may underestimate the magnitude of differences between assessment methods.

MATERIALS AND METHODS

We conducted a large-scale longitudinal reassessment of urine cytology using TPS criteria from specimens collected from 2008 to 2018, prior to the mid-2018 adoption of TPS at an academic medical center.

RESULTS

Findings indicate that differences in atypical assignment were largest at the start of the period and these differences progressively decreased towards insignificance just prior to TPS implementation.

CONCLUSIONS

This finding suggests that cytopathologists had begun to utilize the quantitative TPS criteria prior to official adoption, which may more broadly inform adoption strategies, communication, and understanding for evolving classification systems in cytology.

Urinary Comprehensive Genomic Profiling Correlates Urothelial Carcinoma Mutations with Clinical Risk and Efficacy of Intervention

The clinical standard of care for urothelial carcinoma (UC) relies on invasive procedures with suboptimal performance. To enhance UC treatment, we developed a urinary comprehensive genomic profiling (uCGP) test, UroAmplitude, that measures mutations from tumor DNA present in urine. In this study, we performed a blinded, prospective validation of technical sensitivity and positive predictive value (PPV) using reference standards, and found at 1% allele frequency, mutation detection performs at 97.4% sensitivity and 80.4% PPV. We then prospectively compared the mutation profiles of urine-extracted DNA to those of matched tumor tissue to validate clinical performance. Here, we found tumor single-nucleotide variants were observed in the urine with a median concordance of 91.7% and uCGP revealed distinct patterns of genomic lesions enriched in low- and high-grade disease. Finally, we retrospectively explored longitudinal case studies to quantify residual disease following bladder-sparing treatments, and found uCGP detected residual disease in patients receiving bladder-sparing treatment and predicted recurrence and disease progression. These findings demonstrate the potential of the UroAmplitude platform to reliably identify and track mutations associated with UC at each stage of disease: diagnosis, treatment, and surveillance. Multiple case studies demonstrate utility for patient risk classification to guide both surgical and therapeutic interventions.

Diffusive Ki67 and vimentin are associated with worse recurrence-free survival of upper tract urothelial carcinoma: A retrospective cohort study from bench to bedside

OBJECTIVES

This study aimed to determine the prognostic values of Ki67 and vimentin in upper tract urothelial carcinoma (UTUC) after extirpative surgery.

METHODS AND MATERIALS

Between 2014 and 2019, patients diagnosed with UTUC and receiving radical nephroureterectomy were included retrospectively. Nuclear MIB-1 clones and cytoplasmic VIM 3B4 clones were used to assess Ki67 and vimentin levels, respectively. A unified reading protocol was applied, and the expression level was read by a single pathologist. Receiver operating characteristic curves were utilized to determine the best threshold for Ki67 and vimentin regarding recurrence, and this level was set as the diffusive level. The outcome of recurrence-free survival (RFS) was analyzed via a Cox regression model with univariable and multivariable approaches. Survival outcomes were analyzed via Kaplan-Meier (KM) curves.

RESULTS

A total of 247 patients were included, and the mean follow-up was 29.90 ± 6.80 months. Diffusive thresholds were 17.5% for both Ki67 and vimentin. Under multivariable Cox regression, diffusive Ki67 (hazard ratio: 4.20 [2.39-7.37], P < 0.001) and diffusive vimentin (hazard ratio: 5.34 [3.10-9.22], P < 0.001) were significant prognostic indicators of worse RFS. Diffusive Ki67 was accompanied by diffusive vimentin (chi square with Yates' correction, P = 0.015), and vice versa. In the KM curve, there was no difference between diffusive Ki67/nondiffusive vimentin and nondiffusive Ki67/diffusive vimentin (log-rank test, P = 0.073). Significant differences (log-rank test, P < 0.001) were seen in different combinations of diffusive Ki67/vimentin (Mean RFS: 19.76 [18.56-20.96] months), only one diffusive in Ki67 or vimentin (Mean RFS: 22.94 [21.88-24.00] months), and nondiffusive Ki67/vimentin (Mean RFS: 32.96 [32.43-33.50] months).

CONCLUSIONS

Diffusive Ki67 and vimentin were related to each other, and they exerted equivalent and synergic effects on predicting worse RFS in UTUC.

Urinary Volatiles and Chemical Characterisation for the Non-Invasive Detection of Prostate and Bladder Cancers

Bladder cancer (BCa) and prostate cancer (PCa) are some of the most common cancers in the world. In both BCa and PCa, the diagnosis is often confirmed with an invasive technique that carries a risk to the patient. Consequently, a non-invasive diagnostic approach would be medically desirable and beneficial to the patient. The use of volatile organic compounds (VOCs) for disease diagnosis, including cancer, is a promising research area that could support the diagnosis process. In this study, we investigated the urinary VOC profiles in BCa, PCa patients and non-cancerous controls by using gas chromatography-ion mobility spectrometry (GC-IMS) and gas chromatography time-of-flight mass spectrometry (GC-TOF-MS) to analyse patient samples. GC-IMS separated BCa from PCa (area under the curve: AUC: 0.97 (0.93-1.00)), BCa vs. non-cancerous (AUC: 0.95 (0.90-0.99)) and PCa vs. non-cancerous (AUC: 0.89 (0.83-0.94)) whereas GC-TOF-MS differentiated BCa from PCa (AUC: 0.84 (0.73-0.93)), BCa vs. non-cancerous (AUC: 0.81 (0.70-0.90)) and PCa vs. non-cancerous (AUC: 0.94 (0.90-0.97)). According to our study, a total of 34 biomarkers were found using GC-TOF-MS data, of which 13 VOCs were associated with BCa, seven were associated with PCa, and 14 VOCs were found in the comparison of BCa and PCa.

Advances in Biomarkers for Detection, Surveillance, and Prognosis of Bladder Cancer

Bladder cancer may present management challenges, as it frequently recurs and can progress when not expeditiously diagnosed and carefully monitored following initial therapy for noninvasive disease. Cystoscopy and cytology have long been the primary tools for the urologist treating bladder cancer. However, as a host of potential biomarkers have been developed, new avenues for noninvasive testing have become available in the detection, surveillance, and prognostic setting. Analysis of urine for mutational signatures at the genetic and epigenetic levels appears promising, but such testing has yet to become widely adopted into clinical practice. Here, we review recent advances in bladder cancer biomarker assays, with particular attention to clinical relevance and potential application.

Significant reduction of indeterminate (atypical) diagnosis after implementation of The Paris System for Reporting Urinary Cytology: A single-institution study of more than 27,000 cases

BACKGROUND

Urinary cytology is a noninvasive and cost-effective diagnostic and surveillance test in the clinical management of urothelial carcinoma (UC). The Paris System for Reporting Urinary Cytology (TPS), published in 2016, introduced definite diagnostic criteria aimed at improving performance in detecting high-grade UC (HGUC) and decreasing the indeterminate (atypical) diagnosis.

METHODS

The authors retrospectively reviewed and compared urinary cytology diagnoses reported between January 2013 and December 2014 (pre-TPS, 7658 cases) and between May 2016 and April 2018 (post-TPS, 20,026 cases) to assess the influence of TPS in their practice. The time in between was used as a learning period. Follow-up information and correlation with the UroVysion fluorescence in situ hybridization test were obtained when available.

RESULTS

Urinary cytology diagnoses pre-TPS included negative for UC (NUC) (n = 5293; 69.2%), atypical urothelial cells (AUC) (n = 2227; 29%), and suspicious/positive for HGUC (SHGUC/HGUC) (n = 138; 1.8%). Diagnoses post-TPS included negative for HGUC (NHGUC) (n = 18,507; 92.4%), AUC (n = 1237; 6.2%), and SHGUC/HGUC (n = 282; 1.4%). Comparing the pre-TPS and post-TPS periods, AUC diagnoses decreased from 29% to 6.2% (P < .00001), and the specificity and positive predictive value of AUC to detect HGUC significantly improved from 49% to 86% (P < .00001) and from 9% to 39% (P = .002), respectively. The correlation of an AUC diagnosis with a positive UroVysion test improved from 17% to 38% (P < .00001), whereas overall use of the UroVysion test was decreased.

CONCLUSIONS

Implementation of TPS resulted in a significant reduction in AUC diagnoses that had a superior correlation with a subsequent biopsy and a UroVysion test, resulting in potential reductions in test use and medical cost.

Urine cytology suspicious for urothelial carcinoma: Prospective follow-up of cases using cytology and urine biomarker-based ancillary techniques

BACKGROUND

Urine cytology results that are suspicious for urothelial carcinoma (UC) are challenging. The objective of this study was to elucidate the clinical significance of such results in patients who have a negative cystoscopy.

METHODS

In this prospective study, 83 patients who had urine cytology that was suspicious of UC and a negative cystoscopy underwent a second cystoscopy and urine evaluation by cytology, UroVysion fluorescence in situ hybridization (FISH) assay, FGFR3 (fibroblast growth factor receptor 3) and TERT (telomerase reverse transcriptase) mutations and an 8-gene expression classifier (GEC). Results from all techniques were compared with patients' clinical outcomes.

RESULTS

The presence of tumor was identified in 41% of patients; of these, 82% had tumors identified at their second evaluation (76% high-grade [HG] tumors), and 18% had tumors identified at a later follow-up (50% were HG tumors). After The Paris System for Reporting urinary Cytology (TPS) reclassification, 53 cytology results still had an indeterminate diagnosis (13 were suspicious for HGUC, and 40 had atypical urothelial cells (AUCs)]. Complete results from second evaluations using urine cytology, cytology-TPS, FISH, and GEC were available for 6 cases that were suspicious for HGUC and 34 cases that had AUCs. The sensitivity of these techniques to detect HG tumors in cases that were suspicious for HGUC was 100%, except for cytology-TPS, for which the sensitivity was 50%. The sensitivity of cytology and cytology-TPS to detect HG tumors in cases with AUCs was 33%, whereas the sensitivity of fluorescence in situ hybridization and GEC in these cases was 83% and 75%, respectively, to detect HG tumors at the second evaluation.

CONCLUSIONS

The current results indicate the relevant clinical significance of indeterminate urine cytology findings and strongly suggest the use of complementary evaluations by urine biomarker-based, ancillary techniques to elucidate their significance.

Reclassification of urinary cytology regarding The Paris System for Reporting Urinary Cytology with cytohistological correlation demonstrates high sensitivity for high-grade urothelial carcinoma

BACKGROUND

Recently, The Paris System for Reporting Urinary Cytology (TPS) has led to major changes in the approach to evaluate urine cytology and pattern of reporting. The aim of this study was to reclassify urine cytology reports with TPS in order to determine the frequency of abnormal results compared with the previous system; also, we performed cytohistological correlation in abnormal cytological results.

METHODS

In this study, the voided urine specimens from the patients referred to Shiraz University of Medical Sciences affiliated laboratories were retrieved and analyzed using the laboratory's electronic records system; slides prepared from the samples were reviewed by single cytopathologist blindly according to the proposed criteria of TPS.

RESULTS

Totally, 1842 urine cytology slides from 828 patients were blindly evaluated by TPS criteria and compared with routine urine cytology classification. Then, available cytohistological correlation was done on 99 abnormal urine cytological results from 58 patients. Among the 26 cytology slides with atypical urothelial cell (AUC) in the previous classification, eight (30.70%) slides were downgraded to negative results, and four (15.30%) were upgraded to higher groups. Therefore, through the reclassification of the slides with TPS, 46% of the AUC changed to other groups. Diagnostic accuracy of the TPS classified urine cytology was 78%, including 87.88% sensitivity, 27.27% specificity, 64.44% positive predictive value, and 60% negative predictive value.

CONCLUSION

The findings of the present study confirmed the importance and utility of TPS regarding the reclassification of AUC to other groups and its high sensitivity for detecting high-grade urothelial carcinoma (HGUC).

Unbiased enrichment of urine exfoliated cells on nanostructured substrates for sensitive detection of urothelial tumor cells

Background

Early detection of urothelial carcinoma (UC) by noninvasive diagnostic methods with high accuracy is still underscored. This study aimed to develop a noninvasive assay incorporating both enrichment of urine exfoliated cells and immunoassays for UC detection.

Methods

Polystyrene dishes were exposed to oxygen plasma and modified with 3‐aminopropyltriethoxysilane to prepare amine‐functionalized nanostructured substrates (NS). Performance characterization of NS was evaluated by atomic force microscope and X‐ray photoelectron spectroscopy. Urine exfoliated cells were captured by NS and then immunostained to detect urinary tumor cells (UTCs), which was called UTC assay. The receiver operating characteristic (ROC) curve, area under ROC curve (AUC), and Youden index were used to find the cutoff value of UTC assay. ROC analysis and McNemar test were used to compare the diagnostic accuracy of UTC assay with cytology. Kappa test was used to analyze the agreement of UTC assay and cytology with pathological diagnosis.

Results

Nanostructured substrates had good cell binding yields of nucleated cells and tumor cells. CK20⁺CD45⁻CD11b⁻ cells were considered as UTCs. UTC number ≥ 1 per sample could be considered as a positive result. By AUC and Kappa analysis, UTC assay showed good performance in UC detection. McNemar test demonstrated that UTC assay had a superior sensitivity even in low‐grade subgroup and a similar specificity compared to cytology in UC diagnosis.

Conclusions

Nanostructured substrates could be used to enrich the exfoliated cells from urine samples. UTC assay with NS has the potential to play a role in UC detection. The value of this assay still needs additional validation by large, multi‐center studies.

[A new terminology for urinary cytopathology: The Paris System for Reporting Urinary Cytology (2015)]

As for the Bethesda system for cervical and thyroid cytopathology, a terminology for reporting urinary cytology has been published in 2015. The new "Paris System" provides a consensus terminology for urinary cytology which underlines the criteria for the recognition of high-grade urothelial carcinoma (HGUC) and of those excluding HGUC, or suspicious for HGUC. It also focuses on new rules to recognize and report the subgroup of "atypical urothelial cells". Here we describe and illustrate the various categories as in the reference book. We analyse the main diagnostic criteria, including microscopic features as well as the risk of malignancy associated to every diagnostic category.

Significance of atypical urinary cytology in the evaluation of patients with end-stage renal disease for kidney transplantation - a retrospective study

To determine what percentage of renal transplant candidates have atypical urinary cytology, what proportion have urothelial carcinoma and whether cystoscopy is necessary with atypical cytology. All end-stage renal disease (ESRD) patients (703) presenting for renal transplantation at our institution were retrospectively reviewed. Individuals producing sufficient urine were screened with urine cytology and those with atypical cytology or risk factors for bladder cancer underwent cystoscopy. Four hundred and thirty patients had available urinary cytology and, of these, 151 (35%) had atypical cytology. Of patients with atypical cytology, three were identified to have urothelial carcinoma. However, three additional patients with urothelial carcinoma did not present with atypical cytology. In total, 6 of 703 (0.85%) patients had bladder cancer. All were treated with transurethral resection and eventually underwent renal transplant. One patient has had disease progression post-transplant to distant metastases. This is the largest study to date evaluating the incidence of urothelial carcinoma in ESRD patients presenting for transplant workup. We found the incidence of bladder cancer to be higher than in the general Canadian population, however, most lesions were low grade. We found atypical cytology in transplant candidates to be a poor predictor for these low-grade lesions and do not recommend routine cystoscopy for atypical cytology.

Cell block preparation in urine cytology: examination of utility and workflow in an academic practice

INTRODUCTION

Urine cytology is a common non-invasive test to screen for urothelial carcinoma. Urine cell blocks may sometimes be prepared as a diagnostic aid (eg, to characterize architecture or perform immunohistochemistry). The aim of this study was to determine whether routinely preparing cell blocks on urine specimens improves diagnostic sensitivity.

MATERIALS AND METHODS

Three time periods were compared: time period 1 (prior to November 2009; 1437 consecutive selected cases), when cell blocks were rarely prepared; period 2 (November 2009 to May 2010; 1230 selected cases), when cell blocks were prepared on all cases; and period 3 (after May 2010; 1499 consecutive selected cases), when cell blocks were made only when indicated (for samples with substantial cellular pellets or when requested by a pathologist).

RESULTS

Patient demographics and the type of specimens received were relatively similar during the 3 time periods. Increased preparation of cell blocks was not accompanied by a notable improvement in specimen adequacy rate, given that <1%, 2%, and 1% of samples were unsatisfactory for the 3 periods. Only the proportion of atypical cases differed during the time periods, being highest in period 1 (23%), but lower in periods 2 and 3. Turnaround time was fastest for period 1 (mean: 47 hours, median: 33 hours), and slower for period 2 and period 3.

CONCLUSION

These data show that routinely preparing cell blocks for urine samples did not improve our laboratory's specimen adequacy rate. Nonetheless, cell block preparation on urine samples did help lower the proportion of atypical diagnoses, when routinely or selectively prepared. Because preparation of cell blocks on all urine cases can be costly and only provides minimal added clinical benefit, our recommendation is to rather judiciously utilize cell blocks when screening urine cytology samples.

Effectiveness of urine fibronectin as a non-invasive diagnostic biomarker in bladder cancer patients: a systematic review and meta-analysis

Background

Previous researches pointed out that the measurement of urine fibronectin (Fn) could be a potential diagnostic test for bladder cancer (BCa). We conducted this meta-analysis to fully assess the diagnostic value of urine Fn for BCa detection.

Methods

A systematic literature search in PubMed, ISI Web of Science, EMBASE, Cochrane library, and CBM was carried out to identify eligible studies evaluating the urine Fn in diagnosing BCa. Pooled sensitivity, specificity, and diagnostic odds ratio (DOR) with their 95% confidence intervals (CIs) were calculated, and summary receiver operating characteristic (SROC) curves were established. We applied the STATA 13.0, Meta-Disc 1.4, and RevMan 5.3 software to the meta-analysis.

Results

Eight separate studies with 744 bladder cancer patients were enrolled in this meta-analysis. The pooled sensitivity, specificity, and DOR were 0.80 (95%CI = 0.77–0.83), 0.79 (95%CI = 0.73–0.84), and 15.18 (95%CI = 10.07–22.87), respectively, and the area under the curve (AUC) of SROC was 0.83 (95%CI = 0.79–0.86). The diagnostic power of a combined method (urine Fn combined with urine cytology) was also evaluated, and its sensitivity and AUC were significantly higher (0.86 (95%CI = 0.82–0.90) and 0.89 (95%CI = 0.86–0.92), respectively). Meta-regression along with subgroup analysis based on various covariates revealed the potential sources of the heterogeneity and the detailed diagnostic value of each subgroup. Sensitivity analysis supported that the result was robust. No threshold effect and publication bias were found in this meta-analysis.

Conclusions

Urine Fn may become a promising non-invasive biomarker for bladder cancer with a relatively satisfactory diagnostic power. And the combination of urine Fn with cytology could be an alternative option for detecting BCa in clinical practice. The potential value of urine Fn still needs to be validated in large, multi-center, and prospective studies.

Electronic supplementary material

The online version of this article (10.1186/s12957-018-1358-x) contains supplementary material, which is available to authorized users.

p16/Ki-67 dual labeling and urinary cytology results according to the New Paris System for Reporting Urinary Cytology: Impact of extended follow-up

BACKGROUND

Overexpression of p16^INK4a has been identified in urothelial malignancies both cytologically and histologically. In addition, p16/Ki-67 dual labeling has been shown to identify high-grade urothelial cancer cells and some progression cases within a 12-month delay. The Paris System for Reporting Urinary Cytology (TPS) was published in late 2015. Its aim is to clarify the criteria for diagnosing or, conversely, excluding high-grade urothelial carcinoma (HGUC).

METHODS

Dual labeling was performed on archived ThinPrep-based Papanicolaou slides. A total of 208 samples (negative for high-grade urothelial carcinoma [NHGUC], 59; consistent with low-grade urothelial neoplasia [LGUN], 24; atypical urothelial cells [AUC], 15; and suspicious for or showing HGUC, 110) were analyzed for p16/Ki-67 after reclassification according to TPS. We assessed the oncologic status of the patients with cystoscopy, urinary cytology, histology, and prolonged 36-month follow-up data.

RESULTS

The sensitivity of p16/Ki-67 for life-threatening lesions was not different from that of urinary cytology (82.8% vs 83.6%; P = 1). However, among patients with samples classified as NHGUC and AUC, disease-free survival was significantly shorter for dual-labeled cases versus cases with negative dual labeling (P < .0001). The same tendency was observed in patients with histologically proven LGUN (P < .0001). As for specificity in patients with negative cystoscopy and cytology combined, prolonged follow-up showed 90% overall survival at 24 months.

CONCLUSIONS

A long-term evaluation of p16/Ki-67 dual labeling may identify HGUC and progression in cases with negative/low-grade urinary cytology results, and there are potential implications for the clinical management of patients after the conservative treatment of non-muscle-invasive urothelial carcinoma. Cancer Cytopathol 2017;125:552-62. © 2017 American Cancer Society.

A review of the Paris system for reporting urinary cytology

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

Validation of the diagnostic utility of urinary midkine for the detection of bladder cancer

As it has been demonstrated previously that midkine (also known as neurite growth-promoting factor 2) protein levels in urine of bladder cancer (BCa) patients are increased compared to healthy controls, the present study validated the diagnostic utility of midkine in an independent patient cohort and compared the observed values with voided urine cytology (VUC), which is the current reference standard for non-invasive diagnosis of BCa. Voided urine samples were prospectively collected from 92 BCa patients and 70 control subjects. Protein levels of midkine were assessed using a commercially available enzyme-linked immunosorbent assay and normalized to urinary creatinine. The diagnostic performance of urinary midkine was evaluated by receiver operating characteristic curves. The best combinations of sensitivities and specificities were determined by Youden's Index. Midkine concentrations were significantly elevated in urine samples from BCa patients compared to controls (P<0.001; Mann-Whitney U Test). The level of midkine was associated with disease progression, with the highest concentrations in urine specimens of patients with pT1 and ≥pT2a, as well as high-grade tumors (P<0.001; Mann-Whitney U test). Sensitivities of urinary midkine and VUC were 69.7 and 87.6%, respectively. The corresponding specificities for midkine and VUC were 77.9 and 87.7%, respectively. The combined use of VUC and midkine improved the sensitivity to 93.3%, but reduced the specificity to 66.2%. Despite its reduced discriminatory power for low-grade and low-stage BCa, urinary midkine can be utilized for the identification of high-grade pT1 and ≥pT2a tumors. This means that midkine may potentially be suitable for the identification of patients with high risk BCa.

Effect of contrast media on urinary cytopathology specimens

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Voided urine cytology and low-grade urothelial neoplasia of the bladder: factors that influence the sensitivity

INTRODUCTION

The aims of this study were to show the 10-year results of voided urine cytology (VUC) performed using liquid-based cytology (LBC) with CytoRich Red and to discuss the factors that influence the sensitivity of low-grade urothelial neoplasia (LGUN) of the urinary bladder.

MATERIALS AND METHOD

We calculated the sensitivity of VUC in 421 histologically confirmed cases included in the pathology database of Hokkaido Cancer Center in Japan and studied various factors influencing sensitivity.

RESULTS

The cumulative sensitivity of VUC was 95.8% in 143 cases of primary high-grade urothelial carcinomas, compared with 59.5% in 74 cases of LGUN. These findings were only slightly different from the previous results of Koss et al. The sensitivity in LGUN, however, showed lower values in some conditions, including in secondary cases, with a lower frequency of examinations and smaller tumor volumes. LBC preparations allowed us to observe a greater number of tumor cells and cell clusters than conventional methods in LGUN cases.

CONCLUSIONS

The sensitivity of VUC can be improved by increasing the frequency of examinations and adopting a valid preparation method in order to augment the number of cells and cell clusters on individual glass slides. LBC preparations may allow cytopathologists to obtain a better sense for and understanding of the cytologic findings of LGUN.

Quantitative phase imaging to improve the diagnostic accuracy of urine cytology

BACKGROUND

A definitive diagnosis of urothelial carcinoma in urine cytology is often challenging and subjective. Many urine cytology samples receive an indeterminate diagnosis. Ancillary techniques such as fluorescence in situ hybridization (FISH) have been used to improve the diagnostic sensitivity, but FISH is not approved as a routine screening test, and the complex fluorescent staining protocol also limits its widespread clinical use. Quantitative phase imaging (QPI) is an emerging technology allowing accurate measurements of the single-cell dry mass. This study was undertaken to explore the ability of QPI to improve the diagnostic accuracy of urine cytology for malignancy.

METHODS

QPI was performed on unstained, ThinPrep-prepared urine cytology slides from 28 patients with 4 categories of cytological diagnoses (negative, atypical, suspicious, and positive for malignancy). The nuclear/cell dry mass, the entropy, and the nucleus-to-cell mass ratio were calculated for several hundred cells for each patient, and they were then correlated with the follow-up diagnoses.

RESULTS

The nuclear mass and nuclear mass entropy of urothelial cells showed significant differences between negative and positive groups. These data showed a progressive increase from patients with negative diagnosis, to patients with atypical/suspicious and positive cytologic diagnosis. Most importantly, among the patients in the atypical and suspicious diagnosis, the nuclear mass and its entropy were significantly higher for those patients with a follow-up diagnosis of malignancy than those patients without a subsequent follow-up diagnosis of malignancy.

CONCLUSIONS

QPI shows potential for improving the diagnostic accuracy of urine cytology, especially for indeterminate cases, and should be further evaluated as an ancillary test for urine cytology. Cancer Cytopathol 2016;124:641-50. © 2016 American Cancer Society.

ImmunoCyt test compared to cytology in the diagnosis of bladder cancer: A meta-analysis

The aim of the present study was to evaluate the diagnostic value of the ImmunoCyt test compared with urine cytology in detecting bladder cancer. A systematic literature search was performed to locate all publications reporting on the diagnostic accuracy of the ImmunoCyt test for bladder cancer. Data were extracted from 2×2 tables or calculated from reported accuracy data. Collected data were meta-analyzed for sensitivity, specificity, positive likelihood ratio (LR), negative LR, diagnostic odds ratio (DOR), and summary receiver operator characteristic (sROC) curve analysis. We applied the Meta-DiSc 1.4 and STATA 13.0 software to the meta-analysis. Seven separate studies consisting of 1,602 patients with bladder cancer were considered in the meta-analysis. We found that the ImmunoCyt test had a higher sensitivity than the urine cytology test [0.725, 95% confidence interval (CI) 0.683-0.765 vs. 0.566, 95% CI, 0.521-0.611], but the specificity, positive LR, negative LR, DOR, area under the curve (AUC) and Q index of the ImmunoCyt test were lower compared with the urine cytology test. In addition, the pooled sensitivity, specificity, positive LR, negative LR, DOR, AUC, and Q index of the combined method (combination of ImmunoCyt and cytology) were 0.833, 0.644, 2.804, 0.228, 13.50, 0.8554 and 0.7863, respectively. The results of the Eggers test showed no publication bias (P>0.05). In conclusion, specificity, positive LR, negative LR, DOR, the AUC, and the Q index of the urine cytology test may be superior to the ImmunoCyt test, but the ImmunoCyt test has greater sensitivity than the urine cytology test. Use of ImmunoCyt and cytology in combination has the potential to improve the sensitivity and promises to be an alternative in the detection of bladder cancer.

The cytomorphological features of low-grade urothelial neoplasms vary by specimen type

BACKGROUND

Urinary tract (UT) cytology has been used successfully to diagnose high-grade urothelial carcinoma but is reported to have poor sensitivity for low-grade urothelial neoplasms (LGUNs). However, the literature has shown that LGUN may be associated with atypical findings in UT specimens. The authors determined which features were most commonly observed, and whether the method of specimen procurement had an effect.

METHODS

A total of 326 specimens were identified over an 8-year period. One hundred fifty-three specimens were reviewed and graded for cellularity, number of tissue fragments (TFs), degeneration, inflammation, hyperchromasia, nuclear pleomorphism, nuclear border irregularity, nuclear size, cytoplasmic tails, nuclear eccentricity, and high-grade features.

RESULTS

Of the 153 specimens, 86 specimens (56.2%) demonstrated cellular atypia; of those, 51.2% were voided urine (VU) and 31.4% were UT washing (UW) specimens. The majority of specimens had many cells (46.5%), many single cells (44.2%), few to moderate TFs (46.5% and 27.9%, respectively), mild hyperchromasia (52.3%), mild nuclear pleomorphism (51.2%), mild nuclear border irregularity (60.5%), cytoplasmic tails (51.2%), and few to moderate eccentric nuclei (37.2% and 36.1%, respectively). The presence of TFs, cytoplasmic tails, and eccentric and enlarged nuclei were significantly more common in UW versus VU specimens (P = .036, .012, .014, and .027, respectively) and in UW versus benign UW controls (P = .001, .002, .002, and .003, respectively).

CONCLUSIONS

Approximately 50% of UT specimens with LGUN on follow-up demonstrated atypical features. Based on comparison with benign UW controls, TFs, cytoplasmic tails, nuclear eccentricity, and enlarged nuclei were more pronounced in neoplastic UW than VU specimens, suggesting that the method of urine specimen procurement affects the presence of certain low-grade features. Cancer Cytopathol 2016;124:552-64. © 2016 American Cancer Society.

Subclassifying atypia in urine cytology: what are the helpful features?

INTRODUCTION

The diagnosis "atypical urothelial cells (AUC)" remains an unresolved problem, making many urologists dissatisfied and confused about the management strategy on these cases. To date, a few inspiring attempts were made to subclassify AUC into "atypical urothelial cells of undetermined significance" (AUC-US) and "atypical urothelial cells cannot exclude high grade" (AUC-H). The aim of our study was to investigate the most predictive for high-grade urothelial carcinoma (HGUC) cytomorphologic parameters and whether the proposed classification can be implemented in our institution.

MATERIAL AND METHODS

The electronic medical record system was searched for cytology specimens that were diagnosed as AUC from January 1, 2005 to March 1, 2013 and their relative clinical-pathological follow-up. All specimens were reviewed by an experienced cytopathologist by using 20 published "most predictive" for HGUC criteria.

RESULTS

A total of 162 AUC specimens were reclassified into 3 groups: AUC-H (n = 45), AUC-US (n = 51), and "negative for malignancy" (n = 66). The reclassification of AUC-H and "negative for malignancy" had 79% sensitivity, 77% specificity, 60% positive predictive value, and 89% negative predictive value to histologically proven HGUC diagnosis.

CONCLUSIONS

Our study demonstrated a good correlation between the presence of "HGUC-predictive" cytologic criteria and the final biopsy-proven HGUC in cytologic cases originally diagnosed as "atypical urothelial cells present." We identified 2 of the most predictive for HGUC on follow-up cytomorphologic parameters such as increased nuclear-cytoplasmic ratio >0.7 and coarse chromatin (16 abnormal cells per slide in average). These parameters, along with positive fluorescent in situ hybridization results can help during cytologic evaluation of urine specimens.

Benign-appearing urothelial tissue fragments in noninstrumented voided urine specimens are associated with low rates of urothelial neoplasia

BACKGROUND

The presence of urothelial tissue fragments (UTF) in voided urine (VU) is often considered an abnormal finding that may be associated with the presence of urothelial papillary neoplasms. In the current study, the authors reviewed VU specimens containing benign-appearing UTF (BUTF) to determine the associated rate of urothelial neoplasia at the study institution.

METHODS

A retrospective search of the electronic pathology database system over a 5-year period (2009-2013) revealed 1131 VU specimens containing UTF. Of these, 459 cases (40.6%) did not have a recent history of instrumentation. Fifteen cases were excluded because the slides were not available for review. In the remaining 444 cases, 274 cases (61.7%) had BUTF. A total of 170 cases (38.3%) had UTF with atypical cytologic features and were therefore excluded.

RESULTS

Of the 274 cases, 29 (10.6%) had follow-up surgical pathology specimens available. The overall rate of urothelial neoplasia on follow-up was 3.6% for low-grade urothelial neoplasia (10 cases) and 0.7% for high-grade urothelial carcinoma (2 cases). Forty-five cases (16.4%) were determined to have urinary tract stones on follow-up.

CONCLUSIONS

The presence of BUTF in VU specimens requires careful examination of the medical history because their presence may be explained by recent instrumentation. If recent instrumentation is not identified, the etiology of BUTF is not usually determined; in the current study, BUTF were found to be associated with urinary tract stones in 16.4% of cases. They also present a low risk of low-grade urothelial neoplasia (3.6%) and high-grade urothelial carcinoma (0.7%) when compared with the overall benign category at the study institution (2.3% [P =.15] and 0.7%, respectively).

Atypical urothelial tissue fragments in noninstrumented voided urine specimens are associated with low but significantly higher rates of urothelial neoplasia than benign-appearing urothelial tissue fragments

BACKGROUND

The interpretation of urothelial tissue fragments (UTF) in voided urine (VU) specimens is controversial. If UTF contain cytomorphologically atypical cells, the diagnosis often becomes more challenging. The authors previously analyzed the outcome of patients with benign-appearing UTF in 274 noninstrumented VU specimens. In this retrospective study, noninstrumented VU specimens containing UTF with atypical cytomorphological features (AUTF) were evaluated and compared with the previous results.

METHODS

The Johns Hopkins Hospital electronic pathology database was searched for VU cases containing UTF over a 5-year period.

RESULTS

A total of 170 noninstrumented VU specimens containing AUTF were identified. Twenty-four specimens had subsequent or coincidental surgical pathology specimens with the following overall rates of neoplasia: high-grade urothelial carcinoma: 8.8% (15 specimens), low-grade urothelial neoplasia: 1.2% (2 specimens), and prostate carcinoma invading the bladder: 0.6% (1 specimen). A total of 49 specimens (28.8%) were diagnosed with urolithiasis on follow-up. Twenty-five cases had follow-up cytology specimens, all of which were negative for malignancy. Of 72 cases without histopathologic, radiologic, or cytopathologic follow-up, 62 (86.1%) had a mean clinical follow-up of 22.5 months and 10 cases did not have clinical follow-up.

CONCLUSIONS

The presence of AUTF in noninstrumented VU is associated with low rates of urothelial neoplasia but a statistically higher risk of urothelial neoplasia than the presence of BUTF (10.0% vs 4.4%; P<.05). In particular, the rate of high-grade urothelial carcinoma is significantly higher in noninstrumented VU specimens containing AUTF than those containing BUTF (8.8% vs 0.7%; P<.0001). In addition, urolithiasis is associated with AUTF in a substantial percentage of noninstrumented VU specimens.

APE1/Ref-1 as a Serological Biomarker for the Detection of Bladder Cancer

Purpose

Apurinic/apyrimidinic endonuclease 1/redox factor-1 (APE1/Ref-1) is a multifunctional protein that shows elevated expression in a number of cancers. We attempted to determine whether serum APE1/Ref-1 is elevated in patients with bladder cancer.

Materials and Methods

Serum APE1/Ref-1 levels were determined using enzyme-linked immunosorbent assay in serum from patients with bladder cancer who had not received chemotherapy or radiotherapy (n=51) and non-tumor controls (n=55). The area under the receiver operating characteristic area under the curve was applied to determine the correlation between clinical factors and the serum levels of APE1/Ref-1.

Results

Serum levels of APE1/Ref-1 in bladder cancer patients were significantly elevated compared to those of the control group (3.548±0.333 ng/100 μL [n=51] for bladder cancer vs. 1.547±0.319 ng/100 μL [n=55] for the control group), with a sensitivity and specificity of 93% and 59%, respectively. Serum APE1/Ref-1 levels are associated with tumor stage, grade, muscle invasion, and recurrence.

Conclusion

Serum APE1/Ref-1 might be useful as a potential serologic biomarker for bladder cancer.

Accuracy and risk of malignancy for diagnostic categories in urine cytology at a large tertiary institution

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.

Outcomes of kidney transplant tourism and risk factors for de novo urothelial carcinoma

BACKGROUND

To date, the outcomes of transplant tourism have not been reported extensively. In addition, data about the accuracy of urine cytology for the detection and the role of the BK virus (BKV) in the carcinogenesis of urothelial carcinoma (UC) after renal transplantation are lacking.

METHODS

Three hundred seven patients who received deceased donor kidney transplants between January 2003 and December 2009 were retrospectively studied. The clinical parameters and outcomes between the domestic and tourist groups were compared. We also investigated the risk factors and role of BKV in the carcinogenesis of de novo UC by quantitative real-time polymerase chain reaction.

RESULTS

The subjects in the tourist group were older at transplantation and had a shorter dialysis time before transplantation. There were significantly higher incidence rates of BKV viruria, Pneumocystis jiroveci pneumonia, and malignancy in the tourist group. Graft and patient survival were superior in the domestic group. A total of 43 cancers were identified, and the most common type of malignancy was UC (23 patients, 53.5%). The tourist group had a significantly higher incidence of tumors. The sensitivity and specificity of urine cytology for detecting UC were 73.9% and 94.7%, respectively. Independent predictors of UC included female sex, use of Chinese herbal medicine, and transplant tourism. Only two patients (8.7%) with UC had detectable BKV.

CONCLUSIONS

Transplant tourism was a risk factor for infection and de novo malignancy. Urothelial carcinoma was the most common malignancy after kidney transplantation. Regular screening for the early detection of UC by urine cytology or periodic sonographic surveys is mandatory, especially for those at high risk.

Reflex fluorescence in situ hybridization assay for suspicious urinary cytology in patients with bladder cancer with negative surveillance cystoscopy

OBJECTIVE

To assess the ability of reflex UroVysion fluorescence in situ hybridization (FISH) testing to predict recurrence and progression in patients with non-muscle-invasive bladder cancer (NMIBC) with suspicious cytology but negative cystoscopy.

PATIENTS AND METHODS

Patients under NMIBC surveillance were followed with office cystoscopy and urinary cytology every 3-6 months. Between March 2007 and February 2012, 500 consecutive patients with suspicious cytology underwent reflex FISH analysis. Clinical and pathological data were reviewed retrospectively. Predictors for recurrence, progression and findings on subsequent cystoscopy (within 2-6 months after FISH) were evaluated using univariate and multivariate Cox regression.

RESULTS

In all, 243 patients with suspicious cytology also had negative surveillance cystoscopy. Positive FISH was a significant predictor of recurrence (hazard ratio [HR] = 2.35, 95% confidence interval [CI]: 1.42-3.90, P = 0.001) in multivariate analysis and for progression (HR = 3.01, 95% CI: 1.10-8.21, P = 0.03) in univariate analysis, compared with negative FISH. However, positive FISH was not significantly associated with evidence of tumour on subsequent surveillance cystoscopy compared with negative FISH (odds ratio = 0.8, 95% CI: 0.26-2.74, P = 1).

CONCLUSIONS

Positive FISH predicts recurrence and progression in patients under NMIBC surveillance with suspicious cytology but negative cystoscopy. However, there was no association between the FISH result and tumour recurrence in the immediate follow-up period. Reflex FISH testing for suspicious cytology might have limited ability to modify surveillance strategies in NMIBC.

Peptide-conjugated glass slides for selective capture and purification of diagnostic cells: Applications in urine cytology

Obtaining a clear view of the cells of interest in diagnostic cytology can be challenging when specimens are contaminated with blood or other obscuring cells. In this study, we present a powerful technique for the selective capture of diagnostic epithelial cells directly on a microscope slide, highlighting its applications in urine cytology and immunocytochemistry (ICC). Using phage-display biopanning, we identified and synthesized a series of peptides that bind with high affinity to urothelial cells but not blood cells. We developed methods for conjugating the peptides to glass slides, and we used these slides to selectively capture both normal and cancerous epithelial cells from urine contaminated with blood cells. Unlike non-selective microscope slides, the peptide-conjugated slides selectively retained the cells of interest, recovering up to 75% of urothelial cells, while up to 98% of blood cells were washed away. The slides are compatible with Papanicolaou and hematoxylin and eosin (H&E) staining for cytology preparations, as well as ICC for detecting membrane-associated and nuclear cancer markers. We successfully detected the expression of carcinoembryonic antigen and survivin, two commonly measured bladder cancer markers. In addition to bladder cancer diagnostics, this technology has broad applications for increasing the quality of sample preparations in slide-based diagnostic testing.

Significance of atypical category in voided urine specimens prepared by liquid-based technology: Experience of a single institution

INTRODUCTION

The goal of this study was to evaluate the clinical significance of atypical cytology in voided urine samples. We also studied any differences in outcome that may exist between the patients being surveyed versus high risk for urothelial carcinoma (UC).

MATERIALS AND METHODS

This was a retrospective study of all voided urine specimens with "atypical" cytology over a 10-year period. The patients were categorized into those with and without a prior diagnosis of UC as the "surveillance" and "de novo" (DG) groups. Follow-up was obtained. Clinical impact and outcomes of the 2 groups were compared.

RESULTS

In this study, 5.7% of voided urine specimens were atypical. Mean age of patients in years, male/female ratio, and time to diagnosis in days was 59 versus 71, 23:15 versus 22:1, and 95 versus 43 in the DG and surveillance group, respectively. Rate of progression to UC was similar in both groups. High-grade UC was significantly higher in the DG.

CONCLUSIONS

Approximately 20% of patients in the DG were subsequently diagnosed with UC. The common causes for the atypical diagnosis that did not progress to UC were stones and benign prostatic hyperplasia. In the absence of an etiology for the atypia, further investigations are warranted.

Clinical proteomic biomarkers: relevant issues on study design & technical considerations in biomarker development

Biomarker research is continuously expanding in the field of clinical proteomics. A combination of different proteomic-based methodologies can be applied depending on the specific clinical context of use. Moreover, current advancements in proteomic analytical platforms are leading to an expansion of biomarker candidates that can be identified. Specifically, mass spectrometric techniques could provide highly valuable tools for biomarker research. Ideally, these advances could provide with biomarkers that are clinically applicable for disease diagnosis and/ or prognosis. Unfortunately, in general the biomarker candidates fail to be implemented in clinical decision making. To improve on this current situation, a well-defined study design has to be established driven by a clear clinical need, while several checkpoints between the different phases of discovery, verification and validation have to be passed in order to increase the probability of establishing valid biomarkers. In this review, we summarize the technical proteomic platforms that are available along the different stages in the biomarker discovery pipeline, exemplified by clinical applications in the field of bladder cancer biomarker research.

Utility of MRI features in differentiation of central renal cell carcinoma and renal pelvic urothelial carcinoma

OBJECTIVE

The purpose of this article is to evaluate the utility of various morphologic and quantitative MRI features in differentiating central renal cell carcinoma (RCC) from renal pelvic urothelial carcinoma.

MATERIALS AND METHODS

Sixty patients (39 men and 21 women; mean [± SD] age, 65 ± 14 years; 48 with central RCC and 12 with renal pelvic urothelial carcinoma) who underwent MRI, including diffusion-weighted imaging (b values, 0, 400, and 800 s/mm(2)) and dynamic contrast-enhanced imaging, before histopathologic confirmation were included. Tumor T2 signal intensity and apparent diffusion coefficients (ADCs) were measured and normalized to muscle and CSF (hereafter referred to as normalized T2 signal and normalized ADC, respectively) and then were compared using receiver operating characteristic analysis. Also, two blinded radiologists independently assessed all tumors for various qualitative features, which were compared with the Fisher exact test and unpaired Student t test.

RESULTS

Urothelial carcinoma exhibited significantly lower normalized ADC than did RCC (p = 0.008), but no significant difference was seen in ADC or normalized T2 signal intensity (p = 0.247-0.773). Normalized ADC had the highest area under the curve (0.757); normalized ADC below an optimal threshold of 0.451 was associated with sensitivity of 83% and specificity of 71% for diagnosing urothelial carcinoma. Features that were significantly more prevalent in urothelial carcinoma included global impression of urothelial carcinoma, location centered within the collecting system, collecting system defect, extension to the ureteropelvic junction, preserved renal shape, absence of cystic or necrotic areas, absence of hemorrhage, homogeneous enhancement, and hypovascularity (all p < 0.033). Increased T1 signal intensity suggestive of hemorrhage was significantly more prevalent in RCC (p = 0.02). Interreader agreement for the subjective features ranged from 61.7% to 98.3%.

CONCLUSION

In addition to various qualitative MRI parameters, normalized ADC has utility in differentiating central RCC from renal pelvic urothelial carcinoma. Such differentiation may assist decisions regarding possible biopsy and treatment planning.

Considerations on the use of urine markers in the management of patients with low-/intermediate-risk non-muscle invasive bladder cancer

OBJECTIVES

Many molecular assays for bladder cancer diagnosis and surveillance have been developed over the past several decades. However, none of these markers have been routinely implemented into clinical decision making. Beyond their potential for screening high-risk populations, urine markers likely have the greatest potential in the follow-up of patients with non-muscle invasive bladder cancer (NMIBC).

METHODS

Here, we discuss the current options and limitations of the use of urine markers for patient surveillance, focusing on patients with low-/intermediate-risk NMIBC.

RESULTS

As these patients have a very low risk of tumor progression, the primary goal of surveillance is detection of recurrent disease. Although urine cytology seems to be limited to detection of few patients who would develop high-grade tumors, we conclude that the use of markers with high sensitivity for low-grade disease for patient follow-up has the potential to decrease the frequency of urethrocystoscopy without compromising patient prognosis. Because a single marker may not have sufficient sensitivity for detection of low-grade tumors, different scenarios, e.g., multitesting and reflex or sequential approaches, are discussed.

CONCLUSIONS

There is consensus that currently available markers have the potential to support clinical decision making in follow-up of patients with low-/intermediate-risk NMIBC. In light of our analysis, further additional randomized controlled studies to effectively assess the clinical usefulness of modern urine markers are required.

Genitourinary cytopathology (kidney and urinary tract)

FNA of kidney masses have been performed for the diagnosis of mass lesions,confirmation of advanced neoplasia and metastases, and staging of tumors. In the past, the decision of whether to perform a nephrectomy used to be based on radiographic features and size, precluding the use of FNA. Today, where treatment is not limited to surgery alone, the indications for renal FNA have expanded. Most small renal masses are asymptomatic and are detected incidentally due to improved imaging techniques. Although most urologists agree that the standard of care for renal masses is surgery, if the patient is an elderly individual, or has comorbidities a preoperative FNA could be useful in guiding the management.When we look at data from large referral institutions such as Mayo Clinic, Johns Hopkins Medical Institutions, and the Cleveland Clinic approximately 30 %of the renal masses are benign [86---88]. Therefore, as astutely pointed out by Volpe et al.[3], there is a role for precise pretreatment characterization of the renal masses by FNA, which would decrease the unnecessary treatment for benign diseases and reduce the treatment-related mortality and morbidity in addition to reducing patient care costs.To date, urine cytology remains the gold standard for bladder cancer screening.It has been, and still is, the test against which all new tests are compared when evaluating potential bladder tumor markers. The answer to whether urine cytology possesses the optimal combination of sensitivity and specificity to retain consideration as the best screening device depends on the goals of the practice. Urine cytology has excellent specificity with only few false-positive cases. Its overall sensitivity (including both high grade and low grade lesions) is poor, but this is explained by poor criteria for identifying well-differentiated, low-grade urothelial carcinoma in cytology. The natural history of low grade lesions is that of multiple superficial recurrences in 70 - 80 % of patients, with only a minority ( 10-15 %)progressing to muscle invasive or metastatic disease [89]. Patients with low-grade urothelial carcinoma are at low risk for progression, they are monitored primarily for the development of a subsequent high grade tumor [90]. Therefore, as suggested by Koss, detection of new low-grade lesions may be clinically irrelevant as compared to early detection of disease progression [39]. Contrary to the low grade lesions, however, urine cytology often results in the identification of high-grade malignant cells even before a cystoscopically distinguishable gross lesion is present. In the last 20 years, a number of noninvasive test have been developed to detect urothelial carcinoma. Although some have been able to show a better sensitivity compared to cytology, only a few have been close to reaching the sensitivity seen in cytology. Most of these tests have not added much to the diagnostic evaluation. Combining some of the new markers with each other and/or cytologic evaluation may optimize their performance status.