HG UC

January 29, 2018 | Author: Anonymous | Category: Science, Health Science, Urology
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‫بسم هللا الرحمن الرحيم‬

Interpretation of urine cytology Nashwa Emara M.D.,phd ASS. Prof. Pathology

Function • Majority of UT malignancies

are urothelial CA. • The main function of urine cytology is diagnosis of UC.

Indications Diagnosis of symptomatic patients (hematuria). Screen high risk patients (industrial chemicals, metals, etc.) Follow-up patients with UT neoplasia. Complementary to cystoscopy and biopsy: detect small and hidden lesions (diverticuli, ureters, renal pelvis).. Urine cytology is the most reliable method for detecting urothelial CIS (>biopsies).

Types of Specimens Voided urine (avoid 1st morning specimens) Catheterized urine (in Females) Washings/Brushings Superior to voided urine but localized, may not sample upper urinary tract and urethra Ileal conduit urine

Deep Vs Superficial Cells

Columnar and Squamous Cells

Normal Urine Cytology

Washing, Instrumentation, Lithiasis

Diagnostic Accuracy Number of Specimens: -Voided urine on 3 consecutive days. + 50% accuracy (1 specimen) + 75-90% accuracy (3 specimens) Patient Population: High risk and history of CA Tumor Grade: • HG UC: 78 - 98% • LG UC: 0 - 70%

Grading Systems for Papillary UC 1973 WHO

1998 WHO/ISUP

Urinary Cytology

Papilloma

Papilloma

Low-grade Papillary Urothelial Lesion*

Grade I PUNLMP

Low-grade Papillary Urothelial Lesion

Grade II

Low-Grade

Low-grade Urothelial Carcinoma

Grade III

High-Grade

High-grade Urothelial Carcinoma

WHO Grading of Papillary Urothelial Malignancies Features

PUNLMP

Low-grade UC

High-grade UC

Polarity

Normal

Minimal loss

Disordered

Superficial cells

Usually present

May be present

Absent

Papillary architecture

Delicate

Fused+ Delicate

Fused

Nuclear size

Increased

Increased

Greatly increased

Pleomorphism

Slight

Moderate

Marked

Nuclear polarization

Slight abnormal

Abnormal

Absent

Hyperchromasia

Slight

Moderate

Marked

Mitoses

None or Rare

Present

Prominent

Nuclear grooves

Present

Present

Absent

Chromatin

Fine, uniform

Mild variation

Marked variation

PUNLMP

Low-grade Urothelial Carcinoma Cytologic diagnosis of LG PUC is problematic Minimal shedding of neoplastic cells Subtle cytologic alterations Difficult to distinguish from reactive changes, i.e. stones, instrumentation Cytologic overlap between PUNLMP and LG UC, some cases indistinguishable

Low-grade Urothelial Carcinoma vs Reactive

Low-grade Urothelial Carcinoma

Diff. Diag. of LGUC Reactive/reparative changes Instrumentation effect Lithiasis Upper urinary tract sampling

Low-grade UC Vs Benign

LGUC Vs Instrumentation

Instrumentation Effect Catheterized urine & bl. wash specimens. Large pseudopapillary groups and 3D clusters. Nuclear overlap and crowding. Low N/C ratio. Finely granular chromatin with even distribution. Well defined cytoplasmic borders. Nuclear palisading at periphery of clusters with abundant cytoplasm.

Lithiasis

Cytology of Upper Urinary Tract specimens Direct sampling of upper UT is effective in detecting HG UC, but poor for low grade lesions Normal upper UT epithelium shows more atypia than lower UT and occasionally more than LG UC High N/C ratio, enlarged nuclei, nuclear membrane irregularities Often present in papillary clusters Almost impossible to distinguish low grade UC from upper tract benign changes

Renal Pelvis & Ureter Brushings

High-grade Urothelial Carcinoma Often invasive, 70 mortality. Can not reliably separate CIS from invasive high-grade UC. High diagnostic accuracy of cytology: - Sensitivity 80 %. - Specificity > 95%.

HGUC

Diff. Diag. of HGUC Viral infection Therapy effect Degenerative and reactive changes Upper urinary tract specimens Stones

Polyoma Virus (Decoy Cells)

Therapy Effect

Degenerative Changes

Diagnostic categories Negative Atypical, rule out LGUC /PUNLMP Suspicious for HG UC/ malignancy HG UC/ other malignancies(Murphy)

Summary Urothelial neoplasms can be separated into 2 main categories: –Low grade neoplasia (PUNLMP and LG UC). –High grade UC. Urine cytology best applied to HG UC. Cytology less helpful for detecting and monitoring LG neoplasms. –Not major limitation. –LG neoplasms rarely aggressive and can be readily detected by cystoscopy. N.B.: Ancillary techniques are highly sensitive

GOOD LUCK…..

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