Hypochromatic large urothelial cells in urine cytology are indicative of high grade urothelial carcinoma

In this study, we have examined 67 cytology specimens from patients from 2014 to 2016. The ratio man to women was 4:1 with a median age of 75 years (range: 55–87 years). Thin‐Prep processed urinary cytology specimens demonstrated large urothelial cells, with cytologic features of malignancy, thus including hypochromatic nuclei with occasional peripherally accentuated chromatin rim. The cytological diagnosis of High Grade Urothelial Carcinoma (HGUC) was made in 55 patients while 12 specimens were classified as Atypical Urothelial Cells (AUC). This cases represent the 15% of the HGUC and the 4% of the AUC cases diagnosed in our department between 2016 to 2018. Of note, is the fact that in AUC cases, hypochromatic irregular urothelial cells were the only type of cells with malignant features observed in the specimen, and therefore, according to the Paris System criteria, the absence of nuclear hyperchromasia precludes a diagnosis of suspicious high grade urothelial carcinoma (SHGUC) or High Grade Urothelial Carcinoma (HGUC). Subsequent biopsy diagnosis of high grade urothelial carcinoma confirmed the cytological diagnosis of HGUC in 55 patients but also in all 12 patients with a AUC cytologic diagnosis. Our study series support the hypothesis that malignant urothelial cells with hypochromatic nuclei seen in urine cytologic specimens can be diagnostic for HGUC based on their very large nuclei, high nuclear cytoplasmatic ratio (N/C) >0.7, irregular nuclear outlines and coarse (frequently peripheral) chromatin in the absence of hyperchromasia.     

Persistent uroplakin expression in advanced urothelial carcinomas: implications in urothelial tumor progression and clinical outcome

As the terminal differentiation products of human urothelium, uroplakins (UPs) would be expected to diminish during urothelial tumorigenesis. Surprisingly, recent studies found UPs to be retained even by well-advanced urothelial carcinomas, suggesting that the loss of UPs does not strictly parallel urothelial transformation. Little is known, however, about whether the status of UPs is associated with a particular pathologic parameter, the tumor's biological behavior, or patient outcome. Here we assessed UP expression by immunohistochemistry on tissue arrays from 285 patients with bladder urothelial carcinomas or nontumor conditions. UPs were expressed in all 9 normal urothelial specimens, 63 of 74 (85%) patients with non-muscle-invasive urothelial carcinomas on transurethral resection, 104 of 202 (51.5%) patients who underwent radical cystectomy for advanced urothelial carcinomas, and 33 of 50 (66%) lymph node metastases. Normally associated with urothelial apical surface, UPs were localized aberrantly in tumors, including microluminal, basal-laminal, cytoplasmic, or uniform patterns. In non-muscle-invasive diseases, there was no association between UP expression and disease recurrence, progression, or mortality. In contrast, in invasive diseases, absent UP expression was significantly associated with advanced pathologic stage, lymph node metastases, disease recurrence, and bladder cancer-specific mortality (P = .042, P = .035, P = .023, and P = .022, respectively) in univariate analyses. Furthermore, UP status was independent of key cell-cycle regulators, including p53, pRb, p27, and cyclin D1, thus excluding a functional link between these 2 groups of proteins. Our data demonstrate for the first time that persistent UP expression is associated with a favorable clinical outcome and that UPs may be used as adjunct markers for predicting the prognoses of patients with invasive and metastatic bladder carcinomas. Our results also suggest that UP-positive and -negative carcinomas have different clonal origins or may be derived from different cancer stem cells.     

Atypical squamous cells in exfoliative urinary cytology: clinicopathologic correlates

Presence of atypical squamous cells (ASC) in voided urine is an uncommon finding that may be the harbinger of an underlying malignant process. ASCs in urine may precede a de novo histologic diagnosis of malignancy or be the first sign of a recurrence in the lower urinary tract, or the gynecologic tract (in women). This study analyzed all urine cytology specimens with such diagnoses, with reference to their final histologic outcome. All urine cytology cases (n = 17,446) that included ASCs, evaluated at The Johns Hopkins Hospital between 1989 and 2003 (14 yr), were reviewed for diagnoses. ASCs as defined in this study are keratinizing cells with large and hyperchromatic smudgy nuclei, high N/C ratio, abnormal nuclear or cytoplasmic shapes, and densely orangeophilic cytoplasm. These cases lacked the qualitative and quantitative criteria for malignancy. The final reference outcome was determined by subsequent histologic and clinical follow-up. Of these 17,446 urine specimens, 55 cases (0.3%) from 47 patients had ASCs present. Thirty-two of the 47 patients had adequate follow-up. In 8 of these 32 patients (25%), a diagnosis of squamous-cell carcinoma (SCC) of the urinary bladder or urothelial carcinoma (UC) with squamous differentiation was made on subsequent histologic examination. In two cases (6%) a diagnosis of high-grade cervical SCC was established on subsequent follow-up. Twenty two of 32 cases (69%) remained benign on histologic and prolonged clinical follow-up. We conclude that ASCs in urine are rare (0.3% in this series). An interpretation of ASCs in a urine specimen is made when there is insufficient qualitative/quantitative evidence for a carcinoma diagnosis. ASCs in urine are a clinically valid diagnostic category (31% were later diagnosed with SCC). Most patients with urinary ASCs do not develop malignancy and, therefore, these cells may represent a reactive/inflammatory process most commonly due to vaginal contamination (in women) or exfoliation from the distal urethra (in men). Rarely, ASCs may exfoliate from a uterine cervical SCC and, therefore, a pelvic examination should be considered in such patients.     

E-cadherin cell-adhesion molecule expression as a diagnostic adjunct in urothelial cytology

E-cadherin (E-CD) is a cell-adhesion molecule that has been associated with invasion and metastasis in a wide variety of human neoplasms. We have recently shown that, although decreased E-CD expression is associated with increased bladder-wall invasion and higher tumor grade of infiltrating transitional cell carcinomas (TCC), E-CD expression in the exophytic portion of pure papillary and papillary-infiltrating TCC is increased over that of normal transitional cells. To evaluate whether E-CD levels could serve as a diagnostic adjunct in urinary cytology specimens, we stained 40 alcohol-fixed bladder-washing cytospin preparations with an avidin-biotin-peroxidase method using a monoclonal antibody to E-CD (Sigma Chemical Co., St. Louis, MO). E-CD expression level was defined as a high-intensity or low-intensity staining increase over background squamous cell staining for the transitional cells in 21 biopsy-proven transitional cell carcinomas with papillary components, and in 19 benign or reactive control specimens. Twenty-one of 21 TCC (100%) showed an increased E-CD level over background, with 13 low-intensity and 8 high-intensity cases. Ten of 19 benign cases (53%) showed increased E-CD staining over background, with 8 low-intensity and 2 high-intensity cases. This difference between malignant and benign specimens was statistically significant (chi-square test, P = 0.001). We conclude that increased E-CD expression in the papillary components of TCC can be identified in urinary cytology specimens, may reflect the physical and chemical structural makeup of papillary architecture, and warrants further study as a diagnostic adjunct in the interpretation of urine cytology specimens. Diagn Cytopathol 1996;14:310–315. © 1996 Wiley-Liss, Inc.     

Recommendations for the reporting of urinary bladder specimens containing bladder neoplasms

The Association of Directors of Anatomic and Surgical Pathology have developed recommendations for the surgical pathology report for common malignant tumors. The recommendations for carcinomas of the urinary bladder are reported herein.This report was prepared by an ad hoc committee composed of William M. Murphy (Chair), John D. Crissman, Sonny L. Johansson, and Alberto G. Ayala.     

9p21 index as estimated by dual-color fluorescence in situ hybridization is useful to predict urothelial carcinoma recurrence in bladder washing cytology

Recent studies have shown that chromosome 9p21 locus is frequently deleted in the early stages of urothelial carcinogenesis. To study the predictive value of the 9p21 aberrations in recurrence of urothelial carcinoma of the urinary bladder, we applied dual-color fluorescence in situ hybridization for 9p21 and chromosome 9 centromere to the bladder washing cytology samples that were obtained from the patients with urothelial carcinoma of the urinary bladder treated by transurethral resection. For the evaluation, the 9p21 index was defined as the ratio of the mean number of 9p21 signals per nucleus for that of the chromosome 9 centromere signals per nucleus in each of the bladder washing cytology samples. The 9p21 index values of the bladder washing cytology samples with no (G0) cytologic atypia were significantly higher than those of the bladder washing cytology samples with moderate (G2) (P < .01) and severe (G3) (P < .001) cytologic atypia, but the index values did not statistically differ from those of the bladder washing cytology samples with mild (G1) cytologic atypia. Recurrence-free survival in the patients with a low 9p21 index value (<0.9) was significantly poorer in comparison with the patients with a high 9p21 index value (>0.9). Furthermore, 2 patients of bladder washing cytology G1 with a low 9p21 index value recurred much sooner than the other patients of the bladder washing cytology G1 category. These findings indicate that a decreased 9p21 index value is associated with recurrence of urothelial carcinoma of the urinary bladder, and the 9p21 index may be useful as a marker to identify patients with elevated risk of recurrence of urothelial carcinoma of the urinary bladder.     

Modified UroVysion scoring criteria increase the urothelial carcinoma detection rate in cases of equivocal urinary cytology

Huysentruyt C J R, Baldewijns M M, Rüland A M, Tonk R J W, Vervoort P S A M, Smits K M, van de Beek C & Speel E‐J M
(2011) Histopathology 58 , 1048–1053
Modified UroVysion scoring criteria increase the urothelial carcinoma detection rate in cases of equivocal urinary cytology Aims: UroVysion^® is a four‐target fluorescence in situ hybridization technique for the detection of urothelial carcinoma (UC) in urinary cytology. The aim of this retrospective study was to investigate the UC detection rate of a modified UroVysion test in patients with equivocal urinary cytology. The modification comprised the addition of a cytological prescreening technique and different evaluation criteria. Methods and results: Thin‐layer slides were prepared from the residual urine samples of 82 patients with equivocal urinary cytology, prestained and prescreened to confirm the presence of atypical urothelial cells. The same slides were used for the UroVysion test, and scored according to different evaluation criteria. The results were compared with the outcomes of cystoscopic and histological findings. UroVysion detected 68% of the UCs when the manufacturer’s evaluation criteria were applied. In cases of altered evaluation criteria, the sensitivity increased to 81% when at least one copy number change of a probe target was considered to be a positive test result. The specificity only decreased from 84% to 82%. Conclusions: Our data suggest that the sensitivity of the UroVysion test can be increased by the addition of a cytological pre‐screening technique prior to the UroVysion test and a modification of the UroVysion evaluation criteria.     

CD24 expression in urothelial carcinoma of the upper urinary tract correlates with tumour progression

Expression of the mucin-like adhesion molecule CD24 has been implicated in the progression of several types of cancer and has been identified as new prognostic factor. We evaluated CD24 expression in 268 consecutive cases of upper urinary tract urothelial carcinoma with respect to associations with tumour stage, grade, angioinvasion and infiltrative growth pattern using a tissue microarray technique and correlated data with patient outcome. CD24 expression was demonstrated in 161/259 (62%) evaluable tumours and was associated with high tumour stage [77/139 (55%) pTa/pT1 vs 84/120 (70%) pT2–pT4; P = 0.02] and high tumour grade [68/139 (49%) low vs 93/120 (78%) high grade; P < 0.001] as well as presence of angioinvasion (P = 0.002) and infiltrative pattern of invasion (P = 0.007). Patients with CD24-positive tumours tended to have a higher risk of disease progression (P = 0.065). Multivariate analysis, however, proved pT stage >1 [P < 0.001, risk ratio (RR) = 5.87, 95% confidence interval (CI) = 2.88–11.95] and high tumour grade (P < 0.001, RR = 3.30, 95% CI 1.75–6.22) as only independent predictors of metastatic disease. In conclusion, CD24 expression in upper urinary tract urothelial cancer is associated with advanced tumour stage and high tumour grade as well as histopathological features indicative of aggressive tumour behaviour, but it lacks independent impact on patient outcome.     

Cytological significance of abnormal squamous cells in urinary cytology

The aim of this study was to evaluate the significance of abnormal squamous cells (ASCs) in urinary cytology to clarify whether finding of ASCs could improve diagnostic accuracy. A total of 3,812 urine specimens were reviewed. We focused on three parameters of ASCs, necrotic debris, and ASC clusters, and linked them to histological diagnosis and clinical information. ASCs were identified in 34 (0.9%) specimens from 21 different patients. The incidence of ASCs was higher in females than in males. The 34 urine specimens were categorized as voided urine (16 cases), bladder-catheterized urine (17 cases), and bladder-washed fluid (1 case). Six (28.6%) of 21 patients were histologically diagnosed as having combined urothelial carcinoma and squamous cell carcinoma (SCC). Eight patients (38.1%) were histologically diagnosed as having SCC originating from sites other than the urinary tract; those urine specimens showed ASCs that were likely to have been exfoliated from malignant lesions. Necrotic debris and ASC clusters were identified in 12 specimens (35.3%) from 11 patients and 4 specimens (11.8%) from 4 patients, respectively, from a total of 34 specimens. Our results indicate that a great amount of care is needed for cytological diagnosis when attempting to recognize ASCs in urine specimens because ASCs were identified in not only SCC of the bladder but also in carcinoma or nonmalignant lesions of nonurinary tracts. Necrotic debris was found not only in patients who had malignant bladder tumors but also in those who had malignant lesions in locations other than the bladder.     

Urine cytology of micropapillary carcinoma of the urinary bladder

A case of micropapillary carcinoma (MPC) of urinary bladder is presented, in which the urine smear was studied in detail in an attempt to better characterize the cytologic findings of MPC. When the voided urine was examined in low power, cancer cells were scattered in the specimens as compact papillary/spheroidal clusters composed of pleomorphic cancer cells. Solitary carcinoma cells were occasionally observed. High power view of the smear revealed that the papillae/spheroids consisted of high-grade urothelial carcinoma cells. The cancer cells had pleomorphic nuclei with coarsely granular chromatin and thickened, irregular nuclear membrane, and thick cytoplasm. Histologically, the tumor in the resected bladder appeared as small nests with surrounding hallo both in the luminal surface and in the site of wall involvement. These tightly bound papillary/spheroidal clusters comprised of highly atypical cancer cells were the most specific cytologic finding in the urine of MPC, which were considered as a key diagnostic clue of MPC. The background of the urine smear showed numerous granulocytes and bacilli compatible with cystitis, which is a previously known complication of MPC. Differential diagnoses of MPC from those with pertinent cytologic findings such as conventional UC (including glandular differentiation), and primary/secondary adenocarcinoma of urinary bladder are discussed with a brief review of literature.     

Ultrastructural cytology of human osteosarcoma cells

Summary The cytology of 6 osteosarcomas was examined by electron microscopy. In keeping with the varied pattern of osteosarcomas seen by light microscopy several types of tumor cells could be differentiated: osteoblast-like, fibroblast-like, chondroblast-like, osteoclast-like and histiocyte-like cells. Moreover, atypical malignant mesenchymal cells and vascular spaces were present. The individual cytoplasmic organelles are not considered to be specific to particular types of cell as seen from the discussion of the significance of rough endoplasmic reticulum, microfilaments and lysosomes. Only examination of the composite pattern of subcellular organelles allows the differentiation of certain cell types. All tumor cells visible in osteosarcomas are considered as modifications of a transformed common progenitor cell. Because of the variegated cytological picture a multipotent mesenchymal cell rather than an osteoblastic cell is assumed to be the ancestor cell.Dedicated to Prof. Dr. sc. med. F. Bolck on the occasion of his 60^th birthday     

Lymphoepithelioma-like carcinoma of the urinary bladder

A 78-yr-old woman presented with gross hematuria for 2 weeks. On cystoscopy, a frond-like mass was observed at the bladder trigone. Transurethral resection of bladder tumor was performed for the mass. Histopathological findings showed that 90% of lesions were lymphoepithelioma-like carcinoma (LELCA) and a few lesions were non-invasive transitional cell carcinoma. On microscopy, syncytial growth pattern and indistinct cytoplasmic borders were observed with the severe infiltration of lymphoid cells. The case was followed-up for 8 months without recurrence. This is the first report of a LELCA case in Korea.     

Differential diagnosis of acute allograft rejection and CMV-infection in renal transplantation by urinary cytology

Acute allograft rejection and CMV-infection are the most common complications after renal transplantation. Quick differential diagnosis between these two complications is still difficult but necessary, since both complications demand a different therapy. More than 2500 urinary samples from 33 transplanted patients were prospectively examined and part of them evaluated quantitatively. Urinary samples of patients with acute renal failure, long-term haemodialysis or immunosuppressive therapy served as controls. The following cytomorphological criteria proved to be useful: Tubular epithelial cells, casts, oxalate crystals (sand-glass shaped), dirty background, increasing erythrocyturia, mixed cell clusters, lymphocytes and mitoses. Rejection is going on when the number of renal tubular cells is increased and two or more further criteria are positive. 25 acute allograft rejections without acute renal failure were diagnosed clinically. All 25 rejections were also diagnosed by urinary cytology. Nevertheless, it is not possible to differentiate between acute allograft rejection and acute renal failure of other origin. CMV-infection was serologically detected in 7 patients. In 6 of them viral infected cells were found in the urine shortly after the onset of unspecific clinical symptoms. Besides the typical "owl-eye" cells milkglass nuclei, sometimes with eosinophilic condensation, were seen while criteria for transplant rejection were never observed at the same time. Cytologic examination of voided urine is a simple diagnostic help for the differentiation between allograft rejection and CMV-infection after renal transplantation.     

Multiple minute nests of incidentally detected paraganglionic cells associated with urothelial carcinoma of the urinary bladder in a 73-year-old woman

A 73-year-old woman who had undergone resection of urothelial carcinoma (UC) (G3 > G2) of the ureter was also found to have UC (G3) in the urinary bladder, spread throughout the urinary bladder with multiple foci of carcinoma in situ and small papillary cancers. Total cystectomy was therefore performed. On detailed microscopic examination of the extirpated urinary bladder, multiple minute cell nests, 14 in number and less than 2 mm in diameter each, consisting of cells harboring small nuclei and clear cytoplasm, were incidentally detected within the sub-mucosal layer and the proper muscle layer, mainly in the posterior wall of the urinary bladder. Some cell nests were clearly associated with ganglion cells. The cells in minute nests were positive on Grimelius staining and also strongly positive on staining with antibodies to chromogranin A, neuron-specific enolase (NSE), synaptophysin, and vimentin on immunohistochemical staining. In addition, sustentacular cells in the minute cell nests were positive for S100 protein. Staining with antibodies to pancytokeratin AE1/AE3, glial fibrillary acidic protein, and p53 was negative in the cell nests. Based on these findings, the multiple minute foci were diagnosed as paraganglionic cells (PGCs) incidentally detected in the urinary bladder of an elderly woman, in association with UC. Although PGCs are rarely detected in adult human urinary bladder on routine histopathological examination, the possibility of their existence should be kept in mind by pathologists, especially in coexistence with UC. This is the first case of PGCs associated with UC in the human urinary bladder in the English literature.