Analysis of the Cytomorphological Features in Atypical Urine Specimens following Application of The Paris System for Reporting Urinary Cytology

BACKGROUND

This study investigates the use of The Paris System (TPS) for Reporting Urinary Cytopathology and examines the performance of individual and combined morphological features in atypical urine cytologies.

METHODS

We reviewed 118 atypical cytologies with subsequent bladder biopsies for the presence of several morphological features and reclassified them into Paris System categories. The sensitivity and specificity of individual and combined features were calculated along with the risk of malignancy.

RESULTS

An elevated nuclear-to-cytoplasmic ratio was only predictive of malignancy if seen in single cells, while irregular nuclear borders, hyperchromasia, and coarse granular chromatin were predictive in single cells and in groups. Identification of coarse chromatin alone yielded a malignancy risk comparable to 2-feature combinations. The use of TPS criteria identified the specimens at a higher risk of malignancy.

CONCLUSION

Our findings support the use of TPS criteria, suggesting that the presence of coarse chromatin is more specific than other individual features, and confirming that cytologic atypia is more worrisome in single cells than in groups.

High-Grade Urothelial Carcinoma on Urine Cytology Resembling Umbrella Cells

CONTEXT

High-grade urothelial carcinoma (UC) cells have many appearances on urine cytology, but according to The Paris System, they can be easily distinguished from umbrella cells.

OBJECTIVE

We aimed to define the incidence and appearance of high-grade UC cells that resemble umbrella cells in Cytospin preparations on urine cytology.

RESULTS

Cytospin preparations from 331 cases with biopsy follow-up (230 benign/low-grade and 101 malignant [22 carcinoma in situ, 52 papillary, 19 invasive UC, 8 other] cases) were reviewed. A total of 18 cases with malignant cells resembling umbrella cells were identified (17.8% of the malignant cases) and were the only type of malignant cell in 3% of the cases. Two patterns were identified. Tumor cells were either identifiable by at least 20 abnormal cells which were large, had abundant cytoplasm but an elevated nuclear-to-cytoplasmic ratio, and markedly enlarged, round-to-elongated nucleoli, or else rare cells with abundant cytoplasm but obviously malignant nuclei. Cells without nucleoli or obviously malignant nuclei were not specific.

CONCLUSIONS

Malignant cells resembling umbrella cells can be seen in up to 17% of urine cytology specimens.

Is urinary tract cytology still useful for diagnosis of bladder carcinomas? A large series of 592 bladder washings using a five-category classification of different cytological diagnoses

BACKGROUND

The aim of this study was to estimate the efficiency of a recent five-category urinary cytological classification.

METHODS

A total of 592 bladder washings were fixed immediately with Saccomanno's fixative. All samples were centrifuged in a Hettich cyto-centrifuge. For each sample, the reference standard was the histology when a lesion was present at the time of cystoscopy. A five-category cytological classification was used: negative, suspicious of low (S-Lg) or high (S-Hg) grade neoplasia and consistent with low (Lg) or high (Hg) grade neoplasia.

RESULTS

For cytological diagnoses of S-Lg and Lg, sensitivity was 37% and specificity was 95% for the histological diagnosis of low-grade non-invasive urothelial papillary tumour (Lg-UPT), which included papillary urothelial neoplasm of low malignant potential and low-grade urothelial carcinoma. For cytological diagnosis of S-Hg and Hg, sensitivity was 44% for high-grade non-invasive urothelial papillary carcinoma (Hg-UPC), 70% for carcinoma in situ (CIS) and 81% for invasive carcinoma (T1 and higher). Specificity was 99% in each case. Cytological diagnosis of S-Hg or Hg was not found for Lg-UPT (0/59) and no cytological diagnosis of S-Lg or Lg was found for invasive carcinoma, but was seen for Hg-UPC in 10% (3/28) and for CIS in 6% (3/50) of cases.

CONCLUSION

Despite the absence of international consensus, the recent five-category cytological classification for urine is accurate for current urological practice.

The value of the ImmunoCyt/uCyt+ test in the detection and follow-up of carcinoma in situ of the urinary bladder

BACKGROUND

Urine bound tests, which have been developed for the early detection of urothelial cancer (UC), do not seem to match cytology in the detection of carcinoma in situ (CIS) as their sensitivity in the case of CIS is poor. ImmunoCyt/uCyt+ in CIS seems promising, but the number of analysed CIS is still small. The aim of the present study was to assess the value of this test in the detection and follow-up of carcinoma in situ of the urinary bladder.

PATIENTS AND METHODS

Thirty-five patients, with histologically verified CIS of the urinary bladder, were included in the study. At the first diagnosis, patients underwent cytology, cystoscopy, bioptical bladder mapping and ImmunoCyt/uCyt+. All patients underwent BCG instillation therapy. The patients were followed with cytology, ImmunoCyt/uCyt+, cystoscopy and bladder mapping after every BCG cycle and then every 3 months.

RESULTS

At the first CIS diagnosis, the sensitivity of cytology and ImmunoCyt/uCyt+ was 100%. At the first control after therapy, cytology detected 81.8% of recurrences and ImmunoCyt/uCyt+ detected 90.9%. At the second control, both tests each detected 50% of recurrences. At every control, the combination of both the tests together gave a sensitivity of 100%. The specificity of cytology after therapy improved from 88.2% at the first control up to 100% at the third control. The specificity of ImmunoCyt/uCyt+ after BCG initially decreased from 70.6% to 55.5% and finally increased to 88.9%.

CONCLUSION

ImmunoCyt/uCyt+ is as sensitive as cytology in the first diagnosis of CIS. In the follow-up, even if it is less sensitive, its combination with cytology leads to detection of 100% of the recurrences. Despite decreasing specificity after therapy, the value remains acceptable and increases during maintenance therapy. The ImmunoCyt/uCyt+ test could play an important role in controlling the response of patients to instillation therapies or in the modification of their application schedules.

[Early diagnosis of bladder carcinoma]

Asymptomatic erythrocyturia is an early symptom of urinary tracts and kidney diseases, including bladder carcinoma. The aim of the research was to compare the diagnostic validity of the cytological urine analysis and the DNA flow cytometry in detecting cancer cells in urine and bladder washings, taken from patients with asymptomatic erythrocyturia, as an early symptom of the bladder carcinoma in situ. The research was conducted on a group of 48 patients (32 male, 16 female, aged 28-55) with asymptomatic erythrocyturia, caused, in 16 cases, by bladder carcinoma in situ, in 18 cases, by bladder carcinoma in situ with urinary tracts infection, and in 14 cases, by the infection alone. Flow cytomery showed a higher sensitivity and a higher negative prediction value in detecting cancer cells in bladder washings. Flow cytometry analysis of DNA and phase S is used for detecting early disturbances in the cell cycle which result in aneuploidia, which is impossible to detect in cytological analysis. However peculiarity and positive prediction value were the same (100%) in both methods. On the basis of the research it has been proved that asymptomatic erythrocyturia classifies patients for further, in-depth diagnostic examination for the presence of bladder carcinoma in situ. Furthermore, morning urine and bladder washings analysis, which are non-intrusive tests, are an outstanding diagnostic material for screening for this disease. Detecting aneuploidia with flow cytometry can be an early-detection screening test for bladder carcinoma, while the cytological tests should still be used for confirming the diagnosis.

Numeric aberrations of HER-2 and chromosome 17 detected by fluorescence in situ hybridization in urine-exfoliated cells from patients with urothelial carcinoma

OBJECTIVES

To elucidate the clinical significance of the HER-2 gene alterations in urine-exfoliated cells detected by fluorescence in situ hybridization (FISH) in patients with urothelial transitional cell carcinoma.

METHODS

The relative increase of HER-2 (RI-HER2) and gain of chromosome 17 (G-17) in urine-exfoliated cells were examined using DNA probes for HER-2 and the chromosome 17 centromere in 103 patients. In addition, FISH analysis was performed using corresponding paraffin-embedded tissue sections from 45 cases to compare the results obtained using urine-exfoliated cells and those obtained using paraffin-embedded tissue.

RESULTS

RI-HER2 and G-17 was found in 23 (22.3%) and 46 (44.6%) of 103 patients, respectively. RI-HER2 was significantly more frequent in tumors with two or more recurrences (40.7% versus 15.8%, P = 0.010) and in those with carcinoma in situ (CIS) (35.4% versus 15.9%, P = 0.029). G-17 was more frequent in high-grade tumors (69.1% versus 16.7%, P = 0.032), invasive tumors (63.6% versus 14.3%, P < 0.001), and in patients with CIS (77.1% versus 29.0%, P < 0.001). The positive rate for FISH (presence of RI-HER2 and/or presence of G-17) tended to be more frequent in FISH than in cytology. A comparison of the analyses using urine-exfoliated cells and paraffin-embedded tissue showed identical results in 36 (80.0%) of 45 cases.

CONCLUSIONS

Numeric alterations of the chromosome 17 centromere in urine-exfoliated cells detected by FISH may reflect the malignant potential of urothelial carcinoma. In addition, a relative increase in HER-2 was associated with the number of recurrences and the presence of CIS.

Bladder Carcinoma in Situ in 2003: State of the Art

Carcinoma is situ (CIS) of the bladder is a high-grade non-invasive malignancy with a high tendency of progression and transitional cell carcinoma outside the bladder. The diagnosis is a combination of abnormal cytology and cystoscopy with biopsies. Although cytology has clear limitations in low-grade lesions, such as a low inter- and intra-observer reproducibility, high-grade lesions and CIS should be diagnosed with a high degree of sensitivity and specificity. Currently available urinary markers do not (yet) seem to match cytology. The cystoscopic diagnosis is more difficult, since flat lesions are often difficult to see. The application of fluorescence cystoscopy and resection clearly improves the detection of the number of CIS lesions per patient and also the number of patients with CIS. For treatment of CIS (maintenance) BCG remains the golden standard. BCG appears to be able to prevent or delay progression to muscle invasive disease. BCG refractory patients are at high risk for progression and cancer death, and cystectomy is the treatment of choice. Alternatives for BCG refractory CIS patients, like intravesical chemo-immunotherapy, new chemotherapeutic drugs or photo-dynamic therapy, remain highly experimental. Last but not least, the danger for CIS patients is failure to respond to therapy and a high subsequent chance of progression and cancer-specific death. Unfortunately, despite much research, this prediction is not yet possible with molecular markers in daily practice.

Urinary interleukin-2 may predict clinical outcome of intravesical bacillus Calmette-Guérin immunotherapy for carcinoma in situ of the bladder

PURPOSE

The mechanism by which bacillus Calmette-Guérin (BCG) mediates antitumor activity has not been clearly established. Specific cytokines in the urine after BCG intravesical instillation therapy may serve as a prognostic factor of treatment response. In this study, various urinary cytokines such as interleukin-1beta (IL-1beta), IL-2, IL-6, IL-8. IL-10, IL-12, interferon-gamma (IFN-gamma), and tumor necrosis factor-alpha (TNF-alpha) were measured.

MATERIALS AND METHODS

In total 20 patients were treated with BCG intravesical instillation therapy for carcinoma in situ of the bladder. At the completion of the first and eighth instillations, spontaneously voided urine specimens were collected before BCG instillation, every 2 h until 12 h, and thereafter until 24 h. All specimens were ultrafiltrated using an ADVANTEC UK-10 membrane. The cytokines were measured using ELISA and RIA techniques.

RESULTS

Significantly higher levels of IL-2, IL-6, IL-8, IL-10, IFN-gamma, and TNF-alpha were detected in the eighth instillation as compared to the first instillation ( p<0.001). After BCG intravesical instillation therapy, treatment failure occurred in 6 of the 20 patients (30%), including primary failure (persistence of CIS) in 3, and de novo failure (tumor recurrence) in 3 with a median follow-up of 46.9 months. Significantly higher production of IL-2, IL-6, IL-8, IL-10, and TNF-alpha was observed in the responder group than in the non-responder group ( p<0.05). Multivariate analysis revealed IL-2 as an independent prognostic cytokine of responder status.

CONCLUSIONS

This study indicates that urinary IL-2 at the eighth instillation of BCG may serve as a valuable prognostic factor of treatment efficacy as well as tumor recurrence after treatment.

Urinary interleukin-8 levels are elevated in subjects with transitional cell carcinoma

OBJECTIVES

Interleukin (IL)-8 is one of several angiogenic factors produced in bladder cancer cell lines. Although many studies have indicated that IL-8 is increased in infectious/inflammatory processes, elevated levels of IL-8 in urine also may be indicative of active transitional cell carcinoma (TCC).

METHODS

Urinary IL-8 levels were measured with an enzyme-linked immunosorbent assay in subjects with TCC (n = 51), prostate cancer (n = 17), or a history of successfully treated TCC (n = 23) and in healthy subjects (n = 49). In addition, urinary IL-8 levels were measured in 21 subjects before, during, and 1 month after intravesical therapy with bacille Calmette-Guérin or mitomycin C.

RESULTS

The median urinary IL-8 levels were greater in subjects with TCC (64 pg/mL urine) than in healthy subjects (6 pg/mL urine), subjects with prostate cancer (0.5 pg/mL urine), or subjects with a history of successfully treated TCC (5.0 pg/mL urine). Urinary IL-8 levels were greater in subjects with invasive (high-stage) TCC than in those with low-stage TCC. Furthermore, the postintravesical instillation levels of urinary IL-8 levels were greater in patients whose TCC recurred compared with those whose TCC was in remission.

CONCLUSIONS

IL-8 levels were greater in subjects with TCC compared with those with successfully treated TCC. IL-8 levels increased with TCC stage, indicating that they are greater in more invasive (ie, angiogenic) tumors. A reduction in urinary IL-8 levels after treatment with bacille Calmette-Guérin or mitomycin C may reflect a decrease in bladder cancer cells and/or in other cells that produce IL-8.

Use of ThinPrep monolayer technique and cytospin preparation in urine cytology: a comparative analysis

We compared the ThinPrep (TP) technique to the cytospin (CS) preparation in the cytological diagnosis of urine by processing 79 specimens by these two techniques. Ten cases were positive for malignancy (six high grade (HG)/carcinoma in situ; four low grade (LG) transitional cell carcinomas (TCC)). Forty-eight cases were within normal limits (59%) and 21 cases had atypical cytological features (19%). The TP technique was better in terms of a cleaner background with fewer obscuring inflammatory cells and blood and with a more even distribution of cells. In general, the cytomorphology was comparable in both techniques. However, in cases with malignancy, CS was relatively superior in the cytomorphologic details; in TP, the diagnostic cells were mostly dispersed as single cells with loss of architectural features and were difficult to find. Artifactual empty spaces and air-drying were more frequently present in TP. In cases contaminated with squamous cells, the urothelial cells were difficult to find in TP. Screening time was comparable for both techniques. In conclusion, to avoid false-negative diagnosis, CS would be complementary to the TP technique in malignant cases and, in particular, those with low cellularity.

Sensitivity and specificity of commonly available bladder tumor markers versus cytology: results of a comprehensive literature review and meta-analyses

OBJECTIVES

To determine the clinical utility of urine-based bladder tumor markers (UBBTMs) and cytology in the treatment of patients with transitional cell carcinoma on the basis of their statistical performance.

METHODS

A comprehensive literature review was performed using Medline (1966 to current) and other search engines. Data regarding the statistical performance of UBBTMs were double extracted and rectified. Studies addressing comparable patient populations were combined and hierarchical Bayesian meta-analyses performed to calculate the sensitivity and specificity of commonly used UBBTMs, as well as urinary cytology. Patient populations were stratified by tumor stage and grade when data were presented in an extractable fashion.

RESULTS

The literature review yielded 54 publications, 338 distinct patient groups (controls, screening population, patients with cancer, strata based on grade and stage) and more than 10,000 patients. The number of groups varied from 1 to 18, and the number of patients ranged from less than 100 to more than 1500 for the various markers. All UBBTMs have better sensitivity compared with cytology, especially for low-grade/stage disease, but do not match cytology regarding specificity. In patients with grade 1 and 2 tumors, several UBBTMs are significantly superior statistically in terms of sensitivity compared with cytology. The sensitivity for transitional cell carcinoma in situ (Tis) is surprisingly poor for all UBBTMs.

CONCLUSIONS

UBBTMs can be used for follow-up of low-grade/stage tumors but should not replace cystoscopy. All UBBTMs have better sensitivity than cytology and could potentially replace routine cytology during patient follow-up.

Cytologic evaluation of urine is important in evaluation of chronic prostatitis

OBJECTIVES

Cytologic examination of the urine has not been a recommended part of the diagnostic workup for patients presenting with chronic prostatitis. We identified 3 patients referred to our tertiary Prostatitis Research Clinic who had carcinoma in situ of the bladder discovered after evaluation of urine cytology.

METHODS

One hundred fifty consecutive patients referred to the Queen's University Prostatitis Clinic during 2000 and 2001 underwent extensive evaluation, including collection of urine specimen for cytologic examination if they also had symptoms compatible with interstitial cystitis (urinary frequency, urgency, and suprapubic pain).

RESULTS

Three patients, who were referred to our tertiary prostatitis clinic after being evaluated and treated by other urologists for an average of 3.5 years for chronic prostatitis, were eventually diagnosed with carcinoma in situ of the bladder. The patients were older than the average patient referred to our specialized clinic (average age 61 years compared with 42 years for the average patient). All 3 patients complained of pain (suprapubic and/or perineal) and irritative voiding symptoms, and 2 had dysuria. Only 1 of these patients had microscopic hematuria.

CONCLUSIONS

We recommend that urine cytology become a diagnostic test for men presenting with prostatitis-like symptoms, particularly if the symptom complex includes irritative voiding symptoms, dysuria, and suprapubic/bladder pain.

Leukocyturia as a predictor of tolerance and efficacy of intravesical BCG maintenance therapy for superficial bladder cancer

OBJECTIVES

To examine leukocyturia as a predictor of tumor recurrence and occurrence of adverse events after bacille Calmette-Guérin (BCG) immunotherapy. The use of BCG immunotherapy, a very major advance in the management of superficial bladder cancer, is limited by the frequency of adverse events. As yet, we have no way of predicting the efficacy and tolerability of BCG instillation in clinical practice. This problem is even more acute during BCG maintenance therapy.

METHODS

Adverse events in 72 patients who received 518 instillations were prospectively assessed using a four-class scale based on severity and duration. Urinary leukocytes were counted 3 days after each instillation, using the KOVA-Slide 10 method.

RESULTS

High leukocyturia during BCG treatment (cutoff value 1.65 x 10(5)/mL urine) correlated with recurrence-free status (P = 0.009). The degree of leukocyturia correlated with the severity/duration of adverse events (P <0.0001); the median leukocyturia values associated with class I, II, and III adverse events were 4 x 10(4)/mL, 1.5 x 10(5)/mL, and 3.5 x 10(5)/mL, respectively. No class IV events occurred. The cutoff point indicating treatment cessation for adverse events was leukocyturia of 8.6 x 10(4)/mL.

CONCLUSIONS

These results suggest a link between adverse events and efficacy during BCG maintenance therapy. Leukocyturia appears to correlate with both efficacy and tolerability in this setting. Prospective randomized studies are required to evaluate leukocyturia as a basis on which to adapt the BCG instillation schedule to individual patient susceptibility.

Urinary bladder cancer test: a new urinary tumor marker in the follow-up of superficial bladder cancer

OBJECTIVES

To study the diagnostic performance of the Urinary Bladder Cancer (UBC) test in patients with superficial bladder carcinoma.

METHODS

One hundred one patients in follow-up for superficial bladder cancer (pTa, pT1, carcinoma in situ) were recruited for this study. Each patient underwent cystoscopy and transurethral resection or biopsy, with subsequent histologic confirmation in the case of abnormalities. In addition, specimens were assessed with an immunoenzymometric assay for cytokeratin expression (the UBC test), and the urinary creatinine concentration was determined to correct for different degrees of urinary dilution. Different methods were applied to calculate the diagnostic value of the UBC test.

RESULTS

Both noncorrected and corrected median values of the UBC test were comparable between patients with and without a recurrent bladder tumor. The overall sensitivity, specificity, and positive and negative predictive values of the noncorrected UBC test was 20.7%, 84.7%, 35.3%, and 72.6%, respectively. For the corrected UBC test, the corresponding values were 20.7%, 79.2%, 28.6%, and 71.3%. The area under the receiver operating characteristic curve was not significantly different from 0.50, indicating no diagnostic value of the UBC test in this study.

CONCLUSIONS

The diagnostic value of this new urinary marker appears insufficient for the follow-up of patients with superficial bladder cancer.

The utility of fibrin/fibrinogen degradation products in superficial bladder cancer

Fibrin/fibrinogen degradation products are either absent or present at exceedingly low levels in the urine of healthy persons. Although various nonspecific inflammatory conditions of the urinary tract can result in detectable amounts of FDP in the urine, the presence of FDP is far more prevalent in urine from patients with bladder cancer. Urinary FDP levels tend to be higher in patients with tumors of increasing grade and stage. This correlation results in improved sensitivity in detecting more aggressive tumors. Current monoclonal antibody immunoassays are simple, rapid, and inexpensive, and can be performed on urine samples in the clinical setting. The overall accuracy of these immunoassays ranges from 75% to 80% (Table 1), suggesting that the urine FDP test should not be used alone for the surveillance of superficial bladder cancer. When assays for urine FDP are combined with urine cytology, the sensitivity for detecting tumors is improved. Prospective data are needed to determine whether using these tests in combination can safely permit a reduced frequency of endoscopic surveillance.

The role of urine cytology in the assessment of lower urinary tract symptoms

OBJECTIVE

To evaluate the role of urine cytology in the investigation of men with lower urinary tract symptoms (LUTS) in the absence of haematuria.

PATIENTS AND METHODS

The study comprised 336 men attending a LUTS assessment clinic, who had neither macroscopic nor microscopic haematuria. One sample of urine was collected for cytology. Those with suspicious urine cytology were investigated with intravenous urography and cystoscopy.

RESULTS

Five men had abnormal urine cytology results; on further investigation one of them was found to have carcinoma in situ (CIS) and one to have a transitional cell carcinoma. Three had false-positive urine cytology results.

CONCLUSION

A bladder tumour or CIS was detected in 0.6% of the population tested. The cost per cancer diagnosed was GB pound 2020. Urine cytology is a simple noninvasive way of assisting accurate diagnosis of men who have LUTS in the absence of haematuria.

Prognosis of intravesical bacillus Calmette-Guerin therapy for superficial bladder cancer by immunological urinary measurements: statistically weighted syndrome analysis

PURPOSE

The goal of this research was to discover new biological indicators in urine which could be used for short-term prognosis of local Bacillus Calmette-Guerin (BCG) therapy outcome in patients with superficial bladder cancer.

PATIENTS AND METHODS

We measured and statistically evaluated soluble immunological molecules in urine from bladder cancer patients (n = 34) receiving BCG intravesically. Urine was collected following each of 6 weekly treatments, processed and assayed. The data base included measurements of interleukin-1 (IL-2, IL-4, IL-6, IL-10, IL-12, soluble intercellular adhesion molecule-1 (sICAM-1), tumour necrosis factor-alpha (TNF alpha), soluble CD14 (sCD14), interferon-gamma (IFN gamma), GM-CSF, volume of urine and its pH. The clinical response was evaluated by urine histology and random quadrant biopsy 3 months after the start of therapy. Patients were divided into 2 groups, with good and poor therapeutic effect. The initial complete response rate was 62% (21/34). The data base was analyzed using traditional multivariate statistical methods and a pattern recognition method which deals with combinatorial-statistical analysis (statistically weighted syndromes (SWS) method) of the gradated features. The SWS method is capable of identifying robust patterns in small "fuzzy" sets with high dimensional objects and some missing values.

RESULTS

Only one parameter gave significant differences at p < 0.05, GM-CSF at instillation 6. Repeated measurement analysis of variance, backward stepwise multiple logistic regression and linear discriminant analysis failed to show any significance. However, significant differences in the structure of correlation between features in the groups with and without therapeutic effect were observed and four highly informative variables (the masses of sICAM-1, TNF alpha, sCD14 and pH) relating to 5th-6th installations were selected by SWS. These features provided accurate individual prediction of therapeutic outcome for all our patients. Cross-validation analysis and computer simulation showed the statistically significant stability of the prediction.

CONCLUSION

We have selected a set of urinary variables that could be considered as a perspective combination of indicators (syndromes) of outcome of pre-operation BCG therapy of patients with superficial bladder cancer. A larger patient database will provide testing and evaluation of the biological and clinical significance of selected features. The computational syndrome-disease approach should be applicable for the solution of decision-making problems for management of cancer.

[Changes in the cytokine concentration during immunotherapy of superficial bladder tumors]

A growing number of data support the importance of urinary cytokines in the BCG immunotherapy of superficial bladder tumours. To investigate kinetics and stability, urinary levels of IL-8, IL-2 and IL-6 cytokines after BCG treatment, were determined. Significant elevation in the level of IL-8 was established immediately following the first BCG instillation and it reached its highest value 4-6 hours after the treatment. During the first three weeks of the treatment and follow-up period IL-8 peaked significantly earlier than IL-2 or IL-6. Its early appearance associated with high stability makes IL-8 a good candidate for being considered as an effective agent with high predictive value in BCG immunotherapy.

[Can the combination of bladder ultrasonography and urinary cytodiagnosis replace cystoscopy in the diagnosis and follow-up of tumors of the bladder?]

OBJECTIVES

Cystoscopy is currently the reference examination for the diagnosis and surveillance of bladder tumours (BT). However, this examination remains unpleasant for the patient, despite the development of flexible cystoscopes. Among the many diagnostic methods performed in combination with cystoscopy, the authors decided to evaluate the performances of the combination of ultrasonography+urine cytology in the diagnosis and follow-up of bladder tumours.

METHODS

This prospective study included 124 cases in the context of postoperative surveillance of BT (86) or aetiological assessment of haematuria (38). All patients were assessed by cystoscopy, suprapubic vesical ultrasonography, and urine cytology.

RESULT

Cystoscopy revealed a bladder tumour in 30 patients. Urine cytology had a sensitivity of 53% and a negative predictive value (NPV) of 86%. Vesical ultrasonography had a sensitivity of 50% and an NPV of 85%. The false-positive and false-negative results of ultrasonography and urine cytology make these examinations unreliable when considered separately. The combination of ultrasonography and urine cytology had an overall sensitivity of 80% and an NPV of 93%. However, analysis of the group of patients undergoing postoperative surveillance for BT showed that although the combination of the two examinations had a diagnostic sensitivity of 100% in the case of high-grade tumour or CIS, this value was only 66% for low-grade tumours. The authors review other methods of bladder tumour diagnosis, but none of them appears to have demonstrated a sufficient reliability at the present time.

CONCLUSION

The diagnostic sensitivity of the combination of ultrasonography and urine cytology, accurate but not recommended in high-risk patients with a high-grade BT, does not appear to be sufficient for systematic surveillance of patients with low-grade BT, despite the low risk of recurrence.

Beta-core fragment (beta-core/UGF/UGP), a tumor marker: a 7-year report

In 1988 we published three papers describing immunoassay results for urine beta-core fragment as a marker of gynecological cancers. Many other papers have been published since, and three commercial immunoassays have been established. beta-Core fragment is called beta-core, UGF, or UGP by different commercial vendors. To avoid confusion we call it beta-core/UGF/UGP here. In this 7-year report, we compare the three commercial assays, establish cutoff limits, and use the Ciba-Corning kit for two large studies. The first was a retrospective study, measuring beta-core/UGF/UGP in gynecological cancer and control urines accumulated in our freezers (n = 486). The second is a first prospective study, testing over a 16-month period beta-core/UGF/UGP levels in urines of all new patients attending the Gynecology Oncology Clinic (n = 548). In the retrospective study, elevated beta-core/UGF/UGP levels ( > 1.9 ng/ml) were detected in 11% of urines from healthy individuals (n = 132), in 11% from women with benign gynecological disease (n = 196), in 44% from cervical cancer (n = 68), 56% from ovarian cancer (n = 54), and 47% from endometrial cancer (n = 38). Altogether, beta-core/UGF/UGP levels were elevated in 50% of 170 samples from gynecological cancers. Overall, sensitivity increased with advancing stage of malignancy. Sensitivity was 28% for stage I, 50% for stage II, 47% for stage III, and 68% for stage IV malignancies. In the prospective study very similar results were recorded. Elevated beta-core/UGF/UGP levels ( > 1.9 ng/ml) were detected in 11% of urines from healthy individuals (n = 99), 11% from individuals with benign gynecological disease (n = 196), 7% from women with carcinoma in situ (n = 28), in 42% of samples from cervical cancer (n = 69), 56% from ovarian cancer (n = 59), and 52% from endometrial cancer. Altogether, beta-core/UGF/UGP levels were elevated in 48% of 225 gynecological cancer samples. Overall, sensitivity increased with advancing stage of malignancy. Sensitivity was 29% for stage I, 66% for stage II, 60% for stage III, and 77% for stage IV malignancies. In both studies sensitivity for beta-core/UGF/UGP increased with advancing stage of disease. Sensitivity for cervical and endometrial cancers was slightly lower than that for ovarian malignancies. This difference may be due to the preponderance of advanced-stage-disease patients in the ovarian cancer group. beta-Core/UGF/UGP may be a general stage-dependent marker for all gynecological cancers. The same false-positive results and very similar sensitivity values were found in a retrospective and a prospective study. They confirm each other, and suggest a definitive false-positive rate and sensitivity of this tumor marker for gynecological cancers.

Initial evaluation of the bladder tumor antigen test in superficial bladder cancer

PURPOSE

We analyzed the value of the Bard bladder tumor antigen (BTA*) test for the diagnosis of stage Ta superficial bladder cancer and carcinoma in situ, and compared it to the highly sensitive bladder washing cytology.

MATERIALS AND METHODS

The BTA test is a latex agglutination test that qualitatively detects the presence of basement membrane complexes in the urine. A total of 60 patients with superficial bladder cancer underwent voided urine BTA analysis and bladder washing cytologies.

RESULTS

Of the patients 65% were correctly diagnosed with the BTA test compared to 32% with bladder washings, which is statistically significant (p < 0.001).

CONCLUSIONS

The BTA test is a noninvasive diagnostic tool that is superior to bladder washing cytology for diagnosing superficial bladder cancer.

Detection of bladder tumors by immunostaining of the Lewis X antigen in cells from voided urine

OBJECTIVES

A study was made to determine the sensitivity and specificity of immunostaining of the Lewis X antigen in exfoliated urothelial cells from voided urine, for the detection and surveillance of bladder tumors.

METHODS

Three consecutive voided urine specimens were obtained from 101 patients, 78 of whom were under surveillance because of a history of bladder tumors, and 23 were being evaluated because of hematuria or irritative urinary symptoms. Indirect immunoperoxidase staining of two urine samples was done on cytocentrifuge slides, using the P12 monoclonal antibody against the Lewis X antigen. The diagnosis of the presence of urothelial tumor was made if more than 5% of the cells showed a typical red-brown staining. Cytopathologic examination of the third urine specimen was done according to Papanicolaou. Each patient underwent cystoscopy, and biopsies were obtained whenever there was endoscopic evidence of bladder tumors or carcinoma in situ.

RESULTS

Cystoscopy and biopsies revealed transitional cell carcinoma in 32 patients, whereas 69 patients had no evidence of bladder tumors. Immunocytology of one urine sample showed true-positive results in 26 of the 32 patients with bladder tumors, corresponding to a sensitivity of 81.25%. When two samples were examined, a sensitivity of 97% and a specificity of 85.5% were obtained. When the results of cytology and immunocytology were combined, sensitivity reached 100%. High-grade and low-grade transitional cell tumors were detected with equal efficiency.

CONCLUSIONS

The use of P12 monoclonal antibody for evaluation of Lewis X reactivity in cytologic preparations from multiple voided urine specimens can improve the sensitivity of noninvasive detection of bladder cancer. The technique may ultimately replace cystoscopy in monitoring therapeutic response and tumor recurrence.

Diagnostic problems of urine cytology on initial follow-up after intravesical immunotherapy with Calmette-Guérin bacillus for superficial bladder cancer

After transurethral resection or biopsy, patients with recurrent bladder cancer or in situ carcinoma were given topical immunotherapy with low-dose Calmette-Guérin bacillus (BCG). In the recurrence-free interval they were treated with BCG monthly for 1 year and then every 3 months for the next year. Cytological analysis was always performed concomitant with the administration of immunotherapy. In order to evaluate the therapeutic success, cystoscopy and biopsy were performed after the first cycle of BCG and then every 3 months. At the start of topical therapy with BCG, a great increase in the number of inflammatory cells was seen. In urothelial cells the nuclei were enlarged; they were hyperchromatic with sometimes increased and prominent nucleoli, anisocaryosis and a distorted nucleus-plasma ratio. These cytological findings were also made 1 year after initial therapy and slowly diminished in the 2nd year during immunotherapy at 3-month intervals. The accuracy of urine cytology for carcinoma in situ is 80%. Interpretation of cytology in the recurrence-free interval was impaired. When doubtful, the recurrence of a carcinoma in situ under maintenance therapy with BCG must be proved by biopsy.

A new approach in the diagnosis and follow-up of bladder cancer. FISH analysis of urine, bladder washings, and tumors

The aim of the present study was to ascertain whether fluorescence in situ hybridization (FISH) of urine could be a useful approach in bladder cancer. Herein, we present the cytogenetic and FISH findings in patients with and without bladder cancer. The samples examined with FISH consisted of urine, bladder washings, and tumor tissue, when available. The results obtained show that the FISH technique, particularly when used on urine, is a very useful tool in the diagnosis, early detection, and management of bladder cancer.

[Intravesical instillations of BCG and bladder carcinoma in situ]

32 patients with bladder carcinoma in situ (CIS) were treated by intravesical instillations of BCG immun F Pasteur between 1988 and 1991. The CIS was isolated (13 cases, 40.6%) or associated with a pTa papillary tumour (10 cases, 31.2%), pT1 tumour (8 cases, 25.1%) or pT2 tumour (1 case, 3.1%). The protocol consisted of a series of weekly instillations of 150 mg of BCG for 6 weeks, repeated once in the case of persistent lesions on the first endoscopic follow-up examination. Patients were reviewed in the outpatients department every 3 months for 1 year, then every 6 months for 2 years in the absence of recurrence. Follow-up consisted of clinical examination, urine cytology and histology. The overall success rate, defined by complete resolution of the cytological and histological lesions for the total population was 81.25% (25/32) with a mean follow-up of 22.5 months. 18.75% (6/32) of cases were considered to be failures. Complications of treatment were observed in 59% of patients, but only required discontinuation of instillations in five patients (15.6%). In conclusion, intravesical BCG is the treatment of choice of bladder carcinoma in situ in the absence of detrusor invasion and contraindications to BCG.

Beta-core fragment of human chorionic gonadotropin in cervical intraepithelial neoplasia (CIN)

A low molecular weight glycoprotein immunologically identical with the beta-core fragment of hCG (beta C-hCG) has been described in invasive tumors of the genital tract, particularly carcinoma of the cervix. A previous report has also suggested increased urinary concentrations in subjects with cervical intraepithelial neoplasia (CIN). This prospective study of 107 patients with CIN was conducted to determine concentrations of beta C-hCG in the urine compared to a reference population without CIN. All subjects underwent a cervical smear and colposcopy, with biopsy when indicated. Between 11 and 18% of patients had urinary concentrations of beta C-hCG greater than the upper limit of the reference group and these results were confirmed when corrected for urinary creatinine concentration. A substantial number of subjects (19%) also had a positive result in a C-terminal immunoassay. It is concluded that preinvasive carcinoma of the cervix may secrete hCG or beta C-hCG in the earliest stages although measurement of beta C-hCG is unlikely to prove to be a valuable diagnostic marker in CIN.

Outcome in carcinoma in situ of bladder treated with intravesical bacille Calmette-Guérin

Fifty-three patients with carcinoma in situ of the bladder were treated with Evans strain BCG given intravesically. Complete remission was achieved after either one or two 6-weekly courses in 53% of patients. The median duration of remission was 32 months. Treatment-related bladder symptoms were minor during the first course, more severe during the second. There was no relation between severity of symptoms and likelihood of response. With a median follow-up of 32 months, disease progression has occurred in 10% of complete responders, whereas failure to respond on either cystoscopic, histological or cytological grounds was associated with a 48% progression rate. Although intravesical BCG produces impressive responses in carcinoma in situ of the bladder, managed conservatively the condition remains a dangerous one.

[Urinary cytology for carcinoma of the urinary bladder]

Cytologic examinations of voided urine were reviewed for 82 cases of invasive or noninvasive papillary carcinoma and 25 cases of carcinoma in situ of the urinary bladder. Five of the 82 cases of invasive or noninvasive papillary carcinoma and 3 of the 25 cases of carcinoma in situ were asymptomatic, and malignancy was detected only by urinary cytology. Urinary cytology was positive in 18.5% of the Grade 1, 33.3% of the Grade 2, 75% of the Grade 3 noninvasive carcinomas and in 77.8% of the invasive carcinomas. However, all 25 cases of carcinoma in situ gave positive cytologic results. Malignant cells found in Grade 1 noninvasive papillary carcinoma were slightly atypic in shape. Their nuclei were small but showed mild to moderate hyperchromasia. These malignant cells appeared in small clusters but the number of clusters were few. In Grade 2 or 3 noninvasive papillary carcinoma, malignant cells appeared in small clusters or isolated single cells. Their nuclei were irregular in shape and showed moderate to marked hyperchromasia. In invasive carcinoma and carcinoma in situ, many malignant cells with marked atypia were observed, but in carcinoma in situ, the background of the specimens was clean.

[Suprapubic bladder ultrasonography and urinary cytology: indications and limits in the follow-up of superficial bladder tumors]

139 patients underwent urinary cytology and bladder sonography in follow-up of superficial bladder cancer (Ta G1-3) alternatively or at the same time of cystoscopy. Medium follow-up was 27.2 mos. In 7.91% there was progression to T1 o T2 but no case escaped this protocol. In 9% urinary cytology and bladder sonography were both falsely negative: tumors were smaller than 0.5 cm and low grade. In 76 patients with Tar bladder cystoscopy rate was 1/5.2 mos. before this study and 1/7.2 mos. after this study. In our opinion this protocol reveals the recurrence of superficial bladder tumor, reduce cystoscopy rate with no risk of ignored progression.

Leukocytes in the urine after intravesical BCG treatment for superficial bladder cancer. A flow cytofluorometric analysis

Cellular immunologic reactions occurring in the bladder after intravesical treatment with bacillus Calmette-Guérin (BCG) were investigated by flow cytofluorometric analysis of leukocytes present in the urine. Urine specimens from 11 superficial bladder cancer patients were collected before and 5, 24, 48 and 72 h after repeated BCG instillations. Monoclonal antibodies specific for granulocytes, monocytes/macrophages, and T-and B-lymphocytes were used to characterize and quantify leukocyte subpopulations. The total number of cells in urine was found to be 2- to 485-fold increased 24 h after BCG administration. The predominant cell type present was the polymorphonuclear granulocyte, probably representing a defense mechanism against mycobacteria. The main mononuclear leukocytes in urine specimens were monocytes/macrophages and T-lymphocytes, indicating an ongoing immune response in the bladder wall. Although percentages of lymphocytes were low, T- and B-cells could be identified using a selective cell measurement procedure. In conclusion, a clear increase in the numbers of granulocytes, monocytes/macrophages and T-lymphocytes in urine after intravesical BCG administration was demonstrated, indicating local activation of the immune system.

Presence of activated lymphocytes in the urine of patients with superficial bladder cancer after intravesical immunotherapy with bacillus Calmette-Guérin

To study the mode of action of intravesical bacillus Calmette-Guérin (BCG) immunotherapy in the prevention and cure of superficial bladder cancer, flow-cytofluorometric analysis of the cellular immunological reaction in the urine of patients was performed. Fresh urine-derived leucocytes were obtained from eight patients before (t0) and 24 h (t24) and 48 h (t48) after repeated intravesical BCG instillations (at least 5 instillations). For two patients urine-derived leucocytes were investigated at the first BCG instillation. The number of leucocytes in the urine was markedly increased 24 h after repeated BCG instillations, indicating a local cellular immunological reaction induced by BCG. The mean number of cells per milliliter of urine at that time was 2.9 x 10(6) +/- 3.6 x 10(6) (n = 8). These leucocytes consisted mainly of granulocytes (75 +/- 11%, n = 8). In addition monocytes/macrophages (4 +/- 2%, n = 8) and T lymphocytes were present (1 +/- 1%, n = 5). The relative increase of monocytes/macrophages in the urine after BCG application tended to be higher compared to the other leucocyte subtypes. As T lymphocytes may play an important role in the BCG-mediated anti-tumour activity, subsets of lymphocytes were further characterized at t0, t24, and t48 after repeated BCG instillations. The lymphocyte population consisted mainly of T cells (86% CD3+, t0). Most of the T cells were CD4+ (helper/inducer) and were significantly decreased at 48 h (62 +/- 9% at t0 vs 49 +/- 6% at t48). Lymphocytes partly expressed HLA-DR antigens (44%, t0). The percentage of lymphocytes with interleukin-2 (IL-2) receptors (CD25+) was significantly increased at 24 h and 48 h, compared to pre-instillation values (19 +/- 11% and 10 +/- 4% vs 3 +/- 3% respectively). Natural killer cells (CD16+ and/or CD56+) and B cells (CD19+) were less numerous (10% and 19% at t0 respectively). After the first BCG instillation the increase in the number of leucocytes in urine seemed to be less compared to the numbers after repeated BCG instillations. Lymphocytes could not be detected in the urine collected before or after the first BCG instillation. In conclusion, we demonstrated the presence of considerable numbers of leucocytes in the urine 24 h after repeated BCG instillations, i.e. shortly after immunological activation. The antigen expression of the lymphocytes suggested that they may represent the lymphocytes in the bladder wall. Expression of HLA-DR and IL-2 receptors on lymphocytes indicated activation of T cells by the intravesical BCG treatment.(ABSTRACT TRUNCATED AT 400 WORDS)

Urine cytology in bladder tumors

A review of experience with urine cytology in the diagnosis and follow up of bladder cancer at Roswell Park Memorial Institute from 1971 to 1981 is reported. All patients had biopsy-proven transitional cell carcinoma of the bladder. A total of 677 patients underwent 2,877 cytological evaluations. Of these, 317 patients had concomitant cystoscopy, cytologic evaluations and bladder biopsies. A total of 1,091 evaluations were performed in this group. The overall incidence of positive cytology in the presence of biopsy-proven bladder tumor (all grades included) was 74.4%. A linear correlation is present with grade, stage and positive cytology; high-grade tumors and carcinoma-insitu showed 89.9% and 96.9% incidence of positive cytology, respectively. Grade II tumors showed a 64% incidence of positive cytologies. Regarding correlation with the pathological stage, submucosal involvement of the urothelium was associated with a 62% incidence of positive exfoliative urine cytology, while 80% of tumors invading the bladder muscle were found to have a positive cytology.

Radio-immunoassay detection of interferon-gamma in urine after intravesical Evans BCG therapy

Our previous studies suggested that interferon-gamma (IFN gamma) was produced in the local immune response to intravesical BCG. To confirm this we modified a commercially available radio-immunoassay for detection of this lymphokine in urine. The urinary levels of IFN gamma were compared in serial urine samples taken from six patients undergoing treatment with Evans strain BCG and seven patients receiving intravesical mitomycin C/epirubicin. IFN gamma was detected consistently in response to BCG with levels reaching a peak (mean 67.1 U/ml., range 7.9 to 155.9 U/ml.) four to six hours post-instillation whereas after other intravesical agents no IFN gamma was detectable after seven of 13 instillations. After the remaining six instillations lower levels were detected (mean 7.4 U/ml., range 0.6 to 22.4 U/ml.). The difference in peak levels between the two groups was statistically significant (p less than 0.001 Mann Whitney U test). These results are further evidence of specific cellular immune activity in response to intravesical BCG therapy and suggest anti-tumour mechanisms similar to allograft rejection and autoimmunity.

Multiple mucosal biopsies and postoperative urinary cytology in patients with bladder cancer

Seventy-one patients with bladder tumors of stage Ta, T1 or T2 were studied by bladder mucosal biopsies. In 34 (48%) patients abnormal histology was found in at least one of the biopsies. The occurrence and severity of mucosal abnormalities were related to tumor grade and stage. Urinary cytology after complete tumor resection was positive in 18 of 19 patients with abnormal biopsies and in 6 of 12 patients with normal biopsies. Postoperative urinary cytology seems to be a good indicator for the presence of urothelial atypia.

Urinary interleukins in patients receiving intravesical Bacillus Calmette-Guerin therapy for superficial bladder cancer

Intravesical administration of Bacillus Calmette-Guerin (BCG) causes a localized cell-mediated immune response. The intensity of this inflammatory response may be gauged by measuring the levels of both interleukin-2 (IL-2) and an inhibitor of interleukin-2 (IL-2-IN) activity in the urine during the hours after a BCG instillation. The levels of urinary IL-2 and IL-2-IN in the sixth week of BCG therapy predicted the subsequent clinical course in a group of 25 patients (P less than 0.01). Measurement of urinary IL-2 and IL-2-IN activity may be used to identify accurately those patients likely to develop a tumor recurrence, thereby sparing them the risk associated with inadequately treated bladder cancer. Since IL-2 and IL-2-IN are competitive with respect to biologic activity, and since relatively high urinary levels of either IL-2 or IL-2-IN activity correlated with a favorable clinical course, the authors conclude that the presence of bioactive IL-2 in urine is not required for the prevention of recurrent superficial bladder cancer.

Positive urinary cytology after tumor resection: an indicator for concomitant carcinoma in situ

Concomitant urothelial atypia (grade II atypia or carcinoma in situ) is predictive of new tumor growth after transurethral tumor resection. Concomitant urothelial atypia can be demonstrated by pre-selected site mucosal biopsies. However, a number of patients have new tumors despite normal pre-selected site biopsies. To investigate whether urinary cytology is a better indicator for concomitant urothelial atypia than pre-selected site biopsies, we studied in bladder tumor patients the correlation between the findings of pre-selected site biopsies (8 per patient) at tumor resection and urinary cytology (2 per patient) after successful resection. Concomitant urothelial atypia was demonstrated by biopsies in 52 per cent of the patients, of whom 60 per cent had grade II atypia and 40 per cent had carcinoma in situ. All patients with concomitant carcinoma in situ in biopsies had positive cytology findings. Of the patients with concomitant grade II atypia in biopsies 15 per cent had negative cytology studies. In 48 per cent of the patients no urothelial atypia in pre-selected site biopsies was demonstrable. However, cytology was positive, that is neoplastic cells were present, in 64 per cent of these specimens (19 patients). Of the 19 patients 16 currently have had demonstrable urothelial atypia in pre-selected site mucosal biopsies at a later occasion. We conclude that urinary cytology seems to be a better indicator for the presence of concomitant urothelial atypia than pre-selected site mucosal biopsies and, therefore, it can be used as a screening procedure for patients without demonstrable concomitant carcinoma in situ at tumor resection.

Flat in situ carcinoma of the bladder: cytological examination of urine in diagnosis, follow up, and assessment of response to chemotherapy

Urine cytology was performed for the diagnosis and follow up of flat carcinoma in situ (CIS) of the bladder in a series of 35 patients without associated or previous bladder tumours. Ninety six per cent had positive or suspicious cytology at initial presentation. There were no false positive reports. Cytological diagnosis of malignancy was made before biopsy in 24 patients: CIS in voided urine presents as flat sheets of five to 15 cells with features of high grade malignancy. Development of tumour during follow up was suggested by the appearance of large thick sheets and clusters of 30 or more malignant cells which were large and pleomorphic in high grade tumours and relatively small and closely cohesive in low grade tumours. Eleven of 13 patients with these clusters had bladder or ureteric tumours and two had malignant disease in the prostate. Negative cytological results in the presence of degenerative changes caused by chemotherapy was an unreliable indicator of response to chemotherapy, and there were five patients with false negative reports during treatment, of whom three had developed tumour. Persistence of malignant cells with features similar to those seen in the urine before treatment reliably predicted failure to respond to chemotherapy.

Reliability and accuracy of Urotel test, a device for urinary cytology

Many steps are to be taken before a urinary specimen is cytologically examined. The physician can improve the cytologic results by providing the cytologist with the best possible cellular material collected and fixed in a standardized manner as by using the Urotel test. This is a plastic device prefilled with two fixatives. It means a two-step fixation and spontaneous sedimentation of cells to reduce the amount of liquid for easier and safer transportation from the doctors' offices and hospitals with no cytologic facilities to the diagnosing laboratory. The aim of this study was to obtain an estimate of the accuracy of the Urotel test. Based on 903 patients' first urinary specimen and the original diagnoses, this study indicates that the standardized handling with the device described may increase the possibility for the general practitioner to refer his or her patient, who has an early urothelial malignancy, to the urologist for a quick handling without any delay.

Flow cytometry versus urinary cytology in the evaluation of patients with bladder cancer

We compared the roles of urinary cytology and flow cytometry in the evaluation of patients with bladder cancer in clinical practice situations at a large general hospital. Specimens included 105 bladder washings from patients being followed for urothelial carcinomas and 28 control washings from individuals undergoing cytoscopy for other reasons. Flow cytometry and cytology were performed on aliquots of the same specimen in all bladder cancer samples. When carcinoma was present at the time of specimen collection it was detected by positive cytology in 75 per cent and deoxyribonucleic acid aneuploidy in 78 per cent of the cases. Combination of flow cytometry and urinary cytology increased the diagnostic yield to 95 per cent. Flow cytometry was slightly more sensitive than urinary cytology for detection of abnormalities in specimens from noninvasive and untreated tumors but the only statistically significant difference between the 2 procedures occurred among specimens from treated invasive cancers in which flow cytometry was a less sensitive method than cytology. Abnormal deoxyribonucleic acid ploidy was documented in a few specimens from noncancer-bearing patients having diseases associated with high urothelial cell turnover rates but the concomitant urinary cytology was negative for neoplasia. When used in conjunction with urinary cytology, flow cytometry was a valuable procedure in the followup of patients with bladder cancer. The diagnostic yield with this combination was such that flow cytometry and cytology may be used to reduce the frequency of cystoscopy and biopsy during clinical management in selected situations.

Reliability of urinary cytodiagnosis in urothelial neoplasms

A retrospective study was done to explore the reliability of urinary cytologic examination of 117 cases of transitional cell carcinoma seen at this institution for the period 1980 to 1984. A specificity of 99%, sensitivity of 85%, false-positive rate of 11%, and false-negative rate of 10% were obtained. A single blind review of cytologic and histologic material from 66 of the cases was also performed for evaluation of the cytologic criteria employed for the grading of tumors. Cytohistologic correlation of grade I lesions was poor, whereas correlation of grades II and III was reasonably good. Carcinoma in situ was cytologically recognized in all instances but was difficult to distinguish from grade III carcinoma.

Urinary cytology for carcinoma in situ of the urinary bladder

The urinary cytologies of 14 nonpapillary carcinomas in situ of the urinary bladder were reviewed. Cytologic malignancy was often diagnosed before any clinical manifestation or cytoscopic lesion could be perceived. The cytologic characteristics of this lesion as previously described in the literature were confirmed: the background was usually clean and the tumor cells were numerous and relatively monomorphic, with many atypias. Taking into consideration the limitations discussed, urinary cytology should be regarded as having great accuracy in the early diagnosis of in situ carcinoma of the urinary bladder.

Primary carcinoma in situ of the ureter: a case report

A case of primary carcinoma in situ of the right ureter without a history of bladder tumors is presented. Cytological investigation of the right ureteral urine specimens revealed malignant cells and computerized tomography showed focal thickening of the upper portion of the right ureter. The patient underwent right nephroureterectomy, including excision of a bladder cuff. The diagnostic role of exfoliative urinary cytology is emphasized.

Evaluation of bladder washings and urine cytology in the diagnosis of bladder cancer and its correlation with selected biopsies of the bladder mucosa

We report a prospective study of 136 patients with biopsy proved bladder tumor who underwent 311 evaluations with cystoscopy, urinary cytology, bladder washing and, when indicated, bladder biopsies. Cytology results from bladder washings were superior to routine urinary cytology studies in detecting abnormal cells. Also, there was a significant increase in the number of positive cytology studies in bladder washings from patients with no evidence of tumor by cystoscopy but who had biopsy proved dysplasia. Multiple selective bladder biopsies showed a higher incidence of mucosal abnormalities if the primary tumor was of a higher grade.

[The place of urinary cytology in the diagnosis of urothelial tumors]

A cytologic study was done in three groups of patients, either for screening purposes or for the follow up of vesical tumors already treated by transurethral resection or cystectomy. The reliability of urinary cytology is closely related to the degree of tumor anaplasia (81,8% positive cytology in grade III tumors). When a cytologic and cystoscopic follow-up is done, the results of these two methods are in agreement in 60% of the cases. In the follow up of patients already treated for vesical tumors, the association of cystoscopy and cytology increases the discovery of recurrences by 40%. The persistence of isolated positive cytologies is indicative of highly malignant lesions (grade III). In cystectomized patients, a close correlation exists between the histologic grade and the positivity of the cytologic survey. A cytologic follow up after cystectomy helps to discover a greater number of urethral recurrences.

Urinary cyclic nucleotides and the cytopathology of human uterine cervical dysplasias

Blinded urinary assays for cyclic guanosine 3':5'-monophosphate (cGMP) and cyclic adenosine 3':5'-monophosphate (cAMP) were performed on 49 subjects with documented abnormal cervical cytology and 21 control subjects with normal cytology. A significant difference in the mean cGMP:cAMP ratios between the case and control groups was found. A significantly greater proportion of women with cytological abnormalities had a cGMP:cAMP ratio above the 0.2 level (p less than 0.001). Cases treated surgically for severe dysplasia or carcinoma in situ of the cervix revealed a significant postsurgical fall in the cGMP:cAMP ratios (p less than 0.025). The possibility of utilizing urinary ratios of cyclic nucleotides as an objective index in the detection, monitoring of progression, and therapy of preneoplastic cervical lesions is discussed.