بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم

2. Interpretation of urine cytologyNashwa Emara M.D.,phdASS. Prof. Pathology

3. Function • Majority of UT malignancies are urothelial CA. • The main function of urine cytology is diagnosis of UC.

4. 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).

5. 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

6. Deep Vs Superficial Cells

7. Columnar and Squamous Cells

8. Normal Urine Cytology

9. Washing, Instrumentation, Lithiasis

10. 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%

11. Grading Systems for Papillary UC

12. WHO Gradingof Papillary Urothelial Malignancies

13. PUNLMP

14. 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

15. Low-grade Urothelial Carcinoma vs Reactive

16. Low-grade Urothelial Carcinoma

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

18. Low-grade UC Vs Benign

19. LGUC Vs Instrumentation

20. 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.

21. Lithiasis

22. 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

23. Renal Pelvis & Ureter Brushings

24. 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%.

25. HGUC

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

27. Polyoma Virus (Decoy Cells)

28. Therapy Effect

29. Degenerative Changes

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

31. Summary • Urothelialneoplasms 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 poorly specific, not for routine use 

32. GOOD LUCK…..