How to Read a Urine Cytology Report

Bladder, ureter & renal pelvis

Cytology

Paris system for urothelial neoplasia

Topic Completed: vii September 2020

Minor changes: 12 Nov 2021

Copyright: 2003-2022, PathologyOutlines.com, Inc.

PubMed Search: Paris system [title]

Folio views in 2021: xvi,000

Folio views in 2022 to appointment: 3,095

Cite this folio: Pansare 5., Parakh R. Paris system for urothelial neoplasia. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/bladdercytologyparissystemnew.html. Accessed March 5th, 2022.

Definition / general

• Urine Cytology represents a significant portion on non-gynecologic cytology specimens in daily practice, primarily because of the simplicity and ease of specimen procurement and its pregnant impact on management
• Nonetheless in that location was no consensus on the diverse categories and their cytomorphologic features used for reporting
• Paris System for reporting urinary cytology was an effort to standardize terminology with standardized cytomorphologic criteria for reporting urine cytology (2016)
• Paris System is based on the principle that the ultimate goal of urine cytology is detection of high form urothelial carcinoma

Essential features

• Identification of high course urothelial carcinoma (HGUC) is the ultimate goal of urinary cytology and should always be kept in listen while reporting urine cytology; these patients will receive agile investigation to find the lesion
• Suspicious for High Grade Urothelial Carcinoma (SHGUC) has similar direction due to its strong association with HGUC
• Carcinoma in Situ (CIS) cannot be distinguished from HGUC in urine cytology
• Depression grade urothelial neoplasia (LGUN) can merely be definitively diagnosed in the presence of 3 dimensional cellular papillary clusters with fibrovascular cores; if not present, report equally negative for high class urothelial carcinoma (NHGUC) with a possible comment for consideration of LGUN
• Atypical urothelial cells (AUC) should be reported using strict morphologic criteria with 1 major and i modest criterion (see below)

Diagrams / tables

Contributed past Vaishali Pansare, Grand.D.

Capability of urine specimens

Clinical features

• Cytology is useful to detect carcinoma in situ or marked chronic inflammation (i.eastward. when there is no specific lesion to biopsy), carcinoma hidden in diverticula or for detecting residual tumor from urine specimens
• Cystoscopic biopsy of visible lesions is more than sensitive than cytology in most cases
• Bladder irrigation is superior to collecting voided urine
• Most sensitive and highly specific for loftier grade tumors (diagnosis or follow-upwards) whether flat (carcinoma in situ), papillary or mixed
• Low sensitivity (difficult to diagnose) for papilloma and low cancerous potential lesions because they have normal histology (Mod Pathol 1995;viii:394)
• Follow upwards exam of urine with FISH may improve sensitivity and specificity of cytology (Am J Clin Pathol 2001;116:79)

Types of specimen

Voided urine:

• Not invasive, easiest to obtain
• Obtaining iii second morning voided midstream urine samples collected over 3 consecutive days appears to optimize the detection of urothelial malignancies

Instrumented urine:

• Catheterization of the float or irrigation of float

Ileal conduit urine:

• Ileal conduit and neobladder are the nearly mutual urine diversion techniques used in patients who take undergone cystectomy
• A portion of the ileum is anastomosed with the ureters to the skin or to the urethra

Processing / preservation of specimen

• Immediate processing is recommended or refrigerate if firsthand processing cannot exist washed
• If fixation if needed, utilise equal volumes of 50% ethanol or a methanol based fixative (Cytolyt® or like)

Format of diagnostic report

Recommendations for Diagnostic Format and Categories for Urinary Cytology Specimens Papanicolaou Society of Cytopathology Practice Guidelines Task Strength

I. Adequacy Argument (Optional)

• Satisfactory for evaluation
• List any quality factors affecting specimen
• Unsatisfactory for evaluation (give reason)

II. General Categorization

• Negative for epithelial prison cell aberration (see Descriptive Diagnoses)
• Epithelial cell abnormality present (see Descriptive diagnosis)

3. Descriptive Diagnosis

• Negative for epithelial cell aberration
• Infectious agents
• Bacterial organisms
• Fungal organisms
• Viral changes (CMV, herpes, adenovirus, polyomavirus)
• Nonspecific inflammatory changes
• Acute inflammation
• Chronic inflammation
• Changes consequent with xanthogranulomatous pyelonephritis
• Cellular changes associated with:
  Chemotherapeutic agents
  Radiation
• Epithelial Jail cell Abnormalities
  Atypical urothelial cells (*run across annotate)
  Low-grade urothelial carcinoma
  High-class urothelial carcinoma (invasive carcinoma vs. carcinoma in situ)
  Squamous cell carcinoma
  Adenocarcinoma
  Other cancerous neoplasms (specify blazon)

Iv. Other

• An optional comment section should be used to list additional findings or further clarification of findings
• Diagn Cytopathol 2004;30:24

Specimen adequacy

• Capability refers to the usefulness of the specimen to diagnose or raise suspicion of urothelial carcinoma
• Adequacy is determined past the interplay of four specimen characteristics: drove blazon, cellularity, book and cytomorphologic findings
• Of these, the cytomorphologic findings must be considered first because any atypical, suspicious or malignant cells make the specimen intrinsically adequate regardless of the book, cellularity or collection type
• Similar to Pap smear adequacy, any atypical, suspicious or malignant cells on cytology automatically becomes an acceptable specimen
  • Adequate number of benign urothelial cells besides supercedes whatever volume requirements for adequacy
  • Volume is only considered for voided specimens; low volume samples are less likely to have adequate urothelial cells, simply an optimal volume has not been established
  • The Paris organisation indicates that for SurePath®, 30 ml is an optimal book for voided urines but specimens should not be rejected based on low volume
  • Benign urothelial cellularity cutting offs should be validated for instrumented and voided urines

Negative for High Grade Urothelial Carcinoma (NHGUC)

• To minimize lumping everything into the "atypical" category, the terminology Negative for High Form Urothelial Carcinoma includes all entities that pose no significant run a risk to the patient for developing HGUC based upon bachelor studies
• This term likewise clarifies the goal of the Paris Arrangement - to highlight those cases at risk for HGUC
• For case, radiation associated atypia is classified as Negative for High Grade Urothelial Carcinoma and non atypical
• A urine sample (voided or instrumented) is considered Negative for High Grade Urothelial Carcinoma if any of the following components are present:
  • Benign urothelial, squamous and glandular cells
  • Benign urothelial tissue fragments
  • Changes associated with stones
  • Viral cytopathic effect due to polyoma virus
  • Post therapy effect, including epithelial cells from urinary diversions

Contributed by James Liu, M.D.

Normal

Polyoma (BK) virus

Singular Urothelial Cells (AUC)

• Defined equally cellular changes that fulfill the major (required) criterion and merely 1 minor criterion
  • Note: the presence of 2 or more minor criterion including nuclear hyperchromasia is diagnostic of Suspicious for HGUC (run into below)
• Major benchmark (required):
  • Non superficial and non degenerated urothelial cells with an increased N/C ratio (> 0.5)
• Modest criteria (one required):
  • Nuclear hyperchromasia
  • Irregular nuclear membranes
  • Irregular, coarse and clumped chromatin
• Diagnosis of AUC is appropriate when cells are more abnormal than NHGUC
• AUC is appropriate when there is suspicion of HGUC but also extensive degeneration

Note:

• Normal intermediate and basal urothelial cells, typically seen in instrumented urine, accept high N/C ratio and frequently occur in groups; should exist regarded every bit NHGUC

Contributed past James Liu, M.D.

Atypical urothelial cells

Suspicious for High Class Urothelial Carcinoma (SHGUC)

• Reflects the presence of urothelial cells with severe atypia that falls short for a diagnosis of loftier grade urothelial carcinoma merely beyond atypical urothelial cells
• A diagnosis of SHGUC is defined equally non superficial and non degenerated urothelial cells showing:
  • Increased N/C ratio, at least 0.v - 0.7 (required criterion)
• Moderate to severe nuclear hyperchromasia (required criterion) and at to the lowest degree one of the following:
  • Irregular clumpy chromatin
  • Marked irregular nuclear membranes

High Form Urothelial Carcinoma (HGUC)

• Sensitivity of urine cytology for HGUC is 50 - 85%
• Positive urine cytology is clinically meaningful, is significantly associated with tumor recurrence and is independent of other clinicopathologic variables
  • Hence, positive urine cytology in principal upper urinary tract urothelial carcinoma is valuable to predict prognosis and preoperative positive urine cytology may be associated with higher prevalence of tumor recurrence
• It can be useful to predict tumor progression

Notes:
• Urine cytology cannot distinguish invasive HGUC and carcinoma in Situ (CIS)
• Squamous or glandular differentiation of urothelial carcinoma may be seen in urine cytology but a diagnosis of squamous prison cell carcinoma or adenocarcinoma of the urinary tract tin can simply exist fabricated later examination of biopsy or cystectomy specimens
• HGUC is diagnosed on the basis of this criteria according to the Paris Organization consensus:
  • Cellularity; at to the lowest degree 5 - 10 aberrant cells
  • N/C ratio: 0.7 or greater
  • Nucleus: moderate to severe hyperchromasia
  • Nuclear membrane: markedly irregular
  • Chromatin: coarse / clumped
• Other notable cytomorphologic features of HGUC are:
  • Cellular pleomorphism
  • Marked variation in cellular size and shapes. i.east. oval, rounded, elongated or plasmacytoid (comet cells)
  • Scant, pale or dense cytoplasm
  • Prominent nucleoli
  • Mitoses
  • Necrotic debris
  • Inflammation

Contributed by James Liu, M.D.

Loftier grade urothelial carcinoma (HGUC)

Low Grade Urothelial Neoplasia (LGUN)

• LGUN is a combined cytologic term for depression grade papillary urothelial neoplasms, which includes urothelial papilloma, papillary urothelial tumour of uncertain malignant potential (PUNLMP) and low grade papillary urothelial carcinoma (LGPUC)
• Definitive diagnosis of LGUN is possible just in the presence of this cytologic criteria (regardless of voided urine or instrumented urine):
  • 3 dimensional cellular papillary clusters with fibrovascular cores including capillaries
  • Cellular papillary clusters are defined equally clusters of cells with nuclear overlapping forming papillae
• The following cytologic features should be categorized as NHGUC:
  • 3 dimensional cellular clusters without fibrovascular cores
  • Increased numbers of single monotonous (non umbrella) cells
• Cytoplasmic homogeneity
• Nuclear border irregularity
• Increased Due north/C ratio
• A comment may be added to suggest LGUN in these cases without definitive cytomorphologic features
• Rate of progression is 0% for papillomas, 3.six% for PUNLMP and v - 25% for LGPUC (WHO / ISUP classification (2004))

Squamous Cell Carcinoma (SCC)

• Accounts for 2 - five% of all float cancer in West
• In Due north Africa and Eye East where Schistosoma hematobium infestation is endemic, it accounts for 25 - xxx% of bladder malignancies
• Cases non associated with Schistosoma (not bilharzial) are usually associated with conditions causing urinary stasis with epithelial injury, such as spinal cord injury or paraplegia
• Cytologic features of float SCC are similar to SCC elsewhere
• Diagnostic criteria for SCC:
  • Cellular specimen with numerous private and nests of squamous cells
  • Tumor cells are big, polygonal with keratinized cytoplasm, sharp borders and mildly to markedly atypical hyperchromatic nuclei
  • Fiber and polliwog cells, squamous pearls and "jail cell in cell" arrangement may be present
  • Background may show fragments of anucleated squamous cells, pocket-size singular parakeratotic cells, necrosis, RBCs and neutrophils
  • Nonkeratinizing malignant cell groups with metaplastic appearance may exist present
  • Liquid based preparations show like morphology simply the background is cleaner so jail cell details are better preserved

Adenocarcinoma

• Accounts for 0.5 - two.five% of all primary bladder malignancies and includes vesical and urachal subtypes
• Urachal adenocarcinoma develops within urachal remnants located in bladder dome
• Primary urinary tract adenocarcinoma is less mutual than secondary involvement from adjacent organs
• Adventure factors include cystitis glandularis of intestinal type and float exstrophy
• Diagnostic criteria:
  • Variable cellularity
  • Enteric / colonic type columnar jail cell clusters and single degenerated cells in a background of necrosis and mucin
  • Nuclei are big vesicular or hyperchromatic, with irregular shapes and prominent nucleoli
  • Cytoplasm may be vacuolated
• Mucinous / colloid type has rounded three-D clusters of crowded, banal cells with small to moderate amounts of lacy cytoplasm with occasional mucin vacuoles and medium sized nuclei with visible nucleoli in mucinous groundwork
• Signet band cell adenocarcinoma: cells with large cytoplasmic mucin filled vacuole that appear optically clear or finely vacuolated, pushing the nucleus to the periphery
• Clear cell carcinoma: cells with abundant vacuolated cytoplasm and centrally located nuclei that may be present in clusters with hobnail configuration

Modest cell carcinoma

• Accounts for less than 1% of all bladder malignancies
• Diagnostic criteria:
  • Moderate to high cellularity
  • Hemorrhagic and necrotic groundwork with apoptosis, isolated or small groups of small, undifferentiated malignant cells, mitoses and numerous neutrophils
  • Cells are arranged singly, in linear pattern with rosettes, loosely or tightly cohesive clusters
  • Tumor cells are round to oval or irregular and small-scale to medium in size (two - 3 ten lymphocytes)
  • Nuclei are modest to oval, hyperchromatic with finely granular evenly distributed or smudged chromatin, ill defined membranes, prominent molding and display crush artifact
  • Nucleoli are inconspicuous
  • Scanty cytoplasm
  • Loftier Northward:C ratio

Secondary neoplasms

• Renal cell carcinoma:
  • May be seen in cases of renal pelvis invasion by renal jail cell carcinoma
  • Degenerated cells
  • Cells maintain the aforementioned morphology every bit the tumors in the kidney
• Prostatic carcinoma:
  • Bladder cervix interest by prostatic carcinoma
  • Large cells in clusters with sick defined prison cell borders, vacuolated cytoplasm, round nuclei and prominent nucleoli
  • Immunohistochemistry may be helpful
• Colonic carcinoma:
  • Direct extension to bladder with possible fistulae formation
  • Cells bundled in acinar configuration
  • Coarse chromatin design and prominent nucleoli
  • Necrosis and arable red claret cells
  • Fecal fabric nowadays

Back to top

dowdellgoope1938.blogspot.com

Source: https://www.pathologyoutlines.com/topic/bladdercytologyparissystemnew.html

Share this post