Electrothermal Cautery Artifact in a Urine Cytology Specimen Zulfia McCroskey, M.D.,* and Eva M. Wojcik, M.D., M.I.A.C.
Separating actual pathology (in vivo) changes from manmade or externally introduced artifacts is very important. Different types of artifacts impose a diagnostic challenge and are a known cause of the pitfalls in interpretation of biopsy, resection, and cytology specimens. According to a medical dictionary, “an artifact is a structure seen in tissue after death, fixation, staining that is not normally present in the living tissue.” The etymology of the word “artifact” derived from the Latin “ars” (skill) and “facere” (to make). Artifacts arise for a variety of reasons such as differing surgical techniques, tissue handling, fixation, histologic processing, and staining. 1–3 It is imperative to be aware of these artifacts in order to avoid possible mistakes in interpretation. Herein, we present a case of a 56-year-old man with a history of hematuria. He underwent a cystoscopy which revealed a 1 cm papillary lesion on the posterior wall of the urinary bladder. A subsequent transurethral resection of the lesion with a subsequent urinary bladder barbotage was performed. A tissue specimen was sent for histopathologic examination and a urine specimen was sent for R Papanicolaou stained cytologic evaluation. A ThinPrepV slide revealed loosely cohesive cellular groups without fibrovascular cores composed of spindled cells with elongated “cigar-shaped” nuclei (Figs. 1a–c). Closer examination demonstrated that these cells were located underneath umbrella cells, confirming their benign urothelial nature. Smudged elongated nuclei suggested electroDepartment of Pathology, Loyola University Medical Center, Chicago, Illinois *Correspondence to: Zulfia McCroskey, MD, Department of Pathology, Loyola University Medical Center, 2160 South First Avenue, Bldg. 103, Room #2233, Maywood, IL 60153, USA. E-mail: zmccroskey@ lumc.edu Received 2 January 2015; Revised 23 March 2015; Accepted 30 March 2015 DOI: 10.1002/dc.23283 Published online 23 April 2015 in Wiley Online Library (wileyonlinelibrary.com). C 2015 WILEY PERIODICALS, INC. V
cautery artefact. Although cystoscopic findings were known at the time of cytologic interpretation, careful R specimen did not reveal any feareview of the ThinPrepV tures suggesting papillary neoplasms such as threedimensional papillary structures with nuclear overlap, presence of fibrovascular core, numerous uniform single cells, or increased nuclear–cytoplasmic ratio. A final cytologic diagnosis of “negative for malignancy” was rendered. The concurrent surgical specimen was signed out as “urothelial papilloma.” In 1993 Fanning et al.4 described striking spindling artifact observed in urine cytology specimens obtained immediately after laser treatment of urinary bladder neoplasms which was caused by a non-specific epithelial response to laser heat. There were numerous cells with elongated nuclei present in stacks, loose clusters, and singly in their specimens. Electric current can create a similar artifact, yet the number of spindled cells present in the urinary specimen will be less.4 Transurethral resection of bladder tumors (TURBT) is the currently performed surgical procedure to diagnose and treat lesions of the urinary bladder.5 Electrothermal cautery is used to stop bleeding during the procedure. As a result, most TURBTs have tissue artifacts that can make it difficult to assess invasion. In histologic specimens, cautery artifacts made by electric current causes epithelial tissue to present with smudged elongated spindled nuclei and muscle bundles to be homogenized with loss of details, making diagnosis difficult.3 It is a common practice that either before or after TURBT is done an urologist performs a urinary bladder barbotage and collects a specimen for cytopathology study.6 It is possible to misinterpret the spindled cells of the cautery artifact as mesenchymal cells or sarcomatoid carcinoma. In our case, the elongated cells were observed in loose clusters and stacks adjacent to benign umbrella cells, supporting their urothelial nature. These groups did not form three-dimensional papillary structures and did not have fibrovascular cores, excluding the possibility of papillary neoplasm. Although elongated Diagnostic Cytopathology, Vol. 43, No 10
833
Diagnostic Cytopathology DOI 10.1002/dc
MCCROSKEY AND WOJCIK
Fig. 1. (a,b) Urinary bladder barbotage. A group of cells in the center of the each slide with very long, slender “cigar-shaped” nuclei. These groups of cells are surrounded by large unremarkable and easily recognizable umbrella cells. The nuclear–cytoplasmic ratio is not increased. The nuclear contours are smooth and chromatin is homogeneous, supporting the benign urothelial nature of these cells. (Arrows are pointing at umbrella cells) R , Papanicolaou stain, high magnification). (c) Urinary bladder barbotage. A group of cells with elongated spindle-shaped nuclei on the left (ThinPrepV side of the group (with electric current effect on nuclei of urothelial cells) and oval-shaped nuclei on the right side of the same group (normal looking urothelial cells, unaffected by cautery). The nuclear–cytoplasmic ratio is not increased. The nuclear contours are smooth and chromatin is homogeneR , Papanicolaou stain, high magnification). ous, supporting the benign urothelial nature of these cells. (ThinPrepV
and slightly enlarged, the nuclei of these clusters preserved the normal nuclear–cytoplasmic ratio, homogeneous chromatin pattern, and smooth nuclear contour, features supporting their benign nature. Interpreting cytologist should be aware of possible electrothermal cautery artifacts in urine specimens in order to avoid over interpretation of cellular clusters as atypical or suspicious for malignancy.
References 1. Rastogi V, Puri N, Arora S, Kaur G, Yadav L, Sharma R. Artefacts: A diagnostic dilemma—A review. J Clin Diagn Res 2013;7: 2408–2413.
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2. Goldstein NS, Watts JC, Neill JS, et al. The effect of electrothermal cautery-assisted resection of diminutive colonic polyps on histopathologic diagnosis. Am J Clin Pathol 2001;115:356–361. 3. Nayak A, Bhuiya TA. Utility of cytokeratin 5/6 and highmolecular-weight keratin in evaluation of cauterized surgical margins in excised specimens of breast ductal carcinoma in situ. Ann Diagn Pathol 2011;15:243–249. 4. Fanning CV, Staerkel GA, Sneige N, Thomsen S, Myhre MJ, Von Eschenbach AC. Spindling artifact of urothelial cells in post-laser treatment urinary cytology. Diagn Cytopathol 1993;9:279–281. 5. Wang DS, Bird VG, Leonard VY, et al. Use of bipolar energy for transurethral resection of bladder tumors: Pathologic considerations. J Endourol 2004;18:578–582. 6. Yang SJ, Song PH, Kim HT. Comparison of deep biopsy tissue damage from transurethral resection of bladder tumors between bipolar and monopolar devices. Korean J Urol 2011;52:379–383.
Separating actual pathology (in vivo) changes from manmade or externally introduced artifacts is very important. Different types of artifacts impose a diagnostic challenge and are a known cause of the pitfalls in interpretation of biopsy, resection, and cytology specimens. According to a medical dictionary, “an artifact is a structure seen in tissue after death, fixation, staining that is not normally present in the living tissue.” The etymology of the word “artifact” derived from the Latin “ars” (skill) and “facere” (to make). Artifacts arise for a variety of reasons such as differing surgical techniques, tissue handling, fixation, histologic processing, and staining. 1–3 It is imperative to be aware of these artifacts in order to avoid possible mistakes in interpretation. Herein, we present a case of a 56-year-old man with a history of hematuria. He underwent a cystoscopy which revealed a 1 cm papillary lesion on the posterior wall of the urinary bladder. A subsequent transurethral resection of the lesion with a subsequent urinary bladder barbotage was performed. A tissue specimen was sent for histopathologic examination and a urine specimen was sent for R Papanicolaou stained cytologic evaluation. A ThinPrepV slide revealed loosely cohesive cellular groups without fibrovascular cores composed of spindled cells with elongated “cigar-shaped” nuclei (Figs. 1a–c). Closer examination demonstrated that these cells were located underneath umbrella cells, confirming their benign urothelial nature. Smudged elongated nuclei suggested electroDepartment of Pathology, Loyola University Medical Center, Chicago, Illinois *Correspondence to: Zulfia McCroskey, MD, Department of Pathology, Loyola University Medical Center, 2160 South First Avenue, Bldg. 103, Room #2233, Maywood, IL 60153, USA. E-mail: zmccroskey@ lumc.edu Received 2 January 2015; Revised 23 March 2015; Accepted 30 March 2015 DOI: 10.1002/dc.23283 Published online 23 April 2015 in Wiley Online Library (wileyonlinelibrary.com). C 2015 WILEY PERIODICALS, INC. V
cautery artefact. Although cystoscopic findings were known at the time of cytologic interpretation, careful R specimen did not reveal any feareview of the ThinPrepV tures suggesting papillary neoplasms such as threedimensional papillary structures with nuclear overlap, presence of fibrovascular core, numerous uniform single cells, or increased nuclear–cytoplasmic ratio. A final cytologic diagnosis of “negative for malignancy” was rendered. The concurrent surgical specimen was signed out as “urothelial papilloma.” In 1993 Fanning et al.4 described striking spindling artifact observed in urine cytology specimens obtained immediately after laser treatment of urinary bladder neoplasms which was caused by a non-specific epithelial response to laser heat. There were numerous cells with elongated nuclei present in stacks, loose clusters, and singly in their specimens. Electric current can create a similar artifact, yet the number of spindled cells present in the urinary specimen will be less.4 Transurethral resection of bladder tumors (TURBT) is the currently performed surgical procedure to diagnose and treat lesions of the urinary bladder.5 Electrothermal cautery is used to stop bleeding during the procedure. As a result, most TURBTs have tissue artifacts that can make it difficult to assess invasion. In histologic specimens, cautery artifacts made by electric current causes epithelial tissue to present with smudged elongated spindled nuclei and muscle bundles to be homogenized with loss of details, making diagnosis difficult.3 It is a common practice that either before or after TURBT is done an urologist performs a urinary bladder barbotage and collects a specimen for cytopathology study.6 It is possible to misinterpret the spindled cells of the cautery artifact as mesenchymal cells or sarcomatoid carcinoma. In our case, the elongated cells were observed in loose clusters and stacks adjacent to benign umbrella cells, supporting their urothelial nature. These groups did not form three-dimensional papillary structures and did not have fibrovascular cores, excluding the possibility of papillary neoplasm. Although elongated Diagnostic Cytopathology, Vol. 43, No 10
833
Diagnostic Cytopathology DOI 10.1002/dc
MCCROSKEY AND WOJCIK
Fig. 1. (a,b) Urinary bladder barbotage. A group of cells in the center of the each slide with very long, slender “cigar-shaped” nuclei. These groups of cells are surrounded by large unremarkable and easily recognizable umbrella cells. The nuclear–cytoplasmic ratio is not increased. The nuclear contours are smooth and chromatin is homogeneous, supporting the benign urothelial nature of these cells. (Arrows are pointing at umbrella cells) R , Papanicolaou stain, high magnification). (c) Urinary bladder barbotage. A group of cells with elongated spindle-shaped nuclei on the left (ThinPrepV side of the group (with electric current effect on nuclei of urothelial cells) and oval-shaped nuclei on the right side of the same group (normal looking urothelial cells, unaffected by cautery). The nuclear–cytoplasmic ratio is not increased. The nuclear contours are smooth and chromatin is homogeneR , Papanicolaou stain, high magnification). ous, supporting the benign urothelial nature of these cells. (ThinPrepV
and slightly enlarged, the nuclei of these clusters preserved the normal nuclear–cytoplasmic ratio, homogeneous chromatin pattern, and smooth nuclear contour, features supporting their benign nature. Interpreting cytologist should be aware of possible electrothermal cautery artifacts in urine specimens in order to avoid over interpretation of cellular clusters as atypical or suspicious for malignancy.
References 1. Rastogi V, Puri N, Arora S, Kaur G, Yadav L, Sharma R. Artefacts: A diagnostic dilemma—A review. J Clin Diagn Res 2013;7: 2408–2413.
834
Diagnostic Cytopathology, Vol. 43, No 10
2. Goldstein NS, Watts JC, Neill JS, et al. The effect of electrothermal cautery-assisted resection of diminutive colonic polyps on histopathologic diagnosis. Am J Clin Pathol 2001;115:356–361. 3. Nayak A, Bhuiya TA. Utility of cytokeratin 5/6 and highmolecular-weight keratin in evaluation of cauterized surgical margins in excised specimens of breast ductal carcinoma in situ. Ann Diagn Pathol 2011;15:243–249. 4. Fanning CV, Staerkel GA, Sneige N, Thomsen S, Myhre MJ, Von Eschenbach AC. Spindling artifact of urothelial cells in post-laser treatment urinary cytology. Diagn Cytopathol 1993;9:279–281. 5. Wang DS, Bird VG, Leonard VY, et al. Use of bipolar energy for transurethral resection of bladder tumors: Pathologic considerations. J Endourol 2004;18:578–582. 6. Yang SJ, Song PH, Kim HT. Comparison of deep biopsy tissue damage from transurethral resection of bladder tumors between bipolar and monopolar devices. Korean J Urol 2011;52:379–383.
