VALUE OF URINE CYTOLOGY VERSUS BLADDER WASHING IN BLADDER CANCER HAIM MATZKIN, M.D. SHAMIM M. MOINUDDIN, A4ARK S. SOLOWAY, M.D.
M.D.
From the Department of Urology, University of Tennessee, and Department of Pathology, Baptist Memorial Hospital, Memphis, Tennessee
ABSTRACT-A prospective study compared the diagnostic outcome of paired urine cytology and bladder washings in 26 patients as well as the diagnostic accuracy of cytologic reading of voided urine in 43 patients, all with docxmcnted bladder cancer. We demonstrate the superiority of bladder washing over voided urine cytology and recommend its routine use in spite of the additional cost and patient discomfort.
Urinary cytology is often a useful adjunct to cystoscopy and biopsy in the diagnosis of urothelial cancer of the bladder and prostatic urethra. Its more important role, however, is in the monitoring of patients following the initial management of transitional cell carcinoma (TCC). Following the removal of a urothelial tumor from the bladder, the likelihood of a subsequent tumor ranges from 30 to SO percent depending on several factors, e.g., grade, multifocality, stage, and the presence of dysplasia distant from the observed tumor. The primary methods for detection of a new occurrence or true recurrence are endoscopy and urinary cytology. Not infrequently a recurrence, particularly high grade, is identified by cytology, prior to an obvious alteration of the urothelial surface that can be observed endoscopically. Exfoliated cells can be obtained by two primary methods, voided urine and irrigation of the bladder. The primary advantage of the voided urine is that it is noninvasive.’ ’ Papillary clusters identified in a voided cytology specimen are likely to be from a low-grade tumor. If such a cluster is observed in a barbotage specimen, it ma)’ be due to the trauma associated with the procedure. The advantage of the irrigation technique is a major one-more and better preserved cells. 3 4
UROIDG1
MARC11 1Xli!
I
VOI,UME
XSXIX,
This prospective stud!. compared the diagnostic vield of paired urine cvtologv samplesobtained at the*same setting ai the bladder washing, as well as the diagnostic accuracy of voided urine alone in patients seen for bladder cancer.
NUMRER .3
i/l
Material and Methods In an eight-month interval. 220 Ilatients underwent flexible endoscopy in an outpatient office setting. A voided urine from all patients with a history of bladder cancer was sent for cytologic evaluation. For some, hut not all, of these patients, a bladder washing \vas also sent for cytology at the same visit. If a urothelial abnormality suggestive of neoplasm was observed. or if the cytology was positive without an identifiable lesion, the patient underwent endoscopy under anesthesia with bladder biopsy or tumor resection as warranted. All tissue w’as fixed in Hollande’s solution and submitted for routine histologic evaluation. Voided urine specimens had a minimum volume of 20 mL. Bladder irrigation was performed by insertion of a 16-F urethral catheter and the barbotage of the bladder was obtained with 50-75 mL saline. The solutions were processed fresh onto Millipore filters stained u ith a
20 1
A
-
Ba
modified Papanicolaou technique and evaluated according to previously published criteria.’ Specimens were sent to the laboratory as part of a research protocol without any indication of the clinical history or endoscopic findings. All specimens were examined by a single cytopathologist (SM). There were 48 patients with a history of bladder cancer. Twenty-three (49%) had both a voided specimen and a bladder washing. Histologic examination was obtained in 38 cases (80 Y0) . Results Concomitant voided urine and bladder washing specimens were obtained in 26 patients. Three patients with the cystoscopic appearance of a low-grade bladder tumor were found to have inflammation only on biopsy
TAKE I. Comparison of voided urine and bladder wash cytology in patients with proved bladder tumor
Voided urine Bladder wash
PCS
Neg.
16 23
4 .
1 2 3 4 !5 6 7
202
Findings bluddcr
Bladder
N
23 23
3
TMKE II. Case
susp.
specimen. In each instance, the bladder washing was negative. Of the 23 patients with histologically documented bladder cancer, 23 (100 % ) were diagnosed as having evidence of urothelial cancer by the cytologist reading the bladder washings (Table I), In 4 of those patients (17% ) no tumor cells were found in the voided urine specimen: 16123 (70 % ) were found to have malignant cells in the urine. Three patients (13 % ) had atypical cells, and the voided urine was thus read as suspicious for cancer. Table II details the findings in the 7 cases with a discrepancy between the voided urine and bladder washing. In 6 instances, the tumor in the bladder was grade 1 or 2; only one had a grade 3 TCC (carcinoma in situ). Figure 1 illustrates the cytologic differences obtained using both techniques in one of these patients. Table III summarizes the results obtained in 43 patients with documented bladder cancer who had a voided urine cytologic examination done at the time of diagnosis. While there were comparable numbers of patients in each grade category, the number of false-negative readings is highest in the low and intermediate grades (Gl-2). Only 1 of 23 cases (4%) with highgrade malignancy was interpreted as negative.
in 7 c’ase.yshowing discrepancy wash and voided urine tests
bet u;ccn
Wash
Voided Urine
Histolog!.
Low-grade tumor High-grade tumor Rare clusters, low-grade High-grade tumor High-grade tumor High-grade tumor High-grade tumor
Negative Negative Negative Atypical cells Atypical cells Atypical cells Negative
Gl, Ta TCC Gl, Ta TCC G2, Ta TCC G2-3, Tl + CIS G2-Ta TCC CIS G2-TlpTCC
tumor
‘rAH1.k: 111.
Voided
in documented ___
Tb mar Cradc
-__-
No. of Ph.
I :3 + T(:
M.D.
From the Department of Urology, University of Tennessee, and Department of Pathology, Baptist Memorial Hospital, Memphis, Tennessee
ABSTRACT-A prospective study compared the diagnostic outcome of paired urine cytology and bladder washings in 26 patients as well as the diagnostic accuracy of cytologic reading of voided urine in 43 patients, all with docxmcnted bladder cancer. We demonstrate the superiority of bladder washing over voided urine cytology and recommend its routine use in spite of the additional cost and patient discomfort.
Urinary cytology is often a useful adjunct to cystoscopy and biopsy in the diagnosis of urothelial cancer of the bladder and prostatic urethra. Its more important role, however, is in the monitoring of patients following the initial management of transitional cell carcinoma (TCC). Following the removal of a urothelial tumor from the bladder, the likelihood of a subsequent tumor ranges from 30 to SO percent depending on several factors, e.g., grade, multifocality, stage, and the presence of dysplasia distant from the observed tumor. The primary methods for detection of a new occurrence or true recurrence are endoscopy and urinary cytology. Not infrequently a recurrence, particularly high grade, is identified by cytology, prior to an obvious alteration of the urothelial surface that can be observed endoscopically. Exfoliated cells can be obtained by two primary methods, voided urine and irrigation of the bladder. The primary advantage of the voided urine is that it is noninvasive.’ ’ Papillary clusters identified in a voided cytology specimen are likely to be from a low-grade tumor. If such a cluster is observed in a barbotage specimen, it ma)’ be due to the trauma associated with the procedure. The advantage of the irrigation technique is a major one-more and better preserved cells. 3 4
UROIDG1
MARC11 1Xli!
I
VOI,UME
XSXIX,
This prospective stud!. compared the diagnostic vield of paired urine cvtologv samplesobtained at the*same setting ai the bladder washing, as well as the diagnostic accuracy of voided urine alone in patients seen for bladder cancer.
NUMRER .3
i/l
Material and Methods In an eight-month interval. 220 Ilatients underwent flexible endoscopy in an outpatient office setting. A voided urine from all patients with a history of bladder cancer was sent for cytologic evaluation. For some, hut not all, of these patients, a bladder washing \vas also sent for cytology at the same visit. If a urothelial abnormality suggestive of neoplasm was observed. or if the cytology was positive without an identifiable lesion, the patient underwent endoscopy under anesthesia with bladder biopsy or tumor resection as warranted. All tissue w’as fixed in Hollande’s solution and submitted for routine histologic evaluation. Voided urine specimens had a minimum volume of 20 mL. Bladder irrigation was performed by insertion of a 16-F urethral catheter and the barbotage of the bladder was obtained with 50-75 mL saline. The solutions were processed fresh onto Millipore filters stained u ith a
20 1
A
-
Ba
modified Papanicolaou technique and evaluated according to previously published criteria.’ Specimens were sent to the laboratory as part of a research protocol without any indication of the clinical history or endoscopic findings. All specimens were examined by a single cytopathologist (SM). There were 48 patients with a history of bladder cancer. Twenty-three (49%) had both a voided specimen and a bladder washing. Histologic examination was obtained in 38 cases (80 Y0) . Results Concomitant voided urine and bladder washing specimens were obtained in 26 patients. Three patients with the cystoscopic appearance of a low-grade bladder tumor were found to have inflammation only on biopsy
TAKE I. Comparison of voided urine and bladder wash cytology in patients with proved bladder tumor
Voided urine Bladder wash
PCS
Neg.
16 23
4 .
1 2 3 4 !5 6 7
202
Findings bluddcr
Bladder
N
23 23
3
TMKE II. Case
susp.
specimen. In each instance, the bladder washing was negative. Of the 23 patients with histologically documented bladder cancer, 23 (100 % ) were diagnosed as having evidence of urothelial cancer by the cytologist reading the bladder washings (Table I), In 4 of those patients (17% ) no tumor cells were found in the voided urine specimen: 16123 (70 % ) were found to have malignant cells in the urine. Three patients (13 % ) had atypical cells, and the voided urine was thus read as suspicious for cancer. Table II details the findings in the 7 cases with a discrepancy between the voided urine and bladder washing. In 6 instances, the tumor in the bladder was grade 1 or 2; only one had a grade 3 TCC (carcinoma in situ). Figure 1 illustrates the cytologic differences obtained using both techniques in one of these patients. Table III summarizes the results obtained in 43 patients with documented bladder cancer who had a voided urine cytologic examination done at the time of diagnosis. While there were comparable numbers of patients in each grade category, the number of false-negative readings is highest in the low and intermediate grades (Gl-2). Only 1 of 23 cases (4%) with highgrade malignancy was interpreted as negative.
in 7 c’ase.yshowing discrepancy wash and voided urine tests
bet u;ccn
Wash
Voided Urine
Histolog!.
Low-grade tumor High-grade tumor Rare clusters, low-grade High-grade tumor High-grade tumor High-grade tumor High-grade tumor
Negative Negative Negative Atypical cells Atypical cells Atypical cells Negative
Gl, Ta TCC Gl, Ta TCC G2, Ta TCC G2-3, Tl + CIS G2-Ta TCC CIS G2-TlpTCC
tumor
‘rAH1.k: 111.
Voided
in documented ___
Tb mar Cradc
-__-
No. of Ph.
I :3 + T(:
