Ch. 3 - Urine & Bladder Washings

Question 1

What are some indications for urine cytology?

Answer 1

Hematuria, surveillance of previously diagnosed urothelial carcinoma (field effect), high-risk screening

Question 2

What are the strengths and weaknesses of voided urine cytology?

Answer 2

Easy to collect, but often contaminated with squamous cells and with few urothelial cells.

Question 3

What are the strengths and weaknesses of catheterized urine?

Answer 3

Less lower tract contamination, but invasive and often results in scraping of urothelium (can mimic low-grade).

Question 4

What are the strengths and weaknesses of bladder washings?

Answer 4

High cellularity with freshly exfoliated cells. Invasive, and clusters can mimic low-grade.

Question 5

What is the purpose of upper tract washing and brushing? What is its major drawback?

Answer 5

To look for upper tract urothelial carcinoma. False positives are much more common (due to stones, normal upper tract morphology)

Question 6

What is the purpose of ileal conduit urine cytology?

Answer 6

Can detect for upper tract (ureter, renal pelvis) disease.

Question 7

How long may a urine be kept at room temperature?

Answer 7

12hrs; beyond that they should be refrigerated or fixed.

Question 8

What are the adequacy criteria for urine specimens?

Answer 8

There are no meaningful adequacy criteria.

Question 9

Name 4 situations where a specimen may be called unsatisfactory.

Answer 9

• Voided urines containing only squamous cells (no urothelium)
• Obscuring of urothelium by inflammation/lubricant
• Blood-only specimen
• Marked degenerative changes

Question 10

What is the overall sensitivity and specificity of urine cytology? How can it be improved?

Answer 10

Low sensitivity, high specificity. Better if combined with cystoscopic impression and/or FISH studies.

Question 11

Describe the normal morphology of urothelial cells.

Answer 11

Intermediate urothelial cells with moderate cytoplasm, round nuclei, and small nucleoli.

Question 12

What is the appearance of degenerated urothelium?

Answer 12

Looks histiocytic, sometimes with red/green hyaline inclusions (“Melamed-Wolinska bodies”)

Question 13

Describe the normal morphology of umbrella cells and basal cells.

Answer 13

Umbrella: Large with abundant cytoplasm and large nuclei (commonly multinucleated).

Basal: Higher N:C, still with fine chromatin and smooth nuclear membranes.

Question 14

What is the significance of bacteria in urine? Squamous cells?

Answer 14

Both may represent lower tract contamination. Squamous metaplasia is normal at the trigone.

Question 15

Describe the morphology of seminal vesicle cells in urine. What about ileal conduit cells?

Answer 15

Seminal vesicle: Looks scary/hyperchromatic but contains lipofuscin.

Ileal conduit: Columnar cells often with marked degeneration and eosinophilic intracytoplasmic inclusions.

Question 16

Describe the cytology of malakoplakia.

Answer 16

Granular histiocytes occasionally with lamellated basophilic “Michaelis-Gutmann” bodies.

Question 17

Describe the cytology of polyomavirus infection.

Answer 17

Large eccentric nuclei with basophilic nuclear inclusions that fill the entire nucleus.

Question 18

What is the significance of koilocytes in a urine specimen?

Answer 18

May represent vaginal/vulvar contamination, but may represent a bladder condyloma.

Question 19

Describe the shape of the following crystals:

1. Triple phosphate
2. Ammonium biurate
3. Urate
4. Calcium oxalate

Answer 19

1. Prism & coffin-lid
2. Spherical with protruding spikes (“thorny apples”)
3. Highly variable…
4. Dumbbell or octahedral.

Question 20

What types of casts are significant in urine?

Answer 20

RBC casts suggest glomerular disease.
WBC casts suggest tubulointerstitial disease and transplant rejection.
Fatty casts are associated with nephrotic syndrome.

Question 21

What are the cytologic features of nonspecific reactive urothelial change?

Answer 21

Nuclear enlargement with more prominent nucleoli and coarsely vacuolated cytoplasm.

Question 22

What are the morphologic changes seen with radiation or intravesical chemotherapy?

Answer 22

Cellular and nuclear enlargement with preservation of N:C ratio. Some multinucleation (more common with chemo).

Question 23

How can atypia caused by calculi be distinguished from that of neoplastic atypia?

Answer 23

Often impossible, need to rely on clinical history.

Question 24

What is the annual incidence and mortality of UCC? What are its risk factors?

Answer 24

73k cases per year, 15k deaths.

Risk factors include smoking, occupational exposures (eg aniline), and cyclophosphamide.

Question 25

What role does dysplasia play in urine cytology

Answer 25

It has poorly agreed-upon or reproducible features and should not be called on cytology.

Question 26

Describe the cytology (and epidemiology) of papilloma.

Answer 26

Very rare, occur mainly in young patients. No atypia, so it cannot be distinguished cytologically…

Question 27

Describe the cytology of PUNLMP.

Answer 27

Architectural features include fibrovascular cores (rare!) and cell clusters. Cytologic features include cytoplasmic homogeneity, and somewhat high N:C ratio with some nuclear irregularity.

Question 28

Describe the cytology of high-grade urothelial carcinoma.

Answer 28

Moderate to marked atypia, sometimes with Melamed-Wolinska bodies and some backgrouudn necrosis.

Question 29

What main entities should be kept in the differential for HGUCC in cyotlogy?

Answer 29

Polyomavirus (decoy cells), stone atypia, normal upper tract morphology, treatment effect, and nonspecific reactive changes.

Question 30

What is the primary association in bladder SQC? What is in the differential?

Answer 30

Schistosoma hematobium infection.

Ddx: Focal squamous differentiation of UCC, metastasis, condyloma acuminatum.

Question 31

What is the primary association in bladder adenocarcinoma? What should be considered in the differential?

Answer 31

Associated with bladder exstrophy and urachal remnants. Consider focal glandular differentiation of UCC, and metastatic CRC.

Question 32

Summarize clear cell carcinoma of the bladder.

Answer 32

A rare clear-cell neoplasm associated with mullerian remnants with obvious malignant cytomorphology including abundant clear cytoplasm.

Question 33

What role does urine cytology play in the diagnosis of RCC and prostate cancers?

Answer 33

Such tumor cells can often be found in urines but urine cytology does not play a direct role in the diagnosis of these tumors.

Question 34

What is the UroVysion test?

Answer 34

A multiple-chromophore FISH assay looking for aneuploidies of chromosomes 1, 3, 7, 9, 11, and 17.

Question 35

What is the role of the UroVysion test?

Answer 35

As it has performance comparable to urine cytology (if variable), its main role is in helping to distinguish cases that are equivocal by morphology alone.