Ch. 3 - Urine & Bladder Washings Flashcards
What are some indications for urine cytology?
Hematuria, surveillance of previously diagnosed urothelial carcinoma (field effect), high-risk screening
What are the strengths and weaknesses of voided urine cytology?
Easy to collect, but often contaminated with squamous cells and with few urothelial cells.
What are the strengths and weaknesses of catheterized urine?
Less lower tract contamination, but invasive and often results in scraping of urothelium (can mimic low-grade).
What are the strengths and weaknesses of bladder washings?
High cellularity with freshly exfoliated cells. Invasive, and clusters can mimic low-grade.
What is the purpose of upper tract washing and brushing? What is its major drawback?
To look for upper tract urothelial carcinoma. False positives are much more common (due to stones, normal upper tract morphology)
What is the purpose of ileal conduit urine cytology?
Can detect for upper tract (ureter, renal pelvis) disease.
How long may a urine be kept at room temperature?
12hrs; beyond that they should be refrigerated or fixed.
What are the adequacy criteria for urine specimens?
There are no meaningful adequacy criteria.
Name 4 situations where a specimen may be called unsatisfactory.
- Voided urines containing only squamous cells (no urothelium)
- Obscuring of urothelium by inflammation/lubricant
- Blood-only specimen
- Marked degenerative changes
What is the overall sensitivity and specificity of urine cytology? How can it be improved?
Low sensitivity, high specificity. Better if combined with cystoscopic impression and/or FISH studies.
Describe the normal morphology of urothelial cells.
Intermediate urothelial cells with moderate cytoplasm, round nuclei, and small nucleoli.
What is the appearance of degenerated urothelium?
Looks histiocytic, sometimes with red/green hyaline inclusions (“Melamed-Wolinska bodies”)
Describe the normal morphology of umbrella cells and basal cells.
Umbrella: Large with abundant cytoplasm and large nuclei (commonly multinucleated).
Basal: Higher N:C, still with fine chromatin and smooth nuclear membranes.
What is the significance of bacteria in urine? Squamous cells?
Both may represent lower tract contamination. Squamous metaplasia is normal at the trigone.
Describe the morphology of seminal vesicle cells in urine. What about ileal conduit cells?
Seminal vesicle: Looks scary/hyperchromatic but contains lipofuscin.
Ileal conduit: Columnar cells often with marked degeneration and eosinophilic intracytoplasmic inclusions.
Describe the cytology of malakoplakia.
Granular histiocytes occasionally with lamellated basophilic “Michaelis-Gutmann” bodies.
Describe the cytology of polyomavirus infection.
Large eccentric nuclei with basophilic nuclear inclusions that fill the entire nucleus.
What is the significance of koilocytes in a urine specimen?
May represent vaginal/vulvar contamination, but may represent a bladder condyloma.
Describe the shape of the following crystals:
- Triple phosphate
- Ammonium biurate
- Urate
- Calcium oxalate
- Prism & coffin-lid
- Spherical with protruding spikes (“thorny apples”)
- Highly variable…
- Dumbbell or octahedral.
What types of casts are significant in urine?
RBC casts suggest glomerular disease.
WBC casts suggest tubulointerstitial disease and transplant rejection.
Fatty casts are associated with nephrotic syndrome.
What are the cytologic features of nonspecific reactive urothelial change?
Nuclear enlargement with more prominent nucleoli and coarsely vacuolated cytoplasm.
What are the morphologic changes seen with radiation or intravesical chemotherapy?
Cellular and nuclear enlargement with preservation of N:C ratio. Some multinucleation (more common with chemo).
How can atypia caused by calculi be distinguished from that of neoplastic atypia?
Often impossible, need to rely on clinical history.
What is the annual incidence and mortality of UCC? What are its risk factors?
73k cases per year, 15k deaths.
Risk factors include smoking, occupational exposures (eg aniline), and cyclophosphamide.
What role does dysplasia play in urine cytology
It has poorly agreed-upon or reproducible features and should not be called on cytology.
Describe the cytology (and epidemiology) of papilloma.
Very rare, occur mainly in young patients. No atypia, so it cannot be distinguished cytologically…
Describe the cytology of PUNLMP.
Architectural features include fibrovascular cores (rare!) and cell clusters. Cytologic features include cytoplasmic homogeneity, and somewhat high N:C ratio with some nuclear irregularity.
Describe the cytology of high-grade urothelial carcinoma.
Moderate to marked atypia, sometimes with Melamed-Wolinska bodies and some backgrouudn necrosis.
What main entities should be kept in the differential for HGUCC in cyotlogy?
Polyomavirus (decoy cells), stone atypia, normal upper tract morphology, treatment effect, and nonspecific reactive changes.
What is the primary association in bladder SQC? What is in the differential?
Schistosoma hematobium infection.
Ddx: Focal squamous differentiation of UCC, metastasis, condyloma acuminatum.
What is the primary association in bladder adenocarcinoma? What should be considered in the differential?
Associated with bladder exstrophy and urachal remnants. Consider focal glandular differentiation of UCC, and metastatic CRC.
Summarize clear cell carcinoma of the bladder.
A rare clear-cell neoplasm associated with mullerian remnants with obvious malignant cytomorphology including abundant clear cytoplasm.
What role does urine cytology play in the diagnosis of RCC and prostate cancers?
Such tumor cells can often be found in urines but urine cytology does not play a direct role in the diagnosis of these tumors.
What is the UroVysion test?
A multiple-chromophore FISH assay looking for aneuploidies of chromosomes 1, 3, 7, 9, 11, and 17.
What is the role of the UroVysion test?
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.
