Carcinoma In Situ Is Significantly Underdetected by Prenephroureterectomy Ureteroscopy in the Management of Upper Tract Urothelial Cancers

Abstract

Objective. Diagnostic reliability of prenephroureterectomy ureteroscopy (PNU) for the detection of upper tract carcinoma in situ (CIS) remains unproven in particular and underreported in general. Methods. Patients who underwent radical nephroureterectomy (RNU) in a large multicentre retrospective study for upper tract transitional cell carcinoma (UT-TCC) between January 2002 and December 2013 were identified from our hospitals databases. PNU appearances, stage, and grade of ureteroscopic biopsy were compared with final histology results of RNU to assess the diagnostic reliability of PNU for carcinoma in situ (CIS). Results. Three hundred patients underwent RNU for UT-TCC. 106 (106/300; 35.3%) of the cohort had PNU using white light with biopsies taken in most (92/106; 86.7%). Postnephroureterectomy histology of the cohort showed CIS in 65 (65/300; 21.6%) patients. Thirty nine of patients with CIS (39/65; 60%) had prenephroureterectomy ureteroscopy biopsies. Out of ten patients with CIS on ureteroscopic biopsies, six did not show CIS on final histopathology (6/10; 60%). Moreover, grading and staging on PNU biopsies of obvious tumours showed a significant nonconcordance with final histopathology of RNU specimen (P = 0.02). Overall survival was also shorter in patients with CIS compared with those without; this showed strong statistical significance (P = 0.004). Conclusions. There is a high incidence of CIS in upper tract with significant underdetection and discordance rate between the histopathology of biopsy samples obtained by white light PNU and resected specimen of radical nephroureterectomy. The presence of concomitant CIS and high stage disease in the upper tract TCC carried a poor prognosis following radical nephroureterectomy.

Diagnostic accuracy of computed tomography urography and visual assessment during ureterorenoscopy in upper tract urothelial carcinoma

“…Yamany et al noted that URS will miss lesions in up to 25% of patients, and nearly 50% of these lesions will be CIS. Gillan et al concluded that there is a high incidence of CIS in the upper urinary tract, which is significantly underdetected by URS and biopsy only; in the data investigated by these researchers, URS and biopsy failed to suspect or diagnose CIS in 84.7% of the cases. Our results showed that 16% (16/97) of UTUCs were missed by ureteroscopic inspection only, and 94% (15/16) of these lesions were CIS.…”

Update of the ICUD-SIU consultation on upper tract urothelial carcinoma 2016: treatment of low-risk upper tract urothelial carcinoma

“…Diagnostic URS should assess the ureter before the placement of ureteral access sheath. URS significantly missed concomitant CIS when compared to RNU specimens (9.7% vs. 43.3%) [17]. URS is invaluable in those cases where renal preservation may be paramount, such as individuals with renal insufficiency, solitary kidney, and multiple comorbidities.…”

“…Low-grade disease on biopsy specimen has a positive predictive value of 80–90% in predicting low stage disease, while high-grade disease has lower predictive value for invasiveness. It is often helpful for the pathologist to have more than one biopsy since non-diagnostic tissue materials are found in URS biopsy specimens up to 25% to 31.5% [17, 24, 26]. …”

“…Gillan et al in a retrospective multicenter study reported URS biopsy grade matched with final RNU histopathology on 43.4%, only 32.6% had concordance between URS biopsy and final pathology for both grade and stage of UTUC. Concomitant carcinoma in-situ (CIS) was found in 21.6% of cases in final RNU pathology, with finding of discordance between URS biopsy specimens and RNU specimens in the diagnosis of concomitant CIS in UTUC [17] (Table-1 and 3). …”

“…Biopsy grade was identical in 43.4% to 78% of cases to surgical pathology [17, 24]. The combined use of access sheath, cup biopsies, and baskets (particularly for papillary tumors) can yield substantially more tissue than has been historically possible (Figure 2).…”