The value of the “suspicious for urothelial carcinoma” cytology category: A correlative study of 4 years including 337 patients

Abstract

BACKGROUND:The terminology used in reporting urine cytology lacks uniformity and the significance of the "atypical"and "suspicious" categories is still not well established. This results in variable clinical follow-up and management of those cases. The authors sought to investigate the prognostic value of a diagnosis of "suspicious for high-grade urothelial carcinoma" (HGUCA). METHODS: All cases with a "suspicious" or "positive" cytological diagnosis spanning 4 years were included and correlated with the subsequent biopsies obtained within 6 months of urine collection. RESULTS: A total of 447 correlative events (57% positive and 43% suspicious) corresponding to 773 cytology specimens and 337 patients were included. The morphology of the "suspicious" cells was similar to what has recently been reported in the literature as "atypical urothelial cells, cannot exclude HGUCA." A "suspicious" diagnosis was more often rendered than a "positive" one in voided specimens (80% vs 65%, respectively). The mean interval between cytology and biopsy was 31 days. On follow-up, 92% of "suspicious" diagnoses (176 of 191 diagnoses) and 90% of "positive" diagnoses (230 of 256 diagnoses) were found to have a biopsy with a diagnosis of carcinoma (low grade or high grade). A diagnosis of HGUCA followed a "suspicious" and a "positive" diagnosis in 79% and 86% of cases, respectively. CONCLUSIONS: A "suspicious" diagnosis as defined in the current study warrants close investigations and repeat biopsy to rule out HGUCA. In addition, the findings of the current study raise the question of the need for quantitative criteria for diagnosing HGUCA on cytology. Cancer (Cancer Cytopathol) 2014;122:796-803.

The positive predictive value of “suspicious for high‐grade urothelial carcinoma” in urinary tract cytology specimens: A single‐institution study of 665 cases

“…The results from our study are a useful baseline from which we can determine the changes that the introduction of the rigorously defined diagnostic categories of TPS will bring. Surprisingly, our results are closer to those obtained by Papanicolaou and collaborators in 1958 than to those obtained by more recent studies, which reported either lower or much higher PPV values. This most likely reflects differences in criteria used by different institutions and cytopathologists; although it also may reflect diverse patient populations, clinical practice patterns, types of samples examined (voided urine vs instrumented urine), and cytopreparatory methods.…”

“…Despite having undergone multiple revisions since these first studies regarding UCyt, the diagnostic category of “suspicious” continued to suffer from vague definitions and variable predictive values, resulting in a perceived disconnect between pathologists and clinicians regarding proper follow‐up. The classification scheme proposed by the Papanicolaou Society of Cytopathology Practice Guidelines Task Force in 2004 avoided a diagnosis of suspicious entirely, instead grouping all equivocal results into 1 category titled “atypical.” Before the publication of TPS, several recently published studies reviewed their authors' experience with the diagnosis of “suspicious” and included an analysis of cytomorphologic criteria used to establish the diagnosis of “suspicious for urothelial carcinoma” or its equivalent, “atypical urothelial cells, cannot exclude high‐grade urothelial carcinoma (AUC‐H)” (Table ).…”

“…This most likely reflects differences in criteria used by different institutions and cytopathologists; although it also may reflect diverse patient populations, clinical practice patterns, types of samples examined (voided urine vs instrumented urine), and cytopreparatory methods. In contrast to other studies in which the PPV of “suspicious” was very close to that of “positive,” our results suggest that these 2 categories have rather different underlying risks of malignancy and thus should not be combined. The current management strategies for patients with UCyt diagnosed as “suspicious” or “positive” are similar, with both managed by immediate cystoscopy.…”

“…The clinical significance and risk of HGUC on follow‐up conferred by the TPS diagnostic category “suspicious for HGUC” (SHGUC) has not been well defined, as very few publications have addressed this issue in the recent literature . For over 10 years, we have been using a 5‐tiered reporting system, consisting of unsatisfactory, negative, atypical, “suspicious,” and positive for malignancy (HGUC or other), at Loyola University Medical Center.…”

Young investigator challenge: The accuracy of the nuclear‐to‐cytoplasmic ratio estimation among trained morphologists

“…Morphologists are trained that a high N:C ratio is a worrisome feature but to our knowledge the exact ratio at which a cell becomes atypical is never defined and is dependent on many factors, including tissue type, preparation, inflammation, etc. In the pathology literature, algorithmic systems for determining malignant potential often make reference to an increased N:C ratio and some go so far as to define a specific decimal ratio (as in the Paris system for urinary cytopathology) or range . However, it is typically not revealed how, or even if, this ratio was determined (eg, by micrometer, computer‐aided analysis, or estimation).…”