Elsevier

Urology

Volume 61, Issue 6, June 2003, Pages 1146-1150
Urology

Adult urology
Cytologic analysis of ureteral washings is informative in patients with grade 2 upper tract TCC considering endoscopic treatment

https://doi.org/10.1016/S0090-4295(03)00026-8Get rights and content

Abstract

Objectives

To determine the diagnostic accuracy of ureteroscopic biopsy and whether exfoliated cell cytology can improve diagnostic accuracy.

Methods

Sixty-two cases of upper tract transitional cell carcinoma were diagnosed by ureteroscopic biopsy and treated by nephroureterectomy. Stage and grade evaluation was possible in 51 cases. Cytology for exfoliated cells from the ureter/pelvis was available in 48 cases.

Results

Biopsies were staged as Tis in 3, Ta in 35, and T1 in 13 and graded as G1 in 6, G2 in 32, and G3 in 13. Cytology was positive/suspicious in 40% (19 of 48). The biopsy grade accurately predicted the pathologic grade (P <0.0001) and stage (P = 0.001). The biopsy stage was not associated with the final stage (P = 0.112, Fisher’s exact test). Biopsy G3 accurately predicted high-grade (G3) transitional cell carcinoma in 92% (12 of 13) of cases. The remaining 1 case was G2 by final histologic examination. No case of high-grade (G3) disease was found in the 6 G1 biopsies (100%). Of 32 G2 biopsies, 9 were upgraded to G3. Cytology was available for 8 of the 9 and 5 (63%) were positive. For patients with G2 biopsies, combining cytology and biopsy grade improved the sensitivity and specificity of high-grade tumor detection from 43% to 55% and 23% to 85%, respectively.

Conclusions

The results of this study have shown that biopsy grade reflects the pathologic stage and grade. Combining exfoliated cell cytology improved the predictive power of biopsy G2 disease for high-risk specimen grade. Exfoliated cell cytology in combination with biopsy grade is recommended as part of the evaluation of upper tract transitional cell carcinoma selected for endoscopic management.

Section snippets

Material and methods

Between July 1989 and July 2001, 140 patients with a mean age of 69 years (range 41 to 91) were diagnosed with UUT-TCC and treated by nephroureterectomy. Sixty-two patients who had UUT-TCC and no concomitant bladder TCC completed endoscopic investigations, which included ureteropyelography, ureteroscopy, and biopsy of the tumor before open surgery. A total of 37 left and 25 right collecting systems were affected in 40 men and 22 women. The conditions at presentation included gross and

Results

Of the 62 patients who underwent ureteroscopic biopsy, grade and stage evaluation was possible in 51 cases (82%; Table I).

Comment

Conservation of renal units in patients with UUT-TCC lies in the ability to accurately exclude patients with high-grade invasive tumors who are at increased risk of local recurrence6, 9 and early death.7, 17 The results of our retrospective study not only confirm the diagnostic accuracy of biopsy grade but also identified the clinical utility of exfoliative cytology, obtained from gentle ureteral washings, in further defining patients with grade 2 biopsies who can safely pursue endoscopic

Conclusions

Our data suggest that in patients with ureteroscopic biopsy grade 2 tumors, the demonstration of malignant cells obtained by gentle upper tract washings before biopsy usually indicates undetected high-grade TCC. Patients with biopsy TaG2 UUT-TCC and positive cytology require nephroureterectomy. Patients with TaG1 biopsies can be safely treated endoscopically. Patients with TaG2 biopsies and negative cytology may be candidates for endoscopic treatment, but a small chance of understaging still

Acknowledgements

To the Newcastle upon Tyne Hospitals Special Trustees who funded a part-time data manager to underpin the project.

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