The merits of cytology in the workup for upper tract urothelial carcinoma - a contemporary review of a perplexing issue

Introduction The importance of upper tract cytology for evaluating tumors is unclear. We correlated upper tract cytology with histologic findings in patients who underwent nephroureterectomy for upper tract urothelial carcinoma (UTUC) at a single tertiary care referral center. Materials and Methods 137 patients underwent nephroureterectomy between 2004 and 2012. 18 patients were excluded (benign tumors, atrophic kidneys with the remaining 119 patients serving as our study population). Upper tract cytology from the renal pelvis and/or ureter were retrospectively reviewed and analyzed with final pathology data in the remaining patients with UTUC. Results 57% (68/119) had preoperative upper tract cytology collected. 73% (50/68) patients had abnormal cytology (positive, suspicious) with a sensitivity of 74% (which increased to 90% if atypical included), specificity of 50% and a positive predictive value of 98%. High grade tumors were more common than expected (77% high grade vs. 20% low grade). Abnormal cytology did not predict T stage or tumor grade. Interestingly, positive upper tract cytology was found in all of the UTUC CIS specimen. Conclusions Upper tract cytology has been utilized to support the diagnosis of upper tract urothelial carcinoma. Our data demonstrates that abnormal cytology correlates well with the presence of disease but does not predict staging or grading in these respective patients. .

Cytometric analysis of Fas and Bcl-2 expression in normal prostatic epithelium and prostate cancer.

The apoptosis-inducer Fas and the apoptosis-suppresser Bcl-2 are members of the tumor necrosis factor receptor and Bcl-2 gene superfamilies, respectively. Bcl-2 is overexpressed in hormonally refractory prostate cancer. Fas is expressed in several prostatic carcinoma cell lines but its in vivo expression in normal prostate and in prostate cancer is poorly understood. Formalin-fixed tissue sections from 10 benign prostatic hyperplasias, 10 low-grade and 10 high-grade organ-confined prostate cancers, and 6 metastatic prostate cancers were evaluated for immunoreactivity with Fas and Bcl-2 monoclonal antibodies. In addition, Fas expression was quantitated by computerized cytometry. The results were compared by one-way analysis of variance followed by Bonferroni tests. In benign prostate samples, Bcl-2 and Fas were expressed on basal cells and secretory cells, respectively. Bcl-2 was not expressed in any organ-confined tumors and only in one of six metastatic tumors (17%). Fas was expressed in all organ-confined tumors and in two of six metastatic tumors (33%). Fas expression was significantly decreased (P < 0.001) in prostate cancer (0.20 pg/cell) compared with benign prostate (0.79 pg/cell). The decrease was inversely related to the malignant grade of the tumors (0.30 pg/cell in low-grade tumors, 0.19 pg/cell in high-grade tumors, and 0.003 pg/cell in metastatic tumors). Based on these preliminary data, decreased expression of Fas appears to be an early molecular event in prostate cancer. The decline begins in low-grade tumors. The lowest expression occurs in metastatic carcinomas, which are often Fas negative. Overexpression of Bcl-2 appears to be a later and unrelated molecular event. Both abnormalities may be implicated in tumor progression by prolonging tumor cell survival.

Stage B Prostate Cancer: Correlation of DNA Ploidy Analysis With Histological and Clinical Parameters.

BACKGROUND: The ability to accurately predict tumor behavior and patient survival is a problem in managing patients with prostate cancer. Prognostic variables in predicting death from tumor include prostate-specific antigen (PSA) level, histological grade, and clinical stage. Observer subjectivity is inherent in determining grade and stage; thus, criteria that are more objective are needed to identify patients for appropriate treatment. METHODS: The authors correlated flow cytometric nuclear DNA ploidy with Gleason score, PSA level, and recurrence risk in patients who underwent radical retropubic prostatectomy and bilateral pelvic lymphadenectomy between 1987 and 1993 for histopathologic stage B prostate cancer (T2, N0, M0). RESULTS: Of the tumors analyzed, 64% were DNA diploid with a low proliferative fraction, 25% were DNA diploid with a high proliferative fraction, and 11% were DNA aneuploid. DNA aneuploidy was associated with high Gleason grade (7-10). All Gleason grade 10 tumors were DNA aneuploid. Both DNA aneuploidy and high proliferative fraction (S+G2M) were statistically correlated with high Gleason grade and adverse prognosis but not with PSA level or patient age. CONCLUSIONS: A direct relationship is shown between both DNA aneuploidy and a high proliferation index with aggressive biological behavior in stage B prostatic cancer. Objective tumor criteria are needed to choose treatment more selectively for individual patients.

Long-term urodynamic evaluation of a continent urinary reservoir.

Objective: To characterize urodynamic changes among patients who underwent a continent urinary reservoir (Florida Pouch).Methods: Patients who had a continent urinary diversion performed between January 1988 and December 1991 were asked to undergo sequential urodynamic evaluation to compare early (24 mo) changes in reservoir function. The difference in reservoir function was evaluated by defining change in maximum enterocystometric capacity of >/=100 mL, changes in pressure of 5 cm H(2)O, changes in segmental contractions were >/=3. High pressure contractions were those >/=30 mm H(2)O.Results: Seventeen patients underwent sequential urodynamic evaluation. The mean timing of the early study was 12.2 months (range 3-24 mo). The mean timing of the late study was 47.1 months (range 30-58 mo). The mean capacity of the reservoir initially was 698 mL (range 474-1000 mL). On long-term study the mean was 793 mL (range 400-1000 mL). The capacity remained unchanged or increased in 88% of patients. The pressure within the reservoir remained unchanged in seven patients, decreased in eight, and increased in two. Segmental contractions originally occurred in 15 patients with 11 low pressure and 4 high pressure type contractions. On long-term evaluation, 13 patients demonstrated contractions with 10 low pressure and 3 high pressure in character. Of note, 75% of those with initial high pressure contractions had no (1) or low pressure (2) contractions on subsequent evaluation.Conclusion: In long-term urodynamic evaluation of the continent urinary reservoir the reservoir capacity remained unchanged or increased in 88% of patients, while reservoir pressure remained unchanged or decreased in 88%. This long-term evaluation, therefore, demonstrates the continent urinary reservoir to be a low pressure system of adequate capacity thereby minimizing the risk of reflux.

Bladder Replacement and Urinary Diversion After Radical Cystectomy.

BACKGROUND: The optimal mode of urinary tract reconstruction following cystectomy continues to challenge the urologic surgeon. Disadvantages with bowel conduits have prompted the search for better techniques to improve patient outcomes. METHODS: The development of urinary tract reconstruction is reviewed, and results from several forms of continent urinary diversion and bladder replacement construction are presented. The authors report on their experience in creating continent reservoirs or neobladders in over 400 patients. RESULTS: Several surgical approaches are now available for continent urinary diversion. Metabolic and nutritional abnormalities, stone formation, infection, and cancer formation are potential complications. CONCLUSIONS: Advances in surgical techniques, an understanding of the physiology of isolated bowel segments, and improvements in pre- and post-operative care have altered the field of urinary reconstruction after cystectomy for bladder cancer. Most patients can expect minimal morbidity and mortality.