Bladder & urothelial tract

• Methods of specimen collection: voided urine, catheterized urine, bladder or renal pelvis washing, brushing and ileal conduit
• There are cytological features that delineate benign urine specimens from high grade urothelial carcinoma (HGUC)
• Knowledge of cytological features of normal variants such as urothelial cells, glandular cells and renal tubular cells is key to accurate evaluation; there are also common findings that do not necessarily have clinical significance (e.g., crystals)
• Ancillary tests utilizing novel molecular technology as well as biomarkers increases diagnostic accuracy when paired with cytology
• 34 - 42% sensitivity and 96 - 99% specificity for diagnosing and surveilling urothelial carcinoma by cytology

Contributed by Maria Cecilia D. Reyes, M.D.

• UroVysion™
  • Fluorescence in situ hybridization assay (FISH)
  • Gains of 3, 7 and 17 as well as loss of 9p21 abnormalities are determined using fluorescently labeled pericentromeric DNA probes
  • Sensitivity of 84.2% and specificity of 91.8% for urothelial carcinoma detection
  • Has been shown to be positive in nonurothelial carcinomas, such as primary and secondary bladder adenocarcinoma, squamous cell carcinoma, urachal carcinoma or metastatic carcinoma
  • U-FISH has the advantage of high sensitivity and specificity in cytologically uncertain and negative urine samples not affected by hematuria, urinary tract infection or Bacillus Calmette Guerin (BCG) induced inflammatory response
  • Sensitivity of FISH to detect low grade tumors is low
  • Utilized for the follow up monitoring of bladder cancer
  • FISH has a higher sensitivity and specificity as compared to other noninvasive detection techniques
• Bladder tumor antigen (BTA) (Urol Oncol 2023;41:484.e17)
  • Complement factor H related protein secreted by malignant cells
  • Food and Drug Administration (FDA) approved the point of care (POC) test BTA stat™ and enzyme linked immunosorbent assay (ELISA) test BTA TRAK™ for surveillance of patients with urothelial carcinoma with concurrent use of cystoscopy
  • Urine collection should be without fixative / preservative
  • Higher sensitivity than cytology
  • Use of BTA as biomarker may improve surveillance, allowing more effective tracking for the presence or recurrence of high grade UC
  • Elevated false positive rate in patients with common urinary tract diseases (urinary tract infection [UTI], urolithiasis)
  • Sensitivity and specificity of these tests affected by patient selection in studies
  • Stat™ sensitivity: 64% (range 58 - 69%) specificity: 77% (range 73 - 81%)
  • TRAK™ sensitivity: 65% (range 54 - 75%) specificity: 74% (range 64 - 82%)
• Nuclear matrix protein 22 (NMP22) (Urol Clin North Am 2000;27:47, Urol Oncol 2023;41:484.e17)
  • Detects nuclear matrix protein that comes from apoptotic cells
  • Nuclear matrix proteins play a part in DNA replication, RNA transcription and gene expression regulation
  • NMP22 is elevated in malignant tumor cells
  • Utilized for diagnosis and surveillance of urothelial carcinoma
  • Common bladder conditions (UTI, urolithiasis, trauma) may cause elevated NMP22
  • Has a sensitivity of 32 - 92% and a specificity of 51 - 94%
  • False positive risk if voided urine samples obtained within 5 days after instrumentation
  • FDA approved: quantitative ELISA NMP22 test kit and qualitative NMP22 BladderChek point of care test
  • Cost effective: cheaper than a cytology urine reading
• Bladder cancer immunofluorescence assay (BCIA)
  • 3 fluorescent monoclonal antibodies (M344, LDQ10 and 19A211)
  • Detect carcinoembryonic antigen and sulfated mucin glycoproteins on voided urine
  • Combined with cytology for surveillance
  • More sensitive in detecting low grade tumors
• UBC® rapid test
  • Measures cytokeratin 8 and 18 fragments based on immunochromatographic methods
  • Uses a photometric reader
  • High rate of false positive results
  • Sensitivity: 53.3 - 70.8%, specificity: 61.4 - 93.8%
• Other ancillary tests
  • FDA approved
  • Wide variety of tests utilizing ELISA, polymerase chain reaction (PCR), next generation sequencing (NGS), microRNA, genetic profiling
  • ADXBLADDER, CxBladder Monitor, Bladder EpiCheck, uCAPP-Seq, AssureMDx, UroSeek
  • NGS has a high sensitivity for both low and high grade UC
• References: Wojcik: The Paris System for Reporting Urinary Cytology, 2nd Edition, 2022, Hoda: Diagnostic Liquid-Based Cytology, 1st Edition, 2017

Images hosted on other servers:

Which of the following describes the U-FISH (UroVysion™) test for bladder cancer?

1. Utilizes 3 fluorescent monoclonal antibodies (M344, LDQ10 and 19A211) to detect carcinoembryonic antigen and sulfated mucin glycoproteins on voided urine
2. Detects complement factor H related protein secreted by malignant cells
3. Identifies nuclear matrix protein that comes from apoptotic cells
4. Uses fluorescently labeled pericentromeric DNA probes to detect gains of 3, 7 and 17 as well as loss of 9p21 abnormalities

D. Uses fluorescently labeled pericentromeric DNA probes to detect gains of 3, 7 and 17 as well as loss of 9p21 abnormalities. Answer B is incorrect because bladder tumor antigen (BTA) utilizes complement factor H related protein secreted by malignant cells. Answer C is incorrect because nuclear matrix protein 22 detects nuclear matrix protein that comes from apoptotic cells. Answer A is incorrect because bladder cancer immunofluorescence assay (BCIA) utilizes 3 fluorescent monoclonal antibodies (M344, LDQ10 and 19A211) to detect carcinoembryonic antigen and sulfated mucin glycoproteins on voided urine.

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Reference: Cytology-general, normal findings & biomarker testing

This image above is an example of

1. Ammonium biurate crystals
2. Granular casts
3. Melamed-Wolinska bodies
4. Renal tubular cells (RTCs)

C. Melamed-Wolinska bodies. Melamed-Wolinska bodies are present, which are large eosinophilic intracytoplasmic inclusions. These are seen in degenerative changes. Answer A is incorrect because the morphology is of spiculated spheres. Answer D is incorrect because renal tubular cells (RTCs) have a morphology consisting of high N:C ratio if originating from distal convoluted tubules or low N:C ratios with granular cytoplasm if originating from the proximal convoluted tubules. Answer B is incorrect because these cells consist of coarse or finely granular debris.

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Reference: Cytology-general, normal findings & biomarker testing