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Correlation of cytology and cystoscopy
WROPATHOLOGY
CORRELATION ALBERT
P. SUTTON,
EVA HAJDU, MICHAEL
M.D.
M.D.
GANZ
MITCHELL HENRY
OF CYTOLOGY AND CYSTOSCOPY
BUCHBINDER,
J. ABRAM&
M.D.
M.D.
From the Department of Surgery, Division of Urology, Long Island Jewish-Hillside Medical Center, New Hyde Park, New York
ABSTRACT -A total of 152 patients had cytology and cystoscopy pegormed for either initial or recurrent bladder tumors and postoperative control examinations. Positive cytology was found in 97 per cent of patients with pathologically proved bladder tumors. However, 23 per cent of the patients with negative cytology had positive cystoscopic and pathologically proved findings. Without cystoscopic examination a signijcant number of recurrent tumors may be missed because of a negative cYtoh2Y.
oped, initially had negative cytology. Subsequently, all 15 of these men had abnormal cytologic findings for intervals varying up to several years before histologic confirmation of the lesions. The authors stated that in spite of occasional failures, positive cytology ensures the earliest possible diagnosis of the initial or recurring lesion. Orandi and Orandi3 followed up 73 patients for several years with cytology. Of 56 patients with positive cytology, 49 had a positive tissue diagnosis. Of 2 patients with positive cytology and negative cystoscopic findings, cancer later developed in one. Heney et al4 reported on 267 patients with positive cytology for five years. Nine did not have tumors at their initial cystoscopy, but in 8, tumors developed from one to sixty-one months later. Lewis et a1.5 described 66 patients with 118 bladder lesions proved by biopsy. The authors used bladder irrigations with saline to obtain specimens for cytology. Cytology was positive in 67 per cent of patients with initial bladder tumors, and 72 per cent positive in recurrent tumors. They stated that false negative results occurred mostly in superficial grade I and grade II malignancies. In 12 patients with positive
This article is a preliminary report on the correlation of cytology and cystoscopic and pathologic findings in 152 patients with 88 bladder tumors at the Long Island Jewish-Hillside Medical Center. The patients had either initial or recurrent tumors or underwent postoperative follow-up cystoscopies. Our purpose was to evaluate the accuracy of cytology to determine if cytology could replace routine follow-up cystoscopies. This was thought to be worthwhile, especially in poor-risk cardiac patients and patients taking anticoagulants. It could also be costsaving by avoiding unnecessary admission to a hospital for a possible negative cystoscopic finding. This has been recommended by Blandy’ at the London Hospital Medical Center. He also recommended cytology for employees in occupations known to have a high risk of exposure to bladder carcinogenic chemicals, such as in rubber making (alpha and beta naphthylamine), purification of sewage (benzidine), and rat-catching (alpha naphthylamine). Koss, Melamed, and Kelly* at Memorial Hospital reported in 1969 on a long-term study of 503 men accidentally exposed to a bladder carCytology was used to reduce the cinogen. number of cystoscopies. In their group 15 workers in whom carcinoma of the bladder devel-
UROLOGY
/ JANUARY 1979 / VOLUME
XIII,
NUMBER
1
83
TABLE
Pathologic grade of 88 positice cystoscopies
I.
higher grades. Of 15 with negative cytology, 5 patients had grades II and III lesions and 10 patients had grade I lesions.
Grade Cytology
I
II
III
IV
Total
Positive
6
12
7
8
33
18
15
6
1
40
10
4
1
0
15
Comment Atypical Negative
cytology and negative cystoscopic findings biopsy-proved lesions subsequently developed. Koss, Nakanishi, and Freed6 reported that in 8 cases of total cystectomy for carcinoma, 2 patients had atypical cells and 6 had positive cytology. In our study, 152 patients had cytology and cystoscopy for diagnosis of initial or possible recurrent tumors with control cystoscopies. Eighty-eight of these patients had positive cystoscopy and pathologic grading. Of the 34 patients with positive cytology, 33 (97 per cent) had positive cystoscopic findings. Of 54 patients with atypical cells, 40 (75 per cent) had positive cystoscopy. Of 64 patients with negative cytology, 15 (23 per cent) had positive cystoscopies. Table I shows the grading of the 88 patients with positive cystoscopic findings correlating with positive, atypical, and negative cytology. Of the 33 patients with positive cytology, 27 were of grades II, III, and IV. Of the 40 patients with atypical cytology, 22 were of the
84
From our study and review of the literature, a positive cytology is a strong indication of a serious bladder malignancy; with a negative cytology there is a 33 per cent chance of missing a bladder tumor if cystoscopy has not also been performed. We plan to improve collection techniques to decrease the number of false negative findings in our series. New Hyde Park, New York 11040 (DR. SUlTON) References 1. Blandy JP: The early diagnosis of genito-urinary carcinoma, 218: 81 (1977). Practitioner 2. Koss LG, Melamed MR, and Kelly E: Further cytologic and histologic studies of bladder lesions in workers exposed to paraaminodiphenyl: progress report, J. Natl. Cancer Inst. 43: 233 (1969). 3. Orandi A, and Orandi 0: Urine cytology in the detection of bladder tumor recurrence, J. Urol. 116: 568 (1976). 4. Heney NM, et al: Positive urinary cytology in patients without evident tumor, ibid. 117: 223 (1977). 5. Lewis RW, et al: Cytology in the diagnosis and follow-up of transitional cell carcinoma of the urothelium: a review with a case series, ibid. 116:43 (1976). 6. Koss LG, Nakanishi I, and Freed SZ: Nonpapillary carcinoma in situ and atypical hyperplasia in cancerous bladders: further studies of surgically removed bladders by mapping, Urology 9: 442 (1977).
UROLOGY
/
JANUARY
1979
/
VOLUME
XIII,
NUMBER
1
CORRELATION ALBERT
P. SUTTON,
EVA HAJDU, MICHAEL
M.D.
M.D.
GANZ
MITCHELL HENRY
OF CYTOLOGY AND CYSTOSCOPY
BUCHBINDER,
J. ABRAM&
M.D.
M.D.
From the Department of Surgery, Division of Urology, Long Island Jewish-Hillside Medical Center, New Hyde Park, New York
ABSTRACT -A total of 152 patients had cytology and cystoscopy pegormed for either initial or recurrent bladder tumors and postoperative control examinations. Positive cytology was found in 97 per cent of patients with pathologically proved bladder tumors. However, 23 per cent of the patients with negative cytology had positive cystoscopic and pathologically proved findings. Without cystoscopic examination a signijcant number of recurrent tumors may be missed because of a negative cYtoh2Y.
oped, initially had negative cytology. Subsequently, all 15 of these men had abnormal cytologic findings for intervals varying up to several years before histologic confirmation of the lesions. The authors stated that in spite of occasional failures, positive cytology ensures the earliest possible diagnosis of the initial or recurring lesion. Orandi and Orandi3 followed up 73 patients for several years with cytology. Of 56 patients with positive cytology, 49 had a positive tissue diagnosis. Of 2 patients with positive cytology and negative cystoscopic findings, cancer later developed in one. Heney et al4 reported on 267 patients with positive cytology for five years. Nine did not have tumors at their initial cystoscopy, but in 8, tumors developed from one to sixty-one months later. Lewis et a1.5 described 66 patients with 118 bladder lesions proved by biopsy. The authors used bladder irrigations with saline to obtain specimens for cytology. Cytology was positive in 67 per cent of patients with initial bladder tumors, and 72 per cent positive in recurrent tumors. They stated that false negative results occurred mostly in superficial grade I and grade II malignancies. In 12 patients with positive
This article is a preliminary report on the correlation of cytology and cystoscopic and pathologic findings in 152 patients with 88 bladder tumors at the Long Island Jewish-Hillside Medical Center. The patients had either initial or recurrent tumors or underwent postoperative follow-up cystoscopies. Our purpose was to evaluate the accuracy of cytology to determine if cytology could replace routine follow-up cystoscopies. This was thought to be worthwhile, especially in poor-risk cardiac patients and patients taking anticoagulants. It could also be costsaving by avoiding unnecessary admission to a hospital for a possible negative cystoscopic finding. This has been recommended by Blandy’ at the London Hospital Medical Center. He also recommended cytology for employees in occupations known to have a high risk of exposure to bladder carcinogenic chemicals, such as in rubber making (alpha and beta naphthylamine), purification of sewage (benzidine), and rat-catching (alpha naphthylamine). Koss, Melamed, and Kelly* at Memorial Hospital reported in 1969 on a long-term study of 503 men accidentally exposed to a bladder carCytology was used to reduce the cinogen. number of cystoscopies. In their group 15 workers in whom carcinoma of the bladder devel-
UROLOGY
/ JANUARY 1979 / VOLUME
XIII,
NUMBER
1
83
TABLE
Pathologic grade of 88 positice cystoscopies
I.
higher grades. Of 15 with negative cytology, 5 patients had grades II and III lesions and 10 patients had grade I lesions.
Grade Cytology
I
II
III
IV
Total
Positive
6
12
7
8
33
18
15
6
1
40
10
4
1
0
15
Comment Atypical Negative
cytology and negative cystoscopic findings biopsy-proved lesions subsequently developed. Koss, Nakanishi, and Freed6 reported that in 8 cases of total cystectomy for carcinoma, 2 patients had atypical cells and 6 had positive cytology. In our study, 152 patients had cytology and cystoscopy for diagnosis of initial or possible recurrent tumors with control cystoscopies. Eighty-eight of these patients had positive cystoscopy and pathologic grading. Of the 34 patients with positive cytology, 33 (97 per cent) had positive cystoscopic findings. Of 54 patients with atypical cells, 40 (75 per cent) had positive cystoscopy. Of 64 patients with negative cytology, 15 (23 per cent) had positive cystoscopies. Table I shows the grading of the 88 patients with positive cystoscopic findings correlating with positive, atypical, and negative cytology. Of the 33 patients with positive cytology, 27 were of grades II, III, and IV. Of the 40 patients with atypical cytology, 22 were of the
84
From our study and review of the literature, a positive cytology is a strong indication of a serious bladder malignancy; with a negative cytology there is a 33 per cent chance of missing a bladder tumor if cystoscopy has not also been performed. We plan to improve collection techniques to decrease the number of false negative findings in our series. New Hyde Park, New York 11040 (DR. SUlTON) References 1. Blandy JP: The early diagnosis of genito-urinary carcinoma, 218: 81 (1977). Practitioner 2. Koss LG, Melamed MR, and Kelly E: Further cytologic and histologic studies of bladder lesions in workers exposed to paraaminodiphenyl: progress report, J. Natl. Cancer Inst. 43: 233 (1969). 3. Orandi A, and Orandi 0: Urine cytology in the detection of bladder tumor recurrence, J. Urol. 116: 568 (1976). 4. Heney NM, et al: Positive urinary cytology in patients without evident tumor, ibid. 117: 223 (1977). 5. Lewis RW, et al: Cytology in the diagnosis and follow-up of transitional cell carcinoma of the urothelium: a review with a case series, ibid. 116:43 (1976). 6. Koss LG, Nakanishi I, and Freed SZ: Nonpapillary carcinoma in situ and atypical hyperplasia in cancerous bladders: further studies of surgically removed bladders by mapping, Urology 9: 442 (1977).
UROLOGY
/
JANUARY
1979
/
VOLUME
XIII,
NUMBER
1