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Improving the Predictability of Indeterminate Results of Urinary Cytologic Samples
Abstracts
S25
technically challenging. Accurate diagnosis of UTUC is crucial for the urologist to formulate a proper therapeutic strategy. Our aim is to evaluate the sensitivities of urine cytology and ureteroscopic biopsy on diagnosis of UTUC. Materials and Methods: A total of 80 patients with UTUC, who underwent radical nephroureterectomy or ureterectomy from January 2000 to September 2011 in our institution, were included in the study. Patients who had UC arising from lower tract (LT) were excluded. A total of 142 urinary specimens and 54 biopsies from these patients were evaluated. The sensitivity of each diagnostic modality was calculated with respect to tumor grade, stage, and size. The cytology evaluation was further sub-grouped into selective upper tract (ureteral/renal pelvic washing/brushing) and lower tract (voided urine and bladder barbotage) cytology. The diagnosis was categorized as positive, atypical urothelial cells (AU), and negative. For the statistical purposes, AU was considered as negative for malignancy. The results were analyzed with the Chi-square test. Results: The sensitivities of cytological screening and ureteroscopic biopsy in detecting UTUC, including both high grade and low grade, are summarized in Table 1. Without taking tumor grade into consideration, the overall sensitivity for cytology (both LT and UT) was lower than tissue biopsy (55.2% versus 77.8%). For low grade UTUC, the sensitivities of biopsy, LT cytology and UT cytology were 68.4%, 27.3% and 37.5% respectively. These were 82.9%, 40.7% and 80.6% for high grade UTUC. There is no statistical significance between the sensitivities of UT cytology and biopsy on detection of high grade UTUC (pZ0.07). To evaluate the sensitivity of combined diagnostic modalities, the data from the patients who had concomitant UT biopsy and cytology was further analyzed. There were 16 paired UT cytology and biopsy specimens diagnosed as low grade UC, while 30 paired specimens diagnosed as high grade UC. By combining these two diagnostic modalities, the diagnostic sensitivities increased to 87.5% for low grade UTUC and 100% for high grade UTUC. To compare the sensitivities of UT brushing and washing, 19 paired specimens were evaluated. UT brushing was proved to have a slightly higher sensitivity than UT washing (100% vs. 89.5%). The consistency between biopsy and final surgical diagnosis on tumor grading were 63.2% for low grade UTUC and 68.6% for high grade UTUC respectively. Neither cytology nor biopsy sensitivity correlated with the tumor size (data is not shown). The negative cytology specimens in patients with high grade UTUC were re-examined. These were found to be negative due to sampling error. Table 1 Tumor Grade
Low Grade
High Grade
Results
Positive Atypical Urothelial Cells Negative Total Sensitivity Positive Atypical Urothelial Cells Negative Total Sensitivity
Biopsy
13 1 5 19 68.4% 29 1 5 35 82.9%
Cytology Lower Tract
Upper Tract
6 5 11 22 27.3% 11 6 10 27 40.7%
12 7 13 32 37.5% 50 7 5 62 80.6%
Co-evaluation of Biopsy and Cytology* 14 0 2 16 87.5% 30 0 0 30 100%
*
Positive result was rendered when either or both of UT biopsy and cytology were positive. If both were negative, it was counted as negative result. No paired specimens were diagnosed as atypical urothelial cells by both modalities at the same time.
Conclusions: Both cytology and biopsy showed higher sensitivity in detecting high grade UTUC than low grade UTUC. The sensitivities of UT cytology and ureteroscopic biopsy in detecting high grade UTUC were comparable. The sensitivity was greatly improved when these diagnostic modalities were combined. The selective UT cytology evaluation had superior sensitivity in detecting UTUC compared to lower tract cytology sampling.
24 UroVysion Fluorescence In-Situ Hybridization Demonstrates Aneusomy in High Grade Urothelial Carcinomas with a Hypochromatic Cytologic Appearance Ghada Aramouni, CT(ASCP), Debbie Sabo, CT(ASCP), Deborah Chute, MD. Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio Introduction: Urine cytology is the primary screening test for urothelial carcinoma. It has a high sensitivity for high-grade urothelial carcinoma, which usually demonstrates a high nuclear to cytoplasmic ratio, hyperchromasia, coarse chromatin, and nuclear membrane irregularities. However, some cases of biopsy-proven high-grade urothelial carcinoma are not identified by urine cytology. By reviewing concurrent cytology samples and bladder biopsies of high grade urothelial carcinomas, we previously identified as subset of high grade urothelial carcinomas with a hypochromatic appearance, characterized by large nuclei, pale uniform chromatin, small nucleoli, smooth nuclear contours, and a high nuclear to cytoplasmic ratio (ASC 2011 abstract 31). UroVysionÒ is a multi-target fluorescence in situ hybridization (FISH) assay which detects polysomies of chromosomes 3, 7, and 17, and deletion of the gene locus 9p21. This assay is highly sensitive and specific for the detection of high grade urothelial carcinoma. In this study, we examine cytologically hypochromatic atypical urothelial cells for the presence of aneuploidy using the UroVysionÒ FISH assay. Materials and Methods: Ten previously identified urine cytology cases which had numerous hypochromatic atypical urothelial cells and a concurrent biopsy proven high grade urothelial cell carcinoma were included in the current study. Each slide was marked with a diamond tipped pen on the reverse surface of the slide to indicate the position of hypochromatic atypical urothelial cells. UroVysionÒ FISH was performed according to the manufacturer’s directions on the original urine ThinPrepÒ slide. A minimum of 25 hypochromatic atypical cells were counted for each case. Cases were considered positive for aneusomy if at least 5 hypochromatic abnormal cells showed gains of 2 or more chromosomes (3, 7, or 17) or if more than 12 cells lacked any 9p21 signal. Cells with a tetraploid pattern were not counted. Cases with fewer than 5 hypochromatic abnormal cells with gains in 2 or more chromosomes, or hypochromatic abnormal cells with only 1 chromosomal gain were regarded as negative for aneusomy. Results: All ten cases were positive for aneusomy by UroVysionÒ FISH. The percentage of atypical hypochromatic cells showing aneusomy ranged from 32% to 100% (mean 80%). All ten cases demonstrated a gain in 2 or more chromosomes (3, 7 or 17); one case also showed simultaneous 9p21 loss in 88% of cells. Conclusions: Hypochromatic atypical urothelial cells in patients with high grade urothelial carcinoma show aneusomy by FISH analysis. This indicates that hypochromatic atypical urothelial cells are neoplastic, and represent an unusual pattern of high grade urothelial carcinoma on urine cytology. 25 Improving the Predictability of Indeterminate Results of Urinary Cytologic Samples Christopher VandenBussche, MD, PhD, Hui Guan, MD, PhD, Srividya Sathiyamoorthy, MD, Dorothy Rosenthal, MD. Pathology, The Johns Hopkins Medical Institutions, Baltimore, Maryland Introduction: In most cytopathology laboratories, urinary tract (UT) samples are second only to Pap tests in annual volume. We previously designed a template in order to standardize our UT diagnostic categories to enable our clinicians to uniformly manage their patients. We have also examined the common cytomorphological features found in the category atypical urothelial cells, suspicious for high grade urothelial carcinoma (AUC-H) that proved most predictive of high-grade urothelial carcinoma
S26
Abstracts
(HGUC) (1) and used these features to identify atypical urothelial cells of undetermined significance (AUC-US) specimens more likely to have HGUC on follow-up (2). We now analyze the four morphological criteria individually to see which are most predictive of HGUC. Materials and Methods: The hospital laboratory information system was searched for cytology specimens that were diagnosed as AUC-US from July 1, 2007 to June 30, 2009. Approximately 670 specimens were identified. Of these specimens, 275 were used in this study. The specimens were classified by clinical indication (158 surveillance for neoplasia and 117 for hematuria). Two pathologists (CJV and DLR), blinded to outcome and indication, separately scored each of the AUC-US specimens for previously-identified cytologic criteria (irregular nuclear borders, nuclear hyperchromasia, increased nucleus-to-cytoplasm ratio, and anisonucleosis) most commonly found in AUC-H specimens. The specimens were then matched with the follow-up biopsy or clinical outcomes, which were tracked over the 18 months following the July 2009 cutoff for inclusion in the study. Results: The ability for individual morphological criteria to predict HGUC was strikingly different between the hematuria and surveillance groups (Table 1). Each of the four individual morphological characteristics was statistically significant (P < 0.01) for predicting HGUC in all-comers and surveillance patients but not for hematuria patients (Table 2). Table 1
Cytomorphological Features Used in Predicting HGUC
Indication
Features
Sensitivity
Specificity
NPV
PPV
Hematuria
N/C ratio Nuclear hyperchromasia Irregular nuclear borders Anisonucleosis All features combined N/C ratio Nuclear hyperchromasia Irregular nuclear borders Anisonucleosis All features combined
0.69 0.69 0.63 0.38 0.31 0.87 0.87 0.77 0.63 0.50
0.40 0.50 0.49 0.72 0.81 0.45 0.60 0.62 0.77 0.84
0.89 0.91 0.89 0.88 0.88 0.93 0.95 0.92 0.90 0.88
0.15 0.18 0.18 0.18 0.21 0.27 0.34 0.32 0.40 0.43
Surveillance
Table 2 Indication
documented cytomorphology of 7 RMC including 2 fine needle aspiration biopsies (FNABs) of kidney masses, 1 touch imprint of a kidney mass, 1 urine, 1 pelvic washing, 1 FNAB of a liver metastasis, and 2 pleural effusions. We sought to determine key diagnostic cytologic features of RMC by review of our own cases and comparison with previous reports. We present 3 new patients with FNAB of RMC in primary kidney lesions, a urine specimen, and FNAB of metastatic foci. We believe this is the largest series of FNABs of RMC kidney masses and the first report of FNABs of metastatic RMC in a lung metastasis. Materials and Methods: We reviewed our department files to identify 3 patients with cytologic specimens of RMC: a 10 year old boy (SC disease), a 27 year old man (sickle trait), and a 40 year old female (sickle trait). Cytomorphology was examined in our cases and previous reports to identify consistent diagnostic features. FNAB were examined with air-dried Romanowsky and alcohol-fixed Papanicolau stains, and urine was examined by monolayer. Results: Of 19 features, 8 were most consistent in our cases: loosely cohesive groups and single cells, irregular nuclear outlines, single or multiple conspicuous nucleoli, eccentric nuclei, high N:C ratios, cytoplasmic vacuoles, folded or “kidney bean-shaped” nuclei with curvilinear grooves, and extensive neutrophils in the background and in vacuoles. Nuclear features were better seen in alcohol fixed specimens but were present in air dried aspirates (Figure 1). Urine showed irregular nuclear outlines, multiple nucleoli, high N:C ratios, folded nuclei with grooves, and neutrophils. FNABs of metastatic tumor showed the 8 key features however with a lesser degree of nuclear atypia. Irregular nuclear outlines, folded nuclei, and grooves were only seen in the alcohol fixed preparations of metastases. Extensive neutrophils were still observed in metastases. We did not identify unequivocal drepanocytes in our own specimens.
P-values of Cytomorphological Features Used in the Prediction of HGUC Features
Hematuria
Univariate Analysis Multivariate Analysis
N/C ratio 0.53 Nuclear hyperchromasia 0.16 Irregular nuclear borders 0.41 Anisonucleosis 0.43 Surveillance N/C ratio 0.004* Nuclear hyperchromasia <0.0001) Irregular nuclear borders 0.0004) Anisonucleosis <0.0001)
0.91 0.12 0.22 0.83 0.074 0.035) 0.457 0.222
Statistically significant (P < 0.05).
*
Conclusions: Urine specimens classified as AUC-US at our institution have a low rate of HGUC on short-term follow-up (w15%). As a result, these patients may receive less clinical follow-up, possibly resulting in delayed treatment. We have identified morphological criteria that have a relatively high sensitivity for predicting HGUC in surveillance patients. Reclassifying specimens meeting these criteria into a category with a higher level of suspicion for HGUC (AUC-H) may help guide clinicians to provide more appropriate follow-up to these patients. Interestingly, these criteria do not appear as useful when hematuria is the clinical indication. (1) CJ VandenBussche et al. 2011. CytoJournal 8:A37. (2) CJ VandenBussche et al. 2012. Modern Pathology 25:A109. 26 Identification of Key Cytomorphologic Features of Renal Medullary Carcinoma in Fine Needle Aspiration Biopsy Graham Parks, MD1, Sahussapont Sirintrapun, MD1, Kim Geisinger, MD2. 1 Department of Pathology, Wake Forest Baptist Medical Center, WinstonSalem, North Carolina; 2Piedmont Pathology Associates, Hickory, North Carolina Introduction: Renal medullary carcinoma (RMC) is a rare, aggressive renal cancer occurring with sickle cell trait or disease. Four previous reports
Figure 1 Cytomorphologic features of RMC in FNAB of kidney masses as seen with Romanowsky type (A) and Papanicolau (B) staining.
Conclusions: In the appropriate clinical context, these key features may suggest or exclude RMC. Diagnostic features were seen in multiple specimens in 3 patients, including air-dried Romanowsky stains, thus suspicion for RMC may be raised during onsite evaluation, allowing appropriate workup of this highly aggressive tumor. 27 Cytologic Diagnosis of Metastatic Urothelial Carcinoma: A Retrospective Study at a Tertiary Care Hospital Seema Khutti, MD, Srinivas Mandavilli, MD. Department Of Pathology, Hartford Hospital, Hartford, Connecticut Introduction: The diagnosis of metastatic urothelial carcinoma (MUC) can be challenging due to lack of specific morphologic features and immunohistochemical (IHC) markers. In the absence of supportive clinical findings and, or prior pathology material to compare, it can be very difficult to establish the diagnosis of MUC. Cytologic features of urothelial carcinoma (UC) are well-described in cytology literature, however there is limited literature evaluating application of these morphologic findings in the context of the clinical features and IHC studies. The aim of this study was to evaluate morphologic, clinical, and IHC findings retrospectively in MUC. Materials and Methods: : 32 cases of MUC were retrieved from the cytology files over a 7-year time period (2005-2012). The FNA smears were reviewed and cytologic, relevant clinico-pathologic and IHC (when available) findings were summarized.
S25
technically challenging. Accurate diagnosis of UTUC is crucial for the urologist to formulate a proper therapeutic strategy. Our aim is to evaluate the sensitivities of urine cytology and ureteroscopic biopsy on diagnosis of UTUC. Materials and Methods: A total of 80 patients with UTUC, who underwent radical nephroureterectomy or ureterectomy from January 2000 to September 2011 in our institution, were included in the study. Patients who had UC arising from lower tract (LT) were excluded. A total of 142 urinary specimens and 54 biopsies from these patients were evaluated. The sensitivity of each diagnostic modality was calculated with respect to tumor grade, stage, and size. The cytology evaluation was further sub-grouped into selective upper tract (ureteral/renal pelvic washing/brushing) and lower tract (voided urine and bladder barbotage) cytology. The diagnosis was categorized as positive, atypical urothelial cells (AU), and negative. For the statistical purposes, AU was considered as negative for malignancy. The results were analyzed with the Chi-square test. Results: The sensitivities of cytological screening and ureteroscopic biopsy in detecting UTUC, including both high grade and low grade, are summarized in Table 1. Without taking tumor grade into consideration, the overall sensitivity for cytology (both LT and UT) was lower than tissue biopsy (55.2% versus 77.8%). For low grade UTUC, the sensitivities of biopsy, LT cytology and UT cytology were 68.4%, 27.3% and 37.5% respectively. These were 82.9%, 40.7% and 80.6% for high grade UTUC. There is no statistical significance between the sensitivities of UT cytology and biopsy on detection of high grade UTUC (pZ0.07). To evaluate the sensitivity of combined diagnostic modalities, the data from the patients who had concomitant UT biopsy and cytology was further analyzed. There were 16 paired UT cytology and biopsy specimens diagnosed as low grade UC, while 30 paired specimens diagnosed as high grade UC. By combining these two diagnostic modalities, the diagnostic sensitivities increased to 87.5% for low grade UTUC and 100% for high grade UTUC. To compare the sensitivities of UT brushing and washing, 19 paired specimens were evaluated. UT brushing was proved to have a slightly higher sensitivity than UT washing (100% vs. 89.5%). The consistency between biopsy and final surgical diagnosis on tumor grading were 63.2% for low grade UTUC and 68.6% for high grade UTUC respectively. Neither cytology nor biopsy sensitivity correlated with the tumor size (data is not shown). The negative cytology specimens in patients with high grade UTUC were re-examined. These were found to be negative due to sampling error. Table 1 Tumor Grade
Low Grade
High Grade
Results
Positive Atypical Urothelial Cells Negative Total Sensitivity Positive Atypical Urothelial Cells Negative Total Sensitivity
Biopsy
13 1 5 19 68.4% 29 1 5 35 82.9%
Cytology Lower Tract
Upper Tract
6 5 11 22 27.3% 11 6 10 27 40.7%
12 7 13 32 37.5% 50 7 5 62 80.6%
Co-evaluation of Biopsy and Cytology* 14 0 2 16 87.5% 30 0 0 30 100%
*
Positive result was rendered when either or both of UT biopsy and cytology were positive. If both were negative, it was counted as negative result. No paired specimens were diagnosed as atypical urothelial cells by both modalities at the same time.
Conclusions: Both cytology and biopsy showed higher sensitivity in detecting high grade UTUC than low grade UTUC. The sensitivities of UT cytology and ureteroscopic biopsy in detecting high grade UTUC were comparable. The sensitivity was greatly improved when these diagnostic modalities were combined. The selective UT cytology evaluation had superior sensitivity in detecting UTUC compared to lower tract cytology sampling.
24 UroVysion Fluorescence In-Situ Hybridization Demonstrates Aneusomy in High Grade Urothelial Carcinomas with a Hypochromatic Cytologic Appearance Ghada Aramouni, CT(ASCP), Debbie Sabo, CT(ASCP), Deborah Chute, MD. Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio Introduction: Urine cytology is the primary screening test for urothelial carcinoma. It has a high sensitivity for high-grade urothelial carcinoma, which usually demonstrates a high nuclear to cytoplasmic ratio, hyperchromasia, coarse chromatin, and nuclear membrane irregularities. However, some cases of biopsy-proven high-grade urothelial carcinoma are not identified by urine cytology. By reviewing concurrent cytology samples and bladder biopsies of high grade urothelial carcinomas, we previously identified as subset of high grade urothelial carcinomas with a hypochromatic appearance, characterized by large nuclei, pale uniform chromatin, small nucleoli, smooth nuclear contours, and a high nuclear to cytoplasmic ratio (ASC 2011 abstract 31). UroVysionÒ is a multi-target fluorescence in situ hybridization (FISH) assay which detects polysomies of chromosomes 3, 7, and 17, and deletion of the gene locus 9p21. This assay is highly sensitive and specific for the detection of high grade urothelial carcinoma. In this study, we examine cytologically hypochromatic atypical urothelial cells for the presence of aneuploidy using the UroVysionÒ FISH assay. Materials and Methods: Ten previously identified urine cytology cases which had numerous hypochromatic atypical urothelial cells and a concurrent biopsy proven high grade urothelial cell carcinoma were included in the current study. Each slide was marked with a diamond tipped pen on the reverse surface of the slide to indicate the position of hypochromatic atypical urothelial cells. UroVysionÒ FISH was performed according to the manufacturer’s directions on the original urine ThinPrepÒ slide. A minimum of 25 hypochromatic atypical cells were counted for each case. Cases were considered positive for aneusomy if at least 5 hypochromatic abnormal cells showed gains of 2 or more chromosomes (3, 7, or 17) or if more than 12 cells lacked any 9p21 signal. Cells with a tetraploid pattern were not counted. Cases with fewer than 5 hypochromatic abnormal cells with gains in 2 or more chromosomes, or hypochromatic abnormal cells with only 1 chromosomal gain were regarded as negative for aneusomy. Results: All ten cases were positive for aneusomy by UroVysionÒ FISH. The percentage of atypical hypochromatic cells showing aneusomy ranged from 32% to 100% (mean 80%). All ten cases demonstrated a gain in 2 or more chromosomes (3, 7 or 17); one case also showed simultaneous 9p21 loss in 88% of cells. Conclusions: Hypochromatic atypical urothelial cells in patients with high grade urothelial carcinoma show aneusomy by FISH analysis. This indicates that hypochromatic atypical urothelial cells are neoplastic, and represent an unusual pattern of high grade urothelial carcinoma on urine cytology. 25 Improving the Predictability of Indeterminate Results of Urinary Cytologic Samples Christopher VandenBussche, MD, PhD, Hui Guan, MD, PhD, Srividya Sathiyamoorthy, MD, Dorothy Rosenthal, MD. Pathology, The Johns Hopkins Medical Institutions, Baltimore, Maryland Introduction: In most cytopathology laboratories, urinary tract (UT) samples are second only to Pap tests in annual volume. We previously designed a template in order to standardize our UT diagnostic categories to enable our clinicians to uniformly manage their patients. We have also examined the common cytomorphological features found in the category atypical urothelial cells, suspicious for high grade urothelial carcinoma (AUC-H) that proved most predictive of high-grade urothelial carcinoma
S26
Abstracts
(HGUC) (1) and used these features to identify atypical urothelial cells of undetermined significance (AUC-US) specimens more likely to have HGUC on follow-up (2). We now analyze the four morphological criteria individually to see which are most predictive of HGUC. Materials and Methods: The hospital laboratory information system was searched for cytology specimens that were diagnosed as AUC-US from July 1, 2007 to June 30, 2009. Approximately 670 specimens were identified. Of these specimens, 275 were used in this study. The specimens were classified by clinical indication (158 surveillance for neoplasia and 117 for hematuria). Two pathologists (CJV and DLR), blinded to outcome and indication, separately scored each of the AUC-US specimens for previously-identified cytologic criteria (irregular nuclear borders, nuclear hyperchromasia, increased nucleus-to-cytoplasm ratio, and anisonucleosis) most commonly found in AUC-H specimens. The specimens were then matched with the follow-up biopsy or clinical outcomes, which were tracked over the 18 months following the July 2009 cutoff for inclusion in the study. Results: The ability for individual morphological criteria to predict HGUC was strikingly different between the hematuria and surveillance groups (Table 1). Each of the four individual morphological characteristics was statistically significant (P < 0.01) for predicting HGUC in all-comers and surveillance patients but not for hematuria patients (Table 2). Table 1
Cytomorphological Features Used in Predicting HGUC
Indication
Features
Sensitivity
Specificity
NPV
PPV
Hematuria
N/C ratio Nuclear hyperchromasia Irregular nuclear borders Anisonucleosis All features combined N/C ratio Nuclear hyperchromasia Irregular nuclear borders Anisonucleosis All features combined
0.69 0.69 0.63 0.38 0.31 0.87 0.87 0.77 0.63 0.50
0.40 0.50 0.49 0.72 0.81 0.45 0.60 0.62 0.77 0.84
0.89 0.91 0.89 0.88 0.88 0.93 0.95 0.92 0.90 0.88
0.15 0.18 0.18 0.18 0.21 0.27 0.34 0.32 0.40 0.43
Surveillance
Table 2 Indication
documented cytomorphology of 7 RMC including 2 fine needle aspiration biopsies (FNABs) of kidney masses, 1 touch imprint of a kidney mass, 1 urine, 1 pelvic washing, 1 FNAB of a liver metastasis, and 2 pleural effusions. We sought to determine key diagnostic cytologic features of RMC by review of our own cases and comparison with previous reports. We present 3 new patients with FNAB of RMC in primary kidney lesions, a urine specimen, and FNAB of metastatic foci. We believe this is the largest series of FNABs of RMC kidney masses and the first report of FNABs of metastatic RMC in a lung metastasis. Materials and Methods: We reviewed our department files to identify 3 patients with cytologic specimens of RMC: a 10 year old boy (SC disease), a 27 year old man (sickle trait), and a 40 year old female (sickle trait). Cytomorphology was examined in our cases and previous reports to identify consistent diagnostic features. FNAB were examined with air-dried Romanowsky and alcohol-fixed Papanicolau stains, and urine was examined by monolayer. Results: Of 19 features, 8 were most consistent in our cases: loosely cohesive groups and single cells, irregular nuclear outlines, single or multiple conspicuous nucleoli, eccentric nuclei, high N:C ratios, cytoplasmic vacuoles, folded or “kidney bean-shaped” nuclei with curvilinear grooves, and extensive neutrophils in the background and in vacuoles. Nuclear features were better seen in alcohol fixed specimens but were present in air dried aspirates (Figure 1). Urine showed irregular nuclear outlines, multiple nucleoli, high N:C ratios, folded nuclei with grooves, and neutrophils. FNABs of metastatic tumor showed the 8 key features however with a lesser degree of nuclear atypia. Irregular nuclear outlines, folded nuclei, and grooves were only seen in the alcohol fixed preparations of metastases. Extensive neutrophils were still observed in metastases. We did not identify unequivocal drepanocytes in our own specimens.
P-values of Cytomorphological Features Used in the Prediction of HGUC Features
Hematuria
Univariate Analysis Multivariate Analysis
N/C ratio 0.53 Nuclear hyperchromasia 0.16 Irregular nuclear borders 0.41 Anisonucleosis 0.43 Surveillance N/C ratio 0.004* Nuclear hyperchromasia <0.0001) Irregular nuclear borders 0.0004) Anisonucleosis <0.0001)
0.91 0.12 0.22 0.83 0.074 0.035) 0.457 0.222
Statistically significant (P < 0.05).
*
Conclusions: Urine specimens classified as AUC-US at our institution have a low rate of HGUC on short-term follow-up (w15%). As a result, these patients may receive less clinical follow-up, possibly resulting in delayed treatment. We have identified morphological criteria that have a relatively high sensitivity for predicting HGUC in surveillance patients. Reclassifying specimens meeting these criteria into a category with a higher level of suspicion for HGUC (AUC-H) may help guide clinicians to provide more appropriate follow-up to these patients. Interestingly, these criteria do not appear as useful when hematuria is the clinical indication. (1) CJ VandenBussche et al. 2011. CytoJournal 8:A37. (2) CJ VandenBussche et al. 2012. Modern Pathology 25:A109. 26 Identification of Key Cytomorphologic Features of Renal Medullary Carcinoma in Fine Needle Aspiration Biopsy Graham Parks, MD1, Sahussapont Sirintrapun, MD1, Kim Geisinger, MD2. 1 Department of Pathology, Wake Forest Baptist Medical Center, WinstonSalem, North Carolina; 2Piedmont Pathology Associates, Hickory, North Carolina Introduction: Renal medullary carcinoma (RMC) is a rare, aggressive renal cancer occurring with sickle cell trait or disease. Four previous reports
Figure 1 Cytomorphologic features of RMC in FNAB of kidney masses as seen with Romanowsky type (A) and Papanicolau (B) staining.
Conclusions: In the appropriate clinical context, these key features may suggest or exclude RMC. Diagnostic features were seen in multiple specimens in 3 patients, including air-dried Romanowsky stains, thus suspicion for RMC may be raised during onsite evaluation, allowing appropriate workup of this highly aggressive tumor. 27 Cytologic Diagnosis of Metastatic Urothelial Carcinoma: A Retrospective Study at a Tertiary Care Hospital Seema Khutti, MD, Srinivas Mandavilli, MD. Department Of Pathology, Hartford Hospital, Hartford, Connecticut Introduction: The diagnosis of metastatic urothelial carcinoma (MUC) can be challenging due to lack of specific morphologic features and immunohistochemical (IHC) markers. In the absence of supportive clinical findings and, or prior pathology material to compare, it can be very difficult to establish the diagnosis of MUC. Cytologic features of urothelial carcinoma (UC) are well-described in cytology literature, however there is limited literature evaluating application of these morphologic findings in the context of the clinical features and IHC studies. The aim of this study was to evaluate morphologic, clinical, and IHC findings retrospectively in MUC. Materials and Methods: : 32 cases of MUC were retrieved from the cytology files over a 7-year time period (2005-2012). The FNA smears were reviewed and cytologic, relevant clinico-pathologic and IHC (when available) findings were summarized.