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The Disadvantages of the Electroresectoscope for Bladder Tumor Biopsy
THE JOURNAL OF UROLOGY
Vol. 72, No. 4, October 1954 Printed in U.S.A.
THE DISADVANTAGES OF THE ELECTRORESECTOSCOPE FOR BLADDER TUMOR BIOPSY ARCHIE L. DEAN, JR.
AND
J. E. ASH
From the Armed Forces Institute of Pathology, Washington 25, D. C.
A large proportion of bladder tumor biopsy specimens removed with the electroresectoscope are unfit for detailed microscopic study because of the destructive effects of the electric cutting current. The grading of bladder tumors may be difficult under the best of conditions. Nevertheless, accurate tumor diagnosis is a necessity if the patient is to be offered the best chance for cure. In classifying these tumors for the Bladder Tumor Registry of the American Urological Association at the Armed Forces Institute of Pathology every effort is made to study each specimen according to the following microscopic criteria: 1) cellular structure, that is, the type cell comprising the tumor, its degree of differentiation, and the relative frequency of . mitotic figures; 2) the arrangement of the tumor cells, whether in separate papillary structures or in sheets; 3) the presence or absence of invasion of the bladder musculature. Recent study of 100 consecutive bladder tumor biopsies referred to the Registry shows that most of the specimens were removed by the electroresectoscope. More than one-fourth of these were so extensively damaged by the electric current that accurate microscopic diagnosis was impossible (table 1). The passage of the electric current through tissue causes considerable distortion of the surrounding structures. The cell nuclei become pyknotic and the entire cell, nucleus included, is elongated. The cell boundaries are lost; no mitoses are visible, and even such easily recognized structures as glandular or acinar formations may be disguised. These changes occur both in neoplastic areas and in normal tissue, with the result that the pathologist is unable to distinguish between the two (fig. 1, A and C). The heat affects the tissue to a depth approximating from one to two high power fields of the microscope. Thus in the case of large papillary tumors, it may still be possible to make a correct diagnosis; but when the papillary tumor is small, single, and delicate, its entire thickness may be distorted. It is important also to realize that when the cutting current passes through the pedicle or stalk of a papillary growth, any tumor cells which may be infiltrating this structure or invading the bladder wall are likely to be altered beyond recognition. The TABLE
1. Comparison of biopsies obtained by electroresection and cold resection. Total cases, 100 CASES IN WHICH DISTORTION OF CELLS PRECLUDED DIAGNOSIS
Electrosection, 74 cases ........................... Cold resection, 26 cases ...........................
652
Number
Per cent
21 3
30 12
BLADDER TUMOR BIOPSY
\.,
653
~.-
.~,,... .. .,~ ~,,
FrG. 1. A, low power photomicrograph of segment of non-neoplastic bladder tissue obtained with electrocautery. This biopsy strikingly resembles an infiltrating neoplasm. AFIP Accession No. 267301-2. B, photomicrograph of an area in lesion reproduced in A not distorted by cautery effects. Cystitis and squamous metaplasia of bladder epithelium are clearly visible. C, higher power of an area of cautery distortion in same lesion. Even at this magnification the lesion appears malignant.
654
A. L. DEAN AND J. E. ASH
Frn. 2. A, low power of papillary bladder tumor by cold biopsy. AFIP Accession No. 217462-1. B, higher power of tumor shown in A. Individual cells, cell borders, and cell arrangement are easily visualized. C, low power of bladder tumor removed by electrocautery. Tissue distortion and lack of cell detail can be clearly seen. AFIP Accession No. 204458-1. D, higher power of lesion represented in C. Tumor is unrecognizable.
tissue obtained from cold resection, on the other hand, may occasionally be inadequate, but the cellular detail is clear and undistorted and can be readily identified. Figure 2, A and B illustrates a bladder tumor specimen obtained by cold resection. The intact cell and stromal relationships with preservation of the underlying muscle greatly facilitate accurate diagnosis.
BLADDER TUMOR BIOPSY
655
SUMMARY
The resectoscope appears to be a highly popular instrument for removing specimens of bladder tumors for microscopic examination. In a high proportion of cases, specimens so obtained are unfit for microscopic study because of tissue distortion by the electric current. When the cutting current severs the pedicle of a bladder papilloma it is likely that it will also destroy evidence of infiltration into the underlying bladder tissue. Specimens obtained by cold resection are not subject to these disadvantages.
620 W. 168th St., New York, N.Y. (A.L.D. Jr.) REFERENCES AsCHNER, P. W.: Clinical applications of bladder tumor pathology. Surg., Gynec. & Obst. 52: 979, 1931. DART, R. 0.: The grading of epithelial tumors of the urinary bladder. J. Urol., 36: 651, 1936
Vol. 72, No. 4, October 1954 Printed in U.S.A.
THE DISADVANTAGES OF THE ELECTRORESECTOSCOPE FOR BLADDER TUMOR BIOPSY ARCHIE L. DEAN, JR.
AND
J. E. ASH
From the Armed Forces Institute of Pathology, Washington 25, D. C.
A large proportion of bladder tumor biopsy specimens removed with the electroresectoscope are unfit for detailed microscopic study because of the destructive effects of the electric cutting current. The grading of bladder tumors may be difficult under the best of conditions. Nevertheless, accurate tumor diagnosis is a necessity if the patient is to be offered the best chance for cure. In classifying these tumors for the Bladder Tumor Registry of the American Urological Association at the Armed Forces Institute of Pathology every effort is made to study each specimen according to the following microscopic criteria: 1) cellular structure, that is, the type cell comprising the tumor, its degree of differentiation, and the relative frequency of . mitotic figures; 2) the arrangement of the tumor cells, whether in separate papillary structures or in sheets; 3) the presence or absence of invasion of the bladder musculature. Recent study of 100 consecutive bladder tumor biopsies referred to the Registry shows that most of the specimens were removed by the electroresectoscope. More than one-fourth of these were so extensively damaged by the electric current that accurate microscopic diagnosis was impossible (table 1). The passage of the electric current through tissue causes considerable distortion of the surrounding structures. The cell nuclei become pyknotic and the entire cell, nucleus included, is elongated. The cell boundaries are lost; no mitoses are visible, and even such easily recognized structures as glandular or acinar formations may be disguised. These changes occur both in neoplastic areas and in normal tissue, with the result that the pathologist is unable to distinguish between the two (fig. 1, A and C). The heat affects the tissue to a depth approximating from one to two high power fields of the microscope. Thus in the case of large papillary tumors, it may still be possible to make a correct diagnosis; but when the papillary tumor is small, single, and delicate, its entire thickness may be distorted. It is important also to realize that when the cutting current passes through the pedicle or stalk of a papillary growth, any tumor cells which may be infiltrating this structure or invading the bladder wall are likely to be altered beyond recognition. The TABLE
1. Comparison of biopsies obtained by electroresection and cold resection. Total cases, 100 CASES IN WHICH DISTORTION OF CELLS PRECLUDED DIAGNOSIS
Electrosection, 74 cases ........................... Cold resection, 26 cases ...........................
652
Number
Per cent
21 3
30 12
BLADDER TUMOR BIOPSY
\.,
653
~.-
.~,,... .. .,~ ~,,
FrG. 1. A, low power photomicrograph of segment of non-neoplastic bladder tissue obtained with electrocautery. This biopsy strikingly resembles an infiltrating neoplasm. AFIP Accession No. 267301-2. B, photomicrograph of an area in lesion reproduced in A not distorted by cautery effects. Cystitis and squamous metaplasia of bladder epithelium are clearly visible. C, higher power of an area of cautery distortion in same lesion. Even at this magnification the lesion appears malignant.
654
A. L. DEAN AND J. E. ASH
Frn. 2. A, low power of papillary bladder tumor by cold biopsy. AFIP Accession No. 217462-1. B, higher power of tumor shown in A. Individual cells, cell borders, and cell arrangement are easily visualized. C, low power of bladder tumor removed by electrocautery. Tissue distortion and lack of cell detail can be clearly seen. AFIP Accession No. 204458-1. D, higher power of lesion represented in C. Tumor is unrecognizable.
tissue obtained from cold resection, on the other hand, may occasionally be inadequate, but the cellular detail is clear and undistorted and can be readily identified. Figure 2, A and B illustrates a bladder tumor specimen obtained by cold resection. The intact cell and stromal relationships with preservation of the underlying muscle greatly facilitate accurate diagnosis.
BLADDER TUMOR BIOPSY
655
SUMMARY
The resectoscope appears to be a highly popular instrument for removing specimens of bladder tumors for microscopic examination. In a high proportion of cases, specimens so obtained are unfit for microscopic study because of tissue distortion by the electric current. When the cutting current severs the pedicle of a bladder papilloma it is likely that it will also destroy evidence of infiltration into the underlying bladder tissue. Specimens obtained by cold resection are not subject to these disadvantages.
620 W. 168th St., New York, N.Y. (A.L.D. Jr.) REFERENCES AsCHNER, P. W.: Clinical applications of bladder tumor pathology. Surg., Gynec. & Obst. 52: 979, 1931. DART, R. 0.: The grading of epithelial tumors of the urinary bladder. J. Urol., 36: 651, 1936