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PRINCIPLE OF THE TEST.
Management of inconclusive urine cytologies.
SPECIMEN REQUIRED:
Urine cytology specimens, with a filled-out Tissue Examination Form (SF-515)
REAGENTS, INSTRUMENTATION: N/A.
STEP-BY-STEP DESCRIPTION.
1. The most frequent source of "Inconclusive" non-gynecologic
cytology specimens are urine samples. All "Inconclusive"
specimens require review from our department and
follow-up letters (if additional material was not received
in our department). Follow-up letters require considerable
activity from the GU service to track down the patients
and schedule appointments in many cases. For this reason,
it is important to use the diagnosis of "Inconclusive" only
in deserving cases, and the following policy describes
our way of defining the "Inconclusive" urine.
2.
Cytology has five diagnostic categories,
into which all specimens fall:
POSITIVE FOR MALIGNANT CELLS.
NEGATIVE FOR MALIGNANT CELLS.
INCONCLUSIVE FOR MALIGNANT CELLS.
SUSPICIOUS FOR MALIGNANT CELLS.
UNSATISFACTORY SPECIMEN.
3.
An INCONCLUSIVE DIAGNOSIS means that we see abnormal cells
that may be part of a normal or a neoplastic process....we can
not distinguish between the two possibilities.
4.
A SUSPICIOUS DIAGNOSIS means that we think that the cells in the
specimen are malignant, but they don't meet all of the diagnostic
criteria for a definitive diagnosis.
5.
Since a low-grade transitional cell carcinoma (TCC)
has virtually no cytologic atypia
(on histology or on cytology),
we call any specimen inconclusive
if it has clump cellularity
(i.e., we see clumps of transitional
cells, atypical or not).
Clumps may be detached fragments of
tissue from a low grade TCC.
Or they may signify nothing at all.
6.
Also, if we have cells that are degenerate
on cytology and show atypia,
that may be due to simple (physiologic) degeneration,
we call these cases "inconclusive",
because we have no way of ruling out a TCC.
7.
The main source of "false" inconclusives are due to urine
specimens obtained by instrumentation (catheter or cystoscopy
procedure) or obtained within a few days after such a procedure
or that occur in patients with renal stones or that follow the
passage of the stone.
8.
All these conditions dislodge fragments of transitional
epithelium, and produce cluster cellularity. This is why it
is very important to let us know when a specimen has been
obtained after cystoscopy or by any instrumentation as all such
specimens would be called "Inconclusive".
9.
Another source of inconclusives are specimens with degenerate
cells. When a patient voids after many hours of no voiding
(such as voiding on awakening in the morning or when in a
dehydrated state), the cells voided are cells that were sitting
in the bladder for hours, degenerating in an acidic environment
all the time. That is why we ask for so-called "hydrated"
specimens. The patient is asked to void, then drink a glass
or two of fluid and collect the freshly voided fluid (or the
second void that quickly follows after the first void after
fluid intake). In this case, the cells that are voided were
only floating in the bladder for a very short time and
would show little or no degeneration. Urines collected in the
first a.m. void or urines collected from a "dry" patient will
produce lots of "false" inconclusives.
10.
When we sign a case as inconclusive or suspicious, we follow
the patient's histology and cytology records to see if additional
material is submitted to cytology. Every 3 months we review
cases with inconclusive or suspicious diagnoses and no addtional
material to make sure that our diagnosis was reasonable and
to determine whether a follow-up notice needs to be sent to you.
We compile a list of such cases, and send email notification.
11.
To conform to JCAHO guidelines,
the IPRC (Invasive Procedures Review Committee)
now reviews instances where follow-up letters
are sent for atypical cytologies,
to assure that services receiving follow-up
requests respond to those requests.
In other words, follow-up requests from Pathology must receive a response.
The purpose of the follow-up is to make sure that the patient
with an atypical cytology is not "lost" to follow-up care.
It is in the interests of both the Pathology department and
the GU department to minimize the number of "Inconclusive"
diagnoses rendered. It is preferable to provide a conclusive
diagnosis of "negative for malignant cells" or "positive for
malignant cells." When specimens are obtained optimally and the
submission forms have optimal history (especially regarding
instrumentation, barbatage, post-cystoscopy specimen,
catheterized specimen), our "false" inconclusives are reduced.
REFERENCE.
1.
El-Bolkainy MN.
Cytology of Bladder Carcinoma.
J Urol 1980; 124:20-22.