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- 1. PARIS SYSTEM OFREPORTING URINARY CYTOLOGY MODERATOR- DR. MOMOTA NAIDING PROFESSOR, DEPTT. OF PATHOLOGY PRESENTER- DR. SHATABDI DAS PGT, DEPTT. OF PATHOLOGY
- 2. Introduction • Urine Urineis a liquid by-product of the metabolism in humans and in many animals. • The average urothelial cell has an approximate diameter of 20 μm or a two-dimensional surface area of 314 μm2(314 × 10 −12 m2 ). • The urothelium is about six-seven cells thick, so the total number of urothelial cells lining the bladder is on the order of 10 8 –10 9 cells.
- 3. Goal of urinecytology • A guided system for work up of hematuria. • In follow-up cases of patients with history of bladder cancer. • To monitor patients after therapy for bladder cancer.
- 4. Need for standardizationof urine cytology • To minimize the interobserver variation in reporting urine cytology. • Reproducibility • Improvement of communication • Atypical cells-Wide intraobserver variability
- 5. Normal urinary elements •Urothelial cells -Intermediate and superficial (umbrella) cells (voided urine) -Intermediate, superficial and basal cells (catheterized urine, washing) • Squamous cells • Miscellaneous findings -Prostate and seminal vesicle epithelial cells -Renal tubular cells and casts -Crystals -Inflammatory cells -Degenerated intestinal epithelial cells (ileal conduit)
- 6. PARIS SYSTEM OFREPORTING URINARY CYTOLOGY • The Paris System (TPS) is a standardised, comprehensive system for reporting urinary cytology. • It was developed over several years and published in 2016 by a team of cytopathologists, surgical pathologists and urologists.
- 7. • Aim ofParis system of reporting cytology - Ability to reliably detect high grade urothelial neoplasia.
- 8. Components of Parissystem of reporting 1. Pathogenesis of Urothelial Carcinoma 2. Adequacy 3. Negative for High Grade Urothelial Carcinoma 4. Atypical Urothelial Cells 5. Suspicious for High Grade Urothelial Carcinoma 6. High Grade Urothelial Carcinoma 7. Low Grade Urothelial Neoplasm 8. Other malignancies, both primary and secondary 9. Ancillary Studies 10. Clinical management 11. Preparatory techniques relative to Urinary Tract samples
- 9. Pathogenesis of urothelialcarcinoma Two pathways Hyperplasia pathway More common(80%) Urothelial hyperplasiaDeletion of CDKN2A and FGFR3 mutationLGUC Genetically Stable pathway Dysplasia pathway Less common(20%) High grade papillary tumour/ca-insitu Higher chance of invasion and metastasis Inactivating mutation of Tp53 Genetically unstable pathway
- 11. Preparatory techniques • Materialsand methods- Bladder washings- best Catheterized urine- second best Voided specimens- third • Processing of the urine samples- membrane filtration (e.g.,Millipore), cytocentrifugation (i.e., Shandon Cytospin),(CS) BD SurePath Prep (SP) Hologic ThinPrep (TP)
- 12.
- 13. • Adequacy- isdetermined by the interplay of four specimen characteristics: -collection type -cellularity -volume and -cytomorphological findings. • At least 30 mL are necessary to consider a urine specimen fully adequate when processed with SurePath. • 20 undistorted well visualised cells per 10 hpf in bladder washings.
- 14. Negative for highgrade urothelial carcinoma(NHGUC) NHGUC Urine sample, either voided/instrumente considered NHGUC, if any of the following components are present Benign urothelial/glandular/squamous cells Benign urothelial tissue fragments/urothelial sheets or clusters Changes associated with lithiasis/viral cytopathic effect-polyoma virus(BK virus- decoy cells) Post therapy effect/epithelial cells from urinary diversions
- 15. Frothy and abundant cytoplasm,low N:C ratio, multinucleation common, Nuclei- pale fine granulation, prominent nucleoli Superficial urothelial umbrella cells(NHGUC)
- 16. Nucleus- slightly small, dark, round and smooth nuclear membrane, uniform architecture Cytoplasm- scanty, high N:C ratio Image- clusters of benign smaller cells in addition to benign superficial cells
- 17. Their nuclear andcytoplasmic character is the same as other superficial cells, but additionally, they possess a thickened cytoplasmic edge that doesn’t go all around the cell. This constitutes the asymmetric unit membrane, providing a barrier between the toxic urine and the blood Image: These true tissue fragments (TTF) clearly illustrate the image of “umbrella” cells. By definition, they are the most superfi cial cells in the bladder, creating an “Umbrella” over all other urothelial cells.
- 18. Easily dissociated intosingle cells. These often have cells with cytoplasmic (cercariaform) tails Image: Intermediate urothelial cells. The intermediate layer of urothelium, immediately underneath the umbrella cells.
- 19. Image: Reactive umbrellacells. Most inflamed epithelial cells demonstrate changes, especially in the nuclei. Nucleoli may become prominent, but nuclear chromatin will remain finely granular and shapes will remain round. The cytoplasm retains its transparency. Neutrophils will ordinarily be the inflammatory cells, but lymphocytes may be present if a chronic process is ongoing. Reactive umbrella cells(NHGUC)
- 20. Image: Benign squamouscells. Two benign squamous cells line up below an umbrella cell with three nuclei. Benign squamous cells(NHGUC)
- 21. Image : Benignglandular cells
- 22. Histiocytic type Glandular Cast Renal tubularcells(NHGUC)
- 23. Nuclei- uniform, finelyspaced, finely granular chromatin Benign urothelial tissue fragment(NHGUC) Causes of BUTF in voided urines are multifold, and include: prostate/rectal manipulation prior to collection of the sample, jogging, abdominal palpation etc.
- 24. Urothelium with nephrolithiasis(NHGUC) roundnuclei which are evenly spaced. Chromatin is finely granular and nucleoli are inconspicuous. Calcific concretions in voided urine may be recovered in patients with history of renal calculi
- 25. Infections(NHGUC) enlargement of thenucleus and nuclear chromatin homogenization, caused by the viral infection nucleus is always round or oval with a very smooth outline. Cytoplasm is almost gone. If the focal plane is changed, then a spider web of degenerated chromatin comes into view Almost all the cells display glassy nuclear inclusions diagnostic of Polyoma virus
- 26. Intravesicle BCG immunotherapy(NHGUC) Multinucleationin usual superficial cells is common. In contrast, Langhans-type giant cells resulting from fused macrophages are multinucleated but have their smaller and slightly hyperchromatic nuclei clustered at one pole of the cytoplasm.
- 27. Atypical urothelial cells •The general diagnostic category AUC is reserved for specimens that contain urothelial cells with mild to moderate cytologic (not architectural) atypia.
- 28. Criteria for AUS •One major and one minor criteria out of the following- Major criteria- Non-superficial and non-degenerated urothelial cells with an increased nuclear cytoplasmic (N/C) ratio (>0.5) Minor criteria-(any 1) -Nuclear hyperchromasia -Irregular nuclear membranes (chromatinic rim or nuclear contour) -Irregular, coarse, clumped chromatin
- 29. Normal cluster High N/Cratio, and nuclear contour irregularity. Due to the cytologic atypia seen in the group on the bottom this case should be categorized as AUC AUC High N/C ratios and nuclear contour irregularity Atypical urothelial cells
- 30. Suspicious for High-GradeUrothelial Carcinoma (Suspicious) • Used in cases with abnormal urothelial cells that quantitatively fall short of a definitive diagnosis of HGUC. • A diagnosis of “SHGUC” is defined as non-superficial and non-degenerated urothelial cells showing: -Increased nuclear to cytoplasmic (N/C) ratio, at least 0.5–0.7 -Moderate to severe hyperchromasia • At least one of the two following features: -Irregular clumpy chromatin -Marked irregular nuclear membranes
- 31. Well preserved Intermediateurothelial cells showing increased N/C ratios, hyperchromasia, and irregular nuclear membranes, clumped chromatin
- 32. High grade urothelialcarcinoma • Cellularity: At least 5–10 abnormal cells (>10cells) • N/C ratio: 0.7 or greater • Nucleus: Moderate to severe hyperchromasia • Nuclear membrane: Markedly irregular • Chromatin: Coarse/clumped
- 33. High n:c ratio(>0.7) Nuclearhyperchromasia with presence of necrosis
- 34. nuclear membrane irregularitywith focal thickness of nuclear membranes. Nuclear shapes and sizes vary. coarse and clumped nuclear chromatin
- 35. cytoplasmic vacuolization reflectsglandular differentiation. Nuclear membrane irregularity, hyperchromasia, and coarse chromatin typify HGUC A few cells exhibit classic features of high- grade urothelial carcinoma (HGUC) adjacent to cells of squamous differentiation
- 36. Other notable features •Cellular pleomorphism • Marked variation in cellular size and shapes, i.e., oval, rounded, elongated, or plasmacytoid (Comet cells) • Scant, pale, or dense cytoplasm • Prominent nucleoli • Mitoses • Necrotic debris • Inflammation
- 37. Low grade urothelialneoplasia • Three -dimensional cellular papillary clusters (defined as clusters of cells with nuclear overlapping, forming “papillae”) with fibrovascular cores including capillaries • Only in the presence of this feature is the definitive cytologic diagnosis of LGUN possible.
- 39. Three-dimensional papillary structureshave central cores. Mild cytologic atypia and disorganization of cells forming papillae Three-dimensional cluster of cells with nuclear overlapping, forming papillae. There is a thin capillary vessel running through the center of the cluster
- 40.
- 41. Squamous cell carcinoma •Malignant neoplasm that shows exclusively squamous differentiation, without associated urothelial or glandular elements. • 5% of bladder cancers • Pure squamous cell carcinoma is rare • associated with calculi, diverticuli, schistosomiasis • Squamous differentiation in UC • Cytoplasmic keratinization • Hyperchromatic angulated nuclei
- 42. Adenocarcinoma • Rare, 0.5-2.5%of bladder cancer Enteric (colonic-type) AdCa large nuclei, columnar to round, irregular, hyperchromatic with thick nuclear membranes, prominent nucleoli. cytoplasm-scant and vacuolated Signet ring cell carcinoma a cluster of cells with one cell showing a crescent-shaped hyperchromatic nucleus pushed to the periphery of the cell by a large cytoplasmic mucin-containing vacuole Clear cell AdCa a cluster of cells with projecting cytoplasm in a “hobnail configuration” with abundant vacuolated cytoplasm and centrally located nuclei with prominent nucleoli
- 43. Approach to diagnosisin urinary tract
- 44. Ancillary studies inurine cytology • Urovysion FISH • ImmunoCyt/uCyt+ test • ProEX C • Bladder Tumor Antigen test(BTA) • Nuclear Matrix Protein test(NMP22)
- 45. • >=4 cellsshowing gain of atleast 2 of chromosome 3, chromosome7, chromosome 17 • >= 12 cells showing deletion of p16 signals.
- 46.
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- 49. Summary • HGUC –this is the one that matters –Negative for HGUC • The diagnosis “atypia” should not be used as a waste basket and dx should be based on criteria • LGUN – new diagnostic category, based on presence of fibrovascular cores • Not all malignant cells in urines are urothelial carcinoma • Future studies are needed for validation of TPS.
- 50. REFERENCE • The ParisSystem for Reporting Urinary Cytology- Dorothy L. Rosenthal, Eva M. Wojcik, Daniel F. I. Kurtycz
- 51.