1 / 24

The Role of Urine cytology in the investigation of Haematuria?

The Role of Urine cytology in the investigation of Haematuria?. B Barrass Audit Meeting 17 th May 2006. Overview . Urine Cytology The Role of cytology in haematuria assessment Audit Standards Aims Methods Results Comparison with Audit stanards Discussion Recommendations .

toan
Download Presentation

The Role of Urine cytology in the investigation of Haematuria?

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. The Role of Urine cytology in the investigation of Haematuria? B Barrass Audit Meeting 17th May 2006

  2. Overview • Urine Cytology • The Role of cytology in haematuria assessment • Audit Standards • Aims • Methods • Results • Comparison with Audit stanards • Discussion • Recommendations

  3. Atypical Malignant

  4. Urine Cytology • 1864 -Exfoliated urothelial cells first described • 1945 -First used to diagnose urothelial malignancy • Graded I-V(Papanicolaou & Marshal 1945) • I-II normal • III suspicious • IV-V malignant • Sensitivity 42% - 66% • Specificity up to 97%

  5. Problems with Urine Cytology • Low grade malignancy less likely shed cells • Patients with suspicious cytology faced with: • Anxiety over undiagnosed cancer • Several invasive investigations and F/U • False positive common • Stones • UTI • Radiotherapy • Urinary Instrumentation Only 50% with positive cytology have cancer – who should be investigated?

  6. How Should Suspicious Cytology be Followed-up? • 2005 Nabi et al followed up 70 patients with haematuria & C3-C5 cytology & normal investigations • 25 had normal repeat cytology • 4 had persistent suspicious cytology • 41 developed cancer in mean 5.6 months • 37 had positive repeat cytology • 8 had recurrent haematuria • 4 had prostate cancer • Recommends investigate: • Persistent positive cytology • Symptoms

  7. Audit Standards • Was cytology repeated? • Was repeat abnormal cytology investigated? • Were investigations thorough • Lower tract: -GA cystoscopy • Upper tract: -IVU -Retrograde & washing -Ureteroscopy retrograde abnormal

  8. Aims • Review the investigations & diagnosis for positive cytology • Review additional Investigations to investigate for positive cytology • Review if these investigations generated additional diagnosis • What was the cost & morbidity of additional tests? • How did the results compare with the audit standards? • Recommend use and follow-up of cytology in the investigation of haematuria

  9. Methods • All urine cytology was reviewed between 01/10/2001 and 31/06/2004 • Patients were identified who had C3-5 cytology either • No histological diagnosis • No repeat cytology • Notes were obtained and reviewed • Data was recorded regarding • Investigations & associated morbidity • Diagnosis • Follow-up and survival

  10. Results: Patient identification • 1829 urine samples analysed • 9% were atypical • 11% were inadequate • 80% were benign. • Of the 164 (9%) atypical samples • 53 (32%) had urothelial neoplasia • 33 (20%) had repeat cytology • 14 (8.5%) had other urological / gynaecological malignancy • 61 (42.7%) had no further sample or biopsy • 3 had missing records 65 (40%) had either no biopsy, no repeated cytology or persistently abnormal cytology

  11. Results: Positive Cytology & Cancer • 187 biopsy following urine cytology • 53 TCC with benign cytology • Atypical cytology identified • 42 TCC • 1 breast met (bladder) • 11 prostate cancer • 1 endometrial cancer • 1 penile cancer

  12. Results – reason for checking cytology

  13. Results – Initial Investigation Lower tractUpper tract

  14. Results – Initial Diagnosis • Of those with a diagnosis: • 7 (33%) had a tumour • 14 (66.7%) had a benign diagnosis

  15. Results – Additional Lower Tract Investigation & diagnosis • 11 patients (16.9%) had further investigation • 1 (10%) aspirated after GA cystoscopy • The remaining 54 (83.1%) had either • no further imaging of the lower urinary tract (47) • or were unknown (7)

  16. Results – Additional Upper Tract Investigation & Diagnosis • 9 (13.8%) underwent further upper tract investigations • 2 (22.2%) had a diagnosis (ureteric stones) causing stones positive cytology • 1 (11.%) had diagnosis (duplex) that did not cause abnormal cytology • 6 (66.7%) either had a diagnosis confirmed or were confirmed to be normal.

  17. Results: Follow-up Cytology Six patients (9.2%) also had repeat cytology

  18. Results: Overall Additional Diagnostic Yield of Investigating Cytology • Lower tract diagnosis • Nil • Upper tract diagnosis • 2 upper ureteric stones 3.1% of total, 22.2% of those investigated (found on retrogrades) • No additional malignancies were detected • one patient had a serious complication (aspiration) • There were four false positives (6.2%) detected on re-investigation • 3 found on lower tract imaging and 1 found on cytology

  19. Results: Final Diagnosis after all Investigations • 3 patients have unexplained positive cytology of which only one underwent further investigations • 54 (83.1%) had no further lower tract imaging • and 49 (75.4%) had no further upper tract imaging.

  20. Results: Significance of Frank Haematuria (100% frank haematuria, non-specified or known cancer)

  21. Follow-up and Outcome • The median follow-up • 30 months (1 - 54 months). • Mortality • 13.8% (9 patients) • Disease specific mortality • 6.2% (4 patients) • All disease specific deaths occurred in patients diagnosed with TCC on initial assessment • 2 (50%) had C3-4 cytology and 2 (50%) had C5 cytology • 1 recurrence during follow-up • (2.3% of those found to be normal or benign on initial assessment) • Previous TCC with C5 cytology. • An initial flexible cytoscopy was normal • Disease free interval 40 months • Grade & stage G1Pta TCC • This patient did not contribute to the mortality.

  22. Comparison with Audit Standard

  23. Discussion • The results were below the standard in terms of • repeating positive cytology • Investigating positive cytology • The investigation of positive cytology was variable • Investigation of cytology • didn't yield many additional diagnosis over all (3.1%) • Did not yield any additional cancers • Did yield a high number of diagnosis among those investigated (22.2%) • Retrograde yielded all additional diagnosis • The presence of frank haematuria seemed to correlate with malignancy • C3-4 cytology does not rule out finding tumour • The recurrence rate was low and there were no new cancers during follow-up, suggesting most patients were unlikely to have significant cancer • Most diagnoses were benign (70% C5 and 93.1 C3/4)

  24. Recommendations • Cytology does not seem to increase the diagnosis of malignancy through the haematuria clinic but… • Few were investigated • Low rate of malignancy during F/U • Atypical cytology should be repeated and investigated only if persistently abnormal • A prospective study of the long-term follow-up of atypical cytology is needed • Do patients with benign diagnosis or cytology that normalises on F/U have any increase in risk? • What is the diagnostic yield of full investigation for positive cytology –does it add to the haematuria assessment? • Are there any reliable clinical markers that can be used to identify those who should be investigated e.g. frank bleeding?

More Related