the paris system - moffitt cancer center · •attempt to standardize terminology for urinary...

The Paris System for Reporting Urinary Cytology

J. Dhillon Assistant member

Anatomic Pathology, Cytopathology Moffitt Cancer Center

Assistant Professor Department of Oncologic Sciences and Pathology

University of South Florida

No Disclosures

Classifications

Papilloma Grade I Grade II Grade III

Papilloma PUNLMP Low Grade High Grade

WHO/ISUP 2004

~ 10-20% ~ 50-60% ~ 80-90%

URINE CYTOLOGY SENSITIVITY

High false negatives

WHO 1973

The Paris System

• What is the main goal of urinary cytology?

The Paris System

• What is the main goal of urinary cytology? – Detection of urothelial carcinoma that is clinically

significant – high-grade urothelial carcinoma (HGUC)

The Paris System

• Attempt to standardize terminology for urinary cytology

• Despite two well established pathways in urothelial carcinoma, cytologic terminology remains disparate and complex

• The idea for developing The Paris System for Reporting Urinary Cytopathology was conceived during IAC Congress held in Paris in 2013

• Drs. Rosenthal and Wojcik have led the Paris System Working Group

The Paris System Subgroups prior to The Paris System • Negative for malignant cells • Atypical urothelial cells • Suspicious • High Grade Urothelial

Carcinoma • Low Grade Urothelial

Carcinoma • Other malignancies, both

primary and secondary

Subgroups Defined by the Paris System • Negative for High Grade

Urothelial Carcinoma • Atypical urothelial cells • Suspicious for HGUC • High Grade Urothelial

Carcinoma • Low Grade Urothelial

Neoplasm • Other malignancies, both

primary and secondary

The Paris System Adequacy of Urine Specimens

• 1. Non-urothelial features obscuring urothelial morphology – Numerous acute inflammatory cells, Rbcs, lubricant obscuring

urothelial cell morphology • 2. Inadequate volume with inappropriate benign urothelial

cellularity – <30 ml

• 3. Instrumented urine specimen with inappropriate benign urothelial cellularity – Bladder washes – 10-20 well-preserved and well-visualized urothelial

cells/10 hpfs – Satisfactory but limited by low cellularity – <10 well-preserved and well-visualized urothelial cells/10 hpfs –

unsatisfactory/nondiagnostic

• Presence of any atypical, suspicious, or malignant findings – Adequate

Subgroups Defined by The Paris System

• Adequacy • Negative for High Grade Urothelial Carcinoma (HGUC) • Atypical urothelial cells • Suspicious • High Grade Urothelial Carcinoma • Low Grade Urothelial neoplasm • Other malignancies, both primary and secondary • Ancillary Studies • Clinical management • Preparatory techniques relative to Urinary Tract samples

Negative for HGUC • Benign/reactive urothelial cells, squamous and glandular cells • True tissue fragments and clusters without morphologic changes

in the absence of instrumentation and after instrumentation • Alterations caused by urinary bladder and renal calculi • Viral cytopathic effect, especially polyoma (BK) virus • Post-treatment effect of bladder instillations, especially BCG • Post-treatment effect for non-bladder disease, e.g., pelvic

irradiation for other malignancies; systemic chemotherapy that may effect the urothelium, e.g., cyclophosphamide

• Enteric epithelium following a surgical urinary diversion post-cystectomy

• Unexpected normal cells, e.g., sperm, seminal vesicle cells, cells from the female genital tract

Reactive Urothelial Cells

Glandular Cells

• Sources: endometrium, prostate, kidneys, urachal remnants, metaplasia

Rosenthal, Wojcik, Kurtycz. The Paris System for Reporting Urinary Cytology, Springer , Page 19

Viral Cytopathic Effects

Bladder Diversion Urine

Benign Urothelial Tissue Fragments

Immunotherapy - BCG

Rosenthal, Wojcik, Kurtycz. The Paris System for Reporting Urinary Cytology, Springer , Page 31

Basal Urothelial Cells

What are we calling Atypia?

• There are rare cells, reminiscent to that of high grade UC

• Lots of clusters, worrisome for low grade UC • Other (degenerated cells, cells/groups that

don’t fit in either group above) • Clusters of small basal urothelial cells • Polyoma virus, therapy related changes, atypia

secondary to calculi

Atypia as defined by Paris System

• There are rare cells, reminiscent to that of high grade UC

• Lots of clusters, worrisome for low grade UC • Other (degenerated cells, cells/groups that

don’t fit in either group above) • Clusters of small basal urothelial cells • Polyoma virus, therapy related changes, atypia

secondary to calculi

Negative for High Grade Urothelial Carcinoma

Criteria for Atypical Urothelial Cells

• Cells where cytologic changes fall short of a diagnosis of suspicious for HGUC or HGUC

• MAJOR CRITERION (required)

– Non-superficial and (non-degenerated) urothelial cells with an high N/C ratio >0.5

• MINOR CRITERIA (1 required)

– Nuclear hyperchromasia – Irregular nuclear membranes – Irregular, coarse, clumped chromatin

Diagnosis of AUC is appropriate in cases where there is suspicion for HGUC there is also extensive degeneration.

Atypical Urothelial Cells

N/C – 0.5 HYPERCHROMSIA Note – mild degenerative features preclude adequate assessment of the chromatin

Concurrent Bladder Biopsy

Atypical Urothelial Cells

N/C >0.5 NO HYPERCHROMASIA IRREGULAR MEMBRANES

Rosenthal, Wojcik, Kurtycz. The Paris System for Reporting Urinary Cytology

Urine Specimens MCC DATA

Low Grade Urothelial Neoplasms

• Urothelial papilloma • Papillary urothelial neoplasm of low malignant

potential (PUNLMP) • Low-grade papillary urothelial carcinoma (LGPUC) • Flat low-grade intraurothelial neoplasia (dysplasia)

Note – cytologic distinction between low-grade lesions and normal urothelium is extremely difficult

Cytologic criteria of LGUN

• Definitive Feature – Presence of three-dimensional cellular papillary

clusters with fibrovascular cores including capillaries • Features suggestive of

– Three-dimensional cellular clusters without fibrovascular cores

– Increased numbers of monotonous single (non-umbrella) cells

Note – Cases suggestive of LGUC are categorized as NHGUC

Monotonous single cells, grooves Absence of umbrella cells Increased N/C ratio Category?

Concurrent Biopsy

Suspicious for HGUC

• MAJOR CRITERIA (required) – N/C ratio – 0.5-0.7 – Hyperchromasia – moderate to severe

• MINOR CRITERIA (1 required) – Irregular clumpy chromatin – Marked irregular nuclear membranes

Note – The cells have to be non-superficial and non-degenerating Cut off range 5-10 cells in urine Upper tract – 10 cells

Suspicious for HGUC

Criteria for High-Grade Urothelial Carcinoma (HGUC)

• Cellularity: 5-10 abnormal cells • N/C ratio: 0.7 or greater

– Some may show N/C 0.5-0.7

• Nucleus: Moderate to severe hyperchromasia • Nuclear membrane: Markedly irregular • Chromatin: Coarse/clumped

HGUC

Diagnosis?

Diagnosis?

N/C - >0.7 Hyperchromatic – no Not – HGUC or Suspicious for HGUC

Diagnosis?

N/C - >0.7 Hyperchromatic – no Not – HGUC or Suspicious for HGUC

N/C - >0.5 Hyperchromatic – no Coarse chromatin clumping – no Nuclear membrane irregularity - ?

Diagnosis?

• Negative for HGUC or AUC • History of intravesical therapy – Yes • Reason of “Atypia” is known – excludes it’s

inclusion in the “Atypical” category • Dx – Negative for HGUC • UroVysion FISH and subsequent biopsy were

negative

Other Malignancies and Non-Urothelial Lesions

Other Malignancies and Non-Urothelial Lesions

Other Malignancies and Non-Urothelial Lesions

Other Malignancies and Non-Urothelial Lesions

Other Malignancies and Non-Urothelial Lesions

UroVysion FISH • UroVysion is a commercially available multitarget,

multicolor FISH probe set that was developed in a collaborative effort between Mayo Clinic and Vysis, Inc.

• It contains four single stranded DNA probes – Three probes are chromosome enumeration probes targeting

pericentromeric regions of chromosomes 3, 7, and 17. – The 4th probe is a locus-specific identifier probe targeting 9p21

locus on gene p16. – All probes are directly labeled with fluorescent dyes

• It has been approved by FDA as an aid for initial diagnosis of bladder cancer in patient’s with hematuria and/or subsequent monitoring for tumor recurrence in patient’s previously diagnosed with bladder cancer.

UroVysion FISH

• The pooled sensitivity and specificity of FISH are reported to be 72% and 83% respectively compared with 42% and 96% respectively for cytology

• The most rewarding application – Atypical urothelial cells – U-FISH was positive in 89% of AUC cases (Skacel et al) – “Anticipatory positives” – FISH is positive, AUC but

cystoscopy negative – Currently not generally recommended – not going to

change the surveillance strategies, cost effective

Positive UroVysion Test

• Chromosomal abnormalities tested for by Urovysion FISH

• Distinguishes cancer cells from benign cells • This test is not specific for urothelial

carcinoma; may be seen in non-urothelial carcinomas as well

• Cytopathologists and urologists should correlate Urovysion FISH results with cytomorphology and clinical information.

UroVysion FISH in non-urothelial carcinomas

• Adenocarcinoma, squamous cell carcinoma and small cell carcinoma of the bladder

• Colonic adenocarcinoma • Prostatic adenocarcinoma • Cervical adenocarcinoma • Renal cell carcinomas • Benign cells –

– Reactive umbrella cells (tetraploid) – Post radiation

UroVysion FISH

• Papanicolaou Society of Cytopathology recommends UroVysion FISH testing in combination with routine cytology for the evaluation of PB strictures

Ancillary Tests • Liquid-based Tests – Approved by FDA

BTA (Bladder Tumor Associated Antigen) Test • Measures human complement factor H and related proteins • Elevated in bladder cancer • Hematuria – false positive

NMP22 Test • Immunoassay that detects nuclear mitotic apparatus protein • Levels correspond to cell turnover in bladder • Not a tumor specifc protein • False positive – intrumentation, inflammatory, reparative processes • Specificity of urine cytology is better