Sensitivity of voided urine cytology and CT urography in isolated upper tract transitional cell carcinoma.

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Background:
Voided urine cytology and computerized tomography urography (CTU) are fundamental diagnostic tests utilized in the workup for transitional cell carcinoma (TCC). Although correlation of these tests with lower tract TCC is well studied, less is known about isolated upper tract tumors. Here we review a series of 51 patients with upper tract TCC and the sensitivities of voided urine cytology and CTU as diagnostic tools.
Methods:
A medical record review was performed of all patients who had a nephroureterectomy between 1997 and 2007 for TCC of the upper urinary tract. Data regarding preoperative voided urine cytology, CTU, and surgical specimen pathology were recorded. Patients were excluded from this study if they had a history of TCC in the lower urinary tract before the nephroureterectomy or if there was no recorded voided urine cytology. Urine cytology results were conveyed as one of four diagnoses: malignant cells not identified, atypical cells, suspicious cells for TCC, positive for TCC. CTU results were recorded as positive (clearly identifying a filling defect), suspicious (such as hydronephrosis and transition point with possible mass), and no abnormalities in the GU tract.
Results:
Of the 80 nephroureterectomies analyzed in this series, 18 were excluded due to simultaneous presentation with lower tract TCC. A further 11 were excluded due to absence of recorded voided urine cytology. A total of 51 patients were reviewed. Within this population, 13.7% (7) had grade1/3, 35.3% (18) had grade 2/3 pathology, and 51% (26) had grade 3/3 pathology. Voided urine cytologies in 14% of the total patients (7) showed no malignant cells. Atypical cells was the most common cytology result and was noted in 45% of patients (23). Cells suspicious for malignancy were noted in 22% of patients (11). Lastly, positive transitional cell carcinoma was noted in only 20% of patients (10). The sensitivities thus are 19.6% for positive only and 41.2% for positive and suspicious cytology. Amongst grade 3/3 disease, the test was slightly more sensitive. Cytology showed no malignant cells in 3.8% (1), atypical in 38.5% (10), suspicious in 30.8% (8), and positive for TCC in 26.9% (7) of patients. The sensitivities thus are 26.9% for positive only and 57.7% for positive and suspicious cytology. Within this population, 31patients had a CT urography. Another 11 patients had alternative imaging (I- CT, I+ CT, IV pyelogram). The overwhelming majority of the CTU scans, 96.8% (30) demonstrated either a suspicious scan or filling defect in the upper tract. A smaller proportion, 71% (22) of the CTU scans showed a definite filling defect.
Conclusions:
Retrospective review of patients that had isolated upper tract TCC showed that cytology has a poor sensitivity in diagnosing upper tract TCC, even when only grade 3/3 disease is examined. CT urography by contrast had a high sensitivity in identifying patients with suspicion for upper tract TCC. This study demonstrates that negative voided urine cytology should be looked upon with caution in the workup of a patient for upper tract TCC and confirms the utility of CTU in this workup.

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