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Wednesday, 30 December 2020

EARLY DIAGNOSIS OF UROTHELIAL CARCINOMA BY ABNORMAL CELLS SEEN IN THE URINARY SEDIMENT

Written by Clara Esparza del Valle | Guillermo Velasco de Cos | Germán Moreno de Juan

Figure 1. Images taken in contrast phase (oc x10, obj x40). A) Cells grouped in nests and with great disproportion in nuclear size.  B) Cells with significant cytoplasmic nucleus disproportion.

Bladder cancer is the fifth most frequent cancer in men in developed countries, the principal risk factor is the smoking habit.
 
The treatments vary greatly depending on the stage in which the patient is, from simple transurethral resection, and intravesical BCG instillations to protocols with adjuvant chemotherapy or cystectomy in the most severe cases. The survival and quality of life of the patient depends largely on early diagnosis.
The incidence is higher in men than in women. Worldwide, the data reflect 4 cases in men for every woman, and in Spain the figure increases to 7.

We present the case of a 63-year-old patient who comes to the emergency department due to repeated urinary tract infections. Upon admission, a first urinary sediment was made, presenting the following alterations: Glucose: ++++, leukocyte esterase: +, hemoglobin: +, leukocytes: 60-80/c and abundant bacteriuria. It also presented a PCR of 24.9 mg/dl and feverish peaks for several days. He is admitted for study with a diagnosis of prostatitis and antibiotic treatment is initiated.  

After two days of admission the infection is resolved and in a new urinary sediment the disappearance of the bacteriuria is verified. However, an abundant leukocyturia and abnormal cells are seen in the urinary sediment.

The most remarkable characteristics of the cells observed are:
-    Nest formation
-    Abnormal proportion of nucleus cytoplasm
-    Presence of nucleoli

In the report we recommend to make a request for urine cytology to pathological anatomy in view of the possible malignancy of the cells observed. The following day, the urine cytology is performed, confirming the malignancy of the cells and their bladder origin.

The patient is called in for a cystoscopy, in which a polypoid papillary lesion is observed, confirming the bladder neoformation (figure 2).
A surgical intervention is scheduled where a transurethral resection is performed, classifying the tumor as a moderately differentiated grade two papillary urothelial carcinoma that infiltrates the muscular layer.


imagen2Figure 2. A) HE staining (10x). A complex architectural pattern can be seen, observing fusion between papillae, characteristic of high-grade lesions. B and C) HE staining (20x and 40x). At higher magnification we observe cells with rounded, hyperchromatic, with slight pleomorphism nuclei and cellular disorganization. The presence of atypical mitoses (*) and apoptotic debris stands out. The histological findings are compatible with a moderately differentiated papillary urothelial carcinoma (G2).

In the routine analysis of the sediment, it is not possible to confirm the presence of malignant cells, since the appropriate stains are not usually available and the cells are observed fresh. However, the early finding of suspicious cells and their correct referral to the pathological anatomy service allow an early diagnosis, improving the quality of life and survival of the patient.

REFERENCES
  1. Lorence Prado D, Fernández Aceñero M, Criado Gómez L, Aguirregoicoa García E, Rodríguez Piñero A, Navarro Sebastián J et al. Desarrollo de un protocolo para la derivación de los pacientes con células atípicas en el sedimento urinario: experiencia del hospital de Móstoles. Revista del Laboratorio Clínico. 2009;2(2):87-93.
  2. Dalet Escribá F. Sedimento urinario. Madrid: AEFA; 2000.
  3. Antoni S, Ferlay J, Soerjomataram I, Znaor A, Jemal A, Bray F. Bladder Cancer Incidence and Mortality: A Global Overview and Recent Trends. European Urology. 2017;71(1):96-108.

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