PARIS SYSTEM FOR URINE CYTOLOGY paris system of reporting urine slidespptx

Paris system for reporting urine cytology

1. The Paris System for Urine Cytology Presenter – Dr Samiksha M Deshmukh Moderator – Dr Disha B S

2. Main aim of Urine cytology – Diagnosis of Urothelial Malignancies

3. Normal Urinary Elements Urothelial cells Intermediate and superficial (umbrella) cells (voided urine) Intermediate, superficial and basal cells (catheterized urine, washing) Squamous cells

4. Miscellaneous findings Prostate and seminal vesicle epithelial cells Renal tubular cells and casts Corpora amylacea Crystals Inflammatory cells Degenerated intestinal epithelial cells (ileal conduit) Normal Urinary Elements

5. Umbrella cells Low N/C ratio Pale finely granular chromatin Smooth nuclear shapes Multinucleation common Cytoplasm transparent

6. Intermediate and basal cells High N/C ratio Chromatin darker than superficial cells Nuclei smaller than superficial cells Nuclear shape High N/C ratio Chromatin darker than superficial cells Nuclei smaller than superficial cells Nuclear shape round Even nuclear spacing round • Even nuclear spacing

7. Squamous cells

8. CASTS IN URINE RBC CAST WBC CAST Hyaline CAST

9. Types of Urinary Specimens Voided Urine - Collected 3 - 4hrs after the last void (100-300ml) Catheterized Urine Bladder Washings - Obtained through a catheter by irrigating the bladder with 5-10 pulses of 50 ml sterile saline Upper Tract Washings and Brushings Ileal Conduit Samples

10. Upper Tract Washings and Brushings

11. Ileal Conduit Samples - a surgeon creates a new tube from a piece of intestine that allows the kidneys to drain and urine to exit the body through a small opening called a stoma.

12. The Paris System working group was formed comprising of pathologists and urologists who met in 2013 at the International Congress of Cytology in Paris and proposed The Paris System. Main aim was to detect high grade urothelial carcinoma . The Paris System (TPS)

13. SAMPLE ADEQUACY Includes Quantitative nature of sample i.e cellularity and volume. Qualitative nature of sample i.e morphology details, degeneration, obscuring elements artifacts.

14. Cytomorphological diagnosis being the most important in TPS, any sample with atypical, suspicious or malignant cells should be called adequate and reported. SAMPLE ADEQUACY

15. In instrumentation specimens – 2600 cells or 2 well visualised urothelial cells per HPF in 10 consecutive HPFs (i.e. total of at least 20 cells in 10 HPFs) may be taken as adequacy criteria . 10-20 cells/10 HPF should be reported as “ satisfactory but limited by low cellularity ” <10 cells/10 HPFs should be under “ unsatisfactory/nondiagnostic ” SAMPLE ADEQUACY

16. For voided urine sample – according to preliminary method more than 30 ml of sample is likely to be cellular and satisfactory. But in TPS - Disqualifying the sample only based on volume is not recommended. SAMPLE ADEQUACY

17. To Summarize Sample Adequacy If there are atypical cells – Adequacy does not matter. If there are no Atypical cells – No / less obscuring features Appropriate benign urothelial cellularity – (20 cells/ 10 HPF) Adequate volume – 30 ml Not to discard first drops of urine stream as they are rich in cells Anything below these cut offs is “ less-than-optimal” for evaluation

18. Diagnostic Categories In the Paris System for Reporting Urine Cytology 1. Non-diagnostic / Unsatisfactory 2. Negative for High Grade Urothelial Carcinoma (NHGUC) 3. Atypical Urothelial cell (AUC) 4. Suspicious for High Grade Urothelial Carcinoma (SHGUC) 5. High Grade Urothelial Carcinoma (HGUC) 6. Low Grade Urothelial Neoplasm (LGUN) 7. Other – Primary and Secondary malignancies and miscellaneous lesions

19. Negative for High – Grade Urothelial Carcinoma ( NHGUC) > 70% of all urine cytologies A urine sample is considered benign, i.e NHGUC, if any of the following components are present in the specimen: – Benign urothelial, glandular, and squamous cells Benign urothelial tissue fragments (BUTF) and urothelial sheets or clusters

20. 3. Changes associated with lithiasis Viral cytopathic effect; polyoma virus (BK virus— decoy cells) 5. Post-therapy effect, including epithelial cells from urinary diversions

21. Benign urothelial cells / Umbrella cells Low N/C ratio Pale finely granular chromatin Smooth nuclear shapes Multinucleation common Cytoplasm transparent

22. SQUAMOUS CELLS From urethra, vagina and bladder trigone

23. GLANDULAR CELLS Source – Endometrium Cervix Prostate Renal tubular epithelial cells Cystitis cystica/ glandularis

24. Cystitis cystica/ glandularis

25. Viral cytopathic effect Polyomavirus Herpes CMV HPV - Vaginal contamination

26. Polyomavirus

27. Polyomavirus “Decoy cell”. The enlarged nucleus with the viral inclusion body is easily recognized.

28. Polyomavirus T he classic decoy cell contained enlarged, basophilic, and homogeneous amorphous ground glass-like intra-nuclear inclusion bodies.

29. Cytomegalovirus The typical cytologic features of cellular enlargement, prominent intranuclear inclusions, and occasional binucleation are present in this specimen

30. Herpes Simplex Virus Cytopathic changes include the "3M’s”: Multinucleation, Molding (of nuclei), Margination (of chromatin) Well-defined eosinophilic intranuclear inclusions also seen.

31. Human Papilloma Virus Koilocytes are superficial or intermediate squamous cells with large and irregular, well defined perinuclear halos with a cookie cutter border and cytoplasmic thickening Bi- or multinucleation is often identified Nuclei are enlarged (2 - 3 times normal size)

32. What is atypia? High nuclear cytoplasmic ratio (>0.7) Nuclear hyperchromasia Coarse, clumped chromatin Irregular nuclear membranes

33. Atypical Urothelial Cells (AUC) CRITERIA – ( Required criteria ) Non-superficial and non-degenerated urothelial cells with an high N/C ratio > 0.5

34. AND ONE OF THE FOLLOWING – Hyperchromasia (compared to the umbrella cells or the intermediate squamous cell nucleus) Irregular clumpy chromatin Irregular nuclear contours

35. Atypical Urothelial Cells (AUC)

36. Suspicious for High Grade Urothelial Carcinoma Criteria ( Required )– • Nonsuperficial and nondegenerated urothelial cells with an high N/C ratio > 0.7 Hyperchromasia (compared to the umbrella cells or the intermediate squamous cell nucleus)

37. AND ONE OF THE FOLLOWING Irregular clumpy chromatin Irregular nuclear membranes but less than 10 cells

38. Suspicious for HGUC vs Positive HGUC Quantity matters The number of atypical urothelial cells is an important criterion to classify urine cytology specimens into the ‘positive’ or the ‘suspicious’ categories. A cutoff number of >10 cells to render a definitive diagnosis of HGUCA seems valid from the clinical standpoint .”

39. Suspicious for HGUC vs Positive HGUC Quantity matters SUSPICIOUS HIGH GRADE

40. High Grade Urothelial Carcinoma (HGUC) Cellularity: At least 5–10 abnormal cells N/C ratio: 0.7 or greater Nucleus: Moderate to severe hyperchromasia Nuclear membrane: Markedly irregular Chromatin: Coarse/clumped

41. Other Notable Cytomorphologic Features in HGUC 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

42. High Grade Urothelial Carcinoma (HGUC)

43. Low Grade Urothelial Neoplasia (LGUN) LGUN combined cytologic term for low grade papillary urothelial neoplasms (LGPUN) which includes – Urothelial papilloma PUNLMP LGPUC (Low Grade Papillary Urothelial Carcinoma and Low grade intraurothelial neoplasia

44. Positive for LGUN. Three-dimensional papillary structures have central cores. Notice mild cytologic atypia and disorganization of cells forming papillae.

45. Cytologic Criteria of Low Grade Urothelial Neoplasia (LGUN) Three dimensional cellular papillary clusters (defined as clusters of cells with nuclear overlapping, forming "papillae"). Fibrovascular cores are appreciated in the center of papillary structures

46. REFERENCES Ghosh A. The Paris System–A new insight into reporting urine cytology. J Pathol Nepal. 2016 Mar 17;6(11):953-8. Barkan GA, Wojcik EM, Nayar R, Savic -Prince S, Quek ML, Kurtycz DF, Rosenthal DL. The Paris system for reporting urinary cytology: the quest to develop a standardized terminology. Acta cytologica . 2016;60(3):185-97. Dhakhwa R, Shrestha O, Thapa R, Pradhan S. Utility of reporting urine cytology samples as per the Paris system. J Pathol Nepal. 2022 Mar 31;12(1):1881-5. Kurtycz DF, Sundling KE, Barkan GA. The Paris system of Reporting Urinary Cytology: Strengths and opportunities. Diagn Cytopathol . 2020 Oct;48(10):890-5. Wojcik EM, Kurtycz DF, Rosenthal DL, editors. The Paris system for reporting urinary cytology. Springer; 2022.