World J Oncol

World Journal of Oncology, ISSN 1920-4531 print, 1920-454X online, Open Access

Article copyright, the authors; Journal compilation copyright, World J Oncol and Elmer Press Inc

Journal website https://www.wjon.org

Original Article

Volume 11, Number 5, October 2020, pages 204-215

Fluorescence Emitted by Papanicolaou-Stained Urothelial Cells Improves Sensitivity of Urinary Conventional Cytology for Detection of Urothelial Tumors

Figure 2. Normal urothelial cells. Intermediate and deep urothelial cells showing a nucleus with homogeneous chromatin, regular borders and a nuclear/cytoplasmic ratio (N/C) < 0.5 (a). These cells emit a homogeneous and low intracellular fluorescence signal (b). Note the same fluorescence pattern of the malpighian cell. Transmission (a) and fluorescence microscopic (b) observations of Papanicolaou-stained urothelial cells.

Figure 3. HGUC. Several urothelial deep cells are characterized by a high nuclear/cytoplasmic (N/C) ratio > 0.7, coarse chromatin, hyperchromasia and irregular nuclear membrane; other cells show degenerative alterations (a). A strong and peri-membrane fluorescence signal is emitted by all these cells (b). Transmission (a) and fluorescence microscopic (b) observations of Papanicolaou-stained urothelial cells. HGUC: high-grade urothelial carcinoma.

Figure 4. LGUN. A cluster of urothelial deep cells showing a slightly increased nuclear/cytoplasmic (N/C) ratio, sometimes eccentric and grooved nuclei (a). These cells emit a strong and peri membrane fluorescence signal (b). Transmission (a) and fluorescence microscopic (b) observations of Papanicolaou-stained urothelial cells. LGUN: low-grade urothelial neoplasia.

Figure 5. AUC. An atypical deep urothelial cell showing an increased nuclear/cytoplasmic (N/C) ratio > 0.5 and a hyperchromatic nucleus (a). This cell emits a strong and peri membrane fluorescence signal (b). This patient had a positive cystoscopy and a final diagnosis of HGUC. Transmission (a) and fluorescence microscopic (b) observations of Papanicolaou-stained urothelial cells. AUC: atypical urothelial cell; HGUC: high-grade urothelial carcinoma.

**Table 1.** Results of Transmission and Fluorescence Microscopy in Groups 1 and 2 (N = 91)
Clinical diagnosis	FMi result +/-	UCCy	No. of cases	Follow-up time
HGUC (n = 16)	+	HGUC	+	11	NR
+	SHGUC	+	1	NR
+	AUC	+	2	NR
+	LGUN	+	1	NR
+	Negative	-	1	NR
LGUN (n = 26)	+	LGUN	+	7	NR
+	AUC	+	5	NR
+	Negative	-	14	NR
No tumor (n = 49)	-	Negative	-	36	No follow-up
-	AUC	+	3	No tumor (three cases), 6 - 60 months
+	Negative	-	6	No follow-up (one case), no tumor (five cases), 6 - 72 months
+^a	SHGUC	+^a	1	CIS 18 months
+	AUC	+	3	No tumor (three cases), 6 - 72 months
^aCIS diagnosed after 18 months. Significant threshold: P < 0.05. AUC: atypical urothelial cell; CIS: carcinoma in situ*; FMi: fluorescence microscopy; HGUC: high-grade urothelial carcinoma; LGUN: low-grade urothelial neoplasia; NPV: negative predictive value; PPV: positive predictive value; SHGUC: suspicious for high-grade urothelial carcinoma; TPS: The Paris System; UCCy: urinary conventional cytology.
HGUC + LGUN
Sensitivity, %	100	64.3	0.0001*	100	0.0001*
Specificity, %	79.6	85.7	0.3173	73.47	0.0143*
PPV, %	80.8	79.4	0.8238	76.36	0.5051
NPV, %	100	73.7	0.0001*	100	0.0001*
HGUC
Sensitivity, %	100	93.7	0.3173
LGUC
Sensitivity, %	100	46.2	0.0002*

Table 1. Results of Transmission and Fluorescence Microscopy in Groups 1 and 2 (N = 91)

Clinical diagnosis

FMi result +/-

UCCy

No. of cases

Follow-up time

TPS

Result +/-

HGUC (n = 16)

HGUC

SHGUC

AUC

LGUN

Negative

LGUN (n = 26)

LGUN

AUC

Negative

No tumor (n = 49)

Negative

No follow-up

AUC

No tumor (three cases), 6 - 60 months

Negative

No follow-up (one case), no tumor (five cases), 6 - 72 months

+^a

SHGUC

+^a

CIS 18 months

AUC

No tumor (three cases), 6 - 72 months

Statistics

FMi

UCCy

P* (FMi vs. UCCy)

FMi + UCCy

P* (FMi + UCCy vs. UCCy)

^aCIS diagnosed after 18 months. *Significant threshold: P < 0.05. AUC: atypical urothelial cell; CIS: carcinoma in situ; FMi: fluorescence microscopy; HGUC: high-grade urothelial carcinoma; LGUN: low-grade urothelial neoplasia; NPV: negative predictive value; PPV: positive predictive value; SHGUC: suspicious for high-grade urothelial carcinoma; TPS: The Paris System; UCCy: urinary conventional cytology.

HGUC + LGUN

Sensitivity, %

100

64.3

0.0001*

100

0.0001*

Specificity, %

79.6

85.7

0.3173

73.47

0.0143*

PPV, %

80.8

79.4

0.8238

76.36

0.5051

NPV, %

100

73.7

0.0001*

100

0.0001*

HGUC

Sensitivity, %

100

93.7

0.3173

LGUC

Sensitivity, %

100

46.2

0.0002*

**Table 2.** Results of Transmission and Fluorescence Microscopy in Group 1 (33 Patients Followed Up for Previous Urothelial Neoplasms)
Cystoscopy	Clinical diagnosis	No. of cases	FMi result +/-	UCCy	Follow-up time
Positive	LGUC	pTa	6	+	Negative	-	IR
Positive	LGUC	pTa	2	+	AUC	+	IR
Positive	LGUC	pTa	4	+	LGUN	+	IR
Positive	LGUC	pT1	1	+	AUC	+	IR
Positive	LGUC	pT1	1	+	LGUN	+	IR
Positive	LGUC	pT1	3	+	Negative	-	IR
Positive	HGUC	pTa	1	+	LGUN	+	IR
Positive	HGUC	pTa	1	+	HGUC	+	IR
Positive	HGUC	pT1	1	+	AUC	+	IR
Positive	HGUC	pT1	1	+	HGUC	+	IR
Positive	HGUC	pT2	1	+	Negative	-	IR
			n = 22
Negative	No disease		8	-	Negative	-	No follow-up
Inflammation^a	No tumor		1	+	AUC	+	No tumor, 36 months
Negative^b	No tumor		1	+	SHGUC	+	CIS, 18 months
Negative	No tumor		1	+	AUC	+	No tumor, 6 months
			n = 11
^aBCG therapy. ^bBCG therapy and CIS after 18 months. Significant threshold: P < 0.05. AUC: atypical urothelial cell; CIS: carcinoma in situ*; FMi: fluorescence microscopy; HGUC: high-grade urothelial carcinoma; IR: irrelevant; LGUC: low-grade urothelial carcinoma; LGUN: low-grade urothelial neoplasia; NPV: negative predictive value; PPV: positive predictive value; SHGUC: suspicious for high-grade urothelial carcinoma; TPS: The Paris System; UCCy: urinary conventional cytology; WHO: World Health Organization.
Sensitivity, %	100	54.5	0.0016*
Specificity, %	72.7	72.7	NA
PPV, %	88	80	0.0021*
NPV, %	100	44.4	0.1289

Table 2. Results of Transmission and Fluorescence Microscopy in Group 1 (33 Patients Followed Up for Previous Urothelial Neoplasms)

Cystoscopy

Clinical diagnosis

No. of cases

FMi result +/-

UCCy

Follow-up time

2016 WHO

Stage

TPS

Result +/-

Positive

LGUC

pTa

Negative

Positive

LGUC

pTa

AUC

Positive

LGUC

pTa

LGUN

Positive

LGUC

pT1

AUC

Positive

LGUC

pT1

LGUN

Positive

LGUC

pT1

Negative

Positive

HGUC

pTa

LGUN

Positive

HGUC

pTa

HGUC

Positive

HGUC

pT1

AUC

Positive

HGUC

pT1

HGUC

Positive

HGUC

pT2

Negative

n = 22

Negative

No disease

Negative

No follow-up

Inflammation^a

No tumor

AUC

No tumor, 36 months

Negative^b

No tumor

SHGUC

CIS, 18 months

Negative

No tumor

AUC

No tumor, 6 months

n = 11

Statistics

FMi

UCCy

^aBCG therapy. ^bBCG therapy and CIS after 18 months. *Significant threshold: P < 0.05. AUC: atypical urothelial cell; CIS: carcinoma in situ; FMi: fluorescence microscopy; HGUC: high-grade urothelial carcinoma; IR: irrelevant; LGUC: low-grade urothelial carcinoma; LGUN: low-grade urothelial neoplasia; NPV: negative predictive value; PPV: positive predictive value; SHGUC: suspicious for high-grade urothelial carcinoma; TPS: The Paris System; UCCy: urinary conventional cytology; WHO: World Health Organization.

Sensitivity, %

100

54.5

0.0016*

Specificity, %

72.7

PPV, %

0.0021*

NPV, %

100

44.4

0.1289

**Table 3.** Results of Transmission and Fluorescence Microscopy in Group 2 (58 Patients With Persistent Urinary Symptoms)
Cystoscopy	Clinical diagnosis	No. of cases	FMi result +/-	UCCy	Follow-up time
Positive	LGUC	pTa	4	+	Negative	-	IR
Positive	LGUC	pTa	2	+	AUC	+	IR
Positive	LGUC	pTa	2	+	LGUN	+	IR
Negative^a	LGUC	pTx	1	+	Negative	-	IR
Positive	HGUC	pTa	3	+	HGUC	+	IR
Positive	HGUC	pT1	1	+	SHGUC	+	IR
Positive	HGUC	pT1	1	+	HGUC	+	IR
Positive	HGUC	pT2	1	+	AUC	+	IR
Positive	HGUC	pT2	1	+	HGUC	+	IR
Positive	HGUC	pT3	2	+	HGUC	+	IR
Positive	HGUC	pT4	2	+	HGUC	+	IR
			n = 20
Negative	No disease		14	-	Negative	-	No follow-up
Negative	BPH		5	-	Negative	-	No follow-up
Negative	Lithiasis		3	-	Negative	-	No follow-up
Negative	Infection		4	-	Negative	-	No follow-up
Negative	Inflammation		2	-	Negative	-	No follow-up
Abnormal^b	BPH + inflammation		1	+	Negative	-	No tumor, 6 months
Negative	BPH + inflammation		1	+	Negative	-	No tumor, 72 months
Negative	Prostatitis		2	+	Negative	-	No tumor, 12 and 24 months
Negative	Lithiasis		2	+	Negative	-	No tumor, 0 and 12 months
Negative	Lithiasis		1	-	AUC	+	No tumor, 60 months
Negative	Inflammation		2	-	AUC	+	No tumor, 6 and 24 months
Abnormal^b	Infection		1	+	AUC	+	No tumor, 72 months
			n = 38
^aUreteral urothelial tumor. ^bDiagnosis confirmed by bladder biopsy. *Significant threshold: P < 0.05. AUC: atypical urothelial cell; BPH: benign prostatic hyperplasia; FMi: fluorescence microscopy; HGUC: high-grade urothelial carcinoma; IR: irrelevant; LGUC: low-grade urothelial carcinoma; LGUN: low-grade urothelial neoplasia; NPV: negative predictive value; PPV: positive predictive value; SHGUC: suspicious for high-grade urothelial carcinoma; UCCy: urinary conventional cytology; WHO: World Health Organization.
Sensitivity, %	100	75	0.0253*
Specificity, %	81.6	89.5	0.3173
PPV, %	74.1	78.9	0.6314
NPV, %	100	87.2	0.0255*

Table 3. Results of Transmission and Fluorescence Microscopy in Group 2 (58 Patients With Persistent Urinary Symptoms)

Cystoscopy

Clinical diagnosis

No. of cases

FMi result +/-

UCCy

Follow-up time

2016 WHO

Stage

TPS

Result +/-

Positive

LGUC

pTa

Negative

Positive

LGUC

pTa

AUC

Positive

LGUC

pTa

LGUN

Negative^a

LGUC

pTx

Negative

Positive

HGUC

pTa

HGUC

Positive

HGUC

pT1

SHGUC

Positive

HGUC

pT1

HGUC

Positive

HGUC

pT2

AUC

Positive

HGUC

pT2

HGUC

Positive

HGUC

pT3

HGUC

Positive

HGUC

pT4

HGUC

n = 20

Negative

No disease

Negative

No follow-up

Negative

BPH

Negative

No follow-up

Negative

Lithiasis

Negative

No follow-up

Negative

Infection

Negative

No follow-up

Negative

Inflammation

Negative

No follow-up

Abnormal^b

BPH + inflammation

Negative

No tumor, 6 months

Negative

BPH + inflammation

Negative

No tumor, 72 months

Negative

Prostatitis

Negative

No tumor, 12 and 24 months

Negative

Lithiasis

Negative

No tumor, 0 and 12 months

Negative

Lithiasis

AUC

No tumor, 60 months

Negative

Inflammation

AUC

No tumor, 6 and 24 months

Abnormal^b

Infection

AUC

No tumor, 72 months

n = 38

Statistics

FMi

UCCy

^aUreteral urothelial tumor. ^bDiagnosis confirmed by bladder biopsy. *Significant threshold: P < 0.05. AUC: atypical urothelial cell; BPH: benign prostatic hyperplasia; FMi: fluorescence microscopy; HGUC: high-grade urothelial carcinoma; IR: irrelevant; LGUC: low-grade urothelial carcinoma; LGUN: low-grade urothelial neoplasia; NPV: negative predictive value; PPV: positive predictive value; SHGUC: suspicious for high-grade urothelial carcinoma; UCCy: urinary conventional cytology; WHO: World Health Organization.

Sensitivity, %

100

0.0253*

Specificity, %

81.6

89.5

0.3173

PPV, %

74.1

78.9

0.6314

NPV, %

100

87.2

0.0255*