Table Of ContentFig. 1. Schematic drawing of urothelium of urinary tract: Main source
of exfoliated cells which can be examined by urinary cytology.
H.J. deVoogt PRathert M. E. Beyer-Boon
0 0
Phase Contrast
Microscopy and Analysis of Stained Smears
Foreword by L.G. Koss
79 Mostly (blored Figures in 327 Separate Jllustrations
Springer-Verlag
Berlin Heidelberg New York 1977
Herman]. de Voogt, MD, PhD
Lecturer in Urology, Academisch Ziekenhuis. Department of Urology,
Leiden, The Netherlands
Privatdozent Dr. med. Peter Rathert
Facharzt fiir Urologie, Cytologisches Labor der Abteilung Urologie, Medizinische Fakultiit,
Rheinisch-Westfiilische Technische Hochschule Aachen, Germany
Head of the Department of Urology, Krankenanstalten Diiren, Germany
Mathilde E. Beyer-Boon, MD, PhD
Pathologist-Cytopathologist, Head of the Department of Cytopathology,
Pathology Laboratory, Academisch Ziekenhuis, Leiden, The Netherlands
Director of Het Leids Cytologisch Laboratorium, Head of the School of Cytotechnology,
Leiden, The Netherlands
ISBN-13 978-3-642-96390-2 e-ISBN-l3: 978-3-642-96388-9
DOT: 10.1007/978-3-642-96388-9
Library of Congress Cataloging in Publication Data Voogt. H..I. de, 1925-Atlas of urinary
cytology. Includes bibliographical references and index. I. Urine-Examination -Atlases.
2. Diagnosis, Cytologic - Atlases. I. Rathert, Peter, joint author. II. Beyer-Boon. Mathilde
E., 1941-joint author. III. Title. RB53.V66 616.07'582 77-7021
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by Springer-Verlag, Berlin· Heidelberg 1977
Softcover reprint of the hardcover 1s t edition 1977
Foreword
Cytologic diagnosis of cancer has its roots in clinical micro
scopy as it was shaped during the first half of the 19th
century. In reviewing some of the early writing on this
subject, one is amazed at the accuracy of the descriptions
and soundness of the observations. Cytology of the urine
is no exception: in 1864 Sanders described fragments of
cancerous tissue in the urine of a patient with bladder cancer
(Edinburgh Med. J. 111, 273). This observation was
confirmed by Dickinson in 1869 (Tr. Path. Soc. London,
20, 233). It is a source of special pride to me that in 1892
a New York pathologist, Frank Ferguson, advocated the
examination of the urinary sediment as a best means of
diagnosing bladder cancer, short of cystoscopy. Papanico
laou freely acknowledged these contributions while estab
lishing sound scientific bases for continuation and spread
of this work. Papanicolaou's work in the area of the urinary
tract has not fallen on dead ears. He documented to several
urologists who were within his sphere of personal influence,
mainly Dr. Victor Marshall, Professor of Urology at Cor
nell University Medical School, that urinary tract cytology
was a reliable tool in the diagnosis of urothelial carcinoma.
Some of us who have attempted to spread the master's
word had their share of success within institutions with
which we were associated. Perhaps the most important
contribution of urinary tract cytology has been in the identi
fication of non-papillary carcinoma in situ, a key lesion
in the assessment or prognosis of urothelial neoplasia. Yet,
the authors of this fine Atlas of Urinary Cytology are quite
right when they imply that the vast majority of urologists
are either not aware or are skeptical of this method of
diagnosis. There are many reasons for this, perhaps the
most important of which are its limitations. Well-differen-
v
tiated papillary lesions of the bladder, such as papilloma
and papillary carcinoma, grade I, are unlikely to yield diag
nostic cells. Thus, the expectations of the urologists that
any bladder tumor will be reliably diagnosed by cytology
is false. Similar mistakes are committed by the pathologists
and cytopathologists who often fail to recognize the limita
tions of the method and in attempting to diagnose too
much make major mistakes of judgment and are left with
the mistrust of their clinicaL colleagues. Urinary tract cytol
ogy is difficult and is full of pitfalls and distressing sources
of diagnostic mistakes. It cannot be learned casually but
requires many years of experience and close cooperation
between the pathologist and the urologist. This atlas should
contribute to the popularization of this important method
of diagnosis which admirably complements but does not
replace clinical judgment and the biopsy. The goal of these
efforts is a relatively simple one: to offer the patient with
cancer of the lower urinary tract the best possible chance
for an early diagnosis resulting in a cure or at least contain
ment of the disease and as comfortable a life as possible
if a cure is not possible. To this goal urinary cytology
may contribute in a very significant fashion by identifying
the patients at a very high risk for invasive cancer whose
urinary sediment contains obvious cancer cells. For such
patients radical treatment of the diseased urothelium prior
to the development of metastases may be the best and some
times only change of salvation.
Drs. Beyer-Boon, de Voogt, and Rathert should be congra
tulated on this fine atlas. It should contribute substantially
to the clarification and education of both urologists and
pathologists who are interested in cancer of the lower uri
nary tract.
LEOPOLD G. Koss
Professor and Chairman
Department of Pathology
Albert Einstein College of
Medicine at Montefiore Hospital
and Medical Center
Bronx, New York 10467
VI
Contents
Preface . . . . . . . . . . . . . . . . . . I
I. Clinical Application of Urinary Cytology 5
H.i. de Voogt
2. Preparatory Techniques 7
M.E. Beyer-Boon
2.1. Collection of Material . 7
2. I. I. Urine . . . . . . . . 7
2.1.2. Bladder and Renal Pie vis Washings 7
2.1.3. Brushing Techniques .... 8
2.1.4. Prefixation.... . . . . . 8
2.2. Cell Concentration Techniques 8
2.3. Smear Preparation Techniques 9
2.3.1. Smears for Phase Contrast Microscopy and
Methylene Blue Staining (Non-Permanent). 9
2.3.2. Smears for the Papanicolaou Stain (Per-
manent) . . . . . . . . . . . . 10
2.3.2.1. Smears form Freshly Voided Urine 10
2.3.2.2. Smears from Prefixed Urine II
2.3.2.3. Smears for the MGG Method (Permanent) 11
2.4. Staining Methods . . II
2.4.1. Methylene Blue Stain II
2.4.2. Papanicolaou Stain 12
2.4.3. May-Gruenwald Giesma Staining Method 12
2.5. Pitfalls..... 12
2.5.1. Cell Degeneration . . . . . . . 12
2.5.2. Formalin Effect . . . . . . . . 12
2.5.3. The Damaging Effect of Hypertonic Urine 12
2.5.4. Cell Loss During Staining 13
2.5.5. Overstaining . . . . . . . . 13
2.5.6. Cellular and Nuclear Shrinkage
3. Urinary Cytology and its Relationship to His-
tology of the Urinary Tract. . . 15
M.E. Beyer-Boon
3.1. Normal Structure of Urothelium 15
VII
3.1.1. Histology of Normal Urothelium 15
3.1.2. Epithelial Variants. . . . . . . 16
3.1.3. Cytology of Normal Urothelium 16
3.2. Epithelial Contamination 18
3.3. Benign U rothelial Lesions 18
3.3.1. Inflammatory Changes 18
3.3.1.1. Bacterial Infections 18
3.3.1.2. Viral Infections . . 19
3.3.1.3. Parasitic Infections 19
3.3.1.4. Mycotic Infections 20
3.3.2. Malakoplakia. . . 20
3.3.3. Squamous Metaplasia 20
3.3.4. Glandular Cystitis . . 21
3.3.5. Urinary Calculi . . . 21
3.3.6. Hyperplasia of the Urothelium 22
3.3.7. Atypical Hyperplasia of the Urothelium 22
3.3.8. Condylomata Acuminata 22
3.4. Urothelial Tumors ...... . 23
3.4.1. Introduction . . . . . . . . . . 23
3.4.2. Classification of Urothelial Tumors 23
3.4.2.1. Macroscopy 23
3.4.2.2. Microscopy ....... . 25
3.4.2.3. Stage . . . . . . . . 25
3.4.2.4. Clinical Classification (UICC) 26
3.4.3. Macroscopy and Histology of Pure Transi
tional Cell Tumors 28
3.4.3.1. Papillary Tumors . . . . . . 28
3.4.3.2. Solid Tumors . . . . . . . . 30
3.4.3.3. Flat Intra-Epithelial Carcinomas (Carcinoma
in situ) ............... . 30
3.4.4. Cytology of Pure Urothelial Tumors. . . . 31
3.4.4.1. Papillary Tumors Grade 0 (Benign Papilloma)
and Grade I (Papilloma with Atypia) 31
3.4.4.2. Papillary Tumors, Grade 2, 3 and 4 (Carci-
nomas) ........ . 34
3.4.4.3. Solid Urothelial Carcinomas . . . . . . . 35
3.4.4.4. Carcinoma in situ . . . . . . . . . . . . 36
3.4.5. Squamous Differentiation of Transitional Cell
Carcinoma and Pure Squamous Cell Carci-
noma . . . . . . . . . . . . . . . .. 36
3.4.6. Adenomatous Differentiation of Transitional
Cell Carcinoma and Pure Adenocarcinoma. 37
3.5. Adenocarcinoma of the Prostate ..... 38
3.6. Infiltration of the Bladder or Ureter from Ad
jacent Carcinomas and Metastasis of other
Carcinoma . . . . . . . . . . . . . .. 38
VIII
3.7 Adenocarcinoma of the Kidney . . . 39
3.8. Effect of Radiation on the Urothelium 40
3.9. Effect of Cancer Drugs 40
4. Phase Contrast Microscopy of the Urinary
Sediment .. 43
HJ. de Voogt
5. Methylene Blue Stain of the Urinary Sediment 49
P. Rathert
6. Epidemiology and Etiology of Urothelial Tu-
mors ... 51
P. Rathert
7. Efficacy of Urinary Cytology in the Detection
of Tumors of the Urinary Tract . . . . . . 55
M.E. Beyer-Boon, HI. de Voogt, P. Rathert
7.1. Diagnosis of Patients with positive Cytolog
ical Results . . . . . . . . . . . . . . . 56
7.2. Diagnosis of Patients with Atypical Findings 56
7.3. Sensitivity and Specificity of Urinary Cytol-
ogy ................. . 58
7.4. The Validity of the Provisional Contrast Mic
roscopy Diagnosis . . . . . . . . . . . . 60
7.4.1. Phase Contrast Microscopy Underdiagnosis . 61
7.4.2. Phase Contrast Microscopy Overdiagnosis 61
Acknowledgement 62
References. 63
Illustrations . . . 69
1. Normal Transitional Epithelium . . . . 71
2. Inflammatory Changes. . . . . . . . . 77
3. Non-Bacterial Inflammations and Contaminants 81
4. Atypical Hyperplasia . . . . . . . .. 87
5. Phase Contrast Microscopy: Criteria for Malig-
nancy . . . . . . . . . . . . . . 91
6. Grade 1 Tumors of the Bladder 95
7. Grade 2 Tumors of the Bladder, with and without
Infiltrative Growth . . . . . . . . . . . .. 99
8. Grade 2 Bladder Tumors and Grade 3 U roteral
Tumor. . . . . . . . . . . . . . . . . . . 103
9. Grade 2 Tumors of Bladder and Urethra with
Infiltrative Growth . . . . . . . . 107
10. Grade 3 Tumors of Bladder, Renal Pelvis and
Ureter. . . . . . . . . . . . . . III
IX
II. Grade 3 Tumors of Renal Pelvis, Ureter and
Bladder 117
12. Grade 4 Bladder Tumors 121
13. Grade 4 Solid Carcinoma of the Bladder 123
14. Carcinoma in situ. 127
IS. Squamous Cell Carcinoma of the Bladder 135
16. Adenomatous Differentiation. 141
17. Adenocarcinoma . . . . . . . 147
18. Adenocarcinoma of Kidney lSI
19. Bladder Cancer and Prostate Cancer ISS
20. Cystitis Glandularis Combined with Squamous
Metaplasia . . . . . . . . . . . . . . . . . 159
21. Effects of Radiation . . . . . . . . . . . . . 163
22. Effects of Cytostatic Drugs on Urothelial Cells 167
23. Cytological Changes Due to Urinary Calculi 173
24. Catheter Urine . . 179
25. Ileal Stomal Urine 183
26. Artifacts in PCM 187
Subject Index 191
x
Preface
In all probability urine contents have been observed since
the microscope came into use for human pathology. Micro
scopic examination of unstained urinary sediment was rou
tine long before Papanicolaou (Papanicolaou and Mashall,
1945) introduced urinary cytology. Before that time red
and white blood cells received the most attention as well
as cylinders and crystals. Epithelial cells from the urinary
tract (Fig. 1, p. I) were seen and the possibility of identifying
malignant cells in urine was already thought of in the middle
of the nineteenth century (Beale, 1858).
Several investigators described with painstaking accuracy
normal and abnormal cells in urine as well as in other
body fluids. After Ehrlich introduced dried stained prepara
tions, such investigations increased but urinary cytology re
mained the work of individuals and they somehow did not
succeed in introducing it as a routine diagnostic method
(Deden, 1954).
Following the pioneer work of Papanicolaou many dedi
cated cytologists modified and improved urinary cytology,
but at the same time urologists criticized the method mainly
because of its lack of accuracy as a diagnostic procedure.
This controversy continues up to the present day and for
a long time prevented urinary cytology from becoming a
widely accepted routine diagnostic method. In our opinion
another important cause is a lack of interest on the part
of urologists for a simple diagnostic method, when they
have such sophisticated tools for visualizing the urinary
tract. To this may be added the fact that the Papanicolaou
method cannot be done easily by the urologist himself dur
ing office hours. It is necessary to send fresh voided urine
to the cytology laboratory where it has to be processed
immediately if it is not prefixed. Staining, screening, and
