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Bladder Cancer
Figure 1: Case Study 1 – Carcinoma In Situ Figure 2: Case Study 2 – ‘False-positive’ Papillary Hyperplasia
lesions recurred during surveillance, with four lesions detected by flexible The absence of cancer is indeed a valid definition for a false-positive;
cystoscopy in 2004. In view of the recurring status and the multifocality, however, as shown in this case study, some ‘false-positive’ lesions are
adjuvant mitomycine C instillations were applied, even though the lesion not devoid of clinical implications. Papillary hyperplasia is defined by
remained of low grade and low stage (pTaG1, low-grade [WHO 2004 undulating urothelium arranged into thin mucosal papillary folds that
classification]). In 2007, control flexible cystoscopy revealed an ‘uneven’ lacks both the cytological atypia and the well-developed vascular cores
subureteric area. Cytology remained negative. of a papillary neoplasm. Typical hyperplasia is characterised, as in this
case study, by the absence of cellular atypia, and is considered a
PDD showed a fluorescent micropapillary lesion with sharp limits (see precursor lesion of low-grade papillary urothelial tumours.
11
In
Figures 2A and 2B) that was resected with bipolar resectoscopy. contrast, based on a short series in which most of the patients (nine of
Generous chips were obtained (see Figures 2C [x40] and 2D [x100]), and 10) with papillary hyperplasia and associated dysplastic features –
so-called ‘atypical papillary hyperplasia’ – progressed within one
year to a bona fide high-grade cancer, Epstein proposed that the
The detection of hyperplasia – flat or
prognostication and treatment of atypical papillary hyperplasia should
be similar to those of carcinoma in situ.
12
papillary, typical or atypical – even if
defined as a false-positive result may Another kind of ‘false-positive’ lesion readily visible in PDD is simple
represent pre-malignant lesions, and
urothelial hyperplasia, defined by cytologically unremarkable
urothelium that is more than seven layers thick.
13
In an elegant report
warrants further procedures of
comparing in the same patient the genetic alterations of classic
surveillance or treatment.
papillary tumours and of flat hyperplasia detected by PDD, Hartman
showed that the two shared a common genetic signature.
14
the diagnosis of typical papillary hyperplasia was made in view of the The detection of hyperplasia – flat or papillary, typical or atypical –
wave-like aspect of the mucosa (see Figure 2E [x200]) with minimal even if defined as a false-positive result may represent pre-malignant
mucosal proliferation (see Figure 2F [less than 5%, MIB-1 staining, x400]). lesions, and warrants further procedures of surveillance or treatment.
No adjuvant treatment was recommended.
Case Study 3 – High-grade Lamina Propria
Comments Invasive Carcinoma
While PDD does facilitate the detection of NMIBC, it has a significant rate Mr B, 44 years of age, presented with an initial episode of gross
of false-positive findings, amounting to almost 30% in the seminal paper haematuria. Besides smoking (a pack-year history of 30), his personal
by Jichlinski (57 false-positive results out of 165 fluorescent areas that history was unremarkable. An ultrasound scan showed a thickened
were sampled), who conducted the first head-to-head comparison of bladder wall next to the left ureteric orifice with no upper tract
WLC and PDD using Hexvix.
5
dilation. Office flexible cystoscopy confirmed a single peri-ureteric
42 EUROPEAN UROLOGICAL REVIEW
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