Carcinoma In Situ diagnosis

4 months 1 week ago #61435 by joea73
Replied by joea73 on topic Carcinoma In Situ diagnosis
"Negative for high grade urothelial carcinoma"  is the term used in The Paris System (TPS) for Reporting Urinary Cytology was proposed in the 2013 International Cytology Congress in Paris, France.   The finalized recommendations of TPS were officially released in 2016.   Since then it seems it has become the standard for cytology reporting.   TPS is intended to eliminate great variability by which urinary tract cytology specimens are assessed between individuals and institutions.   Of particular concern was the inconsistent and high rate of indeterminate diagnoses, such as "atypical".  Diagnostic categories for TPS are as follows.

1.  Negative for High Grade Urothelial Carcinoma
2.  Atypical urothelial cells
3.  Suspicious for High Grade Urothelial Carcinoma
4.  High Grade Urothelial Carcinoma
5.  Low Grade Urothelial Neoplasm
6  Other malignancies, both primary and secondary

Prior to TPS,  1. Negative for High Grade Urothelial Carcinoma  was  Negative for malignant cells, and 5. Low Grade Urothelial Neoplasm was Low Grade Urothelial Carcinoma.

In TPS,  criteria for atypical urothelial cells are cells where cytologic changes fall short of  a diagnosis of  33.  Suspicious for High Grade Urothelial Carcinoma or 4.  High Grade Urothelial Carcinoma, and meet the following requirement.

Major criterion (required)   -  Non-superficial and (non-degenerated) urothelial cells with an high N/C (Nucleus / Cytoplasm) ratio > 0.5
Minor criteria (1 required)
  -  Nuclear hyperchromasia
  -  irregular nuclear membranes
 -   Irregular, coarse, clumped chromatin

In Moffitt Caner Center, FL,  cases if Atypical has been reduced from 27% cases in 2015  prior TPS to 10% in 2016 after TPS.

In terms of the diagnosis of "Negative for high grade urothelial carcinoma", according to Dr. Adeniran, MD, Director of cytopathology  of Yale school of Medicine,  risk of malignancy is 0-10%.  So, this is a very good news.

Squamous cell present  is likely contamination from another part of body.   Below is Dr. Abbosh of Fox Chace Cancer Center, PA answering to a patient's question about the subject in a webinar.

I'll mention, there's a question in the pre-webinar, that was solicited pre-webinar, about squamous cells. squamous cells, again, may sound very malignant, but they're really just normal cells that are sloughed off by the urinary tract into the urine, and they're detected by the pathologist, the cytopathologist. They're really just very... Really, they look like large flat cells with a very
small nucleus and a lot of cytoplasm. They're often considered contaminants. So, you guys may
remember, if you give a urine sample in your doctor's office, they will often give you a little sanitary pad
or sanitary napkin to sort of clean off the opening of your urethra. The point of doing that is to try to
reduce the number of squamous cells in the urine sample because, as I mentioned, they tend to be
contaminants.

The comment is also echoed in a government site saying about squamous cells in urine test.

There are three types of epithelial cells that line the urinary tract. They are called transitional cells, renal (kidney) tubular cells, and squamous cells.   If there are squamous epithelial cells in your urine, it may mean your sample was contaminated. This means that the sample contains cells from another part of the body. This can happen if you do not clean your genital area well enough when collecting your urine sample with the clean catch method.

Also, Libre Pathology (Wikipedia of pathology) site says often Large (benign) squamous component in urine cytology is not reported.

medlineplus.gov/lab-tests/epithelial-cells-in-urine/#:~:text=If%20there%20are%20squamous%20epithelial,with%20the%20clean%20catch%20method.

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4 months 2 weeks ago - 4 months 2 weeks ago #61432 by Alan
Replied by Alan on topic Carcinoma In Situ diagnosis
Clyde,

Congrats on getting through so many BCG treatments. I wouldn't be too concerned on completion of all infusions. Very few people complete these due to reactions and other factors. It is a goal, however. Heck, my URO who interned under Dr. Lamm had his own protocol of 6 on, 6 off then a final 6 weeks.

On "The only thing that cautioned me was on my cytology report under Final diagnosis after it stated "Negative for high grade urothelial carcinoma"
it said Urothelial and squamous cells present." That is a question I'd pose directly to your Doc as none of us are doctors here and I sure wouldn't want to give erroneous info about that.

DX 5/6/2008 TAG3 papillary tumor .5 CM in size. 2 TURBS followed by 6 instillations of BCG weekly with a second round of 6 after a 6 week wait.

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4 months 3 weeks ago #61431 by Clyde
Replied by Clyde on topic Carcinoma In Situ diagnosis
Update on my journey. I previously posted that I could no longer get BCG from my large treating facility and that is still the case. Fortunately a local urologist was able to give me three more maintenance BCG to keep up with the SWOG program. I now have had 21 BCG treatments.  Still no major side effects other then burning and frequency for a day. Last week I had a cystoscopy, CT Urogram  and   cytology test which were all negative. So as of now I'm appx 18 months clear of any carcinoma. I still have the testing done at the major facility. I'll be due for another maintenance round of BCG in December. I'll try to get my local urologist to give those treatments.
The only thing that cautioned me was on my cytology report under Final diagnosis after it stated "Negative for high grade urothelial carcinoma" it said Urothelial and squamous cells present. I've never seen that before on these reports. Anyone else get those comments?

I'll check with uro next week.

Again....thank you to everyone on this site that has helped over the last few years to deal with this.

Clyde

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7 months 2 weeks ago #61300 by joea73
Replied by joea73 on topic Carcinoma In Situ diagnosis
I have read BCG have become unavailable so some patients and patients called around large hospitals and secured BCGs.   

Another option is to administer Gemcitabine + Docetaxel while BCG is not available.
I had seen a posting here in this forum , of someone who has been treated by Dr. Joshua Meeks of Northwestern Medicine in Chicago. BCG became unavailable during maintenance course.  Dr. Meeks put the patient to Gemcitabine + Docetaxel  regiments, then put the patient back to BCG when BCG became available.  

best

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7 months 3 weeks ago #61299 by Jack R
Replied by Jack R on topic Carcinoma In Situ diagnosis
Clyde,

Your case is different from mine, except for CIS. What gives us comfort is likely different. Ultimately, we have to choose from the options that are available to us. That said; I offer the following thoughts.

No one knows how much treatment is the necessary amount for any individual. Dr. Lamm and the SWOG (SouthWest Oncology Group) produced massive research driven data based on "the Lamm BCG schedule" and a huge study population. Those results, which included the BCG induction and long-term maintenance schedule remain the foundation work for evaluating other options. HOWEVER, the data applies to the large group, and shows good GROUP results with the extended treatment schedule. AGAIN, the question remains, how little BCG treatment is necessary for any given individual ?

Perhaps the "smart" choice is to go with the group treatment plan. BUT, even on this board, you will find individuals treated with shorter or divergent treatments with good results. Researcher Dr. Michael O'Donnell is a BCG supporter, but has looked at some of the assumptions underlying Lamm's schedule. O;Donnell and Lamm and SWOG are worthwhile search terms for a deep dive into BCG info.

It may be helpful to talk to your doctor about WHY he seems not overly concerned at this point.

Perhaps s/he thinks you are showing a complete response ? Perhaps he is concerned about the side effects of BCG treatment on the bladder ? Perhaps he feels that regular evaluation of the bladder is best until (IF) CIS returns ?

Knowing what the doc would want to do if the CIS returns could be (has been for me) helpful and reassuring. Similar to looking at treatment schedules other than the Lamm/SWOG, which was the treatment I also started on years ago and eventually left.

Let your Doc or care team know you are uncomfortable with the unknown future of treatment. Hopefully, a plan can be made that addresses your concerns. There are always treatment options, and it is our right as patients to be fully involved.

Best
Jack

6/2015 HG Papillary & CIS
3 Years and 30 BCG/BCG+Inf
Tis CIS comes back.
BC clear as of 5/17 !
RCC found in my one & only kidney 10/17
Begin Chemo; Cisplatin and Gemzar
8/18 begin Chemo# 3
Begin year 4 with cis
2/19 Chemo #4
9/19 NED again :)
1/2020 CIS is back
Tried Keytruda, stopped by side effects
Workin on a new plan for 2021

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8 months 2 weeks ago #61292 by Clyde
Replied by Clyde on topic Carcinoma In Situ diagnosis
The good news is that I had a negative cystoscopy today. This gives me a full year of negative cystoscopies. I'll get my cytology results in a week or so but my last three have also been negative.

The bad news is my NEC facility doesn't have BCG available for me to continue with the maintenance protocol. This concerns me since BCG has been so effective for me. The Dr. said I was in a good position and he and shouldn't be overly concerned about it at this point.
He scheduled me for a CT urogram and another surveillance cystoscopy in September.

I'm not sure if I should be trying to find another institution with BCG to continue the maintenance protocol or hold tight until September. Has anyone else had to deal with this? Not even sure where to call to see about BCG availability of if they would just provide me with three maintenance treatments. Any advise? Anyone know where BCG is available?

Thanks,

Clyde

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