Urine Cytology for M-Cells | Reliable or Not

Hi Bills,

Thank you detail rely.  The intention of my reply was never meant to question the validly of cytology process or its reporting.  The cytopathology report is intended communicate the findings to your urologist, and the urologist, with the knowledge of the history of diagnosis and the treatment of your father, the urologist will translate the report in the language you will understand.  I believe the report will go to the urologist soon, and if the urologist thinks it is necessary, the urologist will ask for another test.  The pathologist could have reported Negative for Malignancy or Negative for High Grade Urothelial carcinoma, then it was much clear for us.  Perhaps, it is the usual practice  of the pathology lab that analyzed the urine is to report "No atypical cells in smear examined" meaning  the pathologist did not find any malignant cells or suspicious cells", which can be interpreted as Negative for Malignancy.  This is something you can ask to the urologist for clarity.   If you are interested in how urine cytology done, especially as surveillance for high grade tumor recurrence, 
You may want to watch the video with the link below.  I have watched several cytology videos, and I found this video to be short and good.



I am glad to hear most side effects are gone,  I go to 3-4 times and sometimes more after I go to bed.   I am envious that your dad only has to go twice.   Lets see what your urologist says about many acute inflammatory cells and RBCs cited in the cytopathology report.
In terms of reducing the dose, I am not sure what dose is gives the best therapeutic window.  I have read that Dr. Lamm will go down t0 1/10 and even 1/100 so the BCG treatment can continue, then I hear other prominent urologist says the minimum will be 1/3 considering the efficacy.  There are several studies somewhat giving conflict result.   Some study says 1/3 gives similar effect and similar side effects. Some study says 1/3 gives similar efficacy and reduced side effects.  The hospital I know, with the prominent urologist who will go down up to 1/3 was referring the data from the study comparing the efficacy of 1/3, 1/6 and Mitomycin.   The study says 1/3 gave higher efficacy than 1/6, and 1/6 gave higher efficacy than mitomycin.  Interestingly, 30% experienced with MMC, 64% with 1/6 dose, 65.4% with 1/3 dose.    If 1/6 dose gives higher efficacy than intervesical chemotherapy MMC, do you think your urologist will try with 1/6?

citeseerx.ist.psu.edu/viewdoc/download;jsessionid=DE53441504188D8EFA98D55D85DCE363?doi=10.1.1.510.3570&rep=rep1&type=pdf
 
This study says ofloxacin reduces the side effects without affecting efficacy.
www.auajournals.org/doi/abs/10.1016/j.juro.2006.04.104

Note that those studies were mentioned in a webinar by a urologist as a teaching session to the residences in the same hospital.

best Joe
 

Hi Joea73 ,
Thank you for a detailed reply. I always appreciate when you go and think an extra mile. This is the beauty of your detailed replies and analysis. I always lean new things from you. Appreciate and Respect.
 
I will answer your replies in order
 
Joea73: If the sample does not fit to those categories, it needs to say insufficient sample or something like that.  I think the description of the report, stating few transitional and occasional epithelial cells might have meant that there were not enough cells to confirm "Negative for malignancy" or "Negative for high-grade urothelial carcinoma.". 
Bills: We provided two samples of Urine both containers were fully filled and gave it to lab. Lab confirmed if they suspect sample is not sufficient , they will call back and report. Providing two samples is the protocol the Lab follows. Some labs ask for 3 samples at the same time. So  do you think we should repeat the test may be with another Hospital or Lab? I have not talked to Uro till now by the way.
 
Joea73:So, the pathologist report mentioning of acute inflammatory cells indicates there is recent injury to the bladder lining, or upper tract.   But, knowing that your dad had severe injuries to the lining by BCG induction treatment, initially, and subsequently the one maintenance treatment in June, which also caused some issue, concern is that the report  leads to  acute (recent) inflammation, but it could be that the lining of bladder has developed chronic inflammation, such as cystitis.
 
Bills: As you might be aware that my father had induction BCG(4x80mg) in Oct-Nov 2020 and then 1st maintenance(2x40mg) in June 2021. Which caused him lots of side effects of frequency and Urgency which subsided Nov-2021. And now this time he does not have those side effects at that extend. They are reduced about 95% currently. But sometime he wakes up at night more than 2 times to bathroom which we consider as normal as per his age and cold weather. He also had burning sensation during urination which is also gone now. USG during induction revealed Bladder Cystitis of 6mm but during the maintenance BCG , USG did not revealed any cystitis and things looked good as side effect reduced with time.
What i think is the current inflammation and RBC is an underlying and inherent side effect of BCG and it tend to be there for a long time ( even if one completes the BCG program for 3 years). BCG side effects are long lasting and believe me my dad of his age , I salute his guts ( He turned 77 this year) and I am sure if there would have anyone else , even younger than him, he would not have tolerated even 50% of what my father had.
 
Joea73: We know that the side effects tend to get worse as the number of the BCG treatment increases.  I have read only 20% completes the whole BCG treatment regimen.  But I have also read Dr. Kamat of MD Andersons saying that that was the past and because  urologists learned much about side effects and how to deal with it, that in his practice, over 90% of his patients could complete the entire 3 years BCG treatment program.   Dr. Kamat did not explain how (medication, reducing dosed?)  90% of his patients were able to complete it. 

Bills:  We will have next BCG after father will fully recover from the side effects not matter it may take him 1-2 months (Mach-April 2022). I will try to be more vigilant with other examinations as well( USG, Cytology, CBC ,PSA). I want him to fully recover from last BCG  side effects and I know he is doing well inside with no sign of malignancy. I will try to discuss with our Uro to reduce the dose to 1/3 or 1/4 and intervals between the BCG;s as well, which will give him enough time to stabilize for next dose.
 
What I learned during the recent times since my dad is diagnosed with Bladder Ca, is Hope( in Almighty) and believe(in yourself) is the key you need to fight this beast. If you lose confidence and hope , you will lose the battle. 

I have lots of respect for you and all those who are veterans here on this forum( Alan, Sara, Jack). I am sure that you at your times of fighting this disease , would have relied on Hope and Confidence and I am sure , you  too had hold it TIGHT& FIRM
 
Thank You and Respect

HI Bills, a few points.

As I might have mentioned before the cytology reporting system has changed to improve the accuracy of the reporting, namely recognizing that cytology is more focused on detecting high grade and, reducing atypical, and only reporting low grade if the urine sample includes a specific feature.   If the sample does not fit to those categories, it needs to say insufficient sample or something like that.  I think the description of the report, stating few transitional and occasional epithelial cells might have meant that there were not enough cells to  confirm "Negative for malignancy" or "Negative for high-grade urothelial carcinoma.".  Literatures say less than 10-20 urothelial cells, obscuring inflammation, blood may lead to  inadequate analysis.  The report is the communication media between the pathologist and the urologist,  and I assume they have been communicating for many samples, so I think it is best to wait for the urologist to read the report and explains to you.  

Traditional Cytology Terminology        The Paris System (2013)
Negative for malignancy                         Negative for high-grade urothelial carcinoma
Atypical cells present                              Atypical urothelial cells
Suspicious for malignancy                      Suspicious for high-grade urothelial carcinoma
Positive for malignant cells                     High-grade urothelial carcinoma
                                                                    (Low-grade urothelial neoplasia)


I am also more concerned with the reporting of "Many acute inflammatory cells, RBCs, amorphous deposits".  Google says there are acute and chronic inflammations.  The physical, chemical and other factors can cause injury to tissue- in your case, the lining (epithelial tissue) of bladder I presume.   The early reaction to the injury is the same regardless how the tissue is injured.   First, capillary, through which usually one blood cell ,i.e. one RBC can pass, expand so more RBCs flow and become permeable so blood reaches to injured tissue to deliver more oxygen to generate more energy to kill and repair injured cells, produce more cells.   At the same time, immune cells. initially Neutrophil (WBC) in blood will also reach to injured tissue.  50 to 70% of all circulating WBCs are Neutrophils.   The major role of the neutrophil in acute inflammation is to kill microorganism and foreign material.    In chronic inflammation, usually Monocytes which make up 2-8% circulating WBCs  enter into the tissue and become Macrophage.  Macrophages engulf large particles and pathogens.   

So, the pathologist report mentioning of acute inflammatory cells indicates there is recent injury to the bladder lining, or upper tract.   But, knowing that your dad had severe injuries to the lining by BCG induction treatment, initially,  and subsequently the one maintenance treatment in June, which also caused some issue, concern is that the report  leads to  acute (recent) inflammation, but it could be that the lining of bladder has developed chronic inflammation, such as cystitis. It is something you need to discuss with urologist to find out the nature of the inflammation before the next BCG is infused.   

We know that the side effects tend to get worse as the number of the BCG treatment increases.  I have read only 20% completes the whole BCG treatment regimen.  But I have also read Dr. Kamat of MD Andersons saying that that was the past and because urologists learned much bout side effects and how to deal with it, that in his practice, over 90% of his patients could complete the entire 3 years BCG treatment program.   Dr. Kamat did not explain how (medication, reducing dosed?)  90% of his patients were able to complete it.

 Incidentally, does your dad show any symptoms for inflammation in the bladder, such as frequency, urgency, blood in urine, etc?

best

Hi 
The result of the Cytology came yesterday and it reads

Sample type: Urine
Method: Staining and Microscopy
Result:
Smear shows few transitional and occasional epithelial cells. Many acute inflammatory cells, RBCs, amorphous deposits.
Impression: No atypical cells in smear examined


Thanks to God  all is well and the report is also clear. I am  thinking of acute inflammation cells & RBCs which are there. We had last BCG on 24th June 2021 which was 40mg only in dose. Still there can be side effects of BCG which caused inflammation?

We are supposed to get another BCG in Jan-Feb 2022. Hopefully now Uro will suggest some reduced dose with 2 weeks duration between each BCG.
Waiting to meet Uro to suggest either Cystoscopy and then BCG or directly BCG without cystoscopy.

Thanks

Hi Alan/Joea,

Our Uro wanted to check the ca cells in Urine so he recommended Urine Cytology. He wrote Urine cytology for M-Cells( Malignant Cells) in the prescription. 
We have done it on Saturday 15th Jan 2022 and results are expected in 5 to 7 days. I hope all is well. We had Abdominal USG as well which came out to be all Clear. 

As per Joea , Cytology is accurate in case of HG bladder tumors. 


Thanks