Levi A W, Potter S R, Schoenberg M P, Epstein J I
Departments of Urology and Pathology, The Johns Hopkins University School of Medicine, The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, Maryland 21231, USA.
J Urol. 2001 Aug;166(2):457-60.
Although to our knowledge the significance of denuded urothelium in bladder biopsies has not been studied previously, it is thought to be a problem because benign urothelial cells are cohesive and not expected to shed into the urine. We correlated the pertinent clinical features of patients with denuded bladder biopsies and/or specific pathological features of denuded bladder biopsy specimens with patient outcome in regard to bladder lesions to help predict the subsequent likelihood of diagnosing bladder carcinoma in a patient with a nondiagnostic denuded biopsy.
We studied 51 denuded bladder biopsies from 44 patients in which the average extent of epithelial denudation was 90%.
Of the 27 male (69%) and 17 female (31%) patients 22 to 86 years old (mean age 62) 34% had no history of bladder neoplasms. In remainder there were flat carcinoma in situ with or without other tumors (26%), high (20%) and low (14%) grade papillary tumors without carcinoma in situ and miscellaneous conditions (6%). Overall 31% of patients were diagnosed with carcinoma in situ within 24 months (median 5.5) after the denuded specimen was obtained. Parameters that did not correlate with the subsequent diagnosis of carcinoma in situ included cystoscopic impression, history of intravesical chemotherapy, sex, age, tissue inflammation, percent of tissue fragments with any denudation, number of denuded tissue fragments and percent of overall denuded epithelium. A history of carcinoma in situ before denuded biopsy predicted a diagnosis of carcinoma in situ within 24 months after denuded biopsy in 54% of patients in contrast to 19% of those without a history of carcinoma in situ (p = 0.03). Factoring in a history of other bladder tumor types in various combinations did not predict carcinoma in situ after denuded biopsy. The other predictive factor was cold cup biopsy. Carcinoma in situ developed within 24 months in 45% of patients in whom the denuded specimen was obtained by cold cup biopsy in contrast to none who underwent hot wire loop biopsy (p = 0.007). Cold cup biopsy and a history of carcinoma in situ were independently predictive. Carcinoma in situ developed within 24 months in 75% of patients with a history of that condition and a subsequent cold cup biopsy showing denuded epithelium. However, only 29% of those who underwent cold cup biopsy and had no history of carcinoma in situ were diagnosed with carcinoma in situ.
In bladder biopsies obtained by a hot wire loop denudation most likely results from thermal injury when there is a low risk of subsequent carcinoma in situ. When the denuded biopsy sample was obtained by cold cup biopsy, particularly when associated with a history of carcinoma in situ, most cases represent neoplastic cell denudation and a high risk for subsequent carcinoma in situ.
据我们所知，膀胱活检中裸露尿路上皮的意义此前尚未被研究过，但人们认为这是一个问题，因为良性尿路上皮细胞具有黏附性，预计不会脱落到尿液中。我们将膀胱活检裸露患者的相关临床特征和/或膀胱活检裸露标本的特定病理特征与膀胱病变患者的预后相关联，以帮助预测在活检结果未明确的膀胱活检患者中后续诊断膀胱癌的可能性。
我们研究了44例患者的51份膀胱活检裸露标本，其中上皮剥脱平均范围为90%。
27例男性（69%）和17例女性（31%）患者年龄在22至86岁（平均年龄62岁），34%无膀胱肿瘤病史。其余患者中有伴或不伴其他肿瘤的原位扁平癌（26%）、高级别（20%）和低级别（14%）无原位癌的乳头状肿瘤以及其他情况（6%）。总体而言，31%的患者在获得裸露标本后24个月内（中位数5.5个月）被诊断为原位癌。与后续原位癌诊断无关的参数包括膀胱镜检查印象、膀胱内化疗史、性别、年龄、组织炎症、有任何剥脱的组织碎片百分比、剥脱组织碎片数量以及总体裸露上皮百分比。在裸露活检前有原位癌病史的患者中，54%在裸露活检后24个月内被诊断为原位癌，而无原位癌病史的患者中这一比例为19%（p = 0.03）。将其他膀胱肿瘤类型的各种组合病史考虑在内并不能预测裸露活检后的原位癌。另一个预测因素是冷杯活检。通过冷杯活检获得裸露标本的患者中，45%在24个月内发生原位癌，而接受热丝圈套活检的患者中无一例发生（p = 0.007）。冷杯活检和原位癌病史具有独立预测性。有原位癌病史且随后冷杯活检显示上皮裸露的患者中，75%在24个月内发生原位癌。然而，接受冷杯活检且无原位癌病史的患者中，只有29%被诊断为原位癌。
在通过热丝圈套活检获得的膀胱活检中，当后续原位癌风险较低时，剥脱很可能是热损伤所致。当通过冷杯活检获得裸露活检样本时，特别是与原位癌病史相关时，大多数病例代表肿瘤细胞剥脱且后续原位癌风险较高。
