Abstract
PurposeConfocal laser endomicroscopy (CLE) is a fluorescence-based fiber-optic imaging technique with the potential for intraoperative grading of upper tract urothelial carcinoma (UTUC). This study aims to (1) investigate the prevalence of the previously proposed CLE criteria for bladder cancer in papillary UTUC, (2) estimate the diagnostic value of CLE for UTUC grading and (3) propose a scoring system for a more quantifiable approach of CLE-based grading of UTUC.Materials and methodsUreteroscopic CLE was performed in patients with UTUC. Following CLE imaging, co-localized biopsies were taken for histopathologic comparison. Postoperatively, two blinded raters assessed the CLE images.ResultsFifty-three papillary UTUCs (34 low grade and 19 high grade) were imaged with CLE in 36 patients. All the previously described CLE criteria were identifiable in varying proportions. After excluding 10 non-diagnostic recordings (5 low grade and 5 high grade) due to insufficient image quality, the histopathologic grade was correctly identified with CLE in 26 low-grade UTUCs (90%) and in 12 high-grade UTUCs (86%). The most prevalent CLE criteria with the highest diagnostic potential were cellular organization, morphology and cohesiveness of cells. A scoring system was proposed with these criteria, which yielded similar diagnostic accuracies.ConclusionsBased on the previously proposed criteria, CLE enables accurate grading of papillary UTUC at a non-diagnostic rate of 19%. The most prevalent CLE criteria with the highest diagnostic potential for grading of papillary UTUC are cellular organization, morphology and cohesiveness of cells. The proposed scoring system may simplify the assessment of CLE images for UTUC grading but external validation is required.
Highlights
Materials and methodsThe oncologic effectiveness of kidney-sparing treatment for upper tract urothelial carcinoma (UTUC) can only be warranted in selected patients [1, 2]
The first objective of this study is to identify the prevalence of the proposed Confocal laser endomicroscopy (CLE) criteria for urothelial carcinoma of the bladder (UCB) in papillary UTUC
CLE imaging was performed in 68 procedures, in which upper urinary tract lesions were visualized
Summary
Materials and methodsThe oncologic effectiveness of kidney-sparing treatment for upper tract urothelial carcinoma (UTUC) can only be warranted in selected patients [1, 2]. Risk stratification of UTUC has, become an essential step in the diagnostic pathway [3]. Endoscopic laser ablation is the treatment of choice in low-risk UTUC, while radical surgical resection is indicated in high-risk cases [2]. The histopathologic tumor grade is a key factor in the risk stratification of UTUC. Real-time intraoperative risk stratification by histopathologic assessment is, lacking in the current diagnostic workup. In 10–40% of ureteroscopic biopsies, the histopathologic grade is discordant with the tumor grade from surgical resection specimens [4,5,6,7,8]. The non-diagnostic yield of ureteroscopic biopsies for UTUC grading ranges from 10 to 20% [4,5,6, 8]
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