title: Multiphoton microscopy: a potential intraoperative tool for the detection of carcinoma in situ in human bladder.
abstract: BACKGROUND
  Urothelial carcinoma in situ (CIS) is a precursor of invasive bladder cancer, which if left untreated, will likely progress to more aggressive disease. Approximately 50% of CIS lesions are missed on routine cystoscopy owing to their flat architecture. Furthermore, many benign but abnormal-appearing areas may be biopsied owing to lack of cellular resolution of cystoscopes. Multiphoton microscopy (MPM) is an optical imaging technique that generates subcellular-resolution three-dimensional images from unfixed tissue without using exogenous dyes.
  
  
  OBJECTIVE
  To assess the diagnostic potential of MPM in identifying and differentiating benign from malignant flat bladder lesions, especially CIS.
  
  
  METHODS
  Seventy-eight specimens (benign = 46, CIS = 23, invasive = 9, as diagnosed on histopathology) were obtained from flat bladder mucosa via transurethral resection of bladder, cold cup biopsy, or cystectomy, imaged fresh with a commercial benchtop MPM, and submitted for routine histopathology. Multiphoton microscopy and hematoxylin-eosin diagnoses were compared.
  
  
  RESULTS
  In 77 of 78 specimens (99%), accurate MPM diagnoses (benign/malignant) were given on the basis of their architectural and cytologic features (nuclear to cytoplasmic ratio, pleomorphism, polarity/organization of urothelial layers, etc). The sensitivity and specificity were 97% and 100%, respectively, with positive (malignant) and negative (benign) predictive values of 100% and 98%, respectively. The interobserver agreement, κ, was 0.93.
  
  
  CONCLUSIONS
  Our study demonstrates the capability of MPM to identify and differentiate benign from malignant flat bladder lesions, especially CIS. With the advent of MPM endoscopes, we foresee their potential as a biopsy guidance tool for early detection and treatment of CIS, thus reducing the rate of biopsies with benign diagnoses and their associated complications.
authors.affiliation: From the Departments of Pathology and Laboratory Medicine (Drs Jain, Robinson, and Shevchuk), Urology (Drs Jain, Robinson, and Scherr and Mr Dubin), and Biochemistry (Drs Aggarwal and Mukherjee and Mr Salamoon), Weill Cornell Medical College, New York, New York. Dr Aggarwal is now at the Department of Science, Borough of Manhattan Community College, New York, New York. Mr Dubin is now a medical student at Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey.
authors.forename: Manu
authors.initials: M
authors.lastname: Jain
authors.forename: Brian D
authors.initials: BD
authors.lastname: Robinson
authors.forename: Maria M
authors.initials: MM
authors.lastname: Shevchuk
authors.forename: Amit
authors.initials: A
authors.lastname: Aggarwal
authors.forename: Bekheit
authors.initials: B
authors.lastname: Salamoon
authors.forename: Justin M
authors.initials: JM
authors.lastname: Dubin
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Scherr
authors.forename: Sushmita
authors.initials: S
authors.lastname: Mukherjee
mesh_terms: D000328:Adult; D002278:Carcinoma in Situ / Q000175:diagnosis*; D002295:Carcinoma, Transitional Cell / Q000175:diagnosis*; D015331:Cohort Studies; D005260:Female; D006651:Histocytochemistry; D006801:Humans; D008297:Male; D036641:Microscopy, Fluorescence, Multiphoton / Q000379:methods*; D016343:Monitoring, Intraoperative / Q000295:instrumentation; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D016037:Single-Blind Method; D001743:Urinary Bladder / Q000473:pathology; D001749:Urinary Bladder Neoplasms / Q000175:diagnosis*