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Int J Clin Exp Pathol 2012;5(9):882-891

Original Article
Accuracy of grading of urothelial carcinoma on urine cytology: an analysis of
interobserver and intraobserver agreement

Michelle D Reid, Adeboye O Osunkoya, Momin T Siddiqui, Stephen W Looney

Department of Pathology, Emory University School of Medicine and Department of Biostatistics, Georgia Health Sciences University, Augusta,

Received August 31, 2012; Accepted September 24, 2012; Epub October 20, 2012; Published October 30, 2012

Abstract: Background: Urine samples of known urothelial carcinoma were independently graded by 3 pathologists with (MS, MR) and without
(AO) fellowship training in cytopathology using a modified version of the 2004 2-tiered World Health Organization classification system. By
measuring interobserver and intraobserver agreement among pathologists, compared with the gold standard of biopsy/resection, specimen
accuracy and reproducibility of grading in urine was determined. Methods: 44 urine cytology samples were graded as low or high-grade by 3
pathologists with a 2-3 week interval between grading. Pathologists were blinded to their and others’ grades and histologic diagnoses.
Coefficient kappa was used to measure interobserver and intraobserver agreement among pathologists. Accuracy was measured by
percentage agreement with the biopsy/resection separately for each pathologist, and for all pathologists and occasions combined. Results:
The overall accuracy was 77% (95% C.I., 72% – 82%). Pathologist AO was significantly more accurate than MR on occasion 1 (p = 0.006) and 2
(p = 0.039). No other significant differences were found among the observers. Interobserver agreement using coefficient kappa was
unacceptably low, with all but one of the kappa value being less than 0.40, the cutoff for a “fair” degree of agreement. Intraobserver agreement,
as measured by coefficient kappa, was adequate. Conclusions: Our study underscores the lack of precision and subjective nature of grading
urothelial carcinoma on urine samples. There was poor inter- and intraobserver agreement among pathologists despite fellowship training in
cytopathology. Clinicians and cytopathologists should be mindful of this pitfall and avoid grading urothelial carcinoma on urine samples,
especially since grading may impact patient management. (IJCEP1208028).

Keywords: Urothelial carcinoma, accuracy of grading, urine cytology

Address all correspondence to:
Dr. Michelle D Reid,
Department of Pathology
Emory University School of Medicine
1364 Clifton Rd NE, Room H190
Atlanta, GA 30322, USA.
E-mail: michelle.reid@emory.edu