Improving CIS detection: Diagnostic tools and the urologist–pathologist relationship

In this discussion, Arpeet Shah, MD; Prithvi Murthy, MD; and Kenneth Beck, MD, examine practical strategies for improving the detection of carcinoma in situ (CIS), highlighting the importance of multidisciplinary collaboration, optimized tissue sampling, and complementary diagnostic technologies.

According to the panel, accurate diagnosis of CIS depends not only on expert pathologic interpretation but also on close collaboration between the urologist and pathologist. Beck noted that CIS can be particularly challenging to diagnose, especially in small office-based biopsy specimens or when distinguishing true CIS from changes adjacent to high-grade papillary tumors. He emphasized that simply indicating "rule out CIS" on the pathology requisition provides valuable clinical context, and encouraged urologists to discuss cases directly with pathologists when clinical suspicion remains high despite a negative pathology report. Both Beck and Shah stressed that second reviews and outside pathology opinions should be viewed as collaborative tools to improve diagnostic accuracy.

The panel also highlighted strategies to improve tissue sampling and identify occult CIS. Beck recommended obtaining separate biopsies of suspicious flat or erythematous areas in addition to papillary lesions and submitting specimens in separate containers to preserve orientation and improve pathologic assessment. Murthy discussed the value of enhanced cystoscopic techniques, particularly blue light cystoscopy, in identifying white light–invisible CIS during repeat transurethral resection or in patients with positive urine cytology despite negative office cystoscopy. Shah added that enhanced cystoscopy, urine cytology, and emerging urinary biomarkers should be viewed as complementary diagnostic tools, with cytology remaining highly sensitive for high-grade disease and biomarkers providing additional information to guide decisions about biopsy or repeat transurethral resection.

To strengthen collaboration in community practice, the speakers emphasized consistent communication throughout the diagnostic process. Shah encouraged urologists to clearly document clinical suspicion, positive cytology findings, and the need to evaluate for CIS on pathology requisitions, while also consulting colleagues with bladder cancer expertise and engaging pathologists in difficult cases.

Overall, Shah concluded, “Don't be afraid to reevaluate the patient if the pieces just don't fit. Doing a bladder biopsy is overall low risk, and missing a diagnosis can have significant consequences.”