Screening and monitoring for bladder cancer: refining the use of NMP22

PURPOSE

While detecting bladder cancer, bladder tumor markers demonstrate improved sensitivity compared with urinary cytology but the current limitation is the low specificity and positive predictive value, that is high false-positive rate. We examined the clinical categories of the false-positive results, established relative exclusion criteria, and recalculated the specificity and positive predictive value of this assay with these criteria.

MATERIALS AND METHODS

A total of 608 patients considered at risk for bladder cancer presented to a urology clinic and submitted a single urine sample. Of the 608 patients 529 (87%) presented with de novo hematuria or chronic voiding symptoms without a diagnosis of bladder cancer. There were 79 (13.0%) patients being monitored with a known history of bladder cancer. Each urine sample was examined via cytology, urinalysis, culture and NMP22 protein assay. All patients underwent office cystoscopy, and transurethral resection and/or biopsy if a bladder tumor was suspected.

RESULTS

Of the 608 patients 226 (37.2%) presented with microscopic hematuria, 143 (23.5%) with gross hematuria and 239 (39.3%) had chronic symptoms of urinary frequency or dysuria. There were 52 (8.6%) patients who had histologically confirmed bladder cancer. Of these 52 cancers NMP22 detected 46 (88.5%), whereas cytology identified only 16 (30.8%). When atypical cytology was considered positive, cytology detected 32 (61.5%) cases. In the 135 patients with increased NMP22 values the 46 identified tumors were accompanied by 89 false-positive values yielding a specificity of 83.9% and a positive predictive value of 34.1%. These false-positive results were divided into 6 clinical categories. Exclusion of these categories improved the specificity and positive predictive value of NMP22 to 99.2% and 92.0%, respectively, yielding results similar to urinary cytology (99.8% and 94.1%).

CONCLUSIONS

Awareness and exclusion of the categories of false-positive results can increase the specificity and positive predictive value of NMP22, enhancing the clinical use of this urinary tumor marker.

[Evaluation of usefulness of urinary nuclear matrix protein 22 (NMP22) in the detection of urothelial transitional cell carcinoma]

We evaluated the usefulness of urinary nuclear matrix protein 22 (NMP22) compared to urinary cytology in the detection of urothelial transitional cell carcinoma (TCC). Between July 1999 and March 2000, 227 patients complaining of microscopic or gross hematuria were analyzed. Twenty-four patients (10.6%) had urothelial TCC. The urinary NMP22 level was significantly higher in the patients with urinary TCC compared to the other patients. The sensitivity and specificity of the results obtained with urinary NMP22 were 58.3% and 84.2%, respectively, and those obtained by urinary cytology were 45.8% and 98.0%, respectively. False-positive results were obtained with urinary NMP22 in the patients with urinary diversion using intestine, bladder invasion from other cancers, urinary tract infection, and urolithiasis. The urinary NMP22 level was significantly associated with tumor stage, suggesting its usefulness for detection of urothelial TCC. However, although urinary NMP22 showed equal sensitivity for the detection of TCC, it was not superior to urinary cytology.

[Availability of NMP22 (nuclear matrix protein 22) for the diagnosis of urothelial cancer]

We evaluated the availability of NMP22 for the diagnosis of urothelial cancer. Of 154 patients with gross hematuria or microscopic hematuria, 14 patients with bladder cancer and 4 patients with upper urothelial cancer were detected. Of 73 patients continued to be followed for urothelial cancers, 11 patients with bladder cancer were detected. NMP22 was not available when a large number of RBC was present in urine. Also, NMP22 was significantly higher in patients with urothelial cancers. Interpretation of the ROC curve indicated an optimal cutoff value of 9.2 u/ml. Using 9.2 u/ml as a cutoff, the sensitivity and specificity were, respectively 87.0% and 64.0% in patients with hematuria, and 81.8% and 78.7% in patients with a history of TCC. This indicated that when NMP22 was used for the diagnosis of urothelial cancers, 12.0 u/ml, the value recommended as a cutoff in Japan, might be too high to differentiate patients with urothelial cancers.

[Screening methods in the detection of bladder cancer: comparison of nuclear matrix protein-22, bladder tumor antigen and cytological examinations]

We evaluated the utility of urinary parameters (Nuclear Matrix Protein-22: NMP-22, Bladder Tumor Antigen: BTA, and cytological examinations) for the diagnosis or post-therapeutic monitoring of bladder cancer. Thirty one tumor-bearing cases including 19 fresh cases and 40 tumor-free cases, were subjects of this study. Using identical voided urine samples, NMP-22, BTA and urinary cytology were examined. The mean values of NMP-22 (cut-off value is 12 U/ml) was 100.5 +/- 26.5 U/ml in the tumor-bearing group and 21.9 +/- 7.8 U/ml in the tumor-free group (p < 0.05): Sensitivity was 74.2%, and specificity was 67.5%. Sensitivity of BTA was 58.1%, and specificity was 97.5%. Only five cases were judged positive by urinary cytology: 16.1% in sensitivity and 100% in specificity. Thus, NMP-22 and BTA were more sensitive than urinary cytology. In conclusion, the new urinary parameters, NMP-22 and BTA, would be less invasive and useful as tumor markers of bladder cancer. NMP-22 seems suitable for screening before the diagnosis and BTA for the post-therapeutic follow-up study.

Comparative predictive values of urinary cytology, urinary bladder cancer antigen, CYFRA 21-1 and NMP22 for evaluating symptomatic patients at risk for bladder cancer

PURPOSE

We study the potential diagnostic use of urinary bladder cancer antigen, CYFRA 21-1 and NMP22*; for evaluating symptomatic patients who present with microscopic hematuria and are at risk for bladder cancer.

MATERIALS AND METHODS

Urinary tumor markers were determined in 187 samples from 112 patients symptomatic of bladder cancer (group 1), and 75 with benign and other urological conditions (group 2). Immunoassays were used to measure the 3 selected biomarkers. Sensitivity and specificity were established by previously defined cut points. Biomarker results were reported as corrected and uncorrected for urinary creatinine. Urinalysis was performed in all samples.

RESULTS

Positive and negative predictive values were 85.5%, 80.5% and 81.1%, and 80.8%, 79.2% and 76.5% for urinary bladder cancer antigen, CYFRA 21-1 and NMP22, with the cutoffs 9.7 microg./l., 5.4 microg./l and 10.0 units per ml., respectively. These predictives values were 85.2% and 72.5%, respectively, for urinary cytology. The combination of biomarkers decreased the positive predictive values to 72.3% to 78.6% and increased negative predictive values to 84.2% to 86.1%. Urinary tract infection, inflammation and malignancy associated with other genitourinary organs were the primary cause for false-positive test results in the 3 assays evaluated.

CONCLUSIONS

With a single biomarker, around 80% of the positive results would have correctly identified symptomatic patients for cystoscopy. Of the negative results 75% would have correctly reduced the number of cystoscopies. Sensitivity and negative predictive values could be improved with the combination of biomarkers but with a loss of specificity and positive predictive values. Urinary tract inflammation and other genitourinary malignancies might contribute to the reduction in specificity of these tests.

[Clinical evaluation of urinary nuclear matrix protein 22 as a marker for bladder cancer]

The purpose of this study is to evaluate the clinical usefulness of urinary nuclear matrix protein 22 (NMP22) as a marker for bladder cancer. We examined the positive rates of NMP22 test, urinary cytology and bladder tumor antigen (BTA) test, and compared the positive rate of NMP22 test with that in urinary cytology and BTA test. Urine samples were obtained from 50 patients with histologically confirmed bladder cancer before the treatment. The samples were examined by NMP22 test, urinary cytology and BTA test. In 50 patients with bladder cancer, the overall positive rate was 40% for NMP22 test, 40% for urinary cytology, and 16% for BTA test. A combination of NMP22 test and urinary cytology showed a significantly higher positive rate (54%) as compared to NMP22 test or urinary cytology alone. When NMP22 test and urinary cytology were compared for tumor size, number, shape, stage and grade, NMP22 test showed a significant higher positive rate than urinary cytology in grade 1 bladder cancer. In conclusion, although NMP22 test and urinary cytology gave a similar positive rate, a combination of NMP22 test and urinary cytology is more useful than the NMP22 test or urinary cytology alone for monitoring of bladder cancer.

Clinical application of NMP22 in the management of transitional cell carcinoma of the bladder

The combination of a noninvasive, quantitative immunoassay, NMP22, with voided urinary cytology prior to cystoscopy was evaluated in patients with urothelial transitional cell carcinoma. Fifty-six patients with a history of transitional cell carcinoma were evaluated. Voided urine was obtained for NMP22 and cytology prior to cystoscopy. One hundred and twenty-three NMP22 assays, 124 cytologies, and 124 cystoscopies were performed. The type of anesthesia used for cystoscopic evaluation was determined by the NMP22 value in 30 patients. Cystoscopy results were considered positive on biopsy-confirmed malignancy. The reference value used for NMP22 was 10.0 U/ml. NMP22, cytology, and the combination of NMP22 and cytology were compared to cystoscopy and to pathologic grading and staging. Thirty-four recurrent transitional cell carcinoma episodes occurred; 22 were low-grade (I-II), and 12 were high-grade (III-IV). Twenty-seven were stage Ta; four were T1; and three were T3b or 4. Within this group, NMP22 detected low- and high-grade tumors equally, as compared to cytology, which was sensitive only to high-grade tumors. Nineteen patients were NMP22-negative and underwent cystoscopy under topical anesthesia; 17 were tumor-free. Eleven patients were NMP22-positive and had anesthesia, and all had visible lesions, which were subjected to biopsy and were resected. Six lesions were tumors, five were inflammatory. Overall sensitivity of combined NMP22 and cytology was 70%; specificity was 72%; positive predictive value was 54%; and negative predictive value was 77%. An accurate assessment of the risk of a bladder cancer can be obtained with NMP22, cytology, and cystoscopy in patients with a history of bladder cancer. NMP22 values can be used to determine the level of anesthesia for cystoscopy in patients with a history of bladder cancer.

BTA quantitative assay and NMP22 testing compared with urine cytology in the detection of transitional cell carcinoma of the bladder

PURPOSE

Both BTA TRAK and NMP22 urine concentrations have shown a sensitivity superior to urine cytology in the detection of bladder cancer. We compared these tumor markers with urine cytology performed on 3 consecutive samples and evaluated by an expert cytopathologist.

PATIENTS AND METHODS

The investigations were conducted on 94 patients undergoing a diagnostic cystoscopy for a high suspicion of bladder cancer (group 1) and on 102 patients with previous history of transitional cell carcinoma awaiting a follow-up cystoscopy (group 2). Biopsy specimens were obtained also from tumor negative patients. Immunoassays for BTA TRAK and NMP22 were carried out according to standard methods. The choice of the cut-off was based on the ground of sensitivity and specificity curves intersection. Urine cytology results were expressed as positive, negative and 'dubious'.

RESULTS

Overall sensitivity was 56% for NMP22 (cut-off 11 U/ml) and 57% for BTA TRAK (cut-off 60 U/ml). When dubious results were considered as positive cases, urine cytology achieved a sensitivity of 73.3%. Assuming dubious cases as negative results, urine cytology sensitivity resulted 59.3%. When the 2 groups of patients were evaluated separately with different cut-off, there was no significant gain in sensitivity for BTA TRAK and NMP22 over urine cytology.

CONCLUSIONS

Urine cytology performed on 3 samples showed the highest sensitivity and specificity. The diagnostic advantage of urine cytology over BTA TRAK and NMP22 was maintained when patients were stratified by tumor grade.

Urine based markers of urological malignancy

PURPOSE

A number of urine based markers have been and are being investigated for the diagnosis and prognostication of urological conditions. A majority of these markers have been evaluated in urological neoplasms, particularly bladder cancer. The diagnosis of bladder cancer currently relies on identifying malignant cells in the urine and subsequently visualizing the tumor on cystoscopy. This diagnosis is further confirmed by transurethral resection or biopsy. While urine cytology is specific, it is not sensitive, especially for detecting low grade disease. This characteristic has prompted the search for more accurate markers of bladder cancer. In this review we critically examine the results of studies evaluating various markers for bladder cancer.

MATERIALS AND METHODS

The published literature on urine based markers for all urological diseases, particularly bladder cancer, was identified using a MEDLINE search and critically analyzed. The sensitivity, specificity, positive and negative predictive values of the various markers were compared. The benefit of using combined markers rather than a single marker was also analyzed from published reports.

RESULTS

Most published literature on urine based markers for urological malignancies involve such markers for diagnosing and prognosticating bladder cancer. Hence, we focused mainly on urine based markers in bladder cancer. Most markers appear to have an advantage over urine cytology in terms of sensitivity, especially for detecting low grade, superficial tumors. However, most markers tend to be less specific than cytology, yielding more false-positive results. This scenario is more common in patients with concurrent bladder inflammation or other benign bladder conditions. However, there is reason to be optimistic about several new markers that appear to provide better specificity. Few urine based markers have been identified and investigated in other urological tumors.

CONCLUSIONS

Detecting bladder cancer using diagnostic markers still presents a challenge. A number of new markers are currently available that appear to be significantly more accurate than cytology. However, further studies involving a larger number of patients are required to determine their accuracy and widespread applicability for diagnosing bladder cancer. Urine based markers do not appear to have a significant role in the diagnosis or prognosis of other urological malignancies, such as prostate, kidney or testicular cancer.

Evaluation of the NMP22 test and comparison with voided urine cytology in the detection of bladder cancer

The purpose of this study was to assess the clinical performance of the NMP22 test and to compare it with that of voided urine cytology for the detection of bladder cancer. The NMP22 test was evaluated in two groups of patients. The first group was comprised of patients with histologically confirmed active transitional cell carcinoma (TCC) of the bladder, and the second group contained those with a history of bladder TCC but that were considered to have no evidence of disease on the basis of cystoscopic evaluation of bladder and/or biopsy. Sensitivity was determined in voided urine samples from patients with active TCC of the bladder. Specificity was determined in the urine samples of patients with a history of bladder TCC but no current evidence of disease. The NMP22 test was positive in 53 of 70 samples from patients with active bladder TCC. The sensitivity of the NMP22 test (75.7%) is significantly better than that of voided urine cytology (55.7%). The specificity of the NMP22 test and of voided urine cytology were 72.2% and 88.9% respectively, in patients with a history of bladder TCC but no current evidence of disease. There was no significant difference between the specificity of NMP22 and that of urine cytology. The NMP22 test is superior to voided urine cytology in the detection of TCC of the bladder. The results of this study indicate that the NMP22 test is an useful adjunct to cystoscopy in the detection and monitoring of TCC of the bladder.

[The usefulness of urinary FDP in the diagnosis of bladder cancer: comparison with NMP22, BTA and cytology]

PURPOSE

We assessed the utility of urine fibrin/fibrinogen degradation products (FDP) as the screening test for bladder cancer.

MATERIALS AND METHODS

Single voided specimens were obtained from 87 consecutive patients (61 men and 26 women, mean age 70.7) on cystoscopy, and FDP, NMP22, BTA and cytology test were performed for the same specimens. Final diagnosis of bladder cancer was made by histological examination, which were compared with the results of above four screening methods.

RESULTS

Histologically confirmed bladder cancer was found in 14 cases. Overall sensitivity of urinary FDP, NMP22, BTA and cytology were 79, 64, 36 and 36%, respectively. While the sensitivity of FDP was significantly higher than that of BTA and cytology, no significant difference was found between FDP and NMP22. Overall specificity of these four methods were 69, 78, 92 and 90%, respectively. The specificity of FDP and NMP22 were significantly lower than that of BTA and cytology, but satisfactory as a screening test. The sensitivity of the four methods for low-grade and non-invasive tumors were 70, 50, 30 and 10% (G1 or G2, n = 10), and 75, 58, 33 and 25% (Ta or T1, n = 12), respectively. FDP might have a high sensitivity for even low-grade and non-invasive tumors.

CONCLUSIONS

FDP in voided urine is a good screening method for bladder cancer because of its high sensitivity for low-grade and non-invasive tumors, and its diagnostic ability could be superior to NMP22.

Urinary level of nuclear matrix protein 22 in the diagnosis of bladder cancer: experience with 130 patients with biopsy confirmed tumor

PURPOSE

We prospectively evaluated the value of nuclear matrix protein 22 (NMP22dagger) and cytology in the diagnosis of bladder cancer.

MATERIALS AND METHODS

We analyzed NMP22 in voided urine from 235 patients before cystoscopy. Of the patients 130 had transitional cell carcinoma of the bladder and subsequently underwent surgery. In a subset of 200 patients bladder washout samples for cytology were collected during cystoscopy. The cutoff for NMP22 was 10.0 units per ml. For cytology only high grade atypia was considered positive.

RESULTS

Histology showed 77 superficial (pTa, pTis) and 53 invasive (pT1 or greater) tumors. Sensitivity of NMP22 was 51% and specificity was 83%. NMP22 sensitivity was 36% for superficial tumors and 73% for invasive transitional cell carcinoma. Overall sensitivity of cytology was 52% and specificity was 89%. Cytology sensitivity was 38% for superficial tumors and 83% for invasive transitional cell carcinoma. NMP22 sensitivity for grades 1, 2 and 3 tumors was 30%, 56% and 68%, respectively. Cytology sensitivity for grades 1, 2 and 3 tumors was 30%, 50% and 91%, respectively. Combined NMP22 and cytology had a sensitivity of 70%.

CONCLUSIONS

NMP22 has sensitivity and specificity similar to those of cytology from bladder washout samples. Particularly in low stage and low grade tumors both tests show the same disappointing sensitivity. Because of a false-negative rate of 49%, NMP22 cannot replace cystoscopy in clinical practice, as the danger of missing NMP22 negative tumors is too high to rely on its results in an individual patient.

Comparison of BTA stat and NMP22 tests in the detection of bladder cancer

OBJECTIVE

This study aimed to compare the BTA (bladder tumour antigen) stat and urinary nuclear matrix protein (NMP22) tests in the detection of bladder cancer.

MATERIAL AND METHODS

The office-based qualitative BTA stat and the laboratory-based quantitative NMP22 tests were studied in the same urine samples obtained from 49 patients with a high suspicion of bladder cancer and 20 healthy subjects.

RESULTS

A tumour was identified in 36 patients after the cystoscopy. BTA stat demonstrated a sensitivity of 89%, which was superior to the sensitivity of 66.6% with the NMP22 test in detecting the bladder cancer (p < 0.02). The sensitivities for grade I tumours with BTA stat and NMP22 were 55.5% and 33.3%, respectively. The sensitivity of BTA stat was 100% for tumour categories except for the pTa and grade I tumours. No positive result was observed with both tests among the healthy subjects. The specificities for BTA stat and NMP22 were 78.7% and 69.6%, respectively.

CONCLUSIONS

The BTA stat test was significantly more sensitive than the NMP22 test in the detection of bladder cancer. Although the sensitivity of BTA stat was not sufficient to replace cystoscopy, its ease and low cost may play a role in reducing the number of control cystoscopies, especially in patients with low risk of progression.

Clinical application of NMP22 and urinary cytology in patients with hematuria or a history of urothelial carcinoma

For evaluation of the clinical application of immunoassay for nuclear matrix protein 22 (NMP22 immunoassay) and urinary cytology for early diagnosis and detection of bladder cancer in patients with hematuria and/or a previous history of bladder cancer, 209 urine samples obtained from 137 patients presenting episodes of hematuria or a history of bladder cancer were assayed for NMP22 levels and/or prepared for cytology examination. Biopsy was performed when any visible tumor was identified during cystoscopy examination. The median NMP22 concentrations measured in samples taken from patients with active bladder cancer, from patients with a history of bladder cancer but no active disease, from patients with hematuria, and from healthy volunteers were 18.95, 5.45, 6.39, and 3.75 U/ml, respectively. The urinary NMP22 level recorded for patients with urothelial carcinoma was significantly higher than that noted for individuals without active disease. The sensitivity of the NMP22 assay and of urinary cytology in diagnosing bladder cancer was 69% and 67%, respectively. In contrast, the specificity of these two diagnostic modalities reached 72% and 93%, respectively. The NMP22 assay is slightly more sensitive but less specific than urinary cytology in detecting bladder cancer. This study indicates that determination of urinary NMP22 levels is a useful and noninvasive tool for the detection of bladder cancer because of its high sensitivity. The urinary NMP22 assay may be used as a first-line routine screening method; however, it cannot replace the use of urinary cytology because of its lower specificity.

Urinary NMP22 and karyometry in the diagnosis and follow-up of patients with superficial bladder cancer

OBJECTIVE

To study the value of two outpatient urine tests with regard to the diagnosis and recurrence of bladder tumors.

METHODS

Fifty patients with a history of superficial bladder cancer were evaluated with urinary NMP22 levels (cutoff level 10 U/ml), bladder wash karyometry (low versus intermediate and high risk) and cystoscopy. All patients were followed for 1 year.

RESULTS

Diagnostic negative and positive predictive values (NPV and PPV) of the tests were, respectively: NMP22 91.2 and 56.3%, and karyometry 80 and 33.3%. Prognostic NPV and PPV with regard to a subsequent recurrence were, respectively: NMP22 77.8 and 27.3%, and karyometry 82.6 and 50%.

CONCLUSION

The diagnostic value of NMP22 is good. Since the 3 false-negative results were in low-stage and low-grade lesions, this test could be used as a prescreening for cystoscopy. The NPV of these tests with regard to tumor recurrence is around 80%, but only karyometry has a significant PPV. Change in the follow-up policy on the basis of these tests remains difficult. In patients with neobladders NMP22 appears to be of little use, because of the high urinary NMP22 levels in the absence of malignancy.

[NMP-22 in the diagnosis of bladder cancer]

OBJECTIVE

To evaluate the usefulness of the NMP-22 test in the diagnosis of bladder cancer; to calculate the ideal cutoff and to compare the results among NMP-22, voided urine cytology and cystoscopy.

MATERIAL AND METHODS

166 patients having clinical suspicious of bladder cancer or in follow-up due to a previous one. The exclusions criteria were: other urological conditions, radiotherapy in the last three months, systemic chemotherapy in the last month, recent vesical trauma or indwelling catheter. Prior cystoscopy a recent voided urinary sample was sent to the pathology and biochemistry laboratory to perform cytology and NMP-22. A TUR was performed in patients with bladder tumour. The cutoff was calculated with ROC curves. For each test we calculate sensitivity, specificity, positive and negative predictive value. We use the McNemar test to compare the results, all of which are expressed with a confidence interval of 95%.

RESULTS

The ideal cutoff was 6 U/ml. We have a global sensitivity of 82.75% for NMP-22 and 67.9 for cytology (p = 0.0118); the specificity was 80% and 94.12% respectively (p = 0.0018). By grade the sensitivity was 72.22% G1, 70.97% G2 and 100% G3 for NMP-22 and 44.44%, 58.06% and 90.62% for cytology. By stage it was 68.42% Ta, 83.33% T1 and 100 T2 or more for NMP-22 and 36.84%, 75% and 85.71% for cytology. With the cystoscopy we obtained a 100% sensitivity and 89.41% specificity.

CONCLUSIONS

The NMP-22 is a useful test for the diagnosis of bladder cancer; is more sensitive and less specific than cytology. We think it can replace the cytology in the diagnosis and follow-up of bladder cancer. The ideal cutoff is 6 U/ml.

Urinary BTA-stat, BTA-trak and NMP22 in surveillance after TUR of recurrent superficial transitional cell carcinoma of the bladder

OBJECTIVES

To evaluate NMP22, BTA-Stat and BTA-Trak tests in monitoring recurrent transitional cell carcinoma of the bladder.

METHODS

The tests were performed in 179 selected patients being followed up for recurrent superficial bladder tumors: 55 patients had bladder recurrence and 124 patients were recurrence free. The NMP22 test was obtained in all patients; BTA-Stat and BTA-Trak in the last 96 and 74 patients, respectively. Sixty-four patients (51.6%) were undergoing adjuvant intravesical chemotherapy.

RESULTS

Sensitivity was 74, 57 and 62% and specificity was 55, 62 and 79% for NMP22, BTA-Stat and BTA-Trak, respectively. A high percentage of patients submitted to intravesical chemotherapy had false-positive tests. Positive predictive values of the NMP22, BTA-Stat and BTA-Trak tests were 42.2, 40 and 45.4%, and negative predictive values were 82.9, 76.9 and 88.4%, respectively.

CONCLUSIONS

NMP22, BTA-Stat and BTA-Trak tests cannot replace cystoscopy and cannot be adopted as routine tools in surveillance after TUR in patients with superficial bladder cancer.

Clinical usefulness of the novel marker BLCA-4 for the detection of bladder cancer

PURPOSE

Previous studies at our laboratory identified 6 bladder cancer specific nuclear matrix proteins termed BLCA-1 to 6. We recently developed an immunoassay that detects the bladder cancer specific nuclear matrix protein BLCA-4. We analyzed urine samples from patients with bladder cancer, those with spinal cord injury and normal volunteers to determine the BLCA-4 level in these 3 groups.

MATERIALS AND METHODS

Urine samples obtained from 51 normal controls, and 54 patients with bladder cancer and 202 with spinal cord injury were tested for BLCA-4. We evaluated the association of BLCA-4 level with tumor grade and stage, urine cytology and bladder cancer history in the nonspinal cord injured population. Similarly we compared parameters associated with BLCA-4, such as spinal cord injury duration, catheterization, history of urinary tract infection, smoking and urine culture, in spinal cord injured patients.

RESULTS

We established a normal cutoff point of 13 optical density units per microg. protein for the BLCA-4 assay. The BLCA-4 level was less than the cutoff in all 51 normal controls, while in 53 of the 55 urine samples (96.4%) of patients with bladder cancer and 38 of the 202 (19%) of spinal cord injured patients urinary BLCA-4 was greater than the cutoff. There was no correlation of any individual factors studied in these cases, including urinary tract infection and urinary BLCA-4.

CONCLUSIONS

Elevated urinary BLCA-4 levels may accurately identify bladder cancer and distinguish these patients from normal individuals. There is no correlation of urinary BLCA-4 with a history of urinary tract infection, smoking, catheterization or cystitis considered independently. Urinary BLCA-4 determination appears to have high potential as a test for screening and monitoring bladder cancer in the general population and in groups at high risk for the disease, such as those with spinal cord injury.

Enhanced urinary gelatinase activities (matrix metalloproteinases 2 and 9) are associated with early-stage bladder carcinoma: a comparison with clinically used tumor markers

Matrix metalloproteinases (MMPs) are involved in tumor growth and metastasis, promoting the migration and invasion of cells. In this study, the amount of MMP-2 and MMP-9 activity was measured in urine from superficial bladder carcinoma patients (pTa, pT1) to evaluate their possible diagnostic value. The active and total amount of MMP-2 and MMP-9, respectively, in urine from tumor patients were compared with the levels in urine from age- and gender-matched healthy volunteers. Both MMP-2 and MMP-9 activity levels were significantly enhanced in urine from patients with high invasive cancers (pT2, PT3), whereas in urine from healthy controls no or very low MMP activities were found. More importantly, a substantial number of urine samples from patients with superficial tumors contained elevated MMP-2 and MMP-9 activities, suggesting that enhanced urinary MMP activity levels, indeed, might be indicative for early-stage bladder cancer. Overall, urinary MMP-2 and MMP-9 activity levels were significantly correlated to each other, with some individual exceptions. A comparison between urinary MMP-9 activity and a recently proposed urinary marker for bladder cancer, NMP-22, showed slightly lower numbers of patients with elevated levels for MMP-9. But because MMP-9 and NMP-22 levels were not correlated, enhanced urinary MMP activity might be useful as a marker for superficial bladder carcinoma like, or especially in combination with, other markers.

[Determination of NMP-22 as recurrence marker in bladder cancer. Preliminary study]

OBJECTIVES

The present study was conducted to determine the efficacy of NMP-22 as a diagnostic test for recurrence of bladder tumors and to compare its efficacy with urine cytology.

METHODS

30 patients (25 male, 5 female), aged 41-87 years (mean 73.4), with bladder tumor were evaluated by cytology, cystoscopy and determination of NMP-22 at 3 and 6 months post-TUR of the bladder. A positive test was defined as NMP-22 greater than 10 U/ml.

RESULTS

80.7% were T1, 15.3% T2-T3, 76.8% were grade I and II, and 23.2% were grade III. NMP-22 showed a sensitivity of 69%, a specificity of 64%, a positive predictive value of 52% and a negative predictive value of 78%, using tumor recurrence at 3 and 6 months as the unit of analysis, for a recurrence rate of 36%. Cytology showed a sensitivity of 44%, a specificity of 92%, a positive predictive value of 77% and a negative predictive value of 74%. When both tests were used, we obtained a sensitivity of 87.5%, a specificity of 64.2%, a positive predictive value of 58.3% and a negative predictive value of 90%. In grade I tumors, determination of NMP-22 had a sensitivity of 100%, a specificity of 77.7%, a positive predictive value of 60% and a negative predictive value of 69%.

CONCLUSIONS

NMP-22 showed an acceptable sensitivity but a low positive predictive value, therefore control cystoscopic evaluation cannot be avoided. The sensitivity and negative predictive values increased when NMP-22 and cytology are used in combination. We found NMP-22 to be a very useful marker for recurrence of low grade tumors.

[Cytokeratins (UBC and CYFRA 21-1) and nuclear matrix proteins (NMP22) as urine tumor markers in the diagnosis of bladder cancer]

BACKGROUND

The development of urinary tumor markers such as UBC, CYFRA 21-1 and NMP22 appeared to be non invasive alternative methods for the detection of bladder cancer. We compared the individual and combined sensitivity of the urinary tumor markers in the detection of bladder cancer, contrasting them with the conventional diagnostic procedures.

PATIENTS AND METHODS

237 voided urines from subjects under risk for bladder cancer were collected immediately before the endoscopic examinations: 44 patients under suspicion of a primary bladder tumor and 193 patients under follow-up of a previous bladder cancer were included. UBC and NMP22 were measured by enzyme-immunoabsorbent-assays and CYFRA 21-1 by an electro-chemiluminescense-immunoassay.

RESULTS

Taking the cutoffs of 9.7 micrograms/l for UBC, 5.4 ng/ml for CYFRA 21-1 and 10.0 U/ml for NMP22 sensitivities were 70%, 69% and 67% for UBC, CYFRA 21-1 and NMP22 at specificities of 95%, 94% y 80%, respectively. All tumor markers showed higher sensitivities than urinary cytology (7%), microhematuria (62%) and gross hematuria (10%) at specificities of 99%, 78% and 99%, respectively. The combinations of NMP22 plus CYFRA 21-1 reached the highest sensitivity (79%), slightly lower than simultaneously measuring the three tumor markers (80%).

CONCLUSIONS

The sensitivities of the urinary markers UBC, CYFRA 21-1 and NMP22 appeared to be high enough so as to substitute urinary cytology. The diagnostic similarity between cytokeratins individually and in each type of patients might not recommend their simultaneous determination. The combined measurement of NMP22 and one cytokeratin marker (CYFRA 21-1 or UBC) appeared to be the most recommended.

Usefulness of urinary nuclear matrix protein 22 (NMP22) as a marker for transitional cell carcinoma of the bladder

OBJECTIVES

The purpose of this study was to evaluate an immunoassay for urinary nuclear matrix protein, NMP22, as a novel marker for urothelial cancer.

PATIENTS AND METHODS

NMP22 values were determined for 71 patients and 21 healthy volunteers. Each subject provided a single (3 voids) urine sample for analysis at the time of entry into the study. Each sample was assayed for levels of NMP22.

RESULTS

When the cut-off value was set at 10 U/ml, the positive rate for urinary NMP22 in bladder cancer was 37.8% (17 out of 45), whereas that in post-treatment cases and benign diseases was 30.8% (8 out of 26) compared to 14.3% (3 out of 21) for healthy volunteers. This cut-off value provided a sensitivity of 37.8% and a specificity of 80.9%. In the bladder cancer group, NMP22 levels were related to tumor size, shape, grade and stage.

CONCLUSIONS

Despite the many reports that suggest NMP22 as a promising urinary marker for monitoring transitional cell carcinoma, this study does not support its usefulness as a substitute tool for urinary cytology in the control of bladder tumors.

Urine cytology. It is still the gold standard for screening?

Urine cytology remains the gold standard for bladder cancer screening. It is the test against which all others are compared when evaluating potential bladder tumor markers. The answer to whether urine cytology possess the optimal combination of sensitivity and specificity to retain consideration as the best screening device depends on the goals of the clinical practice. Urine cytology has excellent specificity with few false-positive cases. Its overall sensitivity is poor, but this drawback is explained for the most part by poor criteria for identifying well-differentiated, low-grade TCC. The natural history of such lesions is the occurrence of multiple superficial recurrences in 70% to 80% of patients, with only a minority (10% to 15%) progressing to muscle invasive or metastatic disease. Because patients with low-grade TCC are at low risk for progression, they are monitored primarily for the development of a subsequent tumor. One might argue that the detection of new low-grade lesions is of secondary importance to the early detection of disease progression. The performance characteristics of urine cytology in this regard are much improved. Urine cytology often results in the identification of high-grade malignant cells even before a cystoscopically distinguishable gross lesion is present. Routinely diagnosing grade I TCC may be clinically irrelevant. Ancillary techniques to improve the sensitivity of urine cytology have been insufficiently additive to have much clinical value. Several promising bladder tumor markers have been investigated as potential screening tools and are summarized in Table 3. BTA, nuclear matrix proteins, and fibrin/fibrinogen degradation products share lower specificities than urine cytology and may have high rates of false positivity. Telomerase is highly sensitive and highly specific but is not readily available as a point-of-service test. Hyaluronidase and hyaluronic acid are promising prognostic markers, but hyaluronidase does not detect grade I TCC. Early results from studies of this marker await verification. Combining some of these new markers may optimize their performance status, allowing the advantages of one test to correct the shortcomings of another. Likewise, their combination with urine cytology may prove beneficial. Although adding urine cytology has not increased the sensitivity of some point-of-service tests, few studies have addressed the effect on specificity. Until an obvious winner is declared in the race to find a bladder tumor marker, urine cytology will remain the gold standard screening method because of its comfortable familiarity.

Urinary NMP22 and renal cell carcinoma

OBJECTIVES

To demonstrate the incidence of positive urinary nuclear matrix protein 22 (NMP22) values associated with renal cell carcinoma (RCC) of the kidney. Currently, urinary NMP22 is used to detect recurrent transitional cell carcinoma of the bladder.

METHODS

From May 1997 to March 1998, urinary NMP22 values were obtained from 65 patients who had undergone either computed tomography scanning of the abdomen or renal ultrasound. Of the 65, 32 presented with solid renal masses. These patients underwent radical or partial nephrectomy; subsequent pathologic examination revealed that 30 had RCC. Two patients had oncocytomas. The remaining 33 patients presented with blunt abdominal trauma or abdominal pain or for follow-up for a urologic problem (a kidney stone or benign renal cyst). These patients had no evidence of renal malignancy on imaging and were used as controls.

RESULTS

The urinary NMP22 values of patients with RCC were significantly higher than the values found in the control group (13.69 +/- 8.40 U/mL versus 3.03 +/- 2.70 U/mL, P <0.0078). Of the 30 patients with RCC, 12 (40%) had positive urinary NMP22 values of 10 U/mL or above. Chi-square analysis revealed a significant difference between the NMP22 values of the two groups (P <0.005). There were two false-positive NMP22 values in the 35 control patients.

CONCLUSIONS

Urinary NMP22 values used to detect transitional cell carcinoma in individuals with previously diagnosed bladder cancer should be more broadly evaluated, since elevations have also been found to occur in RCC of the kidney. This finding may result in an increase in the incidental discovery of RCC. Future, more specific, NMP assays may hold promise for the detection of RCC.

Comparison of the monoclonal UBC-ELISA test and the NMP22 ELISA test for the detection of urothelial cell carcinoma of the bladder

OBJECTIVES

To compare the diagnostic value of two enzyme-linked immunosorbent assay (ELISA) tests, the nuclear matrix protein 22 (NMP22) test and a newly developed urinary bladder cancer (UBC) test, in patients having symptoms suggestive of urothelial cell carcinoma (UCC) and patients under follow-up after transurethral resection (TUR).

METHODS

Two hundred forty patients with a mean age of 65.8 years (range 22 to 92) were included in this retrospective study. The tests were performed on previously frozen urine samples. Eighty-one patients had symptoms suggestive of bladder cancer and 159 patients were being followed up after complete TUR of UCC. Voided urine was evaluated by the NMP22 test and the monoclonal UBC-ELISA test, which traces cytokeratins 8 and 18. All patients underwent subsequent cystoscopy and biopsy evaluation of any suspicious lesion. The cutoff levels for bladder cancer positivity were 10 U/mL for the NMP22 test and 12 microg/L for the UBC test.

RESULTS

In the 54 patients with histologically proved UCC, the NMP22 test had a sensitivity of 55.5% and the UBC test a sensitivity of 64.8%. According to the histologic stages, the sensitivity of NMP22 was 51.7% in pTa tumors, 46.1% in pT1, and 70% in pT2 or higher tumors; the sensitivity of UBC was 62.1% in pTa, 53.8% in pT1, and 80% in pT2 or higher tumors. For histologic grades 1 to 3, the sensitivity was 50%, 50%, and 68.7% for NMP22 and 66.6%, 60%, and 68.7% for UBC, respectively. The specificity was 79% and 92% for NMP22 and UBC, respectively.

CONCLUSIONS

The monoclonal UBC-ELISA test is superior to the NMP22 test in both sensitivity and specificity. Nevertheless, neither test can replace cystoscopy.