Guidelines for development of diagnostic markers in bladder cancer

Prominence of urinary biomarkers for bladder cancer in the COVID-19 era: From the commercially available to new prospective candidates

Molecular markers detected in urine may improve our understanding of the evolution of bladder cancer (BCa) and its micro- and macroenvironment. Detection of such markers will identify disease earlier, allow stratification of patients according to risk, and improve prognostication and prediction of outcomes, thereby facilitating targeted therapy. However, current guidelines have yet to embrace such markers for routine management of BCa, and most research studies have focused on urine-based tumor markers. In this review, we summarize known urinary biomarkers for BCa and highlight newly identified molecules. We then discuss the challenges that must be overcome to incorporate these markers into clinical care.

Plasma miRNA profile is a biomarker associated with urothelial carcinoma in chronic hemodialysis patients

The incidence of urothelial carcinoma (UC) is higher in patients undergoing chronic dialysis than in the general population. This study investigated plasma miRNA profiling as the ancillary diagnosis biomarker associated with UC in patients undergoing chronic hemodialysis. We successfully screened out and detected miRNA expression from plasma in eight patients undergoing dialysis through quantitative real-time PCR array analysis and identified eight candidate miRNAs. The candidate miRNAs were then validated using single quantitative RT-PCR assays from 52 plasma samples. The miRNA classifier for ancillary UC detection was developed by multiple logistic regression analyses. Moreover, we validated the classifier by testing another nine samples. Expression levels of miR-150-5p, miR-150-5p/miR-155-5p, miR-378a-3p/miR-150-5p, miR-636/miR-150-5p, miR-150-5p/miR-210-3p, and miR-19b-1-5p/miR-378a-3p were shown to be significantly different between UC and non-UC samples (P = 0.035, 0.0048, 0.016, 0.024, 0.038, and 0.048). Kaplan-Meier curve analysis also showed that low miR-19b-1-5p expression was associated with a worse prognosis (P = 0.0382). We also developed a miRNA classifier based on five miRNA expression levels to predict UC and found that the area under curve was 0.882. The classifier had a sensitivity of 80% (95% confidence interval: 0.5191% to 0.9567%) and a specificity of 83.7% (95% confidence interval: 0.6799% to 0.9381%). This classifier was tested by nine samples with 100% accuracy. The miRNA classifier offers higher sensitivity and specificity than the existing makers. Thus, this approach will improve the prospective diagnosis of UC in patients undergoing chronic hemodialysis.

A two-gene methylation signature for the diagnosis of bladder cancer in urine

AIM

To analyze the potential of 14 cancer-associated genes, including six miRNAs, for bladder cancer (BC) diagnosis in urine.

PATIENTS & METHODS

DNA methylation levels of 14 genes were analyzed in urine of 72 BC patients and 75 healthy controls using quantitative methylation-specific PCR. Multivariate logistic regression analysis was used to determine an optimal marker panel.

RESULTS

Ten genes were significantly hypermethylated in BC patients. The GHSR/MAL combination showed the best diagnostic performance, reaching a sensitivity of 92% (95% CI: 86-99) and a specificity of 85% (95% CI: 76-94).

CONCLUSION

We identified a novel two-gene panel with a high diagnostic accuracy for BC that can be applied in a noninvasive, urine-based test.

Urinary Protein Markers for the Detection and Prognostication of Urothelial Carcinoma

Bladder cancer diagnosis and surveillance is mainly based on cystoscopy and urine cytology. However, both methods have significant limitations; urine cytology has a low sensitivity for low-grade tumors, while cystoscopy is uncomfortable for the patients. Therefore, in the last decade urine analysis was the subject of intensive research resulting in the identification of many potential biomarkers for the detection, surveillance, or prognostic stratification of bladder cancer. Current trends move toward the development of multiparametric models to improve the diagnostic accuracy compared with single molecular markers. Recent technical advances for high-throughput and more sensitive measurements have led to the development of multiplex assays showing potential for more efficient tools toward future clinical application. In this review, we focus on the findings of urinary protein research in the context of detection and prognostication of bladder cancer. Furthermore, we provide an up-to-date overview on the recommendations for the quality evaluation of published studies as well as for the conduction of future urinary biomarker studies.

Combined use of urinary Survivin detection and liquid-based cytology for the early diagnosis of bladder urothelial carcinoma

To assess the possibility of combined using urine Survivin and liquid-based cytology (LBC) tests to improve the diagnosis of bladder urothelial carcinoma (BUC), the present study analyzed urine from 36 patients with bladder cancer and 36 benign cases as control individuals. The Survivin content in the patient's morning urine was assessed by ELISA. When the sample value exceeded double of the average of the control group, it was defined as positive and the patient was diagnosed as bladder cancer. Meanwhile, LBC was performed for the same sample. Urinary Survivin detection combined with LBC test showed a sensitivity of 91.7%, a specificity of 91.7% and accuracy of 91.7% for the diagnosis of BUC. Compared with each test individually, although the specificity decreased, the sensitivity and accuracy of the combined detection improved significantly (P<0.05). The data presented in the current study identified that the LBC test is a novel diagnostic method for urinary tract tumors and its detection rate was superior to the conventional urine cytology test. Additionally, Survivin detection combined with LBC could significantly improve the detection rate of BUC. In addition, this method is non-invasive, economical, simple and precise.

Meta-analysis of a 10-plex urine-based biomarker assay for the detection of bladder cancer

A 10-plex urine-based bladder cancer (BCa) diagnostic signature has the potential to non-invasively predict the presence of BCa in at-risk patients, as reported in various case-control studies. The present meta-analysis was performed to re-evaluate and demonstrate the robustness and consistency of the diagnostic utility of the 10-plex urine-based diagnostic assay. We re-analyzed primary data collected in five previously published case-control studies on the 10-plex diagnostic assay. Studies reported the sensitivity and specificity of ten urinary protein biomarkers for the detection of BCa, including interleukin 8, matrix metalloproteinases 9 and 10, angiogenin, apolipoprotein E, syndecan 1, alpha-1 antitrypsin, plasminogen activator inhibitor-1, carbonic anhydrase 9, and vascular endothelial growth factor A. Data were extracted and reviewed independently by two investigators. Log odds ratios (ORs) were calculated to determine how strongly the 10-plex biomarker panel and individual biomarkers are associated with the presence of BCa. Data pooled from 1,173 patients were analyzed. The log OR for each biomarker was improved by 1.5 or greater with smaller 95% CI in our meta-analysis of the overall cohort compared with each analysis of an individual cohort. The combination of the ten biomarkers showed a higher log OR (log OR: 3.46, 95% CI: 2.60–4.31) than did any single biomarker irrespective of histological grade or disease stage of tumors. We concluded that the 10-plex BCa-associated diagnostic signature demonstrated a higher potential to identify BCa when compared to any single biomarker. Our results justify further advancement of the 10-plex protein-based diagnostic signature toward clinical application.

Review of the Clinical Approaches to the Use of Urine-based Tumor Markers in Bladder Cancer

Bladder cancer is a common disease with a stable incidence for the past few decades despite advancements in molecular and genetic determinants of cancer development and progression. Cystoscopy remains the standard for detection and surveillance of bladder cancer, but it is an invasive and potentially costly procedure. With the knowledge of molecular alterations associated with bladder cancer numerous urine-based tumor markers have become commercially available. These urine markers have been evaluated in all clinical scenarios for the detection of bladder cancer including screening, hematuria, atypical cytology evaluation, and surveillance, but given the relative lack of impactful trials they are not routinely utilized. The efforts to develop markers with increased sensitivity to replace cystoscopy for the detection of bladder cancer have thus far been unsuccessful as well. This review addresses role of urine markers for screening, detection, and surveillance of bladder cancer.

Inhibition of long non-coding RNA UCA1 by CRISPR/Cas9 attenuated malignant phenotypes of bladder cancer

CRISPR/Cas9 is a novel and effective genome editing technique, but its application is not widely expanded to manipulate long non-coding RNA (lncRNA) expression. The lncRNA urothelial carcinoma-associated 1 (UCA1) is upregulated in bladder cancer and promotes the progression of bladder cancer. Here, we design gRNAs specific to UCA1 and construct CRISPR/Cas9 systems targeting UCA1. Single CRISPR/Cas9-UCA1 can effectively inhibit UCA1 expression when transfected into 5637 and T24 bladder cancer cells, while the combined transfection of the two most effective CRISPR/Cas9-UCA1s can generate more satisfied inhibitory effect. CRISPR/Cas9-UCA1s attenuate UCA1 expression via targeted genome-specific DNA cleavage, resulting in the significant inhibition of cell proliferation, migration and invasion in vitro and in vivo. The mechanisms associated with the inhibitory effect of CRISPR/Cas9-UCA1 on malignant phenotypes of bladder cancer are attributed to the induction of cell cycle arrest at G1 phase, a substantial increase of apoptosis, and an enhanced activity of MMPs. Additionally, urinary UCA1 can be used as a non-invasive diagnostic marker for bladder cancer as revealed by a meta-analysis. Collectively, our data suggest that CRISPR/Cas9 technique can be used to down-modulate lncRNA expression, and urinary UCA1 may be used as a non-invasive marker for diagnosis of bladder cancer.

Improving diagnostic molecular tests to monitor urothelial carcinoma recurrence

INTRODUCTION

The high recurrence rates associated with non-muscle invasive bladder cancer require close surveillance with cystoscopy, an invasive and expensive procedure with risk of missing cancer. Finding an accurate urinary biomarker that can detect recurrent disease would represent a significant advancement in management. Areas covered: This review summarizes the commercially-available urinary biomarkers including cytology, UroVysion, BTA, NMP22, uCyt+, and Cxbladder assays. Additionally, we review recent investigational urinary biomarkers that hold promise in bladder cancer surveillance. Expert commentary: The quest for a reliable urinary biomarker for bladder cancer is decades-old and seems intuitive given the direct contact of urine with malignant urothelium. Beyond urine cytology, there are many commercially-available products approved for surveillance. However, none of the assays are routinely used due to lack of sensitivity and/or specificity. As such, emerging technologies, in particular the '-omic' technologies have resulted in a proliferation of promising reports on novel biomarkers in recent literature.

Multiplatform Biomarker Discovery for Bladder Cancer Recurrence Diagnosis

Purpose. Nonmuscle invasive bladder cancer (BCa) has a high recurrence rate requiring lifelong surveillance. Urinary biomarkers are promising as simple alternatives to cystoscopy for the diagnosis of recurrent bladder cancer. However, no single marker can achieve the required accuracy. The purpose of this study was to select a multiparameter panel, comprising urinary biomarkers and clinical parameters, for BCa recurrence diagnosis. Experimental Design. Candidate biomarkers were measured in urine samples of BCa patients with recurrence and BCa patients without recurrence. A multiplatform strategy was used for marker quantification comprising a multiplexed microarray and an automated platform for ELISA analysis. A multivariate statistical analysis combined the results from both platforms with the collected clinical data. Results. The best performing combination of biomarkers and clinical parameters achieved an AUC value of 0.91, showing better performance than individual parameters. This panel comprises six biomarkers (cadherin-1, IL-8, ErbB2, IL-6, EN2, and VEGF-A) and three clinical parameters (number of past recurrences, number of BCG therapies, and stage at time of diagnosis). Conclusions. The multiparameter panel could be a useful noninvasive tool for BCa surveillance and potentially impact the clinical management of this disease. Validation of results in an independent cohort is warranted.

Assessment of the extent of unpublished studies in prognostic factor research: a systematic review of p53 immunohistochemistry in bladder cancer as an example

OBJECTIVES

When study groups fail to publish their results, a subsequent systematic review may come to incorrect conclusions when combining information only from published studies. p53 expression measured by immunohistochemistry is a potential prognostic factor in bladder cancer. Although numerous studies have been conducted, its role is still under debate. The assumption that unpublished studies too harbour evidence on this research topic leads to the question about the attributable effect when adding this information and comparing it with published data. Thus, the aim was to identify published and unpublished studies and to explore their differences potentially affecting the conclusion on its function as a prognostic biomarker.

DESIGN

Systematic review of published and unpublished studies assessing p53 in bladder cancer in Germany between 1993 and 2007.

RESULTS

The systematic search revealed 16 studies of which 11 (69%) have been published and 5 (31%) have not. Key reason for not publishing the results was a loss of interest of the investigators. There were no obviously larger differences between published and unpublished studies. However, a meaningful meta-analysis was not possible mainly due to the poor (ie, incomplete) reporting of study results.

CONCLUSIONS

Within this well-defined population of studies, we could provide empirical evidence for the failure of study groups to publish their results that was mainly caused by loss of interest. This fact may be coresponsible for the role of p53 as a prognostic factor still being unclear. We consider p53 and the restriction to studies in Germany as a specific example, but the critical issues are probably similar for other prognostic factors and other countries.

Elevated levels of the complement activation product C4d in bronchial fluids for the diagnosis of lung cancer

Molecular markers in bronchial fluids may contribute to the diagnosis of lung cancer. We previously observed a significant increase of C4d-containing complement degradation fragments in bronchoalveolar lavage (BAL) supernatants from lung cancer patients in a cohort of 50 cases and 22 controls (CUN cohort). The present study was designed to determine the diagnostic performance of these complement fragments (hereinafter jointly referred as C4d) in bronchial fluids. C4d levels were determined in BAL supernatants from two independent cohorts: the CU cohort (25 cases and 26 controls) and the HUVR cohort (60 cases and 98 controls). A series of spontaneous sputum samples from 68 patients with lung cancer and 10 controls was also used (LCCCIO cohort). Total protein content, complement C4, complement C5a, and CYFRA 21-1 were also measured in all cohorts. C4d levels were significantly increased in BAL samples from lung cancer patients. The area under the ROC curve was 0.82 (95%CI = 0.71-0.94) and 0.67 (95%CI = 0.58-0.76) for the CU and HUVR cohorts, respectively. In addition, unlike the other markers, C4d levels in BAL samples were highly consistent across the CUN, CU and HUVR cohorts. Interestingly, C4d test markedly increased the sensitivity of bronchoscopy in the two cohorts in which cytological data were available (CUN and HUVR cohorts). Finally, in the LCCCIO cohort, C4d levels were higher in sputum supernatants from patients with lung cancer (area under the ROC curve: 0.7; 95%CI = 0.56-0.83). In conclusion, C4d is consistently elevated in bronchial fluids from lung cancer patients and may be used to improve the diagnosis of the disease.

Molecular markers for bladder cancer screening, early diagnosis, and surveillance: the WHO/ICUD consensus

Due to the lack of disease-specific symptoms, diagnosis and follow-up of bladder cancer has remained a challenge to the urologic community. Cystoscopy, commonly accepted as a gold standard for the detection of bladder cancer, is invasive and relatively expensive, while urine cytology is of limited value specifically in low-grade disease. Over the last decades, numerous molecular assays for the diagnosis of urothelial cancer have been developed and investigated with regard to their clinical use. However, although all of these assays have been shown to have superior sensitivity as compared to urine cytology, none of them has been included in clinical guidelines. The key reason for this situation is that none of the assays has been included into clinical decision-making so far. We reviewed the current status and performance of modern molecular urine tests following systematic analysis of the value and limitations of commercially available assays. Despite considerable advances in recent years, the authors feel that at this stage the added value of molecular markers for the diagnosis of urothelial tumors has not yet been identified. Current data suggest that some of these markers may have the potential to play a role in screening and surveillance of bladder cancer. Well-designed protocols and prospective, controlled trials will be needed to provide the basis to determine whether integration of molecular markers into clinical decision-making will be of value in the future.

Assessing the quality of studies on the diagnostic accuracy of tumor markers

OBJECTIVES

With rapidly increasing numbers of publications, assessments of study quality, reporting quality, and classification of studies according to their level of evidence or developmental stage have become key issues in weighing the relevance of new information reported. Diagnostic marker studies are often criticized for yielding highly discrepant and even controversial results. Much of this discrepancy has been attributed to differences in study quality. So far, numerous tools for measuring study quality have been developed, but few of them have been used for systematic reviews and meta-analysis. This is owing to the fact that most tools are complicated and time consuming, suffer from poor reproducibility, and do not permit quantitative scoring.

METHODS

The International Bladder Cancer Network (IBCN) has adopted this problem and has systematically identified the more commonly used tools developed since 2000.

RESULTS

In this review, those tools addressing study quality (Quality Assessment of Studies of Diagnostic Accuracy and Newcastle-Ottawa Scale), reporting quality (Standards for Reporting of Diagnostic Accuracy), and developmental stage (IBCN phases) of studies on diagnostic markers in bladder cancer are introduced and critically analyzed. Based upon this, the IBCN has launched an initiative to assess and validate existing tools with emphasis on diagnostic bladder cancer studies.

CONCLUSIONS

The development of simple and reproducible tools for quality assessment of diagnostic marker studies permitting quantitative scoring is suggested.

Appraisal of diagnostic ability of UCA1 as a biomarker of carcinoma of the urinary bladder

Initial diagnosis of carcinoma of the urinary bladder remains to be a challenge. Urine cytology, as an adjunct to cystoscopy, is less sensitive for low-grade tumors. Urothelial cancer associated 1 (UCA1) is a novel non-coding RNA gene, which plays a pivotal role in bladder cancer progression. Our aim is to investigate the significance of urinary UCA1 for the non-invasive diagnosis of transitional cell carcinoma (TCC) of the urinary bladder. We examined UCA1 expression in a bladder cancer cell line (T24) and in urine of 28 healthy individuals, 46 patients of non-malignant disorders, and 117 cases (69 primary and 48 recurrent cases) of histologically proven TCC prior to transurethral resection by using real-time PCR and compared it with voided urinary cytology. UCA1 expression was found in T24 cell line and also found to be significantly higher in the cancer group as compared to the controls (p<0.001). UCA1 messenger RNA (mRNA) expression showed a significant (p<0.05) association with stage and grade (p<0.05). UCA1 showed a sensitivity of 79.49% and a specificity of 79.73% (p<0.001), whereas urine cytology had a sensitivity of 66.67% and a specificity of 95.95% for TCC cases. Higher expression of UCA1 was associated with high grade (G2-G3, sensitivity=84.09%) (p<0.001). UCA1 mRNA expression did not significantly correlate with the patient's age, sex, and smoking habit (p>0.05). UCA1 can be used as a non-invasive diagnostic biomarker for TCC bladder as an adjunct to cytology in the early diagnosis of primary urinary bladder cancer.

Evaluation of urinary XIAP as a diagnostic biomarker of carcinoma of urinary bladder

Early diagnosis of carcinoma of the bladder remains a challenge. Urine cytology, as an adjunct to cystoscopy, is less sensitive for low-grade tumors. X-linked inhibitor of apoptosis (XIAP), a negative regulator of apoptotic stimuli and a member of apoptosis family, is frequently activated in bladder carcinoma. Our aim is to investigate the significance of urinary XIAP for the noninvasive diagnosis of transitional cell carcinoma (TCC) of the urinary bladder. We examined urinary XIAP expression in a bladder cancer cell line (T24) and in urine of 28 healthy individuals, 46 patients of nonmalignant disorders, and 117 cases (69 primary and 48 recurrent cases) of histologically proven TCC prior to transurethral resection, by using real-time PCR, and compared it with voided urinary cytology (VUC). XIAP expression was found in T24 cell line and also was found to be significantly higher in the cancer group as compared to the controls (p < 0.001). XIAP messenger RNA (mRNA) expression showed a significant (p < 0.05) association with stage and grade (p < 0.05). XIAP shows the sensitivity of 82.91 % and specificity of 78.38 % (p < 0.001), whereas urine cytology had sensitivity of 66.67 % and specificity of 95.95 % for TCC cases. The combination of XIAP and VUC had better sensitivity (98.2 %) and specificity (92.6 %) than they showed individually (p < 0.001). XIAP mRNA expression did not significantly correlated with the patient's age, sex, and smoking (p > 0.05). Urinary XIAP can be used as a noninvasive diagnostic biomarker for bladder TCC in adjunct to cytology mainly for low-grade non-muscle-invasive tumors.

Clinical utility of urinary soluble Fas in screening for bladder cancer

AIM

Early diagnosis of carcinoma of urinary bladder remains a challenge. Urine cytology, as an adjunct to cystoscopy, is less sensitive for low-grade tumors. Soluble Fas (sFas), a cell-surface receptor and member of the tumor necrosis factor superfamily, is frequently expressed in urinary bladder carcinoma. The objective of this study was to investigate the urinary sFas for diagnosis of transitional cell carcinoma (TCC) of urinary bladder.

METHODS

We examined urinary sFas concentration in 74 controls and 117 cases of TCC, both primary and recurrent disease, by using enzyme-linked immunosorbent assay and compared it with urinary cytology.

RESULT

Urinary sFas concentration was found to be significantly higher in the patient as compared to control group (P < 0.05). An optimal cutoff value of 174.0 pg/mL was proposed. The urinary sFas level was found to have an approximate sensitivity and specificity of 88.03% and 89.19% (P < 0.001), whereas urine cytology had sensitivity of 66.67% and specificity of 95.95%. sFas had better sensitivity in higher grade and both primary and recurrent cases of urinary bladder cancer in comparison with cytology. Out of 15 node positive bladder cancer cases, 13 had high urinary sFas levels, whereas 12 were urinary cytology positive for malignancy.

CONCLUSION

Urinary sFas can be used as a non-invasive diagnostic biomarker for TCC of urinary bladder, both for primary and recurrent disease.

[Clinical use of the ImmunoCyt/uCyt+ and fluorescence in situ hybridisation (FISH) tests for urothelial carcinomas]

In recent decades years, we have witnessed the propagation and marketing of numerous diagnostic tests capable of detecting, in the urine of patients, the presence of urothelial tumor markers. Among None of the different markers studied to date , no one has been able to meet all the requirements of the ideal marker. We present and discuss below we discuss the results reported in the literature of about two tests approved by the Food and Drug Administration [ImmunoCyt/uCyt+ and Fluorescence In Situ Hybridisation (FISH)], which have been and commercially available for about 10 years., ImmunoCyt/uCyt + and Fluorescence In Situ Hybridisation (FISH).

Statistical consideration for clinical biomarker research in bladder cancer

OBJECTIVE

To critically review and illustrate current methodological and statistical considerations for bladder cancer biomarker discovery and evaluation.

METHODS

Original, review, and methodological articles, and editorials were reviewed and summarized.

RESULTS

Biomarkers may be useful at multiple stages of bladder cancer management: early detection, diagnosis, staging, prognosis, and treatment; however, few novel biomarkers are currently used in clinical practice. The reasons for this disjunction are many and reflect the long and difficult pathway from candidate biomarker discovery to clinical assay, and the lack of coherent and comprehensive processes (pipelines) for biomarker development. Conceptually, the development of new biomarkers should be a process that is similar to therapeutic drug evaluation-a highly regulated process with carefully regulated phases from discovery to human applications. In a further effort to address the pervasive problem of inadequacies in the design, analysis, and reporting of biomarker prognostic studies, a set of reporting recommendations are discussed. For example, biomarkers should provide unique information that adds to known clinical and pathologic information. Conventional multivariable analyses are not sufficient to demonstrate improved prediction of outcomes. Predictive models, including or excluding any new putative biomarker, need to show clinically significant improvement of performance in order to claim any real benefit. Towards this end, proper model building, avoidance of overfitting, and external validation are crucial. In addition, it is important to choose appropriate performance measures dependent on outcome and prediction type and to avoid the use of cutpoints. Biomarkers providing a continuous score provide potentially more useful information than cutpoints since risk fits a continuum model. Combination of complementary and independent biomarkers is likely to better capture the biological potential of a tumor than any single biomarker. Finally, methods that incorporate clinical consequences such as decision curve analysis are crucial to the evaluation of biomarkers.

CONCLUSIONS

Attention to sound design and statistical practice should be delivered as early as possible and will help maximize the promise of biomarkers for patient care. Studies should include a measure of predictive accuracy and clinical decision-analysis. External validation using data from an independent cohort provides the strongest evidence that a model is valid. There is a need for adequately assessed clinical biomarkers in bladder cancer.

Considerations on implementing diagnostic markers into clinical decision making in bladder cancer

Bladder cancer is a common disease that is often detected late and has a high rate of recurrence and progression. Cystoscopy is the main tool in detection and surveillance of bladder cancer but is invasive and can miss some cancers. Cytology is frequently utilized but suffers from a poor sensitivity. There are several commercially available urine-based tumor markers currently available but their use is not recommended by guideline panels. Markers such as the Urovysion FISH assay and the NMP22 BladderChek test are approved for surveillance and detection in patients with hematuria. The added benefit of these markers and other commercially available markers (e.g. Ucyt+, BTA stat) has not been well investigated though it appears these markers are insufficiently sensitive to replace cystoscopy. Additional studies are needed to determine the clinical scenarios where bladder markers are best utilized (screening, surveillance, early detection, evaluating cytologic atypia) and what impact they should have on clinical decision making. Furthermore, a variety of issues and barriers can affect the movement of clinical tests from research to clinical practice. This article addresses some of the challenges facing research and medical communities in the delivery and integration of markers for bladder cancer diagnosis. Moreover, we attempt to outline criteria for the clinical utility of new bladder cancer diagnostic markers.

New concepts of biobanks--strategic chance for uro-oncology

Cancer, as well as other common diseases, is a complex condition that not only causes a major threat to human health, but also represents a huge burden to society in terms of healthcare cost and loss of economic productivity. Treatment improvements remain elusive, since the causes of cancer are due to a huge number of small and possibly additive effects arising from genetic susceptibility, lifestyle, and environmental conditions. Thus, progress in translational cancer research investigating these changes and their complex interaction is highly dependent on large series of cases (affected and unaffected individuals) including high quality samples and their associated data. Therefore, large and well-organized biobanks have been established, are underway, or are planned in many countries and institutions. The integration of these resources with powerful molecular and "omics" approaches, integrated bioinformatic tools hold the promise to further advance our knowledge of disease development, thus leading to better prevention and treatment strategies. However, these valuable and irreplaceable collections typically suffer from underutilization, due to fragmentation of the collections and their accessibility, lack of common management strategies, including consensus on standard operating procedures, unique policies of utilization, and distribution as well as missing input on a broad basis reflecting research needs on an interdisciplinary, multi-institutional fashion beyond project-driven interest. The uro-oncologic community has not yet contributed to these efforts to its full potential, and broad knowledge on the contemporary developments in the field of biobanking and input into these efforts are still missing. This review presents an overview on biobanking and may serve as an update to be integrated into future discussions on managing biobanks involving uro-oncology. It is based on the discussions at the last meeting of the International Bladder Cancer Network in Barcelona (Spain) in fall 2008 and has been also largely influenced by the works and discussions of the Marble Arch International Working Group on Biobanking for Biomedical Research.

Diagnosis of urothelial carcinoma from urine

Urine cytology is the most widely used noninvasive test to detect urothelial tumors. However, it is limited by its low sensitivity. On the other hand, cystoscopy is the gold standard procedure to follow patients with a history of bladder cancer but this test is invasive and costly. Therefore, there is a real need to develop new tests that can be used in bladder cancer surveillance. Several soluble and cell-based markers have been developed and most of them improve the sensitivity of cytology but the specificity is invariably decreased. Of the cell-based tests, two obtained Food and Drug Administration approval. ImmunoCyt/uCyt is a fluorescent test that uses three monoclonal antibodies and UroVysion is an in situ hybridization test, which uses four different probes to different chromosomes. Both tests have a high sensitivity to detect cancer cells and can help to predict urothelial cancer recurrence. ImmunoCyt/uCyt is somewhat better at detecting low-grade tumors but UroVysion is not affected by prior BCG treatment. However, both tests use fluorescent dyes, are time-consuming and require trained personnel. Because of their high negative predictive value, both tests may help the urologist to postpone a number of cystoscopies, especially in patients with low-risk urothelial cancer.

[Diagnostic procedures in upper urinary tract urothelial carcinoma]

Upper urinary tract transitional cell carcinomas represent 5-6% of all urothelial carcinomas. Macroscopic hematuria is the most common symptom. The diagnostic algorithm contains medical history, clinical investigation, cystoscopy, urinary cytology, ultrasound and intravenous urography. When suspected, a complementary retrograde pyeloureterography with collecting selective urinary cytology is conducted. When radiological findings are doubted or when conservative treatment is planned, an ureterorenoscopy for biopsy of the suspected area is indicated. Computed tomography and magnetic resonance tomography is used to define the local extension of invasive tumors and to detect metastases. The use of urinary markers in the diagnosis of upper urinary tract urothelial carcinoma has to be evaluated in prospective trials.