Photodynamic diagnosis in urology: state-of-the-art. Eur Urol. 2008;53:1138-1148. [PMID: 18096307 DOI: 10.1016/j.eururo.2007.11.048]

Pilot study for bladder cancer detection with volatile organic compounds using ion mobility spectrometry: a novel urine-based approach

PURPOSE

Despite many efforts, no reliable urinary marker system has so far shown the potential to substitute cystoscopy. Measuring volatile organic compounds (VOCs) from urine is a promising alternative. VOCs are metabolic products which can be measured from the headspace of urine samples. Previous studies confirmed that the urine of bladder tumor patients has a different VOC profile than healthy controls. In this pilot study, the feasibility of discriminating VOCs from urine of bladder cancer patients from that of healthy control subjects was investigated. Aim of this study was to investigate whether VOC-based diagnosis of bladder cancer from urine samples is feasible using multicapillary column ion mobility spectrometry (MCC/IMS) and to identify potential molecular correlates to the relevant analytes.

METHODS

Headspace measurements of urine samples of 30 patients with confirmed transitional cell carcinoma (TCC) and 30 healthy controls were performed using MCC/IMS. In the results of the measurements, peaks showing significant differences between both groups were identified and implemented into a decision tree with respect to achieve group separation. Molecular correlates were predicted using a pre-defined dataset.

RESULTS

Eight peaks with significantly differing intensity were identified, 5 of which were highly significant. Using a six-step decision tree, MCC/IMS showed a sensitivity of 90% and specificity of 100% in group separation.

CONCLUSION

VOC-based detection of bladder cancer is feasible. MCC/IMS is a suitable method for urine-based diagnosis and should be further validated. The molecular characteristics and metabolic background of the analytes require further workup.

Clinical Trial Protocol for "Replace Cysto": Replacing Invasive Cystoscopy with Urine Testing for Non-muscle-invasive Bladder Cancer Surveillance-A Multicenter, Randomized, Phase 2 Healthcare Delivery Trial Comparing Quality of Life During Cancer Surveillance with Xpert Bladder Cancer Monitor or Bladder EpiCheck Urine Testing Versus Frequent Cystoscopy

"Replace Cysto" is a multisite randomized phase 2 trial including 240 participants with low-grade intermediate-risk non-muscle-invasive bladder cancer, in which participants will be randomized 1:1:1 to one of two urine marker-based approaches alternating a urine marker test (Xpert Bladder Cancer Monitor or Bladder EpiCheck) with cystoscopy or to frequent scheduled cystoscopy. The primary objective is to determine whether urinary quality of life after surveillance is significantly improved in the urine marker arms. The primary outcome will be the patient-reported urinary quality of life domain score of the validated QLQ-NMIBC24 instrument, measured 1-3 d after surveillance. Exploratory outcomes include discomfort after surveillance, the number of invasive procedures that participants undergo per 1000 person years, complications from these procedures per 1000 person years, nonurinary quality of life, acceptability of surveillance, and bladder cancer recurrence and progression. Comparators include surveillance using (1) the Xpert Bladder Cancer Monitor test, (2) the Bladder EpiCheck urinary marker, or (3) frequent cystoscopy alone. After a negative cystoscopy ≤4 mo following bladder tumor resection, all the participants will undergo surveillance at 6, 12, 18, and 24 mo (with time zero defined as the date of the most recent bladder tumor resection). In the urine marker arms, surveillance at 6 and 18 mo will be performed with the marker. Regardless of the arm, participants will undergo cystoscopy at 12 and 24 mo. End of study for each participant will be their 24-mo cystoscopy. Overall trial duration is estimated at 5 yr from when the study opens to enrollment until completion of data analyses. The trial is registered at clinicaltrials.gov (NCT05796375).

Five historical innovations that have shaped modern urological surgery

Throughout history, many innovations have contributed to the development of modern urological surgery, improving patient outcomes and expanding the range of treatment options available to patients. This article explores five key historical innovations that have shaped modern urological surgery: External shockwave lithotripsy, transurethral resection of prostate, cystoscope, perioperative prostate-specific antigen and robotic surgery. The selection of innovations for inclusion in this article was meticulously determined through expert consensus and an extensive literature review. We will review the development, impact and significance of each innovation, highlighting their contributions to the field of urological surgery and their ongoing relevance in contemporary and perioperative practice.

Bladder cancer: therapeutic challenges and role of 3D cell culture systems in the screening of novel cancer therapeutics

Bladder cancer (BC) is the sixth most common worldwide urologic malignancy associated with elevated morbidity and mortality rates if not well treated. The muscle-invasive form of BC develops in about 25% of patients. Moreover, according to estimates, 50% of patients with invasive BC experience fatal metastatic relapses. Currently, resistance to drug-based therapy is the major tumble to BC treatment. The three-dimensional (3D) cell cultures are clearly more relevant not only as a novel evolving gadget in drug screening but also as a bearable therapeutic for different diseases. In this review, various subtypes of BC and mechanisms of drug resistance to the commonly used anticancer therapies are discussed. We also summarize the key lineaments of the latest cell-based assays utilizing 3D cell culture systems and their impact on understanding the pathophysiology of BC. Such knowledge could ultimately help to address the most efficient BC treatment.

Preparation of a Water-Soluble Glycopolymer Bearing Porphyrin Skeletons and Its Biological Properties

A known tetraphenyl porphyrin (TPP) having an amino functional group [5-(4-aminophenyl)-10,15,20-(triphenyl)porphyrin] was converted into the corresponding monomer by means of condensation with acryloyl chloride. Simple radical polymerization of the porphyrin monomer and a glycosyl monomer in the presence of acrylamide as a regulator monomer in order to avoid steric interference gave a water-soluble glycopolymer bearing porphyrin moieties. Spectroscopic analyses suggested incorporation of porphyrin moieties in the glycopolymer. The physical properties of the water-soluble glycopolymer bearing porphyrin moieties were examined in aqueous media, and the results also indicated the incorporation of TPP moieties in the polymer. Uptake of the polymer into HeLa cells was observed, and the cytotoxicity of the polymer was confirmed by microscopic analyses. The glycopolymer bearing porphyrin moieties is promising not only for photodynamic therapy but also as an anti-cancer reagent.

Deep learning based depth map estimation of protoporphyrin IX in turbid media using dual wavelength excitation fluorescence

This study presents a depth map estimation of fluorescent objects in turbid media, such as biological tissue based on fluorescence observation by two-wavelength excitation and deep learning-based processing. A U-Net-based convolutional neural network is adapted for fluorophore depth maps from the ratiometric information of the two-wavelength excitation fluorescence. The proposed method offers depth map estimation from wide-field fluorescence images with rapid processing. The feasibility of the proposed method was demonstrated experimentally by estimating the depth map of protoporphyrin IX, a recognized cancer biomarker, at different depths within an optical phantom.

Ultrasensitive Electrochemiluminescence Immunosensor for Bladder Marker Human Complement Factor H-Related Protein Detection

The development of noninvasive and sensitive detection methods for the early diagnosis and monitoring of bladder cancer is critical but challenging. Herein, an ultrasensitive electrochemiluminescence (ECL) immunosensor that uses Ru(bpy)₃²⁺-metal-organic framework (Ru-MOF) nanospheres and a DNA tetrahedral (TDN) probe was established for bladder cancer marker complement factor H-related protein (CFHR1) detection. The synthesized Ru(bpy)₃²⁺-metal-organic frameworks (Ru-MOFs) served as a linked substrate for immobilization of AuNPs and antibody (Ab₂) to prepare the ECL signal probe (Ru-MOF@AuNPs-Ab₂), exhibiting a stable and strengthened ECL emission. At the same time, the inherent advantages of TDN probes on the electrode as the capture probe (TDN-Ab₁) improve the accessibility of targets to probes. In the presence of CFHR1, the signal probe Ru-MOF@AuNPs-Ab₂ was modified on the electrode through immune binding, thereby obtaining an outstanding ECL signal. As expected, the developed ECL immunosensor exhibited splendid performance for CFHR1 detection in the range of 0.1 fg/mL to 10 pg/mL with a quite low detection limit of 0.069 fg/mL. By using the proposed strategy to detect CFHR1 from urine, it showed acceptable accuracy, which can effectively distinguish between bladder cancer patients and healthy samples. This work contributes to a novel, noninvasive, and accurate method for early clinical diagnosis of bladder cancer.

Optimization of postoperative surveillance protocols in upper tract urothelial cancer: A retrospective cohort study

Upper tract urothelial carcinoma (UTUC) is an aggressive disease that is managed by radical or organ-sparing surgery. High recurrence rates require early detection and strict follow-up (FU) protocols. Recommendations are assigned to a low level of evidence. Our aim was to identify time-to-tumor recurrence, analyze the temporal relation to recommended FU regimens, and provide a critical proposal for further surveillance. This retrospective study included 54 patients receiving radical nephroureterectomy (RNU) in high-risk UTUC and 14 patients assigned to kidney-sparing surgery (KSS) with low-risk disease. FU surveillance protocols consisted of close intervals irrespective of the received type of surgery. In total, 68 patients were included with a median FU of 23 months. Mean overall survival (OS) was significantly shorter in RNU compared to KSS (P = .027). Recurrence in the bladder and/or upper urinary tract (UUT) was 57.1% in KSS and 38.9% after RNU (P = .241). Mean recurrence-free survival (RFS) was significantly shorter in RNU patients compared to KSS (22.4 vs. 47.9 months, P = .013), and 76.2% of the recurrences in the RNU group occurred in the first postoperative year. UUT recurrence was diagnosed after a median of 3.0 (RNU) and 25.0 (KSS) months. There was a frequent onset of metastases in the RNU group, with 85.7% in the first year compared to the KSS group with 50%. Multivariable regression analysis showed that the tumor stage was the parameter independently related to OS (P = .002), RFS (P = .008), and metastasis-free survival (MFS, P = .002). In conclusion, surveillance of UTUC should be adapted to real-time occurrence patterns. Strict imaging protocols are recommended in the first two years irrespective of the method of surgery. As recurrence is equally distributed over the years after KSS, cystoscopy should be offered regularly for five years and diagnostic URS for three years. After RNU, cystoscopies should be decreased to yearly intervals after year three. Contralateral UUT should also be examined after RNU.

5-Aminolevulinic acid-based photodynamic diagnosis for detection of urothelial carcinoma cells in bladder washing sediment suspension: A pilot study

BACKGROUND

Bladder cancer is a common malignant disease in developed countries. Early detection of malignancy is important using urine cytology. The 5-aminolevulinic acid (ALA)-based photodynamic diagnosis (ALA-PDD) has not been routinely applied in urine cytology analysis yet, although it has been well accepted for tumor lesion marking in cystoscopy.

METHODS

A total of eight volunteers were enrolled in this study. The cells of sediment suspension from bladder washing fluid and random urine were stained by ALA-induced protoporphyrin IX (ALA-PpIX) and the fluorescent intensity of ALA-PpIX was analyzed by ImageJ.

RESULTS

The cutoff value of fluorescent intensity was 90.260 per pixel. The proposed protocol provided an objective fluorescent intensity for evaluation. Sensitivity was 0.931 and specificity was 1.000.

CONCLUSIONS

The staining procedure applied was ALA-PpIX for suspicious cells in the cellular suspension from bladder wash fluid and random urine. ImageJ was applied to the objective measurement for the fluorescent intensity of the stained cells. The cutoff value for the positive result was 90.260 per pixel. Therefore, the protocol proposed in this study provides a potential means to enhance accuracy for urine cytology analysis.

[The impact of using intraoperative photodynamic diagnosis on the prognosis of bladder cancer]

BACKGROUND

Photodynamic Diagnosis (PDD) is widely used today for the diagnosis and treatment of superficial bladder cancer. This study aimed to analyse the impact of using this technique on recurrence rate, residual tumour rate and progression-free survival.

MATERIALS AND METHODS

We conducted this study retrospectively in our unit between 10/2014 and 02/2018. We divided our patients into 2 groups: white light group, 49 patients who underwent primary bladder tumour resection with white light transurethral resection of bladder tumour (WL-TURB), and blue light group, 49 patients treated with blue light transurethral resection of bladder tumour (BL-TURB) with PDD. Patients in both groups were followed up for one year. We collected data for tumour recurrence for the first year, 3-month and 1-year relapse-free survival and 1-year progression-free assessment pursuant to the EORTC risk classification by Sylvester 2006. Furthermore, the residual tumour rate was determined by re-TURB.

RESULTS

The following results were found independent of age, gender and histological findings: Residual tumour rate: blue light group 13.95 % vs. white light group 32.6 %, (p 0.02, OR 3.8, CI 95 % [1.17 - 12.85]).; 3-month relapse-free survival: blue light group 87.7 % vs. white light group 67.4 % (p 0.02, HR 3.18, CI 95 % [1.20 - 8.42]); 1-year relapse-free survival: blue light group 77.6 % vs. white light group 55.1 % (p 0.015, HR 2.56, CI 95 % [1.20 - 5.45]); 1-year progression-free survival: blue light group 95.9 % vs. white light group 79.6 %, p 0.03, HR 5.23, CI 95 % [1.11 - 24.53]) CONCLUSION:  The use of hexaminolevulinate significantly reduces the risk of residual tumours compared with conventional TURB. The PDD technique significantly improved 3- and 12-month recurrence-free survival, especially in low and medium-risk tumours, and 1-year progression-free survival, especially in high-risk tumours.

Fluorescence-Based Microendoscopic Sensing System for Minimally Invasive In Vivo Bladder Cancer Diagnosis

Bladder cancer is commonly diagnosed by evaluating the tissue morphology through cystoscopy, and tumor resection is used as the primary treatment approach. However, these methods are limited by lesion site specificity and resection margin, and can thereby fail to detect cancer lesions at early stages. Nevertheless, rapid diagnosis without biopsy may be possible through fluorescence sensing. Herein, we describe a minimally invasive imaging system capable of sensing even small tumors through a 1.2 mm diameter flexible fiber bundle microprobe. We demonstrate that this new device can be used for the early diagnosis of bladder cancer in rats. Bladder cancer was induced in rats using the carcinogen N-butyl-N-(4-hydroxybutyl)nitrosamine (BBN), and a togglable filter capable of PpIX fluorescence sensing was installed in the microendoscopic system. Following 5-aminolevulinic acid administration, tissue in the early stages of bladder cancer was successfully identified with fluorescence detection and confirmed with hematoxylin/eosin and ferrochelatase staining. Although the time required for BBN to induce bladder cancer varied between 3 and 4 weeks among the rats, the microendoscopic system allowed the minimally invasive follow-up on cancer development.

In vivo Raman spectroscopy for bladder cancer detection using a superficial Raman probe compared to a nonsuperficial Raman probe

Raman spectroscopy is promising as a noninvasive tool for cancer diagnosis. A superficial Raman probe might improve the classification of bladder cancer, because information is gained solely from the diseased tissue and irrelevant information from deeper layers is omitted. We compared Raman measurements of a superficial to a nonsuperficial probe, in bladder cancer diagnosis. Two-hundred sixteen Raman measurements and biopsies were taken in vivo from at least one suspicious and one unsuspicious bladder location in 104 patients. A Raman classification model was constructed based on histopathology, using a principal-component fed linear-discriminant-analysis and leave-one-person-out cross-validation. The diagnostic ability measured in area under the receiver operating characteristics curve was 0.95 and 0.80, the sensitivity was 90% and 85% and the specificity was 87% and 88% for the superficial and the nonsuperficial probe, respectively. We found inflammation to be a confounder and additionally we found a gradual transition from benign to low-grade to high-grade urothelial carcinoma. Raman spectroscopy provides additional information to histopathology and the diagnostic value using a superficial probe.

Artificially Intelligent Olfaction for Fast and Noninvasive Diagnosis of Bladder Cancer from Urine

Globally, bladder cancer (BLC) is one of the most common cancers and has a high recurrence and mortality rate. Current clinical diagnostic approaches are either invasive or inaccurate. Here, we report on a cost-efficient, artificially intelligent chemiresistive sensor array made of polyaniline (PANI) derivatives that can noninvasively diagnose BLC at an early stage and maintain postoperative surveillance through ″smelling″ clinical urine samples at room temperature. In clinical trials, 18 healthy controls and 76 BLC patients (60 and 16 at early and advanced stages, respectively) are assessed by the artificial olfactory system. With the assistance of a support vector machine (SVM), very high sensitivity and accuracy from healthy controls are achieved, exceeding those obtained by the current techniques in practice. In addition, the recurrences of both early and advanced stages are diagnosed well, with the effect of confounding factors on the performance of the artificial olfactory system found to have a negligible influence on the diagnostic performance. Overall, this study contributes a novel, noninvasive, easy-to-use, inexpensive, real-time, accurate method for urine disease diagnosis, which can be useful for personalized care/diagnosis and postoperative surveillance, resulting in saving more lives.

[Follow-up in superficial and metastatic bladder cancer]

Concerning follow-up in bladder cancer, it must be distinguished between superficial, muscle-invasive, and metastatic tumors. In superficial bladder cancer, urethrocystoscopy is still standard for follow-up. Frequency depends on the risk classification. Even muscle-invasive carcinomas, which underwent a R0 resection, will metastasize in about 30% of cases. These tumors as well as primarily metastasized cancer cannot be cured. Therefore, in these cases, one should not speak about follow-up but therapeutic control. Nonetheless, even in these cases the S3 guideline recommends regular follow-up examinations because new therapeutic options can clearly improve patient survival. Possible complications of urinary diversions need consideration during follow-up.

Blue versus white light for transurethral resection of non-muscle invasive bladder cancer

OBJECTIVES

To assess the effects of blue light-enhanced transurethral resection of bladder tumor (TURBT) compared to white light-based TURBT in the treatment of non-muscle invasive bladder cancer (NMIBC).

METHODS

Based on a published protocol we performed a systematic search of multiple databases from their inception to March 2021. We included randomized controlled trials (RCTs) comparing blue light (BL) TURBT to white light (WL) TURBT. Our meta-analysis is based on a random-effect model. We assessed the quality of evidence on a per-outcome basis according to the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach.

RESULTS

We included 16 randomized controlled trials involving a total of 4325 participants in this review. BL TURBT may reduce the risk of disease recurrence over time (hazard ratio (HR) 0.66, 95% confidence interval (CI) 0.54 to 0.81; low certainty evidence) depending on baseline risk. For participants with low-, intermediate-, and high-risk NMIBC, this corresponded to 48 (66 fewer to 27 fewer), 109 (152 fewer to 59 fewer), and 147 (211 fewer to 76 fewer) fewer recurrences per 1000 participants when compared to WL TURBT, respectively. BL TURBT may also reduce the risk of disease progression over time (HR 0.65, 95% CI 0.50 to 0.84; low-certainty evidence) depending on baseline risk. For participants with low-, intermediate-, and high-risk NMIBC, this corresponded to 1 (1 fewer to 0 fewer), 17 (25 fewer to 8 fewer), and 56 (81 fewer to 25 fewer) fewer progressions per 1000 participants when compared to WL TURBT, respectively.

CONCLUSIONS

Our findings suggest a favorable impact of BL TURBT on the risk of disease recurrence and progression; however, whether this risk reduction is clinically relevant greatly depends on the baseline risk of patients. We did not find an increase in severe surgical complications with BL cystoscopy, and we did not find any trial evidence on other, non-surgical adverse events.

Role of Macroscopic Image Enhancement in Diagnosis of Non-Muscle-Invasive Bladder Cancer: An Analytical Review

Early diagnosis of non-muscle-invasive bladder cancer (NMIBC) is of paramount importance to prevent morbidity and mortality due to bladder cancer. Although white light imaging (WLI) cystoscopy has long been considered the gold standard in the diagnosis of bladder cancer, it can miss lesions in a substantial percentage of patients and is very likely to miss carcinoma in situ and dysplasia. Tumor margin detection by WLI can be inaccurate. Moreover, WLI could, sometimes, be inadequate in distinguishing inflammation and malignancy. To improve the diagnostic efficacy of cystoscopy, various optical image enhancement modalities have been studied. These image enhancement modalities have been classified as macroscopic, microscopic, or molecular. Photodynamic diagnosis (PDD), narrow band imaging (NBI), and Storz image 1 S enhancement (formerly known as SPIES) are macroscopic image enhancement modalities. A relevant search was performed for literature describing macroscopic image enhancement modalities like PDD, NBI, and image 1 S enhancement. The advantages, limitations, and usefulness of each of these in the diagnosis of bladder cancer were studied. Photodynamic diagnosis requires intravesical instillation of a photosensitizing agent and a special blue light cystoscope system. PDD has been shown to be more sensitive than WLI in the detection of bladder cancer. It is superior to WLI in the detection of flat lesions. Bladder tumor resection (TURBT) by PDD results in more complete resection and reduced recurrence rates. PDD-guided TURBT may have some role in reducing the risk of progression. Narrow band imaging provides increased contrast between normal and abnormal tissues based on neovascularization, thereby augmenting WLI. NBI requires a special light source. There is no need for intravesical contrast instillation. NBI is superior to WLI in the detection of bladder cancer. The addition of NBI to WLI improves the detection of flat lesions like carcinoma in situ. NBI is not useful in predicting invasive tumors or grades of tumors. NBI-directed TURBT reduces recurrence rates and recurrence free survival. But its efficacy in retarding progression is unproven. Image 1 S-enhancement utilizes software-based image enhancement modes without the need for a special light source or intravesical contrast instillation. This system provides high-quality images and identifies additional abnormal-looking areas. Another advantage of this system is simultaneous side-by-side visualization of WLI and enhanced image, providing WLI images as the control for comparison. As with PDD, S-enhancement produces a lower rate of a missed bladder cancer diagnosis. The system significantly improves the diagnosis of NMIBC. The sensitivity and negative predictive value of image 1 S enhancement increase with the increase in cancer grade. A negative test by S-enhancement effectively rules out NMIBC. All the image enhancement modalities have proven their utility in improving detection and short-term cancer control. But none of these modalities have proven their utility in delaying progression, or in long-term cancer control. Cancer progression and long-term control are governed by the biological nature of cancer cells. Early detection by optical enhancement may not be of utility in this regard. Well-designed studies are needed to establish the efficacy of these modalities in the evaluation of patients with bladder cancer. The last word, in this regard, is yet to be written.

Blue versus white light for transurethral resection of non-muscle invasive bladder cancer

BACKGROUND

Disease recurrence and progression remain major challenges in the treatment of non-muscle invasive bladder cancer (NMIBC). Blue light-enhanced transurethral resection of bladder cancer (TURBT) is an approach to improve staging and achieve a complete resection of NMIBC.

OBJECTIVES

To assess the effects of blue light-enhanced TURBT compared to white light-based TURBT in the treatment of NMIBC.

SEARCH METHODS

We searched several medical literature databases, including the Cochrane Library, MEDLINE, and Embase, as well as trial registers, including ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We performed a comprehensive search with no restrictions on language of publication or publication status until March 2021.

SELECTION CRITERIA

We included randomized controlled trials using blue light versus white light TURBT. Included participants had a high level of suspicion based on imaging or 'visible diagnosis' for primary urothelial carcinoma of the bladder or recurrent urothelial carcinoma of the bladder upon cytoscopy. We excluded studies in which blue light was used in a surveillance setting.  DATA COLLECTION AND ANALYSIS: Two review authors independently performed data extraction and risk of bias assessment. Our primary outcomes were time to disease recurrence, time to disease progression, and serious surgical complications. Secondary outcomes were time to death from bladder cancer, any adverse events, and non-serious complications. We rated the certainty of evidence using the GRADE approach.

MAIN RESULTS

We included 16 randomized controlled trials involving a total of 4325 participants in the review. The studies compared blue light versus white light TURBT for treatment of NMIBC.  Primary outcomes Blue light TURBT may reduce the risk of disease recurrence over time (hazard ratio (HR) 0.66, 95% confidence interval (CI) 0.54 to 0.81; low-certainty evidence) depending on baseline risk. For participants with low-, intermediate-, and high-risk NMIBC, this corresponded to 48 (66 fewer to 27 fewer), 109 (152 fewer to 59 fewer), and 147 (211 fewer to 76 fewer) fewer recurrences per 1000 participants when compared to white light TURBT, respectively.  Blue light TURBT may also reduce the risk of disease progression over time (HR 0.65, 95% CI 0.50 to 0.84; low-certainty evidence) depending on baseline risk. For participants with low-, intermediate-, and high-risk NMIBC, this corresponded to 1 (1 fewer to 0 fewer), 17 (25 fewer to 8 fewer), and 56 (81 fewer to 25 fewer) fewer progressions per 1000 participants when compared to white light TURBT, respectively. Blue light TURBT may have little or no effect on serious surgical complications (risk ratio (RR) 0.54, 95% CI 0.14 to 2.14; low-certainty evidence). This corresponded to 10 fewer (19 fewer to 25 more) surgical complications per 1000 participants with blue light TURBT.  Secondary outcomes Blue light TURBT may have little or no effect on the risk of death from bladder cancer over time (HR 0.55, 95% CI 0.19 to 1.61; low-certainty evidence). This corresponded to 22 deaths per 1000 participants with white light TURBT and 10 fewer (17 fewer to 13 more) deaths per 1000 participants with blue light TURBT.   We are very uncertain how blue light TURBT affects the outcome adverse events of any grade (RR 1.09, 95% CI 0.88 to 1.33; low-certainty evidence).  No analysis was possible for the outcome non-serious surgical complications, as it was not reported by any of the included studies.

AUTHORS' CONCLUSIONS

Blue light-enhanced TURBT for the treatment of non-muscle invasive bladder cancer compared to white light-based TURBT may reduce the risk of disease recurrence and disease progression over time depending on baseline risk. There may be little or no effect on serious surgical complications. The certainty of evidence for our findings was low, meaning that future studies are likely change to the reported estimates of effect. Frequent issues that led to downgrading of the certainty of the evidence were study limitations, inconsistency, and imprecision.

Urine TERT promoter mutations-based tumor DNA detection in patients with bladder cancer: A pilot study

Telomerase reverse transcriptase (TERT) promoter mutations are the most frequent genetic events in bladder cancer (BC). The aim of the present pilot study was to evaluate the diagnostic potential of urine TERT promoter mutations-based liquid biopsy in patients with an ongoing oncological process, as well as in post-resection patients at risk of BC recurrence. A total of 60 patients were enrolled, of whom 27 patients had histologically proven BC; 23 had no signs of BC (control group); and 10 patients underwent transurethral malignancy resection 3-6 months prior to urine donation ('second look' group). Urine TERT promoter mutations were detected using Droplet Digital PCR. Receiver operating characteristic curve analysis revealed significant diagnostic power of the present approach (area under the curve: -0.768). At the cut-off value of tumor DNA fraction 0.34%, the sensitivity and specificity were 55.56 and 100%, respectively. In the positive samples, tumor DNA fraction varied significantly from 0.59 to 48.77%. In the 'second look' group, tumor DNA was detected in 4/10 patients, highlighting the possibility of BC recurrence with its fraction ranging only from 0.90 to 6.61%. Therefore, urine TERT promoter mutations-based liquid biopsy appears to be a promising tool for BC diagnosis and surveillance. The main study will include recruitment of additional patients, extension of the mutation panel, prolonged follow-up of the post-resection patients, as well as screening of industrial workers exposed to specific carcinogens.

Analysis of urinary kallikrein-related peptidase 13 for monitoring bladder cancer

BACKGROUND

Bladder cancer (BC) is one of the 10 most common types of cancer worldwide, with approximately 550,000 new cases each year. Early detection and appropriate diagnosis are important factors in successful treatment of the disease.

MATERIAL AND METHODS

We used specific fluorogenic substrate for the quantitative determination of urine kallikrein 13 (KLK13) activity in healthy (n = 15) and BC (n = 54) patients. The proteolytic activity in individual urine samples was determined by fluorescence measurements. Then, immunoenzymatic analyses (ELISA, Western blot) were performed to confirm the presence of KLK13 in the tested samples.

RESULTS

Urine samples from patients with G2 and G3 grade BC contained proteolytically active KLK13, as confirmed by kinetic analysis and immunochemical detection. KLK13 was not detected in the urine of patients with G1 grade BC.

DISCUSSION

Previous clinical study reveals the KLK13 significance for BC prognosis as increased KLK13 expression was highlighted in bladder tumours compared to normal adjacent tissues. Our findings correlate to the report. KLK13 activity was confirmed in BC patients with G2 and G3 stage of disease development.

CONCLUSIONS

Using specific chromogenic/fluorogenic peptides could be useful for the non-invasive disease monitoring of BC progress.

Time to Turn on the Blue Lights: A Systematic Review and Meta-analysis of Photodynamic Diagnosis for Bladder Cancer

Context

White light (WL) cystoscopy and transurethral resection of bladder tumour (TURBT) comprise the current gold standard technique for detecting and grading bladder cancer. However, with WL cystoscopy, recurrence following initial TURBT is high, and identification of smaller tumours and carcinoma in situ is poor. Photodynamic diagnosis (PDD) has been developed to improve the detection of bladder.

Objective

To assess the effect of PDD-guided TURBT compared with WL on recurrence rates (RRs) in non-muscle-invasive bladder cancer (NMIBC).

Evidence acquisition

A systematic review of the literature from inception to April 2020 using Medline, EMBASE, and CENTRAL was undertaken. Randomised control trials comparing TURBT undertaken with PDD to WL that reported RRs of at least 12 mo were included in the analysis. The primary outcomes were RRs at 12 and 24 mo. The secondary outcomes were reported adverse effects. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of the evidence.

Evidence synthesis

Twelve randomised controlled trials (2288 patients) were included for the meta-analysis. PDD was found to reduce RRs at 12 mo (RR 0.73, confidence interval [CI] 0.60-0.88) and 24 mo (RR 0.75, CI 0.62-0.91). There was an increased risk of recurrence for patients undergoing WL at 12 mo (hazard ratio [HR] 1.14, CI 1.05-1.23) and 24 mo (HR 1.25, CI 1.15-1.35). Two studies reported recurrence data at 60 mo showing statistically significant outcomes in favour of PDD: one showed lower RRs for PDD (49% PDD vs 68% WL), whilst the other showed increased recurrence-free survival (68.2% PDD vs 57.3% WL). Adverse effects appeared to be minimal, though poorly reported. A GRADE analysis showed the evidence to be of moderate certainty overall.

Conclusions

This systematic review found that PDD reduced RRs and improved recurrence-free survival compared with WL in NMIBC over at least 2-yr follow-up. These effects may persist up to 5 yr. Further research in a pragmatic study looking at longer-term outcomes beyond 24 mo will help guide recommendations on clinical adoption.

Patient summary

This review suggests that photodynamic diagnosis, compared with white light cystoscopy, improves recurrence-free survival in non-muscle-invasive bladder cancer over at least 2 yr of follow-up. However, confirmatory pragmatic studies with longer-term outcomes are required for its clinical adoption.

Overcoming barriers in photodynamic therapy harnessing nano-formulation strategies

Photodynamic therapy (PDT) has been extensively investigated for decades for tumor treatment because of its non-invasiveness, spatiotemporal selectivity, lower side-effects, and immune activation ability. It can be a promising treatment modality in several medical fields, including oncology, immunology, urology, dermatology, ophthalmology, cardiology, pneumology, and dentistry. Nevertheless, the clinical application of PDT is largely restricted by the drawbacks of traditional photosensitizers, limited tissue penetrability of light, inefficient induction of tumor cell death, tumor resistance to the therapy, and the severe pain induced by the therapy. Recently, various photosensitizer formulations and therapy strategies have been developed to overcome these barriers. Significantly, the introduction of nanomaterials in PDT, as carriers or photosensitizers, may overcome the drawbacks of traditional photosensitizers. Based on this, nanocomposites excited by various light sources are applied in the PDT of deep-seated tumors. Modulation of cell death pathways with co-delivered reagents promotes PDT induced tumor cell death. Relief of tumor resistance to PDT with combined therapy strategies further promotes tumor inhibition. Also, the optimization of photosensitizer formulations and therapy procedures reduces pain in PDT. Here, a systematic summary of recent advances in the fabrication of photosensitizers and the design of therapy strategies to overcome barriers in PDT is presented. Several aspects important for the clinical application of PDT in cancer treatment are also discussed.

Putative markers for the detection of early-stage bladder cancer selected by urine metabolomics

BACKGROUND

Early detection of bladder cancer remains challenging because patients with early-stage bladder cancer usually have no incentive to take cytology or cystoscopy tests if they are asymptomatic. Our goal is to find non-invasive marker candidates that may help us gain insight into the metabolism of early-stage bladder cancer and be examined in routine health checks.

RESULTS

We acquired urine samples from 124 patients diagnosed with early-stage bladder cancer or hernia (63 cancer patients and 61 controls). In which 100 samples were included in our marker discovery cohort, and the remaining 24 samples were included in our independent test cohort. We obtained metabolic profiles of 922 compounds of the samples by gas chromatography-mass spectrometry. Based on the metabolic profiles of the marker discovery cohort, we selected marker candidates using Wilcoxon rank-sum test with Bonferroni correction and leave-one-out cross-validation; we further excluded compounds detected in less than 60% of the bladder cancer samples. We finally selected eight putative markers. The abundance of all the eight markers in bladder cancer samples was high but extremely low in hernia samples. Moreover, the up-regulation of these markers might be in association with sugars and polyols metabolism.

CONCLUSIONS

In the present study, comparative urine metabolomics selected putative metabolite markers for the detection of early-stage bladder cancer. The suggested relations between early-stage bladder cancer and sugars and polyols metabolism may create opportunities for improving the detection of bladder cancer.

Diagnosis and Staging of Bladder Cancer

Cystoscopic examination remains the gold standard technique for initial diagnosis of bladder cancer (BCa). Despite significant progress in enhanced cystoscopic techniques, blue light cystoscopy and narrow band imaging are the only ones well supported by high-level evidence and, if available, should be used during initial staging of BCa. Multiparametric MRI could be an important imaging tool in local staging of BCa. With ever-expanding targeted therapy and immunotherapy options in both muscle-invasive and non-muscle-invasive BCa, molecular subtyping could become an essential part of initial histologic staging in the near future.

Evaluation of Spectra A and B Modes in Diagnosis of Suspicious Bladder Lesions

Background: White light imaging (WLI) cystoscopy, a "gold standard" for diagnosis of nonmuscle invasive bladder cancer (NMIBC), can miss ∼25% of bladder cancers. Spectra A (SA) and Spectra B (SB) are virtual optical chromoendoscopy modes introduced by Storz. Objective: To evaluate whether SA and SB improve over WLI in diagnosis of NMIBC. Design, Setting, and Participants: Storz Professional Image Enhancement System (SPIES) modes allow side-by-side viewing of WLI and spectra images. Cystoscopy images of some patients with suspected NMIBC and some normal cystoscopy findings were cut in two parts: one WLI and the other SA or SB. Each individual image was sent to the 3721 members of Urological Society of India separately through online survey. Histologic diagnosis was considered final diagnosis. Intervention: The observers were asked whether they considered the image to be cancer; yes, no, or cannot say were the three response options. Outcome Measures and Statistical Analysis: Primary outcome measure was improved diagnosis of NMIBC. Diagnostic efficacy was analyzed through 2 × 2 tables, McNemar test, and Fleiss Kappa. Results and Limitations: A total of 273 observers participated in the study. The sensitivities of WLI, SA, and SB were 89.81, 91.15, and 88.81, respectively. The specificities were 73.18, 66.17, and 68.68, respectively. In patients with cancer, both SA and SB improved the diagnostic efficacy of WLI. SA added significantly to the diagnostic accuracy over WLI (χ² = 12.23, p = 0.00046). SB also added significantly over WLI (χ² = 11.76, p = 0.0006). With increasing cancer grade, the sensitivity and negative predictive value of all modes increased. The major limitation of this study is the online diagnosis based on still images. Conclusions: In patients with cancer, SA and SB significantly add to the diagnostic accuracy of WLI. As compared with the negative WLI, if SA and SB are negative, NMIBC would be less likely.

Probing the Interactions of Porphyrins with Macromolecules Using NMR Spectroscopy Techniques

Porphyrinic compounds are widespread in nature and play key roles in biological processes such as oxygen transport in blood, enzymatic redox reactions or photosynthesis. In addition, both naturally derived as well as synthetic porphyrinic compounds are extensively explored for biomedical and technical applications such as photodynamic therapy (PDT) or photovoltaic systems, respectively. Their unique electronic structures and photophysical properties make this class of compounds so interesting for the multiple functions encountered. It is therefore not surprising that optical methods are typically the prevalent analytical tool applied in characterization and processes involving porphyrinic compounds. However, a wealth of complementary information can be obtained from NMR spectroscopic techniques. Based on the advantage of providing structural and dynamic information with atomic resolution simultaneously, NMR spectroscopy is a powerful method for studying molecular interactions between porphyrinic compounds and macromolecules. Such interactions are of special interest in medical applications of porphyrinic photosensitizers that are mostly combined with macromolecular carrier systems. The macromolecular surrounding typically stabilizes the encapsulated drug and may also modify its physical properties. Moreover, the interaction with macromolecular physiological components needs to be explored to understand and control mechanisms of action and therapeutic efficacy. This review focuses on such non-covalent interactions of porphyrinic drugs with synthetic polymers as well as with biomolecules such as phospholipids or proteins. A brief introduction into various NMR spectroscopic techniques is given including chemical shift perturbation methods, NOE enhancement spectroscopy, relaxation time measurements and diffusion-ordered spectroscopy. How these NMR tools are used to address porphyrin-macromolecule interactions with respect to their function in biomedical applications is the central point of the current review.

Clinically Available Optical Imaging Technologies in Endoscopic Lesion Detection: Current Status and Future Perspective

Endoscopic optical imaging technologies for the detection and evaluation of dysplasia and early cancer have made great strides in recent decades. With the capacity of in vivo early detection of subtle lesions, they allow modern endoscopists to provide accurate and effective optical diagnosis in real time. This review mainly analyzes the current status of clinically available endoscopic optical imaging techniques, with emphasis on the latest updates of existing techniques. We summarize current coverage of these technologies in major hospital departments such as gastroenterology, urology, gynecology, otolaryngology, pneumology, and laparoscopic surgery. In order to promote a broader understanding, we further cover the underlying principles of these technologies and analyze their performance. Moreover, we provide a brief overview of future perspectives in related technologies, such as computer-assisted diagnosis (CAD) algorithms dealing with exploring endoscopic video data. We believe all these efforts will benefit the healthcare of the community, help endoscopists improve the accuracy of diagnosis, and relieve patients' suffering.

A potential panel of five mRNAs in urinary extracellular vesicles for the detection of bladder cancer

Background

Extracellular vesicles (EVs) have showed promising potential in liquid biopsy of cancer. In present study, we evaluate the feasibility to diagnose bladder cancer using EVs RNA markers identified from public tissue RNA sequencing data.

Methods

We used urine samples from a cohort of population with suspected bladder cancer. Disease status (i.e., primary or recurrent bladder cancer) was diagnosed by cystoscopy. A prediction model including the expression of multiple RNAs in urinary EVs were developed in training cohort (n=368, 126 bladder cancer and 242 negative controls). The performance of optimal model (ExoPanel) consists of five mRNAs (MYBL2, TK1, UBE2C, KRT7, S100A2) was further assessed by a validation cohort (n=155, 56 bladder cancer and 99 negative controls).

Results

The performance of ExoPanel in training cohort was AUC 0.7759 (95% CI: 0.7259–0.8260), NPV 90.34% (95% CI: 84.04–94.42%), SN 88.89% (95% CI: 81.75–93.57%), and SP 54.13% (95% CI: 47.63–60.50%) respectively. In the validation cohort, the performance of this model was AUC 0.8402 (95% CI: 0.7690–0.9114), NPV 90.91% (95% CI: 79.29–96.60%), SN 91.07% (95% CI: 79.63–96.67%), and SP 50.51% (95% CI: 40.34–60.63%). Using this model, it is possible to rule out a significant number of non cancer patients, thus reduce the unnecessary operation of cystoscopy.

Conclusions

We discovered a panel of five mRNAs, and evaluated its potential to facilitate bladder cancer diagnosis by analyzing their expression in urinary EVs.

Current Targets and Bioconjugation Strategies in Photodynamic Diagnosis and Therapy of Cancer

Photodynamic diagnosis (PDD) and therapy (PDT) are emerging, non/minimally invasive techniques for cancer diagnosis and treatment. Both techniques require a photosensitizer and light to visualize or destroy cancer cells. However, a limitation of conventional, non-targeted PDT is poor selectivity, causing side effects. The bioconjugation of a photosensitizer to a tumor-targeting molecule, such as an antibody or a ligand peptide, is a way to improve selectivity. The bioconjugation strategy can generate a tumor-targeting photosensitizer conjugate specific for cancer cells, or ideally, for multiple tumor compartments to improve selectivity and efficacy, such as cancer stem cells and tumor neovasculature within the tumor microenvironment. If successful, such targeted photosensitizer conjugates can also be used for specific visualization and detection of cancer cells and/or tumor angiogenesis (an early event in tumorigenesis) with the hope of an early diagnosis of cancer. The purpose of this review is to summarize some current promising target molecules, e.g., tissue factor (also known as CD142), and the currently used bioconjugation strategies in PDT and PDD, with a focus on newly developed protein photosensitizers. These are genetically engineered photosensitizers, with the possibility of generating a fusion protein photosensitizer by recombinant DNA technology for both PDT and PDD without the need of chemical conjugation. We believe that providing an overview of promising targets and bioconjugation strategies will aid in driving research in this field forward towards more effective, less toxic, and non- or minimally invasive treatment and diagnosis options for cancer patients.

Diagnostic accuracy of photodynamic diagnosis for upper urinary tract urothelial carcinoma: A systematic review and meta-analysis

BACKGROUND

This study aimed to evaluate the effectiveness of photodynamic diagnosis (PDD) for upper urinary tract urothelial carcinoma (UTUC) by performing a meta-analysis.

METHOD

Relevant articles were retrieved from the Cochrane Library, PubMed, and Embase databases. Studies evaluating the accuracy of PDD for the diagnosis of upper UTUC were included. The pooled sensitivity, specificity, and area under the curve (AUC) were calculated by STATA 16.0 at the per-lesion level.

RESULTS

Six studies with 289 lesions were included in this systematic review and meta-analysis. The pooled results showed that PDD can differentiate upper UTUC from benign lesions with a sensitivity of 0.96 (95 % confidence interval: 0.85-0.99) and a specificity of 0.86 (95 % confidence interval: [0.64-0.95]; AUC, 0.97). Compared with white-light ureterorenoscopy, PDD can significantly improve the additional detection rate of UTUC (RR 0.16, 95 % CI 0.07-0.34 P = 0.000).

CONCLUSIONS

PDD is a valid technique that improves the diagnostic accuracy of UTUC compared with standard white-light ureterorenoscopy at the per-lesion level. PDD is a promising endoscopic technique for upper UTUC.

Review of non-invasive urinary biomarkers in bladder cancer

Bladder cancer (BC) is the sixth-most prevalent cancer. The standard diagnostic tool of BC is cystoscopy, whereas cystoscopy has several disadvantages in terms of symptomatic invasiveness and operator-dependency. The urinary markers are attractive because the testing is non-invasive and cost-efficient, and sample collection is easy. Urinary marker is thereby a good tool to detect exfoliated tumor cell in the urine samples for the diagnosis and therapeutic surveillance of BC to supplement the limitations of the cystoscopy. However, they are not recommended as a population-based screening tool because of the low rate of BC prevalence. Although both cystoscopy and urine cytology improve BC diagnostic power, the field still needs additional non-invasive, cost-effective, and highly sensitive and specific diagnostic tools. Various urinary markers with different mechanisms and different targets have been developed and under investigation in these days. However, the accuracy of the urinary marker including its sensitivity and specificity is the most important factor for the diagnosis and surveillance in cancer that this review deals with multiple FDA-approved and non-FDA approved commercialized urinary markers with their accuracy in different purposes for BC. We then discuss more about the potential candidate targets for the future urinary markers in BC

Endoscopic visualization of cancer and dysplasia in patients with ulcerative colitis following sensitization with oral 5-aminolevulinic acid

OBJECTIVE

Early diagnosis of colitis-associated cancer and dysplasia through surveillance endoscopy is vital for patients with ulcerative colitis (UC). This study aimed to evaluate the efficacy of autofluorescence endoscopy (AFE) using 5-aminolevulinic acid (ALA) and to investigate the fluorescence signal localization pattern following 5-ALA administration in tumorous lesions diagnosed as colitis-associated cancer and dysplasia. The sensitivity and specificity of tumorous lesions detected by white light endoscopy (WLE) with and without AFE were evaluated.

METHODS

Overall, 13 endoscopic procedures were performed in 11 patients with UC using WLE and AFE following the oral administration of 5-ALA. The biopsied lesions detected via endoscopy and resected specimens from cases underwent colectomy were assessed histopathologically. The sensitivity and specificity of detecting tumorous lesions by WLE with and without AFE were evaluated.

RESULTS

Of the 68 lesions detected and biopsied, 63 were detected via WLE, and five were detected via AFE alone. The sensitivity of detecting colitis-associated cancer and dysplasia via WLE combined with AFE was 36.4%, and the specificity, positive predictive value and negative predictive value were 94.2%, 57.1%, and 87.5%, respectively. Tumorous lesions displayed three types of fluorescence patterns on AFE.

CONCLUSIONS

AFE using 5-ALA can detect colitis-associated cancer and dysplasia in patients with long-standing UC and lesions that could not be detected via WLE. The distinctive fluorescence patterns in lesions may permit qualitative diagnoses of colitis-associated cancer and dysplasia.

Rapid, Low-Cost Dielectrophoretic Diagnosis of Bladder Cancer in a Clinical Setting

Bladder cancer is the 9th most common cancer worldwide. Diagnosing bladder cancer typically involves highly invasive cystoscopy, with followup monitored using uteroscopy. Molecular methods have been developed as an adjunct to this, but tend to be expensive or require expert operator input. Here we present a study of the use of dielectrophoresis (DEP) of voided cells from eight cancer-presenting patients and eight healthy controls as an alternative low-cost and operator-independent method of bladder cancer detection. This study suggests that there are statistically significant differences ([Formula: see text]) between characteristics of the DEP spectrum of clinical samples, and that using this marker we were able to obtain sensitivity of 75% and specificity of 88%, in line with many molecular methods; exclusion of samples where a DEP spectrum is not present (due to low cell counts) increased sensitivity to 100%, showing this can be improved by increasing the cell collection rate. As samples were analyzed a day after collection, we suggest that the method may be amenable to a centralized mail-in analysis service.

Objective tumor distinction in 5-aminolevulinic acid-based endoscopic photodynamic diagnosis, using a spectrometer with a liquid crystal tunable filter

Background

Recent improvement of the endoscopic system such as image enhancement has led to the better accuracy of the diagnosis of the gastric cancer. However, the objective and efficient detection method of the gastric cancer is still needed because the detection efficiency could sometimes be low due to the fact that the image enhancement diagnosis needs magnification for its full utilization. The photodynamic diagnosis (PDD) with oral intake of 5-aminolevulinic acid (5-ALA) has been widely used for the detection of the cancerous region for bladder cancer and glioblastoma. The application of the 5-ALA based PDD (5-ALA PDD) to the diagnosis of gastric cancer is recently reported. The efficiency of the detection is reported to be good, however, the objectivity of the method can be impaired by the photobleaching effect with fast decreasing of the intensity of the fluorescence under light exposure. In this article, we investigated the fluorescence spectrum of the gastric tumor and non-tumor mucosa of 5-ALA PDD and revealed the property of the photobleaching effect.

Methods

Example cases of PDD endoscopy of gastric tumor were investigated for cases of endoscopic submucosal dissection (ESD). Newly developed spectrometer using a spectrometer with a liquid crystal tunable filter was used for investigating the fluorescence spectrum of 5-ALA PDD. The assumed tumor region and non-tumor region in gastric mucosa were biopsied and the fluorescence spectrum was measured using the spectrometer consecutively several times, to estimate the photobleaching effect.

Results

The fluorescence spectrum has a primary peak at 630 nm, with a broad peak ranging from 660 to 700 nm. The 630 nm peak diminished quickly upon ultraviolet light exposure, whereas the broad peak from 660 to 700 nm diminished slowly. The sum of the altitudes at 660–700 nm, normalized to the altitude at 600 nm, was not as affected by the photobleaching effect as the 630 nm peak was, and can thus be used for 5-ALA-based PDD.

Conclusions

The 5-ALA PDD using the average fluorescence altitude of 660–700 nm instead of the peak altitude at 630 nm, is shown to be more effective in distinguishing between tumorous and non-tumorous tissues, because of the lower photobleaching effect at this specific spectral range. The finding is expected to greatly improve the objective diagnosis of gastrointestinal cancers by 5-ALA-based photodynamic diagnostic endoscopy.

Advances in image enhancement for sarcoma surgery

The recurrence rate of soft tissue and bone sarcomas strongly correlates to the status of the surgical margin after excision, yet excessive removal of tissue may lead to distinct, otherwise avoidable morbidity. Therefore, adequate margination of sarcomas both pre- and intra-operatively is a clinical necessity that has not yet fully been met. Current guidance for soft-tissue sarcomas recommends an ultrasound scan followed by magnetic resonance imaging (MRI). For bone sarcomas, two plane radiographs are required, followed similarly by an MRI scan. The introduction of more precise imaging modalities may reduce the morbidity associated with sarcoma surgery; the PET-CT and PET-MRI approaches in particular demonstrating high clinical efficacy. Despite advancements in the accuracy in pre-operative imaging, translation of an image to surgical margins is difficult, regularly resulting in wider resection margins than required. For soft tissue sarcomas there is currently no standard technique for image guided resections, while for bone sarcomas fluoroscopy may be used, however margins are not easily discernible during the surgical procedure. Near infra-red (NIR) fluorescence guided surgery offers an intra-operative modality through which complete tumour resection with adequate tumour-free margins may be achieved, while simultaneously minimising surgical morbidity. NIR imaging presents a potentially valuable adjunct to sarcoma surgery. Early reports indicate that it may be able to provide the surgeon with helpful information on anatomy, perfusion, lymphatic drainage, tumour margins and metastases. The use of NIR fluorochromes have also been demonstrated to be well tolerated by patients. However, prior to widespread implementation, studies related to cost-effectiveness and the development of protocols are essential. Nevertheless, NIR imaging may become ubiquitous in the future, carrying the potential to transform the surgical management of sarcoma.

Evaluation of autofluorescence and photodynamic diagnosis in assessment of bladder lesions

The ability to detect and diagnose bladder cancer early and precisely is crucial for effective treatment. The aim of this study is to assess the utility of optical biopsy performed with autofluorescence cystoscopy (AFC) using the Onco-LIFE system with numerical color values (NCVs) and by ALA/PDD. Histopathological examination of material obtained during TURBT and/or biopsy of the bladder was carried out in 251 patients. In the case of 35 patients, the selection of the specimen collected for histopathological examination was based using ALA/PDD. In the remaining 216 patients, tissue was collected based on the findings of AFC with NCV. Using AFC, the observed NCV ranged from 0 to 3.86; the highest mean NCV was observed in neoplastic muscle invasive lesions and was equal to 3.18. Furthermore, non-muscle invasive tumors were characterized by a mean NCV equal to 1.54. Tissue with inflammation, metaplasia, and healthy tissue demonstrated significantly lower mean NCV values. The presence of a muscle-invasive tumor increased the NCV by approximately 2.86 compared to healthy tissue. The rates of postoperative complications depend on the examining operator and are observed more often, as much as 65.7 % during ALA/PDD. AFC with NCV using the Onco-LIFE system, as well as ALA/PDD are helpful tools for early diagnosis of bladder precancerous and cancer lesions and for performing targeted biopsies. A significant correlation was found between lesion NCV index and the grade of dysplasia or tumor malignancy. Tissue with inflammation, metaplasia, and healthy tissue demonstrated significantly lower mean NCV values. AFE with NCV have a significantly higher sensitivity than specificity. Low rates of postoperative complications are correlated to the experience of the endoscopist and with AFE/NCV in comparison of ALA/PDD.

High performance of 5-aminolevulinic acid-induced fluorescent selective upper tract urinary cytology

OBJECTIVES

To investigate the efficacy of selective upper tract urinary cytology using extracorporeal 5-aminolevulinic acid for the diagnosis of upper urinary tract urothelial carcinoma.

METHODS

We evaluated 104 patients who underwent radical nephroureterectomy and were diagnosed pathologically as having upper urinary tract urothelial carcinoma between March 2013 and May 2019 in Osaka Rosai Hospital. Preoperatively, we collected upper tract urinary cytology from both sides, and compared the sensitivity and specificity between conventional urine cytology and 5-aminolevulinic acid-induced fluorescent urine cytology.

RESULTS

The sensitivity of 5-aminolevulinic acid-induced fluorescent selective upper tract urinary cytology was significantly higher than conventional cytology (90.4% vs 66.3%, P < 0.001), whereas the specificity was equally high (100% vs 98.2%, P = 1.0). In more detailed analysis, the sensitivity of 5-aminolevulinic acid-induced fluorescent selective upper tract urinary cytology was significantly higher than that of conventional cytology unrelated to patients' age (<76 years: 90.2% vs 68.6%, P = 0.013; ≥76 years: 90.6% vs 64.2%, P = 0.021), sex (male: 89.2% vs 67.5%, P = 0.001; female: 95.2% vs 61.9%, P = 0.02) or pT stage (pT1 or less: 91.4% vs 69.0%, P = 0.005; pT2 or more: 89.1% vs 63.0%, P = 0.006), tumor grade (high grade: 91.0% vs 70.5%, P = 0.002; low grade: 88.5% vs 53.8%, P = 0.013), and tended to be more efficacious for tumors that could not be detected by imaging techniques (83.3% vs 50.0%, P = 0.075).

CONCLUSIONS

5-Aminolevulinic acid-induced fluorescent selective upper tract urinary cytology is more sensitive than conventional cytology for the diagnosis of upper urinary tract urothelial carcinoma, regardless of pT stage and tumor grade.

Photodynamic diagnosis and photodynamic therapy of colorectal cancer in vitro and in vivo

This review highlights the various photo diagnostic and treatment methods utilized for CRC, over the last seven years.

Fluorescence Imaging of Breast Tumors and Gastrointestinal Cancer

Optical imaging offers a high potential for noninvasive detection and therapy of cancer in humans. Recent advances in instrumentation for diffuse optical imaging have led to new capabilities for the detection of cancer in highly scattering tissue such as the female breast. In particular, fluorescence imaging was made applicable as a sensitive technique to image molecular probes in vivo. We review recent developments in the detection of breast cancer and fluorescence-guided surgery of the breast by contrast agents available for application on humans. Detection of cancer has been investigated with the unspecific contrast agents "indocyanine green" and "omocianine" so far. Hereby, indocyanine green was found to offer high potential for the differentiation of malignant and benign lesions by exploiting vessel permeability for macromolecules as a cancer-specific feature. Tumor-specific molecular targeting and activatable probes have been investigated in clinical trials for fluorescence-guided tumor margin detection. In this application, high spatial resolution can be achieved, since tumor regions are visualized mainly at the tissue surface. As another example of superficial tumor tissue, imaging of lesions in the gastrointestinal tract is discussed. Promising results have been obtained on high-risk patients with Barrett´s esophagus and with ulcerative colitis by administering 5-aminolevulinic acid which induces accumulation of protoporphyrin IX serving as a tumor-specific fluorescent marker. Time-gated fluorescence imaging and spectroscopy are effective ways to suppress underlying background from tissue autofluorescence. Furthermore, recently developed tumor-specific molecular probes have been demonstrated to be superior to white-light endoscopy offering new ways for early detection of malignancies in the gastrointestinal tract.

DaBlaCa-11: Photodynamic Diagnosis in Flexible Cystoscopy-A Randomized Study With Focus on Recurrence

OBJECTIVE

To examine whether photodynamic diagnosis (PDD) in addition to flexible cystoscopy in the outpatient clinic can reduce risk of tumor recurrence in patients with previous nonmuscle invasive bladder cancer. PDD is an optical technique that enhances the visibility of pathologic tissue and helps guidance tumor resection.

METHODS

From February 2016 to December 2017, 699 patients from 3 urologic departments in Denmark were enrolled in a randomized controlled trial. Four months after transurethral resection of bladder tumor patients were randomized 1:1 to either an intervention group (hexaminolevulinate was instilled in the bladder before flexible cystoscopy with PDD video cystoscope) or a control group (white light flexible cystoscope), only. Primary endpoint was tumor recurrence within 8 months from the randomization. Secondary outcomes were numbers of procedures in general anesthesia, time to the first recurrence, differences in tumor size, risk of tumor progression, and identification of carcinoma in situ.

RESULTS

A total of 351 patients were allocated to the intervention group (flexible PDD), and 348 to the control group (flexible white light). Throughout the following 8 months after randomization, only 117 patients in the intervention group had at least 1 tumor recurrence compared to 143 patients in the control group (P = .049). Odds ratio of 0.67 (P = .02, 95% CI: 0.48-0.95) correlates with a tumor reduction of 33% in favor of the intervention group.

CONCLUSION

Use of PDD in a routine surveillance cystoscopy first time after transurethral resection of bladder tumor for nonmuscle invasive bladder cancer reduces subsequent risk of tumor recurrence compared to WL cystoscopy alone.

Detection of carcinogen-induced bladder cancer by fluorocoxib A

BACKGROUND

Conventional cystoscopy can detect advanced stages of bladder cancer; however, it has limitations to detect bladder cancer at the early stages. Fluorocoxib A, a rhodamine-conjugated analog of indomethacin, is a novel fluorescent imaging agent that selectively targets cyclooxygenase-2 (COX-2)-expressing cancers.

METHODS

In this study, we have used a carcinogen N-butyl-N-4-hydroxybutyl nitrosamine (BBN)-induced bladder cancer immunocompetent mouse B6D2F1 model that resembles human high-grade invasive urothelial carcinoma. We evaluated the ability of fluorocoxib A to detect the progression of carcinogen-induced bladder cancer in mice. Fluorocoxib A uptake by bladder tumors was detected ex vivo using IVIS optical imaging system and Cox-2 expression was confirmed by immunohistochemistry and western blotting analysis. After ex vivo imaging, the progression of bladder carcinogenesis from normal urothelium to hyperplasia, carcinoma-in-situ and carcinoma with increased Ki67 and decreased uroplakin-1A expression was confirmed by histology and immunohistochemistry analysis.

RESULTS

The specific uptake of fluorocoxib A correlated with increased Cox-2 expression in progressing bladder cancer. In conclusion, fluorocoxib A detected the progression of bladder carcinogenesis in a mouse model with selective uptake in Cox-2-expressing bladder hyperplasia, CIS and carcinoma by 4- and 8-fold, respectively, as compared to normal bladder urothelium, where no fluorocoxib A was detected.

CONCLUSIONS

Fluorocoxib A is a targeted optical imaging agent that could be applied for the detection of Cox-2 expressing human bladder cancer.

Narrow-band imaging assisted cystoscopy in the follow-up of patients with transitional cell carcinoma of the bladder: a randomized study in comparison with white light cystoscopy

PURPOSE

To evaluate the diagnostic accuracy of a second look narrow-band imaging (NBI) cystoscopy in the follow-up of patients with NMIBC as compared to a second white light cystoscopy (WLI).

PATIENTS AND METHODS

From August 2013 to October 2014, 600 patients with history of non-muscle invasive bladder cancer (NMIBC), who presented for follow-up cystoscopy at an academic outpatient clinic, were randomized to flexible WLI-cystoscopy plus second look NBI-cystoscopy (n = 300) or flexible WLI-cystoscopy plus second look WLI-cystoscopy (n = 300) in the same session. We analysed the detection rate of bladder tumours in second look cystoscopy as primary endpoint. In addition, we evaluated recurrence rates before study enrolment and after transurethral resection (TUR-BT) in each group.

RESULTS

In 600 patients with a history of NMIBC, 78 out of 300 patients (26%) with WLI-NBI-cystoscopy and 70 out of 300 patients (23%) with WLI-WLI-cystoscopy were diagnosed with cancer recurrence (p = 0.507). Overall, WLI-NBI detected 404 and WLI-WLI 234 lesions, respectively. The second look cystoscopy detected 57 additional cancer lesions: 45 tumours in 18 patients with WLI-NBI and 12 tumours in 9 patients with WLI-WLI (p = 0.035). After initial examination without tumour detection an improvement was determined by the second cystoscopy in 3 patients (75 vs. 78 pat.) with WLI-NBI and in only one patient (69 vs. 70 pat.) with WLI-WLI (p = 0.137). Second look cystoscopy did not influence the detection of carcinoma in situ in both groups (p = 0.120). After TUR-BT the median recurrence-free survival was 4 months in 57 recurring patients (73%) in the group with WLI-NBI- and 6 months in 56 patients (80%) with WLI-WLI-cystoscopy (p = 0.373), respectively.

CONCLUSION

Our study showed no differences in per-patient tumour detection between WLI and NBI. Although NBI has significant benefits for detecting individual lesions overlooked by WLI-cystoscopy, this did not positively affect recurrence-free survival after transurethral resection.

Simultaneous Photodiagnosis and Photodynamic Treatment of Metastatic Melanoma

Metastatic melanoma (MM) has a poor prognosis and is attributed to late diagnoses only when metastases has already occurred. Thus, early diagnosis is crucial to improve its overall treatment efficacy. The standard diagnostic tools for MM are incisional biopsies and/or fine needle aspiration biopsies, while standard treatments involve surgery, chemotherapy, or irradiation therapy. The combination of photodynamic diagnosis (PDD) and therapy (PDT) utilizes a photosensitizer (PS) that, when excited by light of a low wavelength, can be used for fluorescent non-destructive diagnosis. However, when the same PS is activated at a higher wavelength of light, it can be cytotoxic and induce tumor destruction. This paper focuses on PS drugs that have been used for PDD as well as PDT treatment of MM. Furthermore, it emphasizes the need for continued investigation into enhanced PS delivery via active biomarkers and passive nanoparticle systems. This should improve PS drug absorption in MM cells and increase effectiveness of combinative photodynamic methods for the enhanced diagnosis and treatment of MM can become a reality.

Hydrogels: soft matters in photomedicine

Photodynamic therapy (PDT), a shining beacon in the realm of photomedicine, is a non-invasive technique that utilizes dye-based photosensitizers (PSs) in conjunction with light and oxygen to produce reactive oxygen species to combat malignant tissues and infectious microorganisms. Yet, for PDT to become a common, routine therapy, it is still necessary to overcome limitations such as photosensitizer solubility, long-term side effects (e.g., photosensitivity) and to develop safe, biocompatible and target-specific formulations. Polymer based drug delivery platforms are an effective strategy for the delivery of PSs for PDT applications. Among them, hydrogels and 3D polymer scaffolds with the ability to swell in aqueous media have been deeply investigated. Particularly, hydrogel-based formulations present real potential to fulfill all requirements of an ideal PDT platform by overcoming the solubility issues, while improving the selectivity and targeting drawbacks of the PSs alone. In this perspective, we summarize the use of hydrogels as carrier systems of PSs to enhance the effectiveness of PDT against infections and cancer. Their potential in environmental and biomedical applications, such as tissue engineering photoremediation and photochemistry, is also discussed.

Methods for bladder cancer diagnosis - The role of autofluorescence and photodynamic diagnosis

Bladder cancer is one of the most common Genito-urinary malignant tumors in humans. Improved diagnostic and therapeutic methods that aim to reduce rates of recurrence and progression of bladder cancer are needed. In current publications, one can find information on such methods as Raman spectroscopy, ultraviolet autofluorescence microscopy, confocal laser endoscopy, photoacoustic imaging, molecular imaging, multi-photon microscopy and many other new diagnostic techniques. These methods do not show significant adverse effects and are procedures well tolerated by patients as they use mostly physical phenomena that are neutral towards the human body. This review highlights the techniques of autofluorescence (AF) or laser induced fluorescence (LIF) and photodynamic diagnostics (PDD) which have been widely clinically studied for many years as a complement to cystoscopy. These methods can be performed during standard cystoscopy and they can be used in routine practice. This review shows that Autofluorescent and Photodynamic diagnostics are effective and have great potential in enhancing the diagnosis of bladder cancer. However, more research should be performed to help realize their full potential.

High diagnostic efficacy of 5-aminolevulinic acid-induced fluorescent urine cytology for urothelial carcinoma

BACKGROUND

In general, urine cytology is often problematic because of its low sensitivity, especially for low-grade urothelial carcinoma (UC) in clinical practice. To improve the sensitivity, we focused on 5-aminolevulinic acid (5-ALA), because recent studies suggested that 5-ALA-induced urine cytology can be used for photodynamic diagnosis. In this study, we evaluated the diagnostic efficacy of 5-ALA-induced fluorescent urine cytology for UC.

METHODS

We included in this study 318 patients comprising 158 non-cancer patients, 84 bladder tumor patients, and 76 upper urinary tract urothelial carcinoma (UUT-UC) patients treated in our institution from March 2013 to September 2018. Using the same voided urine sample, we compared sensitivity and specificity between conventional urine cytology and 5-ALA-induced fluorescent urine cytology.

RESULTS

Overall, the sensitivity of 5-ALA-induced fluorescent urine cytology was significantly higher than that of conventional urine cytology (86.9% vs. 69.4%; p = 0.0002), and the specificity was equivalently high (96.2% vs. 95.6%; p = 1.0). In subgroup analysis, the high sensitivity of 5-ALA-induced fluorescent urine cytology was also detected regardless of age, sex, and tumor type. However, in terms of stage and grade, differences were only detected in patients with less than pTa stage (89.2% vs. 52.1%; p = 0.0001) and low-grade tumor (91.5% vs. 51.1%; p < 0.0001).

CONCLUSIONS

5-ALA-induced fluorescent urine cytology was significantly more effective for UC diagnosis when compared with the conventional cytology, especially in patients with low-stage and low-grade tumors. These findings indicate that 5-ALA-induced fluorescent urine cytology may potentially be a very useful tool for clinical use.

Efficacy of 5-Aminolevulinic Acid in Photodynamic Detection and Photodynamic Therapy in Veterinary Medicine

5-Aminolevulinic acid (5-ALA), a commonly used photosensitizer in photodynamic detection (PDD) and therapy (PDT), is converted in situ to the established photosensitizer protoporphyrin IX (PpIX) via the heme biosynthetic pathway. To extend 5-ALA-PDT application, we evaluated the PpIX fluorescence induced by exogenous 5-ALA in various veterinary tumors and treated canine and feline tumors. 5-ALA-PDD sensitivity and specificity in the whole sample group for dogs and cats combined were 89.5 and 50%, respectively. Notably, some small tumors disappeared upon 5-ALA-PDT. Although single PDT application was not curative, repeated PDT+/−chemotherapy achieved long-term tumor control. We analyzed the relationship between intracellular PpIX concentration and 5-ALA-PDT in vitro cytotoxicity using various primary tumor cells and determined the correlation between intracellular PpIX concentration and 5-ALA transporter and metabolic enzyme mRNA expression levels. 5-ALA-PDT cytotoxicity in vitro correlated with intracellular PpIX concentration in carcinomas. Ferrochelatase mRNA expression levels strongly negatively correlated with PpIX accumulation, representing the first report of a correlation between mRNA expression related to PpIX accumulation and PpIX concentration in canine tumor cells. Our findings suggested that the results of 5-ALA-PDD might be predictive for 5-ALA-PDT therapeutic effects for carcinomas, with 5-ALA-PDT plus chemotherapy potentially increasing the probability of tumor control in veterinary medicine.

Porphyrinoids in photodynamic diagnosis and therapy of oral diseases

Photodynamic methods have found application not only in the treatment process as photodynamic therapy but also for the early detection of neoplastic lesions and tumors as photodynamic diagnosis. Early detection of the disease allows not only to avoid the patient’s lifetime risk but also significantly reduce the costs of anticancer therapy, which are increasing every year. There is a constant search for new and more effective photosensitizers which will provide safety in therapy while maintaining efficiency. This paper summarizes recent reports focused on the photodynamic diagnosis of oral cancers. Moreover, it shows methods of the photodynamic treatment of oral verrucous hyperplasia, erythroleukoplakia, and oral leukoplakia. The treatment of choice for these diseases is a surgical excision, which always leads to scar formation. Photodynamic therapy provides a new scar-less tool for the treatment.