Fluorescence in situ hybridization performed on exfoliated urothelial cells in patients with transitional cell carcinoma of the bladder

Management of High-grade T1 Urothelial Carcinoma

PURPOSE OF REVIEW

The optimal management of high-grade T1 (HGT1) urothelial carcinoma (UC) is complex given its high rate of recurrence, progression, and cancer-specific mortality as well as its clinical variability. Our current treatment paradigm has been supplemented by recent data describing the expanding options for salvage intravesical therapy, bladder preservation, and the promising role of molecular epidemiology. In the current review, we attempt to summarize and critically analyze these studies.

RECENT FINDINGS

Evidence describing new intravesical therapies has demonstrated an adequate safety profile and some efficacy in BCG-unresponsive patients who desire bladder preservation. However, response rates are still poor in this high-risk patient population, and it is important to keep these data in perspective when counseling patients. Concomitantly, the continued molecular characterization of non-muscle-invasive bladder cancer may suggest potential therapeutic targets as well as predictors of treatment response in the future. The integration of new intravesical therapies and molecular data into the current treatment paradigm for HGT1 urothelial carcinoma will be critical to improving oncologic outcomes in this particularly high-risk population.

Detection of lung cancer using multiple genetic markers--a systematic review

Lung cancer is the leading cause of cancer deaths worldwide, and has one of the lowest survival rates of any solid tumor. In recent years, several attempts have been conducted to improve an early or accelerated diagnosis due to better overall prognosis after therapy. The aim of this study was evaluating the use of genetic markers for diagnosis of lung cancer. This study was conducted in accordance to Transparent Reporting of Systematic Reviews and Meta-Analyses. Three Internet sources were used to search: MEDLINE-PubMed, EMBASE, and LILACS. The databases were searched for studies conducted in the period up to and including May 10, 2011. The following inclusion criteria were applied: lung cancer studies, and the use of genetic markers for diagnosis. Studies using animal models, review articles, meta-analyses, abstracts, conference proceedings, editorials/letters, case reports, incorrect study population, inadequate data, and cytology was not obtained, were excluded. A total of 1,901 abstracts/citations were identified for preliminary review. From 24 final selected studies, 17 referred to chromosomal markers diagnosis, eight to genes as marker, and one to both subjects. Fluorescence in situ hybridization (FISH) was applied in all studies. Despite the limitations of this study, application of genetic markers to lung cancer diagnosis seems to have prognosis value irrespective of detection methodology used. FISH was the main technique applied to diagnose genetics alterations and revealed a high specificity, although some authors reported low sensitivity.

Virtual cystoscopy (pneumo-cystoscopy)-Its utility in the prospective evaluation of bladder tumor

Aim:

To evaluate the role of virtual cystoscopy (VC) comparing it with cystopanendoscopy (CPE) for detecting bladder tumor(s).

Material and Methods:

Ethical clearance was obtained from the Institutional ethics committee. After an informed consent 30 patients fulfilling the inclusion criteria were enrolled in the prospective non-randomized clinical study and were evaluated as per protocol with VC performed by a qualified radiologist who was blinded to the findings of CPE performed by a qualified urologist. The results so obtained were analyzed using appropriate statistical tools.

Results:

The mean age of the patients was 56 years. Sensitivity of VC in detecting bladder lesions was 92%. However, when axial images were also interpreted along with VC, the sensitivity increased to 96% for detecting bladder lesions. The specificity of VC with axial CT was 40% in respect of detecting bladder lesions. VC with axial CT was 85.7% sensitive in identifying multiple bladder tumors. There were no complications on account of performing VC. Minor problems were encountered with VC and CPE in 16.7% and 13.3% patients respectively.

Conclusions:

VC with axial CT is 96% sensitive in detecting bladder lesions and 85.7% sensitive in detecting the multiplicity of the tumors. VC may be a useful complementary diagnostic tool for the workup of select patients with suspected bladder lesions. However, larger randomized controlled studies are needed to better define the precise clinical and diagnostic role of VC in routine practice.

Settings and Design:

Prospective Clinical Comparative Non Randomized Clinical Study.

Basics of cytology

This overview is intended to give a general outline about the basics of Cytopathology. This is a field that is gaining tremendous momentum all over the world due to its speed, accuracy and cost effectiveness. This review will include a brief description about the history of cytology from its inception followed by recent developments. Discussion about the different types of specimens, whether exfoliative or aspiration will be presented with explanation of its rule as a screening and diagnostic test. A brief description of the indications, utilization, sensitivity, specificity, cost effectiveness, speed and accuracy will be carried out. The role that cytopathology plays in early detection of cancer will be emphasized. The ability to provide all types of ancillary studies necessary to make specific diagnosis that will dictate treatment protocols will be demonstrated. A brief description of the general rules of cytomorphology differentiating benign from malignant will be presented. Emphasis on communication between clinicians and pathologist will be underscored. The limitations and potential problems in the form of false positive and false negative will be briefly discussed. Few representative examples will be shown. A brief description of the different techniques in performing fine needle aspirations will be presented. General recommendation for the safest methods and hints to enhance the sensitivity of different sample procurement will be given. It is hoped that this review will benefit all practicing clinicians that may face certain diagnostic challenges requiring the use of cytological material.

p16(INK4a) expression analysis as an ancillary tool for cytologic diagnosis of urothelial carcinoma

We immunochemically studied p16(INK4a) expression in 116 urine cytologic samples and compared results with 190 histologic samples. The cytologic samples were classified into 4 groups: 1, mild cellular atypia; 2, moderate cellular atypia; 3, severe cellular atypia; and 4, malignancy. Overexpression of p16(INK4a) was detected in none of 32 cases in group 1, 8 (16%) of 50 cases in group 2, 5 (42%) of 12 cases in group 3, and 11 (50%) of 22 cases in group 4. In addition, by histologic analysis, p16(INK4a) overexpression was not detected in nonneoplastic urothelium, except for a few cases of reactive atypia, but it was detected in about 50% of urothelial carcinomas. In particular, a high incidence (16/20 [80%]) of p16(INK4a) overexpression in high-grade carcinomas was noted in cytologic samples. Immunocytologic analysis of p16(INK4a) expression in cytologic samples is a useful ancillary tool for detection of urothelial carcinoma with infiltrating potential.

Urinary fluorescence in situ hybridization assay for detecting urothelial carcinoma in Taiwanese patients

OBJECTIVES

To investigate the cytogenetic marker detected by fluorescence in situ hybridization (FISH; UroVysion, Vysis, Inc., Abbott Laboratories, Des Plaines, IL, USA) in the diagnosis of bladder cancer and upper tract urothelial carcinoma (UC) in Taiwanese patients, as FISH has been used in Western countries for detecting UC, but there are limited results in Asian populations.

PATIENTS AND METHODS

We analysed polyploidy of chromosome 3, 7, 17 and aneuploidy of chromosome 21, using uroepithelial cells collected at the first void or by instrumental extraction of urine, for bladder cancer, and shedding cells from the upper tract flushed by normal saline via ureteric catheterization or ureterorenoscopy. The criteria for positive tumour cells included three or more positive staining in two or more chromosomes showing polyploidy or <50% staining of the chromosome 9p21.

RESULTS

In all, 32 patients with bladder UC and 12 with upper tract UC were assessed. The overall sensitivity for bladder cancer by UroVysion was 96.8%. The sensitivity of the cytology test was 36% for UC of the bladder. The sensitivity for UroVysion in upper tract UC was 12/12 but the specificity was three of nine.

CONCLUSIONS

This preliminary report shows that UroVysion was a sensitive screening method for UC of the bladder and upper urinary tract.

UroVysion FISH test for detecting urothelial cancers: meta-analysis of diagnostic accuracy and comparison with urinary cytology testing

OBJECTIVES

Since the introduction of the UroVysion test for detecting urothelial cancers in urine, its reported performance has varied. This article systematically analyzed reported results.

METHODS

Articles in English conforming to the Oxford EBM criteria were included, with the evaluation focused on cancers that were histologically confirmed at the time of testing rather than on any cancers that might develop later. Where applicable, samples with no cells were reclassified as negative so as to further improve the actual estimation of test performance. Where available, cytology data were also analyzed. Meta-DiSc software was used for the statistical analyses.

RESULTS

We identified 14 studies involving 2477 FISH tests. The overall prevalence of urothelial cancers was 35%. The pooled sensitivity and specificity of all studies were 72% (69%-75%) and 83% (82%-85%), respectively. Cytology data were available from 12 studies, with the overall sensitivity and specificity being 42% (38%-45%) and 96% (95%-97%). Excluding Ta tumors, the sensitivity was 86% (82%-89%) for UroVysion and 61% (56%-66%) for cytology. The overall performance was higher for UroVysion than for cytology: diagnostic odds ratio, 16.8 and 14.1; AUC, 0.867 (SE 0.021) and 0.626 (SE 0.091). These differences in overall test performance measures almost disappeared when superficial cancer cases were excluded from the analysis.

CONCLUSIONS

The published trials suggest that for a general mix of cases, cytology results are highly specific. However, a negative cytology result does not meaningfully change the post-test probability of the presence of urothelial cancer. UroVysion FISH test results should not be considered to provide conclusive evidence for the presence or absence of urothelial cancer, but both positive and negative results do moderately influence the post-test probability of disease.

Aneusomy for detection of bladder cancer recurrence: a Southwest Oncology Group study

The high risk of recurrence in superficial transitional cell cancer (TCC) of the bladder prompted evaluation of whether chromosome changes detected at first recurrence were correlated with relapse or with response to fluoroquinolone treatment. Fluorescence in situ hybridization analysis was applied to desquamated cells from bladder washings obtained immediately before surgical resection. Cells were screened for numeric changes in chromosomes 7 and 9. Aberrations were identified in 38/54 patients eligible for evaluation. Although no clear associations were established owing to sample size, the results suggested that risk of progression/relapse was positively associated with loss of chromosome 9 and with polysomy, and negatively associated with gain of chromosome 7, the latter in contrast to published data. A short-term survival advantage was noted anecdotally with gain of chromosome 9.

Expression of DNA repair and metabolic genes in response to a flavonoid-rich diet

A diet rich in fruit and vegetables can be effective in the reduction of oxidative stress, through the antioxidant effects of phytochemicals and other mechanisms. Protection against the carcinogenic effects of chemicals may also be exerted by an enhancement of detoxification and DNA damage repair mechanisms. To investigate a putative effect of flavonoids, a class of polyphenols, on the regulation of the gene expression of DNA repair and metabolic genes, a 1-month flavonoid-rich diet was administered to thirty healthy male smokers, nine of whom underwent gene expression analysis. We postulated that tobacco smoke is a powerful source of reactive oxygen species. The expression level of twelve genes (APEX, ERCC1, ERCC2, ERCC4, MGMT, OGG1, XPA, XPC, XRCC1, XRCC3, AHR, CYP1A1) was investigated. We found a significant increase (P < 0.001) in flavonoid intake. Urinary phenolic content and anti-mutagenicity did not significantly change after diet, nor was a correlation found between flavonoid intake and urinary phenolic levels or anti-mutagenicity. Phenolic levels showed a significant positive correlation with urinary anti-mutagenicity. AHR levels were significantly reduced after the diet (P = 0.038), whereas the other genes showed a generalized up regulation, significant for XRCC3 gene (P = 0.038). Also in the context of a generalized up regulation of DNA repair genes, we found a non-significant negative correlation between flavonoid intake and the expression of all the DNA repair genes. Larger studies are needed to clarify the possible effects of flavonoids in vivo; our preliminary results could help to better plan new studies on gene expression and diet.

Utility of a multiprobe fluorescence in situ hybridization assay in the detection of superficial urothelial bladder cancer

We evaluated the performance of a multiprobe FISH (fluorescence in situ hybridization) assay for noninvasive detection of superficial urothelial carcinoma (UC) in the bladder, in comparison to urinary cytology. Voided urine samples from 74 patients with superficial UC were analyzed by both techniques. Urine samples from 19 patients with muscle-invasive tumors and from 19 healthy control subjects were also studied. For FISH analysis, labeled probes for chromosomes 3, 7, 9, and 17 were used to assess chromosomal abnormalities indicative of malignancy. We found a significant difference between the overall sensitivity of FISH and cytology in superficial UC detection (70.3 versus 35.1%, respectively; P < 0.0001). This significant difference was maintained when superficial UCs were broken down into low grade (52.8 versus 13.9%, respectively; P < 0.0005) and high grade (86.8 versus 55.3%, respectively; P < 0.0015) tumors. Overall specificity was 100% for cytology and 94.7% for FISH (difference not significant). Of patients with suspicious cytology, 69% were positive by FISH. Together, these findings suggest that FISH assay for chromosomes 3, 7, 9, and 17 has a higher sensitivity than cytology and a similar specificity in the detection of superficial UC--which could be useful for reducing some cystoscopies in the accurate follow-up usually performed in these patients.

Fluorescence in situ hybridization: a multitarget approach in diagnosis and management of urothelial cancer

Noninvasive tests for detecting genetic or molecular alterations in urine indicative of urothelial cancer are increasingly becoming the focus of urological cancer research. Since its approval by the US FDA in 2001, the fluorescence in situ hybridization test (Vysis UroVysion) has been widely evaluated. In general, published data demonstrate better sensitivity and equal or better specificity compared with routine cytology, which is still considered the 'gold standard' in diagnosing and monitoring bladder tumors. However, the fluorescence in situ hybridization test seems to provide not only a useful tool in bladder cancer detection, but also in the diagnosis of upper urinary tract tumors, surveillance and determining therapy effectiveness. This multitarget assay that detects four different chromosomal aberrations in tumor cells is a kind of objective molecular cytology and has proven advantages over routinely used cytology.

Urinary markers in the detection of bladder cancer: what's new?

PURPOSE OF REVIEW

Bladder cancer is one of the most common genitourinary malignancies and is a potentially life-threatening diagnosis. For many patients, however, the diagnosis of bladder cancer entails a lifetime of vigilant, costly, and invasive surveillance for recurrent and/or progressive disease. In the context of relative limitations of the current standard of cystoscopy and cytology, there has been burgeoning activity in the development of novel molecular urine-based markers for bladder cancer detection.

RECENT FINDINGS

A large number of candidate bladder cancer biomarkers have emerged as our understanding of the molecular pathogenesis of the disease has evolved. Many of these are in the relatively earlier phases of development but several have received the approval of the United States Food and Drug Administration for clinical use and are already being applied to patients in clinical practice.

SUMMARY

Urine-based markers for bladder cancer detection represent an area of substantial innovation and discovery with potentially profound scientific, clinical, and economic implications. As more of these tests become standardized and undergo evaluation in large multicenter trials, it is conceivable that a novel marker or panel of markers will emerge as a major enhancement to the current standard of care.

Improved detection of bladder carcinoma cells in voided urine by standardized microsatellite analysis

Successful treatment of bladder cancer depends largely on early diagnosis of primary and recurrent disease. Sensitive, specific and noninvasive procedures for detection are especially needed for grade 1 and 2 bladder tumors, because of the relatively low sensitivity of cytology. Here we introduce a novel strategy to improve the sensitivity and reliability of microsatellite analyses by employing marker-specific threshold values for loss-of-heterozygosity (LOH) at 10 loci. These individual cut-offs were experimentally determined with 35 normal control tissues and subsequently validated in a retrospective study with bladder cancer biopsies from 86 patients. In a prospective analysis of voided urines samples and matched blood probes from 91 patients, LOH-analysis, UroVysion FISH and conventional urine cytology were compared with histological findings of consecutive transurethral biopsies. Whereas all samples could be analyzed by our LOH assay, only 56 samples were suitable for all 3 analyses. The highest sensitivity was obtained with our LOH-assay/cytology approach (G1-2: 72%; G3: 96%) being only surpassed by a combination of all 3 techniques (G1-2: 83%; G3: 100%). Since over 93% of the patients with recurrent disease were identified by LOH/cytology-analyses of their voided urine samples, a monitoring scheme alternating cystoscopy with LOH/cytology-examination could now be envisioned to reduce invasive interventions and consequently improve follow-up compliance, especially in patients with low grade tumors.

Toward critical evaluation of the role(s) of molecular biomarkers in the management of bladder cancer

Among genitourinary malignancies, bladder cancer is a common, potentially dangerous and exceedingly costly disease entity. Predicated on substantial gains in our understanding of the natural history and molecular biology of bladder cancer, recent years have seen an explosion of new applied technologies to aid clinicians in the management of bladder cancer. Herein we present a systematic overview of general conceptual issues and specific strategies of potential relevance to the clinical evaluation of patients with bladder cancer. A number of basic epidemiological issues provide the relevant background within which we should consider candidate biomarkers. Within this framework, we highlight a number of important recent research findings representative of the large number of candidate bladder cancer biomarkers that have emerged. With several markers already having obtained regulatory approval for clinical use, this topic is of clear relevance not only to researchers but also to the practicing physician. Bladder cancer is a common, costly, and potentially dangerous disease with the opportunity for significant technological inroads in the area of applied biomarkers. An appreciation of basic epidemiological considerations informs our consideration of the state of the art and identifies specific strategies amenable to further innovation.

DNA–based molecular cytology for bladder cancer surveillance

Surveillance strategies for urothelial cancer (UC) recurrence have historically relied on the diagnostic combination of cystoscopy and conventional urinary cytology. In this review, results of studies evaluating the role of the fluorescence in situ hybridization (FISH) assay in bladder cancer surveillance are critically examined. The published research on FISH compared with conventional cytology and cystoscopy for bladder cancer was identified using a Medline search and was critically analyzed. Sensitivity and specificity data were tabulated and compared. FISH outperformed conventional cytology across all stages and grades in all published reports, and it detected malignancy before the development of lesions visible by cystoscopy. Although overall sensitivity was 48% for cytology and 74% for FISH, its greatest advantage was in the detection of high-grade UC, including carcinoma in situ (CIS). Cumulative data from comparative studies showed the sensitivity of cytology compared with FISH was 19% versus 58% for grade 1, 50% versus 77% for grade 2, and 71% versus 96% for grade 3. Similar findings occurred by stage, where cytology compared with FISH sensitivity was 35% versus 64% for Ta, 66% versus 83% for T1, and 76% versus 94% for muscle-invasive carcinoma. Notably, cytology detected only 67% of CIS versus 100% detection by FISH. Specificity data were comparable. Unlike conventional urinary cytology and cystoscopy, which depend on subjective visible microscopic or macroscopic changes, FISH allows identification of chromosomal abnormalities associated with malignant development before phenotypic expression of those alterations. Use of morphologic cellular changes allows more rapid detection of such alterations, combining the benefits of conventional cytology with molecular diagnostics. It is apparent that we are in the early phases of realizing the potential of molecular diagnostics.

Atypical squamous cells in exfoliative urinary cytology: Clinicopathologic correlates

Presence of atypical squamous cells (ASC) in voided urine is an uncommon finding that may be the harbinger of an underlying malignant process. ASCs in urine may precede a de novo histologic diagnosis of malignancy or be the first sign of a recurrence in the lower urinary tract, or the gynecologic tract (in women). This study analyzed all urine cytology specimens with such diagnoses, with reference to their final histologic outcome. All urine cytology cases (n = 17,446) that included ASCs, evaluated at The Johns Hopkins Hospital between 1989 and 2003 (14 yr), were reviewed for diagnoses. ASCs as defined in this study are keratinizing cells with large and hyperchromatic smudgy nuclei, high N/C ratio, abnormal nuclear or cytoplasmic shapes, and densely orangeophilic cytoplasm. These cases lacked the qualitative and quantitative criteria for malignancy. The final reference outcome was determined by subsequent histologic and clinical follow-up. Of these 17,446 urine specimens, 55 cases (0.3%) from 47 patients had ASCs present. Thirty-two of the 47 patients had adequate follow-up. In 8 of these 32 patients (25%), a diagnosis of squamous-cell carcinoma (SCC) of the urinary bladder or urothelial carcinoma (UC) with squamous differentiation was made on subsequent histologic examination. In two cases (6%) a diagnosis of high-grade cervical SCC was established on subsequent follow-up. Twenty two of 32 cases (69%) remained benign on histologic and prolonged clinical follow-up. We conclude that ASCs in urine are rare (0.3% in this series). An interpretation of ASCs in a urine specimen is made when there is insufficient qualitative/quantitative evidence for a carcinoma diagnosis. ASCs in urine are a clinically valid diagnostic category (31% were later diagnosed with SCC). Most patients with urinary ASCs do not develop malignancy and, therefore, these cells may represent a reactive/inflammatory process most commonly due to vaginal contamination (in women) or exfoliation from the distal urethra (in men). Rarely, ASCs may exfoliate from a uterine cervical SCC and, therefore, a pelvic examination should be considered in such patients.