Urothelial cancer biomarkers for detection and surveillance

Mini-Review: Current Bladder Cancer Treatment-The Need for Improvement

Bladder cancer is the tenth most common cancer and is a significant burden on health care services worldwide, as it is one of the most costly cancers to treat per patient. This expense is due to the extensive treatment and follow-ups that occur with costly and invasive procedures. Improvement in both treatment options and the quality of life these interventions offer has not progressed at the rates of other cancers, and new alternatives are desperately needed to ease the burden. A more modern approach needs to be taken, with urinary biomarkers being a positive step in making treatments more patient-friendly, but there is still a long way to go to make these widely available and of a comparable standard to the current treatment options. New targets to hit the major signalling pathways that are upregulated in bladder cancer, such as the PI3K/AkT/mTOR pathway, are urgently needed, with only one drug approved so far, Erdafitinib. Immune checkpoint inhibitors also hold promise, with both PD-1 and CDLA-4 antibody therapies approved for use. They effectively block ligand/receptor binding to block the immune checkpoint used by tumour cells. Other avenues must be explored, including drug repurposing and novel biomarkers, which have revolutionised this area in other cancers.

Prognostic factors of non-muscle invasive bladder cancer: a study based on next-generation sequencing

Objective

To investigate the genetic prognostic factors for the recurrence of non-muscle invasive bladder cancer.

Materials and methods

The patients underwent transurethral resection of bladder tumor and received bacillus Calmette–Guérin (BCG) or epirubicin. Next-generation sequencing was performed and alterations of genes, pathways, and tumor mutation burden were recorded. Associations between these clinicopathological and genetic variants were estimated, and prognostic factor identified.

Results

A total of 58 cases were included in our study, and 46 patients underwent treatment with BCG. FGFR3 was the most frequently altered gene (48%), and more commonly detected in intermediate-risk patients. Univariate Cox analysis demonstrated that 10 genes were significantly correlated with BCG failure, while NEB, FGFR1 and SDHC were independent recurrence predictors. Besides, epigenetic-related gene pathway mutations were negatively correlated with recurrence (hazard ratio: 0.198, P = 0.023). DNA damage response and repair gene alterations were positively correlated with tumor burden, while altered TP53 was most frequent among these genes and significant correlated with high tumor burden.

Conclusion

BCG instillation significantly reduced the rate of recurrence compared with epirubicin in this population. Potential biomarkers and therapeutic targets were found with the help of next-generation sequencing; correlations between DDR genes alterations and high tumor mutation burden were also demonstrated.

Advances in urinary biomarker discovery in urological research

A disease-specific biomarker (or biomarkers) is a characteristic reflecting a pathological condition in human body, which can be used as a diagnostic or prognostic tool for the clinical management. A urine-based biomarker(s) may provide a clinical value as attractive tools for clinicians to utilize in the clinical setting in particular to bladder diseases including bladder cancer and other bladder benign dysfunctions. Urine can be easily obtained by patients with no preparation or painful procedures required from patients' side. Currently advanced omics technologies and computational power identified potential omics-based novel biomarkers. An unbiased profiling based on transcriptomics, proteomics, epigenetics, metabolomics approaches et al. found that expression at RNA, protein, and metabolite levels are linked with specific bladder diseases and outcomes. In this review, we will discuss about the urine-based biomarkers reported by many investigators including us and how these biomarkers can be applied as a diagnostic and prognostic tool in clinical trials and patient care to promote bladder health. Furthermore, we will discuss how these promising biomarkers can be developed into a smart medical device and what we should be cautious about toward being used in real clinical setting.

Biomarkers of aggressiveness in genitourinary tumors with emphasis on kidney, bladder, and prostate cancer

INTRODUCTION

Over the last decade, the improvement in molecular techniques and the acquisition of genomic information has transformed and increased the quality of patient care and our knowledge of diseases. Areas covered: Protein expression levels in immunohistochemistry and molecular biomarkers are reported for their ability to predict recurrence, progression, development of metastases, or patient survival. In particular, for renal cell carcinoma, we take into consideration the biomarkers applicable to immunohistochemistry and with molecular and genetic analyses. In urothelial carcinoma, there is great interest in the possibility of distinguishing the basal vs. luminal subtypes and to acquire deeper insight into the tumor biology through examining exosomes in urine and biomarkers in the serum. In prostate cancer, single gene expression and multiple gene expression classifiers are reviewed as a tool to distinguish indolent vs. aggressive disease. Expert commentary: The genomic information along with the application of ancillary techniques allow the definition of a neoplasia not only by its morphology but also by its biological signature. This continuous increase in knowledge will result in a better comprehension of oncogenesis, development of targeted therapies and optimizing decision-making processes related to patient care.

Accuracy of urine telomerase activity to detect bladder cancer in symptomatic patients

Telomerase activity assessment in voided urine is an important noninvasive tool for bladder cancer diagnosis. In a previous case-control study we verified that this method can detect tumor cells in urine with high sensitivity and specificity, but few data are still available on its accuracy to detect tumors in patients with symptomatic urinary tract diseases. Following recently published guidelines on bladder cancer, we aimed to define the diagnostic accuracy of urine telomerase levels in symptomatic patients. Telomerase activity, expressed in arbitrary enzymatic units (AEUs), was evaluated in urine collected from 515 patients: 197 with urinary tract symptoms and 318 with a first diagnosis of bladder cancer. Telomerase repeat amplification protocol (TRAP) sensitivity ranged from 93% to 61% and specificity varied from 42% to 88% at the different AEU cutoff values. At the cutoff of 50, the sensitivity was 87% (95% CI 83–91), the specificity was 70% (95% CI 63–75), and the overall accuracy, in terms of true positives and true negatives, was 80%. Sensitivity did not vary in relation to tumor grade or stage at diagnosis, or to patient age. Our results indicate that urine telomerase activity is a good marker for the early diagnosis of bladder tumors in symptomatic patients, a subset which represents an “at-risk” population requiring close surveillance.

Advances in point-of-care diagnostic devices in cancers

The early diagnosis and monitoring of the progress of cancers are limited due to the lack of adequate screening tools.

Follow-up in non-muscle-invasive bladder cancer-International Bladder Cancer Network recommendations

OBJECTIVE

Non-muscle-invasive bladder cancer (NMIBC) comprises a wide spectrum of tumors with different behaviors and prognoses. It follows that the surveillance for these tumors should be adapted according to the risks of recurrence and progression and should be dynamic in design.

METHODS AND MATERIALS

Medline search was conducted from 1980 to 2016 using a combination of MeSH and keyword terms. The highest available evidence was reviewed to define different risk groups in NMIBC. The performance of different follow-up tools such as urine cytology, cystoscopy, and upper tract imaging in detecting bladder carcinoma was assessed. Different commercially available urinary markers were investigated to determine whether such markers would contribute to the surveillance of patients with NMIBC. A follow-up scheme based on the early evidence is proposed.

RESULTS

A risk-based approach is paramount. Cystoscopy and cytology are recommended to be done at 3 months following transurethral resection of bladder tumor. For low-risk tumors, annual cystoscopy alone is sufficient; no upper tract evaluations or cytology is needed except at diagnosis. High-risk tumors should be followed up with a more intense schedule: cystoscopy every 3 months for 2 years, 6 months for 2 years, and then annually, with cytology at frequent intervals, and imaging for upper tract evaluation at 1 year and then every 2 years. Intermediate-risk tumors should be subclassified as per the International Bladder Cancer Group recommendations and when associated with 3 or more of the following findings (multiple tumors, size≥3cm, early recurrence<1 year, frequent recurrences>1 per year) then a surveillance strategy similar to that of high risk should be followed. Several urine markers were more sensitive than cytology in the detection of NMIBC; however, these tests are still costly, require specialized laboratories, and do not replace cystoscopy. Until better and cheaper markers are available, their routine use has not been integrated in the follow-up recommendation of current guidelines.

CONCLUSIONS

Surveillance of NMIBC should follow a risk-adapted approach, with a combination of cystoscopy, cytology, and upper tract imaging. The aim of this approach is to minimize the therapeutic burden of a disease with high recurrence rates without missing progressing tumors. When designing a diagnostic pathway, first-line diagnostic imaging tests should have high sensitivity to ensure disease positives are included in the test population for further investigation. Second-line investigations should be highly specific, to ensure false-positives are minimized.

Reduction of protein kinase C α (PKC-α) promote apoptosis via down-regulation of Dicer in bladder cancer

In clinic, we examined the expression of protein kinase C (PKC)-α and Dicer in the samples of bladder cancer patients, and found that the two proteins have a line correlation. Our study confirmed this correlation existing by clearing the decreasing expression of Dicer after the PKC-α knockdown. Treatment of bladder cancer cell lines (T24, 5637) with the PKC-α or Dicer knockdown and the PKC inhibitors (Calphostin C and Gö 6976) can promote the apoptosis. Inhibition of PKC can increase the activities of caspase-3 and PARP, however, decrease the expression of Dicer. And knockdown of the PKC-α or Dicer can also activate the caspase-3 or the PARP. Considering the reduction of PKC-α can induce the Dicer down-regulation, we make the conclusion that the reduction of PKC-α can promote the apoptosis via the down-regulation of Dicer in bladder cancer.

NRP-1 expression in bladder cancer and its implications for tumor progression

Neuropilin-1 (NRP-1) overexpression has been reported in a variety of human cancers. However, the role of NRP-1 in bladder cancer (BC) remains unclear. The aim of present study was to analyze NRP-1 protein expression in BC tissues and to assess its prognostic significance for BC. NRP-1 messenger ribonucleic acid (mRNA) and protein expression were determined by real-time quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR) and immunohistochemistry in specimens of primary cancer and their adjacent noncancerous tissues in BC patients. Additionally, NRP-1 protein expression in 139 archived paraffin-embedded BC samples was analyzed by immunohistochemistry and correlated with clinicopathological characteristics and survival. Student's t test, Spearman's rank correlation, Kaplan-Meier plots, and Cox's proportional hazards regression model were used to analyze the data. By qRT-PCR and immunohistochemistry, the levels of NRP-1 mRNA and protein were significantly higher in BC, compared to that in adjacent noncancerous tissues (P<0.001). High expression of NRP-1 was significantly associated with histologic grade (P=0.016) and tumor stage (P=0.001). Multivariate analysis showed that high expression of NRP-1 was an independent prognostic factor for overall survival. Our study suggests that overexpression of NRP-1 may play an important role in the progression of BC, and NRP-1 expression may serve as a biomarker for poor prognosis for BC.

PKC α regulates netrin-1/UNC5B-mediated survival pathway in bladder cancer

BACKGROUND

Netrin-1 and its receptor UNC5B play important roles in angiogenesis, embryonic development, cancer and inflammation. However, their expression patttern and biological roles in bladder cancer have not been well characterized. The present study aims to investigating the clinical significance of PKC α, netrin-1 and UNC5B in bladder cancer as well as their association with malignant biological behavior of cancer cells.

METHODS

Netrin-1 and UNC5B expression was examined in 120 bladder cancer specimens using immunohistochemistry and in 40 fresh cancer tissues by western blot. Immunofluorescence was performed in cancer cell lines. PKC α agonist PMA and PKC siRNA was employed in bladder cancer cells. CCK-8, wound healing assays and flow cytometry analysis were used to examine cell proliferation, migration and cell cycle, respectively.

RESULTS

Netrin-1 expression was positively correlated with histological grade, T stage, metastasis and poor prognosis in bladder cancer tissues. Immunofluorescence showed elevated netrin-1 and decreased UNC5B expression in bladder cancer cells compared with normal bladder cell line. Furthermore, cell proliferation, migration and cell cycle progression were promoted with PMA treatment while inhibited by calphostin C. In addition, PMA treatment could induce while calphostin C reduce netrin-1 expression in bladder cancer cells.

CONCLUSIONS

The present study identified netrin-1/UNC5B, which could be regulated by PKC signaling, was important mediators of bladder cancer progression.

High expression of polo-like kinase 1 is associated with the metastasis and recurrence in urothelial carcinoma of bladder

OBJECTIVES

Polo-like kinase 1 (Plk1) has been widely pursued as an oncology target because it is overexpressed in several human tumor types. To investigate whether Plk1 plays a general role in bladder urothelial carcinoma, we examined the expression of Plk1 protein in bladder urothelial carcinoma and cell lines, and analyzed the relationship among Plk1 protein expression, metastasis, and recurrence of urinary bladder urothelial carcinoma.

METHODS

Immunohistochemistry was used to detect the expression of Plk1 in 120 bladder urothelial carcinoma. Moreover, the expression of Plk1 was analyzed by Western blot in 60 bladder urothelial carcinoma and 21 normal epithelial tissues. MTT assay and flow cytometry and transwell assay were used to examine the proliferative and invasive ability of bladder cancer cells with the treatment of scytonemin (the inhibitor of Plk1). Statistical analysis was used to discuss the association between Plk1 expression and clinicopathologic parameters, tumor metastasis and recurrence, and the proliferative and invasive ability and cell cycle process of the bladder cancer cells.

RESULTS

There was a significantly higher Plk1expressions in bladder urothelial carcinoma and highly invasive bladder T24 cells than those in bladder normal tissues and the superficial bladder BIU-87 cells. Plk1 expression was positively correlated with histologic grade, pT stage, recurrence, and metastasis. With the increasing concentration of scytonemin, we found that not only the cell proliferation and invasion activity decreased significantly, but also the cell cycle was blocked at G2/M stage.

CONCLUSION

Plk1 expression status was closely correlated with important histopathologic characteristics (grades and stages) and the recurrence and metastasis of bladder urothelial carcinomas. Furthermore, Plk1 played an important function on the bladder cancer cells' proliferation by regulating the cancer cell cycle from G1/S to G2/M and probably promoted the invasion and metastasis of bladder cancer.

The influence of urine cytology on our practice

OBJECTIVE

Bladder cancer is a common malignancy. It is ranked ninth among male population in Saudi Arabia. Urine cytology is used by some physicians routinely in the workup for diagnosis and follow-up of patients with urothelial cancer. Our objective is to determine whether urine cytology is still essential in the work up of suspected urothelial cancer patients and to measure its cost-effectiveness.

MATERIALS AND METHODS

We reviewed all urine cytology reports that were performed over a period of five years from 2006 to 2010 in the International Medical Center in Jeddah, Saudi Arabia. The medical records of patients with cytology reports of both positive for malignant cells and atypical cells suspicious of malignancy were retrospectively, studied for age, sex, nationality, cystoscopic findings, imaging results, and total cost.

RESULTS

A total of 563 urine cytology tests were done on 516 patients. Two patients were positive for malignant cell and 10 showed atypical cells suspicious of malignancy. All 12 patients underwent imaging and/or cystoscopy as part of their complete work up for hematuria. The two patients with positive cytology had a cystoscopic confirmation of bladder tumor. In the 10 patients with atypical cells, bladder tumor was identified in seven using cystoscopy and/or imaging. The mean age was 54.6±16 year (range 15-95). The total cost was 140,750 SR (37,533 USD) for a yield of 0.3% positive results and 2% atypical cytology.

CONCLUSION

Routine urine cytology did not affect the diagnostic strategy for urothelial cancer. It should be only used in selected patients.

Evaluation of acridine orange fluorescence in exfoliative urinary cytology for diagnosing bladder carcinoma

PURPOSE

This study reviewed acridine orange fluorescence (AO-F) in exfoliative urinary cytology results of 1,016 inpatients with urothelial cell carcinoma of the bladder and 804 outpatients to investigate the value of AO-F in the diagnosis of bladder cancer.

METHODS

A total of 1,016 bladder cancer inpatients from October 1995 to October 2005 and 804 outpatients from January 2004 to January 2006 were enrolled in this study. Each patient provided the morning urine specimen of 30-50 ml in a sterile container. Urine sediments were stained by acridine orange and observed with a fluorescence microscope; 60 bladder cancer inpatients from January 2006 to July 2007 were also chosen for the control study of three different detection methods, including AO-F, hematoxylin and eosin and Feulgen staining.

RESULTS

Of the 1,016 bladder carcinoma samples analyzed, 793 were AO-F positive. Total positive rate of AO-F was 78.05 %. The positive rate was 74.69 % (611/818) for non-muscle invasive bladder carcinoma and 91.91 % (182/198) for muscle invasive bladder carcinoma. A significant correlation of AO-F positivity with clinical stage was observed (P < 0.01). The positive rates among various pathological grades were 66.7 % (32/48) for G1, 67.5 % (319/474) for G2 and 90.4 % (413/457) for G3 with significant differences (P < 0.01). For the 804 outpatients, the sensitivity and specificity of bladder carcinoma were 77.11 and 85.29 %, respectively.

CONCLUSIONS

With its high sensitivity and specificity, AO-F is superior to other detection methods for bladder carcinoma detection. In addition, it is familiar, non-invasive, quick, cheap and easily repeatable.

The ubiquitin-specific protease USP2a enhances tumor progression by targeting cyclin A1 in bladder cancer

The deubiquitinating enzyme USP2a has shown oncogenic properties in many cancer types by impairing ubiquitination of FASN, MDM2, MDMX or Aurora A. Aberrant expression of USP2a has been linked to progression of human tumors, particularly prostate cancer. However, little is known about the role of USP2a or its mechanism of action in bladder cancer. Here, we provide evidence that USP2a is an oncoprotein in bladder cancer cells. Enforced expression of USP2a caused enhanced proliferation, invasion, migration and resistance to several chemotherapeutic reagents, while USP2a loss resulted in slower proliferation, greater chemosensitivity and reduced migratory/invasive capability compared with control cells. USP2a, but not a catalytically inactive mutant, enhanced proliferation in immortalized TRT-HU1 normal human bladder epithelial cells. USP2a bound to cyclin A1 and prevented cyclin A1 ubiquitination, leading to accumulation of cyclin A1 by a block in degradation. Enforced expression of wild type USP2a, but not an inactive USP2a mutant, resulted in cyclin A1 accumulation and increased cell proliferation. We conclude that USP2a impairs ubiquitination and stabilizes an important cell cycle regulator, cyclin A1, raising the possibility of USP2a targeting as a therapeutic strategy against bladder tumors in combination with chemotherapy.

Epigenetics of bladder cancer

Epigenetic changes are closely associated with tumor development and prognosis of bladder cancer, and its detection in specimens (tissue/body fluid) may be feasible and more sensitive than conventional methods. Additionally, the epigenetic changes are interesting from a clinical point of view because it may be possible to reverse epigenetic changes and restore the gene function. Epigenetic markers might therefore be more useful than conventional molecular markers for the detection, prediction of prognosis, and treatment of bladder cancer.

Novel combination markers for predicting progression of nonmuscle invasive bladder cancer

To identify prognostic markers in nonmuscle invasive bladder cancer (NMIBC), the combined effect of RUNX3 and MGC17624 for predicting NMIBC progression was assessed. RUNX3 promoter methylation was examined using methylation specific-polymerase chain reaction (MS-PCR). MGC17624 mRNA expression was evaluated by real-time PCR. Patients were divided into three groups according to the status of the two genes and the prognostic effects of these markers were evaluated. The median follow-up period was 57.8 months (range, 9.1-189.7). The mRNA expression level of MGC17624 was significantly lower in patients with positive RUNX3 methylation than in those with negative methylation (p = 0.047). Kaplan-Meier estimates showed significant differences in time-to-progression between the genetic combination predictors (log-rank test; p < 0.001). Patients with a poor predictive combination were at a significantly higher risk for progression [Hazard ratio (HR), 22.579] than patients with a good predictive combination in multivariate Cox regression analysis. In the subgroup analysis, a poor predictive combination accurately estimated progression in patients with intravesical therapy (HR, 20.081) and in those who experienced recurrence (HR, 54.233). Assessment of the status of RUNX3 and MGC17624 in combination was identified as a reliable method for predicting NMIBC progression.

Biomarkers for detection and surveillance of bladder cancer

INTRODUCTION

Bladder cancer is the fourth most common cancer in men and the ninth most common cancer in women in Canada. Early detection of tumours is essential for improved prognosis and long-term survival. The standard method for detection and surveillance is cystoscopy together with urine cytology. Cystoscopy is relatively sensitive but is expensive and invasive. Urinary cytology is a noninvasive method that has poor sensitivity but high specificity; it is relied on for the detection of carcinoma in situ. Currently, several urinary-based bladder tumour biomarkers with USFDA/Health Canada approval are available commercially, but none have been widely adopted by urologists despite their offering high sensitivity and/or specificity. We present here a review of recent studies evaluating 7 commercial biomarker assays for the detection and/or surveillance of bladder cancer.

RESULTS

SENSITIVITY AND SPECIFICITY RANGES, RESPECTIVELY, FOR EACH MARKER WERE REPORTED AS FOLLOWS: BTA Stat (Polymedco), 52.5%-78.0% and 69.0%-87.1%; BTA Trak (Polymedco), 51%-100% and 73%-92.5%; cytology, 12.1%-84.6% and 78.0%-100%; hematuria dipstick, 47.0%-92.6% and 51.0%-84.0%; NMP22 Bladder Cancer Test (Matritech), 34.6%-100% and 60.0%-95.0%; NMP22 BladderChek (Matritech), 49.5%-65.0% and 40.0%-89.8%; ImmunoCyt/uCyt+ (DiagnoCure), 63.3%-84.9% and 62.0%-78.1%; ImmunoCyt/uCyt+ and cytology, 81.0%-89.3% and 61.0%-77.7%; and UroVysion (Abbott Molecular)/florescence in situ hybridization, 68.6%-100% and 65.0%-96.0%.

CONCLUSION

We find that no currently available bladder cancer urinary marker is sensitive enough to eliminate the need for cystoscopy. In addition, cytology remains integral to the detection of occult cancer. However, owing to their relatively high sensitivities, these markers may be used to extend the period between cystoscopies in the surveillance of patients with transitional cell carcinoma. Further study is required to determine which markers, alone or in panel, would best accomplish this.

[New concepts in management of NMIBC in 2010]

The aim of this article is to make a synthesis of news headlines concerning the follow-up and the management of non-muscle invasive bladder tumors. The diagnosis and the follow-up of non-muscle invasive bladder are based on flexible cystoscopy associated with urinary cytology. At present time, no molecular marker, and no imaging allows to reduce the rhythm and the modalities of surveillance such as defined by the guidelines. Early cystectomy is the current option for BCG-refractory high risk bladder tumor. Rarely, some conservative options, such as endovesical chemotherapy, could be discussed at an individual level.

Identification of C16orf74 as a marker of progression in primary non-muscle invasive bladder cancer

PURPOSE

Methylation-induced silencing of PRSS3 has been shown to be significantly associated with invasive bladder cancer, and expression of the C16orf74 gene locus has been shown to correlate positively with PRSS3. The aim of the current study was to evaluate the relationship between C16orf74 expression level and progression in non-muscle invasive bladder cancer (NMIBC).

MATERIALS AND METHODS

C16orf74 mRNA levels were examined by real-time reverse transcriptase polymerase chain reaction (RT-PCR) analysis of 193 tumor specimens from patients with primary NMIBC. Expression data were analyzed in terms of clinical and experimental parameters. Kaplan-Meier curves and multivariate Cox regression models, respectively, were used to determine progression-free survival and to identify independent predictive parameters of progression.

RESULTS

Analysis using Kaplan-Meier curves revealed prolonged progression-free survival of high-C16orf74-expressors as compared to low-expressors (p<0.001). Multivariate Cox regression analysis revealed that low C16orf74 mRNA expression levels are a significant risk factor for disease progression in patients with primary NMIBC (HR: 10.042, CI:2.699-37.360, p = 0.001).

CONCLUSIONS

Decreased expression of C16orf74 correlates significantly with progression in primary NMIBC. C16orf74 expression level represents a potentially useful marker for predicting progression in primary NMIBC patients.

Integrated genetic and epigenetic analysis of bladder cancer reveals an additive diagnostic value of FGFR3 mutations and hypermethylation events

The bladder cancer genome harbors numerous oncogenic mutations and aberrantly methylated gene promoters. The aim of our study was to generate a profile of these alterations and investigate their use as biomarkers in urine sediments for noninvasive detection of bladder cancer. We systematically screened FGFR3, PIK3CA, TP53, HRAS, NRAS and KRAS for mutations and quantitatively assessed the methylation status of APC, ARF, DBC1, INK4A, RARB, RASSF1A, SFRP1, SFRP2, SFRP4, SFRP5 and WIF1 in a prospective series of tumor biopsies (N = 105) and urine samples (N = 113) from 118 bladder tumor patients. We also analyzed urine samples from 33 patients with noncancerous urinary lesions. A total of 95 oncogenic mutations and 189 hypermethylation events were detected in the 105 tumor biopsies. The total panel of markers provided a sensitivity of 93%, whereas mutation and methylation markers alone provided sensitivities of 72% and 70%, respectively. In urine samples, the sensitivity was 70% for all markers, 50% for mutation markers and 52% for methylation markers. FGFR3 mutations occurred more frequently in tumors with no methylation events than in tumors with one or more methylation events (78% vs. 33%; p < 0.0001). FGFR3 mutation in combination with three methylation markers (APC, RASSF1A and SFRP2) provided a sensitivity of 90% in tumors and 62% in urine with 100% specificity. These results suggest an inverse correlation between FGFR3 mutations and hypermethylation events, which may be used to improve noninvasive, DNA-based detection of bladder cancer.

Identification of S100A8-correlated genes for prediction of disease progression in non-muscle invasive bladder cancer

Background

S100 calcium binding protein A8 (S100A8) has been implicated as a prognostic indicator in several types of cancer. However, previous studies are limited in their ability to predict the clinical behavior of the cancer. Here, we sought to identify a molecular signature based on S100A8 expression and to assess its usefulness as a prognostic indicator of disease progression in non-muscle invasive bladder cancer (NMIBC).

Methods

We used 103 primary NMIBC specimens for microarray gene expression profiling. The median follow-up period for all patients was 57.6 months (range: 3.2 to 137.0 months). Various statistical methods, including the leave-one-out cross validation method, were applied to identify a gene expression signature able to predict the likelihood of progression. The prognostic value of the gene expression signature was validated in an independent cohort (n = 302).

Results

Kaplan-Meier estimates revealed significant differences in disease progression associated with the expression signature of S100A8-correlated genes (log-rank test, P < 0.001). Multivariate Cox regression analysis revealed that the expression signature of S100A8-correlated genes was a strong predictor of disease progression (hazard ratio = 15.225, 95% confidence interval = 1.746 to 133.52, P = 0.014). We validated our results in an independent cohort and confirmed that this signature produced consistent prediction patterns. Finally, gene network analyses of the signature revealed that S100A8, IL1B, and S100A9 could be important mediators of the progression of NMIBC.

Conclusions

The prognostic molecular signature defined by S100A8-correlated genes represents a promising diagnostic tool for the identification of NMIBC patients that have a high risk of progression to muscle invasive bladder cancer.

Predictive value of progression-related gene classifier in primary non-muscle invasive bladder cancer

Background

While several molecular markers of bladder cancer prognosis have been identified, the limited value of current prognostic markers has created the need for new molecular indicators of bladder cancer outcomes. The aim of this study was to identify genetic signatures associated with disease prognosis in bladder cancer.

Results

We used 272 primary bladder cancer specimens for microarray analysis and real-time reverse transcriptase polymerase chain reaction (RT-PCR) analysis. Microarray gene expression analysis of randomly selected 165 primary bladder cancer specimens as an original cohort was carried out. Risk scores were applied to stratify prognosis-related gene classifiers. Prognosis-related gene classifiers were individually analyzed with tumor invasiveness (non-muscle invasive bladder cancer [NMIBC] and muscle invasive bladder cancer [MIBC]) and prognosis. We validated selected gene classifiers using RT-PCR in the original (165) and independent (107) cohorts. Ninety-seven genes related to disease progression among NMIBC patients were identified by microarray data analysis. Eight genes, a progression-related gene classifier in NMIBC, were selected for RT-PCR. The progression-related gene classifier in patients with NMIBC was closely correlated with progression in both original and independent cohorts. Furthermore, no patient with NMIBC in the good-prognosis signature group experienced cancer progression.

Conclusions

We identified progression-related gene classifier that has strong predictive value for determining disease outcome in NMIBC. This gene classifier could assist in selecting NMIBC patients who might benefit from more aggressive therapeutic intervention or surveillance.

Clinical implications and prognostic values of topoisomerase-II alpha expression in primary non-muscle-invasive bladder cancer

OBJECTIVES

To investigate the association between expression levels of topoisomerase-II alpha (TOP-2alpha) and prognosis in primary non-muscle-invasive bladder cancer (NMIBC). TOP-2alpha, a marker of cell proliferation, has been assessed as a prognostic indicator in several types of cancer. However, currently available data on the role of TOP-2alpha in prognosis are inconsistent.

METHODS

Top-2alpha messenger ribonucleic acid (mRNA) levels were examined in 103 tumor specimens from patients with primary NMIBC by real-time polymerase chain reaction. Immunohistochemical staining was performed on 39 matched tumor samples. The median follow-up period for all patients was 51.8 months (range, 3.2-137).

RESULTS

The mRNA expression levels of TOP-2alpha were significantly elevated in subjects with high-grade (P<.001) and high-stage (P=.041) tumors as compared with subjects with low-grade and low-stage tumors. Kaplan-Meier estimates revealed significant variation in tumor recurrence and progression depending on the level of TOP-2alpha expression (log-rank test, P<.05). Multivariate Cox regression analysis revealed that the level of TOP-2alpha expression is a strong predictor of recurrence (hazard ratio, 2.507; 95% confidence interval, 1.228-5.116; P=.012) and progression (hazard ratio, 4.192; 95% confidence interval, 1.002-17.536; P=.049) for NMIBC. The results of immunohistochemical staining generally correlated with mRNA expression levels.

CONCLUSIONS

Enhanced expression of TOP-2alpha is positively associated with a high rate of recurrence and progression in NMIBC. Thus, TOP-2alpha represents a promising marker of prognosis for NMIBC.

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.

Epigenetic biomarkers in urothelial bladder cancer

Bladder cancers comprise heterogeneous cell populations, and numerous factors are likely to be involved in dictating recurrence, progression and patient survival. While several molecular markers that are used to evaluate the development and prognosis of bladder cancer have been studied, the limited value of these established markers has created the need for new molecular indicators of bladder cancer prognosis. Of particular interest is the silencing of tumor-suppressor genes by epigenetic alteration. Recent progress in understanding epigenetic modification and gene silencing has led to new opportunities for the understanding, detection, treatment and prevention of cancer. Moreover, epigenetic silencing of tumor-suppressor genes is interesting from a clinical standpoint, because of the possibility of reversing epigenetic changes and restoring gene function in a cell. This review focuses on the prognostic relevance of epigenetic markers in bladder cancer.

Reflex UroVysion testing in suspicious urine cytology cases

BACKGROUND

UroVysion is a US Food and Drug Administration-approved fluorescence in situ hybridization (FISH) probe set for use in the detection of recurrent urothelial carcinoma and in patients with hematuria. The objective of the current study was to evaluate the usefulness of UroVysion as a reflex test in patients with a suspicious urine cytology diagnosis. The rationale was that a more aggressive workup might be indicated in patients with a suspicious cytology diagnosis and positive UroVysion test.

METHODS

The study population included 161 urine specimens diagnosed as suspicious over a period of 12 months. The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (NPV) were calculated based on the histologic and cystoscopic correlation.

RESULTS

The results using the reporting criteria suggested by the manufacturer demonstrated a sensitivity of 68.3%, a specificity of 39.7%, a PPV of 56.8%, and a NPV of 51.9%. The results using the presence of any cytogenetic abnormality as a positive FISH test demonstrated a sensitivity of 82.9%, a specificity of 21.7%, a PPV of 54.8%, and an NPV of 51.7%.

CONCLUSIONS

A negative UroVysion test did not rule out the presence of low-grade or high-grade urothelial carcinoma in urine specimens diagnosed as suspicious. The use of less strict criteria dramatically increased the sensitivity of UroVysion FISH; however, there was a marked decrease in specificity noted. The results in this current study appear to indicate that a more aggressive workup of patients with a suspicious cytology, positive UroVysion result, and negative cystoscopic evaluation is not currently justified.

Urinary calreticulin in the diagnosis of bladder urothelial carcinoma

OBJECTIVES

To evaluate the potential suitability of calreticulin (CRT) as a urinary marker for bladder cancer.

METHODS

Urine specimens were collected from patients with histologically confirmed bladder urothelial carcinoma (Group 1; n = 109), urological patients without urothelial carcinoma (Group 2; n = 60), and non-urological patients (Group 3; n = 40). We developed an enzyme-linked immunosorbent assay (ELISA) procedure using commercially available anti-CRT mono/polyclonal antibodies, and then measured the concentration of urinary CRT.

RESULTS

Urinary CRT concentration of group 1 was significantly higher than group 2 and 3 (Mann-Whitney U-test, P < 0.001). Groups 2 and 3 were joined together and considered as a non-bladder cancer group (n = 100), and a cutoff value (2.85 ng/mL) was determined using receiver operating characteristic (ROC) analysis. The sensitivity, specificity, and the area under the curve were 67.9%, 80.0%, and 0.742, respectively. The overall sensitivity of voided urine cytology (VUC) was 39.0% (n = 105), and the sensitivity of urinary CRT was significantly superior to VUC (McNemar test, P < 0.001). Higher sensitivity was observed especially in Ta, G1-2, and <or=3 cm tumors.

CONCLUSIONS

Urinary CRT may be useful for diagnosis of bladder urothelial cancer. However, given that its specificity is relatively low, further evaluation in larger series is needed to define its clinical usefulness.

Epigenetic markers as promising prognosticators for bladder cancer

Transitional cell carcinomas of the urinary bladder have diverse biological and functional characteristics. Surveillance strategies for bladder cancer recurrence have historically relied on the diagnostic combination of cystoscopy and urinary cytology. However, the accuracy of both tests depends on subjective and operator-dependent interpretations of the visible findings. In contrast, promoter hypermethylation of CpG islands is strongly associated with tumor development and prognosis of bladder cancer. Detection of DNA methylation in voided urine may be feasible and more sensitive than conventional urine cytology. Ultimately, all types of urological cancers may be screened in urine using a candidate panel of hypermethylated genes. The epigenetic silencing of tumor suppressor genes is interest from a clinical point of view because it is possible to reverse epigenetic changes and restore gene function to a cell. Methylation markers might therefore be more useful than conventional molecular markers for the treatment and prevention of bladder cancer.

Bladder tumor markers: from hematuria to molecular diagnostics--where do we stand?

Bladder cancer is a common malignancy in the USA. Currently, the detection of initial tumors and recurrent disease is based on evaluation of voided urinary specimens, often followed by cystoscopy. With the high rate of recurrence, cystoscopies are regularly repeated with the aim of halting progression of the disease. For patients, this process is fraught with anxiety, pain and high cost. As a result, intense work is being done in the field of bladder tumor markers with the goal of identifying bladder cancer earlier, both in the initial diagnosis and in recurrences of known tumor. The possibility of identifying a marker that could noninvasively differentiate benign and malignant causes of hematuria, and identify recurrences prior to their pathologic progression is the objective of this area of research. Currently, a large number of tumor markers exist, each scrutinized in both the laboratory and in clinical trials. Here we present many of the most widely used and tested markers. Background details are provided as to the mechanism of detection of malignant cells, the results of recent trials and future directions of study. Some novel modalities for tumor detection are also presented. The next few years will no doubt bring newer markers and lead to the elimination of others. Studies continue to refine the role of these markers in clinical practice, but their ultimate efficacy will need to be borne out in large-scale clinical trials in a multitude of settings.

Methylation of the RUNX3 promoter as a potential prognostic marker for bladder tumor

PURPOSE

DNA methylation is a key regulator of gene transcription and genomic stability, and alterations in DNA methylation patterns are frequently detected in human tumors. Previously we reported that inactivation of RUNX3 by primarily epigenetic alterations in DNA methylation is closely associated with bladder tumor development, recurrence and progression. In the current series we evaluated the association between RUNX3 inactivation and bladder tumors after a long-term followup study.

MATERIALS AND METHODS

We used previously published data on the methylation patterns of RUNX3 in bladder tumor samples as well as 25 new data sets obtained by methylation specific polymerase chain reaction and direct DNA sequencing. Of the 149 patients examined 118 were followed periodically and included in the final analysis. Median followup was 49.8 months (range 1 to 146).

RESULTS

RUNX3 promoter methylation was observed in 84 of the 118 tumor samples (71.2%) examined. RUNX3 methylation patterns correlated significantly with the development of invasive tumor, tumor progression, and overall and cancer specific survival (each p <0.05). Kaplan-Meyer curves showed identical results (p <0.05). Multivariate Cox regression models revealed that RUNX3 methylation status was a strong predictor of tumor progression and cancer specific survival.

CONCLUSIONS

Results strongly suggest that inactivation of RUNX3 by the methylation of its promoter region is a significant risk factor for invasive bladder tumors, tumor progression and cancer specific survival. RUNX3 promoter methylation status could be a promising marker for assessing the prognosis of human bladder tumors.

Proteomic strategies in bladder cancer: From tissue to fluid and back

We have applied protein expression profiling technologies in combination with immunohistochemistry, using fresh tissue and urine samples, to assess bladder cancer heterogeneity and prognosis as well as to generate protein markers for tumor progression and early diagnosis of the disease. Here, we review some selected lines of investigation and approaches undertaken by our laboratory, drawing on more than 15 years of experience in bladder cancer proteomics, to highlight a number of issues that may be useful for researchers entering the field. In particular, we address the identification of markers for bladder cancer progression and exemplify the potential of gel-based proteomic profiling of urine samples for the early detection of urothelial carcinomas. In addition, we provide a brief description of a novel and highly promising source of biomarkers, the tumor interstitial fluid (TIF) that perfuses the tumor microenvironment.

Contemporary diagnosis of bladder cancer

BACKGROUND

Early diagnosis of bladder cancer is mandatory, as a delay in treatment has been shown to affect prognosis. The current diagnostic standard of cystoscopy and cytology is costly, invasive and inconvenient, whereas advances in molecular biology have resulted in the evolvement of several markers.

OBJECTIVE

To review diagnostic considerations in the use of old and new technical modalities and tests for the detection of bladder cancer.

METHODS

A PubMed search of the literature concerning bladder cancer diagnosis was performed. Reviews are included on certain topics to avoid extensive reference to separate studies.

CONCLUSION

Recent technical advances have an impact on the management of patients with suspected bladder cancer. Cytology is still an important adjunct in the diagnostic work-up, whereas urine-bound tests may have a role in screening and surveillance. However, cystoscopy is the standard of care for the detection of bladder cancer. Fluorescence cystoscopy is an adjunctive tool, especially for the prompt identification of carcinoma in situ.

Defining the role of NMP22 in bladder cancer surveillance

Despite advances in treatment and knowledge of its pathogenesis, urothelial carcinoma of the bladder remains a significant cause of morbidity and mortality. Experience with the natural course of bladder cancer has revealed that early diagnosis of primary and recurrent disease improves patient prognosis. In this regard, cystoscopy (usually in combination with urinary cytology) has long been regarded as the gold standard for the diagnosis and surveillance of bladder cancer. However, the disadvantages inherent to cystoscopy, including invasiveness and cost, have stimulated a search for alternative methods for detecting urothelial malignancy. The ideal alternative test would duplicate the high accuracy of cystoscopy for detecting bladder tumors while eschewing its invasiveness, attendant morbidity, and high cost. The vast majority of bladder cancers arise from the urothelium, which continually sheds cells as well as intracellular contents into the urine, thereby providing a potential source of cancer-specific markers. Voided cytology and urinalysis are established tests that have been the standard tools for detection of such substances. The last decade has seen the rise of a myriad of novel urine-based bladder tumor markers, including bladder tumor antigen, urinary bladder cancer antigen, fibronectin, telomerase, and nuclear matrix proteins (e.g., NMP22). The NMP22 assay in particular has been the subject of considerable study and has demonstrated some promise as a potential adjunct to cystoscopy and cytology. Through a critical review of the literature, we seek to define the role, if any, of NMP22 in the follow-up of patients with a previous history of urothelial carcinoma of the bladder.

The use and abuse of data: nomograms and talking to patients about clinical medicine

OBJECTIVE

To review the development of nomograms and consortia efforts applying these tools to model outcome predictions associated with radical cystectomy.

FINDINGS

Nomograms have been developed that provide individualized prediction of recurrence and survival following radical cystectomy, which provide significant improvement in predictive accuracy over tradition TNM staging.

CONCLUSIONS

Nomograms provide individualized risk assessment and outperform expert physician and conventional models used to predict outcome. Addition of biologic markers may improve predictive capability and improve the clinical utility of these valuable tools.

Use of urinary biomarkers for bladder cancer surveillance: patient perspectives

PURPOSE

Interest has emerged in urinary biomarkers to replace or alternate with followup cystoscopies for routine bladder cancer surveillance. We assessed whether patients would accept a urine biomarker assay over flexible cystoscopy for monitoring bladder cancer.

MATERIALS AND METHODS

We enrolled 200 consecutive patients previously diagnosed with superficial bladder tumors who were undergoing outpatient flexible cystoscopy as followup. Immediately after cystoscopy each patient completed a pain intensity numerical rating and was interviewed. The standard gamble method was applied to determine the minimal accepted diagnostic accuracy at which a urine test would be favored over cystoscopy for bladder surveillance. Clinical and demographic data with potential to affect patient preferences were analyzed.

RESULTS

Of the 200 patients 75% would accept the results of a urine test as a replacement for cystoscopy only if it was capable of detecting more than 95% of recurrent bladder tumors and an additional 21% would accept it if the urine test was at least 90% to 95% accurate. Anxiety associated with the possibility of missing cancer was the major determinant of the minimal accepted accuracy. While male gender and higher pain intensity at cystoscopy were associated with willingness to accept a small level of uncertainty on univariate and multivariate analyses, the risk of progression to muscle invasion and the convenience of followup did not appear to affect patient preferences.

CONCLUSIONS

From the patient perspective a urinary biomarker would likely require 95% or greater diagnostic accuracy to supplant cystoscopies for routine bladder surveillance. Inadequate sensitivity may be the major impediment to general acceptance of urinary biomarkers in this setting.

Novel approach for developing urinary nucleosides profile by capillary electrophoresis–mass spectrometry

A simple, rapid and efficient capillary electrophoresis-mass spectrometry (CE-MS) method was developed to analyze urinary nucleosides for the first time. The composition of CE buffer and MS parameters were systematically optimized. The optimum buffer was 150 mM acetic acid containing 15% methanol and 15% ethanol. The optimum MS parameters were: methanol containing 0.5% acetic acid was selected as the sheath liquid and the flow rate was 5 microL/min; the flow rate and temperature of drying gas were 6L/min and 150 degrees C, respectively; the pressure of nebulizing gas was 2 psig; and the fragmentor and ESI voltage were 100 V and 4000 V, respectively. Under the optimum CE-MS conditions, the urinary nucleosides were separated within 18 min. The linearity between the relative peak areas and the corresponding concentration of nine nucleosides markers were excellent. The limits of detection (S/N=3) of markers were 0.00862-3.82 nmol/mL. The optimum CE-MS method was applied to analyze urine from 20 bladder cancer patients and 20 healthy volunteers. Considering the standards of many nucleosides cannot be obtained, it is not the ratios of the concentrations of nucleosides to that of creatinine in the literatures, but the ratios of the relative peak area of nucleosides to the concentration of creatinine that used for pattern recognition. And, the statistical analysis result indicated this method was feasible.

Increased CYP1A1 expression in human exfoliated urothelial cells of cigarette smokers compared to non-smokers

Polycyclic aromatic hydrocarbons, arylamines and nitrosamines, constituents of cigarette smoke, are known inducers of bladder cancer. The biochemical response of the target tissue, the bladder urothelium, following inhalation of cigarette smoke has not been studied so far. We used exfoliated transitional urothelial cells from human urine samples to analyze effects of smoking on induction of the cytochrome P450 enzyme CYP1A1. Samples of 40 subjects, including male and female smokers and non-smokers, were examined. A prerequisite for the immunofluorescence microscopic analysis of the cells was the enrichment of the urothelial cell population. This was achieved by a new method which is based on magnetic cell sorting exploiting specific binding of immobilized Griffonia simplicifolia lectin to the surface of urothelial cells. Immunostaining of the final cell preparation with a monoclonal antibody to CYP1A1 showed that about 6% of the urothelial cells of non-smokers stained positive for CYP1A1. However, this fraction of positive cells was more than 44% of the urothelial cells in samples from cigarette smokers. In spite of the individual variation, the difference was statistically significant. There were no gender-related differences in the portion of CYP1A1 expressing urothelial cells of smokers and non-smokers. In essence, we show for the first time that human urothelial cells respond to cigarette smoking by induction of CYP1A1. The approach opens new fields of mechanistic and biomarker research with respect to the pathogenetic processes of cancer development in the human bladder.