Microhematuria assessment an IBCN consensus—Based upon a critical review of current guidelines

Urine biomarkers in bladder cancer - current status and future perspectives

Urine markers to detect bladder cancer have been the subject of research for decades. The idea that urine - being in continuous contact with tumour tissue - should provide a vector of tumour information remains an attractive concept. Research on this topic has resulted in a complex landscape of many different urine markers with varying degrees of clinical validation. These markers range from cell-based assays to proteins, transcriptomic markers and genomic signatures, with a clear trend towards multiplex assays. Unfortunately, the number of different urine markers and the efforts in research and development of clinical grade assays are not reflected in the use of these markers in clinical practice, which is currently limited. Numerous prospective trials are in progress with the aim of increasing the quality of evidence about urinary biomarkers in bladder cancer to achieve guideline implementation. The current research landscape suggests a division of testing approaches. Some efforts are directed towards addressing the limitations of current assays to improve the performance of urine markers for a straightforward detection of bladder cancer. Additionally, comprehensive genetic analyses are emerging based on advances in next-generation sequencing and are expected to substantially affect the potential application of urine markers in bladder cancer.

Discriminative capacity of guideline recommendations in the assessment of patients with asymptomatic microhematuria

BACKGROUND & OBJECTIVE

Asymptomatic microhematuria (aMh) remains a diagnostic challenge in urological practice: while aMh is a risk factor of urothelial carcinoma (UC), prevalence of aMh is high. Guidelines were developed to permit risk stratification and reduce diagnostic workload. This study investigates the efficacy of several recommendations.

MATERIAL & METHODS

Sixty hundred eight patients with newly diagnosed aMh without previous UC from an academic referral center (A; n = 320) and a private outpatient clinic (B; n = 288) were included. All patients underwent clinical workup including medical history, urine cytology, upper tract imaging and cystoscopy. Eleven former and current guidelines were applied to each patient individually; every patient was classified as either low risk (no further workup recommended) or high risk. Furthermore, a recently developed nomogram for hematuria assessment was included.

RESULTS

The cohort comprised 142 females and 466 males (mean age 62 [range 18-92] years). Sixty-one patients (10.0%) were diagnosed with UC. Excluding the Swedish and recent NICE guideline generally advising against urologic workup, application of 9 other recommendations would have diagnosed all UCs and saved 1.6% to 16.1% of patients from workup. For the 2020 US guideline, solely applied to cohort B, 10.6% of patients were classified as low risk. The use of the nomogram would have saved 17.1% to 25% of patients from workup.

CONCLUSIONS

Practical relevance of current guidelines is limited as they do not sufficiently identify patients not requiring clinical work up. Thus, guideline adherence may trigger overdiagnosis and even overtreatment. New ways of risk stratification are needed to improve aMh assessment.

Diagnostic Performance of Novel Urine-Based mRNA Tests (Xpert and Urinary Metabolomics Markers Assay) for Bladder Cancer Detection in Patients with Hematuria

BACKGROUND: Hematuria is the most frequent presenting symptom in the vast majority of bladder cancer (BC) patients. The current recommended evaluation of hematuria includes cross sectional imaging and cystoscopy with possible high negative results, expensive costs and substantial patient burden. OBJECTIVES: To validate novel urine-based mRNA-dependant tests; Xpert test and urinary metabolomics assay (CRAT and SLC 25A20genes expression) for BC detection in patients with hematuria. METHODS: Patients presented with hematuria to our tertiary care hospital were evaluated by CT urogram and office white light cystoscopy with subsequent inpatient biopsy for positive findings. Voided precystoscopy urine samples were prospectively collected. Xpert test, assay of targeted urinary metabolomics and cytology, were performed. The tests characteristics presumably were calculated based on the ability to identify BC noninvasively. RESULTS: Between March 2018 and June 2019, 181 patients were included in the final analysis with mean (±SD) age 62 (±10) years with 168 (92.8%) males. Macroscopic hematuria was encountered in 153 (84.5%) patients with irritative bladder symptoms in 48 (26.5%) patients. BC was confirmed by cystoscopy/biopsy in 36 (19.9%) patients. The performance characteristics of Xpert alone (SN: 73%, SP: 83%, NPV: 92%, PPV: 52%) (AUC 0.84, 95% CI 0.75–0.93, p = 0.001), metabolomics assay alone (SN: 89%, SP: 93%, NPV: 97%, PPV: 78%) (AUC 0.91, 95% CI 0.85–0.98, p < 0.001) and combination of both test results (SN: 66%, SP: 98%, NPV: 92%, PPV: 97%) (AUC 0.83, 95% CI 0.74–0.93, p = 0.001) were notably superior to urine cytology (SN: 30%, SP: 84%, NPV: 83%, PPV: 33%) (AUC 0.58, 95% CI 0.47–0.69, p = 0.154) for BC prediction. Cystoscopy-negative patients (CNP) were followed-up for a median (range) 12 (2–19) months. Re-cystoscopy was done for 35 patients with persistent symptoms. BC was diagnosed in 6 patients. Xpert and urinary metabolomics results were observably positive in those 6 patients. CONCLUSION: Xpert test and assay of urinary metabolomics (CRAT and SLC 25A20 genes expression) have the potential for BC detection in hematuria patients. These non invasive urine based tests can help prioritization of the use of invasive diagnostic tests in systems with long waiting times.

Urinary biomarkers in bladder cancer: A review of the current landscape and future directions

AIM

This narrative review aims to describe established and emerging urinary biomarkers in the diagnosis and surveillance of non-muscle invasive bladder cancer. It provides a comprehensive account of classical, FDA-approved protein biomarkers and discusses their limitations. Further, we discuss the role that epigenetic, genetic, and exosomal markers can play to enhance sensitivity and specificity of the available tests.

BACKGROUND

The initial diagnosis and surveillance of bladder cancer involves a combination of cystoscopy, upper urinary tract imaging, and urine cytology. Despite high specificity, cytology is limited by low sensitivity. There are currently 6 urinary assays approved by the FDA to enhance diagnosis and surveillance of bladder cancer. While these have improved diagnosis and surveillance when combined with cytology, these tests are still not sufficiently sensitive and false positives often occur in benign conditions which result in inflammation of the urinary tract. Advancements in laboratory techniques have produced significant advancements in epigenetic and genetic markers, as well as extracellular vesicles, with DNA- and RNA-based markers dominating the research in this area in recent years.

METHODS

We identified relevant published data, using the PubMed/ Medline search engines as well as Google Scholar. We performed an online search using the terms "bladder cancer", "non-muscle invasive bladder cancer" in combination with "urine biomarkers" and limited articles in English published up to February 2020. This review consolidated on all available narrative and systematic reviews published in the 5 years in this field, while also reviewing the original data of each clinical trial or observational study which led to the development of the biomarkers.

CONCLUSION

The development of laboratory techniques and understanding urine-based biomarkers in BC has fuelled the use of noninvasive liquid-based biomarkers to complement urine cytology. Nonetheless, none are sufficiently effective when used in isolation, and cytology remains the gold standard in many practices. Future efforts will be focused on using these markers in combination as a predictive signature, and moving on to validating them for use in everyday clinical practice.

Superselective Arterial Embolization of Arteriovenous Malformation of Internal Pudendal Artery, a Rare Cause of Hematuria: A Case Report

Arteriovenous malformation (AVM) is a common form of vascular malformation, an abnormal direct communication between an artery and a vein without passing through the capillaries. AVM may just present as hematuria without plain or other symptoms. The article presents a case of a 52-year-old male with gross hematuria diagnosed as AVM of internal pudendal artery, which was successfully managed with superselective arterial embolization using temporary embolization materials.

The Investigation of Hematuria

BACKGROUND

Hematuria can be either grossly visible (macrohematuria) or only detectable under a microscope (microhematuria). Microhematuria is often asymptomatic and has a prevalence of 4-5% in routine clinical practice. It may be due to an underlying disease of the kidneys or the urogenital tract. In this article, we provide an overview of the causes of hematuria and of the recommendations of current guidelines for its diagnostic evaluation. A risk-adapted diagnostic strategy for the evaluation of asymptomatic microhematuria (aMH) is presented.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed, as well as on guidelines from Germany and abroad.

RESULTS

Hematuria has many causes, and a broad urological and nephrological differential diagnosis must be considered. In the absence of high-quality scientific evidence, the recommendations of current guidelines for the diagnostic evaluation of hematuria are not uniform; this is particularly so for aMH. Microhematuria is said to be present when urine microscopy reveals three or more erythrocytes per highpower field. The basic diagnostic evaluation consists of a thorough history and physical examination, measurement of inflammatory parameters and renal function tests, and ultrasonography of the kidneys and bladder. Patients with non-glomerular aMH who have risk factors such as smoking, advanced age, and male sex are more likely to have relevant underlying conditions and should therefore undergo augmented, risk-adapted diagnostic evaluation with urethrocystoscopy, urine cytology, and, when indicated, CT urography. Patients with isolated glomerular hematuria are at elevated risk for renal disease and should undergo follow-up checks at six-month intervals.

CONCLUSION

Although hematuria is common, there is no uniform, internationally accepted, evidence-based algorithm for its diagnostic evaluation. All potential causes of hematuria must be considered, and all individual risk factors taken into account, so that an underlying disease requiring treatment can be identified or ruled out.

Evaluation of Asymptomatic Microscopic Hematuria by Renal Ultrasound to Detect Upper Tract Malignancy: A 20-Year Experience in a Community Hospital

OBJECTIVE

To evaluate the sensitivity of ultrasound imaging in detecting upper urinary tract malignancy in patients with asymptomatic microscopic hematuria (AMH) in an outpatient community setting.

MATERIALS AND METHODS

A list of all patients who received renal ultrasound for hematuria in our health care system between January 1, 1997 and July 1, 2015 was obtained, and electronic health records were retrospectively reviewed. Patients were excluded for age (<18 years), <3 years follow-up, prior upper tract malignancy, recent urinary tract catheterization, inpatient status, pregnancy, insufficient data, or gross hematuria. The initial ultrasound was considered positive if suspicious findings led to a subsequent diagnosis of an upper tract malignancy. False negatives were determined by electronic medical record follow-up for at least 3 years.

RESULTS

Of the 2138 patients with AMH who met inclusion criteria, ultrasound imaging detected suspicious findings in 9 of 9 patients with renal cell carcinoma and 3 of 3 patients with upper tract urothelial cancer, indicating a sensitivity of 100% and 100%, respectively. Four additional malignancies were diagnosed more than 3 years after the initial evaluation for an incidence rate of 1.6 cases of upper tract malignancy per 10,000 person-years.

CONCLUSION

The prevalence of upper urinary tract malignancy was low in patients with AMH. Ultrasonography is an appropriate modality for upper tract imaging in the initial evaluation of patients with AMH. Practice guidelines should be updated to reflect the high sensitivity of ultrasound and low risk of upper tract malignancy in patients with AMH.

Urinary expression of genes involved in DNA methylation and histone modification for diagnosis of bladder cancer in patients with asymptomatic microscopic haematuria

The aim of the present study was to identify and test a urine marker panel of genes involved in DNA methylation and histone modification for the detection of urothelial carcinoma of the bladder (UCB). RNA samples obtained from the voided urine of 227 patients with asymptomatic microscopic haematuria (AMH) were analysed. Gene array analysis was performed on 18 randomly selected cDNA samples, which revealed that histone deacetylase 9 (HDAC9), HDAC3, tRNA (cytosine-5-)-methyltransferase1 and DNA methyltransferase 1 were differentially expressed between patients with UCB and control subjects. Subsequently, reverse transcription-quantitative polymerase chain reaction analysis was employed to test the performance of the identified four-gene panel on the remaining 209 cDNA samples. In this targeted discovery cohort, all four genes were significantly associated with UCB on univariable analyses [each odds ratio (OR) >2, P<0.05], but only HDAC3 was significant following multivariable analysis (OR=2.8, P=0.011). The addition of HDAC3 to a base risk factor model improved its accuracy by 1.4%. These data suggest that urinary HDAC3 is associated with the presence of UCB in patients with AMH; however, HDAC3 improved the accuracy of the established risk factors only to a marginal extent.

Can urinary biomarkers replace cystoscopy?

PURPOSE

Diagnosis and follow-up in patients with non-muscle invasive bladder cancer (NMIBC) rely on cystoscopy and urine cytology. The aim of this review paper is to give an update on urinary biomarkers and their diagnosis and surveillance potential. Besides FDA-approved markers, recent approaches like DNA methylation assays, mRNA gene expression assays and cell-free DNA (cfDNA) are evaluated to assess whether replacing cystoscopy with urine markers is a potential scenario for the future.

METHODS

We performed a non-systematic review of current literature without time period restriction using the National Library of Medicine database ( http://ww.pubmed.gov ). The search included the following key words in different combinations: "urothelial carcinoma", "urinary marker", "hematuria", "cytology" and "bladder cancer". Further, references were extracted from identified articles. The results were evaluated regarding their clinical relevance and study quality.

RESULTS

Currently, replacing cystoscopy with available urine markers is not recommended by international guidelines. For FDA-approved markers, prospective randomized trials are lacking. Newer approaches focusing on molecular, genomic and transcriptomic aberrations are promising with good accuracies. Furthermore, these assays may provide additional molecular information to guide individualized surveillance strategies and therapy. Currently ongoing prospective trials will determine if cystoscopy reduction is feasible.

CONCLUSION

Urinary markers represent a non-invasive approach for molecular characterization of the disease. Although fully replacing cystoscopy seems unrealistic in the near future, enhancing the current gold standard by additional molecular information is feasible. A reliable classification and differentiation between aggressive and nonaggressive tumors by applying DNA, mRNA, and cfDNA assays may change surveillance to help reduce cystoscopies.

Clinical utility of a non-invasive urine test for risk assessing patients with no obvious benign cause of hematuria: a physician-patient real world data analysis

Background

The non-invasive Cxbladder urine test system has demonstrated clinical utility in ruling out urothelial carcinoma (UC) in patients with asymptomatic microscopic hematuria (AMH), suggesting that the number of invasive diagnostic tests, including cystoscopy, used in this patient population may be reduced by Cxbladder testing prior to conducting a full urological work-up. The aim of this study was to demonstrate the enhanced clinical utility of communicating objective information on diagnostic decisions made by individual physicians on individual patients with AMH.

Methods

Three hundred ninety-six physician-patient decisions were generated from twelve participant physicians evaluating real world case notes from the same 33 patients presenting with AMH. Each physician reviewed and recommended diagnostic tests and procedures based on each patient’s referral data and then re-evaluated their clinical recommendation following disclosure of the non-invasive Cxbladder urine test result. Changes assessed were the total number of requested diagnostic procedures and the number of invasive procedures, including cystoscopy, following addition of information from Cxbladder in the Triage and Triage and Detect modalities.

Results

Physicians made significant changes to their diagnostic behavior for patients with AMH when presented with Cxbladder test results, including a reduction in the number of total and invasive procedures including cystoscopy for individuals identified as having a low probability of UC. The intensity of investigation was targeted and increased, including use of total procedures and cystoscopy, for patients identified by Cxbladder tests as having a high probability of UC: urologists increased the level of investigation for both total procedures and invasive procedures. The outcome resulted in patients with a high risk of UC receiving appropriate guideline-recommended invasive diagnostic tests. Patients who tested negative were offered fewer and significantly less invasive procedures. This change in physician behavior results in an increased clinical and patient utility, lower risk of missed UC and invasive test-related harm incidents.

Conclusions

This study demonstrated the potential for increased clinical resolution and significantly enhanced patient management, when physicians consider Cxbladder test results in their clinical evaluation. The change in physician behavior led to more appropriate diagnostic procedure selection and resource allocation to the benefit of both patients and healthcare systems.

Electronic supplementary material

The online version of this article (10.1186/s12894-018-0327-6) contains supplementary material, which is available to authorized users.

[Microscopic hematuria : Reasonable and risk-adapted diagnostic evaluation]

BACKGROUND

Microscopic hematuria that is not explained by an obvious underlying condition is a frequent and often an incidental finding that commonly triggers urological or nephrological evaluation. Potential underlying conditions range from benign to severe malignant diseases of the kidneys and urinary tract.

MATERIALS AND METHODS

A nonsystematic literature search was performed, focusing on potential urological and nephrological causes of hematuria. National and international guidelines were considered and diagnostic as well as follow-up strategies are discussed. We provide a recommendation for practices in the clinical evaluation of hematuria.

RESULTS

The overall prevalence for microscopic hematuria is estimated at approximately 2%, whereas risk populations show an increase to around 30%. In 13-35% of patients presenting with microscopic hematuria, a medical or surgical intervention is required. Malignant tumors of the kidneys or urinary tract can be diagnosed in 2.6-4% of all patients and in up to 25.8% of at-risk populations. "Idiopathic microscopic hematuria" without an obvious underlying medical condition accounts for approximately 80% of patients with asymptomatic hematuria. After exclusion of nephrological diseases, standard diagnostic procedures by means of medical history, physical and laboratory examination as well as ultrasound of the kidneys and the urinary tract should be performed. In the presence of risk factors, an extended diagnostic work-up using cystoscopy, urinary cytology, and cross-sectional imaging of the upper urinary tract is indicated.

CONCLUSION

Evidence-based strategies of a risk-adapted diagnostic evaluation for microscopic hematuria are not available. The development of reliable clinical and molecular markers offers great potential for the identification of patients at higher risk for harboring severe diseases.