IS EVERYTHING ALL RIGHT IF NOTHING SEEMS WRONG? A SIMPLE METHOD OF ASSESSING THE DIAGNOSTIC VALUE OF ENDOSCOPIC PROCEDURES WHEN A GOLD STANDARD IS ABSENT

Diagnostic and therapeutic effects of fluorescence cystoscopy and narrow-band imaging in bladder cancer: a systematic review and network meta-analysis

BACKGROUND

This review aims to compare the efficacies of fluorescence cystoscopy, narrow-band imaging (NBI), and white light cystoscopy in the treatment and diagnosis of bladder cancer.

METHODS

The authors searched PubMed, EMbase, Web of Science, and the Cochrane Library from January 1990 to April 2022. A total of 26 randomized controlled studies and 22 prospective single-arm studies were selected. Most patients had nonmuscle-invasive bladder cancer. The study protocol has been registered at PROSPERO.

RESULTS

In the pairwise meta-analysis, 5-aminolevulinic acid (5-ALA) reduced the short-term and long-term recurrence rates of bladder cancer compared with white light cystoscopy (WLC); however, no statistical difference was observed in intermediate-term recurrence rates (RR=0.79, 95% CI: 0.57-1.09). Hexaminolevulinic acid and NBI reduced short-term, intermediate-term, and long-term recurrence rates. The sensitivity of 5-ALA, hexaminolevulinic acid, NBI, and WLC for bladder cancer were 0.89 (95% CI: 0.81-0.94), 0.96 (95% CI: 0.92-0.98), 0.96 (95% CI: 0.92-0.98), and 0.75 (95% CI: 0.70-0.79), respectively; however, only NBI had the same specificity as WLC (0.74 vs. 0.74). Compared with WLC, 5-ALA improved the detection rate of carcinoma in situ and Ta stage bladder cancer but had no advantage in T1 stage tumors (OR=2.39, 95% CI:0.79-7.19). Hexaminolevulinic acid and NBI improved the detection rates of all nonmuscular-invasive bladder cancers. In the network meta-analysis, there was no significant difference in either recurrence or detection rates between 5-ALA, hexaminolevulinic acid, and NBI.

CONCLUSION

Fluorescence cystoscopy and NBI are advantageous for treating and diagnosing patients with nonmuscle-invasive bladder cancer.

Performance of Narrow Band Imaging (NBI) and Photodynamic Diagnosis (PDD) Fluorescence Imaging Compared to White Light Cystoscopy (WLC) in Detecting Non-Muscle Invasive Bladder Cancer: A Systematic Review and Lesion-Level Diagnostic Meta-Analysis

Despite early detection and regular surveillance of non-muscle invasive bladder cancer (NMIBC), recurrence and progression rates remain exceedingly high for this highly prevalent malignancy. Limited visualization of malignant lesions with standard cystoscopy and associated false-negative biopsy rates have been the driving force for investigating alternative and adjunctive technologies for improved cystoscopy. The aim of our systematic review and meta-analysis was to compare the sensitivity, specificity, and oncologic outcomes of photodynamic diagnosis (PDD) fluorescence, narrow band imaging (NBI), and conventional white light cystoscopy (WLC) in detecting NMIBC. Out of 1,087 studies reviewed, 17 prospective non-randomized and randomized controlled trials met inclusion criteria for the study. We demonstrated that tumor resection with either PDD and NBI exhibited lower recurrence rates and greater diagnostic sensitivity compared to WLC alone. NBI demonstrated superior disease sensitivity and specificity as compared to WLC and an overall greater hierarchical summary receiver operative characteristic. Our findings are consistent with emerging guidelines and underscore the value of integrating these enhanced technologies as a part of the standard care for patients with suspected or confirmed NMIBC.

Efficacy of pirarubicin for nonmuscle invasive bladder cancer: A protocol of systematic review and meta-analysis

BACKGROUND

This study will aim to appraise the efficacy and safety of pirarubicin for the treatment of patients with nonmuscle invasive bladder cancer (NMIBC).

METHODS

We will perform a comprehensive literature search in MEDLINE, EMBASE, Cochrane Library, Scopus, PsycINFO, Web of Science, Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure from their beginning to the February 29, 2020. All randomized controlled trials of pirarubicin for NMIBC will be included regardless limitations related to the language and publication time. Two researchers will independently select studies from searched records, extract data from included randomized controlled trials, and assess study quality using Cochrane risk of bias tool. Any differences between them will be solved with the help of another researcher. RevMan 5.3 software will be utilized for statistical analysis.

RESULTS

This study will provide a synthesis of current evidence to investigate the efficacy and safety of pirarubicin for NMIBC using overall survival, progression-free survival, recurrence-free survival, quality of, rates of recurrence, and adverse events.

CONCLUSION

This study will explore whether or not pirarubicin can be used as an effective and safety treatment for patients with NMIBC.

REGISTRATION NUMBER

INPLASY202040113.

Blue Light Cystoscopy: Indications and Outcomes

PURPOSE OF REVIEW

It has been firmly established that hexaminolevulinate-assisted blue light cystoscopy (HAL-BLC) reduces cancer recurrence rates. This review explores the impact of HAL-BLC on other meaningful outcomes in patients with bladder cancer, including disease progression, and earlier detection of disease at the time of surveillance cystoscopy.

RECENT FINDINGS

A randomized clinical trial confirmed earlier implementation of HAL-BLC at the time of surveillance cystoscopy increased identification of cancerous lesions, including those of high grade, when compared with white light cystoscopy. In addition, the evidence is evolving that the use of HAL-BLC at the time of endoscopic treatment of high-risk tumors may lead to lower rates of progression to muscle invasion, and this in part may be due to better risk stratification leading to changes in treatment plan. The clinical contexts for the use of HAL-BLC are broader than prior knowledge. It is also becoming more clear that the positive impact of HAL-BLC is likely more than just reducing cancer recurrence rates, and patients would benefit from the technology at many time points in the management and follow-up of their disease.

Systematic Review of the Therapeutic Efficacy of Bladder-preserving Treatments for Non-muscle-invasive Bladder Cancer Following Intravesical Bacillus Calmette-Guérin

CONTEXT

There is a critical need for effective bladder-sparing therapies for bacillus Calmette-Guérin (BCG)-unresponsive non-muscle-invasive bladder cancer (NMIBC). Owing to the current lack of effective agents that can be used as a control, the US Food and Drug Administration began to accept single-arm trials for patients with carcinoma in situ (CIS), using complete response rate (CRR) and duration of response as the primary endpoints to support marketing applications. Despite the ensuing growth of clinical trials in this space, no consensus exists on a clinically relevant benchmark for CRR.

OBJECTIVE

To elucidate the CRR and recurrence-free rate (RFR) using bladder-sparing agents after BCG failure in order to provide a frame of reference for future clinical trial results.

EVIDENCE ACQUISITION

We performed a systematic review of clinical trials utilizing bladder-sparing therapeutics for NMIBC recurring after intravesical BCG (PROSPERO CRD42019130553). The search was performed in MEDLINE, EMBASE, and Cochrane Library. Relevant studies identified from bibliography search and conference abstracts were searched to complement the systematic review. A total of 42 studies utilizing 24 treatment options and consisting of 2254 patients were included for final analysis.

EVIDENCE SYNTHESIS

Median CRRs in the treatment of CIS-containing tumors were 26% at 6 mo, 17% at 12 mo, and 8% at 24 mo after treatment. In comparison, median RFRs in the papillary-only studies were 67% at 6 mo, 44% at 12 mo, and 10% at 24 mo. Specifically in the BCG-unresponsive population, 6- and 12-mo CRRs in CIS-containing patients treated with Mycobacterium phlei cell wall-nucleic acid complex were 45% and 27%, respectively, and the median 6-, 12-, and 24-mo disease-free rates in the other studies were 43%, 35%, and 18%, respectively. The median progression-free rate was 91%: 95% in the CIS-containing studies and 89% in studies restricted to papillary-only recurrences. Toxicities of intravesical agents were generally mild, with very few dose limiting toxicities.

CONCLUSIONS

We demonstrate that, to date, bladder-sparing therapies achieved modest efficacy in patients with NMIBC after BCG. Results from the current study will serve as a frame of reference for emerging trial results in the BCG-unresponsive space.

PATIENT SUMMARY

In this study, we found that bladder-sparing therapies achieved modest efficacy in patients with non-muscle-invasive bladder cancer after bacillus Calmette-Guérin (BCG). These results will serve to inform future clinical trial results for salvage agents used to treat BCG-unresponsive bladder cancer.

Blue light flexible cystoscopy with hexaminolevulinate in non-muscle-invasive bladder cancer: review of the clinical evidence and consensus statement on optimal use in the USA - update 2018

Blue light cystoscopy (BLC) with hexaminolevulinate (HAL) during transurethral resection of bladder cancer improves detection of non-muscle-invasive bladder cancer (NMIBC) and reduces recurrence rates. Flexible BLC was approved by the FDA in 2018 for use in the surveillance setting and was demonstrated to improve detection. Results of a phase III prospective multicentre study of blue light flexible cystoscopy (BLFC) in surveillance of intermediate-risk and high-risk NMIBC showed that 20.6% of malignancies were identified only by BLFC. Improved detection rates in the surveillance setting are anticipated to lead to improved clinical outcomes by reducing future recurrences and earlier identification of tumours that are unresponsive to therapy. Thus, BLFC has a role in surveillance cystoscopy, and determining which patients will benefit from BLFC and optimal and cost-effective ways of incorporating this technology into surveillance cystoscopy must be developed.

The use of blue light flexible cystoscopy with hexaminolevulinate & the diagnosis of bladder cancer

Blue light cystoscopy improves the detection of bladder cancer at time of transurethral resection of bladder tumor for nonmuscle-invasive bladder cancer. This has translated to decreased tumor recurrence. Given this improvement in rigid cystoscopy, the question remains whether the use of blue light flexible cystoscopy (BLFC) in the surveillance setting provides the same benefits. This review aims to evaluate the recently reported Phase III prospective multicenter study of BLFC which evaluated the detection of bladder cancer during surveillance, which in its earliest reporting demonstrated improved detection of bladder cancer. This study evaluated 304 patients with findings of 63 confirmed malignancies, with 13 (20.6%) only identified by BLFC (p < 0.0001). The question still remains whether the improved detection rate will translate to improved clinical outcomes. Further, studies will be necessary to determine which patients will benefit from BLFC, optimal ways to incorporate into surveillance strategies and cost-effectiveness.

Urinary mRNA biomarker panel for the detection of urothelial carcinoma

The early detection of bladder cancer is important as the disease has a high rate of recurrence and progression. The development of accurate, non-invasive urinary assays would greatly facilitate detection. In previous studies, we have reported the discovery and initial validation of mRNA biomarkers that may be applicable in this context. In this study, we evaluated the diagnostic performance of proposed molecular signatures in an independent cohort.

Forty-four mRNA transcripts were monitored blindly in urine samples obtained from a cohort of 196 subjects with known bladder disease status (89 with active BCa) using quantitative real-time PCR (RT-PCR). Statistical analyses defined associations of individual biomarkers with clinical data and the performance of predictive multivariate models was assessed using ROC curves. The majority of the candidate mRNA targets were confirmed as being associated with the presence of BCa over other clinical variables. Multivariate models identified an optimal 18-gene diagnostic signature that predicted the presence of BCa with a sensitivity of 85% and a specificity of 88% (AUC 0.935). Analysis of mRNA signatures in naturally micturated urine samples can provide valuable information for the evaluation of patients under investigation for BCa. Additional refinement and validation of promising multi-target signatures will support the development of accurate assays for the non-invasive detection and monitoring of BCa.

Comparing sensitivity and specificity of medical imaging tests when verification bias is present: The concept of relative diagnostic accuracy

Medical imaging plays a key role in all stages of cancer management. In evaluating a new imaging modality, the optimal design involves a comparison with standard test results as well as a gold standard, such as a pathological evaluation to determine disease status. However, when both the standard and experimental test results are negative, a gold standard may not always be performed, especially if it involves an invasive and/or costly procedure. In this situation, true disease status cannot be verified, which creates an estimation problem for sensitivity and specificity. The aim of this article is to present the concept of relative accuracy which permits to remove the bias when only patients with at least one positive test receive the gold standard.

Early diagnosis of bladder cancer through the detection of urinary tyrosine-phosphorylated proteins

Background:

A noninvasive, highly sensitive and specific urine test is needed for bladder cancer (BC) diagnosis and surveillance in addition to the invasive cystoscopy. We previously described the diagnostic effectiveness of urinary tyrosine-phosphorylated proteins (UPY) and a new assay (UPY-A) for their measurement in a pilot study. The aim of this work was to evaluate the performances of the UPY-A using an independent cohort of 262 subjects.

Methods:

Urinary tyrosine-phosphorylated proteins were measured by UPY-A test. The area under ROC curve, cutoff, sensitivity, specificity and predictive values of UPY-A were determined. The association of UPY levels with tumour staging, grading, recurrence and progression risk was analysed by Kruskal–Wallis and Wilcoxon's test. To test the probability to be a case if positive at the UPY-A, a logistic test adjusted for possible confounding factor was used.

Results:

Results showed a significant difference of UPY levels between patients with BC vs healthy controls. For the best cutoff value, 261.26 Standard Units (SU), the sensitivity of the assay was 80.43% and the specificity was 78.82%. A statistically significant difference was found in the levels of UPY at different BC stages and grades between Ta and T1 and with different risk of recurrence and progression. A statistically significant increased risk for BC at UPY-A ⩾261.26 SU was observed.

Conclusions:

The present study supplies important information on the diagnostic characteristics of UPY-A revealing remarkable performances for early stages and allowing its potential use for different applications encompassing the screening of high-risk subjects, primary diagnosis and posttreatment surveillance.

Multicenter evaluation of the role of UroVysion FISH assay in surveillance of patients with bladder cancer: does FISH positivity anticipate recurrence?

BACKGROUND

The significance of a positive UroVysion FISH assay is uncertain in patients with normal cystoscopy. This multicenter study evaluates the clinical significance of a positive FISH assay in patients with no visible tumor and excluding those with a positive cytology.

METHODS

A multi-institutional, retrospective study of patients with a history of urothelial carcinoma of the bladder identified 664 patients with a FISH assay after excluding those with cystoscopic evidence of a tumor and/or positive cytology. Our primary end point was cancer recurrence, defined by biopsy. Progression was defined as recurrence with a tumor stage ≥T2. Statistical analyses were performed using Fisher's exact test as a one-tailed test and Chi-square test with significance at 0.05, using SPSS(®) version 19.0 (SPSS Inc., Chicago, IL, USA).

RESULTS

Of the 664 patients in this study, tumor stage was Ta (363, 55 %), T1 (183, 28 %), and CIS (109, 16 %) and most were high grade (440 pts, 66 %). The median follow-up was 26 months (3-104 months), and 277 (41.7 %) patients were recurred. In patients who were FISH positive, mean time to recurrence was 12.6 months, compared to 17.9 months if FISH negative (p = 0.03). In univariate analysis, atypical cytology, positive FISH, cystoscopic findings (atypical vs. normal), and previous intravesical therapy were associated with recurrence (p < 0.05). On multivariate analysis, pathologic stage, cystoscopic findings, and cytology were independently associated with recurrence (p < 0.05). Progression to ≥T2 disease occurred in 34 (5.1 %) patients in this cohort. On multivariate analysis, only initial T stage and FISH result were found to be independent predictors of progression (p < 0.05).

CONCLUSIONS

Patients with a positive FISH and atypical cytology are more likely to recur even in the absence of visible tumor. FISH positivity may portend a higher risk for progression. These findings require prospective validation.

Bladder cancer diagnosis and identification of clinically significant disease by combined urinary detection of Mcm5 and nuclear matrix protein 22

Background

Urinary biomarkers for bladder cancer detection are constrained by inadequate sensitivity or specificity. Here we evaluate the diagnostic accuracy of Mcm5, a novel cell cycle biomarker of aberrant growth, alone and in combination with NMP22.

Methods

1677 consecutive patients under investigation for urinary tract malignancy were recruited to a prospective blinded observational study. All patients underwent ultrasound, intravenous urography, cystoscopy, urine culture and cytologic analysis. An immunofluorometric assay was used to measure Mcm5 levels in urine cell sediments. NMP22 urinary levels were determined with the FDA-approved NMP22® Test Kit.

Results

Genito-urinary tract cancers were identified in 210/1564 (13%) patients with an Mcm5 result and in 195/1396 (14%) patients with an NMP22 result. At the assay cut-point where sensitivity and specificity were equal, the Mcm5 test detected primary and recurrent bladder cancers with 69% sensitivity (95% confidence interval = 62–75%) and 93% negative predictive value (95% CI = 92–95%). The area under the receiver operating characteristic curve for Mcm5 was 0.75 (95% CI = 0.71–0.79) and 0.72 (95% CI = 0.67–0.77) for NMP22. Importantly, Mcm5 combined with NMP22 identified 95% (79/83; 95% CI = 88–99%) of potentially life threatening diagnoses (i.e. grade 3 or carcinoma in situ or stage ≥pT1) with high specificity (72%, 95% CI = 69–74%).

Conclusions

The Mcm5 immunoassay is a non-invasive test for identifying patients with urothelial cancers with similar accuracy to the FDA-approved NMP22 ELISA Test Kit. The combination of Mcm5 plus NMP22 improves the detection of UCC and identifies 95% of clinically significant disease. Trials of a commercially developed Mcm5 assay suitable for an end-user laboratory alongside NMP22 are required to assess their potential clinical utility in improving diagnostic and surveillance care pathways.

Annual endoscopy and urine cytology for the surveillance of bladder tumors after enterocystoplasty for congenital bladder anomalies

PURPOSE

It is currently recommended that patients with congenital bladder anomalies managed by enterocystoplasty undergo annual surveillance with urine cytology and endoscopy. We reviewed our experience with this protocol and suggest modifications based on this experience.

MATERIALS AND METHODS

A total of 65 patients 10 years or more after enterocystoplasty were placed on an annual surveillance protocol consisting of interval medical history, renal-bladder ultrasound, serum B12, electrolytes, creatinine, urinalysis, urine cytology and endoscopy.

RESULTS

Of the 65 patients 50 (77%) with enterocystoplasty (ileal in 40 and colonic in 10) remain on the protocol. Median age at the initiation of surveillance was 28 years (range 24 to 40) with a median time from augmentation of 15 years (range 12 to 29). During the first 5 years of surveillance 26 of 250 cytology results (10.5%) were suspicious for cancer. Further evaluation revealed no evidence of malignancy. Specificity for cytology was 90% with unknown sensitivity. Of 250 surveillance endoscopic evaluations 4 lesions (1.6%) were identified and biopsied/removed. Pathological evaluation revealed 1 adenomatous polyp, 1 squamous metaplasia and 2 nephrogenic adenomas. Due to the low event rate and high cost routine cytology and endoscopy were discontinued after each patient completed 5 years of followup and annual evaluations were maintained. No tumors developed during the median surveillance interval of 15 years (range 12 to 20). Currently median patient age is 42 years (range 36 to 59) and median time since augmentation is 27 years (range 23 to 40).

CONCLUSIONS

Due to the low incidence of malignancy, lack of proven benefit and enhanced cost containment we recommend that annual surveillance endoscopy and cytology be discontinued.

The sensitivity of fluorescent-light cystoscopy for the detection of carcinoma in situ (CIS) of the bladder: a meta-analysis with comments on gold standard

What's known on the subject? and What does the study add? Fluorescent-light cystoscopy has a high sensitivity, relative to that of white light cystoscopy, for carcinoma in situ of the bladder. However, this systematic review reveals that the absolute sensitivity is unknown due to the absence of proper gold standard which is microscopic examination of whole bladders. •  A literature search was conducted to identify peer-reviewed study reports on the sensitivity of fluorescent-light cystoscopy (FLC) for the detection of carcinoma in situ (CIS) of the bladder. •  Data from 16 original studies comprising 1503 patients were pooled. •  The claimed sensitivity of FLC for detecting patients with CIS using the most commonly reported intravesical agents 5-aminolevulinic acid or hexaminolevulinic acid was 92.4%, while that of white-light cystoscopy (WLC) was 60.5%. The two agents did not differ significantly for sensitivity. •  It must be pointed out that a 'gold standard' is lacking in FLC studies. •  The occurrence of CIS of the bladder can only be established by the pathological examination of whole bladders. The true sensitivities of various modes of cystoscopy for detecting CIS can be revealed if patients scheduled for cystectomy are first examined with WLC, FLC, and optionally random biopsies. •  The absolute sensitivity of FLC for detecting CIS of the bladder is not yet known.

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

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

Hypermethylated SFRP1, but none of other nine genes "informative" for western countries, is valuable for bladder cancer detection in Mainland China

PURPOSE

A 11-gene set by methylation-specific PCR in urine sediments for sensitive/specific detection of bladder cancer has been identified previously. In this study, we have evaluated 10 DNA methylation biomarkers that have been reported informative in western countries for bladder cancer diagnosis for a better set.

MATERIALS AND METHODS

The promoter CpG Islands of the following 10 genes: CDH1, FANCF, LOXL1, LOXL4, p16INK4, SFRP1, SOX9, TIG1, TIMP3, and XAF1 have been subjected to methylation-specific PCR analysis in the DNA of 2 bladder cancer cell lines, 2 normal bladder tissues and urine sediments of 82 bladder cancer patients, 15 non-cancerous urogenital patients and 5 healthy volunteers.

RESULTS

Both XAF1 and LOXL1 genes were heterozygously methylated in the normal bladder tissues, showing no cancer state specificity. While the hypermethylated states were detected in urine sediments of bladder cancer at a frequency not less than 2.4% (2/82 cases), nine genes were also methylated in the patients of the non-cancerous urogenital diseases. The methylated SFRP1 was detected in 36.6% (30/82 cases) of bladder cancer and 6.7% (1/15 cases) of non-cancerous urogenital diseases, showing the bladder cancer specificity.

CONCLUSIONS

Inclusion of the SFRP1 gene into a set of 11 genes has improved the bladder cancer detection. The insufficiency of predicting disease onset in this study with the previously recommended targets in western countries suggests a possible disease disparity between these two populations. Alternatively, the tissue-specific methylation might be mistaken as the cancer specific in the studies where no non-cancerous lesion controls were involved.

A review of solutions for diagnostic accuracy studies with an imperfect or missing reference standard

OBJECTIVE

In diagnostic accuracy studies, the reference standard may be imperfect or not available in all patients. We systematically reviewed the proposed solutions for these situations and generated methodological guidance.

STUDY DESIGN AND SETTING

Review of methodological articles.

RESULTS

We categorized the solutions into four main groups. The first group includes methods that impute or adjust for missing data on the reference standard. The second group consists of methods that correct estimates of accuracy obtained with an imperfect reference standard. In the third group a reference standard is constructed by combining multiple test results through a predefined rule, based on a consensus procedure, or through statistical modeling. In the fourth group, the diagnostic accuracy paradigm is abandoned in favor of validation studies that relate index test results to relevant clinical data, such as history, future clinical events, and response to therapy.

CONCLUSION

Most of the methods try to impute, adjust, or construct a reference standard. In situations that deviate only marginally from the classical diagnostic accuracy paradigm, these are valuable methods. In cases where an acceptable reference standard does not exist, the concept of clinical test validation may provide an alternative paradigm to evaluate a diagnostic test.

Increase sensitivity in detecting superficial, low grade bladder cancer by combination analysis of hypermethylation of E-cadherin, p16, p14, RASSF1A genes in urine

OBJECTIVES

To identify a better set of DNA methylation markers to detect superficial, low grade cancer cell in urine sediment for improving cancer treatment, morbidity, and mortality.

MATERIALS AND METHODS

Methylation-specific PCR (MSP) assay was used to detect promoter hypermethylation in 4 genes (E-cadherin, p16, p14, and RASSF1A) to identify reliable biomarkers for bladder cancer diagnosis in primary tumor DNA and urine sediment DNA from 57 bladder cancer patients. Urine DNA was compared with 20 healthy controls.

RESULTS

Fifty-one (90%) tumor DNA and 47 urine DNA (83%) samples from bladder cancer patients revealed hypermethylation in at least 1 of the 4 analyzed genes, whereas all urine samples from normal controls were negative. The sensitivity of MSP assay for detecting E-cadherin, p16, p14 and RASSF1A in tumor cells in voided urine was 35%, 35%, 33%, and 65%, respectively. Diagnostic sensitivity was 75% for combining RASSF1A and p14, and 83% for RASSF1A, p14 and E-cadherin. Urine cytology, however, detect only 13 (28%) cases of cancer or suspicious cancer. For detecting superficial and invasive bladder tumor, urine cytology revealed a sensitivity of 23% (6/26) and 35% (7/20), respectively. In contrast, MSP detected hypermethylation in the urine of 80% (37/46) bladder cancer patients. Moreover, hypermethylation analysis of E-cadherin, p14 or RASSF1A genes in urine sediment DNA detected in 85% (22/26) of superficial, 85% (11/13) of low grade, 75% (15/20) of invasive and 79% (26/33) of high grade bladder cancers. Importantly, hypermethylation was detected in the urine DNA of 90% (18/20) superficial tumors with negative or atypia cytology.

CONCLUSIONS

Hypermethylation of E-cadherin, p14 or RASSF1A in urine sediment DNA is a potential biomarker for detecting superficial, low grade cancer. Besides, hypermethylation of these 3 genes is a valuable adjunct diagnostic marker to urine cytology, which can enhance the diagnostic accuracy and follow-up treatment of bladder cancer patients.

A novel set of DNA methylation markers in urine sediments for sensitive/specific detection of bladder cancer

PURPOSE

This study aims to provide a better set of DNA methylation markers in urine sediments for sensitive and specific detection of bladder cancer.

EXPERIMENTAL DESIGN

Fifty-nine tumor-associated genes were profiled in three bladder cancer cell lines, a small cohort of cancer biopsies and urine sediments by methylation-specific PCR. Twenty-one candidate genes were then profiled in urine sediments from 132 bladder cancer patients (8 cases for stage 0a; 68 cases for stage I; 50 cases for stage II; 4 cases for stages III; and 2 cases for stage IV), 23 age-matched patients with noncancerous urinary lesions, 6 neurologic diseases, and 7 healthy volunteers.

RESULTS

Despite six incidences of four genes reported in 3 of 23 noncancerous urinary lesion patients analyzed, cancer-specific hypermethylation in urine sediments were reported for 15 genes (P < 0.05). Methylation assessment of an 11-gene set (SALL3, CFTR, ABCC6, HPR1, RASSF1A, MT1A, RUNX3, ITGA4, BCL2, ALX4, MYOD1, DRM, CDH13, BMP3B, CCNA1, RPRM, MINT1, and BRCA1) confirmed the existing diagnosis of 121 among 132 bladder cancer cases (sensitivity, 91.7%) with 87% accuracy. Significantly, more than 75% of stage 0a and 88% of stage I disease were detected, indicating its value in the early diagnosis of bladder cancer. Interestingly, the cluster of reported methylation markers used in the U.S. bladder cancers is distinctly different from that identified in this study, suggesting a possible epigenetic disparity between the American and Chinese cases.

CONCLUSIONS

Methylation profiling of an 11-gene set in urine sediments provides a sensitive and specific detection of bladder cancer.

Impact of risk factors on the performance of the nuclear matrix protein 22 point-of-care test for bladder cancer detection

OBJECTIVES

To evaluate the impact of different risk factors and symptoms on the performance characteristics of the nuclear matrix protein 22 (NMP22) BladderChek test (Matritech Inc., Newton, MA, USA) for the detection of bladder cancer, as this is a point-of-care assay that measures NMPs in voided urine.

PATIENTS AND METHODS

In all, 23 academic, private practice and veterans' facilities in 10 states prospectively enrolled consecutive patients from September 2001 to May 2002. Participants included 1328 patients at elevated risk of bladder cancer from factors such as a history of smoking or symptoms including haematuria and/or dysuria. Patients at risk of malignancy of the urinary tract provided a voided urine sample for analysis of NMP22 protein and cytology before cystoscopy.

RESULTS

Of the 1328 patients: no urinary disease, benign disease and malignancy were found in 545 (41%), 704 (53%) and 79 (6%) patients, respectively. Overall, the positive predictive value (PPV) for detection of bladder cancer was 20.3% (45/222) and negative predictive value (NPV) was 96.9% (1072/1106). The PPV was higher in men (24.0%) than women (13.2%). In men, the PPV increased with smoking (35.4%), gross haematuria (51.2%) and a combination of both factors (70.6%). The impact on the PPV of smoking (9.7%) and gross haematuria (28.6%) was less dramatic in women. The PPV increased from 16.8% in patients aged <65 years to 23.5% in those aged >65 years. The NPV remained almost always >95% except in men with gross haematuria where it decreased to 77% in smokers and 94% in non-smokers.

CONCLUSION

The PPV of the BladderChek test improves in patients at higher risk of bladder cancer reaching 77% in men presenting with gross haematuria who are aged >65 years and smoke. The NPV is highest in women aged <65 years, up to 100%.

Quantitation of promoter methylation of multiple genes in urine DNA and bladder cancer detection

BACKGROUND

The noninvasive identification of bladder tumors may improve disease control and prevent disease progression. Aberrant promoter methylation (i.e., hypermethylation) is a major mechanism for silencing tumor suppressor genes and other cancer-associated genes in many human cancers, including bladder cancer.

METHODS

A quantitative fluorogenic real-time polymerase chain reaction (PCR) assay was used to examine primary tumor DNA and urine sediment DNA from 15 patients with bladder cancer and 25 control subjects for promoter hypermethylation of nine genes (APC, ARF, CDH1, GSTP1, MGMT, CDKN2A, RARbeta2, RASSF1A, and TIMP3) to identify potential biomarkers for bladder cancer. We then used these markers to examine urine sediment DNA samples from an additional 160 patients with bladder cancers of various stages and grades and from an additional 69 age-matched control subjects. Data were analyzed on the basis of a prediction model and were internally validated using a jacknife procedure. All statistical tests were two-sided.

RESULTS

For all 15 patients with paired DNA samples, the promoter methylation pattern in urine matched that in the primary tumors. Four genes displayed 100% specificity. Of the 175 bladder cancer patients, 121 (69%, 95% confidence interval [CI] = 62% to 76%) displayed promoter methylation in at least one of these genes (CDKN2A, ARF, MGMT, and GSTP1), whereas all control subjects were negative for such methylation (100% specificity, 95% CI = 96% to 100%). A logistic prediction model using the methylation levels of all remaining five genes was developed and internally validated for subjects who were negative on the four-gene panel. This combined, two-stage predictor produced an internally validated ROC curve with an overall sensitivity of 82% (95% CI = 75 % to 87%) and specificity of 96% (95% CI = 90% to 99%).

CONCLUSION

Testing a small panel of genes with the quantitative methylation-specific PCR assay in urine sediment DNA is a powerful noninvasive approach for the detection of bladder cancer. Larger independent confirmatory cohorts with longitudinal follow-up will be required in future studies to define the impact of this technology on early detection, prognosis, and disease monitoring before clinical application.

Economic impact of screening for bladder cancer using bladder tumor markers: A decision analysis

PURPOSE

The Food and Drug Administration recently approved the use of bladder markers such as BladderChek (NMP22; Matritech, Inc., Newton, MA) and UroVysion (Abbott Laboratories, Abbott Park, IL) for use in screening for bladder cancer. The purpose of this analysis was to assess the cost associated with implementing a widespread screening program using a noninvasive bladder tumor marker.

METHODS

Data for the accuracy of NMP22 in detecting bladder cancer was gathered from a comprehensive literature review. A decision tree analysis was constructed to evaluate the total cost of screening a low and high-risk population for bladder cancer using NMP22. Sensitivity analyses were conducted to evaluate the effect of relaxing the various assumptions in the model.

RESULTS

Application of the model to all men, regardless of the degree of risk, rendered a cost per cancer detected of $783,913, $269,028, and $139,305 for ages 50-59, 60-69, and 70-79 years, respectively. Screening only patients at high-risk for bladder cancer (annual incidence 6%) would yield a cost per cancer detected of $3,310. Incidence of cancer and marker specificity had the highest influence on cost per cancer detected.

CONCLUSIONS

Application of NMP22 to the entire population would render an extremely high cost per cancer detected. However, application to an appropriate high-risk target population could achieve cost per cancer detected comparable to currently used screening programs for prostate, colon, and breast cancer. Further studies are needed to assess the accuracy of bladder tumor markers in detecting bladder cancer in a completely asymptomatic cohort.

Molecular markers in bladder cancer: A critical appraisal

The diagnosis of both primary and recurrent bladder tumors currently relies upon the urine cytology and cystoscopy. Neither of these diagnostic tools is completely accurate. Prognostication of bladder cancer is largely based on pathologic tumor grade and stage. Over the past 2 decades, there is accumulating evidence that like many other cancers, bladder cancer, too, has a distinct molecular signature that separates it from other cancers and normal bladder tissue. Bladder tumors of different grades and stages even possess unique, and specific genotypic and phenotypic characteristics. Although recognition of several of these molecular alterations is possible by analyzing tumor tissue, urine, and serum samples, few if any of these "molecular markers" for bladder cancer are widely used in clinical practice. These markers include some that can be applied during the diagnostic work-up of symptoms (e.g., hematuria), those under surveillance for recurrence of superficial disease and forecasting long-term prognosis, or response to chemotherapy. In this review of molecular markers for bladder cancer, effectiveness of markers in each of these categories that are identifiable in the urine of patients with bladder cancer was examined. Many of the diagnostic markers appear to hold an advantage over urine cytology in terms of sensitivity, especially for the detection of low-grade superficial tumors. However, most markers tend to be less specific than cytology, yielding more false-positives. This result is more commonly observed in patients with concurrent bladder inflammation or other benign bladder conditions. Although there are several candidate markers for assessing prognosis or response to chemotherapy, studies of large patient populations are lacking. Further studies involving larger numbers of patients are required to determine their accuracy and widespread applicability in guiding treatment of bladder cancer.

5-Aminolevulinic Acid Derivatives in Photomedicine: Characteristics, Application and Perspectives

The introduction of lipophilic derivatives of the naturally occurring heme precursor 5-aminolevulinic acid (5-ALA) into photomedicine has led to a true revival of this research area. 5-ALA-mediated photodynamic therapy (PDT) and fluorescence photodetection (FD) of neoplastic disease is probably one of the most selective cancer treatments currently known in oncology. To date, this method has been assessed experimentally for the treatment of various medical indications. However, the limited local bioavailability of 5-ALA has widely prevented its use in daily clinical practice. Although researchers were already aware of this drawback early during the development of 5-ALA-mediated PDT, only recently have well-established concepts in pharmaceutical science been adapted to investigate ways to overcome this drawback. Recently, two derivatives of 5-ALA, methylaminolevulinate (MAL) and hexylaminolevulinate (HAL), gained marketing authorization from the regulatory offices in Europe and Australia. MAL is marketed under the trade name Metvix for the treatment of actinic keratosis and difficult-to-treat basal cell carcinoma. HAL has recently been launched under the trade name Hexvix to improve the detection of superficial bladder cancer in Europe. This review will first present the fundamental concepts underlying the use of 5-ALA derivatives in PDT and FD from a chemical, biochemical and pharmaceutical point of view. Experimental evidences from preclinical data on the improvements and limits observed with 5-ALA derivatives will then be introduced. The state-of-the-art from clinical studies with 5-ALA esters will be discussed, with special emphasis placed on the process that led to the development of MAL in dermatology and to HAL in urology. Finally, we will discuss promising medical fields in which use of 5-ALA derivatives might potentially lead to further use of this methodology in photomedicine.

Fluorescence detection of bladder cancer: a review

An effective therapeutic outcome in the treatment of bladder cancer is largely defined by its early detection. In this context, big expectations have been placed on the fluorescence-guided diagnosis of bladder cancer. This paper reviews the applications of endo- and exogenous fluorescence for early diagnosis of in situ carcinoma of the bladder. Despite certain advantages of autofluorescence, exogenous fluorescence, based on the intravesical instillation of fluorophores with the following visible light excitation, has been shown to be more effective in terms of sensitivity and specificity for detecting carcinoma in situ. The equipment consists of a slightly modified light source in order to choose between white (conventional endoscopy) or blue light (fluorescence endoscopy) excitation, and specific lenses, in order to enhance maximally the contrast between normal (blue) autofluorescence and red fluorescence from malignancies. Among exogenous fluorophores, a particular emphasis will be put on the 5-aminolevulinic acid (ALA), its ester derivative (h-ALA) and hypericin. These dyes demonstrated an excellent sensitivity above 90% and specificity ranging from 70% to 90%.

[Diagnosis and treatment of bladder tumors by photodynamic therapy]

Experimental results and clinical trials showed that bladder tumours Tis and pT1a can be diagnosed by photodynamic diagnosis and treated by photodynamic therapy. These photochemical methods are based on a selective photosensitizer uptake in the tumour tissue. After subsequent irradiation, these tissues emit a fluorescence (diagnosis) or can be destroyed by chemically induced oxidative compounds (treatment). Hematoporphyrin derivative and its oligomeric part have been the light-sensitizing drugs the most commonly studied. Interest has now shifted to 5-aminolevulinic acid, or its hexylester form, inducing protoporphyrin IX which shows better tumour localising properties and could avoid side effects. While photodynamic treatment is still an experimental modality, photodynamic diagnosis could achieve a more accurate detection of occult dysplasia compared to white light cystoscopy.

Light irradiation increases embryotoxicity of photodynamic therapy sensitizers (5-aminolevulinic acid and protoporphyrin IX) in chick embryos

Photodynamic therapy (PDT) of malignant processes is based on the ability of a photosensitizer to first, accumulate in malignant (immature) tissue and second, to be destroyed following light irradiation. Because of the similarity between malignant and embryonic immature tissues, we investigated the deleterious effect of the PDT procedure on day 4 chick embryos in ovo. We compared experimentally the photodynamic effect (light-toxic) and the side effect (dark-toxic) of the clinically attractive photosensitizers 5-aminolevulinic acid (ALA) and protoporphyrin IX (PP IX). The dark and light embryotoxicity (i.e. lethality plus teratogenicity) was determined after intra-amniotic injection of one of a range of dose of each compound. Under dark conditions, PP IX exhibited embryotoxicity at a dose of 10 microg/embryo; however ALA did not exhibit embryotoxicity even at the highest dose (300 microg/embryo). Light irradiation of embryos following injection induced strong embryotoxic effects of both substances even at dark-ineffective doses.

Biosynthesis and photodynamic efficacy of protoporphyrin IX (PpIX) generated by 5-aminolevulinic acid (ALA) or its hexylester (hALA) in rat bladder carcinoma cells

Hexylester of 5-aminolevulinic acid (hALA) has been considered as an alternative to 5-aminolevulinic acid (ALA) for the treatment of malignancies of different origin. The present study addresses the ALA and hALA-induced PpIX pharmacokinetic profile using rat bladder carcinoma cells (AY27). The total PpIX content measured spectrofluorimetrically after extraction procedure at the end of 2 h incubation was at least 1.5-fold greater with hALA compared to ALA despite the difference in concentration of several orders between the two compounds (1 or 5 mM ALA and 5 or 10 x 10(-3) mM hALA). Considerable PpIX efflux was detected in the extracellular medium at the end of the incubation. With 5 mM ALA and 10 x 10(-3) mM hALA, PpIX build-up was continued beyond the incubation period pointing out to enzyme saturation in the biosynthetic pathway or/and the constitution of ALA reserve. Red laser light (lambda=630 nm) irradiation of AY27 cells after 2 h incubation with increasing ALA or hALA concentrations resulted in a nearly equal photocytotoxicity.

The application of human complement factor H-related protein (BTA TRAK) in monitoring patients with bladder cancer

The BTA TRAK assay is a quantitative sandwich format enzyme immunoassay performed in a reference laboratory. It measures levels of human complement factor H-related protein (hCFHrp) which is similar to human complement factor H. Test characteristics reveal an overall sensitivity of 68% to 77.5% and a specificity of 50%-75%. Retrospective analysis of urine specimens employing hazard analysis suggests that BTA TRAK may have a role as a quantitative diagnostic marker in monitoring bladder cancer patients. Prospective studies are required to validate this application and other uses of the BTA TRAK assay in the management of bladder cancer patients.