Newly diagnosed bladder cancer: the relationship of initial symptoms, degree of microhematuria and tumor marker status

BTA stat®, NMP22® BladderChek®, UBC® Rapid Test, and CancerCheck® UBC® rapid VISUAL as urinary marker for bladder cancer: Final results of a German multicenter study

INTRODUCTION AND OBJECTIVE

BTA stat®, NMP22® BladderChek®, UBC® Rapid Test, and CancerCheck® UBC® rapid VISUAL are urinary-based rapid tests. This multicenter study is the first study comparing all available rapid tests on a large cohort of bladder cancer patients and healthy controls in one setting.

METHODS

In total 732 urine samples (second morning urine) in a real-world assessment have been analyzed. We evaluated clinical samples from 464 patients with histologically confirmed urothelial tumors of the urinary bladder (17 solitary CIS, 189 low-grade, 187 high-grade nonmuscle invasive, 71 high-grade muscle invasive), 77 patients with No Evidence of Disease (NED), and from 191 healthy controls. Urine samples were analyzed by the BTA stat®, NMP22® BladderChek®, UBC® Rapid Test point-of-care (POC) system using the concile Omega 100 POC reader, and CancerCheck® UBC® rapid VISUAL. Sensitivities and specificities were calculated by contingency analyses.

RESULTS

All investigated urinary markers detected more pathological concentrations in urine of bladder cancer patients compared to tumor-free patients. The calculated diagnostic sensitivities for BTA stat®, NMP22® BladderChek®, UBC® Rapid Test, CancerCheck® UBC® rapid VISUAL, and cytology were 62.4%, 13.4%, 58.2%, 28.6%, 36.2% for low-grade, 83.4%, 49.5%, 84.5%, 63.1%, 71.2% for high-grade nonmuscle invasive, and 95.8%, 35.2%, 76.1%, 50.7%, 67.7% for high-grade muscle-invasive bladder cancer. The specificity was 67.9%, 95.5%, 79.4%, 94.4%, and 83.7%, respectively. The area under the curve (AUC) after receiver operating characteristics (ROC) analysis for high-grade non-muscle-invasive tumors was 0.757, 0.725, 0.819, 0.787, and 0.774, respectively.

CONCLUSIONS

The analysis of more than 700 urine samples offers an objective view on urine-based rapid diagnostics. Elevated pathological concentrations of markers in urine of bladder cancer patients were detected in all investigated tests. The highest sensitivities for high-grade non-muscle-invasive tumors were calculated for BTA stat® and UBC® Rapid Test, whereas NMP22® BladderChek®, and cytology showed the highest specificities. BTA stat® and UBC® Rapid Test have the potential to be used as a clinical valuable urinary protein biomarker for the detection of high-grade non-muscle-invasive bladder cancer patients and could be included in the management of these tumors.

Urinary Protein Markers for the Detection and Prognostication of Urothelial Carcinoma

Bladder cancer diagnosis and surveillance is mainly based on cystoscopy and urine cytology. However, both methods have significant limitations; urine cytology has a low sensitivity for low-grade tumors, while cystoscopy is uncomfortable for the patients. Therefore, in the last decade urine analysis was the subject of intensive research resulting in the identification of many potential biomarkers for the detection, surveillance, or prognostic stratification of bladder cancer. Current trends move toward the development of multiparametric models to improve the diagnostic accuracy compared with single molecular markers. Recent technical advances for high-throughput and more sensitive measurements have led to the development of multiplex assays showing potential for more efficient tools toward future clinical application. In this review, we focus on the findings of urinary protein research in the context of detection and prognostication of bladder cancer. Furthermore, we provide an up-to-date overview on the recommendations for the quality evaluation of published studies as well as for the conduction of future urinary biomarker studies.

A Systematic Review of the Diagnostic and Prognostic Value of Urinary Protein Biomarkers in Urothelial Bladder Cancer

For over 80 years, cystoscopy has remained the gold-standard for detecting tumours of the urinary bladder. Since bladder tumours have a tendency to recur and progress, many patients are subjected to repeated cystoscopies during long-term surveillance, with the procedure being both unpleasant for the patient and expensive for healthcare providers. The identification and validation of bladder tumour specific molecular markers in urine could enable tumour detection and reduce reliance on cystoscopy, and numerous classes of biomarkers have been studied. Proteins represent the most intensively studied class of biomolecule in this setting. As an aid to researchers searching for better urinary biomarkers, we report a comprehensive systematic review of the literature and a searchable database of proteins that have been investigated to date. Our objective was to classify these proteins as: 1) those with robustly characterised sensitivity and specificity for bladder cancer detection; 2) those that show potential but further investigation is required; 3) those unlikely to warrant further investigation; and 4) those investigated as prognostic markers. This work should help to prioritise certain biomarkers for rigorous validation, whilst preventing wasted effort on proteins that have shown no association whatsoever with the disease, or only modest biomarker performance despite large-scale efforts at validation.

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.

Incidence and clinical characteristics of lower urinary tract symptoms as a presenting symptom for patients with newly diagnosed bladder cancer

PURPOSE

The incidence of lower urinary tract symptoms (LUTS) as the sole presenting symptom for bladder cancer has traditionally been reported to be low. The objective of this study was to evaluate the prevalence and clinical characteristics of newly diagnosed bladder cancer patients who presented with LUTS in the absence of gross or microscopic hematuria.

MATERIALS AND METHODS

We queried our database of bladder cancer patients at the Atlanta Veteran's Affairs Medical Center (AVAMC) to identify patients who presented solely with LUTS and were subsequently diagnosed with bladder cancer. Demographic, clinical, and pathologic variables were examined.

RESULTS

4.1% (14/340) of bladder cancer patients in our series presented solely with LUTS. Mean age and Charlson Co-morbidity Index of these patients was 66.4 years (range = 52-83) and 3 (range = 0-7), respectively. Of the 14 patients in our cohort presenting with LUTS, 9 (64.3%), 4 (28.6%), and 1 (7.1%) patients presented with clinical stage Ta, carcinoma in Situ (CIS), and T2 disease. At a median follow-up of 3.79 years, recurrence occurred in 7 (50.0%) patients with progression occurring in 1 (7.1%) patient. 11 (78.6%) patients were alive and currently disease free, and 3 (21.4%) patients had died, with only one (7.1%) death attributable to bladder cancer.

CONCLUSIONS

Our database shows a 4.1% incidence of LUTS as the sole presenting symptom in patients with newly diagnosed bladder cancer. This study suggests that urologists should have a low threshold for evaluating patients with unexplained LUTS for underlying bladder cancer.

Medical follow-up for workers exposed to bladder carcinogens: the French evidence-based and pragmatic statement

BACKGROUND

The aim of this work was to establish recommendations for the medical follow-up of workers currently or previously exposed to carcinogenic substances for the bladder.

METHODS

A critical synthesis of the literature was conducted. Sectors of activity where workers are or were exposed to carcinogenic substances for the bladder were listed and classified according to the level of bladder cancer risk. Performances of techniques available for the targeted screening of bladder cancer were analysed, including a simulation of results among high-risk populations in France.

RESULTS

The risk level for the professional group and the latency period between the start of exposure and the natural history of the disease were selected to define a targeted screening protocol. The NMP22BC test, exclusive haematuria testing, and combinations of urine cytology with, respectively, the NMP22BC test and haematuria test, generated an extremely high proportion of false positive results.

CONCLUSION

Urine cytology is the test that offers the best specificity. Although poor for all bladder cancer stages and grades combined, its sensitivity is better for high grades, which require early diagnosis since late-stage cancers are of very poor prognosis. These results suggest that urine cytology is currently the only technique suitable for proposal within the context of a first line targeted screening strategy for occupational bladder cancer. An algorithm summarising the recommended medical follow-up for workers currently or previously exposed to carcinogenic substances for the bladder is proposed, based on the level of risk of bladder cancer.

Predicting results of daily-practice cystoscopies

OBJECTIVE

Our objective was to elaborate a predictive model of bladder cancer, in an unselected clinical population submitted to cystoscopy.

MATERIALS AND METHODS

We recruited consecutive patients that underwent cystoscopy due to suspicion of bladder cancer or surveillance of a previously diagnosed bladder cancer. Urine cytology and a BTA-stat® (BTA) test were carried out for all patients. To avoid an assessment bias, the BTA-tests, cytologies and cystoscopies were conducted in a blinded fashion. We used logistic regression to predict cystoscopy results from cytology, BTA-test and clinical variables.

RESULTS

From August 2011 to July 2012, we recruited 244 patients and 237 were valid for analysis. Newly diagnosed and surveillance cases were 13% and 87% respectively. Cytology and BTA-test sensitivities were 57.9% (CI 95: 42.2-72.1) and 63.2% (CI 95: 47.3-76.6) with specificities of 84.4% (CI 95: 78.7-88.8) and 82.9% (CI 95: 77.1-87.5). The predictive model included the BTA-test, cytology, time since previous tumour, and treatment with mitomicin or BGC during the last three months. The model predictive accuracy (AUC) was .85 (.78-.92), and dropped to 0.79 when excluding the BTA-test (P=.026). For the surveillance of bladder cancer, a 10% threshold on the model predicted probabilities resulted in an overall negative predictive value of 95.7%, and 95.0% in low grade tumours.

CONCLUSION

In a cost containment environment, our prediction model could be used to space out cystoscopies in patients with previous, low grade tumours, resulting in a more efficient use of resources in the healthcare system.

Appraisal of diagnostic ability of UCA1 as a biomarker of carcinoma of the urinary bladder

Initial diagnosis of carcinoma of the urinary bladder remains to be a challenge. Urine cytology, as an adjunct to cystoscopy, is less sensitive for low-grade tumors. Urothelial cancer associated 1 (UCA1) is a novel non-coding RNA gene, which plays a pivotal role in bladder cancer progression. Our aim is to investigate the significance of urinary UCA1 for the non-invasive diagnosis of transitional cell carcinoma (TCC) of the urinary bladder. We examined UCA1 expression in a bladder cancer cell line (T24) and in urine of 28 healthy individuals, 46 patients of non-malignant disorders, and 117 cases (69 primary and 48 recurrent cases) of histologically proven TCC prior to transurethral resection by using real-time PCR and compared it with voided urinary cytology. UCA1 expression was found in T24 cell line and also found to be significantly higher in the cancer group as compared to the controls (p<0.001). UCA1 messenger RNA (mRNA) expression showed a significant (p<0.05) association with stage and grade (p<0.05). UCA1 showed a sensitivity of 79.49% and a specificity of 79.73% (p<0.001), whereas urine cytology had a sensitivity of 66.67% and a specificity of 95.95% for TCC cases. Higher expression of UCA1 was associated with high grade (G2-G3, sensitivity=84.09%) (p<0.001). UCA1 mRNA expression did not significantly correlate with the patient's age, sex, and smoking habit (p>0.05). UCA1 can be used as a non-invasive diagnostic biomarker for TCC bladder as an adjunct to cytology in the early diagnosis of primary urinary bladder cancer.

Urinary markers in the everyday diagnosis of bladder cancer

Bladder cancer (BC) represents the fourth most common neoplasia in men and the ninth most common cancer in women, with a significant morbidity and mortality. Cystoscopy and voided urine cytology (involving the examination of cells in voided urine to detect the presence of cancerous cells) are currently the routine initial investigations in patients with hematuria or other symptoms suggestive of BC. Around 75-85% of the patients are diagnosed as having non-muscle-invasive bladder cancer (NMIBC). Despite the treatment, these patients have a probability of recurrence at 5 years ranging from 50 to 70% and of progression to muscle invasive disease of 10-15%. Patients with NMIBC must undergo life-long surveillance, consisting of serial cystoscopies, possibly urine cytology and ultrasonography. Cystoscopy is unsuitable for screening because of its invasiveness and costs; serial cystoscopies may cause discomfort and distress to patients. Furthermore, cystoscopy may be inconclusive, falsely positive or negative. Although urine cytology has a reasonable sensitivity for the detection of high-grade BC, it lacks sensitivity to detect low-grade tumors (sensitivity ranging from 4 to 31%). The overall sensitivity and specificity of urine cytology range from 7 to 100 and from 30 to 70%, respectively. There is a need for new urine biomarkers that may help in BC diagnosis and surveillance. A lot of urinary biomarkers with high sensitivity and/or specificity have been investigated. Although none of these markers have proven to be powerful enough to replace standard cystoscopy, some of them may represent accurate predictors of BC. A review of recent studies is presented.

[Analyses of the role of immunocytology in the differential diagnosis of patients with asymptomatic microhematuria]

INTRODUCTION

Discriminating between malignant and nonmalignant conditions remains a challenge in the evaluation of patients with asymptomatic microhematuria. In this prospective study the role of immunocytology in the assessment microhematuria was studied.

MATERIAL AND METHODS

uCyt is a commercially available immunocytological assay based on microscopical detection of tumor-associated antigens in urothelial cells by immunofluorescence. Between September 2000 and December 2006, 222 consecutive patients with newly diagnosed painless microhematuria without prior transitional cell carcinoma were included. All urine samples were examined cytologically and immunocytologically. A total of 211 samples (95%) were assessable.

RESULTS

Clinical examination by physical examination, cystoscopy, laboratory tests, and imaging yielded bladder cancer in ten cases (4%). Further diagnoses were BPH (27%), cystitis (including IC) (12%), urolithiasis (9%), urethral or ureteral strictures (6%), papilloma (2%), and"further conditions" (16%). In 52 patients (23%) reasons for hematuria were not identified. Immunocytology was positive in 8 of 10 bladder tumors (80%) and negative in 178 patients with non-tumor-related hematuria (89%).

CONCLUSIONS

The high sensitivity and good specificity of immunocytology is comparable with that reported in the literature despite a very low disease prevalence in this population. If assessment of these patients would have only been based on immunocytology, 180 costly and invasive diagnostic procedures would have been saved, with only 29 individuals (14%) undergoing these examinations unnecessarily. The authors conclude that these findings justify further investigation of this issue.

Screening for bladder tumours in men aged 60–70 years with a bladder tumour marker (UBC) and dipstick-detected haematuria using both white-light and fluorescence cystoscopy

OBJECTIVE

To investigate the relevance of bladder tumour screening using haematuria dipsticks and a bladder tumour marker in a random selection of men, age 60-70 years, from a well-defined geographical area using both fluorescence and white-light cystoscopy.

MATERIAL AND METHODS

A total of 2000 randomly selected men, age 60-70 years, were invited by mail to participate in a screening for bladder tumours by having their urine tested with a dipstick for haematuria and a bladder tumour marker (UBC). Men with 5-10 red blood cells (RBC)/microl and an International Prostate Symptom Score (IPSS) of >10 and all men with =25 RBC/microl and/or elevated UBC levels underwent both white-light and fluorescence cystoscopy.

RESULTS

A total of 1096 men (55%) responded and were included in the study. The incidence of 5-10 RBC/microl was high: 14%. A tumour was detected in one of the 62 men with 5-10 RBC/microl and an IPSS of >10. Among the 10% of men (n=112) with =25 RBC/microl, four bladder tumours were detected. Another two tumours were detected in men without haematuria (positive UBC test). No tumours were observed using only fluorescence cystoscopy.

CONCLUSIONS

Fluorescence cystoscopy and the UBC test were of no use in this screening situation. The incidence of haematuria (=5-10 RBC/microl) was so high (1:4) that this borderline for bladder tumour screening appears unrealistic. The incidence of =25 RBC/microl was 1:10 and one of 28 cystoscopies revealed a bladder tumour. All seven tumours were detected in men who were or had been smokers. A haematuria-based screening among older male smokers with =25 RBC/microl on dipstick testing is thus an option that should be considered.

The value of combined use of survivin, cytokeratin 20 and mucin 7 mRNA for bladder cancer detection in voided urine

OBJECTIVES

To evaluate the value of combined use of survivin, cytokeratin (CK) 20 and mucin (MUC) 7 mRNA in comparison with voided urine cytology in the detection of bladder cancer patients.

METHODS

One hundred and fifty three patients and 20 healthy volunteers were evaluated by RT-PCR for detecting survivin, CK-20 and MUC7 mRNA in voided urine before cystoscopy. The three markers and cytology were evaluated independently or in combinations.

RESULTS

The overall sensitivity and specificity were 90.4 and 94.7% for survivin, 82.6 and 97.4% for CK-20, 62.6 and 94.7% for MUC7 and 46.0 and 100% for voided urine cytology. Combined sensitivity of voided urine cytology with the three biomarkers together was higher than either combined sensitivity of voided urine cytology with one of the biomarkers or than that of the biomarker alone.

CONCLUSIONS

Combined use of the three markers can improve the sensitivity for detecting bladder cancer.

Immunocytology in the Assessment of Patients with Asymptomatic Microhaematuria

INTRODUCTION

Discrimination between malignant and nonmalignant conditions remains the key problem in assessing microhaematuria. This prospective study investigated the role of immunocytology in the evaluation of patients with microhaematuria.

METHODS

uCyt+ is a commercially available immunocytologic assay based on microscopic detection of tumour-associated antigens on the membrane of urothelial cells by immunofluorescence. Between October 2000 and August 2005, 189 consecutive patients with newly diagnosed painless microhaematuria without prior transitional cell carcinoma were included. All urine samples were examined cytologically and immunocytologically. Of the 189 samples, 178 (94%) were assessable.

RESULTS

Clinical assessment by physical examination, laboratory tests, endoscopy, and imaging modalities found bladder cancer in 8 patients (4%). Further diagnoses were benign prostatic hyperplasia (54 cases, 29%), cystitis (including interstitial cystitis; 20 cases, 11%), urolithiasis (18 cases, 9%), tumours of other origin (6 cases, 2%), and "further conditions" (26 cases, 13%). In 57 patients (30%) the reasons for haematuria were not disclosed. Immunocytology was positive in 7 of 8 bladder tumours (87%) and negative in 154 of 170 patients with haematuria for other reasons (91%).

CONCLUSIONS

The high sensitivity and good specificity of immunocytology in the diagnosis of bladder cancer was confirmed in this population with a low disease prevalence. Only one tumour of low malignant potential was missed by immunocytology. If assessment of these patients would have been based only on immunocytology, 154 costly and invasive diagnostic procedures could have been avoided, with only 16 of 170 individuals (9%) undergoing these examinations unnecessarily. The findings justify a prospective investigation of this issue.

Application of multiplex FISH, CGH and MSSCP techniques for cytogenetic and molecular analysis of transitional cell carcinoma (TCC) cells in voided urine specimens

Multiplex FISH (UroVysion), Comparative Genomic Hybridization (CGH), and Multitemperature Single-Strand Conformation Polymorphism (MSSCP) were applied for non-invasive diagnosis and prognosis of bladder cancer. The UroVysion test was positive in 80% of patients with pT1 and in 100% of patients with either pT2 or pT3 tumours. Tumours with pT3T4 stages were characterized by high numbers of chromosomal imbalances, detected by CGH. The mutation of the p53 gene was detected in 16% of patients, but only in those with pT2 or pT3 tumours.

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.

Bladder tumor markers beyond cytology: International Consensus Panel on bladder tumor markers

This is the first of 2 articles that summarize the findings of the International Consensus Panel on cytology and bladder tumor markers. The objectives of our panel were to reach a consensus on the areas where markers are needed, to define the attributes of an ideal tumor marker, and to identify which marker(s) would be suitable for diagnosis and/or surveillance of bladder cancer. Our panel consisted of urologists and researchers from Europe, Asia, and the United States who reviewed original articles, reviews, and book chapters on individual bladder tumor markers published in the English language mainly using the PubMed search engine. Panel members also met during 3 international meetings to write recommendations regarding bladder tumor markers. The panel found that the most practical use of noninvasive tests is to monitor bladder cancer recurrence, thereby reducing the number of surveillance cystoscopies performed each year. Markers also may be useful in the screening of high-risk individuals for early detection of bladder cancer. However, more prospective studies are needed to strengthen this argument. Case-control and cohort studies show that several markers have a higher sensitivity to detect bladder cancer. However, cytology is the superior marker in terms of specificity, although some markers in limited numbers of studies have shown specificity equivalent to that of cytology. Our panel believes that several bladder tumor markers are more accurate in detecting bladder cancer than prostate-specific antigen (PSA) is in detecting prostate cancer. However, bladder tumor markers are held to a higher standard than PSA. Therefore, use of bladder tumor markers in the management of patients with bladder cancer will require the willingness of both urologists and clinicians to accept them.

Qualitative and quantitative assessment of urinary cytokeratin 8 and 18 fragments compared with voided urine cytology in diagnosis of bladder carcinoma

OBJECTIVES

To evaluate the value of urine tests based on the detection of cytokeratins 8 and 18 for the diagnosis of bladder cancer compared with urine cytology.

METHODS

Samples from 112 patients before transurethral resection (group 1), 40 patients before secondary surgical treatment (group 2), 29 healthy control subjects (group 3, controls), and 10 women with acute urinary tract infection (group 4, controls) were examined with the UBC Rapid and UBC II enzyme-linked immunosorbent assay (ELISA) tests and voided urine cytology.

RESULTS

Of the 112 patients in group 1, 90 had transitional cell carcinoma. For the UBC Rapid, UBC ELISA, and cytology, the sensitivity and specificity was 64.4%, 46.6%, and 70.5% and 63.6%, 86.3%, and 79.5%, respectively. The cytology had the greatest accuracy (72.3%) compared with both cytokeratin tests (54.4% and 64.2%). For all three tests, sensitivity increased with tumor grade and stage. In group 2, 16 of 40 patients had residual carcinoma. The sensitivity was similar for all three tests, and the specificity of cytology was lower compared with its specificity in group 1 (47.9% versus 70.5% in group 1). In the controls with or without urinary tract infection, the specificity of cytology was greater than that of both other tests. The combination of the UBC ELISA test with cytology increased the sensitivity to 83% (specificity 68%).

CONCLUSIONS

Both cytokeratin tests detected patients with transitional cell carcinoma, but were inferior to voided urine cytology in test quality.

New diagnostic strategies in the detection and staging of bladder cancer

PURPOSE OF REVIEW

Bladder cancer is a very frequent disease and represents the second most common genitourinary neoplasm. The most prevalent form of the disease, superficial bladder cancer, can recur in more than 70% of cases, despite correct management. Any way to improve our disease diagnostic and treatment policy is therefore welcome.

RECENT FINDINGS

This review covers the following topics: (1). endoscopic tools: standard cystoscopy versus fluorescence cystoscopy and virtual endoscopy; (2). bladder cancer staging: histopathological analysis developments and imaging techniques (positron emission tomography, magnetic resonance imaging, computed tomography); (3). cytology and ancillary procedures (ImmunoCyt and fluorescence in-situ hybridization test, and others); (4). first-generation (bladder tumour antigen, nuclear matrix protein 22, telomerase repeat amplification protocol) and second-generation (loss of heterozygosity, minichromosome maintenance 5, DNA methylation, microsatellite) urine and serum markers.

SUMMARY

New diagnostic and therapeutic (endoscopic) tools in superficial bladder cancer should eventually modify our disease management policy. Fluorescence cystoscopy detects carcinoma in situ with a high accuracy, and seems to have a positive impact on reducing residual tumour and recurrence rate. A more specific staining of tissue specimens facilitates histological analysis and helps achieve better staging, especially in T1 diseases. Improving the sensitivity of cytology for low-grade diseases, ancillary procedures to classic cytology such as fluorescence in-situ hybridization and ImmunoCyt tests, may reduce the number of unpleasant cystoscopies in surveillance protocols of selected groups of patients. Second-generation urine markers such as loss of heterozygosity, microsatellite, minichromosome maintenance 5, with a high level of accuracy, show great potential for influencing bladder cancer detection and screening policy.