Urinary tissue polypeptide-specific antigen for the diagnosis of bladder cancer

Noninvasive Urine-Based Tests to Diagnose or Detect Recurrence of Bladder Cancer

Liquid biopsies are increasingly used for the diagnosis and follow-up of cancer patients. Urine is a body fluid that can be used to detect cancers and others diseases. It is noninvasive and easy to collect. To detect Bladder Cancer (BC), cytology is the first assay used. It is an effective way to detect high grade BC but has a high rate of equivocal results, especially for low grade BC. Furthermore, cystoscopy is used to confirm cytology results and to determine cancer status. Cystoscopy is also effective but highly invasive, and not well accepted by patients, especially for BC follow-up. In this review we survey the numerous assays recently developed in order to diagnose BC at an early stage, and to facilitate the follow-up of patients. We discuss their effectiveness, ease of use, and applications. Finally, we discuss assays that, in the future, could improve the diagnosis and management of BC patients.

Cytokeratins as Serum Markers in Egyptian Bladder Cancer. A Comparison of CYFRA 21–1, TPA and TPS

Cytokeratins (CKs) have been shown to be overexpressed in bladder cancer and to be valuable as tumor markers. The present study was designed to evaluate the single and combined use of three cytokeratin fragments, CYFRA 21–1, TPA, and TPS, in serum of Egyptian bladder cancer patients. The study subjects comprised 40 healthy controls, 30 patients with benign bladder diseases, and 60 patients with histologically confirmed primary bladder cancer. The cutoff was set at 95% specificity versus benign bladder diseases, resulting in cutoff values of 2.93 ng/mL for CYFRA 21–1, 158 U/L for TPA and 143.7 ng/mL for TPS. With 41% true positive results CYFRA 21-1 had a higher sensitivity than TPA (32%) and TPS (27%). Evaluation by histological findings revealed a highest sensitivity of CYFRA 21-1 (46%) in transitional cell carcinoma (TCC) followed by TPA (27%) and TPS (21%). Also in adenocarcinoma CYFRA 21-1 showed the highest sensitivity (38%) followed by TPA (32%) and TPS (28%). A high percentage (41.6%) of Egyptian bladder cancers is represented by squamous cell carcinoma (SCC). In this population TPS showed the highest sensitivity (69%), followed by CYFRA 21-1 (54%) and TPA (41%). The sensitivity of each of the three markers increased with advancing tumor stage and increasing tumor grade. Combined use of two of the three markers did not raise the sensitivities obtained by single determination of CYFRA 21-1. The present study suggests that serum CYFRA 21-1 could be a marker of choice in bladder cancer.

Standardization of diagnostic biomarker concentrations in urine: the hematuria caveat

Sensitive and specific urinary biomarkers can improve patient outcomes in many diseases through informing early diagnosis. Unfortunately, to date, the accuracy and translation of diagnostic urinary biomarkers into clinical practice has been disappointing. We believe this may be due to inappropriate standardization of diagnostic urinary biomarkers. Our objective was therefore to characterize the effects of standardizing urinary levels of IL-6, IL-8, and VEGF using the commonly applied standards namely urinary creatinine, osmolarity and protein. First, we report results based on the biomarker levels measured in 120 hematuric patients, 80 with pathologically confirmed bladder cancer, 27 with confounding pathologies and 13 in whom no underlying cause for their hematuria was identified, designated "no diagnosis". Protein levels were related to final diagnostic categories (p = 0.022, ANOVA). Osmolarity (mean = 529 mOsm; median = 528 mOsm) was normally distributed, while creatinine (mean = 10163 µmol/l, median = 9350 µmol/l) and protein (0.3297, 0.1155 mg/ml) distributions were not. When we compared AUROCs for IL-6, IL-8 and VEGF levels, we found that protein standardized levels consistently resulted in the lowest AUROCs. The latter suggests that protein standardization attenuates the "true" differences in biomarker levels across controls and bladder cancer samples. Second, in 72 hematuric patients; 48 bladder cancer and 24 controls, in whom urine samples had been collected on recruitment and at follow-up (median = 11 (1 to 20 months)), we demonstrate that protein levels were approximately 24% lower at follow-up (Bland Altman plots). There was an association between differences in individual biomarkers and differences in protein levels over time, particularly in control patients. Collectively, our findings identify caveats intrinsic to the common practice of protein standardization in biomarker discovery studies conducted on urine, particularly in patients with hematuria.

CYFRA 21-1: a potential molecular marker for noninvasive differential diagnosis of urothelial carcinoma of bladder

Establishing CYFRA 21-1 detection for noninvasive differential diagnosis of urothelial carcinoma (UC) of bladder would help to improve assessment and follow-up of patients, as well as to improve screening of high-risk groups. The study group comprised of 147 subjects including 72 patients with UC of bladder, 75 controls and 17 follow-up cases. The levels of CYFRA 21-1 in serum, urine and urinary cell lysate were estimated by high sensitivity ELISA. Our results indicate that urinary CYFRA 21-1 provides a high value of overall sensitivity for UC of bladder and is also useful even for detection of low grade tumors that might indicate possible earlier detection and treatment administration.

National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines for use of tumor markers in liver, bladder, cervical, and gastric cancers

BACKGROUND

Updated National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines for the use of tumor markers in the clinic have been developed.

METHODS

Published reports relevant to use of tumor markers for 4 cancer sites--liver, bladder, cervical, and gastric--were critically reviewed.

RESULTS

Alpha-fetoprotein (AFP) may be used in conjunction with abdominal ultrasound for early detection of hepatocellular carcinoma (HCC) in patients with chronic hepatitis or cirrhosis associated with hepatitis B or C virus infection. AFP concentrations >200 microg/L in cirrhotic patients with typical hypervascular lesions >2 cm in size are consistent with HCC. After a diagnosis of HCC, posttreatment monitoring with AFP is recommended as an adjunct to imaging, especially in the absence of measurable disease. Although several urine markers have been proposed for bladder cancer, none at present can replace routine cystoscopy and cytology in the management of patients with this malignancy. Some may, however, be used as complementary adjuncts to direct more effective use of clinical procedures. Although carcinoembryonic antigen and CA 19-9 have been proposed for use gastric cancer and squamous cell carcinoma antigen for use in cervical cancer, none of these markers can currently be recommended for routine clinical use.

CONCLUSIONS

Implementation of these recommendations should encourage optimal use of tumor markers for patients with liver, bladder, cervical, or gastric cancers.

Proteomic assays for the detection of urothelial cancer

Bladder cancer is one of the most expensive cancers from diagnosis to death of the patient due to life-long surveillance involving upper tract imaging, urinary cytology, and cystoscopy. Cytology has been historically used in conjunction with cystoscopy to help detect disease that may be missed by routine cystoscopy (e.g., carcinoma in situ and upper tract disease). Urine cytology is highly cytopathologist dependent and has reasonable sensitivity for detecting high grade disease. However, its sensitivity drops precipitously with regard to well-differentiated low grade cancers. Intensive investigations have been undertaken using proteomics to find an alternative to cystoscopy and cytology. Urine proteomic markers currently evaluated critically in the literature include bladder tumor antigen, nuclear matrix protein 22, BLCA-4, hyaluronic acid, hyaluronidase, cytokeratin 8, cytokeratin 18, cytokeratin 19, tissue polypeptide antigen, and tissue polypeptide-specific antigen. Markers used as alternatives to cystoscopy must be accurate with high sensitivity and specificity, cost effective for life-long surveillance, and minimally invasive to minimize the burden to the patient. To date, no proteomic marker has been developed that can replace cystoscopy for the detection of bladder cancer. However, several urinary markers appear to have higher sensitivity albeit lower specificity than cytology and can be used to supplement cystoscopy. Some of those markers are herein described in this chapter. By defining and characterizing the current state of the art in protein based markers, we are poised to evaluate and benchmark newly discovered protein biomarkers that will be isolated through new proteomics based investigations of urine.

Which urine marker test provides more diagnostic value in conjunction with standard cytology- ImmunoCyt/uCyt+ or Cytokeratin 20 expression

Background

Because of the poor sensitivity of urinary cytological findings for the diagnosis of especially low grade urinary bladder carcinoma, new molecular diagnostic methods have been proposed. We decided to verify the ImmunoCyt/uCyt+ (UCyt+™) test and cytology combination and cytokeratin 20 (CK20) and cytology combination in urine as possible diagnostic and monitoring tool for bladder cancer.

Methods

Evaluation of CK20 expression and UCyt+™ was performed in urine of 90 patients of which 54 with bladder cancer with primary/recurrent diagnosis (low grade urothelial carcinoma (LGUC) = 23/8 patients, high grade urothelial carcinoma (HGUC) = 18/5 patients), and 36 patients as control; except of neoplastic bladder disease patients. For the evaluation of the three tests, CK20 and UCyt+™ tests were combined with urine cytology and compared with each other.

Results

The overall sensitivity detected for each tumor marker was as follows: for urine cytology was 75.9% and UCyt+™ was 83.3%, for CK20 70.4%, while the specificity was 66.7% for urine cytology and 86.1% for UCyt+™ and 83.3% for CK20. The sensitivity of cytology and UCyt+™ combination was higher (88.9%) than the sensitivity cytology and CK20 combination (77.8%). The simultaneous use of the three markers, sensitivity was reaching 92.5%.

Conclusion

The UCyt+™ test and CK20 expression are valid tools for the performance of adjunctive analyses with conventional cytologic examination.

The Simultaneous Use of Telomerase, Cytokeratin 20 and CD4 for Bladder Cancer Detection in Urine

OBJECTIVE

Because of the low sensitivity of urinary cytological diagnosis of urinary bladder carcinoma, new molecular diagnostic methods have been proposed. We decided to verify the expression of telomerase mRNA coding for the catalytic component (hTRT), cytokeratin 20 (CK20) and CD4 antigen mRNAs in urine as possible diagnostic tool.

METHODS

Evaluation of hTRT, CK20, CD4 mRNAs was performed in 50 ml of naturally voided urine of 205 patients of which 153 with bladder cancer (Tis, n = 11; TaGx, n = 4; TaG1, n = 25; TaG2, n = 26; TaG3, n = 8; T1G1, n = 16; T1G2, n = 17; T1G3, n = 20; T2G2, n = 6; T2G3, n = 13; T3G3, n = 7) and 52 controls. A quantitative expression of hTRT at mRNA level versus TRAP (telomeric repeat amplification protocol) assay was performed in 20 patients and 14 controls. The expression of RT-PCR for hTRT, CK20, CD4 versus urinary cytology was analysed in 44 patients with bladder cancer. Evaluating the three molecular markers together, the result was considered correct when at least two of the markers were positive, suspected when only one marker was positive and negative for diagnosis of tumour when all markers were negative. The performance of the diagnostic model resulted from the logistic analysis evaluated with receiver operating characteristics (ROC) curve analysis.

RESULTS

The sensitivity detected for each tumour marker was as follows: for hTRT 90.8%, for CK20 84.3% and for CD4 was 64.7%, while the specificity was 94.2% for CD4 and 78.8% for both hTRT and CK20. When a simultaneous evaluation of the three tumour markers was considered, 88.2% of the diagnoses were correct, 11.8% were suspected for tumour and none were mistaken. When compared with cytology, the simultaneous use of the three markers allowed reaching a correct diagnosis in 88% of the cases in comparison to 25% by urinary cytology. The sensitivity in the detection of bladder cancer was higher for hTRT at mRNA level in comparison with the enzymatic activity detection with TRAP (90% vs. 35%) while the specificity for both markers resulted very high (100%).

CONCLUSIONS

These data show that in the future the diagnostic improvement of urine based molecular markers for the detection of bladder cancer in the urine could improve the sensitivity of urinary cytology reducing the need of a cystoscopy.

Detection of bladder tumours: role of cytology, morphology-based assays, biochemical and molecular markers

PURPOSE OF REVIEW

Cystoscopy is currently considered the gold standard for the detection of bladder tumours. The role of urine cytology in the initial detection and follow-up of patients is under discussion. Many efforts have been made to increase the detection rates and to predict the outcome of bladder cancer. In this subject review, a series of morphology-based, biochemical and molecular markers were compared with urine cytology for the detection of bladder cancer.

RECENT FINDINGS

Among the various markers reviewed, the average published sensitivity and specificity for the Bard tumour antigen test was 60 and 77%; for the nuclear matrix protein 22 test it was 67 and 72%; for the hyaluronic acid and hyaluronidase test it was 91 and 84%; for the ImmunoCyt it was 90 and 75%; for fluorescence in-situ hybridization it was 85 and 95%; for the telomerase assay it was 77 and 85%; and for the microsatellite assay it was 89 and 100%. DNA ploidy measurements, recent molecular markers and immunoassays designed to detect keratins, proteins, cell adhesion molecules, fibrinogen degradation products, and fibrinolysis markers were also included.

SUMMARY

As is clear from the brief summary of available assays, the optimal method of application is not yet clear. The integration of an assay into clinical practice takes more than just the documentation of its sensitivity and specificity. However, several of the procedures have received considerable support from urologists as assisting them in the management of their patients.

Sensitivity and specificity of commonly available bladder tumor markers versus cytology: results of a comprehensive literature review and meta-analyses

OBJECTIVES

To determine the clinical utility of urine-based bladder tumor markers (UBBTMs) and cytology in the treatment of patients with transitional cell carcinoma on the basis of their statistical performance.

METHODS

A comprehensive literature review was performed using Medline (1966 to current) and other search engines. Data regarding the statistical performance of UBBTMs were double extracted and rectified. Studies addressing comparable patient populations were combined and hierarchical Bayesian meta-analyses performed to calculate the sensitivity and specificity of commonly used UBBTMs, as well as urinary cytology. Patient populations were stratified by tumor stage and grade when data were presented in an extractable fashion.

RESULTS

The literature review yielded 54 publications, 338 distinct patient groups (controls, screening population, patients with cancer, strata based on grade and stage) and more than 10,000 patients. The number of groups varied from 1 to 18, and the number of patients ranged from less than 100 to more than 1500 for the various markers. All UBBTMs have better sensitivity compared with cytology, especially for low-grade/stage disease, but do not match cytology regarding specificity. In patients with grade 1 and 2 tumors, several UBBTMs are significantly superior statistically in terms of sensitivity compared with cytology. The sensitivity for transitional cell carcinoma in situ (Tis) is surprisingly poor for all UBBTMs.

CONCLUSIONS

UBBTMs can be used for follow-up of low-grade/stage tumors but should not replace cystoscopy. All UBBTMs have better sensitivity than cytology and could potentially replace routine cytology during patient follow-up.

Potential molecular marker for detecting transitional cell carcinoma

OBJECTIVES

To assess the expression rate of a cancer-related gene, hepatoma-up-regulated protein (HURP), in the tumor tissue of transitional cell carcinoma (TCC), and to assess the potential suitability of using this gene as a novel molecular marker for detecting TCC in voided urine.

METHODS

Total RNA was extracted from 80 TCC tissue samples of the urinary tract. Forty-five of the 80 tumor-adjacent tissue samples were from the same patients and 15 were from control subjects (patients with benign prostatic hyperplasia). The expression levels of HURP mRNA in these specimens were examined using reverse transcriptase-polymerase chain reaction. The HURP mRNA transcripts in voided urine pellets from 14 additional patients were determined using the same method. The messages were normalized to beta-actin mRNA.

RESULTS

The detection of HURP expression in the TCC tissue samples had a sensitivity of 88.8% (71 of 80) and a specificity of 100% (15 of 15). Ten of the 45 grossly tumor-adjacent tissue samples expressed HURP mRNA, which may indicate subtle genetic changes in tissue adjacent to tumor. All seven urine specimens from the patients with TCC revealed HURP expression; however, no specimens from patients with nonmalignant diseases did so.

CONCLUSIONS

A potential molecular marker for detecting TCC with tissue specimens and voided urine samples has been found. Although the real clinical application of this marker requires additional evaluation, the high sensitivity and specificity of the HURP gene amplification method warrants more investigation in the future.

Diagnostic value of cytokeratin-18 as a tumor marker in bladder cancer

OBJECTIVES

The aim of the study was to compare serum levels of cytokeratin-18 of patients with bladder cancer with those of the healthy controls, and to investigate the relation between cytokeratin level and the tumor stage.

DESIGN AND METHODS

Serum cytokeratin-18 levels of 38 patients with bladder cancer and of 25 healthy people were determined. Tumor stage was T(1) in 12 patients, T(2) in 9 patients, T(3) in 10 patients and T(4) in 7 patients. The serum cytokeratin-18 levels in these cases were analyzed with respect to the stage of the tumor.

RESULTS

Cytokeratin-18 level in the patient group was found to be significantly higher than that of the control group (p < 0.010) when the groups were totally compared. However, when the levels in patients with different tumor stages were compared with that of the controls, the difference was not significant in patients with stage 1 and 2 tumors (p > 0.05). Regarding the cut off value as 4.0 ng/mL, sensitivity and specificity for serum cytokeratin-18 were found to be 53% and 72% respectively. When sensitivity was calculated with respect to tumor stages, it was 8% for T(1,) 33% for T(2,) 90% for T(3) and 100% for T(4.) On the other hand, considering higher stage (T(3) and T(4)) tumors only, the sensitivity was calculated as 94%, but the sensitivity for lower stage (T(1) and T(2)) tumors was 19%.

CONCLUSIONS

It is clear that serum cytokeratin-18 level increases in patients with bladder cancer. However, it can only be useful as a tumor marker in the diagnosis of T(3) and higher staged tumors. This study indicated that cytokeratin-18 does not have any diagnostic value in lower stage bladder cancers.

Evaluation of urine CYFRA 21-1 for the detection of primary and recurrent bladder carcinoma

BACKGROUND

The urinary concentration of soluble cytokeratin 19 fragments, measured by the CYFRA 21-1 assay, may be used for the noninvasive, early detection of bladder carcinoma.

METHODS

This prospective study examined urine samples from 325 patients. The authors included 152 patients who presented with hematuria or irritative voiding symptoms (Group 1), 107 patients who were under surveillance after undergoing transurethral resection of bladder carcinoma (Group 2), 46 patients with urinary tract pathology other than bladder carcinoma (Group 3), and 20 healthy participants (Group 4). The urine concentration of CYFRA 21-1 was measured by an immunoradiometric assay. The patients in Groups 1 and 2 underwent cytoscopy and urine cytopathology. Biopsies were obtained if a tumor was seen on cytoscopy or if there was a suspicion of carcinoma in situ (CIS).

RESULTS

The optimal cut-off concentration for the detection of primary bladder tumors, 4.9 microg/L, resulted in a sensitivity of 79.3% and a specificity of 88.6%. The optimal threshold for the detection of recurrent bladder tumors (excluding patients who had been treated with intravesical bacillus Calmette-Guerin [BCG]), 4.04 microg/L, resulted in a sensitivity of 76.2% and a specificity of 84.2%. There was no significant advantage for centrifugation of the urine samples or for determination of the creatinine concentration in the urine samples. The CYFRA 21-1 assay of urine samples provided a three-fold greater sensitivity compared with the sensitivity of cytology for detecting Grade 1 transitional cell tumors. CYFRA 21-1 detected 91.9% of Grade 3 tumors, 100% of CIS, and 92.8% of invasive bladder tumors (T2 or higher classification). The CYFRA 21-1 assay detected all tumors that had positive cytology with the exception of only one tumor. Conversely, the assay identified 71% of primary tumors and 65% of recurrent tumors that were missed by cytopathology. Urinary stones, infection, and previous intravesical BCG immunotherapy caused many false positive results.

CONCLUSIONS

The urinary CYFRA 21-1 assay is a useful test for the noninvasive detection of bladder carcinoma and for surveillance of patients who were not treated previously with BCG. It may be used in combination with urine cytology and bladder ultrasound. Multi-institutional trials are required to compare the accuracy as well as the cost of this combination of tests with cystoscopy.

Can biological markers replace cystoscopy? An update

Cystoscopy is currently considered the gold standard for the detection of bladder tumors. The role of urine cytology in the initial detection and follow-up of patients is under discussion. New elaborative and rapid assays are available that may circumvent the low sensitivity and poor reproducibility of urine cytology. The methods that have been tested extensively are the nuclear matrix protein (NMP22) assay, the BTA stat assay, and the BTA TRAK enzyme-linked immunosorbent assay. Both outperform cytology in the detection of low-grade lesions. The specificity of both assays, however, lags behind that of cytology. The data from retrospective analyses are insufficient to justify clinical integration, and the need to replace cystoscopy with these novel assays remains to be proven.

Detecting recurrent bladder cancer: new methods and biomarkers

In this review, a series of biomarkers and molecular assays are compared with conventional urothelial cytology in their ability to detect recurrent bladder cancer. The tests considered in detail include the BTA test, NMP 22 test, DNA ploidy measurements, telomerase determinations and microsatellite instability assays. Although all of these measurements show some degree of improvement for cancer detection, the microsatellite instability assay shows the highest sensitivity and specificity. Additional biomarkers considered in the review include bladder cancer tumor antigens, growth factors, cell adhesion molecules and various molecular markers including cell cycle regulatory genes and p53 mutations.