Urinary Markers for Detecting Bladder Cancer

Early results of urothelial carcinoma screening in a risk population of coke workers: urothelial carcinoma among coke workers

OBJECTIVE

To present the protocol and the early results of a urothelial carcinoma (UC) screening analysis performed in a risk population of coke workers.

METHODS

Between June 2006 and October 2008, 171 male workers (mean age 43 years), employed in a Ligurian coke plant (Italiana Coke S.r.l) and exposed to polycyclic aromatic hydrocarbons (PAHs) for a median period of 16 years, underwent screening for UC. Urological evaluation included medical history, physical examination, routine laboratory tests, urine analysis, urinary cytology and uCyt+ assay. In the event of signs and symptoms suggestive of UC or positive urinary tests, the workers were also subjected to urinary ultrasonography and cystoscopy with biopsy of any suspicious lesions.

RESULTS

Regarding the laboratory tests, 19/171 (11%) uCyt+ samples were considered inadequate and were excluded from the outcomes assessment. Overall, urine analysis, cytology and uCyt+ were positive in 18/152 (12%) subjects who showed no evidence of UC at the scheduled check-ups. No significant association was identified between marker positivity and occupational activity.

CONCLUSIONS

Our results fail to show an increased risk of UC among the coke workers evaluated. However, they will need to be confirmed in the future by a larger enrollment and a longer follow-up in order to assess the definitive risk for UC after exposure to coke.

Contemporary diagnosis of bladder cancer

BACKGROUND

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

OBJECTIVE

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

METHODS

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

CONCLUSION

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

Urinary CYFRA 21.1 is not a useful marker for the detection of recurrences in the follow-up of superficial bladder cancer

OBJECTIVES

The objective of this prospective study is to establish an appropriate cutoff value of urinary CYFRA 21.1 assay and to assess its utility combined with voided cytology and/or haemoglobin dipstick in the follow-up of patients with superficial bladder cancer.

METHODS

From December 2000 to November 2003, 446 patients in follow-up for superficial bladder cancer (Ta-T1) after transurethral resection of the bladder (TURB) were included in a prospective study. Voided urine specimens were collected 7-14 d before cystoscopy and/or TURB for CYFRA 21.1 (one sample), haemoglobin dipstick (one sample), and cytology (three samples). All samples were processed for CYFRA 21.1 and haemoglobin dipstick according to manufacturer instructions. A control group (n=185) was obtained from patients in follow-up after transurethral resection of superficial disease (without recurrences within the following 6 mo). There were 125 recurrent transitional tumours detected by cystoscopy (34 TaG1; 53 TaG2/T1G1-2; 23 Ta-1G3/Tis, and 15 T2-4). Receiver operator characteristic (ROC) curves were constructed and cutoff values were chosen. Sensitivity, specificity, PPV (positive predictive value), NPV (negative predictive value), and their 95% confidence intervals were calculated.

RESULTS

ROC curve analysis based on the previously reported cutoff value of 4ng/ml for CYFRA 21.1 demonstrated a sensitivity and specificity of 43% and 68%, respectively. At a cutoff value of 1.5ng/ml, sensitivity was 73.8% with a low specificity (41%). Further lowering of the cutoff point below 1.5ng/ml did not demonstrate a significant increase in sensitivity. Therefore, this value was chosen as the most sensitive CYFRA 21.1 cutoff point during the rest of the study. Specificity increased when all the patients treated with pelvic radiotherapy or with UTI, urethral catheterisation, and intravesical instillations within 3 previous months were not included in our analysis. CYFRA 21.1 plus cytology and the combination of CYFRA 21.1, cytology, and haemoglobin dipstick demonstrated the highest overall sensitivities, and detected 91.3% of Ta-1G3 tumours and 93.3% of T2-4 tumours. However, there were one muscle-invasive tumour, two T1G3/Tis, three T1G2, and nine T1G1 neoplasms with negative combination of cytology and CYFRA 21.1 (1,5ng/ml). All these tumours were smaller than 2cm in size; most were single tumours. Nevertheless, there were 16 tumours larger than 0.5cm (0.5-2cm), and multiple neoplasms were endoscopically detected in 14 patients. Similar results were obtained through the combination of CYFRA 21.1 (cutoff: 1.5ng/ml), cytology, and haemoglobin dipstick.

CONCLUSIONS

In our experience the low sensitivity of urinary CYFRA 21.1, even using lower cutoff values and/or a combination with cytology and/or haemoglobin dipstick, makes its application not very useful as a surveillance tool for superficial bladder carcinoma.

Rapid diagnosis and follow up of bladder cancer patients using urinary high molecular weight cytokeratins

We have developed an office-based dot-EIA for the detection of a urinary high molecular weight cytokeratin (CK). Immunohistochemical staining and western blot based on CK1K10 monoclonal antibody were used to identify the CK. Urine of 192 patients with different types, grades, and stages of bladder tumor and 72 controls were evaluated using dot-EIA. An intense and diffuse cytoplasmic reaction was shown in bladder squamous cell carcinoma. The target epitope was identified in urine at 65, 56, and 40-kDa. The CK purified from urine showed single polypeptide at 65-kDa using SDS-PAGE and single peak at 7.4 min using capillary zone electrophoresis. The dot-EIA detected the CK with high sensitivity (97%) and specificity (94%). The CK was not detected in urine of bladder cancer patients showing response to radiotherapy. The sensitive and specific office-based detection of urinary cytokeratin would be helpful in rapid diagnosis and follow up of bladder carcinoma.

uCyt+ test: Alternative to cystoscopy for less-invasive follow-up of patients with low risk of urothelial carcinoma

OBJECTIVES

To assess the utility of ImmunoCyt/uCyt+ in combination with cytology to reduce the number and cost of cystoscopies in the follow-up of patients with urothelial cancer of the bladder.

METHODS

A total of 216 patients under follow-up after transurethral resection of the bladder for urothelial cancer were enrolled in the present study. The mean follow-up time was 26 months (range 3 to 96). Patients were tested for bladder cancer with ImmunoCyt/uCyt+, urinary cytology, and cystoscopy every 3 months. All patients with positive cystoscopy results for recurrence or suspect areas underwent transurethral resection of the bladder. Cystoscopy was considered the reference standard to establish the bladder tumor diagnosis. The patients were divided into low, intermediate, and high risk groups for progression according to the European Association of Urology criteria.

RESULTS

A total of 195 patients were suitable for evaluation. The urine samples from 21 patients were considered not evaluable for ImmunoCyt/uCyt+, and those patients were excluded from the study. Of all the control patients, 69.7% had negative cystoscopy findings. In the low-risk group, 84 patients underwent 131 cystoscopies, which diagnosed 30 Stage pTaG1 recurrences but no progression. Cytology and ImmunoCyt/uCyt+ together had a sensitivity of 86.6% and a negative predictive value of 95.2%.

CONCLUSIONS

Of the cystoscopies performed during the 26 months of follow-up, 69.7% were negative. In the low-risk group, 30 Stage pTaG1 tumors and no progression was detected at a total cost of 14,672 Euros (USD 17,606). ImmunoCyt/uCyt+ and cytology every 6 months combined with annual cystoscopy reduced the morbidity and cost of follow-up in this group.

Elevation of Hyaluronidase-1 and Soluble Intercellular Adhesion Molecule-1 Helps Select Bladder Cancer Patients at Risk of Invasion

BACKGROUND

The identification of accurate bladder tumor marker/tests could improve diagnosis, recurrence monitoring and treatment in patients with bladder cancer. This study evaluates the potential usefulness of hyaluronidase-1 (HYAL-1) and soluble intercellular adhesion molecule-1 (sICAM-1) in Egyptian bladder cancer patients.

METHODS

A total of 210 tissue, serum and urine specimens were used to investigate HYAL-1 and sICAM-1 expression by reverse transcriptase polymerase chain reaction (RT-PCR) and enzyme immunoassay (EIA) techniques, respectively.

RESULTS

The detection of urinary and tissue HYAL-1 mRNA as well as urinary and circulating sICAM-1 were higher in the malignant than the control group (p <0.0001). In the cancer group, both HYAL-1 and sICAM-1 were significantly correlated with each other and with the patient's age. Also, they were increased in advanced and poorly differentiated tumors (p <0.01). Patients with positive HYAL-1 had elevated sICAM-1 in their serum and urine (p <0.05). Although sometimes statistically insignificant, both markers tended to increase in lymph node and cytology positive than the corresponding negative subgroups. The levels of sICAM-1 (urinary and circulating) were elevated in relation to schistosomal infection (p <0.01). Using receiver operating characteristic curve, the best cut-off values for urinary and circulating sICAM-1 were 110 ng/mg creatinine and 130 ng/mL, respectively. Sensitivity, specificity and efficiency were >80%.

CONCLUSIONS

Serial monitoring of sICAM-1 (in urine and/or serum) is potentially recommended for selecting patients who are at risk of tumor invasion.

An office-based immunodiagnostic assay for detecting urinary nuclear matrix protein 52 in patients with bladder cancer

OBJECTIVE

To report the rapid (5 min) and simple detection of a nuclear matrix protein (NMP) in the urine of patients with bladder cancer, using a newly developed office-based dot-enzyme-linked immunosorbent assay (ELISA).

PATIENTS AND METHODS

Western blot and specific immunoglobulin-G antibody were used to identify the urinary NMP marker. Urine samples from 149 patients with bladder cancer and 72 controls were evaluated using the developed dot-ELISA. The initial responses of 43 patients treated by irradiation were followed using the assay.

RESULTS

The NMP marker was identified in the urine of patients with bladder cancer at 52 kDa (NMP-52) by Western blot. The dot-ELISA detected the urinary NMP-52 marker in 92% of patients with squamous cell carcinoma, 98% with transitional cell carcinoma, and all six of those with adenocarcinoma of the bladder, with a specificity of 94%. The positive and negative predictive values (97% and 94%, respectively) and efficiency (96%) of the dot-ELISA were high. In addition, the NMP-52 tumour marker was not detected in the urine of patients who showed a response after radiotherapy.

CONCLUSION

Detecting the urinary NMP-52 marker using dot-ELISA would be helpful in the rapid diagnosis and follow-up of patients with bladder cancer.

Effect of intravesical instillation on performance of uCYT+ test

OBJECTIVES

To assess the influence of intravesical instillation of epirubicin or bacille Calmette-Guérin (BCG) in patients with bladder cancer on the clinical performance of the uCyt+ test, which traces the three monoclonal antibodies M344, LDQ 10, and 19A211 in urothelial cells.

METHODS

A total of 267 patients with a mean age of 70.5 years (range 35 to 87) were included in this prospective study. All patients were being followed up after complete transurethral resection of superficial urothelial cancer. All patients received a single instillation of 80 mg epirubicin within 24 hours of transurethral resection and 163 underwent subsequent cycles of chemotherapy with epirubicin or immunotherapy with BCG. This was because of multifocality, high-recurrence, or high-grade urothelial cancer. At the next control, all patients underwent urinary cytology, with the uCyt+ test performed on liquid-based cytology (ThinPrep), subsequent cystoscopy, and evaluation of any suspicious lesion by biopsy. Patients who underwent intravesical BCG therapy underwent random bladder cold biopsy after every instillation series.

RESULTS

Of the 267 patients, 8 could not be evaluated by uCyt+ because of insufficient cells. Of the remaining 259 patients under assessment, 86 had proven urothelial cancer. In the 101 patients under assessment with only a single intravesical instillation of epirubicin (group 1), the overall sensitivity for cytology and the uCyt+ test was 44.7% and 76.6%, respectively. Cytology had a specificity of 90.7% and uCyt+ of 64.8%. The negative predictive value for cytology and uCyt+ was 65.3% and 76.1%, respectively. Of the 158 patients under evaluation who were treated with long-term intravesical therapy (group 2), the overall sensitivity and specificity for cytology and the uCyt+ test was 37.8% and 84.6% and 94.9% and 70.6%, respectively. The negative predictive value for cytology and the uCyt+ test was 83.1% and 93.3%, respectively. Statistical analysis showed no statistically significant difference between the overall sensitivity (P = 0.512) and specificity (P = 0.558) for the uCyt+ test in the two groups of patients.

CONCLUSIONS

The sensitivity and specificity of the uCyt+ test are not significantly affected by intravesical long-term treatment with epirubicin or BCG.