Comparison of the BTA stat test with voided urine cytology and bladder wash cytology in the diagnosis and monitoring of bladder cancer

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.

Molecular Markers for Bladder Cancer Screening: An Insight into Bladder Cancer and FDA-Approved Biomarkers

Bladder cancer is one of the most financially burdensome cancers globally, from its diagnostic to its terminal stages. The impact it imposes on patients and the medical community is substantial, exacerbated by the absence of disease-specific characteristics and limited disease-free spans. Frequent recurrences, impacting nearly half of the diagnosed population, require frequent and invasive monitoring. Given the advancing comprehension of its etiology and attributes, bladder cancer is an appealing candidate for screening strategies. Cystoscopy is the current gold standard for bladder cancer detection, but it is invasive and has the potential for undesired complications and elevated costs. Although urine cytology is a supplementary tool in select instances, its efficacy is limited due to its restricted sensitivity, mainly when targeting low-grade tumors. Although most of these assays exhibit higher sensitivity than urine cytology, clinical guidelines do not currently incorporate them. Consequently, it is necessary to explore novel screening assays to identify distinctive alterations exclusive to bladder cancer. Thus, integrating potential molecular assays requires further investigation through more extensive validation studies. Within this article, we offer a comprehensive overview of the critical features of bladder cancer while conducting a thorough analysis of the FDA-approved assays designed to diagnose and monitor its recurrences.

Large-scale longitudinal comparison of urine cytological classification systems reveals potential early adoption of The Paris System criteria

INTRODUCTION

Urine cytology is used to screen for urothelial carcinoma in patients with hematuria or risk factors (eg, smoking, industrial dye exposure) and is an essential clinical triage and longitudinal monitoring tool for patients with known bladder cancer. However, urine cytology is semisubjective and thus susceptible to issues including specimen quality, interobserver variability, and "hedging" towards equivocal ("atypical") diagnoses. These factors limit the predictive value of urine cytology and increase reliance on invasive procedures (cystoscopy). The Paris System for Reporting Urine Cytology (TPS) was formulated to provide more quantitative/reproducible endpoints with well-defined criteria for urothelial atypia. TPS is often compared to other assessment techniques to justify its adoption. TPS results in decreased use of the atypical category and better reproducibility. Previous reports comparing diagnoses pre- and post-TPS have not considered temporal differences between diagnoses made under prior systems and TPS. By aggregating across time, studies may underestimate the magnitude of differences between assessment methods.

MATERIALS AND METHODS

We conducted a large-scale longitudinal reassessment of urine cytology using TPS criteria from specimens collected from 2008 to 2018, prior to the mid-2018 adoption of TPS at an academic medical center.

RESULTS

Findings indicate that differences in atypical assignment were largest at the start of the period and these differences progressively decreased towards insignificance just prior to TPS implementation.

CONCLUSIONS

This finding suggests that cytopathologists had begun to utilize the quantitative TPS criteria prior to official adoption, which may more broadly inform adoption strategies, communication, and understanding for evolving classification systems in cytology.

Usefulness of the Urine Methylation Test (Bladder EpiCheck®) in Follow-Up Patients with Non-Muscle Invasive Bladder Cancer and Cytological Diagnosis of Atypical Urothelial Cells—An Institutional Study

Urothelial bladder cancer is a heterogeneous disease and one of the most common cancers worldwide. Bladder cancer ranges from low-grade tumors that recur and require long-term invasive surveillance to high-grade tumors with high mortality. After the initial contemporary treatment in non-muscle invasive bladder cancer, recurrence and progression rates remain high. Follow-up of these patients involves the use of cystoscopies, cytology, and imaging of the upper urinary tract in selected patients. However, in this context, both cystoscopy and cytology have limitations. In the follow-up of bladder cancer, the finding of urothelial cells with abnormal cytological characteristics is common. The main objective of our study was to evaluate the usefulness of a urine DNA methylation test in patients with urothelial bladder cancer under follow-up and a cytological finding of urothelial cell atypia. In addition, we analyzed the relationship between the urine DNA methylation test, urine cytology, and subsequent cystoscopy study. It was a prospective and descriptive cohort study conducted on patients presenting with non-muscle invasive urothelial carcinoma between 1 January 2018 and 31 May 2022. A voided urine sample and a DNA methylation test was extracted from each patient. A total of 70 patients, 58 male and 12 female, with a median age of 70.03 years were studied. High-grade urothelial carcinoma was the main histopathological diagnosis. Of the cytologies, 41.46% were cataloged as atypical urothelial cells. The DNA methylation test was positive in 17 urine samples, 51 were negative and 2 were invalid. We demonstrated the usefulness of a DNA methylation test in the follow-up of patients diagnosed with urothelial carcinoma. The methylation test also helps to diagnose urothelial cell atypia.

Comparison of the clinical usefulness of different urinary tests for the initial detection of bladder cancer: a systematic review

Objectives:

The standard initial approach in patients with hematuria or other symptoms suggestive of bladder cancer (BC) is a combination of cystoscopy and urine cytology (UC); however, UC has low sensitivity particularly in low-grade tumors. The aim of the present review was to critically analyze and compare results in the literature of promising molecular urinary tests for the initial diagnosis of BC.

Methods:

We searched in the Medline and Cochrane Library databases for literature from January 2009 to January 2019, following the PRISMAguidelines.

Results:

In terms of sensitivity, ImmunoCyt showed the highest mean and median value, higher than UC. All tests analyses showed higher mean and median sensitivity when compared with UC. In terms of specificity, only UroVysion and Microsatellite analyses showed mean and median values similar to those of UC, whereas for all other tests, the specificity was lower than UC. It is evident that the sensitivity of UC is particularly low in low grade BC. Urinary tests mainly had improved sensitivity when compared to UC, and ImmunoCyt and UroVysion had the highest improvement in low grade tumors.

Conclusions:

Most of the proposed molecular markers were able to improve the sensitivity with similar or lower specificity when compared to UC. However, variability of results among the different studies was strong. Thus, as of now, none of these markers presented evidences so as to be accepted by international guidelines for diagnosis of BC.

Fluorescence Emitted by Papanicolaou-Stained Urothelial Cells Improves Sensitivity of Urinary Conventional Cytology for Detection of Urothelial Tumors

Background

Urinary conventional cytology (UCCy) is easy to perform, but its low sensitivity, especially for low-grade urothelial neoplasms (LGUNs), limits its indications in the management of patients at risk of bladder cancer. The authors aim at obtaining a complementary test that would effectively increase the sensitivity of UCCy on voided urines by analyzing fluorescence of Papanicolaou-stained urothelial cells with no change of method in slide preparation.

Methods

In this retrospective study of 155 patients, 91 Papanicolaou-stained voided urines were considered satisfactory under fluorescence microscopy (FMi). The results of FMi were compared with UCCy (using transmission microscopy) and correlated to cystoscopy, histology and follow-up data.

Results

The results are given for all patients and for two groups of them according to the patients’ main complaints (group 1: 33 patients followed up for a previously treated bladder tumor; group 2: 58 patients with persistent urinary symptoms). Overall negative predictive value (NPV) and sensitivity of FMi were 100% vs. 73.7% and 64.3% respectively for UCCy (P = 0.0001). Sensitivity of FMi for LGUN was unexpectedly high with a value of 100% vs. 46.2% for UCCy (P = 0.0002). FMi was significantly superior to UCCy for detecting urothelial tumors in every group of patients and would allow a better characterization of atypical urothelial cells (AUCs) defined by the Paris System for Reporting Urine Cytology (TPS).

Conclusions

Because of its sensitivity and NPV of 100%, FMi could complement UCCy to screen voided urines allowing a better detection of primary urothelial tumors or early recurrences of previously treated urothelial carcinoma. Moreover, this “dual screening” would allow completing efficiently cystoscopy to detect flat dysplasia, carcinoma in situ (CIS) and extra bladder carcinoma.

Comparison of 2 new real-time polymerase chain reaction-based urinary markers in the follow-up of patients with non-muscle-invasive bladder cancer

BACKGROUND

The objective of the current study was to compare the diagnostic accuracy of 2 new real-time polymerase chain reaction-based urinary markers with each other and with urinary cytology, cystoscopy, and/or histology in patients being followed for non-muscle-invasive bladder cancer.

METHODS

A total of 487 patients were enrolled in the study. Patients were evaluated using voided urine cytology, the Xpert Bladder Cancer Monitor, the Bladder EpiCheck test, and white light cystoscopy.

RESULTS

The overall sensitivity was 27.17% for cytology, 64.13% for the Bladder EpiCheck test, and 66.3% for the Xpert Bladder Cancer Monitor. The overall specificity was 98.82% for cytology, 82.06% for the Bladder EpiCheck test, and 76.47% for the Xpert Bladder Cancer Monitor. The negative predictive value was very similar for the 3 tests at 83.56% for cytology, 89.42% for the Bladder EpiCheck test, and 89.35% for the Xpert Bladder Cancer Monitor. When combined, the Bladder EpiCheck test and Xpert Bladder Cancer Monitor detected overall 79.35% of the tumors: 70.37% in low-grade and 92.11% in high-grade tumors.

CONCLUSIONS

The Xpert Bladder Cancer Monitor and Bladder EpiCheck test were found to perform very well in terms of sensitivity. Together, the 2 tests detected approximately 92.11% of high-grade tumors. Their specificity was high but could not reach the excellent value of cytology. The negative predictive value was the same for both tests and was higher than that for cytology, especially when the tests were used together (92.24%). These 2 new tests hold promise as urinary biomarkers. They may be used in combination to maximize sensitivity in a less invasive way, thereby reducing invasiveness in the follow-up of patients with non-muscle-invasive bladder cancer and decreasing discomfort for the patients as well as complications and costs.

Diagnostic predictive value of the Bladder EpiCheck test in the follow-up of patients with non-muscle-invasive bladder cancer

BACKGROUND

The objective of this study was to evaluate the diagnostic accuracy of the Bladder EpiCheck test in the follow-up of patients with non-muscle-invasive bladder cancer (NMIBC) and to compare it with the accuracy of urinary cytology, cystoscopy, and/or histology.

METHODS

In total, 243 patients were enrolled in the current study. Patients were evaluated by voided urine cytology, by the Bladder EpiCheck test, and by white-light cystoscopy.

RESULTS

Overall sensitivity was 33.3% for cytology, 62.3% for Bladder EpiCheck, and 66.7% for the 2 tests combined. The sensitivity of cytology increased from 7.7% in low-grade (LG) tumors to 66.6% in high-grade (HG) tumors; whereas, for the Bladder EpiCheck test, the sensitivity was 46.1% in LG tumors and 83.3% in HG tumors. Combined cytology and Bladder EpiCheck testing yielded an overall sensitivity of 56.4% for LG tumors and 90% for HG tumors. Overall specificity was 98.6% for cytology, 86.3% for Bladder EpiCheck, and 85.6% for the 2 tests combined. The positive predictive value was 92% for cytology and 68.2% for Bladder EpiCheck. For the 2 tests combined, it was 68.6%. The negative predictive value was similar for the 2 tests: 75.8% for cytology, 82.9% for Bladder EpiCheck, and 84.5% for the 2 tests combined.

CONCLUSIONS

The sensitivity of the Bladder EpiCheck test was significantly higher than that of cytology. The test performed very well in terms of specificity but could not reach the high value of cytology. The positive predictive value was higher for Bladder EpiCheck, whereas the negative predictive value was approximately the same for both tests.

Diagnostic predictive value of Xpert Bladder Cancer Monitor in the follow-up of patients affected by non-muscle invasive bladder cancer

Aims

Cystoscopy and urine cytology represent the gold standard for monitoring superficial bladder cancer (BC). Xpert BC Monitor is a new urinary marker based on the evaluation of five target mRNAs overexpressed in patients with bladder cancer. The aim of our study was to evaluate the diagnostic accuracy of Xpert BC Monitor in follow-up of patients with non-muscle invasive bladder cancer (NMIBC).

Methods

230 patients were included in this prospective study. Xpert BC Monitor cut-off was set to 0.5. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of cytology, Xpert BC Monitor and their combination were calculated and compared with cystoscopy/histology.

Results

52/230 patients showed a NMIBC recurrence, 45 low grade (LG) and 7 high grade (HG). Overall sensitivity was 11.5% for cytology, 46.2% for Xpert BC Monitor and 48.1% for the two tests combined. Sensitivity of cytology increased from 4.4% in LG to 57.1% in HG tumours whereas for the Xpert BC Monitor it was 40% in LG and 85.7% in HG tumours. Combined cytology and Xpert BC Monitor yielded an overall sensitivity of 42% for LG and 85.7% for HG. Overall specificity was 97.2% for cytology, 77% for Xpert BC Monitor and 75.8% for the two tests.

Conclusions

Sensitivity for the Xpert BC Monitor Test was significantly higher than for cytology. The test performed very well in terms of specificity but could not reach the value of cytology, while PPV and NPV performed approximately the same for both tests.

Systematic verification of bladder cancer-associated tissue protein biomarker candidates in clinical urine specimens

Bladder cancer biomarkers currently approved by the Food and Drug Administration are insufficiently reliable for use in non-invasive clinical diagnosis. Verification/validation of numerous biomarker candidates for BC detection is a crucial bottleneck for novel biomarker development. A multiplexed liquid chromatography multiple-reaction-monitoring mass spectrometry assay of 122 proteins, including 118 up-regulated tissue proteins, two known bladder cancer biomarkers and two housekeeping gene products, was successfully established for protein quantification in clinical urine specimens. Quantification of 122 proteins was performed on a large cohort of urine specimens representing a variety of conditions, including 142 hernia, 126 bladder cancer, 67 hematuria, and 59 urinary tract infection samples. ANXA3 (annexin A3) and HSPE1 (heat shock protein family E member 1), which showed the highest detection frequency in bladder cancer samples, were selected for further validation. Western blotting showed that urinary ANXA3 and HSPE1 protein levels were higher in bladder cancer samples than in hernia samples, and enzyme-linked immunosorbent assays confirmed a higher urinary concentration of HSPE1 in bladder cancer than in hernia, hematuria and urinary tract infection. Immunohistochemical analyses showed significantly elevated levels of HSPE1 in tumor cells compared with non-cancerous bladder epithelial cells, suggesting that HSPE1 could be a useful tumor tissue marker for the specific detection of bladder cancer. Collectively, our findings provide valuable information for future validation of potential biomarkers for bladder cancer diagnosis.

Clinical Significance of Serological and Urological Levels of Bladder Cancer-Specific Antigen-1 (BLCA-1) in Bladder Cancer

Background

The aim of this study was to determine the clinical significance of the expression levels of bladder cancer-specific antigen-1 (BLCA-1) in the diagnosis of bladder cancer (BC). The study also determined the relationship between BLCA-1 expression levels and the clinical manifestation of BC.

Material/Methods

Patient samples were derived from 66 cases of BC that presented at the Department of Urology, Affiliated Hospital of Chengde Medical University, were recruited from April 2014 to May 2015, and 64 healthy control cases. Serum and urine BLCA-1 levels were detected by enzyme-linked immunosorbent assay (ELISA).

Results

Urine BLCA-1 levels in BC patients were significantly higher than that found in healthy controls (P<0.01). BLCA-1 levels in the urine of patients without mucus membrane invasion (Ta) were significantly different from urine levels found in patients with mucus membrane invasion (T1–T4; P=0.022). BLCA-1 levels in the serum of patients without muscular coat invasion (Ta–T1) were significantly different than serum levels of patients with muscular coat invasion (T2–T4; P=0.042).

Conclusions

BLCA-1 is involved in the appearance and development of BC. Clinical detection of serum and urine BLCA-1 protein levels showed a high level of sensitivity and specificity in diagnosing BC. Further study of the functional expression of BLCA-1 levels as a valuable and novel diagnostic marker in BC is clearly warranted.

Diagnostic accuracy of optical coherence tomography in bladder cancer patients: A systematic review and meta-analysis

A meta-analysis was performed to evaluate the accuracy of optical coherence tomography (OCT) for diagnostic accuracy studies in bladder cancer patients. English language studies reporting the diagnostic accuracy of OCT for bladder cancer were retrieved from the PubMed, EMBASE and Cochrane Library databases in December 2014. Histopathology was a reference standard. Sensitivities, specificities, positive likelihood ratios and negative likelihood ratios were calculated, and summary receiver operating characteristic curves were drawn to determine the diagnostic accuracy of OCT. Finally, 9 eligible studies (468 patients) were included in our meta-analysis. The pooled sensitivity, specificity, positive likelihood ratio and negative likelihood ratio of OCT were 0.96 [95% confidence interval (CI): 0.94-0.98], 0.82 (95% CI: 0.80-0.85), 6.83 (95% CI: 3.24-14.1) and 0.05 (95% CI: 0.02-0.16), respectively. The summary diagnostic odds ratio was 138.88 (95% CI: 29.63-650.89) and the overall area under the curve was 0.9735. These results suggest that OCT has excellent diagnostic performance in patients with bladder cancer and recurrent lesions.

[Correlation of genetic and cytogenetic alterations in pathological aggressiveness urothelial carcinoma of the bladder: Performance of BCA-1, a mini-array comparative genomic hybridisation-based test]

INTRODUCTION

Urothelial carcinomas are the fourth leading cause of cancer in humans. Their incidence is increasing by more than 50% in 25 years. The superficial forms (70% cases) require a close active surveillance to identify frequent recurrences and progression to invasive stage. Our main goal was to identify prognostic molecular markers for bladder cancer that could be used alone or in combination in routine clinical practice. In this aim, we evaluated the capability of the BCA-oligo test based on a CGH array to correctly classify tumoral grade/stage.

METHOD

Urinary DNA was extracted from 81 patients with superficial bladder cancer and has been hybridized on the BCA-oligo array. The results from the molecular analysis were correlated with the tumoral grade and stage.

RESULTS

Several chromosomal alterations were significantly more frequent in tumors of higher grade and more advanced stage. A significant association was observed between a high grade and the presence of one of these alterations: loss on 6p, gain on 8q or 13q, loss or gain on 9q or 11q, with an odds ratio of 6.91 (95% CI=2.20-21.64; P=0.0009). Moreover, a significant association was found between a more advanced stage (pT1) and the presence of one of these alterations: loss on 6p, gain on 8q, loss or gain on 5p, with an odds ratio of 15.2 (95% CI=3.71-62.58; P=0.0002).

CONCLUSION

Our results showed that molecular analyses of superficial bladder cancers based on urinary DNA and the BCA-oligo test could be used as prognostic factor for the tumor evolution, allowing then a more adapted clinical management.

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.

Urinary Biomarkers for Diagnosis of Bladder Cancer: A Systematic Review and Meta-analysis

BACKGROUND

Urinary biomarkers may be a useful alternative or adjunct to cystoscopy for diagnosis of bladder cancer.

PURPOSE

To systematically review the evidence on the accuracy of urinary biomarkers for diagnosis of bladder cancer in adults who have signs or symptoms of the disease or are undergoing surveillance for recurrent disease.

DATA SOURCES

Ovid MEDLINE (January 1990 through June 2015), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and reference lists.

STUDY SELECTION

57 studies that evaluated the diagnostic accuracy of quantitative or qualitative nuclear matrix protein 22 (NMP22), qualitative or quantitative bladder tumor antigen (BTA), fluorescence in situ hybridization (FISH), fluorescent immunohistochemistry (ImmunoCyt [Scimedx]), and Cxbladder (Pacific Edge Diagnostics USA) using cystoscopy and histopathology as the reference standard met inclusion criteria. Case-control studies were excluded.

DATA EXTRACTION

Dual extraction and quality assessment of individual studies. Overall strength of evidence (SOE) was also assessed.

DATA SYNTHESIS

Across biomarkers, sensitivities ranged from 0.57 to 0.82 and specificities ranged from 0.74 to 0.88. Positive likelihood ratios ranged from 2.52 to 5.53, and negative likelihood ratios ranged from 0.21 to 0.48 (moderate SOE for quantitative NMP22, qualitative BTA, FISH, and ImmunoCyt; low SOE for others). For some biomarkers, sensitivity was higher for initial diagnosis of bladder cancer than for diagnosis of recurrence. Sensitivity increased with higher tumor stage or grade. Studies that directly compared the accuracy of quantitative NMP22 and qualitative BTA found no differences in diagnostic accuracy (moderate SOE); head-to-head studies of other biomarkers were limited. Urinary biomarkers plus cytologic evaluation were more sensitive than biomarkers alone but missed about 10% of bladder cancer cases.

LIMITATION

Restricted to English-language studies; no search for studies published only as abstracts; statistical heterogeneity present in most analyses; few studies for qualitative NMP22, quantitative BTA, and Cxbladder; and methodological shortcomings in almost all studies.

CONCLUSION

Urinary biomarkers miss a substantial proportion of patients with bladder cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and low-grade tumors.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality. (PROSPERO registration number: CRD42014013284).

Molecular markers for bladder cancer screening, early diagnosis, and surveillance: the WHO/ICUD consensus

Due to the lack of disease-specific symptoms, diagnosis and follow-up of bladder cancer has remained a challenge to the urologic community. Cystoscopy, commonly accepted as a gold standard for the detection of bladder cancer, is invasive and relatively expensive, while urine cytology is of limited value specifically in low-grade disease. Over the last decades, numerous molecular assays for the diagnosis of urothelial cancer have been developed and investigated with regard to their clinical use. However, although all of these assays have been shown to have superior sensitivity as compared to urine cytology, none of them has been included in clinical guidelines. The key reason for this situation is that none of the assays has been included into clinical decision-making so far. We reviewed the current status and performance of modern molecular urine tests following systematic analysis of the value and limitations of commercially available assays. Despite considerable advances in recent years, the authors feel that at this stage the added value of molecular markers for the diagnosis of urothelial tumors has not yet been identified. Current data suggest that some of these markers may have the potential to play a role in screening and surveillance of bladder cancer. Well-designed protocols and prospective, controlled trials will be needed to provide the basis to determine whether integration of molecular markers into clinical decision-making will be of value in the future.

A Comparison Between ThinPrep Monolayer and Cytospin Cytology for the Detection of Bladder Cancer

Purpose

The sensitivity of urine cytology is higher for carcinoma in situ and poorly differentiated tumors in bladder cancer, while being fairly low for low-grade or well-differentiated tumors. Development of a sensitive diagnostic test to detect bladder carcinoma would significantly facilitate patient management and allow earlier treatment of this disease. This study compared ThinPrep urine cytology (Cytyc Co.) and conventional Cytospin urine cytology (Shandon Scientific Ltd.) in the diagnosis of bladder cancer.

Materials and Methods

From January 2002 to December 2010, ThinPrep cytology and conventional urine Cytospin cytologic examination of bladder washings were performed in 3,085 subjects suspected of having bladder cancer and in 379 patients with follow-up after transurethral resection of bladder tumor (TUR-BT). The sensitivity and specificity of the urine ThinPrep test was compared with that of conventional Cytospin cytology according to tumor number, size, pathological stage, grade, and recurrence.

Results

Of 3,085 subjects, bladder cancer was confirmed by TUR-BT in 379 subjects. The overall sensitivity of ThinPrep and Cytospin cytology was 60.9% and 59.9% in patients suspected of having bladder cancer, respectively. The overall specificity of ThinPrep and Cytospin cytology was 94.8% and 95.3% in patients suspected of having bladder cancer, respectively. The sensitivity of ThinPrep and Cytospin cytology was increased with increasing number, size, pathological stage, and grade, but there was no significant difference between the two tests.

Conclusions

These results suggest that ThinPrep cytology has no advantage in the diagnosis of bladder cancer of a low grade or low stage.

Bladder tumour antigen (BTA stat) test compared to the urine cytology in the diagnosis of bladder cancer: A meta-analysis

INTRODUCTION

We evaluate the diagnostic value of bladder tumour antigen (BTA stat) tests compared with urine cytology test in detecting bladder cancer.

METHODS

We searched public databases including PubMed, MEDLINE Springer, Elsevier Science Direct, Cochrane Library and Google Scholar before December 2012. To collect relevant data of BTA stat tests and urine cytology tests in patients with bladder cancer, we studied meta-analyses of sensitivity, specificity, positive likelihood ratio (LR), negative LR and diagnostic odds ratios (DOR) of BTA stat tests and cytology tests from published studies. We applied the software of Rev. Man 5.1 and Stata 11.0 to the meta-analysis.

RESULTS

A total of 13 separate studies consisting of 3462 patients with bladder cancer were considered in the meta-analysis. We found that the BTA stat test had a higher sensitivity than the urine cytology test (0.67, 95% confidence interval [CI] 0.64 to 0.69 vs. 0.43, 95% CI 0.40 to 0.46), but the specificity, positive LR, negative LR, DOR, the area under the curve (AUC) and Q index of the BTA stat test were lower compared with the urine cytology test. The results of the Egger's linear regression test showed no publication bias (p > 0.05).

CONCLUSIONS

Specificity, positive LR, negative LR, DOR, the AUC and the Q index of the urine cytology test may be superior to the BTA stat test, but the BTA stat test has greater sensitivity than the urine cytology test.

Clinical applications of optical coherence tomography in urology

Since optical coherence tomography (OCT) was first demonstrated in 1991, it has advanced significantly in technical aspects such as imaging speed and resolution, and has been clinically demonstrated in a diverse set of medical and surgical applications, including ophthalmology, cardiology, gastroenterology, dermatology, oncology, among others. This work reviews current clinical applications in urology, particularly in bladder, urether, and kidney. Clinical applications in bladder and urether mainly focus on cancer detection and staging based on tissue morphology, image contrast, and OCT backscattering. The application in kidney includes kidney cancer detection based on OCT backscattering attenuation and non-destructive evaluation of transplant kidney viability or acute tubular necrosis based on both tissue morphology from OCT images and function from Doppler OCT (DOCT) images. OCT holds the promise to positively impact the future clinical practices in urology.

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.

Low- and high-grade bladder cancer determination via human serum-based metabolomics approach

To address the shortcomings of urine cytology and cystoscopy for probing and grading urinary bladder cancer (BC), we applied (1)H nuclear magnetic resonance (NMR) spectroscopy as a surrogate method for the identification of BC. This study includes 99 serum samples comprising low-grade (LG; n = 36) and high-grade (HG; n = 31) BC as well as healthy controls (HC; n = 32). (1)H NMR-derived serum data were analyzed using orthogonal partial least-squares discriminant analysis (OPLS-DA). OPLS-DA-derived model validity was confirmed using an internal and external cross-validation. Internal validation was performed using the initial samples (n = 99) data set. External validation was performed on a new batch of suspected BC patients (n = 106) through a double-blind study. Receiver operating characteristic (ROC) curve analysis was also performed. OPLS-DA-derived serum metabolomics (six biomarkers, ROC; 0.99) were able to discriminate 95% of BC cases with 96% sensitivity and 94% specificity when compared to HC. Likewise (three biomarkers, ROC; 0.99), 98% of cases of LG were able to differentiate from HG with 97% sensitivity and 99% specificity. External validation reveals comparable results to the internal validation. (1)H NMR-based serum metabolic screening appears to be a promising and less invasive approach for probing and grading BC in contrast to the highly invasive and painful cystoscopic approach for BC detection.

Urine markers for detection and surveillance of bladder cancer

OBJECTIVES

Bladder cancer detection and surveillance includes cystoscopy and cytology. Urinary cytology is limited by its low sensitivity for low-grade tumors. Urine markers have been extensively studied to help improve the diagnosis of bladder cancer with the goal of complementing or even replacing cystoscopy. However, to date, no marker has reached widespread use owing to insufficient evidence for clinical benefit.

MATERIAL AND METHODS

Pubmed/Medline search was conducted to identify original articles, review articles, and editorials regarding urine-based biomarkers for screening, early detection, and surveillance of urothelial carcinoma of the bladder. Searches were limited to the English language, with a time frame of 2000 to 2013. Keywords included urothelial carcinoma, bladder cancer, transitional cell carcinoma, biomarker, marker, urine, diagnosis, recurrence, and progression.

RESULTS

Although several urinary markers have shown higher sensitivity compared with cytology, it remains insufficient to replace cystoscopy. Moreover, most markers suffer from lower specificity than cytology. In this review, we aimed to summarize the current knowledge on commercially available and promising investigational urine markers for the detection and surveillance of bladder cancer.

CONCLUSIONS

Well-designed protocols and prospective, controlled trials are needed to provide the basis to determine whether integration of biomarkers into clinical decision making will be of value for bladder cancer detection and screening in the future.

Noninvasive urinary metabonomic diagnosis of human bladder cancer

Cystoscopy is considered the gold standard for the clinical diagnosis of human bladder cancer (BC). As cystoscopy is expensive and invasive, it may compromise patients' compliance and account for the failure in detecting recurrent BC in some patients. In this paper, we investigated the role of urinary metabonomics in the diagnosis of human BC. Gas chromatography/time-of-flight mass spectrometry was applied for the urinary metabolic profiling of 24 BC patients and 51 non-BC controls. The acquired data were analyzed using multivariate principal component analysis followed by orthogonal partial least-squares discriminant analysis (OPLS-DA). Model validity was verified using permutation tests and receiver operating characteristic (ROC) analysis. BC patients were clearly distinguished from non-BC subjects based on their global urinary metabolic profiles (OPLS-DA, 4 latent variables, R(2)X = 0.420, R(2)Y = 0.912 and Q(2) (cumulative) = 0.245; ROC AUC of 0.90; 15 marker metabolites). One-hundred percent sensitivity in detecting BC was observed using urinary metabonomics versus 33% sensitivity achieved by urinary cytology. Additionally, urinary metabonomics exhibited potential in the staging and grading of bladder tumors. In summary, urinary metabonomics is amenable for the noninvasive diagnosis of human BC.

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.

Diagnosis of bladder cancer with microelectromechanical systems-based cystoscopic optical coherence tomography

OBJECTIVES

To examine the utility and potential limitations of microelectromechanical systems-based spectral-domain cystoscopic optical coherence tomography (COCT) so as to improve the diagnosis of early bladder cancer.

METHODS

An optical coherence tomography catheter was integrated into the single instrument channel of a 22F cystoscope to permit white-light-guided COCT over a large field of view (4.6 mm wide and 2.1 mm deep per scan at 8 frames/s) and 10-microm resolution. Intraoperative COCT diagnosis was performed in 56 patients, with a total of 110 lesions examined and compared with biopsied histology.

RESULTS

The overall sensitivity of COCT (94%) was significantly higher than cystoscopy (75%, P = .02) and voided cytology (59%, P = .005); the major enhancement over cystoscopy was for low-grade pTa-1 cancer and carcinoma in situ (P < .018). The overall specificity of COCT (81%) was comparable to voided cytology (88.9%, P = .49), but significantly higher than cystoscopy (62.5%, P = .02).

CONCLUSIONS

The microelectromechanical systems-based COCT, owing to its high resolution and detection sensitivity and large field of view, offers great potential for "optical biopsy" to enhance the diagnosis of nonpapillary bladder tumors and their recurrences and to guide bladder tumor resection.

High-resolution imaging diagnosis and staging of bladder cancer: comparison between optical coherence tomography and high-frequency ultrasound

A comparative study between 1.3-microm optical coherence tomography (OCT) and 40-MHz high-frequency ultrasound (HFUS) is presented to enhance imaging of bladder cancers ex vivo. A standard rat bladder cancer model in which transitional cell carcinoma (TCC) was induced by intravesical instillation of AY-27 cells was followed independently with both OCT and HFUS, and the image identifications were compared to histological confirmations. Results indicate that both OCT and HFUS were able to delineate the morphology of rat bladder [e.g., the urothelium (low backscattering/echo) and the underlying lamina propria and muscularis (high backscattering/echo]. OCT differentiated inflammatory lesions (e.g., edema, infiltrates and vasodilatation in lamina propria, hyperplasia) and TCC based on characterization of urothelial thickening and enhanced backscattering or heterogeneity (e.g., papillary features), which HFUS failed due to insufficient image resolution and contrast. On the other hand, HFUS was able to stage large T2 tumors that OCT failed due to limited imaging depth. The results suggest that multimodality cystoscopy combining OCT and HFUS may have the potential to enhance the diagnosis and staging of bladder cancers and to guide tumor resection, in which both high resolution (approximately 10 microm) and enhanced penetration (> 3mm) are desirable.

Evaluation of the Bard BTA-test in the diagnosis of upper urinary tract tumours

The BTA-test is an agglutination assay that qualitatively detects the presence of complexes of basement membrane within the urine of patients with bladder cancer. However, the significance of BTA test in other urotelial tumours has not been extensively studied. Therefore, in the present research, we examined the validity of BTA-test in patients suffering from ureteral or renal pelvis cancer, and compare results with urincitology. 35 patients were included in this study (13 with ureteral and 22 with renal pelvis cancer). BTA-test and urincitology in each patient was performed on two urine specimens: morning voiding urine and separate urine. Separate urine was obtained by means of ureteral catheter. The results of BTA test were compared with urine cytology. All patients udervent routine clinical examination (biochemical analysis, ultrasonography, i.v. urography and retrograde urography). The presence of urothelial carcinoma was histopatologically proved in all cases. 35 patients with renal calculosis without malignancy were control group. Separate and voided urine was taken for examination with BTA test and urincitology from all these patients. BTA test in urine specimen obtained by ureteral catheter were positive in 22 (62.9 %) patients and in complete urine in 18 (51,4%) patients. Urine cytology was positive in 20 (57,1%) separate urine specimen and in complete urine in 17 (48.6%) patients. Characteristics of each patient, clinical findings and patohystology findings take places in statistic evaluation of the results. The sensitivity of BTA test depends directly on histopatology characteristics of tumours. Tumours with high grade and high stage more often have positive resuIts of test and urincitology. The test had the highest sensitivity among the group of high risk patients, with T2, T3, T4 stadium, 77,8% in separate urine and 61.11% in voided urine with specificity of 80% for separate urine and 85.71% for voided urine. Sensitivity for cytology in the same group was 72,22% for separate and 55,56% for voided urine, with specificity of 97,14% in both specimens. Based on the obtained results, we can conclude that simple and rapid BTA test can have significant position in the diagnostics of upper urinary tract tumours, but we still have to search for an ideal tumour marker for transitional cell carcinoma of upper urinary tract.

Bladder tumor markers: from hematuria to molecular diagnostics--where do we stand?

Bladder cancer is a common malignancy in the USA. Currently, the detection of initial tumors and recurrent disease is based on evaluation of voided urinary specimens, often followed by cystoscopy. With the high rate of recurrence, cystoscopies are regularly repeated with the aim of halting progression of the disease. For patients, this process is fraught with anxiety, pain and high cost. As a result, intense work is being done in the field of bladder tumor markers with the goal of identifying bladder cancer earlier, both in the initial diagnosis and in recurrences of known tumor. The possibility of identifying a marker that could noninvasively differentiate benign and malignant causes of hematuria, and identify recurrences prior to their pathologic progression is the objective of this area of research. Currently, a large number of tumor markers exist, each scrutinized in both the laboratory and in clinical trials. Here we present many of the most widely used and tested markers. Background details are provided as to the mechanism of detection of malignant cells, the results of recent trials and future directions of study. Some novel modalities for tumor detection are also presented. The next few years will no doubt bring newer markers and lead to the elimination of others. Studies continue to refine the role of these markers in clinical practice, but their ultimate efficacy will need to be borne out in large-scale clinical trials in a multitude of settings.

Urine cytology and urine-based markers for bladder urothelial carcinoma detection and monitoring: developments and future prospects

Bladder cancer is currently diagnosed using cystoscopy and cytology in patients with suspicious signs and symptoms. These tests are also used to monitor patients with a history of bladder cancer. The recurrence rate for bladder cancer is high, thus necessitating long-term follow-up. Urine cytology has a high sensitivity and specificity for the detection of high-grade urothelial carcinoma, but lacks the sensitivity to detect low-grade tumors. Recently, multiple noninvasive urine-based bladder cancer tests have been developed. Many markers (BTA stat®, BTA TRAK®, ImmunoCyt™, NMP22® and UroVysion™) have already been approved by the US FDA for bladder cancer surveillance, while other markers are still undergoing development, preclinical and clinical investigation. An ideal bladder cancer test would be noninvasive, highly sensitive and specific, inexpensive, easy to perform and yield highly reproducible results. Many of the tests reviewed herein meet some, but not all, of these criteria.

Comparisons of voided urine cytology, nuclear matrix protein-22 and bladder tumor associated antigen tests for bladder cancer of geriatric male patients in Taiwan, China

AIM

To compare the results of bladder tumor associated antigen (BTA TRAK), nuclear matrix protein 22 (NMP 22) and voided urine cytology (VUC) in detecting bladder cancer.

METHODS

A total of 135 elderly male and 50 healthy volunteers enrolled in this study were classified into three groups: (i) 93 patients with bladder cancer; (ii) 42 patients with urinary benign conditions; and (iii) 50 healthy volunteers. BTA TRAK and NMP 22 kits were used to detect bladder cancer. Voided urine cytology was used to compare the sensitivity and specificity of the screening tests.

RESULTS

The sensitivity and specificity of cytology, BTA TRAK and NMP 22 were 24% and 97%, 51% and 73%, 78% and 73%, respectively. The level of NMP 22 increased with tumor grading. The BTA TRAK kit has the lowest sensitivity among the screening tests. The NMP 22 with the best sensitivity can be an adjunct to cytology for evaluating bladder cancer.

CONCLUSION

The NMP 22 test has a better correlation with the grading of the bladder cancer than BTA TRAK. As cytology units are typically not available in hospitals or in outpatient clinics, NMP 22 might be a promising tool for screening bladder cancer.

Ex Vivo Fluorescence Imaging of Normal and Malignant Urothelial Cells to Enhance Early Diagnosis

Urinary cytology is a noninvasive and unconstraining technique for urothelial cancer diagnosis but lacks sensitivity for detecting low-grade lesions. In this study, the fluorescence properties of classical Papanicolaou-stained urothelial cytological slides from patients or from cell lines were monitored to investigate metabolic changes in normal and tumoral cells. Time- and spectrally-resolved fluorescence imaging was performed at the single cell level to assess the spectral and temporal properties as well as the spatial distribution of the fluorescence emitted by urothelial cells. The results reveal quite different fluorescence distributions between tumoral urothelial cells, characterized by a perimembrane fluorescence localization, and the normal cells which exhibit an intracellular fluorescence. This is not caused by differences in the fluorescence emission of the endogenous fluorophores NAD(P)H, flavoproteins or porphyrins but by various localization of the EA 50 Papanicolaou stain as revealed by both the spectral and time-resolved parameters. The present results demonstrate that the use of single-cell endofluorescence emission of Papanicolaou-stained urothelial cytological slides can allow an early ex vivo diagnosis of low-grade bladder cancers.

In vivo bladder imaging with microelectromechanical-systems-based endoscopic spectral domain optical coherence tomography

We report the recent technical improvements in our microelectromechanical systems (MEMS)-based spectral-domain endoscopic OCT (SDEOCT) and applications for in vivo bladder imaging diagnosis. With the technical advances in MEMS mirror fabrication and endoscopic light coupling methods, the new SDEOCT system is able to visualize morphological details of the urinary bladder with high image fidelity close to bench-top OCT (e.g., 10 mum12 mum axial/lateral resolutions, >108 dB dynamic range) at a fourfold to eightfold improved frame rate. An in vivo animal study based on a porcine acute inflammation model following protamine sulfate instillation is performed to further evaluate the utility of SDEOCT system to delineate bladder morphology and inflammatory lesions as well as to detect subsurface blood flow. In addition, a preliminary clinical study is performed to identify the morphological features pertinent to bladder cancer diagnosis, including loss of boundary or image contrast between urothelium and the underlying layers, heterogeneous patterns in the cancerous urothelium, and margin between normal and bladder cancers. The results of a human study (91% sensitivity, 80% specificity) suggest that SDEOCT enables a high-resolution cross-sectional image of human bladder structures to detect transitional cell carcinomas (TCC); however, due to reduced imaging depth of SDEOCT in cancerous lesions, staging of bladder cancers may be limited to T1 to T2a (prior to muscle invasion).

Intérêt des marqueurs urinaires dans le diagnostic et le suivi des tumeurs urothéliales de vessie

Urothelial bladder tumours require regular surveillance: cystoscopy associated with urine cytology are reference examinations. Several new markers currently under evaluation or already validated have recently been proposed to replace cytology and potentially reduce or even replace unnecessary cystoscopies. The biological fluid studied for all of these markers is the same as that of urine cytology, i.e. urine. The authors review the results of recent studies on these new urinary markers. The results of these markers demonstrate a better global sensitivity than urine cytology, but often a lower specificity. In the majority of cases, these tests are performed during patient follow-up (NMP22, BTA, CYFRA 21-l., etc.), but do not replace cystoscopy, due to a large number of false-positives. Other techniques, such as FISH, uCyt+ or microsatellites appear to be more promising, especially for the diagnosis of low-grade tumours. The best solution in practice may consist of a combination of several markers to further improve sensitivity and to decrease the false-positive rate responsible for unnecessary cystoscopies.

[Tumor marker tests in bladder cancer]

The gold standard for detecting bladder cancer is cystoscopy which identifies nearly all papillary and sessile lesions. However, it is an invasive procedure causing some discomfort for patients. Urine cytology is the standard non-invasive marker with very high specificity, but unfavourable poor sensitivity for Ta, G1, and T1 bladder tumors. To improve early detection of bladder cancer as well as to monitor treatment response and tumor recurrence, bladder tumor markers are eligible. An ideal bladder cancer test would have the potential to replace or delay cystoscopy in the follow-up of bladder cancer patients. In recent years, the FDA approved non-invasive tumor marker tests ImmunoCyt / uCyt+, BTA TRAK, BTA stat, NMP22, NMP22 BladderChek, and UroVysion have been investigated. The tests demonstrated higher sensitivity for diagnosis of bladder cancer compared to urine cytology. Overall, the mean sensitivity and mean specificity was 64-80% and 71-95% and the mean positive and negative predictive values to detect malignancy were 49-84% and 79-95%, respectively. BTA TRAK, BTA stat, NMP22, and NMP22 BladderChek assays are limited by false-positive results in patients with benign urological diseases such as hematuria, urocystitis, renal calculi or urinary tract infections. Due to low specificity BTA TRAK, BTA stat, NMP22, and NMP22 BladderChek should not be used without first ruling out benign or malignant genitourinary disease other than bladder cancer. With the exception of UroVysion achieving 80% sensitivity and 94% specificity, none of these non-invasive tests revealed a high sensitivity and specificity at the same time, which is a main demand to be made on an ideal tumor marker. Insufficient sensitivity along with limited specificity does not allow replacing cystoscopy in diagnosis of bladder cancer or treatment decisions based on a positive test result.

Non-invasive diagnostic tests for bladder cancer: a review of the literature

Transitional cell carcinoma of the bladder is the second most common malignancy of the genitourinary tract. Cystoscopy and urine cytology are the traditional most used techniques for diagnosis and surveillance of superficial bladder cancer. Urine cytology is specific for diagnosis of bladder cancer but sensitivity results not high, particularly in low-grade disease. Voided urine can be easily obtained and therefore additional diagnostic urine tests would be ideal for screening or follow-up of transitional cell carcinoma. A number of studies have focused on the evaluation of urinary markers that hold promise as non-invasive adjuncts to conventional diagnostic or surveillance techniques. In this review we discuss several new urinary markers (test for bladder tumor antigen, NMP22, fibrin degradation products, telomerase, fluorescence in situ hybridization test, flow cytometry) and their role in detection and follow-up of bladder cancer. Most of these markers have higher sensitivity than urine cytology, but voided urine cytology has the highest specificity.

FLUORESCENCE GUIDED OPTICAL COHERENCE TOMOGRAPHY FOR THE DIAGNOSIS OF EARLY BLADDER CANCER IN A RAT MODEL

PURPOSE

We describe the technique of fluorescence image guided optical coherence tomography (FG-OCT). We examined its ability to enhance specificity and sensitivity for the noninvasive diagnosis of early bladder cancer.

MATERIALS AND METHODS

Transitional cell carcinoma was developed in 54 Fisher 344 female rats by intravesical methyl-nitroso-urea instillations. Two or three rats were diagnosed sequentially by 5-ALA (5-aminolevulinic acid hydrochloride) induced fluorescence imaging, cross-sectional OCT and histological microscopy weekly during weeks 11 to 33 following initial methyl-nitroso-urea instillation to track the course of carcinogenesis.

RESULTS

The specificity of fluorescence detection was significantly enhanced by FG-OCT (53% and 93%, respectively, p <0.0001). The sensitivity of fluorescence detection and FG-OCT was 79% and 100%, respectively.

CONCLUSIONS

FG-OCT cystoscopy has the potential to diagnose early bladder cancer with high sensitivity and specificity with drastically decreased imaging time compared to that of white light guided OCT cystoscopy.

PERFORMANCE OF URINE TEST IN PATIENTS MONITORED FOR RECURRENCE OF BLADDER CANCER: A MULTICENTER STUDY IN THE UNITED STATES

PURPOSE

We assessed the performance of the ImmunoCyt immunocytochemical test for detecting bladder cancer recurrence in patients with prior superficial bladder cancers compared with cystoscopic and histological findings.

MATERIALS AND METHODS

A total of 341 patients with a history of bladder cancer undergoing monitoring were evaluated at 4 sites. The results of cytology and/or ImmunoCyt were analyzed for sensitivity and specificity compared with biopsy confirmed cancer.

RESULTS

The overall sensitivity of cytology alone, ImmunoCyt alone and the 2 methods combined was 23%, 81% and 81%, respectively. The specificity of cytology alone, ImmunoCyt alone and of the 2 methods combined was 93%, 75% and 73%, respectively. The immunocytochemical test was more sensitive than cytology for detecting grades 1 and 2, and stages Ta, T1, and T2 urothelial carcinoma, and it was equally sensitive for detecting grade 3 cancers and carcinoma in situ (CIS). The sensitivity of the combined tests for grades 1 to 3/CIS was 79%, 90% and 82%, while for stages Ta, T1, T2+ and CIS it was 83%, 75%, 100% and 100%, respectively. The overall positive and negative predictive values of the combined tests were 37% and 95%, respectively. Importantly the immunocytochemical test could detect 71% of small (less than 1 cm) tumors.

CONCLUSIONS

ImmunoCyt is a sensitive test for detecting bladder cancer. Because of its high sensitivity for detecting small tumors, even those of low histological grade, and its high negative predictive value, this test may have a role in decreasing the frequency of cystoscopic examinations for monitoring patients with low risk bladder cancer.

Treatment of Benign Prostatic Hyperplasia Using Transurethral Microwave Thermotherapy and Dilatation with Double-Balloon Catheter

PURPOSE

To improve the outcome of transurethral microwave thermotherapy (TUMT) for the treatment of benign prostatic hyperplasia, we combined TUMT and balloon dilatation (BD) with a double-balloon catheter and investigated its effects.

PATIENTS AND METHODS

For a short-term trial, 40 patients were divided randomly into two groups: 20 patients received TUMT alone, and the other 20 received TUMT followed by BD. The degrees of symptoms were graded according to the International Prostate Symptom Score and Quality of Life score, and the peak urinary flow rate was measured before and 10 weeks after treatment. A historic control study of 527 patients was also performed to evaluate the long-term re-treatment rate: 98 of the patients received TUMT alone, and the other 429 patients received TUMT followed by BD.

RESULTS

The symptom scores improved significantly in both groups. The peak uroflow rate was significantly increased in the group who received TUMT followed by BD (P < 0.01), whereas the change was not significant in the TUMT-alone group. Significant sustainability of long-term effects was more evident in patients receiving TUMT plus BD than in the TUMT-alone group, as judged by the higher proportion of BD-treated patients who required no further treatment during the 5-year study period in comparison with patients who received TUMT alone (66.3% v 28.6%, respectively; P < 0.001).

CONCLUSIONS

Combined TUMT and BD achieves sufficient subjective and objective improvement and a sustainable long-term effect. We consider this combination technique to be useful for the treatment of prostatic hyperplasia.

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.