Urinary Cytology in Bladder Cancer: Why is it Still Relevant?

Metabolomics for the diagnosis of bladder cancer: A systematic review

Objective

Metabolomics has been extensively utilized in bladder cancer (BCa) research, employing mass spectrometry and nuclear magnetic resonance spectroscopy to compare various variables (tissues, serum, blood, and urine). This study aimed to identify potential biomarkers for early BCa diagnosis.

Methods

A search strategy was designed to identify clinical trials, descriptive and analytical observational studies from databases such as Medline, Embase, Cochrane Central Register of Controlled Trials, and Latin American and Caribbean Literature in Health Sciences. Inclusion criteria comprised studies involving BCa tissue, serum, blood, or urine profiling using widely adopted metabolomics techniques like mass spectrometry and nuclear magnetic resonance. Primary outcomes included description of metabolites and metabolomics profiling in BCa patients and the association of metabolites and metabolomics profiling with BCa diagnosis compared to control patients. The risk of bias was assessed using the Quality Assessment of Studies of Diagnostic Accuracy.

Results

The search strategy yielded 2832 studies, of which 30 case-control studies were included. Urine was predominantly used as the primary sample for metabolite identification. Risk of bias was often unclear inpatient selection, blinding of the index test, and reference standard assessment, but no applicability concerns were observed. Metabolites and metabolomics profiles associated with BCa diagnosis were identified in glucose, amino acids, nucleotides, lipids, and aldehydes metabolism.

Conclusion

The identified metabolites in urine included citric acid, valine, tryptophan, taurine, aspartic acid, uridine, ribose, phosphocholine, and carnitine. Tissue samples exhibited elevated levels of lactic acid, amino acids, and lipids. Consistent findings across tissue, urine, and serum samples revealed downregulation of citric acid and upregulation of lactic acid, valine, tryptophan, taurine, glutamine, aspartic acid, uridine, ribose, and phosphocholine.

Diagnostic value of the combination of DAPK methylation in urinary sediment and B ultrasound for recurrent urinary bladder cancer

BACKGROUND

Urinary bladder cancer (UBC) is the most common malignancy affecting the urinary system. This study aimed to investigate the diagnostic value of combining DAPK methylation in urinary sediment and B ultrasound in the detection of recurrent UBC.

METHODS

A total of 1021 cases with primary UBC who underwent electrocision of bladder tumor through urethra were included in this study and followed up. Various parameters including B ultrasound, DAPK methylation in urinary sediment, examination of exfoliated cells in the urine, and cystoscopy were performed. The data collected was analyzed using the Kappa test, and receiver operating characteristic (ROC) curve was constructed to assess the diagnostic role in recurrent UBC.

RESULTS

Among the 1021 patients, 115 patients experienced recurrence confirmed by cystoscopy and biopsy within two years and were excluded from the study, resulting in an effective sample size of 906 primary UBC cases. The results of cystoscopy showed agreement with B ultrasound (Kappa = 0.785, P < 0.05), as well as with DAPK methylation in urinary sediment, and the combination of B ultrasound and DAPK methylation (Kappa = 0.517, P < 0.05, Kappa = 0.593, P < 0.05). The combination of B ultrasound with DAPK methylation yielded an area under the curve of 0.922, with a sensitivity of 92.86%, specificity of 91.63%, and a negative predictive value of 99.4%, suggesting that a negative result indicates a low risk of recurrence.

CONCLUSION

The combination of DAPK methylation in urinary sediment with B ultrasound demonstrates high diagnostic performance for recurrent UBC.

Utilising alternative cystoscopic schedules to minimise cost and patient burden after trimodality therapy for muscle-invasive bladder cancer

BACKGROUND

To assess urinary symptoms and urine cytology as screening tools for cystoscopic detection of local recurrence after bladder-preserving trimodality treatment (TMT).

METHODS

Patients with muscle-invasive bladder cancer receiving definitive TMT follow-up three monthly for 2 years, six monthly for the next 3 years and then yearly, with a clinical review, urine cytology and cystoscopy at each visit (triple assessment, TA). Grade 2+ cystitis/haematuria absent/present was scored 0/1, and urine cytology reported negative/suspicious or positive was scored 0/1, respectively. The performance of these two parameters for predicting local recurrence in cystoscopic biopsy was tested. Other hypothetical surveillance schedules included cystoscopy on alternate visits (COAV), or suspected recurrence (COSR), six-monthly COSR and six-monthly TA.

RESULTS

A total of 630 follow-up visits in 112 patients with 19 recurrences (7 muscle invasive, 12 non-muscle invasive) at a median follow-up of 19 months were analysed. The sensitivity and specificity of clinical symptoms were 47.4% and 92%, and for urine cytology 58% and 85%, respectively. The combination of clinical symptoms and cytology (COSR) was 95% sensitive and 78% specific for local recurrence but 100% sensitive for muscle-invasive recurrence. Both COAV and COSV schedules showed a high area under the curve (AUC) for detecting local recurrence (COAV = 0.84, COSR = 0.83), muscle-invasive recurrence (AUC = 0.848 each) and non-muscle-invasive recurrence (COAV = 0.82, COSR = 0.81); reducing the need for TAs by 64% and 67% respectively, and overall cost by 18% and 33%, respectively.

CONCLUSION

Cystoscopy at suspected recurrence during follow-up is safe and the most cost-effective for detecting muscle-invasive local recurrences, while cystoscopy at alternate visits may be more optimal for detecting any local recurrence.

ADXBladder molecular urine testing to risk stratify and prioritise management of suspected and known bladder cancers during the COVID-19 pandemic

Objective:

COVID-19 has challenged diagnostic and surveillance pathways for suspected and known bladder transitional cell cancer (TCC). Exclusion of high-grade/invasive TCC by molecular urine testing could risk stratify patients for priority flexible cystoscopy and transurethral resection (TUR). We evaluated ADXBladder (ArquerDx), which has a high negative predictive value (NPV) for high-grade and ⩾ pT1 TCC.

Patients and methods:

Prospective cohort study of patients referred with haematuria for diagnostics or on TCC surveillance (Dec 2020–Feb 2021). Patients underwent ADXBladder testing, flexible cystoscopy and imaging (for haematuria), followed by TUR/biopsy as necessary. Clinico-radiological/pathology findings were compared with ADXBladder results.

Results:

Of 117 eligible patients, 39 and 78 had positive and negative ADXBladder tests, respectively. Of 15 suspected TCC on cystoscopy, eight were confirmed on TUR/biopsy. Overall ADXBladder NPV was 96.2% (CI: 91.0–98.4). NPV for high-grade and ⩾pT1 TCC was 97.4% (CI: 94.4–98.8) and 98.7% (CI: 95.0–99.7), respectively.

Conclusions:

Our ‘real world’ evaluation confirmed a high NPV for high grade and ⩾pT1 TCC using ADXBladder. Further larger studies are required to determine whether a negative ADXBladder test combined with negative imaging and patient risk factors may justify patient downgrading on timed diagnostic pathways.

Level of evidence:

IV

Accuracy of cytokeratin 19 fragment in the diagnosis of bladder cancer

Aim: CYFRA21-1 is a biomarker of cancer and has a promising future in the diagnosis of bladder cancer. The purpose of this study was to assess the diagnostic accuracy of CYFRA21-1 for bladder cancer. Methods: We included articles from the Cochrane Library, Web of Science, PubMed and Embase. Meta-DiSc 1.4 and Stata 12.0 were used for data analysis. Results: Twenty-eight articles were analyzed, and the results are as follows: sensitivity, specificity, PLR, NLR, DOR and AUC were 0.69 (95% CI [0.67, 0.71]), 0.81 (95% CI [0.80, 0.83]), 5.99 (95% CI [4.42, 8.11]), 0.31 (95% CI [0.25, 0.38]), 24.58 (95% CI [15.15, 39.89]) and 0.8917, respectively. Conclusion: CYFRA21-1 has a high diagnostic efficiency for bladder cancer.

Discrepancy between German S3 Guideline Recommendations and Daily Urologic Practice in the Management of Nonmuscle Invasive Bladder Cancer: Results of a Binational Survey

INTRODUCTION

Guideline recommendations are meant to help minimize morbidity and to improve the care of nonmuscle invasive bladder cancer (NMIBC) patients but studies have suggested an underuse of guideline-recommended care. The aim of this study was to evaluate the level of adherence of German and Austrian urologists to German guideline recommendations.

METHODS

A survey of 27 items evaluating diagnostic and therapeutic recommendations (15 cases of strong consensus and 6 cases of consensus) for NMIBC was administered among 14 urologic training courses. Survey construction and realization followed the checklist for reporting results of internet e-surveys and was approved by an internal review board.

RESULTS

Between January 2018 and June 2019, a total of 307 urologists responded to the questionnaire, with a mean response rate of 71%. The data showed a weak role of urine cytology (54%) for initial diagnostics although it is strongly recommended by the guideline. The most frequently used supporting diagnostic tool during transurethral resection of the bladder was hexaminolevulinate (95%). Contrary to the guideline recommendation, 38% of the participants performed a second resection in the case of pTa low-grade NMIBC. Correct monitoring of Bacille Calmette-Guérin (BCG) response with cystoscopy and cytology was performed by only 34% of the urologists.

CONCLUSIONS

We found a discrepancy between certain guideline recommendations and daily routine practice concerning the use of urine cytology for initial diagnostics, instillation therapy with a low monitoring rate of BCG response, and follow-up care with unnecessary second resection after pTa low-grade NMIBC in particular. Our survey showed a moderate overall adherence rate of 73%. These results demonstrate the need for sharpening awareness of German guideline recommendations by promoting more intense education of urologists to optimize NMIBC care thus decreasing morbidity and mortality rates.

Diagnostic value of a comprehensive, urothelial carcinoma-specific next-generation sequencing panel in urine cytology and bladder tumor specimens

BACKGROUND

Urine cytology can reliably diagnose high-grade urothelial carcinoma (HGUC) but not low-grade urothelial carcinoma (LGUC), and a more sensitive test is needed. Previously, a pilot study highlighted the possible diagnostic utility of next-generation sequencing (NGS) in identifying both LGUC and HGUC in urine cytology specimens.

METHODS

Twenty-eight urine ThinPrep cytology specimens and preceding or subsequent bladder tumor biopsy/resection specimens obtained within 3 months were included in the study (LGUC, n = 15; HGUC, n = 13). A customized, bladder-specific NGS panel was performed; it covered 69 frequently mutated or altered genes in urothelial carcinoma (UC) that were reported by The Cancer Genome Atlas and the Catalogue of Somatic Mutations in Cancer.

RESULTS

The sequencing results were compared between the urine cytology specimens and the corresponding bladder tumor biopsies/resections. TP53 was the most frequently identified mutation in HGUC cases (11 of 13 [85%]). PIK3CA and KDM6A were the most frequently identified mutations in LGUC: they occurred in 7 of 15 cases (47%) and in 6 of 15 cases (40%), respectively. Additional frequent mutations identified in the panel included ARID1A (n = 5), EP300 (n = 4), LRP1B (n = 3), ERBB2 (n = 2), STAG2 (n = 2), FGFR3 (n = 3), MLL (n = 2), MLL3 (n = 2), CREBBP1 (n = 1), RB1 (n = 1), and FAT4 (n = 1). Overall, the concordance between the cytology and surgical specimens was 75%. The sensitivity and specificity for identifying mutations in urine cytology specimens were 84% and 100%, respectively.

CONCLUSIONS

A bladder-specific NGS panel increases the sensitivity and specificity of urine cytology's diagnostic utility in both low- and high-grade tumors and may serve as a noninvasive surveillance method in the follow-up of patients with UC harboring known mutations.