Targeted education as a method for reinforcing Paris System criteria and reducing urine cytology atypia rates

INTRODUCTION

The Paris System for Urine Cytology (TPS) provides well-defined diagnostic criteria for the category of atypical urothelial cells (AUC). The current study compares the rate of AUC diagnoses at a large academic medical center before and after an educational intervention (EI) by a urine cytology expert.

MATERIALS AND METHODS

An expert in TPS delivered an educational intervention consisting of an interactive microscope session and a didactic session that focused on the AUC diagnostic category. The number of urine cytology cases, the AUC rate, and the false-negative percentage were calculated before and after the EI, using the electronic medical records and cytologic-histologic correlation records.

RESULTS

A total of 4026 urine cytology cases were signed out in the 25 months prior to the educational intervention and 1585 cases were signed out in the 10 months after the intervention. EI had a significant impact on diagnostic categorization, including a reduction in AUC (19.6% versus 12.5%) and suspicious for high-grade urothelial carcinoma (3.9% versus 3.1%) diagnoses. The cytotechnologists also placed fewer cases into the AUC category during primary screening (27.6% versus 23.0%). Although a higher percentage of cases was reported as negative for high-grade urothelial carcinoma, the false-negative rate did not significantly change after the intervention (1.8% versus 2.0% of negative cases, P = 0.65).

CONCLUSIONS

Focused educational sessions for pathologists and cytotechnologists on the diagnostic criteria for AUC as defined by TPS can significantly reduce the rate of atypical diagnoses without a significant increase in the rate of false negatives.

Developing a Machine Learning Algorithm for Identifying Abnormal Urothelial Cells: A Feasibility Study

INTRODUCTION

Urine cytology plays an important role in diagnosing urothelial carcinoma (UC). However, urine cytology interpretation is subjective and difficult. Morphogo (ALAB, Boston, MA, USA), equipped with automatic acquisition and scanning, optical focusing, and automatic classification with convolutional neural network has been developed for bone marrow aspirate smear analysis of hematopoietic diseases. The goal of this preliminary study was to determine the feasibility of developing a machine learning algorithm on Morphogo for identifying abnormal urothelial cells in urine cytology slides.

METHODS

Thirty-seven achieved abnormal urine cytology slides from cases with the diagnosis of atypical urothelial cells and above (suspicions or positive for UC) were obtained from 1 hospital. A pathologist (J.R.) reviewed the slides and manually selected and annotated representative cells to feed into Morphogo with following categories: benign (urothelial cells, squamous cells, degenerated cells, and inflammatory cells), atypical cells, and suspicious cells. Initial validation of the algorithm was performed on a subset of the original 37 cases. Urine samples from additional 12 unknown cases with various histological diagnoses (6 cases of high-grade urothelial carcinoma (HGUC), 1 case of low-grade urothelial carcinoma (LGUC), 1 case of prostate adenocarcinoma, 1 case of renal cell carcinoma, and 4 cases of non-neoplastic conditions) were collected from another hospital for initial blind testing.

RESULTS

A total of 1,910 benign and 1,978 abnormal (atypical and suspicious) cells from 37 slides were annotated for developing and training of the algorithm. This algorithm was validated on 27 slides that resulted in identification of at least 1 abnormal cell per slide, with a total of 200 abnormal cells, and an average of 7.4 cells per slide. Of the 12 unknown cases tested, the original cytology was positive for tumor cells in 2 HGUC samples. Morphogo was abnormal (atypical or suspicious) for 6 samples from patients with UC, including one with LGUC and one with prostate adenocarcinoma.

CONCLUSION

Morphogo machine learning algorithm is capable of identifying abnormal urothelial cells. Further validation studies with a larger number of urine samples will be needed to determine if it can be used to assist the cytological diagnosis of UC.

High-grade urothelial carcinoma in urine cytology: different spaces - different faces, highlighting morphologic variance

INTRODUCTION

The Paris System for Reporting Urinary Cytology (TPS) was first published in 2016 to standardize reporting and placed a specific emphasis on high-grade urothelial carcinoma (HGUC). The urinary tract is anatomically divided into the upper tract (UT) and the lower tract (LT). A major morphologic criterion in TPS for HGUC defines the nuclear-to-cytoplasmic (N/C) ratio as ≥ 0.7. In this study, we evaluated N/C ratios of HGUC arising from UT and LT urine specimens, to ascertain differences due to location.

MATERIALS AND METHODS

Digital annotations of whole slide scanned images were performed and enumerated.

RESULTS

The cohort consisted of 59 ThinPrep specimens from 52 patients. The majority of the tumors were located in LT (39 of 59, 66.1%). A total of 590 cells were analyzed (10 cells per case). In UT, the average N/C was 0.58 and LT the average was 0.54 (P < 0.001). The average nuclear area for UT was 126.3 and for LT was 158.2 μm² (P = 0.01). The average cytoplasmic area for UT was 219.1 μm² and for LT was 296.2 μm² (P < 0.001). The average cellular circumference for UT was 59.4 μm and for LT was 66.1 μm (P < 0.001).

CONCLUSIONS

We found that UT HGUCs have higher N/C ratios, smaller cell circumference, smaller nuclei, and less cytoplasm compared with LT. When UT was divided into renal pelvis and ureter, no statistical difference was identified.

Urinary MicroRNAs as Potential Markers for Non-Invasive Diagnosis of Bladder Cancer

Currently, voided urine cytology (VUC) serves as the gold standard for the detection of bladder cancer (BCa) in urine. Despite its high specificity, VUC has shortcomings in terms of sensitivity. Therefore, alternative biomarkers are being searched, which might overcome these disadvantages as a useful adjunct to VUC. The aim of this study was to evaluate the diagnostic potential of the urinary levels of selected microRNAs (miRs), which might represent such alternative biomarkers due to their BCa-specific expression. Expression levels of nine BCa-associated microRNAs (miR-21, -96, -125b, -126, -145, -183, -205, -210, -221) were assessed by quantitative PCR in urine sediments from 104 patients with primary BCa and 46 control subjects. Receiver operating characteristic (ROC) curve analyses revealed a diagnostic potential for miR-96, -125b, -126, -145, -183, and -221 with area under the curve (AUC) values between 0.605 and 0.772. The combination of the four best candidates resulted in sensitivity, specificity, positive and negative predictive values (NPV), and accuracy of 73.1%, 95.7%, 97.4%, 61.1%, and 80.0%, respectively. Combined with VUC, sensitivity and NPV could be increased by nearly 8%, each surpassing the performance of VUC alone. The present findings suggested a diagnostic potential of miR-125b, -145, -183, and -221 in combination with VUC for non-invasive detection of BCa in urine.

An institutional experience evaluating hTERT immunostaining in 100 consecutive ThinPrep urine specimens

INTRODUCTION

Studies have shown that expression of human telomerase reverse transcriptase (hTERT) in mature urothelial cells indicates an increased risk of urothelial carcinoma. We evaluated the utility of immunocytochemistry with a commercially available anti-hTERT antibody (SCD-A7) in 100 consecutive urine cytology specimens using ThinPrep processing.

MATERIALS AND METHODS

ThinPrep slides prepared from 100 consecutive urine specimens were stained using anti-hTERT antibody (SCD-A7) after staining optimization had been successfully completed. Patient demographics, cytology diagnoses, histologic follow-up data, and anti-hTERT staining results were recorded.

RESULTS

The cytology diagnoses included 7 cases of high-grade urothelial carcinoma (HGUC), 2 cases suspicious for HGUC (SHGUC), 24 cases of atypical urothelial cells (AUCs), and 67 cases negative for HGUC (NHGUC). Of 92 samples, 68 (74%) were positive and 24 (26%) were negative for anti-hTERT staining. Although 31 of 32 specimens (97%) with a diagnosis of AUCs and greater showed positive staining, 37 of 60 NHGUC cases (62%) were also positive for anti-hTERT. Although the HGUC and suspicious for HGUC cases were more likely to show strong staining (6 of 9; 67%), 7 AUC (32%) and 8 NHGUC (22%) cases also demonstrated strong staining. Eight samples (8%) were unsatisfactory for interpretation. Anti-hTERT staining of nonurothelial cells was seen in 77 of 92 samples (84%).

CONCLUSIONS

Interpretation of anti-hTERT immunocytochemical staining of ThinPrep material is challenging owing to obscuring of nonurothelial cell staining and difficulty discerning individual urothelial cell cytomorphology when the cells are stained. The significance of the large number of anti-hTERT-positive but cytology-negative cases in our study is uncertain.

Variability among observers utilizing the CellSolutions BestCyte Cell Sorter imaging system for the assessment of urinary tract cytology specimens

INTRODUCTION

Image analysis systems are not currently commonly used for evaluating urinary cytology specimens. We evaluated whether the BestCyte Cell Sorter (CellSolutions, Greensboro, NC) imaging system can reliably identify atypical cells in urinary cytology specimens.

METHODS

Fifty-three consecutive urine cytology specimens underwent 2 preparations: one slide using SurePath (SP; BD Diagnostics, Sparks, MD)^™ for routine clinical evaluation, and a second slide using the CellSolutions F50 system for analysis by the BestCyte Cell Sorter (BCCS) scanning system. Eight observers reviewed atypical cells flagged by BCCS and assigned a BCCS diagnosis to each of the 53 specimens. The observers also blindly reviewed the SP preparation (when available) and assigned an SP diagnosis. The SP diagnoses given by one "expert" observer was considered as a reference diagnosis.

RESULTS

There was fair-to-moderate agreement among observers for identifying any atypia and high-grade atypia (Fleiss kappa: 0.417 and 0.338, respectively) using BCCS. Review of SP preparations had slightly better agreement (Fleiss kappa: 0.558 and 0.564, respectively). Intraobserver agreement between the two methods varied greatly between individuals (Cohen's kappa range: 0.260 to 0.647). When a consensus diagnosis could be reached among the observers for cases with surgical follow-up, the consensus diagnosis was concordant in 11 of 12 instances, with one instance being a one-step discrepancy.

CONCLUSIONS

Specimen review by BCCS resulted in slightly greater interobserver variability than review of routine SP preparations. This may have been due to variations in observer experience and comfort with the use of a digital imaging system, which is further suggested by the wide range of intraobserver agreement among individuals.

Correlation between chronological and physiological age of males from their multivariate urinary endogenous steroid profile and prostatic carcinoma-induced deviation

The biosynthesis of endogenous androgenic anabolic steroids (EAAS) in males varies with age. Knowledge of the general urinary EAAS profile's dependence from aging - not reported up to now - may represents a prerequisite for its exploitation in the screening and diagnostic support for several pathologies. Extended urinary EAAS profiles were obtained from healthy and pathological individuals, using a GC-MS method which was fully validated by a stepwise, analyst-independent scheme. Seventeen EAAS and five of their concentration ratios were determined and investigated using multivariate statistical methods. A regression model based on Kernel partial least squares algorithm was built to correlate the chronological age of healthy male individuals with their "physiological age" as determined from their urinary EAAS profile. Strong correlation (R² = 0.75; slope = 0.747) and good prediction ability of the real chronological age was inferred from EAAS data. In contrast, patients with recent diagnosis (not pharmacologically treated) of prostatic carcinoma (PCa) exhibited a comprehensive EAAS profile with strong negative deviation from the model, corresponding a younger predicted age. This result is possibly related to the activation of anomalous steroid biosynthesis induced from PCa. Over a restricted 60-80 years-old population, PLS-discriminant analysis (DA) was used to distinguish healthy subjects from patients with untreated PCa. PLS-DA yielded excellent discrimination (sensitivity and specificity >90%) between healthy and pathological individuals. This proof-of-concept study provides a preliminary evaluation of multivariate DA on wide EAAS profiles as a screening method to distinguish PCa from non-pathological conditions, overcoming the potentially interfering effect of ageing.

Profiling the Urinary Microbiota in Male Patients With Bladder Cancer in China

Mounting evidence indicates that microbiome plays an important role in the development and progression of cancer. The dogma that urine in healthy individuals must be sterile has been overturned. Dysbiosis of the urinary microbiome has been revealed responsible for various urological disorders, including prostate cancer. The link between chronic inflammation, microbiome and solid tumors has been established for various neoplastic diseases. However, a detailed and comprehensive analysis of urinary microenvironment of bladder cancer has not been yet reported. We performed this study to characterize the potential urinary microbial community possibly associated with bladder cancer. Mid-stream urine was collected from 31 male patients with bladder cancer and 18 non-neoplastic controls. DNA was extracted from urine pellet samples and processed for high throughput 16S rRNA amplicon sequencing of the V4 region using Illumina MiSeq. Sequencing reads were filtered using QIIME and clustered using UPARSE. We observed increased bacterial richness (Observed Species, Chao 1 and Ace indexes; cancer vs. control; 120.0 vs. 56.0; 134.5 vs. 68.3; and 139.6 vs. 72.9, respectively), enrichment of some bacterial genera (e.g., Acinetobacter, Anaerococcus, and Sphingobacterium) and decrease of some bacterial genera (e.g., Serratia, Proteus, and Roseomonas) in cancer group when compared to non-cancer group. Significant difference in beta diversity was found between cancer and non-cancer group, among different risk level, but not among different tumor grade. Enrichment of Herbaspirillum, Porphyrobacter, and Bacteroides was observed in cancer patients with high risk of recurrence and progression, which means these genera maybe potential biomarkers for risk stratification. The PICRUSt showed that various functional pathways were enriched in cancer group, including Staphylococcus aureus infection, glycerolipid metabolism and retinol metabolism. To our knowledge, we performed the most comprehensive study to date to characterize the urinary microbiome associated with bladder cancer. A better understanding of the role of microbiome in the development and progression of bladder cancer could pave a new way for exploring new therapeutic options and biomarkers.

Analysis of the Cytomorphological Features in Atypical Urine Specimens following Application of The Paris System for Reporting Urinary Cytology

BACKGROUND

This study investigates the use of The Paris System (TPS) for Reporting Urinary Cytopathology and examines the performance of individual and combined morphological features in atypical urine cytologies.

METHODS

We reviewed 118 atypical cytologies with subsequent bladder biopsies for the presence of several morphological features and reclassified them into Paris System categories. The sensitivity and specificity of individual and combined features were calculated along with the risk of malignancy.

RESULTS

An elevated nuclear-to-cytoplasmic ratio was only predictive of malignancy if seen in single cells, while irregular nuclear borders, hyperchromasia, and coarse granular chromatin were predictive in single cells and in groups. Identification of coarse chromatin alone yielded a malignancy risk comparable to 2-feature combinations. The use of TPS criteria identified the specimens at a higher risk of malignancy.

CONCLUSION

Our findings support the use of TPS criteria, suggesting that the presence of coarse chromatin is more specific than other individual features, and confirming that cytologic atypia is more worrisome in single cells than in groups.

High-Grade Urothelial Carcinoma on Urine Cytology Resembling Umbrella Cells

CONTEXT

High-grade urothelial carcinoma (UC) cells have many appearances on urine cytology, but according to The Paris System, they can be easily distinguished from umbrella cells.

OBJECTIVE

We aimed to define the incidence and appearance of high-grade UC cells that resemble umbrella cells in Cytospin preparations on urine cytology.

RESULTS

Cytospin preparations from 331 cases with biopsy follow-up (230 benign/low-grade and 101 malignant [22 carcinoma in situ, 52 papillary, 19 invasive UC, 8 other] cases) were reviewed. A total of 18 cases with malignant cells resembling umbrella cells were identified (17.8% of the malignant cases) and were the only type of malignant cell in 3% of the cases. Two patterns were identified. Tumor cells were either identifiable by at least 20 abnormal cells which were large, had abundant cytoplasm but an elevated nuclear-to-cytoplasmic ratio, and markedly enlarged, round-to-elongated nucleoli, or else rare cells with abundant cytoplasm but obviously malignant nuclei. Cells without nucleoli or obviously malignant nuclei were not specific.

CONCLUSIONS

Malignant cells resembling umbrella cells can be seen in up to 17% of urine cytology specimens.

Utility of the Paris System in Reporting Urine Cytology

OBJECTIVE

To find out the utility of The Paris System (TPS) in reporting urine cytology and to compare it with the reporting system currently used in our laboratory.

STUDY DESIGN

This retrospective study was undertaken over a period of 1 year during which slides of all the urine specimens sent for cytological examination were retrieved from our laboratory filling system. They were blindly reviewed and reclassified according to TPS. Surgical follow-up was obtained from the uropathology services of our department.

RESULTS

A total of 176 cases were meticulously reviewed. The mean age of the patients was 52 years, and 71% of cases presented with hematuria. Histopathological follow-up was available in 34 cases. Reporting by TPS detected 13.0% high-grade urothelial carcinoma (HGUC) and 5.1% atypical urothelial cells versus 7.3 and 11.9% by the current reporting system, respectively. The sensitivity and diagnostic accuracy for detecting HGUC of TPS were higher than those of our reporting system.

CONCLUSION

TPS has increased the rate of detection of HGUC and reduced the rate of reporting "atypical" urothelial cells. TPS has also standardized the diagnostic criteria, thereby bringing uniformity and reproducibility into the system of reporting for urine cytology.

The diagnostic value of cytohistological urine analysis and cytokeratin 20 in malignant and atypical urothelial cells

INTRODUCTION

To determine the ability of cytohistology and cytokeratin 20 (CK 20) expression in malignant and atypical cells (AUC) from urine to serve as a diagnostic tool for assessing urothelial carcinoma (UC).

METHODS

Diagnoses from 55 urine cytological samples from 55 patients were analyzed and correlated with subsequent biopsy findings. A total of 50 archived urine slides from patients that received a cytological diagnosis and histological follow-up were selected for immunostaining with monoclonal CK 20 antibodies and elaborated by Z-test for proportions.

RESULTS

The majority of all positive or atypical smears (24; 89%) were confirmed through histological analysis. The majority of urinary cytological diagnoses reported as negative (15; 54%) were also confirmed through biopsies. The overall sensitivity, specificity, PPV, and NPV were 65%, 83%, 89%, and 54%, respectively. All 13 smears cytologically determined to contain malignant cells, with subsequent biopsies confirming UC, exhibited strong positive staining with the CK 20 antibody. All cases evaluated as benign both cytologically and histologically had negative CK 20 staining. Of the 15 AUC cases with lesions confirmed through biopsies, 11 (73%) had atypical cells that stained positive for CK 20.

DISCUSSION

Our results demonstrate the diagnostic value of urinary cytology and confirm CK 20 as an adjunct marker for the diagnosis of UC and for the triage of AUC.

Genomic complexity of urothelial bladder cancer revealed in urinary cfDNA

Urothelial bladder cancers (UBCs) have heterogeneous clinical characteristics that are mirrored in their diverse genomic profiles. Genomic profiling of UBCs has the potential to benefit routine clinical practice by providing prognostic utility above and beyond conventional clinicopathological factors, and allowing for prediction and surveillance of treatment responses. Urinary DNAs representative of the tumour genome provide a promising resource as a liquid biopsy for non-invasive genomic profiling of UBCs. We compared the genomic profiles of urinary cellular DNA and cell-free DNA (cfDNA) from the urine with matched diagnostic formalin-fixed paraffin-embedded tumour DNAs for 23 well-characterised UBC patients. Our data show urinary DNAs to be highly representative of patient tumours, allowing for detection of recurrent clinically actionable genomic aberrations. Furthermore, a greater aberrant load (indicative of tumour genome) was observed in cfDNA over cellular DNA (P<0.001), resulting in a higher analytical sensitivity for detection of clinically actionable genomic aberrations (P<0.04) when using cfDNA. Thus, cfDNA extracted from the urine of UBC patients has a higher tumour genome burden and allows greater detection of key genomic biomarkers (90%) than cellular DNA from urine (61%) and provides a promising resource for robust whole-genome tumour profiling of UBC with potential to influence clinical decisions without invasive patient interventions.

Relationship between indoleamine 2,3-dioxygenase activity and lymphatic invasion propensity of colorectal carcinoma

AIM

To evaluate whether serum and tumor indoleamine 2,3-dioxygenase activities can predict lymphatic invasion (LI) or lymph node metastasis in colorectal carcinoma.

METHODS

The study group consisted of 44 colorectal carcinoma patients. The patients were re-grouped according to the presence or absence of LI and lymph node metastasis. Forty-three cancer-free subjects without any metabolic disturbances were included into the control group. Serum neopterin was measured by enzyme linked immunosorbent assay. Urinary neopterin and biopterin, serum tryptophan (Trp) and kynurenine (Kyn) concentrations of all patients were determined by high performance liquid chromatography. Kyn/Trp was calculated and its correlation with serum neopterin was determined to estimate the serum indoleamine 2,3-dioxygenase activity. Tissue sections from the studied tumors were re-examined histopathologically and were stained by immunohistochemistry with indoleamine-2,3-dioxygenase antibodies.

RESULTS

Neither serum nor urinary neopterin was significantly different between the patient and control groups (both P > 0.05). However, colorectal carcinoma patients showed a significant positive correlation between the serum neopterin levels and Kyn/Trp (r = 0.450, P < 0.01). Urinary biopterin was significantly higher in cancer cases (P < 0.05). Serum Kyn/Trp was significantly higher in colorectal carcinoma patients (P < 0.01). Lymphatic invasion was present in 23 of 44 patients, of which only 12 patients had lymph node metastasis. Eleven patients with LI had no lymph node metastasis. Indoleamine-2,3-dioxygenase intensity score was significantly higher in LI positive cancer group (44.56% ± 6.11%) than negative colorectal cancer patients (24.04% ± 6.90%), (P < 0.05). Indoleamine 2,3-dioxygenase expression correlated both with the presence of LI and lymph node metastasis (P < 0.01 and P < 0.05, respectively). A significant difference between the accuracy of diagnosis by using either total indoleamine-2,3-dioxygenase immunostaining score or of lymph node metastasis was found during the evaluation of cancer patients.

CONCLUSION

Indoleamine-2,3-dioxygenase expression may predict the presence of unrecognized LI and lymph node metastasis and may be included in the histopathological evaluation of colorectal carcinoma cases.

Prognostic Significance of Preoperative Urine Cytology in Low-grade Non-muscle-invasive Bladder Cancer

AIM

To examine the clinical significance of preoperative urine cytology in patients with low-grade bladder cancer.

PATIENTS AND METHODS

We retrospectively investigated the records of 155 patients diagnosed with primary low-grade (Ta) urothelial carcinoma of the bladder between January 2000 and September 2014.

RESULTS

Patients with class III or greater cytology had significantly higher-grade (G2) (p=0.01), larger tumors (≥15 mm, p=0.0009) and significantly shorter recurrence-free survival compared to patients with class II or lower cytology (p<0.0001). However, Cox proportional hazards analysis for recurrence-free survival only identified tumor size (≥15 mm) (hazard ratio=5.97, 95% confidence interval=2.39-17.29; p<0.0001) as a predictor of poor prognosis, although patients with class III or higher preoperative cytology showed a tendency towards frequent intravesical recurrence (hazard ratio=1.98, 95% confidence interval=0.96-4.2; p=0.063).

CONCLUSION

Preoperative urine cytology, in addition to tumor size, might be a useful predictor of intravesical recurrence of bladder cancer.

Urothelial carcinoma with oncocytic features: an extremely rare case presenting a diagnostic challenge in urine cytology

Recognizing histological variants in urothelial carcinoma (UC) is important because some may be associated with different clinical outcomes and/or therapeutic approaches; being aware of unusual histological variants may also be crucial in preventing diagnostic misinterpretations. Histological variants based on cytoplasmic features, such as clear-cell, plasmacytoid, rhabdoid, and lipoid-rich variants, are described in invasive UC; however, these cytoplasmic features are not formally defined and not usually encountered in non-invasive UC. Oncocytic cytoplasm has not been well described in either invasive or non-invasive UC. Herein, we report an exceedingly rare case of UC with oncocytic features arising in the right renal pelvis, which presented a diagnostic challenge in urine cytology due to the relatively low nuclear-to-cytoplasmic ratio; however, it could definitively be diagnosed using histological specimens. UC diagnosis is based on the presence of papillary architecture and widespread p53 nuclear accumulation, suggesting malignancy. An oncocytic tumor is generally considered to be not actively dividing, as shown by the low Ki-67 labeling index in this case. In spite of the low proliferative activity, the possibility of intravesicle recurrence (IVR) should be considered since positive preoperative cytology of upper tract UC is a risk factor for IVR after nephroureterectomy.

Improved Target Cell Selection and Counting Method for UroVysion Fluorescence in Situ Hybridization

BACKGROUND

The UroVysion Bladder Cancer Kit requires morphological analysis of 4', 6-diamino-2-phenylindole (DAPI)-stained nuclei to identify target cells for fluorescence in situ hybridization (FISH) signals. Reproducibility and efficiency of target cell selection and counting was evaluated by combining immunofluorescence staining of cytokeratin 7 (CK7) and proliferating cell nuclear antigen (PCNA) with DAPI staining.

METHODS

The reactivities to CK7, PCNA, and DAPI were compared between those for different ratios of T24 human bladder carcinoma cells and of cells from the urine of five healthy subjects. Two technicians independently performed five replicate cell counts of urine samples from four bladder cancer patients and one healthy subject.

RESULTS

The positive staining rates for CK7 and PCNA were similar to DAPI, but our method showed enhanced inter-observer repeatability and reduced operating time for signal counting.

CONCLUSIONS

Our proposed method showed better reproducibility and lesser operational time for signal counting than the DAPI method alone.

Use of the nuclear matrix protein 22 Bladder Chek test™ in the diagnosis of residual urothelial cancer before a second transurethral resection of bladder cancer

PURPOSE

To investigate the diagnostic value of the nuclear matrix protein 22 (NMP-22) in residual tumors after complete transurethral resection (TUR) of bladder cancer.

METHODS

A total of 160 patients diagnosed with non-muscle invasive bladder cancer were prospectively enrolled in the study. Before the initial TUR, the patients were evaluated using urine cytology and the NMP-22 Bladder Chek™. After 4-6 weeks, all patients underwent a second TUR, urine cytology and NMP-22 Bladder Chek™ evaluation.

RESULTS

The mean patient age was 59.8 ± 1.0 years. Of the 160 patients, 81 (50.6%) had positive NMP-22 findings and 53 (33.1%) had positive urine cytology findings. In 101 (63.1%) patients, at least one marker was positive. There was no correlation between the positivity ratio of the NMP-22 and the degree of risk group (p = 0.156); however, in the high-risk group, the malignant cytology ratio was higher (p < 0.001). In 60 patients (37.5%), there were tumors in the second TUR. NMP-22 results of 40 of these patients (66.7%) were positive, and for 28 (46.7%), the cytology results were positive. The sensitivity, specificity, positive predictive value, and negative predictive value of the NMP-22 alone was 66.7, 81, 67.8, and 80.2 %, respectively; for the cytology, it was 46.7, 98, 93.3, and 75.4%, respectively; and for the NMP-22 and cytology combined, it was 73.3, 79, 67.7, and 83.2%, respectively.

CONCLUSIONS

NMP-22 Bladder Chek™ test has limited efficacy in detecting residual tumors before a second TUR. The combination of this test with cytology has no additional benefit.

[Antioxidant properties of cluster rhenium compounds and their effect on erythropoiesis of rats with guerin carcinoma]

Biochemical characteristics of kidneys, pe- ripheral blood and bone marrow of rats in model of tumor growth under introduction of cisplatin and cis-tetrachlorodi-μ-isobutyratodirhenium(III), cis-Re2(i-C3H7COO)2Cl4 (I) have been investigated. It was shown that introduction of I alone and together with cisplatin led to decrease of biochemical markers of oxidation of lipids and proteins in tissue homogenates of the kidneys, change of enzyme activity in the urea and tissue homogenates of the kidneys, by a decrease of filtration function of kidneys. Introduction of nanoliposomal forms of the rhenium cluster compound led to a practically normal morphological picture of bone marrow and increase of the RBC (by 60%) with normalization of hematocrit counts, and decrease of quantities of destructed RBC (3.2 times) in comparison with the tumor-bearing animals. A tentative scheme of influence of cluster rhenium compound on erythropoiesis through regulation of synthesis of erythropoietin in kidneys has been proposed.

The impact of iodinated contrast agent administered during preoperative computed tomography scan on body iodine pool in patients with differentiated thyroid cancer preparing for radioactive iodine treatment

BACKGROUND

Iodine in iodinated contrast agents (ICAs) interferes with radioactive iodine treatment (RAIT) and diagnostic scans in patients with differentiated thyroid carcinoma (DTC) because it can compete with ¹³¹I. Published guidelines recommend delaying RAIT for three to four months in patients who have been exposed to ICA. Spot urinary iodine concentration is a useful marker to reflect the body iodine pool. We investigated the impact of ICAs administered at preoperative computed tomography (CT) scan on the body iodine pool to determine the proper time interval between preoperative CT and RAIT in DTC patients.

METHODS

We performed a retrospective review of 1023 patients with DTC who underwent a preoperative CT scan with ICA, total thyroidectomy, and one week of low-iodine diet in preparation for RAIT. Urine iodine excretion (UIE) was measured in spot urine by inductively coupled plasma mass spectrometry and reported both in simple concentration (μg/L) and divided by gram creatinine (μg/gCr). Patients were divided into five groups by time interval in days between preoperative CT scan and spot urine iodine measurement (A, 31-60 [n=29]; B, 61-90 [n=155]; C, 91-120 [n=546]; D, 121-150 [n=226]; E, 151-180 [n=67]).

RESULTS

The median (interquartile range) of UIE (μg/gCr) in each group was 44.4 (27.7-73.2) in group A, 33.3 (22.8-64.7) in group B, 32.7 (20.8-63.0) in group C, 32.0 (20.6-67.0) in group D, and 30.4 (19.6-70.8) in group E. There was no significant difference between group A and the remaining groups (p>0.05) Also, the proportion of patients who achieved the appropriate UIE for RAIT according to our hospital's cutoff (≤66.2 μg/gCr) was not different between groups (A, 72.4%; B, 76.1%; C, 77.5%; D, 74.8%; E, 74.6%) (p=0.78).

CONCLUSION

This study shows that a UIE of one month after preoperative CT scan with ICA was not higher than that of six months after CT scan in patients who underwent total thyroidectomy for DTC. Thus, current guidelines that recommend delay of RAIT for three to four months after CT scan with ICA should be revisited and future studies to clarify the appropriate time interval between CT scan with ICA and RAIT are warranted.

Urinary cytology with acridine orange fluorescence is highly valuable for predicting high-grade upper urinary tract urothelial carcinoma

OBJECTIVES

To evaluate the clinical value of acridine orange fluorescent staining in urinary cytology for the diagnosis of upper urinary tract urothelial carcinoma.

METHODS AND MATERIALS

A retrospective analysis was conducted with 510 cases of upper urinary tract urothelial carcinoma (UTUC) in terms of the results of acridine orange fluorescence (AO-F) staining of the exfoliated cells in urine. The percentage of positive AO-F result and the positive predictive value of AO-F for high-grade and muscle invasive urothelial carcinoma were calculated and analyzed in terms of clinical characteristics.

RESULTS

The overall percentage of positive AO-F result was 49% in the 510 patients, 54.1% for males and 40.6% for females. AO-F was positive in 51.9% of the patients with hematuria and 36.2% of the patients without hematuria. AO-F was positive in 56.4% of the patients with renal pelvis carcinoma and 42.8% of the patients with ureteral cancer; in 44.6% of the patients with non-muscle invasive carcinoma and 53.5% of the patients with muscle-invasive carcinoma. AO-F was positive in 26.8% of the cases with low-grade carcinoma and 55.3% of the patients with high-grade carcinoma. The positive predictive value of AO-F was 88% for high-grade cancer, and only 53.6% for muscle invasive carcinoma.

CONCLUSIONS

Acridine orange fluorescence microscopy cannot increase the sensitivity of urine exfoliative cytology in the diagnosis of UTUC. It may be used as a predictor of high-grade UTUC. Acridine orange fluorescence microscopy in urinary cytodiagnosis does not show high value in predicting muscle invasive UTUC.

Collagen peptides in urine: a new promising biomarker for the detection of colorectal liver metastases

Introduction

For both patients and the outpatient clinic the frequent follow-up visits after a resection of colorectal cancer (CRC) are time consuming and due to large patient numbers expensive. Therefore it is important to develop an effective non-invasive test for the detection of colorectal liver metastasis (CRLM) which could be used outside the hospital. The urine proteome is known to provide detailed information for monitoring changes in the physiology of humans. Urine collection is non-invasive and urine naturally occurring peptides (NOPs) have the advantage of being easily accessible without labour-intensive sample preparation. These advantages make it potentially useful for a quick and reliable application in clinical settings. In this study, we will focus on the identification and validation of urine NOPs to discriminate patients with CRLM from healthy controls.

Materials and Methods

Urine samples were collected from 24 patients with CRLM and 25 healthy controls. In the first part of the study, samples were measured with a nano liquid chromatography (LC) system (Thermo Fisher Scientific, Germaring, Germany) coupled on-line to a hybrid linear ion trap/Orbitrap mass spectrometer (LTQ-Orbitrap-XL, Thermo Fisher Scientific, Bremen, Germany). A discovery set was used to construct the model and consecutively the validation set, being independent from the discovery set, to check the acquired model. From the peptides which were selected, multiple reaction monitoring (MRM's) were developed on a UPLC-MS/MS system.

Results

Seven peptides were selected and applied in a discriminant analysis a sensitivity of 84.6% and a specificity of 92.3% were established (Canonical correlation:0.797, Eigenvalue:1.744, F:4.49, p:0.005). The peptides AGPP(-OH)GEAGKP(-OH)GEQGVP(-OH)GDLGA P(-OH)GP and KGNSGEP(-OH)GAPGSKGDTGAKGEP(-OH)GPVG were selected for further quantitative analysis which showed a sensitivity of 88% and a specificity of 88%.

Conclusion

Urine proteomic analysis revealed two very promising peptides, both part from collagen type 1, AGPP(-OH)GEAGKP(-OH)GEQGVP(-OH)GDLGAP(-OH)GP and KGNSGEP(-OH)GAPGSKGDTGAKGEP(-OH)GPVG which could detect CRLM in a non-invasive manner.

Accuracy of grading of urothelial carcinoma on urine cytology: an analysis of interobserver and intraobserver agreement

BACKGROUND

Urine samples of known urothelial carcinoma were independently graded by 3 pathologists with (MS, MR) and without (AO) fellowship training in cytopathology using a modified version of the 2004 2-tiered World Health Organization classification system. By measuring interobserver and intraobserver agreement among pathologists, compared with the gold standard of biopsy/resection, specimen accuracy and reproducibility of grading in urine was determined.

METHODS

44 urine cytology samples were graded as low or high-grade by 3 pathologists with a 2-3 week interval between grading. Pathologists were blinded to their and others' grades and histologic diagnoses. Coefficient kappa was used to measure interobserver and intraobserver agreement among pathologists. Accuracy was measured by percentage agreement with the biopsy/resection separately for each pathologist, and for all pathologists and occasions combined.

RESULTS

The overall accuracy was 77% (95% C.I., 72%-82%). Pathologist AO was significantly more accurate than MR on occasion 1 (p = 0.006) and 2 (p = 0.039). No other significant differences were found among the observers. Interobserver agreement using coefficient kappa was unacceptably low, with all but one of the kappa value being less than 0.40, the cutoff for a "fair" degree of agreement. Intraobserver agreement, as measured by coefficient kappa, was adequate.

CONCLUSIONS

Our study underscores the lack of precision and subjective nature of grading urothelial carcinoma on urine samples. There was poor inter- and intraobserver agreement among pathologists despite fellowship training in cytopathology. Clinicians and cytopathologists should be mindful of this pitfall and avoid grading urothelial carcinoma on urine samples, especially since grading may impact patient management.

A multi-analyte assay for the non-invasive detection of bladder cancer

Accurate urinary assays for bladder cancer (BCa) detection would benefit both patients and healthcare systems. Through genomic and proteomic profiling of urine components, we have previously identified a panel of biomarkers that can outperform current urine-based biomarkers for the non-invasive detection of BCa. Herein, we report the diagnostic utility of various multivariate combinations of these biomarkers. We performed a case-controlled validation study in which voided urines from 127 patients (64 tumor bearing subjects) were analyzed. The urinary concentrations of 14 biomarkers (IL-8, MMP-9, MMP-10, SDC1, CCL18, PAI-1, CD44, VEGF, ANG, CA9, A1AT, OPN, PTX3, and APOE) were assessed by enzyme-linked immunosorbent assay (ELISA). Diagnostic performance of each biomarker and multivariate models were compared using receiver operating characteristic curves and the chi-square test. An 8-biomarker model achieved the most accurate BCa diagnosis (sensitivity 92%, specificity 97%), but a combination of 3 of the 8 biomarkers (IL-8, VEGF, and APOE) was also highly accurate (sensitivity 90%, specificity 97%). For comparison, the commercial BTA-Trak ELISA test achieved a sensitivity of 79% and a specificity of 83%, and voided urine cytology detected only 33% of BCa cases in the same cohort. These datashow that a multivariate urine-based assay can markedly improve the accuracy of non-invasive BCa detection. Further validation studies are under way to investigate the clinical utility of this panel of biomarkers for BCa diagnosis and disease monitoring.

NMP-22, urinary cytology, and cystoscopy: a 1 year comparison study

INTRODUCTION

Bladder cancer diagnosis and surveillance is costly and frequent. Urinary cytology is used with cystoscopy in the diagnosis and surveillance of bladder cancer with little evidence to support this practice. Nuclear Matrix Protein-22 (NMP-22) is a marker of urothelial cell death and is elevated in the urine of patients with bladder cancer. Our study compares the performance of NMP-22, urinary cytology and office cystoscopy when utilized in a Veteran Affairs urology practice for 1 year.

MATERIALS AND METHODS

A total of 391 consecutive office cystoscopy procedures performed over 1 year were included in the study. NMP-22 and cytology were performed on the urine specimens of patients presenting for cystoscopy. Tumor resection/bladder biopsy was performed when cystoscopy, NMP-22 or urinary cytology were abnormal.

RESULTS

Cystoscopy, NMP-22, and urinary cytology data were available in 351 encounters and 69 tumor resections were performed. Urothelial carcinoma bladder (UCB) was identified in 37 bladder specimens. NMP-22, urinary cytology and cystoscopy demonstrated sensitivity and specificity of (51%/96%), (35%/97%), and (92%/88%), respectively. NMP-22 cost $8,750 in the study group and urinary cytology cost $52,500 in the same group.

CONCLUSIONS

This study demonstrates cystoscopy was the most sensitive test in the diagnosis of UCB. NMP-22 had a higher sensitivity than urinary cytology and similar specificity to cytology. Additional urinary marker testing has a limited role in the management of bladder cancer in the office setting. When adjunct testing is desired in the diagnosis and surveillance of bladder cancer, NMP-22 is a cost effective alternative to urinary cytology.

[Changes of the state of rat kidneys under guerin carcinoma development and use of cytostatics]

It was shown that development of the Guerin carcinoma and introduction of cisplatin led to the damage of the kidneys of rats that was confirmed by a relative increase of weight, proteinuria, change of gamma-glutamyl transpeptidase and lactate dehydrogenase activity in the urea and tissue homogenates of the kidneys, by a decrease of relative reabsorption and glomerular filtration. Introduction of nanoliposomal forms of the rhenium cluster compounds led to normalization of above mentioned diagnostic indexes and to reduction of the toxic cisplatin influence that was confirmed by biochemical and morphological investigations.

Vascular endothelial growth factor, carbonic anhydrase 9, and angiogenin as urinary biomarkers for bladder cancer detection

OBJECTIVE

To investigate whether elevated urinary levels of vascular endothelial growth factor (VEGF), carbonic anhydrase 9 (CA9), and angiogenin are associated with bladder cancer (BCa).

METHODS

This was a case-control study in which voided urine samples from 127 patients (63 control subjects and 64 patients with BCa) were analyzed. The urinary concentrations of VEGF, CA9, angiogenin, and bladder tumor antigen (BTA) were assessed using enzyme-linked immunosorbent assays. We used the area under the curve of receiver operating characteristic curves to determine the ability of VEGF, CA9, and angiogenin to detect BCa in voided urine samples. Data were also compared with the findings from a commercial enzyme-linked immunosorbent assay-based BCa detection assay (BTA-Trak). The sensitivity, specificity, and positive and negative predictive values were calculated.

RESULTS

The urinary concentrations of VEGF, CA9, angiogenin, and BTA were significantly elevated in those with BCa. VEGF was the most accurate urinary biomarker (area under the curve 0.886, 95% confidence interval 0.8301-0.9418). Furthermore, multivariate regression analysis highlighted VEGF (odds ratio 5.90, 95% confidence interval 2.60-13.40, P < .0001) as an independent variable. The sensitivity and specificity for VEGF (83% sensitivity and 87% specificity) outperformed those for BTA (80% sensitivity and 84% specificity).

CONCLUSION

VEGF could be a valuable addition to voided urine sample analysis for the detection of BCa. Larger, prospective studies are needed to determine the clinical utility of urinary VEGF and angiogenin as biomarkers in the noninvasive evaluation of patients with BCa.

Daily urine iodine excretion while consuming a low-iodine diet in preparation for radioactive iodine therapy in a high iodine intake area

OBJECTIVE

Recommended durations of low-iodine diet (LID) in preparation for radioactive iodine therapy (RAIT) vary among major guidelines and are important for patients in areas where iodine intake is high. The aim of this study was to investigate daily changes in urine iodine excretion after starting a LID.

DESIGN

The daily iodine/creatinine (I/Cr) ratios and simple iodine concentration (simple I) of morning spot urine from 19 patients with differentiated thyroid carcinoma were measured for 2 weeks from the start of LID for RAIT preparation. We set the cut-off of I/Cr and simple I for poor LID preparation at >66·2 μg/gCr and >150 μg/l, respectively. The day when daily I/Cr or simple I became equal to or below the cut-off both by 95% CI and 90th percentile was defined as the end-point for the appropriate duration of LID for RAIT.

RESULTS

On day 6 of LID, the I/Cr ratio decreased below the cut-off (≤66·2 μg/gCr) both by 95% CI (0-60·8) and by 90th percentile (51·9). Simple I reached the cut-off (≤150 μg/l) on day 3 by both parameters (95%CI: 2·3-90·5; 90th percentile: 126·5). The morning spot-urine I/Cr and simple I on day 7 and day 14 were significantly lower than on day 0 (P < 0·05).

CONCLUSIONS

One week of a strict LID is enough to decrease the level of urine iodine excretion in preparation for RAIT even in high iodine intake areas. These results provide essential data for future outcome studies regarding LID preparation for RAIT.

Does anastrozole affect bone resorption similarly in early and late postmenopausal women?

The aim of this study was to determine whether the bone-resorption response to anastrozole differed according to initial patient age in postmenopausal women with breast cancer in a cross-sectional study. Second-morning void urines were collected for measurement of urinary cross-linked N-telopeptide of type I collagen (uNTx, corrected for creatinine and log-transformed) from postmenopausal women, 99 with breast cancer on anastrozole (ABC), 88 with newly diagnosed breast cancer (NDBC), and 137 community-dwelling healthy control (HC) women. Bone mineral density (BMD) was also measured at the lumbar spine (LS, L2-L4) and the femoral neck (FN) in the ABC group. uNTx (nanomole bone collagen equivalents/millimole creatinine) levels increased with age in HC subjects. In patients <70 years, anastrozole treatment led to a significant increase in uNTx compared with age-related HC subjects (1.74 vs. 1.55, P < 0.005). Patients >70 years showed no such increase compared to HC (1.72 vs. 1.69, nonsignificant); however, NDBC women >70 years had uNTx levels significantly lower than HC women (1.59 vs. 1.69, P < 0.05). There was no difference in uNTx levels above and below the age of 70 years in NDBC women (1.56 vs. 1.59, nonsignificant). ABC women were more likely to have a positive LS BMD z score than age-matched controls. Anastrozole treatment increases bone turnover more in younger postmenopausal women with breast cancer than in older women compared to healthy controls. Higher LS BMD in ABC patients may help protect against fracture.

A computational method for prediction of excretory proteins and application to identification of gastric cancer markers in urine

A novel computational method for prediction of proteins excreted into urine is presented. The method is based on the identification of a list of distinguishing features between proteins found in the urine of healthy people and proteins deemed not to be urine excretory. These features are used to train a classifier to distinguish the two classes of proteins. When used in conjunction with information of which proteins are differentially expressed in diseased tissues of a specific type versus control tissues, this method can be used to predict potential urine markers for the disease. Here we report the detailed algorithm of this method and an application to identification of urine markers for gastric cancer. The performance of the trained classifier on 163 proteins was experimentally validated using antibody arrays, achieving >80% true positive rate. By applying the classifier on differentially expressed genes in gastric cancer vs normal gastric tissues, it was found that endothelial lipase (EL) was substantially suppressed in the urine samples of 21 gastric cancer patients versus 21 healthy individuals. Overall, we have demonstrated that our predictor for urine excretory proteins is highly effective and could potentially serve as a powerful tool in searches for disease biomarkers in urine in general.

[Value of fluorescence in situ hybridization of urine exfoliative cells in diagnosis of urinary bladder neoplasms]

OBJECTIVE

To investigate the value of fluorescence in situ hybridization (FISH) examination of urine exfoliative cells in the diagnosis of urinary bladder neoplasms.

METHODS

The urine samples were collected from 100 patients with suspected urinary bladder neoplasms and 20 normal control subjects. Both FISH examination and cytology study of urine exfoliative cells were conducted with each sample. The specificity and sensitivity of FISH and cytology were analyzed on the basis of bladder biopsy histology.

RESULTS

The sensitivity of FISH examination of bladder malignant tumor was 93.5% (87/93), which was much higher than that of cytology (49.5%, 46/93). Biopsies confirmed 88 cases of urothelial carcinoma among the 100 suspected patients, with 46 high grade tumors and 42 low grade tumors; 30 cases of high stage (T(2-4)) and 58 cases of low stage (T(a-1)). The sensitivity of FISH examination of urothelial carcinoma was 94.3%, which was much higher than that of cytology (52.3%). FISH examination was significantly more sensitive than cytology for low grade and low stage urothelial carcinoma, as well as for rare non-urothelial malignancies (P < 0.05). The specificity of FISH and cytology of bladder malignancies was 92.6% (25/27) and 96.3% (26/27), for urothelial carcinoma was 81.3% (26/32) and 96.9% (31/32), respectively.

CONCLUSION

FISH shows high sensitivity and relatively high specificity for the detection of urinary bladder neoplasms, especially for the diagnosis of low grade urothelial carcinoma and non-urothelial malignancies, which were difficult to be detected by cytology.

Lack of association between urinary iodine excretion and successful thyroid ablation in thyroid cancer patients

BACKGROUND

Low-iodine diet is prescribed before (131)I administration in patients with differentiated thyroid cancer, although no study has properly quantified its clinical benefit.

OBJECTIVE

Our study aimed to evaluate the association between urinary iodine excretion (UIE) and (131)I ablation by correlating UIE with the rate of successful ablation.

PATIENTS

We retrospectively studied 201 differentiated thyroid cancer patients who had received (131)I therapy and posttherapy whole-body scan (WBS) for remnant ablation after either thyroid hormone withdrawal (THW group, n = 125) or recombinant human TSH (rhTSH group, n = 76). The outcome of thyroid ablation was assessed using two different criteria: no visible uptake at control WBS 8-12 months after ablation or no visible uptake plus undetectable stimulated serum thyroglobulin (Tg).

RESULTS

According to the criterion of no visible uptake, 84.6% of the patients were successfully ablated, with no significant difference between THW and rhTSH groups. Mean UIE at the time of ablation was 132 +/- 160 microg/liter, not significantly different between patients of the THW and rhTSH groups. There was no significant difference in UIE between ablated or nonablated patients both in the whole group and the rhTSH or THW groups. According to the criterion of no visible uptake plus undetectable stimulated serum Tg (in anti-Tg negative patients) at control WBS 8-12 months after ablation, UIE was not significantly different in ablated and nonablated patients.

CONCLUSIONS

Our study indicates that the body iodine content is not an important determinant of thyroid ablation, when preparing the patients with either THW or rhTSH.

Unexpected effect of furosemide on radioiodine urinary excretion in patients with differentiated thyroid carcinomas treated with iodine 131

BACKGROUND

In patients receiving (131)I for therapeutic purposes, diuretics are frequently used in an attempt to accelerate elimination of unbound radioiodine, reduce its adverse effects, and shorten the hospital stay. The aims of our study were to investigate the influence of furosemide therapy on urinary excretion of (131)I in patients with differentiated thyroid cancer (DTC), referred to radioiodine ablation after thyroidectomy, and to investigate whether diuretics are useful in daily practice in patients with DTC.

METHODS

Forty-three patients with DTC who had normal renal function and low (131)I uptake in cervical region (3.55 +/- 3.45%) were included in this study. The furosemide (20 mg) and potassium chloride (250 mg) were given orally to 23 patients 3 hours after the (131)I administration, and then q8h for 3 days. Twenty patients did not receive either furosemide or potassium chloride. After (131)I administration, the patients collected their urine for 3 days, and radioactivity of urine sample from each micturition was expressed as percentage of the administered dose. Radioactivity of blood samples was measured after 72 hours, and the values were corrected for decay of (131)I and expressed in relation to the administered dose. Initial whole-body measurement (immediately after (131)I administration) and the whole-body measurement after 72 hours were recorded for all patients. The 72-hour whole-body measurement was corrected for decay of (131)I, and expressed as a percentage of the initial whole-body measurement.

RESULTS

Urinary excretion of (131)I was significantly lower in the patients who were taking furosemide and potassium chloride compared with the control group. The whole-body measurements after 72 hours (13.22 +/- 6.55% vs. 8.24 +/- 3.39% of the initial; p < 0.01, respectively) and the blood radioactivity (34.66 +/- 24.84 vs. 11.64 +/- 8.32 cpm/mL per 1 MBq of administered (131)I, p < 0.01) were found to be unexpectedly higher in the patients who were taking furosemide and potassium chloride compared with the control group.

CONCLUSION

Our results demonstrated that furosemide given as an adjuvant medication in patients with DTC causes a significant decrease in urinary excretion of radioiodine and its higher blood concentration. Therefore, furosemide should not be recommended as an adjuvant therapy to radioiodine ablation in patients with DTC previously iodine depleted by low-iodine diet.

[Diagnosis of urothelial carcinoma by the general practitioner--significance of haematuria]

In general practice, physicians are confronted with a newly diagnosed bladder cancer patient less than once a year. The role of general practitioners is restricted to just the initial phase of diagnosis and sometimes to the final, palliative stage of the disease. The diagnostic phase, as described in the guideline on urothelial carcinoma of the bladder, is hampered by the absence of clear signs and signals of bladder cancer. Painless gross haematuria is the most important clinical sign with a high predictive value, especially in older men. The value of microscopic haematuria is unclear and most patients with microscopic haematuria do not have a malignancy. Yet despite this, current guidelines still advise additional tests for all types of haematuria. However, we recommend that these patients are not subjected to such tests until their added value has been demonstrated.

Role of urinary cathepsin B and L in the detection of bladder urothelial cell carcinoma

PURPOSE

We tested the hypothesis that urinary cathepsin B and L are associated with bladder cancer recurrence and invasiveness in patients with a history of nonmuscle invasive urothelial carcinoma of the bladder.

MATERIALS AND METHODS

Cathepsin B and L, and NMP22 were determined in the urine specimens of 188 consecutive subjects with a history of treated urothelial carcinoma of the bladder, 31 with noncancerous urological conditions and 10 healthy subjects. Cathepsin B and L were analyzed as continuous and categorical variables based on their quartile distribution.

RESULTS

Urinary cathepsin L was higher in the 122 patients with cystoscopic evidence of bladder tumor compared with levels in 107 with normal cystoscopy (median 5.9, IQR 4.4 vs 3.0, IQR 3.2, p <0.001). Higher levels of cathepsin L were associated with positive cytology assay results, higher NMP22 and T1 or greater pathological stage (each p <0.001). Area under the ROC curves of NMP22 and cathepsin L for bladder cancer detection were 0.704 (95% CI 0.637-0.772) and 0.793 (95% CI 0.736-0.850), respectively. On multivariate analysis cathepsin L, NMP22 and cytology were associated with invasive pathological stage (OR 1.29, 2.42 and 2.76, respectively, p </=0.002). Urinary cathepsin B was not associated with any outcome variables.

CONCLUSIONS

Urinary cathepsin L is an independent predictor of bladder cancer presence and invasiveness in patients with a history of urothelial carcinoma of the bladder. Further evaluation of this marker is necessary before its use as an adjunct to cystoscopy for urothelial carcinoma of the bladder.

Urinary bladder tumor markers

Bladder cancer is amenable to biomarker development because many tumor-associated molecules are secreted in urine. Tumor cells are shed in urine, and, therefore, tests that detect tumor cell-surface markers have also been developed to diagnose bladder cancer and monitor its recurrence. Several bladder tumor markers show higher sensitivity than cytology, but most have lower specificity. In addition to markers that use conventional technologies such as enzyme-linked immunosorbent assay, point-of-care devices, reverse transcriptase polymerase chain reaction, fluorescent in situ hybridization, and immunocytochemistry, proteomic and gene profiling approaches are being used to find new biomarkers to assist in the molecular profiling of bladder cancer. This review describes both new and well-studied bladder tumor markers.

Urinary phytoestrogen excretion of rats bearing methylnitrosourea-induced mammary carcinoma in response to treatment with 2-methoxyestradiol

The effect of treating mammary tumor-bearing rats with 2-methoxyestradiol (2-MeE2) on the urinary excretion of 12 phytoestrogens was investigated and compared with the changes in urinary excretion of estradiol metabolites. Alterations of excretion were registered for isoflavonoids, lignans and coumestans. However, due to large variations statistical significant differences were found only for two lignans, i.e. significant increases of enterodiol and matairesinol. Since the single components of phytoestrogens showed diverse alterations, excretions were expressed also by the ratio of total isoflavonoids to total lignans and compared with the estrogen ratios 2-hydroxyestrone to 16alpha-hydroxyestrone and A-ring to D-ring metabolites. The ratio of isoflavonoids to lignans was consistently decreased, whereas both ratios of estradiol metabolites were highly increased. The latter effect is probably due to demethylation of 2-methoxyestrone resulting in high catechol estrogen levels in urine. These results suggest that the high levels of catechol estrogens, produced by 2-MeE2 treatment, may have influenced the urinary excretion pattern of phytoestrogens.

Methylation profiling of urothelial carcinoma in bladder biopsy and urine

OBJECTIVE

To test DNA methylation profiling in detection of urothelial carcinoma in urine.

STUDY DESIGN

Thirty-three bladder specimens were analyzed for the DNA p16INK4a, RASSF1, APC, GSTP, E-Cad and CyclinD2 genes to determine if there is a difference in gene methylation between benign and malignant cases. Urine samples were analyzed in a feasibility study. Finally, methylation profiles of urine samples were obtained and compared with follow-up biopsy diagnoses.

RESULTS

We found methylated genes in 18% benign, 37% urothelial carcinoma in situ and 93% infiltrating urothelial carcinoma cases (p = 0.001). Methylation profiles from the 18 urine samples revealed a significantly higher prevalence of methylated genes in carcinoma cases than benign cases (100% vs. 50%, p = 0.025). We analyzed methylation profiles in 37 cytologically atypical urine samples with malignant or benign diagnosis on surgical follow-up andfound that only APC (55% in malignant vs. 0% in benign, p=0.025) and CyclinD2 were differentially methylated (35% in malignant vs. 0% in benign, p=0.2) while p14ARF, p16INK4a, RASSF1, GSTP and E-Cad had similar methylation profiles.

CONCLUSION

These results suggest that methylation of p14ARF, p16INK4a, RASSF1, GSTP and E-Cad genes may not accurately identify carcinoma, but methylated APC and CyclinD2 might be useful biomarkers for urothelial carcinoma in urine.

Cytopathology of extramedullary plasmacytoma of the bladder: a case report

BACKGROUND

Plasmacytoma of the bladder is an extremely rare tumor, with all information concerning this neoplasm derived from case reports. It can be a major diagnostic pitfall on both histology and urine cytology.

CASE

A 95-year-old woman presented with gross hematuria and a large bladder mass detected by ultrasound. The case was initially misdiagnosed as a high grade urothelial carcinoma. Since the urine cytology did not show the classical cytologic features of urothelial carcinoma, the histologic sections were reviewed and immunohistochemical staining performed. The final diagnosis was plasmacytoma of the bladder. Subsequently the patient underwent a skeletal survey and bone scan, which did not reveal any lesion suspicious for multiple myeloma. The patient was scheduled for radiotherapy.

CONCLUSION

In this case of bladder plasmacytoma, urine cytology provided a clue to the diagnosis. Urine cytology can be a diagnostic tool to help make this diagnosis in the case of poorly differentiated bladder neoplasm, especially in a patient with a known history of multiple myeloma.

Bone mineral density changes and bone turnover in thyroid carcinoma patients treated with supraphysiologic doses of thyroxine

The aim of this one-year prospective study was to determine whether longterm thyroxine treatment is a risk factor for elevated bone turnover, loss of bone mass and subsequent development of osteoporosis. Premenopausal women (N = 19), and men (N = 9) suffering from differentiated thyroid gland carcinoma in the mean age of 39.0 +/- 8.0 years and 41.8 +/- 10.0 years were investigated. All of them had undergone a total thyroidectomy and subsequent thyroxine therapy. The duration of the TSH-suppressive therapy prior to the the beginning of our study was 9.4 +/- 6.4 years in the female and 8.1 +/- 6.0 years in the male group. The prospective observation was performed by dual X-ray absorptiometry (DXA) at the spine and the femoral neck and by single-photon absorptiometry (SPA) at the distal radius. Laboratory testings included thyroid hormones T3, T4 and TSH, serum calcium, phosphate and PTH, and urinary calcium and phosphate from spontaneous and 24-hour urine samples. Markers of bone formation (osteocalcin, alkaline phosphatase and PICP) and resorption (Ca/Cr and ICTP) were determined. Statistically significant loss of bone mass was observed only on the distal radius in males (p<0.05). At the lumbar spine and femoral neck, only a minor bone loss was registered in a small number of patients. Almost 50 % of the females showed values above the reference range. In more than 30 % of the females, and smaller number of male patients, ICTP values ranged above the reference range, corresponding to elevated bone turnover. These two variables exhibited a slight correlation with bone density at the measured skeletal areas, mostly considering the male group. The results are a proof that accelerated bone turnover and subsequent bone loss occurs during TSH-suppressive thyroxine therapy. In future prospective studies a prolonged time of observation will be necessary, as well as to increase the number of studied patients, in order to better assess the relative risk of osteoporosis in patients undergoing TSH-suppressive treatment more precisely.

Evaluation of nuclear matrix protein-22 as a clinical diagnostic marker for bladder cancer

OBJECTIVES

To evaluate prospectively the prognostic power of urinary nuclear matrix protein-22 (NMP-22) for bladder cancer in Taiwanese screening and surveillance settings.

METHODS

Single voided urine samples were obtained from 68 healthy individuals, 303 patients with benign urothelial diseases, and 28 patients with urogenital tumors. The NMP-22 levels in the urine samples were measured using enzyme-linked immunosorbent assay methods.

RESULTS

The median NMP-22 level in healthy individuals and patients with benign and malignant disease was 5.9, 4.8, and 7.4 U/mL, respectively. The positive NMP-22 rate in healthy individuals and patients with benign and malignant disease was 4.4%, 17.2%, and 50%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value was 50%, 82.8%, 21.2%, and 94.7%, respectively, using 7.5 U/mL as the cutoff value.

CONCLUSIONS

Our data demonstrated that NMP-22 is not a good diagnostic tool for screening or follow-up surveillance of bladder cancer owing to its low sensitivity and positive predictive value. Nevertheless, it could be adopted as a tool to rule out the possibility or risk of developing bladder cancer because of its high negative predictive value in our study.

ProteinChip technology reveals distinctive protein expression profiles in the urine of bladder cancer patients

OBJECTIVE

Since accurate biomarkers for the early diagnosis or individual prognosis of the bladder carcinoma are still not available, we used the ProteinChip technology, to search for discriminating protein expressions associated with this cancer and its subtypes.

METHODS

A training set consisting of 30 archival urine samples from bladder carcinoma patients and 30 urinary samples from healthy volunteers, was analyzed via ProteinChip technology and computer based data mining. Mass clusters of differentially expressed proteins were verified by a second set (test set) comprising 21 bladder carcinoma urine samples and 21 non-tumor urinary samples. Expression differences between carcinoma subtype sample groups of the initial training set were assessed by a trend test.

RESULTS

Bladder carcinoma was segregated from control with a sensitivity and specificity of 80% and 90 to 97% in the trainings set, as well as 52 to 57% and 57 to 62% in the test set, respectively. Segregation of pooled tumor stages pT2-pT3 from stages pT1 and pTa was possible at the 53.3 kDa cluster of the CM10-chip array data derived rule base.

CONCLUSION

ProteinChip technology together with adapted computer based data mining tools are useful for the rapid establishment of potential protein biomarkers.

Use of mailed urine specimens in diagnosing urothelial carcinoma by cytology and DNA image analysis

OBJECTIVE

To evaluate the usefulness of urine specimens collected via a mailer system and analyzed by cytology and DNA ploidy for the detection of urothelial carcinoma (UC).

STUDY DESIGN

We retrospectively reviewed the diagnoses of 91 mailed urine specimens received from 72 patients, 67% of whom had a history of UC. The specimens were fixed in an equal volume of 50% ethanol solution before being mailed. The cytologic findings were interpreted in conjunction with DNA ploidy image analysis. We compared these initial diagnoses with those of follow-up examinations, including biopsies, cystoscopic findings and urinary cytology/DNA ploidy analyses. In addition, to examine the quality of the mailed samples, 3 cytopathologists performed a blinded assessment of cytologic slides of 20 mailed and 17 fresh urinary samples for bacterial overgrowth, urothelial degeneration, and presence of proteinaceous material and crystals.

RESULTS

Follow-up was available for 68 of the 91 mailed specimens. The sensitivity for detecting UC using mailed urine specimens that were analyzed by both cytology and DNA ploidy was 61%, while specificity was 92%. The levels of bacterial overgrowth and urothelial degeneration in the mailed specimens were not significantly greater than in the fresh specimens (p>0.05). The levels of proteinaceous material and crystals were significantly higher in the mailed specimens (p<0.05).

CONCLUSION

The results of combined cytology and DNA ploidy image analysis by using mailed urine samples were comparable to those of fresh urine specimens for the detection of UC reported in previous publications. The increase in crystals and proteinaceous material did not impede diagnostic interpretation. The mailing system is a reliable and convenient method of monitoring and triaging patients with UC or related symptoms.

[Early diagnosis of bladder carcinoma]

Asymptomatic erythrocyturia is an early symptom of urinary tracts and kidney diseases, including bladder carcinoma. The aim of the research was to compare the diagnostic validity of the cytological urine analysis and the DNA flow cytometry in detecting cancer cells in urine and bladder washings, taken from patients with asymptomatic erythrocyturia, as an early symptom of the bladder carcinoma in situ. The research was conducted on a group of 48 patients (32 male, 16 female, aged 28-55) with asymptomatic erythrocyturia, caused, in 16 cases, by bladder carcinoma in situ, in 18 cases, by bladder carcinoma in situ with urinary tracts infection, and in 14 cases, by the infection alone. Flow cytomery showed a higher sensitivity and a higher negative prediction value in detecting cancer cells in bladder washings. Flow cytometry analysis of DNA and phase S is used for detecting early disturbances in the cell cycle which result in aneuploidia, which is impossible to detect in cytological analysis. However peculiarity and positive prediction value were the same (100%) in both methods. On the basis of the research it has been proved that asymptomatic erythrocyturia classifies patients for further, in-depth diagnostic examination for the presence of bladder carcinoma in situ. Furthermore, morning urine and bladder washings analysis, which are non-intrusive tests, are an outstanding diagnostic material for screening for this disease. Detecting aneuploidia with flow cytometry can be an early-detection screening test for bladder carcinoma, while the cytological tests should still be used for confirming the diagnosis.

Radiolabeling, biodistribution, and dosimetry of (123)I-mAb 14C5: a new mAb for radioimmunodetection of tumor growth and metastasis in vivo

This study reports on the in vitro evaluation, biodistribution, and dosimetry of (123)I-labeled monoclonal antibody (mAb) 14C5, a new antibody-based agent proposed for radioimmunodetection of tumor growth and metastasis in vivo.

METHODS

(123)I-mAb 14C5 was prepared by direct iodination and tested for stability in vitro. Binding assays were performed on human SK-BR-3 and HeLa carcinoma cells to investigate the antigen expression, antibody affinity, and kinetics of tracer binding. For the biodistribution and dosimetry study, 3- to 4-wk-old NMRI mice were injected intravenously with (123)I-mAb 14C5 (148.0 +/- 7.4 kBq per mouse) and killed at preset time intervals. Organs, blood, urine, and feces were counted for radioactivity uptake, and the data were expressed as the percentage injected dose per gram tissue (%ID/g tissue) or %ID. The MIRDOSE3.0 program was applied to extrapolate the estimated absorbed radiation doses for various organs to the human reference adult.

RESULTS

(123)I-mAb 14C5 was obtained in radiochemical yields of 85.0% +/- 2.5% and radiochemical purities were >97%. The iodinated antibody demonstrated good in vitro stability with 93.6% +/- 0.1% of (123)I-mAb 14C5 remaining intact at 24 h after radiolabeling. (123)I-mAb 14C5 bound to SK-BR-3 cells (dissociation constant [K(d)] approximately 0.85 +/- 0.17 nmol/L) and HeLa cells (K(d) approximately 1.71 +/- 0.17 nmol/L) with nanomolar affinity and high specificity, whereas both cell types exhibited a high CA14C5 antigen expression (maximum number of binding sites [B(max)] = 40.6 +/- 5.2 and 57.1 +/- 9.6 pmol/L, respectively). In mice, (123)I-mAb 14C5 accumulated primarily in lungs (20.4 %ID/g), liver (15.1 %ID/g), and kidneys (11.1 %ID/g) within 5 min after injection. A delayed uptake was observed in stomach (12.8 %ID/g) and urinary bladder (8.7 %ID/g) at 3 and 6 h, respectively, after injection. Radioactivity clearance was predominantly urinary, with 44.9 +/- 4.5 %ID excreted during the initial 48 h after administration (cumulative amount). The highest absorbed radiation doses determined for the human reference adult were received by the urinary bladder wall (0.1200-0.1210 mGy/MBq), liver (0.0137-0.0274 mGy/MBq), uterus (0.0196-0.0207 mGy/MBq), and lower large intestine wall (0.0139-0.0258 mGy/MBq). The average effective dose resulting from a single (123)I-mAb 14C5 injection was estimated to be 0.017-0.022 mSv/MBq.

CONCLUSION

(123)I-mAb 14C5 shows good in vitro biologic activity and favorable biodistribution properties for imaging carcinomas of different origin and provides an acceptable radiation dose to the patient.

The nested variant of urothelial carcinoma: clinicopathology of 2 cases

The nested variant of urothelial carcinoma is a recently described bladder tumor entity with a rare incidence. Two cases of this disease are presented in this report; the patients in both cases were elderly men, with a predominant involvement of the trigone region. Histologically, the tumor cells were arranged in ill-defined nests and had low-grade nuclear features. Both cases had a diffusely infiltrating growth pattern with widespread local disease at cystectomy. Strong immunohistochemical staining for p63 in the neoplastic cells supports the urothelial cell nature of this neoplasm. High p53 and Ki-67 indices of this tumor correlate with the aggressiveness of this subtype.

Clinical study of urine NMP 22 (nuclear matrix protein 22) as a tumor marker in urinary epithelial cancer

The prognosis of urinary epithelial cancer is still poor, and early detection of this cancer is strongly desirable. The sensitivity of conventional urinary cytology is not satisfactory enough. It is hoped that a specific tumor marker will be established. In recent years, it has been reported that urine NMP 22 is very useful and that urine BFP is also relatively useful. We have now determined urine NMP22 and BFP and studied their clinical usefulness as a tumor marker. Using patients diagnosed with histologically confirmed urinary epithelial cancer as the subjects, we retrospectively studied the usefulness of NMP 22, BFP and cytology mainly with regard to the sensitivity (positivity rate), and also in relation to atypia, degree of infiltration and clinical course.

High levels of urinary midkine in various cancer patients

Midkine (MK) is a heparin-binding growth factor, which promotes growth, migration, and survival of various cells, and MK expression is increased in many human carcinomas. We determined the urinary MK level by enzyme-linked immunoassay. Taking 311pg/mg creatinine as a cut-off level, 70% of patients with various carcinomas (n=142) gave positive values, while only 5.5% of healthy volunteers (n=330) did. In case of gastric carcinoma, 17 out of 21 patients with stage 1 tumor were positive. Urinary MK levels are expected to become a convenient marker as an aid in detection of tumors.