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

Analytical validation of ONCURIA™ a multiplex bead-based immunoassay for the non-invasive bladder cancer detection

Background

The objective of our study was to assess the analytical performance of a multiplex assay (Oncuria™) to quantify protein biomarkers towards a bladder cancer associated diagnostic signature in voided urine.

Method

ology: Using Luminex xMAP technology, a custom immunoassay was developed to measure the concentrations of 10 urinary analytes (angiogenin, ANG; apolipoprotein E, APOE; alpha-1 antitrypsin, A1AT; carbonic anhydrase 9, CA9; interleukin 8, IL8; matrix metallopeptidase 9, MMP9; matrix metallopeptidase 10, MMP10; plasminogen activator inhibitor 1, PAI1; syndecan 1, SDC1; vascular endothelial growth factor, VEGF). Selectivity, sensitivity, specificity, precision, linearity, dynamic range, and detection threshold were assessed using recombinant proteins and human urine samples. Analytical variability with respect to batch size, run, day, operator, and interference were also evaluated.

Results

Analytical evaluation demonstrated a) all antigen cross-reactivity was noted to be <1% of the tested concentration, b) minimal detected dose ranged from 0.295 ​pg/mL in IL8 to 31.1 ​pg/mL in APOE, c) highly reproducible and accurate noting coefficient of variation (CV) and relative error (RE) values below 15% for all analytes and d) minimal interference. The assay can be completed in <5 ​h using as little as 150 ​μL of voided urine.

Conclusion

To our knowledge, this is the first multiplex bead-based immunoassay for the non-invasive detection of bladder cancer that has been analytically validated as a tool with the potential to help clinicians manage patients at risk of harboring bladder cancer.

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Cytology has changed little since its inception in 1947 and suffers from low detection sensitivity for bladder cancer.

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Oncuria™ is a multiplex bead-based immunoassay.

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Oncuria™ has limited antigen cross-reactivity and interference and favorable detected dose and reproducibility.

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Oncuria ™, an accurate multiplex detection assay for bladder cancer, can be performed on <200 ul of urine in <5 hrs.

A label-free immunosensor for the detection of nuclear matrix protein-22 based on a chrysanthemum-like Co-MOFs/CuAu NWs nanocomposite

In this study, a new, simple, and label-free electrochemical immunosensor was presented for the detection of nuclear matrix protein-22 (NMP-22). In order to accurately monitor very small amounts of NMP-22, it was advantageous to use highly efficient nanomaterials as signals. For this reason, we synthesized a chrysanthemum-like nanocomposite (Co-MOFs/CuAu NWs), using Co-based metal-organic frameworks (Co-MOFs) as carriers and copper gold nanowires (CuAu NWs) wrapped around their surface, which was applied for modifying a glassy carbon electrode (GCE). The Co-MOFs/CuAu NWs possessed outstanding catalytic capabilities, which served as signal materials and simultaneously carried the anti-NMP-22 antibody (Ab). When different concentrations of the NMP-22 antigen (Ag) were specifically attached to the immunosensor, the current responses decreased by varying degrees. The designed biosensor used the principle to establish a linear regression equation and achieve an accurate quantification of NMP-22. After optimization, the NMP-22 sensor exhibited a good linear response over a concentration range from 0.1 pg mL^-1 to 1 ng mL^-1, with a lower detection limit of 33 fg mL^-1 (based on S/N = 3). The proposed biosensor demonstrated the advantages of ultra-sensitivity, high specificity and acceptable reproducibility, suggesting that the proposed strategy has the potential for the quantification of NMP-22 in human urine samples. Moreover, the novel nanocomposite Co-MOFs/CuAu NWs are promising materials for electrochemical sensors to detect other biomolecules.

Validation of Urine-based Gene Classifiers for Detecting Bladder Cancer in a Chinese Study

Background: Current standard methods used to detect and monitor bladder cancer (BC) are invasive or have low sensitivity. We have previously reported in an international European study four non-invasive tests for BC diagnosis based on the gene expression patterns of urine.

Objective: to validate the tests in an independent Asian cohort.

Design, setting and participants: Prospective blinded study in which consecutive voided urine samples from BC patients and controls (n=520) were collected in the Fudan University Shanghai Cancer Center from 2014-2016. Gene expression values were quantified using TaqMan Arrays. The same cut-off as previously reported for discrimination between tumours and controls was used in this validation study.

Results and limitations: Finally, a total of 257 tumour and 132 control urine samples were analysed. We found a high accuracy for the four gene classifiers in this independent Asian set, the classifiers composed of 5 and 10 genes achieved the best sensitivity (80.54% and 81.32%, respectively) maintaining a high specificity (91.67% and 85.61%, respectively). Sensitivity of 5-gene (GS_D5) and 10-gene (GS_D10) expression classifiers in recurrent BC cases (78 and 79%, respectively) is comparable to that of primary BC cases (82%). Cytology and NMP22 identified 67% and 40%, respectively, of tumours that have been diagnosed with our tests. In addition, influence of each studied gene was analyzed and showed similar gene rank between Chinese and Caucasian population.

Conclusions: Our study proves that our non-invasive diagnostic BC tests can be reproduced in independent cohorts and in an external laboratory. All the four gene classifiers have shown equal or superior performance to the current gold standard in the present and previously reported validation studies. Consequently, they may be taken for consideration as molecular tests applicable to clinical practice in the management of BC.

Patient summary: Our gene classifiers achieve sensitivities up to 90% in HR NMIBC and MIBC patients, while this achievement is comparatively lower in LR NMIBC ones.

Sensitive Electrochemical Immunosensor for Detection of Nuclear Matrix Protein-22 based on NH2-SAPO-34 Supported Pd/Co Nanoparticles

A novel sandwich-type electrochemical immunosensor using the new amino group functionalized silicoaluminophosphates molecular sieves (NH₂-SAPO-34) supported Pd/Co nanoparticles (NH₂-SAPO-34-Pd/Co NPs) as labels for the detection of bladder cancer biomarker nuclear matrix protein-22 (NMP-22) was developed in this work. The reduced graphene oxide-NH (rGO-NH) with good conductivity and large surface area was used to immobilize primary antibody (Ab₁). Due to the excellent catalytic activity toward hydrogen peroxide, NH₂-SAPO-34-Pd/Co NPs were used as labels and immobilized secondary antibody (Ab₂) through adsorption capacity of Pd/Co NPs to protein. The immunosensor displayed a wide linear range (0.001–20 ng/mL) and low detection limit (0.33 pg/mL). Good reproducibility and stability have showed satisfying results in the analysis of clinical urine samples. This novel and ultrasensitive immunosensor may have the potential application in the detection of different tumor markers.

Clinical proteomic biomarkers: relevant issues on study design & technical considerations in biomarker development

Biomarker research is continuously expanding in the field of clinical proteomics. A combination of different proteomic-based methodologies can be applied depending on the specific clinical context of use. Moreover, current advancements in proteomic analytical platforms are leading to an expansion of biomarker candidates that can be identified. Specifically, mass spectrometric techniques could provide highly valuable tools for biomarker research. Ideally, these advances could provide with biomarkers that are clinically applicable for disease diagnosis and/ or prognosis. Unfortunately, in general the biomarker candidates fail to be implemented in clinical decision making. To improve on this current situation, a well-defined study design has to be established driven by a clear clinical need, while several checkpoints between the different phases of discovery, verification and validation have to be passed in order to increase the probability of establishing valid biomarkers. In this review, we summarize the technical proteomic platforms that are available along the different stages in the biomarker discovery pipeline, exemplified by clinical applications in the field of bladder cancer biomarker research.

Urinary biomarkers of bladder cancer: an update and future perspectives

Bladder cancer is one of the most prevalent cancers worldwide. Early detection of bladder tumors is critical for improved patient outcomes. The standard method for detection and surveillance of bladder tumors is cystoscopy with urinary cytology. Limitations of cystoscopy and urinary cytology have brought to light the need for more robust diagnostic assays. Ideally, such assays would be applicable to noninvasively obtained, voided urine, and be designed not only for diagnosis, but also for monitoring disease recurrence and response to therapy. Consequently, the development of a noninvasive urine-based assay would be of tremendous benefit to both patients and healthcare systems. This article reports some of the more prominent urine-based biomarkers reported in the literature. In addition, some new technologies that have been used to identify novel urinary biomarkers are highlighted.

Bladder cancer detection and monitoring: assessment of urine- and blood-based marker tests

Bladder cancer is one of the most prevalent cancers worldwide, but the treatment and management of this disease can be very successful if the disease is detected early. The development of molecular assays that could diagnose bladder cancer accurately, and at an early stage, would be a significant advance. Ideally, such molecular assays would be applicable to non-invasively obtained body fluids, and be designed not only for diagnosis but also for monitoring disease recurrence and response to treatment. In this article, we assess the performance of current diagnostic assays for bladder cancer and discuss some of the emerging biomarkers that could be developed to augment current bladder cancer detection strategies.

Molecular diagnostic trends in urological cancer: biomarkers for non-invasive diagnosis

The early detection of urological cancers is pivotal for successful patient treatment and management. The development of molecular assays that can diagnose disease accurately, or that can augment current methods of evaluation, would be a significant advance. Ideally, such molecular assays would be applicable to non-invasively obtained body fluids, enabling not only diagnosis of at risk patients, but also asymptomatic screening, monitoring disease recurrence and response to treatment. The advent of advanced proteomics and genomics technologies and associated bioinformatics development is bringing these goals into focus. In this article we will discuss the promise of biomarkers in urinalysis for the detection and clinical evaluation of the major urological cancers, including bladder, kidney and prostate. The development of urine-based tests to detect urological cancers would be of tremendous benefit to both patients and the healthcare system.

Biomarkers for detection and surveillance of bladder cancer

INTRODUCTION

Bladder cancer is the fourth most common cancer in men and the ninth most common cancer in women in Canada. Early detection of tumours is essential for improved prognosis and long-term survival. The standard method for detection and surveillance is cystoscopy together with urine cytology. Cystoscopy is relatively sensitive but is expensive and invasive. Urinary cytology is a noninvasive method that has poor sensitivity but high specificity; it is relied on for the detection of carcinoma in situ. Currently, several urinary-based bladder tumour biomarkers with USFDA/Health Canada approval are available commercially, but none have been widely adopted by urologists despite their offering high sensitivity and/or specificity. We present here a review of recent studies evaluating 7 commercial biomarker assays for the detection and/or surveillance of bladder cancer.

RESULTS

SENSITIVITY AND SPECIFICITY RANGES, RESPECTIVELY, FOR EACH MARKER WERE REPORTED AS FOLLOWS: BTA Stat (Polymedco), 52.5%-78.0% and 69.0%-87.1%; BTA Trak (Polymedco), 51%-100% and 73%-92.5%; cytology, 12.1%-84.6% and 78.0%-100%; hematuria dipstick, 47.0%-92.6% and 51.0%-84.0%; NMP22 Bladder Cancer Test (Matritech), 34.6%-100% and 60.0%-95.0%; NMP22 BladderChek (Matritech), 49.5%-65.0% and 40.0%-89.8%; ImmunoCyt/uCyt+ (DiagnoCure), 63.3%-84.9% and 62.0%-78.1%; ImmunoCyt/uCyt+ and cytology, 81.0%-89.3% and 61.0%-77.7%; and UroVysion (Abbott Molecular)/florescence in situ hybridization, 68.6%-100% and 65.0%-96.0%.

CONCLUSION

We find that no currently available bladder cancer urinary marker is sensitive enough to eliminate the need for cystoscopy. In addition, cytology remains integral to the detection of occult cancer. However, owing to their relatively high sensitivities, these markers may be used to extend the period between cystoscopies in the surveillance of patients with transitional cell carcinoma. Further study is required to determine which markers, alone or in panel, would best accomplish this.

Urinary glycoprotein biomarker discovery for bladder cancer detection using LC/MS-MS and label-free quantification

BACKGROUND

Cancers of the urinary bladder are the fifth most commonly diagnosed malignancy in the United States. Early clinical diagnosis of bladder cancer remains a major challenge, and the development of noninvasive methods for detection and surveillance is desirable for both patients and health care providers.

APPROACH

To identify urinary proteins with potential clinical utility, we enriched and profiled the glycoprotein component of urine samples by using a dual-lectin affinity chromatography and liquid chromatography/tandem mass spectrometry platform.

RESULTS

From a primary sample set obtained from 54 cancer patients and 46 controls, a total of 265 distinct glycoproteins were identified with high confidence, and changes in glycoprotein abundance between groups were quantified by a label-free spectral counting method. Validation of candidate biomarker alpha-1-antitrypsin (A1AT) for disease association was done on an independent set of 70 samples (35 cancer cases) by using an ELISA. Increased levels of urinary A1AT glycoprotein were indicative of the presence of bladder cancer (P < 0.0001) and augmented voided urine cytology results. A1AT detection classified bladder cancer patients with a sensitivity of 74% and specificity of 80%.

SUMMARY

The described strategy can enable higher resolution profiling of the proteome in biological fluids by reducing complexity. Application of glycoprotein enrichment provided novel candidates for further investigation as biomarkers for the noninvasive detection of bladder cancer.

Biomarkers in bladder cancer

Cancer biomarkers provide an opportunity to diagnose tumours earlier and with greater accuracy. They can also identify those patients most at risk of disease recurrence and predict which tumours will respond to different therapeutic approaches. Such biomarkers will be especially useful in the diagnosis and management of bladder cancer. At present, bladder tumours are diagnosed and followed-up using a combination of cystoscopic examination, cytology and histology. These are not only expensive, but also highly subjective investigations and reveal little about the underlying molecular characteristics of the tumour. In recent years numerous diagnostic and prognostic biomarkers of bladder cancer have been identified. Two separate approaches to biomarker discovery have been employed. The first is hypothesis-driven and focuses upon proteins involved in molecular pathways known to be implicated in tumorigenesis. An alternative approach has been to study the global expression of genes (so-called 'genomics') looking for characteristic signatures associated with disease outcomes. In this review we summarize the current state of biomarker development in this field, and examine why so few have made the successful transition into the clinic. Finally, we introduce a novel approach to biomarker development utilizing components of the DNA replication licensing machinery.

Proteomic strategies in bladder cancer: From tissue to fluid and back

We have applied protein expression profiling technologies in combination with immunohistochemistry, using fresh tissue and urine samples, to assess bladder cancer heterogeneity and prognosis as well as to generate protein markers for tumor progression and early diagnosis of the disease. Here, we review some selected lines of investigation and approaches undertaken by our laboratory, drawing on more than 15 years of experience in bladder cancer proteomics, to highlight a number of issues that may be useful for researchers entering the field. In particular, we address the identification of markers for bladder cancer progression and exemplify the potential of gel-based proteomic profiling of urine samples for the early detection of urothelial carcinomas. In addition, we provide a brief description of a novel and highly promising source of biomarkers, the tumor interstitial fluid (TIF) that perfuses the tumor microenvironment.

[Comparison of perioperative methylene blue-stained and permanent Papanicolaou-stained urine cytology to detect patients with high-grade urothelial cancer or the urinary bladder. Part 1]

INTRODUCTION

The aim of the study was to investigate whether intraoperative methylene blue-stained and permanent Papanicolaou-stained urine cytologies show comparable accuracy in detection of high-grade urothelial carcinoma.

PATIENTS AND METHODS

The study included 130 patients; 50 patients were without malignancy (25 follow-up, 25 with hematuria). In 80 patients transurethral resection due to urothelial carcinoma was performed. Per patient two cytology specimens were prepared: one immediate methylene blue-stained specimen, which was evaluated by the surgeon, and one Papanicolaou-stained permanent cytology slide, which was blinded and evaluated by one urologist.

RESULTS

Cytology results of all patients without malignancy were unsuspicious irrespective of the staining method. Of 80 patients with urothelial carcinoma, 50 showed a low-grade tumor. Sensitivity of tumor detection was 20 and 30% for methylene blue/Papanicolaou-stained slides, respectively. Among 30 patients with high-grade carcinoma, 10 were detected by methylene blue cytology and 30 by Papanicolaou-stained slides, corresponding to a sensitivity of 40 and 100%, respectively.

CONCLUSIONS

The results of standard Papanicolaou-stained urine cytology in the detection of clinically relevant high-grade urothelial carcinoma are excellent. The quality of cytological tumor detection by methylene blue-stained cytology made by different evaluators is insufficient in our opinion.

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.

Lack of Progress in Early Diagnosis of Bladder Cancer

OBJECTIVES

The stage of presentation of prostate cancer has changed dramatically in the past two decades, largely because of prostate-specific antigen screening and increased public awareness regarding the disease. Recently, strides have been made in the validation, development, and approval of bladder cancer (BC) markers. We sought to evaluate whether any stage migration has occurred for patients with BC during the same period.

METHODS

A total of 351 and 1262 patients underwent radical cystectomy and radical retropubic prostatectomy, respectively, between 1992 and 2005 by one surgeon. The patients were divided into two consecutive groups: group 1 (1992 to 1998) and group 2 (1999 to 2005). The baseline and pathologic characteristics of the patients were compared.

RESULTS

No differences were found in the clinical or pathologic staging between the two groups of patients undergoing radical cystectomy. The 5-year overall and disease-specific survival also was not different between the two groups. For patients with prostate cancer, those in group 2 presented at a younger age, with a lower prostate-specific antigen level, and had a lower clinical stage. Group 2 patients had a decrease in the incidence of extracapsular extension, a decreased tumor volume, and a decrease in the incidence of Gleason 8 to 10 tumors.

CONCLUSIONS

During two consecutive periods, our patients with prostate cancer presented with the cancer at an earlier stage and had more favorable pathologic features after radical retropubic prostatectomy. However, our patients with BC did not demonstrate any stage migration. Physicians need to be more aggressive in diagnosing BC, especially in patients at high risk of the disease. Risk factors must be emphasized, urine markers should be used in a screening strategy, and the indications for radical cystectomy should be liberalized.

Validation of the diagnostic value of NMP22 BladderChek test as a marker for bladder cancer by photodynamic diagnosis

OBJECTIVES

The aim of the present study was to validate the sensitivity and specificity of the new "point-of-care" NMP22 BladderChek test compared to photodynamic diagnosis (PDD).

METHODS

Voided urine samples from 100 patients with suspicion of bladder cancer were collected to perform the NMP22 BladderChek test and voided urinary cytology. The nuclear matrix protein 22 (NMP22) levels were measured by a lateral flow immunochromatographic qualitative assay, using 10 U/ml as the cut-off value. Subsequently patients underwent PDD, using 5-aminolevulinic acid or hexyl-aminolevulinate; previous bladder washings for cytology were collected. Sensitivity and specificity of the NMP22 BladderChek test were compared with cytology and PDD.

RESULTS

Forty of the 100 patients had urothelial malignancies (22 pTa, 4 pT1, 3 pT2, 9 carcinoma in situ, 2 pTx; 16 G1, 6 G2, 18 G3). The sensitivity was 65% for the NMP22 BladderChek test, 44% for voided cytology, 75% for washing cytology, and 93% for PDD. Specificity rates were 40%, 78%, 62%, and 43%, respectively. Positive predictive values were 0.42, 0.58, 0.53, and 0.52 and the negative predictive values 0.63, 0.68, 0.82, and 0.9, respectively.

CONCLUSIONS

The results demonstrate that the NMP22 BladderChek is an easily applied test, giving diagnostic findings within 30 min. However, validated by the highly sensitive PDD, the NMP22 BladderChek test demonstrates poor specificity and sensitivity and, therefore, cannot be recommended for screening or surveillance in daily clinical routine use. Further studies with careful patient selection are necessary to identify the patient population that might benefit from the NMP22 BladderChek test.