DNA–based molecular cytology for bladder cancer surveillance

Clinical practice guidelines for molecular tumor marker, 2nd edition review part 2

In recent years, rapid advancement in gene/protein analysis technology has resulted in target molecule identification that may be useful in cancer treatment. Therefore, "Clinical Practice Guidelines for Molecular Tumor Marker, Second Edition" was published in Japan in September 2021. These guidelines were established to align the clinical usefulness of external diagnostic products with the evaluation criteria of the Pharmaceuticals and Medical Devices Agency. The guidelines were scoped for each tumor, and a clinical questionnaire was developed based on a serious clinical problem. This guideline was based on a careful review of the evidence obtained through a literature search, and recommendations were identified following the recommended grades of the Medical Information Network Distribution Services (Minds). Therefore, this guideline can be a tool for cancer treatment in clinical practice. We have already reported the review portion of "Clinical Practice Guidelines for Molecular Tumor Marker, Second Edition" as Part 1. Here, we present the English version of each part of the Clinical Practice Guidelines for Molecular Tumor Marker, Second Edition.

A comprehensive comparison of fluorescence in situ hybridization and cytology for the detection of upper urinary tract urothelial carcinoma: A systematic review and meta-analysis

OBJECTIVE

To compare the relative effectiveness of fluorescence in situ hybridization (FISH) and cytology in diagnosing upper urinary tract urothelial carcinoma (UUT-UC) and to evaluate the advantages and potential deficiencies of FISH analysis.

METHODS

We performed a complete systematic review based on studies from PubMed/Medline, Embase, Web of Science, Ovid, Web of Knowledge, and Cochrane Library. We identified 2031 patients with strict criteria in 14 individual studies between January 2005 to November 2017 in accordance to preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines, we summarized the test performance using bivariate random effects models.

RESULTS

FISH was superior to cytology in terms of pooled sensitivities (84.0%, 95% confidence interval [CI] 74.4-90.5% vs 40.0%, 95% CI 33.6-46.7%). FISH and cytology were similar to each other in terms of pooled specificities, which were 89.5% (95% CI 85.3-92.6%) for FISH and 95.9% (95% CI 91.2-98.1%) for cytology.

CONCLUSION

We confirm the superiority of FISH over cytology in terms of sensitivity and find similar diagnostic outcomes between them based on systematic analysis. Therefore, we demonstrate that FISH is extremely sensitive while still very reliable with a relatively low error rate for diagnosing UUT-UC.

A prospective comparison of UroVysion FISH and urine cytology in bladder cancer detection

Background

UroVysion fluorescence in situ hybridization (uFISH) was reported to have superior sensitivity to urine cytology. However uFISH studies are limited by varying definitions of what is considered a positive result, absence of histopathology and small sample size. The aim of our study was to better determine the performance characteristics of uFISH and urine cytology by overcoming some of the deficiencies of the current literature.

Methods

Intraoperative bladder wash cytology and uFISH were collected prospectively on all patients. Strict definitions for positivity of uFISH and cytology were determined before initiating the study. A re-review of false-negative uFISH specimens was performed to analyze potential sources of error. Sixteen bladder tumors embedded in paraffin were analyzed by uFISH and compared with the result in the urine.

Results

One hundred and twenty-nine specimens were analyzed. Sensitivity was 67% and 69% (p = 0.54); specificity was 72% and 76% (p = 1.0), for uFISH and cytology, respectively. Thirty-two false negative uFISH samples were re-reviewed. Low grade tumors often showed cells with abnormal morphology and patchy DAPI staining but diploid chromosomal counts and a few high grade tumors had tetraploid counts but less than needed to interpret uFISH as positive. uFISH study of the tumors revealed three categories; positive in both tumor and urine (9), negative in both tumor and urine (5) and positive in tumor but negative in urine (2).

Conclusion

In a pathologically-confirmed analysis of bladder washed urine specimens, uFISH does not outperform urine cytology in cancer detection.

FISH analysis of washing urine from the upper urinary tract for the detection of urothelial cancers

INTRODUCTION

To evaluate FISH analysis of washing urine from the upper urinary tract (UUT) in comparison with cytology (Cyt) for the detection of urothelial cancers.

PATIENTS AND METHODS

In 82 patients with symptoms or abnormalities of the UUT sampling of washing urine for FISH and Cyt and a stepwise diagnostic work-up (e.g. retrograde ureteropyelography, ureterorenoscopy and endoscopic biopsy) were performed. In case of endoscopically and/or histologically proven malignancy patients either underwent nephroureterectomy, partial ureterectomy or local treatment. Sensitivity and specificity for FISH and Cyt as well as its combination were determined.

RESULTS

Urothelial cancer of the UUT was detected in 20 patients. Eleven patients underwent nephroureterectomy, six partial ureterectomy and three endoscopic tumour treatment. This revealed nine pTa, three pT1 and seven muscle-invasive tumours. Twelve tumours were classified as low and seven as high-grade tumours. In one patient with a macroscopic unequivocal finding of tumour, endoscopic laser ablation without histologic confirmation was performed. FISH was evaluable in 76 patients and detected 16 tumours with a sensitivity and specificity of 84.2 and 91.1 %, respectively. Cyt was performed in 79 and was evaluable in 78 patients. It detected ten tumours with a sensitivity and specificity of 52.6 and 91.4 %, respectively. Cyt and FISH together detected 19 tumours with (sensitivity 100 % and specificity 83.6 %).

CONCLUSION

FISH was more sensitive than and equally specific to Cyt in the detection of urothelial cancers of the UUT. Both markers in combination revealed the best sensitivity, making it a possible approach in future settings.

Fluorescence in situ hybridization and K-ras analyses improve diagnostic yield of endoscopic ultrasound-guided fine-needle aspiration of solid pancreatic masses

OBJECTIVES

Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is the main diagnostic modality for pancreatic mass lesions. However, cytology is often indeterminate, leading to repeat FNAs and delay in care. Here, we evaluate whether combining routine cytology with fluorescence in situ hybridization (FISH) and K-ras/p53 analyses improves diagnostic yield of pancreatic EUS-FNA.

METHODS

Fifty EUS-FNAs of pancreatic masses in 46 patients were retrospectively analyzed. Mean follow-up was 68 months. Thirteen initial cytologic samples (26%) were benign, 23 malignant (46%), and 14 atypical (28%). We performed FISH for p16, p53, LPL, c-Myc, MALT1, topoisomerase 2/human epidermal growth factor receptor 2, and EGFR, as well as K-ras/p53 mutational analyses.

RESULTS

On final diagnosis, 11 (79%) of atypical FNAs were malignant, and 3 benign (21%). Fluorescence in situ hybridization was negative in all benign and all atypical samples with final benign diagnosis. Fluorescence in situ hybridization plus K-ras analysis correctly identified 60% of atypical FNAs with final malignant diagnosis. Combination of routine cytology with positive FISH and K-ras analyses yielded 87.9% sensitivity, 93.8% specificity, 96.7% positive predictive value, 78.9% negative predictive value, and 89.8% accuracy.

CONCLUSIONS

Combining routine cytology with FISH and K-ras analyses improves diagnostic yield of EUS-FNA of solid pancreatic masses. We propose to include these ancillary tests in the workup of atypical cytology from pancreatic EUS-FNA.

Clinical utility of fluorescence in situ hybridization for prediction of residual tumor after transurethral resection of bladder urothelial carcinoma

OBJECTIVES

To evaluate the use of a multiprobe fluorescence in situ hybridization (FISH) assay for predicting the residual tumor load after transurethral resection (TUR) of bladder urothelial carcinoma (UC).

METHODS

Voided urine specimens were collected from 125 consecutive patients with suspected UC who had been admitted for TUR. Of the 125 patients, 89 with UC diagnosed underwent a second procedure (repeated TUR or cystectomy) 4-6 weeks after the initial TUR and were included in the present study. Using the pathologic findings from the second procedure, the patients were divided into those with (n = 38) and those without (n = 51) residual tumor. Urine samples were taken both before and after the initial TUR. The multiprobe FISH assay was performed to detect aneuploidy of chromosomes 3, 7, and 17 and the loss of the 9p21 locus.

RESULTS

Before the first TUR, no significant difference was found in the FISH-positive percentage between those with and without residual tumor. After the first TUR, the FISH-positive percentage in those with residual tumor was significantly greater than in those without residual tumor (42.2% vs 17.6%, P = .003). Moreover, before and after the initial TUR, the percentage of conversion from FISH positive to FISH negative in those with residual tumor was significantly lower than in those without residual tumor (28.9% vs 58.9%, P < .001). No patients were observed with a FISH result of conversion from negative to positive in those with and without residual tumor after the initial TUR.

CONCLUSIONS

FISH appears to be useful for the prediction of the presence of the residual tumor load after TUR of bladder UC.

Multicolor FISH (UroVysion) facilitates follow-up of patients with high-grade urothelial carcinoma of the bladder

The aim of the present prospective study was to assess the diagnostic benefit of UroVysion (Vysis-Abbott Laboratories, Downers Grove, IL) in the follow-up of patients with a history of high-grade non-muscle-invasive urothelial carcinoma of the bladder (NMIBC). An unselected cohort of 25 patients with a history of high-grade NMIBC was prospectively followed up by office-based cystoscopy, cytology, and UroVysion in 210 events. The sensitivity and specificity for standard combined cystoscopy and cytology were 78% and 83%, respectively. UroVysion yielded a considerably higher detection rate with 94% and 93%, respectively. In 89% of the follow-up events of patients with a history of previous carcinoma in situ (CIS) and negative cystoscopy but a positive UroVysion finding, CIS recurrence was noticed within 5 months. UroVysion is a worthwhile approach in patients with previous CIS, a high risk for the development of CIS, or previous unequivocal cytology suggestive of CIS, especially during or shortly after instillation therapy.

Urinary fluorescence in situ hybridization assay for detecting urothelial carcinoma in Taiwanese patients

OBJECTIVES

To investigate the cytogenetic marker detected by fluorescence in situ hybridization (FISH; UroVysion, Vysis, Inc., Abbott Laboratories, Des Plaines, IL, USA) in the diagnosis of bladder cancer and upper tract urothelial carcinoma (UC) in Taiwanese patients, as FISH has been used in Western countries for detecting UC, but there are limited results in Asian populations.

PATIENTS AND METHODS

We analysed polyploidy of chromosome 3, 7, 17 and aneuploidy of chromosome 21, using uroepithelial cells collected at the first void or by instrumental extraction of urine, for bladder cancer, and shedding cells from the upper tract flushed by normal saline via ureteric catheterization or ureterorenoscopy. The criteria for positive tumour cells included three or more positive staining in two or more chromosomes showing polyploidy or <50% staining of the chromosome 9p21.

RESULTS

In all, 32 patients with bladder UC and 12 with upper tract UC were assessed. The overall sensitivity for bladder cancer by UroVysion was 96.8%. The sensitivity of the cytology test was 36% for UC of the bladder. The sensitivity for UroVysion in upper tract UC was 12/12 but the specificity was three of nine.

CONCLUSIONS

This preliminary report shows that UroVysion was a sensitive screening method for UC of the bladder and upper urinary tract.

Molecular markers for detection, surveillance and prognostication of bladder cancer

Many markers for the detection of bladder cancers have been tested and almost all urinary markers reported are better than cytology with regard to sensitivity, but they score lower in specificity. Currently molecular and genetic changes play an important role in the discovery of new molecular markers for detection, prognostication and surveillance. The purpose of this review is to highlight the most important urinary molecular biomarker developments that have been studied and reported recently. In the current review we have summarized the most recent and relevant published reports on molecular urinary markers. The results of this review show that the first generation of urinary markers did not add much to urinary cytology. The current generation of markers is better, but additional clinical trials are needed. Our knowledge of molecular pathways in bladder cancer is growing and new methods of marker development emerge, but the perfect marker is still to be found. Currently, there are not clinically usable molecular markers that can guide us in diagnosis or surveillance, nor guide us in lowering the frequency of urethrocystoscopy in bladder cancer.

The prognostic value of cytology and fluorescence in situ hybridization in the follow-up of nonmuscle-invasive bladder cancer after intravesical Bacillus Calmette-Guérin therapy

Molecular markers reliably predicting failure or success of Bacillus Calmette-Guérin (BCG) in the treatment of nonmuscle-invasive urothelial bladder cancer (NMIBC) are lacking. The aim of our study was to evaluate the value of cytology and chromosomal aberrations detected by fluorescence in situ hybridization (FISH) in predicting failure to BCG therapy. Sixty-eight patients with NMIBC were prospectively recruited. Bladder washings collected before and after BCG instillation were analyzed by conventional cytology and by multitarget FISH assay (UroVysion, Abbott/Vysis, Des Plaines, IL) for aberrations of chromosomes 3, 7, 17 and 9p21. Persistent and recurrent bladder cancers were defined as positive events during follow-up. Twenty-six of 68 (38%) NMIBC failed to BCG. Both positive post-BCG cytology and positive post-BCG FISH were significantly associated with failure of BCG (hazard ratio (HR)= 5.1 and HR= 5.6, respectively; p < 0.001 each) when compared to those with negative results. In the subgroup of nondefinitive cytology (all except those with unequivocally positive cytology), FISH was superior to cytology as a marker of relapse (HR= 6.2 and 1.4, respectively). Cytology and FISH in post-BCG bladder washings are highly interrelated and a positive result predicts failure to BCG therapy in patients with NMIBC equally well. FISH is most useful in the diagnostically less certain cytology categories but does not provide additional information in clearly malignant cytology.

Contemporary diagnosis of bladder cancer

BACKGROUND

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

OBJECTIVE

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

METHODS

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

CONCLUSION

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

Combined morphologic and fluorescence in situ hybridization analysis of voided urine samples for the detection and follow-up of bladder cancer in patients with benign urine cytology

BACKGROUND

Bladder cancer is among the 5 most common malignancies worldwide. Patients with bladder cancer are closely followed with periodic cystoscopies and urine cytology analyses due to the significant risk of tumor recurrence. The UroVysion fluorescence in situ hybridization (FISH) test demonstrated higher sensitivity over urine cytology in detecting bladder cancer by most comparative studies.

METHODS

In the current study, the diagnostic usefulness of a combined cytology and FISH analysis approach was tested using the Duet automatic scanning system in patients with benign urine cytology who were being monitored for recurrent urothelial carcinoma or being assessed for various urologic symptoms.

RESULTS

By combining the benefits of conventional cytology with molecular diagnostics, a more sensitive detection of bladder cancer was attained. All patients who had positive cystoscopy concomitantly with urine sampling were detected by combined analysis. Additional patients that developed transitional cell carcinoma during a follow-up period of 24 months had a previous positive result on combined analysis. Only 2 patients with a negative combined analysis result presented with late disease recurrence (20 months and 22 months, respectively, after the negative test). Therefore, negative combined analysis was found to be predictive of a lack of disease recurrence for at least 12 months. In this timeframe, the overall sensitivity, specificity, negative predictive value (NPV), and positive predictive values of the combined analysis test were 100%, 65%, 100%, and 44%, respectively.

CONCLUSIONS

Given the absolute sensitivity and NPV of the combined analysis test, the management of patients with a negative combined analysis result might be revised and allow for more flexible assessment and management of bladder cancer patients relying more on urine bound tests.

UroVysion FISH test for detecting urothelial cancers: meta-analysis of diagnostic accuracy and comparison with urinary cytology testing

OBJECTIVES

Since the introduction of the UroVysion test for detecting urothelial cancers in urine, its reported performance has varied. This article systematically analyzed reported results.

METHODS

Articles in English conforming to the Oxford EBM criteria were included, with the evaluation focused on cancers that were histologically confirmed at the time of testing rather than on any cancers that might develop later. Where applicable, samples with no cells were reclassified as negative so as to further improve the actual estimation of test performance. Where available, cytology data were also analyzed. Meta-DiSc software was used for the statistical analyses.

RESULTS

We identified 14 studies involving 2477 FISH tests. The overall prevalence of urothelial cancers was 35%. The pooled sensitivity and specificity of all studies were 72% (69%-75%) and 83% (82%-85%), respectively. Cytology data were available from 12 studies, with the overall sensitivity and specificity being 42% (38%-45%) and 96% (95%-97%). Excluding Ta tumors, the sensitivity was 86% (82%-89%) for UroVysion and 61% (56%-66%) for cytology. The overall performance was higher for UroVysion than for cytology: diagnostic odds ratio, 16.8 and 14.1; AUC, 0.867 (SE 0.021) and 0.626 (SE 0.091). These differences in overall test performance measures almost disappeared when superficial cancer cases were excluded from the analysis.

CONCLUSIONS

The published trials suggest that for a general mix of cases, cytology results are highly specific. However, a negative cytology result does not meaningfully change the post-test probability of the presence of urothelial cancer. UroVysion FISH test results should not be considered to provide conclusive evidence for the presence or absence of urothelial cancer, but both positive and negative results do moderately influence the post-test probability of disease.

Urinary markers in bladder cancer

OBJECTIVES

Many markers for the detection of bladder cancers have been tested. Almost all urinary markers reported are better than cytology with regard to sensitivity, but they score lower in specificity. The purpose of this review is to highlight the most important urinary biomarkers studied and reported recently.

METHODS

Literature on bladder cancer markers has been reviewed regularly in the last few years. In the current review we have tried to summarise the most recent literature of urinary markers.

RESULTS

The results of this review show that the first-generation urinary markers did not add much to urinary cytology. The current generation of markers is promising but larger clinical trails are needed. The future of marker development is bright with new techniques emerging, but the perfect marker is still to be found.

CONCLUSION

Currently, no single marker can yet guide us in surveillance and lower the frequency of urethrocystoscopy.

Aneusomy for detection of bladder cancer recurrence: a Southwest Oncology Group study

The high risk of recurrence in superficial transitional cell cancer (TCC) of the bladder prompted evaluation of whether chromosome changes detected at first recurrence were correlated with relapse or with response to fluoroquinolone treatment. Fluorescence in situ hybridization analysis was applied to desquamated cells from bladder washings obtained immediately before surgical resection. Cells were screened for numeric changes in chromosomes 7 and 9. Aberrations were identified in 38/54 patients eligible for evaluation. Although no clear associations were established owing to sample size, the results suggested that risk of progression/relapse was positively associated with loss of chromosome 9 and with polysomy, and negatively associated with gain of chromosome 7, the latter in contrast to published data. A short-term survival advantage was noted anecdotally with gain of chromosome 9.

Clinical utility of fluorescent in situ hybridization for the surveillance of bladder cancer patients treated with bacillus Calmette-Guérin therapy

OBJECTIVE

To evaluate the use of a multiprobe fluorescent in situ hybridization (FISH) assay for determining the response of patients with high-risk superficial bladder tumour (HRSBT) to bacillus Calmette-Guérin (BCG) therapy.

METHODS

Bladder washing specimens from 65 HRSBT patients collected before and after BCG therapy were analyzed by FISH. Labelled probes for chromosomes 3, 7, 9, and 17 were used to assess chromosomal abnormalities indicative of malignancy.

RESULTS

Fifty-five of 65 (85%) patients had a positive pre-BCG FISH result; 29 (45%) patients had a positive and 36 (55%) had a negative post-BCG FISH result. Patients with a positive post-BCG FISH status had a 2.7 times higher risk for tumour recurrence than patients with a negative post-BCG FISH status (p = 0.017; 95% CI: 1.18-6.15). In addition, patients who maintained a positive FISH status before and after BCG therapy had a risk for tumour recurrence 2.96 times higher than patients whose FISH result changed from positive to negative after BCG (p = 0.02; 95% CI: 1.17-7.54). On the other hand, there was no significant difference between the risk for tumour progression in patients with a positive versus a negative post-BCG FISH result (p = 0.49).

CONCLUSIONS

The high percentage of positive pre-BCG FISH results suggests the need for adjuvant therapy in patients with HRSBT after the initial transurethral resection. In addition, patients with a positive post-BCG FISH result were more likely to relapse after therapy. Thus, FISH appears to be useful for the surveillance of patients with HRSBT following BCG therapy.

Fluorescence in situ hybridization: a multitarget approach in diagnosis and management of urothelial cancer

Noninvasive tests for detecting genetic or molecular alterations in urine indicative of urothelial cancer are increasingly becoming the focus of urological cancer research. Since its approval by the US FDA in 2001, the fluorescence in situ hybridization test (Vysis UroVysion) has been widely evaluated. In general, published data demonstrate better sensitivity and equal or better specificity compared with routine cytology, which is still considered the 'gold standard' in diagnosing and monitoring bladder tumors. However, the fluorescence in situ hybridization test seems to provide not only a useful tool in bladder cancer detection, but also in the diagnosis of upper urinary tract tumors, surveillance and determining therapy effectiveness. This multitarget assay that detects four different chromosomal aberrations in tumor cells is a kind of objective molecular cytology and has proven advantages over routinely used cytology.

Urothelial cancer biomarkers for detection and surveillance

Cancer is a complex process, and the US cancer-specific death rate has not changed in the last 50 years. Cure of the disease usually results from early diagnosis and treatment. Urothelial carcinoma (UC) has the highest recurrence rate of any cancer and is the second most common cancer of the genitourinary tract. It usually does not present at a metastatic stage, but only 50% of patients treated with cystectomy survive > or =5 years. There is a UC surveillance protocol, which includes cystoscopy, imaging, and cytology, to detect progression and allow early treatment of life-threatening UC. Many patients may not complete the surveillance protocol, and the cost of these studies is increasing. In addition, questions about the efficacy of these modalities have been raised. Therefore, bladder urinary tumor markers have been developed to aid in the diagnosis and surveillance of UC. Because urothelial cells are bathed in the urine and are continually shed, UC presents a unique opportunity to monitor bladder neoplasia in a noninvasive fashion. Currently, there are many research bladder tumor markers, but only a few are commercially available US Food and Drug Administration (FDA)-approved products. The commercially available bladder tumor markers and potential future markers are discussed. The ideal urinary bladder tumor test is still unavailable, but the eventual "gold standard" will consist of multiplex assays that analyze nucleic acids and proteins for detection. In addition, these tests would also reveal to the clinician both prognostic information and therapeutic targets for personalized medical treatment.