Detection of bladder tumours: role of cytology, morphology-based assays, biochemical and molecular markers

Rare tumours of the bladder: A Saudi registry based descriptive study

Objective

There is limited literature focusing on the characteristics and behaviours of bladder tumours outside of the common three morphologies, that is, urothelial carcinoma, squamous cell carcinoma, and adenocarcinoma. The presented study provides a descriptive analysis of rare bladder tumours in KSA.

Methods

This retrospective cohort study included all patients with a primary rare bladder tumour between 1 January 2008 and 31 December 2017. The data were acquired from the Saudi Tumour Registry. Frequencies and percentages were then generated for the categorical variables, while means and standard deviations were calculated for quantitative variables.

Results

The study included 65 patients. The majority (n = 35, 53.8%) were aged 60 years and older. The patients were predominantly male (n = 53, 81.5%) and the majority lived in the Western region (n = 26, 40.?%). The most diagnosed tumour morphologies were small cell carcinoma in adults (n = 11, 16.9%) and embryonal rhabdomyosarcoma in children (n = 14, 21.5%), with the dominant diagnosis method being histology of primary tumour in 98.5% of the patients. Most tumours were localised (n = 30, 46.2%) and multifocal (n = 34, 52.3%). The overall mortality rate was 24.6%, with an overall diagnosis to death interval of 1.14 ± 0.75 years wherein small cell carcinoma was the shortest (0.84 ± 0.24) days.

Conclusion

There remains a gap in the literature regarding uncommon urologic tumours. Shedding light on these factors will aid in further understanding the patterns of tumour behaviour in the region. This will facilitate enhanced risk-and response-based screening strategies and more favourable outcomes. Additionally, formulating a global registry for such patients is recommended.

Accuracy of the urine UCA1 for diagnosis of bladder cancer: a meta-analysis

Urine UCA1 has been reported as a potential novel diagnostic biomarker for bladder cancer in several studies, but their results are inconsistent. As a result of this, a diagnostic meta-analysis to assess the diagnostic performance of urine UCA1 in detecting bladder cancer was conducted. A systematic electronic and manual search was performed for relevant literatures through PubMed, Cochrane library, Chinese Wan Fang and the China National Knowledge Infrastructure (CNKI) databases up to December 30, 2016. The quality of the studies included in this meta-analysis was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. All analyses were conducted using stata12.0 software. Six studies collectively included 578 bladder cancer patients and 562 controls met the eligible criteria. The overall diagnostic accuracy was measured by the following: sensitivity 0.81 (95% CI = 0.75-0.86), specificity 0.86 (95% CI = 0.73-0.93), positive likelihood ratio 5.85 (95% CI = 2.72-12.57), negative likelihood 0.22 (95% CI = 0.15-0.32), diagnostic odds ratio 27.01 (95% CI = 8.69-83.97), and area under the curve 0.88 (95% CI = 0.85-0.91). Meta-regression analysis suggested that ethnicity significantly accounted for the heterogeneity of sensitivity. Deeks' funnel plot asymmetry test (P = 0.33) suggested no potential publication bias. According to our results, urine UCA1 has greater diagnostic value in diagnosing bladder cancer, however further research studies with more well-designed and large sample sizes are required to confirm our findings.

Shed urinary ALCAM is an independent prognostic biomarker of three-year overall survival after cystectomy in patients with bladder cancer

Proteins involved in tumor cell migration can potentially serve as markers of invasive disease. Activated Leukocyte Cell Adhesion Molecule (ALCAM) promotes adhesion, while shedding of its extracellular domain is associated with migration. We hypothesized that shed ALCAM in biofluids could be predictive of progressive disease. ALCAM expression in tumor (n = 198) and shedding in biofluids (n = 120) were measured in two separate VUMC bladder cancer cystectomy cohorts by immunofluorescence and enzyme-linked immunosorbent assay, respectively. The primary outcome measure was accuracy of predicting 3-year overall survival (OS) with shed ALCAM compared to standard clinical indicators alone, assessed by multivariable Cox regression and concordance-indices. Validation was performed by internal bootstrap, a cohort from a second institution (n = 64), and treatment of missing data with multiple-imputation. While ALCAM mRNA expression was unchanged, histological detection of ALCAM decreased with increasing stage (P = 0.004). Importantly, urine ALCAM was elevated 17.0-fold (P < 0.0001) above non-cancer controls, correlated positively with tumor stage (P = 0.018), was an independent predictor of OS after adjusting for age, tumor stage, lymph-node status, and hematuria (HR, 1.46; 95% CI, 1.03–2.06; P = 0.002), and improved prediction of OS by 3.3% (concordance-index, 78.5% vs. 75.2%). Urine ALCAM remained an independent predictor of OS after accounting for treatment with Bacillus Calmette-Guerin, carcinoma in situ, lymph-node dissection, lymphovascular invasion, urine creatinine, and adjuvant chemotherapy (HR, 1.10; 95% CI, 1.02–1.19; P = 0.011). In conclusion, shed ALCAM may be a novel prognostic biomarker in bladder cancer, although prospective validation studies are warranted. These findings demonstrate that markers reporting on cell motility can act as prognostic indicators.

Clinical value of vascular endothelial growth factor and endostatin in urine for diagnosis of bladder cancer

Aims and background

The aim of the study was to determine whether urinary VEGF and endostatin predict the presence of bladder cancer, and whether these noninvasive biomarkers provide clinically useful information in the bladder cancer patient as well.

Methods and study design

Voided urine samples were collected from 239 patients (109 bladder cancers, 81 urological disorders, 49 healthy controls). The urine levels of VEGF and endostatin were determined with the sandwich enzyme immunoassay technique.

Results

Urine levels of VEGF and endostatin were higher in patients with bladder cancer than those in patients with urological disorders and healthy controls (P <0.01). The difference between patients with urological disorder and healthy controls was significant only for VEGF (P <0.01). Urine level of VEGF was related to the tumor grade, and urine level of endostatin was related to tumor stage, tumor size and tumor number (P <0.05). The optimal cutoffs for VEGF and endostatin were calculated by the ROC curves as 860 pg/ml for VEGF, and 350 pg/ml for endostatin. The five-year survival rate was 60.0% in patients with low level of endostatin (<350 pg/ml) and 7.69% in patients with high level of endostatin (≥350 pg/ml) in the bladder cancer group. Patients with a high level of endostatin had a shorter survival time, whereas patients with a low level of endostatin had a longer survival time (P <0.05).

Conclusions

Urine levels of VEGF and endostatin may be a clinically useful aid in the diagnosis of bladder cancer, and endostatin but not VEGF is a supplementary prognostic marker for predicting tumor progression.

Diagnostic and prognostic value of bladder cancer-related transcript markers in urine

PURPOSE

Since cytology as the current "gold standard" for noninvasive detection of bladder cancer (BCa) is characterized by a relatively low sensitivity, urinary transcript levels of survivin (SVV), Ki-67 and cytokeratin 20 (CK20) were evaluated as alternative or complementary biomarkers. Furthermore, their prognostic value was investigated.

METHODS

Voided urine samples from 105 BCa patients and 156 controls were included. Total RNA was isolated from urine pellets and reverse-transcribed into cDNA. Expression levels of SVV, Ki-67 and CK20 were determined by quantitative PCR and normalized to the housekeeping gene TBP. Diagnostic performance of transcript markers and cytology was assessed by receiver operating characteristic (ROC) curve analyses. The prognostic value of the transcript markers was calculated by Cox proportional hazards models.

RESULTS

ROC analyses resulted in AUC values between 0.71 (Ki-67) and 0.86 (CK20), indicating an appropriate diagnostic power. Using specifically defined cutoff values, the expression levels of the assessed biomarkers were significantly higher in urine specimens from BCa patients compared to control group (Mann-Whitney U test p < 0.001). Specificity ranged from 75% (SVV) to 84% (CK20) and sensitivity from 56% (Ki-67) to 87% (CK20). In combination with cytology, the sensitivity increased up to 97% (CK20). With regard to prognostic power, only SVV showed a significant, but not independent impact on the risk of recurrence (p = 0.008).

CONCLUSIONS

Quantitative assessment of tumor-related transcript markers, particularly of CK20, may serve as a noninvasive method to identify patients with BCa. Moreover, SVV appears to be useful as a marker for a high risk of recurrence.

Knockdown of Bmi1 inhibits bladder cancer cell growth both in vitro and in vivo by blocking cell cycle at G1 phase and inducing apoptosis

Bmi1 is a member of the polycomb group family of proteins, and it drives the carcinogenesis of various cancers and governs the self-renewal of multiple types of stem cells. However, its role in the initiation and progression of bladder cancer is not clearly known. The present study aimed to investigate the function of Bmi1 in the development of bladder cancer. Bmi1 expression was detected in human bladder cancer tissues and their adjacent normal tissues (n=10) by immunohistochemistry, qRT-PCR and Western blotting, respectively. Bmi1 small interference RNA (siRNA) was synthesized and transfected into human bladder carcinoma cells (EJ) by lipofectamine 2000. The Bmil expression at mRNA and protein levels was measured in EJ cells transfected with Bmil siRNA (0, 80, 160 nmol/L) by qRT-PCR and Western blotting, respectively. Cell viability and Ki67 expression (a marker of cell proliferation) were determined in Bmi1 siRNA-transfected cells by CCK-8 assay and qRT-PCR, respectively. Cell cycle of transfected cells was flow-cytometrically determined. Immunofluorescence and Western blotting were used to detect the expression levels of cell cycle-associated proteins cyclin D1 and cyclin E in the cells. Pro-apoptotic proteins Bax and caspase 3 and anti-apoptotic protein Bcl-2 were detected by Western blotting as well. Additionally, xenograft tumor models were established by inoculation of EJ cells (infected with Bmil shRNA/pLKO.1 lentivirus or not) into nude mice. The tumor volumes were measured every other day for 14 days. The results showed that the Bmil expression was significantly increased in bladder tumor tissues when compared with that in normal tissues (P<0.05). Perturbation of Bmi1 expression by using siRNA could significantly inhibit the proliferation of EJ cells (P<0.05). Bmi1 siRNA-transfected EJ cells were accumulated in G1 phase and the expression levels of cyclin D1 and cyclin E were down-regulated. Bax and caspase-3 expression levels were significantly increased and Bcl-2 levels decreased after Bmi1 knockdown. Tumor volume was conspicuously reduced in mice injected with EJ cells with Bmi1 knockdown. Our findings indicate that Bmi1 is a potential driver oncogene of bladder cancer and it may become a potential treatment target for human bladder cancer.

USP28 is a potential prognostic marker for bladder cancer

This study was conducted to analyze the expression of the ubiquitin-specific protease Usp28 and assess its clinical significance in human bladder cancer. mRNA and protein expression levels of Usp28 were determined by real-time polymerase chain reaction (PCR) and Western blot in 24 paired bladder cancers and the adjacent non-cancerous tissues. In addition, the expression of Usp28 protein in 186 bladder cancers was also determined by immunohistochemistry. The relationship between expression of Usp28 and clinico-pathologic features and prognosis was finally evaluated. Usp28 was expressed at a higher level in bladder cancers compared to adjacent non-cancerous tissues at both the mRNA and protein levels in 24 paired samples (all P < 0.01). In immunohistochemical examination, 78 (41.9%) of 186 cases displayed low Usp28 expression in cancerous tissues, whereas 108 (58.1%) cases displayed high Usp28 expression. In the universal analysis, Usp28 correlated strongly with histopathological grade, clinical stage, tumor number and recurrence rate (P = 0.0001, 0.0001, 0.0001 and 0.0051, respectively), but did not correlate with gender or age (P = 0.5588 and 0.6574). After multiple analysis of the above factors and consideration of confounding factors, tumor number, histological grade, clinical stage, and recurrence were related to Usp28 expression (P = 0.001, 0.001, 0.001 and 0.001, respectively). Finally, Usp28 expression was indentified as a independent predictors of survival (P = 0.001). Usp28 protein expression is potentially valuable in prognostic evaluation of bladder cancer.

Detection of hyaluronidase RNA and activity in urine of schistosomal and non-schistosomal bladder cancer

Diagnosis of bladder cancer is done by cystoscopy and cytology. In the last decade, many urine-based tests for bladder cancer have been developed and tested in different populations. Hence, it was relevant to assess the diagnostic significance of urinary hyaluronidase RNA and its enzyme activity in bladder cancer. Seventy patients with bladder cancer, 56 patients with benign bladder lesions, and 49 healthy controls were enrolled in this study. Voided urine samples from all subjects were used for estimation of urinary HAase RNA by semi-quantitative reverse transcription polymerase chain reaction (RT-PCR) and determination of its enzymatic activity by zymography. There was a significant difference in the mean ranks and positivity rates of HAase RNA expression (P < 0.01) and its enzymatic activity among the three investigated groups: malignant, benign, and normal (P < 0.01). In detecting bladder cancer, the sensitivity of urine cytology (42.83 %) was improved to 100 % when combined with urinary Hyal RNA or Hyal enzyme activity. Detection of urinary Hyal RNA and its enzyme activity is promising noninvasive tests with high sensitivities and specificities for detection of bladder cancer.

The clinical relevance of urine-based markers for diagnosis of bladder cancer

The aim of the present study was to evaluate the diagnostic relevance of urinary fibronectin (FN), telomerase (RTA), and cytokeratin 20 (CK20) mRNA in comparison with voided urine cytology (VUC). The study included 132 patients with bladder cancer, 60 patients with benign bladder lesions, and 48 healthy individuals. All were subjected to urine cytology, estimation of fibronectin by ELISA, RTA by TRAP, and CK20 mRNA by conventional RT-PCR in urothelial cells from voided urine. The best cutoff point for FN was determined by receiver operating characteristic curve (41.7 ng/mg protein) revealed the highest sensitivity for malignant (80%) followed by the benign (70%) than the healthy individuals (4.1%) at P < 0.001. Also, RTA and VUC showed significant difference among the three investigated groups (P < 0.001). The overall sensitivity (89.3%) and specificity (98.4%) were the highest for CK20 mRNA. Combined sensitivity of VUC with FN, RTA, and CK20 mRNA together (98.4%) was higher than either the combined sensitivity of VUC with any of them or than that of the biomarker alone. Accordingly, when the diagnostic efficacy was considered, CK20 mRNA had the highest sensitivity and specificity compared to all investigated markers.

Urinary proteomics: ready for prime time in urological cancer diagnostics?

The impact of clinical proteomics on the diagnosis and treatment of urological malignancies is modest in comparison with the high expectations of the past. However, most available studies suffer from flawed clinical designs rather than from technical limitations. This article will briefly introduce the main technological approaches taken, their advantages and disadvantages and will highlight the different challenges associated with urinary proteome analysis. Furthermore, several examples of the successful application of urinary clinical proteomics in the field of prostate and bladder cancer will be introduced. These examples suggest careful validation of novel biomarkers, appropriate study designs using blinded cohorts enrolled from appropriate target populations and the standardization of techniques as key elements required for successful urinary proteomics studies. These prerequisites are essential for turning the old promise of a personalized medicine approach into a new reality to optimize patients’ preventive and therapeutic care.

Identification of a bladder cancer-specific ligand using a combinatorial chemistry approach

OBJECTIVES

To develop bladder cancer-specific ligands using a combinatorial chemistry approach.

MATERIALS AND METHODS

We performed a high-throughput one-bead one-compound combinatorial chemistry approach to identify ligands that bound to bladder transitional cell carcinoma cells. The whole-cell binding assay allowed successful identification of a few peptides that bound selectively to bladder cancer cells. Single cell suspensions derived from clinical bladder cancer specimens and cell lines were used to determine the binding specificity. Studies with mouse xenografts were performed to determine the in vivo binding and targeting efficiency, specificity, and biodistribution of one of the ligands.

RESULTS

One cyclic peptide named PLZ4 (amino acid sequence: cQDGRMGFc) was identified that could selectively bind to bladder cancer cell lines and all of the 5 primary bladder cancer cells from human patients, but not to normal urothelial cells, cell mixtures from normal bladder specimens, fibroblasts, and blood cells. Comparison of PLZ4 binding to cell lines of different cancer origins showed that it was bladder cancer-specific (P < 0.05). PLZ4 could bind to tumor cells treated with urine at pH 6.0, but not to noncancerous cells collected from the urine of 4 patients actively being treated with intravesical Bacillus Calmette-Guerin therapy. In vivo and ex vivo imaging studies showed that PLZ4 linked to Cy5.5 fluorescent dye administered via tail vein injection was specifically taken up in mouse xenografts developed from excised fresh human bladder cancer specimens. Several ligands contain the same DGR motif, but only PLZ4 was bladder cancer-specific. We performed alanine walk and rainbow bead coding experiments, and found that the C-terminal GF residues were also important for cell binding and modulated the binding specificity.

CONCLUSIONS

PLZ4 has the potential to be used for targeted therapy and imaging detection during diagnosis and follow-up/surveillance of noninvasive and advanced bladder cancer.

Diagnostic evaluation of apoptosis inhibitory gene and tissue inhibitor matrix metalloproteinase-2 in patients with bladder cancer

Bladder carcinoma is an important worldwide health problem. Both cystoscopy and urine cytology used in detecting bladder cancer suffer from drawbacks where cystoscopy is an invasive method and urine cytology shows low sensitivity in low-grade tumors. This study validates easier and less time-consuming techniques for the estimation of survivin and TIMP-2 in urine of bladder cancer patients to evaluate them in comparison with cytology. This study includes malignant (bladder cancer patients, n = 42), benign (patients with bilharzial cystitis, n = 22) and healthy (n = 21) groups. The studied groups were subjected to cystoscopic examination, detection of bilharzial antibodies, urine cytology, and estimation of urinary survivin by qualitative RT-nested PCR and TIMP-2 by ELISA. Significantly higher positivity rates of urinary survivin and TIMP-2 were observed in the malignant group compared with benign and healthy groups. On associating the two urinary markers with different clinicopathological factors, only TIMP-2 exerted significantly higher positivity rate in invasive stage (100%) than superficial stage (82.3%). Survivin showed 78.6% sensitivity, 95.3% specificity, 94.3% PPV, 82% NPV, and 87% accuracy. When combined with urine cytology, the sensitivity increased to 83.3%. While on applying the cutoff value of urinary TIMP-2 (< or =639.5 pg/mg protein), it showed 93% sensitivity, 83.7% specificity, 85% PPV, 92.3% NPV, and 88.2% accuracy. When combined with urine cytology, the TIMP-2 sensitivity remained 93%. On combining cytology with both urinary survivin and TIMP-2, the highest sensitivity was reached (98%). Survivin and TIMP-2 can be considered as potentially useful urine markers in early detection of bladder cancer.

A solid-phase method for preparing human DNA from urine for diagnostic purposes

OBJECTIVES

To develop a simple method using paramagnetic beads for isolation of human DNA from small volumes of urine. The method should be amendable for automation. The purified DNA is intended to be used in downstream diagnostics and screening studies using nucleic acid amplification techniques.

DESIGN AND METHODS

Unspecific capture of cells present in urine to magnetic particles, lysis and subsequent binding of the DNA to the same bead surface.

RESULTS

DNA isolated using the method could be used as template for sensitive real-time PCR and end-point PCR using primers targeted to the GAPDH, K-ras, DD3 and p53 genes. Compared to silica spin column-based extraction, the method showed equal or higher DNA yields. The method performed reliably when automated using a liquid handling robot equipped with a magnetic workstation.

CONCLUSIONS

The method generates purified DNA free from inhibitors, applicable for sensitive applications such as real-time PCR, genotyping, and for sequence variant analysis. The use of magnetic beads allows for automation, reducing hands-on time and creating a high throughput and reproducible protocol for the purpose of large-scale screening and diagnostics.

Expression of Bmi-1 is a prognostic marker in bladder cancer

Background

The molecular mechanisms of the development and progression of bladder cancer are poorly understood. The objective of this study was to analyze the expression of Bmi-1 protein and its clinical significance in human bladder cancer.

Methods

We examined the expression of Bmi-1 mRNA and Bmi-1 protein by RT-PCR and Western blot, respectively in 14 paired bladder cancers and the adjacent normal tissues. The expression of Bmi-1 protein in 137 specimens of bladder cancer and 30 specimens of adjacent normal bladder tissue was determined by immunohistochemistry. Statistical analyses were applied to test the relationship between expression of Bmi-1, and clinicopathologic features and prognosis.

Results

Expression of Bmi-1 mRNA and protein was higher in bladder cancers than in the adjacent normal tissues in 14 paired samples (P < 0.01). By immunohistochemical examination, five of 30 adjacent normal bladder specimens (16.7%) versus 75 of 137 bladder cancers (54.3%) showed Bmi-1 protein expression (P < 0.05). Bmi-1 protein expression was intense in 20.6%, 54.3%, and 78.8% of tumors of histopathological stages G1, G2, and G3, respectively (P < 0.05). Expression of Bmi-1 protein was greater in invasive bladder cancers than in superficial bladder cancers (81.5% versus 32.5%, P < 0.05). In invasive bladder cancers, the expression of Bmi-1 protein in progression-free cancers was similar to that of cancers that have progressed (80.0% versus 82.4%, P > 0.5). In superficial bladder cancers, the expression of Bmi-1 protein in recurrent cases was higher than in recurrence-free cases (62.5% versus 13.7%, P < 0.05). Bmi-1 expression was positively correlated with tumor classification and TNM stage (P < 0.05), but not with tumor number (P > 0.05). Five-year survival in the group with higher Bmi-1 expression was 50.8%, while it was 78.5% in the group with lower Bmi-1 expression (P < 0.05). Patients with higher Bmi-1 expression had shorter survival time, whereas patients with lower Bmi-1 expression had longer survival time (P < 0.05).

Conclusion

Expression of Bmi-1 was greater in bladder cancers than in the adjacent normal tissues. The examination of Bmi-1 protein expression is potentially valuable in prognostic evaluation of bladder cancer.

Comparison of CD44 and cytokeratin 20 mRNA in voided urine samples as diagnostic tools for bladder cancer

OBJECTIVES

We evaluated the diagnostic efficacy of urinary CD44 and cytokeratin 20 (CK20) mRNA in comparison with voided urine cytology (VUC) for the detection of bladder cancer.

DESIGN AND METHODS

A total of 136 Egyptian patients provided a single voided urine sample for CD44, CK20 mRNA and VUC before cystoscopy. Of the 136 cases, 111 were histologically diagnosed as bladder cancer whereas the remaining 25 had benign urological disorders. A group of 20 healthy volunteers was also included in this study. Voided urine was centrifuged and the urine sediment was used for cytology, estimation of CD44 by ELISA and RNA extraction. CK20 mRNA was detected by conventional RT-PCR and quantitative real-time RT-PCR.

RESULTS

The best cutoff values for CD44 and relative CK20 mRNA detected by real-time RT-PCR were calculated by receiver operating characteristic curve. The positivity rates and the mean ranks for CD44 and CK20 mRNA showed significant difference among the three investigated groups (p=0.001). Quantitative real-time RT-PCR results were comparable to conventional RT-PCR for the detection of CK20 mRNA. The positivity rate of CD44 was significantly associated with schistosomiasis and urine cytology. The overall sensitivity and specificity were 52.3% and 88.9% for VUC, 63.1% and 88.9% for CD44, and 82.0% and 97.8% for CK20 mRNA. Combined sensitivity of VUC with CD44 and CK20 mRNA together (95.5%) was higher than either the combined sensitivity of VUC with CD44 (78.4%) or with CK20 mRNA (91.0%) or than that of the biomarker alone.

CONCLUSION

Urinary CD44 and CK20 mRNA had higher sensitivities compared to VUC. However, when the diagnostic efficacy was considered, CK20 mRNA by either conventional RT-PCR or real-time RT-PCR had the highest sensitivity and specificity compared to CD44 and VUC.

Challenges of using mass spectrometry as a bladder cancer biomarker discovery platform

INTRODUCTION

Bladder cancer (BCa) is one of the most prevalent malignancies worldwide, mostly due to its high recurrence rates. In consequence, the necessity of repeated screening for reappearance demonstrates the urgent need for novel biomarkers as alternatives to invasive standard procedures.

METHODS

Proteomic technologies have emerged as powerful platforms for unbiased biomarker discovery and revolutionized the classical "target-driven" analysis of single marker candidates. Although proteome profiling is still far from demonstrating its full potential in clinical diagnosis, first studies clearly denote its significant potential.

CONCLUSIONS

This review provides a discussion of the challenges related to clinical proteomics using mass spectrometry, emphasizing bladder cancer biomarker discovery. An outline of the technological prerequisites for reliable proteome profiling, data mining and interpretation, as well as, reflections on future trends in the field are provided.

Detection of telomerase in urine by 3 methods: evaluation of diagnostic accuracy for bladder cancer

PURPOSE

New, noninvasive methods are needed for the diagnosis, followup and screening of patients with bladder cancer. Three methods of detecting telomerase were evaluated in this aspect.

MATERIALS AND METHODS

This study included 200 patients diagnosed with bladder carcinoma, 85 with benign bladder lesions and 30 healthy individuals who served as the control group. All underwent serological schistosomiasis antibody assay in serum, urine cytology and estimation of relative telomerase activity by telomeric repeat amplification protocol, human telomerase RNA by reverse transcriptase-polymerase chain reaction and human telomerase reverse transcriptase by real-time reverse transcriptase-polymerase chain reaction in urothelial cells from voided urine.

RESULTS

The concordance between the positive rates of telomerase detected by the 3 methods was high (90% to 95%). Results were significantly higher in the malignant group than in the benign and control groups. There was a significant difference among the results of the 3 methods in relation to different clinicopathological factors. Overall the sensitivity of human telomerase reverse transcriptase for detecting bladder cancer was the highest compared to that of human telomerase RNA, relative telomerase activity and urine cytology (96%, 92%, 75% and 75%, respectively). Combinations of telomerase results with urine cytology were not useful except in cases of relative telomerase activity.

CONCLUSIONS

Detection of human telomerase reverse transcriptase in urine by real-time polymerase chain reaction, followed by human telomerase RNA by reverse transcriptase-polymerase chain reaction, improves sensitivity and specificity for the diagnosis of bladder cancer. However, regarding cost-effectiveness, human telomerase RNA is superior.

Primary Application Study in Early Diagnosis of Bladder Cancer by Survivin Molecular Beacons

OBJECTIVES

To develop a sensitive method for the detection of bladder cancer cells in the urine castoff cells of patients with bladder cancer, we examined the feasibility of using molecular beacon (MB) probes specific for tumor-specific survivin mRNA.

METHODS

MBs are single-stranded oligonucleotide hybridization probes that form a stem-and-loop structure and have high sensitivity and specificity. Western blot analysis showed that a high level of survivin gene expression is detected in human bladder cancer 5637 and J82 cell lines but not in normal human prostate fibroblast cells. These cell lines were incubated with survivin MBs, and the fluorescence intensity was examined in those cells using a fluorescence microscope.

RESULTS

We found that survivin MBs could detect expression of the survivin gene and generated fluorescent signals in the cancer cells. However, the fluorescence signal was not detected in the normal prostate fibroblast cells. The green fluorescent signal was present in the exfoliated cells of patients with bladder cancer but not in the healthy adult after incubating with survivin MBs.

CONCLUSIONS

Our results have demonstrated that the survivin MB is a specific and sensitive molecular probe for detecting bladder cancer cells and urine castoff cells of patients with bladder cancer. It has great potential for the development of a clinical diagnostic procedure for the early detection of bladder cancer and follow-up after surgery.

Noninvasive diagnosis of bladder cancer by detection of matrix metalloproteinases (MMP-2 and MMP-9) and their inhibitor (TIMP-2) in urine

OBJECTIVES

TIMPs control the activity of MMPs, one of the key molecules for tumor invasion and metastasis. The aim of this study was to assess the usefulness of MMP-2 and MMP-9 in relation to their inhibitor (TIMP2) as noninvasive diagnostic tests for bilharzial bladder cancer.

MATERIAL AND METHODS

Voided urine samples were provided from 244 subjects (154 bladder cancer [136 bilharzial]; 60 benign urologic disorders; 30 healthy volunteers). Urine sediment was used for cytology, and the supernatant for estimation of MMPs and TIMP-2 by ELISA and gelatin zymography.

RESULTS

The best cut-off values for the investigated markers were determined by ROC curve. Positivity rates and median levels for MMP-2, MMP-9, TIMP-2, MMP-2/TIMP-2, and MMP-9/TIMP-2 showed significant difference among the three investigated groups (p<0.001). MMP-9 and MMP-2/TIMP-2 were related to pathologic type, MMP-2/TIMP-2 was inversely related to the grade, and MMP-9/TIMP-2 was related to bilharziasis (p<0.05). MMP zymography results were comparable to those from ELISA.

CONCLUSION

The sensitivity and specificity of MMP zymography, MMP-9/TIMP-2 ratio, and MMP-2/TIMP2 ratio were superior among all investigated parameters; furthermore, combined testing of cytology with them improves the sensitivity even in superficial and low-grade tumors.

Molecular biomarkers for cancer detection in blood and bodily fluids

Cancer is a major and increasing public health problem worldwide. Traditionally, the diagnosis and staging of cancer, as well as the evaluation of response to therapy have been primarily based on morphology, with relatively few cancer biomarkers currently in use. Conventional biomarker studies have been focused on single genes or discrete pathways, but this approach has had limited success because of the complex and heterogeneous nature of many cancers. The completion of the human genome project and the development of new technologies have greatly facilitated the identification of biomarkers for assessment of cancer risk, early detection of primary cancers, monitoring cancer treatment, and detection of recurrence. This article reviews the various approaches used for development of such markers and describes markers of potential clinical interest in major types of cancer. Finally, we discuss the reasons why so few cancer biomarkers are currently available for clinical use.

Improved detection of bladder carcinoma cells in voided urine by standardized microsatellite analysis

Successful treatment of bladder cancer depends largely on early diagnosis of primary and recurrent disease. Sensitive, specific and noninvasive procedures for detection are especially needed for grade 1 and 2 bladder tumors, because of the relatively low sensitivity of cytology. Here we introduce a novel strategy to improve the sensitivity and reliability of microsatellite analyses by employing marker-specific threshold values for loss-of-heterozygosity (LOH) at 10 loci. These individual cut-offs were experimentally determined with 35 normal control tissues and subsequently validated in a retrospective study with bladder cancer biopsies from 86 patients. In a prospective analysis of voided urines samples and matched blood probes from 91 patients, LOH-analysis, UroVysion FISH and conventional urine cytology were compared with histological findings of consecutive transurethral biopsies. Whereas all samples could be analyzed by our LOH assay, only 56 samples were suitable for all 3 analyses. The highest sensitivity was obtained with our LOH-assay/cytology approach (G1-2: 72%; G3: 96%) being only surpassed by a combination of all 3 techniques (G1-2: 83%; G3: 100%). Since over 93% of the patients with recurrent disease were identified by LOH/cytology-analyses of their voided urine samples, a monitoring scheme alternating cystoscopy with LOH/cytology-examination could now be envisioned to reduce invasive interventions and consequently improve follow-up compliance, especially in patients with low grade tumors.

Early bladder cancer: concept, diagnosis, and management

Recent evidence on molecular pathways helps us to understand the pathogenesis of bladder cancer. However, the molecular mechanisms of recurrence of the disease and progression into muscle-invasive disease are not fully understood. The diagnostic accuracy and specificity of innovative markers for detection of the disease currently available in the clinical setting are still far from the level where cystoscopy would not be needed. Although risk factors for progression to muscle-invasive disease have been identified, we still cannot predict accurately the clinical behavior of superficial bladder cancer. In this review article, we summarize recent evidence on molecular pathogenesis, risk factors for recurrence and progression, urine markers for detection, and treatments in superficial bladder cancer.

Mechanisms by which food intake elevates circulating levels of hyaluronan in humans

OBJECTIVES

Plasma hyaluronan is a potentially useful clinical test, especially in liver disease. It rises after eating, but mechanisms by which this occurs are not known. The study aimed at defining the effect of different food and liquid intake on plasma hyaluronan and to address mechanisms.

DESIGN

The effects on plasma hyaluronan of ingestion of high-fat and low-fat meals, glucose solution, and saline, and of intravenous metoclopramide and oral cisapride were defined in healthy fasted subjects by serial measurements over 5 h. Hyaluronan was measured by a radiometric assay.

RESULTS

After test meals and glucose ingestion, plasma hyaluronan rose to 1.7-13 times the fasting levels in 11 healthy volunteers. Peak values were observed in most subjects 45-90 min after ingestion and reached levels in six subjects that might suggest the presence of hepatic fibrosis or cirrhosis. No change occurred after ingestion of 0.48 L iso-osmotic NaCl solution, equal in bulk to the glucose solution. Stimulation of gastrointestinal motility with metoclopramide had no effect but oral cisapride induced a pattern of elevated plasma hyaluronan which mimicked that induced by foodstuffs.

CONCLUSIONS

Displacement of hyaluronan from gastrointestinal tissues prevails over the increased clearance expected from elevated portal blood flow. The heightened flux of tissue fluid necessary to displace tissue hyaluronan is best explained by vasodilatation in response to ingestion of nutrients, and subsequent increase in intestinal lymph flow, rather than by fluid absorption, together with gut contraction. The discriminating value of plasma hyaluronan in clinical practice may be greatly enhanced by sampling in fasted subjects at rest.

Detection of bladder carcinoma by combined testing of urine for hyaluronidase and cytokeratin 20 RNAs

BACKGROUND

A new, sensitive, noninvasive method for the detection of urothelial carcinomas of the urinary bladder would open new possibilities in both the diagnosis and followup of patients.

METHODS

This study included 228 patients diagnosed with bladder carcinoma, 68 patients with benign bladder lesions, and 44 healthy persons served as the control group. All were subjected to: serologic schistosomiasis antibody assay in serum, urine cytology, estimation of urine hyaluronic acid (HA) by enzyme-linked immunosorbent assay, and detection of CK-20 and hyaluronidase (HAase) by reverse transcription polymerase chain reaction (RT-PCR) in urothelial cells from voided urine.

RESULTS

HA mean rank was higher in benign and malignant groups than in the healthy group (P < 0.0001) and was significantly related to tumor grade (P = 0.021). HA best-cutoff, determined using receiver operating characteristic curve to discriminate between malignant and nonmalignant groups, was 58.5 units/mg protein at 85.8% sensitivity and 60.7% specificity. HAase RNA showed superior sensitivity (90.8%) over cytology (68.9%) and CK-20 (78.1%) with specificity of 93.4%, 98.1% and 80.2%, respectively. The sensitivity reached 94.7% at a specificity of 91.5% when combined with CK-20. All 4 of the investigated markers were related to grade at P <0.05. Whereas only HAase and CK-20 were significantly related to stage (P < 0.05). As to schistosomiasis, only HAase RNA positivity was significantly associated (P = 0.038).

CONCLUSIONS

HAase RNA is a promising noninvasive test with high sensitivity and specificity in bladder carcinoma detection.

Comparison of cytokeratin 20 RNA and angiogenin in voided urine samples as diagnostic tools for bladder carcinoma

BACKGROUND

We evaluated the diagnostic efficacy of urinary angiogenin (ANG) and cytokeratin 20 (CK-20) mRNA in comparison with voided urine cytology in the detection of bladder cancer patients.

OBJECTIVES AND METHODS

A total of 97 Egyptian patients provided a single voided urine sample for ANG, CK-20 and cytology before cystoscopy. Of the 97 cases, 63 were histologically diagnosed as bladder cancer; 33 with transitional cell carcinoma (TCC) and 30 with squamous cell carcinoma (SCC), whereas the remaining 34 had benign urological disorders. A group of 46 healthy volunteers were also included in this study. Voided urine was centrifuged and the supernatant was used for estimation of ANG by EIA and confirmed by Western blotting (WB). The urine sediment was used for cytology and RNA extraction. CK-20 RNA was detected by RT-PCR.

RESULTS

The best cutoff value for ANG was calculated by a ROC curve as 322.7 ng/mg protein. The median urinary ANG level in bladder carcinoma, benign urological disorders and healthy volunteer groups was: 802.7, 425 and 33 pg/mg protein, respectively. The positivity rate for urinary CK-20 mRNA of the control, benign and malignant groups was 0%, 2.9% and 82.3%, respectively (P = 0.000); while the rates for ANG were 11.6%, 54.8% and 75.4%, respectively (P = 0.000). There was no significant difference in positivity rates of CK-20 and ANG with respect to sex, smoking, schistosomiasis, urine cytology, tumor grade, tumor stage, hematuria or pus cells. The overall sensitivity and specificity were 71.4% and 90% for voided urine cytology, 75.4% and 70.3% for ANG, and 82.3% and 98.8% for CK-20. Combined sensitivity of voided urine cytology with ANG and CK-20 together (98.2%) was higher than either the combined sensitivity of voided urine cytology with ANG (96.5%) or with CK-20 (91.6%) or than that of the biomarker alone. We demonstrated significant positive correlation between CK-20 positivity with age (P = 0.043) and nodal involvement (P = 0.037); however, there was no significant correlation between CK-20 and ANG with the other clinicopathological parameters.

CONCLUSIONS

Our data indicate that CK-20 and ANG in voided urine had higher sensitivities compared to voided urine cytology. However, when specificity was considered, CK-20 alone had superior sensitivity and specificity compared to ANG and voided urine cytology.

Immunocyt and the HA-HAase Urine Tests for the Detection of Bladder Cancer: A Side-by-Side Comparison

OBJECTIVES

The reliable detection of bladder cancer from urine specimen remains an unsolved problem. Especially superficial bladder cancer can be missed with urine tests. We assessed the sensitivity and specificity of the commercial Immunocyt test in a side-by-side comparison with the HA-HAase urine test and cytology. The Immunocyt test measures the immunocytological expression of sulfated mucin-glycoproteins and glycosylated forms of the carcinoembryonic antigen in urine. With the HA-HAase urine test the level of hyaluronic acid (HA) and its degrading enzyme hyaluronidase (HAase) are measured in an ELISA-like test.

METHODS

A total of 94 consecutive patients were studied and among these 30 patients had bladder cancer and 64 were controls. Among bladder cancer patients, there were 14 pTa, 9 pT1, 5 pT2 and 2 carcinoma in situ (CIS) transitional cell carcinoma of the bladder, respectively. The controls consisted of 55 patients with a history of bladder cancer but no evidence of tumor at the follow-up cystoscopy and 9 benign prostatic hyperplasia (BPH) patients. The 30 transitional cell cancer specimens had 4 (13%) grade 1 tumors, 15 (50%) grade 2 tumors and 11 (37%) grade 3 tumors. Sensitivity and specificity as well as the positive and negative predictive values of each test were evaluated.

RESULTS

The sensitivity of the HA-HAase urine test (83.3%; 25/30) was significantly higher than the Immunocyt at 63.3% (19/30) (p = 0.038, McNemar test) and cytology (73%; p < 0.05). The specificity of the HA-HAase test (78.1%; 50/64), Immunocyt (75%; 48/64) and cytology (79.7%; 51/64) were comparable. The prevalence of bladder cancer in our study was 31%. The positive predictive value (PPV) of the HA-HAase test (64.1%) was significantly higher than the Immunocyt test (54.3%). The negative predictive value (NPV) of the HA-HAase test (90.9%) was also higher than the Immunocyt test (81.3%). The PPV and NPV values for cytology were 62.9% and 86.4%, respectively. False negative patients in the HA-HAase urine test were 5 pTa tumors (2 G1, 2 G2 and 1 G3). False negative patients in the Immunocyt test were 7 pTa tumors (1 G1 and 6 G2), 3 pT1 (2 G2, 1 G3) and 1 pT2 G3, respectively.

CONCLUSIONS

The sensitivity of the HA-HAase urine test is significantly higher than that of the Immunocyt test to detect bladder cancer. Specificity, as well as the PPV and NPV of the HA-HAase test were higher than that of the Immunocyt test. With a prevalence of 31% bladder cancer patients in all hematuria patients studied, a typical distribution of patients in a urological clinic is presented. Longer follow up of the study patients will give more information on the value of these tests in the detection of bladder cancer.