1
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Bratu O, Marcu D, Anghel R, Spinu D, Iorga L, Balescu I, Bacalbasa N, Diaconu C, Savu C, Savu C, Cherciu A. Tumoral markers in bladder cancer (Review). Exp Ther Med 2021; 22:773. [PMID: 34055072 DOI: 10.3892/etm.2021.10205] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/12/2021] [Indexed: 01/15/2023] Open
Abstract
Bladder tumors are frequently diagnosed urologic malignant diseases with an extremely high recurrence rate compared to other neoplastic tumors. Urothelial bladder carcinomas are mostly identified in their incipient form, as non-muscle invasive, but despite that, a third of them develop into aggressive recurrent disease. The diagnosis of bladder carcinoma at this moment is established using cytology and cystoscopy and is a great challenge for clinicians due to the lack of sensitivity. Urinary biomarkers could improve and enhance the diagnosis and screening techniques and determine a more accurate recurrence rate. However, bladder cancer is a heterogeneous disease and the existence of a single marker test with reduced cost is unlikely; thus, until then, the use of a panel of markers to obtain valuable information is inevitable even though suboptimal for use. To improve this deadlock, new biomarker panels should be identified and prepared to equalize the cost-efficiency balance. The present paper is a literature review concerning the most commonly used tumor markers in urinary bladder cancer as well as the most commonly encountered genetic modifications in such patients.
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Affiliation(s)
- Ovidiu Bratu
- Department of Urology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Urology, University Emergency Central Military Hospital, 010825 Bucharest, Romania.,Department of Urology, Academy of Romanian Scientists, 020021 Bucharest, Romania
| | - Dragos Marcu
- Department of Urology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Urology, University Emergency Central Military Hospital, 010825 Bucharest, Romania
| | - Radu Anghel
- Department of Urology, University Emergency Central Military Hospital, 010825 Bucharest, Romania
| | - Dan Spinu
- Department of Urology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Urology, University Emergency Central Military Hospital, 010825 Bucharest, Romania
| | - Lucian Iorga
- Department of Urology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Urology, University Emergency Central Military Hospital, 010825 Bucharest, Romania
| | - Irina Balescu
- Department of Visceral Surgery, 'Ponderas' Academic Hospital, 021188 Bucharest, Romania
| | - Nicolae Bacalbasa
- Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, 023991 Bucharest, Romania.,Department of Visceral Surgery, Center of Excellence in Translational Medicine, 'Fundeni' Clinical Institute, 022328 Bucharest, Romania.,Department of Obstetrics and Gynecology, 'I. Cantacuzino' Clinical Hospital, 030167 Bucharest, Romania
| | - Camelia Diaconu
- Department of Internal Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Internal Medicine, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
| | - Cornel Savu
- Department of Thoracic Surgery, 'Marius Nasta' National Institute of Pneumophtisiology, 050159 Bucharest, Romania.,Department of Thoracic Surgery, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Carmen Savu
- Department of Anesthesiology, 'Fundeni' Clinical Institute, 022328 Bucharest, Romania
| | - Alexandru Cherciu
- Department of Urology, University Emergency Central Military Hospital, 010825 Bucharest, Romania
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2
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Ng K, Stenzl A, Sharma A, Vasdev N. Urinary biomarkers in bladder cancer: A review of the current landscape and future directions. Urol Oncol 2020; 39:41-51. [PMID: 32919875 DOI: 10.1016/j.urolonc.2020.08.016] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/07/2020] [Accepted: 08/02/2020] [Indexed: 12/23/2022]
Abstract
AIM This narrative review aims to describe established and emerging urinary biomarkers in the diagnosis and surveillance of non-muscle invasive bladder cancer. It provides a comprehensive account of classical, FDA-approved protein biomarkers and discusses their limitations. Further, we discuss the role that epigenetic, genetic, and exosomal markers can play to enhance sensitivity and specificity of the available tests. BACKGROUND The initial diagnosis and surveillance of bladder cancer involves a combination of cystoscopy, upper urinary tract imaging, and urine cytology. Despite high specificity, cytology is limited by low sensitivity. There are currently 6 urinary assays approved by the FDA to enhance diagnosis and surveillance of bladder cancer. While these have improved diagnosis and surveillance when combined with cytology, these tests are still not sufficiently sensitive and false positives often occur in benign conditions which result in inflammation of the urinary tract. Advancements in laboratory techniques have produced significant advancements in epigenetic and genetic markers, as well as extracellular vesicles, with DNA- and RNA-based markers dominating the research in this area in recent years. METHODS We identified relevant published data, using the PubMed/ Medline search engines as well as Google Scholar. We performed an online search using the terms "bladder cancer", "non-muscle invasive bladder cancer" in combination with "urine biomarkers" and limited articles in English published up to February 2020. This review consolidated on all available narrative and systematic reviews published in the 5 years in this field, while also reviewing the original data of each clinical trial or observational study which led to the development of the biomarkers. CONCLUSION The development of laboratory techniques and understanding urine-based biomarkers in BC has fuelled the use of noninvasive liquid-based biomarkers to complement urine cytology. Nonetheless, none are sufficiently effective when used in isolation, and cytology remains the gold standard in many practices. Future efforts will be focused on using these markers in combination as a predictive signature, and moving on to validating them for use in everyday clinical practice.
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Affiliation(s)
- Kenrick Ng
- UCL Cancer Institute, London, United Kindom
| | - Arnulf Stenzl
- Department of Urology, Eberhard-Karls-University, Tübingen, Germany
| | - Anand Sharma
- Department of Medical Oncology, Mount Vernon Cancer Centre, Northwood, United Kindom
| | - Nikhil Vasdev
- Hertfordshire and Bedfordshire Urological Cancer Centre, Lister Hospital, Stevenage, United Kindom; School of Life and Medical Sciences, University of Hertfordshire, United Kindom.
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3
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Lopez-Beltran A, Cheng L, Gevaert T, Blanca A, Cimadamore A, Santoni M, Massari F, Scarpelli M, Raspollini MR, Montironi R. Current and emerging bladder cancer biomarkers with an emphasis on urine biomarkers. Expert Rev Mol Diagn 2019; 20:231-243. [DOI: 10.1080/14737159.2020.1699791] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Antonio Lopez-Beltran
- Department of Pathology and Surgery, Faculty of Medicine, Cordoba University, Cordoba, Spain
| | - Liang Cheng
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Thomas Gevaert
- Laboratory of Experimental Urology, Organ Systems, KU Leuven, Leuven, Belgium
- Department of Pathology, AZ Klina, Brasschaat, Belgium
| | - Ana Blanca
- Unit of Experimental Urology, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
| | - Alessia Cimadamore
- Section of Pathological Anatomy, United Hospital, School of Medicine, Polytechnic University of the Marche Region, Ancona, Italy
| | | | | | - Marina Scarpelli
- Section of Pathological Anatomy, United Hospital, School of Medicine, Polytechnic University of the Marche Region, Ancona, Italy
| | - Maria R. Raspollini
- Histopathology and Molecular Diagnostics, University Hospital Careggi, Florence, Italy
| | - Rodolfo Montironi
- Section of Pathological Anatomy, United Hospital, School of Medicine, Polytechnic University of the Marche Region, Ancona, Italy
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4
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Fatma Karaman E, Caglayan M, Sancar-Bas S, Ozal-Coskun C, Arda-Pirincci P, Ozden S. Global and region-specific post-transcriptional and post-translational modifications of bisphenol A in human prostate cancer cells. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2019; 255:113318. [PMID: 31610501 DOI: 10.1016/j.envpol.2019.113318] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/10/2019] [Accepted: 09/27/2019] [Indexed: 06/10/2023]
Abstract
Bisphenol A (BPA), as synthetic monomer used in the production of polycarbonate plastic and epoxy resins, has endocrine disruptor properties and high risk on human health. Epigenetic alterations could act an important role in BPA-induced toxicity, but its mechanism has not been fully understood. We investigated the effects of BPA on gene expression of chromatin modifying enzymes, promoter methylation of tumor suppressor genes and histone modifications in human prostate carcinoma cells (PC-3). IC50 value of BPA was determined as 217 and 190 μM in PC-3 cells by MTT and NRU tests, respectively. We revealed an increase in global levels of 5-methylcytocine and 5-hydroxymethylcytocine at 10 μM of BPA for 96 h. We observed a significant increase on promoter DNA methylation and decrease on gene expression of p16 gene while no change was observed for Cyclin D2 and Rassf1. Significant changes were observed in global histone modifications (H3K9ac, H3K9me3, H3K27me3, and H4K20me3) in PC-3 cells. According to these results, we investigated wide-range epigenetic modifications using PCR arrays. After 96 h BPA exposure, chromatin modifying enzymes including KDM5B and NSD1 were significantly downregulated. Also, promoter methylation of tumor suppressor genes including BCR, GSTP1, LOX, MGMT, NEUROG1, PDLIM4, PTGS2, PYCARD, TIMP3, TSC2 and ZMYDN10 altered significantly. ChIP results showed that H3K9ac, H3K9me3 and H3K27me3 modifications on p16 gene showed significant increases after 1 and 10 μM of BPA exposure. In conclusion, epigenetic signatures such as DNA methylation and histone modifications could be proposed as molecular biomarkers of BPA-induced prostate cancer progression.
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Affiliation(s)
- Ecem Fatma Karaman
- Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Istanbul University, 34116, Beyazit, Istanbul, Turkey
| | - Mine Caglayan
- Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Istanbul University, 34116, Beyazit, Istanbul, Turkey
| | - Serap Sancar-Bas
- Department of Biology, Faculty of Science, Istanbul University, 34134, Vezneciler, Istanbul, Turkey
| | - Cansu Ozal-Coskun
- Section of Biology, Institute of Graduate Studies in Sciences, Istanbul University, 34134, Vezneciler, Istanbul, Turkey
| | - Pelin Arda-Pirincci
- Department of Biology, Faculty of Science, Istanbul University, 34134, Vezneciler, Istanbul, Turkey
| | - Sibel Ozden
- Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Istanbul University, 34116, Beyazit, Istanbul, Turkey.
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5
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Larsen LK, Lind GE, Guldberg P, Dahl C. DNA-Methylation-Based Detection of Urological Cancer in Urine: Overview of Biomarkers and Considerations on Biomarker Design, Source of DNA, and Detection Technologies. Int J Mol Sci 2019; 20:ijms20112657. [PMID: 31151158 PMCID: PMC6600406 DOI: 10.3390/ijms20112657] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 05/23/2019] [Accepted: 05/24/2019] [Indexed: 12/11/2022] Open
Abstract
Changes in DNA methylation have been causally linked with cancer and provide promising biomarkers for detection in biological fluids such as blood, urine, and saliva. The field has been fueled by genome-wide characterization of DNA methylation across cancer types as well as new technologies for sensitive detection of aberrantly methylated DNA molecules. For urological cancers, urine is in many situations the preferred "liquid biopsy" source because it contains exfoliated tumor cells and cell-free tumor DNA and can be obtained easily, noninvasively, and repeatedly. Here, we review recent advances made in the development of DNA-methylation-based biomarkers for detection of bladder, prostate, renal, and upper urinary tract cancers, with an emphasis on the performance characteristics of biomarkers in urine. For most biomarkers evaluated in independent studies, there was great variability in sensitivity and specificity. We discuss issues that impact the outcome of DNA-methylation-based detection of urological cancer and account for the great variability in performance, including genomic location of biomarkers, source of DNA, and technical issues related to the detection of rare aberrantly methylated DNA molecules. Finally, we discuss issues that remain to be addressed to fully exploit the potential of DNA-methylation-based biomarkers in the clinic, including the need for prospective trials and careful selection of control groups.
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Affiliation(s)
| | - Guro Elisabeth Lind
- Department of Molecular Oncology, Institute for Cancer Research, Oslo University Hospital, the Norwegian Radium Hospital, NO-0424 Oslo, Norway.
| | - Per Guldberg
- Danish Cancer Society Research Center, DK-2100 Copenhagen, Denmark.
| | - Christina Dahl
- Danish Cancer Society Research Center, DK-2100 Copenhagen, Denmark.
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6
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Santoni G, Morelli MB, Amantini C, Battelli N. Urinary Markers in Bladder Cancer: An Update. Front Oncol 2018; 8:362. [PMID: 30245975 PMCID: PMC6137202 DOI: 10.3389/fonc.2018.00362] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 08/16/2018] [Indexed: 12/12/2022] Open
Abstract
Bladder cancer (BC) is ones of the most common cancer worldwide. It is classified in muscle invasive (MIBC) and muscle non-invasive (NMIBC) BC. NMIBCs frequently recur and progress to MIBCs with a reduced survival rate and frequent distant metastasis. BC detection require unpleasant and expensive cystoscopy and biopsy, which are often accompanied by several adverse effects. Thus, there is an urgent need to develop novel diagnostic methods for initial detection and surveillance in both MIBCs and NMIBCs. Multiple urine-based tests approved by FDA for BC detection and surveillance are commercially available. However, at present, sensitivity, specificity and diagnostic accuracy of these urine-based assays are still suboptimal and, in the attend to improve them, novel molecular markers as well as multiple-assays must to be translated in clinic. Now there are growing evidence toward the use of minimally invasive “liquid biopsy” to identify biomarkers in urologic malignancy. DNA- and RNA-based markers in body fluids such as blood and urine are promising potential markers in diagnostic, prognostic, predictive and monitoring urological malignancies. Thus, circulating cell-free DNA, DNA methylation and mutations, circulating tumor cells, miRNA, IncRNA and mRNAs, cell-free proteins and peptides, and exosomes have been assessed in urine specimens. However, proteomic and genomic data must to be validated in well-designed multicenter clinical studies, before to be employed in clinic oncology.
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Affiliation(s)
- Giorgio Santoni
- Immunopathology Laboratory, School of Pharmacy, University of Camerino, Camerino, Italy
| | - Maria B Morelli
- Immunopathology Laboratory, School of Pharmacy, University of Camerino, Camerino, Italy.,Immunopathology Laboratory, School of Biosciences, Biotechnology and Veterinary Medicine, University of Camerino, Camerino, Italy
| | - Consuelo Amantini
- Immunopathology Laboratory, School of Biosciences, Biotechnology and Veterinary Medicine, University of Camerino, Camerino, Italy
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7
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Zancan M, Galdi F, Di Tonno F, Mazzariol C, Orlando C, Malentacchi F, Agostini M, Maran M, Del Bianco P, Fabricio AS, Murer B, Pianon C, Gion M. Evaluation of Cell-free DNA in Urine as a Marker for Bladder Cancer Diagnosis. Int J Biol Markers 2018; 24:147-55. [DOI: 10.1177/172460080902400304] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The diagnosis and follow-up of bladder cancer are mainly based on cystoscopy, an invasive method which could be negative in case of flat malignancies such as carcinoma in situ. Other noninvasive diagnostic methods have not yet given satisfactory results. There is a need for a reliable yet noninvasive method for the detection of bladder cancer. Our aim was to investigate whether cell-free DNA quantified in urine (ucf-DNA) could be a useful marker for the diagnosis of bladder cancer. A standard urine test was performed in 150 naturally voided morning urine samples that were processed to obtain a quantitative evaluation of ucf-DNA. Leukocyturia and/or bacteriuria were found in 18 subjects, who were excluded from the study. Statistical analysis was performed on 45 bladder cancer patients and 87 healthy subjects. Ucf-DNA was extracted from urine samples by a spin column-based method and quantified using four different methods: GeneQuant Pro (Amersham Biosciences, Pittsburg, PA, USA), Quant-iT™ DNA high-sensitivity assay kit (Invitrogen, Carlsbad, CA, USA), Real-Time PCR (Applied Biosystems, Foster City, CA, USA), and NanoDrop 1000 (NanoDrop Technologies, Houston, TX, USA). Median free DNA quantification did not differ statistically between bladder cancer patients and healthy subjects. A receiver-operating characteristic (ROC) curve was developed to evaluate the diagnostic performance of ucf-DNA quantification for each method. The area under the ROC curve was 0.578 for GeneQuant Pro, 0.573 for the Quant-iT™ DNA high-sensitivity assay kit, 0.507 for Real-Time PCR, and 0.551 for NanoDrop 1000, which indicated that ucf-DNA quantification by these methods is not able to discriminate between the presence and absence of bladder cancer. No association was found between ucf-DNA quantification and tumor size or tumor focality. In conclusion, ucf-DNA isolated by a spin column-based method and quantified by GeneQuant Pro, Quant-iT™ DNA high-sensitivity assay kit, Real-Time PCR or NanoDrop 1000 does not seem to be a reliable marker for the diagnosis of bladder cancer.
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Affiliation(s)
- Matelda Zancan
- ABO Association, Center for the Study of Biological Markers of Malignancy, AULSS 12, Venice
| | - Francesca Galdi
- ABO Association, Center for the Study of Biological Markers of Malignancy, AULSS 12, Venice
| | - Fulvio Di Tonno
- Unit of Urology, dell'Angelo Hospital, AULSS 12, Mestre-Venice
| | | | - Claudio Orlando
- Clinical Biochemistry and Endocrinology Units, Department of Clinical Physiopathology, University of Florence, Florence
| | - Francesca Malentacchi
- Clinical Biochemistry and Endocrinology Units, Department of Clinical Physiopathology, University of Florence, Florence
| | - Marco Agostini
- Second Division of Surgery, Department of Surgery and Oncology, University of Padua, Padua
| | - Michela Maran
- Unit of Pathology, dell'Angelo Hospital, AULSS 12, Mestre-Venice
| | | | - Aline S.C. Fabricio
- ABO Association, Center for the Study of Biological Markers of Malignancy, AULSS 12, Venice
| | | | - Carlo Pianon
- Unit of Urology, dell'Angelo Hospital, AULSS 12, Mestre-Venice
| | - Massimo Gion
- Center for the Study of Biological Markers of Malignancy, AULSS 12, Venice - Italy
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8
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Volpe A, Racioppi M, D'Agostino D, Cappa E, Gardi M, Totaro A, Pinto F, Sacco E, Marangi F, Palermo G, Bassi P. Bladder Tumor Markers: A Review of the Literature. Int J Biol Markers 2018; 23:249-61. [DOI: 10.1177/172460080802300409] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Bladder cancer is among the top eight most frequent cancers. Its natural history is related to a combination of factors that impact on its aggressiveness. Cystoscopy and urine cytology are the currently used techniques for the diagnosis and surveillance of non-invasive bladder tumors. The sensitivity of urine cytology for diagnosis is not high, particularly in low-grade tumors. The combination of voided urine cytology and new diagnostic urine tests would be ideal for the diagnosis and follow-up of bladder cancer. However, in order to have some clinical utility, new diagnostic and/or prognostic markers should achieve better predictive capacity that the currently used diagnostic tools. None of the markers evaluated over the last years showed remarkable sensitivity or specificity for the identification of any of the diverse types of bladder cancer in clinical practice. The limitations of the known prognostic markers have led to the research of new molecular markers for early detection of bladder cancer. This research focused in particular on the discovery of biomarkers capable of reducing the need for periodic cystoscopies or, ideally, offering a non-invasive examination instead. In this review, we will examine various new markers of bladder cancer and their value in the diagnosis and follow-up of non-muscle-invasive bladder cancer. When compared with urine cytology, which showed the highest specificity, most of these markers demonstrated an increased sensitivity.
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Affiliation(s)
- A. Volpe
- Department of Urology, The Catholic University School of Medicine, Rome - Italy
| | - M. Racioppi
- Department of Urology, The Catholic University School of Medicine, Rome - Italy
| | - D. D'Agostino
- Department of Urology, The Catholic University School of Medicine, Rome - Italy
| | - E. Cappa
- Department of Urology, The Catholic University School of Medicine, Rome - Italy
| | - M. Gardi
- Department of Urology, The Catholic University School of Medicine, Rome - Italy
| | - A. Totaro
- Department of Urology, The Catholic University School of Medicine, Rome - Italy
| | - F. Pinto
- Department of Urology, The Catholic University School of Medicine, Rome - Italy
| | - E. Sacco
- Department of Urology, The Catholic University School of Medicine, Rome - Italy
| | - F. Marangi
- Department of Urology, The Catholic University School of Medicine, Rome - Italy
| | - G. Palermo
- Department of Urology, The Catholic University School of Medicine, Rome - Italy
| | - P.F. Bassi
- Department of Urology, The Catholic University School of Medicine, Rome - Italy
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9
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Peng C, Xiao X, Kang B, He S, Li J. Serum secreted frizzled-related protein 5 levels differentially decrease in patients with hepatitis B virus-associated chronic infection and hepatocellular carcinoma. Oncol Lett 2014; 35:5777-86. [PMID: 25120720 DOI: 10.1007/s13277-014-1767-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 02/17/2014] [Indexed: 01/28/2023] Open
Abstract
The aim of this study was to investigate the characteristics of serum secreted frizzled-related protein 5 (SFRP5), an inhibitor of Wnt signaling, in hepatitis B virus (HBV)-associated infections and hepatocellular carcinoma (HCC) patients. Serum SFRP5 levels were detected in 147 patients with HBV-associated chronic infection or HCC. Compared with the non-HBV-infected and non-HCC group, the HBV-associated chronic infection and HCC groups exhibited decreased serum SFRP5 levels. A significant inverse correlation between serum SFRP5 levels and HBV DNA levels was identified in the HBV-associated chronic infection and HCC groups. Furthermore, SFRP5 levels differentially decreased in patients with HBV-associated diseases, in a manner which was dependent on liver disease status. Compared with patients exhibiting HBV-associated chronic infection, patients with HCC were found to exhibit lower serum SFRP5 levels. The results of the present study indicated that patients with HBV-associated liver infection and HCC exhibited significantly deceased serum SFRP5 levels, which were found to negatively correlate with HBV DNA levels. Serum SFRP5 levels may present a biomarker for the severity of HBV-associated liver infection, and the risk of HCC initiation and progression.
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Affiliation(s)
- Chuan Peng
- Department of Nutrition and Food Hygiene, School of Public Health and Management, Chongqing Medical University, Chongqing 400016, P.R. China
| | - Xiaoqiu Xiao
- Laboratory of Lipid and Glucose Metabolism, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
| | - Bing Kang
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, P.R. China
| | - Song He
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, P.R. China
| | - Jibin Li
- Department of Nutrition and Food Hygiene, School of Public Health and Management, Chongqing Medical University, Chongqing 400016, P.R. China
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10
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Wang Y, Kong CZ, Zhang Z, Yang CM, Li J. Role of CDH1 promoter polymorphism and DNA methylation in bladder carcinogenesis: a meta-analysis. DNA Cell Biol 2014; 33:205-16. [PMID: 24491043 DOI: 10.1089/dna.2013.2100] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Increasing scientific evidences suggest that CDH1 gene promoter polymorphism and DNA methylation may contribute to the development and progression of bladder cancer, but many existing studies have yielded inconclusive results. This meta-analysis aims to assess the role of CDH1 gene promoter polymorphism and methylation in bladder carcinogenesis. An extensive literature search for relevant studies was conducted in PubMed, Embase, Web of Science, Cochrane Library, and CBM databases from their inception through April 1, 2013. This meta-analysis was performed using the STATA 12.0 software. The crude odds ratio with 95% confidence interval was calculated. Fifteen studies were included in this meta-analysis with a total of 824 bladder cancer patients and 818 healthy controls being assessed. Our meta-analysis revealed that the A variant of CDH1 -160C/A polymorphism was associated with an increased risk of bladder cancer. Further analysis by pathological subtype indicated that patients with invasive carcinoma had a higher frequency of CDH1 -160A variant than those with superficial carcinoma. We analyzed the methylation frequency of CDH1 gene in 608 bladder cancer samples and 338 normal bladder samples. Our data strongly suggest that the CDH1 promoter methylation frequencies in bladder cancer tissues were greater than those in normal control tissues. In conclusion, our meta-analysis indicates that promoter polymorphism and methylation of CDH1 gene may be involved in the development and progression of bladder cancer. CDH1 gene promoter polymorphism and methylation might be promising biomarkers for the diagnosis and prognosis of bladder cancer.
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Affiliation(s)
- Yi Wang
- Department of Urology, The First Affiliated Hospital of China Medical University , Shenyang, People's Republic of China
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11
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E-cadherin gene promoter hypermethylation may contribute to the risk of bladder cancer among Asian populations. Gene 2014. [DOI: 10.1016/j.gene.2013.10.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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12
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Sapre N, Anderson PD, Costello AJ, Hovens CM, Corcoran NM. Gene-based urinary biomarkers for bladder cancer: An unfulfilled promise? Urol Oncol 2014; 32:48.e9-17. [DOI: 10.1016/j.urolonc.2013.07.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 07/01/2013] [Accepted: 07/01/2013] [Indexed: 01/05/2023]
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13
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García-Baquero R, Puerta P, Beltran M, Alvarez M, Sacristan R, Alvarez-Ossorio JL, Sánchez-Carbayo M. Methylation of a novel panel of tumor suppressor genes in urine moves forward noninvasive diagnosis and prognosis of bladder cancer: a 2-center prospective study. J Urol 2013; 190:723-30. [PMID: 23485510 DOI: 10.1016/j.juro.2013.01.105] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2013] [Indexed: 12/29/2022]
Abstract
PURPOSE Changes in DNA methylation of tumor suppressor genes early in carcinogenesis represent potential indicators of cancer detection and disease evolution. We examined the diagnostic, stratification and prognostic biomarker roles in urine of the methylation of a novel panel of tumor suppressor genes in bladder cancer. MATERIAL AND METHODS We evaluated the methylation of 18 tumor suppressor genes in 2 prospective, independent sets of urine samples (training set of 120 preparations and validation set of 128) from patients with bladder cancer (170) and controls (78) using methylation specific multiplex ligation-dependent probe amplification. Diagnostic performance was evaluated with ROC curves. Recurrence, progression and disease specific survival were analyzed using univariate and multivariate Cox models. RESULTS PRDM2, HLTF, ID4, DLC1, BNIP3, H2AFX, CACNA1G, TGIF and CACNA1A were methylated in bladder cancer. CCND2, SCGB3A1, BNIP3, ID4 and RUNX3 were the most frequently methylated tumor suppressor genes in each urine set. Methylation of several tumor suppressor genes correlated with clinicopathological variables, such as stage, tumor grade, focality or age. ROC analysis revealed significant diagnostic accuracy for RUNX3 and CACNA1A in the training set, and for RUNX3 and ID4 in the validation set. On univariate and multivariate analysis CACNA1A methylation correlated with recurrence in the training set, while in the validation set PRDM2 and BNIP3 were significantly associated with recurrence and disease specific survival, respectively. CONCLUSIONS Tumor suppressor gene methylation allowed for histopathological and clinical stratification. Urine methylation has noninvasive usefulness not only for diagnostic assessment but also as independent bladder cancer prognosticators.
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Affiliation(s)
- Rodrigo García-Baquero
- Tumor Markers Group, Molecular Pathology Program, Spanish National Cancer Center, Madrid, Spain; Urology Department, Hospital Puerta del Mar, Cadiz, Spain
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14
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Alameda F, Juanpere N, Pijuan L, Lloveras B, Gimeno J, Baró T, Salido M, Serrano S, Lloreta J. Value of p16INK4a in the diagnosis of low-grade urothelial carcinoma of the urinary bladder in urinary cytology. Cancer Cytopathol 2012; 120:276-82. [DOI: 10.1002/cncy.21193] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Revised: 01/11/2012] [Accepted: 01/23/2012] [Indexed: 11/10/2022]
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15
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Hypermethylation in bladder cancer: biological pathways and translational applications. Tumour Biol 2012; 33:347-61. [PMID: 22274923 DOI: 10.1007/s13277-011-0310-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 12/28/2011] [Indexed: 12/18/2022] Open
Abstract
A compelling body of evidences sustains the importance of epigenetic mechanisms in the development and progression of cancer. Assessing the epigenetic component of bladder tumors is strongly improving our understanding of their biology and clinical behavior. In terms of DNA methylation, cancer cells show genome-wide hypomethylation and site-specific CpG island promoter hypermethylation. In the context of other epigenetic alterations, this review will focus on the hypermethylation of CpG islands in promoter regions, as the most widely described epigenetic modification in bladder cancer. CpG islands hypermethylation is believed to be critical in the transcriptional silencing and regulation of tumor suppressor and crucial cancer genes involved in the major molecular pathways controlling bladder cancer development and progression. In particular, several biological pathways of frequently methylated genes include cell cycle, DNA repair, apoptosis, and invasion, among others. Furthermore, translational aspects of bladder cancer methylomes described to date will be discussed towards their potential application as bladder cancer biomarkers. Several tissue methylation signatures and individual candidates have been evidenced, that could potentially stratify tumors histopathologically, and discriminate patients in terms of their clinical outcome. Tumor methylation profiles could also be detected in urinary specimens showing a promising role as non-invasive markers for cancer diagnosis towards an early detection and potentially for the surveillance of bladder cancer patients in a near future. However, the epigenomic exploration of bladder cancer has only just begun. Genome-scale DNA methylation profiling studies will further highlight the relevance of the epigenetic component to gain knowledge of bladder cancer biology and identify those profiles and candidates better correlating with clinical behavior.
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16
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Multiplexed methylation profiles of tumor suppressor genes in bladder cancer. J Mol Diagn 2010; 13:29-40. [PMID: 21227392 DOI: 10.1016/j.jmoldx.2010.11.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Revised: 07/19/2010] [Accepted: 07/20/2010] [Indexed: 12/18/2022] Open
Abstract
Changes in DNA methylation of tumor suppressors can occur early in carcinogenesis and are potentially important early indicators of cancer. The objective of this study was to assess the methylation of 25 tumor suppressor genes in bladder cancer using a methylation-specific (MS) multiplex ligation-dependent probe amplification assay (MLPA). Initial analyses in bladder cancer cell lines (n = 14) and fresh-frozen primary bladder tumor specimens (n = 31) supported the panel of genes selected being altered in bladder cancer. The process of MS-MLPA was optimized for its application in body fluids using two independent training and validation sets of urinary specimens (n = 146), including patients with bladder cancer (n = 96) and controls (n = 50). BRCA1 (71.0%), WT1 (38.7%), and RARB (38.7%) were the most frequently methylated genes in bladder tumors, with WT1 methylation being significantly associated with tumor stage (P = 0.011). WT1 and PAX5A were identified as methylated tumor suppressors. In addition, BRCA1, WT1, and RARB were the most frequently methylated genes in urinary specimens. Receiver operating characteristic curve analyses revealed significant diagnostic accuracies in both urinary sets for BRCA1, RARB, and WT1. The novelty of this report relates to applying MS-MLPA, a multiplexed methylation technique, for tumor suppressors in bladder cancer and body fluids. Methylation profiles of tumor suppressor genes were clinically relevant for histopathological stratification of bladder tumors and offered a noninvasive diagnostic strategy for the clinical management of patients affected with uroepithelial neoplasias.
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Park HJ, Lee EJ, Ha SY, Kwon GY, Oh YL, Kim KM, Kim DS, Seo S, Lee HM, Choi HY. Prognostic Significance of Methylation Profiles in Urothelial Carcinomas of the Bladder. KOREAN JOURNAL OF PATHOLOGY 2010. [DOI: 10.4132/koreanjpathol.2010.44.6.623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Hee Jung Park
- Departmentsof Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eui Jin Lee
- Departmentsof Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Yun Ha
- Departmentsof Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ghee Young Kwon
- Departmentsof Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Lyun Oh
- Departmentsof Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyoung-Mee Kim
- Departmentsof Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dae Shick Kim
- Departmentsof Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seongil Seo
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Moo Lee
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Han Yong Choi
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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19
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Abstract
Bladder cancers comprise heterogeneous cell populations, and numerous factors are likely to be involved in dictating recurrence, progression and patient survival. While several molecular markers that are used to evaluate the development and prognosis of bladder cancer have been studied, the limited value of these established markers has created the need for new molecular indicators of bladder cancer prognosis. Of particular interest is the silencing of tumor-suppressor genes by epigenetic alteration. Recent progress in understanding epigenetic modification and gene silencing has led to new opportunities for the understanding, detection, treatment and prevention of cancer. Moreover, epigenetic silencing of tumor-suppressor genes is interesting from a clinical standpoint, because of the possibility of reversing epigenetic changes and restoring gene function in a cell. This review focuses on the prognostic relevance of epigenetic markers in bladder cancer.
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Affiliation(s)
- Wun-Jae Kim
- 62, Kaeshin-dong, Heungduk-ku, Cheongju, Chungbuk, 361-711, South Korea.
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20
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Brait M, Begum S, Carvalho AL, Dasgupta S, Vettore AL, Czerniak B, Caballero OL, Westra WH, Sidransky D, Hoque MO. Aberrant promoter methylation of multiple genes during pathogenesis of bladder cancer. Cancer Epidemiol Biomarkers Prev 2008; 17:2786-94. [PMID: 18843024 DOI: 10.1158/1055-9965.epi-08-0192] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The aims of our study were to elucidate the role of methylation of a large panel of genes during multistage pathogenesis of bladder cancer and to correlate our findings with patient age and other clinicopathologic features. EXPERIMENTAL DESIGN We studied the methylation status of 21 genes by quantitative methylation-specific PCR in an evaluation set of 25 tumor and 5 normal samples. Based on methylation frequency in tumors and normals in gene evaluation set, we selected 7 candidate genes and tested an independent set of 93 tumors and 26 normals. The presence or absence of methylation was evaluated for an association with cancer using cross-tabulations and chi(2) or Fisher's exact tests as appropriate. All statistical tests were two-sided. RESULTS Most primary tumors (89 of 93, 96%) had methylation of one or more genes of independent set; 53 (57%) CCNA1, 29 (31%) MINT1, 36 (39%) CRBP, 53 (57%) CCND2, 66 (71%) PGP9.5, 60 (65%) CALCA, and 78 (84%) AIM1. Normal uroepithelium samples from 26 controls revealed no methylation of the CCNA1 and MINT1 genes, whereas methylation of CRBP, CCND2, PGP9.5, and CALCA was detected at low levels. All the 7 genes in independent set were tightly correlated with each other and 3 of these genes showed increased methylation frequencies in bladder cancer with increasing age. PGP9.5 and AIM1 methylation correlated with primary tumor invasion. CONCLUSION Our results indicate that the methylation profile of novel genes in bladder cancers correlates with clinicopathologic features of poor prognosis and is an age-related phenomenon.
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Affiliation(s)
- Mariana Brait
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, 1550 Orleans Street, CRB II, 5M, Baltimore, MD 21231, USA
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21
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Patriarca C, Colombo P, Pio Taronna A, Wesseling J, Franchi G, Guddo F, Naspro R, Macchi RM, Giunta P, Di Pasquale M, Parente M, Arizzi C, Roncalli M, Campo B. Cell Discohesion and Multifocality of Carcinoma In situ of the Bladder: New Insight From the Adhesion Molecule Profile (e-Cadherin, Ep-CAM, and MUC1). Int J Surg Pathol 2008; 17:99-106. [DOI: 10.1177/1066896908326918] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Urothelial cell carcinoma in situ (CIS) of the bladder is a superficially diffusive and highly discohesive disease. The authors analyzed the expression of some adhesion molecules (e-cadherin and Ep-CAM) and MUC1 in 32 unifocal and multifocal bladder urothelial cell CIS in an attempt to clarify this discohesion. E-cadherin was strongly expressed, in more than 75% of the cases. The presence of methylation of the CDH1 e-cadherin promoter gene was also investigated, but methylation was found in only one case. Ep-CAM was present in all the cases with a heterogeneous staining pattern. Similarly, MUC1/episialin was variously present in 94% of the cases without a polarized staining pattern and was expressed more strongly in cases with multifocal disease. Because loss of MUC1 polarization leads to interference with cell—cell adhesion mechanisms mediated by cadherins, these findings help explain why bladder urothelial cell CIS often shows a discohesive morphology and multifocality despite a strongly expressed adhesion molecule profile. Finally, Ep-CAM expression might provide some support for future target therapy trials.
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Affiliation(s)
- Carlo Patriarca
- Department of Pathology, Azienda Ospedaliera di Melegnano, Milan,
| | - Piergiuseppe Colombo
- Department of Pathology, University of Milan Medical School, ICH Humanitas Rozzano, Milan
| | - Angelo Pio Taronna
- Department of Experimental Medicine, University of Ferrara Medical School, Ferrara
| | - Jelle Wesseling
- Department of Pathology, Netherlands Cancer Institute, NKI, Amsterdam, Netherlands
| | - Giada Franchi
- Department of Pathology, University of Milan Medical School, ICH Humanitas Rozzano, Milan
| | | | - Richard Naspro
- Department of Urology, ICH Humanitas-Cliniche Gavazzeni, Bergamo Italy
| | | | - Paolo Giunta
- Department of Pathology, Azienda Ospedaliera di Melegnano, Milan
| | | | - Michele Parente
- Department of Pathology, Azienda Ospedaliera di Melegnano, Milan
| | - Carmelo Arizzi
- Department of Pathology, Azienda Ospedaliera di Melegnano, Milan
| | - Massimo Roncalli
- Department of Pathology, University of Milan Medical School, ICH Humanitas Rozzano, Milan
| | - Biagio Campo
- Department of Urology, Azienda Ospedaliera di Melegnano, Milan
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22
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Yu J, Zhu T, Wang Z, Zhang H, Qian Z, Xu H, Gao B, Wang W, Gu L, Meng J, Wang J, Feng X, Li Y, Yao X, Zhu J. A novel set of DNA methylation markers in urine sediments for sensitive/specific detection of bladder cancer. Clin Cancer Res 2008; 13:7296-304. [PMID: 18094410 DOI: 10.1158/1078-0432.ccr-07-0861] [Citation(s) in RCA: 168] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE This study aims to provide a better set of DNA methylation markers in urine sediments for sensitive and specific detection of bladder cancer. EXPERIMENTAL DESIGN Fifty-nine tumor-associated genes were profiled in three bladder cancer cell lines, a small cohort of cancer biopsies and urine sediments by methylation-specific PCR. Twenty-one candidate genes were then profiled in urine sediments from 132 bladder cancer patients (8 cases for stage 0a; 68 cases for stage I; 50 cases for stage II; 4 cases for stages III; and 2 cases for stage IV), 23 age-matched patients with noncancerous urinary lesions, 6 neurologic diseases, and 7 healthy volunteers. RESULTS Despite six incidences of four genes reported in 3 of 23 noncancerous urinary lesion patients analyzed, cancer-specific hypermethylation in urine sediments were reported for 15 genes (P < 0.05). Methylation assessment of an 11-gene set (SALL3, CFTR, ABCC6, HPR1, RASSF1A, MT1A, RUNX3, ITGA4, BCL2, ALX4, MYOD1, DRM, CDH13, BMP3B, CCNA1, RPRM, MINT1, and BRCA1) confirmed the existing diagnosis of 121 among 132 bladder cancer cases (sensitivity, 91.7%) with 87% accuracy. Significantly, more than 75% of stage 0a and 88% of stage I disease were detected, indicating its value in the early diagnosis of bladder cancer. Interestingly, the cluster of reported methylation markers used in the U.S. bladder cancers is distinctly different from that identified in this study, suggesting a possible epigenetic disparity between the American and Chinese cases. CONCLUSIONS Methylation profiling of an 11-gene set in urine sediments provides a sensitive and specific detection of bladder cancer.
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Affiliation(s)
- Jian Yu
- Cancer Genetics and Gene Therapy Program, The State Key Laboratory for Oncogenes and Related Genes, Shanghai Cancer Institute, Shanghai Jiao Tong University, Shanghai, China
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23
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Alvarez A, Lokeshwar VB. Bladder cancer biomarkers: current developments and future implementation. Curr Opin Urol 2007; 17:341-6. [PMID: 17762628 DOI: 10.1097/mou.0b013e3282c8c72b] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Bladder cancer biomarker development has advanced significantly over the last decade, but has not yet been able to make a significant impact in the diagnosis and management of the disease. Many available markers are suitable, but do not meet the expectations of physicians and patients. Patients do not want to compromise accuracy in diagnosing bladder cancer for less-invasive tests. The review highlights the latest developments in bladder cancer biomarkers, including markers developed over the last year, and comments on the high standards placed on these markers which have delayed their widespread implementation into the urologic field. RECENT FINDINGS New markers described in the last year include soluble Fas, urothelial carcinoma-associated 1 and human chorionic gonadotropin beta type II genes. The latter two markers represent the contribution of genomic technology to this field. Also described are updates to known markers, including long-term follow-up of hematuria screening, recent studies in DNA methylation for bladder cancer diagnosis and patient perspectives on bladder tumor markers. SUMMARY Biomarkers for bladder cancer have been intensively scrutinized over the last decade, but despite new findings and good performance characteristics, they are currently not accepted in clinical practice.
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Affiliation(s)
- Alonso Alvarez
- Department of Urology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida 33101, USA
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24
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Linkov F, Yurkovetsky Z, Lokshin A. Biomarker approaches to the development of cancer screening tests: can cancer blood tests become a routine health check-up? Future Oncol 2007; 3:295-8. [PMID: 17547524 DOI: 10.2217/14796694.3.3.295] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Cancer is a deadly disease associated with high rates of morbidity and mortality. The vast majority of cancers are identified at a late stage, when therapy is rarely successful Morbidity and mortality associated with cancer can be reduced with improved prevention and early detection activities. Identification of cancer biomarkers is one of the most promising approaches for the detection of early-stage malignant or even premalignant lesions with a simple blood test. A large number of research teams are investigating the role of biomarkers in cancer detection and progression, making the dream of early and painless cancer detection become a reality.
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Affiliation(s)
- Faina Linkov
- Division of Hematology & Oncology, University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, 5117 Centre Avenue, Suite 1.19, Pittsburgh, PA 15213, USA.
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