The diagnostic accuracy of urine-based tests for bladder cancer varies greatly by patient

Bladder cancer biomarkers: current approaches and future directions

Bladder cancer is a significant health concern worldwide, necessitating effective diagnostic and monitoring strategies. Biomarkers play a crucial role in the early detection, prognosis, and treatment of this disease. This review explores the current landscape of bladder cancer biomarkers, including FDA-approved molecular biomarkers and emerging ones. FDA-approved molecular biomarkers, such as BTA stat, BTA TRAK, and NMP22, have been instrumental in diagnosing and monitoring bladder cancer. These biomarkers are derived from urinary samples and are particularly useful due to their sensitivity and specificity. As we move forward, we should continue to seek ways to optimize our processes and outcomes, these markers remain seriously challenged in the detection of early bladder cancer due to their limited sensitivity and specificity. For instance, sensitivities of BTA stat in bladder tumor detection have varied between 40-72%, while its specificities vary from 29-96%. In the same way, 70% sensitivity and 80% specificity have been recorded for BTA TRAK, while 11-85.7% sensitivity and 77-100% specificity have been documented for NMP22 BladderChek. The given variations, especially the low sensitivity in the diagnosis of bladder cancer at an early stage call for the invention of better diagnostic systems. Moreover, different sample collection and handling procedures applied in different laboratories further contribute to inconsistent results obtained. Extracellular vesicles (EVs) and exosomes, which carry a vast number of proteins, are being considered as potential biomarkers. Although these markers show promise, challenges remain due to non-standardized isolation techniques and lack of reproducibility across studies. Moreover, the discovery of new potential biomarkers is ongoing. For instance, the UBC® Rapid test and UBC ELISA kit, the XPERT BC Monitor, BC UroMark, TaqMan® Arrays, Soluble FAS (sFAS), Bladder tumor fibronectin (BTF), and IGF2 and MAGE-A3 are among the newest biomarkers under investigation. In conclusion, while bladder cancer biomarkers have shown great promise, more research is needed to standardize the testing procedures and validate these biomarkers in a clinical setting. This will pave the way for more accurate and efficient diagnosis and monitoring of bladder cancer, ultimately improving patient outcomes.

Pre-analytical handling conditions and protein marker recovery from urine extracellular vesicles for bladder cancer diagnosis

Extracellular vesicles (EVs) contain a variety of biomolecules and provide information about the cells that produce them. EVs from cancer cells found in urine can be used as biomarkers to detect cancer, enabling early diagnosis and treatment. The potential of alpha-2-macroglobulin (A2M) and clusterin (CLU) as novel diagnostic urinary EV (uEV) biomarkers for bladder cancer (BC) was demonstrated previously. To validate the diagnostic value of these proteins in uEVs in a large BC cohort, urine handling conditions before uEV isolation should be optimized during sample transportation from medical centers. In this study, we analyzed the uEV protein quantity, EV particle number, and uEV-A2M/CLU after urine storage at 20°C and 4°C for 0-6 days, each. A2M and CLU levels in uEVs were relatively stable when stored at 4°C for a maximum of three days and at 20°C for up to 24 h, with minimal impact on analysis results. Interestingly, pre-processing to remove debris and cells by centrifugation and filtration of urine did not show any beneficial effects on the preservation of protein biomarkers of uEVs during storage. Here, the importance of optimizing shipping conditions to minimize the impact of pre-analytical handling on the uEVs protein biomarkers was emphasized. These findings provide insights for the development of clinical protocols that use uEVs for diagnostic purposes.

Surveillance of Low-Grade Non-Muscle Invasive Bladder Tumors Using Uromonitor: SOLUSION Trial

BACKGROUND

The surveillance of non-muscle invasive bladder cancer (NMIBC) requires frequent cystoscopies, which are costly and uncomfortable for patients. Uromonitor is a validated non-invasive urinary test for detecting NMIBC recurrence. However, data on its clinical benefit in an NMIBC surveillance program is limited.

OBJECTIVE

To assess the diagnostic accuracy of Uromonitor in NMIBC surveillance and its potential to limit the number of cystoscopies.

DESIGN, SETTING, AND PARTICIPANTS

The study included 202 patients with previous low-grade (LG) NMIBC tumors. Newly diagnosed patients were scheduled for flexible cystoscopy and Uromonitor test at 4, 12, and 24 months from the time of diagnosis. Patients with tumors diagnosed before entering the study underwent cystoscopy and Uromonitor test at the start of the study and 12 and 24 months from inclusion in the study.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS AND LIMITATIONS

Between February 2020 and October 2022, 202 patients were enrolled in the study. Of these patients, 171 met the eligibility criteria to perform the analysis, with a median age of 69 years, IQR (62-74), and 380 flexible cystoscopies with simultaneous Uromonitor tests. Overall, 39/171 (22.8%) patients had recurrences. Uromonitor showed a sensitivity of 89.7%, specificity of 96.2%, PPV of 72.9%, and NPV of 98.8%. In 28 cases, flexible cystoscopy was falsely positive, leading to surgery, where Uromonitor showed negative results. There were 13 cases of possible false positives for Uromonitor where flexible cystoscopy was negative.

CONCLUSIONS

Uromonitor displays high diagnostic accuracy in detecting NMIBC recurrence with the potential for reducing the number of flexible cystoscopies in the follow-up of low- and intermediate-risk NMIBC.

PATIENT SUMMARY

We followed up on newly and previously diagnosed patients with LG NMIBC. We concluded that Uromonitor could potentially reduce the number of cystoscopies in NMIBC surveillance programs.

Tumor-targeting albumin nanoparticles as an efficacious drug delivery system and potential diagnostic tool in non-muscle-invasive bladder cancer therapy

Current intravesical chemotherapy for non-muscle invasive bladder cancer (NMIBC) has limited efficacy due to loss of the instilled agent from urine voiding and the agent's lack of specificity for the tumors. We developed a nanocarrier (txCD47-HNP, ∼100 nm) based on human serum albumin conjugated with a peptide that targets the cluster of differentiation 47 receptor overexpressed on bladder cancer (BC) cells. The IC₅₀ of gemcitabine elaidate (GEM) loaded in the txCD47-HNP was almost an order of magnitude lower than that of free GEM. In a mouse orthotopic BC model, GEM loaded in txCD47-HNP effectively reduced the tumor burden. Tumor cells in BC patients' urine can also be targeted by fluorescence-labeled txCD47-HNP resulting in >83 % of the cells exhibiting fluorescence. Thus, txCD47-HNP can potentially be a theranostic agent in NMIBC management by serving as a targeted drug delivery vehicle as well as an alternative to urine cytology.

Clinical and Novel Biomarkers in Penile Carcinoma: A Prospective Review

Penile carcinoma is a rare urological neoplasia in men compared to other more common tumors, such as prostate, kidney, or bladder tumors. However, this neoplasm continues to affect a large number of patients worldwide, with developing countries presenting the highest incidence and mortality rates. Important risk factors such as the human papilloma virus, a factor affecting a large number of patients, have been described; however, few studies have evaluated screening programs in populations at risk for this disease, which severely affects the quality of life of older men. The management of these patients is usually complex, requiring surgical interventions that are not without risk and that have a great impact on the functionality of the male reproductive system. In addition, in cases of disseminated disease or with significant locoregional involvement, patients are evaluated by multidisciplinary oncological committees that can adjust the application of aggressive neoadjuvant or adjuvant chemotherapy on numerous occasions without clear improvement in survival. Chemotherapy regimens are usually aggressive, and unlike in other urological neoplasms, few advances have been made in the use of immunotherapy in these patients. The study of serological and histological biomarkers may help to better understand the underlying pathophysiology of these tumors and select patients who have a higher risk of metastatic progression. Similarly, the analysis of molecular markers will improve the availability of targeted therapies for the management of patients with disseminated disease that would benefit prognosis. Therefore, the purpose of this article is to summarize the main advances that have occurred in the development of serological and histological markers and their therapeutic implications in patients diagnosed with penile carcinoma, explaining the limitations that have been observed and analyzing future perspectives in the management of this disease.

Routine urethroscopic surveillance is of limited value after radical cystectomy: a single centre retrospective cohort analysis

PURPOSE

The incidence of urethral recurrence (UR) following radical cystectomy (RC) for transitional cell carcinoma (TCC) of the bladder varies between 1.5 and 6%. There is debate over the timing of urethrectomy for patients undergoing RC. We evaluated the requirement for a formal surveillance programme for UR in patients after RC.

METHODS

We retrospectively reviewed the outcomes of patients who underwent RC between 2006 and 2019. Females, non-TCC cases and patients with neo-bladder diversions were excluded. Histological prostatic urethral involvement at the time of RC was deemed high risk for UR. Carcinoma in-situ, multifocal tumours and bladder neck involvement were deemed intermediate risk and the absence of the above features was considered low risk.

RESULTS

417 patients underwent RC, 300 cases remained after exclusion criteria were applied. 42 patients were high-risk for UR, 102 patients were intermediate risk and 156 were low risk. Of the 300, 24 urethrectomy cases were recorded. Six cases of UR occurred. Of these, 5 presented with symptoms and only 1 case was detected by surveillance. Only 1 low-risk patient developed UR, 7 years post RC. Using our risk stratification, UR rates for high, intermediate and low-risk cohorts were 25%, 10.5% and 0.8%, respectively.

CONCLUSIONS

In our cohort, routine surveillance for all patients with annual urethroscopy was of limited value in detecting UR post RC. Staged Urethrectomy for high and intermediate-risk patients, and patient counselling in self-identification of recurrence symptoms for low-risk patients will improve the early detection of UR.

Comparison of urinary telomerase, CD44, and NMP22 assays for detection of bladder squamous cell carcinoma

Background

Squamous cell carcinoma (SCC) of the bladder is common in many regions around the world. Prognosis is very poor, as most cases are diagnosed at an advanced stage due to a lack of affordable and valid screening markers for this type of cancer. The diagnostic accuracy of urinary nuclear matrix protein-22 (NMP22), telomerase activity, and CD44 were evaluated in urine samples of patients with bladder SCC.

Materials and methods

We conducted a case-control study comprised of 60 consecutive newly diagnosed bladder SCC patients diagnosed by cystoscopy and histopathological examination, and controls were 60 outpatients with benign urologic conditions and healthy clinic visitors. Urine samples collected from each subject underwent testing for NMP22, telomerase activity, and CD44. Descriptive and correlational statistical analysis of cases and controls were carried out and receiver operating characteristic curve analysis was used to determine optimal cut-off points for the three assays.

Results

Area under the curve was calculated at 0.96, 0.93, and 0.62 for NMP22, telomerase, and CD44, respectively. Urine levels of NMP22 and telomerase activity were significantly higher in the SCC group compared to controls (p < 0.001). Urine CD44 levels were not significantly higher in the SCC group compared to controls (p = 0.111). The overall sensitivity of NMP22, telomerase, and CD44 was 96.7%, 87%, and 45%, respectively, while the specificity was 85%, 88.6%, and 86.7%, respectively.

Conclusions

Urinary telomerase activity, followed by NMP22 urine levels, showed high diagnostic yield and could hold potential promise as urinary biomarkers for the diagnosis of bladder SCC.

The bladder epicheck test and cytology in the follow-up of patients with non-muscle-invasive high grade bladder carcinoma

BACKGROUND

The management of non-muscle invasive bladder carcinoma (NMIBC) after transurethral resection of a bladder tumor consists of adjuvant intravesical therapy and strict and long surveillance with urine cytology and cystoscopy. The Bladder EpiCheck test (Nucleix Ltd) (BE) is a newly developed urinary markers based on DNA methylation changes in a panel of 15 genomic biomarkers, with a promising performance in term of non-invasive NMIBC detection.

METHODS

In this study we prospectively enrolled 151 consecutive patients with high grade NMIBC, treated with intravesical BCG and mitomycin C therapy and evaluated during the follow-up by voided urine cytology and white-light cystoscopy, according to the European Association of Urology Guidelines. The Bladder EpiCheck test was performed at the same time of urine cytology in voided specimen. In all cases with positive cytology the diagnosis was confirmed by histology and a diagnosis was made according to the 2017 tumor, node, metastasis (TNM) classification and graded using both the 1973 and the 2004 World Health Organization (WHO) classifications.

RESULTS

At three months of follow-up, we reported similar overall specificity rates for BE and urine cytology (85,1% vs 86,3%). In the group of patients with carcinoma in situ (CIS), we found the same specificity for BE and urine cytology (81,4%), while in the groups of patients with papillary high grade NMIBC, the specificity of BE was higher compared to cytology (96,3% vs 90,4%). The sensitivity of BE was always higher compared to cytology during all the follow-up both for papillary NMIBC and CIS.

CONCLUSION

In the early follow-up of NMIBC the EpiCheck test might replace urinary cytology.

Clinicopathological significance of claspin overexpression and its efficacy as a novel biomarker for the diagnosis of urothelial carcinoma

We previously reported that claspin is a key regulator in the progression of gastric cancer and renal cell carcinoma. However, the clinicopathological significance of claspin in urothelial carcinoma (UC) has not been investigated. We analyzed the expression and distribution of claspin in UC cases by immunohistochemistry. In the non-neoplastic urothelium, the expression of claspin was either weak or absent, whereas UC tissues showed nuclear staining. The expression of claspin was detected in 58 (42%) of a total of 138 upper tract UC cases treated by radical nephroureterectomy without neoadjuvant chemotherapy. Claspin-positive UC cases were associated with nodular/flat morphology, variant histology, high tumor grade, high pathological T grade, and lymphatic and venous invasion. The expression of claspin was significantly associated with decreased progression-free survival and cancer-specific survival. In addition, claspin was co-expressed with Ki-67, PD-L1, HER2, EGFR, and p53 in consecutive tumor sections of UC. An immunohistochemical analysis of claspin in biopsy specimens revealed that strong to moderate claspin staining was more frequently observed in carcinoma in situ in comparison to dysplasia or the benign urothelium. Furthermore, immunocytochemistry for claspin on urine cytology slides demonstrated that the proportion of claspin-positive cells was significantly greater in high-grade UC than in benign cases. These results suggest that claspin may be a novel prognostic marker and a possible therapeutic target molecule for UC. Moreover, claspin could be a useful diagnostic biomarker of urothelial neoplasia.

Application of nanotechnology in the diagnosis and treatment of bladder cancer

Bladder cancer (BC) is a common malignancy in the genitourinary system and the current theranostic approaches are unsatisfactory. Sensitivity and specificity of current diagnosis methods are not ideal and high recurrence and progression rates after initial treatment indicate the urgent need for management improvements in clinic. Nanotechnology has been proposed as an effective method to improve theranosis efficiency for both non-muscle invasive bladder cancer (NMIBC) and muscle invasive bladder cancer (MIBC). For example, gold nanoparticles (AuNPs) have been developed for simple, fast and sensitive urinary sample test for bladder cancer diagnosis. Nanoparticles targeting bladder cancers can facilitate to distinguish the normal and abnormal bladder tissues during cystoscopy and thus help with the complete removal of malignant lesions. Both intravenous and intravesical agents can be modified by nanotechnology for targeted delivery, high anti-tumor efficiency and excellent tolerability, exhibiting encouraging potential in bladder cancer treatment. Photosensitizers and biological agents can also be delivered by nanotechnology, intermediating phototherapy and targeted therapy. The management of bladder cancer remained almost unchanged for decades with unsatisfactory effect. However, it is likely to change with the fast-developed nanotechnology. Herein we summarized the current utility of nanotechnology in bladder cancer diagnosis and treatment, providing insights for the future designing and discovering novel nanoparticles for bladder cancer management.

Staple Line Erosion in a Neobladder Causing Postoperative Hematuria

Erosion of metal surgical staples is a rare but described surgical complication. Staple erosion in a bladder may present with hematuria, urinary tract infection (UTI), bladder pain, or fistula. We present a 64-year-old male with a history of urothelial carcinoma treated by cystoprostatectomy with neobladder reconstruction. Over the next two to three years, he developed hematuria and had multiple urine cytologies suspicious for cancer. The cystoscopic evaluation revealed staple line erosion but no cancer. We believe this to be the first published case of symptomatic staple erosion in a neobladder. Clinicians should be aware that staple line erosion in a neobladder can occur and mimic malignancy recurrence.

Comparing CxBladder to Urine Cytology as Adjunct to Cystoscopy in Surveillance of Non-muscle Invasive Bladder Cancer-A Pilot Study

Purpose: Guidelines advocate cystoscopy surveillance (CS) for non-muscle invasive bladder cancer (NMIBC) post-resection. However, cystoscopy is operator dependent and may miss upper tract lesions or carcinoma in-situ (CIS). Urine cytology is a common adjunct but lacks sensitivity and specificity in detecting recurrence. A new mRNA biomarker (CxBladder) was compared with urine cytology as an adjunct to cystoscopy in detecting a positive cystoscopy findings during surveillance cystoscopy in our center. Materials and Methods: Consented patients older than 18, undergoing CS for NMIBC, provide paired urine samples for cytology and CxBladder test. Patients with positive cystoscopy findings would undergo re-Trans Urethral Resection of Bladder Tumor (TURBT). Results: Thirty-five patients were enrolled from April to June 2019. Seven contaminated urine samples were excluded. The remaining cohort of 23 (82%) and 5 (18%) females had a mean age of 66.69 (36-89). Eight (29%) patients with positive cystoscopy finding underwent TURBT. All 8 patients also had positive CxBladder result. This shows that CxBladder has a sensitivity and negative predictive value (NPV) of 100%, specificity of 75% and positive predictive value (PPV) of 62% in predicting a positive cystoscopy finding. TURBT Histo-pathological findings showed Low-grade Ta NMIBC in one patient (4%), and 7 (25%) patients had inflammatory changes. Urine cytology was only positive in one patient with a positive cystoscopy finding. This led to a sensitivity of merely 13% and NPV of 74%, while specificity and PPV was 100% in predicting a positive cystoscopy finding. Conclusion: CxBladder had high NPV and sensitivity which accurately predicted suspicious cystoscopy findings leading to further investigation. It has great potential for use as adjunct to cystoscopy for surveillance of NMIBC.

The Use of Urine Mycobacterium tuberculosis Complex Polymerase Chain Reaction as a Predictive Factor for Recurrence and Progression After Intravesical Bacillus Calmette-Guérin Therapy in Patients with Non-muscle‑invasive Bladder Cancer

BACKGROUND

Intravesical bacillus Calmette-Guérin (BCG) instillation is a standard treatment for non-muscle-invasive bladder cancer (NMIBC); however, not all patients benefit from BCG therapy. Currently, no surrogate marker exists to predict BCG efficacy, and thereby, identify patients who will benefit from this treatment.

OBJECTIVE

To evaluate the utility of urine Mycobacterium tuberculosis complex polymerase chain reaction (MTC-PCR) assay as a predictive marker for recurrence and progression following BCG therapy.

DESIGN SETTING AND PARTICIPANTS

A prospective analysis was carried out for of intermediate- or high-risk NMIBC patients who received BCG instillation for the first time. Urine samples, for MTC-PCR assay, were collected at baseline and annually for up to 10 yr after the last BCG instillation, including induction and maintenance therapy. The first postoperative sample for MTC-PCR was taken at 1 yr from the last instillation.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

A survival analysis was performed using the Kaplan-Meier method, and risk factors for recurrence and progression after BCG treatment were assessed using Cox regression analysis.

RESULTS AND LIMITATIONS

During follow-up (median: 57 mo), 468/521 samples (89.8%) were MTC-PCR positive, and 108/123 patients (87.8%) exhibited MTC-PCR positivity at least once. Five-year recurrence- and progression-free survival in patients who were not MTC-PCR positive was significantly lower than in patients who were MTC-PCR positive at least once (p <  0.001). Using multivariable Cox regression analysis, MTC-PCR positivity at least once was a significant prognostic factor for recurrence (hazard ratio [HR]: 36.782, p <  0.001) and progression (HR: 47.209, p <  0.001).

CONCLUSIONS

Patients who were not MTC-PCR positive, even once after BCG therapy, were extremely likely to exhibit recurrence and progression. Urine MTC-PCR may be an extremely useful, noninvasive surrogate marker to predict recurrence and progression following BCG therapy.

PATIENT SUMMARY

Urine Mycobacterium tuberculosis complex polymerase chain reaction may be a novel biomarker capable of identifying patients at risk of recurrence and progression after bacillus Calmette-Guérin (BCG) immunotherapy.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Diagnostic accuracy of NMP 22 and urine cytology for detection of transitional cell carcinoma urinary bladder taking cystoscopy as gold standard

Objective:

To determine diagnostic accuracy of NMP 22 and urine cytology in the detection of transitional cell carcinoma (TCC) urinary bladder taking cystoscopy as a gold standard in patients having provisional diagnosis of bladder cancer (BC).

Methods:

This cross sectional validational study enrolled 380 patients fulfilling selection criteria and was conducted at Armed Forces Institute of Urology (AFIU) Rawalpindi, Pakistan form July 2018 to July 2019. The urine sample collected underwent NMP22 and cytological analysis followed by rigid cystoscopy. Reports of all three tests divided patients into positive or negative for malignancy as per defined criteria. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of NMP 22, urine cytology and their combination was determined. Receiver operating characteristic (ROC) curve analysis performed and area under the curve (AUC) compared among these tests.

Results:

The average age of patients was 53.08 ± 12.41 years having male to female ratio 3.75:1(300 males and 80 females). NMP 22 had better sensitivity and comparable specificity to cytology (81.9 & 81.2% vs 54 & 93.9%). Combination of NMP 22 / cytology outperformed both in terms of sensitivity (91.63 vs 81.83 vs 53.96), NPV (87.59 vs 77.46 vs 61.02) and diagnostic accuracy (85.26 vs 81.58 vs 71.32) but at the cost of specificity (76.97 vs 81.21 vs 93.94) and PPV (83.83 vs 85.02 vs 92.06). ROC curve revealed statistically significant higher AUC (0.843 vs .815 vs .73) for combination as compared to NMP 22 and Cytology (p < 0.001).

Conclusion:

NMP22 is a quick, point of care test having higher sensitivity, NPV and accuracy but similar specificity and PPV to urine cytology for detection of TCC urinary bladder. Combination outperformed both in terms of sensitivity while having modest specificity.

Netrin-1: A new promising diagnostic marker for muscle invasion in bladder cancer

BACKGROUND

Bladder cancer is the most common urological malignancy with a high tendency for progression and recurrence. So far, no reliable diagnostic marker is present with 100% sensitivity and specificity. Netrins are related to laminin proteins, and were first discovered to be involved in neural development. After that, they were found in other organs of the body and several studies stated that they have implicated in cancer progression.

PURPOSE

This study aimed at investigating the netrin-1 gene expression in bladder cancer tissues, in addition to the possibility of using urinary netrin-1 as a marker for muscle invasion diagnosis in bladder cancer cases.

METHODS

Netrin-1 gene expression in bladder cancer tissue was detected in this study by real-time polymerase chain reaction. Moreover, netrin-1 protein was measured in tissue and urinary deposit samples by western blotting.

RESULTS

The results of this study revealed that netrin-1 is expressed in bladder cancer and control tissues, with a strong positive correlation between netrin-1 in tissues and urinary netrin-1 (rs = 0.762, P < 0.0005). Receiver operating characteristic curve analysis confirmed the muscle-invasion diagnostic value of urinary netrin-1 with bladder cancer cases, providing an area under the curve equals to 0.758 (95% confidence interval, 0.630-0.886, P < 0.0005), with 96% sensitivity and 67% specificity. Bladder cancer patients had been included to examine risk factors for local recurrence, distant metastasis, and death. Cox regression models showed that netrin-1 gene expression, tumor size, and age are positive predictor markers for local tumor recurrence. Age is a predictor for distant metastasis, and tumor stage is a predictor for death.

CONCLUSION

Urinary netrin-1 can be used as a promising biomarker for diagnosis of muscle invasion, which may help in the follow up of non-invasive tumors. In addition, tissue netrin-1 expression may serve as a predictor of local tumor recurrence.

Diagnostic accuracy, clinical utility and influence on decision-making of a methylation urine biomarker test in the surveillance of non-muscle-invasive bladder cancer

Objectives

To investigate prospectively the clinical utility and influence on decision‐making of Bladder EpiCheck™, a non‐invasive urine test, in the surveillance of non‐muscle‐invasive bladder cancer (NMIBC).

Materials and Methods

Urine samples from 440 patients undergoing surveillance for NMIBC were prospectively collected at five centres and evaluated using the Bladder EpiCheck test (NCT02647112). A multivariable nomogram and decision‐curve analysis (DCA) were used to evaluate the impact of Bladder EpiCheck on decision‐making when used in routine clinical practice. The test was designed to exclude recurrent disease.

Results

Data from 357 patients were available for analysis. The test had a specificity of 88% (95% confidence interval [CI] 84–91), a negative predictive value (NPV) of 94.4% (95% CI 91–97) for the detection of any cancer and an NPV of 99.3% for the detection of high‐grade cancer. In multivariable analysis, positive Bladder EpiCheck results were independently associated with any and high‐grade disease recurrence (odds ratio [OR] 18.1, 95% CI 8.7–40.2; P < 0.001 and OR 78.3, 95% CI 19.2–547; P < 0.001). The addition of Bladder EpiCheck to standard variables improved its predictive ability for any and high‐grade disease recurrence by a difference of 16% and 22%, respectively (area under the curve 85.9% and 96.1% for any and high‐grade cancer, respectively). DCA showed an improvement in the net benefit relative to cystoscopy over a large threshold of probability, resulting in a significant reduction in unnecessary investigations. These results were similar in subgroups assessing the impact of specific clinical features.

Conclusions

Bladder EpiCheck is a robust high‐performing diagnostic test in patients with NMIBC undergoing surveillance that can potentially reduce the number of unnecessary investigations.

Trends in the incidence and mortality of transitional cell carcinoma of the bladder for the last four decades in the USA: a SEER-based analysis

BACKGROUND

Transitional cell carcinoma (TCC) accounts for around 95% of bladder cancers and is the 4th most common cancer among men and the tenth most common in women, in the US. There is a constant need to clarify current TCC incidence and mortality rates among different population groups for better clinical practice guidelines. We aimed to describe the TCC incidence and incidence-based mortality by demographic and tumor-related characteristics over the last 40 years in the US.

METHODS

We obtained data from the SEER 18 registries to study TCC cases that were diagnosed between the years 1973 and 2014. We calculated incidence rates and incidence-based mortality rates in different demographic and tumor-related characteristics and expressed rates by 100,000 person-years. We then calculated the annual changes in incidence and incidence-based mortality rates and displayed them as annual percent changes (APCs).

RESULTS

There were 182,114 patients with TCC between 1973 and 2014 in the United States. Overall incidence rates of TCC increased 0.16% (95% CI, 0.02-0.30, p = .02) per year over the study period. However, the incidence declined significantly since 2007; (95%CI,-1.89- -0.77, p < .001), except among the elderly and African Americans, which increased significantly over the study period. Overall TCC mortality rates did not change over the study period. However, since 2000 it started to decrease significantly.

CONCLUSION

TCC incidence and incidence-based mortality rates had been showing significant increases over the previous decades. However, significant declines in both incidence and incidence-based mortality rates have been observed over the recent years, except in some patients with certain racial groups. Improved understanding of the etiological and ecological factors of TCC could lead to further declines in incidence and incidence-based mortality rates.

The frequencies of micronuclei, nucleoplasmic bridges and nuclear buds as biomarkers of genomic instability in patients with urothelial cell carcinoma

Bladder urothelial cell carcinoma (UCC) is an increasingly prevalent cancer worldwide, and thus, gaining a better understanding of its identifiable risk factors is a global priority. This study addressed this public health need with the understanding that cancer-initiating events, such as chromosome breakage, loss and rearrangement, can be reasonably used as biomarkers to evaluate an individual’s cancer risk. Overall, forty bladder cancer patients and twenty controls were evaluated for genomic instability. To the best of the investigators’ knowledge, this is the first study to perform micronucleus (MN) assays simultaneously in urothelial exfoliated cells (UEC), buccal exfoliated cells (BEC), and peripheral blood lymphocytes (PBL) in first-diagnosed, non-smoker bladder UCC patients. Additionally, the frequency of nucleoplasmic bridges (NPBs) and nuclear buds (NBUDs) in PBL was evaluated. The MN frequencies in UEC, BEC, and PBL, as well as the frequencies of NPBs and NBUDs, were significantly higher in patients than in controls. In conclusion, MN assays, particularly in UEC, may be used to identify individuals who are at high risk of developing UCC, as single or as additional triage test to UroVysion FISH test. Our results further validate the efficacy of biomarkers, such as MN, NPBs, and NBUDs, as predictors of genomic instability.

Urine cytology is a feasible tool for assessing erythematous bladder lesions after bacille Calmette-Guérin (BCG) treatment

OBJECTIVES

To investigate the need to biopsy erythematous lesions of the bladder after bacille Calmette-Guérin (BCG) treatment as well as the diagnostic value of voided urine cytology in the detection of recurrence.

MATERIALS AND METHODS

Data on 206 consecutive patients with non-muscle-invasive bladder cancer treated with one or more BCG instillations in the period 2009-2015 at Satakunta Central Hospital and Turku University Hospital were reviewed. Biopsy histology was pooled according to lesion cystoscopy appearance regarding growth pattern and presence of erythema. Voided urine cytology grading before resection was reviewed. We correlated the cystoscopy findings with histology and calculated the sensitivity, specificity, and positive (PPV) and negative predictive value (NPV) for voided urine cytology.

RESULTS

In total, 159 patients with a median follow-up of 35 months were included in the study. Altogether, 367 biopsies were analysed. In the case of papillary or flat tumours, 76% of biopsies showed malignant histology and the diagnostic value of cytology was very limited (sensitivity 33%, specificity 84%). Erythematous lesions constituted 57% of all biopsy targets, with the majority being either chronic non-specific inflammation or granulomatous inflammation; 10% of erythematous lesions were malignant at pathological examination. In contrast to papillary and flat tumours, cytology proved to be more accurate in the case of erythematous lesions with a sensitivity, specificity, PPV and NPV of 59%, 76%, 23% and 94%, respectively.

CONCLUSION

Bladder lesions after BCG instillations pose a challenge during follow-up and the appropriate management strategy is not clear. Lesions should not be overlooked as being BCG-induced irritation because they may harbour significant malignancies. The presence of papillary or flat tumour always warrants a biopsy or resection. In the case of erythematous lesions, our results suggest that biopsy may be avoided if voided urine cytology is negative.

Application of fluorescence in situ hybridization in the detection of bladder transitional-cell carcinoma: A multi-center clinical study based on Chinese population

Objective

To evaluate the diagnostic value of fluorescence in situ hybridization (FISH) in bladder cancer.

Methods

We enrolled healthy volunteers and patients who were clinically suspected to have bladder cancer and conducted FISH tests and cytology examinations from August 2007 to December 2008. Receiver operating characteristic (ROC) curve analysis was performed and the area under curve (AUC) values were calculated for both the FISH and urine cytology tests.

Results

A cohort of 988 healthy volunteers was enrolled to establish a reference range for the normal population. A total of 4807 patients with hematuria were prospectively, randomly enrolled for the simultaneous analysis of urine cytology, FISH testing, and a final diagnosis as determined by the pathologic findings of a biopsy or a surgically-excised specimen. Overall, the sensitivity of FISH in detecting transitional-cell carcinoma was 82.7%, while that of cytology was 33.4% (p < 0.001). The sensitivity values of FISH for non-muscle invasive and muscle invasive bladder transitional-cell carcinoma were 81.7% and 89.6%, respectively (p = 0.004). The sensitivity values of FISH for low and high grade bladder cancer were 82.6% and 90.1%, respectively (p = 0.002).

Conclusion

FISH is significantly more sensitive than voided urine cytology for detecting bladder cancer in patients evaluated for gross hematuria at all cancer grades and stages. Higher sensitivity using FISH was obtained in high grade and muscle invasive tumors.

Diagnostic accuracy of cystoscopy and ultrasonography in the prenatal diagnosis of abnormally invasive placenta

The aim of this study was to compare the accuracy of cystoscopy and ultrasonography for the prenatal diagnosis of abnormally invasive placenta (AIP), including its subgroups: placenta accreta (PA), placenta increta (PI), and placenta percreta (PP).A retrospective observational study including a total of 85 pregnant women at high risk for AIP underwent prenatal cystoscopy and ultrasonography evaluations. The sensitivity (Se), specificity (Sp), positive predictive value, negative predictive value, and exact diagnosed were calculated and compared for both cystoscopy and ultrasonography. Se and Sp values of cystoscopy and ultrasonography were compared by means of the McNemar test.Of the 85 patients, there were 24 (28.2%) PA, 35 (41.2%) PI, 4 (4.7%) PP, and 22 (25.9%) nonadherent placenta. The mean maternal age and gestational age of delivery were 31.88 ± 4.42 years and 36.14 ± 1.84 weeks, respectively. No one was found to develop any complications with cystoscopy like urinary tract infection, or ureteral injury or perforations. Se in the diagnosis of AIP was 50.8% with ultrasonography and 61.9% for cystoscopy. Sp was 86.4% with cystoscopy and 72.7% for ultrasonography. In subgroups, Se with cystoscopy was 25.0%, 62.9%, and 100.0% in PA, PI, and PP, respectively, and 37.5%, 74.3%, and 100.0%, respectively, for ultrasonography; Sp remained unchanged with 86.4% for cystoscopy and 72.7% for ultrasonography. After McNemar test, no difference was found in either Se or Sp between cystoscopy and ultrasonography in AIP and its subgroups.According to the depth of invasion, the diagnostic value of cystoscopy and ultrasonography is all conspicuous increased and they have similar test validity for prenatal diagnosis of AIP and its subgroups.

Aberrant N-Glycosylation Profile of Serum Immunoglobulins is a Diagnostic Biomarker of Urothelial Carcinomas

The aim of this study to determine whether the aberrant N-glycosylated serum immunoglobulins (Igs) can be applied as a diagnostic marker of urothelial carcinoma (UC). Between 2009 and 2016, we randomly obtained serum available from 237 UC and also 96 prostate cancer as other cancer controls from our serum bank and also obtained-from 339 healthy volunteers (HV)-controls obtained from community-dwelling volunteers in Iwaki Health Promotion Project. A total of 32 types of N-glycan levels on Igs were determined by high-throughput N-glycomics and analyzed by multivariable discriminant analysis. We found five UC-associated aberrant N-glycans changes on Igs and also found that asialo-bisecting GlcNAc type N-glycan on Igs were significantly accumulated in UC patients. The diagnostic N-glycan Score (dNGScore) established by combination of five N-glycans on Igs discriminated UC patients from HV and prostate cancer (PC) patients with 92.8% sensitivity and 97.2% specificity. The area under the curve (AUC) for of the dNGScore was 0.969 for UC detection that was much superior to that of urine cytology (AUC, 0.707) and hematuria (AUC, 0.892). Furthermore, dNGScore can detect hematuria and urine cytology negative patients. The dNGscore based on aberrant N-glycosylation signatures of Igs were found to be promising diagnostic biomarkers of UCs.

Anticipatory Positive Urine Tests for Bladder Cancer

PURPOSE

The aim of this study was to establish the criteria defining an anticipatory positive test for bladder cancer.

METHODS

We reviewed all patients at our institution who underwent urine cytology or UroVysion fluorescence in situ hybridization (FISH) and cystoscopy from 2003 to 2012. Test performance and cancer anticipation was assessed using generalized linear mixed models, mixed-effects proportional hazards models, and cumulative incidence curves using tests performed within 30 days of each other as well as within a lag time of 1 year.

RESULTS

Overall, 6729 urine tests (4729 cytology and 2040 UroVysion FISH) were paired with gold-standard cystoscopies. Sensitivity and specificity were 63 and 41% for cytology, and 37 and 84% for UroVysion FISH, respectively. A 1-year lag time allowed for cancer anticipation and neither test improved. Among patients with positive cytology and initially negative cystoscopy, the hazard ratio of developing a bladder tumor at 1 year was 1.83; 76% of these patients developed a tumor within 1 year. Similarly, among patients with a positive FISH and initially negative cystoscopy, the hazard ratio of developing a bladder tumor at 1 year was 1.56; 40% of these patients developed a tumor within 1 year.

CONCLUSIONS

Urine-based tests for bladder cancer are frequently falsely positive. With further follow-up time, some of these false positive tests are vindicated as true (anticipatory) positive tests, although many will remain false positives. We developed statistical criteria to determine if a test anticipates future cancers or not.