Utility of the Bard BTA test in detecting upper urinary tract transitional cell carcinoma

Thulium-laser retrograde intra renal ablation of upper urinary tract transitional cell carcinoma: an ESUT Study

BACKGROUND

Radical nephroureterectomy (RNU) is the gold standard treatment for upper urinary tract urothelial carcinoma (UTUC); however, patients presenting with small low-grade UTUC have been treated by flexible ureteroscopic laser ablation with good outcomes. Different types of laser have been discussed in the literature including Holmium and Neodymium lasers. We aimed to assess the safety and efficacy of Thulium laser (Tm:YAG) in the ureteroscopic ablation of UTUC.

METHODS

A retrospective observational multicentre study of patients diagnosed with papillary UTUC between January 2015 and December 2016 was carried out. All patients underwent ureteroscopic biopsy of the UTUC followed by Tm:YAG ablation. Based on the histopathological grade of the tumor, patients were counseled to undergo either RNU (high- grade tumors) or conservative management and follow-up (low-grade tumor).

RESULTS

RNU was performed in 31 patients, while the remaining 47 patients (undergone Tm:YAG ablation only) were followed up for a mean of 11.7 months with only 19.2% of patients showing upper tract recurrence and no patients showed postoperative ureteral strictures. Limitations include the short follow-up and retrospective nature of the study.

CONCLUSIONS

On the short term, thulium Laser ablation of UTUC is safe and feasible especially in low-grade UTUC.

Urine-based assays for the detection of bladder cancer

Bladder cancer is one of the most prevalent cancers worldwide. Furthermore, nonmuscle invasive bladder cancer has a 70% rate of recurrence, making it a considerable strain to the healthcare system. Patients with bladder cancer require repeat cystoscopic examinations of the bladder to monitor for tumor recurrence. The reason these patients have to undergo these costly, painful, invasive procedures is owing to the absence of accurate urine-based assays to detect the presence of bladder cancer noninvasively. Consequently, the development of a urine-based test to detect bladder cancer would be of tremendous benefit to both patients and healthcare systems. This article reports some of the more prominent urine markers in use today. In addition, the article will highlight some new technologies that are used to investigate novel urinary markers.

Fluorescence in situ hybridization for detecting upper urinary tract tumors--a preliminary report

OBJECTIVES

To evaluate fluorescence in situ hybridization (FISH) in voided urine specimens and selective upper urinary tract washings obtained from patients with suspected transitional cell cancer of the upper urinary tract (UT-TCC).

METHODS

A total of 16 patients with suspected UT-TCC were included in the study. All patients underwent urinary tract imaging. Endoscopy was also performed. Voided urine specimens from all patients and ureteral washings were subjected to cytologic examination and FISH analysis (UroVysion probe set). If indicated, surgery (nephroureterectomy or ureterectomy) was performed.

RESULTS

Of the 16 patients, 9 (56.25%) were diagnosed with UT-TCC. None of the remaining patients was diagnosed with UT-TCC after a mean follow-up of 21.3 months (median 20, range 11 to 36). For FISH analysis, the sensitivity was 87.5% and specificity 80%. FISH analysis was not possible in 1 patient with UT-TCC because of an insufficient number of cells. For cytology, the sensitivity was 60% and specificity 80%. In patients with UT-TCC, the cytologic findings were inconclusive (atypia of uncertain significance) in 4 patients (44.4%). In contrast to the cytology findings, all results of the FISH analysis of the upper urinary tract washings matched those of the voided urine samples.

CONCLUSIONS

Our preliminary data suggest that FISH analysis of voided urine might be a useful ancillary test in the detection of UT-TCC with excellent sensitivity and specificity. If confirmed in larger studies, FISH might contribute to a more reliable and less-invasive diagnostic approach to UT-TCC.

Molecular markers in bladder cancer: A critical appraisal

The diagnosis of both primary and recurrent bladder tumors currently relies upon the urine cytology and cystoscopy. Neither of these diagnostic tools is completely accurate. Prognostication of bladder cancer is largely based on pathologic tumor grade and stage. Over the past 2 decades, there is accumulating evidence that like many other cancers, bladder cancer, too, has a distinct molecular signature that separates it from other cancers and normal bladder tissue. Bladder tumors of different grades and stages even possess unique, and specific genotypic and phenotypic characteristics. Although recognition of several of these molecular alterations is possible by analyzing tumor tissue, urine, and serum samples, few if any of these "molecular markers" for bladder cancer are widely used in clinical practice. These markers include some that can be applied during the diagnostic work-up of symptoms (e.g., hematuria), those under surveillance for recurrence of superficial disease and forecasting long-term prognosis, or response to chemotherapy. In this review of molecular markers for bladder cancer, effectiveness of markers in each of these categories that are identifiable in the urine of patients with bladder cancer was examined. Many of the diagnostic markers appear to hold an advantage over urine cytology in terms of sensitivity, especially for the detection of low-grade superficial tumors. However, most markers tend to be less specific than cytology, yielding more false-positives. This result is more commonly observed in patients with concurrent bladder inflammation or other benign bladder conditions. Although there are several candidate markers for assessing prognosis or response to chemotherapy, studies of large patient populations are lacking. Further studies involving larger numbers of patients are required to determine their accuracy and widespread applicability in guiding treatment of bladder cancer.

Retrograde endoscopic laser therapy and ureteroscopic surveillance for transitional cell carcinoma of the upper urinary tract

OBJECTIVE

To investigate the efficacy of endoscopic laser therapy and ureteroscopic surveillance for transitional cell carcinoma (TCC) of the upper urinary tract.

METHODS

Tumors of the upper urinary tract were detected at ureteroscopy. After TCC was diagnosed by biopsy, retrograde endoscopic laser therapy was performed. Recurrent tumors were treated endoscopically and the patients were followed by ureteroscopic surveillance at 3- to 6-month intervals.

RESULTS

Seven patients underwent ureteroscopic treatment. The tumor was grade 1 in five patients and grade 2 in two patients. The average tumor size was 1.3 cm. One patient with large, multifocal tumors died of metastatic disease, and one died of an unrelated cause. One patient requested nephroureterectomy after endoscopic treatment. The remaining four patients were followed up for a mean of 32 months after initial treatment. Each patient received an average of 5.3 ureteroscopic surveillance procedures while 3.3 recurrences on average were detected. Recurrence occurred in all the patients who showed normal radiographic findings. Urine cytology was also of little value in predicting tumor recurrence, except in one patient with carcinoma in situ. The recurrent tumors detected by ureteroscopy were successfully treated by repeated endoscopic procedures. After the follow up, three patients remained alive with no signs indicative of disease, but one patient with an initial grade 2 tumor died of recurrence after 30 months.

CONCLUSIONS

Given that ureteroscopic evaluation is essential for surveillance after endoscopic treatment of upper urinary tract TCC because of residual concern about recurrence, patients treated endoscopically should be recommended to undergo long-term endoscopic follow up.

RETRACTED: Highly specific urine-based marker of bladder cancer

OBJECTIVES

Bladder cancer represents a major health problem throughout the world, but advances in tumor biomarker development are revolutionizing how physicians diagnose the disease. We previously used an indirect immunoassay to demonstrate that the bladder cancer specific biomarker, BLCA-4, is present in urine samples from patients with bladder cancer, but not in samples from healthy individuals. In this study, a sandwich immunoassay was used to measure BLCA-4 in urine samples from patient populations with various urologic conditions and healthy individuals.

METHODS

Urine was collected from healthy individuals and from patients with bladder cancer, benign urologic conditions, or prostate cancer. BLCA-4 levels were evaluated by a sandwich immunoassay using two antibodies directed against distinct epitopes on BLCA-4.

RESULTS

Using a prospectively determined cutoff of an absorbance unit (OD) of 0.04, 67 of the 75 samples from patients with bladder cancer were positive for BLCA-4, resulting in an assay sensitivity of 89%. Also, 62 of the 65 samples from individuals without bladder cancer were negative for BLCA-4, resulting in an assay specificity of 95%.

CONCLUSIONS

The high sensitivity and specificity of the sandwich BLCA-4 immunoassay may allow for earlier detection and treatment of disease, thus greatly improving patient care.

Current Practice Patterns in Urologic Management of Upper-Tract Transitional-Cell Carcinoma

PURPOSE

To determine the current practice patterns in the management of upper-tract transitional-cell carcinoma (TCC) among a large group of urologists.

MATERIALS AND METHODS

A survey was sent to 220 practicing members of the Society of Urologic Oncology (SUO) and the Endourological Society (ES) and members of the American Urological Association who did not belong to either society. The survey consisted of 16 focused questions pertaining to the surveillance and management of upper-tract TCC. The responses were used to create a database, which was then analyzed to determine practice trends.

RESULTS

Eighty-four of the urologists responded, for a response rate of 38%. Fourteen responses were excluded because of multiple answers to a given question, so 70 were included in the final analysis. Eighty percent of the respondents were in academic practice. A CT urogram was the favored initial procedure for diagnosis of upper-tract TCC and an intravenous urogram was the next commonest choice (53% and 40%, respectively). Ureterorenoscopy was the surveillance tool of choice (70%) after conservative treatment of upper- tract TCC. Laparoscopic nephroureterectomy was the preferred procedure (73%) for a high-grade, large renal-pelvic TCC. Twenty-one percent of the endourologists recommended ureteroscopic ablation for a high-grade, large distal ureteral tumor. This was in sharp contrast to 77% of the respondents who favored a distal ureterectomy for the same clinical scenario.

CONCLUSIONS

This study confirms that most urologists treating upper-tract TCC follow the principles reported in the published literature regarding the management of these patients. Further, most urologists, regardless of society affiliations or years in practice, favor minimally invasive techniques for the management of upper-tract TCC. This information may be useful in formulating clear guidelines for the management of this disease.

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

PURPOSE OF REVIEW

Cystoscopy is currently considered the gold standard for the detection of bladder tumours. The role of urine cytology in the initial detection and follow-up of patients is under discussion. Many efforts have been made to increase the detection rates and to predict the outcome of bladder cancer. In this subject review, a series of morphology-based, biochemical and molecular markers were compared with urine cytology for the detection of bladder cancer.

RECENT FINDINGS

Among the various markers reviewed, the average published sensitivity and specificity for the Bard tumour antigen test was 60 and 77%; for the nuclear matrix protein 22 test it was 67 and 72%; for the hyaluronic acid and hyaluronidase test it was 91 and 84%; for the ImmunoCyt it was 90 and 75%; for fluorescence in-situ hybridization it was 85 and 95%; for the telomerase assay it was 77 and 85%; and for the microsatellite assay it was 89 and 100%. DNA ploidy measurements, recent molecular markers and immunoassays designed to detect keratins, proteins, cell adhesion molecules, fibrinogen degradation products, and fibrinolysis markers were also included.

SUMMARY

As is clear from the brief summary of available assays, the optimal method of application is not yet clear. The integration of an assay into clinical practice takes more than just the documentation of its sensitivity and specificity. However, several of the procedures have received considerable support from urologists as assisting them in the management of their patients.

Surveillance and management of recurrence for upper tract transitional cell carcinoma

Surveillance of treated upper tract TCC must be tailored to each patient based on individual tumor characteristics. Important risk factors include tumor stage, grade, and multifocality. Molecular markers for TCC may assist in future surveillance strategies, but for now remain experimental. Improvements in imaging eventually may provide the sensitivity needed to determine tumor stage, which would make both initial and recurrence management decisions much more accurate. Initial surgical treatment will influence surveillance when it pertains to superficial disease treated conservatively with either open segmental resection or, now more commonly, with endoscopic resection. Patients treated in this manner require vigilant surveillance of the ipsilateral ureter. Direct visualization in combination with cytology currently appears to be the most effective method, using the same timelines as those used for bladder TCC. Prospective studies concerning surveillance protocols for upper tract TCC would certainly provide more evidence for the current recommendations. However, the evidence does show that upper tract TCC behaves biologically much in the same fashion as does bladder TCC. In light of this fact, the current recommendations are meant to suggest following a patient after treatment for upper tract TCC in a manner similar to that used to follow a patient after treatment of bladder TCC, with individual strategies based on tumor characteristics. For superficial disease, the technology now exists to moniter a patient after endoscopic resection of an upper tract tumor in exactly the same manner used to follow a patient after endoscopic resection of a bladder tumor.

Transitional cell carcinoma of the ureter and renal pelvis

Transitional cell carcinoma (TCC) of ureter and renal pelvis is relatively uncommon. Smoking, occupational carcinogens, analgesic abuse, Balkan nephropathy are the risk factors. Cytogenetic studies revealed that the most frequent aberration is the partial or complete loss of chromosome 9. Approximately 20-50% of patients with upper urinary tract (UUT) TCC have bladder cancer at some point on their course, whereas the incidence of UUT TCC after primary bladder cancer is 0.7-4%. Excretory urography and retrograde pyelography are the conventional diagnostic tools; however, ureteropyeloscopy combined with cytology and biopsy is more accurate. Grade and stage of the disease have the most significant impact on survival. Nephroureterectomy with bladder cuff excision has been the mainstay of treatment. Local resection may be appropriate for distal ureteral lesions especially when the disease is low grade and stage. Advances in endourology have made it possible to treat many tumors conservatively. Ureteroscopic and to a certain extent percutaneous surgical approaches are widely used today especially in patients with low grade, low stage disease. Endoscopic close surveillance is mandatory for these patients. Adjuvant topical therapies appear to be safe but confirmation of any benefits awaits the results of further large studies. More recently, laparoscopic techniques have become a viable alternative to open surgery, but long term cancer control data are lacking. Aggressive surgical resection does not affect the outcome of patients with advanced disease. Adjuvant radiotherapy is ineffective, and systemic chemotherapy results in a low complete response rate for patients with metastases.

Detecting recurrent bladder cancer: new methods and biomarkers

In this review, a series of biomarkers and molecular assays are compared with conventional urothelial cytology in their ability to detect recurrent bladder cancer. The tests considered in detail include the BTA test, NMP 22 test, DNA ploidy measurements, telomerase determinations and microsatellite instability assays. Although all of these measurements show some degree of improvement for cancer detection, the microsatellite instability assay shows the highest sensitivity and specificity. Additional biomarkers considered in the review include bladder cancer tumor antigens, growth factors, cell adhesion molecules and various molecular markers including cell cycle regulatory genes and p53 mutations.

Urine based markers of urological malignancy

PURPOSE

A number of urine based markers have been and are being investigated for the diagnosis and prognostication of urological conditions. A majority of these markers have been evaluated in urological neoplasms, particularly bladder cancer. The diagnosis of bladder cancer currently relies on identifying malignant cells in the urine and subsequently visualizing the tumor on cystoscopy. This diagnosis is further confirmed by transurethral resection or biopsy. While urine cytology is specific, it is not sensitive, especially for detecting low grade disease. This characteristic has prompted the search for more accurate markers of bladder cancer. In this review we critically examine the results of studies evaluating various markers for bladder cancer.

MATERIALS AND METHODS

The published literature on urine based markers for all urological diseases, particularly bladder cancer, was identified using a MEDLINE search and critically analyzed. The sensitivity, specificity, positive and negative predictive values of the various markers were compared. The benefit of using combined markers rather than a single marker was also analyzed from published reports.

RESULTS

Most published literature on urine based markers for urological malignancies involve such markers for diagnosing and prognosticating bladder cancer. Hence, we focused mainly on urine based markers in bladder cancer. Most markers appear to have an advantage over urine cytology in terms of sensitivity, especially for detecting low grade, superficial tumors. However, most markers tend to be less specific than cytology, yielding more false-positive results. This scenario is more common in patients with concurrent bladder inflammation or other benign bladder conditions. However, there is reason to be optimistic about several new markers that appear to provide better specificity. Few urine based markers have been identified and investigated in other urological tumors.

CONCLUSIONS

Detecting bladder cancer using diagnostic markers still presents a challenge. A number of new markers are currently available that appear to be significantly more accurate than cytology. However, further studies involving a larger number of patients are required to determine their accuracy and widespread applicability for diagnosing bladder cancer. Urine based markers do not appear to have a significant role in the diagnosis or prognosis of other urological malignancies, such as prostate, kidney or testicular cancer.

Biomarkers for the detection of bladder cancer

In this subject review, a series of morphology-based and molecular markers were compared with urinary cytology for the detection of recurrent urothelial neoplasia. Among the various biomarkers reviewed, the average published sensitivity and specificity for the Bard BTA test was 60% and 77%; the NMP22 Test was 67% and 72%; the telomerase assay was 77% and 85%; and the microsatellite assay was 89% and 100%. DNA ploidy measurements and immunoassays designed to detect keratins, proteins, hyaluronidase, growth factors, cell adhesion molecules, fibrinogen degradation products, cell cycle regulators, and molecular markers were also included. Although the performance features of these biomarkers have varied and the cytologic methods to which they have been compared have not been standardized, several of the procedures have received considerable support from urologists as assisting them in the management of their patients.

Surveillance of upper urinary tract transitional cell carcinoma: the role of ureteroscopy, retrograde pyelography, cytology and urinalysis

PURPOSE

A select group of patients with upper tract transitional cell carcinoma are treated with ureteroscopic resection. We determine the validity and accuracy of urinalysis, bladder cytology, upper tract biopsy/cytology and retrograde pyelography for the detection of recurrent upper tract transitional cell carcinoma compared to endoscopic findings.

MATERIALS AND METHODS

Patients with ureteroscopically treated upper tract transitional cell carcinoma were followed with surveillance every 3 to 6 months. Surveillance included urinalysis with dipstick and microscopic examination, bladder cytology, retrograde pyelography read by a urologist and radiologist, and ureteropyeloscopy with cytology and biopsy of suspicious areas. Not all results were available for all surveillance procedures. Measures of sensitivity and specificity for the aforementioned surveillance procedures were determined relative to endoscopic findings that were defined as the standard. Confidence intervals were also estimated. Initially, a generalized estimation equation approach was used to take into account the clustering of repeated testing within patients. The accuracy of each procedure was also calculated.

RESULTS

There were 23 patients with previously resected low grade upper tract transitional cell carcinoma who underwent a total of 88 surveillances in 30 months. A total of 56 of 88 (64%) recurrences were detected ureteroscopically, including 11 (12%) associated bladder recurrences. In patients who did not have bladder recurrences urinalysis had a sensitivity of 37.5% but specificity was 85%, while bladder cytology had a sensitivity of 50% and specificity was 100%, and retrograde pyelography read in the endoscopy room revealed a sensitivity of 71.7% and specificity of 84.7%. Ureteroscopic biopsy/cytology had a sensitivity and specificity of 93.4% and 65.2%, respectively.

CONCLUSIONS

Our findings indicate that compared to ureteroscopy, urinalysis, bladder cytology, retrograde pyelography and ureteroscopic cytology/biopsy are less valid and accurate in detecting upper tract transitional cell carcinoma recurrences. Based on our data we recommend ureteroscopic evaluation as an essential procedure for the surveillance of patients treated endoscopically for upper tract transitional cell carcinoma.