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Fan J, Chen B, Luo Q, Li J, Huang Y, Zhu M, Chen Z, Li J, Wang J, Liu L, Wei Q, Cao D. Potential molecular biomarkers for the diagnosis and prognosis of bladder cancer. Biomed Pharmacother 2024; 173:116312. [PMID: 38417288 DOI: 10.1016/j.biopha.2024.116312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/07/2024] [Accepted: 02/17/2024] [Indexed: 03/01/2024] Open
Abstract
Bladder cancer (BC) is a common malignant tumor of urinary system, which can be divided into muscle-invasive BC (MIBC) and nonmuscle-invasive BC (NMIBC). The number of BC patients has been gradually increasing currently. At present, bladder tumours are diagnosed and followed-up using a combination of cystoscopic examination, cytology and histology. However, the detection of early grade tumors, which is much easier to treat effectively than advanced stage disease, is still insufficient. It frequently recurs and can progress when not expeditiously diagnosed and monitored following initial therapy for NMIBC. Treatment strategies are totally different for different stage diseases. Therefore, it is of great practical significance to study new biomarkers for diagnosis and prognosis. In this review, we summarize the current state of biomarker development in BC diagnosis and prognosis prediction. We retrospectively analyse eight diagnostic biomarkers and eight prognostic biomarkers, in which CK, P53, PPARγ, PTEN and ncRNA are emphasized for discussion. Eight molecular subtype systems are also identified. Clinical translation of biomarkers for diagnosis, prognosis, monitoring and treatment will hopefully improve outcomes for patients. These potential biomarkers provide an opportunity to diagnose tumors earlier and with greater accuracy, and help identify those patients most at risk of disease recurrence.
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Affiliation(s)
- Junping Fan
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China; West China School of Medicine, Sichuan University, Chengdu, China
| | - Bo Chen
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China; West China School of Medicine, Sichuan University, Chengdu, China
| | - Qiuping Luo
- Out-patient Department, West China Hospital, Sichuan University, Chengdu, China
| | - Jinze Li
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China; West China School of Medicine, Sichuan University, Chengdu, China
| | - Yin Huang
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China; West China School of Medicine, Sichuan University, Chengdu, China
| | - Mengli Zhu
- Research Core Facility, West China Hospital, Sichuan University, Chengdu, China
| | - Zeyu Chen
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China; West China School of Medicine, Sichuan University, Chengdu, China
| | - Jin Li
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China; West China School of Medicine, Sichuan University, Chengdu, China
| | - Jia Wang
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Liangren Liu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Qiang Wei
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.
| | - Dehong Cao
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.
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Abstract
Bladder cancer is a global health issue with sex differences in incidence and prognosis. Bladder cancer has distinct molecular subtypes with multiple pathogenic pathways depending on whether the disease is non-muscle invasive or muscle invasive. The mutational burden is higher in muscle-invasive than in non-muscle-invasive disease. Commonly mutated genes include TERT, FGFR3, TP53, PIK3CA, STAG2 and genes involved in chromatin modification. Subtyping of both forms of bladder cancer is likely to change considerably with the advent of single-cell analysis methods. Early detection signifies a better disease prognosis; thus, minimally invasive diagnostic options are needed to improve patient outcomes. Urine-based tests are available for disease diagnosis and surveillance, and analysis of blood-based cell-free DNA is a promising tool for the detection of minimal residual disease and metastatic relapse. Transurethral resection is the cornerstone treatment for non-muscle-invasive bladder cancer and intravesical therapy can further improve oncological outcomes. For muscle-invasive bladder cancer, radical cystectomy with neoadjuvant chemotherapy is the standard of care with evidence supporting trimodality therapy. Immune-checkpoint inhibitors have demonstrated benefit in non-muscle-invasive, muscle-invasive and metastatic bladder cancer. Effective management requires a multidisciplinary approach that considers patient characteristics and molecular disease characteristics.
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Affiliation(s)
- Lars Dyrskjøt
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Donna E Hansel
- Division of Pathology and Laboratory Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Margaret A Knowles
- Division of Molecular Medicine, Leeds Institute of Medical Research at St James's, St James's University Hospital, Leeds, UK
| | - Matthew D Galsky
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeremy Teoh
- S.H. Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Dan Theodorescu
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Liu Q, Huang J, Yan W, Liu Z, Liu S, Fang W. FGFR families: biological functions and therapeutic interventions in tumors. MedComm (Beijing) 2023; 4:e367. [PMID: 37750089 PMCID: PMC10518040 DOI: 10.1002/mco2.367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/28/2023] [Accepted: 08/11/2023] [Indexed: 09/27/2023] Open
Abstract
There are five fibroblast growth factor receptors (FGFRs), namely, FGFR1-FGFR5. When FGFR binds to its ligand, namely, fibroblast growth factor (FGF), it dimerizes and autophosphorylates, thereby activating several key downstream pathways that play an important role in normal physiology, such as the Ras/Raf/mitogen-activated protein kinase kinase/extracellular signal-regulated kinase, phosphoinositide 3-kinase (PI3K)/AKT, phospholipase C gamma/diacylglycerol/protein kinase c, and signal transducer and activator of transcription pathways. Furthermore, as an oncogene, FGFR genetic alterations were found in 7.1% of tumors, and these alterations include gene amplification, gene mutations, gene fusions or rearrangements. Therefore, FGFR amplification, mutations, rearrangements, or fusions are considered as potential biomarkers of FGFR therapeutic response for tyrosine kinase inhibitors (TKIs). However, it is worth noting that with increased use, resistance to TKIs inevitably develops, such as the well-known gatekeeper mutations. Thus, overcoming the development of drug resistance becomes a serious problem. This review mainly outlines the FGFR family functions, related pathways, and therapeutic agents in tumors with the aim of obtaining better outcomes for cancer patients with FGFR changes. The information provided in this review may provide additional therapeutic ideas for tumor patients with FGFR abnormalities.
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Affiliation(s)
- Qing Liu
- Cancer CenterIntegrated Hospital of Traditional Chinese MedicineSouthern Medical UniversityGuangzhouGuangdongChina
| | - Jiyu Huang
- Cancer CenterIntegrated Hospital of Traditional Chinese MedicineSouthern Medical UniversityGuangzhouGuangdongChina
| | - Weiwei Yan
- Cancer CenterIntegrated Hospital of Traditional Chinese MedicineSouthern Medical UniversityGuangzhouGuangdongChina
| | - Zhen Liu
- Cancer CenterIntegrated Hospital of Traditional Chinese MedicineSouthern Medical UniversityGuangzhouGuangdongChina
- Key Laboratory of Protein Modification and DegradationBasic School of Guangzhou Medical UniversityGuangzhouGuangdongChina
| | - Shu Liu
- Department of Breast SurgeryThe Affiliated Hospital of Guizhou Medical UniversityGuiyangGuizhouChina
| | - Weiyi Fang
- Cancer CenterIntegrated Hospital of Traditional Chinese MedicineSouthern Medical UniversityGuangzhouGuangdongChina
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Matuszczak M, Kiljańczyk A, Salagierski M. A Liquid Biopsy in Bladder Cancer—The Current Landscape in Urinary Biomarkers. Int J Mol Sci 2022; 23:ijms23158597. [PMID: 35955727 PMCID: PMC9369188 DOI: 10.3390/ijms23158597] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/27/2022] [Accepted: 07/30/2022] [Indexed: 02/06/2023] Open
Abstract
The non-muscle invasive bladder cancer tends to recur and progress. Therefore, it requires frequent follow-ups, generating costs and making it one of the most expensive neoplasms. Considering the expensive and invasive character of the current gold-standard diagnostic procedure, white-light cystoscopy, efforts to find an alternative method are ongoing. Although the last decade has seen significant advancements in urinary biomarker tests (UBTs) for bladder cancer, international guidelines have not recommended them. Currently, the paramount urgency is to find and validate the test with the best specificity and sensitivity, which would allow for the optimizing of diagnosis, prognosis, and a treatment plan. This review aims to summarise the up-to-date state of knowledge relating to UBTs and new developments in the detection, prognosis, and surveillance of bladder cancer and their potential applications in clinical practice.
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Hu X, Li G, Wu S. Advances in Diagnosis and Therapy for Bladder Cancer. Cancers (Basel) 2022; 14:cancers14133181. [PMID: 35804953 PMCID: PMC9265007 DOI: 10.3390/cancers14133181] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/19/2022] [Accepted: 06/24/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary The clinical management of bladder cancer has been developing in the past decade, including diagnostic tools and treatment options. Both monotherapy and combination therapy have been undoubtedly upgraded. Multiple diagnostic techniques and therapeutic strategies have been developed to meet the urgent clinical needs, resulting in the emergence of various explorations for cancer diagnosis and therapy. In this review, we mainly focus on the advances in the diagnosis and treatment of bladder cancer. Abstract Bladder cancer (BCa) is one of the most common and expensive urinary system malignancies for its high recurrence and progression rate. In recent years, immense amounts of studies have been carried out to bring a more comprehensive cognition and numerous promising clinic approaches for BCa therapy. The development of innovative enhanced cystoscopy techniques (optical techniques, imaging systems) and tumor biomarkers-based non-invasive urine screening (DNA methylation-based urine test) would dramatically improve the accuracy of tumor detection, reducing the risk of recurrence and progression of BCa. Moreover, intravesical instillation and systemic therapeutic strategies (cocktail therapy, immunotherapy, vaccine therapy, targeted therapy) also provide plentiful measures to break the predicament of BCa. Several exploratory clinical studies, including novel surgical approaches, pharmaceutical compositions, and bladder preservation techniques, emerged continually, which are supposed to be promising candidates for BCa clinical treatment. Here, recent advances and prospects of diagnosis, intravesical or systemic treatment, and novel drug delivery systems for BCa therapy are reviewed in this paper.
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Affiliation(s)
- Xinzi Hu
- Institute of Urology, The Affiliated Luohu Hospital of Shenzhen University, Shenzhen University, Shenzhen 518000, China; (X.H.); (G.L.)
- Department of Urology, South China Hospital, Health Science Center, Shenzhen University, Shenzhen 518116, China
| | - Guangzhi Li
- Institute of Urology, The Affiliated Luohu Hospital of Shenzhen University, Shenzhen University, Shenzhen 518000, China; (X.H.); (G.L.)
- Department of Urology, South China Hospital, Health Science Center, Shenzhen University, Shenzhen 518116, China
| | - Song Wu
- Institute of Urology, The Affiliated Luohu Hospital of Shenzhen University, Shenzhen University, Shenzhen 518000, China; (X.H.); (G.L.)
- Department of Urology, South China Hospital, Health Science Center, Shenzhen University, Shenzhen 518116, China
- Correspondence:
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Lokeshwar SD, Lopez M, Sarcan S, Aguilar K, Morera DS, Shaheen DM, Lokeshwar BL, Lokeshwar VB. Molecular Oncology of Bladder Cancer from Inception to Modern Perspective. Cancers (Basel) 2022; 14:cancers14112578. [PMID: 35681556 PMCID: PMC9179261 DOI: 10.3390/cancers14112578] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 02/05/2023] Open
Abstract
Within the last forty years, seminal contributions have been made in the areas of bladder cancer (BC) biology, driver genes, molecular profiling, biomarkers, and therapeutic targets for improving personalized patient care. This overview includes seminal discoveries and advances in the molecular oncology of BC. Starting with the concept of divergent molecular pathways for the development of low- and high-grade bladder tumors, field cancerization versus clonality of bladder tumors, cancer driver genes/mutations, genetic polymorphisms, and bacillus Calmette-Guérin (BCG) as an early form of immunotherapy are some of the conceptual contributions towards improving patient care. Although beginning with a promise of predicting prognosis and individualizing treatments, "-omic" approaches and molecular subtypes have revealed the importance of BC stem cells, lineage plasticity, and intra-tumor heterogeneity as the next frontiers for realizing individualized patient care. Along with urine as the optimal non-invasive liquid biopsy, BC is at the forefront of the biomarker field. If the goal is to reduce the number of cystoscopies but not to replace them for monitoring recurrence and asymptomatic microscopic hematuria, a BC marker may reach clinical acceptance. As advances in the molecular oncology of BC continue, the next twenty-five years should significantly advance personalized care for BC patients.
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Affiliation(s)
- Soum D. Lokeshwar
- Department of Urology, Yale University School of Medicine, New Haven, CT 06520, USA;
| | - Maite Lopez
- Departments of Biochemistry and Molecular Biology, Medical College of Georgia, Augusta University, 1410 Laney Walker Blvd., Augusta, GA 30912, USA; (M.L.); (S.S.); (K.A.); (D.S.M.)
| | - Semih Sarcan
- Departments of Biochemistry and Molecular Biology, Medical College of Georgia, Augusta University, 1410 Laney Walker Blvd., Augusta, GA 30912, USA; (M.L.); (S.S.); (K.A.); (D.S.M.)
- Department of Urology, University Hospital Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
| | - Karina Aguilar
- Departments of Biochemistry and Molecular Biology, Medical College of Georgia, Augusta University, 1410 Laney Walker Blvd., Augusta, GA 30912, USA; (M.L.); (S.S.); (K.A.); (D.S.M.)
| | - Daley S. Morera
- Departments of Biochemistry and Molecular Biology, Medical College of Georgia, Augusta University, 1410 Laney Walker Blvd., Augusta, GA 30912, USA; (M.L.); (S.S.); (K.A.); (D.S.M.)
| | - Devin M. Shaheen
- Yale School of Nursing, Yale University, New Haven, CT 06520, USA;
| | - Bal L. Lokeshwar
- Georgia Cancer Center, Medical College of Georgia, Augusta University, 1410 Laney Walker Blvd., Augusta, GA 30912, USA
- Research Service, Charlie Norwood VA Medical Center, Augusta, GA 30904, USA
- Correspondence: (B.L.L.); (V.B.L.)
| | - Vinata B. Lokeshwar
- Departments of Biochemistry and Molecular Biology, Medical College of Georgia, Augusta University, 1410 Laney Walker Blvd., Augusta, GA 30912, USA; (M.L.); (S.S.); (K.A.); (D.S.M.)
- Correspondence: (B.L.L.); (V.B.L.)
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Gao J, Prachyathipsakul T, Thayumanavan S. Multichannel dual protein sensing using amphiphilic supramolecular assemblies. Chem Commun (Camb) 2021; 57:12828-12831. [PMID: 34787137 PMCID: PMC8771897 DOI: 10.1039/d1cc05407d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Protein sensing strategies have implications in detection of many human pathologies. Here, a supramolecular strategy for sensing two different proteins using a multichannel readout approach is outlined. Protein-ligand binding or enzymatic cleavage can both be programmed to induce supramolecular disassembly, which leads to fluorescence enhancement via aggregation-induced emission (AIE), protein-induced fluorescence enhancement (PIFE), or disassembly-induced fluorescence enhancement (DIFE). The accompanying signal change from two different fluorophores and their patterns are then used for specific protein sensing.
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Affiliation(s)
- Jingjing Gao
- Department of Chemistry, University of Massachusetts Amherst, MA, 01002, USA.
| | | | - S Thayumanavan
- Department of Chemistry, University of Massachusetts Amherst, MA, 01002, USA.
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Bamias A, Koutsoukos K, Gavalas N, Zakopoulou R, Tzannis K, Dedes N, Boulouta A, Fragkoulis C, Kostouros E, Dellis A, Mitsogiannis I, Adamakis I, Anastasiou I, Skolarikos A, Papatsoris A, Stravodimos K, Ferakis N, Pagoni S, Ntoumas K, Mitropoulos D, Deliveliotis C, Constantinides CA, Dimopoulos MA. ERCC1 19007 Polymorphism in Greek Patients with Advanced Urothelial Cancer Treated with Platinum-Based Chemotherapy: Effect of the Changing Treatment Paradigm: A Cohort Study by the Hellenic GU Cancer Group. Curr Oncol 2021; 28:4474-84. [PMID: 34898581 DOI: 10.3390/curroncol28060380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/20/2021] [Accepted: 11/01/2021] [Indexed: 11/16/2022] Open
Abstract
We previously showed that ERCC1 19007 C>T polymorphism was associated with cancer-specific survival (CSS) after platinum-based chemotherapy in patients with advanced urothelial cancer (aUC). We aimed to confirm this association in a different cohort of patients. Genotyping of the 19007C>T polymorphism was carried out by polymerase chain reaction (PCR) amplification and restriction fragment length polymorphism (RFLP) in 98 aUC patients, treated with platinum-based chemotherapy. Median age of the patients was 68.8, 13.3% of them were female, 90.8% had ECOG PS of 0 or 1, and 48% received cisplatin-based chemotherapy. In addition to chemotherapy, 32.7% of the patients received immunotherapy, and 19.4% vinflunine. Eighty-one patients (82.7%) were carriers of the 19007T polymorphic allele: 46 (46.9%) were heterozygotes, and 35 (35.7%) were homozygotes. The ERCC1 polymorphism was not associated with CSS, progression-free (PFS), or overall (OS) survival in the total population. Nevertheless, there was a significant interaction between the prognostic significance of ERCC1 polymorphism and the use of modern immunotherapy: the T allele was associated with worse outcome in patients who received chemotherapy only, while this association was lost in patients who received both chemotherapy and immune checkpoint inhibitors. Our study suggests that novel therapies may influence the significance of ERCC1 polymorphism in patients with aUC. Its determination may be useful in the changing treatment landscape of the disease.
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Feldman AS, Lokeshwar V, Lin DW. A 25-year perspective on evaluation and understanding of biomarkers in urologic cancers. Urol Oncol 2021:S1078-1439(21)00269-6. [PMID: 34315659 DOI: 10.1016/j.urolonc.2021.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 12/15/2022]
Abstract
The past 25 years have witnessed an explosion of investigative attempts to identify clinically useful biomarkers which can have meaningful impacts for patients with urologic cancers. However, in spite of the enormous amount of research aiming to identify markers with the hope of impacting patient care, only a handful have proven to have true clinical utility. Improvements in targeted imaging, pan-omics evaluation, and genetic sequencing at the tissue and single-cell levels have yielded many potential targets for continued biomarker investigation. This article, as one in this series for the 25th Anniversary Issue of Urologic Oncology: Seminars and Original Investigations, serves to give a perspective on our progress and failures over the past quarter-century in our highest volume urologic cancers: prostate, bladder, and kidney cancers.
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Shlyapnikov YM, Malakhova EA, Vinarov AZ, Zamyatnin AA, Shlyapnikova EA. Can new immunoassay techniques improve bladder cancer diagnostics With protein biomarkers? Front Mol Biosci 2021; 7:620687. [PMID: 33659273 PMCID: PMC7917292 DOI: 10.3389/fmolb.2020.620687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/30/2020] [Indexed: 12/15/2022] Open
Abstract
The search for new diagnostic tests for cancer or ways to improve existing tests is primarily driven by the desire to identify the disease as early as possible. In this report, we summarize the current knowledge of the most promising diagnostic protein bladder cancer (BC) markers reported over the last decade. Unfortunately, analysis of published data suggests that a reliable, highly sensitive biomarker test-system based on ELISA for detecting BC has not yet been developed. The use of more sensitive assays to detect ultra-low concentrations of biomarkers not available for ELISA, could be very beneficial. Based on the literature and pilot experimental data, we conclude that a highly sensitive immunoassay using microarrays and magnetic labels, could be an effective and cheap technique suitable for the detection of diagnostically relevant BC biomarkers.
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Affiliation(s)
- Yuri M Shlyapnikov
- Institute of Theoretical and Experimental Biophysics RAS, Pushchino, Russia
| | | | - Andrey Z Vinarov
- Institute for Urology and Reproductive Health, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Andrey A Zamyatnin
- Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, Moscow, Russia.,Institute of Molecular Medicine, Sechenov First Moscow State Medical University, Moscow, Russia.,Department of Biotechnology, Sirius University of Science and Technology, Sochi, Russia
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