Reflex ImmunoCyt Testing for the Diagnosis of Bladder Cancer in Patients with Atypical Urine Cytology

Background

ImmunoCyt/uCyt (Scimedx, Denville, NJ, USA) is a well-established urinary marker assay with high sensitivity for the diagnosis of urothelial carcinoma (UC) and can function as a second-level test to arbitrate atypical reads of urine cytology.

Objective

To determine the utility of uCyt as a reflex test for atypical cytology in patients undergoing a hematuria evaluation or surveillance with a history of UC.

Design, setting, and participants

The uCyt assay was performed as a second-level reflex test on all voided urine cytology tests read as atypical between January 2007 and June 2010 in an academic medical center. Records were retrospectively reviewed. Three hundred twenty-four patients underwent a total of 506 uCyt assays.

Intervention

Reflex uCyt assay on atypical urine cytology.

Outcome measurements and statistical analysis

The uCyt test characteristics include sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV).

Results and limitations

Reflex uCyt was performed on 506 atypical voided urine samples that were followed by cystoscopy within 90 d. Reflex uCyt with a history of UC showed a sensitivity of 73%, a specificity of 49%, and an NPV of 80%. In those with a history of low-grade UC, reflex uCyt had a sensitivity of 75%, a specificity of 50%, and an NPV of 82%, while in those with a history of high-grade UC, it had a sensitivity of 74%, a specificity of 44%, and an NPV of 79%. Without prior history of UC, reflex uCyt had a sensitivity of 85%, a specificity of 59%, and an NPV of 94%. This study's limitations include its retrospective design and interobserver variability inherent to cystoscopy, which was used as the reference test.

Conclusions

When used as a reflex test on atypical urine cytology, negative uCyt may predict a negative cystoscopy in select patients and modulate the urgency and further work-up in those with no prior history or low-grade disease.     

端粒酶逆转录酶与血管内皮细胞生长因子在前列腺癌中的表达及其相关性的研究

目的:探讨端粒酶逆转录酶(TRT)、血管内皮细胞生长因子(VEGF)在前列腺癌(PCa)中的表达及两者的相关性。方法:应用免疫组化染色(SP)法结合计算机辅助图像分析方法,对30例病理证实为PCa和30例良性前列腺增生(BPH)穿刺标本中的TRT、VEGF的表达进行半定量分析。结果:30例PCa标本中,TRT、VEGF阳性表达率分别是63.3%(19/30)和76.7%(23/30);30例BPH标本中,TRT、VEGF阳性表达率分别是16.7%(5/30)和46.7%(14/30),组间差异均有显著性意义(P<0.05)。TRT与VEGF的表达显著相关(r=0.833 3,P<0.05)。结论:TRT、VEGF的表达可能是PCa的恶性表型,两者的表达具有显著相关性,但其确切机制还需深入研究。     

Chorionic Gonadotropin β-Subunit and Core Fragment in Bladder Cancer: mRNA and Protein Expression in Urine, Serum and Tissue

Objectives: Many transitional cell carcinomas (TCC) of the bladder express the β-subunit (CGβ) of chorionic gonadotropin (CG), and elevated serum levels occur especially in advanced disease. We have compared the diagnostic utility of various methods for detecting CG and CGβ expression at the protein and mRNA level.Methods: We used RT-PCR to detect CGβ mRNA in urinary cells and highly sensitive immunoassays to determine CG and CGβ in serum and the core fragment of CGβ (CGβcf) in urine from patients under follow-up for bladder cancer. Tissue expression was studied by immunohistochemistry.Results: CGβ mRNA was detected in urinary cells in 50% (n=84) of the cancer cases and in none of the healthy controls (n=15). Positive staining for CGβ in tissue samples was observed not only in 30% (n=96) of the TCC cases, but also in 5 of 20 histologically benign samples from TCC patients, and in 10 of 21 samples from benign bladder diseases. Serum and urinary concentrations of CGβ were elevated in 29% (n=66) and 8% (n=72), respectively, while serum CG was elevated in 18% of the TCC patients. Urinary CGβcf concentrations were higher in invasive (T1–T4) than superficial (T in situ and Ta) tumors (p=0.037), in cases positive for CGβ mRNA (p=0.03) and cases with suspicious or malignant urinary cytology (p=0.002). The ratio of urinary to serum concentration of CGβ showed the strongest correlation with tumor stage (p<0.00001), grade (p<0.00001), and staining for CGβ (p=0.019).Conclusions: Although CGβ expression may occur in benign bladder epithelium, CGβ mRNA in urinary cells is a potential marker of bladder cancer. Urinary and serum CGβ have low sensitivity in early disease, but the urine/serum ratio appears to indicate local release of CGβ into urine. Further studies are needed to evaluate the clinical usefulness of different forms of CGβ expression.     

应用RT-PCR并Southern杂交技术检测乳腺癌骨髓微转移

目的检测原发性乳腺癌骨髓微转移的发生及与其它临床参考指标的关系.方法应用逆转录-聚合酶链反应(RT-PCR)并Southern杂交技术,检测骨髓单个核细胞中细胞角蛋白19(CK-19)基因表达.结果52例骨髓标本共检出微转移19例(36.5%),其中17例淋巴结有转移者,9例CK-19表达阳性(52.9%);而无淋巴结转移的35例中,10例CK-19表达阳性(28.6%).微转移检出率与肿瘤大小有关(P＜0.05).结论以CK-19为标志物,RT-PCR并Southern杂交方法检测原发性乳腺癌骨髓微转移灵敏、特异,可做为临床判断预后的参考指标.     

A New Generation of Optical Diagnostics for Bladder Cancer: Technology,Diagnostic Accuracy,and Future Applications

Context

New developments in optical diagnostics have a potential for less invasive and improved detection of bladder cancer.

Objective

To provide an overview of the technology and diagnostic yield of recently developed optical diagnostics for bladder cancer and to outline their potential future applications.

Evidence acquisition

A PubMed literature search was performed, and papers on Raman spectroscopy (RS), optical coherence tomography (OCT), photodynamic diagnosis (PDD) and narrow-band imaging (NBI) regarding bladder cancer were reviewed. Technology, clinical evidence, and future applications of the techniques are discussed.

Evidence synthesis

With RS, the molecular components of tissue can be measured objectively in qualitative and quantitative ways. The first studies demonstrating human in vivo applicability are still awaited. OCT produces high-resolution, cross-sectional images of tissue, comparable with histopathology, and provides information about depth of tumour growth. The first in vivo studies of OCT demonstrated promising diagnostic accuracy. RS and OCT are not suitable for scanning the entire bladder. PDD is a technique using fluorescence to indicate pathologic tissue. Several studies have shown that PDD increases the detection rate of bladder tumours and improves resection, resulting in fewer early recurrences. The relatively low specificity of PDD remains a problem. NBI enhances contrast of mucosal surface and microvascular structures. The NBI technique has clear advantages over PDD, and the two studies published to date have shown promising preliminary results. PDD and NBI do not contribute to histopathologic diagnosis.

Conclusions

RS and OCT aim at providing a real-time, minimally invasive, objective prediction of histopathologic diagnosis, while PDD and NBI aim at improving visualisation of bladder tumours. For RS, OCT, and NBI, more research has to be conducted before these techniques can be implemented in the management of bladder cancer. All techniques might be of value in specific clinical scenarios.     

Assessing the Use of p16 Promoter Gene Methylation in Serum for Detection of Bladder Cancer

Objective: This study was undertaken to investigate whether hypermethylation in p16^INK4a gene promoter could serve as plasma biomarker of bladder cancer.Methods and Patients: We examined the p16^INK4a status using methylation-specific PCR in 86 cancer patients and 49 controls (31 healthy people and 18 patients with benign urological diseases).Results: The p16^INK4a methylation was found in 22% of the serum samples and in 26% of the bladder cancer biopsies; one of them with carcinoma in situ. The presence of hypermethylated p16^INK4a in serum seems to be a product from tumour cells because a strong statistical association was found between both matched DNA signals (p<0.0001). Using the control group, the presence of methylated p16^INK4a in the serum of individuals with suspicion of bladder cancer was found to be associated with the tumour presence (p=0.0009). Aberrant p16^INK4a methylation was also observed in one non-cancer patient, which is undergoing further assessment.Conclusions: According with our results, methylation of p16^INK4a promoter may be involved in the bladder cancer genesis and the presence of p16^INK4a methylated in serum of these patients could be useful in the cancer diagnosis with values of sensitivity, specificity and positive predictive value of 0.226, 0.950 and 0.98, respectively. These figures support the use of methylated p16^INK4a as a new class of tumour marker in bladder cancer.     

Local Involvement of the Urinary Bladder in Primary Colorectal Cancer: Outcome with En-Bloc Resection

Background Colorectal cancers that adhere to the urinary bladder require en-bloc partial or total cystectomy to achieve negative tumor margins. Methods This prospective study evaluated the outcome of combined bladder resection for carcinoma of the colon or rectum at a unit specializing in gastrointestinal cancer. Results Patients (n = 63) with colorectal tumors adherent to the bladder at operation and without distal metastases were followed. Fifty-eight patients (92%) had tumors of the sigmoid colon or upper rectum. Operative morbidity and mortality rates were 18% and 1.5%, respectively. Histological staging demonstrated bladder adherence in 46% (29/63) and invasion in 54% (34/63). Overall disease-specific survival was 54% with a mean follow-up of 7.6 years (range 5–12). Five-year survival for margin-negative patients was 72% (26/36) and 27% (4/15) for node-negative and -positive tumors, respectively. The bladder was closed primarily in 48 patients and reconstructed by enterocystoplasty in 5, with 10 patients requiring urinary diversion. Conclusions En-bloc bladder resection for adherent or invading tumors of the colon and rectum achieves good local control, but an infiltrative extravesical margin denotes poor prognosis. The potential for cure in completely excised node-negative tumors is good. Bladder reconstruction is achievable in most patients.     

FoxO3 基因在膀胱癌中的表达、功能富集和信号通路生物信息学分析

目的:探讨叉头盒状O转录因子3(FoxO3)在膀胱癌中表达、相关生物学功能和信号通路以及与患者生存期的关系。方法:分析癌症基因组图谱数据库(TCGA)中膀胱癌患者的癌组织和正常膀胱组织中FoxO3基因表达水平。STRING数据库构建FoxO3基因相关蛋白-蛋白相互作用网络,对网络中的基因进行聚类分析,并采用cytoscape筛选网络中的关键基因。采用基因本体论(GO)和京都基因与基因组百科全书(KEGG)对FoxO3和相关基因进行功能富集。Cox回归模型构建生存曲线,比较FoxO3高低表达组患者的总生存期(OS)和无疾病进展生存期(DFS)有无差异。结果:FoxO3表达水平在膀胱癌组织中表达水平显著低于对应的正常膀胱组织(P0.05),而FoxO3表达水平在不同临床分期膀胱癌患者的癌组织中无明显差异(P0.05)。FoxO3蛋白-蛋白相互作用网络中共有51个蛋白和587个相互作用关,各蛋白平均相互作用指数为23,网络中各个蛋白富集明显(P1-16)。FoxO3基因表达与FoxO3B基因表达呈正相关(r=0.94,P0.05),而与TIMM16基因表达呈负相关(r=–0.43,P0.05)。FoxO3低表达组膀胱癌患者的总生存期(HR=1.4,P=0.029)和无疾病进展生存期(HR=1.5, P=0.015)显著高于高表达组。结论:FoxO3在膀胱癌患者肿瘤组织中表达水平明显下调,且FoxO3低表达与患者的预后不良有关。     

Identification and Validation of the Methylated TWIST1 and NID2 Genes through Real-Time Methylation-Specific Polymerase Chain Reaction Assays for the Noninvasive Detection of Primary Bladder Cancer in Urine Samples

Background

Accumulating evidence suggests that DNA methylation markers could serve as sensitive and specific cancer biomarkers.

Objective

To determine whether a panel of methylated genes would have the potential to identify primary bladder cancer (BCa) in voided urine samples.

Design, setting, and participants

A pharmacologic unmasking reexpression analysis in BCa cell lines was initially undertaken to unveil candidate methylated genes, which were then evaluated in methylation-specific polymerase chain reaction (MSP) assays performed on DNA extracted from noncancerous and cancerous bladder tissues. The most frequently methylated genes in cancerous tissues, with 100% specificity, were retained for subsequent MSP analysis in DNA extracted from urine samples to build and validate a panel of potential methylated gene markers. Urine samples were prospectively collected at three urologic centres from patients with histologically proven BCa and processed for use in real-time MSP and cytologic analysis. Patients with nonmalignant urologic disorders were included as controls.

Measurements

A urine sample was classified as valid when ≥10 copies of the gene encoding ß-actin were measured in the urine sediment genomic DNA. Sensitivity, specificity, and predictive values of the MSP and cytology tests were assessed and compared.

Results and limitations

MSP assays performed on 466 of the 496 (94%) valid urine samples identified two genes, TWIST1 and NID2, that were frequently methylated in urine samples collected from BCa patients, including those with early-stage and low-grade disease. The sensitivity of this two-gene panel (90%) was significantly better than that of cytology (48%), with comparable specificity (93% and 96%, respectively). The positive predictive value and negative predictive value of the two-gene panel was 86% and 95%, respectively.

Conclusions

Detection of the methylated TWIST1 and NID2 genes in urine sediments using MSP provides a highly (≥90%) sensitive and specific, noninvasive approach for detecting primary BCa.

Trial registration

BlCa-001 study – EudraCt 2006-003303-40.     

External Beam Radiotherapy Increases the Risk of Bladder Cancer When Compared with Radical Prostatectomy in Patients Affected by Prostate Cancer: A Population-based Analysis

Background

Long-term survival can be achieved in patients affected by localized prostate cancer (PCa) treated with either radical prostatectomy (RP) or external beam radiotherapy (EBRT). However, development of a second primary tumor is still poorly investigated.

Local Involvement of the Urinary Bladder in Primary Colorectal Cancer: Outcome with En Bloc Resection

Background Colorectal cancers that adhere to the urinary bladder require en bloc partial or total cystectomy to achieve negative tumor margins. Methods This prospective study evaluated the outcome of combined bladder resection for carcinoma of the colon or rectum at a unit specializing in gastrointestinal cancer. Results Patients (n = 63) with colorectal tumors adherent to the bladder at operation and without distal metastases were followed. Fifty-eight patients (92%) had tumors of the sigmoid colon or upper rectum. Operative morbidity and mortality rates were 18% and 1.5%, respectively. Histological staging demonstrated bladder adherence in 46% (29/63) and invasion in 54% (34/63). Overall disease-specific survival was 54%, with a mean follow-up of 7.6 (range 5–12) years. Five-year survival for margin negative patients was 72% (26/36) and 27% (4/15) for node negative and positive tumors, respectively. The bladder was closed primarily in 48 patients and reconstructed by enterocystoplasty in five, with ten patients requiring urinary diversion. Conclusions En bloc bladder resection for adherent or invading tumors of the colon and rectum achieves good local control, but an infiltrative extravesical margin denotes poor prognosis. The potential for cure in completely excised node negative tumors is good. Bladder reconstruction is achievable in most patients.     

Correlation of Pathologic Complete Response with Survival After Neoadjuvant Chemotherapy in Bladder Cancer Treated with Cystectomy: A Meta-analysis

ContextNeoadjuvant chemotherapy before radical cystectomy (RC) is the preferred initial option for muscle-invasive bladder cancer (BCa). As in rectal and breast cancer, pathologic downstaging is associated with increased overall survival (OS).ObjectiveWe conducted a meta-analysis to determine whether pathologic complete response (pCR) (pT0N0M0) after neoadjuvant chemotherapy is associated with a better outcome in muscle-invasive BCa.Evidence acquisitionA systematic search was conducted in PubMed, Web of Science, Cochrane Collaboration's Central register of controlled trials, and Embase for publications reporting outcomes of patients with and without pCR. All patients underwent neoadjuvant cisplatin-based polychemotherapy and RC. The primary outcome reported as relative risk (RR) was OS. Secondary end points were recurrence-free survival (RFS) and cancer-specific survival other than distant and locoregional RFS. A meta-analysis was performed using the fixed effects model or random effects model. Overall heterogeneity for RFS and OS was assessed with forest plots and the Q test.Evidence synthesisA total of 13 trials were included, for a total of 886 patients analysed after neoadjuvant chemotherapy and RC, without any postoperative treatment. The pCR rate was 28.6%. Patients who achieved pCR in the primary tumour and the lymph nodes presented an RR for OS of 0.45 (95% confidence interval [CI], 0.36–0.56; p < 0.00001). The number needed to treat to prevent 1 death was 3.7 (absolute risk difference: −26%). The summary RR for RFS was 0.19 (95% CI, 0.09–0.39; p < 0.00001).ConclusionsPatients with BCa who achieved pCR (pT0N0M0 stage) after neoadjuvant chemotherapy have a better OS and RFS than do patients without pCR.     

European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2020 Guidelines

ContextThis overview presents the updated European Association of Urology (EAU) guidelines for muscle-invasive and metastatic bladder cancer (MMIBC).ObjectiveTo provide practical evidence-based recommendations and consensus statements on the clinical management of MMIBC with a focus on diagnosis and treatment.Evidence acquisitionA broad and comprehensive scoping exercise covering all areas of the MMIBC guideline has been performed annually since its 2017 publication (based on the 2016 guideline). Databases covered by the search included Medline, EMBASE, and the Cochrane Libraries, resulting in yearly guideline updates. A level of evidence and a grade of recommendation were assigned. Additionally, the results of a collaborative multistakeholder consensus project on advanced bladder cancer (BC) have been incorporated in the 2020 guidelines, addressing those areas where it is unlikely that prospective comparative studies will be conducted.Evidence synthesisVariant histologies are increasingly reported in invasive BC and are relevant for treatment and prognosis. Staging is preferably done with (enhanced) computerised tomography scanning. Treatment decisions are still largely based on clinical factors. Radical cystectomy (RC) with lymph node dissection remains the recommended treatment in highest-risk non–muscle-invasive and muscle-invasive nonmetastatic BC, preceded by cisplatin-based neoadjuvant chemotherapy (NAC) for invasive tumours in “fit” patients. Selected men and women benefit from sexuality sparing RC, although this is not recommended as standard therapy. Open and robotic RC show comparable outcomes, provided the procedure is performed in experienced centres. For open RC 10, the minimum selected case load is 10 procedures per year. If bladder preservation is considered, chemoradiation is an alternative in well-selected patients without carcinoma in situ and after maximal resection. Adjuvant chemotherapy should be considered if no NAC was given. Perioperative immunotherapy can be offered in clinical trial setting. For fit metastatic patients, cisplatin-based chemotherapy remains the first choice. In cisplatin-ineligible patients, immunotherapy in Programmed Death Ligand 1 (PD-L1)-positive patients or carboplatin in PD-L1–negative patients is recommended. For second-line treatment in metastatic disease, pembrolizumab is recommended. Postchemotherapy surgery may prolong survival in responders. Quality of life should be monitored in all phases of treatment and follow-up. The extended version of the guidelines is available at the EAU website: https://uroweb.org/guideline/bladder-cancer-muscle-invasive-and-metastatic/.ConclusionsThis summary of the 2020 EAU MMIBC guideline provides updated information on the diagnosis and treatment of MMIBC for incorporation into clinical practice.Patient summaryThe European Association of Urology Muscle-invasive and Metastatic Bladder Cancer (MMIBC) Panel has released an updated version of their guideline, which contains information on histology, staging, prognostic factors, and treatment of MMIBC. The recommendations are based on the current literature (until the end of 2019), with emphasis on high-level data from randomised clinical trials and meta-analyses and on the findings of an international consensus meeting. Surgical removal of the bladder and bladder preservation are discussed, as well as the use of chemotherapy and immunotherapy in localised and metastatic disease.     

Recurrence and Progression of Disease in Non–Muscle-Invasive Bladder Cancer: From Epidemiology to Treatment Strategy

Context

This review focuses on the prediction of recurrence and progression in non–muscle invasive bladder cancer (NMIBC) and the treatments advocated for this disease.

Objective

To review the current status of epidemiology, recurrence, and progression of NMIBC and the state-of-the art treatment for this disease.

Evidence acquisition

A literature search in English was performed using PubMed and the guidelines of the European Association of Urology and the American Urological Association. Relevant papers on epidemiology, recurrence, progression, and management of NMIBC were selected. Special attention was given to fluorescent cystoscopy, the new World Health Organisation 2004 classification system for grade, and the role of substaging of T1 NMIBC.

Evidence synthesis

In NMIBC, approximately 70% of patients present as pTa, 20% as pT1, and 10% with carcinoma in situ (CIS) lesions. Bladder cancer (BCa) is the fifth most frequent type of cancer in western society and the most expensive cancer per patient. Recurrence (in ≤80% of patients) is the main problem for pTa NMIBC patients, whereas progression (in ≤45% of patients) is the main threat in pT1 and CIS NMIBC. In a recent European Organisation for Research and Treatment of Cancer analysis, multiplicity, tumour size, and prior recurrence rate are the most important variables for recurrence. Tumour grade, stage, and CIS are the most important variables for progression. Treatment ranges from transurethral resection (TUR) followed by a single chemotherapy instillation in low-risk NMIBC to, sometimes, re-TUR and adjuvant intravesical therapy in intermediate- and high-risk patients to early cystectomy for treatment-refractory high-risk NMIBC.

Conclusions

NMIBC is a heterogeneous disease with varying therapies, follow-up strategies, and oncologic outcomes for an individual patient.     

Detection and Quantification of Soluble Intercellular Adhesion Molecule-1 (slCAM-1) in the Serum and Urine of Patients with Bladder Cancer

Background : A possible role for intercellular adhesion molecules in tumor progression and metastasis has been strongly suggested. To investigate the effect of soluble intercellular adhesion molecule-1 (slCAM-1) on bladder cancer, slCAM-1 serum and urinary concentrations were measured in patients with superficial or invasive bladder cancer and in patients with prostatic hypertrophy.
Methods : Serum and urine samples were obtained from 26 patients with transitional cell carcinoma of the bladder (mean age, 66.8 years) and 14 patients with benign prostatic hypertrophy (BPH; mean age, 70.5 years). Fifteen healthy volunteers served as control patients. Samples were collected before surgery and 5 days after surgery. The serum and urinary slCAM-1 levels were measured by an ELISA.
Results : The preoperative serum concentration of slCAM-1 was significantly higher in patients with invasive bladder cancer (351.8 ±158.0 ng/mL)than in the healthy controls (233.1 ±96.1 ng/mL; P<0.05) or BPH patients (224.7 ± 80.5 ng/mL; P< 0.05). In addition, serum slCAM-1 levels were significantly higher in patients with tumors greater than 3 cm in size (412.7 ± 147.6 ng/mL) than in patients with smaller tumors (246.6 ± 101.2 ng/mL; P<0.05). Urinary slCAM-1 levels in patients with invasive bladder cancer were also significantly higher than in the patients with superficial cancer prior to surgery.
Conclusion : Our results suggested that slCAM-1 may play an important role in the progression of bladder cancer, and that elevated serum slCAM-1 levels may be related to tumor size.