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Urinary UBC Rapid and NMP22 Test for Bladder Cancer Surveillance In Int. J. Med. Sci. 2017, Vol. 14 811 Ivyspring International Publisher International Journal of Medical Sciences 2017; 14(9): 811-819. doi: 10.7150/ijms.19929 Research Paper Urinary UBC Rapid and NMP22 Test for Bladder Cancer Surveillance in Comparison to Urinary Cytology: Results from a Prospective Single-Center Study Renate Pichler1, Gennadi Tulchiner1, Josef Fritz2, Georg Schaefer3, Wolfgang Horninger1, Isabel Heidegger1 1. Department of Urology, Medical University of Innsbruck, Austria 2. Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Austria 3. Department of Pathology, Division of General Pathology, Medical University of Innsbruck, Austria Corresponding author: Renate Pichler, MD, PhD, FEBU and Isabel Heidegger, MD, PhD, FEBU. Medical University Innsbruck, Department of Urology. Anichstrasse 35, A-6020 Innsbruck, Austria. Email: [email protected]; [email protected]; Tel.: +43 (0) 512 504 24811; Fax: +43 (0) 512 504 28365. © Ivyspring International Publisher. This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY-NC) license (https://creativecommons.org/licenses/by-nc/4.0/). See http://ivyspring.com/terms for full terms and conditions. Received: 2017.03.05; Accepted: 2017.05.17; Published: 2017.07.19 Abstract Background: Non-muscle invasive bladder cancer (NMIBC) is associated with high rates of recurrence, resulting in frequent follow-up cystoscopies. We evaluated the use of two point-of-care tests - the nuclear matrix protein 22 (NMP22) and urinary bladder cancer antigen (UBC) Rapid - compared to routine follow-up in patients with a previous history of NMIBC. Methods: 31 patients with cystoscopy-verified active bladder cancer, and 44 follow-up patients without disease as confirmed by cystoscopy were prospectively enrolled. All urine samples were analyzed by voided urine and bladder washing cytology, NMP22 and UBC rapid test (qualitatively and quantitatively). The best cutoff (highest Youden index; ≥6.7 ng/ml) for the quantitative UBC was determined by receiver operating characteristic curves. Results: Voided urine and barbotage cytology resulted in a sensitivity of 25.8% and 32.3%, and a specificity of 100% and 100%, while the NMP22 showed a sensitivity and specificity of 12.9% and 100%, respectively. The qualitative and quantitative UBC Rapid revealed a sensitivity of 61.3% and 64.5%, with a specificity of 77.3% and 81.8%. Barbotage cytology and qualitative UBC test proved to be the best dual combination with the highest overall sensitivity (77.4%). In contrast to barbotage cytology alone, sensitivity increased from 21.4% to 50% for detecting low-grade tumors, and from 43.8% to 100% for high-grade cancers, but reducing specificity from 100% to 77.3%. Conclusion: Compared to urinary cytology, UBC tests alone as well as UBC tests in combination with bladder washing cytology revealed higher sensitivities in detecting low- and high-grade tumors, but at the expense of a lower specificity. Thus, currently cystoscopy cannot be replaced by any of the evaluated methods. Key words: Bladder Cancer; surveillance; recurrence; urine markers; cytology; NMP22; UBC; biomarkers Introduction Bladder cancer (BCa) is the eleventh most death [1-2]. Given the steadily rising life expectancy commonly diagnosed cancer in the world with an and the rising costs of health care systems, BCa has estimated 430 000 new cases reported in 2012. It also become a global problem [1-2]. For example, bladder ranks fourteenth among the leading causes of cancer cancer caused an expense of about 2.9 billion Euros http://www.medsci.org Int. J. Med. Sci. 2017, Vol. 14 812 for public health systems across the European Union the urinary bladder cancer antigen (UBC)® rapid in 2012, constituting 5% of the total health care (qualitative and quantitative) test - for the expenses for cancer [3]. surveillance of patients with a previous history of At the initial diagnosis, as many as 75% of non-muscle invasive bladder cancer (NMIBC). patients with BCa present with non-muscle invasive disease confined to the mucosa or submucosa [4]. The Material and Methods majority of patients in this stage of disease are This prospective single-center study was successfully treated with endoscopic surgery, approved by the local ethics committee (study followed by adjuvant intravesical chemotherapy or number AN2016-0056; 360/4.7) of the Medical Bacillus-Calmette Guérin (BCG) instillation treatment University of Innsbruck (Austria). Informed written in the case of intermediate-risk and high-risk consent for further urine analysis in addition to non-muscle invasive bladder cancer (NMIBC), [5]. standard urine cytology was obtained from each Non-muscle invasive cancer disease has a significant patient prior to inclusion in the study. Patients with a lower risk of cancer-specific mortality with a better previous history of NMIBC who had undergone long-term survival compared to muscle-invasive routine oncological follow-up at our outpatient bladder cancer [4,6]. Nevertheless, lifelong follow-up uro-oncology department between May 2016 and is needed in non-muscle invasive disease because of September 2016 were enrolled prospectively in the the high probability of recurrence (ranging from 15% pilot study. To exclude a urinary tract infection, all to 61% at 1 year and from 31% to 78% at 5 years), patients underwent a routine urine dipstick analysis especially in patients with carcinoma in situ (CIS) and prior to cystoscopy. Symptomatic bacteriuria or a T1 lesions with a high potential for malignancy [5,7]. florid urinary tract infection was a contraindication Thus, surveillance of NMIBC should be risk-adapted, for further investigation, and thus an exclusion with regular cystoscopies, urinary cytology and upper criterion for the study. urinary tract imaging in the follow-up The follow-up protocol included cystoscopy recommendation of current guidelines [8-9]. (flexible in men, rigid in women) in combination with Cytopathology of the voided bladder or bladder voided urine and bladder washing cytology as the washing urine specimens is a widely used and gold standard. In addition, all urinary samples were non-invasive test for the detection or in the analyzed with two POC tests: the NMP22® surveillance of bladder cancer, with a high sensitivity BladderChek and the UBC® Rapid test (visually and of 84% in high-grade BCa [10-11]. Although cytology quantitatively by the Omega 100 POC reader). The is very specific (about 86%), its overall low sensitivity frequency of cystoscopy during follow-up depended (48%) is a clear limitation. In fact, its sensitivity is a on tumor histology and tumor grading. In accordance mere 16% for low-grade tumors [10-11]. Moreover, the with the current European Association of Urology diagnostic accuracy of urinary cytology varies (EAU) guidelines and our institutional practice, between study centers because of subjective cytology patients with low-risk NMIBC underwent a cystosco- interpretation criteria, depending on the expertise and py every 3 months during the first year, and then once experience of cytopathologists requiring highly a year for 5 years. Intermediate-risk and high-risk trained healthcare professionals, who may not be NMIBC were followed by cystoscopy every 3 months available in all areas [11-12]. Over the years, various during the first two years, at 6-month intervals for 5 classification schemes for urinary cytology have been years, and then once a year [8]. Upper urinary tract published, introducing the Paris System for imaging (CT-urography) was carried out once a year Reporting Urine Cytology in 2013 [13-14]. Some in high-risk NMIBC (according to the European limitations of prior classification schemes include a Organization for Research and Treatment of Cancer lack of rigorous definition of validated cytological scoring system and risk tables [5]) or when a disease criteria for individual categories and a lack of recurrence was detected. In case of cystoscopy– consensus for atypical categorization [14]. Hence, verified cancer recurrence or a positive cytology with significant efforts have been made to develop novel no visible tumor, transurethral resection of the molecular and gene-based urinary tests that may bladder (TURB) or PDD-guided, random-biopsies reduce or, ideally replace, the frequency of endoscopy were performed. All cancer specimens obtained from in patients under surveillance for BCa recurrence [15]. TURB were investigated in regard of diagnosis, tumor The aim of this prospective study was to grade (WHO 1973 and 2004) and stage (TNM 2009) by evaluate and compare the diagnostic accuracy of an experienced uropathologist. urinary cytology (voided urine and bladder washing) Cytological evaluation of urinary specimens for with two urine-based point-of-care (POC) tests - the exfoliated tumor cells was performed according to the nuclear matrix protein 22 (NMP22)® BladderChek and Papanicolaou scheme. While classes 1 and 2 were http://www.medsci.org Int. J. Med. Sci. 2017, Vol. 14 813 considered negative, classes 4 and 5 were deemed prospective study. All patients underwent a routine suspicious and positive for bladder cancer [14]. follow-up of a previous NMIBC. Tumor recurrence Patients with class 3 (atypical urothelial cells) was noted in 31 (41.3%) of 75 patients, respectively. cytological findings and negative cystoscopy Histological investigation of TURB confirmed pTa, underwent a cystoscopy and urine cytology control carcinoma in situ (CIS), pT1 and pT2 in 16 (51.6%), 6 three months later. (19.4%), 6 (19.4%) and 3 (9.6%) patients, respectively. The qualitative NMP22® BladderChek test Fifteen (48.4%) and 16 (51.6%) were classified as (Alere, Waltham, Massachusetts, USA) and the UBC® low-grade and high-grade tumors, respectively, Rapid test (Concile, Freiburg im Breisgau, Germany) according to the 2004 WHO classification system. were performed according to the manufacturers` Grades 1, 2, 3 were identified in 10 (32.3%), 9 (29%) protocols. Briefly, the NMP22 enzyme immunoassay and 12 (38.7%) tumors, respectively, based on the 1973 is specific for the nuclear mitotic apparatus protein WHO classification.
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