Combined application of cytology and molecular urine markers to improve the detection of urothelial carcinoma.

BACKGROUND: The sensitivity of cytology for the detection of urothelial carcinoma (UC) is limited. Newer methods such as fluorescence in situ hybridization (FISH), immunocytology (uCyt+), and protein markers have been developed to improve urine-based detection of UC. As only little is known regarding the combined application of these markers, we investigated whether combinations of 4 of the most broadly available tests (cytology, FISH, uCyt+, and nuclear matrix protein 22 [NMP22-ELISA]) may improve their diagnostic performance. METHODS: The study was comprised of 808 patients who were suspected of having UC. All patients underwent urethrocystoscopy and upper urinary tract imaging and, in the case of positive findings, transurethral resection/biopsy. FISH, uCyt+, cytology, and NMP22-ELISA were performed in all patients. RESULTS: UC was diagnosed in 115 patients (14.2%). Cytology and FISH were found to be the single tests with the best overall performance (area under the curve [AUC], 0.78/0.79). Combinations of 2, 3, and 4 markers were found to increase the AUC to various extents compared with the use of single markers. Combining cytology and FISH improved the sensitivity and performance (AUC, 0.83) compared with the single tests and identified 12 tumors that were not detected by cytology alone. The percentage of WHO grade 3/carcinoma in situ tumors not detected by cytology was reduced by 62.5% when FISH was performed in cytology-negative patients. The addition of uCyt+ as a third test further improved performance (AUC, 0.86), whereas the addition of NMP22-ELISA was not found to have any additional influence on the performance of the test combination. CONCLUSIONS: The results of the current study support the combined use of urine markers and may form the basis of further studies investigating whether risk stratification based on urine marker combinations may individualize diagnostic algorithms and the surveillance of patients suspected of having UC.

Impact of different grades of microscopic hematuria on the performance of urine-based markers for the detection of urothelial carcinoma.

OBJECTIVE: To evaluate the performance of urine cytology (CYT), the UroVysion test [(fluorescence-in-situ-hybridization (FISH)], the uCyt+-test, and the nuclear matrix protein 22 ELISA (NMP22) at different grades of microscopic hematuria (HU) in a cohort of 2,365 patients suspicious for urothelial cell carcinoma (UCC). PATIENTS AND METHODS: A cohort of 2,365 consecutive patients suspected to have UCC underwent testing of at least 1 of the 4 noninvasive urine markers followed by cystoscopy, upper urinary tract imaging and, in case of suspicious findings, transurethral biopsy and/or resection of suspicious lesions. The grade of microscopic HU was determined by dipstick evaluation and urine microscopy and subdivided into 4 grades. The test results were compared with the HU status by contingency analysis and Cochran-Armitage test for trend separated for patients without evidence of UCC and with histologically proven UCC. RESULTS: In case of grade 0, I, II, and III HU, rates of false positive CYT were 13.0, 17.4, 16.3, and 19.5% (P = 0.02), false negative CYT distributed 37.9, 18.5, 20.0, and 15.5% (P = 0.0003). FISH was false positive in 16.7, 19.8, 19.8, and 23.3% (P = 0.051) and false negative in 42.7, 27.5, 25.9, and 25.0% (P = 0.1). The uCyt+ was false positive in 12.5, 16.9, 24.0 and 35.1% (P < 0.0001), and false negative in 57.1, 26.4, 31.5, and 12.7% (P = 0.0003). NMP22 was false positive in 35.3, 55.3, 75.2, and 79.7% (P < 0.0001) and false negative in 50.0, 36.2, 22.6, and 8.2% (P < 0.0001). CONCLUSION: The extent of microscopic HU significantly influences the performance of noninvasive urine markers for UC. False positive rates of CYT, uCyt+, and NMP22 significantly increase with the degree of HU whereas false negative results of CYT, uCyt+, and NMP22 are less frequent in patients with high grade microscopic HU. These results underline the relevance of the grade of HU for the appropriate interpretation of urine tests.

Influence of urinary tract instrumentation and inflammation on the performance of urine markers for the detection of bladder cancer.

OBJECTIVE: To evaluate the impact of inflammation and sampling on cytology, immunocytology, and fluorescence in situ hybridization (FISH) in comparison with NMP22 in hematuria patients. The specificity of urine markers for urothelial cancer is subject to exogenous factors. There is evidence that nuclear matrix protein 22 (NMP22) is influenced by urinary tract infection and instrumented urinary sampling (IUS). METHODS: Samples from 1386 patients with histologic work-up were included. Cytology, immunocytology, FISH, and NMP22-enzyme-linked immunosorbent assay were performed. The presence of inflammation was evaluated by microscopy. The method of urine sampling was recorded in all cases. Any type of urinary tract manipulation was considered as IUS. False-positive results were compared with regard to the presence or absence of inflammation and mechanical manipulation. RESULTS: In all, 1050 (75.7%) patients had no evidence of urothelial cancer. NMP22 results were false positive in 74.3% and 38.4% of patients with and without IUS (P < .0001). False-positive test rates of cytology, immunocytology, and FISH were not increased after manipulation. Inflammation led to a rise in false-positive NMP22 test results (85.3% vs 61.4%, P < .0001). The presence of inflammation did not change the rate of false-positive cytology, immunocytology, and FISH results. CONCLUSION: This is the first study to investigate the impact of inflammation and IUS on cell-based urine markers. In contrast to the protein test NMP22, these factors did not impair the performance of cell-based tests. Hence, patients with positive cytology, immunocytology, and FISH results should undergo diagnostic work-up, even in the case of concomitant inflammation or IUS.