This document discusses urine cytology and urinary markers for detecting bladder cancer. It notes that urine cytology has high specificity but low sensitivity for both high and low grade tumors. Several urinary markers are discussed, including BTA, ImmunoCyt, NMP-22, UroVysion, microsatellite analysis, Lewis antigen X, CK20, CYFRA 21.1, survivin, hyaluronic acid and TRAP, along with their reported sensitivities and specificities. However, none meet the 90% sensitivity threshold needed to replace cystoscopy, so the conclusion is that a combination of cystoscopy and urine markers is currently the best approach for bladder cancer surveillance.

1. URINE CYTOLOGY AND
URINARY MARKERS IN
CASE OF CA BLADDER
• Dr. Anees Puthawala

2. URINE CYTOLOGY
• Urine cytology, first introduced
by Papanicolaou in 1945
• Evaluates the morphologic
changes associated with bladder
cancer
• It is the gold standard urinary
marker against which other
markers are held
• Sensitivity 40% to 62%

3. • Positive urine cytology is virtually
diagnostic of a bladder tumor, though
the tumor is not endoscopically visible.
• The sensitivity and specificity of urine
cytology is dependent on the:
Cytopathologist
number of samples evaluated
 stage and grade of the tumor
Associated inflammation, infection, intra-
vesical instillations

4. • Instrumented urine during cystoscopy
has improved sensitivity and specificity,
but an invasive procedure is required
• 15% of patients with atypical cytology
that is not diagnostic of cancer will have
an underlying malignancy
• Thus patients with an atypical cytology
need more frequent evaluation or repeat
random bladder biopsies.

5. • Even in the setting of UC patients with a
negative workup (cystoscopy and upper
tract imaging) with a persistently positive
cytology;
40% were found to have genitourinary
cancer within 24 months, with a mean
time to diagnosis of 5.6 months

6. • Although cytology has traditionally been
believed to have high sensitivity for high-
grade cancer and low sensitivity for low
grade cancer, recent studies do not
support this
• Thus cytology has high specificity but
low sensitivity for both high-grade and
low-grade tumors including CIS

7. URINE MARKERS FOR UROTHELIAL
CANCER

8. • BTA stat(qualitative) & BTA TRAK
(quantitative)
• detect human complement factor H–
related protein
• sensitivity 50% to 80%
specificity 50% and 75%
• These tests are more sensitive than
cytology but can be falsely positive in
patients with inflammation, infection, or
hematuria

9. • ImmunoCyt:
• A hybrid of cytology and an
immunofluorescent assay
• Three fluorescent labeled monoclonal
antibodies are targeted at a UC variant
of carcinoembryonic antigen and two
bladder mucins.

10. • Sensitivity 86%
Specificity 79%
• not been shown to be affected by benign
conditions, but interpretation is complex
and operator dependent

11. • NMP-22 Bladder Check Test
• Based on the detection of nuclear matrix
protein 22, part of the mitotic apparatus
released from urothelial nuclei upon
cellular apoptosis.
• The protein is elevated in UC, but it is
also released from dead and dying
urothelial cells.

12. • Benign conditions of the urinary tract
such as stones, infection, inflammation,
hematuria, and cystoscopy can cause a
false-positive reading.
• Both a laboratory-based, quantitative
immunoassay and a qualitative point-of-
care test are available.

13. • UroVysion (FISH):
• Fluorescence in-situ hybridization
identifies fluorescently labeled DNA
probes that bind to intranuclear
chromosomes.
• The current commercially available
probes evaluate aneuploidy for chr 3, 7,
and 17 and homozygous loss of 9p 21

14. Sensitivity 79%
Specificity 98%
• UroVysion has the highest specificity of
the available tumor markers
• Detects chromosomal changes before
the development of phenotypic
expression of malignancy, so it leads to
an “anticipatory positive” reading in
some patients

15. • Patients testing negative are unlikely to
experience tumor recurrence in less than
1 year
• This may allow identification of patients
at risk of recurrence versus those
unlikely to recur in order to individualize
surveillance protocols

16. • clarify equivocal findings in patients with
atypical or negative cytology
• Not affected by hematuria, inflammation,
or other factors that can cause false-
positive readings with some tumor
markers, so it appears to be useful as a
marker of BCG response

17. • Microsatellite analysis
• Amplifies repeats in the genome that are
highly polymorphic, and PCR
amplification can detect tumor-
associated loss of heterozygosity by
comparing the peak ratio of the two
alleles in tumor DNA in the urine sample
with the presence of the alleles in a
blood sample from the same individual

18. • Interestingly, if the microsatellite
analysis:
persistently positive-83% 2-year
recurrence rate
persistently negative-22% of patients
had recurrent tumors
• standardization of the test will allow
analysis without a blood sample, and
this will significantly improve the patient’s
acceptance

19. • The Lewis blood group antigen X
• Usually absent from urothelial cells in
adults except for occasional umbrella
cells
• There is increased Lewis X expression
in bladder cancers
• It is independent of secretor status,
grade, and stage.

20. • sensitivity 75%
specificity 85%
• There is no commercially available test
to date

21. • CK 20 and CYFRA 21.1
• Fragments of cytoskeletal proteins that
can be detected in the urine of bladder
cancer patients by either protein or
mRNA detection
• CK 20: sensitivity 85%
specificity 76%

22. • CYFRA 21.1: with a cutoff value of 4
ng/mL,
sensitivity 43%
specificity 68%

23. • CpG dinucleotide:
• CpG Islands cluster around promoters
in an unmethylated state to allow gene
expression
• Methylation of the CpG islands shuts
down the promoter, and if the promoter
in question is part of a tumor suppressor
gene then cancer can form.

24. • Survivin:
• An antiapoptotic protein that has a high
expression in urothelial cancer
• Found in 10% to 30% of bladder
cancers and is readily shed into the
urine.
• Sensitivity 64% to 100%
specificity 87% to 93%

25. • This test may be useful in predicting
which patients will respond to
intravesical therapy
• Survivin was relatively poor at detecting
advanced-stage or high-grade tumors

26. • Hylauronic acid:
• Controls intercellular communications
and cell replication.
• Urothelial cancer induces hylauronic
acid production from fibroblasts, and the
amount correlates with the stage of the
disease.
• sensitivity 91% to 100%
• specificity 84% to 90%

27. • TRAP:
• Telomerase resides at the terminal ends
of the chromosomes and duplicates
random DNA repeats to prevent cell
death
• Telomerase activity is measured in
telomeric repeat application protocol
(TRAP) and is detected in 80% of urine
from patients with bladder cancer with
no grade differential.

28. • sensitivity 90%
specificity 88%

29. • Virtually all patients complain of pain and
discomfort with an office cystoscopy
• Urine markers studies could forgo this
pain in select situations as described
above.
• However, patients reported that a urine
marker study would need 90% sensitivity
in order to replace office cystoscopy

30. • None of the currently available urinary
markers meet this 90% sensitivity on a
reliable basis
• Therefore a combination of cystoscopy
with urine markers, in select situations,
is appropriate for surveillance of patients
with non–muscle-invasive bladder
cancer

31. THANK YOU!!