Urinary biomarkers are being developed and used as noninvasive alternatives to cystoscopy for bladder cancer diagnosis and monitoring. While no single biomarker has shown better specificity than urine cytology, many have higher sensitivity. Commonly used biomarkers include NMP22, BTA stat, ImmunoCyt/uCyt+, and UroVysion, with UroVysion and telomerase showing promise in sensitivity and specificity. An ideal biomarker would be noninvasive, highly sensitive and specific, easy to perform, rapid, reproducible, cost-effective, and able to detect cancer before it becomes visible on cystoscopy. Currently, biomarkers are used alongside cystoscopy for surveillance of non-muscle invasive bladder cancer, and may anticipate

1. URINARY BIOMARKERS IN
BLADDER CANCER
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2. URINARY BIOMARKERS
developed as an adjunct to standard diagnostic modalities for bladder
cancer diagnosis and monitoring
• Noninvasive testing with improved sensitivity over urine cytology has
been proposed as a desirable alternative to cystoscopy which costly
and uncomfortable
• Many urine-based markers are being used in clinical practice, but
none of them have shown better specificity than urine cytology, but
have shown definitely a better sensitivity than urine cytology.
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3. • Commercially available biomarkers:-
- NMP22
- BTA stat
- immunocyt/uCyt+
- uroVysion
- CxBladder
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4. • An ideal tumor marker or a test in detecting bladder cancer should be
a one that is non-invasive, has highest specificity and sensitivity, easy
to perform, rapid, reproducible, office based and cost-effective and
should detect bladder cancer even before it becomes visible on
cystoscopy.
• UroVysion and telomerase have shown a great promise in sensitivity
and specificity.
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5. BLADDER TUMOR ANTIGEN
• Detects : Human complement factor H- related protein AND complement factor H
using MA.
• FDAAPPROVED – for diagnosis and follow-up of BC
• 2 assay-1) BTA TRAK- ELISA test. SN-0.65, SP-0.74
2) BTA STAT- immunochromatin POC test. SN- 0.64%, SP-0.77
• Highly sensitive test but specificity remained lower than cytology.
• False positive due to hematuria, BPH, h/o BCG instillation, inflammation,
infection, urolithiasis, bowel interposition…
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6. ImmunoCyt/uCyt+
• Combination of cytology and immunofloroscence.
• Detects exfoliated BC cells in urine by using 3 fluorescent monoclonal antibodies
targeting 3 specific antigen of BC cell.
• M344- high molecular weight CEA
• LDQ10 and 19A11 are bladder tumor cell associated mucin.
• SN- 0.78 & SP-0.78
• As a cell based assay , it is less impacted by hematuria and inflammatory
condition.
• Less frequent use in clinical care due to user dependency, interobserver variability
and limited evidence.
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8. NMP 22
• Important role in structural framework of nucleus.
• Involved in mitosis by enabling correct distribution of chromatin to daughter
cell.
• 20 times more prevalent in malignant urothelial cells compared with normal
cells
• 2 assay- 1) NMP22 BC test kit-ELISA test
2) NMP22 bladder check test – immunochromatin assay i,e
point of care ( POC) test.
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9. • Quantitative test – Sensitivity: 0.68, specificity: 0.77
• Qualitative test – Sensitivity: 0.58, specificity: 0.88
failed to reach the level of specificity due to higher rate of FP d/t
infection, inflammation, hematuria, urolithiasis, instrumentation.
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10. uroVysion
• FISH assay.
• Identifies fluorescently labelled DNA probes that bind to intranuclear
chromosomes
• Detects aneuploidy of chromosomes 3,7,17 and heterozygous loss of
9P21 locus in exfoliated urothelial cells
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11. • Positive test
5 or more urinary cells with gains of 2 or more chromosomes
10 or more cells with gain of single chromosome
Heterozygous deletion of 9P21 in > 20 exfoliated cells.
• Considered as reflex test in the setting of atypical cytology >> a
negative FISH correlates with benign cytological changes.
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12. • Sensitivity : 0.63
• Specificity: 0.87
• Better sensitivity in low grade tumors.
• It Constitute an accurate surveillance assay by anticipating disease
recurrence.
• Useful in monitoring patients treated with intravesical BCG.
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13. CxBladder
• Real-time reverse transcription polymerase chain reaction( RT-qPCR).
• Based on detection of 5 mRNAs with BC ( IGFBP5, HOXA13, MDK, CDK1)
and ( CXCR2) in non malignant inflammatory condition.
• Limited studies. SN-85%, SP-85%
• Able to distinguish between low grade Ta tumors and other detected urothelial
carcinoma.
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15. INVESTIGATIONAL BIOMARKERS
• Protein based and cell based biomarkers-
- apoptosis markers
- angiogenesis markers
- proliferation and invasion
- metabolomics
• Gene based biomarkers-
- Aurora A kinase (AURKA)
- FGFR3
- microsatellite loss of heterozygosity detection
- DNA methylation
- micro RNA
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16. APOPTOSIS MARKERS
• Soluble Fas ( sFas)
isoforms are antiapoptotic proteins produced and released by BC cells.
Measurable by ELISA.
Independent predictor of BC recurrence
• Clusterin
multifunctional secretory glycoprotein .
Measuable by ELISA.
• Survivin
Antiapoptotic protein exclusively expressed by malignant epithelium.
Dot-blot technique ( bio-Dot assay).
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17. Angiogenesis markers-
VEGF:- measured by ELISA in voided urine.
Proliferation and invasion-
Telomerase
Hyaluronic acid
Fibronectin
CD44 antigen
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21. Key points for urinary biomarkers
• Many urinary biomarkers are able to assess BC.
• The Food and Drug Administration in the USA has approved Bladder Check
(NMP22) and UroVysion for use in screening of bladder cancer
• Combination of biomarkers seems to increase their performance.
• Their clinical relevance is not obvious enough to enable their wide spread use.
• Most of them have not reached quality criteria established by guidelines.
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22. CURRENT PRACTICE
• MICROHEMATURIA
- Addition of any current urine biomarkers does not preclude a
cystoscopy and does not change management
• GROSS HEMATURIA
- Negative test also not preclude cystoscopy…
• Currently used in combination with cystoscopy as a surveillance
strategy for pt with H/O NMIBC…
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23. • There are certain situations where the marker is positive but
no tumor is found on white light cystoscopy.
• This phenomenon has been observed in UroVysion FISH test
more predominantly and to moderate extent in cytology and to
lesser extent in BTA test and NMP22
• a positive UroVysion FISH test even in the absence of
confirmatory cystoscopical or cytological findings could
predict disease recurrence in 35-63% of patients within the
next 6-10 months.
• If blue light cystoscopy was used in these situations of
positive marker, ONE CAN DETECT A CANCER
• this phenomenon of anticipatory positive test should be
taken as an advantage, both in screening and surveillance.
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24. THANK YOU
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