Improving detection of carcinoma in situ in bladder cancer: urinary cytology vs the Xpert® BC Monitor.

OBJECTIVE: To investigate and compare the performance of urinary cytology and the Xpert BC Monitor test in the detection of bladder cancer in various clinically significant patient cohorts, including patients with carcinoma in situ (CIS), in a prospective multicentre setting, aiming to identify potential applications in clinical practice. PATIENTS AND METHODS: A total of 756 patients scheduled for transurethral resection of bladder tumour (TURBT) were prospectively screened between July 2018 and December 2020 at six German University Centres. Central urinary cytology and Xpert BC Monitor tests were performed prior to TURBT. The diagnostic performance of urinary cytology and the Xpert BC Monitor was evaluated according to sensitivity (SN), specificity (SC), negative predictive value (NPV) and positive predictive value (PPV). Statistical comparison of urinary cytology and the Xpert BC Monitor was conducted using the McNemar test. RESULTS: Of 756 screened patients, 733 (568 male [78%]; median [interquartile range] age 72 [62-79] years) were included. Bladder cancer was present in 482 patients (65.8%) with 258 (53.5%) high-grade tumours. Overall SN, SC, NPV and PPV were 39%, 93%, 44% and 92% for urinary cytology, and 75%, 69%, 59% and 82% for the Xpert BC Monitor. In patients with CIS (concomitant or solitary), SN, SC, NPV and PPV were 59%, 93%, 87% and 50% for urinary cytology, and 90%, 69%, 95% and 50% for the Xpert BC Monitor. The Xpert BC Monitor missed four tumours (NPV = 98%) in patients with solitary CIS, while potentially avoiding 63.3% of TURBTs in inconclusive or negative cystoscopy and a negative Xpert result. CONCLUSION: Positive urinary cytology may indicate bladder cancer and should be taken seriously. The Xpert BC Monitor may represent a useful diagnostic tool for correctly identifying patients with solitary CIS and unsuspicious or inconclusive cystoscopy.

Multicenter evaluation of complex urinary diversion for renal transplantation: outcomes of complex surgical solutions.

PURPOSE: An abnormal lower urinary tract poses significant challenges for transplant surgeons. Besides the ureteral anastomosis to an ileal conduit, there are diverse complex reconstructive solutions. Due to its rarity, standardization and teaching of complex urinary diversion is extremely difficult. METHODS: The indications and outcomes of complex urinary diversions after kidney transplantation (KT) were retrospectively investigated at eight urologic transplant centers including a current follow-up. RESULTS: Of 37 patients with 21 (56%) males, vesicoureteral reflux (24%), spina bifida (22%), and glomerulonephritis (12%) were the most common causes of terminal renal failure. In 30 (81%) patients, urinary diversion was performed before KT, at a median of 107.5 (range, 10; 545) months before. Transplantations were held at a median patient age of 43 (10; 68) years, including six (16%) living donations. Urinary diversion was modified during 12 (32%) transplantations. After KT, the ileal conduit was the most common incontinent urinary diversion in 25 (67%) patients; a Mainz pouch I and bladder augmentation were the most frequent continent diversions (each n = 3). At a median follow-up of 120 months (range 0; 444), 12 (32%) patients had a graft failure with a 5-year graft survival of 79% (95%CI 61; 90). The median overall survival was 227 months (168; 286) and the 5-year overall survival 89% (69.3; 96.4). CONCLUSION: The mid-term kidney transplant function with complex urinary diversion appears to be comparable to transplants with regular urinary diversions. Hence, complex urinary diversion should always be considered as a surgical option, even during transplantation, if necessary.

[Current recommendations for surveillance, risk reduction and therapy in Lynch syndrome patients]. / Empfehlungen zur Früherkennung, Risikoreduktion, Überwachung und Therapie bei Patienten mit Lynch-Syndrom.

INTRODUCTION: Lynch syndrome (LS) is the most common hereditary colorectal cancer syndrome and accounts for ~3 % of all CRCs. This autosomal dominant disorder is caused by germline mutations in DNA mismatch repair genes (MLH1, MSH2, MSH6, PMS2, and EPCAM). One in 300 individuals of the general population are considered to be mutation carriers (300 000 individuals/Germany). Mutation carriers are at a high CRC risk of 15-46 % till the age of 75 years. LS also includes a variety of extracolonic malignancies such as endometrial, small bowel, gastric, urothelial, and other cancers. METHODS: The German Consortium for Familial Intestinal Cancer consists of 14 university centers in Germany. The aim of the consortium is to develop and evaluate surveillance programs and to further translate the results in clinical care. We have revisited and updated the clinical management guidelines for LS patients in Germany. RESULTS: A surveillance colonoscopy should be performed every 12-24 months starting at the age of 25 years. At diagnosis of first colorectal cancer, an oncological resection is advised, an extended resection (colectomy with ileorectal anastomosis) has to be discussed with the patient. The lifetime risk for gastric cancer is 0.2-13 %. Gastric cancers detected during surveillance have a lower tumor stage compared to symptom-driven detection. The lifetime risk for small bowel cancer is 4-8 %. About half of small bowel cancer is located in the duodenum and occurs before the age of 35 years in 10 % of all cases. Accordingly, patients are advised to undergo an esophagogastroduodenoscopy every 12-36 months starting by the age of 25 years. CONCLUSION: LS colonic and extracolonic clinical management, surveillance and therapy are complex and several aspects remain unclear. In the future, surveillance and clinical management need to be more tailored to gene and gender. Future prospective trials are needed.

Fungaemia caused by obstructive renal candida bezoars leads to bilateral chorioretinitis: a case report.

BACKGROUND: Renal fungal bezoars are remarkably rare and mostly occur in immunodeficient patients. Only a small number of cases with immunocompetent patients have been published so far. The published treatment approaches comprised systemic antimycotic therapy and surgical or minimal invasive removal of the fungal balls. In some cases irrigation of the renal duct system with amphotericin B was performed. By obstruction of the urinary tract bezoars can lead to infected hydronephrosis and severe urosepsis with high lethality. Fungaemia can cause fungal colonization in different distant organs. Fulminant chorioretinitis and irreversible visual impairment can be the consequence of ocular fundus colonization. The following report highlights that a co-operation between urologists and ophthalmologists is absolutely indispensible in case of fungaemia. CASE PRESENTATION: Hereinafter we describe a case of an immunocompetent 56 years old woman, presenting with flank pain and shivering. The diagnosis turned out to be difficult due to initially negative urine culture. The fungaemia caused by obstructive nephropathy led to bilateral candida chorioretinitis. The patient was treated with intravenous amphotericin b and the bezoar was removed by percutaneous "nephrolitholapaxy". After two months, a follow up revealed the patient felt well, chorioretinal lesions regressed and urine culture did not show any fungal growth. CONCLUSION: To the best of our knowledge, this is the first case reporting on obstructive renal bezoars, which lead to haematogenous fungus spread and bilateral chorioretinitis. It points out that extensive ophthalmologic examination should be performed in case of fungaemia even if the patient is not suffering from any visual impairment.

Diagnostic meaning of urodynamic studies in pouch incontinence: results of a small series.

INTRODUCTION: To evaluate the meaning of urodynamic parameters in patients with pouch incontinence. MATERIALS AND METHODS: Thirteen urodynamic studies in patients with an ileal nipple as the efferent segment of an ileocecal pouch or ileum/ileocecal-augmented bladder were performed. The recorded parameters included pouch capacity, leak point pressure/volume, maximum pouch pressure, compliance, static and dynamic closure pressure, and functional length. Three patients suffered from urinary incontinence. RESULTS: In all cases of incontinent patients, no functional length or static or dynamic closure pressure could be revealed. In 8 of 10 cases of continent patients, a positive functional length as well as static and/or dynamic closure pressure were measured (mean value in continent patients: 15.9 mm, 14.5 cm H2O and 26.5 cm H2O, respectively). In 2 of 3 cases of incontinent patients, the pouch compliance was restricted (21 and 37 ml/cm H2O). The pouch capacity of continent patients was greater than the capacity of incontinent patients (377.4 vs. 185.7 ml). CONCLUSIONS: Positive functional length, static and dynamic closure pressures, and a high pouch capacity with an unrestricted compliance are predictive for pouch continence. They may individually not determine continence, but combining them can. However, the meaning of urodynamic studies in pouch incontinence is not the same as with the urinary bladder.

Delayed symptomatic renal arteriovenous fistula in a 24 years old male following renal biopsy.

We report a case of a 24-year-old male with a history of kidney biopsy at young age due to chronic renal dysfunction and challenging hypertension, who presented with flank pain and hematuria. Initial imaging suggested renal pelvis enlargement, but MRI revealed a massive renal arteriovenous malformation (AVM). Angiographic embolization was abandoned due to extensive effluent flow, followed by successful surgical resection preserving healthy kidney tissue. This case underscores the importance of considering renal AVMs in the differential diagnosis of young patients with gross hematuria or refractory hypertension to prevent complications and improve patient outcomes.

Urological surgery in patients with hemorrhagic bleeding disorders Hemophilia A, Hemophilia B, von Willebrand disease: a retrospective study with matched pairs analysis.

PURPOSE: To determine retrospectively the perioperative management and outcome of transurethral prostate/bladder surgery (TURP, TURB) and transrectal prostate biopsy in hemophiliacs. METHODS: Thirty-seven hemophilic patients underwent TURP (12 patients), TURB (13 patients), or transrectal prostate biopsy (12 patients) with proactive hemostaseological management (i.e., factor supply, close meshed hemostaseological analysis). Thirty-seven non-hemophiliac patients served as matched pairs who matched for age, gender, accompanying diseases, and the type of surgical procedure. The resulting pairs were analyzed for duration of surgery, hospital stay, and complications. RESULTS: Average TURP length in hemophiliacs was 77.92 min, in the matched pairs group TURP 67.08 min (p = 0.487). Mean TURB length in hemophiliacs was 43.46 min versus 35.38 min in controls (p = 0.678). More important, the length of hospital stay was significant longer in the hemophiliacs undergoing TURP compared to non-hemophiliac control group (12.08 days vs. 5.83 days; p < 0.001). In TURB patients, similar results were found (11.15 days hemophiliacs vs. 6.15 controls; p = 0.018). Regarding complications (bleeding, hemorrhage, readmission), no significant difference between the groups was obtained. CONCLUSION: Urological interventions in hemophiliac patients with factor supply have the same risk for postoperative complications as in non-hemophiliacs. The only significant difference between hemophiliacs and non-hemophiliacs was the length of hospital stay.

Spindle cell rhabdomyosarcoma of the prostate.

The spindle cell rhabdomyosarcoma is a rare variant of the embryonal rhabdomyosarcoma, mostly occurring in childhood. Only a few cases are described in adults. To date, no case of the spindle cell subtype of the prostatic embryonal rhabdomyosarcoma has been published. We report on a 23-year-old man, initially presenting with obstructive micturition problems, perineal pain and night sweat. After diagnosis by transrectal biopsy of the prostate, radiochemotherapy within the CWS 2002 P study was applied: nine cycles of vincristine, doxorubicin, actinomycin D, ifosfamide, and fractionated radiotherapy of the tumor and suspect lymph nodes (final dose 50.4 Gy). The tumor initially shrank, but an early local recurrence arose. Second-line chemotherapy was applied, followed by a salvage radical cytoprostatectomy. The patient died of disseminated disease 14 months after diagnosis.

Xpert bladder cancer monitor to predict the need for a second TURB (MoniTURB trial).

To determine whether Xpert bladder cancer monitor, a noninvasive PCR-based biomarker test, can predict the need for 2nd transurethral resection of the bladder (TURB) better than clinical assessment. Patients scheduled for TURB were prospectively screened. After initial TURB, patients were assigned to 2nd TURB or follow-up cystoscopy at 3 months (FU) by clinicians' discretion. Central urine cytology and Xpert monitor tests were performed prior to the 1st TURB and 2nd TURB or FU, respectively. Statistical analysis to compare clinical assessment and Xpert monitor comprised sensitivity (SENS), specificity (SPEC), NPV and PPV. Of 756 screened patients, 171 were included (114 with 2nd TURB, 57 with FU). Residual tumors were detected in 34 patients who underwent 2nd TURB, and recurrent tumors were detected in 2 patients with FU. SENS and SPEC of Xpert monitor were 83.3% and 53.0%, respectively, PPV was 32.6% and NPV was 92.1%. Clinical risk assessment outperformed Xpert monitor. In patients with pTa disease at initial TURB, Xpert monitor revealed a NPV of 96%. Xpert monitor was not superior than clinical assessment in predicting the need for 2nd TURB. It might be an option to omit 2nd TURB for selected patients with pTa disease.

Thulium laser (Revolix) vapoenucleation of the prostate is a safe procedure in patients with an increased risk of hemorrhage.

PURPOSE: To evaluate the feasibility and safety of thulium:yttrium-aluminium-garnet laser vapoenucleation of the prostate (ThuVEP) in patients with chronic anticoagulation and bleeding disorders. METHODS: We retrospectively analyzed the clinical data (transfusion rate, hemoglobin changes, residual urine, bleeding complications, complications and residual urine) of patients with chronic anticoagulation and bleeding disorders treated with ThuVEP. Anticoagulation was not paused for surgery. RESULTS: We identified 39 patients who fulfilled the inclusion criteria (32 with chronic anticoagulation, 3 with bleeding disorder, and 4 with both). Mean preoperative hemoglobin was 12.9 g/l; the postoperative hemoglobin was 11.7 g/l. One patient received a blood transfusion. Mean residual urine was 166 ml preoperatively and 47 ml postoperatively, respectively; spontaneous voiding postoperatively was feasible in 36 patients. During follow-up, 5 patients suffered from gross hematuria, which was treated conservatively. CONCLUSIONS: ThuVEP is a safe procedure in patients with therapeutic anticoagulation, bleeding disorders and platelet aggregation inhibitor medication.

Global histone H4K20 trimethylation predicts cancer-specific survival in patients with muscle-invasive bladder cancer.

OBJECTIVE: •To determine the role of global histone methylation as a prognostic parameter in patients with bladder cancer. PATIENTS AND METHODS: •We used a tissue microarray with samples from patients with non-muscle-invasive bladder cancer (NMIBC; n= 161), muscle-invasive bladder cancer (MIBC, n= 127), normal urothelium (NU; n= 31) and bladder cancer metastases (METS; n= 31) to determine global histone methylation (me) levels at histone H3 lysine 4 (H3K4) and H4K20. RESULTS: •Global histone modification levels (H3K4me1, H3K4me3, H4K20me1, H4K20me2, and H4K20me3) were lower in bladder cancer samples than in NU tissue •Global levels of H3K4me1, H4K20me1, H4K20me2 and H4K20me3 were decreasing from NU over NMIBC and MIBC to METS. •H4K20me1 levels were increased in patients with NMIBC with advanced pTstage and less differentiated bladder cancer. •In patients with MIBC, pTstage was negatively correlated with H3K4me1, H4K20me1 and H4K20me2 levels. •H4K20me3 levels were significantly correlated in a univariate and multivariate model with bladder cancer-specific mortality after radical cystectomy in patients with MIBC. CONCLUSION: •Global histone methylation levels may help to identify patients with bladder cancer with poor prognosis after radical cystectomy.

Evoluting the invaginated--one step closer to the perfect valve? Modified serosal lined tapered ileum (Kälble's procedure) as a continence mechanism for catheterizable pouches.

INTRODUCTION: A sufficient and easily catheterizable continence mechanism is essential in continent cutaneous pouches. Kälble embedded a tapered ileum as efferent segment into a serosal lined tunnel formed by an ileal 'U' according to the principle of Abol-Enein and Ghoneim. We report a modified technique applied in a series of 12 patients who had undergone different urinary diversions. METHODS: All patients received a modified Kälble procedure (first-line urinary diversion, n = 8; revision/undiversion, n = 4) for different forms of continent pouches. To alleviate embedding of the efferent segment, ileal detubularization was performed asymmetrically. Mean follow-up was 9.5 months. RESULTS: All patients were continent and performed self-catheterization easily. Of 12 patients, 2 underwent endoscopic incision for stomal stenosis 8 and 12 months postoperatively. CONCLUSIONS: Subject to our short follow-up, Kälble's technique is a promising alternative in patients undergoing a continent cutaneous urinary diversion but offers an inapplicable or missing appendix.

[Long-term follow up of the serosa-lined and tapered Ileum as an efferent segment of various urinary diversion reservoirs ("Fulda-nipple")]. / Langzeitergebnisse des seroserös eingebetteten und getaperten Ileums als efferentes Segment verschiedener Harnableitungsreservoire ("Fulda-Nippel").

BACKGROUND: In 2008, Kälble et al. presented the "serosa-lined and tapered ileum" ("Fulda nipple") as a new continence mechanism of the modified MAINZ-Pouch-I. In accordance with the principle of Abol-Enein, a tapered ileum segment is embedded into a serosa-lined tunnel consisting of a second "U"-shaped ileum segment. Thus a combination of continence mechanism and pouch augmentation - which can be applied to all forms of pouches - was established. PATIENTS AND METHODS: We report on 21 patients who received a serosa-lined and tapered ileum at the Department of Urology of the University Hospital of Bonn for different indications. The aim of this study was to evaluate this technique, especially with regard to stenosis and incontinence rates in the long-term follow up.  RESULTS: At a mean follow-up period of 37 months, stoma stenosis occurred in 33 % of the cases. Incontinence was observed in 21 % (n = 4) of the cases. Remarkably, two of these patients suffered from incontinence due to the phenomenon of "nipple gliding". CONCLUSION: The long-term analysis shows similar stenosis and incontinence rates compared to the two best-established techniques - submucosally embedded appendix and intussuscepted ileum. Despite limitations due to the small number of cases, the Fulda nipple is at least a safe alternative as a "second-line technique" in cases where the initial method has failed.

Impairment of long-term graft function after kidney transplantation by intraoperative vascular complications.

OBJECTIVE: Surgical complications in kidney transplantation often demand reoperation and therefore may severely affect graft survival. Major complications can be divided into ureteral and vascular related. Reoperation for ureteral complications is supposed to worsen graft survival, but vascular complications or anastomosis technique has not been evaluated for this issue. PATIENTS AND METHODS: Between 1994 and 2004 260 patients underwent kidney transplantation. All ureterovesical junctions were performed in extravesical technique with ureteral stenting in 132/260 (50.7%) patients. Arterial end-to-side anastomosis was performed routinely except for 13/260 (5%) with end-to-end anastomosis. Mean follow-up was 43 months (0-121) including serum creatinine and ultrasound inter alia. RESULTS: Graft failure rate was 8.1% 12 months and 12.7% 60 months postoperatively. Of the patients, 29/260 (11.5%) underwent reoperation within 30 days after transplantation (stenosis or leakage of the ureterovesical junction: n = 8; vascular complications: n = 10; thrombectomy for graft vein thrombosis: n = 1; evacuation of hematoma: n = 6; nephrectomy for complete graft ischemia: n = 4). Reoperation for vascular-related complications significantly enhances the risk of graft failure (P < 0.05, Cox proportional hazard) compared to urological complications. Arterial end-to-end anastomosis was also found to have a negative impact on graft survival. No correlation between routine ureteral stenting and ureteral stenosis or leakage was found. CONCLUSION: Our data emphasize the importance of vascular complications compared to ureteral ones in kidney transplantation. Resolving 'non-urological' problems successfully, kidney transplantation is a safe procedure in urological hands.

Evaluation of hypoxia-mediated growth factors in a novel bladder cancer animal model.

BACKGROUND AND AIM: The outcome of advanced transitional cell carcinoma (TCC) is poor. Changes taking place in the tumor microenvironment are receiving increased scrutiny. Hypoxia is the key to increased expression of HIF-1alpha (hypoxia-inducible factor 1alpha) resulting in increased expression of growth factors (e.g. vascular endothelial growth factor (VEGF), epidermal growth factor (EGF)). The aim of our study was to establish an animal model with modulatable tumor hypoxia. Resulting tumor growth and growth factors were assessed. MATERIALS AND METHODS: Low Hb levels were induced in rats by total body irradiation (5 Gy). Twenty animals received EPO erythropoietin (EPO), 1000 IE/kg/week subcutaneously). After subcutaneous injection of NBT-II cells a weekly determination of Hb concentration, leukocyte counts and tumor volume were performed. Serum VEGF levels were quantified and oxygen Hb saturation in healthy tissue and tumors were measured by percutaneous laser spectroscopy. HIF-1alpha and VEGF were examined immunohistochemically. RESULTS: Reduced O2 supply promoted expression of HIF-1alpha and VEGF. Low oxygen availability was essential for tumor growth. EPO improved the O2 supply and decreased expression of growth factors but did not reduce tumor volumes. CONCLUSION: Based on these studies, treatment of low Hb levels appears reasonable in TCC. O2 supply is improved and expression of tumor growth factors is decreased. Tumor volumes did not differ between the groups, causatively adverse effects of EPO overtreatment might negatively affect microcirculation. Restoring low Hb levels and improvement in the O2 supply resulted in tumor shrinkage.

Hyperoxia-induced improvement of the in vitro response to gemcitabine in transitional cell carcinoma.

BACKGROUND: Anemic tissue hypoxia can decrease the effects of chemotherapy in bladder cancer. Hypoxia leads to overexpression of hypoxia-inducible factor (HIF) and increased synthesis of epidermal growth factor (EGF) and vascular endothelial growth factor (VEGF). Tumor cell survival, invasion and angiogenesis thereby compromise treatment. MATERIALS AND METHODS: Monolayer cultures of RT112, RT4, T24 and TCC SUP cells were incubated with or without gemcitabine and different gas mixtures (hypoxia, normoxia or hyperoxia). Cell proliferation (microculture tetrazolium assay), VEGF (enzyme-linked immunosorbent assay) and HIF-1alpha (Western blot analysis) were determined. RESULTS: Hypoxia led to increased proliferation of transitional cell carcinoma (TCC) cells and elevated levels of HIF-1alpha and VEGF. Hyperoxia inhibited cell growth and lowered the concentration of VEGF. Treatment with gemcitabine was less effective under hypoxia. CONCLUSION: Hypoxia enhances TCC growth and may intensify angiogenesis mediated by VEGF. Hypoxia compromises treatment with gemcitabine. Correction of anemia might provide advantages in chemotherapeutic strategies for TCC.

Kidney sparing surgery for urothelial carcinoma of the pyelocalyceal system: is there a role for open techniques? Results from a small series.

PURPOSE: To evaluate individually tailored open nephron-sparing surgical techniques for urothelial carcinoma of the pyelocalyceal system (UCPCS). MATERIALS AND METHODS: Four patients underwent nephron-sparing surgery for UCPCS including, open partial resection of the pyelon with peritoneal reconstruction, partial nephrectomy, open partial resection of the pyelon with kidney autotransplantation, combined open resection and calicoscopic laser coagulation. RESULTS: Recurrence-free survival was 24 months without any impairment of kidney function in all patients. CONCLUSION: Open nephron-sparing surgery for UCPCS should be taken into consideration for selected cases.

Continent ileovesicostomy after bladder neck closure as salvage procedure for intractable incontinence.

INTRODUCTION: We evaluated the success rate of continent vesicostomy using an ileal segment with seroserosally embedded, tapered ileum for bladder augmentation with continent stoma following bladder neck closure (BNC) for severely damaged bladders or persistent urinary incontinence. MATERIAL AND METHODS: A total of 15 patients were treated for persistent urinary incontinence or non-reconstructible bladder outlet between 2003 and 2012. Underlying diagnosis included post-prostatectomy incontinence (n = 5), recurrent bladder neck stenosis (n = 5), neurogenic bladder (n = 3), urethral tumor recurrence following orthotopic neobladder (n = 1) and post-TVT and colposuspension incontinence (n = 1). All patients underwent open BNC, omental interposition and continent vesicoileostomy. The continent outlet was placed in the lower abdomen using a circumferential subcutaneous and skin plasty to avoid retraction. Data collected included age, underlying diagnosis, stoma site, time to complications and need for subsequent surgical revisions. All patients received a standardized questionnaire at the time of data acquisition and were personally interviewed. RESULTS: Median follow-up was 24 months (range: 2-111). Primary BNC was successful in all patients and primary continence rate was 86.7%. Two patients (13.3%) suffered from failure of the continence mechanism, caused by stoma stenosis at skin level and insufficiency of the bladder augmentation and stoma due to local infection. One additional patient developed a mild stomal incontinence without need for further reconstruction. Regardless of the number of revisions, at the last follow-up 93.3% of patients had a functional channel. All complications occurred within the first postoperative year. CONCLUSIONS: This technique is an effective last resort treatment for patients with non-reconstructible bladder outlet.

Serum DNA hypermethylation in patients with kidney cancer: results of a prospective study.

AIM: No reliable biomarker for renal cell carcinoma (RCC) exists. The purpose of this study was to analyze the value of CpG island hypermethylation of cell-free (cf) circulating serum DNA in patients with RCC as a potential biomarker. PATIENTS AND METHODS: In total 35 patients with RCC and 54 healthy individuals were enrolled in this study. Cell-free DNA (cFDNA) in serum was isolated and digested with methylation-sensitive restriction enzymes (Bsh1236I, HpaII and HinP1I) to quantify the amount of methylated Adenomatosis-poliposis-coli gene (APC), Gluthation-a-transferase-protein 1 gene (GSTP1), ARF tumor suppressor protein gene (p14(ARF)), cyclin-dependent kinase inhibitor 2A (p16), Retinoid-acid-receptor-beta gene (RAR-B), RAS-association domain family-1 gene (RASSF1), Tissue inhibitor of metalloproteinase-gene (TIMP3) and Prostaglandin-endoperoxid synthase 2 (PTGS2) DNA fragments. RESULTS: In 30 of 35 investigated patients with RCC, at least one gene was methylated within the serum cfDNA. The methylation frequency ranged from 14.3% for p14(ARF) to 54.3% for APC. All genes, except p16 and TIMP3, were significantly more frequently methylated in patients with RCC compared to healthy individuals. Receiver operator characteristic analysis showed a high specificity for serum cfDNA methylation [between 85.2% for RAR-B and 100% for p14(ARF)], but the sensitivity was low in single-gene analysis [range-14.3% for p14(ARF) to 54.3% for APC]. The combined analysis of multiple genes increased the diagnostic sensitivity (i.e. APC, PTGS2 and GSTP1, 62.9%) at a high specificity (87%). DNA hypermethylation of APC was correlated with advanced tumor stage. CONCLUSION: The detection of hypermethylated cfDNA in serum may be helpful for the identification of RCC; the combinatorial analysis of multiple genes may increase the diagnostic accuracy.

Serum DNA hypermethylation in patients with bladder cancer: results of a prospective multicenter study.

BACKGROUND: Cell-free serum DNA levels are increased in patients with cancer, and at least partially, these DNA fragments are derived from cancer cells. A few reports indicated that methylated serum DNA in patients with bladder cancer (BCA) is a useful non-invasive biomarker. The purpose of this prospective multicenter study was to validate earlier studies. MATERIALS AND METHODS: In total, 227 consecutive participants (non-muscle invasive BCA, n=75; muscle-invasive BCA, n=20; transurethral bladder resection (TURB) without BCA, n=48; benign disease, n=31; healthy individuals, n=53), were recruited for this study. Cell-free serum DNA was isolated and digested with methylation-sensitive restriction-enzymes (Bsh1236I, HpaII and HinP1I) to quantify the amount of methylated (TIMP3, APC, RARB, TIG1, GSTP1, p14, p16, PTGS2 and RASSF1A) DNA fragments. RESULTS: The amount of methylated DNA was usually small (<10%), and the methylation frequencies varied for different genes (e.g. frequent: TIMP3; moderate: APC, RARB, TIG1; infrequent: p16, PTGS2, p14, RASSF1A, GSTP1). Methylation levels at each gene site and the number of methylated genes were increased in BCA compared to healthy individuals, but were similar in BCA and patients with non-malignant disease. The number of methylated genes allowed for discrimination (62% sensitivity, 89% specificity) of BCA patients from healthy individuals. DNA hypermethylation was not correlated with advanced stage or grade in patients with BCA. CONCLUSION: The detection of hypermethylated DNA in serum allows for discrimination of patients with BCA and healthy individuals, but there is no difference between patients with BCA and those with non-malignant disease, thereby limiting its value as a non-invasive biomarker.