Literature sharing∣UroVysion fluorescence in situ hybridization of urothelial carcinoma: review and future prospects

Introduction Urothelial carcinoma (UC) occurs in the upper part (renal pelvis and ureter) or lower part (bladder and urethra) of the urinary tract
.

Bladder cancer (BCa) is the 10th most common cancer in the world, with approximately 550,000 newly diagnosed cases each year
.

Therefore, corresponding requirements are put forward for the simple and non-invasive detection of UC
.

Cystoscopy and urine cytology have recognized diagnostic accuracy and are the gold standard for identifying bladder-originating UC
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However, cystoscopy or other tests, such as ureteroscopy or retrograde pyelography, are not comfortable for the patient
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Urinary system biomarker testing is expected to meet the needs of low-invasive testing, which is beneficial to anxious patients undergoing invasive testing, such as cystoscopy or ureteroscopy
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Although some urine biomarkers, such as CxBladder, BTA, Immnocyt/uCyt+, NMP22, and AssureMDx, have been approved by the FDA as a non-invasive method for the diagnosis of BCa, they also support the diagnosis or follow-up of UC, but their clinical application Not very common
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UroVysion detection is a multi-target, multi-color fluorescence in situ hybridization (FISH) method
.

It is used for the initial diagnosis of hematuria patients or the recurrence monitoring of patients previously diagnosed with bladder cancer
.

Since it was approved by the FDA, nearly 20 years have passed, so this is a mature test
.

The author used PubMed and Google Scholar database to search the English literature on this test as of September 2020, and briefly summarized UroVysion and its characteristics
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What is FISH and UroVysion? Genetic abnormalities, including mutations and abnormal chromosomes and gene copy numbers, drive the occurrence and progression of tumors
.

FISH is a method of detecting genetic abnormalities by hybridizing these genes with oligonucleotide probes labeled with fluorescent substances or enzymes and identifying targets under a fluorescence microscope
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FISH is widely used to detect chromosomal abnormalities in various tumors
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Compared with conventional pathological examinations, it can clearly detect specific gene loci, so it is considered an objective examination
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One of the characteristics of UroVysion is that it relies on specific chromosomal abnormalities that occur in a large number of urothelial carcinomas
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Use 3, 7 and 17 centromeric fluorescent denatured chromosome counting probes (spectrum red, spectrum green and spectrum cyan, respectively), and 9p21 site-specific recognition probe (spectrum gold) to detect exfoliated cells in urine, It has high sensitivity for tumor detection
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The details of each probe are shown in Figure 1, and the negative and some positive signal patterns are shown in Figure 2
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Figure 1 Fluorescence in situ hybridization probe details.
The test was approved by the FDA in 2001 and has been used to diagnose BCa recurrence since 2001, and it has been used to screen gross hematuria since 2005
.

In addition, it is recommended to use UroVysion FISH to judge the response to BCG treatment in the bladder, and it is used when it is judged to be ambiguous cytology in the guidelines of the American Urological Society (recommendation level: expert opinion)
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In the European Urology Association guidelines, UroVysion is also described as a potential urine biomarker for detecting invisible tumors
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In the National Comprehensive Cancer Network (NCCN) guidelines, UroVysion or NMP22 are considered useful markers for monitoring the recurrence of BCa
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However, although various guidelines emphasize the usefulness of UroVysion, it is necessary to recognize the differences in its use in clinical settings
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Figure 2 The application of fluorescence in situ hybridization signal mode UroVysion analysis in urine cytology includes: atypical urine cytology, control after BCG treatment in the bladder, atypical upper urinary tract cytology, follow-up after transurethral resection, and hematuria patients UC increases the risk
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Compared with urine cytology, UroVysion seems to be an objective test, but the results sometimes depend on the skills of the laboratory technician performing the test
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In addition, UroVysion analysis should be performed by experienced cytopathology laboratory technicians
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This is because it is difficult to interpret UroVysion's inspection results using fluorescence technology
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Doctors should also interpret UroVysion's test results based on clinical manifestations, rather than leaving the test to laboratory technicians
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Using UroVysion monitoring can provide prognostic information for patients with non-muscular invasive UC; however, in order to get an accurate diagnosis, it is important to consider the patient's background
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It may be due to the patient's selection bias, and there will be differences in the sensitivity and specificity of the results
.

Compared with the NMP22 test, it is believed that UroVysion and urine cytology are not affected by the presence of red blood cells or white blood cells
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However, due to the presence of umbrella cells, the Urovysion test produces false positives.
In summary, the chromosomal tetraploidy or aneuploidy is due to human polyoma virus infection
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Hematuria screening Hematuria is one of the main complaints of UC including BCa
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Generally, urine cytology is used to diagnose urinary tract tumors or hematuria
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A recent meta-analysis of urine biomarkers to evaluate primary hematuria showed that there is limited evidence for diagnosis of urine biomarkers, which raises questions about the routine use of urine biomarkers instead of cystoscopy
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Compared with cytology, UroVysion is a more accurate and sensitive detection method, and is used to detect BCa in patients with hematuria under the naked eye or under a microscope at all stages and levels
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UroVysion can detect 69% of UCs, while cytology can only detect 38%; excluding low-grade and low-stage tumors, the gap between the two is widening
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Based on these data, the FDA began to approve UroVysion for hematuria in 2005
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Bladder cancer Table 1 lists the main studies comparing UroVysion and urine cytology
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 Table 1 List of main studies comparing UroVysion and urine cytology In a meta-analysis, Hajdinjak reported the superiority of UroVysion over urine cytology, showing 72% sensitivity and 84% specificity, while cytology was respectively 42% and 96%
.

However, when superficial cases were excluded, this difference disappeared
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According to reports, UroVysion combined with urine cytology is a method to improve sensitivity
.

Daniely et al.
reported the use of automated microscopes for urine cytology and UroVysion examinations
.

Kojima et al.
described the effectiveness of consecutive UroVysion tests: among patients followed up for 3 months, the detection rate of cancers with two consecutive UroVysion test results was 14.
8%, which was higher than that of any one of the two tests (7.
2%).
) Or two tests were not positive (1.
2%)
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However, some clinical conditions can lead to suspicious urine cytology results
.

Ferra et al.
reported that a negative UroVysion result did not rule out the presence of high-grade UC
.

A recent prospective study showed that UroVysion is more practical than urine cytology in terms of sensitivity and specificity, and it is recommended to use UroVysion when the urine cytology results are suspicious
.

Several reports have different interpretations of the 9p21 deletion
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Zellweger reported that 9p21 deletion was significantly associated with recurrence
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However, in a prospective study of 1595 male chemists, the 9p21 deletion had poor predictive power for detecting BCa, because low-grade cancers are rarely present in the clinical setting
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Ureteroscopy for upper urinary tract urothelial carcinoma is the main tool for the diagnosis of upper urinary tract UC
.

However, due to its invasive nature, it may cause serious complications such as bleeding, ureteral perforation, or ureteral dissection
.

Compared with urine cytology, UroVysion is significantly more sensitive and specific (76.
7% vs.
36% and 94.
7% vs.
100%, respectively)
.

A multicenter cohort study found that UroVysion has a higher diagnostic accuracy rate for UC
.

The overall sensitivity of UroVysion is higher than that of cytology (100% vs.
20.
8%), UroVysion's specificity is 89.
5%, and cytology is 97.
4%
.

Freund et al.
reported that even if the sample size is small, it is feasible to use UroVysion to detect upper urinary tract UC by passively collecting 1 mL of upper urinary tract urine
.

Compared with a negative result, a positive FISH result predicts a more advanced tumor stage and a higher tumor grade
.

In addition, it has also been reported that when combined with urine cytology, UroVysion can improve the accuracy of the diagnosis of upper urinary tract UC
.

Follow-up monitoring of BCa monitoring without visible tumors There are several reports that UroVysion is useful in predicting the recurrence and progression of BCa
.

Yoder et al.
reported a prospective study to monitor BCa patients who did not show recurrence
.

In 65% of the UroVysion positive group, UC originating from the bladder recurred within 29 months
.

Sarosdy et al.
compared the ability of FISH, BTA statistical test and cytology to predict the recurrence of BCa, and concluded that the overall sensitivity of FISH was 71%, the sensitivity of BTA statistical test was 50%, and the sensitivity of cytology was 26.
%
.

Seideman et al.
also reported that in patients with positive FISH results, BCa is more likely to recur regardless of whether the tumor is visible
.

Kim et al.
reported that in patients with negative cystoscopy and suspicious cytology results, as well as patients with non-muscular infiltrating BCa with negative cystoscopy, UroVysion positive can predict the recurrence and progression of BCa
.

In a prospective follow-up study of patients with low-grade non-muscular invasive BCa, comparing different urine biomarkers, UroVysion is more sensitive and specific than cytology
.

After transurethral resection of bladder tumors (TURBT), continuous UroVysion testing is considered to be a more reliable method for predicting recurrence in the bladder
.

In addition, these conditions may change in the era of high-resolution endoscopy, such as narrow-band imaging or photodynamic diagnosis
.

BCa monitoring after intravesical treatment UroVysion has also been reported as a useful predictive marker for predicting the recurrence of BCa after intravesical treatment
.

Kipp et al.
reported that in patients receiving intravesical treatments (including BCG and other intravesical treatments), the use of UroVysion to monitor the progress of BCa infiltration into the muscle layer is effective
.

Whitson et al.
reported in a retrospective study that after intravesical treatment, UroVysion positive is highly predictive of recurrence
.

Regarding BCG intravesical treatment, Mengual et al.
believe that for patients with high-risk superficial BCa after initial transurethral surgery, UroVysion results can be used to determine whether adjuvant therapy is needed
.

Kamat et al.
also reported the correlation between UroVysion results and BCa recurrence after BCG intravesical treatment; the timing of the positive test is very important for predicting recurrence
.

Freund et al.
reported a significant correlation between the recurrence of bladder-derived middle- and high-risk UC patients after intravesical BCG treatment and the positive UroVysion 3 months after TURBT
.

On the basis of previous results, a recent prospective multicenter diagnostic test showed that a positive UroVysion result indicates the risk of recurrence
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Although many studies have shown that UroVysion is effective as a marker of BCa recurrence, some studies have found the opposite
.

Savic et al.
reported that UroVysion was superior to urine cytology only when the cytology was clearly positive
.

They also concluded that the UroVysion test could not provide further information about definitive malignant cytology
.

Modifications of UroVysion Some research attempts to achieve better diagnostic accuracy than the traditional UroVysion test
.

Kipp et al.
described the utility of counting abnormal cells, the percentage of which can predict cancer recurrence and progression
.

Ferra et al.
reported that the non-strict standard significantly increased the sensitivity of UroVysion, rather than reducing its specificity
.

According to reports, the quantitative detection and evaluation of chromosomal abnormality through UroVysion can be used as a predictor of the progression of non-muscular invasive BCa to muscular invasive BCa
.

Ho et al.
reported that specificity can be improved by excluding the deletion of chromosome 9; UroVysion detection can avoid cystoscopy, thereby saving health resources and minimizing patient trauma
.

Zhou et al.
focused on tetrasomy and insisted that this is a non-specific result often encountered and should be excluded from the multisomy classification
.

However, due to the small sample size, further research is still needed
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Cost-effectiveness of UroVysion Due to monitoring and treatment needs, the associated costs of treatment for BCa patients are the highest of all cancers
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Due to the advent of the new method, the cost of the BCa diagnostic strategy is expected to increase
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Doctors need to consider the cost-effectiveness of each method
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UroVysion is a reasonable test for detecting BCa, but a positive urine cytology test is a much cheaper test; its cost-effectiveness is still questionable
.

Due to high cost constraints and the fact that it is time-consuming as a screening tool, UroVysion testing is not cost-effective
.

Kamat et al.
prospectively studied the cost-effectiveness of cystoscopy in addition to urine cytology and urine biomarkers
.

They concluded that in the BCa follow-up, the cost of using cystoscopy and UroVysion to detect each tumor was much higher than that of cystoscopy itself ($19111 vs $7692); the addition of urine biomarkers did not improve the detection of aggressive diseases
.

In another study, some experts opposed the UroVysion test to screen for hematuria because of low cost-effectiveness and time-consuming
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Since 2016, in the diagnosis era based on the Paris Urological Cytology Reporting System (TPS), UroVysion's role has been for a long time.
There are no universally applicable standard diagnostic criteria for atypical urothelial cells in different international institutions
.

In order to solve this problem, by adopting a clear classification of cell morphology, TPS has been proposed as a pathological standard for diagnosis of urine cytology, and it has gradually become popular
.

So far, there are several reports that TPS can improve the reliability and accuracy of interpretation, especially in the urine cytology of high-grade UC (HGUC)
.

Based on this trend, some studies have focused on the use of TPS to present the effects of UroVysion
.

Miki et al.
reviewed the 6-year UroVysion test cases and reclassified them according to TPS.
They found that in the negative HGUC group, the sensitivity and specificity of UroVysion were 62.
5% and 100%, respectively
.

Recently, Tian et al.
searched and retrospectively compared the urine cytology diagnosis between pre-TPS and post-TPS in chronological order, and described that all categories of urine cytology have superior correlation with the UroVysion results of post-TPS.
In the suspicious HGUC classification, UroVysion positive results rose from 87% to 93%
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Through these results, the application of TPS is expected to significantly reduce the diagnosis of atypical UC and is potentially cost-effective
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UroVysion's future prospects The latest advances in gene mutation research have led to a continuous shift in the paradigm of cancer treatment
.

In the case of observing cell gene mutations in urine samples, UroVysion has played an important role in the improvement of cancer, especially in the management of UC
.

Several reports describe comparing or combining UroVysion with another type of genetic test
.

Montalbo et al.
reported that in high-grade tumor cases, UroVysion, fibroblast growth factor receptor 3 and telomerase reverse transcriptase mutation analysis, and urine-based gene expression analysis are equally sensitive, according to Paris Urology Reclassification reporting system (Paris System), higher than cytological analysis
.

Chen et al.
reported that compared with cytology and UroVysion, urine DNA methylation can improve the sensitivity of detection of low-grade and early-stage BCa
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Various tests based on urine, including genetic mutations, have been reported for decades, but they have not been found to be superior to UroVysion in detecting UC
.

It is envisaged to combine new detection methods with UroVysion, or use a variety of urine-based biomarkers for tailored detection
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Limitations This review has several limitations
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First, there is no quantitative analysis of the included studies
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As the background of each study is different, the data differences between these studies need to be statistically evaluated
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Second, the inclusion/exclusion criteria of the literature review are not clear
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In order to maintain the validity of the review, multiple authors evaluate whether each article is included in the review
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Conclusion The accuracy of UroVysion detection can improve the diagnostic level of UCs
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Although doctors need to consider various indications when using UroVysion, if the test is used blindly to screen for UC recurrence, it will cause cost problems
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UroVysion has the potential to detect genetic mutations in cells from urine samples
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New methods that improve or combine other types of pathological examinations with UroVysion examinations are expected to provide new diagnostic tools for UC
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 Literature link: DOI: 10.
21037/tau-20-1207