title: Validation of a DNA Methylation-Mutation Urine Assay to Select Patients with Hematuria for Cystoscopy.
abstract: Only 3% to 28% of patients referred to the urology clinic for hematuria are diagnosed with bladder cancer. Cystoscopy leads to high diagnostic costs and a high patient burden. Therefore, to improve the selection of patients for cystoscopy and reduce costs and over testing we aimed to validate a recently developed diagnostic urine assay.
  
  
  
  Included in study were 200 patients from a total of 3 European countries who underwent cystoscopy for hematuria, including 97 with bladder cancer and 103 with nonmalignant findings. Voided urine samples were collected prior to cystoscopy. DNA was extracted and analyzed for mutations in FGFR3, TERT and HRAS, and methylation of OTX1, ONECUT2 and TWIST1. Logistic regression was used to analyze the association between predictor variables and bladder cancer.
  
  
  
  Combining the methylation and mutation markers with age led to an AUC of 0.96 (95% CI 0.92-0.99) with 93% sensitivity and 86% specificity, and an optimism corrected AUC of 0.95. The AUC was higher for T1 or greater tumors compared to Ta tumors (0.99 vs 0.93). The AUC was also higher for high grade tumors compared to low grade tumors (1.00 vs 0.93). Overall negative predictive value was 99% based on the 5% to 10% prevalence of bladder cancer in patients with hematuria. This would lead to a 77% reduction in diagnostic cystoscopy.
  
  
  
  Analyzing hematuria patients for the risk of bladder cancer using novel molecular markers may lead to a reduction in diagnostic cystoscopy. Combining methylation analysis (OTX1, ONECUT2 and TWIST1) with mutation analysis (FGFR3, TERT and HRAS) and patient age resulted in a validated accurate prediction model.
authors.affiliation: Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Kim E M
authors.initials: KE
authors.lastname: van Kessel
authors.affiliation: Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Willemien
authors.initials: W
authors.lastname: Beukers
authors.affiliation: Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Irene
authors.initials: I
authors.lastname: Lurkin
authors.affiliation: Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Angelique
authors.initials: A
authors.lastname: Ziel-van der Made
authors.affiliation: Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Kirstin A
authors.initials: KA
authors.lastname: van der Keur
authors.affiliation: Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Joost L
authors.initials: JL
authors.lastname: Boormans
authors.affiliation: Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark.
authors.forename: Lars
authors.initials: L
authors.lastname: Dyrskjøt
authors.affiliation: Genetic and Molecular Epidemiology Group, Spanish National Cancer Research Centre, Madrid.
authors.forename: Mirari
authors.initials: M
authors.lastname: Márquez
authors.affiliation: Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark.
authors.forename: Torben F
authors.initials: TF
authors.lastname: Ørntoft
authors.affiliation: Epithelial Carcinogenesis Group, Spanish National Cancer Research Centre, Madrid; Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain.
authors.forename: Francisco X
authors.initials: FX
authors.lastname: Real
authors.affiliation: Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
authors.forename: Ulrika
authors.initials: U
authors.lastname: Segersten
authors.affiliation: Genetic and Molecular Epidemiology Group, Spanish National Cancer Research Centre, Madrid.
authors.forename: Núria
authors.initials: N
authors.lastname: Malats
authors.affiliation: Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
authors.forename: Per-Uno
authors.initials: PU
authors.lastname: Malmström
authors.affiliation: MDxHealth, Inc., Irvine, California; Laboratory of Bioinformatics and Computational Genomics, Ghent University, Belgium.
authors.forename: Wim
authors.initials: W
authors.lastname: Van Criekinge
authors.affiliation: Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands. Electronic address: e.zwarthoff@erasmusmc.nl.
authors.forename: Ellen C
authors.initials: EC
authors.lastname: Zwarthoff
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D014408:Biomarkers, Tumor / Q000235:genetics* / Q000652:urine*; D003558:Cystoscopy; D019175:DNA Methylation; D004252:DNA Mutational Analysis; D003955:Diagnostic Tests, Routine; D005260:Female; D006417:Hematuria / Q000235:genetics* / Q000652:urine*; D006801:Humans; D008297:Male; D008875:Middle Aged; D060787:Neoplasm Grading; D009426:Netherlands; D018579:Patient Selection; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D013030:Spain; D013548:Sweden; D001749:Urinary Bladder Neoplasms / Q000235:genetics* / Q000652:urine*
chemical_list: D014408:Biomarkers, Tumor
keywords: biomarkers; hematuria; methylation; tumor; urinalysis; urinary bladder neoplasms