Immunohistochemical markers in the evaluation of tumors of the urinary bladder: a review

The clinical utility of immunohistochemistry in the diagnosis of tumors of the urinary bladder is well established. With recent advances in molecular biology and novel technologies, several biomarkers have emerged as important adjuncts in the diagnosis of lesions of the bladder. When used in conjunction with careful histologic examination, immunohistochemistry can be a valuable aid in classifying adenocarcinoma presenting in the bladder and mesenchymal lesions of the bladder and in establishing the urothelial origin of a metastatic tumor. In addition, a number of biomarkers may prove to be important indicators of prognosis or response to chemotherapy.     

Immunohistochemical study of neuroendocrine differentiation in primary glandular lesions and tumors of the urinary bladder

OBJECTIVE: Neuroendocrine (NE) cells are uncommon in primary adenocarcinoma (AC) and other glandular lesions of the bladder, with no recent study series concerning its significance in differential diagnosis, prognosis or biologic significance. STUDY DESIGN: Sixteen primary bladder AC (enteric-type [n = 71, mucinous [n = 6] and not otherwise specified [NOS] [n = 31), 4 cases of urothelial carcinoma with glandular differentiation, 20 cases of glandular cystitis and 3 urachal remnants with intestinal metaplasia constituted the study series. In addition, 20 specimens of normal-looking urothelium, 15 conventional urothelial carcinomas and 5 small cell carcinoma (SCC) cases were included for comparison. NE differentiation included detection of chromogranin A, neuron-specific enolase (NSE) and synaptophysin by immunohistochemistry. The statistical analysis included the chi2 or Fisher exact test. RESULTS: Chromogranin A-positive cells were present in 60% (11 of 16) of primary AC, all of enteric or mucinous type, but not in any of the 3 NOS-type AC investigated. NE differentiation in bladder AC subtypes resulted in highly significant differences between enteric or mucinous vs. NOS type (p = 0.0023). NE differentiation was also different in urachal vs. nonurachal AC (p = 0.020) and primary bladder AC vs. conventional invasive urothelial carcinoma (p < 0.001). Synaptophysin-positive cells were seen in 2 (12.5%) of the 16 primary AC cases, and NSE was negative in the 16 primary bladder AC. All urachal remnants and 70% of glandular cystitis examples had chromogranin A-immunoreactive cells. One of 4 urothelial carcinomas with glandular differentiation had chromogranin A-immunoreactive cells, but this was not significant when compared with primary AC (p = 0.1). Normal-looking bladder urothelium and conventional urothelial carcinoma specimens had no chromogranin A-immunoreactive cells. The 5 SCC cases investigated were positive for chromogranin A. No correlation was found between NE differentiation and outcome of primary bladder AC or urothelial carcinoma with glandular differentiation. CONCLUSION: Primary bladder AC, cystitis glandularis and urachal remnants with intestinal metaplasia showed variable degrees of NE differentiation, with no apparent clinical correlation or prognostic significance. However, the absence of NE differentiation in NOS-type primary bladder AC may help in better defining this uncommon subtype of primary bladder AC.     

Critical evaluation of urinary markers for bladder cancer detection and monitoring

Bladder cancer is currently diagnosed using cystoscopy and cytology in patients with suspicious signs and symptoms. These tests are also used to monitor patients with a history of bladder cancer. The recurrence rate for bladder cancer is high, thus necessitating long-term follow-up. Urine cytology has high specificity but low sensitivity for low-grade bladder tumors. Recently, multiple noninvasive urine-based bladder cancer tests have been developed. Although several markers have been approved by the US Food and Drug Administration for bladder cancer surveillance, only a few are approved for detection of bladder cancer in high-risk patients.     

Tumor markers in the detection of recurrent transitional cell carcinoma of the bladder: a brief review

OBJECTIVE: To determine the status of the most promising tumor markers of bladder cancer, including comparison with cytology, technical complexity and utility in patient management. STUDY DESIGN: An extensive literature search was performed, and multiple markers were evaluated. The markers with the greatest potential for use as an adjunct to cytology were reviewed to determine the value of clinical implementation. Markers with a paucity of clinical research and poor results in clinical trials were omitted from review, as were genetic and cytologic prognostic determinants. RESULTS: NMP22, bladder tumor antigen, fibrin/fibrinogen degradation products, telomerase and QUANTICYT image analysis cytometry produced the most favorable and reproducible results. Each test obtained favorable sensitivities in comparison with cytology, especially in the detection of low grade lesions. Many also retrospectively placed patients in high- and low-risk groups based on the test results, allowing increased follow-up time between cystoscopies. However, inability to detect some high grade lesions reduces their utility. CONCLUSION: Continued clinical trials using these and other predictors of bladder cancer will eventually find a test that is suitable, in sensitivity and specificity, for use in urology clinics. Until that time, these tests may be useful in conjunction with cytology to prolong the interval between cystoscopies.     

Visualization of endocytosed markers in freeze-fracture studies of toad urinary bladder

Antidiuretic hormone (ADH) stimulation increases the apical membrane water permeability of granular cells in toad urinary bladder. This response correlates closely with the fusion of tubular cytoplasmic vesicles with the membrane and delivery of intramembrane particle (IMP) aggregates from the tubules (aggrephores) to the apical membrane. These aggregates are believed to be associated with the channels responsible for the water permeability increase. Removal of ADH triggers apical membrane endocytosis and disappearance of aggregates from the apical membrane. However, it has been unclear whether aggregate disappearance is due to disassembly of aggregates within the apical membrane or to their endocytic retrieval as intact structures. Using colloidal gold and horseradish peroxidase to follow endocytosis from the apical surface after ADH removal, we have directly observed in cross-fractured bladder cells the intramembrane structure of intracellular vesicles that contain these fluid-phase markers. Under these conditions, intact aggregates can be identified in the membrane of tubular endocytosed vesicles. This directly demonstrates that conditions which lower apical membrane water permeability cause the tubular aggrephores to "shuttle" intact aggregates from the apical membrane back into the cytoplasm. An additional population of vesicles with tracer are found which are spherical and display structural features of the apical membrane, as well as occasional aggregates. These vesicles may be responsible for retrieval of aggregates from the surface apical membrane.     

Searching cell-secreted proteomes for potential urinary bladder tumor markers

To search for biomarkers critical for bladder carcinoma diagnosis and prognosis, secreted proteomes of highly malignant U1 and pre-malignant U4 cell lines were initially analyzed. Proteins in the culture media of the U1 and U4 cell lines were systematically examined by SDS-PAGE combined with MALDI-TOF MS. Among them, expression of pro-u-plasminogen activator (pro-u-PA) was confirmed by Western blot analysis and further evaluated. In analyzing urine samples from bladder cancer patients and normal subjects, we established a statistically significant relationship between the low level and absence of pro-u-PA in urine with high stages and grades of the tumor samples. Constitutive expression of Ras dominant negative protein led to increased expression of pro-u-PA in culture media, indicating that the loss of pro-u-PA is associated with oncogenic transformation. Analysis of cancer-secreted proteomes can be a feasible, non-invasive and efficient strategy for searching potential bladder tumor biomarkers. Our work also has identified the loss of pro-u-PA in urine as potential marker of more advanced bladder carcinoma.     

Pathologic guidelines for orthotopic urinary diversion in women with bladder cancer: a review of the literature

Orthotopic lower urinary tract reconstruction to the native intact urethra following radical cystectomy for bladder cancer was slower to gain clinical acceptance for women than for men. Until the 1990s, little was known about the natural history of urethral involvement by urothelial carcinoma in women with primary bladder cancer. The increasing availability of pathologic data to define the incidence of and risks for urethral involvement in women sparked an increasing interest in orthotopic diversion in female patients. Pathologic guidelines have been suggested to identify women suitable for orthotopic diversion. Preoperative involvement of the bladder neck is a significant risk factor for secondary tumor of the urethra, but is not an absolute contraindication, as long as full-thickness, intraoperative frozen-section analysis demonstrates no tumor involvement of the proximal urethra. Although less common, anterior vaginal wall tumor involvement may be a significant risk factor for urethral tumor involvement. Other pathologic parameters, including tumor multifocality, carcinoma in situ of the bladder, and tumor grade and stage, do not seem to be absolute contraindications. Long-term follow-up is critical for all patients. Women undergoing orthotopic reconstruction, if appropriately selected, should be assured of an oncologically sound operation and good function with their neobladder.     

Grading of urinary bladder tumors by automated microscopic image analysis

Studies were undertaken on biopsies from urinary papillomas and urothelial carcinomas of different grades (G1 to G3) along with normal urinary bladder mucosa from a total of 220 patients. They were performed by use of automated microscopic image analysis (system Robotron A 6471, software AMBA/R). As a result, the tumor grading was improved and lead to the separation of both papillomas and G1-carcinomas with high proliferative activity. In addition, it was possible to divide the G2-carcinomas into 2 groups which probably show a different biological behaviour.     

Diverticulum of the urinary bladder in a woman

In the two cases of congenital absence of the vagina reported herein, the embryologic point of arrest of development of the mullerian ducts was identical. Both patients had a rudimentary uterus, and one had a fibroid tumor on the rudimentary uterus. As a part of operation to construct a vagina in such cases, exploratory pelvic laparotomy appears to be a desirable step in order to determine the status of the internal genital organs. The use of a split thickness skin graft sewn around a vaginal mold and inserted into the dissected vaginal space results in more rapid healing, less scar tissue and a vagina that is soft, pliable and normal in appearance, even to the extent of having rugal folds.     

Immunohistochemical localization, purification, and characterization of human urinary bladder glutathione S-transferases

This study describes immunohistochemical localization, purification and characterization of glutathione S-transferase (GST) of human urinary bladder. Even though all the three major classes of isoenzymes (alpha, mu, and pi) were expressed in human bladder, more than 90% of total GST activity was accounted for by a pi class anionic form. Human bladder alpha, mu, and pi class GSTs were immunologically related to respective isoenzymes of other human tissues. GST pi was present in all 13 samples analyzed, whereas GST alpha and mu were detected in nine and eleven samples, respectively. GST alpha of human bladder appeared to be unique, because unlike this class of GSTs of other human tissues, bladder enzyme had lower affinity for GSH linked to epoxy-activated Sepharose 6B affinity resin. Immunohistochemical staining indicated localization of GST alpha in epithelial surface cells, underlying submucosa and smooth muscle, whereas mu and pi class isoenzymes were predominantly distributed in epithelial surface cells. These results suggest that human bladder GSTs may play an important role in providing protection against xenobiotics because epithelium is considered a target for several carcinogens and all the three classes of isoenzymes are expressed in these cells.     

Immunohistochemical markers of cancerogenesis in the lung

Lung cancer is the leading cause of cancer deaths for people of both sexes worldwide. Early diagnosis of precancer lesions may be of crucial significance to lowering lung cancer mortality. The World Health Organization has defined three preneoplastic lesions of the bronchial epithelium: squamous dysplasia and carcinoma in situ, atypical adenomatous hyperplasia and diffuse idiopathic pulmonary neuroendocrine cell hyperplasia. These lesions are believed to progress to squamous cell carcinoma, adenocarcinoma and carcinoid tumors, respectively. Apart from WHO classification, two other lesions such as bronchiolization and bronchiolar columnar cell dysplasia (BCCD) can be observed and thought to be preneoplastic lesions leading to adenocarcinoma. In this review we summarize the data of morphological and cell cycle related proteins changes in both central and peripheral compartments of lung. Many molecular changes, which accompany the multistep process of the development of invasive types of cancer, may be observed thanks to the application of immunohistochemical markers. A deeper knowledge of molecular and genetic changes accompanying pre-cancer states may show new directions of early diagnostics of cancer development.     

Value of quantitative cytologic studies in the grading of papillary tumors of human urinary bladder

Mitotic indices and nuclear volumes were determined in 10 papillomas, 20 grade I, 20 grade II and 20 grade III papillary carcinomas of the urinary bladder. The mean mitotic indices were 1.22% in papillomas, 2.77% in grade I carcinomas, 8.2% in grade II carcinomas and 15.25% in grade III carcinomas. The nuclear volumes showed a gradual shift to larger values paralleling the histological degree. It is suggested that these objective parameters might be especially useful for the cytological assessment of exfoliated tumor cells.     

Microscopic changes of the urinary bladder in patients with primary tumors locally treated with Corynebacterium parvum

The study covered 34 patients with tumors of the urinary bladder treated surgically by transurethral resection and, as an adjuvant therapy, with Corynebacterium parvum intravesically administered. Microscopic observations were performed on smears stained with blue polychrome-tannin and the histologic study used preparata stained with hematoxylin-eosin and van Gieson. After the second series of instillations, many biopsies from the same patient were taken. The investigation revealed the negativity for malignant cells on the cytologically studied smears, and histologically a chronic infiltrate formed of lymphocytes and plasma cells along the basement membrane could be observed; sometimes the infiltrate was follicularly organized. The morphologic changes of the urinary bladder mucosa were correlated with the immunostimulation potential of Corynebacterium parvum.