Information, discrimination and divergence in cytology. II. Total discrimination as a measure of performance

Discrimination is the expectation of log odds ratios. Performance in diagnostic cytology, as compared to the results of histopathology or to a peer-reviewed consensus, can be measured by the total discrimination, which is a well-defined measure of information in information theory and test theory. The total discrimination, as a measure of performance, was calculated for the Gynecologic Cytology Laboratory of the University of Minnesota for the years 1985 through 1987, based on 3,545 sets of single-slide Papanicolaou smears and colposcope-directed biopsies. Similar calculations were made for the performances of physicians and technicians on peer-reviewed "clear-cut" Papanicolaou smears, as reported in a study from the Centers for Disease Control (CDC). For fair comparison of the two different sets of observations, the cytologic categories and corresponding histologic states were merged into five categories and states. The cytologic performance of our laboratory, tested against the histologic diagnoses, and the performances of the physicians and technologists tested against peer-reviewed check samples by the CDC were 0.53, 0.45 and 1.17 decits, respectively. These values generally agree with the conclusions derived by more conventional methods used by the CDC. When sampling errors of cytology specimens are taken into account, the performance of our laboratory, measured by the total discrimination of the cytology-histology confusion matrix, was approximately equal to the performance of the group of technologists studied by the CDC, which was in turn significantly better than that of the group of physicians studied by the CDC. This study demonstrates the value of using the total discrimination for quantifying the performance of a cytology laboratory, a cytopathologist or a cytotechnologist, without the arbitrary means usually used to evaluate such performances.     

Information, discrimination and divergence in cytology. III. Optimization of classification of Papanicolaou smears

The performance of a cytology laboratory can be objectively quantitated as the total discrimination, a defined quantity of information. The total discrimination is dependent on the number of categories used in gynecologic cytology and on the corresponding histologic states; over-classification results in a higher rate of misinformation and reduced total discrimination. Total divergence is another measure of the association between cytologic categories and histologic states; in contrast to the total discrimination, the total divergence does not require a one-to-one correspondence between the cytologic categories and the histologic states. Using data from the Gynecologic Cytology Laboratory of the University of Minnesota, the total discrimination was maximized when gynecologic cytology used three categories of diagnosis, consisting of (1) normal, atypical benign or reactive atypia, (2) cervical intraepithelial neoplasia (CIN) and (3) all malignancies. The use of four categories, (1) normal, atypical benign or reactive atypia, (2) mild or moderate dysplasia, (3) severe dysplasia or squamous carcinoma in situ and (4) all malignancies, was almost equally informative. Observations on the total divergences resulted in similar conclusions. These findings generally support the recommendation of the consensus workshop sponsored by the National Cancer Institute (the Bethesda System nomenclature) to group all degrees of CIN into two large categories.     

Comparison of serological assays for detecting antibodies in ducks exposed to H5 subtype avian influenza virus

ABSTRACT: BACKGROUND: Chicken red blood cells (RBCs) are commonly used in hemagglutination inhibition (HI) tests to measure hemagglutinating antibodies against influenza viruses. The use of horse RBCs in the HI test can reportedly increase its sensitivity when testing human sera for avian influenza antibodies. This study aims to compare the proportion of positives detected and the agreement between two HI tests using either chicken or horse red blood cells for antibody detection in sera of ducks experimentally infected or naturally exposed to Indonesian H5 subtype avian influenza virus. In addition, comparison with a virus neutralisation (VN) test was conducted with the experimental sera. RESULTS: In the experimental study, the proportion of HI antibody-positive ducks increased slightly, from 0.57 when using chicken RBCs to 0.60 when using horse RBCs. The HI tests indicated almost perfect agreement (kappa = 0.86) when results were dichotomised (titre [greater than or equal to] 4 log2), and substantial agreement (weighted kappa = 0.80) for log titres. Overall agreements between the two HI tests were greater than between either of the HI tests and the VN test. The use of horse RBCs also identified a higher proportion of antibody positives in field duck sera (0.08, compared to chicken RBCs 0.02), with also almost perfect agreements for dichotomized results (Prevalence and bias adjusted Kappa (PABAK) = 0.88) and for log titres (weighted PABAK = 0.93), respectively. Factors that might explain observed differences in the proportion of antibody-positive ducks and in the agreements between HI tests are discussed. CONCLUSION: In conclusion, we identified a good agreement between HI tests. However, when horse RBCs were used, a higher proportion of sera was positive (titre [greater than or equal to] 4 log2) than using chicken RBCs, especially during the early response against H5N1 virus. The HRBC-HI might be more responsive in identifying early H5N1 HPAI serological response and could be a recommended assay for avian influenza sero-surveillance in both wild and domestic birds.     

Análisis del impacto presupuestal en Colombia de la prueba de HPV con genotipificación comparada con la citología

Introduction:

The detection of the human papillomavirus (HPV) through the combination of the HPV test and other techniques such as cytology has impacted the detection and timely treatment of lesions associated with cervical cancer.

Objective:

To estimate the budgetary impact of the strategy of early detection of HPV with DNA test genotyping with reflex cytology versus conventional cytology in women aged 30 to 65 years attending the cervical cancer screening program at a health benefit managing entity in Colombia.

Materials and methods:

Using a decision tree and a Markov model, the clinical implications and direct costs of screening, diagnosis, and treatment were estimated in a cohort of women. The analysis considered two screening cycles and their annual costs. The data on the prevalence of clinical results and the costs were taken from the health managing entity. The information on the progression, persistence, and regression of the health states were taken from the ATHENA study.

Results:

The screening scheme with the HPV test, genotyping, and reflex cytology compared to conventional cytology was cost-saving. The average cost per screening cycle with the HPV test was estimated at COP $ 129,201,363 and with cytology at COP $ 186,309,952, i.e., a saving of COP $ 57,108,589 (30.7%).

Conclusion:

The implementation of the screening strategy under evaluation suggests prospective savings derived from the early detection of health states associated with the development of cervical cancer.     

Evaluation of brushing cytology in the diagnosis of Helicobacter pylori gastritis

OBJECTIVE: To evaluate clinical utility of rapid urease test (RUT), brash cytology and histology for detecting Helicobacter pylori. STUDY DESIGN: Brush cytology materials were obtained from the antrum of the stomach in 109 patients who suffered from dyspepsia and were candidates for endoscopy. RUT and histology with hematoxylin-eosin staining were performed. Infection status was established by observation of typical HP in cytology or biopsy. RESULTS: A total of 78% ofpatients were diagnosed as positivefor HP organisms using brush cytology; 66% had histologic results positive for HP and 59% for RUT. Observation of typical organism by cytology or histology was the gold standard; 3 tests results were compared. Sensitivity of brush cytology (95%) was higher than that of histology (80.5%) and RUT (72%). CONCLUSION: Gastric brushing cytology provides a sensitive, inexpensive, accurate and easy technique for rapid detection of HP infection. When additional information on severity of mucosal damage or presence of cell atypias is not necessary, histologic examination can be omitted; a cost-effective strategy for assessing HP status might consist of taking antral biopsies, the former for RUT, and performing brush cytology slides, which should be stained and examined only when the RUT result is negative.     

Vaginal vault cytology tests: analysis of a decade of data from a UK tertiary centre

H. Stokes‐Lampard, S. Wilson, C. Waddell and L. Bentley Vaginal vault cytology tests: analysis of a decade of data from a UK tertiary centre Objectives: To examine temporal trends in the use of vault cytology tests in primary and secondary care and the demographics of those women tested. Methods: Retrospective analysis of routinely collected data concerning women who had a vault cytology test processed during a 10‐year period (1 April 1995 to 31 March 2005) at Birmingham Women’s NHS Foundation Trust. Results: A total of 8457 vault cytology tests from 3164 women (range 1–17 tests, median = 2) were processed, representing approximately 2% of the cervical cytology workload of the Department of Cytopathology at Birmingham Women's Hospital. There was a significant reduction in annual numbers processed (Pearson correlation ?0.958, P < 0.001). Significant abnormalities (mild dyskaryosis or worse) were detected in 4.5%, with malignancy being detected in <0.1%. The unsatisfactory cytology test rate was 10.7% overall. There was a reduction in the numbers of vault cytology tests coming from the community, hospital outpatient clinics and operating theatres over time (χ² for linear trend = 139.53, 9 d.f., P < 0.0001). Tests originating from community settings had the lowest disease detection rates: no malignancies and only two severe abnormalities were detected from almost 4000 primary care samples; abnormal results represented 2.8% (n = 113), of which the majority (n = 73) were borderline results. All cancers (n = 8) were detected in samples taken in gynaecology and colposcopy clinics. Conclusions: Vault cytology test usage appears to be reducing, particularly from outpatient clinics and primary care. Community detection rates are very low. Further research is required to establish the true costs and benefits of vaginal vault cytology.     

Human papillomavirus DNA and liquid-based cervical cytology cotesting in screening and follow-up patient groups

OBJECTIVE: To compare the use of human papillomavirus (HPV) DNA and cervical cytology cotesting in screening and follow-up of patients with previous cervical abnormalities and to assess the significance of a positive HPV DNA test result in re-screening of cytologically normal cases. STUDY DESIGN: Cellular samples collected in liquid-based fixative were used for both cervical cytology and HPV DNA testing. The cervical cytology slides were manually screened by cytotechnologists followed by rapid re-screening by pathologists. The HPV DNA tests were performed using hybrid capture test kits. Statistical analyses of cervical cytology results and HPV DNA tests for high- and low-risk HPV from both patient groups were carried out. RESULTS: The prevalence of HPV DNA-positive cases was higher in younger patients. There was a poor correlation between cervical cytology results and HPV DNA tests for the screening group (kappa = 0.23), but a fair to good correlation was obtained for the follow-up group (kappa = 0.51). The false negative fraction of cytology negative/HPV DNA positive cases (0.1317), as compared with cytology negative/HPV DNA negative cases (0.0056), was statistically significant (p = 0.000001). CONCLUSION: The prevalence of HPV DNA decreased with increasing age in both the screening and follow-up patient groups. Virus clearance was delayed in the follow-up group as compared with the screening group. There was a poor correlation between cervical cytology and HPV DNA tests in the screening group but a fair to good correlation in the follow-up patient group. Cotesting of HPV DNA and cervical cytology increases the sensitivity and decreases the false negative fraction, suggesting that cotesting could be used to increase the interval of screening.     

Theory of molecular machines. I. Channel capacity of molecular machines

Like macroscopic machines, molecular-sized machines are limited by their material components, their design, and their use of power. One of these limits is the maximum number of states that a machine can choose from. The logarithm to the base 2 of the number of states is defined to be the number of bits of information that the machine could "gain" during its operation. The maximum possible information gain is a function of the energy that a molecular machine dissipates into the surrounding medium (Py), the thermal noise energy which disturbs the machine (Ny) and the number of independently moving parts involved in the operation (dspace): Cy = dspace log2 [( Py + Ny)/Ny] bits per operation. This "machine capacity" is closely related to Shannon's channel capacity for communications systems. An important theorem that Shannon proved for communication channels also applies to molecular machines. With regard to molecular machines, the theorem states that if the amount of information which a machine gains is less than or equal to Cy, then the error rate (frequency of failure) can be made arbitrarily small by using a sufficiently complex coding of the molecular machine's operation. Thus, the capacity of a molecular machine is sharply limited by the dissipation and the thermal noise, but the machine failure rate can be reduced to whatever low level may be required for the organism to survive.     

Measurement of body size and abundance in tests of macroecological and food web theory

1. Mean body mass (W) and mean numerical (N) or biomass (B) abundance are frequently used as variables to describe populations and species in macroecological and food web studies. 2. We investigate how the use of mean W and mean N or B, rather than other measures of W and/or accounting for the properties of all individuals, can affect the outcome of tests of macroecological and food web theory. 3. Theoretical and empirical analyses demonstrate that mean W, W at maximum biomass (W(mb)), W when energy requirements are greatest (W(me)) and the W when a species uses the greatest proportion of the energy available to all species in a W class (W(mpe)) are not consistently related. 4. For a population at equilibrium, relationships between mean W and W(me) depend on the slope b of the relationship between trophic level and W. For marine fishes, data show that b varies widely among species and thus mean W is an unreliable indicator of the role of a species in the food web. 5. Two different approaches, 'cross-species' and 'all individuals' have been used to estimate slopes of abundance-body mass relationships and to test the energetic equivalence hypothesis and related theory. The approaches, based on relationships between (1) log(10) mean W and log(10) mean N or B, and (2) log(10) W and log(10) N or B of all individuals binned into log(10) W classes (size spectra), give different slopes and confidence intervals with the same data. 6. Our results show that the 'all individuals' approach has the potential to provide more powerful tests of the energetic equivalence hypothesis and role of energy availability in determining slopes, but new theory and empirical analysis are needed to explain distributions of species relative abundance at W. 7. Biases introduced when working with mean W in macroecological and food web studies are greatest when species have indeterminate growth, when relationships between W and trophic level are strong and when the range of species'W is narrow.     

Quantitation of time- and frequency-resolved optical spectra for the determination of tissue oxygenation.

The recent development of near-infrared time- and frequency-resolved tissue spectroscopy techniques to probe tissue oxygenation and tissue oxygenation kinetics has led to the need for further quantitation of spectroscopic signals. In this paper, we briefly review the theory of light transport in strongly scattering media as monitored in the time and frequency domains, and use this theory to develop algorithms for quantitation of hemoglobin saturation from the photon decay rate (delta log R/delta t) obtained using time-resolved spectroscopy, and from the phase-shift (theta) obtained from frequency-resolved, phase-modulated spectroscopy. To test the relationship of these optical parameters, we studied the behavior of delta log R/delta t and theta as a function of oxygenation in model systems which mimicked the optical properties of tissue. Our results show that deoxygenation at varying hemoglobin concentrations can be monitored with the change in the photon decay kinetics, delta delta log R/delta t in the time-resolved measurements, and with the change in phase-shift, delta theta, in the frequency-resolved technique. Optical spectra of the adult human brain obtained with these two techniques show similar characteristics identified from the model systems.     

Primary HPV testing: a proposal for co‐testing in initial rounds of screening to optimise sensitivity of cervical cancer screening

As explained by Kitchener in a previous issue of Cytopathology (2015; 26 :4‐6), primary human papillomavirus (HPV) testing is likely to be introduced in the UK for all women aged 25–64 years following pilot site studies already in place. This will be necessary when the prevalence of cervical cancer and its precursors declines when vaccination takes effect but there is a risk in abandoning cytology as a primary test: a risk that would be most apparent in the present unvaccinated population in which the prevalence of cervical cancer and its precursors is exceptionally high. HPV testing is more sensitive than cytology but has a significant false‐negative rate that could be detrimental to a successful screening programme if introduced without cytology backup. Accurate cytology would be needed for triage and could be compromised if HPV‐negative tests were excluded from examination. This article proposes a compromise: cytology and HPV co‐testing for the first two screening tests to optimise the sensitivity of the test as a whole. Registrations of invasive and in situ carcinoma of the uterine cervix in England indicate that the prevalence of the disease is highest in young women in the early rounds of screening. Calculations of the likely impact on the workload of this proposal have been based on a service evaluation of 295 cytology tests received at St Thomas’ Hospital, which suggests that the volume of cytology tests would be reduced by approximately 60% compared with 80% for primary HPV testing alone. This proposal should be debated openly before irrevocable changes are made to a skilled workforce.     

Mathematics and medicine. Test reduction: III-Practical applications.

While there is no generally applicable method of test reduction, ways in which the problem can be tackled can usually be suggested. These include the examination of error rates of tests and the use of current statistical methods. When the cost-effectiveness of some more expensive test has to be measured, a model of the decision problem needs to be developed, with an attempted estimation of the values or utilities of the states of health that result from treatment.     

Which women default from follow‐up cervical cytology tests? A cohort study within the TOMBOLA trial

L. Sharp, S. Cotton, A. Thornton, N. Gray, D. Whynes, L. Smart, N. Waugh, I. Duncan, M. Cruickshank and J. Little, on behalf of the TOMBOLA Group Which women default from follow‐up cervical cytology tests? A cohort study within the TOMBOLA trial Objective: To identify factors associated with default from follow‐up cervical cytology tests. Methods: A cohort study was conducted involving 2166 women, aged 20–59, with recent low‐grade cervical cytology taken within the NHS Cervical Screening Programmes in Scotland and England, and managed by 6‐monthly cytology in primary care. For the first (6‐month) and second (12‐month) surveillance cytology tests separately, women were categorized as ‘on‐time attendees’ (attended ≤6 months of test being due), ‘late attendees’ (attended greater than 6 months after test was due) or ‘non‐attendees’ (failed to attend). Multivariate odds ratios (ORs) were computed for factors associated with late and non‐attendance. Results: For the first surveillance test, risk of non‐attendance was significantly higher in younger women, those without post‐secondary education, and non‐users of prescribed contraception. Factors significantly associated with late attendance for the first test were the same as for non‐attendance, plus current smoking and having children. The most important predictor of non‐attendance for the second surveillance test was late attendance for the first test (OR = 9.65; 95% CI, 6.60–16.62). Non‐attendance for the second test was also significantly higher among women who were younger, smokers and had negative cytology on the first surveillance test. Late attendance for the second surveillance test was higher in women who were younger, smokers, had children and attended late for the first test. Conclusions: Women at highest risk of default from follow‐up cytology tend to be young, smoke, lack post‐secondary education, and have defaulted from a previous surveillance appointment. Tackling default will require development of targeted strategies to encourage attendance and research to better understand the reasons underpinning default.     

A Note on the Log‐Rank Test in Life Table Analysis with Correlated Observations

Survival data consisting of independent sets of correlated failure times may arise in many situations. For example, we may take repeated observations of the failure time of interest from each patient or observations of the failure time on siblings, or consider the failure times on littermates in toxicological experiments. Because the failure times taken on the same patient or related family members or from the same litter are likely correlated, use of the classical log‐rank test in these situations can be quite misleading with respect to type I error. To avoid this concern, this paper develops two closed‐form asymptotic summary tests, that account for the intraclass correlation between the failure times within patients or units. In fact, one of these two test includes the classical log‐rank test as a special case when the intraclass correlation equals 0. Furthermore, to evaluate the finite‐sample performance of the two tests developed here, this paper applies Monte Carlo simulation and notes that they can actually perform quite well in a variety of situations considered here.     

Comparing disease screening tests when true disease status is ascertained only for screen positives

Disease screening is a fundamental part of health care. To evaluate the accuracy of a new screening modality, ideally the results of the screening test are compared with those of a definitive diagnostic test in a set of study subjects. However, definitive diagnostic tests are often invasive and cannot be applied to subjects whose screening tests are negative for disease. For example, in cancer screening, the assessment of true disease status requires a biopsy sample, which for ethical reasons can only be obtained if a subject's screening test indicates presence of cancer. Although the absolute accuracy of screening tests cannot be evaluated in such circumstances, it is possible to compare the accuracies of screening tests. Specifically, using relative true positive rate (the ratio of the true positive rate of one test to another) and relative false positive rate (the ratio of the false positive rates of two tests) as measures of relative accuracy, we show that inference about relative accuracy can be made from such studies. Analogies with case-control studies can be drawn where inference about absolute risk cannot be made, but inference about relative risk can. In this paper, we develop a marginal regression analysis framework for making inference about relative accuracy when only screen positives are followed for true disease. In this context factors influencing the relative accuracies of tests can be evaluated. It is important to determine such factors in order to understand circumstances in which one test is preferable to another. The methods are applied to two cancer screening studies, one concerning the effect of race on screening for prostate cancer and the other concerning the effect of tumour grade on the detection of cervical cancer with cytology versus cervicography screening.     

Comparison of five detection methods for Helicobacter pylori

OBJECTIVE: To evaluate which diagnostic test is preferable for the diagnosis of Helicobacter pylori in patients with gastroduodenal disease. STUDY DESIGN: H pylori infection was diagnosed prospectively in 101 patients. Diagnosis of H pylori was made by tests based on five different principles: (1) culture, (2) direct histologic demonstration, (3) imprint cytology, (4) brushing cytology, and (5) gram staining of H pylori. Efficacy of each test was compared. RESULTS: All the tests were reliable for diagnosing H pylori infection; 73.3% of patients showed concordance in at least two tests. All the tests were positive in > 50% of patients. Significant concordance between brushing and imprint cytology was also determined. These two tests have almost similar specificity when compared to other tests. CONCLUSION: When patients undergo upper endoscopy, we recommend taking biopsy specimens for culture and histology. H pylori can be assessed equally well with all the tests, but imprint and brushing cytology have the advantage of rapid response, specificity, much lower cost and reproducibility.     

A novel quantitative multiplex NASBA method: application to measuring tissue factor and CD14 mRNA levels in human monocytes.

A new method to quantify two individual mRNAs in a single NASBA reaction is described. In this study, tissue factor and CD14 mRNAs were used as a model system. RNA ratios of -4 to +4 log units were determined with good precision (within 0.3 log) and accuracy (within 0.2 log). By measuring both mRNAs in human monocytes that were stimulated with LPS, the multiplex Q-NASBA proved to be a successful tool to monitor the expression levels of two individual mRNAs in a single-tube amplification system. The method has potential in all fields in which quantitative information is needed on two individual RNAs.     

Comparison of the Cobas 4800 HPV and HPV 9G DNA Chip Tests for Detection of High-Risk Human Papillomavirus in Cervical Specimens of Women with Consecutive Positive HPV Tests But Negative Pap Smears

Detecting high-risk (HR) HPV is important for clinical management of women with persistent HPV-positive and Pap-negative results. The Cobas 4800 HPV test is the first FDA-approved HPV DNA test that can be used alone as a first-line screening tool. The HPV 9G DNA chip test is a PCR-based DNA microarray assay. We evaluated the patients of consecutive HPV-positivity on HPV 9G DNA chip test without cytologic abnormalities. We then compared the performances of HPV 9G DNA chip and the Cobas 4800 HPV tests for detecting HR HPV with each other and confirmed HPV genotyping using direct sequencing. All 214 liquid-based cytology specimens were collected from 100 women with consecutive HPV-positive and Pap-negative results on the HPV 9G DNA chip test between May 2012 and Dec 2013, but only 180 specimens were available for comparing HPV test results. The HPV 9G DNA chip and the Cobas 4800 HPV tests agreed with each other in 81.7% of the samples, and the concordance rate was greater than 97.2% for detecting HPV-16 or -18. For HR genotypes other than HPV types 16 and 18, the two tests agreed for 81.1% of the samples. The sensitivity of both assays for detecting HR HPV was 100%, regardless of HR genotypes. The HPV 9G DNA chip test may be as effective as the Cobas 4800 HPV test in detecting HR HPV, and has a similar ability to identify HPV-16 and -18.     

Improving efficiency of inferences in randomized clinical trials using auxiliary covariates

Summary .   The primary goal of a randomized clinical trial is to make comparisons among two or more treatments. For example, in a two-arm trial with continuous response, the focus may be on the difference in treatment means; with more than two treatments, the comparison may be based on pairwise differences. With binary outcomes, pairwise odds ratios or log odds ratios may be used. In general, comparisons may be based on meaningful parameters in a relevant statistical model. Standard analyses for estimation and testing in this context typically are based on the data collected on response and treatment assignment only. In many trials, auxiliary baseline covariate information may also be available, and it is of interest to exploit these data to improve the efficiency of inferences. Taking a semiparametric theory perspective, we propose a broadly applicable approach to adjustment for auxiliary covariates to achieve more efficient estimators and tests for treatment parameters in the analysis of randomized clinical trials. Simulations and applications demonstrate the performance of the methods.     

BTA-TRAK combined with urinary cytology is a reliable urinary indicator of recurrent transitional cell carcinoma (TCC) of the bladder

This study evaluated the diagnostic accuracy of BTA-TRAK in combination with urinary cytology (UC) in the follow-up of patients with a history of transitional cell carcinoma (TCC) of the bladder. The overall sensitivity of BTA-TRAK, UC and the two tests combined for the detection of recurrences was 82.7% (48/58), 84.2% (48/57) and 91.2% (52/57), respectively. BTA and UC showed comparable sensitivity for superficial recurrences (76.7% (33/43) and 78.5% (33/42), respectively) and for invasive recurrences (100% (15/15)); when the two tests were used in combination, the sensitivity for superficial lesions increased to 88% (37/42). BTA-TRAK was more sensitive than UC for G1 recurrences (81.2% (13/16) vs. 68.7% (11/16)), and when the two tests were combined the sensitivity increased to 87.5% (14/16). The sensitivity of the combination was 100% (15/15) for G3 lesions. The differences in urinary BTA-TRAK levels between patients with recurrences and those without evidence of disease were statistically significant (Wilcoxon's test, p<0.05); among patients with recurrences BTA levels were significantly higher in the invasive and poorly differentiated subtypes. In the series of patients studied by us, BTA-TRAK combined with UC was shown to be a non-invasive, accurate test to predict TCC recurrences. Periodic measurement of BTA-TRAK combined with urinary cytology seems to provide additional information for the monitoring of patients treated for TCC; however, due to the presence of false positive and false negative results, this test cannot replace cystoscopy. In a selected group of patients it could, if combined with cytology and ultrasonography and if correctly used and interpreted, orient the timing and indication for cystoscopy.