Application of Urovision FISH testing for diagnosis of bladder cancer

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1 Application of Urovision FISH testing for diagnosis of bladder cancer Eva M. Wojcik, MD Chair and Professor of Pathology and Urology Loyola University, Chicago, USA

Bladder cancer - current status ~ 76,900 new cases in 2016 in the USA ~ 16,390 deaths due to bladder cancer ACS 4 th most common ca in men and 9 th in women (1 in 44 people) 9 th most common cause of

2 Bladder cancer - current status ~ 76,900 new cases in 2016 in the USA ~ 16,390 deaths due to bladder cancer ACS 4 th most common ca in men and 9 th in women (1 in 44 people) 9 th most common cause of cancer death (F>M) ~ 75% non-muscle invasive bladder cancers (superficial bladder cancers), Ta, Tis, T1 ~ 30% - 70% - recurrence ~ 5% - 15% - progression (<1% LG Ta) > 535,000 people in the US are survivors of this cancer Highest per patient cost from dx to death of all cancers $4.1 billion/year spent to tx bladder cancer Nielsen ME et al. Trends in stage-specific incidence rates for urothelial carcinoma of the bladder in the United States: 1998 to Cancer 2014:120:86

3 Classifications WHO 1973 Papilloma Grade I Grade II Grade III Papilloma PUNLMP Low Grade High Grade WHO/ISUP 2004 ~ 10-20% ~ 50-60% ~ 80-90% URINE CYTOLOGY SENSITIVITY Very high probability that we are going to be wrong 3

4 Quest for

5 Beyond Urine Cytology S 1 9 S 1 8 S 1 7 S 1 6 S 1 5 S 1 4 S 1 3 S 1 2 S 1 1 S 1 0 S9 S8 S7 S6 S5 S4 S3 S2 S

6 Urothelial carcinoma, low grade, diploid Urothelial carcinoma, high grade, aneuploid

7 Molecular alteration in bladder carcinoma 9p21 Ta 3p, 7, 5q, 17p Normal urothelium T1 T2 T3 N+/M+ Tis 11p, 6q, 13q, 18q

8 Sokolova et al. J Mol Diagn 2000;2:116

9 Ancillary Studies in Urinary Cytology Lukas Bubendorf, Nancy P. Caraway, Andrew H. Fischer, Ruth L. Katz, Matthew T. Olson, Fernando Schmitt, Margareta Strojan Fležar, Theodorus H. Van Der Kwast, Philippe Vielh From Paris System for Reporting Urinary Cytology, eds: Rosenthal, Wojcik, Kurtycz. Published by Springer 2016

10 FISH - DIPLOID

FISH - after UroVysion probe hybridization FOUR COMBINED PROBES DIPLOID - 2 copies of chrom 3 (red) - 2 copies of chrom 7 (green) - 2 copies of chrom 17 (aqua)

11 FISH - after UroVysion probe hybridization FOUR COMBINED PROBES DIPLOID - 2 copies of chrom 3 (red) - 2 copies of chrom 7 (green) - 2 copies of chrom 17 (aqua) - 2 copies of region 9p21 (gold) ANEUPLOID - 2 copies of chrom 3 (red) - 4 copies of chrom 7 (green) - 5 copies of chrom 17 (aqua) - 1 copy of region 9p21 (gold)

12 From Paris System for Reporting Urinary Cytology, eds: Rosenthal, Wojcik, Kurtycz. Published by Springer 2016

13 Haling et al. J Urol 2000;164:1768

14 UroVision Review of the Literature Sensitivity - Initial results early 2000s Author Cytology FISH Haling et al. 58% 81% Fredrich et al. 69% Mian et al. 45% 96% Skacel et al. 85% Dalquen et al. 24% 73% Placer et al. 64% 80% Sarosdy et al. 26% 71% Average 43% 80% Currently Meta-analysis showed UroVision FISH sensitivity 55% and specificity 80% (Chou et al. Urinary Biomarkers for Diagnosis of Bladder Cancer: A Systemic Review and Meta-analysis. Ann Intern Med 2015;163:922-31)

15 Case year old man with hematuria Barbotage Cell block Uretral washing Bladder barbotage and uretral washings positive Aneuploid Laser Scanning Cytometry Biopsy multifocal CIS Cystectomy HG UC involving muscularis propria and extensive CIS (bladder, ureters, urethra); margins free

16 Follow up urines

17 12 specimens from Diploid by LSC FISH (UroVision) negative (X5) Clinically no evidence of disease Late 2012 Liver FNA positive Follow up urines positive/atypical No FISH ordered Patient passed in 2015

18 Case 2 78 years old man with history of HGUC. Bladder barbotage - +HGUC Specimen sent to reference lab for FISH Urovision. Results - Negative

19 Nuclear / cytologic atypia NFHG AUC/SHGUC 8%-30% HGUC low moderate/high certain Probability of high grade UC

Case 3. 57 year old women with upper tract symptoms.

20 Case year old women with upper tract symptoms. Bladder barbotage - AUC Specimen sent to reference lab for FISH Urovision. Results - Positive

Multicolor fish analysis of instrumented urine samples containing a

Mod Pathol 2002 Evaluation of chromosomal aberrations in patients

21 Multicolor fish analysis of instrumented urine samples containing a high proportion of umbrella cells Wojcik et al. Mod Pathol 2002 Evaluation of chromosomal aberrations in patients with benign conditions and reactive changes in urinary cytology Tapia et al. Cancer Cytopathol 2011 Cancer Cytopathology pages n/a-n/a, 5 JUL 2011 DOI: /cncy

22 FISH in Atypical Urothelial Cells Loyola Total urine specimens 12,588 Atypical 1260 (10%) Suspicious 239 (1.9%) Positive for UC 628 (5%) Virk et al. Diagn Cytopath 2016 in press

23 FISH in Atypical Urothelial Cells Loyola Experience Total Urines (n=12588); Excluded (n=11328) UNSAT/NEG and SUSP/POS Eligible participants - AUC (n=1260) No FISH (n=776) FISH (n=484) Repeated testing (n=107) Unique patients FISH test (n=377) 62/377 (16.45%) UC 29 LGUC 33 - HGUC Virk et al. Diagn Cytopath 2016 in press

FISH in Atypical Urothelial Cells FISH Test N=377 FISH Negative N=269 No F/U - 114 FISH Positive N=63 No F/U - 9 FISH Uninformative N=31 No F/U - 0 F/U 155 Bx 58 Cysto/Cyto - 97 F/U 54 Bx 53

24 FISH in Atypical Urothelial Cells FISH Test N=377 FISH Negative N=269 No F/U FISH Positive N=63 No F/U - 9 FISH Uninformative N=31 No F/U - 0 F/U 155 Bx 58 Cysto/Cyto - 97 F/U 54 Bx 53 Cyto/Cyto - 1 F/U 31 Bx 11 Cysto/Cyto - 20 Final Dx UC Present 31 UC Absent 124 Final Dx UC Present 25 UC Absent 29 Final Dx UC Present 6 UC Absent 25 Virk et al. Diagn Cytopath 2016 in press

25 Frequency Frequency Number of aneuploid cells (12 months follow up) Patients without UC # of cells: 4 40 (median 7) 5 4 Patients with UC # of cells: 4 75 (median 10) P value > 0.05 ROC 0.556

26 UC diagnosed within 12 months in patients with AUC Bladder FISH UNINF FISH + FISH - LGUC HGUC ptis pta pt pt UNKNOWN UUT LGUN HGUC ptis pta pt pt URETHRA HGUC ptis pta NEOBLADD ER HGUC Total FISH: fluorescence in situ ybridization UNINF: uninformative; LGUN: Low grade urothelial neoplasia; HGUC: High grade urothelial carcinoma; UUT: Upper urinary tract including renal pelvis and ureter

27 FISH test performance measures after a 12 months follow-up period including only cases with available cystoscopic cytologic or histologic follow-up results ALL CASES INFORMATIVE FISH RESULTS INFORMATIVE FISH RESULTS AND AVAILABLE FOLLOW-UP RESULTS FISH POSITIVE CASES WITH AVAILABLE FOLLOW-UP RESULTS LGUN AT 12 MONTHS FOLLOW-UP HGUC AT 12 MONTHS FOLLOW-UP PREV SENS SPEC PPV NPV ACC PLR NLR n % [95% CI] n % [95% CI] n % [95% CI] n % [95% CI] n % [95% CI] % [95% CI] % [95% CI] % [95% CI] % [95% CI] % [95% CI] % [95% CI] N N 85.64% AGE<= [79.73, 90.06] % [48.90, 64.32] % [11.41, 27.62] % [2.14, 12.93] % [5.27, 18.51] 15.91% [9.59 to 25.08] 35.71% [16.18, 61.4] 85.33% [75.44, 91.78] 31.25% [13.91, 55.85] 87.50% [77.98, 93.6] 77.53% [66.54, 86.04] % AGE> [85.29, 93.78] % [61.76, 75.29] % [22.85, 39.00] % [10.79, 24.05] % [12.15, 25.86] 34.43% [26.57, 43.23] 47.62% [33.36, 62.28] 78.48% [68.12, 86.2] 54.05% [38.38, 68.97] 73.81% [63.46, 82.08] 67.77% [58.99, 75.46] % MALE PATIENTS [82.18, 90.49] % [56.18, 68.73] % [22.20, 37.07] % [9.88, 21.77] % [10.47, 22.56] 30.50% [23.48, 38.55] 46.51% [32.51, 61.09] 78.79% [69.67, 85.76] 48.78% [34.25, 63.52] 77.23% [68.08, 84.38] 69.01% [60.98, 76.05] FEMALE PATIENTS % [83.93, 94.86] % [55.05, 72.92] % [10.08, 28.14] % [1.85, 14.40] % [6.79, 23.19] 18.84% [11.22, 29.75] 38.46% [17.60, 64.59] 87.27% [75.68, 94.00] 41.67% [19.26, 68.11] 85.71% [74.00, 92.84] 77.94% [66.64, 86.26] UC SURVEILLANCE % [82.22, 91.90] % [67.54, 80.97] % [19.71, 35.52] % [10.38, 23.68] % [12.47, 26.48] 34.45% [26.51, 43.37] 43.90% [29.88, 58.97] 82.05% [71.97, 89.12] 56.25% [39.31, 71.85] 73.56% [63.39, 81.74] 68.91% [60.09, 76.54] OTHER INDICATIONS % [82.95, 92.11] % [45.18, 59.90] % [15.55, 32.78] % [2.78, 13.92] % [5.09, 17.94] 16.48% [10.14, 25.55] 46.67% [24.80, 69.89] 81.58% [71.30, 88.82] 33.33% [17.05, 54.78] 88.57% [78.79, 94.34] 75.82% [66.04, 83.52] VOIDED URINE % [75.47, 90.01] % [41.83, 62.72] % [0.42, 15.97] % [3.04, 21.71] % [3.04, 21.71] 18.18% [9.25, 32.22] 12.50% [0.11, 49.22] 97.22% [84.58, 99.99] 50.00% [9.45, 90.55] 83.33% [69.08, 92.00] 81.82% [67.78, 90.75] INSTRUMENTED URINE % [85.33, 92.65] % [60.86, 72.50] % [24.19, 38.12] % [8.36, 18.63] % [11.38, 22.68] 28.92% [22.54, 36.24] 50.00% [36.69, 63.61] 77.12% [68.71, 83.82] 47.06% [34.05, 60.48] 79.13% [70.76, 85.61] 69.28% [61.88, 75.81] ALL CASES % [84.38, 90.98] % [5794 to ] % [19.83, 31.54] % [8.14, 17.04] % [10.56, 20.23] 26.67% [21.13, 33.04] 44.64% [32.38, 57.59] 81.82% [74.93, 97.16] 47.17% [34.38, 60.34] 80.25% [73.30, 85.77] 71.91% [65.46, 77.56]

28 Results Age - Prevalence < % > % Gender No differences in any metrics Indication Prevalence UC Surveillance 34.45% Other 16.48% Type of specimen Specificity Voided 97.22% (Sensitivity 12.50%) Instrumented 77.12% (Sensitivity 50%)

29 FISH in Atypical Urothelial Cells Overall Results Prevalence 26.67% Sensitivity 44.64% Specificity 81.82% PPV 47.17% NPV 80.25% Accuracy 71.91%

30 Impact of extended follow-up periods on the performance of FISH tests FOLLOW- AVAILABLE FU UP INTERVAL N % Prevalence Sensitivity Specificity PPV NPV ACC LR+ LR+ 12 MONTHS N= % 26.67% 44.64% 81.82% 47.17% 80.25% 71.91% MONTHS N= % 26.99% 44.26% 83.64% 50.00% 80.23% 73.01% MONTHS N= % 28.76% 46.27% 84.94% 55.36% 79.66% 73.82% Results argue against anticipatory false positive results

31 Conclusion UroVysion FISH testing may be useful as an adjunct test for AUC in UTCy, allowing stratification of risk in patients with AUC. However, its usefulness is diminished by the high false-positive rate, making it important to interpret FISH results in clinical context and in correlation with cytomorphologic findings

Rationale of The Paris System for Reporting Urinary Cytopathology: The NEW paradigm

Rationale of The Paris System for Reporting Urinary Cytopathology: The NEW paradigm Eva M. Wojcik, MD Professor and Chair of Pathology Professor of Urology Loyola University, Chicago, Il Why to standardize