Alireza Ghoreifi, MD, was one of the recipients of the 2024 Urology Care Foundation™ Research Scholar Awards. These awards provide $40,000 annually for mentored research training for clinical and postdoctoral fellows or early-career faculty. The AUA Southeastern Section sponsored Dr Ghoreifi’s award.

Background

Upper tract urothelial carcinoma (UTUC) is a highly lethal urological cancer that accounts for 5% to 10% of all urothelial tumors.¹ Despite surgery with curative intent, it is associated with poor survival (<50% for stages >1) and high recurrence rates (up to 50%).² Currently available diagnostic tools in UTUC, such as urine cytology, imaging, and ureteroscopy, suffer from technical limitations and lack precision.^3,4 Consequently, decision-making and prognostication for UTUC heavily rely on the pathological stage and grade, information that is not reliably available until after surgery. Hence, markers that help with preoperative decision-making and suggest safe management with endoscopic therapy compared to high-morbid extirpative surgery are lacking.⁵ In addition, postsurgery follow-up necessitates regular urine cytology, cystoscopy, imaging, and, in certain cases, ureteroscopy. Nevertheless, the optimal follow-up of patients with UTUC remains unknown.^3,4

DNA methylation, an epigenetic modification that is often altered during tumorigenesis, has emerged as a potential diagnostic and prognostic factor for several cancers, including urothelial bladder carcinoma.^6-9 However, data on patients with UTUC are sparse. The value of urine-based methylation markers in UTUC has been previously demonstrated by the current research team.¹⁰ Building upon our preliminary work, we hypothesize that this innovative method is correlated with clinical data such as tumor staging, which is difficult to obtain prior to surgery, and it can be used as a diagnostic and monitoring tool in patients with UTUC.

Study Aims

The primary goal of this study is to validate previously determined thresholds of urine methylation biomarkers in patients with known UTUC compared to healthy controls in a large multicenter study (Aim 1). Urine samples will be collected from patients with primary UTUC before surgical intervention, and the methylation markers will be compared to those of a 1:1 age-/sex-matched group of cancer-free healthy donors.

The secondary aim is to determine the relationship between the urine methylation markers and clinical features, including pathologic stage and grade, in patients undergoing extirpative surgery (Aim 2). The last goal is to determine the levels of methylation biomarkers in the urine of patients with UTUC after surgery compared to preoperative thresholds (Aim 3). To achieve this goal, patients will be followed 3 and 6 months after the surgery, and urine samples will be collected at these times, during clinic visits or at home. The outline of the research strategy is presented in the Figure.

Preliminary Data

In a prospective study of 50 patients with UTUC at the University of Southern California, our proposed urine-based test was employed to measure the urothelial-specific methylation levels. Results were reported as the Bladder CARE Index (BCI) score and quantitatively categorized as positive (BCI >5), high risk (BCI 2.5-5), or negative (BCI <2.5). The findings were compared with those of 1:1 sex-/age-matched cancer-free healthy individuals.

This test demonstrated high accuracy in the diagnosis of patients with UTUC, displaying a sensitivity, specificity, positive predictive value, and negative predictive value of 96%, 88%, 89%, and 96%, respectively. Also, this novel urine test exhibited superior accuracy compared to the standard of care (urine cytology). Among patients with low-grade UTUC, BCI was positive in 89% of cases, whereas urine cytology failed to detect any low-grade UTUCs. In high-grade UTUCs, the sensitivities of urine cytology and BCI were 43% and 97.5%, respectively. In addition, despite the limited sample size, a significant correlation was found between methylation values and tumor size (R² = 0.144; P = .009). The findings were published in The Journal of Urology^®.¹⁰

Impact

This study will bridge the current gap in diagnosing and preoperative risk stratification of patients with UTUC in a noninvasive manner. Moreover, at-home sampling offers a more efficient and cost-effective method of monitoring patients after surgery. If successful, our proposed work will optimize the preoperative diagnosis of patients with UTUC and assist in postsurgery monitoring and potentially the selection of appropriate patients for adjuvant therapy. This advancement could lead to treating this deadly disease at earlier stages and potentially increase patient survival rates.