尿细胞角蛋白检测在尿路移行细胞癌诊断和复发监测中的应用研究0_5.doc
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尿细胞角蛋白检测在尿路移行细胞癌诊断和复发监测中的应用研究
李涛 何延瑜 陈梓甫 张延榕 高祥勋 黄超 叶烈夫 黄世清 刘春 陈文榜 詹汉雄 詹天棋
福建省立医院泌尿外科(福州，350001Tel:13705078075)
[摘要] 目的 评价尿细胞角蛋白(CK)检测在尿路移行细胞癌(TCC)诊断和复发监测中的应用价值。 方法 采用ELISA法检测244例尿路TCC及292例泌尿系非TCC患者尿液中CK8和18的含量(UBC值)，应用受试者作业特征曲线(ROC)选择尿CK诊断尿路TCC和监测膀胱癌术后复发的最适临界值。结果 TCC患者尿UBC均值为30.2μg/L, 与泌尿系非TCC患者8.9μg/L的均值比较, 差异有极显著性意义(P<0.001)。ROC曲线(曲线下面积为0.821)确定以8.4μg/L为最适临界值, 尿CK诊断TCC的敏感性为76.6%，特异性为74.3%，阳性预测值为71.4%，阴性预测值为79.2%。32例上尿路TCC和110例非TCC的上尿路疾病患者尿UBC均值分别为20.9μg/L和9.0μg/L(P<0.001)，以8.4μg/L为临界值, 尿CK诊断上尿路TCC的敏感性为78.1%，特异性为71.8%。212例膀胱TCC中，尿UBC值与肿瘤数目(单发或多发)不相关(P=0.415)，但与肿瘤大小(多发肿瘤以最大径之和表示)密切相关(Pearson相关分析，r＝0.342，P<0.001)。组织学分级G1、G2、G3肿瘤患者尿UBC均值分别为23.8μg/L、33.6μg/L和38.4μg/L(P＝0.763)，以8.4μg/L为临界值时尿CK诊断各级TCC的敏感性分别为68.2%、76.6%和88.1%(P＝0.064)。浅表性(Ta～T1)和浸润性(T2～T4)TCC患者尿UBC均值分别为24.4μg/L和47.3μg/L(P<0.001)，以8.4μg/L为临界值时尿CK诊断敏感性分别为69.7%和91.0%(P＝0.001)。ROC曲线分析表明，对已活检确诊的膀胱TCC，尿UBC取13.55μg/L为临界值时诊断浸润癌的敏感性为76.1%，特异性为62.8%，当取25.0μg/L为临界值时敏感性降为52.2%，但特异性达80.0%。膀胱初发性TCC和复发性TCC患者的尿UBC均值分别为22.0μg/L和57.7μg/L(P<0.001)，以8.4μg/L为临界值时尿CK诊断敏感性分别为70.3%和93.0%(P<0.001)。76例膀胱TCC术后膀胱镜检查未见肿瘤复发的患者尿UBC均值为10.5μg/L，与复发瘤比较，差异有极显著性意义(P<0.001)。ROC曲线分析表明，对膀胱TCC术后随访复查时，尿CK取14.6μg/L为临界值时诊断复发癌的敏感性为87.7%，特异性为86.8%；当取11.65μg/L为临界值时敏感性达93%，特异性为78.9%；当取37.5μg/L为临界值时，虽然敏感性仅为43.9%，但假阳性率仅为3.9%。 结论 尿CK检测对尿路TCC的诊断是一种较为敏感、特异且无创的方法，对膀胱TCC的临床分期和术后复发癌的监测有一定应用价值。与影像学和尿细胞学等其它诊断方法相结合，可提高上尿路病变诊断的准确性。
[关键词] 癌，移行细胞； 角蛋白； 膀胱肿瘤； 诊断，实验室
Evaluation of urinary cytokeratin 8 and 18 as a diagnostic marker for transitional cell carcinoma LI Tao, HE Yanyu, CHEN Zifu, ZHANG Yanrong, GAO Xiangxun, HUANG Chao, YE Liefu, HUANG Shiqing, LIU Chun, CHEN Wenbang, ZHAN Hanxiong, ZHAN Tianqi.Department of Urology, Fujian Provincial Hospital, Fuzhou 350001, China
[Abstract]ObjectiveTo determine the clinical efficacy of cytokeratin 8 and 18 as a novel urine marker for transitional cell carcinoma (TCC).MethodsUrinary concentrations of cytokeratin 8 and 18 (urinary bladder cancer antigen, UBC) were determined for 244 cases of TCC and 292 cases of other urological conditions by an enzyme-linked immunosorbent assay (ELISA).ResultsThe UBC concentrations of the TCC patients (mean 30.2μg/L) were significantly higher than the patients without TCC (mean 8.9μg/L)(P<0.001). At a threshold value of 8.4μg/l, the sensitivity of UBC for detection of TCC was 76.6%, the specificity was 74.3%, the positive predictive value was 71.4%, and the negative predictive value was 79.2%. The mean UBC concentrations of 32 cases of TCC and 110 cases of nonurothelial cancer diseases of the upper urinary tract were 20.9μg/L and 9.0μg/L,respectively(P<0.001). At a threshold value of 8.4μg/l, the sensitivity of UBC for detection of TCC ofthe upper urinary tract was 78.1%, and the specificity was 71.8%. No significant difference was found between the UBC values of the single tumors and the multiple tumors(P=0.415) , but significant corelation was found between the UBC values and the tumor size of 212 cases of bladder TCCs (Pearson corelation，r＝0.342，P<0.001). The mean UBC concentrations of G1, G2, G3 TCCs of the bladder were 23.8μg/L,33.6μg/L and 38.4μg/L(P＝0.763)，and the sensitivity were 68.2%,76.6% and 88.1%(P＝0.064), respectively. The mean UBC concentrations of the superficial (pTa-pT1) and muscle-invaded (pT2～pT4) TCCs of the bladder were 24.4μg/L and 47.3μg/L(P<0.001)，and the sensitivity were 69.7% and 91.0%(P＝0.001), respectively. ROC curve analysis of the UBC concentrations of the histologically proved bladder TCCs showed the sensitivity of UBC for diagnosis of muscle-invaded tumors was 76.1%, the specificity was 62.8% at a threshold value of 13.55μg/L, and the sensitivity was 52.2%, the specificity was 80.0% at a threshold value of 25.0μg/L. The mean UBC concentrations of the primary and recurrent TCCs of the bladder were 22.0μg/L and 57.7μg/L(P<0.001)，and At a threshold value of 8.4μg/l, the sensitivity were 70.3% and 93.0%(P<0.001), respectively. The mean UBC concentration of 76 patients without recurrence during follow-up was 10.5μg/L, which is significantly lower than that of the recurrent TCCs(P<0.001). ROC curve analysis of the UBC concentrations of the followed-up patients who had received bladder-reserved surgery for bladder TCCs showed the sensitivity and the specificity of UBC for diagnosis of cancer relapse was 87.7% and 86.8% at a threshold value of 14.6μg/L, 93% and 78.9% at a threshold value of 11.65μg/L, 43.9% and 96.1% at a threshold value of 37.5μg/L, respectively. ConclusionsUrinary cytokeratin 8 and 18 is a sensitive, specific and noninvasive diagnostic marker for TCC, and may be useful in the clinical staging and postoperative follow-up of bladder TCCs. The accuracy of conventional voided urine cytology and imaging examination to diagnose the diseases of the upper urinary tract can be improved by combination with the urine test of cytokeratins.
[Key words]Carcinoma,transitional cell; Keratins; Bladder neoplasms; Diagnosis, laboratory
细胞角蛋白(CK)是分析上皮细胞类型和分化状态的有效指标。一种类型的上皮细胞有一组特定类型的CK合成，且在上皮的恶性转化过程中，这种合成功能常得以保留。故而，CK可能成为检测人类恶性肿瘤的潜在瘤标。我们采用ELISA方法检测了536例疑诊尿路移行细胞癌(TCC)的患者尿液中的CK8和18片段的含量，以评价该项检验在尿路TCC的诊断和复发监测中的应用价值。报告如下。
对象与方法
一、检测对象
2000年7月~2007年7月本院泌尿外科住院患者或膀胱TCC术后门诊随访患者536例，诊断均由手术或膀胱镜检查及病理证实。分2组：(1)尿路TCC组：244例。其中膀胱TCC 212例，上尿路TCC 32例。 (2) 泌尿系非TCC疾病组：292例。其中上尿路非TCC疾病110例，下尿路非TCC疾病106例，膀胱TCC术后复查无瘤状态76例。
二、试剂和方法
术前或膀胱灌注化疗前留取晨尿，经1000×g离心后，吸取上清液置-20℃冰箱保存待检。UBC试剂盒为瑞典IDL生物技术公司产品，其中单克隆抗体对CK18有特异性，同时对CK8有交叉反应。采用ELISA法检测尿液中CK8和18的含量，结果以UBC值表示。
三、统计学分析
所有数据均用SPSS13.0统计软件包处理。应用受试者作业特征曲线(ROC)确定诊断临界值；计数资料采用χ2检验或Fisher精确检验；计量资料采用非参数秩和检验。
结果
ROC曲线(曲线下面积为0.821)确定以8.4μg/L为最适临界值, 尿CK诊断TCC的敏感性为76.6%(187/244)，特异性为74.3%(217/292)，阳性预测值为71.4%(187/262)，阴性预测值为79.2%(217/274)，总准确性为75.4%(404/536)。各组尿UBC均值及尿UBC取8.4μg/L为临界值时的敏感性见表1。尿路TCC患者与泌尿系非TCC疾病患者、上尿路TCC与上尿路非TCC疾病患者尿UBC均值比较, 差异均有极显著性意义(P均<0.001)。以8.4μg/L为临界值, 尿CK诊断上尿路TCC的敏感性为78.1%，特异性为71.8%。
212例膀胱TCC中，尿UBC值与肿瘤数目(单发或多发)不相关(P=0.415)，但与肿瘤大小(多发肿瘤以最大径之和表示)密切相关(Pearson相关分析，r＝0.342，P<0.001)。组织学分级G1、G2、G3肿瘤患者之间尿UBC均值(P＝0.763)以及尿CK诊断敏感性(P＝0.064)比较，差异均无显著性意义。浅表性(Ta～T1)和浸润性(T2～T4)TCC患者之间尿UBC均值(P<0.001)以及取8.4μg/L为临界值时尿CK诊断敏感性 (P＝0.001)比较，差异均有极显著性意义。进一步对已活检确诊的膀胱TCC 进行ROC曲线分析，尿UBC取13.55μg/L为临界值时诊断浸润癌的敏感性为76.1%，特异性为62.8%，当取25.0μg/L为临界值时敏感性降为52.2%，但特异性达80.0%。......（后略) ......
尿细胞角蛋白检测在尿路移行细胞癌诊断和复发监测中的应用研究
李涛 何延瑜 陈梓甫 张延榕 高祥勋 黄超 叶烈夫 黄世清 刘春 陈文榜 詹汉雄 詹天棋
福建省立医院泌尿外科(福州，350001Tel:13705078075)
[摘要] 目的 评价尿细胞角蛋白(CK)检测在尿路移行细胞癌(TCC)诊断和复发监测中的应用价值。 方法 采用ELISA法检测244例尿路TCC及292例泌尿系非TCC患者尿液中CK8和18的含量(UBC值)，应用受试者作业特征曲线(ROC)选择尿CK诊断尿路TCC和监测膀胱癌术后复发的最适临界值。结果 TCC患者尿UBC均值为30.2μg/L, 与泌尿系非TCC患者8.9μg/L的均值比较, 差异有极显著性意义(P<0.001)。ROC曲线(曲线下面积为0.821)确定以8.4μg/L为最适临界值, 尿CK诊断TCC的敏感性为76.6%，特异性为74.3%，阳性预测值为71.4%，阴性预测值为79.2%。32例上尿路TCC和110例非TCC的上尿路疾病患者尿UBC均值分别为20.9μg/L和9.0μg/L(P<0.001)，以8.4μg/L为临界值, 尿CK诊断上尿路TCC的敏感性为78.1%，特异性为71.8%。212例膀胱TCC中，尿UBC值与肿瘤数目(单发或多发)不相关(P=0.415)，但与肿瘤大小(多发肿瘤以最大径之和表示)密切相关(Pearson相关分析，r＝0.342，P<0.001)。组织学分级G1、G2、G3肿瘤患者尿UBC均值分别为23.8μg/L、33.6μg/L和38.4μg/L(P＝0.763)，以8.4μg/L为临界值时尿CK诊断各级TCC的敏感性分别为68.2%、76.6%和88.1%(P＝0.064)。浅表性(Ta～T1)和浸润性(T2～T4)TCC患者尿UBC均值分别为24.4μg/L和47.3μg/L(P<0.001)，以8.4μg/L为临界值时尿CK诊断敏感性分别为69.7%和91.0%(P＝0.001)。ROC曲线分析表明，对已活检确诊的膀胱TCC，尿UBC取13.55μg/L为临界值时诊断浸润癌的敏感性为76.1%，特异性为62.8%，当取25.0μg/L为临界值时敏感性降为52.2%，但特异性达80.0%。膀胱初发性TCC和复发性TCC患者的尿UBC均值分别为22.0μg/L和57.7μg/L(P<0.001)，以8.4μg/L为临界值时尿CK诊断敏感性分别为70.3%和93.0%(P<0.001)。76例膀胱TCC术后膀胱镜检查未见肿瘤复发的患者尿UBC均值为10.5μg/L，与复发瘤比较，差异有极显著性意义(P<0.001)。ROC曲线分析表明，对膀胱TCC术后随访复查时，尿CK取14.6μg/L为临界值时诊断复发癌的敏感性为87.7%，特异性为86.8%；当取11.65μg/L为临界值时敏感性达93%，特异性为78.9%；当取37.5μg/L为临界值时，虽然敏感性仅为43.9%，但假阳性率仅为3.9%。 结论 尿CK检测对尿路TCC的诊断是一种较为敏感、特异且无创的方法，对膀胱TCC的临床分期和术后复发癌的监测有一定应用价值。与影像学和尿细胞学等其它诊断方法相结合，可提高上尿路病变诊断的准确性。
[关键词] 癌，移行细胞； 角蛋白； 膀胱肿瘤； 诊断，实验室
Evaluation of urinary cytokeratin 8 and 18 as a diagnostic marker for transitional cell carcinoma LI Tao, HE Yanyu, CHEN Zifu, ZHANG Yanrong, GAO Xiangxun, HUANG Chao, YE Liefu, HUANG Shiqing, LIU Chun, CHEN Wenbang, ZHAN Hanxiong, ZHAN Tianqi.Department of Urology, Fujian Provincial Hospital, Fuzhou 350001, China
[Abstract]ObjectiveTo determine the clinical efficacy of cytokeratin 8 and 18 as a novel urine marker for transitional cell carcinoma (TCC).MethodsUrinary concentrations of cytokeratin 8 and 18 (urinary bladder cancer antigen, UBC) were determined for 244 cases of TCC and 292 cases of other urological conditions by an enzyme-linked immunosorbent assay (ELISA).ResultsThe UBC concentrations of the TCC patients (mean 30.2μg/L) were significantly higher than the patients without TCC (mean 8.9μg/L)(P<0.001). At a threshold value of 8.4μg/l, the sensitivity of UBC for detection of TCC was 76.6%, the specificity was 74.3%, the positive predictive value was 71.4%, and the negative predictive value was 79.2%. The mean UBC concentrations of 32 cases of TCC and 110 cases of nonurothelial cancer diseases of the upper urinary tract were 20.9μg/L and 9.0μg/L,respectively(P<0.001). At a threshold value of 8.4μg/l, the sensitivity of UBC for detection of TCC ofthe upper urinary tract was 78.1%, and the specificity was 71.8%. No significant difference was found between the UBC values of the single tumors and the multiple tumors(P=0.415) , but significant corelation was found between the UBC values and the tumor size of 212 cases of bladder TCCs (Pearson corelation，r＝0.342，P<0.001). The mean UBC concentrations of G1, G2, G3 TCCs of the bladder were 23.8μg/L,33.6μg/L and 38.4μg/L(P＝0.763)，and the sensitivity were 68.2%,76.6% and 88.1%(P＝0.064), respectively. The mean UBC concentrations of the superficial (pTa-pT1) and muscle-invaded (pT2～pT4) TCCs of the bladder were 24.4μg/L and 47.3μg/L(P<0.001)，and the sensitivity were 69.7% and 91.0%(P＝0.001), respectively. ROC curve analysis of the UBC concentrations of the histologically proved bladder TCCs showed the sensitivity of UBC for diagnosis of muscle-invaded tumors was 76.1%, the specificity was 62.8% at a threshold value of 13.55μg/L, and the sensitivity was 52.2%, the specificity was 80.0% at a threshold value of 25.0μg/L. The mean UBC concentrations of the primary and recurrent TCCs of the bladder were 22.0μg/L and 57.7μg/L(P<0.001)，and At a threshold value of 8.4μg/l, the sensitivity were 70.3% and 93.0%(P<0.001), respectively. The mean UBC concentration of 76 patients without recurrence during follow-up was 10.5μg/L, which is significantly lower than that of the recurrent TCCs(P<0.001). ROC curve analysis of the UBC concentrations of the followed-up patients who had received bladder-reserved surgery for bladder TCCs showed the sensitivity and the specificity of UBC for diagnosis of cancer relapse was 87.7% and 86.8% at a threshold value of 14.6μg/L, 93% and 78.9% at a threshold value of 11.65μg/L, 43.9% and 96.1% at a threshold value of 37.5μg/L, respectively. ConclusionsUrinary cytokeratin 8 and 18 is a sensitive, specific and noninvasive diagnostic marker for TCC, and may be useful in the clinical staging and postoperative follow-up of bladder TCCs. The accuracy of conventional voided urine cytology and imaging examination to diagnose the diseases of the upper urinary tract can be improved by combination with the urine test of cytokeratins.
[Key words]Carcinoma,transitional cell; Keratins; Bladder neoplasms; Diagnosis, laboratory
细胞角蛋白(CK)是分析上皮细胞类型和分化状态的有效指标。一种类型的上皮细胞有一组特定类型的CK合成，且在上皮的恶性转化过程中，这种合成功能常得以保留。故而，CK可能成为检测人类恶性肿瘤的潜在瘤标。我们采用ELISA方法检测了536例疑诊尿路移行细胞癌(TCC)的患者尿液中的CK8和18片段的含量，以评价该项检验在尿路TCC的诊断和复发监测中的应用价值。报告如下。
对象与方法
一、检测对象
2000年7月~2007年7月本院泌尿外科住院患者或膀胱TCC术后门诊随访患者536例，诊断均由手术或膀胱镜检查及病理证实。分2组：(1)尿路TCC组：244例。其中膀胱TCC 212例，上尿路TCC 32例。 (2) 泌尿系非TCC疾病组：292例。其中上尿路非TCC疾病110例，下尿路非TCC疾病106例，膀胱TCC术后复查无瘤状态76例。
二、试剂和方法
术前或膀胱灌注化疗前留取晨尿，经1000×g离心后，吸取上清液置-20℃冰箱保存待检。UBC试剂盒为瑞典IDL生物技术公司产品，其中单克隆抗体对CK18有特异性，同时对CK8有交叉反应。采用ELISA法检测尿液中CK8和18的含量，结果以UBC值表示。
三、统计学分析
所有数据均用SPSS13.0统计软件包处理。应用受试者作业特征曲线(ROC)确定诊断临界值；计数资料采用χ2检验或Fisher精确检验；计量资料采用非参数秩和检验。
结果
ROC曲线(曲线下面积为0.821)确定以8.4μg/L为最适临界值, 尿CK诊断TCC的敏感性为76.6%(187/244)，特异性为74.3%(217/292)，阳性预测值为71.4%(187/262)，阴性预测值为79.2%(217/274)，总准确性为75.4%(404/536)。各组尿UBC均值及尿UBC取8.4μg/L为临界值时的敏感性见表1。尿路TCC患者与泌尿系非TCC疾病患者、上尿路TCC与上尿路非TCC疾病患者尿UBC均值比较, 差异均有极显著性意义(P均<0.001)。以8.4μg/L为临界值, 尿CK诊断上尿路TCC的敏感性为78.1%，特异性为71.8%。
212例膀胱TCC中，尿UBC值与肿瘤数目(单发或多发)不相关(P=0.415)，但与肿瘤大小(多发肿瘤以最大径之和表示)密切相关(Pearson相关分析，r＝0.342，P<0.001)。组织学分级G1、G2、G3肿瘤患者之间尿UBC均值(P＝0.763)以及尿CK诊断敏感性(P＝0.064)比较，差异均无显著性意义。浅表性(Ta～T1)和浸润性(T2～T4)TCC患者之间尿UBC均值(P<0.001)以及取8.4μg/L为临界值时尿CK诊断敏感性 (P＝0.001)比较，差异均有极显著性意义。进一步对已活检确诊的膀胱TCC 进行ROC曲线分析，尿UBC取13.55μg/L为临界值时诊断浸润癌的敏感性为76.1%，特异性为62.8%，当取25.0μg/L为临界值时敏感性降为52.2%，但特异性达80.0%。......（后略) ......