Advances in ImagingTechnologies in the

Evaluation of High-GradeBladder Cancer

Dimitar V. Zlatev, MDa, Emanuela Altobelli, MDa,b,Joseph C. Liao, MDa,c,*

KEYWORDS

� Bladder cancer � Confocal laser endomicroscopy � Fluorescence cystoscopy � Molecular imaging� Narrow band imaging � Optical coherence tomography � Photodynamic diagnosis

KEY POINTS

� Improved optical imaging of the bladder can lead to more effective use of bladder-sparing manage-ment for low-grade cancer and more aggressive treatment for high-grade cancer.

� Photodynamic diagnosis and narrow band imaging are macroscopic imaging modalities andprovide contrast enhancement of suspicious lesions that improve detection rates.

� Confocal laser endomicroscopy is an example of a microscopic optical biopsy technology thatprovides high-resolution and subsurface tissue characterization similar to histology.

� Confocal laser endomicroscopy is the only clinical technology capable of differentiating high-gradeand low-grade bladder cancer.

� The highest image resolution is inferred by molecular specificity. The development of molecularmarkers and binding agents for molecular imaging can serve to differentiate low-grade and high-grade disease.

INTRODUCTION

Bladder cancer is the sixth most common cancerin the United States with 74,690 new cases and15,580 deaths expected in 2014.1 The natural his-tory of bladder cancer is heterogeneous, rangingfrom low-grade variant that does not recur afterlocal resection to a high-grade subtype that recursand progresses to metastatic, lethal disease.2

Although 80% of patients present at a non–

Dr J.C. Liao is supported in part by grant National InstituConflict of Interest: Dr D.V. Zlatev and Dr E. Altobelli decarticle. Dr J.C. Liao received research support from the NIHTechnologies, including expenses covered or reimburseda Department of Urology, Stanford University School of M94305-5118, USA; b Department of Urology, Campus Biomc Urology Section, Veterans Affairs Palo Alto Health C94304, USA* Corresponding author. 300 Pasteur Drive, Room S-287E-mail address: jliao@stanford.edu

Urol Clin N Am 42 (2015) 147–157http://dx.doi.org/10.1016/j.ucl.2015.01.0010094-0143/15/$ – see front matter Published by Elsevier In

muscle-invasive stage (Ta, T1, TIS) that may bemanaged endoscopically, recurrence rate reaches61% at 1 year and 78% at 5 years.3,4 As a result ofits high recurrence rate and associated need forlifelong surveillance and repeat resections, thehealth care costs for bladder cancer are amongthe highest of all malignancies.3,5

White light cystoscopy (WLC) is the standard forevaluation of bladder urothelium. In the officesetting, flexible cystoscopes are used for initial

tes of Health (NIH) R01 CA160986.lare no potential conflicts of interest relevant to this(R01 CA160986) and travel support fromMauna Kea

.edicine, 300 Pasteur Drive, Room S-287, Stanford, CAedico, Via Alvaro del Portillo 200, Rome 00128, Italy;are System, 3801 Miranda Avenue, Palo Alto, CA

, Stanford, CA 94305-5118.

c. urologic.theclinics.com

mailto:jliao@stanford.eduhttp://crossmark.crossref.org/dialog/?doi=10.1016/j.ucl.2015.01.001&domain=pdfhttp://dx.doi.org/10.1016/j.ucl.2015.01.001http://urologic.theclinics.com

Zlatev et al148

identification of suspected lesions and subse-quent surveillance for recurrence. In the operatingroom, complete transurethral resection (TUR) withlarger rigid cystoscopes is performed for tissuediagnosis and local staging. Despite its centralrole, WLC has well-recognized limitations.6,7

Although sufficient for the identification of papillarylesions, visual appearance under white light is un-reliable for the determination of low- and high-grade cancer and cannot assess level of invasion.8

Additionally, nonpapillary and flat malignant le-sions such as carcinoma in situ (CIS) can be diffi-cult to differentiate from inflammation,6 withdetection rates of CIS only 58% to 68% byWLC.9–11 Smaller or satellite tumors can bemissed, which contributes to the up to 40% rateof residual bladder cancer found at the time of‘second-look’ TUR.12,13 Finally, indistinct bordersand difficult visualization of submucosal tumormargins during TUR can lead to incomplete tumorresection and understaging of bladder cancer.14,15

These limitations of WLC contribute to theincreased risk of cancer persistence, recurrence,and in the case of high-grade bladder cancer, pro-gression to metastatic lethal disease.2,16,17

To address the shortcomings of WLC, severaladjunctive optical imaging technologies haveemerged with the goal to improve bladder cancerdetection and resection (Table 1). The imagingtechnologies can be broadly categorized based

Table 1Characteristics and properties of adjunct optical ima

Name MechanismContrastAgent Resolution Dept

PDD Fluorescence HAL mm – cm Surfa

NBI Absorption None mm – cm Surfa

CLE Fluorescence Fluorescein 1–3.5 mm 120 m

OCT Scattering None 10–20 mm w2.5

Raman Scattering Optional(SERS)

— 2 mm

UV Fluorescence None mm – cm Surfa

SFE Reflectance 1fluorescence

None mm – cm Surfa

Abbreviations: CLE, confocal laser endomicroscopy; HAL, hexacoherence tomography; PDD, photodynamic diagnosis; SERS,endoscopy; UV, ultraviolet.

on their field of view. Photodynamic diagnosis(PDD) and narrow band imaging (NBI) are exam-ples of macroscopic imaging modalities that sur-vey a large area of mucosa, similar to WLC, butprovide additional contrast enhancement to distin-guish suspicious lesions from noncancerous mu-cosa. Microscopic modalities including opticalcoherence tomography (OCT) and confocal laserendomicroscopy (CLE) provide high-resolution,subsurface tissue characterization similar to his-tology and thus offer the potential for ‘optical bi-opsy’ of bladder cancer. Molecular imaging,through coupling of optical imaging technologieswith fluorescently labeled binding agents (eg, anti-bodies), may enable real-time cancer imaging withmolecular specificity. These technological ad-vances have the potential to improve optical diag-nosis and endoscopic management of bladdercancer. The most recent literature on adjunctiveoptical imaging technologies is reviewed, withconsideration for the evaluation of high-gradebladder cancer highlighted.

PHOTODYNAMIC DIAGNOSIS

PDD, also known as fluorescence cystoscopy orblue light cystoscopy, provides wide-field fluores-cence imaging of the bladder with a field of viewcomparable to WLC. PDD requires preoperativeintravesical administration of a photosensitive

ging technologies for bladder cancer

hScope or Probe(Diameter) Status

ce Standard rigid cystoscope Clinical

ce Flexible cystoscope(5.5 mm) or standardrigid cystoscope

Clinical

m Probe (0.85–2.6 mm) Clinical/investigational(in vivo)

mm Probe (2.7 mm) Clinical/investigational(in vivo)

Probe (2.1 mm) Investigational(in vivo)

ce Probe (3 mm) Investigational(in vivo)

ce Scope/Probe (1.2 mm) Investigational(ex vivo)

minolevulinate; NBI, narrow band imaging; OCT, opticalsurface-enhanced Raman scattering; SFE, scanning fiber

Optical Imaging of High-Grade Bladder Cancer 149

protoporphyrin IX precursor as the contrast agent,a blue light source that illuminates at 375 to440 nm, and a specialized lens and camerahead. Once taken up by the bladder urothelium,the protoporphyrin accumulates preferentially inneoplastic cells and emits a fluorescence in thered part of the spectrum under blue light excita-tion, allowing visualization of the tumor (Fig. 1).18

Two protoporphyrin analogues, 5-aminolevulinicacid and its ester derivative hexaminolevulinate,have been investigated clinically. Hexaminolevuli-nate is the more potent analog, with greater localbioavailability and superior fluorescence intensity,and is approved for single clinical use in Europeand the United States for patients with suspectedor known bladder cancer. Owing to a false-positive fluorescence from inflammatory lesions,previous biopsy sites, or in patients previouslytreated with bacillus Calmette-Guérin,7,19 hexami-nolevulinate is not approved currently for patientswho received intravesical immunotherapy orchemotherapy within 90 days.

Multi-institutional, randomized, clinical studieshave demonstrated that PDD improves the detec-tion of papillary bladder tumors.19,20 Although PDDdoes not distinguish high-grade from low-gradebladder cancer, several studies have shown that

Fig. 1. Photodynamic diagnosis (PDD) of high-grade papill(WLC) showed a large broad-based papillary tumor. (B) PSubsequent pathology for the lesion imaged in (A) and (noma. In a different patient, (C) WLC showed minimal erwall; however, (D) PDD showed a pink fluorescence ovehigh-grade urothelial carcinoma and carcinoma in situ on

PDD has an increased rate of detection of flat-appearing CIS.19,20 In a meta-analysis of 3 phaseIII studies, the detection of CIS was significantlyhigher byPDDplusWLCcomparedwithWLCalone(87% vs 75% pooled sensitivity; P 5 .006).21 Addi-tionally, several meta-analyses have found signifi-cantly reduced residual tumor rates in patientstreated with PDD, with relative risk of residual tumor2.77-fold higher for WLC compared with PDD.22,23

The recurrence rate of PDD-guided TUR ofbladder tumor remains to be determined. In ameta-analysis that reviewed raw data from pro-spective studies on 1345 patients with known orsuspected non–muscle-invasive bladder cancer,overall recurrence rates up to 12 months weresignificantly lower with PDD compared with WLC(34.5% vs 45.4% pooled sensitivity; P 5 .006)and independent of the level of risk.24 However,a prospective randomized multi-institutional trialfound no difference in tumor recurrence and pro-gression between PDD and WLC in patients withnon–muscle-invasive bladder cancer.25 Additionalstudies with longer follow-up time periods areneeded to better define the optimal indicationsfor PDD use and evaluate the long-term efficacyof PDD with regard to recurrence-free andprogression-free survival.

ary and flat bladder cancer. (A) White light cystoscopyDD showed diffuse pink fluorescence over the tumor.B) confirmed noninvasive high-grade urothelial carci-ythema on the bladder mucosa along the left lateralr the region that was confirmed to be noninvasivehistopathology.

Zlatev et al150

NARROW BAND IMAGING

NBI is a high-resolution wide-field endoscopictechnique that improves detection of bladderneoplasia through enhanced visualization ofmucosal and submucosal vasculature without theuse of exogenous dye. NBI devices (OlympusCorp, Tokyo, Japan) filter out the red spectrumfrom white light, with the resultant blue (415 nm)and green (540 nm) spectra absorbed by hemoglo-bin, thus highlighting the contrast between capil-laries and mucosa. Under NBI, the morevascularized CIS or tumor areas are accentuatedin appearance as green or brown (Fig. 2). NBI isapproved for clinical use in the United States andis available either in an integrated videocysto-scope or through a camera head that can beattached to standard cystoscopes. These devicesinclude a toggling functionality between WLC andNBI, thereby facilitating rapid and real-time evalu-ation of suspected lesions. Although NBI providesa subjective impression of abnormal areas ofbladder mucosa, there does not seem to be a sig-nificant difference in detection rate of bladder tu-mor between new and experienced users.26,27

In a recent meta-analysis of 8 studies including1022 patients, the detection of bladder cancerwas higher by NBI compared with WLC on a per-person basis (94% vs 85% pooled sensitivity)and a per-lesion basis (95% vs 75% pooled sensi-tivity); however, the pooled specificity on a per-lesion basis was lower by NBI compared withWLC (55% vs 72%).28

Similar to PDD, NBI does not distinguish bladdercancer grade, but does improve CIS detection. In astudy of 427 patients that compared NBI plusWLCwith WLC alone for recurrent bladder cancer, thedetection of CIS was significantly improved by

Fig. 2. Narrow band imaging (NBI) of the bladder. (A) Wshowed only mild erythema. (B) Under NBI, brown fluoneoplastic areas, subsequently confirmed on pathology to

NBI over WLC (100% vs 83% sensitivity).29 Asingle-center, prospective, randomized, controlledtrial involving 220 patients with bulky non–muscle-invasive bladder tumor demonstrated an improveddetection rate of CIS for NBI compared with WLC(95% vs 68%).30 A multicenter, prospective studyreported a significantly increased sensitivity forthe detection of CIS from 50% for WLC to 90%for NBI in 104 patients.31

In a recent, single-center, randomized,controlled trial to assess whether NBI improvedTUR of bladder tumors in 254 patients with 2-year follow-up, a reduced recurrence rate (22%vs 33%; P 5 .05) and improved recurrence-freesurvival (22 vs 19 months; P 5 .02) were reportedby NBI compared with WLC.32 A multicenter,randomized, controlled trial to compare the recur-rence rate at 1 year between NBI- and WLC-assisted TUR of bladder tumor in patients withnon–muscle-invasive bladder cancer is ongoing.33

CONFOCAL LASER ENDOMICROSCOPY

CLE is an optical biopsy technology that providesdynamic, high-resolution microscopy of mucosallesions.34 Recently approved for clinical use inthe urinary tract, image acquisition is performedthrough fiber optic probes ranging from 0.85 to2.6 mm in diameter, compatible with workingchannels of standard cystoscopes.35 Fluorescein,a US Food and Drug Administration–approveddrug, is used as the contrast agent and can beadministered intravesically or intravenously withminimal toxicity.36 In the current CLE clinical sys-tem (Mauna Kea Technologies, Paris, France), illu-minating light from a 488-nm laser fiber source isfocused by an objective lens, with scattered lightfrom the in-focus tissue plane converged back

hite light cystoscopy of the left lateral wall regionsrescence delineated the extent of more vascularizedbe high-grade noninvasive urothelial carcinoma.

Optical Imaging of High-Grade Bladder Cancer 151

into the fiber and subsequent signal processinginto an image. CLE provides the highest spatialresolution (1–5 mm) of clinically available technolo-gies, with images comparable with conventionalhistopathology. Video sequences are acquiring at12 frames per second, allowing for real-time dy-namic imaging of physiologic processes such asvascular flow.

Given spatial resolution sufficient to resolve mi-croarchitectural and cellular features, CLE iscapable of differentiating high-grade and low-grade bladder cancer. After the initial pilot studythat demonstrated the feasibility of using CLE inex vivo bladders after cystectomy,37 CLE was con-ducted in 27 patients undergoing cystoscopy andTUR and differences between normal urothelium,low-grade tumors and high-grade tumors werevisualized.34 In normal urothelium, larger umbrellacells were seen most superficially followed byorganized smaller intermediate cells with distinctcell borders. Low-grade papillary tumors demon-strated densely arranged but normal-shaped smallcells extending outward from fibrovascular cores,whereas high-grade tumors and CIS showedmarkedly irregular architecture and cellular pleo-morphism (Fig. 3).

An imaging atlas based on 66 patients has beencreated to establish criteria for CLE diagnosis andgrading of bladder cancer.38 A recent study that

Fig. 3. Optical biopsy of the bladder using confocal laserpapillary bladder cancer, carcinoma in situ (CIS), and inflWLC images and hematoxylin and eosin (H&E) staining froteristically organized papillary structures, in contrast withcells and distorted microarchitecture. (From Hsu M, Gupttissue interrogation during urologic surgery. Curr Opin Ur

analyzed 31 bladder regions with CLE and WLCdemonstrated moderate interobserver agreementin image interpretation between novice and expe-rienced CLE urologists with respect to cancerdiagnosis; interestingly, experienced CLE urolo-gists were found to have higher agreement for im-age interpretation with CLE compared with WLCalone (90% vs 74%).39 Multicenter studies exam-ining the diagnostic accuracy of CLE for real-time cancer diagnosis and grading remain to becompleted.

OPTICAL COHERENCE TOMOGRAPHY

OCT is another optical biopsy technology thatprovides high-resolution, real-time, subsurface im-aging of tissues. Analogous to B-mode ultrasonog-raphy, OCT relies on information gathered byreflectedenergy.Unlikeultrasonography, however,OCT utilizes near-infrared light (890–1300 nm) andmeasures the backscatter properties of differenttissue layers to provide a cross-sectional imagewith 2 mm depth of penetration and 10 to 20 mmspatial resolution.40 Under OCT, normal urotheliumis seen as aweakly scattering darker layer, the lam-ina propria is a bright layer with the highest scat-tering intensity, and the muscularis propria is aless scattering layer beneath the lamina propria.In cancerous tissue, anatomic layers of the

endomicroscopy (CLE). Normal, low-grade, high-gradeammation CLE images are shown with correspondingm subsequent biopsy. Low-grade cancer shows charac-high-grade cancer and CIS that display pleomorphic

a M, Su LM, et al. Intraoperative optical imaging andol 2014;24:66; with permission.)

Zlatev et al152

urothelium are lost.41,42 Limitations of OCT includefalse-positive results, possibly owing to disruptionsof the bladder wall from erosion, scarring, or gran-uloma formation.40,43

Multiple studies have evaluated the real-timeclassification by OCT-assisted cystoscopy ofbladder lesions as benign or malignant, with over-all sensitivity 84% to 100% and overall specificity65% to 89%.40,43–47 Although OCT does notdistinguish neoplastic bladder lesions by tumorgrade, it is the only optical imaging technologywith sufficient subsurface tissue penetration forreal-time assessment of invasiveness of bladderlesions (ie, staging).43–45 In a single-center studyinvolving 24 patients at high risk for bladder can-cer, the positive predictive value for tumor invasioninto the lamina propria diagnosed by OCT was90%.40 Other recent studies have reported anautomated image-processing algorithm to detectbladder cancer from OCT images48 and applica-tion in the upper tract.49 Larger multicenter studiesare needed to evaluate the diagnostic value of tu-mor invasion by OCT as an adjunct to cytology,WLC, and histopathology.

MULTIMODAL IMAGING

The combination of imaging modalities harbors thepotential to increase diagnostic accuracy. Forexample, macroscopic imaging (PDD, NBI) couldbe utilized to identify suspicious lesions, whereasmicroscopic imaging (CLE, OCT) could providegrading or staging information via high-resolutiontissue characterization.7,50 A recent study re-ported the feasibility of simultaneous PDD andCLE; however, intraoperative tumor grading wasnot done because TUR was performed usingPDD followed by ex vivo histologic analysis withCLE.51 Another study evaluated 232 lesions from66 patients with suspected bladder cancer usingWLC, PDD alone, and PDD plus OCT.52 The com-bination of PDD and OCT compared with PDDalone significantly increased per-patient speci-ficity from 62% to 87%. In another study, PDD incombination with standard OCT did not improvediagnostic accuracy in detecting noninvasivebladder cancer, but the combined use of cross-polarization OCT and PDD improved the positivepredictive and negative predictive values in de-tecting bladder cancer in flat suspicious areas.53

OTHER EMERGING TECHNOLOGIES

In addition to these modalities, a number ofemerging technologies are at advanced prototypephase or early clinical feasibility stage. Ramanspectroscopy is based on the principle of

scattering of photons following interaction withmolecular bonds. As near infrared light (785–845 nm) illuminates the tissue, the donation ofenergy to molecular bonds results in a differentwavelength of the photons exiting the sample(Raman shift).54 Detection of these scattered pho-tons is then plotted to create a spectrum of peaks,producing a molecular “fingerprint” of the exam-ined sample without the requirement of an exoge-nous contrast agent.55 In the ex vivo setting,Raman spectroscopy has been shown to differen-tiate the normal bladder wall layers, assess inva-siveness, and identify low- and high-gradebladder cancers.56,57 The first in vivo study utilizeda Raman probe compatible with endoscopic work-ing channels and reported sensitivity of 85% andspecificity of 79% for the detection of bladder can-cer in 62 suspected lesions.55 Surface-enhancedRaman scattering nanoparticles have been shownto augment weak signals and allow for conjugationto cancer-specific antibodies to enable Raman-based molecular imaging.58

Ultraviolet (UV) autofluorescence is based onthe UV laser excitation of the fluorescence of mol-ecules naturally present in tissue. A recent pilotin vivo study compared spectroscopic resultswith histologic findings in 14 patients who under-went cystoscopy.59 Normal urothelium, papillarytumors, and suspicious flat lesions were interro-gated with a UV probe via the working channel ofa standard cystoscope. The diagnostic signalwas then converted into an intensity ratio of theemitted light at approximately 360 and 450 nmand color coded to facilitate real-time interpreta-tion.59 Differentiation of bladder cancer fromnormal urothelium was demonstrated. Additionalstudies are required to investigate signal intensityacross low- and high-grade bladder cancers,reproducibility, and potential for UV-inducedtoxicity.Multiphoton microscopy (MPM) is a laser-

scanning microscopy technique based on thesimultaneous absorption of 2 (or 3) near-infraredphotons (700–800 nm) to cause a localizednonlinear excitation that reduces the potential forcellular damage. MPM enables imaging of un-stained tissue at submicron resolution in 3 dimen-sions to a depth of up to 0.5 mm by using intrinsictissue emissions signals from autofluorescence(nicotinamide adenine dinucleotide hydrogen incells, elastin in connective tissue, lipofuscin infat) and second harmonic generation (collagen).60

The interpretation of acquired images is simplifiedby color coding the detected signals. A recentin vitro study reported MPM imaging on 77 freshbladder biopsies, with 88% accuracy in differenti-ation between benign and neoplastic lesions and

Optical Imaging of High-Grade Bladder Cancer 153

68% accuracy in the assignment of cytologicgrading.61 Similar to CLE, limitations of MPMinclude limited depth of penetration that is notsufficient for cancer staging and a lack of nucleardetail. Current research is focused on the minitua-rization of the MPM system for in vivoapplication.62,63

Scanning fiber endoscopy (SFE) is an ultrathinflexible endoscope containing an optical fiber toprovide wide-angle, full-color, high-resolution im-ages.64,65 The 1.2-mm diameter of the probe de-creases invasiveness and allows versatility of useas either a standalone miniaturized endoscope oras a probe in conjunction with other imaging mo-dalities.66 SFE has been demonstrated in ex vivo

Fig. 4. Endoscopic molecular imaging of human bladder cing agent and confocal laser endomicroscopy (CLE) as thetomy, the ex vivo intact bladder was instilled with theincubated for 30 minutes to allow antibody binding. Afteby endoscopic imaging of the bladder mucosa and normalogic analysis. (B) Representative frames of CLE videos acquwith corresponding hematoxylin and eosin (H&E)–stained(From Pan Y, Volkmer JP, Mach KE, et al. Endoscopic mCD47 antibody. Sci Transl Med 2014;6:260ra148; with perm

bladder models.67 Additional studies are requiredto investigate the feasibility of in vivo SFE. A poten-tial application of SFE involves automated integra-tion with an “image stitching” algorithm togenerate a panoramic view of the urothelium thatcould be used for tumor mapping and surveyingthe bladder longitudinally.67

MOLECULAR IMAGING

Molecular imaging is the visualization and charac-terization of biologic processes at the molecularand cellular levels.68 Molecular specificity may beconferred through coupling of optical imagingtechnologies with fluorescently labeled binding

ancer using fluorescein labeled anti-CD47 as the imag-imaging modality. (A) Immediately after radical cystec-molecular imaging agent via a urinary catheter andr irrigation with saline, bound anti-CD47 was detectedl and suspicious regions were biopsied for histopatho-ired from normal and cancer lesions in 5 bladders (Bl)images. Scale bars, 50 mm. IgG, immunoglobulin G.olecular imaging of human bladder cancer using aission.)

Zlatev et al154

agents such as antibodies, peptides, or small mol-ecules. Bladder, given the ease of access and anestablished track record of intravesical therapy, isa promising target organ for endoscopic molecularimaging. Fluorescently labeled, cancer-specificmolecular imaging agents may provide enhanceddifferentiation between tumor and adjacent normalor benign tissues. Thus, the combination of opticalimaging technologies with cancer-specific molec-ular imaging agents holds the potential for real-time endoscopic cancer detection.69,70

Fig. 5. Endoscopic molecular imaging of human bladdernanocrystal (Qdot625) and imaged with blue light cystoscotem. Representative white light cystoscopy (WLC) and PD(H&E) staining for colocalization of anti–CD47-Qdot625 binof anti-CD47-Qdot625 in a bladder with normal mucosa aof normal urothelium, squamous metaplasia, inflammatioQdot625 binding. (C) Anti–CD47-Qdot625 binding detectedQdot625 bound to adenocarcinoma of the bladder. (E) In(BCG) treatment, anti–CD47-Qdot625 bound to a region wof cystitis. (F) Anti–CD47-Qdot625 bound to residual tumorScale bars, 50 mm. IgG, immunoglobulin G; NOS, not otherKE, et al. Endoscopic molecular imaging of human bla2014;6:260ra148; with permission.)

A recent study used fluorescently labeled CD47antibody (anti-CD47) to successfully demonstrateex vivo endoscopic molecular imaging of bladdercancer using CLE and PDD in 25 intact bladdersderived from radical cystectomy.71 All of the blad-ders were derived from patients with invasive high-grade bladder cancer. CD47 is a surface marker ofhuman solid tumors and is expressed on morethan 80% of bladder cancer cells.72,73 A mono-clonal CD47 antibody under development as atargeted therapy agent was labeled with a

cancer using anti–CD47-labeled with a quantum dotpe from a clinical photodynamic diagnosis (PDD) sys-D images with corresponding hematoxylin and eosinding and histopathology. (A) Cancer-specific binding

nd a carcinoma in situ (CIS) lesion. (B) Benign regionsn, and ulcer (arrows) with no detectable anti–CD47-under PDD on urothelial carcinomas. (D) Anti–CD47-a bladder with a history of bacillus Calmette-Guérinith recurrent carcinoma but did not bind to a regionin a prior resection bed but not to benign scar tissue.wise specified. (Adapted from Pan Y, Volkmer JP, Machdder cancer using a CD47 antibody. Sci Transl Med

Optical Imaging of High-Grade Bladder Cancer 155

fluorescent tag, either fluorescein isothiocyanate(FITC) or quantum dot, a semiconductor nanocrys-tal, was instilled intravesically as a topical molecu-lar imaging agent (Fig. 4A). After allowing sufficienttime for antibody binding, excess antibody wasremoved by bladder irrigation. Bladders incubatedwith anti-CD47–FITC were imaged with CLE (seeFig. 4B) and those incubated with anti–CD47-Qdot625 were imaged by PDD (Fig. 5). In all blad-ders imaged with CLE, anti-CD47–FITC bindingto cancer lesions was between 95- and 1100-fold greater than binding to normal urothelium inthe same bladder. In the bladders imaged withPDD, the sensitivity and specificity for CD47-targeted imaging were 82.9% and 90.5%, respec-tively, indicating the potential of CD47 to serve asa bladder cancer imaging agent with improved dis-ease specificity. Further studies to assess thein vivo binding and toxicity of labeled anti-CD47will be required before clinical translation. Thestudy offers the promising possibility that targetedtherapy may be combined with targeted imaging.

SUMMARY

New optical imaging technologies have emergedand hold the potential to revolutionize the detec-tion and management of bladder cancer beyondWLC. Macroscopic technologies such as PDDand NBI improve the detection of bladder cancerand are already implemented in the clinical setting.Microscopic technologies such as OCT and CLEprovide optical biopsy techniques that enable sub-surface imaging comparable with standard histo-pathology. CLE is the only clinically availableimaging technique capable of differentiating be-tween low-grade and high-grade bladder cancers.Molecular imaging represents an exciting innova-tion that combines optical imaging technologieswith cancer-specific molecular agents to improvethe specificity of disease detection and potentiallygrading differentiation. Additional studies areneeded to further define the role of imaging tech-nologies in the evaluation and management ofhigh-grade bladder cancer.

REFERENCES

1. Siegel R, Ma J, Zou Z, et al. Cancer statistics, 2014.

CA Cancer J Clin 2014;64:9.

2. Kirkali Z, Chan T, Manoharan M, et al. Bladder can-

cer: epidemiology, staging and grading, and diag-

nosis. Urology 2005;66:4.

3. Morgan TM, Keegan KA, Clark PE. Bladder cancer.

Curr Opin Oncol 2011;23:275.

4. Sylvester RJ, van der Meijden AP, Oosterlinck W,

et al. Predicting recurrence and progression in

individual patients with stage Ta T1 bladder cancer

using EORTC risk tables: a combined analysis of

2596 patients from seven EORTC trials. Eur Urol

2006;49:466.

5. Avritscher EB, Cooksley CD, Grossman HB, et al.

Clinical model of lifetime cost of treating bladder

cancer and associated complications. Urology

2006;68:549.

6. Lee CS, Yoon CY, Witjes JA. The past, present and

future of cystoscopy: the fusion of cystoscopy and

novel imaging technology. BJU Int 2008;102:1228.

7. Liu JJ, Droller MJ, Liao JC. New optical imaging

technologies for bladder cancer: considerations

and perspectives. J Urol 2012;188:361.

8. Cina SJ, Epstein JI, Endrizzi JM, et al. Correlation of

cystoscopic impression with histologic diagnosis of

biopsy specimens of the bladder. Hum Pathol

2001;32:630.

9. Fradet Y, Grossman HB, Gomella L, et al.

A comparison of hexaminolevulinate fluorescence

cystoscopy and white light cystoscopy for the

detection of carcinoma in situ in patients with

bladder cancer: a phase III, multicenter study.

J Urol 2007;178:68.

10. Jocham D, Witjes F, Wagner S, et al. Improved

detection and treatment of bladder cancer using

hexaminolevulinate imaging: a prospective, phase

III multicenter study. J Urol 2005;174:862.

11. Schmidbauer J, Witjes F, Schmeller N, et al.

Improved detection of urothelial carcinoma in situ

with hexaminolevulinate fluorescence cystoscopy.

J Urol 2004;171:135.

12. Babjuk M, Soukup V, Petrik R, et al. 5-aminolaevu-

linic acid-induced fluorescence cystoscopy during

transurethral resection reduces the risk of recur-

rence in stage Ta/T1 bladder cancer. BJU Int 2005;

96:798.

13. Daniltchenko DI, Riedl CR, Sachs MD, et al. Long-

term benefit of 5-aminolevulinic acid fluorescence

assisted transurethral resection of superficial

bladder cancer: 5-year results of a prospective ran-

domized study. J Urol 2005;174:2129.

14. Kolozsy Z. Histopathological “self control” in tran-

surethral resection of bladder tumours. Br J Urol

1991;67:162.

15. Cheng L, Neumann RM, Weaver AL, et al. Grading

and staging of bladder carcinoma in transurethral

resection specimens. Correlation with 105 matched

cystectomy specimens. Am J Clin Pathol 2000;113:

275.

16. Brausi M, Collette L, Kurth K, et al. Variability in the

recurrence rate at first follow-up cystoscopy after

TUR in stage Ta T1 transitional cell carcinoma of

the bladder: a combined analysis of seven EORTC

studies. Eur Urol 2002;41:523.

17. Klan R, Loy V, Huland H. Residual tumor discovered

in routine second transurethral resection in patients

http://refhub.elsevier.com/S0094-0143(15)00002-6/sref1http://refhub.elsevier.com/S0094-0143(15)00002-6/sref1http://refhub.elsevier.com/S0094-0143(15)00002-6/sref2http://refhub.elsevier.com/S0094-0143(15)00002-6/sref2http://refhub.elsevier.com/S0094-0143(15)00002-6/sref2http://refhub.elsevier.com/S0094-0143(15)00002-6/sref3http://refhub.elsevier.com/S0094-0143(15)00002-6/sref3http://refhub.elsevier.com/S0094-0143(15)00002-6/sref4http://refhub.elsevier.com/S0094-0143(15)00002-6/sref4http://refhub.elsevier.com/S0094-0143(15)00002-6/sref4http://refhub.elsevier.com/S0094-0143(15)00002-6/sref4http://refhub.elsevier.com/S0094-0143(15)00002-6/sref4http://refhub.elsevier.com/S0094-0143(15)00002-6/sref4http://refhub.elsevier.com/S0094-0143(15)00002-6/sref5http://refhub.elsevier.com/S0094-0143(15)00002-6/sref5http://refhub.elsevier.com/S0094-0143(15)00002-6/sref5http://refhub.elsevier.com/S0094-0143(15)00002-6/sref5http://refhub.elsevier.com/S0094-0143(15)00002-6/sref6http://refhub.elsevier.com/S0094-0143(15)00002-6/sref6http://refhub.elsevier.com/S0094-0143(15)00002-6/sref6http://refhub.elsevier.com/S0094-0143(15)00002-6/sref7http://refhub.elsevier.com/S0094-0143(15)00002-6/sref7http://refhub.elsevier.com/S0094-0143(15)00002-6/sref7http://refhub.elsevier.com/S0094-0143(15)00002-6/sref8http://refhub.elsevier.com/S0094-0143(15)00002-6/sref8http://refhub.elsevier.com/S0094-0143(15)00002-6/sref8http://refhub.elsevier.com/S0094-0143(15)00002-6/sref8http://refhub.elsevier.com/S0094-0143(15)00002-6/sref9http://refhub.elsevier.com/S0094-0143(15)00002-6/sref9http://refhub.elsevier.com/S0094-0143(15)00002-6/sref9http://refhub.elsevier.com/S0094-0143(15)00002-6/sref9http://refhub.elsevier.com/S0094-0143(15)00002-6/sref9http://refhub.elsevier.com/S0094-0143(15)00002-6/sref9http://refhub.elsevier.com/S0094-0143(15)00002-6/sref10http://refhub.elsevier.com/S0094-0143(15)00002-6/sref10http://refhub.elsevier.com/S0094-0143(15)00002-6/sref10http://refhub.elsevier.com/S0094-0143(15)00002-6/sref10http://refhub.elsevier.com/S0094-0143(15)00002-6/sref11http://refhub.elsevier.com/S0094-0143(15)00002-6/sref11http://refhub.elsevier.com/S0094-0143(15)00002-6/sref11http://refhub.elsevier.com/S0094-0143(15)00002-6/sref11http://refhub.elsevier.com/S0094-0143(15)00002-6/sref12http://refhub.elsevier.com/S0094-0143(15)00002-6/sref12http://refhub.elsevier.com/S0094-0143(15)00002-6/sref12http://refhub.elsevier.com/S0094-0143(15)00002-6/sref12http://refhub.elsevier.com/S0094-0143(15)00002-6/sref12http://refhub.elsevier.com/S0094-0143(15)00002-6/sref13http://refhub.elsevier.com/S0094-0143(15)00002-6/sref13http://refhub.elsevier.com/S0094-0143(15)00002-6/sref13http://refhub.elsevier.com/S0094-0143(15)00002-6/sref13http://refhub.elsevier.com/S0094-0143(15)00002-6/sref13http://refhub.elsevier.com/S0094-0143(15)00002-6/sref14http://refhub.elsevier.com/S0094-0143(15)00002-6/sref14http://refhub.elsevier.com/S0094-0143(15)00002-6/sref14http://refhub.elsevier.com/S0094-0143(15)00002-6/sref15http://refhub.elsevier.com/S0094-0143(15)00002-6/sref15http://refhub.elsevier.com/S0094-0143(15)00002-6/sref15http://refhub.elsevier.com/S0094-0143(15)00002-6/sref15http://refhub.elsevier.com/S0094-0143(15)00002-6/sref15http://refhub.elsevier.com/S0094-0143(15)00002-6/sref16http://refhub.elsevier.com/S0094-0143(15)00002-6/sref16http://refhub.elsevier.com/S0094-0143(15)00002-6/sref16http://refhub.elsevier.com/S0094-0143(15)00002-6/sref16http://refhub.elsevier.com/S0094-0143(15)00002-6/sref16http://refhub.elsevier.com/S0094-0143(15)00002-6/sref17http://refhub.elsevier.com/S0094-0143(15)00002-6/sref17

Zlatev et al156

with stage T1 transitional cell carcinoma of the

bladder. J Urol 1991;146:316.

18. Mark JR, Gelpi-Hammerschmidt F, Trabulsi EJ, et al.

Blue light cystoscopy for detection and treatment of

non-muscle invasive bladder cancer. Can J Urol

2012;19:6227.

19. Lapini A, Minervini A, Masala A, et al. A comparison

of hexaminolevulinate (Hexvix((R))) fluorescence

cystoscopy and white-light cystoscopy for detection

of bladder cancer: results of the HeRo observational

study. Surg Endosc 2012;26:3634.

20. Rink M, Babjuk M, Catto JW, et al. Hexyl

aminolevulinate-guided fluorescence cystoscopy in

the diagnosis and follow-up of patients with non-

muscle-invasive bladder cancer: a critical review of

the current literature. Eur Urol 2013;64:624.

21. Lerner SP, Liu H, Wu MF, et al. Fluorescence and

white light cystoscopy for detection of carcinoma

in situ of the urinary bladder. Urol Oncol 2012;30:

285.

22. Shen P, Yang J, Wei W, et al. Effects of fluorescent

light-guided transurethral resection on non-muscle-

invasive bladder cancer: a systematic review and

meta-analysis. BJU Int 2012;110:E209.

23. Kausch I, Sommerauer M, Montorsi F, et al. Photody-

namic diagnosis in non-muscle-invasive bladder

cancer: a systematic review and cumulative analysis

of prospective studies. Eur Urol 2010;57:595.

24. Burger M, Grossman HB, Droller M, et al. Photody-

namic diagnosis of non-muscle-invasive bladder

cancer with hexaminolevulinate cystoscopy: a

meta-analysis of detection and recurrence based

on raw data. Eur Urol 2013;64:846.

25. Schumacher MC, Holmang S, Davidsson T, et al.

Transurethral resection of non-muscle-invasive

bladder transitional cell cancers with or without 5-

aminolevulinic Acid under visible and fluorescent

light: results of a prospective, randomised, multi-

centre study. Eur Urol 2010;57:293.

26. Bryan RT, Shah ZH, Collins SI, et al. Narrow-band

imaging flexible cystoscopy: a new user’s experi-

ence. J Endourol 2010;24:1339.

27. Herr H, Donat M, Dalbagni G, et al. Narrow-band im-

aging cystoscopy to evaluate bladder tumours–indi-

vidual surgeon variability. BJU Int 2010;106:53.

28. Zheng C, Lv Y, Zhong Q, et al. Narrow band imaging

diagnosis of bladder cancer: systematic review and

meta-analysis. BJU Int 2012;110:E680.

29. Herr HW, Donat SM. A comparison of white-light

cystoscopy and narrow-band imaging cystoscopy

to detect bladder tumour recurrences. BJU Int

2008;102:1111.

30. Geavlete B, Multescu R, Georgescu D, et al. Narrow

band imaging cystoscopy and bipolar plasma vapor-

ization for large nonmuscle-invasive bladder tumors–

results of a prospective, randomized comparison to

the standard approach. Urology 2012;79:846.

31. Tatsugami K, Kuroiwa K, Kamoto T, et al. Evaluation

of narrow-band imaging as a complementary

method for the detection of bladder cancer.

J Endourol 1807;24:2010.

32. Herr HW. Randomized trial of narrow-band versus

white-light cystoscopy for restaging (second-look)

transurethral resection of bladder tumors. Eur Urol

2015;67:605–8.

33. Naito S, van Rees Vellinga S, de la Rosette J. Global

randomized narrow band imaging versus white light

study in nonmuscle invasive bladder cancer: acces-

sion to the first milestone-enrollment of 600 patients.

J Endourol 2013;27:1.

34. Sonn GA, Jones SN, Tarin TV, et al. Optical biopsy of

human bladder neoplasia with in vivo confocal laser

endomicroscopy. J Urol 2009;182:1299.

35. Adams W, Wu K, Liu JJ, et al. Comparison of 2.6-

and 1.4-mm imaging probes for confocal laser en-

domicroscopy of the urinary tract. J Endourol

2011;25:917.

36. Wallace MB, Meining A, Canto MI, et al. The safety

of intravenous fluorescein for confocal laser endomi-

croscopy in the gastrointestinal tract. Aliment Phar-

macol Ther 2010;31:548.

37. Sonn GA, Mach KE, Jensen K, et al. Fibered

confocal microscopy of bladder tumors: an ex vivo

study. J Endourol 2009;23:197.

38. Wu K, Liu JJ, Adams W, et al. Dynamic real-time mi-

croscopy of the urinary tract using confocal laser en-

domicroscopy. Urology 2011;78:225.

39. Chang TC, Liu JJ, Hsiao ST, et al. Interobserver

agreement of confocal laser endomicroscopy for

bladder cancer. J Endourol 2013;27:598.

40. Manyak MJ, Gladkova ND, Makari JH, et al. Evalua-

tion of superficial bladder transitional-cell carcinoma

by optical coherence tomography. J Endourol 2005;

19:570.

41. Zagaynova EV, Streltsova OS, Gladkova ND, et al.

In vivo optical coherence tomography feasibility for

bladder disease. J Urol 2002;167:1492.

42. Sergeev A, Gelikonov V, Gelikonov G, et al. In vivo

endoscopic OCT imaging of precancer and cancer

states of human mucosa. Opt Express 1997;1:432.

43. Goh AC, Tresser NJ, Shen SS, et al. Optical coher-

ence tomography as an adjunct to white light

cystoscopy for intravesical real-time imaging and

staging of bladder cancer. Urology 2008;72:133.

44. HermesB, Spoler F, NaamiA, et al. Visualization of the

basement membrane zone of the bladder by optical

coherence tomography: feasibility of noninvasive

evaluation of tumor invasion. Urology 2008;72:677.

45. Karl A, Stepp H, Willmann E, et al. Optical coher-

ence tomography for bladder cancer – ready as a

surrogate for optical biopsy? Results of a prospec-

tive mono-centre study. Eur J Med Res 2010;15:131.

46. Ren H, Waltzer WC, Bhalla R, et al. Diagnosis of

bladder cancer with microelectromechanical

http://refhub.elsevier.com/S0094-0143(15)00002-6/sref17http://refhub.elsevier.com/S0094-0143(15)00002-6/sref17http://refhub.elsevier.com/S0094-0143(15)00002-6/sref18http://refhub.elsevier.com/S0094-0143(15)00002-6/sref18http://refhub.elsevier.com/S0094-0143(15)00002-6/sref18http://refhub.elsevier.com/S0094-0143(15)00002-6/sref18http://refhub.elsevier.com/S0094-0143(15)00002-6/sref19http://refhub.elsevier.com/S0094-0143(15)00002-6/sref19http://refhub.elsevier.com/S0094-0143(15)00002-6/sref19http://refhub.elsevier.com/S0094-0143(15)00002-6/sref19http://refhub.elsevier.com/S0094-0143(15)00002-6/sref19http://refhub.elsevier.com/S0094-0143(15)00002-6/sref20http://refhub.elsevier.com/S0094-0143(15)00002-6/sref20http://refhub.elsevier.com/S0094-0143(15)00002-6/sref20http://refhub.elsevier.com/S0094-0143(15)00002-6/sref20http://refhub.elsevier.com/S0094-0143(15)00002-6/sref20http://refhub.elsevier.com/S0094-0143(15)00002-6/sref21http://refhub.elsevier.com/S0094-0143(15)00002-6/sref21http://refhub.elsevier.com/S0094-0143(15)00002-6/sref21http://refhub.elsevier.com/S0094-0143(15)00002-6/sref21http://refhub.elsevier.com/S0094-0143(15)00002-6/sref22http://refhub.elsevier.com/S0094-0143(15)00002-6/sref22http://refhub.elsevier.com/S0094-0143(15)00002-6/sref22http://refhub.elsevier.com/S0094-0143(15)00002-6/sref22http://refhub.elsevier.com/S0094-0143(15)00002-6/sref23http://refhub.elsevier.com/S0094-0143(15)00002-6/sref23http://refhub.elsevier.com/S0094-0143(15)00002-6/sref23http://refhub.elsevier.com/S0094-0143(15)00002-6/sref23http://refhub.elsevier.com/S0094-0143(15)00002-6/sref24http://refhub.elsevier.com/S0094-0143(15)00002-6/sref24http://refhub.elsevier.com/S0094-0143(15)00002-6/sref24http://refhub.elsevier.com/S0094-0143(15)00002-6/sref24http://refhub.elsevier.com/S0094-0143(15)00002-6/sref24http://refhub.elsevier.com/S0094-0143(15)00002-6/sref25http://refhub.elsevier.com/S0094-0143(15)00002-6/sref25http://refhub.elsevier.com/S0094-0143(15)00002-6/sref25http://refhub.elsevier.com/S0094-0143(15)00002-6/sref25http://refhub.elsevier.com/S0094-0143(15)00002-6/sref25http://refhub.elsevier.com/S0094-0143(15)00002-6/sref25http://refhub.elsevier.com/S0094-0143(15)00002-6/sref26http://refhub.elsevier.com/S0094-0143(15)00002-6/sref26http://refhub.elsevier.com/S0094-0143(15)00002-6/sref26http://refhub.elsevier.com/S0094-0143(15)00002-6/sref27http://refhub.elsevier.com/S0094-0143(15)00002-6/sref27http://refhub.elsevier.com/S0094-0143(15)00002-6/sref27http://refhub.elsevier.com/S0094-0143(15)00002-6/sref28http://refhub.elsevier.com/S0094-0143(15)00002-6/sref28http://refhub.elsevier.com/S0094-0143(15)00002-6/sref28http://refhub.elsevier.com/S0094-0143(15)00002-6/sref29http://refhub.elsevier.com/S0094-0143(15)00002-6/sref29http://refhub.elsevier.com/S0094-0143(15)00002-6/sref29http://refhub.elsevier.com/S0094-0143(15)00002-6/sref29http://refhub.elsevier.com/S0094-0143(15)00002-6/sref30http://refhub.elsevier.com/S0094-0143(15)00002-6/sref30http://refhub.elsevier.com/S0094-0143(15)00002-6/sref30http://refhub.elsevier.com/S0094-0143(15)00002-6/sref30http://refhub.elsevier.com/S0094-0143(15)00002-6/sref30http://refhub.elsevier.com/S0094-0143(15)00002-6/sref31http://refhub.elsevier.com/S0094-0143(15)00002-6/sref31http://refhub.elsevier.com/S0094-0143(15)00002-6/sref31http://refhub.elsevier.com/S0094-0143(15)00002-6/sref31http://refhub.elsevier.com/S0094-0143(15)00002-6/sref32http://refhub.elsevier.com/S0094-0143(15)00002-6/sref32http://refhub.elsevier.com/S0094-0143(15)00002-6/sref32http://refhub.elsevier.com/S0094-0143(15)00002-6/sref32http://refhub.elsevier.com/S0094-0143(15)00002-6/sref33http://refhub.elsevier.com/S0094-0143(15)00002-6/sref33http://refhub.elsevier.com/S0094-0143(15)00002-6/sref33http://refhub.elsevier.com/S0094-0143(15)00002-6/sref33http://refhub.elsevier.com/S0094-0143(15)00002-6/sref33http://refhub.elsevier.com/S0094-0143(15)00002-6/sref34http://refhub.elsevier.com/S0094-0143(15)00002-6/sref34http://refhub.elsevier.com/S0094-0143(15)00002-6/sref34http://refhub.elsevier.com/S0094-0143(15)00002-6/sref35http://refhub.elsevier.com/S0094-0143(15)00002-6/sref35http://refhub.elsevier.com/S0094-0143(15)00002-6/sref35http://refhub.elsevier.com/S0094-0143(15)00002-6/sref35http://refhub.elsevier.com/S0094-0143(15)00002-6/sref36http://refhub.elsevier.com/S0094-0143(15)00002-6/sref36http://refhub.elsevier.com/S0094-0143(15)00002-6/sref36http://refhub.elsevier.com/S0094-0143(15)00002-6/sref36http://refhub.elsevier.com/S0094-0143(15)00002-6/sref37http://refhub.elsevier.com/S0094-0143(15)00002-6/sref37http://refhub.elsevier.com/S0094-0143(15)00002-6/sref37http://refhub.elsevier.com/S0094-0143(15)00002-6/sref38http://refhub.elsevier.com/S0094-0143(15)00002-6/sref38http://refhub.elsevier.com/S0094-0143(15)00002-6/sref38http://refhub.elsevier.com/S0094-0143(15)00002-6/sref39http://refhub.elsevier.com/S0094-0143(15)00002-6/sref39http://refhub.elsevier.com/S0094-0143(15)00002-6/sref39http://refhub.elsevier.com/S0094-0143(15)00002-6/sref40http://refhub.elsevier.com/S0094-0143(15)00002-6/sref40http://refhub.elsevier.com/S0094-0143(15)00002-6/sref40http://refhub.elsevier.com/S0094-0143(15)00002-6/sref40http://refhub.elsevier.com/S0094-0143(15)00002-6/sref41http://refhub.elsevier.com/S0094-0143(15)00002-6/sref41http://refhub.elsevier.com/S0094-0143(15)00002-6/sref41http://refhub.elsevier.com/S0094-0143(15)00002-6/sref42http://refhub.elsevier.com/S0094-0143(15)00002-6/sref42http://refhub.elsevier.com/S0094-0143(15)00002-6/sref42http://refhub.elsevier.com/S0094-0143(15)00002-6/sref43http://refhub.elsevier.com/S0094-0143(15)00002-6/sref43http://refhub.elsevier.com/S0094-0143(15)00002-6/sref43http://refhub.elsevier.com/S0094-0143(15)00002-6/sref43http://refhub.elsevier.com/S0094-0143(15)00002-6/sref44http://refhub.elsevier.com/S0094-0143(15)00002-6/sref44http://refhub.elsevier.com/S0094-0143(15)00002-6/sref44http://refhub.elsevier.com/S0094-0143(15)00002-6/sref44http://refhub.elsevier.com/S0094-0143(15)00002-6/sref45http://refhub.elsevier.com/S0094-0143(15)00002-6/sref45http://refhub.elsevier.com/S0094-0143(15)00002-6/sref45http://refhub.elsevier.com/S0094-0143(15)00002-6/sref45http://refhub.elsevier.com/S0094-0143(15)00002-6/sref46http://refhub.elsevier.com/S0094-0143(15)00002-6/sref46

Optical Imaging of High-Grade Bladder Cancer 157

systems-based cystoscopic optical coherence to-

mography. Urology 2009;74:1351.

47. Sengottayan VK, Vasudeva P, Dalela D. Intravesical

real-time imaging and staging of bladder cancer:

use of optical coherence tomography. Indian J Urol

2008;24:592.

48. Lingley-Papadopoulos CA, Loew MH, Manyak MJ,

et al. Computer recognition of cancer in the urinary

bladder using optical coherence tomography and

texture analysis. J Biomed Opt 2008;13:024003.

49. Bus MT, Muller BG, de Bruin DM, et al. Volumetric

in vivo visualization of upper urinary tract tumors us-

ing optical coherence tomography: a pilot study.

J Urol 2013;190:2236.

50. Lopez A, Liao JC. Emerging endoscopic imaging

technologies for bladder cancer detection. Curr

Urol Rep 2014;15:406.

51. Bonnal JL, Rock A Jr, Gagnat A, et al. Confocal laser

endomicroscopy of bladder tumors associated with

photodynamic diagnosis: an ex vivo pilot study.

Urology 2012;80:1162.e1.

52. Schmidbauer J, Remzi M, Klatte T, et al. Fluores-

cence cystoscopy with high-resolution optical

coherence tomography imaging as an adjunct re-

duces false-positive findings in the diagnosis of uro-

thelial carcinoma of the bladder. Eur Urol 2009;56:

914.

53. Gladkova N, Kiseleva E, Streltsova O, et al. Com-

bined use of fluorescence cystoscopy and cross-

polarization OCT for diagnosis of bladder cancer

and correlation with immunohistochemical markers.

J Biophotonics 2013;6:687.

54. Rao AR, Hanchanale V, Javle P, et al. Spectroscopic

view of life and work of the Nobel Laureate Sir C.V.

Raman. J Endourol 2007;21:8.

55. Draga RO, Grimbergen MC, Vijverberg PL, et al.

In vivo bladder cancer diagnosis by high-volume

Raman spectroscopy. Anal Chem 2010;82:5993.

56. Crow P, Uff JS, Farmer JA, et al. The use of Raman

spectroscopy to identify and characterize transi-

tional cell carcinoma in vitro. BJU Int 2004;93:1232.

57. de Jong BW, Bakker Schut TC, Wolffenbuttel KP,

et al. Identification of bladder wall layers by Raman

spectroscopy. J Urol 2002;168:1771.

58. Vendrell M, Maiti KK, Dhaliwal K, et al. Surface-

enhanced Raman scattering in cancer detection

and imaging. Trends Biotechnol 2013;31:249.

59. Schafauer C, Ettori D, Roupret M, et al. Detection of

bladder urothelial carcinoma using in vivo noncon-

tact, ultraviolet excited autofluorescence measure-

ments converted into simple color coded images:

a feasibility study. J Urol 2013;190:271.

60. Zipfel WR, Williams RM, Webb WW. Nonlinear

magic: multiphoton microscopy in the biosciences.

Nat Biotechnol 2003;21:1369.

61. Jain M, Robinson BD, Scherr DS, et al. Multiphoton

microscopy in the evaluation of human bladder bi-

opsies. Arch Pathol Lab Med 2012;136:517.

62. Rivera DR, Brown CM, Ouzounov DG, et al.

Compact and flexible raster scanning multiphoton

endoscope capable of imaging unstained tissue.

Proc Natl Acad Sci U S A 2011;108:17598.

63. Tewari AK, Shevchuk MM, Sterling J, et al. Multi-

photon microscopy for structure identification in hu-

man prostate and periprostatic tissue: implications

in prostate cancer surgery. BJU Int 2011;108:1421.

64. Seibel EJ, Brentnall TA, Dominitz JA. New endo-

scopic and cytologic tools for cancer surveillance

in the digestive tract. Gastrointest Endosc Clin N

Am 2009;19:299.

65. Seibel EJ, Brown CM, Dominitz JA, et al. Scanning

single fiber endoscopy: a new platform technology

for integrated laser imaging, diagnosis, and future

therapies. Gastrointest Endosc Clin N Am 2008;18:

467.

66. Yoon WJ, Park S, Reinhall PG, et al. Development of

an Automated Steering Mechanism for Bladder Uro-

thelium Surveillance. J Med Device 2009;3:11004.

67. Soper TD, Porter MP, Seibel EJ. Surface mosaics of

the bladder reconstructed from endoscopic video

for automated surveillance. IEEE Trans Biomed

Eng 2012;59:1670.

68. Greco F, Cadeddu JA, Gill IS, et al. Current perspec-

tives in the use of molecular imaging to target surgi-

cal treatments for genitourinary cancers. Eur Urol

2014;65:947.

69. van Dam GM, Themelis G, Crane LM, et al. Intrao-

perative tumor-specific fluorescence imaging in

ovarian cancer by folate receptor-alpha targeting:

first in-human results. Nat Med 2011;17:1315.

70. Nguyen QT, Tsien RY. Fluorescence-guided surgery

with live molecular navigation–a new cutting edge.

Nat Rev Cancer 2013;13:653.

71. Pan Y, Volkmer JP, Mach KE, et al. Endoscopic mo-

lecular imaging of human bladder cancer using a

CD47 antibody. Sci Transl Med 2014;6:260ra148.

72. ChanKS, Espinosa I, ChaoM, et al. Identification,mo-

lecular characterization, clinical prognosis, and ther-

apeutic targeting of human bladder tumor-initiating

cells. Proc Natl Acad Sci U S A 2009;106:14016.

73. Willingham SB, Volkmer JP, Gentles AJ, et al. The

CD47-signal regulatory protein alpha (SIRPa) inter-

action is a therapeutic target for human solid tumors.

Proc Natl Acad Sci U S A 2012;109:6662.

http://refhub.elsevier.com/S0094-0143(15)00002-6/sref46http://refhub.elsevier.com/S0094-0143(15)00002-6/sref46http://refhub.elsevier.com/S0094-0143(15)00002-6/sref47http://refhub.elsevier.com/S0094-0143(15)00002-6/sref47http://refhub.elsevier.com/S0094-0143(15)00002-6/sref47http://refhub.elsevier.com/S0094-0143(15)00002-6/sref47http://refhub.elsevier.com/S0094-0143(15)00002-6/sref48http://refhub.elsevier.com/S0094-0143(15)00002-6/sref48http://refhub.elsevier.com/S0094-0143(15)00002-6/sref48http://refhub.elsevier.com/S0094-0143(15)00002-6/sref48http://refhub.elsevier.com/S0094-0143(15)00002-6/sref49http://refhub.elsevier.com/S0094-0143(15)00002-6/sref49http://refhub.elsevier.com/S0094-0143(15)00002-6/sref49http://refhub.elsevier.com/S0094-0143(15)00002-6/sref49http://refhub.elsevier.com/S0094-0143(15)00002-6/sref50http://refhub.elsevier.com/S0094-0143(15)00002-6/sref50http://refhub.elsevier.com/S0094-0143(15)00002-6/sref50http://refhub.elsevier.com/S0094-0143(15)00002-6/sref51http://refhub.elsevier.com/S0094-0143(15)00002-6/sref51http://refhub.elsevier.com/S0094-0143(15)00002-6/sref51http://refhub.elsevier.com/S0094-0143(15)00002-6/sref51http://refhub.elsevier.com/S0094-0143(15)00002-6/sref52http://refhub.elsevier.com/S0094-0143(15)00002-6/sref52http://refhub.elsevier.com/S0094-0143(15)00002-6/sref52http://refhub.elsevier.com/S0094-0143(15)00002-6/sref52http://refhub.elsevier.com/S0094-0143(15)00002-6/sref52http://refhub.elsevier.com/S0094-0143(15)00002-6/sref52http://refhub.elsevier.com/S0094-0143(15)00002-6/sref53http://refhub.elsevier.com/S0094-0143(15)00002-6/sref53http://refhub.elsevier.com/S0094-0143(15)00002-6/sref53http://refhub.elsevier.com/S0094-0143(15)00002-6/sref53http://refhub.elsevier.com/S0094-0143(15)00002-6/sref53http://refhub.elsevier.com/S0094-0143(15)00002-6/sref54http://refhub.elsevier.com/S0094-0143(15)00002-6/sref54http://refhub.elsevier.com/S0094-0143(15)00002-6/sref54http://refhub.elsevier.com/S0094-0143(15)00002-6/sref55http://refhub.elsevier.com/S0094-0143(15)00002-6/sref55http://refhub.elsevier.com/S0094-0143(15)00002-6/sref55http://refhub.elsevier.com/S0094-0143(15)00002-6/sref56http://refhub.elsevier.com/S0094-0143(15)00002-6/sref56http://refhub.elsevier.com/S0094-0143(15)00002-6/sref56http://refhub.elsevier.com/S0094-0143(15)00002-6/sref57http://refhub.elsevier.com/S0094-0143(15)00002-6/sref57http://refhub.elsevier.com/S0094-0143(15)00002-6/sref57http://refhub.elsevier.com/S0094-0143(15)00002-6/sref58http://refhub.elsevier.com/S0094-0143(15)00002-6/sref58http://refhub.elsevier.com/S0094-0143(15)00002-6/sref58http://refhub.elsevier.com/S0094-0143(15)00002-6/sref59http://refhub.elsevier.com/S0094-0143(15)00002-6/sref59http://refhub.elsevier.com/S0094-0143(15)00002-6/sref59http://refhub.elsevier.com/S0094-0143(15)00002-6/sref59http://refhub.elsevier.com/S0094-0143(15)00002-6/sref59http://refhub.elsevier.com/S0094-0143(15)00002-6/sref60http://refhub.elsevier.com/S0094-0143(15)00002-6/sref60http://refhub.elsevier.com/S0094-0143(15)00002-6/sref60http://refhub.elsevier.com/S0094-0143(15)00002-6/sref61http://refhub.elsevier.com/S0094-0143(15)00002-6/sref61http://refhub.elsevier.com/S0094-0143(15)00002-6/sref61http://refhub.elsevier.com/S0094-0143(15)00002-6/sref62http://refhub.elsevier.com/S0094-0143(15)00002-6/sref62http://refhub.elsevier.com/S0094-0143(15)00002-6/sref62http://refhub.elsevier.com/S0094-0143(15)00002-6/sref62http://refhub.elsevier.com/S0094-0143(15)00002-6/sref63http://refhub.elsevier.com/S0094-0143(15)00002-6/sref63http://refhub.elsevier.com/S0094-0143(15)00002-6/sref63http://refhub.elsevier.com/S0094-0143(15)00002-6/sref63http://refhub.elsevier.com/S0094-0143(15)00002-6/sref64http://refhub.elsevier.com/S0094-0143(15)00002-6/sref64http://refhub.elsevier.com/S0094-0143(15)00002-6/sref64http://refhub.elsevier.com/S0094-0143(15)00002-6/sref64http://refhub.elsevier.com/S0094-0143(15)00002-6/sref65http://refhub.elsevier.com/S0094-0143(15)00002-6/sref65http://refhub.elsevier.com/S0094-0143(15)00002-6/sref65http://refhub.elsevier.com/S0094-0143(15)00002-6/sref65http://refhub.elsevier.com/S0094-0143(15)00002-6/sref65http://refhub.elsevier.com/S0094-0143(15)00002-6/sref66http://refhub.elsevier.com/S0094-0143(15)00002-6/sref66http://refhub.elsevier.com/S0094-0143(15)00002-6/sref66http://refhub.elsevier.com/S0094-0143(15)00002-6/sref67http://refhub.elsevier.com/S0094-0143(15)00002-6/sref67http://refhub.elsevier.com/S0094-0143(15)00002-6/sref67http://refhub.elsevier.com/S0094-0143(15)00002-6/sref67http://refhub.elsevier.com/S0094-0143(15)00002-6/sref68http://refhub.elsevier.com/S0094-0143(15)00002-6/sref68http://refhub.elsevier.com/S0094-0143(15)00002-6/sref68http://refhub.elsevier.com/S0094-0143(15)00002-6/sref68http://refhub.elsevier.com/S0094-0143(15)00002-6/sref69http://refhub.elsevier.com/S0094-0143(15)00002-6/sref69http://refhub.elsevier.com/S0094-0143(15)00002-6/sref69http://refhub.elsevier.com/S0094-0143(15)00002-6/sref69http://refhub.elsevier.com/S0094-0143(15)00002-6/sref70http://refhub.elsevier.com/S0094-0143(15)00002-6/sref70http://refhub.elsevier.com/S0094-0143(15)00002-6/sref70http://refhub.elsevier.com/S0094-0143(15)00002-6/sref71http://refhub.elsevier.com/S0094-0143(15)00002-6/sref71http://refhub.elsevier.com/S0094-0143(15)00002-6/sref71http://refhub.elsevier.com/S0094-0143(15)00002-6/sref72http://refhub.elsevier.com/S0094-0143(15)00002-6/sref72http://refhub.elsevier.com/S0094-0143(15)00002-6/sref72http://refhub.elsevier.com/S0094-0143(15)00002-6/sref72http://refhub.elsevier.com/S0094-0143(15)00002-6/sref73http://refhub.elsevier.com/S0094-0143(15)00002-6/sref73http://refhub.elsevier.com/S0094-0143(15)00002-6/sref73http://refhub.elsevier.com/S0094-0143(15)00002-6/sref73

Advances in Imaging Technologies in the Evaluation of High-Grade Bladder CancerKey pointsIntroductionPhotodynamic diagnosisNarrow band imagingConfocal laser endomicroscopyOptical coherence tomographyMultimodal imagingOther emerging technologiesMolecular imagingSummaryReferences