Abstract
BACKGROUND: Upper tract urothelial carcinoma (UTUC) poses diagnostic challenges due to its anatomical complexity and limited accessibility. METHODS: This prospective multicenter study (NCT05043662) evaluated the diagnostic performance of UroCAD, a novel non-invasive assay based on chromosomal copy number variation (CNV) analysis, in 244 patients with suspected UTUC or benign upper urinary tract conditions. RESULTS: Urine samples were analyzed for arm-level chromosomal aberrations (|Z-score|≥ 3.21), with histopathology as the reference standard. UroCAD demonstrated excellent diagnostic accuracy: sensitivity 91.0%, specificity 97.0%, and overall accuracy 93.4%. Performance was consistent across tumor locations (renal pelvis: 96.8%, ureter: 86.4%) and grades (high-grade: 93.5%, low-grade: 76.2%). Compared to urine cytology, UroCAD showed significantly higher sensitivity (91.2% vs. 52.9%, P < 0.001). CNV profiling revealed grade-associated patterns, with high-grade tumors frequently exhibiting amplifications on 1q and 8q. The extent (MaxZ) and number (CountZ) of chromosomal alterations correlated positively with tumor grade, supporting UroCAD's potential utility in molecular grading. CONCLUSIONS AND CLINICAL IMPLICATIONS: The UroCAD test demonstrates robust diagnostic performance for UTUC detection with high specificity and high sensitivity. The consistent performance across various clinical scenarios and the identification of specific chromosomal alteration patterns support its potential as a valuable clinical tool for both initial diagnosis and treatment monitoring. These findings warrant larger-scale validation studies to confirm its utility in routine clinical practice.