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Electromagnetic Biology and Medicine, 26: 119–134, 2007Copyright © Informa HealthcareISSN 1536-8378 printDOI: 10.1080/15368370701380850

Diagnosis of Bladder Cancer at 465MHz

G. GERVINO1, E. AUTINO2, E. KOLOMOETS3,G. LEUCCI4, AND M. BALMA2

1Dipartimento di Fisica Sperimentale, Università di Torino, Torino, Italy2Galileo Avionica, Torino, Italy3Centro Prevenzione Oncologica, Torino, Italy4Azienda Ospedaliera, “Vito Fazzi”, Lecce, Italy

Current methods for bladder cancer investigation involve cystoscopy, ultrasoundscanning, and contrast urography, with additional information provided by cytology.These methods, although having a high detection rate, are expensive, time-consuming, invasive, and uncomfortable. Therefore, there is a need for aninexpensive, non invasive, quick, and simple investigation with a high sensitivityand specificity. In this study we evaluate the use of an in vivo electromagnetic(EM) interaction as a non invasive method for detecting cancer. A clinical trialwas designed and completed. The main trial target was the feasibility assessmentof the novel method by comparing its results with standard cystoscopy. A physicaldiscussion of the EM interaction with bladder cancer tissue is presented. Onehundred and fourteen patients referred for cystoscopy by microscopic or grosshaematuria, irritative voiding symptoms, or suspected bladder tumor at ultrasoundwere first submitted to EM scan by means of the TRIMprob™ system. Cystoscopywas performed on each patient after the TRIMprob™ examination. Comparisonbetween EM and cystoscopy results provides a high level of agreement (Cohen’sK= 0�77, p < 0�001). The TRIMprob™ performance in malignant cancer cellsdetection suggests that this in vivo EM waves method is also worth investigating forroutine diagnostic procedures.

Keywords Bladder cancer; Electromagnetic wave propagation; Macromolecularresonance; Medical physics; TRIMprob.

1. Introduction

Bladder cancer is the fifth most common malignancy in Europe and the fourth inthe United States. It constitutes 7% of all malignancies in men and 4% in women(Parker et al., 1996). About 75% of patients with bladder cancer are men, and theillness strikes roughly twice as high in white men compared to black men (National

Address correspondence to G. Gervino, Dipartimento di Fisica Sperimentale, Universitàdi Torino, Via P. Giuria 1, 10125 Torino, Italy; E-mail: gervino@to.infn.it

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120 Gervino et al.

Cancer Institute, 1990). Risk rises steeply with age; over half of all deaths frombladder cancer occurs after age 70. Bladder cancer is strongly linked to cigarettesmoking and occupational and environmental exposure to chemicals (Slattery et al.,1988). Aromatic amines used in dry cleaning facilities and in the production ofdyes, rope, twine, paper, and apparel have been associated with increasing risk forbladder cancer (Viscoli et al., 1993). Other industrial exposures implicated as riskfactors in developing bladder cancer include combustion gases and soot from coal,chlorinated aliphatic hydrocarbons, and chlorination by-products in heated water(Anton-Culver et al., 1992). About 80% of bladder tumors are confined to thebladder mucosa, the so-called superficial tumors, and 20% invade the muscle layer.The management and prognosis of the two types of cancer are completely different:superficial tumors are fairly benign, and invasive tumors are highly malignant.The development of the disease is associated with the excretion of carcinogenicmetabolites in the urine. If the tumor is detected at the early stage, it can betreated with resection or chemotherapeutic agents, or with a combination of both.However, in 60% of the cases, another bladder tumor will appear (Cookson et al.,1997). Therefore, the patients need regular monitoring to avoid the recurrence ofthe disease. Cystoscopy is the conventional procedure for detection (E.A.U., 2005)and monitoring the bladder cancer (Raitanen et al., 2001). The clinician inserts aprobe into the patient’s bladder and moves it in order to observe on a monitor thesurface of the bladder cavity. It is required to distinguish the surface deformationsdue to tumors from the surface deformations due to the neighboring structures.Flexible instruments have reduced but not eliminated the discomfort of cystoscopyand the procedure is invasive and relatively expensive. Voided urine cytology is avaluable adjunct to cystoscopy because of its high specificity and sensitivity for high-grade disease (Ro et al., 1992), but its overall value in non invasive detection ofbladder cancer is limited by the fact that it is not sensitive for low-grade diseaseand its accuracy is highly dependent on the experience of the cytopathologist. Thus,great efforts have been done in the last decade to develop new tumor markers aswell as non invasive morphological methods for the detection of this neoplasms(Schroeder et al., 2004). In this article we report the first clinical results obtainedstudying the possibility to recognize the bladder cancer by a non invasive, quick,and inexpensive method based upon electromagnetic (EM) waves interactions withpathological tissues. When an EM radiating antenna is located near a body, themacroscopic averaged fields, inside and outside the body region, depend on theelectrical properties of its constituents, on its size, shape, and proximity to otherobjects. External measurements of the field at suitably chosen points can then beused to deduce the electrical properties of the body and to reveal aspects of itsinside structure. Such observations may involve the field components scattered fromthe body or transmitted into or through it and, by proper inverse mathematicalanalysis, the inner electrical properties of its constituents can be inferred. In thisarea the EM community has been involved in research aimed at the development ofimaging systems and apparatus (Guo, 1984; Caorsi, 1991) and the study of efficientinversion algorithms and numerical codes (Bolomey, 1991; Broquetas, 1991; Caorsi,1991; Ghodgaonkar, 1983; Guo, 1984; Jofre et al., 1990; Joachimowicz, 1991; Larsenand Jacobi, 1986; Pichot, 1985). Several elastic scattering spectroscopic methods,based on the in situ measurement of the light backscattered from tissues, havebeen investigated in the optical range for diagnostic in vivo applications (Bigio andMourant, 1997; Charvet, 2002). Other approaches, starting from the macroscopic

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Diagnosis of Bladder Cancer 121

measurement of reflectance, are expected to provide accurate information on thephysio-pathological state of the tissues (Bays, 1996). Increasing interest in medicalimaging is recently to be acknowledged at terahertz frequencies (Woodward, 2003).Studies in terahertz range have revealed a significant difference between in vivoskin cancer and healthy tissue (Fitzgerald et al., 2003): one of the likely contrastmechanism is the simple variation in water content (Pickwell et al., 2004). Up tonow, less efforts have been devoted to characterize the EM response (Adair, 2002)of diseased biological tissues when exposed to low levels EM radiation in the radio-frequency spectral region (0.4–1.5GHz). The reasons for such a lack of interest aremainly due to the fact that field wavelengths are too large to be used for imagingsmall anomalies and, even if protein and macromolecular aggregates could resonatein this spectral region, the scattering contents is considered almost useless becauseof the difficulty to correlate the pathological state with such a low resolution power.

In this article we propose a quite different approach, which is based on theobservation that an aggregate of bipolar elements, at their resonance, could modifyand deflect in some special way a probing EM field. Pathological tissue cellsare characterized by several forms of metabolic and biochemical atypias, whosepathogenesis membrane alterations concur to, both at sub cellular vescicles level andat cellular surface level (Alberts and Johnson, 2002). The surface cell is generallyrich of electrostatic charges that affect mutual attraction or repulsion: the tissuecells attract themselves and remain cohesive both for the presence of cementingsubstances of glycoproteic nature and for the action of ions neutralizing the surfacecharges and constituting a bridge between nearest neighboring cells. All cells showan electro-negative surface. In tumoral cells, the cellular surface electro negativityincreases, and this is not tackled by the calcium ions (Becker, 1975). In tumoralcells, the extra cellular calcium content is decreased and then is not able to promotenext to neighboring cellular adherence (Mostov, 2003). The proteins, moreover,are appointed to form and maintain the membrane double lipid layer, into whichthey are free to move with translations or rotations, depending on the lipid layerfluidity. This property is strongly altered in case of arising tumoral pathologies.Previous causes lead to inhibition loss due to contact, decrease in cellular adhesion,increase in cellular mobility, increase of bounded water (Dawkins et al., 1979).Therefore, a pathological state provokes new degrees of freedom related to theelectronic and ionic charges involved in the dynamics of cellular exchanges anda localized disease can be viewed as a biophysical anisotropy whose surroundingsare full of electrical charges out of their homeostatic order. The state of sucha charge distribution around the disease can act in a way similar to a passiveantenna that can couple and interact with an impinging low-level EM field (Balmaand Bresciani, 1991). The inner passive antenna model leads us to hypothesizethe diagnostic application of in vivo resonant mechanism, as recently observed inclinical trials on prostate cancer (Bellorofonte, 2005) and breast cancer (De Ciccoet al., 2006).

The existence of a resonance can then be used to enquire about the tissue stateby a measure of the EM interaction. Some phenomenological and methodologicalinsight in the use of low-energy EM field as diagnostic tool for bladder cancerdisease are reported and discussed.

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122 Gervino et al.

2. Materials and Methods

2.1. The TRIMprob™ System

Measures of EM interaction on the bladder were performed using the TRIMprob™

system (Galileo Avionica, Turin, Italy). This consists of a battery-operated detectionprobe, a receiver, and a computer controller (Fig. 1). The probe is about 30cmlong and can easily be held in one hand. It contains an Armstrong-like oscillatorand a small antenna, emitting a weak EM coherent signal with three frequencycomponents: 465, 930, and 1395MHz. The total radiated power is less than 100mW(Vedruccio, 2000). The penetration of the emitted EM wave depends upon itsfrequency and the dielectric properties of the target tissues. The 465MHz frequencyhas a plane wave penetration greater than 7cm, calculated for a typical bladderrelative permittivity of 19.5 with a loss tangent of 0.66 (De Cicco et al., 2006). Thebladder is radiated through the pubic region in the near field of the probe antenna.As pointed out by Kaiser (1983) and reported by Bellorofonte (2005), the proximitybetween the active oscillator and the passive biological antenna is manageablewith the model of coupled nonlinear oscillators (Fröhlich, 1968, 1988). The EMinteraction leads the coupled system in a synchronized configuration, correspondingto an eigenstate in which potential energy is minimized (Sakurai, 1967).

When the steady state is reached, the radiation pattern of the system undergoesa macroscopic change (Munk, 1997). The radiation pattern is a defined observablein the far field region only (Kong, 1986) then the receiver device should belocated about 1.5m away from the transmitting probe. The receiver acts there asa multi-frequency radiation pattern analyzer, displaying the signal for the threedifferent frequencies in real time (Fig. 2). When the probe is brought close tothe patient and an inner biological resonance is stimulated, the deformation ofthe EM pattern emitted by the probe is detectable by changes in one or morefrequency amplitudes. The EM behavior that differentiates a malignant neoplasmswith respect to a healthy tissue can be easily detected by a measure of interaction.

Figure 1. Complete set of devices belonging to TRIMprob™ system.

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Diagnosis of Bladder Cancer 123

Figure 2. Graphics of the three different frequencies (465, 930, 1395MHz) displayed bythe receiver. 1395MHz is used in prostate gland diagnosis.

Such an approach has been developed under the name of TRIMprob™, and the firstclinical trials have been devoted to prostate gland diagnosis (Bellorofonte, 2005,1395MHz plays a role in prostate pathologies). The measure of EM interaction is thequantitative evaluation of the degree of radiation pattern deformation connectedwith the biological resonance. The interaction measured values are representativeof the analyzer received power shown on a logarithmic scale and are expressed inarbitrary units (A.U.) within 0 and 255. The detected signal variation resulting fromthe interaction of the emitted field with bladder anomalies, constitutes the basis todiagnose the radiated organ.

2.2. Clinical Study Design

Patients to be submitted to cystoscopy were enclosed in the open label, blind,prospective study in the Urological Department of Vito Fazzi Hospital (Lecce,Italy). The objective of this investigation is to determine the potentiality of EMinteractions to diagnose the presence of bladder cancer in term of agreementwith the diagnosis obtained from cystoscopy gold standard. Inclusion criteriawere microscopic or gross haematuria and/or irritative voiding symptoms and/orsuspected bladder tumor at ultrasound.

Exclusion criteria ascribed patients with a pacemaker and/or any other activeimplantable device, patients with coexistent pelvic neoplasms, previous diagnosisof bladder cancer, previous diagnosis of prostate cancer. The study was approvedby the local Ethical Committee and the Italian Ministry of Health. Participatingpatients were asked to sign an informed consent. Each patient underwentTRIMprob™ and cystoscopy examinations, both completed within one week fromhis enrollment. A single investigator, blind to every diagnostic information obtainedwith cystoscopy, studied the patients with the EM examination, according to thefollowing method. The patients were instructed not to void the bladder in the 2hbefore the test, in order to have their bladder partly full. Patients were placed instanding position, with the receiver set at about 150cm from their back, roughly atthe same height of their bladder (Fig. 3). The active part of the probe, where theEM field comes from, was positioned at the patient’s pubic level. With the probepositioned there, the operator should then move the probe to find the point wherethe second spectral line (also shown as the b green histogram in Fig. 2) shows a

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124 Gervino et al.

Figure 3. Right distance and position between patient and receiver.

significant reduction. Since the partially full bladder is a dielectric structure whosecharacteristics correspond to a resonator of about 900MHz (Van Bladen, 1982), thereduction is symptomatic of the correct positioning of the probe that is targeting theorgan under test. The anatomical window for bladder is the portion of space alongthe pubic region within which the probe operator is able to find out the decrease ofthe 930MHz signal (b histogram in Fig. 2). After having assessed the extension ofthe anatomical window by searching the typical signal reduction at the frequencyof 930MHz, the response to the 465MHz frequency was measured. Well-definedmovements of the probe ensured that the probe radiating part maintained a goodcontact with the patient pubic zone, so to have a complete examination of thebladder through the anatomical window. The operator positioned himself to thepatient’s side, to avoid interferences between his body and the EM signal emittedby the antenna. For each patient, the probe was moved in at least three standardconventional positions, named median, left, and right projections on the anatomicalwindow (Fig. 4). All the amplitude values corresponding to the three bladderprojections were saved on the receiver controller. The suspect presence of bladdercancer was based on the 465MHz amplitude evaluation displayed in each of the 3acquired projections. Following the protocol rules, the examination was consideredpositive for cancer when it was possible to detect a reduction of the 465MHz band(the a red histogram in Fig. 2) below a threshold set at 20% of its free spaceamplitude in at least one saved projection. All patients were afterwards submittedto cystoscopy.

3. Results

In the period from February 2004 until June 2005, 149 patients of Vito FazziHospital were entered, 114 of whom were eligible to the study. In total, 92 menand 22 women, 18–88 years old (mean age = 68.5), underwent TRIMprob™ andcystoscopy examinations. The result of cystoscopy has been positive for 40 patients(mean age = 70.0 years, range 51–84 years) and negative for the remainders 74(mean age = 65.9 years, range 18–88 years). No adverse effects of the TRIMprob™

test were observed. The procedure was always performed easily, in a short time(around 2–5 min), and was well accepted by all patients.

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Diagnosis of Bladder Cancer 125

Figure 4. Bladder radiated through the pubic region in the standard conventionalmeasurement positions. A: median projection; B: left projection; C: right projection.

According to the protocol rules, patients with the 465MHz signal amplitudelevel measured below the threshold in at least one of the conventional positions havebeen considered positive to the EM interaction. The signal variations as measuredby the receiver of the system were recorded and stored in a PC file with the valuesexpressed in A.U. Using this criterion, the receiver operating characteristic (ROC)curve was developed for the signal amplitude, and a value of 0.906 (p < 0�0001,95% confidence interval: 0.839–0.972) for the area under ROC curve was obtained(Fig. 5).

The area may vary from 0.5, a value denoting the lack of diagnosticdiscrimination, to 1, denoting perfect discrimination (Whiting et al., 2004). p valuewas obtained from multiple discriminant logistic models to test whether estimatedROC area significantly differs from 0.5. Using a cutoff of 40 A.U., amongthe 40 patients with positive cystoscopy, TRIMprob™ found 35 positive patientsand 5 negative, whereas it found 67 negative patients and 7 positive out of74 patients with negative cystoscopy result. Simple descriptive statistics (mean,median, minimum, maximum, standard deviation) were computed for 465MHz fieldamplitude, separately for 8 groups: patients with positive and negative cystoscopy(CIST+ and CIST−), patients with positive and negative TRIMprob™ (TRIM+ andTRIM−), TRIMprob™ true positive and negative diagnosis (TP and TN), TRIMprob™

false positive and negative (FP and FN).The test of agreement Cohen’s K between TRIMprob™ and cystoscopy furnishes

a nice performance with K = 0�77. With respect to the cystoscopy, EM interactionrecognized therefore 35 true positive (30%) patients, 7 false positive (6%), 67 truenegative (58%), and 7 false negative (6%) patients, getting out 87.5% of sensitivity,90.5% of specificity, and 89.5% of accuracy values (see Table 1).

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126 Gervino et al.

Figure 5. TRIMprob™ ROC curve.

4. Discussion

The detection probe must be brought in contact to the epidermis and the diagnosisis based on the far field radiation pattern information read from the receiver.We assume that the EM field propagates in an unbounded complex medium,represented by the organ under test and its surrounding structures. If the wholehealthy tissue is considered as a neutral plasma (Kikuchi, 2001) then an early stagetumor forms an anomalous aggregate of charges whose distribution is similar to aspherical double layer of capacitor, with a charged nucleus (Kikuchi et al., 1996).Such a mesoscopic description lead us to analytically represent the pathology asa uniaxial plasma anisotropy (Alfas, 1985). With the term anisotropy we mean acharacteristic of a substance for which a physical observable, such as the index ofrefraction, varies its value with the direction in or along which the measurement ismade. Because of the uniaxial anisotropy, the permittivity assumes a dyadic natureand, by the plasma approximation, the dyadic permittivity ¯̄� can be written as:

¯̄� = ¯̄1t�t + z̄0z̄0�z�¯̄1t = ¯̄1− z̄0z̄0� (1)

Table 1Results of the test of agreement between TRIMprob™ and cystoscopy

Prevalence Sensitivity Specificity PPV NPV Accuracy

0.35% 87.5% 90.5% 83.3% 93.1% 89.5%

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Diagnosis of Bladder Cancer 127

where ¯̄1 and ¯̄1t are the unit dyadic and the dyadic in the transverse to thez-axis domain, respectively. The parameters �t and �z = �0

(1− �2

p

�2

)are equivalent

to those of an uniaxial cold plasma (Bittencourt, 2004) where �p is the relatedplasma frequency. The uniaxial medium can support for EM waves propagationboth H and E modes but, in contrast with isotropic media, E and H modes aregenerally propagated with different phase speeds. The H modes have the electricfield polarized perpendicular both to z-axis and to the wave vector k along which theequiphase surfaces advance: these waves are propagated as they were in an isotropicmedium with effective transversal permittivity �t. This behavior follows from thetransverse isotropy of the ¯̄� dyadic and from the ineffectiveness of the longitudinaldependence of E for transverse electric waves. The E modes own an electric fieldcomponent with respect to z direction but they display an anisotropic behavior(Felsen and Marcuvitz, 1977). The dependence of the wavenumber along z-axis kzon transversal kt for E modes is expressed by:

kEz =√k20�t

�0

−(k2t �t

�z

)

with kEz and kt that satisfy the dispersion relation:

(kEz

)2 + k2t �t

�z

= k20�t

�0

whereas for H modes, we have:

kHz =√k20�t

�0

− k2t

with the dispersion relation equals to:

k2 = k20�t

�0

and k0 = �√�0�0 the free space wavenumber, � the angular frequency, �0 and �0

the constitutive parameters in vacuum. For sake of simplicity, let us to set thetransversal permittivity �t = �0. According to the previous considerations, for theE modes two distinct solutions arise, depending on whether � = 1− (

�2p/�

2)is

positive or negative. One observe that E-mode plane waves propagate in all spacedirection when � > 0, but when � < 0 their group velocity vectors are confinedinside to a conical region, where �c = arctan

√���. Thus, plane wave propagation for� < 0 is confined to a well-defined angular domain in space. In other words, whilethe group velocity v̄g and k̄ are parallel for H modes, propagating as in vacuum,their directions differ for the E modes and give rise to forbidden propagation paths.Let the TRIMprob™ antenna oriented along the longitudinal z-axis, expressing thecurrent density as J

� = z̄0J� where z̄0 is the unit versor along z-axis. In the uniaxial

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128 Gervino et al.

medium that we are taken into account, the EM field can be derived from a scalarGreen’s function G

(r̄� r̄ ′

)in a spherical coordinate system �r� �� �:

�E�r̄� r̄ ′ = J �

j��

( × × z̄0

)G�r̄� r̄ ′ (2)

�E(r̄� r̄ ′) is the field observed at r due to vector point source excitations of electriccurrents at r’ and:

G′f

(r̄� r̄ ′

) = eik0N���r̄−r̄ ′ �

4�N���r̄ − r̄ ′� (3)

where � = �z/�t = 1− ��2 − �2p, N�� =

√cos2 �+ � sin2 �, with N�� denoting the

ray refractive index. Introducing in (1) the current density as hertzian electric dipole:

J�r̄ ′� t = Il��r̄ ′e−i�tz̄0

where I is the current amplitude and l is the antenna length, resulting fieldscomponents by solving (2) via (1) in spherical coordinates are:

Er =√�0

�0

Ik0l cos �eik0rN��

2�k0r2N 2��

(1+ i

k0rN��

)

E =√�0

�0

−iIk0l� sin �eik0rN��

4�k0r3N 3��

[1+

(1+ 2

�− 1�

cos2 �)(

i

k0rN��− 1

k20r2N 2��

)]

H� = −iIk0l� sin �eik0rN��

4�k0r3N 3��

(1+ i

k0rN��

)Hr = H� = E� = 0

while the radiated power density S is given by:

Sr = Re(E��H

∗�

) = √�0

�0

�2�Ik0l�2 sin2 �

�4�2r2N 5��� N real

Sr = 0 N imaginary

S� = S� = 0 N real or imaginary

Characteristic shapes of the radiation pattern function A�� = sin2 �/N 5�� areshown in the Figs. 6a and 6b.

The closed-form solution Er� E��H�� Sr highlight that when � > 0 the effect ofanisotropy is primarily to distort, but not to alter fundamentally, the equiphasesurfaces and the radiation patterns encountered in an isotropic environment. Thepropagation mechanism in this case may be regarded as undergoing a continuousdistortion in the transition from an isotropic to an anisotropic regime. This is whatit is observable when no resonance is present. In this case, the field level at thereceiver is ranging around an average amplitude of 111.4A.U. (see Table 2, this isthe average value computed for all the true negative patients, TN). Instead, when� < 0 novel and anomalous characteristics appear. First of all, N�� shows a zero

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Diagnosis of Bladder Cancer 129

Figure 6. Pattern function: (a) A�q = sin2 q/N 5�q, with � > 0 and (b) A�q = sin2 q/N 5�q,with � < 0.

on the cone �c = tan−1 1√��� on which all the field components have singularities

regardless to the value of r (we are considering only the far field region). Theanalysis of an oscillating point dipole has, moreover, shown that the fields do notpropagate in the forbidden region outside a cone whose axes is parallel to the axis of

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Table 2Descriptive statistics for the field level of 465MHz frequency

Amplitude level @ 465MHz (A.U.)

Group N Age (%) Median Std Dev Min Max

CIST+a 40 70.0 35�1 24�08 33.64 0 127CIST−b 74 65.9 64�9 102�62 33.4 2 156TRIM+c 42 66.7 36�8 13�6 11.9 0 39TRIM−d 72 66.7 63�2 110�9 19.9 54 156TPe 35 70.1 30�7 12�7 11.2 0 32FPf 7 69.5 6�1 18�4 14.8 2 39TNg 67 66.1 58�8 111�4 19.2 73 156FNh 5 69.6 4�4 103�8 29.8 54 127

aCistoscopy Positive Patients; bCistoscopy Negative Patients; cTRIMprob™ PositivePatients; dTRIMprob™ Negative Patients; eTrue Positive; fTRIMprob™ False Positive; gTrueNegative; hTRIMprob™ False Negative.

anisotropy and whose opening angle is determined by plasma density and incidentfrequency where � tan��� > tan��c. From the equation of S it is observed thatthe energy flows radially outward from the source, thereby confirming the physicalmechanism of energy transport along rays. Propagating rays exist only in the spaceregion wherein N�� > 0, and no energy is carried into the shadow region N�� =i�N���, where the fields are evanescent. This propagation mechanism explains thestrong signal decrease measured at the receiver antenna only in the case of malignant(resonant) pathologies. The field level at the receiver in this case has an averageamplitude of 12.7A.U. (see Table 2, this is the average value computed for all thetrue positive patients, TP). The forbidden propagation paths related to negativedielectric permittivity are a strong argument for which a physical resonance effectis required. When irradiated by an electromagnetic field, molecules like water andproteins aim at forming a line along the field polarization, to minimize the electricdipoles potential energy. From spectroscopic analysis, the rotational motion ofseveral biological macromolecules has its resonance between 100 and 1,000MHz(Edwards et al., 1984). When the resonance is excited on macromolecular structuregenerated by cancer electric anomalies, the structure can adopt a scattering behaviorthat looks like as a negative permittivity matter (Pendry and Smith, 2004; Veselago,1966), whose plasma model (Balmain, 2002) is quite similar to that here presented.

The oscillator module in the probe head generates a fundamental emission at465MHz and his related harmonics at 930MHz and 1,395MHz. As we describedduring the measure of interaction, the second harmonic is used to check if the probeis located on the anatomical window in front of the bladder. This kind of targetingprocedure was carried out previously, by means of preliminary experiments onphantoms with physiological solution bags simulating the bladder.

The interaction of the third harmonic with the tissues seems correlated withinflammatory anomalies of the organs under test, as the results in prostate trials maysuggest (Bellorofonte, 2005). However, to support such assertion, other and specificprotocols are required to statistically asses the diagnostic meaning of the harmonicemissions.

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Diagnosis of Bladder Cancer 131

From the physical point of view, we have also empirically observed that thepresence of harmonic emissions is necessary to obtain a synchronized coupling withthe tissues. In fact, we tried to measure the electromagnetic interaction by means ofdifferent probes with monochromatic 465MHz emission only, but no one was ableto react by indicating the cancer presence in diseased patients. On the contrary, inthe cases where additional non harmonic emission were independently radiated nearthe organ under test, the measure at 465MHz did not suffer from the presence ofsuch interfering signals.

On the basis of our experience, we believe that nonlinear dynamic is a necessaryrequirement for the stimulation of coherent excitations. In this perspective thesimultaneous radiation of fundamental and harmonics waves play an essential roleon the capability to excite biological resonances as theorized by Fröhlich (1988), andon the related scattering properties as here reported.

5. Conclusions

The aim of this research work is to evaluate the feasibility and accuracy of anew, non invasive diagnostic method based on EM oscillating fields. We compareour findings in the detection of bladder cancer with those of cystoscopy, the“gold standard” diagnostic procedure. The EM interaction on bladder tissue wasperformed using the TRIMprob™ system, the observed effects have been describedand discussed from physical and biological side.

In order to estimate the percent amount of EM oscillating field scatteredby the irradiated tissue and available to build up an interference pattern thatreveals the presence of a pathological state, we introduce for diagnostic purpose theconcept of measure of interaction. The measure of interaction represents how muchinformation about the tissue pathological situation would be possible to extractfrom the analysis of the interference pattern. When a bladder cancer is present,the amplitude reduction of 80–90% for 465MHz TRIMprob™ frequency is clearlyobserved in a space region enclosed in a cone of angle �C around the straight linejoining the transmitting point of the TRIMprob™ and the patient’s bladder. Weexplain the observed amplitude reduction putting forward the working hypothesisthat the irradiated tissue could resonate and then assume a negative value for thedielectric constant and the refracting index at this precise frequency. The resonancefrequency is highly selective of and closely linked to the chemical/pathological stateof the tissue. The assumption of a negative refracting index value by the irradiatedtissue allows a considerable fraction of the incident EM power to be backscatteredand the interference pattern encodes the clear signature of the pathological state.There are experimental evidences that other pathologies could be detected anddistinguished by the analysis of the measure of interaction (D’Urso et al., 2004). Ourfindings show that TRIMprob™ is an easy, fast, and inexpensive procedure, with anexcellent degree of acceptance by the patients.

Descriptive statistics for the field level of 465MHz frequency are shown inTable 2. Compared to normal bladder level (102.6A.U., average for negativecystoscopy patients, CIST-), cancer lesion showed a lower level (24.1A.U., averagefor positive cystoscopy patients, CIST+) that leads to easily differentiate healthyand cancerous tissues. Looking at the data shown in Table 2 (% column), thereis a very good agreement between the results of TRIMprob™ and cystoscopy, theTRIMprob™ false positive FP (6.1%), and false negative FN (4.4%) are still a

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matter of investigations. The relative small difference between the average amplitudeof TRIM+ and FP and also of TRIM− and FN suggests the need for widerstatistics. Looking at AUC-ROC results, the estimate for the comparison betweenmalignant and normal tissues was close to 0.91, a figure denoting a very high qualityof discrimination. Sensitivity and specificity were computed using a threshold of40A.U. for the classification as negative (above the threshold) or positive (belowthe threshold). The results, summarized in Table 1 showed a sensitivity of 87.5%corresponding to a specificity of 90.5%. By comparison, urine cytology is universallyaccepted as the non invasive test for the diagnosis and surveillance of bladdercancer (Kryger and Messing, 1996). Although useful in clinical practice, routinevoided urinary cytology has an overall sensitivity of less than 50%, which varieswith tumor grade, tumor stage, urine collection, and processing methods used (Roet al., 1992). Furthermore, inflammatory lesions, intravesical therapy, or radiation-associated changes can lead to false-positive urine cytology results (Loh et al., 1996).

Studies in Schroeder et al. (2004) compared the accuracy of some of the newurinary markers, such as HA-HAase (hyaluronic acid-hyaluronidase), BTA-Stat(qualitative detection of human complement H factor), Hemastix (haematuriadetection), UBC rapid and cytology and found that sensitivity was respectively, 88.1,52.5, 50.8, 35.6, and 70.6%, while specificity was respectively, 81, 76.7, 78.2, 75, and81%. PPV was, respectively, 77.6, 63.3, 63.8, 52.5, and 68.6%. NPV was respectively90.1, 67.8, 67.8, 60, and 82.5%. HA-HAase and cytology performed better than theothers. Nevertheless, an excellent non invasive detection method should approach a95% of overall accuracy and this goal seemed far from being reached for bladdercancer, considering the results of Schroeder et al. (2004)—accuracy of HA-HAase84.1% and cytology 77.2%—and those of Sözen et al. (2003)—accuracy of NMP2281% and cytology 60%.

The present pilot study showed for the TRIMprob™ bladder approach anoverall accuracy of 89.5%, a PPV of 83.3%, and a NPV of 93.1%. The clinicalrelevance of these findings, if confirmed or improved in a larger group of patients,is clear. The EM detection method could be used to control asymptomaticpatients at high risk of bladder cancer, such as smokers or people subjected toprofessional or environmental exposure to carcinogenic agents. Similarly, it couldavoid unnecessary cystoscopies both in patients presenting microscopic or grosshaematuria and/or irritative voiding symptoms, and in patients in surveillance aftertransurethral resection of bladder tumors, with significant reductions in patientsdiscomfort and anxiety as well as doctors burden. Many issues, such as interobservervariability, role of nearby tissues, and/or nearby comorbidities, and so on, needto be fully explored. For the time being, we hope the present results encouragethe scientific community to fully evaluate the role of non invasive electromagneticinteraction both at clinical application and biophysical research levels.

Acknowledgments

The authors wish to thank Mario Francheo for his technical support andDr. Gianfranco Zangari for the manuscript preparation. The TRIMprob™ system wasprovided free of charge to Lecce Hospital by TrimProbe S.p.A. which is gratefullyacknowledged.

Work partially supported by “Fondazione CRT” and Regione Piemonte underthe research contract NANOREM.

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Conflict of Interest Statement

Gianpiero Gervino, Elena Kolomoets, and Giorgio Leucci declare no conflict ofinterest, including employment, consultancies, stock ownership, honoraria, paidexpert testimony, patent applications, and travel grants or personal relations withTrimProbe S.p.A. and/or Galileo Avionica S.p.A,. which may have biased ouropinion in the preparation of the article. Massimo Balma and Elena Autino areemployed in Galileo Avionica S.p.A.. Gianpiero Gervino and Elena Kolomoets hadfull access to the study database and had final responsibility for the decision tosubmit this work for publication.

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