Oncology: Prostate/Testis/Penis/Urethra Expression of Small Noncoding RNAs in Urinary Exosomes Classifies Prostate Cancer into Indolent and Aggressive Disease Wei-Lin Winnie Wang, Igor Sorokin,* Ilija Aleksic, Hugh Fisher, Ronald P. Kaufman, Jr., Andrew Winer, Brian McNeill, Raavi Gupta, Derya Tilki, Neil Fleshner, Laurence Klotz, A. Gregory DiRienzo and Martin Tenniswood† From miR Scientific LLC (WLWW, AGD, MT), Rensselaer, New York, Division of Urology (IS, IA, HF, RPK), Department of Surgery, Albany Medical College, New York, Department of Urology (AW, BM, RG), SUNY Downstate Medical Center, Brooklyn, New York, Martini Klinik (DT), University Hospital, Hamburg, Germany, Division of Urology (NF), Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada, Division of Urology (LK), University of Toronto, Sunnybrook Health Sciences Centre, Sunnybrook Medical Centre, Toronto, Ontario, Canada Purpose: This is the first report of the development and performance of a plat- form that interrogates small noncoding RNAs (sncRNA) isolated from urinary exosomes. The SentinelÔ PCa Test classifies patients with prostate cancer from subjects with no evidence of prostate cancer, the miR Sentinel CS Test stratifies patients with prostate cancer between those with low risk prostate cancer (Grade Group 1) from those with intermediate and high risk disease (Grade Group 2-5), and the miR Sentinel HG Test stratifies patients with prostate cancer between those with low and favorable intermediate risk prostate cancer (Grade Group 1 or 2) and those with high risk (Grade Group 3-5) disease. Materials and Methods: sncRNAs were extracted from urinary exosomes of 235 participants and interrogated on miR 4.0 microarrays. Using proprietary selec- tion and classification algorithms, informative sncRNAs were selected to customize an interrogation OpenArrayÔ platform that forms the basis of the tests. The tests were validated using a case-control sample of 1,436 subjects. Results: The performance of the miR Sentinel PCa Test demonstrated a sensi- tivity of 94% and specificity of 92%. The Sentinel CS Test demonstrated a sensitivity of 93% and specificity of 90% for prediction of the presence of Grade Group 2 or greater cancer, and the Sentinel HG Test demonstrated a sensitivity of 94% and specificity of 96% for the prediction of the presence of Grade Group 3 or greater cancer. Conclusions: The Sentinel PCa, CS and HG Tests demonstrated high levels of sensitivity and specificity, highlighting the utility of interrogation of urinary exosomal sncRNAs for noninvasively diagnosing and classifying prostate cancer with high precision. Key Words: prostatic neoplasms, exosomes, early detection of cancer, diagnosis, RNA PSA screening has been shown to reduce prostate cancer mortality by 20% to 32%. 1,2 However, the benefit of PSA as a screening test is limited because of the high false-positive rate of 65% to 75% 3 and the risk of over diagnosis and overtreatment of clinically insignificant cancer. Use of PSA as a screening tool results in a large number of negative biopsies, patient anxiety, and financial and personal cost. 4 MRI has recently emerged as an initial alternative to biopsy in men at risk for prostate Abbreviations and Acronyms AMC [ Albany Medical Center CS [ clinically significant DMC [ Downstate Medical Center GG [ Grade Group HG [ high grade miRNA [ micro RNA MRI [ magnetic resonance imaging NEPC [ no evidence of prostate cancer NPV [ negative predictive value PCa [ prostate cancer PPV [ positive predictive value PSA [ prostate specific antigen sncRNA [ small noncoding RNA snoRNA [ small nucleolar RNA Accepted for publication March 13, 2020. No direct or indirect commercial, personal, academic, political, religious or ethical incentive is associated with publishing this article. * Current Address: Department of Urology, UMass Memorial Medical Center, 33 Kendall St., Worcester, Massachusetts 01605. † Correspondence: miR Scientific LLC, Suite 202, 1 Discovery Drive, Rensselaer, New York 12144. 0022-5347/20/2043-0466/0 THE JOURNAL OF UROLOGY ® Ó 2020 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH,INC. https://doi.org/10.1097/JU.0000000000001020 Vol. 204, 466-475, September 2020 Printed in U.S.A. 466 j www.auajournals.org/jurology Copyright © 2020 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.