Bladder cancer: Evaluation of staging accuracy using dynamic MRI

doi:10.1016/j.crad.2011.05.019

Clinical Radiology

Volume 66, Issue 12, December 2011, Pages 1140-1145

https://doi.org/10.1016/j.crad.2011.05.019 Get rights and content

Aim

To assess the accuracy of magnetic resonance imaging (MRI) in staging bladder cancer and to assess whether dynamic gadolinium-enhanced sequences have any added benefit in staging.

Materials and methods

Over a 22 month period, the MRI findings of 100 consecutive patients with histologically proven transitional cell carcinoma (TCC) of the bladder were reviewed. The T stage was assessed independently on T2-weighted imaging alone and in combination with gadolinium-enhanced MRI. The final histological diagnosis was considered the reference standard. Statistical analysis was performed to ascertain stage-by-stage accuracy. Accuracy of MRI in differentiating superficial (≤T1) from invasive (≥T2) and in differentiating organ-confined (≤T2) from non-organ-confined (≥T3) disease was assessed.

Results

On a stage-by-stage basis, tumours were correctly staged using MRI in 63% of patients (observed agreement = 0.63, weighted kappa = 0.57). The sensitivity and specificity of MRI to differentiate between superficial (≤T1) from invasive (≥T2) disease was 78.2 and 93.3%. The observed agreement for this group was 85% (kappa = 70%; p < 0.0001). The sensitivity and specificity of MRI to differentiate between organ-confined (≤T2) from non-organ confined (≥T3) disease was 90.5 and 60%. The observed agreement for this group was 89% (kappa = 30%; p < 0.01). Gadolinium-enhanced images improved staging in only three patients.

Conclusion

In the present study MRI was found to be a moderately accurate tool in assessing the T stage. Agreement on a stage-by-stage basis was good. Agreement for differentiating between non-invasive versus muscle-invasive disease was good and that for organ-confined versus non-organ-confined disease was fair. Routine use of gadolinium-enhanced images is not routinely required.

Introduction

Bladder cancer staging is a multifaceted process that utilizes a combination of clinical and radiological assessment to evaluate the degree of disease spread objectively. Imaging forms a vital part of the management protocol. Accurate preoperative staging is key to ensuring correct treatment is instigated and prognosis depends on clinical and radiologic stage at presentation.¹ Superficial tumours are treated by transurethral resection with or without intravesical chemotherapy/immunotherapy. Muscle-invasive bladder tumours are treated by radiotherapy or curative cystectomy plus or minus neoadjuvant systemic chemotherapy.

Although cystoscopy and biopsy can differentiate superficial tumours from muscle-invasive tumours, it is not reliable for differentiating organ-confined disease from non-organ-confined disease.²

Computed tomography (CT) has been used in the past to stage bladder tumours, but dynamic contrast-enhanced magnetic resonance imaging (MRI) has been shown to be superior to CT for this purpose.3, 4, 5 The purpose of the present study was to assess the accuracy of MRI in T staging bladder cancer and to assess whether dynamic gadolinium-enhanced sequences have any added benefit in staging.

Section snippets

Patients

One hundred consecutive patients who had histologically proven transitional cell carcinoma (TCC) of the bladder and had MRI of the bladder for staging over a 22 month period were identified from our urology multidisciplinary team (MDT) database. MRI and CT had been performed in all patients at presentation to stage the disease. The requirement for regulatory permission was waived after communication with the chairman of the ethics committee. The results have been presented locally in accordance

Results

There were 27 female and 73 male patients (age range of 55–95 years). The final pathological staging revealed 25 patients with stage Ta disease, 30 with stage T1 disease, 40 with stage T2 disease, two with stage T3b disease, and three with stage T4 disease.

On a stage-by-stage basis tumours were correctly staged by MRI in 63% of patients (observed agreement = 0.63, weighted kappa = 0.60, 95% CI = 0.48 to 0.72; Table 1). The sensitivity and specificity of MRI to differentiate between superficial (≤T1)

Discussion

MRI, due to its intrinsic soft-tissue resolution is considered to be superior to CT for local staging.9, 10, 11 Staging accuracy is reported to range between 62–75% (4–6). In the present series, consisting of a large patient group, the overall diagnostic accuracy of MRI was 63%. However, the present study demonstrated an accuracy of 85% in distinguishing between superficial and invasive disease and an accuracy of 89% in differentiating organ-confined versus non-organ-confined tumour. This is an

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Cited by (69)

Erratum: French ccAFU guidelines – Update 2018–2020: Bladder cancer (Progrès en Urologie (2018) 28(S1) (R1), (S1166708719300466), (10.1016/j.purol.2019.02.011))
2018, Progres en Urologie
Proposer une mise à jour des recommandations dans la prise en charge des tumeurs de la vessie n’infiltrant pas le muscle vésical (TVNIM) et infiltrant le muscle vésical (TVIM).
Une revue systématique (Medline) de la littérature de 2015 à 2018 a été conduite par le ccAFU concernant les éléments du diagnostic, les options de traitement et la surveillance des TVNIM et TVIM, en évaluant les références avec leur niveau de preuve.
Le diagnostic de TVNIM (Ta, T1, CIS) se fait après une résection tumorale complète et profonde. L’utilisation de la fluorescence vésicale et l’indication d’un second look (4 à 6 semaines) contribuent à améliorer le diagnostic initial. Le risque de récidive et/ou progression tumorale est évalué en utilisant le score EORTC. La stratification des patients en faible, intermédiaire et haut risque permet de proposer le traitement adjuvant : instillations endovésicales de chimiothérapie (postopératoire immédiate, schéma d’attaque) ou de BCG (schéma d’attaque et d’entretien), voire l’indication d’une cystectomie pour les patients résistant au BCG. Le bilan d’extension d’une TVIM repose sur l’uro-scanner couplé au scanner thoracique. L’IRM pelvienne multiparamétrique peut être une alternative. La cystectomie associée à un curage ganglionnaire étendu est le traitement de référence des TVIM non métastatiques. Elle doit être précédée d’une chimiothérapie néoadjuvante à base de sels de platine chez les patients en bon état général avec une fonction rénale satisfaisante. Une entérocystoplastie est proposée chez l’homme et la femme en l’absence de contre-indications et lorsque la recoupe urétrale est négative à l’examen extemporané ; sinon l’urétérostomie cutanée transiléale est le mode de dérivation urinaire recommandé. L’inclusion de tous les patients dans un protocole de RAAC (récupération améliorée après chirurgie) est recommandée. Pour les TVIM métastatiques, une première ligne de chimiothérapie à base de sels de platine (GC ou MVAC) est recommandée, si l’état général (PS > 1) et la fonction rénale (clairance >60 mL/min) l’autorisent (50 % seulement des cas). En deuxième ligne de traitement, l’immunothérapie par pembrolizumab a démontré un bénéfice en survie globale.
Cette actualisation des recommandations françaises doit contribuer à améliorer non seulement la prise en charge des patients, mais aussi le diagnostic et la décision thérapeutique des TVNIM et TVIM.
To propose updated French guidelines for non-muscle invasive (NMIBC) and muscle-invasive (MIBC) bladder cancers.
A Medline search was achieved between 2015 and 2018, as regards diagnosis, options of treatment and follow-up of bladder cancer, to evaluate different references with levels of evidence.
Diagnosis of NMIBC (Ta, T1, CIS) is based on a complete deep resection of the tumor. The use of fluorescence and a second-look indication are essential to improve initial diagnosis. Risks of both recurrence and progression can be estimated using the EORTC score. A stratification of patients into low, intermediate and high risk groups is pivotal for recommending adjuvant treatment: instillation of chemotherapy (immediate post-operative, standard schedule) or intravesical BCG (standard schedule and maintenance). Cystectomy is recommended in BCG-refractory patients. Extension evaluation of MIBC is based on contrast-enhanced pelvic-abdominal and thoracic CT-scan. Multiparametric MRI can be an alternative. Cystectomy associated with extended lymph nodes dissection is considered the gold standard for non-metastatic MIBC. It should be preceded by cisplatin-based neoadjuvant chemotherapy in eligible patients. An orthotopic bladder substitution should be proposed to both male and female patients with no contraindication and in cases of negative frozen urethral samples; otherwise transileal ureterostomy is recommended as urinary diversion. All patients should be included in an Early Recovery After Surgery (ERAS) protocol. For metastatic MIBC, first-line chemotherapy using platin is recommended (GC or MVAC), when performans status (PS < 1) and renal function (creatinine clearance > 60 mL/min) allow it (only in 50 % of cases). In second line treatment, immunotherapy with pembrolizumab demonstrated a significant improvement in overall survival.
These updated French guidelines will contribute to increase the level of urological care for the diagnosis and treatment for NMIBC and MIBC.
French ccAFU guidelines – Update 2018–2020: Bladder cancer
2018, Progres en Urologie
This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy).
Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations.
Le nouvel article est disponible à cette adresse: doi:10.1016/j.purol.2019.01.006.
C’est cette nouvelle version qui doit être utilisée pour citer l’article.
This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published.
The replacement has been published at the doi:10.1016/j.purol.2019.01.006.
That newer version of the text should be used when citing the article.
ACR Appropriateness Criteria <sup>®</sup> Pretreatment Staging of Muscle-Invasive Bladder Cancer
2018, Journal of the American College of Radiology
Muscle-invasive bladder cancer (MIBC) has a tendency toward urothelial multifocality and is at risk for local and distant spread, most commonly to the lymph nodes, bone, lung, liver, and peritoneum. Pretreatment staging of MIBC should include imaging of the urothelial upper tract for synchronous lesions; imaging of the chest, abdomen, and pelvis for metastases; and MRI pelvis for local staging. CT abdomen and pelvis without and with contrast (CT urogram) is recommended to assess the urothelium and abdominopelvic organs. Pelvic MRI can improve local bladder staging accuracy. Chest imaging is also recommended with chest radiograph usually being adequate. FDG-PET/CT may be appropriate to identify nodal and metastatic disease. Chest CT may be useful in high-risk patients and those with findings on chest radiograph. Nonurogram CT and MRI of the abdomen and pelvis are usually not appropriate, and neither is radiographic intravenous urography, Tc-99m whole body bone scan, nor bladder ultrasound for pretreatment staging of MIBC.
The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
Radiomics-guided therapy for bladder cancer: Using an optimal biomarker approach to determine extent of bladder cancer invasion from t2-weighted magnetic resonance images
2018, Advances in Radiation Oncology
Citation Excerpt :
In current practice, cystoscopy, tissue analysis from the transurethral resection of the bladder tumor, pelvic computed tomography (CT), and magnetic resonance imaging (MRI) are the primary modalities used to clinically stage patients with bladder cancer.6 MRI is the most promising imaging method and has been shown to be sensitive to and specific for the detection and localization of macroscopic disease.7-21 However, current MRI techniques are not able to detect microscopic tumor sites and qualitatively differentiate reactive changes after transurethral resection from sites of residual tumor.22-30
Current clinical staging methods are unable to accurately define the extent of invasion of localized bladder cancer, which affects the proper use of systemic therapy, surgery, and radiation. Our purpose was to test a novel radiomics approach to identify optimal imaging biomarkers from T2-weighted magnetic resonance imaging (MRI) scans that accurately classify localized bladder cancer into 2 tumor stage groups (≤T2 vs >T2) at both the patient level and within bladder subsectors.
Preoperative T2-weighted MRI scans of 65 consecutive patients followed by radical cystectomy were identified. A 3-layer, shell-like volume of interest (VOI) was defined on each MRI slice: Inner (lumen), middle (bladder wall), and outer (perivesical tissue). An optimal biomarker method was used to identify features from 15,834 intensity and texture properties that maximized the classification of patients into ≤T2 versus >T2 groups. A leave-one-out strategy was used to cross-validate the performance of the identified biomarker feature set at the patient level. The performance of the feature set was then evaluated at the subsector level of the bladder by dividing the VOIs into 8 radial sectors.
A total of 9 optimal biomarker features were derived and demonstrated a sensitivity, specificity, accuracy of prediction, and area under a receiver operating characteristic curve of 0.742, 0.824, 0.785, and 0.806, respectively, at the patient level and 0.681, 0.788, 0.763, and 0.813, respectively, at the radial sector level. All 9 selected features were extracted from the middle shell of the VOI and based on texture properties.
An approach to select a small, highly independent feature set that is derived from T2-weighted MRI scans that separate patients with bladder cancer into ≤T2 versus >T2 groups at both the patient level and within subsectors of the bladder has been developed and tested. With external validation, this radiomics approach could improve the clinical staging of bladder cancer and optimize therapeutic management.
Fluorodeoxyglucose positron emission tomography (18F-FDG PET)-computed tomography (CT) in the initial staging of bladder cancer: a single institution experience
2023, Journal of the Egyptian National Cancer Institute
An artificial intelligence model for the pathological diagnosis of invasion depth and histologic grade in bladder cancer
2023, Journal of Translational Medicine

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Bladder cancer: Evaluation of staging accuracy using dynamic MRI

Aim

Materials and methods

Results

Conclusion

Introduction

Section snippets

Patients

Results

Discussion

Urol Clin North Am

J Urol

Curr Probl Diagn Radiol

Prog Urol

J Urol

J Urol

Eur Urol

Eur Urol

Staging of bladder carcinoma: MRI–CT–surgical correlation

AJR Am J Roentgenol

Primary staging of urinary bladder carcinoma: the role of MRI and a comparison with CT

Eur Radiol