Do Patients Benefit from Routine Follow-up to Detect Recurrences After Radical Cystectomy and Ileal Orthotopic Bladder Substitution?

Background

The need for and intensity of follow-up to detect disease recurrence after radical cystectomy (RC) for transitional cell carcinoma (TCC) remains a matter for debate.

Objective

To determine whether diagnosis of asymptomatic recurrence after RC by routine follow-up investigations confers a survival benefit versus symptomatic recurrence.

Design, setting, and participants

Retrospective analysis of 479 patients with nonmetastatic bladder TCC receiving no neoadjuvant chemotherapy/radiation therapy and prospectively followed with a standardised protocol for a median 4.3 yr (range: 0.3–20.9) after RC at an academic tertiary referral centre.

Intervention

RC and extended pelvic lymph node dissection with ileal orthotopic bladder substitution.

Measurements

Cancer-specific survival (CSS) and overall survival (OS) probability for asymptomatic and symptomatic recurrent patients were estimated using the Kaplan-Meier method. The effects of age, nerve-sparing surgery, pathologic tumour stage, lymph node status, adjuvant chemotherapy, mode of recurrence diagnosis, and recurrence site on survival were assessed with multivariable Cox regression models.

Results and limitations

Of the 174 of 479 patients (36.3%) with tumour recurrence, 87 were diagnosed by routine follow-up investigations and 87 by symptoms. Routine follow-up mostly detected lung metastases and urethral recurrences, while symptoms were predominantly the result of bone metastases and concomitant pelvic/distant recurrences. Of 24 patients with urethral recurrences, 13 had carcinoma in situ (CIS). Of these, 12 were successfully managed with urethra-sparing treatment, and 6 are still alive with no evidence of disease. Most other recurrent long-term survivors had lung and extrapelvic lymph node metastases. Cumulative 5-yr survival rates of the entire cohort were 69.8% (95% confidence interval [CI], 65.5–74.3%) for CSS and 61.9% (95% CI, 57.4–66.7%) for OS. In multivariable analysis, mode of recurrence diagnosis and site of initial recurrence were the only independent predictors of CSS and OS. Patients with recurrences detected by routine follow-up investigations and with secondary urothelial tumours as site of recurrence had a slightly but significantly higher survival probability.

Conclusions

Patients diagnosed with asymptomatic recurrences during our routine follow-up after RC had a slightly higher survival than patients with symptomatic recurrences. Routine follow-up appears particularly effective in early detection of urethral CIS, which can be treated conservatively. In addition, the predominance of lung and extrapelvic lymph node metastases in survivors may justify the use of routine cross-sectional imaging.     

Evaluation of renal allograft function early after transplantation with diffusion-weighted MR imaging

Aims  

To determine the inter-patient variability of apparent diffusion coefficients (ADC) and concurrent micro-circulation contributions from diffusion-weighted MR imaging (DW-MRI) in renal allografts early after transplantation, and to obtain initial information on whether these measures are altered in histologically proven acute allograft rejection (AR).     

Gustatory stimulation changes the apparent diffusion coefficient of salivary glands: initial experience

Echo-planar diffusion-weighted (DW) magnetic resonance (MR) imaging was used to evaluate changes in the parotid glands during gustatory stimulation. The study protocol was approved by the local ethics committee, and informed consent was obtained from all volunteers. Twelve healthy volunteers (five women, seven men) with a median age of 25 years (range, 22-30 years) were examined with a 1.5-T MR unit. A DW MR imaging sequence was performed once at rest and continuously repeated over a mean period of 26 minutes (range, 24-28 minutes) during salivary stimulation with a tablet of ascorbic acid given orally. During the first 5 minutes (range, 1 minute 30 seconds--7 minutes 30 seconds) of salivary stimulation, a decrease in apparent diffusion coefficient (ADC) was observed in both the parotid (P = .0001) and the submandibular (P = .0004) glands in all volunteers. During the following 15 minutes, a steady increase in ADC from the baseline value was noted for the parotid glands (P = .0022), and peak ADC was reached a median of 21 minutes (range, 14-21 minutes) after the start of gustatory stimulation. The ADC of the submandibular glands did not increase significantly after the start of gustatory stimulation compared with the ADC at baseline. In conclusion, DW MR imaging allows physicians to noninvasively demonstrate functional changes in the salivary glands.     

Twenty years experience with an ileal orthotopic low pressure bladder substitute--lessons to be learned

PURPOSE: We present the long-term results of a large consecutive series of patients undergoing ileal orthotopic bladder substitution following radical cystectomy. MATERIALS AND METHODS: Between April 1985 and 2005 orthotopic bladder substitution with an ileal low pressure reservoir was performed in 482 patients (including 40 women) after radical and, if possible, nerve sparing cystectomy. In 447 cases the procedure was combined with an afferent ileal isoperistaltic tubular segment. The patients were followed prospectively. RESULTS: In the 482 patients 61 early (less than 30 days) diversion related complications requiring prolonged hospital stay or readmission were noted and 115 late complications required treatment. At 1 year continence was good in 92% of patients during the day and in 79% at night. At last followup 93% of patients could void spontaneously. Of 442 evaluable men 99 (22.4%) reported having erections without and 68 (15.4%) with medical assistance. Ureteroileal stenosis was observed in 12 of 447 (2.7%) patients. Urethral recurrence was detected in 25 of 482 (5%) patients. A total of 15 (5%) patients received vitamin B12 substitution. Renal parenchyma decreased only in patients with preoperative or postoperative ureteral obstruction. After 10 years patients with normal renal function had no long-term acidosis and in 20 patients the incidence of osteoporosis resembled that of the normal population. CONCLUSIONS: Ileal orthotopic bladder substitution combined with an afferent ileal tubular segment allows for good long-term functional results provided patients are restrictively selected, postoperative instructions are followed carefully, and typical complications such as outlet obstruction and hernias are treated early.     

Combined Ultrasmall Superparamagnetic Particles of Iron Oxide–Enhanced and Diffusion-weighted Magnetic Resonance Imaging Facilitates Detection of Metastases in Normal-sized Pelvic Lymph Nodes of Patients with Bladder and Prostate Cancer

Background

Conventional cross-sectional imaging with computed tomography and magnetic resonance imaging (MRI) has limited accuracy for lymph node (LN) staging in bladder and prostate cancer patients.

Objective

To prospectively assess the diagnostic accuracy of combined ultrasmall superparamagnetic particles of iron oxide (USPIO) MRI and diffusion-weighted (DW) MRI in staging of normal-sized pelvic LNs in bladder and/or prostate cancer patients.

Design, setting, and participants

Examinations with 3-Tesla MRI 24–36 h after administration of USPIO using conventional MRI sequences combined with DW-MRI (USPIO-DW-MRI) were performed in 75 patients with clinically localised bladder and/or prostate cancer staged previously as N0 by conventional cross-sectional imaging. Combined USPIO-DW-MRI findings were analysed by three independent readers and correlated with histopathologic LN findings after extended pelvic LN dissection (PLND) and resection of primary tumours.

Outcome measurements and statistical analysis

Sensitivity and specificity for LN status of combined USPIO-DW-MRI versus histopathologic findings were evaluated per patient (primary end point) and per pelvic side (secondary end point). Time required for combined USPIO-DW-MRI reading was assessed.

Results and limitations

At histopathologic analysis, 2993 LNs (median: 39 LNs; range: 17–68 LNs per patient) with 54 LN metastases (1.8%) were found in 20 of 75 (27%) patients. Per-patient sensitivity and specificity for detection of LN metastases by the three readers ranged from 65% to 75% and 93% to 96%, respectively; sensitivity and specificity per pelvic side ranged from 58% to 67% and 94% to 97%, respectively. Median reading time for the combined USPIO-DW-MRI images was 9 min (range: 3–26 min). A potential limitation is the absence of a node-to-node correlation of combined USPIO-DW-MRI and histopathologic analysis.

Conclusions

Combined USPIO-DW-MRI improves detection of metastases in normal-sized pelvic LNs of bladder and/or prostate cancer patients in a short reading time.This trial is registered with ClinicalTrials.gov (identifier NCT00622973).     

Genitourinary applications of diffusion-weighted MR imaging in the pelvis

Diffusion-weighted (DW) magnetic resonance (MR) imaging has a large number of potential clinical applications in the female and male pelvis and can easily be added to any routine MR protocol. In the female pelvis, DW imaging allows improvement of staging in endometrial and cervical cancer, especially in locally advanced disease and in patients in whom contrast medium administration should be avoided. It can also be helpful in characterizing complex adnexal masses and in depicting recurrent tumor after treatment of various gynecologic malignancies. DW imaging shows promising results in monitoring treatment response in patients undergoing radiation therapy of cervical cancer. An increase in apparent diffusion coefficient (ADC) values of responders precedes changes in size and may therefore allow early assessment of treatment success. In the male pelvis, the detection of prostate cancer in the peripheral zone is relatively easier than in the central gland based on the underlying ADC values, whereas overlapping values reported in the central gland still need further research. DW imaging might also be applied in the noninvasive evaluation of bladder cancer to differentiate between superficial and muscle-invasive tumors. Initial promising results have been reported in differentiating benign from malignant pelvic lymph nodes based on the ADC values; however, larger-scale studies will be needed to allow the detection of lymph node metastases in an individual patient. Prerequisites for successfully performing DW imaging of the female and male pelvis are standardization of the DW imaging technique, including the choice of b values, administration of an antiperistaltic drug, and comparison of DW findings with those of morphologic MR imaging.     

Diffusion-weighted MR imaging in the head and neck

Extracranial applications of diffusion-weighted (DW) magnetic resonance (MR) imaging are gaining increasing importance, including in head and neck radiology. The main indications for performing DW imaging in this relatively small but challenging region of the body are tissue characterization, nodal staging, therapy monitoring, and early detection of treatment failure by differentiating recurrence from posttherapeutic changes. Lower apparent diffusion coefficients (ADCs) have been reported in the head and neck region of adults and children for most malignant lesions, as compared with ADCs of benign lesions. For nodal staging, DW imaging has shown promise in helping detect lymph node metastases, even in small (subcentimeter) nodes with lower ADCs, as compared with normal or reactive nodes. Follow-up of early response to treatment is reflected in an ADC increase in the primary tumor and nodal metastases; whereas nonresponding lesions tend to reveal only a slight increase or even a decrease in ADC during follow-up. Optimization and standardization of DW imaging technical parameters, comparison of DW images with morphologic images, and increasing experience, however, are prerequisites for successful application of this challenging technique in the evaluation of various head and neck pathologic conditions.