Comparative study of novel endoluminal ultrasonography and conventional transurethral ultrasonography in staging of bladder cancer

BACKGROUND: Recent advances in ultrasonic techniques have improved the image quality and diagnostic accuracy for staging of bladder cancer. The aim of this study was to assess the feasibility and usefulness of endoluminal ultrasonography (ELUS) in staging of bladder cancer, and to compare them with those of conventional transurethral ultrasonography (TUUS). METHODS: From 2000 to 2002, 19 patients with bladder cancer were evaluated by ELUS and TUUS before transurethral resection or biopsy. Clinical staging using ELUS, TUUS, computed tomography (CT) and magnetic resonance imaging (MRI) was compared with the results of pathological staging. RESULTS: In 16 of 19 patients, both ELUS and TUUS were able to diagnose tumor stage. In the remaining three patients, both methods were unable to evaluate stage of tumor. In two of these patients, this inability to evaluate tumor state was caused by a difficulty in depicting the tumor base in rectangular scanning. In the remaining patient, the inability to evaluate tumor stage was caused by a difficulty in recognizing the normal muscularis because of edema around the tumor base. Both diagnostic accuracies of ELUS and TUUS were 84%, which were superior to those of CT (44%) and MRI (82%). CONCLUSIONS: Endoluminal ultrasonography and TUUS were equally useful for staging diagnosis of bladder cancer. Because the ELUS probe is very small in diameter and can be manipulated under direct vision, it is superior to the TUUS in safety and in fine visualization. However, the main limitations of ELUS include an inability to evaluate the depth of invasion of large tumors and an inability to visualize the tumor base in the position of the bladder neck.     

Diagnostic performance of the vesical imaging-reporting and data system for detecting muscle-invasive bladder cancer in real clinical settings: Comparison with diagnostic cystoscopy

PurposeWe herein compared the diagnostic performance of Vesical Imaging-Reporting and Data System (VI-RADS) scoring with diagnostic cystoscopy and evaluated diagnostic accuracies based on tumor locations.Materials and MethodsAmong 112 bladder cancer patients who underwent multiparametric magnetic resonance imaging and diagnostic cystoscopy preoperatively to detect bladder cancer, 61 were analyzed. VI-RADS was categorized into 5 stages by 2 radiologists (R1 and R2). Cut-off values ≥3 indicated muscle-invasive bladder cancer (MIBC). Muscle invasion (MI) was visually evaluated using diagnostic cystoscopy by 2 urologists (U1 and U2). The sensitivity and specificity of VI-RADS scores and diagnostic cystoscopy for diagnosing MI were compared.Results16 patients (26.2%) were pathologically diagnosed with MIBC. Regarding MI diagnostic accuracy, the sensitivity/specificity of VI-RADS scores were 93.8/88.9% by R1 and 87.5/86.7% by R2, while those of diagnostic cystoscopy were 56.3/68.9% by U1 and 68.8/84.4% by U2. Therefore, the diagnostic accuracy of VI-RADS was significantly higher than that of cystoscopy, particularly for tumors located on the bladder neck, trigone, dome, and posterior and anterior walls. Over- and under-diagnosis rates were higher with VI-RADS than with diagnostic cystoscopy (25.9% vs. 14.8%) for tumors located on the lateral wall or ureteral orifice.ConclusionVI-RADS had superior diagnostic performance for detecting MI, especially in tumors located at the bladder neck/trigone/dome/posterior and anterior wall. However, VI-RADS was inferior to cystoscopy in terms of MI detection for tumors located on the lateral wall or ureteral orifice. Therefore, a combination of diagnostic tools is recommended for the accurate staging of these tumors.     

Staging of bladder carcinoma by magnetic resonance imaging compared with computed tomography and transurethral echography

Various techniques are used for tumor staging of bladder carcinoma such as endoscopic photography, transurethral echography, and computed tomographic (CT) scan. Endoscopic photography enables easy observation of tumor morphology, but we utilized other approaches to determine the presence or absence of tumor infiltration. Magnetic resonance imaging (MRI) has recently found widespread use in the staging of tumors. We first employed this approach at our hospital in February 1987. We compared the diagnostic accuracy rate of MRI with that of transurethral echography and CT scan in 10 cases of bladder tumor. The diagnostic accuracy rate of MRI was 70%, while that of transurethral echography and CT scan was 40% and 50%, respectively. We concluded that MRI was very useful in the diagnostic staging of bladder tumor.     

Differential diagnosis and staging of urological tumors by magnetic resonance imaging compared with computed tomography

Magnetic resonance imaging (MRI) was performed on 49 urological tumors (11 renal cell carcinomas, 3 renal pelvic cancers, 2 renal angiomyolipomas, 1 renal leiomyosarcoma, 1 large renal cyst, 4 adrenal tumors, 11 bladder cancers, 2 bone metastasis from bladder cancer, 10 prostatic cancers, 1 prostatic sarcoma, 1 urethral cancer, 1 penile cancer and 1 perivesical granuloma) since October 1985 to September 1986. MRI was performed using a Signa (G.E.) with a 1.5T superconductive magnet and 3 images, including T1 weighted image, T2 weighted image, and proton density image, were obtained. In conclusion MRI is a noninvasive examination and gives more information than computed tomography despite its high cost. In renal cell carcinoma, the chemical shift in MRI and clear visualization of tumor thrombus enable accurate staging. Differential diagnosis from other renal mass lesions may be possible by the T2 weighted image. In adrenal disease, most of the adrenal masses can be differentiated, but in some cases it is impossible. In bladder cancer, wall invasion of tumor may be evaluated in T2 weighted image, and MRI is suitable for staging of locally advanced tumor. In prostatic cancer, visualization of periprostatic plexus and differentiation between internal and external gland may enable local staging and identification of low stage tumors.     

Clinical staging of upper urinary tract urothelial carcinoma for T staging: Review and pictorial essay

Upper urinary tract urothelial carcinoma is staged using the TNM classification of malignant tumors. Preoperative TNM is important for treatment planning. Computed tomography urography is now widely used for clinical survey of upper urinary tract carcinoma because of its diagnostic accuracy. Computed tomography urography is recommended as the first‐line imaging procedure in several guidelines. Several reports stated that computed tomography urography is also useful for staging. However, no educational and practical reviews detailing the T staging of upper urinary tract urothelial carcinomas using imaging are available. We discuss the scanning protocol, T staging using computed tomography urography, limitations, magnetic resonance imaging, computed tomography comparison and pitfalls in imaging of upper urinary tract urothelial carcinoma. A recent study reported the high diagnostic accuracy of computed tomography urography with respect to T3 or higher stage tumors. To date, images that show a Tis–T2 stage have not been reported, but various studies are ongoing. Although magnetic resonance imaging has lower spatial resolution than computed tomography urography, magnetic resonance imaging can be carried out without radiation exposure or contrast agents. Magnetic resonance imaging also offers the unique ability of diffusion‐weighted imaging without contrast agent use. Some researchers reported that diffusion‐weighted imaging is useful not only for detecting lesions, but for predicting the T stage and tumor grade. We recommend the appropriate use of computed tomography and magnetic resonance while considering the limitations of each modality and the pitfalls in upper urinary tract urothelial carcinoma imaging.     

Results of contemporary radical cystectomy for invasive bladder cancer: a clinicopathological study with an emphasis on the inadequacy of the tumor, nodes and metastases classification

We reviewed 261 patients who underwent a radical operation at a single institution as definitive treatment of invasive bladder cancer to evaluate the survival and accuracy of the tumor, nodes and metastasis system in characterizing the prognosis. Between January 1979 and June 1987 the 261 evaluable patients underwent 1-stage radical cystectomy with pelvic node dissection and urinary diversion. No chemotherapy and/or radiation therapy was given before or after the operation. The postoperative mortality rate was 1.8%. The over-all staging error between clinical and pathological stages was as high as 44%. The over-all actuarial 5-year survival rate was 54.5%. The 5-year survival rates were 75% for stage pT1, 63% for stage pT2, 31% for stage pT3 and 21% for stage pT4 disease. A significant difference in the survival (p less than 0.002) was observed in stage pT3 by dividing tumors confined within the bladder wall (pT3a, 50%) from those extending throughout the bladder wall (pT3b, 15%). A careful evaluation of transitional cell involvement of the prostate in stage pT4a cancer led to the identification of 2 different patterns: 1) contiguous when a bladder tumor extended directly into the prostate through the bladder wall and 2) noncontiguous when a bladder tumor and a transitional cell carcinoma of the prostate were found simultaneously. These patterns had completely different (p less than 0.05) survival rates (6 versus 37%). The patients with high grade tumors had a worse prognosis in comparison with those with grades 1 and 2 tumors (41 versus 56%, p less than 0.005). The over-all 5-year survival of patients with positive nodes was 4% in comparison with 60% of those without nodal involvement (p less than 0.001). Despite current optimal surgical treatment, nearly 50% of all patients with invasive bladder cancer continue to die. The need for a modification of the current tumor, nodes and metastasis tumor classification to provide the clinician a more reliable staging system for planning treatment modalities is indeed mandatory.     

Role of multiparametric magnetic resonance imaging in the diagnosis and staging of urinary bladder cancer

ObjectivesTo assess the role of multiparametric magnetic resonance imaging (mp-MRI) in the diagnosis and staging of urinary bladder cancer (BC).Materials and methodsFifty patients diagnosed with bladder masses underwent mp-MRI study. The results of 3 image sets were analyzed and compared with the histopathological results as a reference standard: T2-weighted image (T2WI) plus dynamic contrast-enhanced (DCE), T2WI plus diffusion-weighted images (DWI), and mp-MRI, including T2WI plus DWI and DCE. The diagnostic accuracy of mp-MRI was evaluated using receiver operating characteristic curve analysis.ResultsThe accuracy of T2WI plus DCE for detecting muscle invasion of BC was 79.5% with a fair agreement with histopathological examination (κ = 0.59); this percentage increased up to 88.6% using T2WI plus DWI, with good agreement with histopathological examination (κ = 0.74), whereas mp-MRI had the highest overall accuracy (95.4%) and excellent agreement with histopathological data (κ = 0.83). Multiparametric MRI can differentiate between low- and high-grade bladder tumors with a high sensitivity and specificity of 93.3% and 98.3%, respectively.ConclusionsMultiparametric MRI is an acceptable method for the preoperative detection and accurate staging of BC, with reasonable accuracy in differentiating between low- and high-grade BC.     

The role of magnetic resonance imaging in the staging of bladder carcinoma

The clinical staging of bladder carcinoma traditionally has relied on transurethral resection of the bladder tumor, urinary cytology, excretory urography and an examination with the patient under anesthesia. Recent evidence has shown magnetic resonance imaging to be effective in the staging of bladder cancer. Whether magnetic resonance imaging is more accurate than conventional clinical staging techniques has not been answered. To determine the usefulness of magnetic resonance imaging in this regard 34 patients with bladder carcinoma underwent staging by this technique before radical cystectomy. The magnetic resonance imaging stage and conventional clinical stage were compared to the final pathological stage. Magnetic resonance imaging had an over-all accuracy of 50 per cent versus 57 per cent for conventional staging techniques and it identified 2 of 5 patients with nodal disease. To date magnetic resonance imaging does not appear to be better than conventional clinical staging techniques in patients with bladder carcinoma.     

多层螺旋CT双期增强扫描结合仿真内镜成像在膀胱癌术前分期中的诊断价值

目的 探讨多层螺旋CT双期增强扫描结合仿真内镜成像在膀胱癌术前分期中的诊断价值.方法 经纤维膀胱镜或手术病理证实为膀胱癌患者75例.对患者术前螺旋CT双期增强扫描图像和仿真内镜图像进行分析,比较多层螺旋CT分期与病理分期的准确率.结果 75例患者共发现病灶94个.螺旋CT分期:T1 26例、T2a 27例、T2b 13例、T3 12例、T4 16例;病理分期:pT1 28例、pT2a 24例、pT2b 14例、pT3 12例、pT4 16例.螺旋CT双期增强扫描诊断膀胱癌准确率为89.4%(84/94);腔内息肉样病变,仿真内镜诊断敏感性96.6%(84/87);膀胱壁无蒂隆起性病变诊断敏感性为90.9%(10/11).螺旋CT双期增强扫描结合仿真内镜诊断膀胱癌分期准确率为94.5%(91/94),当肿瘤局限于膀胱壁内(≤T2b)时,诊断准确率为91.2%(51/56);肿瘤侵犯膀胱壁外结构时(≥T3),诊断准确率达100.0%(28/28).结论 多层螺旋CT双期增强扫描结合仿真内镜成像对膀胱癌术前临床分期具有重要价值.     

Role of magnetic resonance imaging in tumor staging and follow-up for bladder cancer

Urothelial carcinoma of the bladder is a common urologic malignancy. Complex factors, such as local stage, tumor grade, biologic potential, and various conditions, can affect the treatment strategy for bladder cancer. However, the local stage—in particular, the presence or absence of muscle invasion—significantly influences decisions regarding treatment strategy. The role of cystoscopy for screening, diagnosis, and transurethral resection cannot be overlooked. The importance of local staging with magnetic resonance imaging is increasing; magnetic resonance imaging of the bladder is considered a useful staging modality. Moreover, a radiologic reporting system for evaluating and scoring muscle invasion of bladder cancer was recently released. This system is based on multiparametric magnetic resonance imaging and is also expected to be feasible for post-treatment follow-up of bladder cancer. In this review, we discuss the role of magnetic resonance imaging in the local staging of urothelial carcinoma of the urinary bladder and post-treatment imaging. In addition, several technical aspects for obtaining appropriate quality magnetic resonance images of the bladder will be discussed.     

Präoperatives Staging von Nierenzellkarzinomen mit Kavazapfen: welches diagnostische Verfahren?

To evaluate whether MRI is usefull in staging renal cell carcinomas with caval thrombus the accuracy of computed tomography (CT) and magnetic resonance imaging (MRI) in staging renal tumors with caval thrombus were preoperatively examined. Tumor staging by CT and MR imaging were correlated with histopathological tumor stadium. In MRI 4 out of 7 thrombi were correctly diagnosed with high accuracy, in CT none. In advanced renal carcinoma MRI with Gadolinium was superior to CT imaging, especially in diagnosing tumor thrombus. Consequently the extent of tumor thrombus may be assessed by MRI which therefore may replace conventional cavography.     

Positronenemissionstomographie (PET) zur Diagnostik und zum Therapiemonitoring bei urologischen Tumoren

Positron emission tomography (PET) using ((18)F)2-fluoro-D-2-desoxyglucose (FDG) has been shown to be a highly sensitive and specific imaging modality in the diagnosis of primary and recurrent tumors and in the control of therapies in numerous non-urologic cancers. It was the aim of this review to validate the significance of PET as a diagnostic tool in malignant tumors of the urogenital tract. A systematic review of the current literature concerning the role of PET for malignant tumors of the kidney, testicles, prostate, and bladder was carried out. The role of FDG PET for renal cell cancer can be seen in the detection of recurrences after definitive local therapy and metastases. The higher sensitivity of PET in comparison to other therapeutic modalities (CT, ultrasound, MRI) in recurrent and metastatic renal cell cancer suggests a supplemental role of this diagnostic procedure to complement other imaging modalities.The clinical value of PET is established for the identification of vital tumor tissue after chemotherapy of seminomatous germ cell tumors. This diagnostic method has little significance for primary tumor staging and diagnosis of non-seminomatous germ cell tumor because of the high probability of false-negative results in adult teratomas. FDG PET is not sensitive enough in the diagnosis of primary or recurrent tumors in prostate or bladder cancer. Also PET did not prove to be superior to conventional bone scintigram in the detection of mostly osteoblastic metastases in prostate cancer. The recent use of alternative tracers, which are partly not eliminated by urinary secretion (acetate, choline) has increased the sensitivity and specificity of PET also in this tumor entity so that further clinical investigations are needed to validate these technical modifications in their significance for this imaging modality. PET appears to be sufficiently evaluated only for the diagnostic follow-up of patients with seminomatous germ cell tumors after chemotherapy to regard it is the diagnostic tool of first choice. For all other tumors of the urogenital tract this proof is still awaited.     

Diagnosis of bladder cancer by transurethral ultrasonic scanning

Transurethral ultrasonographic examination was performed on a total of 24 patients with 40 bladder tumors to evaluate the accuracy of the method to detect bladder tumors and to compare ultrasonographic staging of bladder tumors with pathological staging. The results showed that it was difficult to detect bladder tumors of any size located in the bladder neck or dome and those less than 0.5 cm in diameter located anywhere, indicating the difficulty in tumor staging. On the other hand, diagnostic accuracy was approximately 90% for the tumors larger than 0.5 cm in diameter. Therefore, if a tumor with a diameter larger than 0.5 cm is detected by cystoscopy, we believe that urethral ultrasonographic examination should be performed as a routine protocol after the cystoscopy.     

Transurethral ultrasonography of the urinary bladder

Summary Though considered a pelvic organ, the urinary bladder, unlike the prostate, can be assessed with a variety of radiographic and imaging techniques. Intravenous urography, cystography and abdominal ultrasonography have been shown to be more useful in studying this structure in contrast to the prostate gland. Other imaging studies such as transrectal ultrasonography, computerized tomography and magnetic resonance imaging have been proven to be of value in examining both organs. Most of these latter examinations have been utilized for the purpose of staging bladder tumors and, though noninvasive tumors and tumors demonstrating significant extravesical involvement can be readily identified, these imaging examinations have genrally not been satisfactory in determining the degree of muscle involvement by an invading bladder tumor.     

CT对膀胱癌局部分期的准确性及影响因素分析

目的：探讨CT对膀胱癌局部分期的准确性以及影响因素。方法：回顾性分析44例肿瘤直径大于1cm且CT、上无明显其他盆腔脏器侵犯的膀胱癌患者临床资料，对比CT的局部分期与手术后病理分期。结果：CT对膀胱癌局部分期总的准确率为43．2％，有52.3％患者存在过高分期。直径1～2cm或大于4cm肿瘤CT分期较直径2～4cm肿瘤更为准确；原位复发的肿瘤分期准确性低于初发或异位复发的肿瘤；移行细胞癌的分期水确件高于非移行细胞癌；有蒂的肿瘤分期准确性高于广基肿瘤。结论：CT对膀胱癌局部分期的作用有限，受到肿瘤大小、基底情况、复发位置以及肿瘤病理类型的影响。     

含弥散加权成像磁共振与增强CT对胃癌术前T分期诊断准确率的比较

目的比较增强cT与含弥散加权成像（DWI）的磁共振（MR）成像对胃癌术前T分期诊断的准确率。方法前瞻性纳入2011年11月至2012年8月间经胃镜活检病理证实的41例胃癌患者,术前分别予增强CT和MR检查（包含DWI、T2WI和动态增强扫描）。由两位放射科医师分别对癌灶进行检测和T分期．并以手术病理结果为金标准,比较CT与MR的T分期准确率以及观察者间一致性。结果含DWI的MR对胃癌患者总体T分期的诊断准确率为87．8％（36／41）,明显高于增强cT65．9％（27／41）的诊断准确率（P=0．004）。MR诊断的观察者问一致性（Kappa=O．813）优于增强cT诊断（Kappa=0．603）。结论含DWI的MR成像对胃癌术前T分期的诊断准确率较增强CT显著提高,有望于临床广泛应用。     

Urinmarkersysteme zur Diagnostik des Urothelkarzinoms

Cystoscopy and urinary cytology are standard tools in the diagnostics of urothelial cancer of the urinary bladder; however, cystoscopy is invasive and urinary cytology lacks accuracy for the diagnosis of low grade tumors. More recently several alternative urinary test systems were developed with the aim to make the diagnostics of urothelial tumors more reliable; however, in general all protein-based point of care test systems have a high rate of false positive test results, especially in patients with benign disorders. Fluorescence in situ hybridization, which is highly sensitive and specific, may be a reasonable supplement to the diagnostic spectrum in patients after instillation therapy or bladder replacement. Additionally, there are several new test systems which still need to be tested in large clinical studies with respect to diagnostic accuracy.     

Utility of reassessment after neoadjuvant therapy and difficulties in interpretation

We describe the main tools for MR assessment of the response of rectal cancer tumors after chemotherapy, before surgery. In locally advanced cases of rectal and lower rectal cancer, MR is useful in allowing the treatment strategy to be adjusted, enabling conservative surgery to be performed if the patient responds well. The different types of response (fibrous, desmoplastic and colloid), their appearances and difficulties in MR interpretation are described. We describe the features and performance of MR after neoadjuvant therapy for T and N staging, assessment of circumferential resection margin and diffusion weighted imaging. Quantitative (change in tumor volume) and qualitative (grade of tumor response) MR assessment can distinguish good responders from poor responders.     

Aktuelle Bildgebung beim Rektumkarzinom

Rectal cancer is one of the most common causes of death from cancer. Accurate staging is necessary for optimal treatment. The tumor node metastasis (TNM) system is used to describe numerically the anatomical extent of cancer. Various diagnostic methods provide accurate staging. Endorectal ultrasound (EUS) and magnetic resonance tomography (MR) are most adequate for determining tumor stage. Moreover, MR is highly accurate in predicting the circumferential resection margin. Accurate node staging remains however difficult with both EUS and MR. Modern multidetector row CT is predestined for detecting distant metastases as it is a widespread, fast, and reproducible method.     

Restaging Transurethral Resection of Bladder Tumor for High-risk Stage Ta and T1 Bladder Cancer

Bladder cancer is the most common malignancy of the urinary tract. About 75%–85% of patients present with non–muscle-invasive bladder cancer (NMIBC). However, patients with pT1 tumors, as well as all those with high-grade disease, make up a subset with a high-risk of recurrence and disease progression. Although still regarded as the gold standard, clinical evidence from contemporary published series clearly demonstrates that transurethral resection of tumor (TUR) is a procedure far from optimal, highlighting its limitations and the need for further diagnostic accuracy. Routine use of a restaging TUR (re-TUR), supported by the American Urological Association and European Association of Urology guidelines, detects residual tumor in a significant number of cases after initial TUR. It provides a more accurate staging of the disease and, consequently, helps to guide its treatment. Recent years have seen rapid development of novel optical techniques aimed to optimize resection. Routine implementation of these novel techniques in the context of re-TUR is promising and may potentially result in more tumors being identified and completely resected, leading to significantly lower residual tumor rates than with the standard white-light TUR. This article will focus on re-TUR in the management of high-risk NMIBC, with an up-to-date review of the available literature and detailed analysis of the published series.