Preoperative imaging for locoregional staging of bladder cancer

Role of 64CuCl2 PET/CT in Detecting and Staging Muscle-Invasive Bladder Cancer: Comparison with Contrast-Enhanced CT and 18F-FDG PET/CT

Molecular imaging of muscle-invasive bladder cancer (MBC) is restricted to its locoregional and distant metastases, since most radiopharmaceuticals have a urinary excretion that limits the visualization of the primary tumor. 64CuCl2 , a positron-emitting radiotracer with nearly exclusive biliary elimination, could be well suited to exploring urinary tract neoplasms. In this study, we evaluated the feasibility of 64CuCl2-based staging of patients with MBC; furthermore, we compared the diagnostic capability of this method with those of the current gold standards, that is, contrast-enhanced CT (ceCT) and 18F-FDG PET/CT. Methods: We prospectively enrolled patients referred to our institution for pathology-confirmed MBC staging/restaging between September 2021 and January 2023. All patients underwent ceCT, 18F-FDG, and 64CuCl2 PET/CT within 2 wk. Patient-based analysis and lesion-based analysis were performed for all of the potentially affected districts (overall, bladder wall, lymph nodes, skeleton, liver, lung, and pelvic soft tissue). Results: Forty-two patients (9 women) were enrolled. Thirty-six (86%) had evidence of disease, with a total of 353 disease sites. On patient-based analysis, ceCT and 64CuCl2 PET/CT showed higher sensitivity than 18F-FDG PET/CT in detecting the primary tumor (P < 0.001); moreover, 64CuCl2 PET/CT was slightly more sensitive than 18F-FDG PET/CT in disclosing soft-tissue lesions (P < 0.05). Both PET methods were more specific and accurate than ceCT in classifying nodal lesions (P < 0.05). On lesion-based analysis, 64CuCl2 PET/CT outperformed 18F-FDG PET/CT and ceCT in detecting disease localizations overall (P < 0.001), in the lymph nodes (P < 0.01), in the skeleton (P < 0.001), and in the soft tissue (P < 0.05). Conclusion: 64CuCl2 PET/CT appears to be a sensitive modality for staging/restaging of MBC and might represent a "one-stop shop" diagnostic method in these scenarios.

Performance of 18F-FDG PET/MRI and its parameters in staging and neoadjuvant therapy response evaluation in bladder cancer

18F-FDG PET/MRI shows potential efficacy in the diagnosis of bladder cancer (BLCA). However, the performance of 18F-FDG PET/MRI in staging and neoadjuvant therapy (NAT) response evaluation for BLCA patients remains elusive. Here, we conduct this study to evaluate the performance of 18F-FDG PET/MRI and its derived parameters for tumor staging and NAT response prediction in BLCA. Forty BLCA patients were retrospectively enrolled to evaluate the performance of 18F-FDG PET/MRI in staging and NAT response prediction in BLCA. The feasibility of using 18F-FDG PET/MRI-related parameters for tumor staging and NAT response evaluation was also analyzed. In conclusion, 18F-FDG PET/MRI is found to show good performance in the BLCA staging and NAT response prediction. Moreover, ΔSUVmean is an efficacious candidate parameter for NAT response prediction. This study highlights that 18F-FDG PET/MRI is a promising imaging approach in the clinical diagnosis and treatment for BLCA.

Occult urothelial carcinoma with mediastinal metastasis: A case report

Occult urothelial carcinoma (UC), particularly with mediastinal metastases, is an uncommon clinical occurrence. The present study describes the unusual case of a 70-year-old male patient who developed mediastinal metastases from an occult UC. Histological evaluations and immunohistochemical features of the mediastinal tumor were indicative of UC; however, extensive imaging failed to identify the primary urological lesion. The findings suggest that mediastinal metastases from UCs, despite their rarity, should be considered in cases where patients with mediastinal tumors exhibit chest-related symptoms. Prompt pathological examinations are crucial for ascertaining the nature and origin of the tumor. Moreover, individualized treatment should be performed in strict accordance with the established oncology guidelines.

HER2 overexpression predicts pathological T2 stage and improved survival in de novo muscle-invasive bladder cancer after immediate radical cystectomy: a retrospective cohort study

INTRODUCTION

Human epidermal growth factor receptor type 2 (HER2) overexpression is a prognostic factor and a therapeutic target for breast cancer; however, anti-HER2 therapies are ineffective in patients with bladder cancer. The authors investigated the effect of HER2 overexpression (HER2 + ) on the prognosis of muscle-invasive bladder cancer (MIBC).

MATERIALS AND METHODS

This retrospective cohort study included patients who underwent initial transurethral resection of bladder tumors between 2005 and 2013 and were registered in the Korea National Health Insurance Database, which provides data on overall survival (OS). Sixty-one patients with clinically nonmetastatic de novo MIBC were included in this study. As a subgroup, 33 patients who underwent immediate radical cystectomy (RC) were analyzed. Univariate and multivariate Cox proportional hazards models were used to identify prognostic factors for survival. A multivariable binary logistic regression model was used to identify the favorable T stage.

RESULTS

Among the 61 patients with d-MIBC, 14 were HER2 + and 47 HER2 - . Age less than 70 years [hazard ratio (HR): 0.312, CI: 0.16-0.59, P <0.001] and HER2 + status (HR: 0.40, CI: 0.19-0.85, P =0.02) were favorable prognostic factors for OS after adjusting for clinical variables. In the RC subgroup, HER2 + status was a significant predictive factor for the pT2 stage (HR): 36.8, CI: 4.83-797.41, P <0.01). Age less than 70 years (HR: 0.15, CI: 0.05-0.42, P <0.001) and HER2 + status (HR: 0.11, CI: 0.02-0.54, P =0.01) were favorable prognostic factors for OS after adjusting for RC pathological variables.

CONCLUSIONS

HER2 + status could be a marker for an indolent subset of MIBC and could predict favorable survival regardless of RC status. Moreover, HER2 + status not only consistently predicted a favorable T stage after RC, but also predicted better survival than pathological outcomes.

Recent advances in three-dimensional ultrasound virtual cystoscopy in modeling and local staging for urothelial carcinoma with histopathological correlation: a cohort prospective study

Background

Bladder urothelial carcinoma is an alarming urologic malignancy. Complex factors like modelling and local staging can affect treatment strategy. However, local staging, particularly the muscle invasion status, significantly influences decisions regarding treatment strategies. Therefore, this study aims to evaluate the novel advances of three-dimensional (3D) ultrasound (US) imaging to assess local staging in comparison with conventional cystoscopy.

Methods

Forty-three patients with painless haematuria and conventional cystoscopy findings of bladder mass underwent 3D US virtual cystoscopy. All specimens from conventional cystoscopy were processed histologically.

Results

Out of 43 participants, 18 (41.9%) patients proved to have invasive urothelial carcinoma by histopathology. The 3D US had a sensitivity of 97.5% and a specificity of 100%; however conventional cystoscopy was accurate in only 53.5% of the studied cases. Furthermore, in the case of malignant ulcers, mural extension into both the submucosal and the muscle layers was more readily appreciated in multiplanar images.

Conclusion

3D US updates are promising for use in bladder tumour modelling and local staging; however, they can be of value in evaluating mural and extramural tumour extent and have proven accuracy.

Bladder cancer

Bladder cancer is a global health issue with sex differences in incidence and prognosis. Bladder cancer has distinct molecular subtypes with multiple pathogenic pathways depending on whether the disease is non-muscle invasive or muscle invasive. The mutational burden is higher in muscle-invasive than in non-muscle-invasive disease. Commonly mutated genes include TERT, FGFR3, TP53, PIK3CA, STAG2 and genes involved in chromatin modification. Subtyping of both forms of bladder cancer is likely to change considerably with the advent of single-cell analysis methods. Early detection signifies a better disease prognosis; thus, minimally invasive diagnostic options are needed to improve patient outcomes. Urine-based tests are available for disease diagnosis and surveillance, and analysis of blood-based cell-free DNA is a promising tool for the detection of minimal residual disease and metastatic relapse. Transurethral resection is the cornerstone treatment for non-muscle-invasive bladder cancer and intravesical therapy can further improve oncological outcomes. For muscle-invasive bladder cancer, radical cystectomy with neoadjuvant chemotherapy is the standard of care with evidence supporting trimodality therapy. Immune-checkpoint inhibitors have demonstrated benefit in non-muscle-invasive, muscle-invasive and metastatic bladder cancer. Effective management requires a multidisciplinary approach that considers patient characteristics and molecular disease characteristics.

Contrast-enhanced Ultrasound Combined With Elastography for the Evaluation of Muscle-invasive Bladder Cancer in Rats

OBJECTIVES

By comparing with the control group, we evaluated the usefulness of contrast-enhanced ultrasound (CEUS) combined with elastography for the assessment of muscle invasion by bladder cancer (MIBC) in a Sprague-Dawley (SD) rat model.

METHODS

In the experimental group, 40 SD rats developed in situ bladder cancer (BLCA) in response to N-methyl-N-nitrosourea treatment, whereas 40 SD rats were included in the control group for comparison. We compared PI, Emean , microvessel density (MVD), and collagen fiber content (CFC) between the two groups. In the experimental group, Bland-Altman test was used to assess the relationships between various parameters. The largest Youden value was used as the cut-off point, and binomial logistic regression analysis was performed to analyze the PI and Emean . Receiver operating characteristic (ROC) curve analysis was performed to determine the diagnostic power of parameters, individually and in combination.

RESULTS

The PI, Emean , MVD, and CFC were significantly lower in the control group than in the experimental group (P < .05). The PI, Emean , MVD, and CFC were significantly higher for MIBC than for non-muscle-invasive bladder cancer (P < .05). There were significant correlations between PI and MVD, and between Emean and CFC. The diagnostic efficiency analysis showed PI had the highest sensitivity, CFC had the highest specificity, and PI + Emean had the highest diagnostic efficacy.

CONCLUSION

CEUS and elastography can distinguish lesions from normal tissue. PI, MVD, Emean , and CFC were useful for the detection of BLCA myometrial invasion. The comprehensive utilization of PI and Emean improved diagnostic accuracy and have clinical application.

Bladder preservation after neoadjuvant therapy - 2021 IBCN updates part 1

The morbidity associated with radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC) has fueled investigations into the feasibility of bladder preservation strategies after a favorable clinical response to neoadjuvant therapy (NAT). Identifying optimal candidates for bladder preservation is predicated on our ability to identify tumors with inherent cisplatin sensitivity and accurately stage patients before and after NAT. In the present review, we evaluate the accuracy and limitations of contemporary staging modalities and investigate clinical outcomes in patients with MIBC who were managed with bladder preservation after NAT. Lastly, we discuss the predictive role of cisplatin-sensitizing DNA damage response (DDR) gene alterations as a foundational component to current prospective clinical trials evaluating bladder preservation in the setting of MIBC.

Vascular Enlargement as a Predictor of Nodal Involvement in Bladder Cancer

In bladder cancer (BC), the evaluation of lymph node (LN) involvement at preoperative imaging lacks specificity. Since neoangiogenesis is paired with lymphatic involvement, this study aims to evaluate the presence of perivesical venous ectasia as an indirect sign of LN involvement, together with other conventional CT findings. All the patients who underwent radical cystectomy (RC) for BC between January 2017 and December 2019 with available preoperative contrast-enhanced CT (CECT) within 1 month before surgery were included. Patients without available pathological reports (and pTNM stage) or who underwent neoadjuvant treatments and palliative RC were excluded. Two readers in blind assessed the nodal shape and hilum, the short axis, and the contrast enhancement of suspicious pelvic LNs, the Largest Venous Diameter (LVD) efferent to the lesion, and the extravesical tumor invasion. In total, 38 patients (33 males) were included: 17 pT2, 17 pT3, 4 pT4; pN+: 20/38. LN short axis > 5 mm, LN enhancement, and LVD > 3 mm were significantly correlated with N+ at pathology. LVD > 3 mm had a significantly higher sensitivity and specificity (≥90%, AUC = 0.949) and was an independent predictor (p = 0.0016).

CT of the urinary tract revisited

Computed tomography (CT) of the abdomen is usually appropriate for the initial imaging of many urinary tract diseases, due to its wide availability, fast scanning and acquisition of thin slices and isotropic data, that allow the creation of multiplanar reformatted and three-dimensional reconstructed images of excellent anatomic details. Non-enhanced CT remains the standard imaging modality for assessing renal colic. The technique allows the detection of nearly all types of urinary calculi and the estimation of stone burden. CT is the primary diagnostic tool for the characterization of an indeterminate renal mass, including both cystic and solid tumors. It is also the modality of choice for staging a primary renal tumor. Urolithiasis and urinary tract malignancies represent the main urogenic causes of hematuria. CT urography (CTU) improves the visualization of both the upper and lower urinary tract and is recommended for the investigation of gross hematuria and microscopic hematuria, in patients with predisposing factors for urologic malignancies. CTU is highly accurate in the detection and staging of upper tract urothelial malignancies. CT represents the most commonly used technique for the detection and staging of bladder carcinoma and the diagnostic efficacy of CT staging improves with more advanced disease. Nevertheless, it has limited accuracy in differentiating non-muscle invasive bladder carcinoma from muscle-invasive bladder carcinoma. In this review, clinical indications and the optimal imaging technique for CT of the urinary tract is reviewed. The CT features of common urologic diseases, including ureterolithiasis, renal tumors and urothelial carcinomas are discussed.

Performance of Node-RADS Scoring System for a Standardized Assessment of Regional Lymph Nodes in Bladder Cancer Patients

BACKGROUND

Current cross-sectional imaging modalities exhibit heterogenous diagnostic performances for the detection of a lymph node invasion (LNI) in bladder cancer (BCa) patients. Recently, the Node-RADS score was introduced to provide a standardized comprehensive evaluation of LNI, based on a five-item Likert scale accounting for both size and configuration criteria. In the current study, we hypothesized that the Node-RADS score accurately predicts the LNI and tested its diagnostic performance.

METHODS

We retrospectively reviewed BCa patients treated with radical cystectomy (RC) and bilateral extended pelvic lymph node dissection, from January 2019 to June 2022. Patients receiving preoperative systemic chemotherapy were excluded. A logistic regression analysis tested the correlation between the Node-RADS score and LNI both at patient and lymph-node level. The ROC curves and the AUC depicted the overall diagnostic performance. In addition, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for different cut-off values (>1, >2, >3, >4).

RESULTS

Overall, data from 49 patients were collected. Node-RADS assigned on CT scans images, was found to independently predict the LNI after an adjusted multivariable regression analysis, both at the patient (OR 3.36, 95%CI 1.68-9.40, p = 0.004) and lymph node (OR 5.18, 95%CI 3.39-8.64, p < 0.001) levels. Node-RADS exhibited an AUC of 0.87 and 0.91 at the patient and lymph node levels, respectively. With increasing Node-RADS cut-off values, the specificity and PPV increased from 57.1 to 97.1% and from 48.3 to 83.3%, respectively. Conversely, the sensitivity and NPV decreased from 100 to 35.7% and from 100 to 79.1%, respectively. Similar trends were recorded at the lymph node level. Potentially, Node-RADS > 2 could be considered as the best cut-off value due to balanced values at both the patient (77.1 and 78.6%, respectively) and lymph node levels (82.4 and 93.4%, respectively).

CONCLUSIONS

The current study lays the foundation for the introduction of Node-RADS for the regional lymph-node evaluation in BCa patients. Interestingly, the Node-RADS score exhibited a moderate-to-high overall accuracy for the identification of LNI, with the possibility of setting different cut-off values according to specific clinical scenarios. However, these results need to be validated on larger cohorts before drawing definitive conclusions.

Underlying mechanisms of change in cancer prevalence in older U.S. adults: contributions of incidence, survival, and ascertainment at early stages

PURPOSE

To quantitatively evaluate contributions of trends in incidence, relative survival, and stage at diagnosis to the dynamics in the prevalence of major cancers (lung, prostate, colon, breast, urinary bladder, ovaries, stomach, pancreas, esophagus, kidney, liver, and skin melanoma) among older U.S. adults age 65 +.

METHODS

Trend partitioning was applied to the Surveillance, Epidemiology, and End Results Program data for 1973-2016.

RESULTS

Growth of cancer prevalence in older adults decelerated or even decreased over time for all studied cancers due to decreasing incidence and improving survival for most of cancers, with a smaller contribution of the stage at cancer diagnosis. Changes in the prevalence of cancers of the lung, colon, stomach, and breast were predominantly due to decreasing incidence, increasing survival and more frequent diagnoses at earlier stages. Changes in prevalence of some other cancers demonstrated adverse trends such as decreasing survival in localized and regional stages (urinary bladder and ovarian) and growing impact of late-stage diagnoses (esophageal cancer).

CONCLUSION

While decelerating or decreasing prevalence of many cancers were due to a beneficial combination of decreasing incidence and increasing survival, there are cancers for which decelerating prevalence is due to lack of improvement in their stage-specific survival and/or increasing frequency of diagnosis at advanced stages. Overall, if the observed trends persist, it is likely that the burden associated with cancer prevalence in older U.S. adults will be lower  comparing to projections based on constant increasing prevalence have previously estimated.

Mesenchymal neoplasms of the urinary bladder: a comprehensive review with focus on cross-sectional imaging findings

Mesenchymal neoplasms of the urinary bladder are exceedingly rare and display remarkable diversity. These tumors demonstrate distinct pathological features as well as variable biological behavior and cross-sectional imaging findings. The rarity of tumors, nonspecific symptoms and seemingly normal cystoscopic findings (particularly with small and exophytic tumors) frequently lead to misdiagnosis or missed diagnosis. While some tumors display characteristic cross-sectional imaging findings that may suggest a diagnosis, imaging findings are mostly nonspecific. Histopathological examination is required for accurate diagnosis, management and prognostication. The purpose of this article is to review the cross-sectional imaging findings of a diverse spectrum of mesenchymal tumors of the urinary bladder.

Neuroendocrine Neoplasms of the Female Genitourinary Tract: A Comprehensive Overview

Simple Summary

Primary neuroendocrine neoplasms (NENs) are a rare, heterogeneous group of tumors that include well-differentiated neuroendocrine tumors, poorly differentiated neuroendocrine carcinoma, and paraganglioma. NENs in the urinary tract are observed in <0.05% of individuals, in whom the bladder is the most common site. In this review, we described the epidemiology, pathogenesis, imaging, staging, and management of the genitourinary NENs.

Abstract

Primary neuroendocrine neoplasms are a rare heterogeneous group of tumors that include well-differentiated neuroendocrine tumors, poorly differentiated neuroendocrine carcinoma, and paraganglioma. An extensive literature search was used to compile the data regarding epidemiology, pathogenesis, imaging features, and management of the urinary system NENs. We also included the updated staging of the NENs at various locations of the urinary system.

Implications for pelvic lymph node irradiation in definitive chemoradiotherapy of node negative muscle invasive bladder cancer based on predictive factors of clinicopathologic discrepancy

PURPOSE

To identify pre-surgical imaging predictive value and factors associated with the clinicopathologic discrepancy for implication of definitive pelvic radiotherapy in clinically node-negative bladder cancer.

METHOD

The documented data of bladder cancer patients who underwent radical cystectomy plus pelvic lymphadenectomy were collected retrospectively. Patients' characteristics, last imaging, pathology reports, disease-specific survival and overall survival were retrieved.

RESULTS

From 142 patients, pre-surgical imaging had a sensitivity of 76.4%, specificity of 73.7%, positive predictive value (PPV) of 94.9%, and negative predictive value (NPV) of 32.6% (p value < 0.0001) for detection of muscle invasion. Also, for detection of positive lymph nodes, imaging had a sensitivity of 31.8%, specificity of 85.7%, PPV of 50%, and NPV of 73.7% (p value: 0.022). 44.4% of study population were upstaged after surgery (24.6% associated with N-upstaging) and 18.3% were downstaged (12% associated with N-downstaging). Receipt of neoadjuvant chemotherapy and T-stage were not correlated with N-upstaging. On multivariate analysis, lymphovascular invasion (LVI) maintained its significance for independent prediction of upstaging (OR 3.3, 95% CI 1.5-7.5, p value: 0.004) and inversely with downstaging (OR 0.34, 95% CI 0.12-0.96, p value: 0.04). Older age (OR 1.03, 95% CI 1.0-1.05, p value 0.047), positive margins (OR 2.1, 95% CI 1.2-3.8, p value 0.011), presence of LVI (OR 2.5, 95% CI 1.4-4.7, p value 0.003), perineural invasion (OR 2.0, 95% CI 1.2-3.4, p value 0.013), and lymph node ratio (OR 1.011, 95% CI 1.001-1.021, p value 0.03) were associated with worse survival. Also, N-upstaging independently predicted a worse survival after controlling for surgical pathology stage (OR 2.3, 95% CI 1.2-4.5, p value 0.011).

CONCLUSIONS

The optimal target volume in definitive chemoradiotherapy of node-negative bladder cancer patients remains to be established. Since then, customizing the treatment is considered especially for positive LVI in TURBT specimen.

[Modern tomography imaging techniques in urological diseases]

BACKGROUND

Radiologic imaging is important for the detection, staging and follow-up of urological tumors. Basic therapy decisions for both oncological (surgical vs. systemic therapy, e.g. in testicular cancer) and non-oncological pathologies (interventional vs. conservative therapy, e.g. for ureteral stones) depend largely on the tomographic imaging performed. Due to its almost ubiquitous availability, speed and cost-effectiveness, computed tomography (CT) plays an important role not only in the clarification of abdominal trauma and non-traumatic emergencies, but also in staging and follow-up of oncological patients. However, the level of radiation exposure, impaired renal function and allergies to iodinated contrast media limit the use of CT. Magnetic resonance imaging (MRI) can be a good alternative for many areas of application in oncological and non-oncological imaging due to its high soft tissue differentiation and functional-specific protocols but without the use of ionizing radiation.

AIM

In the following, the main indications of abdominal and pelvic CT and MRI in urology and their limitations are summarized.

RESULTS

The areas of application between CT and MRI are increasingly overlapping, since the latest developments in CT continue to further reduce radiation exposure and increase contrast information, while the speed and robustness of MRI are significantly improving at the same time.

The impact of 18F-fluorodeoxyglucose PET/computed tomography on clinical staging in bladder cancer

AIM

To determine the impact of 18F-FDG PET/computed tomography (CT) on clinical staging in bladder cancer with comparison to conventional CT and MRI.

METHODS

A total of 142 patients who underwent 18F-FDG PET/CT imaging with a diagnosis of bladder cancer between 1 June 2019 and 31 December 2020 were screened retrospectively. Seventy patients who underwent diagnostic CT or MRI within 2 months before or after PET/CT were included in the study. The N and M stages determined by CT, MRI and PET/CT according to the eighth version of the TNM staging system were recorded. T-test was used to determine the levels of significant difference, and univariate logistic regression analysis was used to evaluate the impact of the T stage on nodal up-staging.

RESULTS

According to the PET/CT, the N stage increased in 19 patients (27.14%) and decreased in seven patients (10%). Likewise, the M stage increased in 16 patients (22.86%) and decreased in seven patients (10%). The N stage determined by PET/CT was confirmed by pathologic examination in all cases in which the two modalities were inconsistent. In muscle-invasive cases, the rate of increase in the N stage after PET/CT (36.95%) was found to be significantly higher than in that of cases without invasion (8.33%) (P = 0.011). Increasing T stage was associated with an increase in the N stage after PET/CT (odds ratio: 2.33, 95% confidence interval: 1.02-5.28, P = 0.042).

CONCLUSION

18F-FDG PET/CT can potentially change the clinical stage determined by CT and MRI when used for staging in bladder cancer, and can lead to nodal up-staging particularly in cases with muscle-invasive bladder cancer.

Novel Therapeutic Opportunities in Neoadjuvant Setting in Urothelial Cancers: A New Horizon Opened by Molecular Classification and Immune Checkpoint Inhibitors

Muscle invasive bladder cancer (MIBC) is a widespread malignancy with a worse prognosis often related to a late diagnosis. For early-stage MIBC pts, a multidisciplinary approach is mandatory to evaluate the timing of neoadjuvant chemotherapy (NAC) and surgery. The current standard therapy is platinum-based NAC (MVAC-methotrexate, vinblastine, doxorubicin, and cisplatin or Platinum–Gemcitabine regimens) followed by radical cystectomy (RC) with lymphadenectomy. However, preliminary data from Vesper trial highlighted that dose-dense NAC MVAC is endowed with a good pathological response but shows low tolerability. In the last few years, translational-based research approaches have identified several candidate biomarkers of NAC esponsiveness, such as ERCC2, ERBB2, or DNA damage response (DDR) gene alterations. Moreover, the recent consensus MIBC molecular classification identified six molecular subtypes, characterized by different sensitivity to chemo- or targeted or immunotherapy, that could open a novel procedure for patient selection and also for neoadjuvant therapies. The Italian PURE-01 phase II Trial extended data on efficacy and resistance to Immune Checkpoint Inhibitors (ICIs) in this setting. In this review, we summarize the most relevant literature data supporting NAC use in MIBC, focusing on novel therapeutic strategies such as immunotherapy, considering the better patient stratification and selection emerging from novel molecular classification.

Oncogenic E3 ubiquitin ligase NEDD4 binds to KLF8 and regulates the microRNA-132/NRF2 axis in bladder cancer

The neuronally expressed developmentally downregulated 4 (NEDD4) gene encodes a ubiquitin ligase that targets the epithelial sodium channel for degradation and has been implicated in tumor growth in various cancers. Hence, in this study, we intended to characterize the functional relevance of the NEDD4-mediated Kruppel-like factor 8/microRNA-132/nuclear factor E2-related factor 2 (KLF8/miR-132/NRF2) axis in the development of bladder cancer. NEDD4 and KLF8 were overexpressed in bladder cancer tissues and were associated with poorer patient survival rates. In bladder cancer cells, NEDD4 intensified the stability and transcriptional activity of KLF8 through ubiquitination to augment cell viability and migratory ability. Our investigations revealed that NEDD4 promotes the binding of KLF8 to the miR-132 promoter region and inhibits the expression of miR-132. KLF8 inhibited the expression of miR-132 to augment the viability and migratory ability of bladder cancer cells. Furthermore, miR-132 downregulated the expression of NRF2 to restrict the viability and migratory ability of bladder cancer cells. In addition, in vivo findings verified that NEDD4 regulates the KLF8/miR-132/NRF2 axis by accelerating tumor growth and lung metastasis. In conclusion, this study highlights NEDD4 as a potential therapeutic target against tumor recurrence and metastasis in bladder cancer.

Diagnostic benefit of multiparametric MRI over contrast-enhanced CT in patients with bladder cancer: A single-center 1-year experience

PURPOSE

To assess the clinical applicability of local tumor staging in urinary bladder cancer (BC) with preoperative multiparametric MRI (mpMRI) using the five-point Vesical Imaging-Reporting and Data System (VI-RADS) scoring system and to compare it to dual-phase contrast-enhanced computed tomography (CECT).

METHODS

33 patients with primary untreated bladder cancer underwent CECT followed by preoperative multiparametric 3.0 T MRI between July 2019 and August 2020 and were enrolled in this retrospective study. Two radiologists initially performed staging on the CECT image data sets and - blinded to CT results - on subsequent mpMRI. BCs were staged according to the VI-RADS scoring system. Postoperative pathology was correlated to the VI-RADS score and the CECT results. The performance of VI-RADS in determining detrusor muscle invasion was analyzed using a receiver operating characteristic curve. Based on the histopathology, sensitivity, specificity and accuracy for muscle invasiveness between both image modalities were compared using the Chi square test.

RESULTS

A total of 33 patients (29 male, median age 70 years, IQR: 59-81 years) were included. 10 tumors were categorized as non-muscle invasive (30%) and 23 as muscle invasive BC (70%) in final histology. Tumor stages were correctly assigned as being either muscle invasive or non-muscle invasive on both CECT and mpMRI with regard to both early and late stages of BC (Ta-Tis and T3a-T4b). T-stages bordering the histopathologic limits of muscle invasiveness (T1-T2a-b) resulted in overestimation of muscle invasion in 43% of cases (VI-RADS 3-4) for the mpMRI image data sets and in an underestimation of muscle invasion in up to 55.5% of cases analysing the CECT data. Sensitivity and specificity for the determination of muscle invasion in CECT and mpMRI were 80%/80% and 74%/61% for Radiologist#1 and 70%/90% and 83%/70% for Radiologist#2, respectively.

CONCLUSIONS

There are advantages and disadvantages of both CECT and mpMRI when used in the clinical assessment of BC muscular tumor invasion. In borderline cases, only the combination of cross-sectional imaging and histopathological staging may help in making the optimal treatment decisions.

Visual MRI T-category versus VI-RADS evaluation from multiparametric MRI in the detection of muscle-invasion in patients with suspected bladder cancer: single centre registered clinical trial (MIB-trial)

BACKGROUND

Multiparametric Magnetic Resonance Imaging (mpMRI) has been proposed to add value in the diagnostic pathway of bladder cancer (BC). We wanted to evaluate the performance of mpMRI for muscle-invasion detection in BC patients using a subjective MRI visual T-category and the Vesical Imaging-Reporting and Data System (VI-RADS) score.

METHODS

This single centre clinical trial included 45 patients with suspected BC (ClinicalTrials.gov Identifier: NCT02662166). All patients had mpMRI prior to transurethral resection of bladder tumour (TUR-BT). The imaging was correlated to histopathological findings. Two individual radiologists evaluated all the mpMRI images. A binary cut-off point for the detection of muscle-invasion in the MRI visual T-category was defined between T1 and T2 and the VI-RADS cut-off score was 3. Cohen's Kappa values were used to evaluate the agreement between the two radiologists. Sensitivity, Specificity, Area Under Receiver Operator Characteristics Curve (AUC), Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were calculated to evaluate the performance of both radiologists separately.

RESULTS

AUC values for reader A and B using the MRI visual T-category were 0.76 and 0.56, while the corresponding values for VI-RADS were 0.63 and 0.57, respectively. There was no statistically significant difference between the radiologists nor the reporting systems (p > .05) in the detection of muscle-invasion. The inter-reader agreement was substantial (0.61-0.80).

CONCLUSION

Both the subjective MRI visual T-category and VI-RADS score had only a low to moderate accuracy for the detection of muscle-invasion in BC with no statistically significant difference between the reporting systems.

Deep Learning on Enhanced CT Images Can Predict the Muscular Invasiveness of Bladder Cancer

Background

Clinical treatment decision making of bladder cancer (BCa) relies on the absence or presence of muscle invasion and tumor staging. Deep learning (DL) is a novel technique in image analysis, but its potential for evaluating the muscular invasiveness of bladder cancer remains unclear. The purpose of this study was to develop and validate a DL model based on computed tomography (CT) images for prediction of muscle-invasive status of BCa.

Methods

A total of 441 BCa patients were retrospectively enrolled from two centers and were divided into development (n=183), tuning (n=110), internal validation (n=73) and external validation (n=75) cohorts. The model was built based on nephrographic phase images of preoperative CT urography. Receiver operating characteristic (ROC) curves were performed and the area under the ROC curve (AUC) for discrimination between muscle-invasive BCa and non-muscle-invasive BCa was calculated. The performance of the model was evaluated and compared with that of the subjective assessment by two radiologists.

Results

The DL model exhibited relatively good performance in all cohorts [AUC: 0.861 in the internal validation cohort, 0.791 in the external validation cohort] and outperformed the two radiologists. The model yielded a sensitivity of 0.733, a specificity of 0.810 in the internal validation cohort and a sensitivity of 0.710 and a specificity of 0.773 in the external validation cohort.

Conclusion

The proposed DL model based on CT images exhibited relatively good prediction ability of muscle-invasive status of BCa preoperatively, which may improve individual treatment of BCa.

The Role of Molecular Imaging in a Muscle-Invasive Bladder Cancer Patient: A Narrative Review in the Era of Multimodality Treatment

Diagnostic imaging in bladder cancer plays an important role since it is needed from pretreatment staging to follow-up, but a morphological evaluation performed with both CT and MRI showed low sensitivities and specificities in detecting pathologic lymph nodes, due to the occurrence of false positive results. Implementation of functional information provided by PET/CT could be a determinant in the management of patients with muscle-invasive bladder cancer. A focus on the role of ¹⁸F-FDG PET/CT and alternative tracers in patients with muscle-invasive bladder cancer is provided in this analysis in order to outline its potential applications in staging settings and response evaluation after neoadjuvant chemotherapy.

Therapeutic Effects of Curcumin against Bladder Cancer: A Review of Possible Molecular Pathways

There are concerns about the increased incidence of cancer both in developing and developed countries. In spite of recent progress in cancer therapy, this disease is still one of the leading causes of death worldwide. Consequently, there have been rigorous attempts to improve cancer therapy by looking at nature as a rich source of naturally occurring anti-tumor drugs. Curcumin is a well-known plant-derived polyphenol found in turmeric. This compound has numerous pharmacological effects such as antioxidant, anti-inflammatory, antidiabetic and anti-tumor properties. Curcumin is capable of suppressing the growth of a variety of cancer cells including those of bladder cancer. Given the involvement of various signaling pathways such as PI3K, Akt, mTOR and VEGF in the progression and malignancy of bladder cancer, and considering the potential of curcumin in targeting signaling pathways, it seems that curcumin can be considered as a promising candidate in bladder cancer therapy. In the present review, we describe the molecular signaling pathways through which curcumin inhibits invasion and metastasis of bladder cancer cells.

Application of deep learning as a noninvasive tool to differentiate muscle-invasive bladder cancer and non-muscle-invasive bladder cancer with CT

OBJECTIVE

To construct a deep-learning convolution neural network (DL-CNN) system for the differentiation of muscle-invasive bladder cancer (MIBC) and non-muscle-invasive bladder cancer (NMIBC) on contrast-enhanced computed tomography (CT) images in patients with bladder cancer.

MATERIALS AND METHODS

A total of 1200 cross-sectional CT images were obtained from 369 patients with bladder cancer receiving radical cystectomy from January 2015 to June 2018, including 249 non-muscle-invasive bladder cancer (NMIBC) series and 120 muscle-invasive bladder cancer (MIBC) series. All eligible images were distributed randomly into the training, validation, and testing cohorts with ratios of 70 %, 15 %, and 15 %, respectively. We developed one small DL-CNN containing four convolutional and max pooling layers and eight DL-CNNs with pretrained bases from the ImageNet dataset to differentiate NMIBC from MIBC. The intermediate activations were applied on the test dataset to visualize how successive DL-CNN layers transform their input.

RESULTS

The area under the receiver operating characteristic curve (AUROC) of the validation and testing datasets for the small DL-CNN was 0.946 and 0.998, respectively. The AUROCs of eight deep learning algorithms with pretrained bases ranged from 0.762 to 0.997 in the testing dataset. The VGG16 model had the largest AUROC of 0.997 among the eight algorithms with a sensitivity and specificity of 0.889 and 0.989. The independent features encoded by the small DL-CNN filters were displayed as assemblies of individual channels.

CONCLUSION

Based on contrast-enhanced CT images, our DL-CNN system could successfully classify NMIBC and MIBC with favorable AUROC in patients with bladder cancer. The application of our system in early stage might assist the pathological examination for the improvement of diagnostic accuracy.

Imaging of Bladder Cancer: Standard Applications and Future Trends

The evolution in imaging has had an increasing role in the diagnosis, staging and follow up of bladder cancer. Conventional cystoscopy is crucial in the diagnosis of bladder cancer. However, a cystoscopic procedure cannot always depict carcinoma in situ (CIS) or differentiate benign from malignant tumors prior to biopsy. This review will discuss the standard application, novel imaging modalities and their additive role in patients with bladder cancer. Staging can be performed with CT, but distinguishing between T1 and T2 BCa (bladder cancer) cannot be assessed. MRI can distinguish muscle-invasive from non-muscle-invasive tumors with accurate local staging. Vesical Imaging-Reporting and Data System (VI-RADS) score is a new diagnostic modality used for the prediction of tumor aggressiveness and therapeutic response. Bone scintigraphy is recommended in patients with muscle-invasive BCa with suspected bony metastases. CT shows low sensitivity for nodal staging; however, PET (Positron Emission Tomography)/CT is superior and highly recommended for restaging and determining therapeutic effect. PET/MRI is a new imaging technique in bladder cancer imaging and its role is promising. Texture analysis has shown significant steps in discriminating low-grade from high-grade bladder cancer. Radiomics could be a reliable method for quantitative assessment of the muscle invasion of bladder cancer.

Urothelial Carcinoma of the Bladder: Radiologic Perspective

방광암은 비교적 흔히 진단되는 암이며 재발이 흔해 영상의학적 검사에서 흔히 만날 수 있다. 방광암의 정확한 진단과 병기 평가는 어떤 치료를 할 것인지를 정하고 예후를 평가하는데 큰 영향을 미친다. 방광암의 임상적 병기 평가는 요도경유방광종양절제술로 진단과 치료를 겸해서 이루어졌지만, 저평가되는 경우가 흔히 있다. 수술 전 방광암의 위치, 크기, 근육층 침범 유무, 림프절전이, 원격전이, 상부요로 암 유무 등을 영상의학적 검사에서 정확히 진단 및 평가할 수 있다면 더욱 적절히 처치 및 관리를 할 수 있다. 이런 정확한 진단을 위해서는 영상을 판독하는 영상의학과 의사는 먼저 방광암의 임상적인 특징을 잘 알고 있어야 한다. 그리고 영상 검사들의 종류와 특징, 한계를 알고 있어야 한다. 최근 자기공명영상의 발달로 방광 영상의 질 및 방광암의 진단과 평가가 향상되었다. 그리고 방광 이미징 보고 및 데이터시스템이 발표되어 객관적으로 방광암의 근육층 침범 가능성을 평가할 수 있게 되었다. 방광암 치료 종류를 알고 그에 따른 치료 후 변화에는 무엇이 있는지 어떻게 평가하는지도 알아야 하겠다. 이 종설에서는 방광 요로상피세포암의 특징과 다양한 영상의학 검사와 소견에 대해서 알아보고자 한다.

The Role of Imaging in Bladder Cancer Diagnosis and Staging

Bladder cancer (BC) is the most common cancer of the urinary tract in the United States. Imaging plays a significant role in the management of patients with BC, including the locoregional staging and evaluation for distant metastatic disease, which cannot be assessed at the time of cystoscopy and biopsy/resection. We aim to review the current role of cross-sectional and molecular imaging modalities for the staging and restaging of BC and the potential advantages and limitations of each imaging modality. CT is the most widely available and frequently utilized imaging modality for BC and demonstrates good performance for the detection of nodal and visceral metastatic disease. MRI offers potential value for the locoregional staging and evaluation of muscular invasion of BC, which is critically important for prognostication and treatment decision-making. FDG-PET/MRI is a novel hybrid imaging modality combining the advantages of both MRI and FDG-PET/CT in a single-setting comprehensive staging examination and may represent the future of BC imaging evaluation.

Cutting-edge Management of Muscle-invasive Bladder Cancer in 2020 and a Glimpse into the Future

This case-based discussion describes the clinical course of a 63-yr-old patient who presented with gross hematuria and was diagnosed with a muscle-invasive bladder cancer at transurethral resection. Computed tomography revealed a locally advanced tumor, and the patient underwent neoadjuvant chemotherapy followed by open radical cystectomy with standard pelvic lymph node dissection. In a step-by-step fashion, we elaborate on diagnostic and therapeutic treatment options from two different vantage points: (1) guideline-adherent treatment with the state-of-the-art standard of care, and (2) a glimpse into the future discussing the evidence of potential additional or alternative approaches based on recent scientific advances. PATIENT SUMMARY: In this case-based discussion, we follow the clinical course of a patient with advanced bladder cancer and elaborate how the state-of-the-art treatment looks like in 2020, based on the best available evidence. This is compared with potential future treatment strategies, which may change and alternate our understanding of optimal bladder cancer care.

MRI of Bladder Cancer: Local and Nodal Staging

Accurate staging of bladder cancer (BC) is critical, with local tumor staging directly influencing management decisions and affecting prognosis. However, clinical staging based on clinical examination, including cystoscopy and transurethral resection of bladder tumor (TURBT), often understages patients compared to final pathology at radical cystectomy and lymph node (LN) dissection, mainly due to underestimation of the depth of local invasion and the presence of LN metastasis. MRI has now become established as the modality of choice for the local staging of BC and can be additionally utilized for the assessment of regional LN involvement and tumor spread to the pelvic bones and upper urinary tract (UUT). The recent development of the Vesical Imaging-Reporting and Data System (VI-RADS) recommendations has led to further improvements in bladder MRI, enabling standardization of image acquisition and reporting. Multiparametric magnetic resonance imaging (mpMRI) incorporating morphological and functional imaging has been proven to further improve the accuracy of primary and recurrent tumor detection and local staging, and has shown promise in predicting tumor aggressiveness and monitoring response to therapy. These sequences can also be utilized to perform radiomics, which has shown encouraging initial results in predicting BC grade and local stage. In this article, the current state of evidence supporting MRI in local, regional, and distant staging in patients with BC is reviewed. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY STAGE: 2 J. Magn. Reson. Imaging 2020;52:649-667.