Staging and Staging Errors in Bladder Cancer

Comparing fluorodeoxyglucose positron emission tomography with computed tomography in staging for nodal and distant metastasis in urothelial/bladder cancer

Objectives

We aim to assess the clinical value of 18F-fluorodeoxyglucose positron (18F-FDG-PET) scan in detecting nodal and distant metastasis compared with computed tomography (CT) scan in patients with urothelial carcinoma or bladder cancer, aiming to improve staging accuracy and thereby better prognosticate and determine therapy.

Methods

A retrospective review of 75 patients with invasive bladder cancer (≥T1) who were staged with both CT and 18F-FDG-PET within an 8-week interval was performed for the period between 2015 and 2020. Seventy-two per cent (54/75) had formal pelvic lymph node (LN) dissection or biopsy of lesions suspicious for metastases. FDG-PET definitions for positive sites were assessed depending on SUV Max (nodes with SUVmax >4 at any size, SUV > 2 for lymph nodes >8 mm, or any SUV if the lymph node was >10 mm on axial images). For CT scanning, enlarged LN by RECIST 1.1 criteria (>10 mm) as well as qualitative findings suggesting metastasis were considered positive. The analysis was based on the comparison of CT and 18F-FDG-PET findings to histopathology results from LN dissection or biopsies.

Results

Sensitivity, specificity, positive predictive values (PPV) and negative predictive value (NPV) of CT versus FDG-PET for detecting metastasis, in patients who underwent pelvic LN dissection or biopsy of lesions suspicious of metastases, were 46.6% (95% CI: 21%-70%) versus 60% (95% CI: 32%-84%), 100% (95% CI: 91%-100%) versus 83.78% (95% CI: 69%-94%), 100% (95% CI: 63%-100%) versus 60% (95% CI: 32%-84%), and 82.2% (95% CI: 68%-92%) versus 83.78% (95% CI: 69%-94%), respectively. 7/75 (9.3%) patients avoided cystectomy due to 18F-FDG-PET features of metastases that were not detected by CT.

Conclusion

FDG-PET may be more sensitive than CT for metastases in the staging of bladder cancer, which resulted in significant avoidance of aggressive local management in cases with occult metastasis.

Performing Automatic Identification and Staging of Urothelial Carcinoma in Bladder Cancer Patients Using a Hybrid Deep-Machine Learning Approach

Accurate clinical staging of bladder cancer aids in optimizing the process of clinical decision-making, thereby tailoring the effective treatment and management of patients. While several radiomics approaches have been developed to facilitate the process of clinical diagnosis and staging of bladder cancer using grayscale computed tomography (CT) scans, the performances of these models have been low, with little validation and no clear consensus on specific imaging signatures. We propose a hybrid framework comprising pre-trained deep neural networks for feature extraction, in combination with statistical machine learning techniques for classification, which is capable of performing the following classification tasks: (1) bladder cancer tissue vs. normal tissue, (2) muscle-invasive bladder cancer (MIBC) vs. non-muscle-invasive bladder cancer (NMIBC), and (3) post-treatment changes (PTC) vs. MIBC.

Circulating tumor cells correlating with Ki-67 predicts the prognosis of bladder cancer patients

PURPOSE

To investigate the value of circulating tumor cells (CTCs) and Ki-67 in predicting the prognosis of bladder cancer. Here, we tested CTC counts and Ki-67 levels to assess patient prognosis.

METHODS

84 patients with bladder cancer who underwent surgery were included in this study. Peripheral blood CTCs were detected by SE-iFISH technology before and after surgery, and Ki-67 levels were analyzed by immunohistochemistry. The association between CTCs and Ki-67 and the combination of the two was analyzed to predict the prognosis of patients.

RESULTS

76 out of 84 patients (90.5%) were positive. ROC curve analysis showed that preoperative and postoperative CTC counts = 4 and 2 were the best thresholds for predicting patient recurrence or death. In multivariate analysis, high postoperative CTC count (≥ 2) (P < 0.001) and Ki-67 high expression (≥ 15%) (P < 0.001) were independent poor prognostic factors for PFS in bladder cancer patients. In addition, the study found that Ki-67 levels were positively correlated with high postoperative CTC counts, Bladder cancer patients with Ki-67 high expression and high postoperative CTC counts were associated with extremely poor progression-free survival.

CONCLUSION

Ki-67 high expression is associated with high postoperative CTC counts, both of which predict poor prognosis in bladder cancer patients.

Diagnostic accuracy of vesical imaging-reporting and data system (VI-RADS) in suspected muscle invasive bladder cancer: A systematic review and diagnostic meta-analysis

OBJECTIVE

To investigate the accuracy of Vesical Imaging-Reporting and Data System (VI-RADS) in detection of muscle-invasive bladder cancer (MIBC) we performed a systematic review and meta-analysis of the available literature.

MATERIALS AND METHODS

Scopus, Web of Science, PubMed, and EMBASE were searched up to 8 March 2021 for the studies evaluating the diagnostic performance of VI-RADS for the detection of MIBC. Inclusion criteria were patients with bladder cancer; index test of VI-RADS based on multiparametric MRI; reference test of histopathological findings from TURBT, re-TURBT, or cystectomy and study design of cohort. Case reports, review articles, and editorials were eliminated, as well as studies with insufficient knowledge to acquire TP, FP, FN, and TN values of VI-RADS. The MIDAS module of STATA was for statistical analysis. The heterogeneity was explored using subgroup analysis and meta-regression analysis.

RESULTS

Overall, 22 eligible studies, consisting of 2,576 participants and 5,414 MRI reports, were included in this meta-analysis. The area under curve (AUC) of VI-RADS at cut-point values of 3 and 4 were 0.93 (95%CI: 0.91, 0.95), 0.93 (95%CI: 0.90, 0.95), respectively. Based on Youden's J statistic, the optimal VI-RADS cutoff value for predicting MIBC was determined as 3 which granted a pooled sensitivity of 89% (95%CI: 87%, 91%; I²=48%) and a specificity of 84% (95%CI: 80%, 87%; I²=90%). Based on meta-regression, the sources of inter-study heterogeneity for VI-RADS ≥ 3 were the sample size > 70, study design, single-center vs multi-center, patient population characteristics (i.e., gender, age), reference standard, histology, magnetic strength, T2WI slice thickness, and the number of radiologists reporting the MRI results (P value ≤ 0.01).

CONCLUSION

The VI-RADS demonstrates consistently high diagnostic accuracy to predict MIBC. This scoring system could be applied in standard staging MRI reports of bladder cancer and can be incorporated into future MIBC work up guidelines.

Application of nanotechnology in the diagnosis and treatment of bladder cancer

Bladder cancer (BC) is a common malignancy in the genitourinary system and the current theranostic approaches are unsatisfactory. Sensitivity and specificity of current diagnosis methods are not ideal and high recurrence and progression rates after initial treatment indicate the urgent need for management improvements in clinic. Nanotechnology has been proposed as an effective method to improve theranosis efficiency for both non-muscle invasive bladder cancer (NMIBC) and muscle invasive bladder cancer (MIBC). For example, gold nanoparticles (AuNPs) have been developed for simple, fast and sensitive urinary sample test for bladder cancer diagnosis. Nanoparticles targeting bladder cancers can facilitate to distinguish the normal and abnormal bladder tissues during cystoscopy and thus help with the complete removal of malignant lesions. Both intravenous and intravesical agents can be modified by nanotechnology for targeted delivery, high anti-tumor efficiency and excellent tolerability, exhibiting encouraging potential in bladder cancer treatment. Photosensitizers and biological agents can also be delivered by nanotechnology, intermediating phototherapy and targeted therapy. The management of bladder cancer remained almost unchanged for decades with unsatisfactory effect. However, it is likely to change with the fast-developed nanotechnology. Herein we summarized the current utility of nanotechnology in bladder cancer diagnosis and treatment, providing insights for the future designing and discovering novel nanoparticles for bladder cancer management.

Tissue clearing to examine tumour complexity in three dimensions

The visualization of whole organs and organisms through tissue clearing and fluorescence volumetric imaging has revolutionized the way we look at biological samples. Its application to solid tumours is changing our perception of tumour architecture, revealing signalling networks and cell interactions critical in tumour progression, and provides a powerful new strategy for cancer diagnostics. This Review introduces the latest advances in tissue clearing and three-dimensional imaging, examines the challenges in clearing epithelia - the tissue of origin of most malignancies - and discusses the insights that tissue clearing has brought to cancer research, as well as the prospective applications to experimental and clinical oncology.

Expression of CD10 in urothelial carcinoma of the bladder and its correlation with histopathological grade, pathological stage, and survival of patients

Background

CD10 plays a role in signal transduction pathway and regulation of cell growth apoptosis, and therefore, it has been evaluated in different malignancies. The present study was conducted to study the immunoexpression of CD10 in urothelial carcinoma and to correlate it with histological grade, pathological stage, and survival of patients.

Materials and Methods

The study included 51 cases of urothelial carcinoma diagnosed on histopathology along with 50 controls having nonneoplastic urothelium. All the cases and controls were subjected to CD10 immunostaining. The CD10 expression was compared between the cases and controls and was also correlated with histological grade, pathological stage, histomorphological features, and 1-year survival.

Results

The study included 78.4% of high-grade urothelial carcinoma (HGUC) and 21.6% of low-grade urothelial carcinoma. The positive score of CD10 expression was observed in 68.6% of cases, while 96% of controls observed negative immunostaining. About 90.9% of low-grade carcinoma observed score 0, while 83.7% of high grade observed positive score of 1 and 2. Although there was statistical significant difference between CD 10 score and stage of tumor, its expression did not correlate with 1-year survival of cases.

Conclusion

CD10 expression increases with the grade of tumor and thus may be helpful in differentiating low grade from HGUC. Its expression also increases with stage and poor prognostic factors suggesting its possible role in pathogenesis and progression of urothelial carcinoma. CD 10 may be further analyzed for molecular targeted therapy against urothelial carcinoma.

Microfluidic Assaying of Circulating Tumor Cells and Its Application in Risk Stratification of Urothelial Bladder Cancer

Bladder cancer is characterized by its frequent recurrence and progression. Effective treatment strategies need to be based on an accurate risk stratification, in which muscle invasiveness and tumor grade represent the two most important factors. Traditional imaging techniques provide preliminary information about muscle invasiveness but are lacking in terms of accuracy. Although as the gold standard, pathological biopsy is only available after the surgery and cannot be performed longitudinally for long-term surveillance. In this work, we developed a microfluidic approach that interrogates circulating tumor cells (CTCs) in the peripheral blood of bladder cancer patients to reflect the risk stratification of the disease. In a cohort of 48 bladder cancer patients comprising 33 non-muscle invasive bladder cancer (NMIBC) cases and 15 muscle invasive bladder cancer (MIBC) cases, the CTC count was found to be considerably higher in the MIBC group compared with the NMIBC group (4.67 vs. 1.88 CTCs/3 mL, P=0.019), and was significantly higher in high-grade bladder cancer patients verses low-grade bladder cancer patients (3.69 vs. 1.18 CTCs/3mL, P=0.024). This microfluidic assay of CTCs is believed to be a promising complementary tool for the risk stratification of bladder cancer.

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.

18F-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography in muscle-invasive bladder cancer

PURPOSE OF REVIEW

In this narrative review, we assessed the role of F-fluoro-2-deoxy-D-glucose-positron emission tomography/CT (FDG-PET/CT) in preoperative staging and response evaluation of neoadjuvant chemotherapy in muscle-invasive bladder carcinoma (MIBC), and to assess its incremental value to contrast-enhanced (CE)CT and MRI in terms of patient management at initial diagnosis and detection of recurrence.

RECENT FINDINGS

A literature search in PubMed yielded 46 original reports, of which 15 compared FDG-PET/CT with CECT and one with MRI. For primary tumor assessment, FDG-PET/CT proved not accurate enough (13 reports; n = 7-70). For lymph node assessment, sensitivity of FDG-PET/CT is superior to CT with comparable specificity in 19 studies (n = 15-233). For detection of distant metastases, data from eight studies (n = 43-79) suggests that FDG-PET/CT is accurate, although comparative studies are lacking. Limited evidence (four studies, n = 19-50) suggests that FDG-PET/CT is not accurate for response evaluation of neoadjuvant chemotherapy. FDG-PET/CT incited change(s) in patient management in 18-68% of patients (five reports; n = 57-103). For detection of recurrence, seven studies (n = 29-287) indicated that FDG-PET/CT is accurate.

SUMMARY

Most studies evaluated FDG-PET/CT for lymph node assessment and reported higher sensitivity than CT, with comparable specificity. FDG-PET/CT showed incremental value to CECT for recurrence and often incited change(s) in patient management.

De Ritis ratio: how effectively can we use in bladder cancer management?

Background: This study aims to determine the relationship between the pre-operative De Ritis ratio (DRR) and bladder cancer (BCa) pathological subtypes. Results & methodology: A total of 248 patients with primary BCa were included. Univariate and multivariate analyses were performed to identify whether DRR can be a risk factor for the presence of carcinoma in situ (CIS). There was a statistically significant difference between the nonmuscle invasive BCa risk groups and the muscle-invasive BCa group according to the median DRR levels (p < 0.001). DRR was an independent risk factor for the presence of CIS in multivariate analysis (OR: 1.909; 95% CI: 0.030-0.196; p = 0.008). Discussion & conclusion: DRR can be considered as an independent risk factor for the presence of CIS in patients with primary BCa.

Current Management of Localized Muscle-Invasive Bladder Cancer: A Consensus Guideline from the Genitourinary Medical Oncologists of Canada

BACKGROUND: Despite recent advances in the management of muscle-invasive bladder cancer (MIBC), treatment outcomes remain suboptimal, and variability exists across current practice patterns. OBJECTIVE: To promote standardization of care for MIBC in Canada by developing a consensus guidelines using a multidisciplinary, evidence-based, patient-centered approach who specialize in bladder cancer. METHODS: A comprehensive literature search of PubMed, Medline, and Embase was performed; and most recent guidelines from national and international organizations were reviewed. Recommendations were made based on best available evidence, and strength of recommendations were graded based on quality of the evidence. RESULTS: Overall, 17 recommendations were made covering a broad range of topics including pathology review, staging investigations, systemic therapy, local definitive therapy and surveillance. Of these, 10 (59% ) were level 1 or 2, 7 (41% ) were level 3 or 4 recommendations. There were 2 recommendations which did not reach full consensus, and were based on majority opinion. This guideline also provides guidance for the management of cisplatin-ineligible patients, variant histologies, and bladder-sparing trimodality therapy. Potential biomarkers, ongoing clinical trials, and future directions are highlighted. CONCLUSIONS: This guideline embodies the collaborative expertise from all disciplines involved, and provides guidance to further optimize and standardize the management of MIBC.

Can preoperative imaging characteristics predict pT3 bladder cancer following cystectomy?

PURPOSE

Imaging characteristics in bladder cancer (BC), such as hydronephrosis, are predictive of ≥ pT3 disease at time of radical cystectomy (RC). The predictive capacity of other findings, such as perivesical stranding (PS), remains unclear. We investigated whether PS was associated with ≥ pT3 BC in patients who did not receive neoadjuvant chemotherapy (NAC).

METHODS

We identified 433 patients with BC who underwent RC from 2003 to 2018 of which 128 did not receive NAC. Evidence of PS on pre-TURBT imaging was determined by radiologist review and a stranding grading system was created. Factors associated with PS and hydronephrosis were identified. Multivariable logistic regressions evaluated PS and hydronephrosis as predictors for ≥ pT3 BC.

RESULTS

Of the 128 patients who did not receive NAC, 48 (38%) had pT3 and 12 (9%) had pT4 BC. 125 (98%) patients had CT and three (2%) had MRI. PS and hydronephrosis on imaging were identified in 19 (15%) and 45 (35%) patients. PS was not associated with imaging type (p = 0.38), BMI (p = 0.18), or pathologic T stage (p = 0.24). Hydronephrosis was more frequently associated with higher pathologic T stage (p = 0.034). Multivariable analysis demonstrated that PS was not predictive of ≥ pT3 BC (p = 0.457), while hydronephrosis was positively associated (p = 0.003). Stratification by grade of stranding did not improve the predictive capacity of PS (p = 0.667).

CONCLUSION

While hydronephrosis is an indicator of higher stage BC, PS failed to be a reliable predictor of ≥ pT3 stage. These observations should give pause in using PS on imaging to guide decisions until further investigations can be explored.

Semantic segmentation to identify bladder layers from H&E Images

BACKGROUND

Identification of bladder layers is a necessary prerequisite to bladder cancer diagnosis and prognosis. We present a method of multi-class image segmentation, which recognizes urothelium, lamina propria, muscularis propria, and muscularis mucosa layers as well as regions of red blood cells, cauterized tissue, and inflamed tissue from images of hematoxylin and eosin stained slides of bladder biopsies.

METHODS

Segmentation is carried out using a U-Net architecture. The number of layers was either, eight, ten, or twelve and combined with a weight initializers of He uniform, He normal, Glorot uniform, and Glorot normal. The most optimal of these parameters was found by through a seven-fold training, validation, and testing of a dataset of 39 whole slide images of T1 bladder biopsies.

RESULTS

The most optimal model was a twelve layer U-net using He normal initializer. Initial visual evaluation by an experienced pathologist on an independent set of 15 slides segmented by our method yielded an average score of 8.93 ± 0.6 out of 10 for segmentation accuracy. It took only 23 min for the pathologist to review 15 slides (1.53 min/slide) with the computer annotations. To assess the generalizability of the proposed model, we acquired an additional independent set of 53 whole slide images and segmented them using our method. Visual examination by a different experienced pathologist yielded an average score of 8.87 ± 0.63 out of 10 for segmentation accuracy.

CONCLUSIONS

Our preliminary findings suggest that predictions of our model can minimize the time needed by pathologists to annotate slides. Moreover, the method has the potential to identify the bladder layers accurately. Further development can assist the pathologist with the diagnosis of T1 bladder cancer.

Preliminary Study on Selected Markers of Oxidative Stress, Inflammation and Angiogenesis in Patients with Bladder Cancer

In recent years, bladder cancer (BC) has been reported as one of the most commonly occurring cancers among older people, and its detection is still difficult. Therefore, there is a need to search for additional useful markers of disease. Some studies indicate the important roles of inflammation and oxidative stress (OS) in bladder tumour pathogenesis. The aim of this study was to examine the levels of selected markers of OS, inflammation and angiogenesis in blood plasma/serum samples derived from patients with BC, and a healthy control group. Moreover the degrees of change and strength of correlation between values of the analysed markers and tumour stage or grade were estimated. Concentrations of: malondialdehyde (MDA) and advanced oxidation protein products (AOPP), and total antioxidant status (TAS) divided into slow (TAS-s) and fast (TAS-f) antioxidants (spectrophotometric measurement), angiogenin (ANG) (immunoenzymatic method) and C-reactive protein (CRP) (immunoturbidimetric method) were determined in both the studied groups. The majority of values of the examined parameters were significantly higher among patients, while subfractions of TAS were significantly lower in comparison to the control group. Moreover, different values and different strengths of correlation between the examined parameters and cancer stage or grade were noticed. The most significant changes for CRP were observed in T2 and for MDA in G3, while the lowest TAS-f activity was revealed in G1 patients. Increased values of OS parameters, angiogenesis and inflammation markers, in combination with reduced TAS subfractions activity in BC are important in its pathogenesis and will be helpful in estimation of patients' condition.

Comparative effectiveness of radical cystectomy and radiotherapy without chemotherapy in frail patients with bladder cancer

Objectives: To evaluate cancer-specific (CSS) and overall survival (OS) in a group of frail patients who were treated with RT without chemotherapy and to compare them with a matched cohort of patients treated with RC.Methods: This study identified 71 patients treated with RT only for high-risk bladder cancer. Patients with metastatic (cN + or cM+) or non-resectable tumors (cT4) and those who received any form of chemotherapy were excluded. Patients where matched 1:1 using propensity scores which adjusted for the effects of age, clinical stage and age-adjusted Charlson comorbidity index (CCI). OS and CSS were evaluated using the Cox proportional hazards regression model and the Fine and Gray competing risk model.Results: In the overall population, RT was associated with worse OS (HR = 1.78, 95% CI = 1.15-2.77, p = 0.01) compared to RC, but not with CSS (HR 1.1, p = 0.74). In the matched cohort, RT was neither associated with OS nor CSS (p > 0.05) compared to RC. In the competing risk analyses no statistically significant association of any of the treatments was observed in the total or in the matched data set (p > 0.05).Conclusion: The use of RT may be an alternative option in well selected patients with limited disease who are considered unfit for systemic chemotherapy and RC. Future research should focus on improving patient selection and assess the quality-of-life as well as the need for reintervention in patients treated with RT.

Preoperative imaging for locoregional staging of bladder cancer

Bladder cancer is the ninth most common cancer, expected to lead to an estimated 17,670 deaths in the United States in 2019. Clinical management and prognosis of bladder cancer mainly depend on the extent of locoregional disease, particularly whether bladder muscle is involved. Therefore, bladder cancer is often divided into superficial, non-muscle-invasive bladder cancer and muscle-invasive bladder cancer; the latter often prompts consideration for cystectomy. While precise staging prior to cystectomy is crucial, the optimal preoperative imaging modality used to stage the disease remains controversial. Transurethral resection of bladder tumor (TURBT) followed by computed tomography (CT) urography is the current recommended approach for staging bladder cancer but suffers from a high rate of understaging. We review the recent literature and compare different imaging modalities for assessing the presence of muscle invasion and lymph node involvement prior to cystectomy and highlight the advantages of each modality.

Role of imaging techniques in the diagnosis and follow-up of muscle-invasive bladder carcinoma

INTRODUCTION

Muscle-invasive bladder malignancies represent 20-30% of all bladder cancers. These patients require imaging tests to determine the regional and distant staging.

OBJECTIVE

To describe the role of various imaging tests in the diagnosis, staging and follow-up of muscle-invasive bladder cancer. To assess recent developments in radiology aimed at improving the sensitivity and specificity of local staging and treatment response.

ACQUISITION OF EVIDENCE

We conducted an updated literature review.

SYNTHESIS OF THE EVIDENCE

Computed tomography and magnetic resonance imaging (MRI) are the tests of choice for performing proper staging prior to surgery. Computed tomography urography is currently the most widely used technique, although it has limitations in local staging. Ultrasonography still has a limited role. Recent developments in MRI have improved its capacity for local staging. MRI has been suggested as the test of choice for the follow-up, with promising results in assessing treatment response. Positron emission tomography could improve the detection of adenopathies and extrapelvic metastatic disease.

CONCLUSIONS

Imaging tests are essential for the diagnosis, staging and follow-up of muscle-invasive bladder cancer. Recent technical developments represent important improvements in local staging and have opened the possibility of assessing treatment response.

Diagnostic performance of diffusion-weighted MR imaging at 3.0 T in predicting muscle invasion in urinary bladder cancer: utility of evaluating the morphology of the reactive tumor stalk

PURPOSE

To evaluate the diagnostic performance of stalk morphology on diffusion-weighted imaging (DWI) in comparison with conventional MRI in predicting muscle invasion in urinary bladder cancer.

METHODS

The study was prospective and approved by the institutional ethics committee. A written informed consent was obtained from all the patients. The study included 56 patients who presented with bladder mass between January 2014 and November 2015. After excluding 16 patients, 40 patients with 92 tumors were assessed. All the 40 patients underwent MRI at 3.0 Tesla (Achieva, Philips) inclusive of DWI (b0, 500, 1000 and 1500). Two radiologists evaluated the images independently, and disparities were resolved through consensus. For predicting muscle invasion on T2-weighted images, tumor morphology (papillary versus non-papillary), distensibility of the underlying bladder wall, and perivesical fat infiltration were evaluated. On DWI, the criterion used in a previous study (Takeuchi et al.) was used along with tumor stalk morphology. Findings were compared with histopathology using Pearson's χ² test, and diagnostic performance indices were calculated.

RESULTS

All the evaluated features were present with significantly higher frequency in muscle-invasive tumors (p < 0.001). The finding of absent or distorted stalk on DWI had the highest sensitivity (87.5%) and specificity (97.6%). Conventional imaging features of non-papillary stalk morphology, restricted distension of underlying bladder wall, perivesical fat infiltration, as well as the previous DWI criterion were less sensitive (56.3%, 68.8%, 56.3% and 56.3%, respectively) in predicting muscle invasion.

CONCLUSIONS

Assessment of the morphology of the reactive tumor stalk on DWI has better diagnostic performance in predicting muscle invasion than conventional MRI.

Propensity Score Analysis of Radical Cystectomy Versus Bladder-Sparing Trimodal Therapy in the Setting of a Multidisciplinary Bladder Cancer Clinic

Purpose Multidisciplinary management improves complex treatment decision making in cancer care, but its impact for bladder cancer (BC) has not been documented. Although radical cystectomy (RC) currently is viewed as the standard of care for muscle-invasive bladder cancer (MIBC), radiotherapy-based, bladder-sparing trimodal therapy (TMT) that combines transurethral resection of bladder tumor, chemotherapy for radiation sensitization, and external beam radiotherapy has emerged as a valid treatment option. In the absence of randomized studies, this study compared the oncologic outcomes between patients treated with RC or TMT by using a propensity score matched-cohort analysis. Methods Data from patients treated in a multidisciplinary bladder cancer clinic (MDBCC) from 2008 to 2013 were reviewed retrospectively. Those who received TMT for MIBC were identified and matched (for sex, cT and cN stage, Eastern Cooperative Oncology Group status, Charlson comorbidity score, treatment date, age, carcinoma in situ status, and hydronephrosis) with propensity scores to patients who underwent RC. Overall survival and disease-specific survival (DSS) were assessed with Cox proportional hazards modeling and a competing risk analysis, respectively. Results A total of 112 patients with MIBC were included after matching (56 who had been treated with TMT, and 56 who underwent RC). The median age was 68.0 years, and 29.5% had stage cT3/cT4 disease. At a median follow-up of 4.51 years, there were 20 deaths (35.7%) in the RC group (13 as a result of BC) and 22 deaths (39.3%) in the TMT group (13 as a result of BC). The 5-year DSS rate was 73.2% and 76.6% in the RC and TMT groups, respectively ( P = .49). Salvage cystectomy was performed in 6 (10.7%) of 56 patients who received TMT. Conclusion In the setting of a MDBCC, TMT yielded survival outcomes similar to those of matched patients who underwent RC. Appropriately selected patients with MIBC should be offered the opportunity to discuss various treatment options, including organ-sparing TMT.

Utility of early dynamic and delayed post-diuretic 18F-FDG PET/CT SUVmax in predicting tumour grade and T-stage of urinary bladder carcinoma: results from a prospective single centre study

OBJECTIVE

Accurate pre-treatment grading and staging of bladder cancer are vital for better therapeutic decision and prognosis. The aim of the present study was to evaluate the correlation between maximum standardized uptake value (SUV_max) calculated during early dynamic and post-diuretic fluorine-18 fludeoxyglucose (¹⁸F-FDG) positron emission tomography (PET)/CT studies with grade and pT-stage of bladder cancer.

METHODS

39 patients with suspected/proven bladder carcinoma underwent 10-min early dynamic pelvic imaging and delayed post-diuretic whole-body FDG PET/CT imaging. SUV_max of the lesions derived from both studies was compared with grade and pT-stage. Relationship of SUV_max with grade and pT-stage was analyzed using independent sample t-test and analysis of variance.

RESULTS

SUV_max of the early dynamic imaging showing tumour perfusion was independent from the SUV_max of delayed imaging. High-grade tumours showed higher SUV_max than low-grade tumours in the early dynamic imaging (5.4 ± 1.4 vs 4.7 ± 1.6; p-value 0.144) with statistically significant higher value in Stage pT1 tumours (6.8 ± 0.8 vs 5.5 ± 1.2; p-value 0.04). Non-invasive pTa tumours had significantly less SUV_max than higher stage tumours during early dynamic imaging [F(4,29) = 6.860, p 0.001].

CONCLUSION

Early dynamic imaging may have a role in predicting the grade and aggressiveness of the bladder tumours and thus can help in treatment planning and prognostication. Advances in knowledge: Dynamic PET/CT is a limitedly explored imaging technique. This prospective pilot study demonstrates the utility of this modality as a potential adjunct to standard FDG PET/CT imaging in predicting the grade and aggressiveness of the bladder tumours and thus can impact the patient management.

Assessing Cancer Progression and Stable Disease After Neoadjuvant Chemotherapy for Organ-confined Muscle-invasive Bladder Cancer

OBJECTIVE

To propose and validate a new approach to stratify clinically staged, organ-confined, muscle-invasive bladder cancer patients (cT2N0M0) who are pathologic non-responders to neoadjuvant chemotherapy (NAC) to better characterize NAC non-response.

METHODS

We retrospectively identified radical cystectomy patients with cT2N0M0 disease at our institution (2005-2014) and in the National Cancer Database (2004-2012) for external validation. Patients were stratified as stable (pT2N0M0) or progressors (>pT2 or pN+). The primary end points were cancer-specific survival (CSS), overall survival (OS), and recurrence-free survival (RFS).

RESULTS

In the institutional cohort, NAC stable patients (n = 17) had better OS (P = .05) and RFS (P = .04) than NAC progressors (n = 50), and had comparable OS (P = .7) and CSS (P = .09) with non-NAC stable patients (n = 27). Multivariable Cox proportional hazard models showed that larger tumor size predicted worse OS (hazard ratio [HR] = 1.20 per centimeter, 95% confidence interval [CI: 1.07, 1.35]), CSS (HR = 1.27, 95% CI [1.11, 1.45]), and RFS (HR = 1.24, 95% CI [1.09, 1.42]). Similarly, in the National Cancer Database, NAC stable patients (n = 223) had improved OS (P < .0001) compared with NAC progressors (n = 232) and comparable (P = .4) OS with non-NAC stable patients (n = 950). Multivariable Cox proportional hazard model showed that larger tumor size (HR = 1.03 per centimeter, 95% CI [1.02, 1.03]) and progression (HR = 2.69, 95% CI [2.40, 3.01]) predicted worse OS.

CONCLUSION

Distinct survival outcomes suggest that NAC non-responders should be further stratified into stable disease and progressors. Comparable survival between non-NAC and NAC stable disease patients suggests that NAC stable disease may represent a chemoresistant but more indolent phenotype on the disease spectrum. Moreover, tumor size is an important prognostic biomarker in NAC non-responders. Clinical predictors of disease progression on NAC were not identified, highlighting the need to explore molecular and genomic subtyping determinants of disease progression.

Preoperative Imaging for Clinical Staging Prior to Radical Cystectomy

The importance of patient selection for quality outcomes following radical cystectomy is critical. Clinical staging is one of the key elements necessary for patient selection, and staging relies on accurate preoperative imaging. Many imaging modalities are available and have been utilized for preoperative staging with published operating characteristics. In this update, we review recently published literature for advances in preoperative imaging prior to radical cystectomy.

The Natural History, Treatment Pattern, and Outcomes of Patients With Micropapillary Bladder Carcinoma

OBJECTIVE

Micropapillary bladder carcinoma (MPBC) is a rare variant of urothelial cancer. Most literature on MPBC is from case series reports. This study's objective was to examine the epidemiology, natural history, and prognostic factors of MPBC using a population-based registry, in addition to a literature review.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database identified 98 histologically confirmed MPBC patients from 2001 and 2007. In addition, 213 MPBC cases were identified in published literature. The clinical, demographic characteristics, treatment, and survival outcomes were compared between these 2 cohorts.

RESULTS

Among patients identified in SEER, MPBC accounted for approximately 0.01% of primary bladder tumors, with the median age of 72 years (range, 26 to 95 y). Among the MPBC cases, 56.1% had muscle invasive disease, 75.5% had poor or undifferentiated histology, and 30.6% underwent a radical or partial cystectomy. The 1-, 3-, and 5-year overall survival rates for the SEER cohort were estimated at 84.5%, 57.3%, and 42.3%, respectively. Using multivariate analysis, tumor stage and marital status were the most significant predictors for cancer-specific survival. When comparing published single-institution studies to the SEER cohort, significant differences existed in demographic characteristics including age at diagnosis, male-to-female ratio, tumor stage, cystectomy treatment, and survival outcomes, likely reflecting differences in practice patterns.

CONCLUSIONS

This is the first population-based study to analyze MPBC's epidemiology, tumor characteristics, and survival rates. Emphases on early detection, cystectomy, and multimodality in treatment are needed.

Future directions in bladder cancer immunotherapy: towards adaptive immunity

The clinical management of bladder cancer has not changed significantly in several decades. In particular, intravesical bacillus Calmette-Guérin (BCG) immunotherapy has been a mainstay for high-risk nonmuscle invasive bladder cancer since the late 1970s/early 1980s. This is despite the fact that bladder cancer has the highest recurrence rates of any cancer and BCG immunotherapy has not been shown to induce a tumor-specific immune response. We and others have hypothesized that immunotherapies capable of inducing tumor-specific adaptive immunity are needed to impact bladder cancer morbidity and mortality. This article summarizes the preclinical and clinical development of bladder cancer immunotherapies with an emphasis on the last 5 years. Expected progress in the near future is also discussed.

Predictive value of pretreatment inflammation-based prognostic scores (neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and lymphocyte-to-monocyte ratio) for invasive bladder carcinoma

Purpose

Inflammation-based prognostic scores including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR) are associated with oncologic outcomes in diverse malignancies. We evaluated the predictive value of pretreatment prognostic scores in differentiating nonmuscle invasive (NMIBC) and muscle invasive bladder cancer (MIBC).

Materials and Methods

Consecutive transurethral resection of bladder tumour (TURBT) cases from January 2011 to December 2013 were analysed retrospectively. Patient demographics, tumour characteristics and prognostic scores results were recorded. Receiver operating characteristics curves were used to determine prognostic score cutoffs. Univariate and multivariate binomial logistic regression analysis was performed to evaluate the association between variables and MIBC.

Results

A total of 226 patients were included, with 175 and 51 having NMIBC (stages Ta and T1) and MIBC (stage T2+) groups, respectively. Median age was 75 years and 174 patients were male. The NLR cutoff was 3.89 and had the greatest area under the curve (AUC) of 0.710, followed by LMR (cutoff<1.7; AUC, 0.650) and PLR (cutoff>218; AUC, 0.642). Full blood count samples were taken a median of 12 days prior to TURBT surgery. Multivariate logistic regression analysis identified tumour grade G3 (odds ration [OR], 32.848; 95% confidence interval [CI], 9.818-109.902; p=0.000), tumour size≥3 cm (OR, 3.353; 95% CI, 1.347-8.345; p=0.009) and NLR≥3.89 (OR, 8.244; 95% CI, 2.488-27.316; p=0.001) as independent predictors of MIBC.

Conclusions

NLR may provide a simple, cost-effective and easily measured marker for MIBC. It can be performed at the time of diagnostic flexible cystoscopy, thereby assisting in the planning of further treatment.

Prognostic significance of the epithelial-to-mesenchymal transition markers e-cadherin, vimentin and twist in bladder cancer

OBJECTIVE

The goal of this study was to utilize long-term patient follow-up to determine whether epithelial-to-mesenchymal transition (EMT)-related markers can predict bladder cancer patient survival and progression of disease.

MATERIALS AND METHODS

This study included 121 patients with bladder cancer. Sixty-four of these patients presented with non-muscle invasive (NMI, stage T1) bladder cancer and 57 with muscle invasive (MI, stage T2, T3). The patients were diagnosed and treated between May 1998 and July 2012. The EMT markers E-cadherin, Twist, and Vimentin were detected via immunohistochemistry. Univariate and multivariate/Cox analyses were then utilized to determine whether these EMT markers could be useful prognostic markers for predicting bladder cancer patient outcomes.

RESULTS

Analysis of the 121 bladder cancer patients in this study revealed that the frequency of E-cadherin expression was 59.5% (72/121), Twist was 54.5% (66/121), and Vimentin was 24.8% (30/121). Twist and Vimentin were found to have statistically significant correlations with grade, recurrence, and progression but not with stage, whereas E-cadherin was associated with stage but not with the other parameters. In the univariate analysis, grade (p = 0.02) was the only significant predictor for progression-free survival (PFS). Stage, grade, and expression of E-cadherin, Vimentin and Twist were included in the multivariate analysis of predicting PFS. In this analysis, grade (p = 0.01) and Vimentin expression (p = 0.001) were found to be significant prognostic factors in predicting PFS.

CONCLUSIONS

Grade and Vimentin are potential independent indicators in predicting bladder cancer progression and survival.

[Oncological diseases and postoperative alterations of the bladder and urinary tract]

In the challenging evaluation of upper urinary tract malignancies multidetector computed tomography (CT) has become the standard imaging method. Cross sectional imaging not only allows the detection and visualization of the tumor itself but also provides nodal and metastasis staging in one examination (one-stop-shop). The majority of urothelial carcinomas are located in the urinary bladder. In this case, CT and more recently magnetic resonance imaging (MRI) can also deliver decisive information regarding TNM classification. A combination of clinical, histological, morphological and functional parameters allows both risk stratification and a targeted therapy based on the individual tumor stage.

Current role of PET, CT, MR for invasive bladder cancer

Imaging for urothelial cancer, particularly that located in the bladder, has generally been based on computed tomography (CT). However in more recent times the role of positron emission tomography-CT (PET-CT) has emerged and increasingly magnetic resonance (MR) imaging has become utilised. This concise review will outline the role of these modalities when dealing with muscle-invasive bladder cancer (MIBC).

Contemporary management of low-risk bladder cancer

Bladder cancer comprises a heterogeneous group of tumors, the majority of which are non-muscle-invasive bladder cancer (NMIBC) at initial presentation. Low-risk bladder cancer--defined as pTa low-grade papillary tumors--is the type of NMIBC with the most favorable oncologic outcome. Although the risk of progression is less than 1% in 5 years, almost 15% will recur after 1 year, and 32% after 5 years. A complete transurethral resection, followed by an immediate single postoperative instillation of chemotherapy will reduce the risk of recurrence for the first 2 years. Follow-up cystoscopy is required to detect recurrence; in the vast majority of cases the recurrent tumor is of the same stage and grade as the primary tumor. The first follow-up visit, 3 months after surgery, is the most important in predicting risk of recurrence for the future. Recent developments in profiling urine and cancer tissue make it possible to better predict risk of progression and recurrence. In the future this profiling will play an important role in the timing and the choice of treatment, as well as guiding follow-up procedures.

Optimal timing of radical cystectomy in T1 high-grade bladder cancer

T1 high-grade (formerly T1G3) bladder cancer is a challenging clinical entity representing approximately 10-15% of all new bladder cancer cases. The variable natural history of the disease and possible impairment in quality of life associated with radical treatment makes T1 high-grade one of the most challenging uro-oncological patient groups to manage. In particular, the risk of clinical understaging and not recognizing muscle-invasive disease may have detrimental effects on patient outcome. The cornerstone of contemporary staging is restaging transurethral resection (TUR), which helps in defining further management. In patients with restaging TUR stage less than T1, induction bacillus Calmette-Guérin combined with maintenance offers good results. The option of radical cystectomy should be discussed with patients with restaging TUR stage T1 or higher and it is highly recommended to all patients with recurrent T1 of carcinoma in situ during bacillus Calmette-Guérin maintenance. In addition to restaging TUR stage, several other clinicopathological factors, such T1 substaging, associated carcinoma in situ, tumor size and appearance, lymphovascular invasion, and hydronephrosis, aid in the decision making between radical and conservative treatment. Future prospects include improved staging and molecular markers that may guide toward conservative therapy or allow more cT1 patients to be offered nerve-sparing cystectomies and neobladders and, thus, improving quality of life for patients undergoing radical surgery.