The Role of Imaging in the Surveillance of Urologic Malignancies

Actual frequency of imaging during follow-up of testicular cancer in Israel-a comparison with the guidelines

OBJECTIVES

Computed tomography (CT) examinations are frequent in follow-up care of testicular cancer (TC) but may increase the risk for other cancers. We wanted to assess the actual number of CT and X-ray examinations within the first 5 years after a diagnosis of TC in Israel during 2003-2007.

METHODS

The database of Maccabi Healthcare Services, Israel, was searched for TC patients diagnosed in 2003 to 2007 by direct linkage with the Israel National Cancer Registry. Data on diagnostic imaging examinations (CT of chest, abdomen, or pelvis, unspecified sites; X-ray of chest) were extracted during a 5-year follow-up for 226 incident patients. The actual number of CT and X-ray examinations was compared to the National Comprehensive Cancer Network (NCCN) guideline. We tabulated the median with 10th and 90th percentiles (P10, P90) for the number of CTs and X-rays considering histology, stage, and adjuvant strategy.

RESULTS

The number of abdomen or pelvis CTs for TC patients receiving chemo- or radiotherapy was in accordance with the NCCN guideline. The median of abdomen or pelvis CTs for surveillance patients was 8.5 (P10, P90: 3; 13) for nonseminoma and 5.0 (P10, P90: 5; 13) for seminoma patients compared to 14 to 17 CTs recommended. The number of chest X-rays was lower than recommended in the guideline for all adjuvant strategies.

CONCLUSIONS

The NCCN guidelines regarding CTs were met for TC patients treated with chemo- or radiotherapy but fell below recommendations for surveillance. Guidelines from 2011 and 2012 were updated in favor of fewer CTs during surveillance.

KEY POINTS

• The number of CTs followed the NCCN guidelines in patients treated with chemo- or radiotherapy. • Surveillance patients received fewer CTs and X-rays than recommended in the NCCN guidelines from 2005. • The number of applied CT examinations corresponded to a radiation dose that did not substantially raise the lifetime risk for cancer.

[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.

Frequency of computed tomography examinations in the follow-up care of testicular cancer patients - an evaluation of patterns of care in Germany

BACKGROUND

Exposure to radiation resulting from diagnostic imaging procedures probably increases late cancer risk. Patterns of care regarding the application of computed tomography (CT) imaging in testicular cancer patients were investigated.

METHODS

The database of a large German health insurance company comprising 850,000 insured men was searched for cases of testicular cancer arising in the years 2005 and 2006. The number of CT scans applied during a 3-year period of follow-up was noted for each individual patient and the resulting cumulative radiation dose was estimated. The number of CT scans actually observed was compared to guideline recommendations.

RESULTS

177 patients were identified. Within the 3-year observation period, patients received a mean of 4.4 CT scans (standard error: 0.4) whereas a number of 6.2 would have been expected according to contemporary guidelines. Patients were exposed to an estimated total median diagnostic radiation dose of 30 millisieverts (mSv) (interquartile range: 10-54 mSv).

CONCLUSION

There is a considerable gap between recommendation and actual performance regarding the number of CT scans applied to testicular cancer patients. Unfamiliarity of clinicians with guidelines as well as poor acceptance of high numbers of CT scans scheduled may have contributed to create this particular pattern of care.

MR imaging of urinary bladder carcinoma and beyond

Detection of muscle invasion is a critical aspect in management of urinary bladder cancer. MR imaging has the potential and promise of delivering this premise noninvasively. This article reviews the current status of MR imaging in evaluation of bladder cancer. Also discussed are other important neoplastic and nonneoplastic conditions affecting the bladder.

DW-MRI of the urogenital tract: applications in oncology

Diffusion-weighted magnetic resonance imaging (DW-MRI) appears to hold promise as a non-invasive imaging modality in the detection of early microstructural and functional changes of different organs. DW-MRI is an imaging technique with a high sensitivity for the detection of a large variety of diseases in the urogenital tract. In kidneys, DW-MRI has shown promise for the characterization of solid lesions. Also in focal T1 hyperintense lesions DW-MRI was able to differentiate hemorrhagic cysts from tumours according to the lower apparent diffusion coefficient (ADC) values reported for renal cell carcinomas. Promising results were also published for the detection of prostate cancer. DW-MRI applied in addition to conventional T2-weighted imaging has been found to improve tumour detection. On a 3 T magnetic resonance unit ADC values were reported to be lower for tumours compared with the normal-appearing peripheral zone. The combined approach of T2-weighted imaging and DW-MRI also showed promising results for the detection of recurrent tumour in patients after radiation therapy. DW-MRI may improve the performance of conventional T2-weighted and contrast-enhanced MRI in the preoperative work-up of bladder cancer, as it may help in distinguishing superficial from muscle invasive bladder cancer, which is critical for patient management. Another challenging application of DW-MRI in the urogenital tract is the detection of pelvic lymph node metastases. As the ADC is generally reduced in malignant tumours and increased under inflammatory conditions, reduced ADC values were expected in patients with lymph node metastases.

A rare presentation of metastatic renal clear cell carcinoma to the tongue seen on FDG PET

Renal clear cell carcinoma has a great metastatic potential, with possibly uncommon secondary lesions, notably in the head and neck region. The role of F-18 fluorodeoxyglucose positron emission tomography (F-18 FDG PET) in the staging or follow-up of urological malignancies is still not clearly defined. We report a case of metastatic renal cell carcinoma involving the tongue and a cervical lymph node, 3 years after initial nephrectomy. The use of combined positron emission tomography/computed tomography scan showed increased F-18 FDG activity in these 2 lesions that were then diagnosed and treated by surgery. Although the diagnostic performance of F-18 FDG PET is limited in the detection of primary disease, this imaging modality can be a very useful tool in the follow-up of renal clear cell carcinoma.

MDCT Urography: Exploring a new paradigm for imaging of bladder cancer

OBJECTIVE

The purpose of this article is to review the epidemiology, staging, and treatment of bladder cancer; to discuss the role of MDCT urography for the evaluation of patients with known or suspected bladder cancer; and to address the role of MDCT urography in patients who require follow-up imaging after a diagnosis of bladder cancer has been made.

CONCLUSION

MDCT urography now has a large role in the evaluation of patients with known and suspected bladder cancer. However, its precise role has not been established. Because many bladder neoplasms will not be detected by MDCT urography and more research is needed to determine the optimal technique for diagnosing bladder cancer, we think that MDCT urography cannot replace cystoscopy at present.

Correlation of transabdominal sonographic and cystoscopic findings in the diagnosis of focal abnormalities of the urinary bladder wall: a prospective study

OBJECTIVE

The aim of this study was to prospectively assess the diagnostic capabilities of transabdominal sonography performed with newer sonography machines for showing focal bladder wall abnormalities (FBWAs) detected on cystoscopy.

METHODS

One hundred twelve consecutive patients (97 male and 15 female; mean age, 68 years) underwent cystoscopy. Reasons for referral were macroscopic hematuria (44 cases [39%]), surveillance after transurethral resection (56 cases [49.5%]), and incidental sonographic findings (12 cases [11.5%]). One to 2 days before cystoscopy, sonography was carried out by a single operator who was blinded to clinical and recent sonographic findings. The presence, size, number, and location of FBWAs (eg, polypoid vegetations and asymmetric bladder wall thickening) were recorded and compared with cystoscopic and histologic findings.

RESULTS

One hundred ten patients with a histologic diagnosis were available for the study. Benign conditions, nontransitional tumors, and transitional tumors were found in 26.3%, 3.7% and 70% of the patients, respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of sonography of cystoscopic lesions were 91.4%, 79.3%, 91.4%, 79.3%, and 88.2%. Cancers of 15 mm or smaller and flat tumors were often missed by sonography, whereas chronic cystitis accounted for most of the false-positive sonographic findings; however, sonography had poor capability of characterizing FBWAs, with specificity of 62%. In this respect, color Doppler findings proved of little aid as well.

CONCLUSIONS

In patients selected for cystoscopy, transabdominal sonography with newer sonography machines showed good diagnostic accuracy for focal alterations of the bladder wall found on cystoscopy.