Staging of muscle-invasive bladder cancer: can computerized tomography help us to decide on local treatment?

Abstract

MDCT as a preoperative staging procedure has a low accuracy in predicting the correct tumour and nodal stage, and therefore, it has little impact on decision-making for local treatment of muscle-invasive bladder cancer during radical cystectomy.

Evaluation of Computed Tomography for Lymph Node Staging in Bladder Cancer Prior to Radical Cystectomy

“…In contrast, Tritschler et al [11] reported similar over- and understaging rates (23.4 and 24.7%)[;] other studies reported even a higher chance of understaging with rates of 39% [5] and 50% [12]. We also observed a higher understaging rate with 16% compared to only 6% overstaging in our cohort with CT scans performed after TURB-T. Tritschler et al [11] also reported a similar accuracy of local staging with CT before and after TURB-T. We conclude that available data point to the conclusion that TURB-T does not frequently induce changes suggestive for overstaging. Hence, patients with a CT scan showing LA BCa (cT3/4) should also be considered for neoadjuvant chemotherapy.…”

“…For example, suspicious LN may provide a rationale to employ an inductive or neoadjuvant chemotherapeutic strategy as this may prolong survival [6,7]. There are only a few studies determining the accuracy of staging with conventional CT in the last 10 years [8,9,10,11,12]. These studies demonstrate a limited value of CT imaging with a significant fraction of both over- and understaging in comparison with the final histology after RC [8,9].…”

The importance of clinical stage among patients with a complete pathologic response at radical cystectomy after neoadjuvant chemotherapy

“…The NCCN guidelines recommend imaging with either contrast-enhanced CT scanning or MR Urography [11]; however, the sensitivity of these studies ranges from 60.0 to 76.4 % [17,18]. In order to improve staging-and by corollary assessment of response to chemotherapyalternative modalities are needed.…”

Contemporary role of advanced imaging for bladder cancer staging

“…Recommendations suggest that pelvic lymph nodes greater than or equal to 8 mm and abdominal/retroperitoneal lymph nodes Z1 cm as measured in short axis are suspicious for metastatic involvement [21]. It is well-recognized that using size the sole threshold for deeming a lymph node suspicious for metastatic involvement is fraught with potential error; metabolic and other functional activity is not being assessed and false-negative assessment can result from micrometastatic disease and false-positive assessment can results from the inability to differentiate between cancer and inflammatory enlargement [22,23].…”

“…Up to 25% of patients with lymph node metastases found on final pathology were not visualized on imaging characterization before undergoing radical cystectomy. This realized nodal understaging with conventional imaging, is a result of simply using size parameters as an indirect surrogate for predicting metastatic involvement with reported sensitivity of detecting lymph node positivity in cases of bladder cancer taken to radical cystectomy ranging between 31% and approximately 50% [22,[24][25][26]. Specificity of CT imaging based on size criteria has been reported between 68% and 100%, but falls short of consistently perfect correlation with pathology owing to enlargement of lymph nodes secondary to reactive inflammatory etiologies often propagated by prior intervention or medication administration common in this patient population who has undergone prior TURBT and possibly preoperative intravesical or systemic therapies.…”