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Imaging Recommendations for Diagnosis, Staging, and Management of Bladder and Urethral Malignancies

CC BY 4.0 · Indian J Med Paediatr Oncol 2023; 44(02): 268-274

DOI: DOI: 10.1055/s-0042-1760315

Author : Majithia, Jinita; Prakash, Gagan; Thakur, MH; Popat, Palak; Sable, Nilesh; Katdare, Aparna; Kulkarni, Suyash; Chandra, Daksh

Abstract

Bladder cancer (BCa) is a leading cause of cancer worldwide with high incidence and mortality across all ages. Early diagnosis and treatment can lead to significantly improved survival rate and overall prognosis. Smoking is the biggest contributing factor for the development of BCa. Urothelial carcinoma is the most common histological subtype. Commonly implemented imaging techniques include computed tomography urography (CTU) and multiparametric magnetic resonance imaging (mpMRI). CTU is the investigation of choice for muscle invasive bladder cancer (MIBC) and is best utilized for local assessment and staging of larger and higher staged tumors, that is, T3b and T4. mpMRI encompasses T2-weighted imaging, diffusion-weighted imaging, and dynamic contrast-enhanced imaging. It can differentiate ≤T1 and ≥T2 tumors based on the Vesicle Imaging-Reporting and Data System (VI-RADS) assessment as well as differentiate Ta from T1 tumors, and is useful in post-therapy response assessment of BCa. Positron emission tomography/computed tomography is used in selected patients of MIBC for metastatic evaluation, particularly those with deranged renal function. A synoptic reporting template should be used to have standardization of data. Primary urethral cancer (UCa) is a rare and aggressive malignancy, accounting for less than 1% of all malignancies. MRI is the investigation of choice for UCa.

Keywords

bladder cancer - radiology - staging - urethral cancer - urology


Publication History

Article published online:
04 May 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Thieme Medical and Scientific Publishers Pvt. Ltd.
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Abstract

Bladder cancer (BCa) is a leading cause of cancer worldwide with high incidence and mortality across all ages. Early diagnosis and treatment can lead to significantly improved survival rate and overall prognosis. Smoking is the biggest contributing factor for the development of BCa. Urothelial carcinoma is the most common histological subtype. Commonly implemented imaging techniques include computed tomography urography (CTU) and multiparametric magnetic resonance imaging (mpMRI). CTU is the investigation of choice for muscle invasive bladder cancer (MIBC) and is best utilized for local assessment and staging of larger and higher staged tumors, that is, T3b and T4. mpMRI encompasses T2-weighted imaging, diffusion-weighted imaging, and dynamic contrast-enhanced imaging. It can differentiate ≤T1 and ≥T2 tumors based on the Vesicle Imaging-Reporting and Data System (VI-RADS) assessment as well as differentiate Ta from T1 tumors, and is useful in post-therapy response assessment of BCa. Positron emission tomography/computed tomography is used in selected patients of MIBC for metastatic evaluation, particularly those with deranged renal function. A synoptic reporting template should be used to have standardization of data. Primary urethral cancer (UCa) is a rare and aggressive malignancy, accounting for less than 1% of all malignancies. MRI is the investigation of choice for UCa.


Keywords

bladder cancer - radiology - staging - urethral cancer - urology

Introduction and Epidemiology

As per GLOBOCAN 2020, there were 573,278 new cases with a total of 212,536 number of deaths associated with bladder cancer (BCa) across all ages and both sexes in the year 2020.[1] BCa was ranked 10th in incidence and 13th in mortality among all cancers, and is estimated to be the 6th most commonly diagnosed cancer in men worldwide.[1] In India, it is ranked 17th in incidence and 19th in mortality, having varying incidence rates across different regions and populations.[2]

As per the SEER statistics (Surveillance, Epidemiology, and End Results Program of the National Cancer Institute, US), the 5-year survival rate is as high as 90% for carcinoma in situ and 70% for localized disease, with a significant drop to 36% for regional and 5% for metastatic disease.[3] This indirectly reflects the success of early diagnosis and poor prognosis of metastatic disease. Improved understanding of the disease, superior imaging techniques for diagnosis, and advances in treatment have contributed to a significant decrease in the BCa-related mortality rates worldwide.[4]

A four times higher incidence rate has been observed in men than women.[5] The worldwide age-standardized incidence rate (per 100,000 person/years) is 9.5 for men and 2.4 for women.[5] Almost 90% of the newly diagnosed cases of BCa are seen in individuals of age 55 years or older with an average age of diagnosis of 73 years.[6] BCa is not typically hereditary; however, some cancer syndromes can predispose an individual to BCa, like Cowden syndrome and Lynch syndrome.[7] [8]


Risk Factors and Etiopathogenesis

Active and passive tobacco smoking has a strong relationship with BCa and is one of the greatest risk factors that is quantity and duration dependent. The relative risk for cancer-mortality from smoking is second only to lung cancer.[9] The attributable risk to smoking is similar between men and women.[5] [9] Exposure to aromatic amines, polycyclic aromatic hydrocarbons, and chlorinated hydrocarbons from dyes, paint, metal, rubber, or petroleum industries is another common preventable risk factor for BCa. Occupational exposures are responsible for approximately 18% of all BCa cases.[10] An environmental factor most commonly implicated in BCa is arsenic consumption, typically through ingestion of contaminated water.[11] Increased rates of secondary BCa have also been reported following use of external-beam radiotherapy (EBRT) for gynecological malignancies; however, lower rates have been observed with use of intensity-modulated radiotherapy for prostate cancer.[12] [13] A tropical protozoan schistosomiasis, through generation of N-nitroso carcinogenic compound,[14] and chronic bladder irritation from indwelling catheters or vesicle stones are responsible for squamous cell carcinoma (SCC) of the bladder.

Urothelial carcinoma (UC), also known as transitional cell carcinoma, is the most common subtype of BCa, seen in 90% of cases.[15] At presentation, approximately 2

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