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Clinical Value of T2-Weighted Imaging Combined with Diffusion-Weighted Imaging in Preoperative T Staging of Urinary Bladder Cancer

Posted Jul 31, 2013 Updated Apr 10, 2023
By Lian-Ming Wu MD , Xiao-Xi Chen MD , Jian-Rong Xu MD PhD , Xiao-Fei Zhang MD , Si-Teng Suo ME , Qiu-Ying Yao MD , Yu Fan MD , Jia-Ni Hu PhD
12 min read

Rationale and Objectives

To prospectively assess the incremental value of diffusion-weighted imaging (DWI) combined with T2-weighted images (T2WI) in determining the T stage of bladder cancer by using pathologic findings as the reference standard.

Materials and Methods

This study is approved by the institutional review board; informed consent was waived. The study includes 362 patients (age range, 48–87 years; mean, 71 years) who underwent 3.0-T magnetic resonance imaging and histologic examination. Three observers with varying experience levels reviewed the T2WI data alone, DWI data alone, and combined T2WI and DWI data. Sensitivity, specificity, accuracy, and area under curve (AUC) were determined with the Z test after adjusting for data clustering.

Results

For differentiating Tis to T1 tumors from T2 to T4 tumors, the AUCs for T2WI and DWI (0.97 for observer 1 and 0.96 for observer 2) were greater than those for the DWI alone (0.92 for observer 1 and 0.90 for observer 2) ( P < .05). Observer 3 had similar AUCs for T2WI and DWI compared to DWI alone. The accuracy of T2WI and DWI (observer 1, 98%; observer 2, 96%; observer 3, 92%) was greater than that of DWI alone (observer 1, 92%; observer 2, 90%; observer 3, 87%) for all observers ( P < .05). The specificity of T2WI and DWI (observer 1, 100%; observer 2, 98%; observer 3, 93%) was greater than that of DWI alone (observer 1, 92%; observer 2, 90%; observer 3, 87%) for all observers ( P < .05). Sensitivity was not improved even when T2WI and DWI were used. For differentiating Tis to T2 Tumors from T3 to T4 Tumors, the overall accuracy, specificity, and AUC for diagnosing T2 or higher stages were not significantly improved by combiningT2WI and DWI.

Conclusions

T2WI combined with DWI can be a reliable sequence for preoperative evaluation of T stage urinary bladder cancer. It is particularly more useful in differentiating T1 or lower tumors from T2 or higher tumors compared to DWI alone.

Bladder cancer (BC) is a common type of cancer that can cause substantial morbidity and mortality among both men and women. BC causes 14,880 deaths per year in the United States . Clinical management of urinary BC is determined primarily on the basis of distinguishing superficial tumors (stage T1 or lower) from muscle-invasive tumors (stage T2 or higher), as proper treatment options differ considerably between these two stages. Superficial tumors are treated with transurethral resection (TUR) with or without adjuvant intravesical chemotherapy or photodynamic therapy , whereas invasive tumors are treated with radical cystectomy, radiation therapy, chemotherapy, or a combination . Therefore, preoperative imaging studies play an important diagnostic role in precisely differentiating between the two categories of BC.

Computed tomography (CT), as the preferred method for the staging of BC, has high accuracy in the diagnosis of BC . However, it cannot reliably determine the depth of tumor invasion into the bladder wall, the involvement of adjacent organs, or the presence of nodal disease . In addition, the high radiation exposure and the need for an ionizing contrast agent encourage the use of other imaging modalities for muscle-invasive BC (MIBC) staging . The reported magnetic resonance (MR) staging accuracy for bladder carcinoma ranges from 72% to 96% . Staging is improved with gadolinium enhancement . However, accurate staging with imaging techniques is difficult because of the thinness of the bladder wall, which accounts for the difficulty in distinguishing superficial invasion (pT2a) from deep muscle invasion (pT2 b) and deep muscle invasion from minor tumor extension into perivesical fat (pT3a) .

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Materials and methods

Patients

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MRI Examination

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MR Image Analysis

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Table 1

T Staging for Bladder Cancer

Stage Description N Staging Definition DWI T2WI Tis Carcinoma in situ 257 A thin, flat, high SI area corresponding to the tumor or a high SI tumor with a low SI submucosal stalk or a thickened submucosa Low SI line was present Ta Papillary noninvasive tumor T1 Tumor invades subepithelial connective tissue T2a Tumor invades superficial muscle 25 A high SI tumor without a submucosal stalk and with a smooth tumor margin The low SI line was disrupted focally in the region underlying the tumor T2 b Tumor invades deep muscle T3a Tumor invades perivesical tissue microscopically 40 Extension into the perivesical fat with an irregular margin T3 b Tumor invades perivesical tissue macroscopically T4a Tumor invades prostate, uterus, or vagina 22 Extension into adjacent organs T4 b Tumor invades pelvic or abdominal wall

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Statistical Analysis

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Result

Tumor Characteristics

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Figure 1, A 70-year-old man with urinary bladder carcinomas pathologically diagnosed as stage Tis. (a) Axial T2-weighted image shows a superficial flat lesion at the posterior bladder wall to the left side confined to the wall ( arrow ). (b) Diffusion-weighted image showing a superficial lesion as hyperintense growth and confined to the superficial lining of the bladder ( arrow ).

Figure 2, A 82-year-old man with urinary bladder carcinomas pathologically diagnosed as stage T1. (a) Axial T2-weighted magnetic resonance image shows a soft tissue mass on posterior bladder wall ( arrow ). (b) Axial diffusion-weighted magnetic resonance image shows C-shaped high SI area with a low SI stalk connecting to posterior side of bladder wall ( arrow ).

Figure 3, A 55-year-old man with urinary bladder carcinomas pathologically diagnosed as stage T2. (a) Axial T2-weighted image shows a oval mass with intermediate SI mass on the left lateral wall ( arrow ). (b) Diffusion-weighted magnetic resonance image shows the mass with high SI infiltrating the muscle with no perivesical extension ( arrow ).

Figure 4, A 71-year-old man with urinary bladder carcinomas pathologically diagnosed as stage T3. (a) Axial T2-weighted image shows a soft tissue mass at posterior bladder wall to the right side wall invading the perivesical fat ( arrow ). (b) Diffusion-weighted magnetic resonance image axial image shows tumor with irregular margin spreading toward surrounding fat tissue ( arrow ).

Figure 5, A 68-year-old man with urinary bladder carcinomas pathologically diagnosed as stage T4. (a) Axial T2-weighted image shows diffuse soft tissue mass at the anterior wall with extravesical extension to the left side reaching the pelvic wall. (b) Diffusion-weighted magnetic resonance image showing the hyperintense extension of the mass to the left side reaching the pelvic wall.

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Comparison of Accuracy of Imaging Acquisitions

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Table 2

AUCs of Three Data Sets for Differentiating Stage Tis to T1 Tumors from T2 to T4 Tumors for Three Observers

Observer T2WI Alone DWI Alone T2WI and DWI_P_ Value ∗ P Value † 1 0.90 (0.86–0.94) 0.92 (0.88–0.96) 0.97 (0.95–1.00) <.0001 .001 2 0.86 (0.82–0.91) 0.90 (0.77–0.94) 0.96 (0.93–0.99) <.0001 .014 3 0.85 (0.81–0.80) 0.90 (0.86–0.94) 0.95 (0.93–0.98) <.0001 .184

Data in parentheses are 95% confidence intervals.

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Figure 6, Graphs of receiver operating characteristic curves for differentiating Tis to T1 tumors from T2 to T4 bladder tumors for (a) reader 1, (b) reader 2, (c) reader 3. T2WI, T2-weighted imaging; DWI, diffusion-weighted imaging.

Table 3

AUCs of Three Data Sets for Differentiating Stage Tis to T2 Tumors from T3 to T4 Tumors for Three Observers

Observer T2WI Alone DWI Alone T2WI and DWI_P_ Value ∗ P Value † 1 0.92 (0.88–0.97) 0.96 (0.92–0.99) 0.99 (0.98–1.00) .079 .151 2 0.90 (0.85–0.96) 0.95 (0.91–0.99) 0.98 (0.96–1.00) .051 .164 3 0.88 (0.82–0.94) 0.93 (0.89–0.98) 0.96 (0.92–0.99) .128 .135

Data in parentheses are 95% confidence intervals.

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Table 4

Comparison of Three Data Sets for Differentiating Stage Tis to T1 Tumors from T2 to T4 Tumors for Three Observers

Parameter T2WI Alone DWI Alone T2WI and DWI_P_ Value ∗ P Value † Reader 1 Sensitivity 91 (96/105) 91 (96/105) 94 (99/105) .297 .297 Specificity 79 (203/257) 92 (236/257) 100 (257/257) <.001 <.001 Accuracy 83 (299/362) 92 (332/362) 98 (356/362) <.001 <.001 Reader 2 Sensitivity 87 (91/105) 89 (93/105) 92 (97/105) .13 .241 Specificity 73 (188/257) 91 (234/257) 98 (252/257) <.001 <.001 Accuracy 77 (279/362) 90 (327/362) 96 (349/362) <.001 <.001 Reader 3 Sensitivity 81 (85/105) 86 (90/105) 89 (93/105) .089 .340 Specificity 71 (182/257) 88 (226/257) 93 (239/257) <.001 <.001 Accuracy 74 (267/362) 87 (316/362) 92 (332/362) <.001 <.001

Data are percentages, with numbers used to calculate percentages in parentheses.

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Table 5

Comparison of Three Data Sets for Differentiating Stage Tis to T2 Tumors from T3 to T4 Tumors for Three Observers

Parameter T2WI Alone DWI Alone T2WI and DWI_P_ Value ∗ P Value † Reader 1 Sensitivity 85 (53/62) 88 (55/62) 92 (57/62) .198 .381 Specificity 94 (265/282) 96 (271/282) 100 (282/282) <.001 <.001 Accuracy 92 (318/344) 95 (326/344) 99 (339/344) <.001 .005 Reader 2 Sensitivity 81 (50/62) 85 (53/62) 89 (55/62) .159 .395 Specificity 91 (257/282) 95 (268/282) 97 (274/282) .002 .138 Accuracy 74 (307/344) 93 (321/344) 96 (329/344) <.001 .121 Reader 3 Sensitivity 72 (45/62) 83 (51/62) 87 (54/62) .036 .309 Specificity 85 (240/282) 91 (257/282) 94 (265/282) <.001 .131 Accuracy 83 (285/344) 90 (308/344) 93 (319/344) <.001 .090

Data are percentages, with numbers used to calculate percentages in parentheses.

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Figure 7, Graphs of receiver operating characteristic curves for differentiating Tis to T2 tumors from T3 to T4 bladder tumors for (a) reader 1, (b) reader 2, (c) reader 3. T2WI, T2-weighted images; DWI, diffusion-weighted imaging.

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Comparison of Observer Accuracy for T2WI and DWI

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Discussion

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Academic Radiology, Volume 20, Issue 8
Journals General Radiology
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