Home Clinicopathologic Significance of High Signal Intensity on Diffusion-weighted MR Imaging in the Ureter, Urethra, Prostate and Bone of Patients with Bladder Cancer
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Clinicopathologic Significance of High Signal Intensity on Diffusion-weighted MR Imaging in the Ureter, Urethra, Prostate and Bone of Patients with Bladder Cancer

Posted Jun 30, 2012 Updated Apr 10, 2023
By Mitsuru Takeuchi MD PhD , Tomohiro Suzuki MD , Shigeru Sasaki MD PhD , Masato Ito MD PhD , Shuzo Hamamoto MD PhD , Noriyasu Kawai MD PhD , Kenjiro Kohri MD PhD , Masaki Hara MD PhD , Yuta Shibamoto MD PhD
9 min read

Rationale and Objectives

The aim of this study was to determine the clinicopathologic significance of high-intensity areas in the ureter, urethra, prostate, and bone incidentally found on diffusion-weighted magnetic resonance imaging (DWI) for the staging of bladder cancer.

Materials and Methods

Axial and sagittal DWI and T2-weighted imaging of the pelvis were evaluated in 157 patients with bladder cancer. Two observers assessed T2-weighted imaging with DWI independently. The observers pointed out 67 areas showing abnormal high signal intensity on DWI in the ureter ( n = 17), urethra ( n = 8), prostate ( n = 20), and bone ( n = 22). Of the 67 high-intensity areas, 33 lesions were confirmed histopathologically (ureter, n = 10; urethra, n = 7; prostate, n = 16), and 22 bone lesions were diagnosed using T1-weighted imaging and follow-up computed tomography. Thus, 55 lesions were evaluable for correlation with DWI findings.

Results

Of the 55 high-intensity areas, 28 (53%) were synchronous or metastatic urothelial cancer or invasion of urothelial cancer. The remaining 27 (47%) were a ureteral clot in one, a ureteral stone granuloma in one, prostatic cancer in six, granulomatous prostatitis in three, and normal red bone marrow in 16.

Conclusions

DWI is useful to comprehend the extent of bladder cancer and to detect incidentally coexisting diseases. Other imaging, endoscopic, and clinical findings would be useful to reduce false positivity.

In recent years, the usefulness of diffusion-weighted imaging (DWI) to detect various cancers, including those of the liver, breast, prostate, uterus, colorectum, and bone, has been reported . The usefulness of DWI to detect bladder cancer and determine the tumor stage has also been reported; the apparent diffusion coefficient (ADC) value of bladder cancer is low, and cancer shows high signal intensity (SI) on DWI . When interpreting pelvic DWI to determine the tumor stage of bladder cancer, abnormal high intensity is often found outside the bladder (eg, in the prostate, ureter, urethra, and bone). DWI high intensity may represent invasion or metastasis of bladder cancer, but it has not yet been clarified whether other malignant or nonmalignant lesions can also show such high intensity. Because the strategy for treating bladder cancer changes with the tumor site, extent, and stage, clarifying the clinical significance of such high-intensity areas would be very important. The purpose of this study was to evaluate the clinicopathologic significance of high-intensity areas in the prostate, ureter, urethra, or bone incidentally found on pelvic DWI performed for the purpose of staging bladder cancer.

Materials and methods

Patient Population

The subjects of this study were 157 patients with bladder cancer undergoing pelvic magnetic resonance imaging (MRI) to determine the tumor stage and repeat computed tomography (CT) of the pelvis to evaluate the node and metastasis stages between August 2006 and September 2009. All pelvic MRI studies included T2-weighted imaging (T2WI) and DWI. All patients underwent pelvic CT both at initial diagnosis and 3 to 9 months later. There were 118 men and 39 women aged 38 to 91 years (mean age, 71 years). Two abdominal radiologists reviewed 157 MRI studies and identified 67 areas that showed abnormally high SI in the ureter, urethra, prostate, or bone on DWI in 56 patients, on the basis of criteria described later. Of the patients, 29 underwent surgical intervention for areas showing high SI on DWI, including one-sided nephroureterectomy in nine, cystoprostatectomy in nine, prostatic biopsy in eight, ureteral biopsy in one, and urethral biopsy in two. From these surgical specimens, 33 high-intensity areas on DWI were histopathologically evaluable. One radiologist interpreted T1-weighted imaging (T1WI) and both computed tomographic images to diagnose 22 bony lesions on the basis of criteria described later. Finally, 55 areas in 45 patients (36 men, nine women; age range, 38–91 years; mean age, 71 years) were evaluable for correlation with DWI findings. The local institutional review board approved this retrospective study, and the requirement for patient informed consent was waived.

MRI Protocol

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DWI Interpretation

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Diagnostic Criteria

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Results

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Table 1

Summary of the Lesions Showing High Signal Intensity on DWI

Location DWI Positive Confirmed True-positive False-positive Ureter 17 10 8 2 Urethra 8 7 7 0 Prostate 20 16 7 9 Bone 22 22 6 16 All 67 55 28 27

DWI, diffusion-weighted imaging.

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Ureter

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Figure 1, A 74-year-old man with T1 bladder cancer and left lower ureteral cancer. (a) Transverse diffusion-weighted imaging (DWI; b = 1000 s/mm 2 ) clearly reveals not only a high–signal intensity (SI) lesion corresponding to bladder cancer ( arrow ) but also nodular high SI on the left side of bladder cancer ( arrowhead ). (b) Transverse T2-weighted imaging (T2WI) shows a large nonpapillary tumor at the left-side wall ( arrow ). T2WI shows that the lesion at the left side of bladder cancer on DWI corresponds to the left lower ureter.

Figure 2, A 74-year-old man with T3 bladder cancer, left hydronephrosis, and a clot. (a) Diffusion-weighted imaging (b = 1000 s/mm 2 ) depicts a markedly high–signal intensity (SI) lesion in the middle-lower ureter. (b) The lesion shows high SI on T1-weighted imaging.

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Urethra

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Figure 3, A 67-year-old man with T1 bladder cancer and urethral extension. (a) High–signal intensity lesions are seen at the bladder wall and prostatic urethra with marked contrast to surrounding structures ( arrowhead ) on diffusion-weighted imaging (b = 1000 s/mm 2 ). (b) Multiple papillary bladder tumors are demonstrated on sagittal T2-weighted imaging ( arrows ) but the urethral lesion is not obvious.

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Prostate

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Figure 4, A 75-year-old man with pT4 bladder cancer directly invading the prostate. (a) Sagittal diffusion-weighted imaging (DWI; b = 1000 s/mm 2 ) shows a very high–signal intensity nonpapillary nodule at the trigone, which invades into the prostate through the bladder muscle layer ( arrow ). (b) The lesion seen on DWI is unclear on sagittal T2-weighted imaging.

Figure 5, A 70-year-old man with pT4 bladder cancer invading the prostate via the urethra. (a) Diffusion-weighted imaging (b = 1000 s/mm 2 ) shows very high signal intensity (SI) in both the peripheral-transitional zone ( arrow ) and prostatic urethra ( arrowhead ). (b) Transverse T2-weighted imaging shows a low-SI area in both peripheral and transitional zones. The urethral lesion cannot be recognized.

Figure 6, A 72-year-old man with granulomatous prostatitis after bacille Calmette-Guérin therapy. (a) The signal intensity (SI) of the prostate is diffusely elevated on diffusion-weighted imaging ( arrow ). (b) The prostate is entirely replaced with a lesion which shows moderate SI ( arrow ), and the border between the peripheral and transitional zones is unclear.

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Bone

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Figure 7, An 83-year-old man with metastasis to the left iliac bone. (a) Diffusion-weighted imaging (DWI) reveals a nodular high–signal intensity (SI) lesion in the left iliac bone invading into the gluteus minimus ( arrow ). The extraskeletal lesion is more clearly seen on DWI than T1-weighted imaging (T1WI). (b) T1WI reveals a nodular low-SI lesion corresponding to the lesion seen on DWI ( arrow ).

Figure 8, A 74-year-old man with abundant hematopoietic bone marrow. (a) Bladder mass beside the left-side wall ( arrowhead ). Bilateral iliac and sacral bones show heterogeneous high signal intensity (SI) on diffusion-weighted imaging (DWI) ( arrows ). (b) Poor margin heterogeneous slightly low SI is seen on T1-weighted imaging corresponding to the high SI on DWI.

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Discussion

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Conclusions

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Academic Radiology, Volume 19, Issue 7
Journals General Radiology
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