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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 3  |  Page : 1337-1341

Value of diffusion-weighted MRI in the diagnosis and staging of urinary bladder cancer


1 Department of Radiodiagnosis, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Radiodiagnosis, Ministry of Health, Menoufia, Egypt

Date of Submission15-May-2022
Date of Decision05-Jun-2022
Date of Acceptance19-Jun-2022
Date of Web Publication29-Oct-2022

Correspondence Address:
Magda S.A Elsattar Mohamed
Ashmoun, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_161_22

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  Abstract 


Background
Bladder cancer is one of the most common cancers in Egypt. Currently, diffusion-weighted imaging (DWI) is the only imaging technique that is able to assess molecular diffusion in vivo and provide information about the biophysical properties of tissue such as cell organization, density, and microstructure.
Objectives
This study is designed to detect the value of diffusion-weighted MRI in the diagnosis and staging of urinary bladder cancer.
Patients and methods
This study is a prospective study of descriptive and analytical design. The study included 30 adult patients with suspected bladder mass, who attended Menoufia University Hospitals.
Results
This study included 30 adult patients. Regarding histopathological type results, urothelial tumors were found in 25 (83.3%) patients, squamous cell carcinoma was found in four (13.3%) patients, and adenocarcinoma was found in one (3.3%) patient. According to the staging of urinary bladder lesions in diffusion-weighted MRI among the studied patients, DWI showed restricted diffusion in all cases with a low apparent diffusion coefficient value. T staging by DWI showed 56.7% of the patients were of T3 and 6.7% were of T1.
Conclusion
Adding DWI and the apparent diffusion coefficient value to T2WI improves the accuracy of MRI in bladder cancer detection and staging. This noninvasive method could be efficiently used for the evaluation of patients with hematuria of lower urinary tract origin.

Keywords: apparent diffusion coefficient, bladder cancer, diffusion-weighted imaging sequence, dysuria, hematuria, MRI, squamous cell carcinoma, transitional cell carcinoma


How to cite this article:
Mousa WA, Elsattar Mohamed MS, Maaly MA. Value of diffusion-weighted MRI in the diagnosis and staging of urinary bladder cancer. Menoufia Med J 2022;35:1337-41

How to cite this URL:
Mousa WA, Elsattar Mohamed MS, Maaly MA. Value of diffusion-weighted MRI in the diagnosis and staging of urinary bladder cancer. Menoufia Med J [serial online] 2022 [cited 2024 Mar 28];35:1337-41. Available from: http://www.mmj.eg.net/text.asp?2022/35/3/1337/359670




  Introduction Top


Diffusion-weighted Imaging (DWI) is an MR-based technique that probes the function of tissues[1]. Many studies have demonstrated that DWI is a useful noncontrast MRI technique for evaluating urinary bladder cancer[2].

The DWI signal reflects the degree of diffusivity of water molecules, and this unique signal provides information on physiologic tissue characteristics in a noninvasive manner[3]. Recently, growing evidence has shown that DWI can serve as an imaging biomarker that is useful for characterizing the pathophysiology of various types of malignancies. This review focuses on the potential role of DWI as an imaging biomarker useful for customizing therapeutic approaches to bladder cancer[4]. Differentiation of histopathological types, tumor grade, and depth of tumor invasion is critical for determining the therapeutic approach and are highly correlated with the progression, recurrence, and patient survival[5].

The aim of this study is designed to detect the value of diffusion-weighted MRI in the diagnosis and staging of urinary bladder cancer.


  Patients and methods Top


This study is a prospective study of the descriptive-analytical design; the study included 30 adult patients with suspected bladder mass, who attended Menoufia University Hospital from October 2019 to October 2021.

Inclusion criteria: patients presented with macroscopic hematuria, pelvic pain, dysuria, frequency, or urinary bladder masses detected by computed tomography or ultrasound examination.

Exclusion criteria

Contraindications to MRI (pacemaker, metallic prosthesis, aneurysmal clips), refusal to examination, postoperative cases, and patients with renal impairment.

Ethical approval

The study procedures were reviewed and approved by the research ethics committee (REC), Faculty of Medicine, Menoufia University and the reference number of approvals is 28419-RAD-45. All patients included in this study gave written informed consent to participate in this research.

Full history taking was done in all patients including the name, age, complaint and its onset and duration, family history, and past history.

MRI of the pelvis was done for all patients.

Technique: All studies were performed using 1.5 MR units (Seimens Aera and Toshiba Excelart; Vantage Medical Systems, Tokyo, Japan). Patients were instructed to fast for 6 h and void urine 2 h before examination. Intravenous administration of 10 mg of an antispasmodic drug (Hyoscine butyl bromide) was given through an intravenous line immediately before MRI to reduce bowel peristalsis. Intravenous administration of contrast agent gadolinium (Gd-DTPA) was done in five patients (with normal renal function tests and no allergy to contrast). The standard contrast medium dose was 0.1 mmol Gd/kg body weight. All patients were imaged in supine position using a pelvic phased-array coil. Conventional routine pelvic MRI was performed followed by DWI.

The MRI protocol performed in the current study: T2 axial, T2 sagittal, T2 coronal, T1 axial, DWI axial plane at b value 0, 500, and 1000. In five cases intravenous contrast study was done.

Assessment of incidental findings: images were transferred by a computer network to the workstation (Aze virtual place fujian Raijin 310) on which images were carefully examined. A trained radiologist (with >10 years of experience in pelvic radiology) examined the scans and recorded the presence of incidental findings.

All 30 patients underwent transurethral cystoscopic biopsy. All patients underwent surgery within 30 days, a mean of 10 days, after the MR study. Patients who underwent TUR, an additional deep muscle biopsy was performed. Twenty-five patients who underwent TUR showed positive deep muscle biopsy, so they shifted into invasive bladder cancer management and underwent radical cystectomy. The remaining five patients with noninvasive bladder cancer received concomitant chemoradiotherapy.

Statistical analysis

Results were analyzed using SPSS, (i.e. Statistical Package for the Social Sciences) program, version 20 (IBM Corp. Released 2011. IBM SPSS statistics for Windows, Version 20.0; IBM Corp., Armonk, New York, USA). Twenty-three data were expressed in number, percentage, mean, and SD. Z test was used to compare two proportions in two groups. χ2 test was used to compare two groups or more regarding one qualitative variable. The receiver operating characteristic is used to evaluate the performance of classification schemes in which there is one variable of two categories by which patients are classified. A P value less than 0.05 was considered statistically significant.


  Results Top


This study included 30 adult patients. Regarding histopathological type results, urothelial tumors were found in 25 (83.3%) patients, squamous cell carcinoma was found in four (13.3%) patients, and adenocarcinoma was found in one (3.3%) patient as shown in [Table 1].
Table 1: Distribution of histopathological type of urinary bladder lesions among the studied patients

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According to the staging of urinary bladder lesions in diffusion-weighted MRI among the studied patients, DWI showed restricted diffusion in all cases with low apparent diffusion coefficient (ADC) value. T staging by DWI showed that 56.7% of the patients were T3 and 6.7% were T1 as shown in [Table 2].
Table 2: Characteristics and staging of urinary bladder lesions in diffusion-weighted MRI among the studied patients

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DWI T staging results, compared with histopathological staging, showed a significant relationship between DWI T staging and histopathological staging (P < 0.001) as 73.4% of the studied cases were T3 and T4 by both histopathological staging and DWI T staging [Table 3], [Figure 1],[Figure 2],[Figure 3].
Figure 1: (a and b) (axial and sagittal T2WIs) show a Fungating mass that arises from the bladder dome, associated with circumferential wall thickening. The mass measures 5 × 5 cm. (arrows in a, b). The mass lesion shows isointense signal intensity, with preserved perivesical fat planes. MRI findings suggest stage II. (c and d) Axial DWI and ADC map show restricted diffusion (arrow in d) with low ADC value in the ADC map measuring 90 × 10-3 mm2/s (arrow in c). ADC, apparent diffusion coefficient; DWI, diffusion-weighted imaging.

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Figure 2: (a and b) (axial and sagittal axial T2WIs) show irregular mural thickening with the exothytic component are seen at the posterior and anterior wall of UB about 3 cm along its maximal thickness with perivesical fat stranding. MRI findings suggest stage III. (c and d) (axial DWI and ADC map show restricted diffusion (arrow in c), with low ADC value in the ADC map measuring 80 × 10-3 mm2/s (arrow in d). ADC, apparent diffusion coefficient; DWI, diffusion-weighted imaging.

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Figure 3: (a and b) (axial and sagittal T2WIs) show right anterolateral urinary bladder wall thickening with a soft tissue fungating mass lesion measuring about 2.8 × 3.2 cm in its anteroposterior, transverse, and craniocaudal dimensions. The mass appeared hyper-intense in T2WIs. It was also seen infiltrating the urinary bladder wall, with stranding of perivesical fat planes (arrows in a, b). The arrows should be a little away from the lesion not on the lesion. Also you should mention (incidentally, posterior wall cervical fibroid is noted in b. (c-e) (axial DWI and ADC) show evidence of restricted diffusion of the urinary bladder fungating soft tissue mass lesions with perivesical fat stranding (arrows in c, d) and corresponding low ADC value measuring 90 × 10-3 mm2/s (arrow in e). Findings suggest grade II. (f) Postcontrast axial T1 MRI showed enhancement of the mass lesion (arrow in f). ADC, apparent diffusion coefficient; DWI, diffusion-weighted imaging.

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Table 3: Diffusion-weighted imaging T staging results compared with histopathological staging

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  Discussion Top


Our study was carried out on 30 patients presenting with urinary bladder mass lesions. Of the patients 66.7% were males, while females were 33.3%. The age of the patients was above 43 years with a mean of 64.1 years.

These results agreed with Galgano et al.[6], who found that bladder cancer is more common in men, with a male to female ratio of 3: 1. Regarding distribution of symptoms, the current study found that hematuria was the commonest symptom representing 60% of patient symptoms, followed by dysuria (53.3%), and then frequency (23.3%). The least percentage was pelvic pain (16.7%).

These results were in concordance with the Flaig et al.[7] review on urinary bladder cancer, which found that the most common presenting symptom in patients with urinary bladder cancer was microscopic or gross hematuria, although urinary frequency from irritation or reduced bladder capacity can also develop.

Regarding histopathological results in the current study, urothelial tumors were the most common histopathological tumor representing 83.3%. Our results were in line with Smith[8], who found that urothelial carcinoma was the most histologic type of bladder cancer (90%).

In our study, adenocarcinoma was an uncommon bladder neoplasm representing 3.3% of the cases. Our results are in line with the Wong-You-Cheong et al.[9] review on bladder cancer, which reported that adenocarcinoma is an uncommon bladder neoplasm representing less than 2% of bladder neoplasms.

In the current study, urinary bladder lesions with DWI MRI showed 100% restricted diffusion and 100% low ADC value. DWI T staging (local staging) revealed that 40% of patients were T3 and that tumors invaded the perivesical fat with an irregular margin; DWIs grade showed that about 63.3% of the studied patients were grade III.

These results were in agreement with the Abdel Hameed et al.[10] study, which reported on DWI; 95% of urinary bladder lesions were seen as restricted and ADC was found to be low in 95% of the cases that proved to be bladder cancer on histopathology. Also 42.1% of lesions were of grade III.

The current study revealed a significant relationship between DWI T staging and grading results compared with histopathological staging. The diagnostic accuracy using DWI for differentiation of lower stage tumors (T1–T2) from high stage tumors extending to the perivesical fat and adjacent organs (T3–T4) was 86.67% with a sensitivity of 90.9% and specificity of 75%, with positive predictive value of 90.9% and negative predictive value of 75%.

The current results were in line with Al Johi et al.[11], who reported staging accuracy of DWI alone regarding differentiation of organ-confined from nonorgan-confined bladder cancer which was 77.4%.

Also, the study of Barsoum et al.[12] reported that DW-MRI showed an overall sensitivity of 100%, specificity of 75%, positive predictive value of 98%, negative predictive value of 100% and accuracy of 98%, negative predictive value of 100%, and accuracy of 98%.

Abdel-Rahman et al.[13] concluded that DWI had a higher overall accuracy compared with both T2WI and postcontrast T1WI in the T staging of bladder cancer.


  Conclusion Top


Adding DWI and the ADC value to T2WI improves the accuracy of MRI in urinary bladder cancer detection and staging.

This noninvasive method could be efficiently used for the evaluation of patients with hematuria of the lower urinary tract origin.

Acknowledgements

Author contributions: M.A.E.M. and W.A.E.M. contributed equally to the study design, data collection, analysis, and interpretation of results. All authors read and approved the final manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Choi YJ, Kim JK, Kim N, Kim KW, Choi EK, Cho KS. Functional MR imaging of prostate cancer. Radiographics 2007; 27:63–75.  Back to cited text no. 1
    
2.
Matsuki M, Inada Y, Tatsugami F, Tanikake M, Narabayashi I, Katsuoka Y. Diffusion-weighted MR imaging for urinary bladder carcinoma: initial results. Eur Radiol 2007; 17:201–204.  Back to cited text no. 2
    
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Yoshida S, Takahara T, Kwee TC, Waseda Y, Kobayashi S, Fujii Y. DWI as an imaging biomarker for bladder cancer. Am J Roentgenol 2017; 208:1218–1228.  Back to cited text no. 3
    
4.
Bammer R. Basic principles of diffusion-weighted imaging. Eur J Radiol 2003; 45:169–184.  Back to cited text no. 4
    
5.
Green DA, Rink M, Hansen J, Cha EK, Robinson B, Tian Z, et al. Accurate preoperative prediction of non-organ-confined bladder urothelial carcinoma at cystectomy. BJU Int 2013; 111:404–411.  Back to cited text no. 5
    
6.
Galgano SJ, Porter KK, Burgan C, Rais-Bahrami S. The role of imaging in bladder cancer diagnosis and staging. Diagnostics 2020; 10:703.  Back to cited text no. 6
    
7.
Flaig TW, Spiess PE, Agarwal N, Bangs R, Boorjian SA, Buyyounouski MK, et al. Bladder cancer, version 3.2020, NCCN clinical practice guidelines in oncology. J Natl Compreh Cancer Netk 2020; 18:329–354.  Back to cited text no. 7
    
8.
Smith AB. Recent developments in the management of bladder cancer: introduction. Urol Oncol Semin Orig Investig 2018; 36:95–96.  Back to cited text no. 8
    
9.
Wong-You-Cheong JJ, Woodward PJ, Manning MA, Sesterhenn IA. Neoplasms of the urinary bladder: radiologic-pathologic correlation. Radiographics 2006; 26:553–580.  Back to cited text no. 9
    
10.
Abdel Hameed HA, Nagi MA, Wali DH. Role of diffusion weighted magnetic resonance imaging (DW-MRI) in assessment of urinary bladder carcinoma. Egypt J Hosp Med 2018; 72:5561–5570.  Back to cited text no. 10
    
11.
Al Johi RS, Seifeldein GS, Moeen AM, Aboulhagag NA, Moussa EM, Hameed DA, et al. Diffusion weighted magnetic resonance imaging in bladder cancer, is it time to replace biopsy?. Cent European J Urol 2018; 71:31.  Back to cited text no. 11
    
12.
Barsoum N, Talaat M, Saraya S. Can diffusion-weighted MRI predict the histological grade of urinary bladder carcinoma?. Kasr Al Ainy Med J 2017; 23:86.  Back to cited text no. 12
    
13.
Abdel-Rahman HM, El Fiki IM, Desoky EA, Elsayed ER, Abd Samad KM. The role of diffusion-weighted magnetic resonance imaging in T staging and grading of urinary bladder cancer. Egypt J Radiol Nucl Med 2015; 46:741–747.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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