EAU 2019: What Can We Expect from Imaging - Case-Based Debate No Evidence of Disease After Neoadjuvant Chemotherapy for MIBC: What Next?

Barcelona, Spain (UroToday.com) In the Bladder Cancer in the Young Patient Plenary Session at the 2019 European Association of Urology meeting EAU 2019, Dr. Maurizio Brausi presented the following case to facilitate the debate titled: "No Evidence of Disease After Neoadjuvant Chemoradiation for MIBC: What Next? "  The patient case was as follows: a 45-year-old man who is a heavy smoker, and presented with macroscopic hematuria due to a 3.5 cm mass in the left lateral wall of the bladder. Following a TURBT procedure, he was found to have a transitional cell carcinoma (TCC) high grade (G3) tumor invading the lamina propria and detrusor muscle. No carcinoma in situ (CIS) was found, but lympho-vascular invasion was found. He was staged as a T2-3 HG TCC. He underwent a CT scan showing the thickness of the left lateral wall of the bladder and normal upper urinary tract. No lymph node enlargement was seen. The patient was treated with neoadjuvant chemotherapy with 3 cycles of Gemcitabine and cisplatin. He underwent a CT scan and TURBT after completion of chemotherapy, and he was found to have a T0 disease with a normal CT scan.

At this point the patient was offered 3 treatment options:
  1. Radical cystectomy
  2. Bladder preservation with chemoradiation (Trimodal therapy)
  3. Active surveillance
In bladder cancer patients, CT scan is recommended in the guidelines for proper staging of the bladder and the upper urinary tract. However, it is important to remember that the National Comprehensive Cancer Network (NCCN) guidelines also state that MRI can be performed instead of a CT scan. MRI offers an opportunity to reduce staging errors through better anatomical visualization. 

Furthermore, the MRI has the additional value of functional sequences such as diffuse weighted imaging and dynamic contrast-enhanced imaging. Lastly, MRI also has the advantage of not harboring any associated radiation, like CT scans.

Two meta-analyses have shown that mpMRI has a pooled sensitivity of 87% and 92%, and a specificity of 79% and 87%, respectively, in distinguishing between muscle-invasive bladder cancer and non-muscle invasive bladder cancer1,2.  MRI is impressively successful 95% of cases in differentiating muscle-invasive disease from non-muscle invasive disease3

The VIRADS scoring system is a standardized approach to imaging and reporting mpMRI from bladder cancer, defining the risk of muscle-invasive disease. It was created through consensus using the existing literature. The scoring is applicable preferably to untreated patients before TURBT or at least 2 weeks after diagnostic TURBT or intravesical treatment. A 5-point VIRADS score is generated using the individual T2W, DWI, and DCE MRI categories and suggests the probability of muscle invasion, as seen in table 1, figure 1 and figure 2.

Dr. Panebianco concluded her talk stating that despite the tremendous improvement that has been achieved in bladder cancer, there are still certain issues that can be improved. These include:

  • Better preoperative planning
  • Local staging
  • Improve the quality of TURBT resection and surgical confidence
  • Consider incorporating the use of MRI before planning a re-TURBT
  • Standardize the VIRADS scoring system and implement it on a regular basis to all patients
  • Improve the response to therapy
Use of MRI and the VIRADS scoring system can be applied specifically in young patients, in the setting of neoadjuvant chemotherapy, following immunotherapy, and surveillance of non-muscle invasive bladder cancer.

Table 1 – VIRADS scoring system:

EAU 2019 VIRADS scoring system

Figure 1 – VIRADS score 1,2,3:

EAU 2019 VIRADS score 123

Figure 2 – VIRADS score 4 and 5:

EAU 2019 VIRADS score 45

References:
1. Gandhi N et al. (2018), Diagnostic accuracy of magnetic resonance imaging for tumour staging of bladder cancer: systematic review and meta‐analysis. BJU Int, 122: 744-753. doi:10.1111/bju.14366
2. Woo S. et al. Eur J Radiol 2017
3. Panebianco V et al. Eur Rad 2017

Presented by: Valeria Panebianco, Department of Radiology, University Sapienza, Rome, Italy

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at the 34th European Association of Urology (EAU 2019) #EAU19 conference in Barcelona, Spain, March 15-19, 2019

Further Related Content: What Can We Expect from Trimodal Therapy - Case-Based Debate No Evidence of Disease After Neoadjuvant Chemotherapy for MIBC: What Next?

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