ACR Appropriateness Criteria ® Pretreatment Staging of Muscle-Invasive Bladder Cancer

Abstract

Muscle-invasive bladder cancer (MIBC) has a tendency toward urothelial multifocality and is at risk for local and distant spread, most commonly to the lymph nodes, bone, lung, liver, and peritoneum. Pretreatment staging of MIBC should include imaging of the urothelial upper tract for synchronous lesions; imaging of the chest, abdomen, and pelvis for metastases; and MRI pelvis for local staging. CT abdomen and pelvis without and with contrast (CT urogram) is recommended to assess the urothelium and abdominopelvic organs. Pelvic MRI can improve local bladder staging accuracy. Chest imaging is also recommended with chest radiograph usually being adequate. FDG-PET/CT may be appropriate to identify nodal and metastatic disease. Chest CT may be useful in high-risk patients and those with findings on chest radiograph. Nonurogram CT and MRI of the abdomen and pelvis are usually not appropriate, and neither is radiographic intravenous urography, Tc-99m whole body bone scan, nor bladder ultrasound for pretreatment staging of MIBC. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The Role of Imaging in Bladder Cancer Diagnosis and Staging

“…Most often, this is applied to the setting of MIBC where the risk of pelvic lymph node metastases is far greater than that for NMIBC and useful for preoperative risk stratification (Figure 3). The current ACR Appropriateness Criteria for the pretreatment staging of MIBC rate FDG-PET/CT as "may be appropriate" [49]. Traditionally, FDG-PET/CT for bladder cancer has been limited by a number of factors, including false-positive findings due to inflammation and obscuration of the urinary bladder by radiotracer activity in excreted urine.…”

The Role of 18F-FDG PET/CT in Guiding Precision Medicine for Invasive Bladder Carcinoma

“…Utilizing these techniques, authors report sensitivities between 50 and 96% (9)(10)(11)(12)(13)(14)(15)(16)(17). However, to date, 18F-FDG PET/CT has not be shown to improve primary tumor detection and staging, when compared to cystoscopy and morphological imaging alone performed with CT and especially MRI (18).…”

“…In conclusion, the current literature suggests that 18F-FDG PET/CT provides an incremental value for nodal and distant staging in MIBC at initial diagnosis. However, due to its significant cost for healthcare systems (34), prospective studies with high evidence level are still needed before its use can be formally adopted into consensus guidelines and recommendations (3,18,35,36). In support of its role in distant staging, a recent consensus statement revealed that 18F-FDG PET/CT is the imaging modality of choice to avoid overtreatment in oligometastatic patients with an agreement of 88% of participants (37) (Figure 1B).…”

Multiparametric MRI of the bladder: inter-observer agreement and accuracy with the Vesical Imaging-Reporting and Data System (VI-RADS) at a single reference center

“…Therefore, more accurate, faster, and non-invasive staging techniques are needed to improve the outcomes from BCa. Given its superior contrast resolution and the addition of functional sequences, MRI has proved to be the best imaging modality for local staging [9]. Several studies have tested its ability to differentiate NMIBC from MIBC and two recent meta-analysis have shown a pooled sensitivity of 87% and 92% and a specificity of 79% and 87%, respectively [10,11].…”