Role of Macroscopic Image Enhancement in Diagnosis of Non-Muscle-Invasive Bladder Cancer: An Analytical Review

Abstract

Early diagnosis of non-muscle-invasive bladder cancer (NMIBC) is of paramount importance to prevent morbidity and mortality due to bladder cancer. Although white light imaging (WLI) cystoscopy has long been considered the gold standard in the diagnosis of bladder cancer, it can miss lesions in a substantial percentage of patients and is very likely to miss carcinoma in situ and dysplasia. Tumor margin detection by WLI can be inaccurate. Moreover, WLI could, sometimes, be inadequate in distinguishing inflammation and malignancy. To improve the diagnostic efficacy of cystoscopy, various optical image enhancement modalities have been studied. These image enhancement modalities have been classified as macroscopic, microscopic, or molecular. Photodynamic diagnosis (PDD), narrow band imaging (NBI), and Storz image 1 S enhancement (formerly known as SPIES) are macroscopic image enhancement modalities. A relevant search was performed for literature describing macroscopic image enhancement modalities like PDD, NBI, and image 1 S enhancement. The advantages, limitations, and usefulness of each of these in the diagnosis of bladder cancer were studied. Photodynamic diagnosis requires intravesical instillation of a photosensitizing agent and a special blue light cystoscope system. PDD has been shown to be more sensitive than WLI in the detection of bladder cancer. It is superior to WLI in the detection of flat lesions. Bladder tumor resection (TURBT) by PDD results in more complete resection and reduced recurrence rates. PDD-guided TURBT may have some role in reducing the risk of progression. Narrow band imaging provides increased contrast between normal and abnormal tissues based on neovascularization, thereby augmenting WLI. NBI requires a special light source. There is no need for intravesical contrast instillation. NBI is superior to WLI in the detection of bladder cancer. The addition of NBI to WLI improves the detection of flat lesions like carcinoma in situ. NBI is not useful in predicting invasive tumors or grades of tumors. NBI-directed TURBT reduces recurrence rates and recurrence free survival. But its efficacy in retarding progression is unproven. Image 1 S-enhancement utilizes software-based image enhancement modes without the need for a special light source or intravesical contrast instillation. This system provides high-quality images and identifies additional abnormal-looking areas. Another advantage of this system is simultaneous side-by-side visualization of WLI and enhanced image, providing WLI images as the control for comparison. As with PDD, S-enhancement produces a lower rate of a missed bladder cancer diagnosis. The system significantly improves the diagnosis of NMIBC. The sensitivity and negative predictive value of image 1 S enhancement increase with the increase in cancer grade. A negative test by S-enhancement effectively rules out NMIBC. All the image enhancement modalities have proven their utility in improving detection and short-term cancer control. But none of these modalities have proven their utility in delaying progression, or in long-term cancer control. Cancer progression and long-term control are governed by the biological nature of cancer cells. Early detection by optical enhancement may not be of utility in this regard. Well-designed studies are needed to establish the efficacy of these modalities in the evaluation of patients with bladder cancer. The last word, in this regard, is yet to be written.

Bladder cancer risk stratification with the Oncuria 10-plex bead-based urinalysis assay using three different Luminex xMAP instrumentation platforms

“…Urine testing is a noninvasive approach without the safety risks of cystoscopy, which becomes particularly important in elderly and frail patients. Cystoscopy is sensitive for papillary lesions but tends to miss flat lesions such as carcinoma in situ (CIS), although newer imaging techniques provide improved contrast to differentiate tumor from normal tissue [ 28 ]. While cystoscopy is often used in individuals with NMIBC and in MIBC patients who have undergone bladder-sparing treatments, no global consensus exists for endoscopic follow-up scheduling [ 29 ].…”

Recent advancements in the diagnosis and treatment of non‐muscle invasive bladder cancer: Evidence update of surgical concept, risk stratification, and BCG‐treated disease

“…Lesions overlooked during the initial TURBT led directly to underdiagnosis and intravesical recurrence. Several optical image enhancement technologies have been developed to improve the efficacy of diagnosis and detection 23 . Photodynamic diagnosis (PDD) and narrow‐band imaging (NBI) are the most widely used macroscopic image‐enhancement modalities.…”

“…The basic principle in PDD underlies the selective accumulation of protoporphyrin IX and emission of red fluorescence in cancer cells when excited by blue light, enabling discrimination between non‐cancer lesions and cancer lesions 43 . The reported sensitivity and specificity of PDD are 87%–97% and 43%–67% for detecting BCa lesions, respectively; the sensitivity and specificity of the counterpart WLI are 68%–78% and 43%–89%, respectively 23 . In comparison, NBI requires a special imaging light source (for example, the Olympus VISERA ELITE video system); however, drugs do not need to be administered.…”

“…Mucosal blood vessels are enhanced by blue light, and relatively deeper submucosal blood vessels appear cyan under green‐filtered light. The reported sensitivity and specificity of NBI for detecting BCa lesions were 89.7%–100% and 50%–81.8% for detecting BCa lesions, respectively; the sensitivity and specificity of the counterpart WLI were 50%–96.6% and 25%–86.2%, respectively 23 . There is little data regarding the comparison of cancer detection capability between PDD and NBI.…”

Validation of a White Light and Fluorescence Augmented Panoramic Endoscopic Imaging System on a Bimodal Bladder Wall Experimental Model

“…Currently, cystoscopy is the mainstay of bladder cancer detection and usually works together with cytologic analysis, biomarkers, and imaging [1,2]. Allowing visual inspection of the bladder wall and main cancer lesions, white light cystoscopy (WLC) is the most commonly used in vivo diagnostic imaging modality [3,4] and is still considered to be the "gold standard" for the detection and localization of bladder cancers [2,5]. As a clinical examination, WLC provides direct visual access to the inner wall of the bladder tissue and allows to obtain highly informative images for real-time diagnosis, surgical guidance, and follow-up.…”