Diagnostic Imaging Pathways - Bladder Cancer (Staging)

Pathway Home

Population Covered By The Guidance

This pathway provides a diagnostic imaging algorithm for staging of patients with bladder cancer on histology.

Date reviewed: January 2012

Date of next review: January 2015

Quick User Guide

Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.

SYMBOL RRL EFFECTIVE DOSE RANGE
No radiation None 0
Minimal radiation Minimal < 1 millisieverts
Low radiation Low 1-5mSv
Medium radiation Medium 5-10 mSv
High radiation High >10 mSv

Pathway

Pathway Diagram

Images

Image Gallery


Note: These images open in a new page
1a Papillary TCC

Papillary TCC

Images 1a & 1b: 77yo M had an incidental bladder mass detected on CT abdomen. Patient underwent TURBT & pathology confirmed low grade papillary TCC with no evidence of stromal invasion. Stage: T2N0M0.

1b Papillary TCC
2a Invasive TCC

Invasive TCC

Images 2a & 2b: 66yo F with history of recurrent TCC of bladder & left ureter. Follow-up CT shows left-sided posterolateral bladder tumour invading into adjacent ileum. No lymphadenopathy or distant metastatic disease was seen. Stage: T4N0M0.

2b Invasive TCC
3a Squamous TCC

Squamous TCC

Images 3a & 3b: 91yo M presented with frank haematuria. CT urograph showed a bladder with thickened walls and bilateral diverticulae. The larger right diverticulum had nodular wall thickening of its lateral wall. The patient later underwent open diverticulectomy. Pathological findings were of TCC with squamous differentiation. Stage: T3N0M0.

3b Squamous TCC
4a Metastatic TCC

Metastatic TCC

Images 4a & 4b: 60yo M presented with left hip pain, with initial plain films showing a mixed lytic-sclerotic lesion of his left femur & pelvis. CT abdo/pelvis showed multiple large calcific tumours within the bladder, obstructing the left ureter & causing hydronephrosis. There was a large metastatic deposit involving the left hemipelvis and acetabulum. Pathological findings showed high grade TCC with squamous differentiation. Stage: T4N0M1.

4b Metastatic TCC

Teaching Points

Teaching Points

  • Accurate staging of bladder cancer allows for optimal treatment and prognostication of the individual patient. It is important to differentiate between non-muscle-invasive lesions and muscle invasive bladder lesions.
  • Conventional rigid cystoscopy is the gold standard for diagnosis of bladder tumours, followed closely by flexible cystoscopy. Though small biopsies may be retrieved via a flexible cystoscope, rigid cystoscopy allows for tissue biopsy and formal tumour resection. Tissue histopathology provides further tumour staging information.
  • Radiologic investigations are used in bladder cancer staging for further clarifying the extent of local disease and looking for nodal & metastatic spread.
  • Distant metastatic spread is rarely seen at time of presentation. The most common sites of spread can be investigated appropriately using chest radiography (and/or CT chest) and CT abdomen.

References

References

  1. Australian Institute of Health and Welfare & Australasian Association of Cancer Registries. Cancer in Australia: an overview, 2008. Cancer series no. 46. AIHW cat. no. CAN 42. Available from: http://www.aihw.gov.au/
  2. Vikram R, Sandler CM, Ng CS. Imaging and Staging of Transitional Cell Carcinoma: Part I, Lower Urinary Tract, AJR 2009; 192:1481-1487. (Review)
  3. Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, editors. AJCC cancer staging manual. 7th ed. Chicago: American Joint Committee on Cancer; c2009. p. 497-502.
  4. MacVicar AD. BJU Int. Bladder cancer staging. 2000;86 Suppl 1:111-22. (Review)
  5. Pillai PL, Sooriakumaran P. Flexible cystoscopy: a revolution in urological practice. Br J Hosp Med. 2009;70(10):583-5. (Review)
  6. Battista G, Sassi C, Corcioni B, Bazzocchi A, Golfieri R, Canini R. Latest developments in imaging of bladder cancer. Expert Rev Anticancer Ther. 2010;10(6):881-94. (Review article)
  7. Witjes JA, Redorta JP, Jacqmin D, Sofras F, Malmström PU, Riedl C, et al. Hexaminolevulinate-guided fluorescence cystoscopy in the diagnosis and follow-up of patients with non-muscle-invasive bladder cancer: review of the evidence and recommendations. Eur Urol. 2010;57(4):607-14.
  8. Battista G, Sassi C, Corcioni B, Bazzocchi A, Golfieri R, Canini R. Latest developments in imaging of bladder cancer. Expert Rev Anticancer Ther. 2010;10(6):881-94.
  9. Vikram R, Sandler CM, Ng CS. Imaging and Staging of Transitional Cell Carcinoma: Part I, Lower Urinary Tract, AJR 2009; 192:1481-1487 (Review article)
  10. Paik ML, Scolieri MJ, Brown SL, Spirnak JP, Resnick MI.Fritz GA. Limitations of computerized tomography in staging invasive bladder cancer before radical cystectomy. J Urol. 2000;163(6):1693-6. (Level III evidence)
  11. Caterino M, Giunta S, Finocchi V, Giglio L, Mainiero G, Carpanese L, Crecco M. Primary cancer of the urinary bladder: CT evaluation of the T parameter with different techniques. Abdom Imaging. 2001;26(4):433-8. (Level III evidence)
  12. Kim JK. Park SY. Ahn HJ. Kim CS. Cho KS. Bladder cancer: analysis of multi-detector row helical CT enhancement pattern and accuracy in tumor detection and perivesical staging. Radiology. 2004;231(3):725-31. (Level III evidence)
  13. Qu X, et al. Comparison of virtual cystoscopy and ultrasonography for bladder cancer detection: A meta-analysis. Eur J Radiol. 2010, article in press. (Level II evidence)
  14. Cowan NC, Crew JP. Imaging bladder cancer. Curr Opin Urol. 2010. 20:409-413. (Review article)
  15. Tekes A. Kamel I. Imam K. Szarf G. Schoenberg M. Nasir K. Thompson R. Bluemke D. Dynamic MRI of bladder cancer: evaluation of staging accuracy. Am J Roent. 2005;184(1):121-7 (Level III evidence)
  16. Zhang J, Gerst S, Lefkowitz RA, Bach A. Imaging of bladder cancer. Radiol Clin North Am. 2007;45(1):183-205 (Review article)
  17. Takeuchi M. Sasaki S. Ito M. Okada S. Takahashi S. Kawai T. Suzuki K. Oshima H. Hara M. Shibamoto Y. Urinary bladder cancer: diffusion-weighted MR imaging--accuracy for diagnosing T stage and estimating histologic grade. Radiology. 2009;251(1):112-21. (Level II evidence)
  18. El-Assmy A. Abou-El-Ghar ME. Mosbah A. El-Nahas AR. Refaie HF. Hekal IA. El-Diasty T. Ibrahiem el H. Bladder tumour staging: comparison of diffusion- and T2-weighted MR imaging. Eur Radiol. 2009;19(7):1575-81. (Level II evidence)
  19. Watanabe H. Kanematsu M. Kondo H. Goshima S. Tsuge Y. Onozuka M. Moriyama N. Preoperative T staging of urinary bladder cancer: does diffusion-weighted MRI have supplementary value? Am J Roent. 2009; 192(5):1361-6. (Level III evidence)
  20. Barentsz JO, Jager GJ, van Vierzen PB, Witjes JA, Strijk SP, Peters H, Karssemeijer N, Ruijs SH. Staging urinary bladder cancer after transurethral biopsy: value of fast dynamic contrast-enhanced MR imaging. Radiology. 1996;201:185-193 (Level III evidence)
  21. Deserno WM, Harisinghani MG, Taupitz M, Jager GJ, Witjes JA, Mulders PF, Hulsbergen van de Kaa CA, Kaufmann D, Barentsz JO. Urinary bladder cancer: preoperative nodal staging with ferumoxtran-10-enhanced MR imaging. Radiology. 2004;233(2):449-56. (Level II evidence)
  22. Thoeny HC. Triantafyllou M. Birkhaeuser FD. Froehlich JM. Tshering DW. Binser T. Fleischmann A. Vermathen P. Studer UE. Combined ultrasmall superparamagnetic particles of iron oxide-enhanced and diffusion-weighted magnetic resonance imaging reliably detect pelvic lymph node metastases in normal-sized nodes of bladder and prostate cancer patients. Eur Urol. 2009;55(4):761-9 (Level III evidence)
  23. Lauenstein TC, Goehde SC, Herborn CU, Goyen M, Oberhoff C, et al. Whole-body MR imaging: evaluation of patients for metastases. Radiology. 2004;233(1):139-48. (Level III evidence)
  24. Ozden et al. Effect of bladder carcinoma location on detection rates by ultrasonography and computed tomography. Urology. 2007;69(5):889-92. (Level III evidence)
  25. Itzchak Y., Singer D., Fischelovitch Y.: Ultrasonographic assessment of bladder tumors: 1. Tumor detection. J Urol. 1981;126:31-33. (Level III evidence)
  26. Abu-Yousef M.M., Narayana A.S., Franken E.A., et al: Urinary bladder tumors studied by cystosonography. Part 1: detection Radiology. 1984;153:223-226 (Level III evidence)
  27. Dershaw DD, Scher HI. Sonography in evaluation of carcinoma of bladder. Urology 1987;29:454-457. (Level III evidence)
  28. Qu X, et al. Comparison of virtual cystoscopy and ultrasonography for bladder cancer detection: A meta-analysis. Eur J Radiol (2010), article in press. (Level II evidence)
  29. Hillman BJ et al. Recognition of bladder tumors by excretory urography. Radiology. 1981;138(2):319-23. (Level III evidence)
  30. Sanderson KM, Rouprêt M. Upper urinary tract tumour after radical cystectomy for transitional cell carcinoma of the bladder: an update on the risk factors, surveillance regimens and treatments. BJU Int. 2007;100(1):11-6. (Review article)
  31. Kuroda M et al. Stage specific follow-up strategy after cystectomy for carcinoma of the bladder. Int J Urol. 2002; 9(3):129-133. (Level II evidence)
  32. Anjos DA. Etchebehere EC. Ramos CD. Santos AO. Albertotti C. Camargo EE. 18F-FDG PET/CT delayed images after diuretic for restaging invasive bladder cancer. Journal of Nuclear Medicine. 2007;48(5):764-70. (Level III evidence)
  33. Picchio M. Treiber U. Beer AJ. Metz S. Bossner P. van Randenborgh H. Paul R. Weirich G. Souvatzoglou M. Hartung R. Schwaiger M. Piert M. Value of 11C-choline PET and contrast-enhanced CT for staging of bladder cancer: correlation with histopathologic findings. Journal of Nuclear Medicine. 2006;47(6):938-44. (Level III evidence)
  34. Drieskens O. Oyen R. Van Poppel H. Vankan Y. Flamen P. Mortelmans L. FDG-PET for preoperative staging of bladder cancer. European Journal of Nuclear Medicine & Molecular Imaging. 2005;32(12):1412-7. (Level III evidence)
  35. Simms MS. Perkins AC. Price MR. Scholfield DP. Bishop MC. 99mTechnetium-C595 radioimmunoscintigraphy: a potential staging tool for bladder cancer. BJU International. 2001;88(7):686-91. (Level III evidence)
  36. Hughes OD. Perkins AC. Frier M. Wastie ML. Denton G. Price MR. Denley H. Bishop MC. Imaging for staging bladder cancer: a clinical study of intravenous 111indium-labelled anti-MUC1 mucin monoclonal antibody C595. BJU International. 2001;87(1):39-46. (Level III evidence)

File Formats

Some documents for download on this website are in a Portable Document Format (PDF). To read these files you might need to download Adobe Acrobat Reader.

Get Adobe Reader