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Objectives: To determine whether the failure of chemotherapy in patients with regionally metastatic or unresectable transitional cell carcinoma (TCC) of the bladder can be predicted early in the course of chemotherapy with magnetic resonance (MR) imaging., Methods: In this prospective study, 36 patients with regionally metastatic or unresectable TCC of the urinary bladder underwent MR imaging before and after two, four, and six cycles of chemotherapy with Methotrexate, Vinblastine, Adriamycin (doxorubicin) and Cisplatin (MVAC). The response after two cycles of MVAC was evaluated by using conventional tumour size parameters with unenhanced MR imaging and with changes in the time to the start of tumour or lymph node enhanced at fast dynamic contrast-enhanced MR imaging. The results obtained with these techniques were compared with the findings at histopathology in cystectomy or transurethral resection specimens that were obtained after chemotherapy. Duration of survival was defined as the time from the start of chemotherapy until disease-specific death. Kaplan-Meier curves were drawn to determine the difference in prognosis between responders and nonresponders., Results: After two cycles of chemotherapy, the accuracy, sensitivity, and specificity in distinguishing responders from nonresponders with conventional MR imaging were 69%, 81%, and 50%, respectively. With the fast dynamic contrast-enhanced technique, accuracy, sensitivity, and specificity were 92%, 91%, and 93% respectively. The median bladder cancer specific survival was 28 months for all patients studied. Responders to chemotherapy at fast dynamic contrast-enhanced MR had better median disease-specific survival than nonresponders (42 months vs. 12 months [p<0.0001])., Conclusion: We can predict whether a patient will respond to chemotherapy after two cycles of chemotherapy with fast dynamic contrast-enhanced MR imaging.

A 67-year-old man was treated with maintenance intravesical BCG for superficial bladder cancer. As a culture-proven complication of this therapy, he developed general malaise, high fever, granulomatous hepatitis and a mycotic aneurysm in his left knee. All complications were treated successfully with antituberculous therapy. No vascular surgery was necessary. This case report again stresses the necessity to recognise complications of BCG treatment and to start adequate therapy as soon as possible., (Copyright 2003 S. Karger AG, Basel)

Among the noninvasive imaging modalities, contrast enhanced magnetic resonance (MR) imaging is the most powerful tool with which to visualize vascularity. Common pathology only shows microvessel density, whereas dynamic MR imaging is sensitive to the total endothelial surface area of perfused vessels. Therefore, dynamic MR imaging may be of additional value in tumor staging and in evaluating therapies that affect the perfused microvessel density or surface area, such as chemo-, radiation, or anti-angiogenic therapy. In urinary bladder cancer, this technique results in improved local and nodal staging, in improved separation of transurethral granulation tissue and edema from malignant tumor, and in improved evaluation of the effect of chemotherapy. In prostate cancer, dynamic MR imaging may be of help in problematic cases. This technique can assist in determining seminal vesicle infiltration, in depicting of minimal capsular penetration, and in recognizing tumors within the transitional zone. Also, based on very rapid enhancement, very poorly differentiated tumors can be recognized. Evaluation of the effects of therapy is another promising area, however a lot of research remain to be done. This article reviews some basics of fast enhancement techniques, provides practical information, and shows recent developments, in using these fast techniques for staging and grading of bladder and prostate cancer, and for evaluating the effect of therapy.

Prostate and urinary bladder cancer are the most frequently encountered malignancies of the urinary tract. Appropriate use of the different imaging techniques is crucial for accurate assessment of prognosis and for the development of appropriate treatment planning. Especially determination of local tumor extension and detection of nodal or bone metastases is extremely important. In this regard MR imaging is the most promising imaging technique. Therefore, in this review its role in staging these malignancies is evaluated and compared with clinical staging, and other imaging techniques. Finally, future developments, such as new sequences, new contrast agents, the role of surface coils and MR-guided biopsy, are considered. Also, the preferred radiological approach is discussed.

Purpose: To evaluate if the failure of chemotherapy in patients with advanced urinary bladder cancer can be predicted early in the course of chemotherapy with fast dynamic contrast material-enhanced magnetic resonance (MR) imaging., Materials and Methods: In this prospective study, 22 consecutive patients with histologically proved advanced urinary bladder cancer underwent MR imaging before and after two, four, and six cycles of chemotherapy with methotrexate, vinblastine, adriamycin, and cisplatin (MVAC). The response after two chemotherapy cycles was evaluated by using conventional tumor size parameters at unenhanced MR imaging and with changes in the time to the start of tumor or lymph node enhancement at fast dynamic contrast-enhanced MR imaging. The results obtained with these techniques were compared with the findings at histopathology in cystectomy (n = 9) or multiple transurethral resection (n = 13) specimens obtained after completion of chemotherapy., Results: After two MVAC cycles, the accuracy, sensitivity, and specificity in distinguishing responders from nonresponders with conventional MR imaging were 73%, 79%, and 63%, respectively. With the dynamic technique, these were 95%, 93%, and 100%, respectively. Although the differences between these values are not significant (P = .48 for sensitivity, .25 for specificity, and .07 for accuracy), the data indicate that dynamic enhanced MR imaging performed better than unenhanced MR imaging. Dynamic imaging yielded correct results after two MVAC cycles in 21 cases, and in all cases after four cycles. After four MVAC cycles, the accuracy of dynamic MR imaging was significantly better (P < .05). Persisting early enhancement after four MVAC cycles correctly corresponded with lack of response in all nine cases, and after two cycles in eight of these cases. The unenhanced MR technique showed initial tumor size reduction in three of these cases., Conclusion: Conventional and dynamic enhanced MR imaging were used to evaluate chemotherapy after two, four, and six cycles of MVAC in 22 patients with bladder cancer. After two cycles, dynamic MR imaging helped detect 13 of 14 responders and eight of eight nonresponders. It helped detect five of seven lymph node responders and two of two nonresponders. Thus, it may be possible to predict after two MVAC cycles whether a patient will respond to chemotherapy.

Treatment and prognosis of urinary bladder cancer largely are determined by the tumor stage and presence of metastases. MR imaging and clinical staging complement each other. MR imaging is the most accurate technique for differentiating the various stages of deep tumor infiltration and detection of metastases, whereas clinical staging is the best technique for differentiating between postbiopsy effects and the various stages of superficial tumors. The role of MR imaging in staging of this disease and monitoring of therapy is reviewed and illustrated. Finally, the authors present an overview of current and future applications of this technique.

Objective: The purpose of this study was to evaluate a magnetization-prepared-rapid gradient-echo (MP-RAGE) sequence as a three-dimensional (3D) T1-weighted MR imaging technique to reveal lymph node metastases from carcinoma of the bladder and the prostate., Subjects and Methods: Using a 3D T1-weighted MP-RAGE sequence, MR images of 134 consecutive patients with prostatic carcinoma (n = 63) or urinary bladder carcinoma (n = 71) who were scheduled for radical prostatectomy or radical cystectomy were correlated with histopathologic findings after fine-needle aspiration biopsy (FNAB) (n = 6), open or laparoscopic pelvic lymph node dissection (n = 127), or autopsy (n = 1). MR imaging was used 10 times to guide FNAB in nine patients., Results: The sensitivity, specificity, accuracy, and positive predictive valve of the technique were 75%, 98%, 90%, and 94%, respectively. Thin-slice (1.2-mm) multiplanar reconstructed images correctly revealed diseased nodes in 33 patients. However, MR imaging failed to reveal microscopic metastatic deposits in normally sized nodes in 11 patients. Two other patients had enlarged nodes without metastasis. Furthermore, FNAB guided by MR imaging revealed metastases in six of nine patients., Conclusion: MR imaging with a 3D MP-RAGE sequence was accurate in revealing nodal metastases from carcinoma of the prostate and bladder. This imaging technique can be used to select patients for biopsy or laparoscopic pelvic lymph node dissection.

Purpose: To evaluate contrast enhancement patterns of urinary bladder cancer and surrounding structures and to evaluate a fast dynamic first-pass magnetic resonance (MR) imaging technique in tumor and node staging and in differentiation of urinary bladder cancer from postbiopsy effects., Materials and Methods: Sixty-one consecutive patients with histologically proved urinary bladder cancer were referred to undergo unenhanced and dynamic MR imaging 1-4 weeks after transurethral resection or biopsy. Subtraction and time (to beginning of enhancement) images were acquired., Results: Results with unenhanced T1- and T2-weighted images were compared with those obtained with the unenhanced images plus dynamic contrast material-enhanced single-section turbo fast low-angle shot (FLASH) images. Urinary bladder cancer started to enhance 6.5 seconds +/- 3.5 (standard deviation) after the beginning of arterial enhancement, which was 4 seconds earlier than most other structures (postbiopsy tissue, 13.6 seconds +/- 4.2). In differentiation of postbiopsy tissue from malignancy on the basis of the beginning of enhancement depicted on time and subtracted images, accuracy improved from 79% to 90% (P < .02) and specificity improved from 33% to 92% (not significant). Overall, tumor staging accuracy improved significantly from 67% to 84% (P < .01) by adding the turbo FLASH images., Conclusion: Fast dynamic first-pass MR imaging, with at least one image acquired every 2 seconds, improved delineation of urinary bladder cancer, tumor staging, and detection of metastases.

Since the introduction, pelvic MRI has been considered the best non-invasive technique for primary staging of urinary bladder cancer. Before using MRI an understanding of normal and pathological MR images of the urinary bladder is essential. This review therefore describes the MR anatomy of the urinary bladder as well as the appearances of carcinoma. MRI plays an important clinical role in staging the primary tumour. In superficial tumours, clinical staging, which includes transurethral biopsy, is the best technique. For invasive tumours, MRI is superior to other techniques such as CT scanning, transvesical ultrasonography and clinical staging. A limitation of both MRI and CT scanning is their inability to recognize minimal tumour growth in the muscle layer of the bladder wall, or to differentiate between post-transurethral resection oedema and tumour. Therefore, in all patients with urinary bladder cancer staging should preferably start with MRI followed by clinical staging. Unfortunately, however, because of the high cost of this strategy, MRI has to be reserved for staging deeply invasive and superficial poorly differentiated tumours.

Objective: The purpose of this study was to evaluate a magnetization prepared-rapid gradient-echo (MP-RAGE) sequence as a three-dimensional T1-weighted MR imaging technique for staging urinary bladder cancer and to compare this technique with a commonly used two-dimensional T1-weighted spin-echo sequence technique., Subjects and Methods: For 28 consecutive patients with urinary bladder cancer, MR findings and staging results were compared with histopathologic findings after surgery or autopsy. MR imaging was performed at 1.5 T with a Helmholtz double-surface coil. Conventional T1-weighted spin-echo, three-dimensional MP-RAGE, T2-weighted spin-echo or turbo-spin-echo, and dynamic T1-weighted fast gradient-echo sequences were used. Signal difference-to-noise ratios and T1 contrast were calculated by use of operator-defined regions of interest., Results: The signal difference-to-noise ratios for fluid-tumor and fat-tumor were, respectively, factors of 1.6 and 2.7 better with T1-weighted spin-echo sequences. T1 contrast of fluid-tumor was a factor of 2.6 better with three-dimensional MP-RAGE sequences, resulting in better recognition of small tumors, ascites, and dilated ureters. T1 contrast for fat-tumor was a factor of 2.0 better with T1-weighted spin-echo sequences. With the MP-RAGE sequence, motion artifacts were fewer in number than those noted with the T1-weighted spin-echo sequence, and susceptibility artifacts were equal in number to those noted with the T1-weighted spin-echo sequence. Using the three-dimensional technique, we performed off-line reconstruction of 1- to 2-mm high-resolution images in every desired plane. Because of higher spatial resolution, the availability of multiplanar reconstructions, and better fluid-tumor contrast and despite lower signal difference-to-noise ratios, three-dimensional MP-RAGE images resulted in better recognition of local tumor extension (n = 11), adhesions and bowel wall invasion (n = 5), lymph node metastases (n = 2), and bone marrow metastases (n = 2). The staging accuracy for the combination of three-dimensional MP-RAGE, T2-weighted, and dynamic sequences was 93%; that for the combination of two-dimensional T1-weighted spin-echo, T2-weighted, and dynamic sequences was 78%. Nodal staging was also more accurate with MP-RAGE sequences (accuracy of 93% vs 86% for T1-weighted spin-echo sequences)., Conclusion: Compared with two-dimensional T1-weighted spin-echo imaging, three-dimensional MP-RAGE imaging resulted in a 15% improvement in staging. Our findings suggest that optimal staging of urinary bladder carcinoma requires three-dimensional imaging techniques.

The role of magnetic resonance (MR) imaging in the management of carcinoma of the urinary bladder is reviewed and illustrated. In vivo and in vitro MR images of the normal urinary bladder, carcinoma, and surrounding structures are presented. Factors for optimal MR imaging of urinary bladder carcinoma are reviewed. Pulse sequence optimization, (endorectal) surface coils, and other new developments such as fast spin echo, subtraction turbo-fast low angle shot (FLASH), three-dimensional rapid acquisition gradient echo sequences, and the use of contrast agents are discussed. Finally, the value of MR imaging in staging urinary bladder carcinoma is compared with clinical staging, staging based on findings from computed tomography and intravesical sonography.

In this article, the role of MR imaging in the management of carcinoma of the urinary bladder is reviewed and illustrated. The appearance of the normal urinary bladder and of bladder carcinoma on MR images is shown. Important factors for optimal MR imaging of urinary bladder carcinoma are reviewed. New developments such as three-dimensional and fast spin-echo sequences and the use of contrast agents, endorectal imaging, and phased array coils are discussed. Finally, the value of MR imaging in the staging of bladder carcinoma is described, and MR staging is compared with clinical staging, staging based on findings from intravesical sonography, and CT staging.

Twenty-four patients with carcinoma of the urinary bladder were examined with MR imaging by using both a conventional body coil and a newly designed wraparound double surface coil. All patients had T1- and two patients had T2-weighted pulse sequences with both coils. Because of the long examination times, T2-weighted sequences in all other patients were obtained by using the double surface coil only. Nine patients underwent radical cystectomy, while the other patients had deep transurethral tumor resection and a clinical follow-up of at least 1.5 years. The results of imaging with the surface coil showed a twofold improvement of spatial resolution compared with the images obtained with the body coil. The RF field homogeneity was excellent, and the field of view was sufficiently large to achieve a complete study of the pelvis and the lower abdomen in one sequence. For the T1-weighted images, the higher spatial resolution of the double surface coil resulted in a significant (p less than .10) improvement in tumor staging. The accuracies of double-surface-coil and body-coil imaging were 79% and 54%, respectively. Double-surface-coil imaging appears to provide better MR images of the urinary bladder than body-coil imaging does, resulting in more accurate staging of tumors on T1-weighted pulse sequences.