disease management

Article of the week: How useful is FDG-PET/CT in managing carcinoma invading bladder muscle?

October 16, 2013/by admin Z.9

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video of Ms Mertens and Prof Horenblas discussing their findings.

If you only have time to read one article this week, it should be this one.

Impact of ¹⁸F-fluorodeoxyglucose (FDG)-positron-emission tomography/computed tomography (PET/CT) on management of patients with carcinoma invading bladder muscle

Laura S. Mertens, Annemarie Fioole-Bruining*, Erik Vegt^†, Wouter V. Vogel^†, Bas W. van Rhijn and Simon Horenblas

Departments of Urology, *Radiology and ^†Nuclear Medicine, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands

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OBJECTIVE

• To evaluate the clinical impact of ¹⁸F-fluorodeoxyglucose (FDG)-positron-emission tomography/computed tomography (PET/CT) scanning, compared with conventional staging with contrast-enhanced CT imaging (CECT).

PATIENTS AND METHODS

• The FDG-PET/CT results of 96 consecutive patients with bladder cancer were analysed. Patients included in this study underwent standard CECT imaging of the chest and abdomen/pelvis <4 weeks before FDG-PET/CT.

• Based on the original imaging reports and recorded tumour stage before and after FDG-PET/CT imaging, the preferred treatment strategies before FDG-PET/CT and after FDG-PET/CT were determined for each patient using an institutional multidisciplinary guideline. One of the following treatment strategies was chosen: (i) local curative treatment; (ii) neoadjuvant/induction chemotherapy; or (iii) palliation.

• The changes in management decisions before and after FDG-PET/CT were assessed.

RESULTS

• The median (range) interval between CECT and FDG-PET/CT was 0 (029) days.

• In 21.9% of the patients, stage on FDG-PET/CT and CECT were different. Upstaging by FDG-PET/CT was more frequent than downstaging (19.8 vs 2.1%).

• Clinical management changed for 13.5% of patients as a result of FDG-PET/CT upstaging. In eight patients, FDG-PET/CT detected second primary tumours. This led to changes of bladder cancer treatment in another four of 96 patients (4.2%).

• All the management changes were validated by tissue confirmation of the additional lesions.

CONCLUSIONS

• FDG-PET/CT provides important additional staging information, which influences the treatment of carcinoma invading bladder muscle in almost 20% of cases.

• Patient selection for neoadjuvant/induction chemotherapy was improved and futile attempts at curative treatment in patients found to have metastases were avoided.

Read Previous Articles of the Week

Editorial: Is FDG-PET/CT ready for prime time?

October 16, 2013/by Vicky Goh

Fluorodeoxyglucose positron-emission tomography (FDG PET)/computed tomography (CT) in bladder cancer

In this month’s issue Mertens et al. [1] present a retrospective analysis of the clinical impact of fluorodeoxyglucose positron-emission tomography (FDG PET)/CT in 96 patients with muscle-invasive bladder cancer. Muscle invasion is present in ≈30% of patients presenting with bladder cancer and is associated with a higher incidence of nodal and metastatic disease than non-muscle-invasive tumours [2]. Accurate staging in this patient group will influence management decisions to proceed to local therapies, to instigate neoadjuvant treatment before local therapy, or to offer palliative chemotherapy where there is imaging evidence and subsequent confirmation of metastatic disease [2].

While there have been a few previous studies investigating FDG PET or FDG PET/CT for staging bladder cancer [3-7], with reported sensitivities and specificities ranging from 60 to 81% and 67 to 94% respectively, to date there are few data describing the impact on clinical management. A recent FDG PET/CT study of 57 patients with bladder cancer [3] reported that management was changed in 68% of cases after PET suggesting that FDG PET/CT has a substantial impact on the management of these patients. However, most patients in that study underwent FDG PET/CT for a suspected recurrence (72%) and the remainder for initial staging (21%) or post-treatment monitoring (chemotherapy or radiotherapy; 7%); 44% of patients had metastatic disease.

In the study reported by Mertens et al. [1], clinical data obtained in 96 patients during the patients’ clinical pathway were reviewed retrospectively. FDG PET/CT staging with standard contrast-enhanced CT was discordant in 22% of cases (21 patients), where PET/CT predominantly upstaged patients, consistent with the previous reports [3, 4]. After PET/CT, the treatment recommendations changed in 13.5% (13 patients) due to disease upstaging. In seven of the 13 patients treatment recommendations altered from local to palliative, due to the presence of metastatic disease, and in the remaining six of the 13 patients, neoadjuvant treatment was recommended in addition to planned local therapy. In another four patients management changed as a consequence of detecting other incidental primary tumours with FDG PET/CT.

However, the final clinical impact of FDG PET/CT may be less. When actual treatment changes were recorded, in only eight of these 13 patients were the recommendations implemented, due to patient co-morbidity or patient wishes in the remainder, e.g. FDG PET/CT changed actual treatment in only 8% in this study (eight of 96 patients). Including the four patients in whom incidental other primary tumours were discovered, the management impact of FDG PET/CT was 12.5%.

There is no doubt that from current published data and supported by this study by Mertens et al. [1] that FDG PET/CT improves staging in bladder cancer due to its higher sensitivity for metastatic disease. However, the actual change in management is relatively low and more prospective data will be required to confirm its clinical and cost effectiveness in terms of outcome, both in a single and multicentre setting.

Vicky Goh*^‡ and Gary Cook*^†*Division of Imaging Sciences and Biomedical Engineering, King’s College London, ^‡Department of Radiology, and ^†Clinical PET Imaging Centre, Guy’s and St Thomas’ Hospitals NHS Foundation Trust, London, UK

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References

Mertens L, Fioole-Bruining A, Vegt E, Vogel W, van Rhijn B, Horenblas S. Impact of ¹⁸F-fluorodeoxyglucose (FDG)-positron-emission tomography/computed tomography (PET/CT) on management of patients with carcinoma invading bladder muscle. BJU Int 2013; 112: 729–734
Kaufman DS, Shipley WU, Feldman AS. Bladder cancer. Lancet 2009; 374: 239–249
Apolo AB, Riches J, Schoder H et al. Clinical value of fluorine-18 2-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography in bladder cancer. J Clin Oncol 2010; 28: 3973–3978
Kibel AS, Dehdashti F, Katz MD et al. Prospective study of [¹⁸F] Fluorodeoxyglucose positron emission tomography/computed tomography for staging of muscle-invasive bladder carcinoma. J Clin Oncol 2009; 27: 4314–4320
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. J Nucl Med 2007; 48: 764–770
Drieskens O, Oyen R, Van Poppel H, Vankan Y, Flamen P, Mortelmans L. FDG-PET for preoperative staging of bladder cancer. Eur J Nucl Med Mol Imaging 2005; 32: 1412–1417
Kosuda S, Kison PV, Greenough R, Grossman HB, Wahl RL. Preliminary assessment of fluorine-18 fluorodeoxyglucose positron emission tomography in patients with bladder cancer. Eur J Nucl Med 1997; 24: 615–620

Video: Upstage, downstage: the spotlight on FDG-PET/CT for managing bladder cancer

October 16, 2013/by admin Z.9

Impact of ¹⁸F-fluorodeoxyglucose (FDG)-positron-emission tomography/computed tomography (PET/CT) on management of patients with carcinoma invading bladder muscle

Laura S. Mertens, Annemarie Fioole-Bruining*, Erik Vegt^†, Wouter V. Vogel^†, Bas W. van Rhijn and Simon Horenblas

Departments of Urology, *Radiology and ^†Nuclear Medicine, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands

Read the full article