VI-RADS: The new PI-RADS for bladder cancer? Bladder MRI has the potential to affect the entire management of patients with bladder cancer
investigating the long-term impact of applying MRI and VI-RADS in the pre-operative setting are needed to acknowledge to which extent their use improves health outcomes relative to the current best alternative. For this, results from comparative randomised clinical trials are warranted. The preliminary data of the “BladderPath: Image Directed Redesign of Bladder Cancer Treatment Pathway” trial [15], led by Professor Nicholas James from the University of Birmingham, which aims at assessing whether some bladder tumour surgery can be replaced by MRI scans to determine the stage of the cancer, suggest that this approach is feasible [16]. • Mutual trust and certification: The relationship between physicians, as well as those between academic and non-academic centres must improve. We must also create validation and certification processes to strengthen such connections. New pathways towards certification for bladder MRI acquisition and VI-RADS reporting will be needed. Another potential barrier pertains to the public acceptance of imaging for surgical decision-making. Future developments • non-invasive prediction tool: The VI-RADS score has the potential to become a clinical predictor of perioperative outcomes, as well as a tool for predicting tumour aggressiveness and response to therapy. Multiple studies have demonstrated the validity of MRI functional sequences and quantitative parameters for predicting tumour grade [17–21]. Also, assessment of tumour response can be evaluated in different clinical setting: before, interim and after therapy [22–24]. • radiomics and machine learning : Radiomics analysis and machine learning applications of medical images has developed exponentially over the past decade, in the field of oncological imaging, including for bladder cancer. In spite of early promises, larger, multi-centre datasets are needed before radiomics, and machine learning algorithms can be used in routine clinical practice to support and improve local staging of bladder cancer and assist in optimising therapeutic management. The standard diagnostic pathway for bladder cancer has not changed in 30 years. Bladder MRI has the potential to affect the entire management of patients with bladder cancer, from staging and prediction to assessment of response to treatment. Is VI-RADS the new PI-RADS for bladder cancer? It will likely be so, with further evidence and efforts shedding light on clinical utility, mutual trust between practitioners and institutions, and new pathways towards certification. References 1. Lenis AT, Lec PM, Chamie K, Mshs M. Bladder Cancer: A Review. JAMA 2020;324:1980. https://doi.org/10.1001/ jama.2020.17598. 2. Fisher MR, Hricak H, Tanagho EA. Urinary bladder MR imaging. Part II. Neoplasm. Radiology 1985;157:471–7. https://doi.org/10.1148/radiology.157.2.4048458. 3. Barentsz JO, Richenberg J, Clements R, Choyke P, Verma S, Villeirs G, et al. ESUR prostate MR guidelines 2012. Eur Radiol 2012;22:746–57. https://doi.org/10.1007/ s00330-011-2377-y. 4. Weinreb JC, Barentsz JO, Choyke PL, Cornud F, Haider MA, Macura KJ, et al. PI-RADS Prostate Imaging – Reporting and Data System: 2015, Version 2. European Urology 2016;69:16–40. https://doi.org/10.1016/j. eururo.2015.08.052. 5. Turkbey B, Rosenkrantz AB, Haider MA, Padhani AR, Villeirs G, Macura KJ, et al. Prostate Imaging Reporting and Data System Version 2.1: 2019 Update of Prostate Imaging Reporting and Data System Version 2. European Urology 2019;76:340–51. https://doi.org/10.1016/j. eururo.2019.02.033. 6. Mottet, R.C.N. van den Bergh N., E. Brier, P. Cornford, M. De Santis, S. Fanti, et al. EAU Guidelines: Prostate Cancer. EAU Guidelines 2019. 7. Engels RRM, Israël B, Padhani AR, Barentsz JO. Multiparametric Magnetic Resonance Imaging for the Detection of Clinically Significant Prostate Cancer: What Urologists Need to Know. Part 1: Acquisition. European Urology 2019:S0302283819307419. https://doi. org/10.1016/j.eururo.2019.09.021. 8. Panebianco V, Narumi Y, Altun E, Bochner BH, Efstathiou JA, Hafeez S, et al. Multiparametric Magnetic Resonance Imaging for Bladder Cancer: Development of VI-RADS (Vesical Imaging-Reporting And Data System). European Urology 2018;74:294–306. https://doi.org/10.1016/j. eururo.2018.04.029. 9. Mostafid H, Babjuk M, Bochner B, Lerner SP, Witjes F,
Palou J, et al. Transurethral Resection of Bladder Tumour: The Neglected Procedure in the Technology Race in Bladder Cancer. European Urology 2020;77:669–70. https://doi.org/10.1016/j.eururo.2020.03.005. 10. Wang H, Luo C, Zhang F, Guan J, Li S, Yao H, et al. Multiparametric MRI for Bladder Cancer: Validation of VI-RADS for the Detection of Detrusor Muscle Invasion. Radiology 2019;291:668–74. https://doi.org/10.1148/ radiol.2019182506. 11. Metwally MI, Zeed NA, Hamed EM, Elshetry ASF, Elfwakhry RM, Alaa Eldin AM, et al. The validity, reliability, and reviewer acceptance of VI-RADS in assessing muscle invasion by bladder cancer: a multicenter prospective study. Eur Radiol 2021. https://doi.org/10.1007/ s00330-021-07765-5. 12. Del Giudice F, Flammia RS, Pecoraro M, Moschini M, D’Andrea D, Messina E, et al. The accuracy of Vesical Imaging-Reporting and Data System (VI-RADS): an updated comprehensive multi-institutional, multi-readers systematic review and meta-analysis from diagnostic evidence into future clinical recommendations. World J Urol 2022;40:1617–28. https://doi.org/10.1007/ s00345-022-03969-6. 13. Bryan RT, Catto JWF, Jefferson KP, Patel P, James ND, on behalf of the BladderPath Trial Management Group. Reply to Trey Durdin, Alvin Goh, and Eugene Pietzak. Can an Imaging-guided Pathway Replace the Current Paradigm for Muscle-invasive Bladder Cancer? European Urology 2021;80:18–9. https://doi.org/10.1016/j. eururo.2021.04.034. 14. Del Giudice F, Leonardo C, Simone G, Pecoraro M, De Berardinis E, Cipollari S, et al. Preoperative detection of VI-RADS (Vesical Imaging-Reporting and Data System) score 5 reliably identifies extravesical extension of urothelial carcinoma of the urinary bladder and predicts significant delayed time-to-cystectomy: time to reconsider the nee. BJU Int 2020. https://doi. org/10.1111/bju.15188. 15. https://www.birmingham.ac.uk/research/crctu/trials/ bladder-path/index.aspx n.d. 16. Bryan RT, Liu W, Pirrie SJ, Amir R, Gallagher J, Hughes AI, et al. Comparing an Imaging-guided Pathway with the Standard Pathway for Staging Muscle-invasive Bladder Cancer: Preliminary Data from the BladderPath Study. European Urology 2021;80:12–5. https://doi. org/10.1016/j.eururo.2021.02.021. 17. Li Q, Cao B, Liu K, Sun H, Ding Y, Yan C, et al. Detecting the muscle invasiveness of bladder cancer: An application of diffusion kurtosis imaging and tumor contact length. European Journal of Radiology 2022;151:110329. https:// doi.org/10.1016/j.ejrad.2022.110329. 18. Rosenkrantz AB, Mussi TC, Spieler B, Melamed J, Taneja SS, Huang WC. High-grade bladder cancer: Association of the apparent diffusion coefficient with metastatic disease: Preliminary results. J Magn Reson Imaging 2012;35:1478–83. https://doi.org/10.1002/jmri.23590. 19. Sevcenco S, Ponhold L, Heinz-Peer G, Fajkovic H, Haitel A, Susani M, et al. Prospective evaluation of diffusion- weighted MRI of the bladder as a biomarker for prediction of bladder cancer aggressiveness. Urologic Oncology: Seminars and Original Investigations 2014;32:1166–71. https://doi.org/10.1016/j.urolonc.2014.04.019. 20. Zhang M, Chen Y, Cong X, Zhao X. Utility of intravoxel incoherent motion MRI derived parameters for prediction of aggressiveness in urothelial bladder carcinoma. J Magn Reson Imaging 2018;48:1648–56. https://doi. org/10.1002/jmri.26165. 21. Zhou G, Chen X, Zhang J, Zhu J, Zong G, Wang Z. Contrast-enhanced dynamic and diffusion-weighted MR imaging at 3.0T to assess aggressiveness of bladder cancer. European Journal of Radiology 2014;83:2013–8. https://doi.org/10.1016/j.ejrad.2014.08.012. 22. Bandini M, Calareso G, Raggi D, Marandino L, Colecchia M, Gallina A, et al. The Value of Multiparametric Magnetic Resonance Imaging Sequences to Assist in the Decision Making of Muscle-invasive Bladder Cancer. European Urology Oncology 2020:S2588931120300821. https:// doi.org/10.1016/j.euo.2020.06.004. 23. Ahmed SA, Taher MGA, Ali WA, Ebrahem MAES. Diagnostic performance of contrast-enhanced dynamic and diffusion-weighted MR imaging in the assessment of tumor response to neoadjuvant therapy in muscle- invasive bladder cancer. Abdom Radiol 2021;46:2712–21. https://doi.org/10.1007/s00261-021-02963-7. 24. Pecoraro M, Del Giudice F, Magliocca F, Simone G, Flammia S, Leonardo C, et al. Vesical Imaging-Reporting and Data System (VI-RADS) for assessment of response to systemic therapy for bladder cancer: preliminary report. Abdom Radiol 2022;47:763–70. https://doi. org/10.1007/s00261-021-03365-5.
Prof. Valeria Panebianco Radiological Sciences Sapienza University of Rome (IT)
Figure 3
Bladder cancer diagnostic is evolving, as benefits for patients have demonstrated during the last decade [1]. Evidence on the applicability of bladder Magnetic Resonance Imaging (MRI) for bladder cancer staging in clinical practice has been shown since the in the late 1980s [2]. Since then, the technological advancement have allowed to improve MR acquisition in terms of contrast resolution and tissue characterization, which has now become the imaging gold-standard for different pathologies in urology, particularly prostate cancer [3]. MRI and the development of a standardised system for its reporting, the Prostate Imaging-Reporting and Data System (PI-RADS) [3–5] -, has revolutionised prostate cancer diagnostic pathway, switching from a conventional to a personalised way of diagnosing this disease in 2019 [6]. Indeed, the PI-RADS scoring system was the game-changer in this setting [7], as MRI is currently the first line exam for patients experiencing PSA elevation [6]. The question is are we experiencing what happen with prostate cancer, today for bladder cancer? Do we have, or will we soon have the means, to sustain as a community a new bladder cancer MRI pathway? Let’s now examine the data. In 2018, the Vesical Imaging-Reporting and Data System (VI-RADS) was developed by a group of international experts [8]. Most likely as a solution to determine evidence of mini-invasive surgical advancement. Indeed, the procedure of trans- urethral resection of bladder tumour (TURBT), although being the foundation of bladder cancer surgical management, “ remains an anachronism in modern surgical oncology ” [9]. The VI-RADS score is a 5-point assessment scale, in this case defining the likelihood of staging a bladder tumour as muscle-invasive. The five categories, represent in increasing order respectively, a very low- and low- likelihood of muscle invasiveness (Figure 1-2), an indeterminate likelihood (Figure 3), and a high- and very high- likelihood of muscle invasiveness (Figure 4-5). The VI-RADS score has been validated by research groups worldwide; such as one of the first retrospective investigating its role on a cohort of
Figure 4-5
330 consecutive patients by Wang et al. from China [10] and the prospective multi-centre study by the Egyptian group led by Metwally et al. [11]. Up to date, seven meta-analyses published on its accuracy and reproducibility among different readers. From results of the latest published multi-centre meta-analysis by Del Giudice et al. [12], we can infer that MRI and VI-RADS scoring provide high sensitivity and specificity when using both a VI-RADS cut-off of 3 and 4 for the definition of muscle-invasive bladder cancer, with an area under the curve > 0.9. From this meta-analysis no influence of clinical characteristics, nor of cumulative reader’s experience, were found, differing from study design and radiological characteristics which appeared to influence the estimated outcome [12]. Looking at these data we can conclude that, “on-paper” at least, the VI-RADS score does what it was developed for. Three basic questions exists that we need to answer, in order to understand whether MRI will be used in the daily clinical practice as first line pre-operative imaging, as it is done for prostate cancer: 1. What are the benefits for patients? 2. What are the barriers for its widespread diffusion? 3. what are the future developments that we need to expect? Benefits for patients • Non-invasive staging tool: VI-RADS scoring currently is best suited in the pre-resection setting and before intravesical bacille Calmette-Guerin administration. Pre-operative MRI and VI-RADS scoring allow to non-invasively and accurately stage tumours, and predict therapy response, identifying tumours that need a more radical approach from the start. Among patients with high-risk Non-muscle-invasive bladder cancer (NMIBC), VI-RADS scoring might be of use for disease risk stratification, and as an indication to undergo secondary resection of the tumour in cases of VI-RADS 4 and 5, or to avoid it in cases of VI-RADS 1 and 2. • non-invasive surveillance too: MRI and VI-RADS scoring may be a viable alternative to cystoscopy in NMIBC surveillance, after tumour resection, reducing costs associated with the disease. The bladder wall's structural changes must be considered in this setting, and expert “hands” should be sought by Urologists. • non-invasive surgical timing and planning : MRI and VI-RADS scoring might be useful in patients diagnosed with muscle-invasive bladder cancer (MIBC) to define appropriate timing for radical treatments, and to identify those likely to benefit from neoadjuvant therapy or trimodal therapy, those suitable for bladder-sparing surgery and chemoradiation, or to plan a therapeutic trans- urethral tumour resection that is surgically feasible. • support Patient and Advocacy groups , who are keen to improve the bladder cancer diagnostic paradigm, likely due to long waiting times for diagnostic trans urethral resection of bladder tumour (TURBT), resulting in significant delays to definitive management and potential harm for patients with MIBC [13,14].
Figure 1
Saturday 11 March 10:39 - 10:53 Joint meeting of ESUP, ESUR and ESUI: From conventional to molecular diagnostics Pink Area, Coral 4
Barriers • Understanding the clinical utility: Studies
Figure 2
European Urology Today
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February/March 2023
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