Urology Journal Vol.

2, 22-26 Spring 2004

UNRC/IUA Printed in IRAN

Urological Oncology
A Comparison between Clinical and Pathologic Staging in
Patients with Bladder Cancer
MEHRSAI A1, MANSOORI D2, TAHERI MAHMOODI M1, SINA A1, SERAJI A1,
POURMAND GH1
1- Department of Urology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
2- Department of Urology, Shaheed Mohammadi Hospital, Bandarabbass University of Medical
Sciences, Bandarabbass, Iran

ABSTRACT
Purpose: To determine the accuracy of clinical staging methods of bladder cancer
and TURBT results in estimating the pathologic stage of tumor.
Materials and Methods: Thirty two patients who had undergone radical cystecto-
my were studied in this retrospective survey. The results of bimanual examination, cys-
toscopy, TURBT pathology report and the tumor contour in CT scan, (size, infiltrative
deepness, pelvic lymph nodes involvement and hydronephrosis) were recorded. The
type of surgery and pathologic report of cystectomy sample were analyzed as well.
Then the results of bimanual examination, tumor size, hydronephrosis and CT scan
findings including tumor infiltrative deepness, pelvic lymph adenopathy and TURBT
findings were compared to pathologic results of cystectomy sample.
Results: Seven patients were females and 25 were males. Their mean age was 62
(range 36 to 80) years. Gross hematuria and irritative urinary symptoms were the
most common complaints. The duration between symptom manifestation and patient's
referral was 5 days to 72 months (mean 12 months). Bimanual examination in esti-
mating the extravesical involvement of tumor had a specificity of 82%, sensitivity of
46%, positive predictive value of 70% and negative predictive value of 63%. The size of
tumor in determining extravesical involvement had a specificity of 41%, sensitivity of
93%, and positive predictive value of 58% and negative predictive value of 87%.
Hydronephrosis was present in 15 patients of whom, 14(93%) had bladder muscle
involvement. CT scan specificity was 70%, and sensitivity was 46% regarding pelvic
lymph adenopathy and perivesical fat involvement. In TURBT report no muscle sam-
ple was observed in 11 cases, so that the interpretations of results were impossible.
The reported grade of tumor was lower than pathologic sample of cystectomy in 4
patients.
Conclusion: Clinical staging in invasive bladder cancers has not high accuracy
regarding the involvement of bladder surrounding fats and pelvic adenopathies. A
tumor sized more than 5 cm could be sensitive in estimating extravesical involvement.
Positive predictive value of hydronephrosis is considerable regarding bladder muscle
involvement. Tumor understaging by TURBT is happened in high percentage of
patients with invasive bladder cancer.

KEY WORDS: bladder cancer , bimanual palpation, hydronephrosis, tumor size, TURBT

Accepted for publication in April 2003

22
 A COMPARISON BETWEEN CLINICAL AND PATHOLOGIC STAGING IN PATIENTS 23
WITH BLADDER CANCER

Introduction Patients' preoperative evaluations were as follows:

Radical cystectomy is considered as a standard history taking, physical examination, chest x-ray,
treatment in muscle invasive urothelial bladder CBC, BUN, Cr, electrolytes, liver function tests,
tumors. Before such treatment, clinical staging is CT scan, bone scan, and barium enema or
done by physical examination, imaging, liver func- colonoscopy for patients who were candidates for
tion tests, bladder endoscopy, bimanual examina- urinary diversion, in order to rule out any colorec-
tion under anesthesia, tumor biopsy, and TURBT; tal lesion.
however, pathologic staging which is the most The following data were collected from each
important factor in patient prognosis is done ulti- patient: the results of bimanual bladder examina-
mately following the study of the full thickness of tion, cystoscopy, TURBT or tumor biopsy report,
bladder wall and lymphatic glands, that is after tumor site and size in pelvic CT scan, regarding
radical cystectomy.(1,2) size, infiltrative deepness, hydronephrosis, pelvic
There is always a risk of error in clinical staging lymph nodes involvement as well as type of sur-
of patients with bladder cancer which may even gery and pathologic report of radical cystectomy.
exceed to 50%.(3) Bimanual examination of the In this survey, the efficiency of bimanual exam-
bladder is used to detect palpable extravesical ination, infiltrative deepness, tumor size in CT
mass. Palpable mass particularly after TURBT scan, hydronephrosis, and TURBT or biopsy
affects patient survival.(4) CT scan is a common report in estimating pathologic stage of bladder
method in clinical staging. Its sensitivity in esti- tumor were studied.
mating extravesical involvement of tumor is Tumor staging was performed according to TNM
between 57% and 96% and its specificity is report- classification (Edition 1997) and tumor grading
ed to be between 60% and 93%.(5,6,7) was conducted in accordance with WHO classifica-
Hydronephrosis is a sign of ureteral obstruction tion (grade I to III).
and is regarded as an important factor in staging
.It is associated with muscle invasion in 70-90% Results
and distant metastasis in 55%.(8) The size of tumor Seven out of 32 studied patients were females
is also considered as an effective factor in patients' and 25 were males. Patients mean age was 61
prognosis(9) and finally TURBT is regarded as one (range 36 to 80) years. A history of gross hema-
of the most important methods of clinical staging turia was reported in 29 patients, irritative uri-
and determining biologic characteristics of tumor; nary symptoms in 15, and obstructive urinary
however, there is a risk of error in estimating infil- symptoms in 6 and suprapubic pain in 3.
trative deepness of tumor and its grade and under- One patient suffered form anuria. Mean dura-
staging could be occurred even in more than 50% tion between the disease manifestation and refer-
of cases.(10) ral time was 12 (range 5 to 72) months. The tumor
Muscle invasion is indicated in more than 95% was palpable by bimanual examination in 11
of high grade tumors in patients who underwent patients. Table 1 shows the results of comparing
cystectomy; while, the deepness of high grade palpable tumor and final pathology.
tumors is mostly estimated lower than its actual The specificity of bimanual examination in this
amount via TURBT.(2) The efficiency of the follow- study was 82%, sensitivity was 46%, positive pre-
ing items has been studied in this survey: dictive value was 70%, and negative predictive
1. bimanual examination, value was 63%. According to cystoscopy and CT
2. CT scan findings including tumor size, scan, the tumor was located on the left wall in 11
hydronephrosis, infiltrative deepness of tumor patients, right in 8, bladder base in 7, diffuse in
regarding prevesical fat involvement, and pelvic
adenopathy, TABLE 1. Results of bimanual examination of
3. TURBT report to estimate pathologic stage of tumor and their comparison to pathologic results of
bladder cancer. radical cystectomy samples
No extravesical tumor Extravesical tumor
Total involvement involvement
Materials and Methods (T1 , T2) (T3 , T4)
Thirty two patients with bladder cancer who had 10 3 7 Palpable cases
undergone surgical radical cystectomy from 1999 22 14 8
No-palpable
cases
to 2001, were enrolled in this retrospective survey.
32 17 15 Total
24 A COMPARISON BETWEEN CLINICAL AND PATHOLOGIC STAGING IN PATIENTS
WITH BLADDER CANCER

the bladder in 4, at the bladder dome in 1, and in ductive value was 58% and its negative productive
the bladder diverticulum in 1. Trigone involvement value was 60%.
was not present in 7 patients, while it was In the TURBT report of patients who underwent
observed via cystoscopy in the remained patients. cystectomy, no muscular sample was seen in biop-
Tumor size (the largest dimension of tumor) was sy of 11 patients and only mucosal layer involve-
measured in CT scan. It was compared to final ment with tumor was reported. Tumor grade was
pathologic results (table 2). Tumor size specificity lower than radical cystectomy sample in 4 cases.
in determining extravesical involvement was 41% Clinical evidences of muscular involvement includ-
and its sensitivity was 93%. Its positive productive ing TURBT or CT scan results were the indication
value was 58% and negative productive value was of radical cystectomy in 29 cases. Surgical opera-
87%. Unilateral or bilateral hydronephrosis were tion was performed in 3 cases considering big size
seen in 15 patients. Table 3 shows the relationship of tumor or the presence of bladder diverticulum's,
between hydronephrosis and pathologic findings of despite the lack of evidence of bladder muscular
surgical samples. The specificity of hydronephrosis involvement. Figures 1 and 2 show types of used
in determining the involvement of bladder muscle urinary diversion and final report of patients
was 75%, its sensitivity was 50%, its positive pro- pathology. In situ carcinoma was also simultane-
ductive value was 93%, and its negative productive ously reported in 5 patients.
value was 17%. Table 4 shows the involvement of
perivesical fat or pelvic lymph adenopathy in CT Discussion
scan and its comparison to final pathology. The stage of bladder cancer has been reported in
The specificity of CT scan in determining several reports as the most important criterion of
perivesical fat involvement or pelvic adenophathy prognosis and patient's survival.(11,12) Despite the
was 70%, its sensitivity was 46%, its positive pro- innovation of modern methods of imaging, clinical
staging of bladder cancer has a high percentage of
TABLE 2. A comparison between of tumor size and
errors.(13) A comparison has been conducted
pathologic reports of radical cystectomy samples
between the accuracy of different methods of clin-
No extravesical Extravesical ical staging and final pathologic staging. Bimanual
Total involvement involvement
(T1 or T2 , N0) (T3 or T4 or N+) examination of bladder particularly under anesthe-
24 10 14
Tumor lager than sia and following TURBT is regarded as an impor-
5 cm
tant staging tool. In a study conducted on 276
Tumor smaller
8 7 1 Swedish patients, 5-year patient survival was
than 5 cm
32 17 15 Total

16
14 MAINZ II
12
TABLE 3. A comparison between hydronephrosis and 10
MITROFANOFF
ILEAL CONDUIT
pathologic reports of radical cystectomy samples 8
URETEROSIGMOIDOSTOMY
6
UCLA POUCH
No muscular Muscular 4
CAMEY II POUCH
Total involvement involvement 2
INDIANA POUCH
(T1) (T2 , T3 , T4) 0
1st Qtr
15 1 14 Hydronephrosis

17 3 14
Without FIG. 1. Types of urinary diversion surgeries in
hydronephrosis
patients
32 4 28 Total

14
TABLE 4. A comparison between CT scan findings
12
and pathologic reports of radical cystectomy samples 10

No extravesical Extravesical 8 TCC

Total Involvement involvement 6 SCC
(T1 or T2 , N0) (T3 or T4 or N+) ADENO
4
Presence of Perivesical fat 2
12 5 7 involvement or pelvic
0
adenopathy in CT scan T1 N0 M0 T2 N0 M0 T3 or T 4 or N +,M 0
No extravesical
20 12 8
involvement in CT scan FIG. 2. Results of pathologic report of cystectomy
32 17 15 Total samples of patients
 A COMPARISON BETWEEN CLINICAL AND PATHOLOGIC STAGING IN PATIENTS 25
WITH BLADDER CANCER

reduced from 83% (in not palpable cases) to 50% TURBT is one of the most important approach-
in the cases of palpable mass.(4) es in bladder cancer staging; however, the differ-
The specificity of this examination was accept- ence of surgeons' experience and the variety of
able in the prognosis of extravesical tumor involve- deepness of removed tissue as well as problem in
ment; sensitivity was low, only about 46%. The rea- pathologic interpretation of samples decreases the
son might be bimanual examination without anes- accuracy of this method in determining the stage
thesia, which led to lack of complete relaxation of of tumor. If the sample is so small or if just a biop-
abdominal muscles. Patient obesity, unavailable sy of tumor was taken, a high percentage of error
bladder tumor as well as small size of tumor are would be occurred in determining infiltrative deep-
regarded other influencing factors for false nega- ness of tumor and its grade. In a survey per-
tive results in this examination, as it mentioned in formed on 105 patients, understaging of tumor
references. Previous pelvic surgical history, radio- was reported via TURBT in 55 patients.(10) In this
therapy and inflammatory lesions of rectosigmoid study no muscular sample was seen in TURBT
are among false positive reasons.(2) samples in 11(34%) patients of Mainly, the lack of
The size of tumor is considered as a prognostic muscular sample in bladder biopsy is considered a
factor in bladder tumors. In a study conducted on risk factor in understaging bladder tumor.(19)
64 patients who underwent radical cystectomy, the Tumor grade was lower than final pathology in 4
size of tumor, as an independent factor, affected other patients.
on 10-year cancer- specific survival.(9)
In this study 14 out of 15 patients whose patho- Conclusion
logic stages were T3 or higher, had a tumor larg- This survey which was conducted to assess the
er than 5 cm which indicated the necessity of inva- efficacy of clinical methods for staging of invasive
sive treatment in large tumors particularly high bladder invasive tumors showed that bimanual pal-
grade ones. pation lacks adequate sensitivity for determining
Hydronephrosis is regarded as a prognostic cri- extravesical involvement of tumor but it is mostly
terion in bladder tumors by which muscular specified. A tumor lager than 5 cm could lead to
involvement is reported to be between 70% and high sensitivity in predicting extravesical involve-
90%.(8) No deference has been seen between unilat- ment of tumor, but it has not a high specificity.
eral and bilateral hydronephrosis in most per- Regarding bladder muscle involvement,
formed studies considering the relationship hydronephrosis has a high positive predictive
between the stage of cancer and obstruction,(14,15) value and CT scan has low accuracy in determin-
though, some believe that bilateral hydronephrosis ing the involvement of surrounding bladder tissue
has worsen prognosis.(8) and pelvic lymphadenopathy. Furthermore, under-
CT scan is conducted to determine the infiltra- staging with TURBT or biopsy is occurred in high
tive deepness of tumor in bladder muscle and the percentage of patients, specially, when no bladder
involvement of surrounding soft tissue; however, muscular tissue is seen in TUR samples. Finally, it
these changes could be inflammatory and non- seems that none of the current common methods
infiltrative. In addition, if CT scan is performed is adequately credible for clinical staging of blad-
after bladder tumor TUR, these changes might be der cancer in the prognosis of pathologic stage.
due to extravasation of fluid. In a survey, the sim- Probably, using molecular markers or modern
ilarity between CT scan findings and pathologic methods of imaging like spiral CT scan and MRI
staging was reported in 86% of 50 patients who may be more accurate in staging.
underwent radical cystectomy.(16) In another study It is recommended to perform prospective study
this rate was 68% in 60 patients.(17) In a retrospec- with more samples and with modern imaging
tive study carried out on 82 patients, final result modalities and using molecular markers to predict
showed that CT scan was unable to detect micro- pathologic stage of invasive bladder tumors.
scopic involvement or little extravesical extension
of tumor and lymphatic metastasis; moreover, it
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