Assessing Bladder Radiotherapy Response With Quantitative Diffusion-Weighted Magnetic Resonance Imaging Analysis

Aims: Radiotherapy with radiosensitisation offers opportunity for cure with organ preservation in muscle-invasive bladder cancer (MIBC). Treatment response assessment and follow-up are reliant on regular endoscopic evaluation of the retained bladder. In this study we aim to determine the role of diffusion-weighted magnetic resonance imaging (DWI) and apparent diffusion coefficient (ADC) analysis to assess bladder radiotherapy response. Materials and methods: Patients with T2-T4aN0-3M0 MIBC suitable for radical radiotherapy were recruited prospectively to an ethics approved protocol. Following transurethral resection of the bladder tumour and prior to any treatment, magnetic resonance imaging including DWI was performed on a 1.5T system using b values of 0, 100, 150, 250, 500, 750 s/mm(2). DWI was repeated 3 months after completing radiotherapy. Cystoscopy and tumour site biopsy were undertaken following this. The response was dichotomised into response (< T2) or poor response (>= T2). Tumour region of interest was delineated on b750 s/mm(2) image and transferred to the ADC map to calculate per pixel ADC values for all b values (ADC(all)) and high b values (ADC(b100)). ADC mean, percentiles, skew, kurtosis and their change (delta ADC and %delta ADC) were determined. Threshold predictive of response with highest specificity was ascertained using receiver operating characteristic analysis. Results: Thirty-four patients were evaluated. Response was associated with a significant increase in delta ADC mean compared with poor response at delta ADC(all) (0.57 x 10(-3) mm(2)/s versus -0.01 x 10(-3) mm(2)/s; P < 0.0001) and delta ADC(b100) (0.58 x 10(-3) mm(2)/s versus -0.10 x 10(-3) mm(2)/s; P = 0.007). A 48.50% increase in %delta ADC(all) mean was seen in response compared with a 1.37% decrease in poor response (P < 0.0001). This corresponded to a %delta ADC(b100) mean increase of 50.34% in response versus a 7.36% decrease for poor response (P < 0.0001). Significant area under the curve (AUC) values predictive of radiotherapy response were identified at delta ADC and %delta ADC for ADC(all) and ADC(b100) mean, 10th, 25th, 50th, 75th and 90th percentiles (AUC > 0.9, P < 0.01). delta ADC(all) mean of 0.16 x 10(-3) mm(2)/s and delta ADC(b100) mean 0.12 x 10(-3) mm(2)/s predicted radiotherapy response with sensitivity/specificity/positive predictive value/negative predictive value of 92.9%/100.0%/100.0%/75.0% and 89.3%/100.0%/100.0%/66.7%, respectively. Conclusions: Quantitative DWI analysis can successfully provide non-invasive assessment of bladder radiotherapy response. Multicentre validation is required before prospective testing to inform MIBC radiotherapy follow-up schedules and decision making. (C) 2022 The Authors. Published by Elsevier Ltd on behalf of The Royal College of Radiologists

Automated summary

The role of diffusion-weighted magnetic resonance imaging (DWI) and apparent diffusion coefficient (ADC) analysis in assessing bladder radiotherapy response was investigated in this study. The results showed that quantitative DWI analysis can successfully provide non-invasive assessment of bladder radiotherapy response. Further multicentre validation and prospective testing are needed to determine its application in treatment decision-making.