Original Study|Articles in Press

Added Clinical Value of 18F-FDG-PET/CT to Stage Patients With High-Risk Non-Muscle Invasive Bladder Cancer Before Radical Cystectomy

Published:February 21, 2023DOI:


      Introduction and Objectives

      18F-fluorodeoxyglucose positron-emission tomography-computed tomography (FDG-PET/CT) is increasingly used in the preoperative staging of patients with muscle-invasive bladder cancer. The clinical added value of FDG-PET/CT in high-risk non-muscle invasive bladder cancer (NMIBC) is unknown. In this study, the value of FDG-PET/CT in addition to contrast enhanced (CE)-CT was evaluated in high-risk NMIBC before radical cystectomy (RC).

      Materials and Methods

      This is a retrospective analysis of consecutive patients with high risk and very-high risk urothelial NMIBC scheduled for RC in a tertiary referral center between 2011 and 2020. Patients underwent staging with CE-CT (chest and abdomen/pelvis) and FDG-PET/CT. We assessed the clinical disease stage before and after FDG-PET/CT and the treatment recommendation based on the stage before and after FDG-PET/CT. The accuracy of CT and FDG-PET/CT for identifying metastatic disease was defined by the receiver-operating curve using a reference-standard including histopathology/cytology (if available), imaging and follow-up.


      A total of 92 patients were identified (median age: 71 years). In 14/92 (15%) patients, FDG-PET/CT detected metastasis (12 suspicious lymph nodes and 4 distant metastases). The disease stage changed in 11/92 (12%) patients based on additional FDG-PET/CT findings. FDG-PET/CT led to a different treatment in 9/92 (10%) patients. According to the reference standard, 25/92 (27%) patients had metastases. The sensitivity, specificity and accuracy of FDG-PET/CT was 36%, 93% and 77% respectively, versus 12%, 97% and 74% of CE-CT only. The area under the ROC curve was 0.643 for FDG-PET/CT and 0.545 for CT, P = .036.


      The addition of FDG-PET/CT to CE-CT imaging changed the treatment in 10% of patients and proved to be a valuable diagnostic tool in a selected subgroup of NMIBC patients scheduled for RC.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Clinical Genitourinary Cancer
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Lenis AT
        • Lec PM
        • Chamie K
        • Mshs MD.
        Bladder Cancer: a review.
        JAMA. 2020; 324: 1980-1991
        • Babjuk M
        • Burger M
        • Capoun O
        • et al.
        European association of urology guidelines on non–muscle-invasive bladder Cancer (Ta, T1, and Carcinoma in Situ).
        Eur Urol. 2022; 81: 75-94
        • Sylvester RJ
        • Rodríguez O
        • Hernández V
        • et al.
        European Association of Urology (EAU) Prognostic Factor Risk Groups for Non-muscle-invasive Bladder Cancer (NMIBC) Incorporating the WHO 2004/2016 and WHO 1973 classification systems for grade: an update from the EAU NMIBC guidelines panel.
        Eur Urol. 2021; 79: 480-488
        • Sylvester RJ
        • van der Meijden AP
        • Oosterlinck W
        • et al.
        Predicting recurrence and progression in individual patients with stage Ta T1 bladder cancer using EORTC risk tables: a combined analysis of 2596 patients from seven EORTC trials.
        Eur Urol. 2006; 49 (5discussion 475-7): 466
        • Witjes JA
        • Lebret T
        • Comperat EM
        • et al.
        Updated 2016 EAU guidelines on muscle-invasive and metastatic bladder Cancer.
        Eur Urol. 2017; 71: 462-475
        • Quinn B
        • Dauer Z
        • Pandit-Taskar N
        • Schoder H
        • Dauer LT.
        Radiation dosimetry of 18F-FDG PET/CT: incorporating exam-specific parameters in dose estimates.
        BMC Med Imaging. 2016; 16: 41
        • Girard A
        • Vila Reyes H
        • Shaish H
        • et al.
        The Role of 18F-FDG PET/CT in guiding precision medicine for invasive Bladder Carcinoma.
        Front Oncol. 2020; 10565086
        • Einerhand SMH
        • van Gennep EJ
        • Mertens LS
        • et al.
        18F-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography in muscle-invasive bladder cancer.
        Curr Opin Urol. 2020; 30: 654-664
        • Omorphos NP
        • Ghose A
        • Hayes JDB
        • et al.
        The increasing indications of FDG-PET/CT in the staging and management of Invasive Bladder Cancer.
        Urol Oncol. 2022; 40: 434-441
        • Voskuilen CS
        • van Gennep EJ
        • Einerhand SMH
        • et al.
        Staging 18F-fluorodeoxyglucose positron emission tomography/computed tomography changes treatment recommendation in invasive bladder Cancer.
        Eur Urol Oncol. 2022; 5: 366-369
        • Mertens LS
        • Fioole-Bruining A
        • Vegt E
        • Vogel WV
        • van Rhijn BW
        • Horenblas S.
        Impact of (18) F-fluorodeoxyglucose (FDG)-positron-emission tomography/computed tomography (PET/CT) on management of patients with carcinoma invading bladder muscle.
        BJU Int. 2013; 112: 729-734
        • Apolo AB
        • Riches J
        • Schöder 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
        • Bertolaso P
        • Brouste V
        • Cazeau AL
        • et al.
        Impact of (18) FDG- PET CT in the management of muscle invasive bladder Cancer.
        Clin Genitourin Cancer. 2022; 20 (-e6): 297
        • Mertens LS
        • Meijer RP
        • Alfred Witjes J.
        Positron emission tomography/computed tomography for staging of bladder Cancer: a continuing clinical controversy.
        Eur Urol. 2022;
        • Stein JP
        • Lieskovsky G
        • Cote R
        • et al.
        Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients.
        J Clin Oncol. 2001; 19: 666-675
        • Paner GP
        • Stadler WM
        • Hansel DE
        • Montironi R
        • Lin DW
        • Amin MB.
        Updates in the eighth edition of the tumor-node-metastasis staging classification for urologic Cancers.
        Eur Urol. 2018; 73: 560-569
        • Kinahan PE
        • Fletcher JW.
        Positron emission tomography-computed tomography standardized uptake values in clinical practice and assessing response to therapy.
        Semin Ultrasound CT MR. 2010; 31: 496-505
      1. MedCalcSoftwareLtd. Diagnostic test evaluation calculator. 2022, Available at: Accessed: October 14th 2022

        • Moussa M
        • Chakra MA
        • Saad W
        • Dellis A
        • Papatsoris A.
        The role of 18F-FDG PET/CT scan compared to CT-scan alone for lymph node staging before radical cystectomy in patients with bladder cancer.
        Urol Oncol. 2021; 39 (.e9-17): 833
        • Girard A
        • Rouanne M
        • Taconet S
        • et al.
        Integrated analysis of (18)F-FDG PET/CT improves preoperative lymph node staging for patients with invasive bladder cancer.
        Eur Radiol. 2019; 29: 4286-4293
        • Burger M
        • Catto JW
        • Dalbagni G
        • et al.
        Epidemiology and risk factors of urothelial bladder Cancer.
        Eur Urol. 2013; 63: 234-241
        • Soubra A
        • Hayward D
        • Dahm P
        • et al.
        The diagnostic accuracy of 18F-fluorodeoxyglucose positron emission tomography and computed tomography in staging bladder cancer: a single-institution study and a systematic review with meta-analysis.
        World J Urol. 2016; 34: 1229-1237
        • Hofman MS
        • Lawrentschuk N
        • Francis RJ
        • et al.
        Prostate-specific membrane antigen PET-CT in patients with high-risk prostate cancer before curative-intent surgery or radiotherapy (proPSMA): a prospective, randomised, multicentre study.
        The Lancet. 2020; 395: 1208-1216
        • Khanna A
        • Miest T
        • Sharma V
        • et al.
        Role of Lymphadenectomy during radical cystectomy for nonmuscle-invasive bladder Cancer: results from a multi-institutional experience.
        J Urol. 2022; 207: 551-558
        • Lenis AT
        • Lec PM
        • Michel J
        • et al.
        Predictors of adequate lymph node dissection in patients with non-muscle invasive bladder cancer undergoing radical cystectomy and effect on survival.
        Urol Oncol. 2020; 38 (e7-14): 796
        • Bouchelouche K.
        PET/CT in Bladder Cancer: an update.
        Sem Nucl Med. 2022; 52: 475-485
        • Panebianco V
        • Pecoraro M
        • Del Giudice F
        • et al.
        VI-RADS for bladder Cancer: current applications and future developments.
        J Magn Res Imaging. 2022; 55: 23-36
        • Caglic I
        • Panebianco V
        • Vargas HA
        • et al.
        MRI of Bladder Cancer: local and nodal staging.
        J Magn Res Imaging. 2020; 52: 649-667