LOW POWER OF COMPUTED TOMOGRAPHY WITH IODINE CONTRAST IN DETECTION OF LYMPH NODE METASTASES BEFORE RADICAL CYSTECTOMY, OUR EXPERIENCE F.Catanzariti, U.Cantoro, A.Conti, G.Muzzonigro Clinica Urologica-Università Politecnica delle Marche -Ancona-

INTRODUCTION Lymph nodes metastases in patients with bladder cancer influence negatively survival. Correct detection before surgery could guide surgeon in choosing between pelvic (external iliac vessels, the obturator fossa, the lateral and medial aspects of the internal iliac vessels) or extended lymphadenectomy (at least the distal half of the common iliac vessels together with its bifurcation) with the result of improved survival [1]. Computed tomoghraphy (CT) with iodine contrast is the most used imaging for nodal involvement because of its low cost and its widespread [1] The Impact of Lymphadenectomy and Lymph Node Metastasis on the Outcomes of Radical Cystectomy for Bladder Cancer Alexander Karl, Peter R. Carroll, Jurgen E. Gschwend, Ruth Knuchel, Francesco Montorsi, Christian G. Stief, Urs E. Studer European urology 55 ( 2 0 0 9 ) 826–835

OBJECTIVES To determine the sensibility (SE), the specificity (SP), the positive predictive value (PPV), the negative predictive value (NPV) and the accuracy (AC) of the CT with iodine contrast in detecting lymph node metastases in our experience.

MATERIALS From March 2009 to July 2012 110 consecutive patients with a diagnosis of muscle invasive bladder cancer or carcinoma in situ of the bladder who underwent staging with CT with iodine contrast. Comparing these reports with pathological results of the lymph nodes to evaluate SE, SP, PPV, NPV and AC of this imaging technique.

METHODS Before cystectomy all patients underwent to CT with iodine contrast Lymph nodes examination in the same institute of pathology using the same technique for histological exam Presence of lymph nodes larger than 1 cm reported by the radiologist, as suspicious for lymph node metastases

RESULTS suspicious lymph node involvement at the CT: 28/110 (25,45 %) normal lymph node at CT: 82/110 (74,54 %) lymph node metastases at histologic examination: 34/110 (30,9%) lymph nodes free of metastases: 76/110 (69,09%). Understaging: 19/110 cases (17,27%) Overstaging: 13/110 cases (11,82%). Correct correlation CT-histological results: 78/110 cases, AC of the CT: 70,91% (95% CI: 62,42 to 79,39).

RESULTS SE: 44,12% (95% CI :34,84-53, 40) SP: 82, 89% (95% CI :75,86-89, 93). PPV:53,57% NPV: 76,83%.

DISCUSSION This study has some limits: different radiologists had examined the images different pathologists had analyzed the specimens. However, the results show a clear failure of the CT in staging this disease.

CONCLUSION Other studies in literature showed this lack of ability of the CT in staging [2,3] Correct stadiation before surgery is very important to guide surgeon to a more extended lymphadenectomy in order to have better survival as it described by other authors. [1] [2] STAGING AND STAGING ERORS IN BLADDER CANCER Peter J. Bostrom , Bas W.G. van Rhijn, Neil Fleshner, Antonio Finelli, Michael Jewett ,John Thoms, Sally Hanna, Cynthia Kuk, Alexandre R. Zlotta EUROP E AN UROLOGY SUPP L EMENT S 9 (20 1 0 ) 2 –9 [3] LIMITATIONS OF COMPUTERIZED TOMOGRAPHY IN STAGING INVASIVE BLADDER CANCER BEFORE RADICAL CYSTECTOMY Michael L. Paik, Michael J. Scolieri, Scott L. Brown, J. Patrick Spirnak and Martin I. Resnik THE JOURNAL OF UROLOGY Vol. 163, 1693–1696, June 2000

CONCLUSION Some scientific works had shown that PET in combination with CT could be better in staging, even if more studies and with more numerous cases are needed. [3] Other studies showed the utility of lymphoscintigraphy combined with computed tomography (CT) for preoperative detection of sentinel lymph nodes [4] Other authors had shown better results in lymphnode detection thanks to diffusion weighted MR [5] [3] FDG-PET/CT for the Preoperative Lymph Node Staging of Invasive Bladder Cancer Greet Swinnen, Alex Maes, Hans Pottel, Alain Vanneste, Ignace Billiet,Karl Lesage, Patrick Werbrouck EUROPEAN UROLOGY 5 7 ( 2 0 1 0 ) 6 4 1 – 6 4 7 [4] Hybrid SPECT-CT: An Additional Technique for Sentinel Node Detection of Patients with Invasive Bladder Cancer Amir Sherif et all European urology 50 ( 2 0 0 6 ) 83–91 [5] Diffusion-weighted magnetic resonance imaging in patients selected for radical cystectomy: detection rate of pelvic lymph node metastases Rocco Papalia, et al 2 011 B J U I N T E R N A T I O N A L | doi:10.1111/j.1464-410X.2011.10446.x