Use of arteriography in the demonstration and staging of bladder tumors.

Abstract

A review of the recent literature substantiates Jewett's hypothesis on the relationship between the degree of penetration of bladder tumors and their potential curability. While Jewett's staging of bladder tumors was based on the study of 107 autopsy cases, the clinical findings on bimanual examination under anesthesia and cystoscopy allow a fairly accurate preoperative estimate of the depth of infiltration and staging by this criterion (5, 6). Staging according to the degree of penetration of the bladder wall has revolutionized our concepts of the treatment of bladder carcinomas. The efficacy of various surgical and radiological procedures has been established for the different stages and the survival rate has been significantly increased (1, 3, 4, 7). While there is undoubtedly a correlation between the histologic grade and the early or late invasiveness of a tumor, the salient factor in the determination of surgery vs. irradiation remains the depth of infiltration of the growth, the stage of the lesion (3, 11, 12). Preoperative staging is based on well known and readily practiced procedures such as bimanual examination under anesthesia, cystoscopy, biopsy with the resectoscope, pyelography, and cystography. Marshall reported an accuracy of 81 per cent in the preoperative estimate of tumor penetration in his series of 104 cases subjected to cystectomy (10). For any clinical method this represents an excellent correlation between the preoperative and operative findings. Even Marshall, however, states that most errors in staging will occur in the more advanced stages, involving either the outer layers of the muscularis or the perivesical fat tissues. Unfortunately, these are the cases where accurate staging is most important, since it determines the mode of therapy. In order to avoid understaging, Marshall suggests revision of the estimated degree of penetration upward if a biopsy shows a histologically undifferentiated lesion. A dual classification of bladder tumors utilizing both staging from a clinical examination and grading on a histologic basis from biopsy material is suggested (11). Until recently radiologic procedures were limited to the demonstration of intraluminal masses in the bladder (2). Arteriography of the hypogastric arteries, however, offers a tool to demonstrate bladder tumors in a more positive fashion. The characteristic tumor vessels and staining qualities of the tumor in the later capillary phase can be used for a preoperative estimate of histologic differentiation. A tangential view of the tumor-bearing area allows an accurate estimation of the thickness of the tumor as well as its depth of infiltration into the muscular wall or even the perivesical fat (8). The arteriographic demonstration of bladder neoplasms is distinguished by its specificity and selectivity for the tumor.