Clinical Relevance of Bimanual Palpation in Bladder Cancer Patients Referred to a Tertiary Reference Centre
Mette Holberg Sorensen1, Jorgen Bjerggaard Jensen1
Copyright :© 2018 Authors. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Background: Patients diagnosed with muscle-invasive bladder cancer (MIBC) or high-risk non muscle-invasive bladder cancer (NMIBC), are often referred to specialized uro-oncological centres for further treatment. At some centres, the patients are examined through an uro-oncological assessment including cystoscopy and bimanual palpation (BP) of the pelvis in general anaesthesia to detect an inoperable tumour. The aim of this study was to compare the results of BP at the referring hospital with the results at a tertiary reference center.
Materials and Methods: Medical records from 156 patients referred to a single tertiary referral centre for cystectomy, were reviewed retrospectively. Data from the referring hospital regarding results of BP, pathologic examination of tumour tissue from the transurethral resection of the bladder (TURBT) and anaesthetic assessment were compared with corresponding data from the reference centre. In analysis of the validity of BP, a total of 96 patients who underwent cystectomy or explorative laparotomy were included.
Results: A fixed tumour was found in 5 (5%) of the analysed patients, all had minimum T2 tumour at the primary TURBT specimen. In 2 of these 5 patients, the tumour was already described as fixed or possible fixed at referring hospital. In additionally 2 patients, BP was not described or not performed at the referring hospital. Only in one patient with MIBC, the tumour was described as potentially mobile at referring hospital but was evaluated as fixed at the reference centre.
Conclusion: Information from referring hospital regarding BP is correct in 98% of patient where the tumour is described as non-palpable or mobile. In these cases, a BP in general anaesthesia before radical cystectomy can be omitted.
1. Introduction
2. Materials and Methods
3. RESULTS
4. Discussion
Both national Danish and international guidelines define BP as an integral part of routine pre-treatment evaluation in order to obtain information about mobility of the tumour [1,2]. No palpable tumour at BP indicates a NMIBC or a superficial T2 tumour whereas an immobile mass suggests a T4b tumour. Mobile masses felt by BP, indicates T2 or T3 tumour, for both radical cystectomy is the gold standard treatment [2]. In this study, we evaluated the value of BP at the referring hospital compared to the BP at a tertiary referral centre. When compared with the results at cystectomy, all mobile tumours found on BP at the reference centre, were operable, thus indicating that the BP was accurate. However, it is not clear from the present study whether patients not undergoing cystectomy based on finding of a fixed tumour potentially would have been operable.
In the literature, the accuracy and quality of BP has only scarcely been reported. Thus, only two studies have been made about the accuracy of BP. Mehrsai et al. [3], compared the results of BP with the pathologic results in 32 patients, who had undergone radical cystectomy. They found that BP had a specificity of 82%, sensitivity of 46%, positive predictive value of 70%, and negative predictive value of 63% in estimating extra vesical involvement of tumour [3].
Ploeg et al. [4] aimed to determinate the accuracy of clinical staging through BP. The study included 335 patients who underwent BP and cystectomy. Preoperative tumour-stage determined through BP was compared with post-cystectomy pathologic tumour-stage. They found that accurate staging through BP was observed in 58%. Four of 9 patients who had a suspected T4b tumour on BP but who underwent cystectomy anyway, appeared to have operable tumours at cystectomy. Discrepancy was observed in 42% of the patients: in 11% clinical over-staging and in 31% clinical under-staging. Thus, the study concluded that some caution is warranted when interpreting the findings at BP [4].
Abundant evidence is found in the literature regarding discrepancies between clinical T-stage based on the pathologic examination of the primary TURBT specimen and other diagnostics including BP and pathological outcomes in the cystectomy specimen in MIBC and high risk NMIBC [5-7]. Shari at et al. reported that in 42% of 778 patients, clinical under-staging occurred and clinical over-staging in 22% [6]. McLaughlin et al. found that of 141 patients undergoing cystectomy, 54% were up-staged on the pathological stage in the cystectomy specimen [5]. Thus, the results in the literature suggest that the preoperative clinical staging in bladder cancer is inaccurate and therefore the imaging options and studies play an important role in staging of bladder cancer.
Abdominal and pelvic CT is the most commonly used imaging modality. Unfortunately, CT is unable to differentiate the different layers (lamina propria, superficial and deep muscle) of the bladder [8]. Thus, CT has a limited accuracy in preoperative local tumour staging [9]. When staging the primary tumour, CT under-stage tumour stage in 10-39% and over-stage in 6- 34% [10]. When comparing CT with magnetic resonance imaging (MRI) techniques, MRI seems clinically better with a reported staging accuracy of 62–85% compared with 35–55% in CT studies [8,11]. A major problem is that over- staging occurs when investigating locally invasive bladder cancer with MRI. Tekes et al. reported 32% over-staging [13] and Liedberg et al. 49% over-staging when MRI results were compared with the pathological tumour stage in the cystectomy specimen [12]. With these findings in mind, we cannot rely exclusively on imaging. Thus, the preoperative clinical T-stage based on pathologic examination of the TURBT specimen and BP is still important.
Out of 156 patients in the present study, only 88 (56%) underwent BP at the referring hospital. This implies that in the remaining 44%, the national and international guidelines were not followed or at least the execution and findings of BP were not registered in the clinical files. Both possibilities give cause for concern because guidelines report the most actual insights in the best clinical practice, and correct registration in the patient files is inherent to good medical practice.
Our study had a weakness regarding the evaluation of the quality of BP. Evaluation was only possible in 91 (95%) patients who underwent radical cystectomy. Five patients who had a fixed tumour on BP at the reference centre were not treated with radical cystectomy. Therefore, no judgement could be made about the exact tumour stage.
5. Conclusions
The information from referring hospital regarding BP is valid in cases where the tumour is described as non-palpable or mobile. In these cases, the patients can avoid an additional procedure in general anaesthesia prior to cystectomy. If in doubt or a fixed tumour is described at referring hospital, a BP remains relevant. The study also shows that referring departments generally need to be better to perform and describe BP at the primary TURBT.
References