Amide Proton Transfer-Weighted MRI and Diffusion-Weighted Imaging in Bladder Cancer: A Complementary Tool to the VI-RADS

Rationale and Objectives: To investigate the feasibility of amide proton transfer -weighted (APTw) and diffusion -weighted Magnetic Resonance Imaging (MRI) as a means by which to add value to the Vesical Imaging Reporting and Data System (VI -RADS) for discriminating muscle invasive bladder cancer (MIBC) from nonmuscle invasive bladder cancer (NMIBC). Materials and Methods: This prospective study enrolled participants with pathologically confirmed bladder cancer (BCa) who underwent preoperative multiparametric MRI, including APTw and diffusion -weighted MRI, from July 2020 to January 2023. The exclusion criteria were lesions smaller than 10 mm, missing smooth muscle layer in the operation specimen, neoadjuvant therapy before MRI, inadequate image quality, and malignancy other than urothelial neoplasm. Two radiologists independently assigned the VI -RADS score for each participant. Quantitative parameters derived from APTw and diffusion -weighted MRI were obtained by another two radiologists. Receiver operating characteristic (ROC) curve analysis with the area under the ROC curve (AUC) was performed to evaluate the diagnostic performances of quantitative parameters for discriminating BCa detrusor muscle invasion status. Results:A total of 106 participants were enrolled (mean age, 64 +/- 12 years [SD]; 90 men): 32 with MIBC and 74 with NMIBC. Lower apparent diffusion coefficient (ADC) values (0.88 x 10(-3) mm(2)/s +/- 0.12 vs. 1.08 x 10(-3) mm(2)/s +/- 0.25; P < 0.001) and higher APTw values (6.89% [interquartile range {IQR}, 5.05%-12.17%] vs. 3.61% [IQR, 2.23%-6.83%]; P < 0.001) were observed in the MIBC group. Compared to VI-RADS alone, both APTw (P = 0.003) and ADC (P = 0.020) values could improve the diagnostic performance of VI-RADS in differentiating MIBC from NMIBC. The combination of the three yielded the highest diagnostic performance (AUC, 0.93; 95% CI:0.87,0.97) for evaluating muscle invasion status. The addition of the APTw values to the combination of VI-RADS and ADC values notably improved the diagnostic performance for differentiating NMIBC from MIBC (VI-RADS+ADC vs. VI-RADS+APTw+ADC, P = 0.046) Conclusion: MRI parameters derived from APTw and diffusion -weighted MRI can be used to accurately assess muscle invasion status in BCa and provide additional value to VI -RADS.