Radiomics-Based Preoperative Assessment of Muscle-Invasive Bladder Cancer Using Combined T2 and ADC MRI: A Multicohort Validation Study

Accurate preoperative staging of bladder cancer on MRI remains challenging because visual reads vary across observers. We investigated a multiparametric MRI (mpMRI) radiomics approach to predict muscle invasion (≥T2) and prospectively tested it on a validation cohort. Eighty-four patients with urothelial carcinoma underwent 1.5-T mpMRI per VI-RADS (T2-weighted imaging and DWI-derived ADC maps). Two blinded radiologists performed 3D tumor segmentation; 37 features per sequence were extracted (LifeX) using absolute resampling. In the training cohort (n = 40), features that differed between non-muscle-invasive and muscle-invasive tumors (Mann–Whitney p < 0.05) underwent ROC analysis with cut-offs defined by the Youden index. A compact descriptor combining GLRLM-LRLGE from T2 and GLRLM-SRLGE from ADC was then fixed and applied without re-selection to a prospective validation cohort (n = 44). Histopathology within 6 weeks—TURBT or cystectomy—served as the reference. Eleven T2-based and fifteen ADC-based features pointed to invasion; DWI texture features were not informative. The descriptor yielded AUCs of 0.934 (training) and 0.871 (validation) with 85.7% sensitivity and 96.2% specificity in validation. Collectively, these findings indicate that combined T2/ADC radiomics can provide high diagnostic accuracy and may serve as a useful decision support tool, after multicenter, multi-vendor validation. © 2025 by the authors.