Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Transitional Cell Carcinoma Imaging

  • Author: Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR; Chief Editor: Eugene C Lin, MD  more...
 
Updated: Jul 17, 2013
 

Overview

Embryologic derivation of the collecting system of the urinary tract occurs from the fetal mesonephros. As a result of this development, tumors of the renal collecting system have cell origins different from those of the renal parenchyma. These tumors are classified on the basis of their respective mesodermal or epithelial tissue origin. Primary neoplasms of the renal collecting system represent 10% of renal tumors, of which approximately 80% are malignant. Most are transitional cell carcinomas (TCCs). (See the images below.)

A 21-year old man presented with a history of inte A 21-year old man presented with a history of intermittent hematuria of 1-month duration. Three months previously, he had been assaulted and kicked in the right loin. A 30-minute intravenous urogram shows a moderate right hydronephrosis without filling of the renal pelvis, although some contrast material has passed into the upper ureter. Note also a polypoid intraluminal filling defect within the left side of the bladder (arrow).
Left, transverse sonogram of the right kidney in t Left, transverse sonogram of the right kidney in the same patient as in the previous image shows a centrally placed solid mass within the renal pelvis with low-level echoes and with proximal hydronephrosis. Right, transverse sonogram through the bladder shows a polypoid filling defect in the bladder.
Nonenhanced (top) and enhanced (bottom) CT scans t Nonenhanced (top) and enhanced (bottom) CT scans through the kidneys show a mass in the right renal pelvis. The histologic diagnosis was a right renal pelvis neurofibroma and a bladder transitional cell carcinoma.

Bladder TCC is 50 times more common than renal pelvic tumors. Often, TCCs are multiple, involving any part or all of the collecting system. The tumors are traditionally classified into papillary and nonpapillary types. Nonpapillary tumors are considered malignant.

Staging

The American Joint Committee on Cancer (AJCC) designates stages in the tumor, nodes, metastases (TNM) system. Stages are based on the depth of tumoral invasion, as follows:

  • Ta - papillary noninvasive carcinoma
  • Tis - carcinoma in situ
  • T1 - invasion of the subepithelial connective tissue
  • T2 - invasion of the muscularis propria
  • T3 - invasion beyond the muscularis into the periureteric fat (ureter only), the peripelvic fat (renal pelvis only), or the renal parenchyma
  • T4 - invasion of adjacent organs or through the kidney into the perinephric fat

N0 indicates no regional lymph node metastasis; N1, metastasis in a single lymph node 2 cm in diameter or smaller; N2, metastasis in a single lymph node 2-5 cm in diameter or multiple lymph nodes, none larger than 5 cm in diameter; and N3, metastasis in a lymph node larger than 5 cm in diameter.

M0 indicates no distant metastasis, and M1, distant metastasis.

Therefore, the AJCC defines the stages as follows:

  • Stage 0, localized disease with Ta or Tis/N0/M0
  • Stage I, mucosal lamina propria involved with T1/N0/M0
  • Stage II, disease into but not beyond the muscularis with T2/N0/M0
  • Stage III, invasion of the renal parenchyma and/or fat with T3/N0/M0
  • Stage IV, metastases with T4/N0/M0, any T/N1-3/M0, or any T/any N/M1

Hydronephrosis on preoperative axial CT at the time of diagnosis of upper-tract urothelial carcinoma is associated with advanced-stage cancer and is a predictor of poorer outcomes. Hydronephrosis can be a valuable prognostic tool for preoperative planning and counseling regarding disease outcomes.[1]

Preferred examination

Intravenous urography (IVU) is a common diagnostic test in patients with hematuria, although the early detection of small urothelial tumors may be difficult. A meticulous IVU technique is required.

Retrograde pyelography is useful when the kidney cannot be visualized by means of IVU or when IVU cannot be performed because of renal disease or an adverse response to the contrast agent. Retrograde pyelography also has the advantage of being able to be combined with various biopsy techniques.[2]

Computed tomography (CT) scanning is becoming increasingly sensitive for the staging of early TCC. Developments such as virtual cystoscopy and postmicturition scanning should improve the overall accuracy of staging by the use of CT. Multidetector-row CT scanning with postprocessing image manipulation (contour imaging) is increasingly coming to challenge IVU.[3, 4, 5]

Magnetic resonance imaging (MRI) has the advantages of high intrinsic soft tissue contrast, direct multiplanar capability, and the availability of nontoxic, renally excreted contrast agents. MRI appears to be at least as useful as CT in the evaluation of perivesical fat involvement, and it may be superior to CT in the detection of invasion of the adjacent organs. However, MRI cannot depict well the superficial invasion by TCC of the upper urinary tract.[3, 6, 7, 8, 9, 10, 11, 12]

CT and MRI have been shown to perform better than cystography in the diagnosis of tumors in the bladder diverticula that are not depicted on cystograms because of obstruction at the diverticular orifice.

Ultrasonography is inaccurate for diagnosing early TCC; it is useful in the diagnosis of obstructive uropathy.[13, 14, 15] Ureteric lesions are particularly difficult to visualize unless they cause hydronephrosis and hydroureter. Other limitations of ultrasonography are that it is inaccurate in the staging of bladder TCC, particularly Ta and T1 tumors, and in the detection of pelvic lymph node involvement.

Isotope renography is an extremely sensitive means of assessing relative renal function and obstructive uropathy before surgery. Isotope bone scanning is a useful technique in the investigation of skeletal metastases.[16]

Plain radiographic findings, such as calcifications, are not specific in the diagnosis of urothelial tumors, and they usually contribute little to the diagnosis.

Limitations of techniques

Plain radiographic findings are nonspecific, particularly the presence of calcification, which has a wide differential diagnosis. Filling defects in the renal collecting system and the bladder, as seen with IVU, CT, and retrograde pyelography, are present in a number of other pathologies. These findings are not specific to TCC.

On CT scans, a hyperattenuating TCC may be confused with a blood clot, particularly in the early stages of the disease. Also, inhomogeneous renal fatty attenuation of any cause in a patient with undiagnosed early-stage TCC may hinder accurate diagnosis.

MRI is expensive and has limited availability. False-positive diagnoses have been reported. In staging bladder TCC, tumor extension is overstaged according to the TNM classification in 7.5% of patients; it is understaged in 32.5% of patients.

On sonograms, calculi may be confused with high-grade TCCs, which can be densely echogenic. No sonographic features are specific for TCC, and many filling defects within the renal collecting system and bladder have a nonspecific appearance. It is also difficult to discern nondilated ureters on ultrasonography.

Next

Radiography

Plain radiography

Plain radiographs may first alert the radiologist to presence of a renal mass or a bladder mass. Occasionally, a large renal outline may be seen in a completely obstructed kidney. Uncommonly, radiographically discernible areas of punctate calcification may be seen in TCC. The calcification is on the surface of the tumor and not within the mass duct. Intrinsic calcifications suggest an adenocarcinoma or an unusual cell type.

TCC is associated with analgesic nephropathy. Plain radiographic findings of displacement of renal calcifications, which occur in analgesic nephropathy, may be the first sign of TCC. Surface calcification of a bladder tumor may be seen on plain radiographs in 1% of cases. Osseous expansive destruction or lung metastases may be seen in the presence of renal malignancy.

Intravenous urography

The most common findings in TCC of the kidney are single or multiple filling defects in the renal pelvis, as seen in 35% of cases. In about 26% of patients with renal TCC, the calyx is dilated; such dilation is caused by partial or complete obstruction of the infundibulum. Amputation of the calyx may be seen in 19% of cases.

In 13-31% of cases, the affected kidney is not visualized. Such failure to visualize the kidney is usually secondary to hydronephrosis but can be the result of tumor infiltrating and replacing functioning kidney or of occlusion of the renal vein. Hydronephrosis with renal enlargement caused by tumoral obstruction of the ureteropelvic junction may be seen in 6% of cases. (See the images below.)

Localized views of the right vesicoureteric juncti Localized views of the right vesicoureteric junction obtained after intravenous urography shows a polypoid filling defect in the lower right ureter due to a transitional cell carcinoma.
A 10-minute intravenous urogram in a 56-year-old m A 10-minute intravenous urogram in a 56-year-old man presenting with hematuria. The image shows a mass lesion in the right renal pelvis that bisects the renal sinus and splays the adjacent calyces.
Scout radiograph in a 53-year-old man presenting w Scout radiograph in a 53-year-old man presenting with hematuria shows a few small vague opacities in the left renal area; these are suggestive of renal calculi.
Intravenous urogram shows 2 filling defects: 1 in Intravenous urogram shows 2 filling defects: 1 in the upper pole and 1 in the lower-pole calyces. Conventional tomographic results (bottom) confirm the findings.
An intravenous urogram in a 36-year old woman who An intravenous urogram in a 36-year old woman who presented with evidence of a urinary tract infection and gross hematuria. A 10-minute intravenous urogram shows a filling defect in the lower pole calyx on the right. A provisional diagnosis of transitional cell carcinoma was made. Subsequent investigations and the course of events proved that the filling defect was caused by a blood clot related to the hematuria secondary to acute pyelonephritis.

Various signs have been described in renal TCC. The stipple sign is a rare sign that occurs when contrast material is trapped within the interstices of a papillary tumor. When this is seen en face, the tumor appears to contain multiple stipples. This sign is highly suggestive of TCC. When this sign is seen, blood clots and radiolucent calculi are excluded, and further investigations are superfluous. Punctate calcification on a TCC may mimic the stipple sign.

Punctate calcification is unusual in TCC; such calcification is apparent on the scout image before the intravenous contrast material is delivered. Occasionally, contrast material may be trapped within a blood clot formed in the ureter and then extruded into the bladder as a stringy mass that may trap contrast material in an irregular fashion. However, this entrapment is coarser than that seen with neoplastic stippling.

Fungus balls or mycetoma may also occasionally entrap contrast material. The pattern of entrapment is lamellar; such entrapment is frequently associated with gas formation (frequently, patients have poorly controlled diabetes with urinary tract infections). Rarely, stippling may be observed in tubular ectasia when papillae containing dilated ducts of Bellini are seen en face. Inspection of the other papillae may make the diagnosis obvious.

Phantom calyx represents the failure of a calyx to opacify because of obstruction. Oncocalyx represents calyceal distension caused by the tumor.

In contrast to renal TCC, ureteric tumors show single or multiple filling defects in only 19% of cases. This observation is associated with hydronephrosis and hydroureter in 34% of cases; in advanced cases, it may be associated with a nonfunctioning kidney.

Bladder TCC also shows an irregular filling defect with broad base and fronds. Increased thickness of the bladder wall in the region of the tumor should indicate infiltration.

Retrograde pyelography

Retrograde pyelography in ureteric TCC may show focal expansion of ureters around and distal to the mass; such a finding is called the champagne, or goblet, sign. This finding is helpful in differentiating TCC from focal lesions of other causes, such as calculi or blood clots. Typically, calculi and blood clots do not demonstrate a goblet sign because they do not progressively stretch the ureteral wall from slow growth. Occasionally, the catheter coils below the mass during retrograde catheterization; this is called the Bergman sign. (See the image below.)

Left retrograde pyelogram shows marked irregularit Left retrograde pyelogram shows marked irregularity of the infundibulum of the upper pole calyx caused by infiltration by transitional cell carcinoma. This information was unavailable on the CT scans.

Degree of confidence

Plain radiographic findings, such as calcifications, are not specific in the diagnosis of urothelial tumors. Discernible areas of a coarse, punctate pattern of calcification with a mucosal lesion on excretory urography or retrograde pyelography may suggest TCC. An important role for plain radiography is in searching for evidence of osseous metastases that may herald renal malignancy.

Multidetector-row CT is replacing IVU in the evaluation of hematuria, although IVU is still being used. The early detection of small urothelial tumors demands a meticulous IVU technique. Accurate demonstration of the pelvocaliceal system requires abdominal compression to distend the collecting systems, and oblique imaging or tomography may also be necessary. Diuresis multidetector-row CT with contour reformatting of the axial records may be useful. This technique does not require abdominal compression. Early experience with this method has been most positive because the CT technique demonstrates not only the opacified lumen but also the surrounding soft tissue anatomy.

Filling defects with dilated calyces are easily seen and are readily diagnosed. Hydronephrosis with renal enlargement is easily confused with uncomplicated primary pelvic hydronephrosis; antegrade/retrograde pyelography is usually required for diagnosis.

Adequate depiction of the ureters is difficult, and prone, oblique, or even spot images obtained during fluoroscopy may be required at urography. If an area of constant narrowing of the ureters is seen on more than 1 image and if it cannot be explained by the presence of a crossing vessel or a peristaltic wave, a tumor must be suspected. A meticulous urographic examination (radiographic or multidetector-row CT) can prevent unnecessary pyelography/ureterography in the majority of cases.

Importantly, if the demonstration of the pelvicaliceal system at excretion urography or CT is poor, an upper-tract tumor may be missed, particularly when a decoy of a bladder tumor is present. The coexistence of upper- and lower-tract tumors is not rare.

The sensitivity and specificity with regard to the upper urinary tract pathology are 67% and 91%, respectively, for IVU and 56% and 94%, respectively, for ultrasonography. For both techniques combined, the sensitivity and specificity are 79% and 88%, respectively. IVU has a 70% accuracy rate in the diagnosis of bladder TCC. The role of radiology is in demonstrating the upper urinary tract, both at the time of the initial diagnosis and during the follow-up of urothelial cancer. The statistics for multidetector-row CT are now under investigation.

Retrograde pyelography is useful when the kidney cannot be visualized with IVU or when an intravenous approach cannot be performed because of renal disease or an adverse reaction to contrast agents. Retrograde pyelography in combination with brush biopsy is a highly reliable method for making a definitive diagnosis of TCC. The results are considered diagnostic in 85% of cases.

If spot filming is the imaging technique, this should be performed in an appropriate fluoroscopic digital unit where serial images can be obtained. This may be done during diuresis urography (infusion IVU with 300 mL of 30% contrast media) or during antegrade/retrograde pyelography.

Approximately 5% of ureteric TCCs grow intramurally, resulting in a stricture rather than a filling defect. Radiologically, distinguishing this type of tumor from stricture is impossible. However, at CT, a thickened ureteric wall with stranding may be seen.

False positives/negatives

Calcification is seen in 10% of renal cell carcinomas. Retroperitoneal tumors, infections, or inflammation; pelvic tumors; pelvic lipomatosis; and gynecologic and gastrointestinal pathologies may cause extrinsic ureteric obstruction. Other causes of ureteric obstruction or bladder abnormalities include irradiation, surgery, trauma, or infections such as tuberculosis or schistosomiasis. These conditions may result in telltale signs on plain radiographs.

Other causes of filling defects may mimic a TCC, such as radiolucent or uric acid stones; blood clots; sloughed papilla caused by papillary necrosis; or fungal balls in patients with diabetes. Vessel crossing may cause a linear extrinsic impression; in these cases, oblique or compression images may help in differentiating TCCs from urothelial tumors. Tuberculosis can cause narrowing of the infundibulum and irregular calices. With regard to imaging, tuberculosis is the major disorder in the differential diagnosis.

Other mimics include pyeloureteritis cystica, renal cell carcinoma invading the pelvicaliceal system, or choleastoma. Squamous cell carcinoma (SCC) is radiographically indistinguishable from TCC; however, SCC is less likely to be a polypoid tumor. Although a diagnosis may be made on the basis of urograms or cystograms, a small bladder tumor, especially one of the infiltrative types, may go undetected. Furthermore, a dense concentration of contrast material may obscure the intraluminal part of the urothelial tumor.

Mimics of ureteric TCC include papilloma or polyp, which commonly produces a long, smooth intraluminal filling defect. This defect may prolapse up and down the ureter on serial images, and it may even intussuscept. Avoiding the introduction of air bubbles is important because these could be mistaken for tumors.

Previous
Next

Computed Tomography

The workup of patients in whom TCC is suspected includes ultrasonography and IVU. However, CT scanning enables the detection and staging of TCC, usually without the need for additional imaging. (See the images below).[4, 5, 17]

Nonenhanced (top) and enhanced (bottom) CT scans t Nonenhanced (top) and enhanced (bottom) CT scans through the kidneys show a mass in the right renal pelvis. The histologic diagnosis was a right renal pelvis neurofibroma and a bladder transitional cell carcinoma.
Nonenhanced (top) and enhanced (bottom) CT scans o Nonenhanced (top) and enhanced (bottom) CT scans obtained through the kidneys in a 73-year-old woman show a mass in the left renal pelvis is a transitional cell carcinoma.

The commonly recognized presentations of TCC on CT scans include the following: irregular filling defects of the pelvocaliceal system and ureters, which tend to be associated with obstruction and dilatation of the ureter and pelvis proximal to the lesion; ureteral wall thickening; frondlike growths projecting into the bladder from a fixed mural site; and surface calcification of bladder TCC.

On nonenhanced CT scans, the TCC is hypoattenuated or isoattenuated relative to the normal renal parenchyma, and it is hyperattenuated relative to urine. TCCs demonstrate mild to moderate enhancement after the administration of contrast material, and they are hypoattenuated relative to opacified urine.

Degree of confidence

CT is of limited value in staging low-grade disease because it cannot accurately depict the depths of tumoral invasion. Therefore, stages Ta-T2 cannot be distinguished. The strength of CT lies in the staging of high-grade disease, because of its ability to demonstrate peripelvic, periureteric, and local pelvic extensions, as well as distant metastases.

Inevitably, studies differ with regard to the sensitivity and specificity of preoperative CT scanning in the detection and accurate staging of TCC. The reported range for detection efficiency is 86-100%. The results of most studies suggest a range of 55-64% for correct TNM staging, compared with surgical findings.

Understaging appears to be a limiting factor. However, results with newer scanners and adjunct techniques such as virtual cystoscopy and postmicturition scanning should improve the overall accuracy of staging with CT.

False positives/negatives

In stage I or II disease, conditions such as chronic pyelitis, tuberculosis, and xanthogranulomatous pyelonephritis may mimic TCC.

In stage III or IV disease, CT cannot be used to distinguish edema, infection, inflammatory changes, or hemorrhage from tumor. All of these processes may cause inhomogeneous peripelvic attenuation that is indistinguishable from that caused by the infiltration of fat by tumor. Superimposed pyelonephritis can cause inhomogeneous renal enhancement and thus give a false interpretation of invasion by underlying TCC. Occasionally, renal cell carcinoma may simulate TCC with renal parenchymal infiltration.

The characteristic attenuation of a TCC lesion is normally sufficiently different from renal tract filling defects of other causes, such as calculi and blood clots, to enable the correct diagnosis. However, a blood clot may be confused with a hyperattenuating TCC, particularly in the early stages of the disease. Also, in a patient with undiagnosed early-stage TCC, inhomogeneous renal fat attenuation of any cause may hinder accurate diagnosis.

Previous
Next

Magnetic Resonance Imaging

The advantages of MRI are its high intrinsic soft tissue contrast, its direct multiplanar capability, and the availability of nontoxic renally excreted contrast agents. MRI appears to be at least as useful as CT in the evaluation of perivesical fat involvement, and it may be superior to CT in the detection of invasion of the adjacent organs. However, MRI cannot depict the superficial invasion of the upper urinary tract by TCC well.[6, 7, 8, 9, 10, 11, 12]

Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have recently been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans.

As of late December 2006, the FDA had received reports of 90 such cases of NSF/NFD. Worldwide, over 200 cases have been reported, according to the FDA. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with troublemoving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness.

Degree of confidence

As previously mentioned, CT and MRI have been shown to perform better than cystography in the diagnosis of tumors in the bladder diverticula that are not depicted on cystograms because of obstruction at the diverticular orifice.

False positives/negatives

False-positive diagnoses have been reported. In staging bladder TCC, tumor extension is overstaged according to the TNM classification in 7.5% of patients and is understaged in 32.5% of patients.

Previous
Next

Ultrasonography

The most common sonographic appearance of TCC is that of a hypoechoic mass in the renal collecting system that splits the central echocomplex with varying degrees of infundibular dilatation. Focal hypoechogenicity of adjacent renal cortex reflects local invasion. Occasionally, the central echocomplex may be only segmentally amputated. (See the images below.)[13, 14, 15]

Longitudinal sonogram obtained through the right k Longitudinal sonogram obtained through the right kidney shows a hypoechoic mass bisecting the renal sinus fat. The mass is a transitional cell carcinoma.
Top, Longitudinal sonogram obtained thorough the l Top, Longitudinal sonogram obtained thorough the left kidney in a 58-year-old man presenting with hematuria shows a normal left kidney. Bottom, More medial section through the same kidney shows a vague isoechoic mass in the upper of the kidney. Whether this finding represented an artifact or a genuine lesion was unclear. Technetium-99m dimercaptosuccinate (99mTc DMSA) scanning is good modality for differentiating a renal pseudomass from a genuine mass.
Longitudinal sonogram through left kidney shows th Longitudinal sonogram through left kidney shows that the filling defects are due to calculi. Ultrasonography is an efficient means for differentiating between radiolucent calculi and uroepithelial tumors.

Degree of confidence

Ultrasonography is inaccurate for diagnosing early TCC, and it is useful in the diagnosis of obstructive uropathy. Ureteric lesions are particularly difficult to visualize unless they cause hydronephrosis and hydroureter. The other limitation of ultrasonography is that it is inaccurate in the staging of bladder TCC, particularly Ta and T1 tumors, and also in the detecton of pelvic lymph node involvement.

False positives/negatives

On sonograms, calculi may be confused with high-grade TCCs, which can be densely echogenic. No sonographic features are specific for TCC, and many filling defects within the renal collecting system and bladder may have a nonspecific appearance. In addition, ultrasonography is limited in its capacity to depict nondilated ureters.

Previous
Next

Nuclear Imaging

Isotope renography is an extremely sensitive means of assessing relative renal function and obstructive uropathy before surgery. Isotope bone scanning is a useful technique in the investigation of skeletal metastases. (See the image below.)[16]

Left posterior view of a technetium-99m dimercapto Left posterior view of a technetium-99m dimercaptosuccinate (99mTc DMSA) scan shows a photon-deficient mass in the upper pole of the left kidney; this finding indicates a genuine mass in this region. At partial nephrectomy, transitional cell carcinoma was confirmed.
Previous
 
Contributor Information and Disclosures
Author

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR Consultant Radiologist and Honorary Professor, North Manchester General Hospital Pennine Acute NHS Trust, UK

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR is a member of the following medical societies: American Association for the Advancement of Science, American Institute of Ultrasound in Medicine, British Medical Association, Royal College of Physicians and Surgeons of the United States, British Society of Interventional Radiology, Royal College of Physicians, Royal College of Radiologists, Royal College of Surgeons of England

Disclosure: Nothing to disclose.

Coauthor(s)

Sumaira Macdonald, MBChB, PhD, FRCP, FRCR, EBIR Chief Medical Officer, Silk Road Medical

Sumaira Macdonald, MBChB, PhD, FRCP, FRCR, EBIR is a member of the following medical societies: British Medical Association, Cardiovascular and Interventional Radiological Society of Europe, British Society of Interventional Radiology, International Society for Vascular Surgery, Royal College of Physicians, Royal College of Radiologists, British Society of Endovascular Therapy, Scottish Radiological Society, Vascular Society of Great Britain and Ireland

Disclosure: Received salary from Silk Road Medical for employment.

Lalam Radhesh Krishna, MBBS Specialist Registrar, Department of Radiology, North Manchester General Hospital, UK

Disclosure: Nothing to disclose.

Tufail Ahmed Patankar, MBBS, PhD, MSc, FRCR Consulting Interventional Neuroradiologist, Department of Neuroradiology, Leeds General Infirmary, UK

Tufail Ahmed Patankar, MBBS, PhD, MSc, FRCR is a member of the following medical societies: Royal College of Radiologists, British Society of Neuroradiologists

Disclosure: Nothing to disclose.

Hemalatha Chandramohan, MBBS Registrar, General Practice, West Yorkshire, UK

Hemalatha Chandramohan, MBBS is a member of the following medical societies: Royal College of Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

Rizwan Ahmed Malik, MBBS, MA Specialist Registrar, Department of Radiology, Manchester Training Scheme, Royal Bolton Hospital, UK

Disclosure: Nothing to disclose.

Specialty Editor Board

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD Attending Radiologist, Teaching Coordinator for Cardiac Imaging, Radiology Residency Program, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine

Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, Society of Nuclear Medicine and Molecular Imaging

Disclosure: Nothing to disclose.

Acknowledgements

Steven Perlmutter, MD, FACR Associate Professor of Clinical Radiology, The School of Medicine

at Stony Brook University; Medical Director of Radiology, Peconic Bay Medical Center

Steven Perlmutter, MD, FACR is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, American Medical Association, American Roentgen Ray Society, Association of Program Directors in Radiology, Association of University Radiologists, Medical Society of the State of New York, Radiological Society of North America, Society of Breast Imaging, Society of Nuclear Medicine, andSociety of Uroradiology

Disclosure: Nothing to disclose.

References
  1. Ng CK, Shariat SF, Lucas SM, Bagrodia A, Lotan Y, Scherr DS, et al. Does the presence of hydronephrosis on preoperative axial CT imaging predict worse outcomes for patients undergoing nephroureterectomy for upper-tract urothelial carcinoma?. Urol Oncol. 2011 Jan-Feb. 29(1):27-32. [Medline].

  2. See WA. The efficiency of excretory urography to detect upper urinary tract tumors after cystectomy for urothelial cancer Meissner C, Giannarini G, Schumacher MC, Thoeny H, Studer UE, Burkhard FC, Department of Urology and Institute of Diagnostic Radiology, University of Bern, Bern, Switzerland. Urol Oncol. 2008 May-Jun. 26(3):334-5. [Medline].

  3. Kim B, Semelka RC, Ascher SM, et al. Bladder tumor staging: comparison of contrast-enhanced CT, T1- and T2- weighted MR imaging, dynamic gadolinium-enhanced imaging, and late gadolinium-enhanced imaging. Radiology. 1994 Oct. 193(1):239-45. [Medline].

  4. Schreyer HH, Uggowitzer MM, Ruppert-Kohlmayr A. Helical CT of the urinary organs. Eur Radiol. 2002 Mar. 12(3):575-91. [Medline].

  5. Battista G, Sassi C, Schiavina R, Franceschelli A, Baglivo E, Martorana G, et al. Computerized tomography virtual endoscopy in evaluation of upper urinary tract tumors: initial experience. Abdom Imaging. 2008 Mar 14. [Medline].

  6. Barentsz JO, Jager GJ, Witjes JA. MR imaging of the urinary bladder. Magn Reson Imaging Clin N Am. 2000 Nov. 8(4):853-67. [Medline].

  7. Barentsz JO, Jager GJ, van Vierzen PB, et al. Staging urinary bladder cancer after transurethral biopsy: value of fast dynamic contrast-enhanced MR imaging. Radiology. 1996 Oct. 201(1):185-93. [Medline].

  8. Jung P, Brauers A, Nolte-Ernsting CA, et al. Magnetic resonance urography enhanced by gadolinium and diuretics: a comparison with conventional urography in diagnosing the cause of ureteric obstruction. BJU Int. 2000 Dec. 86(9):960-5. [Medline].

  9. Pretorius ES, Wickstrom ML, Siegelman ES. MR imaging of renal neoplasms. Magn Reson Imaging Clin N Am. 2000 Nov. 8(4):813-36. [Medline].

  10. Robinson P, Collins CD, Ryder WD, et al. Relationship of MRI and clinical staging to outcome in invasive bladder cancer treated by radiotherapy. Clin Radiol. 2000 Apr. 55(4):301-6. [Medline].

  11. Szopinski K, Szopinska M, Borowka A, Jakubowski W. Magnetic resonance urography: initial experience of a low-dose Gd-DTPA- enhanced technique. Eur Radiol. 2000. 10(7):1158-64. [Medline].

  12. Weeks SM, Brown ED, Brown JJ, et al. Transitional cell carcinoma of the upper urinary tract: staging by MRI. Abdom Imaging. 1995 Jul-Aug. 20(4):365-7. [Medline].

  13. Dibb MJ, Noble DJ, Peh WC, et al. Ultrasonographic analysis of bladder tumors. Clin Imaging. 2001 Nov-Dec. 25(6):416-20. [Medline].

  14. Lee DI, Bagley DH, Liu JB. Experience with endoluminal ultrasonography in the urinary tract. J Endourol. 2001 Feb. 15(1):67-74. [Medline].

  15. Tomita Y, Kobayashi K, Saito T, et al. Use of miniature ultrasonic probe system for intravesical ultrasonography for transitional cell cancer of the urinary tract. Scand J Urol Nephrol. 2000 Oct. 34(5):313-6. [Medline].

  16. Simms MS, Perkins AC, Price MR. 99mTechnetium-C595 radioimmunoscintigraphy: a potential staging tool for bladder cancer. BJU Int. 2001 Nov. 88(7):686-91. [Medline].

  17. Hermes B, Spöler F, Naami A, Bornemann J, Först M, Grosse J, et al. Visualization of the Basement Membrane Zone of the Bladder by Optical Coherence Tomography: Feasibility of Noninvasive Evaluation of Tumor Invasion. Urology. 2008 May 1. [Medline].

 
Previous
Next
 
A 21-year old man presented with a history of intermittent hematuria of 1-month duration. Three months previously, he had been assaulted and kicked in the right loin. A 30-minute intravenous urogram shows a moderate right hydronephrosis without filling of the renal pelvis, although some contrast material has passed into the upper ureter. Note also a polypoid intraluminal filling defect within the left side of the bladder (arrow).
Left, transverse sonogram of the right kidney in the same patient as in the previous image shows a centrally placed solid mass within the renal pelvis with low-level echoes and with proximal hydronephrosis. Right, transverse sonogram through the bladder shows a polypoid filling defect in the bladder.
Nonenhanced (top) and enhanced (bottom) CT scans through the kidneys show a mass in the right renal pelvis. The histologic diagnosis was a right renal pelvis neurofibroma and a bladder transitional cell carcinoma.
An intravenous urogram in a 36-year old woman who presented with evidence of a urinary tract infection and gross hematuria. A 10-minute intravenous urogram shows a filling defect in the lower pole calyx on the right. A provisional diagnosis of transitional cell carcinoma was made. Subsequent investigations and the course of events proved that the filling defect was caused by a blood clot related to the hematuria secondary to acute pyelonephritis.
Localized views of the right vesicoureteric junction obtained after intravenous urography shows a polypoid filling defect in the lower right ureter due to a transitional cell carcinoma.
A 10-minute intravenous urogram in a 56-year-old man presenting with hematuria. The image shows a mass lesion in the right renal pelvis that bisects the renal sinus and splays the adjacent calyces.
Longitudinal sonogram obtained through the right kidney shows a hypoechoic mass bisecting the renal sinus fat. The mass is a transitional cell carcinoma.
Nonenhanced (top) and enhanced (bottom) CT scans obtained through the kidneys in a 73-year-old woman show a mass in the left renal pelvis is a transitional cell carcinoma.
Left retrograde pyelogram shows marked irregularity of the infundibulum of the upper pole calyx caused by infiltration by transitional cell carcinoma. This information was unavailable on the CT scans.
Top, Longitudinal sonogram obtained thorough the left kidney in a 58-year-old man presenting with hematuria shows a normal left kidney. Bottom, More medial section through the same kidney shows a vague isoechoic mass in the upper of the kidney. Whether this finding represented an artifact or a genuine lesion was unclear. Technetium-99m dimercaptosuccinate (99mTc DMSA) scanning is good modality for differentiating a renal pseudomass from a genuine mass.
Left posterior view of a technetium-99m dimercaptosuccinate (99mTc DMSA) scan shows a photon-deficient mass in the upper pole of the left kidney; this finding indicates a genuine mass in this region. At partial nephrectomy, transitional cell carcinoma was confirmed.
Scout radiograph in a 53-year-old man presenting with hematuria shows a few small vague opacities in the left renal area; these are suggestive of renal calculi.
Intravenous urogram shows 2 filling defects: 1 in the upper pole and 1 in the lower-pole calyces. Conventional tomographic results (bottom) confirm the findings.
Longitudinal sonogram through left kidney shows that the filling defects are due to calculi. Ultrasonography is an efficient means for differentiating between radiolucent calculi and uroepithelial tumors.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.