Uroepithelial neoplasm

1. UROEPITHELIAL TUMORS
TERRENCE C. DEMOS, MD
DEPARTMENT OF RADIOLOGY
LOYOLA UNIVERSITY MEDICAL CENTER

2. UROEPITHELIAL TUMORS
INCIDENCE
 URINARY BLADDER
(94% OF ALL UROEPITHELIAL TUMORS)
 RENAL PELVIS
(5% OF ALL UROTHELIAL TUMORS)
 URETER
(1% OF ALL UROTHELIAL TUMORS)

3. UROEPITHELIAL TUMORS
INCIDENCE
 URINARY BLADDER
(50 THOUSAND NEW CASES BLADDER CA/YEAR IN USA)
M:F 3:1
 RENAL CELL CARCINOMA OF KIDNEY
(15,000 THOUSAND NEW CASES/YEAR IN USA)

4. UROEPITHELIAL TUMORS
RISK FACTORS
 SMOKING
 ANALGESICS
 PHENACETIN
 CYCLOPHOSPHAMIDE
 OCCUPATIONAL CARCINOGENS
 COAL, ASPHALT, TAR, PETROCHEMICALS, PLASTICS
 PAPILLARY NECROSIS
 FAMILIAL CANCER SYNDROMES
– HEREDITARY NONPOLYPOSIS COLORECTAL CANCER (LYNCH II)

5. UROEPITHELIAL TUMORS
COLLECTING SYSTEM DEVELOPES FROM FETAL MESONEPHROS
UROEPITHELIAL CA: TRANSITIONAL CELL OR SQUAMOUS CARCINOMA
DERIVED FROM
 MESODERM
 EPITHELIAL TISSUE
RENAL PARENCHYMA DEVELOPES FROM METANEPHRIC BLASTEMA
RENAL CELL CA: ADENOCARCINOMA
DERIVED FROM
 TUBULAR EPITHELIUM

6. UROEPITHELIAL TUMORS
 90% TRANSITIONAL CELL
 9% SQUAMOUS CELL
 >1%
– ADENOCARCINOMA
– SARCOMA
– UNDIFFERENTIATED
– BENIGN MESODERMAL

7. UROEPITHELIAL TUMOR
TRANSITIONAL, SQUAMOUS, AND SARCOMA ELEMENTS

8. TRANSITIONAL CELL CARCINOMA

9. TRANSITIONAL CELL CARCINOMA
CLASSIFICATION
PAPILLARY
NONPAPILLARY

10. TRANSITIONAL CELL CARCINOMA
PAPILLARY TYPE 80%
• 50% ARE INFILTRATIVE MALIGNANCIES
NONPAPILLARY TYPE 20%
• ALL CONSIDERED TO BE MALIGNANT

11. PAPILLARY CARCINOMA
INVASIVE VERSUS NONINVASIVE

12. NONPAPILLARY (FLAT) CARCINOMA
INVASIVE VERSUS NONINVASIVE

13. TRANSITIONAL CELL TUMORS
PATHOLOGIC CLASSIFICATION RANGE
– WELL DIFFERENTIATED PAPILLOMA (GRADE 1)
– MALIGNANCY
RANGES FROM LOW-GRADE AND SUPERFICIAL
TO HIGH-GRADE AND INVASIVE

14. UROEPITHELIAL TUMORS
IMAGING MODALITIES
EXCRETORY UROGRAM
SONOGRAPHY
RETROGRADE PYELOGRAM
COMPUTED TOMOGRAPHY
ANGIOGRAPHY

15. TRANSITIONAL CELL TUMORS
GROSS APPEARANCE ON IMAGING STUDIES
– SINGLE LESION
 SMALL AND PAPILLARY TO BULKY AND SESSILE
– MULTIPLE DISCRETE LESIONS
– DIFFUSE AND CONFLUENT LESIONS

16. TRANSITIONAL CARCINOMA
RENAL PELVIS

17. UROEPITHELIAL TUMORS
PAPILLARY TYPE
STIPPLED APPEARANCE

18. TRANSITIONAL CELL CA
PAPILLARY TYPE
STIPPLED APPEARANCE

19. TRANSITIONAL CELL CARCINOMA
 TENDENCY TO BE MULTICENTRIC AND BILATERAL
 BILATERAL IN UP TO 10% OF PATIENTS
– (SYNCHRONOUS OR METACHRONOUS)
 UP TO 1/2 OF PATIENTS WITH CA URETER OR PELVIS
WILL DEVELOP BLADDER CARCINOMA

20. MULTIPLE TRANSITIONAL
CELL CARCINOMAS

21. TRANSITIONAL CELL CARCINOMA
PROGNOSIS
 PATIENTS WITH A RENAL PELVIC PAPILLOMA
• 1/4 WILL DEVELOP A CARCINOMA
 PATIENTS WITH MULTIPLE PAPILLOMAS
• 1/2 WILL DEVELOP A CARCINOMA
 PATIENTS WITH BLADDER/URETER TRANSITIONAL NEOPLASM
• 1/3 ALREADY HAVE ANOTHER BLADDER TCC

22. SQUAMOUS CARCINOMA

23. SQUAMOUS TUMORS
 ASSOCIATED WITH INFECTION AND STONES, LEUKOPLAKIA
 SQUAMOUS METAPLASIA OF TRANSITIONAL EPITHELIUM
 MOST ARE SOLITARY
 CAN BE PAPILLARY OR SESSILE
 HIGHLY INVASIVE
 OVERALL, POOR PROGNOSIS

24. HEMATURIA
SQUAMOUS CARCINOMA
INITIAL CT
CT 8 MONTHS LATER

25. SQUAMOUS TUMORS
 DIFFICULT TO RECOGNIZE DUE TO UNDERLYING DISEASE
 INFECTION
 STONES
 OFTEN INVASIVE OR METASTATIC AT TIME OF DIAGNOSIS
 PREDOMINENTLY EXTRALUMINAL
 MAY APPEAR AS URETERAL STRICTURE

26. DISTAL URETERAL UROEPITHELIAL TUMOR
SQUAMOUS CARCINOMA

27. UROEPITHELIAL NEOPLASMS
IMAGING

28. UROEPITHELIAL TUMORS
IMAGING
COLLECTING SYSTEM
CALYCES
INFUNDIBULI
PELVIS
URETERS
BLADDER

29. UROEPITHELIAL TUMORS
RENAL PELVIS

30. TRANSITIONAL CELL CARCINOMA
INVADES KIDNEY

31. LARGE, INVASIVE UROEPITHEAL TUMOR
RENAL PELVIS

32. TRANSITIONAL CELL CARCINOMA
RENAL PELVIS

33. HEMATURIA
INITIAL IVP
TWO RETROGRADES
IVP 1YEAR LATER

34. NONFUNCTIONING KIDNEY

35. TRANSITIONAL CELL CA
PAPILLARY TYPE
STIPPLED APPEARANCE

36. RENAL SINUS
FAT, OPACIFIED CALYX, TUMOR

37. 48-YEAR-OLD WOMAN
PERSISTENT ABDOMINAL PAIN
CT ONE YEAR LATER

38. CT
10 mm VERSUS 5 mm COLLIMATION

39. TRANSITIONAL CELL CA PELVIS
CT AND ANGIOGRAPHY

40. UROEPITHELIAL TUMORS
CALYCES

41. TRANSITIONAL CELL CA
IVP RETROGRADE
CT

42. TRANSITIONAL CELL CA
LOWER POLE CALYX

43. TRANSITIONAL CELL CARCINOMA
CT, IVP, RETROGRADE PYELOGRAM

44. TRANSITIONAL CELL CARCINOMA
DILATED CALYX
IVP
RETROGRADE

45. TRANSITIONAL CELL CA
AMPUTATED CALYX

46. HEMATURIA
70/M
IVP
CT 1 YEAR LATER

47. TRANSITIONAL CELL CARCINOMA
PAPILLARY TYPE WITH STIPPLING

48. TRANSITIONAL CELL CA
SUBTLE

49. UROEPITHELIAL TUMORS
URETER

50. GROSS HEMATURIA
DISTAL URETERAL CA

51. UROEPITHELIAL TUMORS
BERGMAN SIGN
(RETROGRADE PYELOGRAM)
GOBLET SIGN
(EXCRETORY UROGRAM)

52. TRANSITONAL CARCINOMA OF URETER
BERGMAN SIGN

53. HEMATURIA 52-YEAR-OLD MAN
IVP
IVP 1YEAR LATER

54. TRANSITIONAL CELL CARCINOMA
IRREGULAR DISTAL URETER STRICTURE

55. TRANSITIONAL CELL CA URETER
IVP RETROGRADE

56. VOLUMINOUS RENAL PELVIS
84-YEAR-OLD WOMAN

57. ATROPHIC KIDNEY
DISTAL URETERAL TUMOR

58. ATROPHIC KIDNEY
DISTAL URETER TRANSITIONAL CELL CA

59. ATROPHIC KIDNEY
DISTAL URETER TRANSITIONAL CELL CA

60. PSEUDOURETEROCELE
VERSUS SIMPLE URETEROCELE

61. UROEPITHELIAL TUMORS
BLADDER

62. URINARY BLADDER CARCINOMA
 M:F- 4:1
 MOST COMMON AFTER 5TH DECADE OF LIFE
 12,000 DEATHS AND 50,OOO NEW CASES ANNUALLY
 MEN 4TH LEADING, WOMEN 10TH LEADING CAUSE OF DEATH
 EXCRETORY UROGRAPHY INSENSITIVE FOR DIAGNOSIS
– BUT OPTIMIZE TECHNIQUE AND SCRUTINIZE BLADDER
 CYSTOSCOPY

63. TRANSTIONAL CELL CARCINOMA
BLADDER

64. URINARY BLADDER HALO SIGN

65. BOWEL GAS ETCHED IN WHITE
NEOPLASM WITH NO WHITE HALO

66. URINARY BLADDER CARCINOMA

67. WHAT ABNORMALITIES ARE
DEMONSTRATED ON THIS IVP

68. UROEPITHELIAL TUMORS
TUMOR CALCIFICATION
TRANSITIONAL CELL CARCINOMA
SQUAMOUS CARCINOMA
URACHAL CARCINOMA

69. SQUAMOUS BLADDER CA
CALCIFIED

70. URACHAL CARCINOMA
SQUAMOUS CARCINOMA

71. CYTITIS GLANDULARIS
WITH PELVIC LIPOMATOSIS

72. URETHRA

73. TWO MEN WITH HEMATURIA
LITTRE GLANDS
TRANSITIONAL CA

74. UROEPITHELIAL NEOPLAMS
STAGING

75. UROEPITHELIAL NEOPLAMS
TNM STAGING
 T1 INVASION OF SUBEPITHELIAL CONNECTIVE TISSUE
 T2 INVASION OF MUSCULARIS
 T3 INVASION THRU MUSCULARIS INTO
 PERIPELVIC FAT OR KIDNEY PARENCHYMA BY PELVIC LESION
 INVASION OF PERIURETERIC FAT BY URETERAL LESION
 T4 INVASION INTO PERINEPHRIC FAT OR ADJACENT ORGANS
 N
 M

76. UROEPITHELIAL NEOPLAMS
TNM STAGING
T1 AND T2 (INVASION OF MUSCULARIS)
 T1 AND T2 OFTEN NOT DIFFERENTIATED BY IMAGING STUDIES
 T3 INVASION THRU MUSCULARIS INTO
 PERIPELVIC FAT OR KIDNEY PARENCHYMA BY PELVIC LESION
 INVASION OF PERIURETERIC FAT BY URETERAL LESION
• INFILTRATION OF FAT NOT SPECIFIC FOR TUMOR INVASION
 T4 INVASION INTO PERINEPHRIC FAT OR ADJACENT ORGANS
• TUMOR ABUTTING BUT NOT INVADING MAY NOT BE
DIFFERENTIATED BY IMAGING STUDIES
N FALSE POSITIVE AND FALSE NEGATIVE LYMPH NODES
• LARGE NODES WITHOUT TUMOR AND SMALL NODES WITH TUMOR

77. INVASION OF THE RENAL VEIN
RENAL CELL CARCINOMA
 RENAL PELVIS TRANSITIONAL CELL CA
 ANGIOMYOLIPOMA

78. TRANSITIONAL CELL CARCINOMA
INVADES KIDNEY

79. HEMATURIA 57/M
INITIAL CT
IVP & CT
9 MONTHS LATER

80. UROEPITHELIAL TUMOR
STAGE 4

81. EXTENSIVE UROEPITHELIAL TUMOR

82. UROEPITHELIAL TUMORS
METASTASES

83. D.D. OF A FILLING DEFECT
COLLECTING SYSTEM OR URETER
 STONE
 BLOOD CLOT
 NEOPLASM
 GAS BUBBLE
 CROSSING VESSEL
 PERISTALSIS
 PYELITIS / URETERITIS CYSTICA
 INFECTION / NECROTIC DEBRIS
 FUNGUS BALL
 LEUKOPLAKIA, MALAKOPLAKIA
 SLOUGHED PAPILLA, ABERRANT PAPILLA

84. URETEROPELVIC FILLING DEFECT

85. STONES

86. GROSS HEMATURIA
URETERAL STONE

87. GROSS HEMATURIA
STIPPLED URETERAL LESION

88. DETECTION OF STONES
EXCRETORY UROGRAM
 DETECTS 75% OF ALL CALCULI
CT
 DECTECTS >98% OF ALL CALCULI
SONOGRAPHY
 SENSTIVE FOR RENAL PELVIS AND PROXIMAL
URETERAL CALCULI
 INSENSTIVE FOR DISTAL URETERAL CALCULI

89. RENAL STONE
SONOGRAPHY

90. HEMATURIA CT WITH IV CONTRAST

91. GROSS HEMATURIA

92. BLOOD CLOT
DIAGNOSIS OF HEMATOMAS
RADIOGRAPHS AND EXCRETORY UROGRAMS
 NONSPECIFIC MASS EFFECT
COMPUTED TOMOGRAPY
 ACUTE HEMORRHAGE HAS HIGH ATTENUATION
 LATER, HEMATOMA APPEARS AS LOW DENSITY CYST
MAGNETIC RESONANCE IMAGING
 MOST SENSITIVE FOR DIAGNOSING HEMATOMA
• IN ACUTE, INTERMEDIATE, AND LATE STAGES OF EVOLUTION

93. HISTORY OF UROEPITHELIAL MALIGNANCIES
NOW HAS HEMATURIA

94. BLOOD VESSEL CROSSING PELVIS

95. CROSSING BLOOD VESSELS
EXCRETORY UROGRAM
 SMOOTH FILLING DEFECT
• PERIPHERAL IF VIEW IN PROFILE
• CENTRAL IF VIEWED ENFACE
 INCONSTANT SHAPE
CONFIRM DIAGNOSIS
 CT ANGIO
 MR ANGIO

96. PYELITIS CYSTICA

97. URETERITIS, PYELITIS CYSTICA
 SUBEPITHELIAL FLUID CONTAINING CYSTS
 USUALLY SMALL BUT RANGE FROM 1-20 MM
 ASSOCIATED WITH CHRONIC INFECTION
 PERSISTENT OR PERMANENT
 MAY BE ASSOCIATED WITH CYSTITIS CYSTICA

98. URETERITIS CYSTICA

99. IMMUNE SUPPRESSED PATIENT
TRANSPLANTED KIDNEY
INFECTED URINE

100. URINARY TRACT INFECTION
FUNGAL INFECTION
 HISTORY OF PATIENT SHOULD BE OBTAINED
 BACTERIAL URINARY TRACT INFECTIONS CAN
PRODUCE DEBRIS CAUSING FILLING DEFECTS.
 FUNGAL INFECTION CAN PRODUCE FUNGUS BALLS
 CANDIDA ALBICANS MOST COMMON
• IMMUNOCOMPRIMISED OR DEBILITATED PATIENTS

101. LEUKOPLAKIA

102. LEUKOPLAKIA
 SQUAMOUS METAPLASIA OF TRANSITIONAL CELLS
WITH PROLIFERATION & ATYPIA OF SQUAMOUS
EPITHELIAL LAYER………PREMALIGNANT
 CHOLESTEATOMA……..MASS OF SHED MATRIAL
 IMAGING OF PYELOCALYCEAL SYSTEM AND URETER
• FOCAL OR WIDESPREAD IRREGULAR MARGINS
• IRREGULAR INTRALUMINAL MASS
• STONE DISEASE IN 1/2
• CHRONIC INFECTION IS COMMON
• CARCINOMA IN UP TO 1/4

103. MALAKOPLAKIA

104. MALAKOPLAKIA OF BLADDER
MICHAELIS-GUTMANN BODIES

105. MALAKOPLAKIA
 GRANULOMATOUS RESPONSE TO E. COLI INFECTION
 MACROPHAGES CONTAIN CYTOPLASMIC INCLUSION BODIES CALLED
MICHAELIS-GUTMANN BODIES
 AFFECTS ARE PART OF GU TRACT, BUT MOST COMMON IN BLADDER
 IMAGING SHOWS MULTIPLE IRREGULAR FILLING DEFECTS
 LOWER URINARY TRACT….GOOD PROGNOSIS
 DIFFUSE, MULTIFOCAL OR RENAL TX PATIENT…. POOR PROGNOSIS
 NO MALIGNANT POTENTIAL

106. PAPILLARY NECROSIS

107. PAPILLARY NECROSIS
EXCRETORY UROGRAM AND RETROGRADE PYELOGRAM
 EARLY: SMALL, IRREGULAR COLLECTIONS OF CONTRAST IN PAPILLAE
 LATE: IRREGULAR DILATION OF CALYCES
• FILLING DEFECTS
• SLOUGHED PAPILLA IN CALYX, RENAL PELVIS, OR URETER
 SLOUGHED PAPILLAE THAT CALCIFY HAVE PERIPHERAL
CALCIFICATION….DIFFERENT THAN STONES
 THE CONTOUR OF THE KIDNEY MAY BE WAVY DUE TO SELECTIVE
ATROPHY OF CORTEX OVERLYING THE MEDULLARY SEGMENTS OF THE
KIDNEY
 ETIOLOGY: ANALGESICS, DIABETES, INFECTION with OSTRUCTION
TUBERCULOSIS, SS DISEASE

108. PAPILLARY NECROSIS

109. UROEPITHELIAL TUMORS
RETROGRADE PYELOGRAM

110. EDEMA OF RENAL PELVIS, URETER

111. ANTICOAGULATED PATIENT WITH
HEMATURIA

112. URETHRAL PSEUDODIVERTICULI
RISK OF MALIGNANCY

113. URETERAL PSEUDODIVERTICULI
 SMALL (2-5 MM) OUTPOUCHINGS
 HYPERPLASIA OF TRANSITIONAL EPITHELIUM
 RELATED TO CHRONIC INFECTION
 ASSOCIATED WITH TRANSITIONAL CELL CA
 HAVE PRECEDED MALIGNANCY BY 2-10 YEARS
 PATIENTS MUST BE CLOSELY MONITORED

114. RECURRENT URETERAL MALIGNANCY
POST OP IN URETERAL STUMP

115. UROEPITHELIAL TUMORS
EXCRETORY UROGRAM

116. EXCRETORY UROGRAM
RENAL PELVIS
 FILLING DEFECT
• SINGLE OR MULTILPLE FILLING DEFECTS
• SESSILE OR FLAT
• SMOOTH, IRREGULAR, STIPPLED SURFACE
 COLLECTING SYSTEM
• DILATED CALYX
• DILATED COLLECTING SYSTEM
• AMPUTATED CALYX OR INFUNDIBULUM
• ATROPHIC KIDNEY
• NONFUNCTIONING KIDNEY
 NEPHROGRAM
• DEFECT DUE TO TUMOR INVASION OR COLLECTING SYSTEM
OBSTRUCTION
• MASS LIKE DEFECT

117. EXCRETORY UROGRAM
URETER
 CALIBER OF URETER
• NORMAL CALIBER
• DILATED PROXIMAL TO LESION
– WITH DILATED COLLECTING SYSTEM
– WITHOUT DILATED COLLECTING SYSTEM
• NARROWED AT SITE OF LESION
 URETER AT SITE OF LESION
• GOBLET SIGN (BERGMAN SIGN)
• STRICTURE
– SMOOTH AND CIRCUMFERENTIAL
– ECCENTRIC
– IRREGULAR
 MULTIPLE LESIONS

118. UROEPITHELIAL TUMORS
COMPUTED TOMOGRAPHY

119. COMPUTED TOMOGRAPHY
 SCANNING SEQUENCES
• UNENHANCED
• CORTICOMEDULLARY PHASE
• NEPHROGRAPHIC PHASE
• DELAYED
– OPACIFY COLLECTING SYSTEM, URETER AND BLADDER
 APPROPRIATE COLLIMATION

120. COMPUTED TOMOGRAPHY
 FINDINGS SIMILAR TO EXCRETORY UROGRAPHY
 NEED DELAYED SCANNING TO OPACIFY COLLECTING SYSTEM
 NEED THIN COLLIMATION TO SHOW SMALL LESIONS
 CT AFTER IVP IS VALUABLE TO DIFFERENTIATE TUMOR FROM
• CROSSING VESSEL, STONE, PERIPELVIC FAT OR MASS
 STAGING

121. UROEPITHELIAL TUMORS
ANGIOGRAPHY

122. ANGIOGRAPHY
 UROEPITHELIAL NEOPLASMS ARE HYPOVASCULAR
LARGE TUMOR VESSELS ARE RARE
TUMOR VESSELS MAY BE SUBTLE OR ABSENT
 ABNORMAL VESSELS, WHEN PRESENT
– CAN BE IDENTICAL TO NONMALIGNANT DISEASE
– BE IDENTICAL TO POORLY VASCULARIZED RENAL CELL CA

123. BENIGN UROEPITHELIAL NEOPLASMS
 MESODERMAL NEOPLASMS
 SMOOTH MUSCLE
 NEURAL
 VASCULAR
 PAPILLOMA GRADE 1
 CONSIDERED TO BE MALIGNANCY
 INVERTED PAPILLOMA
 RARE, ALMOST EXCLUSIVELY IN MEN
 FIBROEPITHELIAL POLYPS

124. FIBROEPITHELIAL POLYP
 FIBROUS TISSUE, SMOOTH MUSCLE, VESSELS, NERVE CELLS
COVERED BY UROEPITHELIUM
 MOST ARISE IN URETER
 ELONGATED AND THIN, FINGER LIKE DISTAL BRANCHES
 HIGHLY MOBILE