Imaging of urinary bladder carcinoma by Dr. Prajwal Dhakal

1. Imaging of Urinary bladder
carcinoma
PRAJWAL DHAKAL

2. Introduction
• Fourth most common malignancy in men.
• Tenth most common in female
• Occur 3- 4 times more frequently in male.
• high recurrence rate, necessitating long term surveillance after initial
treatment.
• Up to 47% of cancer related death can be avoided so early diagnosis
is important
• Survival of the patients with bladder cancer is longer than those with
most other cancers.

3. Pathologic features
• About 90% of bladder tumors are urothelial in origin (i.e. transitional
cell carcinomas).
• Squamous cell carcinomas account for 6%–8%
• Adenocarcinomas are rare and typically represent urachal cancer.
• Up to 25% of urothelial cancers have a mixed histology (poor
prognosis).

4. Risk factors
• Cigarette smoking in 50%–60% of men and one-third of women.
• occupational exposure to chemical carcinogens such as aniline dyes
• therapeutic irradiation of neighboring organs
• use of alkylating agents although it is rare.
• genetic predisposition to the development of urothelial tumors in
some families.
• Risk factors for squamous cell cancer include long-term
catheterization, nonfunctioning bladder, urinary tract calculi, and
chronic infection by Schistosoma hematobium

5. Pathologic features
• Urothelial tumors are classified
not invading muscle (superficial or papillary).
Approximately 80%–85% of urothelial tumors
invading muscle (nonpapillary)
Approximately 20%–25% of bladder cancers are muscle invasive
and includes squamous and adenocarcinoma.

6. •

7. Anatomy
• extra peritoneal structure, with
peritoneum covering only the superior
surface of the bladder (bladder
dome).
• The orifices of the ureters at the
ureterovesical junction are joined by
an elevated ridge covered by mucosa
(the interureteric ridge).
• The bladder trigone is a triangular
region on the inferior wall, marked at
its corners by the ureterovesical
junction and the urethra.

8. Clinical staging and management
• most commonly present with painless hematuria (80%–90% of cases).
• CT/ Cystoscopy
Some institutions perform computed tomographic (CT) urography for triage
prior to cystoscopy, whereas others use cystoscopy as the first line of
investigation.
• Magnetic resonance (MR) imaging of the pelvis is usually performed
for T (tumor) staging once bladder cancer has been diagnosed,
although its use is not widespread.

9. • Cystoscopic staging is an initial and important part of pretreatment
planning.
• To assess the pathology, grade, and depth of these tumors cystoscopic
biopsy of suspicious-looking bladder lesions is performed.
• Transurethral resection of bladder tumor ( TURBT) has also been used for
deep biopsy to assess for muscle-invasive tumors .
• Cross-sectional imaging is usually performed afterward for disease staging
in patients who are thought to have solid tumors.

10. TNM Staging
Tumor
• Tx Primary tumor cannot be evaluated
• T0 No primary tumor
• Ta Noninvasive papillary carcinoma
• Tis Carcinoma in situ
• T1 Tumor invades connective tissue under the epithelium (surface layer)
• T2 Tumor invades muscle
• T2a Superficial muscle affected (inner half)
• T2b Deep muscle affected (outer half)
• T3 Tumor invades perivesical fat
• T3a Tumor is detected microscopically
• T3b Extravesical tumor is visible macroscopically
• T4 Tumor invades the prostate gland, uterus, vagina, pelvic wall, or abdominal wall

11. •

12. N – Regional Lymph Nodes
• NX: Regional lymph nodes cannot be assessed
• N0:No regional lymph node metastasis
• N1:Metastasis in a single lymph node in the true pelvis (hypogastric,
obturator, external iliac, or presacral)
• N2:Metastasis in multiple regional lymph nodes in the true pelvis
(hypogastric, obturator, external iliac, or presacral)
• N3: Metastasis in a common iliac lymph node(s)

13. M- Metastasis
• M0: No distant metastasis
• M1a: Non regional lymph nodes
• M1b: Other distant metastasis

14. Treatment
• Non-Muscle-invasive Disease
Non-muscle-invasive tumors are usually treated with TURBT.
 in patients with bulky Ta lesions or T1 tumors, the current trend is to perform
repeat TURBT 2–6 weeks after the first TURBT.
adjuvant intravesical chemotherapy (eg, with mitomycin C or gemcitabine) or
immunotherapy (with bacille Calmette-Guérin [BCG]).
Muscle-invasive Disease
For muscle-invasive tumors, radical cystectomy is the established treatment
with meticulous extended bilateral lymphadenectomy, since extent of
lymphadenectomy is associated with survival.

15. Imaging Consideration
• Plain Xray
• IVU
• CT urography
• MRI

16. X-ray
• X-ray has limited role
• Calcification in bladder cancer is
visible on plain films in
approximately 0.5% of bladder
cancer, usually transitional or
squamous cell carcinoma.
• It may be focal, linear, punctate
or coarse

17. USG
• Superficial bladder tumors may
be seen as mass lesions of
intermediate echogenicity .
• May be sessile or papillary, the
latter being easier to detect,
sometimes down to 2-3 mm
diameter.
• Tumor may be seen infiltrating
the bladder wall and extending
through it in advanced cases

18. IVU
• Both IVU and ultrasound will fail to diagnose a substantial proportion
of cases (with a detection rate as low as 26%).
• May demonstrate tumor but is more important in diagnosing
alternative pathologies (renal cell carcinoma, calculi etc).
• It has also been used to access upper urinary tract for detection of
synchronous or metachronous lesion
• In some institution it has been used as a yearly surveillance
investigation for detecting these lesion. However, its use is being
controversial.

19. •

20. Computed Tomography
• CT urography has a sensitivity and specificity of over 90% for the
diagnosis of bladder cancer in patients with hematuria.
• Despite these encouraging results, CT urography cannot be used as a
replacement for diagnostic cystoscopy in most patients with
suspected bladder cancer.

21. • CT: does not allow the confident diagnosis of flat lesions and lesions
at the bladder base adjacent to the prostate gland ( in BEP).
• Difficulty is differentiating tumor recurrence from inflammatory wall
thickening (following endovesical chemotherapy and scar tissue after
TURBT.
• The homogeneous opacification of urine has been claimed to improve
bladder cancer detection, particularly on the nondependent surface
of the bladder

22. • It is possible to visualize bladder wall enhancement and thickness on
nephrographic phase CT scans.
• Virtual cystoscopy has been performed with the installation of 300–
500 mL of air or carbon dioxide into the bladder lumen via a catheter.
• Some small series have shown CT cystoscopy to have a sensitivity of
over 90%.

23. MR Imaging
• Requires high spatial resolution, thin sections (3 mm), and a large
matrix.
• More accurate staging than CT : high soft-tissue contrast resolution,
which allows clear differentiation between bladder wall layers.
• Better depict intramural tumor invasion as well as extravesical
extension.
• Allows differentiation between muscle-invasive and non-muscle-
invasive disease
• No ionizing radiation.

24. • Local staging of bladder cancer: a multiparametric approach with
conventional and functional sequences is useful.
• Multiparametric MRI: combination of T1- and T2-weighted images
and functional MRI techniques, including DCE imaging and DWI.
• Axial spin-echo (SE) T1-weighted images with a large FOV : for
evaluating the perivesical fat planes for extravesical tumor infiltration,
pelvic lymphadenopathy, and bone metastases.

25. • High-resolution fast SE T2-weighted images in the three orthogonal planes
with a small FOV : to evaluate the detrusor muscle for tumor depth and
invasion of the surrounding organs
• 3D sequences offer the advantages of shorter acquisition time, volumetric
coverage without intersection gaps, and an improved signal-to-noise ratio.
• Techniques useful in rapid pelvic imaging : non-breath-hold ultrafast SE T2-
weighted sequences (eg, single-shot fast SE and GRE sequences) and
steady-state free precession imaging sequences (eg, fast imaging
employing steady-state acquisition [FIESTA]).

26. • Artifacts associated with MR imaging of bladder includes:
 lack of bladder distention,
motion artifact
 chemical shift artifact

27. Dynamic Contrast Enhanced MR Imaging.
 The usefulness of dynamic contrast-enhanced T1-weighted MR
imaging is debatable, with some studies showing that it is a useful
technique and others showing that it is of no additional value
 The bladder tumor, mucosa, and submucosa enhance early (20sec),
but the muscle layer maintains its hypointensity and enhances late
(60 sec)

28. Diffusion-weighted MR Imaging
 Role of diffusion-weighted imaging in bladder cancer is evolving and has
not yet been fully established.
Provides both qualitative and quantitative information that reflects
changes at the cellular level concerning tumor cellularity and cell
membrane integrity.
 For most bladder tumors, increased cellular density manifests as increased
signal intensity on diffusion-weighted images with a reduced apparent
diffusion coefficient (ADC) at quantitative analysis

29. • Changes in signal intensity seen on diffusion-weighted images are
more useful than information from ADC measurements
• Diffusion-weighted imaging in bladder cancer has been evaluated in
terms of diagnosis, staging, prediction of histologic grade, and
assessment of the efficacy of induction chemotherapy).
• It has shown improved differentiation between the tumor, muscle
layer, and thickened submucosa, all of which have different signal
intensities at diffusion-weighted imaging.

30. • Currently, MRI is the best imaging technique for local and nodal staging of
bladder cancer.
• The main advantages of MRI are its superior soft-tissue contrast (especially
T2-weighted imaging) without using radiation.
• The introduction of multiparametric MRI, combining anatomic and
functional sequences seems promising in detection, staging, and follow-up
of bladder cancer

31. • Positron Emission Tomography
Positron emission tomography (PET) with 2-[fluorine-18]fluoro-2-
deoxy-d-glucose is considered to be of lesser value in the local staging
of bladder cancer due to urinary excretion of the radiotracer

34. •

35. •

40. • In patients with known bladder cancer, the important staging question is
whether there is muscle invasion (stage T2 or higher).
• The accuracy of contrast-enhanced CT in the local staging of bladder
cancer is only 40%–60% .
• MR imaging is considered superior to CT in demonstrating the extent of
bladder wall invasion (ie, in differentiating between stage T2a and stage
T2b disease).
• Microscopic perivesical spread (stage T3a disease) cannot be identified at
either CT or MR imaging.
• Recent studies have reported diffusion-weighted imaging to have a high
sensitivity and specificity in the staging of bladder cancer

41. • The most common site of nodal metastasis is the obturator nodes.
About one in six patients presents with lymph nodes above the aortic
bifurcation, and 8% have presacral adenopathy.
• Conventional CT and MR imaging cannot help identify metastases in
lymph nodes less than 10 mm. Enlarged nodes may be reactive, so
that specificity is also limited
• According to recent published reports, diffusion-weighted imaging
has shown promise in differentiating benign from malignant lymph
nodes

43. Post-treatment Surveillance
• Because of the high rate of local recurrence, patients with non-
muscle-invasive bladder cancer must be followed up after treatment
• Cystoscopy, urine cytology, and imaging of the upper tract with
retrograde ureteroscopy are usually performed annually.
• Given the high metastatic recurrence rate of muscle-invasive bladder
cancer, guidelines for post-cystectomy surveillance include urine
cytology, chest radiography, and abdominopelvic imaging every 3–6
months for the first 2 years.

44. Rare malignancies
Urachal carcinoma
• Less than 0.5% of bladder cancer.
• Overwhelmingly adenocarcinoma
• Vast majority arise in the urachus immediately adjacent to the bladder
vault and extends superiorly in the perivesical space towards the umbilicus
and inferiorly to the bladder.
• Considerable extra vesical component and the position in the bladder vault
should suggest the urachal rather than bladder carcinoma.
• Are often mucinous and two third show dystrophic calcification which may
be punctate or curvilinear.
• Three fifth of the cases also show cystic degeneration with mucinous
component

45. Lymphoma
• Primary
nonspecific findings as large lobulated mass or focal wall thickening in
middle aged to elderly female presented with gross hematuria.
Usually non Hodgkins lymphoma.
• Secondary
Common in advanced disease, being found in 13% of postmortem
cases died with lymphoma

46. Mimics of urinary bladder carcinoma
Inflammatory pseudotumor
• Pathogenesis: Unclear
• Can be locally aggressive and
mimic malignancy
• Imaging: Usually solitary bladder
mass (exophytic or polypoid)
• Axial T2-weighted MR image
shows a lobulated polypoid mass
arising from the anterior wall of
the bladder with central
hyperintensity (*) and low
peripheral signal intensity
(arrowhead).

47. endometriosis
• Endometriosis. (a, b) Axial T1-
weighted (a) and fat-suppressed
T1-weighted (b) MR images show
high-signal-intensity foci (arrow)
within a soft-tissue mass in the
vesicouterine space, projecting into
the bladder lumen. (c) Axial T2-
weighted MR image shows the
lesion is predominantly low signal
intensity (arrow), a finding
consistent with fibrosis. (d) Axial
gadolinium-enhanced fat-
suppressed T1-weighted image
shows homogeneous enhancement
of the lesion (arrow).

48. Nephrogenic Adenoma
• Non neoplastic mass (metaplastic)
due to chronic irritation (calculi,
infection).
• Non specific findings of solitary or
multiple sessile or polypoid masses.
• Involves lamina propria, doesn’t
involve muscle layer.
• Anteroposterior view of the bladder
obtained during intravenous
urography shows an irregular
lobulated filling defect at the base of
the bladder. Pathologic evaluation
showed urothelial carcinoma with an
adjacent nephrogenic adenoma.

49. Malacoplakia
• Rare granulomatous inflammation which
can involve any organ, urinary tract
commonest.
• Multiple, polypoid, vascular, solid masses
or circumferential wall thickening.
• Can invade perivesical space and even
cause bone destruction.
• Associated with VUR and
hydroureteronephrosis.
• (a) Axial CT image shows marked
circumferential bladder wall thickening. (b)
Photograph of the cut, resected specimen
shows a friable, hemorrhagic mucosal
surface and dramatic wall thickening.

50. eosinophilic cystitis
• Cystic eosinophilic cystitis. (a, b) Axial
(a) and sagittal reconstructed (b)
contrast-enhanced CT images show a
thick-walled cystic mass (arrow)
arising from the anterior dome of the
bladder. (c) Intraoperative
photograph, with the bladder wall
retracted (arrowheads), shows the
mass (arrow) protruding into the
lumen. (d) Photograph of the cut
specimen shows a circumferentially
thickened wall, as seen on the CT
images. (e) Photomicrograph (original
magnification, 120; H-E stain) shows
an intense infiltration of eosinophils
deep within the muscularis

51. Schistosomiaisis
• • Schistosomiasis.
Anteroposterior radiograph (a)
and axial CT image (b) of the
bladder shows curvilinear
calcification in the bladder wall
(arrowheads), which also
extends to the distal left ureter
(arrow). Calcification,
representing an abundance of
calcified ova, is typically seen in
the chronic phase of the
infection.

52. THANK YOU

53. Role of plain Xray, IVU and USG in bladder ca
Role of CT in bladder ca
Role of conventional MRI in bladder ca
Role of dynamic contrast imaging
Role of DWI
Urachal carcinoma imaging features
List the mimickers of urinary bladder carcinoma.