multimodal imaging findings in urinary bladder cancer

1. IMAGING OF
URINARY
BLADDER
MALIGNANC
Y
DR PRASUN DAS
2ND YR PGT
DEPT OF RADIODIAGNOSIS
NRSMCH

2.  The urinary bladder is formed partly from the endodermal cloaca and partly from the ends of the Wolffian ducts
 The ureters enter the posterolateral angles of the bladder and pass obliquely through the wall for approximately 2 cm before entering the bladder cavity.
 Trigone, transverse ridge
 on anterioposterior radiographs--- a rounded soft tissue mass surrounded by
transradiant perivesical fat.
 Ante/retrograde contrast;micturition corrugations,prostatic impression
IVU: 1.ORAL magnesium citrate
2.History of previous contrast allergy
3.Renal function,pregnancy
4.Cassette on iliac crest+ full insp.(in obese ,umbilicus)
5. two 50-mL syringes of Omnipaque 300.
6. Abdominal compression allows better visualization of the
renal collecting system
7.Modified IVU

3. Excretory urography imaging
sequence: A full KUB
radiograph is obtained after
release of the compression
paddle with the patient in the
prone position
CT URO: 1.good hydration prior to reduce the
risk of contrast-induced nephropathy
2.PRIOR NON CONTRAST
3. the "split dose" technique
4.3D VOLUME

4. 3D post-processing image created
by the radiologist after the
acquisition of the imaging data.
The image has been obliqued to
optimally visualize the left distal
ureter and left ureterovesicular
junction
MR URO: T2> IV CONTRAST(LOW
DOSE)>T1(+/-IV LASIX)
Retrograde ureterogram: Fluoroscopic spot image obtained during ureteral biopsy
demonstrates an elongated stricture of the distal right ureter corresponding to the filling
defect on the CT urogram. Biopsy confirmed a transitional cell carcinoma.

5. Coronal MIP image from excretory MR
urographic data obtained with a 3D
gradient-echo MR angiographic sequence
shows improved background tissue
suppression due in part to the use of a
higher flip angle of 40°.
Low-grade papillary urothelial carcinoma in a 72-year-old man with
hematuria. (a) Axial fat-suppressed gradient-echo T1-weighted MR image
(LAVA) through the urinary bladder obtained after the administration of
gadolinium-based contrast material but before excreted gadolinium had
reached the bladder via the ureters clearly depicts a small enhancing tumor
(arrow) against a dark background of unenhanced urine. (b) VR virtual
cystoscopic image of the bladder created from the source images shows the
small tumor (arrow) as well as a second larger tumor (arrowhead).

6. USG best modality for UB wall;ureteric
jets;hydroureteronephrosis
Scanning is initiated by placing the
transducer approximately 1 cm above the
symphysis pubis
always advisable to re-examine the
patient after partial emptying of the
bladder
the prolate ellipsoid method based on
the formula: volume = length x width x
heigth x 0.52

7. CT uro protocol for hematuria

8. MR URO PROTOCOL

9.  10th MC (GLOBOCAN 2020)
 3rd MC (GU), 2nd MC(GU)-DEATH
 M:F=4:1
 95% - malignant
 95%- epithelial layer
 MC site: Postero-lateral wall > trigone
 MC HISTOLOGY- Transitional
 MC risk factor- nicotine(~47%)
 MC age group- > 50 yrs.
 MC symptom- painless haematuria < Asymptomatic
 Carcinoma in situ-- a/w irritative symptoms
 Advanced cases -- a/w pain d/t ureteric obstruction/invasion
 Lymph nodes, bones, lung, liver, and peritoneum- mets
 Travel history important for Bilharziasis( Squamous variant)
 IOC – urine cytology f/b Flexible cystoscopy guided biopsy f/b TUR-BT

11.  AJCC 8th edition
 Primary tumor (pT)
 pTX: cannot be assessed
 pT0: no evidence of primary tumor
 pTa: noninvasive papillary carcinoma
 pTis: carcinoma in situ
 pT1: invades lamina propria
 pT2a: invades inner half of muscularis propria
 pT2b: invades outer half of muscularis propria
 pT3a: microscopically invades perivesical tissue
 pT3b: macroscopically invades perivesical tissue
 pT4a: directly invades prostatic stroma, seminal vesicles, uterus or vagina
 pT4b: directly invades pelvic wall or abdominal wall

12.  Regional lymph nodes (pN)
 pNX: cannot be assessed
 pN0: no regional lymph node metastasis
 pN1: metastasis in 1 true pelvic lymph node
 pN2: metastasis in greater than 1 true pelvic lymph node
 pN3: metastasis in common iliac lymph node
 Distant metastasis (pM)
 pM1a: metastasis in nonregional lymph node (ex: caval / aortic, inguinal)
 pM1b: metastasis in other distant site
 Histologic grade (G)
 Urothelial carcinoma
 LG: low grade
 HG: high grade
 Squamous cell carcinoma and adenocarcinoma
 GX: cannot be assessed
 G1: well differentiated
 G2: moderately differentiated
 G3: poorly differentiated

13.  Plain abdominal skiagram
 Stippled/floccular dystrophic calcifications in surface(<1%)
 Intrinsic diffuse calcifications– adeno variety
 Large renal outline(d/t hydronephrosis)
 Osseous expansive destruction, lung mets(more common in renal pelvic TCC)
 IVU (EXCRETORY UROGRAPHY)
 more than 1.5 cm-irregular filling defect with broad base and fronds.
 Increased thickness of the bladder wall in the region of the tumor should indicate infiltration.
 metachronous lesions in the upper urinary tract.
 other abnormalities such as stones or masses that could account for the patients’ hematuria.
 Negative findings cannot exclude urothelial cancer.
 Stipple sign(not diagnostic)-also seen in CT ,MR urogram
 Can detect diverticula,bladder wall irregularity,hydroureteronephrosis
 Most common pitfall of IVU: Bowel air superimposed on the urinary bladder

15. rounded filling defect (arrow) on the
right in the bladder without obstruction of
the right ureter
an oval filling
defect ( arrow ) at the right urinary
bladder cavity,
contiguous with the right bladder
profile

16.  ULTRASONOGRAPHY
 external, suprapubic, abdominal approach using a convex 2.5−5-MHz probe.
 TVS/TRUS- bladder floor, intramural part of ureter
 Echo doppler study- to assess vascularity, ureteric jet(VUJ invasion)
 Muscular layer hypoechoic
 Adequately full bladder essential
 the upper limits of wall thickness are 3 and 5 mm for a full bladder and empty
bladder, respectively
 appear as a papillary (polypoid) or sessile (plaque with large base) lesions projecting
into the lumen, usually quite echogenic and fixed with changes in the patient’s
position.
 false-negative False positive
 Bladder Filling (low or excessive) Filling (low)
 Content (catheter, air, clots, stone) Content (clots, stone)
 Detrusor hypertrophy Detrusor hypertrophy
 Side (anterior bladder wall, bladder neck, or trigone)
 Shape (flat lesion)
 Acute or chronic cystitis
 Tumor Size (<5 mm) Side (median lobe)

17. large,
exophytic mass at
anterior bladder wall
A deep
infiltrating bladder mass
seen at transurethral
US. The echostructural
pattern of anterior
bladder wall is easily
seen, and it
demonstrates a diffuse
interruption

19. Tumor obliterans
Encrusted tumor

20. Synchronous TCC

21. TRUS

22.  CEUS
 Application of contrast agents in microbubble form(sonovue)
 More specific (~90%) than conventional transabdominal USG
 Better assessment of grade due to muscle invasion
 large papillary tumors with necrosis or adherent clots can be identified
preoperatively and may help the surgeon in planning the resection
 T staging more helpful
 3D & 4D US/CEUS
 Lamina propria infiltration better evaluated
 Operator dependence
 High learning curve

23. a. Abdominal sonography revealed a hypoechoic mass in the apex of the urinary bladder. b. CDFI showed a rich
blood flow signal inside this mass. c. CEUS imaging showed the mass began to undergo enhancement (wash-in
from its periphery to its center at 10 s. d. CEUS imaging showed persistent high peak enhancement of the mass at
40 s. e. CEUS showed the enhancement signal of the mass was equal to the bladder wall at 120 s. f. Time-intensity
curve showed wash-in time of 10 s, TTP of 33 s, SI of 62.7% and wash-out time > 60 s

24. Type 1
contrast
enhancement
curve
2D and 3D view of a
bladder dome tumour in a
patient with an indwelling
catheter

26.  Conventional CT : staging(Now MDCT)
 MC appearance: mort commonly appear as areas of asymmetric bladder
wall thickening.
 Delayed scans (after 10min) show opacification of the bladder lumen and sometimes the lower ureters as well.
 Imaging of the urinary bladder in the prone and supine position is necessary for visualization of the entire mucosal surface
without obscurity caused by residual urine
 lymph node enlargement and distant metastatic disease as well as the presence of complications such as hydronephrosis.
 CT is not capable of determining the depth of invasion of the bladder wall,
i.e., differentiating stage T2a from T2b disease.
 Perineural spread also difficult unless gross
 CT can detect pelvic sidewall invasion (stage T4 disease) when the fat
between the bladder and the pelvic sidewall is obliterated
 Bladder cancers enhance more intensely than adjacent normal bladder wall
tissue on contrast-enhanced CT scans
 Lymph node >10mm(>8mm for obturator & internal iliac)

27.  CT abdomen – para aortic lymph node enlargement & liver mets
 Carcinoma in diverticulum accurately diagnosed
 Follow up after usage of tropical treatment(BCG/mitomycin)
 1/3rd recurrence after cystectomy at site,rest in pelvic lymph node
 Pitfalls: Pseudo lesions d/t early Post Op CT following TURBT
 Overdistension Must be avoided(underestimation of bladder wall thickness with
effacement of fat planes between the bladder and adjacent structures)
 under-staging - inability to detect tumor in normal-sized lymph nodes
 Over staging: perivesical fibrosis, particularly seen following cystoscopic biopsy
 CT cannot confidently detect flat lesions and lesions at the bladder base near prostate gland.
 CT urogram- IMAGING IOC
 Putting the patient in the prone position, applying abdominal compression, or both,may help distend the urinary collecting system.
 Numerous different image post-processing algorithms are available for CTU (volume
rendering, thick slab averaging, or maximum intensity projections).

28.  Focal wall thickening in dependent wall is hard to detect in delayed-phase images
because of contrast material in the bladder lumen and associated beam-hardening
artefact
 Small lesions show early enhancement after contrast injection (within 60 s) when the
lesion is surrounded by low- attenuated urine
 Filling defect to be noted in delayed phase of imaging in large lesions
 Pitfall: BPH,Chronic hematoma,Detrusor hyperactivity,chronic granulomatous cystitis
 intravenous furosemide has been shown to improve both opacification and
distension of the urinary tract relative to intravenous normal saline(not seen in HIGH
RESIDUAL URINE patients)

29. An image obtained at the level
of the kidneys demonstrates
marked right pelvicaliectasis d/t
the distal right ureteral
obstruction.
Urothelial SOL in the posterolateral
area of the bladder in Contrast
enhanced CT image through
the pelvis.

30. Excretory phase contrast-
enhanced
axial image from a CT
urogram shows a large
area of asymmetric wall
thickening alo.ng the left
lateral aspect of the
bladder.
Corticomedullary phase contrast enhanced axial and coronal reformatted CT
images demonstrate diffuse lobulated circumferential wall thickening of the
bladder, corresponding to a large infiltrative bladder malignancy.
Calcifications, which can be seen in some bladder cancers, are also noted
along the bladder wall surface.

31. Noncontrast coronal CT shows a large right bladder
diverticulum with area of high attenuation within it (calcification
On tumor surface) and in the bladder lumen near the orifice of
the diverticulum
Contrast-enhanced coronal
reformatted CT image shows
sigmoid colon in the bladder
fossa in this patient who has had
a cystectomy

32. An axial image obtained below
the level of the pubis
shows a soft tissue mass in region
of vulva, which proved to be
recurrent tumor.
Maximum- intensity- projection
image of bladder mass ( arrow )
with contrast material filled in the
bladder
lumen.

33. MDCT of the urinary bladder and virtual cystoscopy in a 65-year-old male patient
presenting with painless hematuria. (a) On coronal reconstructed MDCT image of the air-filled
urinary bladder a small papillary and an additional larger lesion that looks sessile can be depicted.
(b) Virtual endoscopic view nicely shows the peduncular morphology of the larger bladder lesion.

34. Contrast-enhanced CT demonstrating soft issue masses in the
left obturator lymph node (white arrow) (a) and the retroperitoneum
(black arrow) (b) consistent with metastatic disease in a patient with
stage T3 tumor

35. (a) Contrast-enhanced CT of the liver demonstrating multiple
hypodensities (arrowheads), with irregular rim enhancement throughout
the liver consistent with metastases in a patient with invasive bladder
cancer. (b) CT of the lung showing multiple metastatic parenchymal
soft tissue nodules of varying sizes in both lung fields (arrows)

36.  Morphological MRI
 T1-weighted spin echo images of the entire pelvis ( peri vesical fat tissue infiltration, pelvic lymphadenopathy and bone metastasis)
 T2-weighted fast spin echo images of the bladder in at least two different planes(better as it differentiates NMIBC from MIBC)
 dynamic contrast-enhanced T1-weighted images
 Tumors of the urinary bladder can be detected with MR imaging if they exceed 7–8mm
in diameter.
 T1--- the bladder tumor typically has a low-to-intermediate signal intensity (similar to
that of the bladder wall and higher than the dark urine)
 On T2-weighted images, the tumor tends to have intermediate signal intensity (brighter
than the dark bladder wall muscle and lower than the high signal urine)
 Gadolinium enhanced T1-weighted imaging demonstrates intense and immediate
enhancement of the tumor compared to the uninvolved bladder wall
 enhance earlier than post-biopsy tissue with an average of 6.5 s following contrast
enhancement(fast dynamic MR)
 A limitation of MR imaging is the differentiation between stages T2 and T3a.

37.  Novel MR imaging with ultrasmall super paramagnetic iron oxide (USPIO) particles has
shown that normal nodal tissue shows uptake of this contrast material and a selective
decrease in signal intensity on T2- or T2∗-weighted MR images, whereas nodal areas
infiltrated with metastases lack uptake and retain their high signal intensity on USPIO
enhanced MR images
 Bone marrow metastases have signal intensity equal to the primary tumor and are
recognized best on T1- weighted images
 Peripheral enhancement can be appreciated following gadolinium administration
 Detect spread of the tumor through the acetabulum that requires palliative orthopedic
surgery.
 Phased-array external surface body coils and endoluminal coils offer higher signal-to-
noise ratio and a smaller field of view resulting in the acquisition of excellent image
quality with high spatial resolution.(invasion into seminal vesicles)

38. Axial T1, T2, and gadolinium-enhanced MR images of a
transmural, polypoid enhancing mass (arrow) arising from the right
inferolateral bladder wall with no evidence of invasion into the extravesical
soft tissue consistent with a stage T2 bladder cancer. The tumor
has intermediate signal intensity on T1 and T2 (a, b) and demonstrates
intense enhancement following administration of gadolinium (c)

39. Sagittal T1 contrast enhanced image: large circumferential bladder
mass (arrows). Disruption of the low signal intensity of the muscle
at the right bladder base is consistent with wall invasion with focal
extravesical soft tissue extension in the
perivesical fat (stage T3b) (arrow head)
Axial T2: multiple slightly hyperintense
lesions in liver

40. USPIO-enhanced T2∗-weighted axial MR images
1- positive uptake and decresed signal(ext. iliac)
2-negative uptake and retain high signal(para aortic)

41.  MR urogram
 Static MRU is performed with heavily T2-weighted images.
 Dynamic MRU uses contrast enhanced T1-weighted images.
 Similar moderate early enhancement after intravenous contrast
 DW-MRI does not require contrast agent, therefore DW-MRI can be used in patients
with renal failure or allergies to contrast agents
 It can demonstrate micro metastasis
 differentiate recurrent tumor from chronic inflammation and fibrosis after surgery.
 DCE-MRI is helpful for predicting recurrence and chemotherapeutic response
 Lymphotropic Nanoparticle Enhanced MRI (Ferumoxtran-10) detection of
malignancy within small lymph nodes (increased sensitivity) and detection of
benignity among enlarged lymph nodes (increased specificity).

43. Axial T2*-weighted MR image
obtained after administration of
ferumoxtran-10 nanoparticles shows
lymph node (arrow) is hypointense,
consistent with benignity (true-
negative).

44.  PET/CT: ~98% SPECIFIC FOR NODAL METS
 18-fluorodeoxyglucose (FDG) is excreted into the collecting system and bladder-
SO NOT USED WIDELY(CARBON CHOLINE TAGGING INSTEAD, cyclotron needed)
 18F-NaF is useful for assessment of blastic bone metastasis
 Bone scintigraphy is recommended for MIBC patients with suspicious bone
metastasis & before TURB
 PET MRI: Carbon-acetate(better in nodal mets)

45. A heterogenous lobulated mass on the right side of mid-line with extension
(white arrow) to perivesical fat seen on T2-weighted image (a), an area of
increased diffusion signal restriction (white arrow) beyond the bladder wall
(b - b value 800 s/mm2 trace diffusion weighted image), an associated right
sided hydroureter, and increased 11C-acetate uptake (c - PET fused with T2-
weighted image, SUV is scaled from 0.0 to 3.5) suggestive of T3 stage
PET/CT
PET MRI

46.  SQ CC: more invasive
 More in diverticula,chronic infections,calculi
 MCC-bilharziasis
 Adeno: in metaplastic change of extropy,urachal remnant
 Malignant counterpart of cystitis cystica glandularis
 More common –trigone
 Small cell(NEC): patchy enhancement,no calcification
 Lateral bladder wall with large size and ulcerated;highly aggressive
 Leiomyoma is the most common mesenchymal tumor of the bladder(MC
BENIGN;M<F)
 MR imaging is superior in demonstrating the submucosal origin of the tumor and
the preservation of the muscle layer
 Leiomyosarcoma is the most common nonepithelial malignant bladder tumor in
adults. Rhabdomyosarcoma is the most common bladder tumor in patients under
the age of 10 years

47. A contrast-enhanced axial CT image in a different
patient shows tumor arising in a diverticulum from the left lateral
wall of the bladder. There are stones in the most dependent
portion of the diverticulum, and calcification is present on the
tumor surface where it protrudes into the bladder lumen.
ADENO CA IN BLADDER
EXTROPHY

48.  the bladder is the most common genitourinary site of a neurofibroma
 Target sign in MRI-plexiform variant
 Ring calcification around the circumference of the mass is highly
suggestive of a bladder paraganglioma(IOC-MIBG)
 Rhabdomyosarcoma-lobulated like cluster of grapes
 Urachal: supravesical-space of retzius (USG)
 The most common secondary tumor found in the bladder is melanoma,
usually presenting as multiple mural nodule f/b prostatic CA

49. Contrast enhanced T1 :
enhancement--leiomyoma
Sigmoid colon cancer with direct invasion of the bladder in a
74-year-old man. Contrast-enhanced CT image shows focal wall
thickening ( white arrow ), which is continuous with the adjacent wall
thickening of the sigmoid colon. Note the circumferential wall thickening
( arrowheads ) of the sigmoid colon and intraluminal stent ( black
arrow ).

50. Paraganglioma of the bladder in a 33-year-old man. ( A and B )
Contrast-enhanced, axial ( A ) and coronally reconstructed CT ( B )
images show a highly enhancing mass ( white arrow ) in the anterior wall
of the bladder. Note prominent vessels ( black arrow in A ) supplying the
mass

51. Embryonal rhabdomyosarcoma in a 5-year-old girl. ( A ) IVU
demonstrates a huge mass in the pelvic cavity with displacement of the
distal ureters. ( B ) Contrast-enhanced CT image demonstrates a bulky,
soft-tissue mass with extensive necrosis. Bladder lumen ( B ) is displaced
anteriorly and partially filled with the tumor. The large size of the bladder
mass in a young patient is a typical feature of rhabdomyosarcoma

52. Neurofi broma of the bladder in a 25-year-old woman. ( A ) Transabdominal
US shows a well-circumscribed mass ( arrows ) of homogeneous
echogenicity between the bladder ( B ) and uterus ( U ). ( B ) Contrastenhanced
CT image shows a homogeneously enhancing tumor ( arrow )
in the left posterolateral aspect of the bladder. ( C ) Tumor ( arrows )
demonstrates slightly heterogeneous signal intensity on T2-weighted
image.

53. Prostate cancer with direct
invasion of the bladder in a 75-
year-old man. T2-weighted MR
images in coronal plane show a
large sessile mass ( arrows ) of
intermediate
signal intensity in the base of the
bladder and prostate
Urachal
adenocarcinoma in
a 48-year-old man.
contrast-enhanced
CT demonstrate a
small, elongated
soft-tissue lesion (
arrow ) in
the course of the
urachus. Follow-up
CT images after 6
months show a
polypoid mass (
arrow ) in the
bladder dome with
more
endophytic growth

55.  STAGING: CT imaging is best used locally in the assessment of higher-staged larger
tumors. (>T3a)
 Lymph node size is the predominant way nodal metastases on CT are suspected.
 cannot be used in differentiating MIBC from superficial, non-MIBC and highly variable results
for the diagnosis of metastatic lymph nodes
 mainstay for initial staging of bladder cancer because of its cost-effectiveness, availability, and
utility in detecting both metastatic disease in the entire abdomen and pelvis and when a CT
urography protocol is used, synchronous upper tract cancers.
 For local T staging of bladder cancer, MRI is superior to CT due to its high soft tissue contrast
resolution
 T2WI is the mainstay of bladder cancer staging
 Studies showed superiority of multiparametric MRI (mpMRI), in which a combination of
anatomic (T2WI and DCE) and functional imaging such as DWI, difusion tensor imaging (DTI)
and perfusion-weighted imaging (PWI)
 In comparison to 11 C-choline PET-CT for bladder cancer staging, 18F-FDG showed a higher
positive predictive value in detecting extravesical lesions.(standardized uptake value)

56. 1.structured reporting
scheme for multiparametric
bladder MRI in the
evaluation of
suspected bladder cancer
2. European Association of
Urology in 2018
3.Structural,Diffusion
weighted, dynamic contrast
enhanced

57. ACR PRE-TREATMENT
STAGING(2017) FOR MIBC
(1) CT abdomen and pelvis
without and with contrast (CT
urography),
(2) CT abdomen and pelvis with
IV contrast,
(3) MRI abdomen and pelvis
without and with IV contrast (MR
urography),
(4) MRI pelvis without and with
IV contrast, and
(5) chest radiographs.

58.  Post treatment imaging: Intravesical medication and transurethral resection or biopsy often
cause inflammation and edema.
 Avid mucosal and submucosal enhancement after intravenous contrast administration can
be observed.
 Intravenous pyelography (IVP) every 6-12 months for atleast 5 yr(CIS)
 IVP or loopography should be performed(intestinal neobladder)
 High risk NMIBC: >3cm,multifocal,prostatic urethra inv.,poor response to
BCG,lymphovascular invasion

59. NMIBC(LOW RISK): urine cytological evaluation
and cystoscopy are sufficiently accurate for the
diagnosis of bladder recurrence
ACR 2020 POST TREATMENT
SURVEILLANCE GUIDELINE
NMIBC(HIGH RISK):
1.MRU(+/-)IV CONTRAST
2.CTU(+/-)IV CONTRAST

60. MIBC(+/-)CYSTECTOMY:
1.Chest radiography
2.Fluoroscopy abdomen loopogram
3.MRU
4.CTU
5.CT abdomen-pelvis with IV
contrast