Transitional cell carcinoma (TCC) originates from the transitional epithelium of the urinary tract. It most commonly occurs in the urinary bladder but can also arise in the renal pelvis or ureter. Risk factors include increasing age, male gender, smoking, and exposure to chemical carcinogens. Patients typically present with hematuria but may also experience flank or abdominal pain. Imaging plays an important role in diagnosis and staging. Intravenous urography can detect filling defects or masses in the renal pelvis or ureter. Computed tomography and magnetic resonance imaging provide detailed images of tumor location and extent.

1. TRANSITIONAL CELL CARCINOMA
Upper urinary tract

2. Transitional Cell Carcinoma
• Originates from Transitional epithelium of urinary tract.
• Most common in urinary bladder, then in renal pelvis,
least in ureter(125:2.5:1)
• 5-10% of upper urinary tract neoplasms.
• Renal TCC most common --extrarenal part of the pelvis,
followed by the infundibulocaliceal region
• 2%–4% ---bilaterally.
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3. Clinical features:
• most common in 7th decade, rare in childhood
• males 3 times > female
• typically presents with hematuria
• 1/3 -- flank pain or acute renal colic
• discovered incidentally at radiologic examination
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4. Tumor spreads by
• mucosal extension
• local
• Hematogenous
• lymphatic invasion
• The most common sites for metastases are the liver,
bone, and lungs
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5. ETIOLOGY
• Increasing age
• Male gender
• Most important risk factor is smoking, 2-3 times
• Chemical carcinogens (aniline, benzidine, aromatic
amine, azo dyes),
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6. • Cyclo-phosphamide therapy
• Heavy caffeine consumption.
• Stasis of urine and structural abnormalities such as
horseshoe kidney.
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7. IMAGING MODALITIES
INTRAVENOUS UROGRAPHY
• noninvasive method of choice.
• detailed anatomy of the pelvicalyceal system and
ureters.
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8. • a filling defect within the contrast-enhanced collecting
system, single or multiple & smooth, irregular or stippled
• Stipple sign---tracking of contrast material into the
interstices of a papillary lesion
• Tumor-filled, distended calyces --“oncocalyces.”
• If these fail to opacify with contrast-- “phantom calyces.”
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9. Retrograde Pyelography
• in inadequately excreting kidneys,
• in cases of contrast allergy.
• facilitates ureterorendoscopy with biopsy or brushing &
cytology of urine
• an intraluminal filling defect,-- smooth, irregular, or
stippled.
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10. • An “apple core” appearance-- eccentric or encircling
ureteric lesions
• localized ureteric dilatation around and distal to the filling
defect may give rise to the “goblet” sign.
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11. Ultrasonography
• a central soft-tissue mass in the echogenic renal sinus,
with or without hydronephrosis.
• TCC is usually slightly hyperechoic relative to
surrounding renal parenchyma; occasionally, areas of
mixed echogenicity.
• typically TCC is infiltrative and does not distort the renal
contour.
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12. • US has a limited role in the evaluation of ureteric TCC
• If visualized, these tumors are typically intraluminal soft-
tissue masses with proximal distention of the ureter
• US also allows limited assessment of periureteric
tissues.
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13. Computed Tomography
• CT is well established in the preoperative staging and
assessment of upper tract TCC.
CT urography
• single breath-hold coverage of the entire urinary tract,
• has improved resolution
• has the ability to capture multiple phases of contrast
material excretion
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14. • hyperdense (5–30 HU) to urine and renal parenchyma
but hypodense than other pelvic filling defects such as
clot or calculus.
• typically seen as a sessile filling defect or
• pelvicaliceal irregularity, focal or diffuse mural thickening,
oncocalyx, and focally obstructed calyces.
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15. • Advanced TCC extends into the renal parenchyma in an
infiltrating pattern --- distorts normal architecture
• However, reniform shape is typically preserved (unlike
in renal cell carcinoma)
• enhances poorly after IV contrast
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16. • Hydronephrosis and hydroureter
• Ureteric TCC-- Ureteric wall thickening (eccentric or
circumferential), luminal narrowing, or an infiltrating
mass.
• A thickened enhancing ureteric wall with periureteric fat
stranding -- suggestive of extramural spread
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17. 24 June 2014 17
TCC of the renal pelvis in a 60-year-old man with painless hematuria. Fifteen-
minute IVU image shows a large irregular filling defect (arrow) involving the right
renal pelvis and extending into the lower pole calyceal system

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TCC of the renal pelvis in a 65-year-old man. Fifteen-minute IVU image
shows a large stippled filling defect involving the collecting system of the right
kidney.

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TCC of the upper pole collecting system in a 55-year-old woman. Fifteen-
minute IVU image shows amputation of the upper pole calyx secondary to
TCC.

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Ureteric TCC in a 68-year-old woman. RP image shows a long irregular
stricture of the left distal ureter with proximal hydroureter and “shouldering” .

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Renal TCC in a 59-year-old woman. Sagittal US scan shows a well defined
hyerechoic mass in the upper pole. Tumor tissue is more echogenic than the
surrounding renal cortex but less echogenic than renal sinus fat.

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Renal TCC in a 65-year-old woman. Sagittal US scan shows a large mass of
mixed echogenicity (arrows) involving the upper pole and overlying renal
parenchyma.

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TCC of the renal pelvis in a 43-year-old man with flank pain and
hematuria. Axial nonenhanced CT scan shows a mass in the right renal
pelvis. The mass is slightly hyperdense relative to the urine and renal
parenchyma.

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Post contrast image shows characteristic early enhancement of the
mass, which is less than that of the surrounding renal parenchyma.

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Renal TCC in a 53-year-old man. Axial nephrographic phase CT scan shows a
well defined heterogenous hypodense lesion in the left kidney with preservation
of its reniform contour

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Bilateral ureteric TCC in a 57-year-old woman. Coronal T2-weighted MR image
show low-signal-intensity tumors in the distal right and distal left ureters.

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Renal TCC in a 68-year-old woman. Coronal gadolinium-enhanced MR
angiogram shows a moderately enhancing TCC in the upper pole of the right
kidney

28. Thank You
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