TRANSITIONAL CELL CARCINOMAUpper urinary tract

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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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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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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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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• Cyclo-phosphamide therapy

• Heavy caffeine consumption.

• Stasis of urine and structural abnormalities such as horseshoe kidney.

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IMAGING MODALITIES

INTRAVENOUS UROGRAPHY

• noninvasive method of choice.

• detailed anatomy of the pelvicalyceal system and ureters.

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• 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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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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• 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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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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• 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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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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• 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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• 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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• 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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 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

Thank You

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