uroepithelial tumors terrence c. demos, md department of radiology loyola university medical center
TRANSCRIPT
UROEPITHELIAL TUMORS
TERRENCE C. DEMOS, MD
DEPARTMENT OF RADIOLOGY
LOYOLA UNIVERSITY MEDICAL CENTER
UROEPITHELIAL TUMORS INCIDENCE
URINARY BLADDER (94% OF ALL UROEPITHELIAL TUMORS)
RENAL PELVIS (5% OF ALL UROTHELIAL TUMORS)
URETER (1% OF ALL UROTHELIAL TUMORS)
UROEPITHELIAL TUMORSINCIDENCE
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)
UROEPITHELIAL TUMORSRISK FACTORS
SMOKING ANALGESICS
PHENACETINCYCLOPHOSPHAMIDE
OCCUPATIONAL CARCINOGENSCOAL, ASPHALT, TAR, PETROCHEMICALS, PLASTICS
PAPILLARY NECROSIS FAMILIAL CANCER SYNDROMES
– HEREDITARY NONPOLYPOSIS COLORECTAL CANCER (LYNCH II)
UROEPITHELIAL TUMORS
COLLECTING SYSTEM DEVELOPES FROM FETAL MESONEPHROSUROEPITHELIAL 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
UROEPITHELIAL TUMORS
90% TRANSITIONAL CELL
9% SQUAMOUS CELL
>1%– ADENOCARCINOMA – SARCOMA– UNDIFFERENTIATED– BENIGN MESODERMAL
UROEPITHELIAL TUMORTRANSITIONAL, SQUAMOUS, AND SARCOMA ELEMENTS
TRANSITIONAL CELL CARCINOMA
TRANSITIONAL CELL CARCINOMA
CLASSIFICATION
PAPILLARY
NONPAPILLARY
TRANSITIONAL CELL CARCINOMA
PAPILLARY TYPE 80%• 50% ARE INFILTRATIVE MALIGNANCIES
NONPAPILLARY TYPE 20%• ALL CONSIDERED TO BE MALIGNANT
PAPILLARY CARCINOMA INVASIVE VERSUS NONINVASIVE
NONPAPILLARY (FLAT) CARCINOMAINVASIVE VERSUS NONINVASIVE
TRANSITIONAL CELL TUMORS
PATHOLOGIC CLASSIFICATION RANGE
– WELL DIFFERENTIATED PAPILLOMA (GRADE 1) – MALIGNANCY
RANGES FROM LOW-GRADE AND SUPERFICIAL
TO HIGH-GRADE AND INVASIVE
UROEPITHELIAL TUMORSIMAGING MODALITIES
EXCRETORY UROGRAM SONOGRAPHY RETROGRADE PYELOGRAM COMPUTED TOMOGRAPHY ANGIOGRAPHY
TRANSITIONAL CELL TUMORS
GROSS APPEARANCE ON IMAGING STUDIES
– SINGLE LESION SMALL AND PAPILLARY TO BULKY AND SESSILE
– MULTIPLE DISCRETE LESIONS
– DIFFUSE AND CONFLUENT LESIONS
TRANSITIONAL CARCINOMA RENAL PELVIS
UROEPITHELIAL TUMORS
PAPILLARY TYPE STIPPLED APPEARANCE
TRANSITIONAL CELL CA
PAPILLARY TYPE STIPPLED APPEARANCE
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
MULTIPLE TRANSITIONAL CELL CARCINOMAS
TRANSITIONAL CELL CARCINOMAPROGNOSIS
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
SQUAMOUS CARCINOMA
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
HEMATURIASQUAMOUS CARCINOMA
INITIAL CT
CT 8 MONTHS LATER
SQUAMOUS TUMORS
DIFFICULT TO RECOGNIZE DUE TO UNDERLYING DISEASEINFECTIONSTONES
OFTEN INVASIVE OR METASTATIC AT TIME OF DIAGNOSIS
PREDOMINENTLY EXTRALUMINAL
MAY APPEAR AS URETERAL STRICTURE
DISTAL URETERAL UROEPITHELIAL TUMORSQUAMOUS CARCINOMA
UROEPITHELIAL NEOPLASMS
IMAGING
UROEPITHELIAL TUMORSIMAGING
COLLECTING SYSTEM
CALYCES
INFUNDIBULI
PELVIS
URETERS
BLADDER
UROEPITHELIAL TUMORS
RENAL PELVIS
TRANSITIONAL CELL CARCINOMA INVADES KIDNEY
LARGE, INVASIVE UROEPITHEAL TUMOR RENAL PELVIS
TRANSITIONAL CELL CARCINOMARENAL PELVIS
HEMATURIA
INITIAL IVP
TWO RETROGRADES
IVP 1YEAR LATER
NONFUNCTIONING KIDNEY
TRANSITIONAL CELL CA
PAPILLARY TYPE STIPPLED APPEARANCE
RENAL SINUSFAT, OPACIFIED CALYX, TUMOR
48-YEAR-OLD WOMAN PERSISTENT ABDOMINAL PAIN
CT ONE YEAR LATER
CT10 mm VERSUS 5 mm COLLIMATION
TRANSITIONAL CELL CA PELVISCT AND ANGIOGRAPHY
UROEPITHELIAL TUMORS
CALYCES
TRANSITIONAL CELL CA
IVP RETROGRADE
CT
TRANSITIONAL CELL CA LOWER POLE CALYX
TRANSITIONAL CELL CARCINOMA CT, IVP, RETROGRADE PYELOGRAM
TRANSITIONAL CELL CARCINOMA DILATED CALYX
IVPRETROGRADE
TRANSITIONAL CELL CAAMPUTATED CALYX
HEMATURIA 70/M
IVP
CT 1 YEAR LATER
TRANSITIONAL CELL CARCINOMAPAPILLARY TYPE WITH STIPPLING
TRANSITIONAL CELL CASUBTLE
UROEPITHELIAL TUMORS
URETER
GROSS HEMATURIADISTAL URETERAL CA
UROEPITHELIAL TUMORS
BERGMAN SIGN(RETROGRADE PYELOGRAM)
GOBLET SIGN (EXCRETORY UROGRAM)
TRANSITONAL CARCINOMA OF URETER
BERGMAN SIGN
HEMATURIA 52-YEAR-OLD MAN
IVP
IVP 1YEAR LATER
TRANSITIONAL CELL CARCINOMAIRREGULAR DISTAL URETER STRICTURE
TRANSITIONAL CELL CA URETER IVP RETROGRADE
VOLUMINOUS RENAL PELVIS84-YEAR-OLD WOMAN
ATROPHIC KIDNEYDISTAL URETERAL TUMOR
ATROPHIC KIDNEYDISTAL URETER TRANSITIONAL CELL CA
ATROPHIC KIDNEYDISTAL URETER TRANSITIONAL CELL CA
PSEUDOURETEROCELEVERSUS SIMPLE URETEROCELE
UROEPITHELIAL TUMORS
BLADDER
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
TRANSTIONAL CELL CARCINOMABLADDER
URINARY BLADDER HALO SIGN
BOWEL GAS ETCHED IN WHITENEOPLASM WITH NO WHITE HALO
URINARY BLADDER CARCINOMA
WHAT ABNORMALITIES ARE DEMONSTRATED ON THIS IVP
UROEPITHELIAL TUMORS
TUMOR CALCIFICATION
TRANSITIONAL CELL CARCINOMA SQUAMOUS CARCINOMA
URACHAL CARCINOMA
SQUAMOUS BLADDER CACALCIFIED
URACHAL CARCINOMA
SQUAMOUS CARCINOMA
CYTITIS GLANDULARISWITH PELVIC LIPOMATOSIS
URETHRA
TWO MEN WITH HEMATURIA
LITTRE GLANDS
TRANSITIONAL CA
UROEPITHELIAL NEOPLAMS
STAGING
UROEPITHELIAL NEOPLAMSTNM 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
UROEPITHELIAL NEOPLAMSTNM 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
INVASION OF THE RENAL VEIN
RENAL CELL CARCINOMA
RENAL PELVIS TRANSITIONAL CELL CA
ANGIOMYOLIPOMA
TRANSITIONAL CELL CARCINOMA INVADES KIDNEY
HEMATURIA 57/M
INITIAL CT
IVP & CT 9 MONTHS LATER
UROEPITHELIAL TUMOR STAGE 4
EXTENSIVE UROEPITHELIAL TUMOR
UROEPITHELIAL TUMORSMETASTASES
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
URETEROPELVIC FILLING DEFECT
STONES
GROSS HEMATURIAURETERAL STONE
GROSS HEMATURIASTIPPLED URETERAL LESION
DETECTION OF STONES
EXCRETORY UROGRAMDETECTS 75% OF ALL CALCULI
CTDECTECTS >98% OF ALL CALCULI
SONOGRAPHYSENSTIVE FOR RENAL PELVIS AND
PROXIMAL URETERAL CALCULIINSENSTIVE FOR DISTAL URETERAL CALCULI
RENAL STONESONOGRAPHY
HEMATURIA CT WITH IV CONTRAST
GROSS HEMATURIA
BLOOD CLOTDIAGNOSIS OF HEMATOMAS
RADIOGRAPHS AND EXCRETORY UROGRAMSNONSPECIFIC MASS EFFECT
COMPUTED TOMOGRAPYACUTE HEMORRHAGE HAS HIGH ATTENUATIONLATER, HEMATOMA APPEARS AS LOW DENSITY CYST
MAGNETIC RESONANCE IMAGINGMOST SENSITIVE FOR DIAGNOSING HEMATOMA
• IN ACUTE, INTERMEDIATE, AND LATE STAGES OF EVOLUTION
HISTORY OF UROEPITHELIAL MALIGNANCIES NOW HAS HEMATURIA
BLOOD VESSEL CROSSING PELVIS
CROSSING BLOOD VESSELS
EXCRETORY UROGRAMSMOOTH FILLING DEFECT
• PERIPHERAL IF VIEW IN PROFILE• CENTRAL IF VIEWED ENFACE
INCONSTANT SHAPE
CONFIRM DIAGNOSISCT ANGIOMR ANGIO
PYELITIS CYSTICA
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
URETERITIS CYSTICA
IMMUNE SUPPRESSED PATIENT TRANSPLANTED KIDNEY
INFECTED URINE
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
LEUKOPLAKIA
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
MALAKOPLAKIA
MALAKOPLAKIA OF BLADDER
MICHAELIS-GUTMANN BODIES
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
PAPILLARY NECROSIS
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
PAPILLARY NECROSIS
UROEPITHELIAL TUMORS
RETROGRADE PYELOGRAM
EDEMA OF RENAL PELVIS, URETER
ANTICOAGULATED PATIENT WITH HEMATURIA
URETHRAL PSEUDODIVERTICULI
RISK OF MALIGNANCY
URETERAL PSEUDODIVERTICULI
SMALL (2-5 MM) OUTPOUCHINGS
HYPERPLASIA OF TRANSITIONAL EPITHELIUM
RELATED TO CHRONIC INFECTION
ASSOCIATED WITH TRANSITIONAL CELL CAHAVE PRECEDED MALIGNANCY BY 2-10 YEARSPATIENTS MUST BE CLOSELY MONITORED
RECURRENT URETERAL MALIGNANCY POST OP IN URETERAL STUMP
UROEPITHELIAL TUMORS
EXCRETORY UROGRAM
EXCRETORY UROGRAMRENAL 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
EXCRETORY UROGRAMURETER
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
UROEPITHELIAL TUMORS
COMPUTED TOMOGRAPHY
COMPUTED TOMOGRAPHY
SCANNING SEQUENCES• UNENHANCED• CORTICOMEDULLARY PHASE• NEPHROGRAPHIC PHASE• DELAYED
– OPACIFY COLLECTING SYSTEM, URETER AND BLADDER
APPROPRIATE COLLIMATION
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
UROEPITHELIAL TUMORS
ANGIOGRAPHY
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
BENIGN UROEPITHELIAL NEOPLASMS
MESODERMAL NEOPLASMSSMOOTH MUSCLENEURALVASCULAR
PAPILLOMA GRADE 1CONSIDERED TO BE MALIGNANCY
INVERTED PAPILLOMARARE, ALMOST EXCLUSIVELY IN MEN
FIBROEPITHELIAL POLYPS
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