UROEPITHELIAL TUMORS TERRENCE C. DEMOS, MD DEPARTMENT OF RADIOLOGY LOYOLA UNIVERSITY MEDICAL CENTER.

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)


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


90% TRANSITIONAL CELL

9% SQUAMOUS CELL

>1%– ADENOCARCINOMA – SARCOMA– UNDIFFERENTIATED– BENIGN MESODERMAL

UROEPITHELIAL TUMORTRANSITIONAL, SQUAMOUS, AND SARCOMA ELEMENTS

TRANSITIONAL CELL CARCINOMA


CLASSIFICATION

PAPILLARY

NONPAPILLARY


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


PAPILLARY TYPE STIPPLED APPEARANCE

TRANSITIONAL CELL CA



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


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



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


CALYCES


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


URETER

GROSS HEMATURIADISTAL URETERAL CA


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


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


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


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


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


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


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

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UROEPITHELIAL TUMORS TERRENCE C. DEMOS, MD DEPARTMENT OF RADIOLOGY LOYOLA UNIVERSITY MEDICAL CENTER.

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