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 TUMORS INCIDENCE

 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 TUMORS

RISK FACTORS  SMOKING  ANALGESICS  PHENACETIN  CYCLOPHOSPHAMIDE  OCCUPATIONAL CARCINOGENS  COAL, ASPHALT, TAR, PETROCHEMICALS, PLASTICS  PAPILLARY NECROSIS  FAMILIAL CANCER SYNDROMES – HEREDITARY NONPOLYPOSIS COLORECTAL CANCER (LYNCH II)

UROEPITHELIAL TUMORS

COLLECTING SYSTEM DEVELOPES FROM FETAL MESONEPHROS

UROEPITHELIAL 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 TUMOR TRANSITIONAL, 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) CARCINOMA INVASIVE 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 TUMORS

IMAGING 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 CARCINOMA

PROGNOSIS

 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

HEMATURIA SQUAMOUS CARCINOMA INITIAL CT CT 8 MONTHS LATER

SQUAMOUS TUMORS

 DIFFICULT TO RECOGNIZE DUE TO UNDERLYING DISEASE  INFECTION  STONES  OFTEN INVASIVE OR METASTATIC AT TIME OF DIAGNOSIS  PREDOMINENTLY EXTRALUMINAL  MAY APPEAR AS URETERAL STRICTURE

DISTAL URETERAL UROEPITHELIAL TUMOR SQUAMOUS CARCINOMA

UROEPITHELIAL NEOPLASMS

IMAGING

UROEPITHELIAL TUMORS IMAGING

COLLECTING SYSTEM CALYCES INFUNDIBULI PELVIS URETERS BLADDER

UROEPITHELIAL TUMORS RENAL PELVIS

TRANSITIONAL CELL CARCINOMA INVADES KIDNEY

LARGE, INVASIVE UROEPITHEAL TUMOR RENAL PELVIS

TRANSITIONAL CELL CARCINOMA RENAL PELVIS

HEMATURIA INITIAL IVP TWO RETROGRADES IVP 1YEAR LATER

NONFUNCTIONING KIDNEY

TRANSITIONAL CELL CA

PAPILLARY TYPE

STIPPLED APPEARANCE

RENAL SINUS FAT, OPACIFIED CALYX, TUMOR

48-YEAR-OLD WOMAN PERSISTENT ABDOMINAL PAIN CT ONE YEAR LATER

CT 10 mm VERSUS 5 mm COLLIMATION

TRANSITIONAL CELL CA PELVIS CT 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 IVP RETROGRADE

TRANSITIONAL CELL CA AMPUTATED CALYX

IVP CT 1 YEAR LATER HEMATURIA 70/M

TRANSITIONAL CELL CARCINOMA PAPILLARY TYPE WITH STIPPLING

TRANSITIONAL CELL CA SUBTLE

UROEPITHELIAL TUMORS URETER

GROSS HEMATURIA DISTAL 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 CARCINOMA IRREGULAR DISTAL URETER STRICTURE

TRANSITIONAL CELL CA URETER IVP RETROGRADE

VOLUMINOUS RENAL PELVIS 84-YEAR-OLD WOMAN

ATROPHIC KIDNEY DISTAL URETERAL TUMOR

ATROPHIC KIDNEY DISTAL URETER TRANSITIONAL CELL CA

ATROPHIC KIDNEY DISTAL URETER TRANSITIONAL CELL CA

PSEUDOURETEROCELE VERSUS SIMPLE URETEROCELE

UROEPITHELIAL TUMORS BLADDER

URINARY BLADDER CARCINOMA  M:F- 4:1  MOST COMMON AFTER 5 TH DECADE OF LIFE  12,000 DEATHS AND 50,OOO NEW CASES ANNUALLY  MEN 4 TH LEADING, WOMEN 10 TH LEADING CAUSE OF DEATH  EXCRETORY UROGRAPHY INSENSITIVE FOR DIAGNOSIS – BUT OPTIMIZE TECHNIQUE AND SCRUTINIZE BLADDER  CYSTOSCOPY

TRANSTIONAL CELL CARCINOMA BLADDER

URINARY BLADDER HALO SIGN

BOWEL GAS ETCHED IN WHITE NEOPLASM 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 CA CALCIFIED

URACHAL CARCINOMA SQUAMOUS CARCINOMA

CYTITIS GLANDULARIS WITH PELVIC LIPOMATOSIS

URETHRA

TWO MEN WITH HEMATURIA LITTRE GLANDS TRANSITIONAL CA

UROEPITHELIAL NEOPLAMS

STAGING

UROEPITHELIAL NEOPLAMS TNM 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 NEOPLAMS TNM 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 TUMORS METASTASES

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 HEMATURIA URETERAL STONE

GROSS HEMATURIA STIPPLED URETERAL LESION

DETECTION OF STONES  EXCRETORY UROGRAM  DETECTS 75% OF ALL CALCULI  CT  DECTECTS >98% OF ALL CALCULI  SONOGRAPHY   SENSTIVE FOR RENAL PELVIS AND PROXIMAL URETERAL CALCULI INSENSTIVE FOR DISTAL URETERAL CALCULI

RENAL STONE SONOGRAPHY

HEMATURIA CT WITH IV CONTRAST

GROSS HEMATURIA

BLOOD CLOT DIAGNOSIS OF HEMATOMAS  RADIOGRAPHS AND EXCRETORY UROGRAMS  NONSPECIFIC MASS EFFECT  COMPUTED TOMOGRAPY  ACUTE HEMORRHAGE HAS HIGH ATTENUATION  LATER, HEMATOMA APPEARS AS LOW DENSITY CYST  MAGNETIC RESONANCE IMAGING  MOST 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 UROGRAM  SMOOTH FILLING DEFECT • • PERIPHERAL IF VIEW IN PROFILE CENTRAL IF VIEWED ENFACE  INCONSTANT SHAPE  CONFIRM DIAGNOSIS  CT ANGIO  MR 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 CA  HAVE PRECEDED MALIGNANCY BY 2-10 YEARS  PATIENTS MUST BE CLOSELY MONITORED

RECURRENT URETERAL MALIGNANCY POST OP IN URETERAL STUMP

UROEPITHELIAL TUMORS EXCRETORY UROGRAM

EXCRETORY UROGRAM RENAL 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 UROGRAM URETER  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 NEOPLASMS  SMOOTH MUSCLE   NEURAL VASCULAR   PAPILLOMA GRADE 1  CONSIDERED TO BE MALIGNANCY INVERTED PAPILLOMA  RARE, 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