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

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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

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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
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 incidence3
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 tumors risk factors
UROEPITHELIAL TUMORSRISK FACTORS
  • SMOKING
  • ANALGESICS
      • PHENACETIN
      • CYCLOPHOSPHAMIDE
  • OCCUPATIONAL CARCINOGENS
      • COAL, ASPHALT, TAR, PETROCHEMICALS, PLASTICS
  • PAPILLARY NECROSIS
  • FAMILIAL CANCER SYNDROMES
    • HEREDITARY NONPOLYPOSIS COLORECTAL CANCER (LYNCHII)
uroepithelial tumors
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 tumors6
UROEPITHELIAL TUMORS
  • 90% TRANSITIONAL CELL
  • 9% SQUAMOUS CELL
  • >1%
    • ADENOCARCINOMA
    • SARCOMA
    • UNDIFFERENTIATED
    • BENIGN MESODERMAL
transitional cell carcinoma
TRANSITIONAL CELL CARCINOMA

CLASSIFICATION

PAPILLARY

NONPAPILLARY

transitional cell carcinoma10
TRANSITIONAL CELL CARCINOMA
  • PAPILLARY TYPE 80%
        • 50% ARE INFILTRATIVE MALIGNANCIES
  • NONPAPILLARY TYPE 20%
        • ALL CONSIDERED TO BE MALIGNANT
transitional cell tumors
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
UROEPITHELIAL TUMORSIMAGING MODALITIES
  • EXCRETORY UROGRAM
  • SONOGRAPHY
  • RETROGRADE PYELOGRAM
  • COMPUTED TOMOGRAPHY
  • ANGIOGRAPHY
transitional cell tumors15
TRANSITIONAL CELL TUMORS

GROSS APPEARANCE ON IMAGING STUDIES

  • SINGLE LESION
    • SMALL AND PAPILLARY TO BULKY AND SESSILE
  • MULTIPLE DISCRETE LESIONS
  • DIFFUSE AND CONFLUENT LESIONS
uroepithelial tumors17
UROEPITHELIAL TUMORS
  • PAPILLARY TYPE
  • STIPPLED APPEARANCE
transitional cell carcinoma19
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
transitional cell carcinoma prognosis
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 tumors
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
HEMATURIASQUAMOUS CARCINOMA

INITIAL CT

CT 8 MONTHS LATER

squamous tumors25
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
uroepithelial tumors imaging

UROEPITHELIAL TUMORSIMAGING

COLLECTING SYSTEM

CALYCES

INFUNDIBULI

PELVIS

URETERS

BLADDER

hematuria
HEMATURIA

IVP 1YEAR LATER

TWO RETROGRADES

INITIAL IVP

transitional cell ca
TRANSITIONAL CELL CA

CT

IVP

RETROGRADE

slide46

HEMATURIA

70/M

IVP

CT 1 YEAR LATER

uroepithelial tumors51
UROEPITHELIAL TUMORS
  • BERGMAN SIGN

(RETROGRADE PYELOGRAM)

  • GOBLET SIGN
        • (EXCRETORY UROGRAM)
hematuria 52 year old man
HEMATURIA 52-YEAR-OLD MAN

IVP

IVP 1YEAR LATER

urinary bladder carcinoma
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
uroepithelial tumors68
UROEPITHELIAL TUMORS
  • TUMOR CALCIFICATION
  • TRANSITIONAL CELL CARCINOMA
  • SQUAMOUS CARCINOMA
  • URACHAL CARCINOMA
urachal carcinoma
URACHAL CARCINOMA

SQUAMOUS CARCINOMA

two men with hematuria
TWO MEN WITH HEMATURIA

LITTRE GLANDS

TRANSITIONAL CA

uroepithelial neoplams tnm staging
UROEPITHELIAL NEOPLAMSTNM STAGING
  • T1INVASION OF SUBEPITHELIAL CONNECTIVE TISSUE
  • T2INVASION OF MUSCULARIS
  • T3INVASION THRU MUSCULARIS INTO
      • PERIPELVIC FAT OR KIDNEY PARENCHYMA BY PELVIC LESION
      • INVASION OF PERIURETERIC FAT BY URETERAL LESION
  • T4INVASION INTO PERINEPHRIC FAT OR ADJACENT ORGANS
  • N
  • M
uroepithelial neoplams tnm staging76
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
  • NFALSE POSITIVE AND FALSE NEGATIVE LYMPH NODES
        • LARGE NODES WITHOUT TUMOR AND SMALL NODES WITH TUMOR
invasion of the renal vein
INVASION OF THE RENAL VEIN
  • RENAL CELL CARCINOMA
  • RENAL PELVIS TRANSITIONAL CELL CA
  • ANGIOMYOLIPOMA
hematuria 57 m
HEMATURIA 57/M

IVP & CT

9 MONTHS LATER

INITIAL CT

d d of a filling defect collecting system or ureter
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
detection of stones
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
blood clot diagnosis of hematomas
BLOOD CLOTDIAGNOSIS 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
crossing blood vessels
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
ureteritis 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
urinary tract infection fungal infection
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 of bladder
MALAKOPLAKIA OF BLADDER

MICHAELIS-GUTMANN BODIES

malakoplakia
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 excretory urogram and retrograde pyelogram
PAPILLARY NECROSISEXCRETORY 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

uroepithelial tumors109
UROEPITHELIAL TUMORS
  • RETROGRADE PYELOGRAM
urethral pseudodiverticuli
URETHRAL PSEUDODIVERTICULI

RISK OF MALIGNANCY

ureteral pseudodiverticuli
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
uroepithelial tumors115
UROEPITHELIAL TUMORS
  • EXCRETORY UROGRAM
excretory urogram renal pelvis
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 urogram ureter
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 tumors118
UROEPITHELIAL TUMORS
  • COMPUTED TOMOGRAPHY
computed tomography
COMPUTED TOMOGRAPHY
  • SCANNING SEQUENCES
        • UNENHANCED
        • CORTICOMEDULLARY PHASE
        • NEPHROGRAPHIC PHASE
        • DELAYED
          • OPACIFY COLLECTING SYSTEM, URETER AND BLADDER
  • APPROPRIATE COLLIMATION
computed tomography120
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
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
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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