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Imaging in Oncology from the

University of Texas M. D. Anderson
Cancer Center
Vikas Kundra 1
Paul M. Silverman
Imaging in the Diagnosis, Staging,
and Follow-Up of Cancer of the
Urinary Bladder

W
e describe the epidemiology, Histology
histology, and imaging features The bladder is lined by a transitional cell
of cancer of the urinary bladder. epithelium that is three to seven cell layers
Included is a review of the staging system used thick. Basal cells are covered by intermediate
for this malignancy. In addition, imaging find- cells, and these are capped by large, flat um-
ings are presented that show the spectrum of brellalike cells. Accordingly, transitional cell
radiographic findings of primary bladder carci- carcinoma accounts for 95% of all bladder
noma and various stages of the disease, as well cancers [3]. Other cell types include squamous
as treatment and surveillance. cell cancer, mixed transitional cell carcinoma,
adenocarcinoma, and undifferentiated tumors.
Epidemiology Rare histologies include lymphoma, carcino-
sarcoma, sarcomas, pheochromocytoma, and
Cancer of the urinary bladder is predomi-
metastasis [3].
nantly a disease of older men. This disease rep-
The patterns of growth are broadly catego-
resents 6% of all malignancies in men, making
rized as papillary or infiltrative. For transi-
it the fourth most common tumor. In women,
tional cell carcinoma, the pattern of growth
bladder carcinoma represents 2% of malignan-
tends to correlate with grade, which ranges
cies, making it the seventh most common tumor
from well-differentiated, grade 1, to poorly
[1]. The incidence increases with age (median
differentiated, grade 3 [4].
age, 69–70 years). Smoking, living in urban ar-
eas, and working in the dye, rubber, or leather
industries increases the risk [2]. In 2001, 39,200 Staging
new cases were predicted in men and 15,100 in Most frequently, cancer of the urinary
women from the United States. In comparison, bladder initially presents as painless hema-
8300 men and 4100 women were estimated to turia. Urine cytology may be performed;
have succumbed to the disease [1]. however, diagnosis usually requires cystos-
The malignancy is found twice as often in copy and biopsy. Bimanual examination is
whites as in African Americans, but the latter used for staging, particularly, to determine
Received March 14, 2002; accepted after revision
tend to have a later stage at diagnosis and a whether adjacent organs are involved. Al-
August 20, 2002. poorer prognosis at all stages. In whites, the though the Jewett-Marshall-Strong staging
1
Both authors: Division of Diagnostic Imaging, The University overall 5-year survival rate is 82% and 95% system [5] is still used, the TNM staging sys-
of Texas M. D. Anderson Cancer Center, 1515 Holcombe for localized disease, but this rate falls to 50% tem [6] is favored (Table 1 and Fig. 1). For
Blvd., Box 57, Houston, TX 77030. Address correspondence for regional disease and 6% when distant me- both, the depth of invasion into the bladder
to V. Kundra.
tastases are found. In comparison, the rates are and the involvement of adjacent and distant
AJR 2003;180:1045–1054
64%, 87%, 41%, and 0%, respectively, for Af- sites are central elements.
0361–803X/03/1804–1045 rican Americans. However, survival rates have To understand the staging systems, one
© American Roentgen Ray Society been increasing since the mid 1970s [1]. must first be aware of bladder anatomy. The

AJR:180, April 2003 1045

 Kundra and Silverman

bladder wall consists of four layers: mucosa

TABLE 1 TNM Classification for the Staging of Cancer of the Urinary Bladder
or epithelium, lamina propria or subepithe-
Stage Characteristics of TNM Classification System [6] lial connective tissue, muscle layer, and se-
Primary tumor (T) rosa or the peritoneal covering found at the
Tis Carcinoma in situ: “flat tumor”
dome [7]. A special case is cancer in a diver-
ticulum, in which lesions tend to be of a
Ta Noninvasive papillary carcinoma
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higher grade and escape the bladder wall ear-

T1 Tumor invades subepithelial connective tissue
lier because of the lack of a muscle layer.
T2 Tumor invades muscle Thus, tumors at this location tend to have a
T2a Tumor invades superficial muscle (inner half) greater potential for metastasis and a corre-
T2b Tumor invades deep muscle (outer half) spondingly poorer prognosis. The incidence
T3 Tumor invades perivesical tissue of a neoplasm in a bladder diverticulum is
T3a Tumor invades perivesical tissue microscopically between 0.8% and 13.5% [8, 9].
T3b Tumor invades perivesical tissue macroscopically (extravesical mass) For superficial disease, stages Ta and T1,
T4 Tumor invades any of the following adjacent organs: prostate, uterus, vagina, Campbell’s Urology [3] recommends no further
pelvic wall, and abdominal wall staging workup after cystoscopy and biopsy.
T4a Tumor invades prostate, uterus, or vagina For muscle invasive disease, stage T2 and be-
T4b Tumor invades pelvic wall or abdominal wall yond, chest radiography, excretory urography,
Lymph nodes (N)
abdominal and pelvic CT, bone scan, and liver
function tests are recommended. Suspected me-
N0 No regional lymph node metastasis
tastasis is confirmed by fine-needle biopsy [3].
N1 Metastasis in a single lymph node ≤ 2 cm in greatest dimension
N2 Metastasis in a single lymph node > 2 cm but ≤ 5 cm in greatest dimension or
metastasis in multiple lymph nodes, none > 5 cm in greatest dimension Imaging Local Disease
N3 Metastasis in a lymph node > 5 cm in greatest dimension Radiologists may encounter cancer of the
Distant metastasis (M) urinary bladder as a mass found on routine im-
M0 No distant metastasis aging, staging, or follow-up after therapy. In
M1 Distant metastasis the first instance, an incidentally noted mass in
the bladder has a broad differential diagnosis,
including benign (papilloma, hamartoma, lei-
omyoma) or malignant neoplasm, hematoma,
calculus, fungus ball, cystitis cystica, foreign
body, and endometriosis. Imaging characteris-
tics such as enhancement and mobility are
helpful for characterization. For staging, cys-
toscopy and biopsy are used for stages Ta–T3a
disease, confined to the bladder. Cross-sec-
tional imaging is useful at stage T3b or later
stages, after the tumor has escaped beyond the
bladder wall.

Exretory Urography
Because transitional cell carcinoma is a multi-
focal disease, excretory urography may identify
synchronous lesions. A primary tumor may ap-
pear as a small-capacity, thick-walled bladder or
as a focal mass (Figs. 2 and 3). It may also appear
as a filling defect or as a stricture along the course
of the ureters. If severe, obstruction may result in
hydroureteronephrosis and a delayed nephro-
gram. Retrograde pyelograms may also assist in
this search (Fig. 4). However, neither of the two
tests will identify spread outside the bladder.
With the advent of CT excretory urography [10],
both the urothelium and adjoining structures may
be evaluated. However, this examination is still in
the process of being evaluated, as are MR urogra-
Fig. 1.—Drawing shows TNM staging system [6] for cancer of urinary bladder. phy and virtual endoscopy [11, 12].

1046 AJR:180, April 2003

 Imaging of Cancer of the Urinary Bladder

Fig. 2.—Excretory urogram obtained in

77-year-old man with hematuria shows
that low-capacity bladder has circum-
ferential wall thickening and irregular-
ity (arrows), consistent with infiltrating
transitional cell carcinoma.
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Fig. 3.—Postvoid excretory urogram

obtained in 66-year-old man with he-
maturia shows irregular mass in blad-
der outlined by contrast material (white
arrows). Presence of retained contrast
material in left ureter (arrowheads) im-
plies that mass obstructs ureteral ori-
fice. Note sutures (black arrow) from
prior colon anastomosis.
2 3

Sonography Fig. 4.—77-year-old woman with he-

Sonography is not routinely used for stag- maturia. Retrograde ureterogram
shows that transitional cell carcinoma
ing cancer of the urinary bladder. If the tu- presents as segmental stricture
mor is found incidentally, it often appears as (arrow) of ureter, resulting in mild hy-
a polypoid or plaquelike, hypoechoic lesion dronephrosis (white arrowheads).
Mild hydroureter (black arrowhead) is
that may project into the bladder [4]. Calcifi- seen inferior to stricture.
cations or fibrosis produce an increase in
echogenicity. Blood flow can be shown in tu-
mors on Doppler sonography (Fig. 5).

CT
CT is the primary imaging modality for cancer
of the urinary bladder. Optimally, rapid scanning
is performed in the nephrographic phase before
excreted IV contrast material reaches the bladder.
Thus, the enhancing tumor can be visualized
against a background of low-attenuation urine
within the bladder (Fig. 6A). On delayed scan-
ning, the lesion appears as a mural nodule against
a background of high-attenuation contrast mate-
rial within the bladder (Fig. 6B). The mass may
appear plaquelike (Fig. 6) or papillary (Fig. 7).
Calcifications may also be noted (Fig. 8). Moon
et al. [13] have noted that 5% of transitional cell

Fig. 5.—48-year-old man with hematuria.

A, Sonogram obtained in sagittal plane reveals heter-
ogeneous, hypoechoic mass (arrows) at antidepen-
dent aspect of bladder. Anechoic material within
bladder represents urine (arrowhead).
B, Color Doppler sonogram obtained in transverse plane
shows blood flow (arrowhead) within tumor (arrows).
A B

AJR:180, April 2003 1047

 Kundra and Silverman

carcinomas contain calcifications. Calcifications orifice, resulting in hydroureteronephrosis (Fig. (Fig. 12). The tumor is classified as T4 disease
are usually in a nodular or arched configuration 10). With more advanced disease, bilateral hydro- if it invades adjacent organs or structures such
on the surface, whereas 50% of adenocarcinomas nephrosis may be noted (Fig. 11). as the pelvic or abdominal walls (Fig. 13). Inva-
contain fine intratumoral calcifications. Mucinous As with all imaging modalities, the depth of sion may present as tissue within the organ en-
adenocarcinomas such as urachal carcinomas can penetration into the bladder wall is difficult to hancing like cancer of the urinary bladder and
have either pattern. As the tumor grows, circum- discern. Stage T3b disease that escapes the se- as enlargement of the invaded organ.
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ferential wall thickening may also be seen (Fig. rosa often manifests as soft-tissue-attenuation Confounders for CT include biopsy and in-
9). In addition, the mass may invade the ureteral stranding in the low-attenuation perivesical fat flammation, which can mimic a cancer. Radia-

Fig. 6.—65-year-old man with hematuria.

A, CT scan shows enhancing mass along left lateral blad-
der wall (arrow) that is consistent with malignancy.
B, On delayed CT scan, mass is persistent and is out-
lined by high-attenuation contrast material (arrow).

A B

Fig. 7.—65-year-old man with hematuria. CT scan

shows papillary mass (arrow). Enhancement and anti-
dependent location of mass differentiate it from for-
eign body.

Fig. 8.—38-year-old man with urachal cancer. CT scan

shows high-attenuation contrast material within blad-
der that represents calcifications (arrow) on surface
of bladder adenocarcinoma.
7 8

Fig. 9.—61-year-old woman with hematuria. CT scan

shows cancer of urinary bladder presenting as cir-
cumferential wall thickening and irregularity (arrows)
with relative sparing of posterior wall. Enhancing le-
sion causes bilateral hydroureters (arrowheads).

Fig. 10.—CT scan of 93-year-old woman shows that di-

lated right ureter is obstructed by tumor. Note circum-
ferentially enhancing, irregular bladder wall (white
arrowhead). More focal mass at right ureteral orifice
(black arrowhead) causes hydroureter (arrow).
9 10

1048 AJR:180, April 2003

 Imaging of Cancer of the Urinary Bladder

tion therapy results in fibrosis and can result in Calmette-Guérin or formalin can also cause limited to the axial plane is not ideal for visual-
circumferential wall thickening, which can also circumferential bladder wall thickening [14]. izing the dome of the bladder or the base. New
be due to obstruction such as that caused by be- Radiation therapy can additionally result in multidetector CT scanners with thin-slice selec-
nign prostatic hyperplasia (Fig. 14) or stricture stranding of pelvic fat, making it difficult to dis- tion and multiplanar reformatting should aid in
of the urethra. Chemotherapy with systemic cern perivesical invasion. If a delay in scanning the evaluation of these areas (Fig. 16). The ac-
agents such as cyclophosphamide and ifosfa- occurs after IV contrast injection, a ureteral jet curacy of CT for staging has been variously re-
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mide or intravesical agents such as Bacillus can mimic bladder cancer as well (Fig. 15). CT ported as 55–92% [3, 15–21].

Fig. 11.—CT of 76-year-old woman with

urosepsis shows cancer of urinary blad-
der causing bilateral hydronephrosis.
A, CT scan shows that bladder wall
thickening and enhancement (black
arrowhead) are more prominent on
left. Nondependent intravesicle air
(white arrowhead) raises question of
emphysematous cystitis or recent in-
strumentation. Arrows show bladder
cancer causing obstruction and
thereby dilatation of both ureters.
B, CT scan obtained more superiorly
than A reveals bilateral hydroneph-
rosis (arrows).

A B

Fig. 12.—CT scan of 61-year-old man with transitional

cell carcinoma shows fat stranding (arrow) anterior to
bladder, implying invasion of tumor into perivesical fat.

Fig. 13.—61-year-old man with hematuria. CT scan shows

cancer of urinary bladder presenting as enhancing focal
wall thickening. In addition, extravesicle invasion of can-
cer (white arrow) and invasion of cancer into left pelvic
sidewall (black arrow) are present. Air (white arrowhead)
within bladder is associated with instrumentation as
evidenced by Foley catheter (black arrowhead).
12 13

Fig. 14.—77-year-old man with prostate cancer.

A, CT scan shows that in addition to cancer of urinary
bladder, circumferential wall thickening (arrowheads)
can be associated with chemotherapy or radiation
therapy, neurogenic bladder, or obstruction caused,
for example, by benign prostatic hyperplasia.
B, CT scan shows hyperplasia of prostate gland
(arrow) resulting in obstruction and subsequent blad-
der wall thickening.
A B

AJR:180, April 2003 1049

 Kundra and Silverman

Fig. 15.—CT of 60-year-old man with hepatocellular

carcinoma shows ureteral jet mimicking cancer of uri-
nary bladder.
A, CT scan shows apparently enhancing lesion (arrow)
along left bladder wall. Indentation along posterior as-
pect of bladder is due to prostate (arrowhead).
B, Lesion is not seen (arrow) on delayed CT scan. In-
dentation along posterior aspect of bladder is due to
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prostate (arrowhead). Indentation may also resemble

cancer of urinary bladder.

A B

A B C

Fig. 16.—65-year-old man with microhematuria. Reformatted CT can further define bladder tumor.
A, CT scan obtained in axial plane shows mass (arrow) in bladder.
B, CT scan obtained in coronal plane further defines mass (arrow) in bladder.
C, CT scan obtained in sagittal plane better shows involvement of base (arrow) of bladder than do A and B. Arrowhead identifies left seminal vesicle.

A B C

Fig. 17.—75-year-old woman with hematuria. Arrowheads indicate cancer of urinary bladder.
A, T2-weighted fast spin-echo MR image shows that tumor has intermediate signal.
B, T1-weighted MR image shows that mass has intermediate signal.
C, T1-weighted MR image shows that mass enhances after IV gadolinium injection.

1050 AJR:180, April 2003

 Imaging of Cancer of the Urinary Bladder

MR Imaging yet appear to be a consensus in the literature signal if faster sequences such as fast spin-echo
The multiplanar imaging capabilities and that MR imaging is superior to CT. are used. Urine has a high signal (Fig. 17A).
high tissue contrast of MR imaging should As with CT, MR imaging cannot depict the On T1-weighted sequences, the tumor has an
theoretically result in increased accuracy for depth of bladder wall invasion, but it is used for intermediate signal and contrasts with the high
staging compared with CT. However, similar stage T3b disease and beyond (i.e., once the tu- signal in fat. In addition, urine in the bladder has
results have been found, with accuracy rang- mor escapes the bladder wall) [29]. On T2- a lower signal than the tumor (Fig. 17B). T1 se-
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ing from 72% to 96% [15–18, 22–25]. Staging weighted imaging, tumor has an intermediate quences are helpful for evaluating spread into the
is improved with gadolinium enhancement signal, slightly higher than that of the bladder perivesical fat. Cancer of the urinary bladder en-
[22, 24–28]. Nonetheless, there does not as wall. Fat has a low signal but may have a high hances after gadolinium injection (Fig. 17C).

A B

C D

Fig. 18.—65-year-old man with hematuria.

A and B, T1-weighted (A) and gadolinium-enhanced (B) MR images show that tumor (short
black arrows) invades perivesical fat (long black arrow) and seminal vesicles (arrowheads and
short white arrows). Curved arrow shows high signal within bladder lumen. B also shows en-
hancement of tumor (short black arrows) and invasion into adjacent structures (long black ar-
row, arrowheads, and short white arrows).
C and D, T1-weighted (C) and gadolinium-enhanced (D) MR images with fat saturation show in-
filtration of tumor into perivesical fat (long white arrow) and seminal vesicles (arrowheads and
short white arrows). Thickening and enhancement of posterior aspect of bladder is noted (short
black arrows). This tumor grew around seminal vesicles to invade them from periphery
(arrowheads) and grew posteriorly to infiltrate them medially (short white arrows). Curved ar-
row shows high signal in bladder lumen.
E, Multiplanar imaging can assist in visualization of tumor. On this coronal T1-weighted MR im-
age, tumor presents as low-signal thickening at base of bladder (arrowheads). On right, bladder
wall is irregular and infiltration of fat is seen. Low-signal wall is disrupted on right compared
with left, implying invasion into perivesical fat (straight arrows). High signal in bladder (curved
arrow) is from prior injection of contrast material.
E

AJR:180, April 2003 1051

 Kundra and Silverman

Peak enhancement is earlier than that of the blad- Lymphatic Metastasis Hematogenous Metastasis
der wall, which may be helpful if dynamic Cancer of the urinary bladder first spreads to Cancer of the urinary bladder, particularly
imaging is performed. Gadolinium contrast en- the perivesical, obturator, internal and external transitional cell carcinoma, spreads through
hancement can obscure discrimination of tumor iliac, and presacral lymph nodes. The perivesi- the blood stream as well. Favored sites for
invading into the adjacent high-signal fat (Fig. cal nodes are less often involved [30]. Eventu- metastasis include the liver, lungs, skeleton,
18A). Fat-saturated images can be helpful in this ally, common iliac and paraaortic lymph node and adrenal glands [34].
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regard (Fig. 18B). Enhancement with or without metastases are noted. Involvement of juxtare-
fat saturation can show invasion into adjacent or- gional sites is uncommon without spread to re- Treatment
gans (Figs. 18A and 18B). Coronal (Fig. 18E) gional sites, implying that, if found, regional The primary surgical procedure for cancer of
and sagittal planes can also be useful in identify- sites should be scrutinized. Evaluation of juxta- the urinary bladder is resection via cystoscopy,
ing perivesical invasion, particularly at the dome regional areas becomes even more important if which is adequate for early stages. Cystoscopic
and at the base of the bladder. Synchronous or the patient has had a lymph node dissection. surgery is not adequate for more advanced dis-
metachronous lesions in the ureters may also be Both CT and MR imaging are dependent on eases; therefore, chemotherapy, radiation ther-
detected on MR imaging (Fig. 19). Confounders lymph node enlargement to detect metastasis apy, and surgery are used. The first two can
on MR imaging are for the most part the same as (Fig. 20). Those lymph nodes greater than 1 result in findings such as a thickened bladder
those for CT, including recent biopsy, inflamma- cm in size in the short axis are considered sus- wall. In addition, radiation therapy can result in
tion, radiation therapy, and chemotherapy- picious [31]. If needed, involvement can be fat stranding that can mimic the original tumor.
induced changes that mimic tumor. confirmed by percutaneous needle biopsy. Types of surgery may include partial cystectomy,
Confounders include benign hyperplasia, in- total cystectomy, or cystoprostatectomy, often
Imaging of Metastasis fection, or inflammation resulting in lymph with lymph node dissection. Two basic types of
Cancer of the urinary bladder may metas- node enlargement. Potentially, MR imaging urinary diversions are performed. Cutaneous uri-
tasize via the lymphatic system or the vascu- with ultrasmall paramagnetic iron oxide non- nary diversions are either incontinent (Bricker il-
lature. In either case, cross-sectional imaging colloid particles will help differentiate lymph eal loop) or continent (Kock ileal pouch or
modalities are vital for diagnosis. nodes containing metastasis [32, 33]. Indiana pouch). The other type is a neobladder

Fig. 19.—77-year-old woman with hematuria. Contrast enhanced T1–weighted MR image shows
enhancing soft-tissue-attenuation material along medial aspect of right ureter (arrow). Transi-
tional cell carcinoma was seen simultaneously with transitional cell carcinoma in bladder.

A B C
Fig. 20.—CT and MR imaging show cancer of urinary bladder with lymph node metastases.
A, CT scan of 76-year-old man shows enlarged obturator (black arrow) and internal iliac (white arrow) lymph nodes.
B, CT scan (same patient as in A) shows lymph node (black arrow). Tumor invasion into fat (white arrow) is also seen adjacent to anterior bladder wall mass.
C, T1-weighted MR image of 75-year-old man shows enhancing lymph node (arrow) on left at level of bifurcation of common iliac artery.

1052 AJR:180, April 2003

 Imaging of Cancer of the Urinary Bladder
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Fig. 21.—68-year-old man with pelvic pain. CT scan shows recurrence of cancer of Fig. 22.—67-year-old man with pelvic pain. Gadolinium-enhanced T1-weighted ax-
urinary bladder presenting as heterogeneous soft-tissue-attenuation lesion invad- ial MR image with fat saturation shows that recurrence of cancer of urinary bladder
ing right pelvic side wall (white arrows). Presacral soft-tissue thickening (black originating in right pelvic side wall (arrows ) has grown through sciatic notch
arrow) is caused by tumor and prior radiation therapy. Clips (black arrowhead) in (arrowhead).
pelvis are from prior cystectomy. White arrowhead identifies midpelvic scar.

consisting of primarily two procedures: Kock setting of an altered urothelium that has a pro- noma of the urinary bladder: MR imaging using a
pouch or Studer pouch. Because of fewer com- pensity for both synchronous and metachro- double surface coil. AJR 1988;151:107–212
8. Lowe FC, Goldman SM, Oesterling JE. Comput-
plications, a Studer pouch is often favored. This nous tumors. Diagnosis of early-stage disease
erized tomography in the evaluation of transi-
procedure is often performed with a prostatec- is performed primarily via cystoscopy. How- tional cell carcinoma in bladder diverticula.
tomy and a lymph node dissection. Thus, aorto- ever, after the tumor escapes the bladder wall, Urology 1989;34:390–395
caval and inguinal lymph nodes may be the first radiologic methods such as CT and MR imag- 9. Das S, Amar AO. Vesical diverticulum associated
to signify recurrence in these patients. With the ing are critical in evaluating local invasion and with bladder carcinoma: therapeutic implications
urinary diversion procedures, hydroureter and distant metastasis. J Urol 1986;136:1013–1014
mild pelvocaliectasis are often seen early and 10. Chow LC, Sommer FG. Multidetector CT urogra-
phy with abdominal compression and three-di-
may either resolve or remain stable. However, Acknowledgment mensional reconstruction. AJR 2001;177:849–
severe pelvocaliectasis implies obstruction from 855
We thank Brenda J. Sommerville for her
a stricture, stone, or recurrence [35]. 11. Nolte-Ernsting CC, Adam GB, Gunther RW. MR
technical support and for her professional il-
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