Imaging in Carcinoma
Urinary Bladder
Trainee
Capt Maqsood Ashraf
Supervisor
Col Abdul Qayyum
Classified Radiologist,
CMH Rwp
Aim
• To see various imaging modalities used for
diagnosis and surveillance of bladder cancer
• To see imaging features and differentials of
bladder masses
Patient’s Particulars
• Name - ABC
• Sex - Male
• Age - 70 yrs
• Resident of - Multan
• DOP - 04 Dec 2007
Presenting Complaints
• Painless Hematuria off & on – 04 months
• Occasionally dysuria
• Frequency 02 months
• Weight loss
• Urinary retention – 01 day
History of Present Illness
• Painless hematuria with clots
• Occasional dysuria
• Frequency
• Progressive weight loss
• Acute Retention
• Past History
NAD
• Family History
• Personal History – Farmer
Smoker – 30 yrs
General Physical Examination
• Pulse - 80 bpm
• BP - 120/ 70 mm Hg
• Temperature - 98 °F
• Respiratory rate - 18 per minute
Other signs
• Pallor ++
• Cyanosis
• Clubbing -ve
• Jaundice
• Dehydration
• Lymph nodes - Not palpable
• JVP - Not raised
Systemic Examination
• GIT
• CVS
NAD
• CNS
• Respiratory
Investigations
• Blood CP – Hb 10 g/dL
• Urine RE – Numerous RBCs
• Urine C/S – Negative
• CXR – Normal
Provisional Diagnosis
• Mass Urinary Bladder
USG Abdomen/ Pelvis
MASS
UB
RK LK
CT Scan Pelvis
Cystoscopy
• Debulking of Tumor to relieve acute urinary
retention – Jan 2008
Histopathology
• Muscle invasive High Grade TCC Urinary
Bladder
Final Diagnosis
• Muscle Invasive (T2) high grade Transitional
Cell Carcinoma (TCC) Urinary Bladder
Management
• Refusal for radical cystectomy
• Referral to Oncologist for chemoradiotherapy
Urinary Bladder Anatomy
Introduction
• 4th common malignancy in males and 8 th most
common cancer in females 1
• Three times more common in men than women 1
• Second most prevalent male cancer 2
• Affects adults from 50 – 69 yrs
• 95% uroepithelial, 4% non – epithelial
(leiomysarcoma, rhabdomyosarcoma below 6
yrs), 1% rarities (carcinoids, mets)
• 92% TCC, 6% SCC, 2% Adenocarcinoma
1 Boring et al, 1995. 2 Feldman et al, 1996
Transitional Cell Carcinoma
• Bladder TCC is 50 times more common than renal
pelvic tumors
• Multiplicity – both synchronous and metachronous
tumors; 3 – 4% develop UUT TCC in 5 yrs
• Broad classification
– Exophytic papillary (85%) – broad based, pedunculated
– Nonpapillary, non infiltrating
– Infiltrating, less common, higher grade
– Ca in situ (CIS)
• According to degree of differentiation TCC may be: -
• Low grade - well differentiated
• High grade - poorly differentiated or anaplastic
Risk Factors
• Gender – 3 times more common in males
• Race & ethnicity – Whites are twice more likely, Asians have lowest rates
• Age
• Tobacco smoking – 2 fold risk
• Occupational exposures – dye (aromatic amines), leather, rubber, textile,
painting industries
• Chronic bladder irritation – infections, stones, congenital variations
• Schistosomiasis
• Previous history of bladder cancer – recurrence
• Genetic mutations
• Chemotherapy & irradiation – cyclophosphomide
• Low fluid consumption
• Diet – low consumption of vit E and fruits
Incidence and Mortality
• 4.8 percent of incident reported to the Ohio
Cancer Incidence Surveillance System
(OCISS) from 1999 to 2003, which is
underestimate, since reporting was complete
only 91%*
• The 1999-2003 Ohio age-adjusted mortality
rate for urinary bladder cancer of 5.0 deaths
per 100,000 residents*
*
Source: Ohio Cancer Incidence Surveillance System, Ohio Department of Health, 2006
Clinical Presentation
• Asymptomatic
• Painless hematuria
• Irritative voiding; esp in CIS
− Frequency
− Urgency
− Dysuria
− Nocturia
• Weight loss
• Abdominal/ flank pain
• Variable in advanced cases
Investigations
• Imaging
− Plain Radiography
− IVU
− Ultrasonography
− CT
− MRI
• Cystoscopy
• Bone Scan – skeletal metastasis
• Urine Culture/ other urine tests (NMP - 22)
• Cytology
Plain films
• Non specific findings, not initial investigation
• Surface calcification 1% – punctate, coarse, linear or
focal, in TCC or Squamous cell carcinoma
• Intrinsic calcification seen in adenocarcinoma, or unusual
type
• Enlarged kidneys, or renal calcifications in UT TCC
• Important role - Osseous expansive metastasis
Plain Radiography
IntraVenous Urography
• To examine UUT for associated urothelial tumors
• Irregular filling defect or asymmetrical wall thickening
• Ureteric obstruction in invasive tumors
IVU
Normal
IVU
A filling defect with a papillary configuration along the right bladder wall (arrow).
IVU
Anteroposterior view of the bladder obtained during intravenous urography shows an irregular lobulated
filling defect at the base of the bladder.
IVU
Small lobulated mass
IVU
Multiple irregular filling defects in lateral wall and base. Bilateral ureteric
obstruction more on Rt
IVU
IVU
Differentials of filling defects
1. Bladder tumor 10. Lymphoma
2. Clot 11. Metastasis
3. Fungal ball 12. Mesenchymal tumor
4. Lucent stones (urates) 13. Prostatic enlargement
5. Air bubble 14. Simple/ Ectopic ureterocele
6. Instrument (Foley) 15. Endometriosis
7. Amyloidosis 16. Intraluminal hematoma
8. Papilloma 17. Malacoplakia
9. Polyp 18. Cystitis
IVU
B
A
Ureteric Calculi
A B
Excretory urogram showing large stone Plain radiograph of pelvis showing
(arrows) in diverticulum (arrowhead) laminated stone and multiple small calculi
BPH
Prostatic Cancer
IVU
B
A
IVU
B
A
Cystitis
Ultrasonography
• Initial investigation
• Intermediate echogenecity, echogenic foci on surface due calcific
encrustration
• Sessile, papillary, infiltrating bladder walls
• Associated Hydronephrosis
• Limitations
− Non specific
− Small sessile lesions are easier to miss
− Calculi may be confused with high grade echogenic TCC
− Can’t depict undilated ureters
− Inaccurate in staging and detecting pelvic lymph nodes
Ultrasonography
Normal
Ultrasonography
Mass
Stone
RK LK
Ultrasonography
Polypoidal bladder carcinoma
Ultrasonography
Sessile deposits of carcinoma
Ultrasonography
Ultrasonography
Ultrasonography
Computed Tomography
• Detection and staging
• Unenhanced – hyperattenuating relative to urine
• Mild to moderate enhancement – hypoattenuating
relative to opacified urine
• Limitations
− Limited value in staging low grade tumors
− 55 – 64% correct TNM staging compared to
surgical findings
CT
Normal
CT
CT
CT
A B
CT
CT
A B
MRI
• Advantages – high intrinsic soft tissue contrast,
multiplanar, non toxic renally excreted contrasts
• Superior to CT in detecting invasion of adjacent organs
• Limitations
− Expensive, limited availability
− Can’t depict superficial invasion of UUT TCC
TNM Staging
MRI
A B
MRI
A B
MRI
A B
MRI
A B
MRI
A B
MRI Urography
A B
MRI
A B
MRI
A B
MRI
A B
MRI
A B
CT and MRI
A B
CT and MRI
A B
