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
IVP 1YEAR LATER
TWO RETROGRADES
INITIAL IVP
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
CT
IVP
RETROGRADE
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
HEMATURIA
70/M
IVP
CT 1 YEAR LATER
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 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 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
IVP & CT
9 MONTHS LATER
INITIAL CT
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