UROEPITHELIAL TUMORS - Stritch School of Medicine
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Transcript UROEPITHELIAL TUMORS - Stritch School of Medicine
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