Transcript Bladder cancer

Dr Mohamed El Safwany, MD.
 The
student should learn at the end of this
lecture principles of CT in bladder cancer.
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CTU is a term used to describe
high-spatial-resolution imaging of
the urinary tract by using contrast
material administration, a
multidetector CT scanner with thin
collimation and imaging in the
excretory phase .
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Hematuria
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Patients at increased risk for having upper or lower tract
urothelial neoplasms
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Urinary diversion procedures following cystectomy
Hydronephrosis, chronic symptomatic urolithiasis or planning of
percutaneous nephrolithotomy (PCNL)
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Traumatic and iatrogenic uretheral injury, and complex urinary
tract infections.
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2 Phase- single bolus CTU:
Oral hydration (700 ml of water, 30 min )
Low dose diuretic (Furosemide): 0.1mg/kg, 1-3 min, before CM
Single bolus of 100 -[320] IV CM
Arterial phase
Nephrographic phase@ 100 sec
Excretory phase @ 12 min (7-15 min)
1.- Ultrasound is widely used.
2.-Using Furosemide there is an improvement in lithiasis diagnosis.
Furosemide decrease the urine attenuation value (< 500 HU) *.
Lithiasis
Calcium oxalate monohydrate
Calcium oxalate dihidrate
Cystine
Struvite
Uric acid
HU
1645+ 238
1417 + 234
711 + 228
666 + 87
409 + 118
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Bladder cancer tends to show peak enhancement with the
60- second (portal Phase) scanning delay *.
Portal phase CTU offers high accuracy detecting BC:
- Sensitivity: 89%–92% in per lesion analysis
95% in per patient analysis
- Specificity: 88%– 97% in per lesion analysis
91%–93% in per patient analysis
 CTU image review and postprocessing: Using a
workstation and/or a picture archiving and communication
system (PACS): Creation of multiplanar reformatted images and 3D
reconstructed images by using:
- Maximum intensity projection techniques (MIP 5-50mm)
- Volume-rendering (VR 5-50 mm)
-Narrow and wide windows and thin sections with MPR and axial
images review (improve the detection rate for tumors smaller than
5 mm)
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Homogeneous bladder opacification: Voiding the
bladder before examination or mixing bladder contents:
patient rolls over supine- prone on the CT table or walks
around the CT room.
All the excretory system must be included in the exam:
Since the urothelium of the entire urinary system is at risk
of developing cancer.
CTU may allow staging of deeply invasive tumors,
detection of metastases and other extra-genitourinary
pathology.
Background
• Is the most common malignancy of the urinary tract.
• Is a disease of older patients (>65).
• Represents the 6.6% of the total cancers in men and
2.1% in women, with an estimated male-to-female ratio
of 3.8:1*.
Risk factors
• Cigarrete smoking: Smokers have a two to sixfold increased risk of
cancer compared to non-smokers.
• Occupational exposures: Exposition to aromatic amines
(petrochemical, textile, printing industries), hairdressing, firefighting,
truck driving, plumbing…
• Exposures to certains medications: Phenacetin, Cyclophosphamide.
• Others: Arsenic in drinking water, prior pelvic irradiation and lower
urinary tract inflammation (schistosomiasis).
Cell type
•I.- Epithelial tumors:
•Urothelial (transitional cell) cancer
(90%). Is the most common urinary
tract cancer in the United States and
Europe.
• Has a propensity to be multicentric
(30-40% ) with synchronous and
metachronous bladder and upper tract
tumors.
• Squamous cell (5-8 %)
• Adenocarcinoma (2%)
•II.- Non-epithelial tumors:
Leiomyosarcomas, lymphoma: Rare
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Ta: Non invasive
CIS: high- grade flat Urothelial
cancer
T1: Invade lamina propria
T2a and T2b: bladder wall
musculature
T3a and T3b: perivesical space
extension
T4: Adyacent organs or pelvic
sidewall invasion.
GRADE:
Grade 1: Well differentiated:
papillary/
superficial
Grade 2: Poorly differentiated:
infiltrative/Invasive
 Microscopic or gross hematuria, but only
13-28% patients with gross hematuria have
bladder cancer.
 Tumor appearance
 Tumor enhancement
Asymmetric diffuse or focal wall thickening
Male, 75 year-old.
Tumor right bladder wall
Male 70 year old.
Tumor at left UVJ
Focal enhancing masses
Small filling defects
Soft tissue window (W:400, L:40)
Wide windows (W:1990, L:362)
67 year-old man. Previous transurethral BC resection.
CTU: Asymetric enhancing right wall thickening
Cystoscopy: Fybrosis
Flat tumors
 Bladder lesions located at the bladder base
(near prostate and urethra)
 The most problematic group: Patients
have already undergone local treatment for
non-invasive bladder tumors .
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72 year-old man.
CTU: Prostatic hypertrophy and diffuse wall thickening and small polipoid
nodule in the posterior bladder wall
Cystoscopy: BC in small nodule
75 year-old man. Previous transurethral resection
CTU: Small bladder, diffuse wall thickening and small enhancing nodule at
bladder dome
Cystoscopy: BC
T3a or T3b ?
T4
 David
Sutton’s Radiology
 Clark’s Radiographic positioning and
techniques
 Two
students will be selected for
assignment.
 Define
value of VRT in urinary tract
examination ?
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Thank You