DOI:10.2214/AJR.07.3649
AJR 2008; 191:416-422
© American Roentgen Ray Society
Transitional Cell Neoplasm of the Upper Urinary Tract: Evaluation with MDCT
Satomi Kawamoto1,
Karen M. Horton1 and
Elliot K. Fishman1
1 All authors: The Russell H. Morgan Department of Radiology and Radiological
Science and Johns Hopkins Hospital, 601 N Caroline St., Baltimore, MD
21287.
Received January 7, 2008;
accepted after revision February 20, 2008.
Address correspondence to S. Kawamoto
(skawamo1{at}jhmi.edu).
CME
This article is available for CME credit. See
www.arrs.org
for more information.
Abstract
OBJECTIVE. MDCT has become a valuable tool with high sensitivity for
detecting transitional cell carcinoma of the upper urinary tract.
CONCLUSION. In this article, we discuss and illustrate the spectrum
of the appearances of transitional cell neoplasm of the upper urinary tract on
16- and 64-MDCT with multiplanar reformation and 3D imaging.
Keywords: MDCT • transitional cell neoplasm • upper urinary tract
Introduction
Upper urinary tract transitional cell carcinoma (TCC) accounts for
approximately 5% of all urothelial neoplasms
[1]. Most upper tract TCCs
occur in adults; patients may present with hematuria, flank pain, or sometimes
without any specific clinical findings.
Assessment of the entire urothelium is essential before treatment because
of the multicentric nature of TCC. Unlike bladder TCC, for which diagnosis is
usually made at cystoscopy, imaging plays an important role in assessment of
upper urinary tract TCC. MDCT has become a valuable tool for the evaluation of
upper urinary tract TCCs and has high sensitivity in detecting these lesions
[2–4].
The objective of this article is to discuss and illustrate the spectrum of the
appearance of transitional cell neoplasms of the upper urinary tract on 16-
and 64-MDCT with multiplanar reformation (MPR) and 3D imaging. MDCT findings
that may help to determine tumor staging are also discussed.
CT Technique
CT was performed with MDCT scanners, including a Sensation 16- or 64-MDCT
scanner (Siemens Medical Solutions). Detector collimation settings of 16
x 0.75 mm or 64 x 0.6 mm were used. The data were reconstructed to
0.75-mm slice thickness at 0.5-mm intervals for MPR and 3D imaging. For
diagnostic reading, 3-mm slice thickness and a 3-mm reconstruction interval
were used. Scanning parameters include 120 kV and 150–200 mAs. For MPR
and 3D rendering, image data were reconstructed with and reviewed on a
workstation (Leonardo, Siemens Medical Solutions) using interactive MPR and
3D-rendering techniques, including maximum intensity projection and volume
rendering. To detect a filling defect in the opacified renal collecting system
and ureter on excretory phase images, wide window settings similar to the bone
window setting are required (Figs.
1B and
2C).
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Fig. 1B —Papillary transitional cell neoplasm of low malignant
potential. Excretory phase axial (B) and anterior volume-rendered
(C) images show small mass (arrow) seen as filling defect.
Ureteroscopy showed small approximately 0.5-cm papillary-appearing lesion in
renal pelvis anteriorly. Pathologically, this was papillary transitional cell
neoplasm of low malignant potential.
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Fig. 2C —Transitional cell carcinoma of right renal pelvis. Patient
has history of hematuria and was found to have transitional cell carcinoma of
bladder and right renal pelvis. Excretory phase axial image shows small
filling defect in right upper pole renal calyx (arrow).
Pathologically, this was noninvasive papillary transitional cell carcinoma
(pTa).
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Our MDCT protocol typically included unenhanced, corticomedullary, and
excretory phase scanning. After fasting for at least 2–3 hours, each
patient ingested 750–1,000 mL of water. Initially, unenhanced images are
obtained from above the kidneys through the symphysis pubis. We injected
100–120 mL of iohexol (Omnipaque 350, GE Healthcare) through a
peripheral venous line at 3–4 mL/s. We typically use a delay of
25–30 seconds for the corticomedullary phase and 4–5 minutes for
excretory phase imaging from the start of an IV contrast material injection.
Typically, scanning through the kidneys for the corticomedullary phase and
scanning through the abdomen and pelvis for the excretory phase are performed.
IV saline infusion was not used in our protocol.
Variable techniques have been developed in MDCT urography, but there is
compromise between the best possible image quality and reasonably low
radiation exposure [5]. In many
institutions, a nephrographic phase is also obtained for evaluation of the
renal parenchyma. For evaluation of the collecting system and the ureter on
the excretory phase, optimal opacification and distention are essential. These
techniques include abdominal compression
[2,
6], using the combination of
prone and supine positioning
[6–8],
IV saline infusion [7], oral
administration of water, IV furosemide injection, longer delay of imaging
acquisition [2], and a
split-bolus technique [8].
CT Appearance of TCC of the Upper Urinary Tract
TCC of the upper urinary tract has three general CT appearances: a focal
intraluminal mass, urothelial wall thickening with luminal narrowing, and an
infiltrating mass [9]. On CT,
TCC is often seen as a soft-tissue-attenuation mass in the renal collecting
system [9] (Figs.
1A,
1B,
1C,
2A,
2B,
2C,
3A,
3B,
3C,
4,
5A,
5B, and
5C). Caoili et al.
[2] reported MDCT urography
detected 24 of 27 (89%) upper tract urothelial neoplasms retrospectively; 10
lesions were seen as a mass and 14 lesions were seen as circumferential
urothelial wall thickening. Among these 10 masses, five masses were smaller
than 5 mm in maximal diameter
[2]. The attenuation of TCC is
typically lower than that of urinary calculi, except indinavir stones
[10]. TCC enhances after
administration of IV contrast material (Figs.
1A,
1B,
1C,
2A,
2B,
2C,
3A,
3B,
3C,
4,
5A,
5B, and
5C), which can help to
differentiate TCC from stone or clot
[10]. Uncommonly, punctate,
linear, or granular calcifications may be seen in TCCs in the upper urinary
tract (Fig. 4).
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Fig. 1C —Papillary transitional cell neoplasm of low malignant
potential. Excretory phase axial (B) and anterior volume-rendered
(C) images show small mass (arrow) seen as filling defect.
Ureteroscopy showed small approximately 0.5-cm papillary-appearing lesion in
renal pelvis anteriorly. Pathologically, this was papillary transitional cell
neoplasm of low malignant potential.
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Fig. 2A —Transitional cell carcinoma of right renal pelvis. Patient
has history of hematuria and was found to have transitional cell carcinoma of
bladder and right renal pelvis. Corticomedullary phase axial (A) and
oblique coronal (B) images show enhancing soft-tissue mass in right
upper pole renal calyx (arrows).
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Fig. 2B —Transitional cell carcinoma of right renal pelvis. Patient
has history of hematuria and was found to have transitional cell carcinoma of
bladder and right renal pelvis. Corticomedullary phase axial (A) and
oblique coronal (B) images show enhancing soft-tissue mass in right
upper pole renal calyx (arrows).
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Fig. 3A —Transitional cell carcinoma of left renal pelvis. Unenhanced
axial (A) and corticomedullary phase oblique coronal (B) images
show soft-tissue mass in lower portion of left renal pelvis and lower pole
calyx (arrow) with punctuate calcification (arrowhead,
A). Note obliteration of peripelvic fat. No clear border between mass
and renal parenchyma is seen.
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Fig. 3B —Transitional cell carcinoma of left renal pelvis. Unenhanced
axial (A) and corticomedullary phase oblique coronal (B) images
show soft-tissue mass in lower portion of left renal pelvis and lower pole
calyx (arrow) with punctuate calcification (arrowhead,
A). Note obliteration of peripelvic fat. No clear border between mass
and renal parenchyma is seen.
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Fig. 3C —Transitional cell carcinoma of left renal pelvis. Excretory
phase oblique coronal image shows hypoattenuating mass in lower pole calyx
involving renal parenchyma (arrows). Pathologically, this was
high-grade invasive transitional cell carcinoma infiltrating into renal
parenchyma (stage pT3).
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Fig. 4 —Multifocal transitional cell carcinoma after
cystoprostatectomy for bladder cancer. Corticomedullary phase coronal image
shows multifocal enhancing masses in renal pelvis and calyces of bilateral
kidneys (white arrows). Enhancing mass is also present in proximal
left ureter (black arrow). Pathologically, masses were high-grade
papillary transitional cell carcinoma with widespread involvement of ureter
and renal pelvis on both sides with invasion into renal parenchyma bilaterally
(stage pT3).
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Fig. 5A —Transitional cell carcinoma of right ureter. CT was performed
for evaluation for aortic aneurysm. Corticomedullary phase axial (A),
oblique sagittal (B), and oblique coronal (C) images show
enhancing soft-tissue mass involving distal right ureter (arrows,
A and B). Note right hydronephrosis and hydroureter with
decreased enhancement of right kidney. There is additional small focus of
enhancing soft tissue in proximal right ureter (arrowhead, B
and C). Pathologically, distal ureteral lesion was high-grade
transitional cell carcinoma invading muscularis (stage pT2). Proximal ureteral
lesion was high-grade noninvasive papillary transitional cell carcinoma (stage
pTa).
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Fig. 5B —Transitional cell carcinoma of right ureter. CT was performed
for evaluation for aortic aneurysm. Corticomedullary phase axial (A),
oblique sagittal (B), and oblique coronal (C) images show
enhancing soft-tissue mass involving distal right ureter (arrows,
A and B). Note right hydronephrosis and hydroureter with
decreased enhancement of right kidney. There is additional small focus of
enhancing soft tissue in proximal right ureter (arrowhead, B
and C). Pathologically, distal ureteral lesion was high-grade
transitional cell carcinoma invading muscularis (stage pT2). Proximal ureteral
lesion was high-grade noninvasive papillary transitional cell carcinoma (stage
pTa).
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Fig. 5C —Transitional cell carcinoma of right ureter. CT was performed
for evaluation for aortic aneurysm. Corticomedullary phase axial (A),
oblique sagittal (B), and oblique coronal (C) images show
enhancing soft-tissue mass involving distal right ureter (arrows,
A and B). Note right hydronephrosis and hydroureter with
decreased enhancement of right kidney. There is additional small focus of
enhancing soft tissue in proximal right ureter (arrowhead, B
and C). Pathologically, distal ureteral lesion was high-grade
transitional cell carcinoma invading muscularis (stage pT2). Proximal ureteral
lesion was high-grade noninvasive papillary transitional cell carcinoma (stage
pTa).
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TCC may appear as thickening of the wall of the renal collecting system or
ureter (Figs. 6A,
6B,
6C,
7A,
7B,
7C,
8A,
8B,
9A, and
9B). The thickening is usually
symmetric [2,
9] but may be eccentric
[9] and is often associated
with circumferential narrowing of the lumen. The thickened wall may enhance
after IV contrast administration (Figs.
6A,
6B,
6C,
7A,
7B,
7C,
8A,
8B,
9A, and
9B), which may help detection
and assessment of the extension of the tumor. Thickening of the renal pelvic
wall can also be seen in inflammation related to infection, nephrolithiasis,
and hemorrhage, and after intervention such as stent placement or surgery.
When distinction from urothelial tumor is difficult, further evaluation with
retrograde pyelography, ureteroscopy, or biopsy is required.
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Fig. 6A —Transitional cell carcinoma of right renal pelvis.
Corticomedullary phase axial (A) and coronal (B) images show
enhancing eccentric wall thickening in right renal pelvis that extends into
calyx in mid pole (arrows). Note minimally decreased parenchymal
enhancement in anterior aspect of right kidney (arrowheads,
A).
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Fig. 6B —Transitional cell carcinoma of right renal pelvis.
Corticomedullary phase axial (A) and coronal (B) images show
enhancing eccentric wall thickening in right renal pelvis that extends into
calyx in mid pole (arrows). Note minimally decreased parenchymal
enhancement in anterior aspect of right kidney (arrowheads,
A).
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Fig. 6C —Transitional cell carcinoma of right renal pelvis. Excretory
phase coronal image shows eccentric wall thickening of right renal pelvis and
filling defect of mid pole calyx (arrows). Pathologically, this was
high-grade papillary transitional cell carcinoma with focal invasion into
renal parenchyma (stage pT3). Patient also had thickening of right distal
ureter extending into bladder (not shown), which was noninvasive high-grade
papillary transitional cell carcinoma.
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Fig. 7A —Transitional cell carcinoma with squamous differentiation of
left renal pelvis. Corticomedullary phase axial (A) and oblique coronal
(B) images show thickening of left renal pelvis with ill-defined
enhancing soft-tissue mass extending into lower pole calices (white
arrows). Note focally decreased contrast enhancement in renal parenchyma
(arrowheads, B) and ill-defined left paraaortic lymph node
(black arrow, B).
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Fig. 7B —Transitional cell carcinoma with squamous differentiation of
left renal pelvis. Corticomedullary phase axial (A) and oblique coronal
(B) images show thickening of left renal pelvis with ill-defined
enhancing soft-tissue mass extending into lower pole calices (white
arrows). Note focally decreased contrast enhancement in renal parenchyma
(arrowheads, B) and ill-defined left paraaortic lymph node
(black arrow, B).
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Fig. 7C —Transitional cell carcinoma with squamous differentiation of
left renal pelvis. Excretory phase coronal image shows ill-defined hypodense
mass and obliteration of lower pole calices. Pathologically, this was
high-grade transitional cell carcinoma with squamous differentiation invading
renal parenchyma (stage pT3). There was metastasis in regional lymph
nodes.
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Fig. 8A —Papillary transitional cell neoplasm of low malignant
potential in right ureter. Corticomedullary phase coronal image shows
enhancing lesion in right ureter (arrows), proximal hydronephrosis,
and hydroureter. Note also parapelvic cyst of left kidney. Contrast
enhancement of right kidney is decreased compared with left kidney.
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Fig. 8B —Papillary transitional cell neoplasm of low malignant
potential in right ureter. Excretory phase axial image shows enhancement and
eccentric thickening in right ureter (arrow), which is not yet
opacified. Pathologically, this was papillary transitional cell neoplasm (2.6
cm) of right ureter with low malignant potential.
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Fig. 9A —Flat transitional cell carcinoma in situ involving left
ureter after radical cystoprostatectomy for bladder cancer. Patient underwent
neobladder reconstruction 9 years previously and developed left
hydronephrosis. Patient then underwent left percutaneous nephrostomy tube
placement. Excretory phase axial (A) and oblique coronal (B)
images show diffuse thickening and periureteric stranding of left ureter
(arrows). Excreted contrast material is seen in normal right ureter
(arrowhead, A). Periureteric stranding is possibly related to
percutaneous nephrostomy tube and prior biopsy. Pathologically, this was flat
transitional cell carcinoma in situ involving approximately two thirds of
distal left ureter (stage pTis).
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Fig. 9B —Flat transitional cell carcinoma in situ involving left
ureter after radical cystoprostatectomy for bladder cancer. Patient underwent
neobladder reconstruction 9 years previously and developed left
hydronephrosis. Patient then underwent left percutaneous nephrostomy tube
placement. Excretory phase axial (A) and oblique coronal (B)
images show diffuse thickening and periureteric stranding of left ureter
(arrows). Excreted contrast material is seen in normal right ureter
(arrowhead, A). Periureteric stranding is possibly related to
percutaneous nephrostomy tube and prior biopsy. Pathologically, this was flat
transitional cell carcinoma in situ involving approximately two thirds of
distal left ureter (stage pTis).
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TCC may present as a locally aggressive infiltrative renal mass
[9,
11] (Figs.
10A,
10B,
11A,
11B, and
11C). Renal parenchymal
infiltration can be suggested by a hypoenhancing mass involving the renal
parenchyma or distortion of the normal renal architecture with heterogeneous
attenuation [12]. The mass
originates from the central region of the kidney and may expand the kidney but
often preserves the renal contour
[11]. Renal sinus fat may be
obliterated by soft-tissue-density tumor
[10–12].
The tumor may have a necrotic component
[10]. When TCC presents as a
large infiltrating renal tumor, it may simulate other tumors such as renal
cell carcinoma, lymphoma, or metastasis
[11]. Acute bacterial
pyelonephritis can also be seen as an infiltrative renal lesion, but most
cases are diagnosed clinically
[11]. In some rare cases,
renal cell carcinoma may invade the renal pelvis and simulate TCC.
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Fig. 10A —Transitional cell carcinoma of left renal pelvis in patient
with history of bladder cancer. Corticomedullary phase axial (A) and
excretory phase coronal (B) images show large mass filling left renal
pelvis and infiltrating renal parenchyma in lower pole (arrows).
Ureteroscopy showed large mass in left renal pelvis and infundibular stenosis
in lower pole due to mass. Biopsy showed transitional cell carcinoma.
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Fig. 10B —Transitional cell carcinoma of left renal pelvis in patient
with history of bladder cancer. Corticomedullary phase axial (A) and
excretory phase coronal (B) images show large mass filling left renal
pelvis and infiltrating renal parenchyma in lower pole (arrows).
Ureteroscopy showed large mass in left renal pelvis and infundibular stenosis
in lower pole due to mass. Biopsy showed transitional cell carcinoma.
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Fig. 11A —Transitional cell carcinoma with squamous differentiation.
Corticomedullary phase axial (A) and oblique coronal (B) images
show large infiltrating mass in right renal hilum causing hydronephrosis. Note
hypodense retroperitoneal adenopathy (arrowhead, A). Mass
infiltrates renal parenchyma and encases right renal arteries
(arrows).
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Fig. 11B —Transitional cell carcinoma with squamous differentiation.
Corticomedullary phase axial (A) and oblique coronal (B) images
show large infiltrating mass in right renal hilum causing hydronephrosis. Note
hypodense retroperitoneal adenopathy (arrowhead, A). Mass
infiltrates renal parenchyma and encases right renal arteries
(arrows).
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Fig. 11C —Transitional cell carcinoma with squamous differentiation.
Excretory phase coronal image shows marked right hydronephrosis due to
hypodense right renal hilar mass (arrows). Pathologically, this was
high-grade transitional cell carcinoma with squamous differentiation. Tumor
invaded periureteric fat and peripelvic fat and renal parenchyma. There was
metastasis in regional lymph node.
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When TCC is multifocal, multiple areas of wall thickening or masses are
seen on CT (Figs. 4,
5A,
5B, and
5C). Hydronephrosis and
hydroureter are commonly associated with upper tract TCC. With urinary
obstruction, there may be decreased perfusion to the involved kidney and
delayed excretion of contrast material from the involved kidney
[10] (Figs.
5A,
5B,
5C,
8A,
8B,
11A,
11B, and
11C). In such cases, tumors
may be seen as enhancing soft-tissue masses partially or entirely surrounded
by a fluid-filled collecting system (Fig.
4). Extension of tumors and location of the tumor relative to the
kidney and adjacent organs are well shown on MPR and 3D images.
Recent studies have reported that the sensitivity of MDCT with a dedicated
protocol for detection of upper tract TCC is 89–100%
[2–4].
However, small or early-stage tumors may be difficult to detect on MDCT (Figs.
12A and
12B). In the study by Caoili
et al. [2], three lesions could
not be detected on MDCT urography among 27 tumors, including two tumors that
were carcinoma in situ [2].
Further experience with MDCT will be necessary to determine the accuracy of
MDCT for the detection of upper tract TCC.
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Fig. 12A —Flat in situ transitional cell carcinoma in left renal pelvis
after cystectomy for bladder carcinoma. Ureteroscopy did not show any frank
filling defect or mucosal lesion; however, brush biopsy specimen from left
renal pelvis showed high-grade transitional cell carcinoma. Corticomedullary
phase coronal (A) and excretory phase coronal (B) images show no
obvious abnormalities in left renal pelvis on soft-tissue or wide window
setting despite careful evaluation with scrolling axial and multiplanar
reformation images. Patient underwent left laparoscopic nephroureterectomy.
Pathology found multifocal flat in situ transitional cell carcinoma involving
left renal pelvis.
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Fig. 12B —Flat in situ transitional cell carcinoma in left renal pelvis
after cystectomy for bladder carcinoma. Ureteroscopy did not show any frank
filling defect or mucosal lesion; however, brush biopsy specimen from left
renal pelvis showed high-grade transitional cell carcinoma. Corticomedullary
phase coronal (A) and excretory phase coronal (B) images show no
obvious abnormalities in left renal pelvis on soft-tissue or wide window
setting despite careful evaluation with scrolling axial and multiplanar
reformation images. Patient underwent left laparoscopic nephroureterectomy.
Pathology found multifocal flat in situ transitional cell carcinoma involving
left renal pelvis.
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Staging of Upper Tract TCC
Staging of upper tract TCC has been valuable in directing treatment and
predicting prognosis. Unfortunately, CT or any other imaging technique is not
accurate for differentiating Ta, T1, and T2 tumors
[9]. A more clinically
pertinent question, however, is the ability to distinguish early-stage (T1 and
T2) tumors from advanced-stage (T3 and T4) tumors
[13]. By TNM classification
designated by the American Joint Committee on Cancer (AJCC), stage T3 tumor
extends beyond the muscularis into the peripelvic or periureteric fat or the
renal parenchyma, and T4 tumors invade through the kidney into perinephric fat
or adjacent organs. Fritz et al.
[4] reported that MDCT was
accurate (87.8%) in predicting pathologic TNM stage (T0a–T2 vs
T3–T4) in 36 of 41 upper urinary tract TCC
[4].
Ta, T1, and T2 tumors usually present as discrete renal pelvic masses with
normal peripelvic fat and appear separated from the renal parenchyma by either
renal sinus fat or excreted contrast material (Figs.
2A,
2B, and
2C) or present as focal or
diffuse thickening of the calyx, the renal pelvis, or the ureter
[14] (Figs.
5A,
5B, and
5C). Stage T3 disease is
diagnosed when tumor infiltrates the renal parenchyma or the peripelvic fat.
As the tumor extends into the renal parenchyma, the peripelvic fat is
obliterated by soft-tissue density
[15] (Figs.
7A,
7B, and
7C). However, tumor without
visible signs of infiltration on CT may lead to understaging of TCC, and
increased heterogeneous peripelvic or periureteral attenuation due to
superimposed infection, hemorrhage, or inflammation may lead to overstaging of
TCC [4,
12,
15] (Figs.
9A and
9B). Focal delay of the
cortical nephrogram is suggestive of parenchyma invasion (Figs.
6A,
6B,
6C,
7A,
7B, and
7C); however, superimposed
pyelonephritis, renal vascular, or caliceal obstruction may cause a
false-positive interpretation of parenchymal invasion
[12]. Metastasis to lymph
nodes (Figs. 7A,
7B,
7C,
11A,
11B, and
11C) and other organs, such as
bone or lung, can also be detected on CT. Microscopic nodal involvement has
been the weak point of CT staging.
Conclusion
High-resolution images obtained with thin-section MDCT can play an
increasing role in the accurate detection and assessment of the upper urinary
tract TCC. Local extension of tumors and location of the tumor relative to the
kidney and adjacent organs are well shown on MPR and 3D images. However, small
or early-stage tumors may be difficult to detect on MDCT. Further experience
with MDCT will determine the accuracy of MDCT for the detection and staging of
upper tract TCC.
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Abstract
Introduction
