Diagnostic Ultrasound - Abdomen and Pelvis

Upper Tract Urothelial Carcinoma
Diagnoses: Urinary Tract
Urothelial Thickening
• Occurs in renal transplant rejection, urinary tract infection,
reflux, chronic obstruction, other malignancies
Pyonephrosis
• Echogenic debris within dilated calyces, signs of infection
Fungus Ball
• Echogenic, avascular, poorly shadowing masses
Sloughed Papilla
• Filling defects in calyces
• Destruction of apex of pyramid → irregular cavitation and
sinus formation between papilla and calyx
Lymphoma
• May also invade renal sinus; usually disseminated disease
Calculus
• Echogenic with posterior shadowing
Other Benign Lesions of Urinary Tract
• Endometriosis, malakoplakia, tuberculosis, fibroepithelial
polyp, xanthogranulomatous pyelonephritis
PATHOLOGY
General Features
• Etiology
○ Risk factors: Tobacco use, aromatic amines, arsenic
ingestion, Balkan nephropathy, phenacetin abuse,
Chinese herbs, cyclophosphamide treatment, recurrent
infections, and stones
• Genetics
○ Linked to hereditary nonpolyposis colorectal carcinoma
(Lynch syndrome) and some genetic polymorphisms
Staging, Grading, & Classification
• Ta: Noninvasive papillary carcinoma, tis: Carcinoma in situ
• T1: Tumor invades lamina propria
• T2: Tumor invades muscularis
• T3: Renal pelvis: Tumor invades beyond the muscularis into
peripelvic fat or renal parenchyma
○ Ureter: Tumor invades beyond muscularis into
periureteric fat
• T4: Tumor invades adjacent organs, pelvic or abdominal
wall, or through the kidney into perinephric fat
• N0: None; N1: Single node < 2 cm; N2: Single node 2-5 cm or
to multiple nodes > 5 cm; N3: Node > 5 cm
• M0: No distant metastasis; M1: Distant metastases
Gross Pathologic & Surgical Features
• Hallmark of TCC is multifocality and highest recurrence rate
of any cancer
• Spectrum ranging from noninvasive papillary tumors
(papillary urothelial tumors of low-malignant potential, lowgrade
papillary UC, high-grade papillary UC) through flat
lesions (carcinoma in situ [CIS]) to invasive carcinomas
• 60% of UTUC are invasive at diagnosis compared with only
15-25% of bladder tumors
• Spread by direct invasion and lymphatic route
Microscopic Features
• 3 grades: Papillary urothelial neoplasm of low malignant
potential, low grade, and high grade; most are high grade
Urine Cytology
• Less sensitive than for bladder UC
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Gross or microscopic hematuria (70-80%), flank pain (20-
40%), lumbar mass (10-20%)
Demographics
• Age
○ Peak incidence: 70-80 years (M:F = 3:1)
• Epidemiology
○ TCC accounts for 90% of all urothelial tumors but only
10% of all renal tumors
Natural History & Prognosis
• Most common sites of recurrence for UTUC include bladder
(22-47%) and contralateral collecting system (2-6%)
• 5-year survival depends on tumor location: Renal pelvis:
83%, ureter: 72%
Treatment
• Radical nephroureterectomy with bladder cuff excision ±
intravesical chemotherapy
• Metastases: chemotherapy ± radiation
• Endoscopic ablation in highly selected low-grade cases
DIAGNOSTIC CHECKLIST
Consider
• Multifocality of UC in upper and lower urinary tract
Image Interpretation Pearls
• Important to define location of tumor (renal pelvis, mid
ureter, distal ureter), extent of the tumor (intraluminal vs.
extraluminal), ± hydroureteronephrosis, ± invasion into
contiguous organs
• Screen entire excretory system for synchronous tumors
• Imaging follow-up for metachronous tumors
SELECTED REFERENCES
1. Gayer G et al: The renal sinus--transitional cell carcinoma and its mimickers on
computed tomography. Semin Ultrasound CT MR. 35(3):308-19, 2014
2. Rouprêt M et al: European guidelines on upper tract urothelial carcinomas:
2013 update. Eur Urol. 63(6):1059-71, 2013
3. Xue LY et al: Evaluation of renal urothelial carcinoma by contrast-enhanced
ultrasonography. Eur J Radiol. 82(4):e151-7, 2013
4. Lee EK et al: Imaging of urothelial cancers: what the urologist needs to
know. AJR Am J Roentgenol. 196(6):1249-54, 2011
5. Vikram R et al: Imaging and staging of transitional cell carcinoma: part 2,
upper urinary tract. AJR Am J Roentgenol. 192(6):1488-93, 2009
6. Park S et al: The impact of tumor location on prognosis of transitional cell
carcinoma of the upper urinary tract. J Urol. 171(2 Pt 1):621-5, 2004
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