Diagnostic Ultrasound - Abdomen and Pelvis

Bladder Carcinoma
Diagnoses: Urinary Tract
Extrinsic Tumor/Mass
• Rectal, ovarian, vaginal tumor or fibroids overlying bladder;
may simulate bladder carcinoma (CT/MR helpful)
Bladder Inflammation
• Cystitis may cause diffuse wall thickening and internal
debris
○ Asymmetric bladder wall should be viewed with
suspicion for tumor
PATHOLOGY
General Features
• Etiology
○ Risk factors
– Environment: Smoking (most common association)
– Infection: Schistosomiasis, chronic cystitis
– Iatrogenic: Cyclophosphamide, radiation therapy
– Occupation: Chemical, dye (e.g., aniline dye), rubber
and textile industries
• 95% of bladder neoplasms are malignant
• Types of bladder carcinoma
○ Transitional cell carcinoma (90-95%), a.k.a. urothelial
cancer
○ Squamous cell carcinoma (5%)
○ Adenocarcinoma (2%): Urachal origin, secondary to
cystitis glandularis, or secondary to extrophy
○ Carcinosarcoma
○ Other rare tumors: Carcinoid, rhabdoid, small cell,
metastases (GI tract, melanoma)
• Types of nonepithelial bladder carcinoma
○ Pheochromocytoma
○ Leiomyosarcoma
○ Embryonal rhabdomyosarcoma (most common bladder
neoplasm in children)
○ Lymphoma
Staging, Grading, & Classification
• TNM classification of bladder carcinoma
○ T0: No tumor
○ Tis: Carcinoma in situ
○ Ta: Papillary tumor confined to mucosa (epithelium)
○ T1: Invasion of lamina propria (subepithelial connective
tissue)
○ T2: Invasion of inner half of muscle (detrusor)
○ T2b: Invasion of outer half of muscle
○ T3a: Microscopic invasion of perivesical fat
○ T3b: Macroscopic invasion of perivesical fat
○ T4a: Invasion of surrounding organs
○ T4b: Invasion of pelvic or abdominal wall
○ N1-3: Pelvic lymph node metastases
○ N4: Lymph node metastases above bifurcation
○ M1: Distant metastases
Gross Pathologic & Surgical Features
• Superficial (70-80%) and are usually papillary (70%)
• Invasive (20-30%), infiltrating in/beyond muscular layer of
wall
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Painless microscopic or macroscopic hematuria
○ Tumor involving ureterovesical junction →
hydronephrosis (flank pain); urethral orifice → urinary
retention
Demographics
• Age
○ 50-60 years of age
○ Increasing incidence in patients < 30 years of age
• Gender
○ M:F = 4:1
• Ethnicity
○ Caucasian to African American ratio = 1.5:1
Natural History & Prognosis
• Complications
○ Hydronephrosis, incontinence, and urethral stricture
• Prognosis
○ 5-year survival rate: 82% in all stages combined
– 94% in localized stages
– 48% in regional stages
– 6% in distant stages
Treatment
• < T2: Local endoscopic resection ± intravesical instillation or
bacille Calmette-Guérin (BCG) therapy
• T2 to T4a: Radical cystectomy or radiotherapy (cure)
• > T4b: Chemotherapy or radiotherapy ± adjuvant surgery
(palliative)
DIAGNOSTIC CHECKLIST
Consider
• Immobile soft tissue mass in bladder ± vascularity
• Distinction of benign from malignant tumor by cystoscopy
± biopsy
• CT/MR used for staging for treatment and prognosis
• Check kidneys, ureters for synchronous and metachronous
tumors
Image Interpretation Pearls
• MR is superior in locoregional staging and used in patients
with high-grade stage T1 or > stage T2
SELECTED REFERENCES
1. Hafeez S et al: Advances in bladder cancer imaging. BMC Med. 11:104, 2013
2. Verma S et al: Urinary bladder cancer: role of MR imaging. Radiographics.
32(2):371-87, 2012
3. Nicolau C et al: Accuracy of contrast-enhanced ultrasound in the detection of
bladder cancer. Br J Radiol. 84(1008):1091-9, 2011
4. Tekes A et al: Dynamic MRI of bladder cancer: evaluation of staging accuracy.
AJR Am J Roentgenol. 184(1):121-7, 2005
5. Wagner B et al: Staging bladder carcinoma by three-dimensional ultrasound
rendering. Ultrasound Med Biol. 31(3):301-5, 2005
6. Koraitim M et al: Transurethral ultrasonographic assessment of bladder
carcinoma: its value and limitation. J Urol. 154(2 Pt 1):375-8, 1995
7. Kim B et al: Bladder tumor staging: comparison of contrast-enhanced CT, T1-
and T2-weighted MR imaging, dynamic gadolinium-enhanced imaging, and
late gadolinium-enhanced imaging. Radiology. 193(1):239-45, 1994
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