Genitourinary Radiology > Bladder > Focal Mural Filling > Bladder Carcinoma


Bladder Carcinoma

 

The differential diagnosis of a focal mural filling defect in the bladder includes common causes, such as neoplasm, stone, blood clot, or enlarged prostate gland; and uncommon causes, such as focal cystitis, ureterocele, benign neoplasm, endometriosis, or fungus ball. The workup is directed at exclusion of malignancy.

90% of bladder carcinomas are transitional cell carcinoma (TCC), 75% of which are papillary, 25% are infiltrative. Other malignant neoplasms include squamous cell carcinoma (after schistosomiasis infection), adenocarcinoma, leiomyosarcoma, lymphoma, rhabdomyosarcoma (in ages 2-6). Benign lesions include leiomyoma, fibroepithelial polyp, hemangioma, pheochromocytoma, and adenoma.

Transitional cell carcinoma peaks at age 50-69 years, with men being affected 3 times as often as women. Risk factors include chemical carcinogens (acrolein, aromatic amines, nitrosamines), analgesic use, and tobacco smoking. Infiltrative TCC is more likely to metastasize, and papillary TCC are often multi-focal with high recurrence rates.

Jewett-Strong-Marshall Staging (TNM staging)
0: carcinoma-in-situ (TIS) and noninvasive papillary tumor (TA)
A: papillary tumor with invasion of lamina propria (T1)
B1: superficial muscle invastion (T2)
B2: deep muscle invasion (T3A)
C: perivesical fat invasion (T3B)
D1: Invasion of contiguous viscera (T4A), invasion of pelvic or abdominal wall (T4B)
D2: Regional lymphadenopathy (N4), distant metastases (M1)

Prognosis is a function of muscular invasion: stage B1 has a 30-80% 5-year survival, while B2 (deep muscle invasion) has a 10-20% 5-year survival.

Workup should include a CT IVP for evaluation of synchronous upper-tract urothelial neoplasms and distant metastatic disease. The urologist performs cystoscopy with biopsy to determine depth of muscle invasion. MRI may play an increasing role for staging as MRI is better than CT for evaluation of depth of bladder wall involvement and adjacent organ infiltration.

Gray scale ultrasound of the bladder shows a focal polypoid mass (M) at the bladder base in a female with hematuria. This was a polypoid TCCA of the bladder.

Delayed contrast enhanced CT scan of the pelvis shows a focal polypoid mass at the left UVJ (M). The polypoid mass is seen as a filling defect outlined by the excreted urine in bladder.

Conventional IVP in excretory phase shows masslike filling defect being outlined by excretion contrast in the bladder (arrows). This was a large bladder carcinoma. The differential diagnosis would include tumor, blood clot, fungus ball. Cystoscopy would be required for further evaluation.

Non contrast CT scan of the pelvis shows focal infiltrative thickening of the posterolateral bladder wall (arrows). Focal cystitis may give a similar appearance, in this case, however, cystoscopy with biopsy confirmed this was TCCA of the bladder.

 

Contrast enhanced CT scan of the pelvis shows marked infiltrating mass thickening the bladder wall and obstructing both ureters (arrows) resulting in bilateral hydroureter and hydronephrosis.



© Copyright Rector and Visitors of the University of Virginia 2013