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Urothelial Carcinoma
Transitional Cell Carcinoma

Submitted by Daniel Kowal, MD

 

  • Accounts for 85-90% of all uroepithelial tumors
  • Exophytic, polypoid  papillary growth pattern most common
    • Attached to the mucosa by stalk
    • Non-papillary tumors less common
  • Most are solid with no characteristic gross findings
  • Location
    • Bladder is 30-50x more often the site of the tumor than ureter or renal pelvis (most common tumor of GU tract)
    • When it occurs in the ureter, it most commonly occurs in the lower 3rd
  • Synchronous (simultaneous) transitional cell carcinomas are common
    • Bladder involvement with
      • 24% of primary renal pelvis involvement
      • 30% of primary ureteral involvement
      • In 2% with primary bladder tumor
    • Both ureters involved in 2-9%
    • Both renal pelves in 1-2%
  • Metachronous (sequential) transitional cell carcinomas in upper tracts
    • With pelvic and ureteral primaries-12% in 25 months
    • With bladder primaries-4% (2/3 in 2 years but can reoccur decades later)
  • Most commonly in men age 60 and older
  • Classically present with “painless hematuria”
  • Risk factors
    • Exposure to cyclophosphamide
    • Phenacetin
    • Chronic urinary stasis
    • Smoking
  • Metastasizes to
    • Regional lymph nodes
    • Liver
    • Lung
    • Bone
  • Imaging findings
    • IVU
      • Enlarged and hydronephrotic kidney
        • Invasive, poorly differentiated tumors are more likely to obstruct
        • Dilated calyx with filling defect
        • Caliceal amputation
        • Partial or complete obstruction of the infundibulum
    • Retrograde studies
      • Papillary tumors
        •  “Goblet” or “Champagne glass sign” of ureteral dilatation distal to a filling defect allows for differentiation from a calculus impacted in the ureter, which causes distal spasm and narrowing

Upper and lower half of right retrograde pyelogram shows
hydronephrosis (yellow arrow), filling defect at head of contrast
column in ureter (red arrow) and "goblet" shaped dilatation distal to filling defect

  • Non-papillary tumors
    • Nodular or flat
    • Cause strictures rather than filling defects
  • CT
    • Can identify dilated collecting system and demonstrate level of obstruction
    • Intraluminal mass (30-60 HU) representing ureteral tumor can be differentiated from obstructing calculus (> 190 HU)
    • May demonstrate extra-ureteral extension
  • US
    • Discrete hypoechoic mass within the renal sinus
    • Absence of acoustic shadowing allows for differentiation from calculi
  • Angiography
    • Hypovascular mass
    • Vessel encasement and stain
    • Not usually necessary
  • Treatment
    • Controversy
      • Nephroureterectomy with resection of a cuff of bladder versus wide excision of the tumor alone
      • Adding chemotherapy (cisplatin) in patients with advanced tumors is of unclear utility