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 3^rd
• 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
• 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

 

 

Goblet Sign. Blue arrow points to “Goblet” or “Champagne glass sign” of ureteral dilatation distal to a filling defect in the right urtere which allows for differentiation from a calculus impacted in the ureter, which causes distal spasm and narrowing
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