Urothelial Carcinoma

Collecting System and Ureter

Transitional cell carcinoma (TCC) of the renal pelvis accounts for approximately 7% of primary malignancies of the kidney. TCC is often multifocal. Two percent to 4% of patients with TCC of the bladder develop upper urinary tract tumors, and metachronous upper tract tumors develop in 19% of upper tract TCC. Urography, sonography, or retrograde pyelography is often the initial study for suspected upper tract urothelial tumors.1 The most sensitive imaging modality for detecting and delineating tumors in the upper urinary tract is retrograde pyelography,30 with sensitivity of 72% and specificity of 85%.31

Transitional carcinoma of the upper urinary tract may be seen on CT as an intraluminal soft tissue mass (Figure 31.5), diffuse or eccentric thickening or irregularity of the wall, or with obstruction of the collecting system proximal to a soft tissue mass.32,33 On noncontrast CT, it is seen as soft tissue density of 10 to 40 Hounsfield units (HU), and there is minimal increase in density after intravenous contrast medium administration.1 With multidetector CT, a ureteral mass as small as 5 mm can be detected. It may displace and compress the renal sinus fat or infiltrate the renal parenchyma (Figure 31.6).32,33 A focal obstructive nephrogram may be seen with a delayed and late persistent dense nephro-

figure 31.4. Malignant lymphoma of the kidney. (A) Contrast-enhanced CT obtained during corticomedullary phase shows large soft tissue mass involving the left kidney. Lymphadenopathy is also seen along the left renal vein (arrow). (B) Contrast-enhanced CT obtained during excretory phase shows minimal, homogeneous contrast enhancement of the mass. The patient underwent ultrasound-guided percutaneous biopsy, which revealed malignant lymphoma.

figure 31.4. Malignant lymphoma of the kidney. (A) Contrast-enhanced CT obtained during corticomedullary phase shows large soft tissue mass involving the left kidney. Lymphadenopathy is also seen along the left renal vein (arrow). (B) Contrast-enhanced CT obtained during excretory phase shows minimal, homogeneous contrast enhancement of the mass. The patient underwent ultrasound-guided percutaneous biopsy, which revealed malignant lymphoma.

figure 31.5. Transitional cell carcinoma of the right renal pelvis. (A) Contrast-enhanced CT scan obtained during excretory phase. There is a soft tissue mass within the right renal pelvis. Right hydronephrosis is caused by the accessory right renal artery crossing the ureterovesical junction seen on arterial phase images (not shown).

figure 31.5. Transitional cell carcinoma of the right renal pelvis. (A) Contrast-enhanced CT scan obtained during excretory phase. There is a soft tissue mass within the right renal pelvis. Right hydronephrosis is caused by the accessory right renal artery crossing the ureterovesical junction seen on arterial phase images (not shown).

(B) Coronal reformatted CT image obtained during excretory phase. Soft tissue mass causes filling defect within the dilated right renal pelvis. The patient underwent laparoscopic nephrectomy. Pathologically, it was superficially invasive low-grade transitional cell carcinoma, and the pathologic stage was T1 Nx Mx.

figure 31.6. Transitional cell carcinoma of the left renal pelvis. (A) Axial T1-weighted gradient echo image with fat suppression obtained at early phase after gadolinium contrast agent injection shows poorly defined mass in the left renal hilum infiltrating the renal parenchyma. (B) Axial Trweighted gradient echo image with fat suppression obtained at nephrographic phase shows focal dilatation of the collecting system (large arrow) with delayed cortical nephrogram (small arrows) in the posterior aspect of the left kidney. (C) Axial T2-weighted breath-hold half Fourier single-shot fast spin-echo image shows the mass in the left renal hilum infiltrating the renal parenchyma. There is focal dilatation of the left collecting system (arrow). Pathologically, it was infiltrating high-grade transitional cell carcinoma involving the renal pelvis. There was extensive infiltration into the peripelvic fat and invasion of renal parenchyma. Metastatic carcinoma was present in the lymph nodes. The pathological stage was pT4 N2 Mx.

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