IMAGING OF CARCINOMA OF URINARY BLADDER

IMAGING OF BLADDER MALIGNANCY

1. IMAGING OF CARCINOMA OF URINARY BLADDER Dr S.KRITHIKA MD Dr I.GURUBHARATH MD PhD

2. INTRODUCTION Epithelial in origin (> 90%) Transitional cell carcinoma (TCC): 90% (Most common) Squamous cell carcinoma (SCC): 1.5–10% associated with chronic infection (e.g. schistosomiasis ) bladder calculi. Adenocarcinoma : 1% of all epithelial tumours associated with bladder exstrophy and urachal remnants Risk factors : Carcinogens present within cigarette smoke (the most important factor ) aromatic amines cyclophosphamides

3. Growth patterns : in situ (non-invasive) papillary infiltrating ulcerating Location: commonly around the region of the trigone or along the lateral bladder walls SYMPTOMS Haematuria dysuria pelvic pain (due to side wall invasion) hydronephrosis (due to ureteric obstruction) 6th and 7 th decades (M>F)

4. INTRA VENOUS UROGRAM

5. ULTRASOUND A sessile or pedunculated mixed echogenicity mass projecting into the bladder lumen (+/- vascularity )

6. CT Distant metastases and detecting perivesical fat invasion (T3b) Cannot distinguish between lesions limited to the lamina propria (T1) and those invading the superficial (T2a) and deep(T2b) muscle.

7. A sessile or pedunculated soft tissue mass projecting into the bladder lumen overlying calcification or localized bladder wall thickening Perivesical fat invasion (T3b ): poor external bladder wall definition increased perivesical fat density Adjacent visceral invasion (T4a): No distinct fat plane between the bladder and rectum, uterus,prostate or vagina Pelvic side wall invasion (T4b): soft tissue extending into the obturator internus muscle. strands of soft tissue extending from the main tumour mass to the pelvic side wall

8. Pelvic lymph nodes (N1–N3): malignant involvement if > 7mm Rare in superficial tumours (< T2b) Increased incidence with deep muscular involvement and extravesical spread. Pattern of nodal spread : obturator and external iliac nodes internal and common iliac nodes Distant metastases : bone,lungs,brain,liver

9. MRI Surface coil imaging (e.g. endorectal coil) : improves the visualization of the bladder wall layers it is better than CT for the evaluation of tumours at the bladder base or dome for differentiation between T3a and T4 disease T1WI : similar SI to normal wall ▶ higher SI to urine T2WI : higher SI to normal wall ▶ lower SI to urine (T2a) and deep (T2b) can be differentiated by assessing the integrity of the bladder wall ‘black line’ between the superficial and deep muscle layers

10. T1WI þ Gad : a higher SI relative to normal bladder wall Bladder wall tumour or perivesical extension=earlier enhancement than simple inflammatory post-biopsy change Metastatic lymph nodes =early enhancement than non-metastatic nodes Seminal vesicle invasion: T2WI: low SI within the seminal vesicles obliteration of the fat angle between the seminal vesicle and posterior bladder wall

11. TREATMENT Tumour confined to the bladder wall or if there is minimal extravesical spread: surgical resection Superficial tumours: intravesical chemotherapy (BCG) Extensive extravesical spread: systemic chemotherapy or palliative radiotherapy RESPONSE TO THERAPY : Dynamic contrast-enhanced MRI: delayed tumour Enhancement in patients responding to chemotherapy (early enhancement in non-responders

12. Thank you