Intended learning outcome The student should learn at the end
of this lecture principles of CT in bladder cancer.
Slide 3
CTU is a term used to describe high-spatial-resolution imaging
of the urinary tract by using contrast material administration, a
multidetector CT scanner with thin collimation and imaging in the
excretory phase.
Slide 4
Hematuria Patients at increased risk for having upper or lower
tract urothelial neoplasms Urinary diversion procedures following
cystectomy Hydronephrosis, chronic symptomatic urolithiasis or
planning of percutaneous nephrolithotomy (PCNL) Traumatic and
iatrogenic uretheral injury, and complex urinary tract
infections.
Slide 5
2 Phase- single bolus CTU: - Oral hydration (700 ml of water,
30 min ) - Low dose diuretic (Furosemide): 0.1mg/kg, 1-3 min,
before CM - Single bolus of 100 -[320] IV CM - Arterial phase -
Nephrographic phase@ 100 sec - Excretory phase @ 12 min (7-15
min)
Slide 6
1.- Ultrasound is widely used. 2.-Using Furosemide there is an
improvement in lithiasis diagnosis. Furosemide decrease the urine
attenuation value (< 500 HU) *. LithiasisHU Calcium oxalate
monohydrate Calcium oxalate dihidrate Cystine Struvite Uric acid
1645+ 238 1417 + 234 711 + 228 666 + 87 409 + 118
Slide 7
Bladder cancer tends to show peak enhancement with the 60-
second (portal Phase) scanning delay *. Portal phase CTU offers
high accuracy detecting BC: - Sensitivity: 89%92% in per lesion
analysis 95% in per patient analysis - Specificity: 88% 97% in per
lesion analysis 91%93% in per patient analysis
Slide 8
CTU image review and postprocessing: Using a workstation and/or
a picture archiving and communication system (PACS): Creation of
multiplanar reformatted images and 3D reconstructed images by
using: - Maximum intensity projection techniques (MIP 5-50mm) -
Volume-rendering (VR 5-50 mm) -Narrow and wide windows and thin
sections with MPR and axial images review (improve the detection
rate for tumors smaller than 5 mm)
Slide 9
Homogeneous bladder opacification: Voiding the bladder before
examination or mixing bladder contents: patient rolls over supine-
prone on the CT table or walks around the CT room. All the
excretory system must be included in the exam: Since the urothelium
of the entire urinary system is at risk of developing cancer. CTU
may allow staging of deeply invasive tumors, detection of
metastases and other extra-genitourinary pathology.
Slide 10
Background Is the most common malignancy of the urinary tract.
Is a disease of older patients (>65). Represents the 6.6% of the
total cancers in men and 2.1% in women, with an estimated
male-to-female ratio of 3.8:1*.
Slide 11
Risk factors Cigarrete smoking: Smokers have a two to sixfold
increased risk of cancer compared to non-smokers. Occupational
exposures: Exposition to aromatic amines (petrochemical, textile,
printing industries), hairdressing, firefighting, truck driving,
plumbing Exposures to certains medications: Phenacetin,
Cyclophosphamide. Others: Arsenic in drinking water, prior pelvic
irradiation and lower urinary tract inflammation
(schistosomiasis).
Slide 12
Cell type I.- Epithelial tumors: Urothelial (transitional cell)
cancer (90%). Is the most common urinary tract cancer in the United
States and Europe. Has a propensity to be multicentric (30-40% )
with synchronous and metachronous bladder and upper tract tumors.
Squamous cell (5-8 %) Adenocarcinoma (2%) II.- Non-epithelial
tumors: Leiomyosarcomas, lymphoma: Rare
Slide 13
Ta: Non invasive CIS: high- grade flat Urothelial cancer T1:
Invade lamina propria T2a and T2b: bladder wall musculature T3a and
T3b: perivesical space extension T4: Adyacent organs or pelvic
sidewall invasion. GRADE: Grade 1: Well differentiated: papillary/
superficial Grade 2: Poorly differentiated:
infiltrative/Invasive
Slide 14
Microscopic or gross hematuria, but only 13- 28% patients with
gross hematuria have bladder cancer.
Slide 15
Tumor appearance Tumor enhancement
Slide 16
Asymmetric diffuse or focal wall thickening Male, 75 year-old.
Tumor right bladder wall Male 70 year old. Tumor at left UVJ
Slide 17
Focal enhancing masses
Slide 18
Small filling defects Soft tissue window (W:400, L:40) Wide
windows (W:1990, L:362)
Slide 19
67 year-old man. Previous transurethral BC resection. CTU:
Asymetric enhancing right wall thickening Cystoscopy: Fybrosis
Slide 20
Flat tumors Bladder lesions located at the bladder base (near
prostate and urethra) The most problematic group: Patients have
already undergone local treatment for non-invasive bladder
tumors.
Slide 21
72 year-old man. CTU: Prostatic hypertrophy and diffuse wall
thickening and small polipoid nodule in the posterior bladder wall
Cystoscopy: BC in small nodule
Slide 22
75 year-old man. Previous transurethral resection CTU: Small
bladder, diffuse wall thickening and small enhancing nodule at
bladder dome Cystoscopy: BC
Slide 23
T3a or T3b ? T4
Slide 24
Text Book David Suttons Radiology Clarks Radiographic
positioning and techniques
Slide 25
Assignment Two students will be selected for assignment.
Slide 26
Question Define value of VRT in urinary tract examination
?
