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Everything you need to know about Computed Tomography (CT) & CT Scanning


MDCT of the Bladder: Spectrum of Disease

MDCT of the Bladder: Spectrum of Disease

Navigating the common, uncommon and commonly misdiagnosed diseases of the bladder

Elie Portnoy, MD
Stanley S. Siegelman, MD
Elliot K. Fishman, MD
Pamela T. Johnson, MD

Johns Hopkins Hospital

 

Objectives

  • The purpose of this exhibit is to emphasize the importance of carefully inspecting the bladder on MDCT (multi-detector CT).
  • This exhibit displays a wide variety of infectious, inflammatory and neoplastic diseases involving the bladder.
  • Protocol design must be tailored when bladder pathology is suspected.
  • Interpretation with axial images and coronal MPRs improves the radiologists ability to identify unsuspected findings.

 

Technique: Hematuria

  • In a patient with hematuria, CT urogram should be performed, using precontrast, arterial, venous and delayed acquisitions
    • All 4 phases are required to evaluate for both renal and urothelial neoplasms
    • Radiation exposure can be reduced by use of mAs and kVp modulation techniques, as well as limiting coverage
      • Precontrast– kidneys only
      • Arterial @ 25-30 seconds – abdomen and pelvis
      • Venous @ 60 seconds– abdomen only
      • Delayed @ 5 minutes– top of kidneys through bladder

 

Technique: Hematuria

  • Arterial phase imaging through the bladder can disclose bladder cancer as well as the delayed phase in many cases.
  • Urothelial masses will enhance against the background of low attenuation urine
  • Bladder distention is important in these cases (patient should drink water prior the CT).
77 year old woman with papillary transitional cell cancer of the bladder

Technique: Hematuria

 

MPRs for Characterization

  • Bladder masses on the superior wall may appear as amorphous enhancement on axial images
  • The wall should be evaluated in axial, coronal and sagittal planes, particularly when focal enhancement is identified on the axial image.
  • Do not mistake for contrast jet!!
MPRs for Characterization

 

Table of Contents

  • Primary malignancy
    • Transitional Cell Carcinoma
    • Adenocarcinoma
    • Paraganglioma
    • Atypical Locations
      • Urachus
      • Diverticulum
  • Secondary malignancy
    • Metastases to bladder
    • Lymphoma
  • Benign Tumor Mimics
    • Bladder hematoma
    • Inflammatory
      • Malakoplakia
      • Cystitis cystica
    • Rare embryological
      • Mullerianosis
  • Morphologic abnormalities
    • Herniated Bladder Diverticula
    • Colovesical fistula
  • Infectious Cystitis
    • Hemorrhagic Cystitis
    • Emphysematous Cystitis
    • Schistosomiasis

 

PRIMARY MALIGNANCIES: Transitional Cell Carcinoma

Range of morphologies of TCC that may be indentified on CT

PRIMARY MALIGNANCIES: Transitional Cell Carcinoma

 

Transitional Cell Carcinoma

42 year old man with papillary transitional cell carcinoma- polypoid configuration.

TCC features on CT: calcification is present in 0.7-6% of bladder TCC

Vikram R, Sandler CM, Ng CS. Imaging and staging of transitional cell carcinoma: part 1, lower urinary tract. AJR 2009 Jun;192(6):1481-7.

PRIMARY MALIGNANCIES: Transitional Cell Carcinoma

 

Multifocal TCC

69 year old man with papillary transitional cell carcinoma of the right renal pelvis and subtle right bladder wall TCC.

TCC features on CT: Multifocal TCC at presentation occurs in 17% of patients.

Cosentino M, Palou J, Gaya JM, et al. Upper urinary tract urothelial: location as a predictive factor for concomitant bladder carcinoma. World J Urol 2013;31:141–5.

Multifocal TCC

 

TCC: Incidental/Unsuspected

  • CTA examinations of the aortiliac and femoral arteries are frequently performed in patients with history of tobacco use (concomitant risk of bladder CA)
    • Smoking tobacco is the strongest linked risk factor to primary bladder CA, with a population attributable risk of 50-65% in men and 20-30% in women.
    • Bladder tumors were identified as incidental findings in 3/605 of patients who underwent aortoiliac and femoral CTA
  • Careful examination of the bladder may reveal incidental lesions of the bladder
Cosentino M, Palou J, Gaya JM, et al. Upper urinary tract urothelial: location as a predictive factor for concomitant bladder carcinoma. World J Urol 2013;31:141–5.
Iezzi R, Cotroneo AR, Filippone A, et al. Extravascular incidental findings at multislice CT angiography of the abdominal aorta and lower extremity arteries: a retrospective review study. Abdom Imaging 2007; 32: 4894–4894

 

Incidental Bladder Tumor

43 y/o male with extensive history of smoking presents for CTA runoff study to evaluate vasculature of the pelvis and lower extremities for claudication.

Arterial phase coronal (A) and sagittal (B) MPRs of the pelvis with incidental note made of superior bladder wall thickening/enhancement, highly suspicious for transitional cell carcinoma.

Incidental Bladder Tumor

 

Primary cancer: Atypical Location

  • Bladder Diverticula
    • Bladder cancer occurs in 0.8-10% of patients with diverticula
      • Region of relatively higher malignant risk due to urinary stasis
    • TCC is most common pathology in a diverticulum
    • Lack of muscular layer may facilitate tumor extension.
    • Transurethral diagnosis and treatments are challenging in these patients
  • Urachus (Adenocarcinoma)
    • 1/3 of bladder adenocarcinoma occurs within the urachus

 

TCC in Bladder Diverticulum

79 year old male with history of bladder diverticula and recent onset hematuria

Axial (A), sagittal (B) and coronal (C) images from oral and IV contrast enhanced CT show multiple large bladder diverticulae, one of which contains a soft tissue mass (arrow).
  • Traditional belief was that TCC within diverticular disease portended an ominous prognosis.
  • In cohort of 39 patients with bladder diverticular TCC, 1/3 of patients had superficial disease, 1/3 had superficially invasive tumors and 1/3 had invasive (extra diverticular) disease
  • Prognosis was related to tumor extension alone without correlate to anatomic location (diverticulum).
Golijanin D, Yossepowitch O, Beck SD, Sogani P, Dalbagni G. Carcinoma in a bladder diverticulum: presentation and treatment outcome. J Urol. 2003;170(5):1761-4::683-7.

TCC in Bladder Diverticulum

 

TCC in Bladder Diverticulum

57 year old male with recurrent bouts of right pelvic pain “concerning for prostatitis”. Images from outside CT.

Precontrast (A), venous phase (B) and delayed phase (C) axial images from IV contrast enhanced CT show an enhancing mass posterior to the right bladder wall.

Differential diagnostic considerations included a mass arising from the seminal vesicle, paraganglioma/neuroendocrine tumor, adenopathy or a diverticulum (although no communication with the bladder was observed. Repeat CT and MRI imaging were performed…

TCC in Bladder Diverticulum

 

TCC in Bladder Diverticulum

Delayed high resolution axial CT (A) reveals diverticulum with direct communication (arrows) with the bladder. Communication to bladder also confirmed on axial T2 weighted MRI (B).

Pathology revealed invasive urothelial carcinoma of the bladder arising in a periureteral diverticulum.

TCC in Bladder Diverticulum

 

Urachal Carcinoma

60 year old man with history of pancreatitis and incidentally noted bladder lesion on CT

Axial image (A) and sagittal MPR (B) from IV contrast enhanced CT shows small polypoid mass in the anterior bladder. Pathology revealed adenocarcinoma of the bladder dome
  • Adenocarcinomas account for <2% of all bladder cancers
    • 90% Transitional Cell Carcinoma
    • 2-15% Squamous Cell Carcinoma
    • <2% Adenocarcinoma
  • 1/3 of bladder adenocarcinomas located within the urachal remnant
  • Squamous cell carcinoma and adenocarcinoma occur in the setting of chronic bladder infection and irritation.
Wong-You-Cheong, J. J. et al. "From the Archives of the AFIP: Neoplasms of the Urinary Bladder: Radiologic-Pathologic Correlation." Radiographics (2006): 553-80.

Urachal Carcinoma

 

Bladder Paraganglioma

66 year old male with history of palpations, headaches and hypertension.

Axial arterial (A), axial delayed (B) and coronal arterial phase (C) from IV contrast enhanced CT show a hypervascular polypoid intraluminal mass in the bladder (arrows).
  • Up to 10% of paragangliomas can be found within the bladder and prostate
  • Paragangliomas account for less than 0.1% of all bladder tumors
Heinrich E, Gattenloehner S, Mueller-Hermelink HK, Michel MS, Schoen G. Paraganglioma of urinary bladder. Urol J. Winter 2008;5(1):57-9. 
Lee JA, Duh QY. Sporadic paraganglioma. World J Surg. 2008;32(5):683-7.

Bladder Paraganglioma

 

Bladder Paraganglioma

60 year old man with metastatic clear cell renal cell carcinoma.

Axial (A) and sagittal (B) images from corticomedullary phase CT reveal a small enhancing mural nodule along the left bladder wall (arrows), presumed to be metastasis. Pathology revealed paraganglioma.

Bladder Paraganglioma

 

Bladder Paraganglioma

65 year old woman with history of hypertension that increased during urination, palpitations and diaphoresis.

Axial arterial (A) and delayed phase (B) IV contrast enhanced CT shows a large mass inseparable from the anterior left wall of the bladder. Pathology revealed 4.5 cm paraganglioma involving the muscularis propria and serosal fat.

Bladder Paraganglioma

 

SECONDARY MALIGNANCIES: Metastatic Disease

65 year old man with metastatic prostate cancer.

Coronal MPRs (A,B) and sagittal MPR (C) from IV contrast enhanced CT of the abdomen and pelvis show multiple masses in the bladder in a patient with prostate cancer, new from prior exam in 2 years earlier and in the setting of new spine and adrenal metastases (not shown). Appearance similar to transitional cell carcinoma, but multiplicity and this setting favor metastatic etiology.

SECONDARY MALIGNANCIES: Metastatic Disease

 

Metastatic Disease

58 year old female who initially presented with hematuria.
  • Serial coronal MPR images (B and C with IV contrast), reveal globally thickened bladder (arrow), more prominently in the inferior portion. Mucosal enhancement evident on image C.
  • Diagnosis of lobular breast CA was made with metastases to bladder, stomach and small bowel.
  • 1% of breast cancer patients metastasize to bladder
  • Secondary malignancies comprise ~1% of all bladder cancers:
    • Among the distant sites of metastatic spread…
      • melanoma (most common) >breast > atomach
    • Among local sites of malignant spread…
      • prostate, colorectal and cervix
Soon PSH, W. Lynch, and P. Schwartz. "Breast Cancer Presenting Initially with Urinary Incontinence: A Case of Bladder Metastasis from Breast Cancer." The Breast (2003): 69-71.

Metastatic Disease

 

Bladder Lymphoma

60 year old man with abnormal labs. Axial contrast enhanced images of the pelvis show diffusely thickened and enhancing bladder (red arrows) along with inguinal and iliac adenopathy (yellow arrows), raising concern for bladder lymphoma. Pathology revealed widely disseminated, large B-cell follicular lymphoma.
  • Most lymphoma cases of the bladder occur in the setting of disseminated disease (rare to have isolated bladder lymphoma)
  • Only approximately 72 cases of primary bladder lymphoma reported in literature since 1960
  • Because the bladder is an embryonic derivative of the cloaca, bladder lymphomas are hypothesized to arise from inherent lymphoid tissue that is similar to Peyer's patches in the gut.
Kempton, Christine L., Paul J. Kurtin, et al."Malignant Lymphoma of the Bladder: Evidence From 36 Cases That Low-Grade Lymphoma of the MALT-Type Is the Most Common Primary Bladder Lymphoma." The American Journal of Surgical Pathology (1997): 1324-333.

Bladder Lymphoma

 

BENIGN MIMICS OF TUMOR: Bladder Hematoma

Noncontrast coronal MPR images of a 66 year old woman with large infiltrative left renal cell carcinoma (RCC) invading left renal vein (V) and gross hematuria. Large hyperattenuating left bladder mass (arrow) was a hematoma, resolved at follow up (not shown).

BENIGN MIMICS OF TUMOR: Bladder Hematoma

 

Malakoplakia

48 y/o female who was referred for an approximately 20-year history of symptoms of cystitis with dysuria, urinary frequency, and intermittent hematuria.

Axial precontrast (A), axial arterial phase (B) and coronal arterial phase (C) images from IV contrast enhanced CT show a 3.6 x 1.4 cm enhancing nodular mass (arrows) along the posterolateral wall of the bladder. Pathology revealed malakoplakia.

Malakoplakia

 

Malakoplakia

  • Malakoplakia is a rare disease process typically seen in the setting of chronic urinary tract infections over many years
    • Often associated with immunocompromised state → recurrent infections
  • Most frequent pathogen associated is E. Coli
  • Can affect kidney, ureters or bladder.
  • Histologically characterized by aggregates of granular “lipid laden histiocytes/macrophages” and pathognomonic Michaelis–Gutmann bodies, which have a concentric target-like appearance
  • Predominant distribution in a 4:1 F:M ratio.
  • Treatment ranges from antibiotic therapy to endoscopic resection, to rare total cystectomy.
Mukha, R., Kumar, S., Ramani, M., & Kekre, N. (2010). Isolated Malacoplakia of the bladder: A rare case report and review of literature. International Urology and Nephrology, 349-350.
Sulman, A., & Goldman, H. (2002). Malacoplakia presenting as a large bladder mass. Urology, 60, 163-163.

 

Cystitis Cystica

37 y/o man with hematuria. Mass identified in posterior bladder at cystoscopy.

Delayed axial image (A) and sagittal MPR (B) of the bladder reveal a soft tissue mass (arrows) along the posterior wall of the bladder. Pathology revealed cystitis cystica and glandularis
  • chronic reactive inflammatory disorder, which occurs in the setting of chronic irritation.
  • cystoscopy typically yields a "cobblestone appearance" of mucosa.
  • as opposed to urothelial carcinoma, cystitis cystica will not invade the muscularis layer of the bladder
  • treatment: removal of inciting irritant (infectious, obstructive, etc)
  • Follow up imaging prudent due to possible association with adenocarcinoma
Wong-You-Cheong, J J, PJ Woodward, "From the Archives of the AFIP: Inflammatory and Nonneoplastic Bladder Masses: Radiologic-Pathologic Correlation." Radiographics (2006): 1847-868.

Cystitis Cystica

 

Mullerianosis

28 year old female with pelvic pain and hematuria. Initial urinalysis revealed “tissue fragments of endometrial type cells”. CT was performed for further analysis

Axial precontrast (A), coronal and sagittal (B,C) delayed phase CT after IV contrast administration show a 3.7 x 2.5 cm anterolateral mass (arrows) of the bladder. Pathology returned as mullerianosis.

Mullerianosis

 

Mullerianosis

  • Rare entity representing an admixture of at least two of endocervicosis, endosalpingiosis, and endometriosis in form of a polypoid bladder wall lesion.
    • Choristoma- a collection of normal tissues, not usually native to the organ involved.
    • ~12 cases reported in literature
  • Endometrial glands and decidualized stroma within detrusor muscle bundles
  • Typically presents from ages 28-53
  • Symptoms include: pelvic pain, hematuria, possible dysmenorrhea.
  • Typically benign with extremely rare cases of malignant conversion
    • Adenocarcinoma or adenosarcoma.
  • Nearly indistinguishable on imaging alone (cystoscopy/biopsy typically performed)
  • Can implant in bladder, ureters, mesosalpinx, or inguinal lymph nodes.

 

Urachal Cyst

62 year old woman with history of lung and endometrial cancer. Small enhancing lesion in anterior bladder increasing in size over serial examinations. At cystoscopy, this was noted to be submucosal.

Coronal (A) and sagittal MPRs (B) from oral and IV contrast enhanced CT show small enhancing nodule in the anterior bladder. Pathology revealed urachal cyst.
  • typically occur in lower 1/3 of remnant urachus after both upper and lower poles have closed
  • majority of cases are asymptomatic
  • symptoms typically present when cyst is infected or grows in size in later years
  • treatment often involves removal of the cyst (not simple drainage) as reinfection rates have been documented as high as 30%
  • carcinoma has been documented to develop in unresected symptomatic urachal remnant (chronic inflammation)
Yu JS, Kim KW: Urachal remnant diseases: spectrum of CT and US findings. Radiographics 2001, 21:451-461.
Friedland GW, Devries PA, Matilde NM, Cohen R, Rifkin MD. Congenital anomalies of the urinary tract. In: Pollack HM, eds. Clinical Urography. Philadelphia, Pa: Saunders, 1990;559-787.

Urachal Cyst

 

CHANGES IN MORPHOLOGY: Colovesical Fistula

52 year old man with h/o longstanding diverticulitis and recurrent peridiverticular abscess

Axial venous-phase CECT (A) shows a gas and fluid collection (yellow arrows) adjacent to the bladder, compatible with abscess. Coronal and sagittal (C,D) venous-phase CECT image shows the fistulous connection (red arrows) between the inflamed sigmoid colon and the abscess cavity, and adjacent bladder wall thickening. Patient subsequently underwent open rectosigmoid colectomy.

CHANGES IN MORPHOLOGY: Colovesical Fistula

 

Herniating Bladder

Axial IV contrast enhanced CT images show the right anterolateral bladder herniating into the right inguinal canal (arrows).
  • Herniation of bladder is seen in 1-3% of inguinal hernias.
  • There is a predilection for right side > left side
  • Risk factors include chronic bladder distension, loss of tone, pelvic mass lesions.
Bacigalupo LE, Bertolotto M, Barbiera F et-al. Imaging of urinary bladder hernias. AJR Am J Roentgenol. 2005;184 (2): 546-51.

Herniating Bladder

 

INFECTIOUS PROCESSES: BK Cystitis

57 y/o male with follicular lymphoma, AML, s/p bone marrow transplant, who developed dysuria, hematuria and fever due to BK cystitis

Axial (A) and sagittal (B) images from oral and IV contrast enhanced CT shows asymmetric bladder wall thickening (arrows), mucosal enhancement, and minimal perivesicular stranding.

Polyomavirus BK cystitis:
  • bladder wall thickening
  • urine attenuation may be increased in patients with hemorrhagic cystitis.
  • minority have intraluminal clots.
  • perivesical stranding uncommon
Schulze M, Beck R, Igney A, Vogel M, Maksimovic O, Claussen CD, Faul C, Horger M. Computed tomography findings of human polyomavirus BK (BKV)-associated cystitis in allogeneic hematopoietic stem cell transplant recipients. Acta Radiol. 2008 Dec;49(10):1187-94.

INFECTIOUS PROCESSES: BK Cystitis

 

Emphysematous Cystitis

Axial (A) and coronal (B) images from IV contrast enhanced CT show intramural (arrows) and perivesicular gas.
  • Predisposing factors include diabetes, neurogenic bladder and outlet obstructions.
  • Gas-producing bacteria (E. coli and K. pneumoniae most common) in the bladder lumen and wall
  • Air must be seen within the bladder wall +/- lumen
  • Medical management (IV antibiotics) rather than surgery
Thomas AA, Lane BR, et al. Emphysematous cystitis: a review of 135 cases. BJU Int. 2007;100(1):17-20.

Emphysematous Cystitis

 

Schistosomiasis

48 year old man from Africa. Axial (A) and coronal (B) noncontrast CT images show dense coarse calcifications within the bladder wall in a “fetal head” pattern (red arrow). Right sided hydronephrosis (yellow arrow) shown in image C.
  • Schistosomiasis places patients at heightened risk for bladder cancers, particularly squamous cell carcinoma.
  • Hematuria is the first sign of disease, appearing 10 to 12 weeks after infection. Late manifestations include proteinuria, bladder calcifications, ureteral obstruction, hydronephrosis, and renal failure. 
Ross AG, Bartley PB, Sleigh AC, et al. Schistosomiasis. N Engl J Med. 2002;346(16):1212-20.

Schistosomiasis

 

Summary

  • The bladder is imaged on every CT of the abdomen and pelvis, and incident pathology may be identified.
  • Detection and characterization are optimized by bladder distention and use of multiplanar reconstructions.
  • Hopefully this exhibit has conveyed the importance of careful inspection of the bladder on all CT scans that include imaging of the pelvis.
© 1999-2020 Elliot K. Fishman, MD, FACR. All rights reserved.