70-year-old man with hematuria and left flank pain

Images

Doctor's Information

Name : Morteza
Family : Sanei Taheri
Affiliation :Radiology Department,Shohada Tajrish Hospital,SBMU
Academic Degree : Associate Professor of Radiology
Email : This email address is being protected from spambots. You need JavaScript enabled to view it.
Resident : Afarin Sadeghian

Case Section

Uroradiology & Genital Male Imaging

Patient's Information

Gender : Male
Age : 70

Clinical Summary

70-year-old man with hematuria and left flank pain

Imaging Findings

Axial and reconstructed contrast-enhanced CT scan images demonstrate small-capacity and irregular, thick-walled bladder along with a soft tissue density-mass grown into the distal part of the left ureter(Fig.5 and 7),leading to ureteral obstruction and left-sided hydroureteonephrosis.There is no evidence of calcification,perivesical fat stranding or regional lymph node enlargement.

Differential Diagnosis

Differential diagnosis of an incidentally noted mass in the bladder:1.benign (papilloma, hamartoma, leiomyoma) or malignant neoplasm,2. Hematoma, 3.calculus,4. fungus ball, 5.cystitis cystica, 6.foreign body, and 7.endometriosis. Differential diagnosis of circumferential bladder wall thickening:1.Radiation therapy and fibrosis,2.Bladder outlet obstruction caused by benign prostatic hyperplasia or stricture of the urethra,3.Chemotherapy with systemic agents such as cyclophosphamide and ifosfamide or intravesical agents such as Bacillus Calmette-Guérin or formalin

Final Diagnosis

Stage III of urinary bladder cancer(TCC)

Discussion (Related Text)

Cancer of the urinary bladder is predominantly a disease of older men.Smoking, living in urban areas, and working in the dye, rubber, or leather industries increases the risk.Transitional cell carcinoma accounts for 95% of all bladder cancers.The patterns of growth are broadly categorized as papillary or infiltrative. For transitional cell carcinoma, the pattern of growth tends to correlate with grade, which ranges from well-differentiated, grade 1, to poorly differentiated, grade 3.Although the Jewett-Marshall-Strong staging system is still used, the TNM staging system is favored. For both, the depth of invasion into the bladder and the involvement of adjacent and distant sites are central elements.To understand the staging systems, one must first be aware of bladder anatomy. The bladder wall consists of four layers: mucosa or epithelium, lamina propria or subepithelial connective tissue, muscle layer, and serosa or the peritoneal covering found at the dome. A special case is cancer in a diverticulum, in which lesions tend to be of a higher grade and escape the bladder wall earlier because of the lack of a muscle layer. Thus, tumors at this location tend to have a greater potential for metastasis and a correspondingly poorer prognosis. Characteristics of TNM Classification System include following items:Tumor invades subepithelial connective tissue in T1,Tumor invades muscle in T2,Tumor invades perivesical tissue in T3(extravesical mass staged as T3b),Tumor invades any of the following adjacent organs: prostate, uterus, vagina, pelvic wall, and abdominal wall inT4.(Stage I:T1,N0,MO,Stage II:T2a or T2b,N0,M0,Stage III:T3a,T3b or T4a,N0,M0,Stage IV:T4b,N0,M0, Any T,N1 to N3,MO, Any T,Any N,M1) Cancer of the urinary bladder first spreads to the perivesical, obturator, internal and external iliac, and presacral lymph nodes. The perivesical nodes are less often involved. Eventually, common iliac and paraaortic lymph node metastases are noted.Those lymph nodes greater than 1 cm in size in the short axis are considered suspicious . If needed, involvement can be confirmed by percutaneous needle biopsy. Cancer of the urinary bladder, particularly transitional cell carcinoma, spreads through the blood stream as well. Favored sites for metastasis include the liver, lungs, skeleton, and adrenal glands.

References

AJR 2003;180:1045–1054