Transitional Cell Carcinoma of the Bladder

Sandra L Mondro, MD
Marla Polger, MD

October 5, 1995

Presentation

A 73-year-old man presented with painless hematuria and urinary frequency.

Imaging Findings

Computed Tomography

CT of the pelvis performed without intravenous contrast demonstrates a circumferentially thickened bladder and a 2.5-cm eccentric mass along the posterior wall (arrow). The indwelling Foley catheter accounts for the intravesical air. There is mild stranding of the surrounding fat. Bilateral hydroureteronephrosis (arrows) is present and a 2.5-cm fluid-filled mass adjacent to the right ureter is consistent with a bladder diverticulum (arrow). No enlarged lymph nodes are visible. Note that the posterior bladder wall mass is contiguous with the seminal vesicles and prostate gland, raising the possibility of invasion of these organs.

Differential Diagnosis

Causes of circumferential bladder wall thickening include acute versus chronic infection or inflammation (including tuberculosis, schistosomiasis, or cystitis from other causes), or muscular hypertrophy secondary to bladder outlet obstruction or a neurogenic origin. In this case the eccentric, mass-like component raises the suspicion of tumor, either malignant (such as transitional cell carcinoma or, less commonly, squamous cell carcinoma, or leiomyosarcoma) or benign (neurofibroma, hemangioma). A pheochromocytoma can also arise from the bladder, most commonly at the trigone.

Diagnosis

Radical prostatocystectomy specimen revealed transitional cell carcinoma with invasion of the muscularis, circumferentially involving the bladder base. Carcinoma in situ was seen at the right ureteral margin along with a right sided bladder diverticulum. There was also invasion of the prostate, local lymph nodes and vascular structures.

Discussion

Carcinoma of the bladder epithelium is the most common tumor of the genitourinary tract, with transitional cell carcinoma accounting for 90% of all bladder malignancies. Bladder carcinoma peaks in the seventh decade; males predominate by 3:1. Hematuria, in the abscence of initiative symptoms, is the most common clinical presentation. Chemical agents such as aniline, biological agents (coffee, artificial sweeteners), radiation, chronic urothelial irritation, and nicotine are associated with bladder carcinogenesis.

Squamous cell carcinoma, which accounts for 5% of all bladder tumors, is most prevalent in patients with chronic inflammatory diseases of the bladder, especially bilharziasis. Adenocarcinoma (2% of all epithelial bladder tumors) is the most common tumor found in the dome of the bladder in the region of the urachal remnant. Squamous cell carcinoma and adenocarcinoma have poor prognoses.

Only 60% of known bladder tumors are detected on urograms. Bladder tumors cause nonspecific intravesical filling defects. The stipple sign (contrast trapped within interstices of tumor) suggests transitional cell carcinoma. CT cannot accurately depict the depth of invasion of the bladder wall and cannot distinguish edema or inflammatory changes from tumor. CT can accurately evaluate perivesical and local pelvic extension. MRI is superior to CT in determining local tumor growth and detection of bone marrow infiltration. However, it is not yet accurate in determining depth of tumor invasion into the bladder wall and is limited in the differentiation of tumor and edema or inflammation.

References

1. The role of MR imaging in carcinoma of the urinary bladder. AJR 1993;160:937-947.

2. Davidson AJ, Hartman DS. Radiology of the kidney and urinary tract. Philadelphia:WB Saunders, 1994.

3. Pollack HM, Banner MP. Clinical urology: an atlas and textbook of urological imaging. Philadelphia: WB Saunders, 1990.

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