DR Mehri Sirous

1. DR MehriSirous Imaging of Bladder Cancer

2. fig. 1. A coronal maximum intensity projection image obtained from excretory phase CT urography (CTU) shows bilateral urinary collecting systems and bladder are opacified with contrast.

3. Fig. 2. 85-year-old woman who has history of bladder cancer, statuspostcystectomy. (A)Coronal MIP image from the excretory phase shows narrowing of a left upper pole infundibulum (arrow). (B) Axial source image obtainedduringthe excretory phase shows corresponding nodular thickening to the urothelium at this location(arrow), which subsequently was proven to represent transitional cell carcinoma on surgical pathology

4. Fig. 3. 85-year-old woman who has transitional cell carcinoma (TCC) of the left renal collecting system. (A)Axialexcretoryphase CTU image demonstrates a discrete nodular filling defect (arrow) within the left renal pelvis. (B)A sagittal oblique MIP reconstruction image of the left kidney demonstrates the tumor (T) within the renal pelvisas seen on A, as well as focal urothelial thickening with irregular narrowing of the upper pole calyx (arrow).

5. Fig. 4. 58-year-old man who has TCC of the right renal pelvis. (A) Axial contrast-enhanced CTU image duringparenchymalphase demonstrates enhancing tumor (arrows) in the right renal pelvis. (B) On axial excretoryphaseCTU images, this lesion persists as a filling defect (T). (C) MIP reconstruction image of the right kidney in the coronal oblique plane provides an IVP-like image and demonstrates the overall extent of the tumor(T). The upper pole calyx is dilated and does not demonstrate contrast excretion, caused by tumor obstruction

6. Fig. 5. 82-year-old man’s status after cystectomy and ilealneobladderreconstruction for bladder cancer, presenting with negative urine cytology. (A) Axial parenchymal phase CTU image shows left ureteral narrowing with mild wall thickening at the level where the ureter crosses the abdominal midline (arrow) right ureteralstump.(B) A coronal thin MIP reconstructed from the excretory phase CTU images confirms the segmental narrowing of distal left ureter as shown on A (arrows). This finding was stable on multiple subsequent surveillance CTUs and considered most likely to be a postoperative change.

7. Fig. 6. 77-year-old man who has TCC of the bladder. (A)Parenchymal phase CTU image demonstrates a 5-mmenhancing papillary lesion (arrow) arising from the anterior bladder wall. (B) Excretory phase images do not readily demonstrate the lesion, as the non-dependent portion of the urine in the bladder is not opacified with contrast. (C). Repeat excretory phase image in the prone position demonstrates the pedunculatedtumor as a discrete filling defect (arrow).

8. Fig. 7. 72-year-old man who has bladder cancer. (A) Early parenchymal phase CTU image demonstrates a bladder mass (arrow) with avid enhancement. (B) Excretory phase CTU image demonstrates the lesion as a papillary, nodular filling defect (arrow) in the opacified bladder adjacent to the left ureterovesicular junction (UVJ). (C) Coronal thin MIP image from excretory phase CTU images demonstrates the mass as a filling defect (arrow) adjacent to the left UVJ.

9. Fig. 8. 67-year-old man who has metastatic bladder cancer. Contrast-enhanced CT image demonstrates a large enhancing mass in the anterior bladder wall (long arrow). The mass has grown through the bladder wall with anterior perivesical soft tissue (short arrow) indicative of perivesical invasion.

10. Fig. 9. 65-year-old man who has remote cystectomy for bladder cancer. Axial contrast-enhanced CT image demonstrates a lytic metastatic lesion in the left acetabulum with large soft tissue component and invasion into the adjacent internal obturator muscle (arrows).

11. Fig. 10. 85-year-old woman who has metastatic bladder cancer. (A) Contrast-enhanced CT image of the abdomen shows an enhancing soft tissue nodule (arrow) anterior to the left psoas muscle consistent with metastatic disease. (B) Contrast-enhanced CT image of the abdomen shows metastatic retroperitoneal adenopathy (*).

12. Fig. 11. 64-year-old woman who has bladder cancer. (A) Sagittal T2 weighted MR image (TR 5167 milliseconds, TE107 milliseconds, field of view 20 cm, matrix 384 256) demonstrates a large bladder mass with invasion of the urethra, anterior uterine myometrium and vagina (arrows). (B) Axial T2 weighted MR image (TR 4400 illiseconds, TE 108 milliseconds, field of view 20 cm, matrix 256 192) demonstrates the large bladder mass with gross extravesicalinvasion, uterine invasion, and obstruction to the right ureter (arrow). (C) Sagittalcontrast enhanced T1 weighted MR image (TR 190 milliseconds, TE 4.2 milliseconds, field of view 28 cm, matrix 256 128) demonstrates avid enhancement (within the large tumor (arrow

13. Fig. 12. 58-year-old man who has bladder cancer. (A) Axial T2 weighted image (TR 5000 milliseconds, TE 112 milliseconds, field of view 20 cm, matrix 448 256) demonstrates multifocal papillary lesions (arrows) projecting into the bladder lumen. The bladder lesions demonstrate slightly higher T2 signal compared with the bladder wall. Note that an intact, low-signal intensity muscle layer is present at the bases of the tumors. The patient was confirmed to have stage T1 bladder cancer on pathology. (B) On axial T1 weighted image (TR 550 milliseconds,TE11 milliseconds, field of view 34 cm, matrix 256 128), the bladder tumors (arrows) demonstrate intermediate signal intensity similar to that of the bladder wall.

14. Fig. 13. 67-year-old man who has metastatic bladder cancer. (A) Axial T2 weighted image (TR 4567 milliseconds , TE 98 milliseconds, field of view 18 cm, matrix 256 224) demonstrates a large infiltrating tumor (vertical arrow)in the anterior bladder wall. The normal low signal of anterior bladder wall muscle is replaced by the intermediate tumor signal throughout its entire thickness, indicative of deep muscle invasion. The outer border is irregular and shaggy, with an ill-defined soft tissue nodule (horizontal arrow) in the prevesical fat, indicating perivesicalinvasion. (B) On axial T1 weighted image (TR 600 milliseconds, TE 14 milliseconds, field of view 32cm, matrix 256 192), the bladder tumor (vertical arrow) demonstrates intermediate signal intensity similar to that of the bladder wall. Perivesical invasion also is seen on this T1 weighted image (horizontal arrow).

15. (C)Sagittal contrast-enhanced T1 weighted image with fat suppression (TR 3.9 milliseconds, TE 1.9 milliseconds,field of view 24cm, matrix 256 192) demonstrates early and avid enhancement in the anterior bladder mass (oblique arrow). Also note the enhancing soft tissue in prevesical fat indicating perivesical tumor invasion (horizontal arrow).

17. Fig. 14. 75-year-old man who has bladder cancer. Longitudinal ultrasound image of the bladder demonstrates a large intraluminal bladder mass. Biopsy of the mass revealed invasive high-grade urothelial carcinoma with sarcomatoid features, myxoid background, and extensive necrosis.

18. Fig. 15. 47-year-old man who has bladder cancer. Transverse ultrasound image of the bladder demonstrates bilateral intraluminal bladder masses (arrows). Feeding blood vessels in the masses are documented by color Doppler. Radical cystectomy was performed, and urothelial carcinoma was found with perivesical invasion.

19. Fig. 16. 65-year-old man who has multiple myeloma presenting with hematuria. Oblique ultrasound image of the bladder demonstrated a well-defined echogenicmass in the dependent portion of the bladder. Doppler ultrasound did not detect any vascularity within this mass. This mass resolved in a fewdayswith bladder irrigation, consistent with a blood clot.

20. Fig. 17. 68-year-old man who has TCC arising from bladder diverticulum with perivesical invasion. (A) Excretory phase CTU image demonstrates a right bladder diverticulum(arrow). (B) More superior portion of the bladder diverticulum demonstrates a filling defect indicative of a soft tissue mass (arrow). This was confirmed to be TCC with perivesicalinvasion on surgical pathology. Mild asymmetric thickening of the right bladder wall also was noted, proven to represent post biopsy reactive changes on pathology

21. Fig. 18. 20-year-old woman who has Hodgkin’s and non-Hodgkin’s lymphoma status after bone marrow transplant, presenting with gross hematuria. Hemorrhagic cystitis was diagnosed on cystoscopy. (A)Contrast-enhanced CT image of the pelvis demonstrated circumferentially thickened bladder wall with vague intraluminalareas of increased attenuation (arrows). (B) Ultrasound image obtained 4 days after the CT demonstrated thickened bladder wall and intraluminalechogenicareas (arrows) consistent with blood clots, corresponding to the areas of increased attenuation on CT.

22. Fig. 19. 64-year-old man’s status after resection of stage T1 high-grade bladder TCC, presenting with chills, arthralgias, and myalgias after commencing second course of intravesical BCG treatment. (A)Contrast-enhanced CT image of the pelvis demonstrated focal nodular thickening with enhancement of the left anterior bladder wall (arrow), which was new compared with prior examinations. After treatment with antituberculosis medications, this completely resolved. Subsequent biopsy showed only inflammatory cells.

23. Fig. 20. 49-year-old man who has urachaladenocarcinoma. Axial contrast-enhanced CT demonstrated a 2 cm focal area of soft tissue thickening (arrow) at the bladder dome with extension into the adjacent perivesicalfat. Patient underwent a partial cystectomy, excision of urachus, and umbilicus. Pathology revealed an urachaladenocarcinoma.

24. Fig. 21. 47-year-old woman who has lymphoma. Contrast-enhanced CT image of the abdomen demonstrated diffuse asymmetric left bladder wall thickening (arrow). Note the presence of air in nondependent portion of the bladder from recent instrumentation.

25. Fig. 22. 57-year-old woman with high-grade sarcomatoid carcinoma of the bladder. Contrast-enhanced CT image of the pelvis (A) and ultrasound image of the bladder (B) demonstrate a poorly defined large mass (arrows) involving the left lateral wall of the bladder with left hydronephrosis (not shown), and invading the vagina and lower uterine segment.

26. Fig. 23. 74-year-old man who has invasive neuroendocrine small cell carcinoma of the bladder. Contrastenhanced CT of the pelvis demonstrates an enhancing 2 1 cmsoft tissue mass (arrow) in the left posterolateral bladder wall.

27. Fig. 24. 64-year-old man’s status after recent transurethral resection of noninvasive bladder tumor. Contrast-enhanced CT image of the pelvis demonstrated posterior bladder wall thickening with superficial enhancement along the bladder mucosa (arrows), and the presence of perivesical inflammatory change.

28. Fig. 25. 52-year-old man who has worsening fever, chills, and night sweats after intravesical BCG therapy for bladder cancer. (A) Contrast-enhanced CT image of the abdomen demonstrated a large hypoattenuating mass (*) in the midportion of the left kidney. After several weeks of antituberculosis therapy, the lesion significantly decreased in size (not shown), and the patient’s constitutional symptoms resolved

29. Fig. 26. 67-year-old man’s status after intravesicalBCG treatment of bladder cancer, presenting with elevated prostate-specific antigen and palpable prostate nodule on digital rectal examination. Axial T2weighted endorectal MR image of the prostate (TR 5017 milliseconds, TE 100 milliseconds, field of view14 cm, matrix 256 192) demonstrates a large nodule (arrows) at the base of the posterior peripheral zone with capsular bulging, corresponding to the nodule palpated on digital examination. Subsequent ultrasound-guided prostate biopsy confirmed granulomatousprostatitis.

30. The End