Which findings on IV urography (IVU) are characteristic of transitional cell carcinomas (TCCs)?

Updated: Mar 18, 2019
  • Author: Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR; Chief Editor: Eugene C Lin, MD  more...
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The most common findings in TCC of the kidney are single or multiple filling defects in the renal pelvis, as seen in 35% of cases. In about 26% of patients with renal TCC, the calyx is dilated; such dilation is caused by partial or complete obstruction of the infundibulum. Amputation of the calyx may be seen in 19% of cases.

In 13-31% of cases, the affected kidney is not visualized. Such failure to visualize the kidney is usually secondary to hydronephrosis but can be the result of tumor infiltrating and replacing functioning kidney or of occlusion of the renal vein. Hydronephrosis with renal enlargement caused by tumoral obstruction of the ureteropelvic junction may be seen in 6% of cases. (See the images below.)

Localized views of the right vesicoureteric juncti Localized views of the right vesicoureteric junction obtained after intravenous urography shows a polypoid filling defect in the lower right ureter due to a transitional cell carcinoma.
A 10-minute intravenous urogram in a 56-year-old m A 10-minute intravenous urogram in a 56-year-old man presenting with hematuria. The image shows a mass lesion in the right renal pelvis that bisects the renal sinus and splays the adjacent calyces.
Scout radiograph in a 53-year-old man presenting w Scout radiograph in a 53-year-old man presenting with hematuria shows a few small vague opacities in the left renal area; these are suggestive of renal calculi.
Intravenous urogram shows 2 filling defects: 1 in Intravenous urogram shows 2 filling defects: 1 in the upper pole and 1 in the lower-pole calyces. Conventional tomographic results (bottom) confirm the findings.
An intravenous urogram in a 36-year old woman who An intravenous urogram in a 36-year old woman who presented with evidence of a urinary tract infection and gross hematuria. A 10-minute intravenous urogram shows a filling defect in the lower pole calyx on the right. A provisional diagnosis of transitional cell carcinoma was made. Subsequent investigations and the course of events proved that the filling defect was caused by a blood clot related to the hematuria secondary to acute pyelonephritis.

Various signs have been described in renal TCC. The stipple sign is a rare sign that occurs when contrast material is trapped within the interstices of a papillary tumor. When this is seen en face, the tumor appears to contain multiple stipples. This sign is highly suggestive of TCC. When this sign is seen, blood clots and radiolucent calculi are excluded, and further investigations are superfluous. Punctate calcification on a TCC may mimic the stipple sign.

Punctate calcification is unusual in TCC; such calcification is apparent on the scout image before the intravenous contrast material is delivered. Occasionally, contrast material may be trapped within a blood clot formed in the ureter and then extruded into the bladder as a stringy mass that may trap contrast material in an irregular fashion. However, this entrapment is coarser than that seen with neoplastic stippling.

Fungus balls or mycetoma may also occasionally entrap contrast material. The pattern of entrapment is lamellar; such entrapment is frequently associated with gas formation (frequently, patients have poorly controlled diabetes with urinary tract infections). Rarely, stippling may be observed in tubular ectasia when papillae containing dilated ducts of Bellini are seen en face. Inspection of the other papillae may make the diagnosis obvious.

Phantom calyx represents the failure of a calyx to opacify because of obstruction. Oncocalyx represents calyceal distension caused by the tumor.

In contrast to renal TCC, ureteric tumors show single or multiple filling defects in only 19% of cases. This observation is associated with hydronephrosis and hydroureter in 34% of cases; in advanced cases, it may be associated with a nonfunctioning kidney.

Bladder TCC also shows an irregular filling defect with broad base and fronds. Increased thickness of the bladder wall in the region of the tumor should indicate infiltration.

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