What is the role of CT scanning in the workup of urothelial tumors of the renal pelvis and ureters?

Answer

Noncontrast CT scanning can be performed, followed by a contrast study, with particular interest in the excretory phase — a so-called CT urogram. Plain radiography, which demonstrates drainage and anatomy, can also be performed after CT scanning. Transitional cell carcinomas (TCCs) are usually visible as an irregular filling defect. They tend to be hypovascular in comparison with the rest of the kidney and demonstrate minimal increased attenuation (enhancement) following intravenous contrast injection. See the images below.

CT scan demonstrating right renal pelvis upper tract urothelial carcinoma (UTUC). Contrast in the renal pelvis is displaced by the tumor. Courtesy of Andrew J. Taylor, MD, University of Wisconsin Medical School.

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CT scan demonstrating left distal ureteral upper tract urothelial carcinoma (UTUC). The left ureter is dilated and a medial filling defect is noted. Courtesy of Andrew J. Taylor, MD, University of Wisconsin Medical School.

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CT scanning sensitivities and specificities based on lesion size are as follows:

For lesions 5-10 mm in size - 96% sensitivity and 99% specificity
For lesions smaller than 5 mm in size - 89% sensitivity
For lesions smaller than 3 mm in size - 40% sensitivity

CT scanning has limited value in staging TCC because stage Ta or superficial lesions cannot be differentiated from T2 or invasive lesions (see Staging). However, CT scanning is helpful in demonstrating peripelvic or periureteral tumor extension, thereby assisting with staging of aggressive disease. Hydronephrosis and obstruction are associated with a higher degree of invasiveness.

As with CT scanning, magnetic resonance imaging (MRI) is also of limited use in staging early TCC; however, it may have greater utility in more advanced disease or in patients with limited renal function. European Association of Urology guidelines note that although CT urography is generally preferred to MRI urography for diagnosing and staging, MR urography is indicated in patients who cannot undergo CT urography, usually when radiation or iodinated contrast media are contraindicated. However, the use of MR urography with gadolinium-based contrast media should be limited in patients with severe renal impairment (creatinine clearance < 30 mL/min), due to the risk of nephrogenic systemic fibrosis.^[1]

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Media Gallery

Intravenous pyelogram (IVP) demonstrating an upper calyx filling defect characteristic of upper tract urothelial carcinoma (UTUC). Blunting of the involved calyx is noted. Courtesy of Andrew J. Taylor, MD, University of Wisconsin Medical School.
CT scan demonstrating right renal pelvis upper tract urothelial carcinoma (UTUC). Contrast in the renal pelvis is displaced by the tumor. Courtesy of Andrew J. Taylor, MD, University of Wisconsin Medical School.
CT scan demonstrating left distal ureteral upper tract urothelial carcinoma (UTUC). The left ureter is dilated and a medial filling defect is noted. Courtesy of Andrew J. Taylor, MD, University of Wisconsin Medical School.
Left retrograde ureterogram demonstrating the classic "goblet" sign of ureteral upper tract urothelial carcinoma (UTUC). Ureteral dilation distally and proximally to the tumor is present. The narrowed wall of the ureter is irregular. Courtesy of Andrew J. Taylor, MD, University of Wisconsin Medical School.
CT scan demonstrating bulky right renal pelvis upper tract urothelial carcinoma (UTUC) replacing the majority of the renal parenchyma. A pericaval lymph node metastasis is noted. Courtesy of Andrew J. Taylor, MD, University of Wisconsin Medical School.
CT scan demonstrating metastatic upper tract urothelial carcinoma (UTUC) of the right adrenal gland. A heterogeneous adrenal mass is noted adjacent to the spine. The superior portion of the right kidney is observed. Courtesy of Andrew J. Taylor, MD, University of Wisconsin Medical School.
Graphic representation of templates for lymph node dissection in patients with upper tract urothelial carcinoma, as proposed by Matin et al. For tumors in the right pelvis and upper ureter, dissection encompassing the right hilar, paracaval, and retrocaval regions (orange) will remove 82.9% of the involved lymph nodes. Adding the inter-aortocaval region (green) will improve coverage to 95.8%. For left-sided pelvic tumors, removal of hilar and para-aortic lymph nodes (violet) will ensure removal of 86.9% of the involved nodes. Adding inter-aortocaval lymph nodes (green) will increase the coverage to 90.2% of involved nodes. The level of dissection along the great vessels varies for pelvic tumors. The lower limit is the inferior mesenteric artery. For upper ureteric tumors, dissection should extend up to the aortic bifurcation. For distal ureteric tumors, pelvic template dissection involving the common iliac, external iliac, obturator, and internal iliac nodes will remove 75% of involved nodes on the right side and 83.3% of involved nodes on the left side (orange and violet circles). However, adding paracaval groups for tumors on the left side (orange rectangle) and para-aortic groups for those on the right side (violet rectangle) will improve coverage to almost 100%.

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Author

Kyle A Richards, MD, FACS Assistant Professor, Department of Urology, University of Wisconsin School of Medicine and Public Health; Chief of Urology, Division of Urology, William S Middleton Memorial Veterans Hospital

Kyle A Richards, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Urological Association

Disclosure: Nothing to disclose.

Coauthor(s)

David F Jarrard, MD Professor of Urologic Surgery and Molecular and Environmental Toxicology, Clinical Vice Chair, John P Livesey Chair in Urologic Oncology, Associate Director for Translational Reserach, Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health

David F Jarrard, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, Society of University Urologists

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: AUA Journal of Urology<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical; Olympus, .

Additional Contributors

Leonard Gabriel Gomella, MD, FACS The Bernard W Godwin Professor of Prostate Cancer Chairman, Department of Urology, Associate Director of Clinical Affairs, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University

Leonard Gabriel Gomella, MD, FACS is a member of the following medical societies: American Association for Cancer Research, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Urological Association, Sigma Xi, The Scientific Research Honor Society, Society for Basic Urologic Research, Society of University Urologists, Society of Urologic Oncology

Disclosure: Received consulting fee from GSK for consulting; Received honoraria from Astra Zeneca for speaking and teaching; Received consulting fee from Watson Pharmaceuticals for consulting.

Tracy Downs, MD Associate Professor of Urology, University of Wisconsin School of Medicine and Public Health

Tracy Downs, MD is a member of the following medical societies: American College of Surgeons, American Urological Association, Society of Urologic Oncology

Disclosure: Nothing to disclose.

Aaron M Potretzke, MD Resident Physician, Department of Urology, University of Wisconsin Hospital and Clinics

Aaron M Potretzke, MD is a member of the following medical societies: American Medical Association, Minnesota Medical Association

Disclosure: Nothing to disclose.

Shivashankar Damodaran, MB, MCh Fellow in Urologic Oncology, Department of Urology, University of Wisconsin School of Medicine and Public Health

Shivashankar Damodaran, MB, MCh is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Acknowledgements

Daniel M Kaplon, MD Fellow in Endourology, Laparoscopy, and Robotics, Department of Urology, University of Wisconsin Medical School

Disclosure: Nothing to disclose.

John N Papadopoulos, MD Resident Physician, Department of Urology, Veterans Administration Hospital and Meriter Hospital

Disclosure: Nothing to disclose.

Dan Theodorescu, MD, PhD Paul A Bunn Professor of Cancer Research, Professor of Surgery and Pharmacology, Director, University of Colorado Comprehensive Cancer Center

Dan Theodorescu, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Urological Association, Medical Society of Virginia, Society for Basic Urologic Research, and Society of Urologic Oncology

Disclosure: Key Genomics Ownership interest Co-Founder-50% Stock Ownership; KromaTiD, Inc Stock Options Board membership

Michael N Wilkin, MD Staff Physician, Division of Urology, University of Wisconsin Hospital and Clinics

Disclosure: Nothing to disclose.

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