Carcinomas are less common than benign lesions. Pain, rapid growth, and neurological involv ement (facial nerve palsy) all suggest malignancy. Imaging Ultrasound Suspected salivary gland tumors should be investigated by ultrasound in the \201 rst instance. Fine needle aspiration can also be performed, but cross- sectional imaging will often be required in addition. CT Findings depend on the particular tumor, but in general CT allows easy assessment of all the major salivary glands, tumor extent and depth, and regional nodal involvement (Fig. 13.13 ). MRI Allows more accurate assessment of the facial nerve than CT in cases of parotid maligna ncy and therefore useful prior to surgery (Fig. 13.14 ). Information for the radiologist \200 History and clinical \201 ndings are important for deciding the most appropriate investigations. Contraindications to IV contrast or MRI will help guide imaging. \200 If recurrence of ma lignant disease is suspected then a detailed history of previous surgery and radiotherapy is necessary to interpret dif \201 cult imaging \201 ndings. SUBASH KC/NMC-15TH/2014 PAROTID AND SUBMANDIBULAR SALIVARY GLANDS: tumors 195 Fig. 13.13 Axial CT image reveals a large, partly necrotic tumor arising from the left paro tid. This was a squamous carcinoma. Fig. 13.14 reveals a well de \201 ned homogeneous lesion in the gland. Biopsy con \201 rm ed a benign cyst. Heavily T2-weighted (with fat saturation) MR image of the left parotid SUBASH KC/NMC-15TH/2014 196 CHAPTER 13 Head and neck conditions Branchial cleft cysts These benign neck cysts usually appear before the age of 30. The 1 br anchial cleft develops into the external auditory canal. The 2nd, 3rd, and 4 th branchial c lefts merge to form the sinus of His, which will normally involute. When a branchial cleft does not properly involute, a branchial cleft cyst forms. See Table 13.1 for classi \201 c ation. st Clinical presentation Branchial cysts are usually asymptomatic, but they may become painful due to secondary infection. Alternatively, they may present with local mass effect such as respiratory compromise. Fine needle aspiration yields pus-like \202 uid that is rich in cholesterol crystals. The treatment is surgical excision. However, recurrence rates of up t o 20 % are reported. Imaging Ultrasound Useful initial investigation of any neck mass (Fig. 13.15a sound can con \201 rm the position and cystic nature of the mass, it does not adequately evaluate the e xtent and depth of neck lesions. ). Although ultra- MRI This more reliably con \201 rms the cystic nature of the mass and provides precise de \201 nition of the extent of the lesion and its relationship to surrounding structures (Fi g. type I 1 st branchial cleft cysts and for parapharyngeal masses that may be 2 nd branchi al cleft cysts. Wall thickness and enhancement following IV contrast administration varies according to the severity of any associ- ated infective/in \202 ammatory process. 13.15b ). MRI is especially advantageous for CT Branchial cleft cysts appear as well-de \201 ned, ovoid, \202 uid- \201 lled lesions . Information for the radiologist \200 Symptoms and signs at presentation. \200 Presence of raised in \202 ammatory markers (WCC, CRP). \200 Any clinical suspicion of malignancy (metastatic squamous cell carcinoma to cervical nodes may mimic a branchial cleft cyst). SUBASH KC/NMC-15TH/2014 BRANCHIAL CLEFT CYSTS 197 (a) (b) Fig. 13.15 in the right neck reveals a well-de \201 ned cystic lesion. b) Coronal T2c weig hted MR scan from the same patient as (a) con \201 rms the anatomical position and benign characteristics of a 2 a) Ultrasound image from a 19-year-old man with a painless swelling nd branchial cleft cyst. SUBASH KC/NMC-15TH/2014 198 CHAPTER 13 Head and neck conditions Table 13.1 Types of branchial cleft cysts 1 st Type I: located near the external auditory canal, most commonly inferior and posterior to t he tragus. May also be in the parotid gland or at the angle of the mandible Type II: associated with submandibular gland or found in the anterior triangle of the neck 2 nd Accounts for 95 % of branchial anomalies May present anywhere from the skin of the lateral neck, between the internal and external c arotid arteries, and into the palatine tonsil Most commonly seen along the anterior border of the upper 1/3 of sternocleidomastoid 3 rd Rare Characteristically located deep to sternocleidomastoid within the posterior triangle of the neck 4 th Extremely rare Arise in various locations, paralleling the course of the recurrent laryngeal nerve, includ ing the thyroid gland and mediastinum SUBASH KC/NMC-15TH/2014 199 Chapter 14 Genitourinary differential diagnosis Bladder \201 lling defects Renal calci \201 cation 200 Testicular lesions 200 Adrenal ca lci \201 cation 201 Dilated ureter 200 201 SUBASH KC/NMC-15TH/2014 200 CHAPTER 14 Genitourinary differential diagnosis Bladder \201 lling defects \200 Blood clot. \200 Tumor (transitional cell carcinoma ( TCC) adult and rhabdomyosarcoma child). Calculus. \200 Infection/debris. \200 Prostate. \200 Foreign body. \200 Ureterocoel e. Renal calci \201 cation \200 Calculi. \200 Dystrophic calci \201 cation due to locali zed disease: Infection. \200 Carcinoma. \200 Aneurysm. \200 Nephrocalcinosis: Medullary: hyperparathyroidism, renal tubular acidosis, medullary sponge kidney etc. Cortical: acute cortical necrosis, chronic glomerulonephritis, chronic transplant rejection. Testicular lesions Testicular masses \200 Germ cell tumors (GCTs): Seminoma: most common testicular tumor in adult. \200 Embryonal carcinoma: 20 \200\22325 % GCT. \200 Choriocarcinoma: rare. \200 Teratoma: 5 \200\22310 % . Non-germ cell tumors: usually benign. \200 Lymphoma or leukemia: may relapse in testis. \200 Metastases: kidney, prostate, bronchus, pancreas. \200 Orchitis. Extra testicular masses \200 Varicocoele. \200 Hydrocoele. \200 Hernia. \200 Testic ular torsion. \200 Epididymitis. \200 Epididymal cyst. \200 Scrotal trauma/oedema. Causes of hydrocoele \200 Congenital. \200 Infantile. \200 Secondary to trauma, infec tion, torsion, or neoplasm. SUBASH KC/NMC-15TH/2014 DILATED URETER 201 Adrenal calci \201 cation \200 Cyst. \200 Carcinoma: irregular, punctate calci \201 c ations. \200 Addison \200\231s disease. \200 Ganglioneuroma. \200 In \202 ammatory: TB/histoplasmosis. \200 Phaeochromocytoma. \200 Ureterocoele. Dilated ureter Obstruction Within the lumen: \200 Calculus. \200 Blood clot. \200 Slo ughed papilla. In the wall: \200 Oedema secondary to a stone. \200 Tumor. \200 TB. \200 Post surgi cal. \200 Ureterocoele. \200 Megaureter. Outside the wall: \200 Retroperitoneal \201 brosis. \200 Carcinoma (cervix, prostate, bladder, rectum). \200 Retrocaval ureter. \200 Pregnancy/postpartum. Other: \200 VUR. \200 Infection. SUBASH KC/NMC-15TH/2014 This page intentionally left blank SUBASH KC/NMC-15TH/2014 203 Chapter 15 Genitourinary presenting syndromes Acute pelvic pain 204 Chronic pelvic pain 206 Acute renal failure 207 Haematuria 208 Hydron ephrosis Hypertension 210 Intermenstrual bleeding 211 Postmenopausal bleeding 212 Testicula r pain 213 209 SUBASH KC/NMC-15TH/2014 204 CHAPTER 15 Genitourinary presenting syndromes Acute pelvic pain Acute pelvic pain is a common presenting complaint, especially in women. However, in addition to gynecological causes there are many other aetiologies: Causes Gynecological \200 Ectopic pregnancy. \200 Ovarian cyst: hemorrhage, torsion. \200 Hydrosalpinx. \200 Mittelschmertz. Urological \200 Renal colic. \200 Cystitis. \200 Acute urinary retention. Surgical \200 Acute appendicitis. \200 Diverticulitis. \200 Localized perforation. \200 In \202 ammatory bowel disease (although likely to be previous episodes). \200 Rup tured iliac aneurysm. \200 Strangulated inguinal/femoral hernia. Clinical presentation The exact presentation depends on the underlying etiology. A thorough history and examination should be conducted in order to establish the most appropriate differential diagnosis. Symptoms \200 Dysuria. \200 Frequency. \200 Haematuria. \200 Signs of sepsis: pyrex ia, night sweats. \200 Menorrhagia. \200 Amenorrhea. \200 Increased bowel frequency. Imaging Pelvic ultrasound Transabdominal (TA) transvaginal (TV) will aid in diagnosing a n ectopic pregnancy or ovarian problems. However, a normal ultrasound in a patient with a p ositive pregnancy test does not rule out an ectopic. \200 Ectopic pregnancy. \200 Ovari an cyst hemorrhage. \200 Dilated fallopian tubes, consistent with hydro-/pyosalpinx. Renal ultrasound \200 Hydronephrosis. \200 Urinary calculi. SUBASH KC/NMC-15TH/2014 ACUTE PELVIC PAIN 205 CT KUB (kidneys, ureters, and bladder) This is used to look for urinary tract calculi. CT abdomen and pelvis \200 For surgical causes of acute pelvic pain, a CT of the abdomen and pelvis is performed. Evaluation of signs of free \202 uid, gas, and in \202 ammation of the bowel. Information for the radiologist \200 Pregnancy test result. \200 Most likely diagnosis \200\224 to aid in appropriate imaging choice. \200 Creatinine level if IV contrast is t o be given. \200 Previous history of urinary calculi or tumors. \200 History of previou s operations. SUBASH KC/NMC-15TH/2014 206 CHAPTER 15 Genitourinary presenting syndromes Chronic pelvic pain This is a common problem among women aged 20 \200\22350 years; accounti ng for 20 \200\22340 % of all gynecological outpatient appointments. The main differential diagnoses include: \200 Endometriosis. \200 Adenomyosis. \200 Pelvic in \202 ammator y disease. \200 Pelvic congestion. \200 Fibroids. \200 Adhesions. \200 Irritable bo wel syndrome. \200 Interstitial cystitis. Clinical presentation Considerable overlap of symptoms in these patients: \200 Dysmenorrh oea. \200 Dyspareunia. \200 Menorrhagia. \200 Fertility problems. \200 Dysuria. Imaging Ultrasound: TA TV \200 Features of endometriosis, e.g. endometrial cysts may b e demonstrated. Smaller endometrial deposits are not easily identi \201 ed on ultrasound. Adenomyosis. \200 Uterine \201 broid. \200 Pelvic varices may be demonstrated using D oppler ultrasound. Pelvic MRI MR is superior to CT in the investigation of pelvic organs. \200 Endometriosis , in particular endometrial deposits, are identi \201 ed better on MR than using ultrasound. Ovarian cysts/masses can be characterized. \200 The blood supply to \201 broids can be assessed for suitability for embolization techniques. Hysterosalpingography This uses a radio-opaque dye to test the patency of the uterine cavit y and fallopian tubes. Venography This can be used to diagnose and treat pelvic varices in pelvic congestion syndr ome . Angiography This technique can be used to embolize and therefore cut off the blood supply t o treat uterine \201 broids. SUBASH KC/NMC-15TH/2014 ACUTE RENAL FAILURE 207 Acute renal failure Deterioration in renal function over hours/days, patient is likely to b e sys- temically unwell and is usually oliguric. Determining causation is vital to direct m anagement. \200 Pre-renal cause : decreased renal perfusion, commonly dehydration. Consider vascular compromise: renal artery stenosis or renal vein thrombosis. Renal cause : acute tubular necrosis (ATN), glomerulonephritis, or interstitial nephritis. Precipitating factors include circulatory collapse, nephrotoxins, medications, and vasculit is. Post renal cause : obstructive uropathy. At the renal pelvis or ureteric level the cause may be intraluminal (stones, pus, haematoma), mural (TCC or in \202 ammato ry) or extra-mural (intra-abdominal/pelvic malignancy or retroperitoneal \201 brosis). Pa thology in the bladder or prostate is also a common cause of obstruction. The initial asses sment is to measure the urine output with catheterization if required. Imaging Ultrasound To assess for hydronephrosis \200\224 if acute this is evidence of obst ruction. A cause should be sought such as the presence of a mass or calculi. Renal parenchy ma, size and contour of the kidney is important to determine the presence of chronic atroph y. CT Caution required for the administration of IV contrast with pre-scan optimal rehydration mandatory. Quoting absolute creatinine levels as a contraindication to IV contrast is a to pic for debate and it is probably unhelpful as risk:bene \201 t assessment is required on a case-by-case basis. Post-scan haemo \201 ltration is possible. NCCT scanning is excellen t to demonstrate stone disease and upstream obstruction can be observed, replacing the IVU. Nephrostomy Percutaneous insertion of a drain through the renal parenchyma into a dilated c alyx, with the tip in the renal pelvis. athy to alleviate renal failure and preserve renal function, or to release infection. Septic obstruction or a single functioning obstructed ki dney should prompt discussion for on-call intervention. Indications: obstructive urop- Information for the radiologist \200 Onset of the renal failure, creatinine levels. \200 What is the urine output? \200 Is there bladder out \202 ow obstruction? \200 Latera lizing signs to suggest a kidney or ureteric cause? \200 Is there a single functioning ki dney? \200 Is the patient septic? SUBASH KC/NMC-15TH/2014 208 CHAPTER 15 Genitourinary presenting syndromes Haematuria Can be frank (visible to inspection) or microscopic (detected on dip test). Alwa ys requires investigation which can be done on an urgent outpatient basis if it is the sole presenting feature. Complications can include reten- tion secondary to clots. Causes \200 Suspect bladder and prostate pathology \201 rst. \200 Stone disease. \200 Malignancy (RCC, TCC, prostate). \200 Infection. \200 Trauma. \200 Renal parenc hymal disease. \200 Urethral pathology. \200 March (microtrauma to red cells, seen in r unners). \200 Hematological paroxysmal nocturnal haemoglobinuria (PNH), bleeding diathesis. Investigation \200 Urine culture and cytology. \200 Flexible cystoscopy. \200 Renal u ltrasound + IVU complete the standard work. \200 Retrograde ureterograms/uretroscopy can be performed in theater by urologists if diagnostic uncertainty remains regarding the upper tracts. CT-IVU are gaining popularity for the investigation of CT-KUB dif \201 cult cases/replacing IVU. Imaging Ultrasound Look for calculi which cast shadows. Assess for renal masses either pare n- chymal (RCC) or collecting system (TCC). Look for dilatation of the pelvi- calyceal syst em or more focal dilatation of a calyx both of which can indicate obstruction from TCC or s tone disease. The bladder should be imaged and a volume obtained post micturition in men to assess for prostatic obstruc- tion. Note ultrasound is no match for cystoscopy in the iden ti \201 cation of bladder pathology. IVU Declining use as CT urography gains popularity. Contraindicated in renal failure and ca ution required in patients taking metformin (stop for 48 hours pre test). CT-KUB/CTU CT-KUB is a NCCT covering the kidneys, ureters, and bladder and is excellent for demonstrating stone disease. CTU adds a second scan after two boluses of IV contrast 6 \200\2238 minutes apart giving excretion and nephro- gram phase imaging. It is excellent fo r demonstrating malignancy. SUBASH KC/NMC-15TH/2014 HYDRONEPHROSIS 209 Hydronephrosis Dilatation of the renal pelvis, due to urinary tract obstruction. Common cau ses are: \200 Luminal: calculus, blood clot, tumor. \200 Wall: ureteric/urethral strict ure, congenital bladder neck obstruction/ urethral valve, neuropathic bladder. Extrinsic: aortic aneurysm, prostatic obstruction, pelvic tumors, diverticulitis. Clinical presentation \200 Loin pain: may be provoked by anything that increases urine vo lume. \200 Complete anuria: suggestive of bilateral obstruction or complete obstruction if single kidney. Infection: malaise, fever, and septicaemia. Imaging Ultrasound Once hydronephrosis is established try to \201 nd cause: \200 Identi \201 cation of renal or bladder calculi. \200 Allows assessment of bladder emptying, th erefore signs of bladder outlet obstruction may be identi \201 ed. If a nephrostomy is required (tube in kidney to relieve the obstruction) ultrasound is used to guide the tube into the dilated calyx. CTU \200 Used to look for presence of urinary tract calci \201 cation. \200 IV contras t is given to assess renal excretion and to look for evidence of any \201 lling defects along the urinary tract (stones or tumors). MRI This technique can be used in patients where there is a contraindication to IV contrast . Nuclear medicine \200 Used (more commonly in children) in obstructive uropathies to look at uptake and excretion. Differential function is calculated. Information for the radiologist \200 Relevant past medical history, i.e. history of malig nancy. Urea and creatinine levels, recent \200\230trend \200\231 in blood results. \200 Clotting if an i ntervention is necessary. SUBASH KC/NMC-15TH/2014 210 CHAPTER 15 Genitourinary presenting syndromes Hypertension Common medical condition characterized by consistently elevated blood pressure . De \201 ned as Hypertension can be either primary or secondary; primary hypertension ess entially means that no cause can be found, accounting for 85 \200\22390 cases. There are ma ny causes of secondary hypertension including chronic renal failure, renal artery stenosis, and tumors such as adrenal adenomas or phaeochromocytomas. > 140mmHg systolic or 90mmHg diastolic. % of Clinical presentation Early hypertension is usually asymptomatic but as the condition progr esses symptoms include dizziness, nausea and vomiting and visual disturbance. High blood pr essure is however a risk factor for many other medical con- ditions such as stroke, heart a ttack, aortic aneurysm, cardiac failure and renal failure. Imaging Plain \201 lm On a chest X-ray hypertension may manifest with cardiomegaly of hea rt failure. In children and young adults coarctation of the aorta may cause hypertension \200\224 in this case the classic \201 nding is notching of the infe- rior surface of the upper ribs. signs Ultrasound Renal ultrasound may be used to look for renal parenchymal disease such as polyc ystic kidney disease or chronic glomerulonephritis. Renal artery Dopplers can also be measu red to assess for signs of renal artery stenosis; however, MRA is more sensitive. Renal tum ors such as renal cell carci- noma and Wilms tumor may also rarely cause hypertension. CT Tumors causing hypertension, e.g. a phaeochromocytoma, may be picked up on CT. The exten t of any atherosclerosis can be assessed, and compli- cations such as aortic aneurysm can b e seen. Angiography Fibromuscular dysplasia is a cause of renovascular hypertension in the young, p articularly women. On angiography the classic \201 nding displayed in the renal arteries is described as the \200\230string of beads sign \200\231. This represents areas of stenos es interspersed with small aneurysms. Echocardiography An echo may show signs of LVH as a result of prolonged systemic hypertensi on. SUBASH KC/NMC-15TH/2014 INTERMENSTRUAL BLEEDING 211 Intermenstrual bleeding Vaginal bleeding (other than postcoital bleeding) which occurs at a ny time during the menstrual cycle which is not during normal menstruation. Causes Many potential causes of intermenstrual bleeding (IMB), some easily diag- nosed, oth ers may require imaging. Causes include: Hormones \200 Combined oral contraceptive pill (COCP): either in too low dose or in combination with an enzyme inducing drug. Progesterone-only pill. \200 Contraceptive depot injections. \200 Intrauterine devices. \200 Emergency contraception. \200 Tamoxifen. Tumors (benign and malignant) \200 Gynecological cancers including vaginal, cervical, and endometrial cancer. \200 Ovarian tumors (usually estrogen secreting tumors). \200 Endo metrial and cervical polyps. \200 Fibroids. Others \200 Following smear test or treatment to the cervix. \200 Cesarean section scar s. \200 Drugs altering clotting parameters, e.g. anticoagulants, SSRIs, corticosteroids. Adenomyosis (ectopic endometrial tissue in the myometrium). Investigation guidelines NICE guidelines for patients presenting with IMB are as follows: \200 A mandatory full pelvic examination, including cervical speculum examination. Do not wait for a smear result or delay due to a previous negative smear result \200\224 refer immediately where there is clinical suspicion. Consider urgent referral for women with persistent IMB but negative examination \201 ndings. Imaging Imaging may not be needed in all cases. Ultrasound First-line investigation. Usually TA and TV pelvic ultrasound will be performed. The endometrial thickness is measured and images of the ovaries, uterus and adnexae are ob tained. CT CT is usually a second-line test if ultrasound has been dif \201 cult or non- conclusiv e. It will also be used in staging of cancers such as ovarian cancer. MRI Will usually be performed if any abnormality is detected on ultrasound. Pelvic masses a re usually characterized using MRI. SUBASH KC/NMC-15TH/2014 212 CHAPTER 15 Genitourinary presenting syndromes Postmenopausal bleeding Endometrial or vaginal atrophy is the most common cause but more si nister causes such as carcinoma must be ruled out. Other causes include trauma or anticoagu lants, hormone replacement therapy, endometrial or cervical polyps, and endometrial hyperpl asia. Imaging \200 Gynecological examination (hysteroscopy) is used in conjunction with imaging. Ultrasound TA imaging is performed \201 rst to gain images of the pelvis and both kidneys . TV ultrasound is used to measure endometrial thickness, generally the greater the endomet rial thickness the greater the chance of sinister pathology. In postmenopausal women, the e ndometrium should be thinner than in pre- menopausal women. A thickness \201 gure of 5mm will mean that sometimes pathology is overlooked, however in cases where clinical suspicion is high then hysteroscopy is also carried out. > 5mm is thought to be abnormal. Using this CT CT would not usually be used a \201 rst line of investigation. Used in staging of canc ers. Intervention such as omental biopsy in cases of ovarian cancer can be performed under CT or ultrasound guidance. MRI MRI is useful in characterizing pelvic masses that have been seen on either ultrasound or CT. The MRI characteristics of a mass can be assessed on different sequences to characte rize it accurately. For example, endometrial cancer has slightly lower signal intensity than normal endometrium on T2 imaging; there may also be disruption of the junctional zone. A de \201 nitive diagnosis is of course only made by endometrial biopsy. Information for the radiologist Any previous gynecological surgery should be noted on the r equest, e.g. hysterectomy and BSO. Any current or previous hormone treatment should also be noted. SUBASH KC/NMC-15TH/2014 TESTICULAR PAIN 213 Testicular pain Causes \200 Testicular torsion. \200 Torsion of the appendix of the tes tis (hydatid of Morgagni). \200 Trauma. \200 Testicular tumor (due to hemorrhage within ). \200 Epididymitis. \200 Orchitis. \200 Varicocoele. \200 Inguinal hernia. \200 Segmental testicular infarction. \200 Renal colic (radiated pain). Imaging Ultrasound The diagnosis of suspected testicular torsion should be made clinically and investigated by surgical exploration without delay. Only in equivocal cases should imag ing be considered (see further details). b Testicular torsion, p. 254 for Ultrasound using a high-frequency probe is the \201 rst-line imaging resource for assessing the scrotum and its contents. It provides high- resolution informati on of both the testes and related structures. In experienced hands, it can reliably differe ntiate between the conditions listed earlier and it is cheap, readily available, and quick to perform. Historically, radionuclide scanning was used in equivocal cases of testicular torsion to as sess testicular blood \202 ow. However, it has become a somewhat redundant technique sinc e the advent of ultrasound. SUBASH KC/NMC-15TH/2014 This page intentionally left blank SUBASH KC/NMC-15TH/2014 215 Chapter 16 Genitourinary conditions Bladder and urothelial cancer Renal cell cancer 218 Testicular cancer 220 Prostate cancer 2 22 Cervical cancer 224 Endometrial cancer 226 Ovarian masses 228 Ovarian cancer 230 Adrenal masses 232 Benign renal masses 234 Pyelonephrosis Renal tract calculi 238 Renal transplant dysfunction Vesico-ureteric re \202 ux 242 Ectopic pregnancy 244 Endometriosis Ovarian to rsion 248 Pelvic in \202 ammatory disease Epididymitis 252 Testicular torsion 216 236 240 246 250 254 SUBASH KC/NMC-15TH/2014 216 CHAPTER 16 Genitourinary conditions Bladder and urothelial cancer \200 Bladder cancer is the commonest malignancy of the urin ary tract; 90 % are transitional cell carcinomas (TCCs). Risk factors: smoking, aromatic chemical exposure. Other primaries of the renal tract inclu de squamous cell cancer (associated with repeated infection or stone disease) and adenocarc inoma. 30 % multifocal, usually with additional sites within the bladder although between 1 \200\2235 % may have proximal disease. Metachronous disease evolves in up to 25 % of cases. Clinical presentation \200 Commonly haematuria although UTI, dysuria, pyuria, and \202 ank pain account for a signi \201 cant number. Initial investigations include FBC, U&Es, urine cytology, and cystoscopy. TNM staging \200 Tis: carcinoma in situ . \200 T1: subepithelial invasion. \200 T2: m uscularis invasion. \200 T3: perivesical invasion. \200 T4: invades side wall, adjacent organ or into perinephric fat for renal TCC. N0: no node spread. \200 N1: single node <2cm. \200 N2: single node 2 \200\2235cm or mu ltiple small nodes. \200 N3: single node > 5cm or multiple nodes > 2cm. \200 M1: distan t metastasis. Imaging Ultrasound (Fig. First-line investigation. Echogenic lesions are seen in the bladde r lumen, arising from the wall. May see hydronephrosis. Limitations include evalua- tion of wall invasion and detection of lymph nodes. 16.1a ) CT (Fig. CT urography used to demonstrate the upper tracts where initial investiga- tions h ave not demonstrated pathology, as an alternative to the conventional approach of retrograd e pyelograms/uretroscopy performed by urologists in theater. TCC appears as a \201 lling defect in the contrast. CT can assess tumor size, local invasion, and hydronephrosis. Stagi ng CT is performed if malignancy is known, looking for nodal and metastatic disease. 16.1b ) MRI MRI scan can be used for local staging in the pelvis but not as a routine investigation in most units. Scintigraphy Demonstrates areas of increased osteoblastic activity associated with metastat ic deposits. SUBASH KC/NMC-15TH/2014 BLADDER AND UROTHELIAL CANCER 217 Information for the radiologist \200 Presenting symptoms including \201 ndings which su ggest metastases. \200 Biopsy and cytology results. \200 Surgical history including pre vious sites of disease, resections and therapy regimens. Renal function if having CT. (a) (b) Fig. 16.1 of the bladder (arrows), in a patient with biopsy proven tumor. a) Ultrasound and b) axial CT showing a \201 lling defect within the right side SUBASH KC/NMC-15TH/2014 218 CHAPTER 16 Genitourinary conditions Renal cell cancer \200 8 th most common malignancy, the peak incidence is in 6 decades. Male: female = 2:1. th th and 7 Associations: long-term dialysis, von Hippel \200\223Lindau syndrome, obesity, smoking, exp osure to petroleum products, heavy metals, and asbestos. Survival is directly linked to stage at presentation with a > 50 % 5-year survival for stage II disease and metastases develop in up to 30 % . lymph nodes. Local rec urrence in 5 > 70 % for stage I disease. Metachronous % predicted by involvement of local Clinical presentation \200 Haematuria, \202 ank pain, and a palpable mass are the class ical features; however, only around 10 % will have all 3. Systemic symptoms include lethargy and weight loss. Calcium and erythropoietin levels should be checked. Robson \200\231s staging system \200 I: tumor con \201 ned to kidney (large or small). \200 II: spread to perinephric fat but within Gerotas fascia. \200 IIIA: spread to renal vein or vena cava. \200 IIIB: spread to local lymph nodes. \200 IIIC: spread to both v enous system and local lymph nodes. \200 IVA: spread to adjacent organs (excludes ipsilat eral adrenal). \200 IVB: presence of distant metastases. Imaging Ultrasound Performed as a \201 rst-line investigation for haematuria. Excellent d etection of renal lesions including solid and cystic masses. Provides Doppler blood \202 ow information regarding invasion of the renal vein or IVC. CT (Fig. Performed pre- and post-IV contrast for lesion analysis, in particular the presenc e of enhancement. If a suspected malignant lesion is present a full chest, abdomen/pelvis s taging scan should be performed to assess local stage, lymph-nodes, vascular invasion, and metastases. 16.2 ) Bone scintigraphy Performed to assess for skeletal metastatic disease in the presence of cl inical suspicion. Metastases show high tracer activity due to increased osteoblastic activi ty. Metastases on plain \201 lm are typically lucent and expansile. Information for the radiologist \200 Presenting symptoms, relevant medical history and te st results including previous imaging. Sites of clinically suspected metastases should be highlighted. SUBASH KC/NMC-15TH/2014 RENAL CELL CANCER 219 Fig. 16.2 Coronal CT image showing solid mass arising from the right kidney (arrow), renal cell cancer, in contrast to the well-rounded, low attenuation simple cysts in the left kidn ey. SUBASH KC/NMC-15TH/2014 220 CHAPTER 16 Genitourinary conditions Testicular cancer \200 95 % are germ cell tumors, typical affect men aged 15 \200\22345 y ears. Divided into non-seminomatous (NSGCT) and seminomatous germ cell tumors. NSGCT include teratomas, affect a younger age, 10 \200\22320 years. Seminomas peak incidence 30 \200\22340 years. Tumor markers include A -fetoprotein (AFP), hCG (mainly NSGCT), and lactic dehydrogenase (LDH) (both). In the UK 1 in 500 men. \200 Risk factors: cryptorchidism, genetic predisposition and mal ignancy in the contralateral testis. Treatment is dependent on pathology and stage with NSGCT responding better to chemotherapy and seminomas to radiotherapy. Clinical presentation Usually with a hard lump in the testis. Pain and tenderness are less common and usually mild. TNM staging \200 Tis: intratubular neoplasia. \200 T1: tumor not invading lymphatics, v essels or tunica vaginalis. \200 T2: vascular/lymphatic invasion and/or invasion of tunic a vaginalis. \200 T3: invades spermatic cord. \200 T4: invades scrotum. \200 N1: regi onal nodes (ipsilateral aorto-caval) <2cm greatest dimension. \200 N2: regional nodes <5c m greatest dimension. \200 N3: regional nodes > 5cm greatest dimension. \200 M1a: non-r egional lymph nodes or pulmonary metastases. \200 M1b: other distant metastases. Imaging Ultrasound (Fig. First-line investigation. Typically hypoechoic, irregular with inc reased blood \202 ow. 16.3 ) CT Used for staging, looking for lymphadenopathy and metastases. Spread is primarily lympha tic to the retroperitoneal aorto-caval nodes, consistent with the embryological origin of t he testis. Mediastinal nodes are seen in more advanced disease. Hematological spread is mos t commonly to the lungs and more rarely to brain, bone, liver, and other abdominal viscera. FDG PET scanning may have a future role in determining residual disease sites to direct th e need for further treatment but it is not used routinely at present. MRI Not used routinely in the diagnosis or staging of testicular cancer but is useful in de tecting cryptorchidism when ultrasound has failed to localize. It offers a wide \201 eld of view from mid abdomen through the inguinal canal into the scrotum. SUBASH KC/NMC-15TH/2014 TESTICULAR CANCER 221 Information for the radiologist Presence of a lump, relevant past history. Fig. 16.3 the testis in a patient with multifocal germ cell tumors. Testicular ultrasound showing multifocal low echogenicity lesion within SUBASH KC/NMC-15TH/2014 222 CHAPTER 16 Genitourinary conditions Prostate cancer \200 2 \200 Risk factors: age > 50 years, genetic predisposition, famil ial/racial nd leading cause of cancer deaths in males in UK. preponderance Afro-Caribbean > Caucasian > Asian. Distinction made between clinical prostate cancer and microscopic, up to 30 % men > 50 years thought to harbor the disease, most of which will never become appar ent. Clinical presentation Symptoms of prostatism, haematuria, urinary obstruction, or metastati c disease; however, an increasing number present with an abnormal digital rectal examinatio n (DRE) or an elevated prostate speci \201 c antigen (PSA). PSA screening is not performed in the UK at present but has gained popu- larity in the USA and some of Europe. TNM staging \200 T1a: on histology only from a TURP malignancy in <5 % of sample. \200 T1b: on histology only from a TURP malignancy in > 5 % of sample. \200 T1c: identi \201 ed on histology from a TRUS biopsy sample. \200 T2a: less than half of one lobe (DRE or i maging). \200 T2b: more than half of one lobe (DRE or imaging). \200 T2c: involves both lobes (DRE or imaging). \200 T3a: extra-capsular extension. \200 T3b: extra-capsular e xtension involves the seminal vesicles. \200 T4: invades local structures other than semi nal vesicles. \200 N1: one or more regional nodes involved. \200 M1a: distant (outside the pelvis) lymph nodes involved. \200 M1b: bone metastases. \200 M1c: non-bone metasta ses. Imaging Plain \201 lm and bone scintigraphy Useful to determine the presence of bone meta stases. Often sclerotic on plain \201 lm. \200\230Hot \200\231 osteoblastic reaction is seen on bone scanning. Request if symptomatic or PSA markedly elevated. Ultrasound: trans-rectal ultrasound guided biopsy (TRUS) The accepted method of obtaining t issue for diagnosis in patients with a raised PSA and suspicion of prostate cancer. Non-tar geted \200\230random \200\231 samples are aimed at the peripheral zone of the gland, due t o the known preponderance of disease here ( > 70 % ). CT Staging CT advised if PSA > 20, T \211 3, Gleason grade suggest metastatic spread. Loo king for upper tract obstruction, lymphad- enopathy, and metastases. \211 8 or symptoms SUBASH KC/NMC-15TH/2014 PROSTATE CANCER 223 MRI (Fig. Used for local staging to predict spread through the prostatic capsule \200\224 important to determine operative or conservative management. It can predict lymph node invo lvement and bone metastases but is limited by the \201 eld of view. Some centers advocate full spinal acquisitions to stage for bone metastases in clinical/biochemically appropriat e cases. 16.4 ) Information for the radiologist PSA level and presence of symptoms suggestive of metastases . Fig. 16.4 the peripheral aspect of the right prostate (arrow). The posterior margin of the prostate is blurred, in keeping with early T3 disease. Axial MRI showing a bulky prostate, with a low signal intensity area within SUBASH KC/NMC-15TH/2014 224 CHAPTER 16 Genitourinary conditions Cervical cancer \200 3 rd most common malignancy worldwide, average age at diagnosis is 50 years. 90 % squamous carcinomas, from squamocolumnar junction; 10 adenocarcinomas/adenosquamous ca rcinomas, arising from glandular elements within the endocervical canal. % Clinical presentation Vaginal bleeding or discharge. Pain suggests more advanced disease. M ay be asymptomatic if screen detected. ) Staging (see Table 16.1 Table 16.1 Staging of cervical cancer FIGO stage MRI features 0: carcinoma in situ Normal IA: microscopic invasive Normal IB1: clinically visible tumor <4cm Intermediate signal tumor on T2-weighted imaging replaces dark cervical stroma. An intact s tromal ring around tumor indicates tumor con \201 ned to cervix IB2: clinically visible tumor > 4cm IIA: invasion of tumor to upper 2/3 vagina, no parametrial invasion Loss of integrity of low signal vaginal wall on T2-weighted sequences IIB: parametrial invasion but not to pelvic side wall Dark cervical stromal ring completely replaced by intermediate signal tumor IIIA: tumor extends to lower 1/3 vagina, not to pelvic side wall Disruption of the vaginal wall extends to the lower 1/3 IIIB: extension to pelvic side wall or hydronephrosis Tumor extends to within 1cm of the pelvic side walls or there is ureteric dilatation due to obstruction from the tumor IVA: bladder or rectal mucosa invaded by tumor Bladder or rectal wall on T2-weighted images is breached IVB: distant metastases Tumor outside the true pelvis Imaging Preoperative staging to determine the size and extent of tumor, lymph node status a nd presence of distant metastases. SUBASH KC/NMC-15TH/2014 CERVICAL CANCER 225 Ultrasound Transrectal transvaginal scanning may determine tumor size and extent. The li mited \201 eld of view reduces assessment of bulky tumors and lymph nodes. CT Useful in advanced disease but not accurate in staging early stage tumors. Assessment of local complications, e.g. hydronephrosis, lymphadenopathy, and detection of distant metast ases. MRI (Fig. Most accurate staging method preoperatively, determining tumor size, volume, exte nt, and nodal status with an overall accuracy of 86 \200\22390 also useful to monitor treat ment response. 16.5 ) % . It is FDG-PET Main advantage is in detection of lymph node metastases in the pelvis and retroperi toneum. It is also useful in the detection of recurrence of cervical tumor. Information for the radiologist Accurate clinical and EUA \201 ndings. Fig. 16.5 a patient with a tumor of the cervix. Sagittal MRI showing exophytic tumor (arrow) arising from the cervix, in SUBASH KC/NMC-15TH/2014 226 CHAPTER 16 Genitourinary conditions Endometrial cancer \200 One of the most common female pelvic malignancies, usually adenocarcinoma. Less common histological types include serous papillary carcinoma, clear ce ll carcinoma and undifferentiated carcinoma, which are more aggressive. Predominantly occurs in postmenopausal women. \200 Risk factors: hypertension, obesity, d iabetes mellitus, late menopause, long-term tamoxifen treatment for breast cancer, a personal or family history of breast or ovarian cancer, and a family history of endometrial or breast cancer, hereditary non-polypo sis colorectal cancer. Clinical presentation Postmenopausal vaginal bleeding or vaginal discharge. Staging (see Table 16.2 ) Table 16.2 Staging of endometrial cancer FIGO stage MRI features IA: con \201 ned to endometrium Junctional zone intact, smooth interface between endometrium and myometrium IB: <50 % invasion into myometrium Tumor signal extends into super \201 cial myometrium. Irregular interface between endometr ium and myometrium IC: > 50 % invasion into myometrum