Answer of March 2010

Clinical History:

A 72 years old man presented with gross haematuria. He is a chronic smoker. There is no history of fever. Urinalysis is negative and KUB shows no radioopaque stone. IVU and CT scan of the abdomen were performed.

            Excretory phase in IVU

                                          Axial and coronal cut of CT abdomen
 

Diagnosis:

Renal transitional cell carcinoma

Discussion:

IVU shows an irregular filling defect causing destruction in the inferior part of right renal pelvis and proximal ureter. There is gross right hydronephrosis with upholding of contrast medium in the right renal pelvocalyceal system. Features are suggestive of an aggressive space-occupying lesion in the right renal pelvis. CT scan confirmed a tumour mass at right renal pelvis and the diagnosis of renal transitional cell carcinoma is confirmed by biopsy.

Transitional cell carcinoma (TCC) is the most common urothelial tumour. 5% of urothelial tumors arise from the ureter or the renal pelvis or calices, accounting for approximately 10% of neoplasms of the upper urinary tract. Risks factors included increasing age, male gender, smoking, chemical carcinogens (aniline, benzidine, aromatic amine, azo dyes), analgesic abuse (phenacetin), cyclophosphamide therapy, heavy caffeine consumption, and chronic/recurrent urinary tract infection.

Patients usually presented with gross painless haematuria. Acute renal colic may also be present when there is obstruction. Diagnosis requires urinalysis and cytologic analysis, cystoscopy, and imaging modalities such as IVU, CT/CT urography, ultrasound or MRI. 

Renal TCC usually manifests as a filling defect within the contrast-enhanced collecting system in IVU. It can infiltrates into the renal parenchyma preserving the renal contour, which differs from typically expansile renal cell carcinoma. CT urography now becomes the imaging modality of choice, as the urothelium, renal parenchyma, and perirenal tissues can be assessed at a single examination and it may reveal other causes of hematuria such as calculi, papillary necrosis, inflammatory lesions, or infarcts. Renal TCC is typically seen as a sessile filling defect in the excretory phase, which expands centrifugally with compression of the renal sinus fat. Advanced TCC extends into the renal parenchyma in an infiltrating pattern that distorts normal architecture. Again, reniform shape is typically preserved, unlike in renal cell carcinoma.

Staging is usually performed with CT or MRI. Synchronous or metachronous tumor of the ipsilateral or contralateral collecting system is common. Accurate radiologic detection and staging of tumor is therefore essential to determine appropriate surgical therapy and follow-up plan.