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The role of CT Urography in the evaluation of Bladder Cancer

The role of CT Urography in the evaluation of Bladder Cancer. Dr Mohamed El Safwany , MD. Intended learning outcome. The student should learn at the end of this lecture principles of CT in bladder cancer. What is CT Urography (CTU)?.

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The role of CT Urography in the evaluation of Bladder Cancer

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  1. The role of CT Urography in the evaluation of Bladder Cancer Dr Mohamed El Safwany, MD.

  2. Intended learning outcome The student should learn at the end of this lecture principles of CT in bladder cancer.

  3. What is CT Urography (CTU)? • CTU is a term used to describe high-spatial-resolution imaging of the urinary tract by using contrast material administration, a multidetector CT scanner with thin collimation and imaging in the excretory phase .

  4. CTU Indications • Hematuria • Patients at increased risk for having upper or lower tract urothelialneoplasms • Urinary diversion procedures following cystectomy • Hydronephrosis, chronic symptomatic urolithiasis or planning of percutaneousnephrolithotomy (PCNL) • Traumatic and iatrogenic uretheral injury, and complex urinary tract infections.

  5. CTU: technique • 2 Phase- single bolus CTU: - Oral hydration (700 ml of water, 30 min ) -Low dose diuretic (Furosemide): 0.1mg/kg, 1-3 min, before CM - Single bolus of 100 -[320] IV CM - Arterial phase - Nephrographicphase@ 100 sec - Excretory phase @ 12 min (7-15 min)

  6. Unenhanced phase? 1.- Ultrasound is widely used. 2.-Using Furosemide there is an improvement in lithiasis diagnosis. Furosemide decrease the urine attenuation value (< 500 HU) *.

  7. Portal versus nephrographic phase? • Bladder cancer tends to show peak enhancement with the 60- second (portal Phase) scanning delay *. • Portal phase CTU offers high accuracy detecting BC: -Sensitivity: 89%–92% in per lesion analysis 95% in per patient analysis -Specificity: 88%– 97% in per lesion analysis 91%–93% in per patient analysis

  8. CTU: Image review, image reconstruction and reformatted images • CTU image review and postprocessing: Using a workstation and/or a picture archiving and communication system (PACS): Creation of multiplanar reformatted images and 3D reconstructed images by using: • - Maximum intensity projection techniques (MIP 5-50mm) • Volume-rendering (VR 5-50 mm) • Narrow and wide windows and thinsectionswith MPR and axial images review (improve the detection rate for tumors smaller than 5 mm)

  9. Bladder cancer CTU • Homogeneous bladder opacification: Voiding the bladder before examination or mixing bladder contents: patient rolls over supine- prone on the CT table or walks around the CT room. • All the excretory system must be included in the exam: Since the urothelium of the entire urinary system is at risk of developing cancer. • CTU may allow staging of deeply invasive tumors, detection of metastases and other extra-genitourinary pathology.

  10. Bladder cancer

  11. Bladder cancer

  12. Bladder cancer

  13. Staging • Ta: Non invasive • CIS: high- grade flat Urothelial cancer • T1: Invade lamina propria • T2a and T2b: bladder wall musculature • T3a and T3b: perivesical space extension • T4: Adyacent organs or pelvic sidewall invasion. GRADE: Grade 1: Well differentiated: papillary/ superficial Grade 2: Poorly differentiated: infiltrative/Invasive

  14. Symptoms • Microscopic or gross hematuria, but only 13-28% patients with gross hematuria have bladder cancer.

  15. CTU Assesment in Bladdercancer • Tumor appearance • Tumor enhancement

  16. CTU appearance of BC Asymmetric diffuse or focal wall thickening Male, 75 year-old. Tumor right bladder wall Male 70 year old. Tumor at left UVJ

  17. Focal enhancing masses

  18. Small fillingdefects Soft tissue window (W:400, L:40) Wide windows (W:1990, L:362)

  19. 67 year-oldman. Previoustransurethral BC resection. CTU: Asymetric enhancing right wall thickening Cystoscopy: Fybrosis

  20. CTU reasons for false negative diagnosis • Flat tumors • Bladder lesions located at the bladder base (near prostate and urethra) • The most problematic group: Patients have already undergone local treatment for non-invasive bladder tumors .

  21. 72 year-oldman. CTU: Prostatic hypertrophy and diffuse wall thickening and small polipoid nodule in the posterior bladder wall Cystoscopy: BC in small nodule

  22. 75 year-oldman. Previoustransurethral resection CTU: Small bladder, diffuse wall thickening and small enhancing nodule at bladder dome Cystoscopy: BC

  23. T3a or T3b ? T4

  24. Text Book David Sutton’s Radiology Clark’s Radiographic positioning and techniques

  25. Assignment Two students will be selected for assignment.

  26. Question Define value of VRT in urinary tract examination ?

  27. Thank You

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