1. MedPix Medical Image Database COW - Case of the Week Case Contributor: Zachary M Alexander Affiliation: National Naval Medical Center Bethesda

2. MedPix No: 11063 - History Pt Demographics: Age = 36 y.o. Gender = woman 36 y.o. woman with gross hematuria Downloaded by (-1)

3. MedPix No: 11063 - EXAM & LABS Urinalysis: SpGrav 1.018, pH 6.5, Prot >300, Ket neg, Gluc neg, Blood largeSerum Chem: Na 141, K 4.3, Cl 107, CO2 28, BUN 12, Cr 0.9, Gluc 104

4. Transverse ultrasound of the bladder Ultrasound images of the bladder demonstrate a lobulated filling defect within the bladder and adherent to the bladder wall. Downloaded by (-1)

5. Transverse ultrasound of the bladder Ultrasound images of the bladder demonstrate a lobulated filling defect within the bladder and adherent to the bladder wall. Downloaded by (-1)

6. Color Doppler ultrasound of the bladder Doppler ultrasound of the lobulated bladder mass demonstrates significant internal blood flow. Downloaded by (-1)

7. Axial CECT Axial contrast enhanced CT images demonstrate a lobulated, irregular mass extending from the posterior bladder wall, with associated hydronephrosis and hydroureter. There is extension of the mass through the posterior bladder wall and into the adjacent uterus. Downloaded by (-1)

8. Axial CECT Axial contrast enhanced CT images demonstrate a lobulated, irregular mass extending from the posterior bladder wall, with associated hydronephrosis and hydroureter. There is extension of the mass through the posterior bladder wall and into the adjacent uterus. Downloaded by (-1)

9. Axial CECT Axial contrast enhanced CT images demonstrate a lobulated, irregular mass extending from the posterior bladder wall, with associated hydronephrosis and hydroureter. There is extension of the mass through the posterior bladder wall and into the adjacent uterus. Downloaded by (-1)

10. Axial CECT Axial contrast enhanced CT images demonstrate a lobulated, irregular mass extending from the posterior bladder wall, with associated hydronephrosis and hydroureter. There is extension of the mass through the posterior bladder wall and into the adjacent uterus. Downloaded by (-1)

11. Axial CECT Axial contrast enhanced CT images demonstrate a lobulated, irregular mass extending from the posterior bladder wall, with associated hydronephrosis and hydroureter. There is extension of the mass through the posterior bladder wall and into the adjacent uterus. Downloaded by (-1)

12. Axial CECT Axial contrast enhanced CT images demonstrate a lobulated, irregular mass extending from the posterior bladder wall, with associated hydronephrosis and hydroureter. There is extension of the mass through the posterior bladder wall and into the adjacent uterus. Downloaded by (-1)

13. Axial CECT Axial contrast enhanced CT images demonstrate a lobulated, irregular mass extending from the posterior bladder wall, with associated hydronephrosis and hydroureter. There is extension of the mass through the posterior bladder wall and into the adjacent uterus. Downloaded by (-1)

14. Axial CECT Axial contrast enhanced CT images demonstrate a lobulated, irregular mass extending from the posterior bladder wall, with associated hydronephrosis and hydroureter. There is extension of the mass through the posterior bladder wall and into the adjacent uterus. Downloaded by (-1)

15. Axial CECT Axial contrast enhanced CT images demonstrate a lobulated, irregular mass extending from the posterior bladder wall, with associated hydronephrosis and hydroureter. There is extension of the mass through the posterior bladder wall and into the adjacent uterus. Downloaded by (-1)

16. Axial CECT Axial contrast enhanced CT images demonstrate a lobulated, irregular mass extending from the posterior bladder wall, with associated hydronephrosis and hydroureter. There is extension of the mass through the posterior bladder wall and into the adjacent uterus. Downloaded by (-1)

17. Axial CECT Axial contrast enhanced CT images demonstrate a lobulated, irregular mass extending from the posterior bladder wall, with associated hydronephrosis (yellow) and hydroureter. There is extension of the mass through the posterior bladder wall and into the adjacent uterus. Downloaded by (-1)

18. Axial CECT Axial contrast enhanced CT images demonstrate a lobulated, irregular mass extending from the posterior bladder wall, with associated hydronephrosis and hydroureter bilaterally. There is extension of the mass through the posterior bladder wall and into the adjacent uterus. Downloaded by (-1)

19. Axial CECT Axial contrast enhanced CT images demonstrate a lobulated, irregular mass extending from the posterior bladder wall, with associated hydronephrosis and hydroureter bilaterally (arrows). There is extension of the mass through the posterior bladder wall and into the adjacent uterus. Also labeled: ascending colon with feces (open arrow) and psoas muscle (ps). Downloaded by (-1)

20. Axial CECT Axial contrast enhanced CT images demonstrate a lobulated, irregular mass extending from the posterior bladder wall, with associated hydronephrosis and hydroureter. There is extension of the mass through the posterior bladder wall and into the adjacent uterus. Downloaded by (-1)

21. Axial CECT Axial contrast enhanced CT images demonstrate a lobulated, irregular mass (asterisk *) extending from the posterior bladder wall, with associated hydronephrosis and hydroureter. There is extension of the mass through the posterior bladder wall and into the adjacent uterus (labeled). Downloaded by (-1)

22. FINDINGS Ultrasound of the bladder reveals a lobulated echogenic mass adherent to the bladder wall - with significant internal blood flow on color Doppler. CT images demonstrate a lobulated, irregular mass of the posterior bladder wall with associated hydronephrosis and hydroureter. Additionally, there is tumor extension posteriorly through the bladder wall and into the adjecent uterus.

23. DIFFERENTIAL DIAGNOSIS What is your Differential Diagnosis? Transitional Cell Carcinoma - Squamous Cell Carcinoma - Metastatic disease - Bladder Polyp - Leiomyoma - Fungal Ball - Blood Clot - Debris -

24. Diagnosis: Transitional Cell Carcinoma, Bladder Dx Confirmed by: Path Proven Biopsy

25. DISCUSSION This case illustrates the classic findings for transitional cell carcinoma of the bladder. These lesions are commonly discovered due to hematuria. As in this case, ultrasound commonly demonstrates a bladder mass with internal blood flow, and associated obstructive hydronephrosis. These US findings were confirmed on CT imaging.