1. 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.  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.  Hematuria  Patients at increased risk for having upper or lower tract urothelial neoplasms  Urinary diversion procedures following cystectomy  Hydronephrosis, chronic symptomatic urolithiasis or planning of percutaneous nephrolithotomy (PCNL)  Traumatic and iatrogenic uretheral injury, and complex urinary tract infections.

5.  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 - Nephrographic phase@ 100 sec - Excretory phase @ 12 min (7-15 min)

6. 1.- Ultrasound is widely used. 2.-Using Furosemide there is an improvement in lithiasis diagnosis. Furosemide decrease the urine attenuation value (< 500 HU) *. LithiasisHU Calcium oxalate monohydrate Calcium oxalate dihidrate Cystine Struvite Uric acid 1645+ 238 1417 + 234 711 + 228 666 + 87 409 + 118

7.  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 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 thin sections with MPR and axial images review (improve the detection rate for tumors smaller than 5 mm)

9.  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. Background Is the most common malignancy of the urinary tract. Is a disease of older patients (>65). Represents the 6.6% of the total cancers in men and 2.1% in women, with an estimated male-to-female ratio of 3.8:1*.

11. Risk factors Cigarrete smoking: Smokers have a two to sixfold increased risk of cancer compared to non-smokers. Occupational exposures: Exposition to aromatic amines (petrochemical, textile, printing industries), hairdressing, firefighting, truck driving, plumbing… Exposures to certains medications: Phenacetin, Cyclophosphamide. Others: Arsenic in drinking water, prior pelvic irradiation and lower urinary tract inflammation (schistosomiasis).

12. Cell type I.- Epithelial tumors: Urothelial (transitional cell) cancer (90%). Is the most common urinary tract cancer in the United States and Europe. Has a propensity to be multicentric (30-40% ) with synchronous and metachronous bladder and upper tract tumors. Squamous cell (5-8 %) Adenocarcinoma (2%) II.- Non-epithelial tumors: Leiomyosarcomas, lymphoma: Rare

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

15.  Tumor appearance  Tumor enhancement

16. 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 filling defects Soft tissue window (W:400, L:40) Wide windows (W:1990, L:362)

19. 67 year-old man. Previous transurethral BC resection. CTU: Asymetric enhancing right wall thickening Cystoscopy: Fybrosis

20.  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-old man. CTU: Prostatic hypertrophy and diffuse wall thickening and small polipoid nodule in the posterior bladder wall Cystoscopy: BC in small nodule

22. 75 year-old man. Previous transurethral 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