Bladder Carcinoma

Bladder Carcinoma

Todd M. Blodgett, MD

Alex Ryan, MD

Omar Almusa, MD

Axial graphic demonstrates a focal mass arising from the posterior aspect of the bladder near the left ureterovesical junction image.

Axial fused PET/CT in a patient scanned in the prone position shows a focal area of activity image, compatible with known bladder cancer.


Abbreviations and Synonyms

  • Bladder carcinoma, urothelial carcinoma, transitional cell carcinoma (TCC)


  • Malignancy of the urinary bladder


General Features

  • Best diagnostic clue

    • PET/CT: Focal increased FDG activity in primary tumor, ± in regional and distant lymph nodes, lung, liver, bone

    • CT: Enhancing focal/asymmetric mass in the urinary bladder

  • Location

    • Usually arises in the bladder wall

    • Can be multifocal

    • Local invasion

      • Detrusor muscle, prostate, uterus, vagina, seminal vesicles, rectum

    • Lymphatic spread (30% of tumors that only involve bladder wall; 60% of those with extravesicular invasion)

      • Regional (pelvic) lymph nodes (LN)

      • Distant LN

    • Hematogenous spread

      • Lung > > liver, bone

    • Recurrences of superficial bladder cancer remain confined to bladder wall in 70-80% of patients

      • Remaining 20-30% may become muscle-invasive and lead to metastatic disease

    • Common metastatic sites include pelvic and retroperitoneal lymph nodes, lungs, liver, and bones

  • Size: Varies from undetectable on CT to large enhancing mass

  • Morphology

    • Superficial: Most common representing 70-80%

      • Confined to mucosa and lamina propria

      • Project into bladder lumen (papillary)

      • Usually low grade

    • Invasive: Less common, representing 20-30%

      • Detrusor muscle involvement

      • Solid, more infiltrating

      • Usually high grade

Imaging Recommendations

  • Best imaging tool

    • Initial workup: Cystoscopy and biopsy; CT or MR for evaluation of primary tumor and LN metastases

      • CT: Reported accuracy in detecting LN involvement 70-90% with false negative rates 25-40%

      • MR: 73-98% reported accuracy for determining nodal metastases

    • PET/CT

      • Utility mostly for pre-operative staging, distinguishing post-surgical change from recurrence

      • Minimally useful for evaluation of primary tumor, usually obscured by excretory FDG

    • Bone scan: Helpful if there is clinical suspicion of bone metastases

    • CT/MR tend to overestimate degree of extension through bladder wall but underestimate presence of pelvic lymph node metastases

  • Protocol advice

    • PET/CT: 10-15 mCi (370-555 MBq) F18-FDG IV, start imaging at pelvis to avoid FDG filling bladder

    • PET/CT: Excreted FDG in urinary bladder can mask pelvic pathology

      • Techniques include Immediate post-void imaging, retrograde bladder irrigation with normal saline, IV Lasix administration with parenteral hydration

      • Prone positioning may be useful for visualization of posteriorly located lesions

    • Urinary excretion of FDG leads to pooled activity in bladder, making evaluation of bladder wall lesions difficult to impossible with standard protocol

      • Furosemide injected at least 2 hours after radiotracer injection provides excellent urinary radiotracer washout, reducing bladder activity to background levels

      • Oral hydration aids in diuresis

      • Full bladder is required to avoid artifactual thickening of the walls

      • Protocol not satisfactory in patients with cystectomy because urinary diversions show higher residual activities, but recurrence is extremely rare in bladder diversion walls

CT Findings

  • CT findings of primary usually nonspecific (diagnosis often based on biopsy performed during cystoscopy)

    • Focal or diffuse bladder wall thickening

    • Mass projecting into bladder ± enhancement

  • Occasionally calcifications

  • Hydronephrosis 2° to tumor near vesicoureteric junction

  • Extravesicular extension: Nodules, irregularity of outer bladder wall, stranding of perivesicular fat

  • T status of tumor most often determined by biopsy

  • Causes of circumferential bladder thickening that can mimic bladder cancer include

    • Previous biopsy, inflammation, radiotherapy, systemic chemotherapy, and intravesical agents like Bacille Calmette-Guérin (BCG)

  • Sessile or pedunculated soft tissue mass projecting into the lumen; similar density to bladder wall

  • ± Enlarged (> 10 mm) metastatic lymph nodes; extravesical tumor extension

  • Fine punctate calcifications with tumor; may suggest mucinous adenocarcinoma

  • Ring pattern of calcification; may suggest pheochromocytoma

  • Inability to distinguish tumors from bladder wall hypertrophy, local inflammation, and fibrosis

  • Unable to differentiate Ta-T3a, invasion of dome/base of bladder or local organ (due to partial volume effect), nonenlarged lymph nodes

  • Also consider urachal adenocarcinoma

    • Midline abdominal mass ± calcification

    • Solitary lobulated tumor arising from dome of bladder on ventral surface

MR Findings

  • T1WI: Isointense to muscle

  • T2WI: Hyperintense to muscle

  • Superior to CT for assessing deep muscle involvement, invasion of adjacent organs

Nuclear Medicine Findings

  • Focal increased FDG activity in primary tumor, regional and distant LN, lung, liver, bone

    • Bladder cancer may have variable uptake of FDG

    • Baseline PET/CT useful for confirmation of FDG avidity

    • Max SUV may range from 5-10 in typical hypermetabolic bladder lesions

  • Primary tumor may be masked by excreted FDG in urine

    • FDG is not resorbed as glucose and is excreted in the urine

    • With delayed imaging, ratio of tumor:bladder FDG uptake was 13:1 in one study

  • False positives: Bladder diverticula and urinary leak

    • CT portion of PET/CT essential for ruling out such pitfalls

    • CT also useful for precise separation of uptake foci in the bladder wall vs. lymph nodes adjacent to bladder

    • One study showed 3 month period post-resection was sufficient to heal inflammatory reactions and reduce false positives

  • C-11-choline PET/CT radiotracer does not collect in urinary tract, but its value for lesion staging has not been shown superior to conventional methods

  • Bone scan: Bone metastases classically appear as multiple, scattered foci of increased activity, axial > appendicular skeleton



  • Usually more diffuse thickening of the bladder wall

  • Chronic urinary tract infection, fungus

  • Radiation- or chemotherapy-induced

  • Hemorrhagic cystitis


  • Trauma

  • Iatrogenic

Cystitis Cystica

  • Degeneration of urothelial cells in Brunn nests

Other Neoplasm

  • Endometriosis

  • Metastases


General Features

  • General path comments

    • ˜ 90% transitional cell carcinomas (TCC); often multifocal

    • 5-10% squamous cell (chronic inflammation)

    • < 5% mixed TCC and squamous cell

    • 2-3% adenocarcinoma (persistent urachal remnant)

    • < 1% rare types (e.g., leiomyomas, lymphoma, melanoma)

  • Etiology

    • Risk factors

      • Cigarette smoking

      • Exposure to aniline, aromatic amines, diesel fumes

      • Phenacetin use (once used as analgesic, now often mixed with cocaine)

      • Infection: Chronic urinary tract infection, schistosomiasis

  • Epidemiology

    • Most common tumor of urinary tract

      • More than 90% are transitional cell carcinoma

    • Men: Fourth most common cancer

      • 7% of all malignancies in men

    • Women: Tenth most common cancer

      • 2% of all malignancies in women

Sep 22, 2016 | Posted by in MAGNETIC RESONANCE IMAGING | Comments Off on Bladder Carcinoma

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