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Journal of Postgraduate Medicine, Vol. 55, No. 1, January-March, 2009, pp. 33-34 Case Report Small cell carcinoma of the urinary bladder: Virtual CT cystoscopic findings Tsili AC, Giannakis D, Sofikitis N, Tsampoulas K Department of Clinical Radiology, University Hospital, Leoforos S. Niarchou - Ioannina-45500 Date of Submission: 13-Jul-2008 Code Number: jp09008 Abstract A 74-year-old man underwent multidetector CT virtual cystoscopy due to macroscopic hematuria. A large, irregularly-surfaced, solid bladder mass was detected, infiltrating the perivesical fat, the seminal vesicles and the prostate. CT examination of the chest and abdomen showed no distant metastases. Radical cystectomy was performed and pathology reported pure small cell carcinoma of the urinary bladder.Keywords: Bladder carcinoma, CT cystoscopy, small cell carcinoma, virtual Primary small cell carcinoma of the urinary bladder (SCCB) is a rare, highly aggressive neoplasm. [1] Virtual CT cystoscopy has been proposed as an alternative imaging modality with advantages in the evaluation of urinary bladder pathology. [2],[3],[4],[5] We present a case of SCC of the urinary bladder, evaluated by virtual multidetector CT cystoscopy and discuss differential diagnosis. Case Report A 74-year-old man was referred to the Urology department for gross painless hematuria. Virtual CT cystoscopy was performed on a 16-row CT scanner, including scanning of the urinary bladder in both supine and prone positions, after bladder insufflation with room air, using the following parameters: detector collimation 16 x 0.75mm, pitch 1.2, slice thickness 1 mm, rotation time 0.5 sec, kV 120 and reconstruction interval 1 mm. A large, irregularly-surfaced, heterogeneous mass involving the posterior wall of the urinary bladder [Figure - 1] was revealed. The tumor infiltrated the perivesical fat [Figure - 1], the seminal vesicles [Figure 1b] and the prostate. Both the ureteral orifices were also infiltrated, causing bilateral ureteral dilatation. No other bladder lesion was revealed on the virtual images [Figure 1c]. The CT cystoscopy findings were similar to that of conventional cystoscopy, performed two days prior to the CT examination. A staging workup was followed, including CT examination of the chest and abdomen, without signs of metastatic disease. The patient was urgently admitted to surgery and radical cystectomy was performed. Due to comorbid conditions, he eventually succumbed two days after the operation. The histological examination was reported as primary pure small cell carcinoma of the bladder [Figure - 2].Discussion The urinary bladder is the commonest site of extrapulmonary SCC in the genitourinary tract. [1] An early metastatic spread, with a high mortality rate, is the typical course of the disease. [1] There are a few reports regarding the CT features of SCCB, as advanced-stage, large, broad-based, heterogeneous bladder masses. [1] These CT features were all consistent with the findings in our case. However, the preoperative characterization of the nature of SCCB based on the imaging findings is difficult, as it was in this patient. Differential diagnosis of large-sized, advanced-stage bladder malignancies should include a high-grade urothelial carcinoma, undifferentiated carcinoma, like small cell carcinoma, primary or secondary lymphoma, metastasis from SCC outside the bladder and sarcoma. Conventional cystoscopy is the standard method for the detection of urinary bladder neoplasms. But the technique is invasive, and uncomfortable. Other drawbacks are the inability to evaluate extravesical pathology and a 5-15% risk of urinary tract infection. [2],[3] Cystoscopy has also a reported sensitivity of 87% for the detection of bladder malignancies. [3] One of the important advantages of virtual CT cystoscopy is the minimal invasiveness of the technique. The evaluation of intravesical and extravesical pathology is possible with the same study, as in our case. Although CT data interpretation was based mainly on the axial images in this case, the combined evaluation of transverse and virtual cystoscopic images has been proved mandatory in CT cystoscopy, since small-sized tumors may be detected only or predominantly on virtual images. [2],[3] Virtual CT cystoscopy for now remains a complementary examination. Its main limitations are the inability to provide biopsy tissue specimens for histopathologic examination, something that is possible with conventional cystoscopy, providing a basis for optimal therapeutic planning. [2],[3],[4] Another disadvantage is the difficulty to depict carcinoma in situ and flat lesions or small-sized tumors. [2],[3],[4] The introduction of multidetector CT scanners improved the feasibility of virtual CT cystoscopy in detecting tumors smaller than 5 mm. [3],[4] Tsampoulas et al., detected 55 (96%) of the 57 bladder lesions using a 16-row CT scanner, 18 of which had a diameter smaller than 5 mm. [3] References
Copyright 2009 - Journal of Postgraduate Medicine The following images related to this document are available:Photo images[jp09008f2.jpg] [jp09008f1.jpg] |
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