Transitional Cell Cancer with Sclerotic Bone Metastases
Updated: Jul 27, 2021
64 year old male presenting with painless gross hematuria, flank pain, unintentional weight loss, and lower back pain. What is the diagnosis? • Xray of the Week
Figure 1. Abdominal CT. What are the significant findings.
A,B: Non contrast axial CT images showing a large transitional cell carcinoma obstructing the left renal pelvis (green arrows). There is an incidental renal calculus in left kidney (red arrow).
C: Non contrast coronal CT image showing large transitional cell carcinoma obstructing the left renal pelvis (green arrows).
D,E: Axial and sagittal CT (Bone window) showing sclerotic metastasis of sacral base (blue arrows)
Transitional cell carcinoma (also called Urothelial cell carcinoma) is the second most common type of kidney cancer, behind renal cell carcinomas, but only accounts for 5-10% of all primary renal malignant tumors . It is 50x less common than transitional cell carcinoma of the bladder. They are more common in males and typically diagnosed between 60-70 years of age with a mean age at diagnosis of 73 years . Patients with transitional cell carcinoma typically present with hematuria (70-80%) and flank pain secondary to ureter/uretopelvic junction obstruction from tumor mass (20-40%). Other symptoms include bladder irritation and constitutional symptoms such as fatigue, nausea, or diarrhea .
The epithelial surface of the renal collecting tubules, calyces, and pelvis share the same embryonic origin as the ureter, bladder, and urethra termed “urothelium”. Transitional/Urothelial carcinoma tend to be multifocal and is believed to arise via field cancerization from potential carcinogens excreted into the urine or active via hydrolyzing enzyme in the urine. Risk factors for developing transitional cell carcinoma include: tobacco use, prolonged exposure to carcinogens (i.e. azo dye, heavy metals, phenacetin, and aromatic amines), chronic/recurrent UTI, schistosomiasis, and prolonged indwelling bladder catheters [3,4,5,6].
Initial choice for diagnosis for patient with suspected transitional/urothelial carcinoma is abdominal CT or retrograde pyelogram. Transitional/urothelial carcinoma typically appear as a soft tissue density with mild enhancement (far less enhancement than renal parenchyma or renal cell carcinomas) [7,8]. They are usually centered on the renal pelvis, rather than the renal parenchyma, and range in size from small filling defects to large masses which can obliterate the renal sinus fat causing appearance of a “faceless” kidney . However, normal renal shape is maintained even in large infiltrating transitional cell carcinomas, whereas large renal cell carcinomas will cause distortion of the renal outline [8,10]. Larger urothelial tumors may have areas of necrosis . In cases of the tumor being small and located at the ureteropelvic junction with resultant hydronephrosis, a small soft tissue mass should be sought. The most common site of metastasis outside the pelvis is the spine, as seen in this patient .
Surgical resection is the only curative treatment for localized transitional cell carcinoma. There is limited data/research indicating efficacy of chemotherapy in patients with advanced upper urinary tract urothelial cancers. Advanced clinical trials have shown response with cisplatin-based chemotherapeutical regimens such as MVAC (Methotrexate, Vinblastine, Doxorubicin, and Cisplatin) or GC (Gemcitabine and Cisplatin) [13,14,15,16]. However, these regimens are often complicated or contraindicated in patients with chronic kidney disease which is a very common comorbid condition in patients with transitional cell carcinoma . For these patients, single-agent chemotherapy or checkpoint inhibitor immunotherapy options are currently being researched. Cisplatin-based chemotherapy is not effective for all patients and those for whom this regimen fails, they are often treated with platinum-based therapies, checkpoint inhibitor immunotherapy with PD-1 (programmed cell death 1) or PD-L1 (programmed death ligand 1) antibodies [18,19,20].
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Jay Vora is a medical student at Edward Via College of Osteopathic Medicine (VCOM) – Virginia and plans to pursue a residency in diagnostic radiology. He graduated from UMBC in 2015 with a major in Biochemistry and Molecular Biology. He worked as a research assistant at Brimrose Engineering Corporation of America for 5 years where he completed projects in nanodot detection using imaging and helped develop cancer detection methods in cells using polarized near-infrared autofluorescence and near-infrared reflectance imaging with laser diodes and continuous-wave imaging. He graduated from Eastern Virginia Medical School with a masters in Biomedical science where he was completed research in the study of the barriers that the homeless population faces when seeking healthcare as well as genetic analysis of brain tissue from patients diagnosed with Alzheimer’s. He discovered his passion for radiology during the first radiology lecture at VCOM. Seeing the radiographic images made medical education come to life for him. While shadowing and on rotations, Jay saw how integral the field of radiology is to every other specialty in medicine and its key role in patient care. In his free time, Jay enjoys playing golf and basketball, playing guitar, and technology.
Follow Jay Vora on Twitter @JS_Vora
Kevin M. Rice, MD is the president of Global Radiology CME
Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.
Follow Dr. Rice on Twitter @KevinRiceMD