Interference

Norifumi Kamo, HMS III
Gillian Lieberman, MD
A 62 Year-Old Man with Painless
Hematuria
Norifumi Kamo, HMS III
Gillian Lieberman, MD
Beth Israel Deaconess Medical Center
1
Norifumi Kamo, HMS III
Gillian Lieberman, MD
Patient Presentation
„
CC: Painless hematuria
„
HPI: AS is a 62 y/o M who presents with gross painless
hematuria for the past 2 months
„
PMH/PSH: s/p MI (s/p CABG), NIDDM
„
Meds: Avandia, glyburide, metoprolol
„
Allergies: NKDA
2
Norifumi Kamo, HMS III
Gillian Lieberman, MD
Patient Presentation (cont’d)
„
SH: smoked 4 PPD for 40 years
„
FH: not significant
„
PE: obese male, AVSS in NAD
„
Labs:
„
„
„
Chem 7, CBC wnl
BUN 13 and Creatinine 0.9
U/A: 10 RBC/hpf, Urine cx negative
3
Norifumi Kamo, HMS III
Gillian Lieberman, MD
Differential Diagnosis:
Painless Hematuria
„
„
„
Kidney Stones
Urinary Tract Infection
Tumors/Neoplasms
„
„
Inflammation
„
„
„
„
Bladder, Kidney, Prostate
Cystitis, Prostatitis, Pyelonephritis
BPH
Trauma
Glomerular Disease
4
Norifumi Kamo, HMS III
Gillian Lieberman, MD
Menu of Radiologic Tests
„
Abdominal Ultrasound
„
CT scan
„
Kidney stone protocol (CT w/o contrast)
„
CT urogram
„
MRI
„
Radionuclide Scan
„
Historical tests: IVP, Retrograde pyelography
5
Norifumi Kamo, HMS III
Gillian Lieberman, MD
Patient AS: Abdominal CT
No evidence of hydronephrosis,
kidney stones
Nml cortical thickness,
no signs of obstruction
Renal cyst
Patient
Patient
AS AS
PACS,
BIDMC
PACS,
BIDMC
„
Axial CT +/- contrast reveals benign renal cyst, nml renal cortical thickness
w/o evidence of obstruction, hydronephrosis, renal mass, kidney stones
6
Norifumi Kamo, HMS III
Gillian Lieberman, MD
Patient AS: Pelvic CT
Thickened bladder wall
Patient AS
PACS, BIDMC
„
Axial CT cystogram with contrast reveals symmetric posterior bladder wall thickening
7
Norifumi Kamo, HMS III
Gillian Lieberman, MD
Differential Diagnosis
„
„
„
Kidney Stones
Urinary Tract Infection
Tumors/Neoplasms
„
„
Inflammation
„
„
„
„
Bladder, Kidney, Prostate
Cystitis, Prostatitis, Pyelonephritis
BPH
Trauma
Glomerular Disease
8
Norifumi Kamo, HMS III
Gillian Lieberman, MD
Differential Diagnosis
„
„
„
Kidney Stones
Urinary Tract Infection
Tumors/Neoplasms
„
„
Inflammation
„
„
„
„
Bladder, Kidney, Prostate
Cystitis, Prostatitis, Pyelonephritis
BPH
Trauma
Glomerular Disease
9
Norifumi Kamo, HMS III
Gillian Lieberman, MD
Transitional Cell Carcinoma of the Bladder
„
„
„
4th most common CA in men, 9th most common in
women
Incidence: 67,000/yr, Mortality: 13,750/yr
Risk factors:
„
„
„
„
SH: smoked 4
Tobacco
PPD for 40 yrs
Schistosomiasis
Chemicals: Aromatic Amines, Phenacetin, Cyclophosphamide
Clinical Presentation:
„
„
„
„
Gross painless hematuria
Pain from locally advanced or metastatic tumor
Voiding symptoms - dysuria, frequency, urgency, obstruction
Constitutional symptoms - fatigue, weight loss, anorexia
10
Norifumi Kamo, HMS III
Gillian Lieberman, MD
TCC of Bladder: Diagnosis
„
U/A: hematuria
„
„
„
„
Companion Patient 1
When bacteruria or
pyuria present urine cx
to r/o UTI
Cystoscopy and
biopsy
Urine cytology
Other
„
„
„
Immunocytochemistry
Proteomics
Biomarkers
http://www.urologychannel.com/bladdercancer/sptumor.shtml
11
Norifumi Kamo, HMS III
Gillian Lieberman, MD
Radiologic Features of TCC
Companion Pt 2
„
„
IVP - historical
CT
„
„
„
„
T1: invades subepithelial
connective tissue
T2 - invades muscle
T3 - invades perivesical
tissue
T4 - invades beyond
Companion Pt 4
Further Imaging
„
„
„
< T2, N0, M0
Staging: TNM system
„
„
Companion Pt 3
CXR - pulmonary mets
Patient AS
MRI - tumors at base and
Kim et al.
PACS, BIDMC
dome of bladder
Bone Scan
http://urology.jhu.edu/bladder/bladder_cancer
_diagnosis.php
http://urology.jhu.edu/bladder/bladder_cancer_diagnosis.php
Companion Pt 5
PACS, BIDMC
12
Norifumi Kamo, HMS III
Gillian Lieberman, MD
Treatment Options for TCC
„
„
„
„
TURBT +/- chemotherapy
Primary radiation therapy
Partial cystectomy
Radical cystectomy indications:
„
„
Infiltrating muscle-invasive bladder CA w/o evidence
of metastatic disease (T2M0)
Superficial bladder tumors (CIS, T1) refractory to
chemotherapy, other surgery
Patient AS: Pathology report revealed high grade papillary TCC
with invasion of lamina propria and muscularis propria
13
Norifumi Kamo, HMS III
Gillian Lieberman, MD
Bladder Anatomy - Male
http://urologyhealth.org
„
Posterior and superior to the pubic bones, inferior to peritoneum,
superior to the prostate, anterior to rectum
14
Norifumi Kamo, HMS III
Gillian Lieberman, MD
Radical Cystectomy
„
„
„
Male - removal of
prostate and bladder
Bilateral pelvic
lymphadenectomy
Urethrectomy
„
„
Tumor in prostatic urethra
Urinary Diversion
„
Ileal loop conduit - urine
directed from ureters
through segment of
isolated ileum to abd wall
http://community.nursingspectrum.com/MagazineArticles/
article.cfm?AID=18622
AS underwent radical cystectomy with ileal loop diversion
15
Norifumi Kamo, HMS III
Gillian Lieberman, MD
Patient AS: Post-Op CT
Post-Op Ileus
No hydronephrosis,
symmetrical excretion
of contrast
Patient AS
PACS, BIDMC
„
CT Abd/Pelvis with IV contrast revealed dilated loops of bowel with
air-fluid levels and no signs of obstruction
16
Norifumi Kamo, HMS III
Gillian Lieberman, MD
Patient AS: Post-Op CT
Urostomy bag
Ureteral stents in place,
no contrast in ileal
conduit
Bilateral ureters
entering ileal conduit
Surgical Clips
Patient
Patient
AS AS
PACS,
PACS,
BIDMC
BIDMC
„
CT Pelvis with contrast reveals multiple surgical clips, ureteral stents are
seen in bilateral ureters, exiting abdomen through urostomy
17
Norifumi Kamo, HMS III
Gillian Lieberman, MD
Ileal Conduit Complications
„
Leak
„
„
„
Fistulas
Infection
„
„
Bleeding, Ileus, Obstruction
Urinary Tract Obstruction
„
„
Wound infection, Abscess, UTI, Pyelonephritis, Sepsis
GI
„
„
Urine, Bowel
Stones, Strictures, Hydronephrosis
Diminished renal function, Renal failure
18
Norifumi Kamo, HMS III
Gillian Lieberman, MD
AS: CT 1 mo s/p surgery
Fluid Collection
w/ thick border
Patient AS
PACS, BIDMC
„
„
Pt presents with abdominal pain, nausea, lethargy, fever
CT with IV contrast reveals fluid collection at level of ileal conduit,
which could represent urine collection or abscess
19
Norifumi Kamo, HMS III
Gillian Lieberman, MD
AS: CT-guided IR drainage
Patient AS
Pig-tail catheter
PACS, BIDMC
Abscess w/ fluid and air
Patient AS
PACS, BIDMC
„
„
„
Pt underwent CT-guided drainage of the fluid collection
50cc of purulent aspirated and was positive for mixed bacteria
Repeat CT 1wk s/p drainage shows drainage catheter within abscess,
which has decreased in size, with residual fluid with air seen in the cavity
20
Norifumi Kamo, HMS III
Gillian Lieberman, MD
„
„
„
„
„
Patient AS: Loopogram
Fluoroscopy-guided
loopogram to assess
leak
Contrast injected
through urostomy
Contrast filled the
ileal conduit
No evidence of leak
No reflux into the
ureters
Stoma
Catheter w/
contrast
Patient AS
PACS, BIDMC
Ileal conduit
+ contrast
Pig-tail
Catheter
21
Norifumi Kamo, HMS III
Gillian Lieberman, MD
Patient AS: Hospital Course
„
„
„
„
„
„
„
„
Started on antibiotics
NPO, started on TPN
No evidence of fistulous connection
Reduction in size of abscess
Good urostomy output
Diet was advanced and tolerated well
CBC, electrolytes remained stable
Pt discharged with plans for close follow-up
22
Norifumi Kamo, HMS III
Gillian Lieberman, MD
AS: CT 5 yrs s/p surgery
Air
Cortical atrophy and
hydronephrosis
Stricture
No excretion
of contrast
Patient AS
Patient AS
PACS, BIDMC
PACS, BIDMC
„
„
BUN: 44, Creatinine: 1.6
Abd/Pelv CT with contrast reveals cortical atrophy of left kidney with
no excretion of contrast and hydronephrosis, air in right collecting
23
system, possible stricture of left ureter
Norifumi Kamo, HMS III
Gillian Lieberman, MD
Conclusions: Role of Radiology
„
Workup for painless hematuria
„
Staging bladder TCC
„
Assess for post-operative complications
„
IR-guided abscess drainage
24
Norifumi Kamo, HMS III
Gillian Lieberman, MD
Acknowledgments
„
„
„
Dr. Andrew Hines-Peralta
Dr. Gillian Lieberman
Maria Levantakis
25
Norifumi Kamo, HMS III
Gillian Lieberman, MD
References
Bochner BH. Urinary diversion and reconstruction following cystectomy. UpToDate
Online. Last updated 8/27/07. Retrieved 11/07/07.
http://utdol.com/utd/content/topic.do?topicKey=gucancer/13454
Donat SM, Dalbagni G, Herr H. Clinical presentation, diagnosis, and staging of bladder
cancer. UpToDate Online. Last updated 1/25/07. Retrieved 11/08/07.
http://utdol.com/utd/content/topic.do?topicKey=gucancer/6264
Eggener SE, Campbell SC. Cystectomy, Radical. eMedicine from WebMD. Last updated
10/11/07. Retrieved 11/08/07. http://www.emedicine.com/med/topic3061.htm
Kim JK, Park S, Ahn HJ, Kim CS, Cho K. Bladder cancer: analysis of multi-detector row
helical CT enhancement pattern and accuracy in tumor detection and perivesical
staging. Radiology 2004; 231:725-731
“Bladder; Lower Genitourinary Calculi and Trauma” in Campbell-Walsh Urology, 9th ed.
Eds Wein, Kavoussi, et al. Saunders Elsevier Philadelphia. 2007. 2418-2566.
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