Urothelial Carcinoma (Bladder Cancer and Upper Tracts)

Urothelial carcinoma is one of the most common carcinomas of the genitourinary system and can develop at multiple sites along the urothelium, from the pyelocaliceal system to the prostatic urethra. Imaging is therefore of paramount importance for the evaluation and detection of upper tract lesions and staging of the lower tract. CT and MRI are the predominant modalities to evaluate the entire urothelium and staging the tumor, lymph nodes, and solid organs for distant metastasis. Additional imaging. It is most common in white men and predominant risk factors include heavy smoking, exposure to chemicals, chronic infections, and inflammation, among others. The bladder is most frequently affected, and the tumors may present as polypoid or sessile lesions, that correspond to non-muscle invasive or muscle invasive tumors respectively, and carry different prognoses, the latter much worse. Patients present classically with painless hematuria, dysuria, or frequency. The tumor spreads through lymphatics and bloodstreams with an increased chance of spreading directly proportional to the tumor size and depth of invasion.The introduction of blue light cystoscopy, which takes advantage of the fluorescent properties of the urothelial carcinoma, has improved accuracy during diagnostic cystoscopy and has allowed noninvasive tumors to be resected earlier by transurethral resection of bladder tumors. Certain patients are at higher risk of recurrence (high grade tumors, > 3cm, multifocal, early recurrence) and can benefit from intravesical immunotherapy or chemotherapy. Muscle invasive tumors are treated more aggressively, and treatment involves cystectomy with urinary diversions, plus adjuvant or neoadjuvant chemotherapy.In the setting of metastatic disease, immunotherapy has been recently adopted and approved as a second line treatment after the standard chemotherapy regimen.Monitoring tumor response depends largely on cystoscopy for the lower tract and imaging for the upper tract, with CT Urogram being the workhorse of our practice to evaluate the urothelium as well as lymph nodes and solid organs. MRI is frequently used on patients with renal insufficiency or in patients with iodine allergy. Several urinary markers are also used for surveillance in urine samples.