Three‐dimensional ultrasonographic findings in bladder cancer

Abstract

Bladder cancer is the second most common cancer of the genitourinary tract, and its most common symptom is hematuria, either gross or microscopic. However, the differential diagnosis for hematuria is extensive1. Patients referred with hematuria in the absence of infection should have renal ultrasonography or intravenous urography, urine cytology and cystourethroscopy to distinguish between a renal or postrenal source of the bleeding1. We report the three-dimensional (3D) sonographic findings in two cases of bladder carcinoma. The first case was a 59-year-old postmenopausal woman who presented with a history of urinary frequency, nocturia and dysuria associated with gross hematuria. Transvaginal ultrasonography (TVS) revealed an ill-defined, 3.2 × 2.7-cm hypoechogenic nodule with an inner calcified ring located in the right anterior lateral aspect of the bladder, protruding into the bladder lumen. 3D scanning revealed invasion of the bladder wall (Figure 1a) and plaque-like extension of the tumor, which increased the thickness of the underlying bladder wall (Figure 1b). Doppler studies revealed increased vascularity in the periphery of the tumor mass (Figure 2). The lowest resistance index value of the tumor vessels was 0.29. Cystoscopy revealed an irregular mass protruding into the bladder cavity (Figure 3). A transurethral biopsy specimen contained malignant cells. Subsequent surgery showed a Stage IV tumor of the right anterior bladder wall. The pathological diagnosis was a poorly differentiated adenosquamous carcinoma. In Case 1, three-dimensional transvaginal ultrasound examination revealed bladder wall invasion (a) and plaque-like extension (b) of the bladder tumor. (a) Bladder wall invasion is recognized by the normal bladder wall (white arrows), which is relatively echogenic, being interrupted by hypoechogenic tumor tissue. (b) The bladder wall underlying the plaque-like extension of the tumor is 11.7 mm thick (black arrows). Doppler study in Case 1. The vascularity is increased at the periphery of the tumor mass. Cystoscopic examination in Case 1 showing an irregular mass. The second case was a 50-year-old woman who was referred to our clinic with a history of frequency, nocturia, urgency and urinary incontinence. Urinalysis revealed numerous red and white blood cells. TVS revealed a 3.2 × 3.1-cm echogenic mass located at the junction of the bladder dome and anterior bladder wall and protruding into the bladder cavity. 3D scanning revealed a tiny tumor invading the bladder wall (Figure 4). Increased vascularity was seen centrally on Doppler studies (Figure 5). Cystoscopy and transurethral biopsy revealed a malignant bladder tumor. On subsequent surgery, a Stage I adenocarcinoma was found. In Case 2, a three-dimensional transvaginal sonographic scan revealed a tiny protuberance (arrows) invading the bladder wall. In Case 2, a Doppler study revealed increased vascularity centrally within the tumor mass. Ultrasound has been reported to be useful for screening and detecting bladder tumors and is considered superior to intravenous urography for this purpose2. Dibb et al. reported varying morphological features of bladder tumors on transabdominal ultrasonography, including: a polypoid, sessile or plaque-like configuration; regular or irregular surface; calcified or uncalcified texture2. TVS with a high-resolution probe can clearly differentiate various intravesical masses such as bladder calculus3, foreign bodies, intravesical blood clots4 and hemorrhagic cystitis5. These conditions may cause hematuria and can appear simply as an intravesical mass on imaging studies, making them difficult to distinguish from bladder cancer3-5. Abnormal ultrasonographic changes of the bladder wall are one of the indications for cystoscopic examination. We suggest that TVS scanning of the lower urinary tract may serve as an initial work-up for women with either gross or microscopic hematuria. For those women who have abnormal sonographic findings, cystourethroscopy is suggested, even in the presence of pyuria. However, for those women with normal ultrasound findings, medical treatment may be attempted to avoid the discomfort of cystourethroscopy. 3D TVS, in addition to detecting a bladder tumor, may also demonstrate bladder wall invasion, and thus assist in surgical planning6. W.-C. Huang*, S.-H. Yang , J.-M. Yang , * Department of Obstetrics Gynecology, Cathay General Hospital, 92 Chung-Shan North Road, Section 2, Taipei 104, Taiwan, R.O.C., Taipei Medical University, 92 Chung-Shan North Road, Section 2, Taipei 104, Taiwan, R.O.C., Division of Urogynecology, Department of Obstetrics Gynecology, Mackay Memorial Hospital, 92 Chung-Shan North Road, Section 2, Taipei 104, Taiwan, R.O.C.