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Transitional Cell Carcinoma
"Goblet Sign"
Submitted by Daniel Kowal, MD
- Accounts for 85-90% of all uroepithelial tumors
- Exophytic, polypoid papillary growth pattern most common
- Attached to the mucosa by stalk
- Non-papillary tumors less common
- Most are solid with no characteristic gross findings
- Location
- Bladder is 30-50x more often the site of the tumor than ureter or renal pelvis (most common tumor of GU tract)
- When it occurs in the ureter, it most commonly occurs in the lower 3rd
- Synchronous (simultaneous) transitional cell carcinomas are common
- Bladder involvement with
- 24% of primary renal pelvis involvement
- 30% of primary ureteral involvement
- In 2% with primary bladder tumor
- Both ureters involved in 2-9%
- Both renal pelves in 1-2%
- Metachronous (sequential) transitional cell carcinomas in upper tracts
- With pelvic and ureteral primaries-12% in 25 months
- With bladder primaries-4% (2/3 in 2 years but can reoccur decades later)
- Most commonly in men age 60 and older
- Classically present with “painless hematuria”
- Risk factors
- Exposure to cyclophosphamide
- Phenacetin
- Chronic urinary stasis
- Smoking
- Metastasizes to
- Regional lymph nodes
- Liver
- Lung
- Bone
- Imaging findings
- IVU
- Enlarged and hydronephrotic kidney
- Invasive, poorly differentiated tumors are more likely to obstruct
- Dilated calyx with filling defect
- Calyceal amputation
- Partial or complete obstruction of the infundibulum
- Retrograde studies
- Papillary tumors
- “Goblet” or “Champagne glass sign” of ureteral dilatation distal to a filling defect allows for differentiation from a calculus impacted in the ureter, which causes distal spasm and narrowing
- Non-papillary tumors
- Nodular or flat
- Cause strictures rather than filling defects
- CT
- Can identify dilated collecting system and demonstrate level of obstruction
- Intraluminal mass (30-60 HU) representing ureteral tumor can be differentiated from obstructing calculus (> 190 HU)
- May demonstrate extra-ureteral extension
- US
- Discrete hypoechoic mass within the renal sinus
- Absence of acoustic shadowing allows for differentiation from calculi
- Angiography
- Hypovascular mass
- Vessel encasement and stain
- Not usually necessary
- Treatment
- Controversy
- Nephroureterectomy with resection of a cuff of bladder versus wide excision of the tumor alone
- Adding chemotherapy (cisplatin) in patients with advanced tumors is of unclear utility
Goblet Sign. Blue arrow points to “Goblet” or “Champagne glass sign” of ureteral dilatation distal to a filling defect in the right ureter which allows for differentiation from a calculus impacted in the ureter, which causes distal spasm and narrowing
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