Patient Profile

Name: 楊 X 淑Sex: FemaleDate of birth: 1947/12/17, 65 y/oFirst Admission Time: 2008/7/21

Chief Complaint

Pink urine noted for 1 month

Clinical Course

2008/7/15, OPD：Sonography：Hydronephrosis, RightKUB：No renal stone.2008/7/19, OPD：For role out right ureter stone, arrange IVP.

Image：IVP

1. Right hydronephrosis2. Filling defect in bladder=> Should r/o bladder CA.

Image：IVP

Image：IVP

Clinical Course2008/7/20~7/24：1st Admission

2008/07/21

Admission for TUR-biopsy, OP findings：1. Papillary lesion at right bladder wall.2. Right ureter orifice was not seen.

2008/07/23Pathology Report:Urinary bladder, right lateral wall:Chronic inflammation.

Clinical Course

Bone Scan：No evidence of metastatic disease.2008/7/24

2008/7/20~7/24：1st Admission

2008/07/23

CT Report：1. An irregular mass at the right lateral wall of

the bladder and occupy over a 1/3 of total volume, measuring about 3.8x8.5x6.7 cm in diameter, whereas homogeneousenhancement on the post-contrast images is noted.

2. There is obvious hydroureter at R’t side.3. There are multiple LAPs or enlarge LNs,

include region of paraaorta

Image：CT

Image：CT

Image：CT

Image：CT

Clinical Course

2008/7/29 OPD：

Transitional cell carcinoma was told in another Hospital.

Clinical Course

Transurethral Resection of Bladder Tumor(TRUBT)OP findings：1. Papillary lesion at right bladder wall.2. Right ureter orifice was not seen.

2008/7/31

2008/7/30~8/2：2nd Admission

2008/8/12Pathological Report：Low grade MALToma with focal high grade tranformation.

Past History

Tonsilar lymphoepitheliomas/p op for 3 times: 1980 at 仁愛 Hospital1982/7/26 at NTUH1983/9/13 at NTUH(post-operation Radiation therapy for 55 days)

Total hip replacement

Physical Examination

General appearance：Chronic ill-lookingHematuria (+)No flank pain.No fever.No dysuria, frequency nor nocturia.No other specific findings.

Lab data2008/7/20

RBC 3.57 x 10^6 /Ul (L)HGB 9.8 g/Dl (L)Na 132 mEq/L (L)

(-)Bacteria10-25WBC5-10RBC(-)Nitrite2+Occult Blood

Urine Analysis

Sonography

2008/9/2For role out Metastatic Lesion：1. Diffuse Liver parenchymal Disease2. Stones, Gallbladder, Multiple3. Distended Intestinal

UGI Scope

2008/9/2For MLAToma pathological report, origin?1. Esophagus : Negative2. Stomach : Much food residue retention

Linear ulcer at GCS of upper body 3. Duodenum : Some food residue retentionEndoscopic diagnosis : Ulcer, Linear, Stomach, Incomplete study

LGI Scope

2008/9/2For MLAToma pathological report, origin? It revealed:

1. Moderate amount of yellowish stool retention.

2. Some polyps (2-3mm) were found within 35cm from anal verge while insertion, but immersed by stool while withdrawal.

3. Internal hemorrhoid.

Image：CT

2008/11/13A small irregular mass at the right lateral wall of the bladder.Evident regressive change compared with the last CT scan.

Image：CT

Clinical Course

2009/12/3Follow-up CT showed：

1. Asymmetrical wall thickening of the bladder.2. No signs of para-aortic lymphadenopathy. 3. No significant change as compare with the last

CT scan.

TreatmentChemotherapy with：COP x2 since 2008/9/18 Mabthera x 1 since 2008/11/28.

Discussion

1. Neoplasms of the urinary bladder：Radiology v.s. Pathology

2. What to order when patient have hematuria ?

3. What is MALToma ?

Neoplasms of the Urinary Bladder

Urothelial Carcinoma

Urothelial Carcinoma

Urothelial (Transitional cell) cancer is the most common urinary tract cancer in the United States.At CT, it appears as an intraluminalpapillary or nodular mass or focal wall thickening.Lesions may be missed without adequate bladder distention.The calcification typically encrusts the surface of the tumor and may be nodular or arched.

SquamousCell Carcinoma

Hemangioma

Squamous Cell Carcinoma

Risk factors in nonbilharzial regions include chronic irritation from indwelling catheters.The imaging findings in squamouscarcinoma are nonspecific.Tumors may appear as a single enhancing bladder mass or as diffuse or focal wall thickening.

Adenocarcinoma

Carcinoid

Adenocarcinoma

It can be subclassified as primary (2/3：Nonurachal；1/3：Urachal) or secondary (metastases).At CT, the tumor is mixed solid and cystic in 84% of cases and solid in the remainder. The cystic contents represent mucin.CT is the most sensitive modality for calcification.

Small CellCarcinoma

Small Cell Carcinoma

Tumors are typically large and polypoid or nodular and may have an ulcerated surface.The lateral bladder walls are the most common site.Central necrosis and cystic changemay be seen with CT.Small cell tumors may exhibit very rapid growth.

Rhabdomyosarcoma

Rhabdomyosarcoma

It can manifest as a diffusely infiltrativelesion or as masses, which can be polypoid and “grapelike” (sarcoma botryoides).The cut surface can be glistening, gray-white, and gelatinous with variable necrosis and hemorrhage.Imaging typically shows large, nodular filling defects or masses often associated with urinary obstruction.

Lymphoma

Inflammatory Pseudotumor

Discussion

1. Neoplasms of the urinary bladder：Radiology v.s. Pathology

2. What to order when patient have hematuria ?

3. What is MALToma ?

Radiologic study for Painless Hematuria

UrolithiasisPapillary Necrosis

Aneurysm, Malformation, Arterial or Venous Occlusion

Vascular Abnormality

Common CausesNeoplasm Kidney, Ureter, Bladder, UrethraGlomerulonephritis

Radiologic study for Painless Hematuria

Required in any adult with unexplained hematuria because other exams normal.Cystoscopy

Excellent for detecting stones and papillary necrosis.

Excretory Urography

Approach to Diagnostic Imaging

CTMore sensitive for renal masses.If combined with an unenhanced exam, will detect urinary tract calculi.

UltrasoundRelatively efficient imaging technique for neoplastic renal masses and vascular anomalies.

Radiologic study for Painful Hematuria

Trauma

Common CausesUreteral calculusInfection Especially cystitis or urethritis

Provides a broad range of morphologic and functional information concerning all portions of the urinary tract.Can define the site of an ureteral stone and the degree of resulting obstruction.

Excretory Urography

Approach to Diagnostic Imaging

Radiologic study for Painful Hematuria

Computed tomography (Unenhanced)1. Can detect even poorly opaque stones (e.g. uric acid

calculi).2. Can detect dilatation of the collecting system proximal

to an obstructing stone.3. Can detect secondary signs of obstruction such as a

perinephric extravasation.4. Presence of tissue (edematous ureter) surrounding a

calcification (rim sign) can differentiate a ureteralcalculus from a phlebolith or other extraurinarycalcification.

5. Can detect extraurinary cause of abdominal pain.

Radiologic study for Painful Hematuria

Ultrasound1. Can demonstrate the presence and degree of ureteral

dilatation.2. Can demonstrate a stone as an echogenic focus with

acoustic shadowing with a non-opaque, completely obstructing stone causing loss of ipsilateral kidney function.

3. Transvaginal US may be used to increase the sensitivity for detection of distal ureteral stones.

4. US may be the procedure of choice for pregnant patients.

++

Discussion

1. Neoplasms of the urinary bladder：Radiology v.s. Pathology

2. What to order when patient have hematuria ?

3. What is MALToma ?

Mucosa - Associated Lymphoid Tissue LymphomaDescribed by Isaacson and Wright in 1983Pseudolymphoma ?????

MALToma

Oncogenic Infectious AgentsAgent Tumor Type Annual Cases WorldwideBacteriaHelicobacter pylori Stomach cancer, gastric lymphoma 505,000Campylobacter jejuni Alpha chain disease rareVirusesHuman papillomavirus Cervical, anal, vaginal, and other 447,000Hepatitis B virus Liver cancer 285,000Hepatitis C virus Liver cancer 113,000Human immunodeficiency virus Kaposis, NHL 52,000Human herpes type 8 Kaposis　 44,000Epstein-Barr virus Lymphomas 30,000Human T-cell lymphotropic virus Adult T-cell leukemia 3000ParasitesSchistosomes Bladder cancer 10,000Liver flukes Cholangiocarcinoma 800

Oncogenic Infectious Agents

Factors associated with acquired MALT

Helicobacter pyloriHelicobacter HeilmaniiChronic infection / inflammationBorrelia BurgdorferiAutoimmune conditions:Sjögren’s SyndromeHashimoto’s Thyroiditis

Predominant sites of MALT-lymphoma

StomachGI-TractLungSalivary GlandsOcular AdnexaSkin

NCCN Guideline

NCCN Guideline

NCCN Guideline