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Describtion :

A 67-year-old man presented with macroscopic haematuria. Cystoscopy was
1. Describe the fi ndings and likely diagnosis.
2. What is the differential diagnosis?
3. How would you manage this patient?
?. Describe what you see in the nephrectomy specimen  


پاسخ سوالات :

Answers to Case1-1-5
1. Figure1-1-5a is a retrograde pyelogram demonstrating a well-defi ned fi lling
defect within the inferior aspect of the left renal pelvis. (Note that retrograde
pyelogram images can be differentiated from IVU images as the kidneys and the
renal parenchyma are not seen in an enhanced state in the former). Axial
(Fig. 1-1-5b ) and coronal (Fig. 1-1-5c ) CT images demonstrate good contrast
opacifi cation of the renal collecting systems and confi rm a mass-like fi lling
defect within the left renal pelvis. There is no local infi ltration.
2. The appearances are suspicious for transitional cell carcinoma, but the differential
diagnosis for a fi lling defect within the collecting system includes a blood
clot, radiolucent calculus, sloughed papilla, gas (from instrumentation or a gas
forming organism) and pyeloureteritis cystica. The CT study shown has been
performed in the excretory phase to optimally visualise the renal collecting system
i.e. a CT urogram. Protocols vary between units, but the usual delay in scanning
post-intravenous contrast is between 5 and 15 min. Longer imaging delays
improve distension of the proximal urinary tract and may aid in visualisation of
the lower segment of the ureter.
3. The diagnosis of upper tract TCC should be confi rmed, either by urinary cytology
or ideally by ureteroscopic biopsy, as this will better stage and grade the
tumour. If this proves to be a localised tumour, with no contralateral upper tract
tumour, then nephro-ureterectomy offers the best hope of cure. Endoscopic management
may be used in selected patients with: smaller, low grade tumours;
bilateral upper tract TCCs; a solitary kidney; chronic kidney disease.
After a diagnosis of non-muscle invasive bladder cancer the incidence of
upper tract TCC is 1.8%, the risk is 7.5% if the bladder tumour involves the
trigone. The incidence of developing a bladder tumour after an upper tract TCC
is 15–50% – these metachronous tumours occur most commonly within the fi rst
two years of diagnosis and are thought to be due either to tumour cell seeding or
the pan-fi eld effect.
4. The nephrectomy specimen demonstrates a papillary transitional cell carcinoma
which is arising from and distending the renal pelvis and upper pole calyces and
is associated with loss of renal parenchyma

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