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May 2020, Volume 70, Issue 5

IMAGING CORNER

A rare presentation of primary synchronous renal tract tumours on (18F)- fluorodeoxyglucose positron emission tomography- computed tomography

Waqas Ahmad  ( Department of Radiology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan. )
Sana Munir Gill  ( Department of Nuclear Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Center Lahore, Pakistan )
Aamna Hassan  ( Department of Nuclear Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan )

Abstract

Synchronous primary tumours along the urinary tract are not common. Preliminary assessment with FDG PET of patients with bladder cancer remains difficult due to intense accumulation of excreted FDG in urine. CT component helps to define the anatomical details and extent when ever other tumours are suspected.

Keywords: Urinary bladder tumour, (18F)-fluorodeoxyglucose positron emission tomography- computed tomography, Renal mass.

 

A 66 year old diabetic female presented with haematuria and right flank pain since 4 months. On initial investigations pelvic imaging showed a bladder growth which on cystoscopy and biopsy was confirmed to be low-grade papillary urothelial carcinoma. As a part of her staging work up, a high resolution computed tomography (HRCT) was performed where mediastinal nodes and tiny pulmonary nodules were noted. Before proceeding with the surgical planning, the patient underwent PET-CT scan to rule out distant metastasis.

Figure-1 (a &b) Axial CT and PET/CT fusion images showing hypermetabolic anterior wall bladder thickening (white arrows) Figure-1 (c & d) Axial CT and PET/CT fusion shoing FDG avid synchronous right renal tumour seen as hypodense solid lesion extending from calyces to pelvis (white arrow heads) Multiple primary malignant neoplasms (MPMNs) are a rare entity in the genitourinary system. They were first described in 1889 by Theodore Bilroth1. The incidence of second primaries in urological malignancies has been reported up to 2.8% to 6.3%2. Synchronous genitourinary tumours are even more uncommon and approximately 50 such cases have been reported3. Synchronous tumours have been reported with transitional cell carcinoma, however, rarely have they been reported with papillary urothelial carcinoma. Considering its rarity, this needs to be highlighted as both bladder and renal carcinomas present with haematuria and back pain. Also, presence of such tumours simultaneously also changes the management plan of the patient. Urinary excretion of FDG and variability in bladder wall uptake hampers to imaging bladder cancer and interferes with easy visualization of the primary bladder mass. Several interventions such as adequate hydration, bladder irrigation, and forced diuresis with furosemide have been used to overcome this handicap. Addition of CT images to PET provides precise anatomic information which can improve the diagnostic ability not only for bladder cancer but for renal lesions in our patient (Figure-2. a & b)

Coronal whole body CT (a) showing right renal pelvicalyceal system tumour and anterior bladder wall thickening (blue arrows) and MIP reconstructed PET image (b) demonstrates FDG uptake in right renal mass and anterior part of urinary bladder (red arrows). Use of other tracers like 11C-choline, 11C-acetate, and 11C-methionine, all of which have minimal urinary excretion can be used for PET-CT in bladder cancer.

 

References

 

1. Billroth T. 51 Vorlesungen: A Textbook for Students and Physicians in Fifty-one Lectures. 14th ed. Berlin: G. Rerimer; 1889. General surgical pathology and therapeutics; p. 908.

2. Smith MT, Taylor FD, Gianakopoulus WP, Brown RR. Two separate synchronous primary genitourinary tumors. Rev Urol. 2012;14:104-107.

3. Mucciardi G, Galì A, D'Amico C, Muscarà G, Barresi V, Magno C. Transitional Cell Carcinoma of the Renal Pelvis With Synchronous Ipsilateral Papillary Renal Cell Carcinoma: Case Report and Review. Urol Case Rep. 2015;3:93-95.

 

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