Inflammatory bladder masses detected with contrastenhanced ultrasound (CEUS): A relatively frequent but

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1 Inflammatory bladder masses detected with contrastenhanced ultrasound (CEUS): A relatively frequent but insufficiently described pathology Poster No.: C-2568 Congress: ECR 2013 Type: Scientific Exhibit Authors: F. J. Pérez Fontán, A. Rois Siso, D. Romeu Vilar, V. Pazos Silva, M. Otero Palleiro, J. Rodriguez Antuña ; A Coruña/ES, 2 3 La Coruña/ES, Corunna/ES Keywords: Neoplasia, Inflammation, Diagnostic procedure, Contrast agentintravenous, Ultrasound, Urinary Tract / Bladder, Contrast agents DOI: /ecr2013/C-2568 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 12

2 Purpose To remind the existence of a relatively frequent but insufficiently described condition, with radiologic and cystoscopic features similar to bladder neoplasm. To describe the CEUS characteristics of bladder inflammatory masses. To disclose similarities and differences of CEUS presentations between bladder neoplasm and pseudotumoral inflammation. Methods and Materials Between June-2008 and December 2011, a total of 131 patients presenting with bladder parietal nodules or masses underwent CEUS study with a second generation contrast agent performed in our tertiary hospital. Non enhanced lesions corresponding to blood clots or inert material were excluded from this review. Pathologic analysis disclosed 112 neoplasms among all cases; while cystocopy, biopsy and follow-up demonstrated a total of 19 inflammatory masses that were the subject of the study. Sonographic examination was performed with pulse inversion harmonic technique after the antecubital vein injection of 2,5 ml aqueous suspension of phospholipid-stabilized microbubbles filled with sulfur-hexafluoride (Sonovue ), followed by a 10ml normal saline flush. The enhancement characteristics of the lesions studied were evaluated continuously for a period of at least 4 minutes. Results The lesions corresponded in pathologic study to: acute and chronic cystitis (n=7) (Fig. 1 on page 3), nodular acute cystitis (n=2) (Fig. 2 on page 4), follicular cystitis (n=2) ( Fig. 3 on page 5), one combined with cystitis glandularis (Fig. 4 on page 6), and one case each of adenoleiomyomatous metaplasia (Fig. 5 on page 7), squamous Page 2 of 12

3 metaplasia (Fig. 6 on page 7), eosinophilic (Fig. 7 on page 8), interstitial and incrustant cystitis. Cystoscopy, CT and clinical evolution contributed also to diagnose 1 case each of parietal flemonous changes and parietal abscess secondary to diverticulitis and Crohn disease, presenting as focal enhancing masses (Fig. 8 on page 8). In 10 cases CEUS findings overlapped with that of neoplastic lesions, while in 9 other cases preservation of the intensely-enhanced superficial mucosa-submucosa-line (where malignancy origins) excluded tumor (Fig. 1 on page 3, Fig. 9 on page 9). In oposition with the inflammatory changes observed in fig 9, in patients with bladder neoplasm CEUS shows irregular, hyperenhancing tissue thickening that effaces mucosasubmucosa line CEUS, invading the hypoechogenic muscular layer in infiltrative cases suggesting neoplasic lesion (Fig. 10 on page 10). Images for this section: Page 3 of 12

4 Fig. 1: Acute and chronic cystitis. A 29 year-old man with neurogenic bladder. Grayscale ultrasound on axial (a) and sagital (b) planes showed a focal tissular thickening in postero-superior bladder wall (arrows). (c, d) CEUS showed preservation of the lineal enhancement in the mucosa-submucosa layer (arrows) and a marked thickening of muscular layer (double head arrow), therefore neoplasia could be excluded. Biopsy confirmed acute and chronic cystitis. Page 4 of 12

5 Fig. 2: Nodular inflammatory lesion. A 62 year-old man with previous transuretral resection of superficial bladder wall tumor. (a, b) Gray-scale ultrasound showed a nodule of 1.2 cm next to right trigone (arrows), associated to ureteral dilatation (open arrow). (c) CEUS showed homogeneous enhancement indistinguishable from a neoplastic lesion. two repeated cystoscopy with biopsy demonstrated inflammation and edema without signs of malignancy. (d) On posterior control, the nodule and ureteral obstruction disappeared. Note the ureteral jet. Page 5 of 12

6 Fig. 3: Follicular cistitis. A 60 year-old man who presented with hematuria. (a) Gray-scale ultrasound showed irregular thickening tissue on the right trigone (arrows), that engulfed distal ureter causing secondary obstructive uropathy (open arrow), and simulating infiltrative carcinoma. CEUS showed arterial phase enhancement (b) with delayed washout (c), similar to urothelial neoplasm. Pathologic study revealed follicular cystitis, reactive to microscopic focus of in situ carcinoma. Page 6 of 12

7 Fig. 4: Cystitis glandularis. A 72 year-old man with paraplegia and obesity. (a) Gray-scale ultrasound showed an irregular echogenic tissue thickening at bladder base, simulating urothelial carcinoma. (b) CEUS showed enhancement similar to urothelial neoplasia with effacement of the mucosa-submucosa line that correlates with mucosal denudation in pathologic analysis. Fig. 5: Adenomatous hyperplasia. A 47 year-old man with hematuria. (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows). (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow), being the finding indistinguishable from a neoplasic lesion. After cystoscopy and biopsy the pathologic diagnosis was adenomatus hyperplasia. Fig. 6: Squamous metaplasia. A 66 year-old woman with previous history of bladder lithiasis and hematuria. (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass. (b) CEUS revealed a non-enhancing clot (asterisk) and Page 7 of 12

8 hyperenhancing papillary nodules in the right bladder wall (arrow), indistinguishable from neoplasic focus. Pathologic study revealed squamous metaplasia, with chronic and acute inflammation. Fig. 7: Eosinophilic cystitis. A 50 year-old woman presenting with hematuria. (a) Grayscale ultrasound showed an intravesical mass (asterisk) non-enhancing on CEUS (b) that corresponds to blood clot, and a hyperenhanced focus of 1,3 cm on the right lateral bladder wall (arrow), simulating neoplastic lesion. On pathologic study this lesion corresponded to eosinophilic cystitis. Page 8 of 12

9 Fig. 8: Bladder wall abscess secondary to Crohn disease. A 56 year-old woman, with Crohn disease presenting with pyuria and hematuria. (a) Gray-scale ultrasound showed a mass protruding intraluminally (arrows). (c) CEUS excluded neoplasia, revealing preservation of the mucosa-submucosa line with a non-enhancing collection inside the bladder wall, corresponding to an abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R: Rectum). Page 9 of 12

10 Fig. 9: Acute cystitis. A paraplegic 20 year-old man presenting with haematuria. (a) Grayscale ultrasound showed irregular tissue thickening on the right bladder wall (arrows). (b) CEUS showed marked enhancement on the preserved mucosa-submucosa line (arrows) with a less-enhanced and thickened muscular layer (discontinuos arrow), with delayed wash-out (c). Pathologic study revealed intense acute inflammatory change. Page 10 of 12

11 Fig. 10: In oposition with the inflammatory changes observed in fig 9, in this patient with infiltrative bladder neoplasm CEUS shows irregular, hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS, invading the hypoechogenic muscular layer (arrows-preserved line),ponting to neoplasic origin. Page 11 of 12

12 Conclusion Bladder inflammatory masses mimic neoplasm during ultrasound exploration. CEUS facilitates their detection and occasionally, gives a clue of their real nature, permitting differentiation with tumors and hence, a more conservative approach. CEUS helps to characterize bladder masses. There are previous reports about its value in bladder neoplasm management but not in the detection and characterization of inflammatory masses. References Wong-You-Cheong JJ, Woodward PJ, Manning MA, Davis CJ. Inflammatory and nonnneoplastic bladder masses: Radiologic-Pathologic Correlation.Radiographics 2006; 26: Wang X,Wang Y, Lei CH. Evaluating the perfusion of ocupying lesions of the kidney and bladder with contrast-enhanced ultrasound.clincal imaging 35 (2011) Caruso G, Salvaggio G, Campisi A, Melloni D, Midiri M, Bertolotto M, Lagalla R. Bladder tumor Staging: Comparision of Contrast-Enhanced and Gray-Scale Ultrasound. AJR 2010; 194: Nicolau C, Bunesch L, Sebastia C, Salvador R. Diagnosis f bladder cancer:contrastenhanced ultrasound. Abdom Imaging (2010) 35: Personal Information Page 12 of 12