1. Imaging in Genitourinary malignancies

2. The evolution of imaging techniques .
Imaging techniques used as tools for
Diagnosis
Staging
Follow up

3. Diagnostic tool - Clinically efficient & cost effective manner .
The ultimate goal of imaging –
Safe and effective examination.
Clinically relevant information for the treatment .

4. Imaging modalities Plain skygram Intravenous urography Ultrasound
Computed tomography
Magnetic Resonance Imaging
Positron emission tomography

5. Strengths and weakness

6. Evaluation of GU neoplasm
Combination of clinical and diagnostic imaging methods
Role of imaging are :-
Detecting & Characterizing mass.
Supplementing clinical staging
Pre-operative planning
Assessment of Tumor recurrence.

7. Kidneys Sky gram KUB Bean shaped retroperitoneal organs
Location D12-L1 level

8. Ultrasonography Extensively used and widely available method.
Often first step in diagnostic workup.
Sensitivity is less than CT. Still questions can be answered.

9. Ultrasonography Solid mass
Cystic lesions diagnosis is based on Bosniak
Classification System

10. Kidney tumour
Diagnostic Modality of choice MDCT( multiphase contrast enhanced CT)
Staging of tumour .
Digital elements and post processing features.
(multiplane reconstruction . 3D or virtual urography images can be generated any time from the primary database)

11. Renal mass invading left renal vein

12. Renal mass

13. MRI Can be used with similar diagnostic efficacy
Advantages and disadvantages

14. Radiological diagnostics of collecting system disease ,Ureters and urinary bladder

15. Ureters Physiological stenosis Ureters are in retroperitoneam
Cross superficial to iliac arteries
Crosses posterior to the testicular artery/ovarian artery
Also pass dorsally to uterine artery and spermatic cord

16. Radiologic imaging Needs contrast filling of the ureters
It is achieved by
anterograde or retrograde filling of the ureters by catheter insertion
In cross-sectional imaging techinique (CT,MR)timed image acquisition is conducted in excretory phase (app 8-10 minutes)

19. Urinary Bladder Is Pelvic Organ in undistended condition
Extends to abdomen when fully distended
Divided into Vertex, Corpus and fundus
Ureters enter the bladder through the posterocaudal part of the fundus (vesical trigone)

20. Radiographic imaging
Definitive diagnosis can be established with Cystoscopy and biopsy .
Imaging plays an important role in early detection and staging of the disease

21. IVU
Bladder mass

22. Ultrasound Pre requirement is full distention of lumen
Normal wall thickness is 3mm.

23. MDCT & MRI Extent of propogation of disease Nodal involvement
Distant metastasis
Virtual endoluminal images can be reconstructed from excretory phase series

24. Urinary bladder mass

25. Urinary bladder mass

26. Urinary bladder mass

27. Prostate (USG) The base line imaging modality It is performed
Perabdominal
Transrectal route (TRUS)
Elastography
TRUS guided biopsy

28. PROSTATE Familiarity with Zonal classification of prostate
is necessary for the understanding of basic
clinical and radiological concepts of prostatic
disease.

29. Prostate

30. Prostate

31. CT Scan Poor in delineating zonal anatomy
Strength is in evaluating regional and distant metastasis

32. MRI Delineates zonal anatomy well Provides most accurate
information to date about anatomy and location of tumour .
Capsule invasion
Seminal vesicle invasion
Bony metastasis

33. Normal MRI appearance of Prostate
Normal prostate has homogenous low signal on T1WI
Zonal anatomy is best demonstrated on T2WI
Comprise of low signal central zone and higher signal peripheral zone
TZ and CZ appears similar in SI and loosely termed the central gland

34. Normal T2 appearance of Prostate
At the base of bladder: The anterior fibromuscular stroma (arrow) consists of nonglandular tissue and appears dark. Note the symmetric homogeneous muscular stroma layer (arrowheads) in the posterior prostate base
Midprostate level : Homogeneously bright peripheral zone (arrowheads) surrounding the central gland (white arrows). The central gland is composed of the transition zone and central zone, which cannot be resolved at imaging. Therefore, they are referred to jointly as the central gland. Note the neurovascular bundles at the 5-o’clock and 7-o’clock positions (black arrows).
At prostate apex : The homogeneous peripheral zone (arrowheads) surrounding the urethra (U). Note that the volume of the peripheral zone increases from the base to the apex.

35. Strength of MRI Contrast enhanced dynamic scan MRS Diffusion Imaging
Biopsy

36. 50-year-old male with prostate cancer.
Axial T2WI showing low signal within the rightward aspect of the peripheral zone (∗). Note the normal-appearing contralateral peripheral zone (PZ) comprised of glandular elements. Also, the right rectoprostatic angle appears slightly ill-defined, although no definite bulge is seen. 50-year-old male with prostate cancer. (b) Axial T1WI showing an enlarged right external iliac chain lymph node, a regional lymph node according to the TNM staging system. This would comprise N1 disease, which would fall under Stage IV category.

37. Axial T2WI showing a right anterior transitional zone tumor within the midgland with the tumor creating a slight anterior bulge.

38. Multifocal peripheral zone tumors

39. MR SPECTROSCOPY OF PROSTATE
NORMAL METABOLITES OF PROSTATE
Citrate : Produced by normal epithelial cells of prostate
Normal Peak at 2.6 ppm
Choline : Precursor of phospholipids cell membrane
Normal Peak at 3.2 ppm
Creatine : Involved in cellular energy
Normal peak at 3 ppm

40. Normal MR Spectroscopy
MR spectroscopic spectrum, obtained at 1.5 T shows a high citrate (Ci) peak (resonance at 2.6 ppm) and a low choline (Ch)peak (resonance at 3.2 ppm), characteristics of benign tissue. The choline and creatine (Cr)peaks are overlapping.
At 3 T : Good separation of the choline (Cho)and creatine (Cr)peaks at higher magnetic field strength. The spectrum is normal, with a high concentration of citrate (Ci)and low concentration of choline.
At 1.5 T
At 3 T

41. Radionuclide Scintigraphy
For metastatic work up

42. PET CT

43. Testicular Imaging
Ultrasonography is the best modality for rapid and accurately assessing scrotal masses
Can determine truly intra or extra testicular masses
Facilitates testicular examination in presence
of hydrocele

44. chest skygram/CT/MRI 85-90% of lung metastasis is detected by skygram
CT is the modality for evaluation of retropertoneum
MRI has no additional value

45. PET Scan
Beneficial in evaluation of residual masses after treatment perticularly viable carcinoma.

46. Uterus
Ultrasound CT
MRI

47. uterus

48. Uterus CT Scan

49. Endometrial carcinoma
MDCT :-
Thin slices ,isotropic database & reconstruction in multiple user defined planes.
Can detect myometrial invasion.
Assessment of nodes.
Distant metastasis
Recurrence.

51. Uterine Cervical Carcinoma
Lesion size
Extension into the uterine corpus.
Depth of stromal invasion .
Parametrial spread.
Loco-regional spread
Pelvic lymphadenopathy
Distant metastasis

55. Ovarian tumors C.T is used to
Adnexal masses are common findings and the key is to distinguish benign from potentially malignant .
C.T is used to
Characterize an adnexal mass
Assess for metastatic disease
Stage patient for metastatic disease.

59. Conclusion
Imaging is the key to evaluate the clinically diagnosed mass
All modalities have their strength and weakness. we need to understand them.
We have to be wise enough to use various modalities judiciously for ultimate benefit of the patient