CT urogram (CTU) in a 60-year-old male smoker shows a 2 cm filling defect in the right renal pelvis with surrounding fat stranding. Urine cytology is positive for malignant cells. What is the most likely diagnosis and standard treatment?
- A Urothelial carcinoma (transitional cell carcinoma) of the renal pelvis — nephroureterectomy with bladder cuff excision ✓
- B Renal cell carcinoma (clear cell) — partial nephrectomy
- C Angiomyolipoma — surveillance or embolization
- D Staghorn calculus — percutaneous nephrolithotomy
Explanation
A soft-tissue filling defect in the renal pelvis or ureter with positive urine cytology is characteristic of urothelial (transitional cell) carcinoma of the upper urinary tract. The standard surgical treatment is radical nephroureterectomy with excision of the bladder cuff (as the ureter must be removed entirely due to field change and risk of recurrence). Renal cell carcinoma is a cortical mass with a different enhancement pattern. AML has diagnostic fat content (<-20 HU). Staghorn calculi are high-density calcifications filling the pelvicalyceal system, not soft-tissue filling defects.
Reference: Grainger & Allison's Diagnostic Radiology, 7th ed.
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