Genitourinar y Imaging Original Research

Liang et al.
CT Manifestations of Urinary System IMTs

Genitourinary Imaging
Original Research

CT Manifestations of Inflammatory
Myofibroblastic Tumors
FOCUS ON:

(Inflammatory Pseudotumors) of
the Urinary System
Wenjie Liang1 OBJECTIVE. The purpose of this study is to characterize the CT manifestations of in-
Xianyong Zhou1 flammatory myofibroblastic tumors (IMTs) of the urinary system in eight patients.
Shunliang Xu1 MATERIALS AND METHODS. The CT images of eight pathologically confirmed IMTs
Shengzhang Lin2 were retrospectively reviewed. Two of the eight IMTs occurred in the kidney, and six occurred
in the bladder. Seven patients underwent both unenhanced CT and contrast-enhanced CT, and
Liang W, Zhou X, Xu S, Lin S one of the patients who had a bladder tumor underwent unenhanced CT only. The site, shape,
size, boundary, internal structure, and enhancement pattern of the lesions were assessed.
American Journal of Roentgenology 2016.206:1149-1155.

RESULTS. The eight patients (five men and three women) whose CT images were re-
viewed were 1877 years old (mean age, 53 years). Only one lesion was seen in each of the
eight patients. The IMTs occurred at the renal parenchyma (n= 1), the renal pelvis (n= 1), or
the bladder (n= 6). Their shape was either roundlike (n= 7) or round (n= 1), and their size
ranged from 1.5 2.0 cm2 to 3.7 5.2 cm2. Tumor margins were smooth (n= 5) or lobulated
(n= 3), and boundaries were clear (n= 5) or ill defined (n= 3). Unenhanced CT scans showed
a low density (n= 4), isodensity (n= 3), or a slightly high density (n= 1). The density noted on
the unenhanced CT scans was homogeneous (n= 7) or heterogeneous (n= 1). The contrast-
enhanced scans showed ring enhancement (n= 3) or significantly heterogeneous enhancement
(n= 4), and the type of enhancement was persistent (n= 6) or washout (n= 1).
CONCLUSION. IMTs in the urinary system commonly occur in the superior wall or the
front wall of the bladder. The observation that polypoid nodules on the bladder walls show
ring enhancement on contrast-enhanced CT may be valuable in the diagnostic imaging of
IMTs of the urinary system.

nflammatory myofibroblastic tu- On imaging, IMTs do not have specific fea-

Keywords: bladder, CT, inflammatory myofibroblastic

tumor, inflammatory pseudotumor, kidney
DOI:10.2214/AJR.15.14494
Received February 3, 2015; accepted after revision
October 11, 2015.
1
Department of Radiology, First Affiliated Hospital,
College of Medicine, Zhejiang University, Hangzhou City,
China.
2
Department of Hepatobiliary and Pancreatic Surgery,
First Affiliated Hospital, College of Medicine, Zhejiang
University, 79 Qingchun Rd, Hangzhou City, Zhejiang
Province 310003, China. Address correspondence to
S.Lin (linszzju@sohu.com).
AJR 2016; 206:11491155
0361803X/16/20661149
American Roentgen Ray Society
I mors (IMTs) are a rare type of
benign spindle cell tumor. Pul-
monary IMTs are the most well-
known and common type of IMT. Other po-
tential sites where IMTs may occur include
the abdomen, retroperitoneum, pelvic cavity,
head and neck, trunk, and limbs [1]. Devel-
opment of IMTs in the urinary system is very
rare, with the bladder being the relatively
most common site of occurrence [2]. Be-
cause clinical symptoms and laboratory test
results lack specificity for the diagnosis of
urinary system IMTs, preoperative imaging-
based examination is very important for
identifying such IMTs and choosing the ap-
propriate way to manage them. So far, to our
knowledge, most relevant studies have fo-
cused on the pathologic manifestations of
urinary system IMTs [1, 37], but they have
rarely focused on associated imaging find-
ings [2, 811].
tures but they do have diverse manifestations
[2]. For example, on ultrasound images, such
masses can be characterized by low or high
echogenicity with clear or obscure boundar-
ies [2, 11]; however, on CT scans, IMTs can
be characterized by low density, isodensity,
or high density [2, 11]. On MRI, masses usu-
ally show low signal intensity, with masses
showing homogeneous or heterogeneous en-
hancement on T1- and T2-weighted contrast-
enhanced MR images [2, 11].
Bladder IMTs may appear in any area of
the bladder, and on the basis of findings from
different imaging methods, they can be de-
scribed as nodules or masses extending into
the bladder lumen or submucosal area with
or without fatty infiltration around the blad-
der [11]. On MRI, bladder IMTs have diverse
manifestations. They may show low-to-mod-
erate signal intensity on T1-weighted imag-
es, and they may show low-to-high signal

AJR:206, June 2016 1149


intensity or mixed signal intensity with vari-
able contrast-enhanced manifestations on
T2-weighted images [2, 911].
IMTs that develop in the kidneys can have
low or high echogenicity on ultrasound im-
ages [2, 11], whereas, on CT scans, such
masses often show low density and can also
show multiple hypovascular lesions after en-
hancement [2, 11]. On imaging, the manifes-
tations of urinary system IMTs are similar to
those of IMTs that occur in other parts of the
body. Most of these cases come from case re-
ports, not imaging reports, so valuable imag-
ing diagnostic clues are lacking.
In this study, we retrospectively investigate
the CT findings of what is, to our knowledge,
the largest number of urinary system IMTs as-
sessed, and we review the existing clinical and
imaging literature pertaining to this entity.
Materials and Methods
American Journal of Roentgenology 2016.206:1149-1155.
This retrospective study was approved by the
ethics committee at the First Affiliated Hospital
of the College of Medicine at Zhejiang University.
We searched a pathologic database at the First
Affiliated Hospital for records from January 2005 to
October 2014. Our search terms were inflammatory
myofibroblastic tumor, inflammatory pseudosar-
coma, kidney, ureter, and bladder. Nine pa- CT images included the degree, uniformity, and
tients were identified in the search, but one patient
was excluded because there was a lack of CT im-
age data for this patient. Therefore, a total of eight
patients were included in the present study. We re-
viewed the clinical data, CT images, and pathologic
results for these patients, and we focused on the im-
aging findings in particular. All patients underwent a
routine unenhanced CT examination at the sites cor-
responding to our search terms, and seven of the pa-
tients also underwent contrast-enhanced CT.
CT was performed using a 16-MDCT scanner
(Aquilion 16, Toshiba Medical Systems). The pa-
rameters used for CT examination of kidney dis-
ease were as follows: tube voltage, 120 kVp; tube
current, 300 mA; slice thickness, 2 mm; recon-
structed slice thickness, 3 mm; pitch, 0.938; and
matrix, 512 512. The area scanned by CT was
from the upper pole (including the adrenal gland)
to the lower pole of the kidney.
The parameters used for CT examination of
bladder lesions were as follows: tube voltage, 120
kVp; tube current, 300 mA; slice thickness, 2 mm;
reconstructed slice thickness, 3 mm; pitch, 0.938;
and matrix, 512 512. The area scanned by CT
ranged from the iliac crest level to the lower edge of
the pubic symphysis. A bolus of the contrast agent
iopromide (1 mL/kg of body weight; Ultravist, Bay-
er Schering Pharma) was injected at a rate of 2.5
3.0 mL/s with the use of a high-pressure syringe.
1150 AJR:206, June 2016
Liang et al.
Contrast-enhanced CT scans of the kidney
were acquired during three phases: a renal cortex
phase (at 30 s), a parenchymal phase (at 60 s), and
a delayed phase (at 510 min). Contrast-enhanced
CT scans of the bladder were acquired during two
phases: an arterial phase (at 30 s) and a delayed
phase (at 90 s). The time until the delayed phase
was counted from the time that injection of the
contrast agent was initiated.
All imaging data evaluated in the present study
were collected from the PACS at our institution.
Two experienced abdominal radiologists, who
each had more than 10 years of experience in di-
agnostic imaging of the abdomen, analyzed all
CT data and were blinded to the pathologic find-
ings. The CT images were analyzed in terms of the
number of tumors and the following tumor char-
acteristics: position, size, shape (round or round-
like), margins, internal components of focus (cal-
cification, necrosis, bleeding, and cystic change),
growth pattern, and enhancement type. In terms
of the degree of enhancement noted during each
phase of unenhanced CT and contrast-enhanced
CT scan acquisition, the attenuation values for the
solid portion of the tumor were measured three
times, and the corresponding mean value was ob-
tained using proper circular ROIs.
Additional features noted on contrast-enhanced
or mass with a wide base in the cavity, and
pattern of enhancement degree (slight or signifi-
cant), uniformity (ring enhancement or heteroge-
neous), and pattern of enhancement (persistent or
washout). High-density, normal-density, and low-
density masses were also defined, renal lesions and
renal parenchyma were compared, and bladder le-
sions and gluteus muscles were compared.
The degree of tumor enhancement was classi-
fied as none, slight (020 HU), moderate (>20 to
40 HU), or significant (> 40 HU). The four en-
hancement patterns noted were persistent en-
hancement, washout, isoenhancement, and ring
enhancement. The growth patterns included
spread of the tumor to the intracavity and under
the mucuous membrane. Evaluations were also
conducted to identify the presence of accompa-
nying enlarged lymph nodes, hydronephrosis or
hydroureter, and abdominal or pelvic fluid on CT
images. Final interpretation of the image was de-
termined through consultation between the two
abdominal radiologists.
All tumors were surgically excised, with partial
segmental cystectomy used for five patients and
with radical nephrectomy, radical resection of re-
nal pelvic carcinoma, and transurethral resection
of a bladder tumor used for one patient each. The
pathologic findings for all eight patients were ret-
rospectively analyzed by two experienced pathol-
ogists to confirm the accuracy of the diagnosis.
Results
All tumors were found to be primary uri-
nary system IMTs. Table 1 presents the clini-
cal and urinary tract CT findings. The eight pa-
tients (five men and three women) who were
evaluated were 1877 years old (mean age, 53
years). Their clinical symptoms included pain
during urination, gross hematuria, and waist
soreness for a duration of 3 days to 2 years. One
patient had renal IMT diagnosed incidentally
while undergoing ultrasonic examination dur-
ing hospitalization for pancreatitis. Three pa-
tients with IMTs had chronic illness associat-
ed with a previous surgery, and another patient
had hypertension and diabetes with a history of
appendectomy and prostatectomy. Hyperten-
sion and heart dysfunction were noted in a pa-
tient with bladder IMT who had a history of ap-
pendectomy, vertebroplasty, hernia repair, and
trauma. Another patient with bladder IMT had
a history of hypertension and renal disease and
had undergone pancreatoduodenectomy.
A single lesion was identified in all eight
patients. Six of the tumors occurred in the
bladder, including three tumors in the supe-
rior wall, two tumors in the front wall, and
one tumor in the left wall. Of the six bladder
lesions, five appeared on imaging as a nodule
one appeared as a submucosal nodule. Two
tumors occurred in the kidney; one was lo-
cated in the upper pole of the left kidney (pa-
tient 1, Fig. 1), and the other was located in
the left renal pelvis (patient 2, Fig. 2).
All lesions appeared as a substantial nodule
or mass on CT. The lesions ranged in size from
1.5 2.0 cm2 to 3.7 5.2 cm2. Their shape was
either roundlike (n= 7) or round (n= 1). Their
margins were smooth (n = 5) or lobulated (n=
3), and their boundaries were either clear (n=
5) or ill defined (n= 3). The unenhanced CT
studies of the eight lesions showed either low
density (n= 4), isodensity (n= 3), or slightly
high density (n= 1), and density was either ho-
mogeneous (n= 7) or heterogeneous (n= 1).
For the seven lesions that were visualized on
contrast-enhanced CT, enhancement was ring-
shaped in three (patient 4, Fig. 3) or heteroge-
neous in four (patient 3, Fig. 4), and the degree
of enhancement was either significant (n= 4),
slight (n= 2), or moderate (n= 1). The enhance-
ment pattern was either a persistent pattern (n =
6) or a washout pattern (n = 1).
For two patients, irregular blood clots oc-
curred on the edge of the lesion. No significant
calcification was found. In addition, no necro-
sis or cystic degeneration was found in any of
the lesions in this group of patients. Only one
 patient, a 50-year-old woman, had complications, which included mild

Enhancement
CT Manifestations of Urinary System IMTs

Persistent

Persistent

Persistent

Persistent

Persistent

Persistent
renal atrophy, hydronephrosis, thickening in the upper ureteral wall,

Washout
Type
and the presence of multiple enlarged lymph nodes in the retroperi-

toneal area. One patient had renal carcinoma, rather than renal IMT,
diagnosed before undergoing surgery, and another patient had renal

Slightly heterogeneous
pelvic carcinoma, rather than renal pelvis IMT, diagnosed before un-

Ring enhancement

Ring enhancement

Ring enhancement
Tumor Uniformity

Heterogeneous
Heterogeneous

Heterogeneous
dergoing surgery. Of the six patients with bladder IMTs, one had blad-
der cancer diagnosed and two had bladder tumor diagnosed before

undergoing surgery. According to the manifestations of pathologic,
histologic, and immunohistochemical findings, all tumors were con-
firmed to be urinary system IMTs.

Discussion

Enhancement

Significant
Significant

Significant

Significant

Moderate
Degree of
Bladder IMTs typically occur in younger individuals, particularly

Slight

Slight

female patients, but they rarely occur in children [11, 12]. Renal in-
flammatory pseudotumors occur among individuals in a wide age
range, but they more commonly develop in male patients. However,

Tumor Internal Enhancement Pattern

in a retrospective study of bladder IMT, Harik et al. [7] revealed re-

TABLE 1: Kidney and Bladder CT Findings for Eight Patients With Inflammatory Myofibroblastic Tumors (IMTs)

Ill defined Homogeneous and isodense

Ill defined Homogeneous and isodense

Roundlike Lobulated Ill defined Homogeneous and isodense

Homogeneous with slightly
sults that differed from those of other reports, noting that the age of

Heterogeneous with low

Homogeneous with low

Homogeneous with low

Homogeneous with low

onset of bladder IMT was from 7 to 77 years (mean age at onset, 47

of Tumor
years) and that the rate of occurrence among male patients was ap-
proximately three times higher than that among female patients. In

high density
the present study, the average age of onset of bladder IMT was 53

density

density

density

density
years, and the rate of occurrence was slightly higher among male
American Journal of Roentgenology 2016.206:1149-1155.

than among female patients. The differences between the present

study and the study by Harik et al. can be attributed to the low fre-
quency of urinary system IMTs and the small sample size. Boundary

Clear

Clear

Clear

Clear
Clear
The major clinical manifestations of bladder IMT include gross he-
maturia, which may be accompanied by pain during urination, an in-
creased urge to urinate, dysuria, urinary incontinence, and abdominal

Roundlike Lobulated
Roundlike Lobulated

Smooth

Smooth

Smooth

Smooth

Smooth
Margin

pain [2]. The renal inflammatory pseudotumor may be asymptomatic.

Tumor

The clinical symptoms of and laboratory test findings for pa-

tients in our study group were consistent with those noted in some
Roundlike

Roundlike

Roundlike

Roundlike
studies in the literature. For example, Kapusta et al. [5] report-

Round
Shape
Tumor

ed that eight of 12 patients with renal IMT (67%) had no clini-

cal symptoms. In addition, according to a study by Harik et al.
[7], only one of 42 patients with bladder IMT (2%) had no clinical
Tumor Location Size (cm2)

2.3 3.3

2.2 2.4

2.0 2.0
3.6 3.9
3.0 3.9

3.7 5.2
3.5 3.7
1.5 2.0
Tumor

symptoms. Only one patient with a renal IMT in the present study
had no related clinical symptoms, a finding that was in accordance
with findings of previous reports.

wall of bladder
Moreover, in some studies, urinary system IMTs were asso-
Superior wall

Superior wall

Superior wall
Front wall of

Front wall of
Left kidney

of bladder

of bladder

of bladder
Left lateral
ciated with a history of undergoing pelvic surgery [7, 13, 14]. In
Left renal

frequent urination, and gross bladder

frequent urination, and gross bladder

1984, Proppe et al. [13] reported that four women and four men
pelvis

presented with proliferative spindle cell nodules from 5 weeks to

3 months after undergoing lower genital tract surgery and lower
urinary tract surgery. These nodules were regarded as benign reac-
Frequent urination, urinary

Pain during urination and

tive lesions that resembled sarcoma. In addition, in 2006, Harik et
Clinical Symptom(s)

incontinence, and pain

Soreness of left waist

Urinary incontinence,

Urinary incontinence,

al. [7] stated that nine of 42 patients with IMT in their study had NoteDash () indicates data were unavailable.
Pain during urination

previously undergone instrumentation or surgery. When these pa-

gross hematuria
during urination
Asymptomatic

tients were compared with other patients who had no history of in-
hematuria

hematuria

strumentation or operation, their clinicopathologic features were

Hematuria

found to be similar [7]. Accordingly, the lesions in two types of pa-

tients were basically considered to be the same [7].
In another study, Montgomery et al. [14] evaluated 46 patients
Age

with IMTs, eight of whom underwent instrumentation 2 weeks to

(y)

50

68

50
35

59
77

70

18

6 months before they were hospitalized because of urinary system

Female
Female

Female

IMTs, including three transurethral resections, two transurethral

Male

Male

Male

Male

Male
Sex

resections of the bladder, one radical prostatectomy, one suprapu-

bic prostatectomy, and one placement of an indwelling uretero-
Pati ent

pelvic junction stent. Montgomery and colleagues discovered that

6
1

a patient who has previously undergone surgery has morpholog-

AJR:206, June 2016 1151

 Liang et al.

A B C
Fig. 177-year-old man with renal inflammatory myofibroblastic tumor.
A, Unenhanced CT image shows mass of slightly high density with lobulated margins, clear boundary, and homogeneous density in upper pole of left kidney.
B and C, Contrast-enhanced CT images show low degree of enhancement (attenuation, 60.6 HU) in arterial phase (B); enhancement (attenuation, 78.1 HU) was higher
in later phases (C).

ic and immunogenotypic findings similar to
those of other patients with IMT. Hence, the
view that previous instrumentation or a his-
tory of surgery was an important risk factor
American Journal of Roentgenology 2016.206:1149-1155.
diagnosis of bladder IMTs [10]. Patients in upper urinary tract tumors [16]. In contrast, all
the present study had bladder cancer or blad- patients with bladder IMT in the present study
der tumors diagnosed on the basis of findings had one lesion but no renal tumor identified be-
from imaging performed preoperatively. fore or after the onset of illness. Third, bladder

for the development of IMT in the urinary
system was supported by all study results.
Three patients in the present study had pre-
viously undergone surgery, and one of them
had previously undergone pelvic surgery;
however, we could not confirm whether there
was an association between the two surgeries
and the development of IMT, because the le-
sion occurred in the kidney.
Previous studies focused on the clinical
diagnosis and treatment of bladder IMTs and
pathologic analysis of related findings, but
they rarely focused on imaging-based analy-
sis of bladder IMTs. In the present study, we
compared IMTs with other bladder tumors
and analyzed their appearance on imaging.
On imaging, the manifestations of bladder
IMTs include polypoid masses or submuco-
sal lesions, which are not very specific for the
A review of 42 cases by Harik et al. [7]
showed that the changes in bladder IMTs not-
ed on imaging are similar to those noted for
bladder cancer and bladder sarcoma; howev-
er, some differences were also noted in other
studies. First, bladder IMT often occurs in men
older than 30 years. The onset of bladder tran-
sitional cell carcinoma (TCC), however, usual-
ly occurs after the age of 65 years, and blad-
der TCC occurs 34 times more frequently
in men than in women [15]. Second, although
there was a wide range in patient age at onset
of both types of tumors, most bladder IMTs oc-
curred in the superior wall and the front wall,
whereas approximately 80% of bladder TCCs
occurred in the bladder base [15]. Of note, no
bladder IMT was identified in the bladder base.
Approximately 40% of bladder TCCs tended to
be multicentral and might be accompanied by
IMTs manifest morphologically as polypoid or
cauliflower-like soft-tissue masses, which gen-
erally are similar to those associated with blad-
der cancer.
The present study involved six cases of
bladder IMTs, which were primarily broad
based, compared with bladder cancers; how-
ever, early-stage bladder IMTs reported else-
where were varied and included narrow-
based polypoid lesions, nodules, or a limited
thick-walled bladder [15, 17]. Flat tumors,
which are characterized by a limited thick-
walled bladder, were not identified in pa-
tients in the present study.
The presence of an irregular blood clot in
the bladder can be considered to aid in the
diagnosis of bladder IMT [18]. In the present
study, blood clots appeared around two of six
bladder tumors; however, this manifestation

A B C
Fig. 250-year-old woman with soreness on left side of waist.
A, Unenhanced CT image shows quasicircular mass with isodensity in left renal pelvis with obscured margins. Mass is accompanied by left hydronephrosis and left
parenchyma atrophy.
B and C, Contrast-enhanced CT images show that, in arterial phase (B), left renal pelvis mass manifests as obviously heterogeneous enhancement (attenuation, 103.3
HU); enhancement decreased (attenuation, 93.2 HU) in later phases (C); enhancement of the left kidney was reduced. Multiple enlarged lymph nodes (arrow) were
found near abdominal aorta.

1152 AJR:206, June 2016

 CT Manifestations of Urinary System IMTs

A B C
Fig. 370-year-old man with urinary incontinence, frequent urination, and gross hematuria.
A, Cross-sectional CT scan of bladder shows polypoid nodule on superior walls, with homogeneous density.
B and C, Contrast-enhanced CT scans show ring enhancement on margin of lesion and low enhancement in center of lesion. Attenuation values noted for central part of
lesion on CT were 36.2 HU (unenhanced), 42.6 HU (arterial phase), and 59.2 HU (later phases).

was comparatively rare in association with
bladder TCCs. The frequency of calcification
in patients with bladder TCC was approxi-
mately 5%. In a study by Moon et al. [19],
calcification often occurred on the surface of
the tumor and had a nodular or arched shape.
American Journal of Roentgenology 2016.206:1149-1155.
hancement may be a clue for the diagnosis of
bladder IMTs on imaging. Pathologic findings
showed that as more tumor cells gathered at the
edge of the lesion, they were accompanied by
inflammatory cell infiltration and a relatively
rich blood supply. Moreover, the stroma was
TCCs induce extension outside the wall and
are seen as increased density of the surround-
ing fat, ill-defined density, or streaklike high
density [15, 17]. The largest bladder IMT iden-
tified among the patients in the present study
invaded the outside wall of the bladder; how-

However, no calcification occurred in pa-
tients with bladder IMT in the present study.
Necrosis or cyst degeneration has been re-
ported in patients with urinary system IMTs
[9]; however, necrosis or cyst degeneration
was not noted in urinary system IMTs in the
present study. Therefore, necrosis and cyst
degeneration were considered to have lim-
ited significance in distinguishing bladder
IMT from bladder TCC.
Compared with bladder TCC, which showed
homogeneous or heterogeneous enhancement
on imaging, with peak enhancement appear-
ing after a delay of approximately 60 seconds
[20], two of five bladder IMTs in the present
study also showed heterogeneous enhance-
ment. However, the remaining three bladder
IMTs displayed ring enhancement on imaging.
This enhancement type has been noted in some
previous case reports [9]. We think that ring en-
loose in the central part of the bladder, and mu-
coid degeneration was noted.
In the present study, five cases of bladder
IMT could be described as showing progres-
sive enhancement. Although a multiphasic
scan was not performed, it was speculated
that, compared with bladder TCC, bladder
IMT may show delayed peak enhancement.
Because of the presence of contrast agent in
the interstitial space in the central part of the
lesion, features of bladder IMTs on dynam-
ic contrast-enhanced need to be further ex-
plored. It may be useful to distinguish IMTs
from other bladder tumors in addition to oth-
er tumor lesions, such as squamous cell car-
cinoma, adenocarcinoma, metastatic tumors,
and leiomyomas.
When bladder IMTs are large, they should
be differentiated from middle- and late-stage
bladder TCCs. Middle- and late-stage bladder
ever, on the basis of histopathologic findings,
it was confirmed to be the result of an inflam-
matory change rather than an invasion of tu-
mor cells. Bladder TCC may involve changes
in shape or density in nearby organs in the pel-
vic cavity, such as the prostate, seminal ves-
icle, uterus, and rectum [15, 17]. It may also
induce the invasion or involvement of lymph
nodes or distant organs by means of distant
metastasis through vascular spread [15, 17]. In
the present study, bladder IMTs did not invade
or transfer to nearby organs, and enlarged
lymph nodes did not develop.
On imaging, large bladder IMTs sometimes
have an appearance similar to that of sarco-
mas of mesenchymal origin. They are easi-
ly identified on the basis of pathologic find-
ings, although different surgical procedures
may be used for the management of such tu-
mors [4, 5]. Bladder sarcomas primarily ap-

A B C
Fig. 435-year-old man with urinary incontinence, frequent urination, and gross hematuria.
A, Cross-sectional CT scan of bladder shows intravesical mass (arrow) with striped margins of slightly high density.
B and C, Contrast-enhanced CT scans show obvious heterogeneous enhancement of mass in arterial phase (B); degree of enhancement was further increased in later
phases (C). No enhancement occurred in striped margins.

AJR:206, June 2016 1153


pear as rhabdomyosarcomas or leiomyosar-
comas. Bladder rhabdomyosarcomas occur
primarily in children. They most often appear
at the base of the bladder with a large focus,
and necrosis is commonly noted [21]. It is dif-
ficult to distinguish bladder leiomyosarcoma
from rhabdomyosarcoma on imaging; howev-
er, the bladder leiomyosarcoma is frequently
found in adult patients [22]. These sarcomas
can easily infiltrate or involve the surround-
ing organs [21]. On imaging, the features of
sarcomas were different from those of bladder
IMTs. Bladder rhabdomyosarcomas showed
heterogeneous enhancement on contrast-en-
hanced CT and were accompanied by evident
ischemic necrosis [21]. On the contrary, blad-
der IMTs were usually small and appeared as
ring-shaped enhanced or heterogeneous mass-
es without evident necrosis.
Urinary IMTs rarely involve the kid-
ney, and only two such cases were includ-
American Journal of Roentgenology 2016.206:1149-1155.
ed in the present study. Renal IMTs are not
consistent in size, ranging from 1.0 to 10.0
cm, and they often have an obscure bound-
ary (which may also be clear). On CT scans,
they have been described as having low den-
sity, a solid mass, and, most likely, focal high
density, with slightly homogeneous enhance-
ment also often noted [11, 2326]. If renal
IMTs appear as cystic masses, they can be
described as having thick wall enhancement
[26, 27]. Kidney IMTs have been reported
to appear on CT images as isodense masses
[27]; however, in the present study, one renal
IMT had a slightly high density.
The differential diagnosis of renal inflam-
matory pseudotumors included renal cell car-
cinoma, renal lymphoma, and renal pelvic
carcinoma. Kidney IMTs were characterized
by obscure edges, whereas the margins of re-
nal cell carcinoma were clear. Pseudocapsules
were also commonly associated with renal
cell carcinoma. All of these features may help
us to distinguish between renal IMTs and re-
nal masses [27]. However, when renal IMTs
appear as hypovascular masses, differentia-
tion between the tumor types becomes more
difficult, as was noted by Nakamura et al. [27].
One patient in that study had a renal IMT that
was characterized by a clear boundary and
gradual enhancement. Because this finding
of gradual enhancement was in contrast to the
flow-type enhancement typical of kidney can-
cer or hypovascular lymphoma, atypical renal
cancer could not be excluded.
The present study included one IMT that
developed in the renal pelvis, and the swollen
lymph node identified in the retroperitoneal
1154 AJR:206, June 2016
Liang et al.
area was preoperatively diagnosed as lymph
node metastasis; on the basis of pathologic
findings, this diagnosis was, instead, confirmed
to be reactive enlargement only. At this point,
differentiation between renal pelvic IMT and
renal pelvis carcinoma was difficult to achieve
before surgery because the appearance of the
two entities was similar on CT. Although estab-
lishing a diagnosis preoperatively was difficult,
a diagnosis may be made on the basis of patho-
logic findings from puncture biopsy performed
under the guidance of kidney CT, which can
help both to establish proper surgical proce-
dures and to avoid nephrectomy.
There are some limitations to the present
study. First, urinary system IMTs are very
rare. Although the time span of our study is
large, the number of suitable cases included is
small. Because of the rarity of urinary system
IMTs, a solution to this limitation would be
the mutual participation of multiple imaging
centers in such a study. Second, the urinary
system IMTs in this study were visualized on
CT without MRI. MRI performed using mul-
tiple positions and multiple sequence assess-
ments of tumorlike lesions will enrich the
evaluation of urinary system IMTs. Regretta-
bly, patients in the present study did not under-
go MRI because their cases were uncommon
and clinicians therefore did not order MRI. In
the future, if a patient is suspected of having a
urinary system IMT on the basis of CT find-
ings, MRI testing can be performed. Third,
our patient sample was analyzed retrospec-
tively, and no control group was established.
Therefore, further research that includes a
control group is needed.
Urinary system IMTs generally are rare.
When polypoid nodules or masses with ho-
mogeneous bladder walls are visualized on
unenhanced CT scans, bladder IMTs must be
included in the differential diagnosis if the
scans show ring-shaped or uneven enhance-
ment. Preoperative identification of renal
IMTs, compared with other types of renal tu-
mors, is very difficult. Percutaneous biopsy
performed under CT guidance may help to
direct appropriate patient management.
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1. Binit Sureka. 2016. Differential Diagnosis of an Inflammatory Pseudotumor of the Urinary Bladder. American Journal of
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