Hematoma in Urinary Bladder Masquerading as Neoplastic Mass.

The most common reason for intraluminal urinary bladder hematoma is trauma. However in gynecological and pelvic malignancies, the pelvic irradiation can affect non targeted organs resulting in urogenital complications like hematoma. Small size hematoma can be easily diagnosed in ultrasound. Large hematoma can mimic as neoplastic mass in imaging modalities. We present here an intresting image of intraluminal urinary bladder mass, where FDG PET CT was helpful to diagnose it as a non neoplastic mass.

We present a case of a large anatomic lesion in the urinary bladder that was erroneously interpreted as a neoplastic pelvic mass in the follow-up of a case of carcinoma cervix.

A 56-year-old female known case of carcinoma cervix Stage IIB postconcurrent chemoradiotherapy and immunochemoradiotherapy in the year 2010 was apparently asymptomatic until January 2018. She developed complaints of diffuse pain in the abdomen, dull in nature, episodic, and associated with nausea. Further, she started experiencing fullness in lower abdomen and dribbling of urine. She also had 1–2 episodes of drops of bleeding per vaginum. Then, she reported to the treating oncophysician in February 2018.

After clinical examination, a provisional diagnosis of radiation-induced cystitis was made, and a ultrasonography (USG) of the abdomen pelvis was carried out. USG showed a large heterogeneous mass in the pelvis. Whole body fluorodeoxyglucose positron emission tomography computed tomography (FDG PET CT) [Figure 1] was done that revealed a non-FDG avid large intraluminal mass in the urinary bladder, with HU (12–40) and having a layered morphology with frond-like appearance.[1] The urinary bladder was distended, and the physiological FDG avidity of urine was seen around this intraluminal mass. Based on FDG PET CT image findings, a differential diagnosis of hematoma or neoplastic mass was given [Figures 2 and 3]. Cystopanendoscopy was done that confirmed hematoma, and blood clots removal was done.

Figure 1

Fluorodeoxyglucose positron emission tomography computed tomography axial section showing a nonfluorodeoxyglucose avid large intraluminal mass in the urinary bladder, HU (12–40), and having a layered morphology with frond-like appearance. The urinary bladder is distended and the physiological fluorodeoxyglucose avidity of urine is seen around this intraluminal mass

Figure 2

Fluorodeoxyglucose positron emission tomography computed tomography sagittal section showing a nonfluorodeoxyglucose avid large intraluminal mass in the urinary bladder, with frond-like appearance

Figure 3

Noncontrast computed tomography axial section showing a large intraluminal mass in the urinary bladder with layered morphology and frond-like appearance

The treatment options for gynecological malignancies are surgery, chemotherapy, or radiation therapy. There is a vital role of posttreatment imaging in the assessment of treatment response and tumor recurrence. As there is an architectural alteration in the normal anatomy and loss of tissue planes, following chemotherapy and radiation therapy, imaging of the female pelvis in such cases is particularly challenging. Lesions such as blood clots, fungus balls, calculi and foreign body can mimic tumor in the urinary bladder.[2]

Apart from its therapeutic effect on actively dividing cells pelvic irradiation, it usually affects the nontargeted organs causing gastrointestinal and urogenital complications. The urinary bladder is highly radiosensitive. Side effects of radiation cystitis occur in 12% of cases and are dose dependent leading to hemorrhage, necrosis, hematuria, defunctionalized bladder, and clot formation. Hemorrhagic cystitis is due to the breakdown of mucosa secondary to loss of supporting submucosal blood supply. As per existing literature, the adverse effects of radiation are documented between 90 days and 5 years.[34]

Intravesical blood clots are usually detected by sonography as an echogenic mass without acoustic shadow and without visible blood flow in Doppler. The mobility of clots on changing the position of the patient is a striking feature in sonography. However, large blood clots and neoplastic lesions may occupy entire lumen and pose an imaging challenge.[2] MRI pelvis will show a frond-like appearance of clot formation inside the urinary bladder; however, similar appearance is noted in cases of transitional cell carcinoma.[3]

A hematoma is non-FDG avid; however, chronic expanding hematoma can show a peripheral rim of increased FDG uptake as a result of the inflammatory reaction and leukocytic infiltration.[5] Granulation tissue associated with resorption of hematoma may result in modest FDG uptake.[6]

The nuclear medicine physician and doctors using imaging modalities should be familiar with the expected posttreatment imaging findings and features of common complications to make correct interpretation and avoid possible pitfalls.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.