Positive Predictive Value of CT Urography in the Evaluation of Upper Tract Urothelial Cancer

OBJECTIVE. The purpose of this study was to determine the positive predictive value of CT urography in the diagnosis of upper tract urothelial malignancies. MATERIALS AND METHODS. Retrospective review of the records of patients who underwent 2,602 CT urographic examinations revealed that 81 (3%) examinations of 77 patients had findings suggesting upper tract urothelial cancer. Two radiologists in consensus categorized the findings as large masses (> 5 mm), small masses (<= 5 mm), or urothelial thickening. The positive predictive value of CT urography was determined with the findings at pathologic examination (n = 42), followup imaging (n = 29), or clinical follow-up alone (n = 5). One patient with insufficient follow-up information was excluded. The effects of age, sex, indication for examination, imaging appearance, and urine cytology were analyzed with the Fisher's exact test or Student's t test. Multivariate logistic regression analysis was used to generate a model for predicting the probability of the presence of upper tract urothelial cancer in patients with positive CT urographic examinations. RESULTS. The positive predictive value of CT urography for upper tract urothelial cancer was 53% (40/76) overall, 83% (29/35) for large masses, 0% (0/17) for small masses, and 46% (11/24) for urothelial thickening. Imaging appearance, urine cytology, and age were significant univariate predictors (p < 0.05) of the presence of upper tract urothelial cancer in patients with positive CT urographic examinations. The independent variables most likely associated with upper tract urothelial cancer were urine cytology (odds ratio, 60.0; 95% CI, 5.5-653.7) and imaging appearance (odds ratio, 24.4; 95% CI, 3.0-201.9) after adjusting for age and clinical indication. CONCLUSION. The positive predictive value of CT urography for upper tract urothelial cancer is moderate because benign findings mimic cancer. Positive findings on a CT urogram are more likely to indicate cancer in the setting of large masses or positive urine cytology.