(Radiology. 1999;210:737-738.)
© RSNA, 1999
The Goblet Sign
Royden E. Daniels, III, MD1
1 Department of Radiology, Medical College of Virginia of Virginia Commonwealth University, 401 N 12th St, Richmond, VA 23298.
Index terms: Pyelography, retrograde, 82.1222 • Ureter, neoplasms, 82.321 • Ureter, stenosis or obstruction, 82.844 • Urography, 82.1221
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APPEARANCE
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The Goblet sign is a cup-shaped collection of contrast material that is seen just distal to an intraluminal filling defect of the ureter (Figure). It is perhaps best demonstrated at retrograde ureterography, but it can also be seen during intravenous urography when there is partial or no obstruction of the ureter (1).
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Figure 1a. The Goblet sign demonstrated on the frontal radiographs obtained in a 73-year-old man during retrograde ureterography. (a, b) Radiographs of the abdomen reveal the Goblet sign, the cup-shaped collection of contrast material (white arrow in a and b) distal to the ureteral filling defect (black arrow in a). (Images courtesy of Ann S. Fulcher, MD, Medical College of Virginia of Virginia Commonwealth University, Richmond.)
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Figure 1b. The Goblet sign demonstrated on the frontal radiographs obtained in a 73-year-old man during retrograde ureterography. (a, b) Radiographs of the abdomen reveal the Goblet sign, the cup-shaped collection of contrast material (white arrow in a and b) distal to the ureteral filling defect (black arrow in a). (Images courtesy of Ann S. Fulcher, MD, Medical College of Virginia of Virginia Commonwealth University, Richmond.)
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EXPLANATION
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The Goblet sign is a clue that the ureteral filling defect is a mass rather than a calculus. The slow expansion of a polypoid intraluminal tumorous mass from a uroepithelial carcinoma causes dilatation of the ureter distal as well as proximal to the mass (2). Propulsion of the mass distally during ureteral peristalsis further contributes to the dilatation of the ureter distal to the tumor and thus causes the cup-shaped collection of contrast material (3,4). On the other hand, the ureteral lumen just distal to a mechanical obstruction caused by a calculus will have a narrowed appearance due to wall spasm, edema, or both (2,3). Dilatation proximal to either a tumor or calculus varies with the degree of obstruction.
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DISCUSSION
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Uroepithelial carcinomas usually occur in older patients and rarely occur in patients younger than 40 years. Peak prevalence occurs in the 50s, 60s, and 70s, with a mean age of 65 years (5). The most common presenting symptom is gross or microscopic hematuria, which occurs in 50%–75% of patients. Flank pain due to obstruction is experienced in approximately 25% of patients, and weight loss occurs in approximately 10% of patients. Patients are asymptomatic in approximately 20% of cases (6). Ureteral tumors are more common in male patients than in female patients (3:1) and in white individuals than in black individuals (2:1) (5).
Uroepithelial carcinomas include transitional cell carcinoma (85%-95%), squamous cell carcinoma (approximately 10%), and adenocarcinoma (<1%) (3). Most (85% or more) transitional cell carcinomas are papillary (3). Squamous cell carcinoma is indistinguishable from transitional cell carcinoma radiographically; however, squamous cell carcinoma is less likely to be a polypoid tumor (1). Uroepithelial carcinoma located in the ureter is relatively uncommon compared with that in other locations in the urinary tract. Primary neoplasms of the ureter account for about 6% of all tumors in the upper urinary tract (7). Transitional cell carcinoma is the most common neoplasm of the ureter and is most often papillary. Papillary transitional cell carcinomas tend to be low grade, are slow to infiltrate, and metastasize late (3,4). Thus, transitional cell carcinoma is most commonly associated with the Goblet sign, which results from the slow growth of a mobile ureteral mass.
Intravenous urography is the primary examination for the evaluation of ureteral neoplasms. However, if complete obstruction exists and the kidney is nonfunctioning, retrograde ureterography is necessary to evaluate the ureter (4). Once a lesion is detected in the ureter, complete examination of the urinary tract is important because of the high propensity of transitional cell carcinoma for multicentricity. Synchronous transitional cell carcinomas occur as often as in 39% of cases of ureteral transitional cell carcinoma (8). Synchronous lesions are located in fairly equal distribution between the bladder and kidney; there is a slightly increased rate of occurrence in the bladder (8). Metachronous transitional cell carcinomas, on the other hand, are found much more commonly in the bladder than in the kidneys or ureters (8). Ureteral neoplasms are most commonly located in the distal third of the ureter. The distribution of tumors in the ureter is 50%–70% in the distal third, 15%–25% in the middle third, and 10%-12% in the proximal third (4).
In summary, patients with the Goblet sign, which is typically due to a less aggressive transitional cell carcinoma, have a favorable prognosis compared with patients who have a diagnosis of another ureteral carcinoma.
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Footnotes
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Address reprint requests to the author.
A trainee (resident or fellow) wishing to submit a manuscript for Signs in Imaging should first write to the Editor for approval of the sign to be prepared, to avoid duplicate preparation of the same sign.
Received March 5, 1998;
revision requested April 2, 1998; revision received June 3, 1998;
accepted October 19, 1998.
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References
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Amis ES, Newhouse JH. The ureter. Essentials of uroradiology Boston, Mass: Little, Brown, 1991; 279-286.
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Bergman H, Friedenberg RM, Sayegh V. New roentgenologic signs of carcinoma of the ureter. AJR 1961; 86:707-717.
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Leder RA, Dunnick NR. Transitional cell carcinoma of the pelvicalices and ureter. AJR 1990; 155:713-722.[Abstract/Free Full Text]
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Parker JA, Doganiero EJ, Popky GL. Ureteral neoplasms. In: Lang EK, eds. Radiology of the lower urinary tract. New York, NY: Springer-Verlag, 1994; 1-11.
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Walsh PC, Ritik AB, Vaughan ED, Wein AJ. Campbell's urology. Vol 3. 7th ed Philadelphia, Pa: Saunders, 1998; 2383-2384.
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Zoretic S, Gonzales J. Primary carcinoma of ureters. Urology 1983; 21:354-356.[Medline]
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Winalski CS, Lipman JC, Tumeh SS. Ureteral neoplasms. RadioGraphics 1990; 10:271-283.[Abstract]
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Yousem DM, Gatewood OMB, Goldman SM, Marshall FF. Synchronous and metachronous transitional cell carcinoma of the urinary tract: prevalence, incidence, and radiographic detection. Radiology 1988; 167:613-618.[Abstract/Free Full Text]
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