11.2: Male genital tract tumours Flashcards
What are the three main tumours that occur in the male genital tract?
- Prostate adenocarcinoma
- Penis squamous cell carcinoma
- Testis germ cell tumours
Name the three zones of the prostate, identify the zones most commonly affected by cancer and benign hyperplasia. Which zones are able to squeeze the urethra when enlarged?
- Central: Directly surrounds the urethra but is only affected by prostatitis and issues with the urethra
- Peripheral: major site of prostatic cancer - squeezes the urethra
- Transitional: the site at which most benign prostatic hyperplasia originates - invades outside before squeezing the urethra
What are corpora amylaceae? Are they pathological?
Aggregations of prostatic secretions, no pathology
Describe the histology of the prostate and how it changes in cancer
- Double layer epithelium: inner secretory which makes PSA (prostate specific antigen), and outer basal cells
* this 2-layer morphology is lost in cancer and usually just a lining of single cells remains with bigger nuclei - Outer limiting BM: cancerous invading cells will breach this layer and invade into the fibromuscular stroma
Who is at risk of benign prostate hyperplasia?
> 50 years, more likely to experience symptoms if there is FH, black African race, changing hormonal levels
What are the symptoms, signs and complications of benign prostatic hyperplasia (BPH)?
Urethral obstruction which leads to infection. This can cause increased frequency and urinary retention
As BPH advances the bladder may undergo dilatation and hypertrophy, and bladder diverticula may form (outpuchings of urethelium into and sometimes outside the bladder wall)
Obstructed urine can generate stones which can also develop inside the diverticula, these are very painful.
Upstream, the increased pressure in the bladder causes ureter dilation and a sigmoid shape - the increased pressure is transmitted to the kidney (hydronephrosis), and can eventually lead to renal failure
How is BPH managed?
*Include the two types of ‘operations’, identify which is the ‘golden standard’ and briefly describe it
Prostate resection: this opens up the urethra and relieves the damage and symptoms
- Open operation: removal of whole gland
- Golden standard: Trans urethral resection of prostate (TURP): a uroscope with a cutting edge is passed through the penis and urethra into the gland and chips away at the prostate until the passage is clear - these chips are sent to the histopathology department so they can be examined for cancer
Name four risk factors for prostate cancer
- Linear with age (the younger the age at presentation, the more aggressive the disease)
- African-american men
- FH
- Possibly diet
What are the important signs and symptoms in early and advanced prostate cancer?
Early: asymptomatic
Advanced: frequent and difficult (starting or stopping) urinating, decreased force of urination. Blood in semen and urine, pain or discomfort in the pelvic area
What symptom can indicate metastasis of prostate cancer?
Bone pain
Where will prostate cancer invade to locally and systemically (and what happens as a consequence of this)?
Locally: seminal vesicles and bladder base
Bones: axial skeleton/vertebrae which becomes osteoblastic (thickened and hardened) as the cancer spreads, increasing the risk of fracture and causing back pain. Some visceral dissemination
If prostate cancer is suspected clinically or as a result of a PSA screening test, what is the standard procedure to make a diagnosis?
The tumour begins in the outer part of the gland and is therefore palpable in a DRE; cancer tissue will feel hard, irregular and gritty.
Trans-rectal biopsies are also done to attain multiple core samples
How is grading of prostatic tumours assessed?
The Gleason’s pattern scale: a 5 point scale that reflects how differentiated the cancerous tissue is from normal tissue: 1 well differentiated - 5 anaplastic
How is the TNM staging applied to prostate cancer?
T: Tumour 1 - incidental finding 2 - confined to prostate 3 - extends outside 4 - direct invasion of contiguous organs
N: nodal invasion (0 or 1; usually of pelvic lymph nodes)
M: metastasis
How is prostate cancer managed and how has this changed over the years? How is it followed up?
Management is controversial and evolving: many were formerly not treated as it wasn’t believed it would make much of a difference in their life span
Nowadays, treatment is more dependent on the stage and grade and can involve…
- Doing nothing
- Surgical: Prostatectomy: open or laparoscopic
Non surgical
- radiotherapy: prostate carcinomas are somewhat radio sensitive
- Hormone therapy: suppress the hormone supporting the multiplication of cancer cells with another hormone (i.e estrogen) to slow the spread
Followed up with blood PSA levels
Are PSA levels part of the UK national screening programme for prostate cancer? Why or why not?
No, as not all cancer patients have a high blood PSA and it can be raised for other reasons including infection, irritation from a DRE, etc. There is also not one level of PSA that is considered ‘normal’.
Name six infections that can affect the penis :)
Syphilis, gonorrhea, lymphogranuloma venereum (LGV, caused by chlamydia), chancroid, herpes simplex and granuloma inguinale
Name three types of cancer that can affect the penis, which is associated with the development of skin cancer?
- Squamous papilloma (condylomas or warts, benign)
- Squamous cell carcinoma in situ/Bowen’s disease: important in development of skin cancers
- Invasive squamous cell carcinoma
What major pathogen is linked to penile cancer? Which strains are responsible for which types?
HPV, strains…
6 - condylomas or warts
16 and sometimes 18 - Bowen’s disease which may progress to an invasive SCC
Describe a condyloma histologically, what is it characteristic of?
Condylomas have benign-looking squamous cells but intracellular vacuolation (white space) called koilocytosis which indicates a watery accumulation within the cell. It is characteristic of an HPV infection at any skin squamous epithelial site (i.e cervix, penis, anus)
What must be done if skin lesions are observed on the penis?
They may be the pre-invasive form of squamous cell skin cancer and require a biopsy to make a diagnosis, as infection vs tumour distinction is impossible with the naked eye alone.
Describe a carcinoma in situ histologically
*hint: 3 features
- NOT invading through the BM (in situ)
1. Atypical cells; large with bizarre and prominent nuclei
2. Atypical mitosis
3. Apoptosis
Name four risk factors for penile cancer, which is associated with a worse prognosis?
- HPV 16 infection
- HIV infection: prognosis worsened
- Not circumcised; less protection of infection and hygiene
- Smoking
What is keratin indicative of on a squamous cell carcinoma histology?
The cells are still well differentiated
Describe the general onset of penile carcinomas, what factor highly influences 5-year survival and how much does it influence it?
Slow growing, locally invasive and ulcerative. Metastasis to the local lymph nodes impacts the 5-year survival:
No node involvement: 66% 5 yr survival
Node involvement: 25% 5 yr survival
How is penile carcinoma managed?
Surgery with amputation so there is none left behind :)
What is one important difference between testicular and ovarian primary tumours?
Most primary tumours are benign in the ovaries, whereas most are malignant in the testis
Name three other potential differentials for testicular carcinomas
- Orchitis (inflammation)
- STIs
- Syphilis
What are the two origins of primary testicular tumours? (that they can be classified from)
Germ cell tumours or sex cord-stromal tumours
What are the two most important germ cell tumours of the testis? Identify the one that is the commonest of all testis tumours, and briefly describe each
- Seminoma: Most common testis tumour (50% of testis primary tumour), looks most like the original germ cells; embryonal carcinoma, yolk sac, choriocarcinomas
- Teratoma: complex tumour with various cellular or organ components of normal derivatives from more than one germ layer
What are the two main sex-cord stromal tumours and one common secondary tumour?
- Leydig cell tumours
- Sertoli cell tumours
*can also have secondary tumours, one of the most common ones are malignant lymphomas
Name three potential causes of testicular tumours
- Cryptochordism: undescended testis (10%)
- Dysgenesis (defective development) of the testis
- Genetic factors (50%); multiple DNA defects
How does a seminoma appear grossly and histologically:
Grossly: A soft, white, fleshy mass in the testis
Histologically: uniform cells with big nuclei and clear cytoplasms that form islands separated by little clusters of small dark lymphocytes (reactive T cells)
Which cancer and other cell type are seminoma cells identical to histologically?
Identical to spermatogonia cells (that make spermatozoa) and to dysgerminoma of the ovary
How are testicular tumours staged?
AJCC staging: uses TNM staging but incorporates a ‘pathology element’ (p) that includes more detail of how the tumour spreads
N: Nodal involvement includes retroperitoneal nodes and under the diaphragm
M: metastasis is outside the retroperitoneal nodes or above the diaphragm
How are seminomas managed? How is prognosis?
Treated with excision of the whole testis and then according to the stage use radio and chemo to manage the tumour
Prognosis is very good!
How do teratomas change in relation to puberty? What factors influence how they’re managed?
Before puberty most are benign
After puberty, most are malignant and can metastasize
Management depends on the histology and stage
How do leydig cell tumours appear grossly and histologically?
Grossly: Large golden brown-yellow (like a fried egg)
Histology: purple cytoplasm and benign-looking cells
How might a leydig cell tumour present and why?
Since they secrete androgens and sometimes estrogens, the patient may present with gynaecomastia or precocious puberty
