Chapter 21: The Male Genital Tract Flashcards
1
Q
What is the most common benign paratesticular tumor?
Typically occur where?
A
- Adenomatoid tumor (mesothelial in nature)
- Typically occurring near upper pole of epididymis
2
Q
Malformation of the urethral groove and urethral canal of the male penis may produce what congenital anomalies?
A
- Hypospadias = urethral opening on ventral surface (more common)
- Epispadias = urethral opening on dorsal surface
3
Q
Which complications may arise in a pt with Hypospadias or Epispadias of the penis?
A
- Urinary tract obstruction and ↑ risk of ascending infection
- Sterility
4
Q
Which complications may arise due to Phimosis?
A
- Difficult to clean –> accumulates secretion under prepuce
- 2’ infection and possible carcinoma
5
Q
Balanoposthitis refers to infection of which penile structures?
A
Glans and prepuce
6
Q
What are the most common organisms responsible for Balanoposthitis?
A
- Candida albicans
- Anaerobic bacteria
- Gardnerella
- Pyogenic bacteria
7
Q
Persistence of the infection in balanoposthitis is a common cause of?
A
Phimosis = orifice of prepuce too small to permit normal retraction
8
Q
What is Condyloma Acuminatum and is caused by what?
A
Benign sexually transmitted wart caused by HPV (type 6; or 11)
9
Q
Most cases of balanoposthitis occur as a consequence of what?
A
Poor local hygiene in uncircumscirbed males –> accumulation of desquamated epithelial cells, sweat, and debris = smegma acts as local irritant
10
Q
What is the histology of Condyloma Acuminatum?
A
- Branching, villous, papillary CT stroma covered w/ superficial hyperkeratotic epithelium
- Thickening of the underlying epidermins (acanthosis)
- Cytoplasmic vacuolization of squamous cells (koilocytosis), characteristic of HPV infection is present
11
Q
Where on the penis does Condyloma Acuminatum most often occur?
Appears how?
A
- About the coronal sulcus and inner surface of the prepuce
- Consist of single or multiple SESSILE or PEDUNCULATED, red papillary excrescences
12
Q
What are the 2 distinct lesions of the male genitalia that display histologic features of CIS?
Both have strong association with what?
A
- Bowen disease
- Bowenoid papulosis
*Strong association w/ HPV 16
13
Q
Bowen disease occurs in most often where in men?
How does it appear grossly?
A
- Skin of shaft of penis and the scrotum –> appears as solitary, thickened, gray-white, opaque plaque
- May also manifest on glans and prepuce as single or multiple shiny red, sometimes velvety plaques
14
Q
Bowen disease is most often seen in what age group vs. Bowenoid Papulosis?
A
- Bowen disease = both men and women, older than age 35 years
- Bowenoid papulosis = sexually active adults (younger)
15
Q
What is the dermal-epidermal border like in Bowen Disease?
A
Sharply delineated by intact BM
*Hence is carcinoma in situ
16
Q
How is Bowenoid Papulosis distinguished from Bowen disease?
A
- Younger age of affected pts
- Presence of multiple (rather than solitary) reddish brown papular lesions
17
Q
How is Bowenoid Papulosis and Bowen Disease different in terms of transformation into invasive carcinoma?
A
- Bowen disease transforms into infiltrative SCC in 10% of pts
- Bowenoid papulosis virtually NEVER becomes invasive carcinoma
18
Q
Where is invasive SCC of the penis more commonly seen?
A
Africa, Asia, South Americ
19
Q
Which types of HPV are strongly associated with SCC of the penis?
A
HPV types 16 and 18
20
Q
Risk factors for SCC of the penis?
A
- Uncircumscribed males
- Cigarette smoking
21
Q
Where on the penis does SCC begin?
What are the 2 macroscopic patterns of growth that may be seen?
A
- Begins on glans or inner surface of the prepuce near coronal sulcus
- Patterns = papillary or flat
22
Q
What does the papillary pattern of penile SCC simulate?
Appears how?
A
- Simulates condyloma acuminata
- May produce cauliflower-like fungating mass
23
Q
What is an exophytic well-differentiated variant of penile SCC that are locally invasive, but rarely metastasize?
A
Verrucous carcinoma
24
Q
Where is the most common site of spread for penile SCC?
A
Inguinal lymph nodes
25
Prognosis of penile SCC is related to what?
Stage of the tumor
26
Invasive SCC of the penis most commonly occurs between what age?
Typical presenation and characterization of this cancer?
- Between **40-70 yo**
- **Slow growing**, locally invasive lesion that is **often present for a year** before brought to medical attention
- **N****onpainful** until they undergo 2' ulceration and infection
27
Where is the most common site for the arrest of the testes during descent?
Inguinal canal
28
What are the histological changes that occur to the tests in Cryptorchidism?
**- M****arked hyalinization**+**thickening**of the**BM** of spermatic tubules
- **Progressive tubular atrophy**: spermatic tubules become hyalinzed CT
29
During the histological changes occuring in Cryptochidism which cells are spared and appear to be prominent?
Leydig Cells
30
When the undescended tests lie in the inguinal canal they are prone to?
- **Trauma** and **crushing injuries**
- Concomitant **inguinal hernia** may develop
31
What is a serious consequence that may arise in cryptorchidism?
- **Germ cell tumor** of undescended testicle
- Cancer may also arise in **contralateral**, normally descended testicle
32
Treatment for cryptorchid testicle?
Reduces risk of?
Should be done when?
- **Orchiopexy** --\> **reduces** risk of **sterility** and **cancer**
- Correction **btw 6-12 mo**., before histologic deterioration begins
33
Inflammation is distinctly more common where (testes/epididymis)?
Epididymis
34
Which 2 infections almost invariably arise in the epididymis first before spread to testis?
1) Gonorrhea
2) Tuberculosis
35
Which infection is disinct in the fact that it arises in the testis first and in many cases spares the epididymis?
Syphilis
36
Although not as common in children, the most common causes of Epididymitis are what?
- Congenital genitourinary abnormality
- Infection w/ **gram-negative rods**
37
What are the 2 most common causes of Epididymitis in sexually active men \<35 yo?
1) *C. trachomatis (D-K)*
2) *N. gonorrhoeae*
38
What are the 2 most common causes of Epididymitis in men \> 35 yo?
1. *E. coli*
2. *Pseudomonas*
39
Granulomatous (autoimmune) Orchitis most often presents in whom and how?
**Middle age** as **tender** testicular **mass** of **sudden onset** sometimes w/ **fever**
40
How is granulomatous (autoimmune) orchitis distinguished histologically?
Granulomas restricted to spermatic tubules
41
What is the most common route of spread of a neglected gonococcal infection starting at the posterior urethra?
Posterior urethra --\> prostate --\> seminal vesicles --\> epididymis
42
Severe cases of gonococcal infection cause what in the epididymis?
Epididymal abscesses ---\> extensive destruction and scarring
43
Acute interstitial orchitis developing 1 week after onset of swelling of the parotid glands in young adult male should raise suspicion of?
Mumps
44
Tuberculosis of the male genital tract arises where first and invokes what characteristic finding?
- Epididymis ---\> Testis
- **Caseating** granulomatous inflammation
45
What are the 2 distinct morphological patterns of inflammation that may occur in the testis in association with Syphillis?
1) Production of **gummas**
2) Diffuse interstital inflammation --\> **obliterative endarteritis** assoc. w/ **perivascular cuffs** or **lymphocytes + plasma cells**
46
In contrast to neonatal testicular torsion, adult torsion results from what bilateral anatomic defect?
Bell-clapper abnormality --\> ↑ mobility of testes
47
What is the prophylactic treatment for testicular torsion?
Testis unaffected by torsion is surgically fixed to scrotum (**orchiopexy**)
48
Which germ cell tumor is composed of cells that resemble primordial germ cells or early gonocytes?
Seminomatous tumor
49
What are the most common **malignant paratesticular** tumors in children and adults?
- **Children** = rhabdomyosarcoma
- **Adults** = liposarcomas
50
What are the 2 major categories of testicular tumors?
Which are aggressive and which are benign?
1. **Germ cell tumors (95%)** = Seminomas and Nonseminomas = **aggressive**
2. **Sex-cord stromal tumors** = generally **benign**
51
What is the most common solid tumor in men aged 15-34 yo?
Testicular germ cell tumors
52
Which ethnicity are at an increased risk of testicular germ cell tumors in the US?
Much more common in **whites** than in blacks (**5:1 ratio**)
53
Klinefelter syndrome is associated w/ a 50x increased risk for development of what kind of germ cell tumor?
**Mediastinal** germ cell tumor, but **NOT** testicular tumors
54
Most testicular germ cell tumors arise from which precursor lesion?
Exceptions?
- Intratubular germ cell neoplasia **(ITGCN)**
- **Exceptions** = **pediatric yolk sac tumors** and **adult spermatocytic seminomas**
55
What are the genetic factors (i.e., **familial and genes**) associated with development of testicular germ cell tumors?
- **Strong** familial predisposition --\> 4x ↑ in fathers/sons of affected pts and 8-10x ↑ risk in brothers
- Genes encoding the ligand for RTK - **KIT** and **BAK**
56
Testicular germ cell tumors are associated with a spectrum of disorders collectively known as what?
Includes which disorders and which is **most important**?
- ***Testicular dysgenesis syndrome (TDS)***
- Cryptorchidism = **most important**
- Hypospadias
- Poor sperm quality
57
In contrast to typical seminomas, spermatocytic seminomas lack which 6 features?
- Lymphocytes
- Granulomas
- Syncytiotrophoblasts
- Extra-testicular sites of origin
- Admixture w/ other germ cell tumors
- Association w/ ITGCN
58
What is the most common type of testicular germ cell tumor?
Peak incidence when?
- **Seminomas**
- Peak incidence in **third decade** (20's)
59
Seminomas contain which genetic mutations (i.e., genes and chromosome)?
- **Isochromosome 12p** (**i12p**)
- Express **OCT3/4** and **NANOG**
- 25% have **KIT** activating mutations
60
How are the spermatic seminomas different from the classic seminoma as far as onset, growth, and prognosis go?
- Rare, **slow-growing** germ cell tumor
- **Predominantly** affect **older men** (**\>65 yo**)
- Prognosis is **excellent**
61
What is the most common testicular tumor in **infants** and **children** up to 3 years of age?
Prognosis?
**- Yolk Sac Tumor** (AKA **endodermal sinus tumor**)
**- Prognosis** = good
62
Germ cell tumors may have a single tissue component, but are most often found containing?
**Mixtures** of **seminomatous** and **nonseminomatous** components + mutiple tissues
63
What 3 tumors of the testicle are classified as nonseminomatous tumors?
1) Embryonal carcinoma
2) Yolk sac (endodermal sinus) tumor
3) Choriocarcinoma
64
Which genetic alteration seen in ITGCN is invariably found in invasive germ cell tumors regardless of histological type?
Reduplication of the **short arm** of **chromosome 12** (**12p**) in form of **isochromosome i(12p)**
65
What is the classic histology of the seminoma cells?
- Large and round to polyhedral w/ distinct cell membrane
- **Clear** or **watery-appearing cytoplasm**
- **Large**, central nucleus w/ **1-2 prominent nucleoli**
66
Which testicular germ cell tumor presents as a bulk **homogenous, gray-white** mass with a **lobulated** cut surface, usually **devoid of hemorrhage or necrosis?**
Seminoma
67
15% of seminomas contain syncytiotrophoblasts, why is this relevant?
Produce **↑ HCG** levels
68
Immunohistochemical stains of seminoma cells will be positive for what markers?
- **KIT**
- OCT4
- Placental alkaline phosphatase (PLAP)
69
Embryonal carcinomas of the testis typically occur in which age group?
Differ from seminomas how?
- Occur mostly in **20- to 30-year age group**
- **MORE aggressive** than seminomas
70
What is the gross morphology of embryonal carcinoma of the testis?
Extension through what?
- **Smaller** than seminomas
- **Extend** thru tunica albuginea **into** epididymis or cord (unlike seminomas)
71
Which germ cell tumor often produces **no** testicular enlargement and are detected only as a small palpable nodule w/ hemorrhage and necrosis being extemely common?
Choriocarcinomas
72
What is the histology of embryonal carcinomas, especially how are they different from seminomas?
- **Poorly demarcated** and contain **foci of hemorrhage and necrosis** (seminomas have no hemorrhage or necrosis)
- Cells grow in **alveolar or tubular patterns**, sometimes w/ **papillary convolutions**
73
Immunohistochemical staining of embryonal carcinoma is positive for what markers, differs from seminomas how?
- **(+)** OCT 3/4
- **(+)** PLAP
- **(+)** for **cytokeratin** and **CD30** (unlike seminomas)
- **Negative** for **KIT** (seminomas are +)
74
**Schiller-Duval bodies** consisting of mesodermal core w/ central capillary + visceral and parietal layer of cells **resembling primitive glomeruli** are found in what type of testicular germ cell tumor?
Yolk sac tumor
75
Immunocytochemical staining of testicular Yolk Sac Tumors is positive for what?
- α-fetoprotein (**AFP**) = **characterisitc**
- α1-antitrypsin
76
Histologically, choriocarcinomas contain what 2 cells types?
1. **Syncytiotrophoblasts** = large, multinucleated cells w/ abundant eosinophilic vacuolated cytoplasm containing **hCG**
2. **Cytotrophoblasts** = regular and polygonal, clear cytoplasm, grow in **cords** or **masses** w/ single uniform nucleus
77
Who are pure teratomas most commonly seen in and who are mixed teratoma/germ cell tumors most commonly seen in?
- **Pure** teratomas = more common in **infants** and **children** (2nd only to yolk sac tumors)
- **Teratomas mixed** w/ other germ cell tumors are **more common** in adults
78
Which type of tumor may be a mix of neural tissue, muscle bundles, islands of cartilage, clusters of squamous epi, thyroid gland-like structures, bronchial epi, and bits of intestinal wall/brain substance?
Teratomas
79
What is the clinical importance of recognizing a non-germ cell malignancy arising within a teratoma?
Secondary tumors are **chemoresistant**; thus **only hope for cure** = **resection**
80
How does the classification of a teratoma differ if found in a child vs. postpubertal male?
- **Children** = usually follow a **benign** course
- **Postpubertal male** = all teratomas regarded as **malignant**
81
What is the standard treatment for a solid testicular mass?
Radical orchiectomy
82
Where do testicular tumors spread first via lymphatics?
- Retroperitoneal para-aortic nodes = **1st**
- Mediastinal and supraclavicular nodes = **2nd**
83
Hematogenous spread of testicular tumors is mainly to where?
May also spread to which sites?
- Mainly to the **lungs**
- May also spread to **liver, bones,** and **brain**
84
How does the behavior/spread of Seminoma GCT's differ from NSGCT's?
Each typically presents clinically in which stage?
- **Seminomas** tend to stay **localized** to testis, present clinically in **stage 1**
- **NSGCT's** tend to **spread** to distant sites and present in **stages 2 and 3**
85
How does the mode of spreading differ between seminoma GCT's and NSGCT's?
- **Seminomas** tend to spread via **LN's** w/ hematogenous spread late
- **NSGCT's** metastasize **earlier** and use **hematogenous** route more frequently
86
What is the most aggressive NSGCT and via which route and to where does it rapidly spread?
- **Pure choriocarcinoma**
- Spreads **rapidly** and **predominantly** via blood to the **lungs** and **liver**
87
Elevation of lactate dehydrogenase associated with germ cell tumors is a useful biomarker to assess what aspects?
- **Mass of tumor cells**
- Tool to asses **tumor burdern**
88
Which biomarker is elevated with a Yolk Sac Tumor?
AFP
89
Which biomarker is elevated with a Choriocarcinoma?
HCG
90
What is the prognosis of Seminomas and NSGCT's?
- **Seminomas** = radiosensitive = remains localized = **best prognosis**
- **NSGCT's** = can be cured w/ **aggressive** chem
\*Pure choriocarcinoma has **poor** prognosis, but better if minor component of mixed GCT.
91
When do most Leydig Cell Tumors arise (age)?
20-60 yo
92
Which testicular tumor elaborates androgens and in some cased both androgens and estrogen, and even corticosteroids?
Leydig Cell Tumors
93
How may a pt with Leydig Cell Tumor present clinically?
Most common manifestation in children?
- Testicular swelling
- **Gynecomastia** may be 1st sx in some cases
- **In children**, manifested primarily as **sexual precocity (advanced for age)**
94
How do Leydig Cell Tumors appear grossly?
Distinctive feature.
- **Circumscribed nodules**, usually \<5cm
- **Distinctive GOLDEN brown**, homogenous cut surface
95
Cells w/ cytoplasm containing lipid droplets, vacuoles, or lipofuscin pigment + **rod-shaped** crystalloids of **Reinke** are characteristic of what type of testicular tumor?
Leydig Cell Tumor
96
If after orchiectomy of testicular germ cell tumor, there is persistent elevations of HCG or AFP concentration this indicates which stage of disease, even if LN's are normal size?
Stage II
97
Sertoli Cell Tumors have cells arranged in what distinct pattern?
Arranged in **trabeculae** that tend to form **cordlike** structures and **tubules**
98
Gonadoblastomas are composed of a mixture of what?
Arise where and in association with what?
Can they become malignant?
- **Germ cells** + Gonadal **stromal** elements
- Always arise in gonads w/ some form of **testicular dysgenesis**
- Germ cell component **may** become malignant --\> **seminoma**
99
What is the most common form of testicular neoplasm in **men \>60 yo**?
Testicular lymphoma (**non-Hodgkin lymphoma**)
100
What are the 3 most common testicular lymphomas in decreasing order of frequency?
**Diffuse large B-cell lymphoma** \> **Burkitt lymphoma** \> **EBV-(+) extranodal NK/T cell lymphoma**
101
Testicular lymphomas have a higher propensity for involvement of what system than do similar tumors arising at other sites?
CNS
