Male Genital Path (Dahmoush) Flashcards
Cells responsible for making testosterone, shown here in the interstitium, with abundant pink cytoplasm:
Leydig cells
Which of the following is NOT included in a work-up of a testicular mass?
A. History
B. Physical Exam
C. Serum markers (AFP, HCG)
D. Biopsy
E. Ultrasound
D. A lot of the time tumors are a mixture of histological patterns so this doesn’t tell you very much about the constituents of the tumor. Also, biopsy can create a needle track for tumor cells to pass through the scrotal skin. And finally, any mass is suspicious, and treated as a neoplasm until proven otherwise.
All of the following statements are true EXCEPT:
A. Inflammation of the testicles occurs most commonly in the vas deferens
B. Granulomatous orchitis is an autoimmune disease that mainly affects older men
C. Torsion (twisting of the spermatic cord) is a medical emergency and requires prompt surgical correction
D. Germ cell tumors are the most common type of testicular tumor and mainly affect young men age 15-34
E. Cryptorchidism can be detected in about 1% of 1-year-old boys, and because it is a risk factor for testicular cancer, is treated by orchiopexy
A. Inflammation occurs most commonly in the epididymus.
The most important distinction in germ cell tumors is between _____ and non-______tumors
seminomas; seminomatous
- Rare condition of unknown etiology that affects middle-aged men
- Presents as a tender testicular mass of sudden onset
- Pathology: Granulomas within spermatic tubules and in between tubules
granulomatous (autoimmune) orchitis
- Related to urinary tract infections (cystitis, urethritis)
- Etiology: gram-negative bacilli (E. coli & pseudomonas); STDs (chlamydia & gonorrhea)
- Pathology: Non-specific acute inflammation, may be followed by scarring
non-specific epididymitis and orchitis
Type of tumor characterized by multiple tumor nodules with homogeneous, gray-white, lobulated cut surfaces without hemorrhage or necrosis; microscopic image shows perfectly round cells with abundant cytoplasm and prominent nucleoli (below)
seminoma; it looks just like dysgerminoma (ovarian tumor) under the microscope and cannot be distinguished without knowing whether the sample came from a male or female
Tumor characterized by multiple neoplastic nodules with variegated hemorrhagic cut surfaces
non-seminomatous germ cell tumor
This tumor’s cells are large and pleomorphic with amphophilic (stains with both acid/basic dyes) cytoplasm, overlapping angry-looking hyperchromatic nuclei with prominent nucleoli arranged in glandular pattern
embryonal carcinoma
most common tumor in children under 3; it has numerous histological patterns but the most common is the microcystic pattern with a lacelike (reticular) network of medium-sized cuboidal or elongated cells (below)
yolk sac tumor; also strongly characterized by AFP which appears as hyaline globules, and by Schiller-Duval bodies which are glomerulus-like structures with a central fibrovascular core
this feature is strongly characteristic of yolk sac tumors, and appears as a microcyst containing a glomerulus-like structure with a central fibrovascular core (below)
Schiller-Duval body
tumor that produces HCG and is characterized by large multinucleated giant cells with abundant eosinophilic vacuolated cytoplasm (syncytiotrophoblasts) that are intimately associated with cytotrophoblasts within areas of extensive hemorrhage
choriocarcinoma
Extremely heterogeneous tumor that contains tissues from all three germ layers (ectoderm, endoderm and mesoderm) and is often composed of cartilage, adipose tissue and a squamous cyst lining
teratoma
Which of the following statements is FALSE?
A. Seminomas are extremely radiosensitive and have the best prognosis (90-95% cure rate)
B. Choricocarcinoma has a 90% metastasis rate, usually to the lung, liver or bone
C. Stage II testicular tumors have metastasized outside of the retroperitoneal nodes
D. Non-seminomatous germ cell tumors metastasize earlier than seminomas and use the hematogenous route more frequently
C.
Stage 1: tumor confined to the testis, epididymis or spermatic cord
Stage 2: distant spread confined to retroperitoneal nodes below the diaphragm
Stage 3: metastases outside the retroperitoneal nodes or above the diaphragm
*note: the rare pure form of choriocarcinoma is especially dangerous, as it may not cause testicular enlargement before metastasizing, so a patient may have no symptoms prior to late stage diagnosis
prostatic adenocarcinoma most of the time presents in this zone of the prostate
peripheral zone (makes up about 70% of the prostate)
remember this
prostatic nodular hyperplasia exclusively occurs in what prostate zone?
in the transitional (peri-urethral) zone; makes up about 10% of the prostate and is most intimately associated with the prostatic urethra
remember this
- condition mostly due to intraprostatic reflux of urine from the urethra or urinary bladder
- occasionally after procedures (catheterization, cystoscopy and prostate resection procedures)
- diagnosis: clinical symptoms such as fever, chills, dysuria and a tender prostate on rectal exam, as well as urine culture
acute prostatitis
- condition that may be caused by bacteria or more commonly not
- often asymptomatic or patient presents with recurrent urinary tract infections
- symptoms when present include low back pain, dysuria, perineal and suprapubic discomfort
chronic prostatitis
- most common type of prostatitis and mimics prostate cancer on rectal exam and ultrasound; may increase PSA level
- may form post biopsy after transurethral resection
- infectious: mycobacterial, including BCG-related (bladder cancer) granulomas and fungal infections
non-specific granulomatous prostatitis
Which of the following statements about nodular hyperplasia is FALSE?
A. Nodular hyperplasia is androgen related and may be treated with 5 alpha-reductase inhibitors
B. Nodular hyperplasia predisposes to adenocarcinoma in men
C. Nodular hyperplasia is exculsively seen in the transitional zone of the prostate
D. Nodular hyperplasia is seen in 90% of men over 70
E. Clinical features include obstruction to urinary outflow and UTIs, bladder hypertrophy, and kidney problems (pyelonephritis)
B. This is false. Although both may be seen especially in men over 70, nodular hyperplasia is not a precursor for this cancer.
remember this
Which of the following is a feature of testicular germ cell tumors:
A. Most common after age 60
B. Low potential for metastasis
C. Usually present with pain and hematuria
D. Often have a mixture of histologic patterns
D.
organ specific marker (not cancer specific) that is increased in both benign prostatic hyperplasia as well as in prostatic adenocarcinoma
PSA - it is NOT synonymous with prostatic adenocarcinoma
True or false: imaging for prostate cancer is helpful in determining the precise location of a tumor
False. Imaging is not able to determine this, and it is why multiple biopsies are taken from both lobes of the prostate at different levels. Also, because of screening, it is very rare to see a prostate tumor on gross pathology (see sample below, taken before prostate screening was in effect)
remember this
All of the following are histologic features of prostatic adenocarcinoma EXCEPT:
A. Architectural disarray
B. Single layer of basal cuboidal/columnar cells
C. Enlarged nuclei
D. Prominent nucleoli
B. The basal cell layer is obliterated leaving a single layer of eptihelial secretory cuboidal or columnar cells lying directly on top of the stroma (see below)
According to the Gleason scale, this number represents a moderate to poorly differentiated tumor; most prostatic adenocarcinomas present at this grade
score of 7
*this score means that within the biopsy samples, you can find separation of the glandular acini and they are beginning to invade the surrounding prostatic tissue (grade 3) and you can also see fusion of the glands (grade 4). 4+3=7
All of the following regarding adenocarcinoma are true EXCEPT:
A. Tends to metastasize to bone and cause fracture (osteolytic metastasis)
B. May be detected by digital rectal exam (DRE) because of its peripheral zone location, which is accessible through the rectum
C. Tends to present with late urinary symptoms
D. A needle biopsy is needed to confirm the diagnosis
E. PSA is specific for this type of cancer
E
what is the treatment for advanced or metastatic prostate cancer? what is the main problem with this treatment
Most commonly, anti-androgen therapy (orchiectomy is also a possibility); the major problem with anti-androgen therapy is that patients may develop resistance to it over time
what are the criteria for active surveillance of localized prostate cancer as an alternative to surgery or radiation?
gleason score <6, positive cores <3, positive involvement of any core <50%
Which of the following statements regarding cystitis is FALSE?
A. Actue and chronic cystitis are both more common in women
B. Most of the time, the culprits are gram negative bacilli
C. Most common symptoms include frequency, dysuria, and lower abdominal pain, +/- hematuria
D. Granulomatous cystitis is often secondary to renal tuberculosis
E. The presence of the inflammatory BCG in the bladder is highly indicative of renal tuberculosis in most patients
E. In the US, BCG is used to treat bladder cancer. Usually it is suspected that the patient is being treated for bladder cancer if this is found, as opposed to the patient has renal TB
malakoplakia is an unusual inflammatory reaction due to defects in the phagocytic function of macrophages, and is diagnostically distinguished by the presence of lymphocytes, foamy PAS+ macophages, multinucleated giant cells, and these perfectly round dark bodies shown below:
michaelis guttman bodies
*gross exam of this disease shows yellow slightly raised mucosal plaques
commonly seen in men with peak onset between 20-30 years of age, characterized by the usually unilateral presence of stones anywhere along the urinary tract, most commonly, the renal pelvis and calyces (upper urinary tract)
urolithiasis
The most common factor in the pathogenesis of urinary bladder cancer is:
A. Long term use of cyclophosphamide
B. Analgesics abuse
C. Smoking
D. Prior bladder exposure to radiation
E. Industrial exposure to arylamines
C. This is the same for renal cell carcinoma.
Infections by this organism are uncommon, but may lead to squamous cell carcinomas of the bladder
Schistosoma hematobium
If you have a lesion that is flat but microscopy shows disorganized urothelium whose cells have lost polarity, it is classified as what?
urothelial carcinoma in situ (has not broken through the basement membrane, but is high grade by definition)
All of the following are true of low grade urothelial carcinoma EXCEPT:
A. It is a papillary neoplasm
B. Accounts for ~ 2/3 of bladder cancers
C. Typically non-invasive with low progression rate
D. Typically has a low recurrence rate
E. Associated with low mortality
D. High recurrence rate
All of the following are true of high grade urothelial carcinoma EXCEPT:
A. Less common than low grade carcinomas
B. Frequently choromosome 9 deletions are present
C. ~80% are invasive
D. May be either papillary or sessile neoplasms
E. Characteristically have a high progression rate and high mortality
B. This is a feature of low grade urothelial carcinomas.
*Note: high grade urothelial carcinoma is defined by cells that no longer resemble the normal epithelium (ie, discohesive, total loss of polarity) and usually are invasive (see below)
Which of the following is the MOST important prognostic factor in bladder cancer?
A. Depth of invasion (stage)
B. Grade
C. Associated carcinoma in situ
D. Multifocality
E. Prior recurrence rate
A
Which of the following is the most common clinical presenation of bladder cancer?
A. Multiple recurrence
B. Metastasis to regional lymph nodes
C. Uretal orifice obstruction
D. Frequency, urgency and dysuria
E. Painless hematuria
E
What are the urgent indications for radical cystectomy in men?
Bladder tumor invading the muscularis propria;
CIS refractory to BCG or one that is extending into the prostatic urethra or prostatic ducts beyond the reach of BCG
True or false: Once a patient has been diagnosed with bladder cancer, regardless of the treatment, all of them must be closely followed with periodic cystoscopies and urine cytology for life
True
Which of the following is NOT important for the work up of a renal mass?
A. Urine cytology
B. Biopsy
C. Imaging
D. Physical exam
E. Chest X-ray
B. Imaging is usually highly effective at finding and diagnosing tumors of the kidney and biopsies are usually unnecessary. Only indications may be for a patient who is high risk, ie, has already lost 1 kidney or if the tumor may be metastatic from another location.
The most common type of malignant renal tumors in adults is:
A. Conventional (clear cell) renal cell carcinoma
B. Papillary renal cell carcinoma
C. Chromophobe renal cell carcinoma
D. Collecting duct carcinoma
E. Renal cell carcinoma, unclassified
A
benign neoplasm of the kidney that is frequently an incidental finding that is:
- <5mm in diatmeter
- pale, yellow and well-circumscribed
- cytogenetics show trisomy 7 and 17
papillary adenoma
most common benign neoplasm that is usually asymptomatic and incidental, but may present with hematuria, flank pain or palpable mass; cytogenetics are loss of chromosome 1 and 14
oncocytoma
*note the mahogany brown color and stellate central scar on gross appearance
appearance of this most common renal cancer type (70-80%) is seen grossly with lots of heterogeneity - variegated lesions of solid and cystic growth pattern, areas of hemorrhage, necrosis, cystic degeneration, etc
clear cell renal carcinoma; these tumors are highly vascularized and the clear cell look is due to lipids and glycogen (see below)
less common type of renal cell carcinom that is well-circumscribed but when cut it starts to fall apart; It is the most common type occurring in dialysis-associated cystic disease
papillary renal cell carcinoma
Malignant neoplasm that is less common (5%) but has an excellent prognosis; it is characterized by large pale cells with prominent cell borders and perinuclear halos
chromophobe renal cell carcinoma; resembles oncocytoma
least common subtype of renal carcinoma (<1%) that is characterized by nests of malignant cells embedded within a fibrotic stroma, in a medullary location; extremely poor prognosis
collecting duct carcinoma; grossly it is distinct from the other subtypes because it does not have well-demarcated borders
a change that can occur in any renal cell subtype that has a very poor prognosis and appears grossly with soft gray-white fleshy lobulated areas
sarcomatoid change; here it is evidenced by chromophobe renal cell carcinoma with a surrounding border of malignant, spindle shaped cells
About 25% of patients with renal cell carcinoma present with metastasis, commonly to where?
bone and lung
most common benign mesenchymal neoplasm or the kidney composed of a mixture of blood vessels, smooth muscle cells and adipose tissue; 25-50% of patients will also have tuberous sclerosis
angiomyolipoma
most common pediatric renal tumor, typical clinical presentation is large abdominal mass, and is usually characterized by a triphasic histology:
- blastemal component: small, closely packed blue cells with frequent mitoses and no evidence of differentiation
- epithelial component: abortive tubules and glomeruli
- stromal component: myxoid and spindle cells and occasional skeletal muscle differentiation
wilms tumor
All of the following statements about renal cell carcinoma are correct EXCEPT:
A. It has an increased incidence with smoking
B. It may be associated with abnormalities of chromosome 3
C. It tends to metastasize to lungs and bone
D. It grossly appears mahogany brown with a central scar and lacks necrosis
E. It may invade renal vein, collecting system and peri-renal fat
D. This is oncocytoma.
Which of the following associations is INCORRECT:
A. Seminoma = Schiller Duval bodies
B. Malakoplakia = Michaelis Gutmann bodies
C. Schistosoma hematobium infection = bladder squamous cell carcinoma
D. Angiomyolipoma = tuberous sclerosis
A. Schiler Duval bodies are characteristic of yolk sac tumors, which are in the non-seminomatous category of tumors.
