male path Flashcards
Cryptorchidism
One or both testes fail to descend into the scrotum, an hCG dependent process, they may be found in the inguinal canal - most common, the upper scrotum, or within the abdomen
Bilateral in 18% of pts, family history of cryptochid testis in 14%
Pravalence - 5% of newborns and 1% of 1 yr old boys
Infertlity is most frequent complication
Germ cell tumors are 4-10 x more likely, even after fixing
inflammatory conditions
Epididymitis- painful inflammatory conditions, can start from a UTI (if older than 35) or an STI (<35), Gonorrhea, chlamydia, TB, E coli, pseudomonas, Prehn’s sign (elevation of scrotum decreases pain
Orchitis- painful inflammatory condition of testis, caused by TB, Mumps, HIV, syphilis, extension from epididymitis, mmps orchitis- compliicates 20% of adult mumps infections, most cases are unilateral
torsion of the tesitis
Twisting of the spermatic cord cuts off the venous/ arterial blood supply
Predisposing factors- violent movement or physical trauma, cryptochid testis, atrophy of testis, needs surgery to prevent hemorrhagic infaction of the testis
Clinical findings- sudden onset of testicular pain, negative prehns sign-elevation of the crotum doesnt decrease pain
Testicular cancer
Risk factors- cryptorchid testis is the most common risk factor, risk is highest if the testis is intra abdominal, testicular feminization, klinefelters syndrome (XXY), clinical finding- unilateral, painless enlargement of the testis
Germ cell neoplasia in situ (GCNIS)
The non invasive precursor of germ cell tumors of the testis (both seminoma and non seminoma)
Seen in cryptorchidism
Share many other features with seminoma, including karyotypic abnormalities, DNA content, ultrastructural changes, and immunohistochemical profiles
Most pts with GCNIS develop an invasive germ cell tumor within 7 years involvement is patchy, and 40% of cases are bilateral, two 3 mm testicular biopsies will identify the majority of patients with GCNIS
Spermatogenesis is absent in involved tubules. cells are atypical with nuclear enlargement and large nucleoli, DNA content is aneuploid, contains isochromosome 12 p, like seminoma does
GCNIS (non-invasive) types
Seminoma 40%, Age late 30s to 40s
Seminoma and non seminoma 30%
Non- seminomatous tumor- 30%, embryonal carcinoma, yolk sac tumor, choriocarcinoma, teratoma (mature, or immature) age 15-30%
non germ cell tumors- leydig cells, sertoli cell, others (lymphomas)
i 12 p
Clear cytoplasms
seminoma
mean pt age 40s, markers- alpha fetoprotein (AFP), B- HvG can be elevated
Arranged in solid nests separated by fibrous septa, lymphoid infiltrate, treatment is dependent on location of tumor, confined to testis: surgery +/- radiation/ chemo (carboplatin)
Outside of testis- radiation +/- chem
Sheet like of cells with lymphocytes
Non seminomatous germ cell tumor
unlike seminoma they are chemo sensitive but not radiosensitive,
Embryonal carcinoma
age 15- 30s, second most common germ line tumor, present in the majority of mixed germ cell tumors but occurs in pure form in only 10 %
MEts in up to 40%, serum AFP is normal, and B- nCG elevated in 60% of cases
Fleshy graypwhite tumor with prominent necrosis, cells of embryonal carcinoma are large, with vesicular nuclei, prominent nucleoli, glandular structures nuclei vesicular
yolk sac tumor (endodermal sinus tumor)
most common germ cell tumor in infants/children, where it occurs in pure form, and 90% are cured by orchiectomy alone
In adults, occurs as a component of mixed germ cell tumor, the main tumor marker in children and adults is elevated serum alpha feto protein (AFP), white to tan masses with myxoid and cystic change
Deposition of Basement membrane material, and schiller- duval bodies (central vessel rimmed by loose CT that in turn is lined by malignant epithelium, all within a cystic space, are characteristic
Teratoma
Pure form with a mean age of diagnosis at 20 months, in kids, no mets, in adults, occurs in mixed germ cell tumor, and is identified in >50% of mixed tumors, mature form is composed of somatic type tissue that can include- intestine type gland, respiratory epithelium, cartilage, muscle squamous epithelium
May have a typia associated with IGCNU, immature teratomas contain immature neuroepithelium, blastema, carcinoid or cell stroma, worse outcome
choriocarcinoma
mets to the brain or lungs, serum b- hCG elevated, confers poorer prognosis, but the tumor is sensitive to chemo, multinucleated syncytiotrophoblastic cells and mononuclear cytotrophoblast or intermediate trophoblast, stains hCG
Speratoocytic tumoe
pts over 50, benign behavior, histologically variable size no lymphoid infiltrate
Sex cord stromal tumors- leydic cell tumor
leydic cell tumor, is 3% to 5% of testicular neoplasms, adults (80%) and kids
in adults 10-17% are malignant
Unilateral with rare exceptions, benign tumors are treate by orchiectomy, malignant ones require retroperitoneal lymph node disections
cells are not nested
sex cord-stromal tumors- sertoli cell tumor
<1% of testicular tumors, malignant in 10% of cases, estrogen production by the tumor can resul in gynecomasia and impotence
Closely packed corms
Lymphoma
Most common testis tumor over age 60, usually the result of secondary spread, involvemnt is bilateral in20% of all cases, survival is stage dependent, white to tan fleshy tumor, has an interstitial growth pattern with sparing of seminferous tubules, most are diffuse large cell types with a B cell phenotype
epididymis- most common tumor is adenomatoid tumor
typically involves epididymis may also be identified in tunica albuginea and spermatic cord, circumscribed nodule, may extend into rete testis testis, alsways benign
Probable mesothelial origin rare cases described in adrenal and other organs
Testicular tunics: Testicular tunics: hydrocele and benign papillary mesothelioma
Hydrocele is most common cause of scrotal swelling, papillary mesothelioma has papillary excrescences present within tunica vaginalis which forms hydrocele sac papillae lined by bland cells with large nuclei
Spermatic cord- vasitis nodosa
usually observed after vasectomy, blind end of transected vas deferens, sperm contianing ductules, which communicate with the central lumen of the vas deferents , extend into the stroma, resembles invasve adenocarcinoma, but the presence of sperm chronic inflammation and lack of atypia
Mets to the testis #1 is prostate Ca
yes
Penis disorders- malformation
types of malformations- hypospadias- most common malformation, epispadias -less common
Pathogenesis-
Hypospadias- abnormal opening on the ventral surface of the penis, due to faulty closure of the urethral folds
Epispadias- abnormal opening on the dorsal surface of the penis, due to a defect in the genital tubercle
Phimosis
orifice of the prepuce is too small to retract over the head of the penis, prepuce scarring from prior infection
Inflammatory lesion
balanitis- inflammation/infection of the glans
Balanoposthitis- inflammaiton/infection of the glans and prepuce
Usually occurs in uncircumcised males with poor hygiene, accumulation of smegma–> infection by candida, pyogenic bacteria Staph, and anaerobes inflammatory scarring may produce an acquired phimosis, must be distinguished from ammoniacal dermatitis, the normal redness seen in boys still in diapers
Peyroinies disease
Fibromatosis on penis, painful contractures of the penis, may cause infertility
Condyloma acuminatum
halos, HPV effect on penile skin, warts
Penile intraepithelial neoplasia (PeIN)
basement membrane intact, bowns disease, erythroplasia of Queyrat, bowenoid papulosis
Bowwns disease- leukoplakia, involves the penile shaft and scrotum, patients usually over 35 yrs old, Association with human papillomavirus, HPV, type 16 and 18
Precursor for invasive squamous cell carcinoma (10% of cases), associateion with other types of visceral cancere
Erythroplasia of Querayt- redness located on the mucsals surface of the glans and prepuce, HPV16 and 18, precursor for invasive squamous cell carcinoma
Bownoid papulosis- Multiple pigmented reddish brown papules on the externalgenitalia, Association with HPV type 16, does not develop into invasice squamous cell carcinoma, is onle PeIN, with no predisposition for invasion
Invasive Squamous cell carcinoma
1% of all male cancers, usually affects men 40-70 yrs old, most common sites (glans or mucosal surface of prepuce, HPV type 16 18, association in 2/3s of cases, smoking may act as a cocarcinogen with HPV, Risk (lack of circumcision, Bowns disease and erythroplasia of Queyrat)
MEts to inguinal and iliac ndes
Varicocele
an abnormal enlargement of the vein that is in the scrotum draining the testicles
Most common cause of left sided scrotal enlargement in an adult, bag of worms appearance, left spermatic vein can also produce a varicocel, ex- renal cell carcinoma invading renal vein
Right spermatic vein drains int the vena cava, Blockage of right spermatic vein produces right sided varicocele, ex- retroperitoneal fibrosis
Very common cause of infertilityp heat makes sperm weak (asthenozoospermia)
hydrocele
accumulation of fluid around the testis, due to fluid secreted into a potential space called the tunica vaginalis, the TV is derived from extension of periotneum wrapped around testes
Most common cause of scrotal enlargement, common problem among bike riders, diagnosis (US distinguishes fluid in the TV versus a testcular mass causing scrotal enlargement), Other fluid accumulations- Hematocele contains blood, Spermatocele contains sperm, trtment -tydrocelectomy- removal of TV
Prostate anatomy
Zones- anterior, peripheral where most (not all) cancer arises, central, transition, normally small but can be huge where BPL arises, is sometimes involved by cancer also
2 layers of cell
columnar secretory and basal layer that is incontact with stroma
Prostatis
inflammatory cells are normal in the prostate, when inflammation is severe of clinically appernet it may be acute, chronic granulomatous, serum findings ( PSA antigen
Acute prostatitis
bacterial, young men, sudden onset of fever, chills, irritative voiding (dysuria, hematuria), myalgia, and back and perineal pain, prostate is warm and swollen on rectal exam, intraprostate reflux of urine from the posterior urethra or urinary bbladder
Pathogens- rods, E coli (80%), p aeruginosa, K pneumoniae
Chronic bacterial proststitis
A common cause of relapsing urinary Tract infection, usually caused by E coli, recurrent, painful ejaculation but other wise no symptom, calculus may serve as a nidus of bacteria, associated UTIs same organism as culture
Chronic a-bacterial 905% prostatits
chronic pelivic pain syndrome Perineal painn (esp post ejaculatory, without history of UTI or positive cultures)
Possible organisms- chlamydia- trachomatis, urea plasma urealyticum, tricomonas vaginalsi, psychologica
Granulomatous prostatits
granuloma- aggregate of histiocytes, macrophages
Infectious (TB)- hematogenous, fungal / mycotic (AIDS)
Non infectious- postsurgical (biopsy site reaction), post BCG, Bacille calmette-Guerin a bladder cancer treatment, non-specific
BPH
Benign prostatic hyperplasia (BPH), a proliferation of the glands and stroma in the Transition zone of the prostate, causes bladder outlet obstruction (BOO) involving urinary frequency, incomplete eptying nocturia, dysuria,
90% prevalence by age 80, is an androgen-dependent process (does not occur in genetic diseases impairing androgen), chiefly caused by DHT, PSA can be midly elevated
Finasteride and dutasteride DHT binds to T receptor more than T
PSA- , prostate specific antigen may be midly elevated
Proteolytic enzzyme, increases sperm motilitity, maintains seminal secretions in the liquid state, PSA is neither sensitive nor speciffic for BPH, PSA usually normal but BPH can increase it slightly
The precursor to invasic cancer High grade prostatic intraepithelial neoplasia (HGPIN)
1 male disease
Men who already have elevated serum PSA have 20% risk of cancer on repeat biopsy, Additional finding of HGPIN on biopsy increases the risk up to 25%-30%, by itself doesnt raise serum PSA
Screening for cancer
PSA serum, 4 or 2.5
Men over the age of 50, 40
Occurs moslty in the prostate
Prostatic carcinoma spread
nodes may be sampled at prostatectomy or not, tumor spreads first to external iliac lymph nodes, then obturator, hypogastric lymph nodes, low back/pelvic bones
