Male Reproductive Pathology

Question 1

Describe Bowen Disease

Answer 1

-Leukoplakia (white patch/plaque)

Premalignant lesion (HPV-associated carcinoma in-situ) on the penis

Question 2

Describe Erythroplasia of Queyrat

Answer 2

-Erythroplakia (red patch/plaque)

Premalignant lesion (HPV-associated carcinoma in-situ) on the penis

Question 3

Describe Bowenoid Papulosis

Answer 3

-Younger patients than the other 2 presentations (Bowen and Erythroplasia of Queyrat)
-Multiple reddish/brown papules on glans penis
-Usually transient, rare transformation to cancer

Premalignant lesion (HPV-associated carcinoma in-situ) on the penis

Question 4

Describe Neoplasms (Penis)

Answer 4

-Squamous cell carcinoma
-Common in developing countries

Question 5

Describe the clinical presentation of Neoplasms (penis)

Answer 5

-Gray, crusted, papular lesion usually on glans or prepuce
-Ulceration, induration, irregular margins
-Risk factors:
*poor hygiene (uncircumcised)
*smoking
*HPV

Question 6

Describe Scrotal enlargement and the different types

Answer 6

Fluid accumulation in the tunica vaginalis (membrane covering the testes)
-Hydrocele: serous fluid
-Hematocele: blood accumulation
-Chylocele: lymph accumulation

Question 7

Cryptorchidism

Answer 7

-Failure of testicular descent from the abdomen into the scrotum; most common congenital male reproductive abnormality
-Most resolve spontaneously; can be surgical repositioning (orchiopexy) if needed by 18 months
-Complications (even with unilateral cases): testicular atrophy (sterility); increased risk of testicular cancer

Question 8

Urinary traction infection (testes)

Answer 8

May be secondary to an ascending bacterial (including STD) - swollen, tender, neutrophilic infiltrate

Question 9

Mumps infection (testes)

Answer 9

Increased risk for infertility

Question 10

Testicular Torsion

Answer 10

-Twisting of the spermatic cord obstructs venous drainage while arteries remain patent –> vascular engorgement and infarction
-Sudden onset of pain; urologic emergency- need to untwist within 6 hours to prevent necrosis

Question 11

________ is the most important cause of firm, painless enlargement of the testis

Answer 11

Testes Neoplasms

Question 12

Seminoma

Answer 12

-Most common testicular tumor (always malignant)
-Usually delayed metastasis
-Highly responsive to radiation; excellent prognosis

Testes (Neoplasms)

Question 13

Teratoma

Answer 13

-Neoplastic germ cells from 2 or 3 embryonic layers differentiate toward multiple somatic cells
-Can be benign or malignant
-“Immature” (fetal-like tissue) or “mature” (fully differentiated tissues - i.e. teeth, hair)

Testes (Neoplasms)

Question 14

Describe the prostate anatomy

Answer 14

-Located at the base of the bladder, encircling the urethra, anterior to the rectum such that the posterior aspect is palpable by digital rectal exam (DRE)
-Androgens maintain the glands and stroma which make a milky fluid added to sperm and fluid from the seminal vesicle to make semen

Question 15

What does the prostate consist of histologically?

Answer 15

3 zones:
-Central zone
-Peripheral zone
-Transitional zone

Question 16

Acute or Chronic Prostatitis

Answer 16

-Usually due to bacterial urinary tract infection
-Fever (in acute) and dysuria (painful or difficult urniation)

Question 17

Chronic pelvic pain syndrome

Answer 17

-May be inflammatory or non-inflammatory (no WBCs in urine)
-Pain localized to the perineum, suprapubic and penis; often pain during or after ejaculation
-Unknown etiology and hard to treat

Prostatitis

Question 18

Benign Prostatic Hyperplasia

Answer 18

-Very common after age 40 (90% have it at 80yrs)
-Only 10% with histologic evidence have symptoms
-Most often arises from the inner transitional or central zones (produces urinary obstruction)

Question 19

Describe the symptoms seen in Benign Prostatic Hyperplasia

Answer 19

(symptoms only seen in 10% of patients)

-Hesitancy (difficulty starting a urinary stream) and intermittent interruption of the urinary stream while voiding
-With obstruction - urgency, frequency, nocturia (irritated bladder)

Question 20

Describe the Etiology, Pathogenesis, and Treatment for Prostatic Hyperplasia

Answer 20

Etiology: Increase in androgens

Pathogenesis:
-Testosterone (converted by 5alpha reductase) –> dihydrotestosterone (DHT) –> nodular hyperplasia
-Increased estrogen may also increase expression of DHT receptors in the prostate

Treatment:
-5alpha reductase inhibitors: finasteride (Proscar, Propecia)
-alpha1-adrenergic blockers: relax prostate smooth muscle (ex: terazosin, tamulosin)

Question 21

What does Prostatic Hyperplasia look like histologically?

Answer 21

-Well-defined nodules compressing the urethra
-Variable amount of normal appearing but hyperplastic glandular and stromal components

Question 22

Prostatic Carcinoma

Answer 22

-Most common cancer in men (excluding skin SCC and BCC); much less deadly than many other cancer types
-Lifetime risk ~11%
-Age: 65-75yrs
-Highly variable disease course; can’t reliably predict which tumors will be aggressive

Question 23

What is the pathogenesis of Prostatic Carcinoma?

Answer 23

-Androgens: promote, don’t initiate, cancer growth
-Hereditary - increased risk in 1st degree relatives
-Environmental - geographic variations, diet?
-Acquired genetic aberrations:
*most often see androgen-regulated fusion genes
*inherited BRCA1, BRCA2 mutations can increase risk

Question 24

Where do Prostatic Carcinomas arise? What is typically the first sign?

Answer 24

-Often clinically silent
-Carcinomas (70-80%) arise from the peripheral zone (palpated on digital rectal exam)
-Often first sign is metastasis. Bone (osteolytic or osteoblastic) involvement is common

Question 25

Prostate Specific Antigen (PSA)

Answer 25

-PSA is a normal product of prostatic epithelium, secreted in the semen
- <4ng/mL is normal, >10ng/mL suggests cancer
-Somewhat helpful for diagnosis when used with other procedures - not highly sensitive or specific
-Very helpful for monitoring patients for progression/recurrence

Question 26

Describe PSA screening: 2018 US Preventive Services Task Force Report for different age groups

Answer 26

For 55-69 years:
-Net benefit is small for some men

For 70+ years:
-Benefits do not outweigh the expected harms

Conclusion: If 55-69 years, patient-driven decision based on discussion with physician whether to screen
-Benefits: Out of 1000 men screened may prevent about 3 cases of metastasis and 1.3 deaths over 13 years (small reduction in risk of death)
-Risks: False positives leading to biopsy with potential overtreatment including complications:
*after prostatectomy: 20% have long-term incontinence and 66% have long-term erectile dysfunction
*after radiation: >50% have long-term erectile dysfunction and ~17% have bowel urgency and fecal incontinence

Question 27

Gleason Score

Answer 27

-From 1 (well differentiated) to 5 (no differentiation) with the 2 most common patterns added together
-Ex: Most differentiated would be (1+1=2) whereas the least differentiated would be (5+5=10).
-(Add together what they have the most of and what else they have. Ex: a lot of 5 with some areas of 1 –> 5+1=6).
-Gleason score given a grade group that correlates with prognosis

Question 28

Prostatic Carcinoma Prognosis

Answer 28

Clinical spread and histological grade (Gleason score) correlate with prognosis

Question 29

What is the treatment and prognosis of Prostatic Carcinoma?

Answer 29

Treatment:
-Active surveillance (watchful waiting)
-Surgery: robotic prostatectomy
-Radiation therapy: external beam or brachytherapy (internal radioactive seeds)
-Androgen deprivation (orchiectomy and/or medications- only for advanced metastatic disease

Prognosis:
-Stage T1,T2 (still in gland) - Good (90% 1- yr survival)
-Disseminated disease (has spread outside the gland) - Poor (10-40% 10 yr survival)