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Hormonal & Reproductive Week 3 - WLB > Male Reproductive Pathology - Twomey > Flashcards

Male Reproductive Pathology - Twomey Flashcards

1
Q

What are the three important anatomical zones of the prostate? How do these relate to cancer pathology?

A

Central zone - CZ
25% of gland mass
40% of epithelial cells
5-10% of all carcinomas

Transitional zone - TZ
5% of gland mass
most cases of BPH
rare carcinomas

Peripheral zone - PZ
70% of gland mass
most carcinomas (can palpate on digital rectal exam)

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2
Q

What are the clinical features of acute bacterial Prostatitis?

A

mostly Gram-negative rods => same organisms as in UTIs

Fever, chills and dysuria

Extremely tender and boggy on exam

Dx. based on urine cx. and clinical features

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3
Q

What are the clinical features of Chronic bacterial Prostatitis?

A

Same organisms as acute

Non-specific sxs: low back pain, dysuria, pelvic pain or no symptoms

May see recurrent UTI’s with same causative agent

Dx: + prostatic massage cxs. & >5 leukocytes/HPF in prostatic fluid, or increase in UA WBC count post massage

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4
Q

What are the clinical features of Chronic abacterial Prostatitis?

A

Most common form of prostatitis today

Similar to chronic bacterial, but culture neg.

Usually sexually active men

STD organisms have been implicated => Chlamydia, Mycoplasma, Ureaplasma

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5
Q

What happens to the PSA in prostatitis?

A

increased PSA

30% of men with prostatitis will have a decreased PSA

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6
Q

How do you treat prostatitis?

A

Tx with abx, NSAIDS – txment may be ineffective in chronic cases

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7
Q

What is the cause of BPH?

A

Androgens - dihydrotestosterone production increases in prostate stromal cells with aging – stimulates growth

Estrogens - estradiol levels increase in men with aging – induce an increase in androgen receptors in prostate

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8
Q

What is the incidence of BPH?

A

40 20% of patients
60 70% of patients
70 90% of patients

50% of men become symptomatic

> 400,000 TURP’s/year by late 80’s in US, less than 1/2 that today with better medical therapy

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9
Q

What is the pathology behind BPH?

A

primarily in TZ & peri-ureth.

Nodular proliferation of both glands and stroma – not pre-malignant

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10
Q

Which symptom of BPH is most indicative of a problem?

A

nocturia (peeing at night)

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11
Q

What are the symptoms of BPH?

A

Hesitancy

Urgency

Frequency

Decreased stream size

Nocturia

Terminal dribbling

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12
Q

How much bigger does the prostate become in BPH?

A

Normal size in young men – 20g

Average size in BPH sufferers – 33g

4% of men will reach 100g (5x normal)

Largest recorded – 820g

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13
Q

What are the complications of BPH?

A

Obstruction

Incomplete bladder emptying

Infection

Infarction

Defective bladder fxn due to muscle hypertrophy and stretch

Renal failure

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14
Q

What are the two most common drug treatments of BPH?

A

5 alpha-reductase inhibitor (Finasteride - Proscar)

(50%+ reduction in PSA,
Multiply PSA X 2.3 if taking 1mg/d >4 years,
25% decrease in prostate Ca., but higher proportion of higher grade cancers)

Alpha-1 blocker (Tamsulosin – Flomax) => Smooth muscle relaxant => instant relief

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15
Q

What are the surgical treatment options for BPH?

A

TURP, Cryotherapy, Microwave, Laser, US

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16
Q

If a patient presents with a varicocele, what side is it most likely to present on?

A

Left (drains into the left renal vein)

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17
Q

What are the two phases of Testicular Descent?

A

Phase 1
Transabdominal
Descends to lower abdomen/pelvic brim
Controlled by mullerian-inhibiting substance

Phase 2
Inguinoscrotal
Descends through the inguinal canal into scrotum
Androgen dependent

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18
Q

What is the incidence of Cryptorchid (abscent) Testis?

A

25% of premature infants
4-6% of newborns have patent inguinal canal
closed by 3 months in most cases
1-2% cryptorchidism by end of first year

Location: 70% high in scrotum, 20% in inguinal canal, 10% intra-abdominal

Unilateral – 75%

Cause poorly understood – rarely seen in hormonal disorders, see in trisomy 13

Asymptomatic

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19
Q

What are the histological changes seen in Cryptorchid Testis?

A

Histologic changes as early as 2 years:

  • Germ cell arrest
  • Basement membrane thickening/hyalinization
  • Decreased germ cells in contralateral testis
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20
Q

What is the clinical importance of Cryptorchid Testis?

A

Sterility if bilateral & uncorrected

Infertility (even if unilateral & uncorrected - implies defective germ cells)

Accompanying hernia 10-20%

Anatomic: increased risk for crush injuries

Oncogenic: 5 to 10-fold increase in germ cell tumors (5-10% of testicular germ cell tumors occur in cryptorchid testes)

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21
Q

What is the treatment for Cryptorchid Testis? Prognosis?

A

Orchiopexy (procedure to free soft tissue that is holding testis and then suture testis to wall of scrotum)

Before 2 years old for fertility, 10 years for neoplasm

Deficient spermatogenesis still in 10-60%

Some increased risk of cancer remains, even in contralateral testis – intrinsic defect in testicular development & cellular differentiation

22
Q

What are the different classes of causes for Male infertility?

A

Hormonally

Testis itself (scarring)

Genetic

Idiopathic (spermatogenic arrest)

Autoimmunity

Varicocele

Drugs (cyclophosphamide)

Post-testicular obstruction

Atherosclerosis

Malnutrition/cachexia

Irradiation

Female sex hormones

23
Q

What is “Sertoli Cell Only” Syndrome?

A

germ cell aplasia => Reduced/absent sperm production

10-20% of all testicular biopsies in infertile males
Small to nml. sized testes with azoosp.

24
Q

What Chromosomal abnormalities can result in male infertility?

A

Klinefelter and Down syndrome

25
Q

Infertility With Oligospermia (2 - 20,000,000/ml)

A

Testicular: many genetic, toxic, endocrine, vascular, infectious causes

Post-testicular: usually obstruction

Key feature: normal testicular biopsy

Post vasectomy - most common

Site of obstruction in non-vasectomy cases:
50% - epididymis,
25% - absence of vas (1% of infertile males),
10% - obstruction of vas or ejaculatory ducts,

40% of male infertility is idiopathic

26
Q

What are the causes of Epididymo-orchitis?

A

Bacterial = Related to UTI’s – spread through vas deferens or lymphatics

Under 35 yrs. old most are sexually transmitted (Neisseria gonorheae, Chlamydia, Mycoplasma, Treponema Pallidum (1T) )

Older than 35 usually associated with recurrent UTI’s or BPH - coliform bacteria

Granulomatous => Tuberculosis uncommon today; typically involves epididymis

Non-tuberculous – unilateral, autoimmune?

Viral - several implicated (Mumps – testes rarely involved pre-pubertal, 20-30% post-pubertal, 2/3 unilateral)

27
Q

What pathologies should you think about when you see granuloma formation (single multi-nucleated giant cell) on a histological slide of the testis?

A

TB or fungal (histo-, crypto-, or coccidio-)

28
Q

What are the two vascular disturbances that can occur in the male genitalia?

A

Torsion and Varicocele

29
Q

What are the clinical features of Torsion?

A

testicle rotates, twisting the spermatic cord that brings blood to the scrotum (Venous > arterial)

Usually before age 30 – can see as early as 1 yr old

Causes - violent motion or trauma, usually in setting of abnormal anatomy ( incomplete descent, atrophy etc.)

Many cases have no history of a defining event

Hemorrhagic infarction - surgical repair within 4 hours may salvage function

30
Q

What are the clinical features of Varicocele?

A

dilation of veins within pampiniform plexus (“bag of worms”)

Incidence: up to 25% of adults

More common on left side; 10-15% bilateral

A cause of infertility (relative hyperthermia, others)

31
Q

Germ Cell Tumors

A

Seminoma

Embryonal carcinoma

Yolk sac tumor

Teratoma

Choriocarcinoma

32
Q

Sex cord stromal tumors

A

Sertolic cell tumor

Leydig cell tumor

Granulosa cell tumor

Mixed

33
Q

What is the Seminomatous Testicular tumor that is more localized and has a better prognosis than non-seminomatous tumors?

What are the four non-Seminomatous that are more likely to metastasize?

A

Seminomatous = Seminoma

Non-Seminomatous = Embyronal, Yolk sac, Teratoma, Choriocarcinoma

34
Q

What is the incidence of germ cell tumors?

A

Incidence - appears to be rising

1-3% of all malignancies in men

30% of all malignancies in age group 20 - 34 yr

Most common solid tumor in men 15-34

Varies by location and ethnic group

6/100,000 in US, highest in Denmark and adjacent
countries

5:1 white:black ratio

7,000 new cases in US/yr; 6,900 in testis, 300 deaths

Most cases are non-familial and no major gene linkages are apparent

35
Q

What is the precursor lesion in testicular cancer?

A

“Intratubular germ cell neoplasia” (CIS) - data from Denmark

0.8 % of all males

2-3 % with cryptorchidism

> 25% with androgen insensitivity syndrome/gonadal dysgenesis/feminization syndrome (no androgen receptors)

36
Q

What are the clinical features of testicular germ cell tumors?

A

Progressive, painless testicular enlargement

Bilateral in 1- 3%; up to 15% in bilateral cryptorchidism

can have different phenotypic expression

lymphoma is most likely cause in older males (>40’s)

37
Q

What are the clinical featurs of Seminoma tumors?

A

50% of all germ cell tumors

***Peak in 30’s

Rare in children

Ovary - dysgerminoma

Phenotypic expression: Typical seminoma—95%, Spermatocytic seminoma—5%

38
Q

What are the histological features of Seminoma tumors?

A

clear cytoplasm (lots of white)

lots of lymphocytes

lot of fibrous tissue

occasional non-caseating granulomas

some syncytiotrophoblast cells (secrete Beta-hCG => can use as tumor marker)

39
Q

What are the clinical features of Embryonal Carcinoma?

A

2nd most frequent form of pure GCT

***20-30 year age group

More aggressive than seminoma

Rare before puberty or after 50

Grossly smaller than seminoma because they are found earlier

Pain/twinge => will precede finding a lump

40
Q

What are the histological features of Embryonal tumors?

A

More pleomorphisms

Dark nuclei, more mitotic activity

Hemorrhage

41
Q

What are the clinical featurs of Yolk Sac Tumors?

A

Most common testicular tumor in infants/young children under 3 years, in pure form

Clear cells recapitulating endodermal sinus

Schiller-Duval bodies (ring of cells, “yolk sac” appearing) and lobules of protein (pink)

Marker—aFP (alpha-feta protein)

42
Q

What are the clinical features of Choriocarcinoma?

A

Highly malignant (spread hematogenously)

Rare in pure form -

43
Q

What are the clinical featurs of Teratomas?

A

Recapitulates tissue from >1 germ cell layer

Infancy to throughout adulthood

Pure form common in infancy/childhood, rare in adults

Mature, immature, malignant forms

***Never benign in adult males

44
Q

What are the gross and histological features of Teratomas?

A

cysts (endodermal tract linings)

fat (mesodermal layer)

skin (multiple forms of epithelium)

45
Q

What are the clinical features of Mixed Testicular Tumors?

A

60% of testicular tumors

Prognosis worsens with inclusion of more aggressive forms

Pattern of metastases:

  • Lymphatic spread (Retroperitoneal (aorta), Mediastinal and supraclavicular nodes)
  • Hematogenous spread (Lung, brain, liver, other organs common depending on tumor phenotype)

Metastasis histology may differ from primary

Seminomatous component of mixed tumors usually does not metastasize

46
Q

What is the basic Staging of Testicular Cancer?

A

Stage I: Local spread (rarely spreads beyond tunica albuginea - Ic)

Stage II: Involvement of retroperitoneal lymphatics

Stage III: Parenchymal metastases or nodes beyond retroperitoneal

47
Q

What is the treatment for Seminomas?

A

exquisitely radiosensitive

Stage I – orchiectomy alone with W.W.

Stage II – orchiectomy and pelvic/paraortic LN XRT or orchiectomy and single agent chemo -cisplatin

48
Q

What are the two Non-Germ Cell Testicular Tumors?

A

Sertoli cell Tumor: Several variants - often admixed with granulosa cells, Associated with gynecomastia

Leydig cell Tumor: elaborate androgens and/or estrogens
1-3% of tumors, Adults with gynecomastia

49
Q

Testicular lymphoma

A

5% of tumors

Older adults, >60

Usually large cell histology and systemic disease

50
Q

What is a hydrocele?

A

cystic space obliterated on each end

51
Q

What is a Spermatocele?

A

cystic mass arising from efferent ducts

lumen filled with sperm

Hormonal & Reproductive Week 3 - WLB (14 decks)

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