Renal Pathology Chapter 21 part 3 Flashcards
Germ cell tumors of the testis often secrete hormones and certain enzymes that can be detected in blood by sensitive assays, including
- HCG, AFP, and lactate dehydrogenase
- the elevation of lactate dehydrogenase correlates withe the mass of tumor cells, and provides a tool to assess tumor burden
Hormones produced by yolk sac tumor
AFP
Hormone produced by choriocarcinoma
HCG
Approximately 15% of summons have
-syncytiotrophoblastic giant cells and minimal elevation of HCG levels, which does not affect prognosis
In the context of testicular tumors, the value of serum markers is 4-fold:
- in the evaluation of testicular masses
- in the staging of testicular germ cell tumors
- in assessing tumor burden
- in monitoring the response to therapy
Leydig Cell Tumors
- may elaborates androgens and in some cases both androgens and estrogens, and even corticosteroids
- may arise at any age, but most common age 20-60
- testicular swelling, some patients have gynecomastia
- in children, hormonal effects, manifested primarily as sexual precocity, are the dominant features
- form circumscribed nodules usually less than 5 cm in diameter
- distinctive golden brown, homogeneous cut surface
- large in size
- cytoplasm frequently contains lipid droplets, vacuoles, or lipofuscin pigment and rod-shaped crystalloids of Reinke
Sertoli Cell Tumors
- most are hormonally silent and present as a testicular mass
- appear as firm, small nodules with a homogeneous gray-white to yellow cut surface
- arranged in distinctive trabeculae that tend to form cordlike structures and tubules
- most are being, but approximately 10% malignant
Gonadoblastoma
Gonadoblastoma -rare neoplasms comprised of a mixture of germ cells and gonadal stromal elements that almost always arise in gonads with some form of testicular dysgenesis
-in some cases, the germ cell component becomes malignant, giving rise to seminoma
Testicular Lymphoma
- aggressive non-Hodgkin lymphomas account for 5% of testicular neoplasms, most common form in testicular neoplasms in men older than age 60
- affected patients may present with only a testicular mass, mimicking other, more common, tumors
- most common are diffuse large B-cell lymphoma, Burkitt lymphoma, and EBV-positive extra nodal NK/T cell lymphoma
- have a higher propensity for CNS involvement than do similar tumors arising at other sites
Tunica Vaginalis
-mesothelial lined surface exterior to the testis that may accumulate serous fluid (hydrocele) causing considerable enlargement of the scrotal sac
Hydrocele sacs
-frequently lined by mesothelial cells
Hematocele
Hematocele -indicates presence of blood in the tunica vaginalis
-uncommon condition usually encountered following testicular trauma or torsion, or in individuals with systemic bleeding disorders
Chylocele
-accumulation of lymph in the tunica and is almost always found in patients with elephantiasis who have widespread, severe lymphatic obstruction caused by filariasis or other organisms
Spemratocele
-small cystic accumulation of semen in dilated efferent ducts or ducts of the rete testis
Varicocele
- dilated vein in the spermatic cord
- may be asymptomatic but have also been implicated in some men as a contributing factor to infertility
In normal adult, the prostate weighs
approximately 20 gm
Prostate is
-a retroperitoneal organ encircling the neck of the bladder and urethra and is devoid of a distinct capsule
In the adult, prostatic parenchyma can be divided into 4 biologically and anatomically distinct zones or regions
- peripheral, central, transitional, and periurethral zones
- types of proliferative lesions are different in each region
Most hyperplasias arise in the
transitional zone
Most carcinomas originate in
the peripheral zone
Histologically, the prostate is composed of
- glands lined by 2 layers of cells; a basal layer of low cuboidal epithelium covered by a layer of columnar secretory cells
- in many areas there are small papillary infolding of the epithelium
- glands are separated by abundant fibromuscular stroma
Control the growth and survival of prostatic cells
-testicular androgens
Acute bacterial prostatitis
- typically results from bacteria such as E. coli, gram-negative rods, enterococci, and staphylococci
- organisms become implanted in the prostate usually by intraprostatic reflux of urine from the posterior urethra or form the urinary bladder, but occasionally seed the prostate by lymphohematogenous routes from distant foci of infection
- fever, chills, dysuria
- on rectal exam the prostate is tender and boggy
Chronic bacterial prostatitis
- may present with low back pain, dysuria, and perineal and suprapubic discomfort or may be virtually asymptomatic
- often have a history of recurrent UTIs caused by same organism
Diagnosis of chronic bacterial prostatitis depends on
demonstration of leukocytosis in the expressed prostatic secretions, along with positive bacterial cultures
Chronic abacterial prostatitis
- most common form of prostatitis
- indistinguishable from chronic bacterial prostatitis in terms of signs and symptoms, but there is no history of recurrent UTIs
- negative bacteria cultures, but leukocytes in prostatic secretions
Granulomatous prostatitis
may be specific or nonspecific
-most common cause in U.S. is instillation of BCG within the bladder for treatment of superficial bladder cancer
Nonspecific granulomatous prostatitis
-relatively common and represents a reaction to secretions from ruptured prostatic ducts and acini
Acute prostatitis morphology
-may appear as minute, disseminated abscesses; as large, coalescent focal areas of necrosis; or as diffuse edema, congestion, and boggy suppuration of the entire gland
Benign Prostatic Hyperplasia
- the most common engine prostatic disease in men older than age 50
- results from nodular hyperplasia of prostatic stromal and epithelial cells and often leads to urinary obstruction
- characterized by formation of large, fairly discrete nodules in the periurethral region of the prostate, which, when sufficiently large, compress and narrow the urethral canal to cause partial, or sometimes virtually complete, obstruction of the urethra
Hyperplasia in benign prostatic hyperplasia
-mainly stems from impaired cell death, resulting in the accumulation of senescent cells in the prostate
In the usual case of benign prostatic enlargement, the prostate weighs
between 60 and 100 gm
Nodular hyperplasia of the prostate
originates almost exclusively in the inner aspect of the prostate gland (transition zone)
Early nodules are composed of
almost entirely stromal cells, and later predominantly epithelial nodules arise
-nodular enlargements may encroach not eh lateral walls of the urethra to compress it to a slitlike orifice
Median lobe hypertrophy
-nodular enlargement may progress up into the floor of the urethra as a hemispheric mass directly beneath the mucosa of the urethra
On cross-section, BPH nodules
vary in color and consistency depending on their cellular content
- nodules that contain mostly glands are yellow-pink and soft, and exude a milky white prostatic fluid
- nodules composed primarily of fibromuscular stroma are pale gray and tough
Microscopically BPH
-glandular proliferation take the form of aggregations of small to large to mystically dilated glands lined by 2 layers of cells, an inner columnar layer and an outer layer of cuboidal or flattened epithelium
Major clinical problem in those with BPH is
- urinary obstruction, which stems form the increased size of the prostate and the smooth muscle-mediated prostatic contraction
- increased resistance to urinary outflow leads to bladder hypertrophy and distention, accompanied by urine retention
BPH patients experience
-increased urinary frequency, nocturne, difficulty in starting and stopping the stream of urine, overflow dribbling, dysuria (painful micturition), and have an increased risk of developing bacterial infections of the bladder and kidney
Cancer of the prostate
- typically a disease of men older than age 50 years
- uncommon in Asians and occurs most frequently among blacks
As with the shortest stretches of polyglutamine have
-the highest sensitivity to androgens
Shortest polyglutamine repeats on average are found in
African Americans
Intermediate polyglutamine repeats
Caucasians
Longest polyglutamine repeats
Asians
In approximately 70% of cases, carcinoma of the prostate arises in
-peripheral zone of the gland, classically in a posterior location, where it may be palpable one ectal exam
On cross section of the prostate, the neoplastic tissue is
-gritty and firm, but when embedded within the prostatic substance it may be extremely difficult to visualize and be more readily apparent on palpation
Metastases from prostatic carcinoma spread via
- lymphatics to the obturator nodes and eventually to the para-aortic nodes
- hematogenous spread occurs chiefly to the bones and are typically osteoblastic
Histologically, most lesions in prostatic cancer are
adenocarcinomas that produce well-defined, readily demonstrable gland patterns
- glands are typically smaller and lined by a single uniform layer of cuboidal or low columnar epithelium
- outer basal cell layer typically absent
- cytoplasm ranges from pale-clear to a distinctive amphiphilic appearance
- nuclei large and often contain one or more large nucleoli
One distinguishing feature between benign and malignant prostate glands is
- benign glands contain basal cells, which are absent in cancer
- this distinction can e brought out by using various immunohistologic markers to label basal cells
Prostatic Intraepithelial neoplasia (PIN)
- architecturally benign large, branching prostatic acini lined by cytologically atypical cells with prominent nucleoli
- cytologically PIN and carcinoma may be identical
- PIN glands are surrounded by a patchy layer of basal cell and an intact basement membrane (unlike malignant glands)
Grade I prostate cancer
- most well differentiated tumors
- neoplastic glands are uniform and round in appearance and packed into well-circumscribed nodules
Grade 5 prostate tumors
-show no glandular differentiation, with tumor cells infiltrating the stroma in the form of cords, sheets, and nests
Most tumors contain more than one pattern, so primary grade is assigned to
the dominant pattern and a secondary grade to the second most frequent pattern
Prostate tumors with only one pattern are
treated as if their primary and secondary grades are the same, and so the number is doubled
Most well differentiated prostate tumors have a Gleason score of
2
Lest differentiated prostate tumors have a Gleason score of
10
Gleason scores 2-6
well-differentiated tumors with an excellent prognosis
Gleason score 3+4=7
moderately differentiated tumors
Gleason score 4+3=7
moderately to poorly differentiated tumors
Gleason score 8-10
poorly to undifferentiated tumors with aggressive biologies
Stage T1
-incidentally found cancer, either on TURP done for BPH symptoms (T1a and Tlb depending on the extent and grade) or on needly biopsy typically performed for elevated serum PSA levels (stage T1c)
Stage T2
-organ-confined cancer
Stage T3a and T3b
extra-prostatic extension, with and without seminal vesicle invasion, respectively
Stage T4
-direct invasion of contiguous organs
Localized prostate cancer is
-asymptomatic, and is usually discovered by the detection of a suspicious nodule on renal exam or elevated serum PSA level
Most prostatic cancers arise
-peripherally away from the urethra and therefore urinary symptoms occur late
Patients with clinically advanced prostate cancer may present with
-urinary symptoms, such as difficulty in starting or stopping the stream, dysuria, frequency, or hematuria
Prostate Ductal adenocarcinomas
- those arising in peripheral ducts may present in a fashion similar to ordinary prostate cancer
- those arising in the larger periurethral ducts may show signs and symptoms similar to urothelial cancer, causing hematuria and urinary obstruction symptoms
- poor prognosis
