Robbins Flashcards
What is hypospadias?
Opening of the urethral canal on the ventral surface of the penis
What is epispadias?
Opening of the urethra on the dorsal surfaces
What are the complications of hypospadias and epispadias?
The abnormal opening is often constricted, resulting in urinary tract obstruction and a higher risk for UTI.
Could also block normal ejaculation – sterility
What is phimosis?
When the orifice of the prepuce is too small to permit normal retraction
What usually causes phimosis?
Repeated attacks of infection that cause scarring of the preputial ring
What are the complications of phimosis?
Permits accumulation of secretions and detritus under the prepuce
What is balanoposthitis?
Infections of the glans and prepuce caused by a wide variety of organisms.
What are the common microbes that cause balanoposthitis?
Candida, Anaerobic bacteria, Gardernella, Pyogenic bac
What is smegma?
Accumulation of desquamated epi cells, sweat, debris that can act as an irritant
What does smegma cause?
Phimosis
What is Bowen disease?
CIS of genital region
Appears as solitary, thickened, gray-white, opaque-plaque on shaft
Appears as multiple, red, velvety plaques
What kind of cells do you see in Bowen disease?
Markedly dysplastic with large hyperchromatic nuclei and lack of orderly maturation
How old are the patients with Bowen disease?
Over the age of 35
What percentage of Bowen disease transforms into SCC?
10%
Who gets bowenoid papulosis?
Occurs in sexually active adults
What does bowenoid papulosis?
The presence of reddish brown papular lesions.
What is the natural outcome of bowenoid papulosis?
Spontaneous regresses sometimes
Never develops into invasive carcinoma
What offers protection against invasive carcinoma?
Circumcision
What elevates the risk of developing cancer of the penis?
Cigarette smoking
What age do patients typically get carcinoma of the penis?
40-70
What does the papillary type SCC of the penis look like?
Cauliflower-like fungating mass
What does the flat type of SCC of the penis look like?
Areas of epithelial thickening accompanied by fraying and fissuring of the mucosal surface —- ulcerates
What does the verrucous carcinoma of penis look like?
Exophytic well-differentiated variant
Low malignant potential
What is the pathological potential of SCC of penis?
Slow growing
Locally invasive
Not painful
What is the prognosis to the SCC of the penis related to?
Stage of the tumor
What is cryptorchidism?
Complete or incomplete failure of the intra-abdominal testes to descend into the scrotal sac
In what phase do the testis settle into the lower abdomen?
The phase controlled by Müllerian inhibiting substance.
In what phase do the testes descend through the inguinal canal into the scrotal sac?
Androgen dependent phase 2 mediated by calcitonin gene-related peptide, from the genitofemoral nerve.
What does the histo of cryptorchidic testes look like?
Arrest in development of germ cells
Marked hyalinization and thickening of basement membrane of the spermatic tubules.
Leydig cells are prominent
Contralateral testis has paucity of germ cells too
What do cryptorchidic testes look like?
Small and firm
What are the complications of cryptorchidism?
Sterility
Trauma
Inguinal hernia (10-20%)
Higher risk of testicular cancer
What is the treatment for an undescended testicle?
Surgical correction - orchiopexy
What is orchiopexy?
Placing the undescended testicle into the scrotal sac surgically
What is cryptorchidism associated with?
An intrinsic defect in testicular development and cellular differentiation
What are the causes of atrophy of the testes?
- Progressive atherosclerosis narrowing the blood supply
- End stage of inflammatory orchitis
- Cryptorchidism
- Hypopituitarism
- Malnutrition or cachexia
- Irradiation
- Prolonged admin of anti-androgens
- Exhaustion following persistent stimulation of FSH
What is the histo of atrophy of the testes?
Same as for cryptorchidism
No spermatogenesis, thickened basement membrane and hyalinization. Prominent Leydig cells
What is atrophy of the testicles?
The end stage to testicular injury characterized by:
Hypospermatogenesis
Maturation arrest
Vas deferens obstruction
Where do gonorrhea and TB arise in the male genital tract?
Epididymis
What organ does syphilis arise in first in the male genital tract?
Testes
What is epididymis is usually caused by in children?
Congenital genitourinary abnormalities and infection with gram neg rods
What is the cause of epididymitis in sexually active men below the age of 35?
STDs - chlamydia and gonorrhea
What is the cause of epididymitis in men older than 35?
UTI pathogens - E.coli, Pseudomonas
What can epididymitis and orchitis lead to?
Abscess formation and suppurating necrosis
Fibrous scarring —- infertility
What disease presents in the Middle Ages with fever and sudden onset of moderately tender testicular mass?
Granulomatous orchitis
What is the histo of granulomatous autoimmune orchitis?
Granulomas only in the spermatic tubules - look like tubercles
What kind of infection is usually from the posterior urethra to the prostate to the seminal vesicles to the epididymis?
A neglected gonorrheal infection
What viral diseases may cause orchitis?
Mumps
Orchitis develops one week after swelling of the parotid glands.
Happens in 20-30% of postpubertal males
What does syphilis produce?
Gummas, diffuse inflammation + obliterative endarteritis, peri secular cuffing of lymphocytes and plasma cells.
What happens in a torsion?
The venous drainage of the testis is cut off and there is vascular engorgement from the arteries leading to infarction
What are the 2 types of torsion?
- Neonatal
2. Adult
What is the time frame for saving a testicle from torsion?
Under 6 hours for it to remain viable
What is adult torsion a result of?
Bilateral anatomical defect where the testis has hyper mobility and has the bell clapper effect
What is the treatment for torsion?
Untwist it and fix it to the scrotum
What is the most common benign paratesticular tumor?
Adenomatoid tumor
What are adenomatoid tumors?
Small nodules occurring at the top of the epididymis that can be minimally invasive to the testes.
What are the most common malignant paratesticular tumors?
Rhabdomyosarcomas in kids
Liposarcomas in adults
What are common lesions found in the spermatic cord during inguinal hernia repair?
Lipoma
Where do most testicular tumors arise from?
95% from germ cells
Are sex cord STROMAL cell tumors usually benign or malignant?
Benign
At what age is testicular cancer most common?
15-34 years old
What are germ cell tumors associated with?
TDS - testicular dysgenesis syndrome: cryptorchidism, hypospadias, poor sperm quality
What can cause TDS?
In uteri exposure to pesticides and non steroidal estrogens
What is the most important risk factor for testicular cancer?
Cryptochidism
What kind do cancers do patients with Klinefelter’s develop?
Mediastinal germ cell tumors
What are seminomatous tumors composed of?
Cells that resemble primordial germ cells
What are the non-seminomatous tumors composed of?
Undifferentiated cells that resemble embryonic stem cells
What percentage of germ cell tumors are mixed?
60%
What is the most common testicular tumor?
Seminoma
What lesion do testicular germ cell tumors originate from?
Intra tubular germ cell neoplasia
What have ITGCN not been implicated in?
A precursor lesion to pedi yolk sac tumors, teratomas or adult spermatocytic seminoma.
When does ITGCN occur?
In utero
Stay dormant until puberty
What does ITGCN consist of?
Atypical primordial germ cells with large nuclei and clear cytoplasm.
What do the cells of ITGCN express?
OCT3/4, NANOC
Copies of 12p
Activating muts of ckit
What percentage of patients develop invasive tumors from ITGCN.?
100%
When do patients get seminoma?
Third decade
What do seminomas express?
OCT3/4, NANOC
Ckit activation
12p copies
What do seminomas look like?
Bulky grey-white masses
Do not penetrate tunica albuginea
What is the histo of a seminoma?
Composed of sheets of uniform cells divided into lobules by fibrous septa containing lymphocytes.
The cell = large, round, watery cytoplasm, large central nucleus with 1-2 prominent nucleoli.
15% contain synctiotrohphoblasts
Can increase hCG!
Can also see granulomas
What are seminoma cells positive for?
Ckit
PLAP - placental alkaline phosphatase
OCT3/4
What does anaplastic seminoma look like?
More mitosis
Nuclear irregularity
Not associated with a worse prog
Who gets spermatocytic seminoma?
Over 65
What is a spermatocytic seminoma?
Slow growing tumor that does not mets!
Soft, pale grey tumor with mucous cysts
What is the histo of spermatocytic seminoma?
3 cells:
- Medium with round nucleus and Eosinophilic cytoplasm
- Small with rim of Eosinophilic cytoplasm resembling secondary spermatocytes
- Giant cells
Who gets embryonal carcinoma of the testes?
20-30 years old
What does an embryonal carcinoma of the testis look like?
Smaller and more aggressive than a seminoma punctuated by foci of hemorrhage and necrosis
Extends thru tunica albuginea
What is the histo of embryonal carcinoma of the testis?
Cells grow in alveolar or tubular patterns with papillary convolutions
Large anaplastic cells with hyperchromatic nuclei with prominent nucleoli
Lots of mitotes and tumor giant cells
What markers do embryonal carcinoma of the testis express?
OCT3/4, PLAP
Cytokeratin 34
CD 30
What is the most common testicular tumor in children and infants (younger than 3)?
Yolk sac endodermal sinus tumor
What does a yolk sac tumor of the testis look like?
Nonencapsulated yellow-white homogenous mucinous tumor
What is the histo of a yolk sac tumor of the testis?
Lacelike reticular network of cuboidal / flattened cells
May see Schiller Duvall bodies
Also see hyaline-like globules with alpha fetoprotein and alpha1 antitrypsin
What testicular tumor is detected as a small palpable nodule?
Choriocarcinoma
What is the histo of choriocarcinoma of the testis?
Hemorrhage and necrosis
Synctiotrohphoblasts and cytotrophoblastic cells
Make high levels of hCG
What does a synctiotrohphoblast look like?
Cell with irregular lobular hyperchromatic nuclei in Eosinophilic cytoplasm
What does a cytotrophoblast look like?
Polygonal cell with distinct borders and clear cytoplasm
What is the second most common testicular tumor in children?
Pure teratomas
What is the importance of recognizing a non-germ cell malignancy in a teratoma?
Because the non-germ cell component does not respond to chemo when it spreads outside the testis.
Have isochromosome 12p
What is the course of a teratoma?
In children - benign
In postpubertal male - all malignant
What is the standard tx of a testicular mass?
Radical orchiectomy
What is the mode of spread of testicular cancer?
Lymph: to para-aortic nodes to mediastinal and supraclavicular
Blood: to the lungs primarily
What kind of testicular tumor tends to stay in the testis for a long time and so is often discovered at stage 1?
Seminoma
In what stage are the non-seminomatous tumors found?
Stage II and III
How do non-seminomatous tumors usually spread?
Hematogenously
What tx are seminomas sensitive to?
Radiation
What are the clinical stages of testicular tumors?
Stage I: tumor confined to testis,epididymis, spermatic cord
Stage II: spread to retroperitoneal nodes and below diaphragm
Stage III: mets outside the retro nodes and above diaphragm
What peptide correlates with the mass of tumor cells providing a marker for tumor burden?
LDH
How can remission be achieved in someone with non-seminomatous tumor?
Aggressive chemo
What are the sex cord stromal tumors?
Leydig cell tumors
Sertoli cell tumors
What are the germ cell tumors of the testis?
Seminoma Spermatocytic seminoma Embryonal carcinoma Yolk sac tumor Choriocarcinoma Teratomas
When do leydig cell tumors usually happen?
Between 20 and 60
How do leydig cell tumors present?
Testicular swelling, gynecomastia precocious puberty
What do leydig cell tumors look like?
They are well circumscribed modules that are golden brown
What is the histo of leydig cell tumors?
Cells look like normal leydig cells
Contain crystals of Reinke
Is a leydig cell benign or malignant?
Benign
What do Sertoli cell tumors look like?
Firm small nodules with gray white to yellow color.
What is the histo of a Sertoli cell tumor?
Cells arranged in trabeculae
Which sex cord stromal tumor is hormonally active?
Leydig cell
What are gonadoblastomas?
Neoplasm containing a mix of germ cells and gonadal stromal elements
What is the most common form of testicular neoplasms in men over 60?
Aggressive non-Hodgkins lymphoma
Most common: diffuse large B cell, Burkett lymphoma, EBV-positive extra nodal NK/T lymphoma
What is a hydrocele?
Accumulation of serous fluid in the tunica vaginalis
What is a hematocrit caused by?
Trauma or torsion or hemorrhagic disease
Who gets chyloceles?
Patients with elephantiasis or filariasis
What is a complication of a varicocele?
Infertility
What controls the growth of the prostate?
Testicular androgens
What is acute bacterial prostatitis caused by?
UTI or after surgical manipulation of the urethra
What is the clinical presentation of acute prostatitis?
Fever. Chills, dysuria
DRE reveals tender, boggy prostate
How does chronic bacterial prostatitis present?
Low back pain, dysuria, perineal and suprapubic pain
What do patients with chronic bacterial prostatitis have a hx of?
Recurrent UTIs with the same organism
How do you diagnose prostatitis?
With leukocytes in the prostatic secretions and positive bac cultures
What is the most common form of prostatitis?
Chronic abacterial prostatitis
How is chronic abac prostatitis diagnosed?
More than 10 leukocytes per hpf and negative bac cultures
What is the most common cause of granulomatous prostatitis?
Instillation of BCG in the bladder for tx of bladder cancer
Why is biopsy of the prostate contraindicated in prostatitis?
It may lead to sepsis
What is BPH?
Hyperplasia of stromal and epi cells in periurethal region of prostate.
What is the pathogenesis of BPH?
Impaired cell death
What is the main androgen of the prostate?
DHT
What cell converts testosterone to DHT
Stromal cells by 5 alpha reductase
What does DHT do?
Binds the AR and mediates transcription of genes for growth factors and receptors
What is the most important GF stimulated by DHT contributing to BPH?
FGF-7
What does BPH look like?
Tissue is yellow-pink with soft consistency and milky ooze if made of glands
Firm and grey is fibromuscular stroma
Glandular prolif = cystically dilated glands lined by inner columnar and outer cuboidal epi
What are the complications of BPH?
Bladder hypertrophy and distention
Urinary retention
Urethral obstruction
Higher risk of infection
What are the tx for BPH?
Lower caffeine and alcohol intake
Timed voiding schedule
Alpha blockers
What is the gold standard for reducing BPH symptoms?
TURP - transurethral resection
What is the most common form of cancer in men?
Adenocarcinoma of the prostate
Who gets adenocarcinoma of the prostate?
Men over 50
Most common in AAs
What are the factors that increase the risk for adenocarcinoma of the prostate?
High fat diet Short repeats of CAG - more sensitivity to androgens Increased androgens First degree relative BRCA2 mutation Mut at 8q24 Overexpression of ETS hyper methylation of GSTP1 Loss of e-cadherin Upreg of AMACR Overexpression of EZH-2 PCA3
What does over expression of ETS do?
Makes normal prostate epi cells more invasive thru upreg of MMPs
What is the most common epi genetic alteration in prostate cancer?
Hyper methylation of glutathione s-transferase
Where does prostate cancer usually arise?
In the peripheral zone and posteriorly
What does prostate cancer look like?
It’s embedded in the tissues
Gritty and firm
What is the lymphatic pattern of spread for prostate cancer?
Obturator nodes to para-aortic nodes
What is the hematogenous pattern of spread?
To the bones of the axial skeleton
Lumbar spine to proximal femur to pelvis, thoracic spine, ribs
What is the histo of prostate cancer?
Crowded Glands lined by cuboidal cells
No outer basal layer
Tumor cells = pale clear to amphophilic. Large nuclei
What are some markers for prostate cancer?
AMACR
What is PIN?
Benign prostatic acini lined by cytologically atypical cells with prominent nucleoli
Larger branching glands and papillary infoldings surrounded by basal cells and basement membrane
What is the grading system of prostate cancer?
The Gleason system
Grade 2-4: well-diff, small in transition zone
Grade 5-7: intermediate - treatable
Grade 8-10: no differentiation and tumor cells infiltrate the stroma - unlikely to be cured
What are the best prognostic indicators for prostate cancer?
Grade and stage
What are the stages for prostate cancer?.
T1- found incidentally
T2 - organ confined
T3 - extra prostatic extension
T4 - direct invasion of other organs
What is required for dx of prostate cancer?
A transrectal needle biopsy
What is PSA?
A product of prostatic epithelium normally secreted n semen.
It is a serine protease
What is a normal level of PSA?
Less than 4 ng/ml
What is the most important test used in diagnosis and management of prostate cancer?
PSA level
How is PSA velocity used?
Used for distinguishing between men with and without prostate cancer.
More than .75ng/ml per year is bad!
What percentage of free PSA confers a lower risk to prostate cancer?
Above 25%
What is the most common treatment for localized prostate cancer?
Radical prostatectomy
What therapy is used for prostate cancer that is too far advanced for surgery?
External beam radiation
What therapy is used for advanced mets from prostate?
Androgen deprivation by orchiectomy or LHRH agonists
What is the most aggressive variant of prostate cancer?
Small cell
What is the most common tumor to secondarily involve the prostate?
Urothelial cancer
What is the prognosis of ductal adenocarcinoma of the prostate
.
Poor
