Robbins, Chapter 21, Lower UT and Male GU System Flashcards
What is the significance of urinary stasis in diverticulae?
Increased propensity for infection and formation of bladder calculi.
Patients with exstrophy have increased risk of what neoplasm and where?
adenocarcinoma in bladder remnant
Child with recurrent UTI, think what?
Vesicoureteral Reflux (1/3 of kids with recurrent UTIs have have this)
4yo F with abdominal pain and fever. CT showed heterogeneous mass in midline, anterior to bladder. What could this be?
Infected urachal remnant/cyst.
What two pathologies may arise within urachal cyst or patent urachus?
Carcinomas or infection
Woman from Egypt (schisto) OR E coli, Proteus, Klebsiella, Enterobacter. OR immunocompromised person (candida) OR sequel to renal tuberculosis Think what?
Bacteria pyelonephritis
What does this triad indicate?
(1) Frequency
(2) lower abdominal pain localized over bladder region
(3) dysuria (pain/burning urination)
Also, low grade fever, turbid urine, and occasional hematuria.
Cystitis
30-40yoF comes in with intermittent, severe suprapubic PAIN, urinary frequency, urgency, hematuria and dysuria negative urine cultures for bacteria.
Chronic mucosal ulcers (Hunner ulcers) are associated with what?
Cytoscopic findings of fissures and punctate hemorrhages in bladder mucosa after luminal distention. MAST CELLS, lymphocytes, fibrosis and inflammation of the bladder wall.
Interstitial Cystitis (Chronic Pelvic Pain Syndrome)
Middle aged F»M.
Arises in setting of chronic bacteria infection (E. COLI or Proteus), occurs more in IMMUNOSUPPRESSED TRANSPLANT PATIENTS.
See slightly raised, broad, flat mucosal plaques.
Michaelis-Gutmann bodies present in macrophages in areas that form granulomas.
Malakoplakia (cystitis)
Number of organisms indicative of UTI in women v. men/asymptomatic women.
Women - 100organisms/mL + pyuria
Men/asymptomatic - 1000organisms/mL
When should a negative urine culture be reexamined?
When the patient is on antimicrobial therapy when the culture is obtained.
All of the following are predisposing factors for what?
- Bladder calculi, urinary obstruction/structural abnormalities, DM, instrumentation, immune deficiency.
- Radiation of bladder
Acute cystitis
Acute/chronic irradiation cystitis
TNTC WBCs in urine indicative of what?
Acute cystitis
Antecedent bacterial cystitis can progress to what?
Mortality increased in patients with what preexisting disease?
Pyelonephritis
Diabetes
A patient on anti-tumor drugs OR who has an adenovirus infection can develop what?
Hemorrhagic Cystitis
What am I?
Person had an indwelling catheter that resulted in irritation of the bladder mucosa.
Polyploid urothelium results from extensive submucosal edema. May be misdiagnosed as papillary carcinoma.
Polyploid cystitis
CHILD 4yo (M=F). Malignant mesenchymal tumor.
Rare.
??”Grape like”??
Rhabdomyosarcoma (Sarcoma botryoides)
ADULT 60yo (2M>1F), some post-RaRx or chemoRx. Malignant mesenchymal tumor, typically of adults. Rare
Leiomyosarcoma
ADULT 65yo 1M
Non-epithelial malignancy
Name the 5 types of urothelial (transitional cell tumors) that make up more than 90% of the tumors of the urinary bladder.
M or F?
W or B?
White males have highest risk! Industrial > Non Urban > Rural.
Exophytic papilloma
Inverted papilloma
Carcinoma in situ
Papillary urothelial neoplasm of low malignant potential - PUNLMP
Low grade and high grade papillary urothelial cancers
Thickened epithelium covering papillary projections is the major pathologic finding of what neoplasm?
Papillary urothelial neoplasm of low malignant potential - PUNLMP
What are the known (7) risk factors of urothelial neoplasia?
Known genetic risk factors? Ch# deletion (two), which has p53 associated (is this good or bad?)
CIGARETTE SMOKING (Industrial) dyes Cyclophosphamide Phenacetin Schisto Long term analgesic use Radiation
Ch 9 monosomy or deletions - superficial and non invasive, some invasive
Ch 17p deletion -invasive and CIS; p53 (BAD prognostic sign)
Describe pt presentation:
Flat lesions
Papillary lesions
Flat - discomfort likely
Papillary - hematuria likley
73yo white male presents with PAINLESS HEMATURIA. May also have frequency, urgency dysuria. Atypical cells seen in urine cytology.
What is the dx? What is the frequency of finding multiple tumors upon initial diagnosis?
Urothelial Carnicoma
40% have multiple tumors upon initial diagnosis.
Are most urothelial carcinomas non-invasive or invasive?
What are their treatment options, respectively?
Majority NON-invasive. (1) Transurethral resection (2) Intravesical therapy - chemotherapy or BCG Minority invasive (3) segmental cystectomy (4) radical cystectomy with urinary diversion (5) immunotherapy and photodynamic therapy
High grade Papillary Carcinomas are what % of papillary tumors at high/low recurrence rate?
What severe cytologic atypia do you find?
30%
HIGH RECURRENCE rate.
Cytologic atypia - hyperchromatic, huge nuclei, high N/C ratio
Layers of the bladder wall (4). What do TCC invade?
What depth of invasion is the major prognostic issue to be established?
Urothelium»_space; Lamina Propria»_space;Muscularis Propria»_space; Adventitia
Muscular invasion is the major prognostic issue. T2-T4 50% 5-year disease-specific survival.
What are the features of advanced stage (T3) High Grade Invasive Urothelial Carcinoma?
Huge nodular tumor fills blader lumen.
Hemorrhagic tan tumor extends full-thickness of bladder wall.
Yellow areas represent ulceration and necrosis.
What can stimulate low grade urothelial neoplasia?
Inflammatory of stone disease, instrumentation artifact.
MALE 40-70yo, HPV 16 and 18.
Poor genital hygiene and high risk HPV infection is associated with what neoplasm in males, especially in Asia, Africa, and South America?
It occurs on the glans of shaft of the penis as an ulcerated infiltrative lesion that may spread to INGUINAL NODES and infrequently to distant sites.
What confers protection (think Jews and Muslims).
Squamous Cell Carcinoma of the PENIS
Circumcision
Most common tumor in men, especially 5W:1B.
testicular germ cell tumors
What carries a 3-5 fold higher risk for germ cell testicular cancer, which arises from intratubular germ cell neoplasia within atrophic tubules.
Cryptorchidism
(1) What type of testicular germ cell tumor remains confined to testis for a long time and spreads mainly to paraaortic nodes. DISTANT SPREAD IS RARE. Peak at 30-40yo
(2) What type of testicular germ cell tumor spread earlier via both lymphatics and blood vessels?
- Seminomas
2. Nonseminomatous tumors
What is elevated when there is a yolk sac tumor component?
AFP
65-75yo males, B>W
Markers: TPRSS2-ETS fusion genes and PCA3
Bone metastases (osteoblastic) most tipify advanced stage.
What is used to monitor progressive disease?
Carcinoma of the Prostate
PSA used in monitoring progressive or recurrent disease.
Gleason scoring of prostate carcinoma.
High grade 8
Low grade 3
Tumor that elaborates HCG.
Tend to have 2 cell population with central cytotrophoblasts and peripheral syncytiotrophoblasts.
THEY DO NOT ELARGE TESTICLES. Tend to be nodular and grow so quickly that they can grow outsidetheir vacular supply and go to the lungs.
Tends to be metastatic upon elaboration.
Choriocarcinoma
Young man, 15-34yoM. The right testicle is significantly enlarged but PAINLESS upon palpation. Biopsies show clear sheets of clear cells with distinct borders and pale blue nuclei. There is sparse, but generalized lymphocytic infliltrate. Focally there appear to be rather poorly formed granulomas. Serum HCG elevated. Most likely?
Germ cell tumor - Classic seminoma
Seminomatous of NSGCT:
Which respond to radiotherapy?
Which do not + more aggressive?
seminomatous
Nonseminomatous
Cystitis cystica and cystitis glandularis - difference. Is there an associated risk with developing adenocarcinoma?
Glandularis - grow down into lamian propria. Cystica - flattened, fluid filled cysts
Squamous cell carcinomas of ___ are associated with inflammation, infection, and urinary schistosomiasis?
bladder
(Bladder cancer = M:F, age, urban v. rural)
3M:1F, 50-80yo, industrialized nations urban>rural
What are the most common non-gonococcal urethritis?
E. coli and enterics, chlamydia (M>F)
HPV 6 and 11 are associated with what type of benign tumor (sexually transmitted epithelial proliferation)?
Condyloma acuminatum
HPV 16 us associated with what malignant tumors (2)(Carcinoma in situ)?
Bowen Disease
Bowenoid papulosis
M or F, age, histology, regression?:
Bowen Disease
Bowenoid papulosis
Bowen Disease - M, 35+yo, NO INVASION of epithelium, SOLITARY plaque over penile shaft
Bowenoid papulosis - young sexually active, MULTIPLE pigmented papular lesions, SPONTANEOUS REGRESSION
What am I?
Slow growth, metastases in INGUINAL and iliac LN, distant metastases uncommon.
Squamous cell carcinoma
CHILD - 1yoM, palpable in inguinal canal,
What age does orchiopexy improve fertility and decrease cancer risk?
(Undescended testis begin decreased germ cell development, thickening, HYALINIZATION of seminiferous tubule basement membrane, and interstitial FIBROSIS?)
Cryptorchidism
2yo
Are inflammatory conditions more common in epididymis or testis?
What disease is the exception?
Epididymis
Syphilis = begins in testis and progresses to epididymis
Causes of nonsepecific epidiymitis and orchitis by age in MALES:
- Childhood epididymis
- Less than 35yo, sexually active
- Older than 35yo
- Childhood epididymis - gram negative rods
- Less than 35yo, sexually active - C. trachomatis, N. gonorrheae
- Older than 35yo - E. coli, Pseudomonas (common UTI agents)
What am I? and What is the suspected cause?
MALE middle aged.
Sudden onset of painless to moderately tender testicular mass. Histo revelas spermatic tubule granulomas.
Granulomatous (autoimmine) orchitis.
Cause of suppurative orchitis
Gonorrhea
Cause of -
acute interstital orchitis 1 week AFTER ONET OF PAROTID INFLAMMATION. Postpubertal males.
Mumps
Where does TB always begin when it causes caseating granulmoas in this area?
epididymis
Casue of gummas and diffuse interstitial inflammation with edema, obliterative endarteritis
Syphilis
Most common benign paratesticular neoplasm
adenomatoid tumor
Most common malignant paratesticular tumor in spermatic cord in (1) children (2) adults
Children - rhabdomyosarcoma
Adults - liposarcoma
What is this? What is it a risk factor for?
A male exposed to pesticide and non-steroidal estrogens in utero. Associated with cryptorchidism, hypospadia, and poor sperm quality.
Testicular dysgenesis syndrome (TDS)
Risk factor for testicular germ cell tumor
When do most germ cell tumors arise (but then remain dormant)?
in utero
What are these associated with? OCT3/4, c-KIT, Placental ALkaline Phosphatase (PLAP) NANOG ch12p duplicates c-KIT activating mutations hCG
Testicular germ cell tumors
65+yo, indolent tumor, tend not to metastacize, NOT ASSOCIATED WITH ITGCN (intratubular germ cell neoplasm)
Spermatocytic seminoma
Peak incidence between 20-30 years, more aggressive than seminomas.
Positive for OCT3/4, PLAP, CD30, cytokeratin.
Negative for c-KIT
embryonal carcinoma
Younger than 3yo, most common testicular neoplasm for this age group.
Good prognosis.
Yolk Sac Tumor (endodermal sinus tumor)
Is choriocarcinoma malignant or benign neoplasm, what is it composed of?
hCG
highly malignant
composed of both cytotrophoblastic and syncytiotrophoblastic elements
Teratomas in children v. post-pubertal men = malignant or benign?
Children - benign
Adults - malignant
Typical (1) lymphatic and (2) hematogenous metastasis of Germ Cell Testicular Tumors.
(1) Lymphatics first involve RETORPERTONEAL PARAORTIC NODES, then spread more widely.
(2) LUNG then liver, brain, bone
What can be used do diagnose and monitor germ cell neoplasms?
AFP, hCG, lactate dehydrogenase.
Occur between 20-60yo.
Produce androgens, estrogens, and or corticosteroids.
Present with TESTICULAR MASS. Possible hormone elaboration with gynecomastia or sexual precocity. Generally benign.
Leydig Cell Tumor
Tumor that only presents as a testicular mass. Generally benign
Sertoli Cell Tumor
Recurrent UTI differentiates ___ from ____.
Chronic bacterial prostatitis (recurrent UTI) v. Chronic abacterial prostatitis (without recurrent UTIs)
What prostatic tumor is:
Males 50+yo (much incidence from 20% to 70% form 50yo to 70yo). B>W>Asians (uncommon)
adenocarcinoma - prostatic carcinoma
What are these risk factors for?
X-linked, CAG repeats, B>W
1st degree relative 2fold increase in chances
BRCA2 mutation = 20fold incrase
ETS and TMPRSS2 and EZH-2 overexpression.
Increased fat consumption
Prostatic intraepithelial neoplasia as a precursor lesion.
adenocarcinoma
Gleason system does what?
stratifies prostate cancers into five grades based on glandular pattern. 1=closest to normal, 5=no glandular differentiation.
T1 or T2 stage of prostate cancer is treated how?
surgery or radiotherapy
Where does hematogenous dissemination of prostatic carcinoma generally occur?
to bone
Is PSA cancer specific?
No, it is organ specific.
Increased age = increased PSA
PSA useful in what setting?
Assessing response to therapy or progression of disease.
