Urogenital pathology Flashcards
What is the definition of nodular hyperplasia of the prostate?
Also known as nodular hyperplasia or benign prostatic hyperplasia (BPH)
Enlargement of the prostate, consists of overgrowth of the epithelium and fibromuscular tissue of the transition zone and peri-urethral area
What are the symptoms of nodular hyperplasia caused by?
Interference with muscular sphincteric function and by obstruction of urine flow through the prostatic urethra
What type of symptoms are caused by nodular hyperplasia/BPH?
Lower urinary tract symptoms
What 6 symptoms make up the lower urinary tract symptoms?
1) Urgency
2) Difficulty in starting urination (hesitation)
3) Diminished stream size and force
4) Increased frequency
5) Incomplete bladder emptying
6) Nocturia
What are the 4 main distinct zones in the prostate?
1) Peripheral zone
2) Central zone
3) Transitional zone
4) Periurethral zone
Where do prostatic carcinomas arise from, which zone is this?
Carcinomas typically arise from the peripheral glands of the organ - peripheral zone
When may a prostatic carcinoma be palpable?
During digital examination of the rectum
Nodular hyperplasia tends to arise from which parts of the prostate gland, which zones does this include?
Nodular hyperplasia arises from more centrally situated glands - transitional zone and central zone
Is nodular hyperplasia or prostatic carcinoma more likely to produce urinary symptoms earlier?
Nodular hyperplasia as the area of enlargement is closer to the urethra
Development of nodular hyperplasia includes which 3 pathological changes, which tend to be more common in men under 70 and which in men over 70?
1) Nodule formation
2) Enlargement of nodules
Above 2 tend to be more common in men over 70
3) Diffuse enlargement of the transition zone and peri-urethral tissue
Above tends to be the case in men under 70
What is believed to be the main component of the hyperplastic process in nodular hyperplasia?
Impaired cell death - reduction in cell death leads to accumulation of senescent cells in the prostate
How does the role of androgens support the theory that nodular hyperplasia is due to impaired cell death?
Androgens (mainly DHT) which are required for the development of BPH, can not only increase cellular proliferation but also inhibit cell death
95% of prostatic carcinomas are what type?
Adenomas
After what age does the incidence of prostatic carcinoma begin to rise rapidly?
40
Is prostatic carcinoma often the cause of death when it is identified at autopsy?
No, the autopsy based prevelance is much higher than the clinical incidence, thus you are more likely to die with prostatic carcinoma than from prostatic carcinoma
In what 3 ways is cancer of the prostate treated?
1) Surgery
2) Radiation therapy
3) Hormonal manipulations
Prognosis is good with this treatment)
What is the most common treatment for clinically localised prostate cancer?
Radical prostatectomy (take the whole prostate out)
What 3 things is the prognosis of prostate cancer following radial prostatectomy affected by?
1) Pathological state
2) Margin status
3) Gleason grade
What is used to treat prostate cancer which is too locally advanced to be treated by surgery?
External beam radiation
What are the 2 alternative treatments for localized prostate cancer is surgery is not an option?
1) External beam radiation
2) brachytherapy - interstitial radiotherapy - plate of radioactive material implanted near the prostate
Name one common type of hormone manipulation for prostate cancer?
Zoldex - anti androgen therapy (helps reduce tumour bulk)
What 5 risk factors are suspected to play a role in the development of prostate cancer?
1) Age
2) Race
3) Family history
4) Hormone levels
5) Environmental influences such as increased consumption of fats
What factor is known to play an important role in the development of prostate cancer and why?
Androgens - the importance of androgens in maintaining the growth and survival of prostate cancer cells can be seen in the therapeutic effect of castration of treatment with anti-androgens which usually induce disease regression
How does family history play a role in risk of developing prostate cancer?
Men with one first degree relative with prostate cancer have twice the risk of developing it
Men with 2 first degree relatives have 5 times the risk of developing it
Men with a strong family history also tend to develop it at an earlier age
A germline mutation in which gene leads to a 20x increased risk of developing prostate cancer?
BRCA2
What is the currently only accepted grading system for prostate cancer?
Gleason scoring system or modified gleason scoring system
How is prostate cancer staged?
TMN staging
1) Clinical appearance of primary tumour T
2) Extent of primary tumour M
3) Extent of involvement of regional lymph nodes N
There is currently no screening program for prostate cancer in the UK, give 5 reasons why?
1) Role of PSA - gives too many false positives and negatives
2) Complications of treatments (impotence, incontinence etc.)
3) Unecessary treatments
4) Limited benefits
5) Reduced mortality vs. risk of overtreatment
Into what 2 broad categories can testicular tumours be divided?
Primary and secondary
What are the 2 main categories of primary testicular cancers, where does each arise from?
1) Germ line tumours - arise from the spermatagonia
2) Non germ cell - arise from supporting cells such as leydig or sertoli cells or supporting tissue
After germ cell and non germ cell, what are the 5 other classifications of testicular tumours?
1) Miscellaneous
2) Haematopoietic tumours
3) Tumours of collecting ducts and rete
4) Tumours of paratesticular structures
5) Mesenchymal tumours of spermatic cord and testicular adnexa
What is a harmatoma?
Tumour found within a tissue containing structures which would not usually be found in that region but are native to that organ
What is a teratoma?
Tumours, whether benign or malignant which shows epithelial/ mesenchymal structures which are not native to that organ
Testicular cancer incidence is higher among which ethnicities?
Men of northern European ancestory and lowest in Asian and African men
Which 9 medical conditions have been associated with the development of testicular germ cell tumours?
1) Prior TGCT in the contralateral tissue
2) Cryptorchidism
3) Impaired spermatogenesis
4) Inguinal hernia
5) Hydrocele
6) Disorders of sexual development
7) Prior testicular biopsy
8) Atopy
9) Testicular atrophy
What are the 2 most testicular germ cell tumours?
1) Seminoma
2) Teratoma
In which group of people is a seminoma most common?
35-45 year old males, rare in children
In which 2 decades of life is a teratoma most common?
first 2 decades
What is the common clinical presentation of seminoma?
Testicular enlargement with or without pain and metastases
Some patients do have no symptoms
Name 3 rare symptoms of seminoma?
1) Gynecomastia
2) Exophthalmos
3) Infertility
Which 2 hormones are sometimes found to be elevated in the serum in seminoma?
1) PLAP
2) hCG (cause of gynecomastia)
What is the clinical presentation of teratoma?
Gradual testicular swelling with or without pain
If develops after puberty then commonly aggressive and metastasises
What is the most important thing about the teratoma in terms of prognosis?
When it develops - regardless of whether mature or immature
If it develops before puberty then its not necessarily malignant
If it develops after puberty then it is always treated as malignant
What is epididymoorchitis?
Can be acute or chronic - inflammation of the epididymis and testis, caused by infection
How does epidiymo-orchitis appear histologically?
Infarcted seminiferous tubules surrounded by purulent exudate containing neutrophils and other inflammatory cells
What is idiopathic granulomatous orchitis?
Inflammatory condition of the testis with the formation of granulomas with unknown cause
In which group does idiopathic granulomatous orchitis tend to develop?
Older adults
What are the 5 components of clinical presentation of idiopathic granulomatous orchitis?
1) Symptoms of UTI
2) Symptoms of trauma
3) Flu-like illness
4) Swollen painful and tender testis
5) Later may have a residual mass which is indistinguishable from a neoplasm
Sarcoidosis of the testis is likely to be accompanied by radiological abnormalities of what organ?
Lungs
How would sarcoidosis of the testis appear histologically?
Non necrotizing granulomas involving testicular parenchyma
Which 2 organisms should be tested for in sarcoidosis of the testis?
1) Fungal organisms
2) Acid fast bacilli - ie. TB
What is sarcoidosis?
disease of unknown cause featuring granulomas in many parts of the body including lymph nodes, liver, lungs, skin and eyes
What is malakoplakia of the testis?
Another inflammatory condition of the testes - results from the bodies inability to deal with infection properly through phagocytosis
Can affect testis and epididymis
How does malakoplakia of the testes appear histiologically?
1) soft yellow, tan or brown nodules replace the normal testicular parenchyma
2) Tubules and interstitium are extensively infiltrated by large histiocytes (macrophages) that have abundant eoisinophilic cytoplasm (full of the stuff they cant properly phagocytose)
What basically is a granuloma?
Histiocytes (macrophage) surrounded by other inflammatory cells like lymphocytes
What percentage of cases of renal TB are accompanied by epididymal infection?
40%
What are the 4 main components of the clinical presentation of tuberculous orchitis?
1) Painless scrotal swelling
2) Unilateral or bilateral mass
3) Infertility
4) Scrotal fistula
What are the histological features of tuberculous orchitis?
- Caseating granulomatous inflammation is prominent
- Fibrous thickening and enlargement of epididymis and adjacent structures
What percentage of patients with cryptorchidism have an empty scrotum?
25%
Where are the testis most frequently found in cryptorchidism?
In the inguinal canal or upper scrotum - arrest within the abdomen is less frequent
On which side is cryptorchidism most common, what percentage of cases are bilateral?
Right is most common
18% are bilateral
What are the 2 main types of cryptorchidism?
Aquired or congenital
What are the 5 causes of acquired cryptorchidism?
1) Postoperative or spontaneous ascent due to various mechanisms
2) Inability of the spermatic blood vessels to grow adequately
3) Anomalous insertion of the guberaculum
4) Failure in reabsorption of the vaginal process
5) Failure in post natal elongation of spermatic cord
What are the 3 main complications of cryptorchidism?
1) testicular atrophy
2) Infertility
3) Carcinoma (TGCTs)
Give 9 causes of primary hypogonadism (testicular failure)?
1) undescended testis
2) Klinefelter syndrome
3) Hemochromatosis
4) Mumps
5) Orchitis
6) trauma
7) CF
8) Testicular torsion
9) Varicocele
Give 4 causes of secondary hypogonadism?
1) Pituitary failure
2) Drugs (glucocorticoids, ketoconazole, chemo and opioids)
3) Obesity
4) Aging
Why does obesity lead to secondary hypogonadism?
Adipose tissue converts testosterone into oestrogen - more adipose tissue = more conversion of testosterone
What is varicocele?
Mass of varicose veins in the spermatic cord
