Flashcards in (33) Urogenital Pathology Deck (76)
What is nodular prostatic hyperplasia also know as?
Benign prostatic hyperplasia (BPH)
What is nodular prostatic hyperplasia/BPH?
Enlargement of the prostate - overgrowth of the epithelium and fibromuscular tissue of the transition zone and periurethral area
What are the lower urinary tract symptoms (LUTS) of BPH?
- difficulty starting urination
- diminished stream size and force
- increased frequency
- incomplete bladder emptying
What causes the LUTS in BPH?
Interference with the muscular sphincteric function and by obstruction of urine flow through the prostatic urethra
The normal prostate contains several distinct regions. Name 4 regions
- central zone
- peripheral zone
- transitional zone
- periurethral zone
Where do most carcinomas of the prostate arise from?
The peripheral glands of the organ - may be palpable on digital examination of rectum
In contrast to carcinomas, where does nodular prostatic hyperplasia arise?
More centrally situated glands - more likely to produce urinary obstruction earlier than carcinoma
Development of nodular hyperplasia includes what 3 pathologic changes?
- nodule formation
- diffuse enlargement of the transition zone and periurethral tissue
- enlargement of nodules
Which feature of nodular hyperplasia is predominant among under 70s
Diffuse enlargement of transition zone and periurethral tissue
Which feature of nodular hyperplasia is predominant among older men?
Nodule formation and enlargement of nodules
Describe 2 histologically different types of nodules you can get in nodular hyperplasia
- pure stromal nodule (uniform and circumscribed with stromal fibroblasts and scattered lymphocytes)
- mixed epithelial-stromal nodule
What is the aetiology behind BPH?
- impaired cell death = accumulation of senescent cells in prostate
- androgens (mainly DHT) involved in BPH can increase cellular proliferation and inhibit cell death
95% of prostatic malignancies are what type?
At what age does the incidence of prostatic adenocarcinoma rise quickly?
What is the different between autopsy-based prevalence and clinical incidence of prostatic adenocarcinoma?
Autopsy studies of prostates from men without clinical evidence of cancer have sown a very high level of latent cancer
autopsy > clinical
The incidence of prostatic adenocarcinoma is much higher in men of what ancestry?
African (100 per 100,000)
compared to European (70.1 per 100,000)
How is cancer of the prostate treated?
- hormonal manipulations
How long can those receiving treatment for prostate cancer expect to live?
More than 90% of patients who receive such therapy can expect to live for 15 years
What is the most common treatment for clinically localised prostate cancer?
What is the prognosis following radical prostatectomy based on?
- pathologic stage
- margin status
- Gleason grade
What are the alternative treatments for localised prostate cancer? (other than radical prostatectomy)
- external-beam radiation therapy
- interstitial radiation therapy (brachytherapy)
External-beam radiation therapy is also used to treat prostate cancer that is what?
Too locally advanced to be cured by surgery
What are the risk factors involved in carcinoma of the prostate?
- family history
- hormone levels (androgens)
- environmental influence eg. increased consumption of fats
Which hormones play a big part in prostate cancer?
What role do androgens play in prostate cancer?
Maintain growth and survival of prostate cancer cells
How can the effects of androgens in prostate cancer be seen?
In the therapeutic effect of castration or treatment with anti-androgens, which usually induce disease regression
How does family history (inherited polymorphisms) affect risk of prostate cancer?
- 1 first-degree relative with prostate cancer = 2x the risk
- 2 first-degree relatives = 5x the risk
Strong family history also = develop disease at earlier age
Men with germline mutations of which gene have a 20-fold increase in risk of prostate cancer?
tumour suppressor BRCA2 gener
What is currently the only accepted grading system for prostate carcinoma?
Gleason scoring system (recommended by WHO)
What are the 5 stages of prostate cancer according to Gleason scoring system?
1. Small, uniform glands. Well differentiated
2. More stroma between glands
3. Distinctly infiltrative margins. Moderately differentiated
4. Irregular masses of neoplastic cells
5. Only occasional gland formation. Poorly differentiated/anaplastic
Why might screening for prostate cancer not be beneficial?
- role of PSA - false positives and false negatives
- complications of treatment (impotence, incontinence etc)
- unnecessary treatments
- limited benefits
- consideration in high risk groups
- reduced mortality vs. risks of over treatment
Who is the incidence of testicular tumours highest amongst globally?
Among men of northern European ancestry
Lowest among men of Asian and African descent
What pre-existing medical conditions have been associated with development of testicular germ cell tumours (TGCT)?
- prior TGCT in the contralateral testicle
- impaired spermatogenesis
- inguinal hernia
- disorders of sex development
- prior testicular biopsy
- testicular atrophy
What is cryptorchidism?
The absence of one or both testes from the scrotum. It is the most common birth defect of the male genitalia
Name 2 types of testicular cancer
At what age is seminoma most common?
- uncommon in men >50
- rare in children
At what age is teratoma most common?
In the 1st and 2nd decades of life
Describe the typical clinical presentation of seminoma
- testicular enlargement
- with or without pain
- some patients have no symptoms
- rare symtoms = gynaecomastia, exophthalmos, infertility
What is the typical clinical presentation of teratoma?
- gradual testicular swelling
- with or without pain
Can mature teratoma be benign?
Mature teratoma is almost always benign in prepubertal patients
However, it can pursue an aggressive clinical course after puberty i.e. metastasis
Immature teratoma is a common component of what?
NSGCTs (non-seminomatous germ cell tumours)
Teratoma in its pure form is very rare
What are the tumour markers in seminoma?
- elevated serum PLAP (40%)
- elevated hCG (10%) - cause of gynaecomastia
What are the tumour markers in teratoma?
Purely teratomatous tissues do not secrete tumour markers
Describe the macroscopic appearance of seminoma
- coarsely lobulated
Describe the microscopic appearance of teratoma
- monotonous polygonal cells with mostly clear cytoplasm and central nuclei divided into lobules by thin bands of fibrovascular stroma
Describe the microscopic appearance of teratoma
- mixture of ectoderm, endoderm, and mesoderm
Name 7 inflammatory conditions of the testis
- acute and chronic epididymoorchitis
- idiopathic granulomatous orchitis
- sarcoidosis of the testis
- malakoplakia of testis
- myofibroblastic pseudo tumour of testis
- sperm granuloma
- tuberculous orchitis
What do you seen on histology in acute/chronic epididymoorchitis?
- ghostly outlines of infarcted seminiferous tubules
- surrounded by purulent exudate containing neutrophils and other inflammatory cells
Idiopathic granulomatous orchitis typically presents in older adults, with associated symptoms of what?
- flu-like illness
What happens to the testis in idiopathic granulomatous orchitis?
Becomes swollen, painful and tender initially but later may have a residual mass indistinguishable from a neoplasm, prompting orchiectomy
What causes the granulomatous appearance in idiopathic granulomatous orchitis?
No granulomas present but the interstitial and intratubular aggregation of epithelioid histiocytes, lymphocytes and plasma cells imparts a granulomatous appearance
Sarcoidosis can affect the testis. What may it mimic?
Malignancy, particularly if accompanied by radiologic pulmonary abnormalities
What may you see on histology in sarcoidosis of the testis?
- non-nectrotising granulomas involving testicular parenchyma
- special stains for fungal organisms and acid-fast bacilli are negative
What may malakoplakia affect?
Only the testis, or less commonly, both the testis and the epididymis
What does malakoplakia of the testis result in the formation of?
Soft yellow, tan, or brown nodules that replace normal testicular parenchyma
What is seen on histology in malakoplakia of the testis?
The tubules and interstitium are extensively infiltrated by large histiocytes that have abundant eosinophilic granular cytoplasm
What are the histiocytes called in malakoplakia?
von Hansemann histiocytes
What is myofibroblastic pseudotumour of testis?
An atypical inflammatory and myofibroblastic reaction with fasciitis-like large cells
Features of malignancy are absent
A benign reactive and proliferative process of uncertain aetiology
What is a sperm granuloma?
An exuberant foreign body giant cell reaction to extravasated sperm
How common is sperm granuloma?
Occurs in up to 42% of patients after vasectomy
2.5% of routine autopsies
What are signs and symptoms of sperm granuloma?
May have no symptoms
Often present with history of pain and swelling of the upper pole of the epididymis, spermatic cord, and rarely, the testis
Others have a history of trauma, epididymiditis and orchitis
Where is the reservoir for tuberculous involvement in the male genital tract?
With secondary testicular involvement and other local sites of involvement in about 80% of cases
How many cases of renal tuberculosis are accompanied by epididymis infection?
How do patients usually present with tuberculous orchitis?
With painless scrotal swelling
Other signs include unilateral or bilateral mass, infertility, and scrotal fistula
What kind of inflammation do you get in tuberculous orchitis?
Caseating granulomatous inflammation is prominent, with fibrous thickening and enlargement of the epididymis and adjacent structures
What makes up 25% of cases of empty scrotum?
In, cryptorchidism, where are the testes most frequently found?
In the inguinal canal or upper scrotum; arrest within the abdomen is less frequent
On which side is cryptorchidism more common?
Slightly more common on the right; 18% are bilateral
What is the causes of congenital cryptorchidism?
Anomalies in anatomic development or hormonal mechanisms involved in testicular descent
What are the causes of acquired cryptorchidism?
Postoperative or spontaneous ascent
- inability of spermatic vessels to grow adequately
- anomalous insertion of the gubernaculum
- failure in reabsorption of the vaginal process
- failure in postnatal elongation of the spermatic cord
What are the potential complications associated with cryptorchidism?
- testicular atrophy
- carcinoma (TGCTs)
What is hypogonadism?
Reduction or absence of hormone secretion or other physiological activity of the gonads (testes or ovaries).
What are the primary causes of hypogonadism/testicular failure?
- undescended testis
- Klinefelter syndrome
- testicular torsion
What are the secondary cause of hypogonadism/testicular failure?
- pituitary failure
- drugs (glucocorticoids, ketoconazole, chemotherapy, opioids)
What is Klinefelter syndrome?
Set of symptoms that arise from 2 or more X chromosomes in males