Chapter 21: Penis and Prostate Flashcards
(106 cards)
1
Q
_________ are the most important penile lesions and may be associated with ______.
A
- Squamous cell carcinoma
- HPV and poor genital hygeine.
2
Q
- Squamous cell carcinoma of the penis occurs most often in _________ males.
- Occurs on the ________ on the penis, as an __________.
- Does it spread?
A
- Uncircumcized
- Glans or shaft, as an ulcerative infiltrative lesion.
- Can spread to inguinal nodes or infrequently to distal sites.
3
Q
Malformation of the urethral groove and urethral canal of the male penis may produce what congenital anomalies?
A
- Hypospadias = urethral opening on ventral surface (more common)
- Epispadias = urethral opening on dorsal surface
4
Q
A
5
Q
Complications with Hypospadias or Epispadias of the penis include:
A
- Urinary tract obstruction and ↑ risk of ascending infection
- Sterility
6
Q
Phimosis (cannot pull foreskin back) has what complications?
A
1. Hard to clean
2. Infection and cancer
7
Q
What is Condyloma Acuminatum and is caused by what?
A
Benign sexually transmitted wart caused by HPV (type 6; or 11)
8
Q
What is the cellular manifestation of HPV?
A
- Koliocytosis: Cytoplasmic vacuolization of squamous cells
9
Q
Squamous cell carcinoma of the penis is most common in whom?
A
People who are not circumsized: jews and muslims
10
Q
Which types of HPV are strongly associated with SCC of the penis?
A
- HPV types 16 and 18
11
Q
With the exception of the ___________, congenital anomalies of the testes are RARE and include _______.
A
Cryptochidism (undescended testes)
Absence of one or both testes or fusion
12
Q
What is cryptochidism?
Cryptochidism is associated with _________.
A
- Complete or partial failure of the intra-abdominal testes to descend into the scrotal sac
- Testicular dysfunction & increased risk of testicular cancer.
13
Q
Where is the most common site for the arrest of the testes during descent?
A
Inguinal canal
14
Q
What are the histological changes that occur to the tests in Cryptorchidism?
A
- Marked hyalinization + thickening of the BM of spermatic tubules
- Progressive tubular atrophy: spermatic tubules become hyalinzed CT
15
Q
Cryptochidism is associaged with ___% of 1 YO and may be accompanied by what?
A
- 1%
- Other malformations of the GU tract, such as hypospadias.
16
Q
During the histological changes occuring in Cryptochidism _______ cells are spared and are most prominent.
A
Leydig cells
17
Q
Bilateral, or in some cases, even unilateral cryptochidism is associated with _________
A
Tubular atrophy and sterility
18
Q
Cryptorchid testis has a 3-5 fold risk higher of _____, which arises from _____
A
- Testicular cancer, even in the NL undescended teste
- Foci of intratubular germ cell neoplasia in the atrophic tubules
19
Q
Treatment for cryptorchid testicle?
Reduces risk of?
Should be done when?
A
- Orchiopexy (placement in the sac) –> reduces risk of sterility and cancer
- Between 6-12 mo., before histologic deterioration begins
20
Q
Inflammation is distinctly more common where (testes/epididymis)?
A
Epididymis
21
Q
Which 2 infections almost invariably arise in the epididymis first before spread to testis?
A
1) Gonorrhea
2) Tuberculosis
22
Q
Which infection is disinct in the fact that it arises in the testis first and in many cases spares the epididymis?
A
Syphilis
23
Q
Although not as common in children, the most common causes of Epididymitis are what?
A
- Congenital genitourinary abnormality
- Infection w/ gram-negative rods
24
Q
What is the most common route of spread of a neglected gonococcal infection starting at the posterior urethra?
A
Posterior urethra –> prostate –> seminal vesicles –> epididymis
25
Severe cases of gonococcal infection cause what in the epididymis?
**Epididymal abscesses** ---\> extensive **destruction** and **scarring**
26
In contrast to neonatal testicular torsion, adult torsion results from what bilateral anatomic defect?
**Bell-clapper abnormality** --\> **↑ mobility of testes**
27
Testicular neoplasms can be divided into 2 categories: ______ and \_\_\_
* 1. **Germ cell tumors** (seminomas or nonseminomatous)
* **\*95%**
* 2. **Sex cord stromal tumors.**
28
**Men 15-34,** what is the most common tumor?
**Testicular germ cell tumor.**
Most common in **WHITES**.
29
Describe MOST germ cell tumors in contrast to sex-cord, stromal tumors.
* **Germ cell tumors:** aggressive, rapidly spread but most can be cured.
* **Sex-cord stromal tumors:** generally benign.
30
**Germ cell tumors** can be seminomas or non-seminomas.
What are the difference between the two?
* **Seminomas tumors** are made up of cells that resemeble _primordial germ cells_ or _early gonocytes._
* **Nonseminantous tumors** are made up of undifferentied cells that resemble embroyonci stem cells, but malignant can differentiate along other lineages.
31
What are the two 2 types of **seminomatous tumors?**
1. **Seminoma**
2. **Spermatocytic seminoma**
32
What are the 3 **nonseminomatous tumors?**
* **1. Embryonal carcinoma**
* **2. Yolk sac tumor**
* **3. Choriocarcinomas**
33
What are the **2 sex cord stromal tumors?**
**1. Leydig cell tumor**
**2. Sertoli cell tumor**
34
Germ cell tumors can be seminomas or non-seminomas.
## Footnote
**How do they spread?**
* **Seminomas** remain in the testis for a long time and spread to via **LN** to [para-aortic LNs]. It is rare to spread further.
* Spread by blood in advanced courses
* **Nonseminomas** rumors spread **earlier** by and use **hematongeous route more (and LN)**
35
\_\_\_\_\_\_\_ are the most common cause of **painless testicular enlargement.**
Testicular tumors.
36
**Testicular tumors** occur with increased frequency in \_\_\_\_\_\_\_\_\_\_\_\_.
* **Undescended testis.**
* **Testicular dysgenesis.**
37
**Germ cell tumors** can have which two histological patterns?
Which is most common
**1. Single histologic pattern (\*)**
**2. Mixed pattern**
38
What are the most common "pure" histologic patterns of germ cell tumors?
**1. Seminoma**
**2. Embryonal carcinoma**
**3. Yolk sac tumors**
**4. Choriocarcinomas**
**5. Teratoma**
39
**Mixed** germ cell tumors contain more than 1 element and are more commonly:
**1. Embryonal carcinoma**
**2. Teratoma**
**3. Yolk sac tumor**
40
Most **testicular germ cell tumor**s arise from which precursor lesion?
Exceptions?
**- Intratubular germ cell neoplasia(ITGCN)**
- Exceptions =
1. pediatric yolk sac tumors and terotoma
2. adult spermatocytic seminomas
41
What are the genetic factors (i.e., **familial** and **genes**) associated with development of testicular germ cell tumors?
- **Strong** familial predisposition --\> 4x ↑ in fathers/sons of affected pts and 8-10x ↑ risk in brothers
- Genes encoding the ligand for RTK - **KIT** and **BAK**
42
**Testicular germ cell tumors** are associated with a spectrum of disorders collectively known as what?
Includes which disorders and which is most important?
**- Testicular dysgenesis syndrome (TDS)**
* - Cryptorchidism = most important
* - Hypospadias
* - Poor sperm quality
43
How does the precursor lesion (**ITGCN**) progress?
* Arises in **utero**
* **Stays dormant until puberty**, where it can become seminomatous or nonseminatous.
44
What kind of cells make up **ITGCN**?
* **Atypical primordial cells germ cells** that are 2x the size of NL germ cells with large nuclei and clear cytoplasms.
* -Retain expression of **OTC3/4** and **NANOG** TF.
* -Reduplication of chromosome 12p, which is also found in all invasive germ cel ltumors.
45
**Seminomas** contain which genetic mutations (i.e., genes and chromosome)?
**- Isochromosome 12p (i12p)**
- Express **OCT3/4** and **NANOG**
- 25% have **KIT** activating mutations
46
How are the **spermatic seminomas** different from the classic seminoma as far as onset, growth, and prognosis go?
- Rare, **slow-growing** germ cell tumor
- Predominantly affect **older men (\>65 yo)**
- Prognosis is **excellent**
47
**Seminomas** alter the testis how?
-**Enlarge testis,** homogenous grey, lobulated surface that does **not** have hemorrage or necrosis.
48
**15%** of **seminomas** contain **syncytiotrophoblasts**, why is this relevant?
**Produce ↑ HCG levels**
49
In contrast to TB, **seminomas** may be accompanied by \_\_\_\_\_\_
**Poorly defined granulomas reactions**
50
Immunohistochemical stains of **seminoma** cells will be positive for what markers?
**- KIT**
**- OCT4**
- Placental alkaline phosphatase (**PLAP**)
51
**Embryonal carcinomas** of the testis typically occur in ____ YO.
Differ from seminomas how?
**- 20-30 YO**
**- MORE aggressive**
52
What is the gross morphology of **embryonal carcinoma** of the testis?
Extension through what?
- **Smaller** than seminomas
- **Extend** **thru** **tunica albuginea into epididymis or cor**d (unlike seminomas)
53
Immunohistochemical staining of **embryonal carcinoma** is positive for what markers, differs from seminomas how?
**- (+) OCT 3/4**
**- (+) PLAP**
- (+) for **cytokeratin** and **CD30** (unlike seminomas)
- **(-) for KIT** (seminomas are +)
54
**Yolk sac tumors** are also called what?
Why do researchers find it so interesting?
* **Endodermal sinus tumors**
* Most common testicular tumors in **infants** and children **up to 3,** with good prognosis.
55
Immunocytochemical staining of testicular **Yolk Sac Tumors** is positive for what?
* - **α-fetoprotein (AFP**) = characterisitc\*\*\*\*\*\*
* **- α1-antitrypsin**
56
**Schiller-Duval bodies** consisting of mesodermal core w/ central capillary + visceral and parietal layer of cells resembling primitive glomeruli are **found in what type of testicular germ cell tumor?**
**Yolk sac tumor**
57
**Choroicarinomas** are a HIGHLY _______ type of testicular tumor.
**MALIGNANT**
58
Which germ cell tumor often produces **no testicular enlargement** and are detected only as a **small palpable nodule w/ hemorrhage** and **necrosis** being extemely common?
**Choriocarcinomas,** but may outgrow BS and metastsize, even though primary site is hard to find.
59
Histologically, **choriocarcinomas** contain what 2 cells types?
1. **Syncytiotrophoblasts** = large,
* Many nuclei
* Cytoplasm has a bunch of abundant eosinophillic vacoules that contain hCG
2. **Cytotrophoblasts** = regular and polygonal, clear cytoplasm, grow in cords or masses w/ single uniform nucleus
60
Which type of tumor may be a mix of neural tissue, muscle bundles, islands of cartilage, clusters of squamous epi, thyroid gland-like structures, bronchial epi, and bits of intestinal wall/brain substance?
Who is it more comon in?
* **Teratoma**
* Pure forms are common in **infants andkids**
* In adults: pure forms are rare but can occur with OTHER germ cell tumors in 45% of cases.
61
How do **mature, differentiated teratomas** found in children differ from post-pubertal males
* If found in child: usually **benign**
* In post-pubertal male: all are **malignant,** _no matter if mature or immature._
* So **not important** to determine maturity in adults .
62
What is the clinical importance of recognizing a **non-germ cell malignancy** arising within a teratoma?
Secondary tumors are **chemoresistant**; thus **only hope for cure = resection**
63
What is the standard treatment for a **solid testicular mass?**
**Radical orchiectomy**
64
Where do **testicular tumors** spread first via **lymphatics**?
- Retroperitoneal **para-aortic nodes** = 1st
- **Mediastinal** and **supraclavicular** nodes = 2nd
65
Hematogenous spread of testicular tumors is mainly to where?
- Mainly to the **lungs**
66
How does the behavior/spread of **Seminoma GCT's** differ from **NSGCT's**?
Each typically presents clinically in which stage?
- **Seminomas** tend to stay **localized** to testis, **present clinically in stage 1**
- **NSGCT's** tend to **spread** to **distant** sites and present in stages **2 and 3**
67
What is the **most aggressive NSGCT** and via which route and to where does it rapidly spread?
**- Pure choriocarcinoma**
- Spreads **rapidly** and predominantly via **blood** to the lungs and liver
68
What is useful to assess the **mass/burdern** of a **germ cell tumor?**
High **lactate DH**
69
Which biomarker is elevated with a **Yolk Sac Tumor?**
Which biomarker is elevated with a **Choriocarcinoma?**
1. **AFP**
2. **HCG**
70
What is the prognosis of **Seminomas** and **NSGCT's**?
- **Seminomas** = **radiosensitive** = remains localized = best prognosis
- **NSGCT's** = can be cured w/ **aggressive chem**
**\*Pure choriocarcinoma** has **poor prognosis,** but better if minor component of mixed GCT.
71
Which testicular tumor elaborates **androgens** and in some cased both androgens and **estrogen**, and even **corticosteroids**?
**Leydig Cell Tumors**
72
How may a pt with Leydig Cell Tumor present clinically?
Most common manifestation in children?
* **- Testicular swelling**
* - **Gynecomastia** may be 1st sx in some cases
* - In children, manifested primarily as **sexual precocity** (advanced for age)
73
What is characteristic of cytoplasm of **Leydig cell tumors**
**Crystalloids of Reinke** rods
74
What is the most common form of testicular neoplasm in men \>60 yo?
**Testicular lymphoma (non-Hodgkin lymphoma)**
75
What are the 3 most common testicular lymphomas in decreasing order of frequency?
**Diffuse large B-cell lymphoma** \> Burkitt lymphoma \> EBV-(+) extranodal NK/T cell lymphoma
76
**Testicular lymphomas** have a higher propensity for involvement of what system than do similar tumors arising at other sites?
CNS
77
In which anatomic zone of the prostate do most **hyperplasias** arise?
Where do most **carcinomas** arise?
- Hyperplasias: **transitional zone (TZ)**
- Carcinomas: **peripheral zone (PZ**)
78
**Bacterial prostatis** can be acute or chronic.
What is the most common bacteria?
* **1. E.coli**
* **2. Gram (-) rods**
* 3. Enterococcus spp.
* 4. Staphylococci
79
* How does **acute bacterial prostatitis** present clinically (sx's)?
* Diagnosed how?
- **Fever** + **chills** + **dysuria**
- Dx: urine culture
80
Chronic bacterial prostatitis may present with what sx's?
Pts often have a hx of what?
**- Low back pain+ Dysuria + S**uprapubic/perineal discomfort
- May also be **asymptomatic**
- Often have a **hx of recurrent UTI's** (cystitis, urethritis)
81
Diagnosis of **chronic bacterial prostatitis** is made how?
**- (+) leukocytosis in prostatic secretions**
- **(+) bacterial cultures**
82
What is the most common type of prostatitis?
**Chronic abacterial prostatitis**
83
How does c**hronic abacterial prostatitis** differ from chronic bacterial prostatitis based off of history and cultures?
**No hx** of recurrent UTI's
- **(+) leukocytosis o**f prostatic secretions w/ **negative** bacterial cultures
84
What is the most common cause of **Granulomatous Prostatitis** seen in the US?
**Fungal granulomatous prostatitis** seen in whom?
- **Instillation of BCG (attenuated mycobacterial strain)** for tx of superficial bladder cancer
- Fungal causes is typically only seen in **immunocompromised** pts
85
Which method of diagnosis for men w/ sx's of **acute or chronic _bacterial_ prostatitis** is contraindicated as it may lead to sepsis?
**Biopsy**
86
**BPH** is characterized by proliferation of \_\_\_\_\_\_\_\_.
What hormone is responsible?
* **Benign stromal and glandular elements**
* **DHT**
*
87
**BPH** originates almost exclusively where?
**Inner periurethral (transition zone),** making nodules that compress the prostatic urethra.
88
Nodules in BPH exhibit what?
Hyperplastic glands are lined by what?
* Diff amounts of **stroma and glands.**
* 2 cell layers: **inner columnar laye**r and **outer layer** made up of **flattened basal cells**
89
What is the major clinical problem in those with BPH?
**urinary obstruction**
90
is BPH pre-neoplastic?
**no**
91
The inability to empty the bladder in BPH causes an increased risk for?
**Infections**
92
Can diagnosis of BPH be made with a needle biopsy?
**No**, biopsies are too small and do not usually sample the TZ
93
What is the most common form of cancer in men?
**Adenocarcinoma** of the **Prostate**
94
Cancer of the prostate is typically a disease in men of what age?
Which race has a high incidence of prostate cancer and which race has a low incidence?
**Older than 50 yo** --\> **65-75 yo**
**Most** frequently in **blacks**
- **Uncommon** in **Asians**
95
What are the most commonly acquired genetic lesions in **prostatic carcinomas?**
* **1. TPRSS2-ETS fusion gene**
* 2. Mutations or deletions that activate **PI3K/AKT signaling**
96
Prostate cancer arises most commonly where?
**Outer peripheral gland** and can be palpated by rectal exam
97
Where does lymphatic spread and hematogenous spread of prostate cancer go?
- Lymphatic ---\> Obturator nodes and then para-aortic
- Hematogenous --\> Axial skeleton
98
What are the 2 best prognostic predictors for **prostate cancer?**
**Grade** via the Gleason system; correalted with **stage** and **prognosis**.
99
Which factors indicate that **prostatic intraepithelial neoplasia (PIN)** is a precursor lesion for prostate cancer?
Is PIN considered CIS?
- **Both** PIN and cancer **predominate in peripheral zon**e and are uncommon in other zones
- Prostate cancers have **high frequency** of PIN
- Share many of the molecular changes
\*NOT considered CIS!\*
100
What maintains growth and survival aof prostate cells?
What may set te stage for development of prostate cancer?
**Androgens**
**Inflammation**
101
Which histological finding on biopsy is specific for **prostate cancer?**
**Perineural invasion**
102
* **DRE** and detection of **PSA level**s are useful in detection of prostate cancer, but lack what 2 things?
**Sensitivity** and **specificity**
103
The real value of PSA for prostate cancer comes in its utility for assessing what?
**PSA** = best for **monitoring** response to **therapy**
104
Which 2 additional genetic markers have **increased sensitivity and specificity** of detecting prostate cancer compared to just PSA alone?
Screen urine for:
* 1) **PCA3** = noncoding RNA overexpressed in 95% of pts
* 2) **TMPRSS2-ERG fusion DNA**
105
What is the most common treatment for clinically localized prostate cancer?
**Radical prostatectomy**
106
What typifies **advanced** prostate cancer?
**Bony metases**, often **osteoblastic**.
