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Flashcards in Pathology - Handorf Deck (44):
1

Congenital Anomalies of the Penis

1. Penile agensis
2. Duplication - 2 urethral orifices come out
3 Epispadias
4. Hypospadias

2

Penile Epispadias/Hypospadias

-abnormal openings of the urethra on the dorsal or ventral penis from malformations of the urethral canal, can be associated with undescended testes
-Hypospadias is more common (1 in 300 births)
-Clinical: urethral obstruction or failure of normal ejaculatory function

3

Inflammation of Penis

-most commonly related to phimosis (inability to easily retract foreskin) or venereal disease
-in circumcised/uncircumcised adults, balanoposthitis (glans inflamation = balanitis, foreskin = posthitis) is related to poor hygiene

4

Circumcision

AAP says there is no absolute medical indication for circumcision
-60-75% of males in US are circumcised
-decrease in HIV transmission from females to circumcised males of 57%

5

Penis - Condyloma acuminata

-"warty," cauliflower like growths which occur primarily in the anogenital region
-venerallly transmitted and most often caused by HPV types 6 or 11
-not premalignat, but tend to recur despite vigorous therapy
-micro: exuberant exophytic (growing outward) growth pattern of the papillary lesion is seen, few mitosis, no necrosis

6

Penis - Carcinoma in situ

"Bowen disease" - on skin
"erythroplasia or Queyrat" - on glans
-80% related to HPV (type 16)
-10% progress to squamous cell carcinoma if untreated
-red, slightly raised, rough, painless, nonulcerated lesions

7

Carcinoma in situ: Histology

-hyperkeratosis with disordered maturation and elongation of rete ridges and thickening of epidermis

8

Penis - Squamous Carcinoma

-related to HPV 50% of the time (type 16 & 18)
-other risk factors: poor hygiene & smoking

9

Testis - Cryptorchidism

undescended testes (from abdomen to scrotum)
-1% or one year old boys
-75% unilateral/25% bilateral
-may be related to other anomalies (hypospadias)
Transabdominal phase
-mullerian inhibiting substance
-takes testis to brim of pelvis
-failure here in 5-10% of cases
Inguinoscrotal phase
-androgen induced release of calcitonin-gene related peptide
-takes testis from brim of pelvis into sscrotum
-failure here is 90-95% of cases

10

Cryptochidism Complications

-inguinal testis susceptible to trauma
-Sterility
-decreased spermatogenesis in BOTH testes in unilateral cryptorchidism
-systemic mechanism, poorly understood (not just "overheated testis")
-orchiopexy before age 2 improves (does not guarantee) chances of normal spermatogenesis
-Neoplasms
-5-10 fold increase in risk of malignant neoplasm in cryptorchid testis
-some increased risk in contra lateral normally descended testis
-both risks are reduced but not totally eliminated by orchiopexy

11

Klinefelter Syndrome

-abnormal # or X chromosomes (XXY), primary gonadal insufficiency
-Frequency: 1/1000-4000 live male births; 1/100 patients in mental institutions and 3.4/100 infertile men

12

Clinical Appearance of Klinefelter Syndrome

-eunuchoid appearance with increased stature and small to normal-sized, well developed testes (firm)
-incomplete virilization
-gyneocomastia
-mental retardation, speech difficulties

-increased incidence of extragonadal germ cell tumors (mediastinum>pineal gland, CNS, retroperitoneum) as well as hypopituitarism

13

Histology of Klinefelter Syndrome

-small hyalinized seminiferous tubules
-pseudoadenomatous clusters of Leydig cells (appear to increase in number though b/c of decreased testicular volume)

14

Testis - Mumps orchitis

-focal atrophy of testicular tubules (most common cause)
-post puberty complicated by architis on fourth to third of cases
-unilateral & patchy so that sterility following infection is uncommon
-echovirus, lymphocytic choriomeningitis virus, influenza virus, Coxsckie virus, arboviruses

15

Epididymitis

-more frequent cause for scrotal pain and swelling in adult males and is most likely to be the result of a sexually transmissible diseases such as chlamydia trachomatis or Neisseria gonorrheae in younger males or gram negative bacteria from urinary tract infection of older males
-disseminated tuberculosis may occassionally involved the epididymis

16

Testis - Syphilis

Tertiary: involves testis first, then epididymis
-micrograph shows a silver stain of testis with numerous spirochetes

17

Testis - Gonorrhea

-spreads retrograde from the urethra to the prostate, seminal vesicles, epididymis, and prostate

18

Testis - Tuberculosis

-spreads retrograde from the prostate to the epididymis, then to the testis
-granuloma

19

Testis - Granulomatous Orchitis

-uncommon inflammatory testicular lesion that follows a gram negative urinary tract infection in the majority of cases
-most prevalent in 5th/6th decades
-testicular involvement is usually diffuse (may be localized nodular lesion & may simulate neoplasm)
-epididymis & spermatic cord may be involved

20

Inflammatory Process of Granulamatous Orchitis

-predominately intratubular with the cellular infiltrate containing a majority of histiocytes admixed with lymphocytes and plasma cells
-giant cells
-predominance of histiocytes imparts a granulomatous appearance but distinct granulomas are not formed
-non-specific chronic interstitial inflammation
-intratubular localization of inflammation in granulamatous orchitis aids in its distinction from infectious granulomas and sarcoidosis (interstitial)
-necrosis is NOT seen

21

Autoimmune orchitis

-rapid onset testicular enlargement in middle aged men
-may be associated with febrile illness
-granulomas without organisms

22

Testis - Regression

V - Vascular conditions bring to mind varicoceles, which cause atrophy on the side of the dilated veins
I - Inflammation recalls the atrophy following mumps orchitis and other causes of epidydimoorchitis
N - Neoplasms sugest the atrophy that occurs in the estrogen treatment of prostatic carcinoma
D - Degenerative suggests the atrophy resulting from aging
I - Intoxication should remind one of the atrophy resulting from chronic alcholism, Laennec cirrhosis, and hemochromatosis (x-ray exposure may also produce atrophy)
C - Congenital recalls undescended testes and torsion
A - Autoimmune and allergic suggest nothing
T - Trauma reminds one of the atrophy following vasectomy & accidental ligation of the blood supply during hernia repair
E - Endocrine suggests the atrophy of hypopituitarism, Klinefelter syndrome, & other eunuchoidal states

23

Testis - Torsion

-twisting of the spermatic cord, leading to ischemia and venous stasis
-may be related to trauma, but frequently the inciting event is obscure
-predisposing anatomic abnormality which allows the testis excess mobility within the scrotum (bell clapper phenomenon), may be bilateral, which is why there is a risk of contra lateral torsion in a patient who has torsion
-true urologic emergency, since surgery within 4-6 hrs may save testis, after that hemorrhagic infarction with obliteration of the testis is inevitable if reduction of torsion is too late

24

Testicular Neoplasms: Germ Cell Tumors

1. Seminomas
2. Embryonal Carcinoma
3. Yolk sac tumor
4. Choriocarcinoma
5. Teratoma

25

Seminomas

-50% of germ cell tumors
-most common germ cell tumor to occur in "pure" form
-grossly homogeneous, not typically necrotic or hemorrhagic
-microscopically has characteristic distinct cell membrane and clear cytoplasm
-15% produce human chorionic gonadotropin (HCG)

26

Embryonal Carcinoma

-occasionally a pure tumor, but much more commonly a component of a mixed germ cell tumor
-more aggressive than seminomas
-grossly more likely to be hemorrhagic or necrotic
-microscopically shows sheets, alveoli, tubules or papillary formations - generally anaplastic looking cells

27

Yolk Sac Tumor

-endodermal sinus tumor
-almost exclusively a tumor of infants and children up to 3 years of age
-in adults, more commonly seen mixed with other germ cell tumor patterns
-main distinguishing features is production of alpha fetoprotein (AFP) which serves as a serum marker
-immunohistochemical stain is positive for alpha fetoprotein

28

Choriocarcinoma

-only 1% of germ cell tumors are pure chorio, but chorio is commonly represented in mixed germ cell tumors
-highly aggressive
-mimics the histology of normal placenta (syncitiotropoblasta & cytotrophoblasts) & produces HCG (tumor marker)
-grossly & microscopically very vascular, metastases bleed easily

29

Teratoma

-more common in children, rare in adulats, commonly mixed with other germ cell type tumors in adults
-mature types (with adult tissues) and immature types with (fetal tissues) exist
-tissue represents more than one germ layer
-may be grossly quite large with variegated color and texture (cysts are common)

30

Prostate

-retroperitoneal gland which encircles the neck of the bladder
-composed of glandular cells within a supporting stroma; the glands produce secretions which constitute seminal fluid
-the gland is divided into peripheral, central, transitional, and periurethral zones (hyperplasia arises in the transitional and periurethral zones whereas carcinoma arises in the peripheral zone)

31

Prostate: Microscope

Prostate glands have two types of epithelium, luminal and basal; these may be distinguished on H and E stain, though they are not always obvious. The luminal cells are responsible for producing seminal fluid and express prostate specific antigen, a serine protease which liquefies the seminal fluid coagulum. An immunoperoxidase stain for PSA (right upper panel) decorates the luminal epithelium. The basal cells do not produce PSA

32

Prostate Inflammation

-acute & chronic bacterial prostatitis and chronic abacterial prostatitis are general categories
-also gonorrhea can cause it

33

Acute Bacterial prostate inflammation

-usually urinary tract pathogens such as E. coli (other gram negative rods), Enterococci, Staph

34

Chronic Bacterial Prostate Inflammation

-same organisms as acute bacterial, but more indolent course
-common history of UTI

35

Chronic Abacterial Prostate Inflammation

-same course as chronic bacterial but organisms more difficult to identify
-ex: mycoplasma, ureaplasma, and chlamydia

36

Prostate Hyperplasia

-nodular hyperplasia (benign) - androgen driven
-results from hyperplasia of prostatic glands & stroma
-main symptoms relate to bladder obstruction and urinary stasis
-70% of 60 y/o, 90% of 70 y/o, many asymptomatic
- >400,000 resections performed annually

37

Prostate Carcinoma

-most common cancer in men
-300,000 new cases yearly, 40,000 deaths
-rare under 50, at 70, 70% have at least latent
-most tumors never progress, or do so very slowly
-Japan 3-4/100,000, white 50-60/100,000 more in black

38

Prostate Carcinoma Etiology

-Androgen related - but there is no correlation of testosterone levels to risk prostate carcinoma
-Genetically & ethnically related, but only minority of cases (10%) can be linked to inheritance of germline susceptibility genes
-Environmentally related—but low risk ethnic groups (Japanese) who move where high risk groups live (America) only modestly increase their risk

39

Prostate Carcinoma Diagnosis

-physical exam or PSA elevation in blood (both may be done if over 60)

40

PSA

organ (prostate) specific, but not cancer specific
-rises in in a number of benign conditions, including BPH and prostatitis
-Biopsy is essential to make the diagnosis

41

AUA Screening Recommendation

-no screening under 40
-individualized decisions about screening for men under 55 at higher risk (AA or positive family history)
-greatest screening benefit ages 55-69
-every two year screening may be preferred to annual screening
-no routine screening after age 70

42

Prostate Carcinoma Microscope

-can be nearly benign glands to highly anaplastic malignant cells
-back to back glands in crowded, disorganized pattern
-perineural invasion
-extracapsular externsion of the tumor

43

Gleason Grading System

-for prostate carcinoma
-Grade 1 - best differentiated
-Grade 6 - worst
-add grade from 2 most prevalent patterns (best score is 2, worst is 10)

44

Prostate Carcinoma Metastases

-bone (almost always osteoblastic rather than osteolytic)