What tumor marker would you order on a patient if you suspect an endodermal sinus (yolk sac) tumor?
What is the most common type of germ cell tumor in women?
Teratoma (more than 90% of tumors); mature teratomas are the most common benign ovarian tumors in women
Is there a difference in the prognosis of a patient with an immature teratoma compared to a mature teratoma?
immature teratomas are malignant whereas mature teratomas or dermoid cysts are benign
What kind of tumor contains cells from two or three germ cell layers?
A woman presents with palpitations, sweating, weight loss, and a low thyroid-stimulating hormone level; what ovarian pathology could be responsible?
Struma ovarii, in which functional thyroid tissue within a teratoma can cause symptoms of hyperthyroidism
Which benign non-germ cell ovarian tumor is frequently bilateral and has a fallopian tube-like epithelium?
Serous cystadenoma, which compose 20% of non-germ cell tumors
Which malignant non-germ cell tumor represents 50% of ovarian tumors and is frequently bilateral?
Which benign non-germ cell tumor has multilocular cysts lined with mucus-secreting epithelium?
Mucinous cystadenoma; this can often look like intestinal tissue
Which malignant ovarian non-germ cell tumor can progress to pseudomyxoma peritonei?
What is pseudomyxoma peritonei?
An intraperitoneal accumulation of mucinous material from an ovarian or appendiceal tumor
Which benign ovarian non-germ cell tumor resembles bladder epithelium?
(remember: Brenner is Benign and looks like Bladder)
Which benign ovarian non-germ cell tumor contains bundles of spindle-shaped fibroblasts and can cause Meigs' syndrome?
What triad is associated with Meigs' syndrome?
Ovarian fibroma, ascites, and hydrothorax
A patient with an ovarian non-germ cell tumor has small follicles filled with eosinophilic secretions on histopathology. What are these called and what tumor do they signify?
Call-Exner bodies, indicative of granulosa cell tumors
How can the presentation of a granulosa cell tumor differ based on age?
Granulosa cell tumors secrete estrogen; in childhood, this can result in precocious puberty, whereas adults may see abnormal uterine bleeding, endometrial hyperplasia, or carcinoma
What is the most important risk factor for ovarian cancer?
Family history, since there is a strong genetic component to development of the disease
What histologic appearance is seen in a Krukenberg tumor of the ovary?
Signet cell adenocarcinoma, which produces mucin
Krukenberg tumor is an ovarian tumor that has its origin in what organ system?
Gastrointestinal system, usually as gastric cancer
What serum marker would you follow in a patient with any form of ovarian cancer?
CA-125 is a general marker for ovarian cancer
Name two genetic risk factors for developing ovarian tumors with a non-germ cell origin.
Being positive for BRCA-1 mutation or HNPCC (hereditary nonpolyposis colorectal cancer) genes
What vaginal cancer develops secondary to cervical carcinoma?
Vaginal squamous cell carcinoma develops from cervical squamous cell carcinoma
Diethylstilbestrol exposure can lead to what type of vaginal carcinoma?
A girl younger than 4 years of age has a vaginal mass that shows spindle-shaped tumor cells positive for desmin staining; what is the diagnosis?
Sarcoma botryoides; a variant of rhabdomyosarcoma
A sexually active female presents with vaginal pain, and on exam you note a tender mass in the labia majora; this is suspicious for what disorder?
Bartholin's gland cyst, a rare lesion that may be a result of a prior infection
Sarcoma botryoides is a variant of what type of malignancy?
What is the most common breast tumor among women younger than 25 years of age?
Fibroadenoma, a benign tumor
A 20-year-old woman has a small, mobile, firm breast mass with well-defined borders; what is the most likely etiology?
Fibroadenoma, the most common tumor in women younger than 25 years of age
A 24-year-old woman notes a breast mass that becomes more tender during menstruation and asks you if this means she has breast cancer; what is your reply?
The age and description of the breast tenderness are consistent with a fibroadenoma, which is a benign breast mass
What neoplasm would be likely in a woman with serosanguinous discharge from her nipple but without a palpable breast mass?
Intraductal papilloma, which grows in the lactiferous ducts, often below the areola
What is the relationship between an intraductal papilloma and the development of breast cancer?
There is a small increase in the risk of carcinoma (1.5-2 times increased risk)
What is the likely diagnosis of a breast mass removed from a 55-year-old woman that is a large, bulky tumor composed of connective tissue and cysts with leaf-like projections?
Phyllodes tumor (remember: phyllodes means leaf-like)
What is the prognosis of a woman with a phyllodes tumor of the breast?
Although typically regarded as a benign breast tumor, some may become malignant
What are the two types of breast tissue from which breast carcinoma can arise?
Mammary duct epithelium or lobular glands
Which cellular markers that affect both treatment and prognosis should you test for in a patient with a new diagnosis of breast cancer?
Hormone receptor expression (estrogen, progesterone receptors) and erb-B2 or HER-2, an epidermal growth factor receptor
What is the single most important prognostic factor in malignant breast cancer?
Axillary lymph node involvement
Name four risk factors for breast malignancies.
Increased estrogen exposure, obesity (which also results in increased estrogens), increased number of total menstrual cycles, and advanced age at the first live birth
What type of breast carcinoma should you suspect if a biopsy shows ductal tissue filling the lumen that does not cross the basement membrane?
Ductal carcinoma in situ, an early malignancy that arises from ductal hyperplasia
What type of breast carcinoma should you suspect if you note a rock-hard mass on exam and a biopsy shows a fibrous mass with small, interspersed, glandular, duct-like cells?
Invasive ductal carcinoma
What type of malignant breast tumor is most invasive and has the worst prognosis?
Invasive ductal carcinoma; it is also the most common (75% of breast malignancies)
How can a comedocarcinoma be distinguished from ductal carcinoma in situ?
Comedocarcinoma is a subtype of ductal carcinoma in situ, notable for caseous necrosis within the duct
A woman presents to your office and on breast exam you note that she has a mass and the overlying skin looks like an orange peel; what is the cause of these dermatologic findings?
This is inflammatory breast carcinoma with the classic peau d'orange appearance, caused by malignant involvement of the dermal lymphatics
Which type of breast carcinoma should you suspect in a woman with bilateral masses when biopsy reveals orderly rows of cells?
Invasive lobular carcinoma, which is often bilateral and multiple
Which histologic type of breast carcinoma is a fleshy tumor with lymphocytic infiltration and a good prognosis?
A woman presents to your office complaining of a chronic nonhealing eczematous patch on her nipple; what do you expect to see on biopsy?
Paget cells (large epidermal cells with a clear halo around the nucleus) on biopsy; she has Paget's disease of the breast
What work-up should be done in a patient with Paget's disease of the nipple?
Work-up for underlying carcinoma of the breast
Name four histologic types of fibrocystic breast disease.
Fibrotic, cystic, sclerosing adenosis, and epithelial hyperplasia
Which form of fibrocystic breast disease increases the risk of breast carcinoma?
Epithelial hyperplasia when atypical cells are present; otherwise, there is no increased risk of carcinoma
A patient notes that she has several breast masses that have been causing her pain and that seem to change in size during her menstrual cycle; what is the most likely diagnosis?
Fibrocystic disease of the breast, the most common cause of breast lumps in woman between 25 years of age and menopause
How does the fibrotic type of fibrocystic disease appear on histopathology?
Hyperplasia of the breast stroma
What is the gross appearance of cystic-type fibrocystic breast disease?
Fluid-filled, blue dome cysts
How does sclerosing adenosis appear on histopathology in fibrocystic breast disease?
Increased acini and intralobular fibrosis; calcifications can also be seen
What is the histologic appearance of the epithelial hyperplasia subtype of fibrocystic breast disease?
The terminal ductal tissue has an increased number of epithelial cell layers
A breastfeeding woman presents with a fluctuant breast mass that is hot and tender and she is febrile; what is the diagnosis?
Acute mastitis that has progressed to form an abscess
What organism most commonly causes acute mastitis?
Staphylococcus aureus, which enters through cracks in the nipple (common during breastfeeding)
What diagnosis should you suspect in a woman who presents with a painless breast lump following trauma to her chest?
This is likely fat necrosis, a benign process that occurs after trauma (although 50% of patients may not recall an injury)
Name five conditions that can cause gynecomastia in males due to hyperestrogenism.
Puberty, old age, testicular tumors, cirrhotic liver disease, estrogen therapy
Name a genetic abnormality that can result in gynecomastia.
Name nine drugs or substances that cause gynecomastia.
Spironolactone, Digitalis, Cimetidine, Alcohol, Ketoconazole (remember: Some Drugs Create Awesome Knockers) along with marijuana, estrogen, heroin, and psychoactive drugs
What physical examination would be useful in an older male who has symptoms of pain, increased frequency and urgency on urination, and lower back pain?
A rectal/prostate exam; this patient has symptoms suggestive of prostatitis
What species is the most common etiology of bacterial prostatitis?
Is chronic prostatitis most commonly bacterial or abacterial?
What role do circulating hormones play in the pathogenesis of benign prostatic hyperplasia?
Age-related increases in estradiol and greater sensitivity to dihydrotestosterone are thought to cause prostate hyperplasia
A 65-year-old man presents with increased frequency of urination, nocturia, and difficulty starting and stopping his urine stream. What common benign urologic condition is high on the differential diagnosis?
Benign prostatic hyperplasia
Looking at a prostate specimen in a patient with benign prostatic hyperplasia, what is notable about the lobes of the prostate and the prostatic urethra on gross pathology?
The lateral and middle periurethral lobes are hyperplastic, and the urethra is compressed into a vertical slit
Name a vasoactive class of drugs effective in treating benign prostatic hyperplasia.
a1-Blockers like terazosin and tamsulosin; these relax the smooth muscle in the prostate and reduce urinary symptoms
What serious complications can arise in a patient with benign prostatic hyperplasia?
Distention or hypertrophy of the bladder, hydronephrosis, and urinary tract infection
Prostate-specific antigen can be elevated in men with what two conditions?
Benign prostatic hyperplasia and prostate cancer
Prostatic adenocarcinoma is common among men in what age group?
Benign prostatic hyperplasia is often more likely located in the _____ (periurethral/posterior) lobe, whereas prostatic adenocarcinoma is more likely located in the _____ (periurethral/posterior) lobe.
What is the most common way to diagnose prostatic adenocarcinoma?
Digital rectal exam (hard nodule) and biopsy
Name two useful tumor markers for prostatic adenocarcinoma.
Prostatic acid phosphatase and prostate-specific antigen
An elderly male has lower back pain and a hard nodule on prostate exam; what should you suspect if he has elevated prostate-specific antigen and alkaline phosphatase levels?
Prostate adenocarcinoma with metastases to bone causing osteoblastic lesions
How can benign prostatic hyperplasia be distinguished from prostatic adenocarcinoma using the prostate-specific antigen test?
Generally, benign prostatic hyperplasia has an elevated free prostate-specific antigen, whereas adenocarcinoma has an elevated total prostate-specific antigen with a decreased free prostate-specific antigen fraction
On a male newborn exam, you fail to palpate testicles in the scrotum; name two potential complications of this condition.
This child has cryptorchidism and may develop infertility or testicular (germ cell) cancer
Why does cryptorchidism cause infertility?
The increased temperature of the testes when they are close to the body leads to a lack of spermatogenesis
Name a risk factor for cryptorchidism.
Premature birth; because cryptorchidism occurs when the testicle does not fully descend
What type of testicular tumor is more common: germ cell tumors or non-germ cell tumors?
Germ cell tumors make up 95% of testicular tumors; non-germ cell tumors account for 5%
What is the most common testicular tumor?
A 25-year-old male presents with a painless testicular mass that on biopsy has lobules of large cells with a fried egg appearance; what is his prognosis?
Seminoma, which in spite of being malignant has an excellent prognosis and only metastasizes late in its course
What treatment can be used in a patient with seminoma?
Radiation therapy; this tumor, mostly affecting males aged 15-35 years, is extremely radiosensitive
What malignant testicular germ cell tumor typically has glandular histopathology and can differentiate to other tumors?
In males, seminoma presents with a _____ (painful/painless) testicular mass, whereas embryonal carcinoma presents with a _____ (painful/painless) mass.
What tumor markers are elevated in a patient with embryonal carcinoma?
α-Fetoprotein and human chorionic gonadotropin
What germ cell tumor should you suspect if the histopathology indicates Schiller-Duval bodies?
Yolk sac (endodermal sinus) tumors; Schiller-Duval bodies, which resemble primitive glomeruli, are found in these tumors
What tumor marker is associated with yolk sac (endodermal sinus) tumors?
A testicular germ cell tumor has disordered syncytiotrophoblastic and cytotrophoblastic elements on histopathology; what serum marker should you check?
Human chorionic gonadotropin; these findings are consistent with choriocarcinoma, which has an elevated human chorionic gonadotropin
Most germ cell tumors of the testicle are _____ (benign/malignant) whereas non-germ cell tumors are usually _____ (benign/malignant).
In men, mature teratomas are _____ (benign/malignant) and in women, mature teratomas are _____ (benign/malignant).
What benign testicular non-germ cell tumor is associated with Reinke's crystals?
Leydig cell tumor
What symptoms would you expect to see in a child with a testicular Leydig cell tumor? An adult?
This androgen-producing tumor will result in precocious puberty in boys and often causes gynecomastia in adult men
How can you distinguish between testicular cancer and most tunica vaginalis lesions on exam of a patient who has felt a lump?
A lesion of the tunica vaginalis will transilluminate whereas a testicular tumor will not
What is the most common testicular cancer among older men?
What is a varicocele?
A dilated vein in the pampiniform plexus
When performing a testicular exam on a patient you note that there is a bag of worms quality to the scrotum; what long-term complication should you warn your patient about?
Infertility; this is consistent with a varicocele, which can lead to infertility
What embryologic abnormality causes a hydrocele?
Incomplete fusion of processus vaginalis resulting in retention of fluid within the tunica vaginalis
What is a spermatocele?
A dilated epididymal duct
What diagnosis is likely in a 45-year-old male who presents with a gray, crusty plaque on the scrotum or shaft of the penis?
Bowen's disease, most common in men in their fifth decade
What may occur if Bowen's disease is left untreated?
Squamous cell carcinoma, which occurs in 10% of untreated lesions
What diagnosis is likely in a male patient who presents with red, velvety plaques on the glans of the penis?
Erythroplasia of Queyrat
Name two risk factors associated with an increased rate of penile squamous cell carcinoma.
Lack of circumcision and human papillomavirus infection
Geographically, where is penile squamous cell carcinoma most common?
The condition is uncommon in Europe and the United States and more common in Asia, Africa and South America
What condition results in a bent penis due to an acquired fibrous tissue formation?
What type of penile pathology is characterized by multiple papular lesions in younger men that generally do not become invasive?
Which chromosomal disorder is marked by testicular atrophy, eunuchoid body shape, long extremities, gynecomastia, and female hair distribution?
Klinefelter's syndrome(XXY), which has an incidence of 1:850
When looking at a blood smear of a male patient you note a small dumbell-shaped extension on a cell nucleus that you identify as a Barr body; what does this represent and what is the condition?
This is an inactivated X chromosome, normal in women but indicative of Klinefelter's syndrome (XXY) in men
Which chromosomal disorder is marked by short stature, webbing of the neck, and coarctation of the aorta in a female?
Turner's syndrome (XO)
(remember: "Hugs and Kisses"; [XO] from Tina Turner [female])
What is the most common cause of primary amenorrhea?
Turner's syndrome (XO)
Which chromosomal disorder is implicated in men who are phenotypically normal although very tall with severe acne and are known for antisocial behavior (in 1% to 2% of cases)?
Double Y males (XYY), which has an incidence of 1:1000
True or False? Double Y males are infertile.
double Y males have normal fertility
What happens to the levels of follicle-stimulating hormone and luteinizing hormone in a patient with Turner's syndrome?
Because ovarian failure results in a decrease in estrogen, follicle-stimulating hormone and luteinizing hormone levels are elevated due to lack of negative feedback
How many Barr bodies are seen when the cells of a patient with Turner's syndrome are examined under the microscope?
What happens to follicle-stimulating hormone levels in a patient with Klinefelter's syndrome?
Due to dysgenesis of the seminiferous tubules levels of inhibin are reduced; with no negative feedback follicle-stimulating hormone is increased
What happens to luteinizing hormone levels in a patient with Klinefelter's syndrome? What effect does this have on sex hormones?
Patients with Klinefelter's syndrome have abnormal Leydig cell function, resulting in low testosterone levels and thus increased luteinizing hormone; increased luteinizing hormone stimulates an increase in estrogen levels
What gonadal tissue is present in a patient with true hemaphroditism?
Both ovarian and testicular tissue is present
What are the two possible karyotypes of true hemaphroditism?
46, XX and 47 XXY are the possible karyotypes of this very rare disorder