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Flashcards in Robbins Deck (169):
1

What is hypospadias?

Opening of the urethral canal on the ventral surface of the penis

2

What is epispadias?

Opening of the urethra on the dorsal surfaces

3

What are the complications of hypospadias and epispadias?

The abnormal opening is often constricted, resulting in urinary tract obstruction and a higher risk for UTI.
Could also block normal ejaculation -- sterility

4

What is phimosis?

When the orifice of the prepuce is too small to permit normal retraction

5

What usually causes phimosis?

Repeated attacks of infection that cause scarring of the preputial ring

6

What are the complications of phimosis?

Permits accumulation of secretions and detritus under the prepuce

7

What is balanoposthitis?

Infections of the glans and prepuce caused by a wide variety of organisms.

8

What are the common microbes that cause balanoposthitis?

Candida, Anaerobic bacteria, Gardernella, Pyogenic bac

9

What is smegma?

Accumulation of desquamated epi cells, sweat, debris that can act as an irritant

10

What does smegma cause?

Phimosis

11

What is Bowen disease?

CIS of genital region
Appears as solitary, thickened, gray-white, opaque-plaque on shaft
Appears as multiple, red, velvety plaques

12

What kind of cells do you see in Bowen disease?

Markedly dysplastic with large hyperchromatic nuclei and lack of orderly maturation

13

How old are the patients with Bowen disease?

Over the age of 35

14

What percentage of Bowen disease transforms into SCC?

10%

15

Who gets bowenoid papulosis?

Occurs in sexually active adults

16

What does bowenoid papulosis?

The presence of reddish brown papular lesions.

17

What is the natural outcome of bowenoid papulosis?

Spontaneous regresses sometimes
Never develops into invasive carcinoma

18

What offers protection against invasive carcinoma?

Circumcision

19

What elevates the risk of developing cancer of the penis?

Cigarette smoking

20

What age do patients typically get carcinoma of the penis?

40-70

21

What does the papillary type SCC of the penis look like?

Cauliflower-like fungating mass

22

What does the flat type of SCC of the penis look like?

Areas of epithelial thickening accompanied by fraying and fissuring of the mucosal surface ---- ulcerates

23

What does the verrucous carcinoma of penis look like?

Exophytic well-differentiated variant
Low malignant potential

24

What is the pathological potential of SCC of penis?

Slow growing
Locally invasive
Not painful

25

What is the prognosis to the SCC of the penis related to?

Stage of the tumor

26

What is cryptorchidism?

Complete or incomplete failure of the intra-abdominal testes to descend into the scrotal sac

27

In what phase do the testis settle into the lower abdomen?

The phase controlled by Müllerian inhibiting substance.

28

In what phase do the testes descend through the inguinal canal into the scrotal sac?

Androgen dependent phase 2 mediated by calcitonin gene-related peptide, from the genitofemoral nerve.

29

What does the histo of cryptorchidic testes look like?

Arrest in development of germ cells
Marked hyalinization and thickening of basement membrane of the spermatic tubules.
Leydig cells are prominent
Contralateral testis has paucity of germ cells too

30

What do cryptorchidic testes look like?

Small and firm

31

What are the complications of cryptorchidism?

Sterility
Trauma
Inguinal hernia (10-20%)
Higher risk of testicular cancer

32

What is the treatment for an undescended testicle?

Surgical correction - orchiopexy

33

What is orchiopexy?

Placing the undescended testicle into the scrotal sac surgically

34

What is cryptorchidism associated with?

An intrinsic defect in testicular development and cellular differentiation

35

What are the causes of atrophy of the testes?

1. Progressive atherosclerosis narrowing the blood supply
2. End stage of inflammatory orchitis
3. Cryptorchidism
4. Hypopituitarism
5. Malnutrition or cachexia
6. Irradiation
7. Prolonged admin of anti-androgens
8. Exhaustion following persistent stimulation of FSH

36

What is the histo of atrophy of the testes?

Same as for cryptorchidism
No spermatogenesis, thickened basement membrane and hyalinization. Prominent Leydig cells

37

What is atrophy of the testicles?

The end stage to testicular injury characterized by:
Hypospermatogenesis
Maturation arrest
Vas deferens obstruction

38

Where do gonorrhea and TB arise in the male genital tract?

Epididymis

39

What organ does syphilis arise in first in the male genital tract?

Testes

40

What is epididymis is usually caused by in children?

Congenital genitourinary abnormalities and infection with gram neg rods

41

What is the cause of epididymitis in sexually active men below the age of 35?

STDs - chlamydia and gonorrhea

42

What is the cause of epididymitis in men older than 35?

UTI pathogens - E.coli, Pseudomonas

43

What can epididymitis and orchitis lead to?

Abscess formation and suppurating necrosis
Fibrous scarring ---- infertility

44

What disease presents in the Middle Ages with fever and sudden onset of moderately tender testicular mass?

Granulomatous orchitis

45

What is the histo of granulomatous autoimmune orchitis?

Granulomas only in the spermatic tubules - look like tubercles

46

What kind of infection is usually from the posterior urethra to the prostate to the seminal vesicles to the epididymis?

A neglected gonorrheal infection

47

What viral diseases may cause orchitis?

Mumps
Orchitis develops one week after swelling of the parotid glands.
Happens in 20-30% of postpubertal males

48

What does syphilis produce?

Gummas, diffuse inflammation + obliterative endarteritis, peri secular cuffing of lymphocytes and plasma cells.

49

What happens in a torsion?

The venous drainage of the testis is cut off and there is vascular engorgement from the arteries leading to infarction

50

What are the 2 types of torsion?

1. Neonatal
2. Adult

51

What is the time frame for saving a testicle from torsion?

Under 6 hours for it to remain viable

52

What is adult torsion a result of?

Bilateral anatomical defect where the testis has hyper mobility and has the bell clapper effect

53

What is the treatment for torsion?

Untwist it and fix it to the scrotum

54

What is the most common benign paratesticular tumor?

Adenomatoid tumor

55

What are adenomatoid tumors?

Small nodules occurring at the top of the epididymis that can be minimally invasive to the testes.

56

What are the most common malignant paratesticular tumors?

Rhabdomyosarcomas in kids
Liposarcomas in adults

57

What are common lesions found in the spermatic cord during inguinal hernia repair?

Lipoma

58

Where do most testicular tumors arise from?

95% from germ cells

59

Are sex cord STROMAL cell tumors usually benign or malignant?

Benign

60

At what age is testicular cancer most common?

15-34 years old

61

What are germ cell tumors associated with?

TDS - testicular dysgenesis syndrome: cryptorchidism, hypospadias, poor sperm quality

62

What can cause TDS?

In uteri exposure to pesticides and non steroidal estrogens

63

What is the most important risk factor for testicular cancer?

Cryptochidism

64

What kind do cancers do patients with Klinefelter's develop?

Mediastinal germ cell tumors

65

What are seminomatous tumors composed of?

Cells that resemble primordial germ cells

66

What are the non-seminomatous tumors composed of?

Undifferentiated cells that resemble embryonic stem cells

67

What percentage of germ cell tumors are mixed?

60%

68

What is the most common testicular tumor?

Seminoma

69

What lesion do testicular germ cell tumors originate from?

Intra tubular germ cell neoplasia

70

What have ITGCN not been implicated in?

A precursor lesion to pedi yolk sac tumors, teratomas or adult spermatocytic seminoma.

71

When does ITGCN occur?

In utero
Stay dormant until puberty

72

What does ITGCN consist of?

Atypical primordial germ cells with large nuclei and clear cytoplasm.

73

What do the cells of ITGCN express?

OCT3/4, NANOC
Copies of 12p
Activating muts of ckit

74

What percentage of patients develop invasive tumors from ITGCN.?

100%

75

When do patients get seminoma?

Third decade

76

What do seminomas express?

OCT3/4, NANOC
Ckit activation
12p copies

77

What do seminomas look like?

Bulky grey-white masses
Do not penetrate tunica albuginea

78

What is the histo of a seminoma?

Composed of sheets of uniform cells divided into lobules by fibrous septa containing lymphocytes.
The cell = large, round, watery cytoplasm, large central nucleus with 1-2 prominent nucleoli.
15% contain synctiotrohphoblasts
Can increase hCG!
Can also see granulomas

79

What are seminoma cells positive for?

Ckit
PLAP - placental alkaline phosphatase
OCT3/4

80

What does anaplastic seminoma look like?

More mitosis
Nuclear irregularity
Not associated with a worse prog

81

Who gets spermatocytic seminoma?

Over 65

82

What is a spermatocytic seminoma?

Slow growing tumor that does not mets!
Soft, pale grey tumor with mucous cysts

83

What is the histo of spermatocytic seminoma?

3 cells:
1. Medium with round nucleus and Eosinophilic cytoplasm
2. Small with rim of Eosinophilic cytoplasm resembling secondary spermatocytes
3. Giant cells

84

Who gets embryonal carcinoma of the testes?

20-30 years old

85

What does an embryonal carcinoma of the testis look like?

Smaller and more aggressive than a seminoma punctuated by foci of hemorrhage and necrosis
Extends thru tunica albuginea

86

What is the histo of embryonal carcinoma of the testis?

Cells grow in alveolar or tubular patterns with papillary convolutions
Large anaplastic cells with hyperchromatic nuclei with prominent nucleoli
Lots of mitotes and tumor giant cells

87

What markers do embryonal carcinoma of the testis express?

OCT3/4, PLAP
Cytokeratin 34
CD 30

88

What is the most common testicular tumor in children and infants (younger than 3)?

Yolk sac endodermal sinus tumor

89

What does a yolk sac tumor of the testis look like?

Nonencapsulated yellow-white homogenous mucinous tumor

90

What is the histo of a yolk sac tumor of the testis?

Lacelike reticular network of cuboidal / flattened cells
May see Schiller Duvall bodies
Also see hyaline-like globules with alpha fetoprotein and alpha1 antitrypsin

91

What testicular tumor is detected as a small palpable nodule?

Choriocarcinoma

92

What is the histo of choriocarcinoma of the testis?

Hemorrhage and necrosis
Synctiotrohphoblasts and cytotrophoblastic cells
Make high levels of hCG

93

What does a synctiotrohphoblast look like?

Cell with irregular lobular hyperchromatic nuclei in Eosinophilic cytoplasm

94

What does a cytotrophoblast look like?

Polygonal cell with distinct borders and clear cytoplasm

95

What is the second most common testicular tumor in children?

Pure teratomas

96

What is the importance of recognizing a non-germ cell malignancy in a teratoma?

Because the non-germ cell component does not respond to chemo when it spreads outside the testis.
Have isochromosome 12p

97

What is the course of a teratoma?

In children - benign
In postpubertal male - all malignant

98

What is the standard tx of a testicular mass?

Radical orchiectomy

99

What is the mode of spread of testicular cancer?

Lymph: to para-aortic nodes to mediastinal and supraclavicular
Blood: to the lungs primarily

100

What kind of testicular tumor tends to stay in the testis for a long time and so is often discovered at stage 1?

Seminoma

101

In what stage are the non-seminomatous tumors found?

Stage II and III

102

How do non-seminomatous tumors usually spread?

Hematogenously

103

What tx are seminomas sensitive to?

Radiation

104

What are the clinical stages of testicular tumors?

Stage I: tumor confined to testis,epididymis, spermatic cord
Stage II: spread to retroperitoneal nodes and below diaphragm
Stage III: mets outside the retro nodes and above diaphragm

105

What peptide correlates with the mass of tumor cells providing a marker for tumor burden?

LDH

106

How can remission be achieved in someone with non-seminomatous tumor?

Aggressive chemo

107

What are the sex cord stromal tumors?

Leydig cell tumors
Sertoli cell tumors

108

What are the germ cell tumors of the testis?

Seminoma
Spermatocytic seminoma
Embryonal carcinoma
Yolk sac tumor
Choriocarcinoma
Teratomas

109

When do leydig cell tumors usually happen?

Between 20 and 60

110

How do leydig cell tumors present?

Testicular swelling, gynecomastia precocious puberty

111

What do leydig cell tumors look like?

They are well circumscribed modules that are golden brown

112

What is the histo of leydig cell tumors?

Cells look like normal leydig cells
Contain crystals of Reinke

113

Is a leydig cell benign or malignant?

Benign

114

What do Sertoli cell tumors look like?

Firm small nodules with gray white to yellow color.

115

What is the histo of a Sertoli cell tumor?

Cells arranged in trabeculae

116

Which sex cord stromal tumor is hormonally active?

Leydig cell

117

What are gonadoblastomas?

Neoplasm containing a mix of germ cells and gonadal stromal elements

118

What is the most common form of testicular neoplasms in men over 60?

Aggressive non-Hodgkins lymphoma
Most common: diffuse large B cell, Burkett lymphoma, EBV-positive extra nodal NK/T lymphoma

119

What is a hydrocele?

Accumulation of serous fluid in the tunica vaginalis

120

What is a hematocrit caused by?

Trauma or torsion or hemorrhagic disease

121

Who gets chyloceles?

Patients with elephantiasis or filariasis

122

What is a complication of a varicocele?

Infertility

123

What controls the growth of the prostate?

Testicular androgens

124

What is acute bacterial prostatitis caused by?

UTI or after surgical manipulation of the urethra

125

What is the clinical presentation of acute prostatitis?

Fever. Chills, dysuria
DRE reveals tender, boggy prostate

126

How does chronic bacterial prostatitis present?

Low back pain, dysuria, perineal and suprapubic pain

127

What do patients with chronic bacterial prostatitis have a hx of?

Recurrent UTIs with the same organism

128

How do you diagnose prostatitis?

With leukocytes in the prostatic secretions and positive bac cultures

129

What is the most common form of prostatitis?

Chronic abacterial prostatitis

130

How is chronic abac prostatitis diagnosed?

More than 10 leukocytes per hpf and negative bac cultures

131

What is the most common cause of granulomatous prostatitis?

Instillation of BCG in the bladder for tx of bladder cancer

132

Why is biopsy of the prostate contraindicated in prostatitis?

It may lead to sepsis

133

What is BPH?

Hyperplasia of stromal and epi cells in periurethal region of prostate.

134

What is the pathogenesis of BPH?

Impaired cell death

135

What is the main androgen of the prostate?

DHT

136

What cell converts testosterone to DHT

Stromal cells by 5 alpha reductase

137

What does DHT do?

Binds the AR and mediates transcription of genes for growth factors and receptors

138

What is the most important GF stimulated by DHT contributing to BPH?

FGF-7

139

What does BPH look like?

Tissue is yellow-pink with soft consistency and milky ooze if made of glands
Firm and grey is fibromuscular stroma
Glandular prolif = cystically dilated glands lined by inner columnar and outer cuboidal epi

140

What are the complications of BPH?

Bladder hypertrophy and distention
Urinary retention
Urethral obstruction
Higher risk of infection

141

What are the tx for BPH?

Lower caffeine and alcohol intake
Timed voiding schedule
Alpha blockers

142

What is the gold standard for reducing BPH symptoms?

TURP - transurethral resection

143

What is the most common form of cancer in men?

Adenocarcinoma of the prostate

144

Who gets adenocarcinoma of the prostate?

Men over 50
Most common in AAs

145

What are the factors that increase the risk for adenocarcinoma of the prostate?

High fat diet
Short repeats of CAG - more sensitivity to androgens
Increased androgens
First degree relative
BRCA2 mutation
Mut at 8q24
Overexpression of ETS
hyper methylation of GSTP1
Loss of e-cadherin
Upreg of AMACR
Overexpression of EZH-2
PCA3

146

What does over expression of ETS do?

Makes normal prostate epi cells more invasive thru upreg of MMPs

147

What is the most common epi genetic alteration in prostate cancer?

Hyper methylation of glutathione s-transferase

148

Where does prostate cancer usually arise?

In the peripheral zone and posteriorly

149

What does prostate cancer look like?

It's embedded in the tissues
Gritty and firm

150

What is the lymphatic pattern of spread for prostate cancer?

Obturator nodes to para-aortic nodes

151

What is the hematogenous pattern of spread?

To the bones of the axial skeleton
Lumbar spine to proximal femur to pelvis, thoracic spine, ribs

152

What is the histo of prostate cancer?

Crowded Glands lined by cuboidal cells
No outer basal layer
Tumor cells = pale clear to amphophilic. Large nuclei

153

What are some markers for prostate cancer?

AMACR

154

What is PIN?

Benign prostatic acini lined by cytologically atypical cells with prominent nucleoli
Larger branching glands and papillary infoldings surrounded by basal cells and basement membrane

155

What is the grading system of prostate cancer?

The Gleason system
Grade 2-4: well-diff, small in transition zone
Grade 5-7: intermediate - treatable
Grade 8-10: no differentiation and tumor cells infiltrate the stroma - unlikely to be cured

156

What are the best prognostic indicators for prostate cancer?

Grade and stage

157

What are the stages for prostate cancer?.

T1- found incidentally
T2 - organ confined
T3 - extra prostatic extension
T4 - direct invasion of other organs

158

What is required for dx of prostate cancer?

A transrectal needle biopsy

159

What is PSA?

A product of prostatic epithelium normally secreted n semen.
It is a serine protease

160

What is a normal level of PSA?

Less than 4 ng/ml

161

What is the most important test used in diagnosis and management of prostate cancer?

PSA level

162

How is PSA velocity used?

Used for distinguishing between men with and without prostate cancer.
More than .75ng/ml per year is bad!

163

What percentage of free PSA confers a lower risk to prostate cancer?

Above 25%

164

What is the most common treatment for localized prostate cancer?

Radical prostatectomy

165

What therapy is used for prostate cancer that is too far advanced for surgery?

External beam radiation

166

What therapy is used for advanced mets from prostate?

Androgen deprivation by orchiectomy or LHRH agonists

167

What is the most aggressive variant of prostate cancer?

Small cell

168

What is the most common tumor to secondarily involve the prostate?

Urothelial cancer

169

What is the prognosis of ductal adenocarcinoma of the prostate
.

Poor