Pathology Chapter 21 Review Male Genital Tract

Front 1

30 year old man comes to his physician because he has noticed increasing enlargement and a feeling of heaviness in his scrotum for the past year. Right testis is twice its normal size, and it is firm and slightly tender. An ultrasound shows a 3.5cm solid mass in the right testis. CT shows enlargement of the para-aortic lymph nodes. Multiple lung nodules are seen on a chest radiograph. Lab findings include markedly increased serum levels of chorionic gonadotropin and alpha-fetoprotein. What testicular neoplasm is the most likely diagnosis

Back 1

Mixed germ cell tumor. Although a modest elevation of the hCG concentration can occur when a seminoma contains some syncytial giant cells, significant elevation of the AFP level never occurs with pure seminomas. Elevated AFP and hCG effectively exclude the diagnosis of a pure seminoma and indicate the presence of a nonseminomatous tumor of the mixed type. The most common form of testicular neoplasm combines multiple elements; thus the term "teratocarcinoma" is sometimes used to describe tumors with elements of teratoma, embryonal carcinoma, and yolk sac tumor. The yolk sac element explains the high AFP level. Mixed tumors may include seminoma.

Front 2

What hormone may Leydig cell tumors elaborate

Back 2

Androgens

Front 3

What do Choriocarcinomas secrete

Back 3

High levels of hCG, but no AFP

Front 4

For the past year, a 65 year old man has had multiple, recurrent urinary tract infections. E coli and streptococcal organisms have been cultured from his urine during several of these episodes, with bacterial counts of more than 10^5. He has difficulty with urination, including starting and stopping the urinary stream. Over the past week, he has again developed burning pain with urination. Urinalysis shows a pH of 6.5 and specific gravity of 1.020. No blood or protein is present in the urine. Tests for leukocyte esterase and nitrite are positive. Microscopic exam of the urine shows numerous WBCs and a few WBC casts. Diagnosis?

Back 4

Prostatic nodular hyperplasia. Prostatic nodular hyperplasia is common in older men. When it causes obstruction of the prostatic urethra, it can predispose to bacterial infections. Vesicoureteral reflux is more likely to be present at an earlier age, and it does not account for the obstructive symptoms the patient has on urination. Prostatic adenocarcinomas are less likely than hyperplasia to cause obstructive symptoms

Front 5

What is a condition that can occur in uncircumcised males; it may be congenital or acquired from inflammation.

Back 5

Phimosis

Front 6

35 year old man has noticed a slight enlargement of the right testis over the past 3 months. He has also noticed bilateral breast enlargement over the past 6 months. Right testis is 1.5 times larger than the left testis. Both are firm and normal to touch. An ultrasound shows discrete, rounded 2cm mass in the body of the right testis, and a right orchiectomy is performed. The mass has a grossly uniform, brown cut surface. Ten years later, the patient is healthy. What description best explains the microscopic appearance of the testicular mass

Back 6

Rounded cells with abundant granular eosinophilic cytoplasm containing crystalloids of Reinke. The patient has a Leydig cell tumor of the testis. These tumors are most often small benign masses that may go unnoticed. Some patients, however, have gynecomastia caused by androgenic or estrogenic hormone production by the tumor. Most patients are young to middle-aged men; sexual precocity may occur in the few boys who have such tumors.

Front 7

A prostatic growth with back-to-back irregular glands lined by cells with nuclei containing prominent nucleoli suggests what

Back 7

Prostatic adenocarcinoma

Front 8

A growth containing large monomorphic lymphoid cells with scant cytoplasm, clumped chromatin, and prominent nucleoli suggests what

Back 8

Non-Hodgkin lymphoma

Front 9

What characteristic symptom would be present with acute orchitis caused by diffuse suppurative inflammation

Back 9

Diffuse suppurative inflammation indicates an infection, which should make the mass very tender

Front 10

A growth with full-thickness epithelial dysplasia and an intact underlying basement membrane suggests what

Back 10

Epithelial dysplasia may be seen involving transitional or squamous epithelial surfaces

Front 11

A testicular growth that contains elements of the three primary germ layers, with cartilage, squamous epithelium, and glands, suggests what

Back 11

A teratoma

Front 12

A testicular growth that contains nests of large polyhedral cells with watery cytoplasm and large nuclei with prominent nucleoli, surrounded by a lymphoid stroma, suggests what

Back 12

A seminoma

Front 13

A testicular growth that contains rounded cells with abundant granular eosinophilic cytoplasm containing crystalloids of Reinke suggests what

Back 13

A Leydig cell tumor

Front 14

A growth that contains syncytiotrophoblasts and cytotrophoblasts arranged in sheets, with extensive hemorrhage and necrosis, suggests what

Back 14

A choriocarcinoma

Front 15

A 23 year old sexually active man has been treated for N gonorrhoeae infection several times during the past 5 years. He now comes to the physician because of the increasing number and size of warty lesions on his external genitalia. The lesions have enlarged slowly during the past year. Multiple 1-3mm sessile, nonulcerated, papillary excrescences over the inner surface of the penile prepuce. These lesions are excised, but two years later, similar lesions appear. What description best explains the microscopic appearance of these lesions

Back 15

Thickened squamous epithelium with acanthosis, koilocytosis, and overlying hyperkeratosis. This patient's lesions are characteristic of condyloma acuminata, which is typical of human papillomavirus infection. A condyloma acuminatum is a benign, recurrent squamous epithelial proliferation resulting from infection with HPV, one of the many sexually transmitted diseases that can occur in sexually active persons. Koilocytosis is particulary characteristic of HPV infection. Recurrent gonococcal infection indicates that the patient is sexually active

Front 16

What will cause suppurative lesions on the penis in which there may be liquefactive necrosis and a neutrophilic exudate or mixed inflammatory infiltrates with chancroid

Back 16

Gonococcal infection

Front 17

55 year old man has dysuria, increased frequency, and urgency of urination for the past 6 months. He has sometimes experienced mild lower back pain. Afebrile. No costovertebral angle tenderness. The prostate gland feels normal in size; no nodules are palpable. Expressed prostatic secretions contain 30 leukocytes per high-power field. Diagnosis?

Back 17

Chronic abacterial prostatitis. The patient has more than 10 leukocytes per high-power field, indicating prostatitis. Chronic abacterial prostatitis is the most common form of the disorder. Patients typically do not have a history of recurrent urinary tract infections.

Front 18

32 year old man has noticed an increased feeling of heaviness in his scrotum for the past 10 months. On physical exam, the left testis is three times the size of the right testis and is firm on palpation. US shows a 6cm solid mass within the body of the left testis. Elevated serum alpha-fetoprotein level. What cellular compents are most likely to be present in this mass

Back 18

Yolk sac cells. AFP is a product of yolk sac cells that can be demonstrated by immunohistochemical testing. Pure yolk sac tumors are rare in adults, but yolk sac components are common in mixed nonseminomatous tumors.

Front 19

What cells produce androgens

Back 19

Leydig cells

Front 20

What do syncytiotrophoblasts produce

Back 20

Human chorionic gonadotropin

Front 21

25 year old man has occasionaly felt pain in the scrotum for the past 3 months. The right testis is more tender than the left but does not appear to be appreciably enlarged. US shows a 1.5 cm mass. A right orchiectomy is performed, and gross examination shows the mass to be hemorrhagic and soft. A retroperitoneal lymph node dissection is performed. In sections of the lymph nodes, a neoplasm is seen with grossly extensive necrosis and hemorrhage. Areas of viable tumor are composed of cuboidal cells intermingled with large eosinophilic syncytial cells containing multiple dark, pleomorphic nuclei. Immunohistochemical staining of the tumor is most likely to show what antigenic components in the syncytial cell

Back 21

Human chorionic gonadotropin. This patient has a choriocarcinoma, the most aggressive testicular carcinoma. It often metastasizes widely. The primitive syncytial cells mimic the syncytiotrophoblast of placental tissue and, therefore, stain for hCG.

Front 22

When is vimentin likely to be seen in immunohistochemical stains of the testes

Back 22

In sarcomas, which are rare in the testicular region

Front 23

CD20 is a lymphoid marker for what cells

Back 23

B cells

Front 24

Where is testoterone found

Back 24

Leydig cells

Front 25

Where is carcinoembryogenic antigen (CEA) found

Back 25

A varitey of epithelial neoplasms, particulary adenocarcinomas

Front 26

What is a marker for ovarian epithelial malignant tumors

Back 26

Cancer antigen 125

Front 27

70 year old man comes to his physician for a routine health exam. Prostate is normal in size. PSA level 17, four times the upper limit of normal and twice the value reported 1 year ago in this patient. Urinalysis shows no abnormalities. Patient is healthy, with no history of major illnesses. What histologic finding in a subsequent biopsy will most likely account for this patient's current status

Back 27

Poorly differentiated glands lined by a single layer of epithelium and packed back to back. The PSA level is significantly elevated in this patient. The increase over time is more likely to be indicative of carcinoma. Typically, prostatic carcinomas are adenocarcinomas that form small glands packed back to back; unlike hyperplastic glands, malignant glands are lined by a single layer of epithelium. Many adenocarcinomas of the prostate do not produce obstructive symptoms and may not be palpable on digital rectal exam. Hyperplasias can increase the PSA level, although not to a high level that increases significantly over time. Prostatitis, like hyperplasia, can elevate the PSA level slightly

Front 28

35 year old man and his 33 year old wife are childless. They have tried to conceive a child for 12 years and believe that time is running out for them. They undergo an infertility workup. Neither spouse has remarkable findings. The man has a sperm count in the low-normal range. Sperm have a normal morphologic appearance. Biopsy shows patchy atrophy of seminiferous tubules, but the remaining tubules show active spermatogenesis. Diagnosis?

Back 28

Mumps virus infection. Mumps is a common childhood infection that can produce parotitis. Adults who have this infection more often develop orchitis. The orchitis is usually not severe, and its involvement of the testis is patchy; therefore, infertility is not a common outcome.

Front 29

What disease results from failure of the testis to descend into the scrotum normally; the abnormally positioned testis becomes atrophic throughout

Back 29

Cryptorchidism

Front 30

What is the name of a fluid collection outside the body of the testis that does not interfere with spermatogenesis

Back 30

Hydrocele

Front 31

What are two things that can cause generalized tubular atrophy in the testis

Back 31

Klinefelter syndrome and estrogen therapy

Front 32

What does patchy loss of seminiferous tubules indicate

Back 32

A local inflammatory process

Front 33

The mother of a 2year old child notices that he has had increasing asymmetric enlargement of the scrotum over the past 6 month. There is a well-circumscribed 2.5cm mass in the left testis. Sheets of cells and ill-defined glands composed of cuboidal cells, some of which contain eosinophilic hyaline globules. Microcysts and primitive glomeruloid structures are also seen. Immunohistochemical staining shows AFP in the cytoplasm of the neoplastic cells. Diagnosis?

Back 33

Yolk sac tumor. Yolk sac tumors are typically seen in boys younger than 3 years of age. The primitive glomeruloid structures are known as Schiller-Duval bodies.

Front 34

What type of testicular tumor contains large, hyperchromatic, syncytiotrophoblastic cells

Back 34

Choriocarcinoma

Front 35

What testicular tumor has sheets and nests of cells resembling primitive germ cells, often with an intervening lymphoid stroma

Back 35

Seminomas

Front 36

Embryonal carcinomas with yolk sac cells are seen in what age group

Back 36

Adults.

Front 37

A 19 year old man comes to his physician complaining of worsening local pain and irritation with difficult urination over the past 3 years. He has become more sexually active during the past year and describes his eretions as painful. Physical exam show that he is not circumcised. The prepuce cannot be easily retracted over the glans penis. Diagnosis?

Back 37

Phimosis. Phimosis can be congenital but is more often a consequence of multiple episodes of balanitis (inflammation of the glans penis or foreskin). Balanitis leads to scarring that prevents retraction of the foreskin. Forcible retraction may result in vascular compromise, with further inflammation and swelling (paraphimosis).

Front 38

What is the name of a congenital condition where the penile urethra opens onto the dorsal surface of the penis

Back 38

Epispadias

Front 39

What is the name of a premalignant lesion of the penile shaft resulting from viral infection; it appears with multiple papules on the penile shaft and perineum that may coalesce and resemble condyloma. It frequently regresses spontaneously and does not progress to invasive cancer

Back 39

Bowenoid papulosis

Front 40

How will Candidiasis present on the penis

Back 40

Shallow ulcerations that are intensely pruritic

Front 41

19 year old man comes to his physician for a routine health maintenance examination. No left testis palpable in the scrotum. Healthy patient, no major illnesses, normal sexual function. What counsel should be given to this patient

Back 41

He is at increased risk of developing a testicular tumor. This patien has cryptorchidism, which results from failure of the testis to descend during fetal development. One or both testes may be involved. It is associated with an increased risk of testicular cancer. An undescended testis eventually atrophies during childhood. Unilateral cryptorchidism usually does not lead to infertility, but it may be associated with atrophy of the contralateral descended testis.

Front 42

5 year old boy has a history of recurrent urinary tract infections. Urine cultures have grown E coli, P mirabilis, and enterococcus. Abnormal constricted opening of the urethra on the ventral aspect of the penis, about 1.5cm from the tip of the glans penis. There is also a cryptorchid testis on the right and an inguinal hernia on the left. What term best describes the child's penial abnormality

Back 42

Hypospadias. Hypospadias is a congenital condition seen in about 1 in 300 male infants. The inguinal hernia and the cryptorchidism are abnormalites that may accompany this condition

Front 43

What is the name for a constriction preventing retraction of the prepuce

Back 43

Phimosis. It can be congenital but more likely is the result of inflammation of the foreskin of the penis (eg balanitis, a form of local inflammation of the glans penis).

Front 44

What is Bowen disease

Back 44

Squamous cell carcinoma in situ of the penis, which occurs in adults

Front 45

46 year old man with a history of poorly controlled diabetes mellitus comes to the physician because he has had painful, erosive, markedly pruritic lesions on the glans penis, scrotum, and inguinal regions of the skin for the past 2 months. Irregular, shallow 1-4cm erythematous ulcerations. Scrapings of the lesions are examined under the microscope. What findings will most likely be reported

Back 45

Budding cells with pseudohyphae. Genital candidiais can occur in persons without underlying illnesses, but it is far more common in those with diabetes mellitus. Warm, moist conditions at these sites favor fungal growth.

Front 46

Where are scabies mites likely to be found

Back 46

In linear burrows in epidermis scraped from the extremities

Front 47

Scrapings that reveal spirochetes under darkfield examinination indicate what

Back 47

Syphilis

Front 48

A clinical trial of two pharmacologic agents compares one agent that inhibits 5alpha-reductase and diminishes dihydrotestosterone (DHT) synthesis in the prostate with another agent that acts as an alpha1-adrenergic receptor. The subjects are 40-80 years of age. The study will determine whether symptoms of prostate disease are ameliorated in the persons who take these drugs. What disease of the prostate is most likely to benefit from one or both of these drugs

Back 48

Nodular hyperplasia. Androgens are the major hormonal stimuli of glandular and stromal proliferation resulting in nodular prostatic hyperplasia. Although testosterone production decreases with age, prostatic hyperplasia increases, probably because of an increased expression of hormonal receptors that enhance the effect of DHT that is present. The 5alpha-reductase inhibitors, such as finasteride, diminish the prostate volume, specifically the glandular component, leading to improved urine flow. However, the alpha1-adrenergic receptor blockers, sush as tamsulosin, cause smooth muscle in the bladder neck and prostate to relax, which relieves symtoms and improves urine flow immediately

Front 49

A 33 year old man has noted asymmetric enlargement of the scrotum over the past 4 months. The right testis is twice its normal size and has increased tenderness to palpation. The right testis is removed. The epididymis and the upper aspect of the right testis have extensive granulomatous inflammation with epitheliod cells, Langhans giant cells, and caseous necrosis. Diagnosis?

Back 49

Tuberculosis. TB is an uncommon infection in the testes, but it can occur with disseminated disease. The infection typically starts in the epididymis and spreads to the body of the testis.

Front 50

What produces patchy orchitis with minimal inflammation, which heals with patchy fibrosis?

Back 50

Mumps

Front 51

What disease involves the body of the testis, and there can be gummatous inflammation with neutrophils, necrosis, and some mononuclear cells

Back 51

Syphilis

Front 52

A 48 year old man has noticed a reddish area on the penis for 3 months. He has had no episodes of sexual intercourse for more than 1 month. Solitary 0.8cm plaquelike, erythematous area on the distal shaft of the penis. A routine microbiologic culture with a Gram-stained smear of the lesion shows normal skin flora. Microscopic exam of a biopsy specimen of the lesion shows dysplasia involving the full thickness of the epithelium. Diagnosis?

Back 52

Bowen disease. Bowen disease is a form of squamous cell carcinoma in situ. Like carcinoma in situ elsewhere, it has a natural history of progression to invasive cancer if untreated. Poor hygiene and infection with HPV (particularly 16 and 18) are factors that favor development of dysplasias and cancer of the genital epithelia

Front 53

What sexually transmitted disease produces a hard chancre

Back 53

Syphilis

Front 54

What sexually transmitted disease produces a soft chancre

Back 54

Haemophilus ducreyi infections

Front 55

What do Condylomas appear like

Back 55

Raised, whitish lesions

Front 56

85 year old man comes to the physician because he had had urinary hesitancy and nocturia for the past 6 months. On digital rectal exam, there is a hard, irregular prostate gland. A bone scan shows increased areas of uptake in the throacic and lumbar vertebrae. Lab studies show alk phos 300, prostatic acid phosphatase 8, PSA 72l. BUN 44, serum creatinine 3.8. Transrectal biopsies of all lobes of the prostate are performed. 90% of the tissue has a pattern of cords and sheets of cells with hyperchromatic pleomorphic nuclei, prominent nucleoli, and scant cytoplasm. How should this patient's disease be classified?

Back 56

Stage D2, Gleason grade 5,5. The presence of a hard irregular nodule, along with the extremely high PSA level, points most clearly to prostate carcinoma. Modest elevations of the PSA concentration can occur in nodular hyperplasia of the prostate and prostatitis. Symptoms of urinary obstruction are more prominent in nodular hyperplasia because the nodules are in the periurethral region, but this sign is not sufficient to distinguish cancer from hyperplasia. Similarly, renal failure due to obstruction or infiltration is more common with nodular hyperplasia but can occur with cancer as well. Levels of alkaline phosphatase are elevated when prostate carcinoma gives rise to osteoblastic metastases. Although staging and grading schemes for malignant disease appear daunting, they are applied intuitively. The lowest stage is the smallest, most localized tumor; higher stages represent larger tumors or spread of the disease inside or outside of the primary organ site. Grading schemes also start with the lowest, most well differentiated tumor, as seen with the microscope. Higher-grade tumors have increasingly abnormal-appearing cells and structures so poorly differentiated that they hardly resembe their site of origin. In this case, the prostate cancer has the highest grade (it does not have glandular structures) and the highest stage (it has metastasized to the spine)

Front 57

59 year od man notices gradual enlargement of the scrotum over the course of 1 year. The growth is not painful but produces a sensation of heaviness. He has no problems with sexual function. Physical examination shows no lesions of the overlying scrotal skin and no obvious masses, but the scrotum is enlarged, boggy, and soft bilaterally. The transillumination test result it positive. Diagosis?

Back 57

Hydrocele. Hydrocele is one of the most common causes of scrotal enlargement. It consists of a fluid collection within the tunica vaginalis. Most cases are idiopathic, although some may result from local inflammation.

Front 58

What is the name for a collection of dilated veins in the scrotum (pampiniform plexus) that may produce increased warmth, which inhibits spermatogenesis

Back 58

Varicocele

Front 59

What is the name for a complication of parasitic filarial infections involving the inguinal lymphatics

Back 59

Elephantiasis

Front 60

What scrotal lesion involves the body of the testis without marked enlargement but with tenderness

Back 60

Orchitis

Front 61

An otherwise healthy 72 year old man has had increasing difficulty with urination for the past 10 years. He now has to get up several times each night because of a feeling of urgency, but each time the urine volume is not great. He has difficulty starting and stopping urination. On physical exam, the prostate is enlarged to twice its normal size but is not tender to palpation. One year ago, his serum PSA level was 6, and it is still at that level when retested. What finding is most likely to be seen in a biopsy specimen of the prostate

Back 61

Hyperplastic nodules of stroma and glands lined by two layers of epithelium. The clinical features are typical of nodular hyperplasia of the prostate. Slight elevation of the PSA level can occur with nodular hyperplasia. A PSA level that remains unchanged for a year, as in this case, is unlikely to be found with a prostate cancer. The area of the prostate most often involved in nodular hyperplasia producing significant obstruction is the inner (transitional and periurethral zone). The hyperplastic nodules consist of proliferating glands, lined by two layers of cells, and the intervening fibromuscular stroma.

Front 62

What prostatic lesion will have foci of chronic inflammatory cells in the stroma and in normal-appearing glands

Back 62

Prostatitis. It may cause dysuria and increased frequency because of inflammation, but it is less common than hyperplasia in older males and is less likely to produce obstructive symptoms

Front 63

What prostatic lesion will have areas of liquefactive necrosis filled with neutrophils

Back 63

Acute prostatitis

Front 64

Over the past 9 months, a 30 year old man has noticed increased heaviness with enlargement of the scrotum. There is an enlarged, firm, left testis but no other remarkable physical findings. An US shows a 5cm solid mass within the body of the left testis. An orchiectomy of the left testis is performed. The mass shows areas of mature cartilage, keratinizing squamous epithelium, and colonic glandular epithelium. Elevated levels of hCG and AFP. Despite the appearance of the cells in the tumor, the surgeon tells the patient that he probably has a malignant testicular tumor. His conclusions are most likely to be based on what factor

Back 64

Elevation of hCG and AFP levels. The tumor has elements of all three germ layers and is a teratoma. It is uncommon for teratomas in adult men to be completely benign. The most common additional histologic component is embryonal carcinoma. The elevated levels of hCG and AFP indicate that this is a mixed tumor with elements of choriocarcinoma and yolk sac cells. The size of the tumor, age of the patient, location of the tumor, and differentiation of the glandular epithelium are not markers of malignancy. Upon examining more histologic sections from the mass, the pathologist will find malignant elements

Front 65

71 year old currently healthy man comes to his physician for a checkup because he is worried about his family history of prostate cancer. Physical exam does not indicate any abnormalities. Because of the patient's age and family history, his PSA is immediately measured, and the level is 5. Six months later, the PSA test measures 6. A urologist performs transrectal biopsies, and microscopic exam shows multifocal areas of prostatic intraepithelial neoplasia as well as glandular hyperplasia. Based on these findings, what is the most appropriate course of management for this patient

Back 65

Monitoring PSA levels. Prostatic intraepithelial neoplasia (PIN) is a potential precursor of prostatic adenocarcinoma. By itself it does not warrant therapy, because only about one third of patients diagnosed with PIN develop invasive cancer within 10 years. Conversely, in about 80% of cases in which prostate cancer is present, PIN can be found in the surrounding tissue. PIN does not usually increase the PSA levels. In this case, the elevation in PSA levels was probably caused by the coexistent hyperplasia. Thus, following the patient with PSA tests can aid in determining if cancer has developed

Front 66

25 year old previously healthy man suddenly develops severe pain in the scrotum. The pain continues unabated for 6 hours, and he goes to the ER. Afebrile. There is exquisite tenderness of a slightly enlarged right testis, but there are no other remarkable findings. The gross appearance of the right testis is shown in the figure above. What condition is most likely to produce these findings

Back 66

Obstruction of blood flow. The markedly hemorrhagic appearance results from testicular torsion that obstructs venous outflow to a greater extent than the arterial supply. Doppler ultrasound shows reduced or no vascular flow in the affected testis. An abnormally positioned or anchored testis in the scrotum is a risk factor for this condition.