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240 Cards in this Set
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Congenital Anomalies
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a. double ureters
b. (UPJ) obstruction c. Diverticular out-pouching d. Hydroureter |
Ureters: Easily obstructed
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1. Usually seen in infants and young children
2. More common in boys 3. Abnormal organization of smooth muscle with collagen deposits 4. Results in hydronephrosis 5. 20% of the time may be bilateral in nature |
Ureteral-pelvic junction (UPJ) obstruction
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It represents the major cause of hydronephrosis occurring in a child.
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usually associated with double kidneys (4 ureters, 2 kidneys)
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Double ureters
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Congenital Anomaly
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When it is symptomatic it may cause an obstruction of the lower portion of the ureter.
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Diverticular out-pouching of the ureteral wall
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May be symptomatic or asymptomatic
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A congenital or acquired dilatation of the ureter
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Hydroureter
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Congenital Anomaly
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Represents a ureter in which there are multiple small mucosal cysts
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Ureteritis cystica
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Small 2 to 5 mm cysts on ureter
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Represents an accumulation of lymphocytes within the wall of the ureter presenting a fine granular appearance on the surface of the mucosa
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Ureteritis follicularis
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Collections of lymphocytes on mucosa
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Ureteritis – chronic UTI
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Ureteritis cystica
Ureteritis follicularis |
Inflammation
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Tumors and tumor like lesions: rare - Benign
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Fibro epithelial polyp and leiomyoma
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Uncommon
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Tumors and tumor like lesions: rare - Malignant
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Majority are transitional carcinomas
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It is generally seen in the 50-60 year old patient
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Obstructive lesions result in
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Hydroureter/Megaloureter
Hydronephrosis Pyelonephritis |
Cause obstruction
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Intrinsic obstructions
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Calculus
Stricture Tumor Blood clot Neurogenic |
Cause obstruction
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Extrinsic obstructions
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Pregnancy
Inflammation Endometriosis Tumor |
Cause obstruction
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In Extrinsic obstructions Inflammation is caused by?
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Salpingitis or Diverticulitis
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Extrinsic
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This is a fibroproliferative inflammatory response in which there is an excessive growth of inflammation and fibrosis surrounding the ureter resulting in blockade or obstruction
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Sclerosing retro peritoneal fibrosis
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70% are idiopathic
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sometimes referred to as idiopathic retroperitoneal fibrosis
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Sclerosing retroperitoneal fibrosis
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It is a process encasing...
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It occurs in middle to late age
70% are idiopathic Associated with ergot and beta blockers |
Sclerosing retro peritoneal fibrosis
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It is possibly autoimmune in origin
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It occurs in other areas such as the mediastinum (sclerosing mediastinitis)
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Sclerosing retro peritoneal fibrosis
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Fibroproliferative
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Reidel’s fibrosing thyroiditis and Crohn’s disease
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Sclerosing retro peritoneal fibrosis
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70% are idiopathic
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Nests of urothelial cells may invaginate into the lamina propria and are known as?
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Cell nests of von Brunn
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These have no significance
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Due to persistent urethral obstruction e.g. BPH with resultant increased intravesicle pressure
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Diverticula: Acquired
Congenital is rare |
1-5 cm pouch
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People with diverticula of the urinary bladder are more prone to develop
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Urinary stasis, infection, calculus formation, predisposition to vesico-ureteral reflux
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Clinical implications of Diverticula
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Abnormality characterized by the absence of a portion of the anterior abdominal wall, so that the urinary bladder wall is exposed to the outside.
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Exstrophy
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metaplasia of transitional epithelium, usually adenocarcinoma
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Exstrophy
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Developmental failure of the anterior abdominal wall; bladder communicates through a large defect on the abdominal wall surface or lies as an open sac to the outside.
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bladder is continuously subjected to increasing episodes of chronic inflammation
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This represents a fistulous track between the urinary bladder and the ureter, or even the uterus.
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Congenital vesico-uterine fistula
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A track
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A combination between the urinary bladder and the umbilicus
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A Urachus
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Between bladder and Urachus
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Sometimes this urachus does not completely atrophy,so that you develop an actual fistulous track between the urinary bladder and the umbilicus
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Patent urachus
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An abnormal communication of the bladder with the outside
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Capable of urinating outside umbilicus. Subject to repeated inflammation and can undergo metaplasia which can leads to the formation of an adenocarcinoma.
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Patent urachus
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He took a pee outside his umbilicus
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Causes of Acute and chronic cystitis
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Age, Sex, the presence of stones or obstruction, Calculus, Infection, Hemorrhage, Radiation, or Chemotherapy
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ASS, CALCULUS gives me INFECTIONS, and causes me to BLEED, when I have RADIATION or CHEMOTHERAPY
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Signs and Symptoms of Acute cystitis
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Fever, Abdominal Pain and Dysuria
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S & S: - triad
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Acute cystitis will present itself as a clinical triad, namely?
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Fever, Abdominal Pain and Dysuria
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May work its way retrograde up to produce a secondary pyelonephritis
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Acute cystitis is usually associated with inflammatory conditions such as:
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E. coli
Pseudomonas Proteus Klebsiella Enterobacter Schistosomes |
A Cute Bug's Life
EPPKES |
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Painful or difficult urination in the Far East
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Schistosomiasis (Schistosomes)
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Haematobium
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Hemorrhagic cystitis due to?
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Cytotoxic drugs
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Cyclophosphamide
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People who received irradiation
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Radiation cystitis
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Irradiation - Inflammation
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Long-term inflammatory condition of the bladder
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Chronic cystitis
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UF
LAP D |
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Most frequently associated in the male with benign prosthetic hypertrophy BPH
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Chronic cystitis
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Long-term
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Common cause is BPH
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Fibromatous hyperplasia -Histologic variants:
1. Follicular 2. Eosinophilic |
Increasing thickness
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As a special form of cystitis
Interstitial cystitis is sometimes called? |
Hunner’s ulcer
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A finding not present in chronic cystitis
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A persistent form of cystitis that does not respond to treatment
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Interstitial cystitis (Hunner’s ulcer)
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Ulcers Ulcers Ulcers
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It presents with painful cystitis, frequency, mucosal ulceration, hematuria, and dysuria
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Interstitial cystitis (Hunner’s ulcer)
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Unknown cause
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middle-aged female. Urine cultures are negative
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Interstitial cystitis (Hunner’s ulcer)
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Intermittent pain
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An increase in number of mast cells - significant in making diagnosis.
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Interstitial cystitis (Hunner’s ulcer)
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Middle-aged female
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Intermittent pain, urinary frequency, even blood in the urine, and painful urination
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Interstitial cystitis (Hunner’s ulcer)
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Middle-aged female
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Hypertrophy of the bladder wall - fibrotic
Increased numbers of mast cells |
Interstitial cystitis (Hunner’s ulcer)
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Special form of cystitis
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• Chronic inflammatory disease of the urinary bladder,
• Sometimes producing ulcerations Hunner’s ulcer, • Histologically shows the presence of increased Mast cells. |
Interstitial cystitis (Hunner’s ulcer)
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Special form of cystitis
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A vesicle inflammatory reaction showing raised soft yellow mucosal plaques
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Malacoplakia
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Foamy macrophages
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If you stain these areas they will show the presence of PAS (+) granules.
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multi-nucleated giant cells & lymphocytes - Malacoplakia
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Raised soft yellow mucosal plaques
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These foamy macrophages will colace to form multi-nucleated giant cells and lymphocytes - What is the Condition?
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Malacoplakia
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Foamy macrophages
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The microscopic finding which is diagnostic for Malacoplakia is a body we call?
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Michaelis-Gutman bodies (Calcospheroids)
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Deposition of Calcium
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These are small (little) laminated basophilic mineral concretions that you see within the walls or on the surface of the bladder.
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Michaelis-Gutman bodies (Calcospheroids)
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Diagnostic for Malacoplakia
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It is generally thought that Malacoplakia is related to?
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A chronic bacterial infection
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A BAD "B"
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The other important thing to remember about Malacoplakia is that?
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It has no malignant potential
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Yeah, Right!
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It may be seen in the testis, kidney and prostate
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Malacoplakia
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TKP
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The diagnostic finding is laminated basophilic mineral concretions called Michaelis-Gutman bodies which are found in macrophages or between cells.
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Malacoplakia
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Diagnostic
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Malacoplakia is thought to be related to chronic bacterial infections of?
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E. coli and Proteus
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Those little rascals - E & P
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It will show small yellow mucosal plaques with PAS (+) granules.
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Malacoplakia
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Yellow plaques
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Nests of transitional epithelial cells grow down into the mucosa forming cysts & glands. With extensive intestinal metaplasia there is an increased risk of Ca.
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Cystitis glandularis and Cstitis cystica
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(von Brunn)
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An invagination of nest of transitional epithelial cells into the underlying lamina propria, we call these: Cell nests of von Brunn and there are seen in?
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Cystitis glandularis
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Nests
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This is the same as Cystitis glandularis but it is seen in the ureter where small little cysts are formed on the mucosal surface
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Cystitis cystica
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Same but in the ureter
May give rise to metaplasia |
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You can see ectopic endometrial tissues occurring within the wall of the urinary bladder giving rise to a chronic inflammatory reaction.
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Endometriosis
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Ectopic
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Urothelial tumors: Size, higher grade give
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A worse prognosis
Deeper penetration means worse prognosis |
Neoplasms
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Transitional cell tumors make up about how much % of bladder tumors?
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90% of bladder tumors
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Neoplasms
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The ISUP grading system (International Society of Urologic Pathologists) is used to stage the disease.
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It depends on the layer into which the neoplasm has infiltrated.
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Neoplasms
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Muscularis propria
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Large bundles of smooth muscle cells
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Tumor grading by layers
The layers are, from deepest to surface |
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Muscularis mucosae
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Scattered smooth muscle cells
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Tumor grading by layers
The layers are, from deepest to surface |
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Lamina propria; basement membrane; and mucosa
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3-7 layers thick
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Tumor grading by layers
The layers are, from deepest to surface |
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Urothelial papilloma: Transitional cell papillomas account for what % of bladder neoplasms?
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Transitional cell papillomas account for 1% of bladder neoplasms
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These are usually seen in younger patients
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7% of these will develop into carcinomas. A small nodule is attached to the bladder wall by a delicate stalk.
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Urothelial papilloma
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(stalk is diagnostic)
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Invertede papillomas are similar to papillomas, but exhibit a?
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Thickened mucosa with large cells penetrating the lamina propria
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Endothitic instead of Exothytic
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These lesions have a thickened epithelium with diffuse nuclear enlargement & are generally non-invasive.
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Urothelial lesion of low malignant potential (TCC Grade I)
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Mitoses are rare
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Invasion of the muscularis propria is the diagnostic finding
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Urothelial lesion of low malignant potential (TCC Grade I)
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They are usually larger than urothelial papillomas
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With full thickness dysplasia, 50% will become malignant and invasive.
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Urothelial lesion of low malignant potential (TCC Grade I)
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Invasion of the muscularis propria is the diagnostic finding
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These exhibit good polarity and cohesion and nuclear atypism at the basal cell layer.
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Urothelial carcinoma - low grade (TCC Grade II)
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(TCC Grade II)
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It is usually papillary and invasion is rare, occurring in less than 10% of cases
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Urothelial carcinoma - low grade (TCC Grade II)
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UC-LG
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Patients are treated with intravesicle chemotherapy, not by cystectomy.
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Urothelial carcinoma - low grade (TCC Grade II)
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It is not considered to be a major threat to the patient.
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These may be papillary, nodular, allomorphic, or anaplastic
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Urothelial carcinoma - high grade (TCC Grade III)
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(TCC Grade III)
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Characterized by dys-cohesiveness with increased mitotic figures.
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Urothelial carcinoma - high grade (TCC Grade III)
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(TCC Grade III)
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It may exhibit extreme anaplasia, and invasion is common, occurring in 80% of cases.
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Urothelial carcinoma - high grade (TCC Grade III)
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It may invade the bladder wall.
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Involves the full thickness of the bladder
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Carcinoma-in-situ
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CIS
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It is characterized by cytologic malignant cells within a flat urothelial surface & is usually not big.
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Carcinoma-in-situ
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CIS
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The extent of the invasion is of prognostic importance
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Invasive urothelial carcinoma
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It is difficult to cure (IUC) IN-U-CA
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3%-7% of cases and almost always associated with chronic bladder infections
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Squamous cell carcinoma
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It is not common in the US
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It shows an increased incidence with Schistomiasis infection
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Squamous cell carcinoma
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It is not common in the US
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Is rare and is usually due to cystitis cystica or cystitis glandularis
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Adenocarcinoma
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A malignant process
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Mesenchymal Tumors – may be very large - Benign are?
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Leiomyomas
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MT
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Mesenchymal Tumors: Malignant - Produce large masses of tumor(10-15 cm) that are soft and fleshy.
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Sarcomas
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Uncommon
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Adults over the age of 40 years
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Rhabdomyosarcomas
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Sarcomas
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Seen in infancy and early childhood. They are large tumors. Biopsy will show strap cells with cross striations.
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Embryonal rhabdomyosarcomas (sarcoma botryoides)
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(sarcoma botryoides)
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Strap cells with cross striations.
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Embryonal rhabdomyosarcomas (sarcoma botryoides)
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(sarcoma botryoides)
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similar to that of lung cancer
Male affected more than female 3:1 |
Bladder cancer
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80% of patients are 50-80 years of age.
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Risk factors for bladder cancer
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Cigarette smoking
Industrial exposures Schistosomiasis Long-term use of analgesics Gene mutations |
CISLG
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Incites inflammation; there is a 3-7 X increased risk.
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Cigarette smoking
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Risk factors
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Shows a 50-80% association in men who smoke.
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Bladder cancer
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Risk factors
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Industrial exposures more common in the West
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Alpha-napthayl amines
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Risk factors
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70% are squamous cell carcinomas
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Schistosomiasis
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Risk factors
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Risk factor for bladder cancer - Long term use of analgesics, especially?
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Phenacetin
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Risk factors
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Painless hematuria; also associated with frequency, urgency and dysuria
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Clinical Findings in Bladder cancers
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BC
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Pyelonephritis - due to urethral orifice involvement
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Clinical Findings in Bladder cancers
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BC
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Hydronephrosis
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Clinical Findings in Bladder cancers
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BC
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Recurrence rate is high with anaplastic tumors 80-90%.
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Clinical Findings in Bladder cancers
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BC
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Grade I has a 98% 10 year survival rate
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Bladder cancers
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BC
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Grade III has a 40% 10 year survival rate
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Bladder cancers
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BC
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Squamous Cell Carcinoma - 20% dead in one year
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Bladder cancers
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BC
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Regarding Bladder Cancer: Early diagnosis is key to survival and is aided by?
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Urine cytology – flow cytometry of urine sediment for aneuploid tumor cells (high S-phase).
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BC
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Regarding Bladder Cancer: The last step of diagnosis is?
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Biopsy
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BC
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Obstructions: clinically important - Kidney
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Pyelonephritis
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Obstructions
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Obstructions: clinically important - Prostate gland
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BPH
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Most common obstruction
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Obstructions: clinically important - Bladder
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Calculi
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Obstructions
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Obstructions: clinically important - Cystocele
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Narrowing or stricture of urethra - seen in females
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Obstructions
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Obstructions: clinically important - Gross
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Hypertrophy and trabeculation
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Obstructions
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Invasion of the muscularis propria
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has the worst prognosis. 50% of these patients will be dead in 5 years.
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Bladder cancer has a high rate of recurrence.
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Treatment for bladder cancer:
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1. Cauterization of nodules
2. Interstitial chemotherapy 3. Cystectomy – removal of the bladder is the ultimate treatment |
BC
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Urethra:
Inflammations: Urethritis is classically divided into: |
1. Gonococcal
2. Non-gonococcal 3. Reiter’s syndrome |
Cause Urethral Inflammations
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Urethra:
Urethritis is an early sign of |
Gonococcal infection
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Cause Urethral Inflammations
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These are often accompanied by cystitis in female and prostatitis in male
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Non-gonococcal – E coli, Chlamydia, Mcoplasma infections
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Non-gonococcal
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Arthritis, urethritis, conjunctivitis – associated with mycoplasma infection
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Reiter’s syndrome
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Inflammations
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Tumors:
Is an inflamed painful red nodule at the external urethral meatus in female. It may ulcerate and bleed. Treatment is surgical excision. |
Urethral caruncle
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Surgical excision
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Tumors:
Occurs at external meatus. It may be viral in origin. exhibits highly vascular fibroblastic connective tissue |
Papilloma
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Highly vascular fibroblastic connective tissue
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Tumors:
Usually squamous cell carcinoma. It is seen in older females, and is more aggressive than transitional cell ca. |
Carcinoma
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SCC is uncommon
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Male Genital Tract:
Congenital disorders: |
1. Hypospadias
2. Epispadias 3. Phimosis |
3 enemies of the Penis
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Penis:
Congenital disorder: ventral opening (under-surface; more common) |
Hypospadias
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Penis - Congenital
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Penis:
Congenital disorder: Dorsal Opening |
Epispadias
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Penis - Congenital
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Penis:
Congenital disorder: Phimosis - prepuce is too small to permit normal retraction of foreskin - risk of infections due to poor hygiene |
Phimosis
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Penis - Congenital
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Penis:
Inflammation: These infections are the most common causes |
Syphilis, g.c. chancroid, herpes
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Penis - Inflammation
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Penis:
Inflammation: Balanoposthitis |
Inflammation of the glans and prepuce
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Penis - Inflammation
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Penis:
Inflammation: Balanoposthitis may be caused by? |
Candida and Gardnerella
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Penis - Inflammation
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Male Genital Tract:
Tumors: Is caused by HPV type 6. It can be a sessile or pedunculated lesion. |
Condyloma accuminata
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Male Genital Tract - Tumors
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The picture of condyloma acuminata is
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Red papillary excressences showing a branching villous architecture with underlying stroma covered by epithelium and exhibits koilocytic changes (clear vacuolization of prickle cells - characteristic of HPV infection - bigger than normal cells with a central nucleus).
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Male Genital Tract - Tumors
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A squamous cell dysplasia confined to the epithelium, full thickness but without invasion.
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Carcinoma-in-situ
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Male Genital Tract - Tumors
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It is considered to be pre-invasive carcinoma
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Carcinoma-in-situ
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Male Genital Tract - Tumors
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Is carcinoma-in-situ occurring in men and women over 35 years of age. The lesion shows a thick grey-white membrane with shallow ulceration and crusting.
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Bowen’s disease
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Male Genital Tract - Tumors
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Microscopically, there are atypical squmaous cells with increased mitoses but no invasion. 10% will develop SCC – involving the skin of penis
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Bowen’s disease
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Male Genital Tract - Tumors
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(on glands penis) forms a shiny red plaque, single or multiple lesions. It is histologically indistinguishable from Bowen’s disease. Patients can develop carcinoma.
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Erythroplasia of Queyrat
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Male Genital Tract - Tumors
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The lesion usually involves the surface of the glans only
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Erythroplasia of Queyrat
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Male Genital Tract - Tumors
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Occurs on external genitalia in sexually active young patients and multipigmented red brown papule associated with HPV 16.
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Bowenoid papulosis
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Male Genital Tract - Tumors
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It is histologically similar to BD but does not develop Ca.
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Bowenoid papulosis
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Male Genital Tract - Tumors
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High rate in Asia and Africa. Circumcision protects due to better hygiene.
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Carcinoma
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Male Genital Tract - Tumors
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Carcinoma is usually?
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A squamous cell carcinoma
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SCC
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Male Genital Tract:
Tumors: Verrucous carcinoma is a giant condyloma and is also called? |
(Buschke-Lowenstein tumor)
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Male Genital Tract - Tumors
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It is slow growing, with local spread to inguinal and iliac lymph nodes.
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Carcinoma: Verrucous carcinoma is a giant condyloma (Buschke-Lowenstein tumor)
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Male Genital Tract - Tumors
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It is associated with HPV 16 &18 and forms a painless ulcer. There is a direct relationship to cigarette smoking.
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Carcinoma: Verrucous carcinoma is a giant condyloma (Buschke-Lowenstein tumor)
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Male Genital Tract - Tumors
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Cryptorchidism?
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A failure of the testicle to descend into the scrotal sac.
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Congenial anomaly
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The testicle is palpable in inguinal canal, small, firm, and atrophic. It is usually unilateral.
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Cryptorchidism
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Congenial anomaly
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Microscopically there is arrest of germ cell development with habitation and thickening of the basement membrane with hyalinization and obliteration, and increased interstitial cells of Leydeg.
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Cryptorchidism
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Congenial anomaly
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Cryptorchidism results in?
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Sterility
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Congenial anomaly
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There is a 5-10 X risk of a germ cell tumor. Treatment is by orchiplexy – surgically moving the testicle into the scrotum.
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Cryptorchidism
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Congenial anomaly
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Regressive changes:
Causes may be inflammation, atherosclerosis, cryptorchdism, hypopituitarism, radiation, or estrogen therapy (prostate Ca) |
Atrophy
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Testes and Epididymis
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Regressive changes:
Causes include GC, TB, Syphilis, Mumps. |
Inflammation
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Testes and Epididymis
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Regressive changes:
True inflammation is? |
Orchiditis
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Testes and Epididymis
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Vascular disturbances:
Will result in infarct due to decreased oxygen, and commonly occurs in athletes. |
Torsion
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Testes and Epididymis
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Testicular Tumors are associated with?
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Cryptorchidism
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Testes and Epididymis
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The higher up the greater risk of Ca
Genetic factors - racial differences |
Testicular Tumors
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Testes and Epididymis
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Testicular Tumors:
Tsticular feminization and Klinefelter’s syndrome show an increased risk of Ca |
Testicular dysgenesis
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Testes and Epididymis
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Appear as painless mass and characteristically spread to the retro- peritoneal lymph nodes to the par aortic, to mediastinal lymph node, and then to supraclavicular nodes.
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Testicular tumors
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TT
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Testicular tumors are divided into two major types?
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1. Germ cell tumors
2. Non-germ cell tumors |
TT
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Testicular tumor:
Two major categories? |
1. Germ Cell tumors
2. Sex-Cord Tumors |
TT
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Occur in younger males, blacks more than whites. These may be of 2 types:
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Germ Cell tumors
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TT
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Germ Cell tumors may be of 2 types?
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a. Pure or Single Histologic Pattern
b. Mixed Histologic Pattern |
TT
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40% of testicular tumors
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Pure or Single Histologic Pattern type.
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TT
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Pure or Single Histologic Pattern:
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i. Seminomatous tumors Seminomas (seminiferous tubule tumor)
ii. Non-seminatous tumors |
TT
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Non-seminatous tumors -
A subcategory of Pure or Single Histologic Pattern: |
1. bEmbryonal carcinoma
2. Yolk sac tumor (endodermal sinus tumor) 3. Choriocarcinoma: may be mature, immature, or malignant transformation |
TT
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60% of testicular tumors. These are not as treatable as pure cell tumors.
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Mixed Histologic Pattern
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TT
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Embryonal carcinoma with teratoma (teratocarcinoma)
Choriocarcinoma with any other type |
Mixed Histologic Pattern
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TT
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Sex-Cord Tumors:
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a. Leydig cell tumor
b. Sertoli cell tumor c. Granulosa cell tumor |
Are well differentiated
TT |
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Are the most common form of testicular tumor with a peak age of 30 years.
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Seminomas
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TT
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They are similar to an ovarian neoplasm (dysgerminoma). There is usually no invasion.
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Seminomas
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TT
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These may be up to 10 mm, or very small and they respond well to radiation therapy.
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Seminomas
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TT
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There are 3 histologic variants of Seminomas, name them?
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1. Typical seminomas
2. Anaplastic seminomas 3. Spermatocytic seminomas |
TT
Seminomas |
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85% - Homogeneous, grey white with no penetration of the tunica vaginalis and usually shows no hemorrhage or infarct.
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Typical seminomas
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TT
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Consist of sheets of uniform appearing cells with delicate fibers infiltrated with lymphocytes and rare mitosis
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Typical seminomas
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TT
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5-10% - It is a more aggressive tumor with marked cellular and nuclear changes with giant cells and many mitoses (More than 3 per high power field)
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Anaplastic seminomas
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TT
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4-6% - It is a distinct but uncommon tumor, usually seen over the age of 60 years and is composed of three cell types: large, small and giant cells.
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Spermatocytic seminomas
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TT
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They do not secrete alpha-fetoprotein or HCG. They do exhibit high levels of placental alkaline phosphatase.
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Seminomas
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TT
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Non-Seminomatous tumors:
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1. Embryonal carcinoma
2. Yolk Sac tumor 3. Choriocarcinoma 4. Teratomas 5. Mixed Tumors |
TT
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Most often in the 20-30 age group. Gross appearance: poorly defined tumor boundaries - usually smaller than seminomas, characterized by hemorrhage and/ necrosis. May penetrate the tunica albunigea.
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Embryonal carcinoma
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TT
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Microscopically, there is a glandular alveolar or tubular pattern with papillary convolutions, and frequent mitoses and giant cells. The carcinoma may show syncytial cells which may contain HCG or AFP (Mixed type)
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Embryonal carcinoma
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TT
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Is an infantile embryonal carcinoma or endodermal sinus tumor and is the most common testicular tumor in infants up to three years. It has a yellow-white mutinous appearance.
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Yolk Sac tumor
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TT
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The microscopic appearance is a micro-cystic papillary pattern containing glomerular type structures known as Schiller-Duval bodies. Within the cytoplasm of these cells are eosinophilic hyaline globules which contain alpha-fetoprotein and alpha-1-antitrypsin.
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Yolk Sac tumor
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TT
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occurs in 1% of these tumors, usually mixed with some other form of neoplasm. It is a highly malignant tumor which consists of both synctiotrophoblasts (large irregular hyperchromatic nuclei with eosinophilic cytoplasm) and cytotrophoblasts (regular polygonal distinct cell borders with clear cytoplasm).
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Choriocarcinoma
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TT
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Is aggressive but remains of small size. Hemorrage and necrosis are extremely common and the tumor does produce extremely high levels of HCG.
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Choriocarcinoma
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TT
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Possess various cellular or organoid components (endoderm, ectoderm, and mesoderm) and occur at any age.are usually very large - 5-10 cm. There are multiple histologic types:
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Teratomas
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TT
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Different types of teratomas:
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a. Mature teratomas
b. Immature teratomas c. Teratomas with malignant transformation |
TT
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are well differentiated cells such as nerve, muscle cartilage, squamous epithelium, thyroid, GI or brain tissue, and are usually seen in children.
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Mature teratomas
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TT
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Have 3 germ cell layers with incomplete differentiation.
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Immature teratomas
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TT
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Are clearly the appearance of a malignant neoplasm. Examples are Squamous cell Carcinoma, adenocarcinoma, or sarcoma.
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Teratomas with malignant transformation
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TT
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These are tumors composed of more than one type of tumor and account for 60% of testicular tumors.
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Mixed Tumors
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TT
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Examples of mixed tumors include
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Seminoma with embryonic Carcinoma, and embryonal Carcinomas with teratoma (teratocarcinoma).
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TT
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From the clinical standpoint tumors of the testis are classified into two broad categories:
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1. Seminomas
2. Non-seminomatous tumors |
TT
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Tend to remain local
70% stage I tumors Mets via lymphatic Radiosensitive |
Seminomas
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TT
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60% have advanced clinical disease
Mets via blood Non-radiosensitive |
Non-seminomatous tumors
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TT
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Clinical Staging of Testicular tumors:
STAGE I |
Confined to testicle
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TT
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Clinical Staging of Testicular tumors:
STAGE II |
Distant spread to retro peritoneal nodes below the diaphragm
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TT
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Clinical Staging of Testicular tumors:
STAGE III |
Distant spread above the diaphragm
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TT
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Characteristic mode of spread of testicular cancer is via?
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Lymphatic
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TT
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Characteristic mode of spread of testicular cancer is via lymphatic
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1. Retro peritoneal (para-aortic nodes first)
2. Mediastinal 3. Supraclavicular 4. Hematogenous spread: lungs, liver, brain, bone |
TT
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Biologic Markers:
A glycoprotein containing two polypeptide chains: alpha and beta, normally synthesized and secreted by placental syncytiotrophoblasts? |
HCG
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Biologic Markers
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A serum protein synthesized in the fetal gut, liver and yolk sac. After the first year of life it is normally undetectable. It is seen in yolk sac tumors but also seen in hepatocellular carcinomas and ulcerative colitis?
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AFP
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Biologic Markers
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Biologic Markers:
Only produced by seminomas |
Placental alkaline phosphatase
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Biologic Markers
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Biologic Markers:
High in seminomas |
LDH
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Biologic Markers
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Biologic Markers:
Are elevated in mixed cell tumors; (Note:Placental alkaline phosphatase and LDH are elevated in seminomas) |
HCG & AFP
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Biologic Markers
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Biologic Markers:
Yolk sac tumors will produce? |
AFP only
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Biologic Markers
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Biologic Markers:
Choriocarcinoma will produce? |
HCG only
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Biologic Markers
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Value of Markers:
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1. In the initial evaluation of a testicular mass
2. For staging following orchidectomy 3. LDH will asses tumor burden 6 months post-operative 4. Predict possible recurrence if levels remain elevated after surgery |
Value of Markers
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Tumors of Sex cord- gonadal stroma:
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1. Leydig cell (interstitial) tumors
2. Sertoli cell tumors 3. Testicular lymphomas |
Tumors of Sex cord- gonadal stroma
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Are derived from stromal tissues and may elaborate androgens and/or estrogens. Patients will show enlarged testicles or gynecomastia. In children you will see precocious puberty. Microscopically there are large round to oval cells with abundant eosinophilic cytoplasm (diagnostic feature is crystalloids of Reinke - rectangular, eosinophilic cytoplasm inclusions).
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Leydig cell (interstitial) tumors
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Tumors of Sex cord- gonadal stroma
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Are derived from sex cords. Sertoli cell tumors were previously called androblastomas. They occur in younger patients and are composed of sertoli cells which resemble semeniferous tubules. Estrogenic effect causes gynecomastia.
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Sertoli cell tumors
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Tumors of Sex cord- gonadal stroma
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Are usually a B-cell lymphoma, usually occurring after age 60. They are rare but very aggressive.
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Testicular lymphomas
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Tumors of Sex cord- gonadal stroma
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Lesions of the Tunica Vaginalis:
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1. Hydrocele
2. Hematocele 3. Spermatocele 4. Varicocele 5. Chylocele |
Lesions of the Tunica Vaginalis
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Is an accumulation of clear fluid within the scrotal sac – may be up to 10 cm in diameter. Diagnosis is by transillumination
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Hydrocele
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Lesions of the Tunica Vaginalis
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Results from blood in the sac, usually due to trauma or torsion
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Hematocele
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Lesions of the Tunica Vaginalis
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Is a cyst with accumulation of spermatozoa, usually occurring due to surgery for an orchidectomy.
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Spermatocele
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Lesions of the Tunica Vaginalis
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Dilated veins in the spermatic cord
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Varicocele
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Lesions of the Tunica Vaginalis
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Elephantiasis
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Chylocele
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Lesions of the Tunica Vaginalis
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Prostate Gland:
Inflammation (prostatis): |
a. Acute bacterial prostatitis
b. Chronic bacterial prostatitis c. Chronic abacterial prostatitis |
Prostate Gland
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Diagnose with urine culture. It may be a focal or diffuse suppurative inflammation, usually caused by E. coli or other gram negative rod. Symptoms are fever, chills, dysuria, and an acutely tender prostate with rectal exam.
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Acute bacterial prostatitis
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Prostate Gland
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Presents with low back pain and dysuria. It is characterized by recurrent UTI, cystitis, and urethritis. Diagnosis: leukocytes in prostatic secretions and a positive culture.
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Chronic bacterial prostatitis
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Prostate Gland
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Is the most common form of prostatitis. It is similar to chronic bacterial prostatitis except for negative culture and is seen commonly in sexually active individuals. Chronic abacterial prostatis may be caused by Chlamydia trachoma and Mycoplasma hominis.
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Chronic abacterial prostatitis
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Prostate Gland
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Benign enlargememt:
Occurs in 20% of males over 40, 70% of males over 60, and 90% of males over 70. Is related to androgens |
(prostatic hyperplasia) BPH.
|
Benign enlargememt
|
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Benign enlargememt:
Is a metabolite of testosterone and acts on androgen receptor sites of the prostate maintaining normal prostate function. It is 10X more potent in its effect than testosterone. |
Dihydrotestosterone
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Benign enlargememt
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Benign enlargememt:
Estrogens induce or increase androgen receptor sites rendering the cells more susceptible to the action of DHT resulting in |
Prostatic Hyperplasia
|
Benign enlargememt
|
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Benign enlargememt:
As males age, there is a decreased ability to detoxify |
DNT
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Benign enlargememt
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Benign enlargememt:
Gross appearance of BPH? |
Is a nodular, whorled pattern
|
Benign enlargememt
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Benign enlargememt:
Microscopic appearance of BPH? |
Glands exhibit a double layer of cells with inner columnar and outer cuboidal hyperplasia. BPH may be asymptomatic. There may be areas of infarct, indicated by foci of squamous metaplasia.
|
Benign enlargememt
|
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Clinical symptoms of BPH:
|
a. Compress the urethra
b. Retention of urine in bladder - thus vulnerable to infections c. Generally considered not to be a pre-malignant process |
Clinical symptoms of BPH
|
|
|
Is the most common cancer in men. It usually occurs after 50 years. Latent ca is present at 20% in 50 year olds, and 70%= 70-80 year olds. It is rare in Asians, but has an increased incidence in blacks.
|
Prostate cancer
|
Tumors of the Prostate Gland
|
|
|
Etiology of prostate cancer is influenced by?
|
Age, race, family history, hormone levels, environmental factors(as evidenced by the fact that a man going from low incidence areas to high incidence areas show increased risk of developing Ca). It is thought that androgens play a part in development of prostate cancer.
|
Tumors of the Prostate Gland
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Tumors of the Prostate Gland:
Morphology of Prostate cancer |
70% occur peripherally, most commonly in the posterior lobe, and almost all are adenocarcinoma.
|
Tumors of the Prostate Gland
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Prostate cancer spreads via:
|
1. Direct invasion or contiguous spread
2. Hematogeneous spread 3. Lymphatic spread |
Tumors of the Prostate Gland
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Prostate cancer:
Beginning at the base of bladder, seminal vesicles |
Direct invasion or contiguous spread
|
Prostate cancer
|
|
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Prostate cancer:
Is chiefly to bone by osteoblastic mets (more common) or osteolytic lesions. Cranial mets seen as a result of passage up the vertebral column through the paravertebral veins of Batson and invades the calvarium. |
Hematogeneous spread
|
Prostate cancer
|
|
|
Prostate cancer:
Is via the obturator nodes, inguinal, and pelvic lymph nodes. Upon pelvic lymphadenectomy if there are positive Obturator lymph nodes, surgery (prostatectomy) is not done. |
Lymphatic spread
|
Prostate cancer
|
|
|
Prostate cancer:
Shows malignant cells one layer thick, back to back with little stroma (normal prostatic gland arrangement is 2 layers thick. The best indication of malignancy is capsular invasion and perineural invasion |
Adenocarcinoma
|
Prostate cancer
|
|
|
Prostate cancer:
A precancerous lesion exhibiting dysplastic cells. It is thought to be a intermediate lesion between normal and malignant tissues |
Concept of PIN
|
Prostate cancer
|
|
|
Grading:
Gleason’s grading system |
Gleason’s grading system
There are five grades, based on the histologic pattern and degree of differentiation - assess and add to a total of ten. Assign a primary grade to the dominant cellular type and then assign a secondary grade to the sub-dominant type. Add the two together to come up with the Gleason’s grade. For example a well differentiated tumor 1+2=3; Good correlation with prognosis. |
Prostate cancer
|
|
|
Biochemical markers:
In normal males, it is seen in small amounts (<4 ng/ml). Is organ specific but not cause specific, as it is also seen in nodular hyperplasia and prostatitis |
Prostatic specific antigen (PSA), a product of prostatic epithelium.
Prostatic acid phosphatase (PAP) old type, has been supplanted by PSA. |
Prostate cancer
|
|
|
Biochemical markers:
% free PSA - differentiates between? |
Non-neoplastic and neoplastic prostatic lesions.
|
Prostate cancer
|
|
|
Biochemical markers:
Free PSA is lower in Ca. Use free PSA to test when? |
Levels of PSA are in the gray zone (4-10).
|
Prostate cancer
|
|
|
Biochemical markers:
Serial measurement valuable in assessing |
Response to therapy
|
Prostate cancer
|
|
|
Treatment for Prostate cancer
|
Surgery – transurethral prostatic resection – cauterize and remove select areas of the prostate. Over age 70, often no treatment is done.
Radiotherapy Hormonal manipulation – useful if there is mets Orchiectomy Estrogen therapy |
Prostate cancer
|
