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240 Cards in this Set

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Congenital Anomalies
a. double ureters
b. (UPJ) obstruction
c. Diverticular out-pouching
d. Hydroureter
Ureters: Easily obstructed
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
It represents the major cause of hydronephrosis occurring in a child.
usually associated with double kidneys (4 ureters, 2 kidneys)
Double ureters
Congenital Anomaly
When it is symptomatic it may cause an obstruction of the lower portion of the ureter.
Diverticular out-pouching of the ureteral wall
May be symptomatic or asymptomatic
A congenital or acquired dilatation of the ureter
Hydroureter
Congenital Anomaly
Represents a ureter in which there are multiple small mucosal cysts
Ureteritis cystica
Small 2 to 5 mm cysts on ureter
Represents an accumulation of lymphocytes within the wall of the ureter presenting a fine granular appearance on the surface of the mucosa
Ureteritis follicularis
Collections of lymphocytes on mucosa
Ureteritis – chronic UTI
Ureteritis cystica
Ureteritis follicularis
Inflammation
Tumors and tumor like lesions: rare - Benign
Fibro epithelial polyp and leiomyoma
Uncommon
Tumors and tumor like lesions: rare - Malignant
Majority are transitional carcinomas
It is generally seen in the 50-60 year old patient
Obstructive lesions result in
Hydroureter/Megaloureter
Hydronephrosis
Pyelonephritis
Cause obstruction
Intrinsic obstructions
Calculus
Stricture
Tumor
Blood clot
Neurogenic
Cause obstruction
Extrinsic obstructions
Pregnancy
Inflammation
Endometriosis
Tumor
Cause obstruction
In Extrinsic obstructions Inflammation is caused by?
Salpingitis or Diverticulitis
Extrinsic
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
Sclerosing retro peritoneal fibrosis
70% are idiopathic
sometimes referred to as idiopathic retroperitoneal fibrosis
Sclerosing retroperitoneal fibrosis
It is a process encasing...
It occurs in middle to late age
70% are idiopathic
Associated with ergot and beta blockers
Sclerosing retro peritoneal fibrosis
It is possibly autoimmune in origin
It occurs in other areas such as the mediastinum (sclerosing mediastinitis)
Sclerosing retro peritoneal fibrosis
Fibroproliferative
Reidel’s fibrosing thyroiditis and Crohn’s disease
Sclerosing retro peritoneal fibrosis
70% are idiopathic
Nests of urothelial cells may invaginate into the lamina propria and are known as?
Cell nests of von Brunn
These have no significance
Due to persistent urethral obstruction e.g. BPH with resultant increased intravesicle pressure
Diverticula: Acquired

Congenital is rare
1-5 cm pouch
People with diverticula of the urinary bladder are more prone to develop
Urinary stasis, infection, calculus formation, predisposition to vesico-ureteral reflux
Clinical implications of Diverticula
Abnormality characterized by the absence of a portion of the anterior abdominal wall, so that the urinary bladder wall is exposed to the outside.
Exstrophy
metaplasia of transitional epithelium, usually adenocarcinoma
Exstrophy
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.
bladder is continuously subjected to increasing episodes of chronic inflammation
This represents a fistulous track between the urinary bladder and the ureter, or even the uterus.
Congenital vesico-uterine fistula
A track
A combination between the urinary bladder and the umbilicus
A Urachus
Between bladder and Urachus
Sometimes this urachus does not completely atrophy,so that you develop an actual fistulous track between the urinary bladder and the umbilicus
Patent urachus
An abnormal communication of the bladder with the outside
Capable of urinating outside umbilicus. Subject to repeated inflammation and can undergo metaplasia which can leads to the formation of an adenocarcinoma.
Patent urachus
He took a pee outside his umbilicus
Causes of Acute and chronic cystitis
Age, Sex, the presence of stones or obstruction, Calculus, Infection, Hemorrhage, Radiation, or Chemotherapy
ASS, CALCULUS gives me INFECTIONS, and causes me to BLEED, when I have RADIATION or CHEMOTHERAPY
Signs and Symptoms of Acute cystitis
Fever, Abdominal Pain and Dysuria
S & S: - triad
Acute cystitis will present itself as a clinical triad, namely?
Fever, Abdominal Pain and Dysuria
May work its way retrograde up to produce a secondary pyelonephritis
Acute cystitis is usually associated with inflammatory conditions such as:
E. coli
Pseudomonas
Proteus
Klebsiella
Enterobacter
Schistosomes
A Cute Bug's Life
EPPKES
Painful or difficult urination in the Far East
Schistosomiasis (Schistosomes)
Haematobium
Hemorrhagic cystitis due to?
Cytotoxic drugs
Cyclophosphamide
People who received irradiation
Radiation cystitis
Irradiation - Inflammation
Long-term inflammatory condition of the bladder
Chronic cystitis
UF
LAP
D
Most frequently associated in the male with benign prosthetic hypertrophy BPH
Chronic cystitis
Long-term
Common cause is BPH
Fibromatous hyperplasia -Histologic variants:
1. Follicular
2. Eosinophilic
Increasing thickness
As a special form of cystitis
Interstitial cystitis is sometimes called?
Hunner’s ulcer
A finding not present in chronic cystitis
A persistent form of cystitis that does not respond to treatment
Interstitial cystitis (Hunner’s ulcer)
Ulcers Ulcers Ulcers
It presents with painful cystitis, frequency, mucosal ulceration, hematuria, and dysuria
Interstitial cystitis (Hunner’s ulcer)
Unknown cause
middle-aged female. Urine cultures are negative
Interstitial cystitis (Hunner’s ulcer)
Intermittent pain
An increase in number of mast cells - significant in making diagnosis.
Interstitial cystitis (Hunner’s ulcer)
Middle-aged female
Intermittent pain, urinary frequency, even blood in the urine, and painful urination
Interstitial cystitis (Hunner’s ulcer)
Middle-aged female
Hypertrophy of the bladder wall - fibrotic
Increased numbers of mast cells
Interstitial cystitis (Hunner’s ulcer)
Special form of cystitis
• 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)
Special form of cystitis
A vesicle inflammatory reaction showing raised soft yellow mucosal plaques
Malacoplakia
Foamy macrophages
If you stain these areas they will show the presence of PAS (+) granules.
multi-nucleated giant cells & lymphocytes - Malacoplakia
Raised soft yellow mucosal plaques
These foamy macrophages will colace to form multi-nucleated giant cells and lymphocytes - What is the Condition?
Malacoplakia
Foamy macrophages
The microscopic finding which is diagnostic for Malacoplakia is a body we call?
Michaelis-Gutman bodies (Calcospheroids)
Deposition of Calcium
These are small (little) laminated basophilic mineral concretions that you see within the walls or on the surface of the bladder.
Michaelis-Gutman bodies (Calcospheroids)
Diagnostic for Malacoplakia
It is generally thought that Malacoplakia is related to?
A chronic bacterial infection
A BAD "B"
The other important thing to remember about Malacoplakia is that?
It has no malignant potential
Yeah, Right!
It may be seen in the testis, kidney and prostate
Malacoplakia
TKP
The diagnostic finding is laminated basophilic mineral concretions called Michaelis-Gutman bodies which are found in macrophages or between cells.
Malacoplakia
Diagnostic
Malacoplakia is thought to be related to chronic bacterial infections of?
E. coli and Proteus
Those little rascals - E & P
It will show small yellow mucosal plaques with PAS (+) granules.
Malacoplakia
Yellow plaques
Nests of transitional epithelial cells grow down into the mucosa forming cysts & glands. With extensive intestinal metaplasia there is an increased risk of Ca.
Cystitis glandularis and Cstitis cystica
(von Brunn)
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?
Cystitis glandularis
Nests
This is the same as Cystitis glandularis but it is seen in the ureter where small little cysts are formed on the mucosal surface
Cystitis cystica
Same but in the ureter

May give rise to metaplasia
You can see ectopic endometrial tissues occurring within the wall of the urinary bladder giving rise to a chronic inflammatory reaction.
Endometriosis
Ectopic
Urothelial tumors: Size, higher grade give
A worse prognosis

Deeper penetration means worse prognosis
Neoplasms
Transitional cell tumors make up about how much % of bladder tumors?
90% of bladder tumors
Neoplasms
The ISUP grading system (International Society of Urologic Pathologists) is used to stage the disease.
It depends on the layer into which the neoplasm has infiltrated.
Neoplasms
Muscularis propria
Large bundles of smooth muscle cells
Tumor grading by layers
The layers are, from deepest to surface
Muscularis mucosae
Scattered smooth muscle cells
Tumor grading by layers
The layers are, from deepest to surface
Lamina propria; basement membrane; and mucosa
3-7 layers thick
Tumor grading by layers
The layers are, from deepest to surface
Urothelial papilloma: Transitional cell papillomas account for what % of bladder neoplasms?
Transitional cell papillomas account for 1% of bladder neoplasms
These are usually seen in younger patients
7% of these will develop into carcinomas. A small nodule is attached to the bladder wall by a delicate stalk.
Urothelial papilloma
(stalk is diagnostic)
Invertede papillomas are similar to papillomas, but exhibit a?
Thickened mucosa with large cells penetrating the lamina propria
Endothitic instead of Exothytic
These lesions have a thickened epithelium with diffuse nuclear enlargement & are generally non-invasive.
Urothelial lesion of low malignant potential (TCC Grade I)
Mitoses are rare
Invasion of the muscularis propria is the diagnostic finding
Urothelial lesion of low malignant potential (TCC Grade I)
They are usually larger than urothelial papillomas
With full thickness dysplasia, 50% will become malignant and invasive.
Urothelial lesion of low malignant potential (TCC Grade I)
Invasion of the muscularis propria is the diagnostic finding
These exhibit good polarity and cohesion and nuclear atypism at the basal cell layer.
Urothelial carcinoma - low grade (TCC Grade II)
(TCC Grade II)
It is usually papillary and invasion is rare, occurring in less than 10% of cases
Urothelial carcinoma - low grade (TCC Grade II)
UC-LG
Patients are treated with intravesicle chemotherapy, not by cystectomy.
Urothelial carcinoma - low grade (TCC Grade II)
It is not considered to be a major threat to the patient.
These may be papillary, nodular, allomorphic, or anaplastic
Urothelial carcinoma - high grade (TCC Grade III)
(TCC Grade III)
Characterized by dys-cohesiveness with increased mitotic figures.
Urothelial carcinoma - high grade (TCC Grade III)
(TCC Grade III)
It may exhibit extreme anaplasia, and invasion is common, occurring in 80% of cases.
Urothelial carcinoma - high grade (TCC Grade III)
It may invade the bladder wall.
Involves the full thickness of the bladder
Carcinoma-in-situ
CIS
It is characterized by cytologic malignant cells within a flat urothelial surface & is usually not big.
Carcinoma-in-situ
CIS
The extent of the invasion is of prognostic importance
Invasive urothelial carcinoma
It is difficult to cure (IUC) IN-U-CA
3%-7% of cases and almost always associated with chronic bladder infections
Squamous cell carcinoma
It is not common in the US
It shows an increased incidence with Schistomiasis infection
Squamous cell carcinoma
It is not common in the US
Is rare and is usually due to cystitis cystica or cystitis glandularis
Adenocarcinoma
A malignant process
Mesenchymal Tumors – may be very large - Benign are?
Leiomyomas
MT
Mesenchymal Tumors: Malignant - Produce large masses of tumor(10-15 cm) that are soft and fleshy.
Sarcomas
Uncommon
Adults over the age of 40 years
Rhabdomyosarcomas
Sarcomas
Seen in infancy and early childhood. They are large tumors. Biopsy will show strap cells with cross striations.
Embryonal rhabdomyosarcomas (sarcoma botryoides)
(sarcoma botryoides)
Strap cells with cross striations.
Embryonal rhabdomyosarcomas (sarcoma botryoides)
(sarcoma botryoides)
similar to that of lung cancer
Male affected more than female 3:1
Bladder cancer
80% of patients are 50-80 years of age.
Risk factors for bladder cancer
Cigarette smoking
Industrial exposures
Schistosomiasis
Long-term use of analgesics
Gene mutations
CISLG
Incites inflammation; there is a 3-7 X increased risk.
Cigarette smoking
Risk factors
Shows a 50-80% association in men who smoke.
Bladder cancer
Risk factors
Industrial exposures more common in the West
Alpha-napthayl amines
Risk factors
70% are squamous cell carcinomas
Schistosomiasis
Risk factors
Risk factor for bladder cancer - Long term use of analgesics, especially?
Phenacetin
Risk factors
Painless hematuria; also associated with frequency, urgency and dysuria
Clinical Findings in Bladder cancers
BC
Pyelonephritis - due to urethral orifice involvement
Clinical Findings in Bladder cancers
BC
Hydronephrosis
Clinical Findings in Bladder cancers
BC
Recurrence rate is high with anaplastic tumors 80-90%.
Clinical Findings in Bladder cancers
BC
Grade I has a 98% 10 year survival rate
Bladder cancers
BC
Grade III has a 40% 10 year survival rate
Bladder cancers
BC
Squamous Cell Carcinoma - 20% dead in one year
Bladder cancers
BC
Regarding Bladder Cancer: Early diagnosis is key to survival and is aided by?
Urine cytology – flow cytometry of urine sediment for aneuploid tumor cells (high S-phase).
BC
Regarding Bladder Cancer: The last step of diagnosis is?
Biopsy
BC
Obstructions: clinically important - Kidney
Pyelonephritis
Obstructions
Obstructions: clinically important - Prostate gland
BPH
Most common obstruction
Obstructions: clinically important - Bladder
Calculi
Obstructions
Obstructions: clinically important - Cystocele
Narrowing or stricture of urethra - seen in females
Obstructions
Obstructions: clinically important - Gross
Hypertrophy and trabeculation
Obstructions
Invasion of the muscularis propria
has the worst prognosis. 50% of these patients will be dead in 5 years.
Bladder cancer has a high rate of recurrence.
Treatment for bladder cancer:
1. Cauterization of nodules
2. Interstitial chemotherapy
3. Cystectomy – removal of the bladder is the ultimate treatment
BC
Urethra:
Inflammations: Urethritis is classically divided into:
1. Gonococcal
2. Non-gonococcal
3. Reiter’s syndrome
Cause Urethral Inflammations
Urethra:
Urethritis is an early sign of
Gonococcal infection
Cause Urethral Inflammations
These are often accompanied by cystitis in female and prostatitis in male
Non-gonococcal – E coli, Chlamydia, Mcoplasma infections
Non-gonococcal
Arthritis, urethritis, conjunctivitis – associated with mycoplasma infection
Reiter’s syndrome
Inflammations
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
Surgical excision
Tumors:
Occurs at external meatus. It may be viral in origin. exhibits highly vascular fibroblastic connective tissue
Papilloma
Highly vascular fibroblastic connective tissue
Tumors:
Usually squamous cell carcinoma. It is seen in older females, and is more aggressive than transitional cell ca.
Carcinoma
SCC is uncommon
Male Genital Tract:
Congenital disorders:
1. Hypospadias
2. Epispadias
3. Phimosis
3 enemies of the Penis
Penis:
Congenital disorder:
ventral opening (under-surface; more common)
Hypospadias
Penis - Congenital
Penis:
Congenital disorder:
Dorsal Opening
Epispadias
Penis - Congenital
Penis:
Congenital disorder:
Phimosis - prepuce is too small to permit normal retraction of foreskin - risk of infections due to poor hygiene
Phimosis
Penis - Congenital
Penis:
Inflammation:
These infections are the most common causes
Syphilis, g.c. chancroid, herpes
Penis - Inflammation
Penis:
Inflammation:
Balanoposthitis
Inflammation of the glans and prepuce
Penis - Inflammation
Penis:
Inflammation:
Balanoposthitis may be caused by?
Candida and Gardnerella
Penis - Inflammation
Male Genital Tract:
Tumors:
Is caused by HPV type 6. It can be a sessile or pedunculated lesion.
Condyloma accuminata
Male Genital Tract - Tumors
The picture of condyloma acuminata is
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).
Male Genital Tract - Tumors
A squamous cell dysplasia confined to the epithelium, full thickness but without invasion.
Carcinoma-in-situ
Male Genital Tract - Tumors
It is considered to be pre-invasive carcinoma
Carcinoma-in-situ
Male Genital Tract - Tumors
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.
Bowen’s disease
Male Genital Tract - Tumors
Microscopically, there are atypical squmaous cells with increased mitoses but no invasion. 10% will develop SCC – involving the skin of penis
Bowen’s disease
Male Genital Tract - Tumors
(on glands penis) forms a shiny red plaque, single or multiple lesions. It is histologically indistinguishable from Bowen’s disease. Patients can develop carcinoma.
Erythroplasia of Queyrat
Male Genital Tract - Tumors
The lesion usually involves the surface of the glans only
Erythroplasia of Queyrat
Male Genital Tract - Tumors
Occurs on external genitalia in sexually active young patients and multipigmented red brown papule associated with HPV 16.
Bowenoid papulosis
Male Genital Tract - Tumors
It is histologically similar to BD but does not develop Ca.
Bowenoid papulosis
Male Genital Tract - Tumors
High rate in Asia and Africa. Circumcision protects due to better hygiene.
Carcinoma
Male Genital Tract - Tumors
Carcinoma is usually?
A squamous cell carcinoma
SCC
Male Genital Tract:
Tumors:
Verrucous carcinoma is a giant condyloma and is also called?
(Buschke-Lowenstein tumor)
Male Genital Tract - Tumors
It is slow growing, with local spread to inguinal and iliac lymph nodes.
Carcinoma: Verrucous carcinoma is a giant condyloma (Buschke-Lowenstein tumor)
Male Genital Tract - Tumors
It is associated with HPV 16 &18 and forms a painless ulcer. There is a direct relationship to cigarette smoking.
Carcinoma: Verrucous carcinoma is a giant condyloma (Buschke-Lowenstein tumor)
Male Genital Tract - Tumors
Cryptorchidism?
A failure of the testicle to descend into the scrotal sac.
Congenial anomaly
The testicle is palpable in inguinal canal, small, firm, and atrophic. It is usually unilateral.
Cryptorchidism
Congenial anomaly
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.
Cryptorchidism
Congenial anomaly
Cryptorchidism results in?
Sterility
Congenial anomaly
There is a 5-10 X risk of a germ cell tumor. Treatment is by orchiplexy – surgically moving the testicle into the scrotum.
Cryptorchidism
Congenial anomaly
Regressive changes:
Causes may be inflammation, atherosclerosis, cryptorchdism, hypopituitarism, radiation, or estrogen therapy (prostate Ca)
Atrophy
Testes and Epididymis
Regressive changes:
Causes include GC, TB, Syphilis, Mumps.
Inflammation
Testes and Epididymis
Regressive changes:
True inflammation is?
Orchiditis
Testes and Epididymis
Vascular disturbances:
Will result in infarct due to decreased oxygen, and commonly occurs in athletes.
Torsion
Testes and Epididymis
Testicular Tumors are associated with?
Cryptorchidism
Testes and Epididymis
The higher up the greater risk of Ca
Genetic factors - racial differences
Testicular Tumors
Testes and Epididymis
Testicular Tumors:
Tsticular feminization and Klinefelter’s syndrome show an increased risk of Ca
Testicular dysgenesis
Testes and Epididymis
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.
Testicular tumors
TT
Testicular tumors are divided into two major types?
1. Germ cell tumors
2. Non-germ cell tumors
TT
Testicular tumor:

Two major categories?
1. Germ Cell tumors
2. Sex-Cord Tumors
TT
Occur in younger males, blacks more than whites. These may be of 2 types:
Germ Cell tumors
TT
Germ Cell tumors may be of 2 types?
a. Pure or Single Histologic Pattern
b. Mixed Histologic Pattern
TT
40% of testicular tumors
Pure or Single Histologic Pattern type.
TT
Pure or Single Histologic Pattern:
i. Seminomatous tumors Seminomas (seminiferous tubule tumor)
ii. Non-seminatous tumors
TT
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
60% of testicular tumors. These are not as treatable as pure cell tumors.
Mixed Histologic Pattern
TT
Embryonal carcinoma with teratoma (teratocarcinoma)

Choriocarcinoma with any other type
Mixed Histologic Pattern
TT
Sex-Cord Tumors:
a. Leydig cell tumor
b. Sertoli cell tumor
c. Granulosa cell tumor
Are well differentiated
TT
Are the most common form of testicular tumor with a peak age of 30 years.
Seminomas
TT
They are similar to an ovarian neoplasm (dysgerminoma). There is usually no invasion.
Seminomas
TT
These may be up to 10 mm, or very small and they respond well to radiation therapy.
Seminomas
TT
There are 3 histologic variants of Seminomas, name them?
1. Typical seminomas
2. Anaplastic seminomas
3. Spermatocytic seminomas
TT
Seminomas
85% - Homogeneous, grey white with no penetration of the tunica vaginalis and usually shows no hemorrhage or infarct.
Typical seminomas
TT
Consist of sheets of uniform appearing cells with delicate fibers infiltrated with lymphocytes and rare mitosis
Typical seminomas
TT
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)
Anaplastic seminomas
TT

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.
Spermatocytic seminomas
TT
They do not secrete alpha-fetoprotein or HCG. They do exhibit high levels of placental alkaline phosphatase.
Seminomas
TT
Non-Seminomatous tumors:
1. Embryonal carcinoma
2. Yolk Sac tumor
3. Choriocarcinoma
4. Teratomas
5. Mixed Tumors
TT
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.
Embryonal carcinoma
TT
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)
Embryonal carcinoma
TT
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.
Yolk Sac tumor
TT
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.
Yolk Sac tumor
TT
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).
Choriocarcinoma
TT
Is aggressive but remains of small size. Hemorrage and necrosis are extremely common and the tumor does produce extremely high levels of HCG.
Choriocarcinoma
TT
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:
Teratomas
TT
Different types of teratomas:
a. Mature teratomas
b. Immature teratomas
c. Teratomas with malignant transformation
TT
are well differentiated cells such as nerve, muscle cartilage, squamous epithelium, thyroid, GI or brain tissue, and are usually seen in children.
Mature teratomas
TT
Have 3 germ cell layers with incomplete differentiation.
Immature teratomas
TT
Are clearly the appearance of a malignant neoplasm. Examples are Squamous cell Carcinoma, adenocarcinoma, or sarcoma.
Teratomas with malignant transformation
TT
These are tumors composed of more than one type of tumor and account for 60% of testicular tumors.
Mixed Tumors
TT
Examples of mixed tumors include
Seminoma with embryonic Carcinoma, and embryonal Carcinomas with teratoma (teratocarcinoma).
TT
From the clinical standpoint tumors of the testis are classified into two broad categories:
1. Seminomas
2. Non-seminomatous tumors
TT
Tend to remain local
70% stage I tumors
Mets via lymphatic
Radiosensitive
Seminomas
TT

60% have advanced clinical disease
Mets via blood
Non-radiosensitive
Non-seminomatous tumors
TT
Clinical Staging of Testicular tumors:
STAGE I
Confined to testicle
TT
Clinical Staging of Testicular tumors:
STAGE II
Distant spread to retro peritoneal nodes below the diaphragm
TT
Clinical Staging of Testicular tumors:
STAGE III
Distant spread above the diaphragm
TT
Characteristic mode of spread of testicular cancer is via?
Lymphatic
TT
Characteristic mode of spread of testicular cancer is via lymphatic
1. Retro peritoneal (para-aortic nodes first)
2. Mediastinal
3. Supraclavicular
4. Hematogenous spread: lungs, liver, brain, bone
TT
Biologic Markers:
A glycoprotein containing two polypeptide chains: alpha and beta, normally synthesized and secreted by placental syncytiotrophoblasts?
HCG
Biologic Markers
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?
AFP
Biologic Markers
Biologic Markers:
Only produced by seminomas
Placental alkaline phosphatase
Biologic Markers
Biologic Markers:
High in seminomas
LDH
Biologic Markers
Biologic Markers:
Are elevated in mixed cell tumors; (Note:Placental alkaline phosphatase and LDH are elevated in seminomas)
HCG & AFP
Biologic Markers
Biologic Markers:
Yolk sac tumors will produce?
AFP only
Biologic Markers
Biologic Markers:
Choriocarcinoma will produce?
HCG only
Biologic Markers
Value of Markers:
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
Tumors of Sex cord- gonadal stroma:
1. Leydig cell (interstitial) tumors
2. Sertoli cell tumors
3. Testicular lymphomas
Tumors of Sex cord- gonadal stroma
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).
Leydig cell (interstitial) tumors
Tumors of Sex cord- gonadal stroma
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.
Sertoli cell tumors
Tumors of Sex cord- gonadal stroma
Are usually a B-cell lymphoma, usually occurring after age 60. They are rare but very aggressive.
Testicular lymphomas
Tumors of Sex cord- gonadal stroma
Lesions of the Tunica Vaginalis:
1. Hydrocele
2. Hematocele
3. Spermatocele
4. Varicocele
5. Chylocele
Lesions of the Tunica Vaginalis
Is an accumulation of clear fluid within the scrotal sac – may be up to 10 cm in diameter. Diagnosis is by transillumination
Hydrocele
Lesions of the Tunica Vaginalis
Results from blood in the sac, usually due to trauma or torsion
Hematocele
Lesions of the Tunica Vaginalis
Is a cyst with accumulation of spermatozoa, usually occurring due to surgery for an orchidectomy.
Spermatocele
Lesions of the Tunica Vaginalis
Dilated veins in the spermatic cord
Varicocele
Lesions of the Tunica Vaginalis
Elephantiasis
Chylocele
Lesions of the Tunica Vaginalis
Prostate Gland:
Inflammation (prostatis):
a. Acute bacterial prostatitis
b. Chronic bacterial prostatitis
c. Chronic abacterial prostatitis
Prostate Gland
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.
Acute bacterial prostatitis
Prostate Gland
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.
Chronic bacterial prostatitis
Prostate Gland
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.
Chronic abacterial prostatitis
Prostate Gland
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
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
Benign enlargememt
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
Benign enlargememt:
As males age, there is a decreased ability to detoxify
DNT
Benign enlargememt
Benign enlargememt:

Gross appearance of BPH?
Is a nodular, whorled pattern
Benign enlargememt
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
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
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
Prostate cancer spreads via:
1. Direct invasion or contiguous spread
2. Hematogeneous spread
3. Lymphatic spread
Tumors of the Prostate Gland
Prostate cancer:
Beginning at the base of bladder, seminal vesicles
Direct invasion or contiguous spread
Prostate cancer
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