Repro 17: Robbins Case Study Questions Male Reproduction

Front 1

30 yr man visits his physician b/c he has noticed increasing enlargement and a feeling of heaviness in his scrotum for the past year. On PE, the right testis is twice its normal size, and it is firm and slightly tender. An ultrasound exam shows a 3.5 cm solid mass in the right testis. Abdominal CT scan shows enlargement of the para-aortic lymph nodes. Multiple lung nodules are seen on chest xray. Lab findings include markedly increased serum levels of chorionic gonadotropin and α-feto protein. which testicular neoplasm is most likely?

Back 1

mixed germ cell tumor

altho a modest elevation of hCG can occur when a seminoma contains some synctial giant cells, significant elevation of α-fetoprotein (AFP) levels never occurs with pure seminomas. Elevated AFP and hCG effectively exclude the dx of pure seminoma and indicate the presence of a nonseminomatous tumor of the mixed type. the most common form of testicular cancer combines multiple elements; the term teratocarcinoma is sometimes used to describe tumors with elements of teratoma, embryonal carcinoma, and yolk sac tumor. The yolk sac element explains the high AFP level. mixed tumors may include seminoma.

Front 2

for the past year, 65 yr old man has had multiple, recurrent UTIs. E. coli and streptococcal organisms have been cultured from his urine during several of these episodes. He has difficulty with urination, including starting and stopping the urinary stream. Over the past week, he has again developed burning pain with urination. Urinalysis shows a pH of 6.5, and specific gravity of 1.020. No blood or protein is present in the urine. Tests for leukocyte esterase and nitrite are positive. Micro exam of the urine shows numerous WBCs and a few WBC casts. What is the most likely dx?

Back 2

prostatic nodular hyperplasia

this condition is most common in older men. When it causes obstruction of the prostatic urethra, it can predispose to bacterial infxns.

Front 3

35 yr man has noticed bilateral breast enlargement over the past 6 months. On PE, both breasts are enlarged without masses. His right testis is 1.5 times larger than his left testis; both are firm and round. His serum estrogen is increased. An ultrasound scan shows a circumscribed 2cm mass in the body of the right testis, and a right orchiectomy is performed. The mass has a grossly uniform, brown cut surface. On micro exam, the cells are large and round with granular eosinophilic cytoplasm along with rod-shaped crystalloids of Reinke. What is the most likely dx?

Back 3

Leydig cell tumor

these tumors are most often small, benign masses that may go unnoticed. Some patients have gynecomastia, however, caused by androgenic or estrogenic hormone production (or both) by the tumor. Most pts are young to middle-aged men; sexual precocity may may occur in the few boys who have such tumors.

Front 4

23 yr old sexually active man has been treated for neisseria gonorrhoeae infxn several times during the past 5 years. He now comes to the physician b/c of increasing number and size of warty lesions slowly enlarging on his external genitalia during the past year. On PE, there are multiple 1-3mm sessile, nonulcerate, papillary excrescences over the inner surface of the penile prepuce. These lesions are excised, by 2 year later, similar lesions appear. Which condition most likely predisposed him to development of these recurrent lesions?

Back 4

human papillomavirus infection

the pt's lesions are characteristic of condyloma acuminatum, which is typical of human papillomavirus (HPV) infection. A condyloma acuminatum is a benign, recurrent squamous epithelial proliferation resulting from infxn with HPV, one of many sexually transmitted diseases that can occur in sexually active individuals. Koilocytosis is particularly characteristic of HPV infection.

Front 5

55 yr man had dysuria, increased frequency, and urgency of urination for the past 6 months. he has sometimes experienced mild lower back pain. On PE, he is afebrile. There is no costovertebral angle tenderness. The prostate gland feels normal in size; no nodules are palpable. Lab studies show that expressed prostatic secretions contain 30 leukocytes per high-power field. What is the most likely dx?

Back 5

chronic abacterial prostatitis

the patient has more than 10 leukocytes per high power field, indicating prostatitis. Chronic abacterial prostatitis is the most common form of this disorder. Pts typically do not have a hx of recurrent UTIs.

Front 6

32 yr man has noticed an increased feeling of heaviness in his scrotum for the past 10 months. On PE, the left testis is 3x the size of the right testis and is firm on palpation. An ultrasound scan shows a 6cm solid mass w/in the body of the left testis. Lab studies include and elevated serum α-fetoprotein level. What cellular component is most likely to be present in this mass?

Back 6

yolk sac cells

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

Front 7

25 yr man has occasionally felt pain in the scrotum for the past 3 months. On PE< the right testis is more tender than the left, but does not appear to be appreciably enlarged. an ultrasound scan shows a 1.5-cm mass. A right orchitectomy is performed, and gross exam shows the mass to be hemorrhagic and soft. A retroperitoneal lymph node dissection is done. In sections of the lymph nodes, a neoplasm is seen with grossly extensive necrosis and hemorrhage. Micro exam shows that areas of viable tumor are composed of cuboidal cells intermingled with large eosinophilic syncytial cells containing multiple dark, pleomorphic nuclei. Immunohistochemical staining of the tumor is most likely to show which antigenic component in the syncytial cells?

Back 7

human chorionic gonadotropin (hCG)

this patient has a choriocarcinoma, the most aggressive testicular carcinoma. It often metastasizes widely. the primitive syncytial cells mimic the syncytiotrophioblast of placental tissue and stain for hCG.

Front 8

70 yr old, previously healthy male comes to his physician for a routine exam. on palpation, his prostate is normal in size. Lab studies show a serum PSA level of 17, however, twice the value he had 1 yr ago. Which histologic findings in a subsequent biopsy specimen of the prostate is most likely to account for the patient's current status?

Back 8

adenocarcinoma

the PSA level is significantly elevated in this patient. The increase over time is more likely indicative of carcinoma. Typically, prostatic carcinomas are adenocarcinomas that form small glands packed back to back. Many adenocarcinomas of the prostate do not produce obstructive symptoms and may not be palpable on digital rectal exam.

Front 9

35 yr old man and his 33 yr wife are childless. they have tried to conceive a child for 12 years, and now they undergo an infertility work-up. On PE, neither spouse has any remarkable findings. Lab studies show that the man has sperm ct in the low-normal range. On micro exam of the seminal fluid, the sperm have a normal morphologic appearance. A testicular biopsy is done. The biopsy specimen shows patchy atrophy of seminiferous tubules, but the remaining tubules shows active spermatogenesis. Which disorder is the most likely cause of these findings?

Back 9

mumps virus infection

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

Front 10

25 yr old, previously healthy male suddenly develops severe pain in the scrotum. The pain continues unabated for 6 hrs, and he goes to the ER. on PE, he is afebrile. There is exquisite tenderness of a slightly enlarged right testis, but there are no other remarkable findings. The gross appearance of the right testis is shown in the figure. Which condition is most likely to cause these findings?

Back 10

obstruction of blood flow (testicular torsion)

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

Front 11

the mother of a 2 yr old boy notices that he has had increasing asymmetric enlargement of the scrotum over the past 6 months. On PE, there is a well-circumscribed, 2.5-cm mass in the left testis. A left orchiectomy is performed, and histologic exam of this mass shows sheets of cells and ill-defined glands composed of cuboidal cells, some of which contain eosinophilic hyaline globules. Microcysts and primitive glomeruloid structures also are seen. Immunohistochemical staining shows α-fetoprotein in the cytoplasm of the neoplastic cells. What is the most likely dx?

Back 11

yolk sac tumor

Front 12

19 yr old man comes to his physician complaining of a worsening local pain and irritation with difficult urination over the past 3 years. He has become more sexually active during the past year and described his erections are painful. PE shows that he is not circumcised. The prepuce (foreskin) cannot be easily retracted over the glans penis. What is the most likely dx?

Back 12

phimosis

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

Front 13

19 yr old man comes to his physician for a routine health maintenance exam. On PE, there is no left testis palpable in the scrotum. The patient is healthy, has had no major illness, and has normal sexual function. In counseling this patient, what would you tell this patient regarding his condition?

Back 13

you are at increased risk of developing testicular tumor

this patient has cryptorchidism, which results from failure of the testis to descend from the abdominal cavity into the scrotum during fetal development. One or both testes may be involved. It is assoc. with an increased risk of testicular cancer. An undescended testis eventually atrophies during childhood. Unilateral cryptochidism usually does not lead to infertility, but it may be assoc with atrophy of contralateral descended testis.

Front 14

29 yr man complains of a vague feeling of heaviness in the scrotum, but he has had no increased in pain for the past 5 months. He is otherwise healthy. PE shows that the left testis is slightly larger than the right testis. An ultrasound scan shows the presence of a solid, circumscribed, 1.5-cm mass in the body of the left testis. A biopsy is done, and micro exam of the mass shows uniform nests of cells with distinct cell borders, glycogen rich cytoplasm, and round nuclei with prominent nucleoli. There are aggregates of lymphocytes btw these nests of cells. How does this tumor respond to therapy?

Back 14

excellent response to radiation therapy

this is the most common form a "pure" testicular germ cell tumor that may remain confined to the testis (stage I). The prognosis is good in most cases, even with metastases, because seminomas are radiosensitive. hCG levels may be slightly elevated in about 15% of patients.

Front 15

5 yr old boy has a hx of recurrent UTIs. Urine culture has grown E. coli , proteus mirabilis, and enterococcus. Physical exam now shows an abnormal constricted opening of the urethra on the ventral aspect of the penis, about 1.5 cm from the tip of the glans penis. There is also a cryptorchid testis on the right and an inguinal hernia on the left. What term best described the child's penile abnormality?

Back 15

hypospadias

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

Front 16

46 yr male with a hx of poorly controlled diabetes comes to the physician b/c he has had painful, erosive, markedly pruiritic lesions on the glans penis, scrotum, and inguinal regions of the skin for the past 2m onths. PE shows irregular, shallow, 1-4cm erythematous ulcerations. Scrapings of the lesions are examined under the microscope- what is the doc expecting to see?

Back 16

budding cells with pseudohyphae

genital candidiasis can occur in indvs w/o an underlying illness, but it is far more common in individuals with diabetes. Warm, moist conditions at these sites favor fungal growth.

Front 17

a clinical trial of 2 drugs compares one agent that inhibits 5-α-reductase and diminishes DHT synthesis in the prostate with another agent that acts as an α1-adrenergic receptor. the subjects are 40-80 yrs old. The study will determine whether symptoms of prostate disease are ameliorated int he individuals who take these drugs. Which disease of the prostate is most likely to benefit from one or both of these drugs?

Back 17

nodular hyperplasia

androgens are the major hormonal stimuli of glandular and stromal proliferation resulting in nodular prostatic hyperplasia. Altho testosterone production decreases with age, prostatic hyperplasia increases, probably b/c of an increased expression of hormonal receptors that enhance the effect of DHT that is present. 5-α-reductase inhibitors, such as finasteride, diminish the prostate volume, specifically the glandular component, leading to improved urine flow. The α1-adrenergic receptor blockers, such as tamsulosin, cause smooth muscle in the bladder neck and prostate to relax, which relieves symptoms and improved urine flow immediately.

Front 18

33 yr old man has noticed a reddish area on the penis for the past 3 months. He has had sexual intercourse for more than 1 month. On PE, there is a solitary 0.8cm, plaquelike, erythematous area on the distal shaft of the penis. A routine microbiologic culture with a gram-stained smear of the lesion shows normal skin flora. Micro exam of a biopsy shows dysplasia involving the full thickness of the epithelium. What is the most likely dx?

Back 18

Bowen Disease

bowen disease is a form of squamous cell carcinoma in situ. Similar to carcinoma in situ elsewhere, it has a natural hx of progression to invasive cancer if untreated. poor hygiene and infection with HPV (esp type 16 & 18) are factors that favor the development of dysplasias and cancer of the genital epithelia.

Front 19

45 yr male comes to physician for routine health maintenance exam. On PE< there are no remarkable findings. Lab findings include serum creatinine = 1.1, urea/nitrogen 17, glucose 76, alkaline phosphatase 89, and PSA 8ng/mL. Prostate biopsies are performed and the picture is shown. What is the most likely risk factor for this disease?

Back 19

epigenetic hypermethylation of GSTP1 gene.

he has prostatic adenocarcinoma with back-to-back glands and prominent nucleoli. Alterations of the glutathione S-transferase (GSTP1) gene allow damage from carcinogens. Other genetic abnormalities in prostate cancer include variations in CAG repeats in the androgen receptor gene, BRCA2 mutations, and translocation of ETS family transcription genes. His PSA antigen level is 2x the upper limit of normal. This is worrisome, but not an absolute indication of prostate cancer. Elevated PSA can occur with nodular hyperplasia or prostatitis. A higher level or a level that has increased over time or an increased free PSA is more suggestive of carcinoma.

Front 20

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

Back 20

hydrocele

hydrocele is one of the most common causes of scrotal enlargement. It consists of fluid collection w/in the tunica vaginalis. Most cases are idiopathic, altho some may result from local inflammation.

Front 21

an otherwise healthy, 72 yr man has had increasing difficulty with urination for the past 10 years. He now has to get up several times each night b/c of a feeling of urgency, but each time the urine volume is not great. He has difficulty starting & stopping urination. On PE, the prostate is enlarged to 2x its normal size, but is not tender to palpation. One yr ago, his serum PSA level was 6, and it is still at that level when retested. Which of the following drugs is most likely to be effective in treating this man?

Back 21

Finasteride, (5-α-reductase inhibitor)

the clinical features are typical of nodular hyperplasia of the prostate, and slight elevation of the PSA level can occur. A PSA level that remains unchanged for 1 yr, as in this case, is less likely to be found with a prostate cancer. Finasteride is a 5-alpha-reductase inhibitor that decreases formation of DHT that binds to androgen receptors in prostatic stromal and epithelial cells, driving proliferation with prostate gland enlargement. however, alpha-1adrenergic blockers that diminish smooth muscle tone are somewhat more effetive in treating nodular hyperplasia (was not an answer choice...)

Front 22

What is an important risk factor for testicular tumors?

Back 22

Cryptorchidism is an important risk factor for testicular tumors.

Front 23

What is the prognosis for classic seminomas confined to the testicle?

Back 23

The prognosis is excellent.

Front 24

What is the prognosis for metastatic classic seminoma?

Back 24

More than 95% of patients with tumors confined to the testicle or metastatic to the subdiaphragmatic lymph nodes are cured.

Front 25

In addition to surgery, is the primary mode of therapy for pure classic seminomas chemotherapy or radiotherapy?

Back 25

The primary mode of therapy is radiotherapy because seminomas are very radiosensitive.

Front 26

Are seminomas associated with increases in serum levels of HCG or AFP?

Back 26

Seminomas are not associated with an increase in AFP levels. Approximately 10% to 15% of seminomas contain syncytial giant cells that contain HCG. In these patients, serum HCG is moderately elevated. This feature does not affect treatment or prognosis.

Front 27

Note the gray, glassy, chondroid region; this chondroid element is a portion of what type of germ cell tumor?

Back 27

This chondroid element is part of a teratoma; teratomas can have tissues derived from all three germ cell layers.

Front 28

Nonseminomatous germ cell tumors have often metastasized by the time they are discovered; after orchiectomy, is the primary mode of therapy chemotherapy or radiotherapy?

Back 28

Chemotherapy is the primary mode of therapy

Front 29

What serum marker may be present in germ cell tumors with syncytiotrophoblasts?

Back 29

HCG may be present.

Front 30

Which serum marker is often elevated with yolk sac tumor?

Back 30

AFP is often elevated with yolk sac tumor.

Front 31

What is the most common testicular tumor of infants and children up to 3 years of age?

Back 31

Yolk sac tumor (endodermal sinus tumor) is the most common testicular tumor of infants and children up to 3 years of age. This tumor has an excellent prognosis.

Front 32

What symptom is associated with this lesion?

Back 32

Sudden severe testicular pain is an associated symptom.

Front 33

What group of lymph nodes (location) is typically the first involved by metastatic penile squamous cell carcinoma?

Back 33

The inguinal lymph nodes typically are first.

Front 34

Which sexually transmitted disease is associated with the development of penile squamous cell carcinoma?

Back 34

Human papillomavirus infection is associated with the development of penile squamous cell carcinoma.

Front 35

Is nodular hyperplasia found most commonly in the central or peripheral portions of the prostate gland?

Back 35

Nodular hyperplasia is found in the central portions of the prostate gland, which explains its clinical association with urinary hesitancy.

Front 36

How can the production of this hormone be interrupted biochemically?

Back 36

Dihydrotestosterone can be interrupted by blocking 5α-reductase activity.

Front 37

Is there a drug that is considered useful in the treatment of prostatic hyperplasia?

Back 37

Yes, an inhibitor of 5α-reductase (finasteride) is considered useful in the treatment of prostatic hyperplasia.

Front 38

How do malignant prostatic glands differ from benign prostatic glands in histologic appearance?

Back 38

Malignant prostatic glands tend to be small, back-to-back, and infiltrating; they have a single cell layer and prominent nucleoli. Benign prostatic glands tend to be larger, have a lobular configuration, and are lined by two cell layers.

Front 39

What symptoms might result from this condition?

Back 39

Urinary obstructive symptoms result from this condition, including hesitancy, frequency, nocturia, dribbling, and dysuria.

Front 40

In the prostate gland, compare where hyperplasia tends to occur vs carcinomas

Back 40

Nodular hyperplasia typically occurs periurethrally, whereas carcinomas tend to occur peripherally.

Front 41

What tumor marker would likely be elevated in patients with prostate cancer, and how specific is it?

Back 41

The serum level of PSA, a product of prostatic epithelial cells, is elevated in prostate cancer; however, this is not specific for cancer. PSA levels may also be elevated in patients with nodular hyperplasia of the prostate gland or prostatitis. Serum PSA levels by themselves cannot be used for a definitive diagnosis of prostate cancer.

Front 42

What are some common metastatic sites for prostatic adenocarcinoma?

Back 42

Pelvic lymph nodes, bone, and lungs are common metastatic sites.