Transcript of The Male Genital System pathology. The Male Genital System Penis scrotum and testes prostate.
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- The Male Genital System pathology
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- The Male Genital System Penis scrotum and testes prostate
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- Malformations Inflammatory conditions & STDs Neoplasms
Disease Categories
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- Penis Malformations Hypospadias epispadias
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- Hypospadias more common (1 in 250 live male births) urethral
opening along ventral aspect urinary tract obstruction risk of
infections other anomalies: Inguinal hernias UDTs
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- Epispadias Orifice on dorsal aspect of penis Lower urinary
tract obstruction Urinary incontinence Commonly associated with
bladder extrophy..
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- balanitis : glans penis balanoposthitis : glans penis &
prepuce by smegma Phimosis paraphimosis congestion, swelling &
pain Urinary retention Candidiasis Penis Inflammatory Lesions
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- Neoplasms of the Penis >95% originate from squamous
epithelium Higher rates in developing countries Most cases are
uncircumcised & older than 40 Pathogenesis: Poor hygiene
(smegma) Smoking HPV 16 and 18
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- Intraepithelial neoplasia (carcinoma in situ) Three clinical
variants : 1-Bowen disease Older uncircumcised males Solitary,
plaquelike lesion on shaft Malignant cells throughout epidermis No
invasion of stroma Invasive SCC in 33%..
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- Bowen disease (carcinoma in situ) Hyperchromatic Dysplastic
Dyskeratotic epithelial cells scattered mitoses
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- Intraepithelial neoplasia (carcinoma in situ) 2-Erythroplasia
of Queyrat Erythematous patch on glans
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- Intraepithelial neoplasia (carcinoma in situ) 3-Bowenoid
papulosis young, sexually active males multiple reddish brown
papules on glans most often transient rare progression to carcinoma
in immunocompetent patients
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- Squamous cell carcinoma of penis gray, crusted, papular lesion
on glans penis or prepuce infiltrates underlying tissue indurated,
ulcerated lesion irregular margins keratinizing SCC with
infiltrating margins
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- Glans penis deformed by a firm, ulcerated, infiltrative
mass
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- Gray, crusted, papule on glans or prepuce that infiltrates
underlying tissue
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- Most case are indolent locally infiltrative Regional metastases
in inguinal lymph nodes (25% ) Distant metastases relatively
uncommon Overall 5-year survival rate averages 70%
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- Verrucous carcinoma a variant of SCC papillary architecture
less striking cytologic atypia rounded, pushing deep margins
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- SCROTUM SCC: Sir Percival Pott observed a high incidence in
chimney sweeps
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- SCROTUM Hydrocele: most common cause of scrotal enlargement
serous fluid within tunica vaginalis causes: infections tumors
idiopathic
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- SCROTUM blood : Hematoceles Lymphatic fluid :chyloceles
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- SCROTUM Elephantiasis lymphatic obstruction (filariasis)
Scrotum & lower extremities
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- The Testes Cryptorchidism & Testicular Atrophy Inflammatory
Lesions Testicular Neoplasms
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- Cryptorchidism failure of testicular descent into scrotum
Descent from coelomic cavity into pelvis by the third month of
gestation Through inguinal canals into scrotum during the last 2
months of intrauterine life Diagnosis difficult to establish before
1 yr
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- Cryptorchidism By 1 yr seen in 1% of the male population 10%
are bilateral Causes: hormonal intrinsic testicular abnormalities
mechanical (inguinal canal obstruction) congenital syndromes
(Prader-Willi) unknown
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- Cryptorchidism Sterility Risk of testicular malignancy x3-5
times unilateral cryptorchidism : 1- cancer risk in contralateral,
descended testis 2- atrophy of contralateral gonad and
sterility
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- Orchiopexy Surgical placement of UDT into scrotum before
puberty decreases likelihood of atrophy,cancer and infertility
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- Cryptorchidism Right >left 10% bilateral normal size early
in life at 5 to 6 yrs: tubular atrophy at puberty: hyalinization
hyperplasia of Leydig cells intratubular neoplasia
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- Atrophic changes Cryptorchidism chronic ischemia Trauma
Radiation antineoplastic chemotherapy chronic elevation in estrogen
levels (cirrhosis)
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- Inflammatory Lesions epididymis > testis Acute gonococcal
epididymitis (abscess)
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- Inflammatory Lesions Nonspecific epididymorchitis : begins as a
primary UTI secondary ascending infection of testis testis is
swollen and tender with PMNs
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- Inflammatory Lesions mumps orchitis 20% of infected adults
rarely in children testis is edematous and congested
lymphoplasmacytic infiltrate tubular atrophy, fibrosis &
sterility
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- Inflammatory Lesions Testicular TB: most common cause of
testicular granulomas epididymitis testis granulomas & caseous
necrosis
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- Testicular Neoplasms Firm, painless enlargement 5 /100,000
males peak 20 - 34 yrs
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- Testicular Neoplasms cause unknown Cryptorchidism (10%): X3-5
in both sides syndromes: androgen insensitivity gonadal dysgenesis
isochromosome 12p risk in siblings of patients risk in
contralateral testis whites >blacks Caucasians
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- Heterogeneous group: 1-germ cell tumors (95%,all are malignant)
2-sex cord/stromal tumors (uncommon,usually benign)
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- Classification of Germ Cell Tumors One Histologic Pattern ( 60%
) Seminoma nonseminoma Embryonal carcinoma Yolk sac tumor
Choriocarcinoma Teratomas Mature Immature malignant transformation
More Than One Histologic Pattern
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- Intratubular germ cell neoplasia most tumors arise from in situ
lesions in situ foci are adjacent to germ cell tumors in almost all
cases
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- Seminoma 1- classic : 50% of germ cell neoplasms identical to
dysgerminomas & CNS germinomas
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- Large Soft well-demarcated Homogeneous gray-white bulge from
cut surface confined to testis intact tunica albuginea foci of
coagulation necrosis usually without hemorrhage
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- Large,uniform cells distinct cell borders Clear,glycogen-rich
cytoplasm round nuclei conspicuous nucleoli small lobules
intervening fibrous septa lymphocytic infiltrate granulomatous
reaction
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- cells staining positively for hCG in 25 % similar to
syncytiotrophoblasts elevated serum hCG concentrations
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- Seminoma 2- spermatocytic occur in older patients medium-sized
cells large uninucleate or multinucleate cells small cells with
round nuclei no association with intratubular germ cell neoplasia
metastases are exceedingly rare
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- Embryonal carcinomas Ill-defined,invasive masses Hemorrhage
& necrosis primary lesions may be small,even in cases with
metastases may invade epididymis & spermatic cord
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- Embryonal carcinomas Large,primitive cells basophilic cytoplasm
indistinct cell borders large nuclei prominent nucleoli
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- Embryonal carcinomas undifferentiated, solid sheets glandular
structures & irregular papillae other patterns are admixed with
embryonal areas
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- Embryonal carcinomas Pure forms 2% to 3% of all testicular germ
cell tumors foci of intratubular germ cell neoplasia frequently
present in adjacent tubules
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- Yolk sac tumors (endodermal sinus tumors) the most common
primary testicular tumor in children
- Morphology periurethral glands of prostate prostate is enlarged
even >300 gm cut surface well-circumscribed nodules solid or
with cystic spaces urethra is usually compressed (slit-like
orifice) may project into bladder lumen
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- Well-defined nodules compress urethra into a slitlike
lumen
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- Microscopical appearance Glands tall columnar epithelial cells
flattened basal cells crowding of epithelium (papillary
projections) corpora amylacea Infarction (advanced cases) squamous
metaplasia in adjacent glands
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- Microscopical appearance fibromuscular stroma surround glands
Spindle cells & connective tissue nodules
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- basal cell and secretory cell layers
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- Clinical Features in only about 10% of patients lower urinary
tract obstruction & infections Hesitancy intermittent
interruption of urinary stream painful distention of bladder
hydronephrosis bladder irritation ( frequency, nocturia &
urgency)
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- Carcinoma of the Prostate the most common visceral cancer in
males 2nd cancer-related death cause in men >50 peak incidence
between 65 and 75 years overall frequency >50% in men above
80
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- Pathogenesis Hormones: not seen in males castrated before
puberty androgens probably contribute growth inhibited by
orchiectomy or DES Genes: Higher risk among 1st-degree relatives
Environment: American blacks >whites, Asians or Hispanics A high
animal fat diet is suggested as a risk factor
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- prostatic intraepithelial neoplasia (PIN) frequent coexistence
with infiltrating carcinoma probable precursor to carcinoma
high-grade and low-grade patterns degrees of atypia vary an
intermediate between normal & malignant tissue
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- Gross pathology 70-80 % in periphery irregular hard nodules
less likely to cause urethral obstruction ill-defined masses firm,
gray-white to yellow Infiltrative margins
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- Microscopy adenocarcinoma small glands lie "back to back"
single layer of cuboidal cells basal cell layer absent conspicuous
nucleoli
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- perineural invasion by malignant glands
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- Low-grade (Gleason score 2) back to back uniformly sized
glands
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- Anaplasia irregular, ragged glands papillary or cribriform
structures sheets of poorly differentiated cells
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- (Gleason score 6) variably sized widely dispersed Moderately
differentiated (Gleason score 10) Poorly differentiated sheets of
malignant cells
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- Clinical Features often clinically silent during early stages
may be discovered by routine rectal exam 10% found in histologic
examination of tissue removed for nodular hyperplasia autopsy
studies,30% in men 30 to 40 years Prostatism when more extensive :
local discomfort lower urinary tract obstruction
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- More aggressive cases come to attention because of metastases
regional pelvic LN seminal vesicles periurethral zones bladder wall
Invasion of rectum less common Clinical Features
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- Bone metastases axial skeleton common: osteolytic (destructive)
osteoblastic (bone-producing) osteoblastic metastases in an older
male strongly suggests advanced carcinoma
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- Metastatic osteoblastic prostatic carcinoma within vertebral
bodies
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- prostate-specific antigen (PSA) proteolytic enzyme secreted
into prostatic acini and seminal fluid increases sperm motility
serum level 4.0 ng/L is the upper limit of normal Cancer cells
produce more PSA also elevated in : nodular hyperplasia
prostatitis
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- prostate-specific antigen limited value when used as an
isolated screening test for cancer diagnostic value enhanced when
used with digital rectal examination transrectal sonography needle
biopsy
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- prostate-specific antigen great value in monitoring patients
after treatment for cancer rising levels indicate recurrence and/or
metastases
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- prostate-specific antigen useful refinements PSA (4 to 10) gray
zone: PSA velocity PSA density free vs bound forms of PSA Free PSA
level >25% indicate a lower risk level