True or False:

The penis has no fat or hair, but has sweat glands

1) Non-specific balanitis

2) Plasma cell balanitis

3) Balanitis xerotica obliterans

4) Peyronie's disease

5) Sclerosing lipogranuloma

phimosis: cannot retract foreskin

paraphimosis: cannot draw retracted foreskin over the glans and can cause urethral obstruction and pain to penis

fibrosis: from chronic inflammation

either plasma cell balanitis or squamous cell carcinoma (erythroplasia of queyrat)

the only way to tell them apart is by doing a biopsy

1) inflamed glans penis

2) bright red moist path on glans

3) Histologically see epidermal atrophy and subepithelial dense band-like chronic inflammatory infiltrate of plasma cells

Balanitis Xerotica Obliterans is synonymous with what in women?

1) epidermal atrophy

2) Stromal fibrosis

3) white patches on glans

some say autoimmune

usually in associated with phimosis

Which non-infectious inflammatory penile condition may be linked with fibromatosis?

Peyronie's Disease- bending of the penis and painful erection

- they have noted an associate with palmar/plantar fibromatosis

In Peyronie's Disease, what structure is fibrotic?

Syphilis

Chancroid

Granuloma Inguinale

Lymphogranuloma Venereum

Condyloma Acuminatum

How do you culture Neisseria gonorrhea?

Chlamydia

(Gonorrhea is second most common(

urethritis or epidiymitis

in immunocompromised patients, can become disseminated

septic arthritis

rash of hemorrhagic papules and pustules

1. Pustule --> PAINFUL chancre, less indurated than in syphilis, more superficial
2. Enlarged Inguinal lymph nodes
3. Chancre has superficial necrosis underneath zone of acute inflammation and vasculitis; underneath that is fibrosis of mixed acute and chronic inflammation

Papules that pogress to ulcers (painless)

marked necrosis and scarring --> leakage of blood and mucous

suppurative inflammation

usually found in underdeveloped countries

Chlamydia trachomatic causes which STD?

1. Penile ulcers
2. Inguinal lymphadenitis
3. stellate suppurative granulomas in LN's- surrounded by histiocytes
4. inguinal sinus tracts in skin can develop

How does condyloma acuminatum present in males?

Condyloma Acuminatum has which histological features?

Acanthosis (diffuse epidermal hyperplasia)

Hyperkeratosis

Papillomatosis

Koilocytes present in epidermis: perinuclear vacuolization, nuclear hyperchromasia and binucleation

Is Condyloma acuminatum a risk for cancer?

Which two types of penile carcinoma in situ have malignant potential and occur between the ages of 30-60?

Erythroplasia of Queyrat

Bowen's Disease (red or white plaques on shaft of penis)

10% of the time if not excised

HPV type 16

also, all through look the same histologically

poor hygeine

phimosis

lack of circumcision

late circumcision

smoking- may be associated with the fact that many have risk for having/had other primary cancers

HPV (16 or 18)- 1/3 of all cases

age 40-70 years

Which structures are usually affected by invasive squamous cell carcinoma of the penis?

first to inguinal lymph nodes and then to the iliac nodes

if there are mets, there is a 27% survival rate

What is verrucous carcinoma?

a rare variant of SCC that is bulky, exophytic, papillary

it has little cytologic atypia, but instead it causes destruction by pushing on structures

non-invasive and no mets

tends to recur if not completely excised

If a man is infertile, but on testis Bx he is normal, what is the most likely cause?

If an infertile man comes in and his tisse Bx reveals immature testis, what is the most likely etiology?

hypospermatogenesis

maturation arrest

immature testis from hypopituitarism

obstruction

germ cell aplasia

End organ androgen insensitivity

Results in female external gentialia with rudiemntary vagina, usually the uterus and uterine tubes are absent due to AMH from sertoli cells, develops tests usually in the labia majora that are removed to prevent malignancy

What would a testis look like in a Klinefelter's patient?

Small, atrophic seminiferous tubules and peritubular fibrosis

Leydig cells remain unaffected

Where do germ cell tumors in Klinefelter's usually occur?

Crytporchism

Klinefelter's

Testicular Feminization (androgen receptor insensitivity)

First is transabdominal phase bringing the testes to the pelvic brim controlled by AMH

Secind is the inguinoscrotal phase which is androgen dependent

2 years old

because this is when histological evidence of atrophy is present and there is an increased risk of cancer

testicular atrophy

maturation arrest of germ cells

interstitial fibrosis

reflux from a UTI, this is why it is usually bilateral

initially, the infected urine gets into the prostate and then progresses retrograde into the vas deferens and climbs into the epididymis

A week prior to unilateral testis swelling and pain, the male had a swollen parotid gland on the ipsilateral side

this may cause sterility

infectious causes of granulomas- TB, fungus

Sarcoidosis

Seminoma because it sometimes is marked by granulomatous reaction

One of the most common cancers in males 15-34 years old, but only accounts for 1% of cancer related deaths in men is ____

teratomas if it's from embryonic (somatic) differentiation

yolk sac tumor or choriocarcinoma if from extra-embryonic differentiation

these are embryonal carcinomas

cryptorchid testes

testicular dysgenesis

infertility

"normal" contralateral testis in patient with germ cell tumor

spermatocytic seminoma

pediatric yolk sac tumors

pediatric teratomas

Most common germ cell tumor of one histologic type and represents about 30% of germ cell tumors is ___?

Seminoma: homogenous, lobulated, gray white mass without hemorrhage or necrosis

well circumscribed and confined to the testis

Classic seminoma, polyhedral cells with clear cytoplasm, large nuclei and prominent nucleoli

lots of glycogen in the cytoplasm

80% of cases associated with lumphocytic infiltrate

granulomatous reaction in 20%

Spermatocytic seminoma, usually large and bulky tumors that occur in older men 

have small  and large cells

lots of cystic, hemorrhagic and necrotic areas

not well circumscribed

Embryonal carcinoma: more necrosis, nuclear pleomorphism and eosinophilic cytoplasm

"dirty anaplastic tumor"

in children, the tumor is usually pure

in adults, it is usually part of a mixed germ cell tumor

Which testicular tumor would stain positive for AFP?

yolk sac tumor

looks lacy on lower power

characertistic Schiller-Duval body (looks like glomerulus) which is a papillary structure surrounded by cystic space

choricarcinoma

sometimes, seminomas can too

syncytiotrophoblasts

cytotrophoblasts

Whenever you see a testicular tumor with necrosis and hemorrhage, what should you think of and do?

choriocarcinoma, get extra tissue to look for this because it is highly malignant and can become systemic

often at presentation, the choriocarcinoma met is more extensive than the primary tumor

Which cells in choriocarcinoma actually stain positive for hCG?

Are germ cell tumor markers limited to histological samples?

no, they can be found in the serum

these are helpful in diagnosis, staging and monitoring response of Tx to germ cell tumors

surgery

radiation- seminomas are very responsive

chemotherapy- has greatly improved survival for NSGCTs

Sex cord/ gondal stromal tumors are composed of either of these cells:

leydig

sertoli

What is the age range of leydig cell tumors?

benign,

so most are well circumscribed and tan colored grossly

Crystals of Reinke in a leydig cell tumor

refractile eosinophilic cytoplasmic inclusions

90% of sertoli tumors are benign or malignant?

lymphoma

most are high grade and have a poor prognosis

5% of testis tumors

transitional zone, which is why BPH leads to urinary frequency

usually this is 20% of the prostate volume

the more superior central zone also surrounds the urethra

HMW-cytokeratin

p63

acini (acinar adenocarcinoma)

to diagnose prostate cancer

now they take about 12-14 biopsies per case to increase cancer detection because with only 6 there is a high false negative rate

BPH

Neurogenic Bladder

GU catheterization/instrumentation

gram negative rods

enterococci

staphylococci

difficult to diagnose and to treat

can develop de novo or after a bout of acute prostatitis

can be bacterial or not

may or may not be symptomatic, and may or may not have serum PSA elevation

it is called non-specific GP due to a reaction to secretions in leaky prostatic ducts and acini

it is associated with an increased PSA

non-specific

reaction to BCG tx of bladder cancer

infectious in immunocompromised patients from TB or fungi

post Bx/ TURP

Medical: antiandrogens which blocks DHT syntehsis and shrinks the prostate (finasteride)

alpha-1 andrenergic blockers decreases muscle tone to allow urine to flow

Once they become refractory, use TURP + prostate tissue ablative procedures

glandular variants of BPH that are funny looking on low power but bland on high power

ie: sclerosing adenosis, basal cell hyperplasia, clear cell cribiform hyperplasia, atypical adenomatous hyperplasia

small acini (like in cancer)

clustered acini (not infiltrative)

benign nuclei/nucleoli

patchy basal cell layer

adenocarcinoma variants

urothelial carcinoma

sarcoma

urinary retention

bony mets

BPH

infarction

prostatitis

instrumentation

10 ng/mL

but if it is confined, it could still be less than 4 (20-40% of patients--> false negatives)

transitional cell carcinoma

leiomyosarcoma- most common stromal in adults

rhabdomyosarcoma is the number one stromal tumor in kids

chronic infections

developing bladder carcinoma (usually adenocarcinoma) later in life

female anatomy

bladder calculi

urinary outlet obstruction

diabetes mellitus

instrumentation and immune deficiency

adenovirus infection

complication of radiation therapy

complication of chemotherapy (cyclophosphamide)

a non-specific cystitis as the result of a systemic allergic reaction (sometimes)

in addition to chronic inflammatory infiltrate, there are many eosinophils

severe painful chronic cystitis without evidence of infection

cause is unknown, but may be autoimmune disorder

cure= cystectomy

transmutal inflammationa nd fibrosis

mucosal fissures

hemorrhage

ulcers

transmural inflammation and fibrosis

non-specific, chronic inflammation

many mast cells present

epithelial tumors (most are transitional cell)

often are multifocal

papilloma and papillary urothelial neoplasm of low malignant potential (Pun-LMP)

urothelial carcinoma- low grade

urothelial carcinoma - high grade

carcinoma in situ (part of urothelial carcinoma- high grade)

hemturia

other symptoms are cystitis like

bladder wall thickening

acquired mucosal diverticula

bladder dilation and thinning

pyelonephritis and hydronephritis

you see intralobular stroma increase in size without any atypia, mitotic activity or hypercellularity

it distorts he surrounding epithelium

makes the ducts like slits

well demarcated lesion

fibro: teens and pre-menopausal females

IDP: 30-50

estrogen sensitivity

also implicated in FCC, endometrial hyperplasia, 

intense inflammation with foamy macrophages and foreign body cells

grossly: necrosis, hemorrhage and granulation tissue

it is a proliferative type of FCC that lacks atypia, but it has similar clinicala nd morphological features to carcinoma

there is marked intralobular fibrosis and proliferation of small ducts and acini

retains myoepithelial layer

increased mitoses

stromal overgrowth

anaplasia

recur almost all even with complete recision

increase in age

family Hx

low parity

longer reproductive life

later age of breast feeding

proliferative FCC with atypia

LCIS

cancer of contralateral breast

ovarian cancer

DCIS

sclerosing adenoma (prolif. FCC)

epithelial hyperplasia with atypia (prolif. FCC)

fibroadenoma

fat necrosis

solid

cribiform

papillary (intracystic papillary breast carcinoma)

micropapillary (no vascular core)

malignant epithelial cells set in a background of lymphocytic infiltrate with well defined, pushing borders

cellular atypia with high mitotic activity

small, angulated tubules with desmoplastic stroma

cells look low grade

fixation to chest wall

skin retraction

orange peel

palpable regional LNs

bilateral mastectomy

anti-estrogen therap with watchful waiting

indian filing with concentric growth around ducts/blood vessels

signet ring cells (maybe)

small cells

transmembrane glycoprotein involved in cell growth control, a receptor tyrosine kinase

poor prognositic factor

present in 20-30% of breast carcinomas

amplification of gene on chr 17q21

What are some causes of gynecomastia (breast enlargement in males)?

things that cause estrogen excess:

puberty, Klinefelters, functioning testicular neoplasms, cirrhosis, drugs

stromal fibrosis

hyperplasia of ducts

syphilis

granuloma inguinale caused by Calymmatobacterium granulomatis with diagnostic donovan bodies