Prostatic Diseases
Penile Diseases
--- Content provided by FirstRanker.com ---
?Congenital Anomalies
?Inflammation
? Tumors
? Benign Tumors
--- Content provided by FirstRanker.com ---
? Premalignant lesion(carcinoma in situ)? Malignant Tumors
?WHO histological classification
of tumours of the penis
--- Content provided by FirstRanker.com ---
?
__________
--- Content provided by FirstRanker.com ---
Malignant epithelial tumours of the penis? Squamous cell carcinoma 8070/31
? Basaloid carcinoma 8083/3
--- Content provided by FirstRanker.com ---
? Warty (condylomatous) carcinoma 8051/3
? Verrucous carcinoma 8051/3
--- Content provided by FirstRanker.com ---
? Papillary carcinoma, NOS 8050/3? Sarcomatous carcinoma 8074/3
? Mixed carcinomas
? Adenosquamous carcinoma 8560/3
--- Content provided by FirstRanker.com ---
? Merkel cell carcinoma 8247/3? Small cell carcinoma of neuroendocrine type 8041/3
? Sebaceous carcinoma 8410/3
? Clear cell carcinoma 8310/3
? Basal cell carcinoma 8090/3
--- Content provided by FirstRanker.com ---
Precursor lesions? Intraepithelial neoplasia grade I I Bowen disease 8081/2
? Erythroplasia of Queyrat 8080/2
--- Content provided by FirstRanker.com ---
? Paget disease 8542/3
? Melanocytic tumours
--- Content provided by FirstRanker.com ---
? Melanocytic nevi 8720/0? Melanoma 8720/3
? Mesenchymal tumours
--- Content provided by FirstRanker.com ---
? Haematopoietic tumours
? Secondary tumours
--- Content provided by FirstRanker.com ---
Benign Tumors1-Condyloma Acuminatum-
? Wart
? STD
--- Content provided by FirstRanker.com ---
? HPVMorphology-
? coronal sulcus and inner surface of the prepuce
--- Content provided by FirstRanker.com ---
? single or multiple sessile or pedunculated, red papillary excrescencesHistologically-
? Acanthosis
? koilocytosis
2-Peyronie Disease-(Idiopathic Fibrous Induration )
--- Content provided by FirstRanker.com ---
? fibromatosis? fibrous bands involving the corpus cavernosum of the penis
? Microscopically, dense fibrosis is associated with sparse, nonspecific,
chronic inflammatory infiltration
--- Content provided by FirstRanker.com ---
Precursor lesions-
? Intraepithelial neoplasia Grade II
qClinical Variant
?Bowenoid papulosis
--- Content provided by FirstRanker.com ---
?Bowen disease?Erythroplasia of Queyrat
? Paget disease
Bowenoid papulosis ?
? younger age
--- Content provided by FirstRanker.com ---
? multiple reddish brown papular lesions? histologically indistinguishable from Bowen disease
? HPV type 16
Bowen disease-
--- Content provided by FirstRanker.com ---
? >35Yr? shaft of the penis and the scrotum
? solitary, thickened, gray-white, opaque plaque
? turn in to 10% scc (5-33% WHO)
--- Content provided by FirstRanker.com ---
Normal Skin histology
Invasive Carcinoma-
squamous cell carcinomas
Etiology-
--- Content provided by FirstRanker.com ---
? phimosis? chronic inflammatory conditions, especially lichen sclerosus
? smoking
? ultraviolet irradiation
? history of warts, or condylomas
--- Content provided by FirstRanker.com ---
Clinical features
? 40 -60 years
? glans or inner surface of the prepuce
MORPHOLOGY-
--- Content provided by FirstRanker.com ---
? papillary? flat
? Ulcerated
? Exophytic
--- Content provided by FirstRanker.com ---
Histopathology-? spectrum of differentiation from well to poorly differentiated.
? Superficial ?WD
? Deep-PD
--- Content provided by FirstRanker.com ---
Verrucous carcinoma-
? variant of squamous cell carcinoma
? exophytic well-differentiated
? locally invasive, but rarely metastasize
--- Content provided by FirstRanker.com ---
Other variants? basaloid, warty, and papillary variants
? acanthosis and hyperkeratosis
--- Content provided by FirstRanker.com ---
? into the underlying stroma with a broad based, pushing border? No koilocytotic changes
? Not HPV related
? D/D Condyloma acuminatum
--- Content provided by FirstRanker.com ---
Tumour spread-
? superficial inguinal lymph node
? deep groin and pelvic nodes
--- Content provided by FirstRanker.com ---
Three most important pathological factors to predict final outcome are
? histological grade
? depth of invasion
? vascular invasion
--- Content provided by FirstRanker.com ---
Diseases of Prostate? Inflammation
? Benign Enlargement
? Tumors
--- Content provided by FirstRanker.com ---
q Inflammation
?Acute bacterial prostatitis
?Chronic bacterial prostatitis
?Chronic abacterial prostatitis
--- Content provided by FirstRanker.com ---
?Granulomatous prostatitis1. Acute bacterial prostatitis
Etiology-
? bacteria ,E. coli,
? from the urethra
--- Content provided by FirstRanker.com ---
? Diagnosis-cultureMORPHOLOGY-
Gross- enlarged, swollen and tense
Cut section- abscesses and foci of necrosis
--- Content provided by FirstRanker.com ---
M/E-? Necrosis
? Or as diffuse edema
? Congestion
?biopsy is contraindicated
--- Content provided by FirstRanker.com ---
2-Chronic Prostatitis-?Chronic bacterial prostatitis-
? consequence of recurrent UTI
? E coli
? 10-12 wbc/hpf
--- Content provided by FirstRanker.com ---
?Chronic abacterial prostatitis-
? more common
? No h/o Reccurent UTI
? Wbc in prostatic secretion
--- Content provided by FirstRanker.com ---
? culture of urine and prostatic secretions is always negative? Chlamydia trachomatis and Ureaplasma urealyticum
MORPHOLOGY-
? Grossly, enlarged, fibrosed and shrunken
? Histologically-lymphocytes, plasma cells, macrophages and
--- Content provided by FirstRanker.com ---
neutrophils within the prostatic tissue
3-Granulomatous Prostatitis-
--- Content provided by FirstRanker.com ---
? variety of chronic prostatitis?Etiology-
? Tubercular
--- Content provided by FirstRanker.com ---
? Fungal? autoimmune origin
?MORPHOLOGY-
--- Content provided by FirstRanker.com ---
? Grossly-firm to hard? Histology-macrophages, lymphocytes, plasma cel s and some multinucleate
giant cel s
--- Content provided by FirstRanker.com ---
qBenign Prostatic Hyperplasia or Nodular Hyperplasia-
? most common benign prostatic disease
? Incidence increases >50yrs
--- Content provided by FirstRanker.com ---
? 70% >60yrsETIOLOGY-
? endocrinologic, racial, inflammation and arteriosclerosis
? advancing age,--androgen-- oestrogen-periurethral inner prostatsensitive to
--- Content provided by FirstRanker.com ---
estrogen oestrogen--
Nod hyprplasia
--- Content provided by FirstRanker.com ---
? Stromal cell produce type 2 5-reductase enzyme
? epithelial cells do not express type 2 5-reductase
? DHT-induced growth factors-- increasing the proliferation of
--- Content provided by FirstRanker.com ---
stromal cells and decreasing the death of epithelial cells
? MORPHOLOGY-
--- Content provided by FirstRanker.com ---
? Gross- nodular, smooth and firm and weighs 2-4 times its normalweight
Cut surface-
--- Content provided by FirstRanker.com ---
?pale gray and tough-fibromuscular stroma-EARLY?yellow-pink and soft- gland-LATER
--- Content provided by FirstRanker.com ---
Microscopy- hyperplasia of all three tissue elements in varying
proportions--
? glandular
--- Content provided by FirstRanker.com ---
? fibrous? Muscular
called as fibromyoadenomatous nodules- well developed satge
Variable histological features-
? lymphocytic aggregates
--- Content provided by FirstRanker.com ---
? small areas of infarction? corpora amylacea
? foci of squamous metaplasia
CLINICAL FEATURES-
--- Content provided by FirstRanker.com ---
? frequency, nocturia? difficulty in micturition
? pain
? haematuria
--- Content provided by FirstRanker.com ---
Complications of NPH
CARCINOMA OF PROSTATE
--- Content provided by FirstRanker.com ---
? men older than age 50 years? ETIOLOGY-
?Endocrinologic factors
?Racial and geographic influences-
? uncommon in Japanese and Chinese, while the prevalence is high in
--- Content provided by FirstRanker.com ---
Americans
?Environmental influences-
? high dietary fat, and exposure to polycyclic aromatic hydrocarbons
--- Content provided by FirstRanker.com ---
?Nodular hyperplasia?Heredity-
?2-fold higher frequency in first-degree relatives
Molecular Pathogeneis
--- Content provided by FirstRanker.com ---
? Most common-TPRSS2-ETS fusion genes and mutations or deletions
that activate the PI3K/AKT signalling pathway
--- Content provided by FirstRanker.com ---
Others
--- Content provided by FirstRanker.com ---
? PTEN? BRCA2
? HOXB13
? 8q24 amplification
? Loss of P53, in last stage
--- Content provided by FirstRanker.com ---
? Glutathione S-transferase P1 gene,hypermethylation? Epigenetic modification ?RB,CDKN2A
--- Content provided by FirstRanker.com ---
MORPHOLOGIC FEATURES.? Grossly, enlarged, normal in size or smaller than normal
? Cut section- gritty and firm,homogeneous and contains irregular
yellowish areas
--- Content provided by FirstRanker.com ---
Microscopically-? Adenocarcinoma ,96%
? transitional cell carcinoma
? squamous cell carcinoma
? undifferentiated carcinoma
--- Content provided by FirstRanker.com ---
Histologic characteristics-
? Architectural disturbance-closely packed in back-to-back arrangement
without intervening stroma
--- Content provided by FirstRanker.com ---
? Gland pattern
? Stroma- scant , tumour cells may penetrate and replace the
fibromuscular stroma
--- Content provided by FirstRanker.com ---
High-grade prostatic intraepithelial neoplasia (PIN)
? Gleason's microscopic grading system- based on two features:
i) Degree of glandular differentiation
--- Content provided by FirstRanker.com ---
ii) Growth pattern of the tumour in relation to the stromaThese features are assessed by low-power examination
? Only one pattern- double the number
? Two pattern- predominant p+ secondary p
--- Content provided by FirstRanker.com ---
? Three pattern- pred p+ higher pattern3 (70%)+4(20%)+5(10%)3+5=8
? 2 (1 + 1)- well-differentiated
? 10 (5 + 5)-and the least-differentiated tumors
--- Content provided by FirstRanker.com ---
closely packed uniform
glands
--- Content provided by FirstRanker.com ---
loosely packed slightly
variable glands
--- Content provided by FirstRanker.com ---
Single glands of variable sizeand density, with an
infiltrative pattern
--- Content provided by FirstRanker.com ---
Ragged infiltration with poorly
formed glands or sheets and
--- Content provided by FirstRanker.com ---
cords of fused glandsSingle cel s,Solid
sheet,comedonecrosis
--- Content provided by FirstRanker.com ---
3+3
3+4
--- Content provided by FirstRanker.com ---
4+4
4+4
--- Content provided by FirstRanker.com ---
4+44+4
GS-5+5
--- Content provided by FirstRanker.com ---
Biomarkers of prostate cancer1-PSA
?PSA density
?PSA velocity
--- Content provided by FirstRanker.com ---
?age-specific reference ranges?ratio of free and bound PSA (free psa low in cancer)
2-PCA3
3-combination of urinary PCA3 with screening of urine for TMPRSS2-
--- Content provided by FirstRanker.com ---
ERG fusion DNA>psa aloneTestis
Must know
--- Content provided by FirstRanker.com ---
1-Classification of testicular tumor2-Tumor markers in diagnosis
3-Morphology of
a)
--- Content provided by FirstRanker.com ---
Seminomab)
Embryonal carcinoma
--- Content provided by FirstRanker.com ---
c)
Yolk sac tumor
--- Content provided by FirstRanker.com ---
4-CryptorchidismTesticular lesion
--- Content provided by FirstRanker.com ---
? CongenitalAnomalies? RegressiveChanges
? Inflammation (Nonspecific , Specific Inflammations, Granulomatous
(Autoimmune) Orchitis)
--- Content provided by FirstRanker.com ---
? VascularDisorders(torsion)
? SpermaticCordandParatesticularTumors
? TesticularTumors
INFLAMMATIONS-
--- Content provided by FirstRanker.com ---
? Inflammation of the testis is termed as orchitis and of epididymis iscalled as epididymitis; the latter being more common
1-Non-specific Epididymitis and Orchitis-
--- Content provided by FirstRanker.com ---
? may be acute or chronic? common routes of spread are via the vas deferens, or lymphatic and
haematogenous routes
--- Content provided by FirstRanker.com ---
? caused by urethritis, cystitis, prostatitis and seminal vesiculitis? common infecting organisms in Neisseria gonorrhoeae and Chlamydia
trachomatis
Grossly,
--- Content provided by FirstRanker.com ---
? acute stage- firm, tense, swollen and congestedmay be multiple abscesses, especially in gonorrhoeal
infection
--- Content provided by FirstRanker.com ---
? chronic stage- variable degree of atrophy and fibrosisHistological y,
? acute- congestion, oedema and diffuse infiltration by neutrophils, or formation of
--- Content provided by FirstRanker.com ---
neutrophilic abscesses? Chronic- focal or diffuse chronic inflammation, disappearance of seminiferous
tubules, fibrous scarring and destruction of interstitial Leydig cells
--- Content provided by FirstRanker.com ---
2-Granulomatous (Autoimmune) Orchitis -Non-tuberculous granulomatous orchitis-
? unilateral, painless testicular enlargement
? may resemble a testicular tumour clinically
? autoimmune basis is suspected
--- Content provided by FirstRanker.com ---
Gross- enlarged
? Cut section of the testicle is greyish-white to tan-brown
? Histological y, granulomatous reaction(non caseating) is present diffusely
--- Content provided by FirstRanker.com ---
throughout the testis and is confined to the seminiferous tubules? Peritubular fibrosis
? interstitial lymphocytes and plasma cells
3-Tuberculous Epididymo-orchitis-
--- Content provided by FirstRanker.com ---
? invariably begins in the epididymis and spreads to the testis? May spread via -tuberculous seminal vesiculitis, prostatitis and renal tuberculosis
? haematogenous spread- from tuberculosis of the lungs
--- Content provided by FirstRanker.com ---
Grossly, discrete, yellowish, caseous necrotic areas? Microscopical y, numerous tubercles which may coalesce to form large caseous
mass
--- Content provided by FirstRanker.com ---
? Characteristics of typical tubercles such as epithelioid cells, peripheral mantle oflymphocytes, occasional multinucleate giant cells and central areas of caseation
necrosis are seen
--- Content provided by FirstRanker.com ---
? AFB positive
4-Spermatic Granuloma(epididymitis nodosa)
--- Content provided by FirstRanker.com ---
? inflammatory lesions due to invasion of spermatozoa into the stromaMORPHOLOGIC FEATURES-
Grossly,
? a small nodule, 3 mm to 3 cm in diameter in head of epididymis
--- Content provided by FirstRanker.com ---
? firm, white to yellowish-brown? Histological y,
? Characteristical y, the centre of spermatic granuloma contains
--- Content provided by FirstRanker.com ---
spermatozoa and necrotic debris+epethelioid cell granulomaVascular disorder
Torsion of Testis
? usually followed by sudden muscular effort or physical trauma
--- Content provided by FirstRanker.com ---
? Twisting of the spermatic cord? sudden cessation of venous drainage and arterial supply
? Trauma may occure in either in a fully-descended testis or in an
undescended testis
--- Content provided by FirstRanker.com ---
1-Neonatal torsion-
? occurs either in utero or shortly after birth
? It lacks any associated anatomic defect in testis
--- Content provided by FirstRanker.com ---
2-"Adult" torsion-
? is typically seen in adolescence and presents with the sudden onset of
testicular pain
--- Content provided by FirstRanker.com ---
? Viable- manually untwisted within approximately 6 hours of theonset of torsion
MORPHOLOGIC FEATURES-
--- Content provided by FirstRanker.com ---
duration and severity of vascular occlusion? may be coagulative necrosis of the testis and epididymis
? may be haemorrhagic infarction
Spermatic Cord and Paratesticular Tumors
--- Content provided by FirstRanker.com ---
1-Lipomas? common lesions involving the proximal spermatic cord, identified at
the time of inguinal hernia repair
--- Content provided by FirstRanker.com ---
? represent retroperitoneal adipose tissue that has been pulled into theinguinal canal along with the hernia sac, rather than a true neoplasm
2-Adenomatoid tumor-
--- Content provided by FirstRanker.com ---
? most common benign paratesticular tumor? upper pole of the epididymis
? grossly , well circumscribed small nodules
? Microscopically- Proliferation of glandular structures, irregularly lined by cuboidal
--- Content provided by FirstRanker.com ---
to flattened epithelial cell
? Treatmet- local excision
--- Content provided by FirstRanker.com ---
Malignant tumor? rhabdomyosarcomas -children
? liposarcomas- adults
--- Content provided by FirstRanker.com ---
CLASSIFICATION OF TESTICULAR TUMOR
? most useful classification of tumors is histogenetic
? Named according to from which tissue they arise and of which they consist
--- Content provided by FirstRanker.com ---
WHO histological classification of testis tumours
? Germ cell tumours
--- Content provided by FirstRanker.com ---
? Tumours of one histological type (pure forms)? Tumours of more than one histological type (mixed forms)
? Sex cord/gonadal stromal tumours Pure forms
? Miscellaneous tumours of the testis
? Haematopoietic tumours
--- Content provided by FirstRanker.com ---
? Tumours of collecting ducts and rete? Tumours of paratesticular structures
? Mesenchymal tumours of the spermatic cord and testicular adnexae
? Secondary tumours of the testis
--- Content provided by FirstRanker.com ---
Testicular cancer is staged using the TNM system created by the American JointCommittee on Cancer (AJCC)
It's based on 4 key pieces of information:
? T refers to how much the main (primary) tumor has spread to tissues next to the
--- Content provided by FirstRanker.com ---
testicle
? N describes how much the cancer has spread to regional (nearby) lymph nodes
? M indicates whether the cancer has metastasized (spread to distant lymph nodes
--- Content provided by FirstRanker.com ---
or other organs of the body)
? S indicates the serum (blood) levels of tumor markers that are made by some
--- Content provided by FirstRanker.com ---
testicular cancers? Letters or numbers appear after T, N, M, and S to provide more details about
each piece of information.
--- Content provided by FirstRanker.com ---
? The numbers 0 through 4 indicate increasing severity? The letters "IS" after the T stand for in situ, which means the tumor is contained
in one place and has not yet penetrated to a deeper layer of tissue.
--- Content provided by FirstRanker.com ---
? The letter X after T, N, M, or S means "cannot be assessed" because theinformation is not known
TNM classification of germ cel tumours of the testis
--- Content provided by FirstRanker.com ---
pTNM pathological classification
? pTx ?Primary tumour cannot be assessed
? pT0 No evidence of primary tumour pTis Intratubular germ cell neoplasia
--- Content provided by FirstRanker.com ---
(carcinoma in situ)? pT1 Tumour limited to testis and epididymis without vascular/lymphatic
invasion; tumour may invade tunica albuginea but not tunica vaginalis
--- Content provided by FirstRanker.com ---
? pT2 Tumour pT1+v/L + involvement of tunica vaginalis
? pT3 Tumour invades spermatic cord with or without vascular/lymphatic invasion
? pT4 Tumour invades scrotum with or without vascular/lymphatic invasion
pN ? Regional lymph nodes
--- Content provided by FirstRanker.com ---
? pNX Regional lymph nodes cannot be assessed
? N0 No regional lymph node metastasis
? pN1 <2 cm or </=5 or fewer positive nodes
? pN2 2 to 5 cm in greatest dimension; or more than 5 nodes positive, none more
--- Content provided by FirstRanker.com ---
than 5 cm; or evidence of extranodal extension of tumour
? pN3 Metastasis with a lymph node mass more than 5 cm in greatest dimension
--- Content provided by FirstRanker.com ---
S ? Serum tumour markers? SX Serum marker studies not available or not performed
? S0 Serum marker study levels within normal limits
? LDH, hCG (mIU/ml) ,AFP (ng/ml)
Cryptorchidism
--- Content provided by FirstRanker.com ---
? Cryptorchidism is a complete or partial failure of the intra-abdominal testes todescend into the scrotal sac
associated with
--- Content provided by FirstRanker.com ---
? testicular dysfunction? an increased risk of testicular cancer
? In 70% of cases, the undescended testis lies in the inguinal ring
? in 25% in the abdomen
--- Content provided by FirstRanker.com ---
ETIOLOGY. exact etiology is not known in majority of cases1. Mechanical factors-
? short spermatic cord
? narrow inguinal canal
? adhesions to the peritoneum
--- Content provided by FirstRanker.com ---
? problems with development of the gubernaculum? a patent processus vaginalis, or impaired intra-abdominal pressure have also
been hypothesized to contribute to cryptorchidism
--- Content provided by FirstRanker.com ---
2. Genetic factors-? up to 23% of cases
? Mutations in insulin-like factor 3 and its receptor, LGR8, have been
demonstrated in a small number of cases
--- Content provided by FirstRanker.com ---
? trisomy 13
3. Hormonal factor- rarely associated
? deficient androgenic secretions
? mullerian inhibiting substance
--- Content provided by FirstRanker.com ---
? insulin-like 3 hormone4. Neuromuscular- abnormalities of the genitofemoral nerve's calcitonin gene-
related peptide
--- Content provided by FirstRanker.com ---
Miscellaneous-? Maternal alcohol consumption
? analgesic consumption
? smoking
? Gestational diabetes
--- Content provided by FirstRanker.com ---
MORPHOLOGIC FEATURES. Cryptorchidism is unilateral in 80% casesGrossly, small in size, firm and fibrotic
Histology-
--- Content provided by FirstRanker.com ---
1-Seminiferous tubules? tubular basement membrane is thickened
? hyalinised tubules with a few Sertoli cells
? foci of spermatogenesis are discernible in 10% of cases
2. Interstitial stroma: usually increase in the
--- Content provided by FirstRanker.com ---
?interstitial fibrovascular stroma? Leydig cells,
--- Content provided by FirstRanker.com ---
? CLINICAL FEATURES. asymptomatic and is discovered only on physicalexamination
1. Sterility-infertility. Bilateral cryptorchidism is associated with sterility while
--- Content provided by FirstRanker.com ---
unilateral disease may result in infertility
2. Inguinal hernia. A concomitant inguinal hernia is frequently present along with
cryptorchidism
--- Content provided by FirstRanker.com ---
3-Malignancy. Cryptorchid testis is at 30-50 times increased risk of developing
testicular malignancy
? most commonly seminoma and embryonal carcinoma, than a normally
--- Content provided by FirstRanker.com ---
descended testis
? risk of malignancy is greater in intraabdominal testis than in testis in the inguinal
--- Content provided by FirstRanker.com ---
canal? current recommendations are for correction at 6 to 12 months of age
? carcinoma arises from foci of intratubular germ cell neoplasia within the
atrophic tubules
--- Content provided by FirstRanker.com ---
? Orchiopexy reduces the risk of sterility and cancer
Tumour marker
--- Content provided by FirstRanker.com ---
Tumour markers- Germ cell tumours of the testis secrete polypeptide hormonesand certain enzymes which can be detected in the blood
There are two principal serum tumour markers
? alpha fetoprotein (AFP) and
--- Content provided by FirstRanker.com ---
? beta subunit of human chorionic gonadotropin (shCG)? In addition, carcinoembryonic antigen (CEA), human placental lactogen (HPL),
placental alkaline phosphatase, testosterone, oestrogen and luteinising hormone
--- Content provided by FirstRanker.com ---
may also be elevated
AFP-
? synthesized by fetal yolk sac and also the liver and intestine
? elevated in 50-70% of testicular germ cell tumours
--- Content provided by FirstRanker.com ---
? Markedly elevated in yolk sac tumor? a serum half life of 4.5 days
? However, elevated serum AFP levels are also found in liver cell carcinoma
hCG-
--- Content provided by FirstRanker.com ---
? secreted by placental trophoblastic cells? elevated in non-seminomatous germ cell tumours of the testis (e.g. in
choriocarcinoma, yolk sac tumour and embryonal carcinoma)
--- Content provided by FirstRanker.com ---
? elevated in 50% of patients with germ cell tumours? elevation in seminoma in 10-25% of cases
Lactate dehydrogenase (LDH)-
? may also be elevated
--- Content provided by FirstRanker.com ---
? direct relationship between LDH and tumour burden? However, this test is nonspecific although its degree of elevation correlates with
bulk of disease
Applications-
--- Content provided by FirstRanker.com ---
? In the evaluation of testicular masses? In the staging of testicular germ cell tumors. For example, after orchiectomy,
persistent elevation of HCG or AFP concentrations indicates stage II disease even
--- Content provided by FirstRanker.com ---
if the lymph nodes appear of normal size by imaging studies? In assessing tumor burden
? In monitoring the respons to therapy. After eradication of tumors there is a
--- Content provided by FirstRanker.com ---
rapid fall in serum AFP and HCG. With serial measurements it is often possible topredict recurrence before the patients become symptomatic or develop any other
clinical signs of relapse
--- Content provided by FirstRanker.com ---
TESTICULAR TUMOR
Testicular tumor
? Most germ cell tumours occur between the ages of 20 and 50 years
--- Content provided by FirstRanker.com ---
? usual germ cell tumours , yolk sac tumour and the better differentiated types ofteratoma
? older patients-Spermatocytic seminoma and malignant lymphoma
--- Content provided by FirstRanker.com ---
? Before puberty, seminoma is extremely uncommonETIOLOGIC FACTORS
? Cryptorchidism
? Other developmental disorders- androgen insensitivity syndrome
--- Content provided by FirstRanker.com ---
? Genetic factors-high incidence in first-degree family members, twins? Other factors. A few less common factors
?Orchitis
?Trauma
?Carcinogens. LSD, hormonal therapy for sterility, copper, zinc etc
--- Content provided by FirstRanker.com ---
Prenatal risk factors ?? consistent associations of testicular cancer with low birth weight
Exposures in adulthood
? Possible etiological clues, however, include a low level of physical activity
--- Content provided by FirstRanker.com ---
qPATHOGENESIS-vast majority of these tumours originate from germ cells1-Developmental disorders- contribute to the pathogenesis
2-Molecular genetic features-common molecular pathogenesis of all germ cell
tumours:
--- Content provided by FirstRanker.com ---
? Hyperdiploidy is almost a constant feature? isochromosome of short arm of chromosome 12
? Telomerase activity is present in all germ cell tumours of the testis
? Other mutations include p53, cyclin E and FAS gene
3-Intratubular germ cel neoplasia (ITGCN) or carcinoma insitu-
--- Content provided by FirstRanker.com ---
Most testicular germ cel tumors originate from a precursor lesion calledintratubular germ cell neoplasia (ITGCN)exceptions to this rule are
? pediatric yolk sac tumors
? Teratomas
--- Content provided by FirstRanker.com ---
? adult spermatocytic seminoma4-Three hit' process. Germ cells in seminiferous tubules undergo
a. first hit-activate the cell
b. second hit- occure in CIS cell and further activate
--- Content provided by FirstRanker.com ---
c. third hit- via some epigenetic phenomena cell become invasivethis sequential tumorigenesis explains the development of seminomatous tumours
CLINICAL FEATURES AND DIAGNOSIS
--- Content provided by FirstRanker.com ---
? gradual gonadal enlargement and a dragging sensation in the testis
? secondary symptoms such as pain, lymphadenopathy, and urinary obstruction
(Metastatic involvement )
--- Content provided by FirstRanker.com ---
SPREAD-
? Lymphatic spread- retroperitoneal para-aortic lymph nodes, mediastinal lymph
nodes and supraclavicular lymph nodes
--- Content provided by FirstRanker.com ---
? Haematogenous spread -lungs, liver, brain and bones
1-Intratubular germ cel neoplasia, unclassified type (IGCNU)
? Also called carcinoma in situ (CIS) stage of germ cell tumours
? preinvasive stage of germ cell tumours
--- Content provided by FirstRanker.com ---
? intratubular seminoma and intratubular embryonal carcinoma are common? 2-4% of cryptorchidism pt show
? Clinical features - atrophic testis, infertility, maldescended testis, and intersex
features
--- Content provided by FirstRanker.com ---
? gross- no grossly visible lesion
? Histopathology - Germ cells with abundant vacuolated cytoplasm, large, irregular
nuclei and prominent nucleoli located within the seminiferous tubules
--- Content provided by FirstRanker.com ---
? restricted to the seminiferous tubules without evident invasion into the
interstitium
--- Content provided by FirstRanker.com ---
? Immunoprofile- PLAP can be demonstrated in 83-99% of intratubular germ cellneoplasia of the unclassified type (IGCNU) cases and is widely used for diagnosis
--- Content provided by FirstRanker.com ---
Comparison of morphological features of normal seminiferous tubules (left part) and intratubulargerm cel neoplasia (IGCNU) in seminiferous tubules (right part).
Seminoma
--- Content provided by FirstRanker.com ---
? Seminomas are the most common type of germ cell tumor, making up about(50%)
? peak incidence is the third decade
--- Content provided by FirstRanker.com ---
? it is called dysgerminoma in ovary.
--- Content provided by FirstRanker.com ---
MORPHOLOGY- cut surface has a homogeneous, graywhite, lobulated, usuallydevoid of hemorrhage or necrosis
Generally the tunica albuginea is not penetrated
but occasionally extension to the epididymis, spermatic cord, or scrotal sac occurs
--- Content provided by FirstRanker.com ---
Microscopy- typical seminoma is composed of sheets of uniform cells dividedinto poorly demarcated lobules by delicate fibrous septa containing a lymphocytic
infiltrate
--- Content provided by FirstRanker.com ---
Tumor cell-cell is large and round to polyhedral and has a distinct cell membrane; clear or
watery-appearing cytoplasm; and a large, central nucleus with one or two
--- Content provided by FirstRanker.com ---
prominent nucleoliStroma-
? delicate fibrous tissue which divides the tumour into lobules
? characteristic lymphocytic infiltration, indicative of immunologic response of the
--- Content provided by FirstRanker.com ---
host to the tumour
Variable features-
? tumor giant cells and greater mitotic activity
--- Content provided by FirstRanker.com ---
? 15% of seminomas contain syncytiotrophoblasts? ill-defined granulomatous reaction (20%)
Special stain-Cytoplasm contains variable amount of glycogen that stains positively
--- Content provided by FirstRanker.com ---
with PAS reaction
IHC- seminoma cells stain positively for KIT, (regardless of KIT mutational status),
--- Content provided by FirstRanker.com ---
OCT4, and placental alkaline phosphatase (PLAP)Prognosis-
? better than other germ cell tumours
? tumour is highly radiosensitive
--- Content provided by FirstRanker.com ---
Spermatocytic Seminoma-? Spermatocytic seminoma is both clinically and morphologically a distinctive
tumour from classic seminoma
--- Content provided by FirstRanker.com ---
? Incidence of about 5% of all germ cell tumours? older patients
? generally in 6th decade of life
? bilateral in 10% of patients
? Grossly, spermatocytic seminoma is homogeneous, larger, softer and
--- Content provided by FirstRanker.com ---
more yellowish and gelatinous than the classic seminoma
? Histological y, the distinctive features are as under:
1. Tumour cells. lymphocyte-like to huge mononucleate or multinucleate giant
--- Content provided by FirstRanker.com ---
cells. Majority of cells are, however, of intermediate size. Mitoses are often
frequent.
2. Stroma. stroma lacks lymphocytic and granulomatous reaction seen in classic
--- Content provided by FirstRanker.com ---
seminoma.
? prognosis of spermatocytic seminoma is excellent
? slow-growing and rarely metastasises
? tumour is radiosensitive
--- Content provided by FirstRanker.com ---
Embryonal Carcinoma-
? 30% of germ cell tumours more common
? 2nd to 3rd decades of life
? 90% cases are associated with elevation of AFP or hCG or both
--- Content provided by FirstRanker.com ---
Grossly,- a small tumour in the testis
? distorts the contour of the testis as it frequently invades the tunica and the
--- Content provided by FirstRanker.com ---
epididymis? Cut surface- grey white, soft with areas of haemorrhages and necrosis
--- Content provided by FirstRanker.com ---
Microscopy-1. tumour cells are arranged in a variety of patterns-- glandular, tubular, papillary
and solid
2.tumour cells are highly anaplastic carcinomatous cells having large size,
--- Content provided by FirstRanker.com ---
amphophilic cytoplasm and prominent hyperchromatic nucleoli
Yolk Sac Tumour (Synonyms: Endodermal Sinus Tumour,
Orchioblastoma, Infantile Embryonal Carcinoma)
--- Content provided by FirstRanker.com ---
? most common testicular tumour of infants and young children upto the age of 4year
? may be present as the major component in 40% of germ cell tumours
--- Content provided by FirstRanker.com ---
? AFP levels are elevated in 100% cases of yolk sac tumours? Grossly, the tumour is generally soft, yellow-white, mucoid with areas of necrosis
and haemorrhages
--- Content provided by FirstRanker.com ---
Microscopical y, yolk sac tumour has the following features
1. patterns--loose reticular network, papil ary, tubular and solid arrangement
2. flattened to cuboid epithelial cells with clear vacuolated cytoplasm
3.A pathognomonic feature is Schil er -Duvel body
--- Content provided by FirstRanker.com ---
a central vessel surrounded by tumor cells in a cystic space often lined by flattenedtumor cells
4. presence of both intracellular and extracellular PAS-positive hyaline globules
--- Content provided by FirstRanker.com ---
Choriocarcinoma
? highly malignant tumour composed of syncytiotrophoblast and cytotrophoblast
? 2nd decade of life
? serum and urinary levels of hCG are greatly elevated in 100% cases
--- Content provided by FirstRanker.com ---
? Grossly, the tumour is usually small and may appear as a soft, haemorrhagic
and necrotic mass
--- Content provided by FirstRanker.com ---
? Microscopical y, the characteristic feature is syncytiotrophoblast and
cytotrophoblast without formation of definite placental-type vil i
--- Content provided by FirstRanker.com ---
Teratoma-
? Teratomas are complex tumours composed of tissues derived from more than
one of the three germ cell layers--endoderm, mesoderm and ectoderm
--- Content provided by FirstRanker.com ---
? more common in infants and children and constitute ( 40%)
? in adults they comprise 5% of all germ cell tumours
MORPHOLOGIC FEATURES. Testicular teratomas are classified into 3 types:
1. Mature (differentiated) teratoma
--- Content provided by FirstRanker.com ---
2. Immature teratoma3. Teratoma with malignant transformation
Gross-
? large, grey-white masses enlarging testis
--- Content provided by FirstRanker.com ---
? Cut surface shows characteristic variegated appearance--grey-white solid areas,
cystic and honey-combed areas, and foci of cartilage and bone
--- Content provided by FirstRanker.com ---
Microscopicy-
? three categories of teratomas show different appearances:
1-Mature (differentiated) teratoma. Well differentiated structures such as
--- Content provided by FirstRanker.com ---
cartilage, smooth muscle, intestinal and respiratory epithelium, mucus glands, cystslined by squamous and transitional epithelium, neural tissue, fat and bone
--- Content provided by FirstRanker.com ---
2-Immature teratoma.? incompletely differentiated and primitive or embryonic tissues
? Mature+poorly-formed tissue (cartilage, mesenchyme, neural tissues, abortive
eye, intestinal and respiratory tissue elements) etc
--- Content provided by FirstRanker.com ---
? Mitoses are usual y frequent
Immature stroma
--- Content provided by FirstRanker.com ---
3-Teratoma with malignant transformation-
? extremely rare form of teratoma
? one or more of the tissue elements show malignant transformation
?squamous cell carcinoma
--- Content provided by FirstRanker.com ---
?mucin-secreting adenocarcinoma,?sarcoma, or other cancers
? importance of recognizing a non?germ cell malignancy arising in a teratoma is
that these secondary tumors are chemoresistant
--- Content provided by FirstRanker.com ---
Mixed Germ Cell Tumours? About 60% of germ cel tumours have more than one of the above
histologic types (except spermatocytic seminoma) and are cal ed mixed
--- Content provided by FirstRanker.com ---
germ cel tumoursmost common combinations of mixed germ cel tumours are as under:
1. Teratoma, embryonal carcinoma, yolk sac tumour and syncytiotrophoblast
2. Embryonal carcinoma and teratoma (teratocarcinoma)
--- Content provided by FirstRanker.com ---
3. Seminoma and embryonal carcinoma? SEX CORD-STROMAL TUMOURS-Tumours arising from specialised gonadal
stroma
--- Content provided by FirstRanker.com ---
source of tumor-
? theca, granulosa and lutein cells in the female
? Sertoli and interstitial Leydig cells in the male
Must know
--- Content provided by FirstRanker.com ---
1-classification
2-Tumor markers in diagnosis
3-Morphology of
a)
--- Content provided by FirstRanker.com ---
Seminoma
b)
--- Content provided by FirstRanker.com ---
Embryonal carcinomac)
Yolk sac tumor
--- Content provided by FirstRanker.com ---
4-Cryporchidism