Diseases of the Penis Congenital Anomalies

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Diseases of the Penis Congenital Anomalies

• EPISPADIAS Dorsal surface opening HYPOSPADIAS
  Ventral surface opening
• MISCELLANEOUS
• PHIMOSIS Small prepuce orifice secondary to
  repeated infections
• INFLAMMATIONS Balanoposthitis, infection of
  glans and prepuce with smegma.
• Organisms candida, anaerobes, pyogenic

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Tumors of the Penis

• BENIGN
• 1. CONDYLOMA ACCUMINATUM Human papilloma
  virus (HPV)
• Sexual transmission
• HPV types 6 - 11 associated with carcinoma
• CARCINOMA IN SITU 3 types
• A. BOWEN DISEASE Limited by basement
  membrane mainly in shaft
• B. ERYTHROPLASIA OF QUEYRAT Similar to
  Bowens but in glans-prepuce
• C. BOWENOID PAPULOSIS Sexually active
  pigmented lesions

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Tumors of the Penis Malignant

• SQUAMOUS CELL CARCINOMA
• HPV INFECTION type 16 most common, also 18
• 40 - 70 years of age
• More common in uncircumcised populations
• Glans - inner surfer of prepuce
• Papillary or flat
• VERRUCOUS CARCINOMA Giant condyloma
  (BUSCHKE-LOWENSTEIN TUMOR)
• Also HPV related types 6, 11
• Invasive carcinoma metastasizes to inguinal-iliac
  LN
• 66 5-year survival, if LN involved 27 5-year
  survival

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SQUAMOUS CELL CARCINOMA
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Testis Epididymis Congenital anomalies

• CRYPTORCHIDISM Undescended testis
• Descent in 2 phases
• a. Transabdominal, to lower abdomen
• b. Inguino-scrotal, to scrotum (MOST
  COMMON DEFECT)
• Asymptomatic - bilateral 25
• Testicular atrophy prominent Leydig
• cells
• Complications Sterility - cancer

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CRYPTORCHID
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Diseases of Testis Inflammation

• TB, GONORRHEA Epididymis, spreads to testis
• SYPHILIS Testis involved first
• CHLAMYDIA Epididymitis in sexually active
• E. COLI PSEUDOMONAS Epididymitis in older than
  35 may cause abscess, sterility
• MUMPS Orchitis
• VASCULAR DISTURBANCES Torsion due to trauma,
  incomplete descent, may cause hemorrhage-infarctio
  n

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GONORRHEA
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Testicular Tumors

• A. GERM CELL TUMORS
• B. NONGERMINAL CELL TUMORS
• (STROMA - SEX CORD)

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Germ Cell Tumors

• A. SEMINOMA Typical, anaplastic,
• spermatocytic
• B. EMBRYONAL CARCINOMA
• C. YOLK SAC TUMOR
• D. POLYEMBRYOMA
• E. CHORIOCARCINOMA
• F. TERATOMA Mature, immature,
• malignant
• G. MIXED Teratocarcinoma
• (EMBRYONAL, CHORIOCARCINOMA)

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Testicular Tumors

• A. SEMINOMAS
• Morphology
• 1. TYPICAL Grossly white-gray homogeneous.
  Microscopic large, polyhedral cells with
  large central nucleus, nucleoli, by IP positive
  for Placenta like alkaline phosphatase (PLAP)
  lymphocytic reaction, granulomas
• 2. ANAPLASTIC Large, irregular cells, frequent
  mitoses
• 3. SPERMATOCYTIC Medium and large cells,
  giant cells

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SEMINOMA
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Testicular Tumors

• B. EMBRYONAL CARCINOMA Hemorrhage - necrosis.
  Cells are large, hyperchromatic nuclei,
  nucleoli, arranged in glandular, alveolar or
  tubular patterns, with papillary
  convolutions. 20 - 30 years
• C. YOLK SAC TUMORS (INFANTILE EMBRYONAL OR
  ENDODERMAL SINUS TUMOR)
• Children up to 3 years
• Cuboidal or elongated cells, with papillary
  formation
• Endodermal sinus (50) resemble primitive
  glomeruli, mesodermal core, central capillary
  lined by visceral and parietal layers
• Eosinophilic globules with alpha-fetoprotein

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EMBRYONAL CARCINOMA
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YOLK SAC TUMORS
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Testicular Tumors

• D. CHORIOCARCINOMA
• Aggressive, small tumors, metastasize
  widely
• Hemorrhage - necrosis common
• Syncytiotrophoblastic - Cytotrophoblastic
  components positive for HCG

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CHORIOCARCINOMA
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Testicular Tumors

• E. TERATOMAS
• Common in child, rare in adults
• Gross large (SOLID, CARTILAGINOUS, CYSTIC)
• Three histologic variants
• 1. MATURE nerve, muscle, cartilage, thyroid,
  bronchial,
• intestinal, brain in myxoid or fibrous
  stroma.
• All well differentiated.
• 2. IMMATURE poorly differentiated tissues, but
  identifiable.
• Glands, neuroblasts, cartilage
• 3. MALIGNANT TRANSFORMATION squamous or
• adenocarcinoma, sarcoma

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Testicular TumorsMixed

• 60 e.g. teratomas - embryonal
• teratoma - yolk sac
• seminoma - embryonal
  or teratoma

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Teratocarcinoma Mixed Embryonal and
Choriocarcinoma
HCG
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Testicular Tumors Clinical Features

• CLINICALLY Classified as seminomatous or
  nonseminomatous
• Painless masses
• LYMPHATIC SPREAD TO LYMPH NODES Retroperitoneal,
  paraaortic, mediastinal, supraclavicular
• HEMATOGENOUS SPREAD
• Lung, liver, bones, brain

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Testicular Tumors Staging

• STAGE 1 Confined to testis, epididymis,
  spermatic cord
• STAGE IIRetroperitoneal lymph nodes, below the
  diaphragm
• STAGE III
• Metastases into lymph nodes above thediaphragm
• STAGE IV
• Metastases into other organs or lung, liver,
  brain, bones

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Testicular Tumors Biologic Markers

• 1. HUMAN CHORIONIC GONADOTROPHINS (HCG)
  choriocarcinomas
• 2. ALPHAFETOPROTEIN (AFP) yolk sac tumors
• 3. PLACENTA-LIKE ALKALINE PHOSPHATASE (PLAP)
  seminomas
• Others include placental lactogen, LDH
• Helpful in diagnosis, staging, monitoring
• testicular tumors

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Testicular Tumors Sex Cord Gonadal Stromal
Tumors

• SEX CORD (SERTOLI)
• Estrogen or androgen producers
• Gynecomastia, precocious masculinization
• MORPHOLOGY gray, white or yellow nodules
• Entirely Sertoli type or partly granulosa cells
• Cordlike structures, resembling
  seminiferoustubules
• Benign tumors 10 malignant

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SERTOLI TUMOR
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Gonadal Stromal Tumors Leydig Cell Tumors

• May produce androgens, estrogens, corticosteroids
• Gynecomastia sexual precocity in children
• Golden brown, homogeneous nodules
• Cells are large, round or polygonal
• Eosinophilic cytoplasm, central, round nucleus
• Reinke crystalloids in 25 of tumors
• Benign 10 invasive

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Leydig Cell Tumor
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Tunica Vaginalis

• Hydrocele (FLUID ACCUMULATION)
• Hematocele (TRAUMA)
• Chylocele (ELEPHANTIASIS)
• Spermatocele
• Varicocele

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Prostate

• EMBRYO 5 lobes
• Posterior, middle, anterior, 2 laterals
• ADULT 4 lobes
• Peripheral, central, transitional, periurethral
• GLANDS 2 cell layers basal, columnar

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ProstateInflammation

• ACUTE BACTERIAL Gram negative rods,
  staphylococci
• CHRONIC BACTERIAL Same organisms
• CHRONIC ABACTERIAL Most common type
• Sexual activity (CHLAMYDIA, MYCOPLASMA)
• MORPHOLOGY Necrosis, later fibrosis, chronic
  with lymphocytes, neutrophils,lymphs, macrophages

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Prostate Inflammation
ACUTE
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Prostate

• HYPERPLASIA
• Glandular - stromal
• INCIDENCE20 over age 40, 70 by age 60, 90 by
  age 70
• ENLARGEMENT
• Androgens stimulate growth (DHT)
• DHT synthesized in prostatic stromal cells
• DHT inhibitors cause decrease in volume
• MORPHOLOGYCellular nodules in transitional
  zone later stromal periurethral nodules
  compress urethra and prostate, creating cleavage
  (NOT CAPSULE). Nodules with squamous metaplasia
  or infarction.

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HYPERPLASIA Glandular - stromal
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Carcinoma of Prostate

• Most common tumor in males
• 300,000 new cases / year 69/100,000
• 20 50 60 years
• 70 70 80 years
• Highest rates in blacks

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Carcinoma of Prostate
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Carcinoma of Prostate

• ETIOLOGY
• Unknown
• RISK FACTORS
• Age environmental
• Role of androgens
• Genetics
• Molecular

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Carcinoma of Prostate

• 70 arise in peripheral zone, posterior aspect
• Detectable by rectal examination
• May invade seminal vesicles, base of bladder
• HEMATOGENOUS METASTASES TO BONES
• Lumbar spine, femur, pelvis, ribs (OSTEOBLASTIC)
• LYMPHATIC SPREAD TO LYMPH NODES
• Obturator, perivesical, hypogastric, iliac,
  paraaortic

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Carcinoma of Prostate Morphology

• MICROSCOPIC Well-defined small glands
• Uniform layer cuboidal or low columnar cells
• Occasionally larger with papillary or cribriform
  pattern
• Nuclei large, vacuolated, 1 2 nucleoli
• Mitoses uncommon
• GROWTH PATTERN Rounded masses, back to back
  pattern
• UNDIFFERENTIATED Cords, nests, sheets
• Tendency to invade capsule, lymphatic vascular
  channel and nerves
• PREMALIGNANT LESION PIN (PROSTATIC
  INTRAEPITHELIAL NEOPLASIA)
• DIFFERENCE Presence of basal layer

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Carcinoma of ProstateClinical Features

• 70 incidence in men over 80 years,
• Stage A
• VISUAL COURSE
• Non-progressive
• Stage A2 progresses (30 50)
• Over 60 present with local disease
• Urinary symptoms are late
• DIAGNOSTIC APPROACH
• Rectal exam, serum PSA, biopsy

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Carcinoma of Prostate Grading (Gleason System)

• GRADE 1 Closely packed single or separate
  uniform glands
• GRADE 2 Same as 1 with less uniformity, limited
  infiltration
• GRADE 3 Separate, irregular glands, cribriform
  pattern
• GRADE 4 Fused glands and cords, cribriform
  pattern
• GRADE 5 Sheets or cords few or no glands

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GRADE 1 Closely packed single or separate
uniform glands
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GRADE 3 Separate, irregular glands, cribriform
pattern
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GRADE 5 Sheets or cords few or no glands
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Carcinoma of ProstateProstate Specific Antigen
(PSA)

• Serine protease produced by prostatic epithelium
• SERUM LEVEL 4 ng/ml upper limit
• Organ specific, not cancer specific
• Elevated in BPH, prostatitis cancer
• BPH 30 have elevated PSA
• CARCINOMA 80 have elevated PSA, 20 40 have
  less than 4 ng/ml

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Prostatic Specific Antigen (PSA)

• TWO FORMS
• a) Free
• b) Bound to alpha 1 antichymotrypsin
• Free PSA is lower in cancer than in BPH
• Specially important in values 4 10 ng/ml

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Carcinoma of ProstateTreatment

• SURGERY
• Localized disease (Stages A B)
• RADIATION
• Localized disease (Stages A B)
• HORMONAL TREATMENT
• Metastatic disease (Stages C D)
• (ESTROGEN THERAPY ORCHIECTOMY)