|
Diseases of the liver and pancreas
|
səhifə | 19/19 | tarix | 26.03.2018 | ölçüsü | 1,15 Mb. | | #33477 |
| PROSTATE - Inflammation
Acute and chronic prostatitis:
-
Extend from the bladder or urethra
-
Nonspecific infection caused by
-
Coliform bacteria
-
Gonococci
-
Chlamydia
Granulomatous prostatitis:
-
May be caused by specific infections such as tuberculosis or syphillis
-
Nonspecific inflammatory reaction to inspissated secretion/ autoimmune causation
Benign nodular hyperplasia (BNH) / Benign prostatic hyperplasia (BPH)
-
Extremely common disorder in men over 50
-
Gross - distinct circumscribed grey white nodules in the periurethral zone
-
Histology - proliferation of both glandular and fibromuscular stromal elements + infarct, infection, squamous metaplasia
Benign prostatic hyperplasia (BPH)
-
Proliferation of glands, some cystically dilated within a well defined nodule
Benign prostatic hyperplasia (BPH)
-
High power view showing hyperplastic glands with two layers
-
Inner columnar
-
Outer cuboidal
Clinical Features & Complications
-
Asymptomatic
-
Compression of urethra - difficulty in urination, frequency or dribbling
-
Retention of urine
-
Bladder distention and hypertrophy
-
Hydroureters and hydronephrosis
Prostatic carcinoma
Incidence:
-
Marked geographical and racial difference: common in American males (more prevalent in blacks) but uncommon in orientals
Etiology:
-
Role of androgen in the growth of the tumor
Clinical presentation
-
Clinical symptoms (prostatism) is present, hard mass find during rectal examination.
-
Incidental finding during microscopic examination of the tissue surgically removed for non-malignant disease, particularly BPH.
-
Present with signs and symptoms of metastasis (e.g. back pain due to vertebral metastasis)
-
Tumors of the prostate detected during autopsy on patients that showed no clinical evidence of prostatic cancer
Tumour markers:
-
Prostatic acid phosphatase
-
Prostatic specific antigen
Gross:
-
Yellowish, hard, gritty tissue
Histology:
-
Adenocarcinoma, usually microacini
-
Perineural invasion
Modes of spread:
-
Local - causing prostatic urethra obstruction and may infiltrate into periphery adjacent tissue
-
Lymphatics - presacral in pelvis, iliac and paraaortic lymph nodes
-
Blood - vertebra, osteoblastic, widespread metastasis
Treatment: Surgery + hormonal therapy
Staging of Prostatic Cancer
Testicular Tumors
St Christopher’s College of Medicine
Testicular tumors - Objectives
-
Germ Cell Tumors:
-
know the classification of testicular germ cell tumors and how they originate
-
know the commonest type
-
be able to describe clinical and histologic features
-
know which tumor produces which marker
-
predict possible clinical outcomes and response to treatment
GERM CELL TUMORS
Epidemiology:
-
More common in whites than blacks
-
Peak incidence is between 20 and 34 years when it is the most common malignancy in males.
-
Mean age
-
Seminoma is about 40 years
-
Teratoma is about 30 years.
-
Are uncommon after 50 years of age.
-
Cause of germ cell tumors is unknown.
-
Cryptorchidism significantly increases the risk, 4 to 10 fold, of subsequent development of germ cell tumors.
-
Development of a germ cell tumor in one testis increases the risk of developing a tumor in the contralateral testis.
GERM CELL TUMORS
-
GCTs have the following subtypes and frequencies:
-
seminoma (40%),
-
embryonal (25%),
-
teratocarcinoma (25%),
-
teratoma (5%),
-
choriocarcinoma (pure) (1%).
-
The most important clinical distinction is between seminoma and nonseminoma, 2 broad categories with different treatment algorithms:
-
(1) seminoma as a classification refers to pure seminoma upon histopathologic review, and
-
(2) any nonseminomatous elements (even if seminoma is prevalent) change the classification to nonseminoma.
-
After a radical orchiectomy, testicular seminoma is a pathologic diagnosis in which
-
only seminomatous elements are observed upon histopathologic review and
-
serum alpha-fetoprotein (AFP) is normal.
-
Any elevation of AFP or nonseminomatous elements in the testis specimen mandates diagnosis of nonseminomatous GCT (NSGCT) and an appropriate change in treatment
Seminoma
-
Commonest type of primary testicular tumor.
-
Accounts for 35 - 70% of testicular neoplasms
-
Types:
-
Classic (or conventional)
-
Anaplastic
-
Spermatocytic seminomas.
-
Does not develop before puberty
Classic seminoma
-
A nodular tumor completely replaces the testis
Classic seminoma
Classic seminoma
-
The tumor is composed of sheets of uniform undifferentiated germ cells
-
with clear or fine granular cytoplasm,
-
well-defined cell border and round nuclei, frequently with prominent nucleoli.
-
Sheets of tumor cells are separated by slender fibrous septa.
-
Diffuse or focal intense lymphoid infiltrate is seen in most tumors.
-
Glycogen may be demonstrated in the cytoplasm of the tumor cells.
Classic seminoma
Seminoma – “fried-egg” appearance
Classic seminoma
-
Mitotic figures are usually infrequent.
-
Approx 35% cases, noncaseating granulomatous areas containing small giant cells are found.
-
Tumor giant cells that mimic syncytiotrophoblasts in appearance and which may contain intracytoplasmic ß-hCG are present in some tumors.
-
This may lead to a mild increase in serum ß-hCG.
Mitotic figure in intestinal epithelial cell
Classic seminoma
-
Left panel shows multinucleate giant cells of foreign body type.
-
Right panel shows syncytiotrophoblast-like tumor giant cell.
Classic seminoma - syncytiotrophoblast-like tumor giant cell
ANAPLASTIC SEMINOMAS
-
In some seminomas, the neoplastic cells are more pleomorphic and have more mitotic figures than in typical seminoma.
-
These tumors have been called anaplastic seminomas.
-
Although these tumors tend to occur at higher stages than classical seminoma, stage for stage this subgroup has the same prognosis as the classical type.
SPERMATOCYTIC SEMINOMA
-
Is a rare but distinct clinicopathologic variant of seminoma
-
Occurs only in the descended testes of elderly men
-
Forming about 5% of seminomas.
-
The tumor is bilateral in about 6% of cases compared to about 2% in classic seminoma.
SPERMATOCYTIC SEMINOMA
-
The tumor tends to be poorly demarcated, usually soft with a gelatinous or mucoid appearance.
-
Cystic areas, especially in the center, are common but hemorrhage or necrosis is almost always absent.
Histology - Spermatocytic seminomas
-
Forms solid sheets of cells without the nesting pattern of classical seminoma.
-
Three populations of tumor cells, separated according to size, are seen:
-
small cells that superficially resemble lymphocytes,
-
intermediate or medium-sized cells, the commonest cell type, have round nuclei and finely granular chromatic pattern,
-
large or giant cells.
-
Mitotic figures are usually abundant
-
Lymphocytic infiltrate and granulomas seen in classic seminoma are absent.
-
Spermatocytic seminoma is an extremely indolent tumor with rather limited malignant potential and rarely if ever metastasizes.
EMBRYONAL CARCINOMA
-
This subtype of GCTs represents the most primitive form of the NSGCTs.
-
Accounts for about 15-35% of testicular GCTs.
EMBRYONAL CARCINOMA
-
Grossly, the tumors are large, often hemorrhagic and necrotic producing a variegated cut surface.
Embryonal Cell Carcinomas
-
Sheets of undifferentiated cells and glandular differentiation
EMBRYONAL CARCINOMA
-
Extremely pleomorphic
-
Show a variety of patterns forming glands, tubules, and even primitive embryo-like structures.
-
Many mitotic figures are present.
EMBRYONAL CARCINOMA
-
Anaplastic and solid undifferentiated areas may present as sheets of cells with large, hyperchromatic nuclei, prominent nucleoli and poorly-defined cell borders.
EMBRYONAL CARCINOMA
-
Poorly differentiated area in embryonal carcinoma.
EMBRYONAL CARCINOMA
-
Metastasizes early and widely via both lymphatic and hematogenous routes.
-
Radiation is not as effective as with seminoma, but newer chemotherapeutic agents have greatly improved prognosis.
-
Tumors confined to the testis now have a prognosis essentially identical to that of seminoma (95% 5-year survival).
YOLK SAC TUMOR (ENDODERMAL SINUS TUMOR)
-
Is a distinct entity from embryonal carcinoma of which it was considered a variant in the past.
-
Noted for its:
-
Resemblance to rat fetal yolk sac
-
Presence of microscopically distinctive structures known as Schiller-Duval bodies.
YOLK SAC TUMOR
-
Testicular yolk sac tumors occur in two forms:
-
A pure form in young children
-
A focal differentiation within other NSGCTs, mainly embryonal carcinoma, in adults.
YOLK SAC TUMOR
-
The cut surface is gray-white and may be cystic
YOLK SAC TUMOR
-
Tumor shows a variety of patterns,
-
Commonest: loose meshwork of small spaces and cysts (producing a sieve-like appearance) lined by either flattened cells or vacuolated cells with nuclei that protrude in a "hobnail" fashion.
YOLK SAC TUMOR
-
In some tumors, Schiller-Duval bodies (endodermal sinus) are seen.
-
These are glomerulus-like structures with a central core of blood vessel surrounded by an inner layer of epithelial-like cells, a space and an outer layer of similar cells.
YOLK SAC TUMOR
-
Almost invariably associated with production of large amounts of alpha-fetoprotein (AFP)
-
AFP may be followed as a marker of disease progression in the patient's serum.
-
Antibodies directed against AFP may also be used to stain the tumors and aid in their diagnosis.
YOLK SAC TUMOR
-
Yolk sac tumor stained with antibodies against AFP. Note the brown staining of the epithelium indicating the presence of AFP
TERATOMA
-
In the WHO classification (used in the US) the term is restricted to a tumor typically composed of several tissues representing two or more germinal layers.
-
Are further subdivided into
-
Mature
-
Immature
-
Teratoma with malignant transformation.
Mature Teratoma
-
The tumor is composed exclusively of well-differentiated tissues and by definition, contains no malignant-looking tissue.
-
Some may consist of nests of mature cartilage, smooth muscle and squamous or mucous epithelial-lined cysts.
-
In others, more complex and organoid arrangement is seen and abortive gastrointestinal tract, brain, eye, pancreas, salivary gland, and other organs can easily be recognized.
Mature Teratoma
-
Showing cysts lined by mucous epithelium (left) and keratinizing squamous epithelium (right).
Mature Teratoma
-
Mature cartilage (left) and spaces lined by mucus secreting glandular epithelium (right) are present
Mature Teratoma
Mature Teratoma
Mature Teratoma
-
Although the tumor has a benign histologic appearance, its clinical course in the adult is unpredictable and it can metastasize.
-
The metastases show the same well-differentiated picture as the primary tumor.
-
In children, teratomas whatever their histological appearances behave in a benign fashion.
-
Teratoma is the 2nd most common testicular germ cell tumor in children (after Yolk Sac Tumor).
Immature Teratoma
-
In this type of teratoma there are incompletely differentiated, fetal-appearing tissues, often of neural differentiation.
Immature Teratoma
-
Primitive brain tissue (upper left corner)
-
Well-differentiated glands (lower half)
Choriocarcinoma
-
This is a highly malignant neoplasm that is usually widely disseminated and frequently fatal.
-
The cells differentiate in the direction of trophoblastic (placental) tissue
-
Both cytotrophoblast and syncitiotrophoblast must be present for the diagnosis to be made.
-
Pure choriocarcinoma of the testis is extremely rare, and the tumor is much more common as a component of mixed GCTs.
Choriocarcinoma
-
The tumor typically presents in adolescent or young adults with widespread disease, and an often small, painless primary lesion in the testis.
-
It is extensively hemorrhagic and necrotic and, sometimes, may be reduced to a fibrous scar, leaving widespread metastases with no apparent testicular mass.
-
On occasion, the tumor may be large and bulky.
-
Hemoptysis due to pulmonary involvement is common.
Choriocarcinoma
Choriocarcinoma
-
Tumor is composed of two types of cells:
-
Syncytiotrophoblasts: large multinucleate cells with abundant vacuolated cytoplasm containing hCG
-
Cytotrophoblasts: polygonal cells with distinct cell borders and single nuclei, which grow in clusters and are surrounded by the syncytiotrophoblasts.
-
Choriocarcinoma, left panel, and placenta, right panel.
-
Note similarity in histologic appearances.
Choriocarcinoma
-
Sheet of cytotrophoblasts surrounded by syncytiotrophoblasts.
Choriocarcinoma
-
This image shows admixture of polygonal cells with clear cytoplasm (cytotrophoblast) and large multinucleated cells with smudged nuclear chromatin (syncytiotrophoblast).
Choriocarcinoma
-
In classic cases of choriocarcinoma, syncytiotrophoblasts form a “cap” around clusters of cytotrophoblasts in an attempt to mimic the architecture of immature placental villi
Age Incidences of Germ-Cell Tumors
-
What is the commonest malignant testicular tumor after 50 years of age?
-
Choriocarcinoma is one of the very few carcinomas that metastasize more frequently via bloodstream than lymphatics. What are the others?
-
Follicular carcinoma of the thyroid
-
Renal cell carcinoma.
Tumour Markers
Human chorionic gonadotrophin (HCG)
-
Secreted by syncytiotrophoblastic cells in the placenta
-
Elevated levels are seen in most choriocarcinomas, some embryonal carcinomas and some seminoma containing syncytiotrophoblasts.
Alpha-fetoprotein (AFP)
-
Secreted in yolk sac tumors and some embryonic carcinoma.
Significance of Tumour Markers
-
Detection of non-seminomatous elements
-
Detection of recurrence
-
Detection of metastasis
Non-Germ Cell Tumors
Leydig (Interstitial) Cell Tumors
-
Tumors of Leydig cells may elaborate
-
Androgens
-
Androgens + estrogens
-
Corticosteroids
-
They arise at any age
-
Majority between 20 - 60 years of age
-
The most common presenting feature is testicular swelling
-
In some patients gynecomastia may be the first symptom
-
In children, hormonal effects, manifested primarily as sexual precocity, are the dominating features
Morphology
-
Most are benign tumors
-
Form circumscribed nodules <5 cm in size
-
Have golden-brown, homogeneous cut surface
Histologically:
-
Tumorous Leydig cells are large and round or polygonal, and they have an abundant granular eosinophilic cytoplasm with a round central nucleus.
-
The cytoplasm frequently contains lipid granules, vacuoles, or lipofuscin pigment, but, most characteristically, rod-shaped crystalloids of Reinke occur in about 25% of the tumors
Leydig (Interstitial) Cell Tumors
-
Sheets of large polygonal cells with round nuclei, single prominent nucleolus and abundant eosinophilic cytoplasm
Leydig (Interstitial) Cell Tumors
-
Several plump rod-shaped intracytoplasmic crystals of Reinke can be seen in the center of the photomicrograph.
Leydig (Interstitial) Cell Tumors
-
The smear was alcohol-fixed and stained with H&E. Several intact and fragmented Reinke’s crystalloids can be seen
Sertoli Cell Tumors (Androblastoma)
-
Tumors of Sex Cord - Gonadal Stroma
-
Composed entirely of Sertoli cells or may have a component of granulosa cells
-
Some induce endocrinologic changes
-
Estrogens or androgens may be elaborated
-
Only infrequently in sufficient quantity to cause precocious masculinization or feminization.
-
As with Leydig cell tumors - gynecomastia may appear
Sertoli Cell Tumors (Androblastoma) - Morphology
-
Appear as firm, small nodules with a homogeneous gray-white to yellow cut surface.
Histologically:
-
Tumor cells arranged in distinctive trabeculae
-
Tendency to form cord-like structures resembling immature seminiferous tubules
-
Majority of Sertoli cell tumors are benign
Testicular Lymphoma
-
Lymphomas account for 5% of testicular neoplasms
-
Most common form of testicular cancer in men over the age of 60.
-
In most cases, disseminated disease is already present at the time of detection of the testicular mass
-
Only rarely does it remain confined to the testis
-
Histologic type in almost all cases is the diffuse large cell lymphoma
-
The prognosis is extremely poor.
5>
Dostları ilə paylaş: |
|
|