PROSTATE GLAND : Benign nodular prostatic hyperplasia (BPH) non-neoplastic enlargement

1. PROSTATE GLAND: • Benign nodular prostatic hyperplasia (BPH) • non-neoplastic enlargement • common > 50y •  recurrent urinary infection • eventually  renal function • Morphology • both lateral lobes + ‘median lobe’ • cut surface: • multiple solid nodules /some cystic areas • histology: hyperplasia of glands and stroma • Clinical features • Obstructive symptoms • 2 factors: • hyperplastic nodules  • distortion of course of prostatic urethra • peri- urethral zone involvement  interferes with • sphincter mechanism •  Obstructive symptoms

2. Complications • Continuedobstruction: • hypertrophy of bladder musculature • trabeculation / diverticulae if compensatory mech. fails • dilatation of bladder  hydroureter hydronephrosis Also: • incomplete bladder emptying • residual urine   infection (bladder) • also ascending  pyelonephritis / septicaemia -  renal function / ± stones

3. Prostatic carcinoma • one of commonest cancers • 2nd most NB cause of ♂ † from malignancy • usually > 50 y (peak 60-85) • adenocarcinoma in posterior sub-capsular area • invasion of stroma / perineural spaces • osteosclerotic bone metastases (pelvis + other sites) • gross findings on cut surface: • tumour ill-defined, gray or yellow, firm • histology: • adenocarcinoma usually moderately / well differentiated • Gleason grading system 1 (well)  5 (poor diff.) • correlates with clinical behaviour PSA stain useful to confirm origin from prostate in cases of metastases

4. in some cases especially elderly patients a microscopic focus of • tumour is found incidentally • ‘dormant lesions’ • rather low risk of metastasis • Mode of spread of prostate carcinoma • •direct • - stromal invasion • - prostatic capsule • - urethra, bladder base, seminal vesicle • • via lymphatics to nodes • - sacral • - iliac • - para-aortic • • via blood to bone (osteosclerotic) • - pelvis • - lumbo-sacral spine • - femur • - lungs • - liver

5. Testis • Tumours: • - relatively uncommon • important – young men • highly malignant   improved prognosis with • chemo • Aetiology • maldescended testis • 10 x higher risk • Classification: • Germ cell NB (85 – 90 %) • Non-Germ cell • Germ cell • Seminomas • Teratomas

6. Classification in use: • Seminoma (most common) • Teratoma ( less common) • Combined / mixed (seen, but less common) • Malignant lymphoma • Yolk sac uncommon • Leydig cell tumour • + others

7. Seminoma • commonest type • germ cell origin • peak incidence 30 – 50 years • Morphology: • testes enlarged by homogenous firm white • solid tumour (potato-like) • Histological subtypes • Classical seminoma: - commonest • histology: • uniform cells, clear / vacuolated cytoplasm • lymphocytic infiltrate, granulomatous reaction • other histological types less common • may also have precurser lesions ajacent to • tumour – called intra-tubular germ cell neoplasia • seminomaspreads to para-aortic nodes • good prognosis • very radiosensitive

8. Teratoma • Germ cell origin • Peak incidence 20-30 y • More aggressive than seminomas • composed of several types of tissue (variably • differentiated) representing: • endoderm - bowel type mucosa, etc. • ectoderm - skin, appendages,neural • mesoderm – cartilage, fat, mesenchymal

9. Classification of Teratomas • difficult • - prognostic relevance • differentiated • undifferentiated (malignant)somatic and/or extra • embryonic differentiation (yolk-sac/choriocarcinoma) • 2 Classifications: UK and USA (WHO) • UK:USA (WHO) • Differentiated same • Malignant • Malignant undifferentiated embryonal carcinoma • (WHO) • Malignant trophoblastic choriocarcinoma • (WHO)

10. - differentiated - rare - malignant teratoma (variably differentiated) - partly solid / cystic - poorer differentiated extensive tumour necrosis with haemorrhagevariegated appearance on cut surface • some may contain trophoblastic tissue • choriocarcinoma (haemorrhagic) • associated  serum(HCC) human chrorionic • gonadotrophin, ( AFP) also yolk-sac/ embryonal • carcinoma components •  aggressive tumours with vascular invasion •  blood-borne metastases common

11. Combined germ cell tumours • seminoma / teratoma intermingled • teratoma component determines prognosis • Yolk-sac tumour • - pure type • usually before 3 years • in adults – usually one component of mixedgerm • cell tumour • AFP raised in serum

12. Non-germ cell tumours • Primary malignant lymphoma • uncommon • elderly • bi-lateral • non-Hodgkin B-cell lymphoma (testes may be) • secondarily involved in cases of widespread • seeding of an underlying • primary lymphoma i.e. • lymphoblastic lymphoma in children

13. Tumours of the penis • 2 types • • Intra-epidermal carcinoma (Bowen’s disease) • rare • sharply circumscribed erythematous (red) patch • risk for invasive squamous carcinoma • • Invasive squamous carcinoma • more common Africa / Asia • only in uncircumcised males • papilloma virus may play role • glans / inner part of foreskin • nodule / plaque  ulcer • histology: well differentiated squamous carcinoma • invades corpora • metastases:inguinal lymphnodes • Carcinoma of scrotum • rare • previously described in chimney sweeps – occupational • exposure to carcinogens

14. Bladder • Pathological changes following chronic cystitis • von Brunn cell nests develope as a result of nests of • urothelial cells becoming trapped in inflammatory • fibrous tissue in chronic cystitis • may become cystic • cystitis cystica • show glandular metaplasia • cystitis glandularis Tumours • most bladder tumours are transitional cell(TCC) • carcinomas • squamous cell / adenocarcinomas are far less common • sarcomas rare • aetiological factors for TCC include: - exposure to • dyes (aniline compounds) • chronic smoking • analgesic abuse • aetiological factors for squamous cell carcinoma • include • schistosomiasis (bilharzia) • calculi

15. Transitional cell carcinoma • - arises from urothelium • frequently multiple • ‘field effect’ • often preceded by dysplasia • Morphology • most are papillarywith delicate fronds • covered by variably atypical urothelium • Histology: • Low and High-grade tumours • Low-grade: • papillary • cells show minimal atypia • usually no invasion • good prognosis High-grade: • less papillary • solid, usually invasive • severe cellular atypia • high grade may show squamous / glandular • metaplasia • poor prognosis

16. Carcinoma in situ • often multi-focal change between tumours • precursor for invasive tumour • Squamous cell carcinoma • arises from metaplastic epihelium • schistosomiasis / calculi • usually solid / invasive • poorer prognosis than TCC • Adenocarcinoma • uncommon • arises from: • urachal remnants • cystitis glandularis • peri – urethral / prostatic glands • TCC with glandular differentiation • Mesenchymal tumours • uncommon • benign: - leiomyoma etc. • malignant:rhabdomyosarcoma • Children (embryonal) – polypoid ‘grape-like’ called • sarcoma botryoides

17. Adults – rhabdomyosarcoma (straited muscle) • Secondary tumours: • direct extension • • cervix • • prostate • • rectum

18. Obstructive uropathy • Causes: • Infancy:congenital anomalies: • uretero – pelvic stenosis • vesico – ureteric reflux • urethral valves • Puberty to middle-age (females) • - short urethra predisoses to • ascending infection with • - minor trauma • - pregnancy • 40 + years (men) – prostatic disease (BPH) • - less common calculi • - cancer bladder / • advanced prostate cancer • all ages – instrumentation (catherisation, • cystoscopy) • - underlying diabetes

19. Pathogenesis • pelvic and calyceal system become dilated due to • back pressure (mild in acute obstruction) • gross dilation result of prolonged back pressure • hydroureter / nephrosis • kidney becomes dilated sac-like structure • loss of functional kidney tissue

20. Urinary calculi (stones) • 1-5% of population (UK) • mainly 30+ • > males • common in renal pelvis • Causes • substance in excess   (precipitation to form • stone) • factors affecting solubility abnormal (citrates, • others inhibit ) • factors also NB: • pH • mucoproteins from nidus • Classification • According to composition • Ca-oxalate (± Ca-phosphate / uric acid) commonest • triple stones – Mg/Am/ PO4 • may form large ‘staghorn’ stones - uric acid stones

21. NB: 90% of patients with Ca-containing stones have idiopathic hypercalcuria with normal serum Ca 10% - hyperparathyrodism or other cause of hypercalcaemia

22. Mg/Am /PO4 (triple) stones: • associated with UTI (Proteus) organisms • - change urea  ammonia • alkaline conditions +  flow  precipitation • staghorn may form • chronic irritataion metaplasia  carcinoma if very longstanding Uric acid stones: • gout • radiolucent