PROSTATE GLAND Benign nodular prostatic hyperplasia BPH nonneoplastic

PROSTATE GLAND: Benign nodular prostatic hyperplasia (BPH) - non-neoplastic enlargement - common > 50 y 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

Complications Continued obstruction: 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

Prostatic carcinoma - one of commonest cancers - 2 nd 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

- 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

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 Seminomas Teratomas

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

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 - seminoma spreads to para-aortic nodes - good prognosis - very radiosensitive

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

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 Malignant same Malignant undifferentiated embryonal carcinoma (WHO) choriocarcinoma (WHO) Malignant trophoblastic

- 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

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 mixed germ cell tumour - AFP raised in serum

• 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

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

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

Transitional cell carcinoma - arises from urothelium - frequently multiple - ‘field effect’ - often preceded by dysplasia Morphology - most are papillary with 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

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

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

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

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

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: - p. H - mucoproteins from nidus Classification - According to composition - Ca-oxalate (± Ca-phosphate / uric acid) commonest - triple stones – Mg/Am/ PO 4 may form large ‘staghorn’ stones - uric acid stones

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

Mg/Am /PO 4 (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