1. 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

2. CARCINOMA IN SITU: 3 types
Tumors of the Penis
BENIGN:
1. CONDYLOMA ACCUMINATUM: Human papilloma virus (HPV)
Sexual transmission
HPV types associated with carcinoma
CARCINOMA IN SITU: 3 types
A. BOWEN DISEASE: Limited by basement membrane; mainly in shaft
B. ERYTHROPLASIA OF QUEYRAT: Similar to Bowen’s but in glans-prepuce
C. BOWENOID PAPULOSIS: Sexually active; pigmented lesions

3. Tumors of the Penis Malignant
SQUAMOUS CELL CARCINOMA
HPV INFECTION: type 16 most common, also 18
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

4. SQUAMOUS CELL CARCINOMA

5. 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

6. CRYPTORCHID

7. 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-infarction

8. GONORRHEA

9. A. GERM CELL TUMORS B. NONGERMINAL CELL TUMORS (STROMA - SEX CORD)
Testicular Tumors
A. GERM CELL TUMORS
B. NONGERMINAL CELL TUMORS
(STROMA - SEX CORD)

10. Germ Cell Tumors spermatocytic malignant (EMBRYONAL, CHORIOCARCINOMA)
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)

11. Testicular Tumors Morphology A. SEMINOMAS
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

12. SEMINOMA

13. Testicular Tumors Children up to 3 years
B. EMBRYONAL CARCINOMA: Hemorrhage - necrosis Cells are large, hyperchromatic nuclei, nucleoli, arranged in glandular, alveolar or tubular patterns, with papillary convolutions 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

14. EMBRYONAL CARCINOMA

15. YOLK SAC TUMORS

16. Testicular Tumors Aggressive, small tumors, metastasize widely
D. CHORIOCARCINOMA
Aggressive, small tumors, metastasize widely
Hemorrhage - necrosis common
Syncytiotrophoblastic - Cytotrophoblastic components; positive for HCG

17. CHORIOCARCINOMA

18. Three histologic variants
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

19. Testicular Tumors Mixed
60% e.g. teratomas - embryonal
teratoma - yolk sac
seminoma - embryonal or teratoma

20. Mixed: Embryonal and Choriocarcinoma
Teratocarcinoma
Mixed: Embryonal and Choriocarcinoma
HCG

21. 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

22. Testicular Tumors Staging
STAGE 1: Confined to testis, epididymis, spermatic cord
STAGE II: Retroperitoneal lymph nodes, below the diaphragm
STAGE III:
Metastases into lymph nodes above the diaphragm
STAGE IV:
Metastases into other organs: or lung, liver, brain, bones

23. 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

24. 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 seminiferous tubules
Benign tumors; 10% malignant

25. SERTOLI TUMOR

26. 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

27. Leydig Cell Tumor

28. Tunica Vaginalis Hydrocele (FLUID ACCUMULATION) Hematocele (TRAUMA)
Chylocele (ELEPHANTIASIS)
Spermatocele
Varicocele

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

30. Prostate Inflammation
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

31. Prostate
Inflammation
ACUTE

32. Prostate Glandular - stromal Androgens stimulate growth (DHT)
HYPERPLASIA:
Glandular - stromal
INCIDENCE: 20% 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
MORPHOLOGY: Cellular nodules in transitional zone; later stromal periurethral nodules; compress urethra and prostate, creating cleavage (NOT CAPSULE). Nodules with squamous metaplasia or infarction.

33. HYPERPLASIA:
Glandular - stromal

34. 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

35. Carcinoma of Prostate

36. Carcinoma of Prostate Unknown Age – environmental Role of androgens
ETIOLOGY:
Unknown
RISK FACTORS:
Age – environmental
Role of androgens
Genetics
Molecular

37. 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

38. 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

39. Carcinoma of Prostate Clinical 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

40. 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

41. GRADE 1: Closely packed single or separate uniform glands

42. GRADE 3: Separate, irregular glands, cribriform pattern

43. GRADE 5: Sheets or cords; few or no glands

44. Carcinoma of Prostate Prostate 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

45. 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

46. Carcinoma of Prostate Treatment
SURGERY:
Localized disease (Stages A – B)
RADIATION:
HORMONAL TREATMENT:
Metastatic disease (Stages C – D)
(ESTROGEN THERAPY – ORCHIECTOMY)