DISEASES OF TESTIS DISEASES OF TESTIS AND EPIDIDYMISAND EPIDIDYMIS

Congenital AnomaliesCongenital Anomalies

1. Cryptorchidism: 1. Cryptorchidism: Failure of Failure of testicular descent into the scrotal testicular descent into the scrotal sac which occurs in 0.7% of male sac which occurs in 0.7% of male population. population.

Malpositioned testis may be found Malpositioned testis may be found any where along the normal any where along the normal pathway of descent from the pathway of descent from the abdominal cavity to inguinal canal.abdominal cavity to inguinal canal.

Causes: Causes: Most cases are idiopathic. Most cases are idiopathic. Causes include hormonal Causes include hormonal

abnormalities (e.g. deficiency of abnormalities (e.g. deficiency of luteinizing hormone-releasing luteinizing hormone-releasing hormone), hormone),

genetic abnormalities e.g. (trisomy genetic abnormalities e.g. (trisomy 13), short spermatic cord, 13), short spermatic cord,

or mechanical obstruction in the or mechanical obstruction in the inguinal canal.inguinal canal.

Morphology: Morphology: Cryptorchidism Cryptorchidism occurs more in the right testis occurs more in the right testis and may be bilateral in 25% of and may be bilateral in 25% of cases. Malpositioned testis may cases. Malpositioned testis may be of normal size in early life, but be of normal size in early life, but it shows some degree of atrophy it shows some degree of atrophy at puberty at puberty

Microscopically, Microscopically, at the age of 6 at the age of 6 years, there is atrophy of years, there is atrophy of seminiferous tubules, associated seminiferous tubules, associated with Leydig cell hyperplasia and with Leydig cell hyperplasia and interstitial fibrosis. interstitial fibrosis.

At puberty, hyalinization of the At puberty, hyalinization of the seminiferous tubules is evident.seminiferous tubules is evident.

Regressive changes may also Regressive changes may also occur in the other descended testis occur in the other descended testis

Effects: Effects: Cryptorchidism is asymptomatic. Cryptorchidism is asymptomatic. Usually discovered at the time of Usually discovered at the time of

puberty (after testicular atrophy has puberty (after testicular atrophy has occurred). occurred).

If cryptorchidism is bilateral, it leads to If cryptorchidism is bilateral, it leads to sterility. sterility.

The malpositioned testis has high The malpositioned testis has high incidence and tendency for incidence and tendency for development of malignancy compared development of malignancy compared to the normal positioned testis to the normal positioned testis

22 . .Testicular atrophyTesticular atrophy

May occur as a primary developmental May occur as a primary developmental abnormality in patients with klinefelters' abnormality in patients with klinefelters' syndrome. syndrome.

May be secondary to cryptorchidism, vascular May be secondary to cryptorchidism, vascular disease.disease.

Inflammatory disease. Inflammatory disease. Hypopituitrism.Hypopituitrism. Malnutrition. Malnutrition. Obstruction of outflow of semen.Obstruction of outflow of semen. Elevated level of female sex hormones, Elevated level of female sex hormones,

persistantly elevated level of follicle persistantly elevated level of follicle stimulating hormone.stimulating hormone.

Radiation, and chemotherapy. Radiation, and chemotherapy.

InflammationsInflammations

Epididymo-orchitis: Epididymo-orchitis: Inflammatory lesions start by Inflammatory lesions start by epididymitis with subsequent epididymitis with subsequent inflammation of the testis proper inflammation of the testis proper (orchitis). The causative organisms (orchitis). The causative organisms reach the testis by ascending reach the testis by ascending infection via the vas deferens, by infection via the vas deferens, by lymphatics of the spermatic cord, lymphatics of the spermatic cord, or by hematogenous spread.or by hematogenous spread.

Nonspecific epididymitis and Nonspecific epididymitis and orchitis: orchitis: Begins as a primary infection Begins as a primary infection in the urinary tract. Secondary infection in the urinary tract. Secondary infection of epididymis and testis occurs through of epididymis and testis occurs through ascending infection via vas deferens or ascending infection via vas deferens or lymphatics of the spermatic cord. lymphatics of the spermatic cord.

Causative organisms are E.coli, Causative organisms are E.coli, pseudomonas, gram negative rods, and pseudomonas, gram negative rods, and chlamydia trachomatis chlamydia trachomatis

Autoimmune (granulomatous) Autoimmune (granulomatous) orchitis: orchitis: Its origin is obscure. Its origin is obscure. Trauma and autoimmune Trauma and autoimmune disorders have been postulated disorders have been postulated as causes of the lesion as causes of the lesion

Specific inflammationSpecific inflammation

Gonorrheal infection: Gonorrheal infection: It is a sexually It is a sexually transmitted disease caused bytransmitted disease caused byNeisseria gonorrhea.Neisseria gonorrhea.

b.b. Mumps: Mumps: Is a systemic viral infection Is a systemic viral infection that commonly affects school-agethat commonly affects school-agechildren. Testicular involvement is extremely children. Testicular involvement is extremely uncommon in these age groups.uncommon in these age groups.When mumps occurs in postpubertal males, When mumps occurs in postpubertal males, it is followed by orchitis in aboutit is followed by orchitis in about20%-30% of cases. The testicular 20%-30% of cases. The testicular involvement is unilateral in 70% of theseinvolvement is unilateral in 70% of thesecases.cases.

Tuberculosis: Tuberculosis: Almost always begins in the Almost always begins in the epididymis, with secondaryepididymis, with secondaryinvolvement of the testis. It results from involvement of the testis. It results from hematogenous spread secondary tohematogenous spread secondary totuberculosis of the lungs and/or the kidney.tuberculosis of the lungs and/or the kidney.

d.d. Syphilis: Syphilis: It always begins as orchitis, It always begins as orchitis, with secondary involvement of thewith secondary involvement of theepididymis. In many cases orchitis is not epididymis. In many cases orchitis is not associated with epididymitis. It mayassociated with epididymitis. It mayoccur in both congenital and acquired occur in both congenital and acquired syphilis. The reaction may be localizedsyphilis. The reaction may be localized(gumma) or diffuse (diffuse syphilitic (gumma) or diffuse (diffuse syphilitic granulation tissue).granulation tissue).

Vascular DisturbancesVascular Disturbances

Torsion Torsion of the testis is due to of the testis is due to twisting of the spermatic cord, with twisting of the spermatic cord, with resultant venous obstruction. The resultant venous obstruction. The thick-walled arteries remain opened thick-walled arteries remain opened resulting in severe venous resulting in severe venous engorgement and development of engorgement and development of venous infarction of the testis (a sac venous infarction of the testis (a sac of soft, necrotic, hemorrhagic of soft, necrotic, hemorrhagic tissue).tissue).

Cause: Cause: Occurs in patients with Occurs in patients with incompletely descended testicles, incompletely descended testicles, absence of scrotal ligament, or absence of scrotal ligament, or testicular atrophy. testicular atrophy.

Torsion is usually precipitated by Torsion is usually precipitated by trauma or violent movement trauma or violent movement

Miscellaneous Lesions Miscellaneous Lesions of Tunica Vaginalisof Tunica Vaginalis

Hydrocele: Hydrocele: Accumulation of Accumulation of serous fluid within the tunica serous fluid within the tunica vaginalis either due to incomplete vaginalis either due to incomplete closure of processous vaginalis or closure of processous vaginalis or secondary to generalized edema. secondary to generalized edema. It may be secondarily infected It may be secondarily infected

Hematocele: Hematocele: Accumulation of Accumulation of blood within tunica vaginalis blood within tunica vaginalis secondary to trauma, torsion, secondary to trauma, torsion, hemorrhage, generalized hemorrhage, generalized bleeding diathesis or invasion by bleeding diathesis or invasion by malignancy malignancy

Chylocele: Chylocele: Accumulation of Accumulation of lymphatic fluid within the tunica lymphatic fluid within the tunica vaginalis due to lymphatic vaginalis due to lymphatic obstruction, e.g. elephantiasis in obstruction, e.g. elephantiasis in filaria.filaria.

Spermatocele: Spermatocele: Local Local accumulation of semen within accumulation of semen within dilated efferent ducts in the head dilated efferent ducts in the head of epididymis due to obstructive of epididymis due to obstructive lesions in the vas deferenslesions in the vas deferens

Varicocele: Varicocele: Dilated, tortuous, Dilated, tortuous, elongated veins in the spermatic elongated veins in the spermatic cord.cord.

Testicular NeoplasmsTesticular Neoplasms

Testicular neoplasms are the most Testicular neoplasms are the most important cause of firm, painless, important cause of firm, painless, enlargement of the testis.enlargement of the testis.

Peak incidence lies between 15 to 35 Peak incidence lies between 15 to 35 years.years.

95% of these tumors arise from germ 95% of these tumors arise from germ cells (all of them are malignant). cells (all of them are malignant).

5% arise from Leydig cells or Sertoli 5% arise from Leydig cells or Sertoli cells, are more benign than germ cell cells, are more benign than germ cell tumors and are characterized by tumors and are characterized by endocrine abnormalities.endocrine abnormalities.

WHO Classification of WHO Classification of Testicular NeoplasmsTesticular Neoplasms

I.I. Germ cell tumorsGerm cell tumors A.A. Tumors of one histologic Tumors of one histologic

patternpattern SeminomaSeminoma Embryonal carcinoma Yolk sac tumor Embryonal carcinoma Yolk sac tumor

Choriocarcinoma TeratomaChoriocarcinoma Teratoma a.a. MatureMature b.b. ImmatureImmature c.c. Teratoma with malignant Teratoma with malignant

transformation of somatic elements.transformation of somatic elements.

B.B. Tumors of more than one Tumors of more than one histologic patternhistologic pattern

Embryonal carcinoma and Embryonal carcinoma and teratoma (teratocarcinoma). teratoma (teratocarcinoma).

Choriocarcinoma and other typesChoriocarcinoma and other types Other combinations Other combinations

II.II. Sex cord-stromal cell Sex cord-stromal cell tumorstumors

A.A. Well differentiated formsWell differentiated forms Leydig cell tumor Sertoli cell tumor Leydig cell tumor Sertoli cell tumor

Granulosa cell tumorGranulosa cell tumor B.B. Mixed formsMixed forms C.C. Incompletely differentiated Incompletely differentiated

forms.forms.

Pathogenesis: Pathogenesis: The cause for testicular The cause for testicular tumors remains unknown. Important risk tumors remains unknown. Important risk factors include:factors include:

Cryptorchidism in 10% of testicular tumors.Cryptorchidism in 10% of testicular tumors. Testicular feminization and klinefilter Testicular feminization and klinefilter

syndrome.syndrome. Genetic factors; as evidenced by the high risk Genetic factors; as evidenced by the high risk

of testicular neoplasia among siblings of of testicular neoplasia among siblings of patients with testicular tumors. Some familial patients with testicular tumors. Some familial clustering are reported. Significant racial clustering are reported. Significant racial differences also occur (rare in African differences also occur (rare in African blacks).blacks).

I. Germ Cell Tumors I. Germ Cell Tumors A. Tumors of One A. Tumors of One Histologic PatternHistologic Pattern . Seminoma: . Seminoma: It is the most It is the most

common germ cell tumor in common germ cell tumor in adults; it represents 30% of adults; it represents 30% of testicular germ cell tumors that testicular germ cell tumors that shows a peak incidence in the shows a peak incidence in the fourth decade. It is the fourth decade. It is the counterpart of dysgerminoma in counterpart of dysgerminoma in females.females.

Grossly, Grossly, seminoma appears as seminoma appears as large, soft, well demarcated, large, soft, well demarcated, homogeneous, gray-white tumor homogeneous, gray-white tumor that bulges from cut surface of the that bulges from cut surface of the affected testis. Large tumors contain affected testis. Large tumors contain foci of coagulative necrosis. foci of coagulative necrosis. Seminomas are usually confined to Seminomas are usually confined to the testis by an intact tunica the testis by an intact tunica albuginea albuginea

Microscopically, Microscopically, there are 3 there are 3 variants of seminomavariants of seminoma

Classic (typical) seminoma Classic (typical) seminoma constitutes 85% of cases,constitutes 85% of cases,

Anaplastic seminoma (10%) andAnaplastic seminoma (10%) and Spermatocytic seminoma (5%).Spermatocytic seminoma (5%).

Classic seminoma: Classic seminoma: Composed of Composed of large cells with distinct borders, clear large cells with distinct borders, clear glycogen-rich cytoplasm, and glycogen-rich cytoplasm, and rounded nuclei with prominent rounded nuclei with prominent nucleoli. The cells are arranged in nucleoli. The cells are arranged in small lobules, separated by fibrous small lobules, separated by fibrous septae containing lymphocytic septae containing lymphocytic infiltrate. A granulomatous reaction infiltrate. A granulomatous reaction containing giant cells may be seen in containing giant cells may be seen in some cases.some cases.

Embryonal carcinoma: Embryonal carcinoma: More More aggressive than seminoma with a aggressive than seminoma with a peak incidence between 20- 30 peak incidence between 20- 30 years.years.

Yolk sac tumor: Yolk sac tumor: (endodermal (endodermal sinus tumor). sinus tumor). The most common The most common testiculartesticularneoplasm in infants and young neoplasm in infants and young children. In adults, it occurs as a children. In adults, it occurs as a component ofcomponent ofmixed germ cell neoplasm.mixed germ cell neoplasm.

Choriocarcinoma: Choriocarcinoma: Highly Highly malignant testicular tumor with malignant testicular tumor with widespread hematogenous widespread hematogenous metastasis to the liver and lung. It metastasis to the liver and lung. It occurs as a component of mixed occurs as a component of mixed germ cell tumor. Peak incidence germ cell tumor. Peak incidence between 20-30 years.between 20-30 years.

Teratomas: Teratomas: A group of A group of neoplasms that show evidence of neoplasms that show evidence of simultaneoussimultaneousdifferentiation along endodermal, differentiation along endodermal, mesodermal, and ectodermal mesodermal, and ectodermal lines. Theylines. Theymay occur at any age.may occur at any age.

Morphology: Grossly, Morphology: Grossly, teratomas teratomas have variegated appearance, and have variegated appearance, and are firm in consistency. Cut surface are firm in consistency. Cut surface contains cysts and cartilaginous contains cysts and cartilaginous areas. areas. Microscopically, Microscopically, 3 variants 3 variants are recognized based on the are recognized based on the degree of differentiation namely; degree of differentiation namely; mature, immature, and teratoma mature, immature, and teratoma with malignant transformationwith malignant transformation

Mature teratomas: Mature teratomas: Contain fully Contain fully differentiated tissues from the threedifferentiated tissues from the threegerm cell layers in a haphazard arrangement. germ cell layers in a haphazard arrangement. Structures related to ectoderm (e.g skin, Structures related to ectoderm (e.g skin, neural tissue, and skin appendages), to neural tissue, and skin appendages), to mesoderm (e.g muscle, cartilage, adipose mesoderm (e.g muscle, cartilage, adipose tissue, fatcells, lymphoid tissue, and blood tissue, fatcells, lymphoid tissue, and blood cells), and to endoderm (e.g. gut, bronchial cells), and to endoderm (e.g. gut, bronchial epithelium, glandular elements). Mature epithelium, glandular elements). Mature teratomas are more common in infants andteratomas are more common in infants andchildren. In adults, it should be considered children. In adults, it should be considered malignant.malignant.

Immature teratomas: Immature teratomas: Contain Contain elements of the 3 germ cell layers elements of the 3 germ cell layers ininincomplete stages of incomplete stages of differentiation. They should be differentiation. They should be considered malignantconsidered malignantespecially in adults.especially in adults.

Teratomas with malignant Teratomas with malignant transformation: transformation: Characterized by Characterized by frankfrankmalignancy (e.g. squamous cell malignancy (e.g. squamous cell carcinoma, adenocarcinoma) developing carcinoma, adenocarcinoma) developing in ain amature teratoma. It occurs in adult.mature teratoma. It occurs in adult.

NB: All teratomas in adults should NB: All teratomas in adults should be considered as malignant be considered as malignant neoplasm.neoplasm.

Patients with testicular germ cell tumors Patients with testicular germ cell tumors present mostly with painless enlargement present mostly with painless enlargement of the testis; non-seminomatous tumors of the testis; non-seminomatous tumors may present with widespread metastasis.may present with widespread metastasis.

Clinically, Clinically, germ cell tumors are classified germ cell tumors are classified into two groups namely: into two groups namely: seminomas; seminomas; and and non seminomatous germ cell tumors. non seminomatous germ cell tumors. The 2 groups differ in presentation as well The 2 groups differ in presentation as well as in prognosis and treatment.as in prognosis and treatment.

Seminomas remain confined to Seminomas remain confined to testis reaching a considerable testis reaching a considerable size before diagnosis. Non size before diagnosis. Non seminomatous germ cell seminomatous germ cell neoplasms may have wide spread neoplasms may have wide spread metastases at the time of metastases at the time of diagnosis in the absence of a diagnosis in the absence of a palpable testicular mass.palpable testicular mass.

Seminomas metastasize by lymphatic route Seminomas metastasize by lymphatic route to the para aortic and iliac lymph nodes. to the para aortic and iliac lymph nodes. Hematogenous spread is unusual in Hematogenous spread is unusual in seminoma. Non seminomatous germ cell seminoma. Non seminomatous germ cell neoplasms tend to metastasize early by neoplasms tend to metastasize early by lymphatic; and hematogenous routes (to liver lymphatic; and hematogenous routes (to liver and lung).and lung).

Seminomas are radiosensitive whereas non-Seminomas are radiosensitive whereas non-seminomatous germ cell neoplasms are seminomatous germ cell neoplasms are relatively radioresistant and are more relatively radioresistant and are more aggressive, with poorer prognosis than aggressive, with poorer prognosis than seminomas.seminomas.

Clinical staging: Clinical staging: Is achieved by Is achieved by physical examination, radiographic physical examination, radiographic imaging and studies of various tumor imaging and studies of various tumor markers. Clinical stages include:markers. Clinical stages include:

Stage I: Stage I: Tumor confined to the testis.Tumor confined to the testis. Stage II: Stage II: Metastases limited to Metastases limited to

retroperitoneal nodes below diaphragm.retroperitoneal nodes below diaphragm. Stage III: Stage III: Metastases outside the Metastases outside the

retroperitonal nodes or above retroperitonal nodes or above diaphragm.diaphragm.

Tumor markers: Tumor markers: Serum markers are of value in;Serum markers are of value in; The evaluation of testicular masses.The evaluation of testicular masses. The staging of germ cell tumors.The staging of germ cell tumors. Monitoring the response of a germ cell tumor Monitoring the response of a germ cell tumor

to therapy.to therapy. Diagnosis of recurrence during follow up.Diagnosis of recurrence during follow up. e.g. Alfa-feto protein is elevated in germ cell e.g. Alfa-feto protein is elevated in germ cell

neoplasms containing yolk sac elements.neoplasms containing yolk sac elements. Human chorionic gonadotropin is elevated Human chorionic gonadotropin is elevated

in germ cell neoplasms containing in germ cell neoplasms containing syncytiotrophoblastic elements.syncytiotrophoblastic elements.

II. Tumors of Sex Cord-II. Tumors of Sex Cord-Gonadal Stroma A. Well Gonadal Stroma A. Well Differentiated FormsDifferentiated Forms

Leydig (Interstitial) cell Leydig (Interstitial) cell tumor: tumor: Uncommon. It occurs at Uncommon. It occurs at any age, mostly at 20-60 years. It any age, mostly at 20-60 years. It secretes androgen, and other secretes androgen, and other steroids such as estrogen and steroids such as estrogen and corticosteroids.corticosteroids.

Clinical features: Clinical features: Presents as a Presents as a painless testicular mass with painless testicular mass with hormonal changes (gynecomastia in hormonal changes (gynecomastia in adults and precocious puberty in adults and precocious puberty in children). children).

Prognosis:Prognosis: 90% are benign and have 90% are benign and have excellent prognosis; and 10% are excellent prognosis; and 10% are malignant (i.e. have infiltrative and malignant (i.e. have infiltrative and spreading tendency).spreading tendency).

2. Sertoli cell tumor 2. Sertoli cell tumor (Androblastoma): U(Androblastoma): Uncommon.ncommon. It isIt is composed of Sertoli cells, or a mixture of composed of Sertoli cells, or a mixture of Sertoli and granulosa cellsSertoli and granulosa cells. .

It secretes estrogen and/or androgen but It secretes estrogen and/or androgen but in amounts that are insufficient to in amounts that are insufficient to produce feminization or precocious produce feminization or precocious puberty. puberty.

Most tumors are benign, Most tumors are benign, 10% 10% only spread only spread and infiltrate.and infiltrate.

Testicular LymphomaTesticular Lymphoma

It is not a primary tumor of testis. It is not a primary tumor of testis. However, the affected patients may However, the affected patients may present with onlypresent with only a testicular mass.a testicular mass.

It constitutes 5% of all testicular It constitutes 5% of all testicular neoplasms.neoplasms.

It is the most common tumor of the It is the most common tumor of the testis in men over the age of 60 years.testis in men over the age of 60 years.

It is diffuse, large cell, non-Hodgkins It is diffuse, large cell, non-Hodgkins lymphoma, which disseminates widely.lymphoma, which disseminates widely.

The prognosis is extremely poor.The prognosis is extremely poor.

DISEASES OF DISEASES OF PROSTATEPROSTATE

Prostatitis (Inflammation of Prostatitis (Inflammation of prostate)prostate)

Acute prostatitis: Usually Acute prostatitis: Usually associated with acute bacterial associated with acute bacterial urinary tract infection e.g. E urinary tract infection e.g. E coli, gram negative rods, coli, gram negative rods, enterococci, gonococci, and enterococci, gonococci, and staphylococcus aureus.staphylococcus aureus.

Clinically: Clinically: There is fever, chills, There is fever, chills, dysuria, and low backache. The dysuria, and low backache. The prostate is enlarged, tender, prostate is enlarged, tender, spongy, and soft.spongy, and soft.

Chronic prostatitis: Chronic prostatitis: Bacterial or non Bacterial or non bacterial. Occur on top of acute bacterial. Occur on top of acute prostatitis, or develop insidiously prostatitis, or develop insidiously without previous acute infection.without previous acute infection.

Clinically, Clinically, even if asymptomatic, even if asymptomatic, chronic prostatitis may serve as a chronic prostatitis may serve as a reservoir for organisms capable of reservoir for organisms capable of causing urinary tract infection.causing urinary tract infection.

Senile Prostatic Senile Prostatic Hyperplasia (BPH)Hyperplasia (BPH) Hyperplasia of both prostatic glands and its Hyperplasia of both prostatic glands and its

fibromuscular stromafibromuscular stroma Incidence: Incidence: Present in 20% of males at the Present in 20% of males at the

age of 40years, increasing to 70% by the age age of 40years, increasing to 70% by the age of 60 years and to 90% by the eighth decade.of 60 years and to 90% by the eighth decade.

Aetiology: Aetiology: Uncertain, likely related to Uncertain, likely related to effects of hormonal changes. In old age, effects of hormonal changes. In old age, normal androgens drop, leaving action of the normal androgens drop, leaving action of the normally present estrogen unopposed. normally present estrogen unopposed. Estrogens may increase sensitization, mainly Estrogens may increase sensitization, mainly the central portion of the prostate, to the the central portion of the prostate, to the effect of dihydrotestosterone.effect of dihydrotestosterone.

Grossly: Grossly: Usually affects the Usually affects the periurethral glands. periurethral glands. The prostate is The prostate is enlarged, its cut surface shows multiple enlarged, its cut surface shows multiple well circumscribed nodules, (solid or well circumscribed nodules, (solid or contain cystic spaces). The urethra is contain cystic spaces). The urethra is compressed. Sometimes the compressed. Sometimes the hypertrophied gland bulge in the urinary hypertrophied gland bulge in the urinary bladder lumen as a pedunculated mass, bladder lumen as a pedunculated mass, resulting in a ball- valve type of urethral resulting in a ball- valve type of urethral obstruction.obstruction.

Hyperplastic nodules are composed of varying Hyperplastic nodules are composed of varying proportions of proliferating glands and proportions of proliferating glands and fibromuscular stroma. fibromuscular stroma.

The glands are lined by 2The glands are lined by 2 cell layers (an inner cell layers (an inner tall columnar and a peripheral layer of tall columnar and a peripheral layer of flattened basal cells). Some glands show flattened basal cells). Some glands show intraluminal papillae, others are cystically intraluminal papillae, others are cystically dilated; still others contain inspissated dilated; still others contain inspissated lamellated, proteinaceous material lamellated, proteinaceous material (corpora (corpora amylacia) amylacia) in their lumina. in their lumina.

The glands are separated from each other by The glands are separated from each other by proliferated fibromuscular stroma. In hugely proliferated fibromuscular stroma. In hugely enlarged cases, there are areas of infarcts and enlarged cases, there are areas of infarcts and squamous metaplasia of some glands.squamous metaplasia of some glands.

Clinical features and Clinical features and complicationscomplications::

Frequency, urgency, and nocturia (due to urinary Frequency, urgency, and nocturia (due to urinary bladder irritation).bladder irritation).

Difficulty in starting and stopping of urinary stream.Difficulty in starting and stopping of urinary stream. Painful distention of the urinary bladder.Painful distention of the urinary bladder. Infection (cystitis and / or pyelonephritis) due to Infection (cystitis and / or pyelonephritis) due to

residual urine in the bladder and chronic obstruction.residual urine in the bladder and chronic obstruction. Stone formation (due to stasis associated with Stone formation (due to stasis associated with

infection).infection). Hypertrophy, dilatation, and urinary bladder Hypertrophy, dilatation, and urinary bladder

diverticulae.diverticulae. Bilateral hydronephrosis leading to chronic renal Bilateral hydronephrosis leading to chronic renal

failure.failure.

Carcinoma of the Carcinoma of the ProstateProstate It is the most common visceral cancer It is the most common visceral cancer

in males.in males. It is the second most common cause of It is the second most common cause of

cancer-related deaths in men older than cancer-related deaths in men older than 50 years, after carcinoma of the lung.50 years, after carcinoma of the lung.

Its peak incidence is between 65-75 Its peak incidence is between 65-75 years.years.

Occult cancers of the prostate are more Occult cancers of the prostate are more common than those that are clinically common than those that are clinically apparent.apparent.

PathogenesisPathogenesis: The cause of prostatic : The cause of prostatic carcinoma is unknown. However, carcinoma is unknown. However, clinical and experimental evidence clinical and experimental evidence suggest that hormonal, genetic, and suggest that hormonal, genetic, and environmental factors may play a role environmental factors may play a role in its pathogenesis. Hormonal factors in its pathogenesis. Hormonal factors are evidenced by absence of prostatic are evidenced by absence of prostatic carcinoma in males castrated before carcinoma in males castrated before puberty. Also, its growth inhibition by puberty. Also, its growth inhibition by orchiectomy and by administration of orchiectomy and by administration of estrogen (eg. dihydrostilbosterol).estrogen (eg. dihydrostilbosterol).

The role of genetic influence could be The role of genetic influence could be proved by increased incidence of proved by increased incidence of prostatic cancer in the first degree prostatic cancer in the first degree relatives of patients with cancer of relatives of patients with cancer of prostate.prostate.

The role of environmental factors is The role of environmental factors is verified by its occurrence in certain verified by its occurrence in certain industrial settings and by the significant industrial settings and by the significant geographic difference in incidence of the geographic difference in incidence of the disease.disease.

Ill-defined masses beneath the Ill-defined masses beneath the capsule in the capsule in the outer peripheral outer peripheral part part of the prostate. Cut section of the prostate. Cut section shows foci of carcinoma shows foci of carcinoma appearing as firm, gray white-to appearing as firm, gray white-to yellow masses with ill-defined yellow masses with ill-defined margins.margins.

Most cases are adenocarcinoma with Most cases are adenocarcinoma with variable degrees of differentiation. variable degrees of differentiation.

Well differentiated carcinoma, is Well differentiated carcinoma, is composed of small glands that composed of small glands that infiltrate the adjacent stroma in an infiltrate the adjacent stroma in an irregular haphazard fashion. These irregular haphazard fashion. These glands are not encircled by collagen or glands are not encircled by collagen or stromal cells, but they lie back-to-back, stromal cells, but they lie back-to-back, sharply dissecting through the stroma. sharply dissecting through the stroma.

The malignant glands are lined by The malignant glands are lined by a single layer of cuboidal cells a single layer of cuboidal cells with prominent nucleoli in their with prominent nucleoli in their nuclei. The basal cell layer seen in nuclei. The basal cell layer seen in normal or senile hyperplastic normal or senile hyperplastic glands is absent. The epithelial glands is absent. The epithelial cells of adjacent glands show cells of adjacent glands show dysplastic changes.dysplastic changes.

The grading schema used for prostate cancer is The grading schema used for prostate cancer is the Gleason system. According to this system, the Gleason system. According to this system, prostate cancers are stratified into five grades on prostate cancers are stratified into five grades on the basis of glandular patterns of differentiationthe basis of glandular patterns of differentiation..

Grade 1 represents the most wellGrade 1 represents the most well--differentiated differentiated tumors, in which the neoplastic glands are tumors, in which the neoplastic glands are uniform and round in appearance and are packed uniform and round in appearance and are packed into wellinto well--circumscribed nodules. circumscribed nodules.

By contrast, grade 5 tumors show no glandular By contrast, grade 5 tumors show no glandular differentiation, and the tumor cells infiltrate the differentiation, and the tumor cells infiltrate the stroma in the form of cords, sheets, and nestsstroma in the form of cords, sheets, and nests

Spread: Spread: byby Direct extension to seminal Direct extension to seminal

vesicles, wall of urinary bladder. vesicles, wall of urinary bladder. Extension to rectum is rare.Extension to rectum is rare.

Lymphatic spread to regional Lymphatic spread to regional lymph nodes (occurs early).lymph nodes (occurs early).

Blood spread especially to bones Blood spread especially to bones

Staging:Staging: Staging of prostatic Staging of prostatic cancer is important in the selection cancer is important in the selection of the appropriate form of therapy. of the appropriate form of therapy. Stage T1 refers to incidentally found Stage T1 refers to incidentally found cancer. Stage T2 is organ-confined cancer. Stage T2 is organ-confined cancer. Stage T3show extra-cancer. Stage T3show extra-prostatic extension. Stage T4 prostatic extension. Stage T4 reflects direct invasion of reflects direct invasion of contiguous organs. contiguous organs.

Clinical features: Clinical features: A minority of cases are asymptomatic and A minority of cases are asymptomatic and

diagnosed at autopsy or in removal of diagnosed at autopsy or in removal of prostate for senile hyperplasia.prostate for senile hyperplasia.

Locally advanced cases produce signs and Locally advanced cases produce signs and symptoms of prostatism (lower urinary tract symptoms of prostatism (lower urinary tract obstruction, local discomfort, dysuria, obstruction, local discomfort, dysuria, frequency, hematuria, difficulty in starting or frequency, hematuria, difficulty in starting or stopping urination). stopping urination).

Advanced cases may present with back pain. Advanced cases may present with back pain. Bone osteoblastic metastases occur in late Bone osteoblastic metastases occur in late cases. cases.

DiagnosisDiagnosis: More than 70% of : More than 70% of carcinomas are found peripherally carcinomas are found peripherally and can be palpated through and can be palpated through digital rectal examination. digital rectal examination. Transrectal ultra sonography, Transrectal ultra sonography, computerized tomography (CT), computerized tomography (CT), and magnetic resonance imaging and magnetic resonance imaging (MRI) are useful in diagnosis and (MRI) are useful in diagnosis and staging of prostatic carcinoma staging of prostatic carcinoma

The use of The use of tumor markers tumor markers may be may be beneficial in diagnosis of prostatic carcinoma. beneficial in diagnosis of prostatic carcinoma. Serum acid phosphatase and prostatic Serum acid phosphatase and prostatic specific antigen are used as markers to specific antigen are used as markers to monitor the presence of metastases, the monitor the presence of metastases, the progress of the disease, and the effect of progress of the disease, and the effect of treatment. Immunohistochemical localization treatment. Immunohistochemical localization of these markers in tissue sections is helpful of these markers in tissue sections is helpful in verification of the prostatic origin of in verification of the prostatic origin of metastatic tumors.metastatic tumors.

NB: NB: Prostatic carcinoma may be small in size Prostatic carcinoma may be small in size and hidden; and the patient presents for the and hidden; and the patient presents for the first time by its metastases. The carcinoma in first time by its metastases. The carcinoma in such case is called such case is called “occult carcinoma”.“occult carcinoma”.