Male genitaltract 4

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Male genitaltract 4

  1. 1. ProstateDr.CSBR.Prasad, M.D.
  2. 2. Normal Prostate• Retroperitoneal organ• Encircles the neck of the bladder and urethra• No definitive capsule• Weighs approx 20gms• Measures 3-4cms in greatest dimension• Divided into 4 anatomically and biologically distinct zones 1-Peripheral 2-Central 3-Transitional zones 4-Region of anterior fibromuscular stromaNote: Most hyperplasias arise in the transitional zone, whereas most carcinomas originate in the peripheral zone. CSBRP-July-2012
  3. 3. This is a transverse (axial) section through a normal prostate. There is a central urethra (Whitearrow) at the depth of the cut made to open this prostate anteriorly at autopsy, with the left laterallobe (Red arrow) and the right lateral lobe (Yellow arrow) and the posterior lobe (Green arrow).The consistency is uniform, without nodularity. The normal prostate is 3 to 4 cm in diameter.
  4. 4. CSBRP-July-2012
  5. 5. This is a diagram of the classic 4 prostatic lobes. The x marks thesite through which the urethra traverses. It is easy to see that mostpathology related to the prostate will present with obstructiveuropathy symptoms. CSBRP-July-2012
  6. 6. Normal ProstateHistology:• Compound tubuloalveolar organ• Glandular lining epithelium has two layers of cells and has distinct BM 1-Basal layer of cuboidal epithelium & 2-Tall columnar secretory cells towards the lumen• There are small papillary inbuddings of the epithelium• Glands are separated by abundant fibromuscular stroma CSBRP-July-2012
  7. 7. The normal male prostate gland below the bladder is composed of amixture of glands and intervening fibromuscular stroma, in about equalproportions, as seen here at low power.
  8. 8. Normal prostate is composed of a mixture of glands lined by tallcolumnar cells with infoldings and the intervening fibromuscular stroma,in about equal proportions, as seen here at medium power.
  9. 9. The normal appearance of prostate is shown at high magnification. Note the small pinklaminated concretion (these are corpora amylacea) in the gland lumen to the left ofcenter. Note the infoldings of the columnar epithelium.
  10. 10. CSBRP-July-2012
  11. 11. Pathological processes involving prostate • Inflammations • Nodular hyperplasia • Tumors CSBRP-July-2012
  12. 12. Prostatitis1. Acute bacterial prostatitis2. Chronic bacterial prostatitis3. Granulomatous prostatitis CSBRP-July-2012
  13. 13. Acute bacterial prostatitis• Usually due to extension of infection from the urethra or bladder• It can follow manipulation of the urethra or prostate secondary to catherization or cystoscopy• The bacterial "culprits" are:• -- Urinary pathogens (Enterobacteriaceae)• -- Enterococcus and Staphylococcus• CF: dysuria, chills and fever• The prostate is very tender to palpation• Neutrophilic infiltrate CSBRP-July-2012
  14. 14. Acute bacterial prostatitis CSBRP-July-2012
  15. 15. Chronic Prostatitis• Chronic Bacterial Prostatitis Antibiotics do not penetrate the prostate well The common presentation is recurrent UTI• Chronic Prostatitis Lymphocytic infiltrate and fibrosis Chronic non-bacterial prostatitis: -- the most common type -- WBCs may been seen in prostatic secretions, but -- no bacteria can be identified -- suspects – ‘chlamydia and mycoplasma’ infection CSBRP-July-2012
  16. 16. Chronic Prostatitis CSBRP-July-2012
  17. 17. Granulomatous Prostatitis• Tuberculosis• Fungal (immunocompromised patients)• Secondary to secretions from obstructed ducts CSBRP-July-2012
  18. 18. CSBRP-July-2012
  19. 19. Prostatic hyperplasia CSBRP-July-2012
  20. 20. BPH (Nodular hyperplasia)• Common disorder, aging process. >40yrs=20%, >60yrs=70%, >70yrs=90%.• >50yrs• Periurethral portion is involved• Present with urinary obstruction• Hyperplasia of stroma and epithelial cells CSBRP-July-2012
  21. 21. BPH / NPH (Nodular hyperplasia)Pathogenesis:• Androgen related• Dihydrotestosterone mediates growth and proliferation in stromal and epithelial cells CSBRP-July-2012
  22. 22. CSBRP-July-2012
  23. 23. Clinical Features• Retention of urine• UTIThe most commonly used and effective medical therapy:• α-blockers, which decrease prostate smooth muscle tone via inhibition of α1-adrenergic receptors• Shrinking the prostate with inhibitor of DHT synthesis (5-α-reductase Inhibitors) CSBRP-July-2012
  24. 24. BPH / NPH• Prostate is enlarged, 60-100gms• Nodular in the inner aspect of the gland• Compressed urethra• c/s milky white fluid may ooze• Bladder wall thickening / Trabaculation• Microscopically – fibromyoglandular hyperplasia CSBRP-July-2012
  25. 25. Bladder This anatomical midline sagital section reveals a markedly enlarged prostate with a nodular appearance from hyperplasia. The prostatic urethra (Yellow) that traverses the enlarged gland is compressed. The bladder wall is hypertrophic. Other structures seen here include the pubic symphysis (White), the rectum (Blue), and the penile urethra (Red). CSBRP-July-2012
  26. 26. CSBRP-July-2012
  27. 27. Multinodularity Solid areas Microcystic areasCSBRP-July-2012
  28. 28. This is the gross appearance of nodular prostatic hyperplasia (benignprostatic hyperplasia, or BPH). The normal prostate is 3 to 4 cm in crosssection, by comparison.
  29. 29. BPH
  30. 30. CSBRP-July-2012
  31. 31. This is the microscopic appearance of nodular prostatic hyperplasia at medium power.Note that the columnar arrangement of cells near the gland lumina is preserved. Noteseveral pink corpora amylacea in gland lumens.
  32. 32. This is the microscopic appearance of nodular prostatic hyperplasia at lowmagnification. Note the nodule filled with enlarged glands. Though crowded, there isstill stroma between the glands. CSBRP-July-2012
  33. 33. The enlarged prostate gland seen here not only has enlarged lateral lobes, but also a greatly enlarged median lobe that obstructs the prostatic urethra. This led to obstruction with bladder hypertrophy, as evidenced by the prominent trabeculation of the bladder wall seen here from the mucosal surface. Obstruction with stasis Median also led to the formation of the lobe yellow-brown calculus (stone).Lateral CSBRP-July-2012 lobes
  34. 34. Trabaculation and thickening of the wall [Fighting Urinary bladder] CSBRP-July-2012
  35. 35. Do you know what is fighting Gall bladder? CSBRP-July-2012
  36. 36. The prostate "chips" seen here are the firm, rubbery fragments obtainedfrom transurethral resection of prostate (TUR-P) performed forsymptomatic nodular hyperplasia.
  37. 37. Areas of nodular hyperplasiaAreas of infarction CSBRP-July-2012
  38. 38. BPH and malignancyNodular hyperplasia is NOT considered to be a premalignant lesion CSBRP-July-2012
  39. 39. Carcinoma of Prostate CSBRP-July-2012
  40. 40. Prostatic carcinoma• One of the most common cancers in men• >50yrs (men from the age of 40yrs should be screened for prostatic cancer)• The incidence increases with age 50s 20%; 70s 70%• More common in whites (50-60/lakh) and rare in Asians (1-4/lakh) CSBRP-July-2012
  41. 41. Prostatic carcinoma – Etiology • Risk factors: age, race, family history, hormone levels, environmental factors • Familiy history: One 1 relative – 2x Two 1 relatives – 5x • Androgens (AR mutations in CAG repeats) • Prostatic cancer susceptibility gene – 1q24-25 • Loss of cancer supressor genes: 8p, 10q, 13q, 16q. • Mutations in p53, PTEN and KAI 1 • Over expression of : Hepsin, alfa-methyl-acyl COA racemase, and EZH2. • Hypermethylation of GSTP1 CSBRP-July-2012
  42. 42. Prostatic carcinoma – GROSS • 70% of cancers arise in the periphery • Firm to gritty • Local extensions involve seminal vesicles, base of the bladder and may result in urinary obstruction • Blood spread: Bone (axial skeleton, femur, pelvis, ribs) • Bone mets: Osteoblastic • Lymphatic spread: perivesical, hypogastric, iliac, parasacral, para-aortic CSBRP-July-2012
  43. 43. This is a diagram of the classic 4 prostatic lobes. The x marks thesite through which the urethra traverses. It is easy to see that mostpathology related to the prostate will present with obstructiveuropathy symptoms. CSBRP-July-2012
  44. 44. Bladder This anatomical midline sagital section reveals a markedly enlarged prostate with a nodular appearance from hyperplasia. The prostatic urethra (Yellow) that traverses the enlarged gland is compressed. The bladder wall is hypertrophic. Other structures seen here include the pubic symphysis (White), the rectum (Blue), and the penile urethra (Red). CSBRP-July-2012
  45. 45. Pathology PearlsSecondary deposits in bone• Breast• Kidney• Prostate B.K.PATIL• Adrenals• Testis• Intestines• Lung CSBRP-July-2012
  46. 46. Pathology Pearls “Bone seeking Kidney tumor”• Clear cell sarcoma of the kidney CSBRP-July-2012
  47. 47. CSBRP-July-2012
  48. 48. The gross appearance ofadenocarcinoma of the prostateis shown here in cross section.The entire prostate is involved.The yellowish nodulesrepresent larger foci ofcarcinoma. CSBRP-July-2012
  49. 49. Prostatic carcinoma – micro• Gland formations: 1-Single cell layer, no basal layer 2-Small, crowded glands 3-Nuclei are large, contain 1-2 nucleoli 4-Mitotic figures are uncommon• Perineural invasion• One feature that distinguishes benign from malignant gland is – basal layer (HMWCK) CSBRP-July-2012
  50. 50. CSBRP-July-2012
  51. 51. CSBRP-July-2012
  52. 52. CSBRP-July-2012
  53. 53. Whole mount of large duct adenocarcinoma. The tumor iscentrally located and has a distinctly papillary configuration.
  54. 54. Lack of basal cells around the malignant acini.Some benign glands show basal layer (arrow)
  55. 55. CSBRP-July-2012
  56. 56. CSBRP-July-2012
  57. 57. Adenocarcinoma of the prostate is shown here at medium power. Someof the neoplastic glands have lumens, but there is no stroma between.
  58. 58. This is a high grade, poorly differentiated adenocarcinoma of prostate.There is no gland formation, only single cells infiltrating through thestroma. CSBRP-July-2012
  59. 59. ProstateThis is a moderately well-differentiated adenocarcinoma of the prostateat high magnification. CSBRP-July-2012
  60. 60. A hallmark of prostatic adenocarcinoma is the presence of prominentlarge nucleoli, as seen here. CSBRP-July-2012
  61. 61. Many large nucleoi are seen here in the nuclei of cells in this prostaticadenocarcinoma. CSBRP-July-2012
  62. 62. Adenocarcinoma of the prostate is shown here at low power on the left, compared tobenign prostate (in which glands contain corpora amylacea) at the right. Note how smalland close-packed the neoplastic glands are.
  63. 63. This is a high grade adenocarcinoma of prostate. There are ill-definedglands, and at the top just single infiltrating cells.
  64. 64. Grading of prostatic carcinoma Gleason’s grading: grade 1-5 grade-1: WD tumor grade-5: PD tumor Reported score which is a total of predominant grade and other grade eg: Score 3+5=8 CSBRP-July-2012
  65. 65. CSBRP-July-2012
  66. 66. CSBRP-July-2012
  67. 67. Prostatic intraepithelial neoplasia - PIN • Benign glands with intraacinar proliferations of cells which exhibit nuclear anaplasia • glands surrounded by patchy layer of basal cells and have intact BM • Larger branching glands with papillary infoldings (in cancers – small glands with straight luminal border) CSBRP-July-2012
  68. 68. Prostatic intraepithelial neoplasia - PIN • Evidence that link high grade PIN to invasive Ca: 1-high grade predominate at the periphery 2-high grade PIN is also seen in association with invasive Ca. 3-molecular abnormalities seen in invasive cancers are also present in PINs CSBRP-July-2012
  69. 69. CSBRP-July-2012
  70. 70. Prostatic intraepithelial neoplasia (PIN) can be low or high grade (as seen here). Thefinding of PIN suggests that prostatic adenocarcinoma may also be present (about halfthe time with high grade PIN). CSBRP-July-2012
  71. 71. CSBRP-July-2012
  72. 72. Diagnosis of prostatic carcinoma • DRE • PSA • TRUS (transrectal US) • Biopsy CSBRP-July-2012
  73. 73. Diagnosis of prostatic carcinoma PSA: 1. Serien protease-liquifies semen 2. 4ng/ml 3. PSA value 4. PSA density 5. PSA velocity 6. Age specific reference range 7. Ratio of free and bound forms PSA is of great value in assessing the response to Tx CSBRP-July-2012
  74. 74. ENDCSBRP-July-2012
  75. 75. E N D

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