B13 Male GU Questions
6) A 32-year-old man has noticed an increased feeling of heaviness in his scrotum for the past 10 months. On physical examination, the left testis is three times the size of the right testis and is firm on palpation. An ultrasound scan shows a 6cm solid mass within the body of the left testis. Laboratory studies include an elevated serum α-fetoprotein level. Which of the following cellular components is most likely to be present in this mass? □ (A) Yolk sac cells □ (B) Leydig cells □ (C) Seminoma cells □ (D) Cytotrophoblasts □ (E) Embryonal carcinoma cells □ (F) Lymphoblasts
(A) Yolk sac cells α-Fetoprotein (AFP) is a product of yolk sac cells that can be shown by immunohistochemical testing. Pure yolk sac tumors are rare in adults, but yolk sac components are common in mixed nonseminomatous tumors. Leydig cells produce androgens. Pure seminomas do not produce AFP. Cytotrophoblasts do not produce a serum marker, but they may be present in a choriocarcinoma along with syncytiotrophoblasts, which do produce human chorionic gonadotropin. Embryonal carcinoma cells by themselves do not produce any specific marker. Embryonal carcinoma cells are common in nonseminomatous tumors, however, and are often mixed with other cell types. Lymphoblasts may be seen in high-grade non-Hodgkin lymphomas, which do not produce hormones.
8) A 70-year-old, previously healthy man comes to his physician for a routine health examination. On palpation, his prostate is normal in size. Laboratory studies show a serum prostate-specific antigen (PSA) level of 17 ng/mL, however, twice the value he had 1 year ago. A routine urinalysis shows no abnormalities. Which of the following histologic findings in a subsequent biopsy specimen of the prostate is most likely to account for the patient's current status? □ (A) Acute prostatitis □ (B) Adenocarcinoma □ (C) Chronic abacterial prostatitis □ (D) Nodular hyperplasia □ (E) Prostatic intraepithelial neoplasia
(B) Adenocarcinoma The prostate-specific antigen (PSA) level is significantly elevated in this patient. The increase over time is more likely to be indicative of carcinoma. Typically, prostatic carcinomas are adenocarcinomas that form small glands packed back to back. Many adenocarcinomas of the prostate do not produce obstructive symptoms and may not be palpable on digital rectal examination. Inflammation and nodular hyperplasias can increase the PSA level, although not to a high level that increases significantly over time. Prostatic intraepithelial neoplasia, although an antecedent to adenocarcinoma, is not likely to increase the PSA significantly over time.
A 25-year-old man and his wife undergo an infertility workup. His wife's reproductive function is normal. On physical examination he has descended testes that appear decreased in size. A sperm count shows aspermia. A testicular biopsy is performed and on microscopic examination only Sertoli cells are present in the seminiferous tubules. Which of the following laboratory test findings is he most likely to have? A Increased FSH B Increased HCG C Increased alpha-fetoprotein D Decreased testosterone E Decreased muellerian inhibiting substance F Decreased luteinizing hormone
(A) CORRECT. Such a 'Sertoli cell only' syndrome is a cause for male infertility and may be idiopathic. A similar pattern would be present in a cryptorchid testis.
A 70-year-old healthy man has a routine check-up. On physical examination there is a firm nodule palpable in the prostate via digital rectal examination. Prostate biopsies are performed and on microscopic examination show small, crowded glands containing cells with prominent nucleoli within the nuclei. Which of the following is the most likely diagnosis? A Adenocarcinoma B Nodular hyperplasia C Chronic prostatitis D Urothelial carcinoma E Recent infarction
(A) CORRECT. Such a nodule at that age strongly suggests carcinoma. Most carcinomas of the prostate arise in the posterior portion of the gland where they can be palpated on digital rectal examination. Microscopically, prostatic adenocarcinomas have irregular glands without intervening stroma. Large nucleoli are a characteristic microscopic feature.
An epidemiologic study is performed to determine potential risk factors for development of penile squamous intraepithelial neoplasia. It is observed that persons who develop this disease are elderly men. The medical histories of these men are reviewed. Which of the following diseases is most likely to be found to precede development of penile neoplasia in these men? A Phimosis B Herpes simplex virus infection C Lichen simplex chronicus D Balanitis xerotica obliterans E Epispadias
(A) CORRECT. The chronic irritation from accumulation of secretions and smegma under the prepuce is the likely risk.
A 33-year-old G3 P2 woman gives birth at term following an uncomplicated pregnancy to a male infant. On physical examination he has an abnormal opening of the urethra onto the ventral surface of the penis for a distance of 0.3 cm. Which of the following is the most likely diagnosis? A Hypospadias B Exstrophy C Phimosis D Epispadias E Cryptorchidism
(A) CORRECT. This is a congenital anomaly. Infection is a common complication, and partial urethral stricture may lead to urinary tract obstruction.
14) A 29-year-old man complains of a vague feeling of heaviness in the scrotum, but he has had no increase in pain for the past 5 months. He is otherwise healthy. Physical examination shows that the right testis is slightly larger than the left testis. An ultrasound scan shows the presence of a solid, circumscribed, 1.5-cm mass in the body of the right testis. A biopsy is done, and microscopic examination of the mass shows uniform nests of cells with distinct cell borders, glycogen-rich cytoplasm, and round nuclei with prominent nucleoli. There are aggregates of lymphocytes between these nests of cells. Which of the following features is most characteristic of this lesion? □ (A) Excellent response to radiation therapy □ (B) Likelihood of extensive metastases early in the course of disease □ (C) Elevation of human chorionic gonadotropin levels in the serum □ (D) Elevation of α-fetoprotein levels in the serum □ (E) Elevation of serum testosterone levels □ (F) Association with 46,X(fra)Y karyotype □ (G) Association with 46,XXY karyotype
(A) Excellent response to radiation therapy This is the most common form of "pure" testicular germ cell tumor that may remain confined to the testis (stage I). The prognosis is good in most cases, even with metastases, because seminomas are radiosensitive. Human chorionic gonadotropin (hCG) levels may be slightly elevated in about 15% of patients with seminoma. Elevated hCG levels suggest a component of syncytial cells; very high levels suggest choriocarcinoma. α-Fetoprotein levels are elevated in testicular tumors with a yolk sac component, and many tumors with an embryonal cell component also contain yolk sac cells. Testosterone is a product of Leydig cells, not germ cells. Fragile X syndrome is associated with mental retardation. The testes are enlarged bilaterally. Klinefelter syndrome is associated with decreased testicular size and reduced fertility.
16) A 46-year-old man with a history of poorly controlled diabetes mellitus comes to the physician because he has had painful, erosive, markedly pruritic lesions on the glans penis, scrotum, and inguinal regions of the skin for the past 2 months. Physical examination shows irregular, shallow, 1- to 4-cm erythematous ulcerations. Scrapings of the lesions are examined under the microscope. Which of the following microscopic findings in the scrapings is most likely to be reported? □ (A) Eggs and excrement of Sarcoptes scabiei □ (B) Budding cells with pseudohyphae □ (C) Atypical cells with hyperchromatic nuclei □ (D) Enlarged cells with intranuclear inclusions □ (E) Spirochetes under dark-field examination
(B) Budding cells with pseudohyphae Genital candidiasis can occur in individuals without underlying illnesses, but it is far more common in individuals with diabetes mellitus. Warm, moist conditions at these sites favor fungal growth. Scabies mites are more likely to be found in linear burrows in epidermis scraped from the extremities. Neoplasms may ulcerate, but such lesions are unlikely to be shallow or multiple without a mass lesion present. Intranuclear inclusions suggest a viral infection; however, diabetes is not a risk factor for genital viral infections. These lesions are too large and numerous to be syphilitic chancres.
A clinical study is performed with male subjects diagnosed with sexually transmitted diseases. The clinical and laboratory findings in their medical records are analyzed. It is observed that in some cases there is ulceration of the male external genitalia while in others no ulceration is observed on physical examination. Which of the following organisms is most likely to result in non-ulcerated lesions? A Chlamydia trachomatis B Human papillomavirus C Klebsiella granulomatis D Treponema pallidum E Hemophilus ducreyi F Herpes simplex virus
(B) CORRECT. HPV produces genital warts and cancers, but not typically ulcers.
A 31-year-old man has had a feeling of heaviness in his scrotum for over 6 months. On exam he has an enlarged right testis. An ultrasound reveals a solid 5 cm mass in the body of the right testis. Laboratory studies show a serum alpha-fetoprotein (AFP) of 81 ng/mL and human chorionic gonadotrophin (HCG) of 15 IU/L. A right orchiectomy is performed, and on gross examination the testicular mass is soft and reddish brown. Microscopic examination shows cords and sheets of primitive cells with large nuclei. Which of the following is the most likely diagnosis? A Teratoma B Embryonal carcinoma C Mumps orchitis D Leydig cell tumor E Squamous cell carcinoma F Choriocarcinoma
(B) CORRECT. The embryonal carcinoma is likely to have an elevated AFP. Many malignant testicular neoplasms produce some detectable HCG, but this does not mean that choriocarcinoma is present.
A 40-year-old man has noted gradual enlargement of his scrotum, more on the right side, for the past 2 years. There is no associated pain, but the size is becoming uncomfortable. Physical examination reveals that the right side of the scrotum is enlarged to three times the size of the testis palpable on the left. This mass transilluminates. There is no tenderness on palpation. There is no inguinal lymphadenopathy. An ultrasound reveals a 5 cm thin-walled cystic fluid-filled area in the region of the right testis. Which of the following is the most likely diagnosis? A Seminoma B Torsion C Hydrocele D Varicocele E Orchitis
(C) CORRECT. A hydrocele is just a fluid filled sac that gradually enlarges.
A pathologic study is performed in men ranging from 50 to 100 years of age who had serum prostate specific antigen levels above 15 ng/mL and who underwent prostatectomy following biopsies in which there was adenocarcinoma on microscopic examination. The resected prostates were examined pathologically and the sites of the adenocarcinomas mapped within the prostate. In which of the following regions of the prostate are these adenocarcinomas most likely to arise? A Anterior fibromuscular stroma B Central zone C Peripheral zone D Periurethral zone E Transitional zone
(C) CORRECT. Most prostatic adenocarcinomas arise in the peripheral zone posteriorly where they can potentially be palpated by digital rectal examination.
A clinical study is conducted to determine the survival following treatment for testicular neoplasms utilizing subjects recorded into a hospital tumor registry. Treatments included surgery, chemotherapy, and radiation therapy. The patient records are reviewed to determine the pathologic diagnosis and the 5 year survivals for these patients. Which of the following types of testicular neoplasm is most likely to have responded best to radiation therapy? A Choriocarcinoma B Embryonal carcinoma C Seminoma D Teratoma E Yolk sac tumor
(C) CORRECT. Seminomas are the most radiosensitive of testicular carcinomas.
A 30-year-old man has had a feeling of heaviness in his left testis for the past 6 months. Physical examination reveals enlargement of the left testis, while the right testis appears normal. There is a palpable left inguinal lymph node. An ultrasound reveals a 4 cm solid mass within the body of the left testis. Laboratory findings included a serum beta-HCG of 5 IU/L and alpha-fetoprotein of 2 ng/mL. The left testis is removed and with on sectioning reveals a firm, lobulated light tan mass without hemorrhage or necrosis. He receives radiation therapy. Which of the following neoplasms is he most likely to have? A Choriocarcinoma B Embryonal carcinoma C Seminoma D Yolk sac tumor E Leydig cell tumor
(C) CORRECT. The most common pure form of testicular cancer is seminoma, a type of germ cell tumor which is radiosensitive. The tumor markers are not markedly elevated. This form of testicular carcinoma has the best prognosis overall, when not mixed with other elements.
A 43-year-old man has noted a lesion on his penis for the past year. On physical examination there is a 0.9 cm diameter rough, tan, firm, slightly raised area at the right lateral base of the glans. He is uncircumcised, and there is difficulty in retracting the foreskin. Which of the following is the most likely diagnosis? A Angiokeratoma B Balanitis xerotica obliterans C Bowen disease D Hard chancre E Lichen simplex chronicus F Paraphimosis
(C) CORRECT. This is squamous cell carcinoma in situ. If excised at this stage, it is curable. If not treated, it can progress to an invasive carcinoma.
A 20-year-old man has noted a penile discharge with some pain on urination for the last 2 days. On physical examination there is a small amount of whitish exudate that can be expressed from the urethral meatus. Laboratory studies with culture of the penile discharge reveal Neisseria gonorrheae. If untreated, which of the following complications is he most likely to develop as a consequence of his disease? A Aortitis B Balanitis C Epididymitis D Orchitis E Sacroiliitis
(C) CORRECT. When the testis is involved by gonorrhea, it is typically the epididymis. Many male gonorrheal infections are asymptomatic and not followed by significant complications. Urethritis with stricture is a possible complication.
11) The mother of a 2-year-old boy notices that he has had increasing asymmetric enlargement of the scrotum over the past 6 months. On physical examination, there is a well-circumscribed, 2.5-cm mass in the left testis. A left orchiectomy is performed, and histologic examination of this mass shows sheets of cells and ill-defined glands composed of cuboidal cells, some of which contain eosinophilic hyaline globules. Microcysts and primitive glomeruloid structures also are seen. Immunohistochemical staining shows α-fetoprotein in the cytoplasm of the neoplastic cells. What is the most likely diagnosis? □ (A) Choriocarcinoma □ (B) Seminoma □ (C) Yolk sac tumor □ (D) Teratoma □ (E) Leydig cell tumor
(C) Yolk sac tumor Yolk sac tumors are typically seen in boys younger than 3 years old. The primitive glomeruloid structures are known as Schiller-Duval bodies. Choriocarcinomas contain large, hyperchromatic, syncytiotrophoblastic cells. Seminomas have sheets and nests of cells resembling primitive germ cells, often with an intervening lymphoid stroma. Teratomas contain elements of mature cartilage; bone; or other endodermal, mesodermal, or ectodermal structures. Embryonal carcinomas with yolk sac cells contain α-fetoprotein, but they are seen in adults. They are composed of cords and sheets of primitive cells. Leydig cell tumors may produce androgens or estrogens or both.
19) A 48-year-old man has noticed a reddish area on the penis for the past 3 months. He has had no sexual intercourse for more than 1 month. On physical examination, there is a solitary 0.8-cm, plaquelike, erythematous area on the distal shaft of the penis. A routine microbiologic culture with a Gram-stained smear of the lesion shows normal skin flora. Microscopic examination of a biopsy specimen of the lesion shows dysplasia involving the full thickness of the epithelium. What is the most likely diagnosis? □ (A) Primary syphilis □ (B) Balanitis □ (C) Soft chancre □ (D) Bowen disease □ (E) Condyloma acuminatum
(D) Bowen disease Bowen disease is a form of squamous cell carcinoma in situ. Similar to carcinoma in situ elsewhere, it has a natural history of progression to invasive cancer if untreated. Poor hygiene and infection with human papillomavirus (particularly types 16 and 18) are factors that favor development of dysplasias and cancer of the genital epithelia. Syphilis is a sexually transmitted disease that produces a hard chancre, which heals in a matter of weeks. Balanitis is an inflammatory condition without dysplasia. A soft chancre may be seen with Haemophilus ducreyi infections. Condylomas are raised, whitish lesions.
A 72-year-old man gets up several times during a football match to go to the restroom to urinate, even though he has had only one beer. This is a problem that has plagued him for 4 years. When he visits his physician for a checkup, on physical examination he has a diffusely enlarged prostate palpated on digital rectal examination. Laboratory studies show his serum prostate specific antigen is 6 ng/mL. Which of the following pathologic findings is most likely to be present in this man? A Adenocarcinoma B Acute inflammation C Multiple infarctions D Nodular hyperplasia E Granulomas
(D) CORRECT. Benign prostatic hyperplasia (BPH) is a common finding in older men. The lateral lobes are typically involved (in contrast to carcinomas which are most often found in the posterior lobe), and the increasing prostatic urethral obstruction leads to the classic symptoms of frequency and hesitancy with urination. The PSA can be mildly elevated with hyperplasia, but the level tends not to increase significantly over time.
A 22-year-old G2 P1 woman gives birth following an uncomplicated pregnancy to a term male infant weighing 2850 gm. On physical examination he has incomplete development of the dorsal aspect of the penile urethra, with the defect extending to the bladder, which is open onto the lower abdominal wall. Which of the following is the most likely diagnosis? A Hypospadias B Bowen disease C Balanoposthitis D Epispadias E Paraphimosis
(D) CORRECT. Epispadias is a rare congenital anomaly that may be mild or, as in this case, severe with a large open defect that must be repaired.
A 35-year-old healthy man and his wife are unable to conceive for the past year, despite trying repeatedly for pregnancy. On physical examination his height is at the 80th percentile and weight at the 50th percentile for age. Palpation of his scrotum reveals that testes are small. Breasts are slightly enlarged. Laboratory studies show oligospermia. Which of the following is the most likely problem leading to infertility in this man? A Cachexia with poor nutrition B Cryptorchidism C Hypopituitarism D Klinefelter syndrome E Repeated sexual intercourse
(D) CORRECT. His height, gynecomastia, and infertility are features of Klinefelter syndrome. About 1 in 500 males has a 47, XXY karyotype. Oligospermia does not preclude fertility; assisted reproduction techniques could be employed.
A 77-year-old man has a routine check-up by his physician. The only physical examination finding is slight nodularity of his prostate on digital rectal examination. Laboratory studies show a serum prostate specific antigen of 6 ng/mL. A prostate biopsy is performed and on microscopic examination shows prostatic intraepithelial neoplasia (PIN). Which of the following is the best medical care option to offer this man? A Radical prostatectomy B Multiagent chemotherapy C Transurethral prostate resection D Monitoring PSA levels E Nothing
(D) CORRECT. PIN is a potential precursor of prostatic adenocarcinoma, but by itself does not warrant therapy.
A 19-year-old university student notes the sudden onset of severe discomfort in his scrotum late one evening. No position is comfortable for him to sit or lie down. Aspirin and beer have no effect. He has a friend drive him to the emergency room. On physical examination his vital signs include temperature 37°C, respirations 22/minute, pulse 80/minute, and blood pressure 100/65 mm Hg. His left testis is slightly enlarged and exquisitely tender. There is no inguinal adenopathy. A doppler ultrasound scan shows decreased blood flow in the left testis. Which of the following conditions is he most likely to have? A Choriocarcinoma B Varicocele C Lithiasis D Torsion E Hydrocele
(D) CORRECT. Testicular torsion often has a sudden onset and you must recognize this condition, because it must be treated immediately, for the lack of blood flow can lead to hemorrhagic infarction. An ultrasound can be used to help identify this condition, demonstrating lack of blood flow.
A 23-year-old healthy man has been unable to father a child. He and his wife have a workup for infertility. His wife's reproductive function is normal. On physical examination both his testes are palpable in the scrotum and the testes and scrotum are normal in size, with no masses palpable. However, the spermatic cord on the left has the feel of a 'bag of worms'. Laboratory studies show oligospermia. Which of the following conditions is this man most likely to have? A Hydrocele B Testicular torsion C Spermatocele D Varicocele E Seminoma
(D) CORRECT. The increased warmth from the vascularity reduces sperm production. Spermatogenesis needs to occur at a temperature below that of the body as a whole, which explains why testes are in the scrotum.
17) A clinical trial of two pharmacologic agents compares one agent that inhibits 5α-reductase and diminishes dihydrotestosterone (DHT) synthesis in the prostate with another agent that acts as an α1-adrenergic receptor. The subjects are 40 to 80 years old. The study will determine whether symptoms of prostate disease are ameliorated in the individuals who take these drugs. Which of the following diseases of the prostate is most likely to benefit from one or both of these drugs? □ (A) Acute prostatitis □ (B) Adenocarcinoma □ (C) Leiomyoma □ (D) Chronic prostatitis □ (E) Nodular hyperplasia
(E) Nodular hyperplasia Androgens are the major hormonal stimuli of glandular and stromal proliferation resulting in nodular prostatic hyperplasia. Although testosterone production decreases with age, prostatic hyperplasia increases, probably because of an increased expression of hormonal receptors that enhance the effect of any dihydrotestosterone that is present. The 5α-reductase inhibitors, such as finasteride, diminish the prostate volume, specifically the glandular component, leading to improved urine flow. The α1-adrenergic receptor blockers, such as tamsulosin, cause smooth muscle in the bladder neck and prostate to relax, which relieves symptoms and improves urine flow immediately. The other listed conditions are not amenable to therapy with these drugs.
7) A 25-year-old man has occasionally felt pain in the scrotum for the past 3 months. On physical examination, the right testis is more tender than the left, but does not appear to be appreciably enlarged. An ultrasound scan shows a 1.5-cm mass. A right orchiectomy is performed, and gross examination shows the mass to be hemorrhagic and soft. A retroperitoneal lymph node dissection is done. In sections of the lymph nodes, a neoplasm is seen with grossly extensive necrosis and hemorrhage. Microscopic examination shows that areas of viable tumor are composed of cuboidal cells intermingled with large eosinophilic syncytial cells containing multiple dark, pleomorphic nuclei. Immunohistochemical staining of the tumor is most likely to show which of the following antigenic components in the syncytial cells? □ (A) Human chorionic gonadotropin □ (B) α-Fetoprotein □ (C) Vimentin □ (D) CD20 □ (E) Testosterone □ (F) Carcinoembryonic antigen □ (G) CA-125
(A) Human chorionic gonadotropin This patient has a choriocarcinoma, the most aggressive testicular carcinoma. It often metastasizes widely. The primitive syncytial cells mimic the syncytiotrophoblast of placental tissue and stain for human chorionic gonadotropin. αFetoprotein is a marker that is more likely to be found in mixed tumors with a yolk sac component. Vimentin is more likely to be seen in sarcomas, which are rare in the testicular region. CD20 is a lymphoid marker for B cells. Testosterone is found in Leydig cells. Carcinoembryonic antigen (CEA) is found in a variety of epithelial neoplasms, particularly adenocarcinomas. CA-125 is best known as a marker for ovarian epithelial malignant tumors.
15) A 5-year-old boy has a history of recurrent urinary tract infections. Urine cultures have grown Escherichia coli, Proteus mirabilis, and enterococcus. Physical examination now shows an abnormal constricted opening of the urethra on the ventral aspect of the penis, about 1.5 cm from the tip of the glans penis. There also is a cryptorchid testis on the right and an inguinal hernia on the left. What term best describes the child's penile abnormality? □ (A) Hypospadias □ (B) Phimosis □ (C) Balanitis □ (D) Epispadias □ (E) Bowen disease
(A) Hypospadias Hypospadias is a congenital condition seen in about 1 in 300 male infants. The inguinal hernia and the cryptorchidism are abnormalities that may accompany this condition. Phimosis is a constriction preventing retraction of the prepuce. It can be congenital, but more likely is the result of inflammation of the foreskin of the penis (e.g., balanitis, a form of local inflammation of the glans penis). Epispadias is a congenital condition in which the urethra opens on the dorsal aspect of the penis. Bowen disease, which is squamous cell carcinoma in situ of the penis, occurs in adults.
9) A 35-year-old man and his 33-year-old wife are childless. They have tried to conceive a child for 12 years, and now they undergo an infertility work-up. On physical examination, neither spouse has any remarkable findings. Laboratory studies show that the man has a sperm count in the low-normal range. On microscopic examination of the seminal fluid, the sperm have a normal morphologic appearance. A testicular biopsy is done. The biopsy specimen shows patchy atrophy of seminiferous tubules, but the remaining tubules show active spermatogenesis. Which of the following disorders is the most likely cause of these findings? □ (A) Mumps virus infection □ (B) Cryptorchidism □ (C) Hydrocele □ (D) Klinefelter syndrome □ (E) Prior chemotherapy
(A) Mumps virus infection Mumps is a common childhood infection that can produce parotitis. Adults who have this infection more often develop orchitis. The orchitis is usually not severe, and its involvement of the testis is patchy; infertility is not a common outcome. Cryptorchidism results from failure of the testis to descend into the scrotum normally; the abnormally positioned testis becomes atrophic throughout. A hydrocele is a fluid collection outside the body of the testis that does not interfere with spermatogenesis. Klinefelter syndrome and estrogen therapy can cause tubular atrophy, although it is generalized in both cases. Patchy loss of seminiferous tubules indicates a local inflammatory process. Many chemotherapeutic agents are particularly harmful to rapidly and continuously proliferating testicular germ cells, but the effect would not be patchy within the testicular parenchyma. Patients who wish to father children may want to store sperm in a sperm bank before undergoing chemotherapy.
1) A 30-year-old man visits his physician because he has noticed increasing enlargement and a feeling of heaviness in his scrotum for the past year. On physical examination, the right testis is twice its normal size, and it is firm and slightly tender. An ultrasound examination shows a 3.5-cm solid mass in the right testis. Abdominal CT scan shows enlargement of the para-aortic lymph nodes. Multiple lung nodules are seen on a chest radiograph. Laboratory findings include markedly increased serum levels of chorionic gonadotropin and α-fetoprotein. Which of the following testicular neoplasms is the most likely diagnosis? □ (A) Leydig cell tumor □ (B) Mixed germ cell tumor □ (C) Pure spermatocytic seminoma □ (D) Choriocarcinoma □ (E) Metastatic adenocarcinoma of the prostate gland □ (F) Large diffuse B-cell lymphoma
(B) Mixed germ cell tumor Although a modest elevation of the human chorionic gonadotropin (hCG) concentration can occur when a seminoma contains some syncytial giant cells, significant elevation of the α-fetoprotein (AFP) level never occurs with pure seminomas. Elevated levels of AFP and hCG effectively exclude the diagnosis of a pure seminoma and indicate the presence of a nonseminomatous tumor of the mixed type. The most common form of testicular neoplasm combines multiple elements; the term teratocarcinoma is sometimes used to describe tumors with elements of teratoma, embryonal carcinoma, and yolk sac tumor. The yolk sac element explains the high AFP level. Mixed tumors may include seminoma. Leydig cell tumors are non-germ cell tumors derived from the interstitial (Leydig) cells; they may elaborate androgens. Choriocarcinomas secrete high levels of hCG, but no AFP. It is unusual for a tumor to metastasize to the testis; this patient is of an age at which a primary cancer of the testis should be considered when a testicular mass is present. Lymphomas may involve the testis, usually when there is systemic involvement by a high-grade lesion. Lymphomas do not elaborate hormones.
25) A 71-year-old, currently healthy man visits his physician for a checkup because he is worried about his family history of prostate cancer. Physical examination does not indicate any abnormalities. Because of the patient's age and family history, his prostate-specific antigen (PSA) level is immediately measured, and the PSA level is 5 ng/mL. Six months later, the PSA level is 6 ng/mL. A urologist obtains transrectal biopsy specimens, and microscopic examination shows multifocal areas of prostatic intraepithelial neoplasia and glandular hyperplasia. Based on these findings, what is the most appropriate course of management for this patient? □ (A) Antibiotic therapy □ (B) Monitoring PSA levels □ (C) Multiagent chemotherapy □ (D) Radiation therapy □ (E) Radical prostatectomy □ (F) Transurethral prostate resection
(B) Monitoring PSA levels Prostatic intraepithelial neoplasia (PIN) is a potential precursor of prostatic adenocarcinoma. By itself, it does not warrant therapy because only about one third of patients diagnosed with PIN develop invasive cancer within 10 years. Conversely, in about 80% of cases in which prostate cancer is present, PIN can be found in the surrounding tissue. PIN usually does not increase the PSA levels. In this case, the elevation in PSA levels was probably caused by the coexistent hyperplasia. Following the patient with PSA tests can aid in determining if cancer has developed. Antibiotic therapy is appropriate in the treatment of an infectious process, not for PIN. Radiation and chemotherapy are reserved for malignancies, not for a preneoplastic condition. Surgical resection of the prostate gland is considered when a diagnosis of adenocarcinoma is established
A 32-year-old has noted bilateral breast enlargement over the past 7 months. On physical examination there is bilateral gynecomastia without tenderness or masses. His external genitalia appear normal. An ultrasound scan reveals a 1 cm solid mass within the body of the right testis. Laboratory studies show a serum testosterone of 550 ng/dL and estradiol of 36 pg/mL. His serum alpha-fetoprotein is 9 ng/mL and HCG non-detectable. Which of the following neoplasms is this man most likely to have? A Choriocarcinoma B Embryonal carcinoma C Leydig cell tumor D Seminoma E Yolk sac tumor
(C) CORRECT. A Leydig cell tumor is most often seen in adult men. It may produce androgens and/or estrogens, leading to gynecomastia and/or feminization. It is histologically benign. Most are small in size.
2) For the past year, a 65-year-old man has had multiple, recurrent urinary tract infections. Escherichia coli and streptococcal organisms have been cultured from his urine during several of these episodes, with bacterial counts of more than 105/mL. He has difficulty with urination, including starting and stopping the urinary stream. Over the past week, he has again developed burning pain with urination. Urinalysis shows a pH of 6.5, and specific gravity of 1.0 20. No blood or protein is present in the urine. Tests for leukocyte esterase and nitrite are positive. Microscopic examination of the urine shows numerous WBCs and a few WBC casts. Which of the following is the most likely diagnosis? □ (A) Neisseria gonorrhoeae infection □ (B) Prostatic nodular hyperplasia □ (C) Phimosis □ (D) Epispadias □ (E) Adenocarcinoma of the prostate gland □ (F) Vesicoureteral reflux
(B) Prostatic nodular hyperplasia Of the diseases listed, prostatic nodular hyperplasia is the most common in older men. When it causes obstruction of the prostatic urethra, it can predispose to bacterial infections. Gonorrhea is more likely to be seen in younger, sexually active men, and obstruction is not a key feature. Phimosis can occur in uncircumcised men. It may be congenital or acquired from inflammation, usually at a much younger age. Epispadias is a congenital condition, observed at birth. Prostatic adenocarcinomas are less likely than hyperplasia to cause obstructive symptoms. Vesicoureteral reflux is more likely to be present at an earlier age, and it does not account for the obstructive symptoms the patient has on urination.
13) A 19-year-old man comes to his physician for a routine health maintenance examination. On physical examination, there is no left testis palpable in the scrotum. The patient is healthy, has had no major illnesses, and has normal sexual function. In counseling this patient, which of the following statements regarding his condition would be most appropriate? □ (A) You will be unable to father children □ (B) You are at increased risk of developing a testicular tumor □ (C) This is a common finding in more than half of all men □ (D) This is an outcome of childhood mumps infection □ (E) This is an inherited disorder
(B) You are at increased risk of developing a testicular tumor This patient has cryptorchidism, which results from failure of the testis to descend from the abdominal cavity into the scrotum during fetal development. One or both testes may be involved. It is associated with an increased risk of testicular cancer. An undescended testis eventually atrophies during childhood. Unilateral cryptorchidism usually does not lead to infertility, but it may be associated with atrophy of the contralateral descended testis. Mumps infection tends to produce patchy testicular atrophy, usually without infertility. Isolated cryptorchidism is a developmental defect that is usually sporadic and is not inherited in the germline.
4) A 23-year-old, sexually active man has been treated for Neisseria gonorrhoeae infection several times during the past 5 years. He now comes to the physician because of the increasing number and size of warty lesions slowly enlarging on his external genitalia during the past year. On physical examination, there are multiple 1- to 3-mm sessile, nonulcerated, papillary excrescences over the inner surface of the penile prepuce. These lesions are excised, but 2 years later, similar lesions appear. Which of the following conditions most likely predisposed him to development of these recurrent lesions? □ (A) Candida albicans infection □ (B) Circumcision □ (C) Human papillomavirus infection □ (D) Neisseria gonorrhoeae infection □ (E) Paraphimosis □ (F) Phimosis
(C) Human papillomavirus infection The patient's lesions are characteristic of condyloma acuminatum, which is typical of human papillomavirus (HPV) infection. A condyloma acuminatum is a benign, recurrent squamous epithelial proliferation resulting from infection with HPV, one of many sexually transmitted diseases that can occur in sexually active individuals. Koilocytosis is particularly characteristic of HPV infection. Candidiasis can be associated with inflammation, such as balanoposthitis, but not condylomata. Recurrent gonococcal infection indicates that the patient is sexually active and at risk for additional infections, but is not the cause for the condylomata. Gonococcal infection causes suppurative lesions in which there may be liquefactive necrosis and a neutrophilic exudate or mixed inflammatory infiltrates with chancroid. Circumcision generally reduces risks for infections. Phimosis is a nonretractile prepuce, and paraphimosis refers to forcible retraction of the prepuce that produces pain and urinary obstruction
12) A 19-year-old man comes to his physician complaining of worsening local pain and irritation with difficult urination over the past 3 years. He has become more sexually active during the past year and describes his erections as painful. Physical examination shows that he is not circumcised. The prepuce (foreskin) cannot be easily retracted over the glans penis. What is the most likely diagnosis? □ (A) Epispadias □ (B) Bowenoid papulosis □ (C) Phimosis □ (D) Genital candidiasis □ (E) Paraphimosis
(C) Phimosis Phimosis can be congenital, but is more often a consequence of multiple episodes of balanitis (inflammation of the glans penis or foreskin). Balanitis leads to scarring that prevents retraction of the foreskin. Forcible retraction may result in vascular compromise, with further inflammation and swelling (paraphimosis). Epispadias is a congenital condition in which the penile urethra opens onto the dorsal surface of the penis. Bowenoid papulosis is a premalignant lesion of the penile shaft resulting from viral infection. Candidiasis is most likely to produce shallow ulcerations that are intensely pruritic.
18) A 33-year-old man has noted asymmetric enlargement of the scrotum over the past 4 months. On physical examination, the right testis is twice its normal size and has increased tenderness to palpation. The right testis is removed. The epididymis and the upper aspect of the right testis have extensive granulomatous inflammation with epithelioid cells, Langhans giant cells, and caseous necrosis. Which of the following is the most likely cause of these findings? □ (A) Mumps □ (B) Syphilis □ (C) Tuberculosis □ (D) Gonorrhea □ (E) Sarcoidosis
(C) Tuberculosis Tuberculosis is an uncommon infection in the testes, but it can occur with disseminated disease. The infection typically starts in the epididymis and spreads to the body of the testis. Mumps produces patchy orchitis with minimal inflammation, which heals with patchy fibrosis. Syphilis involves the body of the testis, and there can be gummatous inflammation with neutrophils, necrosis, and some mononuclear cells. Gonococcal infections produce acute inflammation. Sarcoidosis produces noncaseating granulomas that are not likely to be found in the testis.
24) Over the past 9 months, a 30-year-old man has noticed increased heaviness with enlargement of the scrotum. On physical examination, there is an enlarged, firm left testis, but no other remarkable findings. An ultrasound scan shows a 5cm solid mass within the body of the left testis. An orchiectomy of the left testis is performed. Microscopic examination of the mass shows areas of mature cartilage, keratinizing squamous epithelium, and colonic glandular epithelium. Laboratory findings include elevated levels of serum human chorionic gonadotropin (hCG) and α-fetoprotein (AFP). Despite the appearance of the cells in the tumor, the surgeon tells the patient that he probably has a malignant testicular tumor. The surgeon's conclusion is most likely based on which of the following factors? □ (A) Size of the tumor □ (B) Age of the patient □ (C) Presence of colonic glandular epithelium □ (D) Elevation of hCG and AFP levels □ (E) Location of the mass in the left testis
(D) Elevation of hCG and AFP levels The tumor has elements of all three germ layers and is a teratoma. It is uncommon for teratomas in men to be completely benign. The most common additional histologic component is embryonal carcinoma. The elevated levels of human chorionic gonadotropin and α-fetoprotein indicate that this is a mixed tumor with elements of choriocarcinoma and yolk sac cells. The size of the tumor, age of the patient, location of the tumor (e.g., right, left, cryptorchid), and differentiation of the glandular epithelium are not markers of malignancy. On examining more histologic sections from the mass, the pathologist would find the malignant elements.
3) A 35-year-old man has noticed bilateral breast enlargement over the past 6 months. On physical examination, both breasts are enlarged without masses. His right testis is 1.5 times larger than his left testis; both are firm and round. His serum estrogen is increased. An ultrasound scan shows a circumscribed 2-cm mass in the body of the right testis, and a right orchiectomy is performed. The mass has a grossly uniform, brown cut surface. On microscopic examination, the cells are large and round with granular eosinophilic cytoplasm along with rod-shaped crystalloids of Reinke. What is the most likely diagnosis? □ (A) Choriocarcinoma □ (B) Embryonal carcinoma □ (C) Gonadoblastoma □ (D) Leydig cell tumor □ (E) Seminoma □ (F) Teratoma
(D) Leydig cell tumor The patient has a Leydig cell tumor of the testis. These tumors are most often small, benign masses that may go unnoticed. Some patients have gynecomastia, however, caused by androgenic or estrogenic hormone production (or both) by the tumor. Most patients are young to middle-aged men; sexual precocity may occur in the few boys who have such tumors. Choriocarcinomas are grossly soft and hemorrhagic masses that have large bizarre syncytiotrophoblast and cytotrophoblast cells and are aggressive. Embryonal carcinomas are large, aggressive tumors that have a variegated gross appearance and primitive cells with large, hyperchromatic nuclei. Gonadoblastomas are rare testicular tumors that arise in the setting of gonadal dysgenesis. A pure seminoma can be uniformly brown on cut surface, but often has a lymphoid stroma, and is not likely to secrete androgens or estrogens. Pure teratomas are rare and contain elements of three germ layers. Yolk sac tumors have cells that organize into primitive endodermal sinuses (Schiller-Duval bodies).
10) A 25-year-old, previously healthy man suddenly develops severe pain in the scrotum. The pain continues unabated for 6 hours, and he goes to the emergency department. On physical examination, he is afebrile. There is exquisite tenderness of a slightly enlarged right testis, but there are no other remarkable findings. The gross appearance of the right testis is shown in the figure. Which of the following conditions is most likely to cause these findings? □ (A) Disseminated tuberculosis □ (B) Invasive germ cell tumor □ (C) Lymphedema □ (D) Obstruction of blood flow □ (E) Previous vasectomy
(D) Obstruction of blood flow The markedly hemorrhagic appearance results from testicular torsion that obstructs venous outflow to a greater extent than the arterial supply. Doppler ultrasound shows reduced or no vascular flow in the affected testis. An abnormally positioned or anchored testis in the scrotum is a risk factor for this condition. Tuberculosis can spread from the lung through the bloodstream, producing miliary tuberculosis, seen as multiple pale, millet-sized lesions, most often involving the epididymis. Testicular carcinomas do not obstruct the blood flow. Parasitic infestation, typically filariasis, obstructs the flow of lymph, leading to gradual enlargement of the scrotum with thickening of the overlying skin. A previous vasectomy may lead to a small leakage of fluid and sperm, producing a localized sperm granuloma.
22) A 59-year-old man notices gradual enlargement of the scrotum over the course of 1 year. The growth is not painful, but produces a sensation of heaviness. He has no problems with sexual function. Physical examination shows no lesions of the overlying scrotal skin and no obvious masses, but the scrotum is enlarged, boggy, and soft bilaterally. The transillumination test result is positive. What is the most likely diagnosis? □ (A) Varicocele □ (B) Elephantiasis □ (C) Orchitis □ (D) Seminoma □ (E) Hydrocele
(E) Hydrocele Hydrocele is one of the most common causes of scrotal enlargement. It consists of a fluid collection within the tunica vaginalis. Most cases are idiopathic, although some may result from local inflammation. A varicocele is a collection of dilated veins (pampiniform plexus) that may produce increased warmth, which inhibits spermatogenesis. Elephantiasis is a complication of parasitic filarial infections involving the inguinal lymphatics. Orchitis involves the body of the testis without marked enlargement, but with tenderness. A seminoma is typically a firm unilateral mass.
A 35-year-old man has a routine check of his health status. On physical examination the prepuce cannot be fully retracted from the glans of his penis. No other abnormalities are noted. Which of the following is the most likely diagnosis? A Balanoposthitis B Epispadias C Exstrophy D Hypospadias E Phimosis
(E) CORRECT. Inflammation with scarring may prevent full retraction. There is an increased risk for phimosis and for balanitis in uncircumcised males.
A 2-year-old boy is brought to the physician because his mother (a geometry teacher) has observed that his scrotum is no longer symmetrical. On physical examination the child has enlargement of the left testis. An ultrasound scan shows a 2 cm solid mass within the body of the testis. Laboratory studies show a serum alpha-fetoprotein of 226 ng/mL. Which of the following neoplasms is this child most likely to have? A Leydig cell tumor B Neuroblastoma C Rhabdomyosarcoma D Teratoma E Yolk sac tumor
(E) CORRECT. The most common testicular tumor under the age of 3 is a yolk sac tumor (infantile embryonal carcinoma). However, finding any testicular tumor in children is uncommon. The prognosis is good in most cases.