ࡱ> 6NP-./0123456789:;<=>?@ABCDEFGHIJKLMRSTUVWX1115@ 0$ bjbjw:w:  PPwRLLLL 2.0 to 2.5 mg/dl Unconjugated bilirubin is not soluble in aqueous solution and is tightly complexed to albumin As such, it cannot be excreted in urine even when the blood levels are high The small amount of unbound pigment, when present in excess, may cause toxic damage to the neonatal brain (kernicterus) owing to immaturity of the blood-brain barrier. In contrast, conjugated bilirubin is water-soluble, nontoxic, and weakly associated with albumin. When present in excess, it is readily excreted in urine (bilirubinuria). With both unconjugated and conjugated hyperbilirubinemia, pigmentation of the skin and sclerae is readily visible. Jaundice occurs when bilirubin production exceeds hepatic clearance capacity, via the following mechanisms: Unconjugated hyperbilirubinemia: Excessive production of bilirubin Reduced hepatic uptake Impaired hepatic conjugation. Conjugated hyperbilirubinemia: Decreased hepatic excretion of bilirubin conjugates Impaired extrahepatic bile flow In general one mechanism predominates in a given disease state. Therefore, when a patient presents with jaundice, a knowledge of the predominant form of plasma bilirubin is of value in arriving at the possible cause of hyperbilirubinemia.   TEST: FROM TABLE: Gilberts syndrome Decreased intrahepatic excretion of bilirubin: Crigler-Najjar syndromes types I and II) Impaired canalicular transport of bilirubin glucuronides (Dubin-Johnson Rotors syndromes) Extrahepatic biliary obstruction: Gallsonte obstruction of biliary tree Extrahepatic biliary atresia Fluke infestation Cholestasis Refers to bile secretory failure per se, which is accompanied by the accumulation in blood of substances normally excreted in bile (bilirubin, bile salts, and cholesterol) Cholestatic conditions, which may result from hepatocellular dysfunction or intrahepatic or extrahepatic biliary obstruction, may also present with jaundice. Alternatively, pruritus is a common presenting symptom, presumably related to the elevation in plasma levels of bile acids. Skin xanthomas sometimes appear, the result of hyperlipidemia and impaired excretion of cholesterol. A characteristic laboratory finding is elevated serum alkaline phosphatase, an enzyme present in bile duct epithelium and the canalicular membrane of hepatocytes. An isozyme is normally present in many other tissues such as bone, and so the increased levels must be verified as being hepatic in origin. Other manifestations of reduced bile flow relate to intestinal malabsorption, including deficiencies of the fat-soluble vitamins A, D, or K. Three major conditions cause unconjugated hyperbilirubinemia (80% or more of the serum bilirubin is unconjugated): Bilirubin overproduction: Hemolytic disease is the most common cause. Resorption of major hemorrhages into the lungs, alimentary tract or other tissues Reduced hepatic uptake of bilirubin: Gilberts syndrome #1 cause: dx? After administration of certain drugs such as rifampin Impaired conjugation of bilirubin: The activity of hepatocellular bilirubin UGT is low at birth and does not reach normal levels until about two weeks of age. Thus, almost every newborn develops transient and mild unconjugated hyperbilirubinemia, called neonatal jaundice or physiologic jaundice of the newborn. Breast-fed infants tend to exhibit jaundice with greater frequency, possibly the result of beta-glucuronidases present in maternal milk. Hereditary Hyperbilirubinemias Dubin-Johnson Syndrome  Coarse pigmented granules within the cytoplasm of hepatocytes Table exam questions: Unconjugated hyperbilrubinemia: Auto. Recessive (Crigler-Najjar syndrome type I) Auto. Domin (Crigler-Najjar syndrome type II) Gilberts syndrome: Conjugated hyperbilrubinemia: -dubin Johnson ndrome: aut recessive: impaired bilary excretion, pigmented cytoplasmic globules Hepatic Failure Hepatic failure reflects the destruction of overall hepatic function Loss of hepatic functional capacity must exceed 80 to 90% before hepatic failure ensues This may come about through Insidious action of a chronic progressive disorder Repetitive discrete bouts of parenchymal damage Sudden and massive obliteration In most cases of severe hepatic dysfunction, liver transplantation is the only hope for survival Mortality from hepatic failure is 70 to 95%. Major disorders causing hepatic failure can be divided into three categories: Ultrastructural lesions that do not produce overt liver cell necrosis: Reyes syndrome, acute fatty liver of pregnancy, tetracycline toxicity. Chronic liver disease: Relentless chronic hepatitis, cirrhosis, inherited metabolic disorders. Massive hepatic necrosis: Fulminant viral hepatitis; massive toxic damage as from acetaminophen, halothane, monoamine oxidase inhibitors used as antidepressants; industrial chemical agents such as carbon tetrachloride and phosphorus; and mushroom poisoning (e.g., Amanita species).  Table exam: Jaundice Fetor hepaticus increased serums levels of hepatic enzymes Gynecomastia Low yield: Hypoalbuminemia Coagulopathy Hepatorenal syndrome Hepatic Failure - Hepatic Encephalopathy A metabolic disorder of the central nervous system and neuromuscular system Patients exhibit a spectrum of disturbances in consciousness Subtle behavioral abnormalities - marked confusion and stupor- deep coma and death. Fluctuating neurologic signs such as nonspecific electroencephalographic changes, limb rigidity and hyperreflexia, and rarely seizures. Particularly characteristic is asterixis: nonrhythmic, rapid extension-flexion movements of the head and extremities, best seen when the arms are held in extension with dorsiflexed wrists. Two physiologic factors appear to be important in the genesis of this disorder: Shunting of blood around the liver Spontaneous portosystemic connections - advanced cirrhosis Surgical portocaval anastomosis Severe loss of hepatocellular function The net result is exposure of the brain to an altered metabolic milieu, the specifics of which are not yet clear Hepatic Failure - Hepatorenal Syndrome Refers to the appearance of renal failure in patients with severe liver disease, in whom there are no intrinsic morphologic or functional causes for the renal failure. Kidney function improves if hepatic failure is reversed Pathophysiology of renal failure unclear The favored theory is reduction of renal blood flow, particularly to the cortex, the result of vasoconstriction This is accompanied by a decreased glomerular filtration rate and avid renal retention of sodium. Cirrhosis End-stage form of liver disease Defined by 3 characteristics: Fibrosis in the form of Delicate bands (portal-central, portal-portal, central-central) Broad scars replacing multiple adjacent lobules Parenchymal nodules created by regeneration of hepatocytes. Parenchymal architecture of the entire liver is disrupted Etiology Alcoholic liver disease (60 - 70%) Viral hepatitis (10%) Biliary diseases (5 -10%) Primary hemochromatosis (5%) Wilsons disease (rare) Alpha1-antitrypsin (AAT) deficiency (rare) Cryptogenic cirrhosis (10 - 15%) Clinical Features May be asymptomatic When symptomatic, lead to nonspecific clinical manifestations: Anorexia Weight loss Weakness Frank debilitation Ultimate mechanism of most cirrhotic deaths is Progressive liver failure Complication related to portal hypertension Development of hepatocellular carcinoma. Cirrhosis - Portal Hypertension Increased resistance to portal blood flow Causes: Prehepatic Obstructive thrombosis and narrowing of the portal vein before it ramifies within the liver. Massive splenomegaly shunts excessive blood into splenic vein, which drains into the portal vein Intrahepatic Cirrhosis, accounting for most cases of portal hypertension. Schistosomiasis Veno-occlusive disease Massive fatty change Diffuse fibrosing granulomatous disease - sarcoidosis and miliary tuberculosis Diseases affecting the portal microcirculation - nodular regenerative hyperplasia Posthepatic Severe right-sided heart failure Constrictive pericarditis Hepatic vein outflow obstruction Four major clinical consequences are Ascites Formation of porto-systemic venous shunts Congestive splenomegaly Hepatic encephalopathy Portal Hypertension Portal Hypertension - Ascites Refers to the collection of excess fluid in the peritoneal cavity. Usually becomes clinically detectable when at least 500 ml has accumulated, Many liters may collect and cause massive abdominal distention. The pathogenesis of ascites is complex, involving one or more of the following mechanisms: Sinusoidal hypertension Percolation of hepatic lymph from the liver capsule into the peritoneal cavity Renal retention of sodium and water, despite a total body sodium that is greater than normal. Portosystemic Shunts With the rise in portal system pressure, bypasses develop wherever the systemic and portal circulation share common capillary beds. Principal sites are Veins around and within the rectum (manifested as hemorrhoids), Cardioesophageal junction (esophagogastric varices) Retroperitoneum Falciform ligament of the liver (periumbilical and abdominal wall collaterals) Esophagogastric varices appear in about 65% of patients with advanced cirrhosis of the liver and cause massive hematemesis and death in about half of them Abdominal wall collaterals appear as dilated subcutaneous veins extending from the umbilicus toward the rib margins (caput medusae) Are an important clinical hallmark of portal hypertension. Splenomegaly Long-standing congestion may cause congestive splenomegaly. The degree of enlargement varies widely up to 1000 gm and is not necessarily correlated with other features of portal hypertension. Massive splenomegaly may secondarily induce a variety of hematologic abnormalities attributable to hypersplenism Hepatitis Serology  Hepatitis B serology  KNOW EVERYTHING ON THE TABLES: High yield: Hep B Hep A and Hep E Know: HBeAb: antibody to e antigen; indicates low transmissibility!!! Window period: HbcAb IgM is + Immunization is + at HbsAb IgG Viral Hepatitis Clinicopathologic Syndromes A number of clinical syndromes may develop after exposure to hepatitis viruses: Carrier state: without clinically apparent disease with chronic hepatitis. Asymptomatic infection: serologic evidence only. Acute hepatitis: Anicteric Icteric. Chronic hepatitis: Without progression to cirrhosis. With progression to cirrhosis. Fulminant hepatitis: Submassive to massive hepatic necrosis. Viral Hepatitis - Carrier State An individual who harbors one of the Hepatitis viruses without manifesting symptoms Therefore can transmit an organism A carrier can be a healthy carrier - suffering from little or no adverse effects having chronic disease but free of symptoms / disability Both constitute reservoirs of infection Carrier state is best characterized for Hepatitis B Virus Infection early in life, particularly via vertical transmission during childbirth, produces a carrier state 90 to 95% of the time. In contrast, only 1 to 10% of adult infections yield a carrier state. Healthy HBV carrier state - liver biopsy normal Viable isolated hepatocytes or clusters of cells have ground-glass, finely granular, eosinophilic cytoplasm laden with HBsAg Other cells have sanded nuclei imparted by abundant HBcAg, indicating active viral replication. Hepatitis B infection Carrier State Ground glass hepatocytes Acute Viral Hepatitis Any one of the hepatotropic viruses can cause acute viral hepatitis. Whatever the agent, the disease is more or less the same and can be divided into four phases: An incubation period Peak infectivity occurs during the last asymptomatic days of the incubation period and the early days of acute symptoms. A symptomatic preicteric phase : Nonspecific, constitutional symptoms Illness may be dismissed as flu-like, unless its true nature is revealed by elevated serum aminotransferase levels A symptomatic icteric phase : Caused mainly by conjugated hyperbilirubinemia Urine turns darker (conjugated bilirubinuria), and the stools may become lighter owing to cholestasis Retention of bile acids can cause distressing pruritus The liver may be mildly enlarged and moderately tender to percussion. Laboratory findings include prolonged prothrombin time Convalescence The morphologic changes in acute viral hepatitis are virtually the same regardless of the causative agent and can be mimicked by drug reactions. Grossly, the liver is slightly enlarged and more or less green depending on the phase of the acute disease and the degree of jaundice. Histologically the major findings are Necrosis of random, isolated liver cells or small cell clusters Evident as fragmented, eosinophilic Councilman bodies Bridging necrosis connecting portal-to-portal, central-tocentral, or portal-to-central regions of adjacent lobules Diffuse liver cell injury lobular disarray Reactive changes in Kupffer cells and sinusoidal lining cells and an inflammatory infiltrate in portal tracts Evidence of hepatocytic regeneration during the recovery phase. Acute hepatitis Chronic Viral Hepatitis Symptomatic, biochemical, or serologic evidence of continuing or relapsing hepatic disease for > 6 months, optimally with histologically documented inflammation and necrosis, is taken to mean chronic hepatitis Classified according to the extent of inflammation: Chronic persistent hepatitis - inflammation confined to portal tracts. Chronic active hepatitis - portal tract inflammation spills into the parenchyma and surrounds regions of necrotic hepatocytes. Chronic lobular hepatitis - persistent inflammation is confined to the lobule Morphology of chronic hepatitis Ranges from exceedingly mild to severe, to eventual cirrhosis. Mildest form: An inflammatory infiltrate limited to portal tracts Liver architecture usually well preserved Progressive disease: Histologic hallmark is piecemeal necrosis Chronic inflammatory infiltrate spills out from portal tracts into adjacent parenchyma Associated necrosis of hepatocytes in the limiting plate Bridging necrosis may connect adjacent portal-portal, central-central, and portal-central zones. Although piecemeal and bridging necrosis do not imply inevitable progression of disease, continued loss of hepatocytes results in fibrous septum formation, which, accompanied by hepatocyte regeneration, results in cirrhosis. Piecemeal Necrosis Chronic Active Hepatitis Features of Acute and Chronic Hepatitis   Exam from picture: Piecemeal necrosis = chronic hepatitis Autoimmune Hepatitis Is a chronic hepatitis of unknown etiology, which has clinical and histologic features virtually indistinguishable from chronic viral hepatitis May run an indolent or a severe and progressive course Responds dramatically to immunosuppressive therapy. Salient features include: Female predominance (70%), particularly young and perimenopausal women. Absence of viral serologic markers. Elevated serum IgG levels High serum titers of autoantibodies in 80% of cases, including antinuclear (ANA), antismooth muscle (SMA), antimitochondrial (AMA), and antiliver and kidney microsome (LKM) antibodies. Because there is often a positive lupus erythematosus (LE) test, autoimmune hepatitis was formerly called lupoid hepatitis. An increased frequency of HLA B8 or DRw3. Fulminant Hepatitis Hepatic insufficiency progressing from onset of symptoms>hepatic encephalopathy within 2-3wks  Drug-Induced and Toxin-Induced Liver Disease Liver is the major drug-metabolizing and drug-detoxifying organ Therefore is subject to potential damage from pharmaceutical and environmental chemicals Injury may result from : Direct toxicity Hepatic conversion of a xenobiotic to an active toxin Via immune mechanisms, usually when the drug or a metabolite acts as a hapten to convert a cellular protein into an immunogen. Drug reactions may be classified as Intrinsic (predictable) reactions: Occur in anyone who accumulates a sufficient dose Examples: Acetaminophen, Tetracycline, Anti-neoplastic agents, Amanita phalloides toxin, CCl4 Idiosyncratic (Unpredictable) reactions: Depend on idiosyncrasies of the host Hosts propensity to mount an immune response to the antigenic stimulus Rate at which the host metabolizes the agent Examples: Sulfonamides, Methyldopa, Allopurinol Injury may be Immediate Develop in weeks/ months - manifesting only after liver is damaged severely Injury may take the form of Hepatocyte necrosis Cholestasis Insidious onset of liver dysfunction Drug-induced chronic hepatitis is clinically and histologically indistinguishable from chronic viral hepatitis Diagnosis of drug-induced liver disease may be made based on a temporal association of liver damage with drug administration Exposure to a toxin or therapeutic agent should be included in the differential diagnosis of any form of liver disease. Drug-Induced and Toxin-Induced Liver Disease   Table exam: Centrilobular necrosis ( CCl4 Diffuse or massive necrosis ( halothane Hepatitis acute and chronic ( isoniazid, oxyphenisation Cholestasis ( CONTRACEPTIVES Hepatic or portal vein thrombosis: estrogens, including oral contraceptives: TEST ( hepatocellular carcinoma Reyes Syndrome Is a rare disease characterized by fatty change in the liver and encephalopathy that in its most severe forms may be fatal. Primarily affects children < 9 years (most < 4 years of age) Typically, Reyes syndrome develops 3 to 5 days after a viral illness, heralded by vomiting and accompanied by irritability or lethargy and hepatomegaly. 75% of the patients progress no further and recover with no residual effects Remaining 25% have more serious illness Progressively deeper levels of coma Elevated levels of serum bilirubin, aminotransferases Survivors may be left with permanent neurologic impairments Death results from progressive deterioration of the mental state with delirium, convulsions, and coma. Therapy for Reyes syndrome is entirely symptomatic and supportive. Alcoholic Liver Disease Alcohol abuse constitutes the major form of liver disease More than 10 million Americans are alcoholics Alcohol abuse causes 200,000 deaths annually It is the fifth leading cause of death 25-30% of hospitalized patients have problems related to alcohol abuse Three distinctive, albeit overlapping, forms of liver disease collectively referred to as alcoholic liver disease: Hepatic steatosis Alcoholic hepatitis Cirrhosis These conditions may exist independently of each other and do not necessarily represent a continuum of changes Hepatic Steatosis (Fatty Liver) Moderate intake of alcohol: Small (microvesicular) lipid droplets accumulate in hepatocytes. Chronic intake of alcohol: GROSS: Liver often enlarged: upto 4 - 6 kg Is soft, yellow and greasy MICROSCOPIC: Lipid accumulates creating large clear macrovesicular spaces, compressing and displacing the nucleus to the periphery of the hepatocyte. Initially centrilobular In severe cases involves the entire lobule Fibrous tissue develops around the central veins and extends into the adjacent sinusoids. Up to the time that fibrosis appears, the fatty change is completely reversible if there is further abstention from alcohol. Fatty Liver Alcoholic Hepatitis Alcoholic hepatitis exhibits the following: Liver cell necrosis Single or scattered foci of cells undergo swelling (ballooning) and necrosis, more frequently in the centrilobular regions Mallory bodies Scattered hepatocytes containing eosinophilic cytoplasmic inclusions (tangled skeins of cytokeratin intermediate filaments and other proteins) These may also be seen in: Primary biliary cirrhosis Wilsons disease Chronic cholestatic syndromes Focal nodular hyperplasia Hepatocellular carcinoma Neutrophilic reaction: Neutrophils accumulate around degenerating liver cells, particularly those having Mallory bodies Lymphocytes and macrophages also enter portal tracts and spill into the lobule Fibrosis: Almost always present Sinusoidal and perivenular fibrosis Occasionally periportal fibrosis may predominate Particularly with repeated bouts of heavy alcohol intake Fat may be present or entirely absent Deranged iron processing leads to a modest accumulation of hemosiderin in hepatocytes and Kupffer cells Alcoholic Hepatitis cluster of neutrophils marks the site Mallory Body of a necrotic hepatocyte Eosinophilic Mallory body (arrow) Alcoholic Cirrhosis Final and irreversible form of alcoholic liver disease Usually evolves slowly and insidiously GROSS: Initially cirrhotic liver is yellow-tan, fatty, enlarged, usually weighing > 2 kg Over the span of years, transformed into a brown, shrunken, nonfatty organ, sometimes < 1 kg in wt MICROSCOPIC: Cirrhosis may develop within 1 to 2 years in the setting of alcoholic hepatitis Initially developing fibrous septae are delicate Regenerative activity of the entrapped parenchymal acini generates micronodules With time, the nodularity becomes more prominent; scattered nodules may become quite large, and occasionally nodules > 2 cm in diameter may develop macronodules As fibrous septae dissect and surround nodules, the liver becomes more fibrotic, loses fat, and shrinks progressively in size. Parenchymal islands are engulfed by ever wider bands of fibrous tissue, and the liver is converted into a mixed micronodular and macronodular pattern Alcoholic Cirrhosis - Micro-nodular Cirrhosis Micro- and macro-nodules entrapped in fibrous tissue Fatty change also present GROSS: Further ischemic necrosis + fibrous obliteration of nodules > broad expanses of tough, pale scar tissue, leaving residual parenchymal nodules that protrude like hobnails from the surface of the liver - Laennecs cirrhosis MICROSCOPIC: Septae contain scattered lymphocytes Some reactive bile duct proliferation Bile stasis often develops Mallory bodies rarely evident at this stage. Thus, end-stage alcoholic cirrhosis comes to resemble, both macroscopically and microscopically, postnecrotic cirrhosis. Alcoholic Liver Disease Clinical Course Short-term ingestion of up to 80 gm of ethanol per day (8 beers or 7 ounces of 80 proof liquor) = mild, reversible hepatic changes, such as fatty liver. Daily ingestion of >160 gm of ethanol for 10 - 20 years is associated more consistently with severe injury Chronic intake of 80 160 gm/day = borderline risk for severe injury Only 10 to 15% of alcoholics, however, develop cirrhosis. Susceptibility to alcoholic hepatic injury: Women > men Hepatic steatosis : Asymptomatic May become evident as mild elevation of serum bilirubin and alkaline phosphatase Severe hepatic compromise (e.g., malaise, anorexia, hepatic failure and death) is unusual Alcohol withdrawal and the provision of an adequate diet are sufficient treatment. Alcoholic hepatitis: Tends to appear relatively acutely, usually following a bout of heavy drinking. Asymptomatic to fulminant hepatic failure Between these two extremes are the nonspecific symptoms Malaise, anorexia, weight loss, upper abdominal discomfort, tender hepatomegaly Hyperbilirubinemia, elevated alkaline phosphatase Fever and neutrophilic leukocytosis frequently occur Outlook - unpredictable Each bout of hepatitis incurs about a 10 to 20% risk of death Cirrhosis appears in 30% of patients within a few years if there are repeated bouts With proper nutrition and total cessation of alcohol consumption, alcoholic hepatitis may slowly clear. In some patients, however, the hepatitis persists despite abstinence and progresses to cirrhosis. Alcoholic cirrhosis: First signs of cirrhosis relate to complications of portal hypertension, sometimes as life-threatening variceal hemorrhage. Alternatively- malaise, weakness, weight loss, and loss of appetite precede the appearance of jaundice, ascites, and peripheral edema (impaired albumin synthesis) The stigmata of cirrhosis (e.g., grossly distended abdomen, wasted extremities, caput medusae) may be dramatically evident Laboratory findings reflect the developing hepatic compromise Elevated serum transaminase levels Hyperbilirubinemia Variable elevation of serum alkaline phosphatase Hypoproteinemia Anemia. In some instances, liver biopsy may be indicated because in ~ 10 to 20% of cases of presumed alcoholic cirrhosis, another disease process is found on biopsy In the end-stage alcoholic, the immediate causes of death are : Hepatic coma Massive gastrointestinal variceal hemorrhage Intercurrent infection (to which these patients are predisposed) Hepatorenal syndrome following a bout of alcoholic hepatitis In ~ 3 to 6% of cases, death is related to the development of hepatocellular carcinoma Non-Alcoholic Steato-Hepatitis Occurs in patients who do not drink alcohol Non-specific symptoms of fatigue and malaise Risk factors Obesity - most important Diabetes mellitus Type II Hypertriglyceridemia Chief risk development of cirrhosis Microscopically: Sinusoidal fibrosis Mallory hyaline Steatosis Inborn Errors of Metabolism and Pediatric Liver Disease Hemochromatosis Wilsons Disease Alpha-1-Antitrypsin Deficiency Reyes Syndrome Neonatal Hepatitis Table: exam: qs Hereditary hemochromatosis African iron overload (Bantu siderosis) Hemochromatosis Definition: Excessive accumulation of body iron, most of which is deposited in the parenchymal cells of various organs, particularly liver and pancreas. Primary or idiopathic hemochromatosis: Also known as Hereditary Hemochromatosis (HHC) Is a homozygous recessive heritable disorder. Secondary hemochromatosis: Disorders in which the source of excess iron can be defined In normal adults ~ 0.5 gm iron stored in liver, 98% of which is in hepatocytes. Hemochromatosis gene is located on the short arm of chromosome 6, close to the HLA gene locus Associated HLA haplotypes include A3 in 70% of patients (versus 25% in the normal population) and, to a lesser extent, B7, B14, or Bw35 Total iron accumulation may exceed 50 gm Males predominate (5 to 7:1) Symptoms first appear in the fifth to sixth decades of life. Clinically fully developed cases exhibit the following features: Micronodular cirrhosismost patients Diabetes mellitus75 to 80% Skin pigmentation75 to 80% of cases. Pathogenesis Symptoms typically develop after 20 gm of storage iron have accumulated. Fundamental disease mechanism appears to be direct iron toxicity to host tissues, mediated by the following proposed mechanisms: Lipid peroxidation via iron-catalyzed free radical reactions Iron stimulation of collagen formation Direct interactions of iron with DNA, leading to lethal alterations or predisposing to hepatocellular carcinoma. Whatever the actions of iron, it is reversible in cells not fatally injured, and removal of excess iron during therapy promotes recovery of tissue function. Iron accumulates as ferritin and hemosiderin in the parenchymal tissues of the body Liver Pancreas Myocardium Endocrine glands Linings of joints No significant deposition in the bone marrow LIVER: Iron appears as golden-yellow hemosiderin granules in the cytoplasm of periportal hepatocytes Grossly, liver appears slightly larger than normal, dense, and chocolate brown. Microscopically, fibrous septa develop slowly, leading ultimately to a micro-nodular pattern of cirrhosis. PANCREAS: Becomes intensely pigmented, Has diffuse interstitial fibrosis May exhibit some parenchymal atrophy Hemosiderin is deposited in the acinar and the islet cells Intensity of iron staining in the pancreatic islets correlates somewhat with the occurrence and severity of the diabetes Dark brown color of the liver, pancreas and lymph node Hemosiderin deposition Dark brown deposits of hemosiderin in Fibrous bands cirrhosis hepatocytes and Kupffer cells HEART: Often enlarged Hemosiderin granules deposited within the myocardial fibers, inducing a striking brown coloration to the myocardium. SKIN: Usually has increased pigmentation, mainly owing to increased epithelial melanin (seen also with other forms of cirrhosis). A distinctive, metallic, slate-gray pigmentation is related to accumulation of hemosiderin in dermal macrophages and fibroblasts. JOINTS: Deposition in joint synovial linings, acute synovitis may develop. Excessive deposition of calcium pyrophosphate damages the articular cartilage, producing disabling arthritis referred to as pseudogout. TESTES: May be small and atrophic but are not usually significantly pigmented Clinical Features Hepatomegaly Abdominal pain Skin pigmentation (particularly in sun-exposed areas) Diabetes mellitus. Also called as Bronzed Diabetes Cardiac dysfunction (arrhythmias, cardiomyopathy) Atypical arthritis. In some patients, the presenting complaint is hypogonadism, for example, amenorrhea in the female and loss of libido and impotence in the male. Death may result from cirrhosis or cardiac disease. The most common cause of death in established HHC is hepatocellular carcinoma, for which the risk is 200-fold greater than the general population. Screening for HHC is accomplished by measuring: serum iron Total iron binding capacity Serum Ferritin levels Liver biopsy if indicated. Secondary causes of iron overload must be excluded history of numerous blood transfusions grossly excessive iron ingestion dyserythropoietic syndromes. Most important for identification of patients with asymptomatic HHC is screening of family members of probands, which includes HLA typing. Treatment: Use of iron chelators Wilsons Disease Autosomal recessive disorder of copper metabolism Accumulation of toxic levels of copper in many tissues and organs, principally the liver, brain, and eye: hepatolenticular degeneration. Genetic defect is on chromosome 13, in linkage with the esterase D locus. Initial steps of copper absorption and transport to the liver are normal. Absorbed copper, however, fails to enter the circulation in the form of ceruloplasmin, and biliary excretion of copper is markedly diminished. Copper thus accumulates progressively in the liver, in excess of the metallothionein-binding capacity causing toxic liver injury. Usually by five years of age, nonceruloplasmin-bound copper spills over into the circulation, causing hemolysis and pathologic changes at other sites, such as brain, cornea, kidneys, bones, joints, and parathyroids. Concomitantly, urinary excretion of copper becomes markedly increased. Biochemical diagnosis of Wilsons disease Decrease in serum ceruloplasmin Increase in hepatic copper content Increased urinary excretion of copper Morphology Fatty change Focal hepatocyte necrosis With more severe disease, Acute hepatitis or chronic hepatitis develops, both of which are similar in histologic appearance to viral hepatitis With progression of chronic hepatitis, cirrhosis develops A rare manifestation is massive hepatic necrosis. Histologic changes are not pathognomonic because Copper accumulates in chronic obstructive cholestasis Histology cannot reliably distinguish Wilsons disease from viral-induced and drug-induced hepatitis (and vice versa) Most helpful is hepatic copper determination, which is characteristically in excess of 250 mg/gm dry weight. Red-brown granular material seen is excessive lysosomal copper in hepatocytes Neurologic changes constitute toxic injury to neurons, most marked in the basal ganglia, particularly the putamen, sometimes leading to grossly visible cavitations. Kayser-Fleischer rings appear in the cornea in almost all patients with neurologic involvement. Green-to-brown deposits of copper in Desemets membrane (close to the limbus of the cornea) Are characteristic but not pathognomonic May be found in other forms of chronic cholestasis Clinical Features Presents in childhood or adolescence Usually with manifestations of liver disease Jaundice Hepatomegaly In the absence of neurologic changes Reverse is true in 40% of cases Neurological manifestations: Parkinson-like movement disorder Psychiatric disturbance - behavioral disorders to frank psychosis Ocular changes Treatment: Long-term use of copper chelators (e.g., penicillamine) Liver transplantation - fulminant hepatitis and unmanageable cirrhosis Alpha-1-Antitrypsin Deficiency Is an autosomal recessive disorder Abnormally low serum levels of major protease inhibitor (Pi) Deficiency leads to the development of Pulmonary disease (emphysema) Hepatic disease (cholestasis or cirrhosis) Alpha-1-AT gene is located on human chromosome 14 The most common phenotype is PiMM, occurring in 90% of individuals Homozygotes for the PiZZ protein, however, have circulating a1-AT levels that are only 10% of normal levels and are at highest risk for developing clinical disease. Characterized by round-to-oval cytoplasmic globular inclusions of impounded a1-AT in hepatocytes Manifestations include: Neonatal hepatitis without or with cholestasis and fibrosis Childhood cirrhosis Cirrhosis that becomes apparent only late in life when liver scarring is well advanced Hepatocellular carcinoma develops in 2 to 3% of PiZZ adults, usually but not always in the setting of cirrhosis Treatment: For severe hepatic disease is liver transplantation, with restoration of normal a1-AT synthesis and release Red hyaline globules cytoplasmic inclusions Intrahepatic Biliary Tract Disease Secondary Biliary Cirrhosis Primary Biliary Cirrhosis Primary Sclerosing Cholangitis Anomalies of the Biliary Tree Secondary Biliary Cirrhosis Prolonged obstruction to the extrahepatic biliary tree results in profound alteration of the liver architecture Causes: Impacted gallstone in the CBD (Most common cause) Biliary atresia Malignancies of the biliary tree and head of the pancreas Strictures resulting from previous surgical procedures Changes: Initially, features of cholestasis Reversible with correction of the obstruction Initiation of periportal fibrosis secondary to inflammation Leading to secondary biliary cirrhosis Secondary bacterial infection (ascending cholangitis) may contribute to the damage Enteric organisms such as coliforms and enterococci are common culprits. Morphology End-stage obstructed liver exhibits extraordinary yellow-green pigmentation Accompanied icteric discoloration of body tissues and fluids. Grossly: Liver is hard with a finely granular appearance Microscopically: Large and small bile ducts distended + contain inspissated bile Portal tracts interconnected by inflamed fibrous septa Cholestatic features may be severe Cytoplasmic and canalicular accumulation of bile Extensive feathery degeneration of hepatocytes Formation of bile lakes Primary Biliary Cirrhosis Is a chronic, progressive, and often fatal cholestatic liver disease Characterized by: Nonsuppurative, granulomatous destruction of medium-sized intrahepatic bile ducts Portal inflammation and scarring Eventual development of cirrhosis and liver failure. It is a focal and variable disease Exhibits different degrees of severity in different portions of the liver Destruction of bile ductules w/Mononuclear inflammatory infiltrate Morphology PBC is the prototype of all conditions leading to small-duct biliary fibrosis and cirrhosis Four histologic stages have been described: The florid duct lesion (granulomatous destruction of interlobular bile ducts) Ductular proliferation with periportal hepatitis Scarring, with bridging necrosis and septal fibrosis Cirrhosis Primarily a disease of middle-aged women (Female-to-male predominance 6:1) Age of onset 20 and 80 years - peak 40 to 50 years. May be asymptomatic for years Onset insidious, usually presenting with pruritus Jaundice develops late in the course Hepatomegaly is typical Xanthomas and xanthelasmas arise as a result of cholesterol retention. Serum alkaline phosphatase and cholesterol almost always elevated Hyperbilirubinemia is a late development Signifies incipient hepatic decompensation Striking feature is autoantibodies, especially antimitochondrial antibodies in > 90% of patients Characteristic are M2 antibodies against mitochondrial pyruvate dehydrogenase Extrahepatic manifestations associated with PBC include the sicca complex of dry eyes and mouth (Sjdogrens syndrome), scleroderma, thyroiditis, rheumatoid arthritis, Raynauds phenomenon, membranous glomerulonephritis, and celiac disease. Primary Sclerosing Cholangitis Characterized by inflammation, obliterative fibrosis, and segmental dilatation of the intrahepatic and extrahepatic bile ducts. Irregular strictures and dilatations of affected bile ducts leads to characteristic beading of a barium column in radiographs of intrahepatic and extrahepatic biliary tree Commonly seen in association with inflammatory bowel disease Chronic ulcerative colitis coexists in approximately 70% of patients Occurs in the third through fifth decades of life Males predominate 2:1 Onion-skin fibrosis in portal region Beaded appearance on cholangiogram Morphology PSC is a fibrosing cholangitis of bile ducts, with a lymphocytic infiltrate Progressive atrophy of the bile duct epithelium, and obliteration of the lumen The concentric periductal fibrosis around affected ducts (onionskin fibrosis) is followed by their disappearance, leaving behind a solid, cord-like fibrous scar. In between areas of progressive stricture, bile ducts become ectatic and inflamed, presumably the result of downstream obstruction. As the disease progresses, the liver becomes markedly cholestatic, culminating in biliary cirrhosis. Clinical Course Asymptomatic patients may come to attention based only on persistent elevation of serum alkaline phosphatase. Alternatively, progressive fatigue, pruritus, and jaundice may develop. Severely afflicted patients exhibit symptoms associated with chronic liver disease, including weight loss, ascites, variceal bleeding, and encephalopathy. Ten-year survival is 50 to 75% Progressive decline is arrested only by liver transplantation  Exam table: Distinctive pathologic findings of bile ducts: Periductal fibrosis: Neonatal Hepatitis Prolonged conjugated hyperbilirubinemia in the neonate is termed as neonatal cholestasis The major conditions causing it are Cholangiopathies, primarily extrahepatic biliary atresia (EHBA) Variety of disorders causing conjugated hyperbilirubinemia in the neonate, collectively referred to as neonatal hepatitis Finding of neonatal cholestasis should evoke a diligent search for recognizable toxic, metabolic, and infectious liver diseases Clinical Presentation: Jaundice, dark urine, light or acholic stools, and hepatomegaly. Variable degrees of hepatic synthetic dysfunction may be identified, such as hypoprothrombinemia. Liver biopsy is critical in distinguishing neonatal hepatitis from an identifiable cholangiopathy. The morphologic features of neonatal hepatitis are as follows: Lobular disarray with focal liver cell necrosis Panlobular giant cell transformation of hepatocytes Prominent hepatocellular and canalicular cholestasis Mild mononuclear infiltration of the portal areas Reactive changes in the Kupffer cells Extramedullary hematopoiesis Circulatory Disorders of Liver Liver Infarction Portal Vein Obstruction and Thrombosis Passive Congestion and Centrilobular Necrosis Peliosis Hepatis Hepatic Vein Thrombosis (Budd-Chiari Syndrome) Veno-Occlusive Disease Liver Infarction Liver infarcts are rare, thanks to the double blood supply to the liver. However, thrombosis or compression of an intrahepatic branch of the hepatic artery by embolism, neoplasia, polyarteritis nodosa, or sepsis may result in a localized infarct that is usually anemic and pale tan. Portal Vein Obstruction and Thrombosis May be insidious and well tolerated or may be a catastrophic and potentially lethal event Extrahepatic causes of portal vein obstruction include Massive enlargement of hilar lymph nodes owing to metastatic abdominal cancer Pylephlebitis resulting from peritoneal sepsis (e.g., acute diverticulitis or appendicitis) Propagation of splenic vein thrombosis secondary to pancreatitis Postsurgical thrombosis following upper abdominal procedures Most common intrahepatic cause is cirrhosis of the liver In all cases, retrograde propagation of thrombus or growth of tumor may completely occlude splanchnic inflow to the liver. Abdominal pain Massive ascites and esophageal varices Impairment of splanchnic blood flow often leads to profound bowel congestion and infarction. When the condition is secondary to pylephlebitis, anterograde spread of infection may yield multiple liver abscesses. Bantis syndrome Characterized by Splenomegaly Hypersplenism Portal hypertension More aptly termed noncirrhotic or idiopathic portal hypertension Condition arises following subclinical occlusion of the portal vein, usually years after the occlusive event Postulated causes include neonatal omphalitis, dehydration, sepsis, or umbilical vein catheterization for exchange transfusion therapy; hypercoagulable myeloproliferative disorders; biliary tract surgery; peritonitis; and exposure to arsenicals. Prognosis is generally excellent, and clinical outcome relates primarily to the complications of chronic portal hypertension Passive Congestion and Centrilobular Necrosis Acute and chronic passive congestion of the liver usually reflects acute or slowly developing cardiac decompensation, most commonly right-sided failure. Liver is slightly enlarged, tense, and cyanotic, with rounded edges. On cut section, excessive ooze of blood, and centrilobular areas dusky and soft, surrounded by paler, fatty liver substance in the portal areas (the nutmeg liver) Microscopically there is congestion of centrilobular sinusoids. With time, centrilobular hepatocytes become atrophic, resulting in markedly attenuated liver cell cords. Nutmeg Liver congestion around central vein Cardiac Sclerosis Chronic severe congestive heart failure may lead to fibrosis of the liver Due to complication of sustained increased venous backpressure and centrilobular hypoxia. Pattern of liver fibrosis is distinctive - it is mostly centrilobular Scarring of cardiac sclerosis is delicate and subtle and easily missed on both gross and microscopic examination. Liver is slightly reduced in size and has a fine pigskin grain on its external surface. Microscopically there is a subtle increase in fibrous tissue about the central veins, from which delicate strands fan out into the surrounding liver substance. Interconnection of the fibrous strands to produce bridging tracts of fibrous tissue is seen only in extreme examples, usually in association with tricuspid insufficiency. Peliosis Hepatis Peliosis hepatis is a rare condition Primary dilatation of the sinusoids impeding efflux of hepatic blood. Most commonly associated with exposure to anabolic steroids and rarely oral contraceptives and danazol. Mottled and blotchy areas develop in the liver, consisting of irregular blood-filled lakes ranging from < 0.1to>1 cm Microscopically, the lesions consist of irregular cystic spaces - dilated sinusoids lined by an endothelium There are no intrinsic abnormalities in hepatocytes or hepatic venules. Hepatic Vein Thrombosis (Budd-Chiari Syndrome) Acute, usually fatal thrombotic occlusion of the hepatic veins. Definition now includes subacute and chronic occlusive syndromes, characterized by hepatomegaly, weight gain, ascites, and abdominal pain. Hepatic vein thrombosis is associated with (in order of frequency) Polycythemia vera Pregnancy Postpartum state Use of oral contraceptives Paroxysmal nocturnal hemoglobinuria Intra-abdominal cancers, particularly hepatocellular carcinoma. All these conditions produce thrombotic tendencies or, in the case of liver cancers, sluggish blood flow. 30% of cases are idiopathic in origin. Untreated the mortality of acute Budd-Chiari syndrome is high. Tumors of the Liver Benign Cavernous Hemangiomas (most common) Nodular hyperplasia Focal nodular hyperplasia Nodular regenerative hyperlasia Adenomas Malignant Primary Hepatoblastoma Angiosarcoma Hepatocellular carcinoma Cholangiocarcinoma Secondary / Metastatic Cavernous Hemangiomas The most common benign lesion Appears as discrete red-blue, soft nodules Usually < 2 cm in diameter Often directly beneath the capsule Importance of recognizing these lesions is: Not to mistake them for metastatic tumors Not to perform blind percutaneous biopsies on them Focal Nodular Hyperplasia Solitary or multiple benign hepatocellular nodules may develop in the liver, in the absence of cirrhosis Appears as a well-demarcated but poorly encapsulated nodule Up to many centimeters in diameter Gross examination: Is lighter than the surrounding liver and brown to tan (sometimes yellow). Typically, central gray-white depressed stellate scar from which radiate fibrous septa to the periphery Central scar contains arteries which show Fibromuscular hyperplasia Eccentric or concentric narrowing of the lumen. Radiating septa contain foci of intense lymphocytic infiltrates and exuberant bile duct proliferation along septal margins Parenchyma between the septa is composed largely of normal hepatocytes Occurs most frequently in young to middle-aged adults Does not appear to pose a risk for malignancy Nodular Hyperplasias Nodular regenerative hyperplasia Is a diffuse, nonfibrosing version of focal nodular hyperplasia, affecting the entire liver with roughly spherical nodules of plump hepatocytes surrounded by rims of atrophic cells Is associated with the development of portal hypertension, with attendant symptoms. Is a nonspecific transformation that may occur in association with such diverse conditions as bone marrow transplantation and primary biliary cirrhosis Adenomas Benign neoplasms developing from hepatocytes Occur in young women using oral contraceptives Regress on discontinuation Liver cell adenomas have clinical significance for three reasons: Present as an intrahepatic mass - may be mistaken for Hepatocellular Carcinoma Subcapsular adenomas may rupture causing severe intraperitoneal hemorrhage (particularly during pregnancy - under estrogenic stimulation) Rarely they may harbor hepatocellular carcinoma. Gross Morphology Are pale, yellow-tan, frequently bile-stained nodules Often beneath the capsule. May reach 30 cm in diameter. Although they are usually well demarcated, encapsulation may not be grossly evident Histologic Morphology Composed of sheets and cords of cells that resemble normal hepatocytes Portal tracts are absent A capsule (delicate collapsed reticulin or well-defined connective tissue) usually separates the lesion from the surrounding parenchyma A. Gross Pathology B. Cut Section of Gross Pathology C. CT of same D.Normal hepatic tissue on the left side/Adenoma on the right:Disorganized hepatocyte cords Absent normal architecture Malignant Tumors - Hepatoblastoma Is a tumor usually of young childhood Exhibits two anatomic variants: Epithelial type: Composed of small, compact fetal or smaller embryonal cells, forming acini, tubules, or papillary structures vaguely recapitulating the development of the liver Mixed type: Containing an epithelial element interspersed with foci of mesenchymal differentiation that may consist of primitive mesenchyme, osteoid, cartilage, or striated muscle. Unless successfully resected, both variants are usually fatal within a few years. Malignant Tumors - Angiosarcoma Resembles those occurring elsewhere in the body It is associated with exposure to vinyl chloride, arsenic, or Thorotrast (once used in radiography as a hepatic contrast medium). The latent period between exposure to the putative carcinogen and the appearance of the neoplasm may be several decades. Are highly aggressive neoplasms Metastasize widely Generally death within a year. Primary Carcinoma of the Liver Basically two types of primary liver carcinoma: Hepatocellular carcinoma (HCC) sometimes still called a hepatoma, accounts for more than 90% of all primary liver cancers. Cholangiocarcinoma: Composed of bile duct epithelium Epidemiology Highest numbers of cases of hepatocellular carcinoma are found in Taiwan, Mozambique, and Southeast China Blacks > whites Males > females Global distribution strongly linked to prevalence of HBV infection In high-incidence regions: HBV carrier state begins in infancy following vertical transmission of virus from infected mothers, conferring a 200-fold increased risk of HCC by adulthood. In these regions, cirrhosis may be absent in 50% of HCC patients Cancer often occurs between 20 and 40 years of age In the Western world, where HBV is not prevalent: Cirrhosis is present (in 85 - 90% of cases of HCC) along with other chronic liver diseases (including HCV infection and alcohol) Cancer is seldom encountered before age 60. Three major etiologic associations for HCC HBV infection Aflatoxin exposure Cirrhosis. 40% of patients of hereditary tyrosinemia develop this tumor despite adequate dietary control None of the influences related to HCC has any bearing on the development of cholangiocarcinoma Recognized causal influences of this tumor are: Previous exposure to Thorotrast (formerly used in radiography) Invasion of the biliary tract by the liver fluke Opisthorchis sinensis Hepatocellular Carcinoma Morphology HCC or cholangiocarcinoma may appear grossly as: Unifocal (usually large) mass Multifocal, widely distributed nodules of variable size Diffusely infiltrative cancer, permeating widely and sometimes involving the entire liver All three patterns may cause liver enlargement (2000 to 3000 gm), particularly the unifocal massive and multinodular patterns. Discrete masses are yellow-white, punctuated sometimes by areas of hemorrhage or necrosis May have a green hue when composed of well-differentiated hepatocytes capable of secreting bile Have a strong propensity for invasion of vascular channels Extensive intrahepatic metastases ensue, and occasionally long, snake-like masses of tumor invade Portal vein (with occlusion of the portal circulation) Inferior vena cava, extending even into the right side of the heart. Microscopic Features of HCC HCCs range from well-differentiated to highly anaplastic undifferentiated lesions. In well-differentiated and moderately well-differentiated tumors, cells recognizable as hepatocytic in origin are disposed in a trabecular or acinar/ pseudoglandular pattern. Supporting connective tissue is minimal to absent therefore are of soft consistency Bile may occasionally be seen in canalicular spaces or lumens between tumor cells, and bile canaliculi may be present ultrastructurally. HCC HCC HCC Fibro-Lamellar Carcinoma -fibro-lamellar carcinoma -nests and cords of malignant-appearing hepatocytes -separated by dense bundles of collagen Fibro-lamellar Carcinoma A distinctive variant of HCC Occurs in young men and women (20 to 40 years of age) Equal incidence No association with HBV or cirrhosis risk factors Has a distinctly better prognosis It usually constitutes a single large, hard scirrhous tumor with fibrous bands coursing through it. Histologically composed of well-differentiated polygonal cells growing in nests or cords and separated by parallel lamellae of dense collagen bundles hence the name fibrolamellar. Microscopic Appearance (See D above) Nests and cords of malignant-appearing hepatocytes Separated by dense bundles of collagen Cholangiocarcinoma Morphology - Cholangiocarcinomas are rarely bile stained because differentiated bile duct epithelium does not synthesize pigmented bile. Cholangiocarcinoma are more firm and gritty as compared with HCC Resemble adenocarcinomas arising in other parts of the body and may exhibit the full range of morphologic variation. Most are well-differentiated sclerosing adenocarcinomas with clearly defined glandular and tubular structures lined by anaplastic cuboidal-to-low columnar epithelial cells. Mucus present within cells & lumina but not bile There is no reliable histologic feature distinguishing intrahepatic cholangiocarcinoma from metastatic adenocarcinoma Diagnosis depends on reasonable exclusion of an extrahepatic primary Vascular invasion is less common with cholangiocarcinomas than with HCC. Glandular appearance (on the left) Gross Appearance Mucin production No bile production Primary Carcinoma of the Liver-Clinical Course Clinical manifestations are seldom characteristic Most patients have ill-defined upper abdominal pain, malaise, fatigue, weight loss, and sometimes awareness of an abdominal mass or abdominal fullness. In many cases, the enlarged liver can be felt on palpation, with sufficient irregularity or nodularity to permit differentiation from cirrhosis. Jaundice, fever, and gastrointestinal or esophageal variceal bleeding are inconstant findings. Laboratory studies may be helpful but are rarely conclusive Elevated levels of serum alpha-fetoprotein (in 60 to 75% ) Elevated levels of Carcinoembryonic antigen These biochemical tests fail to detect small lesions, when curative resection might be possible. Most valuable for small tumors are ultrasonography, hepatic angiography, computed tomography, and magnetic resonance imaging scans. False-positive results of elevated alpha fetoprotein are encountered with : yolk-sac tumors Non-neoplastic conditions Cirrhosis Massive liver necrosis Chronic hepatitis Normal pregnancy Fetal distress or death Fetal neural tube defects such as anencephaly and spina bifida Prognosis The natural course of primary liver cancer is progressive enlargement of the primary mass until it encroaches on hepatic function or metastasizes, generally first to the lungs and then to other sites Overall death usually occurs within 6 months of diagnosis from: Cachexia Gastrointestinal or esophageal variceal bleeding Liver failure with hepatic coma Rupture of the tumor with fatal hemorrhage Possibility of significantly reducing the global mortality from HCC by immunization of high-risk populations against HBV, in whom infections are commonly acquired in early life. Such public-health measures provide the extraordinary opportunity to eradicate a major cancer by a vaccination program. Fibrolamellar variant of HCC is associated with a far more favorable outlook. It arises in otherwise healthy young adults and may be discovered while still amenable to surgical resection. About 60% of patients are alive at 5 years Cholangiocellular carcinoma is not usually detected until late in its course Clinical outlook is dismal Death characteristically ensuing within 6 months. Metastatic Tumors Metastatic involvement of the liver is far more common than primary neoplasia. Most common primaries producing hepatic metastases are those of Breast Lung Colon However, any cancer in any site of the body may spread to the liver, including leukemias and lymphomas. Often the only clinical telltale sign is hepatomegaly, sometimes with nodularity of the free edge. With massive or strategic involvement (obstruction of major ducts), however, jaundice and abnormal elevations of liver enzymes may appear Typically multiple nodular implants are found that often cause striking hepatomegaly and may replace more than 80% of existent hepatic parenchyma There is a tendency for metastatic nodules to outgrow their blood supply, producing central necrosis and umbilication Cholelithiasis (Gallstones) Gallstones afflict 10 to 20% of adult populations in developed countries There are two main types of gallstones. Cholesterol stones - containing more than 50% of crystalline cholesterol monohydrate. Pigment stones - composed predominantly of bilirubin calcium salts Cholesterol stones Arise exclusively in the gallbladder Consist of 100% down to around 50% cholesterol Pure cholesterol stones are pale yellow and round to ovoid and have a finely granular, hard external surface On transection reveals a glistening radiating crystalline palisade. With increasing proportions of calcium carbonate, phosphates, and bilirubin, the stones exhibit discoloration and may be lamellated and gray-white to black on transection. Most often, multiple stones are present Rarely there is a single, much larger stone that may virtually fill the fundus. Surfaces of multiple stones may be rounded or faceted, owing to tight apposition. Stones composed largely of cholesterol are radiolucent Sufficient calcium carbonate is found in 10 to 20% of cholesterol stones to render them radiopaque. Pigment gallstones Black pigment stones Are found in sterile gallbladder bile Are composed of oxidized polymers of the calcium salts of unconjugated bilirubin, calcium carbonate, calcium phosphate, and mucin glycoprotein < 1.5 cm in diameter Present in great number (with an inverse relationship between size and number) May crumble to the touch. Contours are usually spiculated and molded ~ 50 to 75% of black stones are radiopaque Brown stones Are found in infected intrahepatic or extrahepatic ducts. Contain pure calcium salts of unconjugated bilirubin, mucin glycoprotein, a substantial cholesterol fraction, and calcium salts of palmitate and stearate. Tend to be laminated and soft and may have a greasy consistency Are radiolucent Stages in Cholesterol Stone Formation  -exam: biliary infection A.Cholesterol Stones B.Black pigment stones Cholecystitis Acute Calculous Cholecystitis Acute Acalculous Cholecystitis Chronic Cholecystitis Acute Calculous Cholecystitis Acute calculous cholecystitis is an acute inflammation of the gallbladder, precipitated 90% of the time by obstruction of the neck or cystic duct. It is the primary complication of gallstones Is the most common reason for emergency cholecystectomy. May appear with remarkable suddenness and constitute an acute surgical emergency or may present with mild symptoms that resolve without medical intervention An attack of acute cholecystitis Begins with progressive right upper quadrant or epigastric pain Associated with mild fever, anorexia, tachycardia, diaphoresis, and nausea and vomiting Upper abdomen is tender Most patients are free of jaundice; the presence of hyperbilirubinemia suggests obstruction of the common bile duct. Mild-to-moderate leukocytosis may be accompanied by mild elevations in serum alkaline phosphatase values. In the absence of medical attention, the attack usually subsides over 7 to 10 days and frequently within 24 hours. Up to 25% of patients, however, develop progressively more severe symptoms, requiring immediate medical intervention. In those patients that recover, recurrence is common. Mucocele/Empyema of the gall bladder Chronic cholecystitis Thickening and fibrosis of gall bladder wall Variable chronic inflammatory infilterate in the mucosa and submucosa Disorders of the Extrahepatic Bile Ducts Biliary Atresia Choledocholithiasis and Ascending Cholangitis Stone in the bile duct Choledochal Cysts Biliary Atresia A major contributor to neonatal cholestasis is extrahepatic biliary atresia (EHBA) Representing 30% of infants with neonatal cholestasis EHBA is defined as a complete obstruction of bile flow owing to destruction or absence of all or part of the extrahepatic bile ducts It is the single most frequent cause of death from liver disease in early childhood Accounts for 50-60% of children referred for liver transplantation, owing to the rapidly progressing secondary biliary cirrhosis Pathogenesis Most infants with EHBA are born with an intact biliary tree In the weeks following birth, the biliary tree undergoes progressive inflammatory destruction Cause remains unknown Possibly: Viral infection Reovirus 3 Cytomegalovirus Rubella virus Genetic inheritance Anomalous embryologic development Morphology The salient features of EHBA include Inflammation and fibrosing stricture of the hepatic or common bile ducts Periductular inflammation of intrahepatic bile ducts Progressive destruction of the intrahepatic biliary tree Biliary atresia can be of three types: Type I: Disease is limited to the common duct Type II: Disease is limited to hepatic bile ducts with patent proximal branches Type III: Obstruction of bile ducts at or above the porta hepatis (most common 90%) Surgically correctible lesions are type I and II Noncorrectable type III because there are no patent extrahepatic ducts amenable to surgical anastomosis Clinical Course Infants with EHBA present with neonatal cholestasis, These infants exhibit normal birth weight and postnatal weight gain Slight female preponderance Progression of initially normal stools to acholic stools as the disease evolves. Treatment: Liver transplantation with accompanying donor bile ducts Without surgical intervention, death usually occurs within 2 years of birth. Choledochal Cysts Are congenital dilatations of the common bile duct In children < age 10 Nonspecific symptoms of jaundice or recurrent abdominal pain typical of biliary colic, or both. ~ 20% of patients become symptomatic only in adulthood sometimes occur in conjunction with cystic dilatation of the intrahepatic biliary tree (Carolis disease). Female-to-male ratio is 4:1 Choledochal cysts predispose to stone formation, stenosis and stricture, pancreatitis, and obstructive biliary complications within the liver In the older patient, the risk of bile duct carcinoma is elevated Tumors Adenomas are benign epithelial tumors, representing localized neoplastic growth of the lining epithelium. Adenomas are classified as Tubular Papillary Tubulopapillary Histologically indistinguishable from intestinal adenomas In the gallbladder, they may be sessile or pedunculated and are generally under 1 cm in size and are visualized as immobile translucent lesions on imaging studies or found incidentally on cholecystectomy. Adenomas of the bile ducts are even less common and frequently present with obstructive symptoms. As with alimentary tract adenomas, a close relationship appears to exist with the development of carcinoma; some 10% of adenomas show evidence of carcinoma in situ. Carcinoma of the Gallbladder Carcinoma of the gallbladder is the fifth most common cancer of the digestive tract Is slightly more common in women Occurs most frequently in the seventh decade of life. Mean 5-year survival has remained for many years at about 1%, despite surgical intervention Gallstones present in 60-90% cases, not 100% Morphology Infiltrating Is more common Usually appears as a poorly defined area of diffuse thickening and induration of the gallbladder wall that may cover several square centimeters or may involve the entire gallbladder Tumors are scirrhous and have a firm consistency Fungating Grows into the lumen as an irregular, cauliflower-like mass May be necrotic, hemorrhagic, and ulcerated At the same time invades the underlying wall Most common sites of involvement are the fundus and neck ~ 20% involve the lateral walls Direct penetration of the gallbladder wall into the liver bed Fistula formation to adjacent viscera may occur. Most carcinomas of the gallbladder are adenocarcinomas. Some are papillary and others are infiltrative and poorly differentiated to undifferentiated About 5% are squamous cell carcinomas or have adenosquamous differentiation By the time these neoplasms are discovered, most have spread locally and invaded the liver, and many have extended to the cystic duct and adjacent bile ducts and portahepatic lymph nodes. The peritoneum, gastrointestinal tract, and lungs are common sites of seeding; distant metastasis is uncommon Carcinoma of the Extrahepatic Bile Ducts Refers to malignancies of the extrahepatic biliary tree, down to the level of the ampulla of Vater Cancers arising in the immediate vicinity of the ampulla are known as periampullary carcinomas and include Pancreatic carcinoma Adenomas of the ampullary orifice Bile duct carcinoma Are uncommon Age range as in carcinoma of the gallbladder Slightly more frequent in males The role of gallstones is unconvincing because they are present in only 35 to 50% of cases. Choledochal cysts, ulcerative colitis, and chronic biliary infection with Clonorchis sinensis and Giardia lamblia impart an increased risk for bile duct carcinoma, but such cases represent a minority of patients. Morphology Are generally small lesions at the time of diagnosis Most appear as firm, gray nodules within the bile duct wall Some may be diffusely infiltrative lesions, and others are papillary, polypoid lesions Vast majority of bile duct tumors are adenocarcinomas May or may not be mucin secreting Uncommonly squamous features are present. For the most part, an abundant fibrous stroma accompanies the epithelial proliferation. Tumors arising from the part of the common bile duct between the cystic duct junction and the confluence of the right and left hepatic ducts at the liver hilus are called Klatskin tumors These tumors are notable for their slow-growing behavior, marked sclerosing characteristics, and the infrequent occurrence of distal metastases. Clinical Course Jaundice generally arises owing to obstruction, often preceded by decolorization of the stools, nausea and vomiting, and weight loss. Hepatomegaly is present in about 50% Palpable gallbladder in about 25% Associated changes are elevated levels of serum alkaline phosphatase and transaminases and bile-stained urine. Differentiation of obstructive jaundice owing to calculous disease or other benign conditions from neoplasia is a major clinical problem because the presence of stones does not preclude the existence of concomitant malignancy Majority of ductal cancers are not surgically resectable at the time of diagnosis, despite their small size Mean survival times range from 6 to 18 months, regardless of whether aggressive resections or palliative surgery are performed Metastatic spread is uncommon because death comes so soon. PANCREAS Exocrine Inflammation Pancreatitis Acute Chronic Tumors Benign Cysts Pseudocysts Malignant Carcinoma Endocrine Diabetes Mellitus Islet cell tumors Insulinoma Gastrinoma Pancreatitis Inflammation of the pancreas Almost always associated with acinar cell injury Types: Acute pancreatitis Acute hemorrhagic pancreatitis Chonic pancreatitis Acute pancreatitis Condition characterized by an acute onset of abdominal pain due to enzymatic necrosis and inflammation of the pancreas 80% of cases are associated with two conditions: Biliary tract disease Alcoholism Acute hemorrhagic pancreatitis: Is a severe form of acute pancreatitis There is extensive fat necrosis in and about the pancreas and in other intra-abdominal fatty depots Hemorrhage into the parenchyma of the pancreas   The morphology of acute pancreatic necrosis stems directly from the action of activated pancreatic enzymes that are released into the pancreatic substance. The basic alterations are: Proteolytic destruction of pancreatic substance Necrosis of blood vessels with subsequent hemorrhage Necrosis of fat - pancreatic and peripancreatic fat Accompanying inflammatory reaction Microscopic Pancreatitits Acute Hemmorhagic Pancreatitis Central focus of necrotic fat Surrounding leucocytic infiltrate Clinical Features Abdominal pain is the cardinal manifestation of acute pancreatitis. Varies from mild and tolerable, to severe and incapacitating. Localization in the epigastrium with radiation to the back is characteristic. Mild acute pancreatitis is diagnosed primarily by the presence of elevated plasma levels of amylase and lipase and exclusion of other causes of abdominal pain. Full-blown, acute pancreatic necrosis is a medical emergency of the first magnitude. Differential Diagnosis of acute abdomen Ruptured acute appendicitis Perforated peptic ulcer Acute cholecystitis with rupture Occlusion of mesenteric vessels with infarction of the bowel. Systemic features attributed to release of toxic enzymes into the systemic circulation: Leukocytosis Hemolysis Disseminated intravascular coagulation Fluid sequestration (due to a leaky vasculature) Adult respiratory distress syndrome Diffuse fat necrosis Peripheral vascular collapse Shock with acute renal tubular necrosis may occur due to: loss of blood volume electrolyte disturbances Endotoxemia release of vasodilatory agents, such as bradykinin and prostaglandins. Laboratory findings Marked elevation of the serum amylase during the first 24 hours, Rising serum lipase level within 72 to 96 hours Glycosuria occurs in 10% of cases. Hypocalcemia may result from precipitation of calcium soaps in the fat necrosis if persistent, it is a poor prognostic sign. Direct visualization of the enlarged inflamed pancreas by radiographic means is useful in the diagnosis of pancreatitis. Complications and Sequelae About 5% die of shock during the first week Complications: Acute adult respiratory distress syndrome Acute renal failure Sequelae : Pancreatic abscess Pseudocyst Duodenal obstruction Also termed as chronic relapsing pancreatitis Progressive destruction of the pancreas by repeated bouts of silent or mildly symptomatic acute pancreatitis. As in acute pancreatitis most commonly the middle-aged, male alcoholic, and less frequently the patient with biliary tract disease Hypercalcemia and hyperlipidemia also predispose to chronic pancreatitis. Morphology Chronic pancreatitis is distinguished by Irregularly distributed fibrosis Reduced number and size of acini with relative sparing of the islets of Langerhans Variable obstruction of pancreatic ducts of all sizes Grossly: Gland is hard Exhibits foci of calcification Fully developed pancreatic calculi Therefore the term chronic calcifying pancreatitis. Pseudocyst formation is common. Clinical Features Can present as repeated attacks of abdominal pain, or persistent and intractable abdominal and back pain. Entirely silent until pancreatic insufficiency and diabetes develop. Recurrent episodes of mild jaundice or bouts of indigestion. Diagnosis requires a high index of suspicion. Attacks may be precipitated by alcohol abuse, overeating, or the use of opiates and other drugs. Abdominal imaging may show calcification in of the pancreas. Pancreatic pseudocysts occur frequently Profound weight loss Hypoalbuminemic edema A modestly increased risk of pancreatic carcinoma. Causes and Consequences of chronic pancreatitis  Tumors: Non-Neoplastic Cysts Cysts of the pancreas are infrequent Congenital cysts: Result from anomalous development of the pancreatic ducts. Congenital polycystic disease: Cysts coexisting in the kidney, liver, and pancreas Von Hippel-Lindau disease: Angiomas found in the retina and cerebellum or brain stem Associated cysts in the pancreas, liver, and kidneys Cysts lined by a smooth, glistening membrane that may exhibit Ductal-type cuboidal epithelium Completely atrophic, attenuated cell layer. Cysts usually enclosed in a thin, fibrous capsule Filled with a clear-to-turbid mucoid or serous fluid Pseudocysts Are localized collections of pancreatic secretions that develop following Inflammation of the pancreas - acute / chronic (commonest) Traumatic injury to the abdomen Are to be distinguished from sterile pancreatic abscesses, -liquefactive necrosis of severely damaged pancreatic parenchyma. Both entities lack a true epithelial lining, unlike congenital cysts.. Clinical Features: Abdominal pain Hemorrhage Infection Generalized peritonitis Are usually unilocular distinguishing them from neoplastic cysts, which tend to be multiloculated Tumors - Neoplastic Cysts Comprise 5% of all pancreatic neoplasms Mucinous cystadenoma of Pancreas Are usually located in the body or tail Present as painless, slow-growing masses. Mucinous cystic tumors: Multiloculated, cystic neoplasms filled with mucinous secretions resembling their histologic counterpart in the ovary Mucinous cystadenoma: Benign Cystadenocarcinoma: Malignant Microcystic adenoma: A rare cystic tumor with serous secretions Is almost always benign. Papillary-cystic tumor: Solid-cystic predominantly in adolescent girls and women < 35 years of age. Is a large, rounded, well-circumscribed mass that has solid and cystic zones. Histologically: Tumor cells are small and uniform Have a finely granular eosinophilic cytoplasm Grow in solid sheets or papillary projections Cause abdominal discomfort and pain Treatment: Resection. Carcinoma of the Pancreas Most frequent causes of death from cancer in the US Lung Colon Breast Prostate Pancreas Arising in the exocrine portion of the gland. Almost all are adenocarcinoms arising in the ductal epithelium Causation unknown Strong association with smoking Inconsistent risk factors: Chronic alcohol intake High energy diets rich in fat May arise anywhere in the pancreas: Head of pancreas - 60% Body of pancreas - 15 to 20% Tail of pancreas - 5% Cancer of the head of the pancreas can impinge on : Ampulla of Vater Common bile duct Duodenum Can cause obstructive biliary symptoms relatively early in their life history May be discovered before widespread metastasis has occurred Cancers of the body and tail may grow silently until such time as extension to adjacent structures and metastatic dissemination preclude surgical intervention Histologic appearance: Poorly differentiated adenocarcinoma forming abortive tubular structures or cell clusters Exhibit an aggressive, deeply infiltrative growth pattern Dense stromal fibrosis accompanies tumor invasion Proclivity for perineural invasion within and beyond the organ Well to moderately differentiated tumors are the exception. Normal Acinar Structure (Right) Adenocarcinoma (Left) Low power microscope Clinical Features Are insidious lesions Present for months and possibly years before they produce symptoms referable to their expansive growth. Major symptoms include : Weight loss Abdominal pain Back pain Anorexia Nausea / vomiting Generalized malaise Weakness Jaundice (in 90% of patients with carcinomas of the head) Migratory thrombophlebitis, known as Trousseaus syndrome Occurs in 10% of patients Attributed to the elaboration of platelet-aggregating factors and procoagulants from the tumor or its necrotic products Laboratory Diagnosis: Elevated levels of CEA and CA 19-9 antigen Treatment: Surgical Whipples procedure Prognosis: Poor One-year survival < 20% 5-year survival 3% The Endocrine Pancreas The endocrine pancreas consists of about 1 million microscopic cellular unitsthe islets of Langerhans Consist of four major and two minor cell types. The four main types are B (beta) -produce insulin (maximum in number 70%) A (alpha) Account for 20% of all the islet cells Secrete glucagon Glucagon induces hyperglycemia by its glycogenolytic activity in the liver D cells (delta) 5-10% contain somatostatin, which suppresses both insulin and glucagon release PP (pancreatic polypeptide) cells - 1 to 2%, respectively, of the islet cell population. contain a unique pancreatic polypeptide that exerts a number of gastrointestinal effects, such as stimulation of secretion of gastric and intestinal enzymes and inhibition of intestinal motility The two rare cell types are D1 cells elaborate vasoactive intestinal polypeptide (VIP), a hormone that induces glycogenolysis and hyperglycemia and also stimulates gastrointestinal fluid secretion and causes secretory diarrhea Enterochromaffin cells. synthesize serotonin and are the source of pancreatic tumors that induce the carcinoid syndrome. Diabetes Mellitus It is a chronic disorder of carbohydrate, fat and protein metabolism Characteristic feature: A defective or deficient insulin secretory response resulting in impaired carbohydrate use and hyperglycemia Diabetes mellitus represents a heterogenous group of disorders that have hyperglycemia as a common feature Can be Primary Secondary Classification of Diabetes Insulin-dependent diabetes mellitus (IDDM), also called type I diabetes /Juvenile-onset and Ketosis-prone diabetes. Accounts for about 10 to 20% of all cases Non-insulin dependent diabetes mellitus (NIDDM), also called type II diabetes / adult-onset diabetes Accounts for 80 to 90% of cases A third rare form, known as maturity-onset diabetes of the young (MODY). MODY is manifested by mild hyperglycemia Transmitted as an autosomal dominant trait. Accounts for < 5% of the cases The two major types of diabetes have different pathogenetic mechanisms and metabolic characteristics However, the chronic, long-term complications in blood vessels, kidneys, eyes, and nerves occur in both types Complications are the major cause of morbidity / death in diabetes  Table: exam: IDDM (type I) Islet cell antibodies HLA-D linked Severe insulin deficiency NIDDM (type II) Insulin resistance Mild-beta-cell depletion Morphology of Diabetes and its Late Complications Morphologic changes in diabetes are responsible for many late systemic complications There is extreme variability among patients in : Time of onset Severity of these complications Particular organ or organs involved Regardless of the type of diabetes, when the disease has been present for 10 to 15 years, morphologic changes are likely to be found in : Basement membranes of small vessels (microangiopathy) Arteries (atherosclerosis) Kidneys (diabetic nephropathy) Retina (retinopathy) Nerves (neuropathy) Morphology of Pancreas - Islet Changes Lesions in the pancreas are neither constant nor necessarily pathognomonic More likely to be distinctive in type I than in type II One or more of the following alterations may be present: Reduction in the size and number of islets Leukocytic infiltration of the islets Insulitis: Is a heavy lymphocytic infiltrate within and about the islets Eosinophilic infiltrates may also be found Beta-cell degranulation Amyloid replacement of islets Increase in the size and number of islets Diabetic Microangiopathy One of the most consistent morphologic features of diabetes is diffuse thickening of basement membranes. It is most evident in the capillaries of the skin, skeletal muscles, retina, renal glomeruli, and renal medulla, giving rise to the characteristic diabetic microangiopathy of these organs. Microangiopathy is clearly related to the hyperglycemia. Hyaline arteriolosclerosis is both more prevalent and more severe in diabetics than in nondiabetics. Atherosclerosis Increased rate of atherosclerosis Arterial narrowings or occlusions and attendant ischemic injury to organs May induce aneurysmal dilatation, seen most often in the aorta, with the grave potential of rupture. Myocardial infarction, cerebral stroke, and gangrene of the lower extremities in these patients. Diabetic nephropathy Renal artery atherosclerosis Arteriolosclerosis Glomerulosclerosis Diffuse Nodular- Kimmelstiel- Wilson disease Nodular Glomerulosclerosis Diabetic Ocular Complications Development of visual impairment consequent to Retinopathy Cataract formation Glaucoma In the development of diabetic retinopathy, the duration of disease appears to be a very important determinant. Diabetic Retinopathy Retinopathy takes two forms: Nonproliferative, or background, retinopathy Proliferative retinopathy. Nonproliferative, or background, retinopathy includes: Intraretinal or preretinal hemorrhages Retinal exudates Thickening of the retinal capillaries (microangiopathy) Development of microaneurysms. Proliferative retinopathy is associated with neovascularization and fibrosis. Neovascularization at periphery Small hemorrhages Diabetic Neuropathy Peripheral nerves, brain, and spinal cord all may be damaged in long-standing diabetes. Most commonly encountered is symmetric peripheral neuropathy affecting both motor and sensory nerves of the lower extremities. It is characterized by Schwann cell injury, myelin degeneration, and also axonal damage. The peripheral neuropathy is sometimes accompanied by disturbances in the neural innervation of the pelvic organs (autonomic neuropathy), leading to Sexual impotence Bowel and bladder dysfunction. Islet Cell Tumors Are rare in comparison with tumors of the exocrine pancreas Are most common in adults Can occur anywhere along the length of the pancreas May be hormonally functional / nonfunctional May be single / multiple When multiple, each tumor may be composed of a different cell type Benign / malignant Metastasize to lymph nodes and liver Three most common and distinctive clinical syndromes associated with hyperfunction of the islets of Langerhans are: Hyperinsulinism (Insulinoma) Zollinger-Ellison syndrome (gastrinoma) Multiple endocrine neoplasia. Each of these may be caused by : Diffuse hyperplasia of the islets of Langerhans Benign adenomas that occur singly or multiply Malignant islet tumors Beta-Cell Tumors (Insulinoma) Are the most common of islet cell tumors Elaboration of insulin to induce clinically significant hypoglycemia Characteristic clinical triad resulting from these pancreatic lesions: Attacks of hypoglycemia Attacks consist of central nervous system manifestations as Confusion Stupor Loss of consciousness Related to fasting or exercise Promptly relieved by the feeding or parenteral administration of glucose. Laboratory findings : High circulating levels of insulin and a high insulin-to-glucose ratio. Surgical removal of the tumor is usually followed by prompt reversal of the hypoglycemia. A variety of functional and organic disorders, in addition to the beta-cell lesions, cause hypoglycemia: These include : Early diabetes mellitus Partial gastrectomy Starvation Diffuse liver disease Glycogenoses Hypofunction of the anterior pituitary and adrenal cortex Variety of extrapancreatic neoplasms Idiopathic hypoglycemia. Morphology Of all insulinomas: ~70% are solitary adenomas ~10% are multiple adenomas ~10% are metastasizing tumors that must be interpreted as carcinomas remainder are a mixed group of diffuse hyperplasia of the islets and adenomas occurring in ectopic pancreatic tissue. Insulinomas vary in size from minute lesions that are difficult to find even on the dissecting table to huge masses of over 1500 gm Grossly: Are usually encapsulated, firm, yellow-brown nodules, Histologically: Composed of cords and nests of well-differentiated beta cells that do not differ from those of the normal islet On electron microscopy: Tumor cells exhibit beta-cell granules Immunohistochemistry: insulin can be visualized in tumor cells. Five per cent of insulinomas are malignant. Zollinger-Ellison Syndrome (Gastrinoma) Syndrome classically composed of the triad of Recalcitrant peptic ulcer disease Gastric hypersecretion Pancreatic islet cell tumor Fundamental to peptic ulcerations is gastric hypersecretion, induced by gastrin, so the tumor is also known as a gastrinoma. Although most common in the pancreas, 10 to 15% of gastrinomas occur in the duodenum. Serum gastrin levels are elevated ~ 60% of gastrinomas are malignant, and 40% are benign. Only spread to lymph nodes or metastasis marks the tumors as malignant Problems in clinical management: Gastric hypersecretion produces intractable ulcers Diarrhea often extreme - causes serious problems in fluid and electrolyte control - development of malabsorption syndromes Pancreatic lesions may be very small or multiple - difficult to discover at surgical exploration Therefore recurrent symptoms following removal of any apparent solitary lesion with later discovery of additional lesions within the pancreas DISEASES OF THE RENAL SYSTEM Overview of Renal Diseases Subdivided into Congenital diseases Renal Cystic Diseases Glomerular diseases- most commonly immunologic Tubular diseases Interstitial diseases- usually combined with tubular as tubulointerstitial-usually due to drug toxicity or infections Vascular diseases- most commonly related to hypertension or diabetes Obstructive uropathy Tumors of the kidney Congenital Anomalies Agenesis Hypoplasia Kidney fails to develop to its normal size Ectopic Kidneys Developmentally at an abnormal position Just above the pelvic brim / within the pelvis Horseshoe Kidney Cystic Diseases of the Kidney Agenesis of the Kidney Total bilateral agenesis: Is incompatible with life Is usually encountered in stillborn infants Often associated with many other congenital disorders (limb defects, hypoplastic lungs) Unilateral agenesis: Is compatible with normal life, if no other abnormalities exist. Opposite kidney undergoes compensatory hypertrophy Horseshoe Kidney Two kidneys fused at the poles Lower poles in 90% (pelvic kidney) Upper poles in 10% Usually located at the level of the lower lumbar vertebrae Ascent is stopped by the root of the inferior mesenteric artery Associated abnormalities of the ureters: In their course Abnormal openings into the bladder or urethra Infections and stone formation are common Seen in Turners syndrome Cystic Diseases of the Kidneys Cystic renal dysplasia Polycystic kidney disease Autosomal dominant (adult) polycystic disease Autosomal recessive (childhood) polycystic disease Medullary cystic disease Medullary sponge kidney Nephronophthisisuremic medullary cystic disease (UMCD) complex Acquired (dialysis-associated) cystic disease Localized (simple) renal cysts Renal cysts in hereditary malformation syndromes (e.g., tuberous sclerosis) Glomerulocystic disease Extraparenchymal renal cysts (pyelocalyceal cysts, hilar lymphangitic cysts) Renal Cystic Disease in Children Oligohydramnios is a clinical feature Due to urinary obstruction and absence of fetal urine Leads to decrease in the amount of amniotic fluid Most syndromes are autosomal recessive Cystic renal disease is the MOST COMMON cause of a palpable abdominal mass in a newborn Usually infantile polycystic disease or renal dysplas Potters Facies Low set ears Parrot beak-like nose Receding chin. Associated with: Renal agenesis Bilateral renal dysplasia Infantile polycystic kidney Renal Dysplasia MOST COMMON cystic disease in children-associated with Potters syndrome Disturbed differentiation-failure of differentiation of metanephric tissue Whole kidney or just one segment Unilateral or bilateral-incompatible with life in severe form Solid or cystic masses with predominant cartilage Oligohydramnios and abnormalities of urinary tract, lungs, and CNS Disorganized architecture Dilated tubules Islands of immature cartilage Autosomal Recessive Polycystic Kidney Disease (Infantile Polycystic Kidney Disease) Autosomal recessive Massive enlargement of the kidneys at birth Common cause of a palpable abdominal mass in a newborn-may impede delivery The kidneys are thought to develop normally during most of the fetal period but some unidentified stimulus causes dilatation of the collecting ducts Bilateral; also cysts of liver, proliferation of bile-ducts and congenital hepatic fibrosis Potters facies Death in infancy or childhood Autosomal Recessive Polycystic Kidney Disease Hypoplastic lungs Note the massive enlargement Small but evenly distributed Enlarged kidneys of both kidneys in this infant cysts in the renal parenchyma Cysts fill most of the parenchyma Hard to find glomeruli Many of the cysts are elongated and radially arranged from the center of the kidney (on the right) like spokes on a wagon wheel Autosomal Dominant Polycystic Kidney Disease (Adult Polycystic Kidney Disease) MOST COMMON INHERITED RENAL DISEASE Autosomal dominant; bilateral Aberrant gene on chromosome 16 Bilateral-kidneys greatly enlarged Cysts not manifest at birth Usually presents in 4th decade with hypertension and hematuria-renal failure within a decade Berry aneurysms may present with subarachnoid hemorrhage (10-15%) Cysts in liver (30%) Approximately 30% of patients die of renal failure; Another 30% die of complications relating to hypertension Medullary Cystic Disease Two major types of medullary cystic disease: Medullary sponge kidney - a relatively common and usually innocuous structural change Nephronophthisis - uremic medullary cystic disease complex, almost always associated with renal dysfunction. Medullary Sponge Kidney Lesions consist of multiple cystic dilatations of the collecting ducts in the medulla. Occurs in adults Is usually discovered radiographically incidentally or sometimes in relation to secondary complications. Calcifications within the dilated ducts Hematuria Infection Urinary calculi Renal function is usually normal NephronophthisisUremic Medullary Cystic Disease (UMCD) Complex Onset in childhood Presence of a variable number of cysts in the medulla associated with significant cortical tubular atrophy and interstitial fibrosis - is the cause of the eventual renal insufficiency Accounts for about 20% of cases of chronic renal failure in children and adolescents. Affected children present first with polyuria and polydipsia Reflect a marked tubular defect in concentrating ability Sodium wasting and tubular acidosis Consistent with initial injury to the distal tubules and collecting ducts Progresses to terminal renal failure in 5 to 10 years High index of suspicion in children or adolescents with otherwise unexplained chronic renal failure, a positive family history, and chronic tubulointerstitial nephritis on biopsy. Cysts at cortico-medullary junction Simple Retention Cysts MOST COMMON FORM OF RENAL CYSTIC DISEASES (not inherited) 50% incidence in patients > 50 Usually cysts are large and solitary May be confused with renal cell carcinoma Note the smooth lining to this large retention cyst Acquired Cysts (Dialysis-associated) Disease Seen in kidneys of patients who are treated by dialysis or transplantation Associated with renal cell carcinoma   Table: exam: proteinuria (<3.5 g/day) Severe proteinuria (>3.5 g/day) Generalized edema Hyperlipidemia lipiduria Glomerular Diseases Nephritic Syndrome Post-Streptococcal Glomerulonephritis Goodpastures Syndrome Rapidly Progressing Glomerulonephritis (RPGN) IgA Nephropathy (Buergers Disease) Membrano-proliferative Glomerulonephritis (MPGN) Nephrotic Syndrome Membranous Glomerulonephritis Minimal Change Disease Focal Segmental Glomerulosclerosis GLOMERULAR DISEASES RENAL BIOPSY Light microscopy Immuno-fluorescence Electron-microscopy PRIMARY GLOMERULOPATHIES Acute Post-Streptococcal Glomerulonephritis Also called as acute proliferative / Post infectious glomerulonephritis Children 2-4 weeks after a Streptococcus infection Smoky urine Organism: - hemolytic group A streptococcus Can be associated with other bacteria, viruses and systemic infections Nephritic syndrome Normal colored urine Urine with frank blood Smoky urine typical of Nephritic Syndrome Laboratory Findings: Elevated ASO titers evidence of streptococcal infection Low complement (immune complexes are being formed, activating complement and lowering its levels) Light Microscopy: Not very specific Hypercellular glomeruli Red cell casts ImmunoFluorescence: IMPORTANT Granular deposits within the glomeruli Highlighted by IgG or IgM antibodies Electron Microscopy: Immune complexes Occur in subepithelial locations in 2 sizes (small and large) Large deposits called as subepithelial humps. Subepithelial hump Glomerular hypercellularity Red cell casts in tubules Acute Post-Streptococcal Glomerulonephritis Treatment: Conservative Most children do well 95% recover completely 1% develop aggressive RPGN or chronic glomerulonephritis Prognosis: Children - excellent Adults- worse GOODPASTURES SYNDROME Also known as anti-GBM disease Pathogenesis : Autoantibodies against type IV collagen of basement membrane Damage to the lungs + kidneys Clinical features : Males 20-40 years of age Hemoptysis presents earlier ! renal manifestations Light Microscopic: Non specific Some crescents ElectronMicroscopy: Non specific - GBM disruption ImmunoFluorescence: IMPORTANT Neon sign (smooth and linear) Stain positive for IgG and C3 complement component Linear pattern of immune-complex deposition seen by immunofluorescence microscopy Treatment : Plasma exchange Steroids Prognosis : Poor Death from pulmonary hemorrhage / RPGN RAPIDLY PROGRESSING GLOMERULONEPHRITIS Clinical Features: Also known as Crescentic Glomerulonephritis Rapid progression ! renal failure Span of weeks to months Several settings that will arise into this glomerulonephritis Following Goodpasture s Syndrome Vasculitis (eg Wegener s ) Idiopathic (50%) Light Microscopic: Crescent formation in glomeruli Composed of ! fibrin, proliferation of parietal epithelial cells and an influx of Monocytes/ macrophages Prognosis: Poor IgA NEPHROPATHY (Berger s disease) Clinical Most common glomerulonephritis in the world France, Japan, Italy Male, young adults Gross hematuria Associated with respiratory infection and other IgA diseases like celiac sprue, Henoch-Schnlein purpura Light Microscopy Mesangial proliferation ImmunoFluorescence: IMPORTANT Mesangial deposition of IgA ElectronMicroscopy: Immune complexes Prognosis Slowly progress ! renal failure MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS Types of MPGN: Type I Type II (dense deposit disease) Clinical features: Nephrotic +/or nephritic Lab findings: Type II produce an antibody called C3 nephritic factor is produced Light Microscopy: Lobulated glomeruli Mesangial proliferation Tram-tracking (splitting of basement membrane due to mesangial proliferation) ImmunoFluorescence: Granular pattern (not specific) ElectronMicroscopy: Type I- subendothelial immune complexes Type II- deposits within GBM Prognosis: Slowly progressive course renal failure in 10-15 years Top- Lobulated glomeruli ,Mesangial proliferation Bottom- Silver stain demonstrates "tram-tracking - double contour to many basement membranes that results from basement membrane reduplication Middle- Bright deposits scattered along capillary walls and in the mesangium with antibody to C3 are typical for membranoproliferative glomerulonephritis, type II (Dense deposit disease). Most patients have detectable circulating C3 nephritic factor, an IgG autoantibody Glomerular Diseases Nephrotic Syndrome Membranous Glomerulonephritis Minimal Change Disease Focal Segmental Glomerulosclerosis Membranous Glomerulonephritis Most common cause of adult nephrotic syndrome Etiology Idiopathic Drugs Hepatitis SLE Diabetes Genetic predisposition Light Microscopy: Diffuse thickening of capillary walls Spiking of basement membrane (on silver stain) ImmunoFluorescence: Granular and linear pattern ElectronMicroscopy: Subepithelial deposits Prognosis: Variable spontaneous remission / persistence Diffuse thickening of of proteinuria / end stage renal disease glomerular capillary walls Electron Dense Sub-epithelial Deposits in Glomerular Basement Membrane Diagrammatic Representation showing deposits and spike formation MINIMAL CHANGE DISEASE Clinical features: Also known as Lipoid Nephrosis or Nils Disease Most common cause in children 2-6 years old Diagnosis of exclusion Light Microscopy+ImmunoFluorescence: Normal ElectronMicroscopy: No immune complexes Effacement of foot processes Treatment: Steroids Prognosis: Excellent Thin Basement Membrane Absence of proliferation FOCAL SEGMENTAL GLOMERULOSCLEROSIS Clinical: African American- all ages Nephrotic Etiology: Idiopathic Sickle cell anemia Heroin abuse AIDS Light Microscopy: IMPORTANT Segmental sclerosis Glomerular hyalinization ImmunoFluorescence +ElectronMicroscopy: Nonspecific Treatment: Poor response to steroids Recur in renal transplants Prognosis: Children better than adults ! chronic renal failure Low Power view showing segmental sclerosis in one out of three glomeruli High-power view showing hyalime mass and lipid in sclerotic areas SECONDARY DISEASES OF THE KIDNEY Diabetes Mellitus Kimmelstein- Wilson disease Nephrotic Amyloidosis Nephrotic syndrome Congo red stain CHRONIC GLOMERULONEPHRITIS Definition End stage renal disease Uremia Clinical Anemia HTN Azotemia Gross Small kidneys Micro Hyalinization of glomeruli Treatment Dialysis Transplant Diseases Affecting Tubules and Interstitium Diseases characterized by Ischemic or toxic tubular injury, leading to acute tubular necrosis and acute renal failure Inflammatory involvement of the tubules and interstitium (tubulointerstitial nephritis) Acute Tubular Necrosis Is a clinicopathologic entity characterized: Morphologically by destruction of tubular epithelial cells Clinically by acute suppression of renal function Is a reversible renal lesion that arises in a variety of clinical settings It is the most common cause of acute renal failure (ARF) Acute suppression of renal function and urine flow (<400ml/24 hours) Acute Renal Failure ARF can be caused by the following conditions: Organic vascular obstruction Polyarteritis nodosa Malignant hypertension Hemolytic-uremic syndrome Severe glomerular disease - rapidly progressive glomerulonephritis Acute tubulointerstitial nephritis - hypersensitivity to drugs Pyelonephritis - especially when accompanied by papillary necrosis Disseminated intravascular renal coagulation Urinary obstruction Tumors Prostatic hypertrophy Blood clots (so-called postrenal ARF) Acute tubular necrosis (ATN) Acute Tubular Necrosis Types of ATN Ischemic ATN Nephrotoxic ATN The critical event in both ischemic and nephrotoxic ATN is tubular damage Patterns of Tubular Damage Ischemic type: Patchy involvement of tubules specially PCT and HL (ascending part) Toxic type: Extensive necrosis of PCT + some HL Lumina of DCT and CD contain casts in both Acute Tubular Necrosis Ischemic ATN is characterized by Focal tubular necrosis at multiple points along the nephron Large skip areas in between Rupture of basement membranes (tubulorrhexis) Occlusion of tubular lumina by casts Especially vulnerable Straight portion of the proximal tubule Ascending thick limb in the renal medulla Common casts found are: Eosinophilic hyaline casts Pigmented granular casts These casts consist principally of Tamm-Horsfall protein + hemoglobin, myoglobin, and other plasma protein Tamm-Horsfall protein: A specific urinary glycoprotein normally secreted by the cells of ascending thick limb and distal tubules Toxic ATN is characterized by Acute tubular injury most obvious in the proximal convoluted tubules Histologically the tubular necrosis may be: Nonspecific Distinctive in poisoning with certain agents Mercuric chloride severely injured cells contain large acidophilic inclusions. Carbon tetrachloride poisoning - accumulation of neutral lipids in injured cells followed by necrosis. Ethylene glycol - marked ballooning and hydropic or vacuolar degeneration of proximal convoluted tubules Clinical Course Divided into initiating, maintenance, and recovery stages: Initiating phase: Lasting for about 36 hours Dominated by the inciting medical, surgical, or obstetric event in the ischemic form of ATN Indication of renal involvement: Slight decline in urine output+rise in BUN Maintenance phase: Sustained decreases in urine output to 40 - 400 ml / day (oliguria) Salt and water overload Rising blood urea nitrogens, hyperkalemia, metabolic acidosis, and other manifestations of uremia dominating this phase. Treatment: Maintenance of water and blood electrolytes Dialysis Recovery phase: A steady increase in urine volume that may reach up to 3 liters per day The tubules are still damaged, so that large amounts of water, sodium, and potassium are lost in the urinary flood. Hypokalemia, rather than hyperkalemia, becomes a clinical problem Prognosis: Depends on the clinical setting surrounding its development Recovery is expected with nephrotoxic ATN when the toxin has not caused serious damage to other organs, such as the liver or heart. Conversely, in shock related to sepsis or extensive burns, the mortality rate may rise to over 50%. Nonoliguric ATN: Up to 50% of patients with ATN may not have oliguria, and may in fact have increased urine volumes. Occurs particularly often with nephrotoxins Generally tends to follow a more benign clinical course. Tubulointerstitial Nephritis Group of renal diseases characterized by histologic and functional alterations that involve predominantly the tubules and interstitium Have diverse causes and different pathogenetic mechanisms Tubulointerstitial nephritis (TIN) can be acute or chronic Acute TIN: An acute clinical onset Characterized histologically by Interstitial edema Leukocytic infiltration Focal tubular necrosis Chronic interstitial nephritis (CIN): Infiltration with mononuclear cells Prominent interstitial fibrosis Widespread tubular atrophy  Clinically distinguished from glomerular diseases by: Early stages: Absence of nephritic or nephrotic syndromes Presence of defects in tubular function Impaired ability to concentrate urine - polyuria or nocturia Salt wasting MM.Diminished ability to excrete acids (metabolic acidosis) Advanced stages: Difficult to distinguish clinically from other causes of renal insufficiency Tubulointerstitial Nephritis - Pyelonephritis (PN) and UTI Pyelonephritis: Renal disorder affecting tubules, interstitium and renal pelvis Is one of the most common diseases of the kidney Occurs in two forms: Acute PN Caused by bacterial infection Renal lesion associated with urinary tract infection Chronic PN is a more complex disorder: Bacterial infection plays a dominant role Other factors (vesicoureteral reflux, obstruction) are also involved Urinary tract infection (UTI): Implies involvement of either Bladder (cystitis) or Kidneys and their collecting systems (pyelonephritis), or Both UTIs are extremely common disorders. Ascending Infection: 85% of cases of UTI are: Gram-negative bacilli that are normal inhabitants of the intestinal tract Most common is Escherichia coli, followed by Proteus, Klebsiella, and Enterobacter Hematogenous Infection: Occurs In presence of ureteral obstruction In debilitated patients Immunosuppressive therapy With non-enteric organisms: Staphylococci and certain fungi. Vesico-Ureteric Reflux (A) Intra vesical portion of the ureter is oblique closes during micturition (B) VUR occurs due to complete or partial absence of intra-vesical ureter Acute Pyelonephritis Is an acute suppurative inflammation of the kidney caused by bacterial infectionwhether Hematogenous/induced by septicemic spread Ascending and associated with VUR Hallmarks of acute PN are Patchy interstitial suppurative inflammation. May occur as: Discrete focal abscesses involving one or both kidneys Large, wedge-shaped areas of coalescent suppuration Tubular necrosis Characteristically, glomeruli are resistant to infection Destruction of glomeruli takes place: With large areas of severe necrosis Fungal PN (e.g., Candida) Complications Papillary necrosis: Seen in diabetics + in those with urinary tract obstruction Is usually bilateral One or all of the pyramids of the affected kidney involved On cut section, the tips or distal two-thirds of the pyramids have gray-white to yellow necrosis that resembles infarction Pyonephrosis Is seen when there is total or almost complete obstruction, particularly when it is high in the urinary tract. Suppurative exudate is unable to drain > fills the renal pelvis, calyces, and ureter > pyonephrosis Perinephric abscess Extension of suppurative inflammation through the renal capsule into the perinephric tissue. Papillary necrosis Predisposing Conditions For Acute Pyelonephritis Urinary obstruction, either congenital or acquired. Instrumentation of the urinary tract, most commonly catheterization. Vesicoureteric reflux. Pregnancy Patients sex and age. Upto 1st year Males> Females (Congenital anomalies more evident) Upto around 40 years, infections are much more frequent in females With increasing age, males > females due to the development of prostatic hypertrophy and frequent instrumentation. Pre-existing renal lesions, causing intrarenal scarring and obstruction. Diabetes mellitus, in which acute PN is caused by More frequent instrumentation General susceptibility to infection Neurogenic bladder dysfunction Immunosuppression and immunodeficiency. Clinical Features Sudden onset pain at the costovertebral angle Evidence of systemic infection, such as fever and malaise. Indications of bladder/urethral irritation - dysuria, frequency, and urgency. Urine contains many leukocytes (pyuria) derived from the inflammatory infiltrate, but pyuria does not differentiate upper from lower UTI. Finding of leukocyte casts (pus casts) indicates renal involvement, because casts are formed only in tubules. Diagnosis of infection: Urine culture. Clinical Course Uncomplicated acute PN usually follows a benign course, and the symptoms disappear within a few days after the institution of appropriate antibiotic therapy. In the presence of unrelieved urinary obstruction, diabetes mellitus, and immunocompromise, acute PN may be more serious, leading to repeated septicemic episodes. Superimposition of papillary necrosis often leads to acute renal failure. Chronic Pyelonephritis (CPN) and Reflux Nephropathy CPN is a chronic tubulointerstitial renal disorder in which chronic tubulointerstitial inflammation and renal scarring are associated with pathologic involvement of the calyces and pelvis Pelvocalyceal damage is important in that many diseases produce chronic tubulointerstitial alterations, but except for CPN and analgesic nephropathy, none affects the calyces CPN is an important cause of end-stage kidney disease CPN can be divided into two forms: Chronic obstructive Chronic reflux-associated. Chronic Obstructive PN Obstruction predisposes kidney to infection. Recurrent infections > recurrent bouts of renal inflammation and scarring> CPN Disease can be Bilateral: as with obstructive anomalies of the urinary tract (e.g., posterior urethral valves) Unilateral: such as occurs with calculi and unilateral obstructive anomalies of the ureter Reflux Nephropathy Is the more common form of chronic pyelonephritic scarring. Occurs early in childhood, as a result of superimposition of a urinary infection on congenital VUR and intrarenal reflux Reflux may be unilateral or bilateral VUR occasionally causes renal damage in the absence of infection (sterile reflux), but only in the presence of severe obstruction. Morphology-Chronic Pyelonephritis Gross: Kidneys usually are irregularly scarred If bilateral, the involvement is asymmetric. This contrasts with chronic glomerulonephritis, in which the kidneys are diffusely and symmetrically scarred. The hallmark of CPN is the coarse, discrete, corticomedullary scar overlying a dilated, blunted, or deformed calyx Microscopic: Changes involve predominantly tubules and interstitium. Tubules show atrophy in some areas and hypertrophy in others, or dilatation. Dilated tubules may be filled with colloid casts - thyroidization Tubulointerstitial Nephritis (TIN) Induced by Drugs and Toxins Toxins and drugs produce renal injury in three ways: Trigger an interstitial immunologic reaction Eg, acute hypersensitivity nephritis induced by methicillin Cause ARF Cause subtle but cumulative injury to tubules that takes years to become manifest, resulting in chronic renal insufficiency Eg., analgesic abuse nephropathy, detected only after onset of chronic renal insufficiency Acute Drug-Induced Interstitial Nephritis This is a well-recognized adverse drug reaction Most frequently occurs with Synthetic penicillins (methicillin, ampicillin) Other synthetic antibiotics (rifampin) Diuretics (thiazides) Nonsteroidal anti-inflammatory agents (phenylbutazone) Miscellaneous drugs (phenindione, cimetidine) Disease begins about 15 days after exposure to the drug Characterized by Fever Eosinophilia Skin rash in about 25% of patients Renal abnormalities Hematuria Mild proteinuria Leukocyturia (including eosinophils). A rising serum creatinine level or ARF with oliguria develops in about 50% of cases, particularly in older patients. Analgesic Abuse Nephropathy Is a form of chronic renal disease Caused by excessive intake of analgesic mixtures Characterized morphologically by chronic tubulointerstitial nephritis with renal papillary necrosis The renal damage was first ascribed to phenacetin Analgesic mixtures consumed often contain, in addition, aspirin, caffeine, acetaminophen (a metabolite of phenacetin), and codeine Patients who develop this disease usually ingest large quantities of analgesic mixtures (more than 2 kg of aspirin or phenacetin over 3 years) Grossly: Kidneys are either normal or slightly reduced in size Cortex exhibits depressed and raised areas, the depressed areas representing cortical atrophy overlying necrotic papillae. The papillae show various stages of necrosis, calcification, fragmentation, and sloughing. This gross appearance contrasts with the papillary necrosis seen in diabetic patients, in which all papillae are at the same stage of acute necrosis. Microscopically: Papillary changes may take one of several forms: In early cases: Patchy necrosis In the advanced form: Entire papilla is necrotic Cortical changes consist of loss and atrophy of these tubules, and interstitial fibrosis and inflammation. The small vessels in the papilla and submucosa of the urinary tract exhibit characteristic PAS-positive basement membrane thickening (analgesic microangiopathy). Clinical Course Women > men Particularly prevalent in individuals with recurrent headaches and muscular pain, in psychoneurotic patients, and in factory workers. Early renal findings include inability to concentrate the urine, as would be expected with lesions in the papilla. Acquired distal renal tubular acidosis contributes to the development of renal stones. Headache, anemia, gastrointestinal symptoms, and hypertension are common accompaniments of analgesic nephropathy. The anemia in particular is out of proportion to the renal insufficiency, owing to damage to red cells by the phenacetin metabolites. Urinary tract infection complicates about 50% of patients. Occasionally, entire tips of necrotic papillae are excreted, and these may cause gross hematuria or renal colic due to obstruction of the ureter by necrotic fragments. Progressive impairment of renal function may lead to chronic renal failure, but with drug withdrawal and proper therapy for infection renal function may either stabilize or actually improve. Rarely can develop transitional papillary carcinoma of the renal pelvis Diseases of Blood Vessels Benign Nephrosclerosis Malignant Phase of Hypertension (Malignant Nephrosclerosis) Renal Artery Stenosis Thrombotic Microangiopathies Benign Nephrosclerosis It is the term used for the kidney associated with sclerosis of renal arterioles and arteries Resultant effect: Focal ischemia of the renal parenchyma supplied by the thickened narrowed arteriole Pathogenesis: Two processes induce the arterial changes - Medial and intimal thickening of the arterioles Hyaline deposition in arterioles Grossly: Kidneys are either normal/moderately reduced in size Cortical surfaces have a fine, even granularity that resembles grain leather On section, the loss of mass is due mainly to cortical narrowing. Histologically: Narrowing of the lumina of arterioles and small arteries, caused by thickening and hyalinization of the walls Larger interlobular and arcuate arteries exhibit a characteristic lesion called Fibroelastic hyperplasia Consists of reduplication of the elastic lamina + increased fibrous tissue in the media, with resultant luminal narrowing. Consequent to the hyaline vascular narrowing, there is patchy ischemic atrophy, which consists of : Foci of tubular atrophy and interstitial fibrosis A variety of glomerular alterations Collapse of glomerular basement membranes Deposition of collagen within Bowmans space Periglomerular fibrosis Total sclerosis of glomeruli. Uncomplicated benign nephrosclerosis alone Rarely causes renal insufficiency or uremia Only moderate reductions in renal plasma flow Normal or slightly reduced GFR Mild proteinuria occasionally Renal failure may supervene in 5% of patients with prolonged benign hypertension In most patients however results from the development of the malignant or accelerated phase of hypertension Malignant nephrosclerosis It is the form of renal disease associated with the malignant or accelerated phase of hypertension Occasionally develops in previously normotensive individuals Often is superimposed on: Pre-existing essential benign hypertension Secondary forms of hypertension Underlying chronic renal disease Glomerulonephritis Reflux nephropathy Is uncommon, occurring in 1-5% of all patients with elevated blood pressure Usually affects younger individuals Males > Females Commoner in blacks Morphology Grossly: Kidney size is dependent on the duration and severity of the hypertensive disease. flea-bitten appearance - Small, pinpoint petechial hemorrhages on the cortical surface from rupture of arterioles or glomerular capillaries Histologically: Two characteristic alterations of blood vessels Fibrinoid necrosis of arterioles. Hyperplastic arteriolitis, also referred to as onionskinning Intimal thickening caused by proliferation of elongated, concentrically arranged cells, smooth muscle cells plus with fine concentric layering of collagen specially in the interlobular arteries and arterioles Sometimes the glomeruli become necrotic and infiltrated with neutrophils, and the glomerular capillaries may thrombose (necrotizing glomerulitis). The arteriolar and arterial lesions result in considerable narrowing of all vascular lumina, with ischemic atrophy and infarction distal to the abnormal vessels. Clinical Course The full-blown syndrome of malignant hypertension is characterized by Diastolic pressures > 130 mm Hg Papilledema retinopathy Encephalopathy Cardiovascular abnormalities Renal failure. Hypertensive crises are sometimes encountered, characterized by episodes of loss of consciousness or even convulsions. At the onset of rapidly mounting blood pressure Marked proteinuria Microscopic / macroscopic hematuria But no significant alteration in renal function Soon, however, renal failure makes its appearance. Treatment: The syndrome is a true medical emergency Aggressive and prompt antihypertensive therapy before the development of irreversible renal lesions Prognosis: Before introduction of the new antihypertensive drugs, malignant hypertension was associated with a 50% mortality rate within 3 months of onset, progressing to 90% within a year. At present, however, about 75% of patients will survive 5 years, and 50% survive with precrisis renal function. Renal Artery Stenosis Uncommon cause of hypertension( 2 to 5% of cases) BUT it is the most common curable form of hypertension Surgical treatment being successful in 70 to 80% of carefully selected cases The classic experiments of Goldblatt in 1934 showed that constriction of one renal artery in dogs results in hypertension The hypertensive effect is due to stimulation of renin secretion by cells of the juxtaglomerular apparatus > production of the vasoconstrictor angiotensin II. Other factors, however, play a role in the maintenance of renovascular hypertension including sodium retention and, possibly, inhibition of medullary vasodepressor substances. Morphology Males > Females Incidence increases with advancing age and DM Causes of renal artery stenosis: Occlusion by an atheromatous plaque at the origin of the renal artery (70% of cases) The plaque is usually concentrically placed, and superimposed thrombosis often occurs. Fibromuscular dysplasia of the renal artery Fibrous or fibromuscular thickening May involve the initima, the media (commonest), or the adventitia of the artery Lesions may: Consist of a single well-defined constriction, or Series of narrowings, usually in the middle or distal portion of the renal artery. Involve segmental branches Be bilateral. The ischemic kidney: Usually reduced in size Shows signs of diffuse ischemic atrophy Crowded glomeruli Atrophic tubules Interstitial fibrosis Focal inflammatory infiltrate. Ipsilateral kidney: Only mild arteriolosclerosis Ischemic kidney are usually protected from the effects of high pressure Contralateral nonischemic kidney: Hyaline arteriolosclerosis Depending on the severity of the preceding hypertension. Clinical Course In general these patients resemble those presenting with essential hypertension Occasionally, a bruit can be heard on auscultation of the kidneys. Diagnosis: Elevated plasma or renal-vein renin Response to ACE inhibitors (captopril) Renal scans Intravenous pyelography Arteriography is required to localize the stenotic lesion. Treatment: Surgical Prognosis: Cure rate after surgery in Fibromuscular dysplasias ~ 80% Atherosclerotic stenosis ~ 60 - 75% Urinary Tract Obstruction (Obstructive Uropathy) Recognition of urinary obstruction is important because of: Increased susceptibility to infection Increased susceptibility to stone formation Unrelieved obstruction almost always leads to permanent renal atrophy, termed hydronephrosis or obstructive uropathy Causes of Urinary Tract Obstruction Congenital anomalies Posterior urethral valves and urethral strictures Meatal stenosis Bladder neck obstruction Ureteropelvic junction narrowing or obstruction Severe vesicoureteral reflux Urinary calculi Benign prostatic hypertrophy Tumors Carcinoma of the prostate Bladder tumors Contiguous malignant disease (retroperitoneal lymphoma) Carcinoma of the cervix or uterus Inflammation Prostatitis Ureteritis Urethritis Retroperitoneal fibrosis Sloughed papillae or blood clots Normal pregnancy Uterine prolapse and cystocele Functional disorders: Neurogenic (spinal cord damage) Other functional abnormalities of the ureter or bladder (often termed dysfunctional obstruction) Hydronephrosis: Dilatation of the renal pelvis and calyces associated with progressive atrophy of the kidney due to obstruction to the outflow of urine Hydronephrosis of the Kidney Marked dilation of the pelvis and calyces Thinning of renal parenchyma Morphology When the obstruction is sudden and complete Reduction of glomerular filtration Usually leads to mild dilatation of the pelvis and calyces Sometimes to atrophy of the renal parenchyma When the obstruction is subtotal or intermittent, glomerular filtration is not suppressed, and progressive dilatation ensues Depending on the level of urinary block, the dilation may affect first the bladder or ureter and then the kidney. Grossly, the kidney may have slight-to-massive enlargement. Histologically, Cortical tubular atrophy with interstitial fibrosis. Progressive blunting of the apices of the pyramids occurs, and eventually these become cupped. In far-advanced cases, the kidney may become transformed into A thin-walled cystic structure having a diameter of up to 15 to 20 cm Striking parenchymal atrophy Total obliteration of the pyramids Thinning of the cortex. Clinical Course Acute obstruction May provoke pain attributed to distention of the collecting system or renal capsule. Most of the early symptoms are produced by the basic cause of the hydronephrosis. Thus, calculi lodged in the ureters may give rise to renal colic, and prostatic enlargements to bladder symptoms. Unilateral, complete, or partial hydronephrosis May remain silent for long periods of time, since the unaffected kidney can maintain adequate renal function. In bilateral partial obstruction Earliest manifestation is that of inability to concentrate the urine, reflected by polyuria and nocturia. Some patients will have acquired distal tubular acidosis, renal salt wasting, and secondary renal calculi, and a typical picture of tubulointerstitial nephritis with scarring and atrophy of the papilla and medulla. Hypertension is common in such patients. Complete bilateral obstruction Results in oliguria or anuria Is incompatible with long survival unless the obstruction is relieved. Urolithiasis (Renal Calculi, Stones) Stones may form at any level in the urinary tract, but most arise in the kidney Urolithiasis is a frequent clinical problem, affecting 5 to 10% of Americans in their lifetime Males are affected more often than females Peak age at onset is between 20 and 30 years. Familial and hereditary predisposition to stone formation has long been known Many of the inborn errors of metabolism, such as gout, cystinuria, and primary hyperoxaluria, provide good examples of hereditary disease characterized by excessive production and excretion of stone-forming substances. Cause and Pathogenesis There are four main types of calculi: Calcium oxalate, or mixed with calcium phosphate (75%) Triple stones or struvite stones, composed of magnesium ammonium phosphate (15%) Uric acid stones (6%) Cystine (1-2%) An organic matrix of mucoprotein, making up 1 to 5% of the stone by weight, is present in all calculi. Although there are many causes for the initiation and propagation of stones, the most important determinant is an increased urinary concentration of the stones constituents, such that it exceeds their solubility in urine (supersaturation). A low urine volume in some metabolically normal patients may also favor supersaturation. Urolithiasis (Renal Calculi, Stones) Calcium Oxalate stones Hypercalciuria Hypercalcemia Hyperuricosuria Hyperoxalauria Hypocitraturia Calcium oxalate stones are associated With both hypercalcemia and hypercalciuria (5% of patients) Hyperparathyroidism, diffuse bone disease, sarcoidosis, and other hypercalcemic states. Hypercalciuria without hypercalcemia (~ 55%) Absorptive hypercalciuria - hyperabsorption of calcium from the intestine Renal hypercalciuria - an intrinsic impairment in renal tubular reabsorption of calcium Idiopathic fasting hypercalciuria with normal parathyroid function. ~ 20% are associated with increased uric acid secretion (hyperuricosuric calcium nephrolithiasis), with or without hypercalciuria. The mechanism of stone formation in this setting involves nucleation of calcium oxalate by uric acid crystals in the collecting ducts. ~ 5% associated with hyperoxaluria, either hereditary (primary oxaluria) or, more commonly, acquired by intestinal overabsorption in patients with enteric diseases. The latter, so-called enteric hyperoxaluria, also occurs in vegetarians, because much of their diet is rich in oxalates. Hypocitraturia associated with acidosis and chronic diarrhea of unknown cause may produce calcium stones. In a variable proportion of patients with calcium stones no cause can be found (idiopathic calcium stone disease). Magnesium ammonium phosphate stones: Are formed largely following infections by urea-splitting bacteria (e.g., proteus and some staphylococci), which convert urea to ammonia. The resultant alkaline urine causes the precipitation of magnesium ammonium phosphate salts. These form some of the largest stones, as the amounts of urea excreted normally are huge. Staghorn calculi are almost always associated with infection. Uric acid stones: Are common in patients with hyperuricemia, such as gout, and diseases involving rapid cell turnover, such as the leukemias. In contrast to the radiopaque calcium stones, uric acid stones are radiolucent. Cystine stones: Are associated with a genetically determined defect in the renal transport of certain amino acids, including cystine General Stones are unilateral in about 80% of patients. The favored sites for their formation are Within the renal calyces and pelves In the bladder If formed in the renal pelvis: Tend to remain small Have an average diameter of 2 to 3 mm May have smooth contours or may take the form of an irregular, jagged mass of spicules. Occasionally, progressive accretion of salts leads to the development of branching structures known as staghorn stones, which create a cast of the pelvic and calyceal system. Clinical Course Stones are of importance when they obstruct urinary flow or produce ulceration and bleeding. They may be present without producing any symptoms or significant renal damage. In general, smaller stones are most hazardous, as they may pass into the ureters, producing pain referred to as colic (one of the most intense forms of pain) as well as ureteral obstruction. Larger stones cannot enter the ureters and are more likely to remain silent within the renal pelvis. Commonly, these larger stones first manifest themselves by hematuria. Stones also predispose to superimposed infection, both by their obstructive nature and by the trauma they produce. Nephrolitihiasis Large stone impacted in the renal pelvis Malignant Tumors Renal Cell Carcinoma (Hypernephroma, Adenocarcinoma of Kidney) Urothelial Carcinomas of Renal Pelvis Renal Cell Carcinoma (Hypernephroma, Adenocarcinoma of Kidney) Renal cell carcinomas represent about 1 to 3% of all visceral cancers and account for 85 to 90% of all renal cancers in adults. Occur most often in older individuals, usually in the sixth and seventh decades of life, A male preponderance in the ratio of 3:1. Because of their gross yellow color and the resemblance of the tumor cells to clear cells of the adrenal cortex, they are also called hypernephroma. These tumors arise from tubular epithelium and are therefore renal adenocarcinomas. A greater frequency of adenocarcinoma of the kidney in cigarette, pipe, and cigar smokers. Genetic factors also play a role Nearly two-thirds of patients with the von Hippel-Lindau syndrome (VHL), characterized by hemangioblastomas of the central nervous system and retina, develop bilateral, often multiple renal cell carcinomas. Morphology May arise in any portion of the kidney, but more commonly it affects the poles, particularly the upper one. Usually these neoplasms occur as solitary unilateral lesions. They are spherical masses, 3 to 15 cm in diameter, composed of bright yellowgray-white tissue that distorts the renal outline. Commonly there are large areas of ischemic, opaque, gray-white necrosis, foci of hemorrhagic discoloration, and areas of softening. The margins are usually sharply defined and confined within the renal capsule However, small satellite nodules are often found in the surrounding substance, providing clear evidence of the aggressiveness of these lesions. As the tumor enlarges, it may bulge into the calyces and pelvis and eventually may fungate through the walls of the collecting system to extend even into the ureter. One of the striking characteristics of this tumor is its tendency to invade the renal vein and grow as a solid column of cells within this vessel. Further extension produces a continuous cord of tumor in the inferior vena cava and even in the right side of the heart. Histologically, the growth pattern varies from papillary to solid, trabecular (cord-like), or tubular (resembling tubules). In any single tumor, all variations in patterns of growth may be present. The most common tumor cell type (70% of cases) is the clear cell, having a rounded or polygonal shape and abundant clear cytoplasm Fifteen per cent are papillary, composed of either clear cells or granular cells (granular cell renal carcinoma). Have a moderately eosinophilic cytoplasm, grow in sarcomatoid pattern, and have a decidedly worse prognosis. Most tumors are well differentiated (grades I and II), but some (grade IV) show marked nuclear atypia with formation of bizarre nuclei and giant cells. The stroma is usually scanty but highly vascularized. Clinical Course The three classic diagnostic features of unfortunately appear in only 10% of cases. costovertebral pain, palpable mass, and hematuria The most reliable of the three is hematuria, which eventually appears in about 90% of cases. However, the hematuria is usually intermittent and may be microscopic Generalized constitutional symptoms, such as fever, malaise, weakness, and weight loss. This pattern of asymptomatic growth occurs in many patients, so that the tumor may have reached a diameter of more than 10 cm when it is discovered. Renal cell carcinoma is classified as one of the great mimics in medicine, because it tends to produce a diversity of systemic symptoms not related to the kidney. In addition to the fever and constitutional symptoms mentioned earlier, renal cell carcinomas produce a number of paraneoplastic syndromes ascribed to abnormal hormone production, including polycythemia, hypercalcemia, hypertension, hepatic dysfunction, feminization or masculinization, Cushings syndrome, eosinophilia, leukemoid reactions, and amyloidosis. One of the common characteristics of this tumor is its tendency to metastasize widely before giving rise to any local symptoms or signs. In 25% of new patients with renal cell carcinoma, there is radiologic evidence of metastases at presentation. The most common locations of metastasis are the lungs (over 50%) and bones (33%), followed in order by the regional lymph nodes, liver and adrenals, and brain. In 10 to 15% of cases, the primary tumor metastasizes across the midline to the opposite kidney. It is essential that renal cell carcinomas be diagnosed at the earliest possible stage, which is usually accomplished during the investigation of hematuria in a middle-aged or an elderly patient. Renal ultrasonography, nephrotomography, computed tomography scanning, and intravenous pyelography aid in the differential diagnosis of a simple cyst from a tumor. Urinary cytology may also be helpful in identifying tumor cells. The average 5-year survival of patients with renal cell carcinoma is about 45%, and up to 70% in the absence of distant metastases. With renal vein invasion or extension into the perinephric fat, the figure is reduced to approximately 15 to 20%. Nephrectomy is the treatment of choice. Urothelial Carcinomas of Renal Pelvis ~ 5 to 10% of primary renal tumors occur in the renal pelvis These tumors span the range from apparently benign papillomas to frank papillary carcinomas, but, as with bladder tumors, the benign papillomas are difficult to differentiate from the low-grade papillary cancers. Renal pelvic tumors usually become clinically apparent within a relatively short time because they lie within the pelvis and, by fragmentation, produce noticeable hematuria. They are almost invariably small when discovered. These tumors are almost never palpable clinically; however, they may block the urinary outflow and lead to palpable hydronephrosis and flank pain. Occasionally, urothelial tumors may be multiple, involving the pelvis, ureters, and bladder. Infiltration of the wall of the pelvis and calyces is common, and renal vein involvement likewise occurs. For this reason, despite their apparently small, deceptively benign appearance, the prognosis for these tumors is not good. Five-year survival rates vary from 50 to 70% for low-grade superficial lesions to 10% with high-grade infiltrating tumors. WILMS TUMOR DEFINITION: An embryonal renal neoplasm characterized usually by an abdominal mass. EPIDEMIOLOGY: Prevalence: 1/12,000 live births 2nd most common extracranial solid tumor in children makes up 7% of all childhood cancers Peak age of onset: 6 months - 10 years (greatest in first 5 years) Risk factors: familial - autosomal dominant (in some families) chrom.#: 11p13 M = F Most common renal cancer in children Pathogenesis Tumor origin - kidney (bilateral in only 5%) Wilms' tumor is a nephroblastoma which can arise by a variety of pathogenic pathways from primitive metanephric blastema The gene for Wilms' tumor (WT2-1) is located at 11p13 Encodes a DNA-binding protein that is expressed Primarily in the fetal kidney In tissue that gives rise to the genitourinary system Inactivation of this gene may be responsible for the occurrence of a Wilms' tumor Wilms Tumor associated anomalies 1. WAGR Syndrome Wilms' tumor Aniridia lack or defect of the iris Genitourinary Anomalies gonadal dysgenesis, hypospadias, cryptorchidism, duplication of collecting system mental Retardation deletion of chromosome 11p13 tumor develops at a younger age increased incidence of bilateral tumor 2. Beckwith-Wiedemann Syndrome rearrangement of chromosome 11p15 hemihypertrophy 3. Drash Syndrome Wilm's Tumor Nephropathy - hypertension, proteinuria, renal failure Genitourinary Anomalies - ambiguous genitalia 4. Perlman Malformation Syndrome  Table exam: 0-4 years Leukemia: Retinoblastoma Neuroblastoma Wilms tumor 5-9 years Leukemia Retinoblastoma Wilms tumor Ewings tumor 10-14 years: hepatocarcinoma osteogenic sarcoma thyroid carcinoma hodgkins Pathology of Wilms Tumor Macroscopic usually confined to the kidney most of affected kidney usually replaced may be cystic Histologic Types Phasic Classic histology is triphasic: blastemal, epithelial, and/or stromal elements constitute 90% of tumors: favourable prognosis Anaplastic constitute 10% of tumors: unfavourable prognosis Pathology of Wilms Tumor Usually confined to the kidney Most of affected kidney usually replaced Pathology of Wilms Tumor Triphasic histology of Wilms Tumor Stromal, less cellular area (left) Spindle and epithelial cells (center) Blastemal cells (Tightly packed blue cells) Pathology of Wilms Tumor Tumor shows attempts at formation of primitive glomerulus and tubules CLINICAL FEATURES Primary Tumor Abdominal mass Abdominal pain Hematuria - gross or microscopic, painless, in up to 25% Hypertension - in 25% (due to renin-secreting tumor or renovascular hypertension) Others - fever, malaise, anemia, weight loss, left varicocele Syndromes - aniridia, hemihypertrophy, etc. Metastases Lung (10% have metastasis at time of diagnosis, isolated or multiple) Lymph nodes Liver Brain Rare - bone, skin, pleura, heart, epidural space Investigations Imaging Studies Tumor Abdominal X-Ray (rim-ring calcification) Abdominal Ultrasound (intra- or extrarenal, uni- or bilateral, uni- or multi-focal, solid or cystic) Abdominal CT IVP - internal compression of calyceal system For Metastases Chest X-Ray CT Chest STAGING National Wilms' Tumor Society (NWTS) Stages I -> V Staging system has prognostic significance Stage I The tumor is limited to the kidney. Stage II The tumor extends beyond the kidney. Stage III Residual non-hematogenous tumor is present, and confined to the abdomen. Stage IV Hematogenous metastases (lung, liver, bone, brain, etc.) Lymph node metastases outside the abdomino-pelvic region Stage V Bilateral renal involvement is present at diagnosis. PROGNOSTIC INDICATORS: 1. Stage extent of tumor 2. Histology favourable or unfavourable 3. Basic Fibroblast Growth Factor (bFGF) a heparin-bound blood vessel-generating peptide associated with the growth and spread of bladder, prostate, and kidney cancer measured as pg/g creatinine in the urine for those with Stage III or IV, preoperative bFGF levels are 25x higher than in those with Stage I or II for those with persistent or recurrent Wilms' tumor, post-operative bFGF levels are 100x higher than in those who remain disease-free there is a 1.6x greater chance of tumor recurrence in those with elevated postoperative bFGF levels MANAGEMENT Surgery Primary and second-look operations Removal of involved kidney with evaluation and biopsy of the opposite kidney Explore for extension, lymph node involvement, liver metastases Chemotherapy Actinomycin-D and vincristine +/- Doxorubicin Prognosis Greater than 85% cure rare with current therapy Stage - Cure Rate I - 98% II - 95% III - 90% IV - 80%  Diseases of the Lower Urinary Tract Ureters Congenital Anomalies Inflammations Tumors/ tumor-like conditions Obstructive Lesions Urinary Bladder Congenital Anomalies Inflammations Neoplasms Obstructions Urethra Congenital Anomalies of the Ureter Double and bifid ureters: Derived from a double or split ureteral bud Almost invariably associated either with Totally distinct double renal pelves Anomalous development of a very large kidney, having a partially bifid pelvis terminating in separate ureters May pursue separate courses to the bladder but commonly are joined within the bladder wall and drain through a single ureteral orifice. Ureteropelvic junction obstruction (UPJ): A congenital disorder Results in hydronephrosis Usually presents in male infants More common in the left ureter For unknown reasons, there is agenesis of the contralateral kidney Diverticula: Saccular outpouchings of the ureteral wall Congenital / acquired Are of importance as pockets of stasis and secondary infections Hydroureter: Dilatation, elongation, and tortuosity of the ureters Congenital / acquired Reflects some neurogenic defect in the innervation of the ureteral musculature Megaloureter: Massive enlargement of the ureter Due to a functional defect of ureteral muscle. Diverticula A pouch-like eversion or evagination of the bladder wall Congenital/ acquired due to persistent urethral obstruction with prostatic enlargement (hyperplasia or neoplasia) Usually consists of a round-to-ovoid, sac-like pouch that varies from <1 cm to 5-10 cm in diameter. Clinical significance: Constitute sites of urinary stasis Predispose to Infection Formation of bladder calculi. Vesicoureteric reflux Rarely, carcinomas may arise in bladder diverticuli Acute cystitis Secondary to bacterial infection (usually E. coli) Other pathogens include Proteus, Klebsiella, Staphylococcus saprophyticus, and Enterobacter spp. Other causes of cystitis include: Adenovirus Instrumentation Cyclophosphamide therapy (hemorrhagic cystitis) Most commonly due to ascending infection from urethra (women > men) Secondary to trauma during intercourse Organisms originate from fecal flora in women and prostate in men Clinical features: Frequency of urination, dysuria, sense of urgency, discomfort over the bladder (suprapubic); fever is uncommon Urinalysis: Pyuria, hematuria sometimes Positive dipstick for nitrite and leukocyte esterase WBC casts would indicate acute pyelonephritis Malakoplakia Chronic inflammatory cystitis characterized by yellow plaques, nodules, or polyps in the bladder mucosa. Microscopically: Accumulations of macrophages filled with round, laminated concretions (Michaelis-Gutman bodies) which stain positive with PAS, calcium, and iron stains. Is most commonly found in the bladder; also found in renal pelvis, ureter, prostate, epididymis, colon, and lungs Related to chronic bacterial infection, mostly E.coli Large macrophages with granular PAS positive cytoplasm Several dense round Michaelis Gutman bodies Bladder Neoplasms Increasing incidence Around 10,000 deaths in the US annually ~95% are epithelial in origin 90% are composed of urothelial (transitional) cell type ~5% are mesenchymal tumors Urothelial (Transitional) cell Tumors Classified into two major categories: Low grade urothelial tumors Always papillary Non-invasive Recurrent Excellent prognosis High grade urothelial carcinoma Maybe papillary / nodular or both Exhibit pleomorphism and anaplasia Frequently metastasize Poor prognosis Grading of Urothelial Tumors WHO Classification (1972) Papilloma TCC Grade I TCC Grade II TCC Grade III ISUP Consensus (International Society of Urological Pathology-1998) Urothelial Papilloma Urothelial neoplasm of low malignant potential Urothelial Carcinoma, low grade Urothelial Carcinoma, high grade Urothelial (Transitional) cell Tumors 50% of all bladder tumors are high grade lesions Most arise from the posterior/ lateral wall of the base of the bladder Gross appearance of all vesical cancers may be described as: Papillary exophytic polypoid lesions attached by a stalk to the mucosa. Penetration of the basement membrane by the neoplastic cells may or may not be present. Flat lesions growing as plaque-like thickenings of the mucosa without the formation of well-defined papillary structures May be in situ or invasive (more often the latter) More anaplastic than the papillary lesions. Noninvasive thickening of the mucosa by proliferation of cancer cells, but without penetration of the basement membrane. Invasive penetrating the mucosal basement membrane into the bladder wall, and possibly into contiguous structures. Morphologic patterns of Bladder Carcinoma TEST: PICTURE Papilloma of Urinary Bladder Small branching structure Individual finger-like papillae have a central core of loose fibrovascular tissue covered by normal-appearing transitional cells seven or fewer layers in thickness Cells recapitulate the normal architecture of transitional urinary tract epithelium Normal Transitional Epithelium of the Bladder Morphology of Urothelial Tumors GRADE I: Tumor cells display some atypia But are well differentiated Closely resemble normal transitional cells Mitoses are rare There is a significant increase in the number of layers of cells, that is, more than seven layers but only slight loss of polarity Grade I (Low Malignant Potential Tumor) GRADE II Tumor cells are still recognizable as of transitional origin. The number of layers of cells is increased (often more than ten), Number of mitoses is increased There is greater loss of polarity Greater variability in cell size, shape, and chromaticity is present. GRADE III Tumor cells are barely recognizable as of transitional origin All the changes of grade II are more aggravated Disarray of cells with loosening and fragmentation of the superficial layers of cells. Sometimes the cells tend to flatten out, and the lesions come to resemble squamous cell carcinomas Alternatively, foci of glandular differentiation may be present. Grade III (High Grade) Carcinoma In Situ Carcinoma in situ (CIS) is a high-grade flat abnormality confined to the bladder mucosa Usually occurs as a diffuse area of mucosal reddening, granularity, or thickening without producing an evident intraluminal mass In some instances the in situ changes involve most of the bladder surface and may even extend into the ureters and urethra Other Types of Bladder Carcinoma Squamous cell carcinomas represent about 3 to 7% of bladder cancers. Arise in areas of squamous metaplasia of the bladder mucosa Adenocarcinomas of the bladder are rare. Rare variants are Highly malignant signet cell carcinoma Mixed adenocarcinoma and transitional cell carcinomas. Epidemiology and Pathogenesis The incidence of carcinoma of the bladder resembles that of bronchogenic carcinoma Males > females (3:1) Industrialized > developing nations Urban > rural dwellers About 80% of patients are between the ages of 50 and 80 years. Factors implicated in the causation of TCC Cigarette smoking is clearly the most important influence Risk increased three- to sevenfold Depends on the pack-years and smoking habits Industrial exposure to arylamines, particularly 2-naphthylamine Cancers appear 15 to 40 years after the first exposure. Schistosoma haematobium infections are an established risk Ova deposited in the bladder wall > brisk chronic inflammatory response > progressive mucosal squamous metaplasia, dysplasia and neoplasia ~ 70% of the cancers are squamous cell in type, the remainder being TCC. Long-term use of phenacetin, implicated also in analgesic nephropathy Heavy long-term exposure to cyclophosphamide induces hemorrhagic cystitis Increases the risk of bladder cancer almost tenfold after 12 years of exposure Clinical Course of Bladder Cancer All bladder tumors classically produce painless hematuria Their dominant and sometimes only clinical manifestation. Occasionally, frequency, urgency, and dysuria accompany the hematuria. When the ureteral orifice is involved, pyelonephritis or hydronephrosis may follow. When first discovered ~60% neoplasms are single ~70% localized to the bladder Urothelial tumors, whatever their grade, have a tendency to recur following excision, and usually the recurrence exhibits a higher grade ~50% of papillomas and low-grade carcinomas recur ~80-90% of high grade tumors recur Prognosis of Bladder Cancers Papillomas and Grade I cancers (those of low malignant potentials) 98% 10-year survival rate regardless of the number of recurrences Grade III cancer ~ 40% 10-year survival rate Squamous cell carcinomas ~70% mortality within a year The prognosis depends on: Histologic pattern Grade of the tumor Stage when first diagnosed Other factors that may influence the prognosis: Expression of blood group antigens by tumor cells Tumor cells that express A, B, and H antigens have a better prognosis than those that do not or lose this capacity Analogously, the detection of a T antigen, increased c-myc expression, and multiple chromosomal mutations all worsen the outlook. Diagnosis of Bladder Cancers The clinical challenge with these neoplasms is early detection and adequate follow-up Cytoscopy and biopsy are the mainstays of diagnosis for regular neoplastic lesions Difficult to detect lesions Carcinoma in situ producing no or only subtle gross mucosal changes Early small papillary lesions Of value in these circumstances are Cytologic examination Flow cytometric analyses of urinary sediment specially for DNA content differentiates the high-grade tumors from the benign ones Mesenchymal Tumors Benign: Variety of benign mesenchymal tumors may arise in the bladder Are rare Most common is leiomyoma All tend to grow as isolated, intramural, encapsulated, oval-to-spherical masses, varying in diameter up to several centimeters Sarcomas: Uncommon in the bladder Produce large masses (10-15 cm in diameter) that protrude into the vesical lumen Are soft, fleshy, gray-white in gross appearance Rhabdomyosarcoma takes one of two forms: Adult form occurs mostly in adults older than 40 years of age Embryonal rhabdomyosarcoma, or sarcoma botryoides Most common sarcoma in children Present with grape-like masses Protruding from the urethra in males (arise in the prostate) and vagina in females Secondary Tumors Most often by direct extension from primary lesions in nearby organs Cervix Uterus Prostate Rectum Common sequelae: Hemorrhage Ureteral obstruction Vesicovaginal fistulas Obstruction of Urinary Bladder Variety of intrinsic and extrinsic diseases of the bladder narrow the urethral orifice and cause partial or complete vesical obstruction. In males: Most important lesion is enlargement of the prostate gland due either to nodular hyperplasia or to carcinoma In females: Vesical obstruction is somewhat less common Is most often caused by cystocele of the bladder The more infrequent causes can be listed as: Congenital narrowings or strictures of the urethra Inflammatory strictures of the urethra Inflammatory fibrosis and contraction of the bladder following varying types of cystitis Bladder tumors either benign or malignantwhen strategically located Secondary invasion of the bladder neck by growths arising in perivesical structures, such as the cervix, vagina, prostate, and rectum Mechanical obstructions caused by foreign bodies and calculi Injury to the innervation of the bladder causing neurogenic or cord bladder. Morphology In the early stages: Some thickening of the bladder wall, presumably due to hypertrophy of the smooth muscle. Mucosal surface may be entirely normal. With progressive hypertrophy of the muscular coat: Individual muscle bundles greatly enlarge Produce trabeculation of the bladder wall Crypts form and may then become converted into true acquired diverticula. Obstruction of Urinary Bladder Urethra-Inflammation Urethritis is classically divided into Gonococcal - Is one of the earliest manifestations of this venereal infection Nongonococcal urethritis Is very common Caused by a variety of bacteria specially E. coli and other enteric organisms Urethritis is often accompanied by cystitis in females and prostatitis in males. Chlamydia trachomatis is responsible for 25 - 60% Urethritis is also one component of Reiters syndrome arthritis+ conjunctivitis+ urethritis. May cause considerable Local pain Itching Frequency Tumors - Urethral caruncle Is an inflammatory lesion presenting as a small, red, painful mass about the external urethral meatus in the female Found at any age More common in later life Grossly: A hemispheric, friable, 1-2 cm nodule Occurs singly, either just outside or just within the external urethral meatus May be covered by an intact mucosa Is extremely friable, and the slightest trauma may cause ulceration of the surface and bleeding. Histologically: Composed of a highly vascularized, young, fibroblastic connective tissue, more or less heavily infiltrated with leukocytes The overlying epithelium, where present, is either transitional or squamous cell in type Treatment: Surgical excision Tumors of the Urethra Papillomas: Occur usually just within or on the external meatus. They may be of viral origin, analogous to those affecting the vulva. Carcinoma of the urethra: Is an uncommon lesion It tends to occur in advanced age in women Begins about the external meatus or on the immediately surrounding structures, such as the glans penis or the introitus in the female. Appear as warty, papillary growths that at first resemble the sessile papillary carcinomas in the bladder. As they progress, they tend to become ulcerated on their surfaces and to assume the characteristics of a fungating, ulcerating lesion Most of these malignancies are squamous cell carcinomas. Overall, they are more aggressive than bladder cancers, more often invasive, and more difficult to eradicate despite the fact that they seldom metastasize probably because most lead to death within a few years. Diseases of the Breast Normal Anatomy and Major Lesions Congenital Anomalies Supernumerary Nipples or Breasts Result from the persistence of epidermal thickenings along the milk line Extends from the axilla to the perineum Below and above adult breast in the anterior axillary fold Accessory Axillary Breast Tissue May give rise to tumors that appear to be outside the breast Are commonly misidentified as Lesions of the axillary lymph nodes Metastases from an occult breast cancer Congenital Inversion of Nipples Occurs in many women, particularly with large/pendulous breasts Is corrected during the growth activity of pregnancy By simple traction on the nipples Clinical significance: Failed attempts at nursing Confused with acquired retraction of the nipple observed in Mammary cancer Inflammation of the breasts Inflammation of breast Acute Mastitis and Breast Abscess Mammary Duct Ectasia Fat Necrosis Acute Mastitis and Breast Abscess Vulnerable to bacterial infection by the development of cracks and fissures in the nipples During the early weeks of nursing Predisposing factors Eczema Other dermatologic conditions Staphylococcus aureus usually Streptococci less commonly Acute Mastitis and Breast Abscess Usually the disease is unilateral Staphylococcus - a localized area of acute inflammation that may progress to the formation of single or multiple abscesses Streptococcus - a diffuse spreading infection that eventually involves the entire organ Surgical drainage and antibiotic therapy may limit the spread of the infection With extensive necrosis Destroyed breast substance is replaced by fibrous scar as a permanent residual of the inflammatory process A localized area of increased consistency Sometimes accompanied by retraction of the skin or the nipple May later be mistaken for a neoplasm Mammary Duct Ectasia Characterized by: Dilatation of ducts Inspissation of breast secretions A marked periductal and interstitial chronic granulomatous inflammatory reaction, sometimes associated with large numbers of plasma cells (plasma cell mastitis) Occurs in the fifth or sixth decade of life Usually in multiparous women Results from obstruction of ducts due to inspissation of secretions Clinical significance: Can be mistaken for a carcinoma clinically, grossly, and by mammography Mammary Duct Ectasia Usually affects a single area of the breast substance drained through one of the major excretory ducts A poorly defined area of induration, thickening, or ropiness results On section, thick, cheesy material can be extruded from the ducts by slight pressure Dilated ducts filled by granular, necrotic, acidophilic debris that contains principally lipid-laden macrophages Destruction of the ductal epithelium Peri-ductal infilteration with leucocytes Fat Necrosis Focal necrosis of fat tissues in the breast, followed by an inflammatory reaction Is an uncommon lesion Occurs as an isolated, sharply localized process in one breast Almost all patients give a history of Trauma Prior surgical intervention Radiation therapy Clinical significance: Its possible confusion with a tumor, when fibrosis has created a clinically palpable mass, and focal calcification is seen on mammography. Lipid laden macrophages in necrosis of breast tissue Fibrocystic Changes (Fibrocystic Disease) Three dominant patterns of morphologic change: Cyst formation and fibrosis (simple fibrocystic change and gross cysts) Epithelial hyperplasia (ductal and lobular) Sclerosing adenosis A common feature is palpable lump in most of them Incidence and Pathogenesis Together these variants compose the single most common disorder of the breast Account for >50% of all surgical operations on the breast Is unusual before adolescence Is diagnosed frequently between the ages of 20 and 40, peaks at or just before the menopause Rarely develops after the menopause Hormonal imbalances are considered to be basic to the development Excess estrogens Functioning ovarian tumors Deficiency of progesterone In anovulatory women Oral contraceptive use decreases the risk of fibrocystic disease, Supplies a balanced source of progesterone and estrogen Simple Fibrocystic Change Is the most common type of alteration Characterized by Increase in fibrous stroma Associated dilatation of ducts Formation of cysts of various sizes Disorder usually multifocal and often bilateral Large cyst may be formed within one breast On palpation and gross examination An ill-defined diffuse increase in consistency and discrete nodularities Are brown to blue (blue-dome cysts), owing to the contained semitranslucent, turbid fluid Microcalcifications detected by mammography Secretory products within cysts of the breast calcify Mammogram Microcalcification Cancer Fibrocystic changes Blue domed cyst Simple Fibrocystic Change In smaller cysts Epithelium is more cuboidal to columnar Multilayered in focal areas In larger cysts May be flattened or may even be totally atrophic Apocrine metaplasia Cysts lined by large polygonal cells having an abundant granular, eosinophilic cytoplasm, with small, round, deeply chromatic nuclei Is found commonly in the normal breast Virtually always benign Epithelial overgrowth and papillary projections are common in cysts lined by apocrine epithelium Multiple cystic spaces Normal Lining (Left) Some filled with precipitated fluid and stromal fibrosis Apocrine Metaplasia (Right) Epithelial Hyperplasia Fibrocystic changes can be accompanied by epithelial hyperplasia Has an increased risk of the subsequent development of carcinoma The more severe and atypical the hyperplasia, the greater the risk of developing cancer Gross appearance is that of accompanying fibrosis, cysts, or adenosis. Microscopically Increase in the layers of the duct-lining epithelium beyond the usual double layer May take the form of solid masses extending and encroaching into the duct lumen, partially obliterating it, but usually irregular lumina (so-called fenestrations) can be discerned at the periphery of the cellular masses Alternatively, papillary epithelial projections may grow into the lumen (ductal papillomatosis). If extensive, this is termed florid papillomatosis. A.Epithelial hyperplasia Multilayered epithelial cells, No atypia No increased risk of cancer B. Florid Ductal Epithelial Hyperplasia C. Atypical Ductal Epithelial Hyperplasia Florid Ductal Epithelial Hyperplasia Epithelial Hyperplasia Both papillary and solid proliferations may sometimes show various degrees of cellular and architectural atypia (atypical hyperplasia). In general, greater cellular uniformity, more regular sharply defined gland lumina (so-called cribriform pattern), and nuclear hyperchromasia favor intraductal carcinoma. Atypical lobular hyperplasia Hyperplasias of the terminal duct and ductules (acini) that have somebut not allthe features of lobular carcinoma in situ Cytologically Atypical cells resemble those of lobular carcinoma in situ but do not fill or distend more than 50% of the terminal duct units. When it affects ducts (rather than only acini), is associated with an increased risk of invasive carcinoma Atypical Ductal Epithelial Hyperplasia Tumors of the Breast Fibroadenoma Phyllodes Tumor Intraductal Papilloma Carcinoma Fibroadenoma Most common benign tumor of the female breast Is a new growth composed of both fibrous and glandular tissue Arises from intralobular stroma Occurring at any age within the reproductive period of life More common before age 30 Multiple small areas closely resembling a fibroadenoma are sometimes found in cases of cystic disease, termed fibroadenomatosis. Usually appears as a solitary, discrete, freely movable nodule within the breast Epithelium of the fibroadenoma is normally responsive Can undergo lactational change during pregnancy Increase in size / infarction and inflammation Fibroadenoma mimicking carcinoma in a pregnant woman Slight increase in size may occur during the late phases of each menstrual cycle Postmenopausally, regression or calcification may result. Grows as a spherical nodule Sharply circumscribed Freely movable from the surrounding breast substance Frequently occur in the upper outer quadrant of the breast Size < 1 cm to giant forms 10 to 15 cm in diameter (giant fibroadenoma) Most are surgically removed when 2 to 4 cm in diameter On section they are grayish white, and often contain slit-like spaces Histologic pattern: Delicate, cellular, fibroblastic stroma resembling intralobular stroma, enclosing glandular and cystic spaces lined by epithelium Intact, round-to-oval gland spaces may be present, lined by single or multiple layers of cells (pericanalicular fibroadenoma) In other areas, the connective tissue stroma appears to have undergone more active proliferation with compression of the gland spaces. In consequence, glandular lumina are collapsed or compressed into slit-like, irregular clefts, and the epithelial elements then appear as narrow strands or cords of epithelium lying with the fibrous stroma (intracanalicular fibroadenoma) Both pericanalicular and intracanalicular patterns often coexist in the same tumor Cystosarcoma phyllodes Arise from intralobular stroma but may recur or be frankly malignant Are much less common than fibroadenomas Majority of the tumors behave in a relatively benign fashion Distinguished from fibroadenoma on the basis of cellularity, mitotic rate, nuclear pleomorphism, loss of the usual biphasic pattern of stroma and associated benign epithelium, and infiltrative borders Low-grade tumors are Seen most commonly May recur locally Only rarely metastasize High-grade lesions Rare Behave aggressively Local recurrences common Distant hematogenous metastases Lymph node metastases are rare as with other sarcomas Size variable: Few centimeters to massive lesions involving the entire breast. Larger lesions often are lobulated owing to the presence of nodules of proliferating stroma lined by epithelium (phyllodes is Greek for leaf-like) Histologically: Lower grade lesions resemble fibroadenomas but with increased cellularity and mitotic figures. High-grade lesions may be difficult to distinguish from other types of soft tissue sarcomas Carcinoma of the Breast Incidence and Epidemiology Rare before the age of 25 except in certain familial cases May occur at any age thereafter, with a peak incidence at or after the menopause. Geographic influences: Five times more common in the United States than in Japan and Taiwan. Genetic predisposition: Well defined Magnitude of risk is in proportion to Number of close relatives with breast cancer Age when cancer occurred in relatives The younger the relatives at the time of development of cancer and the more bilateral cancers, the greater the genetic predisposition Increasing age: Uncommon before age 25, but then a steady rise to the time of menopause, followed by a slower rise throughout life. Length of reproductive life: Risk increases with early menarche and late menopause. Parity: More frequent in nulliparous than in multiparous women. Age at first child: Increased risk when older than 30 years of age at time of first child. Obesity: Increased risk attributed to synthesis of estrogens in fat depots. Exogenous estrogens: Moderately increased risk with high-dosage therapy for menopausal symptoms. Oral contraceptives: No clear-cut increased risk; attributed to balanced content of estrogens and progestins in currently used oral contraceptives. Fibrocystic changes with atypical epithelial hyperplasia: Increased risk, as noted in earlier discussion of this condition. Carcinoma of the contralateral breast or endometrium: Increased risk. Classification and Distribution Is more common in the left breast than in the right ~50% arise in the upper outer quadrant 10% in each of the remaining quadrants ~20% in the central or subareolar region WHO classification of histologic tumor types: Noninvasive 1a. Intraductal carcinoma 1b. Intraductal carcinoma with Pagets disease 2. Lobular carcinoma in situ Invasive (infiltrating) 1a. Invasive ductal carcinomanot otherwise specified (NOS) 1b. Invasive ductal carcinoma with Pagets disease 2. Invasive lobular carcinoma 3. Medullary carcinoma 4. Colloid carcinoma (mucinous carcinoma) 5. Tubular carcinoma 6. Adenoid cystic carcinoma 7. Apocrine carcinoma 8. Invasive papillary carcinoma Intraductal Carcinoma Constitutes approximately 20 to 30% of carcinomas Defined as a malignant population of cells that lack the capacity to invade through the basement membrane and, therefore, are incapable of distant metastasis. However, these cells can spread throughout a ductal system and produce extensive lesions involving an entire sector of a breast Movement of these cells up the main duct and into the nipple skin results in the clinical appearance of Pagets disease of the nipple Histologically, these tumors are divided into five subtypes: Comedocarcinoma Solid Cribriform Papillary Micropapillary Except for comedocarcinoma, these lesions are usually clinically occult and are detected as incidental findings in breast biopsies or by mammography Intraductal carcinoma Comedocarcinoma Characterized by rapidly proliferating high-grade malignant cells Cells in the center of the ducts are often necrotic and commonly calcify These necrotic cells are detected Grossly - Cut section by punctate areas of cheesy necrotic material (comedone like) Mammography - Linear and branching microcalcifications Are thought to be precursors/predictors of invasive cancer In women with intraductal carcinoma treated with lumpectomy alone, recurrences or invasion occurs in from 0 to 10% of low-grade or intermediate nonpalpable tumors to 40% of high-grade comedocarcinomas COMEDOCARCINOMA Pagets disease of the nipple Is a form of ductal carcinoma Arises in the main excretory ducts of the breast and extends intraepithelially to involve the skin of the nipple and areola. Most striking gross characteristics Involvement of the skin of the nipple and areola Is frequently fissured, ulcerated, and oozing. There is surrounding inflammatory hyperemia and edema and, occasionally, total nipple ulceration. An underlying lump or mass is present in 50 to 60% of cases. Histologic hallmark Involvement of the epidermis by malignant cells, referred to as Pagets cells. Large, have abundant clear or lightly staining cytoplasm Nuclei with prominent nucleoli Stain positively for mucin, epithelial membrane antigens, and low-molecular-weight keratins. Lobular Carcinoma in Situ Is a histologically unique lesion Manifested by proliferation, in one or more terminal ducts and/or ductules (acini), of cells that are loosely cohesive, are somewhat larger than normal, and have rare mitoses and oval or round nuclei with small nucleoli Seen in breasts removed For fibrocystic disease In the vicinity of invasive carcinoma Admixed with the foci of intraductal carcinoma Is a marker for invasive carcinoma Invasive (infiltrating) Carcinoma Invasive Ductal Carcinoma NOS (Not Otherwise Specified) Medullary Carcinoma Colloid or Mucinous Carcinoma Invasive Lobular Carcinoma NST (No Special Type) Is the most common type ~70 to 80% of all mammary cancers Most exhibit a marked increase in dense, fibrous tissue stroma, giving the tumor a hard consistency (scirrhous carcinoma) Sharply delimited nodules Stony-hard consistency ~1 to 2 cm in diameter and rarely exceed 4 to 5 cm On palpation Infiltrative attachment to the surrounding structures Fixation to the underlying chest wall Dimpling of the skin Retraction of the nipple On cut section: the mass is quite characteristic Retracted below the cut surface Has a hard cartilaginous consistency Produces a grating sound when scraped. Within the central focus, there are small pinpoint foci or streaks of chalky-white necrotic tumor and small foci of calcification. Scirrhous Carcinoma Invasive Ductal Carcinoma Histologically Malignant duct lining cells diposed in cords, solid cell nests, tubules, glands, anastomosing masses, and mixtures of all these Cells clearly invade the connective tissue stroma Tumor cells varies from small cells with moderately hyperchromatic regular nuclei to huge cells with large irregular and hyperchromatic nuclei Frequently, invasion of perivascular and perineural spaces as well as blood and lymphatic vessels is readily evident Tumors are graded according to Degree of nuclear atypia Histologic differentiation (tubule formation) into Well differentiated Moderately differentiated Poorly differentiated Tumor cells in cords and tubules infilterating stroma Medullary Carcinoma ~1 to 5% of all mammary carcinomas Average size is 2 to 3 cm, but some produce large, fleshy tumor masses up to 5 cm in diameter or greater On section Has a soft, fleshy consistency and tends to be discrete Foci of necrosis and hemorrhage are large and numerous Histologically, the carcinoma is characterized by Solid, syncytium-like sheets of large cells with vesicular, often pleomorphic nuclei, containing prominent nucleoli and frequent mitoses (the syncytial cells occupy more than 75% of the tumor) Moderate-to-marked lymphocytic infiltrate between these sheets Scant fibrous component Distinctly better prognosis than the usual infiltrating duct carcinomas, even in the presence of axillary lymph node metastases The ten-year survival rate is more than 70%. Medullary Carcinoma Invasive Lobular Carcinoma 5-10% Bilateral more frequently than others Multicentric within the same breast More frequently metastasize to CSF, serosal surfaces, ovary and uterus, and bone marrow as compared to other subtypes Colloid or Mucinous Carcinoma Unusual variant Occurs in older women Grows slowly over the course of many years The tumor is extremely soft Consistency and appearance of pale gray-blue gelatin Pure form 75% of the tumor is mucinous or mixed, in association with other types of infiltrating duct carcinoma. Large lakes of lightly staining, amorphous mucin that dissect and extend into contiguous tissue spaces and planes of cleavage Floating within this mucin are small islands and isolated neoplastic cells, sometimes forming glands Vacuolation of at least some of the cells is characteristic Mixed mucinous tumors Large areas with mucin + areas of typical nonmucinous invasive duct carcinoma. Lakes of mucin Islands of tumor cells ID/CC A 52 year old unmarried white nulliparous female smoker with early menarche presents with a painless lump in her right breast. HPI The patient has a history of atypical hyperplasia of the right breast. Her mother died of breast cancer at age 46. PE A 3 cm, fixed, hard, and nontender mass in the upper outer quadrant of right breast; retraction of overlying skin and nipple; no nipple discharge; palpable axillary lymph nodes on right side Imaging Mammo: spiculated mass with architectural distortion and multiple clustered pleomorphic microcalcifications; skin thickening and retraction Peau D Orange OVARIAN TUMORS Among cancers of the female genital tract, the incidence of ovarian cancer ranks below only carcinoma of the cervix and the endometrium. There are numerous types of ovarian tumors, both benign and malignant. About 80% are benign, and these occur mostly in young women between the ages of 20 and 45 years. The malignant tumors are more common in older women, between the ages of 40 and 65 years. Risk factors for ovarian cancer are much less clear than for other genital tumors General agreement on two risk factors: nulliparity family history The most intriguing risk factor is genetic and candidate host genes, which may be altered in susceptible families (i.e., ovarian cancer genes). Several are being considered, and at least one (BRCA1) increases susceptibility to breast cancer and resides on chromosome 17q21. Approximately 30% of ovarian adenocarcinomas express high levels of HER-2/neu oncogene, which correlates with a poor prognosis. Mutations in a host tumor suppressor gene p53 are found in 50% of ovarian carcinomas. TYPES OF OVARIAN TUMORS THREE main types of PRIMARY ovarian tumors: Epithelial ovarian tumors: Derived from the cells on the surface of the ovary. Most common form of ovarian cancer Occur primarily in adults Germ cell ovarian tumors: Derived from the egg producing cells within the body of the ovary. Occur primarily in children and teens Rare by comparison to epithelial ovarian tumors Sex cord stromal ovarian tumors Also rare in comparison to epithelial tumors Often produces steroid hormones Cancers derived from other organs can also spread to the ovaries (METASTATIC cancers). Distribution of Benign Ovarian Neoplasms Distribution of Malignant Ovarian Neoplasms  Tumors of Surface (Coelomic) Epithelium Most of the primary neoplasms in the ovary arise from the surface epithelium. Types : Serous Mucinous Endometrioid Clear cell carcinoma Brenners tumor Cystadenofibroma Mixtures of these epithelia frequently occur in the same tumor Tumors of Surface (Coelomic) Epithelium Benign tumors ( Tumors of borderline malignancy (malignant tumors Range in size and composition Size: Small and grossly imperceptible or massive, filling the pelvis and even the abdominal cavity. Components of the tumors: cystic areas (cystadenomas) cystic and fibrous areas (cystadenofibromas) fibrous areas (adenofibromas) On gross examination, the risk of malignancy increases as a function of the amount of discernible solid epithelial growth, including papillary projections of soft tumor, thickened tumor lining the cyst spaces, or solid necrotic friable tissue depicting necrosis Although termed epithelial in differentiation, these tumors are derived from coelomic mesothelium Has the capability to evolve into different types of epithelia present in the normal female genital tract serous (tubal) endometrioid (endometrium) mucinous (cervix) Serous Tumors Account for about 30% of all ovarian tumors Biologic behavior of serous tumors depends on Degree of differentiation Distribution of the tumor Ovarian surface Peritoneal surface Prognosis is closely related to histologic appearance of the tumor growth pattern on the peritoneum. Benign + Borderline Approx 75% Are most common between the ages of 20 and 50 Borderline tumors can originate from or extend to the peritoneal surfaces May remain localized ( causing no symptoms; or Spread slowly ( producing intestinal obstruction / other complications after many years 5-year survival for borderline tumors confined within the ovarian mass is 100% involving the peritoneum is about 90% Malignant Approx 25% Serous Cystadenocarcinomas occur later in life on average Serous cystadenocarcinomas account for approximately 40% of all cancers of the ovary Are the most common malignant ovarian tumors. Infiltrate the soft tissue and form large intra-abdominal masses and rapid deterioration The 5-year survival for malignant tumors confined within the ovarian mass is 70%, involving the peritoneum is 25% For this reason, careful pathologic classification of the tumor, even if it has extended to the peritoneum, is relevant to both prognosis and selection of therapy. Unencapsulated serous tumors of the ovarian surface are more likely to extend to the peritoneal surfaces Gross morphology One or a few fibrous walled cysts 10-15 cm in diameter and occasionally up to 40 cm. Bilaterality is common Benign: ( e.g: Benign serous cystadenoma) Contain a smooth glistening cyst wall with no epithelial thickening or small papillary projections (i.e., papillary cystadenoma) 20% bilateral Borderline tumors Contain an increasing amount of papillary projections 30% bilateral Malignant: (Malignant serous cystadenocarcinoma) Large amounts of solid or papillary tumor mass Irregularity in the tumor mass Fixation or nodularity of the capsule 66% bilateral Benign Serous Cystadenoma Smooth glistening cyst wall Multiloculated smooth glistening cyst wall with no epithelial thickening or papillary projections MRI Borderline serous cystadenoma cavity lined by delicate papillary structures Papillary serous cystadenoma Papillary serous cystadenocarcinoma Predominately cystic but the granular excresences on the lower half of the mass indicate peritoneal extension. Papillary serous cystadenocarcinoma Note the many papillations on the inner surface. Cystadenocarcinoma opened to reveal large bulky tumor mass Histology of serous tumors Benign tumors Lining epithelium is composed of columnar epithelium With abundant cilia Microscopic papillae may be found Borderline malignancy Lining epithelium is composed of columnar epithelium Increased complexity of the stromal papillae with stratification of the epithelium and nuclear atypia Destructive infiltrative growth into the stroma is not seen. Malignant / Cystadenocarcinomas Even more complex growth with infiltration or frank effacement of the underlying stroma by solid growth The individual tumor cells in the carcinomatous lesions display the usual features of all malignancy, and with the more extreme degrees of atypia, the cells may become quite undifferentiated. The presence of concentric calcifications (psammoma bodies) characterizes serous tumors, although they are not specific for neoplasia when found alone. Borderline serous cystadenoma Papillary projections of epithelium extending into the lumen of the tumor. There is no invasion of the stroma or capsule. Borderline papillary serous tumor Note absence of stromal invasion High power view of papillary tuft in borderline serous tumor., Note cellular pleomorphism. Papillary serous cystadenocarcinoma More pronounced papillary growth with more hyperchromatic cells showing malignant glands invading stroma. Psammomma bodies- papillary serous cystadenocarcinomas Small concretions seen here as purplish rounded and laminated objects. Essentially a form of dystrophic calcification in neoplasms. Mucinous Tumors Closely resemble their serous counterparts. Less common ( 25% of all ovarian neoplasms. Occur principally in middle adult life Rare before puberty and after menopause. Benign or borderline: 80% Malignant: 15% Mucinous cystadenocarcinomas are relatively uncommon Account for only 10% of all ovarian cancers. Gross Morphology Differences from serous tumors: More cysts of variable size Less frequently bilateral. Approximately 5% of mucinous cystadenomas and 20% of mucinous cystadenocarcinomas are bilateral. Mucinous tumors tend to produce larger cystic masses, and some have been recorded with weights of more than 25 kg. Grossly they appear as multiloculated tumors filled with sticky, gelatinous fluid rich in glycoproteins Histology of mucinous tumors Characterized by a lining of tall columnar epithelial cells with apical mucin and the absence of cilia similar to benign cervical or intestinal epithelia Borderline tumors exhibit abundant gland-like or papillary growth with nuclear atypia and stratification Appear similar to tubular adenomas or villous adenomas of the intestine. Cystadenocarcinomas contain more solid growth with conspicuous epithelial cell atypia and stratification, loss of gland architecture and necrosis Are similar to colonic cancer in appearance Mucinous cystadenoma, ovary, medium power Mucinous cystadenoma Cyst wall lined by mucous containing tall Mucinous cystadenoma with basally placed columnar epithelial cells. nuclei and apical mucin. Four locules are These mucin secreting cells have characteristics present in this section. Note resemblance of intestinal type differentiation, endocervical to endocervical type epithelium type differentiation can also be seen Borderline mucinous tumor Showing papillary configuration of lining epithelium High power view. Note nuclear stratification. Mucinous cystadenocarcinoma. Pseudomyxoma peritonei Note bulging, glistening cysts filled with mucin Pseudomyxoma peritonei Mucinous tumors (like serous tumors) may involve the peritoneal surface with collection of extensive mucinous material resembling cystic contents within the peritoneal cavity Is a rare condition Seen with primarily borderline or malignant neoplasms. Major complication: Extensive interadherence and adhesion of the viscera, producing a matting together of the abdominal contents and intestinal obstruction Endometrioid Tumors Approximately 20% of all ovarian cancers Most endometrioid tumors are carcinomas. Less commonly, benign formsusually cystadenofibromasare encountered. Distinguished from serous and mucinous tumors by the presence of tubular glands bearing a close resemblance to benign or malignant endometrium. 15 to 30% of endometrioid carcinomas are accompanied by a carcinoma of the endometrium About 15% of cases with endometrioid carcinoma coexist with endometriosis Morphology Grossly, endometrioid carcinomas present as a combination of solid and cystic areas, similar to other cystadenocarcinomas 40% bilateral bilaterality usually implies extension of the neoplasm beyond the female genital tract. Endometrioid adenocarcinoma Glandular patterns bearing a strong resemblance to endometrial origin Well-differentiated endometrioid adenocarcinoma. Glands show irregular budding but have smooth contours High power view showing well-formed glands with nuclear stratification. Clear Cell Adenocarcinoma Uncommon Characterized by large epithelial cells with abundant clear cytoplasm. Can be predominantly solid or cystic. In the solid neoplasm, the clear cells are arranged in sheets or tubules. In the cystic variety, the neoplastic cells line the spaces. The 5-year survival rate is approximately 50% when the tumors are confined to the ovaries Tend to be aggressive, and with spread beyond the ovary, a survival of 5 years is exceptional. Clear Cell Adenocarcinoma Clear Cell Adenocarcinoma Tumor cells with clear well-defined borders and abundant pale or clear cytoplasm containing a small, often eccentric nucleus, lining tubules or cysts or forming solid sheets Showing a tubulopapillary pattern with prominent hobnail cells. Brenner Tumor Uncommon Epithelial component consists of nests of transitional cells resembling those lining the urinary bladder. May be solid or cystic Usually unilateral (approximately 90%) Vary in size from small lesions <1cm to massive tumors up to 20-30 cm. Majority of Brenner tumors are benign Histology Brenner Tumor The histologic appearance of benign Brenner tumor is quite distinctive. Variable numbers of nests of transitional epithelial cells with coffee bean-shaped nuclei scattered in a dense fibrous stroma. Cell nests often become cystic containing eosinophilic debris or mucin. Brenner Tumors Gross section showing well circumscribed, yellow lobulated tumor Low Power Histology Showing nests of transitional epithelium in cellular fibrous stroma. Nest containing microcysts, one filled with eosinophilic debris. High power view showing the "coffee-bean" appearance of the nuclei High power view showing Reinke's crystalloids. Clinical Course of Surface Epithelial Tumors All ovarian epithelial carcinomas produce similar clinical manifestations, most commonly lower abdominal pain and abdominal enlargement. Gastrointestinal complaints, urinary frequency, dysuria, pelvic pressure, and many other symptoms may appear. Benign lesions are easily resected with cure. The malignant forms, however, tend to cause the progressive weakness, weight loss, and cachexia characteristic of all malignancies. Surface epithelial ovarian cancer Seen here is a laparotomy on a patient with intermittent small bowel obstruction. A loop of small bowel (bottom of frame) is adherent to a poorly differentiated primary epithelial ovarian carcinoma (left of frame) that has spread to involve the pelvic sidewall, the bladder peritoneum, the serosa of the uterus, and the fallopian tube. Clinical Course of Surface Epithelial Tumors (cont.) If the carcinomas extend through the capsule of the tumor to seed the peritoneal cavity, massive ascites is common. Characteristically, the ascitic fluid is filled with diagnostic exfoliated tumor cells. The peritoneal seeding that these malignancies produce is quite distinctive: They tend to seed all serosal surfaces diffusely with 0.1- to 0.5-cm nodules of tumor. These surface implants rarely invade deeply into the underlying parenchyma of the organ. The regional nodes are often involved, and metastases may be found in the liver, lungs, gastrointestinal tract, and elsewhere. Because ovarian carcinomas often remain undiagnosed until very large, many patients are first seen with lesions that are no longer confined to the ovary. This is perhaps the primary reason for the relatively poor 5- and 10-year survival rates for these patients, compared with rates in cervical and endometrial carcinoma. For these reasons, specific biochemical markers for tumor antigens or tumor products in the plasma of these patients are used to identify them One such marker is a high-molecular-weight glycoprotein present in more than 80% of serous and endometrioid carcinomas, known as CA-125 Surface epithelial ovarian cancer Metastases from epithelial ovarian carcinoma involving the omentum Germ Cell Tumors Constitute 15 to 20% of all ovarian tumors. Majority (95%) are benign cystic teratomas (dermoid cysts) Remainder tend to be malignant. Unlike the malignant epithelial tumors, which usually occur during the sixth decade, this group of malignant tumors tends to occur mainly in children and young adults Rare after menopause Remarkable homology to germ tumors in the male testis and arise from germ cell differentiation in a similar manner As a group, the tumors are characterized by Rapid growth Predilection for lymphatic and hematogenous spread Predominantly unilateral development Frequent mixtures of germ cell types Associated with good prognosis. Types of Germ Cell Tumors Teratomas Mature (Benign) Teratomas Immature Malignant Teratomas Monodermal or Specialized Teratomas Dysgerminoma Endodermal Sinus (Yolk Sac) Tumor Choriocarcinoma Germ Cell Tumor Classification Dysgerminoma Ovarian counterpart of the seminoma of the testis. Similar to the latter, it is composed of large vesicular cells having a cleared cytoplasm, well-defined cell boundaries, and centrally placed regular nuclei. Relatively uncommon tumors, the dysgerminomas account for about 2% of all ovarian cancers yet form about half of malignant germ cell tumors. 75% occur in the second and third decades. Most of these tumors have no endocrine function. Few produce elevated levels of chorionic gonadotropin May have syncytiotrophoblastic giant cells on histologic examination Tumors confined to the ovary have an excellent prognosis, with 5-year survival approaching 100%. Dysgerminomas, like their testicular counterparts, are highly radiosensitive. Morphology Usually large, solid and bosselated with a smooth surface. Cut surface is soft, fleshy and bulging with a homogeneous pink-tan color Dysgerminoma Note lobulation and uniform tan color with foci of hemorrhage. Histology Sheets of monotonous rounded cells with central nuclei containing 1 to 2 prominent nucleoli, surrounded by fibrous stroma infiltrated with mature lymphocytes. Occasional giant cells which stain positively with hCG may be seen. There may be enough of these giant cells to produce clinically detectable hCG levels. Dysgerminoma Sheets of monotonous rounded cells with pale cytoplasm and central nuclei. Lymphocytes infiltrate the stroma. Teratoma A teratoma is a germ cell tumor that shows differentiation toward embryonic tissues. They are usually composed of tissues from any, but usually all three germ (embryonic) layers and which are foreign to the ovary. Subdivided into: Mature Immature Monodermal Unlike in the testis, the vast majority of ovarian germ cell tumors are benign mature cystic teratomas. Mature teratomas Are benign May be solid or cystic. Solid mature teratomas Are uncommon Always unilateral. Mature cystic teratomas 25% of all ovarian tumors 33% of all benign ovarian tumors Found mainly in young women between 20 and 30 years Are usually unilateral Also called dermoid cysts because 90% of the cysts are lined by mature epidermal tissue with underlying pilosebaceous structures. Typically filled with sebaceous material and hair. 30% contain well-formed teeth in the wall. Other tissues commonly seen include cartilage, bone, and respiratory epithelium Mature cystic teratoma - gross Containing hair and inspissated sebaceous material (lower right corner) Note well-formed tooth (upper right corner) Mature cystic teratoma histology showing keratinized squamous epithelium, and respiratory epithelium. Immature teratomas Composed totally or partially of immature or fetal tissues. Found mainly in young pre-pubertal adolescents and young women < 20 years ~ 20% of all malignant germ cell tumors Immature teratoma Gross Immature teratoma Microscopic Tumors are bulky with smooth external surfaces Usually unilateral Cut surface shows a solid or partly solid tumor with areas of necrosis and hemorrhage. There is a disorganized collection of tissues from the three germ layers with at least part showing immature, embryonic appearance. Neuroepithelium (brain tissue) is the most common immature element. Seen here is primitive neuroepithelium with multiple neural tubes High power view showing neural epithelium and neural tube. Monodermal teratomas Are teratomas that show unidirectional development to produce one tissue type. Are rare Most common are struma ovarii and carcinoid Are always unilateral Struma ovarii Composed entirely of mature thyroid tissue. There may be hyperfunction of the thyroid tissue to cause hyperthyroidism. Ovarian carcinoid Monodirectional differentiation toward argentaffin type cells The tumor may be functional, producing 5-hydroxytrptamine (serotonin) and cause the carcinoid syndrome Struma ovarii Showing mature thyroid follicles containing colloid. Endodermal sinus tumor (Yolk sac carcinoma) A highly malignant and clinically aggressive neoplasm Seen most frequently in young females particularly in the first three decades. It is rare after 40 years and is perhaps, the most rapidly growing neoplasm that occurs at any site. Is large, predominantly solid and shows extensive necrosis and hemorrhage. Many have already spread beyond the ovary at time of surgery with bulky, friable tumor filling the pelvic cavity. Patients commonly present with abdominal pain resembling acute abdomen The tumor displays multiple histologic patterns. Presence of Schiller-Duval body A glomerulus-like structure with central blood vessel surrounded by embryonal cells lying within a space also lined by embryonal cells. Conspicuous intra and extra cellular hyaline globules of alpha-fetoprotein are seen. AFP is secreted and appears in the blood as a biologic marker for the tumors used both for diagnosis and monitoring response to therapy Endodermal sinus tumor (Yolk sac carcinoma) Endodermal sinus tumor showing a Schiller-Duval body. Pink globules of alpha-fetoprotein are present both intra- and extra-cellularly. Choriocarcinoma Majority of choriocarcinomas occurring in women arises within the uterus, placental in origin. Arises much less commonly in the ovary from ovarian germ cells, unrelated to pregnancy and which differentiates into extra-embryonic (trophoblastic) tissue. Usually unilateral, solid and hemorrhagic. Clinically, the tumor behaves like the testicular form and has undergone wide hematogenous spread by the time of diagnosis. The serum marker for choriocarcinoma is beta-HCG used in diagnosis and to monitor response to treatment or tumor recurrence. Unlike gestational choriocarcinoma, the ovarian tumor is resistant to methotrexate, used in treating the former. There is often a marked response to newer forms of chemotherapy. Histologically, it is composed of malignant cytotrophoblasts and intermediate trophoblasts surrounded by syncytiotrophoblasts. Immunohistochemical staining shows production, or at least storage of hCG in syncytiotrophoblasts, but not in cytotrophoblasts. Choriocarcinoma Choriocarcinoma showing syncytiotrophoblasts (lower right corner) and cytotrophoblasts (upper left corner) Sex Cord - Stromal Tumors Account for about 3% of all ovarian tumors Are derived from the gonadal (sex) cords and stroma Thus tumors in this group may consist of ovarian stromal cells, theca cells, granulosa cells, Sertoli cells and Leydig cells either singly or in various combination. Account for the substantial majority of the hormonally active neoplasms of the ovary Neoplasms are either feminizing or virilizing The cells from which they are derived normally secrete estrogens (theca and granulosa cells), or , androgens (Leydig cells) Granulosa-theca cell tumor Composed almost entirely of granulosa cells or with varying proportions of theca cells. Granulosa-theca cell tumors the most common estrogenic ovarian neoplasm. Tumors with a prominent theca cell component are almost always hormonally active 75% of pure granulosa cell tumors are functional Virtually always unilateral The tumors exist in an adult and juvenile forms. Adult form occurs mainly in postmenopausal women Juvenile type occurs in the first two decades. Functioning tumors in prepubertal girls may cause precocious sexual development. In adults, they are associated with endometrial hyperplasia and carcinoma. Granulosa-theca cell tumor Gross-The tumors vary in size from small incidental findings to very large, focally cystic to entirely solid masses. Gross-Cut surface shows yellow and white areas with focal hemorrhages, which may be massive. Histologically- These tumors have very diverse appearances. The most well-known pattern consists of monotonous islands of granulosa cells with "coffee-bean" nuclei Containing small punched out spaces lined by granulosa cells giving a follicle-like appearance called Call-Exner bodies Fibroma-Thecoma Tumors arising in the ovarian stroma that are composed of either Fibroblasts (fibromas), or, Plump spindle cells with lipid droplets (thecomas) Mixture of these cells (fibroma-thecomas) Fibroma-thecomas of the ovary are unilateral in about 90% of cases Usually are solid, spherical or slightly lobulated, encapsulated, hard, gray-white masses covered by glistening, intact ovarian serosa Histologically, they are composed of well-differentiated fibroblasts with a more or less scant collagenous connective tissue interspersed between the cells. Fibromas Are the commonest ovarian stromal tumors. Pure forms are nonfunctioning Usually occur in middle-aged, perimenopausal women as unilateral, fibrous solid growths, with a hard, gray to white, whorled cut surface. Frequently extensively calcified and difficult to cut. Composed of well-differentiated fibroblasts in a collagenous stroma. Thecoma Pure theca cell tumors also occur, although rare. Are functional tumors producing estrogen and occur in postmenopausal women. Cause menstrual irregularities and breast enlargement. Endometrial hyperplasia or carcinoma may develop. Thecomas vary in size from small, impalpable tumors to large, rubbery, solid tumors, usually 5 to 10 cm in diameter and vary in color from yellow to orange depending on the amount of lipid content. Are virtually never malignant. Thecoma Solid tumor with variegated yellow - orange appearance due to lipid content Composed of sheets of round to oval cells with pale cytoplasm containing lipid. Sertoli-Leydig Cell Tumors (Androblastoma) Extremely rare (<1% of ovarian neoplasms) Unilateral Presence of cells resembling the Sertoli and Leydig cells of the testis. Predominantly in young women with mean age in the mid-twenties. Commonly androgenic May cause defeminization of women manifested as breast atrophy, amenorrhea, and loss of hair and hip fat. This may progress to virilization with hirsutism, male distribution of hair, hypertrophy of clitoris and deepening of the voice. Microscopically, well-differentiated tumors contain tubules composed of Sertoli cells surrounded by a stroma filled with Leydig cells, mimicking the architecture of the testis. Sertoli-Leydig Cell Tumors (Androblastoma) Gross-Vary in size from microscopic to very large, forming yellow to tan lobulated masses. Areas of hemorrhage and necrosis are present in some tumors Microscopically-Tubules lined by Sertoli cells and sheet of Leydig cells (upper right corner). Microscopically-Homogeneous, eosinophilic, rod-shaped structures - Reinkes crystals may be seen in some of the Leydig cells (Repeat Picture see also-Brenner Tumor, Female Genital Tract pg 35) Metastatic Ovarian Tumors The ovary may be the site of metastatic tumor. About 3% of malignant tumors in the ovary are metastatic. The most common primary site is the breast followed by the large intestine, stomach, and other genital tract organs. Most metastastases from the breast are microscopic. Metastases from the colon produce large ovaries, which may mimic primary ovarian tumor. Krukenberg tumor is applied to the uniform enlargement of the ovaries (usually bilaterally) due to diffuse infiltration of the ovarian stroma by metastatic signet-ring cell carcinoma. The commonest primary site is the stomach followed by the colon Diseases Of The Female Genital Tract Normal Embryology Anatomy Endometrial Histology and Menstrual Cycle Pathology Female Genital Infections Vulva Vagina Cervix Body of Uterus and Endometrium Fallopian Tubes Ovaries Gestational and Placental Disorders Female Genital Infections A large variety of organisms can infect the female genital tract Common, may cause significant discomfort with no serious sequelae: Candida infections Trichomoniasis Gardnerella Major causes of female infertility Gonorrhea Chlamydia Implicated in spontaneous abortions Mycoplasma infections Pathogenesis of vulvar and cervical cancer Viruses, principally the human papillomaviruses Infections Confined to Lower Genital Tract Herpes simplex infection Is common Lesions begin 3 to 7 days after sexual relations Lesions heal spontaneously in 1-3 weeks Involves the vulva, vagina, and cervix Vulva: Painful red papules > vesicles > coalescent ulcers Contains numerous virus particles High transmission rate during active infection Cervix and Vagina: Severe leukorrhea (genital discharge) Systemic symptoms, such as fever, malaise, and tender inguinal lymph nodes Gravest consequence: Transmission to the neonate during birth Highest risk infection is active during delivery and particularly if it is a primary (initial) infection in the mother Mycotic and yeast (Candida) infections Are common Diabetes mellitus, oral contraceptives, and pregnancy may enhance the development of infection Manifests as Small white surface patches Leukorrhea Pruritus Trichomonas vaginalis, a large, flagellated ovoid protozoan May occur at any age Seen in ~15% of women in STD clinic Purulent vaginal discharge and discomfort Vaginal and cervical mucosa has a characteristic fiery red appearance, called strawberry cervix. Diagnosis: Finding the organism in wet mounts of the lesions Pelvic Inflammatory Disease (PID) PID is a common disorder characterized by pelvic pain, adnexal tenderness, fever, and vaginal discharge Results from infection by one or more of the following groups of organisms: Gonococcus, chlamydia, and enteric bacteria Gonococcal inflammation begins usually in Bartholins and other vestibular glands or periurethral glands Cervix involvement is common and frequently asymptomatic From any of these loci, the organisms may spread upward to involve the tubes and tubo-ovarian region. The adult vagina is remarkably resistant to gonococcus, but in the child, presumably because of a more delicate lining mucosa, vulvovaginitis may develop. The nongonococcal bacterial infections that follow induced abortion, dilatation and curettage of the uterus, and other surgical procedures on the female genital tract are thought to spread from the uterus upward through the lymphatics or venous channels rather than on the mucosal surfaces. These infections therefore tend to produce less mucosal involvement but more reaction within the deeper layers. Morphology The complications of PID include (1) peritonitis; (2) intestinal obstruction owing to adhesions between the small bowel and the pelvic organs; (3) bacteremia, which may produce endocarditis, meningitis, and suppurative arthritis; and (4) infertility, one of the most commonly feared consequences of long-standing chronic PID. In the early stages, gonococcal infections are readily controlled with antibiotics, although regrettably penicillin-resistant strains have emerged. When the infection becomes walled off in suppurative tubes or tubo-ovarian abscesses, it is difficult to achieve a sufficient level of antibiotic within the centers of such suppuration to control these infections effectively. Postabortion and postpartum PIDs are also amenable to antibiotics but are far more difficult to control than the gonococcal infections. Sometimes it becomes necessary to remove the organs surgically. With the gonococcus, approximately 2 to 7 days after inoculation of the organism, inflammatory changes appear in the affected glands. Wherever it occurs, gonococcal disease is characterized by an acute suppurative reaction with inflammation largely confined to the superficial mucosa and underlying submucosa. Smears of the inflammatory exudate should disclose the intracellular gram-negative diplococcus, but absolute confirmation requires culture. If spread occurs, the endometrium is usually spared, for obscure reasons. Once within the tubes, an acute suppurative salpingitis ensues. The tubal serosa becomes hyperemic and layered with fibrin, the tubal fimbriae are similarly involved, and the lumen fills with purulent exudate that may leak out of the fimbriated end. Over days or weeks, the fimbriae may seal or become plastered against the ovary to create a salpingo-oophoritis. Collections of pus within the ovary and tube (tubo-ovarian abscesses) or tubal lumen (pyosalpinx) may occur. Adhesions of the tubal plica may produce gland-like spaces (follicular salpingitis). In the course of time, the infecting organisms may disappear, the pus undergoing proteolysis to a thin, serous fluid, to produce a hydrosalpinx or hydrosalpinx follicularis. PID caused by staphylococci, streptococci, and the other puerperal invaders tends to have less exudation within the lumina of the tube and less involvement of the mucosa, with a greater inflammatory response within the deeper layers. The infection tends to spread throughout the wall to involve the serosa and may often track into the broad ligaments, pelvic structures, and peritoneum. Bacteremia is a more frequent complication of streptococcal or staphylococcal PID than of gonococcal infections. VULVA Vulva is prone to skin infections because it is constantly exposed to secretions and moisture Nonspecific vulvitis is particularly likely to occur in blood dyscrasias, uremia, diabetes mellitus, malnutrition, and avitaminoses Diseases: Bartholins Cyst Vestibular Adenitis Vulvar Dystrophy Tumors Bartholins Cyst Acute infection of Bartholins gland produces Acute inflammation of the gland (adenitis) May result in a Bartholins abscess Bartholins cysts Common Occur at all ages Result from obstruction of Bartholins duct, usually by a preceding infection Can be up to 3 to 5 cm in diameter. Cyst is lined by either the transitional epithelium of the normal duct or squamous metaplasia Produce pain and local discomfort Treatment: Excised or opened permanently (marsupialization) Vestibular Adenitis Vulvar vestibule: Located in the posterior introitus at the entrance to the vagina Contains small glands in the submucosa (vestibular glands) Vestibular adenitis: Inflammation of vestibular glands Is associated with a chronic, recurrent, and exquisitely painful condition Treatment: Surgical removal of the inflamed mucosa Non-neoplastic Epithelial Disorders Characterized by opaque, white, scaly, plaque-like mucosal thickenings that produce vulvar discomfort and itching (pruritus) Non specific inflammatory alterations of vulva can be classified as: Lichen sclerosus: a characteristic disorder manifested by subepithelial fibrosis Squamous hyperplasia: characterized by epithelial hyperplasia and hyperkeratosis Lichen sclerosus Squamous Hyperplasia Fibrosis (arrow) Epithelial hyperplasia Thinning of epithelial layer Dermal chronic inflammation Vulval Tumors Benign Tumors Papillary Hidradenoma Condyloma Acuminatum Malignant Tumors Carcinoma and Vulvar Intraepithelial Neoplasia(VIN) Extramammary Pagets Disease Malignant Melanoma Vulva contains modified apocrine sweat glands Vulva may contain tissue closely resembling breast (ectopic breast) Develops two tumors with counterparts in the breast Papillary hidradenoma is identical in appearance to intraductal papillomas of the breast. Pagets disease Hidradenoma Presents as a sharply circumscribed nodule Most commonly on the labia majora or interlabial folds May be confused clinically with carcinoma because of its tendency to ulcerate Histologically: Tubular ducts lined by a single or double layer of nonciliated columnar cells Layer of flattened myoepithelial cells underlying the epithelium Characteristic of sweat glands and sweat gland tumors Condyloma Acuminatum Benign raised or wart-like (verrucous) conditions of the vulva occur in three forms. Condyloma acuminatum, a papillomavirus-induced squamous lesion also called venereal wart. Mucosal polyps, which are benign stromal proliferations covered with squamous epithelium Syphilitic condyloma latum Are sexually transmitted Benign tumors Have a distinctly verrucous gross appearance May be solitary , frequently multiple Involve perineal, vulvar, and perianal regions as well as the vagina and, less commonly, the cervix Lesions are identical to those found on the penis and around the anus in males A,B. External genitalia (female) C. Cytoplasmic Vacuolization (Koilocytosis) Marker for cytopathic effect of viruses D. Koilocytosis Condyloma Acummantum (cont.) Histologically: Consist of branching, tree-like proliferation of stratified squamous epithelium supported by a fibrous stroma Acanthosis, parakeratosis, hyperkeratosis, and, most specifically, nuclear atypia in the surface cells with perinuclear vacuolization (called koilocytosis) are present. Condylomata are caused by the human papillomavirus, specifically types 6 and 11,20 which are associated with benign warts and replicate in the squamous epithelium. Are not considered to be precancerous lesions Are a marker for sexually transmitted disease Malignant Tumors Carcinoma and Vulvar Intraepithelial Neoplasia (VIN) Extramammary Pagets Disease Malignant Melanoma Carcinoma and Vulvar Intraepithelial Neoplasia (VIN) Is an uncommon malignancy >65% occur in women over age 60 years 85% of these malignant tumors are squamous cell carcinomas In terms of etiology, pathogenesis, and clinical presentation, vulvar squamous cell carcinomas may be divided into two general groups: Associated with papillomavirus Asssociated with vulvular dystrophies Associated with papillomaviruses Coexists with or is preceded by a defined precancerous change, called vulvar intraepithelial neoplasia (VIN) Also known as carcinoma in situ or Bowens disease VIN is characterized by Nuclear atypia in the epithelial cells Increased mitoses Lack of surface differentiation Based on the severity of atypia, VIN may be graded as I (mild) II (moderate) III (severe) Lesions usually present as white or pigmented plaques on the vulva Associated with vulvar dystrophies Squamous cell hyperplasia / lichen sclerosus Etiology is unclear Infrequently associated with papillomaviruses Morphology Begin as small areas of epithelial thickening that resemble leukoplakia In the course of time, progress to create firm, indurated, exophytic tumors or ulcerated, endophytic lesions Are misinterpreted as dermatitis, eczema, or leukoplakia for long periods. Clinical manifestations Pain, local discomfort, itching, and exudation because superficial secondary infection is common Histologically Tumors associated with human papillomavirus or VIN tend to be poorly differentiated Others are usually well differentiated, with the formation of keratohyaline pearls and prickle cells Cancer of the Vulva Squamous Cell Carcinoma of Vulva Epithelial Pearl Squamous Cell Carcinoma Risk of metastatic spread is linked to Size of tumor Depth of invasion Involvement of lymphatic vessels Inguinal, pelvic, iliac, and periaortic lymph nodes are most commonly involved Dissemination to the lungs, liver, and other internal organs Lesions less than 2 cm in diameter have a 60 to 80% 5-year survival rate after treatment with one-stage vulvectomy and lymphadenectomy Larger lesions with lymph node involvement yield a less than 10% 5-year survival rate. Extramammary Pagets Disease Rare lesion of the vulva usually on the labia majora Manifests as a pruritic red, crusted, sharply demarcated, map-like area Diagnostic microscopic feature: Presence of large, anaplastic tumor cells lying singly or in small clusters within the epidermis and its appendages These cells are distinguished by a clear separation (halo) from the surrounding epithelial cells Finely granular cytoplasm containing PAS, alcian blue, or mucicarmine-positive mucopolysaccharide. Prognosis : Poor A.Note the appearance like an eczematoid rash (fiery red background mottled with white hyperkeratotic islands) B.Large Clear Tumor cells within squamous epithelium Malignant Melanoma Melanomas of the vulva are rare Peak incidence is in the sixth or seventh decade Overall survival rate is < 32% Prognosis depends on depth of invasion, > 60% mortality for lesions invading deeper than 1 mm Lesion stains with S100 which helps to differentiate it from Pagets disease Vagina Congenital Anomalies Premalignant and Malignant Neoplasms Congenital Anomalies Atresia Total absence of the vagina Septate, or double, vagina Arises from failure of total fusion of the mllerian ducts Accompanies double uterus (uterus didelphis) Gartners duct cysts Common lesions Found along the lateral walls of the vagina Derived from wolffian duct rests Are 1- to 2-cm, fluid-filled cysts that occur submucosally Premalignant and Malignant Neoplasms Benign tumors of the vagina Occur in reproductive-age women Consist of skeletal muscle (rhabdomyomas) Stromal (stromal polyps) tumors Leiomyomas Hemangiomas Malignant tumors Carcinoma Embryonal rhabdomyosarcoma (sarcoma botryoides) Adenocarcinoma Are rare Have received attention because of the increased frequency of clear cell adenocarcinomas in young women whose mothers had been treated with diethylstilbestrol (DES) during pregnancy (for a threatened abortion) < 0.14% of such DES-exposed young women develop adenocarcioma Tumors are usually discovered between the ages of 15 and 20 Composed of vacuolated, glycogen-containing cells, hence the term clear cell Because of its insidious, invasive growth, vaginal cancer (squamous and adenocarcinoma) is difficult to cure. Early detection by careful follow-up is mandatory in DES-exposed women Treatment: Surgery and irradiation Clear cell Carcinoma showing vacuolated tumor cells forming glands ( Morphology Most often located On the anterior wall of the vagina Usually in the upper third Vary in size from 0.2 to 10 cm in greatest diameter. A probable precursor of the tumor is vaginal adenosis A condition in which glandular columnar epithelium of mllerian type either appears beneath the squamous epithelium or replaces it. Adenosis presents clinically as red, granular foci contrasting with the normal pale pink, opaque vaginal mucosa. Microscopically the glandular epithelium may be either Mucus-secreting, resembling endocervical mucosa Tuboendometrial, often containing cilia Adenosis has been reported in 35 to 90% of the offspring of estrogen-treated mothers Vaginal Adenosis Red granular patches on the vaginal mucosa on the left Embryonal Rhabdomyosarcoma Also called sarcoma botryoides Very uncommon vaginal tumor Most frequently found in infants and in children under the age of 5 Consists predominantly of malignant embryonal rhabdomyoblasts Is thus a type of rhabdomyosarcoma Gross: Tumor tends to grow as polyploid, rounded, bulky masses that sometimes fill and project out of the vagina Have the appearance and consistency of grape-like clusters (hence the designation botryoides, grape-like) Histologically: Tumor cells are small and have oval nuclei, with small protrusions of cytoplasm from one end, so they resemble a tennis racket Treatment: Conservative surgery + chemotherapy Sarcoma Botyroides Cervix Inflammations Acute and Chronic Cervicitis Endocervical Polyps Intraepithelial and Invasive Squamous Neoplasia Chronic Cervicitis Chronic inflammation, sometimes ulceration with repair, atypia or dysplasia, nabothian cysts (from endocervical glands) Backache is a common symptom Chronic Cervicitis Chronic Cervicitis Nabothian Cysts  A.Endocervical glands blocked by inflammation or scarring. B.Chronic inflammation underlies an area of cervical dysplasia Cervix - Intraepithelial and Invasive Squamous Neoplasia Risk factors for cervical cancer: Early age at first intercourse Multiple sexual partners Male partner with multiple previous sexual partners Other risk factors (are subordinate to these three influences, primarily multiple sexual partners) Oral contraceptive use Cigarette smoking Parity Family history Associated genital infections Lack of circumcision in the male sexual partner. Pathogenesis Human papillomavirus is linked to cervical cancer Human papillomavirus DNA is detected in ~ 85% of cervical cancers ~ 90% of cervical condylomata and precancerous lesions Specific human papillomavirus types are associated with Cervical cancer (high risk) - Types 16, 18, 31, and 33 Condylomata (low risk) - Types 6, 11, 42, and 44 Human papillomavirus is not the only factor A high percentage of young women are infected with one or more human papillomavirus types during their reproductive years, and only a few develop cancer. Factors influencing whether the human papillomavirus infection remains subclinical (latent), turns into a precancer, or eventually progresses to cancer: Other co-carcinogens Immune status of the individual Nutrition ~15% of cervical cancers are not associated with human papillomavirus, implying other modes of cancer development, including host gene mutations Postulated Steps In Pathogenesis Cervical Intraepithelial Neoplasia Pre-cancerous lesion: May exist in the noninvasive stage for as long as 20 years Shed abnormal cells - detected on cytologic examination Represent a continuum of morphologic change with relatively indistinct boundaries Do not invariably progress to cancer May spontaneously regress Risk of cancer increasing with the severity of the precancerous change Associated with papillomaviruses Papanicolaou smear screening is an effective method in preventing cervical cancer Reason: Majority of cancers preceded by a precancerous lesion A.Normal exfoliated superficial squamous cervical epithelial cells B.Papanicolou Smear CIN I C.Papanicolou Smear CIN II D.Papanicolou Smear CIN III Note the increase in Nuclear-Cytplasmic Ratio Cervical intraepithelial neoplasia (CIN) classification CIN grade I: Mild dysplasia CIN grade II CIN grade III: Carcinoma in situ CIN I Extreme low end of the spectrum of morphologic change Lesions indistinguishable histologically from condylomata acuminata Exhibit koilocytotic atypia (viral cytopathic effect) with few alterations in the other cells in the epithelium Viral Cytopathic Effect of HPV in Condyloma CIN II Appearance of atypical cells in the lower layers of the squamous epithelium Atypical cells show changes characteristics of malignant cells: Change in nucleocytoplasmic ratio Variation in nuclear size (anisokaryosis) Loss of polarity Increased mitotic figures Hyperchromasia CIN III Progressive loss of differentiation with involvement of more and more layers of the epithelium Until totally replaced by immature atypical cells, exhibiting no surface differentiation Salient Points of CIN CIN almost always begins at the squamocolumnar junction, in the transformation zone. Lowest grade CIN lesions, including condylomata, mostly do not progress Lesions containing greater degrees of cellular atypia are at greater risk One-third of CIN I and two-thirds of CIN II lesions persist or progress to high grade Not all lesions begin as condylomata or as CIN I May enter at any point in the spectrum, depending on the associated human papillomavirus type and other host factors Lesions that have completely evolved (CIN III) constitute the greatest risk CIN III is most frequently associated with invasive cancer May develop in from a few months to over 20 years.45 Normal Cervical Epithelial Cervical Cancer Transformation Zone Squamous Cell Carcinoma Squamous cell carcinoma may occur at any age From the second decade of life to senility Peak incidence is occurring at an increasingly younger age: 40 to 45 years for invasive cancer 30 years for high-grade precancers Represents the combination of Earlier onset of sexual activity (i.e., earlier acquisition of human papillomavirus infection) Active Papanicolaou smear screening programs Detecting either cancers or precancerous lesions at an earlier point in life Squamous Cell Carcinoma Epithelial Pearls Invasive cervical carcinoma manifests in three distinctive patterns: Fungating (or exophytic) Most common variant Produces mass that projects above the surrounding mucosa Ulcerating Infiltrative cancer Advanced cervical carcinoma extends by direct continuity Involve every contiguous structure Peritoneum Urinary bladder Ureters Rectum Vagina Local and distant lymph nodes are also involved Distant metastasis - Liver, lungs, bone marrow, and other structures Normal Cervix (Nulliparous) Cervical Carcinoma Cervical Carcinoma Histologically: ~95% of squamous carcinomas composed of relatively large cells Keratinizing (well-differentiated) Nonkeratinizing (moderately differentiated) <5% are poorly differentiated small cell squamous More rarely small cell undifferentiated carcinomas (neuroendocrine or oat cell carcinomas) Resemble oat cell carcinomas of lung Unusually poor prognosis owing to early spread by lymphatics and systemic spread Cervical cancer Staging Stage 0: Carcinoma in situ (CIN III). Stage I: Carcinoma confined to the cervix. Ia: Preclinical carcinoma, i.e., diagnosed only by microscopy but showing: Ia1: Minimal microscopic invasion of stroma (minimally invasive carcinoma) . Ia2: Microscopic invasion of stroma of less than 5 mm in depth (microinvasive carcinoma). Ib: Histologically invasive carcinoma of the cervix that is greater than stage Ia2. Stage II: Carcinoma extends beyond the cervix but not onto the pelvic wall. Carcinoma involves the vagina but not the lower third. Stage III: Carcinoma has extended onto pelvic wall. On rectal examination, there is no cancer-free space between the tumor and the pelvic wall. The tumor involves the lower third of the vagina. Stage IV: Carcinoma has extended beyond the true pelvis or has involved the mucosa of the bladder or rectum. This stage obviously includes those with metastatic dissemination. Extensive Spread 10-25% of cervical carcinomas constitute adenocarcinomas, adenosquamous carcinomas, undifferentiated carcinomas, or other rare histologic types. Adenocarcinomas tend to have a less favorable prognosis than squamous cell carcinoma of similar stage Clear cell adenocarcinomas of the cervix in DES-exposed women are similar to those occurring in the vagina Clinical Course Precancer / Precursors Cancer of the cervix and its precursors evolve slowly over the course of many years During this interval, the only sign of disease may be the shedding of abnormal cells from the cervix Periodic Papanicolaou smears Performed on all women after they become sexually active Detects the possible presence of a cervical precancer or cancer It does not make an absolute diagnosis Colposcopic examination of the cervix CIN lesions are characterized by white patches on the cervix following the application of acetic acid Clinically overt cervical cancers produce Irregular vaginal bleeding Leukorrhea Bleeding Pain on coitus Dysuria Treatment Depend on the stage of the neoplasm Treatment of precursors Papanicolaou smear follow-up (for mild lesions) Cryotherapy Laser Wire loop excision Cone biopsy Invasive cancers Hysterectomy Radiation for advanced lesions Prognosis Prognosis and survival for invasive carcinomas depends on the stage at which cancer is first discovered With current methods of treatment, there is a 5-year survival rate: Stage I - 80 to 90% Stage II - 75% Stage III - 35% Stage IV - 10 to 15% Die as a consequence of local extension of the tumor Into and about the urinary bladder and ureters, leading to ureteral obstruction, pyelonephritis, and uremiarather than distant metastases Functional Endometrial Disorders (Dysfunctional Uterine Bleeding)  During active reproductive life Pituitary and ovarian hormones > Endometrium sheds and regrows Alterations may result in a spectrum of disturbances Atrophy Abnormal proliferative or secretory patterns Hyperplasia Occurrence of excessive bleeding during or between menstrual periods most common problem Causes of abnormal bleeding from the uterus are many and varied Largest single group is dysfunctional uterine bleeding Abnormal bleeding in the presence of a functional disturbance rather than an organic lesion of the endometrium or uterus Dysfunctional Uterine Bleeding - Anovulatory Cycle Mostly is due to the occurrence of an anovulatory cycle Most common at menarche and the perimenopausal period Results in excessive and prolonged estrogenic stimulation without the development of the progestational phase that regularly follows ovulation Failure of ovulation results in prolonged, excessive endometrial stimulation by estrogens Endometrial glands undergo mild architectural changes, including cystic dilatation (persistent proliferative endometrium) Less commonly, lack of ovulation is the result of An endocrine disorder Thyroid disease Adrenal disease Pituitary tumors Primary lesion of the ovary Functioning ovarian tumor (granulosatheca cell tumors) Polycystic ovaries Generalized metabolic disturbance Marked obesity Severe malnutrition Chronic systemic disease In most patients, however, anovulatory cycles are unexplainable Oral Contraceptives and Induced Endometrial Changes Oral contraceptives containing synthetic or derivative ovarian steroids induces a wide variety of endometrial changes, depending on the steroid used and the dose. A common response pattern is a discordant appearance between glands and stroma usually with inactive glands amidst a stroma showing large cells with abundant cytoplasm reminiscent of the decidua of pregnancy. When such therapy is discontinued, the endometrium reverts to normal. All these changes have been minimized with the newer low-dose contraceptives. Adenomyosis Definition: Some endometrial glands extending beneath this interface to form nests deep within the myometrium Endo-myometrial interface is usually sharply demarcated Cause: Unknown Incidence: ~15 to 20% of uteri Result: Causes expansion (enlargement) of the uterine wall Gross Examination: Numerous small cysts Microscopically: Irregular nests of endometrial stroma, with or without glands Arranged within the myometrium, separated from the basalis by at least 2 to 3 mm Consequences: Shedding of the endometrium during the menstrual cycle Hemorrhage within these small adenomyotic nests results in: Menorrhagia Colicky dysmenorrhea Dyspareunia Pelvic pain Particularly during the premenstrual period. Endometriosis Presence of endometrial glands or stroma in abnormal locations outside the uterus Seen in active reproductive life Most often in the third and fourth decades It occurs in the following sites, in descending order of frequency: Ovaries Uterine ligaments Rectovaginal septum Pelvic peritoneum Laparotomy scars Rarely in the umbilicus, vagina, vulva, or appendix Three potential explanations exist to explain the origin of these dispersed lesions Regurgitation theory: Retrograde menstruation through the fallopian tubes occurs regularly even in normal women Could mediate spread of endometrial tissue to the peritoneal cavity Metaplastic theory: Endometrium could arise directly from coelomic epithelium Vascular or lymphatic dissemination theory: Explains the presence of endometriotic lesions in the lungs or lymph nodes Morphology Foci of endometrium is under the influence of the ovarian hormones Therefore undergo the cyclic menstrual changes with periodic bleeding Produces nodules Red-blue to yellow-brown appearance On/just beneath the serosal surfaces in the site of involvement In extensive disease Organizing hemorrhage causes extensive fibrous adhesions between tubes, ovaries, and other structures and obliteration of the pouch of Douglas Ovaries may become markedly distorted by large cystic spaces (3 to 5 cm in diameter) filled with brown blood debris to form so-called chocolate cysts A histologic diagnosis of endometriosis is satisfied if two of the three following features are identified: Endometrial glands Stroma Hemosiderin pigment Ovary sectioned to reveal large endometriotic cyst Contains necrotic brown blood (chocolate cyst) Lining of an endometrial cyst Endometrial gland (right) Endometrial stroma with plump stromal cells charecteristic of decidual changes (left) Macrophages containing hemosiderin (centre) Clinical features Severe dysmenorrhea Dyspareunia Pelvic pain owing to Intrapelvic bleeding Periuterine adhesions Pain on defecation Rectal wall involvement Dysuria Involvement of the serosa of the bladder Intestinal disturbances may appear when the small intestine is affected Menstrual irregularities are common Infertility is the presenting complaint in 30 to 40% of women Endometrial hyperplasia Is another cause of abnormal bleeding Differs from typical anovulation by the degree of glandular epithelial alterations in the endometrium There is a relationship with endometrial carcinoma Related to an abnormally high, prolonged level of estrogenic stimulation with diminution or absence of progestational activity Occurs most commonly Around menopause In association with persistent anovulation in younger women. Conditions leading to hyperplasia include Polycystic ovarian diseaseincluding Stein-Leventhal syndrome Functioning granulosa cell tumors of the ovary Excessive cortical function (cortical stroma hyperplasia) Prolonged administration of estrogenic substances (estrogen replacement therapy) Morphology Endometrial hyperplasia exhibits a continuum of alterations in gland architecture, epithelial growth pattern and cytology, and the grade increases as a function of the severity of these changes. Lower grade hyperplasias Include simple hyperplasia and complex hyperplasia Simple hyperplasia Also known as cystic or mild hyperplasia Characterized by the presence of architectural alterations in glands of various sizes, producing irregularity in gland shape with cystic alterations. The epithelial growth pattern and cytology are similar to proliferative endometrium, although mitoses are not as prominent The stroma between glands also is frequently increased These lesions uncommonly progress to adenocarcinoma cystic hyperplasia frequently evolves into cystic atrophy in which the epithelium and stroma become atrophic. Complex hyperplasia, also known as adenomatous hyperplasia without atypia, exhibits an increase in the number and size of endometrial glands, with gland crowding and a disparity in their size and irregularity in their shape. The glands undergo budding with finger-like outpouchings into the adjacent endometrial stroma. The lining epithelium may appear more stratified than simple hyperplasia but is regular in contour and devoid of conspicuous cytologic atypia (see Figure 23.28B ). In the absence of cytologic atypia, less than 5% of these lesions evolve into carcinoma. Simple (cystic) hyperplasia Higher grade hyperplasias are usually termed atypical hyperplasia, or adenomatous hyperplasia with atypia. In addition to glandular crowding and complexity, epithelial lining is irregular, characterized by stratification, scalloping, and tufting. Importantly, there is cellular atypia with cytomegaly, loss of polarity, hyperchromatism, prominence of nucleoli, and altered nuclear cytoplasmic ratio (see Figure 23.29 ). Mitotic figures are common. Predictably, in the most severe forms, cytologic and architectural atypia may resemble frank adenocarcinoma, and an accurate distinction between atypical hyperplasia and cancer may not be made without hysterectomy (see Figure 23.30 ). In one study, 23% of patients with atypical hyperplasias eventually developed adenocarcinoma.55 In another study in which atypical hyperplasias were treated with progestin therapy alone, 50% persisted despite therapy, 25% recurred, and 25% progressed to carcinoma.56 Carcinoma of the endometrium Uncommon in women younger than 40 years of age Peak incidence 55- to 65-year-old woman A higher frequency of this form of neoplasia is seen with Obesity Diabetes (abnormal glucose tolerance is found in more than 60%) Hypertension Infertility Women who develop cancer of the endometrium tend to be single and nulliparous and to give a history of functional menstrual irregularities consistent with anovulatory cycles In terms of potential pathogenesis, two general groups of endometrial cancer can be identified The first and the most well studied develops on a background of prolonged estrogen stimulation and endometrial hyperplasia. Both conditionshyperplasia and cancerappear related to obesity and anovulatory cycles. Additional support includes the following: Women with ovarian estrogen-secreting tumors have a higher risk of endometrial cancer Endometrial cancer is extremely rare in women with ovarian agenesis and in those castrated early in life Estrogen replacement therapy is associated with increased risk in women, and prolonged administration of DES to laboratory animals may produce endometrial polyps, hyperplasia, and carcinoma In postmenopausal women, there is greater synthesis of estrogens in body fats from adrenal and ovarian androgen precursors, a finding that may partly explain why there is increased risk of endometrial cancer with age and obesity. Endometrial carcinomas that are associated with the aforementioned risk factors tend to be well differentiated and mimic normal endometrial glands (endometrioid) in histologic appearance. This group of tumors is generally associated with a more favorable prognosis, as described subsequently.62 A second and not insignificant subset of patients with endometrial cancer less commonly exhibits the stigmata of hyperestrinism or pre-existing hyperplasia and acquires the disease at a somewhat older age on average. In this group, tumors are generally more poorly differentiated, including tumors that resemble subtypes of ovarian carcinomas (serous carcinomas). Overall these tumors have a poorer prognosis than endometrioid tumors, and the factors predisposing to their development are obscure Endometrial Polyp Benign; arise in fundus Women over 40 Cause vaginal bleeding (menorrhagia) Not precancerous but may harbor an adenocarcinoma Usually sessile masses composed of hyperplastic endometrium which is cystic Endometrial Polyp Endometrial polyps cause vaginal bleeding and must be differentiated from uterine cancer Endometrial Hyperplasia Abnormal proliferation of endometrial glands Due to prolonged estrogenic stimulation unopposed estrogen therapy hyperestrinism (Stein-Leventhal or granulosa cell tumors of ovary) Clinically present with vaginal bleeding Endometrial Hyperplasia WHO Committee Classification Simple hyperplasia without atypia (SH)-(Cystic hyperplasia): large dilated glands, minimal glandular complexity, no cytologic atypia; 1% progress to adenocarcinoma Simple hyperplasia with atypia (SAH)-no previous category in old classificati Complex hyperplasia without atypia-CH (adenomatous hyperplasia without atypia): complex glands with crowding but no atypia; 3% progress Complex hyperplasia with atypia-(CAH) (Atypical Hyperplasia): more glands, crowding with back-to-back glands; atypia; 33% chance of progression-(progression takes 4 years)-15-33% of patients will have a well-differentiated adenocarcinoma in the hysterectomy specimen Endometrial Hyperplasia A,B.Simple Endometrial Hyperplasia Large, dilated glands with minimal glandular complexity and minimal proliferation C.Complex hyperplasia Complex glands with crowding ID/CC: A 60 year old obese, nulliparous white female presents with intermittent postmenopausal vaginal bleeding of three months duration HPI: she has a history of diabetes, hypertension, and infertility with polycystic ovaries; menopause began at 56 years of age PE: Uterus is not enlarged on bimanual palpation; remainder of physical exam unremarkable Imaging stripe: US-Pelvic: thickening of endometrial Endmetrial Carcinoma: * MC invasive cancer of the female genital tract; best prognosis of gynecologic cancers Endometrial Carcinoma Risk Factors: Hyperestrinism or prolonged estrogenic stimulation of endometrium Obesity Nulliparity Diabetes Hypertension Infertility Breast Cancer; Colon Cancer Low fiber/High fat diet Early menarche or late menopause Granulosa cell tumors of ovary Tamoxifen (a nonsteroidal hormone with antiestrogenic effect in reproductive age women) Has a weak estrogenic effect in postmenopausal women. Over 80 cases of endometrial carcinoma have been reported in women with breast cancer who have been treated with tamoxifen Endometrial or clear cell carcinomas of ovary Peak age Overall: 55-65 years Fungating, polypoid tumors presenting with VAGINAL BLEEDING MC site of metastasis-lung Depth of myometrial invasion and stage are key prognostic factors MC histologic type: Endometrioid Adenocarcinoma (more solid areas reflect poor differentiation)-low grade, estrogen related, usually associated with endometrial hyperplasia, occurs in younger perimenopausal women Other types: Serous, Adenosquamous, Cell cell carcinomas: more aggressive, older women, unrelated to estrogen Endometrial Carcinoma: #1 cause of post menopausal A large, fungating mass is filling the endometrial cavity. ID/CC A 39 year old black female presents with a several-month long history of profuse menstruation and frequent menstrual periods HPI Further questioning also reveals painful periods and increasing urinary frequency. She has a history of infertility and recurrent spontaneous abortions. PE Enlarged, irregular uterus on bimanual palpation with several masses on posterior wall LEIOMYOMA OF UTERUS Fibroid tumor: benign tumor of smooth muscle origin; MC uterine tumor MC overall tumor in women MC location- uterus; second-stomach More common in blacks Estrogen-sensitive-may enlarge during pregnancy If subendometrial-present with vaginal bleeding Leiomyoma of Uterus A well-circumscribed A small intramyometrial composed of interlacing bundles leiomyoma leiomyoma of smooth muscle cells with rare mitotic figures ID/CC A 60 year old woman visits her gynecologist because of a foul-smelling, blood-tinged purulent vaginal discharge HPI She has never been married and has never been pregnant. She is hypertensive and takes oral hypoglycemic agents for diabetes PE VS: BP normal at present. PE: overweight; fleshy, bulky, fungating tumor protruding from cervical os on vaginal speculum exam Leiomyosarcoma of Uterus MC uterine sarcoma Arises de novo and not from leiomyoma Mean age of patients is > 50; more common in Blacks Bulky tumor with areas of necrosis and hemorrhage Look for increased numbers of mitoses per high powered field and atypical mitoses Salpingitis Most often associated with inflammation of ovaries and other adjacent tissue (PID) Most infections are polymicrobial Chlamydia trachomatis is most common followed by Neisseria gonorrhea Others including anaerobes, Bacteroides, Clostridium, Mycoplasma hominis, Ureaplasma urealyticum Anaerobes TB in underdeveloped countries Acute Salpingitis A normal fallopian tube distention of the fimbriae with acute inflammatory cells Higher magnification of acute salpingitis. violin-string adhesions in Fitz-Hugh-Curtis syndrome Pelvic Inflammatory Disease Causes: Ascending infection via sexual intercourse IUDs Postpartum endometritis Curettage from abortion that becomes infected Complications ectopic pregnancy, infertility, tubo-ovarian abscesses, pyosalpinx, peritonitis, bacteremia, Fitz-Hugh-Curtis (perihepatitis, violin-string adhesions) syndrome, bowel obstruction ID/CC A 25 year old woman presents with amenorrhea of six weeks duration and pelvic pain over the past day HPI She has a history of vaginal spotting off and on for the past two weeks and has been using an IUD for the past three years. She has no history of vaginal discharge and no urinary symptoms, and her previous menstrual history is normal. She has had multiple bouts of PID. PE VS: normotension. PE: pallor; abdominal distention and decreased bowel sounds; cervical motion tenderness; uterus soft and slightly enlarged on pelvic exam; soft, tender boggy mass in right adnexa and pouch of Douglas Labs CBC: anemia. -hCG levels lower than expected for this period of gestation; culdocentesis reveals presence of blood in the cul-de-sac; Imaging US-pelvic: no products of conception in uterus PathologyArias-Stella reaction without villi Ectopic Pregnancy 95% occur in fallopian tube due to previous PID Produce hematosalpinx MC cause is chronic salpingitis; PID Clinical presentation Abdominal pain-sudden onset-may be hypogastric Anomalous uterine bleeding following a period of amenorrhea Rupture is most common cause of death in early pregnancy Differential: Acute appendicitis, Torsion of ovarian cyst or ruptured ovarian cyst, PID, Mesenteric Lymphadenitis DX: Ultrasound, Serum beta hCG, unclotted blood in rectovaginal pouch Ectopic Pregnancy An ectopic pregnancy showing a developing fetus. Fallopian tube tumors Adenomatoid tumor: MC benign tumor of the fallopian Adenocarcinoma Most often results from direct extension or metastasis from tumors originating elsewhere Fallopian Tube Tumors This is an example of an adenocarcinoma of the fallopian tube which is the most common primary tumor Pouch of Douglas Pathology Anterior to the rectum and posterior to the uterus; palpable with a rectal exam Induration in a young woman: endometrial implants Induration in elderly: seeding from primary ovarian cancer Unclotted blood: ruptured ectopic Pus: PID Manifestations of Ovarian Disease Infertility: caused by failure of ovulation Menstrual irregularities: due to abnormal patterns of secretion of ovarian hormones Ovarian Masses Pelvic discomfort: very large masses Pelvic pain General Points - Ovary Pregnancy is the MCC of a pelvic mass associated with amenorrhea A functional ovarian cyst is the MC pelvic mass in menstruating reproductive-age women Most childhood pelvic masses in females are either neoplastic or endocrine in origin Originate from germ cells 80% of the time During infancy, the MC adnexal mass is an ovarian cyst (relates to maternal estrogen); transient menses; regresses In children <2, 40% of abdominal masses are renal in origin The occurrence of new pelvic pain in a pre-menarchial girl or a postmenopausal woman is more often found associated with significant pathology ID/CC A 20 year old Asian female visits her family doctor because of chronic, intermittent left lower quadrant pain. HPI The pain is not accompanied by dyspareunia, menstrual irregularity, vaginal discharge, abdominal distention, nausea, vomiting, or diarrhea. It is not correlated with her menstrual periods PE Left adnexal mass on bimanual exam; uterosacral ligaments normal; pouch of Douglas normal; McBurneys point nontender; no evidence of ascites; remainder of exam normal Labs Routine labs normal; CA-125 not elevated Follicular Cyst of Ovary Unruptured graafian follicles or follicles that have ruptured and immediately sealed Filled with clear serous fluid and lined by a grey, glistening membrane Unilocular without internal excrescences Sometimes associated with hyperestrinism and endometrial hyperplasia MOST COMMON OVERALL OVARIAN MASS Follicular Cysts  Follicular cysts have smooth linings and are unilocular with no excrescences. The arrow is pointing to the single cell lining of a cyst Large cysts are noted in both of these ovaries Both of the ovaries from the specimen on the left have multiple follicular cysts; The cyst on the right has hemorrhaged. ID/CC A 27 year old white female is admitted to the infertility clinic for evaluation of her inability to conceive; she also complains of dyspareunia and dysmenorrheal HPI She is nulligravida. On directed history she admits to having rectal pain during menstruation; she also complains of having an abundant menstrual period (=menorrhagia or hypermenorrhea) PE Bluish spots in posterior fornix on vaginal speculum exam; fixed tender bilateral ovarian masses palpable during menstruation on bimanual exam; induration in pouch of Douglas with multiple small nodules palpable through posterior fornix Endometriosis Ovary most common location Produces Chocolate cysts Multiple Filled with dark-brown iron-containing fluid Cysts lined by endometrial epithelium and stroma A cyst of the ovary (endometrioma) is filled with dark blood (chocolate cyst). Polycystic Ovarian Disease Bilateral Multiple follicular cysts (lack of FSH leads to atresia of follicles) Absence of corpora lutea Hyperplastic ovarian stroma-low FSH and high LH (ratio > 3/1) FSH is not increased with LH, probably because of the synergistic negative feedback of chronically elevated estrogen levels and normal follicular inhibin Increased LH stimulates the ovary to produce testosterone and 17-ketosteroids (androgens leading to hirsutism); increased adipose aromatizes androgens to estrogens (endometrial hyperplasia/cancer) Polycystic Ovarian Syndrome: Oligomenorrhea, Amenorrhea, infertility, virilism (Stein-Leventhal syndrome) and obesity Excess androgens-hirsutism Elevated estrogens- endometrial hyperplasia and menorrhagia Increased risk of endometrial CA Insulin resistance and hyperinsulinism-caused by obesity SHBG is decreased with excess androgens and insulin increase leading to increase in free testosterone Acanthosis nigricans is a marker for insulin resistance in hirsute women Treatment: Birth control pills or clomiphene if patient wants to become pregnant Note the hirsuitism and obesity. The section of ovary on the right shows a hyperplastic stroma and multiple follicular cysts Surface Coelomic Epithelium Derived Tumors Clear Cell Carcinoma Serous Tumors Mucinous Tumors Endometrioid Tumor Brenner Tumor Undifferentiated Sex-Cord-Stromal Cell Derived Tumors Granulosa-Theca Cell Tumors Thecoma-Fibromas Sertoli-Leydig Cell Tumors (Androblastomas) Sex Cord Tumor with Annular Tubules Steroid (Lipid) Cell Tumors Stromal luteomas Hilum cell tumors Germ Cell Derived Ovarian Tumors Teratoma (Cystic and Immature) Dysgerminoma Yolk Sac tumor Embryonal Cell carcinoma Choriocarcinoma Facts Regarding Ovarian Tumors 80-90% of ovarian neoplasms are benign Most common overall benign tumor and most common benign surface derived tumor: serous cystadenoma; second is Brenners tumor Most ovarian tumors are in 20-45 year olds High mortality rate in ovarian cancer due to late clinical presentation Risk factors for cancer nulliparity family history Fixed, irregular nodular adnexal mass with cul-de-sac nodularity or a palpable post-menopausal ovary should be considered malignant until ruled otherwise Facts Regarding Ovarian Neoplasms MC gynecologic malignancy=endometrial CA of uterus Second MC gynecologic malignancy=ovary Third MC gynecologic malignancy=cervix 30% of adnexal masses in women >50 are malignant Most ovarian tumors arise from surface epithelium (65%) SURFACE EPITHELIAL DERIVED TUMORS REPRESENT 94% OF MALIGNANT TUMORS OF THE OVARY The MC pelvic mass in postmenopausal women is a leiomyoma of uterus Ca 125 is the tumor marker for surface epithelial derived tumors of ovary; CEA is associated with mucinous cystadenoma (borderline) and cystadenocarcinoma Serous cystadenoma-Benign 20% bilateral 75% of serous tumors are benign or borderline 20-50 years of age Unilocular or multilocular with lining epithelium resembling fallopian tube-no papillary structures or epithelial thickening Most common overall benign tumor Serous Cystadenoma  The lining of cysts in a serous cystadenoma resembles fallopian tube epithelium. It is a single cell layer. ID/CC A 56 year old white nulliparous woman is referred for evaluation of pelvic mass found on routine physical HPI She reports increased frequency of micturition and irregular periods until they ceased three years previously. She has a history of breast cancer in the distant past. PE Large cystic mass the size of a grapefruit in right pelvis that can be felt above the pubis symphysis Labs CA-125 levels elevated Serous Cystadenocarcinoma 40% of all cancers of ovary MC malignant primary ovarian tumor 66% bilateral Psammoma bodies-see on x-ray Stratification >3 cell layers; nuclear atypia; stromal invasion; hemorrhage and necrosis; solid areas Serous Cystadenocarcinoma    A,B. These tumors have solid areas and the cyst lining is stratified with >3 cell layers. Nuclear atypia is noted; Psammoma bodies are present C. Another example of a malignant serous tumor with psammoma bodies Mucinous Cystadenoma These tumors reach the largest sizes of all ovarian tumors. Mucinous Cystadenoma The lining of the cysts resembles endocervical mucosa. It will be a single cell layer. The cysts are filled with sticky, gelatinous fluid Mucinous Cystadenocarcinoma 20% bilateral Solid areas with atypia and no connective tissue supports or cribriform pattern, stratification ( > 4 cell layers), necrosis, glandular structures Pseudomyxoma peritonei-may cause bowel obstruction; most common associated with pseudomyxoma peritonei Also due to CA of Gastrointestinal tract and appendix) Associated with CEA production Mucinous Cystadenocarcinoma The patient on the left has pseudomyxoma peritonii with massive ascites. Malignant serous tumors have solid areas and complex lining to the cystic spaces with a cribriform appearance Endometrioid Tumors 20% of malignant ovarian tumors Most are malignant; greatest association of ovarian tumors with endometriosis 40% bilateral Composed of glands resembling endometrial glands 15-33% accompany carcinoma of endometrium 40-50% 5-year survival-Best of surface epithelial derived tumors mimics the endometrial glands and stroma best prognosis of all of the surface derived ovarian tumors Clear Cell Adenocarcinoma May occur in association with endometriosis or endometrioid CA of ovary Resembles clear cell CA of endometrium (A histologic variant of endometrial CA) Solid or Cystic-large cells with clear abundant cytoplasm; the cells lining the cysts are called hobnail cells Another example of clear cell carcinoma. Note the hob-nail cells lining the cysts on the right Brenner Tumor of Ovary Adenofibroma-composed of nests of epithelial cells which resemble transitional cells of the urinary bladder (Walthards rests) + fibrous stroma Benign 90% unilateral Note the presence of Walthard Rests resembling transitional epithelium. These are diagnostic features of the Brenner tumor Germ cell tumors of ovary 15-20% of all ovarian tumors Most are benign cystic teratomas Composed of cells derived from oocytes Teratoma-Mature (Benign) Also called Dermoid Cysts; originate from a single germ cell after its first meiotic division Young women (age 20-40) Contain ectoderm, endoderm, and mesoderm Often are calcified usually bone or tooth formation; most cysts are unilocular and lined by skin tissue 10-15% bilateral; risk is undergoing torsion If malignant component-squamous cell carcinoma ovarian cystic teratomas Benign Cystic Teratoma Gross of a teratoma on left; on right, CNS tissue, pigmented retina, and sebaceous glands Immature Malignant Teratomas Component tissue resembles fetal tissue Mean age=18 Solid tumors; 3rd most common malignant ovarian germ cell tumor Grading of tumor based on amount of tumor tissue that is immature neuroepithelium Note the presence of immature neuroepithelium Specialized Teratomas Struma ovarii Unilateral Mature thyroid tissue which may produce hyperthyroidism Carcinoid tumor Unilateral May produce carcinoid syndrome Distinguish from metastatic carcinoid to ovary=bilateral; AGGRESSIVE Struma ovarii (thyroid tissue) on the left Carcinoid tumor on the right Dysgerminomas of Ovary 2% ovarian cancers 50% of malignant germ cell tumors; most common malignant germ cell tumor 75% occur in 2nd and 3rd decade Unilateral-80-90% Large anaplastic cells with prominent nucleoli + benign lymphoid stroma Usually no endocrine function; few produce hCG; LDH elevated Radiosensitive; now being treated with cisplatin Associated with Turners syndrome A,B. Dysgerminomas are solid tan tumors; microscopically, they are composed of nests of germ cells with lymphocytes in the stroma C. High magnification showing the nests of germ cells and lymphocytes in the stroma. Endodermal Sinus (Yolk Sac Tumor) Second MC malignant germ cell tumor; rare Alpha-fetoprotein is tumor marker Also produces Alpha-1-antitrypsin Glomerular like structures composed of a central blood vessel enveloped by germ cells (Schiller-Duval body) Patients are children or young women (in age group under 20 years, yolk sac tumors are as common as dysgerminoma) who present with abdominal pain and a rapidly expanding pelvic mass Unilateral A.Yolk sac tumors resemble primitive lung tissue. B.A Schiller-Duval body is seen on the far right (blood vessel surrounded by germ cells) C.A Schiller-Duval Body on the left D.The slide on the right show eosinophilic droplets of alpha-fetoprotein Embryonal Carcinoma Unilateral; young patients Present with an abdominal mass Positive pregnancy test due to -hCG; tumor also produced alpha-fetoprotein (only tumor producing both) A pluripotential stem cell tumor capable of differentiating along different pathways Choriocarcinoma Nongestational primary choriocarcinoma of the ovary is rare and malignant Sex Cord-Stromal Tumors Tumors derived from ovarian stroma which is derived from the sex cords of the embryonic gonad Counterpart tumors in males May be associated with Peutz-Jegher syndrome Granulosa-Theca Cell Tumor 5% of all ovarian tumors 2/3 occur in post-menopausal women Present with endometrial hyperplasia, cystic disease of breast, endometrial carcinoma Also occur in young girls Precocious sexual development Excess estrogen Call-Exner body-central cystic cavity filled with eosinophilic fluid surrounded by granulosa cells resembling a follicle These tumors are typically hormone-producing A microscopic marker is the Call-Exner body(a cluster of tumor cells resembling a graffian follicle of the ovary Granulosa-Theca Cell tumor Call-Exner Body on the left Granulosa cells with bean-shaped nuclei Thecoma-Fibromas 90% unilateral Fibroblasts (fibromas)(no estrogen) or plump spindle cells with lipid droplets (thecomas)-produce estrogen Fibromas are the MC sex-cord stromal tumor-frequently calcify Thecoma: 80% of patients are postmenopausal; less common than granulosa cell tumors Present with pain and pelvic mass Meigs syndrome: Hydrothorax (right side) + ovarian tumor (fibroma) + ascites Associated with basal cell nevus syndrome The yellow-staining portions of the tumor are the hormone positive areas. This can be demonstrated by lipid stains of the tumor (note the red areas) Ovarian Fibromas Bilateral Ovarian Fibromas Note the massive enlargement of both ovaries by fibromas. The arrow indicates the uterus Sertoli-Leydig Cell Tumors (Androblastoma or Arrhenoblastoma) Peak age: 2nd and 3rd decade Virilizing tumors-excess androgens Rarely produce estrogens Benign These tumors typically produce androgens Sex Cord Tumor with Annular Tubules (SCTAT) 33% of cases are associated with Peutz-Jeghers syndrome Features are intermediate between a granulosa cell tumor and a Sertoli cell tumor Hilar Cell (Steroid) Tumors (Leydig Cell Tumors) Benign Secrete androgens Unilateral Contain large, lipid filled cells and rod-like crystals called REINKE CRYSTALLOIDS A characteristic microscopic feature of the hilar cell tumor is the Reinke crystalloid.  Gonadoblastoma Ovarian Tumors of Dysgenetic Gonads Combination of a germ cell tumor plus a sex-cord stromal tumor Occurs with gonadal dysgenesis-usually Turners syndrome with a Y chromosome; all patients are genotypic males with a Y chromosome 80% are phenotypic females 50% have associated dysgerminoma May calcify Benign Characteristic features of gonadoblastoma. Note the glandular spaces on the left and right and the calcifications on the right (arrow) Ovarian Tumors that may Calcify Fibromas Cystic Mature Teratomas Gonadoblastomas Serous Epithelial Tumors with Psammoma bodies Metastatic Tumors to Ovary Breast Cancer MC Carcinoma of stomach (signet ring type) Krukenberg tumors-metastatic mucin-producing adenocarcinomas-usually gastric-but may be from other sites Colon carcinoma: may be microscopically confused with endometrioid carcinoma Burkitts lymphoma may involve ovary Metastatic Adenocarcinoma to Ovary Note the nests of malignant cells within mucin lakes on the left; the slide on the right shows signet ring cells from stomach producing a Krukenberg tumor Female Genital Tumors The only primary tumors of the female genital tract that are associated with ascites are derived from the ovary!! Placental Pathology Spontaneous Abortion A pregnancy that terminates usually before the 22nd week of gestation (before the fetus is capable of extrauterine life) 45% of fertilized ova are aborted Majority of errors are in maternal gametogenesis Causes include: problems with the ovum or fetus (50% have trisomy 16; hydatidiform mole, neural tube defects) infection early in pregnancy mechanical factors affecting the uterus endocrine factors or immunologic factors Patients present with vaginal bleeding and lower abdominal pain Placenta accreta Attachment of the placenta directly to the myometrium; decidual layer is defective Placenta does not separate easily after delivery causing significant bleeding problems MC presenting sign is bleeding in the 3rd trimester Uterine rupture in 15% Due to scars (Ashermans syndrome) from previous C-sections or endometrial inflammation; loss of decidua basalis Placenta Previa Implantation over or close to the cervical os Presents with PAINLESS bleeding Most common cause of antepartum hemorrhage Predisposing factors include maternal age, parity, anatomic uterine abnormalities, and previous uterine surgery Abruptio Placenta A significant complication of preeclampsia Due to a premature separation of the placenta with a resultant retroplacental clot Patient presents with PAINFUL, vaginal bleeding Hematomas involving 1/3 or more of the maternal surface can result in fetal death Associated with maternal hypertension or cocaine abuse Abruptio Placenta Note the large amount of retroplacental hemorrhage in both specimens Enlarged Placentas Syphilis Diabetes mellitus Rh hemolytic disease (erythroblastosis fetalis) Multiple Gestation Dizygotic (fraternal twins)-fertilization of two separate ova producing twins that are genetically different-same or different sexes Monozygotic twins-early division of a single fertilized ovum producing twins that are identical and same sex MONOCHORIONIC=identical twins whether monoamniotic (Siamese twins, fetal to fetal transfusion, entanglement in umbilical cord) or diamniotic DICHORIONIC=fraternal or identical twins Identical twins can arise from a dichorionic, diamniotic placenta if the division of the fertilized ovum occurs before the chorion is formed (before day 3 following fertilization). If the division of the morula occurs after the chorion is complete, then the placenta will be monochorionic and may be diamniotic or monoamniotic Chorioamnionitis Infection of the fetal membranes Usually from an ascending infection from the vagina and cervix or premature rupture of the membranes for greater than 18 hours Group B Streptococci (Strep. agalactiae) Funisitis may also occur (infection of the umbilical cord) Villitis Infection of the chorionic villi resulting from endometritis or transplacental passage of organisms delivered by way of the maternal circulation (hematogenous infections): acute villitis is usually caused by maternal bacterial sepsis Microorganisms: Bacteria: T. pallidum, M. tuberculosis, Mycoplasma, Chlamydia Viruses: rubella, CMV, herpes-usually chronic villitis or chronic chorioamnionitis Protozoa: toxoplasma Fungi: Candida ID/CC A 30 year old white primigravida at 36 weeks of gestation visits her obstetrician for the first time in her pregnancy complaining of swollen legs and headache. HPI Her medical history is unremarkable, and her pregnancy has apparently developed with no complications until the onset of her symptoms PE VS: hypertension (BP 170/110). PE: excessive weight gain; funduscopic exam does not show changes of hypertensive retinopathy; 3+ pitting pedal edema; 1+ periorbital edema; 3+proteinuria Pregnancy-Induced Hypertension Usually occurs after the 12th week of gestation (MC the 32 week) in primigravidas Pre-eclampsia: sudden development of maternal hypertension, edema and proteinuria (nephrotic syndrome) Eclampsia: includes generalized convulsions Etiology: Loss of the protective effect of uterine prostaglandin E which neutralizes the vasoconstrictive effect of angiotensin II Predisposing factors: Primigravidas Polyhydramnios Preexisting hypertension or diabetes mellitus Hydatidiform mole (PIH in first trimester is presumptive evidence for a mole) Gestational Trophoblastic Disease A gestational neoplasm should be suspected when the uterus is too large for date and no fetal heart sounds or movements are detected Hydatidiform moles, invasive moles, and choriocarcinoma All three secrete beta hCG Increased theca lutein cysts ID/CC A 25 year old Filipina in her 20th week of pregnancy presents with vaginal bleeding but no pain HPI She has been feeling inordinated nauseated and has suffered from ringing in her ears PE VS: moderate hypertension (BP 150/95). Uterus large for gestational age; lower extremity 2+ nonpitting edema Labs Markedly increased beta hCG. UA: proteinuria but no casts seen on microscopic exam. Elevated blood uric acid level. Imaging:US: snowstorm appearance and no fetus in uterine cavity Hydatidiform Moles Incidence high in Asian countries; associated with alpha-thalassemia (spontaneous abortions) Chorionic villi are swollen, avascular, and resemble clusters of grapes Ultrasound shows snowstorm appearance Present with PAINLESS vaginal bleeding, usually during 1st trimester Uterus too large for gestational age; Increased beta-hCG The entire chromosome component is derived from the sperm; Complete mole: no associated embryo; may have choriocarcinomas; full chromosome set (46XX most common; fertilized by two sperm or one diploid sperm Partial mole: embryo; no choriocarcinomas; partial chromosome set (trisomy); fertilized by either two sperm or one diploid sperm Invasive Moles May invade the myometrium and metastasize invasive implies that molar villi and trophoblasts have extended more deeply and widely than the normal uterine implantation More common in patients over 40 Still considered a benign tumor ID/CC A 29 year old Vietnamese female visits her family doctor because of protracted nausea, vaginal bleeding, dyspnea, and hemoptysis HPI Her history reveals one previous normal gestation and one spontaneous abortion as well as a dilatation and curettage four months ago for a hydatidiform mole PE Vaginal examination with speculum reveals a bluish-red vascular tumor and enlarged uterus; adnexa and ovaries are normal Labs Markedly elevated serum and urinary hCG levels Imaging CXR: multiple metastatic nodules Choriocarcinoma Arise from complete hydatidiform moles in 50% of cases, previous abortions in 25%, and normal or ectopic pregnancies in the remainder; makes (-hCG and human placental lactogen Only composed of trophoblastic tissue and lack villous structures; composed of a central core of cytotrophoblasts surrounded by a covering of syncytiotrophoblasts Metastasize to lungs (cannon-ball metastases) Also go to vagina, brain and liver Sensitive to chemotherapy (actinomycin D and methotrexate***)  Gestationally derived Choriocarcinomas   Syncytotrophoblasts are the cells with groups of nuclei and a large mass of cytoplasm (small arrow). Cytotrophblasts are the cells in the central portions (large arrow) Diseases of the Male Genital Tract &Testicular Tumors St Christophers College of Medicine Male Genital Tract Penis: Congenital Anomalies Hypospadias and Epispadias Phimosis Inflammations Tumors Benign tumors Carcinoma in situ Carcinoma Testis and Epididymis Prostate Hypospadias and Epispadias Abnormal site of external uretheral meatal opening Due to malformation of the urethral groove and urethral canal Abnormal openings can either be on Ventral surface of the penis - Hypospadias Dorsal surface of the penis - Epispadias Commonly associated with Failure of normal descent of the testes Malformations of the urinary tract Clinical Significance: If the abnormal opening is constricted - partial urinary obstruction >Cystitis > spread to the rest of urinary tract Are a possible causes of sterility in men Orifice situated near the base of the penis > normal ejaculation and insemination are hampered or totally blocked Hypospadias Epispadias Phimosis Prepucial orifice too small to permit its normal retraction Congenital / acquired by inflammatory scarring of the prepuce Clinical Significance: Interferes with cleanliness and permits the accumulation of secretions under the prepuce > development of secondary infections and possibly carcinoma Paraphimosis: When a phimotic prepuce is forcibly retracted over the glans penis, marked constriction and subsequent swelling may block the replacement of the prepuce Is extremely painful May be a potential cause of urethral constriction and serious acute urinary retention. Inflammations Specific infections: Syphilis, gonorrhea Chancroid Granuloma inguinale Lymphopathia venereum Genital herpes Nonspecific infections: Balanoposthitis Inflammations Balanoposthitis: Is a nonspecific infection of the glans and prepuce Caused by a wide variety of organisms Pyogenic bacteria (staphylococci, coliforms) Fungi (Candida albicans) Mycoplasmas Chlamydia Encountered in patients having phimosis or a large, redundant prepuce This interferes with cleanliness Predisposes to bacterial growth within the accumulated secretions and smegma If neglected such inflammations may lead to frank ulcerations of the mucosal covering of the glans If they persist and become chronic > further inflammatory scarring of the phimosis > aggravation of the underlying condition. Balanoposthitis Tumors of the Penis Benign Condyloma Acuminatum Carcinoma in situ Bowens Disease Erythroplasia of Queyrat Bowenoid papulosis Carcinoma of the penis Condyloma Acuminatum Benign tumor Caused by human papillomavirus (HPV)-types 6 and 11 Is related to the common wart (verruca vulgaris) May occur on any moist mucocutaneous surface of the external genitals in either sex Condyloma Acuminatum Occur most often about the coronal sulcus and inner surface of the prepuce Consist of single or multiple sessile or pedunculated, red papillary excrescences Vary from 1 to several millimeters in diameter Condyloma Acuminatum Low magnification reveals the papillary (villous) architecture Condyloma Acuminatum Histologically: Branching, villous, papillary connective tissue stroma Covered by a thickened hyperplastic epithelium Superficial hyperkeratosis Thickening of the underlying epidermis (acanthosis) The normal orderly maturation of the epithelial cells is preserved. Clear vacuolization of the prickle cells (koilocytosis), characteristic of HPV infection, is noted in these lesions Basement membrane is usually intact, and there is no evidence of invasion of the underlying stroma Condyloma Acuminatum Clear vacuolization of the prickle cells (koilocytosis) - characteristic of HPV infection Carcinoma In Situ It is a histologic term to describe epithelial lesions having the cytologic changes of malignancy confined to the epithelium with no evidence of local invasion or distant metastases Considered a precancerous condition because of its potential to evolve into invasive cancer In the external male genitalia, three lesions that display histologic features of carcinoma in situ have been described: Bowens disease Erythroplasia of Queyrat Bowenoid papulosis Bowens disease Occurs in the genital region of both males and females >35 years of age group Involves the shaft of the penis and the scrotum Grossly: Appears as a solitary, thickened, gray-white, opaque plaque with shallow ulceration and crusting Histologically: Epidermis shows proliferation with numerous mitoses Cells are markedly dysplastic with large hyperchromatic nuclei Total lack of orderly maturation Dermal-epidermal border is sharply delineated by an intact basement membrane Over the span of years, Bowens disease may become invasive and transform into typical squamous cell carcinoma in ~ 10 to 20% of patients. Occurrence of visceral cancer in ~30% of cases of Bowens Disease. Bowens disease Dermal-epidermal border is sharply delineated by an intact basement membrane Bowens disease Hyperchromatic and dysplastic epithelial cells Erythroplasia of Queyrat Appears on the glans and prepuce as single or multiple shiny red, sometimes velvety plaques Histologically: Dysplasia is of variable severity From mild disorientation of cells to a picture indistinguishable from that of Bowens disease. Like Bowens disease, it has the potential to develop into invasive carcinoma. In contrast to Bowens disease, there is no reported association with visceral malignancy. Bowenoid papulosis Occurs in sexually active adults Clinically it differs from Bowens disease by Younger age of patients Presence of multiple (rather than solitary), pigmented (reddish brown) papular lesions Histologically: It is indistinguishable from Bowens disease Carcinoma Squamous cell carcinoma of the penis represents about 1% of cancers in males in the United States. Is extremely rare among Jews and Moslems Protection apparently conferred by circumcision Prevention of accumulation of smegma Carcinomas are usually found in patients between the ages of 40 and 70. Carcinoma of the Penis Begins on the glans or inner surface of the prepuce near the coronal sulcus First observable changes A small area of epithelial thickening accompanied by graying and fissuring of the mucosal surface With progression An elevated papule that often ulcerates By the time most patients seek medical attention Large characteristic malignant ulcers having necrotic, secondarily infected bases with ragged, irregular, heaped-up margins In far-advanced lesions Ulceroinvasive disease destroys the entire tip of the penis or large areas of the shaft Carcinoma of the Penis Second pattern of macroscopic tumor growth Papillary tumor that simulates the condyloma Progressively enlarges to form a cauliflower-like, ulcerated, fungating mass Histologically: Both the papillary and ulceroinvasive lesions are squamous cell carcinomas similar to those that occur elsewhere on the skin surface. Carcinoma of Penis Carcinoma of Penis Clinical Course Carcinoma of the penis is a slowly growing, locally metastasizing lesion Often is present for a year or more before it is brought to medical attention. Unawareness of the significance of the developing papule Existence of a phimosis that completely hides the developing lesion Lesions are nonpainful until they undergo secondary ulceration and infection. Frequently bleed Metastasis: To inguinal and iliac lymph nodes Prognosis: Related to the stage of advancement of the tumor. Limited lesions without invasion of the inguinal lymph nodes: 66% 5-year survival rate Metastasis to the lymph nodes: 27% 5-year survival. Male Genital Tract Penis Testis and epididymis Congenital anomalies Cryptorchidism Regressive changes Atrophy Inflammations Non-specific epididymitis and orchitis Granulomatous (Autoimmune) orchitis Specific inflammations Vascular disturbances Torsion Testicular tumors Germ cell tumors Sex cord-stromal tumors Testicular lymphoma Prostate Normal Testis Body Epididymis Spermatic cord Cryptorchidism Is synonymous with undescended testes Found in ~1% of 1 year old boys Represents a complete or incomplete failure of the intra-abdominal testes to descend into the scrotal sac Testicular descent occurs in two phases: Trans-abdominal phase Testis comes to lie within the lower abdomen/ brim of the pelvis Controlled by Mullerian-Inhibiting substance Inguino-scrotal phase Descent is through the inguinal canal into the scrotal sac Is androgen dependent Commoner Cryptorchidism Is unilateral in the majority of cases May be bilateral in 25% of patients Cryptorchid testis is small in size and is firm in consistency owing to fibrotic changes Histologic changes in the malpositioned testis begin as early as two years of age An arrest in the development of germ cells Associated marked hyalinization and thickening of the basement membrane of the spermatic tubules Histologic deterioration, leading to a paucity of germ cells, has also been noted in the contralateral (descended) testis in patients with unilateral cryptorchidism Cryptorchidism When the testis lies in the inguinal canal, it is particularly exposed to trauma and crushing against the ligaments and bones. Concomitant inguinal hernia frequently accompanies. Sterility can occur in bilateral cryptorchidism uncorrected unilateral cryptorchidism contralateral descended testis may also be deficient in germ cells Undescended testis is at a greater risk of developing testicular cancer Requires surgical correction (Orchiopexy placement of testis in the scrotal sac) preferably before histologic deterioration sets in at two years of age Normal Testis Cryptorchid Testis Atrophy Causes: Progressive atherosclerotic narrowing of the blood supply in old age End stage of an inflammatory orchitis, whatever the etiologic agent Cryptorchidism Hypopituitarism Generalized malnutrition, or cachexia Obstruction to the outflow of semen Irradiation Prolonged administration of female sex hormones Treatment of patients with carcinoma of the prostate Exhaustion atrophy may follow the persistent stimulation produced by high levels of follicle-stimulating pituitary hormone. Atrophy Torsion Twisting of the spermatic cord may cut off the venous drainage and the arterial supply to the testis. Usually, however, the thick-walled arteries remain patent so that intense vascular engorgement and venous infarction follow Usual precipitating cause is some violent movement or physical trauma There are predisposing causes: Incomplete descent Absence of the scrotal ligaments or the gubernaculum testis Atrophy of the testis so it is abnormally mobile within the tunica vaginalis Abnormal attachment of the testis to the epididymis Torsion Torsion Immediate surgery is required to reduce the risk of testicular loss (< 4 hours) Contralateral orchiopexy prophylactically (high incidence of bilaterality) Atrophic testicle should be removed due to possible autoimmune destruction of contralateral testis Doughnut sign seen with Tc99 MRI scan Due to central testicular ischemia and circumferential collateral flow Testicular Tumors Two types: Germ Cell Tumors Highly aggressive Early metastasis 15-34 year age group peak incidence Most common tumor of men Whites > blacks Non-Germ Cell Tumors Derived from Sex cord / Stroma Benign Some produce steroids leading to endocrinologic syndrome Germ Cell Tumors - Seminoma Seminomas are the most common type of germinal tumor (50%) The type most likely to produce a uniform population of cells Almost never occur in infants Peak in the fourth decade A nearly identical tumor arises in the ovary, where it is called dysgerminoma Seminoma ~ 15% of seminomas contain syncytial giant cells that resemble the syncytiotrophoblast of the placenta both morphologically and in that they contain HCG. In this subset of patients, serum HCG levels are also elevated Spermatocytic Seminoma It is an uncommon tumor The age of involvement is much later than for most testicular tumors Affected individuals are generally over the age of 65 years In contrast to classic seminoma, it is a slow-growing tumor that rarely if ever produces metastases Hence the prognosis is excellent Seminoma Seminoma Histological Types Seminoma (classical): Well-demarcated tan-white homogeneous mass composed of uniform cells in lobules separated by a fine stroma. Tumour cells are large and round with a large central hyperchromatic nucleus, prominent nucleoli and a sharp cell border The cells contain glycogen. Classical seminoma is radiosensitive with favourable prognosis after orchidectomy and postsurgical irradiation. Seminoma Low magnification showing clear seminoma cells divided into poorly demarcated lobules by delicate septa Seminoma High power view of clear seminoma cells Histological Types Embryonal Carcinoma: A highly malignant tumour with variable pattern Glandular Alveolar Tubular The cells resemble anaplastic epithelial cells Spread is by lymphatics but haematogenous dissemination is frequent Prognosis is poor Embryonal Cell Carcinomas Sheets of undifferentiated cells and glandular differentiation Histological Types Yolk-Sac Tumour: Also known as Infantile Embryonal Carcinoma or Endodermal Sinus Tumor Most common testicular tumor in infants and children upto 3 years Microscopically characterised by distinctive perivascular structures and hyaline globules Tumour contains demonstrable alpha-fetoprotein Spread is via lymphatics and blood Histological Types Choriocarcinoma: A highly malignant tumour composed of two elements Cytotrophoblastic cells Syncytiotrophoblastic cells. Serum and urinary Human chorionic gonadotrophin (HCG) is elevated Distinct propensity to haematogenous dissemination. Histological Types Teratoma: A histologically complex tumour composed of tissue derived from more than one of the three primary germ layers: Ectodermal elements (skin, hair, keratin and skin appendages) Mesodermal elements (e.g. bone, cartilage, smooth muscle) Endodermal elements (e.g. intestine and bronchial mucosa, thyroid, etc). Subdivided into mature and immature teratomas. Teratomas in adults are capable of metastasis, even if they appear entirely mature. For unknown reasons, differentiated mature teratomas of testis in infants and small children are usually benign. Germ Cell Tumours (mixed type) Age Incidences of Germ-Cell Tumors Tumour Markers Human chorionic gonadotrophin (HCG) Secreted by syncytiotrophoblastic cells in the placenta Elevated levels are seen in most choriocarcinomas, some embryonal carcinomas and some seminoma containing syncytiotrophoblasts. Alpha-fetoprotein (AFP) Secreted in yolk sac tumors and some embryonic carcinoma. Significance of Tumour Markers Detection of non-seminomatous elements Detection of recurrence Detection of metastasis Non-Germ Cell Tumors Leydig (Interstitial) Cell Tumors Tumors of Leydig cells may elaborate Androgens Androgens + estrogens Corticosteroids They arise at any age Majority between 20 - 60 years of age The most common presenting feature is testicular swelling In some patients gynecomastia may be the first symptom In children, hormonal effects, manifested primarily as sexual precocity, are the dominating features Morphology Most are benign tumors Form circumscribed nodules <5 cm in size Have golden-brown, homogeneous cut surface Histologically: Tumorous Leydig cells are large and round or polygonal, and they have an abundant granular eosinophilic cytoplasm with a round central nucleus. The cytoplasm frequently contains lipid granules, vacuoles, or lipofuscin pigment, but, most characteristically, rod-shaped crystalloids of Reinke occur in about 25% of the tumors Sertoli Cell Tumors (Androblastoma) Tumors of Sex Cord - Gonadal Stroma Composed entirely of Sertoli cells or may have a component of granulosa cells Some induce endocrinologic changes Estrogens or androgens may be elaborated Only infrequently in sufficient quantity to cause precocious masculinization or feminization. As with Leydig cell tumors - gynecomastia may appear Sertoli Cell Tumors (Androblastoma) - Morphology Appear as firm, small nodules with a homogeneous gray-white to yellow cut surface. Histologically: Tumor cells arranged in distinctive trabeculae Tendency to form cord-like structures resembling immature seminiferous tubules Majority of Sertoli cell tumors are benign Testicular Lymphoma Lymphomas account for 5% of testicular neoplasms Most common form of testicular cancer in men over the age of 60. In most cases, disseminated disease is already present at the time of detection of the testicular mass Only rarely does it remain confined to the testis Histologic type in almost all cases is the diffuse large cell lymphoma The prognosis is extremely poor. PROSTATE - Inflammation Acute and chronic prostatitis: Extend from the bladder or urethra Nonspecific infection caused by Coliform bacteria Gonococci Chlamydia Granulomatous prostatitis: May be caused by specific infections such as tuberculosis or syphillis Nonspecific inflammatory reaction to inspissated secretion/ autoimmune causation Benign nodular hyperplasia (BNH) / Benign prostatic hyperplasia (BPH) Extremely common disorder in men over 50 Gross - distinct circumscribed grey white nodules in the periurethral zone Histology - proliferation of both glandular and fibromuscular stromal elements + infarct, infection, squamous metaplasia Benign prostatic hyperplasia (BPH) Proliferation of glands, some cystically dilated within a well defined nodule Benign prostatic hyperplasia (BPH) High power view showing hyperplastic glands with two layers Inner columnar Outer cuboidal Clinical Features & Complications Asymptomatic Compression of urethra - difficulty in urination, frequency or dribbling Retention of urine Bladder distention and hypertrophy Hydroureters and hydronephrosis chronic renal failure superimposed infections Prostatitis Cystitis Prostatic carcinoma Incidence: Marked geographical and racial difference: common in American males (more prevalent in blacks) but uncommon in orientals Etiology: Role of androgen in the growth of the tumor Clinical presentation Clinical symptoms (prostatism) is present, hard mass find during rectal examination. Incidental finding during microscopic examination of the tissue surgically removed for non-malignant disease, particularly BPH. Present with signs and symptoms of metastasis (e.g. back pain due to vertebral metastasis) Tumors of the prostate detected during autopsy on patients that showed no clinical evidence of prostatic cancer Tumour markers: Prostatic acid phosphatase Prostatic specific antigen Gross: Yellowish, hard, gritty tissue Histology: Adenocarcinoma, usually microacini Perineural invasion Modes of spread: Local - causing prostatic urethra obstruction and may infiltrate into periphery adjacent tissue Lymphatics - presacral in pelvis, iliac and paraaortic lymph nodes Blood - vertebra, osteoblastic, widespread metastasis Treatment: Surgery + hormonal therapy Staging of Prostatic Cancer Testicular Tumors St Christophers College of Medicine Testicular tumors - Objectives Germ Cell Tumors: know the classification of testicular germ cell tumors and how they originate know the commonest type be able to describe clinical and histologic features know which tumor produces which marker predict possible clinical outcomes and response to treatment GERM CELL TUMORS Epidemiology: More common in whites than blacks Peak incidence is between 20 and 34 years when it is the most common malignancy in males. Mean age Seminoma is about 40 years Teratoma is about 30 years. Are uncommon after 50 years of age. Cause of germ cell tumors is unknown. Cryptorchidism significantly increases the risk, 4 to 10 fold, of subsequent development of germ cell tumors. Development of a germ cell tumor in one testis increases the risk of developing a tumor in the contralateral testis. GERM CELL TUMORS GCTs have the following subtypes and frequencies: seminoma (40%), embryonal (25%), teratocarcinoma (25%), teratoma (5%), choriocarcinoma (pure) (1%). The most important clinical distinction is between seminoma and nonseminoma, 2 broad categories with different treatment algorithms: (1) seminoma as a classification refers to pure seminoma upon histopathologic review, and (2) any nonseminomatous elements (even if seminoma is prevalent) change the classification to nonseminoma. After a radical orchiectomy, testicular seminoma is a pathologic diagnosis in which only seminomatous elements are observed upon histopathologic review and serum alpha-fetoprotein (AFP) is normal. Any elevation of AFP or nonseminomatous elements in the testis specimen mandates diagnosis of nonseminomatous GCT (NSGCT) and an appropriate change in treatment Seminoma Commonest type of primary testicular tumor. Accounts for 35 - 70% of testicular neoplasms Types: Classic (or conventional) Anaplastic Spermatocytic seminomas. Does not develop before puberty Classic seminoma A nodular tumor completely replaces the testis Classic seminoma The cut surface is tan and bosselated Classic seminoma The tumor is composed of sheets of uniform undifferentiated germ cells with clear or fine granular cytoplasm, well-defined cell border and round nuclei, frequently with prominent nucleoli. Sheets of tumor cells are separated by slender fibrous septa. Diffuse or focal intense lymphoid infiltrate is seen in most tumors. Glycogen may be demonstrated in the cytoplasm of the tumor cells. Classic seminoma Seminoma fried-egg appearance Classic seminoma Mitotic figures are usually infrequent. Approx 35% cases, noncaseating granulomatous areas containing small giant cells are found. Tumor giant cells that mimic syncytiotrophoblasts in appearance and which may contain intracytoplasmic -hCG are present in some tumors. This may lead to a mild increase in serum -hCG. Mitotic figure in intestinal epithelial cell Classic seminoma Left panel shows multinucleate giant cells of foreign body type. Right panel shows syncytiotrophoblast-like tumor giant cell. Classic seminoma - syncytiotrophoblast-like tumor giant cell ANAPLASTIC SEMINOMAS In some seminomas, the neoplastic cells are more pleomorphic and have more mitotic figures than in typical seminoma. These tumors have been called anaplastic seminomas. Although these tumors tend to occur at higher stages than classical seminoma, stage for stage this subgroup has the same prognosis as the classical type. SPERMATOCYTIC SEMINOMA Is a rare but distinct clinicopathologic variant of seminoma Occurs only in the descended testes of elderly men Forming about 5% of seminomas. The tumor is bilateral in about 6% of cases compared to about 2% in classic seminoma. SPERMATOCYTIC SEMINOMA The tumor tends to be poorly demarcated, usually soft with a gelatinous or mucoid appearance. Cystic areas, especially in the center, are common but hemorrhage or necrosis is almost always absent. Histology - Spermatocytic seminomas Forms solid sheets of cells without the nesting pattern of classical seminoma. Three populations of tumor cells, separated according to size, are seen: small cells that superficially resemble lymphocytes, intermediate or medium-sized cells, the commonest cell type, have round nuclei and finely granular chromatic pattern, large or giant cells. Mitotic figures are usually abundant Lymphocytic infiltrate and granulomas seen in classic seminoma are absent. Spermatocytic seminoma is an extremely indolent tumor with rather limited malignant potential and rarely if ever metastasizes. EMBRYONAL CARCINOMA This subtype of GCTs represents the most primitive form of the NSGCTs. Accounts for about 15-35% of testicular GCTs. EMBRYONAL CARCINOMA Grossly, the tumors are large, often hemorrhagic and necrotic producing a variegated cut surface. Embryonal Cell Carcinomas Sheets of undifferentiated cells and glandular differentiation EMBRYONAL CARCINOMA Extremely pleomorphic Show a variety of patterns forming glands, tubules, and even primitive embryo-like structures. Many mitotic figures are present. EMBRYONAL CARCINOMA Anaplastic and solid undifferentiated areas may present as sheets of cells with large, hyperchromatic nuclei, prominent nucleoli and poorly-defined cell borders. EMBRYONAL CARCINOMA Poorly differentiated area in embryonal carcinoma. EMBRYONAL CARCINOMA Metastasizes early and widely via both lymphatic and hematogenous routes. Radiation is not as effective as with seminoma, but newer chemotherapeutic agents have greatly improved prognosis. Tumors confined to the testis now have a prognosis essentially identical to that of seminoma (95% 5-year survival). YOLK SAC TUMOR (ENDODERMAL SINUS TUMOR) Is a distinct entity from embryonal carcinoma of which it was considered a variant in the past. Noted for its: Resemblance to rat fetal yolk sac Presence of microscopically distinctive structures known as Schiller-Duval bodies. YOLK SAC TUMOR Testicular yolk sac tumors occur in two forms: A pure form in young children A focal differentiation within other NSGCTs, mainly embryonal carcinoma, in adults. YOLK SAC TUMOR The cut surface is gray-white and may be cystic YOLK SAC TUMOR Tumor shows a variety of patterns, Commonest: loose meshwork of small spaces and cysts (producing a sieve-like appearance) lined by either flattened cells or vacuolated cells with nuclei that protrude in a "hobnail" fashion. YOLK SAC TUMOR In some tumors, Schiller-Duval bodies (endodermal sinus) are seen. These are glomerulus-like structures with a central core of blood vessel surrounded by an inner layer of epithelial-like cells, a space and an outer layer of similar cells. YOLK SAC TUMOR Almost invariably associated with production of large amounts of alpha-fetoprotein (AFP) AFP may be followed as a marker of disease progression in the patient's serum. Antibodies directed against AFP may also be used to stain the tumors and aid in their diagnosis. YOLK SAC TUMOR Yolk sac tumor stained with antibodies against AFP. Note the brown staining of the epithelium indicating the presence of AFP TERATOMA In the WHO classification (used in the US) the term is restricted to a tumor typically composed of several tissues representing two or more germinal layers. Are further subdivided into Mature Immature Teratoma with malignant transformation. Mature Teratoma The tumor is composed exclusively of well-differentiated tissues and by definition, contains no malignant-looking tissue. Some may consist of nests of mature cartilage, smooth muscle and squamous or mucous epithelial-lined cysts. In others, more complex and organoid arrangement is seen and abortive gastrointestinal tract, brain, eye, pancreas, salivary gland, and other organs can easily be recognized. Mature Teratoma Showing cysts lined by mucous epithelium (left) and keratinizing squamous epithelium (right). Mature Teratoma Mature cartilage (left) and spaces lined by mucus secreting glandular epithelium (right) are present Mature Teratoma Mature Teratoma Mature Teratoma Although the tumor has a benign histologic appearance, its clinical course in the adult is unpredictable and it can metastasize. The metastases show the same well-differentiated picture as the primary tumor. In children, teratomas whatever their histological appearances behave in a benign fashion. Teratoma is the 2nd most common testicular germ cell tumor in children (after Yolk Sac Tumor). Immature Teratoma In this type of teratoma there are incompletely differentiated, fetal-appearing tissues, often of neural differentiation. Immature Teratoma Primitive brain tissue (upper left corner) Well-differentiated glands (lower half) Choriocarcinoma This is a highly malignant neoplasm that is usually widely disseminated and frequently fatal. The cells differentiate in the direction of trophoblastic (placental) tissue Both cytotrophoblast and syncitiotrophoblast must be present for the diagnosis to be made. Pure choriocarcinoma of the testis is extremely rare, and the tumor is much more common as a component of mixed GCTs. Choriocarcinoma The tumor typically presents in adolescent or young adults with widespread disease, and an often small, painless primary lesion in the testis. It is extensively hemorrhagic and necrotic and, sometimes, may be reduced to a fibrous scar, leaving widespread metastases with no apparent testicular mass. On occasion, the tumor may be large and bulky. Hemoptysis due to pulmonary involvement is common. Choriocarcinoma Large, hemorrhagic, necrotic tumor Choriocarcinoma Tumor is composed of two types of cells: Syncytiotrophoblasts: large multinucleate cells with abundant vacuolated cytoplasm containing hCG Cytotrophoblasts: polygonal cells with distinct cell borders and single nuclei, which grow in clusters and are surrounded by the syncytiotrophoblasts. Choriocarcinoma, left panel, and placenta, right panel. Note similarity in histologic appearances. Choriocarcinoma Sheet of cytotrophoblasts surrounded by syncytiotrophoblasts. Choriocarcinoma This image shows admixture of polygonal cells with clear cytoplasm (cytotrophoblast) and large multinucleated cells with smudged nuclear chromatin (syncytiotrophoblast). Choriocarcinoma In classic cases of choriocarcinoma, syncytiotrophoblasts form a cap around clusters of cytotrophoblasts in an attempt to mimic the architecture of immature placental villi Age Incidences of Germ-Cell Tumors Question: What is the commonest malignant testicular tumor after 50 years of age? Malignant lymphoma Question: Choriocarcinoma is one of the very few carcinomas that metastasize more frequently via bloodstream than lymphatics. What are the others? Follicular carcinoma of the thyroid Renal cell carcinoma. Tumour Markers Human chorionic gonadotrophin (HCG) Secreted by syncytiotrophoblastic cells in the placenta Elevated levels are seen in most choriocarcinomas, some embryonal carcinomas and some seminoma containing syncytiotrophoblasts. Alpha-fetoprotein (AFP) Secreted in yolk sac tumors and some embryonic carcinoma. Significance of Tumour Markers Detection of non-seminomatous elements Detection of recurrence Detection of metastasis Non-Germ Cell Tumors Leydig (Interstitial) Cell Tumors Tumors of Leydig cells may elaborate Androgens Androgens + estrogens Corticosteroids They arise at any age Majority between 20 - 60 years of age The most common presenting feature is testicular swelling In some patients gynecomastia may be the first symptom In children, hormonal effects, manifested primarily as sexual precocity, are the dominating features Morphology Most are benign tumors Form circumscribed nodules <5 cm in size Have golden-brown, homogeneous cut surface Histologically: Tumorous Leydig cells are large and round or polygonal, and they have an abundant granular eosinophilic cytoplasm with a round central nucleus. 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7$8$@&H$^`gdC $7$8$@&H$a$gdC7$8$@&H$^`gdC::b:;\;v;;<<<<<O=_=t==/>m>>>>>>>>?&?a??????@@$@@@A>/>m>>>>>>>>>>%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: & F ^7$8$@&H$^^`gdC $7$8$@&H$a$gdC 7$8$@&H$gdC & F 7$8$@&H$^`gdC7$8$@&H$^`gdC>>>>>>>?&?4?J?a??????%v:%v:%v:%v:%v:%v:%v:%v:%?%?%v:%v:%v:%?%?%v: & F I7$8$@&H$^I`gdC & F 7$8$@&H$^`gdC7$8$@&H$^`gdC & F 7$8$@&H$^`gdC $7$8$@&H$a$gdC??@$@@@AAZzZZZ0[u[v[[[[%v:%v:%v:%v:%?%v:%v:%v:%?%v:%v:%?%?%v:%v:%v:%v:%v: & F I7$8$@&H$^I`gdC & F 7$8$@&H$^`gdC $7$8$@&H$a$gdC7$8$@&H$^`gdC & F7$8$@&H$gdC[[\\_\\\]"])]?]e]]]]]]%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%?%v: & F I7$8$@&H$^I`gdC & F 7$8$@&H$^`gdC $7$8$@&H$a$gdC7$8$@&H$^`gdC & F7$8$@&H$gdC & F *7$8$@&H$^*`gdC]]^^*^+^,^-^.^/^0^1^2^3^4^5^6^7^8^9^:^^%v:%?%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: & F7$8$@&H$gdC $7$8$@&H$a$gdC & F 7$8$@&H$^`gdC & F I7$8$@&H$^I`gdC^^^^!_]_y____ `7`O`j```paa%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%? & F 7$8$@&H$^`gdC & F 7$8$@&H$^`gdC & F *7$8$@&H$^*`gdC $7$8$@&H$a$gdC & F7$8$@&H$gdC^^^``;bLbbbbc^cncffhhjjkkkl`lalplxlzlllLmXmYmmmEncnnn;ox~xxxxy*yuyy@zezzzv||g}}}~~~~~~~Kǻh))hC5CJaJh7rhC6CJaJ *hphCCJH*aJh7rhC5CJaJ *hphC5CJaJhCCJaJh zhC6CJaJ *hphCCJaJh!UhCCJaJ:sstttuyuuuuuvvvvvvvvv v v;v%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: $7$8$@&H$a$gdC7$8$@&H$^`gdC & F 7$8$@&H$^`gdC;vovvvvv.wqww-x`x~xxxxx*yfyy@zz%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%?%?%?%z%? & F 7$8$@&H$^`gdC 7$8$@&H$gdC & F I7$8$@&H$^I`gdC & F 7$8$@&H$^`gdCzzzz{+|u|v||}Q}i}}~~Q~%?%v:%v:%z%z%?%v:%v:%v:%v:%v:%v:%v:%v:7$8$@&H$`gdC & F 7$8$@&H$^`gdC $7$8$@&H$a$gdC & F I7$8$@&H$^I`gdC 7$8$@&H$gdC7$8$@&H$^`gdC & F 7$8$@&H$^`gdCQ~u~~~~~~~;KX%v:%v:%v:%v:%v:%v:%v:%z%?%v:%v:%v:%v:%v:%? & F I7$8$@&H$^I`gdC & F 7$8$@&H$^`gdC $7$8$@&H$a$gdC7$8$@&H$^`gdC & F 7$8$@&H$^`gdC & F 7$8$@&H$^`gdCz|k߂+:Vtuv  (L&/ӋuĐ͑rMjٓ *h8))hC5CJaJh))hC6CJaJ *h8))hC6CJaJ *h8))hCCJaJhCCJaJ *h8))hCCJaJh))hC5CJaJ 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*h8))hCCJaJh!UhCCJaJh))hC6CJaJ>Tڗi՘֘S֙%?%v:%v:%v:%v:%?%?%v:%v:%v:%v:%v:%v:%v:%v: & F 7$8$@&H$^`gdC & F 7$8$@&H$^`gdC $7$8$@&H$a$gdC & F I7$8$@&H$^I`gdC & F 7$8$@&H$^`gdC*=Кۚ8ƛ֛*j<ϝq%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: & FL7$8$@&H$^`LgdC & F *7$8$@&H$^*`gdC 7$8$@&H$gdC & F 7$8$@&H$^`gdC & F 7$8$@&H$^`gdCqrstuvwxyz{|Ӟ 7F'%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: & F *7$8$@&H$^*`gdC & F 7$8$@&H$^`gdC 7$8$@&H$gdC 7$8$@&H$gdC'X &1UVl֢#%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:{%v:%v: & F 7$8$@&H$^`gdC $7$8$@&H$a$gdC7$8$@&H$^`gdC & F 7$8$@&H$^`gdC 7$8$@&H$gdC & F 7$8$@&H$^`gdC & F *7$8$@&H$^*`gdC<6W3X%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: & F 7$8$@&H$^`gdChh7$8$@&H$^h`hgdC & F 7$8$@&H$^`gdC7$8$@&H$`gdC 7$8$@&H$gdC & F 7$8$@&H$^`gdC=Xf{ͧާF̨%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: 7$8$@&H$gdC & F 7$8$@&H$^`gdC & FL7$8$@&H$^`LgdC & F 7$8$@&H$^`gdC & F *7$8$@&H$^*`gdCf٩ $`tN%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%? & F 7$8$@&H$^`gdC 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F7$8$@&H$^`gdCQs)gq%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: $7$8$@&H$a$gdC & F L7$8$@&H$^`LgdC & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC'Q}_-9%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: & F7$8$@&H$^`gdC $7$8$@&H$a$gdC & F7$8$@&H$^`gdC7$8$@&H$^`gdC & FI7$8$@&H$^I`gdC9%v: %v:%v:%v:%v:%v:%v:%v:%U%Q%U%v:%v:%v:%v: & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC $7$8$@&H$a$gdC7$8$@&H$^`gdC & F 7$8$@&H$^`gdC & F7$8$@&H$^`gdC=Pd%_` 2GmL"Q˿ԴԴܐhShCCJaJmH sH  *h;PhCCJaJ *h3hCCJaJh][hC5CJaJh$0hCCJaJh$0hC5CJaJhC5CJaJhCCJaJhihC5CJaJh jhCCJaJ *h3hCCJaJ0<`sz\~$_%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%U%v:%v: & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC $7$8$@&H$a$gdC_u=P     %U%U%U%U%v:%v:%v:%Q%U%U%U%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: $7$8$@&H$a$gdC7$8$@&H$^`gdC & F7$8$@&H$^`gdCw Tr/%v:%v:%v:%v:%v:%v:%v:%v:%U%v:%v:%U%v:%v:%v:%U%U%U & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC $7$8$@&H$a$gdC & F7$8$@&H$^`gdC $7$8$@&H$a$gdC/ 6Zj12GRm%v:%v:%v:%v:%U%U%U%v:%v:%U%U%v:%v:%v:%U%U%U%U%U%U7$8$@&H$^`gdC & F7$8$@&H$^`gdC $7$8$@&H$a$gdC & FI7$8$@&H$^I`gdCL"2%U%U%U%U%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: 7$8$@&H$gdC 7$8$@&H$gdC7$8$@&H$^`gdC & F7$8$@&H$^`gdC234QazM{|},G%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%U%U%U%v:%v:%U & F7$8$@&H$^`gdC $7$8$@&H$a$gdC & F7$8$@&H$^`gdC 7$8$@&H$gdC $7$8$@&H$a$gdC 7$8$@&H$gdCQa|},mu   5 H I n    c r +,-@GQRZr躮覮уwwwih bhC5>*CJaJh bhC5CJaJh bhCCJaJh bhC6CJaJhihC6CJaJhCCJaJhihC5CJaJhC5CJaJhihC5>*CJaJhC5>*CJaJ *h;PhCCJaJh jhCCJaJh][hC6CJaJ)Gm/ N t u   6 O v     %U%U%Q%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC$7$8$@&H$^`a$gdC $7$8$@&H$a$gdC & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC   H I n     0    c r  %v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: 7$8$@&H$gdC & F7$8$@&H$^`gdC 7$8$@&H$gdC$7$8$@&H$^`a$gdC & F7$8$@&H$^`gdC & FI7$8$@&H$^I`gdC +,-%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: & F7$8$@&H$^`gdC $7$8$@&H$a$gdC $7$8$@&H$a$gdC & F7$8$@&H$^`gdC&u9+K"%v:%v:%v:%v:%v:%v:%v:%v:%v:%U%U%U%v:%v:%v: & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC $7$8$@&H$a$gdC7$8$@&H$^`gdC & F7$8$@&H$^`gdC & FI7$8$@&H$^I`gdC+KMNa13Z[4YEU149 +m1=ԧ *h@hCCJaJhihC6CJaJ jh[Y*hCCJaJh;PCJaJhihC5>*CJaJhC5CJaJhCCJaJ *h;PhCCJaJh jhCCJaJhihC5CJaJ8MN%U%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: $7$8$@&H$a$gdC 7$8$@&H$gdC7$8$@&H$^`gdC & F7$8$@&H$^`gdCNa123[%v:%U%U%U%U%U%v:%v:%v:%v:%v:%v:%v:%v:%U%U%v:%v:%U7$8$@&H$^`gdC7$8$@&H$^`gdC 7$8$@&H$gdC & F7$8$@&H$^`gdC $7$8$@&H$a$gdCX234Yv %U%U%v:%v:%U%v:%v:%v:%v:%v:%v:%v:%U%v:%v:%v:%v:%U%v: $7$8$@&H$a$gdC7$8$@&H$^`gdC & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdCEU_1o5o %v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: & F7$8$@&H$^`gdC 7$8$@&H$gd;P 7$8$@&H$gdC & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC $7$8$@&H$a$gdC & FI7$8$@&H$^I`gdC +?b}mGo%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: 7$8$@&H$gdC $7$8$@&H$a$gdC & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC 7$8$@&H$gdC1Pm%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: & F7$8$@&H$^`gdC $7$8$@&H$a$gdC 7$8$@&H$gdCA C W   9![!`!a!e!f!h!!!!!!;"t"" ####$$$$l&&&&*'0'Q'_'')Y))))))ӪӞ+j *h@h;PCJUaJmHnHu *h@hCCJaJh[Y*hC6CJaJ"jhCCJUaJmHnHuh[Y*hCCJaJ *h@hCCJaJhihC5>*CJaJhCCJaJh jhCCJaJ/ B C D W   L!\!]!^!_!`!b!c!d!%v:%U%v:%v:%U%v:%v:%v:%Q%U%v:%v:%v:%v:%v:%v:%v:%v:7$8$@&H$^`gdC 7$8$@&H$gdC & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC $7$8$@&H$a$gdCd!e!f!!!!"<"["t"" #"#4#;#J#h##%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC7$8$@&H$^`gdC $7$8$@&H$a$gdC 7$8$@&H$gdC7$8$@&H$^`gdC###$$T$$$$"%%W&l&&&('%v:%U%U%v:%v:%U%v:%v:%v:%v:%v:%v:%v:%v:%v: & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC 7$8$@&H$gdC(')'*'+','-'.'/'0'Q'R'S'T'U'V'W'X'Y'Z'['\']'^'_''%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: 7$8$@&H$gdC $7$8$@&H$a$gdC7$8$@&H$^`gdC''' (_(((()Y))))))))))))))%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:7$8$@&H$^`gdC & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC))))))))))))))))*-*z*{**%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%U & F7$8$@&H$^`gdC $7$8$@&H$a$gdC 7$8$@&H$gdC 7$8$@&H$gdC7$8$@&H$^`gdC)-*/*J*L***+++ ,%,B-C-..(.).0Z00011)181O1P1g11-2>3m33333u5555557777.97999t:|:$;4;õާދhPAhC6CJaJ *h@hCCJaJmHsH *h@hC6CJaJhXhC5>*CJaJ *h@hC5>*CJaJ *h@hCCJaJh jhCCJaJhCCJaJhShCCJaJmHsH6****+<++++++ ,!,",#,$,%,%v:%v:%v:%v:%U%U%v:%v:%v:%v:%v:%v:%v:%v:%v: $7$8$@&H$a$gdC & F7$8$@&H$^`gdC 7$8$@&H$gdC & F7$8$@&H$^`gdC7$8$@&H$^`gdC & FI7$8$@&H$^I`gdC%,&,.,{,,,--3-B-C-D-E-F-O--.. .%v:%v:%U%U%U%U%U%U%U%v:%v:%v:%v:%v:%U%U%v:%v: & FL7$8$@&H$^`LgdC & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC7$8$@&H$^`gdC $7$8$@&H$a$gdC . . . . .......).../g//0Z000%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC $7$8$@&H$a$gdC00*1+1,1-1.1/1011121314151617181P1~111%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%U%v:%U & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC $7$8$@&H$a$gdC7$8$@&H$^`gdC1 2-2L222'33333333333333%v:%v:%U%U%U%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: & F7$8$@&H$^`gdC $7$8$@&H$a$gdC & F7$8$@&H$^`gdC & FI7$8$@&H$^I`gdC33384C4W444444445Z5555555%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: $7$8$@&H$a$gdC & F7$8$@&H$^`gdC & F L7$8$@&H$^`LgdC & FI7$8$@&H$^I`gdC55555555)6M6z667.77777%v:%v:%v:%v:%v:%v:%U%U%v:%v:%U%U%v:%v:%v:%v:%v: & F7$8$@&H$^`gdC 7$8$@&H$gdC & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC $7$8$@&H$a$gdC73888.99t:$;5;6;7;8;9;:;;;<;=;>;?;@;A;%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: $7$8$@&H$a$gdC & F7$8$@&H$^`gdC & FL7$8$@&H$^`LgdC & FI7$8$@&H$^I`gdCA;B;C;;;<<<#====>F>l>>>?%v:%v:%Q%U%U%v:%v:%v:%v:%v:%v:%v:%v:%v:%U%v: & FI7$8$@&H$^I`gdC & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC 7$8$@&H$gdC & F7$8$@&H$^`gdC $7$8$@&H$a$gdC4;B;C;{;;;<g<r<<<==F>l>>C?M???*@4@@cAAAAB2B5B6B?BEBMBoDDEEEEFFyGGGG*HH3J4Jӭӵއӭ *h@hCCJaJh;PCJaJ"jh;PCJUaJmHnHuhCCJaJhPAhC5CJaJh;P5CJaJhC5CJaJh jhCCJaJ *h@hCCJaJhPAhC6CJaJhC6CJaJ0?#?,?;?C?M?q???????? @*@4@@@@A%v:%v:%v:%v:%v:%U%U%v:%v:%v:%v:%v:%U%v:%v:%v:%v:%v:%v:%v: & F7$8$@&H$^`gdC & F7$8$@&H$^`gdC 7$8$@&H$gdC & FI7$8$@&H$^I`gdCAA-AcAAA3B4B5B7B8B9B:B;BB?B@BABBB%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: $7$8$@&H$a$gdC & FL7$8$@&H$^`LgdC & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdCBBCBDBEBFBGBHBIBJBKBLBMBNBnBBBBC#C~CCCnD%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC $7$8$@&H$a$gdCnDoDDDEEEtFFFFFF GCGWGyGGGGGG*H%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC $7$8$@&H$a$gdC*HH3J4J@JJJJKQKyKKKL*LbLL%Q%< %v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%U%U 7$8$@&H$gdC & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC $7$8$@&H$a$gdC7$8$@&H$^`gdC & F7$8$@&H$^`gdC4J@JJJJKKL*LbLLLLM M MMmMMNNNOOOPQPhPvPwPPQQ(RRRR.S\S]S_SaSSSSS0T1TTTTUUUV V V!Vǿ۳۪hz8hC5CJaJhz8hC6CJaJhC6CJaJ *h@hCCJaJh;PCJaJhCCJaJhPAhC6CJaJh jhCCJaJ *h@hCCJaJ *h@hC5CJaJ9LLLLLMMMM M M M M MMmM%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%U & F7$8$@&H$^`gdC $7$8$@&H$a$gdC7$8$@&H$^`gdCI7$8$@&H$^I`gdC & FL7$8$@&H$^`LgdC & FI7$8$@&H$^I`gdCmMMMMNN,N>NONNNNHOOOOPQPRP%U%U%U%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: $7$8$@&H$a$gdC7$8$@&H$^`gdC & F7$8$@&H$^`gdC & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdCRPSPTPUPVPWPXPYPZP[P\P]P^P_P`PaPbPcPdPePfPgPhPiPjPkPlPmPnP%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: $7$8$@&H$a$gdCnPoPpPqPrPsPtPuPvPwPPP QQDQQQ(RR.SASHS%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: & FI7$8$@&H$^I`gdC & F7$8$@&H$^`gdC 7$8$@&H$gdC $7$8$@&H$a$gdCHS\S]S^S_S`SaSSSSSSSSSSSSS%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v:%v: & F7$8$@&H$^`gdC 7$8$@&H$gdC & F7$8$@&H$^`gdC7$8$@&H$^`gdC & 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