Tag: PATHOLOGY

Hepatorenal Syndrome

HEPATORENAL SYNDROME


HEPATORENAL SYNDROME

  • HRS is development of acute renal failure due to severe hepatic (advanced cirrhosis) or bilary disease with jaundice.
  • Low cardiac putput and high plasma rennin predicts development of HRS.
  • Patient develops oliguria, azotaemia and hyponatraemia.

ETIOLOGY-

  • Bile salt sludging in the tubules
  • Absorption of toxins
  • Increase ADH release
  • Hypoperfusion and renal ischaemia
  • Precipitated by surgery, stress

 PATHOLOGY-

  • Increase in renal vascular resistance along with reduction in systemic vascular resistance
  • Pathogenic marker is intense renal vasoconstriction with vasodilatation

INVESTIGATIONS-  

TYPES-

1. Type 1 HRS-

  • Oliguria
  • Decrease serum creatinine
  • Poor prognosis
  • No proteinuria
  • Urine sodium excretion  <10mmol/day
  • Urine/ plasma osmolarity ration >1.5

Treatment-

  • Albumin + terlipressin

2. Type 2 HRS

  • Refractory ascites
  • Better prognosis
  • Increase serum creatinine levels

Treatment-

  • Terlipressin- DOC
  • Midodrine + pctreotide + IV albumin- reverse renal failure
  • Best therapy for HRS- liver transplantation
  • Dopamine or prostaglandin analogues for renal vasodilation

Exam Important

PATHOLOGY-

  • Increase in renal vascular resistance along with reduction in systemic vascular resistance
  • Pathogenic marker is intense renal vasoconstriction with vasodilatation

INVESTIGATIONS-  

TYPES-

1. Type 1 HRS-

  • Oliguria
  • Decrease serum creatinine
  • Poor prognosis
  • No proteinuria
  • Urine sodium excretion  <10mmol/day
  • Urine/ plasma osmolarity ration >1.5

Treatment-

  • Albumin + terlipressin

2. Type 2 HRS

  • Refractory ascites
  • Better prognosis
  • Increase serum creatinine levels

Treatment-

  • Terlipressin- DOC
  • Midodrine + pctreotide + IV albumin- reverse renal failure
  • Best therapy for HRS- liver transplantation
  • Dopamine or prostaglandin analogues for renal vasodilation
Don’t Forget to Solve all the previous Year Question asked on HEPATORENAL SYNDROME

Module Below Start Quiz

Hepatorenal Syndrome

Hepatorenal syndrome

Q. 1 Albumin treatment along with antibiotic in the setting of SBP(spontaneous bacterial peritonitisis indicated to prevent the development of hepatorenal syndrome is in all , EXCEPT:

 A

Serum creatine is > 1 mg/dl

 B

BUN > 30mg/dl

 C

Total bilirubin is > 4 mg/dl

 D

INR > 2

Q. 1

Albumin treatment along with antibiotic in the setting of SBP(spontaneous bacterial peritonitisis indicated to prevent the development of hepatorenal syndrome is in all , EXCEPT:

 A

Serum creatine is > 1 mg/dl

 B

BUN > 30mg/dl

 C

Total bilirubin is > 4 mg/dl

 D

INR > 2

Ans. D

Explanation:

In patients with SBP along  with cefotaxime albumin infusion is indicated in the setting , when

1.Serum creatine is  > 1 mg/dl
2. BUN >   30 mg/dl
3. Total bilirubin is > 4 mg/dl
 
Dose o f albumin: 1. g/Kg within 6 hours of antibiotic treatment and 1 g/kg  on day 3.
A decrease in mortality from 30%to 10 % is noted.
Ref: AASLD practice  guidelines:Hepatology, Vol.49 ,No.6 ,2009.

Q. 2 Features of Hepatorenal syndrome are

 A

Urine sodium < 10 meq/1

 B

Normal renal histology

 C

Renal function abnormal even after liver become normal

 D

a and b

Q. 2

Features of Hepatorenal syndrome are

 A

Urine sodium < 10 meq/1

 B

Normal renal histology

 C

Renal function abnormal even after liver become normal

 D

a and b

Ans. D

Explanation:

Answer is A & B (urine Na < 10 meq/l and Normal Renal Histology)

Hepatorenal syndrome is associated with normal renal histology and supported by a urine sodium excretion l0meq/L

Hepatorenal syndrome

  • Hepatorenal syndrome is defined as a state of functional renal failure (Reduced GFR) in patients with severe liver disease
  • Structurally /Histologically the kidneys are normal and recover function after successful liver transplantation.
  • The pathogenetic hallmark of hepatorenal syndrome is intense renal vasoconstriction with coexistent systemic vasodilatation
  • The diagnosis of hepatorenal syndrome is considered in accordance with the following diagnostic criteria.

Diagnostic of Hepatorenal Syndrome

Major criteria

  • Low glomerular filtration rate. as indicated by serum creatinine > 1.5 mg/dL or 24-hr creatinine clearance < 40 mL/min
  • Absence of shock, ongoing bacterial infection, fluid losses, and current treatment with nephrotoxic drugs
  • No sustained improvement in renal function (decrease in serum creatinine to 1.5 nig/dL or increase in creatinine clearance to 40 mL/min) after diuretic withdrawal and expansion of plasma volume with 1.5L of a plasma expander
  • Proteinuria mg/d1, and no uhrasonographic evidence of obstructive uropathy or parenchymal renal disease Additional criteria
  • Urine volume < 500 mL/d
  • Urine sodium < 10 meq/L
  • Urine osmolality greater than plasma osmolality
  • Urine red blood cells <50/high- power. field
  • Serum sodium concentration < 130 niEqL

Note: All major criteria must be present for the diagnosis of hepatorenal syndrome.

Additional criteria are not necessary for the diagnosis but provide supportive evidence.


Q. 3 Which of the following statements is incorrect with regard to Hepatorenal syndrome in a patient with cirrhosis

 A

Createnine clearance < 40 ml/min

 B

Urinary sodium < 10mq/L

 C

Urine osmolality lower than plasma osmolality

 D

No sustained improvement in renal function after volume expansion.

Q. 3

Which of the following statements is incorrect with regard to Hepatorenal syndrome in a patient with cirrhosis

 A

Createnine clearance < 40 ml/min

 B

Urinary sodium < 10mq/L

 C

Urine osmolality lower than plasma osmolality

 D

No sustained improvement in renal function after volume expansion.

Ans. C

Explanation:

Answer is C (Urine osmolality is lower than plasma osmolality):

Hepatorenal syndrome is associated with urine osmolality greater than plasma osmolality (and not lower than plasma osmolality).

creatinine clearance < 40 ml/minute and poor response to volume expansion are major diagnostic features of hepatorenal syndrome while urinary sodium of less than 10 mmol/L is an additional criteria that provides supportive evidence.

Quiz In Between


Q. 4

Hepatorenal syndrome is characterized by all of the following except:     
March 2005

 A

Reduction in creatinine clearance

 B

Managed effectively by renal vasodilating agents.

 C

Proteinuria less than 500 mg/ d

 D

Normal intrinsic kidney

Q. 4

Hepatorenal syndrome is characterized by all of the following except:     
March 2005

 A

Reduction in creatinine clearance

 B

Managed effectively by renal vasodilating agents.

 C

Proteinuria less than 500 mg/ d

 D

Normal intrinsic kidney

Ans. B

Explanation:

Ans. B: Managed effectively by renal vasodilating agents.

HRS is defined as worsening azotemia with avid sodium retention and oliguria in the absence of identifiable specific cause of renal dysfucntion in setting of acute or advanced chronic liver disease

No specific tests establish the diagnosis of HRS.

Diagnosis of HRS is based on the presence of a reduced GFR in the absence of other causes of renal failure in patients with chronic liver disease. The following criteria help to diagnose HRS:

Major criteria: All major criteria are required to diagnose HRS.

  • Low GFR, indicated by a serum creatinine level higher than 1.5 mg/ dL or 24-hour creatinine clearance lower than 40 mL/ min
  • Absence of shock, ongoing bacterial infection and fluid losses, and current treatment with nephrotoxic medications
  • No sustained improvement in renal function (decrease in serum creatinine to40 mL/ min) after diuretic withdrawal and expansion of plasma volume with 1.5 L of plasma expander
  • Proteinuria less than 500 mg/ d and no ultrasonographic evidence of obstructive uropathy or intrinsic parenchymal disease

Additional criteria: Additional criteria are not necessary for the diagnosis but provide supportive evidence.

  • Urine volume less than 500 mL/d
  • Urine sodium level less than 10 mEq/ L
  • Urine osmolality greater than plasma osmolality
  • Urine red blood cell count of less than 50 per high-power field
  • Serum sodium concentration less than 130 mEq/ L

The best therapy for HRS is liver transplantation.


Q. 5 All are true about hepatorenal syndrome except:

 A

Creatinine level raised

 B

Albumin infusion given

 C

Liver transplantation improves renal functions

 D

May occur in cirrhosis

Q. 5

All are true about hepatorenal syndrome except:

 A

Creatinine level raised

 B

Albumin infusion given

 C

Liver transplantation improves renal functions

 D

May occur in cirrhosis

Ans. E

Explanation:

Answer- E. Low dose dopamine infusion is very effective

  • The hepatorenal syndrome (HRS) is a form of functional renal failure without renal pathology that occurs in about 10% of patients with advanced cirrhosis or acute liver failure.
  • There are marked disturbances in thc arterial renal circulation in Patients with HRS.
  • TyPe I HRS- a significant reduction in creatinine clearance within 1-2 weeks of presentation.
  • Type 2 HRS- an elevation of serum creatinine level.
  • HRS is often seen in patients with refractory ascites.

Treatment-

  • dopamine or prostaglandin analogues were used as renal vasodilating medications.
  • Patients are treated with midodrine, an alpha-agonist, along with octreotide and intravenous albumin.
  • The best theragy for HRS is liver transplantation.

Quiz In Between



Carcinoma Of Prostate

CARCINOMA OF PROSTATE


CARCINOMA OF PROSTATE

  • Carcinoma of prostate is the MC malignant tumour in men over 65 years.
  • MC cause of bone secondaries
  • Carcinoma of prostate occurs in peripheral zone in prostatic gland proper (commonly in posterior lobe)

RISK FACTORS-

  • Advancing age + increase fat intake
  • Genetic alterations is hypermethylation of glutathione transferase (GSTP-1) located on chromosome 11

PATHOLOGY-

  • Adenocarcinoma of prostate is the MC form of cancer in males
  • They are multifocal and heterogenous

SPREAD-

1. Local spread-

  • Upward- seminal vesicles, bladder neck, trigone
  • Downward- distal sphincter

2. Blood spread-

  • Bones- pelvic bones, lumbar vertebrae, femoral head, ribs and skull
  • MC site of origin- for skeletal metastases

3. Lymphatic spread-

  • Obturator lymph nodes

CLINICAL FEATURES-

  • Bladder outlet obstruction
  • Haematuria
  • Commonly asymptomatic
  • Pelvic pain, back pain, arthritic pain
  • Renal failure
  • Perineural invasion
  • Rectal examination- prostate feels hard, nodular, irregular and obliteration of medial sulcus

STAGING-  

INVESTIGATIONS-

1. Hb%

  • Anemia
  • Thrombocytopenia
  • DIC

2. Plain X-ray, KUB-

  • Shows sclerotic metastases in lumbar vertebrae and pelvic bones

3. Serum acid phosphatase-

  • Responsible for acidic pH in the prostatic urethra and normally drained in urine
  • Increase acid phosphatase

4. Serum alkaline phosphatase-

  • Increase in extensive liver metastasis or bone metastasis

5. Prostate specific antigen(PSA)

  • It is a glycoprotein, serine protease elaborated by columnar prostatic acinar epithelial cells.
  • Free- 10- 40%, complexed to antiprotease- 60 to 90%
  • Formed in prostate and secreted in seminal fluid
  • Causes liquefaction of seminal coagulum
  • More than 4nmol/ml- carcinoma detected
  • 10 nmol/ml- prostatic carcinoma
  • 35 nmol/ ml- disseminated carcinoma
  • Prostate specific, but not prostate cancer specific
  • Most efficient test and for staging and assessing

6. Abdominal and transrectal USG- staging of the disease

7. CT scan or MRI scan

  • Staging of the disease
  • MRI is ideal for most accurate for local staging

8. Bone scan-

  • Increased ALP
  • Increased PSA (>20nmol/ml)
  • For diagnosing metastasis

TREATMENT-

I) Early malignancy

a) T1 a-

  • Well differentiated associated with very slow growth rate
  • Regular follow up with DRE and PSA

b) T1b T1c, T2

  • Radical prostactectomy or radiotherapy
  • External beam radiotherapy- T1 or low T2 disease
  • Branchytherapy- low T1 disease

II) Late malignancy (T3, T4 or any metastasis)

  • Androgen ablation is the first line of treatment followed by antiandrogenic measure
  • Orchiectomy + flutamide or LHRH + flutamide
  • Palliative radiotherapy

Exam Important

  • Carcinoma of prostate is the MC malignant tumour in men over 65 years.
  • MC cause of bone secondaries
  • Carcinoma of prostate occurs in peripheral zone in prostatic gland proper (commonly in posterior lobe)

CLINICAL FEATURES-

  • Bladder outlet obstruction
  • Haematuria
  • Commonly asymptomatic
  • Pelvic pain, back pain, arthritic pain
  • Renal failure
  • Perineural invasion
  • Rectal examination- prostate feels hard, nodular, irregular and obliteration of medial sulcus

INVESTIGATIONS-

1. Hb%

  • Anemia
  • Thrombocytopenia
  • DIC

2. Plain X-ray, KUB-

  • Shows sclerotic metastases in lumbar vertebrae and pelvic bones

3. Serum acid phosphatase-

  • Responsible for acidic pH in the prostatic urethra and normally drained in urine
  • Increase acid phosphatase

4. Serum alkaline phosphatase-

  • Increase in extensive liver metastasis or bone metastasis

5. Prostate specific antigen(PSA)

  • It is a glycoprotein, serine protease elaborated by columnar prostatic acinar epithelial cells.
  • Free- 10- 40%, complexed to antiprotease- 60 to 90%
  • Formed in prostate and secreted in seminal fluid
  • Causes liquefaction of seminal coagulum
  • More than 4nmol/ml- carcinoma detected
  • 10 nmol/ml- prostatic carcinoma
  • 35 nmol/ ml- disseminated carcinoma
  • Prostate specific, but not prostate cancer specific
  • Most efficient test and for staging and assessing

6. Abdominal and transrectal USG- staging of the disease

7. CT scan or MRI scan

  • Staging of the disease
  • MRI is ideal for most accurate for local staging

8. Bone scan-

  • Increased ALP
  • Increased PSA (>20nmol/ml)
  • For diagnosing metastasis

TREATMENT-

I) Early malignancy

a) T1 a-

  • Well differentiated associated with very slow growth rate
  • Regular follow up with DRE and PSA

b) T1b T1c, T2

  • Radical prostactectomy or radiotherapy
  • External beam radiotherapy- T1 or low T2 disease
  • Branchytherapy- low T1 disease

II) Late malignancy (T3, T4 or any metastasis)

  • Androgen ablation is the first line of treatment followed by antiandrogenic measure
  • Orchiectomy + flutamide or LHRH + flutamide
  • Palliative radiotherapy
Don’t Forget to Solve all the previous Year Question asked on CARCINOMA OF PROSTATE

Module Below Start Quiz

Carcinoma Of Prostate

Carcinoma of prostate

Q. 1 Which is the most common site of carcinoma prostate?

 A

Peripheral

 B

Centre

 C

Verumontum

 D

None of the above

Q. 1

Which is the most common site of carcinoma prostate?

 A

Peripheral

 B

Centre

 C

Verumontum

 D

None of the above

Ans. A

Explanation:

85% of prostate carcinoma arise from the peripheral zone.
Ninety five percent of tumors are adenocarcinoma.
Prostate carcinoma rarely occur before the age of 40 years, and the incidence increases with age. 

  • PSA is elevated in 60% of men with prostate cancer. Levels above 4ng/ml is considered abnormal.
  • Levels of PSA can be elevated with age and BPH. 
  • Falsely elevated PSA can be seen following cystoscopy, prostate biopsy, or urethral catheterization.
  • PSA is not elevated following digital rectal examination.

Ref: CURRENT Diagnosis & Treatment: Surgery, 13e, chapter 38


Q. 2

Trans rectal ultrasonogram in evaluation of carcinoma prostate most useful for:

 A

Taking guided biopsy

 B

Identifying seminal vesicle invasion

 C

Nodal sampling

 D

Measuring the extent of invasion

Q. 2

Trans rectal ultrasonogram in evaluation of carcinoma prostate most useful for:

 A

Taking guided biopsy

 B

Identifying seminal vesicle invasion

 C

Nodal sampling

 D

Measuring the extent of invasion

Ans. A

Explanation:

Ans. is ‘a’ Taking guided biopsy 

“TRUS is the imaging technique most frequently used to assess the primary tumor, but its chief use is directing prostate biopsies, not staging” – Harrison

  • Thus primary role of TRUS is guiding prostate biopsies
  • Other uses are

– assessing extent of invasion if cancer is detected.

– measurement of prostate volume which is needed in the calculation of the PSA density. – also used in performance of cryosurgery & brachytherapy.


Q. 3

Which is not used in carcinoma prostate ‑

 A

Estrogen

 B

Progesterone

 C

Cyproterone acetate

 D

Flutamide

Q. 3

Which is not used in carcinoma prostate ‑

 A

Estrogen

 B

Progesterone

 C

Cyproterone acetate

 D

Flutamide

Ans. C

Explanation:

Ans. is ‘c’ i.e., Conservative treatment 

Quiz In Between


Q. 4

In carcinoma prostate with matastasis which is raised

 A

ESR

 B

Alkaline phosphatase

 C

Acid phosphatase

 D

All

Q. 4

In carcinoma prostate with matastasis which is raised

 A

ESR

 B

Alkaline phosphatase

 C

Acid phosphatase

 D

All

Ans. B

Explanation:

Ans. is ‘b’ i.e., Alkaline phosphatase 


Q. 5

70 year old man with Ca.prostate with osteoblastic secondaries in pelvis and lumbar vertebra showed well differentiated Adeno Carcinoma prostate on needle biopsy. He is idealy treated by –

 A

Radical prostectomy

 B

TURP

 C

Radiation

 D

Hormonal manipulation

Q. 5

70 year old man with Ca.prostate with osteoblastic secondaries in pelvis and lumbar vertebra showed well differentiated Adeno Carcinoma prostate on needle biopsy. He is idealy treated by –

 A

Radical prostectomy

 B

TURP

 C

Radiation

 D

Hormonal manipulation

Ans. D

Explanation:

Ans. is ‘d’ i.e., Hormonal manipulation 

Quiz In Between



Carcinoma Of Penis

CARCINOMA OF PENIS


CARCINOMA OF PENIS

  • MC type – SCC

ETIOLOGY-

  1. Premalignant lesions-
  • Genital warts- Bushke- Lowenstein tumour is a giant penile condyloma (verrucous carcinoma of penis)
  • Erythroplasia of Queyrat or Paget’s disease of penis- precancerous lesion
  • Leukoplakia of glans
  • Bowen’s disease- small eczematous plaque
  • Chronic balanoposthitis, phimosis (50%), Balanitis xerotica obliterans
  • Condyloma auminata (HPV)
  • Most important carcinogens- HPV (16, 18, 31, 33)
  • Poor hygiene

PATHOLOGY-

  1. Infiltrating type- pre-existing leukoplakia
  2. Papilliferous type
  3. Ulcerative type- glans penis MC site. 80% are low grade tumours

SPREAD-

  1. Lymphatics-
  • Spreads to horizontal group of inguinal lymph nodes and are nodular, hard, fixed which suggests metstasis.
  • Carcinoma from shaft of penis spreads to external iliac LN
  • Initernal and paraaortic LN get enlarged

2. Blood spread is rare

3. Death may occur due to erosions of femoral vessels by iguinal LN.

CLINICAL FEATURES-

  • Occurs in 6th decade
  • Neonatal circumcision helps in immunity against carcinoma penis, HIV or STD.
  • MC orginates from glans > sulcus > prepuce > shaft
  • Foul smelling discharge is common
  • In adults, recent onset of phimosis
  • Haematuria, pain while passing urine- advanced tumours
  • On examination, fungation and induration, everted edge
  • Pain, oedema, tenderness, redness present on infection
  • Urethra is rarely involved as it is protected by tough Buck’s fascia

 

INVESTIGATIONS-

  • Incisional biopsy for grade and depth of invasion and wedge biopsy for SCC
  • Senitel LN biopsy (Cabana sentinel LN)
  • USG- assessment of depth
  • MRI- IOC for staging in CA penis

STAGING-

  1. Stage 1- Confined to glans or prepuce
  2. Stage 2- involving penile shaft or copora cavernosa
  3. Stage 3- Operable inguinal LN metastasis
  4. Stage 4- inoperable inguinal LN metastasis Or advanced spread

TNM STAGING 

TREATMENT-

  • Surgery is the TOC
  • Ca in situ- topical 5- FU cream, Nd- YAG laser, radiotherapy + follow up
  • Ca in situ
  • Young’s operation- for glans involvement without extending into proximal part of shaft
  • Total amputation with perineal urethrostomy- if shaft is involved
  • Piersey Gold operation- total amputation + total scrotectomy + total orchidectomy
  • Laser ablation- stage T1 tumour
  • Enlarged inguinal node- block dissection

Exam Important

  • MC type – SCC

ETIOLOGY-

  1. Premalignant lesions-
  • Genital warts- Bushke- Lowenstein tumour is a giant penile condyloma (verrucous carcinoma of penis)
  • Erythroplasia of Queyrat or Paget’s disease of penis- precancerous lesion
  • Leukoplakia of glans
  • Bowen’s disease- small eczematous plaque
  • Chronic balanoposthitis, phimosis (50%), Balanitis xerotica obliterans
  • Condyloma auminata (HPV)
  • Most important carcinogens- HPV (16, 18, 31, 33)
  • Poor hygiene

SPREAD-

1. Lymphatics-

  • Spreads to horizontal group of inguinal lymph nodes and are nodular, hard, fixed which suggests metstasis.
  • Carcinoma from shaft of penis spreads to external iliac LN
  • Initernal and paraaortic LN get enlarged

2. Blood spread is rare

3. Death may occur due to erosions of femoral vessels by iguinal LN. 

CLINICAL FEATURES-

  • Occurs in 6th decade
  • Neonatal circumcision helps in immunity against carcinoma penis, HIV or STD.
  • MC orginates from glans > sulcus > prepuce > shaft
  • Foul smelling discharge is common
  • In adults, recent onset of phimosis
  • Haematuria, pain while passing urine- advanced tumours
  • On examination, fungation and induration, everted edge
  • Pain, oedema, tenderness, redness present on infection
  • Urethra is rarely involved as it is protected by tough Buck’s fascia

TREATMENT-

  • Surgery is the TOC
  • Ca in situ- topical 5- FU cream, Nd- YAG laser, radiotherapy + follow up
  • Ca in situ
  • Young’s operation- for glans involvement without extending into proximal part of shaft
  • Total amputation with perineal urethrostomy- if shaft is involved
  • Piersey Gold operation- total amputation + total scrotectomy + total orchidectomy
  • Laser ablation- stage T1 tumour
  • Enlarged inguinal node- block dissection
Don’t Forget to Solve all the previous Year Question asked on CARCINOMA OF PENIS

Module Below Start Quiz

Carcinoma Of Penis

Carcinoma Penis

Q. 1 Carcinoma penis is rarest among –

 A

Americans

 B

Indians

 C

Swedes

 D

Jews

Q. 1

Carcinoma penis is rarest among –

 A

Americans

 B

Indians

 C

Swedes

 D

Jews

Ans. D

Explanation:

Ans. is `d’ i.e., Jews

Carcinoma of penis

  • Penile cancer is a malignant growth found on the skin or in the tissue of penis.
  • Circumcision confers protection hence, this cancer is extremely rare among jews and moslems and is correspondingly more common in populations in which circumcision is not routinely practiced. Predisposing factors : – 

 Smoking    

  • Infection with HPV16 and HPV- 18
  • Presence of pre-cancerous lesion —> Bowen disease.

Q. 2 Not true about carcinoma penis is –

 A

Erythroplasia of Queret is a precancerous condition

 B

40% of pts are under 40 year of age

 C

Circumcision if done any time before puberty provides 100% protection against carcinoma penis

 D

More than 50% pt. have inguinal 1.n enlargement when they present

Q. 2

Not true about carcinoma penis is –

 A

Erythroplasia of Queret is a precancerous condition

 B

40% of pts are under 40 year of age

 C

Circumcision if done any time before puberty provides 100% protection against carcinoma penis

 D

More than 50% pt. have inguinal 1.n enlargement when they present

Ans. C

Explanation:

Ans. ie ‘c’ ie Circumcision if done any time before puberty provides 100% protection 

  • The circumcision that is done soon after birth in infancy gives almost complete immunity against Ca penis; but that done later in life does not have the same effect, so Muslims circumcised between the ages of 4 and 9 years are still liable to the disease.
  • About Ca Penis

Most common histological type is –> sq. cell Ca (98%)

Erythroplasia of Queret is precancerous condition. It’s the in-situ form of Ca Penis.

[Carcinoma in situ of the penis is called Erythroplasia of Queyrat if it involves the glans penis, prepuce or penile shaft, and is called Bowen’s disease if it involves the remainder of the genitalia or perinea! region” – Cambell’s Urology 8/e, p 2950]

  • Premalignant lesions of Ca Penis

a.          Penile cutaneous horn
b.          Balanitis xerotica obliterans
c.          Leukoplakia
d.          Viral (Human papilloma virus) related Dermatologic lesion

– Condyloma acuminata (also k/a genital warts)

– Bowenoid papulori

  • The one etiological factor most commonly associated with penile carcinoma is poor hygine.
  • Clinical features
  • Age – Penile Ca occurs most commonly in the sixth decade of life, but its presentation in younger age group is not uncommon (“40% of pts are under 40 years of age” – Bailey)
  • Most common complaint at presentation is the lesion itself. Pain is rare.
  • Most common site of involvement (% from Cambell’s Urology 8/e, p 2953)

Glans

—>

-48%

Prepuce

—>

-21%

Both Glans & Prepuce

-4

9%

Coronal sulcus

 

-6%

Shaft

—>

-2%

  • Lymph node involvement

More than 50% of patients present with enlarged inguinal lymph nodes (but half of these are reactive enlargement d/t sepsis).

–  The presence and the extent of metastasis to the inguinal region is the most important prognostic factor for survival in patients with Ca Penis.

  • Distant metastasis is infrequent
  • Diagnosis is made by biopsy of lesion.
  • Treatment is discussed ahead.

Q. 3

Cause of death in Carcinoma penis is usually –

 A Metastasis to lung

 B

Metastasis to liver

 C

Erosion of Femoral blood vessels

 D

Urinary obstruction

Q. 3

Cause of death in Carcinoma penis is usually –

 A

Metastasis to lung

 B

Metastasis to liver

 C

Erosion of Femoral blood vessels

 D

Urinary obstruction

Ans. C

Explanation:

Ans. is ‘c’ i.e., Erosion of femoral blood vessels 

Inguinal lymph nodes erode the skin of the groin and the death of the patient may be due to involvement of the femoral or external iliac artery with torrential haemorrhage.

Quiz In Between


Q. 4 What is true about carcinoma penis – 

 A

Metastasis is rare

 B

Occurs more commonly in circumcised male

 C

Arises from corona of glans

 D

Pain is frequent

Q. 4

What is true about carcinoma penis – 

 A

Metastasis is rare

 B

Occurs more commonly in circumcised male

 C

Arises from corona of glans

 D

Pain is frequent

Ans. C

Explanation:

Ans. is ‘c’ i.e., Arises from corona of glans 

  • As already mentioned persons circumcised at birth or soon after are immune to Ca Penis.
  • Metastasis to lymph nodes is quite common. Distant metastasis occurs in less than 10% of pts.
  • MC site is glans penis
  • Pain is infrequent
  • Bailey writes – “There is little or no pain”

Q. 5

Features of carcinoma penis are all EXCEPT:

March 2013

 A

Circumcision soon after birth provides total immunity

 B

Pagets disease is not a premalignant disease

 C

Metastasis to inguinal nodes

 D

Surgery is treatment of choice

Q. 5

Features of carcinoma penis are all EXCEPT:
March 2013

 A

Circumcision soon after birth provides total immunity

 B

Pagets disease is not a premalignant disease

 C

Metastasis to inguinal nodes

 D

Surgery is treatment of choice

Ans. B

Explanation:

Ans. B i.e. Pagets disease is not a premalignant disease

Quiz In Between


Q. 6

Features of carcinoma penis include all except:
March 2007

 A

Metastasize to inguinal lymph nodes

 B

Surgery is the treatment of choice

 C

Hypospadias is a premalignant lesion

 D

Circumcision provides protection

Q. 6

Features of carcinoma penis include all except:
March 2007

 A

Metastasize to inguinal lymph nodes

 B

Surgery is the treatment of choice

 C

Hypospadias is a premalignant lesion

 D

Circumcision provides protection

Ans. C

Explanation:

Ans. C: Hypospadias is a premalignant lesion

Following as risk factors for penile cancer:

Human papillomavirus (HPV) infection, smoking, smegma, phimosis, treatment of psoriasis, age, and AIDS. The other etiologic factor most commonly associated with penile carcinoma is poor hygiene. Lichen sclerosus (also known as balanitis xerotica obliterans) may also be a risk factor.

Symptoms

Redness, irritation and a sore or a lump on the penis.

Pathology

  • Precancerous Dermatologic Lesions
  • Carcinoma in Situ (Bowen Disease, Erythroplasia of Queyrat)
  • Invasive Carcinoma of the Penis

A Squamous cell carcinoma usually originating in the glans or foreskin is by far the most common type, occurring in 9 out of 10 cases.

Staging

The stages are assessed as follows:

  • Stage I – Cancer has only affected the glans and/or foreskin.
  • Stage II – Cancer has spread to the shaft of the penis.
  • Stage III – Cancer has affected the penis and surrounding lymph nodes.
  • Stage IV – Cancer has moved beyond the groin area to other parts of the body.
  • Recurrent – Cancer that has returned after treatment.

The most common treatment is one of five types of surgery:

  • Wide local excision – The tumor and some surrounding healthy tissue are removed
  • Microsurgery – Surgery performed with a microscope is used to remove the tumor and as little healthy tissue as possible
  • Laser surgery – laser light is used to burn or cut away cancerous cells
  • Circumcision – cancerous foreskin is removed
  • Amputation (penectomy) – a partial or total removal of the penis, and possibly the associated lymph nodes. This is the most common and effective treatment.

Radiation therapy is usually used adjuvantly with surgery to reduce the risk of recurrence.

With earlier stages of penile cancer, a combination of topical chemotherapy and less invasive surgery may be used. More advanced stages of penile cancer usually require a combination of surgery, radiation and chemotherapy.


Q. 7 All of the following are features of carcinoma penis Except:        
March 2005

 A

Surgery is the treatment of choice

 B

Balanoposthitis may be a predisposing factor

 C

Metastaizes to inguinal nodes

 D

Histologically a transitional cell carcinoma

Q. 7

All of the following are features of carcinoma penis Except:        
March 2005

 A

Surgery is the treatment of choice

 B

Balanoposthitis may be a predisposing factor

 C

Metastaizes to inguinal nodes

 D

Histologically a transitional cell carcinoma

Ans. D

Explanation:

Ans. D: Histologically a transitional cell carcinoma

Penile squamous cell carcinoma, the most common penile malignancy, behaves similarly to squamous cell carcinoma in other parts of the skin.

Chronic balanoposthitis is known to be a contributory factor for penile carcinoma.

Metastasis, which is possible with this type of carcinoma, is often lethal.

Quiz In Between



Buerger Disease

BUERGER DISEASE


BUERGER’S DISEASE (THROMBOANGITIS OBLITERANS)

  • Buerger’s disease is a non- atherosclerotic, progressive, segmental, occlusive inflammatory disorder involving small and medium sized arteries with cell mediated sensitivity to Type I and Type II collage in upper and lower extremities.
  • Inflammatory process does involve adjacent nerves and veins.
  • Triad of thromboangitis obliterans- occlusion of small and medium sized vessels, superficial thrombophelbitis, Raynaud’s phenomenon.

ETIOLOGY-

  • Mainly seen in smokers and tobacco users.
  • Common in Jewish people
  • Hormonal influence
  • Familial nature
  • Poor hygiene

PATHOLOGY-

  • Smoke → vasospasm & hyperplasia initma → thrombus & obliteration medium sized vessels → Panarteritis → Artery, vein & nerve are involved  → Blockage leads to collateral open up → Blood supply to ishchaemic areas → Compensatory peripheral vascular disease
  • Microabscesses, giant cells are found.

CLASSIFICATION-

  • Type I- upper limb TAO (rare)
  • Type II- involving legs & infrapopliteal
  • Type III- femoropopliteal
  • Type IV- aortoiliofemoral
  • Type V- generalised

CLINICAL FEATURES-

  • Common in male smokers between 20- 40 years
  • Intermittent claudication in foot & calf progressing to rest pain, ulceration & gangrene.
  • Absence of atheromas.
  • Small & medium sized vessels such as dorsalis, pedis, posterior tibial, popliteal are commonly involved.

INVESTIGATIONS-

1. Arterial Doppler & Duplex scan

2. Transformed retrograde angiogram-

  • Shows blockage
  • Cork screw appearance of the vessel
  • Inverted tree/ spider leg collaterals
  • Severe vasospasm causing rippled artery

3. Transbranchial angiogram- if femorals are not felt then transbranchial angiogram is done.

4. USG abdomen- shows abdominal aorta for block 

TREATMENT-

  • Stop smoking
  • Vasodilators- nifedipine, xanthinol nicotinate
  • Antithrombin activity- low dose of aspirin
  • Analgesics
  • Lumbar sympathectomy- for rest pain and ulcerations
  • Omentoplasty, profundoplasty
  • Amputation in gangrene

Exam Important

PATHOLOGY-

  • Smoke → vasospasm & hyperplasia initma → thrombus & obliteration medium sized vessels → Panarteritis → Artery, vein & nerve are involved  → Blockage leads to collateral open up → Blood supply to ishchaemic areas → Compensatory peripheral vascular disease
  • Microabscesses, giant cells are found.

ETIOLOGY-

  • Mainly seen in smokers and tobacco users.
  • Common in Jewish people
  • Hormonal influence
  • Familial nature
  • Poor hygiene

CLINICAL FEATURES-

  • Common in male smokers between 20- 40 years
  • Intermittent claudication in foot & calf progressing to rest pain, ulceration & gangrene.
  • Absence of atheromas.
  • Small & medium sized vessels such as dorsalis, pedis, posterior tibial, popliteal are commonly involved.
Don’t Forget to Solve all the previous Year Question asked on BUERGER DISEASE

Module Below Start Quiz

Buerger Disease

Buerger Disease

Q. 1

All of the following are the clinical feature of thromboangitis obliterans except :

 A Raynaud’s phenomenon

 B

Claudication of extremeties

 C

Absence of popliteal pulse

 D

Migratory superficial thrombophlabitis

Q. 1

All of the following are the clinical feature of thromboangitis obliterans except :

 A

Raynaud’s phenomenon

 B

Claudication of extremeties

 C

Absence of popliteal pulse

 D

Migratory superficial thrombophlabitis

Ans. C

Explanation:

Ans. is ‘c’ i.e., Absence of popliteal pulse


Q. 2

Commonest site of thromboangitis obliterans is 

 A

Femoral artery

 B

Popiteal artery

 C

iliac artery

 D

None

Q. 2

Commonest site of thromboangitis obliterans is 

 A

Femoral artery

 B

Popiteal artery

 C

iliac artery

 D

None

Ans. D

Explanation:

Ans. is ‘None’ 
Distal circulation is involved in Buerger’s disease, usually distal to popliteal and brachial artery.


Q. 3

Thromboangitis obliterans is associated with

 A

HLA B27

 B

HLA – DR4

 C

HLA – B5

 D

HLA – DR2

Q. 3

Thromboangitis obliterans is associated with

 A

HLA B27

 B

HLA – DR4

 C

HLA – B5

 D

HLA – DR2

Ans. C

Explanation:

Ans. is ‘c’ i.e., HLA – B5 

Thromboangitis obliterans (Berger disease)

  • Thrombangitis obliterans is a distinctive disease that is characterized by segmental, thrombosing acute and chronic inflammation of medium sized and small sized arteries, and sometimes secondarily extending to veins and nerves.
  • Thromboangitis obliterans occurs almost exclusively among heavy-cigarrete-smoking persons.
  • It is more common in men but incidence is increasing in women because of increasing smoking habit in women. o Buerger disease is associated with HLA B-5 and HLA-A9.
  • In thrombongitis obliterans there is acute and chronic segmental inflammation of vessels with accompanied thrombosis in the lumen.
  • Typically, the thrombus contains microabscesses with a central focus of neutrophils surrounded by gran u lomatous inflammation.
  • Later, the inflammatory process extends into contiguous veins and nerves and in time all three structures (arteries, veins and nerves) become encased in fibrous tissue, a characterstic that is very rare with other form of vasculitis.
  • Clinical manifestations
  • Thrombangitis obliterans affects vessels of upper and lower extremities.
  • Symptoms are due to vascular insufficiency, i.e. Ischemia of toes, feet and fingers that can lead to ulcer and frank gangrene.
  • Due to neural involvement, there may be severe pain, even at rest.

Q. 4 True about Buerger disease

 A

Affects larger artery only

 B

Younger males are more commonly affected

 C

Phlebitis migrans is characteristic

 D

Cold intolerance

Q. 4

True about Buerger disease

 A

Affects larger artery only

 B

Younger males are more commonly affected

 C

Phlebitis migrans is characteristic

 D

Cold intolerance

Ans. B:C:E

Explanation:

Answer- B,Younger males are more commonly affected C,Phlebitis migrans is characteristic E,Veins may involved
Also called as Thromboangiitis Obliterans
It is a inflammatory occlusive vascular disorder involving small and medium sized arteries and veins in upper and lower extremities.
It involves tibial and radial arteries and sometimes secondarily extending to veins and nerves of extremities.
The clinical features of thromboangiitis obliterans includes a triad of claudication of the affected extremity, Raynaud’s phenomenon, and migratory superficial vein thrombophlebitis.

Quiz In Between



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