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How might the findings on rectal examination differ in a man with benign prostatic hyperplasia compared with a man with cancer of the prostate?
Which part of the gland is predominantly affected by cancer?
Lymphatics from the prostate gland drain mainly into which lymph nodes?
What is the main arterial supply of the prostate gland?
- 1.) In rectal exams, the tumorous prostate feels "rock" hard, rough and nodular
- - Benign prostatic hypertrophy generally involves the more central regions of the prostate, which gradually enlarge. The prostate feels "bulky" but smooth on digital rectal examination.
- 2.) Prostate cancer typically occurs in the peripheral regions of the prostate and is relatively asymptomatic
- 3.) Internal iliac and sacral lymph nodes; receive afferents from all the pelvic viscera (e.g., cervix, prostate, and rectum) and from the perineum, buttock, and thigh; they drain into the common iliac nodes.
- 4.) Inferior vesical artery (men) supplies branches to the prostate (and bladder, ureter, seminal vesicle)
Identify the structures indicated in the diagram below.
*Give functions where you can
- Parts of the urethra:
- - Prostatic
- - Membranous
- - Spongy
- Rectovesical pouch
- Seminal vesicle: secrete alkaline, viscous fluid that helps neutralize acid in the female reproductive tract, provides fructose for ATP production by sperm, contributes to sperm motility and viability.
- Ejaculatory duct:
- Bulbourethral gland: alkaline fluid that neutralizes the acidic environment of the urethra and mucus that lubricates the lining of the urethra and the tip of the penis during sexual intercourse
The histological photographs below are taken from a normal part of the male reproductive system
In the lower magnification photograph:
(i) Name the tubular structure indicated by the arrow.
(ii) Name the tubular structure to the right of the label C.
In the higher magnification photograph:
(i) Name the tissue indicated at A.
(ii) Describe the function of the tissue indicated by the arrow.
(iii) Indicate the significance of the intraluminal structures (B) in older men.
- In the lower magnification photograph:
- (i) Ejaculatory duct.
- (ii) Prostatic urethra.
- In the higher magnification photograph:
- (i) Stroma containing smooth muscle and fibrous connective tissue
- (ii) The secretory tissue of the prostate produces approximately 30% of the ejaculate. The secretions are rich in citric acid and prostaglandins which neutralize the acidic vagina.
- (iii) Prostatic concretions are composed of calcified secretions and epithelial cells. These are usually only found in the lumina of the secretory portions of the prostate in older men.
Below is a prostatic biopsy
State two histologic features which support the diagnosis of cancer.
Based on this diagnosis what are the two most important prognostic predictors?
- Adenocarcinoma formed when malignant acini infiltrate prostatic tissue
- Malignant glands are typically smaller than benign ones; they are lined by a single layer of cuboidal cells
- Malignant cells have clear to deeply stained cytoplasm. Nuclei are large, hyperchomatic with more prominent nucleoli
- - Pleomorphism and mitoses are NOT a feature in prostate adenocarcinoma
- Protein crystalloid structures (above) are seen in the glandular lumen of some prostatic adenocarcinomas. They usually indicate malignancy, but can be present in benign glands (and even old people??)
- Prognosis is well correlated with Gleason grade (addition of the most common 2 patterns of cells - out of a score of 5 - in the cancer = Gleason score)
This is a sagital T2 weighted MRI image of a normal male pelvis. Name the labelled structures
Which of the four labelled structures is likely to be enlarged on Mr Wayne’s MRI?
What structure(s) may be compressed by this enlarged structure?
- Urinary Bladder, Seminal vesicles, Rectum and Prostate
- I think the seminal vesicles
- The vas deferens, urinary bladder and rectum probably insignificantly
A registrar examined the swelling she noticed that the swelling moved up and down with deglutition (swallowing). What structure is likely to be the cause of this swelling? Explain why the thyroid moves up and down with deglutition
- An enlarged thyroid (goitre) can be seen moving up and down with swallowing
- The thyroid is anchored to the cricoid and thyroid cartilages of the larynx through the thickened pretracheal fascia (suspensory/Berry's ligament)- hence up and down
After further investigation it was decided that a total thyroidectomy was necessary. Before surgery a carotid angiogram was requested.
1.) How can you distinguish between the external and internal carotid arteries in the carotid angiogram?
2.) Which of these two branches stays within the carotid sheath?
3.) The carotid angiogram image below is taken from a normal neck. Name the structures indicated by the 4 arrows.
- 1) The internal carotid artery gives no branches in the neck
- 2) Internal carotid artery (above carotid bifurcation, otherwise it is the common carotid artery within the sheath)
- 3) Occipital artery, Facial artery, Lingual artery, Superior thyroid artery
During surgery the blood vessels supplying the upper and lower poles of the gland were isolated and ligated.
(i) Name the two arteries that supply the thyroid gland.
(ii) From which major arteries do these originate?
(b) What other endocrine gland is at risk in this surgical procedure? (1 minute)
(c) (i) Which nerve is closely related to the superior artery? (3 minutes)
(ii) Which intrinsic muscle of the larynx does it supply?
(iii) What is the action of this muscle?
- (a) Superior thyroid artery: Branch of the external carotid artery
- - Inferior thyroid artery: Branch of the thyrocervical trunk from the subclavian artery
- (b) Parathyroid
- (i) External branch of the laryngeal nerve
- (ii) Cricothyroid muscle
- (iii) Stretches and tenses vocal fold (perhaps hoarse voice upon damage)
(a) During surgery the surgeon encountered several structures of tissue as he approached the thyroid gland. Label the structures in the diagram below.
(b) After surgery Mary noticed that she choked regularly while eating (food entered the larynx). She also noticed her voice was hoarse. Which nerve was most likely to have been injured?
(c) On follow-up two months post-operatively Mary was found to have a loss of sensation in the region of her laryngopharynx. Which nerve is most likely to have been injured?
- Pretracheal fascia
- Infrahyoid muscles
- Investing layer of cervical fascia
- (b) Recurrent laryngeal nerve: which lies close to the inferior thyroid artery. It supplies all intrinsic muscles of the larynx except cricothyroid
- - Unilateral damage will produce a hoarse voice
- (c) Pharyngeal branch of the vagus nerve: carrying sensory information from the laryngopharynx.
Case: Abdominal pain.
1(a) The registrar suspected acute appendicitis. Assuming this is the diagnosis, explain why Hayley's pain shifted from her umbilical region to the right lower quadrant of her abdomen.
- When the appendix becomes inflamed, the visceral sensory fibers are stimulated. These fibers enter the spinal cord with the sympathetic fibers at spinal cord level T10.
- - pain is referred to the dermatome of T10, which is in the umbilical region.
- - The pain is diffuse, not focal; every time a peristaltic wave passes through the ileocecal region, the pain recurs. This intermittent type of pain is referred to as colic.
- In the later stages of the disease, the appendix contacts and irritates the parietal peritoneum in the right iliac fossa, which is innervated by somatic sensory nerves. This produces a constant focal pain, which predominates over the colicky pain that the patient felt some hours previously. The patient no longer interprets the referred pain from the T10 dermatome.
Hayley proceeded to have a laparoscopy.
(a) In this laparoscopic image of a normal female pelvis, identify A-D:
(b) Briefly state the significance of D in the context of a perforated appendicitis?
- (a) Fallopian tube (left), Ovary (right), Round ligament (right) and Pouch of Douglas
- (b) Puss from the burst appendix can accumulate here
(i) What is the approximate surface marking for the base of the appendix?
(ii) The tip of the appendix is most commonly found in one of two positions. Name both.
- (i) A common surface projection of the appendix is *McBurney's point*, which is one-third of the way up along a line from the right anterior superior iliac spine to the umbilicus.
- (ii) Retrocaecal and subcaecal.
Describe the layers of the abdominal wall that the surgeon will need to identify on his or her approach to the appendix
- The surgeon will start by making a McBurney incision centred at McBurney's point, which is two-thirds or the way along a line between the umbilicus and the anterior superior iliac spine.
- Skin -> Camper's fascia (fatty layer) -> Scarpa's fascia (membranous layer) -> External oblique muscle -> Internal oblique muscle -> Transversus abdominus muscle -> Transversalis fascia -> Extraperitoneal fat -> Parietal peritoneum
- *The underlying muscles are split in the direction of their fibres.
What further problems might have developed as a complication of his ruptured appendix? Explain the mechanism of his right sided shoulder pain and a high swinging temperature
- When the appendix ruptures, it's perforated contents is emptied into the peritoneal cavity where it can be spread to the pelvis or the right subphrenic space via the right paracolic gutter.
- - The high swinging temperature is a symptom of bacterial infection, most likely a right-sided subphrenic abscess.
- The referred pain to the right shoulder can be explained by the subphrenic abscess causing irritation to the right hemidiaphram, which is innervated by the phrenic nerve (spinal roots C3, 4, 5). The nervous system interprets the pain as coming from C3, 4, 5 dermatomes which cover the shoulder region rather than from the diaphragm. This is an example of referred pain.
In the cross-section of the pelvis shown below, label the numbered structures that are normally palpable on rectal examination
Identify the muscle indicated by an asterisk (*) and state its innervation.
- 1) rectum, coccyx, prostate, external anal sphincter
- 2) Levator ani muscle which is innervated by the pudendal nerve
In the diagram below, label the parts of the large bowel (A to F) inspected at colonoscopy.
Identify X and state how this structure differs in the rectum.
- 1) Caecum, Ascending colon, hepatic flexure, transverse colon, splenic flexure, sigmoid colon
- 2) Taenia coli
- - the TC runs along the entire length of the colon in three longitudinal SM bands. On reaching the rectum, these bands "fan out" and completely surround the rectum
Colonoscopy revealed a tumour in Mr Middleton's sigmoid colon from which biopsies were taken. The adjacent healthy bowel was also biopsied. The histological section below shows an area of normal sigmoid colon. Submucosal collagen at lower right in the image is stained light green.
(a) What layer of tissue is characterised by abundant plasma cells?
(b) In which area (A, B, or C) are proliferative epithelial cells located in normal colon?
(c) Name the tissue layer indicated by the arrows.
(d) Name the function of the main secretory epithelial cells of the mucosa.
- (a) Lamina propria
- (b) C (stem cells)
- (c) Basement membrane
- (d) Secretion of mucus to aid the passage of bolus through the intestine
Following identification of a tumour in Mr Middleton's sigmoid colon, an abdominal CT scan was performed.
Identify the structures labelled 1-7 in this CT scan.
Describe the route by which malignant cells may spread from the sigmoid colon to the liver.
- Liver, Hepatic portal vein, Abdominal aorta, Right pleural cavity, Spleen, gastric or SI air bubble?, inferior vena cava
- Haematogenous spread. Malignant cells gain entry into the inferior mesenteric vein which drains the sigmoid colon. This joins the splenic vein which then joins the portal vein and finally reaches the liver.
1) What abnormality might be found in Mr Smith’s full blood count with a tumour?
2) Name another investigation she might arrange
- 1) Likely microcytic anemia (low MCH and MCV)
- 2) colonoscopy
Name two of the three sources of arterial blood supply to the rectum. For each named artery state the parent artery from which it is derived.
- Superior rectal artery: from the inferior mesenteric artery
- Middle rectal artery: from internal iliac artery
- Inferior rectal artery: from internal pudendal artery from internal iliac artery
It was decided that Mr Middleton should undergo surgery and a successful operation was performed to remove his sigmoid colon. The photomicrograph below is of a routine H&E stained histological section of a well differentiated colonic adenocarcinoma invading through the muscularis propria.
Based on the histologic features in the section above, would the tumor be likely to show intraperitoneal spread?
What is the TNM stage for a colorectal cancer that has invaded into an adjacent organ, that has metastasized to one regional lymph node, and that has metastasized to the liver?
- This section shows an adenocarcinoma infiltrating the deep muscularis propria muscle.
- The architecture is abnormal with irregular tubular formation and gland-in-gland formation.
- Mucin lakes are also seen.
- The signs show that this cancer is not well differentiated, and would likely have a high grade. We already see the invading cells migrating in the direction of the peritonium, and so it would be no surprise if there was intraperitoneal spread.
- T4 - invaded into an adjacent organ or structure or perforates visceral peritoneum
- N1 - metastasis to 1 - 3 regional lymph nodes
- M1 - distant metastasis
Case PE: Five days after surgery, patient developed sudden right-sided chest pain and shortness of breath. You are concerned that Mr Smith has a pulmonary embolism.
What other common diagnoses should be considered?
- Could this be an myocardial infarction (MI), dissecting aortic aneurysm, pericarditis, or pulmonary embolism
- - Angina
- - Pleuritic pain (i.e., exacerbated by inspiration) implies inflammation of the pleura secondary to pulmonary infection, inflammation, or infarction.
Using a labelled diagram, describe the pathway by which a blood clot passes from the popliteal vein to the pulmonary artery.
- *Don't forget to state left or right*
- Popliteal vein -> femoral vein -> external iliac vein -> joins with internal iliac vein to form common iliac vein -> unites with contralateral common iliac vein to form the inferior vena cava -> right atrium -> through tricuspid valve to right ventricle -> through pulmonary valve into pulmonary artery
Describe the location of the lump (marked in indelible pen) in the photo. Is this an unusual site for a breast cancer?
- Upper outer quadrant of the right breast
- No. This is the most common site for breast cancer, accounting for about 50% of breast cancers at presentation
What is the name of the region of the breast indicated by the arrows in the image below?
Describe the major pathways for lymphatic drainage of the breast.
- Axillary tail/process
- There are three major pathways for lymphatic drainage of the breast:
- 1. Several groups of axillary nodes which drain into the subclavian lymph trunks:
- - pectoral (anterior)
- - subscapular (posterior)
- - humeral (lateral)
- - central
- - apical
- These connect with the supra and infra-clavicular nodes
- 2. The parasternal nodes along the internal thoracic artery deep to the costal cartilages just lateral to the sternal edge
- 3. Along the intercostal lymphatics to the intercostal nodes near the necks of the ribs.
The GP arranges an urgent Final Needle Aspiration (FNA) of her breast lump. The histology reveals malignant cells so the GP immediately arranges referral of Mrs Small to a surgeon. After discussing the results with the surgeon, she undergoes excision of the tumour and removal of some associated draining lymph nodes.
From the image of normal breast histology below identify the structures labelled.
- Adipose tissue
- Intralobular connective tissue/lobule
- Terminal duct
The photograph below represents the histology of the breast lump from Mrs Small
What histological features indicate this is a malignant lesion?
- Invasion of normal breast stroma with clusters of malignant cells.
- Dysplastic cells with large, prominent nucleii.
- Loss of normal lobular structure and well defined acini.
- Tumour cells have crossed the basement membrane and invaded.
- Upper left side?
- Mitotic rate?
The histology confirms the diagnosis of breast cancer (oestrogen receptor positive) with lymph node involvement. Mrs Small is also referred for an ultrasound scan of her liver as part of staging her disease. This shows a small nodule which is investigated further by an abdominal CT scan.
In this abdominal CT scan, identify the 8 labelled structures
- Portal vein
- Inferior vena cava
- Right lobe of the liver
- Left kidney
Four years later Mrs Small re-presents with back and left thigh pain and bone metastases are diagnosed.
With reference to the radiograph of Mrs Small’s pelvis and femora (above) describe the abnormalities shown
Describe the clinical problems that Mrs Small may experience from the bone metastases
- Question 1
- - Mrs Small has an artificial hip joint on the right hand side.
- - The majority of bone lesions seen in patients with breast cancer are osteolytic in appearance but some also develop osteoblastic features.
- - The vertebra have increased opacity are are indistinguishable from one another, inferring osteoblastic activity, which would explain the back pain.
- - There is a single circular lesion on the left iliac fossa which has decreased opacity indicating osteolytic disease.
- - Both iliums, ischiums and the heads and greater trochanters of both femurs show decreased opacity indicating osteolytic behaviour.
- The bone marrow in the pelvis and heads of the femurs are sites of red bone marrow where hematopoiesis occurs forming the erythrocytes, leukocytes and thrombocytes. Crowding out of the normal bone marrow contents will result in:
- - fatigue (anemia)
- - excessive bleeding times (thrombocytopenia)
- - susceptibility to infection (neutropenia)
- - bone pain (which may also be due to invasion of periosteum and bone turnover)
- - reducing mobility and independence
- Increased bone turnover will result in:
- - hypercalcaemia
- - osteoporitic symptoms
- - pathologic fractures