Discuss clinical, laboratory, and pathologic findings in the workup of a patient with a nodule in the prostate on physical examination. (<250 words)

Palpation of a nodule in the prostate on rectal exam could be due to either of two common conditions. Benign prostatic hyperplasia (BPH) is associated with diffuse enlargement and multiple nodules which have a spongy feel on palpation. In contrast, prostatic adenocarcinoma more often is a single nodule that has a firm feel on palpation. Both of these conditions frequently occur in older men, but BPH is more common. In either case, most patients are asymptomatic. A minority of patients may present with symptoms of obstruction with difficulty starting and/or stopping the urinary stream, later progressing to anuria or polyuria, and uremia.

Laboratory findings in either BPH or carcinoma would include an increased serum prostate specific antigen (PSA). The increase would be greater with prostatic adenocarcinoma. Prostatic acid phosphatase may also be elevated, particularly with advanced carcinoma. A patient with either condition that has progressed to obstructive uropathy may have an elevated serum BUN and creatinine as evidence for renal failure, as well as electrolyte abnormalities--hyperkalemia, hyperphosphatemia, etc.

Pathologic findings on prostate biopsy can help to differentiate these two conditions and confirm the diagnosis. Biopsy with BPH will show hyperplasia in a nodular configuration with enlarged prostate glands that have a 2 cell layer epithelium. BPH is more prominent in the central portion of the gland. Prostatic adenocarcinoma usually occurs peripherally and posteriorly in the prostate. Microscopically, there are small, crowded glands with large nuclei and prominent nucleoli. More advanced cancers demonstrate capsular and perineural invasion, regional node metastases, and distant osteoblastic bone metastases.

Discuss the clinical and pathologic findings in a man and/or a woman with Neisseria gonorrheae infection. (<250 words)

N. gonorrheae is a common sexually transmitted disease in young adults. In males, gonorrheal infection is characterized grossly by a purulent, thick urethral discharge in most cases. Some patients also have dysuria. Prostatitis and epididymitis may also result from gonorrheal infection, but infection of the testis is uncommon. Gram stain of the urethral exudate will demonstrate gram negative diplococci within PMN's. Culture must be done on Thayer-Martin media. Infertility and long-term complications in males are uncommon.

In contrast to males, N. gonorrheae infections in females are often initially asymptomatic, though a vaginal or cervical discharge may be noted on physical examination. Long-term consequences are more serious, because gonorrheal infections have a tendency to cause inflammation and scarring of the fallopian tubes. This may manifest as pelvic inflammatory disease. Another complication is tubo-ovarian abscess, which may resolve to hydrosalpinx. The tubal scarring may result in infertility as well as an increased risk for ectopic pregnancy because movement of ova is hindered. Other complications in the female genital tract include infection of a Bartholin's gland, with possible abscess. In female children, gonococcal infection usually produces a vaginitis, and this finding should suggest sexual abuse.

Additional sequelae of disseminated gonococcal infections are tenosynovitis and arthritis. These acute infections usually involve one or two large joints, often the knee, with a purulent exudate. A skin rash may be noted at the same time.

Discuss gestational trophoblastic disease (molar pregnancy) in terms of clinical findings, types of pathologic appearances, and possible outcomes. (<300 words)

The incidence of molar pregnancy in the U.S. is about 1/2000 gestations. Most of these cases are hydatitiform moles. Typically, the patient is unaware of this problem early in pregnancy, but may develop vaginal bleeding into the second trimester. The size of the uterus is usually larger than expected for dates, and an ultrasound will show that no fetus is present. Sometimes, the patients may pass grape-like masses. Hydatidiform moles grossly are masses of enlarged, grape-like villi without normal placental tissue present. Microscopically, the villi are greatly enlarged and poorly vascular and accompanied by trophoblastic proliferation. Molar pregancy may be suspected by a beta-HCG level that is much higher and rises more quickly than that of a normal pregnancy. Most moles are complete and all villi are affected, but partial moles can occur and most of these are associated with triploidy. 80 to 90% of moles act in a benign fashion and do not recur after curretage.

About 10% of moles are "invasive" and penetrate into the myometrium, sometimes with rupture. These can be detected by persistently elevated beta-HCG levels after curretage. Histologically, they have the benign appearance of a typical hydatidiform mole.

A small percentage of moles give rise to choriocarcinoma, a highly malignant neoplasm. Choriocarcinomas can also rarely follow any form of normal or abnormal pregnancy, including ectopic pregancy and spontaneous abortion. Grossly, choriocarcinomas are hemorrhagic and friable but usually not large masses. They invade the uterus and can metastasize widely. Microscopically, villi are absent and the tumor consists of atypical trophoblastic cells. Beta-HCG can be used as a marker to detect their presence or recurrence. Patients may present irregular vaginal bleeding or discharge.

Why is a routine Pap smear test useful? (<100 words)

Example 1

The Pap smear is perhaps one of the best cancer screening tests available in clinical medicine. While many tumor markers can screen for pre-existing cancer that is of advanced stage, the Pap smear can detect dysplasia early on and therefore allows intervention before fulminant squamous cell carcinoma develops. There is virtually a 100% cure for CIN if detected by routine Pap smear analysis. It is important to educate patients and also learn appropriate sampling techniques to ensure the full benefits of this test.

Example 2

Many pathological conditions may be detected and treated early by routine Pap smear testing. Neoplastic precursors such as cervical epithelial dysplasia, if treated early, can be prevented from progressing to cervical carcinoma. Infectious disorders such as gonorrhea, trichomonas, and especially chlamydia (which otherwise may be symptomatic) can be detected and treated, hopefully reducing the incidence of PID and its sequelae: infertility and ectopic pregnancy.