Practice questions Male reproductive system II

Practice questions II
Male reproductive system
© Jun Wang, MD, PhD

1. A 45-year-old man presents with a painless swelling of his right testicle for 3 months. He denies fever, weight loss and night sweating. His past medical history is unremarkable. Physical examination reveals a 7.5 cm firm non tender right testis. Laboratory test results, including CBC, AFP, beta hCG, and LDH, are all within normal ranges. Sonographic examination reveals a bulky right testicle with an ill-defined mass. Right orchiectomy is performed. Microscopically, the mass contains tubules with thickened basement membrane. Many large atypical cells with clear cytoplasm are seen within the tubules. These cells have a fried egg appearance. No spermatogenesis is noted. No atypical cells are seen outside the tubules. What is the diagnosis?
A. Embryonal carcinoma
B. Hairy cell leukemia
C. Intratubular germ cell neoplasia
D. Seminoma
E. Teratoma

2. Use this case for next three questions. A 43-year-old man presents with a painful scrotal mass for 2 weeks. He denies history of trauma, fever, infection and weight loss. He has cervical Hodgkin lymphoma 20 years ago that was treated with radiation therapy and chemotherapy. Physical examination reveal a 2.5 cm firm mass at this left testis. No lymphadenopathy is noted. His CBC, renal function and liver function  tests are within normal range. Sonographic examination reveals a poorly defined left testicular mass. A few enlarged periaortic lymph nodes are noted. Left radical orchiectomy is performed. Microscopically the mass is composed of sheets of large atypical cells with round nuclei, clear cytoplasm, and well defined cell borders. Per immunohistochemistry, these cells are positive for OCT3/4 and KIT, but negative for CD3, CD20, CD30 and CD45. Scattered dilated tubules with thickened basement membrane are seen. Same large atypical cells are seen in these tubules. No other abnormalities are noted. What is the diagnosis?
A. Diffuse large B cell lymphoma
B. Embryonal carcinoma
C. Mixed germ cell tumor
D. Seminoma
E. Teratoma

3. A 43-year-old man presents with a painful scrotal mass for 2 weeks. He denies history of trauma, fever, infection and weight loss. He has cervical Hodgkin lymphoma 20 years ago that was treated with radiation therapy and chemotherapy. Physical examination reveal a 2.5 cm firm mass at this left testis. No lymphadenopathy is noted. His CBC, renal function and liver function  tests are within normal range. Sonographic examination reveals a poorly defined left testicular mass. A few enlarged periaortic lymph nodes are noted. Left radical orchiectomy is performed. Microscopically the mass is composed of sheets of large atypical cells with round nuclei, clear cytoplasm, and well defined cell borders. Per immunohistochemistry, these cells are positive for OCT3/4 and KIT, but negative for CD3, CD20, CD30 and CD45. Scattered dilated tubules with thickened basement membrane are seen. Same large atypical cells are seen in these tubules. No other abnormalities are noted. What serum marker is most likely elevated?
A. AFP
B. CD30
C. hCG
D. PLAP
E. PSA

4. A 43-year-old man presents with a painful scrotal mass for 2 weeks. He denies history of trauma, fever, infection and weight loss. He has cervical Hodgkin lymphoma 20 years ago that was treated with radiation therapy and chemotherapy. Physical examination reveal a 2.5 cm firm mass at this left testis. No lymphadenopathy is noted. His CBC, renal function and liver function  tests are within normal range. Sonographic examination reveals a poorly defined left testicular mass. A few enlarged periaortic lymph nodes are noted. Left radical orchiectomy is performed. Microscopically the mass is composed of sheets of large atypical cells with round nuclei, clear cytoplasm, and well defined cell borders. Per immunohistochemistry, these cells are positive for OCT3/4 and KIT, but negative for CD3, CD20, CD30 and CD45. Scattered dilated tubules with thickened basement membrane are seen. Same large atypical cells are seen in these tubules. No other abnormalities are noted. What is the next step for his management?
A. Bone marrow biopsy
B. Flow cytometry studies
C. Radiation therapy
D. Watchful waiting


5. A 65-year-old man presents with a slowly growing painless left testicle mass for 4 months. His past medical history is unremarkable. Physical examination reveals enlarged left testicle. Image studies reveals a 5.5 cm well-defined testicular mass. No other abnormalities are noted. Left orchiectomy is performed. Microscopically, these mass is composed of sheets of atypical cells with small to intermediate sized round to oval nuclei. Scattered multinucleated giant cells are seen. All these cells have eosinophilic cytoplasm. Per immunohistochemistry studies, these cells are focally positive for KIT, but negative for PLAP, AFP, hCG, CD3, CD20 and CD45. What is most likely the diagnosis?
A. Diffuse large B cell lymphoma
B. Embryonal carcinoma
C. Mixed germ cell tumor
D. Seminoma
E. Spermatocytic seminoma

6. A 32-year-old man presents with pain in left groin for a month. He has progressive left scrotum swelling for 6 months. He has a history of penile condyloma 5 years ago. His past medical history is otherwise unremarkable. Physical examination reveals an enlarged left testis. No lymphadenopathy is noted. Routine laboratory tests are within normal range. Image studies reveals a heterogeneous left testicular mass. A few nodules are seen in liver. Additional laboratory tests reveals an AFP of 5 ng/ml (normal < 10 ng/ml) and hCG of 1.5 mIU/ml (normal <5 mIU/ml). Left orchiectomy is performed. Grossly the mass is approximately 5.5 cm in greatest dimension. Hemorrhage and necrosis are seen. Microscopically the mass is composed of cords of cells with minimal differentiation. Per immunohistochemistry, these cells are positive for CD30 and cytokeratin. What is the diagnosis?
A. Choriocarcinoma
B. Embryonal carcinoma
C. Hodgkin lymphoma
D. Seminoma
E. Spermatocytic seminoma

7. Use this case for the next two questions. A 2-year-old boy presents with progressive swelling of left scrotum for a months. He has no history of trauma or infection. Past medical history is unremarkable. Physical examination reveals a 3.5 cm firm irregular mass, likely arising from left testis. Image studies reveal a heterogeneous testicular mass. Left orchiectomy is performed. Microscopically the lesion is composed primarily of loosely cohesive immature cells, some surrounding a central thin-walled blood vessel, with loose connection to other surrounding tumor cells. Vaguely formed space are seen between these two groups of cells with similar morphology. No multinucleated cells are seen. What is most likely diagnosis?
A. Choriocarcinoma
B. Embryonal carcinoma
C. Seminoma
D. Teratoma
E. Yolk sac tumor

8. A 2-year-old boy presents with progressive swelling of left scrotum for a months. He has no history of trauma or infection. Past medical history is unremarkable. Physical examination reveals a 3.5 cm firm irregular mass, likely arising from left testis. Image studies reveal a heterogeneous testicular mass. Left orchiectomy is performed. Microscopically the lesion is composed primarily of loosely cohesive immature cells, some surrounding a central thin-walled blood vessel, with loose connection to other surrounding tumor cells. Vaguely formed space are seen between these two groups of cells with similar morphology. No multinucleated cells are seen. What serum marker is most likely to be elevated?
A. AFP
B. CD30
C. hCG
D. PLAP
E. PSA


9. A 37-year-old man presents with painless left testicle mass for 4 months. He has no history of trauma or infection. He has a history of multiple epidermoid cysts of face and back, that were treated with suegery. Physical examination reveals a 2.5 cm firm left testicular mass. No other abnormalities are noted. His laboratory tests, including AFP, hCG and PLAP, are within normal range. Sonographic examination reveals a heterogenous mass within the left testis. Left orchiectomy was performed. Microscopically, the tumor is cystic with stratified squamous epithelial lining, pilosebaceous apparatii, many hair follicles, luminal lamellar keratin, fibrofatty tissues, and focally bone trabeculae. There are no immature components. What is the diagnosis?
A. Choriocarcinoma
B. Embryonal carcinoma
C. Mixed germ cell tumor
D. Teratoma
E. Yolk sac tumor

10. A 33-year-old man presents with vague right groin pain for 2 weeks. He does not have other symptoms. He has a history of cervical Hodgkin lymphoma that was treated with chemotherapy and radiation therapy 10 years ago. His past medical history is otherwise unremarkable. Physical examination reveals a larger right testis. Laboratory tests reveal an AFP of 150 ng.ml (normal < 10 ng/ml), hCG of 5450 mIU/ml (normal <5mIU/ml), and LDH of 850 U/L (normal 100-190 U/L). Sonographic examination reveals a 1.5 cm hyperechoic mass in the right testis. Right orchiectomy is performed. Microscopically, the tumor is composed predominantly of cysts lined by mature squamous epithelium. Skin adnexa are seen. Focally there are solid clusters of epithelial cells with minimal differentiation. No multinucleated cells are seen. Per immunohistochemistry, these epithelioid cells are positive for CD30, cytokeratin, AFP and hCG. What is the diagnosis?
A. Choriocarcinoma
B. Embryonal carcinoma
C. Metastatic Hodgkin lymphoma
D. Mixed germ cell tumor with teratoma and choriocarcinoma
E. Mixed germ cell tumor with teratoma and embryonal carcinoma
F. Pure teratoma

11. A 67-year-old man presents with fatigue, night sweating, 20 pound weight loss and left testicle swelling for 4 months. He has a history of prostatic adenocarcinoma, Gleason score 3+3, that was treated with total prostatectomy 8 years ago. He has no history of trauma or infection. Physical examination reveals a markedly enlarged left testicle. His laboratory tests, including AFP, hCG and PLAP, are within normal range. No lymphadenopathy is noted. Image studies reveals diffusely enlarged left testicle with diffuse hypoechogenicity and increased vascularity. Left orchiectomy is performed. Microscopically, the testis contains sheets of markedly atypical cells with variable sized nuclei. Per immunohistochemistry, these cells are positive for CD20, bcl2 and negative for cytokeratin, AFP, PLAP, and hCG. What is most likely the diagnosis?
A. Diffuse large B cell lymphoma
B. Embryonal carcinoma
C. Mixed germ cell tumor
D. Seminoma
E. Spermatocytic seminoma

12. Use this case for the next two cases. A 55-year-old man presents with fever, chills, lower back pain, dysuria and urinary frequency for 3 days. He has a history of type 2 diabetes. He has a family history of prostate cancer. Physical examination reveals suprapubic tenderness and distended bladder. Digital rectal exam reveals diffusely enlarged prostate. Laboratory tests reveal a white count of 17 x 109/L (normal 4.5 – 10.3 x 109/L), with 85% neutrophils (normal 50-70%), and a PSA of 3.5 ng/ml (normal < 4 ng/ml). What is most likely the diagnosis?
A. Acute Cystitis
B. Acute prostatitis
C. Diabetic nephropathy
D. Prostatic adenocarcinoma
E. Prostatic hyperplasia

13. A 55-year-old man presents with fever, chills, lower back pain, dysuria and urinary frequency for 3 days. He has a history of type 2 diabetes. He has a family history of prostate cancer. Physical examination reveals suprapubic tenderness and distended bladder. Digital rectal exam reveals diffusely enlarged prostate. Laboratory tests reveal a white count of 17 x 109/L (normal 4.5 – 10.3 x 109/L), with 85% neutrophils (normal 50-70%), and a PSA of 5.5 ng/ml (normal < 4 ng/ml). What is the best test to confirm the diagnosis?
A. Cystoscopy
B. Prostate biopsy
C. Prostate image studies
D. Urine albumin test
E. Urine Gram stain and culture


14. A 48-year-old man presents with urinary urgency, frequency and dysuria for 2 days. He has a history of vague suprapubic pain for 15 years. He does not have fever or other symptoms. General physical examination reveals no significant abnormality. Digital rectal examination reveals a diffusely enlarged painful prostate. Laboratory tests reveal a PSA of 4.5 ng/ml (normal < 4 ng/ml). Urinalysis reveals 7 red blood cells and 11 white cells per high power field. Urine culture grows E. coli. What is the diagnosis?
A. Acute prostatitis
B. Chronic cystitis
C. Chronic abacterial prostatitis
D. Chronic bacterial prostatitis
E. Prostatic adenocarcinoma

15. A 50-year-old man presents with moderate to severe lower abdominal pain and intermittent dysuria for 10 years. His past medical history is unremarkable. He has a family history of colon cancer. Routine physical examination reveals no significant abnormality. Digital rectal examination reveals a slightly enlarged painful prostate. Laboratory tests, include PSA and repeated urine culture, are unremarkable. Image studies reveals no abnormalities of prostate and other pelvic organs. What is the most likely diagnosis?
A. Acute prostatitis
B. Chronic cystitis
C. Chronic abacterial prostatitis
D. Chronic bacterial prostatitis
E. Prostatic adenocarcinoma

16. Use this case for the three two cases. A 66-year-old man presents with progressive low urinary tract symptoms, including urinary frequency, urgency, hesitancy and incomplete bladder emptying for 8 years. He has a history of bladder papilloma 5 years ago that was treated by local resection. He has multiple family members with prostate adenocarcinoma and bladder cancer. Physical examination reveals distended bladder. Digital rectal exam reveals markedly enlarged prostate with irregular surface. Laboratory tests reveal a PSA of 2.1 ng/ml (normal < 4 ng/ml). Cystoscopy examination reveals linear bulging of bladder mucosa surface. Biopsy of prostate reveals proliferation of glands with increased buds and infoldings. Basal layers are intact. What is the diagnosis?
A. Adenocarcinoma of bladder involving prostate
B. Adenocarcinoma of prostate
C. Papilloma of bladder
D. Prostate nodular hyperplasia
E. Urothelial carcinoma

17. A 66-year-old man presents with progressive low urinary tract symptoms, including urinary frequency, urgency, hesitancy and incomplete bladder emptying for 8 years. He has a history of bladder papilloma 5 years ago that was treated by local resection. He has multiple family members with prostate adenocarcinoma and bladder cancer. Physical examination reveals distended bladder. Digital rectal exam reveals markedly enlarged prostate with irregular surface. Laboratory tests reveal a PSA of 2.1 ng/ml (normal < 4 ng/ml). Cystoscopy examination reveals linear bulging of bladder mucosa surface. Biopsy of prostate reveals proliferation of glands with increased buds and infoldings. Basal layers are intact. What is most likely associated with these prostate changes?
A. Amplification of androgen receptor
B. Aneuploidy of urothelial cells
C. Gain-of-function mutation of androgen receptor
D. Mutation of FGFR3
E. Over activity of type II 5-a-reductase

18. A 66-year-old man presents with progressive low urinary tract symptoms, including urinary frequency, urgency, hesitancy and incomplete bladder emptying for 8 years. He has a history of bladder papilloma 5 years ago that was treated by local resection. He has multiple family members with prostate adenocarcinoma and bladder cancer. Physical examination reveals distended bladder. Digital rectal exam reveals markedly enlarged prostate with irregular surface. Laboratory tests reveal a PSA of 5.1 ng/ml (normal < 4 ng/ml). Cystoscopy examination reveals linear bulging of bladder mucosa surface. Biopsy of prostate reveals proliferation of glands with increased buds and infoldings. Basal layers are intact. What is most likely associated with these bladder changes?
A. Aneuploidy of urothelial cells
B. Benign smooth muscle proliferation
C. Chronic inflammatino
D. Mutation of FGFR3
E. Over activity of type II 5-a-reductase


19. Use this case for the three two cases. A 63-year-old man presents with elevated PSA of 7.3 ng/ml found through screening test. He has a history of long adenocarcinoma diagnosed at age 59, that was treated with surgery and chemotherapy. Physical examination is compatible with previous surgery but otherwise unremarkable. Digital rectal exam reveals a slightly enlarged prostate. Laboratory tests are within normal range, except a PSA of 7.2 ng/ml (normal <4 ng/ml). Prostate biopsy reveal many small glands lined by single layer of cells with mild cytological atypia, irregularly distributed in a fibrotic stroma. Per immunohistochemistry studies, these glandular cells are positive for racemase. No reactivity to TTF1, p63 or 34betaE12 is detected. What is the diagnosis?
A. Chronic abacterial prostatitis
B. Chronic bacterial prostatitis
C. Metastatic adenocarcinoma of lung
D. Prostate adenocarcinoma
E. Prostate nodular hyperplasia

20. A 63-year-old man presents with elevated PSA of 7.3 ng/ml found through screening test. He has a history of long adenocarcinoma diagnosed at age 59, that was treated with surgery and chemotherapy. Physical examination is compatible with previous surgery but otherwise unremarkable. Digital rectal exam reveals a slightly enlarged prostate. Laboratory tests are within normal range, except a PSA of 7.2 ng/ml (normal <4 ng/ml). Prostate biopsy reveal many small glands lined by single layer of cells with mild cytological atypia, irregularly distributed in a fibrotic stroma. Per immunohistochemistry studies, these glandular cells are positive for racemase. No reactivity to TTF1, p63 or 34betaE12 is detected. What is most likely associated with these bladder changes?
A. Amplification of androgen receptor
B. Bacterial spreading from urinary tract
C. BCG treatment
D. Mutation of FGFR3
E. Over activity of type II 5-a-reductase


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