Page 19 of 21
PA28.1-6 | Male Genital Tract — Graded Quiz
Graded
12 questions · Untimed · 2 attempts
Click any question card to reveal the correct answer.
A 22-year-old man presents with a painless right testicular swelling. Serum AFP is 8,200 ng/mL and β-hCG is 45,000 mIU/mL. LDH is elevated. CT scan shows a para-aortic mass at the level of L2. Orchiectomy reveals a haemorrhagic, necrotic variegated tumour. Histology shows a mixture of two populations: large undifferentiated cells forming solid sheets and glandular structures with high N:C ratio and brisk mitoses, PLUS papillary structures lined by cuboidal cells with eosinophilic hyaline cores that are PAS-positive and AFP-immunoreactive. What is the MOST accurate classification of this tumour and its implications for staging?
A
Pure seminoma, Stage IIB — AFP elevation demands re-staging but does not alter histological classification
B
Mixed NSGCT (embryonal carcinoma + yolk sac tumour), Stage IIB — the AFP marks yolk sac elements and drives a more aggressive chemotherapy protocol than Stage I
✓
C
Choriocarcinoma, Stage IIB — the β-hCG elevation identifies trophoblastic elements as the dominant component
D
Mixed NSGCT (teratoma + embryonal carcinoma), Stage IIB — elevated AFP in teratoma with immature elements is expected and marks somatic transformation
Click to reveal answer
A 30-year-old man undergoes radical orchiectomy for a 3.5 cm right testicular tumour. Histology confirms pure seminoma. Post-operatively, serum AFP is 410 ng/mL (pre-op was not measured). The oncologist proposes surveillance-only management. What is the MOST appropriate pathological/clinical decision at this point?
A
Proceed with surveillance: AFP can be mildly elevated in seminoma due to reactive hepatic changes from inguinal surgery
B
Request CT chest/abdomen/pelvis immediately and resubmit all tissue blocks for deeper section review — a raised AFP in 'pure' seminoma mandates search for a missed NSGCT component
✓
C
Classify as Stage IS (marker-positive) and begin carboplatin single-agent chemotherapy as per seminoma guidelines
D
Repeat AFP in 3 weeks — the half-life of AFP is 7 days, so a falling level from a pre-operative peak will confirm no residual disease
Click to reveal answer
A 26-year-old man develops a right testicular mass. After radical orchiectomy, CT shows retroperitoneal nodes up to 1.8 cm at L1–L2. Three months into BEP chemotherapy, serum markers normalise, but CT shows an enlarging 4 cm retroperitoneal mass. A retroperitoneal lymph node dissection is performed. Histology reveals no viable tumour — only mature cartilage, respiratory epithelium, and smooth muscle within a fibrous background. Which statement BEST characterises this phenomenon?
A
This represents a complete pathological response to chemotherapy with fibrosis replacing the prior metastatic mass
B
Growing teratoma syndrome — chemotherapy has eradicated the malignant elements but the teratomatous component is chemoresistant and grows autonomously; surgical resection is the only effective treatment
✓
C
Malignant transformation within a teratoma — the mature elements have undergone somatic malignant change and require escalated salvage chemotherapy
D
Treatment failure — viable embryonal carcinoma has developed platinum resistance and is presenting as a retroperitoneal mass despite marker normalisation
Click to reveal answer
A 62-year-old man is investigated for a 3-month history of nocturia (×4), weak stream, and terminal dribbling. DRE reveals a smooth, symmetrically enlarged, non-tender prostate. PSA is 5.8 ng/mL. TRUS-guided biopsy of the transition zone shows nodular proliferation of glands and fibromuscular stroma. His PSA fails to fall after 6 months of 5-alpha-reductase inhibitor (finasteride) therapy. What would be the MOST helpful next investigation to distinguish BPH from an early peripheral-zone carcinoma?
A
Repeat DRE in 6 months — carcinoma would produce a palpable nodule not yet present
B
PSA density calculation and PSA velocity measurement, followed by repeat TRUS-guided biopsy targeting the peripheral zone
✓
C
Serum free:total PSA ratio — a ratio >25% confidently excludes carcinoma in this age group
D
Urine cytology — malignant ductal cells from a peripheral-zone carcinoma shed into the urine and can be detected by Pap staining
Click to reveal answer
A 74-year-old man with known metastatic prostate carcinoma and a PSA of 142 ng/mL is commenced on androgen deprivation therapy (ADT). After 18 months, PSA falls to 4.2 ng/mL but then begins rising steadily to 68 ng/mL despite continued ADT. Bone scan shows new lesions in the femoral neck. Which pathological mechanism BEST explains this clinical pattern?
A
BPH progression in residual prostate tissue producing a false PSA rise independent of the carcinoma
B
Development of castration-resistant prostate carcinoma (CRPC) through androgen receptor amplification, splice variant expression (AR-V7), or intratumoral androgen synthesis enabling continued tumour growth despite castrate testosterone levels
✓
C
Transdifferentiation to a neuroendocrine (small cell) carcinoma which is PSA-negative — the rising PSA represents a rebound from the initial ADT-induced suppression
D
Metastases to bone stimulate PSA release from osteoblasts at metastatic sites, unrelated to tumour biology
Click to reveal answer
A 70-year-old man with type 2 diabetes undergoes TURP for refractory retention. The pathology report reads: 'Prostate chips — Gleason grade 3+4=7, ISUP Grade Group 2; Perineural invasion present; No seminal vesicle involvement in chips; Basal cell layer absent by HMWCK/p63 IHC.' His post-TURP PSA remains at 6.8 ng/mL at 3 months. Which statement about the SIGNIFICANCE of the Gleason 3+4=7 (ISUP GG2) classification is MOST accurate?
A
Gleason 3+4=7 and 4+3=7 have identical prognosis because both sum to 7 — the individual component scores are irrelevant
B
Gleason 3+4=7 (ISUP GG2) has a significantly better prognosis than 4+3=7 (ISUP GG3) because the dominant pattern (pattern 3 — well-formed glands) determines the biological behaviour more than the minor pattern
✓
C
Gleason 3+4=7 places this patient in the high-risk category by D'Amico stratification regardless of other parameters
D
Perineural invasion upgrades any Gleason score to Grade Group 5 because nerve involvement signifies extraprostatic extension has already occurred
Click to reveal answer
A 60-year-old diabetic man presents with high fever (39.5°C), rigors, severe perineal pain, and acute urinary retention. He underwent prostate biopsy 5 days ago. DRE reveals an exquisitely tender, boggy, warm prostate. Blood cultures grow E. coli. PSA is transiently 65 ng/mL. He is started on IV ciprofloxacin. What is the PRIMARY pathological mechanism responsible for the markedly elevated PSA in this setting?
A
E. coli produces a protease that cross-reacts with the PSA monoclonal antibody used in the immunoassay, causing a false positive
B
Acute bacterial prostatitis disrupts the tight junctions of the prostatic epithelium and the basal cell layer, allowing PSA to leak from acini into the circulation at high concentrations
✓
C
E. coli upregulates KLK3 (the PSA gene) transcription in prostate epithelial cells through NF-κB activation, increasing PSA production
D
The elevated PSA is due to urethral contamination during the biopsy procedure — PSA from prostatic secretions enters the blood via needle tracks
Click to reveal answer
A 58-year-old uncircumcised man presents with a painless, indurated ulcer at the glans penis with raised everted edges and bilateral palpable inguinal lymphadenopathy. He has phimosis since childhood. Biopsy of the ulcer confirms invasive squamous cell carcinoma (SCC). Staging CT shows enlarged bilateral inguinal nodes but no pelvic or iliac involvement. Which is the BEST characterisation of the clinical stage and expected metastatic pathway?
A
Stage III penile SCC — primary lymphatic spread to bilateral inguinal nodes; next echelon is external iliac then common iliac nodes
B
Stage IIIb penile SCC — bilateral inguinal node involvement without pelvic nodal disease; prognosis is significantly worse than unilateral inguinal involvement and 5-year survival drops to ~50%
✓
C
Stage IV penile SCC — bilateral inguinal nodes constitutes M1 disease regardless of pelvic or visceral involvement
D
Stage II penile SCC — inguinal lymph nodes in penile SCC are reactive, not metastatic, because penile tumours drain primarily to the iliac chain
Click to reveal answer
Examination of an orchiectomy specimen from a 34-year-old man shows a tumour with the following features on histology: (i) Lobulated cream-white homogeneous cut surface; (ii) Sheets of large polygonal cells with clear glycogen-rich cytoplasm and well-defined borders; (iii) Round to oval nuclei with prominent central nucleolus; (iv) Lymphocytic infiltrate in fibrous septa; (v) Granulomatous reaction at the tumour edge. Serum AFP = normal; β-hCG = 900 mIU/mL (mildly elevated). What is the MOST complete and accurate diagnosis, including the explanation for the marker profile?
A
Spermatocytic tumour — lymphocytic stroma and granulomas are characteristic; mild β-hCG is expected in this subtype
B
Classic seminoma — the morphology is diagnostic; mild β-hCG elevation is explained by syncytiotrophoblastic giant cells (STGCs) present in 15–20% of seminomas without implying a trophoblastic component
✓
C
Mixed NSGCT with seminoma and choriocarcinoma — the β-hCG elevation indicates trophoblastic differentiation mandating reclassification as NSGCT
D
Lymphoma of the testis — lymphocytic infiltrate is the dominant feature; granulomas reflect a paraneoplastic reaction
Click to reveal answer
A 67-year-old man presents with progressive lower urinary tract symptoms (LUTS). PSA is 3.8 ng/mL. MRI prostate shows a PI-RADS 4 lesion in the peripheral zone. Systematic and targeted biopsies show: (i) 3/12 cores positive for cancer; (ii) Gleason 3+3=6 (ISUP GG1) in 2 cores, occupying 20% each; (iii) Gleason 3+4=7 (ISUP GG2) in 1 core, occupying 40%. No perineural invasion. No extraprostatic extension. PSA density = 0.08. What is the MOST appropriate characterisation of risk stratification and management implication?
A
Very-low risk — all three criteria (GG1 dominant, low PSA density, <50% core involvement) qualify for immediate curative treatment to prevent progression to GG2
B
Intermediate-risk (favourable) — the GG2 core upgrades from very-low to intermediate; Active Surveillance remains an option in young, fit patients with favourable features, but requires careful discussion given the GG2 component
✓
C
High-risk — any Gleason 4 pattern (present in the GG2 core) constitutes high-risk disease requiring immediate radical therapy
D
Low-risk — GG1 in 2/3 positive cores means the dominant grade is GG1, which qualifies for active surveillance without concern about the single GG2 core
Click to reveal answer
A 50-year-old man on long-term spironolactone for hepatic cirrhosis presents with bilateral, tender, firm retroareolar breast enlargement. A biopsy is taken to exclude primary breast carcinoma. Histology shows florid ductal epithelial hyperplasia with peri-ductal oedematous, loose stroma and scattered lymphocytes. There is no glandular architecture resembling breast lobules. No atypical cells are seen. Immunostaining is ER-positive in ductal cells. What is the MOST accurate pathophysiological explanation for this finding?
A
Spironolactone activates ER-alpha in male breast ductal cells directly as a partial agonist, bypassing androgen/estrogen ratios
B
Spironolactone is an aldosterone antagonist that also inhibits 5-alpha-reductase and competes with androgen at AR, reducing the effective androgen:estrogen ratio, shifting the hormonal milieu toward relative estrogen excess — triggering florid gynecomastia
✓
C
Hepatic cirrhosis reduces protein C and S synthesis, leading to thrombosis of the thoracoepigastric veins, causing reactive breast swelling mimicking gynecomastia histologically
D
Spironolactone stimulates pituitary LH, which cross-reacts with breast FSHR, producing ductal proliferation in the male breast
Click to reveal answer
A urological pathologist reviewing a TURP specimen identifies the following features in several chips: (i) Small glands crowded together with minimal intervening stroma; (ii) Single layer of columnar cells with pale-to-clear cytoplasm; (iii) Prominent eosinophilic nucleoli (>1 µm); (iv) Complete absence of basal cells on HMWCK stain; (v) Perineural invasion in one chip; (vi) A few intraluminal blue-tinged mucinous secretions (blue mucin sign). No necrosis. Gleason pattern grade is 3. Which finding is the SINGLE MOST SPECIFIC indicator of malignancy in this specimen, and why?
A
Prominent eosinophilic nucleoli — because nucleolar size >1 µm is present in malignant but not benign prostatic glands
B
Absence of basal cells on HMWCK — because the basal cell layer is invariably present in ALL benign prostatic glands (hyperplastic, atrophic, and normal), and its complete absence is a defining hallmark of prostatic adenocarcinoma
✓
C
Perineural invasion — because benign glands can undergo neurotropic growth into perineural spaces, making this finding specific only when multiple nerves are involved
D
Blue mucinous secretions — because intraluminal blue mucin is produced exclusively by malignant prostatic glands and never seen in benign conditions
Click to reveal answer