A 67-year-old man comes to the physician because of a 3-month history of difficulty initiating urination. He wakes up at least 3–4 times at night to urinate. Digital rectal examination shows a symmetrically enlarged, nontender prostate with a rubbery consistency. Laboratory studies show a prostate-specific antigen level of 2.1 ng/mL (N < 4). Which of the following is the most likely underlying cause of this patient's symptoms?

Hypertrophy of middle prostatic lobe tissue

Lymphocytic infiltration of anterior prostatic lobe stroma

Hyperplasia of lateral prostatic lobe tissue

Infiltrating dysplasia of posterior prostatic lobe epithelium

Infiltrating neoplasia of bladder urothelium

A 25-year-old man presents to his primary care provider complaining of scrotal swelling. He is a college student and plays basketball with his friends regularly. Two days ago, he sustained an injury close to his thigh. He does not have any significant past medical history. Today, his vitals are normal. A focused scrotal examination reveals a firm painless lump on the right testicle which is irregular and small. Ultrasound of the scrotum reveals a vascular 0.6 x 0.5 cm testicular mass. A pelvic lymph node exam is negative. He undergoes a radical orchiectomy and subsequent histopathological examination reveals sheets of small cuboidal cells, multinucleated cells, and large eosinophilic cells with pleomorphic nuclei consistent with choriocarcinoma. Which of the following tumor marker is most likely elevated in this patient?

Beta-human chorionic gonadotropin

A 54-year-old woman comes to the physician because of an ulcer on her left ankle for 6 years. She has had multiple ulcers over her left lower extremity during this period that have subsided with wound care and dressing. She has type 2 diabetes mellitus and gastroesophageal reflux disease. Current medications include metformin, sitagliptin, and omeprazole. She appears anxious. She is 162 cm (5 ft 4 in) tall and weighs 89 kg (196 lb); BMI is 34 kg/m2. Vital signs are within normal limits. Examination shows a 7.5-cm (3-in) ulcer with elevated, indurated margins and a necrotic floor above the left medial malleolus. There are multiple dilated, tortuous veins along the left lower extremity. There is 2+ pretibial edema of the lower extremities bilaterally. The skin around the left ankle appears darker than the right and there are multiple excoriation marks. Cardiopulmonary examination shows no abnormalities. Which of the following is the most appropriate next step in management of this patient's current condition?

Digital subtraction angiography

Male reproductive pathology — USMLE Lesson

Testicular Tumors - Nuts & Bolts

95% of testicular tumors are Germ Cell Tumors (GCTs), mostly malignant.

Seminoma (~50% of GCTs)
- Markers: ↑ Placental ALP (PLAP), sometimes ↑ hCG. AFP is always normal.
- 📌 Seminomas are Simple (uniform cells), Sensitive (to radiotherapy), Slow-growing.
Non-Seminoma
- Markers: ↑ AFP (Yolk Sac), ↑ hCG (Choriocarcinoma), ↑ LDH (tumor burden).

Seminoma vs. Non-Seminoma Histology

Sex Cord-Stromal Tumors
- Leydig Cell: Produces androgens → precocious puberty or gynecomastia.
- Sertoli Cell: Often hormonally silent.

⭐ Yolk sac (endodermal sinus) tumor is the most common testicular tumor in boys < 3 years old, characteristically showing Schiller-Duval bodies.

Prostate Pathology - Gland Finale

Benign Prostatic Hyperplasia (BPH)
- Hyperplasia of stromal/epithelial cells in the periurethral/transitional zone, causing urinary obstruction (hesitancy, nocturia).
- Driven by DHT. Rx: 5α-reductase inhibitors, α1-blockers.
Prostate Adenocarcinoma
- Arises in the peripheral zone; often asymptomatic.
- Screening via PSA (> 4 ng/mL is concerning) & DRE.
- Diagnosis by biopsy, graded with Gleason score (architecture).

Prostate zones and tumor locations

⭐ Most prostate cancers are adenocarcinomas found in the posterior lobe (peripheral zone), making them palpable on a digital rectal exam (DRE).

Penile & Scrotal Issues - The Lowdown

Cryptorchidism: Failure of testes to descend into the scrotum. ↑ risk of seminoma & infertility. Orchiopexy recommended before age 2.
Hydrocele: Peritoneal fluid collection in the tunica vaginalis that transilluminates. Common in newborns.
Varicocele: Dilation of the pampiniform plexus; feels like a "bag of worms." Does not transilluminate. Usually left-sided.
Peyronie Disease: Fibrous plaque formation in the tunica albuginea, leading to penile curvature and painful erections.
Squamous Cell Carcinoma (SCC): Precursor lesions are linked to HPV, especially types 16 and 18.
- Bowen Disease: Carcinoma in situ presenting as leukoplakia (white plaque) on the penile shaft.
- Erythroplasia of Queyrat: Carcinoma in situ appearing as erythroplakia (red plaque) on the glans.

Varicocele: Healthy vs. Affected Testicle Anatomy

⭐ Cryptorchidism is the most significant risk factor for testicular germ cell tumors, increasing the risk 3-5x.

High‑Yield Points - ⚡ Biggest Takeaways

Testicular germ cell tumors are the most common solid tumors in young men; seminomas are radiosensitive, while non-seminomas are aggressive.

Prostate adenocarcinoma typically arises in the peripheral zone, is often palpable, and is monitored with PSA.

Benign Prostatic Hyperplasia (BPH) occurs in the transitional zone, causing urinary obstruction, but does not increase cancer risk.

Cryptorchidism (undescended testis) significantly increases the risk of seminoma and infertility.

Testicular torsion is a surgical emergency presenting with acute pain and an absent cremasteric reflex.

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