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Difference between revisions of "Prostate cancer"
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{{ Infobox diagnosis | {{ Infobox diagnosis | ||
| Name = | | Name = Prostate carcinoma | ||
| Image = Prostate cancer with Gleason pattern 4 low mag.jpg | | Image = Prostate cancer with Gleason pattern 4 low mag.jpg | ||
| Width = | | Width = | ||
| Caption = Prostate carcinoma. [[H&E stain]]. | | Caption = Prostate carcinoma. [[H&E stain]]. | ||
| Line 10: | Line 10: | ||
| IHC = PSA +ve, PSAP +ve, AMACR +ve, p63 -ve, CK34betaE12 -ve | | IHC = PSA +ve, PSAP +ve, AMACR +ve, p63 -ve, CK34betaE12 -ve | ||
| EM = | | EM = | ||
| Molecular = | | Molecular = +/-[[BRCA1]] mutation (genetic predisposition), +/-[[BRCA2]] mutation (genetic predisposition) | ||
| IF = | | IF = | ||
| Gross = | | Gross = usu. posterior aspect of the prostate - often not apparent at gross | ||
| Grossing = | | Grossing = [[prostate biopsy]], [[prostate chips]], [[radical prostatectomy]] | ||
| Staging = [[prostate cancer staging]] | |||
| Site = [[prostate gland]] | | Site = [[prostate gland]] | ||
| Assdx = | | Assdx = | ||
| Syndromes = | | Syndromes = | ||
| Clinicalhx = | | Clinicalhx = | ||
| Signs = firm, nodular prostate on digital rectal exam | | Signs = firm, nodular prostate on digital rectal exam | ||
| Symptoms = often asymptomatic | | Symptoms = often asymptomatic | ||
| Prevalence = very common | | Prevalence = very common | ||
| Bloodwork = PSA elevated | | Bloodwork = PSA elevated (common) | ||
| Rads = hypoechoic areas, no apparent abnormality | | Rads = hypoechoic areas, no apparent abnormality | ||
| Endoscopy = | | Endoscopy = | ||
| Prognosis = good-to-poor (depends on [[Gleason score]] and [[stage]]) | | Prognosis = good-to-poor (depends on [[prostate cancer grading|grade (Gleason score)]] and [[stage]]) | ||
| Other = | | Other = | ||
| ClinDDx = [[prostatitis]], [[nodular hyperplasia of the prostate]] | | ClinDDx = [[prostatitis]], [[nodular hyperplasia of the prostate]] | ||
| Tx = observation (common for low-grade, low tumour burden), radiation or radical prostatectomy | |||
}} | }} | ||
This article deals with '''prostate [[cancer]]'''. | This article deals with '''prostate [[cancer]]'''. | ||
| Line 37: | Line 39: | ||
==General== | ==General== | ||
*Very common. | *Very common. | ||
*Increasing incidence with age - the age in years is an approximation of the percentage of men with prostate cancer. | *Increasing incidence with age - the age in years is an approximation of the percentage of men with prostate cancer.<ref>{{cite journal |author=Sakr WA, Haas GP, Cassin BF, Pontes JE, Crissman JD |title=The frequency of carcinoma and intraepithelial neoplasia of the prostate in young male patients |journal=J. Urol. |volume=150 |issue=2 Pt 1 |pages=379–85 |year=1993 |month=August |pmid=8326560 |doi= |url=}}</ref>{{fact}} | ||
*Usually an indolent course - most old men die with prostate cancer ''not'' from prostate cancer. | *Usually an indolent course - most old men die with prostate cancer ''not'' from prostate cancer. | ||
*Risk increased with a [[BRCA1]] or [[BRCA2]] mutation<ref name=pmid23747895>{{Cite journal | last1 = Li | first1 = D. | last2 = Kumaraswamy | first2 = E. | last3 = Harlan-Williams | first3 = LM. | last4 = Jensen | first4 = RA. | title = The role of BRCA1 and BRCA2 in prostate cancer. | journal = Front Biosci (Landmark Ed) | volume = 18 | issue = | pages = 1445-59 | month = | year = 2013 | doi = | PMID = 23747895 }}</ref> - families have a mix of [[breast cancer]] and prostate cancer. | |||
**BRCA2 mutation risk >8x for men over 65 years old.<ref name=pmid22522501>{{Cite journal | last1 = Castro | first1 = E. | last2 = Eeles | first2 = R. | title = The role of BRCA1 and BRCA2 in prostate cancer. | journal = Asian J Androl | volume = 14 | issue = 3 | pages = 409-14 | month = May | year = 2012 | doi = 10.1038/aja.2011.150 | PMID = 22522501 }}</ref> | |||
**A BRCA2 founder mutation is described in French Canadians.<Ref name=pmid23318356>{{Cite journal | last1 = Taherian | first1 = N. | last2 = Hamel | first2 = N. | last3 = Bégin | first3 = LR. | last4 = Bismar | first4 = TA. | last5 = Goldgar | first5 = DE. | last6 = Feng | first6 = BJ. | last7 = Foulkes | first7 = WD. | title = Familial prostate cancer: the damage done and lessons learnt. | journal = Nat Rev Urol | volume = 10 | issue = 2 | pages = 116-22 | month = Feb | year = 2013 | doi = 10.1038/nrurol.2012.257 | PMID = 23318356 }}</ref> | |||
===Management=== | ===Management=== | ||
====Dirty first approximation==== | ====Dirty first approximation==== | ||
*The management changes between [[Gleason score]] 6, 7 and 8. | *The management changes between [[Gleason score]] 6, 7 (3+4), 7 (4+3) and 8. | ||
Typically, the implications are: | Typically, the implications are: | ||
* Gleason 6: observation ''or'' radioactive seeds; surgery if patient wants. | * Gleason 6: observation ''or'' radioactive seeds; surgery if patient wants. | ||
* Gleason 7: do something -- surgery ''or'' radiation therapy. | * Gleason 7 with a bit of Gleason pattern 4 and a low tumour volume: it is reasonable to watch ''or'' do something. ‡ | ||
* Gleason 7 with a lot of Gleason pattern 4 ''or'' a high tumour volume: do something -- surgery ''or'' radiation therapy. | |||
* Gleason 8+: bad cancer -- do something quickly! | * Gleason 8+: bad cancer -- do something quickly! | ||
Note: | |||
* ‡ It has been said that ''Gleason score 7 with a bit of Gleason pattern 4 is the new Gleason score 6''. | |||
Bottom line: | Bottom line: | ||
| Line 73: | Line 83: | ||
Clinical criteria: | Clinical criteria: | ||
*PSA <= 10 ng/mL.<ref name=pmid22314081/> | *PSA <= 10 ng/mL.<ref name=pmid22314081/> | ||
*Negative DRE. | |||
==Gross== | ==Gross== | ||
| Line 85: | Line 96: | ||
===Prostatectomy grossing=== | ===Prostatectomy grossing=== | ||
{{Main|Radical prostatectomy}} | |||
===Cytoprostatectomy grossing=== | ===Cytoprostatectomy grossing=== | ||
{{Main|Cystoprostatectomy grossing}} | |||
*Limited sampling of the prostate may lead to undersampling error.<ref name=pmid11182038>{{Cite journal | last1 = Cindolo | first1 = L. | last2 = Benincasa | first2 = G. | last3 = Autorino | first3 = R. | last4 = Domizio | first4 = S. | last5 = De Rosa | first5 = G. | last6 = Testa | first6 = G. | last7 = D'Armiento | first7 = M. | last8 = Altieri | first8 = V. | title = Prevalence of silent prostatic adenocarcinoma in 165 patients undergone cystoprostatectomy: a retrospective study. | journal = Oncol Rep | volume = 8 | issue = 2 | pages = 269-71 | month = | year = | doi = | PMID = 11182038 }}</ref> | *Limited sampling of the prostate may lead to undersampling error.<ref name=pmid11182038>{{Cite journal | last1 = Cindolo | first1 = L. | last2 = Benincasa | first2 = G. | last3 = Autorino | first3 = R. | last4 = Domizio | first4 = S. | last5 = De Rosa | first5 = G. | last6 = Testa | first6 = G. | last7 = D'Armiento | first7 = M. | last8 = Altieri | first8 = V. | title = Prevalence of silent prostatic adenocarcinoma in 165 patients undergone cystoprostatectomy: a retrospective study. | journal = Oncol Rep | volume = 8 | issue = 2 | pages = 269-71 | month = | year = | doi = | PMID = 11182038 }}</ref> | ||
| Line 113: | Line 113: | ||
#Basal cells lacking. | #Basal cells lacking. | ||
#Cytological abnormalities: | #Cytological abnormalities: | ||
#*Nuclear enlargement. | #*Nuclear enlargement (subtle). | ||
#*Nucleoli. | #*[[Nucleoli]] (prominent). | ||
Minor criteria:<ref name=pmid17213347/> | Minor criteria:<ref name=pmid17213347/> | ||
| Line 134: | Line 134: | ||
**Thus, it has been suggested that six or more glands should be present to diagnose cancer.<ref name=pmid20061936/> | **Thus, it has been suggested that six or more glands should be present to diagnose cancer.<ref name=pmid20061936/> | ||
===Low power features=== | Features considered pathognomonic for prostate carcinoma by some authorities:<ref name=pmid16613324>{{Cite journal | last1 = Egevad | first1 = L. | last2 = Allsbrook | first2 = WC. | last3 = Epstein | first3 = JI. | title = Current practice of diagnosis and reporting of prostate cancer on needle biopsy among genitourinary pathologists. | journal = Hum Pathol | volume = 37 | issue = 3 | pages = 292-7 | month = Mar | year = 2006 | doi = | PMID = 16613324 }}</ref><ref name=pmid10435561>{{Cite journal | last1 = Baisden | first1 = BL. | last2 = Kahane | first2 = H. | last3 = Epstein | first3 = JI. | title = Perineural invasion, mucinous fibroplasia, and glomerulations: diagnostic features of limited cancer on prostate needle biopsy. | journal = Am J Surg Pathol | volume = 23 | issue = 8 | pages = 918-24 | month = Aug | year = 1999 | doi = | PMID = 10435561 }}</ref> | ||
#Perineural invasion. | |||
#*Must be circumferential (>95% of circumference{{fact}}). | |||
#Glomeruloid bodies. | |||
#[[Collagenous micronodules]] also known as ''mucinous fibroplasia''. | |||
<gallery> | |||
Image: Intraluminal eosinophilic crystalloid of prostate gland - high mag.jpg| Intraluminal eosinophilic crystalloid - high mag. (WC) | |||
Image: Prostate carcinoma with blue mucin -- very high mag.jpg | Whispy blue mucin - very high mag. (WC) | |||
Image: Prostate carcinoma with blue mucin - a1 -- intermed mag.jpg | Whispy blue mucin - intermed. mag. (WC) | |||
</gallery> | |||
===Divided into high and low power=== | |||
====Low power features==== | |||
*Architecture is the '''key''' to diagnosing low grade cancer. | *Architecture is the '''key''' to diagnosing low grade cancer. | ||
**Back-to-back glands or crowding of glands -- think low grade cancer (Gleason pattern 3). | **Back-to-back glands or crowding of glands -- think low grade cancer (Gleason pattern 3). | ||
| Line 143: | Line 156: | ||
**"Infiltrative": small round/oval (malignant) glands (approx. 5 cells across) interspersed with larger (benign) glands that are 2-3 times larger. | **"Infiltrative": small round/oval (malignant) glands (approx. 5 cells across) interspersed with larger (benign) glands that are 2-3 times larger. | ||
===High power features=== | ====High power features==== | ||
* | *Nuclear changes. | ||
**Hyperchromatic nuclei (like in HGPIN). | **Hyperchromatic nuclei (like in HGPIN). | ||
**Nuclear enlargement. | **Nuclear enlargement, mild (10%?). | ||
***Difficult to appreciate (if cancer isn't side-by-side with normal prostate). | ***Difficult to appreciate (if cancer isn't side-by-side with normal prostate). | ||
***Difficult/impossible to see at low power. | ***Difficult/impossible to see at low power. | ||
* | *"Large" nucleoli. | ||
**May be difficult to see - especially if light intensity is low. | **Visible on intermediate and high power (100x / 200x magnification). | ||
***One should not use 400x to look for nucleoli (it is a waste of time + you risk | ***May be difficult to see - especially if light intensity is low or the staining is of poor quality. | ||
** | ***One should not use 400x to look for nucleoli (it is a waste of time + you risk over-calling something benign). | ||
**"Large" is rarely precisely quantified; 3 micrometres has been suggested as "large" based on one study.<ref name=pmid1688728>{{Cite journal | last1 = Kelemen | first1 = PR. | last2 = Buschmann | first2 = RJ. | last3 = Weisz-Carrington | first3 = P. | title = Nucleolar prominence as a diagnostic variable in prostatic carcinoma. | journal = Cancer | volume = 65 | issue = 4 | pages = 1017-20 | month = Feb | year = 1990 | doi = | PMID = 1688728 }}</ref> | |||
***Three micrometres is a little more than 1/3 of [[RBC]] diameter. | |||
*Loss of basal cells - diagnostic feature. | *Loss of basal cells - diagnostic feature. | ||
**Like in [[breast pathology]] (where one looks for loss of myoepithelial cells) - this may be difficult to see. | **Like in [[breast pathology]] (where one looks for loss of myoepithelial cells) - this may be difficult to see. | ||
Notes: | Notes: | ||
*Mitoses are not a common feature - | *Mitoses are not a common feature. | ||
**If you find them the lesion is probably high-grade. | |||
**Generally, it isn't worth looking for them. | |||
===Mimics=== | ===Mimics=== | ||
| Line 172: | Line 189: | ||
| many small glands, lack nuclear size variation, basal layer present | | many small glands, lack nuclear size variation, basal layer present | ||
| nucleoli may be present; may need to do p63 or 34betaE12 to find basal layer | | nucleoli may be present; may need to do p63 or 34betaE12 to find basal layer | ||
| [ | | [[Image:Adenosis of prostate_--_intermed_mag.jpg|thumb|150px|center| Adenosis of prostate. (WC)]] | ||
|- | |- | ||
| Sclerosing adenosis | | Sclerosing adenosis | ||
| Line 178: | Line 195: | ||
| many small glands, lack nuclear size variation, basal layer present | | many small glands, lack nuclear size variation, basal layer present | ||
| analogous to [[sclerosing adenosis of the breast]]{{fact}} | | analogous to [[sclerosing adenosis of the breast]]{{fact}} | ||
| [http://webpathology.com/image.asp?case=21&n= | | [http://webpathology.com/image.asp?case=21&n=40 Sclerosing adenosis (webpathology.com)] | ||
|- | |- | ||
| [[atrophy of the prostate|Atrophy]] | | [[atrophy of the prostate|Atrophy]] | ||
| Line 184: | Line 201: | ||
| nuclear hyperchromasia, scant cytoplasm | | nuclear hyperchromasia, scant cytoplasm | ||
| may appear right beside non-atrophic tissue | | may appear right beside non-atrophic tissue | ||
| [ | | [[Image:Atrophic_prostatic_glands_--_high_mag.jpg|thumb|150px|center| Prostatic atrophy. (WC)]] | ||
|- | |- | ||
| [[Basal cell hyperplasia of the prostate|Basal cell hyperplasia]] | | [[Basal cell hyperplasia of the prostate|Basal cell hyperplasia]] | ||
| Line 190: | Line 207: | ||
| abundant epithelial cells; nucleoli in pale ('blue') nuclei of basal cells, glandular cell nuclei darker ('purple') | | abundant epithelial cells; nucleoli in pale ('blue') nuclei of basal cells, glandular cell nuclei darker ('purple') | ||
| vaguely similar to epithelial hyperplasia of usual type (EHUT) in breast | | vaguely similar to epithelial hyperplasia of usual type (EHUT) in breast | ||
| [ | | [[Image:Basal_cell_hyperplasia_of_prostate_-_high_mag.jpg|thumb|150px|center| Prostatic BCH. (WC)]] | ||
|- | |- | ||
| [[Bulbourethral gland]] | | [[Bulbourethral gland]] | ||
| Line 196: | Line 213: | ||
| clear cytoplasm | | clear cytoplasm | ||
| apex of prostate | | apex of prostate | ||
| [ | | [[Image:Bulbourethral gland -- very high mag.jpg |thumb|150px|center| Bulbourethral gland. (WC)]] | ||
|- | |- | ||
| [[Seminal vesicles]] / ejaculatory ducts | | [[Seminal vesicles]] / ejaculatory ducts | ||
| Line 202: | Line 219: | ||
| fern-like arrangement of epithelium (low power), nucleoli, surrounded by muscle, +/- nuclear inclusions | | fern-like arrangement of epithelium (low power), nucleoli, surrounded by muscle, +/- nuclear inclusions | ||
| involvement by cancer changes staging, lipofuscin may be present in prostate, often has marked nuc. size var.; location: usu. base of prostate | | involvement by cancer changes staging, lipofuscin may be present in prostate, often has marked nuc. size var.; location: usu. base of prostate | ||
| [[Image:Seminal_vesicle_high_mag.jpg |thumb|150px|center| | | [[Image:Seminal_vesicle_high_mag.jpg |thumb|150px|center|Seminal vesicles. (WC)]] | ||
|- | |- | ||
| Radiation effect | | [[Radiation effect]] | ||
| marked nuclear size variation | | marked nuclear size variation | ||
| increased stroma (fibrosis), lack nucleoli ??? | | increased stroma (fibrosis), lack nucleoli ??? | ||
| history of Rx; uniform nuc. size with Hx of Rx should raise susp. of cancer | | history of Rx; uniform nuc. size with Hx of Rx should raise susp. of [[postradiation prostatic carcinoma|postradiation cancer]] | ||
| [ | | [[Image:Prostate_with_radiation_changes_--_high_mag.jpg|thumb|150px|center|Radiation change. (WC)]] | ||
|- | |- | ||
| Prostatitis | | Prostatitis | ||
| Line 224: | Line 241: | ||
Memory device: '''AAABBRS''' = atrophy, adenosis, adenosis (sclerosing), basal cell hyperplasia, bulbourethral gland, radiation, seminal vesicles. | Memory device: '''AAABBRS''' = atrophy, adenosis, adenosis (sclerosing), basal cell hyperplasia, bulbourethral gland, radiation, seminal vesicles. | ||
=== | ===Situations where prostate adenocarcinoma may be missed=== | ||
Key reasons for false negative prostate samples<ref>{{cite journal |authors=Yang C, Humphrey PA |title=False-Negative Histopathologic Diagnosis of Prostatic Adenocarcinoma |journal=Arch. Pathol. Lab. Med. |volume=144 |issue=3 |pages=326–334 |date=March 2020 |pmid=31729886 |doi=10.5858/arpa.2019-0456-RA |url=}}</ref>: | |||
*Tissue artefacts (try levels and/or IHC): | |||
**Crush artefact | |||
**Thick sections | |||
**Aberrant H&E staining | |||
**Freezing artefact | |||
**Cautery | |||
*Minimal adenocarcinoma (less than 1mm long or involving less than 5% of a core biopsy): | |||
*Prostatic adenocarcinoma variants that mimic benign: | |||
**[[Atrophic prostate carcinoma]] | |||
**[[Pseudohyperplastic adenocarcinoma]] | |||
**[[Foamy gland adenocarcinoma]] | |||
* | **[[PIN-like adenocarcinoma]] | ||
** | **Microcystic adenocarcinoma | ||
*Single cells of Gleason 5 adenocarcinoma (missed or mistaken for lymphocytes; try IHC for cytokeratins, prostatic and/or hematologic markers) | |||
*Treatment effect (check clinical information and look for treatment effect in benign glands) | |||
* | |||
* | |||
* | |||
* | |||
* | |||
* | |||
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* | |||
* | |||
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** | |||
* | |||
*[ | |||
* | |||
* | |||
* | |||
=== | ===Prostate cancer grading=== | ||
{{Main|Prostate cancer grading}} | |||
It covers the ''Gleason grading system'' and the (new) ''prognostic grade groupings''. | |||
Gleason | |||
===Staging parameters, margins and more=== | |||
===Staging parameters and | |||
====Surgical margins==== | ====Surgical margins==== | ||
{{Main|Surgical margins}} | {{Main|Surgical margins}} | ||
*Positive is ''tumour touching ink''.† <ref name=pmid22578729>{{Cite journal | last1 = Lu | first1 = J. | last2 = Wirth | first2 = GJ. | last3 = Wu | first3 = S. | last4 = Chen | first4 = J. | last5 = Dahl | first5 = DM. | last6 = Olumi | first6 = AF. | last7 = Young | first7 = RH. | last8 = McDougal | first8 = WS. | last9 = Wu | first9 = CL. | title = A close surgical margin after radical prostatectomy is an independent predictor of recurrence. | journal = J Urol | volume = 188 | issue = 1 | pages = 91-7 | month = Jul | year = 2012 | doi = 10.1016/j.juro.2012.02.2565 | PMID = 22578729 }}</ref> | *Positive is ''tumour touching [[ink]]''.† <ref name=pmid22578729>{{Cite journal | last1 = Lu | first1 = J. | last2 = Wirth | first2 = GJ. | last3 = Wu | first3 = S. | last4 = Chen | first4 = J. | last5 = Dahl | first5 = DM. | last6 = Olumi | first6 = AF. | last7 = Young | first7 = RH. | last8 = McDougal | first8 = WS. | last9 = Wu | first9 = CL. | title = A close surgical margin after radical prostatectomy is an independent predictor of recurrence. | journal = J Urol | volume = 188 | issue = 1 | pages = 91-7 | month = Jul | year = 2012 | doi = 10.1016/j.juro.2012.02.2565 | PMID = 22578729 }}</ref> | ||
**"Close" margins (<0.1 mm) have an increased recurrence risk.<ref name=pmid22578729/> | **"Close" margins (<0.1 mm) have an increased recurrence risk.<ref name=pmid22578729/> | ||
| Line 436: | Line 286: | ||
*Significant modest negative affect on long-term outcome in node negative cancers (pT2-4 pN0).<ref name=pmid22901983>{{Cite journal | last1 = Mauermann | first1 = J. | last2 = Fradet | first2 = V. | last3 = Lacombe | first3 = L. | last4 = Dujardin | first4 = T. | last5 = Tiguert | first5 = R. | last6 = Tetu | first6 = B. | last7 = Fradet | first7 = Y. | title = The Impact of Solitary and Multiple Positive Surgical Margins on Hard Clinical End Points in 1712 Adjuvant Treatment-Naive pT2-4 N0 Radical Prostatectomy Patients. | journal = Eur Urol | volume = | issue = | pages = | month = Aug | year = 2012 | doi = 10.1016/j.eururo.2012.08.002 | PMID = 22901983 }}</ref> | *Significant modest negative affect on long-term outcome in node negative cancers (pT2-4 pN0).<ref name=pmid22901983>{{Cite journal | last1 = Mauermann | first1 = J. | last2 = Fradet | first2 = V. | last3 = Lacombe | first3 = L. | last4 = Dujardin | first4 = T. | last5 = Tiguert | first5 = R. | last6 = Tetu | first6 = B. | last7 = Fradet | first7 = Y. | title = The Impact of Solitary and Multiple Positive Surgical Margins on Hard Clinical End Points in 1712 Adjuvant Treatment-Naive pT2-4 N0 Radical Prostatectomy Patients. | journal = Eur Urol | volume = | issue = | pages = | month = Aug | year = 2012 | doi = 10.1016/j.eururo.2012.08.002 | PMID = 22901983 }}</ref> | ||
*Weaker impact than stage and Gleason score.<ref>{{Cite journal | last1 = Chalfin | first1 = HJ. | last2 = Dinizo | first2 = M. | last3 = Trock | first3 = BJ. | last4 = Feng | first4 = Z. | last5 = Partin | first5 = AW. | last6 = Walsh | first6 = PC. | last7 = Humphreys | first7 = E. | last8 = Han | first8 = M. | title = Impact of surgical margin status on prostate-cancer-specific mortality. | journal = BJU Int | volume = | issue = | pages = | month = Jul | year = 2012 | doi = 10.1111/j.1464-410X.2012.11371.x | PMID = 22788795 }}</ref> | *Weaker impact than stage and Gleason score.<ref>{{Cite journal | last1 = Chalfin | first1 = HJ. | last2 = Dinizo | first2 = M. | last3 = Trock | first3 = BJ. | last4 = Feng | first4 = Z. | last5 = Partin | first5 = AW. | last6 = Walsh | first6 = PC. | last7 = Humphreys | first7 = E. | last8 = Han | first8 = M. | title = Impact of surgical margin status on prostate-cancer-specific mortality. | journal = BJU Int | volume = | issue = | pages = | month = Jul | year = 2012 | doi = 10.1111/j.1464-410X.2012.11371.x | PMID = 22788795 }}</ref> | ||
*Bladder neck margin positivity may change the T-stage - see below. | |||
=====Bladder neck margin===== | |||
{{Main|Bladder neck invasion}} | |||
:[[AKA]] ''invasion of the bladder neck''.<ref name=pmid19914651/> | |||
*Bladder neck margin positivity typically is '''pT3a'''.<ref name=pmid23225909>{{Cite journal | last1 = Chung | first1 = MS. | last2 = Lee | first2 = SH. | last3 = Lee | first3 = DH. | last4 = Chung | first4 = BH. | title = Evaluation of the 7th American Joint Committee on cancer TNM staging system for prostate cancer in point of classification of bladder neck invasion. | journal = Jpn J Clin Oncol | volume = 43 | issue = 2 | pages = 184-8 | month = Feb | year = 2013 | doi = 10.1093/jjco/hys196 | PMID = 23225909 }}</ref> | |||
*Seen in approximately 1% of prostatectomies.<ref name=pmid19914651>{{Cite journal | last1 = Pierorazio | first1 = PM. | last2 = Epstein | first2 = JI. | last3 = Humphreys | first3 = E. | last4 = Han | first4 = M. | last5 = Walsh | first5 = PC. | last6 = Partin | first6 = AW. | title = The significance of a positive bladder neck margin after radical prostatectomy: the American Joint Committee on Cancer Pathological Stage T4 designation is not warranted. | journal = J Urol | volume = 183 | issue = 1 | pages = 151-7 | month = Jan | year = 2010 | doi = 10.1016/j.juro.2009.08.138 | PMID = 19914651 }}</ref> | |||
====Extraprostatic extension==== | ====Extraprostatic extension==== | ||
:Abbreviated ''EPE''. | :Abbreviated ''EPE''. | ||
{{Main|Prostate cancer staging#Extraprostatic extension}} | |||
==== | ====Seminal vesicle invasion==== | ||
:Abbreviated ''SVI''. | |||
{{Main|Prostate cancer staging#Seminal vesicle invasion}} | |||
===== | ====Perineural invasion==== | ||
{{Main|Perineural invasion}} | |||
*''Not'' a staging parameter. | |||
*Seen in approximately 20% of core biopsies.<ref name=pmid16096404>{{Cite journal | last1 = Ali | first1 = TZ. | last2 = Epstein | first2 = JI. | title = Perineural involvement by benign prostatic glands on needle biopsy. | journal = Am J Surg Pathol | volume = 29 | issue = 9 | pages = 1159-63 | month = Sep | year = 2005 | doi = | PMID = 16096404 }}</ref> | |||
*Complete wrapping of a nerve by epithelium is considered pathognomonic for cancer.<ref name=pmid10435561>{{Cite journal | last1 = Baisden | first1 = BL. | last2 = Kahane | first2 = H. | last3 = Epstein | first3 = JI. | title = Perineural invasion, mucinous fibroplasia, and glomerulations: diagnostic features of limited cancer on prostate needle biopsy. | journal = Am J Surg Pathol | volume = 23 | issue = 8 | pages = 918-24 | month = Aug | year = 1999 | doi = | PMID = 10435561 }}</ref><ref name=pmid16096404/> | |||
Note: | Note: | ||
* | *Occasionally, benign glands are found perineural.<ref name=pmid16096404/> | ||
**These should ''not'' completely wrap around the nerve and should be cytologically benign. | |||
===== | ==IHC== | ||
===General recommendations=== | |||
ISUP consensus statement:<ref name=pmid25025364>{{cite journal |author=Amin MB, Epstein JI, Ulbright TM, ''et al.'' |title=Best practices recommendations in the application of immunohistochemistry in urologic pathology: report from the international society of urological pathology consensus conference |journal=Am. J. Surg. Pathol. |volume=38 |issue=8 |pages=1017–22 |year=2014 |month=August |pmid=25025364 |doi=10.1097/PAS.0000000000000254 |url=}}</ref> | |||
*Should ''not'' be used if cancer is obvious. | |||
*Should ''not'' be used if it isn't going change the clinical management. | |||
* | |||
===Prostate markers=== | |||
*[[PSA]] (prostate specific antigen) +ve. | |||
*[[PSAP]] (prostatic specific acid phosphatase) +ve. † | |||
*P501S +ve. ‡ | |||
*[[NKX3.1]] +ve. ‡ | |||
Notes: | Notes: | ||
* | *† PSAP may be positive in hindgut [[neuroendocrine tumour]]s.<ref name=pmid>{{Cite journal | last1 = Azumi | first1 = N. | last2 = Traweek | first2 = ST. | last3 = Battifora | first3 = H. | title = Prostatic acid phosphatase in carcinoid tumors. Immunohistochemical and immunoblot studies. | journal = Am J Surg Pathol | volume = 15 | issue = 8 | pages = 785-90 | month = Aug | year = 1991 | doi = | PMID = 1712549 }}</ref> | ||
*‡ P501S and NKX3.1 are considered second line markers.<ref name=pmid25025364/> | |||
*Prostate carcinoma is typically CK7 -ve and CK20 -ve; however, in high [[Gleason score]] cancers focal positivity of these markers can be seen.<ref name=pmid11888088>{{Cite journal | last1 = Goldstein | first1 = NS. | title = Immunophenotypic characterization of 225 prostate adenocarcinomas with intermediate or high Gleason scores. | journal = Am J Clin Pathol | volume = 117 | issue = 3 | pages = 471-7 | month = Mar | year = 2002 | doi = 10.1309/G6PR-Y774-X738-FG2K | PMID = 11888088 }}</ref> | |||
**CK7: >25-50% staining seen in ~5% of cases. | |||
***>50% staining with CK7 is not report. | |||
**CK20: >25-50% staining seen in ~10% of cases. | |||
***>50% staining with CK20 is not reported. | |||
===Benign prostate versus neoplastic prostate=== | ===Benign prostate versus neoplastic prostate=== | ||
*AMACR +ve. | *AMACR +ve. | ||
*p63 -ve. | *p63 -ve. | ||
*HMWCK (34betaE12) -ve. | *HMWCK (34betaE12) -ve. | ||
| Line 496: | Line 344: | ||
***Why '''CAP'''? | ***Why '''CAP'''? | ||
****A. '''CA'''ncer of the '''P'''rostate. | ****A. '''CA'''ncer of the '''P'''rostate. | ||
Other IHC stains: | |||
*AR +ve -- in prostate confined cancer. | |||
**Usually -ve in lymph node +ve disease.<ref name=pmid20878946>{{Cite journal | last1 = Fleischmann | first1 = A. | last2 = Rocha | first2 = C. | last3 = Schobinger | first3 = S. | last4 = Seiler | first4 = R. | last5 = Wiese | first5 = B. | last6 = Thalmann | first6 = GN. | title = Androgen receptors are differentially expressed in Gleason patterns of prostate cancer and down-regulated in matched lymph node metastases. | journal = Prostate | volume = 71 | issue = 5 | pages = 453-60 | month = Apr | year = 2011 | doi = 10.1002/pros.21259 | PMID = 20878946 }}</ref> | |||
Note: | |||
*Bcl-2 marks basal cells in prostate cancer.<ref name=pmid20189848>{{Cite journal | last1 = Boran | first1 = C. | last2 = Kandirali | first2 = E. | last3 = Yilmaz | first3 = F. | last4 = Serin | first4 = E. | last5 = Akyol | first5 = M. | title = Reliability of the 34βE12, keratin 5/6, p63, bcl-2, and AMACR in the diagnosis of prostate carcinoma. | journal = Urol Oncol | volume = 29 | issue = 6 | pages = 614-23 | month = | year = | doi = 10.1016/j.urolonc.2009.11.013 | PMID = 20189848 }}</ref> | |||
====Prostate carcinoma versus urothelial carcinoma==== | ====Prostate carcinoma versus urothelial carcinoma==== | ||
* | The ISUP panel recommends:<ref name=pmid25025364>{{cite journal |author=Amin MB, Epstein JI, Ulbright TM, ''et al.'' |title=Best practices recommendations in the application of immunohistochemistry in urologic pathology: report from the international society of urological pathology consensus conference |journal=Am. J. Surg. Pathol. |volume=38 |issue=8 |pages=1017–22 |year=2014 |month=August |pmid=25025364 |doi=10.1097/PAS.0000000000000254 |url=}}</ref> | ||
* | *PSA +ve (-ve in UCC). | ||
*GATA3 -ve (+ve in UCC). | |||
Another panel - if GATA3 isn't available: | |||
*AMACR not useful | *Prostate: PSA +ve, p63 -ve, HWMCK -ve. | ||
*Urothelial: p63 +ve, HWMCK +ve, PSA -ve. | |||
Notes: | |||
*AMACR not useful; it is positive in ~50% of [[UCC]].<ref name=pmid16315020>{{Cite journal | last1 = Langner | first1 = C. | last2 = Rupar | first2 = G. | last3 = Leibl | first3 = S. | last4 = Hutterer | first4 = G. | last5 = Chromecki | first5 = T. | last6 = Hoefler | first6 = G. | last7 = Rehak | first7 = P. | last8 = Zigeuner | first8 = R. | title = Alpha-methylacyl-CoA racemase (AMACR/P504S) protein expression in urothelial carcinoma of the upper urinary tract correlates with tumour progression. | journal = Virchows Arch | volume = 448 | issue = 3 | pages = 325-30 | month = Mar | year = 2006 | doi = 10.1007/s00428-005-0129-6 | PMID = 16315020 }}</ref> | |||
*CK7 and CK20 are typically negative in prostate carcinoma, and classically positive in urothelial carcinoma. | |||
*CK34betaE12 may be positive in prostate cancer; 43% of cases in one small series of cases with lymph node metastases.<ref name=pmid9024071>{{Cite journal | last1 = Googe | first1 = PB. | last2 = McGinley | first2 = KM. | last3 = Fitzgibbon | first3 = JF. | title = Anticytokeratin antibody 34 beta E12 staining in prostate carcinoma. | journal = Am J Clin Pathol | volume = 107 | issue = 2 | pages = 219-23 | month = Feb | year = 1997 | doi = | PMID = 9024071 }}</ref> | |||
===Rate of utilization=== | ===Rate of utilization=== | ||
| Line 517: | Line 379: | ||
==Sign out== | ==Sign out== | ||
===Prostatectomy specimens=== | ===Prostatectomy specimens=== | ||
*A prostatectomy that appears to be negative should be worked-up. This is discuss in the ''[[negative prostatectomy]]'' article. | |||
*[http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=/portlets/contentViewer/show&_windowLabel=cntvwrPtlt&cntvwrPtlt{actionForm.contentReference}=committees/cancer/cancer_protocols/protocols_index.html&_pageLabel=cntvwr CAP checklist]. | |||
<pre> | <pre> | ||
| Line 533: | Line 396: | ||
===Transurethral resection of prostate=== | ===Transurethral resection of prostate=== | ||
<pre> | |||
Prostate Tissue, Transurethral Resection of Prostate (TURP): | |||
- ADENOCARCINOMA, Gleason score 6/10 (3+3); | |||
-- Approximately 2% of tissue involved; | |||
-- Please see tumour summary. | |||
Comment: | |||
The World Health Organization (WHO) grade is: 1 out of 5. | |||
</pre> | |||
<pre> | |||
Prostate Tissue, Transurethral Resection of Prostate (TURP): | |||
- ADENOCARCINOMA, Gleason score 7/10 (3+4); | |||
-- Approximately 4% of tissue involved; | |||
-- Please see tumour summary. | |||
- Benign inflamed urothelium. | |||
Comment: | |||
The World Health Organization (WHO) grade is: 2 out of 5. Gleason pattern 3 represents 90% of the tumour, and Gleason pattern 4 represents 10% of the tumour. | |||
</pre> | |||
====Block letters==== | |||
<pre> | <pre> | ||
PROSTATE TISSUE, TRANSURETHRAL RESECTION OF PROSTATE (TURP): | PROSTATE TISSUE, TRANSURETHRAL RESECTION OF PROSTATE (TURP): | ||
| Line 562: | Line 447: | ||
NODULAR PROSTATIC HYPERPLASIA. | NODULAR PROSTATIC HYPERPLASIA. | ||
CHRONIC INFLAMMATION. | CHRONIC INFLAMMATION. | ||
</pre> | |||
<pre> | |||
PROSTATE TISSUE, TRANSURETHRAL RESECTION OF THE PROSTATE (TURP): | |||
- ADENOCARCINOMA, GLEASON SCORE 6/10 (3+3); | |||
- APPROXIMATELY 5% OF TISSUE INVOLVED; | |||
- PLEASE SEE TUMOUR SUMMARY. | |||
</pre> | |||
<pre> | |||
Prostate Tissue, Transurethral Resection of Prostate (TURP): | |||
- Adenocarcinoma, Gleason score 7 (3+4) | |||
- Approximately 3% of sampled tissue involved | |||
- Please see tumour summary | |||
Tumour summary: | |||
Procedure: Transurethral resection of prostate | |||
Specimen weight: 11.7 g | |||
Histologic type: Adenocarcinoma, acinar type | |||
Histologic grade: | |||
Primary pattern: 3 | |||
Secondary pattern: 4 (<15% of tumor) | |||
Total Gleason score: 7/10 (3+4) | |||
Tumor volume: 3% of tissue | |||
Periprostate fat invasion: Periprostatic fat not identified | |||
Seminal vesicle invasion: Seminal vesicle not identified | |||
Lymphovascular inasion: Not identified | |||
Perineural invasion: Not identified | |||
Additional findings: | |||
Glandular and stromal hyperplasia | |||
Mild chronic inflammation | |||
</pre> | </pre> | ||
| Line 576: | Line 496: | ||
Notes: | Notes: | ||
*‡ "Percent area involved" may seem like an odd thing to request 'cause it is sampling dependent, i.e. if the radiologist sticks the biopsy needle deeper into the lesion more of the core is positive, but urologists think it is important -- more important than perineural invasion.<ref name=pmid15223967>{{cite journal |author=Rubin MA, Bismar TA, Curtis S, Montie JE |title=Prostate needle biopsy reporting: how are the surgical members of the Society of Urologic Oncology using pathology reports to guide treatment of prostate cancer patients? |journal=Am. J. Surg. Pathol. |volume=28 |issue=7 |pages=946–52 |year=2004 |month=July |pmid=15223967 |doi= |url=}}</ref> | *‡ "Percent area involved" may seem like an odd thing to request 'cause it is sampling dependent, i.e. if the radiologist sticks the biopsy needle deeper into the lesion more of the core is positive, but urologists think it is important -- more important than perineural invasion.<ref name=pmid15223967>{{cite journal |author=Rubin MA, Bismar TA, Curtis S, Montie JE |title=Prostate needle biopsy reporting: how are the surgical members of the Society of Urologic Oncology using pathology reports to guide treatment of prostate cancer patients? |journal=Am. J. Surg. Pathol. |volume=28 |issue=7 |pages=946–52 |year=2004 |month=July |pmid=15223967 |doi= |url=}}</ref> | ||
**There is disagreement on how one should measure patchy cancer (cancer when there is interspersed normal). Epstein believes one should include the interspersed benign if the cancer is patchy, as | **There is disagreement on how one should measure patchy cancer (cancer when there is interspersed normal). Epstein believes one should include the interspersed benign if the cancer is patchy, as the groupings of tumour likely join out of the plane of section.<ref name=pmid21788055>{{Cite journal | last1 = Epstein | first1 = JI. | title = Prognostic significance of tumor volume in radical prostatectomy and needle biopsy specimens. | journal = J Urol | volume = 186 | issue = 3 | pages = 790-7 | month = Sep | year = 2011 | doi = 10.1016/j.juro.2011.02.2695 | PMID = 21788055 }}</ref> | ||
**A review by Epstein on the topic of tumour volume suggests it does not have predictive value in multivariante analyses.<ref name=pmid21788055/> | **A review by Epstein on the topic of tumour volume suggests it does not have predictive value in multivariante analyses.<ref name=pmid21788055/> | ||
**The biopsy tumour volume is a predictor of Gleason score upgrading on prostatectomy.<ref name=pmid22688447>{{Cite journal | last1 = Fu | first1 = Q. | last2 = Moul | first2 = JW. | last3 = Bañez | first3 = LL. | last4 = Sun | first4 = L. | last5 = Mouraviev | first5 = V. | last6 = Xie | first6 = D. | last7 = Polascik | first7 = TJ. | title = Association between percentage of tumor involvement and Gleason score upgrading in low-risk prostate cancer. | journal = Med Oncol | volume = 29 | issue = 5 | pages = 3339-44 | month = Dec | year = 2012 | doi = 10.1007/s12032-012-0270-4 | PMID = 22688447 }}</ref> | **The biopsy tumour volume is a predictor of Gleason score upgrading on prostatectomy.<ref name=pmid22688447>{{Cite journal | last1 = Fu | first1 = Q. | last2 = Moul | first2 = JW. | last3 = Bañez | first3 = LL. | last4 = Sun | first4 = L. | last5 = Mouraviev | first5 = V. | last6 = Xie | first6 = D. | last7 = Polascik | first7 = TJ. | title = Association between percentage of tumor involvement and Gleason score upgrading in low-risk prostate cancer. | journal = Med Oncol | volume = 29 | issue = 5 | pages = 3339-44 | month = Dec | year = 2012 | doi = 10.1007/s12032-012-0270-4 | PMID = 22688447 }}</ref> | ||
| Line 685: | Line 605: | ||
- PERINEURAL INVASION PRESENT. | - PERINEURAL INVASION PRESENT. | ||
</pre> | </pre> | ||
=====Tumour summaries===== | |||
*These are not completely without controversy. | |||
*It should be noted that treatment is driven by the highest Gleason score.{{fact}} | |||
<pre> | <pre> | ||
| Line 707: | Line 631: | ||
</pre> | </pre> | ||
<pre> | |||
TUMOUR SUMMARY - PROSTATE CORE BIOPSIES: | |||
- HISTOLOGIC TYPE: ADENOCARCINOMA (ACINAR, NOT OTHERWISE SPECIFIED). | |||
- HIGHEST GLEASON SCORE: 8 (4+4). | |||
- SUMMARY GLEASON SCORE: 7 (4+3). | |||
- PERCENT OF TUMOUR WITH PATTERN 4: 55%. | |||
- PERCENT OF TUMOUR WITH PATTERN 5: 0%. | |||
- NUMBER OF CORES POSITIVE: 12. | |||
- TOTAL NUMBER OF CORES: 12. | |||
- TOTAL LINEAR MILLIMETERS OF NEEDLE CORE TISSUE: 178 MM. | |||
- PERCENT OF NEEDLE CORE TISSUE THAT IS TUMOUR: 80%. | |||
- PERINEURAL INVASION: PRESENT. | |||
- PERIPROSTATIC FAT INVASION: PRESENT. | |||
- LYMPHOVASCULAR INVASION: NOT IDENTIFIED. | |||
- SEMINAL VESICLE INVASION: NOT IDENTIFIED. | |||
</pre> | |||
=== | ===Seminal vesicle/ejaculatory duct invasion on biopsy=== | ||
<pre> | |||
COMMENT: | |||
The seminal vesicles and ejaculatory ducts have the same histology; thus, it is not | |||
usually possible to confidently differentiate them in a needle biopsy. | |||
SV/ED invasion was demonstrated with CK7, CK34betaE12/AMACR, PSA and p63 immunostaining. | |||
The tumour is PSA and AMACR positive. | |||
</pre> | |||
=== | =Intraductal spread of prostate cancer= | ||
==Intraductal carcinoma of the prostate== | |||
* | *[[AKA]] ''[[intraductal carcinoma]]''. | ||
* | *[[AKA]] ''intraductal prostate carcinoma''. | ||
{{Main|Intraductal carcinoma of the prostate}} | |||
=Unusual forms of prostate cancer= | =Unusual forms of prostate cancer= | ||
| Line 748: | Line 670: | ||
*[[AKA]] ''ductal adenocarcinoma of the prostate''. | *[[AKA]] ''ductal adenocarcinoma of the prostate''. | ||
*[[AKA]] ''prostatic adenocarcinoma, large duct type''. | *[[AKA]] ''prostatic adenocarcinoma, large duct type''. | ||
{{Main|Ductal adenocarcinoma of the prostate gland}} | |||
==PIN-like prostatic ductal adenocarcinoma== | ==PIN-like prostatic ductal adenocarcinoma== | ||
{{Main|High-grade prostatic intraepithelial neoplasia-like ductal adenocarcinoma of the prostate}} | |||
==Foamy gland carcinoma== | ==Foamy gland carcinoma== | ||
*[[AKA]] ''foamy gland adenocarcinoma'' | *[[AKA]] ''foamy gland adenocarcinoma''.<ref name=pmid19033862>{{Cite journal | last1 = Zhao | first1 = J. | last2 = Epstein | first2 = JI. | title = High-grade foamy gland prostatic adenocarcinoma on biopsy or transurethral resection: a morphologic study of 55 cases. | journal = Am J Surg Pathol | volume = 33 | issue = 4 | pages = 583-90 | month = Apr | year = 2009 | doi = 10.1097/PAS.0b013e31818a5c6c | PMID = 19033862 }}</ref> | ||
{{Main|Foamy gland carcinoma}} | |||
==Atrophic prostate carcinoma== | ==Atrophic prostate carcinoma== | ||
*[[AKA]] ''atrophic carcinoma''. | *[[AKA]] ''atrophic carcinoma''. | ||
{{Main|Atrophic prostate carcinoma}} | |||
==Mucinous prostate carcinoma== | ==Mucinous prostate carcinoma== | ||
{{Main|Mucinous adenocarcinoma of the prostate}} | |||
==Pseudohyperplastic prostatic adenocarcinoma== | ==Pseudohyperplastic prostatic adenocarcinoma== | ||
*[[AKA]] ''pseudohyperplastic adenocarcinoma''. | |||
* | {{Main|Pseudohyperplastic prostatic adenocarcinoma}} | ||
==Prostatic signet ring cell carcinoma== | ==Prostatic signet ring cell carcinoma== | ||
| Line 891: | Line 700: | ||
*Signet ring cells - see ''[[basics]]'' article. | *Signet ring cells - see ''[[basics]]'' article. | ||
DDx: | |||
* | *Acinar adenocarcinoma - Gleason pattern 4 with very small glands. | ||
== | ====Images==== | ||
*[[ | *[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2996149/figure/F1/ Prostatic SRCC (nih.gov)]. | ||
*[http://www.nature.com/modpathol/journal/v17/n3/fig_tab/3800052f7.html#figure-title Prostatic SRCC (nature.com)]. | |||
*[http://www.nature.com/modpathol/journal/v17/n3/fig_tab/3800052f8.html Prostatic SRCC (nature.com)]. | |||
*[http://www.webpathology.com/image.asp?case=23&n=34 Prostatic SRCC (webpathology.com)] - looks like ''acinar adenocarcinoma''. | |||
=== | ===Stains=== | ||
*Alcian blue-PAS stain +ve. | |||
* | *[[PAS stain|PAS]] -- 50% of cases +ve.<ref name=pmid21123640/> | ||
*[[Alcian blue stain|Alcian blue]] -- 44% of cases +ve.<ref name=pmid21123640/> | |||
* | |||
== | ==Sarcomatoid carcinoma of the prostate== | ||
{{Main|Sarcomatoid carcinoma of the prostate}} | |||
==Small cell carcinoma of the prostate gland== | ==Small cell carcinoma of the prostate gland== | ||
{{Main|Small cell carcinoma | {{Main|Small cell carcinoma of the prostate gland}} | ||
==Adenoid cystic/basal cell carcinoma of the prostate== | ==Adenoid cystic/basal cell carcinoma of the prostate== | ||
*Abbreviated ''ACBCC''. | *Abbreviated ''ACBCC''. | ||
{{Main|Adenoid cystic/basal cell carcinoma of the prostate}} | |||
== | ==Postradiation prostate cancer== | ||
{{Main|Postradiation prostate cancer}} | |||
=Metastatic disease and other cancers of the prostate= | =Metastatic disease and other cancers of the prostate= | ||
==Urothelial carcinoma== | ==Urothelial carcinoma== | ||
{{Main| | {{Main|Urothelial carcinoma of the urethra}} | ||
=See also= | =See also= | ||
| Line 996: | Line 739: | ||
[[Category:Genitourinary pathology]] | [[Category:Genitourinary pathology]] | ||
[[Category:Prostate carcinoma]] | |||