Difference between revisions of "Prostate cancer"

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Prostate cancer (view source)

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| Gross      = usu. posterior aspect of the prostate - often not apparent at gross
| Gross      = usu. posterior aspect of the prostate - often not apparent at gross
| Grossing  = [[prostate biopsy]], [[prostate chips]], [[radical prostatectomy]]
| Grossing  = [[prostate biopsy]], [[prostate chips]], [[radical prostatectomy]]
| Staging    = [[prostate cancer staging]]
| Site      = [[prostate gland]]
| Site      = [[prostate gland]]
| Assdx      =
| Assdx      =
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| 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]]
Line 82: 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 239: 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.


===Prostatic adenocarcinoma variants that mimic benign===
===Situations where prostate adenocarcinoma may be missed===
*[[Atrophic prostate carcinoma]].
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>:
*[[Pseudohyperplastic adenocarcinoma]].
*Tissue artefacts (try levels and/or IHC):
*[[Foamy gland adenocarcinoma]].
**Crush artefact
*[[PIN-like adenocarcinoma]].
**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)


===Gleason grading system===
===Prostate cancer grading===
*[[AKA]] ''modified Gleason grading system''.
{{Main|Prostate cancer grading}}
====Overview====
It covers the ''Gleason grading system'' and the (new) ''prognostic grade groupings''.
*This system is only one any one talks about and there is consensus on how it is done.<ref name=pmid16096414>{{Cite journal  | last1 = Epstein | first1 = JI. | last2 = Allsbrook | first2 = WC. | last3 = Amin | first3 = MB. | last4 = Egevad | first4 = LL. | title = The 2005 International Society of Urological Pathology (ISUP) Consensus Conference on Gleason Grading of Prostatic Carcinoma. | journal = Am J Surg Pathol | volume = 29 | issue = 9 | pages = 1228-42 | month = Sep | year = 2005 | doi =  | PMID = 16096414 }}</ref>
*Score range: 6-10.
**Technically 2-10... but almost no one uses 2-5.
*Reported on biopsy (and [[TURP]]) as: (primary pattern) + (highest non-primary pattern) = sum.
**''Gleason score 3+4=7'' means: pattern 3 is present and dominant, pattern 4 is the remainder of the tumour - but present in a lesser amount than pattern 3.
**''Gleason score 4+5=9'' means: pattern 4 is present and dominant, pattern 5 is present in a lesser amount that pattern 4. Pattern 3 may be present in a quantity less than pattern 4 or is absent.
*Reported as on prostatectomies as: (primary pattern) + (secondary pattern) = sum, (tertiary pattern)
 
*Tertiary Gleason pattern - definition: a pattern that is seen in less than 5% of the tumour (volume), that is higher grade than the two dominant patterns.<ref name=Ref_GUP72>{{Ref GUP|72}}</ref>
**The presence of a tertiary patterns adversely affect the prognosis; however, the prognosis is not as bad as when the tertiary pattern is the secondary pattern, i.e. 3+4 tertiary 5 has a better prognosis than 3+5 (with some small amount of pattern 4).<ref name=Ref_GUP72>{{Ref GUP|72}}</ref>
 
Testing yourself:
*There is a nice test-yourself quiz from Johns Hopkins: [http://162.129.103.34/prostate/ http://162.129.103.34/prostate/].
**It was studied in a paper by Kronz et al.<ref name=pmid11014569>{{Cite journal  | last1 = Kronz | first1 = JD. | last2 = Silberman | first2 = MA. | last3 = Allsbrook | first3 = WC. | last4 = Bastacky | first4 = SI. | last5 = Burks | first5 = RT. | last6 = Cina | first6 = SJ. | last7 = Mills | first7 = SE. | last8 = Ross | first8 = JS. | last9 = Sakr | first9 = WA. | last10 = Tomaszewski | first10 = JE. | last11 = True | first11 = LD. | last12 = Ulbright | first12 = TM. | last13 = Weinstein | first13 = MW. | last14 = Yantiss | first14 = RK. | last15 = Young | first15 = RH. | last16 = Epstein | first16 = JI. | title = Pathology residents' use of a Web-based tutorial to improve Gleason grading of prostate carcinoma on needle biopsies. | journal = Hum Pathol | volume = 31 | issue = 9 | pages = 1044-50 | month = Sep | year = 2000 | doi = 10.1053/hupa.2000.16278 | PMID = 11014569 }}</ref>
 
=====Examples=====
*A biopsy with 80% pattern 4, 16% pattern 3 and 4% pattern 5... would be reported as: 4+5=9.
*A biopsy with 92% pattern 4, and 8% pattern 3... would be reported as: 4+3=7.
*A biopsy with 98% pattern 4, and 2% pattern 3... would be reported as: 4+4=8.
*A prostatectomy with 80% pattern 4, 16% pattern 3 and 4% pattern 5... would be reported as: 4+3=7 with tertiary pattern 5.
 
====Grade groupings====
*[[AKA]] ''prognostic Gleason grade groupings''.
 
Proposed new system and old (modified) Gleason score:<ref name=jhu2014>URL: [http://urology.jhu.edu/newsletter/2014/prostate_cancer_2014_19.php http://urology.jhu.edu/newsletter/2014/prostate_cancer_2014_19.php]. Accessed on: 28 March 2015.</ref>
{| class="wikitable sortable"  style="margin-left:auto;margin-right:auto"
! Prognostic group
! Gleason score
|-
| I
| 3+3
|-
| II
| 3+4
|-
| III
| 4+3
|-
| IV
| 8 (4+4, 3+5, 5+3)
|-
| V
| 9 or 10 (4+5, 5+4, 5+5)
|}
 
Rationale:
*Patients won't be told they have a 6 out of 10 cancer, and then think it is an intermediate grade cancer that is worrisome. Instead, they will be told they have a 1 out of 5 cancer.<ref name=jhu2014>URL: [http://urology.jhu.edu/newsletter/2014/prostate_cancer_2014_19.php http://urology.jhu.edu/newsletter/2014/prostate_cancer_2014_19.php]. Accessed on: 28 March 2015.</ref>
 
====Gleason patterns (modified)====
=====Gleason pattern 1 & 2=====
*Use strongly discouraged by a number of GU pathology experts.
 
Notes:
*Gleason pattern 1 - probably represents what today would be called ''adenosis''.
**Should never be used.
*Gleason pattern 2 - used by few GU pathology experts occasionally.
**Generally, should '''not''' be diagnosed on core biopsies.<ref name=pmid20006878>{{Cite journal  | last1 = Epstein | first1 = JI. | title = An update of the Gleason grading system. | journal = J Urol | volume = 183 | issue = 2 | pages = 433-40 | month = Feb | year = 2010 | doi = 10.1016/j.juro.2009.10.046 | PMID = 20006878 }}</ref>
 
=====Gleason pattern 3=====
*Glands smaller than normal prostate glands + loss of epithelial folding.
*Can draw a line around each gland.
*May have ''gland branching''.
**Glands have a X, U, V or Y shape.
 
Notes:
*Gland lumina should be seen.
*All ''cribriform'' is now, generally, classified as Gleason pattern 4.<ref name=pmid20006878>{{cite journal |author=Epstein JI |title=An update of the Gleason grading system |journal=J. Urol. |volume=183 |issue=2 |pages=433–40 |year=2010 |month=February |pmid=20006878 |doi=10.1016/j.juro.2009.10.046 |url=}}</ref>
 
=====Gleason pattern 4=====
*Loss of gland lumina.
*Gland fusion.
*Benign looking cords ('hypernephroid pattern').
*Cribriform.
*Glomeruloid pattern - resembles a glomerulus.
 
Notes:
*One gland is not enough to call Gleason 4.
 
======Images======
<gallery>
Image:Prostate_cancer_with_Gleason_pattern_4_low_mag.jpg | Gleason pattern 4 - cribriform. (WC)
Image:Gleason_4_and_5_intermed_mag.jpg | Gleason pattern 4 - small glands & Gleason pattern 5 - single cells. (WC)
</gallery>
www:
*[http://www.nature.com/modpathol/journal/v17/n3/fig_tab/3800050f9.html#figure-title Glomeruloid pattern (nature.com)].
 
=====Gleason pattern 5=====
*Sheets.
**Must be differentiated from [[intraductal carcinoma of the prostate|intraductal growth]] (which like in the breast are well circumscribed nests).
*Single cells.
**May be confused with stromal/lymphocytic infiltration.
***Look for nucleoli, cells should be round (prostatic stroma cells are spindle cells).
*Cords (strands).
**Line of cells.
**Should not be intermixed with clumps of cells (pattern 4).
*Nests of cells with [[necrosis]] (at the centre) (comedonecrosis) ''or'' (intraluminal) necrosis in a cribriform pattern.<ref name=pmid16096414/>
**Necrosis:
***Nuclear changes:
****Karyorrhexis (nuclear fragmentation).
****Pynosis (nuclear shrinkage).
****Karyolysis (nuclear dissolution).
***Cell ghosts (cells without a nucleus).
 
Notes:
*Pattern 5 may be under-diagnosed.
*Single cells is the most commonly missed pattern.<ref name=pmid21997691>{{Cite journal  | last1 = Fajardo | first1 = DA. | last2 = Miyamoto | first2 = H. | last3 = Miller | first3 = JS. | last4 = Lee | first4 = TK. | last5 = Epstein | first5 = JI. | title = Identification of Gleason pattern 5 on prostatic needle core biopsy: frequency of underdiagnosis and relation to morphology. | journal = Am J Surg Pathol | volume = 35 | issue = 11 | pages = 1706-11 | month = Nov | year = 2011 | doi = 10.1097/PAS.0b013e318228571d | PMID = 21997691 }}
</ref>
 
======Images======
<gallery>
Image:Gleason_4_and_5_intermed_mag.jpg | Gleason pattern 4 - small glands (left) & Gleason pattern 5 - single cells (right). (WC)
</gallery>
www:
*[http://www.webpathology.com/image.asp?n=17&Case=20 Gleason pattern 5 - sheeting (webpathology.com)].
 
====Special types====
Special types of prostate cancer have suggested Gleason patterns:<ref name=pmid14976541>{{cite journal |author=Grignon DJ |title=Unusual subtypes of prostate cancer |journal=Mod. Pathol. |volume=17 |issue=3 |pages=316–27 |year=2004 |month=March |pmid=14976541 |doi=10.1038/modpathol.3800052 |url=}}</ref>
{| class="wikitable sortable"  style="margin-left:auto;margin-right:auto"
! Special type
! Gleason pattern
! Comment
|-
|Ductal carcinoma
| 4
| may be graded 3 or 5<ref name=bostwicklabs>URL: [https://www.bostwicklaboratories.com/global/physicians/medical-library/articles/gleason-grading.aspx https://www.bostwicklaboratories.com/global/physicians/medical-library/articles/gleason-grading.aspx]. Accessed on: 26 November 2011.</ref>
|-
|Mucinous carcinoma
| 3 or 4 - dependent on morphology<ref name=pmid18487999>{{Cite journal  | last1 = Osunkoya | first1 = AO. | last2 = Adsay | first2 = NV. | last3 = Cohen | first3 = C. | last4 = Epstein | first4 = JI. | last5 = Smith | first5 = SL. | title = MUC2 expression in primary mucinous and nonmucinous adenocarcinoma of the prostate: an analysis of 50 cases on radical prostatectomy. | journal = Mod Pathol | volume = 21 | issue = 7 | pages = 789-94 | month = Jul | year = 2008 | doi = 10.1038/modpathol.2008.47 | PMID = 18487999 }}</ref><ref name=pmid18300802>{{Cite journal  | last1 = Osunkoya | first1 = AO. | last2 = Nielsen | first2 = ME. | last3 = Epstein | first3 = JI. | title = Prognosis of mucinous adenocarcinoma of the prostate treated by radical prostatectomy: a study of 47 cases. | journal = Am J Surg Pathol | volume = 32 | issue = 3 | pages = 468-72 | month = Mar | year = 2008 | doi = 10.1097/PAS.0b013e3181589f72 | PMID = 18300802 }}</ref>
| some advocate grade 4<ref name=pmid14976541/>
|-
|Sarcomatoid carcinoma
| 5
| glands graded separately
|-
|Signet ring cell carcinoma
| 5
|
|-
|Small cell carcinoma
| not graded (ISUP 2005 consensus<ref name=pmid16096414>{{Cite journal  | last1 = Epstein | first1 = JI. | last2 = Allsbrook | first2 = WC. | last3 = Amin | first3 = MB. | last4 = Egevad | first4 = LL. | title = The 2005 International Society of Urological Pathology (ISUP) Consensus Conference on Gleason Grading of Prostatic Carcinoma. | journal = Am J Surg Pathol | volume = 29 | issue = 9 | pages = 1228-42 | month = Sep | year = 2005 | doi =  | PMID = 16096414 }}</ref>)
| may be graded 5<ref name=bostwicklabs/>
|-
|[[Adenosquamous carcinoma|Adenosquamous]] and [[squamous carcinoma]]
| not graded
|
|-
|[[Lymphoepithelioma-like carcinoma]]
| not graded
|
|-
|[[Adenoid cystic carcinoma]]
| not graded
|
|-
|[[Urothelial carcinoma]]
| not graded
|
|-
|Undifferentiated carcinoma, NOS
| not graded
|
|}
 
How to remember the ones that aren't graded - think of '''Ur''' '''L'''ung carcinomas ('''Ur'''othelial carcinoma, '''L'''ymphoepithelioma-like carcinoma):
*Small cell carcinoma.
*Squamous cell carcinoma.
*Adenosquamous carcinoma.
*Adenoid cystic carcinoma.
 
====Biopsy-prostatectomy concordance of Gleason score====
*Discordance is common.
**Upgrade on prostatectomy: 25-40%.
**Downgrade on prostatectomy: 5-15%.
 
Selected studies on concordance:
{| class="wikitable sortable"  style="margin-left:auto;margin-right:auto"
! Study
! Upgrade
! Downgrade
! Notes
|-
| Sfoungaristos et al.<ref name=pmid22277633>{{Cite journal  | last1 = Sfoungaristos | first1 = S. | last2 = Perimenis | first2 = P. | title = Clinical and pathological variables that predict changes in tumour grade after radical prostatectomy in patients with prostate cancer. | journal = Can Urol Assoc J | volume =  | issue =  | pages = 1-5 | month = Jan | year = 2012 | doi = 10.5489/cuaj.11067 | PMID = 22277633 }}</ref>
| 42.1%
| 13.7%
| high volume of tumour predicts upgrade
|-
| Thomas et al.<ref name=pmid21592293>{{Cite journal  | last1 = Thomas | first1 = C. | last2 = Pfirrmann | first2 = K. | last3 = Pieles | first3 = F. | last4 = Bogumil | first4 = A. | last5 = Gillitzer | first5 = R. | last6 = Wiesner | first6 = C. | last7 = Thüroff | first7 = JW. | last8 = Melchior | first8 = SW. | title = Predictors for clinically relevant Gleason score upgrade in patients undergoing radical prostatectomy. | journal = BJU Int | volume = 109 | issue = 2 | pages = 214-9 | month = Jan | year = 2012 | doi = 10.1111/j.1464-410X.2011.10187.x | PMID = 21592293 }}</ref>
| 38.1%
| 4.7%
|
|-
| Truesdale et al.<ref name=pmid20840549>{{Cite journal  | last1 = Truesdale | first1 = MD. | last2 = Cheetham | first2 = PJ. | last3 = Turk | first3 = AT. | last4 = Sartori | first4 = S. | last5 = Hruby | first5 = GW. | last6 = Dinneen | first6 = EP. | last7 = Benson | first7 = MC. | last8 = Badani | first8 = KK. | title = Gleason score concordance on biopsy-confirmed prostate cancer: is pathological re-evaluation necessary prior to radical prostatectomy? | journal = BJU Int | volume = 107 | issue = 5 | pages = 749-54 | month = Mar | year = 2011 | doi = 10.1111/j.1464-410X.2010.09570.x | PMID = 20840549 }}</ref>
| 23%
| 11%
|
|}
 
=====Sign out=====
=====Upgrading=====
<pre>
Gleason score upgrading on prostatectomy is considered relatively common; it is reported
to occur in 23% to 42.1% of cases.[1][2]
 
1. BJU Int. 2011 107 (5): 749-54.
2. Can Urol Assoc J. 2012 Jan 24:1-5.
</pre>
 
=====Downgrading=====
<pre>
Gleason score downgrading on prostatectomy is considered uncommon; however, it is reported
in 4.7% to 13.7% of cases.[1][2]
 
1. BJU Int. 2012 Jan; 109(2):214-9.
2. Can Urol Assoc J. 2012 Jan; 24;1-5.
</pre>
 
=====Order of Gleason score components changed=====
<pre>
COMMENT:
The change in the order of the Gleason score components (3+4 on prostatectomy
versus 4+3 on core biopsy) may be explained by sampling.
</pre>


===Staging parameters, margins and more===
===Staging parameters, margins and more===
====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 497: Line 289:


=====Bladder neck margin=====
=====Bladder neck margin=====
{{Main|Bladder neck invasion}}
:[[AKA]] ''invasion of the bladder neck''.<ref name=pmid19914651/>
:[[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>
*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>
*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}}
=====General=====
*Extraprostatic extension (EPE) is difficult to assess in prostatectomy specimens.<ref name=pmid20802467>{{Cite journal  | last1 = Magi-Galluzzi | first1 = C. | last2 = Evans | first2 = AJ. | last3 = Delahunt | first3 = B. | last4 = Epstein | first4 = JI. | last5 = Griffiths | first5 = DF. | last6 = van der Kwast | first6 = TH. | last7 = Montironi | first7 = R. | last8 = Wheeler | first8 = TM. | last9 = Srigley | first9 = JR. | title = International Society of Urological Pathology (ISUP) Consensus Conference on Handling and Staging of Radical Prostatectomy Specimens. Working group 3: extraprostatic extension, lymphovascular invasion and locally advanced disease. | journal = Mod Pathol | volume = 24 | issue = 1 | pages = 26-38 | month = Jan | year = 2011 | doi = 10.1038/modpathol.2010.158 | PMID = 20802467 }}</ref>
**The prostate does NOT have a well defined capsule.
***Intraobserver agreement for EPE is fair-moderate and lower than for the surgical margin.<ref name=pmid18708939>{{Cite journal  | last1 = Evans | first1 = AJ. | last2 = Henry | first2 = PC. | last3 = Van der Kwast | first3 = TH. | last4 = Tkachuk | first4 = DC. | last5 = Watson | first5 = K. | last6 = Lockwood | first6 = GA. | last7 = Fleshner | first7 = NE. | last8 = Cheung | first8 = C. | last9 = Belanger | first9 = EC. | last10 = Amin | first10 = MB. | last11 = Boccon-Gibod | first11 = L. | last12 = Bostwick | first12 = DG. | last13 = Egevad | first13 = L. | last14 = Epstein | first14 = JI. | last15 = Grignon | first15 = DJ. | last16 = Jones | first16 = EC. | last17 = Montironi | first17 = R. | last18 = Moussa | first18 = M. | last19 = Sweet | first19 = JM. | last20 = Trpkov | first20 = K. | last21 = Wheeler | first21 = TM. | last22 = Srigley | first22 = JR. | title = Interobserver variability between expert urologic pathologists for extraprostatic extension and surgical margin status in radical prostatectomy specimens. | journal = Am J Surg Pathol | volume = 32 | issue = 10 | pages = 1503-12 | month = Oct | year = 2008 | doi = 10.1097/PAS.0b013e31817fb3a0 | PMID = 18708939 }}</ref>
*EPE, typically, upstages tumours from T2x to T3a.
 
=====Prostatectomy specimens=====
EPE is present in a prostatectomy if there is either:
#A "significant bulge" in the contour of the prostate at low power ''and'' no fibromuscular tissue surrounding the malignant cells.
#Malignant cells directly adjacent to peri-prostatic adipose tissue.
 
Note:
*The apex of the prostate gland may have some skeletal muscle. Thus, it is difficult to define extension at this site. EPE is not called at the apex by some pathologists; however, it is generally believed to exist.<ref name=pmid20802467/>
 
=====Prostate biopsy=====
EPE is present in prostate biopsy if:
*Tumour touches adipose tissue.<ref name=pmid17707261>{{Cite journal  | last1 = Epstein | first1 = JI. | last2 = Srigley | first2 = J. | last3 = Grignon | first3 = D. | last4 = Humphrey | first4 = P. | title = Recommendations for the reporting of prostate carcinoma. | journal = Hum Pathol | volume = 38 | issue = 9 | pages = 1305-9 | month = Sep | year = 2007 | doi = 10.1016/j.humpath.2007.05.015 | PMID = 17707261 }}</ref>
 
======Images======
<gallery>
Image: Prostate carcinoma with extraprostatic extension -- intermed mag.jpg | EPE - intermed. mag.
Image: Prostate carcinoma with extraprostatic extension -- high mag.jpg | EPE - high mag.
</gallery>


====Seminal vesicle invasion====
====Seminal vesicle invasion====
:Abbreviated ''SVI''.
:Abbreviated ''SVI''.
General:
{{Main|Prostate cancer staging#Seminal vesicle invasion}}
*Typically upstages to pT3b.
*Associations:<ref name=pmid23194127>{{Cite journal  | last1 = Sapre | first1 = N. | last2 = Pedersen | first2 = J. | last3 = Hong | first3 = MK. | last4 = Harewood | first4 = L. | last5 = Peters | first5 = J. | last6 = Costello | first6 = AJ. | last7 = Hovens | first7 = CM. | last8 = Corcoran | first8 = NM. | title = Re-evaluating the biological significance of seminal vesicle invasion (SVI) in locally advanced prostate cancer. | journal = BJU Int | volume = 110 Suppl 4 | issue =  | pages = 58-63 | month = Dec | year = 2012 | doi = 10.1111/j.1464-410X.2012.11477.x | PMID = 23194127 }}</ref>
**Most SVI is by direct extension ~90%.
**Approximately 20% of patients with pT3x have SVI.
**Usually associated with a large tumour volume (22% versus 12%).
 
Microscopic:
*Tumour '''must''' be in the muscle surrounding the epithelial component; tumour in the adventitia (the loose connective tissue surrounding the seminal vesicles) does not count.<ref name=Ref_Lester3_409>{{Ref Lester3|409}}</ref><ref name=pmid20818343>{{Cite journal  | last1 = Berney | first1 = DM. | last2 = Wheeler | first2 = TM. | last3 = Grignon | first3 = DJ. | last4 = Epstein | first4 = JI. | last5 = Griffiths | first5 = DF. | last6 = Humphrey | first6 = PA. | last7 = van der Kwast | first7 = T. | last8 = Montironi | first8 = R. | last9 = Delahunt | first9 = B. | title = International Society of Urological Pathology (ISUP) Consensus Conference on Handling and Staging of Radical Prostatectomy Specimens. Working group 4: seminal vesicles and lymph nodes. | journal = Mod Pathol | volume = 24 | issue = 1 | pages = 39-47 | month = Jan | year = 2011 | doi = 10.1038/modpathol.2010.160 | PMID = 20818343 }}</ref>
 
Notes:
*Invasion of the adventitia (only) would quality as EPE; this is, usually, T3a.
*Immunostains useful to separate prostate carcinoma from [[SV]] are discussed in the ''[[seminal vesicle]]'' article.
*It is not possible to differentiate the ''seminal vesicles'' and ''ejaculatory ducts'' based only on histology; thus, on biopsy one can generally comment only on ''seminal vesicle/ejaculatory duct invasion''.
 
====Lymph node metastases====
{{Main|Lymph node metastasis}}
*Essentially never happens in Gleason score 6 cancers.
**A study of over 14,000 Gleason score <=6 cases found 22 cases with lymph node metastases -- all of the 19 cases available for review were determined to have a higher Gleason score and some Gleason pattern 4 or 5.<ref name=pmid22531173>{{Cite journal  | last1 = Ross | first1 = HM. | last2 = Kryvenko | first2 = ON. | last3 = Cowan | first3 = JE. | last4 = Simko | first4 = JP. | last5 = Wheeler | first5 = TM. | last6 = Epstein | first6 = JI. | title = Do adenocarcinomas of the prostate with Gleason score (GS) ≤6 have the potential to metastasize to lymph nodes? | journal = Am J Surg Pathol | volume = 36 | issue = 9 | pages = 1346-52 | month = Sep | year = 2012 | doi = 10.1097/PAS.0b013e3182556dcd | PMID = 22531173 }}</ref>


====Perineural invasion====
====Perineural invasion====
Line 568: Line 320:
===Prostate markers===
===Prostate markers===
*[[PSA]] (prostate specific antigen) +ve.  
*[[PSA]] (prostate specific antigen) +ve.  
*PSAP (prostatic specific acid phosphatase) +ve. †
*[[PSAP]] (prostatic specific acid phosphatase) +ve. †
*P501S +ve. ‡
*P501S +ve. ‡
*[[NKX3.1]] +ve. ‡
*[[NKX3.1]] +ve. ‡
Line 644: 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 896: 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''.
===General===
{{Main|Ductal adenocarcinoma of the prostate gland}}
*Sometimes it is referred to as ''endometrioid'' or ''endometrial'' adenocarcinoma; both terms are discouraged.<ref name=pmid18773743>{{Cite journal  | last1 = Samaratunga | first1 = H. | last2 = Delahunt | first2 = B. | title = Ductal adenocarcinoma of the prostate: current opinion and controversies. | journal = Anal Quant Cytol Histol | volume = 30 | issue = 4 | pages = 237-46 | month = Aug | year = 2008 | doi =  | PMID = 18773743 }}</ref>
*Not completely uncontroversial - may represent ''acinar adenocarcinoma'' with periurethral ducts involvement.<ref name=pmid10403300>{{Cite journal  | last1 = Bock | first1 = BJ. | last2 = Bostwick | first2 = DG. | title = Does prostatic ductal adenocarcinoma exist? | journal = Am J Surg Pathol | volume = 23 | issue = 7 | pages = 781-5 | month = Jul | year = 1999 | doi =  | PMID = 10403300 }}</ref>
*More aggressive than conventional (acinar) prostate carcinoma.
 
===Microscopic===
Features:<ref name=Ref_GUP88>{{Ref GUP|88}}</ref>
#Pseudostratified (crowded appearing) columnar (or cigar-shaped) nuclei - '''key feature'''.
#*Vaguely resembles [[colonic adenocarcinoma]].
#Compatible architecture:
#*Papillary.
#*Cribriform.
#*Single gland (large glands).
#*Endometrioid - vaguely looks like [[endometrioid endometrial carcinoma]] (with back-to-back glands).
#>= 50% of tumour.<ref name=pmid21383610/> ‡‡
#*If ductal component <50%, it is a conventional (acinar) adenocarcinoma with a ductal component.
 
Notes:
*Proportion of ductal component should be quantified:
**<10% ductal component of no prognostic significance.<ref name=pmid21383610>{{Cite journal  | last1 = Amin | first1 = A. | last2 = Epstein | first2 = JI. | title = Pathologic stage of prostatic ductal adenocarcinoma at radical prostatectomy: effect of percentage of the ductal component and associated grade of acinar adenocarcinoma. | journal = Am J Surg Pathol | volume = 35 | issue = 4 | pages = 615-9 | month = Apr | year = 2011 | doi = 10.1097/PAS.0b013e31820eb25b | PMID = 21383610 }}</ref>
*‡‡ ''Mahul Amin'' advocates that >=80% should be ductal morphology to call ''ductal adenocarcinoma''.<ref>{{Ref Amin|3-102}}</ref>
Images:
*[http://path.upmc.edu/cases/case203.html Prostatic ductal adenocarcinoma - several images (upmc.edu)].
*[http://path.upmc.edu/cases/case711.html Prostatic ductal adenocarcinoma - another case - several images (upmc.edu)].
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3024288/figure/F1/ Prostatic ductal adenocarcinoma - F1 (nih.gov)].
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3024288/figure/F2/ Prostatic ductal adenocarcinoma - F2 (nih.gov)].
*[http://www.webpathology.com/image.asp?case=23&n=6 Prostatic ductal adenocarcinoma (webpathology.com)].
*[http://www.webpathology.com/image.asp?n=7&Case=23 Prostatic ductal adenocarcinoma (webpathology.com)].
 
===IHC===
Features:<ref name=pmid22583364>{{Cite journal  | last1 = Tarján | first1 = M. | last2 = Lenngren | first2 = A. | last3 = Hellberg | first3 = D. | last4 = Tot | first4 = T. | title = Immunohistochemical verification of ductal differentiation in prostate cancer. | journal = APMIS | volume = 120 | issue = 6 | pages = 510-8 | month = Jun | year = 2012 | doi = 10.1111/j.1600-0463.2011.02862.x | PMID = 22583364 }}</ref>
*p53 +ve in ~ 75% of cases.
*Ki-67 high in ~ 70% of cases.
*Chromogranin A +ve (cytoplasm) in ~ 70% of cases.
 
Others:<ref name=pmid20368883>{{Cite journal  | last1 = Kumar | first1 = A. | last2 = Mukherjee | first2 = SD. | title = Metastatic ductal carcinoma of the prostate: a rare variant responding to a common treatment. | journal = Can Urol Assoc J | volume = 4 | issue = 2 | pages = E50-4 | month = Apr | year = 2010 | doi =  | PMID = 20368883 }}</ref>
*PSA +ve.


==PIN-like prostatic ductal adenocarcinoma==
==PIN-like prostatic ductal adenocarcinoma==
===General===
{{Main|High-grade prostatic intraepithelial neoplasia-like ductal adenocarcinoma of the prostate}}
*Recently described.<ref name=pmid16607376>{{Cite journal  | last1 = Hameed | first1 = O. | last2 = Humphrey | first2 = PA. | title = Stratified epithelium in prostatic adenocarcinoma: a mimic of high-grade prostatic intraepithelial neoplasia. | journal = Mod Pathol | volume = 19 | issue = 7 | pages = 899-906 | month = Jul | year = 2006 | doi = 10.1038/modpathol.3800601 | PMID = 16607376 }}</ref><ref name=pmid20438402>{{Cite journal  | last1 = Lee | first1 = TK. | last2 = Miller | first2 = JS. | last3 = Epstein | first3 = JI. | title = Rare histological patterns of prostatic ductal adenocarcinoma. | journal = Pathology | volume = 42 | issue = 4 | pages = 319-24 | month = Jun | year = 2010 | doi = 10.3109/00313021003767314 | PMID = 20438402 }}</ref>
*May be confused with [[prostatic intraepithelial neoplasia]] (PIN).
 
===Microscopic===
Features:<ref name=pmid16607376>{{Cite journal  | last1 = Hameed | first1 = O. | last2 = Humphrey | first2 = PA. | title = Stratified epithelium in prostatic adenocarcinoma: a mimic of high-grade prostatic intraepithelial neoplasia. | journal = Mod Pathol | volume = 19 | issue = 7 | pages = 899-906 | month = Jul | year = 2006 | doi = 10.1038/modpathol.3800601 | PMID = 16607376 }}</ref>
*Stratified malignant epithelium.
 
Note:
*Vaguely similar to a tubular adenoma of the colon.
 
DDx:
*[[HGPIN]].
 
Image:
*[http://www.nature.com/modpathol/journal/v19/n7/fig_tab/3800601f1.html#figure-title PIN-like adenocarcinoma (nature.com)].


==Foamy gland carcinoma==
==Foamy gland carcinoma==
Line 961: Line 684:


==Mucinous prostate carcinoma==
==Mucinous prostate carcinoma==
===General===
{{Main|Mucinous adenocarcinoma of the prostate}}
*Rare.
*Most often Gleason 3+4 ~ 80% in one series of 47 cases.<ref name=pmid18300802>{{Cite journal  | last1 = Osunkoya | first1 = AO. | last2 = Nielsen | first2 = ME. | last3 = Epstein | first3 = JI. | title = Prognosis of mucinous adenocarcinoma of the prostate treated by radical prostatectomy: a study of 47 cases. | journal = Am J Surg Pathol | volume = 32 | issue = 3 | pages = 468-72 | month = Mar | year = 2008 | doi = 10.1097/PAS.0b013e3181589f72 | PMID = 18300802 }}</ref>
 
Gleason pattern:
*In the past, it has been suggested that the mucinous component be assigned ''Gleason pattern 4''.<ref name=pmid14976541>{{cite journal |author=Grignon DJ |title=Unusual subtypes of prostate cancer |journal=Mod. Pathol. |volume=17 |issue=3 |pages=316–27 |year=2004 |month=March |pmid=14976541 |doi=10.1038/modpathol.3800052 |url=}}</ref>
*The prognosis is similar or may be better than the conventional type of prostate cancer in a large series;<ref name=pmid18300802/> thus, it seems reasonable to grade based on the pattern (as advocated by some experts<ref name=pmid18487999>{{Cite journal  | last1 = Osunkoya | first1 = AO. | last2 = Adsay | first2 = NV. | last3 = Cohen | first3 = C. | last4 = Epstein | first4 = JI. | last5 = Smith | first5 = SL. | title = MUC2 expression in primary mucinous and nonmucinous adenocarcinoma of the prostate: an analysis of 50 cases on radical prostatectomy. | journal = Mod Pathol | volume = 21 | issue = 7 | pages = 789-94 | month = Jul | year = 2008 | doi = 10.1038/modpathol.2008.47 | PMID = 18487999 }}</ref>).
 
===Microscopic===
Features:
*Cytologically malignant cells floating in mucin.
*> 25% of tumour mucinous.<ref name=pmid14976541>{{cite journal |author=Grignon DJ |title=Unusual subtypes of prostate cancer |journal=Mod. Pathol. |volume=17 |issue=3 |pages=316–27 |year=2004 |month=March |pmid=14976541 |doi=10.1038/modpathol.3800052 |url=}}</ref>
**Two studies suggests '''>=''' 25%.<ref>{{cite journal |author=Osunkoya AO, Nielsen ME, Epstein JI |title=Prognosis of mucinous adenocarcinoma of the prostate treated by radical prostatectomy: a study of 47 cases |journal=Am. J. Surg. Pathol. |volume=32 |issue=3 |pages=468–72 |year=2008 |month=March |pmid=18300802 |doi=10.1097/PAS.0b013e3181589f72 |url=}}</ref><ref name=pmid23060063>{{Cite journal  | last1 = Bohman | first1 = KD. | last2 = Osunkoya | first2 = AO. | title = Mucin-producing tumors and tumor-like lesions involving the prostate: a comprehensive review. | journal = Adv Anat Pathol | volume = 19 | issue = 6 | pages = 374-87 | month = Nov | year = 2012 | doi = 10.1097/PAP.0b013e318271a361 | PMID = 23060063 }}</ref>
 
Notes:
*[[Mucinous carcinoma]] - percentage required to call varies by site.
 
DDx:
*Metastatic [[mucinous carcinoma]].
*Mucinous adenocarcinoma of the prostatic urethra - analogous to the mucinous adenocarcinoma of the [[urinary bladder]].<ref name=pmid23060063/>


==Pseudohyperplastic prostatic adenocarcinoma==
==Pseudohyperplastic prostatic adenocarcinoma==
Line 1,014: Line 718:


==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}}
===General===
*Very rare.<ref name=pmid22110988>{{Cite journal  | last1 = Furtado | first1 = P. | last2 = Lima | first2 = MV. | last3 = Nogueira | first3 = C. | last4 = Franco | first4 = M. | last5 = Tavora | first5 = F. | title = Review of small cell carcinomas of the prostate. | journal = Prostate Cancer | volume = 2011 | issue =  | pages = 543272 | month =  | year = 2011 | doi = 10.1155/2011/543272 | PMID = 22110988 }}</ref>
*Most common small cell carcinoma outside of the lung.<ref name=pmid22110988/>
*Poor prognosis.
*Not graded (ISUP 2005 consensus on [[Gleason score]]<ref name=pmid16096414>{{Cite journal  | last1 = Epstein | first1 = JI. | last2 = Allsbrook | first2 = WC. | last3 = Amin | first3 = MB. | last4 = Egevad | first4 = LL. | title = The 2005 International Society of Urological Pathology (ISUP) Consensus Conference on Gleason Grading of Prostatic Carcinoma. | journal = Am J Surg Pathol | volume = 29 | issue = 9 | pages = 1228-42 | month = Sep | year = 2005 | doi =  | PMID = 16096414 }}</ref>).
 
===Microscopic===
Features:
*Small cells with:
**Nuclear moulding.
**Stippled chromatin.
**High [[NC ratio]].
*+/-High-grade acinar adenocarcinoma, i.e. conventional prostate carcinoma, seen in ~50% of cases.<ref name=pmid22110988/>
 
Notes:
*Similar to [[small cell carcinoma of the lung]].
*High-grade squamoid component favours metastatic [[urothelial carcinoma]].
**UCC usu. HWCK +ve.
 
DDx:
*[[Small cell carcinoma of the urinary bladder]].
*[[Lymphoma]], large cell.
*Other [[small round cell tumours]].
 
====Images====
*[http://www.webpathology.com/image.asp?case=23&n=25 SmCC of the prostate - low mag. (webpathology.com)].
*[http://www.webpathology.com/image.asp?case=23&n=26 SmCC of the prostate - high mag. (webpathology.com)].
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3200299/figure/fig1/ SmCC of the prostate - low mag. (nih.gov)].
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3200299/figure/fig3/ SmCC of the prostate - high mag. (nih.gov)].
 
===IHC===
Features:<ref name=pmid22110988/>
*PSA weak +ve/-ve.
*Chromogranin +ve.


==Adenoid cystic/basal cell carcinoma of the prostate==
==Adenoid cystic/basal cell carcinoma of the prostate==
Line 1,059: Line 729:
=Metastatic disease and other cancers of the prostate=
=Metastatic disease and other cancers of the prostate=
==Urothelial carcinoma==
==Urothelial carcinoma==
{{Main|Urothelial carcinoma}} {{Main|Urothelium}}
{{Main|Urothelial carcinoma of the urethra}}
:''Prostatic urothelial carcinoma'' redirects here.
===General===
*Spreads from the [[urinary bladder]] usually - common.<ref name=pmid22520044>{{Cite journal  | last1 = Huguet | first1 = J. | title = [Prostatic involvement by urothelial carcinoma in patients with bladder cancer and their implications in the clinical practice]. | journal = Actas Urol Esp | volume = 36 | issue = 9 | pages = 545-53 | month = Oct | year = 2012 | doi = 10.1016/j.acuro.2012.02.005 | PMID = 22520044 }}</ref>
*Identified by endoscopic loop biopsy.<ref name=pmid17338657>{{Cite journal  | last1 = Liedberg | first1 = F. | last2 = Chebil | first2 = G. | last3 = Månsson | first3 = W. | title = Urothelial carcinoma in the prostatic urethra and prostate: current controversies. | journal = Expert Rev Anticancer Ther | volume = 7 | issue = 3 | pages = 383-90 | month = Mar | year = 2007 | doi = 10.1586/14737140.7.3.383 | PMID = 17338657 }}</ref>
 
Treatment:<ref name=pmid17338657/>
*[[Cystoprostatectomy]] - stromal invasion ''or'' extensive intraductal involvement.
*Endoscopic resection and BCG - limited extent without stromal invasion.
 
===Microscopic===
Features:
*Divided into tumours with:
*#Stromal invasion.
*#Without stromal invasion.
 
Notes:
*Stromal involvement common ~ 75% of cases.<ref name=pmid23250619>{{Cite journal  | last1 = Ichihara | first1 = K. | last2 = Masumori | first2 = N. | last3 = Kitamura | first3 = H. | last4 = Hasegawa | first4 = T. | last5 = Tsukamoto | first5 = T. | title = Clinical outcomes of urothelial carcinoma of the prostate detected in radical cystectomy specimens. | journal = Int J Clin Oncol | volume =  | issue =  | pages =  | month = Dec | year = 2012 | doi = 10.1007/s10147-012-0508-3 | PMID = 23250619 }}</ref>
 
====Images====
<gallery>
Image: Urothelial carcinoma in prostate -- low mag.jpg | UCC in prostate - low mag. (WC/Nephron)
Image: Urothelial carcinoma in prostate -- intermed mag.jpg | UCC in prostate - intermed. mag. (WC/Nephron)
Image: Urothelial carcinoma in prostate -- high mag.jpg | UCC in prostate - high mag. (WC/Nephron)
Image: Urothelial carcinoma in prostate - alt -- high mag.jpg | UCC in prostate - high mag. (WC/Nephron)
 
Image: Urothelial carcinoma in prostate - portrait -- intermed mag.jpg | UCC in prostate - intermed. mag. (WC/Nephron)
Image: Urothelial carcinoma in prostate - portrait -- high mag.jpg | UCC in prostate - high mag. (WC/Nephron)
Image: Urothelial carcinoma in prostate - portrait -- very high mag.jpg | UCC in prostate - very high mag. (WC/Nephron)
 
Image: Urothelial carcinoma in prostate - 2 -- intermed mag.jpg | UCC in prostate - intermed. mag. (WC/Nephron)
Image: Urothelial carcinoma in prostate - 2 -- high mag.jpg | UCC in prostate - high mag. (WC/Nephron)
Image: Urothelial carcinoma in prostate - 2 -- very high mag.jpg | UCC in prostate - very high mag. (WC/Nephron)
</gallery>
 
===Sign out===
<pre>
PROSTATE TISSUE, TRANSURETHRAL RESECTION:
- HIGH-GRADE UROTHELIAL CARCINOMA WITH FOCAL STROMAL INVASION, AND EXTENSIVE
  INTRADUCTAL SPREAD IN FRAGMENTS WITH BENIGN PROSTATIC GLANDS.
</pre>


=See also=
=See also=
Michael
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