Prostate cancer staging
The article deals with prostate cancer staging. A general discussion about staging is found in cancer staging.
An introduction to prostate cancer is found in the prostate cancer article.
- Important for prognosis and treatment.
TNM staging system
|T2||confined to prostate||subdivision based on bilateral/unilateral involvement not predictive|
|T3a||extension into periprostatic soft tissue (see extraprostatic extension) or bladder neck invasion|
|T3b||extension into the muscle of the seminal vesicles (see seminal vesicle invasion)|
|T4||extension into a surrounding anatomical structure, e.g. urinary bladder||bladder neck invasion is T3b|
- Abbreviated EPE.
- Extraprostatic extension (EPE) is difficult to assess in prostatectomy specimens.
- The prostate does NOT have a well defined capsule.
- Intraobserver agreement for EPE is fair-moderate and lower than for the surgical margin.
- The prostate does NOT have a well defined capsule.
- EPE, typically, upstages tumours from T2x to T3a.
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.
- 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.
EPE is present in prostate biopsy if:
- Tumour touches adipose tissue.
Bladder neck invasion
- Defined as tumour within the thick muscle bundles of the bladder neck or at the bladder neck margin.
- Bladder neck invasion is pT3a.
- Seen in approximately 1% of prostatectomies.
- Bladder neck involvement can be seen without extraprostatic extension.
Seminal vesicle invasion
- Abbreviated SVI.
- Typically upstages to pT3b.
- 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%).
- 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.
- 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.
- SVI has been subdivided into three types by pattern of spread (type I: spread along ejaculatory duct complex and into SV, type II: through prostate capsule and then into SV; type III: discontinuous spread/metastasis).
- Lymph node metastases essentially never happen 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.
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