Prostate Pathology
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Prostate Pathology

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Prostate Pathology Prostate Pathology Presentation Transcript

  • Prostate Pathology Martha K. Terris, M.D. Medical College of Georgia
  • Normal
    • Complex glands with 2 cell layers, epithelial and basal cell layers
  • Normal
    • Complex glands with 2 cell layers, epithelial and basal cell layers, no nucleoli
  • Normal
    • HMW keratin stains basal layer
  • BPH
    • Occurs in Transition Zone
    • Due to androgen stimulation & estrogen synergism
    • Histologic features:
      • both glands and stroma can become hyperplastic
      • cytologically benign with 2 cell layers, bland nuclei and abundant cytoplasm
      • nonspecific chronic lymphocytic infiltrate is common
  • BPH
    • Stromal Hyperplasia
    • Theorized to respond better to alpha-blockade
      • Corpora amylacea may be identified (laminated eosinophilic concretions within the lumen of the gland)
  • BPH
    • Basal Cell Layer not always easy to identify
  • BPH
    • HMW keratin staining may show gaps in basal layer but will always be at least partial
  • BPH
    • Like normal prostate tissue, nucleoli are not typically identified
  • BPH
    • Branching glands, corpora amylacea, no nucleoli
  • BPH
    • Nodule of glandular hyperplasia
    • Theorized to respond better to finasteride
  • BPH
    • Nodule of glandular hyperplasia
    • Theorized to respond better to finasteride
  • BPH
    • Nodule of glandular hyperplasia
    • Glands can be dilated with secretions
  • BPH
    • Nodule of glandular hyperplasia
    • Glands can be dilated with secretions
  • Polypoid Hyperplasia
    • Aka Prostatic urethral polyps; Present with hematuria
    • Small polyps demonstrating typical prostatic-type epithelium; PSA and PAP positive; behavior is benign and recurrence after TUR is unusual.
    • Histology can also be adenomatoid (nephrogenic adenoma; frequent recurrence) and adenomatous (endometroid)
  • Infarcts
    • 20-25% of BPH specimens have infarcts
    • Patients may present with acute retention due to a sudden increase in the size of the prostate
    • Gross: mottled and yellowish, or may appear hemorrhagic
  • Infarcts
    • Histologic features: typically shows three zones
      • central zone of coagulative necrosis (everything looks reddish with faint outlines of the cells, like “ghost cells”)
      • middle zone of hemorrhage and inflammation
      • peripheral zone of glands with squamous metaplasia
  •  
  • Acute Prostatitis
    • Inflammatory infiltrate within gland lumens
  • Chronic Prostatitis
    • Inflammatory infiltrate surrounds the glands, involving the surrounding stroma
  • Acute and Chronic Prostatitis
    • Infiltrate both in lumens and surrounding glands
  • Malignant Lymphoma
    • Diffuse infiltration of parenchyma by small round blue cells with minimal cytoplasm
    • Typically the normal architecture is spared
    • Stains for leukocyte markers are positive
  • PIN
    • Probable precursor lesion for prostatic carcinoma
    • Divided into low grade (mild dyplasia/ grade I) and high grade (moderate dysplasia/ grade 2 and severe dysplasia/ grade 3)
    • High grade PIN is a marker for cancer
    • Histologic features:
      • on low power, the glands appear large and complex, but more basophilic (blue) than the normal glands of BPH
      • basal cells are present, if only focally
      • high power shows prominent nucleoli, nuclear crowding and pseudostratification (piling up of the nuclei)
      • also: the papillary structures at low power turn out to be caused by the cellular pile-up; in BPH, the papillary structures actuallly have fibrovascular cores and therefore are true papillae.
  • PIN
  • PIN
  • Normal Gland and PIN
  • PIN
  • PIN
    • Papillary lumenal projections have NO fibrovascular core
  • Compare to BPH
    • Papillary structures each have a fibrovascular core
  • Low Grade PIN
    • Multiple epithelial cell layers but unlike high grade PIN, has no nucleoli
  • High Grade PIN
  • High Grade PIN
    • HMW keratin shows fragmented basal cell layer
  • Beware: Basal Cell Hyperplasia
    • Nuclei are ovoid with finely reticular chromatin and rare punctate nucleoli. The cytoplasm is pale eosinophilic or clear
  • Basal Cell Hyperplasia
  • Basal Cell Hyperplasia
  • Prostate Adenocarcinoma
    • Microscopic foci of cancer may begin in the 30’s, present in 70% of men by the age of 70
    • 80% occur in the peripheral zone, 10-20% in the transition zone; most appear yellow or gray-white grossly
    • Histologic features:
      • Unlike other malignancies, neoplastic glands are very small, simple, and bland. Complexity in the prostate is generally a good sign, whereas small simple glands may herald cancer.
      • helpful findings: blue mucin, crystalloids, prominent nucleoli, single layer of cells (immuno)
      • Gleason’s grading system
  • Prostate Cancer Crystalloids
    • Elongated, refract light
    Corpora amylacea
  • Prostate Cancer Blue Mucin
  • Prostate Immunohistology
    • Alpha-methylacyl-CoA-racemase (racemase)  aka, P504S, is an enzyme involved in beta-oxidation of branched chain fatty acids. Moderate to strong staining is seen in prostate cancer and high-grade PIN, but not in benign prostatic tissue.
    • HMW cytokeratin antibody (34ß-E12)  stains the cytoplasm of basal cells of the prostate. Increasing grades of PIN are associated with progressive disruption of the basal cell layer. Cancer cells consistently fail to react with this antibody.
    • p63  antibody stains the nucleus of basal cells. Basal cell cocktail (34 ß-E12 and p63) increases the sensitivity of the basal cell detection and reduces staining variability, thus rendering basal cell immunostaining more consistent.
    • PSA, PAP antibodies are useful in cases of unknown primary or very de-differentiated tumors.
  • Prostate Immunohistology
    • HMW keratin and p63 stain basal cell layer of atrophic benign gland
    • Racemase stains malignant cells
  • Gleason Grade
    • Gleason grading assigns prostatic malignancy a rank from 1 to 5 based on level of dedifferentiation. 1 being best. 1 and 2 are rarely used any more so really a rank from 3-5
    • Prostatic cancers are typically heterogenous therefore receive the sum of their two most common architectural patterns
      • the first number is the most prevalent pattern
      • the second number is the second most prevalent pattern (a minimum of 10% of the cancer volume)
      • Denoted the two numbers separately is the Gleason score, i.e. 4+3
      • the sum of the two, e.g., 7 is the Gleason sum or grade and is an excellent predictor of clinical behavior.
      • Sometimes a tertiary grade will be mentioned (or used as the secondary grade) if it is poorly differentiated.
    • Grades 1-3 consist of small, simple round glands with a single cell layer surrounded by stroma
      • Grade 1: Glands in nodular pattern
      • Grade 2: Glands in vaguely rounded configuration
      • Grade 3: Glands infiltrating between normal glands
    • Grade 4: “Fused” glands (no stroma separating some of the glands) or multiple lumens in a single gland.
    • Grade 5: No longer attempting to create glands; cells in sheets, clumps, rows, or individual.
  • Gleason Grading
    • Do not try to assign a grade to treated tissue
      • Hormone therapy
      • Prior radiation therapy of any kind
  • Gleason Grade 1
    • nodules of uniform, closely-packed malignant glands, nucleoli are relatively inconspicuous
  • Gleason Grade 2
    • Nodular configuration but more loosely packed.
  • Gleason Grade 2
    • Nodular configuration but more loosely packed.
  • Gleason Grade 3
    • Tumor infiltrates in and among the non-neoplastic prostatic glands
  • Gleason Grade 3
    • Tumor infiltrates in and among the non-neoplastic prostatic glands
  • Gleason Grade 3
    • Tumor infiltrates in and among the non-neoplastic prostatic glands
  • Gleason Grade 4
    • Fused glands without completely surrounding stroma, poorly formed or multiple lumens
  • Gleason Grade 4
    • Fused glands without completely surrounding stroma, poorly formed or multiple lumens
  • Gleason Grade 4
    • Fused glands without completely surrounding stroma, poorly formed or multiple lumens
  • Gleason Grade 4
    • Fused glands without completely surrounding stroma, poorly formed or multiple lumens
  • Hypernephroid Gleason Grade 4
    • Abundant clear cytoplasm with a dot-like nucleus
  • Mucinous Gleason Grade 4
    • Extracellular mucin makes up at least 25% of tumor volume
  • Gleason Grade 5
    • Minimal gland formation, cells in sheets, clumps, cords
  • Gleason Grade 5
    • May need PSA stain to confirm diagnosis
  • Gleason Grade 5
    • Minimal gland formation, cells in sheets, clumps, cords
  • Gleason Grade 5
    • Minimal gland formation, cells in sheets, clumps, cords
  • Gleason Grade 5
    • Signet Ring Histology
  • Cribriform
    • Smoothly-circumscribed nodules with large ducts that are filled and distended with tumor in a cribriform pattern can be called grade 3 or 4. The presence of central necrosis in a cribriform carcinoma raises the grade to 5.
  • Gleason Grade 5
    • Grade 5 Cribiform with comedonecrosis
  • Seminal Vesicle
    • Beware of trick questions!
  • Seminal Vesicle
    • Look for golden-brown granules of lipofuscin pigment
  • Small Cell Carcinoma
    • Small round blue cells in sheets, necrosis, high mitotic rate.
    • “ Molded” nuclei with inconspicuous nucleoli
    • PSA and PAP stains are typically negative and serum PSA levels may be only mildly elevated. Neuroendocrine stains positive
  • Endometroid Carcinoma
    • Typically arises in area of urethra/prostatic utricle
    • PSA and PAP positive
    • Often grade 3 or 4 but 5 if has necrosis
  • Transitional Cell Carcinoma
    • Typically involves large ducts
    • More cytologic atypia than prostate cancer
    • PSA negative
  • Squamous Cell Carcinoma
    • Rare in North America, more often in areas where Schistosomiasis is endemic
    • Histologic features include keratin pearl formation, intercellular desmosomes, etc. 
  • Rhabdomyosarcoma
    • Average age 7 years, rapid growth
    • Sheets of small round blue cells with scattered strap cells (tadpole cells) having cross-striations