Your SlideShare is downloading. ×
Pathology of Prostate
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Pathology of Prostate

8,553
views

Published on

Published in: Health & Medicine

0 Comments
6 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
8,553
On Slideshare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
416
Comments
0
Likes
6
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. CPC4.3- MR 68y Carpenter
    • Lives in Kuranda. He attends the GP for a ‘check up’ and towards the end of the consultation mentions casually: “ I’ve also got a few things happening with the old waterworks , Doc.”
    • Urine frequency (4-5xday; 2xnight); Terminal dribbling .
    • Worsening over months - ? couple of years ’.
  • 2. CPC4.3- Matthew Rice 68y Carpenter
    • Urgency yes, but then doesn’t pass much urine on forcing. Cannot empty the bladder empty.
    • Urinary stream - poor
    • Urinary incontinence - occasional but embarrassing.
    • Dysuria, Haematuria No
    • Bowel habit no change, prone to slight constipation
    • Sexual history - heterosexual; 2nd wife Dawn, monogamous for 23 years. Has early morning erections, but difficulty sustaining an erection . No hx STIs
  • 3. CPC4.3- Differential Diagnosis
    • Benign prostatic hyperplasia ( BPH )
    • Prostatitis, Cancer, stones , rectal tum.
    • Strictures, UTI, Diuretics,
    • Spinal injury, Autonomic neuropathy ???
    • What other causes of urinary obstruction?
      • urine retention , lack of urine , urinary dribbling
      • urinary urgency , urination pain , weak urination
      • reduced urine
        • (links to wrongdiagnosis.com)
  • 4. Pathology Symptom Testicular tum Gynaecomastia Testicular tum teratoma. Raised α FP/HCG Prostate carcinoma Raised acid Phos. Prostate carcinoma Bone pain STI, syphilis Ulceration UTI, urethritis, gonorrhoea Discharge Prostate, stone, stricture, tumor Retention Prostate, UTI, Polyuria Frequency Bladder neck obstruction. Prostate BPH (rarely stricture/tumor) Poor stream / dribbling. Inflammation urethra, UTI Dysuria
  • 5. Causes of Obstructive Uropathy
    • INTRINSIC:
      • Calculi - Lithiasis
      • Strictures – congenital, inflammatory
      • Tumors – Transitional cell Ca.
      • Blood clots – UTI, Glomerulonephritis
    • EXTRINSIC:
      • Pregnancy
      • Inflammation- PID, peritonitis, diverticulitis, salphingitis.
      • Tumors: Prostate , rectum, bladder, ovaries etc.
  • 6. When you lose, don’t lose the lesson. Lao Tzu Everyone makes Mistakes, only intelligent learn from it.
  • 7. CPC 4.2: Core Learning Issues:
    • Pathology Major CLI :
      • Nephrolithiasis – Types, Pathogenesis, clinical features.
      • Tumors of Kidney . – Renal cell carcinoma, Nephroblastoma,
      • Disorders of Prostate – Prostatitis, BPH and carcinoma.
      • Urinary tract infection – Microbiology common organisms and their lab diagnosis.
    • Pathology Minor CLI :
      • Differential diagnosis of hematuria.
      • Tumors of Urinary tract and bladder .
      • Cystic Diseases of Kidney
      • Hydronephrosis .
      • Recurrent UTIs
      • Congenital disorders of kidney.
  • 8. Pathology of Prostate Dr. Shashidhar Venkatesh Murthy Associate Professor & Head of Pathology
  • 9. Introduction
    • Anatomy – 5 lobes.
    • Function – Semen, acid phosphatase.
    • Hormone response – Estrogen like
    • Median lobe – BPH
    • Lateral/Posterior lobes - Cancer)
    • Enlargement – Inflammation / growth
    • Neoplastic / Non neoplastic growth.
    • BPH / Cancer.
  • 10. Male Urogenital System - anatomy
  • 11. Male Urogenital System - anatomy Ca BPH
  • 12. Zonal Histology:
    • BPH
    • Ca.
  • 13. Normal Histology: Fibro-Musclular-Gland Two Layer Ep. Fibromuscular stroma Secretions
  • 14. Enlargement of Prostate:
    • Inflammations – infections
    • BPH – Benign Prostatic Hyperplasia
    • Neoplasms – Carcinoma.
    SAP Morph -DRE location Incidence Disease Raised. Adenocarcinoma Hard stony, irregular, fixed No median grove. Posterior subcapsular Latent is Common. Clinical not. Carcinoma normal Nodular Hyperplasia, Firm, smooth Median grove Central / periurethra >80% at 80y BPH
  • 15. Prostatitis:
    • Inflammation, edema, rectal pain, urinary obstruction.
    • Acute suppurative prostatitis
      • E.coli, rarely Staph or N. gonorrhoeae
    • Chronic non-specific prostatitis
      • recurrent acute  fibrosis, lymph + plasma.
    • Granulomatous prostatitis-
      • BPH, infarction, post TURP, idiopathic, TB, or allergic(eosinophilic).
  • 16. Prostatitis:
  • 17. BPH-Introduction
    • Common non-neoplastic hormone induced hyperplasia.
    • 75% among men aged 70-80years
    • Over 90% in people aged over 90y
    • Involves peri urethral & central zones.
    • Rare before the age of 40y.
    • Hormone induced – Androgens.
    • Castration  no BPH
  • 18. Patho-Physiology: Testosterone  DHT  GF Finasteride
  • 19. BPH-Morphology
    • Microscopically, nodular prostatic hyperplasia consists of nodules of glands and intervening stroma . (both)
    • The glands variably sized, with larger glands have more prominent papillary infoldings, double layered epithelium (like normal) some may be cystic with secretions.
    • Nodular hyperplasia is NOT a precursor to carcinoma.
  • 20. Benign Prostatic Hyperplasia:
  • 21. BPH-mechanism of obstruction:
    • Median lobe (3 rd lobe)
    • Ball valve mechanism
    • Obstruction.
    • Urgency/hesitation..
  • 22. BPH-Bladder Gross – Identify Cues?
    • Trabeculations
    • Hypertrophy of wall
    • Stone - urolithiasis
    • Inflammation
    • Median lobe- ball valve.
    • Enlarged prostate.
  • 23. BPH-Bladder morphology:
    • Hypertrophy of wall.
    • Trabeculation
    • Median lobe protrusion (ball valve)
    • Prostatic enlargement.
  • 24. Mucosal trabeculation: Muscular hypertrophy
  • 25. Mucosal trabeculation: Muscular hypertrophy Bulging BPH central Lobes
  • 26. TURP-Bits (Diagnosis + Treat ) Transurethral resection of Prostate - TURP Partial removal by resectoscope. Complications: Hemorrhage, Infection, Granulomatous prostatitis Retrograde ejaculation.
  • 27. BPH: Nodular, Gland+stromal hyperplasia Cystic Gl Nodule of BPH Secretions
  • 28. BPH - Morphology Corpora Amylacea
  • 29. BPH-Complications:
    • Obstructive Uropathy
    • Bladder hypertrophy
    • Trabeculation
    • Diverticula formation
    • Hydroureter – bilateral
    • Hydronephrosis
    • Lithiasis / stone.
    • Secondary infection.
    • Not a risk factor for Carcinoma prostate.
  • 30. Normal – Prostatitis - BPH
  • 31. Adenocarcinoma Prostate:
    • Most common cancer in elderly males.
    • Adenocarcinoma.
    • It is rare before the age of 50, but seen in over 70% of men over 70y old.
    • Many of these carcinomas are small and clinically insignificant. (Incidental ca)
    • Second common cause of death due to cancer in males. (First is lung carcinoma)
    • Aetiology unknown - Hormones, genes & environment most likely. ( Not BPH )
  • 32. Cancer Statistics – 2002 USA
  • 33. Cancer Statistics – 2002 USA
  • 34. Pathogenesis: PIN & carcinoma
    • Prostatic intraepithelial neoplasia (PIN) Multilayered , pleomorphic (low & High grade).
    • Malignancy is single layered , & well differentiated to start with …!
  • 35. Diagnosis:
    • Clinical: Digital Rectal examination (DRE)
      • hard, gritty, fixed tumor.
      • Loss of median groove.
    • Imaging:
      • Ultrasonography (transrectal), CT Scan, MRI.
    • Laboratory:
      • Tumor Marker – PSA
      • Biopsy - TURP
    • Note: None of these methods can reliably detect small cancers & microscopic occult cancers may remain in-situ for several years. (PSA misleading*). Occult cancer is more common than clinical ca.
  • 36. BPH with Adenocarcinoma:
  • 37. BPH with Adenocarcinoma: Ca Ca BPH BPH
  • 38. “ The only gracious way to accept an insult is to ignore it. If you can’t ignore it, top it. If you can’t top it, laugh at it. If you can’t laugh at it, it’s probably deserved ...! ” –Joseph Russell Lynes
  • 39. Adeno-Ca Prostate
    • Posterior Lateral lobes: Carcinoma
    • Rectal examination.
    • Solid, hard, adenocarcinoma
  • 40. Adeno-Ca Prostate
  • 41. Adeno-Carcinoma + BPH
  • 42. Adeno Carcinoma + BPH Stone Solid-Ca Cystic, soft BPH
  • 43. PIN: Crowding, stratification Pleomorphism Nuclear enlargement. Low grade PIN  High grade PIN  Grade II - III 
  • 44. Prostatic Carcinoma: grade 4
  • 45. Adenocarcinoma Prostate: (High grade)
  • 46. Gleason Grading & Scoring of Prostatic Ca.
  • 47. Gleason Grading & Scoring.
    • Grade/Pattern 1 – well defined glands with limited infiltration of the surrounding tissue.
    • Grade/Pattern 2 – not well demarcated, pleopmorphic cells.
    • Grade/Pattern 3 – Crowding of glands, irregular glands.
    • Grade/Pattern 4 – Fusion of glands.
    • Grade/Pattern 5 – cell clusters, No clear gland structure.
    • Gleason Score: Add to most prominent grades in the slide. E.g. 3+4=7
    Prostate Cancer
  • 48. Gleason score – 1+1=2
  • 49. Gleason score – 2+2=4
  • 50. Prostate Cancer – Gleason grade 3 Gleason grade 3: Pleomorphic glands. There is considerable variation in size, shape, and spacing of the glands. The glands are haphazardly infiltrating the stroma; however, they are still discrete (i.e. there is no fusion of glands - a hallmark of Gleason grade 4). Some of the glands have occluded or abortive lumens.
  • 51. ? Gleason Grade 4 – Gland Fusion, no stroma
  • 52. Small irregular nests & ribbons - Gleason grade 4+4.  Prostate Cancer
  • 53. Prostate Cancer-High grade. Grade 5 – sheets, no attempts at gland or clustering.
  • 54. Most prostatic tumours include components of two or more patterns and therefore current practice gives the grade of the two most common components and their sum. This is known as the combined Gleason grade or score. For example, in this image many glands in this example are fused (Gleason grade 4); others maintain individual outlines but are closely packed with their neighbours (Gleason grade 3). Therefore, the score is 7 (4+3). Prostate Cancer High grade
  • 55. Prostate Ad.Ca:
    • Benign:
      • Double layer,
      • Secretion (clear cytopl)
      • Uniform cells
      • Papillary folds
    • Malignant
      • Single / crowded.
      • Less/no secretion.
      • Uniform/Pleomorphic
      • No papillary folds. But crowding & clustering.
    Normal Ca. Normal Ca.
  • 56. Prostate Cancer Poorly differentiated: Normal Gl. Malignant cells
  • 57. Adenocarcinoma – PSA IPx +ve :
  • 58. Prognosis of Adenocarcinoma:
    • Grade & Stage  Prognosis.
    • Gleason score 2-4 – well differentiated.
    • Gleason score 8-10 – poorly differentiated.
    • Urinary obstruction
    • Metastasize to lymph nodes and bones.
    • Bladder, kidney damage - Hematuria.
    • Spread to rectum – bleeding.
    • Spread to Lungs or liver – rare.
  • 59. Ca Prostate – Stage & Prognosis: <10% Evident distant metastases D2 17-20% Metastases to regional lymph nodes, or extensive regional spread D1 33-39% Invades seminal vesicle C2 40-50% Invades capsule of prostate C1 62% Larger palpable nodule B2 70-75% Palpable nodule in one lobe but <1.5 cm in diameter B1 50% Incidental, >5% of volume, or high grade A2 93-98% Incidental, <5% of volume A1 10y Survival Definition Stage
  • 60. Transitional cell Neoplasms:
    • 90% of bladder ca.
    • Precursor – papilloma
    • Dysplasia, in-situ ca,
    • Papillary carcinoma.
  • 61. “ The weak can never forgive. Forgiveness is the attribute of the strong.” –Mohandas Gandhi
  • 62. Urinary Calculi: Dr. Shashidhar Venkatesh Murthy Associate Professor & Head of Pathology
  • 63. Nephrolithiasis
    • Usually unilateral, small 1-3 mm ,
    • Flank pain & tenderness – renal capsule.
    • Passage marked by Paroxysmal, intense colicky pain in the back (loin) with radiation to anterior (renal or ureteral &quot;colic“)
    • “ writhing in pain, pacing about, and unable to lie still”
    • Hematuria macro/micro
    • Larger stones that cannot pass produce hydronephrosis or hydroureter.
  • 64. Levels - Clinical symptoms
    • Ureteropelvic junction - deep flank pain No radiation. Distension of the renal capsule. (Symp. T11-L2)
    • Ureter – Acute, severe, colicky pain in the flank and ipsilateral lower abdomen with radiation to the testes/vulva (ilioinguinal n.). nausea / vomiting.
      • Upper ureter – cholecystitis.
      • Middle – appendicitis
      • Distal ureter – Pelvic Infl. Dis.
    • Ureterovesical junction - Cause irritative voiding, urinary frequency and dysuria.
    Calcium Oxalate
  • 65. Nephrolithiasis: Organic matrix(3%) + salts (97%) ~
    • Calcium stones (80%): oxalate/phosphate/urate salts.
      • Increased gut absorption or defective tubular reabsorphtion of calcium – Common, high pH.
      • Hyperparathyroidism (10%)
      • Hyperuricosuria – high pH
    • Struvite Stones (15%) magnesium ammonium phosphate (triple phos). Staghorn stone.
      • Chronic UTI with gram-negative rods (split urea) pH >7
      • Proteus, Pseudomonas, and Klebsiella (not E. coli) .
    • Uric acid stones (6%):
      • pH <5.5, high protein (meats), malignancy, 25% have gout.
    • Cystine stones (2%)
      • Genetic disorder - Failure of reabsorption
    Calcium Oxalate
  • 66.   Small renal calculus that would likely respond to extracorporeal shock-wave lithotripsy
  • 67. Nephrolithiasis:
    • Hypercalciuria, Hypocitraturia - commonest risk factor.
    • A positive family history in 54%.
    • UTI in 62%, recurrent UTI in 60% (T.Phosphate).
    • Significant association with citrate & Phosphate excretion and UTI.
    • Stone analysis, together with serum and 24-hour urine metabolic evaluation crucial for management.
  • 68. Staghorn: (Triple Phos/Struvite)
    • 10% of nephrolithiasis.
    • Large stone moulds to pelvis and calyceal system.
    • Secondary to obstruction / infection proteus sp.
    • Proteus – break urea to form ammonia (alk. ph)
    • Triple (struvite) Phos. magnesium ammonium phosphate.
    • Chronic irritation, sq metaplasia & sq carcinoma rarely occur.
  • 69. Staghorn Calculus:
  • 70. Staghorn Calculus
  • 71. Complications:
    • Hydronephrosis
    • Renal failure
    • Ureteral stricture
    • Infection, sepsis
    • Urine extravasation
    • Perinephric abscess
    • Xanthogranulomatous pyelonephritis
  • 72. Hydronephrosis:
  • 73. CPC-4.3– REN–BPH
    • Pathology - Core Learning Issues:
      • Overview of gross & microscopic Pathology of Prostate BPH & Prostatic cancer.
      • Laboratory diagnosis of prostatic tumors. (debate)
      • Occult prostatic cancers (Recent media report on a Pathology report of cancer later denied).
      • Pathology overview of chronic urinary retention..
      • Pathology of Nephrolithiasis, common types & their clinical presentation & Diagnosis.
    • Basic science - Core Learning Issues:
      • Anatomy & histology of Prostate gland.
      • Prostate gland function, hormonal control.
  • 74.
    • “ Pleasure & Pain ,
    • Happiness & Suffering
    • are our teachers”.
    • Through their impact
    • on the mind
    • “ Character ” develops.
  • 75. Prostate: M ost likely site of ? pathology
    • Benign Hyperplasia.
    • Prostatitis
    • Stone formation
    • Adenocarcinoma
    • Transitional carcinoma
  • 76. 62y male chronic urinary retention. ? Diagnosis
    • Prostatic carcinoma
    • Benign P. Hyperplasia
    • Bladder carcinoma
    • Trabeculations
    • Bladder hypertrophy
  • 77. BPH: what feature is shown ?
    • Bladder Wall Thickening
    • trabeculation
    • Stone formation
    • Ball valve obstruction
    • Enlarged lateral lobes
  • 78. Kidney: What type of stone ?
    • Oxalate & calcium
    • Calcium phosphate
    • Pure Uric acid
    • Triple phosphate
    • Cystine
  • 79. 74y M, dysuria, hematuria, prostate ? Diagnosis
    • Prostatitis
    • Benign Prostatic Hyperpl.
    • Low grade carcinoma
    • Transitional carcinoma
    • High grade Carcinoma.
  • 80. 74y male, dysuria, hematuria, prostate ? Diagnosis
    • Prostatitis
    • BPH
    • Adenocarcinoma
    • Transitional carcinoma
    • BPH with carcinoma
  • 81. 74y male, dysuria, hematuria, prostate ? Diagnosis
    • Prostatitis
    • BPH
    • Adenocarcinoma
    • Transitional carcinoma
    • BPH with carcinoma
  • 82. 70y backpain, DRE-rock-hard, enlarged prostate. X-rays show multicentric, osteoblastic lesions of the lumbar vertebral bodies. An orchiectomy is performed. What is the rationale for this surgical procedure?
    • Leydig cells release tumor chemotactic factors.
    • Prostate carcinomas frequently metastasize to the gonads.
    • Sertoli cells release tumor chemotactic factors.
    • The tumor is well known to invade the testes.
    • Tumor cells exhibit androgen-dependent growth.
  • 83. 68y male, painless hematuria 4wk. Bladder image. What is the most likely risk factor?
    • Bladder calculi
    • Chronic HPV infection
    • Diabetes mellitus
    • Exposure to Azo dyes
    • Previous catheterization.
  • 84. 68y male, Image shows prostate biopsy. What is the most likely complication of this lesion ?
    • Destructive vertebral lesions.
    • Bladder hypertrophy.
    • Calcium oxalate nephrolithiasis.
    • Gram negative septicaemia.
    • Lead to Prostatic carcinoma
  • 85. 68y man elevated serum PSA (>6 ng/mL). Biopsy of the prostate reveals a poorly differentiated adenocarcinoma. Which of the following best describes the putative precursor of this neoplasm?
    • Basal cell hyperplasia
    • Chronic prostatitis
    • Obstructive uropathy
    • Nodular BPH
    • PIN.
  • 86. 55y man, urinary urgency and frequency. DRE enlarged prostate. PSA of 4.9 (normal = 0–4). Needle biopsy - two cancer-positive needle cores: Gleason grades 4 and 5. Which of the following is the appropriate diagnosis?
    • Adenocarcinoma
    • Nodular BPH
    • PIN-3
    • Squamous Carcinoma
    • Transitional Carcinoma
  • 87. 68y male, Image shows prostate biopsy. What is the most likely complication?
    • Destructive vertebral lesions.
    • Bladder hypertrophy.
    • Calcium oxalate nephrolithiasis.
    • Gram negative septicemia.
    • Infertility.
  • 88. 68y male, Image shows Bladder & prostate. What complication is not shown?
    • Invasive bladder cancer.
    • BPH.
    • Ball valve obstruction.
    • Bladder diverticula.
    • Tumor necrosis & hemorrhage.
  • 89. Today is the First Day, of Rest of Your Life...!
  • 90. CPC-4.3– KFP Questions:
    • BPH – etiology, Pathogenesis, morphology & complications.
    • Testosterone, DHT, Fenosteride.
    • TURP – brief notes.
    • Prostatic carcinoma – etiology, Pathogenesis, morphology & spread, metastases.
    • Staging, Grading & Prognosis.
    • Urolithiasis : Renal stones
    • Other obstructive uropathy.
  • 91. Referral - if >5 mm or has not passed after two weeks. US X-Ray no contrast Helical CT Management
  • 92. 70y male
    • Problems passing urine.
    • Difficult to start even though he badly needs to go. After passing.. He feels the urge but cannot pass..
    • High frequency, 2-3 times in the night.
    • For several months getting slowly worse
    • Now urine dribbles, Added to this, the force with which he can urinate is very much reduced and it is difficult for him to avoid soiling his clothing.
  • 93. 70y male
    • What are differential diagnosis?
    • What complication he has?
    • Should PSA be tested for all?
    • When is biopsy indicated?
    • Does BPH lead to Carcinoma?
    • What is the best screening test for Ca?
    • What investigations are available?
  • 94. Prostatic neoplasms: Overview Rare Normal Microscopic focus of adenocarcinoma Any site Commoner than clinical carcinoma; 80% of glands over 75 years Latent (incidental) carcinoma Bone Lymph node Lung Liver Raised in approximately 60% of cases Infiltrating adenocarcinoma Posterior subcapsular zone Common tumour; peak 60-85 years Clinical (symptomatic) carcinoma None Normal Nodular hyperplasia of glands and stroma Peri-urethral zone 75% of men >70 years Benign nodular hyperplasia Metastases Serum acid phosphatase Morphology Location in gland Incidence Condition

×