Chapter 11 - Prostate Flashcards
What are the usual indications for prostate biopsy?
Elevated PSA
Palpalble nodule
History of abnormal biopsy
Describe the low power features of prostatic adenocarcinoma.
Small individual glands infiltating among larger benign glands.
Crowded, cribriform glands
Mucin, crystalloids, or pink luminal secretions
NO desmoplastic response
Describe the high power features of prostatic adenocarcinoma.
Large, cherry-red nucleoli
Enlarged & hyperchromatic nuclei
Lack of basal cell layer
Mitoses (uncommon)
What three features guarantee a diagnosis of prostatic adenocarcinoma?
- Perineural invasion
- Mucinous fibroplasia (hyalinized whorls of secretions)
- Glomeruloid forms
What is Gleason grading?
How does it differ between cancer resections and biopsies?
A histologic grade determined by architecture–not cytology.
In cancer resections, the second number is the second most common population. In biopsies, it is the highest secondary grade.
What are the features of Gleason grades 1 and 2?
- Rarely used; a circumscribed nodule of uniform crowded glands.
- A circumscribed nodules of well-defined glands with minimal infiltration at the peirphery; less uniform than pattern 1.
What are the features of Gleason grade 3?
Highly infiltrative glands with discrete and individual gland profiles (can draw a circle around each gland)
What are the features of Gleason grade 4?
Fused and ill-defined glands, sheets of cribriform glands, poorly formed lumens.
What are the features of Gleason grade 5?
A complete absence of glandular differentiation, solid sheets and cords of cells, single cells.
Why can’t Gleason 1/2 be diagnosed on biopsies?
They can only be identified in the context of surrounding tissue.
What features must be mentioned in the signout of a prostate biopsy?
Number of involved cores, percentage involvement, size of foci.
Perineural invasion, extraprostatic extension.
What is the clinical significance of prostatic intraepithelial neoplasia (PIN)?
It is considered a precursor lesion to prostate cancer but does not warrant excision or re-biopsy. Low-grade PIN is not reportable, but high-grade is.
What is the morphologic appearance of prostatic intraepithelial neoplasia (PIN)?
Glands with prominent papillary or micropapillary luminal surfaces. Can be cribriform but not back-to-back.
Darker and bluer glands.
Enlarged, hyperchromatic nuclei.
Retention of the basal cell layer (at least patchy)
Name 7 mimics of prostate cancer.
Adenosis
Atrophy
Basal cell hyperplasia
Cowper’s glands
Radiation changes
Seminal vesicle
Sclerosing adenosis
Describe the morphologic appearance of prostatic adenosis.
A hyperplastic lesion consisting of a lobular group of crowded glands which overlap with larger, benign glands. Can have nucleoli, but should have a basal layer.
Describe the morphologic appearance of prostatic atrophy.
Shrinkage of the cells forming the lumen, leaving rows of essentially flat nuclei. Small and irregular, angulated/staghorn appearing. Basal layer present.
Describe the morphologic appearance of prostatic basal cell hyperplasia.
Denim-blue, oval, regular nuclei surrounding the glandular nuclei. Recognize the dual population and do not worry about the multiple layers. Immunostain if needed.
Describe the morphologic appearance of Cowper’s glands.
What do they stain?
Mucous-filled secretory glands surrounding a coil of ducts. Lobular architecture with bland nuclei.
PAS+, PSA/PSAP-
Describe the morphologic appearance of radiation changes in prostate.
TOO much pleomorphism to be cancer. Atrophic cytoplasm and wildly pleomorphic nuclei.
Describe the morphologic appearance of seminal vesicle.
Very pleomorphic nuclei, like radiation atypia.
Golden globs of lipofuscin.
Describe the morphologic appearance of prostatic sclerosing adenosis
Hyperplastic and proliferative lesion with a hypercellular stroma. Remember that prostate cancer does not induce a stromal reaction.
How can one approach the presence of a few isolated abnormal glands?
Sign out as a focus of atypical glands (generating a repeat biopsy)
Immunostain for the basal layer (CK903, p63) or cancer (racemase).
What are the margins of the radical prostatectomy?
Left and right vas deferens (rarely submitted)
Apical (distal) margin
Bladder neck margin
How can anterior and posterior prostate be oriented histologically?
Posterior features neurovascular bundles (at the posterolaterla corners)
Anterior sections shoudl have smooth muscle bundles and a poorly defined capsule
(Verumontanum points anteriorly, too)
What features define extraprostatic extension? How can it be assessed?
Presence of glands in the fat; not necessarily the same as a positive margin or capsular incision
Best appreciated at low power by following the contour of the edge of the prostate.
What feature defines seminal vesicle invasion?
Tumor must be in the parenchyma of the seminal vesicle, not just be next to it.
What are the morphologic features of prostatic ductal adenocarcinoma?
Tall, stratified columnar cells making papillary or cribfriform structures. May grow into urethra as exophytic masses. Behaves like a Gleason 4 lesion.
Name some other forms of carcinoma in the prostate.
Mucinous carcinoma
Squamous cell carcinoma
Urothelial carcinoma
Sarcomatoid carcnoma
Basal cell carcinoma
variants of usual prostate cancer.
Pseudohyperplastic carcinoma (mimics papillary architecture of benign hyperplasia)
Atrophic cancer (mimics atrophy)
Foamy gland cancer (abundant xanthomatous appearing cytoplasm)
What are some prostatic stromal lesions?
Benign stromal nodules, stromal tumors of uncertain malignant potential, and stromal sarcomas.
Most common is leiomyosarcoma.
Rhabdomyosarcoma in children.
Prostatic adenocarcinoma, low power.
Arrow: Adenocarcinoma
Arrowheads: Benign glands
Benign prostatic glands
Arrowhead: Basal layer
Arrow: Papillary fronds
Prostatic adenocarcinoma, high-power.
Arrowhead: Distinct nucleoli
Arrow: Benign adjacent glands
Perineural invasion in prostatic adenocarcinoma
Arrow: Invasive malignant glands
Gleason pattern 3
Arrow: Blue mucin in glands
Gleason pattern 4
Arrow: Cribriform growth and adjacent fused glands
Gleason pattern 5
Circle: Individual malignant invasive glands with prominent nucleoli
High-grade prostatic intraepithelial neoplasia
Arrow: Larger and darker nucleoli with nucleoli
Arrowhead: Retained basal layer
Atrophy
Arrow: Low cuboidal epithelium with attenuated cytoplasm
Arrowhead: Corpora amylacea
Basal cell hyperplasia
Arrow: Cells with prominent nucleoli
Arrowhead: Benign epithelium
Radiation atypia
Arrow: Pronounced nuclear pleomorphism
Seminal vesicle
Arrowhead: Crowded, hyperchromatic nuclei
Arrow: Golden pigment
Extraprostatic extension and perineural invasion.
Note, margin is negative.
Ductal adenocarcinoma
Note tall columnar morphology with usual prostatic cytology.
