Male Pathology: Prostate Flashcards
What are the 4 zones of the prostate?
- Anterior
-
Peripheral
- Most cancers
- Palpable on rectal exam
- Central
- Transition – BPH, some cancers
What does a normal prostate look like on histology?
- Double layer of cells
- Secretory & basal
- Double layer is absent in prostate cancer
What are the benign conditions of the prostate?
- Acute Prostatitis
- Chronic Prostatitis
- Granulomatous Prostatitis
**Acute Prostatitis **
Definition
Presentation
Pathogens
- Intraprostate reflux of urine from the posterior urethra or urinary bladder
- Young men
- Low back pain, fever, myalgia
- Pathogens: rods (gram negative bacilli, gram positive cocci)
- E. coli
- P. aeruginosa
- K. pneumoniae
**Acute Prostatitis **
Clinical Findings
Serum Findings
-
Clinical Findings
- Fever
- Lower back, perineal or suprapubic pain
- Painful/swollen gland on rectal exam
- Dysuria, hematuria
-
Serum Findings
- Raised serum PSA above normal
- >4.0 ng/mL
**Chronic Prostatitis **
Definition
Clinical Findings
- Majority abacterial
- Chronic bacterial infection (recurrent acute prostatitis)
-
Clinical Findings
- Lower back, perineal or suprapubic pain
- Painful/swollen gland on rectal exam
- Dysuria, hematuria
**Chronic Prostatitis **
Properties
- Recurrent
- Associated w/ UTIs
- Same organism in each culture
- Asymptomatic
- Calculi
Chronic Prostatitis
Serum Findings
Diagnosis
-
Serum Findings
- Raised serum PSA above normal
- >4.0 ng/mL
-
Diagnosis
- 10-12 WBC/field in secretions/urine
- Positive bacterial cultures
What is Chronic Nonbacterial Prostatitis?
“Chronic Pelvic Pain Syndrome”
- 95% of prostatitis
- Prostatitis w/o UTI or positive cultures
- Possible organisms
- Chlamydia trachomatis
- Ureaplasma urealyticum
- *Trichomonas vaginalis *
**Granulomatous Prostatitis **
Infectious
Non-Infectious
-
Infectious
- Tuberculosis (hematogenous)
- Fungal/mycotic (AIDS)
-
Non-infectious
- Post-surgical (biopsy site rxn)
- Post-BCG (Bacille Calmette-Guérin)
- Non-specific
How does Granulomatous Prostatitis present on histology?
Granuloma
- Aggregate of histiocytes (MΦ)
- Single to multiple nuclei
- Chronic inflammation
What are the neoplasms of the prostate?
- Benign Prostatic Hyperplasia (BPH)
- High Grade Prostatic Intraepithelial Neoplasia (HGPIN)
- Prostatic Adenocarcinoma (Prostate Cancer)
What is Benign Prostatic Hyperplasia?
What effect does it have on the bladder outlet?
- Proliferation of glands and stroma in the transitional zone
- Bladder outlet obstruction (BOO)
- Urinary frequency, incomplete emptying, nocturia, dysuria
- 90% prevalence by age 80
- Androgen-dependent process
- Chiefly caused by DHT
- Binds to AR w/ 5X higher affinity than testosterone
What is PSA?
How is this affected by BPH?
- PSA can be mildly elevated
- Proteolytic enzyme
- Increases sperm motility
- Maintains seminal secretions in the liquid state
- PSA is neither sensitive nor specific for BPH
- PSA is usually normal (0-4 ng/mL) but BPH can increase it to 4-10 ng/mL (rarely over 10 ng/mL)
Nodular Benign Prostatic Hyperplasia
- Nodules of hyperplastic glands & stroma
- Urethra gaping – tissue removal by resection
- Transurethral resection of nodules
How does BPH present in histology?
Glandular nodules
Stromal nodule
What is High Grade Prostatic Intraepithelial Neoplasia (HGPIN)?
- Precursor to invasive cancer
- Men w/ elevated serum PSA: 20% risk of cancer on repeat biopsy
- Additional finding of HGPIN on biopsy increases the risk (25-30%)
- By itself, _does not raise serum PSA _
How does HGPIN present on histology?
High grade PIN: large nucleoli
- Nuclear enlargement
- Chromatin clumped
- Prominent nucleoli
Prostate Adenocarcinoma (Cancer)
Statistics
Presentation
- Men have 1/6 chance of being diagnosed w/ in lifetime [#1 cancer incidence, #2 cancer deaths]
- Prostate cancer occurs (almost entirely) in the peripheral zone
- Horseshoe-shaped part of the prostate
- Posterior & accessible to rectal palpation
- Tumor >0.5cm = palpable
Prostate Cancer
PSA
Screening
-
Prostate Specific Antigen (PSA)
- Protease formed by epithelial cells of the prostate
- Keeps the semen in a liquefactive form
- Increased by cancer, inflammation, BPH
- Used as screen for cancer
-
PSA Screening
- PSA blood tests & digital rectal exam recommended annually for men >50 YO
- Increased risk factors
- FaHx of prostate cancer
- African American men
- Increased risk: start screening at age 40
What is the Gleason Grading of Prostate Cancer?
- 1 = well-differentiated
- 5 = poorly differentiated
- Primary grade = most common pattern
- Secondary grade = least common pattern
- Sum of grades = Gleason score (6-10)
Histologic Grades of Prostatic Adenocarcinoma
- Grade 1 = atypical adenomatous hyperplasia (benign)
- Advised against using (not predictive of prostatectomy)
- In needle biopsies, grades 3 & 4 the most common
What grade of prostate cancer is this?
Grade 3
What grade of prostate cancer is this?
Grade 4
*note fusion of glands
What grade of prostate cancer is this?
Grade 5
*single cells
Whether the tumor has ________ or not is KEY consideration for management & prognosis
gotten outside the prostate or not
How does Prostate Cancer typically spread?
- Special propensity to spread to seminal vesicles
- Spreads first to external iliac lymph nodes
- May or may not be sampled at prostatectomy
- Low back/pelvic pain portends bony metastases to vertebra & pelvic bones
- Spread via Batson venous plexus
- Serum prostatic alkaline phosphatase increased
- Osteoblastic metastases
- Serum PSA markedly increased
- Compression of the spinal cord
