Prostate

Question 1

Acute bacterial prostatitis

Answer 1

E coli, gram – rods, enterococci, staph implanted by urine reflux or lymphohematogenous seeding

• minute, disseminated abscesses; large, coalescent focal areas of necrosis; diffuse edema, congestion, boggy suppuration
• Biopsy → sepsis

Fever, chills, dysuria
RE; tender, boggy

Urine culture

Catheterization, cystoscopy, urethral dilation, resection

Question 2

Chronic bacterial prostatitis

Answer 2

Abx penetrate prostate poorly, seed UTIs

• leukocytosis in prostatic secretions, positive bacterial cultures

Low back pain, dysuria, perineal and suprapubic discomfort; or asymptomatic

Hx: recurrent UTI same organism

Question 3

Chronic abacterial prostatitis

Answer 3

• Expressed prostatic secretions >10 leukocytes, bacterial cultures negative

No hx of UTI recurrence

Question 4

Granulomatous prostatitis

Answer 4

Instillation of BCG within bladder for tx of superficial bladder cancer

• Nonspecific: No bacteria seen within tissue; rxn to secretions from ruptured prostatic ducts, acini

Fungal in immunocomp.

Question 5

Benign Prostatic Hyperplasia or Nodular Hyperplasia

Answer 5

Nodular hyperplasia of prostatic stromal and epithelial cells → urinary obstruction

> 50 yo

Question 6

Adenocarcinoma pathogenesis

Answer 6

X-linked – androgen receptor – CAG repeats

Germline mutation BRAC2, HOXB13
Chr rearrangements: ERG or ETV1 next to androgen regulated TMPRSS2 promoter – Whites

Amplification of 8q24 – MYC
Deletions of PTEN
Loss of TP53 (deletion or mutation)
Deletion of RB
Amplifications of AR gene locus
Hypermethylation of GSTP1 on 11q13: downregs GSTP1 

Epigenetic modifications: RB, CDKN2A, MLH1, MSH2, suppression of APC (Wnt pathway)

Urine PCA3 – 95% prostate CA; TMPRSS2-ERG fusion DNA

Precursor lesion: prostatic intraepithelial neoplasia (PIN) – rearrangements of ETS genes

Question 7

Adenocarcinoma pathology

Answer 7

• Peripheral zone, posterior location
• Gritty, firm; within tissue – difficult to visualize, readily palpable
• Local extension: periprostatic tissue, seminal vesicles, base of urinary bladder
• Advanced: ureteral obstruction
• Mets via lymphatics to obturator nodes then paraaortic nodes.
• Hematogenous spread to bones – axial skeleton; some widely to viscera (exception)
• Bone mets: osteoblastic – lumbar spine, proximal femur, pelvis, thoracic spine then ribs
• Gland pattern, well defined; smaller than benign glands, lined with single uniform cuboidal or low columnar epithelium; crowded
• Absent basal cell layer; mitotic figures uncommon
• Pale-clear to amphophilic cytoplasm; large nuclei, 1+ nucleoli
• Perineural invasion
• AMACR + (upregulated)
• PIN: architecturally benign, branching prostatic acini lined by atypical cells with prominent nucleoli. – surrounded by patchy layer of basal cells and intact BM

Question 8

Adenocarcinoma clinical features

Answer 8

• Peripheral zone, posterior location
• Gritty, firm; within tissue – difficult to visualize, readily palpable
• Local extension: periprostatic tissue, seminal vesicles, base of urinary bladder
• Advanced: ureteral obstruction
• Mets via lymphatics to obturator nodes then paraaortic nodes.
• Hematogenous spread to bones – axial skeleton; some widely to viscera (exception)
• Bone mets: osteoblastic – lumbar spine, proximal femur, pelvis, thoracic spine then ribs
• Gland pattern, well defined; smaller than benign glands, lined with single uniform cuboidal or low columnar epithelium; crowded
• Absent basal cell layer; mitotic figures uncommon
• Pale-clear to amphophilic cytoplasm; large nuclei, 1+ nucleoli
• Perineural invasion
• AMACR + (upregulated)
• PIN: architecturally benign, branching prostatic acini lined by atypical cells with prominent nucleoli. – surrounded by patchy layer of basal cells and intact BM

Question 9

Adenocarcinoma other

Answer 9

Large CAG stretches – Kennedy disease – muscle cramping/weakness

Tx: castration, antiandrogens

Resistance to antiandrogens: AR gene amplification, ligand-independent activation, mutations allowing non-androgen ligands; alternative signaling pathways

Question 10

Ductal adenocarcinomas

Answer 10

• Peripheral ducts
• Squamous differentiation following hormone therapy or de novo

Hematuria, urinary obstructive sumptoms
Poor prognosis

Question 11

Colloid carcinoma of prostate

Answer 11

• Abundant mucinous secretion

Question 12

Mesenchymal tumors

Answer 12

• Prostatic stroma derived