Prostate Pathology

Question 1

What are the prostate zones? Which site is most likely to have cancer growth and which site hypertrophies with age?

Answer 1

TZ = transitional zone (surrounds urethra and is part of prostate predominantly affected by nodular hyperplasia) !20% of carcinomas occur here

CZ = Central zone

PZ = Peripheral zone (palpable on rectal exam and 75% of prostate carcinomas occur here)

Anterior fibromuscular stroma

Question 2

How many layers do normal glandular cells of the prostate have?

Answer 2

2 layers: basal cell layer and epithelial cell layer (tall columnar cells)

Question 3

What conditions most commonly affect the prostate gland?

Answer 3

3 common conditions:

Nodular hyperplasia (BPH) - most common

Neoplasms of the prostate

Inflammatory conditions (prostatitis - acute, chronic, bacterial, abacterial, granulomatous)

Less common:

Thrombosis and infarction

Cysts

Parasitic infections

Amyloidosis

Question 4

What is nodular hyperplasia?

Answer 4

Also known as benign prostatic hyperplasia which is very common after 50 years of age and uncommon before 40

Seen at autopsy in 95% of 70 year old males but only clinically significant in 5 - 10%

Question 5

What causes nodulat hyperplasia?

Answer 5

Cause unknown but theory is that it is caused by an imbalance of oestrogen, testosterone, and dihydrotestosterone

Question 6

How does nodular hyperplasia affect the body?

Answer 6

Results in urethral compression making urine storage and passage more difficult. Symptoms include:

Frequency, nocturia, urgency, and incontinence.

Slow and weak stream, difficulty initiating, stopping flow, dribbling.

Question 7

What happens in nodular hyperplasia?

Answer 7

Proliferation of epithelial cells of the glands and ducts

Proliferation of smooth muscle cells and fibroblasts within the stroma

Question 8

What are complications associated with nodular hyperplasia?

Answer 8

Chronic obstruction: Hypertrophy of the bladder, urinary stasis, recurrent urinary tract infections, backpressure if obstruction is prolonged, causing hydroureter, hydronephrosis, renal failure, and death.

Question 9

What is the most common cancer of the prostate?

Answer 9

Prostate adenocarcinoma

All other tumours of the prostate are rare

Others are very rare like TCC, SCC, sarcomas, and lymphomas

Question 10

How common is prostate cancer?

Answer 10

Very common, in Australia it is the most common cause of cancer in men after non-melanoma skin cancer. 2nd most common cause of cancer related death in Australia.

For male patients the lifetime risk of being diagnosed with prostate cancer is 1 in 6 and lifetime risk of dying from prostate cancer is 1 in 30

Question 11

What are the risk factors of prostate cancer?

Answer 11

Increasing rate with age

Ethnicity: Black most common (also highest death rates) rare in Asian males.

Family history (risk increases 2 fold when a first degree relative has prostate cancer.

Genetic factors: Especially germline mutations in DNA repair genes like BRCA2, BRCA1 and lynch syndrome

Dietary factors: Obesity, diet high in fat

Question 12

How is prostate carcinoma diagnosed?

Answer 12

Clincal exam

Most men with early stage prostate cancer have no symptoms

Urinary frequency, urgency, nocturia and hesitancy - difficult to separate from symptoms of nodular hyperplasia.

Haematuria/haematospermia (uncommon)

Bone pain - when carcinoma metastasizes.

80% of the time the diagnosis is made on a biopsy done for an elevated PSA

Question 13

How is prostate cancer screened?

Answer 13

PSA is a protein made only in the prostate and produced by secretory cells (and cancer cells)

PSA rises with age so should be compared to norm for that age group

In ca PSA production is increased and tissue barriers between prostate glands and capillaries are disrupted, releasing more into the blood stream

Question 14

What other conditions besides prostate cancer can cause elevated PSA?

Answer 14

Nodular hyperplasia

Prostate carcinoma

Prostatits

Perineal trauma

Question 15

What is the approach taken to PSA screening?

Answer 15

Some organisations are for PSA screening. Others recommend discussion with health care provider before PSA screening.

Not before 50 years of age and not after 70 years of age

Question 16

How is the prostate biopsied?

Answer 16

Through the rectum

Question 17

What does acinar adenocarcinoma look like under the microscope?

Answer 17

Infiltrative glands that are too small, too crowded, or too clear.

Absent basal cell layer

Large nuclei

Prominent nucleoli

Question 18

What kind of disease is prostate carcinoma?

Answer 18

Prostate cancer is a heterogeneous disease with a highly variable clinical course.

Many patients have an indolent disease that will not threaten their health during their lifetime.

Others have an aggressive disease with progression, metastasis and death.

Question 19

How can architecture of prostate cancer impact clinical course?

Answer 19

Aggressiveness of prostate cancer can be assessed by Gleason scoring: In this scoring method 2 numbers are assigned to a cancer the first number is the most prominent architecture type the second is the second most common:

Pattern 1 and 2 are no longer used.

Pattern 3: single well formed glands infiltrating normal glands

Pattern 4: Fused glands, poorly formed glands

Pattern 5: Sheets of cells, single cells, tumour necrosis

To understand this look at slide with Gleason scoring

Total of the score correlates with the outcome

Question 20

What other factors are included in prostate pathology report?

Answer 20

Type of tumour

Size of tumour (Volume and % involved)

Grade (Gleason score

Stage (TNM): Extraprostatic extension, lymph node status, distant metastases

Perneural invasion

Margins

Question 21

How is prostate cancer treated?

Answer 21

Active surveillance

Surgery

Radiation therapy

Hormone therapy

Chemotherapy