Difference between revisions of "Prostate gland"

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The '''prostate gland''' adds juice to the sperm.  In old men it creates lotsa problems... [[nodular hyperplasia]] (commonly called BPH or [[benign prostatic hyperplasia]]) and cancer (adenocarcinoma).   
[[Image:Prostatelead.jpg|thumb|right|200px|The prostate gland and its surrounding structures. (WC/NCI)]]
The '''prostate gland''' adds juice to the sperm.  In old men it creates a lot of problems... [[nodular hyperplasia]] (commonly called BPH or [[benign prostatic hyperplasia]]) and cancer (usually adenocarcinoma).   


[[Prostate cancer]] is such a big topic it is dealt with in its own article.
[[Prostate cancer]] is such a big topic it is dealt with in its own article.
 
The female homologue of the prostate gland is considered to be Skene's gland.<ref name=pmid8522254>{{Cite journal  | last1 = Dodson | first1 = MK. | last2 = Cliby | first2 = WA. | last3 = Pettavel | first3 = PP. | last4 = Keeney | first4 = GL. | last5 = Podratz | first5 = KC. | title = Female urethral adenocarcinoma: evidence for more than one tissue of origin? | journal = Gynecol Oncol | volume = 59 | issue = 3 | pages = 352-7 | month = Dec | year = 1995 | doi = 10.1006/gyno.1995.9963 | PMID = 8522254 }}</ref>


=Normal prostate gland=
=Normal prostate gland=
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**Second cell layer may be difficult to see (like in breast).
**Second cell layer may be difficult to see (like in breast).
*Epithelium in glands is "folded" or "tufted".
*Epithelium in glands is "folded" or "tufted".
**Very important - helps on differentiate from Gleason pattern 3.
**Very important - helps to differentiate from Gleason pattern 3.
*Luminal epithelium often clear cytoplasm.
*Luminal epithelium often clear cytoplasm.
*Single nucleus.
*Single nucleus.
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Notes:
Notes:
*Tufted epithelium is a strong indicator of benignancy; however two uncommon prostate cancer typically have tufted epithelium:
*Tufted epithelium is a strong indicator of benignancy; however two uncommon prostate cancer variants typically have tufted epithelium:
**[[Pseudohyperplastic adenocarcinoma]].
**[[Pseudohyperplastic adenocarcinoma]].
**[[Foamy gland carcinoma]].
**[[Foamy gland carcinoma]].
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==IHC of normal prostate==
==IHC of normal prostate==
Normal prostate:  
Normal prostate:  
*AMACR -ve (mark epithelial cells).  
*[[AMACR]] -ve (mark epithelial cells).  
*CK5/6 +ve,<ref name=pmid19605815>{{Cite journal  | last1 = Trpkov | first1 = K. | last2 = Bartczak-McKay | first2 = J. | last3 = Yilmaz | first3 = A. | title = Usefulness of cytokeratin 5/6 and AMACR applied as double sequential immunostains for diagnostic assessment of problematic prostate specimens. | journal = Am J Clin Pathol | volume = 132 | issue = 2 | pages = 211-20; quiz 307 | month = Aug | year = 2009 | doi = 10.1309/AJCPGFJP83IXZEUR | PMID = 19605815 }}</ref> p63 +ve, HMWCK +ve (mark basal cells).
*[[CK5/6]] +ve,<ref name=pmid19605815>{{Cite journal  | last1 = Trpkov | first1 = K. | last2 = Bartczak-McKay | first2 = J. | last3 = Yilmaz | first3 = A. | title = Usefulness of cytokeratin 5/6 and AMACR applied as double sequential immunostains for diagnostic assessment of problematic prostate specimens. | journal = Am J Clin Pathol | volume = 132 | issue = 2 | pages = 211-20; quiz 307 | month = Aug | year = 2009 | doi = 10.1309/AJCPGFJP83IXZEUR | PMID = 19605815 }}</ref> p63 +ve, HMWCK +ve (mark basal cells).
*PSA (prostate-specific antigen) +ve, PSAP (prostatic-specific acid phosphatase) +ve.
*PSA ([[prostate-specific antigen]]) +ve, PSAP ([[prostatic-specific acid phosphatase]]) +ve.
 
==Sign out==
===Staining slightly abnormal - morphology not definitely abnormal===
<pre>
COMMENT:
Very focal AMACR staining is seen; this is interpreted as negative, in the
context of no definite cytologic changes.  The basal cells appear to be
preserved in all of the tissue sampled.
</pre>
 
===Compatible with previous biopsy===
<pre>
COMMENT:
Siderophages are seen in several cores; this is compatible with the history
of a previous biopsy.
</pre>


=Other accessory glands=
=Other accessory glands=
==Bulbourethral gland==
==Bulbourethral gland==
*[[AKA]] ''Cowper's gland''.
*[[AKA]] ''Cowper's gland''.
===General===
{{Main|Bulbourethral gland}}
*Mucinous glands at the apex of the prostate.
 
===Microscopic===
Features:<ref name=pmid9158679>{{Cite journal  | last1 = Cina | first1 = SJ. | last2 = Silberman | first2 = MA. | last3 = Kahane | first3 = H. | last4 = Epstein | first4 = JI. | title = Diagnosis of Cowper's glands on prostate needle biopsy. | journal = Am J Surg Pathol | volume = 21 | issue = 5 | pages = 550-5 | month = May | year = 1997 | doi =  | PMID = 9158679 }}</ref>
*Lobular glands with abundant pale cytoplasm.
**Resemble (mucinous) [[salivary gland]]s.
*Often assocatiated with skeletal muscle.<ref>URL: [http://webpathology.com/image.asp?case=21&n=4 http://webpathology.com/image.asp?case=21&n=4]. Accessed on: 3 June 2013.</ref>
 
DDx:
*[[Foamy gland carcinoma]].
*Mucinous metaplasia of the prostate.
 
Images:
*[http://pathology.mc.duke.edu/research/histo_course/mixed_saliv.jpg Mucinous/serous salivary gland (duke.edu)].
*[http://webpathology.com/image.asp?case=21&n=4 Cowper gland (webpathology.com)].
 
===Stains===
*[[Mucicarmine]] +ve.
*[[PAS-D]] +ve.
 
===IHC===
Features:<ref name=pmid9158679/>
*PSAP -ve.
*PSA +ve.
*HMWCK +ve.


==Seminal vesicles==
==Seminal vesicles==
===General===
{{Main|Seminal vesicles}}
*Seen in radical prostatectomies and occasionally in core biopsies.
 
===Microscopic===
*Fern-like architecture - epithelial component clustered closely, looks like it connects.
**Epithelium surrounded by a thick layer of muscle (>10 cells across ~80 microns).
*Lipofuscin (coarse cytoplasmic yellow granules approximately 1-2 micrometers) - '''key feature'''.
*Nucleoli - common.
*Nuclear inclusions - common.<ref>URL: [http://surgpathcriteria.stanford.edu/prostate/adenocarcinoma/benign-vs-carcinoma.html http://surgpathcriteria.stanford.edu/prostate/adenocarcinoma/benign-vs-carcinoma.html]. Accessed on: 10 January 2013.</ref>
 
Notes:
*The ''ejaculatory ducts'' have the same epithelium as the seminal vesicles.<ref name=pmid12657938>{{cite journal |author=Leroy X, Ballereau C, Villers A, ''et al.'' |title=MUC6 is a marker of seminal vesicle-ejaculatory duct epithelium and is useful for the differential diagnosis with prostate adenocarcinoma |journal=Am. J. Surg. Pathol. |volume=27 |issue=4 |pages=519–21 |year=2003 |month=April |pmid=12657938 |doi= |url=}}</ref>
 
====Images====
<gallery>
Image:Seminal_vesicle_low_mag.jpg | SV - showing fern-like architecture. (WC/Nephron)
Image:Seminal_vesicle_high_mag.jpg | SV - looking vaguely like to prostate adenocarcinoma. (WC/Nephron)
Image:Seminal_vesicle_intermed_mag.jpg | SV - looks a bit like prostate but lumina too big. (WC/Nephron)
</gallery>
www:
*[http://dspace.udel.edu:8080/dspace/bitstream/19716/2016/1/cmrsvlm3.GIF SV (udel.edu)].
 
===IHC===
*PSA -ve.<ref name=pmid22895132>{{Cite journal  | last1 = Itami | first1 = Y. | last2 = Nagai | first2 = Y. | last3 = Kobayashi | first3 = Y. | last4 = Shimizu | first4 = N. | last5 = Yamamoto | first5 = Y. | last6 = Minami | first6 = T. | last7 = Hayashi | first7 = T. | last8 = Nozawa | first8 = M. | last9 = Yoshimura | first9 = K. | title = [A case of prostatic cancer with a low PSA level accompanied with cystic formation requiring differentiation from adenocarcinoma of the seminal vesicle]. | journal = Hinyokika Kiyo | volume = 58 | issue = 7 | pages = 349-53 | month = Jul | year = 2012 | doi =  | PMID = 22895132 }}</ref>
*CK7 +ve.<ref name=pmid19468449>{{Cite journal  | last1 = Tarján | first1 = M. | last2 = Ottlecz | first2 = I. | last3 = Tot | first3 = T. | title = Primary adenocarcinoma of the seminal vesicle. | journal = Indian J Urol | volume = 25 | issue = 1 | pages = 143-5 | month = Jan | year = 2009 | doi = 10.4103/0970-1591.45557 | PMID = 19468449 }}</ref><ref name=pmid22076175>{{Cite journal  | last1 = Terada | first1 = T. | title = Monstrous epithelial cell clusters in the seminal vesicle. | journal = Int J Clin Exp Pathol | volume = 4 | issue = 7 | pages = 727-30 | month =  | year = 2011 | doi =  | PMID = 22076175 }}</ref>
*CK20 -ve.<ref name=pmid19468449/>
*p63 +ve.<ref name=pmid22076175/>
*CK34betaE12 -ve.<ref name=pmid22076175/>
*AMACR -ve.<ref name=pmid22076175/>
 
===Sign out===
<pre>
B. PROSTATE, RIGHT MEDIAL SUPERIOR, BIOPSY:
- BENIGN PROSTATE TISSUE.
- BENIGN SEMINAL VESICLE/EJACULATORY DUCT.
</pre>


=Specimens=
=Specimens=
*Prostate core biopsy - done transrectal.
*[[Prostate core biopsy]] - done transrectal.
*Prostate chips (from a ''transurethral resection of the prostate'', abbreviated ''TURP'') - usu. done for [[nodular hyperplasia of the prostate gland]]; may be done in the context of obstructing cancer.
*[[Prostate chips]] (from a ''transurethral resection of the prostate'', abbreviated ''TURP'') - usu. done for [[nodular hyperplasia of the prostate gland]]; may be done in the context of obstructing cancer.
*Radical prostatectomy - includes the [[seminal vesicles]].
*[[Radical prostatectomy]] - includes the [[seminal vesicles]].
*Radical cystoprostatectomy - includes the [[urinary bladder]] and [[seminal vesicles]].<ref>URL: [http://www.cancer.gov/dictionary?cdrid=446218 http://www.cancer.gov/dictionary?cdrid=446218]. Accessed on: 23 February 2012.</ref>
*[[Radical cystoprostatectomy]] - includes the [[urinary bladder]] and [[seminal vesicles]].<ref>URL: [http://www.cancer.gov/dictionary?cdrid=446218 http://www.cancer.gov/dictionary?cdrid=446218]. Accessed on: 23 February 2012.</ref>


=Approach=
=Approach=
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==Common diagnoses==
==Common diagnoses==
*Benign.
*Benign.
**[[atrophy of the prostate|Atrophy]] - may resemble adenocarcinoma - typically not reported.
**[[Atrophy of the prostate|Atrophy]] - may resemble adenocarcinoma - typically not reported.
**Adenosis - may resemble adenocarcinoma - typically not reported.
**[[Adenosis of the prostate|Adenosis]] - may resemble adenocarcinoma - typically not reported.
*[[Prostate adenocarcinoma]].  
*[[Prostate adenocarcinoma]].  
**Most common Grade is 3+3=6.
*[[HGPIN]] (high-grade prostatic intraepithelial neoplasia) - prostate adenocarcinoma precursor lesion.
*[[HGPIN]] (high-grade prostatic intraepithelial neoplasia) - prostate adenocarcinoma precursor lesion.
*[[ASAP]] (atypical small acinar proliferation) - used if you have a few abnormal appearing glands... but can't decide between prostate adenocarcinoma & benign.
*[[ASAP]] (atypical small acinar proliferation) - used if you have a few abnormal appearing glands... but can't decide between prostate adenocarcinoma & benign.
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=Clinical history=
=Clinical history=
*PSA (serum).
{{Main|Prostate specific antigen}}
*[[PSA]] (serum).
** >10 ng/mL worrisome for prostate cancer.
** >10 ng/mL worrisome for prostate cancer.
** Normal is age dependent - increases with age, usu. cut-off ~ 4 ng/mL.
** Normal is age dependent - increases with age, usu. cut-off ~ 4 ng/mL.
*HIFU = ''High Intensity Focused Ultrasound'' - an ablation procedure for prostate cancer.<ref>URL: [http://www.internationalhifu.com/what-is-hifu-mainmenu-132.html http://www.internationalhifu.com/what-is-hifu-mainmenu-132.html]. Accessed on: 15 June 2010.</ref>
*HIFU = ''High Intensity Focused Ultrasound'' - an ablation procedure for prostate cancer.<ref>URL: [http://www.internationalhifu.com/what-is-hifu-mainmenu-132.html http://www.internationalhifu.com/what-is-hifu-mainmenu-132.html]. Accessed on: 15 June 2010.</ref>


=Specific conditions=
=Benign changes and remnants=
==Adenosis of the prostate gland==
*[[AKA]] ''atypical adenomatous hyperplasia of the prostate gland'' (or ''atypical adenomatous hyperplasia'').
{{Main|Adenosis of the prostate gland}}
 
==Basal cell hyperplasia of the prostate==
{{Main|Basal cell hyperplasia of the prostate}}
 
==Atrophy of the prostate==
*[[AKA]] ''atrophy''.
*[[AKA]] ''prostatic atrophy''.
*[[AKA]] ''atrophy of the prostate gland''.
{{Main|Atrophy of the prostate gland}}
 
==Mesonephric remnant of the prostate gland==
{{Main|Mesonephric remnant of the prostate gland}}
 
=Benign conditions=
==Prostatic nodular hyperplasia==
==Prostatic nodular hyperplasia==
*[[AKA]] ''nodular hyperplasia of the prostate''.
*[[AKA]] ''nodular hyperplasia of the prostate''.
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*AKA ''benign prostatic hypertrophy''.
*AKA ''benign prostatic hypertrophy''.
**This is a misnomer. It is ''not'' a hypertrophy.
**This is a misnomer. It is ''not'' a hypertrophy.
 
{{Main|Nodular hyperplasia of the prostate}}
===General===
*Very common.
*Incidence increases with age.
 
Clinical - mnemonic ''I WISH 2p'':<ref>{{Ref TN2006| U5}}</ref>
*Intermittency.
*Weak stream.
*Incomplete emptying.
*Straining.
*Hesitancy.
*Post-void dribbling.
*Prolonged voiding.
 
Treatment:
*Medications.
*Transurethral resection of the prostate (TURP).
 
===Microscopic===
Features:
*Stromal and/or glandular hyperplasia.
 
Note:
*Should '''not''' be diagnosed on core biopsy!
 
DDx:
*[[Urothelial carcinoma]] - significant nuclear atypia.
 
====Images====
<gallery>
Image:Nodular_hyperplasia_of_the_prostate.jpg | Prostatic nodular hyperplasia. (WC/Nephron)
Image:Urethral_urothelial_cell_carcinoma.jpg | UCC. (WC/Nephron)
</gallery>
 
===Sign out===
====Urothelium present====
<pre>
PROSTATE TISSUE, TRANSURETHRAL RESECTION OF THE PROSTATE (TURP):
- BENIGN PROSTATIC TISSUE WITH GLANDULAR AND STROMAL PROLIFERATION.
- UROTHELIAL MUCOSA WITH A MILD LYMPHOCYTIC INFILTRATE.
- NEGATIVE FOR MALIGNANCY.
</pre>
 
<pre>
PROSTATE TISSUE, TRANSURETHRAL RESECTION OF THE PROSTATE (TURP) AND URINARY BLADDER NECK:
- BENIGN PROSTATIC TISSUE WITH GLANDULAR AND STROMAL PROLIFERATION.
- UROTHELIUM WITH THE CHANGES OF CYSTITIS CYSTICA ET GLANDULARIS.
- NEGATIVE FOR MALIGNANCY.
</pre>
 
<pre>
PROSTATE TISSUE, TRANSURETHRAL RESECTION OF THE PROSTATE (TURP) AND URINARY BLADDER NECK:
- BENIGN PROSTATIC TISSUE WITH GLANDULAR AND STROMAL PROLIFERATION, AND FOCAL
  ACUTE AND CHRONIC INFLAMMATION.
- UROTHELIUM WITH THE CHANGES OF CYSTITIS CYSTICA ET GLANDULARIS.
- NEGATIVE FOR MALIGNANCY.
</pre>
 
====No urothelium present====
<pre>
PROSTATE GLAND, TRANSURETHRAL RESECTION OF THE PROSTATE (TURP):
- BENIGN PROSTATIC TISSUE WITH GLANDULAR AND STROMAL PROLIFERATION.
</pre>
 
====Post-TURP granuloma present====
<pre>
PROSTATE TISSUE, TRANSURETHRAL RESECTION OF THE PROSTATE (TURP):
- BENIGN PROSTATIC TISSUE WITH GLANDULAR AND STROMAL PROLIFERATION WITH
PROMINENT BLOOD VESSELS AND SQUAMOUS METAPLASIA.
- PALISADING GRANULOMA WITH NECROTIC CORE, SEE COMMENT.
- UROTHELIAL MUCOSA WITH A MILD INFLAMMATORY INFILTRATE.
- NEGATIVE FOR MALIGNANCY.
 
COMMENT:
This is morphologically consistent with a post-TURP granuloma.
</pre>


==Acute inflammation of the prostate gland==
==Acute inflammation of the prostate gland==
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==Granulomatous prostatitis==
==Granulomatous prostatitis==
{{Main|Granulomatous prostatitis}}
{{Main|Granulomatous prostatitis}}
==Atrophy of the prostate==
*[[AKA]] ''atrophy''.
*[[AKA]] ''prostatic atrophy''.
*[[AKA]] ''atrophy of the prostate gland''.
===General===
*Small glands (may mimic Gleason score 3 pattern).
===Microscopic===
Features:
*Glands often have a jagged edges/prows (in cancer the glands tend to have round edges) - '''key feature'''.
**Prow = forward most part of a ship's bow that cuts through the water.<ref>[http://en.wikipedia.org/wiki/Prow http://en.wikipedia.org/wiki/Prow]</ref>
***You may have come across ''prow'' in the context of [[breast cancer]], i.e. ''tubular carcinoma''.
*Gland density is usually lower than in prostate carcinoma, i.e. glands are not back-to-back - '''key feature'''.
*Atrophic glands are often hyperchromatic.<ref>SN. June 3, 2009.</ref>
*Scant cytoplasm - usually.
Negatives:
*Nuclei like normal, i.e. nucleoli uncommon.
*Should have two cell layers, i.e. epithelial and myoepithelial (may be difficult to see).
Notes:
*Atrophic glands may be scattered with non-atrophic ones.
*IHC may be misleading - basal cell loss.
DDx:
*[[Atrophic prostate carcinoma]].
====Atrophy versus cancer====
{| class="wikitable sortable"
! Histologic feature
! Atrophy
! Cancer
|-
|Glandular architecture/<br>arrangement
|angulated glands, may <br>look like they originate <br>from one large duct
|round glands, <br>often back-to-back
|-
|Nuclear <br>hyperchromasia
|marked
|moderate
|-
|Cytoplasm
|scant/minimal
|moderate, may <br>be amphophilic
|-
|Basal cells
|may be visible
|absent
|-
|Nucleoli
|absent
|present
|-
|Secretions in <br>glands
|no
|yes - eosinophilic <br>or blue
|}
===Sign out===
Generally, this finding is ''not'' reported; it is considered a normal finding.


==Prostatic infarct==
==Prostatic infarct==
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*[http://www.sciencephoto.com/media/258565/enlarge Prostatic thrombosis (sciencephoto.com)].
*[http://www.sciencephoto.com/media/258565/enlarge Prostatic thrombosis (sciencephoto.com)].


==Basal cell hyperplasia of the prostate==
=Preneoplastic changes and atypical changes=
*[[AKA]] ''[[basal cell hyperplasia]]''.
===General===
*Benign lesion that can be misdiagnosed as cancer.<ref name=pmid6195916>{{Cite journal  | last1 = Cleary | first1 = KR. | last2 = Choi | first2 = HY. | last3 = Ayala | first3 = AG. | title = Basal cell hyperplasia of the prostate. | journal = Am J Clin Pathol | volume = 80 | issue = 6 | pages = 850-4 | month = Dec | year = 1983 | doi =  | PMID = 6195916 }}</ref>
 
===Microscopic===
Features:<ref>URL: [http://pathologyoutlines.com/prostate.html#bch http://pathologyoutlines.com/prostate.html#bch]. Accessed on: 28 June 2010.</ref>
*Low power gland architecture near normal.<ref>URL: [http://www.nature.com/modpathol/journal/v16/n6/fig_tab/3880810f1.html http://www.nature.com/modpathol/journal/v16/n6/fig_tab/3880810f1.html]. Accessed on: 28 June 2010.</ref><ref>URL: [http://www.nature.com/modpathol/journal/v16/n6/fig_tab/3880810f2.html http://www.nature.com/modpathol/journal/v16/n6/fig_tab/3880810f2.html]. Accessed on: 28 June 2010.</ref>
**Glands ''not'' as small as cancer.
**Folds in gland lumina.
*No nuclear hyperchromasia.
*Two cell populations (as in normal prostate glands).
*Basal cells may have nucleoli.
 
DDx:
*[[High-grade prostatic intraepithelial neoplasia]] - has nuclear hyperchromasia, architecture usually different (micropapillary, tufted, cribriform or flat).
*[[Prostatic adenocarcinoma]].
 
Image:
*[http://webpathology.com/image.asp?case=18&n=1 Basal cell hyperplasia of the prostate (webpathology.com)].
 
==High-grade prostatic intraepithelial neoplasia==
==High-grade prostatic intraepithelial neoplasia==
*Abbreviated as ''HGPIN''.
*Abbreviated as ''HGPIN''.
*May be referred to as ''prostatic intraepithelial neoplasia'', abbreviated ''PIN''.
*May be referred to as ''prostatic intraepithelial neoplasia'', abbreviated ''PIN''.
===General===
{{Main|High-grade prostatic intraepithelial neoplasia}}
*Thought to be a precursor lesion for prostate adenocarcinoma.
**Multifocal HGPIN considered a risk for prostate cancer on re-biopsy.<ref name=pmid21191509>{{Cite journal  | last1 = Srigley | first1 = JR. | last2 = Merrimen | first2 = JL. | last3 = Jones | first3 = G. | last4 = Jamal | first4 = M. | title = Multifocal high-grade prostatic intraepithelial neoplasia is still a significant risk factor for adenocarcinoma. | journal = Can Urol Assoc J | volume = 4 | issue = 6 | pages = 434 | month = Dec | year = 2010 | doi =  | PMID = 21191509 }}</ref><ref name=pmid19524976>{{Cite journal  | last1 = Merrimen | first1 = JL. | last2 = Jones | first2 = G. | last3 = Walker | first3 = D. | last4 = Leung | first4 = CS. | last5 = Kapusta | first5 = LR. | last6 = Srigley | first6 = JR. | title = Multifocal high grade prostatic intraepithelial neoplasia is a significant risk factor for prostatic adenocarcinoma. | journal = J Urol | volume = 182 | issue = 2 | pages = 485-90; discussion 490 | month = Aug | year = 2009 | doi = 10.1016/j.juro.2009.04.016 | PMID = 19524976 }}</ref>
**A small focus of HGPIN does not appear to be associated with an increased risk for prostate cancer on re-biopsy at one year if the initial biopsy had 8 or more cores.<ref name=pmid16406886>{{Cite journal  | last1 = Herawi | first1 = M. | last2 = Kahane | first2 = H. | last3 = Cavallo | first3 = C. | last4 = Epstein | first4 = JI. | title = Risk of prostate cancer on first re-biopsy within 1 year following a diagnosis of high grade prostatic intraepithelial neoplasia is related to the number of cores sampled. | journal = J Urol | volume = 175 | issue = 1 | pages = 121-4 | month = Jan | year = 2006 | doi = 10.1016/S0022-5347(05)00064-9 | PMID = 16406886 }}</ref>
 
Low-grade prostatic intraepithelial neoplasia:
*Not reported and generally believed to be irrelevant biologically/clinically.
**''PIN'' not otherwise specified refers to ''HGPIN''.
**Low-grade PIN has the architecture of HGPIN but lacks the nuclear atypia.
 
====HGPIN and cancer on follow-up biopsy====
Prostate cancer on follow-up biopsy by number of HGPIN sites from Merrimen ''et al.'':<ref name=pmid19524976>{{Cite journal  | last1 = Merrimen | first1 = JL. | last2 = Jones | first2 = G. | last3 = Walker | first3 = D. | last4 = Leung | first4 = CS. | last5 = Kapusta | first5 = LR. | last6 = Srigley | first6 = JR. | title = Multifocal high grade prostatic intraepithelial neoplasia is a significant risk factor for prostatic adenocarcinoma. | journal = J Urol | volume = 182 | issue = 2 | pages = 485-90; discussion 490 | month = Aug | year = 2009 | doi = 10.1016/j.juro.2009.04.016 | PMID = 19524976 }}</ref>
{| class="wikitable sortable"
! Number of cores<br> with HGPIN
! Odds ratio of cancer<br> on follow-up (95% CI)
|-
| 0
| 1.00 (reference)
|-
| 1
| 1.02 (0.73-1.40)
|-
| 2
| 1.55 (1.08-2.21)
|-
| 3
| 1.99 (1.16-3.40)
|-
| 4
| 2.66 (1.10-6.40)
|}
 
===Gross===
*Not evident on gross.
 
===Microscopic===
Features:<ref name=Ref_Amin3-56>{{Ref Amin|3-56}}</ref><ref name=pmid2002502>{{Cite journal  | last1 = Chin | first1 = AI. | last2 = Dave | first2 = DS. | last3 = Rajfer | first3 = J. | title = Is repeat biopsy for isolated high-grade prostatic intraepithelial neoplasia necessary? | journal = Rev Urol | volume = 9 | issue = 3 | pages = 124-31 | month =  | year = 2007 | doi =  | PMID = 17934569 | PMC = 2002502 }}</ref>
*Medium to large glands with architectural changes - see ''HGPIN architecture'' below.
**Described as "epithelial hyperplasia".
*Diagnosed on basis of nuclear changes.
**Hyperchromatic nuclei - '''key (low power) feature'''.
**Nucleoli present - '''key (high power) feature'''.
**Often increased NC ratio.
**Nuclear enlargement.
 
Notes:
*Nucleoli should be visible with the 20x objective.
**If one uses the 40x objective... one over calls.
*May need IHC for cancer versus HGPIN.
*Nucleoli should be present in >= 10% of cells in a gland to call it HGPIN.<ref>{{Ref Amin|3-55}}</ref>
**This criterium is not required by all pathologists.
 
DDx:
*[[Basal cell hyperplasia of the prostate]].
*[[Intraductal carcinoma of the prostate]].
*[[Prostatic adenocarcinoma]] - glands with HGPIN have two or more distinct cells layers.
**[[PIN-like prostatic ductal adenocarcinoma]] - glands crowded.
*Benign prostate - HPGIN has nuclear changes.
 
====HGPIN architecture====
There are several forms:<ref name=Ref_WMSP380>{{Ref WMSP|380}}</ref><ref name=pmid14739906>{{Cite journal  | last1 = Bostwick | first1 = DG. | last2 = Qian | first2 = J. | title = High-grade prostatic intraepithelial neoplasia. | journal = Mod Pathol | volume = 17 | issue = 3 | pages = 360-79 | month = Mar | year = 2004 | doi = 10.1038/modpathol.3800053 | PMID = 14739906 | url=http://www.nature.com/modpathol/journal/v17/n3/pdf/3800053a.pdf }}</ref>
*Flat - uncommon.
*Tufting - common.
*Micropapillary - common.
*Cribriform - rare.
 
Note:
*The architectural pattern is '''not''' thought to have any prognostic significance; however, it may be useful for differentiating it from benign prostate.
 
====Images====
<gallery>
Image:High-grade_prostatic_intraepithelial_neoplasia_low_mag.jpg | HGPIN - low mag. (WC/Nephron)
Image:High-grade_prostatic_intraepithelial_neoplasia_intermed_mag.jpg | HGPIN - intermed. mag. (WC/Nephron)
Image:High-grade_prostatic_intraepithelial_neoplasia_high_mag.jpg | HGPIN - high mag. (WC/Nephron)
</gallery>
===IHC===
*HGPIN: AMACR +ve, p63 +ve, HMWCK +ve.
*Cancer: AMACR +ve, p63 -ve, HMWCK -ve.
*Normal: AMACR -ve, p63 +ve, HMWCK +ve.
 
===Sign out===
<pre>
A. PROSTATE, RIGHT LATERAL SUPERIOR, BIOPSY:
- HIGH-GRADE PROSTATIC INTRAEPITHELIAL NEOPLASIA;
- NEGATIVE FOR MALIGNANCY.
</pre>


==Atypical small acinar proliferation==
==Atypical small acinar proliferation==
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*[[AKA]] ''suspicious for carcinoma''.<ref>THvdK. 19 June 2010.</ref>
*[[AKA]] ''suspicious for carcinoma''.<ref>THvdK. 19 June 2010.</ref>
**''ASAP'' is preferred as it does not contain the word ''carcinoma'' and, thus, cannot be misread as ''carcinoma'', i.e. positive for malignancy.
**''ASAP'' is preferred as it does not contain the word ''carcinoma'' and, thus, cannot be misread as ''carcinoma'', i.e. positive for malignancy.
 
{{Main|Atypical small acinar proliferation}}
===General===
*It is a [[waffle diagnosis]], i.e. it is not considered an entity with a distinct pathobiology.<ref name=pmid17378841>{{cite journal |author=Flury SC, Galgano MT, Mills SE, Smolkin ME, Theodorescu D |title=Atypical small acinar proliferation: biopsy artefact or distinct pathological entity |journal=BJU International |volume=99 |issue=4 |pages=780-5 |year=2007 |month=January |pmid= 17378841 |doi= |url=http://www3.interscience.wiley.com/journal/118508438/abstract}}</ref>
**Analogous to ''[[ASCUS]]'' on a pap test.
*ASAP should be used sparingly.
**One benchmark is < 3-5% of biopsies.<ref>THvdK. 19 June 2010.</ref>
*Never diagnosed on excision, i.e. prostatectomy specimen.
 
====Association with adenocarcinoma====
*On subsequent [[biopsy]] - chance of finding [[adenocarcinoma]] is approximately 40%; this is higher than if there is [[high-grade prostatic intraepithelial neoplasia]] (HGPIN).<ref>{{cite journal |author=Leite KR, Camara-Lopes LH, Cury J, Dall'oglio MF, Sañudo A, Srougi M |title=Prostate cancer detection at rebiopsy after an initial benign diagnosis: results using sextant extended prostate biopsy |journal=Clinics |volume=63 |issue=3 |pages=339–42 |year=2008 |month=June |pmid=18568243 |doi= |url=http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322008000300009&lng=en&nrm=iso&tlng=en}}</ref>
 
====Management====
*ASAP is considered an indication for re-biopsy;<ref>{{cite journal |author=Bostwick DG, Meiers I |title=Atypical small acinar proliferation in the prostate: clinical significance in 2006 |journal=Arch. Pathol. Lab. Med. |volume=130 |issue=7 |pages=952–7 |year=2006 |month=July |pmid=16831049 |doi= |url=http://journals.allenpress.com/jrnlserv/?request=get-abstract&issn=0003-9985&volume=130&page=952}}</ref> in one survey of [[urologist]]s<ref>{{cite journal |author=Rubin MA, Bismar TA, Curtis S, Montie JE |title=Prostate needle biopsy reporting: how are the surgical members of the Society of Urologic Oncology using pathology reports to guide treatment of prostate cancer patients? |journal=Am. J. Surg. Pathol. |volume=28 |issue=7 |pages=946–52 |year=2004 |month=July |pmid=15223967 |doi= |url=}}</ref> 41/42 (~98%) of respondents considered it a sufficient reason to re-biopsy.
 
===Microscopic===
Features:
*Atypical appearing acini.
*Limited extent, e.g. 2-3 glands.
 
Notes:
*IHC not contributory.
*Deeper cuts didn't yield anything - '''important'''.
 
DDx:
*[[Prostatic adenocarcinoma]].


=Prostate cancer=
=Prostate cancer=
Line 549: Line 260:
{{reflist|2}}
{{reflist|2}}


=External links=
*[http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2006/prostate06_ckw.pdf CAP prostate check list] - cap.org.
*[http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2006/prostate06_ckw.pdf CAP prostate protocol] - cap.org.
*[http://162.129.103.34/prostate/ Gleason score quiz] - Johns Hopkins Prostate Center.


[[Category: Genitourinary pathology]]
[[Category: Genitourinary pathology]]

Latest revision as of 19:21, 10 February 2019

The prostate gland and its surrounding structures. (WC/NCI)

The prostate gland adds juice to the sperm. In old men it creates a lot of problems... nodular hyperplasia (commonly called BPH or benign prostatic hyperplasia) and cancer (usually adenocarcinoma).

Prostate cancer is such a big topic it is dealt with in its own article.

The female homologue of the prostate gland is considered to be Skene's gland.[1]

Normal prostate gland

Anatomy

Divided into three zones:[2]

  1. Peripheral zone - posterior aspect, palpable with digit.
  2. Central zone - considered resistant to disease.
  3. Transition zone - usual location for nodular hyperplasia.

Histology

  • Glands have two cell layers (similar to glands in breast).
    • Second cell layer may be difficult to see (like in breast).
  • Epithelium in glands is "folded" or "tufted".
    • Very important - helps to differentiate from Gleason pattern 3.
  • Luminal epithelium often clear cytoplasm.
  • Single nucleus.

Benign normal:

  • Corpora amylacea.
    • Round/ovoid-eosinophilic bodies -- with laminations (layered appearance).
    • In gland lumina.
    • Usually in benign glands - but cannot be used to exclude cancer.[3]
    • Very common.
    • These should be differentiated from eosinophilic proteinaceous debris - which is associated with cancer.

Negatives:

  • No nucleoli present (if you see nuclei think: cancer, HGPIN, reactive changes, basal cell hyperplasia).
  • No mitoses - these are uncommon... even in high grade prostate cancer.

Notes:

Images

  • Benign prostate with corpora amylacea - low mag. (WC/Nephron)

  • Benign prostate with corpora amylacea - high mag. (WC/Nephron)

IHC of normal prostate

Normal prostate:

Sign out

Staining slightly abnormal - morphology not definitely abnormal

COMMENT:
Very focal AMACR staining is seen; this is interpreted as negative, in the
context of no definite cytologic changes.  The basal cells appear to be 
preserved in all of the tissue sampled.

Compatible with previous biopsy

COMMENT:
Siderophages are seen in several cores; this is compatible with the history 
of a previous biopsy.

Other accessory glands

Bulbourethral gland

  • AKA Cowper's gland.
Main article: Bulbourethral gland

Seminal vesicles

Main article: Seminal vesicles

Specimens

Approach

  • Know the common diagnoses well.
  • Core biopsies - scan the slides with the 10x objective.

Common diagnoses

  • Benign.
    • Atrophy - may resemble adenocarcinoma - typically not reported.
    • Adenosis - may resemble adenocarcinoma - typically not reported.
  • Prostate adenocarcinoma.
  • HGPIN (high-grade prostatic intraepithelial neoplasia) - prostate adenocarcinoma precursor lesion.
  • ASAP (atypical small acinar proliferation) - used if you have a few abnormal appearing glands... but can't decide between prostate adenocarcinoma & benign.
  • Chronic inflammation.
  • Acute inflammation - can result in an elevated PSA and may have prompted the biopsy you're looking at.
  • Nodular hyperplasia of the prostate; AKA benign prostatic hypertrophy (BPH).
    • Not diagnosed on needle biopsies.
    • BPH is technically incorrect -- the process is a hyperplasia.
      • Hyperplasia = proliferation of cells, hypertrophy = enlargement of cells.
        • How to remember? A. Prostate... hyperPlasia.

Clinical history

Main article: Prostate specific antigen
  • PSA (serum).
    • >10 ng/mL worrisome for prostate cancer.
    • Normal is age dependent - increases with age, usu. cut-off ~ 4 ng/mL.
  • HIFU = High Intensity Focused Ultrasound - an ablation procedure for prostate cancer.[6]

Benign changes and remnants

Adenosis of the prostate gland

  • AKA atypical adenomatous hyperplasia of the prostate gland (or atypical adenomatous hyperplasia).
Main article: Adenosis of the prostate gland

Basal cell hyperplasia of the prostate

Main article: Basal cell hyperplasia of the prostate

Atrophy of the prostate

  • AKA atrophy.
  • AKA prostatic atrophy.
  • AKA atrophy of the prostate gland.
Main article: Atrophy of the prostate gland

Mesonephric remnant of the prostate gland

Main article: Mesonephric remnant of the prostate gland

Benign conditions

Prostatic nodular hyperplasia

  • AKA nodular hyperplasia of the prostate.
  • AKA benign prostatic hyperplasia (abbreviated BPH).
  • AKA benign prostatic hypertrophy.
    • This is a misnomer. It is not a hypertrophy.
Main article: Nodular hyperplasia of the prostate

Acute inflammation of the prostate gland

Prostate gland
External resources
EHVSC 10176
  • AKA prostate gland with acute inflammation.

General

  • A may lead to an increase in the PSA and prompt biopsy.

Note:

  • "Prostatitis" is considered a clinical diagnosis.
    • Cases are signed out as "acute inflammation".
      • Some pathologists do not comment on the presence (or absence) of inflammation.

Microscopic

Features:

  • Neutrophils within the glands, between the epithelial cells or within the stroma - key feature.
  • +/-Chronic inflammation (lymphocytes) within the surrounding stroma.

DDx:

Image

  • Prostate with acute inflammation. (WC/Nephron)

Sign out

G. PROSTATE, LEFT LATERAL SUPERIOR, BIOPSY:
- BENIGN PROSTATE TISSUE;
- FOCAL ACUTE INFLAMMATION. 

G. PROSTATE, LEFT LATERAL SUPERIOR, BIOPSY:
- BENIGN PROSTATE TISSUE;
- FOCAL ACUTE AND CHRONIC INFLAMMATION.

Chronic inflammation not otherwise specified

General

  • Common.
  • Non-specific finding.
  • Etiology usually not apparent on histomorphology.

Microscopic

Features:

  • Lymphocytes within the glands, between the epithelial cells or within the stroma - key feature.

Notes:

  • Rare scattered lymphocytes are common, especially in the central portion of the gland.
  • "Focal" one field with a 2.2 mm diameter involved.

Image

  • Prostate with chronic inflammation. (WC/Nephron)

Sign out

G. PROSTATE, LEFT LATERAL SUPERIOR, BIOPSY:
- BENIGN PROSTATE TISSUE;
- FOCAL CHRONIC INFLAMMATION. 

F. PROSTATE, RIGHT MEDIAL MIDZONE, BIOPSY:
- BENIGN PROSTATE TISSUE;
- CHRONIC INFLAMMATION.

Note:

  • Opinion is divided on whether this finding should be reported.
    • Advocates for reporting inflammation say "[i]t is just reporting what you see and may explain the bump in PSA."
    • Naysayers opine that "[i]t may provide false assurance that no cancer is present."

Granulomatous prostatitis

Main article: Granulomatous prostatitis

Prostatic infarct

General

Microscopic

Features:

  • Classic findings of necrosis:
    • Karyolysis (loss of nuclei), karyorrhexis (frag. of nuclei), pyknosis (small shrunken nuclei).
  • +/-Squamous metaplasia of prostate gland epithelium.

Notes:

  • Corpora amylacea - help... call it benign.
  • Glands maintain normal spacing.

DDx:

Image:

Preneoplastic changes and atypical changes

High-grade prostatic intraepithelial neoplasia

  • Abbreviated as HGPIN.
  • May be referred to as prostatic intraepithelial neoplasia, abbreviated PIN.
Main article: High-grade prostatic intraepithelial neoplasia

Atypical small acinar proliferation

  • Abbreviated ASAP.
  • AKA suspicious for carcinoma.[8]
    • ASAP is preferred as it does not contain the word carcinoma and, thus, cannot be misread as carcinoma, i.e. positive for malignancy.
Main article: Atypical small acinar proliferation

Prostate cancer

Main article: Prostate cancer

This is a big topic that is dealt with in its own article.

See also

References

  1. ↑ Dodson, MK.; Cliby, WA.; Pettavel, PP.; Keeney, GL.; Podratz, KC. (Dec 1995). "Female urethral adenocarcinoma: evidence for more than one tissue of origin?". Gynecol Oncol 59 (3): 352-7. doi:10.1006/gyno.1995.9963. PMID 8522254.
  2. ↑ McNeal, JE. (Aug 1988). "Normal histology of the prostate.". Am J Surg Pathol 12 (8): 619-33. PMID 2456702.
  3. ↑ Christian JD, Lamm TC, Morrow JF, Bostwick DG (January 2005). "Corpora amylacea in adenocarcinoma of the prostate: incidence and histology within needle core biopsies". Mod. Pathol. 18 (1): 36–9. doi:10.1038/modpathol.3800250.
  4. ↑ Trpkov, K.; Bartczak-McKay, J.; Yilmaz, A. (Aug 2009). "Usefulness of cytokeratin 5/6 and AMACR applied as double sequential immunostains for diagnostic assessment of problematic prostate specimens.". Am J Clin Pathol 132 (2): 211-20; quiz 307. doi:10.1309/AJCPGFJP83IXZEUR. PMID 19605815.
  5. ↑ URL: http://www.cancer.gov/dictionary?cdrid=446218. Accessed on: 23 February 2012.
  6. ↑ URL: http://www.internationalhifu.com/what-is-hifu-mainmenu-132.html. Accessed on: 15 June 2010.
  7. ↑ 7.0 7.1 Milord, RA.; Kahane, H.; Epstein, JI. (Oct 2000). "Infarct of the prostate gland: experience on needle biopsy specimens.". Am J Surg Pathol 24 (10): 1378-84. PMID 11023099.
  8. ↑ THvdK. 19 June 2010.
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