prostatepathology-091013220052-phpapp02

7/29/2019 prostatepathology-091013220052-phpapp02

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Prostate Pathology

Martha K. Terris, M.D.

Medical College of Georgia


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Normal

Complex glands with 2 cell layers, epithelial

and basal cell layers


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Normal

Complex glands with 2 cell layers, epithelial

and basal cell layers, no nucleoli


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Normal

HMW keratin stains basal layer


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BPH

Occurs in Transition Zone

Due to androgen stimulation & estrogen synergism


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Histologic features: both glands and stroma can become hyperplastic cytologically benign with 2 cell layers, bland nuclei and

abundant cytoplasm nonspecific chronic lymphocytic infiltrate is common


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BPH

Stromal Hyperplasia

Theorized to respond better to alpha-

blockade


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Corpora amylacea may be identified (laminatedeosinophilic concretions within the lumen of the gland)


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BPH

Basal Cell Layer not always easy to identify

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BPH

HMW keratin staining may show gaps in

basal layer but will always be at least partial

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BPH

Like normal prostate tissue, nucleoli are nottypically identified

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BPH

Branching glands, corpora amylacea, nonucleoli

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BPH

Nodule of glandular hyperplasia

Theorized to respond better to finasteride

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BPH


Theorized to respond better to finasteride

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BPH


Glands can be dilated with secretions

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BPH


Glands can be dilated with secretions

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P l id H l i


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Polypoid Hyperplasia

Aka Prostatic urethral polyps; Present with hematuria Small polyps demonstrating typical prostatic-type

epithelium; PSA and PAP positive; behavior is benign andrecurrence after TUR is unusual.

Histology can also be adenomatoid (nephrogenic adenoma;frequent recurrence) and adenomatous (endometroid)

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Infarcts

20-25% of BPH specimens have infarcts Patients may present with acute retention due to a

sudden increase in the size of the prostate

Gross: mottled and yellowish, or may appear

hemorrhagic

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Infarcts

Histologic features: typically shows three zones central zone of coagulative necrosis (everything looks

reddish with faint outlines of the cells, like ghost cells) middle zone of hemorrhage and inflammation

peripheral zone of glands with squamous metaplasia

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Acute Prostatitis

Inflammatory infiltrate within gland lumens

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Chronic Prostatitis

Inflammatory infiltrate surrounds the glands,involving the surrounding stroma

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Acute and Chronic Prostatitis

Infiltrate both in lumens and surrounding

glands

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Malignant Lymphoma

Diffuse infiltration of parenchyma by small roundblue cells with minimal cytoplasm

Typically the normal architecture is spared

Stains for leukocyte markers are positive

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PIN

Probable precursor lesion for prostatic carcinoma Divided into low grade (mild dyplasia/ grade I) and

high grade (moderate dysplasia/ grade 2 and severedysplasia/ grade 3)

High grade PIN is a marker for cancer Histologic features:

on low power, the glands appear large and complex, butmore basophilic (blue) than the normal glands of BPH

basal cells are present, if only focally

high power shows prominent nucleoli, nuclear crowdingand pseudostratification (piling up of the nuclei)

also: the papillary structures at low power turn out to becaused by the cellular pile-up; in BPH, the papillarystructures actuallly have fibrovascular cores and therefore

are true papillae.

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PIN

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PIN

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Normal Gland and PIN

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PIN

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PIN

Papillary lumenal projections have NO

fibrovascular core

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Compare to BPH

Papillary structures each have afibrovascular core

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Low Grade PIN

Multiple epithelial cell layers but unlike highgrade PIN, has no nucleoli

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High Grade PIN

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High Grade PIN

HMW keratin shows fragmented basal cell

layer

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Beware: Basal Cell Hyperplasia

Nuclei are ovoid with finely reticular chromatin andrare punctate nucleoli. The cytoplasm is paleeosinophilic or clear

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Basal Cell Hyperplasia

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Basal Cell Hyperplasia

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Prostate Adenocarcinoma

Microscopic foci of cancer may begin in the30s, present in 70% of men by the age of 70

80% occur in the peripheral zone, 10-20% inthe transition zone; most appear yellow or

gray-white grossly Histologic features:

Unlike other malignancies, neoplastic glands arevery small, simple, and bland. Complexity in theprostate is generally a good sign, whereas smallsimple glands may herald cancer.

helpful findings: blue mucin, crystalloids,prominent nucleoli, single layer of cells (immuno)

Gleasons grading system

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Prostate Cancer Crystalloids

Elongated, refract light

Corpora

amylacea

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Prostate Cancer Blue Mucin

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Prostate Immunohistology Alpha-methylacyl-CoA-racemase (racemase) aka,

P504S, is an enzyme involved in beta-oxidation of branchedchain fatty acids. Moderate to strong staining is seen inprostate cancer and high-grade PIN, but not in benignprostatic tissue.

HMW cytokeratin antibody (34-E12) stains the cytoplasm

of basal cells of the prostate. Increasing grades of PIN areassociated with progressive disruption of the basal celllayer. Cancer cells consistently fail to react with thisantibody.

p63 antibody stains the nucleus of basal cells. Basal cell

cocktail (34 -E12 and p63) increases the sensitivity of thebasal cell detection and reduces staining variability, thusrendering basal cell immunostaining more consistent.

PSA, PAP antibodies are useful in cases of unknownprimary or very de-differentiated tumors.

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Prostate Immunohistology

HMW keratin and p63 stain basal cell layer of atrophicbenign gland

Racemase stains malignant cells

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Gleason Grade Gleason grading assigns prostatic malignancy a

rank from 1 to 5 based on level of dedifferentiation.1 being best. 1 and 2 are rarely used any more soreally a rank from 3-5

Prostatic cancers are typically heterogenous

therefore receive the sum of their two mostcommon architectural patterns the first number is the most prevalent pattern the second number is the second most prevalent pattern

(a minimum of 10% of the cancer volume)

Denoted the two numbers separately is the Gleasonscore, i.e. 4+3 the sum of the two, e.g., 7 is the Gleason sum or grade

and is an excellent predictor of clinical behavior. Sometimes a tertiary grade will be mentioned (or used as

the secondary grade) if it is poorly differentiated.

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Grades 1-3 consist of small, simple round glandswith a single cell layer surrounded by stroma Grade 1: Glands in nodular pattern Grade 2: Glands in vaguely rounded configuration

Grade 3: Glands infiltrating between normal glands

Grade 4: Fused glands (no stroma separating someof the glands) or multiple lumens in a single gland.

Grade 5: No longer attempting to create glands; cells

in sheets, clumps, rows, or individual.

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Gleason Grading

Do not try to assign a grade totreated tissueHormone therapyPrior radiation therapy of any kind

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Gleason Grade 1

nodules of uniform, closely-packed malignantglands, nucleoli are relatively inconspicuous

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Gleason Grade 2

Nodular configuration but more looselypacked.

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G G


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Gleason Grade 2

Nodular configuration but more looselypacked.

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Gl G d 3


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Gleason Grade 3

Tumor infiltrates in and among the non-neoplastic prostatic glands

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Gl G d 3


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Gleason Grade 3


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Gl G d 3


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Gleason Grade 3


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Gl G d 4


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Gleason Grade 4

Fused glands without completely surrounding

stroma, poorly formed or multiple lumens

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Gl G d 4


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Gleason Grade 4

Fused glands without completely surrounding

stroma, poorly formed or multiple lumens

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Gl G d 4


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Gleason Grade 4

Fused glands without completely surroundingstroma, poorly formed or multiple lumens

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Gl G d 4


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Gleason Grade 4

Fused glands without completely surroundingstroma, poorly formed or multiple lumens

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H h id Gl G d 4


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Hypernephroid Gleason Grade 4

Abundant clear cytoplasm with a dot-likenucleus

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M i Gl G d 4


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Mucinous Gleason Grade 4

Extracellular mucin makes up at least 25% of

tumor volume

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Gl G d 5


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Gleason Grade 5

Minimal gland formation, cells in sheets,

clumps, cords

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Gl G d 5


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Gleason Grade 5

May need PSA stain to confirm diagnosis

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Gl G d 5


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Gleason Grade 5


clumps, cords

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Gleason Grade 5


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Gleason Grade 5


clumps, cords

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Gleason Grade 5


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Gleason Grade 5

Signet Ring Histology

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Cribriform


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Cribriform

Smoothly-circumscribed nodules with large ductsthat are filled and distended with tumor in acribriform pattern can be called grade 3 or 4. Thepresence of central necrosis in a cribriform

carcinoma raises the grade to 5.

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Gleason Grade 5


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Gleason Grade 5

Grade 5 Cribiform with comedonecrosis

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Seminal Vesicle


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Seminal Vesicle

Beware of trick questions!

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Seminal Vesicle


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Seminal Vesicle

Look for golden-brown granules of

lipofuscin pigment

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Small Cell Carcinoma


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Small Cell Carcinoma

Small round blue cells in sheets, necrosis, high mitotic rate.

Molded nuclei with inconspicuous nucleoli

PSA and PAP stains are typically negative and serum PSAlevels may be only mildly elevated. Neuroendocrine stains

positive

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Endometroid Carcinoma


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Endometroid Carcinoma

Typically arises in area of urethra/prostatic utricle

PSA and PAP positive

Often grade 3 or 4 but 5 if has necrosis

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Transitional Cell Carcinoma


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Transitional Cell Carcinoma

Typically involves large ducts

More cytologic atypia than prostate cancer

PSA negative

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Squamous Cell Carcinoma


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Squamous Cell Carcinoma

Rare in North America, more often in areaswhere Schistosomiasis is endemic

Histologic features include keratin pearl

formation, intercellular desmosomes, etc.

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Rhabdomyosarcoma


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Rhabdomyosarcoma

Average age 7 years, rapid growth

Sheets of small round blue cells with scatteredstrap cells (tadpole cells) having cross-striations

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