On this resource, the following formatting is used for comprehensiveness:
- Minimal depth
- (Moderate depth)
As prostatectomy or biopsy.
- Before microscopy, look at each microscopy slide by eye, to plan the microscopy screening so as to not miss peripheral fragments.
- Screen at low power, and switch to high power when encountering glandular structures that can not otherwise be cleared. Look in particular for those surrounding nerves.
- At least if no cancer is seen, also look for inflammation.[notes 2]
- Relatively common and highly specific
Eccentric nucleoli (pictured example has double and eccentric nucleoli).
- Specific but relatively rare signs of adenocarcinoma
- [notes 3]
- Collagenous micronodules for acinar adenocarcinoma
- Angiolymphatic invasion
- Extraprostatic extension, which in biopsies can be diagnoses when tumor cells are located in fatty tissue.
- Less specific findings
Intraluminal blue mucin (pictured in acinar adenocarcinoma)
Intraluminal atypical eosinophilic secretions.
Glomerulations, for acinar adenocarcinoma, consisting of epithelial proliferations into one or more gland lumina, typically a cribriform tuft with a single attachment to the gland wall.
- Prominent nucleoli
- Nuclear enlargement
In case of only less specific findings, consider an atypical small acinar proliferation (ASAP), which is a lesion that is probably carcinoma but either lacks definitive diagnostic features, or is too small to be certain. It should not be used for benign lesions that are just unusual looking.
In uncertain cases, a diagnosis of malignancy can be excluded by immunohistochemical detection of basal cells (or confirmed by absence thereof), such as using the PIN-4 cocktail of stains (which consists of P504S, p63 and high-molecular-weight keratins (HMWK) such as CK5 and CK14).
Picture at left compares a PIN-4 immunohistochemistry of benign gland (left) and adenocarcinoma (right) using PIN-4. The adenocarcinoma lacks the basal epithelial cells (stained dark brown by p63 and HMWK). Also, in PIN-4 stained samples, adenocarcinoma cells generally display red cytoplasms (stained by AMACR, also known as P504S), while benign glands do not.
The histopathologic subdiagnosis of prostate cancer has implications for the possibility and methodology of any subsequent Gleason scoring. The most common histopathological subdiagnosis of prostate cancer is acinar adenocarcinoma, constituting 93% of prostate cancers. The most common form of acinar adenocarcinoma, in turn, is "adenocarcinoma, not otherwise specified", also termed conventional, or usual acinar.
|Subdiagnosis||Relative incidence||Image||Microscopic characteristics||Immunohistochemistry||Gleason scoring|
(not otherwise specified/
|77%[notes 6]||54%[notes 6]||Tumorous glands:||As usual|
|Foamy gland carcinoma||17%[notes 5]||13–23%[notes 5]||Based on architecture, discounting foamy cytoplasms|
|Atrophic carcinoma||2%[notes 7]||16%[notes 7]||Tumorous glands:||As usual|
|Microcystic carcinoma||11%||On (usually) adjacent acinar adeocarcinoma|
(or mixed acinar/
|Ductal adenocarcinoma||3% to 12.7%[notes 5]|
H&E and CK5/6
|Urothelial carcinoma||0.7 to 2.8%||Not recommended|
|Small-cell carcinoma||0.3–2%[notes 5]||
Half of cases have usual acinar components
||Tumorous glands:||4+4=8 for irregular cribriform glands floating in mucin.|
||Tumorous glands:||Not recommended|
|Basal-cell carcinoma||0.01%||Basaloid tumor:
Rate the dominant, or most common cell morphology (scored 1—5), in addition to the non-dominant cell pattern with the highest grade (scored 1—5).
Gleason score is as follows:
- Gleason score ≤3: Only individual discrete well-formed glands
- Gleason score 4: Poorly-formed, fused and/or cribriform glands
- Gleason score 5: Lacks gland formation, or has necrosis
(In a moderately comprehensive report, also state the overall grade group for the adenocarcinoma:
- Grade group 1 (Gleason score ≤6) - Only individual discrete well-formed glands
- Grade group 2 (Gleason score 3+4=7) - Predominantly well-formed glands with a lesser component of poorly-formed, fused and/or cribriform glands
- Grade group 3 (Gleason score 4+3=7) - Predominantly poorly-formed, fused, and/or cribriform glands with a lesser component of well-formed glands
- Grade group 4 (Gleason score 8), either of the following
- Only poorly-formed, fused and/or cribriform glands
- Predominantly well-formed glands with a lesser component that lacks glands
- Predominantly lacking glands with a lesser component of well-formed glands
- Grade group 5 (Gleason scores 9-10): Any area that lacks gland formation, or with necrosis)
Depending on sample type:
- Multiple biopsy specimens: Adenocarcinoma presence in how many of the biopsies
- Prostatectomy: Stage by TNM:
- Evaluation of the (primary) tumor ('T')
- TX: cannot evaluate the primary tumor
- T0: no evidence of tumor
- T1: tumor present, but not detectable clinically or with imaging
- T1a: tumor was incidentally found in 5% or less of prostate tissue resected (for other reasons)
- T1b: tumor was incidentally found in greater than 5% of prostate tissue resected
- T1c: tumor was found in a needle biopsy performed due to an elevated serum PSA
- T2: the tumor can be felt (palpated) on examination, but has not spread outside the prostate
- T2a: the tumor is in half or less than half of one of the prostate gland's two lobes
- T2b: the tumor is in more than half of one lobe, but not both
- T2c: the tumor is in both lobes but within the prostatic capsule
- T3: the tumor has spread through the prostatic capsule (if it is only part-way through, it is still T2)
- T3a: the tumor has spread through the capsule on one or both sides
- T3b: the tumor has invaded one or both seminal vesicles
- T4: the tumor has invaded other nearby structures
- Evaluation of the regional lymph nodes ('N')
- NX: cannot evaluate the regional lymph nodes
- N0: there has been no spread to the regional lymph nodes
- N1: there has been spread to the regional lymph nodes
- Evaluation of distant metastasis ('M')
- MX: cannot evaluate distant metastasis
- M0: there is no distant metastasis
- M1: there is distant metastasis
- M1a: the cancer has spread to lymph nodes beyond the regional ones
- M1b: the cancer has spread to bone
- M1c: the cancer has spread to other sites (regardless of bone involvement)
- Further information: Evaluation
- Gleason score, and optionally grade group
- Prostatectomy: Stage.
- Prostate biopsies: Number of biopsies where tumor is found, and percentage of involvement in those cases.<ref group=notes>Percentage of involvement can be estimate by first estimated what percentage of the field-of-view diameter the tumorous area occupies, or how many field-of-view diameters it occupies, divided by how many field-of-view diameters the entire biopsy occupies.
- Any perineural or angiolymphatic invasion.
- ((Any inflammation.[notes 2]))
|(Prostate, left apex, needle biopsy:)|
Prostatic adenocarcinoma, gleason score 3+3 = 6 (grade group 1), involving 30% of out of one core.
For cancers, generally include a synoptic report, such as per College of American Pathologists (CAP) protocols at cap.org/protocols-and-guidelines.
- See also: General notes on reporting
- For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
- Inflammation can explain for example a high PSA value in the absence of adenocarcinoma, so its reporting is usually only needed in such cases.
- "Rare" here refers to prevalence at least in core biopsies.(Cruz 2016)
- Glands adjacent to and indenting nerves is not sufficient as a diagnostic criterion by itself. Glands partially surrounding a nerve is an indication of carcinoma. (Stanford)
- At least where noted, the numbers include cases where the pattern is found admixed with usual acinar adenocarcinoma.
- Numbers for usual acinar adenocarcinoma do not include mixed patterns with other subdiagnoses.
- Number refers to sporadic atrophic pattern adenocarcinoma.
- Initially largely copied from: Cruz, Andrea O.; Santana, Amanda L. S.; Santos, Andréia C.; Athanazio, Daniel A. (2016). "Frequency of the morphological criteria of prostate adenocarcinoma in 387 consecutive prostate needle biopsies: emphasis on the location and number of nucleoli ". Jornal Brasileiro de Patologia e Medicina Laboratorial. doi:10.5935/1676-2444.20160018. ISSN 1676-2444.
- Robert V Rouse MD. Prostatic Adenocarcinoma. Stanford Medical School. Last update 2/2/16
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