Prostate adenocarcinoma: Difference between revisions

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{{Top
<noinclude>{{Top
|author1=[[User:Mikael Häggström|Mikael Häggström]]
|author1=[[User:Mikael Häggström|Mikael Häggström]]
|author2=Authors of integrated Creative Commons article<ref name="CruzSantana2016">Initially largely copied from: {{cite journal|last1=Cruz|first1=Andrea O.|last2=Santana|first2=Amanda L. S.|last3=Santos|first3=Andréia C.|last4=Athanazio|first4=Daniel A.|title=Frequency of the morphological criteria of prostate adenocarcinoma in 387 consecutive prostate needle biopsies: emphasis on the location and number of nucleoli|journal=Jornal Brasileiro de Patologia e Medicina Laboratorial|year=2016|issn=1676-2444|doi=10.5935/1676-2444.20160018}}</ref>
|author2=
|author3=
|author3=
}}
}}
 
{{Comprehensiveness}}
</noinclude>
==Gross processing==
==Gross processing==
As '''[[prostatectomy]]''' or biopsy.
As '''[[prostatectomy]]''' or biopsy.


==Microscopic evaluation==
==Microscopic evaluation==
 
{{Prostate screening method}}
===Characteristics===
;Specific but relatively rare:<ref group="notes">"Rare" here refers to prevalence at least in core biopsies.(Cruz 2016)</ref>
*'''Collagenous micronodules''' for acinar adenocarcinoma (the most common subdiagnosis)<ref name="CruzSantana2016"/>
*'''Glomerulations''', for acinar adenocarcinoma,<ref name="CruzSantana2016"/> consisting of epithelial proliferations into one or more gland lumina, typically a cribriform tuft with a single attachment to the gland wall.<ref name=Stanford/>
<gallery>
File:Micrograph of prostate adenocarcinoma with a glomeruloid gland.jpg|Glomerulation.
</gallery>
*Perineural invasion.<ref name="CruzSantana2016"/> It should be circumferential to count.<ref name=Stanford>{{cite web|url=http://surgpathcriteria.stanford.edu/prostate/adenocarcinoma/|title=Prostatic Adenocarcinoma|website=Stanford Medical School|author=Robert V Rouse MD}} Last update 2/2/16</ref><ref group="notes>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)</ref>
*Angiolymphatic invasion<ref name="CruzSantana2016"/>
*Extraprostatic extension <ref name="CruzSantana2016"/>
;Relatively common and highly specific :<ref name="CruzSantana2016"/>
*Multiple nucleoli
*Eccentric nucleoli<ref name="CruzSantana2016"/>
<gallery mode=packed heights=180>
File:Micrograph of acinar adenocarcinoma of the prostate with multiple nucleoli.jpg|Acinar adenocarcinoma with multiple nucleoli.
File:Micrograph of acinar adenocarcinoma of the prostate with double and marginated nucleoli.jpg|Acinar adenocarcinoma with double and eccentric nucleoli.
</gallery>
;Less specific findings.
*Mitoses (also seen in for example [[high-grade prostatic intraepithelial neoplasia]] (HGPIN) and [[prostate inflammation]]).<ref name="CruzSantana2016"/>
*Prominent nucleoli<ref name="CruzSantana2016"/>
*Intraluminal eosinophilic secretion<ref name="CruzSantana2016"/>
*Intraluminal blue mucin<ref name="CruzSantana2016"/>
<gallery mode=packed heights=180>
File:Micrograph of adenocarcinoma of the prostate with two mitoses in reactive epithelium.jpg|Adenocarcinoma with two mitoses in reactive epithelium.
File:Micrograph of acinar adenocarcinoma of the prostate with blue mucin.jpg|Acinar adenocarcinoma with intraluminal blue mucin.
</gallery>
 
In uncertain cases, a diagnosis of malignancy can be discarded by immunohistochemical detection of basal cells.<ref name="CruzSantana2016"/>
 
===Subdiagnoses===
===Subdiagnoses===
[[File:Prostate cancer types.png|thumb|300px|Pie chart of subdiagnoses.<ref group="notes" name="mixed"/>]]
[[File:Prostate cancer types.png|thumb|300px|Pie chart of subdiagnoses.<ref group="notes" name="mixed"/>]]
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[[File:Gleasonscore.jpg|370px|right]]
[[File:Gleasonscore.jpg|370px|right]]
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).
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).
<gallery mode=packed>
<gallery mode=packed heights=220>
File:Micrograph of prostate cancer with Gleason pattern 6 (3+3).jpg|Gleason pattern 6 (3+3).jpg
File:Micrograph of prostate cancer with Gleason pattern 6 (3+3).jpg|Gleason pattern 6 (3+3).jpg
File:Micrograph of prostate cancer with Gleason pattern 7 (3+4).jpg|Gleason pattern 7 (3+4).jpg
File:Micrograph of prostate cancer with Gleason pattern 7 (3+4).jpg|Gleason pattern 7 (3+4).jpg
Line 214: Line 186:
File:Micrograph of prostate cancer with Gleason pattern 10 (5+5).jpg|Gleason pattern 10 (5+5).jpg
File:Micrograph of prostate cancer with Gleason pattern 10 (5+5).jpg|Gleason pattern 10 (5+5).jpg
</gallery>
</gallery>
<gallery mode=packed heights=170>
Gleason score is as follows:<ref name=JohnHopkins>{{cite web|url=http://pathology.jhu.edu/prostatecancer/newgradingsystem.cfm|title=New Contemporary Prostate Cancer Grading System|website=Johns Hopkins University, Department of Pathology|accessdate=2020-09-21}}</ref>
*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
<gallery mode=packed heights=200>
File:Micrograph of prostate cancer with Gleason score 6 (3+3).jpg|Gleason score 6 (3+3)
File:Micrograph of prostate cancer with Gleason score 6 (3+3).jpg|Gleason score 6 (3+3)
File:Invasive cribriform prostate carcinoma.jpg|Cribriform pattern: Gleason grade 4
File:Invasive cribriform prostate carcinoma.jpg|'''Cribriform''' pattern: Gleason '''grade 4'''
File:Micrograph of prostate cancer with Gleason score 7 (3+4) with minor component of cribriform glands.jpg|Gleason score 7 (3+4) with minor component of cribriform glands
File:Micrograph of prostate cancer with Gleason score 7 (3+4) with minor component of cribriform glands.jpg|Gleason score 7 (3+4) with minor component of '''cribriform glands'''
File:Micrograph of prostate cancer with Gleason score 8 (4+4) with glomeruloid glands.jpg|Gleason score 8 (4+4) with glomeruloid glands
File:Micrograph of prostate cancer with Gleason score 8 (4+4) with glomeruloid glands.jpg|Gleason score 8 (4+4) with '''glomeruloid glands'''
File:Micrograph of prostate cancer with Gleason score 8 (4+4) with irregular cribriform glands.jpg|Gleason score 8 (4+4) with irregular cribriform glands
File:Micrograph of prostate cancer with Gleason score 8 (4+4) with irregular cribriform glands.jpg|Gleason score 8 (4+4) with '''irregular cribriform glands'''
File:Micrograph of prostate cancer with Gleason score 8 (4+4) with fused glands with cytoplasmic vacuoles.jpg|Gleason score 8 (4+4) with fused glands with cytoplasmic vacuoles
File:Micrograph of prostate cancer with Gleason score 8 (4+4) with fused glands with cytoplasmic vacuoles.jpg|Gleason score 8 (4+4) with '''fused glands with cytoplasmic vacuoles'''
File:Micrograph of prostate cancer with Gleason score 8 (4+4) with poorly-formed glands.jpg|Gleason score 8 (4+4) with poorly-formed glands
File:Micrograph of prostate cancer with Gleason score 8 (4+4) with poorly-formed glands.jpg|Gleason score 8 (4+4) with '''poorly-formed''' glands
File:Micrograph of prostate cancer with Gleason score 9 (4+5) with cribriform glands, some with necrosis.jpg|Gleason score 9 (4+5) with cribriform glands, some with necrosis
File:Micrograph of prostate cancer with Gleason score 9 (4+5) with cribriform glands, some with necrosis.jpg|Gleason score 9 (4+5) with '''cribriform glands''', some with necrosis
File:Micrograph of prostate cancer with Gleason score 10 (5+5) with cords of cells.jpg|Gleason score 10 (5+5) with cords of cells
File:Micrograph of prostate cancer with Gleason score 10 (5+5) with cords of cells.jpg|Gleason score 10 (5+5) with '''cords of cells'''
File:Micrograph of prostate cancer with Gleason score 10 (5+5) with individual cells.jpg|Gleason score 10 (5+5) with individual cells
File:Micrograph of prostate cancer with Gleason score 10 (5+5) with individual cells.jpg|Gleason score 10 (5+5) with '''individual cells'''
File:Micrograph of prostate cancer with Gleason score 10 (5+5) with solid sheets of cells.jpg|Gleason score 10 (5+5) with solid sheets of cells
File:Micrograph of prostate cancer with Gleason score 10 (5+5) with solid sheets of cells.jpg|Gleason score 10 (5+5) with '''solid sheets''' of cells
</gallery>
</gallery>
The '''percentage of pattern 4''' should be reported for Gleason score 3+4 {{Comprehensive-begin}}and 4+3{{Comprehensive-end}}.<ref>{{cite web|url=https://documents.cap.org/protocols/Prostate.Needle.Case.Bx_1.0.0.1.REL_CAPCP.pdf|title=Protocol for the Examination of Prostate Needle Biopsies From Patients With Carcinoma of the Prostate Gland: Case Level Reporting|website=College of American Pathologists}} Version: 1.0.0.1. Protocol Posting Date: November 2021</ref>
In case of '''3 patterns''' in one specimen:<ref name="MOLAVI p. ">{{cite book | last=MOLAVI | first=DIANA WEEDMAN | title=PRACTICE OF SURGICAL PATHOLOGY : a beginner's guide to the diagnostic process. | publisher=SPRINGER INTERNATIONAL PU | publication-place=[Place of publication not identified] | date=2018 | isbn=3-319-86570-6 | oclc=1085201203 | page=}}</ref>
*On a '''biopsy''': most common pattern + the highest pattern. For example, mostly pattern 3, a bit of 4, and a tiny bit of 5 would be graded 3 + 5 = 8.
*On a '''prostatectomy''': First and second most prevalent patterns, and if there is a minor or third component of higher grade, that is termed a tertiary pattern. The same example as above would be classified as 3 + 4 = 7 with tertiary pattern 5.
{{Comprehensive-begin}}In cases of Gleason pattern 3+4 and 4+3, also state the percentage of Gleason pattern 4 compared to the entire tumor area.<ref name="pmid30363387">{{cite journal| author=Sharma M, Miyamoto H| title=Percent Gleason pattern 4 in stratifying the prognosis of patients with intermediate-risk prostate cancer. | journal=Transl Androl Urol | year= 2018 | volume= 7 | issue= Suppl 4 | pages= S484-S489 | pmid=30363387 | doi=10.21037/tau.2018.03.20 | pmc=6178316 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30363387  }} </ref>{{Comprehensive-end}}
====Grade group====
{{Moderate-begin}}In a moderately comprehensive report, also state the overall grade group for the adenocarcinoma:<ref name=JohnHopkins/>
*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{{Moderate-end}}


===Staging===
===Staging===
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*Prostatectomy: Stage by TNM:
*Prostatectomy: Stage by TNM:


From the AJCC 7th edition<ref name="AJCC 7th ed.">{{cite book|title=AJCC cancer staging manual.|last1=American Joint Committee on Cancer. Edge, Stephen B, ed.|date=2010|publisher=Springer|isbn=9780387884400|edition=7th|location=New York|page=457–468}}</ref> and International Union Against Cancer (UICC) 7th edition.<ref name="UICC TNM">{{cite web|title=TNM {{!}} UICC|url=https://www.uicc.org/resources/tnm|website=Union for International Cancer Control|accessdate=11 November 2017|language=en}}</ref>
The AJCC 8th edition<ref>{{AJCC-8|chapter=58 - Prostate}}</ref> has a shorter pathological tumor classification (pT) than the clinical one (cT). pT does not have any T1 category, and is as follows:


;Evaluation of the (primary) tumor ('T')
;Evaluation of the (primary) tumor ('T')
*'''TX''': cannot evaluate the primary tumor
*'''T2''': Organ confined
*'''T0''': no evidence of tumor
[[File:Histopathology of prostate adenocarcinoma involving adipose tissue.jpg|thumb|There may be adipose tissue within the prostate gland, but nevertheless, definite '''fat involvement''' by prostate cancer (as pictures) in a needle biopsy counts as extraprostatic or extracapsular extension.<ref>Image by Mikael Häggström, MD. Reference for implication: {{cite journal| author=Grignon DJ| title=Prostate cancer reporting and staging: needle biopsy and radical prostatectomy specimens. | journal=Mod Pathol | year= 2018 | volume= 31 | issue= S1 | pages= S96-109 | pmid=29297497 | doi=10.1038/modpathol.2017.167 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29297497  }}</ref>]]
*'''T1''': tumor present, but not detectable clinically or with imaging
[[File:Histopathology of prostate adenocarcinoma involving skeletal muscle.jpg|thumb|In contrast, skeletal muscle is normally present within the prostate, so involvement thereof does '''not''' count as extraprostatic or extracapsular extension.<ref>Image by Mikael Häggström, MD. Reference for implication: {{cite journal| author=Ye H, Walsh PC, Epstein JI| title=Skeletal muscle involvement by limited Gleason score 6 adenocarcinoma of the prostate on needle biopsy is not associated with adverse findings at radical prostatectomy. | journal=J Urol | year= 2010 | volume= 184 | issue= 6 | pages= 2308-12 | pmid=20952012 | doi=10.1016/j.juro.2010.08.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20952012  }} </ref>]]
**'''T1a''': tumor was incidentally found in 5% or less of prostate tissue resected (for other reasons)
*'''T3''': Extraprostatic extension
**'''T1b''': tumor was incidentally found in greater than 5% of prostate tissue resected
**'''T3a''': Extraprostatic extension (unilateral or bilateral) or microscopic invasion of bladder neck
**'''T1c''': tumor was found in a needle biopsy performed due to an elevated serum PSA
**'''T3b''': Tumor invades seminal vesicle(s)
*'''T2''': the tumor can be felt (palpated) on examination, but has not spread outside the prostate
*'''T4''': Tumor is fixed or invades adjacent structures other than seminal vesicles such as external sphincter, rectum, bladder, levator muscles, and/or pelvic wall
**'''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')
;Evaluation of the regional lymph nodes ('N')
*'''NX''': cannot evaluate the regional lymph nodes
*'''NX''': Regional lymph nodes cannot be assessed
*'''N0''': there has been no spread to the regional lymph nodes
*'''N0''': No positive regional nodes
*'''N1''': there has been spread to the regional lymph nodes
*'''N1''': Metastases in regional node(s)


;Evaluation of distant metastasis ('M')
;Evaluation of distant metastasis ('M')
*'''MX''': cannot evaluate distant metastasis
*'''M0''': No distant metastasis
*'''M0''': there is no distant metastasis
*'''M1''': Distant metastasis
*'''M1''': there is distant metastasis
**'''M1a''': Nonregional lymph node(s)
**'''M1a''': the cancer has spread to lymph nodes beyond the regional ones
**'''M1b''': Bone(s)
**'''M1b''': the cancer has spread to bone
**'''M1c''': Other site(s) with or without bone disease
**'''M1c''': the cancer has spread to other sites (regardless of bone involvement)
When more than one site of metastasis is present, the most advanced category is used.
{{CAP}}
{{Evaluation}}
 
==Reporting==
*'''Diagnosis'''
*'''Gleason score''', and optionally grade group
*'''Extent'''
:*Prostatectomy: '''Stage'''.
:*Prostate '''biopsies''': '''Number''' of biopsies where tumor is found
:*Both prostatectomy and biopsies: '''Percentage''' of tumor involvement (see Percentage section below).
:*Any '''perineural''' or '''angiolymphatic''' invasion.
:*{{Comprehensive-begin}}Any '''inflammation'''.<ref name=inflammation group=notes/>{{Comprehensive-end}}
 
Examples in a '''biopsy with adenocarcinoma''':
{|class=wikitable
| (Prostate, left apex, needle biopsy:)<br>Prostatic adenocarcinoma, Gleason score 3+3 = 6 (grade group 1), involving 30% of one out of one core.
|}
If the microscopy and gross description give discordant number of cores, you may use the gross number.
 
{|class=wikitable
| Prostate, right apex, needle biopsy:
*Prostatic adenocarcinoma, Gleason score 3+4 = 7 (grade group 2), discontinuously involving ~50% of the specimen (one out of two cores contain carcinoma), with 4 mm linear involvement.
*Gleason pattern 4 comprises ~10% of carcinoma.
*Perineural invasion is identified.
|}
 
Template for '''prostatectomy''':
{|class=wikitable
| Prostate and seminal vesicles, radical robotic prostatectomy:
*Prostatic adenocarcinoma, Gleason score __+__=__ (grade group __).
*Carcinoma involves approximately __% of the submitted tissue.
*<Positive / Negative> for extraprostatic extension.
*<Positive / Negative> for perineural invasion.
*<Positive / Negative> for  for lymphovascular invasion.
*Surgical margins are <positive / negative> for carcinoma.
*See synoptic report.
|}
{{CAP}}
===Percentage===
In '''prostatectomies''', percentage of involvement can be estimated by marking the tumor edges with a marker pen under the microscope, and looking at the slide without microscope to roughly estimate the percentage of involvement. The total percentage can be calculated as the average of the involvement of each slide.


===Report===
In '''biopsies''', percentage of involvement can be estimated by first estimating 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. When there is at least 1 mm of non-involved segment between separate tumor foci in a biopsy, give the percentage as if the tumor involved such segments too, but denote it as '''"discontinuously"''' involving it.
*Diagnosis
<noinclude>{{Reporting}}
*Gleason score
*Extent
:*Prostatectomy: Stage.  
:*Prostate biopsies: Number of biopsies where tumor is found.
:*Any perineural or angiolymphatic invasion.
{{Reporting}}
{{Bottom}}
{{Bottom}}
</noinclude>
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