Prostate adenocarcinoma: Difference between revisions

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Mikael Häggström (talk | contribs)
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{{Top
<noinclude>{{Top
|author1=[[User:Mikael Häggström|Mikael Häggström]]
|author1=[[User:Mikael Häggström|Mikael Häggström]]
|author2=
|author2=
|author3=
|author3=
}}
}}
{{Comprehensiveness}}
{{Comprehensiveness}}
</noinclude>
==Gross processing==
==Gross processing==
As '''[[prostatectomy]]''' or biopsy.
As '''[[prostatectomy]]''' or biopsy.
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==Microscopic evaluation==
==Microscopic evaluation==
{{Prostate screening method}}
{{Prostate screening method}}
===Characteristics===
;Relatively common and highly specific:<ref name="CruzSantana2016">{{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}}<br>[https://creativecommons.org/licenses/by/4.0/ Attribution 4.0 International (CC BY 4.0) license]</ref>
<gallery mode=packed heights=180>
File:Micrograph of acinar adenocarcinoma of the prostate with multiple nucleoli.jpg|'''Multiple nucleoli''' (Pictured in an acinar adenocarcinoma, the most common subdiagnosis of prostate adenocarcinoma)
File:Micrograph of acinar adenocarcinoma of the prostate with double and marginated nucleoli.jpg|'''Eccentric nucleoli'''<ref name="CruzSantana2016"/> (pictured example has double and eccentric nucleoli).
</gallery>
;Specific but relatively rare signs of adenocarcinoma:<ref group="notes">"Rare" here refers to prevalence at least in core biopsies.(Cruz 2016)</ref>
<gallery mode=packed heights=180>
File:Histopathology of prostatic adenocarcinoma with circumferential perineural invasion.jpg|'''Perineural invasion'''.<ref name="CruzSantana2016"/> It should be circumferential (as pictured) to count.<ref name=Stanford-prostate-adenoca>{{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>
</gallery>
*'''Collagenous micronodules''' for acinar adenocarcinoma<ref name="CruzSantana2016"/>
*'''Angiolymphatic''' invasion<ref name="CruzSantana2016"/>
*'''Extraprostatic''' extension,<ref name="CruzSantana2016"/> which in biopsies can be diagnoses when tumor cells are located in fatty tissue.
;Less specific findings:
<gallery mode=packed heights=180>
File:Micrograph of adenocarcinoma of the prostate with two mitoses in reactive epithelium.jpg|'''Mitoses''': also seen in for example [[high-grade prostatic intraepithelial neoplasia]] (HGPIN) and [[prostate inflammation]].<ref name="CruzSantana2016"/> Picture shows adenocarcinoma with two mitoses in reactive epithelium.
File:Micrograph of acinar adenocarcinoma of the prostate with blue mucin.jpg|Intraluminal '''blue mucin'''<ref name="CruzSantana2016"/> (pictured in acinar adenocarcinoma)
File:Histopathology of prostatic adenocarcinoma with atypical eosinophilic secretions.jpg|Intraluminal '''atypical eosinophilic''' secretions.<ref name="CruzSantana2016"/>
File:Histopathology of prostatic intraluminal crystalloid.jpg|thumb|Intraluminal '''crystalloids'''.<ref name="SvatekKaram2007">{{cite journal|last1=Svatek|first1=R S|last2=Karam|first2=J A|last3=Rogers|first3=T E|last4=Shulman|first4=M J|last5=Margulis|first5=V|last6=Benaim|first6=E A|title=Intraluminal crystalloids are highly associated with prostatic adenocarcinoma on concurrent biopsy specimens|journal=Prostate Cancer and Prostatic Diseases|volume=10|issue=3|year=2007|pages=279–282|issn=1365-7852|doi=10.1038/sj.pcan.4500954}}</ref>
File:Histopathology of prostatic adenocarcinoma with uneven distribution and infiltrative pattern.jpg|'''Uneven distribution''' and '''infiltrative pattern''' of glands
File:Micrograph of prostate adenocarcinoma with a glomeruloid gland.jpg|'''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.<ref name=Stanford-prostate-adenoca/>
</gallery>
*'''Prominent nucleoli'''<ref name="CruzSantana2016"/>
*'''Nuclear enlargement'''
===Precancerous lesions===
[[File:Histopathology of small acinar cell proliferation (annotated).jpg|thumb|210px|Histopathology of a '''small acinar cell proliferation''', with acinar cells with large nuclei, prominent nucleoli (arrows marking two of them) and no certain basal cell lining.]]
In case of only less specific findings, consider a '''Prostatic intraepithelial neoplasia''' ('''PIN''') or an '''atypical small acinar proliferation''' ('''ASAP''').
A '''PIN''' is where acini are architecturally benign, but individual cells display atypia. In high-grade PIN (HGPIN), the changes are similar to those of prostate cancer, whereas in low-grade (LGPIN) the changes are milder. Most pathologists do not report the presence of LGPIN.<ref>{{cite web|url=https://emedicine.medscape.com/article/447780-overview|title=Precancerous Lesions of the Prostate|author=Stanley A Brosman, MD|website=Medscape}} Updated: Feb 26, 2020</ref>
An '''ASAP''' is a lesion that is probably carcinoma but either lacks definitive diagnostic features, or is too small to be certain.<ref name=stanford-asap>{{cite web|url=http://surgpathcriteria.stanford.edu/prostate/adenocarcinoma/atypical-small-acinar-proliferation-asap.html|title=Prostatic Adenocarcinoma - Atypical Small Acinar Proliferation (ASAP)|website=Stanford Medical School|accessdate=2020-09-14}}</ref> It should not be used for benign lesions that are just unusual looking.<ref name=stanford-asap/> In uncertain cases, a diagnosis of adenocarcinoma can be excluded by immunohistochemical detection of basal cells (or confirmed by absence thereof),<ref name="CruzSantana2016"/> 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).
[[File:PIN-4 staining of benign prostate gland and adenocarcinoma.jpg|left|220px]]
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.
<br clear=all>
===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: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}}
{{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}}


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;Evaluation of the (primary) tumor ('T')
;Evaluation of the (primary) tumor ('T')
*'''T2''': Organ confined
*'''T2''': Organ confined
[[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>]]
[[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>]]
*'''T3''': Extraprostatic extension
*'''T3''': Extraprostatic extension
**'''T3a''': Extraprostatic extension (unilateral or bilateral) or microscopic invasion of bladder neck
**'''T3a''': Extraprostatic extension (unilateral or bilateral) or microscopic invasion of bladder neck
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{{Evaluation}}
{{Evaluation}}


===Report===
==Reporting==
*'''Diagnosis'''
*'''Diagnosis'''
*'''Gleason score''', and optionally grade group
*'''Gleason score''', and optionally grade group
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:*Any '''perineural''' or '''angiolymphatic''' invasion.
:*Any '''perineural''' or '''angiolymphatic''' invasion.
:*{{Comprehensive-begin}}Any '''inflammation'''.<ref name=inflammation group=notes/>{{Comprehensive-end}}
:*{{Comprehensive-begin}}Any '''inflammation'''.<ref name=inflammation group=notes/>{{Comprehensive-end}}
Examples in a '''biopsy with adenocarcinoma''':
{|class=wikitable
{|class=wikitable
| (Prostate, left apex, needle biopsy:)<br>Prostatic adenocarcinoma, Gleason score 3+3 = 6 (grade group 1), involving 30% of out of one core.
| (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.
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===
===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.
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.


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.
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.
 
<noinclude>{{Reporting}}
{{CAP}}
{{Reporting}}
{{Bottom}}
{{Bottom}}
</noinclude>
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