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 1]
Characteristics of adenocarcinoma
- Relatively common and highly specific findings of prostatic adenocarcinoma
Eccentric nucleoli (pictured example has double and eccentric nucleoli).
- Specific but relatively rare signs of adenocarcinoma
- [notes 2]
On biopsies, look in particular near the tips for perineural invasion, as it is most likely seen by the capsule. 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.
- 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 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.
An ASAP 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 adenocarcinoma 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 4]||54%[notes 4]||Tumorous glands:||As usual|
|Foamy gland carcinoma||17%[notes 3]||13–23%[notes 3]||Based on architecture, discounting foamy cytoplasms|
|Atrophic carcinoma||2%[notes 5]||16%[notes 5]||Tumorous glands:||As usual|
|Microcystic carcinoma||11%||On (usually) adjacent acinar adeocarcinoma|
(or mixed acinar/
|Ductal adenocarcinoma||3% to 12.7%[notes 3]|
H&E and CK5/6
|Urothelial carcinoma||0.7 to 2.8%||Not recommended|
|Small-cell carcinoma||0.3–2%[notes 3]||
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
The percentage of pattern 4 should be reported for Gleason score 3+4 ((and 4+3)).
In case of 3 patterns in one specimen:
- 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.
((In cases of Gleason pattern 3+4 and 4+3, also state the percentage of Gleason pattern 4 compared to the entire tumor area.))
(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:
The AJCC 8th edition 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')
- T2: Organ confined
- T3: Extraprostatic extension
- T3a: Extraprostatic extension (unilateral or bilateral) or microscopic invasion of bladder neck
- T3b: Tumor invades seminal vesicle(s)
- T4: Tumor is fixed or invades adjacent structures other than seminal vesicles such as external sphincter, rectum, bladder, levator muscles, and/or pelvic wall
- Evaluation of the regional lymph nodes ('N')
- NX: Regional lymph nodes cannot be assessed
- N0: No positive regional nodes
- N1: Metastases in regional node(s)
- Evaluation of distant metastasis ('M')
- M0: No distant metastasis
- M1: Distant metastasis
- M1a: Nonregional lymph node(s)
- M1b: Bone(s)
- M1c: Other site(s) with or without bone disease
When more than one site of metastasis is present, the most advanced category is used. For cancers, generally include a synoptic report, such as per College of American Pathologists (CAP) protocols at cap.org/protocols-and-guidelines.
- Further information: Evaluation
- Gleason score, and optionally grade group
- 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.
- ((Any inflammation.[notes 1]))
|(Prostate, left apex, needle biopsy:)|
Prostatic adenocarcinoma, Gleason score 3+3 = 6 (grade group 1), involving 30% of out of one core.
If the microscopy and gross description give discordant number of cores, you may use the gross number.
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.
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
- 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)
- 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.
- 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.
Attribution 4.0 International (CC BY 4.0) license
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- For access, see the Secrets chapter of Patholines.
- Copyright note: The AJCC, 8th Ed. is published by a company in Switzerland, and the tables presented therein are Public Domain because they consist of tabular information without literary or artistic innovation, and therefore do not fulfil the inclusion criterion of the Swiss Copyright Act (CopA) which applies to "literary and artistic intellectual creations with individual character" (see Federal Act on Copyright and Related Rights (Copyright Act, CopA) of 9 October 1992 (Status as of 1 January 2022)).