Prostate
Prostatic carcinoma
General

Author: Kenneth Iczkowski, M.D. (see Authors page)

Revised: 8 August 2016, last major update April 2015

Copyright: (c) 2003-2016, PathologyOutlines.com, Inc.

PubMed Search: Prostatic carcinoma [title]
Epidemiology
  • 300,000 cases/year in US (#1 after skin cancer), 41,000 deaths/year (#2 after lung cancer)
  • 20% of American men are diagnosed with prostate cancer during their lifetimes; 3% die of prostate cancer
  • Age adjusted incidence is increasing
  • 99% with clinical disease are age 50+
  • A sizable minority of prostate cancers, those with Gleason score 3+3=6 (or less), have been shown almost never to metastasize to lymph nodes (Am J Surg Pathol 2012;36:1346), and lately it has been proposed to designate these not even as cancer, but by the name Indolent Lesion of Epithelial Origin (IDLE) (Curr Opin Urol 2015;25:238)
    • However, most pathologists endorse that Gleason 3+3=6 cancer is still cancer (Oncology (Williston Park) 2014;28:22), and a variety of surgical and non-surgical management options are now available for low-grade cancer
    • Low grade or "latent" cancers comprise 20% in cancers in men in their 50's, and 70% in men in 70'­s; usually one must examine the entire gland to find them
  • Clinical disease and high grade prostatic intraepithelial neoplasia (HGPIN) are more common in African-Americans than whites; blacks have higher stage at presentation, but stage adjusted survival is similar
  • Clinical disease is rare in Asians (3-4 / 100,000 vs 50-60 / 100,000 in US whites); higher rates in Scandinavians; all groups have similar incidence of latent cancers, suggesting importance of environmental or other genetic factors
  • No carcinoma if prepubertal castration, low incidence with hyperestrogenism (liver cirrhosis)
  • Not associated with sexually transmitted disease, smoking, occupational exposure, diet, nodular hyperplasia
Sites
  • Prostatic apex is more often involved than the bladder base
  • Peripheral zone is more often involved than transition zone or central zone
  • Posterior peripheral zones are more often involved than anterior / lateral horns of the peripheral zones
  • But bladder base, transitional / central zone and anterior / lateral horns of peripheral zones are more difficult to sample
Clinical Features
  • Prostate cancer is detected by digital rectal exam (DRE), transurethral ultrasound (misses 30% of carcinomas that are isoechoic), or elevated PSA (either above 4 ng/dL or increasing over time)
  • Some evidence favors using > 2.5 ng/dL as a cutoff for biopsies to miss fewer cancers, particularly in men over 60 (J Urol 2005;174:2154)
Diagnosis
  • Today, most prostate cancer is diagnosed on needle biopsy; more rarely, it is diagnosed in transurethral resection specimens
  • Reporting standards
    • In a sample from a single vial, report the fraction of cores involved by cancer (J Urol 2000;163:174), the percent of each core with cancer (J Urol 1996;156:1375), and the length (in mm) of tumor on needle biopsy cores (J Urol 2004;171:1093); all carry important prognostic value (J Urol 2011;186:790)
      • All cancer reports should list the fraction of cores or core fragments with cancer, and at least either the percent individual core involvement or the tumor length (in mm or cm)
      • Many commercial urologic pathology laboratories and individual pathologists report both percent and tumor length
    • When there are intervening areas of benign prostate in the core biopsy, the tumor is designated multifocal or discontinuously involving the core, and one of those two terms should appear in the diagnosis
Laboratory
  • Clinical screening:
    • Prostate carcinomas secrete 10x the PSA of normal tissue (in the past, 50% had levels > 10 mg/ml), BUT
      • The U.S. Preventive Services Task Force (USPSTF) issued a blanket "D" recommendation against all prostate-specific antigen (PSA) based early detection efforts for prostate cancer (Ann Intern Med 2012;157:120)
      • The American Urological Association (AUA) counteracted the USPSTF statement (J Urol 2013;190:419), noting that this recommendation is based on crucial misinterpretations of the risks and benefits of screening and issued its own recommendation that men aged 55-69 be offered biennial (every 2 year) screening and that men under age 40 or over 69 not normally be screened
      • Overall impact of this controversy on the volume of prostate biopsies prompted by an elevated PSA seems to be minimal
    • Use of the PCA3 molecular urine assay (Urology 2007;69:532) in addition to the PSA improves sensitivity and specificity for cancer detection
Radiology Description
Prognostic Factors
  • Prostatic adenocarcioma Gleason grade, stage, and margin status are the most well established factors
  • Cytologic and nuclear features of the cancer are less well established but do have some value (Arch Pathol Lab Med 2000;124:995)
Case Reports
Treatment
  • A variety of treatments besides radical prostatectomy are available, including targeted focal therapy involving cryotherapy; radiation brachytherapy; hormonal therapy; and watchful waiting
Clinical Images

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Bone metastates

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Bone scan

Gross Images

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Firm, gritty tissue

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Testicular metastases

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Bone metastases

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Liver metastases

Micro Images

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Whole mount

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Neuroendocrine cells

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Skeletal muscle

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Seminal vesicle

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Testicular metastases

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Bone metastases

Differential Diagnosis