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=
|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>{{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/>
</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: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 227: Line 190:
*Gleason score '''4''': Poorly-formed, fused and/or cribriform glands
*Gleason score '''4''': Poorly-formed, fused and/or cribriform glands
*Gleason score '''5''': Lacks gland formation, or has necrosis
*Gleason score '''5''': Lacks gland formation, or has necrosis
<gallery mode=packed heights=170>
<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'''
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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}}


====Grade group====
====Grade group====
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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}}
{{Evaluation}}
===Report===
 
==Reporting==
*'''Diagnosis'''
*'''Diagnosis'''
*'''Gleason score''', and optionally grade group
*'''Gleason score''', and optionally grade group
*'''Extent'''
*'''Extent'''
:*Prostatectomy: '''Stage'''.  
:*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.
:*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 '''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.
 
{|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}}
{{CAP}}
{{Reporting}}
===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 '''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}}
{{Bottom}}
{{Bottom}}
</noinclude>

Latest revision as of 09:48, 14 June 2024

Author: Mikael Häggström [note 1]

Comprehensiveness

On this resource, the following formatting is used for comprehensiveness:

  • Minimal depth
  • (Moderate depth)
  • ((Comprehensive))

Gross processing

As prostatectomy or biopsy.

Microscopic evaluation

Screening method

  • 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
[1]
  • Multiple nucleoli (Pictured in an acinar adenocarcinoma, the most common subdiagnosis of prostate adenocarcinoma)
    Multiple nucleoli (Pictured in an acinar adenocarcinoma, the most common subdiagnosis of prostate adenocarcinoma)
  • Eccentric nucleoli[1] (pictured example has double and eccentric nucleoli).
    Eccentric nucleoli[1] (pictured example has double and eccentric nucleoli).
Specific but relatively rare signs of adenocarcinoma
[notes 2]
  • Perineural invasion.[1] It should be circumferential (as pictured) to count.[2]
    Perineural invasion.[1] It should be circumferential (as pictured) to count.[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.[2]

  • Collagenous micronodules for acinar adenocarcinoma[1]
  • Angiolymphatic invasion[1]
  • Extraprostatic extension,[1] which in biopsies can be diagnosed when tumor cells are located in fatty tissue.
Less specific findings
  • Mitoses: also seen in for example high-grade prostatic intraepithelial neoplasia (HGPIN) and prostate inflammation.[1] Picture shows adenocarcinoma with two mitoses in reactive epithelium.
    Mitoses: also seen in for example high-grade prostatic intraepithelial neoplasia (HGPIN) and prostate inflammation.[1] Picture shows adenocarcinoma with two mitoses in reactive epithelium.
  • Intraluminal blue mucin[1] (pictured in acinar adenocarcinoma)
    Intraluminal blue mucin[1] (pictured in acinar adenocarcinoma)
  • Intraluminal atypical eosinophilic secretions.[1]
    Intraluminal atypical eosinophilic secretions.[1]
  • Intraluminal crystalloids.[3]
    Intraluminal crystalloids.[3]
  • Uneven distribution and infiltrative pattern of glands
    Uneven distribution and infiltrative pattern of glands
  • 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.[2]
    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.[2]
  • Prominent nucleoli[1]
  • Nuclear enlargement

Precancerous lesions

File:Histopathology of high-grade prostatic intraepithelial neoplasia (HGPIN), annotated.jpg
High-grade prostatic intraepithelial neoplasia (HGPIN) with typical features, H&E stain.[4]

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.[5]

An ASAP is a lesion that is probably carcinoma but either lacks definitive diagnostic features, or is too small to be certain (see image below).[6] It should not be used for benign lesions that are just unusual looking.[6] In uncertain cases, a diagnosis of adenocarcinoma can be excluded by immunohistochemical detection of basal cells (or confirmed by absence thereof),[1] 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 above 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.

Subdiagnoses

File:Prostate cancer types.png
Pie chart of subdiagnoses.[notes 3]

The histopathologic subdiagnosis of prostate cancer has implications for the possibility and methodology of any subsequent Gleason scoring.[8] The most common histopathological subdiagnosis of prostate cancer is acinar adenocarcinoma, constituting 93% of prostate cancers.[9] The most common form of acinar adenocarcinoma, in turn, is "adenocarcinoma, not otherwise specified", also termed conventional, or usual acinar.[10]

Subdiagnosis Relative incidence Image Microscopic characteristics Immunohistochemistry Gleason scoring
Core
biopsy		 Radical prostatectomy
Acinar adenocarcinoma
- 93%[9]		 Adenocarcinoma
(not otherwise specified/
conventional/
usual acinar)[10] 		77%[notes 4] 54%[notes 4] File:Micrograph of prostate cancer with Gleason score 8 (4+4) with glomeruloid glands.jpg
  • Collagenous micronodules[1]
  • Glomerulations[1]
  • May be mixed with other subdiagnoses.
 Tumorous glands:
  • 34βE12- and p63-[9] (+ in adjacent benign glands)[9]
  • Alpha-methylacyl-CoA racemase (AMACR) + (- in adjacent benign glands)[9]
  • PSA+ (>10 ng/ml) in 60% of cases[9]
 As usual
Foamy gland carcinoma 17%[11][notes 3] 13–23%[11][notes 3]
  • Abundant foamy cytoplasm[8]
  • Nuclei may be small and pyknotic - benign-looking[8]
  • Infiltrative pattern
  • Foamy cells:
  • PSA+ and CD68− [8]
  • AMACR+ in 68% of cases[8]
 Based on architecture, discounting foamy cytoplasms[8]
Atrophic carcinoma 2%[11][notes 5] 16%[11][notes 5]
  • Glands lined by cells with scant cytoplasm, resembling atrophy[8]
  • Infiltrative growth[8]
  • Usually admixed with non-atrophic components[8]
 Tumorous glands:
  • 34βE12- and p63- [8]
  • AMACR+ in 70% of cases[8]
 As usual[8]
Pseudohyperplastic carcinoma 2%[11] 11%[11]
  • Large-sized or dilated glands[8]
  • Branching and papillary infolding[8]
  • Tall columnar cells[8]
  • Abundant pale to slight granular luminal cytoplasm[8]
  • Nuclei towards basement membrane[8]
 Tumorous glands:
  • 34βE12- and p63- [8]
  • AMACR+ in 70–83% of cases[8]
 3+3=6[8]
Microcystic carcinoma 11%[11]
  • Cystic dilatation and rounded expansion of malignant glands[12]
  • Lined by flat cells[12]
  • Intraluminal crystalloids, and wispy blue intraluminal mucin[12]
 On (usually) adjacent acinar adeocarcinoma[12]
PIN-like 1.3%[13]
  • Glands lined by ≥2 layers of malignant cells[8]
  • May resemble flat or tufted high-grade PIN, but lacks basal cells[8]
 Tumorous glands:
  • 34βE12- and p63- [8]
 Not recommended[8]
Non acinar
(or mixed acinar/
non-acinar)
adenocarcinoma		 Ductal adenocarcinoma 3% to 12.7%[14][notes 3] File:Micrograph of typical ductal adenocarcinoma of the prostate.jpg
  • Large glands and papillary formations, lined by tall columnar cells, often pseudostratified[8]
  • Papillary, cribriform, individual glands, or solid variants[8]
  • Cytoplasm usually amphophilic[8]
  • Nuclei are large and hyperchromatic, with prominent nucleoli[15]
  • AMACR+ in 77% of cases[8]
  • Usually negative for basal cells stains[8]
Intraductal adenocarcinoma 2.8%[16] File:Micrograph of intraductal carcinoma of the prostate with an infiltrative growth pattern.jpg
H&E and CK5/6
  • Carcinoma cells spanning entire lumen of ducts and acini[17]
  • At least focal preservation of the basal cell layer[17]
Urothelial carcinoma 0.7 to 2.8%[18] File:Urothelial carcinoma in the prostatic urethra, low mag.jpg
  • Umbrella cells are usually present in low-grade tumors[19]
  • Frequently branching fibrovascular cores[19]
  • Frequently fusing of papillae[19]
 Not recommended[8]
Small-cell carcinoma 0.3–2%[20][21][notes 3] File:Micrograph of small-cell carcinoma of the prostate.jpg
  • Small blue cells with scant cytoplasm[8]
  • High nucleus/cytoplasm ratio[8]
  • "salt and pepper" chromatin[8]
  • Nuclear molding[8]
  • Necrosis of single cells, or geographic[8]
  • Smearing artifacts[8]

Half of cases have usual acinar components[8]

Mucinous adenocarcinoma 0.2%[18] File:Micrograph of mucinous adenocarcinoma of the prostate with Gleason score 7 (3 + 4) with individual well-formed glands and minor component of cribriform glands floating in extracellular mucin.jpg
  • ≥25% of tumor shows extracellular mucin[8]
  • Intraluminal mucinous material does not qualify[8]
  • No extraprostatic origin found[8]
 Tumorous glands:
  • 34βE12- and p63-[8]
  • PSA+ and CK8/18+[8]
 4+4=8 for irregular cribriform glands floating in mucin.[8]
Signet-ring adenocarcinoma 0.02%[22] File:Micrograph of signet-ring adenocarcinoma of the prostate.jpg
  • ≥25% of tumor shows signet-ring cells (widely infiltrative cells with optically clear vacuoles displacing the nuclei)[8]
 Tumorous glands: Not recommended[8]
Basal-cell carcinoma 0.01%[23] Basaloid tumor:
  • Scant cytoplasm[8]
  • High nucleus/cytoplasm ratio[8]
  • Irregular or angulated nuclei[8]
  • Euchromatic[8]
  • May have nuclear and cytoplasmic micro-vacuolation[8]
  • Infiltration of adjacent parenchyma[8]

BCC-pattern:

  • Variably sized solid nests, cords, or trabeculae[8]
  • Peripheral palisading[8]
  • p63+ [8]
  • HMCK(34βE12)+[8]
  • Typically CK20−/CK7+, but CK7− in pure solid basal cell nests[8]
  • Bcl-2+, strongly and diffusely[8]
  • Ki-67 nuclear staining in >20%[8]
 Not recommended.[8]

Gleason scoring

File:Gleasonscore.jpg

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:[24]

  • 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)).[25]

In case of 3 patterns in one specimen:[26]

  • 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.[27]))

Grade group

(In a moderately comprehensive report, also state the overall grade group for the adenocarcinoma:[24]

  • 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)

Staging

Depending on sample type:

  • Multiple biopsy specimens: Adenocarcinoma presence in how many of the biopsies
  • Prostatectomy: Stage by TNM:

The AJCC 8th edition[28] 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
File:Histopathology of prostate adenocarcinoma involving adipose tissue.jpg
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.[29]
File:Histopathology of prostate adenocarcinoma involving skeletal muscle.jpg
In contrast, skeletal muscle is normally present within the prostate, so involvement thereof does not count as extraprostatic or extracapsular extension.[30]
  • 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

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.
  • ((Any inflammation.[notes 1]))

Examples in a biopsy with adenocarcinoma:

(Prostate, left apex, needle biopsy:)
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.

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:

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.

For cancers, generally include a synoptic report, such as per College of American Pathologists (CAP) protocols at cap.org/protocols-and-guidelines.

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 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.

  See also: General notes on reporting


Notes

  1. ↑ 1.0 1.1 Inflammation can explain for example a high PSA value in the absence of adenocarcinoma, so its reporting is usually only needed in such cases.
  2. ↑ "Rare" here refers to prevalence at least in core biopsies.(Cruz 2016)
  3. ↑ 3.0 3.1 3.2 3.3 3.4 At least where noted, the numbers include cases where the pattern is found admixed with usual acinar adenocarcinoma.
  4. ↑ 4.0 4.1 Numbers for usual acinar adenocarcinoma do not include mixed patterns with other subdiagnoses.
  5. ↑ 5.0 5.1 Number refers to sporadic atrophic pattern adenocarcinoma.
  1. ↑ 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.

Main page

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 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
  2. ↑ 2.0 2.1 2.2 Robert V Rouse MD. Prostatic Adenocarcinoma. Stanford Medical School. Last update 2/2/16
  3. ↑ Svatek, R S; Karam, J A; Rogers, T E; Shulman, M J; Margulis, V; Benaim, E A (2007). "Intraluminal crystalloids are highly associated with prostatic adenocarcinoma on concurrent biopsy specimens ". Prostate Cancer and Prostatic Diseases 10 (3): 279–282. doi:10.1038/sj.pcan.4500954. ISSN 1365-7852. 
  4. ↑ Image by Mikael Häggström, MD. Reference for features:
    - Margaret Sanders, M.B.B.Ch., Murali Varma, M.B.B.S.. High grade prostatic intraepithelial neoplasia (HGPIN). Pathology Outlines. Last author update: 23 February 2021
  5. ↑ Stanley A Brosman, MD. Precancerous Lesions of the Prostate. Medscape. Updated: Feb 26, 2020
  6. ↑ 6.0 6.1 . Prostatic Adenocarcinoma - Atypical Small Acinar Proliferation (ASAP). Stanford Medical School. Retrieved on 2020-09-14.
  7. ↑ Image by Mikael Häggström, MD. Reference for findings: Faryal Shoaib, M.D., Chinedum Okafor, M.D., Y. Albert Yeh, M.D., Ph.D.. Anatomy & histology-seminal vesicles / ejaculatory duct. Pathology Outlines. Last staff update: 20 November 2023
  8. ↑ 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.11 8.12 8.13 8.14 8.15 8.16 8.17 8.18 8.19 8.20 8.21 8.22 8.23 8.24 8.25 8.26 8.27 8.28 8.29 8.30 8.31 8.32 8.33 8.34 8.35 8.36 8.37 8.38 8.39 8.40 8.41 8.42 8.43 8.44 8.45 8.46 8.47 8.48 8.49 8.50 8.51 8.52 8.53 8.54 8.55 8.56 8.57 8.58 8.59 8.60 "The pathology of unusual subtypes of prostate cancer ". Chin. J. Cancer Res. 28 (1): 130–43. February 2016. doi:10.3978/j.issn.1000-9604.2016.01.06. PMID 27041935. 
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 Baig, Faraz A.; Hamid, Amna; Mirza, Talat; Syed, Serajuddaula (2015). "Ductal and Acinar Adenocarcinoma of Prostate: Morphological and Immunohistochemical Characterization ". Oman Medical Journal 30 (3): 162–166. doi:10.5001/omj.2015.36. ISSN 1999768X. 
  10. ↑ 10.0 10.1 . Prostatic Adenocarcinoma. Stanford University School of Medicine. Retrieved on 2019-10-30.
  11. ↑ 11.0 11.1 11.2 11.3 11.4 11.5 11.6 Humphrey, Peter A (2018). "Variants of acinar adenocarcinoma of the prostate mimicking benign conditions ". Modern Pathology 31 (S1): 64–70. doi:10.1038/modpathol.2017.137. ISSN 0893-3952. 
  12. ↑ 12.0 12.1 12.2 12.3 12.4 12.5 Yaskiv, Oksana; Cao, Dengfeng; Humphrey, Peter A. (2010). "Microcystic Adenocarcinoma of the Prostate: A Variant of Pseudohyperplastic and Atrophic Patterns ". The American Journal of Surgical Pathology 34 (4): 556–561. doi:10.1097/PAS.0b013e3181d2a549. ISSN 0147-5185. 
  13. ↑ Zhou, Ming (2018). "High-grade prostatic intraepithelial neoplasia, PIN-like carcinoma, ductal carcinoma, and intraductal carcinoma of the prostate ". Modern Pathology 31 (S1): 71–79. doi:10.1038/modpathol.2017.138. ISSN 0893-3952. 
  14. ↑ "The update of prostatic ductal adenocarcinoma ". Chin. J. Cancer Res. 28 (1): 50–7. February 2016. doi:10.3978/j.issn.1000-9604.2016.02.02. PMID 27041926. 
  15. ↑ Robert V Rouse (2012-01-06). Prostatic Ductal Adenocarcinoma. Stanford University School of Medicine.
  16. ↑ 16.0 16.1 16.2 16.3 Magers, Martin; Kunju, Lakshmi Priya; Wu, Angela (2015). "Intraductal Carcinoma of the Prostate: Morphologic Features, Differential Diagnoses, Significance, and Reporting Practices ". Archives of Pathology & Laboratory Medicine 139 (10): 1234–1241. doi:10.5858/arpa.2015-0206-RA. ISSN 0003-9985. 
  17. ↑ 17.0 17.1 Roberts, Jordan A.; Zhou, Ming; Park, Yong Wok; Ro, Jae Y. (2013). "Intraductal Carcinoma of Prostate: A Comprehensive and Concise Review ". Korean Journal of Pathology 47 (4): 307. doi:10.4132/KoreanJPathol.2013.47.4.307. ISSN 1738-1843. 
  18. ↑ 18.0 18.1 Grignon, David J (2004). "Unusual subtypes of prostate cancer ". Modern Pathology 17 (3): 316–327. doi:10.1038/modpathol.3800052. ISSN 0893-3952. 
  19. ↑ 19.0 19.1 19.2 Robert V Rouse. Papillary Urothelial (Transitional Cell) Carcinoma. Stanford University School of Medicine. Original posting/updates: 10/20/12, 12/29/12
  20. ↑ 0.3%-1%: Page 77 in:Beltran, Antonio (2017). Pathology of the prostate : an algorithmic approach . Cambridge, United Kingdom New York, NY: Cambridge University Press. ISBN 978-1-108-18565-3. OCLC 1011514854. 
  21. ↑ 0.5-2%: Kumar, Kishore; Ahmed, Rafeeq; Chukwunonso, Chime; Tariq, Hassan; Niazi, Masooma; Makker, Jasbir; Ihimoyan, Ariyo (2018). "Poorly Differentiated Small-Cell-Type Neuroendocrine Carcinoma of the Prostate: A Case Report and Literature Review ". Case Reports in Oncology 11 (3): 676–681. doi:10.1159/000493255. ISSN 1662-6575. 
  22. ↑ Wang, Jue; Wang, Fen Wei; Hemstreet, George P. (2011). "Younger Age Is an Independent Predictor for Poor Survival in Patients with Signet Ring Prostate Carcinoma ". Prostate Cancer 2011: 1–8. doi:10.1155/2011/216169. ISSN 2090-3111. 
  23. ↑ Ninomiya, Sahoko; Kawahara, Takashi; Iwashita, Hiromichi; Iwamoto, Genta; Takamoto, Daiji; Mochizuki, Taku; Kuroda, Shinnosuke; Takeshima, Teppei; et al. (2018). "Prostate Basal Cell Carcinoma: A Case Report ". Case Reports in Oncology 11 (1): 138–142. doi:10.1159/000487389. ISSN 1662-6575. 
  24. ↑ 24.0 24.1 . New Contemporary Prostate Cancer Grading System. Johns Hopkins University, Department of Pathology. Retrieved on 2020-09-21.
  25. ↑ . Protocol for the Examination of Prostate Needle Biopsies From Patients With Carcinoma of the Prostate Gland: Case Level Reporting. College of American Pathologists. Version: 1.0.0.1. Protocol Posting Date: November 2021
  26. ↑ MOLAVI, DIANA WEEDMAN (2018). PRACTICE OF SURGICAL PATHOLOGY : a beginner's guide to the diagnostic process. . [Place of publication not identified]: SPRINGER INTERNATIONAL PU. ISBN 3-319-86570-6. OCLC 1085201203. 
  27. ↑ Sharma M, Miyamoto H (2018). "Percent Gleason pattern 4 in stratifying the prognosis of patients with intermediate-risk prostate cancer. ". Transl Androl Urol 7 (Suppl 4): S484-S489. doi:10.21037/tau.2018.03.20. PMID 30363387. PMC: 6178316. Archived from the original. . 
  28. ↑ Amin, Mahul (2017). AJCC cancer staging manual (8 ed.). Switzerland: Springer. ISBN 978-3-319-40617-6. OCLC 961218414.  Chapter: 58 - Prostate.
    - 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)). edit
  29. ↑ Image by Mikael Häggström, MD. Reference for implication: Grignon DJ (2018). "Prostate cancer reporting and staging: needle biopsy and radical prostatectomy specimens. ". Mod Pathol 31 (S1): S96-109. doi:10.1038/modpathol.2017.167. PMID 29297497. Archived from the original. . 
  30. ↑ Image by Mikael Häggström, MD. Reference for implication: Ye H, Walsh PC, Epstein JI (2010). "Skeletal muscle involvement by limited Gleason score 6 adenocarcinoma of the prostate on needle biopsy is not associated with adverse findings at radical prostatectomy. ". J Urol 184 (6): 2308-12. doi:10.1016/j.juro.2010.08.006. PMID 20952012. Archived from the original. . 

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