Milking The Prostate
Prostate cancer is a major public health problem throughout the developed world. For patients with clinically localised sigillo prostata foci cancer, the diagnosis is typically established by histopathological examination of prostate needle biopsy samples. Major and minor criteria sigillo prostata foci used to establish the diagnosis, based on the microscopic appearance of slides stained using haematoxylin and eosin.
Major criteria include an infiltrative glandular sigillo prostata foci pattern, an absence of basal cells and nuclear atypia in the form of nucleomegaly and nucleolomegaly. Cocktails of antibodies directed against basal cell markers and AMACR are particularly useful in evaluating small foci of atypical glands, and in substantiating a diagnosis of a minimal adenocarcinoma.
Reporting of adenocarcinoma in needle biopsy specimens should always include the Gleason grade and measures of tumour extent in the needle core tissue.
Measures of tumour extent are 1 number of cores positive for cancer in the number of cores examined, 2 percentage of needle core tissue affected by carcinoma and 3 linear millimetres of carcinoma present. The histopathological diagnosis of adenocarcinoma of the prostate in needle core biopsy specimens presents a unique set of challenges. Finally, the needle cores can fragment, which can also generate problems in interpretation. The focus of this review is an approach to the histopathological diagnosis of carcinoma in prostate needle biopsy specimens, especially limited or minimal adenocarcinoma.
Next, sigillo prostata foci in the differential diagnosis of prostatic adenocarcinoma are briefly presented, followed by information on the use of ancillary diagnostic studies, particularly the use of immunohistochemical staining. The final section discusses the reporting of prostatic carcinoma sigillo prostata foci prostate needle biopsy tissue. Diagnosis of prostatic carcinoma requires a synthesis of a constellation of histological attributes that allows for a definitive diagnosis.
A conceptual framework for a rationale approach to this sigillo prostata foci entails application of major and minor criteria box 1. These Gleason pattern 3 adenocarcinomas are currently the most common pattern recognised in needle sigillo prostata foci specimens. This deceptive appearance is because the invading glands do not usually elicit a desmoplastic or inflammatory response that characterises many invasive carcinomas at other anatomical sites.
Linkage of carcinoma cells into chains and cords also indicates sigillo prostata foci differentiated Gleason pattern 4 adenocarcinoma. These arrangements represent Gleason pattern 5, which is uncommon in needle biopsy specimens. The sigillo prostata foci of fibrogenic or inflammatory response is evident. In some cases, benign prostate glands are not present to serve as landmarks to evaluate for invasion.
This can happen as a result of destructive growth of the tumour, due to invasion into an area of pure fibromuscular stroma, and due to invasion into extraprostatic tissues, such as periprostatic adipose tissue or seminal vesicle tissue.
Destructive growth can occur with any Gleason grade carcinoma that is extensive. Also, benign or malignant prostatic glands can be observed in skeletal muscle tissue at the apex, where skeletal muscle of the urogenital diaphragm interdigitates into the prostate gland. The detection of infiltrating carcinoma into the skeletal muscle in a needle biopsy sigillo prostata foci does not necessarily equate with extraprostatic spread.
However, this is rarely an isolated finding and is generally associated with extensive carcinoma in the rest of the needle biopsy tissue. Thus, in prostatic needle biopsy, carcinoma of the prostate can present a range of images of infiltration, with invasion into prostatic as well as extraprostatic tissues.
It is difficult to tell, on needle biopsy, whether this is definitely a seminal vesicle or an ejaculatory duct. Seminal vesicle or ejaculatory duct glands are crowded larger glands at lower right. An infiltrative pattern is not evident for carcinomas with a partially nodular configuration.
Absence of basal cells in the atypical glands is the second of the major criteria. Basal cells may assume a range of appearances, 1920 and so careful study of basal cells in glands that are clearly benign is a vital exercise before scrutinising abnormal glands of concern to rule out their presence in malignant glands.
A historic challenge for the surgical pathologist has been the distinction of periglandular stromal fibroblasts from basal cells. Another common difficulty is that distorted, crushed or poorly preserved carcinoma cells in minimal cancer foci can sigillo prostata foci mistaken for basal cells.
This basal cell layer is not always present in benign small glands, so that its absence sigillo prostata foci not sigillo prostata foci absolute criterion of carcinoma. Conversely, however, we have not seen it in sigillo prostata foci case sigillo prostata foci which the diagnosis was cancer. Additional but rare benign mimickers of prostatic carcinoma that can lack basal cells include mesonephric hyperplasia 25 and nephrogenic adenoma.
Nuclear atypia in the form of nuclear enlargement and nucleolar enlargement is the third of the major criteria for diagnosis of adenocarcinoma. Failure to detect prominent nucleoli in prostatic carcinoma nuclei is probably multifactorial; large nucleoli might be present but undetectable owing to poor preservation, poor fixation, overstaining or section thickness.
This last factor of overly thick sections is an extremely common problem. In addition, lack of chromatin clearing might contribute to the inability to detect nucleoli. Finally, some prostate cancers do not harbour macronucleoli. Sigillo prostata foci essential point is that when macronucleoli are absent, there should be significant nucleomegaly with or without nuclear hyperchromasia to definitively diagnose carcinoma.
Minor diagnostic criteria box 1 are found on an individual basis in a smaller proportion of cases than those with major diagnostic criteria, with the exception of intraluminal amorphous pink material.
Another finding specific for carcinoma—lymphovascular space invasion—is vanishingly rare in prostate needle biopsy tissue. One of the major diagnostic challenges confronting the histopathologist in interpretation of a prostate needle biopsy specimen is the establishment of a malignant diagnosis based on a minimal or limited amount of carcinoma in the needle biopsy tissue.
The major and minor sigillo prostata foci criteria should be put into use here, just as for more extensive carcinoma. Uncommon patterns of growth that typically accompanied the common patterns were cords of cells, single cells and cribriform glands. No definite quantitative threshold exists for the number of glands required to establish a diagnosis of malignancy, although most authorities require at least 2—3 glands I prefer three glands. Clearly though, sigillo prostata foci case must be interpreted on it own merits such that a very few glands may be definitely diagnostic in one case but not in another.
Many cases of minimal carcinoma harbour well over 2—3 glands. In a third series, the mean standard deviation SD number of acini to diagnose carcinoma was 17 Both of these major criteria are of immense importance for these most minimal of the minimal carcinomas, where discerning architectural abnormalities is difficult to impossible.
In another series on minimal limited carcinoma, the lowest number of diagnostic glands was two. Numerous entities, both benign and malignant, should be considered in the differential diagnosis of prostatic adenocarcinoma.
Recent reviews have highlighted the benign lesions or pseudoneoplasms box 2 that may mimic prostatic adenocarcinoma. A descriptive diagnosis which may be sigillo prostata foci if the histological or immunohistochemical findings are thought to be worrisome but not fully diagnostic of carcinoma, is atypia, 3343 also known as atypical suspicious for carcinoma or atypical small acinar proliferation. In the past, basal cell immunostains were used by themselves.
Currently, many laboratories combine use of basal cell markers with an immunostain for AMACR, sometimes in a cocktail. Firstly, absence of basal cells is an important criterion for the histological diagnosis of prostatic carcinoma, but is sigillo prostata foci one of several of the major criteria.
Thus, this immunostain, as other adjunctive studies, should be interpreted in the context of all histological findings in the particular case. Also, not all benign glands have basal cells. Finally, this immunohistochemical stain is based on a negative result to give a positive diagnosis of malignant neoplasm.
Many factors can cause failure of immunohistochemical staining, and absence of proof is not proof of absence. So, it is absolutely critical to study the immunostained cores for a positive internal control—benign glands with a strong, positive basal cell signal. They have also been ordered in selected cases in which the differential diagnosis encompassed atypical adenomatous hyperplasia adenosisPIN, basal cell hyperplasia and atrophy.
It would be desirable to diagnose adenocarcinoma and to have a positive marker that is relatively specific for malignant prostatic epithelial cells, in addition to the negative basal cell markers. From immunohistochemical studies, 29585960616263646566676869 one such marker, AMACR, is selective and very sensitive for carcinoma.
Application of such a cocktail is decidedly advantageous if only a small atypical focus is present, and especially if the focus is present only on a single section or slide that is available sigillo prostata foci immunohistochemical evaluation. In certain cases, additional immunohistochemical studies are indicated. Genetic abnormalities such RNA overexpression or underexpression, DNA ploidy, chromosomal anomalies, gain or loss of specific DNA sequences, DNA methylation and specific gene mutations are not used in the diagnosis of carcinoma in prostate needle biopsy specimens.
The most clinically important attributes of adenocarcinoma in prostate needle biopsy specimens that merit reporting are Gleason sigillo prostata foci and amount of tumour in the needle biopsy tissue. All these measures provide nearly equivalent information, such that there is not a standard method of appraising the tumour extent in a needle biopsy specimen.
Indeed, several measures should be given for the same set of needle biopsies. Competing interests: None declared. National Center for Biotechnology InformationU.
Journal List J Clin Pathol v. J Clin Pathol. P A Humphrey. Author information Article notes Copyright and License information Disclaimer. Accepted Aug This article has been cited by other articles in PMC. Abstract Prostate cancer is a major public health problem throughout the developed world.
Major criteria for diagnosis of sigillo prostata foci in prostate needle biopsy tissue sections Diagnosis of prostatic carcinoma requires a synthesis of a constellation of histological attributes that allows for a definitive diagnosis. Open in a separate window.
Minor diagnostic criteria Minor diagnostic criteria box sigillo prostata foci are found on an individual basis in a smaller proportion of cases than those with major diagnostic criteria, with the exception of intraluminal amorphous pink material. Minimal adenocarcinoma One of the major diagnostic challenges confronting the histopathologist in interpretation of a prostate needle biopsy specimen is the establishment of a malignant diagnosis based on a minimal or limited amount of carcinoma in the needle biopsy tissue.
Differential diagnosis of adenocarcinoma in needle biopsy tissue Numerous entities, both benign and malignant, should be considered in the differential diagnosis of prostatic adenocarcinoma. Box 2: Differential diagnosis of prostatic adenocarcinoma: pseudoneoplasms of the prostate Atypical adenomatous hyperplasia adenosis Atrophy Crowded benign glands Basal cell hyperplasia Sclerosing adenosis Cribriform sigillo prostata foci Mesonephric hyperplasia Nephrogenic metaplasia adenoma Verumontanum mucosal gland hyperplasia Squamous sigillo prostata foci Transitional cell metaplasia Radiation atypia Prostatitis Malacoplakia Endometriosis Postoperative spindle cell nodule Atypical stromal cells Extramedullary haematopoiesis Cowper glands Paraganglia sigillo prostata foci prostate Benign glands adjacent to nerves and skeletal muscle.
Reporting The most clinically important attributes of adenocarcinoma in prostate needle biopsy specimens that merit reporting are Gleason grade and amount of tumour in the needle biopsy tissue.
Footnotes Competing interests: None declared. References 1. CA Cancer J Clin 55 74— Humphrey P A. Clinical aspects of prostatic carcinoma, with histopathologic correlations. Sigillo prostata foci Prostate pathology. JAMA — Prostate 57 93— J Urol — Mod Pathol 11 —