prostate








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  • Normal

    • zones
      • transition zone: surrounds prostatic urethra, adjacent glands may have urothelial metaplasia
      • central zone: surrounds ejaculatory ducts, glands here are complex and may mimick cribiforming
      • peripheral zone: posterior and lateral
    • regions
      • anterior: fibromuscular stroma
      • posterior: contains the zones, cancer occurs here, especially transition and peripheral zones
      • apex
      • base
        • bladder neck: smooth muscle
        • seminal vesicles: has small invaginations mimicking malignant glands, muscular stroma, has pigment
    • glands
      • 2 layers
      • secretory cells: PSA+
      • basal cells: p63+
      • glands are large, intraluminal complexity
    • fibromuscular stroma
    • other
      • contains skeletal muscle
      • ganglion cells in extraprostatic tissue mimicks carcinoma
  • Approach

  • Non-neoplastic

  • WHO neoplasms

  • Seminal vesicle tumors

  • Grading

    • Gleason
      • Gleason 3 = discrete glands
      • Gleason 4 = fused, cribiform glands
      • Gleason 5 = solid sheets, single cells, comedo necrosis, karyorrhexis
      • Total score for bx: most prevalent grade + 2nd or 3rd most prevalent pattern (pick the higher grade out of the two)
      • For resections: give all grades and percent of each
    • Grade group
      • 1: Gleason score 3+3=6
      • 2: Gleason score 3+4=7
      • 3: Gleason score 4+3=7
      • 4: Gleason score 8
      • 5: Gleason 9, 10
    • Bx caveats
      • lower grade < 5% are ignored (Eg. 4+3 with minute 3 becomes 4+4)
      • For Gleason 4+3 or 3+4, give % that is Gleason 4
      • Gleason 4 has worse prognosis if has cribiform, so comment
      • For bx, grade separately for each bx location
    • Resection caveats
      • For multifocal resections, note each foci, but overall staging purposes, pick the worst from each nodule
      • For resections, if tertiary grade is < 5%, change wording to minor high grade pattern
  • TNM (using for grossing)

    • T1: microscopic
      • T1a: incidental tumor, <= 5% specimen
      • T1b: incidental tumor, > 5% specimen
      • T1c: tumor on needle biopsy
    • T2: prostate confined (including capsule)
      • T2a: unilateral, <= half of the involved side
      • T2b: unilateral, > half of the involved side
      • T2c: bilateral
    • T3: extraprostatic extension
      • T3a: extracapsular extension, including microscopic bladder neck involvement
      • T3b: seminal vesicle invasion (into muscular wall, not just surrounding stroma)
    • T4: adjacent structure invasion
      • bladder neck
      • external sphincter
      • rectum
      • levator muscles
      • pelvic wall
    • M1: metastasis
      • M1a: nonregional lymph node(s)
      • M1b: bone
      • M1c: other sites
  • Stage

    • I
      • T1-2a, PSA < 10, Gleason <= 6
      • T1-2a, PSA and Gleason unknown
    • IIA
      • T1a-c, PSA < 20, Gleason 7
      • T1-2a, PSA >=10 <20, Gleason <= 6
      • T2a, PSA < 20, Gleason 7
      • T2b, PSA < 20, Gleason <= 7
      • T2b, PSA and Gleason unknown
    • IIB
      • T2c
      • T1-2, PSA >= 20
      • T1-2, Gleason >= 8
    • III: T3a-c
    • IV: T4 or N1 or M1