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Designed for UG teaching.
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Prostate Dr.CSBR.Prasad, M.D.
Normal Prostate • Retroperitoneal organ
• Encircles the neck of the bladder and urethra
• No definitive capsule
• Weighs approx 20gms
• Measures 3-4cms in greatest dimension
• Divided into 4 anatomically and biologically distinct zones
1-Peripheral
2-Central
3-Transitional zones
4-Region of anterior fibromuscular stroma
Note: Most hyperplasias arise in the transitional zone, where
as most carcinomas originate in the peripheral zone.
CSBRP-July-2012
This is a transverse (axial) section through a normal prostate. There is a central urethra (White
arrow) at the depth of the cut made to open this prostate anteriorly at autopsy, with the left lateral
lobe (Red arrow) and the right lateral lobe (Yellow arrow) and the posterior lobe (Green arrow).
The consistency is uniform, without nodularity. The normal prostate is 3 to 4 cm in diameter.
CSBRP-July-2012
This is a diagram of the classic 4 prostatic lobes. The x marks the
site through which the urethra traverses. It is easy to see that most
pathology related to the prostate will present with obstructive
uropathy symptoms.
CSBRP-July-2012
Histology:
• Compound tubuloalveolar organ
• Glandular lining epithelium has two layers of cells and has distinct BM
1-Basal layer of cuboidal epithelium &
2-Tall columnar secretory cells towards the lumen
• There are small papillary inbuddings of the epithelium
• Glands are separated by abundant fibromuscular stroma
Normal Prostate
CSBRP-July-2012
The normal male prostate gland below the bladder is composed of a
mixture of glands and intervening fibromuscular stroma, in about equal
proportions, as seen here at low power.
Normal prostate is composed of a mixture of glands lined by tall
columnar cells with infoldings and the intervening fibromuscular stroma,
in about equal proportions, as seen here at medium power.
The normal appearance of prostate is shown at high magnification. Note the small pink
laminated concretion (these are corpora amylacea) in the gland lumen to the left of
center. Note the infoldings of the columnar epithelium.
CSBRP-July-2012
Pathological processes
involving prostate
• Inflammations
• Nodular hyperplasia
• Tumors
CSBRP-July-2012
Prostatitis
1. Acute bacterial prostatitis
2. Chronic bacterial prostatitis
3. Granulomatous prostatitis
CSBRP-July-2012
Acute bacterial prostatitis
• Usually due to extension of infection from the urethra or bladder
• It can follow manipulation of the urethra or prostate secondary to catherization or cystoscopy
• The bacterial "culprits" are:
• -- Urinary pathogens (Enterobacteriaceae)
• -- Enterococcus and Staphylococcus
• CF: dysuria, chills and fever
• The prostate is very tender to palpation
• Neutrophilic infiltrate
CSBRP-July-2012
Acute bacterial prostatitis
CSBRP-July-2012
Chronic Prostatitis
• Chronic Bacterial Prostatitis Antibiotics do not penetrate the prostate well
The common presentation is recurrent UTI
• Chronic Prostatitis
Lymphocytic infiltrate and fibrosis
Chronic non-bacterial prostatitis:
-- the most common type
-- WBCs may been seen in prostatic secretions, but
-- no bacteria can be identified
-- suspects – ‘chlamydia and mycoplasma’ infection
CSBRP-July-2012
Chronic Prostatitis
CSBRP-July-2012
Granulomatous Prostatitis
• Tuberculosis
• Fungal (immunocompromised patients)
• Secondary to secretions from
obstructed ducts
CSBRP-July-2012
CSBRP-July-2012
Prostatic hyperplasia
CSBRP-July-2012
BPH (Nodular hyperplasia)
• Common disorder, aging process. >40yrs=20%, >60yrs=70%, >70yrs=90%.
• >50yrs
• Periurethral portion is involved
• Present with urinary obstruction
• Hyperplasia of stroma and epithelial
cells
CSBRP-July-2012
BPH / NPH
(Nodular hyperplasia)
Pathogenesis:
• Androgen related
• Dihydrotestosterone mediates growth and
proliferation in stromal and epithelial cells
CSBRP-July-2012
CSBRP-July-2012
Clinical Features
• Retention of urine
• UTI
CSBRP-July-2012
The most commonly used and effective medical therapy:
• α-blockers, which decrease prostate smooth muscle
tone via inhibition of α1-adrenergic receptors
• Shrinking the prostate with inhibitor of DHT synthesis
(5-α-reductase Inhibitors)
BPH / NPH
• Prostate is enlarged, 60-100gms
• Nodular in the inner aspect of the
gland
• Compressed urethra
• c/s milky white fluid may ooze
• Bladder wall thickening / Trabaculation
• Microscopically – fibromyoglandular
hyperplasia
CSBRP-July-2012
This anatomical midline
sagital section reveals a
markedly enlarged prostate
with a nodular appearance
from hyperplasia. The
prostatic urethra (Yellow)
that traverses the enlarged
gland is compressed. The
bladder wall is
hypertrophic. Other
structures seen here include
the pubic symphysis
(White), the rectum (Blue),
and the penile urethra
(Red).
Bladder
CSBRP-July-2012
CSBRP-July-2012
Multinodularity
Solid areas
Microcystic areas
CSBRP-July-2012
This is the gross appearance of nodular prostatic hyperplasia (benign
prostatic hyperplasia, or BPH). The normal prostate is 3 to 4 cm in cross
section, by comparison.
BPH
CSBRP-July-2012
This is the microscopic appearance of nodular prostatic hyperplasia at medium power.
Note that the columnar arrangement of cells near the gland lumina is preserved. Note
several pink corpora amylacea in gland lumens.
This is the microscopic appearance of nodular prostatic hyperplasia at low
magnification. Note the nodule filled with enlarged glands. Though crowded, there is
still stroma between the glands. CSBRP-July-2012
The enlarged prostate gland seen
here not only has enlarged
lateral lobes, but also a greatly
enlarged median lobe that
obstructs the prostatic urethra.
This led to obstruction with
bladder hypertrophy, as
evidenced by the prominent
trabeculation of the bladder wall
seen here from the mucosal
surface. Obstruction with stasis
also led to the formation of the
yellow-brown calculus (stone).
Lateral
lobes
Median
lobe
CSBRP-July-2012
Trabaculation and thickening of the wall [Fighting Urinary bladder]
CSBRP-July-2012
Do you know what is fighting
Gall bladder?
CSBRP-July-2012
The prostate "chips" seen here are the firm, rubbery fragments obtained
from transurethral resection of prostate (TUR-P) performed for
symptomatic nodular hyperplasia.
Areas of infarction Areas of nodular hyperplasia
CSBRP-July-2012
BPH and malignancy
Nodular hyperplasia is NOT
considered to be a
premalignant lesion
CSBRP-July-2012
Carcinoma of Prostate
CSBRP-July-2012
Prostatic carcinoma
• One of the most common cancers in
men
• >50yrs (men from the age of 40yrs should be screened for prostatic
cancer)
• The incidence increases with age
50s 20%; 70s 70%
• More common in whites (50-60/lakh)
and rare in Asians (1-4/lakh)
CSBRP-July-2012
• Risk factors: age, race, family history, hormone levels, environmental factors
• Familiy history: One 1 relative – 2x
Two 1 relatives – 5x
• Androgens (AR mutations in CAG repeats)
• Prostatic cancer susceptibility gene – 1q24-25
• Loss of cancer supressor genes: 8p, 10q, 13q, 16q.
• Mutations in p53, PTEN and KAI 1
• Over expression of : Hepsin, alfa-methyl-acyl COA racemase, and EZH2.
• Hypermethylation of GSTP1
Prostatic carcinoma – Etiology
CSBRP-July-2012
• 70% of cancers arise in the periphery
• Firm to gritty
• Local extensions involve seminal vesicles, base of the bladder and may result in urinary obstruction
• Blood spread: Bone (axial skeleton, femur, pelvis, ribs)
• Bone mets: Osteoblastic
• Lymphatic spread: perivesical, hypogastric, iliac, parasacral, para-aortic
Prostatic carcinoma – GROSS
CSBRP-July-2012
This is a diagram of the classic 4 prostatic lobes. The x marks the
site through which the urethra traverses. It is easy to see that most
pathology related to the prostate will present with obstructive
uropathy symptoms.
CSBRP-July-2012
This anatomical midline
sagital section reveals a
markedly enlarged prostate
with a nodular appearance
from hyperplasia. The
prostatic urethra (Yellow)
that traverses the enlarged
gland is compressed. The
bladder wall is
hypertrophic. Other
structures seen here include
the pubic symphysis
(White), the rectum (Blue),
and the penile urethra
(Red).
Bladder
CSBRP-July-2012
Secondary deposits in bone
• Breast
• Kidney
• Prostate
• Adrenals
• Testis
• Intestines
• Lung
B.K.PATIL
CSBRP-July-2012
Pathology Pearls
“Bone seeking Kidney tumor”
• Clear cell sarcoma of the kidney
CSBRP-July-2012
Pathology Pearls
CSBRP-July-2012
The gross appearance of
adenocarcinoma of the prostate
is shown here in cross section.
The entire prostate is involved.
The yellowish nodules
represent larger foci of
carcinoma.
CSBRP-July-2012
• Gland formations:
1-Single cell layer, no basal layer
2-Small, crowded glands
3-Nuclei are large, contain 1-2 nucleoli
4-Mitotic figures are uncommon
• Perineural invasion
• One feature that distinguishes benign from
malignant gland is – basal layer (HMWCK)
Prostatic carcinoma – micro
CSBRP-July-2012
CSBRP-July-2012
CSBRP-July-2012
CSBRP-July-2012
Whole mount of large duct adenocarcinoma. The tumor is
centrally located and has a distinctly papillary configuration.
Lack of basal cells around the malignant acini.
Some benign glands show basal layer (arrow)
CSBRP-July-2012
CSBRP-July-2012
Adenocarcinoma of the prostate is shown here at medium power. Some
of the neoplastic glands have lumens, but there is no stroma between.
This is a high grade, poorly differentiated adenocarcinoma of prostate.
There is no gland formation, only single cells infiltrating through the
stroma. CSBRP-July-2012
This is a moderately well-differentiated adenocarcinoma of the prostate
at high magnification.
Prostate
CSBRP-July-2012
A hallmark of prostatic adenocarcinoma is the presence of prominent
large nucleoli, as seen here. CSBRP-July-2012
Many large nucleoi are seen here in the nuclei of cells in this prostatic
adenocarcinoma. CSBRP-July-2012
Adenocarcinoma of the prostate is shown here at low power on the left, compared to
benign prostate (in which glands contain corpora amylacea) at the right. Note how small
and close-packed the neoplastic glands are.
This is a high grade adenocarcinoma of prostate. There are ill-defined
glands, and at the top just single infiltrating cells.
Grading of prostatic carcinoma
Gleason’s grading:
grade 1-5
grade-1: WD tumor
grade-5: PD tumor
Reported score which is a total of
predominant grade and other grade
eg: Score 3+5=8
CSBRP-July-2012
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Prostatic intraepithelial neoplasia -
PIN
• Benign glands with intraacinar
proliferations of cells which exhibit
nuclear anaplasia
• glands surrounded by patchy layer of
basal cells and have intact BM
• Larger branching glands with papillary
infoldings (in cancers – small glands
with straight luminal border)
CSBRP-July-2012
• Evidence that link high grade PIN to invasive Ca:
1-high grade predominate at the periphery
2-high grade PIN is also seen in association with invasive Ca.
3-molecular abnormalities seen in invasive cancers are also present in PINs
Prostatic intraepithelial neoplasia -
PIN
CSBRP-July-2012
CSBRP-July-2012
Prostatic intraepithelial neoplasia (PIN) can be low or high grade (as seen here). The
finding of PIN suggests that prostatic adenocarcinoma may also be present (about half
the time with high grade PIN). CSBRP-July-2012
CSBRP-July-2012
Diagnosis of prostatic carcinoma
• DRE
• PSA
• TRUS (transrectal US)
• Biopsy
CSBRP-July-2012
PSA:
1. Serien protease-liquifies semen
2. 4ng/ml
3. PSA value
4. PSA density
5. PSA velocity
6. Age specific reference range
7. Ratio of free and bound forms
PSA is of great value in assessing the response to Tx
Diagnosis of prostatic carcinoma
CSBRP-July-2012
E N D
CSBRP-July-2012
E N D