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PROSTATE and TESTIS PATHOLOGY “A Coin Has Two Sides”, the Duality of Male Pathology

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PROSTATE and TESTIS PATHOLOGY “A Coin Has Two Sides”, the Duality of Male Pathology 7/12/2017 PROSTATE AND TESTIS PATHOLOGY “A Coin Has Two Sides”, The Duality Of Male Pathology • Jaime Furman, M.D. • Pathology Reference Laboratory San Antonio. • Clinical Assistant Professor Departments of Pathology and Urology, UT Health San Antonio. Source: http://themoderngoddess.com/blog/spring‐equinox‐balance‐in‐motion/ I am Colombian and speak English with a Spanish accent! o Shannon Alporta o Lindsey Sinn o Joe Nosito o Megan Bindseil o Kandace Michael o Savannah McDonald Source: http://www.taringa.net/posts/humor/7967911/Sindrome‐de‐la‐ Tiza.html 1 7/12/2017 The Prostate Axial view Base Apex Middle Apex Sagittal view Reference: Vikas Kundra, M.D., Ph.D. , Surena F. Matin, M.D. , Deborah A. Kuban, M.Dhttps://clinicalgate.com/prostate‐cancer‐4/ Ultrasound‐guided biopsy following a specified grid pattern of biopsies remains the standard of care. This approach misses 21% to 28% of prostate cancers. JAMA. 2017;317(24):2532‐2542. http://www.nature.com/nrurol/journal/v10/n12/abs/nrurol.2013.195.html Prostate Pathology Inflammation / granulomas Categories Adenosis, radiation, atrophy seminal vesicle Biopsy Benign TURP HGPIN Unsuspected carcinoma is seen in 12% of Atypical IHC TURP cases. glands Prostatectomy Subtype, Gleason, Malignant fat invasion, vascular invasion Other malignancies: sarcomas, lymphomas Benign Prostate Remember Malignant Glands Lack Basal Glands Cells Basal cells Secretory cells Stroma 2 7/12/2017 Benign Prostatic Lesions Atrophy Corpora amylacea (secretions) Seminal Vesicle Acute inflammation GMS Basal cell hyperplasia Basal cell hyperplasia Granulomas (BPH) (BPH) coccidiomycosis Mimics of Prostate Carcinoma Atrophy. Benign Carcinoma with atrophic features Prostate Carcinoma 1. Prostate cancer is the most common, noncutaneous cancer in men in the United States. 2. In 2017, approximately 160,000 men will be diagnosed with prostate cancer. 3. Remains the third‐leading cause of cancer death in men. The indolent course of many tumors and the potential for adverse treatment effects have generated controversy regarding the utility of screening and early detection. The diagnosis of prostate cancer is based on the microscopic evaluation of prostate tissue obtained via needle biopsy. http://www.medscape.org/viewarticle/710056 JAMA. 2017;317(24):2532‐2542. 3 7/12/2017 Source: Source: Wikipedia How To Make The Wallpapercave Histologic Diagnosis Of Prostate Carcinoma Low power High Prominent power nucleoli Carcinoma involving 5% of the biopsy The Histologic Features of Prostate Carcinoma Architecture Small glands Sometimes large Infiltrating glands Gland Appearance Round or angulated glands Rigid lumen Blue mucin Purple cytoplasm Basal cells absent Important to understand IHC Cytology Large nuclei and nucleoli Tumor Invasion perineural , vascular, fat, extension and other organs Remember in difficult lesions: 1. Levels 2. Immunohistochemical stains (IHC) ( judicious application) 3. Consultation (second opinion) Terminology 1 1. Gland 2. Lumen 3. Nuclei 4. Nucleoli 5. Stroma 3,4 5 2 4 7/12/2017 Malignant gland Malignant invading a gland Prostate Carcinoma nerve Blue mucin Rigid lumen Nerve Common finding seen 11— 37% of biopsies Vascular Invasion Special Stains Are Benign Prostate Glands Helpful In a Difficult Diagnosis Cancer Benign Basal cell stain brown. Secretory cells and stroma without staining (blue) Stain: Pin 4 cocktail Stain: High molecular weight immunostain cytokeratin Remember: Carcinoma lacks basal cells and The Precursor: High Grade HGPIN has basal cells Intraepithelial Neoplasia Malignant glands (HGPIN) Incidence in biopsies 7% Does not raise PSA Higher risk for carcinoma if HGPIN involves HGPIN several cores HGPIN Basal cells The cells contain large nuclei with nucleoli similar to carcinoma 5 7/12/2017 Reporting Discontinuous Foci Of Prostate Carcinoma Red=tumor = mm. Option 1 + + Option 2 = mm. • Discontinuous involvement by prostate carcinoma is common • Two methods for measuring the discontinuous foci: 1. Adding each foci Report includes 2. Assessing discontinuous foci as a single focus a diagram • Reported as % and mm of tumor Source: Dr. Ming Zhou, USCAP Conference. San Antonio, March 2017. The Gleason Grading System. The Gleason score assigned to a case of prostate cancer is an important prognostic indicator that guides therapeutic decisions. A Practical Approach Prostate carcinoma usually has > two patterns Steps: 1 1. Confirm the histologic diagnosis of cancer 2. Match the pattern(s) with a specific Gleason grade 2 3. Decide which pattern is more common (primary pattern) and the second most common pattern (secondary pattern) 4. Add the primary and secondary pattern (Gleason score) 5. Assign the Gleason group (new) 3 Biopsy core 4 Gleason 3 (60%) Gleason 4 (40%) 5 Original (initial) Modified 2015 by Dr. Gleason Reference: Am J Surg Pathol. 2016 Feb;40(2):244‐52. GLEASON 3+4 = GLEASON SCORE 7 Gleason Grade 3 Gleason Grade 4 Gleason Grade 5 Individual malignant glands Fusion & ragged edges Haphazardly arranged cells, individual cells, Invading between benign glands signet ring cells Gleason clinical significance Overall, Gleason scores of 6–7 with • Grade is a strong predictor of invasiveness and metastatic potential embedded pattern 3 are the most • Not reliable when used alone to predict outcome common histologic grades of prostatic • Clinically, needle biopsy Gleason grade is usually combined with other adenocarcinoma. pretreatment factors, such as serum total PSA, % free PSA, local clinical T stage, and amount of tumor in needle biopsy, to predict pathologic stage Reference: Am J Surg Pathol. 2016 Feb;40(2):244‐52. 6 7/12/2017 Gleason Grade Signet ring nuclei Grade 3 Grade 5 1+1 1+2 1+3 1+4 1+5 2+1 70% Gleason grade grade 3 combinations not in use 2+2 2+3 2+4 2+5 3+1 4+1 5+1 3+2 4+2 5+2 Possible Gleason grade 3+3 3+4 3+5 4+3 combinations 4+4 4+5 5+3 5+4 5+5 Example 1 Gleason 4 3 90% 10% 4+3 Example 2 Gleason 4 3 Lower grade <5% 97% 4+4 Example 3 Gleason 3 Higher grade <5% 97% 4 3+4 Example 4 30% Gleason 3 Gleason 5 grade 4 50% 50% 5+5 Example 5 Gleason 4 100% 4+4 Final Gleason score ? Source: Dr. Ming Zhou, USCAP Conference. San Antonio, March 2017. The new grading system is based on the modified (2005 and 2014) Gleason score groups, resulting in 5 prognostically distinct GRADE GROUPS BEST PROGNOSIS A multi‐institutional study, based upon 2005 grading 3+3 GRADE GROUP 1 criteria was undertaken with Johns Hopkins Hospital, Memorial Sloan‐Kettering Cancer Center (MSKCC), University of Pittsburgh, Cleveland Clinic, and the Karolinska Institute to validate 3+4 GRADE GROUP 2 the new grading system. * Increased probability of recurrences 4+3 * GRADE GROUP 3 Biochemical recurrence‐free progression after Radical Prostatectomy 4+4 GRADE GROUP 4 stratified by grade 1. Green line —Gleason score 6 [grade group1]. (best prognosis] 4+5 2. Orange—Gleason score 3+4 [grade group 2], 3. Dark blue —Gleason score 4+3 [grade group 3], GRADE GROUP 5 5+4 4. Brown—Gleason score 8[grade group 4], 5. Gray—Gleason score >9 [grade group 5] (worst prognosis) 5+5 WORST PROGNOSIS Reference: Am J Surg Pathol. 2016 Feb;40(2):244‐52. 7 7/12/2017 New Grading Grading Subjectivity System. Why? Gleason grading has an inherent level 1. Gleason scores 2 to 5 are currently no longer assigned of subjectivity, depending on individual interpretations 2. In practice, the lowest score now assigned is 6. This leads to a logical yet incorrect assumption on the part of patients of an expectation that definite treatment is always necessary. 3. Separate 3+4 V.s 4+3 Studies of intraobserver variability demonstrate agreement in up to 78% of cases; therefore, at least 22% of cases may be reread by the same pathologist as a different Gleason score. Source: Am J Surg Pathol. 2016 Feb;40(2):244‐52. Source picture: https://www.linkedin.com/pulse/violence‐mindlessness‐subjectivity‐ jayashree‐mukherjee Multiple Biopsy Cores With Different Gleason Assign a Composite Gleason To All Grade Positive Biopsy Cores Submitted In The Same Container 3+3 3+3 APEXEX A Only 1 container with Benign 3+4 4 core biopsies MIDD Benign 3+4 A BAEXSE A B C D 3+3 4+3 Final Gleason: 4+3 E F Assign individual Gleason to different cores as long as cores are submitted in separate containers Source: Dr. Ming Zhou, USCAP Conference. San Antonio, March 2017. Prostatectomy With Multiple Tumor Nodules Showing Different Gleason 3+3 Dominant 4+4 nodule 4+4 3+3 o Dominant nodule is Final Gleason reported reported 3+3 and small nodule o Not necessary to report the 4+4 small nodule (3+3) o Final Gleason: 4+4 1. ALWAYS REPORT THE DOMINANT NODULE 2. Report the secondary nodule only if contains high grade Gleason grade Source: Dr. Ming Zhou, USCAP Conference. San Antonio, March 2017. 8 7/12/2017 T1 clinically Clinical unapparent non palpable T2 Tumor is palpable and confined within prostate T3 Extraprostatic tumor that does not invade adjacent structures For tumor confined to the prostate there is only 1 pathology category =pT2 T4 tumor invades adjacent Diagram reference: Vikas Kundra, M.D., Ph.D. , Surena F. structures other than seminal Matin, M.D. , Deborah A. Kuban, M.D vesicles: rectum, bladder, pelvic https://clinicalgate.com/prostate ‐cancer‐4/ Reference: AJCC , Cancer Staging Manual 8th Edition wall The Stage I I IIA IIA IIB IIC IIIA IIIB IIIC IVA IVB Reference: AJCC , Cancer Staging Manual 8th Edition The Stage Gross bladder neck • Microscopic bladder involvement involvement T4 • Presence of cancer glands within smooth bundles of bladder Reference: AJCC , Cancer Staging Manual 8th neck without benign glands Edition • Staged as pT3a no pT4 9 7/12/2017 Staging Radical Prostatectomy Source:http://www.avidphone.co m/change‐part‐i/ (AJCC 8th) Summary Of Changes Between 7th And 8th AJCC Cancer Staging: 1.
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