GU BreakOut Session

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GU Break-Out Session

• L. Priya Kunju, M.D.
• Assistant Professor
• Department of Pathology
• The University of Michigan

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Case 1

• 62 Y, PSA 8.1
• Underwent prostate NBX

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Case 1

• Diagnosis
• Prostate carcinoma, pseudohyperplastic variant,
  Gleason Score 336

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Pseudohyperplastic Prostate Carcinoma

• Recently recognized entity
• Resembles architecturally benign hyperplastic
  prostate glands and/or HGPIN
• Incidence NBX 2, Rad Prostatectomy 11
• Cytologic atypia always present
• 
  
  (Humphery et al, AJSP,1998)

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Pseudohyperplastic CarcinomaDiagnostic Criteria

• Numerous closely packed glands with complex,
  undulating architecture and papillary infoldings.
• Numerous markedly dilated back to back glands
  with abundant cytoplasm and rigid luminal borders
• Infiltrative growth pattern
• Cytologic atypia including enlarged nuclei and
  prominent macronucleoli, amphophilic cytoplasm
  and blue mucin
• Majority represent Gleason pattern 3
• IHC Very USEFUL provide objective
  support/evidence

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Pseudohyperplastic CarcinomaImmunohistochemistry

• Negative with basal markers
• AMACR slightly lower sensitivity
• (70-77) for this variant compared to
  conventional PCa

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Pseudohyperplastic CarcinomaSignificance

• Uncommon variant of PCa
• Diagnostic challenge on NBX
• Critical not to
• Under-diagnose this variant as benign ( IHC
  useful)
• Over-diagnose in minute foci as HGPIN cannot be
  ruled out with certainty. (IHC may not be very
  useful in this setting)

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Case 2

• 55 Y , PSA 5.0
• H/O Minute focus of Prostate adenocarcinoma,
  Gleason score 6, lt5 of biopsy
• Underwent Radical Prostatectomy

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Case 2

• Diagnosis
• Prostate adenocarcinoma with atrophic features,
  Gleason score 336.

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Prostate cancer, Atrophic Variant

• Unusual variant, confused with benign acinar
  atrophy
• Incidence NBX 2, Rad Pros 3
• Resemble atrophy or PAH on low-power
• (due to scant cytoplasm) but has cytologic
  atypia of malignancy

Egan et al, AJSP, 1997
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Prostate cancer, Atrophic VariantDiagnostic
Criteria

• Abnormal architecture is subtle due to scant
  cytoplasm
• Rare in a pure form conventional PCA is
  typically present
• Infiltrative architecture
• Round, often dilated acini, lined by falltened
  attenuated epithelium with scant cytoplasm and
  high N/C ratio
• Cytologic atypia (nuclear) beyond that seen in
  atrophy
• Scant cytoplasm compared to conventional PCa,
  less amphophilic
• Acini commonly show blue mucin and/or
  eosinophilic secretions

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Basal marker
P504S
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Prostate cancer, Atrophic VariantImmunohistochemi
stry

• Basal markers negative
• AMACR lower sensitivity (70) for this variant
  compared to conventional PCa

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Prostate cancer, Atrophic VariantSignificance

• Uncommon
• Significant diagnostic pitfall in NBX
• Crticial not to under-diagnose as benign
• Majority are Gleason score 6, (few Gleason score
  7).

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Case 3

• 73Y African-American
• S/P radiation therapy for prostate adenocarcinoma
  
• (Gleason score 6, diagnosed in 2004)

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Case 3

• Diagnosis
• Prostate adenocarcinoma
• Well-differentiated mimicking adenosis
• Morphologically resembles Gleason score 6 with
  minimal therapy change

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Adenosis

• Incidence NBX 0.8
• Common in TURP as incidental finding

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Adenosis vs. Well-Diff PCaDiagnostic Criteria

• ADENOSIS
• Well circumscribed,lobular
• Similar-appearing small glands mixed with large
  glands
• Occasional glands with recognizable basal cell on
  HE
• Pale clear cytoplasm
• Small nucleoli
• Blue mucin rare
• Basal cells present on IHC ( may be patchy)

• WELL-DIFFERENTIATED PCA
• Haphazard, disorganized growth
• Small glands appear different from large glands
• Basal cells not recognized on HE
• Occasional amphophilic cytoplasm
• Occasional large prominent nucleoli
• Blue mucin common
• Basal cells absent

Epstein 2008
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Adenosis
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Adenosis vs. Well-Diff PCa

• Constellation of features outweigh the
  significance of any one feature
• Adenosis 19 show some infiltration
• 40 show prominent nucleoli
• Well-Diff PCa 30 lack prominent nucleoli
• Both Crowded glands, crystalloids,
  AMACR positivity

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Well-Differentiated PCa mimicking Adenosis
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Case 4

• 85Y H/O hematuria
• Prostatic urethral mass on cystoscopy

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Case 4

• Diagnosis
• Prostatic Duct Adenocarcinoma
• Behave like Gleason score 448

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Prostatic duct adenocarcinoma

• Incidence 0.4-0.8 of PCa
• Frequently admixed with PCa showing acinar
  differentiation
• Can arise in large primary peri-urethral
  prostatic ducts
• Exophytic papillary lesions
• Obstructive symptoms, hematuria
• Can arise in peipheral prostatic ducts

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Prostatic duct adenocarcinomaDiagnostic criteria

• Papillary fronds with fibrovascular cores
• Lined by pseudostratified columnar epithelium
  with abundant amphophilic cytoplasm

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Prostatic duct adenocarcinoma
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Prostatic duct adenocarcinomaDiagnostic criteria

• Papillary fronds with fibrovascular cores
• Lined by pseudostratified columnar epithelium
  with abundant amphophilic cytoplasm
• Cribriform pattern formed by back to back large
  glands lined by pseudostratified columnar
  epithelium with intraglandular bridging and
  slit-like lumens
• No Basal cells present

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Prostatic duct adenocarcinomaSignificance

• Diagnostic pitfall in NBX
• Mild cytologic atypia without prominent
  nucleoli
• Tumor fragmentation
• DD Prostatic urethral polyp
• HGPIN

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Prostatic Urethral Polyp
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Prostatic Duct AdenocarcinomaSignificance

• Diagnostic pitfall in TUR
• DD may mimic high-grade papillary urothelial
  carcinoma
• Nuclear features useful
• UC nuclei pleomorphic vs. monotonous nuclei of
  PCa
• IHC Very useful
• PCa PSA ,CK903 p63 , CK 7
• UC PSA -, CK 903 p63 ,CK 7

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