HISTOPATHOLOGY APPROACH TO PROSTATE

MODERATOR DR. P.KUMUDA CHALAM Professor .

NORMAL ANATOMY
DIMENSIONS MC NEALS MODEL OF PROSTATE ZONES . LOBES OF PROSTATE .

DIMENSIONS
Prostrate is a compound tubuloalveolar exocrine gland of the male reproductive system. The prostate (approximately 3 cm long, 4 cm wide, and 2 cm in AP depth) is the largest accessory gland of the male reproductive system The normal prostate weighs approximately 20 g.

MAC NEALS MODLE OF ZONES

SAGITAL SECTION
SAGITAL SECTION OF THE PROSTATE GLAND Seminal Vesicle Bladder

Central Zone

Peri-urethral zone

Transition Zone Peripheral Zone

Anterior Zone Fibro-muscular

Urethra

CROSS SECTION
FIBROMUSCULAR STROMA anterior PERI-URETHRAL STROMA

EJACULATORY DUCTS

ZONES
Peripheral zone forms disc of tissue on the postrolateral aspects of the gland, representing posterior and lateral lobes. It constitutes about 70% of the glandular part of the prostate. Its ducts open into prostatic urethra distal to verumontanum. Almost all carcinoma arise here. Central zone is wedge-shaped. It is surrounded by the peri-pheral zone in its distal part. It comprises of 25% of the gla-ndular prostate that surrounds the ejaculatory ducts. Its ducts open into the prostatic urethra close to the ejaculatory duct. This zone is relatively resistant to carcinoma and other dise-ases.

ZONES
Transitional zone forms two independent lobes of glandu-lar tissue in fibromuscular components of preprostatic sphi-ncter. Its ducts open in postrolateral part of urethra. It is cli-nically important as it grows with age and is the commonest site where benign prostatic hypertrophy originates. Periurethral zone is only a fraction of the size of the transi-tion zone. It consists of small ducts and acini which are not completely developed. These are scattered along the proxi-mal urethral segment inside the preprostatic sphincter.

LOBES
The "lobe" classification is more often used in anatomy. Anterior lobe (or isthmus) roughly corresponds to part of transitional zone, lies anterior to the urethra.
Posterior lobe roughly corresponds to peripheral zone . lies posterior to the urethra and inferior to the ejaculatory ducts it is readily palpable by digital rectal examination. Lateral lobes spans all zones, on either side of the urethra form the major part of the prostate Median lobe (or middle lobe) roughly corresponds to part of central zone, lies between the urethra and the ejaculatory ducts and is closely related to the neck of the bladder

HISTOLOGY OF PROSTATE
NORMAL HISTOLOGY ZONAL VARIATION IN THE HISTOLOGY

Histological variation

TYPES OF SPECIMENS
Trans-rectal ultrasound guided needle core biopsy Trans-urethral resection of prostate chips Simple prostatectomy tissues Radical prostatectomy

TRUS BIOPSY

TRUS

INDICATIONS
TRUS guided prostate needle biopsy should be performed in men with an abnormal DRE, an elevated PSA (>4.0 ng/ml) or PSA velocity (rate of PSA change) >0.4 to 0.75ng/ml/yr. Also, men who were diagnosed with highgrade prostatic intraepithelial neoplasia (PIN) or atypia on a previous prostate needle biopsy should undergo a repeat biopsy 3 to 12 months later.

PATIENT PREPARATION
3 prior antibiotic treatment usually flouroquinilones. Discontinuation of Aspirin before 3-7 days Anticoagulant medication adjusted to INR.

Technique
The patient is positioned in either the right or left lateral decubitus position (lying on left side). This allows for easier insertion of the rectal probe. A topical anesthetic ointment is applied to the index fi nger prior to performing the DRE. A 5.0 to 7.5mHz transducer is used for transrectal imaging of the prostate. The probe is gently advanced into the rectum, to the base of the bladder until the seminal vesicles are visualized.

Technique
Images are taken Dimensions are recorded. Biopsy are collected . An 18-gauge biopsy needle loaded in a spring-action automatic biopsy device is commonly used to procure multiple 1.5cm prostate biopsy specimens . When a biopsy is directed at a suspicious lesion, it is important for the needle tip to be placed precisely at the boundary of the lesion before activating the biopsy gun.

TRUS
Indications for a repeat prostate biopsy include the following: 1) A highly suspicious DRE (digital rectal examination) 2) A persistently rising serum PSA (> 0.4 0.75 ng/ml/yr.) 3) A low free PSA (certainly < 10%, maybe < 22% - 25%) 4) Presence of PIN or atypia on prior biopsy

Tissue processing
Formalin 10% for fixation . At least 6 hrs of fixation . 2 core biopsies /block . 3-4 serial sections /slide. 3-4 slides are to be examined .

TURP

TURP

Tissue processing
Record the weight of the total sent TURP chips. 1-2 gm / cassette up to 12gms . 1 cassette for every 5 gm of additional material . All embed must be done in case of suspicion of PIN .

RADICAL PROSTATECTOMY
Orientation of specimen . Ink rt side and lt side. Cut the seminal vesicles. marginal sections at the apex and base are cut . Then sections perpendicular to the urethra are taken at 4mm thickness .

INFLAMMATORY CONDITIONS

BENIGN CONDITIONS

METAPLASIA

PROSTATE INTRAEPITHELIAL NEOPLASIA

Divided into three grades depending on the severity of the following alterations: cell crowding and stratification; nuclear enlargement, pleomorphism, and chromatin pattern; nucleolar appearance. These three grades (I, II, and III) are currently grouped into two categories: low-grade PIN (corresponding to grades I and II) and highgrade PIN (corresponding to grade III)

PIN

MALIGNANT CONDITIONS

CRITERIA FOR ADENOCARCINOMA

MAJOR CRITERIA
Architecture infiltrative small glands or cribriform glands too large or irregular to represent HPIN. Single cell layer ( absence of basal cell layer ) Nuclear atypia nuclear and nucleolar enlargement .

Minor criteria
Intraluminal blue mucin Pink amorphous secretions . Mitotic figures Intraluminal crystalloids Adjacent high grade PIN Amphophilic cytoplasm .

Gleason grading system

All the tumors fall into 5 grades . 9 patterns have been described . Purely based on architecture not on cytology . Score = sum of grades of two common patterns Prognosis is decided by score+PSA+DRE findings .

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