What is the weight of a normal adult prostate?
20gm
Describe some general features of the prostate?
- Retroperitoneal organ
- Encircles the neck of the bladder and urethra
- Devoid of a distinct capsule
What are 4 biologic/anatomic distinct zones of the prostate?
- Peripheral: Most carcinomas
- Central
- Transitional: Most hyperplasia
- Region of the anterior fibromuscular stroma
What 3 pathological processes can happen in the prostate?
- Inflammation
- Benign nodular enlargement (hyperplasia): This is most common and can be part of the normal aging process
- Tumors
What are the 2 forms of bacterial prostatitis?
Acute and chronic
What does acute bacterial prostatitis result from?
Bacterial similar to those that cause UTI
- Various strains of E. Coli
- Gram - Rods
- Enterococci
- Staphylococci
What can acute bacterial prostatitis be secondary to?
Surgical manipulation of the urethra or prostate from catheterization, cystoscopy, urethral dilation, resection procedures on the prostate (these can all cause inflammation and become infected)
What is clinically assocaited with acute bacterial prostatitis?
Fever, chills, and dysuria
What is chronic bacterial prostatisis assocaited wtih?
A history of recurrent UTIs (cystitis and urethritis)
-This is difficult to diagnose and treat
What are the symptoms of chronic bacterial prostatitis?
Low back pain, dysuria, and perineal and suprapubic discomfort
How is chronic bacterial prostatitis diagnosed?
-Demonstration of leukocytosis (leukocytes and lymphocyres) in expressed prostatic secretions (massage the prostate) and positive bacterial culutes
What is the most common form of prostatitis?
Chronic abacterial prostatitis
Is chronic abacterial prostatitis clinically distinguishable from chronic bacterial prostatitis?
NO
What is seen in chronic abacterial prostatitis?
- No history of recurrent UTIs
- Expressed prostatic secretions contain more than 10 leukocytes per high power field (inflammation of prostate)
- Bacterial cultures are uniformly negative*** CULTURE SHOWS NOTHING
What is the most common cause of granulomatous prostatits related to?
Instillation of BCG with in the bladder
What is BCG?
AN attenuated mycobacterial strain
Why would you put BCG in a bladder?
It can help treat superficial bladder cancer
So, if you are putting a mycobacteria into the bladder, what will probably be seen in the bladder?
GRANULOMAS
When do you see fungal granulomatous prostatitis?
Only in immunoscompromised hosts
What is nonspecific granulomatous prostatitis?
It represents a reaction to secretions from ruptured prostatic ducts and acini (secreting into surrrounding tissue)… this is relative common and no “solid” reason
What is the morphology of acute prostatitis?
- Minute, disseminated abscesses (small collection of neutrophils)
- Large, coalescent focal areas of necrosis
- Diffuse edema, congestion, and boggy suppuration of the entire gland
Why is biopsy of a man with acute prostatitis contraindicated?
Because it would HURT
and it can lead to sepsis when you drag the infection out
What is another name for benign prostatic hyperplasia?
Nodular hyperplasia
Is BPH common?
Yes very
Who does BPH affect?
Men over 50
What is BPH?
- Hyperplasia of prostatic stromal and epithelial cells
- Formation of large discrete nodules: Periurethral region of the prostate
- Large nodules compress and narrow the urethral canal: Partial, or sometimes virtually complete, obstruction of the urethra
What is the weight of the prostate in BPH?
Between 60-100gm
Where does nodular hyperplasia originate?
In the inner aspect (transition zone)
*Remember, carcinoma is in the peripheral zone
What are early nodules composed of?
Stromal cells
What are later nodules composed of?
Epithelial nodules
What can nodular enlargements cause?
- May encroach on the lateral walls of the urethra: Compress it to a slit like orifice
- May project up into the floor of the urethra: Hemispheric mass directly beneath mucosa of the urethra –> Median lobe hypertrophy
Describe the gross appearance of nodules that contain mostly glands?
- Tissue is yellow-pink with a soft consistency
- Milky-white prostatic fluid oozes out
Describe the gross appearance of nodules that are compoased primarily of fibromuscular stroma?
- Pale gray, tough, and doesn’t exude fluid
- Less clearly demarcated from uninvolved prostatic tissue
What is the hallmark of BPH?
Nodularity
What 3 things are seen on microscopic examination of BPH?
- Purely stromal fibromuscular nodules
- Fibroepithelial nodules with a glandular predominance
- Glandular proliferation: Aggregations of small to large to cystically dilated glands lined by two layers (Inner columnar and an outer cuboidal epithelium)
Can the diagnosis of BPH be made with needle biopsy?
NO
Why can’t you diagnose BPH with a needle biopsy?
- Histology of BPH nodules cannot be appreciated in limited samples (it is too small of a piece…you need a bigger piece to see nodules)
- Needle biopsies do not typically sample the transition zone, BPH occurs here
What are clinical features of BPH?
- Increased size of the gland
- Smooth muscle-mediated contraction of the prostate: Cause uretheral obstruction
- Increased resistance to urinary outflow: Bladder hypertrophy and distension, Urine retention
- Inability to empty the bladder completely: Creates a reservoir of residual urine which is a common source of infection
What are some symptoms of BPH?
- Increased urinary frequency, Nocturia, Difficulty in starting and stopping urine, Overflow dribbling (hard time controlling urine flow)
- Dysuria (painful micturition)
- Increased risk of bacterial infections (Bladder and kidney)
What is the most common form of CA in men?
Adenocarcinoma of the prostate
Who does adenocarcinoma of the prostate affect?
Men over the age of 50
If you are increased risk due to family history, when should you start screening for prostate cancer?
At age 40
What ethnicities is adenocarcinoma of the prostate more or less common in?
- Uncommon in Asians
- Most frequent in African Americans
Where is the common or acinar variant of prostate cancer found?
In the peripheral zone of the gland, classically in a posterior location
How can you detect the common or acinar variant of prostate cancer?
It may be palpable on rectal examination (screening) or you can use the prostate specific antigen blood test
Where do metastases from prostate cancer spread?
- First via lymphatics
- Then hematogenous spread (Batson’s plexus)
- Then bones (axial skeleton)
What is seen on gross examination of prostate cancer?
- It is gritty and firm
- It can have local extension to periprosatic tissue, seminal vesicles, and the base of the urinary bladder
What is seen on microscopic examination of prostate cancer?
- Well-defined gland patterns
- Absent outer basal cell layer (prostate usually has 2 layers lining its glands)
- Cytoplasm of the tumor cells is pale-clear as seen in benign glands to a distinctive amphophilic appearance
- Nuclei are large; contain one or more large nucleoli
- Pleomorphism is not marked
- Mitotic figures are uncommon
What are the gland patterns seen in prostate cancer?
- Smaller than benign glands
- Single uniform layer of cuboidal or low columnar epithelium
- Crowded
- Lack branching and papillary infoldings
What grading system is used for prostate cancer?
The gleason system
What is the gleason system stratified into and how?
5 grades on the basis of glandular patterns of differnetiation
Describe Gleason Grade 1
- Most well-differentiated tumors
- Neoplastic glands are uniform and round in appearance
- Packed into well-circumscribed nodules
- This looks like adenocarcinoma
Describe Gleason Grade 5
- No glandular differentiation
- Infiltration of the stroma (cords, sheets, and nests)
- This is poorly differentiated and almost solid-looking with cells all over the place
Do most tumors contain more than 1 pattern?
Yes
What is the primary grade?
The dominant pattern
What is the secondary grade?
The second most frequent pattern
What do you do with the primary and secondary grade?
You add them together to get a combined Gleason grade or score
What is the highest gleason score?
10 (5+5), but you rarely have this because most tumors have areas of other patterns
What are the best prognostic predicators?
Grade and stage
If you see crowded glands that almost look malignant on biopsy, but there are some yellow/tan brown colored areas, what are you looking at?
The seminal vesicle (it could be mistaken for adenocarcinoma
What are the nucleoli like in adenocarcinoma of the prostate?
Prominent and cherry red
