- Email: [email protected]
Diagnostic criteria for histopathologic evaluation of prostatic tissue sections
UROPATHOLOGY
DIAGNOSTIC
CRITERIA FOR HISTOPATHOLOGTC
EVALUATION
OF PROSTATIC TISSUE SECTIONS
MYRON TANNENBAUM,
M.D.,
PH.D.
From the Uropathology Laboratories, Departments of Urology and Pathology, Columbia-Presbyterian Medical Center, New York, New York
It has been frequently stated that carcinomas of the prostate present many different patterns that can place the diagnosis in the wrong histopathologic categ0ry.l This is not only disastrous for the patient but also will allow many false therapeutic interpretations to be perpetuated. We are all cognizant that a time-proved method for the recognition of prostatic cancer is the light histologic tissue section taken from the prostate at the time of surgery or autopsy. In many instances, there is difficulty in defining pathologically the potential neoplastic activity of the prostate because of the multiform configurations displayed in one microscopic field by this tumor. These patterns could include such morphoses as small as an in situ carcinoma,’ in addition to small and large gland carcinomas, “indian file” and cribiform patterns (Fig. lA-D), as well as other possible and different forms of endometrial and periurethral cancers of the prostate. All of this and more, we hope to illustrate in this article and several subsequent ones and to provide some useful guidelines in recognizing these different prostatic cancer morphoses. In the histopathologic evaluation of the biopsy or a tissue section taken from the surgically rethe following guidelines are moved prostate, helpful to the surgical pathologist or urologist who examines his own slides. Commonly seen in prostatic cancers are: 1. Prostatic acini back to back (Fig. 2A). 2. Cells lining acini are often in a single layer. The basal layer of cells are not present (Fig. 2B and C).
UROLOGY
!
MARCH 1975 / VOLWME V, NUMBER
3
3. There are prominent eosinophilic large nucleoli. This depends on quick and proper fixation in formalin or Bouin’s solution (Fig. 2B). 4. The prostatic acini may or may not be seen as linear infiltrates in the fibromuscular stroma, like boats racing up or down a river. 5. There may or may not be nuclear hyperchromatism. More often than not this can be due to improper fixation (Fig. 2D). 6. There may or may not be perineural invasion. This, when found, especially on a frozen section, is very helpful in placing a well-differentiated glandular pattern into the malignant cache. The variations on a theme or patterns that are seen can vary from one microscopic field to another. The tumor may also be seen as a solid cell mass resembling a granuloma. Fortunately, the “indian file” pattern and signet-ring cell or mucin-producing carcinomas are rare. Caution must be the word because some of the features mentioned (1 to 6) may be present, and yet the diagnosis is benign disease. Not all of the criteria need be present to make the diagnosis of a malignancy. Microacini are often present in the posterior lobe of the prostate. They are frequently present in prostatitis, and yet pathologically, they are benign. Many of the microacini are not back to back and are lined by a double layer of cells when such glands are examined under high-power microscopy. The periacinar ducts as well as the periurethral glands may be filled with cells that are mitotically
407
FIGURES. (A) Infiltrating small gland carcinomas of the prostate in afibromuscular stroma surrounding a few photomicrograph demonstrating a small large dilated normal prostatic ducts ( x 64). (B) Higher-magnijcation gland carcinoma; glands have some cell secretion in lumen and nuclei with prominent nucleoli and some lymphocytes in stroma (X 140).(C)Another area depicting invasion of area that contains some skeletal muscle or striated demonstrating cytologic detail of invading prostatic muscle (upper left corner) ( x 140). (D) Higher-magni$cation glands adjacent to striated muscle (left side) (X 370).
408
UROLOGY
/ MARCH1975
/ VOLUMEV.
NUMBER3
FIGURE 2. (A) Low-power photomicrograph of carcinoma of prostate replacing most of normal benign prostate. power (X 4?). (B) lnvasice carcinoma of Small glands. crihifn-m, and other patterns discernible at this lots; prostate with small glandular and cribiform patterns. Latter id in center of picture adjacent to vascular .spa~:e; of c&form pattern of carcinoma of left side demonstrates some cautery artifact ( x 70). (c) Photomicrograph prostate adjacent to and invading lymphatic space (lower left corner) ( x 400). (0) High-power photolnic~rogr~lI,k of crih~form pattern u)ith 2 mitoses (arrows); nuclei of these cells have prominent nucleoli ( X 906).
UROI,OCY
/ hIARCH 1975 / VOLUME
V. NUMBER 3
109
active, bizarre, and yet they are not prostatic cancer. This form of cancer which is transitional cell in type is often misdiagnosed and treated as prostatic carcinoma. The periurethral ducts as well as the glands around an area of infarction may show extensive squamous cell metaplasia and nuclei with prominent nucleoli. This is not a Diethylstilbestrol may induce malignancy. squamous metaplasia as well as obscure the carcinoma in the biopsy or tissue section. A group of bizarre glands with pleomorphic nuclei will most likely be seminal vesicles. Look for the brownish refractile cytoplasmic pigment, Mechanical distortion or compression of the hyperchromatic nuclei will definitely confuse the diagnosis either in the direction of malignancy or benignity.
410
If the answer is in doubt, the surgical pathologist should order additional levels or else say “ic na wat!” If there is still confusion about the diagnosis, get another biopsy.
630 West 168th Street New York, New York 10032
References 1. FRANKS, L. M.: Latent carcinoma of the prostate, J. Pathol. Bact. 68: 603 (1954). 2. MOSTOFI, F. K., and PRICE, E. B., JR.: Malignant
tumors of the prostate, in Tumors of the Male Genital System, Atlas of Tumor Pathology, series 2, part 8, Washington, D.C., Armed Forces Institute of Pathology, 1973, p. 218.
UROLOGY
I
MARCH 1975
I
VOLUME V. NUMBER 3
DIAGNOSTIC
CRITERIA FOR HISTOPATHOLOGTC
EVALUATION
OF PROSTATIC TISSUE SECTIONS
MYRON TANNENBAUM,
M.D.,
PH.D.
From the Uropathology Laboratories, Departments of Urology and Pathology, Columbia-Presbyterian Medical Center, New York, New York
It has been frequently stated that carcinomas of the prostate present many different patterns that can place the diagnosis in the wrong histopathologic categ0ry.l This is not only disastrous for the patient but also will allow many false therapeutic interpretations to be perpetuated. We are all cognizant that a time-proved method for the recognition of prostatic cancer is the light histologic tissue section taken from the prostate at the time of surgery or autopsy. In many instances, there is difficulty in defining pathologically the potential neoplastic activity of the prostate because of the multiform configurations displayed in one microscopic field by this tumor. These patterns could include such morphoses as small as an in situ carcinoma,’ in addition to small and large gland carcinomas, “indian file” and cribiform patterns (Fig. lA-D), as well as other possible and different forms of endometrial and periurethral cancers of the prostate. All of this and more, we hope to illustrate in this article and several subsequent ones and to provide some useful guidelines in recognizing these different prostatic cancer morphoses. In the histopathologic evaluation of the biopsy or a tissue section taken from the surgically rethe following guidelines are moved prostate, helpful to the surgical pathologist or urologist who examines his own slides. Commonly seen in prostatic cancers are: 1. Prostatic acini back to back (Fig. 2A). 2. Cells lining acini are often in a single layer. The basal layer of cells are not present (Fig. 2B and C).
UROLOGY
!
MARCH 1975 / VOLWME V, NUMBER
3
3. There are prominent eosinophilic large nucleoli. This depends on quick and proper fixation in formalin or Bouin’s solution (Fig. 2B). 4. The prostatic acini may or may not be seen as linear infiltrates in the fibromuscular stroma, like boats racing up or down a river. 5. There may or may not be nuclear hyperchromatism. More often than not this can be due to improper fixation (Fig. 2D). 6. There may or may not be perineural invasion. This, when found, especially on a frozen section, is very helpful in placing a well-differentiated glandular pattern into the malignant cache. The variations on a theme or patterns that are seen can vary from one microscopic field to another. The tumor may also be seen as a solid cell mass resembling a granuloma. Fortunately, the “indian file” pattern and signet-ring cell or mucin-producing carcinomas are rare. Caution must be the word because some of the features mentioned (1 to 6) may be present, and yet the diagnosis is benign disease. Not all of the criteria need be present to make the diagnosis of a malignancy. Microacini are often present in the posterior lobe of the prostate. They are frequently present in prostatitis, and yet pathologically, they are benign. Many of the microacini are not back to back and are lined by a double layer of cells when such glands are examined under high-power microscopy. The periacinar ducts as well as the periurethral glands may be filled with cells that are mitotically
407
FIGURES. (A) Infiltrating small gland carcinomas of the prostate in afibromuscular stroma surrounding a few photomicrograph demonstrating a small large dilated normal prostatic ducts ( x 64). (B) Higher-magnijcation gland carcinoma; glands have some cell secretion in lumen and nuclei with prominent nucleoli and some lymphocytes in stroma (X 140).(C)Another area depicting invasion of area that contains some skeletal muscle or striated demonstrating cytologic detail of invading prostatic muscle (upper left corner) ( x 140). (D) Higher-magni$cation glands adjacent to striated muscle (left side) (X 370).
408
UROLOGY
/ MARCH1975
/ VOLUMEV.
NUMBER3
FIGURE 2. (A) Low-power photomicrograph of carcinoma of prostate replacing most of normal benign prostate. power (X 4?). (B) lnvasice carcinoma of Small glands. crihifn-m, and other patterns discernible at this lots; prostate with small glandular and cribiform patterns. Latter id in center of picture adjacent to vascular .spa~:e; of c&form pattern of carcinoma of left side demonstrates some cautery artifact ( x 70). (c) Photomicrograph prostate adjacent to and invading lymphatic space (lower left corner) ( x 400). (0) High-power photolnic~rogr~lI,k of crih~form pattern u)ith 2 mitoses (arrows); nuclei of these cells have prominent nucleoli ( X 906).
UROI,OCY
/ hIARCH 1975 / VOLUME
V. NUMBER 3
109
active, bizarre, and yet they are not prostatic cancer. This form of cancer which is transitional cell in type is often misdiagnosed and treated as prostatic carcinoma. The periurethral ducts as well as the glands around an area of infarction may show extensive squamous cell metaplasia and nuclei with prominent nucleoli. This is not a Diethylstilbestrol may induce malignancy. squamous metaplasia as well as obscure the carcinoma in the biopsy or tissue section. A group of bizarre glands with pleomorphic nuclei will most likely be seminal vesicles. Look for the brownish refractile cytoplasmic pigment, Mechanical distortion or compression of the hyperchromatic nuclei will definitely confuse the diagnosis either in the direction of malignancy or benignity.
410
If the answer is in doubt, the surgical pathologist should order additional levels or else say “ic na wat!” If there is still confusion about the diagnosis, get another biopsy.
630 West 168th Street New York, New York 10032
References 1. FRANKS, L. M.: Latent carcinoma of the prostate, J. Pathol. Bact. 68: 603 (1954). 2. MOSTOFI, F. K., and PRICE, E. B., JR.: Malignant
tumors of the prostate, in Tumors of the Male Genital System, Atlas of Tumor Pathology, series 2, part 8, Washington, D.C., Armed Forces Institute of Pathology, 1973, p. 218.
UROLOGY
I
MARCH 1975
I
VOLUME V. NUMBER 3