Dr Malini Goswami

RADICAL PROSTATECTOMYGROSSING AND REPORTING

ANATOMY OF PROSTATE

The prostate includes a base and an apex. The base of the prostate is near the inferior surface of the bladder and is directed

upward. A large part of the base is continuous with the bladder wall. The apex is directed downward and is in contact with the urogenital diaphragm

(pelvic floor). There are anterior, posterior, and two lateral surfaces.

The anterior lobe is the portion of the gland that lies in front of the urethra. It contains no glandular tissue but is made up completely of fibromuscular tissue.

The median or middle lobe is situated between the two ejaculatory ducts and the urethra.

The lateral lobes make up the main mass of the prostate. They are divided into a right and left lobe and are separated by the prostatic urethra.

The posterior lobe is the medial part of the

lateral lobes and can be palpated through the rectum during digital rectal exam (DRE).

The prostate is surrounded by the prostatic capsule. Invasion of the capsule changes the stage of disease

Lobes of prostate

ZONES OF THE PROSTATE

The peripheral zone is in the outer most part of the prostate, and the lower peripheral zone is fairly close to the rectal wall.

The peripheral zone is the most common site for prostatic adenocarcinoma.

The central zone is in the center of the prostate and cancer does not originate there often.

The transitional zone is above the central zone and is a common site for benign prostatic hypertrophy, a non-malignant condition of the prostate

Grossing

1.ORIENTATION• Orientation of the prostate is

most easily accomplished by identifying the seminal vesicles.

• These structures are attached at the base and posterior aspect of the prostate.

• The opposing pole is the apex.• The anterior aspect of the

prostate is convex shaped, whereas the posterior aspect is more broad and flattened.

2.INKING The entire external surface of the prostate should be inked, preferably the different surfaces with different colors.

3.WEIGHT: the prostate weight is taken

• 4.SERIAL TRANSVERSE SECTIONING FOLLOWED BY FIXATION:

DESCRIPTION• Total size• Prostate size• Seminal vesicle size• Vas deferens size• Urethra size• c/s of prostate: appearance• : if any dominant nodule present-size

5.SECTIONING • Lay the individual slices out

sequentially from apex (distal) to base (proximal).

• Be careful to maintain the orientation (i.e., right vs. left, anterior vs. posterior) of each slice.

SECTIONING

TISSUES SUBMITTED FOR MICROSCOPY:

1) PROSTATE LOBES Upper 1/3rd : Right anterior : Right posterior : Left posterior : Left anterior Middle 1/3rd : Right anterior Right posterior Left posterior Left anterior Lower 1/3rd : Right anterior Right posterior Left posterior Left anterior

2) SEMINAL VESICLES AT JUNCTION WITH PROSTATE Right: Left: 3) VAS CUT ENDS Right: Left 4) APEX OF PROSTATE 5) VESICAL NECK MARGIN (BASE OF PROSTATE)

MICROSCOPY

1) TUMOR: a) HISTOLOGIC TYPE b) GLEASONS SCORE (WITH PRIMARY AND SECONDARY GRADES) c) GRADE GROUP d) HIGH GRADE PROSTATIC INTRAEPITEHLIAL NEOPLASIA: p/a c) LOCATIONS d) EXTENT OF LOCAL INVASION i) EXTRAPROSTATIC EXTENSION : Not identified Present: Focal/ Nonfocal (established, extensive) ii) SEMINAL VESICAL INVOLVEMENT

2) Treatment Effect on Carcinoma Not identified Radiation therapy effect present Hormonal therapy effect present Other therapy effect

3) MARGINS Apical Bladder neck Anterior(inked) Lateral(inked) Postero-lateral (neurovascular bundle) (inked) Posterior(inked) Vas cut ends: 4) Lymph-Vascular Invasion Not identified/ Present/ Indeterminate

5)Perineural Invasion Not identified/Present

6) REGIONAL LYMPHNODES

FINAL OPINION:

pSTAGE:

HISTOLOGIC TYPEAdenocarcinoma (acinar, not otherwise specified)___ Prostatic duct adenocarcinoma___ Mucinous (colloid) adenocarcinoma___ Signet-ring cell carcinoma___ Adenosquamous carcinoma___ Small cell carcinoma___ Sarcomatoid carcinoma___ Undifferentiated carcinoma, not otherwise specified___ Other (specify): ____________________________

• Score :?? 6,7,8,9,10• Grade : ?? 3+4,4+3,5+5• Grade group:?? 1,2,3,4,5

HISTOLOGIC GRADE (GLEASON SCORE)• The Gleason score is the sum of the primary (most

predominant in terms of surface area of involvement) Gleason grade and the secondary (second most predominant) Gleason grade.

• Where no secondary Gleason grade exists, the primary Gleason grade is doubled to arrive at a Gleason score.

• The primary and secondary grades should be reported in addition to the Gleason score, that is, Gleason score 7(3+4) or 7(3+4).

• If the secondary grade is <5%----no need to report it.• Tertiary pattern is reported if it is of higher grade than

primary or secondary

Pattern 3

(A) Gleason pattern 4 with glomeruloid glands.

(B) Gleason pattern 4 with medium-sized rounded cribriform gland. Associated small glands of pattern 3.

(C) Gleason pattern 4 with poorly formed and fused glands.

(D) Gleason pattern 4 with irregular cribriform gland with adjacent Gleason pattern 3.Pattern 4

WHAT IS THE SIGNIFICANCE OF GRADE GROUPINGS?• The lowest score, assigned 6, may be misunderstood as a cancer

in the middle of the grading scale• 3 + 4 = 7 and 4 + 3 = 7 are often considered the same

prognostic group.• Large differences in recurrence rates between both Gleason 3 +

4 versus 4 + 3 and Gleason 8 versus 9 was seen• The hazard ratios relative to Gleason score 6 were 1.9, 5.1, 8.0,

and 11.7 for Gleason scores 3 + 4, 4 + 3, 8, and 9–10,respectively.

LOCATION AND EXTENTpT2: Organ confined ___ pT2a: Unilateral, involving one-half of 1 side or less ___ pT2b: Unilateral, involving more than one-half of 1 side but not both sides ___ pT2c: Bilateral disease pT3: Extraprostatic extension ___ pT3a: Extraprostatic extension or microscopic invasion of bladder neck ___ pT3b: Seminal vesicle invasion ___ pT4: Invasion of rectum, levator muscles and/or pelvic wall

QUANTITATION OF TUMOR • In subtotal and radical prostatectomy specimens, the percentage

of tissue involved by tumor can also be “eyeballed” by simple visual inspection.

• ≤5% involvement being T1a and >5% being T1b.

PERINEURAL INVASION• Perineural invasion has also been found to be an independent

risk factor, in some studies, for predicting an adverse outcome in patients treated with external beam radiation

LYMPHOVASCULAR INVASION

PROSTATIC INTRAEPITHELIAL NEOPLASIA • The diagnostic term prostatic intraepithelial neoplasia (PIN),

unless qualified, refers to high-grade PIN. • Low-grade PIN is not reported. • The presence of an isolated PIN (PIN in the absence of

carcinoma) should be reported in all biopsy specimens.• The reporting of PIN in biopsies with carcinoma is considered

optional

MARGINS• The entire surface of the prostate should be inked to evaluate the

surgical margins.• Usually, surgical margins should be designated as “negative” if

tumor is not present at the inked margin and as “positive” if tumor cells touch the ink at the margin.

• When tumor is located very close to an inked surface but is not actually in contact with the ink, the margin is considered negative

APEX AND BLADDER NECK

• The apex should be carefully examined because it is a common site of margin positivity.

• At the apex, tumor admixed with skeletal muscle elements does not constitute extraprostatic extension.

• The apical and bladder neck surgical margins should be submitted entirely, preferably with a perpendicular sectioning technique.

• Microscopic involvement of bladder neck muscle fibres in radical prostatectomy specimens indicates pT3a disease

FINAL IMPRESSION• Prostatic acinar

sdenocarcinoma ,gleasons score 7(4+3),grade froup 3,with extensions as described and uninvolved regional lymph nodes

IHC• TO DIFFERENTIATE BETWEEN PIN/ INVASIVE CA• The loss of basal cells in prostate carcinomas is the most• important diagnostic hallmark of malignancy• Basal cell cytokeratins (CK HMW, CK 5/6, CK 14) and p63 are both

equally eligible for staining of basal cells and yield similar results

• TO CONFIRM MALIGNANCY• AMACR (Alpha-methylacyl-CoA racemace)

PRIMARY ADENOCARCINOMA OF THE PROSTATE FROM SECONDARY TUMORSPSA (Prostate-specific antigen) not entirelyspecific for prostate since it has also been detected in carcinomas of the ovary and the breast, including male breast cancer But it still is probably the most commonly used prostate marker NKX3.1 (Homeobox protein NKX3.1)Prostein (P501S)Prostein’s prostate-specificity has been independently confirmed and several groups have successfully applied prostein IHC to discriminate a prostatic cancer origin from tumors of the colon and the bladder