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Male genitaltract 4
- 2. Normal Prostate • Retroperitoneal organ • Encircles the neck of the bladder and urethra • No definitive capsule • Weighs approx 20gms • Measures 3-4cms in greatest dimension • Divided into 4 anatomically and biologically distinct zones 1-Peripheral 2-Central 3-Transitional zones 4-Region of anterior fibromuscular stroma Note: Most hyperplasias arise in the transitional zone, where as most carcinomas originate in the peripheral zone. CSBRP-July-2012
- 3. This is a transverse (axial) section through a normal prostate. There is a central urethra (White arrow) at the depth of the cut made to open this prostate anteriorly at autopsy, with the left lateral lobe (Red arrow) and the right lateral lobe (Yellow arrow) and the posterior lobe (Green arrow). The consistency is uniform, without nodularity. The normal prostate is 3 to 4 cm in diameter.
- 5. This is a diagram of the classic 4 prostatic lobes. The x marks the site through which the urethra traverses. It is easy to see that most pathology related to the prostate will present with obstructive uropathy symptoms. CSBRP-July-2012
- 6. Normal Prostate Histology: • Compound tubuloalveolar organ • Glandular lining epithelium has two layers of cells and has distinct BM 1-Basal layer of cuboidal epithelium & 2-Tall columnar secretory cells towards the lumen • There are small papillary inbuddings of the epithelium • Glands are separated by abundant fibromuscular stroma CSBRP-July-2012
- 7. The normal male prostate gland below the bladder is composed of a mixture of glands and intervening fibromuscular stroma, in about equal proportions, as seen here at low power.
- 8. Normal prostate is composed of a mixture of glands lined by tall columnar cells with infoldings and the intervening fibromuscular stroma, in about equal proportions, as seen here at medium power.
- 9. The normal appearance of prostate is shown at high magnification. Note the small pink laminated concretion (these are corpora amylacea) in the gland lumen to the left of center. Note the infoldings of the columnar epithelium.
- 10. CSBRP-July-2012
- 11. Pathological processes involving prostate • Inflammations • Nodular hyperplasia • Tumors CSBRP-July-2012
- 12. Prostatitis 1. Acute bacterial prostatitis 2. Chronic bacterial prostatitis 3. Granulomatous prostatitis CSBRP-July-2012
- 13. Acute bacterial prostatitis • Usually due to extension of infection from the urethra or bladder • It can follow manipulation of the urethra or prostate secondary to catherization or cystoscopy • The bacterial "culprits" are: • -- Urinary pathogens (Enterobacteriaceae) • -- Enterococcus and Staphylococcus • CF: dysuria, chills and fever • The prostate is very tender to palpation • Neutrophilic infiltrate CSBRP-July-2012
- 14. Acute bacterial prostatitis CSBRP-July-2012
- 15. Chronic Prostatitis • Chronic Bacterial Prostatitis Antibiotics do not penetrate the prostate well The common presentation is recurrent UTI • Chronic Prostatitis Lymphocytic infiltrate and fibrosis Chronic non-bacterial prostatitis: -- the most common type -- WBCs may been seen in prostatic secretions, but -- no bacteria can be identified -- suspects – ‘chlamydia and mycoplasma’ infection CSBRP-July-2012
- 16. Chronic Prostatitis CSBRP-July-2012
- 17. Granulomatous Prostatitis • Tuberculosis • Fungal (immunocompromised patients) • Secondary to secretions from obstructed ducts CSBRP-July-2012
- 18. CSBRP-July-2012
- 19. Prostatic hyperplasia CSBRP-July-2012
- 20. BPH (Nodular hyperplasia) • Common disorder, aging process. >40yrs=20%, >60yrs=70%, >70yrs=90%. • >50yrs • Periurethral portion is involved • Present with urinary obstruction • Hyperplasia of stroma and epithelial cells CSBRP-July-2012
- 21. BPH / NPH (Nodular hyperplasia) Pathogenesis: • Androgen related • Dihydrotestosterone mediates growth and proliferation in stromal and epithelial cells CSBRP-July-2012
- 22. CSBRP-July-2012
- 23. Clinical Features • Retention of urine • UTI The most commonly used and effective medical therapy: • α-blockers, which decrease prostate smooth muscle tone via inhibition of α1-adrenergic receptors • Shrinking the prostate with inhibitor of DHT synthesis (5-α-reductase Inhibitors) CSBRP-July-2012
- 24. BPH / NPH • Prostate is enlarged, 60-100gms • Nodular in the inner aspect of the gland • Compressed urethra • c/s milky white fluid may ooze • Bladder wall thickening / Trabaculation • Microscopically – fibromyoglandular hyperplasia CSBRP-July-2012
- 25. Bladder This anatomical midline sagital section reveals a markedly enlarged prostate with a nodular appearance from hyperplasia. The prostatic urethra (Yellow) that traverses the enlarged gland is compressed. The bladder wall is hypertrophic. Other structures seen here include the pubic symphysis (White), the rectum (Blue), and the penile urethra (Red). CSBRP-July-2012
- 26. CSBRP-July-2012
- 27. Multinodularity Solid areas Microcystic areas CSBRP-July-2012
- 28. This is the gross appearance of nodular prostatic hyperplasia (benign prostatic hyperplasia, or BPH). The normal prostate is 3 to 4 cm in cross section, by comparison.
- 29. BPH
- 30. CSBRP-July-2012
- 32. This is the microscopic appearance of nodular prostatic hyperplasia at medium power. Note that the columnar arrangement of cells near the gland lumina is preserved. Note several pink corpora amylacea in gland lumens.
- 33. This is the microscopic appearance of nodular prostatic hyperplasia at low magnification. Note the nodule filled with enlarged glands. Though crowded, there is still stroma between the glands. CSBRP-July-2012
- 34. The enlarged prostate gland seen here not only has enlarged lateral lobes, but also a greatly enlarged median lobe that obstructs the prostatic urethra. This led to obstruction with bladder hypertrophy, as evidenced by the prominent trabeculation of the bladder wall seen here from the mucosal surface. Obstruction with stasis Median also led to the formation of the lobe yellow-brown calculus (stone). Lateral CSBRP-July-2012 lobes
- 35. Trabaculation and thickening of the wall [Fighting Urinary bladder] CSBRP-July-2012
- 36. Do you know what is fighting Gall bladder? CSBRP-July-2012
- 37. The prostate "chips" seen here are the firm, rubbery fragments obtained from transurethral resection of prostate (TUR-P) performed for symptomatic nodular hyperplasia.
- 38. Areas of nodular hyperplasia Areas of infarction CSBRP-July-2012
- 39. BPH and malignancy Nodular hyperplasia is NOT considered to be a premalignant lesion CSBRP-July-2012
- 40. Carcinoma of Prostate CSBRP-July-2012
- 41. Prostatic carcinoma • One of the most common cancers in men • >50yrs (men from the age of 40yrs should be screened for prostatic cancer) • The incidence increases with age 50s 20%; 70s 70% • More common in whites (50-60/lakh) and rare in Asians (1-4/lakh) CSBRP-July-2012
- 42. Prostatic carcinoma – Etiology • Risk factors: age, race, family history, hormone levels, environmental factors • Familiy history: One 1 relative – 2x Two 1 relatives – 5x • Androgens (AR mutations in CAG repeats) • Prostatic cancer susceptibility gene – 1q24-25 • Loss of cancer supressor genes: 8p, 10q, 13q, 16q. • Mutations in p53, PTEN and KAI 1 • Over expression of : Hepsin, alfa-methyl-acyl COA racemase, and EZH2. • Hypermethylation of GSTP1 CSBRP-July-2012
- 43. Prostatic carcinoma – GROSS • 70% of cancers arise in the periphery • Firm to gritty • Local extensions involve seminal vesicles, base of the bladder and may result in urinary obstruction • Blood spread: Bone (axial skeleton, femur, pelvis, ribs) • Bone mets: Osteoblastic • Lymphatic spread: perivesical, hypogastric, iliac, parasacral, para-aortic CSBRP-July-2012
- 44. This is a diagram of the classic 4 prostatic lobes. The x marks the site through which the urethra traverses. It is easy to see that most pathology related to the prostate will present with obstructive uropathy symptoms. CSBRP-July-2012
- 45. Bladder This anatomical midline sagital section reveals a markedly enlarged prostate with a nodular appearance from hyperplasia. The prostatic urethra (Yellow) that traverses the enlarged gland is compressed. The bladder wall is hypertrophic. Other structures seen here include the pubic symphysis (White), the rectum (Blue), and the penile urethra (Red). CSBRP-July-2012
- 46. Pathology Pearls Secondary deposits in bone • Breast • Kidney • Prostate B.K.PATIL • Adrenals • Testis • Intestines • Lung CSBRP-July-2012
- 47. Pathology Pearls “Bone seeking Kidney tumor” • Clear cell sarcoma of the kidney CSBRP-July-2012
- 48. CSBRP-July-2012
- 49. The gross appearance of adenocarcinoma of the prostate is shown here in cross section. The entire prostate is involved. The yellowish nodules represent larger foci of carcinoma. CSBRP-July-2012
- 50. Prostatic carcinoma – micro • Gland formations: 1-Single cell layer, no basal layer 2-Small, crowded glands 3-Nuclei are large, contain 1-2 nucleoli 4-Mitotic figures are uncommon • Perineural invasion • One feature that distinguishes benign from malignant gland is – basal layer (HMWCK) CSBRP-July-2012
- 51. CSBRP-July-2012
- 52. CSBRP-July-2012
- 53. CSBRP-July-2012
- 54. Whole mount of large duct adenocarcinoma. The tumor is centrally located and has a distinctly papillary configuration.
- 55. Lack of basal cells around the malignant acini. Some benign glands show basal layer (arrow)
- 56. CSBRP-July-2012
- 57. CSBRP-July-2012
- 58. Adenocarcinoma of the prostate is shown here at medium power. Some of the neoplastic glands have lumens, but there is no stroma between.
- 59. This is a high grade, poorly differentiated adenocarcinoma of prostate. There is no gland formation, only single cells infiltrating through the stroma. CSBRP-July-2012
- 60. Prostate This is a moderately well-differentiated adenocarcinoma of the prostate at high magnification. CSBRP-July-2012
- 61. A hallmark of prostatic adenocarcinoma is the presence of prominent large nucleoli, as seen here. CSBRP-July-2012
- 62. Many large nucleoi are seen here in the nuclei of cells in this prostatic adenocarcinoma. CSBRP-July-2012
- 63. Adenocarcinoma of the prostate is shown here at low power on the left, compared to benign prostate (in which glands contain corpora amylacea) at the right. Note how small and close-packed the neoplastic glands are.
- 64. This is a high grade adenocarcinoma of prostate. There are ill-defined glands, and at the top just single infiltrating cells.
- 66. Grading of prostatic carcinoma Gleason’s grading: grade 1-5 grade-1: WD tumor grade-5: PD tumor Reported score which is a total of predominant grade and other grade eg: Score 3+5=8 CSBRP-July-2012
- 67. CSBRP-July-2012
- 68. CSBRP-July-2012
- 70. Prostatic intraepithelial neoplasia - PIN • Benign glands with intraacinar proliferations of cells which exhibit nuclear anaplasia • glands surrounded by patchy layer of basal cells and have intact BM • Larger branching glands with papillary infoldings (in cancers – small glands with straight luminal border) CSBRP-July-2012
- 71. Prostatic intraepithelial neoplasia - PIN • Evidence that link high grade PIN to invasive Ca: 1-high grade predominate at the periphery 2-high grade PIN is also seen in association with invasive Ca. 3-molecular abnormalities seen in invasive cancers are also present in PINs CSBRP-July-2012
- 72. CSBRP-July-2012
- 73. Prostatic intraepithelial neoplasia (PIN) can be low or high grade (as seen here). The finding of PIN suggests that prostatic adenocarcinoma may also be present (about half the time with high grade PIN). CSBRP-July-2012
- 74. CSBRP-July-2012
- 75. Diagnosis of prostatic carcinoma • DRE • PSA • TRUS (transrectal US) • Biopsy CSBRP-July-2012
- 76. Diagnosis of prostatic carcinoma PSA: 1. Serien protease-liquifies semen 2. 4ng/ml 3. PSA value 4. PSA density 5. PSA velocity 6. Age specific reference range 7. Ratio of free and bound forms PSA is of great value in assessing the response to Tx CSBRP-July-2012
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