3/28/2017. Disclosure of Relevant Financial Relationships. GU Evening Subspecialty Case Conference. Differential Diagnosis:

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1 GU Evening Subspecialty Case Conference Rajal B. Shah, M.D. VP, Medical Director, Urologic Pathology Miraca Life Sciences, Irving, Texas Clinical Associate Professor of Pathology Baylor College of Medicine, Houston, Texas Disclosure of Relevant Financial Relationships USCAP requires that all planners (Education Committee) in a position to influence or control the content of CME disclose any relevant financial relationship WITH COMMERCIAL INTERESTS which they or their spouse/partner have, or have had, within the past 12 months, which relates to the content of this educational activity and creates a conflict of interest. Dr. Rajal B. Shah declares affiliation with Miraca Life Sciences A 58 year old African American male presented with an elevated and rising PSA for over 2 years PSA (ng/ml) PSA (ng/ml) The patient underwent repeat (2 nd ) 12 pack prostate core biopsy Differential Diagnosis: High grade prostatic intraepithelial neoplasia (HGPIN) Intraductal carcinoma of the prostate (IDC P) Ductal adenocarcinoma, Gleason score 4+4=8 PIN like prostatic adenocarcinoma, Gleason score 3+3=6 1

2 Numerous large Strips simple of non-cribriform epithelium at biopsy glands edge with crowding PIN4 Differential Diagnosis: High grade prostatic intraepithelial neoplasia (HGPIN) Intraductal carcinoma of the prostate (IDC P) Ductal adenocarcinoma, Gleason score 4+4=8 PIN like prostatic adenocarcinoma, Gleason score 3+3=6 Ductal Adenocarcinoma: Morphologic Features Prominent cribriform, papillary or rarely solid architecture Columnar cell lining epithelium with stratified nuclei Lack cribriform or prominent papillary architecture Lack columnar epithelium with stratified nuclei 2

3 Differential Diagnosis: High grade prostatic intraepithelial neoplasia (HGPIN) Intraductal carcinoma of the prostate (IDC P) Ductal adenocarcinoma, Gleason score 4+4=8 PIN like prostate adenocarcinoma, Gleason score 3+3=6 Histologic variants of usual acinar adenocarcinoma that may mimic benign lesions Histological pattern of cancer Foamy gland carcinoma Atrophic carcinoma Benign condition they may mimic Cowper s glands Mucinous metaplasia Xanthoma Benign atrophy Pseudohyperplastic carcinoma PIN-like prostate adenocarcinoma Benign prostatic hyperplasia (BPH) High grade prostatic intraepithelial neoplasia (HGPIN) Diagnostic Criteria (Definition) of PIN-like Prostate Adenocarcinoma Proliferation of several simple (non-cribriform/nonpapillary) large glands with flat, tufted or micropapillary architecture Stratified malignant epithelium Lack basal cells 8 needle biopsy cases 4 cases had pure morphology while 4 with mixed acinar component ranging from 5 30% of tumor Two morphological spectrum: 5 cases composed of non columnar cells with rounded nuclei, similar to ordinary acinar adenocarcinoma 3cases composed of columnar cells with oval nuclei, similar to ductal adenocarcinoma PIN-like adenocarcinoma, conventional acinar epithelial features PIN-like adenocarcinoma exhibiting ductal epithelial features 3

4 PIN-like Ductal Adenocarcinoma Simple glands (non cribriform/non papillary morphology) with flat, tufted, or micropapillary architecture Flat most common pattern (42%), followed by tufted (41%), and micropapillary (17%) Fourteen cases had segments of dilated glands on the edge of biopsy suggesting a large cystically dilated gland component Cytologically, tall columnar atypical cells with basally located nuclei Lack of basal cells (100%) and AMACR expression (80%) PIN-like Ductal Adenocarcinoma PIN-like adenocarcinoma: Acinar epithelial features Simple non-cribriform/non-papillary glands Non-columnar epithelium with stratified round nuclei PIN-like adenocarcinoma: Ductal epithelial features Simple non-cribriform/non-papillary glands Columnar epithelium with stratified ovoid nuclei PIN-like prostate adenocarcinoma (15) from over 4000 consecutive biopsies (<1% of PCas) Acinar epithelial features (12) Ductal epithelial features (3) Pure (2) Mixed (10) Pure (0) Mixed (3) Flat - 83% Tufted - 100% Micropapillary- 17% Strips of - 8% epithelium at edge of biopsy Flat - 100% Tufted- 100% Micropapillary- 50% Strips of - 50% epithelium at edge of biopsy How to grade PIN-like prostate adenocarcinoma? 4

5 PIN like ductal adenocarcinoma demonstrated less aggressive behavior similar to Gleason score 6 acinar adenocarcinoma Concurrent conventional Gleason score 6 acinar adenocarcinoma seen in 6 of 9 radical prostatectomy Only one PIN like ductal adenocarcinoma had extraprostatic extension Pure PIN like ductal adenocarcinoma should be assigned pattern 3 Is it important to differentiate PIN-like acinar from PIN-like ductal adenocarcinoma? Differential Diagnosis of Large Atypical Glandular Proliferation in Prostate Biopsy High grade prostatic intraepithelial neoplasia PIN-like prostate adenocarcinoma Atypical Intraductal proliferation/intraductal carcinoma of the prostate (IDC-P) Ductal adenocarcinoma, Gleason score 4+4=8 PIN-like Adenocarcinoma versus HGPIN PIN-like Prostate Adenocarcinoma HGPIN Architecture Flat, Tufted, Micropapillary Flat, Tufted, Micropapillary, Cribriform (rare) Back to back glands, Infiltrative More stroma separating glands Cytological features Conventional acinar or ductal Conventional Basal cells Absent Present (could be absent in small focus) High index of suspicion critical to avoid misdiagnosis! 5

6 IDC-P: Hallmark Histological Features PIN4-ERG Numerous large branching glands with loose cribriform architecture PTEN loss Atypical Intraductal Proliferation (Atypical cribriform lesion) Dense PRESENTATION cribriform architecture TITLE Intraluminal necrosis Marked nuclear atypia Solid Shah RB et al, USCAP Poster #1046, Monday Afternoon PIN-like Adenocarcinoma versus IDC-P PIN-like Prostate IDC-P Adenocarcinoma Architecture Flat, Tufted, Micropapillary Cribriform (dense or loose), Solid, Micropapillary Cytological features Conventional acinar or ductal Conventional, rarely marked nuclear atypia Basal cells Absent Present PIN-like Ductal Adenocarcinoma versus Ductal Adenocarcinoma PIN-like Ductal Adenocarcinoma Ductal Adenocarcinoma Architecture Flat, Tufted or Micropapillary Cribriform, Papillary, Solid Cytological features Columnar cells with basally located nuclei Columnar cells with basally located nuclei Basal cells Absent Focally may be preserved Gleason grade 3 4 or 5 Ductal adenocarcinoma, Gleason score 4+4=8: Prominent cribriform papillary morphology Ductal adenocarcinoma, Gleason score 4+4=8 6

7 Ductal adenocarcinoma, Gleason score 4+4=8 Mixed PIN-like ductal adenocarcinoma and ductal adenocarcinonma, Gleason score 3+4=7 PIN-like Prostate Adenocarcinoma: Summary Rare histological variation Simple non cribriform glandular proliferation with nuclear stratification that closely mimics HGPIN Two morphological spectrum: conventional acinar and ductal epithelial morphology It may uncommonly present in pure form Pure PIN like adenocarcinoma component should be assigned Gleason pattern 3 Take home messages (1): Large number of crowded PIN-like glands Workup for basal cell stains before diagnosing the case as HGPIN! Take home messages (2): Large glands with ductal epithelium PIN-like ductal adenocarcinoma, Gleason score 3+3=6 Ductal adenocarcinoma, Gleason score 4+4=8 Pay careful attention to architectural details to differentiate PIN-like ductal adenocarcinoma from traditional ductal adenocarcinoma 7

8 Important Information Regarding CME/SAMs The Online CME/Evaluations/SAMs claim process will only be available on the USCAP website until September 30, No claims can be processed after that date! After September 30, 2017 you will NOT be able to obtain any CME or SAMs credits for attending this meeting. 8