Uropathology January 2012 Jon Oxley
Background to seminar These slides were available to view via the web from scanned slides The junior pathologists answered questions on them via the web The answers given, Gleason scores etc are also in this presentation, highlighting the problems of subjectivity of Gleason scoring.
Case 1 Prostate 39 Clinical History: 33M lump in prostate Macro: TURP Immunohistochemistry: CD34 positive stroma
Diagnoses offered STUMP (6) Solitary fibrous tumour (3) Benign Stromal lesion (2) Atypical lipoma (1) Stromal sarcoma (2) Sclerosing adenosis (1)
Diagnosis: Stromal proliferation of uncertain malignant potential (STUMP) Hypercellular stroma +/- cytologic atypia, +/- glandular component Phylloides like pattern CD34 and progesterone receptor +ve Desmin, SMA +ve (-ve in PSS) c/w prostatic stromal sarcoma (PSS)higher cellularity, nuclear atypia, necrosis
45yr lesion on glans Case 2 - Penis 9
Diagnoses offered SCC (3) SCC in situ (1) Dysplasia falling short of CIS (1) Condyloma (4) giant condyloma (1) BXO (1) Zoon s (1)
Diagnosis: Penile squamous cell carcinoma with background differentiated PeIN SCC rare, approx 70 cases per year in SW super network. Severe dysplasia, carcinoma in situ, PeIN3, Bowen s disease, erythroplasia of Queyrat all interchangable and best to stick to carcinoma in situ Differential diagnosis of Bowenoid papulosis in young but clinically different (multiple papules in Bowenoid papulosis) Recognise Differentiated PeIN just the basal layer is atypical P16 expressed by basaloid subtypes of CIS.
References Oertell J,et al. Differentiated precursor lesions and low-grade variants of squamous cell carcinomas are frequent findings in foreskins of patients from a region of high penile cancer incidence. Histopathology. 2011 May;58(6):925-33. Chaux A, et al. Distinctive immunohistochemical profile of penile intraepithelial lesions: a study of 74 cases. Am J Surg Pathol. 2011 Apr;35(4):553-62.
Case 3 Prostate 47 63M TURP There are two pathologies present select both, and Gleason score
Diagnoses offered CaP Microacinar (8) CaP Ductal (1) CaP Colloid (1) PIN (1) Acute inflammation (2) Atrophy (1) TCC (2)
Diagnosis: Prostate cancer with TCC in ducts At cystectomies for TCC approx 70% of prostates contain CaP. Always assess and comment on urothelium of TURPs. Assessing invasion of TCC outside ducts always difficult foci of inflammation are often a hint that invasion has occurred. TCC = 34BE12, p63 and CK7 positive
Gleason score Not relevant 3+3 3+4 4+3 4+4 4+5 5+5 Primary diagnosis 0.0% (0) 20.0% (2) 50.0% (5) 0.0% (0) 10.0% (1) 10.0% (1) 10.0% (1) 10 Second diagnosis 70.0% (7) 20.0% (2) 0.0% (0) 10.0% (1) 0.0% (0) 0.0% (0) 0.0% (0) 10
Case 4 Prostate 5 77M, prostatic chips There are two pathologies present select both, and Gleason score.
Diagnoses offered Lymphoma (7) Leukaemia (1) Acute prostatitis (2) CaP microacinar (6) CaP Ductal (2) Metastatic tumour (1) Germ cell tumour (1)
Diagnosis: CaP + CLL TURP s are often performed in elderley patients who often have unsuspected CLL. Simple immunopanel CD3,CD5, CD20, CD23 Check blood counts Refer to haematology Hint lymphocytes associated with blood vessels and not acini.
Gleason score Not relevant 3+3 3+4 4+3 4+4 4+5 5+5 Primary diagnosis 30.0% (3) 10.0% (1) 10.0% (1) 30.0% (3) 0.0% (0) 20.0% (2) 0.0% (0) 10 Second diagnosis 90.0% (9) 0.0% (0) 10.0% (1) 0.0% (0) 0.0% (0) 0.0% (0) 0.0% (0) 10
Case 5 Prostate 22 72M PSA 13 DRE Benign Answer all parts to question Gleason score Volume
Diagnoses offered CaP Ductal (1) CaP Foamy (3) CaP Microacinar (3) CaP pseudohyperplastic (1) PIN (1)
Diagnosis: Foamy gland CaP Trap as bland at low power 34BE12 very useful AMACR no use as can be negative Hint nucleoli in this case but can sometime lack this low threshold for 34BE12
Gleason score 3+3 3+4 4+3 4+4 4+5 5+5 50.0% (5) 40.0% (4) 0.0% (0) 10.0% (1) 0.0% (0) 0.0% (0) 10
Volume <5% 5-10% 11-20% 21-30% 31-40% 41-50% 51-60% 61-70% >70% 20.0% (2) 20.0% (2) 10.0% (1) 10.0% (1) 20.0% (2) 0.0% (0) 0.0% (0) 10.0% (1) 10.0% (1) 10
72yr old TURP. Case 6 Prostate 43
Diagnoses offered CaP endocrine differentiation (5) CaP Microacinar (2) Basal cell carcinoma (2) Basal cell hyperplasia (1) TCC (3) Small cell (1) Carcinoid (1)
Diagnosis: Carcinoid Very rare primary carcinoid (most commonly metastatic) Typical immunophenotype = CG, CD56,synaptophysin Differential = Small cell carcinoma commonly post CaP post hormone therapy beware bladder small cell invading prostate. Primary small cell carcinoma of prostate does occur but very rare.
Case 7 Prostate 9 75M PSA 5.8, core There are two pathologies present select both, and Gleason score
Diagnoses offered CaP microacinar (8) CaP ductal (1) PIN (2) Amyloid (2) Atrophy (3) Sclerosing adenosis (1) Seminal vesicle
Diagnosis: CaP with seminal vesicle amyloid Amyloid seen in seminal vesicle in about 1% of radical prostates. Derived from semenogelin I (involved in the formation of a gel matrix that encases ejaculated spermatozoa, and is degraded by the proteolytic action of prostate specific antigen/psa ) No clinical significance
Gleason Score Not relevant 3+3 3+4 4+3 4+4 4+5 5+5 11.1% (1) 11.1% (1) 0.0% (0) 44.4% (4) 0.0% (0) 33.3% (3) 0.0% (0) 9
Case 8 Prostate 29A 64M?TCC in prostatic fossa
Diagnoses offered CaP Ductal (5) CaP Pseudohyperplastic (1) Adenocarcinoma not prostatic (2) Nephrogenic adenoma (1) PIN (3) TCC (2)
Diagnosis: Ductal carcinoma of the Gleason pattern 4 prostate PSA +ve, 34BE12 ve (can grow into ducts so basal layer can be highlighted) Often co-exist with microacinar. Don t mistake it for TCC!!
Gleason Score Not relevant 3+3 3+4 4+3 4+4 4+5 5+5 66.7% (6) 0.0% (0) 0.0% (0) 0.0% (0) 33.3% (3) 0.0% (0) 0.0% (0) 9
Case 9 Prostate 14 65M PSA 7.4 There are two pathologies present select both, and Gleason score
Diagnoses offered CaP microacinar (5) CaP Colloid (1), endocrine (1), foamy (1) PIN (1) TCC (1) Angiosarcoma (1) Seminal vesicle (1), cribriform clear cell (1) Adenosis (3), BPH (1), mesonephric remnant (1)
Diagnosis: Inverted growth pattern HGPIN and CaP Rare subtype (I have never seen it without cancer) Usual type of HGPIN seen in 5% of cores (varies considerably)
Gleason Score Not relevant 3+3 3+4 4+3 4+4 4+5 5+5 55.6% (5) 33.3% (3) 0.0% (0) 0.0% (0) 0.0% (0) 11.1% (1) 0.0% (0) 9 55.6% (5) 33.3% (3) 0.0% (0) 0.0% (0) 11.1% (1) 0.0% (0) 0.0% (0) 9
Case 10 - Penis 65yr lesion on glans and foreskin.
Diagnoses offered Melanoma (8) Basaloid carcinoma (2) Merkel carcinoma (3) SCC (1)
Diagnosis : Penile melanoma Poor prognosis often delay presentation BRAF and KIT mutations described but not detected in our series.
Opinion on trial Using the images was easy The speed was acceptable Quality of image was excellent More tutorials should use this I recommend the process for future tutorials Strongly disagree Disagree Neutral Agree Strongly agree 0.0% (0) 0.0% (0) 50.0% (5) 50.0% (5) 0.0% (0) 0.0% (0) 20.0% (2) 10.0% (1) 70.0% (7) 0.0% (0) 0.0% (0) 20.0% (2) 30.0% (3) 40.0% (4) 10.0% (1) 0.0% (0) 20.0% (2) 50.0% (5) 20.0% (2) 10.0% (1) 0.0% (0) 30.0% (3) 30.0% (3) 30.0% (3) 10.0% (1) This is the future 20.0% (2) 20.0% (2) 0.0% (0) 50.0% (5) 10.0% (1) 1 0 1 0 1 0 1 0 1 0 1 0 total number of responses = 10
REFERENCES Genitourinary Pathology: A Volume in Foundations in Diagnostic Pathology Series, by Zhou.