Prostate biopsy interpretation : an illustrated guide

214 Pages·2019·53.036 MB·English

by  Rajal B. Shah, Ming Zhou

Rajal B. Shah
Ming Zhou
Prostate Biopsy
Interpretation
An Illustrated Guide
Second Edition
123
Prostate Biopsy Interpretation
Rajal B. Shah • Ming Zhou
Prostate Biopsy Interpretation
An Illustrated Guide
Second Edition
Rajal B. Shah Ming Zhou
Robert J Tomsich Pathology and Laboratory Tufts Medical Center
Medicine Institute Boston, MA
Cleveland Clinic USA
Cleveland, OH
USA
ISBN 978-3-030-13600-0 ISBN 978-3-030-13601-7 (eBook)
https://doi.org/10.1007/978-3-030-13601-7
© Springer Nature Switzerland AG 2019
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed
to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty,
express or implied, with respect to the material contained herein or for any errors or omissions that may have been
made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
To my wife, Ami Shah, and sons, Ansh and Alay, for their unconditional love
and support and for constantly reminding me that there is life beyond work.
To my parents, Bipin Shah and Sharmishtha Shah, for their genes, sacrifice,
and motivation.
Rajal B. Shah
To my wife, Lan Zhou, and daughters, Grace and Rebecca, for their
unwavering support.
Ming Zhou
Preface
Since the publication of the first edition of this book, there have been many significant devel-
opments in prostate cancer diagnosis and treatment. We have witnessed a paradigm shift in the
objectives of prostate cancer management, from diagnosing and treating all cancers to clini-
cally significant ones. Recent publication of the World Health Organization (WHO) genitouri-
nary bluebook brought forth numerous significant changes in the diagnosis, classification,
grading, staging, and reporting of prostate cancer that every pathologist needs to know and
integrate in his/her practice. New diagnostic tools, including magnetic resonance imaging
(MRI), genomic testing and artificial intelligence (AI), are rapidly reshaping the landscape of
prostate cancer diagnosis and management. Pathologists need to understand how these novel
diagnostic modalities may dramatically change their practice of prostate biopsy diagnosis.
This book retains the core contents of its successful first edition and covers all the practical
issues related to prostate biopsy diagnosis in day-to-day practice. Pertinent new information is
incorporated in all chapters. In particular, how novel diagnostic tools such as MRI and genomic
tests may affect prostate biopsy practice is discussed. An entirely new chapter on pattern-based
approaches to prostate biopsy interpretation has been added.
This book is not meant to be an all-encompassing, definitive bibliography of pathology of
prostate cancer. The primary goal of this book is to provide practicing surgical pathologists as
well as trainees a quick and handy reference for all the practical issues relevant to day-to-day
interpretation of prostate biopsy. This second edition keeps the format of the original book. It
uses abundant algorithms, flow charts, and tables to simulate a pathologist’s thought process
during evaluation of prostate biopsies. Readers will learn the most effective way to evaluate a
prostate biopsy and how to formulate a diagnostic approach upon encountering a specific clini-
cal problem.
Cleveland, OH, USA Rajal B. Shah

Boston, MA, USA Ming Zhou
vii
Acknowledgments
We wish to express our profound appreciation to many of our colleagues who have generously
provided material presented in this book. We also wish to express our gratitude to the trainees
and practicing pathologists with whom we have worked for their valuable feedback, which has
motivated us to further improve this book for the second edition.
Our thanks are also extended to Springer, the publisher of this book, who saw the value of
updating this practical atlas as a handy reference for busy practicing pathologists. Our sincere
thanks also go to Ms. Diane Lamsback, who has worked tirelessly and meticulously through-
out this project to keep us on track to produce a book that we are very proud of.
ix
Contents
1 Anatomy and Normal Histology of the Prostate Pertinent
to Biopsy Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Anatomy of Normal Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Anatomy and Disease Preference of Three Zones of the Prostate . . . . . . . . . . . . 2
1.3 Histology of Normal Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.4 Immunophenotype of Prostate Glandular Cells . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.5 Histology of Three Zones of Normal Prostate Glands, Other Intraprostatic
Structures, and Their Mimics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.6 Histologic Variations of Normal Prostate Tissue . . . . . . . . . . . . . . . . . . . . . . . . . 8
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2 Needle Biopsy Sampling Techniques and Role of Multiparametric-Magnetic
Resonance Imaging Modality in Prostate Cancer Diagnosis
and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.1 Comparisons of Three Biopsy Techniques Utilized
for Prostate Cancer Detection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.2 Comparisons of Transrectal and Transperineal Biopsy Approach . . . . . . . . . . . . 13
2.3 Multiparametric-Magnetic Resonance Imaging (mp-MRI)
for Prostate Cancer Diagnosis and Management . . . . . . . . . . . . . . . . . . . . . . . . . 13
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3 Diagnosis of Limited Cancer in Prostate Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.1 General Approach to Prostate Needle Biopsy Evaluation . . . . . . . . . . . . . . . . . . 19
3.2 Histological Features Considered Specific for and Diagnostic of Cancer . . . . . . 20
3.3 Major and Minor Diagnostic Features of Prostate Cancer in Biopsy . . . . . . . . . 21
3.4 Benign Conditions That Cause Architectural and Cytological Atypia . . . . . . . . 27
3.5 Quantitative Threshold for Diagnosing Limited Cancer in Biopsy . . . . . . . . . . . 29
3.6 Histological Features for and against Cancer Diagnosis in Biopsy . . . . . . . . . . . 30
3.7 A Practical Approach to Diagnosis of Limited Cancer in Needle Biopsy . . . . . . 30
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
4 Immunohistochemistry in Prostate Biopsy Evaluation . . . . . . . . . . . . . . . . . . . . . . 33
4.1 Commonly Used Immunohistochemical Markers for Diagnosis
of Prostate Cancer in Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
4.2 Basal Cell Markers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4.3 Alpha-Methylacyl-CoA Racemase (AMACR) . . . . . . . . . . . . . . . . . . . . . . . . . . 37
4.4 ERG Protein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.5 Antibody Cocktails . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.6 Differential Diagnosis of Prostate Cancer by Immunohistochemistry . . . . . . . . 41
4.7 Immunohistochemical Markers for Prognosis and Risk Stratification . . . . . . . . 42
4.8 Practical Guideline for Using Immunohistochemistry in Work-Up
of Prostate Biopsies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
xi
xii Contents
5 Contemporary Approach to Gleason Grading of Prostate Cancer . . . . . . . . . . . . 45
5.1 Significance of Gleason Grading in Prostate Cancer Management . . . . . . . . . . 46
5.2 Prostate Cancer Nomograms and National Comprehensive Cancer Network
(NCCN) Risk Categories and Prediction Models . . . . . . . . . . . . . . . . . . . . . . . . 46
5.3 2005/2014 Modifications of Gleason Grading System . . . . . . . . . . . . . . . . . . . . 48
5.4 Contemporary Gleason Pattern 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
5.5 Contemporary Gleason Pattern 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
5.6 Contemporary Gleason Pattern 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
5.7 Common Pitfalls of Pattern 3 (Reasons for Over-interpretation
of Pattern 3 as Pattern 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
5.8 Contemporary Gleason Pattern 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5.9 Recommendations to Improve Reproducibility of
“Poorly Formed” Gleason Pattern 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
5.10 Common Pitfalls of Pattern 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
5.11 Contemporary Gleason Pattern 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
5.12 Morphologic Features That Are Associated with
High Reproducibility for Gleason Pattern 5 Prostate Cancer . . . . . . . . . . . . . . . 57
5.13 Gleason Grading of Unusual “Variant” Histology Types and Patterns . . . . . . . . 60
5.14 New Grading System: Grade Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
5.15 Important Facts About Grade Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
5.16 Recommendations for Gleason Grading in the Post-therapy Setting . . . . . . . . . 63
5.17 Rationale for Reporting Percentage Pattern 4 in Gleason Score 7
Prostate Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
5.18 Summary of Current Concepts of Gleason Grading of Prostate Cancer . . . . . . . 66
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
6 Histologic Variants of Acinar Adenocarcinoma, Ductal Adenocarcinoma,
Neuroendocrine Tumors, and Other Carcinomas . . . . . . . . . . . . . . . . . . . . . . . . . . 69
6.1 The 2016 World Health Organization Classification of Histological
Variants of Acinar Adenocarcinoma, Ductal Adenocarcinoma,
Neuroendocrine Tumors, and Other Carcinomas . . . . . . . . . . . . . . . . . . . . . . . . . 69
6.2 Histologic Variants of Acinar Prostate Carcinoma Mimicking
Benign Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
6.3 Atrophic Adenocarcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
6.4 Pseudohyperplastic Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
6.5 Microcystic Adenocarcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
6.6 Foamy Gland Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6.7 Mucinous (Colloid) Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
6.8 Signet Ring Cell-Like Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
6.9 Pleomorphic Giant Cell Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
6.10 Sarcomatoid Carcinoma (Carcinosarcoma) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
6.11 Prostatic Intraepithelial Neoplasia- Like (PIN-Like) Adenocarcinoma . . . . . . . . 81
6.12 Ductal Adenocarcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
6.13 The 2016 World Health Organization(WHO) Pathologic Classification and
Clinical Significance of Neuroendocrine (NE) Differentiation in Prostate
Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
6.14 Small-Cell Neuroendocrine (NE) Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
6.15 Utility of Immunohistochemistry in Neuroendocrine Tumors of the Prostate . . 89
6.16 Urothelial Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
6.17 Squamos and Adenosquamos Cell Carcinoma (SCC) . . . . . . . . . . . . . . . . . . . . . 92
6.18 Basal Cell Carcinoma (BCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Contents xiii
7 Benign Mimics of Prostate Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
7.1 Summary of Atypical Morphological Features Commonly Encountered
in Various Benign Mimics of Prostate Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
7.2 Seminal Vesicle/Ejaculatory Duct Epithelium . . . . . . . . . . . . . . . . . . . . . . . . . . .100
7.3 Verumontanum Mucosal Gland Hyperplasia (VMGH) . . . . . . . . . . . . . . . . . . . .101
7.4 Cowper’s Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102
7.5 Mesonephric Remnant Hyperplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103
7.6 Mucinous Metaplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103
7.7 Classification of Focal Atrophy Lesions of the Prostate . . . . . . . . . . . . . . . . . . .104
7.8 Focal Atrophy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104
7.9 Partial Atrophy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105
7.10 Postatrophic Hyperplasia (PAH) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107
7.11 Adenosis (Atypical Adenomatous Hyperplasia) . . . . . . . . . . . . . . . . . . . . . . . . .108
7.12 Basal Cell Hyperplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .110
7.13 Postradiation Atypia in Benign Prostate Glands . . . . . . . . . . . . . . . . . . . . . . . . .112
7.14 Nephrogenic Adenoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .114
7.15 Cribriform Proliferations Encountered in the Prostate Gland . . . . . . . . . . . . . . .117
7.16 Central Zone Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117
7.17 Clear Cell Cribriform Hyperplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .118
7.18 Nonspecific Granulomatous Prostatitis (NSGP) . . . . . . . . . . . . . . . . . . . . . . . . .119
7.19 Malakoplakia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121
7.20 Sclerosing Adenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .122
7.21 Paraganglia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .123
7.22 Xanthoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .124
7.23 Benign Mimics of Prostate Cancer: Take-Home Messages . . . . . . . . . . . . . . . . .124
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125
8 Intraductal Carcinoma of the Prostate (IDC-P)
and Atypical Intraductal Proliferation (AIP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127
8.1 Intraductal Carcinoma of the Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .128
8.2 Pathologic Features That Are Associated with IDC-P
and Helpful to Differentiate from Cribriform HGPIN . . . . . . . . . . . . . . . . . . . . .131
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .132
9 High-Grade Prostatic Intraepithelial Neoplasia . . . . . . . . . . . . . . . . . . . . . . . . . . .133
9.1 Histological Features of High-Grade Prostatic Intraepithelial
Neoplasia (HGPIN) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133
9.2 Clinical Significance of HGPIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138
9.3 Differential Diagnosis of HGPIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138
9.4 Reporting of HGPIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .140
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .140
10 Atypical Glands Suspicious for Cancer (ATYP) . . . . . . . . . . . . . . . . . . . . . . . . . . .143
10.1 Histological Features Resulting in ATYP . . . . . . . . . . . . . . . . . . . . . . . . . . . . .143
10.2 Working Up Cases with ATYP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .148
10.3 Clinical Significance and Management of ATYP . . . . . . . . . . . . . . . . . . . . . . .149
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .149
11 Spindle Cell Lesions of the Prostate Gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151
11.1 Classification of Spindle Cell Lesions of the Prostate . . . . . . . . . . . . . . . . . . . .151
11.2 Specialized Stromal Tumors of the Prostate Gland . . . . . . . . . . . . . . . . . . . . . .152
11.3 Solitary Fibrous Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .154
11.4 Inflammatory Myofibroblastic Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155