Designed for UG teaching.

1. Prostate
Dr.CSBR.Prasad, M.D.

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.

4. CSBRP-July-2012

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

77. END
CSBRP-July-2012

78. E N D