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REGUB - Pathology of Male GUT (i) (PSA (prostate specific antigen, small…
REGUB - Pathology of Male GUT (i)
Prostatitis
mostly clinical relevance, not a specific query to a histopathologist (but can raise PSA + thus raise concern for cancer)
acute bacterial prostatitis
usually seen in UTI
mostly in adult men
systemic (ILI) + local symptoms (dysuria)
chronic bacterial prostatitis
same as acute except relapsing + less symptoms
granulomatous prostatitis
uncommon
causes
infectious (e.g. TB)
other (e.g. sarcoid)
often unknown
can have same symptoms as other types
can have v high PSA + hard prostate on DRE (clinically can mimic cancer)
Basic prostate anatomy
transitional zone: BPH, 20-25% of cancer here
peripheral zone: 70-75% of cancer here, easy to access via transrectal bx
BPH
HYPERPLASIA
V common - frequent referral for a urologist
aetiology
hormonal (castrated men don't get BPH)
age-related
possible genetic predisposition (family hx relevant)
symptoms (prostatism)
obstructive (due to prostate)
poor flow
hesitancy
feeling of incomplete bladder emptying
dribbling
irritative (due to irritative interaction with bladder)
urgency
polyuria
nocturia
causes trabeculation of bladder mucosa, hypertrophy (due to urine obstruction)
Malignant prostate tumours
primary tumours
adenocarc
(>90%)
microacinar variant
ductal (large duct) variant (rare, usually mixed with microacinar)
others
rare
SCC
small cell carc
sarcoma
lymphoma
others
secondary tumours
rare
usually by direct extension of bladder or rectal cancer
risk factors
age (v rare <40, rare <50)
ethnicity (increased incidence in Afro-Americans)
genetic (family hx +ve in 10% - BRCA, Lynch)
possible: hormones, diet, obesity
epidemiology
most common non-skin cancer in men
3rd most common cause of cancer deaths in men
most cases do not die from prostate cancer (mostly indolent)
autopsy studies show that u to 50% of men > 60 have prostate cancer
5 yr survival when early + detected > 95%
US lifetime risk = 16%, but risk from dying from it = 2.9%
symptoms
most incidental - PSA, DRE, resection for BPH, well man clinics
local (late, may mimic BPH)
met (e.g. bone - acute onset back pain)
pathological features
often v subtle
macroscopic: multifocal, infiltrative, usually not seen
microscopic: minimal pleomorphism, mitoses infrequent, often small foci
architecture: small crowded glands
nuclear features: enlargement, large nucleoli
lack of basal myoepithelial cells (IHC)
no single defining features
PSA
prostate specific antigen
small gp secreted by prostatic epithelial cells to liquify semen in seminal vesicle ejaculate
leaked into serum in v low quantities in normal men (<4 ng/ml - higher acceptable value in older men)
serum PSA increased in prostate cancer + other reasons (e.g. prostatitis)
not all prostate cancer cases have elevated PSA (can't give all clear)
widely used as 'screening'
if +ve: bx
Traditional prostate bx
transrectal
extended sextant - 12 cores
limitation = lack of targeting (sampling error, so a -ve bx does not mean prostate is cancer free)
sometimes cancer extent + grade in bx may not reflect actual cancer extent + grade in prostate (although it often does)
Template prostate bx
transperineal
better access to ant, base + apex
main indication: persistent concern despite -ve bx's
US probe in rectum
patient under general anaesthesia in stirrups
MRI in prostate cancer
v useful in identifying prostate cancer (esp high risk)
mix of T2-weighted, diffusion, dynamic studies
PI-RADS
prostate imaging reporting + data system
for standardisation
1 = most probably benign
1-5 score
5 = most probably malignant
3 = indeterminate
1-2: no need to bx