Older Male with Elevated Serum PSA

Specimen Type:

Prostate

History:

A 66-year-old male with an elevated serum PSA underwent prostate needle biopsies. The entire material was submitted.

Pathologic Features:

At low magnification, the majority of the glands have open dilated lumens and are lined by flattened attenuated epithelium (figure 1). At higher magnification, the cells have scant cytoplasm, nuclear enlargement and prominent nucleoli are present (figure 2). Immunostain for high molecular weight keratin (34βE12) reveals an absent basal cell layer in these acini (figure 3).

Differential Diagnosis:

  • Benign atrophic glands (figure 4)
  • Prostatic adenocarcinoma with atrophic features (figure 5)
  • Postatrophic hyperplasia (figure 6)

Diagnosis:

Prostatic adenocarcinoma with atrophic features

Key Features:

  • Rare, may be present on needle biopsy
  • Architecturally resembles atrophy or postatrophic hyperplasia
  • Usually NOT associated with hormone therapy
  • Diagnosis of carcinoma is made on:
    • a truly infiltrative process with individual small atrophic glands situated between larger benign glands;
    • the concomitant presence of ordinary less atrophic carcinoma; and
    • greater cytologic atypia than is seen in benign atrophy.
  • Atrophic features represent mean 25% of total tumor
  • Usually Gleason score 6-7, coexisting with typical Gleason score 5-7
  • Luminal eosinophilic proteinaceous secretions, blue mucin, crystalloids, apocrine blebs, collagenous micronodules, and high-grade prostatic intraepithelial neoplasia within two high-power fields can be observed

Table 1 compares postatrophic hyperplasia and prostatic adenocarcinoma with atrophic features.

References:

  1. Srigley JR. Benign mimickers of prostatic adenocarcinoma. Mod Pathol. 2004 Mar;17(3):328-48.
  2. Kaleem Z, Swanson PE, Vollmer RT, Humphrey PA. Prostatic adenocarcinoma with atrophic features: a study of 202 consecutive completely embedded radical prostatectomyspecimens. Am J Clin Pathol. 1998 Jun;109(6):695-703.
  3. Egan AJ, Lopez-Beltran A, Bostwick DG. Prostatic adenocarcinoma with atrophic features: malignancy mimicking a benign process. Am J Surg Pathol. 1997 Aug;21(8):931-5.
  4. Cheville JC, Bostwick DG. Postatrophic hyperplasia of the prostate. A histologic mimic of prostatic adenocarcinoma. Am J Surg Pathol. 1995 Sep;19(9):1068-76.