Urothelial Carcinoma of Prostate



Urothelial Carcinoma of Prostate


Gladell P. Paner, MD

Mahul B. Amin, MD





Key Facts


Terminology



  • UroCa involving prostate arising from prostatic urethra, periurethral glands, and proximal prostatic ducts


  • Clinicopathologically distinct from bladder UroCa transmurally invading through bladder wall and extending into prostate (pT4 bladder cancer)


Clinical Issues



  • Primary prostate UroCa is uncommon, comprising 1-4% of prostate cancers in adults


  • Prostate involvement in cystoprostatectomy for invasive bladder UroCa is relatively more common, ranging from 12-58%


  • Similar in age distribution to bladder UroCa


  • Most primary prostatic UroCa presents with obstructive urinary symptoms


  • Disease specific survival higher in CIS of prostatic urethral glands, ducts, and acini vs. urethral submucosal and prostatic stromal invasion


  • Prostatic stromal invasion associated with higher incidence of nodal metastasis


  • Survival rate poorer for bladder UroCa transmurally invading through bladder wall and extending into prostate (pT4 bladder cancer) vs. with prostatic stromal invasion arising intraurethrally


Microscopic Pathology



  • Diagnostic criteria identical to those of bladder UroCa


  • CIS can spread from prostatic urethra, involves ducts and acini, or grows along ejaculatory duct to seminal vesicle


  • Stromal invasion may arise anywhere along this spread







UroCa is shown involving prostatic ducts and acini. Preexisting acini are expanded and completely filled by UroCa. Stromal invasion may arise anywhere along prostatic urethra to the acini.






UroCa is shown involving prostatic ducts without stromal invasion. The outlines of the glands are smooth. Invasion of stroma should be recognized using strict criteria as it is of prognostic importance.


TERMINOLOGY


Abbreviations



  • Urothelial carcinoma (UroCa)


  • Carcinoma in situ (CIS)


Synonyms



  • Intraepithelial carcinoma of periurethral glands and prostatic ducts


  • Periurethral prostatic duct carcinoma


Definitions



  • UroCa involving prostate arising from prostatic urethra, periurethral glands, and proximal prostatic ducts


  • Clinicopathologically distinct from bladder UroCa transmurally invading through bladder wall and extending into prostate (pT4 bladder UroCa)


ETIOLOGY/PATHOGENESIS


Origin



  • Urothelium in periurethral mucosal and submucosal glands &/or junction with prostatic ducts



    • In strict terms, UroCa arising from these sites is true primary prostatic UroCa


  • Prostatic urethral urothelium



    • Frequently coexists with primary prostatic UroCa


CLINICAL ISSUES


Epidemiology



  • Incidence



    • Primary prostate UroCa is uncommon, comprising 1-4% of prostate cancers in adults



      • 64% have concomitant bladder urothelial CIS


      • 24% have no prior or concurrent invasive or in situ bladder UroCa


    • Prostatic involvement in cystoprostatectomy for bladder UroCa is relatively more common, ranging from 12-58%



      • UroCa extending from prostatic urethra and ducts comprises 76-87%


      • UroCa transmurally invading bladder wall into prostate (pT4 bladder UroCa) comprises 13-24%


  • Age



    • Similar in age distribution to bladder UroCa


    • Mean: 66 years, range: 52-87 years


Presentation



  • More commonly detected in cystoprostatectomies for UroCa of bladder


  • Most primary prostatic UroCa present with obstructive urinary symptoms, such as hesitancy, slowed stream, frequency, and dysuria



    • May have rapid progression of obstruction, usually < 6 months


  • Other symptoms include hematuria, prostatism, weight loss, and rectal pain


  • Prostate may be large on rectal examination, and may be mistaken clinically as benign prostatic hyperplasia, prostatitis, or prostate cancer


  • Symptomatic cases more often encountered in transurethral resection of prostate (TURP) specimens performed for obstructive symptoms


Laboratory Tests



  • Serum PSA level typically not elevated



    • However, 1 study showed 78% of prostate UroCa detected by needle biopsy had elevated serum PSA levels



      • Although this high percentage is perhaps reflective of specimen type performed for elevated PSA, which may or may not be due to UroCa


  • May have elevated serum alkaline phosphatase level, due to bone metastasis


Treatment



  • Depends on extent, location, and stage of disease




    • In patients presenting with limited disease in TUR specimens



      • Prostatic urethral UroCa with minimal or superficial prostatic acinar involvement without stromal involvement may be treated with bacillus Calmette-Guérin (BCG)


      • Cystoscopy should be performed to determine presence of bladder neoplasia


      • 1 study reported 87% complete response rate for BCG, but only 17% of these had prostatic acinar involvement and none had stromal invasion


    • For cases involving prostatic stroma and peripheral zone



      • Radical cystoprostatectomy is treatment of choice


      • Chemotherapy and radiotherapy may have role


Prognosis



  • Depends on extent, location, and stage of disease


  • Primary prostatic UroCa with no invasive bladder UroCa



    • Disease-specific survival higher in CIS of prostatic urethra and involvement of prostatic ducts and acini vs. UroCa involving suburethral glands or prostatic stroma


    • 5-year disease-specific survival



      • Prostatic urethral CIS and CIS involving prostatic ducts and acini without stromal invasion (100%)


      • Prostatic stromal invasion (45%)


      • Extraprostatic extension (0%)


      • Lymph node extension (30%)


      • Prostate primary UroCa overall (52%)


    • Concurrent prostate adenocarcinoma seen in 8%


    • Subsequent UroCa of upper urinary tract seen in 6%


    • Metastases most commonly occur in bone, lung, and liver


  • Prostate UroCa in patients with invasive bladder UroCa



    • Bladder UroCa with no prostatic involvement vs. with involvement



      • Bladder UroCa patients without prostatic involvement 5-year survival rate: 64%


      • Bladder UroCa patients with either prostatic CIS and urethral lamina propria invasion 5-year survival rate: 44%


      • Bladder UroCa patients with prostatic stromal/periprostatic/seminal vesical invasion 5-year survival rate: 32%


    • Bladder UroCa patients with prostatic urethral UroCa involving prostatic stroma vs. pT4 bladder UroCa



      • Prostate involvement by UroCa from urethra 5- year overall survival: 43-64%


      • pT4 bladder UroCa 5-year overall survival: 22-25%


    • Bladder UroCa patients with prostatic urethral UroCa, noninvasive (involving ducts and acini only) vs. invasive (involving prostatic stroma)



      • Survival rates similar for prostatic urethral and noninvasive prostatic urethral UroCa


      • Prostatic stromal invasion associated with higher incidence of nodal metastasis and worse survival


      • Noninvasive UroCa 5-year overall survival rate: 49%


      • Stromal invasive UroCa 5-year overall survival rate: 25%


    • Prostate involvement decreases survival of bladder cancer, which varies according to primary stage of bladder cancer


    • Age, degree of prostate invasion, and lymph node involvement are independent prognostic variables

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Jul 7, 2016 | Posted by in PATHOLOGY & LABORATORY MEDICINE | Comments Off on Urothelial Carcinoma of Prostate

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