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34 Prostate

(Sarcomas and transitional cell carcinomas are not included.)

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SUMMARY OF CHANGES

• T2 lesions have been divided to include T2a, T2b, and T2c once again. These are the same subcategories found in the Fourth Edition of the AJCC Manual.

• Gleason score is emphasized as the grading system of choice and using the terms well differentiated, moderately differentiated, and poorly differentiated for grading is not recommended.

C61.9 Prostate gland

INTRODUCTION

Prostate cancer is the most common cancer in men, with increasing incidence in older age groups. Prostate cancer has a tendency to metastasize to bone.

Earlier detection is possible with a blood test, prostate-specific antigen (PSA), and diagnosis is generally made using transrectal ultrasound (TRUS) guided biopsy.

ANATOMY

Primary Site. Anatomy of the prostate is illustrated in Figure 34.1. Adenocar- cinoma of the prostate frequently arises within the peripheral zone of the gland, where it may be amenable to detection by digital rectal examination (DRE). A less common site of origin is the anteromedial prostate, the transition zone, which is remote from the rectal surface and is the site of origin of benign nodular hyperplasia. The central zone, which makes up most of the base of the prostate, seldom gives rise to cancer but is often invaded by the spread of large cancers.

Pathologically, cancers of the prostate are often multifocal.

There is agreement that the incidence of both clinical and latent carcinoma increases with age. However, this cancer is rarely diagnosed clinically in men under 40 years of age. There are substantial limitations in the ability of both DRE and TRUS to define precisely the size or local extent of disease; DRE is cur- rently the most common modality used to define the local stage. Heterogeneity within the T1c category resulting from inherent limitations of either DRE or imaging to quantify the cancer may be balanced by the inclusion of other prog- nostic factors, such as histologic grade, PSA level, and possibly extent of cancer on needle biopsies that contain cancer. Diagnosis of clinically suspicious areas of the prostate can be confirmed histologically by needle biopsy. Less commonly, prostate cancer may be diagnosed by inspection of the resected tissue from a transurethral resection of the prostate (TURP) for obstructive voiding symptoms.

The histologic grade of the prostate cancer is important for prognosis. The

histopathologic grading of these tumors can be complex because of the

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morphologic heterogeneity so often encountered in surgical specimens. Either a histologic or a pattern type of grading method can be used. The Gleason score for assessing the histologic pattern of prostate cancer is preferred.

Regional Lymph Nodes. The regional lymph nodes are the nodes of the true pelvis, which essentially are the pelvic nodes below the bifurcation of the common iliac arteries (Figure 34.2). They include the following groups:

Pelvic NOS Hypogastric Obturator

Iliac (internal, external, or NOS)

Sacral (lateral, presacral, promontory [Gerota’s], or NOS) Laterality does not affect the “N” classification.

C61.9

FIGURE 34.1. Anatomy of the prostate.

C77.5

FIGURE 34.2. Shaded area represents regional distribution of lymph nodes.

Nonshaded area indicates nodes outside of regional distribution.

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Distant Lymph Nodes. Distant lymph nodes lie outside the confines of the true pelvis. They can be imaged using ultrasound, computed tomography, mag- netic resonance imaging, or lymphangiography. Although enlarged lymph nodes can occasionally be visualized, because of a stage migration associated with PSA screening, very few patients will be found to have nodal disease, so false- positive and false-negative results are common when imaging tests are employed. In lieu of imaging, risk tables are generally used to determine indi- vidual patient risk of nodal involvement. Involvement of distant lymph nodes is classified as M1a. The distant lymph nodes include:

Aortic (para-aortic lumbar) Common iliac

Inguinal, deep

Superficial inguinal (femoral) Supraclavicular

Cervical Scalene

Retroperitoneal, NOS

The significance of regional lymph node metastasis, pN, in staging prostate cancer lies in the presence of metastatic foci within the lymph nodes.

Metastatic Sites. Osteoblastic metastases are the most common non-nodal site of prostate cancer metastasis. In addition, this tumor frequently spreads to distant lymph nodes. Lung and liver metastases are usually identified late in the course of the disease.

DEFINITIONS Primary Tumor (T) Clinical

TX Primary tumor cannot be assessed T0 No evidence of primary tumor

T1 Clinically inapparent tumor neither palpable nor visible by imaging T1a Tumor incidental histologic finding in 5% or less of tissue resected

(Figure 34.3)

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T1a T1b

£5% >5%

FIGURE 34.3. T1a (left) shows tumor incidental histologic finding in 5% or less of

tissue resected. T1b (right) shows tumor incidental histologic finding in more than

5% of tissue resected.

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T1b Tumor incidental histologic finding in more than 5% of tissue resected (Figure 34.3)

T1c Tumor identified by needle biopsy (e.g., because of elevated PSA) T2 Tumor confined within prostate

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T2a Tumor involves one-half of one lobe or less (Figure 34.4)

T2b Tumor involves more than one-half of one lobe but not both lobes (Figure 34.4)

T2c Tumor involves both lobes (Figure 34.5) T3 Tumor extends through the prostate capsule

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T3a Extracapsular extension (unilateral or bilateral) (Figures 34.6A, B) T3b Tumor invades seminal vesicle(s) (Figure 34.7)

T2a T2b

FIGURE 34.4. T2a (left) shows tumor involving one-half of one lobe or less whereas T2b (right) shows tumor involving more than one-half of one lobe but not both lobes.

T2c

FIGURE 34.5. T2c tumor involving both lobes

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T4 Tumor is fixed or invades adjacent structures other than seminal vesicles:

bladder neck, external sphincter, rectum, levator muscles, and/or pelvic wall (Figures 34.8A, B)

Pathologic (pT)

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pT2 Organ confined

pT2a Unilateral, one-half of one lobe or less

pT2b Unilateral, involving more than one-half of lobe but not both lobes pT2c Bilateral disease

pT3 Extraprostatic extension pT3a Extraprostatic extension

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pT3b Seminal vesicle invasion pT4 Invasion of bladder, rectum

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T3a

A

T3a

B

FIGURE 34.6. A,B. T3a is defined as a tumor with unilateral extracapsular extension, as shown in A, or with bilateral extracapsular extension, as shown in B.

T3b

FIGURE 34.7. T3b tumor invading seminal vesicle(s).

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T4

A T4

Tumor is fixed

B

FIGURE 34.8. A. T4 tumor invading adjacent structures other than seminal vesicles

such as bladder neck, as shown here, external sphincter, rectum, levator muscles,

and/or pelvic wall or tumor is fixed. B. T4 showing tumor fixed to adjacent

structures.

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N1

A

N1

B

FIGURE 34.9. A. N1 metastasis in regional lymph nodes, here shown unilaterally.

B. N1 metastasis in regional lymph nodes, here shown bilaterally.

Regional Lymph Nodes (N) Clinical

NX Regional lymph nodes were not assessed N0 No regional lymph node metastasis

N1 Metastasis in regional lymph node(s) (Figures 34.9A, B)

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Regional Lymph Nodes (N) Pathologic

pNX Regional nodes not sampled pN0 No positive regional nodes pN1 Metastases in regional node(s) Distant Metastasis (M)

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MX Distant metastasis cannot be assessed (not evaluated by any modality) M0 No distant metastasis

M1 Distant metastasis

M1a Nonregional lymph node(s) M1b Bone(s)

M1c Other site(s) with or without bone disease

STAGE GROUPING

I T1a N0 M0 G1

II T1a N0 M0 G2,3–4

T1b N0 M0 Any G

T1c N0 M0 Any G

T1 N0 M0 Any G

T2 N0 M0 Any G

III T3 N0 M0 Any G

IV T4 N0 M0 Any G

Any T N1 M0 Any G

Any T Any N M1 Any G

HISTOLOGIC GRADE (G)

Gleason score is considered to be the optimal method of grading, because this method takes into account the inherent heterogeneity of prostate cancer, and because it has been clearly shown that this method is of great prognostic value.

A primary and secondary pattern (the range of each is 1–5) are assigned and then summed to yield a total score. Scores of 2–10 are thus possible. (If a single focus of disease is seen, it should be reported as both scores. For example, if a single focus of Gleason 3 disease is seen, it is reported as 3 + 3).

GX Grade cannot be assessed

G1 Well differentiated (slight anaplasia) (Gleason 2–4)

G2 Moderately differentiated (moderate anaplasia) (Gleason 5–6) G3–4 Poorly differentiated/undifferentiated (marked anaplasia) (Gleason

7–10)

NOTES

1. Tumor found in one or both lobes by needle biopsy, but not palpable or reliably visible by imaging, is classified as T1c.

2. Invasion into the prostatic apex or into (but not beyond) the prostatic capsule is classified not as T3, but as T2.

3. There is no pathologic T1 classification.

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4. Positive surgical margin should be indicated by an R1 descriptor (residual micro- scopic disease).

5. When more than one site of metastasis is present, the most advanced category is used. pM1c is most advanced.

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