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
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.
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.
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
(1)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
(2)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
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)
(3)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
(4)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).
T4
A T4
Tumor is fixed
