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Presented by Lauren Schwartz, M.D. and prepared by Mohammed Lilo, M.D.
Case 3: A 71-year-old man underwent a TURP for urinary obstructive symptoms.
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Week 596: Case 3
A 71-year-old man underwent a TURP for urinary obstructive symptoms.images/D Nguyen/8-25-14/case 3/2X_2_450 pixels.jpg
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images/D Nguyen/8-25-14/case 3/2X_3_450 pixels.jpg
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images/D Nguyen/8-25-14/case 3/40X_450 pixels.jpgCorrect
Answer: Adenosis and basal cell carcinoma
Histology: One aspect of this case is a proliferation of small to medium sized glands that both have a lobular and diffuse growth pattern. These glands have in general straight luminal borders and very bland nuclei, lacking prominent nucleoli. In addition, there are fewer basaloid nests with multilayering of nuclei with in some of the nest an inner gland containing eosinophilic cytoplasm.
Discussion: This case is not typical for adenosis, where there are small crowded glands suspicious for carcinoma merging in with more recognizably benign glands with papillary infolding and branching. In this case, there is a uniform population of crowded glands with straight luminal borders which is a feature more seen with carcinoma than benign glands. However, the absence of cytological atypia given that there are so many glands available for examination, would be unusual for carcinoma. In this case, stains for high molecular weight cytokeratin and p63 showed patchy staining throughout the lesion ruling out carcinoma and verifying the diagnosis of adenosis.
Basal cell hyperplasia consists of either a proliferation of small glands with multilayered cells with scant cytoplasm or pseudocribriform glands consisting of back-to-back glands mimicking a cribriform gland. Basal cell carcinoma has a more variable appearance:
1) Variably small/medium-sized nests with irregular shapes with multilayered basal cells;
2) Adenoid cystic pattern;
3) Large basaloid nests with necrosis;
4) Anastomosing basaloid nests with central tubules lined by eosinophilic cells; or
5) Indistinguishable from basal cell hyperplasia, diagnosed by the presence of extension into periprostatic adipose tissue, seminal vesicles, or bladder neck muscle.Basal cell carcinomas tends to have more of a stromal response than basal cell hyperplasia. In this case the presence of the basaloid nests with tubules lined by cells with eosinophilic cytoplasm is diagnostic of basal cell carcinoma. In addition, stains were done for BCL2 which were diffusely positive in the basal cell carcinoma, which is typically not seen in basal cell hyperplasia. Ki-67 showed approximately 5-10% positivity which was more than the staining seen in basal cell hyperplasia. Only a small subset of basal cell carcinomas behaves aggressively with local recurrences and distant metastases, most commonly cases with large solid nests with central necrosis, high Ki-67 rate.
Incorrect
Answer: Adenosis and basal cell carcinoma
Histology: One aspect of this case is a proliferation of small to medium sized glands that both have a lobular and diffuse growth pattern. These glands have in general straight luminal borders and very bland nuclei, lacking prominent nucleoli. In addition, there are fewer basaloid nests with multilayering of nuclei with in some of the nest an inner gland containing eosinophilic cytoplasm.
Discussion: This case is not typical for adenosis, where there are small crowded glands suspicious for carcinoma merging in with more recognizably benign glands with papillary infolding and branching. In this case, there is a uniform population of crowded glands with straight luminal borders which is a feature more seen with carcinoma than benign glands. However, the absence of cytological atypia given that there are so many glands available for examination, would be unusual for carcinoma. In this case, stains for high molecular weight cytokeratin and p63 showed patchy staining throughout the lesion ruling out carcinoma and verifying the diagnosis of adenosis.
Basal cell hyperplasia consists of either a proliferation of small glands with multilayered cells with scant cytoplasm or pseudocribriform glands consisting of back-to-back glands mimicking a cribriform gland. Basal cell carcinoma has a more variable appearance:
1) Variably small/medium-sized nests with irregular shapes with multilayered basal cells;
2) Adenoid cystic pattern;
3) Large basaloid nests with necrosis;
4) Anastomosing basaloid nests with central tubules lined by eosinophilic cells; or
5) Indistinguishable from basal cell hyperplasia, diagnosed by the presence of extension into periprostatic adipose tissue, seminal vesicles, or bladder neck muscle.Basal cell carcinomas tends to have more of a stromal response than basal cell hyperplasia. In this case the presence of the basaloid nests with tubules lined by cells with eosinophilic cytoplasm is diagnostic of basal cell carcinoma. In addition, stains were done for BCL2 which were diffusely positive in the basal cell carcinoma, which is typically not seen in basal cell hyperplasia. Ki-67 showed approximately 5-10% positivity which was more than the staining seen in basal cell hyperplasia. Only a small subset of basal cell carcinomas behaves aggressively with local recurrences and distant metastases, most commonly cases with large solid nests with central necrosis, high Ki-67 rate.
