Benign and precancerous processes
Non-malignant and pre-tumor changes include specific forms of epithelial hyperplasia and dysplasia.
Basal cell hyperplasia This is a rare variant of benign prostatic hyperplasia (BPH). The process is localized predominantly in the transition and peripheral zones. The clinical picture is completely identical to classic BPH. Microscopically, the parenchyma of the nodules consists of solid nests and cords built from monomorphic dark basal-type cells. A relatively high nuclear-cytoplasmic ratio is noted. Differential diagnosis must be performed with classic BPH, cancer, and PIN.
Prostatic intraepithelial neoplasia (PIN) PIN (synonyms: atypical primary hyperplasia, ductal-acinar dysplasia) is a focal proliferative process in the lining of the acini. It is accompanied by progressive atypia and polymorphism of secretory-luminal type cells. Two forms of PIN are distinguished:
- Low-grade: early or mild dysplasia.
- High-grade: moderate or severe dysplasia, as well as carcinoma in situ.
PIN is most frequently detected in patients over 60 years of age and is asymptomatic. High-grade PIN is an obligate precancerous condition — it is believed that the disease results in the development of cancer in 100% of cases.
Prostate cancer: etiology and statistics
Prostate cancer (PCa) is diagnosed predominantly in elderly and senile age groups. In the early stages, the tumor develops latently and is hormone-sensitive in the majority of patients.
Risk factors and etiology:
- Genetics: chromosomal aberration 1q24–25 (characteristic of familial forms).
- Hormones: the concentration of testosterone, dihydrotestosterone, and androstenedione increases within the cancer tissue itself, while the estrone/androsterone ratio increases in the urine. Important: serum androgen levels have no diagnostic value.
- Environment: exposure to radiation, cadmium, contact with components of the textile and rubber industries.
- Viruses: the role of HSV, cytomegalovirus, and RNA-containing viruses is being discussed.
Patient distribution at the time of diagnosis:
- 10% — microscopic nature (incidental finding in biopsy specimens).
- 30% — clinically detectable tumor volume.
- 50% — involvement of the majority of the organ and regional lymph node metastases.
- 10% — invasive tumor with distant metastases.
Clinical presentation, diagnosis, and morphology of PCa
Symptoms appear in late stages and include increasing pelvic pain, hematuria, as well as compression of the bladder neck and rectum. With progression, hematogenous metastases to the skeleton and invasion into pelvic organs are possible (e.g., small cell prostate cancer can grow into the urinary bladder, causing obstruction of the vesicoureteral junction and left-sided hydroureter).
Diagnostic triad:
- Digital rectal examination (DRE).
- Transrectal ultrasound (TRUS).
- Blood test for PSA (prostate-specific antigen). Pathological values are considered to be: a relative amount of free PSA less than 25% and a free-to-total PSA ratio less than 0.15.
The gold standard of diagnosis remains histological examination of material obtained via multifocal core needle biopsy or prostatectomy. Macroscopically, cancer appears as multiple dense yellow-white nodules located beneath the capsule and in the periphery of the gland. Microscopically, adenocarcinoma (complexes of atypical glands) is most frequently detected.
Interventional treatment: arterial embolization
Prostatic artery embolization is used as a minimally invasive treatment for an enlarged prostate (nodular formations in the central zone protruding into the bladder neck).
inferior vesical artery
For basic prostate cancer screening, remember the "Rule of Three": Finger (rectal examination), Probe (TRUS), and Blood (assessment of PSA fractions).
Class and exam questions
Does it make sense to determine serum androgen levels for diagnosing prostate cancer?
No, serum androgen levels have no diagnostic value. However, the concentration of testosterone and dihydrotestosterone increases within the cancer tissue itself.
What is the prognosis when high-grade PIN is detected?
High-grade PIN is considered an obligate precancerous condition. According to statistics, this condition transforms into prostate cancer in 100% of cases over time.
What PSA changes indicate a high probability of a malignant process?
Suspicious findings include a decrease in the proportion of free PSA (less than 25%) and a drop in the free-to-total PSA ratio (usually less than 0.15).
What does prostate cancer look like macroscopically?
The tumor is represented by multiple dense yellow-white nodules, which are most frequently localized in the periphery of the gland and directly beneath its capsule.
What else to study on this topic
- Morphological differences between basal cell hyperplasia and adenocarcinoma
- Mechanisms of formation and clinical significance of PIN
- Radiation anatomy of the pelvis during prostatic artery embolization
- Complications of invasive cancer: invasion into the vesicoureteral junction
- Histological picture of prostate adenocarcinoma
Master the entire topic in the "Propaedeutics" course
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Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.