CK5, CK5/6, and double-stains CK7/CK5 and p53/CK5 discriminate in situ vs invasive urothelial cancer in the prostate

Characteristics and survival of primary urothelial carcinoma of the prostate: A multi-center retrospective study of 18 cases

OBJECTIVES

To explore the features, treatment, and outcomes of primary urothelial carcinoma of the prostate (PUCP) in a multicenter study.

METHODS

The clinical and imaging features, pathological findings, treatment, and outcomes of patients diagnosed with PUCP from January 2011 to April 2022 at three institutions were collected and analyzed. The Kaplan-Meier method and log-rank test were used to assess survival rates of the overall group and survival differences between groups according to TNM stage.

RESULTS

The study cohort comprised 18 patients with PUCP of mean age 72.4±7.8 years. Dysuria and urinary frequency were the most common symptoms (77.8 %). Sixteen (88.9 %) patients had normal serum total PSA concentrations. Most patients showed abnormalities on urinalysis. MRI was the most accurate diagnostic imaging method (88.9 %). As to immunohistochemistry findings, GATA-3 (81.8 %) and P63 (84.6 %) were positive in most examined patients; however, no lesions were positive for PSA. Three (17.6 %) patients with T1N0M0 and T2N0M0 tumors underwent radical cystectomy. Eleven (64.7 %) patients which almost all had T4 tumors received systematic therapy, most of them receiving chemotherapy with gemcitabine and cisplatin, and radiotherapy. The median overall survival was 42 months, and the median progression-free survival 25 months, the latter being significantly longer in patients with T1-2 than in those with T3-4 disease (p=0.035).

CONCLUSION

PUCP, a rare but highly aggressive type of prostate cancer, should be considered in men with abnormalities on MRI and normal serum PSA concentrations. Positive GATA-3, P63, and negative PSA are typical immunohistochemistry features. Radical cystectomy and systematic therapies can be effective.

Utility of D2-40, Cytokeratin 5/6, and High-Molecular-weight Cytokeratin (Clone 34βE12) in Distinguishing Intraductal Spread of Urothelial Carcinoma From Prostatic Stromal Invasion

Intraductal spread of urothelial carcinoma (UC) is not an uncommon finding in bladder cancer that requires appropriate clinical management. The presence of prostatic stromal invasion in non-muscle-invasive bladder cancer upstages the disease, necessitating cisplatin-based neoadjuvant chemotherapy and subsequent cystroprostatectomy. However, the identification of prostatic stromal invasion can be challenging, especially in biopsy and transurethral resection specimens. We assess the utility of D2-40, CK5/6, and high-molecular-weight cytokeratin (HMWCK) immunohistochemistry as an ancillary tool to differentiate prostatic stromal invasion from intraductal UC spread. We reviewed 13 cystoprostatectomies performed for UC with prostatic involvement. The presence of stromal invasion was histologically determined by the presence of circumferential retraction artifact, paradoxical differentiation, complex architecture, and desmoplastic reaction. The areas of interest were subsequently stained with D2-40, CK5/6, and HMWCK (clone 34βE12). Four bladder biopsies were used as a control to assess labeling in the benign urothelium. Nine cases had histologic evidence of prostatic stromal invasion (4 transmurally through bladder wall). D2-40 highlighted basal cells in all benign prostatic ducts and was consistently negative in UC, benign urothelium, prostatic adenocarcinoma, and benign luminal prostatic epithelium. D2-40 and CK5/6 performed similarly for intraductal UC, labeling only the basal cell layer with the exception of 1 case with squamous differentiation where CK5/6 exhibited full thickness staining. HMWCK diffusely stained 9 of 10 intraductal UCs without squamous differentiation and 1 intraductal UC with squamous differentiation. All 8 cases of invasive UC without squamous differentiation were negative for D2-40. Seven of these cases had focal CK5/6 and diffuse HMWCK staining. In 1 case of invasive UC with squamous differentiation, all stains were positive. D2-40 is expressed in prostatic basal cells, but it is not expressed in the benign or neoplastic urothelium. D2-40 and CK5/6 effectively highlight the intraductal spread of UC. While invasive UC is negative for D2-40, CK5/6 is usually patchy and localized to the periphery of the tumor nests. HMWCK often demonstrates diffuse staining in both scenarios. However, these stains do not perform well in cases of UC with squamous differentiation. Thus, D2-40 can be used as an ancillary tool to rule out prostatic stromal invasion.

Double cocktail immunostains with high molecular weight cytokeratin and GATA-3: useful stain to discriminate in situ involvement of prostatic ducts or acini from stromal invasion by urothelial carcinoma in the prostate

BACKGROUND

Distinguishing prostatic stromal invasion (PSI) by urothelial carcinoma (UC) from in situ UC involving prostatic ducts or acini with no stromal invasion (in situ involvement) may be challenging on hematoxylin and eosin stained sections. However, the distinction between them is important because cases with PSI show worse prognosis. This study was performed to assess the utility of double cocktail immunostains with high molecular weight cytokeratin (HMWCK) and GATA-3 to discriminate PSI by UC from in situ UC involvement of prostatic ducts or acini in the prostate.

METHODS

Among 117 radical cystoprostatectomy specimens for bladder UCs, 25 cases showed secondary involvement of bladder UC in prostatic ducts/acini only or associated stromal invasion and of these 25 cases, seven cases revealed equivocal PSI. In these seven cases with equivocal PSI, HMWCK, and GATA-3 double immunohistochemical stains were performed to identify whether this cocktail stain is useful to identify the stromal invasion.

RESULTS

In all cases, basal cells of prostate glands showed strong cytoplasmic staining for HMWCK and UC cells showed strong nuclear staining for GATA-3. In cases with stromal invasion of UC, GATA-3-positive tumor cells in the prostatic stroma without surrounding HMWCK-positive basal cells were highlighted and easily recognized. Among seven equivocal cases, two cases showed PSI and five in situ UC in the prostate. In two cases, the original diagnoses were revised.

CONCLUSIONS

Our study suggested that HMWCK and GATA-3 double stains could be utilized as an adjunct method in the distinction between PSI by UC from in situ UC involving prostatic ducts or acini.

Morphological and Immunohistochemical Biomarkers in Distinguishing Prostate Carcinoma and Urothelial Carcinoma: A Comprehensive Review

The differential diagnosis between high-grade prostate carcinoma and infiltrating urothelial carcinoma (UC) in transurethral resection prostate specimens as well as cystoprostatectomy specimens may often be challenging due to morphologic and clinical overlap of the 2 entities. Such distinction has critical therapeutic and staging consequences, yet it is hampered by both issues in morphology and by the low accuracy rates of single immunohistochemical markers, as reported in literature. This review aims to provide a comprehensive analysis of the available morphological and immunohistochemical parameters, which may allow to discriminate between prostate carcinoma and urothelial carcinoma in the proper clinical context and to discuss their diagnostic applications in daily practice.

Mucinous and secondary tumors of the prostate

Primary mucinous tumors and secondary tumors involving the prostate gland are relatively uncommon, however they have important diagnostic, therapeutic, and prognostic implications. The primary mucinous tumors of the prostate include mucinous (colloid) adenocarcinoma of the prostate, prostatic adenocarcinoma with mucinous features, and mucinous adenocarcinoma of the prostatic urethra (mucin-producing urothelial-type adenocarcinoma of the prostate). Mucinous adenocarcinoma of the prostate is defined as a primary prostatic acinar tumor characterized by the presence of at least 25% of the tumor composed of glands with extraluminal mucin. This diagnosis can only be made in radical prostatectomy specimens. Recent studies have shown that these tumors have a similar or in some cases better prognosis than conventional prostatic adenocarcinoma treated by radical prostatectomy. The preferred terminology for tumors that are composed of <25% extraluminal mucinous component in radical prostatectomy specimens is 'prostatic adenocarcinoma with mucinous features.' All cases of prostatic adenocarcinoma with extraluminal mucinous components in prostate needle core biopsies or transurethral resection of the prostate specimens are also referred to as 'prostatic adenocarcinoma with mucinous features.' Mucinous adenocarcinoma of the prostatic urethra (mucin-producing urothelial-type adenocarcinoma of the prostate) as the name implies, does not arise from prostatic acini or ducts, and is a distinct entity that arises from the prostatic urethra usually from urethritis glandularis or glandular metaplasia with malignant transformation, and is analogous to adenocarcinoma with mucinous differentiation arising from the urinary bladder. This tumor is aggressive and has a relatively poor prognosis. The most common secondary tumors that arise from adjacent organs and spread (direct extension or metastasis) to the prostate gland, include urothelial carcinoma of the bladder and colorectal adenocarcinoma. Other secondary tumors that may involve the prostate include metastatic epithelial tumors from several other sites, malignant melanoma and soft tissue tumors.

Lycopene Extracts from Different Tomato-Based Food Products Induce Apoptosis in Cultured Human Primary Prostate Cancer Cells and Regulate TP53, Bax and Bcl-2 Transcript Expression

Carotenoids are the main tomato components, especially lycopene. Lycopene is more bioavailable in tomato processed products than in raw tomatos, since formation of lycopene cis-isomers during food processing and storage may increase its biological activity. In the current study, we evaluated the influence of lycopene extracts (5 mg / mL) from different tomato-based food products (paste, sauce, extract and ketchup) on cell viability and apoptosis on primary human prostate cancer cells (PCa cels) for 96h. Using MTT assay, we observed a significant decrease on primary PCa cell viability upon treatment with lycopene extracted from either 4 tomato-based food products. Flow cytometeric analysis revealed that lycopene from tomato extract and tomato sauce promoted up to fifty-fold increase on the proportion of apoptotic cells, when compared to the control group. Using real time PCR assay, we found that lycopene promoted an upregulation of TP53 and Bax transcript expression and also downregulation of Bcl-2 expression in PCa cells. In conclusion, our data demostrate that cis-lycopene promoted a significant inhibition on primary PCa cell viability, as well as an increase on their apoptotic rates, evidencing that cis-lycopene contained in tomato sauce and extract cain mainly modulate of primary human prostate cancer cell survival.

Prostate cancer metastasis to the distal phalanx of the left hallux: The first confirmed case and literature review

Prostate cancer is one of the most common carcinomas in Asia, as well as all over the world. The vast majority of prostate cancer patients present with bone metastases, which mainly involve the axial bones, with pain as the most common symptom. The present study reports the first case of prostate cancer metastasis to the hallux in a 73-year-old man who presented with pain and a swollen phalanx of the left hallux. This symptom developed gradually over a period of several months and could not be improved with the common treatments. Due to a pathological fracture, amputation of the left phalanx was performed. Notably, the immunohistochemical examinations of the surgical sample demonstrated the presence of a metastatic lesion from prostate cancer. The present study describes an unusual presentation involving phalangeal metastasis in a prostate cancer patient, and a systematic review of reported cases of rare metastatic events in prostate cancer is also discussed.

Invasive urothelial carcinoma exhibiting basal cell immunohistochemical markers: A variant of urothelial carcinoma associated with aggressive features

We characterize invasive urothelial carcinoma (UC) exhibiting urothelial basal cell immunohistochemical markers. Consecutive invasive UCs were immunostained with CK20 and urothelial basal cell markers, cytokeratin 5 (CK5)/CD44. Immunostaining for CK5 and CD44 was scored as follows: positive for staining of more than 25% thickness of the epithelial nest or epithelium and low for lesser immunoreactivity. Invasive urothelial carcinoma (UC) exhibiting positive CK5/CD44 staining was designated as basal-like UC (BUC). In this study, of 251 invasive UC (pT1 in 57% and pT2-4 in 43%), BUC accounted for 40% of cases (accounting for most pT2-4 UC) and often presented as non-papillary UC without previous history of UC. In addition, BUC exhibited uniform nuclei with lesser degree of atypia than non BUC and decreased or negative cytokeratin 20 reactivity. Nested and microcystic variants of UC immunohistochemically stained as BUCs. Invasive non-BUCs were often papillary with marked cytologic atypia and pleomorphism, and accounted for most pT1 UC. The rates of perivesical invasion, lymph node and distant metastases were higher for BUC than non-BUC. All nine cases with absent/minimal residual in situ UC in 102 radical cystectomy specimens were from invasive non-BUC. BUC is distinguished from non-BUC due to this aggressive behavior, distinct immunohistochemical profile, and predominant non-papillary architecture. Our findings are consistent with recent studies identifying a subtype of muscle-invasive UC with molecular expression of basal cell and luminal cell molecular profiles. Our study further supports categorizing invasive UCs into these subtypes with different biological behaviors, possibly contributing to better therapeutic strategies.

Correlation analysis of nuclear morphology, cytokeratin and Ki-67 expression of urothelial carcinoma cells

We aimed to delineate the morphogenesis of aberrant nuclear features of urothelial carcinoma (UC) cells in association with cytokeratin (CK) expression patterns and cell proliferation activity. Correlation analysis of the nuclear area by morphometry and the expression patterns of CK5, CK20 and Ki-67 by triple immunofluorescence analysis was applied to 1699 cells from five low-grade and seven high-grade cases of UC. The majority of UC cells showed aberrant cellular differentiation represented by abnormal CK expression patterns of CK5+ / CK20+ (40.5%) or CK5- / CK20+ (56.0%). CK5+ / CK20- cells, a phenotype of cancer stem/progenitor cells, represented a very small population (1.9%) and showed a low proliferation activity. Ki-67+ cells showed a significantly different CK expression pattern compared with that of Ki-67(-) cells. The nuclear areas of CK5- / CK20+ cells (71.3 ± 25.9 μm2) were significantly larger than those of CK5+ / CK20+ cells (66.6 ± 25.5 μm2). Negativity for CK5 was related to the grade of UC and an increased number of CK5- / CK20+ / Ki-67+ cells was related to a higher malignant potential. We conclude the nuclear morphology is related to cell differentiation represented by CK expression and cell proliferative activity.

Challenges in the pathological reporting of urothelial carcinoma involving prostatic transurethral resection specimens within a single institution

AIM

Primary bladder urothelial carcinoma (UC) may involve the prostate with differing management depending on whether tumour is in situ or invades the prostatic subepithelium or fibromuscular stroma. We aim to understand challenges in reporting UC within prostate transurethral resection (TUR).

METHODS

A retrospective review from 2007 to 2010 identified prostate TUR performed for primary bladder UC.

RESULTS

25.1% of cystoprostatectomy patients (60/239) had a prior prostate TUR; 129 patients had a prostate TUR for UC and 50.4% (65/129) were given a neoplastic diagnosis. Prostatic fibromuscular stroma was present in 84.6% of cases, with a comparable rate among surgeons. Diagnostic concordance of UC versus a non-neoplastic diagnosis was 96.7%, with rare cases initially diagnosed as non-neoplastic having in situ UC on review. Of reports with invasive tumour, 19.4% did not specify extent of invasion (e.g., bladder muscularis propria, prostate fibromuscular stroma) and 13.9% had discordant extent of invasion on review. Terminology typically used for bladder (lamina propria/muscularis propria) was found in 23.1% of reports without explicit reference to the bladder or prostate.

CONCLUSION

This study reveals difficulties in reporting UC within prostatic TUR specimens. We recommend documenting tumour extent and referencing the organ of origin if ambiguous anatomical terms are used.