Sunteți pe pagina 1din 66

PROSTAT

dr. Delyuzar Sp.PA


Prostate Gland
• The prostate is a walnut-sized gland that forms part of the male
reproductive system.

• The prostate is located in front of the rectum and just below the
bladder (where urine is stored).

• The prostate also surrounds the urethra (the canal through


which urine passes out of the body).

• Scientists do not know all the prostate's functions.


One of its main roles, though, is to squeeze fluid into the
urethra as sperm move through during sexual climax.
This fluid, which helps
- make up semen
- energizes the sperm
- makes the vaginal canal less acidic.
Prostate Gland…

• Divide into several regions:


– Peripheral zone
– Central zone
– Transitional zone
– Periurethral zone
Microscopic feature of prostate
• Stroma: Abundant and continuous with the gland capsule, it
constitutes one third to one fourth of the gland volume and is
composed of fibroelastic connective tissue intermixed with smooth
muscle fibers. Glands are embedded in the stroma.

• Tubuloalveolar glands: Irregular, large lumen, widely spaced tubules


with alveolar extensions, which vary greatly in shape and size.
Epithelial lining in tissue sections is simple cuboidal to columnar in
shape, depending upon physiological state.

• Prostatic concretions: Corpora amylacea, acidophilic condensed


secretions of prostatic glands. They may be lamellated and increase
in number with advancing age. Source of prostatic calculi.
Normal prostate
Benign Prostate Hyperplasia
• Hyperplasia = Benign = (Redundant & Misnomer)

• BPH is characterized by proliferation of both epithelial and stromal


elements

• BPH rarely causes symptoms before age 40, but more than half of
men in their sixties and as many as 90 percent in their seventies and
eighties have some symptoms of BPH
(prostate enlargement is as common a part of aging as gray hair)
Benign Prostate Hyperplasia

MORPHOLOGY…
Macroscopic features of BPH
• BPH arises most commonly in the inner, periurethral glands of the
prostate

• The affected prostate is enlarged (>300g in severe cases)

• The cut surface contains multiple, fairly well circumscribed nodules,


which bulge from the cut surface

• The nodules may have a solid appearance, or they may contain cystic
spaces (the latter corresponding to dilated glandular elements seen
in histologic sections)
• The urethra is usually compressed by the hyperplastic nodules
Normal prostate and benign prostatic hyperplasia (BPH).
- A normal prostate does not block the flow of urine from the bladder.
- An enlarged prostate presses on the bladder and urethra and blocks the flow of
urine.
Prostate hyperplasia

Severe prostatic hyperplasia (arrows) with bladder neck obstruction


and bladder calculi. Note the 4 bladder stones.
The prostate is on the bottom, and the bladder, with its front opened, is on top.
You can see the enlarged central lobe of the prostate gland protruding into the bladder cavity.
The prostate gland obstructed outflow from the bladder, forcing the bladder wall to become
thicker and stronger
Microscopic features of BPH
• Proliferation of glands.
• Hyperplastic stromal muscle
• Glands larger than normal
• Papillary ingrowth.
Prostate hyperplasia
www.pathguy.com

BPH

Notice the large number


of complex, infolded
glands
Notice that its epithelium is
infolded. Even within the
glands, the cells are too
numerous
BPH, micro, HP.
A tin rim of connective tissue (not very obvious) separates the 2
glands; hence the glands are not truly back to back.
ETIOLOGY
• Still not known
• Hypothetically: Induced by testosterone
dihydrotestosterone derived from testosterone

through the action of 5α-reductase and its metabolite (3α-


androstanediol) appear to be the major hormonal stimuli
for glandular and stromal proliferation

DHT binds to nuclear receptor and stimulates synthesis of


DNA, RNA, growth factor and other cytoplasmic protein 
HYPERPLASIA
increasing need dribbling at the end
difficulty with
to urinate of urination
starting to urinate
during the night

difficulty maintaining
Feeling need
a constant flow
to urinate frequently
of urine

SYMPTOMS
urinary tract
infections urgency to urinate

not being able


blood in urine to empty bladder overflow incontinence
completely
DIAGNOSIS
of
enlarged prostate

Digital rectal exam Urine test Blood test


To feel for To eliminate other to detect high
prostate diseases with levels of PSA
enlargement similar symptoms (prostate specific antigen)

IF ALL 3 Indicate prostate enlargement


POSITIVE Other tests may be required.
cancerinfo.tri-kobe.org

Digital rectal exam (DRE).


The doctor inserts a gloved, lubricated finger into the rectum and
feels the prostate to check for anything abnormal.
Diagnostic tests
for enlarged prostate

Prostate biopsy Non biopsy

Needle biopsy via perineum Intravenous pyelogram


Needle biopsy via rectum Urinary flow test
Cytoscopy Ultrasound
Volume test
cancerinfo.tri-kobe.org
COMPLICATIONS

• Complications of Benign Prostate Hyperplasia are


secondary conditions, symptoms, or other disorders
that are caused by Benign Prostate Hyperplasia.

• In many cases the distinction between symptoms of


Benign Prostate Hyperplasia and complications of
Benign Prostate Hyperplasia is unclear or arbitrary.
1.Bladder obstruction
• Voiding (obstructive) symptoms = (intermittent flow,
hesitancy before urinating)
• Storage (irritative) symptoms = (urgency, frequency,
urination at night).
• Acute Urinary Retention – Can’t urinate at all. It is a
dangerous complication that can damage the kidneys and
may require emergency surgery.

2. Prostate cancer
• current evidence indicates that there is no link between hypertrophy
prostate with cancer.
• The two conditions develop in different parts of the prostate:
– BPH occurs in the inner transition zone
– While cancer tends to develop in the peripheral outer zone.
The list of other complications :

• Acute urinary retention


• Urinary blockage (Lack of urine)
• Hydronephrosis
• Urinary tract infections
• Cystitis
• Kidney damage
• Pyelonephritis
• Bladder damage (Bladder symptoms)
• Bladder diverticula
• Bladder stones
• Urinary stones
• Urinary incontinence
Treatment for prostate hyperplasia
Medical :
- alpha-adrenergic blockers
=relaxing the smooth muscle of the prostate and bladder neck to improve urine flow
- 5-Alpha reductase inhibitors
(finasteride and dutasteride, once a day)
=inhibit production of the hormone DHT
Surgical :
- Transurethral resection of the prostate (TURP)
- Prostatectomy
- Transurethral incision of the prostate (TUIP)
Thermal treatment (minimally invasive) :
- Interstitial Laser Coagulation
- Photoselective vaporization of the prostate (PVP)
- HoLAP (holmium laser ablation of the prostate)
Alternative :
Nutrition, suplement, herbal medicine.
Carcinoma Prostat
EPIDEMIOLOGI
• Tahun 2000 terbanyak ke-6
• 9,7% kasus kanker pada pria
15,3% pada negara maju
4,3% negara sedang berkembang.
• Ca prostat 5,6% mortalitas kanker pria
3,2% dari keseluruhan angka mortalitas
akibat kanker.
• Tingkat fatalitasnya rendah
EPIDEMIOLOGI

• Insidensi tertinggi USA dan negara Eropa


Barat : ras kulit hitam dan Afrika.
• 1 diantara 6 pria
• Insidensi rendah pada penduduk Asia
2-10 per 100.000 pria
Faktor Migrasi
• Migran dari negara resiko rendah
ke negara resiko tinggi
menunjukkan kenaikan insidens.
• Misalnya orang Jepang (negara
resiko rendah) migrasi ke USA
insidens Ca prostat
Distribusi usia
• Resiko Ca prostat meningkat seiring
dengan usia.
• Jarang dijumpai pada pria < 40 thn.
• Sekitar 3/4 kasus Ca prostat terjadi
pada pria berusia > 65 tahun.
• Usia 60-70 tahun, 64% pria.
• Usia >> 80 tahun, 70-80%
pria.
ETIOLOGI

Kombinasi antara susceptibilitas gen dengan


faktor lingkungan.
FAKTOR RESIKO KANKER PROSTAT
• Umur
• Hormonal
Testosteron dan Estrogen

enzim 5-alpha
Testosteron reductase type II DHT

Berikatan dengan DNA Berikatan dengan AR


dalam nukleus
• Pria yang telah dikastrasi & yang tingkat
testosteron rendah sebelum pubertas tidak
pernah menderita Ca prostat.

• Pria dengan jumlah reseptor androgen (AR)


CAG yang rendah
resiko Ca prostat
Diet dan Gaya Hidup
• Tinggi lemak hewani dan daging
• Rendahnya konsumsi buah-buahan dan
sayuran
• Antioksidan carotenoid lycopene tomat,
vitamin E, produk susu, Calcium, vit D dan
Selenium akan mengurangi resiko kanker
prostat.
• Phytoestrogen kedelai
RIWAYAT KELUARGA
• Riwayat ayah atau saudara laik-laki dengan
Ca prostat resiko
• X- linked resesif inheritance
• Dalam penelitian faktor resiko kanker dari
44.788 pasangan kembar di Swedia, Denmark
dan Finlandia, 42% kasus Ca prostat berkaitan
dengan faktor keturunan.
RIWAYAT KELUARGA
• Keluarga Ca mammae atau ovarium
mempunyai resiko lebih tinggi untuk Ca
prostat.
• Mutasi BRCA1 atau 2 pada pria dengan kanker
prostat (+)
LOKASI ANATOMIS

• Bagian posterior atau posterolateral dari


prostat teraba DRE , needle biopsy
• Tumor zona transisi yang besar TURP
• Jarang berasal dari zona tengah.
GEJALA KLINIS
• Sering asimptomatik

Tahap lanjut :
• Nyeri pelvis
• Sering buang air kecil
• Nyeri saat buang air kecil
• Buang air kecil berdarah
• Nyeri saat ejakulasi
• Hilangnya nafsu makan dan BB
• Nyeri tulang
• Pembesaran KGB terutama pelvis
PATOLOGI
• Lesi dini massa berbatas tak
tegas tepat dibawah kapsul
prostat.
• Pada potongan permukaan,
fokus karsinoma tampak
sebagai lesi keras, berwarna
putih keabuan hingga kuning
yang berinfiltrasi ke kelenjar
terdekat dengan batas tak
jelas.
Mikroskopis

• Umumnya adenokarsinoma (90%)


• Lesi berdiferensiasi baik terdiri dari kelenjar kecil
yang menginfiltrasi stroma terdekat dengan model
ireguler dan tak menentu.
• Kelenjar neoplastik dilapisi oleh selapis sel kuboidal
dengan nucleoli prominen.
• Lapisan sel basal hilang.
• Dengan bertambahnya derajat anaplasia , akan
tampak struktur kelenjar yang irregular dan tak rata
disertai struktur epitel papilari atau cribiformis.
Gambaran intraluminal
1. Kristaloid prostat.
 Struktur kristal-like yang padat eosinofilik
 Bentuk geometris : segi empat, hexagonal,
segitiga, atau seperti batang.
 Tidak diagnostik untuk Ca
 Kristaloid lebih sering tampak pada Ca daripada pada
kelenjar benigna.
 Sering juga pada adenosis (atipikal hyperplasia
adenomatosa).

2. Blue-tinged mucinous secretion


3. Pink intraluminal secretion
Numerous eosinophilic crystalloids are seen in this
focus.
Note the irregular shape of the glands and
presence of intraluminal basophilic secretion.
Crystalloids may also been seen in metastatic The contrast with the non-neoplastic glands
deposits of prostatic adenocarcinoma. When the present in the field is obvious
primary site is unknown, the presence of crystalloids
in metastases is strong evidence of prostatic origin.
Corpora amylacea

• Struktur sekresi normal pada prostat


• Bulat / oval , circumscribe
• Batas tegas
• Cincin lamellar konsentris
• Lebih banyak dijumpai pada kelenjar benigna
• Sangat jarang dijumpai pada Ca prostat.
This benign gland contains corpora Well-differentiated prostatic
amylacea. Even at low magnification, adenocarcinoma showing
basal cells can be clearly seen. intraluminal crystalloids
GAMBARAN SPESIFIK PADA PROSES
MALIGNAN PROSTAT

Ada 3 gambaran yang bila ditemukan pasti


menunjukkan dx/ Ca pada prostat , yaitu:

1. Invasi perineural
 Indentasi perineural yang melibatkan
keseluruhan lingkar ruang perineural
 Bukan hanya pada satu tepi dari saraf.
2. Mucinous fibroplasia (mikronodul kolagen)
Jaringan fibrous longgar /kolagen yang sangat
halus dengan pertumbuhan fibroblast ke dalam.
Kadang tampak seperti musin intraluminal.

3. Glomerulasi
Proliferasi kelenjar cribriform yang bukan
transluminal.
Formasi cribriform ini melekat hanya pada satu tepi
kelenjar menghasilkan struktur yang
menyerupai glomerulus.
Variasi gambaran histologis dari
kanker prostat :
Atrophic variant
Pseudohyperplastic variant
Foamy gland variant
Colloid & signet ring variant
Oncocytic variant
Lymphoepithelioma-like variant
Sarcomatoid variant (carcinosarcoma)
glom

In this prostate biopsy,


malignant glands are seen Prominent cytoplasmic vacuolation in prostatic
surrounded by adipose tissue. carcinoma as a result of hormonal treatment. The
This is an example of vacuolization is also present in the area of perineural
extraprostatic extension (EPE). invasion
PROSTATIC INTRAEPITHELIAL NEOPLASIA
(PIN)

• Kelenjar yang mempunyai fokus epitel atipia.


• PIN : high grade dan low grade.
• PIN diperkirakan merupakan lesi prakanker
prostat, yang muncul pada pria pada usia 20
tahunan.
• Sekitar 50% pria mempunyai PIN pada saat
mereka mencapai usia 50 tahun.
Low-grade prostatic intraepithelial neoplasia (PIN I).
KLASIFIKASI

• Sistem TNM yang telah direvisi (2002)


• Gleason Grading System
• AJCC (American Joint Committee on Cancer)
stage groupings
ASPEK BIOMOLEKULER KANKER PROSTAT

• HPC 1 (Hereditary Prostat Cancer 1)


• PSA / PAP
• Low molecular weight keratin, Leu7, EMA,
CEA, B72.3, cathepsin D, dan Gastricsin.
• 34B E12 (Cytokeratin-903)  (-)
•  -Methyl-CoA racemase (AMACR) Androgen
receptor (AR)
Lack of basal cells around the
Basal cells are present in a continuous neoplastic acini, as evidenced by
layer in most benign glands. The immunostaining for high-
antibodies to high molecular weight molecular-weight keratin. The few
cytokeratin 34bE12 stain basal cells residual non-neoplastic glands
but not secretory or stromal cells in provide an internal control.
the prostate. Besides cancer, the basal
cell layer may be disrupted in atrophy,
inflammation, atypical adenomatous
hyperplasia (adenosis), and high-
grade PIN.
TEST LABORATORIUM

PSA dikatakan meningkat Usia Level PSA


bila berada diatas cutoff < 50 tahun < 2,5 ng/ml
4,0 ng/ml.
< 60 tahun < 3,5 ng/ml
< 70 tahun < 4,5 ng/ml
< 80 tahun < 6,5 ng/ml
METASTASIS
• Leher buli-buli
• Vesika seminalis
• Tulang :
pelvis
tulang vertebra lumbar
iga
tulang vertebra servikalis
femur
tulang tengkorak
sakrum dan
humerus.
This biopsy is completely replaced by
Gleason grade 4 adenocarcinoma. The
glands are fused and there is no intervening Gleason pattern 4. Most glands have occluded
stroma. Glandular fusion is a hallmark of lumens. The nuclei are hyperchromatic.
Gleason grade 4.

Mucinous adenocarcinoma of prostate. Most of


the mucin is located extracellularly
Acidic mucin is commonly found in the glands of
prostate cancer. It is seen as fine wisps of basophilic
material in the gland lumen.

Neuroendocrine cells are seen in benign


prostate, high-grade PIN, and cancer. In this
The focus of cancer is not circumscribed. The glands image, many neuroendocrine cells with large
are round to oval and uniformly placed. There are eosinophilic granules (Paneth cell-like
no sharply-angulated or distorted glands. change) are seen in atrophic prostate glands.
Gleason grade 3 is the most commonly seen
pattern. Even at low magnification, one can
Occasional glands in this example of Gleason easily appreciate the variation in size, shape,
grade 2 show angulated or distorted contours; and spacing of glands. Many small glands
however, the majority of the glands are relatively have occluded or abortive lumens. There is
uniform in size. no evidence of glandular fusion.
The large gland variant of Gleason
grade 3 (variant 3A) is not difficult
to distinguish from the small gland
This example of Gleason grade 3 cancer shows
variant (3B) and the cribriform
abundant amphophilic cytoplasm, enlarged nuclei
variant (3C). The three variants have
with prominent nucleoli.
similar cancer-specific death rates,
therefore their separation in a
pathology report is unnecessary.
The majority of the glands in this field
have occluded or small abortive lumens. Fused glands irregularly infiltrating
Many glands have sharply angulated fibrotic stroma. Gleason grade 4.
contours. Gleason grade 3 was assigned
to this biopsy.

S-ar putea să vă placă și