Prostate gland & seminal vesicles

Contributed by Alcino Pires Gama, M.D. and Bonnie Choy, M.D.

• Up to 90% of cases are positive for at least 1 neuroendocrine marker (Am J Surg Pathol 2006;30:705)
  • Synaptophysin
  • Chromogranin
  • CD56
  • INSM1
• TTF1 (positive in 50% of cases of SCNEC)
• Ki67: up to 90% in SCNEC and up to 50% in LCNEC
• p53: nuclear staining in most SCNEC
• Pankeratin: may be positive in a dot-like cytoplasmic pattern

A 56 year old man with a medical history of prostatic adenocarcinoma (Gleason score 8 [4+4], grade group 4) treated with antiandrogen receptors presents with recurrence of urinary symptoms. A prostate transurethral resection is performed (see H&E and synaptophysin images above). Which of the following statements is true?

1. Prostatic small cell neuroendocrine carcinomas are typically negative for TTF1
2. Treatment related neuroendocrine prostatic carcinoma is usually positive for androgen receptors
3. Treatment related neuroendocrine prostatic carcinoma with pure neuroendocrine component carries a worse prognosis than ones with conventional acinar adenocarcinoma component
4. Tumor should be graded as Gleason score 10 (5+5), grade group 5

C. Treatment related neuroendocrine prostatic carcinoma (tNEPC) with pure neuroendocrine component carries a worse prognosis than ones with a conventional acinar adenocarcinoma component. Tumors with pure small cell neuroendocrine carcinoma (SCNEC) or large cell neuroendocrine carcinoma (LCNEC) morphology have a worse overall survival than those presenting with a conventional adenocarcinoma component. Answer D is incorrect because the neuroendocrine component should not be given a Gleason score. Answer A is incorrect because TTF1 is positive in up to 50% of prostatic SCNECs. Answer B is incorrect because tNEPCs are typically negative for androgen receptors.

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Reference: Treatment related neuroendocrine prostatic carcinoma

A 74 year old man with a medical history of prostatic adenocarcinoma (Gleason score 7 [4+3], grade group 3) treated with antiandrogen receptors develops osteolytic bone metastasis and a liver lesion measuring 4.2 cm. A prostate core needle biopsy is performed. 2 areas of the same core are highlighted above. Which of the following statements is true?

1. Cystoscopy evaluation is warranted, given that there is high grade urothelial carcinoma invading the prostate
2. Findings are consistent with therapy related prostatic carcinoma, large cell neuroendocrine carcinoma combined with acinar adenocarcinoma
3. Findings are consistent with melanoma
4. Tumor should not be given a Gleason score

B. Findings are consistent with therapy related prostatic carcinoma, large cell neuroendocrine carcinoma combined with acinar adenocarcinoma. The presence of a large cell neuroendocrine component (solid sheets of large cells with brisk mitotic activity and prominent nucleoli) and concurrent conventional adenocarcinoma, in the setting of antiandrogen receptor therapy, indicates treatment related neuroendocrine prostatic carcinoma (tNEPC). Answers A and C are incorrect because although melanoma and high grade urothelial carcinoma may be in the differential diagnosis, the presence of a concurrent acinar prostatic adenocarcinoma on the same core, in the setting of antiandrogen therapy, is diagnostic of tNEPC and the neuroendocrine component is large cell type. Answer D is incorrect because this tumor should be given a Gleason score but only the acinar prostatic adenocarcinoma component should be considered for scoring purposes.

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Reference: Treatment related neuroendocrine prostatic carcinoma