1. health and fitness
2. disease
3. cancer

“Histopathological study of prostate carcinomas with clinical
correlation and correlation with Karnofsky performance
status - A Hospital based cross sectional study.”
By
Reg No - BN0110002
Dissertation submitted to the
KLE UNIVERSITY, BELGAUM,
KARNATAKA
In partial fulfilment of the requirements for the degree of
DOCTOR OF MEDICINE
IN
PATHOLOGY
DEPARTMENT OF PATHOLOGY
J. N. MEDICAL COLLEGE, BELGAUM
KARNATAKA
APRIL / May 2013
I
KLE UNIVERSITY, BELGAUM,
KARNATAKA
ENDORSEMENT BY HEAD OF DEPARTMENT AND
PRINCIPAL / HEAD OF THE INSTITUTION
This is to certify that the dissertation entitled “Histopathological study
of prostate carcinomas with clinical correlation & correlation with
Karnofsky performance status - A Hospital based cross sectional
study” is a bonafide research work done by the candidate Register no.
BN0110002.
Dr. Ganga S. Pilli MD, DCP
Professor and Head,
Department of Pathology
J. N. Medical College,
Nehru Nagar,
Belgaum – 590 010
Dr. A. S. Godhi MS, FICS
Principal,
J. N. Medical College,
Nehru Nagar,
Belgaum – 590 010
Date:
Place: Belgaum
Date:
Place: Belgaum
II
LIST OF ABBREVIATIONS
AMACR =
Alpha Methyl Acyl Co-A NCRP =
National Cancer Registry Program
Racemase
APACHE =
Acute
Physiology
and ng =
nanograms
Chronic Health Evaluation
BPH =
Benign Prostatic Hyperplasia
PAP =
Prostatic Acid Phosphatase
CLIA =
Chemiluminescence Immuno
PAS =
Periodic Acid Schiff
Assay
DF =
Degree of Freedom
PIN =
Prostatic Intraepithelial Neoplasia
DRE =
Digital Rectal Examination
PSA =
Prostate Specific Antigen
gms =
Grams
PSAD =
Prostate Specific Antigen Density
Hb =
Hemoglobin
PSAV =
Prostate Specific Antigen Velocity
H&E =
Hematoxylin and Eosin
PSMA =
Prostate Specific Membrane Antigen
hK =
human kallikrein
SD =
Standard Deviation
ICMR =
Indian Council of Medical
TRUS =
Transrectal Ultrasonography
TURP =
Trans-Urethral Resection of Prostate
VACURG =
Veteran Administration Co-operative
Research
KPS =
Karnofsky Performance
Status
ml =
Millilitre
Urological Research Group
MRI =
Magnetic Resonance
WHO =
Imaging
III
World Health Organization
ABSTRACT
Background & Objectives: Prostate cancer is one of the most common cancer in
men. Gleason’s grading system is a globally accepted grading system, for accurate
diagnosis of prostate cancer. It also has prognostic significance. Karnofsky
performance scale index is a questionnaire based performance scoring system and has
been correlated to other prognostic factors in various other studies. Increased total
serum Prostate Specific Antigen (PSA) levels are seen in majority of prostate
carcinoma & helps in decision to undertake needle biopsy. The study was undertaken
to evaluate histopathological grading of prostate carcinoma with clinical correlation
and correlation with Karnofsky Performance Status as well as preoperative total serum
PSA levels.
Methodology: A total 33 histopathologically diagnosed patients, attending Urology
OPD or admitted in Urology ward, during the study period of 1 year (January 2011December 2011) were included in the study. Detailed clinical history and laboratory
investigations including preoperative total serum PSA levels were collected, after
obtaining consent from patients. Patients were interviewed with preformed
questionnaire to evaluate Karnofsky Performance Status. The needle biopsy &
transurethral
resection
of
prostate
(TURP)
specimens
were
grossed
and
microscopically evaluated for the Gleason’s grading.
Results: The most prevalent age group for prostate carcinoma was 61-70 years. Most
common symptom was frequency of micturition (90%). Majority of the (66.66%)
patients (66.66%) showed insidious onset of symptoms. Anemia was observed in
78.78% cases. All the cases in present study showed moderate (45.45%) to high grade
(54.55%) adenocarcinoma. The most common grade encountered was grade 4 and
IV
most common Gleason’s score was score 7. Of the 33 patients 63% showed normal
Karnofsky Performance Status. Increasing age showed significant correlation with
decreased Performance. No correlation was found between Gleason’s grade and
Karnofsky performance status. Serum PSA levels were significantly (>20ng/ml)
raised in all cases but did not showed any correlation with differentiation (Grade).
Conclusion: Karnofsky performance decreases with increasing age, suggesting that
the patients presenting at early age do better than those who present in later ages. As
patients in India present at an early age as compared to western population, they are
potential candidates for curative treatment. Karnofsky performance is a measure of
stage rather than grade. In the present study, most of the prostate carcinomas have
shown normal Karnofsky performance scores despite higher grades of Gleason’s score
and PSA levels. At present, the preoperative total serum PSA level is a reliable marker
for detection of carcinoma prostate, as all the cases in the present study showed
significant increase in serum.
Key Words: Prostate carcinoma, Gleason’s Grade, Karnofsky Performance Status,
Prostate Specific Antigen.
V
CONTENTS
SL.
NO.
TITLE
PAGE
NO.
1.
INTRODUCTION
2.
OBJECTIVES OF THE STUDY
3.
REVIEW OF LITERATURE
5 – 47
4.
METHODOLOGY
48 – 51
5.
RESULTS
52 – 78
6.
DISCUSSION
79 – 87
7.
CONCLUSION
88
8.
SUMMARY
89 – 91
9.
BIBLIOGRAPHY
92 – 109
10.
1–3
4
ANNEXURE
110 - 113

CONSENT FORM

PROFORMA
114 - 117

FIXATION, PROCESSING,
STAINING PROCEDURES
118 - 120

MASTER CHART
121 - 123
VI
LIST OF TABLES
No.
TITLE
PAGE No.
1
2005 ISUP Modified Gleason System
30
2
Stage grouping of Prostate cancer
35
3
Molecular forms of PSA in serum
38
4
Age distribution
53
5
Distribution of prostate carcinoma according to socio-economic
status
54
6
Clinical features
55
7
Onset of symptoms
57
8
Addictions
57
9
Digital rectal examination for prostate enlargement
58
10
Haemoglobin levels Distribution
59
11
Serum creatinine level
60
12
Gleason’s Grade (primary pattern)
61
13
Gleason’s Grade (secondary pattern)
61
14
Gleason’s Score Distribution
62
15
Karnofsky Score Distribution
63
16
Serum PSA level Distribution
64
17
Metastasis by radiological diagnosis
66
18
Correlation of Gleason’s grade with Karnofsky score
66
VII
19
Correlation of Gleason’s grade with serum PSA levels
68
20
Correlation of Gleason’s grade with Haemoglobin levels
69
21
Gleason’s grade and mean serum PSA levels
70
22
Age distribution correlation with Karnofsky score
72
VIII
LIST OF GRAPHS
No.
TITLE
PAGE No.
1
Age distribution
53
2
Clinical features
56
3
Haemoglobin Distribution
59
4
Serum creatinine Distribution
60
5
Gleason’s Score Distribution
62
6
Karnofsky Score Distribution
63
7
Serum PSA
65
8
Correlation of Gleason’s grade with Karnofsky score
67
9
Correlation of Gleason’s grade with serum PSA levels
68
10
Correlation of Gleason’s grade with Haemoglobin levels
69
11
Gleason’s grade and mean serum PSA levels
71
IX
LIST OF FIGURES
No.
TITLE
PAGE No.
1
Male reproductive tract
7
2
Zonal anatomy of prostate
7
3
Whole mount section of prostate
11
4
Normal histology of prostate
11
5
Normal histology of prostate
12
6
Schematic diagram of Gleason’s grading
31
7
8
Gleason’s grade 3A with well formed medium to large glands
having hyperchromatic pleomorphic nuclei. (H and E: 100X)
Gleason’s grade 3B. Lesion with well formed small glands of
equal sizes. (H and E: 100X)
73
73
Gleason’s Grade 4A showing cells arranged in ill defined glands
9
and sheets with stromal invasion. Individual cells are showing
large hyperchromatic pleomorphic nuclei with moderate to scant
74
amount of cytoplasm. (H and E: 100X)
Gleason’s
10
grade
4A.
Individual
cells
showing
large
hyperchromatic pleomorphic nucleus with moderate to scant
amount of cytoplasm. Note stromal invasion by carcinoma cells.
74
(H and E: 400X)
11
12
13
Grade 4A showing cribriform pattern & irregular border.
(H and E: 100X)
Gleason’s grade 4A showing slit like glands with multilayering of
cells. (H and E: 100X)
Gleason’s grade 4B with clear cell pattern. (H and E 100X)
75
75
76
Needle biopsy showing Gleason’s score 7 (4+3). Note cribriform
14
pattern of glands with irregular borders (grade 4) and individually
placed small glands of equal sizes with back to back arrangement
at places (grade 3). (H and E : 40X)
X
76
15
16
Grade 5A showing tumour cells arranged in glandular pattern
with central comedonecrosis. (H and E : 100X)
Gleason’s grade 5B showing sheets of tumour cells with high N:
C ratio invading the stroma. (H and E: 400X)
77
77
Signet ring cell variant of prostate carcinoma. Note signet ring
17
cells with clear cytoplasm & peripherally placed hyperchromatic
78
nucleus. (H and E: 400X)
18
Perineural invasion. Note large pleomorphic cells infiltrating into
perineurium of the nerve. (H and E : 400X)
XI
78
Chapter 1
Introduction
Introduction
INTRODUCTION
Prostate, an accessory gland of male reproductive system, gives rise to
various pathological conditions leading to disease related morbidity in
considerable number of males in their late adulthood.1
Urinary outflow obstruction is a common presenting symptom in such
patients. Various causes leading to urinary outflow obstruction are benign
prostatic hyperplasia (BPH), carcinoma prostate and any other disease process
leading to prostatic enlargement.1
Many prostatic cancers are relatively slow growing and remain clinically
unrecognized. Their course is often unpredictable. An increase in incidence of
carcinoma in the last decade has been noted probably owing to the advances
made in early detection because of improved diagnostic modalities and to some
extent due to increased awareness of prostate cancer, and also due to better
management of disease resulting into longevity. This has allowed prostate cancer
to become clinically significant in elderly.2
Cancer prostate is most common cancer in men and second most common
cause of death due to cancer in men, first being lung cancer.3,4
Histological diagnosis of prostate cancer on biopsy specimens is one of
the most difficult challenges for pathologist, because of scant amount of tissue
which often contain few malignant glands among many benign glands.3,4
A standard grading system which is accepted universally for prostate
carcinoma is Gleason’s grading system, introduced by Donald F Gleason in 1966.
1
Introduction
It is based on low power architectural features of prostate cancer. Over a period
of time Gleason’s grading is refined depending on the change in diagnostic
modalities and previous observations. This refinement in the Gleason grading
system is known as migration of Gleason’s grade.1,5
Gleason grading was introduced by Gleason in the era of radical
prostatectomy specimen, but now a days most of biopsies are needle biopsies,
which make this migration of Gleason’s grading system essential.6,7
Prostate Specific antigen (PSA) is a tumor marker for prostate carcinoma.
Normal levels of serum PSA are between 0 – 4 ng/ml. Detection of elevated
levels of total serum PSA may help in early detection of prostate carcinoma. PSA
is organ specific and not cancer specific. Various benign prostatic diseases like
BPH and prostatitis may show elevated serum PSA levels. It may also rise due to
iatrogenic manipulation like digital rectal examination (DRE) and needle
biopsy.3,4
Therefore utility of serum PSA as a tumor marker in screening and early
detection of carcinoma depends on clear understanding of its levels in neoplastic
and non neoplastic conditions. This will also help the clinicians in designing
treatment strategies for staging and monitoring patient response in cases of
carcinoma.2,3,4,5
Various performance scales are in use for stratifying treatment modalities
in various debilitating diseases. Karnofsky performance scale is used for
measuring performance of patients with disease or those patients who are on
2
Introduction
treatment. It is a simple questionnaire based score which indicates quality of life
of patients with disease or treatment under study.8
There are many studies in which debilitating diseases like malignancies
e.g. carcinoma lung, neoplastic meningitis etc. have used Karnofsky Performance
Scale (KPS) as a measure of performance. Karnofsky Performance Scale has
been correlated with other prognostic factors for those diseases.8,,9,10,11
This study will focus on clinical correlation with Gleason’s grading.
It will also focus on correlation between Gleason’s grade and Karnofsky
performance Scale.
It will also focus on correlation between Gleason’s grade and serum PSA
levels which will ascertain utility of this tumor marker in diagnosis of carcinoma.
This becomes important as majority of studies in this regard have been carried
out on western population. This study will throw light on its application in Indian
context.
3
Chapter 2
Objectives
Objectives
OBJECTIVES
PRIMARY OBJECTIVES:
1. Clinical correlation with Gleason’s grading.
2. Correlation between Gleason’s grade and Karnofsky performance Scale.
SECONDARY OBJECTIVE:
1. Correlation between Gleason’s grade and serum PSA levels.
4
Chapter 3
Review of Literature
Review of Literature
REVIEW OF LITERATURE
NORMAL ANATOMY OF PROSTATE GLAND
The first description of the prostate was given by Herophilus,
an Alexandrian Greek anatomist in the fourth century BC.12
The literal meaning of the word ‘prostate’ is “that which stands before.”
As it is an accessory reproductive organ, here it means – prostate stands before
male external genitalia.12
The gland is located in deeper pelvis behind inferior border of symphysis
pubis. It resembles an inverted pyramid and approximately measures 4x3x2 cms
and weighs 10-20 grams in a normal healthy adult. The gland consists of
glandular and fibromuscular stromal components.5,12,13
Traditionally gland was divided into five lobes but subsequently a refined
zonal model has been proposed from morbid anatomical perspective. This zonal
model of prostate was given by McNeal in last quarter of 20th century. According
to this model prostatic tissue may be subdivided into following zones.12
1. Peripheral zone (70% by volume)
2. Central zone (25% by volume)
3. Transitional zone (5 – 10% by volume)
4. Anterior fibromuscular stroma.12
Peripheral zone constitutes approximately 70% of the gland and is
characterized by ducts radiating laterally from the distal prostatic urethra.
5
Review of Literature
Peripheral zone has smaller acini and less complex ductal branching and
sacculations than the central zone. Stroma is loose as compared to the central
zone. Ducts of peripheral zone open into prostatic sinuses.12,13
Central zone constitutes 20 – 25% of the prostate. It surrounds the
ejaculatory ducts and forms entire base of the prostate. The acini are large and
complex with intraluminal ridges and papillary infoldings. Stroma is denser in
central zone as compared to other zones of prostate. The normal central zone
contains approximately 50% of the prostate epithelium.12,13
Transitional zone constitutes less than 5% of the glandular prostate.
Stroma of transition zone continues with preprostatic sphincter stroma medially
and bladder neck smooth muscles proximally, that is why the name is transitional
zone i.e. transition from prostate to bladder is stromal and not glandular.12,13
Peripheral zone surrounds central, transitional and preprostatic urethra
except anteriorly, where the space is filled by anterior fibro muscular stroma.12,13
Prostate is covered by two layers of capsule. The inner true capsule is a
condensation of connective tissue at periphery of the gland and the outer false
capsule is made up of condensed pelvic fascia. Between these two capsules, lies
the prostatic plexus of veins.12,13
The clinical importance of the zonal model given by McNeal is that
different diseases have predilection for different zones e.g. benign prostatic
hyperplasia is more common in transitional zone and carcinoma is more common
in peripheral zone.12
6
Review of Literature
Figure 1. Male reproductive tract
Source: Nature Reviews Cancer 7, 256-269 (April 2007)
Figure 2. Zonal anatomy of prostate
Source: Nature Reviews Cancer 7, 256-269 (April 2007)
7
Review of Literature
Lymphovascular supply
Arterial supply to prostate gland is mainly from prostatic artery, a branch
of inferior vesical artery. Other branches from middle rectal and internal
pudendal arteries also supply prostate14.
Veins run in a plexus between true and false capsule and drain into
internal iliac veins. They also communicate with vesical venous plexus and
vertebral venous plexus. The communicating veins to vertebral venous plexus do
not have valves, which is one of the important reasons for vertebral metastasis in
carcinoma prostate.14
The lymphatic vessels drain chiefly into the internal iliac and sacral
lymph nodes.14
Nerve supply
Acini of prostate gland receive parasympathetic and the stroma receives
sympathetic innervation. The nerve supply of the prostate is furnished by paired
neurovascular bundles that run along the posterolateral edge of the prostate from
apex to base. Surgical sparring of these structures during radical prostatectomy
preserves sexual potency. Autonomic ganglia are clustered near the neurovascular
bundles sending out small nerve trunks, that arborize over the surface of the
prostate penetrating through the capsule and branching to form an extensive
network of nerve twigs that are often in intimate contact with wall of the duct and
acini.5,14
8
Review of Literature
Development
Prostatic acini of peripheral zone are formed from the pelvic part of
endodermal urogenital sinus.5,12
Acini of central zone are result of dorsal outgrowth above the level of
mesonephric duct.5,12
The fibromuscular stroma (term given by McNeal) develops from
surrounding mesenchyme. The different sites of origin of inner and outer zone
acini may account for different sites of benign and malignant diseases.5,12
Normal Histology of Prostate
Prostate is largest accessory sex gland of the male reproductive system.
Prostate is composed of glandular and stromal components.
Prostate is actually a conglomeration of 30 – 50 individual compound
tubulo-alveolar glands that are arranged in three discrete, concentric layers:
mucosal, submucosal and glands of outer prostate. The inner prostate is
composed of mucosal and submucosal glands which drain via short ducts into
urethral sinuses. Glands of outer prostate are large and branched. Their ducts
curve backwards and open into prostatic sinuses.15
Prostate consists of epithelial and stromal cells. Epithelial cells are
arranged in glands consisting of ducts that branch out from urethra and terminate
into the acini. Ducts consist of elongated tubular structures with branching
pattern in contrast to acini which are more rounded structures grouped into lobes.
9
Review of Literature
The Epithelial cells in the prostate are
a. Transitional cells
b. Secretory cells
c. Basal cells
d. Neuroendocrine cells.
The proximal portion of prostatic ducts are lined by transitional cells and
distal portion lined by columnar cells. Columnar secretory epithelial cells are tall
with pale clear cytoplasm. These cells are terminally differentiated and stain
positively with prostate specific antigen (PSA) and prostatic acid phosphatase.
They also produce androgen receptors and acidic mucin. They also express high
levels of keratins 8 and 18 but lack keratin 5, keratin 14 and p63.5,16
The basal cells lie beneath the secretory cells. These are cigar shaped or
fibroblastic in appearance. It is difficult to distinguish them from stromal
fibroblasts. They are oriented parallel to basement membrane. Basal cells may be
recognized from their more ovoid nucleus with lighter chromatin in contrast to
surrounding fibroblasts, which have a pointed nucleus which is darkly stained.
They are identified on immunohistochemical reaction with antibodies to high
molecular weight keratins such as clone 34B–E12, a property which is used
immnuohistochemically to differentiate benign process (such as atrophy where
basal cells are intact) from carcinoma of prostate. Exact function of basal cells is
not known, but is thought to replace secretory layer. Basal cells also express high
levels of keratins 5 and 14 and also p63, thus acting as a basal cell markers. They
lack keratin 8, keratin 18, PSA and prostatic acid phosphatase. Stroma is mainly
10
Review of Literature
composed of smooth muscle cells and fibroblasts. In apical region of prostate
gland skeletal muscle fibers of urogenital diaphragm extend into stroma.5,16
Figure 3. Whole mount section of prostate
Source: Youngs et al. Wheater’s functional histology
Figure 4. Normal histology of prostate
Source: http://www.grin.com/en/doc/277428/analysis of novel targets in the
pathobiology of prostate cancer
11
Review of Literature
Figure 5. Normal histology of prostate
Source: Youngs et al. Wheater’s functional histology
Neuroendocrine cells are least common cell type of prostatic epithelium
and are usually not identified in routine haematoxylin and eosin stained sections
except for rare cells with large eosinophilic granules. These cells co-express PSA
and androgen receptors suggesting common cell of origin for epithelial cells and
neuroendocrine
cells.
Serotonin
and
chromogranin
are
the
best
immunohistochemical markers of neuroendocrine cells.5,16
Corpora amylacea are inspissated secretions present within lumina of
glands. These are calcified glycoproteins by chemical nature. Exact significance
is not known for presence of corpora amylacea but most literatures mention it as
age related changes in prostate gland.5,15,16
HISTOPATHOLOGICAL CLASSIFICATION OF PROSTATE TUMORS
The classification of prostatic tumors has evolved over a period of time.
Prostatic tumors are classified on the basis of cell of origin into epithelial tumors
and non epithelial neoplasms.
12
Review of Literature
Following is the comprehensive classification of prostatic tumours given
by World Health Organization (WHO) in 2004.17
WHO histological classification of the tumors of the prostate (2004)17
Epithelial tumours
Glandular neoplasms

Adenocarcinoma (acinar)
o Atrophic
o Pseudohyperplastic
o Foamy
o Colloid
o Signet ring
o Oncocytic
o Lymphoepithelioma-like

Carcinoma with spindle cell differentiation
o Carcinosarcoma
o Sarcomatoid carcinoma

Prostatic intraepithelial neoplasia (PIN)

Prostatic intraepithelial neoplasia, grade III (PIN III)

Ductal adenocarcinoma
o Cribriform
o Papillary
o Solid
13
Review of Literature
Urothelial tumours

Urothelial carcinoma
Squamous tumours

Adenosquamous carcinoma

Squamous cell carcinoma
Basal cell tumours

Basal cell adenoma

Basal cell carcinoma
Neuroendocrine tumours

Endocrine differentiation within adenocarcinoma

Carcinoid tumour

Small cell carcinoma

Paraganglioma

Neuroblastoma
Prostatic stromal tumours

Stromal tumour of uncertain malignant potential

Stromal sarcoma
Mesenchymal tumours

Leiomyosarcoma

Rhabdomyosarcoma

Chondrosarcoma

Angiosarcoma

Malignant fibrous histiocytoma
14
Review of Literature

Malignant peripheral nerve sheath tumour

Haemangioma

Chondroma

Leiomyoma

Granular cell tumour

Haemangiopericytoma

Solitary fibrous tumour
Hematolymphoid tumours

Lymphoma

Leukaemia
Miscellaneous tumours

Cystadenoma

Nephroblastoma (Wilms tumour)

Rhabdoid tumour

Germ cell tumours
o Yolk sac tumour
o Seminoma
o Embryonal carcinoma & teratoma
o Choriocarcinoma

Clear cell adenocarcinoma

Melanoma
Metastatic tumours
15
Review of Literature
TUMOURS OF THE SEMINAL VESICLES
Epithelial tumours

Adenocarcinoma

Cystadenoma
Mixed epithelial and stromal tumours

Malignant

Benign
Mesenchymal tumours

Leiomyosarcoma

Angiosarcoma

Liposarcoma

Malignant fibrous histiocytoma

Solitary fibrous tumour

Haemangiopericytoma

Leiomyoma
Miscellaneous tumours

Choriocarcinoma

Male adnexal tumour of probable Wolffian origin
Metastatic tumours
EPIDEMIOLOGY OF PROSTATE CANCER
Cancer prostate is the most common cancer in men and second most
common cause of death due to cancer in men.3,4
16
Review of Literature
Trends in prostate cancer worldwide
Prostate cancer has become a major public health burden worldwide with
an estimated number of 679,000 new cases in the year 2002.18
The incidence of prostate cancer varies worldwide, with the highest rates
found in United States and Canada, and the lowest rates found in China and other
parts of Asia. Similarly prostate cancer mortality varies worldwide, with the
highest rates reported in Caribbean and Scandinavia, and lowest rates in China
and Japan. The worldwide burden of disease is expected to increase in near
future.19 In most of the parts of the world, especially in developed countries, the
detection rate of prostate cancer has increased owing to the development of test
for prostate specific antigen (PSA) in the 1980s. The detection rate declined
from 1997 onwards but again increased in 2000.19,20
Trends in disease stage and mortality
With the wide spread use of PSA screening, the mortality rates decreased
in 1990-2000 due to early detection of cancer. Marked stage migration was also
observed in a series of 2042 patients, presenting with prostate cancer at Walter
Reed Army Medical Center between 1988 and 1998. The proportion of metastatic
disease also decreased in this period significantly.19
Trends in the Prostate Cancer Incidence in India and South East Asia
In the countries of Asia, prostatic cancer incidence rates varied from, as
low as 2.0/100,000 in Iran to as high as 20.3/100,000 in the Philippines in the
year 2002.18
17
Review of Literature
Yeole B made an attempt to study the trends in prostate cancer, in five
population based cancer registries (Mumbai, Chennai, Bangalore, Delhi and
Bhopal) in India, over a period of last two decades. All these registries are under
the network of National Cancer Registry Program (NCRP) of Indian Council of
be established in 1964 by Indian Cancer Society.18
The average age adjusted incidence rates for prostate cancer in Indian
registries are ranged from 3.38/100,000 for Chennai to 6.98/100,000 for Delhi
registry.18,21
The incidence rates at early and late period of study were compared in all
five registries. The trend of increase in incidence of prostate cancer was observed
in all five registries.
The maximum increase in age adjusted incidence rate, over entire period
of observation (1982 – 2003), was noted for Chennai registry (4.95%) followed
by Bhopal (3.45%), Delhi (2.40%), Bangalore (2.02%) and Mumbai (0.89%)
registries. Only Chennai registry shows decline in incidence after 1997.18,21
A study carried out by Rastogi et al. in Indian migrants, in four
geographic regions (India, Singapore, UK, US) showed that the incidence of
prostate carcinoma, is increased in migrants of India than the natives of India,
indicating that the environmental factors play an important role in occurrence of
prostate cancer.22
18
Review of Literature
RISK FACTORS FOR PROSTATE CANCER
The most significant risk factor is age. As age increases the incidence of
prostate cancer also increases. Most of the autopsy studies showed 20 to 30% of
men aged 50 to 70 years and 50% of those aged 80 years had histological
evidence of malignancy.19,20
Even some studies showed up to 80% of incidence of malignancy on
autopsy. Thus most of the men die with prostate cancer rather from it and the
physicians are yet unable to stratify patients into progressive and non progressive
disease.5
Another risk factor is race; African-Americans appear to have worse
prognosis.19
Fat intake is directly correlated to prostate carcinoma.19
Family history is also a significant risk factor; which increases the
likelihood of cancer prostate by 2 folds when father or brother is affected.19,20
Protective factors like tomatoes (contains bycopene), broccoli and vitamin
D3 have also been suggested to play a role. Men with high levels of selenium are
at a lower risk of prostate cancer.19,20
Tissue methods of detection
There are four methods of tissue sample collection, namely needle core
biopsy, trans-urethral resection of prostate (TURP), radical prostectomy and fine
needle aspiration cytology.
19
Review of Literature
1. Needle core biopsy: The introduction of the fine needle for transrectal biopsy
of the prostate in 1980, together with use of serum PSA levels, revolutionized
early detection efforts for prostate cancer. Most of the centers for prostate
cancer diagnosis use extended sextant biopsy. Extended sextant biopsy
includes 6 cores from medial part of peripheral zone and 6 cores from lateral
part of peripheral zone i.e. 12 cores. Recently a randomized trial in Mexico
by Francisco et al. showed that increasing the number of cores from 12 to 18,
increased prostate carcinoma detection rate at first biopsy without increasing
morbidity.23,24 18 gauge and 29mm cutting needle is preferred for TRUS
(Transrectal ultrasonography) guided needle biopsy and is done under local or
short intravenous anesthesia.5 Infection and post biopsy bleeding are most
common complications, which are taken care by antibiotic prophylaxis and
pressure dressing respectively.1,5
2. Trans-urethral resection of prostate (TURP): Transurethral resection
specimen usually consist tissue from transitional zone, urethra, periurethral
area, bladder neck and anterior fibro muscular stroma. As carcinoma arises
most commonly in peripheral zone, there are high chances of missing
carcinoma on TURP, as it does not sample the peripheral zone. For suspected
carcinoma cases all tissue should be processed.1,5
3. Radical prostatectomy: With the advent of early detection by TRUS guided
needle biopsy, routine PSA screening and treatment modalities, the number of
radical prostatectomies for prostate carcinoma have come down. The
completeness of pathological examination of prostatectomy specimens affects
determination of the pathological stage. There was a significant increase in
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positive surgical margins (12% vs. 59%) and pathologic stage with complete
sectioning as compared to limited sampling.25
Desai and colleagues found that complete sectioning showed higher detection
rates of extraprostatic extension (34% vs. 55%) and seminal vesicle invasion (8%
vs. 15%) than with lesser methods of sampling.26 Sehdev and colleagues
compared different methods of prostatectomy sampling using complete
sectioning as a gold standard.27
ADENOCARCINOMA OF THE PROSTATE
Gross identification of prostate cancer is difficult. In TURP specimens,
cancer is difficult to identify because of confounding macroscopic features of
BPH. In prostatectomy specimens cancer tends to be multifocal with predilection
for peripheral zone. Apparent tumor foci are at least 5 mm in greatest dimension
and appear yellowish – white with stony hard consistency due to stromal
desmoplasia. Some tumors appear as yellow granular masses which contrast
sharply with normal spongy prostatic parenchyma.4,5
Microscopically, diagnosis relies on the combination of architectural and
cytologic findings and may be aided by ancillary studies such as
immunohistochemistry. This includes variation in gland size and irregular
glandular contours as contrasted with smooth, round contours of normal glands.
Malignant glands often exhibit an irregular haphazard arrangement sometimes
with splitting or distortion of muscle fibers in the stroma.4,5
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Cytological features include nuclear and nucleolar enlargement.
Prominent nucleoli are 1.25 to 1.5 µm in diameter and are often eccentrically
placed.
Identification of more than one nucleolus is virtually diagnostic of
malignancy. Another important feature is the loss of basal cell layer in
adenocarcinoma.5
There are certain cancer-associated pathologic findings which are not
specific but are helpful in diagnosis. These include perineural invasion, microvascular invasion, luminal mucin, crystalloids, collagenous micronodule and
increased micro vessel density.5,28
Perineural invasion is the major mechanism of cancer spread outside the
prostate and is evident in different studies from 17% to 38% of biopsies. This
finding is strong presumptive but not pathognomonic, because it occurs rarely
with benign acini. Perineural invasion indicates tumor spread along the path of
least resistance and does not represent lymphatic invasion. Half of the patients
with perineural invasion on biopsy have extraprostatic extension, but it has no
independent predictive value (prognostic value).29,30
Microvascular invasion is important predictor of outcome after radical
prostatectomy and carries fourfold greater risk of tumor progression and death.5
Acidic-sulfated and non-sulfated mucin is often seen in the acini of
adenocarcinoma. This mucin stains with Alcian blue and is best demonstrated at
acidic pH, whereas normal prostatic epithelium contains periodic acid-Schiff
(PAS) reactive neutral mucin. It is not specific for carcinoma and seen in few
cases of PIN and BPH also.31,32,33
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Salient features of some of the variants of adenocarcinoma: 5,17,34
1. Adenocarcinoma with neuroendocrine differentiation
Neuroendocrine differentiation is present, at least focally, in virtually all
cases of prostatic carcinoma. These cells are scattered and are inapparent on light
microscopy but revealed by immunoreactivity. Serotonin and chromogranin are
best and commonly used markers for these cells.
Neuroendocrine cells have no apparent clinical or prognostic significance
in benign epithelium, primary prostate cancer or lymph node metastasis.5
2. Mucinous carcinoma of the prostate
Mucinous carcinoma of the prostate is defined as adenocarcinoma of
prostate with at least 25% of the tumor composed of pools of extracellular mucin.
This is a rare and aggressive variant with Gleason’s pattern 3 or 4.5,17
3. Signet ring cell carcinoma
Signet ring cell carcinoma is a rare and aggressive variant. It is graded as
Gleason’s grade 5. It is characterized by clearing of cytoplasm and peripherally
placed nucleus. Criteria for diagnosis require 25% or more of tumor composed of
signet ring cells. Most of them are PAS positive and Alcian blue negative.5,34
4. Adenoid cystic / Basal cell carcinoma
Adenoid cystic / Basal cell carcinoma grossly is white, fleshy and
sometimes shows microcysts. Microscopically it shows nests or nodules of
varying sizes embedded in desmoplastic stroma. Peripheral palisading like basal
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cell carcinoma is seen in some cases. Perineural invasion is common. No bony
metastases are evident till date.5
5. Atrophic variant
Atrophic variant shows decreased cytoplasm and hence can mimic benign
atrophy. It usually presents as Gleason’s grade pattern 3. These changes can be
seen with hormonal and radiation therapy.17
6. Foamy gland carcinoma
Foamy gland carcinoma is characterized by xanthomatous cytoplasm and
bland nuclei. These usually fall in to Gleason’s score 5 – 7.5
7. Lymphoepithelioma like carcinoma
Lymphoepithelioma like carcinoma is characterized by closely packed
glands set in dense lymphocytic stroma.17,34
8. Urothelial carcinoma
Urothelial carcinoma may be primary in prostate gland or represents
secondary spread from the urinary bladder. The frequency of primary urothelial
carcinoma ranges from 0.7 to <4% of prostatic tumors in adult. There is limited
data on PSA levels in patients with urothelial carcinoma.5,34
Most cases are diagnosed by transurethral resection or less often by
needle biopsy. One should exclude secondaries from primary urothelial neoplasm
from bladder before making diagnosis of primary urothelial carcinoma of
prostate. It usually arises from prostatic ducts and has the same features as that of
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the urothelial carcinoma of bladder. It also shows pagetoid spread and
comedonecrosis in many cases. It is prognostically important to identify prostatic
stromal invasion in case of intraductal transitional cell carcinomas in low-stage
bladder tumors, which indicates poor prognosis.1, 34
9. Pseudohyperplastic carcinoma
Pseudohyperplastic carcinoma mimics benign hyperplastic glands. Here
the glands show complex architecture with papillary projections, branching and
cystic dilatation.17
GRADING OF PROSTATE CARCINOMA
In 1860, Rudolf Virchow said, “Malignity only differs in degree”.
Grading of tumours was introduced about 90 years back by Broders
(1925). Broders graded tumours, based on degree of differentiation as well
differentiated, moderately differentiated and undifferentiated.35, 36
Ever since the introduction of the first grading system by Broders for
prostate adenocarcinoma, many grading systems have been used.36, 37
The characteristic histologic variability exhibited by typical prostatic
adenocarcinoma, apparently has served as a major obstacle to the general
acceptance of any one amongst many proposed tumor grading protocols. The
limitations in the needle biopsy such as small amount of available tissue, tissue
sampling error and tumor heterogeneity further compound the difficulty in
accurate grading. The histological pattern of prostate cancer correlates strongly
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with biologic behavior and hence grading is of paramount importance. More than
40 histological grading systems have been proposed for prostatic carcinoma.
Gleason’s system and Mostofi (WHO) systems are the two most widely used
protocols for grading prostatic carcinoma.37
Gleason’s grading is most widely used method for prostate carcinoma. It
was developed by Dr. Donald F Gleason, a pathologist in Minnesota and
members of the Veterans Administration Co-operative Urological Research
Group (VACURG), based on study of 5000 prostate cancer patients from 1960 to
1975.37
The Gleason’s grading system is based entirely on the histologic pattern
of arrangement of carcinoma cells i.e. architecture, in hematoxylin and eosin
stained prostatic tissue sections. It is assessed at low power magnification. Nine
growth patterns were consolidated into five grades and these were illustrated in
drawing by Dr. Gleason.5, 37
The five basic grade patterns are used to generate histological score,
which can range from 2 to 10, by adding the primary grade pattern and secondary
grade pattern. Grades are allotted from 1 to 5, Grade 1 being well differentiated
and grade 5 being undifferentiated. The primary pattern is one that is
predominant in the area by simple visual inspection. The secondary pattern is the
second most common pattern.5, 37
For example, Gleason’s Grade 3 (primary) + 5 (secondary) = 8 (score).
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If only a single grade is seen in the section, it is multiplied by 2 to give
the score (e.g. 3x2 = 6).6,37
Addition of two grades is unique feature of Gleason’s grading. For other
human malignancies, it is the worst grade that determines patient outcome.
Peculiarly, for prostatic carcinoma, when there are two different Gleason’s grade
patterns, the cancer death rates are intermediate between the rates for patients
with only the pure form of each of those two grades.37
The number of grades assigned, depends on tumor sample size and size of
the tumor in whole gland. So more than 2 grades is more often observed in TURP
chips compared to needle biopsies.38,39
Following are the guidelines for reporting Gleason’s score.40
General features
1. The Gleason’s grading is performed at low magnification using a 4x or 10x
objective lens.
2. The primary pattern and secondary pattern is reported and Gleason’s score
assigned.
3. If only one pattern is present, double it to yield Gleason’s score.
4. In the needle biopsy with more than two patterns (tertiary pattern), the worst
pattern must be reflected in the Gleason’s score even if it is not the
predominant or secondary pattern. Use the rule “the most and the worst” as
tertiary grade is seen to increase prognosis by one score.40,41,42
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5. In radical prostatectomy with more than two patterns, Gleason’s score should
be given and tertiary pattern should be given as a note.
6. The Gleason’s score should be given for each separately involved core when
identified and give overall Gleason’s score when mixed in one container.43
7. In general a diagnosis of Gleason’s scores 2 – 4 should not be made on needle
biopsies.
8. The Gleason’s score should not be reported after hormonal or radiation
therapy except if cancer shows no treatment effect.
Optional features (Gleason’s differential)44
1. Provide percent of tumor with Gleason’s pattern 4 in score 7.
2. Provide percent of tumor with Gleason’s patterns 4 and 5 in tumors with
Gleason’s scores 8 to 10.
Gleason’s Grade Migration
Gleason’s grade migration refers to the observation that prostate cancers
are today commonly graded higher in the contemporary era, than previous
decades resulting in greater percentage of higher grade prostate cancers. Many
studies have shown Gleason’s grade migration and its impact on important
clinical measures such as recurrence and cancer related deaths. According to the
study of Albertsen et al. average Gleason’s score increased from 5.9 to 6.8 on
comparing the original reading to contemporary reading.7
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Thus over a period of time Gleason’s grading system has undergone
significant changes. The original Gleason’s grading, given in 1966, underwent
major changes in 1967, 1974, 1977 and 2005.45
For almost three decades Gleason’s grading system was used and
evaluated in several studies and found to be the most significant factor for disease
management. Still there were some controversies which were solved by the 2005
International Society of Urologic Pathology (ISUP) consensus conference on
Gleason’s grading of prostatic carcinoma”. Following table gives modifications
by 2005 ISUP.45, 46, 47
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Table 1. 2005 ISUP Modified Gleason System
Pattern
Morphology
Pattern 1
Circumscribed nodule of closely packed but separate, uniform,
rounded to oval, medium-sized acini (larger glands than pattern 3).
Pattern 2
Like pattern 1, fairly circumscribed, yet at the edge of the tumor
nodule there may be minimal infiltration.
Glands are more loosely arranged and not quite as uniform as
Gleason’s pattern 1.
Pattern 3
Discrete glandular units.
Typically smaller glands than seen in Gleason’s pattern 1 or 2 (3A).
Infiltrates in and amongst nonneoplastic prostate acini (3A)
Marked variation in size and shape (3B).
Smoothly circumscribed small cribriform nodules of tumor (3C).
Pattern 4
Fused microacinar glands (4A).
Ill-defined glands with poorly formed glandular lumina (4A).
Large cribriform glands (4A).
Cribriform glands with an irregular border (4A)
Hypernephromatoid (4B).
Pattern 5
Essentially no glandular differentiation composed of solid sheets,
cords, or single cells (5A)
Comedocarcinoma with central necrosis surrounded by papillary,
cribriform, or solid masses (5A).
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Figure 6. Schematic diagram of Gleason’s grading
Source: The Journal of Urology 2010;183(2):p.433–440
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Some important consensus made in ISUP 2005 consensus conference.45
1. Gleason’s score 1+1=2 should not be diagnosed regardless of the type of
specimen.
2. Gleason’s scores 3 – 4: Cribriform patterns are not allowed in Gleason pattern
2. Diagnosis of Gleason’s score 3-4 should not be given on needle biopsy
because of poor reproducibility, poor correlation with prostatectomy grade
and risk of inadequate treatment.7, 45, 46, 47 Gleason score of 3 – 4 on needle
biopsy will almost always show higher grade cancer on prostatectomy and
hence even if diagnosis of 3 – 4 score is made, a note should be added
mentioning that these scores are almost always associated with high grades.
3. Gleason Pattern 3: Cribriform pattern of Gleason 3 has stringent criteria for
diagnosis. Only rounded well circumscribed glands of same size as that of
normal glands are said to be grade 3. Rest all cribriform patterns are graded as
grade 4.
4. Gleason Pattern 4: Fused glands, cribriform pattern, irregular borders and
hypernephromatoid cells are accepted as pattern 4.
5. Gleason Pattern 5: Shows solid sheets and comedonecrosis.
6. Special account has been given for the Gleason score 7 which can be 3 + 4 or
4+3. Many studies including a study by Amin et al, indicated that score 7
with 4 as primary pattern behaves prognostically more adverse and hence
Gleason score 7 should not be taken as a single entity.40,48
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TNM CLASSIFICATION OF CARCINOMAS OF THE PROSTATE17
T – Primary tumour
TX
Primary tumour cannot be assessed
T0
No evidence of primary tumour
T1
Clinically inapparent tumour not palpable or visible by imaging
o T1a Tumour incidental histological finding in 5% or less of tissue
resected
o T1b Tumour incidental histological finding in more than 5% of tissue
resected
o T1c Tumour identified by needle biopsy (e.g., because of elevated
PSA)
T2
Tumour confined within prostate
o T2a Tumour involves one half of one lobe or less
o T2b Tumour involves more than half of one lobe, but not both lobes
o T2c Tumour involves both lobes
T3
Tumour extends beyond the prostate
o T3a Extracapsular extension (unilateral or bilateral)
o T3b Tumour invades seminal vesicle(s)
T4
Tumour is fixed or invades adjacent structures other than seminal
vesicles: bladder neck, external sphincter, rectum, levator muscles, or
pelvic wall.
Notes:
1. Tumour found in one or both lobes by needle biopsy, but not palpable or
visible by imaging, is classified as T1c.
2. Invasion into the prostatic apex yet not beyond the prostate is not classified as
T3, but as T2.
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3. There is no pT1 category because there is insufficient tissue to assess the
highest pT category.
4. Microscopic bladder neck involvement at radical prostatectomy should be
classified as T3a.
N – Regional lymph nodes
NX
Regional lymph nodes cannot be assessed
N0
No regional lymph node metastasis
N1
Regional lymph node metastasis
Note: Metastasis no larger than 0.2cm can be designated pN1mi.
M – Distant metastasis
MX
Distant metastasis cannot be assessed
M0
No distant metastasis
M1
Distant metastasis
M1a
Non-regional lymph node(s)
M1b
Bone(s)
M1c
Other site(s)
G - Histopathological grading
GX
Grade cannot be assessed
G1
Well differentiated (Gleason 2-4)
G2
Moderately differentiated (Gleason 5-6)
G3–4 Poorly differentiated/undifferentiated (Gleason 7-10)
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Table 2. STAGE GROUPING OF PROSTATE CANCER
Stage
Tumor
Node
Metastasis
Grade
Stage I
T1a
N0
M0
G1
T1a
N0
M0
G2, 3-4
T1b,c
N0
M0
Any G
T1,T2
N0
M0
Any G
T3
N0
M0
Any G
T4
N0
M0
Any G
Any T
N1
M0
Any G
Any T
Any N
M1
Any G
Stage II
Stage III
Stage IV
ANCILLARY DIAGNOSTIC AIDS FOR PROSTATE CANCER
Immunohistochemistry4, 5, 49
1. Prostate specific antigen (PSA) and prostatic acid phosphatase (PAP)
PSA and PAP are the markers of prostatic cell differentiation.
Neuroendocrine cells in the prostate also co-express PSA. Expression of both the
markers is generally greater in low grade tumors than in high grade tumors.
Decreased expression is seen in PIN as compared to normal epithelium. These
markers are also useful in differentiating high grade prostatic cancer from other
poorly differentiated tumors.4, 5
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2. Basal cell markers
Specific monoclonal antibodies directed against high molecular weight
keratin (keratin 34B-E12) are useful to evaluate the basal cell layer which is
intact in benign glands and completely lacking in carcinoma.4, 5
p63 is a nuclear protein and is a useful basal cell marker. Zhou et al.
demonstrated that basal cell cocktail (high molecular weight. keratin and p63)
increased sensitivity of basal cell detection and reduced staining variability. Nasir
Ud Din et al. concluded in their study that p63 can be used to distinguish
prostatic adenocarcinoma from urothelial carcinomas.49
3. α Methylacyl CoA – racemase/P5045 (AMACR)
α Methylacyl CoA-racemase was found to be positive in 80-90% of
prostate cancer. It’s an enzyme involved in oxidation of branched chain fatty
acids.4,5
4. Human glandular kallikrein 2 (hK2)
It has 78% amino acid homology with PSA and can be used as a marker
for diagnosis and monitoring of prostate cancer.4, 5
5. Prostate Specific Membrane Antigen (PSMA)
PSMA is highly specific for benign and malignant prostatic epithelium.
The number of immunoreactive cells increases from benign epithelium to high
grade PIN and prostatic adenocarcinoma. Most extensive and intense staining is
seen in virtually every cell of Gleason’s primary pattern 4 or 5.4,5
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TUMOR MARKERS FOR PROSTATE CANCER
The term ‘tumor marker’ designates a broad category of substances whose
increased levels are associated with malignant transformation of cells. Various
types of tumor markers are recognized viz. cell surface antigens, cytoplasmic
protein, enzymes and hormones. A tumor marker can be detected in solid
tumor,circulating tumor cells, peripheral blood, lymph nodes, bone marrow and
body fluids (stool, urine). A tumor marker can be used for population screening
and for detection, diagnosis, staging, prognosis or follow up of malignant
diseases.50
Prostate specific antigen (PSA) and prostatic acid phosphatase (PAP) are
used as serum and tissue markers of prostatic carcinoma.4, 5
PROSTATE SPECIFIC ANTIGEN (PSA)
Discovery of PSA produced by prostatic tissue was a major step towards
the screening and early detection of prostatic carcinoma.
PSA was first identified by the team of Dr. Richard Ablin. Dr. Ablin and
his co-workers have published their results in two renowned journals (Journal of
Reproduction and Fertility and Journal of Immunology) in 1970.51 PSA was first
measured quantitatively in blood by Papsidero (1980). Stamey carried out initial
work on clinical use of PSA as tumor marker. It was proved in 1980, that serum
PSA is identical to one purified directly from prostatic tissue.51, 52
PSA is a single chain glycoprotein that contains 7% of carbohydrates and
93% amino acids. It is a monomer of 237 amino acid residues and 4 carbohydrate
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side chains. It has molecular weight of 28,430.53,54 The complete gene encoding
PSA has been sequenced and localized to chromosome 19.54,55
Function
PSA is a kallikrein like serine protease that is produced exclusively by
epithelial cells lining acini and ducts of prostate gland. It liquefies seminal
coagulum formed at ejaculation.5, 53
Molecular forms of PSA in serum
PSA, a protease, has extensive structural similarity to the kallikreins, and
now PSA is also known as human kallikrein 3 ‘hK3’.52 PSA exists in both free
and complexed forms in blood circulation. In blood it is complexed with α1
antichymotrypsin and minor fraction with α2 macroglobulin.53, 56
Table 3. Molecular forms of PSA in serum53
Percentage
Comments
Free PSA
10 – 40%
Percentage of free PSA decreases in
serum of cancer patients as TPSA
increases.
PSA – α1 antichymotrypsin
60 – 90%
Molecular Form
PSA α2 macroglobulin
PSA α1 proteinase inhibitor
PSA–inter–α trypsin
inhibitor
<0.1%
<1%
Present only when PSA exceeds
40µg/L
< 0.1%
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Benign prostatic hyperplasia and cancer occur in same age group and both
of them can give rise to increased serum PSA levels. It is mandatory to define a
tumor marker which can differentiate both diseases clearly, and helps in avoiding
unnecessary biopsies as well as under diagnosis of prostate carcinomas.53
In a study conducted in 773 men (379 with prostate cancer and 394 with
BPH) having PSA level of 4 to 10ng/ml with palpably benign gland, showed that
estimation of free PSA percentage can reduce unnecessary biopsies in patients
undergoing evaluation for prostate cancer, with minimal loss in sensitivity in
detecting cancer.57
There are many studies which proved, that free PSA is usually associated
with benign conditions where as protein bound PSA usually is associated with
prostate malignancies.58
Clinical characteristics of PSA
To be able to use a serum marker successfully, it is necessary to have the
complete understanding of inherent physiological properties of the marker as well
as the working knowledge of all the factors that influence its serum
concentration.50
1. Half life and metabolic clearance rate: The half life of total PSA in serum was
determined to be 3.15 ± 0.09 days59 where as it was 2.2 days by another
study.60
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2. Lack of diurnal or circadian variation: PSA concentration does not fluctuate
unpredictably or in a circadian manner over 24 hours. So there is no fixed
timing for obtaining the blood sample for its determination.61
3. Ambulatory versus sedentary concentrations: Serum PSA concentration
decreases by a mean of 18% in 24 hours after hospitalization. In some
patients decrease approached 50% so it is suggested that all PSA
measurements be made on sera collected on the ambulatory basis.5
Variables affecting Serum PSA concentrations
1. Effect of digital rectal examination (DRE): A multicenter prospective trial by
Crawford et al., consisting of 2754 healthy men concluded that DRE does
not affect serum PSA levels significantly and PSA levels after DRE can be
used reliably for patient management.62
2. Cystoscopic examination effect: A study by Oesterling et al (1993) showed
no significant difference in total serum PSA levels before and after
cystoscopy. They concluded that, the PSA levels after cystoscopy can be
reliably used in patient management.63
3. Effect of urinary retention on serum PSA concentration: Patients with acute
urinary retention show at least two fold increase in serum PSA levels and this
impact will disappear after two weeks. Semjonov and colleagues observed
50% decrease in PSA over 24 to 48 hours after relieving the retention.64
4. Effect of ejaculation on serum PSA concentration: In a study conducted by
Herschman J D and colleagues, serum PSA concentration after ejaculation
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was measured at one hour, six hours and 24 hours. Most of volunteers showed
immediate rise in serum PSA which comes down to base line in 24 hours.
Hence it was suggested that men abstain from ejaculation for at least 48 hours
before serum PSA, to avoid spurious PSA elevation.65
5. Effect of Transrectal Ultrasonography (TRUS): Klomp et al (1994) found that
there was statistically a significant rise in serum PSA of 20% after TRUS.
They recommended that serum PSA determination be done before TRUS or
seven days after TRUS.66
6. Effect of TURP: Effect of TURP on PSA in benign prostatic hyperplasia was
studied by Cetinkaya et al. They found an increase in total PSA level after the
procedure but no significant change in free/total PSA ratio. This suggests that
estimation of free/total PSA ratio may be more reliable parameter in early
period after intervention such as TURP.67
7. Effect of Needle biopsy: Serum PSA level increases immediately after needle
biopsy and comes down to baseline in three to four weeks. Hence it is
recommended to estimate serum PSA levels after six weeks of biopsy.63
8. Serum PSA and race: Age specific reference ranges for serum PSA are lower
in Asians as compared to Caucasians. In Asians, Taiwanese have highest PSA
levels and Chinese men have the lowest.68 Age specific reference ranges for
serum PSA are lower for Indian men as compared to Caucasians.69
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IMPLICATIONS OF SERUM PSA IN PROSTATIC PATHOLOGY
1. Serum PSA and benign diseases of prostate
Serum PSA is widely used for diagnosis and monitoring of carcinoma
prostate. PSA is however not specific for carcinoma and increased levels are also
seen in BPH, prostatitis or PIN (Prostatic Intraepithelial neoplasia). Increase in
serum PSA is however more frequent and high in carcinoma prostate. 5, 15, 17
Amayo and Obara in their study showed that 63% BPH cases had rise in
PSA concentrations above cut off value of 4ng/ml and 29% were in the
diagnostic gray zone.70
Estimation of free/total PSA ratio helps in identifying more cases of
carcinoma as free PSA is raised in benign, while protein bound PSA is raised in
carcinoma.57
2. PSA in early detection and screening of prostate cancer
PSA is not tumor specific but is tissue specific and as a result benign
conditions can influence its serum concentration.52
In a study carried out in Austria 21,078 subjects were screened. 18% had
elevated serum PSA levels. Out of these patients, 25% showed positive prostate
biopsy for cancer, 70% were missed by DRE and detected solely by PSA. TRUS
was normal in 65% of cancer patients. Over all 10% staged lesions were found to
be organ confined. Of these lesions 90% were missed by digital rectal
examination and detected by estimation of PSA alone.71
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A study consisting of 10251 men aged 50 years and above showed
screening based on PSA identifies significant number of organ confined tumors
compared to those detected by abnormal digital rectal examination alone.72
The metanalysis for PSA and digital rectal examination (DRE), as a
screening test by Kishor Mistry and Greg Cable showed 83.4% of total prostate
cancers were localized. When patient has abnormal PSA value chance of having
cancer is one in four or five and when PSA levels are normal the chance of
missing cancer is about 10%.73
A study was conducted to predict occurrence of carcinoma prostate 20 –
30 years later based on single estimation of serum PSA at or before 50 years of
age. For this study blood was collected from 21,277 men during 1974 – 86 and in
2006 cancer was diagnosed in 1408 participants. Age group of 44 – 50 was
specifically assessed. The risk of subsequent clinically diagnosed prostate cancer
was low for men with PSA < 0.5ng/ml and risk was high for PSA values above
1.50 ng/ml.74
All the above evidences prove the importance of PSA estimation in early
detection of carcinoma prostate.
Several studies showed PSA levels of 4–10 ng/ml as gray zone where
considerable number of BPH and prostate carcinoma cases overlap. Thus Serum
PSA lacks sufficient sensitivity and specificity to be an ideal marker. 53, 59, 72
Several concepts have been developed in recent years to improve ability
of Serum PSA to identify clinically significant prostate cancers at curable stage.
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These include PSA density, PSA velocity, age specific reference ranges and ratio
of free to total PSA concentration.
PSA Density (PSAD)
It is defined as quotient of Serum PSA and prostate volume measured by
MRI. The normal value is 0.05 or less, intermediate when the value is >0.05 but
less than 0.2
and abnormal if the value is > 0.1.1, 5
These values might help in distinguishing BPH and prostate cancer.75
It also gives us information about aggressiveness of the tumor.76
PSA Velocity
It is defined as rate of change of serum PSA concentration over period of
time. It can be used to distinguish an expected rise in PSA that occurs with the
age and rise in PSA that suggests cancer. It helps in early diagnosis. Less than 5%
men without prostate cancer will have PSAV of 0.75ng/ml/year.77
Percentage and ratio of different forms of PSA
Serum free PSA levels rise in benign diseases while protein bound PSA
rise in carcinoma and helps distinguishing benign lesions from carcinoma,
especially in gray zone values.57
Non prostatic sources of PSA
Periurethral glands in females are found to produce PSA. Subsequently it
is found in many tissues like, breast, amniotic fluid, ovarian and lung cancer.52
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Other applications of total serum PSA estimation59, 78
Serum PSA levels correlates with stage of carcinoma but cannot
accurately predict pathological stage in localized prostate cancer because of two
reasons.
1. Unpredictable contribution from BPH component.
2. Decreasing production of PSA by higher grade lesions.
Serum PSA and treatment modalities
Detectable serum PSA after radical prostatectomy has been shown to be
an indicator of residual or metastatic disease. Rising titers of PSA levels after
radical prostatectomy also means recurrence and chemical recurrence precedes
clinical signs of recurrence which provides time to plan treatment against
recurrence.58,60
Increasing PSA levels after radiotherapy is an ominous sign. Men with
increasing PSA levels after hormonal therapy indicates progressive disease.5, 58
KARNOFSKY PERFORMANCE STATUS
The Karnofsky performance status scale (KPS) was designed to measure
the level of patient activity and medical care requirement.79, 80
This performance scale which is a measure of physical activity was given
by Karnofsky in 1949. Since its inception the scale was widely accepted and used
for making clinical decisions.79, 80
45
Review of Literature
It is used for stratification of patients on clinical trials and to monitor the
quality of life in cancer patients who are on chemotherapy.81
Cyndie and Richard in 1984 had conducted study to test reliability,
validity and guidelines for use of Karnofsky performance score. They found
validity of KPS is good but reliability is poor in terms of reproducibility. They
recommend need for more accurate KPS scoring system.79
Yates et al. in 1980 showed KPS as valid reliable and simple performance
scale. He also proved strong association of death with low KPS score.80
KPS is a simple questionnaire based assessment of physical performance
of the individual. The score ranges from 0 – 100 (100 = normal and 0 = death).6
Many studies used KPS to correlate other prognostically significant
systems like Gleason grade in prostate carcinoma, Acute Physiology and Chronic
Health Evaluation (APACHE II) and infection probability score for blood stream
infections. 81, 82, 83
It has been also used to correlate for the study in circulating tumor cells in
prostate carcinoma which showed that, baseline Hemoglobin, KPS and bone scan
index were strongly associated with survival time but not the Gleason’s
grading.84
Karnofsky performance score should not be used for evaluation of benign
diseases. However, Elieni et al. have used it for comparison with infection
probability score in condition like infection in hematologic malignancies.83
46
Review of Literature
It has also been used in patients with subarachnoid hemorrhage,
intracranial tumors and neoplastic meningitis to predict survival. So over all,
above studies show that KPS scores are reliable, valid and can be compared with
other clinical factors.10, 85
47
Chapter 4
Methodology
Methodology
METHODOLOGY
The present study was a cross sectional study carried out on patients
attending outpatient department of Department of Urology or admitted in
Urology wards and Department of Pathology for a period of one year from
January 2011 to December 2011.
Source of data
Patients presenting with urinary complaints, prostate enlargement and
having carcinoma prostate proved on biopsy were included in study group.
Sample size
A total of 33 prostate carcinoma cases were studied.
Sampling procedure
Based on the 80% of average for the past three years hospital statistics the
sample was calculated as 30. However during the study period 33 patients
satisfied the selection criteria hence 33 patients were included in the study.
Selection criteria
Inclusion

Patients presenting with urinary complaints, prostate enlargement and
histopathologically diagnosed carcinoma prostate on biopsy.
48
Methodology
Exclusion

Other lesions of prostate such as benign prostatic hyperplasia, chronic
prostatitis and granulomas.
Ethical Clearance
Ethical clearance for the study was obtained from Institutional Ethics
Committee on Human Subjects Research.
Informed Consent
Based on the selection criteria, patients with histologically diagnosed
carcinoma prostate were briefed about the nature of the study and a written
informed consent was obtained from the selected patients (Annexure I).
Data collection
Patients details such as age, socioeconomic status and thorough history
such as presenting complaints, onset and addictions was taken and findings were
recorded on predesigned and pretested proforma (Annexure II).
Investigations
Routine investigations such as hemoglobin and serum creatinine were
performed along with pre-operative total serum PSA levels. Biopsy and
postoperative histopathological evaluation was done on the prostatic tissue
submitted, using Gleason’s grading system.
49
Methodology
Study variables
Determination of serum PSA levels
Blood sample for total serum PSA estimation was collected in plain
vacutainer. Quantitative estimation of total serum PSA was done by using
Chemiluminescence Immunoassay (CLIA) on Immunospec Corporation. The
minimum detectable concentration of PSA on this assay is 0.5 ng/ml.86
Determination of Karnofsky Performance Status Score
Patients were interviewed with the help of questionnaire and Karnofsky
performance score was determined and classified into normal (100-80), reduced
(70-50) and severely reduced (40-0).5,6
Histopathological examination of Prostate tissue specimens
Prostate tissue specimens were received in 10% formalin (Annexure
IIIA). Prostatic tissue was grossly examined first and findings were noted. In case
of needle biopsy, all the tissue sent was submitted for processing (Annexure
IIIB). Transurethral Resection of Prostate chips were carefully examined. Any
tissue suspicious of carcinoma (yellow and firm to hard in consistency) was
identified and submitted for processing and subsequent histopathological
examination. Otherwise tissue was submitted till four cassettes were filled and
one additional cassette was submitted for each additional 10 grams of tissue.5
50
Methodology
Thin sections, 3-4 microns thick, were cut from the paraffin block. The
slides prepared were routinely stained by Harris’ Hematoxylin and Eosin stain107
(Annexure IIIC) and evaluated by light microscopy
Statistical analysis
Data obtained was coded and entered into Microsoft Excel Spreadsheet
(Annexure IV). The continuous variables were expressed as mean ± standard
deviation (SD) and categorical data was analyzed by rates, ratios and percentages.
The correlation for categorical data was done by chi-square test and correlation of
continuous data was done by student ‘t’ test and Fischer exact test. A probability
value ‘p’ of less than or equal to 0.05 was considered as statistically significant.
51
Chapter 5
Results
Results
RESULTS
The present one year hospital based prospective study was carried out on
33 patients with urinary complaints, prostate enlargement and having carcinoma
prostate proved on biopsy at Department of Pathology for a period of one year
from January 2011 to December 2011.
Data obtained was coded and entered into Microsoft Excel Spreadsheet
and analyzed as follows.
52
Results
Table 4. Age distribution
Distribution (n=33)
Age group (Years)
Number
Percent
50 to 60
10
30.30
61 to 70
12
36.36
71 to 80
10
30.30
> 80
1
3.03
Total
33
100.00
Graph 1. Age distribution
40%
35%
36.36%
30.30%
30.30%
Distribution
30%
25%
20%
15%
10%
3.03%
5%
0%
50 to 60
61 to 70
71 to 80
> 80
Age group (Years)
Age of patients in our study ranged from 55-85 years. The mean (± SD)
age of presentation for carcinoma prostate was 67.00 (± 7.90) years and the most
prevalent age group was 61-70 years accounting for 12 cases (36.36%). This was
followed in descending order by, 71-80 years and 51-61 years age group with 10
cases (30.30%) respectively and 81-89 year age group with one case (03.03%).
53
Results
Table 5. Distribution of prostate carcinoma according to socio-economic
status
Distribution (n=33)
Socio economic status
Number
Percent
Class I
1
3.03
Class II
2
6.06
Class III
6
18.18
Class IV
13
39.39
Class V
10
30.30
Class VI
1
3.03
Total
33
100.00
Cases participated were categorized into six socioeconomic strata
according to modified B.G Prasad classification.87 as shown in the table.
Carcinoma prostate was more prevalent in class 4 and class 5 individuals
accounting for 13(39.39%) and 10(30.30%) cases respectively.
54
Results
Table 6. Clinical features
Distribution (n=33)
Clinical features
Number
Percent
Frequency
30
90.91
Urgency
22
66.67
Nocturia
22
66.67
Difficulty in micturation
21
63.64
Weight loss
16
48.48
Dysuria
9
27.27
Hematuria
8
24.24
Retention
5
15.15
Back/Bone pain
2
6.06
55
Results
Graph 2. Clinical features
Back/Bone pain
6.06%
Retention
15.15%
Clinical features
Hematuria
24.24%
Dysuria
27.27%
Weight loss
48.48%
Difficulty in
micturation
63.64%
Nocturia
66.67%
Urgency
66.67%
Frequency
90.91%
0%
20%
40%
60%
80%
100%
Distribution
Out of 33 patients, 30 (90.91%) presented with complaint of frequency of
micturition, 22 (66.67%) with urgency, 22 (66.67%) with nocturia, 21(63.64%)
with difficulty in micturition, 16 (48.48%) with weight loss, nine (27.27%) with
dysuria, eight (24.24%) with haematuria, five (15.15%) with retention and two
(6.06%) with back/bone pain. Thus the frequency of micturition was the most
common presenting complaint & back/bone pain was the least common
complaint.
56
Results
Table 7. Onset of symptoms
Distribution (n=33)
Onset
Number
Percent
Acute
11
33.33
Insidious
22
66.67
Total
33
100.00
Out of 33 patients, 11 (33.33%) presented with acute onset and 22
(66.67%) presented with insidious onset of complaints.
Table 8. Addictions
Distribution (n=33)
Addictions
Number
Percent
Tobacco
18
54.55
Alcohol
5
15.15
Out of 33 patients, 18 (54.55%) were addicted to tobacco in the form of
smoking or chewing and five (15.15%) were addicted to alcohol for a minimum
period of 15 years.
57
Results
Table 9. Digital rectal examination for prostate enlargement88
Distribution (n=33)
Prostatomegaly
Number
Percent
Grade I
0
0.00
Grade II
26
78.79
Grade III
7
21.21
Total
33
100.00
Out of 33 patients, 26 (78.79%) showed grade 2 asymmetric enlargement
and remaining seven (21.21%) patients showed grade 3 asymmetric enlargement
of prostate. Thus about 80% of the prostate carcinomas present with grade 2
asymmetric enlargement.
58
Results
Table 10. Haemoglobin levels
Distribution (n=33)
Haemoglobin levels (gm%)
Number
Percent
> 13.0
7
21.21
11.0 to 12.9
10
30.30
8.0 to 10.9
16
48.48
Total
33
100.00
Graph 3. Haemoglobin
60%
48.48%
Distribution
50%
40%
30.30%
30%
21.21%
20%
10%
0%
> 13.0
11.0 to 12.9
8.0 to 10.9
Haemoglobin levels (gm%)
Haemoglobin values were grouped into four groups according to World
Health Organization (WHO)89 recommendation, as normal (>13 gm%), mild
anemia (11-12.9 gm%), moderate anemia (8-10.9 gm%) and severe anemia (<8
gm%).89
59
Results
In our study, mild and moderate anemia was observed in 10 (30.30%) and
16 (48.48%) patients of prostate carcinoma respectively. Normal haemoglobin
levels were observed in seven (21.21%) patients.
Table 11. Serum creatinine level
Distribution (n=33)
Serum creatinine (mg/dL)
Number
Percent
0.3 to 1.3
29
87.88
> 1.3
4
12.12
Total
33
100.00
Graph 4. Serum creatinine
12.12%
87.88%
0.3 to 1.3
> 1.3
Serum creatinine was elevated in 4 (12.12%) patients. In all other patients
serum creatinine was in normal range of 0.3 – 1.3mg/dl. The mean serum
creatinine value was 1.1 ± 0.9 mg/dl with minimum value of 0.8 mg/dl &
maximum of 6 mg/dl.
60
Results
Table 12. Gleason’s Grade (primary pattern)
Distribution (n=33)
Primary Pattern
Number
Percent
Three
7
21.21
Four
15
45.45
Five
11
33.33
Total
33
100.00
Gleason’s primary pattern represents the dominant grade observed in the
given histological section. In the present study only three grades were observed
namely 3, 4 and 5. Gleason’s primary pattern 3 was seen in seven (21.21%)
cases, 4 in 15 (45.45%) cases and 5 in 11 (33.33%) cases.
Table 13. Gleason’s Grade (secondary pattern)
Distribution (n=33)
Secondary pattern
Number
Percent
Three
11
33.33
Four
16
48.48
Five
06
18.18
Total
33
100.00
Gleason’s secondary pattern is the non dominant grade in the given
histological section. Gleason’s secondary pattern 3 was seen in 11 (33.33%)
cases, 4 in 16 (48.48%) cases and 5 in six (18.18%) cases.
61
Results
Table 14. Gleason’s Score
Distribution (n=33)
Gleason's Score
Number
Percent
Well differentiated (2 to 5)
0
0.00
Moderately differentiated(6 to 7)
15
45.45
Poorly differentiated (8 to 10)
18
54.55
Total
33
100.00
Graph 5. Gleason's score
0.00%
45.45%
54.45%
Well differentiated
Moderate
Poorly differentiated
Gleason’s score for each case was calculated by adding primary and
secondary pattern. Out of 33 cases, 15 (45.45%) cases showed moderately
differentiated carcinoma with score of 7 and 18 (54.54%) cases showed poorly
differentiated carcinoma with Gleason’s score of 8-10.
Most common Gleason’s score observed was 7 accounting for 15 (45.45%)
cases and most common grade observed was 4 in 28 (84.84%) cases.
62
Results
Of the 15 cases where Gleason’s score was 7, six (40%) cases showed pattern
3+4 and nine (60%) cases showed pattern 4+3.
Gleason’s grade 5A was seen as primary pattern in three cases and as a
secondary pattern in one case. Only one case showed Gleason’s grade 4B
(clear cell pattern) as secondary pattern. Similarly only one case of signet ring
carcinoma with grade 5 was observed in the study. Perineural invasion was
demonstrated in 30 out of 33 cases.
Table 15. Karnofsky Score
Distribution (n=33)
Karnofsky Score
Number
Percent
Normal (100 - 80)
21
63.64
Reduced (70-50)
12
36.36
Severely Reduced (0 - 40)
0
0.00
Total
33
100.00
Graph 6. Karnofsky Score
0.00%
36.36%
63.64%
Normal
Reduced
Severely reduced
63
Results
Karnofsky performance score is a simple questionnaire based scoring
system & is classified into normal (100-80), reduced (70-50) & severely reduced
(40-00) performance. Karnofsky performance score in our study ranged from 6090 with median score of 80. Out of 33 cases 21 (63.64%) showed normal
performance & 12 (36.36%) showed reduced performance. None of the patients
showed severely reduced performance.
Table 16. Serum PSA level
Distribution (n=33)
Serum PSA levels
Number
Percent
Normal (0 to 4)
0
0.00
Grey zone (5 to10)
0
0.00
Significant zone (>10)
33
100.00
Total
33
100.00
64
Results
Graph 7. Serum PSA
0.00%
100.00%
Normal
Grey zone
Significant zone
All 33 cases showed rise in total serum PSA levels above 20 ng/ml. Thus
all the cases in our study are in the significant zone of > 10ng/ml. The total
preoperative serum PSA value in our study ranged from 21.4 to 1014.0 ng/ml
with an overall mean of 112.4 ng/ml.
65
Results
Table 17. Metastasis by radiological diagnosis
Distribution (n=33)
Diagnosis
Number
Percent
Positive
5
15.15
Negative
28
84.85
Total
33
100.00
Out of 33 patients, five (15.15%) cases of prostatic carcinomas showed
evidence of bony metastasis by radiological means like computerized
tomography or bone scan. Out of these, five patients two gave history of
bone/back pain.
Table 18. Correlation of Gleason’s grade with Karnofsky score
Karnofsky Score
Normal
(n=21)
Gleason's grade
Reduced
(n=12)
Severely
reduced
(n=0)
Total
(n=33)
No.
%
No.
%
No.
%
No.
%
Well differentiated (2-5)
0
0
0
0
0
0.00
0
0.00
Moderate (6-7)
12
57.14
3
25
0
0.00
15
45.45
Poorly differentiated (8-10)
9
42.86
9
75
0
0.00
18
54.55
Total
21
100
12
100
0
0
33
100
x2=3.182
DF=1
p=0.74
66
Results
Graph 8. Correlation of Gleason's grade with
Karnofsky score
Number of patients
20
15
9
10
5
9
12
3
0
Normal
Reduced
Karnofsky performance status
Moderate
Poorly differentiated
Twenty one patients had normal Karnofsky score, of which 12 (57.14%)
were diagnosed with moderately differentiated carcinoma (Gleason’s score 6-7)
and nine (42.86%) patients had poorly differentiated carcinoma (Gleason’s score
8-10).
Twelve patients had reduced Karnofsky score of which three (25%) had
moderately differentiated carcinoma and nine (75%) had poorly differentiated
carcinoma.
Chi-square test was applied to see the correlation between Gleason’s
score & Karnofsky performance score. The results obtained showed chi square
value of 3.82 and p value of 0.074 which was not significant, indicating that there
is no correlation between Gleason’s score and Karnofsky performance status.
67
Results
Table 19. Correlation of Gleason’s grade with serum PSA levels
Serum PSA levels
Normal
(n=0)
Gleason's grade
Grey zone
(n=0)
Significant
(n=33)
Total
(n=33)
No.
%
No.
%
No.
%
No.
%
Well differentiated (2-5)
0
0
0
0
0
0
0
0.00
Moderate (6-7)
0
0
0
0
15
45.45
15
45.45
Poorly differentiated (8-10)
0
0
0
0
18
54.55
18
54.55
Total
0
0
0
0
33
100
33
100
45.45%
Graph 9. Correlation of Gleason's grade with
serum PSA levels
60%
40%
30%
Well differentiated
Moderate
0.00%
0.00%
0.00%
0.00%
0%
0.00%
10%
0.00%
20%
0.00%
Distribution
50%
54.55%
p=1 (Fisher’s Exact test)
Poorly differentiated
Gleason's grade
Normal
Grey zone
Significant
All the 33 cases included in our study had total serum PSA levels of more
than 20ng/ml. Fifteen cases (45.45%) were diagnosed as moderately
differentiated and 18 (54.55%) were diagnosed as poorly differentiated
carcinoma. Fisher exact test was applied to see the correlation between Gleason’s
68
Results
score and serum PSA values. The ‘p’ value calculated was 1 which is more than
0.05 and hence is not significant. This suggests that no significant correlation
exists between Gleason’s score and the levels of total serum PSA.
Table 20. Correlation of Gleason’s grade with Haemoglobin levels
Haemoglobin levels (gm%)
Gleason's grade
> 13 (n=7)
11 – 12.9
(n=10)
8 – 10.9
(n=16)
No.
%
No.
%
No.
%
Well differentiated (2-5)
0
0
0
0
0
0
Moderate (6-7)
3
42.85
4
40.00
9
56.25
Poorly differentiated (8-10)
4
57.15
6
60.00
7
43.75
Total
7
100
10
100
16
100
x2=0.761
DF=2
p=0.683
43.75%
56.25%
40.00%
50%
40%
10%
0.00%
20%
0.00%
30%
0.00%
Distribution
60%
57.15%
42.85%
70%
60.00%
Graph 10. Correlation of Gleason’s grade with
Haemoglobin levels
0%
> 13.00
11 to 12.9
8.00 to 10.09
Haemoglobin Levels (gm%)
Well differentiated
Moderatele differentiated
Pooly differentiated
Haemoglobin levels were normal in seven (21.21%) of the 33 cases, of
which 3 had moderately differentiated and four had poorly differentiated
69
Results
carcinomas. Ten patients (30.30%) had mild anemia of which four had
moderately differentiated and six had poorly differentiated carcinoma. Sixteen
patients (48.48%) had moderate anemia of which nine had moderately
differentiated and seven had poorly differentiated carcinoma.
Above table shows distribution of prostate carcinomas according to
Gleason’s score and hemoglobin levels. Chi –square test was applied to see the
correlation between the Gleason’s score and hemoglobin levels (severity of
anemia). The ‘p’ value calculated was 0.683, which indicates a non significant
correlation between Gleason’s score and severity of anemia
Table 21. Gleason’s grade and mean serum PSA levels
Distribution (n=33)
Gleason's grade
Mean
SD
Well differentiated (2 to 5)
-
-
Moderate (6 to 7)
92.05
115.32
Poorly differentiated (8 to 10)
129.44
229.77
t = 0.572
DF = 31
p = 0.571
70
Results
129.44
Graph 11. Gleason's grade and mean serum
PSA levels
140
92.05
100
80
60
40
20
0
0.00
Distribution
120
Well differentiated
Moderate
Poorly differentiated
Gleason's grade
Pre operative total serum PSA levels ranged from 21.4ng/ml to
1014ng/ml. Overall mean total serum PSA level was 112ng/ml. Mean total
serum PSA level for moderately differentiated (Gleason’s score 6-7) carcinomas
& poorly differentiated (Gleason’s score 8-10) carcinomas were 92ng/ml &
129ng/ml respectively. Student ‘t’ test was applied to see correlation between
Gleason’s score and preoperative total serum PSA levels. The ‘t’ value was 0.572
and the ‘p’ value calculated was 0.571, which is not significant. Non significant
p value indicates that no significant correlation exists between Gleason’s score
and serum total PSA values.
71
Results
Table 22. Age distribution correlation with Karnofsky score
Age group
Normal
(n=21)
(Years)
Karnofsky Score
Severely
Reduced
reduced
(n=12)
(n=00)
Total
(n=33)
No.
%
No.
%
No.
%
No.
%
50 to 60
7
33.33
3
25.00
0
0
10
30.30
61 to 70
11
52.38
1
8.33
0
0
12
36.36
71 to 80
3
14.28
7
58.33
0
0
10
30.30
> 80
0
0
1
8.33
0
0
1
3.03
Total
21
100
12
100
0
0
33
100
x2=10.535
DF=2
p=0.005
The normal Karnofsky performance was seen in 21 cases of which seven
(33.33%) were in the age group of 50-60 years, 11 (52.38%) were in the age
group of 61-70 yrs and three (14.28%) cases were in the age group 71-80 yrs. The
reduced Karnofsky performance score was seen in 12 cases of which three were
in the age group of 50-60 yrs, one case in the age group of 61-70 yrs, seven in the
age group of 71-80 yrs and one case in the age group of above 81 years. Chisquare test was applied to see correlation of Karnofsky performance score with
increasing age. The ‘p’ value obtained was 0.005 which is significant indicating
that, as age increases, performance decreases.
72
Results
PHOTOGRAPHS
Figure 7: Gleason’s grade 3A with well formed medium to large glands having
hyperchromatic pleomorphic nuclei. (H and E: 100X)
Figure 8: Gleason’s grade 3B. Lesion with well formed small glands of equal
sizes (H and E: 100X)
73
Results
Figure 9: Gleason’s Grade 4A showing cells arranged in ill defined glands and
sheets with stromal invasion. Individual cells are showing large hyperchromatic
pleomorphic nuclei with moderate to scant amount of cytoplasm
(H and E: 100X)
Figure 10: Gleason’s grade 4A. Individual cells showing large hyperchromatic
pleomorphic nucleus with moderate to scant amount of cytoplasm. Note stromal
invasion by carcinoma cells (H and E: 400X)
74
Results
Figure 11: Grade 4A showing cribriform pattern & irregular borders.
(H and E: 100X)
Figure 12: Gleason’s grade 4A showing slit like glands with multilayering of
cells. (H and E: 100X)
75
Results
Figure 13: Gleason’s grade 4B with clear cell pattern. (H and E 100X)
Figure 14: Needle biopsy showing Gleason’s score 7 (4+3). Note cribriform
pattern of glands with irregular borders (grade 4; thick arrow) and individually
placed small glands of equal sizes with back to back arrangement at places
(grade 3; thin arrow). (H and E : 40X)
76
Results
Figure 15: Grade 5A showing tumour cells arranged in glandular pattern with
central comedonecrosis. (H and E : 100X)
Figure 16: Gleason’s grade 5B showing sheets of tumour cells with high N: C
ratio invading the stroma. (H and E: 400X)
77
Results
Figure 17: Signet ring cell variant of prostate carcinoma. Note signet ring cells
with clear cytoplasm & peripherally placed hyperchromatic nucleus.
(H and E: 400X)
Figure 18: Perineural invasion. Note large pleomorphic cells infiltrating into
perineurium of the nerve. (H and E : 400X)
78
Chapter 6
Discussion
Discussion
DISCUSSION
The present study consisted of 33 patients, attending Urology OPD or
admitted in Urology ward over a period of one year i.e. between January 2011 to
December 2011. Only histopathologically diagnosed cases of carcinoma prostate
were included in this study. Detailed clinical history was obtained with laboratory
investigations.
Total serum PSA levels were determined preoperatively by obtaining blood
samples on ambulatory basis from the patients. Patients were interviewed for
determining Karnofsky Performance Status (KPS) score. Biopsies from all 33
patients were studied histopathologically to determine Gleason’s grade and score.
The most prevalent age group for carcinoma of prostate in our study was 6170 years. The mean age at diagnosis was 67 years as compared to western
literature where median age at diagnosis was 72 years.58,64,90 Other Indian or
Asian studies have shown that the mean age at diagnosis was 67 years which is in
concordance with our study.91,92,93,94
Carcinoma prostate cases were more prevalent in class IV (lower middle)
and class V (poor) socioeconomic status accounting for about 70% of total cases.
A study carried out in Netherland showed a slight but statistically non
significant higher risk of prostate cancer in low socioeconomic status. 95 One of
the recent study also states that, the patients of prostate cancer belonging to low
socioeconomic class were found to be at increased risk of death.96 In a review of
about 42 studies of different malignancies, poor survival rates were correlated
79
Discussion
with low socioeconomic status.97 An Indian study showed correlation of low
socioeconomic status with disease status in case of cervical carcinoma.98 After
1995 the
incidence of prostate carcinoma showed positive correlation with
higher socioeconomic status.99
In our study frequency was the most common presenting complaint
accounting for 90% cases and bone pain was the least common with 6.06% cases.
In a population based case control study frequency (35%) was the most common
presentation followed by urgency, haematuria and nocturia resembling our
study.100 In an another study similar symptoms were observed, with hesitancy as
the most common symptom.101
In our study eighteen (54.55%) patients were addicted to tobacco mostly
in the form of smoking and tobacco chewing. Five patients were addicted to
alcohol with a minimum duration of 15 years. In various studies including a case
control study conducted in Delhi proved that, smoking as an important risk
factor for prostate carcinoma and its recurrence.92,102,103,104 There are studies
which disagree, with the role of smoking and alcohol as risk factors for prostate
cancer.105,106
Studies have shown mild anemia in 78% of prostate cancer patients.107,108
In our study 78.78% patients showed mild to moderate anemia.
Serum creatinine was raised in 4 patients. Of which 2 patients showed
primary renal disease on ultrasonographic examination. In a nested case control
study carried out in Finnish men, serum creatinine concentration was higher
among 79% of men with symptomatic prostate cancer than non symptomatic
80
Discussion
men, suggesting that high serum creatinine was associated with a significantly
greater risk of prostate cancer. In most of the cases serum creatinine levels ranged
from 0.1 to 2.3 mg/dl with median of 1.15 in symptomatic cancers. Serum
creatinine levels did not show any correlation with the stage of the disease .109
Five (15.15%) patients in our study who had underwent a bone scan
showed evidence of bony metastasis. Four of these cases had metastasis in the
thoracolumbar vertebrae and one had metastasis in the ribs. Two of these patients
gave history of bone pain. An autopsy study on prostate carcinoma deaths from
1967-1995 showed spine as the most common site of metastasis in 90% cases. 110
In another study for prostate carcinomas with 8q24 variation conducted in north
India showed 79% prevalence of bone metastasis.111
In our study all the 33 cases had preoperative total serum PSA levels
above 20ng/ml. The PSA value in our study ranged from 21.4ng/ml to
1014.0ng/ml. The overall mean was 112.4ng/ml.
Our analysis of preoperative total serum PSA levels shows interesting
differences from reports of non-Asian population.
In a study conducted at Indianapolis preoperative serum PSA values were
available in 370 men. Of these 226 (61%) had PSA values less than 10 ng/ml,
100 (27%) had values between 10-20 ng/ml and 44 (12%) had PSA of more than
20 ng/ml.112
81
Discussion
In a Korean study it was demonstrated that, the PSA levels of more than
20 ng/ml, independent of digital rectal examination (DRE) was 81% accurate in
predicting presence of prostate cancer on biopsy.113
In a study conducted at Hyderabad (India) prostate cancer was found in
only about 7% of patients with PSA less than 20 ng/ml as compared to 52.2%
patients with PSA more than 20 ng/ml. similar findings were confirmed in a
study conducted in Mumbai. It showed that about 90% of carcinoma prostate
cases had preoperative total serum PSA levels of more than 20 ng/ml.91,113
In contrast, a study from North Indian tertiary center, men with PSA levels
of 4-10 ng/ml were positive for cancer in 24% cases.91 This difference of cancer
detection rate in India can be explained on the basis of heterogeneity of
population. Thus we should not assume India as a homogenous population and
extrapolate data from one part to other part of country.
Some studies have recommended a higher cut off value of 20ng/ml in case
of Indian population.113 While our data also agrees that, the pickup rate for
cancer was low in men with PSA levels of less than 20 ng/ml, as we did not
found any case of prostate cancer below PSA levels of 20 ng/ml.
Such recommendation of higher cut off of 20ng/ml would need data
showing that, raising the cut off is not impacting the stage of diagnosis and
disease specific mortality significantly. Such data is not available currently for
our patients. Two Indian studies have proved that, the prostate cancers are of a
higher stage at the time of diagnosis as compared to western population.94, 114
82
Discussion
Most of the studies have also proved that when PSA estimation was
combined with DRE, preoperative total PSA showed higher detection rates for
carcinoma prostate as compared to preoperative total serum PSA estimation
alone.69, 72, 91
In our study all the patients had increased PSA levels as well as palpable
enlarged asymmetric hard prostate on DRE.
The higher serum PSA levels in the Indian context, in contrast to western
population can be attributed to overall low incidence of carcinoma prostate in
Asians, indolent nature of prostate cancer and lack of awareness about the
disease115. As seen in our study most of the patients of carcinoma prostate belong
to lower middle (class IV) or poor (class V) socioeconomic group, 95 who are less
educated and hence unaware of the health related aspects. This explains the
presentation of patients, in later stages94,
116
, when the volume of tumor is
increased leading to higher PSA levels at diagnosis than the western
recommendation.
In our study the prostatic biopsies had Gleason’s grade 3, 4 and 5
respectively. The most common Gleason’s grade was 4 (84.84%) and most
common Gleason’s score was 7 (45.45%).
The mean serum PSA levels were slightly higher in poorly differentiated
carcinomas (Gleason’s score 8-10) as compared to moderately differentiated
carcinomas (Gleason’s score 7). The statistical analysis showed no significant
correlation of Gleason’s score with total serum PSA levels.
83
Discussion
A study conducted in Hyderabad showed similar findings, in which
distribution of high grades did not showed any statistical correlation with serum
PSA levels suggesting that there was no difference in the overall distribution of
Gleason’s grade based on serum PSA levels.91
Similar findings were noted in a Jamaican study where the serum PSA
levels were increased with the increase in Gleason’s score but the difference was
not statistically significant.117
In contrast a Brazilian study on radical prostatectomy showed a positive
correlation in high grade Gleason’s score in surgical specimens with higher
preoperative serum PSA.118
A study from Serbia consisting of 40 prostate carcinoma cases showed
significant positive correlation of preoperative PSA with Gleason’s grade. 119 It
also mentions that the determination coefficient is low and PSA levels in men
with carcinoma prostate is determined in 18.7% by tumor grade while 81.3%
represent other factors like age or tumor volume.119
In a study done at Stanford Medical Centre, California, serum PSA levels
were strongly correlated with volume of prostate cancer. Thus it is the tumor
volume and not the grade which primarily determines the serum PSA levels.120
As our study lacks information regarding volume of tumor, no comment can be
made regarding this issue.
Most common grade observed in our study was grade 4 (84.84%). In
contrasts grade 3 was the most common grade observed in most of the studies.
84
Discussion
Most common score in our study was Gleason’s score 7 (45.45%) which is
comparable with other studies.37,47 In case of Gleason’s score 7, 6 (40%) cases
showed pattern 3+4 & 9(60%) cases showed pattern 4+3. There is a conflicting
data on the prognostic difference of Gleason’s score 7 on whether primary pattern
is 3 or 4.40 The recent study at Johns Hopkins Medical Center based on very large
number of patients concluded that the Gleason’s score 7 should not be considered
as a homogeneous group for purpose of disease management and prognosis.48 In
present study the sample size was very small and no comment can be made about
this issue.
The Karnofsky performance status (KPS) scores were determined and
classified into 3 groups as normal (KPS of 80-100), reduced (KPS of 50-70) and
severely reduced (KPS <40). The Karnofsky performance status has been related
to other prognostic factors like grade, stage, hemoglobin, APACHE score and
survival in other malignancies like lung carcinoma and intracranial tumors. 81, 82, 83
In our study we analyzed correlation of Gleason’s score with Karnofsky
performance score and found that there is no significant correlation.
In a retrospective study conducted in Spain on 170 patients of progressive
prostate cancer treated with androgen blockade, showed no significant correlation
between stage of the disease, Gleason’s grade or Karnofsky performance score
and clinical benefit (confirmed PSA decline of 50%).82
A study conducted in Alabama in the year 1985 showed that there is
no correlation of Gleason’s grade with patient survival.121
85
Discussion
In another study conducted in New York to determine prognostic
significance of circulating tumor cells in prognosis of castration resistant prostate
cancer showed that, the circulating tumor cells, PSA, Karnofsky Performance
Status, baseline hemoglobin, albumin, alkaline phosphatase and bone scan index
were all strongly associated with survival time. The Gleason’s score at the time
of diagnosis was not associated with survival time. This is in contrast to several
studies which showed significant correlation between Gleason’s grade and
survival. In this study multiple variables were correlated to survival and some of
them help in staging the carcinoma e.g. bone scan index. In contrast this study
also showed no correlation of Gleason’s grading with the survival. It indicates
that survival is significantly associated with Karnofsky performance score as well
as stage but not with the grade. In the same study KPS and base line hemoglobin
were correlated to survival. 44, 122 Thus Karnofsky performance and hemoglobin
may show indirect correlation.
This view can be supported by the studies on newly diagnosed
metastatic prostate cancer and stage III / IV squamous cell carcinoma of head and
neck, which, showed that low hemoglobin levels were associated with low
Karnofsky performance score.108 Similar findings were also noted in women with
breast or gynaecological malignancy in which low hemoglobin and poor
Karnofsky performance status were correlated significantly. In our study we did
not found any statistically significant correlation of Gleason’s score (grade) with
Karnofsky performance status or hemoglobin levels.
In our study, the median Karnofsky performance score was 80 which is
comparable with other studies. A study which was conducted at various centers
86
Discussion
worldwide have shown that, a lower Karnofsky performance status is a well
accepted strong risk factor for reduced overall median survival.85
In a Serbian study, conducted on locally advanced non small cell lung
cancer, statistically significant correlation was observed between stage of disease
and Karnofsky performance status. In our study the stage at diagnosis data was
not available. The same study also showed that, the lower values of Karnofsky
performance score corresponded with higher age of the patient, which is
comparable with our study.123
In a study conducted in China to know prognostic significance of
Neuroepithelial transforming protein-1 (NET-1) expression in human Gliomas,
showed that there is significant correlation between NET-1 expression with high
grade tumors and lower Karnofsky performance score.124
Many prostate carcinomas were downgraded in needle biopsy. The
accuracy of Gleason scores determined by needle biopsy in patients with prostate
cancer seems to be unreliable, as proved by correlation study between needle
biopsy and total prostatectomy in Taiwan. Gleason’s grading on needle biopsy
alone is not reliable in predicting a pathological stage, as 40% of needle biopsies
were downgraded.125 Karnofsky performance status is a measure of pathological
stage and age rather than grade alone, as stated by one of the studies.123
The statistical power of this study was not very significant as sample
size was small. The other factor which can influence statistical significance of the
present study is limited sensitivity of Karnofsky performance status in evaluating
community dwelling elderly patients with cancer.108
87
Chapter 7
Conclusions
Conclusions
CONCLUSIONS
In conclusion Karnofsky performance decreases with increasing age,
suggesting that the patients presenting at early age do better than those who
present at a later age. As patients in India present at an early age as compared to
western population, they are potential candidates for curative treatment.
Karnofsky performance is a measure of stage rather than grade. In the
present study, most of the prostate carcinomas have shown normal Karnofsky
performance scores despite higher grades of Gleason’s score and PSA levels.
At present, the preoperative total serum PSA level is a reliable marker for
detection of carcinoma prostate, as all the cases in the present study showed
significantly elevated values.
88
Chapter 8
Summary
Summary
SUMMARY
The present work was a descriptive study carried out at a tertiary care
hospital to observe clinical correlation with Gleason’s grading. It was also carried
out to know the correlation between Gleason’s grading with Karnofsky
Performance Status and preoperative total serum PSA levels.
The present study consisted of 33 histopathologically confirmed cases of
prostate carcinoma. Detailed clinical history and lab diagnosis including
preoperative total serum PSA levels were obtained in all cases. The patients were
interviewed in accordance with the format for determining Karnofsky
Performance Status (KPS).
The most prevalent age group for prostate carcinoma was 61-70 years.
About 70% prostate carcinomas were seen in lower middle to poor
socioeconomic strata. Out of 33 patients, 18 (54.55%) were addicted to tobacco
in the form of smoking or chewing and five (15.15%) were addicted to alcohol
with a minimum period of 15 years.
Frequency of micturation (90%) was the most common symptom and
bone/back pain (6%) was the least common presentation. Of the 33 cases,
11 (33.33%) presented with acute onset and 22 (66.66%) presented with insidious
onset. All the patients showed prostatomegaly on DRE.
In our study 78.78% of the patients with prostate carcinoma showed mild
(30.30%) to moderate (48.48%) anemia. Serum creatinine levels were raised in
89
Summary
four (12%) patients of whom two patients had primary renal pathology. In the
remaining two patients, the values were 1.4 mg/dl and 1.5 mg/dl respectively.
All the cases in present study showed moderate to high grade
adenocarcinoma. Fifteen (45.45%) cases of moderately differentiated and
18 (54.55%) cases of poorly differentiated carcinomas were diagnosed. The most
common grade encountered was grade 4 and most common Gleason’s score was
score 7.
Out of 33 cases, 21 (63.64%) showed normal and 12 (36.36%) showed
reduced Karnofsky performance score respectively. None of the patients showed
severely reduced performance. The age distribution of Karnofsky performance
status showed significant correlation between increasing age and reduced
Karnofsky performance status. However there was no significant correlation
between Gleason’s score and Karnofsky performance score.
No significant correlation was found between Gleason’s score and the
hemoglobin levels.
Preoperative total serum PSA levels were elevated significantly in all the
cases. Mean total serum PSA value was high in poorly differentiated carcinomas
as compared to moderately differentiated carcinomas, but no significant
correlation was found between Gleason’s score and preoperative total serum PSA
levels.
Thus in conclusion Karnofsky performance decreases with increasing age,
suggesting that the patients presenting at early age do better than those who
90
Summary
present in later ages. As patients in India present at an early age as compared to
western population, they are potential candidates for curative treatment.
Karnofsky performance in a measure of stage rather than grade. In the
present study, most of the prostate carcinomas have shown normal Karnofsky
performance scores despite higher grades of Gleason’s score and PSA levels.
At present, the preoprative total serum PSA level is a reliable marker for
detection of carcinoma prostate, as all the cases in the present study showed
significant increase in serum PSA levels, but histopathological examination
remains the gold standard for deciding aggressiveness (differentiation) of the
carcinoma.
91
Chapter 9
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100 Hamilton W, Sharp DJ, Peters TJ, Round AP. Clinical features of prostate
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117 Jackson LA, McGrowder DA, Lindo RA. Prostate Specific Antigen and
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109
Chapter 10
Annexure
Annexure
ANNEXURE I: INFORMED CONSENT FORM
Consent for Participation in a study titled “Histopathological study of
prostate carcinomas with clinical correlation & correlation with Karnofsky
performance status - A Hospital based cross sectional study” of the patients
attending a tertiary care hospital.
Mr.___________________, you are being requested to be a subject in a
research study “Histopathological study of prostate carcinomas with clinical
correlation & correlation with Karnofsky performance status - A Hospital
based cross sectional study.” conducted between January 2011 and December
2011, by a post graduate student in Dept of Pathology.
Introduction and Purpose:
Prostate cancer is most common cancer in men & 2nd most common cause
of death due to cancer in men. Histopathological study of prostate specimens
helps in early diagnosis as well as grading of malignancies. Gleason’s grading
system is globally accepted grading system for prostate cancer, which in addition
has prognostic significance. Patients with Early diagnosis & low grade of tumor
will have better outcome of disease on treatment. It also helps in line of disease
management.
Karnofsky performance scale index allows cancer patients to be classified
using standard way of measuring ability to perform ordinary task. This study
presumes that the patients with low grade prostate cancer will perform better than
high grade cancers, hence this study is undertaken to test this presumption
110
Annexure
(correlation). This study is also undertaken to correlate histopathological findings
with clinical findings.
The clinical utility of histopathology is increased by effective
communication between clinician & pathologist with appropriate attention to the
clinical & epidemiological context of the lesions under study.
Procedure involved:
The surgically resected specimens of prostate (needle biopsy, TURP, total
prostatectomy) are sent to histopathology for microscopic examination. If you
agree to be a part of the study, you will be asked to give a detailed history of your
disease, undergo a physical examination & consent to routine investigations.
Surgically resected specimens of prostate, transurethral resection of prostate or
TRUS guided needle biopsy will then be sent to the Department of Pathology for
histopathological examination.
Risks and benefits involved:
Benefits:
1. Early diagnosis will have better prognosis i.e outcome of disease on treatment.
2. Accurate grading will help in disease management
3. The result of you taking part in this research would help health care providers
towards a better understanding of this disease, and thus we will be able to provide
improved patient care.
Risks:
No risk is involved in participation for this study.
111
Annexure
Alternatives:
Yours participation in this study is totally a voluntary decision. If you
don’t want to be a part of the study, you may refuse for the same or if you are
already a part of the study and if you want to withdraw from the study for any
reason, you may do so without any hesitation. Discontinuation from the study for
any reason will not affect your current or future relationship with the hospital.
Privacy and confidentiality:
The information provided by you will be known to the principle investigator
and the members of the research team. This information will remain confidential.
Your identity will remain undisclosed and will be disclosed to others only with
your written permission or if required by the law.
Financial incentives for participation:
You will not be paid / offered any gifts for participation in the research.
There will not be any remuneration for participating in the research and you will
not be reimbursed for any expenses, such as bus/train/companion/assistant etc.
Authorization to publish results:
When the results of the research are to be published or discussed in
conferences by the PI, no information will be disclosed that will reveal your
identity.
112
Annexure
STATEMENT OF CONSENT:
I, Mr._________________________ have read and have completely
understood the entire information given in the consent form which explains all
the details of the study like the purpose, procedure involved, risks & benefits,
privacy & confidentiality, incentives and the authorization to publish the results
of the study. My signature in the space provided for signature below indicates
that I have voluntarily agreed to participate in the study. I may withdraw my
participation myself for any reason or may be withdrawn by the investigator from
the study for any reason at any time. I am not giving up any of my legal rights by
signing this consent form. I will be given a copy of this consent form.
Signature of the participant with date: ________________________
Name of the participant
: __________________________________
Signature of the authorized representative with date: ______________
Name of the authorized representative: _________________________
Signature of the witness with date: _____________________________
Name of the witness: ________________________________________
Signature of the Investigator with date: _________________________
113
Annexure
ANNEXURE II: DATA COLLECTION PROFORMA
Title: "Histopathological study of prostate carcinomas with clinical
correlation & correlation with Karnofsky performance status -A Hospital
based cross sectional
study.”
Name:
Case No:
Age:
Sex:
Date:
OPD/IP NO:
Address with Phone Number:
Occupation:
Income status (According to modified B.G. Prasad’s classification):
1. Upper high
5. Poor
2. High
6. Very poor (BPL)
3. Upper middle
4. Lower middle
PRESENT HISTORY
Present Complaints:
Frequency of micturition
Urgency of micturition
Difficulty in micturition
Retention of urine
Haematuria
Back pain/ bone pain
114
Annexure
Associated symptoms:
Weight loss
Present / Absent
Anemia
Present / Absent
Malaise
Present / Absent
General debility
Present / Absent
Loss of apetite
Present / Absent
Pathological fracture
Present / Absent
Headache
Present / Absent
Vomiting
Present / Absent
Drowsiness
Present / Absent
If Any other: ____________________________
Past History:
Family History:
Personal History:
PHYSICAL EXAMINATION:
Built:
Weight:
Vital Signs:
Pulse: ___ /min
B.P: __________mm of Hg
R/R: ___ /min
Temp: _________ oF
Pallor
Edema
Lymphadenopathy
Icterus
Cyanosis
Clubbing
115
Annexure
SYSTEMIC EXAMINATION:
Respiratory system:
Cardiovascular system:
Per Abdomen:
Central nervous system:
LOCAL EXAMINATION:
P/R: prostate:
palpable / non palpable
If palpable:
regular bilobed/ irregular nodular
Rectal mucosa:
tethered / movable
INVESTIGATIONS:
Hemoglobin: __________gm%
Serum creatinine: ___________ mg/dl
PSA: ___________ ng/ml
BIOPSY:
1. Gross:
2. Microscopy:
3. Final histopathological diagnosis:
116
Annexure
KARNOFSKY PERFORMANCE SCALE INDEX
Normal: Able to carry on normal activity and to work; no special care
needed.
100
Normal no complaints; no evidence of disease.
90
Able to carry on normal activity; minor signs or symptoms of disease.
80
Normal activity with effort; some signs or symptoms of disease.
Reduced: Unable to work; able to live at home and care for most personal
needs; varying amount of assistance needed.
70
Cares for self; unable to carry on normal activity or to do active work.
60
Requires occasional assistance, but is able to care for most of his
personal needs
50
Requires considerable assistance and frequent medical care.
Severely Unable to care for self; requires equivalent of institutional or
Reduced: hospital care; disease may be progressing rapidly.
40
Disabled; requires special care and assistance.
30
Severely disabled; hospital admission is indicated although death not
imminent.
20
Very sick; hospital admission necessary; active supportive treatment
necessary.
10
Moribund; fatal processes progressing rapidly.
0
Dead
117
Annexure
ANNEXURE III: FIXATION, PROCESSING, STAINING
PROCEDURES
A. 10% FORMALIN (FIXATIVE)126
Composition
Volume (ml)
40% formaldehyde
100
Tap water
900
Volume of the formalin used for fixation is ten times the volume of the specimen.
B. PROTOCOL OF TISSUE PROCESSING126
Reagents
1. 10% formalin
2. Alcohol – 70%, 80%, 90%, 95%, absolute alcohol
3. Acetone
4. Xylene
5. Paraffin wax
Steps of processing
1. The tissues were fixed in 10% formalin for 6 to 8 hours.
2. After fixation, tissues were dehydrated by passing through a series of
ascending grades of alcohol.
3. Then clearing was done by passing the tissues through two changes of xylene.
4. Tissue impregnation followed by embedding was done in molten paraffin
wax. Wax blocks were made using Leuckhart’s mould.
118
Annexure
5. Sections, 3 to 4 microns thick, were cut and mounted onto albumin coated
glass slides.
Processing agent
Timings (hours)
10% Formalin
6-8 hours
70% Alcohol
1 hour
80% Alcohol
1 hour
90% Alcohol
1 hour
95% Alcohol
1 hour
Absolute Alcohol
1 hour
Acetone
1 hour
Xylene
1 hour
Paraffin wax
1 hour
Paraffin wax
2 hours
C. HARRIS’S HEMATOXYLIN AND EOSIN (H&E) STAIN126
Reagents:
1. Harris’s hematoxylin
2. 1% eosin
3. 1% acid alcohol
Procedure of H&E staining:
1. The sections were deparaffinised in xylene and hydrated through graded
alcohols.
2. The sections are stained in Harris’s haematoxylin for 3-5 minutes.
3. The slides are washed thoroughly in running tap water, until sections ‘blue’
for 5 minutes or less.
119
Annexure
4. The sections are differentiated in 1% acid alcohol for 5-10 seconds, if
required and rinsed in running tap water, until the sections are again ‘blue’.
5. The sections are counter stained with 1% eosin.
6. The sections are washed in running tap water, dehydrated through graded
alcohol, cleared in xylene and mounted.
120
ANNEXURE IV: MASTER CHART
Investigations
Previous
Pallor
Oedema
Lymphadenopathy
Serum PSA (ng/mL)
KPS
Primary
Secondary
439.0
80
NB
AC
4a
3a
7
+
+
+
-
62
64
-
-
-
NAD
Gr III
13.7
0.9
47.7
80
NB
AC
4a
4a
8
+
-
+
+
-
61
63
+
-
-
NAD
Gr II
9.6
1.0
62.0
80
NB
AC
4a
3a
7
-
-
+
-
+
+
58
-
+
-
-
NAD
Gr II
9.2
0.9
24.0
80
NB
AC
3c
4a
7
-
-
-
+
+
+
-
60
63
+
+
-
NAD
Gr II
9.0
1.3
21.4
80
NB
AC
4a
3a
7
-
-
-
-
+
-
-
-
58
-
-
-
-
NAD
Gr III
11.5
0.9
84.0
70
NB
AC
5b
4a
9
+
+
+
-
+
-
-
+
+
70
-
-
-
-
BD
Gr II
11.8
1.2
100.0
70
NB
AC
5b
4a
9
-
-
-
+
+
+
-
+
-
+
68
-
+
-
-
NAD
Gr II
9.6
1.0
50.0
70
TURP
AC
5a
4a
9
-
+
+
+
+
-
+
-
-
-
-
77
80
-
-
-
BD
Gr III
12.0
0.8
37.0
90
TURP
AC
4a
5a
9
-
-
+
-
-
-
-
+
-
-
-
-
53
-
+
-
-
NAD
Gr II
11.0
0.9
66.0
70
NB
AC
3c
4a
7
+
+
+
-
-
-
-
-
-
+
-
+
+
55
-
+
-
-
NAD
Gr II
9.6
1.1
114.0
60
NB
AC
3c
4a
7
III
+
+
-
-
+
-
-
-
-
+
-
-
-
70
71
-
-
-
NAD
Gr III
12.0
-
45.6
80
NB
AC
3c
4a
7
70
V
+
+
+
-
+
-
-
-
-
+
-
+
-
58
-
+
-
-
NAD
Gr II
9.8
0.9
62.4
80
NB
AC
4a
3b
7
14
62
II
-
+
+
-
+
-
+
-
+
-
-
-
-
60
-
-
-
-
NAD
Gr II
12.5
1.4
74.0
80
NB
AC
5b
3b
8
15
72
V
+
+
+
-
-
-
-
-
+
+
+
-
54
56
+
-
-
NAD
Gr II
10.0
0.9
40.0
70
NB
AC
5b
5b
7
1.5
1014.
0
70
NB
AC
4a
5b
9
+
-
+
-
-
-
2
55
V
+
-
+
-
+
-
-
-
3
75
IV
+
+
+
+
+
-
-
-
4
75
IV
+
-
+
+
+
+
-
5
58
III
+
-
+
+
-
+
6
72
IV
+
+
+
-
+
7
75
III
+
-
-
-
8
71
V
+
-
-
9
63
IV
-
-
10
70
I
-
11
85
V
12
65
13
16
121
58
V
+
-
+
-
-
+
-
-
+
-
+
+
-
62
65
+
-
-
NAD
Gr III
11.0
Gleason
Grade
Gleason's score
-
Histopathological diagnosis
Present
6.0
+
Preoperative
Type of biopsy/surgery
Alcohol
8.8
IV
Sr. Creatinine (%)
Smoking
Gr III
65
Haemoglobin (gm%)
History of weight loss
PE
1
Wt (Kgs)
DRE
Insidious onset
-
Back/Bone pain
+
Retension
+
Dysuria
70
Difficulty in micturation
66
Hematuria
-
Nocturia
-
Urgency
+
Frequency
-
Age (Years)
+
Serial Number
Acute onset
Socio Economic Status
Physical examination
Systemic examination
Addictions
Presenting complaints
17
60
II
+
+
+
-
-
-
-
-
+
+
+
-
60
63
-
-
-
NAD
Gr II
12.2
1.0
87.2
80
NB
AC
3c
4a
7
18
60
V
+
+
+
-
-
-
-
-
-
+
+
+
-
54
56
+
+
-
NAD
Gr II
9.8
0.9
166.3
70
NB
SR
5
5
10
19
70
V
+
+
+
-
-
-
-
-
-
+
-
-
-
58
-
+
-
-
NAD
Gr II
9.8
0.8
52.4
90
NB
AC
5b
4a
9
20
64
III
+
+
-
-
-
-
-
-
+
-
-
-
58
59
-
-
-
NAD
Gr II
11.2
0.9
38.4
80
NB
AC
4a
3c
7
21
72
III
+
+
-
+
+
-
-
-
+
+
-
-
62
64
-
-
-
NAD
Gr II
14.6
1.0
57.0
80
NB
AC
5b
3c
8
22
80
IV
+
+
-
+
-
-
+
+
-
+
-
-
42
45
+
-
-
NAD
Gr II
9.6
0.9
22.0
70
NB
AC
4a
4a
8
23
60
V
+
+
+
-
-
-
+
-
-
+
-
+
-
60
-
-
-
-
NAD
Gr II
12.6
0.8
161.2
80
NB
AC
4a
4b
8
24
65
VI
+
-
-
-
+
+
-
-
-
+
-
+
-
56
-
-
-
-
NAD
Gr II
14.9
0.8
279.0
80
NB
AC
4a
3c
7
25
65
IV
+
+
+
-
+
+
-
-
-
+
+
-
-
62
-
-
-
-
NAD
Gr II
13.2
0.8
35.6
80
NB
AC
4a
3b
7
26
60
III
+
+
+
+
+
-
-
-
+
-
-
+
+
64
-
+
-
-
NAD
Gr II
9.8
3.1
39.2
70
NB
AC
5a
4a
9
27
68
IV
+
-
+
-
+
+
-
-
-
+
-
+
-
58
-
-
-
-
NAD
Gr II
13.0
0.9
273.0
80
NB
AC
5a
4a
9
28
59
IV
+
+
-
-
+
-
-
-
-
+
+
-
-
66
68
-
-
-
NAD
Gr II
13.5
1.0
35.2
90
TURP
AC
3c
4a
7
29
59
IV
+
+
+
-
+
-
-
-
-
+
-
+
-
60
-
-
-
-
NAD
Gr II
13.6
0.9
24.0
90
NB
AC
3a
5b
8
30
55
V
+
+
+
-
+
-
-
-
-
+
+
-
-
58
60
+
-
-
NAD
Gr II
10.2
0.9
21.4
80
NB
AC
4a
3c
7
31
80
IV
+
+
+
-
+
-
-
-
-
+
-
+
-
56
-
+
-
-
NAD
Gr III
9.3
1.0
42.0
70
NB
AC
4a
5b
9
32
63
IV
+
+
+
-
-
-
-
+
-
-
+
-
62
-
+
-
-
NAD
Gr II
10.5
0.9
46.2
80
NB
AC
5b
4a
9
33
80
IV
+
+
-
+
-
-
-
-
+
+
-
-
59
62
+
-
-
NAD
Gr II
9.6
0.8
49.5
70
NB
AC
4a
3b
7
122
+
+
KEY TO MASTER CHART
AC = Adenocarcinoma
BD = Bladder distension
BL PE = Bilateral pleural effusion
Gr = Grade
NAD = No abnormality detected
NB = Needle biopsy
SC = Signet ring cell variant of adenocarcinoma
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