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Pseudohyperplastic Prostatic Adenocarcinoma on Needle Biopsy and Simple Prostatectomy

Levi, Angelique W. M.D.; Epstein, Jonathan I. M.D.

American Journal of Surgical Pathology: August 2000 - Volume 24 - Issue 8 - pp 1039-1046
Original Articles

Prostatic adenocarcinoma resembling benign hyperplastic glands architecturally is a recently recognized entity. In the only prior study on this entity, 100 needle biopsies were studied and only two contained carcinoma with pseudohyperplastic features, which occupied a small percentage of the cancer. The current study investigates histologic attributes of pseudohyperplastic prostatic adenocarcinoma on needle biopsy and simple prostatectomy in which the pseudohyperplastic regions represent the majority of the cancer. The authors reviewed outside cases received in consultation by one of the authors (J.I.E.) and the surgical pathology files of Johns Hopkins Hospital from January 1991 to August 1998 and identified 20 cases of needle biopsy and simple prostatectomy in which ≥60% of the cancer had benign architectural features. The majority (19 of 20) were consult cases. Of the 20 cases studied, 16 were needle biopsies, two were transurethral resections of the prostate, and two were enucleations. Cancer involved one core in 75% of the needle biopsies. In 13 of the 20 cases (65%), ≥90% of the cancer had pseudohyperplastic features. Benign features included papillary infoldings in all cases, large atypical glands in 95% of cases, branching in 45% of cases, and corpora amylacea in 20% of cases. The extent of pseudohyperplastic cancer ranged from 1.0 to 10.0 mm (average, 3.7 mm). Within the pseudohyperplastic foci, features helpful in establishing a malignant diagnosis were nuclear enlargement in 95% of cases, pink amorphous secretions in 70% of cases, occasional to frequent nucleoli in 45% of cases, and crystalloids in 45% of cases. Other features associated with malignancy (mitoses, blue-tinged mucin, adjacent high-grade prostatic intraepithelial neoplasia, and perineural invasion) were seen infrequently. Immunohistochemical stains for high-molecular weight keratin showed an absence of basal cells in the pseudohyperplastic areas in all 20 cases, confirming the diagnosis of cancer. It is critical to recognize pseudohyperplastic prostatic adenocarcinoma and the features needed to establish a malignant diagnosis so these carcinomas are not misdiagnosed as benign.

Pseudohyperplastic prostatic adenocarcinoma is characterized by malignant glands that resemble benign hyperplastic glands architecturally. Pseudohyperplastic histologic patterns of growth include papillary infoldings, most often arising in large atypical and/or branching glands. 7,8 The deceptively benign architectural features of the pseudohyperplastic glands make this pattern of prostate cancer difficult to diagnose, particularly on needle biopsy specimens. 6 In the single prior study describing pseudohyperplastic prostatic adenocarcinoma, only four needle biopsies were identified showing pseudohyperplastic features, and within those specimens the pseudohyperplastic areas occupied a small percentage of the cancer. 12 The current study investigates the histologic attributes of pseudohyperplastic cancer present in a series of needle biopsy and simple prostatectomy specimens in which the pseudohyperplastic regions represent the majority of the cancer. The aim of this study was to characterize better the histologic features that are critical to the recognition and diagnosis of this variant in the difficult setting of smaller specimens with limited diagnostic material. In addition, subsequent resection specimens were reviewed to gain insight into the biologic behavior of pseudohyperplastic prostatic adenocarcinoma.

From the Departments of Pathology (A.W.L., J.I.E.) and Urology (J.I.E.), The Johns Hopkins Medical Institutions, Baltimore, Maryland, U.S.A.

Address correspondence and reprint requests to Jonathan I. Epstein, MD, Johns Hopkins Hospital, Department of Pathology, 600 N. Wolfe Street, Baltimore, MD 21287, U.S.A.; e-mail:

© 2000 Lippincott Williams & Wilkins, Inc.