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ABSTRACT

OBJECTIVE: To calculate the frequencies of various histopathological types of prostatic diseases and to assess the grade of the prostate cancer.STUDY DESIGN: A cross sectional study.PLACE AND DURATION: The study was conducted from 1st January 2014 to 31st August 2015 at pathology laboratory of Al Nafees Medical College & Hospital, Islamabad.METHODOLOGY: 170 Prostate specimen including, Transurethral resection of prostate (TURP), transvesical prostatectomy (TVP) and Needle biopsies were included in the study. Cases of carcinoma were graded according to Modified Gleason score for diagnostic purpose and to assess the frequency. Data was analyzed by SPSS version 17. Frequencies were calculated in terms of percentages.RESULTS: Out of 170 prostate samples, there were 78.8% Benign and 21.2% malignant cases. All Benign cases were diagnosed as Benign Prostatic Hyperplasia (BPH) i-e 78.8%. The additional findings noted in the benign cases along with BPH were prostatitis in 5.2% cases. There was Acute/chronic prostatitis in 3% cases, Granulomatous prostatitis in 1.5% cases and Eosinophilic prostatitis in 0.7% case. Among the Malignant 21.2% cases, Prostatic acinar adenocarcinoma was seen in 11.1%. Among the malignant cases there were 5.8% cases of Transitional cell carcinoma. All cases of adenocarcinoma were graded by Modified Gleason scoring. Grade 8 (38.2%) was most frequently diagnosed. CONCLUSION: Benign prostatic hyperplasia (BPH) was the most common pathology followed by prostatic acinar adenocarcinoma. KEY WORDS: Benign prostate hyperplasia (BPH), prostate adenocarcinoma, Frequency, Histopathology.

ORIGINAL ARTICLE ISRA MEDICAL JOURNAL | Volume 8 - Issue 3 | July - Sep 2016

INTRODUCTION

The male prostate gland is located under the bladder. The urethra from the bladder passes through it and then out as

1penile urethra. The most common types of prostate diseases are Benign prostatic hyperplasia (BPH), Prostatitis and Prostate

2cancer. The incidence of benign and malignant prostatic 3diseases increases with age. Pathological changes of BPH are

evident in 50% of men in the 5th decade of life and 90% of men 4in the 9th decade. Prostate cancer is the second most common

cancer in males after lung carcinoma, but since 1990s there has been a decrease in prostate cancer related deaths. Most important reason for this decrease is that more than 90% of detected cases are localized cancers, while metastatic cancers

5constitute only about 5%. Prostate cancer is potentially 6,7curable. The 5-year survival rate for localized prostate cancer

in developed countries is nearly 100%, while with distant

7,8metastasis it is 28%. In Asia, a rise in the incidence of prostate 9cancer is noted in recent decades. The economic cost burden of

prostate diseases in general and carcinoma in particular has risen significantly due to availability of a variety of diagnostic

10and therapeutic modalities.We conducted this study in our institute to calculate the frequency of benign and malignant prostate diseases and to assess the grade of the prostate cancer. This study will be a guide line for reviewing the diagnostic protocols of prostatic pathologies. Screening protocols and awareness programs of Prostatic Cancer need to be introduced as localized, low grade cancer is curable.

METHODOLOGY

A total of 170 prostate samples were included in the studies which were received in Pathology Department of Al-Nafees Medical College and Hospital during 1st January 2015 to 31st August 2015. A Convenient sampling technique was adopted for the proceedings.All prostate specimens including TURP, TVP, Needle biopsies and others were included. While improperly processed, stained and inadequate specimens were excluded.Specimen were received in 10% buffered formalin and processed in auto processor. Paraffin embedded sections were stained with routine Hematoxylin and Eosin method. The cases were diagnosed as benign or malignant and then further sub classified. All cases of carcinoma were graded according to Modified Gleason score. Data was analyzed by SPSS version 17 and is represented in tables.

RESULTS

During the period of 8 months i-e 1st January 2015 to 31st

BENIGN AND MALIGNANT PROSTATIC DISEASES: A HISTOPATHOLOGICALPERSPECTIVE TO ASSESS THE FREQUENCIES

1. Post Graduate Resident- MPhil Histopathology,3. Professor of Pathology Department 4. Assistant Professor of Microbiology Al-Nafees Medical College & Hospital, Isra University Islamabad Campus, Pakistan2. Assistant Professor of Operative Dentistry, Rawal Institute of Health Sciences, Islamabad

Correspondence to:Ayesha AliPost Graduate Resident Department of HistopathologyAl-Nafees Medical College & Hospital, Isra University Islamabad Campus, PakistanEmail: ayeshaali1019@gmail.com

Received for Publication: 28-01-16Accepted for Publication: 29-07-16

1 2 1 3 4AYESHA ALI , NAUMAN NOOR , ANUM USMAN , NOOR KHAN LAKHANNA , HUMAIRA ZAFAR

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August 2015 a total of 170 prostate specimen were received in the pathology laboratory. Out of total (n=170) cases there were 78.8%(134) benign and 21.2%(n=36) malignant cases. The age of patients ranged from 41 to 88 years. Most cases of benign diseases were diagnosed between 50-60 years and malignant between 61-70 years (Table I).7 cases of grade 10 cancers were present in age group of 60-70 and 2 cases in more than 70 years. All Benign cases were diagnosed as Benign Prostatic Hyperplasia 78.8%(n=134). Out of 134 BPH cases 7 had an additional diagnosis of Prostatitis (5.2%). The types of Prostatitis diagnosed in these cases were, Acute/chronic prostatitis 3%(n=4), Granulomatous prostatitis 1.5%(n=2) cases

DISCUSSION

All over the world, diseases of Prostate gland are responsible for 11,12significant morbidity and mortality among adult males. Most

common diseases affecting prostate are Benign prostatic 13 hyperplasia, Prostatitis and Prostatic cancer.

Both benign and malignant diseases become common as age advances. This finding is in accordance with both local and international data. Benign prostatic hyperplasia (BPH) is 12,13

diagnosed histologically. Both non-modifiable (age, genetics 14

and geography) and modifiable risk factors (metabolic syndrome and cardiovascular disease, obesity, diabetes, diet, physical activity, and inflammation) play important roles in the pathogenesis of BPH. It is expected that the incidence and 15

prevalence of BPH will rise in near future due to aging of the world population and the increased prevalence of the metabolic syndrome. In our study of 170 cases of prostate 16,17

pathologies there were 134 cases of BPH, which constituted the largest group. This is in accordance with observations of Albasri et al (2014) , Anunobi et al (2011) , Hafiz et al (2013) , Xia et al 18 2 12

(2012).9

Prostatitis -- inflammation or an infection of the prostate – affects mainly the young and middle-aged men. Only about 5% to 10% of men develop prostatitis in their lifetime. Prostatitis is classified according to National Institute of Health into: Acute bacterial (category I), Chronic bacterial (category II), Chronic nonbacterial/ chronic pelvic pain syndrome (category III), and

and Eosinophilic prostatitis 0.7%(n=1, Table II). In the malignant biopsies the most common diagnosis was Prostatic acinar adenocarcinoma, 94.2%(n=34), and there were 5.8%(n=2) cases of Transitional cell carcinoma. All cases of adenocarcinoma were graded by Modified Gleason scoring (Table IV). They were diagnosed as Gleason score 6: 5.8%(n=2), Gleason score 7: 11.7%(n=4), Gleason score 8: 38.2%(n=13), Gleason score 9: 17.6%(n=6) and Gleason score 10: 26.4%(n=9). Among the malignant cases perineural invasion was observed in 66.6%(n=24). Morphologically signet ring carcinoma was diagnosed in one case. TURP specimens were 102 and TVP were 68.

19-21Asymptomatic inflammatory prostatitis (category IV). 90% cases are of nonbacterial prostatitis/chronic pelvic pain

20,21syndrome. It is caused by an infectious or inflammatory 22 initiator that results in neurological injury. In our study we

found 5.2%(n=7) prostatitis cases, all of which had concurrent 23finding of BPH. Nickle et al have reported lesser figures (2.7%).

A study conducted by Mosli et al in Saudi Arabia showed 43.3% cases of benign prostatic hyperplasia (BPH), BPH with inflammation was present in 20.3% cases and inflammation

24 alone in 4.2% cases. Granulomatous prostatitis is categorized into 4 subgroups as specific infectious granulomatous prostatitis, nonspecific granulomatous prostatitis (NSGP), post-biopsy granulomas, and as systemic granulomatous prostatitis

25according to the underlying cause. In our study there were 2 cases of granulomatous prostatitis. Mohan et al studied 20 cases of granulomatous prostatitis. His most frequent diagnosis was (12 cases) non-specific granulomatous prostatitis, they suggested that in areas of high prevalence of Tuberculosis, the

26 infectious cause must be ruled out. Increased number of eosinophils in prostate can be due to nonspecific

granulomatous prostatitis, allergic prostatitis. Other rare causes can be iatrogenic granulomas and parasitic infestation, but the presence of increased eosinophils is not definitive for allergic

27prostatitis.Prostate cancer is a major health concern. It is estimated that

28about 41,000 Americans die from prostate cancer annually. It 29constitutes 7% of all malignant neoplasms in Pakistan. Ahmed

TABLE-I: DISTRIBUTION OF PROSTATE DISEASES INDIFFERENT AGE GROUPS (n=170)

TABLE-II: FREQUENCY OF BENIGN PROSTATICDISEASES (n=134)

TABLE - III: BENIGN AND MALIGNANT PROSTATE DISEASEACCORDING TO TYPE OF SPECIMEN (n=170)

TABLE-IV: DISTRIBUTION OF GLEASON SCORE IN PROSTATICADENOCARCINOMA (n=34)

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patterns of prostate cancer incidence and mortality. Int J Cancer. 2012; 85 (1): 60–67.

8.� Di Blasio CJ, Rhee AC, Cho D. Predicting clinical end points: treatment nomograms in prostate cancer. Semin Oncol.2003; 30 (5): 567–86.

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10.� Daskivich TJ, Kwan L, Dash A. Racial parity in tumor burden, treatment choice and survival outcomes in men with prostate cancer in the VA healthcare system. Pro Can Pro Dis. 2015;18(10):104-09

11.� Joseph C. Prostate Biopsy: Current Status and Limitations. Rev Urol. 2007;9(3): 93–98.

12.� Naseem AS, Hiba AS, Shafaq S. Spectrum of prostatic lesions. Int Arch Med. 2013;9(6):36-38

13.� Abrar MM, Iqbal KJ. Histopathological lesions in transrectal ultrasound guided biopsies of prostate in patients with raised serum prostate specific antigen: A preliminary report. J Nephro-Urology. 2011;3(3):186–90.

14.� Claus GR. Benign Prostatic Hyperplasia: An Overview. Rev Urol. 2005; 7 (9): 3–14.

15.� Manjit SK, Goyal AK, Singla N. Prostatic lesions in surgical biopsy. JK-practitioner. 2011;16(2):33–34.

16.� Bozdar HR, Memon SR, Paryani JP. Outcome of transurethral resection of prostate in Clinical benign p r o s t a t i c h y p e r p l a s i a . J A y u b M e d C o l l Abbottabad.2010;22(4):21-23

17.� Nishant D, Patel J, Kellogg P. Epidemiology and etiology of benign prostatic hyperplasia and bladder outlet obstruction. Indian J Urol. 2014; 30(2): 170–76.

18. Albasri A, El-Siddig A, Hussainy A. Histopathologic characterization of prostate diseases in Madinah, Saudi Arabia. Asian Pac J Cancer Prev. 2014;15(10):4175-79.

19.� Wagenlehner FM, Naber KG, Bschleipfer T. Prostatitis and male pelvic pain syndrome: diagnosis and treatment. Dtsch Arztebl Int. 2009; 106 (11): 175–83.

20.� Nickel JC, Krieger JN, Naughton MC. Chronic Prostatitis Collaborative Research Network. Alfuzosin and symptoms of chronic prostatitis-chronic pelvic pain syndrome. N Engl J Med. 2008;359(25):2663-73.

21.� Anothaisintawee T, John A, Curtis N. Management of Chronic Prostatitis/ Chronic Pelvic Pain Syndrome. A Systematic Review and Network Meta-analysis. J Amer Med Assoc. 2011;305(1):78-86.

22.� Murphy AB, Macejko A, Taylor A. Chronic prostatitis: management strategies. Drugs. 2009;69(1):71-84.

23.� Curtis N. Prostatitis. Can Urol Assoc J. 2011; 5(5): 306–15.24.� Mosli HA, Abdel TA, Maghrabi JA. The clinicopathologic

patterns of prostatic diseases and prostate cancer in Saudi patients. Saudi Med J. 2009 ;30(11):1439-43.

25.� Mehmet B, Metin D, Abdulkadir K. Investigation of granulomatous prostatitis incidence following intravesical BCG therapy. Int J Clin Exp Med. 2014; 7(6): 1554–57.

26.� Mohan H, Bal A, Punia RP. Granulomatous prostatitis--an infrequent diagnosis. Int J Urol. 2005;12(5):474-78.

27.� Yuji O, Naotami T, Morimasa K. Eosinophil infiltration in

thet al have reported most cases to be in 6 decade which is 30consistent with our findings. There were 36(21.2%) malignant

cases in our study. Among which 34 were primary and 2 were of Transitional cell carcinoma which had involved prostate gland. In our study maximum number of cases were of Gleason score 8 while 2 cases scored 6. In contrast, Okolo et al found Gleason

31 score 6 to be most common. Huma et al have also reported 32score 7 as the most frequent type of adenocarcinoma. A large

study comprising 300 patients by Carolina et al showed Gleason 32,33score 7 and grade 3 pattern to be most common. They along

with Epstein et al, at John Hopkins have extensively studied and concluded that there is upgrading or downgrading of Gleason score on prostatectomy as compared to needle biopsy

34specimen. In our study we found Gleason score 8 being most common. It is in contrast to the usual finding of score 6 and 7. High intake of fats, red meat and dairy products are implicated

35in increasing incidence of prostate cancer in Pakistani men. Carcinoma can also coexist with BPH and physical examination

28without biopsy will miss it.

CONCLUSION

Benign prostatic hyperplasia (BPH) was the most common pathology followed by prostatic acinar adenocarcinoma. Most frequently diagnosed Gleason grade was Score 8 (high grade) for prostatic acinar adenocarcinoma.

Contribution of authors: Ayesha Ali: Corresponding author, provoking the idea of manuscript, introduction and methodology writing.Nauman Noor: Data gathering, summarizing the Results and discussion writing.Anum Usman: Collection of References for introduction & discussionNoor Khan Lakhnana: Histopathological diagnosis of all prostate specimensHumaira Zafar: Final formatting of entire manuscript

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