Pathology of prostate cancer. Old problems and new facts

Based on autopsy and epidemiologic data the lifetime risk of developing prostate cancer for a 50-year-old man is 42%, but only 9.5% will develop a clinically manifest disease and only 2.9% will die from this disease. The actual rate of carcinoma detection using PSA, digital rectal examination and transrectal ultrasound is 1%-3%. The majority of prostate carcinoma never progress to clinically significant disease, a minor portion remains confined to the prostate for many years and other carcinomas progress rapidly to a life threatening disease. The dilemma for clinicians and pathologists dealing with this tumor is how to distinguish these three biologically different types. Pathologists play an important role in preoperative diagnosis and in the postoperative prognosis oriented evaluation of the prostatectomy material. Volunteer PSA screening trials have led to an enormous increase in core-needle biopsies of the prostate. Since biopsies are often performed in men without palpable or ultrasound-visible nodules, are now faced with an increasing number of equivocal morphological features which can not be clearly defined, even with standardized criteria. Further investigations are also required to elucidate the clinical importance of PIN detection in biopsies. The heterogeneous histomorphology of prostate carcinoma can not be used as a prognostic factor. Therefore the histological grading is a very important factor for the assessment of prognosis. Carcinoma grading in biopsies is also of limited value in predicting tumor stage. Currently, several different grading systems are in use. Gleason's grading is the most favored, although its reproducibility is very low. The stage of the prostate carcinoma is still the best prognostic factor. In order to accurately assess the pTNM stage, TUR or prostatectomy material must be subject to extensive and standardized processing. Additionally, the volume of the tumor, the vascular invasion, the amount of extension of the tumor through the prostate capsule and perhaps the neoangiogenesis might be valid prognostic factors for disease progress and for survival. The value of novel methods (p53, bcl-2, apoptosis, microvessel density, interphase cytogenetics, androgen receptor mutation, neuroendocrine cells, E-Cadherin) remains to be proved. DNA ploidy is a good prognostic factor after prostatectomy and can be used to plan adjuvant hormone therapy.