1、 WHO 前列腺癌少見(jiàn)組織學(xué)類型介紹第4次編輯、21個(gè)國(guó)家、110位作者，600多幅圖表，3000多條參考文獻(xiàn)主要涵蓋了國(guó)際泌尿病理協(xié)會(huì)（ISUP）近十年來(lái)提出的關(guān)于泌尿生殖各器官病理診斷的共識(shí)和進(jìn)展。1.膀胱非浸潤(rùn)性尿路上皮腫瘤的分類和演進(jìn)2. 對(duì)新增的腎細(xì)胞癌類型的認(rèn)識(shí)和分類3.前列腺和腎臟腫瘤規(guī)范化的取材、診斷和病理報(bào)告的一系列共識(shí)意見(jiàn)。4.前列腺癌 Gleason 評(píng)分的分級(jí)和新分組5.新增前列腺腺癌亞型6.免疫組化以及分子遺傳學(xué)檢測(cè)在泌尿男性生殖系統(tǒng)腫瘤的病理診斷和治療以及預(yù)后評(píng)估中的作用 2014版 2004版atrophic-microcystic variant萎縮性腺癌 (伴

2、萎縮特征的前列腺腺癌） 散發(fā)、放療后、激素治療后 穿刺活檢腺癌2%；Pca RP 16% 常與普通腺癌并存 Cytoplasmic volume loss 類似萎縮腺體，但呈浸潤(rùn)性生長(zhǎng), 常為 Gleason 3 核變扁平，核仁可不突出 AMACR （+）70%，P63/HCK （-） 與預(yù)后無(wú)明顯關(guān)聯(lián) Diagnostic CriteriaInfiltrative growth patternMacronucleoliPresence of adjacent non-atrophic cancer萎縮性腺癌與前列腺萎縮形態(tài)學(xué)類似單純性萎縮基底細(xì)胞存在萎縮性癌，下圖示 部分基底細(xì)胞消失炎性萎縮

3、是前列腺腺癌的癌前病變？-尚未達(dá)成共識(shí)正方觀點(diǎn)：兩者共存通常都在外周帶前列腺萎縮伴炎癥時(shí)KI-67增加炎癥已被證實(shí)能夠誘導(dǎo)腫瘤轉(zhuǎn)化萎縮的腔緣分泌細(xì)胞呈現(xiàn)不成熟表型（ARPSAPSAP弱表達(dá)）基因改變類似前列腺腺癌或HGPIN( x染色體 70%，AR突變30%,8P22 21%，GSTP1甲基化6%等）反方觀點(diǎn)： 文獻(xiàn)1 100例男性尸檢的前列腺外周帶。 文獻(xiàn)2 202例前列腺活檢病例，8年隨訪。 文獻(xiàn)3 前列腺腺癌和HGPIN中存在TMPRSS2-ERG基因融合， 前列腺萎縮中不存在此基因的融合。 均提示萎縮與癌、PIN無(wú)關(guān)。1. Billis A.prostatic atrophy:an

4、autopsy study of a histologic Mimic of adenocarcinoma. Mod pathol 1998;11(1):47-542.Kaleem Z;et al .Prostatic adenocarcinoma with atrophic features: a study of 202 consecutive completely embedded radical prostatectomy specimens.American Journal Of Clinical Pathology 1998.3.Perner S,Mosquera JM.et al

5、 TMPRSS2-ERG fusion prostate cancer :an early mocular event associated with invasion.AM J Surg Pathol 2002;52(4):27-287microcystic variant微囊型前列腺腺癌Pca RP 11% Intermediate gland size (10 x usual small acinar Pca) Cystic dilatation; round profile, flat luminal layer Cytoplasmic volume loss (cystic atro

6、phy-like) AMACR （+），P63/HCK （-） Gleason 3Gleason4+3 Pseudohyperplastic variant 假增生型前列腺腺癌 PZ or TZ Pca RP: often with small acinar Pca Needle biopsy: may predominant BPH-like: nodular; luminal cell hyperplasia, undulations, papillary infoldings, branching Round nuclei, prominent nucleoli; AMACR （+）77

7、%，P63/HCK （-） Gleason 3 Prognosis may be favorable HOXB13 G84E-related familial Pca (transcription factor of homeobox gene family, locus 17q21-22) 前列腺增生foamy gland variant 泡沫腺腺癌 Seen in 16-22% of acinar Pca Rarely pure： 0.2-2% patient age and PSA similar to non-foamy caAbundant foamy（xanthomatous）cy

8、toplasm Pyknotic nuclei, nucleoli usually not prominent; Nucleoli may be prominent in higher grade (GS 7, 16%; GS7, 52%) Desmoplasia in GS =7 cases GS 7 (60%), 6 (32%), 9-10 (5%), 8 (3%) AMACR （+），P63/HCK （-） CD68 (-)TMPRSS2-ERG: 29%; ERG-IHC (+): 42% Prognosis similar to non-foamy ca Partial Atroph

9、y: The most common mimicker of prostate cancer on needle biopsyPartial Atrophy in Prostate Needle Cores: Another diagnostic pitfall for the surgical pathologist. Oppenheimer & Epstein (AJSP 1998)透明細(xì)胞型的部分萎縮腺體，極易誤診為泡沫細(xì)胞癌 signet ring-like cell variant 印戒細(xì)胞樣前列腺腺癌 25% or more signet ring-like cells Not c

10、ommon 30 in 100 000 Pcas Gleason 5 AMACR (+), PSA (+) Major DD: GI / urothelial tract ca invasion /metastases Prognosis poor: 29 months mean survival 不是真正的印戒細(xì)胞癌，只是細(xì)胞內(nèi)空泡，沒(méi)有粘液 印戒細(xì)胞樣前列腺腺癌PSA (+)印戒細(xì)胞樣前列腺腺癌-容易誤診前列腺炎癥激素治療后的前列腺腺癌mucinous/ colloid variant 粘液腺癌 /膠樣癌25% or more areas with extracellular mucin

11、pool Rare: 0.2% Pca Diagnosis by RP Biopsy: Pca with mucinous features GS 7 or 8 ( ignore mucin! ) PSA (+), P63 (-), ERG(+/-) ,CDX2（-） Major DD: GI / urothelial tract ca invasion /metastases Prognosis may be better than originally considered pleomorphic giantcellvanriant 多形性巨細(xì)胞癌 Lacking spindle cell

12、 component Very rare: 10 cases Some with prior history of RT/HT treatment of Pca Admixed with GS 9 Pca Occasionally with other types (DC, SCC, NEC) focally PSA (+) 50%, AE1/AE3(+), CAM5.2 (+) Major DD: metastases, sarcomatoid ca, osteoclast-like giant cells, trophoblastic giant cells Prognosis poor

13、sarcomatoid variant肉瘤樣癌 （癌肉瘤） Biphasic: epithelial (usually high GS Pca) and mesenchymal (spindle cell or heterologous) component (same clonal origin) older man (68) 50% with prior history of RT/HT treatment of Pca Epithelial: PSA (+), P63(-) DD: STUMP /PSS, other mesenchumal tumors Prognosis poor 2

14、014版 2004版one case:(住院號(hào)1290166）男、67歲，夜尿增多1個(gè)半月，血尿1個(gè)月余入院。原單位B超：左腎囊腫，膀胱內(nèi)偏高回聲，前列腺增生。我院B超： 膀胱占位性病變，前列腺腫瘤。MRI： 前列腺占位，癌可能。血清PSA 1.22ng/ml前列腺穿刺病理： 左葉前列腺腺癌，Gleason5+4膀胱三角區(qū)活檢病理：高級(jí)別尿路上皮癌術(shù)中所見(jiàn)：膀胱三角區(qū)菜花狀腫塊1*1CM,行膀胱+前列腺根治術(shù)術(shù)后病理：大導(dǎo)管，篩狀 大導(dǎo)管，篩狀 伴壞死P504s (+) PSA (-) 其他尿路上皮標(biāo)記： P63(-), 34BE12（-）診斷： 前列腺導(dǎo)管腺癌，篩狀型為主 Cribrifor

15、m DA前列腺導(dǎo)管腺癌 Ductal adenocarcinoma, DAOften periurethral 定義: Large glands, tall pseudostratified columnar cancer cells亞型： Papillary, Cribriform, Solid PSA(+), PSMA(+), AMACR(+), P63(-) TMPRSS2-ERG: 11%; ERG-IHC(+): 38% 3.2% of Pca; pure DA 0.2-0.4%; DA-AA: 1-5% 血清PSA常升高,但可不明顯 易轉(zhuǎn)移；預(yù)后較差 Papillary DA其他少見(jiàn)前列腺導(dǎo)管腺癌其他少見(jiàn)前列腺導(dǎo)管腺癌前