A 66-year-old man comes to the office due to 2 episodes of hematuria over the past month. Digital rectal examination reveals an indurated prostate with no palpable nodules. An image from a transrectal prostate biopsy is shown in the exhibit. Which of the following is the most likely underlying cause of this patient's symptoms?
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This older man with an indurated prostate has histopathologic evidence of crowded glands composed of atypical cells with large nuclei and prominent nucleoli, raising strong suspicion for prostate adenocarcinoma. Because most cases of prostate cancer arise in the periphery of the gland (peripheral zone) far from the prostatic portion of the urethra, patients do not typically present with urinary symptoms. However, a minority of cases occur in the portion of the gland (transition zone) that abuts the urethra, which can lead to hematuria and/or obstructive voiding manifestations.
Diagnostic evaluation begins with digital rectal examination; patients with prostate cancer often have an indurated (ie, abnormally firm), nontender gland with or without a nodule. An elevated prostate-specific antigen level adds supporting evidence. Confirmation is typically made by transrectal prostate biopsy, in which 10-12 random core biopsies of the gland are obtained. In contrast to normal prostatic cells, cancer cells typically display varying degrees of cellular atypia, including enlarged nuclei and prominent nucleoli, and commonly form crowded, infiltrative glands.
(Choices A and C) Acute prostatitis typically causes systemic symptoms (eg, fever, malaise), dysuria, and a tender, boggy prostate on digital rectal examination. Chronic prostatitis is generally marked by perineal pain and recurrent symptoms of urinary tract infection. Although patients can have hematuria with these conditions, biopsy would show inflammatory, not atypical glandular, cells.
(Choice B) Benign prostatic hyperplasia is common in older men. Hyperplasia of prostatic stroma in the area of the prostate that surrounds the urethra generally results in voiding symptoms (eg, hesitancy, dribbling, frequency). Hematuria may occasionally occur. Digital rectal examination generally reveals a symmetrically enlarged prostate with no nodules. Biopsy would show extensive stromal hyperplasia, not atypical glands.
(Choice D) Urothelial carcinoma from the bladder or urethra can occasionally invade the prostate. Although this cancer often causes hematuria, biopsy typically shows cancerous urothelial cells, not atypical glands. Furthermore, prostate cancer is a far more common cause of an indurated prostate than a urothelial tumor invading the prostate.
Educational objective:
Prostate adenocarcinoma is generally diagnosed with transrectal prostate biopsy, which often reveals atypical cells with enlarged nuclei and prominent nucleoli forming crowded, infiltrative glands.