Extent Of Local Tumour Spread

Border: pushing/infiltrative. Lymphocytic reaction: prominent/sparse.

Weight of chippings or length of cores and proportion (%) or number involved. For a focal lesion give a maximum dimension (mm). Apex of gland, urethral limit, proximal bladder limit, capsule and margins, seminal vesicles.

The TNM classification applies only to prostatic adenocarcinomas. Transitional cell carcinoma of the prostate is classified as a urethral tumour.

pT1 clinically inapparent tumour not palpable or visible by imaging T1a incidental histological finding in <5% of tissue resected T1b incidental histological finding in >5% of tissue resected T1c identified by needle biopsy (e.g. because of elevated PSA) pT2 tumour confined within the prostate

T2a involves one-half of one lobe or less T2b involves more than one-half of one lobe but not both T2c involves both lobes pT3 tumour extends through the prostatic capsule

T3a extracapsular extension (unilateral or bilateral) T3b invades seminal vesicle(s) pT4 tumour is fixed or invades neighbouring structures: bladder neck, external sphincter, rectum, levator muscles, and/or pelvic wall.

Invasion into but not beyond prostatic apex or capsule is pT2. The capsule is a condensation of smooth muscle and collagen-rich soft tissue around the prostate but with no clear fascia. It can be difficult to define in a prostatectomy specimen for the purposes of assessing extracapsular disease (tumour in fat or neurovascular bundles beyond the contour of the prostate) and sometimes has to be visually extrapolated from more obvious adjacent areas in any given slide. Completeness of the capsule pT1a = < 5% of tissue resected pT1b > 5% tissue resected pT1c = needle biopsy diagnosis

Clinically inapparent tumour

Gland confined disease pT2a = < 50% one lobe involved pT2b = > 50% one lobe involved

Gland confined disease pT2a = < 50% one lobe involved pT2b = > 50% one lobe involved

pT2c = both lobes involved
Figure 31.2. Prostatic carcinoma. QA|

also depends on patient anatomy, surgical expertise and choice of operative technique, e.g. a nerve-sparing procedure. Extracapsular extension can be described as focal or extensive (adverse prognosis).

Due to the inferoposterior approach of per rectal needle biopsy there may be representation of extracapsular and seminal vesicle tissues which should be assessed for invasion (=pT3). Note that fat and muscle can also be intraprostatic and involvement on its own in a needle biopsy does not necessarily imply extracapsular disease. However, tumour in perineural spaces in neurovascular bundles in fat is an indicator of extracapsular spread, as is infiltration around ganglion cells. Occasionally benign acini may be present in perineural spaces. Seminal vesicle involvement (pT3b) is defined as invasion of its smooth muscle wall and not just the surrounding connective tissue between it and the

Figure 31.3. Prostatic carcinoma. |W
Extracapsular Spread Prostate
Figure 31.4. Prostatic carcinoma. |W

prostate. This is not to be confused with similar looking ejaculatory duct type epithelium which is oriented to loose, vascular connective tissue. Advanced disease manifests spread into seminal vesicle, prostatic urethra and bladder. Presentation can be by an anterior rectal mass or stricture and PSA staining of rectal biopsy material is of use. "Frozen pelvis" is a clinical term meaning tumour extension to the pelvic wall(s) with fixation and is designated pT4. Optional descriptors are pT4a (bladder neck, external sphincter, rectum) and pT4b (levator muscles, fixed to pelvic wall). Note that the normal prostatic apex may incorporate some striated muscle fibres and cancer lying in relation to these does not necessarily imply extraprostatic disease.

Histological cancer in TURPs performed within 2 months of each other should have a pT1a orlb designation based on the sum total of carcinoma over both specimens. In a prostatectomy specimen where part of the capsule is missing, the pT designation can be accurately assigned only if the tumour is clearly surrounded by non-tumorous prostatic tissue.

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