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CASE REPORT Table of Contents   
Year : 2010  |  Volume : 53  |  Issue : 1  |  Page : 152-154
Nonspecific granulomatous prostatitis with prostatic adenocarcinoma


Department of Pathology and Laboratory Medicine, The University of Texas Medical School at Houston, USA

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Date of Web Publication19-Jan-2010
 

   Abstract 

Granulomatous prostatitis is an infrequently seen entity in routine practice. One of its most common subtypes is nonspecific granulomatous prostatitis (NSGP), the etiology of which is still under debate. Such cases may be mistaken for adenocarcinoma clinically and radiologically. Histological resemblance to adenocarcinoma may arise when there is a xanthogranulomatous pattern or a prominence of epithelioid histiocytes. However, NSGP may rarely coexist with adenocarcinoma and it is critical to sample these cases thoroughly to exclude the presence of malignancy.

Keywords: Granulomatous prostatitis, nonspecific granulomatous prostatitis, prostatic adenocarcinoma

How to cite this article:
Murugan P, Brown RE, Zhao B. Nonspecific granulomatous prostatitis with prostatic adenocarcinoma. Indian J Pathol Microbiol 2010;53:152-4

How to cite this URL:
Murugan P, Brown RE, Zhao B. Nonspecific granulomatous prostatitis with prostatic adenocarcinoma. Indian J Pathol Microbiol [serial online] 2010 [cited 2019 Oct 14];53:152-4. Available from: http://www.ijpmonline.org/text.asp?2010/53/1/152/59211



   Introduction Top


Granulomatous prostatitis is an infrequently encountered entity first described by Tanner and McDonald in 1943, as cited by Mohan et al. [1] It is often mistaken for prostatic carcinoma clinically, radiologically and at times even in histological sections. The importance of making a distinction between these two entities cannot be overemphasized. However, the coexistence of prostatic adenocarcinoma with granulomatous prostatitis has rarely been reported. [1],[2],[3],[4],[5] A case of florid nonspecific (idiopathic) granulomatous prostatitis (NSGP) in the background of low grade prostatic adenocarcinoma is presented in this report.


   Case Report Top


A 59-year-old gentleman presented with history of progressive difficulty in urination. His vital signs were normal, with a temperature of 97.2°F, pulse rate of 91/min, respiratory rate of 20/min and blood pressure of 130/84 mm Hg. The hemoglobin was 12.4 g/dl with a hematocrit of 25.9 %. The serum prostate specific antigen (PSA) measured 20 ng/mL. A digital rectal examination was done and following a clinical suspicion of prostate cancer, the patient underwent a transrectal ultrasound guided biopsy. The diagnosis of adenocarcinoma, Gleason score 3+3 at the right lateral, mid and lateral apex was confirmed on histological examination. A robot assisted laparoscopic prostatectomy was performed. The postoperative period was uneventful.

On gross examination, the prostate gland measured 12.7 x 4.5 x 4.4 cms and weighed 57.8 grams. The capsule was intact. The cut surface was firm, nodular with multiple tiny cystic structures. The seminal vesicles and vas deferens were free of tumor. The specimen, submitted entirely as whole mount cross sections from apex to base, on microscopic examination showed adenocarcinoma, Gleason's score 7 (3+4). There was no predominant tumor mass and the carcinoma presented as multiple small nodules throughout the entire prostate. The maximum dimension of the tumor mass, located at the right central zone was 0.6 cm. Other tumor nests were seen in the posterior peripheral zone, anterior transitional zone as well as in the central zone. The total tumor volume was less than three per cent of the prostate. Intraluminal crystalloids were also noticed [Figure 1]. No perineural invasion, capsular invasion, extra prostatic extension or lymphovascular invasion was seen. All the margins were free of tumor.

Besides adenocarcinoma of the prostate, a florid (non-caseating) granulomatous inflammation mainly located close to the right apex but scattered throughout the lobe was seen along with Langhans type multinucleated giant cells. In some regions, the granulomas were seen surrounding and effacing dilated ducts containing inspissated secretion often admixed with acute inflammatory cells, histiocytes, giant cells and desquamated epithelial cells [Figure 2],[Figure 3]. Striking multinucleated giant cell reactions embracing the corpora amylacea were also noticed [Figure 4]. Special stains using Gomori methenamine silver (GMS) and Ziel Neelsen (ZN) did not reveal any fungal or acid fast micro-organisms. Other pathological findings included cystic atrophy, chronic inflammation, benign prostatic hyperplasia and adenosis. Eosinophils and necrosis were not prominent. The carcinomatous foci and the granulomas did not seem to have any particular spatial association.

Pathological diagnosis of a multifocal and bilateral adenocarcinoma, Gleason score 7 (3+4) associated with NSGP and nodular hyperplasia was made.


   Discussion Top


As noted previously, granulomatous prostatitis is an infrequently encountered entity that was first described by Tanner and McDonald in 1943 as cited by Mohan et al. [1] The most commonly followed classification is attributed to Epstein and Hutchins who categorized it into four major groups: infectious, iatrogenic, secondary to systemic granulomatous diseases and idiopathic (nonspecific). [6] Cases of malakoplakia and xanthogranulomatous prostatitis have also been described. [1] Among these, the nonspecific type is said to be the most frequently encountered lesion with incidence ranging from 60-77.7%. [1]

The etiology of NSGP is still under contention though various theories, including reaction to extravasated secretions from blocked prostatic ducts, bacterial products and refluxed urine have been proposed. [1] An autoimmune etiology has also been projected, suggesting an association between NSGP and HLA-DRB1*1501. [7] Evidence of T lymphocyte recall response to PSA was found in the afore-mentioned study. This case had striking giant cell reaction to the corpora amylacea in the ducts [Figure 4]. It is well known that PSA is part of the high protein secretory product which precipitates as prostatic concretions or corpora amylacea in the glandular and ductal lumina. The aforementioned findings in this case may hence support the autoimmune theory.

Clinically the patients present with symptoms of obstructive uropathy, as seen in our case. A few cases may also present with high fever and symptoms of prostatitis. [5] The firmness of the lesion often leads to a clinical diagnosis of adenocarcinoma. There are no well defined radiological differences between granulomatous prostatitis and prostatic adenocarcinoma as well. PSA levels may be normal or increased. [5]

Histological resemblance to adenocarcinoma may arise when there is a xanthogranulomatous pattern or a prominence of epithelioid histiocytes. In such cases an immunohistochemical (IHC) panel including antibodies to CD68 and PSA will aid in arriving at the right diagnosis. [5] However, NSGP may rarely coexist with adenocarcinoma as in this case. To date and to the best of our knowledge, there are only four such documentations. Mbakop et al. [3] had encountered one case of prostatic carcinoma in a study of 53 NSGP specimens while Gujral and Gillatt [4] as well as Val-Bernal et al. [5] reported a case each. Mohan et al. [1] had come across one case of coexisting adenocarcinoma in a study of 20 cases of granulomatous prostatitis although they did not specify whether it was a case of NSGP. Furthermore, there are two undocumented associations in the study by Oppenheimer et al. [2] It should also be mentioned that in a study of 21 cases of NSGP by Osca Garcia et al, [8] four patients developed prostate carcinoma, with an average presentation time of 5.5 years after the diagnosis of NSGP.

Specific granulomatous prostatitis, especially the infectious type, has to be differentiated from NSGP by using histochemical stains like periodic acid Schiff stain, Gomori's stain and ZN stain since the former requires treatment and the latter is a self limiting condition. [1]

In conclusion, it has to be emphasized that despite being an uncommonly encountered association, all cases of NSGP should be thoroughly sampled and studied to rule out the presence of carcinomatous foci.

 
   References Top

1.Mohan H, Bal A, Punia RP, Bawa AS. Granulomatous prostatitis--an infrequent diagnosis. Int J Urol 2005;12:474-8.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Oppenheimer JR, Kahane H, Epstein JI. Granulomatous prostatitis on needle biopsy. Arch Pathol Lab Med 1997;121:724-9.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Mbakop A, Reverdin N, Cox JN. Prostatites granuloma- Granulomatous Prostatitis and Adenocarcinoma 245 teuses non spe´cifiques. Etude histopathologique de 53 cas avec revue de la litte´rature. Schweiz Med Wochenschr 1985;115:522-5.  Back to cited text no. 3      
4.Gujral S, Gillatt DA. A peculiar case of granulomatous prostatitis: A cause for concern. Br J Urol 1998;81:775.  Back to cited text no. 4      
5.Val-Bernal J, Zaldumbide L, Garijo M, González-Vela M. Nonspecific (idiopathic) granulomatous prostatitis associated with low-grade prostatic adenocarcinoma. Ann Diagn Pathol 2004;8:242-6.  Back to cited text no. 5      
6.Epstein JI, Hutchins GM. Granulomatous prostatitis: Distinction among allergic, nonspecific, and post transurethral resection lesions. Hum Pathol 1984;15:818-25.  Back to cited text no. 6      
7.Alexander RB, Mann DL, Borkowski AA, Fernandez-Vina M, Klyushnenkova EN, Kodak J et al. Granulomatous prostatitis linked to HLA-DRB1*1501. J Urol 2004;171:2326-9.   Back to cited text no. 7      
8.Osca Garcý´a JM, Alfaro Ferreres L, Vera Donoso CD, Ruíz Cerdá JL, Martínez Jabaloyas JM, Jiménez Cruz JF. Non-specific granulomatous prostatitis. Relationship and differential diagnosis with prostatic cancer. Actas Urol Esp 1994;18:287-90.  Back to cited text no. 8      

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Correspondence Address:
Paari Murugan
8, Kesari Nagar Main Road, Adambakkam, Chennai, India

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.59211

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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