European Journal of Cardiovascular Medicine

The prostate is a pearshaped glandular organ that weighs up to 20 grams in normal adult male and that depends for its differentiation and subsequent growth on androgenic hormones synthesized in the testis. Benign prostatic hyperplasia, prostatitis, prostatic carcinoma are the three principal conditions involving the prostate accounting for more than 95% of lesions. There are several benign proliferations of prostate which mimic malignancy and their awareness is essential to avoid diagnostic pit falls. The incidence of prostatic lesions, both benign and malignant increases with age and are rare before 40 years of age. High grade prostatic intraepithelial neoplasia and Atypical Adenomatous Hyperplasia (AAH) are now considered to be the most likely precursors of prostate cancer. Prostatic intraepithelial neoplasia lesions can only be diagnosed by histopathological examination of prostatic tissue and it is not possible to detect clinically by direct rectal examination, prostatic specific antigen assay or ultrasound. ^1,2,3

Prostate cancer is one of the leading causes of morbidity and mortality worldwide. Cancer of prostate is typically a disease of men over age 50. Africans and Americans have higher incidence than Japanese and Asians.

The incidence of prostatic carcinoma is 0.13% in Americans and 0.09% in Japanese and 0.10% in other Asian countries. In view of the increased life expectancy the absolute number of clinically significant prostate carcinomas will probably increase in the coming decades. Despite prostate cancer high morbidity its etiology remains obscure with only established risk factors being increasing age, race, hormones, dietary factors, obesity, physical inactivity, occupation, vasectomy, smoking, sexual factors and genetic susceptibility. In the hormones androgens play an important role in prostatic cancer.  ^4,5

In the view of increasing trend of the occurrence of both neoplastic and non-neoplastic lesions of the prostate in elderly, the current study was carried out at evaluating the histopathological features of various benign, premalignant and malignant lesions of prostate. Use of immunohistochemical markers in this study helps in arriving at diagnosis and to know prognosis and develop therapeutic strategies.

AIM

The prospective work “Histopathological study of prostatic lesions in correlation with immunohistochemistry is aimed to study the histopathological spectrum of various non neoplastic and neoplastic lesions of prostate among the specimens received in a period of August 2013 to September 2015 at Department of pathology, Siddhartha medical college, Vijayawada by using immunohistochemical markers p63 and P504s that are helpful in differentiating benign, pre-malignant and malignant lesions and to compare statistical data with similar other studies.

OBJECTIVES

1. To study the age wise distribution of various non neoplastic and neoplastic lesions of prostate.
2. To study association of prostatic intraepithelial neoplasia in different prostatic lesions.
3. To find out expression of immunohistochemical markers p63 and P504s in BPH, prostatic intraepithelial neoplasia and carcinoma cases.
4. To analyze and correlate the available clinical data with other studies

This is a prospective study done from August 2013 to September 2015 at Siddhartha Medical College Vijayawada. The TURP specimens were received to the Department of Pathology, Siddhartha medical college from Government general hospital, Vijayawada.

Inclusion criteria:

1. All neoplastic and non-neoplastic lesions of prostate were included in the study.
2. All TURP specimens were included in the study.

Exclusion criteria:

1. Patients below age of 40 years were excluded from the study.
2. All metastatic tumors of prostate were excluded from the study.

The clinical details of each case were recorded according to age, clinical features, per rectal examination findings, PSA levels and clinical diagnosis. The TURP specimens obtained were fixed in 10% buffered formalin for a minimum period of 12hrs and then entire bits were submitted for routine processing, fixation, dehydration, clearing and embedding in paraffin wax. Sections were prepared from the blocks for routine staining.

The nuclei and calcium were stained blue. Cytoplasm was stained pale pink. Erythrocytes, muscle, and eosinophil granules were stained bright red. The histopathological sections were reported accordingly as inflammatory, benign or malignant lesions. All malignant lesions were graded according to Gleason’s grading developed by Gleason in conjunction with the Veterans Administrative Cooperative Urological Research Group. Subsequently all sections were subjected to immunohistochemical staining.

IMMUNOHISTOCHEMICAL STAINING (67)

This is a technique of identifying cellular or tissue constituents (antigens) by means of antigen antibody interactions, the site of antibody binding being identified either by direct labeling of the antibody, or by use of secondary labeling method. The amino acid side chains of the variable domain of an antibody form a cavity which is geometrically and chemically complementary to single type of antigen epitope. The associated antigen and antibody are held together by a combination of hydrogen bonds, electrostatic interactions and Vander Waals’ forces.

Interpretation of p63 staining in prostate glands (59)

• Negative or
• Positive – complete
• Positive- partial (<25% of gland’s circumference is stained).

P504s STAINING:

The immunohistochemistry staining procedure steps were performed same as that of p63 staining except that here the antibody used was p504s polyclonal antibody and probe is not applicable for p504s staining. Cellular localization: Granular and cytoplasmic Positive control: Prostate cancer. Normal tissue: Not applicable

Interpretation of AMACR staining (66)

Positive staining pertains to dark diffuse or granular, cytoplasmic or luminal, but circumferential. The percentage positivity was graded from 0+ to 3+ as follows: -  0% cells

• - 0+, negative 1-10% cells
• - 1+, mild 11-50% cells
• - 2+, moderate
• >50% cells - 3+, strong

The clinical details of the cases like age, clinical history, clinical diagnosis was collected from the patients requisition forms. The histopathological findings were noted and the sections were submitted for immunohistochemistry and results were noted accordingly. The master chart was prepared by using all these details and statistical analysis was done. The obtained results were interpreted in form of tables, charts, bar diagrams and pie diagrams. Further the salient features of the present study were discussed and compared with the other similar recent studies. At last the salient points of the present study were given in the form of conclusion.

OBSERVATIONS AND RESULTS

The present study comprises of 82 cases of TURP specimens received in the department of pathology, Siddhartha medical college, Vijayawada during the period from August 2013 to September 2015. The clinical data was collected from patient’s requisition forms and recorded as per proforma. The microscopic and other findings were taken into proforma and master chart was prepared from these details. Overall analysis of the results was done by using tables, pie diagrams by obtaining data from master chart.

A total number of 82 cases were studied. The cases were distributed in the age group of 46-88 years. The maximum numbers of patients were in age group 60-69 years and the next common age group affected was 70-79 years. Out of 82 cases 68 were BPH, 13 were prostatic adenocarcinomas and 1 case was urothelial carcinoma. Foci of low-grade PIN was identified in 12 cases. All low-grade PIN foci were associated with BPH. High grade PIN was identified in 13 cases. Out of these 2 high grade PIN foci were seen in BPH and 11 were seen associated with adenocarcinoma. Miscellaneous features like cystic atrophy, chronic non-specific prostatitis, basal cell hyperplasia were also seen associated with these lesions.

Immunohistochemistry was done using p63 and P504S markers in cases of benign prostatic hyperplasia, prostatic intraepithelial neoplasia and carcinoma cases. All cases of BPH showed complete positivity for p63 immunostaining in the basal nuclei of the glands and all these glands of BPH were negative for P504S immunostaining. Out of 13 cases of high-grade PIN all cases of showed positivity for p63 stain in the basal cell nuclei of HGPIN glands and 12 cases showed moderate to strong positivity for P504S immunostaining. Out of 13 cases of adenocarcinoma of prostate all the cases showed negativity for p63 immunostaining and all cases showed strong cytoplasmic, granular positivity for P504S immunostaining. One case of urothelial carcinoma showed p63 positivity ( of score 5) and strong cytoplasmic positivity for P504S immunostaining.

Table 1: Distribution of cases according to Histopathological diagnosis

In the present study out of 82 cases there were 68 (82.93%) cases of BPH constituting the majority, 13 (15.86) cases were adenocarcinomas and 1 (1.21%) case of urothelial carcinoma.

Table 2: Distribution of cases according to age group

In the present study maximum number of patients i.e., 40 (48.78%) cases were in age group 60-69 yrs, 16 (19.52%) cases were in 70-79 yrs, 12(14.63%) cases were in 50-59 yrs, 12(14.63%) cases were in 80-89 yrs and 2(2.44%) were in 40-49 yrs.

Table 3: Age wise distribution of cases according to histopathological diagnosis

In the present study maximum number of carcinoma cases i.e.,8 (57.15%) were in age group of 80-89 yrs out of 14 cases and maximum number of BPH cases i.e.,34 (50%) were in age group of 60-69 yrs.

Table 4: Mean age (yrs) of cases according to histopathological diagnosis

In the present study all cases were distributed in age group of 46-88 yrs. The mean age for carcinoma is 78.42 and for BPH is 67.10.

Table 5: Distribution of Prostatic Intraepithelial Neoplasia in different cases

In the present study out of 13 cases of adenocarcinoma, 11(84.62%) cases showed HGPIN and 2(15.38%) cases were negative for PIN and out of 68 cases of BPH, 12(17.65%) cases showed LGPIN and 2(2.94%) cases showed HGPIN.

Table 6: Different microscopic patterns of HGPIN

There were 4 patterns identified in HGPIN usually with multiple patterns in each case. Tufting pattern was seen in 10(76.92%) cases, flat pattern was seen in 7(53.85%), micropapillary pattern was seen in 2(15.38%) and cribriform pattern was seen in 1(7.69%) case out of 11 cases of adenocarcinoma and 2 cases of BPH showing HGPIN. The common pattern identified was tufting type and the next common was flat type.

Table 7: Distribution of cases of Prostatic Adenocarcinoma according to Gleason’s Grading system

The Gleason score 5,7,8,9,10 constituted 1(7.69%) case, 2(15.38%) cases, 3(23.09%) cases, 5(38.46%) cases and 2(15.38%) cases respectively.

Table 8: Expression of p63 immunostaining in different cases

All the BPH and HGPIN cases showed positivity for p63 and all adenocarcinoma cases showed negativity for p63 immunostaining

Table 9: Expression of P504s immunostaining in different cases

All adenocarcinomas and 12(92.3%) cases of HGPIN showed P504S positivity and all BPH cases were negative for P504S immunostaining.

Figure:1Showing benign prostatic hyper plasia H& E (100x)

Figure: 2Benignglandsin BPH showing positivity forp63nuclearstainingIHC(400x)

Figure 3: Showing basal cellhyperpl Asia H&E (100x)

Figure4:Basalcellhyperplasiashowingpositivityforp63nuclearstainingIHC(400x)

Figure:5 Showing lowgrade PINH&E(400x)

Figure:6 High grade PIN-Tufting pattern H&E (400x)

Figure:7 High grade PIN-Flatty pe H &E (400x)

Figure:8 High grade PIN–Micro papillary pattern H&E(400x)

Figure:9 High grade PIN- Cribriform pattern H&E(400x)

Figure:10HighgradePINshowingpositivityforp63nuclearstainingIHC (400x)

Figure:11HighgradePINshowingpositivityforP504ScytoplasmicstainingIHC (400x)

Figure:12 Prostaticadeno carcinoma Gleason’ grade 2H &E (100x)

Figure: 13 Prostaticadeno carcinoma Gleason’s grade3H &E(100x)

Figure:14Prostaticadeno carcinoma Gleason’sgrade4H&E(400x)

Figure:15Prostaticadeno carcinoma Gleason’s grade5H&E(100x)

Figure:16 Adeno carcinoma showing positivity for P504Scytoplasmicstaining IHC (400x)

Figure:17Adenocarcinomashowingnegativityforp63nuclearstainingIHC(400x)

Figure:18 Invasive urothelial carcinoma H&E(100x)

Figure:19Urothelialcarcinomashowingpositivityforp63nuclearstainingIHC(100x)

Figure:20UrothelialcarcinomashowingpositivityforP504ScytoplasmicstainingIHC(400x)

The present study was carried out on 82 cases of TURP specimens received to the Department of Pathology, Siddhartha medical college, Vijayawada during the period of August 2013 to September 2015. The specimens were examined and analyzed for histopathology of various non neoplastic and neoplastic lesions of prostate. Immunohistochemical markers like p63 and P504S were used in this study. Several studies were available on various types of prostatic lesions. In this part, salient features of the present study were discussed and compared with the other similar recent studies. Out of 82 cases 68 were BPH, 13 were prostatic adenocarcinoma and 1 case was urothelial carcinoma. Foci of low grade PIN was identified in 12 cases. All low grade PIN foci were associated with BPH. High grade PIN was identified in 13 cases. Out of these 2 cases of high grade PIN foci were seen in BPH and 11 cases were seen associated with adenocarcinoma. Benign proliferative lesions: Benign prostatic hyperplasia is an extremely common disorder in men over age 50 years. The disease represents a nodular enlargement of the gland caused by hyperplasia of both glandular and stromal components. It is fundamentally the consequence of a hormonal imbalance which leads to an alteration of the delicate balance that exists both in the epithelium and the stroma between cell death and proliferation. Other possible contributing factors include inflammation-induced release of platelet-derived growth factor and human papilloma virus. In the present study out of 82 TURP specimens’ benign prostatic hyperplasia was diagnosed in 68 (82.93%) of cases and it was the major type of lesion found in this study. These results were compared with similar other studies. In Haroun et al (1) study the incidence of BPH was found to be 64.48%. In Djavan et al (2) study the incidence was 83%. In Jasani et al (3) study the incidence was 56%.In Pacelli and Bostwick studies (4) the incidence of BPH was 81.7% of total cases which correlated with the present study.

Comparison of age wise distribution of BPH: All the cases of BPH were distributed between the ages of 40-89 years. The peak incidence was observed in age group of 60-69 years. Jasani et al (3) showed in their study the age wise distribution as, 3.92% below 50 years, 96.08% at 51-70 years and no cases were found above 70 years. In the present study the age incidence was 2.94% below 50 years, 67.64% at 51-70 years and 29.42% above 70 years. Like Jasani et al (3) study the present study also showed majority of patients in the age group of 51-70 years.

Mean age of BPH:

In the present study mean age of BPH patients was 67.10 years. It is comparable with the study done by Mwakyoma HA (5) in which the mean age was 67 years.

Microscopic findings: On microscopy the sections consisted of proliferation of both glandular and stromal components. The glands were variable in size, at places showed cystic dilation and contained an inspissated secretion called corpora amylacea. The lining epithelium was flat to columnar. The cytoplasm was pale, and the nuclei were regular and basally located with inconspicuous nucleoli. The epithelium showed papillary infoldings. The outer basal layer composed of flattened to cuboidal cells placed on an intact basement membrane. Associated with benign prostatic hyperplasia there were other findings like chronic non-specific prostatitis, basal cell hyperplasia and cystic atrophy. Chronic non-specific prostatitis microscopically is characterized by aggregates of lymphocytes, plasma cells and macrophages within the prostatic stroma. In few cases the epithelium displayed reactive atypia with occasional prominent nucleoli. Basal cell hyperplasia showed solid nests of basal cells without central lumen and few cases showed the lumen lined by secretory cells with clear cytoplasm and these were surrounded by multiple layers of basal cells. These basal cells were positive for p63 staining and negative for P504S. Glandular atrophy is commonly associated with chronic prostatitis which may have active component characterized by intraglandular neutrophils.

Expression of p63 staining in BPH:

In all 68 (100%) cases of BPH the basal cell nuclei of the glands showed positivity for p63 immunostaining which was complete positivity. The results were compared with other studies like Shah et al (6) and Kruslin et al (7) in which the percentage of positivity was 95% and 100% respectively. The percentage of p63 positivity in BPH in the present study correlated with Kruslin et al study.

Expression of P504S staining in BPH: In all the 68 (100%) cases of BPH, the glands were negative for P504S immunostaining. The percentage negativity was 100%. The results were compared with other studies like Jiang et al (8) and Kumaresan et al (9). Jiang et al (8) found P504S negativity in 254 (91.7%) cases out of 277 cases of benign prostate. The percentage of P504S negativity in Kumaresan et al (9) study was 100%. The percentage of P504S negativity in BPH in the present study correlated with Kumaresan et al study which was 100%. Premalignant lesions of the prostate: In the present study foci of low grade PIN was identified in 12 cases. All low grade PIN foci were associated with BPH. High grade PIN was identified in 13 cases. Out of these 2 cases of high grade PIN foci were seen in BPH and 11 cases were seen associated with adenocarcinoma. Comparison of incidence of HGPIN in TURP specimens: In the present study out of 82 cases high grade PIN was present in 13 cases and the incidence was 15.85%. The incidence was compared with similar other studies. Gaudin et al (10) studied 158 cases of TURP specimens and found HGPIN in 3.2% cases. In a study of 698 TURP specimens, Pacelli and Bostwick found the overall incidence of HGPIN 4.2%, including 2.8% in BPH and 10.2% with coexistent cancer (4) .Skjorten et al (11) found 33% of HGPIN in 731 TURP specimens.Present study showed 12 (14.63%) cases of low grade PIN and 13 (15.85%) cases of high grade PIN in 82 TURP specimens. The results were compared with similar other studies. The incidence of high grade PIN in Gaudin et al (10) was 3.2%, in Pacelli and Bostwick (4) the incidence was 4.2% and in Skjorten et al (11) the incidence was 33%

Association of LGPIN with BPH and adenocarcinoma: In the present study there were 12 cases of low grade PIN associated with BPH and no case of low grade PIN was seen with adenocarcinoma. Out of 68 cases of BPH 12 (17.65%) cases showed low grade PIN and these results were compared with similar other study. In Rekhi et al (12) study low grade PIN was seen in 18.6% cases of BPH and 5.8% of cases of adenocarcinoma. The association of low grade PIN with BPH of Rekhi et al (12) study correlated with the present study. On microscopy low grade PIN showed crowding and stratification of glandular secretory epithelium. The nuclei were variably increased in size with thin nuclear membrane and inconspicuous nucleoli. The basal cell layer was intact and composed of flattened to cuboidal cells placed on an intact basement membrane.

Association of HGPIN with BPH and Adenocarcinoma:

Rekhi et al (12) found 18.6% cases of low grade PIN and 11.2% cases of high grade PIN out of 29.9% cases of PIN seen in 177 specimens of benign prostatic hyperplasia. In cases of adenocarcinoma of prostate 86.9% of cases were associated with high grade PIN and 5.8% were associated with low grade PIN. In a study of 110 prostate specimens, to document the prevalence of HGPIN in a low-risk Indian population, Desai and Borges observed a majority of prostate carcinoma specimens (85.24%) were found to harbor HGPIN. Conversely, none of the benign prostate samples were found to have HGPIN (13). In the present study high grade PIN was observed in 2.94% of the cases of BPH and 84.62% of the cases of adenocarcinoma. The results were compared with Rekhi et al (12) study in which HGPIN was observed in 11.2% of cases of BPH and 86.9% of adenocarcinoma. In Desai and Borges (13) study HGPIN was observed in 85.24% of cases of adenocarcinoma which correlated with the present study. On microscopy high grade PIN consisted of crowding and stratification of glandular secretory epithelium. The nuclei were enlarged with variation in size and shape with clumping of chromatin and the nucleoli were prominent. The basal cells were intact but few cases showed discontinuity.

Microscopic patterns of HGPIN:

In the present study there were four microscopic patterns identified in HGPIN usually with multiple patterns in each case.

Tufting pattern was seen in 10 (76.92%) cases out of 13 cases of HGPIN. On microscopy the neoplastic cells were seen growing towards lumen, forming wave or mound like structures. This was the commonest pattern identified in the present study and it was compared with Bostwick et al (14) study which also showed that the commonest pattern was tufting type which constituted 87%.

Flat pattern was seen in 7(53.85%) cases out of 13 cases of HGPIN. In the present study this is the commonest pattern next to tufting pattern. On microscopy the glands were lined by one to two layers of atypical cells without significant architectural abnormality.

Micro papillary pattern was seen in 2(15.38%) cases out of 13 cases of HGPIN. On microscopy it was composed of glands lined by atypical secretory epithelial cells arranged in micro papillary structures, lacking fibro vascular cores.

Cribriform pattern was seen in 1(7.69%) case out of 13 cases of HGPIN. Microscopy showed glands with epithelium forming cribriform structures p63 expression in HGPIN: In immunohistochemical study of 28 cases of PIN and 41 cases of adenocarcinoma, Kruslin et al(7) found that p63 was positive around whole circumference in 12 out of 28 cases with PIN, and discontinuously positive in all the remaining cases, suggesting initial disruption of the basal cell layer; positivity was observed in all normal glands, and negative in all carcinomas In the present study all the 13(100%) cases of high grade PIN showed positivity for p63 staining. The present study was compared with the study done by Kruslin et al(7) which also showed 100% positivity for p63 staining in cases of high grade PIN in their study.

P504S Expression in HGPIN:

Yu et al (15) studied 42 cases of prostate cancer and 12 cases of high grade PIN for immunostaining of AMACR and basal cell markers p63 and 34βE12. They observed the positivity rate of AMACR in prostate carcinoma and in high grade PIN about 100% and 91.67% respectively. The present study showed moderate to strong positivity for P504S stain in 12 (92.3%) cases of HGPIN and 1(7.7%) case showed negativity. The presentstudy was compared with similar other studies. In Molinie et al (16) study the percentage of P504S positivity was 70% and in Wu et al (17), Yu et al (15) and Kunju et al (18) the percentage of P504S positivity was 90%, 91.67% and 89% respectively. The present study correlated with Yu et al study.

Malignant lesions of prostate

In the present study there were 13 (15.86%) cases of adenocarcinoma and 1(1.21%) case of urothelial carcinoma out of 82 cases. All 14 malignant lesions constituted 17.07% of cases. Malignant lesions in the age group of 60-69 years, 70-79 years, and 80-89 years constituted 2(14.28%) cases, 4 (28.57%) cases and 8(57.15%) cases respectively. The peak incidence was seen in 9th decade. Rullis et al (19) gives an incidence of 66.7% in 57 cases in men over 80 years of age. In the present study there were 13 (15.86%) cases of adenocarcinoma out of 82 cases. This was compared with similar other studies like Haroun et al(20) in which it was 27.1%,in Jasani et al(3) it was 32%, Djavan et al (21) it was 17%. The incidence of adenocarcinoma in the present study correlated with Djavan et al study.

Age incidence of carcinoma prostate: In the present study out of 14 cases of carcinoma (adenocarcinoma and urothelial carcinoma) of prostate, 13(92.85%) cases were seen above 65 years of age. In the present study the minimum age at which adenocarcinoma of prostate identified was 64 years and the maximum age was 86 years. Only one case of urothelial carcinoma identified in the present study and the age was 87 years. The peak incidence of carcinoma of prostate was seen in 9th decade with total 8(57.15%) cases were seen out of total 14 cases of carcinoma followed by 8th decade with an incidence of 28.57% and 14.28% in the 7th decade. Xie et al (22) found in their study that the percentage of carcinoma prostate was 84.2% over 65 years of age. Shimada et al (23) found 75% of cases of carcinoma above 65 years of age. The variation in age incidence could be due to small sample size of cases of carcinoma in the present study. The mean age was 78.42 years.

Mean age of carcinoma prostate: In the present study the mean age of carcinoma of prostate was 78.42 years. The minimum age was 64 years and the maximum age was 87 years. The mean age was compared with Lyn et al (24) study, Mwakyoma HA (5) study and Mwakyoma and Mabandi (25) study in which the mean age in their studies was 65 years, 75.6 years and 68 years respectively. The mean age in the present study correlated with study conducted by Mwakyoma HA (5)

Distribution of Gleason’s score in prostatic carcinoma:  Presence of infiltrative architecture, nuclear hyperchromasia and prominent nucleoli and absence of basal cell layer favor malignancy. In the present study Gleason score of 5 ,7, 8, 9 and 10 constituted 1(7.64%) case, 2(15.38%) cases, 3(23.08%) cases, 5(38.46%) cases and 2(15.44%) cases respectively. Majority of patients diagnosed as conventional adenocarcinoma were graded as score 9 (5 cases, 38.46%) followed by score8 (3 cases, 23.08%).

The distribution of patients in the present study was 0%, 23.08% and 76.92% in Gleason’s score 2-4, 5-7 and 8-10 respectively. Mwakyom and Mabandi(25) in their study showed the distribution of patients were 5.3%, 61.1% and 33.6% in Gleason’s score of 2-4, 5-7 and 8-10 respectively. Divrik et al (26) observed in their study that the distribution of patients were 9.7%, 76.7% and 13.6% in Gleason’s score of 2-4, 5-7 and 8-10 respectively. The present study showed more number of patients in Gleason’s score 8-10.

Immunohistochemistry:

76.92% When there were atypical glands in one or more foci and the architectural pattern of these glands was not overwhelmingly suggestive of malignancy, then the diagnostic dilemma was solved by use of immunohistochemical markers like p63 and P504S

In the present study out of 13 cases of adenocarcinoma of prostate all the 13 cases showed negativity for p63 immunostaining. The percentage of negativity was 100% and these results were compared with similar other studies. In Molinie et al (16) study the percentage of p63 negativity was 100%. In Signoretti et al (27) study the percentage of p63 negativity was 97%. In Shah et al (27) and Ud Din et al(60) also the percentage of negativity of p63 was 100% . Hence the present study correlated with Molinie et al (16), Shah et al(6) and Ud Din et al(28) studies in which it was also100%.

P504S expression in adenocarcinoma:

AMACR, a cytoplasmic protein recently identified by CDNA library subtraction in conjunction with high output microarray analysis of prostatic carcinoma, has been considered as a marker that is substantially upregulated in prostate cancer. A monoclonal antibody to AMACR, known as P504S has been developed and is available commercially for use on routine formalin-fixed, paraffin embedded tissue specimens. Molinie et al (16) studied immunohistochemistry of 260 prostate cases and found 97% of prostatic cancer showed AMACR over expression. Yu et al (15) studied 42 cases of prostate cancer and 12 cases of HGPIN for the immuno staining of AMACR and basal cell markers p63 and 34 beta E12. They observed the positivity rate of AMACR in prostate carcinoma and in HGPIN about 100% and 91.67% respectively.

In the present study out of 13 cases of adenocarcinoma all cases showed strong positivity to P504S immunostaining. The percentage of positivity was 100%. This was compared with similar other studies. In Molinie et al (16) and Rubin et al (29) the percentage of P504S positivity was 97%. In Jiang et al (30) , Yu et al (15) and Yang et al (31) the percentage of P504S positivity was 100% respectively. So the present study correlated with Jiang et al (30), Yu et al (15) and Yang et al (31) studies.

Urothelial carcinoma:

Primary urothelial carcinomas presumably arise from the urothelial lining of the prostatic urethra and the proximal portions of prostatic ducts. The frequency of primary urothelial carcinoma of prostate ranges from 0.7 to 2.8% of prostatic tumors in adults. Microscopy showed infiltrating sheets and solid nests of neoplastic transitional epithelial cells with moderate to scanty cytoplasm with pleomorphic and hyper chromatic nuclei having prominent nucleoli with occasional mitotic figures. There were occasional inflammatory cells around these tumor cells.

Expression of p63 and P504S immunostaining in urothelial carcinoma: In the present study the case of urothelial carcinoma showed p63 positivity (75-90% of cancer cell nuclei positive) and strong cytoplasmic positivity for P504S immunostaining. Langner et al (32) performed p63 stain in 53 urothelial carcinomas and found positivity in 51 (96.2%) cases. In the present study the case showed positivity for p63 immunostain. (Score 5 = 75--90% of cancer cell nuclei positive) Beach et al (33) found 5 (83%) out of 6 cases of invasive urothelial carcinoma showed P504S positivity. In the present study the case showed strong cytoplasmic positivity for P504S immunostaining.

BPH is the most common lesion of the prostate in the elderly males.  Conventional adenocarcinoma is the commonest type of prostatic carcinoma.  Gleason‘s score of 8-10 is the most common score in adenocarcinoma of prostate.  High grade PIN has a high degree of association with prostatic carcinoma. This reflects a greater possibility of high grade PIN as a precursor lesion to carcinoma prostate.  Basal cell marker p63 is really helpful in differentiating benign and HGPIN glands from malignant glands.

P504S is of great value in differentiating HGPIN and malignant glands from benign glands.  In view of high degree of association of HGPIN with prostatic carcinoma, it is suggested that these HGPIN patients need close follow-up, observations and investigations to rule out existence of carcinoma.

Conflict of Interest: None

Funding Support: Nil

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