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Quality assurance in anatomic and clinical pathology plays a critical role in the management of patients with prostate cancer, integrating quality development, quality maintenance, and quality improvement to ensure valid test results. This report describes the current efforts to ensure and improve quality in the pathology laboratory as it relates to prostate cancer. Recent advances have been made by many regulatory groups to improve the quality of laboratory diagnosis in prostate cancer and other cancers. Advances include publication of practice protocols for prostate specimen handling and results reporting, comparative interlaboratory proficiency testing, and consensus on grading and diagnostic criteria. Despite these advances, numerous unsettled issues remain, including observer variability in pathologic staging and grading, lack of agreement on terminology, and interlaboratory reproducibility of assays, such as serum prostate specific antigen (PSA) determination. Current efforts in quality assurance in anatomic and clinical pathology are expected to improve the accuracy and validity of pathologic diagnosis, grading, staging, prediction of outcome in prostate cancer, and serum PSA assays. Cancer 1995; 75:1994-9.

The search for the precursor of prostatic adenocarcinoma has focused in recent years on the spectrum of histopathologic changes referred to as high grade prostatic intraepithelial neoplasia (PIN). This review describes the diagnostic criteria and clinical significance of PIN. PIN coexists with cancer in more than 85% of cases, but retains an intact or fragmented basal cell layer, unlike cancer, which lacks a basal cell layer. High grade PIN in biopsies predicts the presence of cancer in subsequent biopsies, and PIN provides the highest risk ratio of all known predictive factors (14.93). The continuum that culminates in high grade PIN and early invasive cancer is characterized by progressive basal cell layer disruption, loss of markers of secretory differentiation, nuclear and nucleolar abnormalities, increasing proliferative potential, variation in DNA content, and allelic loss. Clinical studies suggest that PIN predates carcinoma by 10 years or more, with low grade PIN first appearing in men in their thirties. The significance of recognizing PIN is based on its strong association with prostatic carcinoma. This finding indicates the need for repeat biopsy and follow-up when PIN is identified on biopsy, especially in patients with elevated serum prostate specific antigen concentration. PIN also offers promise as an intermediate end point in studies of chemoprevention of prostatic carcinoma. Cancer 1995;75:1823-36.

An unique case of high-grade phyllodes tumor (cystosarcoma phyllodes) arising in the seminal vesicle is reported. A 61-year-old man had symptoms of urinary obstruction, and ultrasonography and computed tomography showed a large mass posterior to the bladder. Using cystoprostatoseminovesiculectomy, a high-grade phyllodes tumor of the left seminal vesicle was found that did not involve the bladder or prostate. Histologically, the tumor consisted of benign irregular slit-like glands set in a mitotically active cellular sarcomatous stroma. The epithelium displayed intense cytoplasmic immunoreactivity with all keratin proteins (AEL/AE3, CAM 5.2, and high-molecular-weight keratin [clone 34[Beta]E12]). The stromal cells were strongly positive for vimentin, and approximately 30% were positive for muscle-specific actin and desmin. Four years after resection, a lung metastasis was removed, which was histologically and immunohistochemically identical to the seminal vesicle tumor. This case represents the malignant end of the range of phyllodes tumors (cystosarcoma phyllodes). Like similar tumors in the breast and prostate, phyllodes tumors of the seminal vesicle should be considered high-grade lesions (malignant) in which there is significant mitotic activity, stromal pleomorphism, and stromal overgrowth. Cancer 1993; 71:2055-61.

There are a number of similarities between benign prostatic hyperplasia (BPH) and cancer. Both display a parallel increase in prevalence with patient age according to autopsy studies (86.2% and 43.6%, respectively, by the ninth decade), although cancer lags by 15-20 years. Both require androgens for growth and development, and both respond to antiandrogen treatment regimens. Most cancers arise in prostates with concomitant BPH 83.3%), and cancer is found incidentally in a significant number of transurethral prostatectomy (TURP) specimens (10%). The clinical incidence of cancer arising in patients with surgically treated BPH is approximately 3%. BPH may be related to a subset of prostate cancer which arises in the transition zone, perhaps in association with atypical adenomatous hyperplasia (AAH). It is important to exclude cancer in patients presenting with symptoms of bladder outlet obstruction presumably due to BPH. For such patients, we recommend digital rectal examination (DRE) and, at least in high-risk patients, serum prostate specific antigen (PSA) determination. Transrectal ultrasound (TRUS) should be employed in patients with elevated PSA levels to determine the volume of the prostate, the relative contribution of BPH to volume, and the PSA density (ratio of PSA level to volume). Biopsy should be obtained from any area suspicious for cancer. Early detection and treatment of cancer when it is localized offers the greatest chance for cure. Cancer 1992; 70:291-301.

For many years, the only method of treating breast cancer was radical mastectomy. One unfortunate consequence of this surgery is that the patient must deal with the psychological aspects of disfiguring surgery at the same time she is dealing with the emotional consequences of a potentially fatal illness. In the past 20 years, however, advances both in the treatment of breast cancer and in its early diagnosis have made breast conserving surgery possible. When this is an appropriate alternative, breast conserving surgery is as effective as mastectomy. However, not all breast cancers are amenable to breast conserving treatment, even when diagnosed early. For these women mastectomy remains the only possible treatment. Advances in cosmetic surgery have made it possible, however, to reconstruct a natural-looking breast to help alleviate some of the effects of losing this psychologically important symbol of femininity. The author describes the current techniques for breast reconstruction. In some patients, particularly those with early Stage I cancer, reconstruction may begin at the time of mastectomy surgery. More often, however, breast reconstruction will begin several months after the end of adjuvant chemotherapy; this practice may result in better healing. Reconstruction of the breast is accomplished in several steps; often the first is the implantation of an inflatable device to expand the overlying skin and provide a skin area comparable to the unaffected breast. For women with particularly large or droopy breasts, a tissue expander is inadequate and flaps of skin must be transplanted. Next, the silicone implant may be put into place. The last step is the creation of a nipple and areola, which can be color-matched by judicious choice of transplanted skin or by the use of injected tattoo dyes. It should be emphasized that breast reconstruction should not be considered as an afterthought; planning must be integrated into the initial treatment plan. (Consumer Summary produced by Reliance Medical Information, Inc.)