UROPATHOLOGY
SQUAMOUS CELL CARCINOMA OF PROSTATE DEBA P. SARMA, M.D. THOMAS G. W E I L B A E C H E R , M.D. TIMOTHY D. MOON, M.D. From the Department of Pathology, Veterans Administration Medical Center, Louisiana State University Medical School, and Tulane University Medical School, New Orleans, Louisiana
ABSTRA C T--A primary squamous cell carcinoma occurring in the prostate of a sixty-nine-year-~ man is described. A radical excision that included cystoprostatectomy, total penectomy, scroti tomy, pubic symphysiectomy, and abdominoperineal resection of rectum was done. The patii died of systemic metastases six months after diagnosis. Review of the literature suggests that sucJ cancer of the prostate is rare, highly aggressive, and responds poorly to any mode of therai Histogenesis of this tumor remains controversial; however, it probably does not originate from ! prostatic acinar cells.
Primary squamous cell carcinoma of the prostate is rare. It appears to differ from common prostatic adenoeareinoma in its histogenesis, clinical course, and therapeutic response. In a review of 481 eases of prostatic carcinoma seen in the New Orleans VA Hospital's laboratory service over a period of ten years (January 1976 to December 1985), only 1 ease of keratinizing squamous cell carcinoma of the prostate has been found. We report this ease along with a review of the literature with special attention to the histogenesis of the tumor. Case Report A sixty-nine-year-old black man presented with acute urinary retention. He had undergone multiple urethroplasties in the past for recurrent bulbar urethral strictures. Past history included recurrent urinary tract infections, prostatitis, bladder diverticuli, and chronic pyelonephritis. Physical examination was unremarkable except for a palpable right inguinal lymph node. Cystoscopy revealed an irregular, friable urethral mucosa extending from the bladder neck to the bulbar urethra. There was almost complete obstruction of the prostatic
260
u r e t h r a by t u m o r that a b showed squamous cell eareino the abdomen and pelvis did n~ tra-abdominal spread of the t: chest roentgenogram and rout and serum chemical tests were The patient underwent a stt inguinal lymphadenectomy. T w e r e free of metastatic ear quently the patient underwe~ teration that included a radica tomy with ileal conduit, total bilateral orchiectomy and scr symphysiectomy, and abdomi~ tion of rectum with colostomy. fect was reconstructed with muscle flaps. Gross examination of the rc showed a gray-white, focally [ mor involving the entire prost~ plete obstruction of the prosta tumor had extended into the 1: had projected into the lumen however, the bladder mueosa tumor had also invaded the l tissue. Microscopically, the keratinizing squamous cell care
UROLOGY
/ MARCH 1991 / VOLUME XXXVII, NU: ~
0st the entire prostate and prostatic urethra i iymphatie and vascular invasion (Fig. 1). ddfinite site of origin, such as urethra or Urethral duets could be ascertained. Seatd[ remaining prostatic glands were normal. ii:hnoperoxidase study revealed the presence iirhstate-speeific antigen in the few remain~i!ostatie glands but complete absence in the ~ecl'lastiecells. The sections from the bladder neoplastic cells in the subepithelial tisith normal overlying urothelium. e patient was discharged one month after i~tion. Two months later he was admitted ii symptoms of small-bowel obstruction due idhesions. At laparotomy metastatic earima was noted in the liver. Subsequently ~ionary metastases were noted on chest ~i!genogram. During the course of the dist h e patient's serum acid phosphatase level :remained normal. The patient died six i!hS after diagnosis or about four months afi~dical resection.
i ~ii:i
:
7
Comment ist of the cancers occurring in the prostate denocarcmomas. Primary squamous cell aoma of the prostate is rare accounting for L0.5 to 1 percent of prost.ate cancers. 2 Beof the rarity of such tumors as well as the L~ion in differentiating squamous cell caraa from squamous metaplasia (commonly '~ing around prostatic infarcts, in chronic i[itis, and after estrogen therapy or radiaiherapy), strict diagnostic criteria such as suggested by Mott 2 should be followed. [,ia for the diagnosis of primary squamous ~rcinoma are: (1) clearly malignant neoi judged by invasion, growth pattern, and ~r anaplasia; (2) squamous features of [nization, squamous pearls, and intercelbridges; (3) lack of glandular differentia:(~) no prior estrogen therapy; and (5) ab:of primary squamous cell carcinoma here, particularly in the bladder. Our ease ~filled all the criteria. ically primary squamous cell carcinoma f b e distinguished from adenocarcinoma } prostate. Usual presentation is prostatic ~al obstruction or symptoms due to metab o n e disease in elderly men. However, ~ith metastatic disease serum acid phos~e level is usually not elevated in squa~eell earcinomas~,a in contrast to primary icarcinomas Radiologically, the bone me!is from prostatic adenocarcinoma is
i~
!?'
FmURE 1. lslands o] keratinizing squamous cell carcinoma have occuppied entire prostate (hematoxylin eosin, original magnification x 90).
usually osteoblastic compared with the osteolytic lesions in cases of metastatic squamous cell carcinoma of the prostate. 2 Squamous cell carcinoma of the prostate is a highly aggressive tumor. Various therapeutic modalities are not very effective in controlling this cancer. Surgical therapy has included total prostatectomy, 4's transurethral prostatic resection, ~'3,6 and o r c h i e c t o m y . 2,~,7 E s t r o g e n t h e r a p y ~,4,~ is usually ineffective. Radiation therapy has been used to control the primary disease 3,4 as well as for palliation of bone metastasis. 2 Chemotherapy with doxorubicin hydrochloride (Adriamyein) was met with good therapeutic response lasting up to five months in a patient with systemic metastases. 3 Average survival after diagnosis is about fourteen months. 2 Longest survival up to nine years was reported in a patient treated primarily with radiation.* In a reported case s radical surgical therapy that included cystoprostatectomy, total urethrectomy, bilateral pelvic node dissections, pubic symphysieetomy, and abdominoperineal resection of rectum was not successful. Perineal recurrence developed, and the patient died six months after surgery. Histogenesis of squamous cell carcinoma remains debatable. Several authors believe that the prostatic urethral urothelium is the origin of s q u a m o u s cell c a r c i n o m a . 1,6,s G r a y and MarshalP think that squamous cell carcinoma arises from the transitional epithelium of the periurethral ducts. Sieracki 4 has speculated that the basal or the reserve cells of the prostatic acini are the ceils of origin for squamous cell carcinoma. The common acinar columnar ceils
/ MARCH1991 / VOLUMEXXXVII,NUMBER3
261
may also be the source of squamous cell carcinoma because they retain the ability for squamous differentiation.2 Many reports describing mixed carcinoma or adenosquamous .carcinoma of the prostate clearly show that common prostatic adenocarcinomas may develop foci of squamous carcinoma especially after hormone or radiation therapy. 9-n In two reports the squamous cell carcinoma component was positive for prostate-specific antigen by immunoperoxidase study indicating that the neoplastic squamous cells were prostatic glandular epithelium in origin. 1°,11 In our case, the neoplastic squamous cells were completely negative for prostate-specific antigen suggesting that the cell of origin probably was not the prostatic acini. Whereas the clinical course and therapeutic response (specifically to hormonal manipulation) of mixed adenosquamous carcinomas are similar to those of prostatic adenoearcinomas, the primary prostatic squamous cell carcinoma is clinically very aggressive with poor response to any therapy. It appears that the histogenesis of pure squamous cell carcinoma of the prostate may be distinctly different from that of adenosquamous cancers, n
262
V.A. MedicalCen[i ~ 1601 Perdido Sfr~ New Orleans, Louisiana 70i~ (DR. S A R ~ References i. Mostofi FK, and Price E B Jr: Tumor,, system, in Atlas of Tumor Pathology, Washington, D.C., Armed Forces Instituteo 245-246. 2. Mort LJM: Squamous cellcarcinoma o of 2 eases and review of the literature,J Ur 3. Corder MP, and Ciemil GA: Effeetiv, staticsquamous eel]carcinoma of the prostat Urol 115:222 (1976). 4. SierackiJC: Epidermoid carcinoma of report of three eases, Lab Invest 4:232 (191
5. Gray GF Jr, and Marshall VF: Squam prostate, J Urol 113:736 (1975). 6. Thompson GJ, Mbers DD, and Brodc cinemas involving the prostate gland, J Ure 7. Sharma SK, Malik AK, and Bapna B( cinema of prostate, Indian J Cancer 17: 13, 8. Utz DC, and Farrow GM: Pathologi, prognosis of prostatic carcinoma, JAMA 20c, 9. Bennett RS, and Edgerton EO: Mixed j Urol 110:561 (1973). 10. Accetta PA, and Garnder WA Jr: cinema of prostate, Urology 22:73 (1983). 11. Saito R, Davis BK, and Ollapally EP: cinema of the prostate, Hum Pathol 15:87
UROLOGY
/
MARCH 1991 /
VOLUME XXXVII, NU
SQUAMOUS CELL CARCINOMA OF PROSTATE DEBA P. SARMA, M.D. THOMAS G. W E I L B A E C H E R , M.D. TIMOTHY D. MOON, M.D. From the Department of Pathology, Veterans Administration Medical Center, Louisiana State University Medical School, and Tulane University Medical School, New Orleans, Louisiana
ABSTRA C T--A primary squamous cell carcinoma occurring in the prostate of a sixty-nine-year-~ man is described. A radical excision that included cystoprostatectomy, total penectomy, scroti tomy, pubic symphysiectomy, and abdominoperineal resection of rectum was done. The patii died of systemic metastases six months after diagnosis. Review of the literature suggests that sucJ cancer of the prostate is rare, highly aggressive, and responds poorly to any mode of therai Histogenesis of this tumor remains controversial; however, it probably does not originate from ! prostatic acinar cells.
Primary squamous cell carcinoma of the prostate is rare. It appears to differ from common prostatic adenoeareinoma in its histogenesis, clinical course, and therapeutic response. In a review of 481 eases of prostatic carcinoma seen in the New Orleans VA Hospital's laboratory service over a period of ten years (January 1976 to December 1985), only 1 ease of keratinizing squamous cell carcinoma of the prostate has been found. We report this ease along with a review of the literature with special attention to the histogenesis of the tumor. Case Report A sixty-nine-year-old black man presented with acute urinary retention. He had undergone multiple urethroplasties in the past for recurrent bulbar urethral strictures. Past history included recurrent urinary tract infections, prostatitis, bladder diverticuli, and chronic pyelonephritis. Physical examination was unremarkable except for a palpable right inguinal lymph node. Cystoscopy revealed an irregular, friable urethral mucosa extending from the bladder neck to the bulbar urethra. There was almost complete obstruction of the prostatic
260
u r e t h r a by t u m o r that a b showed squamous cell eareino the abdomen and pelvis did n~ tra-abdominal spread of the t: chest roentgenogram and rout and serum chemical tests were The patient underwent a stt inguinal lymphadenectomy. T w e r e free of metastatic ear quently the patient underwe~ teration that included a radica tomy with ileal conduit, total bilateral orchiectomy and scr symphysiectomy, and abdomi~ tion of rectum with colostomy. fect was reconstructed with muscle flaps. Gross examination of the rc showed a gray-white, focally [ mor involving the entire prost~ plete obstruction of the prosta tumor had extended into the 1: had projected into the lumen however, the bladder mueosa tumor had also invaded the l tissue. Microscopically, the keratinizing squamous cell care
UROLOGY
/ MARCH 1991 / VOLUME XXXVII, NU: ~
0st the entire prostate and prostatic urethra i iymphatie and vascular invasion (Fig. 1). ddfinite site of origin, such as urethra or Urethral duets could be ascertained. Seatd[ remaining prostatic glands were normal. ii:hnoperoxidase study revealed the presence iirhstate-speeific antigen in the few remain~i!ostatie glands but complete absence in the ~ecl'lastiecells. The sections from the bladder neoplastic cells in the subepithelial tisith normal overlying urothelium. e patient was discharged one month after i~tion. Two months later he was admitted ii symptoms of small-bowel obstruction due idhesions. At laparotomy metastatic earima was noted in the liver. Subsequently ~ionary metastases were noted on chest ~i!genogram. During the course of the dist h e patient's serum acid phosphatase level :remained normal. The patient died six i!hS after diagnosis or about four months afi~dical resection.
i ~ii:i
:
7
Comment ist of the cancers occurring in the prostate denocarcmomas. Primary squamous cell aoma of the prostate is rare accounting for L0.5 to 1 percent of prost.ate cancers. 2 Beof the rarity of such tumors as well as the L~ion in differentiating squamous cell caraa from squamous metaplasia (commonly '~ing around prostatic infarcts, in chronic i[itis, and after estrogen therapy or radiaiherapy), strict diagnostic criteria such as suggested by Mott 2 should be followed. [,ia for the diagnosis of primary squamous ~rcinoma are: (1) clearly malignant neoi judged by invasion, growth pattern, and ~r anaplasia; (2) squamous features of [nization, squamous pearls, and intercelbridges; (3) lack of glandular differentia:(~) no prior estrogen therapy; and (5) ab:of primary squamous cell carcinoma here, particularly in the bladder. Our ease ~filled all the criteria. ically primary squamous cell carcinoma f b e distinguished from adenocarcinoma } prostate. Usual presentation is prostatic ~al obstruction or symptoms due to metab o n e disease in elderly men. However, ~ith metastatic disease serum acid phos~e level is usually not elevated in squa~eell earcinomas~,a in contrast to primary icarcinomas Radiologically, the bone me!is from prostatic adenocarcinoma is
i~
!?'
FmURE 1. lslands o] keratinizing squamous cell carcinoma have occuppied entire prostate (hematoxylin eosin, original magnification x 90).
usually osteoblastic compared with the osteolytic lesions in cases of metastatic squamous cell carcinoma of the prostate. 2 Squamous cell carcinoma of the prostate is a highly aggressive tumor. Various therapeutic modalities are not very effective in controlling this cancer. Surgical therapy has included total prostatectomy, 4's transurethral prostatic resection, ~'3,6 and o r c h i e c t o m y . 2,~,7 E s t r o g e n t h e r a p y ~,4,~ is usually ineffective. Radiation therapy has been used to control the primary disease 3,4 as well as for palliation of bone metastasis. 2 Chemotherapy with doxorubicin hydrochloride (Adriamyein) was met with good therapeutic response lasting up to five months in a patient with systemic metastases. 3 Average survival after diagnosis is about fourteen months. 2 Longest survival up to nine years was reported in a patient treated primarily with radiation.* In a reported case s radical surgical therapy that included cystoprostatectomy, total urethrectomy, bilateral pelvic node dissections, pubic symphysieetomy, and abdominoperineal resection of rectum was not successful. Perineal recurrence developed, and the patient died six months after surgery. Histogenesis of squamous cell carcinoma remains debatable. Several authors believe that the prostatic urethral urothelium is the origin of s q u a m o u s cell c a r c i n o m a . 1,6,s G r a y and MarshalP think that squamous cell carcinoma arises from the transitional epithelium of the periurethral ducts. Sieracki 4 has speculated that the basal or the reserve cells of the prostatic acini are the ceils of origin for squamous cell carcinoma. The common acinar columnar ceils
/ MARCH1991 / VOLUMEXXXVII,NUMBER3
261
may also be the source of squamous cell carcinoma because they retain the ability for squamous differentiation.2 Many reports describing mixed carcinoma or adenosquamous .carcinoma of the prostate clearly show that common prostatic adenocarcinomas may develop foci of squamous carcinoma especially after hormone or radiation therapy. 9-n In two reports the squamous cell carcinoma component was positive for prostate-specific antigen by immunoperoxidase study indicating that the neoplastic squamous cells were prostatic glandular epithelium in origin. 1°,11 In our case, the neoplastic squamous cells were completely negative for prostate-specific antigen suggesting that the cell of origin probably was not the prostatic acini. Whereas the clinical course and therapeutic response (specifically to hormonal manipulation) of mixed adenosquamous carcinomas are similar to those of prostatic adenoearcinomas, the primary prostatic squamous cell carcinoma is clinically very aggressive with poor response to any therapy. It appears that the histogenesis of pure squamous cell carcinoma of the prostate may be distinctly different from that of adenosquamous cancers, n
262
V.A. MedicalCen[i ~ 1601 Perdido Sfr~ New Orleans, Louisiana 70i~ (DR. S A R ~ References i. Mostofi FK, and Price E B Jr: Tumor,, system, in Atlas of Tumor Pathology, Washington, D.C., Armed Forces Instituteo 245-246. 2. Mort LJM: Squamous cellcarcinoma o of 2 eases and review of the literature,J Ur 3. Corder MP, and Ciemil GA: Effeetiv, staticsquamous eel]carcinoma of the prostat Urol 115:222 (1976). 4. SierackiJC: Epidermoid carcinoma of report of three eases, Lab Invest 4:232 (191
5. Gray GF Jr, and Marshall VF: Squam prostate, J Urol 113:736 (1975). 6. Thompson GJ, Mbers DD, and Brodc cinemas involving the prostate gland, J Ure 7. Sharma SK, Malik AK, and Bapna B( cinema of prostate, Indian J Cancer 17: 13, 8. Utz DC, and Farrow GM: Pathologi, prognosis of prostatic carcinoma, JAMA 20c, 9. Bennett RS, and Edgerton EO: Mixed j Urol 110:561 (1973). 10. Accetta PA, and Garnder WA Jr: cinema of prostate, Urology 22:73 (1983). 11. Saito R, Davis BK, and Ollapally EP: cinema of the prostate, Hum Pathol 15:87
UROLOGY
/
MARCH 1991 /
VOLUME XXXVII, NU
