| Abstract|| |
Background: Elderly men are at high risk of various prostatic diseases carrying high morbidity and mortality rates. For screening large populations, there is a need for a simple, reliable, and noninvasive test with high sensitivity and specificity. Exfoliated prostatic cancer cells can be harvested by prostatic massage and subjected to cytologic examination and molecular tests. Aims: This study was undertaken to evaluate the morphology of various prostatic lesions on post prostatic massage urine cytology and correlate cytologic, histologic, and clinical findings. It was further proposed to establish the diagnostic accuracy of post prostatic massage urine cytology in different prostatic lesions. Materials and Methods: Totally, 100 cases including 50 cases each from study group and control group were subjected to post prostatic massage urine cytology and correlated with clinical and histological findings. Results: Five out of 50 cases were diagnosed as prostatic carcinoma, of which 60% were clinically detected. Diagnostic accuracy by histology and cytology independently was 80%, and 20% remained false negative by each technique. On combining both the techniques, diagnostic accuracy was 100%. For nine cases each of prostatitis and nodular hyperplasia diagnosed clinically, the diagnostic accuracy by cytology was 100 and 66.6%, respectively. 62% (31) cases were diagnosed as nodular hyperplasia including 22 (44%) cases of nodular hyperplasia with prostatitis. Conclusion: Collection of urinary specimens after prostatic massage provides adequate samples for cytological examination and carries great importance in establishing the preoperative morphologic diagnosis in cases of malignancy, prostatitis, and prostatic calculi.
Keywords: Nodular hyperplasia, prostatic carcinoma, prostatitis, tuberculosis, urine cytology
|How to cite this article:|
Choudhury M, Agarwal S. Evaluation of the efficacy of post prostatic massage urine cytology in diagnosis of various prostatic lesions with cytohistological and clinical correlation. J Cytol 2017;34:212-6
|How to cite this URL:|
Choudhury M, Agarwal S. Evaluation of the efficacy of post prostatic massage urine cytology in diagnosis of various prostatic lesions with cytohistological and clinical correlation. J Cytol [serial online] 2017 [cited 2020 Feb 21];34:212-6. Available from: http://www.jcytol.org/text.asp?2017/34/4/212/216121
| Introduction|| |
Presenile and senile men are at high risk of various prostatic diseases which carry high morbidity and mortality rates and pose diagnostic difficulties. Often a morphological confirmation is required to substantiate the clinical diagnosis. Carcinoma of the prostate is the commonest malignancy affecting males and is the second most common cause of cancer-related deaths in males. Incidence of carcinoma prostate increases with age and 30% cases are detected between 30 and 49 years and 64% cases are detected between 60 and 70 years; hence screening for all men is recommended after 50 years of age. For screening a large population, there is a need for a simple, reliable, and noninvasive test with high sensitivity and specificity. Prostatic cancer cells have increased tendency to exfoliate and these cells can be harvested by prostatic massage and subjected to cytologic examination and various molecular tests. Exfoliated cells represent the disease status of entire gland and hence this method can be used for the detection of various benign and malignant processes affecting the prostate. This study was undertaken to evaluate the morphology of various prostatic lesions on post prostatic massage urine cytology and to correlate cytologic, histologic, and clinical findings. It was further proposed to establish the diagnostic accuracy of post prostatic massage urine cytology for different prostatic lesions, particularly for the preoperative diagnosis of carcinoma, in symptomatic patients.
| Materials and Methods|| |
The present prospective study was carried out in the Department of Pathology and Department of Surgery at Lady Hardinge Medical College New Delhi on 100 cases in which study group and control group comprised 50 cases each. Control group comprised cases who presented with complaints other than those related to genito-urinary system.
In all the cases, detailed history and clinical examination was conducted. Based on clinical and rectal examination, 50 cases of study group were divided under following subgroups: Group I – Prostatitis (9 cases), Group IIa – Nodular hyperplasia with prostatitis (16 cases), Group IIb – Nodular hyperplasia (16 cases), Group III – Suspicious for carcinoma (6 cases), and Group IV – Carcinoma (3 cases).
Pre and post massage urine samples were collected and subjected to routine biochemical and microscopic examination. Urine culture was done in selected cases only. Detailed hematological investigations, serum alkaline and acid phosphatase, were measured. X-ray chest and abdomen, intravenous pyelogram, and endoscopy were done as per clinical indication.
After evacuating the bladder, prostatic massage was carried out on all cases by Fergusson and Gibson technique and first 10 ml of voided urine was collected in plastic centrifuge tubes. In cases with urinary retention, both pre and post massage urine samples were collected. Urine samples were centrifuged at 1500 rpm for 5 min and sediment was spread on the glass slides and fixed in equal parts of ether and 95% alcohol for 30 min and subjected to Papanicolaou staining. Surgical or needle biopsy specimen of the prostate gland was obtained in 38 out of 50 cases. Cytologic and histopathologic diagnosis was established without the knowledge of other.
| Results|| |
Age range in the study group varied from 30 to 90 years. Age distribution of various subgroups is shown in [Table 1]. Majority of the patients presented with symptoms of frequency with nocturia, dysuria, and retention of urine. Hematuria and pain in lower abdomen were present in some cases with prostatitis or concurrent vesicle calculi.[Figure 1], [Figure 2]
|Table 1: Significant clinical, radiological, and urinary findings in various subgroups|
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|Figure 1: (a) Smear shows a group of prostatic epithelial cells having slightly enlarged and smudgy nuclei, cytoplasmic vacuolization, along with neutrophils, macrophages, and lymphocytes in the background ((Pap stain ×400)). (b) Smear shows large foam cells with vacuolated cytoplasm, few lymphocytes and macrophages ((Pap stain ×400)). (c) Smear shows honeycomb sheet of benign prostatic epithelial cells with uniform chromatin pattern (Pap stain ×400)|
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|Figure 2: (a) Smear shows a loose cluster of poorly differentiated malignant cells with scanty frayed cytoplasm, enlarged hyperchromatic nuclei with irregular chromatin clumping and conspicuous nucleoli (Pap stain ×400). (b) Smear shows malignant cells showing microacinar arrangement. Cytoplasm in most of the acini is concentrated in the centre and the hyperchromatic nuclei are arranged in the periphery (Pap stain ×400)|
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Per rectal examination findings of 50 cases of study group are shown in [Table 1] and no abnormality was observed in control group. Examination of pre prostatic massage urine sample was performed in all 100 cases. Significant findings are shown in [Table 1]. Albuminuria was not observed in control group and none of the cases in the study and control group had urinary sugar or ketone.
Urine culture was performed in 35 cases of study group showing significant number of pus cells and Escherichia More Details coli, Streptococcus pyogenes, Klebsiella, and Pseudomonas aeruginosa were the various organisms grown in different subgroups.
Alkaline phosphatase levels were slightly elevated [15–17 King Armstrong (KA) units] in three cases of carcinoma prostate. Acid phosphatase levels were raised in two cases of carcinoma with values of 5 and 7 KA units.
Post prostatic massage urine samples were subjected to cytological examination in all 100 cases. 41 out of 50 (82%) study cases were adequate. Smears from all the cases were assessed for cellularity, pattern of cells, type of epithelial cells – prostatic, transitional, squamous and seminal vesicle, inflammatory cells, and other components – sperms, red cells, calculi, and corpora amylacea.
Cytological examination in the study group demonstrated – prostatitis 14 cases (28%), granulomatous prostatitis 1 case (2%), prostatic calculi 2 cases (4%), nodular hyperplasia with prostatitis 10 cases (20%), nodular hyperplasia 10 cases (20%), prostatic carcinoma 4 cases (8%), and inadequate in 9 cases (18%).
Nine out of 50 control cases showed an occasional benign prostatic epithelial cell, transitional cells, and few lymphocytes and rest were inadequate.
Specimen for histopathological examination was available in 38 out of 50 cases. In 12 cases histopathology was not done (nine cases of prostatitis confirmed on culture and two cases of prostatic calculi and one case of suspicious for carcinoma that did not turn up for follow-up). Following, histopathologic diagnoses were made – tubercular prostatitis 2 cases (4%), nodular hyperplasia with prostatitis 22 cases (44%), nodular hyperplasia 9 cases (18%), carcinoma prostate 4 cases (8%), and normal prostatic tissue 1 case (2%).
[Table 2] shows correlation of clinical and cytological diagnosis with histopathology. The diagnostic accuracy by cytology and histopathology was assessed in relation to the final diagnosis based on clinical, cytological, and histological evaluations as shown in [Table 3].
|Table 2: Correlation of clinical and cytological diagnosis with histopathology|
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| Discussion|| |
A high percentage of carcinoma is known to remain asymptomatic and hence remain undiagnosed until it has transgressed the bounds of surgical removal and cure. A preoperative morphological diagnosis in such cases and in early suspicious lesions would be invaluable in ruling out the possibility of malignancy and helping us in guiding the treatment. Conditions involving the prostate are usually diagnosed by digital examination. A needle biopsy can provide a morphological diagnosis in symptomatic patients but this technique is not simple and involves a certain degree of risk, and moreover, it has the potential to miss the lesion. Several methods for sampling prostate are in use, including fine needle aspiration cytology, urine and prostatic secretion cytology. Cytodiagnosis by post prostatic massage has been adopted as the technique for sampling prostate in the present study. Nine cases (18%) were diagnosed as prostatitis that showed degenerative changes in the epithelium along with mixed inflammatory infiltrate. Magri et al. and Hessler  in their study found that cytological examination of post prostatic massage urine sample was a reliable method for diagnosis of prostatitis and also found it to be more feasible than examination of expressed prostatic secretion. Pre and post prostatic massage urine culture and cytology was proposed as simple and cost-effective screening test for diagnosis of prostatitis by Nickel. Post prostatic massage leucocyte count was found to be a useful finding for screening of prostatitis before biopsy. Cytological examination was demonstrated as being the simplest and most reliable method for both diagnosis and follow-up after treatment in chronic prostatitis. Two cases belonging to the suspicious group were diagnosed as tubercular prostatitis on histopathology, and both these cases yielded inadequate smears following prostatic massage. For one case from clinically suspicious group, diagnosed as granulomatous prostatitis on cytology, biopsy for confirmation was not available. Oppenheimer et al. reported the incidence of granulomatous prostatitis to be 0.36% in their study. Granulomatous prostatitis may clinically mimic prostatic cancer  as can be seen in the present study where two cases from clinically suspicious group were reported as tubercular prostatitis. Both the cases had past history of tuberculosis and had taken irregular antitubercular treatment. Mycobacterial infection of prostate causing granulomatous prostatitis can occur following miliary tuberculosis and the diagnosis can be confirmed by demonstration of acid fast bacilli on prostatic tissue, by culture, and polymerase chain reaction of prostatic fluid., Diagnosis of prostatic calculi was made in two cases (4%) belonging to clinically suspicious group. Both the cases were confirmed radiologically and had normal levels of acid and alkaline phosphatases. Cytologically, these cases showed fair number of dense basophilic concretions and laminated corpora amylacea admixed with isolated prostatic epithelial cells. Totally, 62% (31) cases were diagnosed as nodular hyperplasia, including 22 (44%) cases of nodular hyperplasia with prostatitis. An attempt was made to separate these two entities preoperatively in order to reduce the incidence of septicemia following surgery in cases with prostatitis. Prostatic epithelial cells showing inflammatory changes were easily differentiated from those of malignancy. In 5 cases (10%), the final diagnosis of carcinoma was given based on histologic and cytologic features. Histological diagnosis was established in 80% cases. One case on needle biopsy yielded normal prostatic tissue.
Importance of exfoliative cytology in diagnosing bladder tumors is well known. The same method following prostatic massage can be used very efficiently for the detection of prostatic cancer as well. Varo et al. reported 100% specificity, 67% sensitivity, 100% positive predictive value, and 92% negative predictive value for detecting prostatic cancer by this technique. Important diagnostic features of prostatic adenocarcinoma on ThinPrep® as described by Tyler et al. are clustering, high nuclear to cytoplasmic ratio, and nucleolar prominence. Few molecular techniques, such as measurement of telomerase activity, and demonstration of protoporphyrin IX fluorescence are also being developed for detection of prostatic carcinoma cells in urinary sediments.
Hence cytology of the prostate is a valuable adjunct to the clinical diagnosis. It has been found to be of great importance in establishing the preoperative morphologic diagnosis in cases of malignancy, prostatitis, and prostatic calculi. Collection of the urinary specimen after prostatic massage for cytology is a simple, safe office procedure, which provides adequate samples for cytological examination.
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Conflicts of interest
There are no conflicts of interest.
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Department of Pathology, Uttar Pradesh University Of Medical Sciences, Saifai, Etawah - 206 130, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]