338 actas urol esp. 2010;34(4):333–339
pseudohyperplastic carcinoma, and the minimal cell atypia
characteristic of the foamy gland carcinoma. Four of the five
cases were originally diagnosed with nodular hyperplasia of
the prostate; the exception was case 5, which showed small
glands in an infiltrative pattern.
The diagnosis of pseudohyperplastic carcinoma with
xanthomatous changes should be suspected when there are
irregularly-arranged medium or large neoplastic glands with
foldings, undulations and papillary projections resembling
hyperplastic nodes. If the lining cells have xanthomatous
cytoplasm and small, hyperchromatic nuclei at the base, the
diagnosis of pseudohyperplastic carcinoma with xanthomatous
changes should be considered. When in doubt, the diagnosis
should be confirmed with immunohistochemical staining,
since xanthomatous cells are occasionally found in prostate
. Another difference that helps to distinguish
between hyperplastic from pseudohyperplastic neoplastic
glands is the presence of easily recognizable basal cells in
most hyperplastic nodes.
Several useful criteria for diagnosis of prostate carcinoma,
including perineural infiltration, mitoses, crystalloids,
blue secretions, and prostatic intraepithelial neoplasia,
were absent. Additionally, there were scarce intraluminal
secretions, which were limited to isolated fields. The absence
of several useful criteria for the diagnosis of malignancy
in the usual type pseudohyperplastic carcinomas has been
The absence of nucleomegaly and the presence of
prominent nucleoli in most cells in foamy gland carcinoma
is well documented, and most of these neoplasms show
small, hyperchromatic, basophilic nuclei
. In the five cases
described here, the nuclei were small and hyperchromatic,
and uniformly situated at the base of the neoplastic cells.
Iczkowsky and Bostwick
have pointed out that nuclear
hyperchromasia is often a staining artifact, and its presence
may support the diagnosis of carcinoma in glandular
proliferations suspected of malignancy.
The differential diagnosis of foamy gland carcinoma
includes prostate adenosis, xanthogranulomatous
prostatitis, Cowper glands, mucinous metaplasia, low-
, and clear cell cribriform hyperplasia
Since the neoplastic glands in foamy gland carcinoma
with a pseudohyperplastic pattern contain medium and
large cells, the differential diagnosis includes nests of
hyperplastic glands, low-grade carcinoma, clear cell
cribriform hyperplasia, usual type pseudohyperplastic
carcinoma, and prostatic intraepithelial neoplasia.
The differences between hyperplastic glands and
pseudohyperplastic carcinoma are mentioned above. Low-
grade carcinoma may have glands lined with clear cells
resembling those of foamy gland carcinoma
cells often show nucleomegaly and prominent nucleoli,
and have smaller amounts of clear cytoplasm. In clear
cell cribriform hyperplasia, basal cells are identified in the
periphery of the acini, which become more apparent with
high molecular weight cytokeratin staining. Additionally,
pseudohyperplastic carcinoma shows non-fused
neoplastic glands, which provide a cribriform aspect
difference between pseudohyperplastic carcinoma with
xanthomatous features and the usual pseudohyperplastic
carcinoma resides in the absence of nucleomegaly and/or
prominent nucleoli in the former; most cases of usual type
pseudohyperplastic carcinoma show nucleomegaly and
. Prostatic intraepithelial neoplasia
appears in medium and large ducts, lacks foldings, and
the lining cells have variable amounts of nucleoli that
contrast with the small, hyperchromatic nuclei present
in pseudohyperplastic carcinoma with xanthomatous
The prognosis of neoplasms with a combination of different
histological findings described here is unknown. Metastasis
was found in none of the five cases; however, the follow-up
period was too short, never exceeding two years.
Figure 10 – (Case 5). On the left, the neoplasm shows
glands in an branching pattern, with multiple foldings and
papillary projections. On the right, smaller glands with
infiltrative aspect are observed.
Figure 11 – (Case 5). Detail of the pseudohyperplastic
glands. There are xanthomatous changes in the cytoplasm.
The nuclei are small and hyperchromatic, and arranged
uniformly at the base of the cells.
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