Clinical History:  A 68-year-old Black male presents with the chief complaint of increased urinary frequency and dysuria. Over the past three years he has had difficulty in starting urination and experienced a need to urinate frequently, especially at night.  Once flow is initiated, it is weak and often interrupted with a "burning" sensation.  Laboratory evaluations are unremarkable except for a mildly elevated serum prostate specific antigen (PSA) level. Digital examination of the prostate reveals a diffuse, soft enlargement of the gland.  Cystoscopy reveals enlargement of both lateral lobes and the median lobe of the prostate.

Questions:

1. A transurethral prostatectomy (TURP) is carried out. One half of the resected tissue is submitted for histological evaluation. A representative section is seen in Figure A1.  What is your diagnosis?

2. Further examination of tissue sections reveals the presence of 7 TURP "chips" which contain the feature seen in Figure A2. What is your diagnosis?

3. One of the 7 chips shows the finding seen in Figure A3. What is the eosinophilic "wavy" structure seen near the center of the photomicrograph? What is the significance of this finding?

4. One of the TURP chips, in addition to carcinoma, also includes epithelial structures as seen in Figure A4. What is this structure? What is the significance of finding a carcinoma invading it?

5. The remaining half of the resected material is submitted for evaluation. Four TURP chips containing the lesion seen in Figure A5 are identified. What is your diagnosis?  Discuss how this finding affects the patient's prognosis?

6. Discuss the significance of finding two morphologically dissimilar areas of prostatic carcinoma in the same patient.  Is this uncommon?

7. In view of the laboratory findings, would you expect to find this carcinoma invading distant sites such as bones or lymph nodes?