Metastases from Prostate Cancer: Autopsy Findings

by Richard Mitchell, MD

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    00:01 Okay, welcome back.

    00:04 We're going to look at metastatic disease.

    00:07 We're going to look at a particular case that is illustrative.

    00:10 But tumors in general, do their darndest to get loose into the bloodstream and to go to other places within the body.

    00:21 And it's frequently the metastases rather than the primary tumor that is the ultimate cause of significant morbidity and mortality.

    00:30 There are exceptions, of course but metastases are often kind of a very important step in the progression of malignancy and usually indicates the patient is not going to do well.

    00:47 So here's where we are in terms of paraneoplastic syndromes, local growth and invasion and metastases, and without any further ado, let's look at our case.

    00:56 This was a 60-year old man who had a prostate cancer.

    01:01 What's being shown on the left hand side is the bladder.

    01:04 It's been opened up so we can see inside the bladder.

    01:07 And at higher magnification, what we can see is that there is a kind of a bulging tumor mass in the middle of the slide on the right hand side, that represents prostate cancer that is growing into the bladder wall.

    01:23 If we cut that in a different plane, we can see this nodule of tumor this is up is into the bladder wall, down is towards the seminiferous tubules, which are shown as well as the prostate and there was just this local extension of the tumor.

    01:39 This was a surgical specimen that was resected in hopes of curing the patient.

    01:46 Unfortunately, at the time of the surgical resection, we did not know that there was any metastatic disease.

    01:52 The patient subsequently died, not as a consequence of that primary tumor in that site but because of the metastatic spread.

    02:01 Where did it go? Well, we're just going to look at examples.

    02:06 This is the lung and both lungs were affected.

    02:09 And in the upper lobes, we can see tumor that has infiltrated and arrived via the circulation.

    02:17 We also have tumor that is extending into the lymphatics.

    02:20 So the panel on the left hand side is showing the surface of the lung and you see this lacy reticulate-likepattern of white tan material that's actually tumor that's within the lymphatics.

    02:33 So it had gone to the lung and then the lung lymphatics had picked it up.

    02:37 We're seeing that grossly on the left hand side.

    02:39 On the right hand side, we're seeing lymphatic vessels stuffed with a tumor.

    02:44 Each ball there is a bunch of tumor cells in the lymphatic and that will also have gone to the lymph node.

    02:52 So that we have expression of the tumor, so called lymphangitic spread.

    02:59 This is an autopsy.

    03:01 Obviously in this patient we have opened the rib cage.

    03:05 The red circle indicates the normal appearance of a cross section of rib with the marrow that should be kind of red tan.

    03:14 The white circle on the other hand is demonstrating an area where the tumor had completely replaced the bone in the rib and that all that white tan material is metastatic tumor.

    03:27 Interestingly, as we discussed previously, prostate does like to go to bone for reasons that are not entirely completely understood.

    03:36 But prostate cancer not only was it in the ribs, it was in the vertebral bodies and what is circled on the lower inset now is an area of tumor invasion causing an osteoblastic, as opposed to an osteolytic but an osteoblastic sclerosing area of metastasis and multiple bones in the vertebral bodies were affected by the tumor.

    04:02 This is the adrenal and the normal adrenal kind of thickness and appearance is on the right hand side.

    04:09 All those big lumps of kind of red, brown hemorrhagic material represent tumor metastasis to the adrenal.

    04:18 It is possible to have adrenal insufficiency due to tumor metastasis.

    04:22 And in this particular case, there was sufficient adrenal function on the contralateral side that the patient didn't suffer any adrenal insufficiency manifestations Tumor can go and in this case did go to the liver, so we have multiple nodules of tumor.

    04:41 They are centrally hemorrhagic and necrotic because the tumor has grown too quickly.

    04:46 Compared to its vascularization, it's angiogenesis, so we have central zones of necrosis.

    04:52 And there are multiple different size tumors, so there are large tumors, large metastases that had probably been there for weeks, maybe months as they've grown.

    05:03 There are smaller ones.

    05:04 They represent tumor cells that are in the circulation and arrived more recently, so they tend to be smaller, small, round nodules.

    05:12 Important kind of take home, just as a pathologist and let you in on this.

    05:17 The liver is so redundant, it's over engineered, we have such an excess capacity that this amount of involvement by cancer in the liver would not have caused any significant hepatic dysfunction.

    05:30 You have to replace greater than 70% of the liver in order to have hepatic failure.

    05:35 So this patient may not have had any symptoms and didn't have any symptoms related to the hepatic metastasis.

    05:42 The tumor went to a variety of interesting places.

    05:44 What is shown on the left hand side is the dura that was taken off the brain at the time of autopsy.

    05:52 And on the right hand side, you can see the bright, pink-red material.

    05:58 On the left hand side that linear material, that's the dura.

    06:02 But in the dura, attached to the dura is a metastasis of the same tumor.

    06:07 So this tumor went into multiple locations.

    06:11 And it also into the heart.

    06:13 This patient had a history of hypertension, so there is left ventricular wall thickness increase.

    06:21 There's hypertrophy.

    06:22 There is a remote scar as indicated there, that white, collagenous, scar-like material in the posterior wall.

    06:31 But that, there wasn't any gross manifestation of the malignancy.

    06:36 However, when we looked microscopically, we could find tumor within the lymphatics in the small vessels within the heart.

    06:43 Again, the metastasis here were not sufficient to cause any significant cardiac dysfunction, but we're definitely there.

    06:54 And with that, just an example of metastatic spread, you can think of any of a variety of tumors and how things spread either via lymphatics or through the blood vessels.

    About the Lecture

    The lecture Metastases from Prostate Cancer: Autopsy Findings by Richard Mitchell, MD is from the course Cancer Morbidity and Mortality.

    Author of lecture Metastases from Prostate Cancer: Autopsy Findings

     Richard Mitchell, MD

    Richard Mitchell, MD

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