Prostate atrophy

Last revised by Joachim Feger on 11 Feb 2022

Prostatic atrophy is characterized by reduced cytoplasm prostatic acinar cells and constitutes a benign mimic of prostate cancer not only on imaging but also histologically.

The term 'proliferative inflammatory atrophy (PIA)' is used if it is associated with inflammation.

Prostatic atrophy is very common and can be seen in the majority of elderly men 1,2 and has been reported in up to 85% of autopsy specimens 1.

Prostatic atrophy has been associated with prostatic inflammation 1. There are theories about a potential role in prostatic carcinogenesis but this is still unclear 1.

The diagnosis of prostatic atrophy is based on typical pathological more specifically histological features.

Extensive focal prostatic atrophy can be present with an elevated prostate-specific antigen (PSA) level 2.

Prostatic atrophy is characterized by the microscopical appearance of small and crowded glands, which suggest a slow proliferation rate in contrast to the fact that proliferation indices are actually higher than that of normal benign glands 1.

Causes of prostatic atrophy include 2:

Prostatic atrophy can be subdivided into the following subtypes 1,2:

  • simple atrophy
  • partial or focal atrophy
  • sclerotic atrophy with cyst formation
  • post-atrophic hyperplasia

Microscopically prostatic atrophy is characterized by the following histological features 2:

  • crowded glands with little stroma in between
  • scant basophilic cytoplasm
  • crowded nuclei and prominent nucleoli

Immunohistochemistry stains might be positive for p63 or cytokeratin 34βE12.

On transrectal ultrasound prostatic atrophy might appear hypoechoic similar to prostate cancer.

On prostate MRI prostatic atrophy usually appears as wedge-shaped or geographic areas of low signal intensity on T2w images with mildly low ADC values or mild diffusion restriction and/or enhancement often accompanied with volume loss or contour retraction 2,3.

  • T1: isointense
  • T2: hypointense usually wedge-shaped or geographic
  • DWI: mild diffusion restriction
  • DCE (Gd): moderate enhancement

The radiological report should include a likelihood score, e.g. PI-RADS. If suspicious lesions are found, they should include a description of the following 3:

  • form, location and size
  • prostatic margins, including retracting contours
  • associated findings of the prostate

Prostatic atrophy may mimic prostate adenocarcinoma not only on imaging but also on histology especially the atrophic subtype 1-3.

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