Vasitis nodosa and related lesions: a modern immunohistochemical staining profile with special emphasis on novel diagnostic dilemmas

Highlights

• Vasitis nodosa is a benign proliferation with worrisome histologic features.

• Immunohistochemical characteristics can mimic prostate cancer (AMACR+, p63−).

• However, glands consistently label for PAX8 and not for prostate markers.

• Labeling for GATA3 and p63 is usually basal, but lacking in small glands.

Summary

Vasitis nodosa is a benign proliferation of vas deferens epithelium, thought to be a response to trauma or obstruction, usually vasectomy. Although histologic features mimic malignancy, diagnosis is usually straightforward due to the clinical context. We analyzed 21 specimens with vasitis or epididymitis nodosa with antibodies to PAX8, CD10, p63, α-methyl-acyl-coA-racemase (AMACR), GATA3, prostein, NKX3.1, and prostate-specific antigen (PSA). Two diagnostically problematic cases included (1) florid bladder muscle involvement after prostatectomy and (2) involvement of the ampulla and ejaculatory duct in a radical prostatectomy specimen. Vasitis nodosa was excluded in 3 additional histologic mimics (2 post-treatment prostate cancers and 1 bladder cancer). PAX8 yielded consistent positive (100%) nuclear staining in the proliferative glands of vasitis nodosa, often stronger and more uniform than native vas deferens. CD10 labeling was common but also labeled secretions and other structures. Labeling for p63 was often basally located in glands with a multilayered appearance, but often markedly attenuated or lacking in the proliferative glands compared to native epithelium. AMACR positivity was variable but often present (19/21). PSA, prostein, and NKX3.1 were consistently negative. Rare problematic cases of vasitis nodosa include “invasion” of the ejaculatory duct at the prostate and involvement of bladder muscle after prostatectomy. The proliferative vasitis nodosa glands often have a prostate cancer–like staining pattern with variable AMACR positivity and negative or patchy p63. However, reliable positivity for PAX8, patchy GATA3, and negative staining for PSA, NKX3.1, and prostein aid in distinguishing from prostate cancer and tubular variants of bladder cancer.

Introduction

Vasitis nodosa is a benign proliferation of vas deferens epithelium, thought to occur as a response to mechanical obstruction or traumatic injury. It is hypothesized that mechanical obstruction leads to increased intraluminal pressure and resulting spermatic fluid leakage. This extravasation of fluid is thought to result in subsequent inflammation and glandular proliferation. Vasitis nodosa typically occurs in the setting of prior vasectomy, but has been reported in other clinical scenarios, such as trauma, primary infertility, cystitis, or surgery. Clinical findings can include palpable nodules, scrotal pain, or swelling [1], [2], [3], [4].

In the usual clinical context (characteristically post-vasectomy), vasitis nodosa is a relatively straightforward diagnosis, despite that it is known to have worrisome histologic characteristics, such as prominent nucleoli, pseudoinvasive growth pattern, and vascular and perineural invasion [5], [6], [7], [8]. However, we have encountered rare clinical scenarios in which vasitis nodosa presented a diagnostic challenge, including occurrence at the ampulla of the vas deferens (the tortuous and dilated segment at the junction with the prostate and ejaculatory duct) in a prostate cancer specimen and in the wall of a cystectomy specimen after radical prostatectomy. Conversely, we have encountered occasional cancers that raised morphologic consideration of vasitis nodosa in these sites. Although a few immunohistochemical markers have been previously studied in vasitis nodosa, we sought to characterize the immunohistochemical staining pattern of vasitis nodosa with a modern antibody panel to aid in such scenarios.