Endometrial tumors and/or associated carcinomas of prostate

Current Understanding and Management of Intraductal Carcinoma of the Prostate

PURPOSE OF REVIEW

This review will discuss current understanding and management approaches of Intraductal carcinoma of the prostate (IDC-P). IDC-P is a histological finding characterized by neoplastic cells that expand but do not invade prostate ducts.

RECENT FINDINGS

The presence of IDC-P on a prostate biopsy is almost always associated with an invasive disease component and is independently associated with worse clinical outcomes in both early and late disease. These tumors are enriched for mutations in homologous DNA recombination repair (HRR) leading to high genomic instability. Multiparametric MRI with targeted biopsy may aid in diagnosis. Given the poor clinical outcomes associated with this histologic entity, its presence in biopsies should warrant consideration of aggressive management.

Prostatic ductal adenocarcinoma variant predicts worse pathological and oncological outcomes: Insight from over 1000 consecutive patients from a large prospective uro-oncology registry

OBJECTIVE

To evaluate if prostatic ductal adenocarcinoma (PDA) independently predicts poorer pathological and oncological outcomes after radical prostatectomy (RP).

METHODS AND MATERIALS

Utilizing a large prospective uro-oncology registry, clinicopathological parameters of 1027 consecutive patients who underwent RP (2008-2017) were recorded. Oncological outcomes were determined by failure to achieve unrecordable PSA postoperatively and biochemical failure (BCF).

RESULTS

PDA was present in 79 (7.7%) patients, whereas 948 (92.3%) patients had conventional prostatic acinar adenocarcinoma (PAA). Patients with PDA were older (mean 64.4 vs. 62.8-years old; p = .045), had higher PSA at diagnosis (mean 12.53 vs. 10.80 ng/ml; p = .034), and a higher percentage of positive biopsy cores (mean 39.34 vs. 30.53%; p = .006). Compared to PAA, PDA exhibited a more aggressive tumor biology: (1) Grade groups 4 or 5 (26.6 vs. 9.4%, p < .001), (2) tumor multifocality (89.9 vs. 83.6%; p = .049), and (3) tumor size (mean 2.97 vs. 2.00 cm; p < .001). On multivariate analysis, PDA was independently associated with locally advanced disease (p = .002, hazard ratio [HR]: 2.786, 95% confidence interval [CI]: 1.473-5.263), with a trend towards positive surgical margins (p = .055) and nodal involvement (p = .061). Translating the poorer pathological features to oncological outcomes, presence of PDA independently predicted less likelihood of achieving unrecordable PSA (p = .019, HR: 2.368, 95% CI: 1.152-4.868, and higher BCF (p = .028, HR: 1.918, 95% CI: 1.074-3.423). Subgroup analysis demonstrated that a higher ductal component greater than 15% proportionally predicted worse oncological outcomes, with a shorter time to BCF of 14.3 months compared to 19.8 months in patients with ductal component lesser than 15% (p = .040, HR: 2.660, 95% CI: 1.046-6.757).

CONCLUSION

PDA is independently associated with adverse pathological and oncological outcomes after RP. A higher proportion of PDA supports a higher BCF rate with a shorter time interval. An aggressive extirpative approach with close monitoring of postoperative serum PSA levels is warranted for these patients.

Ductal adenocarcinoma of the prostate: A systematic review and meta-analysis of incidence, presentation, prognosis, and management

Context

Ductal adenocarcinoma (DAC) is relatively rare, but is nonetheless the second most common subtype of prostate cancer. First described in 1967, opinion is still divided regarding its biology, prognosis, and outcome.

Objectives

To systematically interrogate the literature to clarify the epidemiology, diagnosis, management, progression, and survival statistics of DAC.

Materials and methods

We conducted a literature search of five medical databases from inception to May 04 2020 according to PRISMA criteria using search terms "prostate ductal adenocarcinoma" OR "endometriod adenocarcinoma of prostate" and variations of each.

Results

Some 114 studies were eligible for inclusion, presenting 2 907 170 prostate cancer cases, of which 5911 were DAC. [Correction added on 16 January 2021 after the first online publication: the preceding statement has been corrected in this current version.] DAC accounts for 0.17% of prostate cancer on meta-analysis (range 0.0837%-13.4%). The majority of DAC cases were admixed with predominant acinar adenocarcinoma (AAC). Median Prostate Specific Antigen at diagnosis ranged from 4.2 to 9.6 ng/mL in the case series.DAC was more likely to present as T3 (RR1.71; 95%CI 1.53-1.91) and T4 (RR7.56; 95%CI 5.19-11.01) stages, with far higher likelihood of metastatic disease (RR4.62; 95%CI 3.84-5.56; all P-values < .0001), compared to AAC. Common first treatments included surgery (radical prostatectomy (RP) or cystoprostatectomy for select cases) or radiotherapy (RT) for localized disease, and hormonal or chemo-therapy for metastatic disease. Few studies compared RP and RT modalities, and those that did present mixed findings, although cancer-specific survival rates seem worse after RP.Biochemical recurrence rates were increased with DAC compared to AAC. Additionally, DAC metastasized to unusual sites, including penile and peritoneal metastases. Where compared, all studies reported worse survival for DAC compared to AAC.

Conclusion

When drawing conclusions about DAC it is important to note the heterogenous nature of the data. DAC is often diagnosed incidentally post-treatment, perhaps due to lack of a single, universally applied histopathological definition. As such, DAC is likely underreported in clinical practice and the literature. Poorer prognosis and outcomes for DAC compared to AAC merit further research into genetic composition, evolution, diagnosis, and treatment of this surprisingly common prostate cancer sub-type.

Patient summary

Ductal prostate cancer is a rare but important form of prostate cancer. This review demonstrates that it tends to be more serious at detection and more likely to spread to unusual parts of the body. Overall survival is worse with this type of prostate cancer and urologists need to be aware of the presence of ductal prostate cancer to alter management decisions and follow-up.

Prostatic Duct Carcinoma with Combined Prostatic Duct Adenocarcinoma and Urothelial Carcinoma Features

We report a unique case of prostatic duct carcinoma (PDC) featuring both prostatic duct adenocarcinoma (PDA) and high-grade urothelial carcinoma (HG-UC). An 84-year-old man presenting with hematuria showed at ultrasonography and cystoscopy a papillary neoplasia located near to the verumontanum. Histopathologic examination of specimens from transurethral resection revealed a tumor originating from large prostatic ducts showing 2 different components: PDA with endometrioid features (main pattern) and HG-UC (minor part). Immunohistochemically, the areas of PDA were positive for prostatic acid phosphatase (PAP), prostatic specific antigen (PSA), and androgen receptors (AR), while negative for estrogen (ER) and progesterone receptors (PGR). Prognostic factors evaluation pointed out a low proliferation index (10%) and focal expression of p53 (6%); c-erb-B2 was not overexpressed. The HG-UC areas were negative for all previous markers, while positive for thromobomodulin. The proliferation index was high (60%), and p53 was diffusely expressed (55%). The incidence and significance of PDC with combined features is discussed with reference to literature data.

Pathologic stage of prostatic ductal adenocarcinoma at radical prostatectomy: effect of percentage of the ductal component and associated grade of acinar adenocarcinoma

It is unknown whether ductal adenocarcinomas are more aggressive when matched for Gleason score (assigning the ductal component as Gleason pattern 4). Moreover, little is known whether a certain percentage of the ductal component is needed to account for its more aggressive behavior. Of 18,552 radical prostatectomies performed from 1995 to 2008, 93 cases with a ductal adenocarcinoma component were identified. Cases were classified based on their ductal/acinar ratio (<10%; ≥10% and <50%; ≥50%). There was no difference in the distribution of Gleason score 3+4=7 versus 4+3=7 between ductal and nonductal tumors, such that cases were combined as Gleason score 7. There was no age, race, and serum prostate-specific antigen difference between patients with and without ductal adenocarcinoma. Cases with ductal adenocarcinoma were less likely to be organ confined (36.6% vs 65.6%) and more likely to show seminal vesicle invasion (SVI) (19.3% vs 5.3%), P<0.0001. There was no difference in lymph node metastases or positive margins between cases with and without ductal features. An increasing percentage of the ductal component correlated with an increased risk of extraprostatic extension (P=0.04) and SVI (P<0.0001). To account for overall different Gleason scores between ductal and nonductal cases, and the effect of differing percentages of ductal features as well, the following analysis was carried out. For Gleason score 7 cases and ≥10% ductal differentiation, cases with ductal features were more likely to have nonfocal extraprostatic extension (64.0%) versus cases without ductal features (34.7%), P=0.002. In this group, there was no statistically significant difference in SVI or lymph node involvement between Gleason score 7 ductal and nonductal tumors. For Gleason score 7 cases with <10% ductal features, there was no difference in pathologic stage versus nonductal cases. There was no difference in pathologic stage between ductal and nonductal cases for Gleason score 8 to 10 cases, regardless of the percentage of the ductal component. This study shows that ductal adenocarcinoma admixed with Gleason pattern 3 is more aggressive than Gleason score 7 acinar cancer, as long as the ductal component is ≥10%. In cases with a very minor ductal component, these differences are lost. In addition, Gleason score 8 to 10 tumors with ductal features are not significantly more aggressive that acinar Gleason score 8 to 10 cancers in which the pure high-grade tumor, regardless of ductal features, determines the behavior.

Does prostatic ductal adenocarcinoma exist?

Prostatic ductal (endometrioid) adenocarcinoma has been considered a distinct pathologic and clinical entity since it was first described more than 30 years ago. Its current status as a unique neoplasm is controversial, however, because it has considerable histologic overlap with typical acinar adenocarcinoma, particularly in small specimens such as needle biopsies. There are also conflicting views regarding its clinical behavior. We recently encountered a series of typical peripheral zone cancers of the prostate gland with prominent papillary or cribriform pattern that apparently did not involve the large periurethral prostatic ducts or verumontanum. To determine the incidence of these "ductal features" in nonductal carcinoma, we reviewed the findings in 338 consecutive totally embedded whole-mount prostatectomy specimens with typical clinical and pathologic features of acinar carcinoma. We defined carcinoma with significant "ductal features" as one that displayed papillary or cribriform pattern involving an arbitrarily defined aggregate focus at least 5 mm in diameter. Anti-keratin 34beta-E12 immunohistochemical staining for basal cells allowed exclusion of areas of papillary or cribriform pattern of high-grade prostatic intraepithelial neoplasia. We identified carcinoma with ductal features (papillary or cribriform growth) in 17 prostatectomy specimens (5% of cases) exclusively in the peripheral zone without involving the periurethral region. Papillary pattern was present in 11 of these cases (65%) and cribriform pattern in 10 (59%), including 4 cases (24%) with both patterns. Of 11 needle biopsy specimens available for examination from these 17 cases, 4 (36%) contained at least focal papillary or cribriform pattern of carcinoma. We conclude that adenocarcinoma arising in the peripheral zone of the prostate gland may display ductal carcinoma features (papillary or cribriform growth) classically associated with ductal adenocarcinoma. These findings, together with the recognized near-constant association of prostatic ductal adenocarcinoma and typical prostate cancer, suggest that ductal adenocarcinoma results from spread of typical prostatic acinar carcinoma into the large accommodating periurethral ducts and stroma, and that there are no unique histologic features other than site of growth. Identification of papillary or cribriform growth of cancer in prostate needle biopsies usually results from peripheral zone adenocarcinoma and not ductal adenocarcinoma.

Ductal carcinomas of the prostate: a clinicopathological and immunohistochemical study

OBJECTIVES

To confirm the expression of prostate specific antigen (PSA) and prostatic acid phosphatase (PAP) in ductal carcinomas of the prostate, and to analyse p53, Ki67, oestrogen (ER) and androgen (AR) receptors in these tumours.

MATERIALS AND METHODS

Paraffin-embedded samples from 12 patients with ductal carcinoma of the prostate were assessed for pattern, mitotic count and the presence of a microacinar carcinoma component. There were six pure ductal and six mixed microacinar and ductal carcinomas. Sections were stained immunohistochemically for the expression of PSA, PAP, Ki67, p53, AR and ER. Clinical data were obtained from case notes.

RESULTS

Six of the ductal tumours had a papillary pattern whilst the others had a cribriform appearance. The mitotic rates in the ductal areas were high in the tumours from eight of the 12 patients. PSA and PAP immunohistochemistry were positive in all the cases. No ER immunoreactivity was found in any of the patients. Ten of the ductal tumours showed strong reactivity with AR, the other two were weakly positive; two of the tumours were strongly positive for p53 protein. All the ductal carcinomas expressed Ki67, three having > 25% nuclear marking. One patient who was strongly positive for p53 and had a high Ki67 score survived only one year after diagnosis. Survival ranged from 1 to 13 years after diagnosis.

CONCLUSION

This study confirms the expression of PSA and PAP in ductal carcinomas of the prostate. The percentage of tumours expressing p53 was similar to that published for high-grade microacinar carcinomas. The results for Ki67 suggest that ductal tumours have higher scores than microacinar tumours, but further studies are required to ascertain if this is significantly different. As half the patients with ductal tumours had co-existent microacinar tumours, we advise transrectal prostatic biopsies in patients diagnosed with pure ductal carcinomas on transurethral resection specimens, to exclude high-grade microacinar carcinomas. The presence of AR and the lack of ER in all the ductal carcinomas confirms that these tumours are prostatic in origin and should be treated with antiandrogen therapy.

Exophytic papillary prostatic duct adenocarcinoma with endometrioid features, occurring in prostatic urethra after TURP

We present an eighty-three-year-old man with an exophytic lesion in the prostatic cavity, diagnosed three years after transurethral resection of the prostate, and extending into the bladder. Histopathologically, the tumor was recognized as a papillary ductal adenocarcinoma (primary duct type) with endometrioid features, probably associated with prostatic adenomatous polyp. Acinic adenocarcinoma was absent. The lesion was treated by deep transurethral resection with objective follow-up results after six months. Review of the literature concerning history, embryology, possible pathogenesis, differential diagnosis, and treatment options is included.

Endometrioid adenocarcinoma of the prostate: a clinicopathologic and immunohistochemical study

On retrospective review of the tumor registry files between 1979 and 1992 at the North Iowa Medical Center, six cases of endometrioid adenocarcinoma of the prostate were identified among 1582 cases of prostatic carcinoma. Along with long-term clinicopathologic follow-up, immunohistochemical studies of the prostatic tumor tissues were performed. All six cases of endometrioid carcinoma, together with control cases of benign prostatic hypertrophy (BPH) and ordinary adenocarcinoma of the prostate had unequivocal diffuse positive staining for PSA and similar reactivity to ER-D5 and PS2. Thus, endometrioid carcinoma is most likely derived from the prostate or prostatic urethral duct rather than the utricle. However, due to its unusual initial clinical manifestations, biological behavior, and distinctive histomorphology, the term "endometrioid adenocarcinoma of the prostate" is worth preserving.

Prostatic duct adenocarcinoma. Findings at radical prostatectomy

Previous studies of prostatic duct adenocarcinoma have reported a poor prognosis, but they included few patients treated by radical prostatectomy. The authors studied 15 cases treated with radical prostatectomy to define more completely their pathologic features and determine the clinical outcome in these surgically treated patients. The study included morphometry and DNA image analysis using the CAS-200 system. The most common presentation was urinary outlet obstruction (n = 9), and most patients were clinical Stage B with palpable prostatic lesions (n = 12). Compared with acinar cancers of similar clinical stage, duct cancers were large (tumor volume, 8.4 +/- 10.0 cc) and occupied a large portion of the gland (23 +/- 21%). Duct cancers were in an advanced final pathologic stage with 93% having capsular penetration, 47% positive margins, 40% seminal vesicle invasion, and 27% positive pelvic lymph nodes. The DNA analysis on cells disaggregated from paraffin revealed that 54% of cases were diploid, 15% tetraploid, 8% aneuploid, and 23% tetraploid/aneuploid. On clinical follow-up, eight patients had no evidence of tumor at intervals ranging from 1 to 28 months, and seven patients (47%) had persistent tumor at intervals of 3 to 18 months. This study demonstrates that duct cancers are in an advanced pathologic stage by the time of presentation and have a much higher short-term failure rate after radical prostatectomy compared with acinar cancers.

Papillary carcinoma of the prostate, location, morphology, and immunohistochemistry: the histogenesis and entity of so-called endometrioid carcinoma

Fifty carcinomas that were partially to completely papillary in nature were examined. According to urethroscopic and rectal palpation findings, six of the carcinomas were located centrally, 40 tumors were in the prostate proper, and four were clinical stage T0. The epithelium of the papillary portions of the tumors was dark in some instances, light in others. Immunohistochemistry revealed that 20 of 22 tumors were positive for prostatic acid phosphatase (PAP) and prostate-specific antigen (PSA). In no case was a topical relationship to the utriculus prostaticus demonstrable. The epithelium of the utriculus in seven additional patients who were not involved in this series also stained positively for PAP and PSA. Usual carcinomas of the prostate proper can develop endometrioid structures that do not differ immunohistochemically from ordinary portions of the carcinoma. Tumors located in central portions of the prostate are, in our opinion, morphologic variants of usual prostatic carcinomas, and apparently arise in prostatic ducts. We conclude that a distinction between endometrioid carcinomas and tumors of prostatic ducts does not seem justified and that papillary prostatic carcinomas should be treated like common prostatic cancer.

Endometrial carcinoma of prostate

In the rare group of atypical adenocarcinomas of the prostate gland, endometrial carcinoma arising from the prostatic utricle can be perplexing to diagnose because of its histologic similarity with other ductal carcinomas and frequent simultaneous admixture of microacinar adenocarcinomas. Two cases of endometrial carcinoma of the prostate are detailed, and the therapeutic implications of such histologic diagnosis are reviewed.

Endometrial carcinoma of prostate

Endometrial carcinoma of the prostate is a unique lesion which contrasts markedly to the more ubiquitous prostatic acinar carcinoma with regard to morphology, clinical manifestations, localization stage at diagnosis, and possibly prognosis. Although endometrial carcinoma of the prostate may occur more commonly than previously recognized, wider recognition and study are essential for further delineation of this lesion. Finally, the inherent limits of endoscopic or of enucleative surgery and the propensity of endometrial carcinoma to present at a low stage suggest in appropriately selected cases that radical prostatectomy or possible external radiotherapy may offer the best opportunity for cure.

Adenocarcinoma of the prostate with endometrioid features. A light microscopic and immunohistochemical study of ten cases

The authors reviewed the histologic slides of 2600 prostatic carcinomas seen at Memorial Hospital from 1963 to 1983. In ten cases, resection specimens had a predominantly endometrioid appearance. Six patients had polypoid lesions in and around the verumontanum, and one had a polypoid lesion away from the verumontanum. Two patients had no mucosal lesions and one was not cystoscoped. Histologically, the tumors showed a tall pseudostratified columnar epithelium, usually with amphophilic cytoplasm. The cells were arranged either along papillae or in complexes of large acini or in single glands. In eight of the ten cases, the endometrioid carcinomas were associated with a prior or coexistent typical microacinar prostatic adenocarcinoma. In four cases, the endometrioid pattern existed in a pure form, although in two such cases with urethral tumors, the patients had histories of successfully treated microacinar adenocarcinomas of the posterior prostatic lobe. In one case, a urethral endometrioid tumor coexisted with a small posterior lobe microacinar adenocarcinoma. In five cases, both endometrioid and microacinar carcinomas were seen, including endometrioid and microacinar carcinomas found at the same site at different times (2 cases), tumors with a predominantly endometrioid, yet focally microacinar pattern (1 case), and primary tumors where lymph node metastases had different histologic features (2 cases). Of the three patients with a pure or predominantly endometrioid pattern treated with diethylstilbestrol, two had a marked clinical response. All ten endometrioid prostatic adenocarcinomas showed prostate-specific antigen and prostate-specific acid phosphatase immunoreactivity, in contrast to none of the control uterine endometrial carcinomas. In material spanning a 20-year period, the authors have not seen a single prostatic tumor entirely analogous to the uterine endometrial carcinoma. Until such proof exists, prostatic carcinomas with endometrioid features are best classified and treated as variants of prostatic duct carcinomas.

Endometrial carcinoma of the prostatic utricle: a tumor of prostatic origin

Endometrial carcinoma of the prostatic utricle previously was believed to be of müllerian origin. We report 2 cases studied by ultrastructural and immunoperoxidase techniques. Our results, as well as those presented by others, demonstrate the prostatic origin of this tumor.

Papillary adenocarcinoma of the prostatic urethra with clear-cell appearance

The second reported papillary prostatic urethral carcinoma displaying an unusual clear-cell or so-called mesonephroid histologic appearance is described. Neoplasms arising from the utricular region have generated considerable discussion of their histogenesis and hormone-responsiveness. A review of the literature as well as consideration of this case suggests that the lesion's clear-cell appearance should not be used as evidence for müllerian derivation from the utricle. The authors favor a periurethral gland origin for this particular tumor.

Multiple primary prostate cancer

Although increasing reports are noted of apparent endometrial carcinoma of prostatic origin, the controversy is present of the actual existence of such an entity. The association of papillary prostatic cancer (endometrial or ductal) with the typical microacinar variety has also been previously presented. This report is an account of 2 cases of multiple prostatic primary tumors. The first case is the twelfth reported case of endometrial (utricular) carcinoma not only simultaneously associated with microacinar type carcinoma, but also with a previous transitional carcinoma of the urinary bladder. The second case is a papillary carcinoma and associated microacinar type with the papillary component responding dramatically to chemotherapy. Significant aspects of interest in this case include the site of papillary metastasis to the lungs, elevated estrogen levels with normalization after treatment, and finally response to chemotherapy.

Endometriosis of the urinary bladder in a man with prostatic carcinoma

A case of endometriosis of the urinary bladder in a man is described. The patient had been treated with estrogen for several years following radical prostatectomy and orchiectomy for prostatic carcinoma. The only other reported case of endometriosis in a male presented in a strikingly similar manner. Pathogenic speculations are briefly presented.

Papillary adenocarcinoma of prostate

Papillary adenocarcinomas of the prostate are rare tumors which may arise from the prostatic ducts and the utricle; 2 cases are described. The diagnosis of these tumors is best established by cystourethroscopy and transurethral resection. The more common prostatic acinar adenocarcinoma is frequently associated with these tumors. The histopathologic recognition of papillary adenocarcinoma of the prostate and its differentiation from acinar adenocarcinoma is important since the natural history and response to treatment may be different.

Endometrial carcinoma of prostatic utricle with osseous metastases

Endometrial carcinoma of the prostatic utricle is a rare pupillary prostatic tumor arising in the region of the prostatic urethra and verumontanum. Since the first description by Melicow and Pachter in 1967, 8 additional cases have been reported. This case is the tenth reported, and the first in which metastases to bone have been proved by biopsy. Transurethral resection of the tumor with postoperative radiation therapy to the prostatic region and metastases has resulted in clinical improvement. The importance of accurate diagnosis of this neoplasm is emphasized to avoid unnecessary delay in the appropriate choice of therapeutic modalities.