Table of Contents
Definition / general | Essential features | Terminology | ICD coding | Epidemiology | Sites | Pathophysiology | Etiology | Clinical features | Diagnosis | Laboratory | Radiology description | Radiology images | Prognostic factors | Case reports | Treatment | Gross description | Microscopic (histologic) description | Microscopic (histologic) images | Virtual slides | Cytology description | Positive stains | Negative stains | Molecular / cytogenetics description | Sample pathology report | Differential diagnosis | Board review style question #1 | Board review style answer #1 | Board review style question #2 | Board review style answer #2Cite this page: Findeis S, Huang H. Ductal adenocarcinoma. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/prostateprostaticduct.html. Accessed January 22nd, 2021.
Definition / general
- Rare subtype of prostatic carcinoma composed of glands lined by pseudostratified columnar cells resembling intestinal / endometrioid epithelium
Essential features
- More likely to be mixed with acinar adenocarcinoma than to be pure
- Locally aggressive with seminal vesicle invasion and extraprostatic extension
- Similar mortality rate to Gleason score 8 - 10 acinar adenocarcinoma
Terminology
- Prostatic ductal adenocarcinoma
ICD coding
- ICD-10: C61 - malignant neoplasm of prostate
Epidemiology
- Prostate cancer in general: 1.6 million men are diagnosed and over 366,000 die every year (Cold Spring Harb Perspect Med 2018;8:pii: a030361)
- Accounts for 3.2% of all prostate cancers; most are mixed with acinar adenocarcinoma; pure ductal carcinoma incidence: 0.4 - 0.8% of prostate cancers (Histopathology 2012;60:59, Cancer 1986;57:111)
Sites
- Prostate
Pathophysiology
- Unknown
Etiology
- Unknown
Clinical features
- Periurethral tumor may cause hematuria and urinary tract symptoms; peripheral tumors have clinical features similar to acinar adenocarcinoma (Moch: WHO Classification of Tumor of the Urinary System and Male Genital Organs, 4th Edition, 2016)
- More likely to present with distant disease than acinar adenocarcinoma (J Urol 2010;184:2303)
Diagnosis
- Similar to other prostate cancers, often diagnosed through transrectal needle biopsies
- Periurethral tumor may be diagnosed by transurethral resection of the prostate
Laboratory
- More likely to have a PSA less than 4.0 ng/mL; have a mean lower PSA at presentation compared with acinar adenocarcinoma (J Urol 2010;184:2303, Urology 2015;86:777)
Radiology description
- Not diagnostically helpful at this time
Prognostic factors
- Has similar mortality rate to acinar carcinoma with Gleason score of 8 - 10 (Urology 2015;86:777)
Case reports
- 59 year old man, status postandrogen deprivation treatment, with conversion of mixed acinar and ductal adenocarcinoma into neuroendocrine differentiation (Hum Pathol 2017;64:186)
- 65 year old man with retrovesical mass and high PSA (Urology 2014;84:e9)
- 67 year old man with gastric metastasis (mixed ductal and acinar) (Urol Case Rep 2016;7:28)
- 76 year old man with ductal carcinoma which mimicked a urethral polyp (Pathology 2007;39:476)
- 29 patients with metastatic prostatic ductal adenocarcinoma to the penis (Am J Surg Pathol 2015;39:67)
Treatment
- Hormonal therapy, radiation or surgery
Gross description
- Similar to prostatic acinar adenocarcinoma
Microscopic (histologic) description
- Glands composed of tall columnar cells which are either in a cribriform, papillary, solid and prostatic intraepithelial neoplasia-like pattern which arise in primary periurethral ducts or in peripheral prostatic ducts
- Cytoplasm is typically amphophilic, although can be clear (Med Princ Pract 2010;19:82)
- In contrast to cribriform acinar adenocarcinoma, the cribriform pattern is composed of intraglandular epithelial bridging with slit-like lumens instead of the punched out lumens of an acinar adenocarcinoma cribriform pattern (Am J Surg Pathol 2011;35:615)
- Most ductal adenocarcinoma is considered as Gleason pattern 4 (5 if with comedonecrosis)
- Prostatic intraepithelial neoplasia-like ductal adenocarcinoma is assigned as Gleason pattern 3 (Histopathology 2012;60:59)
- Other unusual patterns that have been reported are foamy gland and Paneth cell-like (Pathology 2010;42:319)
- Associated with seminal vesical invasion and less likely to be confined to the prostate than acinar carcinoma Gleason score 7 and below (Hum Pathol 2010;41:281, Virchows Arch 2013;46:429)
- Will likely be intermixed with acinar component
- Scored via the Gleason scoring system
Microscopic (histologic) images
Cytology description
- Sheets of columnar cells with some gland formation or papillary architecture with inconspicuous nucleoli (Acta Cytol 2013;57:184)
Positive stains
Molecular / cytogenetics description
- PTEN loss by IHC was less frequent compared with pure acinar carcinoma; TMPRSS2-ERG gene fusion infrequent (Mod Pathol 2009;22:359)
- Low rates of ERG rearrangement by IHC and FISH (Prostate 2015;75:1610)
- Gene expression overlaps a lot with acinar adenocarcinoma but early research suggests prolactin receptor does seem overexpressed in ductal compared to acinar (Mod Pathol 2009;22:1273)
- High percentage of DNA damage repair pathway alterations (JCO Precis Oncol 2019;3:doi: 10.1200)
Sample pathology report
- Prostate, radical prostatectomy:
- Prostatic ductal adenocarcinoma, Gleason score 4+4=8, grade group 4 (see synoptic report)
Differential diagnosis
- Acinar adenocarcinoma, Gleason pattern 4
- Cuboidal tumor cells with smooth and rounded luminal space
- Lack of true papillary structure
- Metastatic colorectal adenocarcinoma:
- CK20+, CDX2+, NKX3.1-
- May contain extracellular or intracellular mucin (Med Princ Pract 2010;19:82)
- Intraductal adenocarcinoma:
- Preserved basal cells, highlighted by p63, HMWCK or CK5 / 6
- Cuboidal neoplastic cells, rounded luminal spaces and lack of true papillae (Am J Surg Pathol 2011;35:615)
- May show more nuclear pleomorphism
- Cribriform high grade prostatic intraepithelial neoplasia:
- Micropapillary frond without fibrovascular stalks
- No comedonecrosis, large glands or back to back glands
- Preserved basal cells, highlighted by p63, HMWCK or CK5 / 6
- Low Ki67 (Hum Pathol 2005;36:531)
- Papillary urothelial carcinoma:
- Prostatic urethral polyp:
- Especially on needle core biopsy as it can look relatively bland (Am J Surg Pathol 1999;23:1471, Med Princ Pract. 2010;19(1):82)
- AMACR-, p63+ and CK7+ (Pathology 2007;39:476)
Board review style question #1
Board review style answer #1
B. NKX3.1+, CK20-, PSA+. Ductal adenocarcinoma is CK7-, CK20-, PSA+, PSAP+, AMACR+, NKX3.1+.
Reference: Prostate - Prostatic duct carcinoma / ductal adenocarcinoma
Comment here
Reference: Prostate - Prostatic duct carcinoma / ductal adenocarcinoma
Comment here
Board review style question #2
You suspect prostatic ductal adenocarcinoma but your differential includes acinar adenocarcinoma, Gleason pattern 4. Which of the following findings favor ductal adenocarcinoma over acinar adenocarcinoma, Gleason pattern 4?
- High PSA serum levels
- Glands composed of columnar cells
- Smooth, punched out luminal shape
- Stronger AMACR staining pattern
Board review style answer #2
B. Glands composed of columnar cells. Acinar adenocarcinoma Gleason pattern 4 is composed of cribriforming glands
with cuboidal cells whereas ductal adenocarcinoma has columnar cells. Other
answer choices: Ductal adenocarcinoma tends to have lower PSA serum levels. The
lumens are slit-like, not punched out. AMACR does not have a significantly different
staining pattern between the two entities.
Reference: Prostate - Prostatic duct carcinoma / ductal adenocarcinoma
Comment here
Reference: Prostate - Prostatic duct carcinoma / ductal adenocarcinoma
Comment here