Ductal adenocarcinoma

Prostate
Prostatic carcinoma variants
Ductal adenocarcinoma

Authors: Sarah Findeis, M.D., He Huang, M.D., Ph.D.

Editor-in-Chief: Debra Zynger, M.D.

Topic Completed: 18 October 2019

Minor changes: 10 January 2020

Copyright: 2003-2020, PathologyOutlines.com, Inc.

PubMed search: Prostatic ductal adenocarcinoma [title]

Page views in 2019: 8,417

Page views in 2020 to date: 3,511

Table of Contents

Cite this page: Findeis S, Huang H. Ductal adenocarcinoma. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/prostateprostaticduct.html. Accessed May 29th, 2020.

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

Radiology images

Images hosted on other servers:

Cystic ductal adenocarcinoma

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

Contributed by He Huang, M.D., Ph.D.

Glandular, cribriform and papillary patterns

Pseudostratified columnar cells

Mitotic figures

Virtual slides

Prostatic ductal adenocarcinoma

Cytology description

Sheets of columnar cells with some gland formation or papillary architecture with inconspicuous nucleoli (Acta Cytol 2013;57:184)

Positive stains

PSA, PSAP, AMACR, NKX3.1, androgen receptor

Negative stains

CK7, CK20; typically negative for CDX2

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:
- GATA3+, p63+, CK7+, PSA-, NKX3.1-
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

A single discrete lesion is identified within the prostate. What immunohistochemical profile would you expect to have with the following prostatic tumor?

CDX2+, AMACR+, PSAP+
NKX3.1+, CK20-, PSA+
PSA+, CK7+, AMACR+
CK5+, CK20+, NKX3.1+

Board review answer #1

B. NKX3.1+, CK20-, PSA+. Ductal adenocarcinoma is CK7-, CK20-, PSA+, PSAP+, AMACR+, NKX3.1+.

Reference: Prostate - Prostatic duct carcinoma / ductal adenocarcinoma

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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 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