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Year : 2020  |  Volume : 63  |  Issue : 2  |  Page : 338-339
A rare case of primary signet ring-like cell carcinoma of prostate in an elderly male

Department of Pathology, Bhopal Memorial Hospital and Research Centre, Bhopal, Madhya Pradesh, India

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Date of Web Publication18-Apr-2020

How to cite this article:
Gupta A, Gulwani HV. A rare case of primary signet ring-like cell carcinoma of prostate in an elderly male. Indian J Pathol Microbiol 2020;63:338-9

How to cite this URL:
Gupta A, Gulwani HV. A rare case of primary signet ring-like cell carcinoma of prostate in an elderly male. Indian J Pathol Microbiol [serial online] 2020 [cited 2021 Nov 27];63:338-9. Available from: https://www.ijpmonline.org/text.asp?2020/63/2/338/282684

Dear Editor,

Worldwide prostate cancer is the sixth most common cancer in males.[1] Majority of prostatic malignancies are adenocarcinoma (acinar type). Primary signet ring-like cell variant (PSRCC) of prostate carcinoma is rare with an estimated incidence of 30 cases per 100,000 cases of prostatic malignancy.[2] As per WHO classification of Male genital tract (2016) at least 25% of the tumour cells should exhibit classical signet ring cell morphology for the diagnosis of the entity.

A 72 years old male patient presented to outpatient services with complaints of urinary frequency, urgency and dysuria. On digital rectal examination (DRE) a firm nodular prostate of grade 3 enlargement was palpated. His serum PSA (prostate specific antigen) level was 6.5 ng/ml (normal value ≤ 4 ng/ml). With the clinical impression of benign prostatic hyperplasia patient underwent transurethral resection of prostate. Sections from prostatic tissue fragments were stained with Haematoxylin and Eosin stain, 50% of which showed tumour infiltration [Figure 1]a. More than 80% of tumour cells exhibited signet ring cell morphology that were arranged in sheets and diffusely infiltrating the prostatic stroma [Figure 1]b. Gleason's score of 10 (5+5) was assigned to the tumour. Special stains were carried out to determine the nature of intracytoplasmic vacuole in signet ring-like cells. These tumour cells were negative for PAS (periodic acid-schiff), mucicarmine and alcian blue stains. The tumour cells exhibited strong cytoplasmic positivity for Pancytokeratin, PSA and AMACR and were negative for CK7, CK20, CEA, LCA and SMA. [Figure 2]a, [Figure 2]b, [Figure 2]c. On the basis of these findings, diagnosis of primary signet ring cell like variant of the prostate was made. The patient underwent abdominal CT, chest roentgenography, upper GI endoscopy and colonoscopy and there was no evidence of any other primary lesion or metastases.
Figure 1: (a) Low power magnification showing prostatic tissue fragments that are replaced by tumour. (b) High power magnification demonstrating presence of numerous signet ring like cells that are diffusely infiltrating the prostatic stoma

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Figure 2: Immunohistochemical stains. (a) Pan cytokeratin: Tumour cells are strongly positive that are infiltrating the sub epithelial region of prostatic urethra. (b) Prostate specific antigen. Strong cytoplasmic positivity is noted in tumour cells. (c) AMACR (alpha methyl co A racemase) Tumor cells showing positive expression for the antibody

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Signet ring-like cell variant of prostate has been classified as a subtype of high grade adenocarcinoma rather than a separate histologic diagnosis. Primary signet ring cell carcinoma of prostate was first described in 1979.[3] Less than 100 cases have been reported in literature till date. In the largest analysis done by Warner et al. (Mayo clin Proc. 2010), the average age at diagnosis was 68 years (range; 50-85 years); PSA levels varied widely from 1.9-536 ng/ml and most patients (33%) presented in stage 4 cancer.[2] A primary Gleason's score of 5 is assigned to singly infiltrating signet ring cells in prostatic adenocarcinoma.

Histological identification of signet ring cells in prostatic malignancies warrants a pathologist to rule out metastasis from gastrointestinal tract or urogenital system in prostate which is more common than primary signet ring-like cell variant of prostatic adenocarcinoma. Signet ring-like appearance in tumor cells may result from various factors such as mucin, fat vacuole or artifactual cytoplasmic lumina formation. The cytoplasmic clearing of prostatic PSRCC is rarely mucicarminophilic, in contrast to mucicarmine positive signet ring cell carcinoma of bladder, urachus, stomach and other sites. Ro et al.[4] reported eight such cases in which tumour cells did not stain for alcian blue, mucicarmine or PAS with or without diastase. Similar findings were observed in our present case.

Primary signet cell adenocarcinoma of the prostate is more aggressive with less treatment response and poor prognosis when compared to the classical type of the prostate adenocarcinoma. Three-year survival is 55% and 5-year survival is 12%.[5] Poor response to antihormonal therapy has been reported in earlier studies. Our patient was referred to cancer institute for further adjuvant treatment. He has been disease free after six months follow up.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Humphrey PA, Amin MB, Berney DM, Billis A, Egevad L, Epstein JI, et al. Acinar adenocarcinoma. In: Moch H, Humphrey PA, Ulbright TM, Reuter VE, editors. WHO Classification of Tumours of the Urinary System and Male Genital Organs. 4th ed. Lyon: IARC Press; 2016. p. 150-1.  Back to cited text no. 1
Warner JN, Nakamura LY, Pacelli A, Humphreys MR, Castle EP. Primary signet ring cell carcinoma of the prostate. Mayo Clin Proc 2010;85:1130-6.  Back to cited text no. 2
Torbenson M, Dhir R, Nangia A, Becich MJ, Kapadia SB. Prostatic carcinoma with signet ring cells: A clinicopathologic and immunohistochemical analysis of 12 cases, with review of the literature. Mod Pathol 1998;11:552-9.  Back to cited text no. 3
Ro JY, el-Naggar A, Ayala AG, Mody DR, Ordóñez NG. Signet-ring-cell carcinoma of the prostate. Electron-microscopic and immunohistochemical studies of eight cases. Am J Surg Pathol 1988;12:453-60.  Back to cited text no. 4
Fujita K, Sugao H, Gotoh T, Yokomizo S, Itoh Y. Primary signet ring cell carcinoma of the prostate: Report and review of 42 cases. Int J Urol 2004;11:178-81.  Back to cited text no. 5

Correspondence Address:
Hanni Vasudev Gulwani
Department of Pathology, B-19, Type II Doctors Quarters, Bhopal Memorial Hospital and Research Centre Campus, Raisen Bypass Road, Bhopal - 462 038, Madhya Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJPM.IJPM_172_18

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