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Year : 2020  |  Volume : 63  |  Issue : 4  |  Page : 674-675
Ductal adenocarcinoma of prostate–A diagnostic dilemma

1 Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

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Date of Submission23-Jul-2019
Date of Decision06-Sep-2019
Date of Acceptance14-Sep-2019
Date of Web Publication28-Oct-2020

How to cite this article:
Sharma S, Kakkar N, Devana SK. Ductal adenocarcinoma of prostate–A diagnostic dilemma. Indian J Pathol Microbiol 2020;63:674-5

How to cite this URL:
Sharma S, Kakkar N, Devana SK. Ductal adenocarcinoma of prostate–A diagnostic dilemma. Indian J Pathol Microbiol [serial online] 2020 [cited 2020 Nov 25];63:674-5. Available from: https://www.ijpmonline.org/text.asp?2020/63/4/674/299314

Dear Editor,

Ductal adenocarcinomas comprise <1% of prostatic tumors.[1] They are difficult to diagnose clinically as well as morphologically because of low prostate-specific antigen (PSA) level, central location, and varied morphologic presentations.[2],[3] Morphological features mislead the pathologist and a strong suspicion and confirmation with immunohistochemistry is important.

A 69-year-old-male presented with frequency, urgency of urination, and intermittent hematuria for 1 year. Per rectal examination was normal and serum PSA was 5 ng/ml. Transurethral resection of prostate (TURP) done outside our institute with bilateral orchidectomy was reported as metastatic adenocarcinoma. Magnetic resonance imaging (MRI) showed a tumor in the prostate extending into the urinary bladder with bony metastasis. The patient had persistent lower urinary tract symptoms with significant post-void residual urine, hence planned for TUR channeling. Intraoperative examination showed a tumor in the floor and left lateral part of prostate with intravesical extension anteriorly. Verumontanum and external sphincter were involved by tumor. Whole intraprostate extension and floor of prostate were resected.

Histopathology showed complex papillae with a central fibrovascular core. Tumor cells were markedly pleomorphic with prominent nucleoli and frequent mitosis [Figure 1]a and [Figure 1]b. A diagnosis of high grade papillary urothelial carcinoma invading the prostate was given. Subsequently, slides from outside were reviewed that showed areas of cribriform pattern with central necrosis along with papillary arrangement [Figure 1]c and [Figure 1]d. Immunohistochemistry was positive for alpha-methylacyl coenzyme A (CoA)-reductase (AMACR) and PSA and negative for high molecular weight cytokeratin (HMWCK) and GATA3 [Figure 1]e, [Figure 1]f, [Figure 1]g, [Figure 1]h, from which a diagnosis of prostatic ductal adenocarcinoma was given. Positron emission tomography scan showed lung metastasis. The patient received six cycles of chemotherapy, subsequently expired 2 years after the diagnosis.
Figure 1: (a-d) (Histopathologic features) (a) Papillae lined by pseudostratified epithelium (H and E, 200×); (b) Columnar tumor cells with frequent mitosis (H and E, 400×); (c and d) Cribriform pattern with central necrosis along with papillae (H and E, 100×); (e-h) (Immunohistochemistry) (e) Alpha-methylacyl coenzyme A (CoA)-reductase (AMACR) positive (Immunohistochemistry, AMACR, 400×); f. Prostate specific antigen (PSA) positive (Immunohistochemistry, PSA, 400×); (g) High molecular weight cytokeratin (HMWCK) negative (Immunohistochemistry, HMWCK, 400×); (h) GATA3 (Immunohistochemistry, GATA3, 400×)

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Ductal adenocarcinoma of prostate occurs at 60 to 80 years and arises in large primary periurethral prostatic ducts.[1],[2] These tumors are usually located around the verumontanum and are diagnosed on TUR.[1] PSA levels are low, but rise if the tumor invades the peripheral zone of prostate.[4]

Varying architectural patterns are seen, papillary and cribriform being the most common. Cells are columnar with a single macronucleus.[2] The cribriform pattern of acinar adenocarcinoma shows cuboidal epithelium with punched-out lumina. Gleason grading is usually not done in these tumors.

The papillary pattern, as seen in our case, can mislead to the diagnosis of papillary urothelial carcinoma. Nuclear features can help in diagnosis. Urothelial carcinoma shows pleomorphic, angulated nuclei with variable number of nucleoli, and lack columnar appearance of ductal adenocarcinoma. On immunohistochemistry, ductal adenocarcinomas of prostate are positive for PSA, PSAP, AMACR, and CK7 and negative for HMWCK, GATA3, thrombomodulin, and uroplakin.[5]

Another entity to be distinguished from ductal adenocarcinoma is pseudopapillary prostatic adenocarcinoma, which is diagnosed by presence of pseudopapillae in high-grade acinar prostate adenocarcinoma. In our case, ductal carcinoma was diagnosed depending on the location of tumor, low PSA levels, and absence of acinar pattern.[6]

Prostatic ductal carcinomas are aggressive and can metastasize to bone, testis, penis, brain, liver, and lungs.[1],[4] Differentiation from high grade urothelial carcinoma is important because of different management. Histopathology with immunohistochemistry helps to differentiate between the two.

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 b'e 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

LiuT, Wang Y, Zhou R, Li H, Cheng H, Zhang J. The update of prostatic ductal adenocarcinoma. Chin J Cancer Res 2016;28:50-7.  Back to cited text no. 1
Epstein JI. Prostatic ductal adenocarcinoma: A mini review. Med Princ Pract 2010;19:82-5.  Back to cited text no. 2
Hameed O, Humphrey PA. Stratified epithelium in prostatic adenocarcinoma: Amimic of high-grade prostatic intraepithelial neoplasia. Mod Pathol 2006;19:899-906.  Back to cited text no. 3
Morgan TM, Welty CJ, Lopez FV, Lin DW, Wright JL. Ductal adenocarcinoma of the prostate: Increased mortality risk and decreased PSA secretion. J Urol 2010;184:2303-7.  Back to cited text no. 4
Mai KT, Collins JP, Veinot JP. Prostatic adenocarcinoma with urothelial (transitional cell) carcinoma features. Appl Immunohistochem Mol Morphol 2002;10:231-6.  Back to cited text no. 5
VermaA, Menon S, Bakshi G, Desai S. Pseudopapillary prostatic adenocarcinoma: A diagnostic pitfall for pathologistsIndian J PatholMicrobiol2016;59:203-5.  Back to cited text no. 6

Correspondence Address:
Nandita Kakkar
Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJPM.IJPM_578_19

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