Uropathology

Case 11111969

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  Patient de 71 ans, hématurie, rétention urinaire. PSA peu élevée. TR non suspect. Résection prostatique trans-uréthrale.   71 yo patient, haematuria, urinary retention. PSA slightly elevated. Transurethral resection of the prostate.  
     
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  PSAP   PSAP  
 

Diagnostic proposé

 

 

 

 

 

 

 

Adénocarcinome canalaire (des gros canaux)

 

Proposed diagnosis

 

 

 

 

 

 

 

Ductal adenocarcinoma

 
  Arguments      
 

   

Pathology and Genetics of Tumours of the Urinary System and Male Genital Organs. WHO 2004

Definition
Subtype of adenocarcinoma composed of large glands lined by tall pseudostratified
columnar cells.

Synonyms
Several terms used in the past are no longer appropriate. Endometrial carcinoma was originally used to describe this entity because of its morphologic similarity to endometrium. This tumour was previously believed to be derived from a Müllerian structure named prostatic utricle. However, subsequent studies on favourable response to orchiectomy, ultrastructural studies, histochemistry and immunohistochemistry have proven the prostatic origin of this tumour. Therefore, the term endometrial or endometrioid carcinoma should not be used. Prostatic duct carcinoma should be used with caution, because it could also refer to urothelial carcinoma involving prostatic ducts.

Epidemiology
In pure form, ductal adenocarcinoma accounts for 0.2-0.8% of prostate cancers. More commonly it is seen with an acinar component.

Etiology
No specific etiologic factors have been defined for this particular type.

 

Localization
Ductal adenocarcinoma may be located centrally around the prostatic urethra or more frequently located peripherally admixed with typical acinar adenocarcinoma.
Both centrally and peripherally located ductal adenocarcinoma components can be present in the same prostate. A centrally located adenocarcinoma may also be associated with a peripherally located acinar adenocarcinoma.

 
 

Clinical features
Signs and symptoms
Periurethral or centrally located ductal adenocarcinoma may cause haematuria, urinary urgency and eventually urinary retention. In these cases, there may be no abnormalities on rectal examination. Tumours arising peripherally may lead to enlargement or induration of the prostate. Although ductal adenocarcinoma strongly expresses prostate specific antigen (PSA) immunohistochemically, they are associated with variable serum PSA levels.
Methods of diagnosis
Serum PSA levels may be normal particularly in a patient with only centrally located tumour. In most cases, transurethral resections performed for diagnosis or relief of the urinary obstruction will provide sufficient diagnostic tissue. Transrectal needle core biopsies may also obtain diagnostic tissue when the tumour is more peripherally located. In addition, areas of ductal adenocarcinoma may be incidentally identified
in prostatectomy specimens.

 
 

Macroscopy/Urethroscopy
Centrally occurring tumours appear as exophytic polypoid or papillary masses protruding into the urethra around the verumontanum. Peripherally occurring tumours
typically show a white-grey firm appearance similar to acinar adenocarcinoma.

 
 

Tumour spread and staging
Ductal adenocarcinoma usually spread along the urethra or into the prostatic ducts with or without stromal invasion. Other patterns of spread are similar to that of acinar prostatic adenocarcinoma with invasion to extraprostatic tissues and metastasis to pelvic lymph nodes or distal organs. However, ductal adenocarcinomas appear to have a tendency to metastasize to lung and penis. The metastasis of ductal adenocarcinoma may show pure ductal, acinar or mixed components.

 

Histopathology
Ductal adenocarcinoma is characterized by tall columnar cells with abundant usually
amphophilic cytoplasm, which form a single or pseudostratified layer reminiscent
of endometrial carcinoma
. The cytoplasm of ductal adenocarcinoma is often
amphophilic and may occasionally appear clear. In some cases, there are numerous mitoses and marked cytological atypia. In other cases, the cytological atypia is minimal, which makes a diagnosis difficult particularly on needle biopsy.
Peripherally located tumours are often admixed with cribriform, glandular or solid patterns as seen in acinar adenocarcinoma.
Although ductal adenocarcinomas are not typically graded, they are mostly equivalent to Gleason patterns 4. In some cases comedo necrosis is present whereby they could be considered equivalent to Gleason pattern 5. In contrast to ordinary acinar adenocarcinoma, some ductal adenocarcinomas are associated with a prominent fibrotic response often including haemosiderin-laden macrophages. Ductal adenocarcinoma displays a variety of architectural patterns, which are often intermingled.

Papillary pattern can be seen in both centrally or peripherally located tumours, yet
is more common in the former. Cribriform pattern is more commonly seen in peripherally located tumours, although they may be also present in centrally located
tumours. The cribriform pattern is formed by back-to-back large glands with intraglandular bridging resulting in the formation of slit-like lumens.
Individual gland pattern is characterized by single glands.
Solid pattern can only be identified when it is associated with other patterns of
ductal adenocarcinoma. The solid nests of tumour cells are separated by incomplete
fibrovascular cores or thin septae.
Ductal adenocarcinoma must be distinguished from urothelial carcinoma, ectopic prostatic tissue, benign prostatic polyps, and proliferative papillary urethritis.
One of the more difficult differential diagnoses is cribriform high grade prostatic
intraepithelial neoplasia. Some patterns of ductal adenocarcinoma may
represent ductal carcinoma in situ.
Immunoprofile
Immunohistochemically ductal adenocarcinoma is strongly positive for PSA and PAP. Tumour cells are typically negative for basal cell specific high molecular weight cytokeratin (detected by 34βE12), however, preexisting ducts may be positive for this marker.

Prognosis and predictive factors
Most studies have demonstrated that ductal adenocarcinoma is aggressive.
Some reported that 25-40% of cases had metastases at the time of diagnosis with a poor 5-year survival rate ranging from 15-43%. It is not known whether prognosis correlates with the degree of cytological atypia or growth patterns. Even limited ductal adenocarcinoma on biopsy warrants definitive therapy.
Androgen deprivation therapy may provide palliative relief, even though these cancers are less hormonally responsive than acinar adenocarcinoma.