Intraductal Adenocarcinoma of the Prostate With Cribriform or Papillary Ductal Morphology

Abstract

Prostatic duct adenocarcinoma, characterized by pseudostratified columnar epithelium, has historically been considered invasive carcinoma, although it may commonly have an intraductal component. Usual (acinar) intraductal carcinoma of the prostate (IDC-P) is a noninvasive high-risk lesion typically associated with high-grade, high-stage prostate cancer. Whereas there have been rare biopsy studies of pure acinar IDC-P or IDC-P associated with only low-grade carcinoma, there have been no analogous series of IDC-P with cribriform or papillary ductal morphology on biopsy unassociated with invasive high-grade carcinoma. We identified 14 patients with biopsies showing IDC-P with ductal morphology, defined as prostatic duct adenocarcinoma confined to glands/ducts with immunohistochemically proven retention of basal cells. Our series includes 12 patients with pure IDC-P and 2 patients with concurrent low-volume Grade Group 1 invasive cancer in unassociated cores. Three patients underwent radical prostatectomy: 2/3 had high-grade cancer in their resection specimen (Grade Group 3, Grade Group 5), including 1 with advanced stage and nodal metastases; 1/3 had Grade Group 1 organ-confined carcinoma and spatially distinct IDC-P with ductal morphology. Five men had only follow-up biopsies: 2/5 had cancer (Grade Group 2, Grade Group 4); 1/5 had IDC-P (on 2 repeat biopsies); and 2/5 had benign transurethral resection of the prostate. In all 5 cases with invasive cancer, the invasive portion was comprised purely of acinar morphology; no invasive ductal component was identified. Five patients did not have follow-up biopsies and were treated with radiation therapy±androgen deprivation. One patient had no follow-up information. In an analogous situation to acinar IDC-P, we propose that rarely there is a precursor form of ductal adenocarcinoma that can exist without concurrent invasive high-grade carcinoma and propose the term “IDC-P with ductal morphology,” consistent with the terminology for acinar prostate adenocarcinoma. Until more evidence is accumulated, we recommend reporting and treating patients with IDC-P with ductal morphology in a manner analogous to those with acinar IDC-P. As with pure IDC-P with acinar morphology, we would also recommend not grading pure IDC-P with ductal morphology. Finally, we propose a new addition to the diagnostic criteria of IDC-P to include intraductal lesions with ductal morphology consisting of papillary fronds or cribriform lesions lined by cytologically atypical pseudostratified epithelium.

Intraductal Carcinoma of the Prostate

“…Similarly, in cases of ductal IDCP, the degree of nuclear enlargement and pleomorphism is not a diagnostic criterion. 4 It is not surprising that Samaratunga and colleagues did not encounter cases fitting the second criterion within the 100 cases they examined, as this is a rare phenomenon seen only a few times a year within one of the current authors GU Consult Service of ∼10,000 prostate cases per year. Even though these cases of pleomorphic IDCP are very rare, they still need to be recognized as worse than HGPIN and as a variant of IDCP since these are overtly malignant prostate cancer cells within prostatic ducts/ acini (Figs.…”

“…In some cases, they can be even smaller than nuclei of benign glandular epithelium, yet the IDCP diagnosis can be rendered based on the architectural growth pattern or the presence of comedonecrosis. Similarly, in cases of ductal IDCP, the degree of nuclear enlargement and pleomorphism is not a diagnostic criterion 4…”

Investigation of ERG and PTEN expressions in benign, precursor and malignant epithelial proliferations of prostate and clinicopathological correlation of findings

“…Ancak bilindiği gibi zamanla tedaviye direnç geliĢmesi, bu tedavi direncini belirleyebilmek ve yeni hedefe yönelik tedavi modalitelerini geliĢtirebilmek için doku bazlı moleküler biyobelirteçlerin yoğun bir Ģeklide araĢtırılmasına neden olmuĢtur. Son zamanlarda, transkripsiyonel regülatör ERG, PTEN gibi biyobelirteçlerin tanısal ve prognostik değerini araĢtıran çalıĢmalar yayınlanmıĢtır (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17). PTEN 10q23.3 kromozomal bölgede yer alan bir tümör baskılayıcı gendir (18).…”

“…Agresif bir tümör olan ĠDK'un ayrımı hasta yönetimi açısından önemlidir. Ayrıca PĠN ve ĠDK tanı kriterlerini karĢılamayan yeni bir grup "atipik intraduktal proliferasyonlar" (AĠP) tanımlanmaya ve bu konuda çalıĢmalar yapılmaya baĢlanmıĢtır (13)(14)(15)(16)(17). ÇalıĢmamızda; ĠDK ve AĠP'nin Türk hasta popülasyonundaki insidansı yanı sıra ERG ve PTEN ekspresyonlarının prognostik değerini ve morfolojik özellikleri nedeniyle ayırıcı tanı zorluğu yaratabilecek PĠN, AĠP ve ĠDK patogenezinde bu biyobelirteçlerin katkısını araĢtırmayı amaçladık.…”

In Reply: Intraductal Carcinoma of the Prostate and Nuclear Size

“…As Dr Epstein has not refuted this in subsequent publications discussing the possibility that IDCP may exist as a precursor lesion, we conclude that there are only 3 cases on record, which is certainly surprising for the putative precursor lesion of a process as common as IDCP. The fourth reference cited in the letter, that purports to show that IDCP can exist as a precursor lesion in the absence of invasive acinar carcinoma, relates to ductal adenocarcinoma not acinar carcinoma 10. Although not relevant to the context of Kryvenko and Epstein’s letter, the evidence is again limited.…”