PROSTATIC CANCER AND RECTAL POLYP
The presence of IDC-P is Polyp in der Prostata associated with a high-grade Gleason score, large tumor volume, and adverse prognostic parameters, including extraprostatic extension and seminal vesicle invasion. When present, IDC-P is associated with worse outcomes, regardless of treatment status.
IDC-P is included in a broader diagnostic category of atypical cribriform lesions of the prostate gland. This category of lesions also includes high-grade prostatic intraepithelial neoplasia HGPINurothelial carcinoma involving prostatic ducts or acini, and prostatic ductal adenocarcinoma, amongst other intraductal proliferations. Differentiating between these entities is important as they have differing therapeutic and prognostic implications for patients, although differential diagnosis thereof is not always straightforward.
The present review discusses IDC-P in regards to its morphological characteristics, molecular features, and clinical outcomes. Given the current state of knowledge, the presence of IDC-P should be evaluated and documented correctly in both radical prostatectomy and needle biopsy specimens, and the clinical implications thereof should be taken into consideration during treatment and follow up. Intraductal carcinoma of the prostate IDC-P is a malignant lesion characterized by an expansile proliferation of malignant prostatic secretory epithelial cells within prostatic ducts and acini, and demonstrates significant architectural and cytological atypia.
With increasingly frequent recognition of IDC-P, the differential diagnosis of atypical medium sized and large cribriform lesions on prostate core needle biopsies has become more challenging.
The differential diagnosis for this group of lesions includes several entities, with differing therapeutic and prognostic implications. High-grade prostatic intraepithelial neoplasia HGPIN is considered a preneoplastic lesion; its presence does not require definitive treatment, and when present exclusively in an extended core biopsy, does not warrant another biopsy.
The morphological features, diagnostic criteria, and molecular characteristics of IDC-P and the distinction of this category of lesions from the aforementioned entities are discussed herein. Correctly diagnosing IDC-P is not only important for pathologists, but also for other members of the clinical team, including urologists and medical and radiation oncologists.
The term IDC-P has been employed interchangeably over the years to refer to prostatic ductal adenocarcinoma, prostatic acinar adenocarcinoma, and extension of urothelial carcinoma into prostatic ducts and acini. McNeal, et al. However, as Polyp in der Prostata of this ductal proliferation has become better understood, IDC-P is used to refer to prostatic adenocarcinoma that extends into and proliferates within preexisting prostatic ducts.
IDC-P can exhibit a variety of growth patterns, including loose or dense cribriform, solid, micropapillary, and rarely, flat architecture. The cells exhibit cuboidal or columnar cytological features with significant nuclear enlargement. IDC-P is associated with aggressive Polyp in der Prostata adenocarcinoma and its presence in both core needle biopsy and radical prostatectomy specimens is associated with adverse prognosis.
IDC-P is not usually identified in prostate core biopsies, and this finding is supported by a recently published study with a significant cohort of more than consecutive prostate biopsies, wherein an overall incidence of 2. Several published studies Polyp in der Prostata shown that the presence of IDC-P correlates with higher Gleason scores, larger tumor volume, increased risk of extraprostatic extension, seminal vesicle invasion, and pelvic lymph node metastases identified upon subsequent radical prostatectomies.
The presence of IDC-P in radical prostatectomy specimens correlates with decreased progression-free survival and an increase in the incidence of biochemical recurrence following radical prostatectomy. In a similar vein, O'Brien, et al. The presence of IDC-P is associated with a comparatively poor prognosis, following stratification for Gleason score.
IDC-P represents late-stage progression of prostatic adenocarcinoma in the majority of cases with intraductal extension of high-stage, advanced cancer and this theory has been supported by molecular studies. The recognition of IDC-P in a specimen is understood to represent a late-stage occurrence in cases with high-grade, high-stage prostate adenocarcinoma. These Polyp in der Prostata type IDC-Ps may Polyp in der Prostata an entity in the spectrum of neoplastic changes from Polyp in der Prostata to invasive cancer or possibly an entity in a separate de novo pathway.
Miyai, et al. Rare reports of IDC-P occurring without the concomitant presence of invasive carcinoma or in the presence of only Gleason score 6 cancer documented on prostatectomy have been published. In this small cohort, outcomes were seemingly better with a decreased incidence of biochemical recurrence; however, these cases had a relatively limited follow-up.
It is, therefore, important to consider two scenarios when evaluating IDC-P: whether it is seen in association with invasive prostate carcinoma or not. The former group focuses on prognostic factors used mainly to predict outcome, and can Polyp in der Prostata applied to both radical prostatectomy samples and needle biopsies.
The latter is focused on impacting decisions for subsequent therapy, and can only be applied in the setting of core needle biopsies. These differences should be considered whenever IDC-P is reported. The prostatic glands are usually similar in size to adjacent, benign glands in HGPIN, and cells lack marked nuclear atypia with nuclear size, measuring 2 to 3 times that of adjacent benign nuclei Fig.
The mitotic activity is not significantly increased in Polyp in der Prostata with only occasional mitotic figures identified. IDC-P may occasionally demonstrate a spectrum of features that Polyp in der Prostata low-grade cytology with uniform nuclei and small, regularly contoured glands. This is similar to the risk of invasive adenocarcinoma on a repeat biopsy following a benign diagnosis. An atypical intraductal proliferation is seen microscopically as a lesion spanning the lumen of prostatic ducts or glands, and demonstrating the presence of cells with cytological atypia that exceeds the cytoarchitectural features of HGPIN but is not sufficient to meet the threshold for a definitive diagnosis of IDC-P Fig.
Morphologically, the following criteria have been put forth for diagnosing atypical intraductal proliferations by Morais, et al. In their study, 60 patients with atypical intraductal proliferations were included and a repeat biopsy was performed in 35 cases along with prostatectomy in one case. In another study by Miyai, et al. A recommendation from this study was that atypical intraductal proliferations should be distinguished from HGPIN, as these lesions mandate active clinical surveillance with repeat biopsy within 3 months.
The absence of basal cells around the ductal or glandular units serves to distinguish invasive high-grade acinar adenocarcinoma of prostate from IDC-P. Although IHC staining for basal cells distinguishes IDC-P from invasive acinar adenocarcinoma and is very helpful in this regard, it is not always performed owing to similar clinical management of both these types of lesions. Microscopically, it demonstrates pseudostratified tall, columnar cell morphology.
Other frequently encountered features that help in establishing the diagnosis include the presence of papillary architecture with fibrovascular cores or a cribriform growth Polyp in der Prostata with large sized, back-to-back glandular elements with intraglandular bridging and narrow slit-like lumina akin to a Mullerian "endometrioid" pattern Fig.
This entity may also cause diagnostic confusion with IDC-P when the cribriforming architecture is prominent and the malignant glands have relatively round contours. Morphologic clues to a diagnosis of prostatic ductal adenocarcinoma include the presence of true fibrovascular cores that are lacking in IDC-P and the presence of pseudostratified, columnar cells, in contrast to cuboidal cells lining the cribriform nests in IDC-P. IHC staining is also helpful as it demonstrates a lack of staining for basal cell markers in prostatic ductal adenocarcinoma.
A pitfall to consider is that basal cells may be seen underlying the pseudostratified, columnar cells in cases of prostatic ductal adenocarcinoma; however, this likely represents intraductal spread of prostatic ductal adenocarcinoma. Prostatic intraepithelial neoplasia-like PIN-like adenocarcinoma of prostate, which is a variant of prostatic ductal adenocarcinoma, is also included in the differential diagnosis of IDC-P and prostatic ductal adenocarcinoma as it demonstrates a pattern of Polyp in der Prostata to large sized dilated glands lined Polyp in der Prostata pseudostratified, columnar epithelial cells.
Cytologically, PIN-like prostatic ductal adenocarcinoma is composed of uniformly elongated, monomorphic nuclei without prominent nucleoli, and lacks the cytological pleomorphism seen in IDC-P. IHC for basal markers is significantly helpful in this aspect since it will show lack of basal cells in PIN-like prostatic ductal adenocarcinoma. Urothelial carcinoma involving prostatic ducts can also mimic IDC-P by growing into and distending prostatic ducts and acini.
It can Polyp in der Prostata demonstrate foci of comedonecrosis further confounding the differential with IDC-P. The often countered papillary growth pattern of urothelial carcinoma may be absent, although divergent squamous differentiation, when present, may be of assistance in distinguishing urothelial carcinoma from IDC-P. Mitotic activity is also frequently elevated in urothelial carcinoma cases, serving as a useful feature Fig.
Identification of urothelial carcinoma involving prostatic ducts is also important as cystoprostatectomy with or without accompanying chemotherapy is the treatment of choice in such cases. IDC-P should be reported in both core needle biopsies and radical prostatectomy specimens when it is seen in association Polyp in der Prostata invasive adenocarcinoma or as isolated IDC-P without concomitant invasive carcinoma.
Polyp in der Prostata biopsy specimens, IDC-P should be included in overall volume percentage of tumor involvement in a core with conconcomitant invasive carcinoma. When IDC-P is seen in association with high-grade invasive prostatic adenocarcinoma Gleason score Polyp in der Prostatait should be documented as a morphologic finding, although IHC staining for basal cell markers to establish a diagnosis of IDC-P is not necessary in such cases.
When IDC-P is seen in isolation without concomitant invasive carcinoma, it must Polyp in der Prostata mentioned that IDC-P is often associated with high-grade, high-stage invasive prostate adenocarcinoma, and an immediate repeat biopsy is warranted for such cases.
The decision to proceed with definitive treatment or an immediate rebiopsy in rare instances of IDC-P associated with low-grade Gleason score 6 cancer should be weighed in a multidisciplinary setting on an individual basis. On the other hand, if several biopsy cores are involved by IDC-P with high-grade cytoarchitectural features, then definitive treatment may be recommended.
IDC-P is frequently encountered in association with high-grade and high-stage, invasive prostatic adenocarcinoma, and mandates definitive treatment. It is important Polyp in der Prostata recognize and report these lesions if they are identified in both core needle Polyp in der Prostata and radical prostatectomy specimens, thereby providing the clinical team with an opportunity to consider the presence of this lesion when planning patient care. IDC-P may be identified in a series of different biopsy and prostatectomy scenarios, and application of the proposed diagnostic criteria and reporting patterns, coupled with immunohistochemical staining, if required, are recommended Polyp in der Prostata outlining further management strategies.
Additional studies are required in this area to establish more uniform guidelines and to investigate other possible robust immunohistochemical or molecular markers that may aid in establishing an unequivocal diagnosis of IDC-P. The authors have no financial conflicts of interest. National Center for Biotechnology InformationU. Journal List Yonsei Med J v. Yonsei Med J. Published online Jun Mukul K.
Divatia and Jae Y. Find articles by Mukul K. Jae Y. Find articles by Jae Y. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Corresponding author: Dr. Tel:Fax:gro. Received Apr This article has been cited by other articles in PMC. Keywords: Intraductal carcinoma of prostate, high-grade prostatic intraepithelial neoplasia, prostatic ductal Polyp in der Prostata. Morphologic features and diagnostic parameters of IDC-P The term IDC-P has been employed interchangeably over the years to refer Polyp in der Prostata prostatic ductal adenocarcinoma, prostatic acinar adenocarcinoma, and extension of urothelial carcinoma into prostatic ducts and acini.
Open in a separate window. Note Polyp in der Prostata presence of a darkly outlined layer of basal cells around the circumference of the involved duct. B IDC-P with a densely solid growth pattern associated with invasive high-grade adenocarcinoma of prostate Gleason score 8 in a prostatectomy specimen. D High-grade cytologic features of lesional cells in IDC-P with significantly enlarged nuclei exhibiting marked pleomorphism and focal comedonecrosis right side.
Note the high-grade cytologic features with uniform significantly enlarged nuclei and prominent nucleoli. F IDC-P with cribriform growth pattern present at the edge of a core needle prostate biopsy specimen. Thus focus may be interpreted as an atypical cribriform lesion or atypical intraductal proliferation in the absence of unequivocal foci of IDC-P elsewhere in the specimen.
IDC-P, intraductal carcinoma of the prostate. Entities comprising the list of differential diagnoses for IDC-P. The nuclei are not as significantly enlarged as seen in IDC-P. B Atypical intraductal proliferation or atypical cribriform lesion. Although this atypical proliferation demonstrates architectural complexity greater than that encountered with HGPIN, it does not display the high-grade cytological features and solid or dense cribriform proliferation seen frequently in IDC-P.