{"entity":{"id":"prostate-ductal-adenocarcinoma","kind":"cancer","name":"Ductal adenocarcinoma of the prostate","aka":["Prostatic ductal adenocarcinoma","Ductal adenocarcinoma","Ductal prostate cancer","Adenocarcinoma with ductal features","Mixed acinar-ductal adenocarcinoma","Endometrioid carcinoma of the prostate","DAC"],"tldr":"Ductal adenocarcinoma is a rare type of prostate cancer, roughly one case in six hundred, that grows from the larger ducts of the gland rather than from its small acini. It tends to make less PSA than ordinary prostate cancer, so it is found later and more often after it has spread, and it is treated as high-risk disease from the day it is named.","summary":"What it is. Ductal adenocarcinoma of the prostate is a carcinoma of the larger, more central prostatic ducts. Under the microscope it is built of tall columnar cells with stratified nuclei arranged in papillary, cribriform, glandular or solid patterns, in contrast to the cuboidal cells in small round acini that make up ordinary, acinar prostate cancer. The fifth edition of the WHO Classification of Tumours reserves the term ductal adenocarcinoma for radical prostatectomy specimens with more than 50 percent ductal morphology, and asks for the phrase 'adenocarcinoma with ductal features' on a needle biopsy whether the biopsy is pure ductal or mixed, because a needle sees too little of the gland to know the proportion.\n\nHow it differs from its parent. The fifth edition considered making ductal adenocarcinoma a subtype of acinar adenocarcinoma and decided against it, keeping it a separate type because of how differently it behaves (Kench 2022). It makes less PSA for the same amount of cancer: in a series of 371 ductal cases, ductal histology was associated with a 30 percent lower geometric mean PSA and more than twice the chance of a PSA under 4 ng/mL, independent of everything else. It presents more locally advanced (22.2 percent T3 against 8.9 percent for acinar on meta-analysis, relative risk 1.71 for T3 and 7.56 for T4) and with a 4.62 times higher relative risk of metastatic disease at diagnosis. It goes to places prostate cancer usually does not: lung, liver, brain, skin, penis, peritoneum and testis, which is why an unusual secondary tumour in a man with prostate cancer is a reason to look again at the histology.\n\nHow common it is. About 0.17 percent of prostate cancer by meta-analysis, so of the order of 100 cases a year in the UK if the same proportion holds, which has not been measured directly here. Most are mixed with acinar cancer rather than pure. It is under-diagnosed by systematic biopsy: in one series using MRI-targeted biopsy, 19 of 23 ductal cases (83 percent) had been missed entirely by a prior 12-core systematic biopsy, and expert uropathologists agreed on the diagnosis in only 52 percent of cases in a 20-reader study, so the reported incidence is a floor and the range between series is wide.\n\nHow it is treated. As high-risk prostate cancer, with no guideline written specifically for it and no randomised trial of its own. Radical prostatectomy or radical radiotherapy are used for localised disease and hormonal therapy with or without chemotherapy for metastatic disease; the few studies comparing surgery and radiotherapy are small and disagree, with cancer-specific survival looking worse after prostatectomy in the pooled picture. On meta-analysis five-year cancer-specific and overall survival were both worse than for acinar cancer (relative risks 0.85 and 0.83). DNA-repair alterations are commoner in ductal disease, reported in 49 percent of one series of 51 cases, and both the NCCN and the Philadelphia Prostate Cancer Consensus Conference recommend germline genetic testing for anyone whose prostate cancer shows ductal, intraductal or cribriform morphology, which is the one management change the diagnosis reliably triggers.","asOf":"2026-09-25","wikipedia":"https://en.wikipedia.org/wiki/Prostate_cancer","links":[{"label":"Ranasinha et al., BJUI Compass 2021: ductal adenocarcinoma of the prostate, a systematic review and meta-analysis of incidence, presentation, prognosis and management","url":"https://doi.org/10.1002/bco2.60"},{"label":"Kench et al., Histopathology 2022: WHO Classification of Tumours fifth edition, evolving issues in the classification, diagnosis and prognostication of prostate cancer","url":"https://doi.org/10.1111/his.14711"},{"label":"WHO Classification of Tumours, 5th edition: tumours of the prostate (IARC, 2022)","url":"https://tumourclassification.iarc.who.int/chapters/36"},{"label":"Royal College of Pathologists G084: dataset for histopathology reports for prostatic carcinoma, version 4, October 2024","url":"https://www.rcpath.org/static/8cc88604-2c8d-4df4-a99542df41c102af/G084-dataset-for-histopathology-reports-for-prostatic-carcinoma.pdf"},{"label":"Netto et al., European Urology 2022: the 2022 WHO classification of tumours of the urinary system and male genital organs, part B (prostate and urinary tract)","url":"https://pubmed.ncbi.nlm.nih.gov/35965208/"}],"tags":["gu","subtype-page"],"related":["prostate","prostate-nepc","prostate-high-risk","prostate-mhspc"],"cancers":[],"sections":[],"technologies":["mp-mri","germline-testing","histopathology-ihc"],"targets":[],"drugs":[],"companies":[],"institutions":[],"pathways":[],"terms":["gleason-grade-group","intraductal-carcinoma-prostate","cribriform-prostate-cancer","psa","prostate-acinar-adenocarcinoma","tnm-prostate-cancer","cambridge-prognostic-group"],"trials":[],"people":[],"bottlenecks":[],"keyPapers":[],"journals":[],"dependsOn":[],"notes":["Ductal is not intraductal. They sound alike, they are often found in the same gland, and they mean different things. Ductal adenocarcinoma is an invasive cancer whose cells look like duct lining; intraductal carcinoma of the prostate is cancer growing inside ducts and acini that still have their own basal cell layer, a pattern reported beside an invasive cancer rather than a tumour type of its own. Both are reasons for germline testing and both mean a worse outlook, which is probably why the two words get run together.","Why a needle biopsy report says 'adenocarcinoma with ductal features' instead. The WHO fifth edition reserves the term ductal adenocarcinoma for prostatectomy specimens where more than half the tumour is ductal, and asks for 'adenocarcinoma with ductal features' on needle biopsies whether the sample is pure or mixed, because a needle cannot measure the proportion in the whole gland. A report using the longer phrase is following the classification, not hedging.","Why the incidence figures disagree so much. The meta-analysed range across case series is 0.084 to 13.4 percent, a spread of more than a hundredfold, and the reason is diagnostic rather than biological: there is no single agreed histological definition, twenty expert uropathologists agreed on a positive ductal diagnosis in 52 percent of cases, and systematic biopsy misses the ductal component in most cases that MRI-targeted biopsy finds. Any single number quoted for how common ductal prostate cancer is should be read as an estimate of how often it is recognised."],"group":"genitourinary","burden":"About 0.17 percent of prostate cancer: a systematic review of 114 studies covering 2,907,170 prostate cancers found 5,911 ductal cases, and meta-analysis of the 21 case series that counted both types consecutively gave 0.17 percent, with a range across series of 0.084 to 13.4 percent, the spread reflecting how differently the diagnosis is made rather than how differently the disease occurs. Pure ductal disease is rarer still: in 1,051 radical prostatectomy specimens from the Karolinska University Hospital, 2 (0.2 percent) were pure ductal and 84 (8 percent) mixed acinar-ductal (BJUI Compass 2021).","subtypes":[],"biomarkers":["Ductal morphology on the report: more than 50 percent ductal at prostatectomy, or 'adenocarcinoma with ductal features' on a needle biopsy","PSA, read with caution because ductal disease makes less of it for the same tumour burden","Germline and somatic homologous recombination and mismatch repair genes, tested because ductal morphology is one of the triggers"],"standardOfCare":[{"setting":"Localised","approach":"Treated as high-risk prostate cancer: radical prostatectomy or radical radiotherapy with androgen deprivation. No guideline and no randomised trial is specific to ductal histology, and the retrospective comparisons of surgery against radiotherapy are small and inconsistent.","refs":["robotic-surgery","imrt-igrt","androgen-deprivation","prostatectomy"],"guideline":{"version":"NCCN Guidelines: Prostate Cancer","url":"https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1459"}},{"setting":"Any stage, at diagnosis","approach":"Germline genetic testing, which the NCCN and the Philadelphia consensus conference recommend for ductal, intraductal or cribriform morphology whatever the stage.","refs":["germline-testing","intraductal-carcinoma-prostate","cribriform-prostate-cancer"],"guideline":{"version":"NCCN Guidelines: Prostate Cancer","url":"https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1459"}},{"setting":"Metastatic","approach":"Treated as metastatic acinar prostate cancer, with androgen deprivation and an androgen receptor pathway inhibitor. In the one study that asked the question, 35 ductal cases among 634 men with de novo metastatic prostate cancer had no worse overall or cancer-specific survival than acinar cases, so the histology's disadvantage appears to be in getting to metastasis sooner rather than in behaving worse once there.","refs":["androgen-deprivation","psma-pet"],"guideline":{"version":"NCCN Guidelines: Prostate Cancer","url":"https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1459"}}],"stateOfArt":[],"history":[],"pipeline":[],"openProblems":[],"parent":"prostate"},"route":"/cancers/prostate-ductal-adenocarcinoma/","neighbours":{"cancer":[{"id":"prostate-high-risk","kind":"cancer","name":"Localised prostate cancer, high and very high risk","route":"/cancers/prostate-high-risk/"},{"id":"prostate-intermediate-risk","kind":"cancer","name":"Localised prostate cancer, intermediate risk","route":"/cancers/prostate-intermediate-risk/"},{"id":"prostate-low-risk","kind":"cancer","name":"Localised prostate cancer, very low and low risk","route":"/cancers/prostate-low-risk/"},{"id":"prostate-mhspc","kind":"cancer","name":"Metastatic hormone-sensitive prostate cancer","route":"/cancers/prostate-mhspc/"},{"id":"prostate-nepc","kind":"cancer","name":"Neuroendocrine and small-cell prostate cancer","route":"/cancers/prostate-nepc/"},{"id":"prostate","kind":"cancer","name":"Prostate cancer","route":"/cancers/prostate/"}],"technology":[{"id":"androgen-deprivation","kind":"technology","name":"Androgen deprivation & AR pathway inhibitors","route":"/technologies/androgen-deprivation/"},{"id":"germline-testing","kind":"technology","name":"Germline (hereditary) testing","route":"/technologies/germline-testing/"},{"id":"histopathology-ihc","kind":"technology","name":"Histopathology & immunohistochemistry","route":"/technologies/histopathology-ihc/"},{"id":"imrt-igrt","kind":"technology","name":"IMRT / IGRT (modern external beam)","route":"/technologies/imrt-igrt/"},{"id":"mp-mri","kind":"technology","name":"Multiparametric prostate MRI (PI-RADS)","route":"/technologies/mp-mri/"},{"id":"psma-pet","kind":"technology","name":"PSMA PET","route":"/technologies/psma-pet/"},{"id":"robotic-surgery","kind":"technology","name":"Robotic & minimally invasive surgery","route":"/technologies/robotic-surgery/"}],"term":[{"id":"prostate-acinar-adenocarcinoma","kind":"term","name":"Acinar adenocarcinoma of the prostate","route":"/terms/prostate-acinar-adenocarcinoma/"},{"id":"cambridge-prognostic-group","kind":"term","name":"Cambridge Prognostic Group (CPG 1 to 5)","route":"/terms/cambridge-prognostic-group/"},{"id":"cribriform-prostate-cancer","kind":"term","name":"Cribriform growth pattern in prostate cancer","route":"/terms/cribriform-prostate-cancer/"},{"id":"gleason-grade-group","kind":"term","name":"Gleason score / Grade Group","route":"/terms/gleason-grade-group/"},{"id":"intraductal-carcinoma-prostate","kind":"term","name":"Intraductal carcinoma of the prostate (IDC-P)","route":"/terms/intraductal-carcinoma-prostate/"},{"id":"psa","kind":"term","name":"PSA (prostate-specific antigen)","route":"/terms/psa/"},{"id":"prostatectomy","kind":"term","name":"Radical prostatectomy","route":"/terms/prostatectomy/"},{"id":"tnm-prostate-cancer","kind":"term","name":"TNM staging for prostate cancer, and what changed in the 9th edition","route":"/terms/tnm-prostate-cancer/"}]}}