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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.
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.
How 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.
How 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.
How 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.
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).
About three quarters of cancers arise in the peripheral zone at the back of the gland, the part a finger or a biopsy needle reaches; drainage is to the obturator and iliac nodes.
Same organ: Prostate cancer, Localised prostate cancer, very low and low risk, Localised prostate cancer, intermediate risk, Localised prostate cancer, high and very high risk, Biochemical recurrence of prostate cancer, Metastatic hormone-sensitive prostate cancer, Non-metastatic castration-resistant prostate cancer, Metastatic castration-resistant prostate cancer, Neuroendocrine and small-cell prostate cancer
No subtypes recorded beyond the ones named in the family strip above.
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.
Germline genetic testing, which the NCCN and the Philadelphia consensus conference recommend for ductal, intraductal or cribriform morphology whatever the stage.
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.
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Query for this cancer: (TITLE:"Ductal adenocarcinoma of the prostate" OR ABSTRACT:"Ductal adenocarcinoma of the prostate" OR TITLE:"Prostatic ductal adenocarcinoma" OR ABSTRACT:"Prostatic ductal adenocarcinoma" OR TITLE:"Ductal adenocarcinoma" OR ABSTRACT:"Ductal adenocarcinoma" OR TITLE:"Ductal prostate cancer" OR ABSTRACT:"Ductal prostate cancer" OR TITLE:"Adenocarcinoma with ductal features" OR ABSTRACT:"Adenocarcinoma with ductal features" OR TITLE:"Mixed acinar-ductal adenocarcinoma" OR ABSTRACT:"Mixed acinar-ductal adenocarcinoma") AND (treatment OR therapy OR trial OR survival OR diagnosis). Results are unfiltered search hits about Ductal adenocarcinoma of the prostate, not a curated reading list.
No targets or pathways are linked to this cancer yet. Browse the gene hub →
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