Loading
5 slides generated from the cancer page, with a quiz from the open benchmark and speaker notes that cite the sources. Arrow keys move between slides; Print gives one slide per page.
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.
| Setting | Approach | Guideline |
|---|---|---|
| Localised | 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. | not mapped |
| Any stage, at diagnosis | Germline genetic testing, which the NCCN and the Philadelphia consensus conference recommend for ductal, intraductal or cribriform morphology whatever the stage. | not mapped |
| Metastatic | 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. | not mapped |