Case 2 -
Prostatic Adenocarcinoma with Wide Intraductal Growth (Intraductal carcinoma of the prostate--IDC-P)
Pathology Section. Fundació Puigvert
Universitat Autónoma de Barcelona- UAB
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57 years old man with perineal pain and painful digital rectal examination.
Total serum PSA 3.67µg/L , free PSA 0.33 µg/L, ratio 0.08.
A prostate needle biopsy was do.
Case 2 - Slide 1
Ten core biopsies (five for every site) were received.
All cores show many well-outlined nodular areas of a epithelial proliferation of secretory cells with
mild nuclear atypia and occasional nucleoli, with a cribriform aspect. Some of them has central
comedonecrosis. All of this areas have preserved basal cells with 34βE12 positive expression.
Additionally to this predominant aspect isolated monolayer microglands without basal cells and with
nuclear atypia are present, some of them with a circumferential intraprostatic nerve invasion.
Prostatic Adenocarcinoma with Wide Intraductal Growth (Intraductal carcinoma of the prostate--IDC-P).
- Are the this intraductal growth a ductal carcinoma or a High Grade Prostatic Intraepithelial
Neoplasia or a Intraductal expansion of a standard carcinoma?
- Is it acceptable the presence of basal cells in a prostatic adenocarcinoma?
- If the previous question is yes. Are we able to recognize them and what must be our report to the
- If it is and adenocarcinoma, What Gleason pattern is it?
Cribriform prostate proliferations can be present without and with basal cells (34βE12 and/or p63
positive). In the first situation it is considered as an invasive prostate carcinoma Gleason pattern 3
or 4, but in the second suppose, what is it?. For some authors it is always a pattern of High Grade
Prostatic Intraepithelial Neoplasia (HGPIN)
, but others believe that some of them may represent a
real intraductal carcinoma of the prostate (IDC-P).
Four architectural patterns of HGPIN (flat 28%, tufting 87%, micropapillary 85% and cribriform 32%)
have been described . Even though the patterns often merge with each other, the possibility of a
progressive transformation of the flat pattern into a micropapillary one and a cribriform one is a
tempting thought. This hypothesis was partially supported by the observation that patients with isolated
papillary-cribriform HGPIN in needle biopsy has a higher incidence of ulterior carcinoma that the other
HGPIN patterns (58.3% versus 16.7%)
. In other ways this supposition is reinforced by some authors'
observation that the most central cells of the papillary and cribriform patterns are more
undifferentiated and lose more heterozygosity than those that are closer to the basement membrane, and
also that carcinomas associated with cribriform pattern of HGPIN are clinically more aggressive
which seems to be confirmed by the description of unusual cells types as signet ring cells PIN and
small cell or neuroendocrine cell PIN types in cribriform types  similar to invasive carcinomas. All
of these observations have been the reason why some authors consider the possibility that some of these
changes are IDC-P . This can explain that when the evolution of the isolated HGPIN is considered
avoiding the cases with a huge cribriform-solid pattern the ulterior carcinoma incidence is similar among
all the HGPIN patterns (31.9% versus 22%)
For all of these considerations it seems that the IDC-P is a real possibility different that the
papillary-cribriform HGPIN, with clinical implications, and recently a genetic-molecular correlation is
demonstrated with the TMPRSS2-ERG gene fusion 
For all of these we need a very strict diagnosis criteria to distinguish both lesions. The criteria
to recognise the IDC-P, besides the total/partial basal cell preservation, are the enlargement of the
large-caliber glands, the spanning of the gland lumen by malignant cells, and the frequent double cell
population . A intraductal cellular growth with basal cell preservation with comedonecrosis never
must be considered as a HGPIN .
Intraductal prostate carcinoma may arise by two non excluding mechanisms, by spread of invasive
adenocarcinoma into adjacent normal ducts or by HGPIN evolution. This last is supported in some cases
for the distance between both lesions, the right branching with smooth out-line of the glands and the
continuum with the non-neoplastic cells.
In practice invasive carcinoma is almost always concomitant with the IDC-P as in this case
presentation. The infiltrating adenocarcinoma is in general Gleason pattern 4 or 5, and this correlate
with the ability of prostatic cells to grow without stromal attachment, similar to the intraductal growth
, an for this reason the IDC-P can be considered as a Gleason 4 or 5, position that is supported for
the high aggressivity of the cases with infiltrating adenocarcinoma associated with IDC-P
In the occasional cases with an isolated IDC-P in needle biopsy it is not recommended the biopsy
repetition if a comedonecrosis pattern is present , in the other patterns it is prudent an immediate
repetition of the biopsy, not delayed as in HGPIN.
- The IDC-P exist.
- It evolves late in cancer progression.
- It must be considered Gleason pattern 4 or 5.
- In case of isolated IDC-P with comedonecrosis no more biopsies are necessary
- In case of isolated IDC-P without comedonecrosis an immediate repetition of the biopsy is wise.
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