394

Journal of the Royal Society of Medicine- Volume 85 July 1992

Endometriold carcinoma of the prostate:

a

misnomer?

J A Vale FRCS2

A Patel FRCS2 A J Ball MD FRCS2 W F Hendry chM FRcs1 M E Chappeli mUCPath3 C Fisher MD FRQPat4 Departments of 'Urology and 4Pathology, Royal Marsden Hospital, Fulham Roadi London SW3 6JJ and Departments of 2Urology and 3Pathology, Southend Hospital, Prittlewell Chase, Westcliff-on-Sea Essex 850 ORY

Keywords: endometrioid; endometrial-type; adenocarcinomw,; prostate

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Summary The origin of this unusual variant of carcinoma ofthe prostate has provoked discussion ever since its first' description in 1967. This is of both embryological interest and therapeutic importaice. Four cases have been reviewed, and all havef., demonstrated imm sohistochemical features con-. sistent with an origin from prostatic tissue. In addition, three had evidence of dieseminoted disease. which responded well to. androgen ablation.JIt is concluded that the term endometrioid carcinoma is of descriptive value only, and these tumours bre a variant of primary duct prostatic caihoma. Patients should be treated by androgen ablation when metastases are present. Introduction Endometrioid or endometrial-type adenocarcinoma of prostate is a morphological varint with glandular Oaed and papillary structures lined by tall, columnar epithelium. Standard textof urologyate that this is best regarded as an adenocarcinom-a arising from the prostatic primary ductL. Howeveer,; when it was first described and named iii a case report in 19672, a quite different conclusion was reached. On the basis of its location within or near the prostatic utricle, and its histological similarities to carcinoaa. of the uterine endometrium, it was believed-todevelop from a Miillerian duct remnant. Since this is a female structure embryologically, it was speculated $;hat these tumours would be oestrogen dependent. In 1971, a further 6 cases3 were reported, and progestogens were recommended as appropriate treatment for cases showing disseminated disease. However, since then there has been increasing evidence that these tumours are derived from the prostate. In 1975, one of the above cases was reclassified as being of prostatic origin on the basis of electron microscopic and histochemical findings4. In another case report5, the ultrastructural features were described as being similar to those of other prostatic carcinomas, and there were high levels of intracytoplasmic acid phosphatase. Indirect immunohistochemical techniques6 have also supported a prostatic origin, with the demonstration of prostate specific acid phosphatase (PSAP) and prostate specific antigen (PSA) immunoreactivity7'8.

Correspondence to: Dr J A Vale, Department of Urology, St Bartholomew's Hospital, West Smithfield, London EClA 7BE

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Figure 1. CT scan of the pelvis to show the extent of local disease, case 1. Top, before orchidectomy; bottom, 3 months after orchidectomy

We have reviewed our experience of this unusual prostatic adenocarcinoma.

Patients Case 1 This 55-year-old Greek underwent transurethral prostatectomy CTURP) in Athens, having presented with symptoms of bladder outflow obstruction and haematuria. Prostatic chippigs showed adenocarcinoma with an unusual cribriform pattern, and the patient sought a second opinion in

0141-0768/92/

070394-03/402.00/0 0 1992

The Royal Society of Medicine

Journal of the Royal Society of Medicine Volume 85 July 1992

Figure 3. Typical histological pattern of endometrioid carcinoma of the prostate. Haematoxylin and eosin, x325

Four months later the patient returned complaining of severe left hip pain. Serum PSAP was 31 iu/l, and a bone scan showed an area of raised uptake in the left acetabulum. Trucut biopsy of the prostate showed the typical features of an endometrioid carcinoma (igure. 3), with PSA and PSAP immumoreartivity. It seemed unlikely that this stage Ti prostate cancer could explain the solitary area of increased uptake on the bone scan, and the patient was very reluctant to consider androgen ablation in view of his infertility. He was reviewed by an orthopaedic surgeon, who diagnosd severe degenerative disease ofthe left hip which could account for the bone-scan findings. Te patient therefore underwent radiotherapy for localized prostate cancer. Nine months later further hip pain developed; chest X-ray and bone scan demonstrated multiple m sta, and serum PSAP was mildly elevated at 8.8 iun/. Bilateral orchidectomy was performed, and chest X-ray and PSAP returned to normal. He remains alive and symptom-free 3 years after orchidectomy.

and metastases (Figure 2). The patient remained in remision for 2 years, but then developed spinal metastases and cord compression from which he ultimately died.

Case 3 This 70-year-old man presented with acute retention of urine and an -antecedent history of haematuria. Ten years prevously he had undergone radical radiotherapy for transitional cell carcinoma of the bladder. At cystoscopy he was noted to have a frondy growth throughout the prostatic urethra, and a large benign-feeling prostate. TURP was performed; histology demonstrated a moderately differentiated adenocarcinoma of the prostate with a papillary pattern. SpeciMa stains were not performed at this time. Serum PSAP and bone scan were normal, and an expectant policy was adopted. However 6 months later he developed acute urinary retention again, and rectal examination demonstrated advanced local disease (T4). TURP and orchidectomy were performed; histology revealed an endometrial-type carcinoma, with PSA immunoreactivity. The patient -remained well following this, but 30 months later required further endocrine manipulation for a rising PSA and positive bone scan. He is currently maintained on aminoglutethimide 250 mg three times a day and hydrocortisone 10 mg three times a day, and has required frequent revision TURP's for recurrent haematuria.

Case 2 This 60-year-old Nigerian presented with secondary infertility, having noticed that his ejaculatory volume had progressively decreased to less than 0.25 ml. He also complained of mild obstructive urinary symptoms. Seminal analysis revealed the volume of ejaculate to be 0.1 ml only, and serum antisperm antibodies were present. Cystoscopy and bimanual examination were unremarkable, apart from a large benign-feeling prostate. Vasography demonstrated a blockage of the right ejaculatory duct, and although the left ejaculatory duct was patent there was no filling of the left seminal vesicle.

Case 4 This 51-year-old man presented with classic features of bladder outflow tract obstruction. Cystoscopy revealed a florid, frondy growth throughout the urethra, and on bimanual examination there was a stage T3 prostatic carcinoma. TURP was performed; histology showed a moderately differentiated adenocarcinoma with an endometrioid pattern, and PSA immunoreactivity. There was no evidence of bony metastases on bone scan, and serum PSAP was within normal limits. Radical radiotherapy was performed, and 3 years later the patient remains well with no evidence of disease progression.

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Figure2. Abdominal CT scan to demonstrate liver metastases, case 1. Top, before orchidectomy; bottom, 3 months after orchidectomy this country. Rectal examination demonstrated very extensive carcinoma, and needle biopsy confirmed prostatic adenocarcinoma with an endometrioid pattern, and PSA immunoreactivity. There were multiple pulmonary metastases shown on chest X-ray, and computerized tomography (CT) showed very extensive local disease (Figure 1) with pelvic nodal involvement, and liver metastases (Figure 2). Serum PSAP was elevated at 7.2 Wi/l, and PSA was 26.4 yg/l. In view of this advanced disseminated disease, bilateral orchidectomy was performed. Following this there was a dramatic improvement in the patient's condition, with complete radiological resolution of primary disease

(gure 1)

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Journal of the Royal Society of Medicine Volume 85 July 1992

Discussion There are a number of interesting features about the presentation of this unusual type of prostatic adenocarcinoma which are well demonstrated by these patients. Firstly, haematuria tends to develop at an early stage9'11, as primary ductal carcinoma are frequently papillary and project into the urethra. Two of the four patients had a history of haematuria, and in one the cystoscopic appearances were so papillary that the lesion was thought initially to represent a recurrence of the patient's previous transitional cell carcinoma. Secondly, obstructive symptoms may develop at an early stage when the tumour is still small, and rectal examination is often normal or suggestive of benign prostatic disease only. Two of the four patients had such benign rectal findings, which is consistent with other series9. They reported that only half of their patients with a primary ductal carcinoma had rectal findings suspicious of malignancy, as compared with over 90% of patients with carcinoma affecting the secondary ducts. This compares with 94% of patients with newly-diagnosed acinar prostate cancer'2. The presenting complaint of secondary infertility (case 2) was uniquely well demonstrated by the patient's painstaking documentation of a declining ejaculatory volume. This was highly suggestive of an obstructive process developing within the ejaculatory ducts, and indeed this was confirmed by vasography. However, the disease process was at such an early stage that cystoscopy and examination under anaesthesia were normal, and diagnosis was only made at a later date in the light of a rising PSAP. In all four cases, histological findings were characteristic of endometrioid carcinoma of the prostate, with the tumour being well or moderately differentiated and exhibiting a cribriform, glandular or papillary pattern. The PSA/PSAP staining characteristics were consistent with an origin from prostatic tissue rather than Mullerian duct derivation7 0. It has been stated that endometrioid carcinomas grow centrally into the urethra and infiltrate locally, but rarely metastasize4. This is not supported by the cases presented here, and three have shown metastatic disease. Two of these had an unusual distribution of metastases for prostatic carcinoma, with pulmonary deposits and hepatic involvement. The three patients with disseminated disease underwent orchidectomy, which produced a marked response in terms of symptoms, biochemistry and radiology. It has been speculated that primary duct carcinomas should show a relatively favourable prognosis, as their per/intraurethral location results in their presentation at an early stage. However the rarity of this type of carcinoma makes evaluation difficult, particularly as it may occur in association with the more common acinar carcinoma9"O03. In summary, the cases presented support the widely held view that endometrioid carcinoma ofthe prostate

is a primary duct carcinoma showing histological features similar to carcinoma of the uterine endometrium. It responds to androgen ablation as does the ocarcinoma, and this is the more common acinar t fype treatment ofchoice for cases showing dissemination. All this suggests that the term endometrioid' is really a misnomer, and should be abandoned in favoiur of more up-to-date classifications of prostate cancer. However, a word of caution is necessary: in 1988 a case of endometrioid carcinoma of the prostate was reported which failed to demonstrate PSA or PSAP staining4. Perhaps this was a true case of endometrioid carcinoma of theprostate, with an origin from Millerian duct remnants. References 1 Kozlowski JM, Grayhack JT. Caoma of the prostate. In: Gillenwater JY, Grayhack JT, Howards SS, Duckett JW, eds. Adult and diatric -urology. C o: Year

Book Publishers, 1987:i139-40

2 Melicow MM, Pachtr MR. Endomta carcinoma of prostatic utricle (uterus masculinus). Cancer 1967;20:1715-22 _ 3 Melicow MM, Tannenbaum M. Endomet*isl carcnoma of uterus masclinus (ptatic utrice). Report of 6 cases. J Urol 1971;106:892-902 4 Tannenbaum M. Endometrial rsand/or aociated carcinomas of prostate. Urology-1975;6:372-5 5 Zaloudek C, Williams JW, Kempson RL. 'Endometrial' adenocarcinomas of the prostate. Cancer 1976;37: 2255-62 6 Jobsis AC, De Vries GP, Anholt RRM Sanders GT. Demonstration of the prostatic origin or metastass; an immunohistochemical method for formalin-fixed embedded tissue. Cancer 1978,41:1788-93 7 Nadji M, Tabei SZ, Castro A, et aL Prostatic origin of tumours. An immunohistological study. Am J Clin

Pathol 1980;73:735-9 8 Walker AN, Mills SE, Feciner RE, Perry JM.

9 10 11

12

13 14

he otatic urethra "Endometrial" aa arising in a villous polyp. A light micoscopic and immunoperoxidase study. Arch Pathol Lab Med 1982; 106:624-7 Dube VE, Farrow GM, Greene LF. Prostatic adenocarcinoma of ductal origin. Cancer 1973;32:402-9 Walther MM, Nassar V, Harruf RC, et aL Endometrial carcinoma of the prostatic utricle: a tumour of prostatic origin. J Urol 1985;134:769-73 Epstein JI, Woodruff JM. Adenocarcinoma of the prostate with endometrioid features. Cancer 1986; 57:111-19 The Veterans Administration Co-operative Urological Research Group. Treatment and survival of patients with cancer of the prostate. Surg Gynecol Obstet 1967;124:1011-17 Rotterdam HZ, Melicow MM. Double primary prostatic adenocarcinoma. Urology, 1975;6:245-8 Gillatt DA, O'Reilly PH, Reeve NL. Endometrioid carcinoma of the prostatic utricle. Br J Urol 1986; 58:559-60

(Accepted 11 December 1991)

Endometrioid carcinoma of the prostate: a misnomer?

The origin of this unusual variant of carcinoma of the prostate has provoked discussion ever since its first description in 1967. This is of both embr...
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