MUCINOUS

ADENOCARCINOMA

ROBERT

P. CRICCO,

JOSEPH

KASSIS,

OF PROSTATE

M.D.

M.D.

From the Division of Urology, West Virginia University Medical Center, Morgantown; and Department of Surgery, Veterans Administration Hospital, Clarksburg, West Virginia

ABSTRACT - Primary mutinous adenocarcinoma of the prostate is rare. The presence of mucin in prostatic carcinoma is usually associated with decreased tumor aggressiveness and increased survival rates. When mutinous adenocarcinoma of the prostate is found, it is necessary to exclude extraprostatic primary sources particularly from the urinary bladder and the gastrointestinal tract.

Cancer of the prostate is the third most common cause of male cancer deaths in the United States with over 19,000 reported in 1974. In 1977 alone, it was estimated there would be 57,000 new cases ofcancerofthe prostate, second only tocarcinoma of the lung-l This neoplasm is most common in older men and rarely seen in men younger than Hty years of age. There is a wide range of histologic patterns seen with prostatic neoplasms. The most common is glandular arising from columnar cells lining the prostatic acini. This pattern can range from well-differentiated to extremely anaplastic. It is rare to see the glandular (adenocarcinoma) pattern with mucin production. These tumors are made up of acini of varying sizes with the lumens containing variable amounts of mucin. When this pattern is found, it is necessary to rule out an extraprostatic source from the gastrointestinal tract or bladder as a primary site. Carcinoma of periurethral or Cowper glands must also be excluded. Recently a patient was found to have primary carcinoma of the prostate with mucin production. In addition, we believe this case represents the youngest patient diagnosed with this disorder. A second case is also presented illustrating the need to be aware of an extraprostatic primary source when mutinous adenocarcinoma of the prostate is found.

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Case Reports Case 1 A thirty-two-year-old white man was admitted to the urology service because of urinary hesitancy, decreased force and caliber of his stream, and nocturia. He denied any dysuria or hematuria. Physical examination revealed a young, healthy-appearing man. On rectal examination, the prostate was diffusely rock hard, significantly enlarged, and tender to digital examination. Results of urinalysis were normal, as was the acid phosphatase level.

FIGURE 1. Case 1. Biopsy mutinous adenocarcinoma.

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Intravenous urography revealed speckled calcification in the region of the base of the bladder on the left. The remainder of the study was normal. Cystoscopy revealed exudative-like debris in the prostatic fossa extending into the bladder neck. Results of biopsies of this area along with perineal biopsy of the prostate revealed mutinous adenocarcinoma in all specimens (Fig. 1). The primary site was undetermined. He then underwent bone scan, liver scan, lung tomograms, upper gastrointestinal series, and barium enema, results of which were normal. On sigmoidoscopy a polyp at 14 cm. was noted, which a biopsy revealed to be an adenomatous polyp. Once the workup for metastatic disease was completed, the patient underwent exploratory laparotomy, bilateral pelvic lymphadenectomy, cystoprostatectomy, and ileal loop diversion. No abnormalities were noted in the viscera. Mucinous adenocarcinoma was found in a biopsy of a suspicions node at the bifurcation of the right common iliac. The pathologic report of the resected specimen rehealed mutinous adenocarcinoma of the prostate invading the trigone, urethra, and seminal vesicles. Tumor was also noted in three iliac lymph nodes. The specimen was sent to the Armed F’orces Institute of Pathology for review with the findings that no mucosal involvement was seen in the bladder, and that the tumor was probably of prostatic origin. The patient’s postoperative course was unremarkable, and consideration was given to chemotherapy. On bone scan five months postoperatively, the patient was found to have metastatic involvement of the ninth thoracic vertebra and the sixth rib on the left; fifteen months postoperatively he died.

tion at the time revealed a lesion in the rectum which biopsy showed to be adenocarcinom:t. He then underwent abdominal perineal resection. Pathologic examination revealed adenwed metastases. Chest x-ray film in Mat’. i975, showed evidence of metastatic disease g ,oved by needle biopsy of the right lung. The% patient was then given chemotherapy. He was evaluated in January, 1977, bg the urology service because of increasing symptoms of prostatism. Rectal examination was irn;>ossible due to the previous surgery. Urinalysis revealed microhematuria, pyuria, and bactel iuria; acid phosphatase was normal. Findings c-n intravenous urogram and bone scan wert’ ucrmal. Cystoscopy revealed a moderate cystitis confirmed by biopsy. Lateral lobe enlargctmr,nt of the prostate with obstruction was n Ited. Cystometrogram findings were normal. T1.e patient underwent transurethral resection (.f the prostate. His postoperative course ~tas unremarkable. Pathologic report of the resected spec,imen revealed the prostate to be composed of rnalignant glands containing mucin (Fig. 2 pathology slides of the rectal carc&oma were reviewed, and the pathologist believed that the resected prostatic tissue represented m&static adenocarcinoma, mutinous type.

Case 2 A sixtt-two-year-old white man was seen initially in :972 because of rectal bleeding. Evalua-

Comment The first mucin-forming carcinoma (If the prostate was described by Boyd in I8cil. ’ In a recent review of the literature, Joshi, Seer].*, and Neier3 reviewed 17 reports of mutinous adenocarcinoma of the prostate and added 3 c:ases of their own, which were confirmed by mucicsrmine and para-aminosalicylic staining. An additional case, this with bladder invasion, was reported Abrams, and Seymour in by Lightbourn, 1969. 4

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The majority of these patients were in their seventh and eight decades, with the youngest thirty-four and the oldest eighty-five. Presenting symptoms ranged from vesical irritability to symptoms of prostatism and urinary obstruction. Hematuria, back pain, and weight loss were sometimes also found. Inconsistent findings on rectal examination were noted with both benign and malignant prostate glands seen. The acid phosphatase was invariably normal, and only 2 reported cases of bony metastases were found, one to a vertebral body and the other to the bony pelvis. Other metastases noted were to local, inguinal, and cervical nodes, to base of the bladder, liver, lungs, and widespread to soft tissues. Therapy included radical prostatectomy and irradiation. No significant trials of hormonal therapy or chemotherapy were noted, although Tannenbaum5 believes that these tumors are markedly less responsive to diethylstilbestrol therapy. Mutinous adenocarcinomas are composed of cells which actually f&-m mucin and have the appearance of signet rings, because the cells are distended and the nucleus is displaced eccentrically by the mucin produced. Histologic examination of biopsy material from suspected malignancies has been helpful in elucidating the source of the neoplasm. The presence of mucin has been used to exclude certain malignancies, such as prostate, thyroid, kidney, and hepatic parenchyma. Ackerman6 believes that positive mucin stains rule out prostatic carcinoma in most instances. Small amounts of mucin can be demonstrated by histochemical staining in a great number of prostatic neoplasms. However, true mutinous carcinoma of the prostate is rare. In a previous study of 125 prostatic neoplasms, Foster and Levine7 found 63 per cent of prostates examined to contain areas with mutinous positive-staining material but in very small amounts. Franks, O’Shea, and Thompson* reported on a series of 134 prostatic neoplasms and observed only 2 cases of true mutinous adenocarcinoma. Franks,g in a previous article, demonstrated that although mucin is not secreted by the nor-

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mal prostate, it can be found often in the small acinar type of prostatic carcinoma. In addition, it seems that when prostatic epithelium undergoes malignant change, it apparently develops the ability to secrete mucin, which the normal prostate is unable to do. True mutinous adenocarcinoma differs from the small acinar type in its ability to secrete more mucin. The actual etiology of mucin-producing adenocarcinoma of the prostate is unknown, but there is little doubt as to its occurrence. Although the number of reported cases is small and firm conclusions as to the significance of mucin production cannot be drawn, it has been thought that the presence of significant amounts of mucin in prostatic carcinoma may be associated with decreased tumor aggressiveness and increased survival rates typically seen with most well-differentiated tumors. However, if adenocarcinoma with mucin production is found on prostatic biopsy, a diligent search for an extraprostatic source must be made with particular emphasis on the bladder and gastrointestinal tract before concluding that the prostate is the primary site.

Charlestown,

R.F.D. #l, Box 950 Lover’s Lane Road New Hampshire 03693 (DR. CRICCO)

References 1. 1977 Cancer Facts and Figures, New York, American Cancer Society, 1977. 2. Boyd S: Case of colloid scirrhus of prostate, Trans. Pathol. Sot, London, 33: 266 (1881). 3. Joshi DP, Seery WH, and Neier CR: Mucogenic adenocarcinema of the prostate, J. Vrol. 98: 241 (1967). 4. Lightbourn GA, Abrams M, and Seymour L: Primary mucoid adenccarcinoma of prostate gland with bladder invasion, ibid. 101: 78 (1969). 5. Tannenbaum M: Mu&-secreting carcinoma of prostate, Urology 5: 543 (1975). 6. Ackerman LV: Surgical Pathology, 2nd ed., St. Louis, C. V. Mosby Co., 1959, p. 575. 7. Foster EA, and Levine AJ: Mucin production in metastatic carcinoma, Cancer 16: 566 (1963). 8. Franks LM, O’Shea JD, and Thompson AER: Mucin in the prostate: a histochemical study in normal glands, latent clinical and colloid cancers, ibid. 17: 983 (1964). 9. Franks LM: Latent carcinoma of the prostate, J. Pathol. 58: 603 (1954).

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Mucinous adenocarcinoma of prostate.

MUCINOUS ADENOCARCINOMA ROBERT P. CRICCO, JOSEPH KASSIS, OF PROSTATE M.D. M.D. From the Division of Urology, West Virginia University Medical...
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