The Gulf Journal of Oncology

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2 The Gulf Journal of Oncology ISSUE 12 JULY 2012 Original Studies Table of Contents Penile Cancer in India: A Clinicoepidemiological Study M. Pahwa, M. Girotra, A. Rautela, R. Abrahim Gastric Cancer: A Retrospective Analysis from AIIMS, New Delhi R. Hadi, B.K. Mohanti, S. Pathy, G.K. Rath, N.K. Shukla, S.V.S. Deo, A. Sharma, V. Raina Review Articles Intensity Modulated Radiotherapy (IMRT) In Head and Neck Cancers An Overview C.M. Nutting Adult T-Cell Leukemia/Lymphoma K.I. Rasul, Z.A. Barwari Case Reports Adrenocortical Tumors in Children: A Kuwait Experience R. Mittal, D. G. Ramadan, N. M. Khalifa, S. O. Khalifa, Z. Mazidi, M. Zaki Limb Sparing Surgery in Soft Tissue Sarcoma of Extremities: An Indian Perspective R.V. Bhargavan, P. Kumar, K.C. Kothari Mixed Germ Cell Tumor of Ovary and Clitoromegaly in Swyer s Syndrome: A Case Report S. Aminimoghaddam, B. Mokri, F. Mahmoodzadeh Palmar Fasciitis and Arthritis Syndrome Associated With Metastatic Ovarian Cancer: A Paraneoplastic Syndrome I.K. Nahar and M. S. Al-Rajhi Trichilemmal Pilar Tumor of the Scalp: A Case Report K. Al Saleh, H.S. Hooda, H. El-Wakiel, R. Safwat, A. Bedair, W. Eskaf Carcinosarcoma of Renal Pelvis with Immunohistochemical Correlation S.D. Deshmukh, V.L.Gaopande, D.P. Pande, G.S. Pathak, B.K. Kulkarni 5-Flourouracil Cardiotoxicity An Elusive Cardiopathy: Case Report G. M. Bhat, M. H. Mir, H. I. Showkat, B. Kasanna, F. Bagdadi, A. H. Sarmast, S. Qadri An Unusual Variant of Prostatic Adenocarcinoma with Metastasis to Testis: A Case Report K. R. Anila, T. Somanathan, A. Mathews, K. Jayasree Mammary Fibromatosis in a Male Breast N. Al-Saleh, T. Amir, I. N. Shaf Primary Isolated Extramedullary Plasmacytoma of Mesentry: A Rare Case Report R. Galhotra, K. Saggar, K. Gupta, P. Singh Feature Article Balsam Organization for rehabilitation and support for cancer patients and their families Conference Highlights /Scientific Contribution Conference Highlights 1 st Palliative Care Conference in Kuwait...86 News Notes...89 Advertisements...91 Scientific events in the GCC and the Arab World for the 2 nd Semester of

3 An Unusual Variant Of Prostatic Adenocarcinoma With Metastasis To Testis: A Case Report K. R. Anila, T. Somanathan, A. Mathews, K. Jayasree Department of Pathology, Regional Cancer Centre, Thiruvananthapuram, Kerala Abstract Ductal adenocarcinoma of the prostate is considered to be a rare variant of prostatic adenocarcinoma when compared to the more common acinar adenocarcinoma. We report here a case of ductal adenocarcinoma of the prostate in a 68-year old man who presented with complaints of abdominal pain, retention of urine and hematuria of one month duration. Clinical examination showed prostatomegaly. The serum Prostate Specific Antigen (PSA) value was raised to 79ng/mL. Histopathological and immunohistochemical evaluation of resected specimen of prostate revealed ductal adenocarcinoma of the prostate. The patient was lost to follow up and presented four years after Introduction Ductal adenocarcinoma of the prostate is a rare histological subtype of prostatic adenocarcinoma affecting the large central periurethral ducts. In its pure form, ductal adenocarcinoma accounts for 0.4 to 0.8% of all prostatic cancers (1). More commonly it is seen with an acinar component. These tumors tend to present at an advanced stage (2). Those cases of ductal adenocarcinoma that are diagnosed on prostatic needle biopsies are also tumors at an advanced stage (3). The patterns commonly identified in ductal adenocarcinoma are papillary, cribriform, individual gland and solid pattern. Though not typically graded ductal adenocarcinomas are mostly equivalent to Gleason score of 8 (4+4) due to the morphology (4). Though prostatic carcinomas have the potential for wide spread metastasis, metastasis to testis is rare. Immunohistochemical markers like PSA and PAP will help in confirming the prostatic origin of the neoplasm. the initial diagnosis with metastasis to the bone and testis. Though prostatic cancers have the ability for wide spread dissemination, metastasis to testis is rare. Immunohistochemical staining with PSA and Prostatic Acid Phosphatase (PAP) can help in establishing prostatic nature of the neoplasm. We are reporting this case because of the rarity of metastasis of prostatic carcinoma to testis and for stressing the need for keeping in mind the possibility of metastatic carcinoma also while dealing with testicular tumors. Keywords Prostate, ductal adenocarcinoma, metastasis, testis Case Report A 68-year old man presented with complaints of abdominal pain, retention of urine and hematuria of one month duration. Clinical examination revealed grade 3 to 4 prostatomegaly. The serum PSA value was raised to 79 ng/ml. Transurethral resection of prostate was done. The resected specimen was received as irregular fragments of pale brown fleshy soft tissue aggregate measuring 5 x 4 x 4cm. Corresponding author: Dr. Anila K.R, Lecturer, Department of Pathology, Regional Cancer Centre, Thiruvananthapuram, Kerala , India. Phone: venuanila@yahoo.com 73 Figure 1: Prostatic ductal adenocarcinoma showing papillary pattern (H &E x100)

4 Variant of Prostatic Adenocarcinoma with Metastasis to Testis, K.R. Anila, et. al. Figure 2: Higher power view of glandular areas showing cells with pale eosinophilic cytoplasm and vesicular nucleus many showing prominent nucleoli (H &E X200) Figure 4: Prostatic ductal adenocarcinoma metastasizing to testis (H&Ex100) Figure 3: Positive staining with Prostatic Specific Antigen (IHC x200) Histopathological examination showed a neoplasm composed of cells arranged in papillary pattern (Figure 1), glandular pattern and in solid sheets. Individual cells had moderate amount of pale eosinophilic cytoplasm and vesicular nucleus many showing prominent nucleoli (Figure 2). Some fields showed glands with secretory epithelium. Also seen were clear cell areas. Immunostaining for PSA showed diffuse positivity in the tumor cells (Figure 3). A diagnosis of prostatic ductal adenocarcinoma was given. The patient was lost to follow up. The patient presented four years later with bone pain. Bone scan showed osteoblastic bone metastasis at L5 level and right ilium.the serum PSA value was 60 ng/ml. On examination he had left sided hydrocoele. Patient was given radiotherapy for metastatic bone disease and advised to undergo 74 Figure 5: Atrophic testicular tissue with neoplastic infiltration (H & E x100) bilateral orchiectomy but was not willing for the same. He was hence managed medically. The serum PSA values progressively decreased. The patient was kept on follow up with regular monitoring of serum PSA values. While on follow up the serum PSA levels started increasing and reached a value of 75 ng/ml. Subsequently the patient agreed for surgery and underwent bilateral therapeutic orchiectomy. The specimen we received consisted of both testes, with the left showing features of hydrocele. The cut surface of the left testis showed cystic areas of hemorrhage and necrosis. Normal testicular tissue was not identified grossly. Microscopical examination revealed metastasis from prostatic adenocarcinoma which was confirmed by immunohistochemistry and by comparing with the histopathological appearance of the previous biopsy (Figure 4, 5).

5 G. J. O. Issue 12, 2012 The right testis showed no significant pathology on gross and microscopic examinations. The patient is now on follow up and has multiple bone metastases. He is being given palliative care for bone pain and other co-morbidities. Discussion Prostatic ductal adenocarcinoma was first recognized by Melicow and Pachter in 1967 (5). The patients are usually elderly males with age ranging from 52 to 73 years. The usual symptoms are urinary obstruction and hematuria. This symptomatology is attributed to the predominant involvement of central periurethral ducts in ductal adenocarcinoma, unlike the usual acinar adenocarcinoma wherein mostly the peripheral ducts are involved. This tumor accounts for less than 1% of prostatic adenocarcinomas, as a dominant pattern and has been referred to under a number of different names including endometrioid and papillary carcinoma. The incidence of ductal adenocarcinoma, including both pure ductal and mixed ductal-acinar adenocarcinomas is 3.2% of all prostatic carcinomas. Earlier it was thought that ductal adenocarcinomas developed in vestigial mullerian tissue and hence were called as endometrioid carcinoma (6). The current view is that these carcinomas are of prostatic origin only (7). The positivity of these tumors for PSA and PAP confirms the prostatic origin. The patterns seen in ductal adenocarcinoma of the prostate can give rise to doubt of secondary infiltration from carcinomas of adjacent organs especially urothelial carcinoma. In such cases also immunohistochemistry will help in reaching the diagnosis. In terms of treatment ductal adenocarcinoma usually responds to regimens used in classical acinarcarcinoma TURP, orchiectomy and anti-androgen therapy. There is controversy regarding clinical behavior of ductal adenocarcinoma. Several studies suggest a poorer prognosis when compared to typical acinar carcinoma, whereas few others showed no difference or even improved prognosis (2, 8). Our patient presented four years after the initial diagnosis with metastases to bone and testis. According to one study it is thought that ductal adenocarcinoma of prostate may be a distinct biological entity with an inherently more aggressive potential than acinar carcinoma and hence aggressive management is indicated even with low-volume metastatic disease (9). Despite the high incidence of prostatic adenocarcinoma and its ability for wide spread dissemination metastasis to testis is rare. The reason for the low incidence of metastasis to testis may be due to relatively low temperature of scrotum which is unfavorable for establishment of metastasis (10). Involvement of testis by metastasis is usually unilateral (11). It is known that unlike the usual acinar adenocarcinoma, ductal adenocarcinoma of prostate usually involves the central periurethral ducts. This increases the chance of involvement of prostatic urethra by prostatic ductal adenocarcinoma (12). This results in increased likelihood of metastasis to testis by retrograde venous spread or by direct invasion into lymphatics and lumen of vasdeference. One study has shown that demonstration of C-Kit positivity may help to pick up prostatic cancer with higher risk for relapse. More studies are necessary to consider whether C-Kit can serve as an independent prognostic marker in predicting outcome of prostatic cancer (13). Conclusion Ductal adenocarcinoma of the prostate originates in the large ducts in the periurethral location. This accounts for the obstructive symptoms in these patients. Rare metastasis to testis can occur and this should be kept in mind while dealing with orchiectomy specimens in such patients. Immunohistochemical staining with PSA and PAP can help in establishing prostatic origin of the neoplasm. 75

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