|Ahead of print publication
The prostatic adenocarcinoma with mucinous features: A review of the literature with three case reports
Nejdet Karsiyakali1, Emre Karabay2, Ugur Yucetas3, Sevim Baykal Koca4, Ali Ferruh Akay5, Mustafa Kadihasanoglu3
1 Department of Urology, Cukurca State Hospital, Hakkari, Turkey
2 Department of Urology, Haydarpasa Training and Research Hospital, Istanbul, Turkey
3 Department of Urology, Istanbul Training and Research Hospital, Istanbul, Turkey
4 Department of Pathology, Istanbul Training and Research Hospital, Istanbul, Turkey
5 Department of Urology, Istanbul Health Application and Research Center, Baskent University, Istanbul, Turkey
|Date of Submission||14-Oct-2018|
|Date of Acceptance||03-Jun-2019|
|Date of Web Publication||26-Nov-2020|
Istanbul Training and Research Hospital, Istanbul
Source of Support: None, Conflict of Interest: None
Mucinous adenocarcinoma of the prostate is one of the rare variants of the prostatic carcinoma, and its incidence among all prostatic carcinomas is reported to be 0.3% in the literature. If the tumor variant containing extracellular mucin in <25% of the resected tumor mass, the histology is defined as adenocarcinoma with mucinous features. The mucinous adenocarcinoma of the prostate displays similar prognostic features with the classic adenocarcinoma. In this study, the treatment and surveillance processes of our three patients with prostatic adenocarcinoma with mucinous features were presented along with a literature review.
Keywords: Adenocarcinoma, mucinous, prostate, surveillance
|How to cite this URL:|
Karsiyakali N, Karabay E, Yucetas U, Koca SB, Akay AF, Kadihasanoglu M. The prostatic adenocarcinoma with mucinous features: A review of the literature with three case reports. J Can Res Ther [Epub ahead of print] [cited 2021 Apr 17]. Available from: https://www.cancerjournal.net/preprintarticle.asp?id=301003
| > Introduction|| |
Prostate cancer (PCa) is the second most common type of cancer in men, and it is estimated that PCa accounted for 15% of all diagnosed cancers worldwide. The most common type of PCa is acinar adenocarcinoma beside the rare histologic subtypes including the atrophic, pseudohyperplastic, foamy gland, small cell, basal cell, lymphoepithelioma-like, and sarcomatoid carcinoma variants. Only 806 cases were diagnosed to have mucinous adenocarcinoma. In this case series, we present three cases who had undergone radical retropubic prostatectomy (RRP) due to localized PCa and been diagnosed to have prostatic adenocarcinoma with mucinous features.
| > Case Report|| |
The first patient was 62 years old and presented with dysuria, frequency, and nocturia in October 2006. The digital rectal examination (DRE) was Grade 2 and benign. Because the prostate-specific antigen (PSA) level was 14.43 ng/ml, 12-quadrant biopsy of the prostate was performed with transrectal ultrasonography (TRUS). The result of the pathology was acinar adenocarcinoma at 8 of 12 quadrants with a Gleason score as 7 (3 + 4). The patient was prediagnosed with localized PCa according to the clinical staging and underwent RRP and bilateral pelvic lymph node dissection (PLND) in December 2006. The pathology result was mixed-type prostatic adenocarcinoma (65% acinar, 30% ductal, and 5% mucinous) [Figure 1], with positive surgical margins, Gleason 7 (3 + 4), and staged as pT2cN0M0. After 7 years under follow-up in different urology clinics without any intervention or medication, the patient revisited our department and biochemical recurrence (PSA: 0.62 ng/ml) was identified. The whole-body bone scintigraphy and multiparametric magnetic resonance imaging (MRI) revealed local recurrence, and radiotherapy was applied to the prostatic bed between November 2013 and January 2014. The patient has been followed up at our clinic for more than 10 years without receiving any adjuvant androgen deprivation treatment. No recurrences were observed in the multiparametric MRI in July 2017. The PSA level measured in January 2018 was 0.41 ng/ml.
The second patient was 61 years old and he presented to the outpatient clinic in November 2008 with voiding difficulty. The physical examination and laboratory investigation findings were detected as DRE of Grade 2 with a hardened right lobe and a PSA level of 7.3 ng/ml. The patient underwent 12-quadrant prostate biopsy under TRUS. The pathology results revealed a prostatic adenocarcinoma with mucinous features in the 12/12 quadrant with a Gleason score of 6 (3 + 3). The patient was diagnosed to have localized PCa and undergone RRP + bilateral PLND in January 2009. The final pathology was acinar adenocarcinoma (75% classic variant, 15% mucinous variant, 5% foamy gland variant, and 5% pseudohyperplastic variant) [Figure 2] with a Gleason score of 9 (4 + 5), and the tumor stage was pT3bN0M0. The surgical margin was positive in the distal urethra. Thus, the patient received adjuvant radiotherapy and androgen deprivation therapy. During the 10 years of follow-up of the patient, no biochemical recurrence was detected as well as no metastasis. The last PSA value was 0.202 ng/ml in December 2017.
The third patient was 45 years old and he presented to the urology department with dysuria in March 2017. His physical examination findings revealed a DRE of Grade 1.5 with benign features. The PSA level was 5.38 ng/ml. The result of the TRUS-guided biopsy pathology was acinar adenocarcinoma in 1/12 quadrant with a Gleason score of 6 (3 + 3). Based on the findings, active surveillance was offered to the patient; however, the patient did not agree. Because of normal erectile function, a nerve-sparing bilateral RRP was performed together with bilateral PLND in September 2017. The final pathology was revealed as adenocarcinoma with mucinous features with negative surgical margins [Figure 3]. Gleason score was 7 (3 + 4), and the tumor was staged as pT2cN0M0. The PSA level in January 2018 was 0.07 ng/ml. The patient has no incontinence, but mild erectile dysfunction.
| > Discussion|| |
The unusual histological variants of the prostate adenocarcinoma, including the atrophic, pseudohyperplastic, foamy gland, mucinous, and signet ring cell types, may be similarly responsive to the hormone deprivation treatment as the classic adenocarcinoma. In addition, some variants may be rated with different Gleason scores and may display different prognostic courses compared to the acinar adenocarcinoma.
The mucinous adenocarcinoma of the prostate is one of the rare variants of the PCa and its incidence among all PCa is reported to be 0.3% in the literature. To make a diagnosis of a mucinous type prostatic carcinoma, at least 25% of the excised tumor mass should contain extracellular mucin lakes. In addition to this criterion, other mucinous carcinomas of the colon, urinary bladder, and prostatic urethra must be ruled out.
Mucinous carcinomas were classified into three groups. The most common form is the pure mucinous carcinoma. Adenocarcinoma with mucinous features is defined as the tumor variant containing mucin in <25% of the resected RRP material. Mucinous type prostate adenocarcinoma displays a clinical behavior similar to classical prostate adenocarcinoma., The prostate biopsies were recommended to be graded independent of the mucinous component in the pathology reports. All three patients in our case series were diagnosed with mucinous adenocarcinoma as they had mucin components in their biopsy specimens at a rate <25%.
Two studies, evaluating the mucinous adenocarcinoma cases treated with RRP, reported that mucinous adenocarcinomas may display less aggressive clinical courses compared to that of the normal acinar adenocarcinoma., The long-term response rates of our cases to the treatment were similar to the classic adenocarcinoma treatment. Guler et al. reported successful results with radiotherapy and hormonal therapy in a 60-year-old patient, who was not eligible for surgery due to comorbidities, diagnosed with mucinous adenocarcinoma with cribriform features with a Gleason score of 8 (4 + 4) after TURP and had invasion into seminal vesicles demonstrated with multiparametric MRI. Samaratunga et al. retrospectively evaluated the data of 6440 cases who had undergone RRP due to PCa and determined that, in 143 (2.2%) patients, mucinous adenocarcinoma was identified at rates varying from 5 to 100%. They reported that mucinous carcinomas had similar prognostic features with the nonmucinous carcinomas. In addition, comparing the subgroups containing mucinous components at rates of either ≤25% or >25% in terms of prognosis, no difference was reported.
The mucinous adenocarcinoma is a rare variant of the PCa and displays similar features with acinar adenocarcinoma. The patients diagnosed with mucinous adenocarcinoma displayed similar treatment and surveillance processes with the classic adenocarcinoma cases.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]