Endometrial carcinoma of the prostatic utricle: Report of a case RONNIE L. KEITH, ao. GERHARD FLEGEL, D.O. St. Louis, Missouri results. Cystoscopy revealed a grade 3-4 enlargement of This is the thirteenth recorded case of the prostatic urethra. endometrial carcinoma of the The patient underwent transurethral resection of the prostate (TUR). Two distinct carcinomas were identified prostatic utricle. This tumor arises in upon histopathologic examination of the tissue: (1) ad- the region of the verumontanum and enocarcinoma of the prostate gland; and (2) endometrial prostatic urethra. It has a more carcinoma of the prostatic utricle. Biochemical testing favorable prognosis than the more by acid and alkaline phosphatase assays and radionu- common prostatic carcinomas, with clide bone scan detected rib metastasis. The hospital no mortality to date; however, course was unremarkable and the patient received post- one case of osseous metastasis has operative radiation therapy. been reported. Local excision without The original pathology report stated that microscopic orchiectomy or administration of examination demonstrated glandlike spaces that varied estrogen is the approach preferred by in size, and intraluminal papillary formations of atypi- most authorities. The controversy cal columnar epithelial cells which demonstrated endo- over the histopathologic status of this metrioid characteristics. Two pathology consultations were obtained, one agreeing with the diagnosis of endo- neoplasm is reviewed. metrial carcinoma of the prostatic utricle, and the other denying the existence of such a classification. However, the latter consultant stated that microscopic study showed that the predominant pattern was moderately differentiated adenocarcinoma, but a smaller compo- The prostatic utricle is a vestige of the embryonic nent consisted of moderately differentiated adenocarci- miillerian duct. If the duct were present, it would noma with a papillary pattern reminiscent of endome- extend from the upper end of the testis, between trioid carcinoma. the testicle and epididymis, continuing up the The patient has been readmitted to the hospital sever- spermatic cord, between the vas deferens and blad- al times for nonrelated problems, with the last admis- der, into the musculature of the bladder wall, and sion in March 1982. Rectal examination revealed a pal- pable nodule, which biopsy proved to be adenocarcinoma through the prostate, ending in the prostatic utri- of the prostate. Acid and alkaline phosphatase levels cle.2 In the female, the duct forms the fallopian have been normal at each admission. tubes, uterus, cervix and upper vagina, but in the male embryo begins to degenerate after the sixth Pathology week of gestation.3 The prostatic utricle is a tube The pathologic characteristics of neoplasms in or with a folded mucous membrane. The lining con- near the prostatic utricle are a subject of some de- sists of a simple or pseudostratified columnar type bate, as seen in this case. Melicow and Tennen- of epithelium which composes short, tubular baum5 described two pathologic types: (1) an exo- glands. Groups of ciliated cells are occasionally phytic lesion projecting into the urethral lumen present.4 either as ribbons or polypoid masses, with cells that are narrow and multilayered in a palisade ar- Report of case rangement, and clear cytoplasm, with cilia some- An 81-year-old black man was referred to the urology times present; and (2) an infiltrating type with service in February 1979 with complaints of dysuria, hematuria, and recurrent urinary tract infections. Rec- broad columnar cells occurring in masses tending tal examination revealed an enlarged, hard, non-nodu- to form glands with a cribiform pattern resembling lar prostate. Acid and alkaline phosphatase levels were endometrial carcinoma. normal. The urine had 2-3 erythrocytes per high-power Carney and Kelalis4 proposed a more limited field and greater than 106 colonies of Enterobacter aero- pathologic definition. They believed that, because genes. Intravenous pyelography yielded unremarkable the urethral papillary lesions are often confused Endometrial carcinoma of the proatatic utricle 551/75 Fig. 1. High power view of moderately differentiated adenocarcinoma of the prostate. A few of the TUR fragments also showed a second malignancy in the form of endometrioid carcinoma of the prostate ( utricle). Fig. 2. Low power view. This is another view of the endome- trioid carcinoma in the prostate. This view shows both columnar epithelial cells covering the papillary processes and lining the glands, as well as some areas where the neoplastic epithelium constitutes heaped up cuboidal rather than columnar cells. Fig. 3. Low power view. This field reveals the marked papillary nature of some parts of the lesion. Note that the papillary processes are covered by tall columnar epithelial cells showing stratification of nuclei. Fig. 4. High power view shows the columnar epithelial and the papillary-glandular architecture of the lesion. with carcinomas of the large prostatic ducts, the Most patients presented with hematuria or vesi- distinguishing feature should be that the cells cle outlet obstructive symptoms, and none had ele- have dark cytoplasm, whereas the cytoplasm of vated acid or alkaline phosphatase levels. The tu- microacinar and ductal prostatic carcinoma tend mor does not appear to have the poor prognosis to be clear. When ciliated tumor cells are seen, the associated with acinar adenocarcinoma or transi- diagnosis is even more convincing, since these tional cell carcinoma of the prostate or with papil- structures are sometimes seen in endometrial car- lary adenocarcinoma of the large prostatic ducts.° cinoma of the female, but never in prostatic carci- Only a single case of documented metastases has noma of ductal or microacinar origin. Satter and been reported. 11 The patients bone scan revealed Blumenfeld considered the presence of cilia as the osteoblastic lesions, and bone marrow biopsy major distinguishing characteristic. showed infiltration by tumor cells identical to those of the primary prostatic neoplasm. Discussion Melicow and Uson 12 presented a clsssification Endometrial carcinoma of the prostatic utricle is for neoplasms of the prostate gland based on a very rare, with only thirteen cases reported, in- study of some 1,600 patients, concluding that cluding the one presented here. Melicow and knowledge of the neoplastic source would be help- Pachter7 reported the first recognized case in 1967. ful in diagnosis, proper management, and progno- Five additional cases were reported by Melicow sis (Table 1). Young and Lagios 8 reported a case of and Tannenbaum in 1971, but only six more cases endometrial carcinoma of the prostatic utricle 4,6,8-11 appeared in the literature through 1977. which involved the bladder trigone and ureteral 552/76 April 1983/Journal of AOA/vol. 82/no. 8 orifices and caused a nonfunctioning right kidney TABLE 1. PATTERNS OF EPITHELIAL TUMORS OF THE PROSTATE and left hydronephrosis. Orchiectomy produced re- GLAND.(ADAPTED FROM MELICOW AND USON, WITH PERMISSION2) gression of the tumor and noticeable clinical im- I. Intraprostatic provement. The tumor, therefore, showed andro- A. Glandular 1. Microacinar: origin usually in posterior lamella gen rather than estrogen dependence. 2. Macroacinar: origin from central sets of alveoli It has been shown that hormonal manipulation 3. Rare patterns: Signet ring, mucin forming is less effective in transitional cell carcinoma of B. Cancer of the prostatic ducts 1. Columnar-cell-lined the prostate and adenocarcinoma of the large pros- 2. Periurethral urothelium-lined ducts tatic ducts than in the usual prostatic adenocarci- II. Paraprostatic noma.4 The normal male hormonal pattern may be A. Urethral mucosa attached to prostatic bed B. Utricle: endometrial inhibitory on the growth of utricular carcinoma.4 C. Ejaculatory duct However, the coexistence of a more common andro- M. Extraproatatic gen-dependent tumor must be considered a possi- A. Extension from neighboring organs B. Metastases from distant organs bility with endometrial carcinoma of the prostatic utricle. In the latter event, hormonal manipula- tion could be of benefit. Some investigators propose that endometrial carcinoma of the prostatic utricle should not be considered as a separate neoplasm." Zaloudek hormonal manipulation probably is not indicated and associates have studied this tumor by light in the pure lesion. and electron microscopy and histochemical tech- niques. Using colloidal iron stain to demonstrate 1. Catalona, WJ., and Scott, W.G.: Carcinoma of the prostate. In Camp- abundant acid phosphatase and no alkaline phos- bells Urology, edited by J.H. Harrison, et al. W.B. Saunders Co., Phila- phatase, they concluded that the tumor was more delphia, 1979, vol. 2 2. Prakash, A.: Multilocular cystadenofibroma of miallerian duct. J characteristic of prostate than endometrial carci- Urol 114:653-4, Oct 75 noma. Adenocarcinoma arising in the endome- 3. ernes, G.C., and Rubin, DJ.: Squamous cell carcinoma in a mailer- trium is characterized by cytoplasmic alkaline ian duct cyst. J Urol 100:40-3, Jul 68 4. Carney, J.A., and Kelalis, P.P.: Endometrial carcinoma of the pros- phosphatase and a relative paucity of acid phos- tatic utricle. Am J Clin Pathol 60:565-9, Oct 73 phatase. There is disagreement as to the exact na- 5. Melicow, M.M., and Tannenbaum, M.: Endometrial carcinoma of uterus masculinus (prostatic utricle). Report of 6 cases. J Urol