Clear cell adenocarcinoma of the urethra: evidence for origin within paraurethral ducts

Mullerian Duct-Type Clear Cell Adenocarcinoma of the Urethra in a Woman Presenting As Groin Swelling

Primary Mullerian duct-type clear cell adenocarcinoma of the urethra is a rare clinical entity with a varied clinical presentation. This can be diagnosed only with a high index of suspicion. Clinical examination, biopsy, and immunohistochemistry are essential for diagnosis. Management will need a multimodal approach with a combination of chemotherapy and surgical excision.

Analysis of survival and prognostic factors of clear cell adenocarcinoma of the prostate: a case-control study for a rare cancer entity

Clear cell adenocarcinoma of the prostate (CCPC) is a rare entity compared to acinar carcinoma of the prostate (APC). The survival rate and prognostic factors of CCPC are still unclear and deserve further study. We downloaded data on prostate cancer from the Surveillance, Epidemiology, and End Results database for 1975-2019. After inclusion and exclusion criteria, we compared APC and analyzed cancer-specific mortality (CSM) and overall mortality (OM) in CCPC patients and prognostic risk factors using a propensity score matching (PSM) study and multivariate Cox regression. We included 408,004 cases of APC as a control group and 130 cases of CCPC as a case group. Compared with APC patients, the incidence of CCPC was extremely low, and the median age of diagnosis was older (72.00 years vs. 69.00 years, p < 0.01). In addition, more rates were diagnosed at an earlier stage (1975-1998, 93.1% vs. 50.2%, p < 0.001), more unstaged or unknown stage ratios (87.7% vs. 42.7%, p < 0.001), and more surgical treatments (66.2% vs. 47.6%, p < 0.001), but the prognosis of CCPC patients was worse. After PSM, the median survival time of CCPC patients was shorter (57.50 month vs. 88.00 month, p < 0.01), the rate of CSM was higher (41.5% vs. 27.7%, p < 0.05), and the rate of OM was higher (99.2% vs. 90.8%, p < 0.01). In the adjusted model 2 after PSM, the CSM risk of CCPC patients reached HR 1.76 (95%CI 1.13-2.72), which was 76% higher than that of APC patients (p < 0.05). It was further found that surgical treatment might benefit CSM in CCPC patients (HR 0.39, 95%CI 0.18-0.82, p < 0.05) in Univariate analysis, but it was insignificant in further multivariate analysis. This is the first large-scale case-control report on the survival risk and prognostic factors of CCPC patients. We found that the prognosis of CCPC patients was significantly worse than that of APC. Surgery might be an effective treatment that may improve its prognosis. Clear cell adenocarcinoma, prostate, acinar carcinoma, survival rate, rare cancer, propensity score matching, case-control study.

Clear Cell Adenocarcinoma in Men: A Series of 15 Cases

Clear cell adenocarcinoma (CCA) is a rare tumor in the genitourinary tract with female predominance and few reports in men. We identified 15 cases of CCA in men evaluated at our institution. Five arose in the bladder, 7 in the prostate or prostatic urethra, 2 in the membranous urethra (1 multifocal in the prostatic and membranous urethra), 1 periprostatic (likely from an embryologic remnant), and 1 between rectum and bladder (likely in a prostatic utricle cyst). No cases showed associated Müllerian structures. One case showed separate foci of nephrogenic adenoma at diagnosis, and 1 case showed urothelial carcinoma in situ on a later follow-up biopsy. Four tumors extended into other organs (prostate to seminal vesicle and periprostatic soft tissue, periprostatic soft tissue to prostate, prostatic urethra to bladder and rectum, and prostate to bladder neck). One tumor showed extraprostatic extension alone. Four tumors metastasized to lymph nodes, with 3 also metastasizing to other sites (bladder, lung and adrenal, and right flank). Eleven patients underwent resection, including 3 transurethral resections. Seven underwent other treatments, including radiation (5 [1 for recurrence]), chemotherapy (3), hormonal therapy (3), immunotherapy with nivolumab (1), and targeted therapy with gefitinib (1). The mean follow-up was 35 months (range: 1 to 138 mo). At the last follow-up, 7 patients showed no evident disease and 3 were alive with disease. Four died with the cause of death unknown, with 2 cases having confirmed disease at the time of death and the remaining 2 dying less than a year after diagnosis. The mean time to death was 16 months (range: 6 to 39 mo). No follow-up was available on 1 patient. All patients who died in this series had CCA of the prostate or prostatic urethra. Pathologists need to be attuned to CCA occurring in males, given that the literature emphasizes its occurrence in females. In addition to established sites such as bladder and urethra, our series demonstrates that tumor may present in unusual adjacent sites, such as in periprostatic embryologic remnants or prostatic utricle.

Histopathological Subtypes and PD-L1 Expression in Primary Urethral Adenocarcinoma: A Series of 5 Cases

BACKGROUND AND OBJECTIVES

Urethral adenocarcinoma is a rare disease with poor prognosis that can display multiple histologic patterns and has an unclear histogenesis. Radical surgery with extensive periurethral resection is the preferred therapeutic approach. Both chemotherapy and radiotherapy have been used as complementary treatment options. Due to the tendency of these tumors to recur, treatment-associated complications, and the limited choice of therapeutic options, patient management can be difficult. Given the lack of literature regarding immunotherapy in urethral adenocarcinoma, our objective was to explore the expression of programmed death receptor-ligand 1 (PD-L1) throughout the different histological subtypes of primary urethral adenocarcinoma.

METHODS

We reviewed all primary urethral adenocarcinomas diagnosed at our hospital between 1965 and 2019, performed immunohistochemical assays on the tissue blocks, classified them according to their histology and origin, and performed PD-L1 (22C3) immunohistochemistry assays in all cases.

RESULTS

We found a total of 5 cases of primary urethral adenocarcinoma. All of the patients were women. One of the cases was a cribriform adenocarcinoma, 2 were columnar-mucinous adenocarcinomas, and 2 were clear cell adenocarcinomas. One of the clear cell adenocarcinomas strongly expressed PD-L1. In addition, a profuse inflammatory infiltration constituted by CD3-positive and CD8-positive T lymphocytes within tumor cells was observed in this case. None of the other cases showed PD-L1 expression.

CONCLUSIONS

In conclusion, some urethral adenocarcinomas may strongly express PD-L1 and thus could potentially allow the use of immunotherapy in selected cases of advanced or recurrent adenocarcinoma.

Primary adenocarcinomas of the vulva and related structures: An enigmatic and diverse group of tumors✰

Approximately half of adenocarcinomas that involve the vulva are secondary, either through direct extension or metastases from elsewhere. Primary vulvar adenocarcinomas are rare and encompass a diverse array of neoplasms that are nominally classified based on the presumed tissue or organ of origin, the tumoral phenotype, or both. In this review, we summarize the clinicopathologic features of adenocarcinomas that originate from the vulva and related structures, including the terminal urethra. Adenocarcinomas of this region encompass lesions that are defined by their primary site (such as adenocarcinomas of the Bartholin gland, which by definition must be in the region of the Bartholin gland), histomorphology and immunophenotype (such as clear cell carcinoma and adenocarcinoma of intestinal [cloacogenic] type), or both (such as adenocarcinoma of skene gland origin, which is associated with that specific organ but which also displays a distinctive phenotype that is similar to the phenotype of high grade prostatic adenocarcinoma). Other types, such as mammary-type adenocarcinomas, are presumed to originate from the putative mammary-like glands of the vulva and display a spectrum of pathologic features that are similar to their mammary counterparts. Similarly, vulvar carcinomas of sweat gland origin are pathologically similar to their counterparts in the non-vulvar skin and include a variety of cutaneous adnexal-type malignancies such as apocrine adenocarcinoma and eccrine adenocarcinoma. Some tumors, such as adenoid cystic carcinoma, may represent a Bartholin gland adenocarcinoma, a carcinoma of sweat gland origin, or a carcinoma arising from extramammary Paget disease (EMPD), depending on the context. Invasive carcinomas of various types have been reported in 7-12.7% of EMPD, and these are likely the most common primary glandular malignancy of the vulva. Occasional vulvar adenocarcinomas have been reported to be HPV-associated, although this association has not been established for the broader group of vulvar adenocarcinomas. Rare adenocarcinomas are not classifiable by the aforementioned nosologic scheme, and are designated as vulvar adenocarcinoma NOS.

European Association of Urology Guidelines on Primary Urethral Carcinoma-2020 Update

CONTEXT

Primary urethral carcinoma (PUC) is a rare cancer accounting for <1% of all genitourinary malignancies.

OBJECTIVE

To provide updated practical recommendations for the diagnosis and management of PUC.

EVIDENCE ACQUISITION

A systematic search interrogating Ovid (Medline), EMBASE, and the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews was performed.

EVIDENCE SYNTHESIS

Urothelial carcinoma of the urethra is the predominant histological type of PUC (54-65%), followed by squamous cell carcinoma (16-22%) and adenocarcinoma (10-16%). Diagnosis of PUC depends on urethrocystoscopy with biopsy and urinary cytology. Pathological staging and grading are based on the tumour, node, metastasis (TNM) classification and the 2016 World Health Organization grading systems. Local tumour extent and regional lymph nodes are assessed by magnetic resonance imaging, and the presence of distant metastases is assessed by computed tomography of the thorax/abdomen and pelvis. For all patients with localised distal tumours (≤T2N0M0), partial urethrectomy or urethra-sparing surgery is a valid treatment option, provided that negative intraoperative surgical margins can be achieved. Prostatic Ta-Tis-T1 PUC can be treated with repeat transurethral resection of the prostate and bacillus Calmette-Guérin. In prostatic or proximal ≥ T2N0 disease, neoadjuvant cisplatin-based chemotherapy should be considered prior to radical surgery. All patients with locally advanced disease (≥T3N0-2M0) should be discussed within a multidisciplinary team. In men with locally advanced squamous cell carcinoma, curative radiotherapy combined with radiosensitising chemotherapy can be offered for definitive treatment and genital preservation. In patients with local urethral recurrence, salvage surgery or radiotherapy can be offered. For patients with distant metastatic disease, systemic therapy based on tumour characteristics can be evaluated.

CONCLUSIONS

These updated European Association of Urology guidelines provide up-to-date guidance for the contemporary diagnosis and management of patients with suspected PUC.

PATIENT SUMMARY

Primary urethral carcinoma (PUC) is a very rare, but aggressive disease. These updated European Association of Urology guidelines provide evidence-based guidance for clinicians treating patients with PUC.

Prognostic and diagnostic role of PSA immunohistochemistry: A tissue microarray study on 21,000 normal and cancerous tissues

To assess the prognostic and diagnostic utility of PSA immunostaining, tissue microarrays containing 17,747 prostate cancers, 3,442 other tumors from 82 different (sub) types and 608 normal tissues were analyzed at two different antibody concentrations (1:100 and 1:800). In normal tissues, PSA expression was limited to prostate epithelial cells. In prostate cancers, PSA staining was seen in 99.9–100% (1:800–1:100) primary tumors, 98.7–99.7% of advanced recurrent cancers, in 84.6–91.4% castration resistant cancers, and in 7.7–18.8% of 16 small cell carcinomas. Among extraprostatic tumors, PSA stained positive in 0–3 (1:800-1:100) of 19 osteosarcomas, 1-2 of 34 ovarian cancers, 0-2 of 35 malignant mesotheliomas, 0–1 of 21 thyroid gland carcinomas and 0–1 of 26 large cell lung cancers. Reduced staining intensity and loss of apical staining were strongly linked to unfavorable tumor phenotype and poor prognosis (p < 0.0001 each). This was all the more the case if a combined “PSA pattern score” was built from staining intensity and pattern. The prognostic impact of the “PSA pattern score” was independent of established pre- and postoperative clinico-pathological prognostic features. In conclusion, PSA immunostaining is a strong prognostic parameter in prostate cancer and has high specificity for prostate cancer at a wide range of antibody dilutions.

Lesions of Skene glands and periurethral region: a review

The periurethral (Skene) glands may become involved by a variety of conditions. Mass-like lesions need to be distinguished from other lesions arising from the anterior vagina. Familiarity with these lesions will be helpful if a patient with a lesion of the Skene glands or periurethral region is encountered.

Primary urethral clear-cell adenocarcinoma: comprehensive analysis by surgical pathology, cytopathology, and next-generation sequencing

Primary clear-cell adenocarcinoma of the urethra, a rare tumor that histomorphologically resembles clear-cell carcinoma of the female genital tract, occurs predominantly in women and is associated with a relatively poor prognosis. The histogenesis of this rare urethral neoplasm has not been completely resolved, but it is thought to arise from either müllerian rests or metaplastic urothelium. Herein, we present comprehensive surgical pathological and cytopathological findings from a patient with primary urethral clear-cell adenocarcinoma and describe next-generation sequencing results for this patient's unique tumor-the first such reported characterization of molecular aberrations in urethral clear-cell adenocarcinoma at the transcriptomic and genomic levels. Transcriptome analysis revealed novel gene fusion candidates, including ANKRD28-FNDC3B. Whole-exome analysis demonstrated focal copy number loss at the SMAD4 and ARID2 loci and 38 somatic mutations, including a truncating mutation in ATM and a novel nonsynonymous mutation in ALK.

Histology and immunohistochemistry of clear cell adenocarcinoma of the urethra: histogenesis and diagnostic problems

Clear cell adenocarcinoma (CCAC) of the urethra is a rare neoplasm, morphologically identical to its homologue arising in the female genital tract. The histogenesis of this neoplasm is uncertain. We present clinical, histopathologic, and immunohistochemical findings of four CCAC of the urethra and discuss the histogenesis and difficulties in diagnosis and differential diagnosis. CCAC of the urethra occurred in females (4/4). Two neoplasms were identified in urethral diverticulum; one of the two cases, in close proximity to a nephrogenic adenoma. CCAC exhibited tubulocystic, papillary, and diffuse/solid growth patterns. The neoplastic cells were cuboidal or columnar with eosinophilic or clear cytoplasm, and nuclear pleomorphism of at least moderate degree. Hobnail features and tumor necrosis were also observed. CCAC expressed p53 (4/4), AMACR (3/4), vimentin (3/4), PAX8 (2/4), CK7 (2/4), cytokeratin 34betaE12 (2/4), RCC (1/4), and CK20 (1/4) and were negative for PSA, WT1, ER, CA 125, uroplakin III, p16, and p63. The immunohistochemical profile supports a possible renal tubular cell differentiation/mesonephric origin for some urethral CCAC. Nephrogenic adenoma and metastatic clear cell carcinoma are the most important differential diagnostic considerations. Multicenter studies on more cases may improve our understanding of this malignancy.

Clear cell adenocarcinoma of the urinary bladder: a short review

In this short review, we discuss clear cell adenocarcinoma of the urinary bladder, a rare tumor that primarily affects women. The histogenesis of this neoplasm is uncertain; in some tumors the clinicopathologic and histologic features are suggestive of a müllerian origin. Clear cell adenocarcinoma consists of cells with abundant clear cytoplasm, arranged in solid, glandular, or tubulocystic patterns. These tumors are positive for pancytokeratin, cytokeratin 7, and CA 125 immunohistochemical stains. Patients typically present with gross hematuria, dysuria, and discharge. The natural history is poorly understood and patient outcomes remain unclear. Currently, surgery is the treatment of choice. Nephrogenic adenoma is the most important differential diagnostic consideration, followed by metastatic clear cell carcinoma.

Female urethral carcinoma: evidences to origin from Skene's glands

PURPOSE

Urethral carcinoma is among the rarest neoplasias of the genitourinary tract and its origin is unclear. Prostate-specific antigen (PSA) is considered an evidence of origin from Skene's glands. We considered the origin from these glands in PSA negative cases.

MATERIAL AND METHODS

We studied 3 patients with urethral carcinoma surgically treated. The surgical specimens were examined including cytochemical and immunohistochemical stains. The possible origin of the tumors was based on a comparative study of normal Skene's glands from autopsies and noninvolved glands in periurethral tumors.

RESULTS

The gross findings and the microscopic examination of 2 adenocarcinomas, including the cytochemical and immunohistochemical studies, favor an origin from Skene's glands.

CONCLUSIONS

The origin from Skene's glands may be established in PSA negative cases. The establishment of this origin in a higher number of urethral carcinomas may have an impact on diagnostic and treatment strategies in the future.

Primary clear-cell adenocarcinoma of the proximal female urethra: case report and review of the literature

Primary carcinoma of the female urethra is a rare entity. Adenocarcinomas account for only 10% of cases. Clear cell adenocarcinoma (CCA) of the urethra is more common among women than men.1 We report a case of primary CCA of the urethra and review the literature concerning the histogenesis, management, and outcome of this uncommon tumor.

Advanced clear-cell adenocarcinoma of the bladder successfully treated by radical surgery with adjuvant chemoradiotherapy

A 52-year-old woman was referred to our institute for the evaluation of a tumor in her pelvic cavity. The tumor seemed to have arisen from the bladder or urethra, and bilateral iliac lymphadenopathy was seen. Her urethral mucosa looked intact according to the results of cystourethroscopy. Histopathological examination of the biopsy specimens showed clear-cell adenocarcinoma. She underwent radical cystourethrectomy with complete pelvic lymph node dissection and the construction of a bilateral ureterocutaneostomy. Macroscopically, the tumor had arisen from the trigone of the bladder, and histopathological examination of the tumor revealed adenocarcinoma exhibiting solid clear cells with glandular and papillary patterns. The tumor had infiltrated perivesical structure (pT3a), and metastases in multiple pelvic lymph nodes were recognized (pN3). Postoperatively, three courses of systemic combination chemotherapy with 5-fluouracil (FU) and cisplatin, along with a total of 45 Gy of irradiation during the second course of chemotherapy, were conducted. No evidence of the disease has been seen 28 months after the surgery.

Mucinous adenocarcinoma of posterior urethra. Report of a case

Primary carcinoma of the male urethra accounts for less than 1% of malignancies in males. Mucinous adenocarcinoma of the urethra is extremely rare, and its biologic behavior is not well known. We report a case of mucinous adenocarcinoma showing the histologic features of colloid adenocarcinoma that appears to have evolved either by neoplastic degeneration of goblet cells found in the urethral epithelium or by malignant degeneration of persistent glandular elements of uretheritis cystica and glandularis.

Female para-urethral adenocarcinoma: Histological and immunohistochemical study

BACKGROUND

Female urethral cancer with a diverticular form is assumed to originate from the para-urethral duct, which is embryologically homologous to the male prostate gland. The purpose of the present paper was to investigate the female para-urethral adenocarcinomas histologically and immunohistochemically.

METHODS

Surgical specimens obtained from six female patients with para-urethral adenocarcinomas were examined histologically, and an immunohistochemical study using antibodies against carcinoembryonic antigen (CEA), prostate specific antigen (PSA), and chromogranin A was performed.

RESULTS

On histologic examination, the female para-urethral cancers were divided into five cases of mucin-producing-type adenocarcinoma and one case of clear cell-type adenocarcinoma. All five mucin-producing-type adenocarcinomas were positive with anti-CEA, and two of them showed neuroendicrine differentiation. One of them showed a focally positive area with anti-PSA. The clear cell-type adenocarcinoma had no positive reactions to these antibodies.

CONCLUSIONS

On the basis of histologic structure, positive CEA staining, and the presence of focal neuroendocrine differentiation, mucin-producing-type adenocarcinomas may arise from the proximal part of the para-urethral duct.

Skene's Gland Adenocarcinoma Resembling Prostatic Adenocarcinoma

An 88-year-old woman presented with gross hematuria and a 3-cm periurethral mass. Biopsy revealed an adenocarcinoma resembling prostatic adenocarcinoma; the tumor cells were positive for keratin and prostate-specific antigen. The serum level of prostate-specific antigen was elevated; the carcinoembryonic antigen and CA-125 serum levels were normal. One year after external beam radiotherapy, the patient is without evidence of disease. This is the sixth case of a urethral prostatic-type adenocarcinoma, tumors that are most likely of Skene's gland origin.

Clear cell adenocarcinoma of the male urethra

We present a rare case of clear cell adenocarcinoma of the male urethra. These tumors are usually presented with hematuria, obstructive voiding symptoms or urinary retention. Histologically, they display tubulocystic, tubular, papillary or diffuse patterns with clear and hobnail cells. The present case of this rare disease emphasizes the aggressive nature of urethral clear cell adenocarcinoma in males.

Female prostatitis

Female prostatitis is described as a frequent cause of the urethral syndrome. Appropriate localization of tenderness to the paraurethral glands allows the diagnosis and treatment of female prostatitis as in its male counterpart. All urologists are urged to adopt the finger pressure (Fig. 3) maneuver in the pelvic examinations of their female patients.

Adenocarcinoma of female paraurethral duct showing neuroendocrine differentiation

Two cases are presented in which a female urethral adenocarcinoma took the form of a diverticular cancer. The pathologic examination of each tumor revealed a columnar/mucinous type of adenocarcinoma with evidence of abundant mucous secretion. Some of the cancer cells were positive on immunohistochemical staining with the conventional neuroendocrine marker chromogranin A, indicating focal neuroendocrine differentiation. The present cases may indicate a possible site of origin for female paraurethral adenocarcinomas.

The role of molecular forms of prostate-specific antigen (PSA or hK3) and of human glandular kallikrein 2 (hK2) in the diagnosis and monitoring of prostate cancer and in extra-prostatic disease

Prostate-specific antigen (PSA or hK3) is a glandular kallikrein with abundant expression in the prostate that is widely used to detect and monitor prostate cancer (PCa), although the serum level is frequently elevated also in benign and inflammatory prostatic diseases. PSA testing is useful for early detection of localized PCa and for the detection of disease recurrence after treatment. However, PSA has failed to accurately estimate cancer volume and preoperative staging. There is no PSA level in serum that definitively distinguishes men with benign conditions from those with prostate cancer, although PCa is rare in men with PSA levels in serum < 2.0 ng/ml. This prompted searches for enhancing parameters to combine with PSA testing, such as PSA density, PSA velocity, and age-specific reference ranges. Due to the protease structure, PSA occurs in different molecular forms in serum and their concentrations vary according to the type of prostatic disease. Human glandular kallikrein 2 (hK2) is very similar to PSA, but expressed at higher levels in prostate adenocarcinoma than in normal prostate epithelium. Blood testing for hK2 combined with different PSA forms improves discrimination of men with benign prostatic disease from those with prostate cancer. Many data have also been reported on the extra-prostatic expression of both PSA and hK2, and it is now believed that they may both have functions in tissues outside the prostate.

The diagnostic and prognostic utility of prostate-specific antigen for diseases of the breast

Although prostate-specific antigen (PSA) is the most valuable tumor marker for the diagnosis and management of prostate carcinoma, it is widely accepted that PSA is not prostate specific. Numerous studies have shown that PSA is present in some female hormonally regulated tissues, principally the breast and its secretions. In this review, we summarize the findings of PSA in the breast, and focus on its potential for clinical applications in breast disease. PSA is produced by the majority of breast tumors and is a favorable indicator of prognosis in breast cancer. Low levels of PSA are released into the female circulation, and while the level of serum PSA is elevated in both benign and malignant breast disease, the molecular form of circulating PSA differs between women with and without breast cancer. These findings indicate that PSA may have potential diagnostic utility in breast cancer. PSA may also have a clinical application in benign breast disease, as both the level and molecular form of PSA differ between Type I and II breast cysts. High levels of PSA have been reported in nipple aspirate fluid (NAF) and recent studies have shown that the concentration of PSA in NAF is inversely related to breast cancer risk, indicating that NAF PSA may represent a clinical tool for breast cancer risk assessment. Thus, PSA represents a marker with numerous potential clinical applications as a diagnostic and/or prognostic tool in breast disease.

Endocrine cell distribution and expression of tissue-associated antigens in human female paraurethral duct: possible clue to the origin of urethral diverticular cancer

BACKGROUND

To investigate (i) what determines the histologic differences seen among female urethral diverticular cancers and (ii) the possible embryologic origin of the female paraurethral duct, we performed a distribution analysis of endocrine cells and a comparative study of tissue-associated antigens in the female paraurethral duct.

METHODS

Six human female urethras were obtained from surgical and autopsy cases including two cases of urethral diverticular cancer (columnar/mucinous type adenocarcinoma). The urethral and paraurethral epithelia were examined histologically and immunohistochemically.

RESULTS

Immunoreactive endocrine cells predominated and carcinoembryonic antigen (CEA) was strongly expressed in the larger portion of the paraurethral duct close to the urethral lumen. Conversely, prostate-specific antigen and prostatic acid phosphatase were positive only in the smaller distal duct. In two cases of adenocarcinoma including endocrine cells, cancer cells were strongly positive for CEA.

CONCLUSIONS

This study suggests that the proximal and distal parts of the paraurethral duct have different histologic characteristics and that the pathologic differences seen among female diverticular cancers may result from their cancer-genesis from different parts of the paraurethral duct.

FEMALE URETHRAL ADENOCARCINOMA: IMMUNOHISTOCHEMICAL EVIDENCE OF MORE THAN 1 TISSUE OF ORIGIN

PURPOSE

Urethral adenocarcinoma is a rare malignancy whose origin remains controversial. The monoclonal antibody mAbDas1 (formerly 7E12H12) was developed against a unique colonic epithelial epitope and is reactive in areas of intestinal metaplasia. Recently the antibody was shown to react in cystitis glandularis as well as adenocarcinoma of the bladder, suggesting that cystitis glandularis may be the precursor of bladder adenocarcinoma. We examined urethral adenocarcinomas and benign urethral specimens using mAbDas1 to determine whether it could provide insight into their histogenesis.

MATERIALS AND METHODS

Archival tissue from 12 cases of primary female urethral adenocarcinoma and urethral specimens of inflamed urethral mucosa, urethritis glandularis and transitional cell carcinoma was studied. Immunohistochemical analysis of formalin fixed, paraffin embedded archival tissue was done using the monoclonal antibody mAbDas1. Tumors were also evaluated with a prostate specific antigen (PSA) polyclonal antibody as previous studies have noted PSA reactivity in these tumors.

RESULTS

Of the 12 cases 9 were columnar/mucinous adenocarcinoma, 2 clear cell adenocarcinoma and 1 a cribriform pattern resembling adenocarcinoma of the prostate. All columnar/mucinous adenocarcinomas reacted positively (6 strongly and 3 focally) with the mAbDas1 antibody but did not react with the PSA antibody. The tumor with a cribriform pattern reacted strongly with PSA but did not react with mAbDas1. The 2 clear cell adenocarcinomas did not react with either antibody. The benign urethral specimens demonstrated strong reactivity to the mAbDas1 antibody in areas of urethritis glandularis but normal and inflamed urethral mucosa and transitional cell carcinoma did not react.

CONCLUSIONS

Primary adenocarcinoma of the female urethra arises from more than 1 tissue of origin. Columnar/mucinous adenocarcinomas of the female urethra and urethritis glandularis demonstrate consistent reactivity with the mAbDas1 antibody, suggesting that these tumors arise from glandular metaplasia analogous to the potential histogenesis previously demonstrated in the bladder. PSA reactivity occurred in 1 tumor with a cribriform pattern and likely represents origin from Skene's glands. Clear cell adenocarcinomas did not react with either antibody, suggesting a third possible pathway in the development of this rare subset of adenocarcinomas.

Clear cell adenocarcinoma and nephrogenic adenoma of the urethra and urinary bladder: a histopathologic and immunohistochemical comparison

Because of histological similarities between nephrogenic adenomas and clear cell adenocarcinomas of the urinary tract, there is the potential for diagnostic confusion between these two entities. The histopathologic features of 13 nephrogenic adenomas and five clear cell adenocarcinomas of the urethra and urinary bladder are compared in this report, and detailed immunohistochemical staining profiles are provided for these tumors. Only 2 of the 13 nephrogenic adenomas contained clear cells, and these constituted less than 10% of the lesions. In contrast, four of the five clear cell adenocarcinomas contained prominent areas with clear cells. Nephrogenic adenomas generally showed only mild cytologic atypia, whereas four of the five clear cell adenocarcinomas showed severe atypia. A single mitotic figure was identified in only two of the nephrogenic adenomas, whereas the mitotic rate in the clear cell adenocarcinomas ranged from 2 to 14 per 10 high-power fields. None of the nephrogenic adenomas showed evidence of necrosis, but focal necrosis was noted in four of the five clear cell adenocarcinomas. In general, the nephrogenic adenomas and clear cell adenocarcinomas showed negative to weak staining with CK903 but strong staining with AE1, AE3, and Cam 5.2. Variable staining was observed with Brst-3 and antibodies to S-100, CEA (monoclonal and polyclonal), LeuM-1, and CA19.9. Nephrogenic adenomas and clear cell adenocarcinomas were all negative for prostate-specific acid phosphatase (PSAP), prostate-specific antigen (PSA), and estrogen and progesterone receptors (except for two nephrogenic adenomas, which showed only focal weak staining for estrogen receptor). Neither bcl-2 nor c-erbB-2 staining was able to discriminate between the tumors. However, strong staining for p53 was noted in each clear cell adenocarcinoma and in none of the nephrogenic adenomas. MIB-1 positivity in nephrogenic adenomas ranged from 0 to 13 (average of 5.5) per 200 cells, whereas the positive range for clear cell adenocarcinomas was 33 to 70 (average of 47) per 200 cells. In summary, histopathologic features that favor clear cell adenocarcinoma over nephrogenic adenoma include a predominance of clear cells, severe cytological atypia, high mitotic rate, necrosis, high MIB-1 positivity, and strong staining for p53.

Human Kallikrein 2 (hK2) and prostate-specific antigen (PSA): two closely related, but distinct, kallikreins in the prostate

Recent studies on human kallikrein 2 (hK2) have revealed striking similarities and significant differences with the closely related kallikrein PSA. Both PSA and hK2 are primarily localized to the prostate and share close structural similarities. Although both kallikreins are produced by the same secretory epithelial cells in the prostate, hK2 is associated more with prostate tumors than PSA and is highly expressed in poorly differentiated cancer cells. The potent trypsin-like activity of hK2 contrasts with the weak chymotrypsin-like activity of PSA. The inactive precursor form of PSA, proPSA, is converted rapidly to active PSA by hK2, suggesting an important in vivo regulatory function by hK2 on PSA activity. The high homology between hK2 and PSA results in significant cross-reactivity to hK2 by polyclonal and some monoclonal antibodies to PSA. Future studies on both PSA and hK2 need to take into account this potential for cross-reactivity. Specific monoclonal antibodies to hK2 have now demonstrated that serum levels of hK2, like PSA, are correlated with prostate cancer. The production of hK2 protein in active protease form and specific monoclonal antibodies to the hK2 antigen will allow extensive future studies delineating the physiological and clinical utility of this new prostate antigen.

Metastasizing adenocarcinoma of the female prostate (Skene's paraurethral glands). Histological and immunohistochemical prostate markers studies and first ultrastructural observation

The case of a 46-year-old women with well-differentiated adenocarcinoma of the female prostate (Skene's paraurethral glands and ducts) with inguinal metastases is reported. Besides adenocarcinomatous structures, also more solid parts of the tumor and anaplastic regions with dark cells were found on histological examination. Clear cancerous cells were typical for glandular and solid tumor parts. The cancerous cells showed distinct immunohistochemical positivity of prostate specific antigen (PSA) and prostate (specific) acid phosphatase [P(S)AcP]. These are the first published results of electron microscopic examination of formalin fixed tissue showing the ultrastructure of female prostate carcinoma, comparable to that of the male prostate carcinoma. In the female, similar to the male, the prostate carcinoma probably originates from the secretory (luminal) cells of the female prostatic glands.

Carcinoembryonic antigen positive adenocarcinoma of a female urethral diverticulum: case report and review of the literature

Paraurethral glands of the female urethra, which are assumed to be embryologically homologous to the male prostate gland, are possible origins for diverticular cancer of the urethra. A case of primary adenocarcinoma arising in a female urethral diverticulum is presented. Pathology revealed a columnar/mucinous type adenocarcinoma which stained positively for carcinoembryonic antigen (CEA) and negatively for PSA. Normal paraurethral ducts located near the urethra and normal urethral epithelium also stained positively for CEA. These findings suggest that the adenocarcinoma in our case originated from the paraurethral duct near the urethral lumen.

Early detection of recurrent prostate cancer with an ultrasensitive chemiluminescent prostate-specific antigen assay

OBJECTIVES

Treatment failure after radical prostatectomy is most commonly heralded by an increase in serum prostate-specific antigen (PSA) to detectable levels. We evaluated the clinical utility of an ultrasensitive chemiluminescent PSA assay.

METHODS

We evaluated the assay in banked sera obtained from 170 men after radical prostatectomy. Controls consisted of 142 females, 29 men who had undergone cystoprostatectomy without evidence of prostate cancer, and 25 men without evidence of recurrent disease at least 5 years after prostatectomy for organ-confined disease. Lead time to diagnosis of recurrence was based on comparisons with the IMx or Tandem E assays using a cutoff of 0.1 ng/mL (100 pg/mL).

RESULTS

The biologic level of detection of this assay is 8 pg/mL. Serum PSA levels were undetectable in 82.4% of females, 86.2% of the cystoprostatectomy patients, and 96% of the radical prostatectomy controls. After radical prostatectomy, PSA levels were undetectable at last check in 104 of 168 (61.9%) men. In the 24 men with prostate cancer recurrence, the enhanced sensitivity of 8 pg/mL provided a mean lead time based on conservative calculations of 12.7 to 22.5 months over conventional assays. Thirty-four of the 41 men with detectable PSA levels and no evidence of disease recurrence had PSA levels of 30 pg/mL or less.

CONCLUSIONS

PSA levels are undetectable in most men who do not have recurrence of disease after radical prostatectomy. Low but detectable serum PSA levels less than or equal to 30 pg/mL can be produced by nonmalignant sources of PSA. PSA assays with enhanced sensitivity can detect recurrent prostate cancer with significant lead time over conventional assays.

Immunohistochemical labelling for prostate specific antigen in non-prostatic tissues

Immunohistochemical detection of prostate specific antigen (PSA) in metastases of adenocarcinomas is widely used as an aid to identify the prostatic origin of metastatic cells. However, on the one hand, PSA may not be expressed in some poorly differentiated prostatic carcinomas, while on the other, PSA immunoreactivity has been found in small amounts in non-prostatic tissues. The aim of the current study was to evaluate the prevalence of PSA immunoreactivity in normal non-prostatic tissues and in breast carcinoma. PSA was localized by immunohistochemistry with four commercial antibodies in 34 different normal human tissues, and in 15 ductal and seven apocrine breast carcinomas. Concentrations of PSA in tissue homogenates of prostate and nine non-prostatic tissues from autopsied subjects were measured by a two-site immunoradiometric assay. Weak PSA immunoreactivity was found by immunohistochemistry in kidney, parotid gland and pancreatic tissues. Variable PSA immunoreactivity was seen in three cases of ductal (20%) and two cases of apocrine breast carcinoma (28%). No consistent PSA immunoreactivity was found in homogenates of non-prostatic tissues by the immunoradiometric assay. We conclude that PSA is a quite specific marker of prostatic tissue. However, there are some non-prostatic neoplastic and normal tissues that express PSA. Therefore, a definite diagnosis of metastasis of prostatic origin cannot be made on the basis of immunolabelling for PSA alone.

The histogenesis of clear cell adenocarcinoma of the lower urinary tract. Case series and review of the literature

Clear cell adenocarcinoma of the lower urinary tract is a rare neoplasm whose histogenesis has not been thoroughly investigated. We have examined six specimens of clear cell adenocarcinomas collected from three institutions using histological, histochemical, and immunohistochemical techniques. Results indicate that almost all clear cell adenocarcinomas of this region express morphological and antigenic features, suggesting müllerian differentiation, and that müllerian differentiation is not a feature of either nonclear cell adenocarcinomas or normal female paraurethral glands. Including the authors' six specimens, 46 specimens have been reported in the available English literature. The accumulated experience confirms the initial impression that these tumors develop predominantly in the urethras of women and occur over a wide age range. Despite high stage at diagnosis, most patients have been alive with no evidence of disease when reported, a prognosis that seems to apply regardless of length of follow-up.

Clear cell adenocarcinoma of the female urethra showing positive staining with antibodies to prostate-specific antigen and prostatic acid phosphatase

A case of clear cell adenocarcinoma arising from the female urethra is described. Histologically, solid and glandular areas consisted of clear cells. The tumor cells stained positively with antibodies to prostate-specific antigen and prostatic acid phosphatase, suggesting that the clear cell adenocarcinoma arises from the female paraurethral duct, rather than embryonic remnants.

Immunohistochemical localization of prostate-specific markers within the accessory male sex glands of Cowper, Littre, and Morgagni

OBJECTIVES

The aim of the study was to explore possible production of prostate-specific markers by the embryologically and physiologically related accessory male sex glands, other than the prostate.

METHODS

The accessory male sex glands of Cowper, Littre, and Morgagni were studied systematically in 10 whole-mount autopsy and 5 surgical cystoprostatourethrectomy specimens. Immunohistochemistry was applied with the avidin-biotin-peroxidase method and commercially available monoclonal antibodies raised against prostate-specific antigen (PSA) and prostate-specific acid phosphatase (PSAP).

RESULTS

All specimens showed clear microscopic identification of these glands except for Cowper's glands, which were not found in most of the surgical cystoprostatourethrectomy specimens but were found coincidentally in one. Localization of the prostate-specific markers PSA and PSAP was demonstrated for the first time in three Cowper's glands, but they were a consistent finding in Littre's and Morgagni's glands when immunohistochemical identification was performed in a systematic fashion.

CONCLUSIONS

PSA and PSAP are mostly produced by prostatic tissue, but not exclusively. These findings may have an impact on the specificity and sensitivity of PSA serum levels after radical prostatectomy because they support the hypothesis of extraprostatic sources of PSA.