Introduction

Prostate cancer (PCa) remains one of the most prevalent malignancies among men worldwide and a leading cause of cancer-related mortality. While most prostate cancers are acinar adenocarcinomas, prostatic ductal adenocarcinoma (PDA) represents a distinct and aggressive histologic subtype. It is important to distinguish PDA from intraductal carcinoma, a pre-invasive lesion often co-existing with high-grade acinar carcinoma, and from aggressive-variant prostate cancer, characterized by rapid progression and resistance to androgen receptor–targeted therapies. Understanding these less common histologic patterns has evolved in recent years, and as PDA is associated with poor prognosis compared with PAA, accurate recognition of its hallmarks is paramount for clinical decision-making [1]. Ductal histologic patterns are acknowledged in contemporary pathological and clinical consensus recommendations due to their association with aggressive disease characteristics and unfavorable oncologic outcomes. Consequently, the presence of ductal differentiation is generally considered a contraindication to active surveillance strategies in routine clinical practice [2].

In routine histopathological assessment, International Society of Urological Pathology (ISUP) Grade Group upgrading and pathological upstaging are frequently observed at final radical prostatectomy (RP). However, dedicated data on PDA are limited [3]. Clinically, PDA presents at more advanced stages and is associated with higher ISUP GG, increased extraprostatic extension, seminal vesicle invasion, and positive surgical margins following RP [4, 5]. Notably, PDA may exhibit lower serum prostate-specific antigen (PSA) levels despite aggressive nature, potentially leading to underdiagnosis [6]. Overall survival (OS) for metastatic PDA is 72% at 5 years with a median of 77 months [7, 8], and PDA is linked to higher disease-specific mortality and metastasis to atypical sites such as lungs, brain, and testis [7–9]. Even a small ductal component on initial biopsy associates with higher risk of biochemical recurrence (BCR) and early metastatic progression [5, 10].

Given its distinct features, accurate PDA identification is crucial for guiding treatment decisions. This study aims to analyse oncologic outcomes, particularly therapeutic courses, including respective systemic and local treatments for PDA.