Incidental Finding of Cryptococcus on Prostate Biopsy for Prostate Adenocarcinoma Following Cardiac Transplant: Case Report and Review of the Literature.

BACKGROUND Cryptococcus is the third most common invasive fungal organism in immunocompromised patients, including transplant patients, and usually involves the central nervous system and lungs, with a median time to infection of 25 months. We report a case of Cryptococcus of the prostate gland, found as an incidental finding on prostate biopsy for prostate adenocarcinoma, four months following cardiac transplantation. CASE REPORT A 62-year-old male African-American who had a cardiac transplant four months previously, underwent a six-core prostate biopsy for a two-year history of increasing prostate-specific antigen (PSA) levels, and a recent history of non-specific urinary tract symptoms. A prostatic adenocarcinoma, Gleason grade 4+4=8, was diagnosed on histopathology, and 'foamy' cells were seen in the biopsies. Histochemical stains, including Grocott methenamine silver (GMS), and periodic acid-Schiff (PAS) showed abundant round and oval 5-7 µm diameter fungal elements; mucicarmine highlighted the fungal polysaccharide capsule, diagnostic for Cryptococcus. Cryptococcal antigen detection was made by the latex agglutination test and cultures. We reviewed the literature and found 70 published cases (from 1946-2008) of Cryptococcus of the prostate gland, with only one previous case presenting five years following cardiac transplantation. CONCLUSIONS Fungal infections of the prostate are rare, and occur mainly in immunocompromised patients. We present a unique case of prostatic Cryptococcus found incidentally at four months following cardiac transplantation. This case report highlights the need to consider atypical fungal infection as a differential diagnosis for prostatitis in immunosuppressed patients, including transplant patients.

Metastatic renal cell carcinoma, clear cell type, of the parotid gland: a case report, review of literature, and proposed algorithmic approach to salivary gland clear cell neoplasms in fine-needle aspiration biopsies.

Renal cell carcinoma (RCC), clear cell type, is a commonly encountered metastatic tumor that can present at unusual anatomic sites many years after the primary tumor resection. Noncutaneous metastasis to the parotid gland is unusual; however, a number of cases of parotid RCC metastasis have been reported. Fine-needle aspiration biopsy (FNAB) is regularly utilized during the evaluation of salivary gland lesions, where it has a high sensitivity, specificity, and accuracy; however, the identification and definitive diagnosis of primary and metastatic clear cell neoplasms is a potential diagnostic pitfall for salivary gland FNAB. Here, we describe a case of RCC, clear cell type, metastatic to the parotid gland that was diagnosed entirely from FNAB cell block material, which is the first such reported case to our knowledge. We review the literature for cases of parotid RCC metastasis and focus on the utility of FNAB for synchronous versus metachronous presentations. Finally, we evaluate the differential diagnosis of clear cell parotid lesions, including ancillary histologic studies, and propose an algorithmic approach to clear cell neoplasms of the salivary gland.

Metaplastic carcinomas of the breast: diagnostic challenges and new translational insights.

Comprising less than 1% of invasive carcinomas of the breast, metaplastic carcinomas are a heterogeneous group of malignant tumors in which part or all of the carcinomatous epithelium is transformed into a nonglandular (metaplastic) growth process. Metaplastic carcinomas with a low-grade spindle cell component resembling fibromatosis, as in our present case, are worthy of particular note because they are infrequent, difficult to recognize, and have a high risk of local recurrence. The differential diagnosis of metaplastic carcinomas depends on the degree of atypia observed in the tumor and includes exuberant scars, fibromatosis, nodular fasciitis, myofibroblastomas, pseudoangiomatous stromal hyperplasia, acute and chronic abscess with fat necrosis, malignant phyllodes tumor, and primary or metastatic sarcoma. Limited studies done on the molecular pathology of metaplastic carcinomas show that activation of the Wnt signaling pathway is common in these tumors and that approximately 70% of metaplastic carcinomas show EGFR gene amplification and overexpression. This may have treatment implications because they may lead to targeted treatment for patients with metaplastic carcinomas.