Cryptococcus neoformans ( C. neoformans) is a ubiquitous encapsulated, obligate anaerobe, a dimorphic fungus that can be pathogenic in humans. C. neoformans infections arise primarily in immunocompromised individuals, such as human immunodeficiency virus (HIV) patients, as well as those who use inhaled corticosteroids regularly. Due to the wide variety of clinical findings associated with C. neoformans, infection within the head and neck is occasionally misdiagnosed as malignancy due to its protean manifestation. In this report, we describe the case of a C. neoformans infection resulting in an initial misdiagnosis due to an overlying laryngeal squamous cell proliferation mimicking laryngeal squamous cell carcinoma (SCC). This case is intended to provide further evidence for inhaled corticosteroid use predisposing patients to fungal infections, as well as to provide insight into the possible mechanism resulting in the initial diagnosis of malignancy. A review of recent literature is also discussed.

A 69-year-old woman presented with an 18-24 month history of a lump on her left buttock. She noticed that it had been enlarging over the previous several months and that it was becoming darker in color. She had no significant associated symptoms or past medical history.On examination, there was a lesion of her left buttock measuring approximately 10 cm in diameter. It was firm, mobile, and hot. There was a purple hue to the skin suggesting a vascular tumor with impending skin breakdown. The remainder of the examination, including bimanual exam, rectal exam and examination of the inguinal regions, was normal.A pre-operative ultrasound revealed a mass of mixed echogenicity, with prominent vasularity. Margins were well defined though lobulated. The lesion appeared to extend into the subcutaneous tissues, but not to penetrate the fascial aspect of the gluteus maximus muscle layer.The patient proceeded to the operating room for a wide local en-bloc resection including superficial gluteal fascial resection. Primary closure with skin advancement was possible. Subsequent pathologic examination concluded that the lesion was in fact a Merkel cell carcinoma (Fig. 1). Of note, immunohistochemical stains were positive for CK20 in a paranuclear dot pattern. Pancytokeratin and EMA were also positive, while vimentin and chromogranin showed rare positive cells. Stains for the following markers were all negative-CD99, LCA, HMB45, actin, and desmin. Margins were free of tumor involvement. The closest margin was the deep margin which was 0.2 cm from the lesion and included the gluteal fascia.Following multidisciplinary consultation, it was decided that lymphoscintigraphy would be used to evaluate lymph node drainage from the primary tumor site in order to guide adjuvant radiation therapy (Fig. 2). Filtered technetium sulfur colloid was injected in multiple aliquots along the surgical scar. There was prompt tracking to the right inguinal region. Nodes on the left side were not visualized; however, due to technical limitations, the possibility of nodes on the left could not be excluded. Given this pattern, a decision was made to treat the entire potential lymph node basin with radiation therapy, including inguinal, iliac, and femoral nodes bilaterally.The results of the lymphoscintigraphy were used in the planning of the radiation fields (Fig. 3). Phase I of the radiotherapy delivered a total dose of 4,500 mGy (18 mV photons) in 25 fractions to the tumor bed and first

Introduction. Triple negative breast carcinomas are characterized by a lack of hormone receptor and HER2 expression and inconsistent expression of breast-specific immunohistochemical markers. The expression of many site-specific markers in these tumors is largely unknown. The objective of the study was to examine the expression of widely used immunohistochemical markers on a large cohort of triple negative breast cancer. Methods. Sections from tissue microarrays were stained with 47 markers using routine protocols. Most markers were scored using a modified Allred method. ATRX, BAP1, SMAD4, e-cadherin, and beta-catenin were scored as retained or lost. Mammaglobin was considered positive if there was at least moderate intensity staining in any tumor cells. P16 was scored as overexpressed or not overexpressed; p53 was scored as wildtype, overexpressed, null, or cytoplasmic. Results. The cohort consisted of 639 tumors including 601 primary and 32 metastases. Overall, 96% expressed GATA3, mammaglobin, and/or SOX10 while 97% of no special type tumors expressed this panel. Carcinoma of apocrine differentiation demonstrated an AR positive, SOX10 negative, K5 negative/focal immunophenotype. PAX8 (SP348), WT1, Napsin A, and TTF1 (8G7G3/1) were never or rarely expressed while CA9, CDX2, NKX3.1, SATB2 (SATBA410), synaptophysin, and vimentin were variably expressed. Conclusions. Almost all TNBC express at least 1 of the 3 IHC markers: GATA3, mammaglobin, and/or SOX10. Carcinoma of apocrine differentiation is characterized by an AR positive, SOX10 negative, K5 negative or focal immunophenotype. Cautious interpretation of so-called site-specific markers, with knowledge of antibody clones, is required in excluding the diagnosis of triple negative breast cancer.