Circulation 30 E1 Dr S. Mathe, Wishaw

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1 Circulation 30 E1 Dr S. Mathe, Wishaw F, 79 R5 mammographic abnormality. Wide local excision. Metaplastic ductal carcinoma of breast with high grade DCIS

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6 P53

7 Cytokeratin

8 Cytokeratin

9 E1 83 responses received Metaplastic carcinoma ± DCIS 34 Malignant phyllodes tumour + DCIS19 Carcinosarcoma 14 Sarcomatoid carcinoma ± DCIS 5 Carcinoma 3 Malignant myoepithelial lesion 1 Complex sclerosing lesion + DCIS 1

10 E1 83 responses received DCIS + stroma? 2 DCIS micropapillary 1 DCIS + post-radiation angiosarcoma 1 DCIS + fibroadenoma 1 Breast infarct 1 Stromal elements negative for cytokeratins in resection but + in previous biopsy

11 Metaplastic breast carcinoma <1% of invasive breast carcinomas Variable terminology Heterogeneous in differentiation and grade May express cytokeratins, p63 Usually ER, PR negative, Her2+ rarely Often large at presentation Prognosis influenced by grade

12 Metaplastic breast carcinoma See For concise discussion and recent references.

13 Circulation 30 E12 Dr S. Mathe, Wishaw F, 78 Large cystic lesion R breast. Previous biopsy intraductal papilloma. Fleshy mass in brown fluid in cyst. Intracystic papillary carcinoma

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18 Ck 5/6

19 Ck 5/6

20 Ck 5/6 Normal Actin Tumour

21 Progesterone receptor

22 E2 83 responses received Intracystic / encysted carcinoma 72 (+ neuroendocrine differentiation?) 5 Carcinoma 1 Papillary DCIS 3 Intraduct papilloma with DCIS 1

23 E1 83 responses received Intraduct proliferation, suspicious of malignancy 1 Intraductal papillomatous tumour with neuroendocrine diferentiation 1 Carcinoid tumour 1 Skin/salivary type lesion 1 Papilloma 1 Monomorphic adenoma 1

24 Intracystic papillary carcinoma Traditionally regarded as in situ but myoepithelial markers usually negative at periphery Collins LC AJSP Attenuated? Actually low grade invasive papillary carcinomas? At all events, prognosis excellent with adequate local treatment

25 Intracystic papillary carcinoma Grabowski J, Cancer year survival 97% of 427 without invasion 94% of 439 with localized invasion SLNBX justifiable in presence of invasion

26 Case 3 Male 54 Raised red plaques on back and shoulder. Sarcoid? Lymphoma? Punch biopsy performed

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32 CD20

33 CD3

34 CD3

35 Kappa ISH

36 Lambda ISH

37 Secondary Syphilis Diagnosis

38 Answers E3 Syphilis 7 Infective 15 Leishmaniasis 5 not specified 4 Leprosy 2 Atypical Mycobacteria 2 Borrellia 1, viral 1

39 Answers E3 Lymphoma - 45 T cell - MF,LyP, B cell - DLBCL, plasmablastic, myeloma, marginal zone, MALT, lymphoplasmacytic, lymphomatoid granulomatosis Histiocytic

40 Answers E3 Miscellaneous -16 Sarcoid Insect bite reaction Rosai-Dorfman IgG4 sclerosing disease Reactive/benign

41 Secondary Syphilis Syphilis is a rare condition Incidence peaked in UK in late 1990s : 2524 cases (4% reduction) Most cases present at Primary stage Secondary may present to dermatologist

42 Secondary Syphilis (clinical) Multisystem disease within first 2 years of infection Skin involvement may mimic any disease Macular erythematous rash Head,face, trunk, palms,soles, alopecia. Annular, lichenoid, papulomatous, psoriasiform, bullous, pustular, nodular Systemic: pyrexia,lymphadenopathy, hepatitis, uveitis, meningitis

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46 Secondary Syphilis(Pathology) Variable pathology depending on clinical appearance Histology is non-specific. Macular Sparse perivascular lymphohistiocytic,few plasma cells +/- neutrophils Papular Superficial/deep perivascular infiltrate with prominent plasma cells and epidermal changes spongiosis vague granulomas

47 Secondary Syphilis(Pathology Psoriasiform Nodular variant Pseudolymphomatous pattern Dense dermal infiltrate Granulomatous + plasma cells Thick walled blood vessels /endothelial swelling

48 Diagnosis Differential Lymphoma granulomatous reaction related to marginal zone lymphoma Exclude lymphoma light chain assessment Infective Mycobacterium, fungal PAS, ZN, Wade-Fite Warthin-Starry -difficult to interpret due to background staining

49 Diagnosis Clinicopathological correlation Serology

50 Case E4

51 E4 Previously fit medical professor fell ill 3 days after returning from digestive diseases week, Chicago, May 2009 Anorexia, nausea, fever, malaise, weight loss. Giardia? Microbiology negative Day 10 - endoscopy and biopsy by registrar

52 E4 Histology - possible celiac disease TTG antibodies negative. Empirical treatment with metronidazole Day 20 - still unwell. Wt 5kg. Poor gastric emptying, mild chronic dehydration. Biopsy review requested by patient.

53 Patient

54 Normal control

55 Patient

56 Normal control

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60 E4 Possible parasites in vacuoles Wrong for Cryptosporidium Patient informed - further samples to parasitology Prof. Sebastian Lucas suggested Isospora belli Autofluorescent oocysts of Cyclospora cayetanensis in stools (Prof Huw Smith) Septrin - no oocytes in stools after 1 week gradual but complete recovery

61 Cyclosporiasis Diagnosis

62 Infective 52 Coeliac/lymphocytic duodenitis 13 +/- drugs,crohns, T cell lymphoma Tropical Sprue. 8 Chronic duodenitis 1

63 Infective: 52 NOS 12 Bacterial 2 Viral 6 Protozoal 3 Parasites 3 Cryptosporidiosis 14 Microsporidiosis 7 Cyclospora 3 Isopsora 2

64 Cyclospora cayetanensis Apicomplexan parasite Early work in Lima, Peru Fecal/oral spread Food-bourn outbreaks in non-endemic areas Eg raspberries, salads from central America Endemic and sporadic Cayetano Heredia

65 Cyclospora cayetanensis life cycle

66 Cyclospora cayetanensis Ortega and Sanchez Clin Microbiol Rev Van Nhiet at al Hum Pathol