Journal of Postgraduate Medicine
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CASE REPORT
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Year : 2004  |  Volume : 50  |  Issue : 3  |  Page : 202-204  

Lateral cervical cyst with unsuspected metastasis from an occult tonsillar carcinoma

G Pavlakis1, GH Sakorafas2, George K Anagnostopoulos2, K Grigoriadis3, G Symeonidis2,  
1 Department of Oncology, 251 Hellenic Air Force and Veterans General Hospital, Athens, Greece
2 Department of Surgery, 251 Hellenic Air Force and Veterans General Hospital, Athens, Greece
3 Department of Pathology, 251 Hellenic Air Force and Veterans General Hospital, Athens, Greece

Correspondence Address:
George K Anagnostopoulos
Department of Surgery, 251 Hellenic Air Force and Veterans General Hospital, Athens
Greece

Abstract

Lateral cervical cysts containing squamous cell carcinoma is a diagnostic and therapeutic challenge for the clinician since they usually represent a cystic metastasis from an occult carcinoma. Various imaging modalities or even blind biopsies will help identify the primary tumour. If the primary tumour is identified, an appropriate treatment decision can be made that incorporates both the primary tumour and the cervical node. If the primary remains unidentified, the neck is treated with a modified or radical neck dissection, depending on the extent of metastatic disease, and radiation therapy is administered to Waldeyer’s ring and both necks. We present in this paper, a case with a large cervical cyst where histology showed the presence of a poorly differentiated squamous cell carcinoma in the wall of the cyst. A diagnostic evaluation of the patient was negative. Blind biopsies of the right tonsil revealed occult squamous cell carcinoma. The patient was treated by combined chemo/radiotherapy and she is doing well nine months following excision of the mass. The relevant literature is briefly reviewed.



How to cite this article:
Pavlakis G, Sakorafas G H, Anagnostopoulos GK, Grigoriadis K, Symeonidis G. Lateral cervical cyst with unsuspected metastasis from an occult tonsillar carcinoma.J Postgrad Med 2004;50:202-204


How to cite this URL:
Pavlakis G, Sakorafas G H, Anagnostopoulos GK, Grigoriadis K, Symeonidis G. Lateral cervical cyst with unsuspected metastasis from an occult tonsillar carcinoma. J Postgrad Med [serial online] 2004 [cited 2023 Jan 30 ];50:202-204
Available from: https://www.jpgmonline.com/text.asp?2004/50/3/202/12575


Full Text

Lateral cysts of the neck containing malignant epithelium represent a diagnostic and therapeutic challenge for the clinician. Much attention in the literature has recently been focused on the frequent relationship between a solitary cystic cervical metastasis and an occult primary tumour in the tonsil or tongue base. It has been suggested that metastases from primary carcinomas in these sites may have a particular tendency to undergo cyst formation. Despite rigorous investigation, however, a high proportion of primary sites still remain occult.[1] The early detection of a cystic metastasis is of crucial importance for the patient to receive the appropriate treatment with the minimum delay. We present a patient with a lateral cervical cyst, which contained unsuspected metastasis from an occult tonsillar carcinoma; the relevant literature is briefly reviewed.

 Case History



A 45-year-old woman presented with a tender, moveable, firm mass in the right lateral neck, which had been present for the last 3 months. Ultrasonography and computed tomography showed a cystic mass (diameter, 3 cm) just behind the right submandibular salivary gland and anterior to the jugular vein, with smooth margins. The cyst was excised with the presumed diagnosis of branchial cyst. Histology showed the presence of a poorly differentiated squamous cell carcinoma [Figure:1], which was considered as having developed in the epithelium of a branchial cyst. Diagnostic work-up included endoscopy of the upper aero-digestive tract, and head / neck Magnetic Resonance Imaging (MRI) was negative for other localization(s) of the disease. Despite this negative clinical and laboratory investigation and in order to exclude a primary in the right tonsil, blind biopsies of the right tonsil were performed which revealed occult squamous cell carcinoma [Figure:2]. The patient underwent combined radiotherapy (6,000 cGy) and chemotherapy (Cisplatin + Navelbine). She is doing well nine months after excision of the mass.

 Discussion



Most lateral cervical cysts in adult patients are benign lesions. Cystic masses in the lateral neck lined by malignant epithelium usually represent a cystic metastasis from an occult carcinoma. Another possibility is that these masses result from malignant transformation of (or metastasis to) branchial cleft cysts (the so-called malignant branchioma).[1] However, squamous cell carcinoma arising from a branchial cleft cyst is a very rare entity and many authors have expressed strong doubt about the existence of branchiogenic squamous cell carcinoma.[2],[3] The mechanism of cyst formation in cystic metastases remains unknown. Cystic degeneration with a central collection of cellular debris has been observed in the majority of cystic metastases.[4] Cyst formation is often observed in primary squamous cell carcinoma of Waldeyer's ring, and it has been proposed as an intrinsic characteristic of keratinocytes from these sites.[4]

About 10 % of patients with lateral cervical cysts contain foci of squamous cell carcinoma.[4] However, the incidence of malignancy is significantly higher in patients more than 40 years of age (about 25 %, p 40 years) - with cervical cysts should undergo FNA.[7] The clinician, however, should be aware that a negative FNA result may be misleading, because of hypocellularity of the cyst fluid.

Unfortunately, despite the availability of sophisticated diagnostic methods, these are frequently unreliable to exclude the presence of malignancy within a cystic mass in the neck.[6] Therefore, cyst biopsy should be performed to exclude malignancy, especially in patients more than 40 years of age. Frozen section at the time of cyst excision may be performed.[1]

If a squamous cell carcinoma is diagnosed within the cyst, the most probable primary can be expected in the nasopharynx, tonsil, or tongue base (Waldeyer's ring). These patients should undergo careful clinical examination with panendoscopy. In the absence of overt anomalies, a CT or MRI of the head and neck is a useful diagnostic step.[8] Positron emission tomography (PET) is a reliable method to detect tumours that may be considered in the preoperative evaluation of a patient with biopsy-proven head and neck cancer.[9] The patient should also be scheduled for an exam under anaesthesia in the operating room for the purpose of obtaining biopsies. However, how to perform these biopsies remains debatable. One approach advocates "blind" biopsies of the ipsilateral nasopharynx, tonsil, base of tongue, pyriform sinus, and even postcricoid area. Alternatively, only sites of mucosal abnormalities, however minor, are biopsied. If the primary tumour is identified, an appropriate treatment decision can be made that incorporates both the primary tumour and the cervical node. An ipsilateral tonsillectomy biopsy is also recommended.[8]

If the primary remains unidentified, the neck is treated with a modified or radical neck dissection, depending on the extent of metastatic disease, and radiation therapy is administered to Waldeyer's ring and neck. Before proceeding to neck dissection, a "second-look" panendoscopy and additional biopsies should be considered.[1] It should be noted that these cystic metastases are usually solitary, and if additional surgery in the form of a neck dissection is performed (only for metastatic foci that are greater than 3 cm or in multiple lymph nodes, it is recommended that the dissection be as limited and conservative as is feasible).[10] External beam and/or interstitial radiation have been used for the curative treatment of carcinoma of the oropharynx.[10] Cancer of the tonsillar fossa responds best to radiotherapy. Surgical excision of all but the smallest palatal and tonsillar lesions is generally inadequate. If the primary is proven to have arisen in the nasopharynx, first-line therapy would consist of radiotherapy of the primary tumour and draining lymph nodes. Surgical resection, even of small tumours, is of limited benefit because of the associated high morbidity.[10]

References

1Flanagan PM, Roland HJ, Jones AS. Cervical node metastases presenting with features of branchial cysts. J Laryngol Otol 1994;108:1068-71.
2Thompson LD, Heffner DK. The clinical importance of cystic squamous cell carcinomas of the neck. Cancer 1998;82:944-56.
3Swoboda H, Braun O. The branchiogenic cyst in an oncologic context. Laryngorhinootologie 1989;68:337-41.
4Regauer S, Mannweiler S, Anderhuber W, Gotschuli A, Berghold A, Schachenreiter J, et al. Cystic lymph node metastases of squamous cell carcinoma of Waldayer's ring origin. Br J Cancer 1999;79:1437-42.
5Shingaki S, Suzuki I, Nakajima T, Hayashi T, Nakayama H, Nakamura M. Computed tomographic evaluation of lymph node metastasis in head and neck carcinomas. J Craniomaxillofac Surg 1995;23:233-7.
6Pisharodi LR. False-negative diagnosis in FNA of squamous-cell carcinoma of head and neck. Diagn Cytopathol 1997;17:70-3.
7Sheahan P, O'leary G, Lee G, Fitzgibbon J. Cystic cervical metastases: Incidence and diagnosis using fine needle aspiration biopsy. Otolaryngol Head Neck Surg 2002;127:294-8.
8Milas M. Carcinoma of the Head and Neck. In: Feig BW, Berger DH, Fuhrman GM, editors. The M.D. Anderson Surgical Oncology Handbook, 2nd Ed. Lippincott Williams & Wilkins Ed, Philadelphia, 1999. p. 93-108.
9Sigg MB, Steinert H, Gratz K, Hugenin P, Stoeckli S, Eyrich GK. Staging of head and neck tumors: [18F] fluorodeoxyglucose positron emission tomography compared with physical examination and conventional imaging modalities. J Oral Maxillofac Surg 2003;61:1022-9.
10Raghavan U, Bradley PJ. Management of cystic cervical metastasis. Curr Opin Otolaryngol Head Neck Surg 2003;11:124-8.

 
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