Incidence of occult thyroid carcinoma metastases in lateral cervical cysts

Metastatic Papillary Thyroid Microcarcinoma Presenting as a Branchial Cleft Cyst in Young Female

Though aetiology of lateral neck masses is complex, branchial cleft cyst is the second most common congenital lesions of the neck next only to thyroglossal duct cysts. Rarely ectopic thyroid tissue within a branchial cleft cyst may develop into primary papillary carcinoma, and even more rarely it may harbour metastases of primary thyroid papillary carcinoma. We report a rare case of lateral cystic neck mass in a 24-year-old female patient diagnosed as metastatic PTC. The patient was diagnosed after she underwent surgical excision of branchial cleft cyst. Later prospectively the patient underwent total thyroidectomy which revealed papillary thyroid micro invasive carcinoma.

Whispers in the Neck: Unmasking Cystic Metastases From Hidden Papillary Thyroid Carcinoma

Papillary thyroid carcinoma is the most common thyroid malignancy and it frequently causes lymph node metastases. Approximately 50% of patients with papillary thyroid carcinoma have cervical lymph node metastases at the time of their initial presentation. Here we report a case of a young female who presented with a benign-appearing cystic neck mass, which was revealed to be metastases from occult papillary thyroid carcinoma. Completion thyroidectomy and neck dissection were done after the diagnosis of papillary thyroid carcinoma.

Some uncommon cystic lesions in the anterior head and neck region: Pitfalls to be avoided on cytology

Cystic lesions of the anterior head and neck region are a challenging and frequent finding on cytological smears. The scant amount of cellular material in cystic slides poses the greatest difficulty to interpretation, so that frequently they are diagnosed as inadequate or with minimal cellular component. Despite the majority of cystic lesions being benign, a minor portion consist of malignant cystic entities. In these latter cases, the evidence of very scant malignant cells can be misdiagnosed and/or underestimated, leading to a false negative diagnosis. Many papers have already described and detailed the range of possible benign and malignant cystic lesions in head and neck. In the current review we have focused on the less common entities that often lead to serious misinterpretation.

Diagnostic strategy of fine needle aspiration cytology of cystic cervical lymph node metastasis from papillary thyroid carcinoma

BACKGROUND

Cystic cervical lymph node metastasis from papillary thyroid carcinoma (CLMPTC) initially presents as cervical cystic lesions, which are often underdiagnosed as other cystic cervical lesions. There is no comprehensive diagnostic strategy of fine needle aspiration (FNA) cytology for CLMPTC.

METHODS

The clinical and FNA cytomorphology data of 87 patients with CLMPTC were analyzed. Thyroglobulin (TG) immunostaining was performed in 40 cases; BRAF V600E mutation was evaluated in 42 cases; the thyroglobulin (Tg) levels of aspiration fluids were assessed in 46 cases. Correspondingly, the data of 42 cases with solid cervical lymph node metastasis from papillary thyroid carcinoma (SLMPTC) and 32 cases with other cystic cervical lesions were collected as controls.

RESULTS

Compared with SLMPTC, CLMPTC has less classical PTC cytomorphology characteristics-for example, nuclear crowding/overlapping, nuclear irregular contours, etc. (p < .05). Additionally, micropapillary architecture and histiocyte-like tumor cells were more often observed in CLMPTC than in SLMPTC (p < .01). The positive rate of TG immunocytochemistry in CLMPTC was 100% (40/40). The positive rate of BRAF V600E mutation in CLMPTC was 81.0% (34/42), which was higher than that in SLMPTC (64.3%; 27/42) (p = .087). The Tg levels in aspiration fluids were significantly higher in CLMPTC (all>500 μg/L) than in other cervical cystic lesions (range: 2.9 μg/L to 40.1 μg/L) (p < .01).

CONCLUSION

To reduce underdiagnoses of CLMPTC, a reasonable diagnostic strategy, as summarized in this study is needed: according to the number of tumor cells, choosing immunocytochemistry (TG) and/or thyroglobulin in fine needle aspirates testing as auxiliary diagnostic measures.

Lateral neck cyst as initial presentation of thyroid malignancy

INTRODUCTION

A mass in the lateral aspect of the neck may cause a diagnostic dilemma for the clinician. Cystic lateral neck masses in young adults are most often benign as the most frequent cause is a branchial cleft cyst. However, this may be a pitfall as such a cystic mass can be a first presentation of occult malignancy.

CASE REPORT

Here we present a case of a 25-year-old female patient with a cystic mass in the right lateral neck. This lesion was eventually diagnosed as cystic degeneration within a metastatic invaded lymph node from papillary thyroid carcinoma. Total thyroidectomy with right central and lateral lymphadenectomy was performed.

DISCUSSION

The correct diagnosis risked to be missed as the initial appearance was mimicking a benign branchial cleft cyst.

CONCLUSION

We aimed to highlight the possibility of an underlying unsuspected thyroid carcinoma in young patients initially presenting with a neck mass mimicking the more common benign branchial cleft cyst. We underline the necessity of thoroughly examining suspected cysts as adequate diagnosis should avoid delayed treatment as it directly affects the tumor stage and prognosis.

Metastatic Squamous Cell Carcinoma to the Cervical Lymph Nodes From an Unknown Primary Cancer: Management in the HPV Era

Background

Patients with metastases in the lymph nodes of the neck and no obvious primary tumor, neck cancer with unknown primary (NCUP), represent a management challenge. A majority of patients have metastatic squamous cell carcinoma (SCC), although other histologies do occur.

Methods

We comprehensively reviewed the literature, compared available guidelines, and conferred with an international team of experts.

Results

Positron emission tomography-computed tomography (PET-CT) and fine needle aspiration (FNA) under ultrasound guidance increase accuracy of diagnosis. Immunohistochemistry (IHC), determination of human papilloma virus (HPV) status, by p16 staining or by in situ hybridization (ISH), and next-generation gene sequencing can guide us regarding probable primary sites and tumor biology. Narrow Band Imaging (NBI) has been introduced for the early detection of subtle mucosal lesions. Direct laryngoscopy (DL) and tonsillectomy have long been procedures used in the search for a primary site. More recently, TransOral Robotic Surgery (TORS) or Transoral LASER Microsurgery (TLM) have been introduced for lingual tonsillectomy.

Conclusions

New technologies have been developed which can better detect, diagnose, and treat occult primary tumors. Decisions regarding therapy are based on the primary tumor site (if discovered) and N stage. Options include neck dissection with or without postoperative adjuvant therapy, primary irradiation, or combined chemotherapy with irradiation. The preferred treatment of patients whose primary remains unidentified is controversial.

Cutaneous ciliated cyst on the anterior neck in young women: A case report

BACKGROUND

A cutaneous ciliated cyst (CCC) is a rare, benign tumor in young female adults, which is usually found on the lower extremities.

CASE SUMMARY

We found an uncommon location of CCC in the anterolateral cervical area and reviewed the literature. A 20-year-old female complained of a well-defined, painless, palpable mass that started several years ago. The mass was tense and movable and located at the anterolateral aspect of the neck. Imaging showed a non-enhancing round mass. Surgical excision biopsy was performed, and the cystic mass was revealed to be a CCC.

CONCLUSION

The rare location of CCC can be found in anterior neck area, which should be another diagnostic option for mass on anterior neck.

Papillary Thyroid Carcinoma Spreading into Branchial Cleft Cyst

Papillary thyroid carcinoma (PTC) is the most common type of thyroid malignancy and it can cause cystic metastasis to the neck region. Branchial cleft cysts (BCCs) are among the most commonly encountered congenital cystic neck masses. PTC metastasis into BCC has been rarely reported in the literature. In this case report we report a patient presenting with a cystic neck mass for which fine needle aspiration biopsy was reported as benign cytology and eventually was diagnosed as PTC metastasis to the BCC. The importance of investigating the thyroglobulin levels in fine needle aspiration materials of cystic neck masses for early diagnosis of possible PTC metastasis is specifically emphasized.

Radiologic Features of Papillary Carcinoma in the Second Branchial Cleft Cyst

Clinically, it may be very difficult to differentiate between benign branchial cleft cyst (BCC) and malignant BCC with papillary carcinoma preoperatively. Radiological features were reviewed retrospectively between benign BCC and malignant BCC with papillary carcinoma using computed tomography (CT) and magnetic resonance (MR) images. All patients had only a mass on the right upper lateral neck without lesion in the thyroid gland. Two patients had a mass in the upper medial part of BCC on CT images and one patient showed a well-circumscribed mass in the upper portion of BCC on MR image. Two patients received BCC removal only and one patient underwent total thyroidectomy including removal of BCC. As results, most cases of papillary carcinoma in the BCC were detected incidentally after surgical resection of BCC. However, we can differentiate between benign BCC and malignant BCC with primary papillary carcinoma by carefully reviewing radiologic images before surgery.

Cystic masses of the lateral neck: Diagnostic value comparison between fine-needle aspiration, core-needle biopsy, and frozen section

BACKGROUND

The usefulness of fine-needle aspiration (FNA), core-needle biopsy (CNB), and frozen section (FS) for assessing lateral cystic neck masses (LCNM) remains unclear.

METHODS

A retrospective review of patients presenting with a LCNM was undertaken.

RESULTS

In total, 135 patients were included. FNA had a lower sensitivity then CNB (59% vs 83%; P = .036) and FS (59% vs 93%; P = .01). FS had a better negative predictive value (NPV) when compared to FNA (92% vs 40%; P < .001) and CNB (92% vs 50%; P = .062). Positive predictive values (PPV) and sensitivities were similar among all groups.

CONCLUSION

Given its adequate PPV (92%), FNA should be used initially on LCNM. Because of its high sensitivity, CNB should be considered if FNA is not diagnostic of malignancy. FS should always follow a CNB indicative of malignancy, because of low NPV. A diagnosis of malignancy on FNA, CNB, or FS strongly indicates presence of malignancy.

Ultrasonography, Cytology, and Thyroglobulin Measurement Results of Cervical Nodal Metastasis in Patients With Unclear Papillary Thyroid Carcinoma

Objective: This study aimed to evaluate the ultrasonography (US), cytology, and thyroglobulin (Tg) measurement results of nodal metastasis in patients showing unclear US or cytology results of primary papillary thyroid carcinoma (PTC). Methods: From January 2016 to December 2018, 179 patients underwent US-guided fine-needle aspiration (FNA) to diagnose lymphadenopathy in the neck. Among them, 36 patients underwent subsequent total thyroidectomy and nodal dissection, and cervical lymph node (LN) metastasis from PTC was confirmed. However, two patients were excluded because of mismatch between the US and pathological findings of LNs. US images and cytological slides for metastatic LNs were retrospectively analyzed, and serum and FNA Tg levels for metastatic LNs were investigated using data from the electric medical records. Primary PTC patients with suspicious results on both US and cytology were classified as the clear group, and the remaining patients were classified as the unclear group. Results: Of the 34 patients, 24 had clear results of primary PTC on both US and cytology (clear group), whereas 10 had unclear results of primary PTC on US or cytology (unclear group). Of the 10 patients in the unclear group, seven had suspicious nodal metastasis from PTC on cytology after US-guided FNA of the cervical LN, and the remaining three had negative cytology but a positive Tg measurement. Metastatic LNs with cystic change tended to show a positive Tg measurement but negative cytology. Conclusions: The combination of US, cytology, and Tg measurement is necessary for diagnosing nodal metastasis from PTC. In cases with unclear primary PTC on US or cytology, the detection of nodal metastasis may be helpful for assessing primary PTC.

The incidence of malignancy in clinically benign cystic lesions of the lateral neck: our experience and proposed diagnostic algorithm

AIM

Solitary cystic masses of the lateral neck in an adult patient can pose a diagnostic dilemma. Malignancy must be ruled out since metastases arising from H&N cancers may mimic the presentation of benign cystic masses. Only a small number of studies have investigated the diagnostic management and malignancy rate of clinically benign solitary cervical cystic lesions. There are no established guidelines for the diagnostic evaluation.

METHODS

Retrospective review of the clinical, cytological, radiological, and pathological records of all adult patients (> 18 years) operated on for second branchial cleft cysts (BrCC) between 1/2008-2010/2016. Patients with apparent primary H&N malignancy, history of H&N cancer or irradiation, preoperative fine needle aspiration (FNA) of highly suggestive or confirmed malignancy, missing pertinent data, or age less than 18 years were excluded from analysis.

RESULTS

28 patients were diagnosed as having BrCC. The diagnosis was based on clinical findings, FNA cytology, and typical sonographic features. The histologic analysis determined an overall rate of malignancy of 10.7% (3/28): two patients had metastatic papillary thyroid carcinoma, and one patient had metastatic tonsillar squamous cell carcinoma. Purely cystic features on pre-operative ultrasound was the only significant predictor for true BrCC on final histology (p = .02).

CONCLUSIONS

Occult malignancy is not rare among adult patients presenting with a solitary cystic mass of the lateral neck. A diagnostic algorithm is proposed. Further studies are needed to establish the appropriate workup and management of an adult patient presenting with a solitary cystic mass of the lateral neck.

Clinical Practice Guideline: Evaluation of the Neck Mass in Adults

Objective Neck masses are common in adults, but often the underlying etiology is not easily identifiable. While infections cause most of the neck masses in children, most persistent neck masses in adults are neoplasms. Malignant neoplasms far exceed any other etiology of adult neck mass. Importantly, an asymptomatic neck mass may be the initial or only clinically apparent manifestation of head and neck cancer, such as squamous cell carcinoma (HNSCC), lymphoma, thyroid, or salivary gland cancer. Evidence suggests that a neck mass in the adult patient should be considered malignant until proven otherwise. Timely diagnosis of a neck mass due to metastatic HNSCC is paramount because delayed diagnosis directly affects tumor stage and worsens prognosis. Unfortunately, despite substantial advances in testing modalities over the last few decades, diagnostic delays are common. Currently, there is only 1 evidence-based clinical practice guideline to assist clinicians in evaluating an adult with a neck mass. Additionally, much of the available information is fragmented, disorganized, or focused on specific etiologies. In addition, although there is literature related to the diagnostic accuracy of individual tests, there is little guidance about rational sequencing of tests in the course of clinical care. This guideline strives to bring a coherent, evidence-based, multidisciplinary perspective to the evaluation of the neck mass with the intention to facilitate prompt diagnosis and enhance patient outcomes. Purpose The primary purpose of this guideline is to promote the efficient, effective, and accurate diagnostic workup of neck masses to ensure that adults with potentially malignant disease receive prompt diagnosis and intervention to optimize outcomes. Specific goals include reducing delays in diagnosis of HNSCC; promoting appropriate testing, including imaging, pathologic evaluation, and empiric medical therapies; reducing inappropriate testing; and promoting appropriate physical examination when cancer is suspected. The target patient for this guideline is anyone ≥18 years old with a neck mass. The target clinician for this guideline is anyone who may be the first clinician whom a patient with a neck mass encounters. This includes clinicians in primary care, dentistry, and emergency medicine, as well as pathologists and radiologists who have a role in diagnosing neck masses. This guideline does not apply to children. This guideline addresses the initial broad differential diagnosis of a neck mass in an adult. However, the intention is only to assist the clinician with a basic understanding of the broad array of possible entities. The intention is not to direct management of a neck mass known to originate from thyroid, salivary gland, mandibular, or dental pathology as management recommendations for these etiologies already exist. This guideline also does not address the subsequent management of specific pathologic entities, as treatment recommendations for benign and malignant neck masses can be found elsewhere. Instead, this guideline is restricted to addressing the appropriate work-up of an adult patient with a neck mass that may be malignant in order to expedite diagnosis and referral to a head and neck cancer specialist. The Guideline Development Group sought to craft a set of actionable statements relevant to diagnostic decisions made by a clinician in the workup of an adult patient with a neck mass. Furthermore, where possible, the Guideline Development Group incorporated evidence to promote high-quality and cost-effective care. Action Statements The development group made a strong recommendation that clinicians should order a neck computed tomography (or magnetic resonance imaging) with contrast for patients with a neck mass deemed at increased risk for malignancy. The development group made the following recommendations: (1) Clinicians should identify patients with a neck mass who are at increased risk for malignancy because the patient lacks a history of infectious etiology and the mass has been present for ≥2 weeks without significant fluctuation or the mass is of uncertain duration. (2) Clinicians should identify patients with a neck mass who are at increased risk for malignancy based on ≥1 of these physical examination characteristics: fixation to adjacent tissues, firm consistency, size >1.5 cm, or ulceration of overlying skin. (3) Clinicians should conduct an initial history and physical examination for patients with a neck mass to identify those with other suspicious findings that represent an increased risk for malignancy. (4) For patients with a neck mass who are not at increased risk for malignancy, clinicians or their designees should advise patients of criteria that would trigger the need for additional evaluation. Clinicians or their designees should also document a plan for follow-up to assess resolution or final diagnosis. (5) For patients with a neck mass who are deemed at increased risk for malignancy, clinicians or their designees should explain to the patient the significance of being at increased risk and explain any recommended diagnostic tests. (6) Clinicians should perform, or refer the patient to a clinician who can perform, a targeted physical examination (including visualizing the mucosa of the larynx, base of tongue, and pharynx) for patients with a neck mass deemed at increased risk for malignancy. (7) Clinicians should perform fine-needle aspiration (FNA) instead of open biopsy, or refer the patient to someone who can perform FNA, for patients with a neck mass deemed at increased risk for malignancy when the diagnosis of the neck mass remains uncertain. (8) For patients with a neck mass deemed at increased risk for malignancy, clinicians should continue evaluation of patients with a cystic neck mass, as determined by FNA or imaging studies, until a diagnosis is obtained and should not assume that the mass is benign. (9) Clinicians should obtain additional ancillary tests based on the patient's history and physical examination when a patient with a neck mass is deemed at increased risk for malignancy who does not have a diagnosis after FNA and imaging. (10) Clinicians should recommend evaluation of the upper aerodigestive tract under anesthesia, before open biopsy, for patients with a neck mass deemed at increased risk for malignancy and without a diagnosis or primary site identified with FNA, imaging, and/or ancillary tests. The development group recommended against clinicians routinely prescribing antibiotic therapy for patients with a neck mass unless there are signs and symptoms of bacterial infection.

Papillary Thyroid Carcinoma Cervical Lymph Node Metastasis with Cystic Change Differentiated from Congenital Cystic Lesions with the Assistance of Immunohistochemistry: A Case Study

Diagnosis of cystic papillary thyroid carcinoma (PTC) lymph node metastasis at head neck region can be a challenge in the absence of known PTC history. The congenital cystic lesions of head neck, especially thyroglossal duct cyst (TGDC) and branchial cleft cyst (BCC), are major differential diagnoses in this clinicopathological scenario. The location of cyst and morphology of lining epithelium are critical clues for reaching correct diagnosis. However it is not uncommon that the flattened bland epithelial lining can be seen in both cystic metastases and congenital cystic lesions. Given that Pax8 and TTF-1 are common markers in thyroid follicular epithelium; we applied immunohistochemical stains of those two markers on aforementioned cystic lesions. Here we reported a case of cystic PTC metastasis to lymph node without prior malignancy history and cases of TGDC and BCC. Both Pax8 and TTF-1 stainings highlighted the cyst lining in PTC metastatic lymph node, while they were negative in the lining of TGDC and BCC. Collectively, Pax8 and TTF-1 immunohistochemical studies are very helpful tools for making correct diagnosis of head neck cystic lesions in the challenging clinical cases.

Papillary Thyroid Microcarcinoma with a Large Cystic Dilated Lymph Node Metastasis to the Neck Mimicking a Branchial Cleft Cyst: A Potential Pitfall

Lateral cervical cystic mass in a young adult very rarely could be a first sign of an occult thyroid papillary microcarcinoma metastasis. In this paper, we presented a 37-year-old male patient whose preoperative 6 cm left lateral cervical cystic mass was initially diagnosed as branchial cleft cyst, but then the postoperative histopathological examination of the mass was revealed as papillary thyroid carcinoma metastasis. Preoperative fine needle aspiration biopsy was relevant with a branchial cleft cyst. In the left thyroid lobe there were 3 solid nodules with 4, 6, and 12 mm dimensions, respectively. One of the nodules had malignant well-differentiated cells diagnosed after fine needle aspiration biopsy. After total thyroidectomy, histopathologic evaluation of biopsy material's showed papillary thyroid microcarcinomas. This case indicates that especially in a young adult lateral cervical cystic mass should be carefully considered preoperatively for the possibility of metastatic occult thyroid carcinoma, especially for papillary carcinoma in differential diagnosis, and evaluation of the thyroid gland should be taken into account.

Papillary carcinoma of thyroid with an unusual presentation

Papillary thyroid carcinoma is well known for its low malignant potential and good prognosis. The outcome can be fatal in patients with low compliance and delayed treatment. Recent advances in ultrasonographic screening and US guided fine needle aspiration biopsy has facilitated early diagnosis of papillary thyroid carcinomas. This epithelial thyroid tumour accounts for more than 80 % of all thyroid tumours. An occult primary carcinoma of thyroid presenting as lymphangioma has been reported rarely. We present a case of a 40-year-old female patient with huge cystic midline swelling on the right side of the neck mimicking lymphangioma on USG. MRI neck showed a cystic mass causing displacement of the trachea and arising from Rt lobe of thyroid gland. Hemithyroidectomy was carried out and histopathology revealed papillary carcinoma. In patients with neck swellings presenting as huge cystic mass the differential diagnosis of Intra cystic variant of papillary carcinoma thyroid and metastatic thyroid papillary carcinoma must always be considered prior to planning surgery.

[Cysts in the posterior triangle of the neck in adults]

Cystic lesions of the posterior triangle are a pathologic entity whose diagnosis is made in the first two years of life. Its presentation in adulthood is an incidental finding and the differential diagnosis includes cystic lymphangioma, lymphatic metastasis of thyroid cancer and branchial cyst. Often with the finding of a cervical lump, FNA is made before diagnostic imaging is performed, however, this procedure is not always advisable. We reviewed the cases of patients who came last year to our department with a cystic mass in this location and correlating the imaging findings with pathologic specimen. We show characteristic findings of these lesions in order to make an early diagnosis and thus to get the approach and treatment appropriate of adult patients with a cystic lesion in the posterior cervical triangle.

Measurement of fine-needle aspiration thyroglobulin levels increases the detection of metastatic papillary thyroid carcinoma in cystic neck lesions

BACKGROUND

Patients with previously resected papillary thyroid carcinoma (PTC) are monitored for disease recurrence/metastasis by ultrasound surveillance and fine-needle aspiration (FNA) cytology. However, accurate diagnosis in lesions with cystic degeneration may be difficult due to scant cellularity. In the current study, the authors evaluated thyroglobulin in FNA (Tg-FNA) for detecting metastatic and/or recurrent PTC in patients with cystic neck lesions after thyroidectomy.

METHODS

The pathology records were retrospectively searched for patients with previously resected PTC and subsequent Tg-FNA on a cystic neck mass. Tg-FNA was measured in needle rinses using a Tg assay. The ultrasound findings, Tg-FNA concentrations, and cytological and follow-up histological diagnoses were correlated.

RESULTS

A total of 21 FNA specimens of cystic lesions from 19 patients were identified. Of 7 cases with cytologic and subsequent histologic diagnoses of metastatic PTC, the median Tg-FNA level was 100,982 ng/mL. Of 8 cytologically benign cases, 7 cases had Tg-FNA levels < 0.2 ng/mL, and 1 aberrant case demonstrated elevated Tg-FNA of > 1000 ng/mL. For 6 cytologically equivocal cases, including 3 classified as atypical/suspicious for carcinoma, 2 classified as insufficient/acellular debris, and 1 classified as spindle cell neoplasm, 4 patients demonstrated markedly elevated Tg-FNA levels (> 150 ng/mL) with subsequent surgical confirmation of metastatic PTC, whereas 2 patients had Tg-FNA levels of < 0.2 ng/mL with negative follow-up. Using a cutoff value of 0.2 ng/mL, Tg-FNA demonstrated a sensitivity of 100% and specificity of 87.5%.

CONCLUSIONS

Tg-FNA is a useful ancillary test that improves the detection of cystic PTC metastases. Particularly in cytologically nondiagnostic cases, the measurement of Tg-FNA helps to distinguish benign from malignant cystic lesions.

Branchial cleft cyst carcinoma: fact or fiction?

PURPOSE OF REVIEW

With the recent changes in the cause of head and neck cancer and the association of cystic metastatic neck squamous cell carcinoma with human papilloma virus (HPV), patients who are diagnosed with a cystic lesion in their upper neck need thorough investigation before commencing any treatment.

RECENT FINDINGS

The differential diagnosis of a cystic mass in the upper neck of an adult over the age of 40 years is a branchial cleft cyst, cystic metastatic squamous cell carcinoma or a branchial cleft cyst carcinoma (BCCC). Investigation must include diagnostic imaging, biopsy or excision biopsy of likely primary sites, such as oropharyngeal sub-sites, and testing for HPV, Epstein-Barr virus immunological status.

SUMMARY

The existence of BCCC is an exceptional diagnosis, with less than 40 cases considered proven. Consensus agreement has been proposed on making such a diagnosis. The diagnosis of a BCCC should be one of exclusion rather than presumption, after all other possible diagnoses have been considered and excluded.

Papillary Thyroid Carcinoma in a Branchial Cleft Cyst without a Thyroid Primary: Navigating a Diagnostic Dilemma

We report a rare case of papillary thyroid carcinoma incidentally found within a branchial cleft cyst. Only four other cases have been described in the literature. A total thyroidectomy and selective neck dissection was performed, and no evidence of occult primary disease was found after review of fine sections. Branchial cleft cysts are the most common lateral neck masses. Ectopic thyroid tissue within a branchial cleft cyst is an unusual phenomenon, and papillary thyroid carcinoma arising from this tissue is extremely rare. Clinicians are left with a diagnostic dilemma when presented with thyroid tissue neoplasm within a neck cyst in the absence of a thyroid primary—is this a case of metastatic disease with a missed primary or rather carcinoma arising in ectopic thyroid tissue? A thorough discussion of the etiologies of these lateral neck masses is reviewed including the embryogenesis of thyroid tissue in a branchial cleft cyst. The prognosis of patients with papillary thyroid carcinoma in lateral neck cysts without a primary site identified appears to be good following excision of the cyst and total thyroidectomy. Other management recommendations regarding these unique lateral neck malignancies are also presented.

Papillary thyroid carcinoma in a lateral neck cyst: primary of ectopic thyroid tissue versus cystic metastasis

Objective:

To review the diagnosis of primary papillary carcinoma of ectopic thyroid tissue within branchial cleft cysts, and to discuss the diagnostic challenge of differentiating this condition from metastatic disease when an occult microcarcinoma is found in the thyroid gland.

Methods:

These comprise a case report and a literature review. We present the case of a 75-year-old woman with papillary thyroid carcinoma within the wall of a recurrent, 15 cm, lateral neck cyst.

Results:

Histological examination of the patient's thyroid gland found a 0.5 mm papillary thyroid microcarcinoma.

Conclusion:

Our differential diagnosis was primary papillary carcinoma arising from ectopic thyroid tissue, or metastatic cystic degeneration of a lateral lymph node. We make an argument for the former.

Unusual presentation of cystic papillary thyroid carcinoma

Papillary thyroid carcinoma is the most common thyroid malignancy, accounting for 80% of all thyroid cancers. The most common presentation of thyroid cancer is an asymptomatic thyroid mass or a nodule. Usually as thyroid enlarges, it extends in to mediastinum. Papillary thyroid carcinoma presentation as multiple true cystic swelling extending from neck to anterior chest wall in subcutaneous plane is not present in the literature. We present a rare case of cystic papillary thyroid carcinoma which is presented as subcutaneous swelling with sinus formation.

Papillary carcinoma of thyroid arising from ectopic thyroid tissue inside branchial cleft cyst: a rare case

Ectopic thyroid glands generally occur in the midline as a result of abnormal median migration. The presence of these ectopic glands, lateral to the midline is rare. Here, the authors present one case of papillary carcinoma of thyroid arising from an ectopic thyroid tissue in branchial cleft cyst presented as a swelling in lateral neck diagnosed after cystectomy. Total thyroidectomy and neck dissection were done to rule out occult primary carcinoma of thyroid. Histopathology report showed thyroid and lymph nodes were normal.

Primary papillary carcinoma originated from a branchial cleft cyst

Although branchial cleft cysts are common, papillary carcinomas arising from them are rare. Here we report a 41-year-old woman with papillary carcinoma originating from a right lateral branchial cleft cyst without any evidence of a papillary carcinoma in the thyroid gland. The patient underwent right lateral neck dissection followed by total thyroidectomy. We then confirmed papillary carcinoma arising from the branchial cleft cyst through microscopic and immunohistochemical staining with thyroglobulin (TG), thyroid-associated transcription factor-1 (TTF-1) and p63. It is the 10th case worldwide describing papillary carcinoma in a branchial cleft cyst with a review of the literature on the features of the disease and discussion of the role of immunohistochemical staining with TG, TTF -1 and p63. In conclusion, it should be emphasized that the surgeon must be cautioned of the possibility of primary papillary carcinoma in the branchial cleft cyst.

Differential diagnosis of cystic neck lesions

OBJECTIVES

In patients less than 40 years of age who present with an upper anterior triangle cystic mass, branchial cyst is the presumed clinical diagnosis. Squamous cell malignancy is the important differential diagnosis in a patient more than 40 years of age. We sought to identify the range of lesions that can be clinically mistaken for, and removed as, branchial cysts.

METHODS

We performed retrospective reviews of 29 neck masses removed as branchial cysts and 47 solitary neck masses diagnosed as cancer between January 2003 and January 2008 across two teaching hospitals in Leeds, England.

RESULTS

Of the 29 lesions removed, 23 (79.3%) were confirmed to be branchial cysts. The remainder comprised 2 thyroid papillary carcinomas (6.9%) and 4 benign lesions (13.6%; laryngocele, neurilemmoma, parotid gland cyst, and cystadenoma). Of the 47 cases of metastatic cancer, 3 lesions (6.4%) were clinically mistaken as branchial cysts but were subsequently diagnosed as squamous cell carcinomas.

CONCLUSIONS

When presented with a solitary lateral cystic mass, clinicians should consider the possibility of squamous cell carcinoma in patients more than 40 years of age, and thyroid papillary cancer should be considered particularly in the younger age groups. In our series, 30.8% of the neck lesions believed to be branchial cysts in patients over 40 were malignant, in contrast to 5.3% of those lesions in patients under 40.

Cervical cystic swelling in an adolescent: unusual association of a cervical mature teratoma with vertebral anomalies and a history of gastric duplication cyst

A 14-year-old girl presented with a cervical cystic swelling in association with deformity of cervical vertebrae. As a child, she had been treated for gastric duplication. Pathologic examination of the resected cervical swelling revealed a mature teratoma. We discuss possible embryologic associations, which could explain the unusual combination of a mature teratoma with vertebral anomalies and gastric duplication.

Cervical lymphadenopathies signaling thyroid microcarcinoma. Case study and review of the literature

BACKGROUND

Some lateral cervical lymphadenopathies may lead to the discovery of papillary microcarcinomas (PMC) of the thyroid that are not radiologically apparent. This relatively rare clinical situation raises questions about the diagnostic approach to chronic cervical lymphadenopathy and the impact of lymph node metastasis on PMC prognosis. PURPOSE OF THE ARTICLE: To study the epidemiologic, clinical, and prognostic criteria of cases of lymphadenopathy that signaled PMC.

PATIENTS AND METHODS

A retrospective study of 167 consecutive cases of PMC compared with 13 cases where a cervical mass signaled other forms of PMC.

RESULTS

The mean age was 48.5 years, the ratio of men to women was 5:8, and the mean PMC size was 5.5mm. These data did not differently significantly from those of the other PMC cases. The preoperative imaging found fluid content in six cases, with microcalcifications in three cases. All cases were treated by modified radical neck dissection on the side with the lymphadenopathy and total thyroidectomy with central neck dissection. The lymphadenopathy included a ruptured capsule in five cases and was accompanied by central lymph node metastases in three cases. Thyroid capsule involvement was significantly more common in cases of PMC discovered due to lymphadenopathy than in other cases of PMC (69% versus 9.7%, respectively; p<0.001). The mean follow-up was 7.3 years. There were no deaths due to PMC signaled by lymphadenopathy. Two cases of lymph node recurrence after 8 and 10 years were controlled by another surgery and radioactive iodine treatment.

CONCLUSION

Any chronic cervical mass should suggest the possibility of thyroid origin, especially in cases with cystic content or microcalcifications in subjects with no particular risk factors. An ultrasound of the thyroid should be done, as well as a fine needle aspiration biopsy of the lymphadenopathy with a thyroglobulin assay. Treatment is the same as for any thyroid carcinoma, and results in a good oncological outcome, despite the possibility of lymph node recurrences.

Cystic masses of the supraclavicular fossa: clinical features and diagnostic strategies

PURPOSE

Cystic masses of the supraclavicular fossa (SCF) are uncommon. The diverse anatomical structures within the SCF create an extended differential diagnosis for any mass arising in the SCF. This study describes the presenting symptoms, radiologic findings, medical and surgical management, and posttreatment outcomes of various cystic mass presenting in the SCF. A review of the literature and diagnostic and therapeutic algorithms are also provided.

METHODS

A retrospective study of an academic tertiary care head and neck cancer center was done. Seven cases of treated cystic masses of the SCF were identified. Diagnostic and therapeutic interventions are described.

RESULTS

Cross-sectional imaging and needle aspiration or biopsy were obtained in all 7 cases. Aspirates accurately differentiated benign from malignant lesions in 6 cases, identified the offending pathology in 3 cases, and provided inoculum for culture-directed antibiotic therapy in 1 case. Surgical intervention was used for definitive therapy in 6 cases. All patients achieved complete resolution of signs and symptoms of the mass.

CONCLUSIONS

Effective evaluation of a cystic lesion within the SCF mandates a thorough understanding of the anatomy and differential diagnosis. A well-defined algorithm allows successful management of benign and malignant lesions in the SCF.

Cystic neck lesions: clinical, radiological and differential diagnostic considerations

CONCLUSIONS

Metastatic disease should always be considered as a potential differential diagnosis in the adult patient with a cystic neck lesion.

OBJECTIVES

The most common cause of a cystic neck lesion in young adults is a branchial cleft cyst (BCC). In older patients metastatic lymph nodes may be easily misdiagnosed as BCC. This study aimed to investigate the incidence of unsuspected carcinoma in routinely excised cervical cysts at a tertiary care teaching hospital and to determine the characteristics of benign BCC and cystic malignancy in preoperative imaging.

PATIENTS AND METHODS

A total of 196 consecutive adult patients operated on with the initial diagnosis of benign lateral cervical cyst were identified and the hospital charts and imaging studies were reviewed. The mean age of the patients was 40 years (range 17-79 years).

RESULTS

Metastatic squamous cell carcinoma was demonstrated histologically postoperatively in six (3.1%) patients and metastatic papillary thyroid carcinoma in one (0.5%) patient. Therefore, the incidence of unsuspected carcinoma in the cystic neck lesions initially diagnosed as BCC was 3.6%. The preoperative imaging appearances of these lesions had been considered identical to that of BCC.

Papilläres Schilddrüsenkarzinom in einer medianen Halszyste

Thyroglossal duct cysts are the most common anomaly in thyroid development. The occurrence of carcinoma in a cyst is reported to be about 1% of cases. Histopathological examinations reveal a papillary thyroid carcinoma in about 94% of these. We report the case of 38-year-old female having a massive, cervical cystic mass over a period of 18 months. An ectopic papillary thyroid carcinoma was diagnosed. A total thyoidectomy and bilateral neck dissection were performed. This revealed a small thyroid carcinoma and three positive lymphatic nodes. Whether the cystic carcinoma is the primary or a metastasis of the thyroid carcinomais discussed.

Branchial cleft cyst as the initial impression of a metastatic thyroid papillary carcinoma: two case reports

Branchial cleft cysts are the most common lesions in lateral neck cysts, predominantly occurring in the fourth decade of life and without sexual propensity. Rare branchial cleft cysts are associated with malignant tumors metastatic from the oral cavity, nasal cavity, pharynx or thyroid gland. Occult thyroid papillary carcinomas often present as a solid mass in the lateral neck, with only a few cases revealing a branchial cleft cyst as the initial manifestation. Herein, we report two cases of metastatic thyroid papillary carcinoma that presented as lateral neck cysts, with preoperative diagnosis of branchial cleft cyst. Finally, after complete surgical resection and histopathologic examination, one case was diagnosed as cystic change of metastatic lymph node from thyroid papillary carcinoma, and the other was determined to be a branchial cleft cyst with concurrent lymph node metastasis from thyroid papillary carcinoma. When a branchial cleft cyst is diagnosed by clinical or histopathologic examination, a metastatic thyroid papillary carcinoma should be considered as part of the differential diagnosis.

Thoracic duct cyst: sclerotherapy as alternative for surgical treatment

BACKGROUND

Thoracic duct cysts of the cervical portion are rare benign lesions for which surgery is the treatment of choice.

METHODS

We present 2 cases of a thoracic duct cyst of the cervical portion. One patient was treated by surgery and the other patient by ethanol sclerotherapy.

RESULTS

After establishing diagnosis by radiologic assessment and chemical and cytological fine-needle aspirate of the cystic masses, both patients were treated successfully.

CONCLUSION

Ethanol sclerotherapy provides an alternative therapy for thoracic duct cyst when evaluation establishes a high likelihood of clinical diagnosis.

Thyroid papillary carcinoma arising in ectopic thyroid tissue within a neck branchial cyst

Background

Thyroid gland derives from one median anlage at the base of the tongue, and from the two fourth branchial pouches. A number of anomalies may occur during their migration. These can be in form of ectopic tissues, which are frequently found along the course of thyroglossal duct and rarely in other sites, many of these may develop same diseases as the thyroid gland.

Case presentation

A 36-years-old female presented with a 3 month history of left side neck mass. The mass disappeared following aspiration of brown colored fluid, which on cytological examination showed cells with nuclear irregularities that warranted the resection of the lesion. The histology demonstrated a thyroid papillary carcinoma arising within the branchial cyst. Thereafter, the patient underwent a total thyroidectomy with central lymph nodes dissection. Histology showed a multifocal papillary carcinoma with central lymph nodes metastases. Only four cases of primary thyroid carcinomas in neck branchial cyst have been described so far.

Conclusion

In a lateral cystic neck mass, although rare, occurrence of ectopic thyroid tissue and presence of a papillary thyroid carcinoma should be kept in mind.

Thyroid transcription factor 1 (TTF-1) and p63 expression in two primary thyroid papillary carcinomas of branchial cleft cysts

Malignant lateral cervical cysts can be related to metastatic tumors or rarely to primary thyroid carcinoma arising in branchial cleft cysts. This study evaluates the expression of thyroid-associated transcription factor-1 (TTF-1) and p63 in three branchial cleft cysts and in two primary thyroid papillary carcinoma of branchial cleft cysts. TTF-1 was negative in the nuclei of the lining epithelia of branchial cleft cysts, but positive in the adjacent normal thyroid tissue, while TTF-1 was positive in the nuclei of the lining epithelia and in the nuclei of the papillae and follicles in branchial cleft cysts with ectopic thyroid carcinoma. P63 was positive in the nuclei of the lining epithelia of branchial cleft cysts, but negative in the adjacent normal thyroid tissue. Papillary thyroid carcinoma of branchial cleft cysts displayed p63-positive foci. In conclusion, our results demonstrate that TTF-1 cannot distinguish between primary and metastatic tumors of branchial cleft cysts. The detection of p63 in papillary thyroid carcinomas of branchial cleft cysts could suggest that p63 contributes to the onset of this tumor. It is really important to evaluate if the case has a metastatic derivation or represents papillary thyroid carcinoma arising in ectopic thyroid tissue in a branchial cleft cyst.

Papillary thyroid microcarcinoma: A surgical perspective

Papillary thyroid microcarcinoma (PTMC) is defined as a papillary thyroid cancer measuring less than 10mm in its greatest diameter. It is the most common form of thyroid cancer, detected in up to 36% in autopsy studies. The wide availability and use of neck ultrasonography in the evaluation of carotid arteries and of the thyroid resulted in an increased detection of PTMC. PTMC is often multifocal. The diagnosis is usually based on a combination of clinical examination, laboratory investigations, and specialized radiological techniques (mainly neck ultrasonography combined with fine-needle aspiration cytology). A common scenario is the diagnosis of PTMC as an incidental finding following thyroidectomy for a presumably benign thyroid disease. Despite some controversy, most authors agree that PTMC should be treated by total or near-total thyroidectomy, provided it can be performed safely. Because of its many and major advantages, in our clinical practice, total or near-total thyroidectomy is the procedure of choice for the management of PTMC. Given the high incidence of PTMC as an incidental finding and the frequent multi-focality, we also favor total or near-total thyroidectomy for the surgical management of nodular thyroid disease (multinodular goiter or dominant presumably benign thyroid nodule/s). Despite some controversy, we perform central neck lymph node dissection electively, in the presence of cervical lymphadenopathy. Radioiodine ablation therapy may be used as an adjuvant therapy. Prognostic factors (such as tumor multicentricity, positive lymph nodes, capsular or vascular invasion) or scoring systems (such as the AMES) can be used to select patients for radioiodine adjuvant therapy. Suppression therapy is needed after surgical management. Despite the potential for neck lymph node and even distant metastases, the biological behavior of PTMC is in general benign and the prognosis is very good.