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

Unusual coexistence: branchial cleft cyst harboring papillary thyroid carcinoma with lymph node metastasis - a rare case report and clinical insights

Background

The simultaneous occurrence of Branchial Cleft Cyst (BCC) and Papillary Thyroid Carcinoma (PTC) represents an unusual malignant tumor, with cases featuring associated lymph node metastasis being particularly rare. This combination underscores an increased potential for metastasis, and the assessment of neck masses, particularly on the lateral aspect, may inadvertently overlook the scrutiny of the thyroid. Therefore, healthcare providers should exercise vigilance, especially in patients over the age of 40, regarding the potential for neck masses to signify metastasis from thyroid malignancies. Currently, surgical intervention stands as the primary effective curative method, while the postoperative administration of radioactive iodine therapy remains a topic of ongoing debate.

Case report

In the presented case, a 48-year-old male patient with a right neck mass underwent surgical intervention. The procedure included the excision of the right neck mass, unilateral thyroidectomy with isthmus resection, and functional neck lymph node dissection under tracheal intubation and general anesthesia. Postoperative pathology findings revealed the coexistence of a BCC with metastatic PTC in the right neck mass, as well as papillary carcinoma in the right thyroid lobe. Lymph node metastasis was observed in the central and levels III of the right neck.

Conclusion

The rare amalgamation of a BCC with PTC and concurrent lymph node metastasis underscores the invasive nature of this malignancy. Healthcare professionals should be well-acquainted with its clinical presentation, pathological characteristics, and diagnostic criteria. A multidisciplinary approach is strongly recommended to enhance patient outcomes.

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.

Papillary thyroid carcinoma arising from ectopic thyroid tissue in a neck branchial cyst

A 35-year-old man presented with a right lateral neck mass for 6 years. Thyroid function test was within normal limits. Computed tomography scan of the neck was suggestive of branchial cyst, tuberculous lymphadenopathy and normal thyroid gland. Fine needle aspiration cytology of cervical lymph node was suggestive of metastatic carcinoma. Branchial cystectomy spearing the thyroid gland was undertaken. Histopathology analysis of the resected specimen confirmed it to be papillary thyroid carcinoma originating from ectopic thyroid tissue in a branchial cyst. The patient was scheduled for total thyroidectomy and neck dissection. Unfortunately, he was lost to follow-up. A brief review of the literature regarding this unusual presentation of thyroid cancer has been provided.

First case of huge classic papillary thyroid cancer rupturing spontaneously leading to ischemic necrosis, perforation and inflammation of overlying skin: Case report and review of the literature

Introduction

Papillary thyroid cancer (PTC) is the commonest form of well-differentiated endocrine carcinoma. It is categorized into indolent and aggressive, where the indolent subtypes (classic, follicular) rarely demonstrate aggressive behavior. We present a classic PTC presenting with a rapidly growing huge anterior neck mass that subsequently spontaneously ruptured subcutaneously resulting in ischemia, necrosis, and perforation of overlying skin leading to inflammation.

Presentation of case

A 37-year-old female with no comorbidities presented to our emergency department with a neck swelling of 2 years duration that rapidly enlarged one week prior to presentation. Though the mass initially appeared of inflammatory nature, the tumor was a PTC, and she underwent total thyroidectomy with selective right side neck dissection and debridement of necrotic skin. The gross specimen revealed a fragmented non-intact right thyroid lobe mass causing pressure ischemia, necrosis and perforation of the skin. Histopathology showed a 9 × 9 × 5 cm classic PTC staged as pT3b N1b. Postoperative course was uneventful, she was discharged by the eighth postoperative day, and then she received a high dose of radioactive iodine ablation (RAI).

Discussion

Classic PTC is usually of a smaller size and a relatively benign course compared to other PTC subtypes and thyroid cancers. It is indolent with favorable prognosis. Although it is associated with increased risk of lymph node metastases at the time of diagnosis, it is slow growing with high survival rates approaching 95%.

Conclusion

Despite that classic PTC progresses slowly, it should still be suspected in neck swellings presenting with rapid and aggressive behavior. Prompt and systematic assessment is required with surgical intervention and radioactive iodine ablation therapy.

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Classic PTC is of indolent nature, slow progression and favorable prognostic outcomes when treated.

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We present a huge mass, rapid progression, spontaneous rupture causing ischemia, necrosis and perforation of overlying skin.

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Systematic investigations are required using US, FNA and CT followed by surgical intervention is the mainstay of treatment.

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High risk patients must undergo RAI soon after surgery with semiannual then annual follow-up to assess any recurrence.

PET/CT Evaluation of Head and Neck Cancer of Unknown Primary

The diagnosis of carcinoma of unknown primary in the head and neck is made when there is a metastasis but no primary lesion is identified after physical exam and diagnostic CT or MR imaging. PET/CT is the first step in searching for a primary lesion, followed by more invasive techniques such as endoscopy and surgery. Knowledge of the different tumor histologic types, preferential locations of nodal spread, imaging pitfalls, and other special considerations such as cystic metastases can be helpful in the ultimate identification of primary tumors, which leads to improved overall patient survival.

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.

Papillary Thyroid Carcinoma as a Lateral Neck Cyst: A Cystic Metastatic Node versus an Ectopic Thyroid Tissue

Papillary thyroid carcinoma is the most common thyroid malignancy and frequently metastasizes to regional lymph nodes. Occasionally, metastatic lymph nodes are palpable without the evidence of primary tumour. Papillary thyroid carcinoma of lateral neck cyst is a rare condition. It may arise from thyroid primary which underwent cystic degeneration or true malignant transformation of ectopic thyroid tissue. Herein, we reported two cases with preoperative diagnosis of benign lateral neck cyst but postoperative histopathological results showed primary papillary thyroid carcinoma. Ultrasonography and computed tomography of the neck in both cases showed no significant thyroid lesion. However, the patient in Case  2 was subjected for total thyroidectomy and histopathological results showed the origin of primary tumour. In conclusion, thorough investigations including total thyroidectomy are indicated in cases of papillary thyroid carcinoma of lateral neck cyst. This practice is to ensure that this type of thyroid cancer can be detected earlier because it has a very good prognosis if treated earlier.

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.

18F-FDG PET/CT to differentiate malignant necrotic lymph node from benign cystic lesions in the neck

OBJECTIVE

Patients presenting with cystic lesions in the neck without obvious signs of malignancy constitute a diagnostic challenge since fine needle aspiration is often insufficient and a diagnosis may not be reached until surgical resection/biopsy is performed. The differential diagnosis of a cystic cervical mass comprises a variety of benign conditions, but malignancy must be ruled out. We examined the diagnostic performance of fluorine-18 fluorodeoxyglucose (¹⁸F-FDG) PET/CT to identify malignancy.

METHODS

We retrospectively included consecutive patients referred from the Department of ENT Head and Neck Surgery for ¹⁸F-FDG PET/CT-scans because of a solitary neck cyst. Scan results were compared to histopathology and follow-up.

RESULTS

The study comprised 58 patients. Twenty patients (34%) were diagnosed with cancer during follow-up. PET/CT suggested malignancy in 34 patients (19 true positive, 15 false positive) and showed no malignancy in 24 (23 true negative, 1 false negative). The sensitivity, specificity, accuracy, positive and negative predictive values were 95% (76-99%), 61% (45-74%), 72% (60-82%), 56% (39-71%), and 96% (80-99%), respectively (95% confidence intervals in brackets). The primary tumor was identified in 14 out of the 20 patients with confirmed cancer. Increased metabolism, as evaluated by PET, was the only imaging characteristic among several others, which associated independently with malignancy in the cystic neck lesions, odds ratio 1.27 (1.07-1.50), p = 0.006.

CONCLUSION

¹⁸F-FDG PET/CT could reliably rule out malignancy (NPV 96%), albeit with a high frequency of false positive scans, requiring further diagnostic work-up. Increased metabolism was the best imaging parameter to differentiate between malignant and benign lesions.

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.

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

Ectopic thyroid tissue comprises a rare clinical entity which can clinically manifest with the whole spectrum of thyroid disorders, including thyroid malignancy. Thyroid carcinoma arising in ectopic thyroid tissue is extremely rare, with only a few cases described in the literature so far. We present a very unusual case of a primary papillary thyroid carcinoma arising in a left lateral branchial cyst, describing our diagnostic and therapeutic approach for this uncommon clinical entity. This is the first case where recombinant thyrotropin was used along with radioiodine treatment in primary ectopic thyroid cancer.

Unusual metastases from tall cell variant of papillary thyroid cancer

BACKGROUND

Tall cell variant (TCV) cancer is considered more aggressive than the classic variant of papillary thyroid cancer (PTC). Distant metastases are more common among this variant and affect survival. Little is known about the molecular pattern of this histotype.

METHODS

This is a report of 2 cases of unusual metastases from TCV, BRAF V600E-positive.

RESULTS

A 38-year-old woman developed subcutaneous metastases during short-term follow-up; at medium-term follow-up, the patient showed detectable stimulated serum thyroglobulin without disease evidence at imaging. A 33-year-old man presented incidental thymic metastases at time of surgical treatment; this is the first case of not ectopic thymic metastases from PTC.

CONCLUSION

TCV may present with unusual metastases already during early follow-up. The more aggressive behavior could be linked to the higher prevalence of BRAF point mutations, but only a long-term follow-up might clarify if this association could worsen the prognosis. Moreover, skin metastases have been predictive factors of worse outcome in our patients, but not thymic metastases.

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.

Branchial cleft cyst: an unusual ultrasound diagnosis in an austere environment

Branchial cleft cysts are typically benign congenital cysts lined by epithelial cells that arise on the lateral part of the neck. Ultrasound is useful in situations, where CT scanning and MRI are unavailable. We report a case of a 29-year-old Ugandan male who presents with a unilateral neck mass. We highlight the usefulness of ultrasound in diagnosing a lesion consistent with a branchial cleft cyst, while ruling out other causes of neck masses.

Pulmonary squamous cell carcinoma associated with repaired congenital tracheoesophageal fistula and esophageal atresia

We report a 19-year-old man with pulmonary squamous cell carcinoma (SCC) who had a history of vertebral, anal, cardiac, tracheal, esophageal, renal, and radial limb defects (VACTERL) association and tracheoesophageal fistula (TEF) + esophageal atresia (EA) repair as an infant. Children that undergo TEF + EA repair may have an increased risk for developing cancer as they reach adulthood.