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

A case of fine-needle aspiration of a neck mass with atypical squamous cells and macrophages

Head and neck lesions often undergo fine-needle aspiration to determine the appropriate management and therapeutic decisions. However, there are numerous diagnostic challenges encountered with these specimens, particularly, if atypical squamous cells are identified. Here, we present a case of an enlarging right neck mass in a 38-year-old female and discuss the diagnostic difficulties and potential pitfalls. Additionally, we review the approach to diagnosis, including differential diagnostic considerations as well as available ancillary testing.

Efficiency of Fine-Needle Aspiration (FNA) in Relation to Tru-Cut Biopsy of Lateral Neck Swellings

Background Lateral neck masses have always been difficult to diagnose without proposing a differential diagnosis. Fine-needle aspiration (FNA) was proposed to be a cost-effective method and less invasive than a tru-cut biopsy and may provide a provisional diagnosis in relation to cytopathology. FNA has also been shown to improve the diagnosis of neck masses such as cervical lymphadenopathy, neck cysts, and parotid masses, whether malignant or benign. This study aims to evaluate the accuracy of FNA cytopathology versus a tru-cut biopsy histopathological examination. Materials and methods This study was conducted retrospectively in King Hussein Medical Hospital, Royal Medical Services, Hashemite Kingdom of Jordan, from January 2019 to January 2024. Ethical approval was taken to conduct this study with reference number 06/2024. All patients included in this study have given verbal and written consent to perform FNA and surgical tru-cut biopsy. The inclusion of patients was based on any person above the age of 16 who underwent an FNA followed by a surgical biopsy to correlate with the primary diagnosis. Exclusion criteria involved any patient who missed one of the above criteria. Statistical analysis was performed using IBM SPSS v29 (IBM Corp., Armonk, NY, US) with significant results considered with a p-value <0.05. Results A total of 107 patients were included in this study. A correlation between FNA results and final histopathological biopsy was done with an accuracy of 90.6%, specificity of 94.3, predictive positive value of 73.6%, and negative predictive value of 94.3%. There was a statistical significance between FNA and tru-cut biopsy with a p-value of <0.001. Conclusion FNA is a great tool to consider when diagnosing lateral neck swellings. Since it was statistically significant, FNA should be considered for any lateral neck swelling before any surgical tru-cut biopsy for a definitive diagnosis.

Advancement in the Oropharyngeal Primary Unknown Cancer Diagnostic and Current Treatments Pathway: A Narrative Review

Objective: The objective of this article is to define a correct diagnostic pathway for oropharyngeal cancer of unknown primary (OPCUP) identification. Background: OPCUP represents one of the most frequent causes of neck metastases onset without the identification of the primary tumor. Therefore, there is a high percentage of late or missing diagnoses, resulting in treatment delay or in a wrong therapeutic process. The up-to-date diagnostic procedures can help us to begin therapies at the right time. Methods: This is a review of the latest articles about diagnostic pathways in the OPCUP. A selection of the references was carried out in PubMed, EMBASE, Cochrane, and CENTRAL electronic databases. Conclusion: The oropharynx represents the most common site of primary unknown head and neck cancer (HNCUP). Recent epidemiologic data reported an increasing incidence of HNCUP related to human papilloma virus positive squamous cell carcinoma. Positron emission tomography combined with computerized tomography scanning or magnetic resonance imaging allows for improving the detection of primary unknown tumors and distant and locoregional metastases. Finally, the introduction of the trans-oral robotic surgical approach has introduced a new role of surgery in the HNCUP diagnosis and treatment. Hence, the new technological improvement allows reaching in most HNCUP patients an early diagnosis, achieving targeted management and better treatment outcomes, as well as decreasing toxicity and the side effects of treatment options.

Fine-needle aspiration biopsy versus frozen section examination in assessing cervical lymph node metastasis in primary clinically positive neck papillary thyroid carcinoma

BACKGROUND

Both fine-needle aspiration biopsy (FNAB) and frozen section (FS) examination are reliable methods for assessing cervical lymph node (level II-V) metastasis (LNM) in papillary thyroid carcinoma (PTC). Our goal was to compare the diagnostic accuracy of FNAB and FS in clinically positive neck (cN+) PTC patients.

METHODS

Altogether, 264 lymph node samples from 220 patients were prospectively enrolled. Samples were assessed by FNAB cytology (FNAB-C), thyroglobulin (Tg) FNAB needle wash testing (FNAB-Tg), and FS simultaneously. Diagnostic performance of the different methods were analyzed by the Chi-square test.

RESULTS

The sensitivity and specificity of FNAB-C alone in predicting LNM was 87.4% and 85.7%, respectively. Combined with FNAB-Tg, the sensitivity and specificity of FNAB-C increased to 98.9% and 81.6%, respectively. The sensitivity and specificity of FS in predicting LNM was 92.4% and 81.1%, respectively. FNAB-C and FNAB-Tg had better sensitivity than FS when applied to solid lymph nodes, and comparable sensitivity when applied to cystic and cystic-solid lymph nodes.

CONCLUSION

The utilization of FNAB-Tg significantly improved the diagnostic ability of FNAB-C. FS can be replaced by preoperative FNAB combined with FNAB-Tg without compromising diagnostic accuracy.

Challenges in Pathology Specimen Processing in the New Era of Precision Medicine

CONTEXT.—

Precision therapies for patients with driver mutations can offer deep and durable responses that correlate with diagnosis, metastasis prognosis, and improvement in survival. Such targeted therapies will continue to increase, pushing us to change our traditional approaches. We needed to search for new tools to effectively integrate technological advancements into our practices because of their capability to improve the efficiency and accuracy of our diagnostic and treatment approaches. Perhaps nothing is as relevant as identifying and implementing new workflows for processing pathologic specimens and for improving communication of critical laboratory information to and from clinicians for appropriate care of patients in an efficient and timely manner.

OBJECTIVES.—

To define the gold standard in delivering the best care for patients, to identify gaps in the process, and to identify potential solutions that would improve our process, including gaps related to knowledge, skills, attitudes, and practices.

DESIGN.—

We assembled a team across disciplines to systematically perform a gap analysis study to clarify the discrepancy between the current reality in pathology specimen processing and the desired optimal situation to deliver the results intended for patient care.

RESULTS.—

A practical collaborative workflow for specimen management seeking the cooperation of the stakeholders in each medical discipline to provide guidelines in specimen collection, delivery, processing, and reporting of results with the ultimate goal of improving patients' outcomes is provided.

CONCLUSIONS.—

New tools are required to effectively integrate data-driven approaches in specimen processing to meet the new demands.

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.

Should uncertainty concerning the risk of malignancy be included in diagnostic (nongynecologic) cytopathology reports?

In diagnostic cytology, the known site-specific false positive rates at various anatomical sites for the risk malignancy (ROM) when a confirmed malignant diagnosis is made are comparatively well documented. ROM figures for diagnostic cytology specimens may vary according to the anatomical site of the specimen, the exact nature of the specimen received, the staining method(s) used, and the use of additional laboratory techniques including molecular profiling; furthermore, they often differ to some extent from institution to institution, between differing cytologists within the same institution, and over time. A brief literature review for a selected group of routine diagnostic cytology specimens shows a published ROM for a confirmed malignant diagnosis as follows: bile duct brushings, ~99% (range, 97%-100%); breast fine needle aspiration, 98.5% (range, 92%-100%); serous effusion fluid, 98.9% (range, 90%-100% although lower for squamous cell carcinoma, mesothelioma, and lymphoma), pulmonary endobronchial ultrasound cytology, ~99% (range, 86.6%-100%); thyroid FNA, 98% (range, 97%-99% if NIFTP tumors are excluded), salivary gland FNA, ~90%; (range 57%-100%) and lateral neck cyst FNA, ~99% (range, 95.5%-100%). Because most diagnostic cytology specimens have a small but accepted false-positive rate, this information is vitally important for the clinical management of patients and for shared patient decision making. In our view, the known false-positive rate for a given diagnostic cytology specimen could be included within the cytology report to assist in explaining the limitations of the diagnostic cytology interpretation and help facilitate the clinical decision-making process.