Branchial cleft cyst: An unusual site for the cervical metastasis of nasopharyngeal carcinoma

Two-year follow-up of a rare primary branchial cleft carcinoma: Case analysis and management insights

Branchial cleft cysts are congenital anomalies of development, with the second branchial cleft cyst being the most common clinically. In extremely rare cases, branchial cleft cysts can undergo malignant transformation. Herein, we present a rare case of a 65-year-old male patient who had a painless neck mass on the left side for 6 months. Routine postoperative histopathological examination of the resected mass revealed branchial cleft carcinoma. We excluded the possibility of systemic metastasis through PET-CT and subsequently performed radical neck dissection. Routine follow-up revealed no recurrence after surgery. A PubMed search of the literature over the past 10 years yielded only 11 articles related to branchial cleft carcinoma. We hope this case will remind clinicians of the insidious nature of branchial cleft carcinoma and the importance of routine histopathological examination of seemingly benign surgical lesions.

Clinical Controversy Surrounding the Differential Diagnosis of Branchiogenic Carcinoma

Clinical evaluation, differential diagnosis, and management of a neck mass constitute commonly encountered problems for the head and neck surgeon. An asymptomatic neck mass in adults may be the only clinical sign of head and neck cancer. A 50-year-old female patient presented with a painless, slowly enlarging, left lateral neck lump. Ultrasonography described a possible lymph node with cystic degeneration, and fine needle aspiration biopsy only detected atypical cells of squamous epithelium. An open biopsy under general anesthesia was performed. Histopathological findings suggested the diagnosis of lymph node infiltration by squamous cell carcinoma of an unknown primary site, but differential diagnosis also included branchiogenic carcinoma arising in a branchial cleft cyst. A diagnostic algorithm for metastatic squamous cell carcinoma of an unknown primary site was followed, including positron emission tomography with computed tomography. The patient underwent panendoscopy and bilateral tonsillectomy, and an ipsilateral p16 positive tonsillar squamous cell carcinoma was detected. Further appropriate management followed. The existence of true branchiogenic carcinoma is controversial. When such a diagnosis is contemplated, every effort should be made to detect a possible primary site. Branchiogenic carcinoma, if exists at all, remains a diagnosis of exclusion.

Patho-Anatomic Spectrum of Branchial Cleft Anomalies: Proposal of Novel Classification System

PURPOSE

Histogenesis, nomenclature, and classification of branchial cleft anomalies (BCAs) have been subjects of controversy for decades. The purpose of this study was to investigate the accuracy of current developmental theories (congenital, lymph node, and hybrid branchial inclusion theories) in defining the anatomic and histopathological characteristics of BCAs.

METHODS

Ninety consecutive patients with BCAs who underwent surgical excision were enrolled in this 2-center retrospective cohort study.

RESULTS

The present study included 90 patients: 46 (51.11%) women and 44 (48.89%) men (P > .05). The mean age at presentation was 31.89±17.31 years. Altogether, 92 BCAs were identified within the study population including 49 (53.26%) on the left side and 43 (46.74%) on the right side (P > .05). The BCAs included 79 (85.87%) branchial cleft cysts, 11 (11.96%) branchial cleft sinuses, and 2 (2.17%) branchial cleft fistulae. Three (3.26%) BCAs were distributed in the head regions, 88 (95.65%) in the neck regions, and 1 (1.09%) in the thoracic cavity. Following surgery, lymphoepithelial tissue was detected in the histopathological examination in 83 (90.22%) BCAs. The hybrid branchial inclusion theory exhibited significantly higher accuracy in defining patho-anatomic characteristics of BCAs than the branchial apparatus, precervical sinus, thymopharyngeal, and inclusion theories (90.22, 9.78, 2.17, 0.00, and 0.00%; respectively) (P < .05).

CONCLUSION

The novel branchial node (BN) classification system based on the hybrid branchial inclusion theory appears to be superior to other classification systems in determining the patho-anatomy of BCAs.

Primary branchiogenic carcinoma: malignant degeneration of a branchial cyst, a case report

Background

Primary branchiogenic carcinoma (PBC) is an extremely rare and poorly documented disease developed from a brachial cleft cyst.

Case

A 51‐year‐old patient was referred to our unit for an upper neck mass. PBC was confirmed in accordance with Kahfif's diagnostic criteria. Prophylactic selective neck dissection was performed in a second‐stage surgery to ensure the complete removal of the neoplasm. Branchiogenic origin with lymphoid tissue was confirmed in the “host cyst” after histological examination and no other tumors were found elsewhere. Regular follow up documented no relapse 12 months after surgery.

Conclusions

Although rare, PBC must be suspected in presence of cervical masses, especially in patients older than 40 years. A standardized treatment algorithm still lacks, but prophylactic selective neck dissection could be considered as the first line choice after the diagnosis has been confirmed.