Branchial cleft cyst carcinoma: fact or fiction?

Primary or metastatic branchial cleft carcinoma?: a case report

The brachial cleft carcinoma is an extremely rare head and neck facial malignancy, and there is some disagreement about its differential diagnosis. In this paper, we report a 63-year-old male patient who had a mass on the left side of the neck and diagnosed as the brachial cleft carcinoma by intraoperative biopsy pathology. However, this patient was diagnosed with the carcinoma of the left soft palate more than 20 days after surgery and esophageal cancer 2 years later, and was treated accordingly. Therefore, it is hard to confirm whether the branchial cleft carcinoma is primary or metastatic. In fact, the diagnostic criteria for primary squamous cell carcinoma of branchial cleft cysts are very rigorous. Confirmation of the diagnosis is based on pathological examination of the branchial cleft cyst epithelium lined with squamous cells, meanwhile, a thorough examination should also be performed to exclude the presence of other primary cancers.

Primary or metastatic branchial cleft carcinoma?: A case report.. [DOI: 10.21203/rs.3.rs-2696069/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

The brachial cleft carcinoma is an extremely rare head and neck facial malignancy, and there is some disagreement about its differential diagnosis. In this paper, we report a 63-year-old male patient who had a mass on the left side of the neck and diagnosed as the brachial cleft carcinoma by intraoperative biopsy pathology. However, this patient was diagnosed with the carcinoma of the left soft palate more than 20 days after surgery and esophageal cancer 2 years later, and was treated accordingly. Therefore, it is hard to confirm whether the branchial cleft carcinoma is primary or metastatic. In fact, the diagnostic criteria for primary squamous cell carcinoma of branchial cleft cysts are very rigorous. Confirmation of the diagnosis is based on pathological examination of the branchial cleft cyst epithelium lined with squamous cells, meanwhile, a thorough examination should also be performed to exclude the presence of other primary cancers.

Branchial cleft cyst and branchial cleft cyst carcinoma, or cystic lymph node and cystic nodal metastasis?

BACKGROUND

Lateral cervical cysts are usually considered as of branchial cleft origin, despite many studies showing that branchial cysts do not arise from the remnants of the branchial apparatus. In the same way, some authors still consider that a true clinicopathological entity such as 'branchial cleft cyst carcinoma' could exist, at least in theory. Despite insufficient evidence in support of the branchial theory, a number of publications continue to emphasise this concept.

METHODS

A literature review of articles in Medline and PubMed databases was carried out to retrieve papers relevant to the topic.

RESULTS AND CONCLUSION

The evidence from lateral cervical cyst studies and knowledge about cystic metastasis of Waldeyer's ring could be applicable for both diagnoses. Terms such as 'branchial cleft cyst' and 'branchial cleft cyst carcinoma' are confusing and misleading, and it is questionable as to whether their usage is still tenable.

Evaluation of Neutrophil-to-Lymphocyte Ratio, Platelet-to-Lymphocyte Ratio and Mean Platelet Volume in Patients with Branchial Cleft Cyst

Branchial cleft cysts are benign masses of the head and neck. Etiopathogenesis is unclear and many factors such as inflammatory mechanisms can play a role. The aim of our study is to investigate the predictive value of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and mean platelet volume (MPV), which are hematologic inflammatory markers, in branchial cleft cyst (BCC). The records of 27 patients who were operated with the diagnosis of BCC in the ENT clinic between January 2011 and March 2020 and 27 healty subjects were retrospectively reviewed. The control group consisted age and sex-matched subjects scheduled for rhinoplasty. Neutrophil, lymphocyte, platelet and MPV values were recorded from the complete blood count samples for all participants. The statistical relationship for NLR, PLR and MPV values between the patient and the control groups was investigated. The NLR values of the patients were significantly lower than the healthy controls (p:0.007). But no statistically significant correlation was found for PLR (p:0.586) and MPV(p:0.676) values between the groups. This is the first study to evaluate the significance of NLR, PLR and MPV in branchial cleft cyst. Decreased NLR may be used as a predictive marker for BCC. But PLR ande MPV should not be used to predict branchial cleft cyst.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-021-02789-1.

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.

Update from the 5th Edition of the World Health Organization Classification of Head and Neck Tumors: The Neck and Lymph Nodes, Metastasis, and Melanocytic Tumors

The changes made in the fifth edition of the WHO Classification of Head and Neck Tumors demonstrate the recent diagnostic, histopathological, and molecular advances in the field, and this updated information will hopefully lead to improved and standardized tumor subtyping. This review summarizes the changes related tumors and tumor-like lesions of the neck and lymph nodes (Chapter 11), metastasis to the head and neck region (Chapter 15), and melanocytic tumors (Chapter 10).

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.

Surgical Management of an Intrathoracic Branchial Cyst in a Yellow-crested Cockatoo (Cacatua sulphurea)

A 40-year-old, female lesser crested cockatoo (Cacatua sulphurea) was presented with a complaint of hyporexia and sudden onset of sneezing and wheezing. Physical examination revealed mild stertorous inhalation, and the apex of the heart was palpable caudoventral to the distal tip of the sternum. Projection radiographic images showed a soft tissue mass displacing the heart and the thoracic portion of the trachea. A subsequent computed tomography series revealed a single, large, and predominantly encapsulated soft-tissue mass. The mass was contained within the cranial thoracic region and occupied most of the anatomic location of the thoracic portion of the clavicular air sac, extending around a portion of the trachea. A surgical exploratory procedure was performed, with a thoracic inlet thoracotomy, and the mass was found to be cystic and deeply attached to surrounding tissues at its caudal-most aspect. Complete excision was not possible, and the mass was drained and an incomplete resection was accomplished with approximately one-half of the cystic structure removed and submitted for histopathology. The mass was found to be benign, epithelial-lined, dense, fibrous connective tissue that would be consistent with a branchial cyst.

Head and neck carcinoma of unknown primary

In adult cervicofacial pathology, carcinoma of unknown primary is defined as lymph-node metastasis the anatomic origin of which is not known at the time of initial management. It constitutes up to 5% of head and neck cancers. Presentation may suggest benign pathology, delaying and confusing oncologic treatment. Diagnostic strategy in cervical lymph node with suspicion of neoplasia requires exhaustive work-up to diagnose malignancy and, in 45% to 80% of cases, depending on the series, to identify the primary site. Histologic types comprise squamous cell carcinoma, thyroid carcinoma, adenocarcinoma, neuroendocrine carcinoma and undifferentiated carcinoma. Association is sometimes found with human papilloma virus or Epstein Barr virus, guiding treatment. The objective of the present study was to provide clinicians with the necessary diagnostic tools, based on the current state of clinical, imaging and pathologic knowledge, and to detail treatment options.

Intraoperative injection of combined fibrin sealant and methylene blue dye for surgery of branchial cleft cysts: A case report

Differential diagnosis of a lateral neck mass, especially in paediatric patients, should include branchial cleft cysts (BrCC). It is often difficult to identify and completely resect all cystic components, especially when the lesion becomes infected and/or gigantic. Incomplete excision increases the likelihood of recurrences. We reported a simple technique to facilitate the BrCC resection. Tisseel fibrin glue (FG: Baxter AG, Vienna, Austria) was mixed with methylene blue dye in inverse portion to the cyst size and/or the FG volume before injecting into the cystic lumen. After polymerisation of the dyed glue, the lesion was better visualised and extirpated in toto with the aid of the dye colour and gelatinisation by FG. An up-to-date diagnostic and therapeutic algorithm for BrCC was also presented.

CT and MR imaging findings of infection-free and benign second branchial cleft cysts

PURPOSE

The present study aimed to assess CT and MR imaging findings of infection-free and benign second branchial cleft cysts (SBCCs).

METHODS

Eleven patients with histopathologically confirmed infection-free and benign SBCCs underwent preoperative contrast-enhanced CT (CECT) and/or MR imaging. We assessed qualitative (presence and extent of wall thickening, degree of contrast enhancement of the thickened wall on CECT images, and signal intensity of the thickened wall on T2-weighted images) and quantitative (maximum thickness of the thickened wall) imaging findings.

RESULTS

Eccentric and smooth wall thickening was observed in 11/11 (100%) patients. The wall thickening extent (percentage of the thickened wall to the circumference of the wall) was small (1%-25%) in 4/11 (36%), moderate (26%-50%) in 6/11 (54%), extensive (51%-75%) in 1/11 (9%), and diffuse (76%-100%) in 0/11 (0%) patients. Mild homogeneous enhancement of the thickened wall on CECT images was observed in 7/7 (100%) patients. The signal intensity of the thickened wall on T2-weighted images was isointense relative to that of normal lymph nodes in 7/8 (88%) and mildly hyperintense in 1/8 (12%) patient. The maximum thickness of the thickened walls ranged from 2 to 4 (mean 3.4) mm.

CONCLUSIONS

Infection-free and benign SBCCs are identifiable as cysts with eccentric and smooth wall thickening on CECT and MR images. The wall thickness was almost always less than half of the wall circumference, isointense relative to normal lymph nodes, and showed mild homogeneous enhancement.

Cervical metastasis of gingival carcinoma misdiagnosed as branchiogenic carcinoma, a rare entity - report of a case and review of literature

BACKGROUND

A cervical cystic mass is associated with a number of pathologies that present with similar symptoms. These conditions are difficult to differentiate using fine-needle aspiration (FNA), ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI). Another dilemma in the differential diagnosis of cervical cystic masses is due to the controversies associated with the existence of branchiogenic carcinoma (BC). BC is an extremely rare disease that must be differentiated from other conditions presenting with cervical cystic masses, especially cystic metastasis from occult primary lesions.

CASE PRESENTATION

We present a case report of a right cervical cystic metastasis from a significantly small squamous cell carcinoma primary gingival lesion misdiagnosed as BC by histopathology. A 62-year-old female presented with a painless progressively enlarging cervical mass at the anterior edge of the sternocleidomastoid muscle in the right submandibular region. Preoperative MRI and US revealed a well-defined cystic round mass. Postoperative histological examination indicated BC. Positron emission tomography/computed tomography (PET/CT) revealed high 18F-FDG (18F 2-fluoro-2-deoxy-D-glucose) uptake in surgical regions with a SUV (standard uptake value) max 4.0 and ipsilateral nasopharynx with a SUVmax 4.4, without any distant metastasis. Pathologic results revealed nasopharyngeal lymphadenosis. Considering the low incidence of BC and the limitation of diagnosis in one institution, the patient was referred to another hospital. Physical examination detected a significantly small neoplasm (~3 mm diameter) in the right lower gingiva. Histopathological examination of the neoplasm revealed a well-differentiated squamous cell carcinoma. Surgery, including a partial mandibulectomy and modified neck dissection (neck level I-V and submental lymph nodes) were undertaken. Postoperative histopathological results revealed a well-differentiated squamous cell carcinoma of right lower gingiva and two metastatic lymph nodes in the 18 lymph nodes of level II. A month later, recurrence occurred in the right cervical level II. The patient was placed on postoperative concurrent chemo-radiotherapy and supportive care. The patient suffered from cachexia and survived for only six months after surgery.

CONCLUSIONS

In cases of cervical cystic masses that appear after the age of 40, clinicians should bear in mind that occult primary lesions should be excluded and examination of the gingiva should be undertaken. PET/CT has a limited role in identifying small occult primary lesions and a comprehensive physical examination must be carefully performed.

Update from the 4th Edition of the World Health Organization Classification of Head and Neck Tumours: What Is New in the 2017 WHO Blue Book for Tumors and Tumor-Like Lesions of the Neck and Lymph Nodes

The World Health Organization (WHO) 2017 Classification of Head and Neck Tumors ("Blue Book") will now include a new chapter on tumors and tumor-like lesions of the neck and lymph nodes, which was not included in the previous edition. Tumors and tumor-like lesions, including a variety of cysts and metastases, can arise in any component in the neck, including soft tissue, lymph nodes, and developmental remnants. The pathology and clinical features of metastatic carcinoma of unknown primary in the head and neck has changed dramatically in the last several years. Many of these tumors which were previously diagnosed as unknown primary are now identified as oropharyngeal and nasopharyngeal carcinomas related to human papillomavirus (HPV), less commonly to Epstein-Barr virus (EBV) and occasionally even to Merkel cell polyomavirus. Many unusual features can arise in these metastases, such as undifferentiated morphology, extensive cystic change with central degeneration, gland formation, and even ciliated cells. Rarely, carcinoma in the neck can arise in association with a heterotopic tissue, primarily thyroid or salivary gland tissue. Tumor-like lesions include branchial cleft cysts, thyroglossal duct cyst, dermoid and teratoid cyst, and ranula. Pathologists should be familiar with the diagnostic features and clinicopathologic corrections of these neck lesions in order to correctly diagnosis them and to provide for proper clinical management. This article will briefly describe the pathologic and clinical features of these entities as they are covered in the new 2017 Blue Book.

Morphologic diversity in human papillomavirus-related oropharyngeal squamous cell carcinoma: Catch Me If You Can!

As the human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma epidemic has developed in the past several decades, it has become clear that these tumors have a wide variety of morphologic tumor types and features. For the practicing pathologist, it is critical to have a working knowledge about these in order to make the correct diagnosis, not to confuse them with other lesions, and to counsel clinicians and patients on their significance (or lack of significance) for treatment and outcomes. In particular, there are a number of pitfalls and peculiarities regarding HPV-related tumors and their nodal metastases that can easily result in misclassification and confusion. This article will discuss the various morphologic types and features of HPV-related oropharyngeal carcinomas, specific differential diagnoses when challenging, and, if established, the clinical significance of each finding.

Cystic metastatic nasopharyngeal carcinoma presenting as branchial cleft cyst: report of two cases and review of the literature

PURPOSE

To describe the differential diagnosis between solitary cystic metastatic carcinoma from branchial cleft cyst and provide references for clinicians to treat cystic metastases from primary sites of the head and neck region.

MATERIALS AND METHODS

Two cases of cystic metastatic nasopharyngeal carcinoma (NPC) are presented and a review of the relevant English literature on cystic metastasis from head and neck cancer was performed.

RESULTS

Two adult patients with a lateral cystic neck mass were initially clinically diagnosed as branchial cleft cysts. Based on the postoperative histopathologic examination and nasopharyngeal blind biopsy, they were finally diagnosed as cystic metastases from occult nasopharyngeal carcinoma. After a review of the literature, diagnostic strategies, histopathologic features, and therapeutic options for cervical cystic metastases were discussed.

CONCLUSION

Cervical cystic metastasis of NPC in adults may mimic branchial cleft cyst in clinical, radiological, and even histological features. Surgeons should bear in mind that when lateral neck cysts with characteristics of suspected malignancy are confronted, nasopharynx examination, including blind or random biopsy, is highly recommended before surgery. Metastatic disease should always be considered as a potential differential diagnosis in adult patients with a cystic neck lesion. Correct diagnosis is important so that appropriate surgical and radiotherapeutic treatment can be delivered.