Cystic metastasis from occult tonsillar primary simulating branchiogenic carcinoma: the case for tonsillectomy as a "grand biopsy"

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.

Squamous carcinoma arising in a branchial cleft cyst: have you ever treated one? Will you?

The existence of primary branchiogenic carcinoma - that is, carcinoma arising in a pre-existing branchial cleft cyst (a benign developmental cyst) - has in recent decades been the subject of increasing scepticism. Recognition of the propensity of a variety of head and neck sites - including in particular the tonsil - to give rise to cervical metastases while the primary tumours themselves remain undetected has given rise to the idea that virtually all cystic carcinomas of the neck represent metastatic deposits, whether or not their primary sites are found. A diagnosis of primary branchiogenic carcinoma should be viewed with extreme scepticism, and every effort should be made (e.g. imaging, panendoscopy, elective tonsillectomy) to exclude the existence of a primary site elsewhere, before considering a diagnosis of primary branchiogenic carcinoma.

The topography of cervical lymph node metastases revisited: the histological findings in 526 sides of neck dissection from 439 previously untreated patients

The pathological reports, minimum datasets and topographical plots of the neck dissections from 439 cases of oral and oropharyngeal cancer reported by a single pathologist following a standard protocol were analysed. Metastasis was evident in 47% of patients including bilateral metastases in 6%, extracapsular spread in 29% and matting in 7%. The extent of metastasis (both volume and distribution) was greatest in tumours of the oropharynx followed by lateral tongue, ventral tongue and floor of mouth. The typical 'inverted-cone pattern' was seen in 67% of patients with metastasis. A single micrometastasis was seen in 14%, skip lesions in 10% and involvement of 'other' nodal groups in 4%. Contralateral neck metastases (0.4%), peppering (2%), flushing of lymph node sinuses (1%) and all nodes positive (0.4%) accounted for the remaining 'aberrant' patterns. Skip lesions were seen in tumours at all sites other than retromolar.

Cervical cystic metastasis of squamous cell carcinoma: a case report with an unusual presentation

Cervical cystic masses may be a diagnostic challenge, especially in patients older than 40 years. We present the case of a 62-year-old male patient with a large cystic metastasis of squamous cell carcinoma to the neck and discuss this rare condition regarding diagnostic, pathologic and therapeutic features.

Cervical lymph node metastasis from an unknown primary: is a tonsillectomy necessary?

PURPOSE

The detection of an infraclinical primary by tonsillectomy in case of cervical lymph node of an epidermoid carcinoma with unknown primary after a radical neck dissection, allows avoiding irradiation of the normal larynx. The aim of this study is to quantify the rate of tonsil primary to justify this procedure.

METHODS AND MATERIALS

From 1969 to 1992, 87 patients had a tonsillectomy as part of the workup for cervical nodal metastasis of an epidermoid carcinoma with unknown primary. The mean age was 57 years (range: 39-75 years) and the sex ratio was 8.6. Sixty-seven patients had a single cervical adenopathy (17 N1, 30 N2a, 5 N3, 15 Nx), and 20 patients multiple cervical adenopathies (17 N2b, 3 N2c). The treatments included always an irradiation to the node areas (50 Gy), and to the pharyngolarynx in case of normal tonsil (50 Gy), or to the tonsil if it was the primary (50 Gy with a brachytherapy boost of 20-25 Gy). In this last case, the larynx could be protected.

RESULTS

Tonsillectomy never induced specific complication. Out of 87 patients, 26% had a tonsil primary. There was not specific histological differentiation in this group. In the 67 patients with a single cervical adenopathy, 31% had a tonsil primary (6 N1, 7 N2, 1 N3, 7 Nx). It was a subdigastric adenopathy in 38%, a submandibular in 28% and a midjugulocarotidian in 23%. Among the 17 patients N2b, none had a tonsil primary. In the three patients N2c, two presented a tonsil carcinoma (two subdigastric nodes).

CONCLUSION

Tonsillectomy allows avoiding irradiation of normal larynx in 26% of patients who have a cervical lymph node with unknown primary. It should be performed in case of a single node of the subdigastric, midjugulocarotidian or submandibular area or bilateral subdigastric adenopathies.

Cervical node metastases presenting with features of branchial cysts

For many years it has been recognized that seemingly benign neck cysts may contain carcinoma. The true incidence is unknown. This paper investigated nine out of 270 patients presenting with a neck mass--which proved to contain a squamous carcinoma. Records (from a 30-year period) of over 3400 patients with squamous carcinoma of the head and neck, were examined. The histology slides were reviewed, the number of cystic lesions was noted and also the clinical outcome. Out of the 270 patients nine presented with a cystic lesion and these were studied. Six cystic lesions were originally diagnosed as branchial cysts although the youngest age was 39 years. All patients underwent a simple excision. In six cases the tonsil was the primary site, in one the primary was in the base of tongue and in two the primary remained occult. One-third of the patients had died of their disease by the time this report was written and the maximum follow-up time for the remaining patients was 18 months. Therefore 16 per cent of branchial cysts in this series represented metastases from squamous cell carcinoma. At the Royal Liverpool University Hospital only 25 patients had branchial cysts excised between 1988 and 1993: out of these only four contained squamous carcinoma. In patients over 40 years of age panendoscopy and ipsilateral tonsillectomy is mandatory prior to cyst excision.

Branchial cyst--to endoscope or not?

Cervical cystic metastases are uncommon, originating predominantly from an oropharyngeal primary. Pre-operative differentiation from a branchial cyst can prove difficult. Three cases which presented clinically as branchial cysts but were subsequently found to be cystic metastases are described, and the literature is reviewed. Endoscopy, ipsilateral tonsillectomy and blind biopsies of Waldeyer's ring, combined with excision of the cervical lesion are recommended in patients over 40 years old.

Malignant cyst of the lateral aspect of the neck: branchial cleft carcinoma or metastasis?

A 58-year-old man had a left jugulodigastric mass, which was found to be cystic by computed tomography, and no evidence of other lesions. Grossly and histologically, the surgical specimen consisted of a thin-walled, fluid-filled cyst lined by squamous epithelium that varied in appearance from benign to invasive squamous cell carcinoma. The findings supported a differential diagnosis of branchial cleft carcinoma (BCCA) versus cystic growth of a lymph node metastasis from an occult malignancy. On this basis, guided biopsies of the upper aerodigestive tract were performed, with strong suspicion of a tonsillar bed lesion. Microscopic examination revealed the primary tumor within tissue excised from the left tonsillar fossa. Comparison of the current case with cases of BCCA and cystic tonsillar metastases from the literature illustrated the potential pitfalls in rendering a diagnosis of BCCA. Recognition of this lesion as a distinctive clinical variant of oropharyngeal carcinoma is warranted.

The relationship between cervical cysts and tonsillar carcinoma in adults

An investigation of the clinical results in 42 patients with lateral cervical cysts is presented. Fine needle aspiration biopsy suggested malignancy in three cases. After surgical removal, another six cases of malignancy were revealed by histologic examination. In six of the nine cases of malignancy, an ipsilateral tonsillar carcinoma was found on routinely performed tonsillectomy. However, the clinical appearance of the tonsils was normal in four of these patients. Analysis of all patients according to age revealed that the malignancy rate was 80% among those aged greater than 40 years. It is suggested that tonsillectomy for histologic examination should be performed routinely when lateral cervical cysts are removed in adults.