Delayed Recurrence of Gall Bladder Cancer as Port-site Metastases with Occult Primary Detected on Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography: A Tale of Two Cases

Laparoscopic cholecystectomy is a fairly common procedure and is currently considered the gold standard for cholecystectomy. However, the laparoscopic procedure in the presence of gall bladder cancer (GBC) is associated with the risk of port-site metastasis (PSM). Furthermore, in few cases, GBC remains occult even on postoperative histopathology and presents with PSM remotely. Here, we describe two such cases of GBC with occult primary who presented with PSM and also defined the role of fluorine-18 fluorodeoxyglucose positron emission tomography-computed tomography in the management of such cases.

Solitary cystic metastatic lymph node of occult human papillomavirus-related oropharyngeal cancer mimicking second branchial cleft cyst: A case report

RATIONALE

Human papillomavirus (HPV)-related oropharyngeal cancer is becoming more common, the primary cancer AQ4 usually occult and appearing only as cystic cervical lymph node (LN) metastasis. Distinguishing between a benign cystic lesion and cystic LN metastasis is challenging given their similar radiologic and histologic appearances.

PATIENT CONCERNS

A 54-year-old man presented with a bulging cystic mass measuring 6.4cm on the right side of neck.

DIAGNOSES

Postexcision diagnosis was second branchial cleft cyst. After 2 years, the cystic mass recurred, and HPV-related tonsillar squamous cell carcinoma with cystic metastatic LNs was confirmed after wide tonsillectomy and neck dissection. The previous cystic lesion proved to be a cystic metastatic LN from the same malignancy with additional p16 immunostain.

INTERVENTIONS

The patient was treated with adjuvant concurrent chemoradiation therapy.

OUTCOMES

The patient was followed up in the outpatient department with no evidence of recurrence after 1 year.

LESSONS

When an adult has a cystic mass in the upper neck, we must rigorously exclude it as a cystic metastatic LN of occult HPV-related oropharyngeal cancer. Additional p16 staining might be helpful.

18 F-FDG PET/CT vs. human papillomavirus, p16 and Epstein-Barr virus detection in cervical metastatic lymph nodes for identifying primary tumors

Squamous cell carcinoma of unknown primary of the head and neck (SCCUP) is a heterogeneous disease entity that requires careful examination to locate the occult primary. We examined the diagnostic value of expression of biomarkers, such as human papillomavirus (HPV), p16 and Epstein-Barr virus (EBV), in metastatic lymph nodes vs. ¹⁸ F-fluorodeoxyglucose (¹⁸ F-FDG) positron emission tomography/computed tomography (PET/CT). We prospectively enrolled 54 consecutive SCCUP patients who received HPV, p16 and EBV analyses of lymph node fine-needle aspirates and ¹⁸ F-FDG PET/CT scans and subsequently underwent examinations and biopsies under general anesthesia to detect primary tumors. The diagnostic performance of the biomarkers and ¹⁸ F-FDG PET/CT were compared by using receiver operating characteristics (ROC) curve analyses with histopathological results for identification of primary tumors. Primary tumors were identified in 28 (51.9%) of 54 patients: the palatine tonsil in 24, base of the tongue in 1, nasopharynx in 2, and hypopharynx in 1. The sensitivity of p16 (85.7%) and accuracy of HPV (85.2%) were higher than those (42.9% and 68.5%) of ¹⁸ F-FDG PET/CT (p < 0.05). The area under the ROC curve of HPV was higher than that of ¹⁸ F-FDG PET/CT (0.857 vs. 0.666, p = 0.007). The disease-free survival rates were higher in the patients with primary tumor detection or p16 nodal immunopositivity than in the other patients (p < 0.05). The results showed that HPV and p16 detection in metastatic lymph nodes can help locate hidden primary tumors, guide definitive treatment and predict patient survival.

Transoral Robotic Surgery and the Unknown Primary: A Cost-Effectiveness Analysis

OBJECTIVE

To evaluate the cost-effectiveness of transoral robotic surgery (TORS) for the diagnosis and treatment of cervical unknown primary squamous cell carcinoma (CUP).

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary academic hospital.

SUBJECTS AND METHODS

A retrospective chart review was performed on patients with new occult primary squamous cell carcinoma of the head and neck with nondiagnostic imaging and/or endoscopy who were treated with TORS at a tertiary hospital between 2009 and 2012. Direct costs were obtained from the hospital's billing system, and national data were used for inpatient hospital costs and physician fees. The proportion of tumors found in 3 strategies was used as effectiveness to calculate the incremental cost-effectiveness ratio.

RESULTS

In total, 206 head and neck robotic cases were performed at our institution between December 2009 and December 2012. Three surgeons performed TORS on 22 patients for occult primary squamous cell carcinoma. The primary tumor was located in 19 of 22 patients (86.4%). The incremental cost-effectiveness ratio for sequential and simultaneous examination under anesthesia with tonsillectomy (EUA) and TORS base of tongue resection was $8619 and $5774 per additional primary identified, respectively.

CONCLUSION

Sequential EUA followed by TORS is associated with an incremental cost-effectiveness ratio of $8619 compared with traditional EUA alone. Bilateral base of tongue resection should be considered in the workup of these patients, particularly if the palatine tonsils have already been removed.