IP Journal of Otorhinolaryngology and Allied Science

Print ISSN: 2582-4147

Online ISSN: 2582-421X

CODEN : IJOABK

IP Journal of Otorhinolaryngology and Allied Science (JOAS) open access, peer-reviewed quarterly journal publishing since 2018 and is published under the Khyati Education and Research Foundation (KERF), is registered as a non-profit society (under the society registration act, 1860), Government of India with the vision of various accredited vocational courses in healthcare, education, paramedical, yoga, publication, teaching and research activity, with the aim of faster and better dissemination more...


  • Article highlights
  • Article tables
  • Article images

Article statistics

Viewed: 100

PDF Downloaded: 57

Singh, Gupta, Kaur, and Gupta: Cystic cervical metastasis: A diagnostic dilemma


Introduction

Up to the first half of 20th century all cystic cervical metastasis of squamous cell carcinoma were thought to be of branchiogenic origin. They were labeled as cancers of branchial cleft cysts, which have undergone malignant degeneration. Now it is known, that certain squamous cell carcinoma of waldeyer’s ring is capable of producing a cystic cervical metastasis. The aim of this case report is to highlight such phenomenon which aids doctors in such diagnostic dilemmas.1, 2, 3 The majority of cystic secondaries arise from oropharyngeal tumors.4

Figure 1

Clinical preoperative picture showing the extent and surface of the right-side swelling.

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/5ca1e77e-445c-4ef4-b3df-6cc934cb8ad9/image/7fb510bf-b2c7-4541-ab49-de1dee97c60d-uimage.png

Figure 2

Clinical picture showing positive trans illumination confirming cystic mass.

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/5ca1e77e-445c-4ef4-b3df-6cc934cb8ad9/image/f9bb048a-ef2c-453c-a7f9-4a2c77bf01f2-uimage.png

Figure 3

Axialcut section of contrast enhanced computed tomogram showing a hypodense lesionon the right of neck extending up to clavicle with no contrast uptake and withno significant central necrosis.

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/5ca1e77e-445c-4ef4-b3df-6cc934cb8ad9/image/a274c260-fe2d-41b9-a839-1edc849595a1-uimage.png

Figure 4

Clinical picture showing left side cervical swelling at the level II A, seen after a month of initial presentation.

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/5ca1e77e-445c-4ef4-b3df-6cc934cb8ad9/image/aaffd108-b45e-445c-a110-a2fe1508a8ff-uimage.png

Figure 5

Axialsection of 18 FDG PET-CT showing hypodense lesion on right side neck with central necrosis and enhanced uptake at periphery and left side base of tongue.

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/5ca1e77e-445c-4ef4-b3df-6cc934cb8ad9/image/d3072310-ebf7-431a-8bf1-0a165e2b6a05-uimage.png

Case Report

A 57-year-old male presented to our department with a right side slow growing neck swelling for 2 years. The swelling was about 9cmX7 cm in dimension and it extended from below the ear lobule on the right side to two fingers above the clavicle in vertical dimension and horizontally from anterior border of sternocleidomastoid to anterior border of trapezius. On clinical examination it was a solitary swelling with diffuse margins, uniform with non-bosselated surface, skin over the swelling appeared normal [Figure 1]. On palpation the swelling was having normal temperature, non-tender, cystic, fluctuant, but fixed to underlying structures, compressible but not reducible. Skin was pinchable over the swelling. There was no bruit on auscultation and swelling was trans-illuminant [Figure 2]. There was history of smoking and alcohol consumption. There was no history of weight loss or night sweats. No history of hemoptysis and hematemesis.

Rest of ear, nose and throat examination was normal. Ultrasonography revealed a heterogenous, hyperechoic cystic lesion on the right side. FNAC from the right side swelling aspirated 10 ml of straw-colored fluid which neither revealed any malignant cell nor cholesterol crystals. CECT neck revealed a large hypodense lesion on the right side with no contrast uptake [Figure 3]. Since a malignant lesion couldn’t be identified a diagnosis of branchial cleft cyst was made and surgery advised, which the patient refused.

The patient presented after a month with voice change, difficulty in swallowing and another swelling on left side of the neck. The second swelling was about 3cmX2 cm behind the angle of mandible [Figure 4]. It was hard in consistency and fixed. Direct endoscopy revealed right vocal cord paralysis. Rest of the cranial nerve examination were normal. FNAC from the left neck swelling revealed metastatic squamous cell carcinoma. Patient was advised for PET-CT to pick up unknown primary, which revealed a left tongue base lesion [Figure 5 ]. Patient underwent excision biopsy from tongue base and extended radical neck dissection on right side (internal jugular vein thrombosed, sternocleidomastoid, platysma, vagus and hypoglossal nerve involved) and modified radical neck dissection type III on left side.

Discussion

Cystic cervical swelling often presents a diagnostic challenge for an otorhinolaryngologist because these lesions can be either benign or malignant. According to literature, any cervical swelling in an adult above 40 years of age should be considered malignant till proven otherwise 5. Previously, patients with cystic cervical metastasis were considered to be having branchiogenic carcinoma, which occurs due to malignant transformation in vestigial remnants of the branchial pouches.1, 2, 3

The recent literature, lays suggests that a solitary cystic cervical secondary may be associated with an occult or unknown primary in the tonsils, base of tongue or nasopharynx.6 The cystic secondary has a better prognosis, in comparison to solid neck secondaries of squamous cell carcinomas of the head and neck. It carries, 5-year survival rate of 77% and a 10-year survival rate of 50% (4).

The cystic metastatic lymph node has the major volume of liquid center with peripheral solid rim of lymphatic tissue. This occurs due to pseudocystic changes resulting from spontaneous breakdown of keratin and necrotic degradation of carcinomatous deposit.7 It also, may occur due to blockage of lymphatic flow in a metastatic node and collection of lymph.8 The nodal metastases in human papilloma virus associated squamous cell carcinoma of oropharynx, have been found to be prone for cystic degeneration.9 Also, the malignant cells have a slower growth rate in cystic metastasis10, that explains our patient long history of 2 years before presentation.

In an adult patient with cystic cervical mass, there is a possibility of malignancy and the clinical and radiological assessment should include whole head and neck area, in particular tonsils, base of tongue and nasopharynx. Any suspicious looking lesion should be biopsied and submitted for histopathology examination.

FNAC is a routine, simple investigation helpful in solid cervical lesions, but the sensitivity to reach a true diagnosis is low in malignant cystic metastases and branchial cysts (73% and 60% respectively).6 The false negative report in cystic secondary patient, may lead to false security, resulting in delay in search for primary and initiation of appropriate oncologic treatment. The FNAC should be repeated under ultrasound guidance from solid parts in the cyst, when in doubt.

The ultrasonography and Computed Tomography aids in the diagnosis of a cervical cystic mass. The branchial cleft cyst is well circumscribed, oval-shaped, with a non-contrast enhanced thin wall, with a hypodense and homogeneous center and with no septations. While the nodal metastatic lesion will be irregular, with peripheral contrast enhancement, invasion of adjacent structures, internal vascularization, heterogeneous center and internal septations.4 PET- CT, as in our case is helpful to identify unknown primary and also rule out chest metastasis, in patients presenting with secondaries, but negative clinical and radiological work-up.11

Conclusion

Cystic cervical metastatic swelling is uncommon presentation as it mimics branchial cleft anomaly. In an adult over 40 years of age, thorough clinical, Histopathological and radiological examination of head and neck is necessary. As the treatment protocol for benign and malignant pathology is very different, delay in treatment may be life threatening for the patient with malignancy. This case report specifically highlights these points.

Source of Funding

None.

Conflict of Interest

None.

References

1 

P M Flanagan N J Roland A S Jones Cervical node metastases presenting with features of branchial cystsJ Laryngology Otol19941081210687110.1017/s0022215100128907

2 

Z James M D Cinberg ervical cysts: Cancer until proven otherwise?Laryngoscope1982921273010.1288/00005537-198201000-00006

3 

G Granström S Edström The relationship between cervical cysts and tonsillar carcinoma in adultsJ Oral Maxillofac Surg1989471162010.1016/0278-2391(89)90117-1

4 

G Z Zhang Z L Liu J S Gong Z Q Cheng C Ke Cystic metastatic nasopharyngeal carcinoma presenting as branchial cleft cyst: report of two cases and review of the literatureJ Oral Maxillofac Surg2014721123667410.1016/j.joms.2014.05.020

5 

P J Andrew C E B Giddings A P Su Management of lateral cystic swellings of the neck, in the over 40s’ age groupJ Laryngology Otol200311743182010.1258/00222150360600977

6 

P Sheahan G O Leary G Lee J Fitzgibbon Cystic Cervical Metastases: Incidence and Diagnosis using Fine Needle Aspiration BiopsyOtolaryngol Head Neck Surg20021274294810.1067/mhn.2002.128600

7 

K Verma S Mandal K Kapila Cystic change in lymph nodes with metastatic squamous cell carcinomaActa Cytol199539347880

8 

D Goldenberg S Begum W H Westra Z Khan J Sciubba S I Pai Cystic lymph node metastasis in patients with head and neck cancer: An HPV-associated phenomenonHead Neck200830789890310.1002/hed.20796

9 

E B Stelow V Y Jo M H Stoler S E Mills Human Papillomavirus-associated Squamous Cell Carcinoma of the Upper Aerodigestive TractAM J Surg Pathol2010347e15e2410.1097/pas.0b013e3181e21478

10 

L D Thompson D K Heffner The clinical importance of cystic squamous cell carcinomas in the neckCancer19988259445610.1002/(sici)1097-0142(19980301)82:5<944::aid-cncr21>3.0.co;2-#

11 

J Johansen S Buus A Loft S Keiding M Overgaard H S Hansen Prospective study of 18FDG-PET in the detection and management of patients with lymph node metastases to the neck from an unknown primary tumor. Results from the DAHANCA-13 studyHead Neck2008304471810.1002/hed.20734



jats-html.xsl

© This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Article type

Case Report


Article page

75-78


Authors Details

Anshul Singh, Manish Gupta, Cynthia Kaur, Akanksha Gupta


Article History

Received : 24-06-2021

Accepted : 12-07-2021

Available online : 04-08-2021


Article Metrics


View Article As

 


Downlaod Files

   








Wiki in hindi