Branchial cleft cyst presenting as metastatic squamous carcinoma in fine needle aspirates 43 Imaging techniquesused for these patients can yield incorrect results In fact inour Case 1 MRI performed ID: 938224
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Cilt/ Volume3|/ Issue1|/ April2013 Branchial cleft cyst presenting as metastatic squamous carcinoma in fine needle aspirates 43 Imaging techniquesused for these patients can yield incorrect results. In fact, inour Case 1, MRI performed wrongly defined brachial cystas a cystic tumor originating from parotid gland.Another factor leading to misdiagnosis is the emer-gence of the cyst at an unexpected location with unusualmanifestations. In the literature, a 45-year-old malepatient who presented with cystic erosion of the skull base,patient who presented with cystic erosion of the skull base,As indicated before,in a 77-year-old patient, salivary gland, and lymphoid tis-in a 77-year-old patient, salivary gland, and lymphoid tis-Since we experienced uncertainties during diagnosticprocess and also clinical manifestations suggested a benignevent in addition to benign frozen section examinationresults of surgical specimens of both patients, we terminat-ed the operation after excision of cysts.icsquamous cell carcinoma and inflamed branchial cyst can1.van den Brekel MW, Castelijns JA, Stel HV, et al. Occultmetastatic neck disease: detection with US and US guided fine-2.Engzell U, Zajicek J. Aspiration biopsy of tumors of the neck. I.Aspiration biopsy and cytologic findings in 100 cases of congen-3.Burgess KL, Hartwick RW, Bedard YC. Metastatic squamouscarcinoma presenting as a neck cyst. Differential diagnosis frominflamed branchial cleft cyst in fine needle aspirates. Acta Cytol4.Thompson HY, Fulmer RP, Schnadig VJ. Metastatic squamouscell carcinoma of the tonsil presenting as multiple cystic neckmasses. Report of a case with fine needle aspiration findings.5.Engzell U, Jakobsson PA, Sigurdson A, Zajicek J. Aspiration biop-6.Granstrom G, Edstrom S. The relationship between cervical7.Warson F, Blommaert D, De Roy G. Inflamed branchial cyst: a8.Burgess KL, Hartwick RWJ, Bedard YC. Metastatic squamouscarcinoma presenting as a neck cyst. Differential diagnosis from9.Granstrom G, Edstrom S. The relationship between cervical10.Ahuja A, Ng CF, King W, Metreweli C. Solitary cystic nodal11.Ahn JY, Kang SY, Lee CH, Yoon PH, Lee KS. Parapharyngealbranchial cleft cyst extending to the skull base: a lateral transzy-gomatic-transtemporal approach to the parapharyngeal space.12.Takita M, Hamaguchi H, Lin YT, et al. Lymphoepithelial cyst needle aspirates: report of three cases.J Med Updates2013;3(1):40-43. Journal of Medical UpdatesSongu M et al. 42 Fine-needle aspiration cytology is an accurate techniquefor evaluating enlarged, solid, cervical nodes with very lowfor evaluating enlarged, solid, cervical node
s with very lowHowever,in cystic lesions, it may be difficult, or sometimes impossi-ble, to distinguish between benign and malignant squa-mous cells in aspirates, which, then, results in a high false-negative rate.[2,6]On the one hand, this diagnostic dilemmais related to reactive squamous atypia secondary to super-is related to reactive squamous atypia secondary to super-Conversely, metastatic SCC maytures that mimic benign lesions, such as keratinous cysts ortures that mimic benign lesions, such as keratinous cysts orA false-negative FNA cytologyfinding is likely to delay both the search for a primarytumor and adequate therapy. In contrast, the conse-quences of a false-positive diagnosis of metastatic SCC onradical neck dissection.While a FNA biopsy may aid diagnosis, it has beenreported that branchial cysts if inflamed can show bothcellular and nuclear pleomorphism when FNA examina-tion has been undertaken, such that the appearances cantion has been undertaken, such that the appearances canFor this rea-son, most of the time, tests, and time spent to search forthe primary focus are wasted. These frustrating efforts alsodelay proper treatment of the patient. Main factors facili-the time of diagnosis. A series consisting of 42 patientsdemonstrated the presence of malignancy in 80% of thepatients over 40 years of age, and despite FNA biopsiesperformed, the authors arrived at an accurate peroperativediagnosis in only three out of nine patients with differentdiagnosis of malignancy could only be made after postop-This study gives an idea about reliability of FNA biopsy. a Cilt/ Volume3|/ Issue1|/ April2013 Branchial cleft cyst presenting as metastatic squamous carcinoma in fine needle aspirates 41 We deemed it appropriate to present the findings, andmanagement results of our three patients treated in ourclinics for brachial cleft cysts, whose repetitive FNA biopsyresults were submitted as metastatic SCC, but compliedclinically with brachial cleft cyst. Case ReportsA 35-year-old female patient consulted to us with a swellingon the right side of her neck persisting for two months. Herphysical examination revealed a palpable, non-pulsatile,non-fluctuant, painless, and mobile mass with a consistencyof a rubber localized at the posterior aspect of the rightmandibular angle without any evidence of fixation to theskin or deeper layers whose dimensions did not change withstraining. Magnetic resonance imaging (MRI) results wereinterpreted as a cystic mass suggestive of a cystic tumor orig-inating from the parotid gland. The result of the first FNAbiopsy was interpreted as an evidence of a malig
n cytology(Fig. 1a). Subsequently, the patient had undergone panen-doscopy, and nasopharyngeal blind biopsy. A second FNAbiopsy, performed because of still undefined primary focus,was reported as a metastatic lesion of a cystic SCC. Due toinconclusive results, nasopharyngeal biopsy was repeatedand histopathologic result was recorded as a benign lesion.Accordingly, surgery was performed, and intraoperativefrozen section examination revealed a benign lesion, whichurged us to extirpate the mass. Postoperative histopatholog-ic examination was reported as brachial cleft cyst (Fig. 1b). Case 2A 40-year-old male patient consulted to our clinics withcomplaints of a swelling on his neck persisting for sometime. The result of his FNA biopsy was reported as suspectcytology, and tissue correlation was suggested for differen-tial diagnosis between metastatic SCC and lymphoma (Fig.2). However, it was learnt that the patient had been operat-ed in another medical center, and the mass lesion had beendiagnosed as a brachial cyst. Fig. 1.(a)demonstrating hyperchromatic squamous epithelium with large nuclei, inflammatory elements mainlycomposed of lymphocytes, and anuclear squamous components on a necrotic background (Giemsa x20). Postoperative histopathologic appearance of Case1 (b)demonstrating lymphoid elements, and inflammatory cells on the cyst wall lined with multilayered squamous epithelium with patchy areas of desqua-mation (HE x20). Fig. 2.Cytologic examination of the fine needle aspiration biopsy inCase 2 demonstrating necrotic changes on a dirty background, squama-toid cells with dark hyperchromatic nuclei, and eosinophilic dense cyto-plasm in loose cohesive groups or isolated cells some of them with elon-gated cytoplasms, and lymphocytes (HE x20). a The natu-ral history of upper aerodigestive tract malignancy is ofmetastasis to cervical lymph nodes. Occasionally, these necknodes may be the first mode of presentation.[2]Fine-needle aspiration (FNA) cytology has been shownto be very useful in the preoperative evaluation of neckmasses.[1]Most cases of solid metastatic squamous cell carci-noma (SCC) can be accurately diagnosed by FNA; howev-er, in cystic lesions, the cytologic distinction of SCC frombenign squamous cell lesions, particularly the ones withsuperimposed inflammatory atypia, can be diagnosticallyvery challenging.[2]Squamous cells in inflamed BCC canshow significant cytologic atypia and nuclear hyperchroma-tism and, therefore, can be easily confused with cysticmetastatic SCC to lymph nodes.[3]Conversely, cells frommetastatic, cystic, well differentiated SCC can be cytologi-cally bla
nd and may be difficult to distinguish from BCC.[4]Case Report/ Olgu SunumuJ Med Updates2013;3(1):40-43Murat Songu,Demet EtitDepartment of Otorhinolaryngology, zmir Atatürk Research and Training Hospital, Katip Çelebi University,zmir, Turkey Murat Songu, MD. Department of Otorhinolaryngology, zmir Atatürk Research andMay 4, 2013©2013 Sürekli E¤itim ve Bilimsel Aratrmalar Derne¤i(SEBAD) doi:10. ÖzetBa ve boynun metastatik skuamöz karsinomunun bir alt kümesi bo-yunda kistik kitlelerle ortaya çkmaktadr. Sklkla yass epitel hücrelikarsinomun bu kistik metastazlarn brankiyal yark kist gibi iyi huylukistik boyun lezyonlarndan ayrt etmek çok zor olabilmektedir. yihuylu kistik lezyonlarn iç yüzeyini kaplayan yass epitel hücreler önem-li hücre atipisi gösterebilerek yass epitel hücreli karsinomdan kaygla-nlmasna neden olurlar. Kstl sayda numune alnan ince i¤ne biyop-silerini de¤erlendirirken boynun iyi ve kötü huylu kistik skuamöz lez-yonlar arasnda ayrm yapmak daha çok zorlamaktadr. Burada bran-kiyal yark kistleri olan üç hasta sunulmaktadr. Hepsine balangçtametastatik yass epitel hücreli karsinom tans konmutu. Gereksiz radi-kal boyun diseksiyonu gibi cerrahi prosedürlerin uygulanmasna yolaçabilen metastatik yass epitel hücreli karsinom eksizyonu ihtimalin-den kaçnmak için deneyimli bir sitolog tarafndan ince i¤ne aspirasyonsitolojisinin yorumlanmasnn önemi vurgulanmaktadr. Anahtar sözcükler:Brankiyal yark kist, ince i¤ne biyopsisi, metastatikyass epitel hücreli karsinom. AbstractA subset of metastatic squamous cell carcinoma of the head and neckpresents as cystic masses in the neck. Often, distinguishing betweenthese cystic metastases of squamous cell carcinoma from benign cysticneck lesions, such as branchial cleft cyst, can be very challenging.Squamous lining cells in benign cystic lesions may exhibit significantcytologic atypia, raising concern for squamous cell carcinoma. Thechallenge in distinguishing benign from malignant cystic squamouslesions of the neck is made more difficult when evaluating fine needleaspiration biopsies given the limited sample size. Herein, three patientswith branchial cleft cysts are presented. All were initially diagnosed asmetastatic squamous cell carcinomas. The importance of interpretationof fine needle aspiration cytology by an experienced cytologist isemphasized to avoid the possibility of excising metastatic squamous cellcarcinomas, which could lead to unnecessary surgical procedures suchas radical neck dissection. Key words:Branchial cleft cyst, fine needle aspiration, metastaticsquamous cell carcinoma.