Nasopharyngeal Carcinoma with Cystic Cervical Metastasis Masquerading as Branchial Cleft Cyst: A Potential Pitfall in Diagnosis and Management

Document Type: Case Report

Authors

1 Department of Otorhinolaryngology – Head and Neck Surgery, University Kebangsaan Malaysia Kebangsaan Medical Centre (UKMMC), Kuala Lumpur, Malaysia.

2 Department of Pathology, Hospital Serdang, Selangor, Malaysia.

Abstract

Introduction:
Most metastatic lymph nodes from head and neck malignancy are solid. Cystic nodes are found in 33% - 61% of carcinomas arise from Waldeyer’s ring, of which only 1.8% - 8% originate are from the nasopharynx. Some cystic cervical metastases were initially presumed to be branchial cleft cyst. This case report aims to highlight the unusual presentation of cystic cervical metastasis secondary to nasopharyngeal carcinoma in a young adult. The histopathology, radiological features and management strategy were discussed.
 Case Report:
A 36-year-old man presented with a solitary cystic cervical swelling, initially diagnosed as branchial cleft cyst. Fine needle aspiration yielded 18 ml of straw-coloured fluid. During cytological examination no atypical cells were observed. Computed tomography of the neck showed a heterogeneous mass with multiseptation medial to the sternocleidomastoid muscle. Histopathological examination of the mass, post excision, revealed a metastatic lymph node. A suspicious mucosal lesion at the nasopharynx was detected after repeated thorough head and neck examinations and the biopsy result confirmed undifferentiated nasopharyngeal carcinoma.
 Conclusion:
Cystic cervical metastasis may occur in young patients under 40 years. The primary tumour may not be obvious during initial presentation because it mimicks benign branchial cleft cyst clinically. Retrospective review of the computed tomography images revealed features that were not characteristic of simple branchial cleft cyst. The inadequacy of assessment and interpretation had lead to the error in diagnosis and subsequent management. Metastatic head and neck lesion must be considered in a young adult with a cystic neck mass.

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1. Gourin CG, Johnson JT. Incidence of unsuspected metastases in lateral cervical cysts. Laryngoscope 2000; 110: 1637-41.

2. Regauer S, Mannweiler S, Anderhuber W, Gotschuli A, Berghold A, Schachenreiter J. Cystic lymph node metastases of squamous cell carcinoma of Waldeyer’s ring origin. Br J Cancer 1999; 79: 1437-42.

3. Goldenberg D, Sciubba J, Koch WM. Cystic metastasis from head and neck squamous cell cancer: A distinct disease variant? Head Neck 2006; 28: 633-8.

4. Zhang GC, Liu ZL, Gong JS, Cheng ZQ, Ke CY. Cystic metastatic nasopharyngeal carcinoma presenting as branchial cleft cysts: Report of two cases and review of the literature. J Oral Maxillofac Surg 2014; 72: 2366-74.

5. Andrews PJ, Giddings CEB. Management of lateral cystic swelling of the neck, in the over 40s’ age group. J Laryngol Otol 2003; 117: 318-20.

6. Tsukuda M, Ooishi K, Mochimatsu I, Sato H. Head and neck carcinomas in patients under the age of forty years. Jpn J Cancer Res 1993; 84:
748-52.

7. Jereczek-Fossa BA, Casadio C, Jassem J, Luzzatto F, Viale G, Bruschini R et al. Branchiogenic carcinoma – conceptual or true clinic-pathological entity? Cancer Treat Rev 2005; 31(2): 106-14.

8. Sheahan P, O’Leary G, Lee G, Fitzgibbon J. Cystic cervical metastases: incidence and diagnosis using fine needle aspiration biopsy. Otolaryngol Head Neck Surg 2002; 127: 294-8.

9. Mallet Y, Lallemant B, Robin YM, Lefebvre JL. Cystic lymph node metastases of head and neck squamous cell carcinoma: Pitfalls and controversies. Oral Oncol 2005; 41: 429-34.