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Presented by William Westra, M.D. and prepared by Maryam Farinola M.D.
Case 3: 44 year-old man with a neck mass.
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1. Question
Week 190: Case 3
44 year-old man with a neck mass.images/met SCC from tonsil 1.jpg
images/met SCC from tonsil 2.jpg
images/met SCC from tonsil 3.jpg
images/met SCC from tonsil 4.jpg
images/met SCC from tonsil 5.jpgCorrect
Answer: Metastatic squamous cell carcinoma from the tonsil
Histology: An enlarged lymph node is largely replaced by ribbons, lobules and sheets of basaloid squamous cells. In some areas, expanding lobules have undergone cystic change. At high magnification, the cells lining these cysts are lined by cells with moderate cellular atypia and increased mitotic activity. By in-situ hybridization, the tumor cells demonstrate an intranuclear dot-like signal for HPV-16 consistent with viral integration.
Discussion: Patients with squamous cell carcinoma of the head and neck have a tendency to present with advanced disease. Indeed, most patients already have metastatic spread to regional lymph nodes at the time of presentation, 13% of patients present with a neck mass as the first and only clinical manifestation, and 3% -9% of the primary tumors continue to elude detection even after clinical, radiographic, endoscopic and histopathologic evaluation. Pathologists are now equipped with an elemental armament to help discern the primary site of tumor origin for patients who present with lymph node metastases.
The first of these is morphological. Squamous cell carcinomas of tonsillar origin typically demonstrate a non-keratinizing basaloid morphology. Conversely, they lack the syncytial growth of nasopharyngeal carcinoma. Perhaps more helpful is the presence of cystic change. This feature is consistently present in metastatic carcinomas derived from the tonsil, and it is consistently absent in the metastases from other non-tonsillar sites.
Another tool takes advantage of the fact that some HNSCCs are caused by certain oncogenic viruses that target specific regions of the upper aerodigestive tract. In effect, detection of a specific virus in the metastasis implicates site of tumor origin. Most notably, Epstein-Barr virus is an etiologic agent in most carcinomas derived from the nasopharynx, and detection of Epstein-Barr virus in a neck metastasis reliably points to tumor origin from this site. In contrast, most tonsillar carcinomas (60%) harbor the Human papillomavirus type 16. By in-situ hybridization, HPV-16 can be detected in most metastatic carcinomas of tonsillar origin, but not in metastatic squamous cell carcinomas arising from other head and neck sites.
In this particular case, the presence of a basaloid morphology, cystic change, and HPV-16 all pointed to origin from the tonsil. A primary tonsillar carcinoma was indeed documented on a subsequent tonsillectomy.
Incorrect
Answer: Metastatic squamous cell carcinoma from the tonsil
Histology: An enlarged lymph node is largely replaced by ribbons, lobules and sheets of basaloid squamous cells. In some areas, expanding lobules have undergone cystic change. At high magnification, the cells lining these cysts are lined by cells with moderate cellular atypia and increased mitotic activity. By in-situ hybridization, the tumor cells demonstrate an intranuclear dot-like signal for HPV-16 consistent with viral integration.
Discussion: Patients with squamous cell carcinoma of the head and neck have a tendency to present with advanced disease. Indeed, most patients already have metastatic spread to regional lymph nodes at the time of presentation, 13% of patients present with a neck mass as the first and only clinical manifestation, and 3% -9% of the primary tumors continue to elude detection even after clinical, radiographic, endoscopic and histopathologic evaluation. Pathologists are now equipped with an elemental armament to help discern the primary site of tumor origin for patients who present with lymph node metastases.
The first of these is morphological. Squamous cell carcinomas of tonsillar origin typically demonstrate a non-keratinizing basaloid morphology. Conversely, they lack the syncytial growth of nasopharyngeal carcinoma. Perhaps more helpful is the presence of cystic change. This feature is consistently present in metastatic carcinomas derived from the tonsil, and it is consistently absent in the metastases from other non-tonsillar sites.
Another tool takes advantage of the fact that some HNSCCs are caused by certain oncogenic viruses that target specific regions of the upper aerodigestive tract. In effect, detection of a specific virus in the metastasis implicates site of tumor origin. Most notably, Epstein-Barr virus is an etiologic agent in most carcinomas derived from the nasopharynx, and detection of Epstein-Barr virus in a neck metastasis reliably points to tumor origin from this site. In contrast, most tonsillar carcinomas (60%) harbor the Human papillomavirus type 16. By in-situ hybridization, HPV-16 can be detected in most metastatic carcinomas of tonsillar origin, but not in metastatic squamous cell carcinomas arising from other head and neck sites.
In this particular case, the presence of a basaloid morphology, cystic change, and HPV-16 all pointed to origin from the tonsil. A primary tonsillar carcinoma was indeed documented on a subsequent tonsillectomy.
