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Presented by Dr. White and prepared by Austin McCuiston.
75 year old female with a lateral neck mass.
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1. Question
75 year old female with a lateral neck mass.
Correct
Answer: B
Histology: At low magnification, there is a cystic epithelial lined lesion with associated lymphoid tissue involving fibrovascular and adipose tissue. A small focus of benign salivary gland tissue is present. The epithelial lining shows an undulating interface with the associated lymphoid and fibrous tissue. On higher magnification, the epithelial cells show squamous features, with distinct cell borders, areas of keratinization, and prominent glyocgenated cytoplasm. The nuclei are hyperchromatic with varying degrees of atypia, and some showing marked pleomorphism. Scattered mitotic figures are identified, in addition to areas of necrosis. The associated lymphoid tissue shows scattered germinal centers, and areas with intact lymphoid sinuses are seen.
Discussion: Patient demographics and specific anatomic location are critical when assessing cystic epithelial lined lesions in the neck. Although the differential for cystic squamous lesions in the lateral neck includes branchial cleft cysts, a retrospective review by Gourin demonstrated that the incidence of metastatic squamous cell carcinoma in isolated lateral cervical cysts is significantly higher in patients greater than 40 years of age. Although the patient in this case had a known history of a primary head and neck SCC, it is not uncommon for a patient to present with a lateral neck SCC metastasis and an occult primary. Specifically this is well-described for HPV-related oropharyngeal SCC. In the absence of a known primary and a lateral neck SCC metastasis, it is prudent to perform p16 and confirmatory high risk HPV ISH. P16 positivity (> or equal to 70% nuclear and cytoplasmic expression with at least moderate to strong intensity) alone is not entirely specific for HPV related OPSCC, as p16 has been reported to be positive in up to 43% of benign lymphoepithelial cysts of the lateral neck (ie branchial cleft cyst) and parotid gland.
References:
Gourin CG, Johnson JT. Incidence of unsuspected metastases in lateral cervical cysts. Laryngoscope. 2000 Oct;110(10 Pt 1):1637-41. PubMed PMID: 11037817.Cao D, Begum S, Ali SZ, Westra WH. Expression of p16 in benign and malignant cystic squamous lesions of the neck. Hum Pathol. 2010 Apr;41(4):535-9. doi: 10.1016/j.humpath.2009.09.006. Epub 2009 Dec 11. PubMed PMID: 20004950.
Fakhry C, Lacchetti C, Rooper LM, Jordan RC, Rischin D, Sturgis EM, Bell D, Lingen MW, Harichand-Herdt S, Thibo J, Zevallos J, Perez-Ordonez B. Human Papillomavirus Testing in Head and Neck Carcinomas: ASCO Clinical Practice Guideline Endorsement of the College of American Pathologists Guideline. J Clin Oncol. 2018 Sep 6:JCO1800684. doi: 10.1200/JCO.18.00684. [Epub ahead of print] PubMed PMID: 30188786.
Incorrect
Answer: B
Histology: At low magnification, there is a cystic epithelial lined lesion with associated lymphoid tissue involving fibrovascular and adipose tissue. A small focus of benign salivary gland tissue is present. The epithelial lining shows an undulating interface with the associated lymphoid and fibrous tissue. On higher magnification, the epithelial cells show squamous features, with distinct cell borders, areas of keratinization, and prominent glyocgenated cytoplasm. The nuclei are hyperchromatic with varying degrees of atypia, and some showing marked pleomorphism. Scattered mitotic figures are identified, in addition to areas of necrosis. The associated lymphoid tissue shows scattered germinal centers, and areas with intact lymphoid sinuses are seen.
Discussion: Patient demographics and specific anatomic location are critical when assessing cystic epithelial lined lesions in the neck. Although the differential for cystic squamous lesions in the lateral neck includes branchial cleft cysts, a retrospective review by Gourin demonstrated that the incidence of metastatic squamous cell carcinoma in isolated lateral cervical cysts is significantly higher in patients greater than 40 years of age. Although the patient in this case had a known history of a primary head and neck SCC, it is not uncommon for a patient to present with a lateral neck SCC metastasis and an occult primary. Specifically this is well-described for HPV-related oropharyngeal SCC. In the absence of a known primary and a lateral neck SCC metastasis, it is prudent to perform p16 and confirmatory high risk HPV ISH. P16 positivity (> or equal to 70% nuclear and cytoplasmic expression with at least moderate to strong intensity) alone is not entirely specific for HPV related OPSCC, as p16 has been reported to be positive in up to 43% of benign lymphoepithelial cysts of the lateral neck (ie branchial cleft cyst) and parotid gland.
References:
Gourin CG, Johnson JT. Incidence of unsuspected metastases in lateral cervical cysts. Laryngoscope. 2000 Oct;110(10 Pt 1):1637-41. PubMed PMID: 11037817.Cao D, Begum S, Ali SZ, Westra WH. Expression of p16 in benign and malignant cystic squamous lesions of the neck. Hum Pathol. 2010 Apr;41(4):535-9. doi: 10.1016/j.humpath.2009.09.006. Epub 2009 Dec 11. PubMed PMID: 20004950.
Fakhry C, Lacchetti C, Rooper LM, Jordan RC, Rischin D, Sturgis EM, Bell D, Lingen MW, Harichand-Herdt S, Thibo J, Zevallos J, Perez-Ordonez B. Human Papillomavirus Testing in Head and Neck Carcinomas: ASCO Clinical Practice Guideline Endorsement of the College of American Pathologists Guideline. J Clin Oncol. 2018 Sep 6:JCO1800684. doi: 10.1200/JCO.18.00684. [Epub ahead of print] PubMed PMID: 30188786.
