Elsevier

Surgery

Volume 129, Issue 4, April 2001, Pages 429-432
Surgery

Original Communications
Occult papillary carcinoma of the thyroid presenting as a cervical cyst*,**

https://doi.org/10.1067/msy.2001.112965Get rights and content

Abstract

Background. A cystic neck mass representing metastatic papillary thyroid cancer to a cervical lymph node may be the presenting symptom in patients with an occult papillary cancer of the thyroid. This cystic change can cause diagnostic problems and not infrequently delay identification of the primary thyroid tumor. This study investigates the frequency, treatment, and pathologic features of this entity. Methods. All clinical charts and microscopic slides of 136 consecutive patients who underwent thyroid operation for papillary carcinoma (PC) from 1990 to 1995 were reviewed. Hematoxylin-and-eosin and immunohistochemical stains (IMHS) for thyroglobulin also were reviewed. Results. Eight patients (5.8%) presented with a cystic neck mass and no palpable thyroid lesion. In all 8 patients, the diagnosis was made by an excision of the cystic neck mass. In 3 patients, the cyst demonstrated classical features of PC, such as papillae and psammoma bodies. In the remaining 5 (62%), only focal papillae or nuclear features of papillary carcinoma were present. A careful review of the histology and IMHS were necessary to arrive at the correct diagnosis in these 5 patients. Conclusions. Occult papillary cancer of the thyroid presenting as a cystic neck mass is not uncommon and must be considered in the differential diagnosis. Excision and careful review of the histology and IMHS is necessary to prevent delay of the proper diagnosis. Although the thyroid tumor was less than 1 cm and sometimes only microscopic, the extensive nodal metastasis has led us to favor near total or total thyroidectomy and modified neck dissection in this entity. (Surgery 2001;129:429-32.)

Section snippets

Materials and methods

Our recent encounter with a lateral neck cyst with minimal architectural evidence of papillary thyroid carcinoma (PTC) prompted a review of the mode of presentation of PTC diagnosed and treated in our institution. The files of the Department of Pathology of Rhode Island Hospital were searched for all the cases of PTC diagnosed between 1990 and 1995 that presented solely as a cystic neck mass. There were 136 consecutive patients diagnosed and treated for PTC in this period, and 8 of these

Discussion

The usual differential diagnosis of a cystic neck mass includes branchial cleft cyst; teratoma, dermoid, and epidermoid cyst; hemangioma; and cystic hygroma. A malignancy can present as a lateral neck cyst, the most common being metastatic cystic squamous cell carcinoma of Waldeyer's tonsillar tissue.5, 6 Branchial cleft cyst carcinoma remains a controversial issue and strict criteria must be applied to accept this diagnosis.7, 8 Malignant salivary gland tumors and nasopharyngeal carcinoma less

Conclusion

OPC presenting as a cystic neck mass is not uncommon and must be considered in the differential diagnosis of any cystic neck mass. The presence of enlarged, optically clear, overlapping, and grooved nuclei and immunohistochemical staining for thyroglobulin can be the only defining criteria for the diagnosis of metastatic PTC in a cervical cyst. These features must be carefully searched for to prevent a delay in the proper diagnosis and treatment of the primary tumor.

Patients with OPC presenting

References (16)

  • I Levy et al.

    Cystic metastases of the neck from occult thyroid adenocarcinoma

    Am J Surg

    (1992)
  • ML Carcangiu et al.

    Papillary carcinoma of the thyroid. A clinicopathologic study of 241 cases treated at the University of Florence, Italy

    Cancer

    (1985)
  • ML Carcangiu et al.

    Papillary thyroid carcinoma: a study of its many morphologic expressions and clinical correlates

    Pathol Annu

    (1985)
  • F Tovi et al.

    Solitary lateral cyst: presenting symptom of papillary thyroid adenocarcinoma

    Ann Otol Rhinol Laryngol

    (1983)
  • JZ Clinberg et al.

    Cervical cysts: cancer until proven otherwise

    Laryngoscope

    (1982)
  • H Hall et al.

    Cystic cervical metastases are not branchiogenic carcinoma

    J Otolaryngol

    (1993)
  • H Martin et al.

    The case for branchiogenic cancer (malignant branchioma)

    Ann Surg

    (1950)
  • RA Khafif et al.

    Primary branchiogenic carcinoma

    Head Neck

    (1989)
There are more references available in the full text version of this article.

Cited by (57)

  • Metastatic thyroid carcinoma without identifiable primary tumor within the thyroid gland: a retrospective study of a rare phenomenon

    2017, Human Pathology
    Citation Excerpt :

    However, we have encountered rare cases where the primary tumors were not detected even after thorough and complete pathologic examination of the thyroid. To date, only 2 well-documented cases with entire microscopic examination of the thyroid gland but without mutation analysis have been reported [2,4]. The clinical presentation, pathologic features, molecular findings, and outcome of these metastatic thyroid carcinomas without detectable primary have not been well characterized.

  • Cervical adenopathies revealing thyroid microcarcinomas. Case study and literature review

    2011, Annales Francaises d'Oto-Rhino-Laryngologie et de Pathologie Cervico-Faciale
  • Cervical lymphadenopathies signaling thyroid microcarcinoma. Case study and review of the literature

    2011, European Annals of Otorhinolaryngology, Head and Neck Diseases
    Citation Excerpt :

    131I remnant ablation is the rule [25]. Prognosis seems controversial: Coleman reports a good prognosis [17], while others report a 28% rate of lateral lymph node recurrence after dissection [7]. In our series, two patients experienced a cervical lymph node recurrence at level IVb in one case and IIb in another, both with initial capsule rupture – a potentially poor prognostic factor.

View all citing articles on Scopus
*

Reprint requests: Jack M. Monchik, MD, 154 Waterman St, Providence, RI 02906.

**

Surgery 2001;129:429-32.

View full text