Prevalence of cystic metastases in a consecutive cohort of surgically removed branchial cleft cysts.

BACKGROUND: Solitary cystic lesion of the neck may often be the only initial presenting symptom for branchial cleft cysts and cystic metastases. AIMS/OBJECTIVES: To analyse the malignancy rate detected in patients undergoing surgical treatment for lateral branchial cleft cyst. MATERIAL AND METHODS: The records of all patients with surgical procedure code ENB40 (Excision of lateral branchial cleft cyst- or fistula) between 2003 and 2019 were reviewed. After excluding 150 patients, 436 patients were included for final analysis. Re-evaluation of the cytology including HPV-analysis was performed in those who had a malignant cyst. RESULTS: Cystic metastases were demonstrated histologically after surgical excision in 13 patients (3%). In patients over 18 years of age, the prevalence of cystic metastasis regardless of the primary tumour type was 3.3%. CONCLUSION AND SIGNIFICANCE: When the investigation protocol for solitary cystic lesions of the neck is followed, the negative predictive value for malignancy is 97%. All adult patients with a cytologic verified diagnosis of branchial cyst should be examined with HPV-analysis of the cystic sample before excision of the cyst. Failure of predicting a malignancy is often associated with cytology of poor cellularity which may be improved by more frequent use of ultrasound guided fine-needle aspiration cytology (FNAC).

Validation of Human Papillomavirus as a Favourable Prognostic Marker and Analysis of CD8+ Tumour-infiltrating Lymphocytes and Other Biomarkers in Cancer of Unknown Primary in the Head and Neck Region.

BACKGROUND: Human papillomavirus (HPV) is a favourable prognostic factor in oropharyngeal cancer. Moreover, we and others reported that HPV-positive cancer of unknown primary in the head and neck region (HNCUP) has better outcome than HPV-negative HNCUP. However, not all studies concord. Here, our previous finding was investigated in a new cohort and additional biomarkers were analyzed. MATERIALS AND METHODS: A total of 19 HNCUPs diagnosed 2008-2013 were analyzed for HPV DNA by polymerase chain reaction assay (PCR) and p16 by immunohistochemistry (IHC). Thereafter, 69 HNCUPs diagnosed between 2000-2013 were analyzed for HPV16 mRNA by PCR (if HPV16DNA-positive) and cluster of differentiation 8 positive (CD8+) tumour-infiltrating lymphocytes (TILs) and human leukocyte antigen (HLA) class I-expression using IHC. RESULTS: HPV DNA, alone and in combination with p16 overexpression, was validated as a favourable prognostic factor in HNCUP. HPV16 mRNA was present in most HPV16 DNA-positive cases, confirming HPV-driven carcinogenesis in HNCUP. High CD8+ TIL counts indicated favourable prognosis. CONCLUSION: HPV status is useful for the management of patients with HNCUP and the role of CD8+ TILs should be further explored.

Human papillomavirus and p53 expression in cancer of unknown primary in the head and neck region in relation to clinical outcome.

Patients with cancer of unknown primary (CUP) in the head neck region are generally treated with neck dissection followed by radiotherapy at times combined with chemotherapy, a treatment associated with considerable side effects. Some of these tumors may originate as human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OSCC), with better clinical outcome than head neck squamous cell cancer (HNSCC) in general, and could potentially do well with less treatment. Here, we therefore investigated whether HPV status and p53-expression correlated to clinical outcome in patients with CUP in the head neck region. Fifty metastases were analyzed for presence of HPV DNA, and expression of p16(INK4A) and p53 and the data were correlated to clinical outcome. Patients with HPV DNA-positive (HPVDNA+) metastases had significantly better 5-year overall survival (OS) compared to those with HPVDNA- metastases (80.0% vs. 36.7%, respectively; P = 0.004), with a similar tendency for disease-free survival (DFS). These survival rates showed excellent concordance with those of HPVDNA+ and HPVDNA- OSCC in Sweden during the same time period, strengthening the hypothesis that HPVDNA+ head and neck CUP may originate from HPVDNA+ OSCC. In addition, having absent/intermediary-low as compared to high expression of p53 correlated to a better prognosis with a 69% as compared to 14% 5-year OS, respectively (P < 0.001), and for DFS the tendency was analogous. In conclusion, both HPV status and p53 expression are valuable prognostic factors in patients with CUP in the head and neck region and should be further explored for clinical use.

Image cytometry DNA-analysis of fine needle aspiration cytology to aid cytomorphology in the distinction of branchial cleft cyst from cystic metastasis of squamous cell carcinoma: a prospective study.

OBJECTIVE: Frequently, the distinction between branchial cleft cyst and cystic metastases from squamous cell carcinoma is difficult by cytomorphology. In a prospective study, we investigated the need for, and the value of, image cytometry DNA-analysis as a complement to cytologic evaluation of cystic lesions in the neck. STUDY DESIGN: Image cytometry DNA-analysis was performed on the fine needle aspiration cytology smears from 50 patients, referred to our department, with a solitary cystic lesion in the lateral region of the neck. METHODS: Smears from aspirates were Giemsa stained and cytologically evaluated. Ahrens image analysis was used for DNA analysis on smears stained with Schiff reagent, and lymphocytes were used as control cells. Epithelial cells with DNA values exceeding 5c were regarded as aneuploid, indicating malignancy. RESULTS: Nine lesions were diagnosed as squamous cell cancer metastases cytologically. DNA analysis showed aneuploidy in all of them except one. Three of these lesions had earlier been diagnosed as branchial cleft cyst at the referring hospital. Eight lesions were cytologically inconclusive and four of them were revealed as cystic metastasis at histopathologic analysis, and DNA analysis showed aneuploidy in all but one, which could not be analyzed. Two of these lesions were also diagnosed as branchial cleft cysts at the referring hospital. All benign lesions were diploid. Nine lesions were thyroid and salivary gland lesions. CONCLUSION: Image cytometry DNA-analysis was shown to help in the distinction between benign and malignant cystic lesions. Thus, when conventional cytomorphology does not suffice, DNA-analysis is clearly a valuable supplement.

Laminin-5 gamma 2: a marker to identify oral mucosal lesions at risk for tumor development?

Mucosal lesions of various types are frequently encountered in the oral cavity and a limited proportion of these will eventually progress to invasive cancer. Neither macroscopic nor microscopic evaluation can give reliable information concerning risk for cancer development which is why a marker indicating high risk for tumor progression would be of significant value. Laminins are a family of alpha beta gamma heterotrimeric proteins found in basement membranes and earlier studies have shown that laminin-5 gamma 2 expression is a useful marker of invasiveness in head and neck squamous cell carcinomas. Unique material comprising 36 different oral mucosal lesions from 15 patients, prior to the development of invasive carcinoma (12 cases) or cancer in situ (CIS) (3 cases) on the same site, was investigated. For controls we had mucosal lesions from 15 patients without malignant progression. These 15 lesions matched with the specific site in the oral cavity of the initial patients. The minimum follow-up time for the control group was at least 36 months. We performed immunohistochemical staining with a monoclonal antibody against the recombinant gamma 2 chain of laminin-5 in the archived biopsies of preneoplastic oral lesions. Nine out of 15 cases of preneoplastic lesions which became invasive/CIS were laminin-5-positive (60%) whereas only 3 out of 13 (2 were excluded due to sparse material for laminin-5 analysis) lesions which did not progress were laminin-5-positive (23%) (p = 0.05). The results indicate that oral mucosal lesions expressing laminin-5 show an increased risk for tumor progression.

The clinical value of image cytometry DNA analysis in distinguishing branchial cleft cysts from cystic metastases of head and neck cancer.

OBJECTIVES/HYPOTHESIS: A branchial cleft cyst presents as a lump in the neck that, generally, is easily cured by surgical excision. The preoperative diagnosis is based on clinical examination and, especially in the Scandinavian countries, fine-needle aspiration cytology. However, at times, the histopathological analysis of the excised cyst reveals a cystic metastasis of squamous cell carcinoma of the head and neck. If adequate diagnosis could be obtained preoperatively, patients would most likely fare better. The study was performed to investigate whether the diagnostic accuracy for these lesions could be improved preoperatively by image cytometry DNA analysis of the fine-needle aspiration cytology specimen. STUDY DESIGN: Image cytometry DNA analysis was performed on the preoperative fine-needle aspiration cytology specimen and the surgical specimens from 51 patients with solitary cysts in the lateral region of the neck. Thirty-six patients were selected because there was a discrepancy between findings on fine-needle aspiration cytology and the final histopathological diagnosis or an uncertain cytological diagnosis. There were 25 metastatic squamous cell carcinomas and 3 thyroid cancers, there was 1 lymphoma and 1 sialoadenitis, and there were 21 branchial cleft cysts. METHODS: The cytodiagnostic Giemsa-stained slides were destained in Methanol and then stained with Schiff's reagent. The paraffin-embedded material from excised cysts were cut and deparaffinized and then stained with Schiff's reagent. Ahrens image analysis was used for DNA analysis and lymphocytes were used as control cells. DNA valves exceeding 5c was regarded as aneuploid. RESULTS: Image cytometry DNA analysis of the preoperative cytological specimen was possible in 41 of 51 patients. We found that in 53% of the cases with cystic metastasis, image cytometry DNA analysis, when possible, revealed aneuploidy, thus indicating malignancy. DNA analysis showed diploidy in all benign cases. CONCLUSIONS: Aneuploidy is highly specific for malignancy. Image cytometry DNA analysis increases the diagnostic sensitivity for malignant cystic metastasis and therefore is a valuable supplement to conventional cytological study for these lesions.