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Case Report

Case Report: A case of metastasis to branchial cleft cyst from papillary thyroid cancer

[version 1; peer review: 1 approved with reservations]
PUBLISHED 06 Jun 2024
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This article is included in the Datta Meghe Institute of Higher Education and Research collection.

Abstract

Branchial cleft cysts are frequently encountered congenital anomalies, arising from the first to fourth pharyngeal clefts and second branchial cleft anomalies are the most common. These anomalies, even though present from birth, become symptomatic only later in life. Majority of them are benign in nature. However, these cysts can get secondarily infected or can harbour secondary metastases and sometimes even primary malignancy in very rare cases. Here we discuss a case of a middle-aged female presenting with a gradually increasing branchial cleft cyst with incidental thyroid lesion on ultrasonography, later proven to be papillary thyroid carcinoma with metastatic spread to the brachial cleft cyst.

Keywords

Branchial cleft cyst, ultrasonography, thyroid gland, papillary carcinoma, metastases

Introduction

Incomplete obliteration of the first four pharyngeal arches gives rise to branchial cleft anomalies in the form of cysts, sinus or fistulae formation depending on the degree of obliteration during embryonic development.1,2 The most common branchial cleft anomaly is the branchial cleft cyst arising from the second pharyngeal cleft.1,3 Their most common location is below the mandible just anterior to sternocleidomastoid but can occur at any location along the path of second branchial apparatus.4 Since most of them are benign, their presentation to a clinician is usually when it increases in size or post-infection when it becomes tender with or without surrounding inflammatory skin changes.5,6 Investigating a symptomatic branchial cleft cyst becomes important to rule out neoplastic etiology and for early management.

Case Presentation

A 35-year-old female presented to the surgery OPD with a 2-3 cm swelling on the left side of the neck along the middle third of sternocleidomastoid muscle (Figure 1). The patient said that the swelling was present since many years. However, in the past three months there was gradual increase in the size of the swelling. It was round to oval in shape, soft in consistency, non-tender and freely movable over the underlying muscle. There was no evidence of adjacent skin changes or any other neck swelling on physical examination.

8e6ad066-fe4a-4f75-ba12-83521e0a0988_figure1.gif

Figure 1. Clinical image of the patient with a localized left sided anterior neck swelling.

The patient had no complains of difficulty in breathing or deglutition and no restriction in movement of the neck. She had no history of trauma, fever or any event of tuberculosis. Her routine blood investigations as well as thyroid profile was within normal ranges.

On ultrasound of the neck, the lesion measured 2 x 1.5 cm, was thin walled solid-cystic (cystic component> solid) with echogenic debris and abutting sternocleidomastoid muscle (Figure 2a). The solid component showed internal vascularity on color doppler (Figure 2b).

8e6ad066-fe4a-4f75-ba12-83521e0a0988_figure2.gif

Figure 2. Grey scale ultrasound images of the swelling showing the solid cystic nature of the lesion (a) and evident vascularity within the solid component on color doppler (b).

Thyroid gland was further examined on ultrasonography and appeared normal in maximum dimensions. The isthmus and right lobe were normal in echotexture (Figure 3).

8e6ad066-fe4a-4f75-ba12-83521e0a0988_figure3.gif

Figure 3. Grey scale ultrasound images with linear probe showing normal isthmus (a) and right lobe (b) of the thyroid gland.

However, the left lobe of thyroid revealed an ill-defined round (1 x 1 cm) hypoechoic solid lesion with punctate microcalcifications and increased vascularity within (Figure 4a). Rest of the left lobe appeared normal in echotexture as well as vascularity (Figure 4b). The lesion was graded BIRADS-4 on ultrasound indicating moderate suspicion for malignancy.

8e6ad066-fe4a-4f75-ba12-83521e0a0988_figure4.gif

Figure 4. Grey scale ultrasound images of the left lobe of thyroid showing a hypoechoic lesion with punctate microcalcifications (a) with peripheral vascularity in color doppler (b).

The patient was then further evaluated on computed tomography before subjecting the patient to FNAC (fine needle aspiration cytology) of the neck lesion. On contrast enhanced CT of the neck, there is a well-defined round solid-cystic lesion lying posterior to middle one-third of the left sternocleidomastoid muscle and focally abutting the left jugular vein. The lesion has thin enhancing wall and enhancing internal solid component (Figure 5).

8e6ad066-fe4a-4f75-ba12-83521e0a0988_figure5.gif

Figure 5. Contrast CT axial (a), coronal (b) and sagittal (c) images showing a well-defined cystic lesion with thin wall and enhancing solid component.

After these radiological investigations, the patient was then taken for FNAC of the swelling. The first sample that was fluid aspirate came out to be indeterminate in nature. However, in the next sampling, the solid component was targeted and it came out to be positive for malignant cytology. Since the patient had concurrent BIRADS-4 thyroid lesion, there was suspicion of thyroid malignancy with metastasis to the branchial cleft cyst. The thyroid lesion was then taken up for aspiration and was proven to be papillary thyroid carcinoma.

Discussion

Branchial cleft cysts are one of the most commonly encountered lateral neck masses.6,7 These are embryological remnants that occur due of failure of closure of the pharyngeal arches before birth.8 Metastases to the branchial cleft cyst is rare and identifying, differentiating it from cystic metastatic lymph nodes is important to plan treatment.9,10 Papillary thyroid carcinoma frequently metastasizes and therefore it is necessary to evaluate the thyroid gland in such instances to narrow down the diagnoses.11,12

Consent

Written informed consent for publication of their clinical details and clinical images was obtained from the patient.

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Shelar S, Gupta R, Dhande R and Parihar PH. Case Report: A case of metastasis to branchial cleft cyst from papillary thyroid cancer [version 1; peer review: 1 approved with reservations]. F1000Research 2024, 13:586 (https://doi.org/10.12688/f1000research.147343.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Open Peer Review

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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 1
VERSION 1
PUBLISHED 06 Jun 2024
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Reviewer Report 12 Aug 2024
Nor Azirah Salahuddin, Universiti Sains Islam Malaysia, Nilai, Malaysia 
Approved with Reservations
VIEWS 3
Major comment
  1. The discussion is too short. As we know branchial cyst can represent primary malignancy or secondary mets. How the author differentiates the initial diagnosis of branchial cystic vs malignant cystic swelling/secondary metastasis cystic neck swelling
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HOW TO CITE THIS REPORT
Salahuddin NA. Reviewer Report For: Case Report: A case of metastasis to branchial cleft cyst from papillary thyroid cancer [version 1; peer review: 1 approved with reservations]. F1000Research 2024, 13:586 (https://doi.org/10.5256/f1000research.161530.r307444)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (0)

Version 1
VERSION 1 PUBLISHED 06 Jun 2024
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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