Tonsillar Carcinoma Research Articles

Outcomes of primary trans-oral surgical management of early tonsillar squamous cell carcinoma with risk-adapted adjuvant radiotherapy

Background: Transoral robotic surgery (TORS) is an accepted surgical treatment modality for patients with oropharyngeal squamous cell carcinoma (OPSCC). A prospective study was conducted to test patient selection for unimodality TORS in early OPSCC, with the primary endpoint being avoidance of adjuvant radiotherapy (RT) or chemoradiation (CRT) as per recommended guidelines. Methods: Patients underwent comprehensive evaluation including multidisciplinary team (MDT) review and staging (AJCC 7 th edition). Primary TORS was offered to patients with T1–2 lateralized tonsillar tumours, N0–1 with no extracapsular spread (ECS). Adjuvant RT or CRT were recommended if prespecified pathologic criteria were met, including close or positive margins, ECS and N2b disease. Results: Twenty-six patients underwent TORS, all with negative margins. Seven patients (26.9%) met one or more upstaging criteria, most commonly pN2b (5 patients, 19.2%) and close margin (3 patients, 11.5%). Five patients (19.2%) proceeded to adjuvant therapy with two patients declining further treatment. Conclusions: Single modality treatment of early tonsillar SCC utilising TORS is feasible amongst patients who undergo comprehensive evaluation including MDT review.

Reduced Intensity Conditioning for Allogeneic Hematopoietic Cell Transplantation Utilizing Cladribine and Melphalan

Introduction Reduced intensity conditioning (RIC) allogeneic hematopoietic cell transplantation (HCT) has been shown to be successful; however, the ideal RIC regimen is not known. In this study, we report the pooled results of three separate prospective studies utilizing cladribine (2CdA) and melphalan (Mel) based conditioning in patients undergoing allogeneic HCT. Objectives To determine the feasibility, toxicity, and efficacy of a 2Cda/Mel based regimen in patients requiring RIC HCT. Methods 63 adult patients were treated with 2Cda/Mel and included for analysis (84% greater than 50 years of age). 40 men and 23 women received HCT between 1999 and 2014 at Scripps Clinic. 17 patients had previously undergone autologous HCT. All patients received 2CdA 0.14 mg/kg/day for either 4 or 5 days and Mel at either 100 mg/m2 or 180mg/m2 total dose. All patients received rabbit-derived anti-thymocyte globulin (ATG). 22 unrelated recipients received Methotrexate. 41 related recipients received oral cyclosporine as GVHD prophylaxis. 22 patients received tacrolimus as GVHD prophylaxis. Donor lymphocyte infusions (DLI) were allowed but not scheduled. Results Two patients expired prior to neutrophil engraftment; for the remaining 61 the median time to recovery of absolute neutrophil count > 0.5 × 109/L was 12 days (range 9-21). 7 patients expired prior to platelet engraftment; for the remaining 56 the median time to platelets >20 × 109/L without transfusion support was 19 days (12-55). Median overall survival for all 63 patients was 17 months (11 days to 16 years). 10 patients expired prior to day 100, 19 between day 101 and 365, and 14 greater than one year. Diseases included AML (18), Lymphoma (15), MDS (8), Multiple Myeloma (5) and others (17). Non-relapse mortality (NRM) at 100 days, NRM at 365 days, and 1 year OS were 18%, 53%, and 26% for AML, 0%, 37%, and 63% for MDS, and 13%, 27%, and 73% for Lymphoma. In evaluable patients, Grade 2-4 acute GVHD was seen in 47%. Grade 3-4 acute GVHD was seen in 34%. Chronic GVHD was seen in 45% of patients. For 2 patients, acute GVHD was the primary cause of death. 18 patients received DLI; reasons for DLI were relapse (11), mixed chimerism (5), post-transplant lymphoproliferative disorder (PTLD) (1), and idiopathic hemolytic anemia (1). Several patients developed second malignancies after HCT including non-melanoma skin cancers (8), melanoma (1), PTLD (4), myeloproliferative disorder (1), breast cancer (1), cervical cancer (1), and tonsillar squamous cell carcinoma (1). Conclusion 2CdA and Mel are effective agents for RIC HCT. This is the largest study of this regimen published to date. Though it is difficult to fully compare the results from different non-randomized trials, rates of NRM, OS, and GVHD appear similar to other published RIC regimens.

Bilateral acute Ocular Ischemic Syndrome following head and neck radiation

Previous literature has established a clear correlation between radiation therapy (RT) to the head and neck leading to aggressive atherosclerosis of the carotid arteries and subsequent increased risk for ischemic stroke. Stenosis of carotid arteries can lead to Ocular Ischemic syndrome (OIS). We present a case of acute bilateral OIS following head and neck RT for left tonsillar squamous cell carcinoma (SCC) in a 64 year-old Caucasian male. Routine large vessel cerebrovascular screening following head and neck radiotherapy should be considered as a means of potentially mitigating future stroke risk through initiation of medical therapy and interventional modalities as a means of primary prevention. In addition to large vessel screening by carotid duplex ultrasound, it may also be pertinent to consider further evaluation with more detailed medium and small vessel imaging through CT angiography in select cases.

Metachronous and Synchronous Multiple Primary Carcinomas in an Elderly

The prognosis of most cancers has been improved in recent years due to the increased survival of cancer patients, the prolonged lifespan of the general population, and better diagnostic and surgical approaches. Subsequently, the number of patients with multiple primary carcinomas (MPCs) has become greater. In this report, we describe a unique case of a 71-year-old man with five metachronous and synchronous primary malignant tumors. The patient was first diagnosed with synchronous, left posterior tonsillar pillar squamous cell carcinoma (SCC) and right lingual surface of epiglottis SCC in June 2016. Two years later, he presented with three other primary carcinomas within a 3-month time span: right lower lobe lung SCC, right tongue invasive SCC and hepatocellular carcinoma (HCC), consecutively. Investigations revealed no metastases of the primary neoplasms. As the population of older adults with cancer and multimorbidity grows, the therapeutic options usually become limited. On the other hand, understanding the effect of multimorbidity on the care of patients with cancer and developing therapeutic interventions for these elderly patients would be crucial for geriatric care. J Med Cases. 2019;10(1):8-13 doi: https://doi.org/10.14740/jmc3172

Necrotizing myopathy as paraneoplastic disorder in tonsillar squamous cell carcinoma

Introduction: Myositis including polymyositis and dermatomyositis has been reported in different types of cancer mainly lung, breast and ovarian cancer. Case Report: We report a case of necrotizing myopathy presenting in a 59-year-old patient after a recent diagnoses of squamous cell carcinoma of the tonsil. Three weeks later, the patient was admitted for worsening generalized weakness, dysphagia and constipation. Patient was bed bound requiring full assistance. Physical examination was significant for symmetrical weakness in his proximal muscle groups of upper and lower extremity. Creatinine kinase (CK) was 13,000 U/L with markedly elevated liver enzymes. EMG showed myotonia in all muscle groups with more prominence in axial and proximal muscles than distal. Following the biopsy of biceps muscle, IV steroid was initiated. IVIG was started later in addition to oral steroids due to suboptimal response. In the interim, biopsy showed severe necrotizing myopathy. Myositis Ab panel and paraneoplastic antibody panel including voltage gated potassium channel (VGPC) Ab, ANNA-1, ANNA-2 and PCA-1 Abs were negative. CK trended down to 1196 U/L after three weeks of steroids with moderate improvement in the muscle weakness. Conclusion: Necrotizing myopathy can be associated with squamous cell carcinoma of tonsil. Serology may be negative and the presence of diffuse myotonia suggests myopathy. However, biopsy shows myofibers undergoing myophagocytosis with minimal inflammatory cells thus confirming necrotizing myopathy.

Metachronous and Synchronous Multiple Primary Carcinomas in an Elderly

The prognosis of most cancers has been improved in recent years due to the increased survival of cancer patients, the prolonged lifespan of the general population, and better diagnostic and surgical approaches. Subsequently, the number of patients with multiple primary carcinomas (MPCs) has become greater. In this report, we describe a unique case of a 71-year-old man with five metachronous and synchronous primary malignant tumors. The patient was first diagnosed with synchronous, left posterior tonsillar pillar squamous cell carcinoma (SCC) and right lingual surface of epiglottis SCC in June 2016. Two years later, he presented with three other primary carcinomas within a 3-month time span: right lower lobe lung SCC, right tongue invasive SCC and hepatocellular carcinoma (HCC), consecutively. Investigations revealed no metastases of the primary neoplasms. As the population of older adults with cancer and multimorbidity grows, the therapeutic options usually become limited. On the other hand, understanding the effect of multimorbidity on the care of patients with cancer and developing therapeutic interventions for these elderly patients would be crucial for geriatric care. J Med Cases. 2019;10(1):8-13 doi: https://doi.org/10.14740/jmc3172

Initial presentation of tonsillar carcinoma with candidiasis

Initial presentation of tonsillar carcinoma with candidiasis

Palatine tonsil SUVmax on FDG PET-CT as a discriminator between benign and malignant tonsils in patients with and without head and neck squamous cell carcinoma of unknown primary

To analyse the maximum standardised uptake value (SUVmax) ratio between tonsils in patients with and without tonsillar carcinoma to determine useful diagnostic thresholds. Positron-emission tomography (PET)/computed tomography (CT) examinations of patients with suspected head and neck squamous cell carcinoma (SCC) and controls from April 2013 to September 2016 were reviewed retrospectively. Tonsillar SUVmax ratios (ipsilateral/contralateral for malignant tonsils, maximum/minimum for patients without [controls]) were calculated and used to construct a receiver operating characteristic (ROC) curve. Twenty-five patients had tonsillar carcinoma (mean SUVmax ratio of 2, range 0.89-5.4) and 86 patients acted as controls (mean SUVmax ratio of 1.1, range 1-1.5). Using the ROC, the most accurate SUVmax ratio for identifying malignancy was >1.2 (77% sensitivity, 86% specificity). A potentially more clinically useful SUVmax ratio is ≥1.6 with 62% sensitivity and 100% specificity. An SUVmax ratio between tonsils of ≥1.6 is highly suspicious for SCC and could be used to direct site of biopsy. Some malignant tonsils had normal FDG uptake; therefore, PET/CT should not be used to exclude tonsillar cancer. Minor asymmetrical uptake is frequently seen in non-malignant tonsils and does not necessarily require further investigation. Due to the single centre nature of this study and the recognised variation in SUV measurements between PET scans, other centres may need to develop their own cut-offs.

Treatment of Tonsillar Carcinoma following Nononcologic Tonsillectomy: Efficacy of Transoral Robotic Revision Tonsillectomy

To evaluate whether transoral robotic surgery (TORS) is a suitable treatment approach for patients diagnosed with tonsillar carcinoma after a standard palatine tonsillectomy. Retrospective cohort study. Tertiary care medical center. Patients who underwent TORS at the University of Washington from 2010 to 2017 (n = 150) were identified. All patients who were diagnosed with tonsillar carcinoma following a nononcologic tonsillectomy and subsequently underwent TORS radical tonsillectomy were included (n = 14). Tumor stage-matched subjects (n = 44) were included who did not undergo standard tonsillectomy prior to TORS. Our primary outcome was final margin status. Secondary outcomes were presence of residual tumor, receipt and dose of postoperative adjuvant therapy, disease-free survival (DFS), and disease-specific survival. Patients with <6 months of follow-up following definitive treatment were excluded from survival analyses. Final margin status was clear in all subjects. Residual tumor was not identified in 13 of 14 (92.9%) prior-tonsillectomy subjects following TORS radical tonsillectomy. Seven of 14 (50%) prior-tonsillectomy subjects and 12 of 44 (27.3%) TORS-matched subjects did not require adjuvant therapy due to favorable pathology. Among subjects who received post-TORS radiation therapy (RT) at our institution, RT dose reduction was achieved in 3 of 4 (75%) prior-tonsillectomy subjects and 21 of 24 (87.5%) TORS-matched subjects. Ten of 14 (71.4%) prior-tonsillectomy subjects and 31 of 44 (70.5%) TORS-matched subjects avoided post-TORS chemotherapy. DFS was not significantly different ( P = .87) between prior-tonsillectomy and TORS-matched groups, and no subjects died of related disease. Patients diagnosed with tonsillar carcinoma following a prior nononcologic standard palatine tonsillectomy are suitable candidates for revision surgery with TORS radical tonsillectomy.

Combination of panendoscopy and positron emission tomography/computed tomography increases detection of unknown primary head and neck carcinoma.

With positron emission tomography/computed tomography (PET/CT) now commonplace as a diagnostic tool, new questions have arisen regarding the utility and cost-effectiveness of panendoscopy. In this retrospective review of a large cohort of head and neck squamous cell carcinoma of unknown primary (HNSCC-UP), we describe the enduring utility of panendoscopy in the detection of the primary site of mucosal disease even when PET/CT is negative. Retrospective cohort study. A retrospective analysis of patients presenting to the senior author (y.d.) from July 1 1997 to July 1 2017 with fine-needle aspiration-proven metastatic squamous cell carcinoma to the neck. All patients underwent formal panendoscopy (direct laryngoscopy, bronchoscopy, and rigid esophagoscopy). Presence of squamous cell carcinoma on final pathology was examined. A total of 190 patients had HNSCC-UP, with 87 positive and 103 negative on PET/CT. Of the PET/CT-negative patients, 71 patients retained the HNSCC-UP designation after panendoscopy. Eighteen patients (56% of cases) were found to have primary tonsillar squamous cell carcinoma. Eight of 32 primary sites were found in the base of tongue (25%), with HPV positivity in two of these patients. The sensitivity and negative predictive value of PET/CT in detecting the primary site in unknown primary head and neck squamous cell carcinoma in the total study population were 73.1% and 68.9%, respectively. Surgical panendoscopy has an important role in the workup of patients with unknown primary head and neck squamous cell carcinoma. There is a high rate of cancer diagnosis, even in PET/CT negative patients. 4 Laryngoscope, 2573-2575, 2018.

Distribution of Metastatic Nodes in N0-1 Patients with Tonsillar Squamous Cell Carcinoma and Its Implications for Selective Neck Dissection

We aimed to evaluate the pattern of neck metastasis in patients with primary tonsillar carcinoma treated by primary surgery and neck dissection. Impact of the extent of neck dissection and level of metastatic nodes on survival were also evaluated. We evaluated 163 consecutive patients with tonsillar squamous cell carcinoma submitted for neck dissection and staged as cN0-1. Selective neck dissection was performed using a template encompassing levels I-III, whereas radical neck dissection led to the removal at levels I-V. For each patient, number of metastatic nodes, their distribution, and data regarding postoperative treatment and oncologic outcomes were analyzed. Occult neck metastasis at levels I, IV, and V were rare with two cases each. In the clinically negative (cN0) patients, there were no cases of metastasis at level V and two cases at level I or IV. The extent of neck dissection and level of metastatic nodes had no impact on disease-specific survival or neck recurrence. We conclude that in cN0 patients, removal at levels II and III is mandatory but levels I, IV, and V may be spared.

A rare case of cutaneous metastasis of primary tonsillar squamous cell carcinoma

A rare case of cutaneous metastasis of primary tonsillar squamous cell carcinoma

Solitary Extramedullary Plasmacytoma of the Thyroid Gland Following Head and Neck External Beam Radiotherapy

Objective: We report a case of a solitary plasmacytoma of the thyroid gland that was diagnosed 17 years after external beam radiotherapy for treatment of tonsillar squamous cell carcinoma in a patient on long-term immunosuppression. Although radiation exposure has been reported to be associated with solitary bone plasmacytoma, this is the first case report of an association with external beam radiotherapy and long-term immunosuppression with plasmacytoma of the thyroid. Methods: A 54-year-old man presented to the outpatient endocrinology clinic with a 2-year history of a fluctuating but progressively enlarging tender goiter. Past medical history included tonsillar squamous cell carcinoma treated with surgical resection and head and neck external beam radiotherapy 17 years previously, external beam radiotherapy for metastatic squamous cell carcinoma to jugular digastric lymph node, and long-term immunosuppression for liver transplant. Results: Fine-needle aspiration biopsy revealed numerous plasmacytoid ce...

Survival outcome of tonsillar squamous cell carcinoma (TSCC) in the context of human papillomavirus (HPV): A systematic review and meta-analysis

ObjectiveThe objective of our study was to assess whether HPV-positive TSCC had better survival and prognosis rates, when compared to HPV-negative TSCC. MethodA systematic review and meta-analysis was performed comparing HPV status in TSCC patients. TSCC was confirmed with histopathology and HPV status was confirmed with PCR, immunohistochemistry and/or in-situ-hybridisation. The primary endpoints were overall survival (OS) and disease free survival (DFS). ResultsTwenty-four studies were identified, involving 1921 TSCC cases, of which 56.2% (1079) were HPV positive. OS was significantly higher in patients with HPV-positive compared to HPV-negative TSCC in years 1–5 (OR 2.54, P < 0.01; OR 2.93 P < 0.01; OR 2.74 P < 0.01; OR 2.20 P < 0.01, and OR 2.14 P < 0.01 respectively). Similarly, DFS was also significantly higher in patients with HPV-positive compared to HPV-negative TSCC in years 1–3 (OR 2.86, P < 0.01; OR 2.60 P < 0.02; and OR 2.60 P < 0.01 respectively), which was attenuated in years 4 and 5 (OR 1.83, P = 0.10 and OR 1.50, P = 0.12). ConclusionThis is the largest meta-analysis with 1921 patients, comparing non-HPV induced TSCC and HPV induced TSCC, looking at outcome and survival. HPV-positive had better OS and DFS.

Síndrome de Bazex asociado a carcinoma de orofaringe. Descripción de un caso

Introduction and objective: Bazex syndrome is an infrequent paraneoplastic syndrome that is related to an upper aerodigestive epidermoid carcinoma. A case of characteristic Bazex syndrome is presented to contribute to an early diagnosis of the associated underlying tumor pathology. Case description: 57-year-old male, smoker and regular drinker, presented with a cervical mass associated with scaly and violaceous eczema on hands, feet, ears and knees. After examination and complementary tests, the diagnosis of T2N3M0 tonsillar squamous cell carcinoma and paraneoplastic syndrome was established. Conclusions: Oropharyngeal carcinoma is one of the most frequent tumors associated with Bazex syndrome. Therefore, if we observe these skin lesions, we should always rule out oncological pathology at that level.

Clinical implication of programmed cell death-1 ligand-1 expression in tonsillar squamous cell carcinoma in association with intratumoral heterogeneity, human papillomavirus, and epithelial-to-mesenchymal transition

Programmed cell death-1 ligand-1 (PD-L1), essential for immune evasion, is a potential candidate for pathogenesis and therapeutic target of human papillomavirus (HPV)-positive tonsillar squamous cell carcinomas (TSCCs). MET/hepatocyte growth factor signaling and transcription factors involved in epithelial-to-mesenchymal transition (EMT) upregulate PD-L1, which can contribute to clinical outcome. Intratumoral heterogeneity of PD-L1 expression is of clinical importance in selection bias due to false-negative patient enrollment. However, the clinicopathological features, prognostic value, and coexpressed molecules of PD-L1 remain unclear in TSCCs. PD-L1 expression was evaluated via immunohistochemistry using a specific monoclonal antibody (SP142) between whole-tissue and tissue microarray (TMA) sections of 79 tumors (5% cutoff value with weak staining). Expressions of EMT markers (TWIST1, Snail, and SNIP1) and MET/hepatocyte growth factor were also analyzed. Staining of the TMA sections showed 78.5% concordance rate to the whole section. PD-L1 positivity and its intratumoral heterogeneity were 29.1% and 15.2% of TSCCs by whole section, respectively. PD-L1 positivity was prevalent in females, HPV-positive tumors without base of tongue invasion, and SNIP1-overexpressed tumors. SNIP1 overexpression, unmethylated TWIST1, smoking, and poorly differentiated tumors were predictive for PD-L1 overexpression. PD-L1 positivity was a favorable independent prognostic factor. Subgroup analyses according to the coexpression of PD-L1 with HPV, SNIP1, or unmethylated TWIST1 indicated the best clinical outcome than any other subgroups. In conclusion, intratumoral heterogeneity of PD-L1 expression was frequent, warranting a caution in punching TMA cores. A combined analysis of PD-L1 with EMT and HPV may define a characteristic subset of patients and prognostic group.

Association Between Fibroblast Growth Factor Receptor 1 Gene Amplification and Human Papillomavirus Prevalence in Tonsillar Squamous Cell Carcinoma With Clinicopathologic Analysis

Amplification of fibroblast growth factor receptor 1 ( FGFR1) has been reported in many squamous cell carcinomas, and human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma has been characterized as a distinct subset with favorable prognosis. Here, we investigated the FGFR1 amplification and HPV status in tonsillar squamous cell carcinoma (TSCC) and analyzed the clinical characteristics. HPV in situ hybridization (HPV ISH) and FGFR1 fluorescence in situ hybridization (FISH) were performed using tissue microarray from 89 cases of TSCC. Fourteen of 89 (15.7%) TSCC cases had FGFR1 amplification, and HPV was detected in 59 of 89 (66.3%) cases. FGFR1 amplification status was not associated with HPV positivity ( p=0.765). Outcomes were not significantly different between FGFR1 amplified and non-amplified patients. Although FGFR1 amplified patients ( n=4) in the HPV ISH-negative group ( n=30) had a tendency for poorer overall survival, no statistical significance was identified ( p=0.150, log-rank). FGFR1 protein overexpression showed better disease-free survival ( p=0.031, log-rank) in HPV-negative TSCC. This study suggests FGFR1 amplification may be important in the pathogenesis of TSCC regardless of HPV status.

Patients Report Less Severe Symptoms With Unilateral Radiation Therapy Than Bilateral Radiation Therapy for Tonsillar Squamous Cell Carcinomas

The goal of this study was to examine the effects of radiation treatment volume on quality of life in patients with squamous cell carcinoma of the tonsil. Clinical characteristics of patients with tonsillar squamous cell carcinoma (n=30) treated at Roswell Park Cancer institute (2013-2015) were abstracted from the medical records. Patients were either treated with radiation therapy to one side of the head and neck, unilateral radiation (n=15), or treated with radiation therapy to both sides of the head and neck, bilateral radiation (n=15). Quality of life data was evaluated using the European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire (QLQ-30) and head and neck 35 (H&N 35). The EORTC survey was administered prior to the start of radiation therapy treatment, at the end of radiation therapy treatment, and at each follow-up appointment up to 1-year posttreatment. Mann Whitney U tests were used to examine differences in QOL scores between patients treated unilaterally and patients treated bilaterally at various time points posttreatment. Patients who received bilateral treatment had significantly more appetite loss six months posttreatment (55.56% vs 15.15%, t=2.92, P=.02), more dysphagia 3 months posttreatment (40.48% vs 13.63%, t=2.85, P=.03), and more xerostomia e month posttreatment (62.5% vs 33.33%, t=2.37, P=.0486) than patients receiving unilateral radiation. Unilateral patients reported more sticky saliva posttreatment (93.33% vs 75.56%, t=-2.12, P=.01) than patients who received bilateral treatment. Results of this small cohort study indicate that unilateral radiation therapy in tonsillar squamous cell carcinoma may be associated with less severe symptoms than bilateral radiation therapy and more studies on a larger scale are needed to further investigate this association.

Impact of HPV and other tumoral markers in tonsillar squamous cell carcinoma (SCC) – a retrospective study

Impact of HPV and other tumoral markers in tonsillar squamous cell carcinoma (SCC) – a retrospective study

The incidence of malignancy in clinically benign cystic lesions of the lateral neck: our experience and proposed diagnostic algorithm.

Solitary cystic masses of the lateral neck in an adult patient can pose a diagnostic dilemma. Malignancy must be ruled out since metastases arising from H&N cancers may mimic the presentation of benign cystic masses. Only a small number of studies have investigated the diagnostic management and malignancy rate of clinically benign solitary cervical cystic lesions. There are no established guidelines for the diagnostic evaluation. Retrospective review of the clinical, cytological, radiological, and pathological records of all adult patients (> 18years) operated on for second branchial cleft cysts (BrCC) between 1/2008-2010/2016. Patients with apparent primary H&N malignancy, history of H&N cancer or irradiation, preoperative fine needle aspiration (FNA) of highly suggestive or confirmed malignancy, missing pertinent data, or age less than 18years were excluded from analysis. 28 patients were diagnosed as having BrCC. The diagnosis was based on clinical findings, FNA cytology, and typical sonographic features. The histologic analysis determined an overall rate of malignancy of 10.7% (3/28): two patients had metastatic papillary thyroid carcinoma, and one patient had metastatic tonsillar squamous cell carcinoma. Purely cystic features on pre-operative ultrasound was the only significant predictor for true BrCC on final histology (p = .02). Occult malignancy is not rare among adult patients presenting with a solitary cystic mass of the lateral neck. A diagnostic algorithm is proposed. Further studies are needed to establish the appropriate workup and management of an adult patient presenting with a solitary cystic mass of the lateral neck.