Malignant cyst of the lateral aspect of the neck: Branchial cleft carcinoma or metastasis? R. D. Foss, LT, DC, USN,a G. R. Warnock, CAPT, DC, USN,b W. B. Clark, LCDR, MC, USNR,” S. J. Graham, LCDR, MC, USNR,d A. L. Morton, LCDR, MC, USNR,e and E. S. Yunan, CDR, MC, USNR/ Bethesda, Md. NAVAL DENTAL SCHOOL, NATIONAL NAVAL DENTAL CENTER, AND NATIONAL NAVAL MEDICAL CENTER A 58.year-old man had a left jugulodigastric mass, which was found to be cystic by computed tomography, and no evidence of other lesions. Grossly and histofogically, the surgical specimen consisted of a thin-walled, fluid-filled cyst lined by squamous epithelium that varied in appearance from benign to invasive squamous cell carcinoma. The findings supported a differential diagnosis of branchial cleft carcinoma (BCCA) versus cystic growth of a lymph node metastasis from an occult malignancy. On this basis, guided biopsies of the upper aerodigestive tract were performed, with strong suspicion of a tonsillar bed lesion. Microscopic examination revealed the primary tumor within tissue excised from the left tonsillar fossa. Comparison of the current case with cases of BCCA and cystic tonsillar metastases from the literature illustrated the potential pitfalls in rendering a diagnosis of BCCA. Recognition of this lesion as a distinctive clinical variant of oropharyngeal carcinoma is warranted. (ORAL SURC ORAL MED ORAL PATHOL 1991;71:214-7)
C
ysts of the lateral aspect of the neck lined by malignant epithelium have long been an unusual diagnostic challenge for both the clinician and the pathologist. Almost without exception, these lesions represent a cystic metastasisfrom an undetected carcinoma. However, the possibility, albeit an unlikely one, remains that these lesions result from malignant Presented in part at the meeting of the American Academy of Oral
Pathology, April 26, 1989, Savannah, Ga. The opinions or assertationscontained in this article are the private onesof the writers and are not to be construed as official or as reflecting the views of the Department of the Navy, Department of Defense, or the U.S. Government. BResident,Oral Pathology Department, Naval Dental School, National Naval Dental Center. bHead, Oral Pathology Department, Naval Dental School, National Naval Dental Center. CFormerly, Resident, Otolaryngology/Head and Neck Surgery; currently, Staff, OtolaryngoIogy/Head and Neck Surgery, Naval Hospital, Orlando, Fla. dResident, Anatomic Pathology, National Naval Medical Center. %taff, Otolaryngology/Head and Neck Surgery, National Naval Medical Center. ‘Head Anatomic Pathology, National Naval Medical Center. 7/14/;453a 214
Fig. 1. Segment of cystic lesion showing pseudopapillary or polypoid projections, lymphoid tissue, and thin connective tissue capsule. (Original magnification, X20.)
transformation of branchial cleft cysts. The theory that malignant lesionsof the lateral aspectof the neck might arise from remnants of the branch&l clefts was provided by Von Volkmann’ in 1882. This premise
Malignant lateral neck cyst 215
Volume7I Number 2
Fig. 2. Portions of epithelial lining varying in appearancefrom benign (A) to dysplastic (B) to invasive (C). (Original magnification: A and B, X200; C, X100.)
received relatively wide acceptance during the first half of this century but was vigorously disputed by Martin et al.* in 1950. Martin and his colleagues proposed the following Memorial Hospital criteria for the tentative diagnosis of branchiogenic or branchial cleft carcinoma (BCCA): 1. The tumor must have occurred along the anterior margin of the sternocleidomastoid. 2. Histologic findings must be consistent with a known branchial cleft component. 3. The patient must survive 5 years without detection of a possible primary tumor. 4. The best criterion of all is the histologic demonstration of cancer developing in the wall of an epithelial-lined cyst in the lateral aspect of the neck.* Martin conceded that malignant transformation of a branchial cleft cyst was possible but that the diagnosis should be made only with considerable caution. Despite this skepticism, sporadic reports of purported BCCA continue to appear as small seriesand individual case reports.3V” During the past 15 years, the concept of BCCA has been questioned further by Micheau et al., I2 Compagno et a1.,13and most recently by Granstrom and Edstrom.14 These authors and othersI note that sometonsillar carcinomas have
an unusual propensity for the formation of a single cystic metastasiswhile remaining clinically undetectable. Our case is exemplary of a tonsillar carcinoma presenting in such a manner and illustrates a number of potential pitfalls in the diagnosis of BCCA. CASE REPORT
In May 1988 a 58-year-old white man was seenwith a 3 cm, nontender, firm, freely movable left jugulodigastric cervical mass, which had been present for 4 months. The patient was a nonsmoker and nondrinker with a medical history significant for tonsillectomy as a child. Complete head and neck examination was unremarkable except for the mass. Fine needle aspiration (FNA) was suggestive of salivary gland elements.At a follow-up examination in July, the masswas unchanged, as were the remainder of the head and neck findings. A computed tomographic scan revealed the mass to be cystic, and repeated FNA showed atypical squamouscells. The surgical plan was panendoscopy,with selective biopsies and excision of the cervical cyst. Additionally, a radical neck dissection was to be performed if frozen sections revealed carcinoma. The patient underwent panendoscopy,with unremarkable findings, followed by excision of the cyst. The cyst “shelled out” easily from its site adjacent to the anterior border of the sternocleidomastoid muscle. Visually, the neck contents were within normal limits. Intraoperative frozen sections revealed dysplastic epithelium, but the diagnosis of malignancy could not be made and the incision was closed. Grossly, the neck mass
216
Foss et al. DISCUSSION
Fig. 3. Squamous cell carcinoma excised from left tonsillar bed. (Original magnification, X40.) consisted of a thin-walled cyst filled with clear yellow fluid. Several small polypoid or pseudopapillary intraluminal projections were seen on the internal surface (Fig. 1). Histologic examination revealed a cystic lesion lined by a layer of epithelium that varied in appearance from relatively benign or bland, to dysplastic, to areas of malignant change with frank invasion (Fig. 2). Keratin formation was not observed. Subjacent to the epithelium was a prominent rim of lymphoid tissue with germinal center formation. The entire lesion was surrounded by a thin connective tissue capsule. Because of areas of apparent transition from benign to malignant epithelium, malignant transformation of a branchial cleft cyst was included in the differential diagnosis, A lymph node metastasis from an occult primary tumor of Waldeyer’s ring, probably tonsillar, was considered more likely. On this basis, and despite the history of childhood tonsillectomy, excision of the clinically normal mucosa covering the tonsillar fossae, and standard selective biopsies of the upper aerodigestive tract, were performed. A 1 cm focus of squamous cell carcinoma was identified in tissue excised from the left tonsillar bed. The histologic characteristics of this lesion were comparable to those of the cystic neck carcinoma (Fig. 3). The mucosa overlying this focus appeared normal. After removal of the presumed primary tumor, the patient received a course of radiation therapy to tonsillar and neck fields. The patient continues follow-up monthly and has no evidence of disease. Retrospectively, immunohistochemical staining of the cystic metastasis with a monoclonal antibody against basement membrane collagen type IV (BioGenex, Dublin, Calif.) was performed. For purposes of comparison, a branchial cleft cyst was stained simultaneously. The staining was done with a 1:200 antibody dilution after digestion of the tissues with pepsin. No reactivity was identified in any area of the cystic metastasis, regardless of the degree of apparent benignancy, dysplasia, or invasion present. Conversely, the branchial cleft cyst was irregularly positive for type IV collagen.
It is evident that several features of this case have the potential to support a misdiagnosis of BCCA, particularly in view of the criteria of Martin et al.,” which are generally well accepted. First, on the basis of location and clinical presentation, the neck mass was indistinguishable from a branchial cleft cyst (benign cervical lymphoepithelial cyst). Second, the primary tumor was clinically undetectable and potentially controllable within standard radiation fields for occult upper aerodigestive tract carcinoma.‘6 Radiation therapy is often cited in reports of BCCA and in the current case would likely have precluded the eventual discovery of the primary tumor.“, ‘, ‘). ’ ’ Finally and most significantly, areas of benign-appearing epithelium and apparent transition of this epithelium from benign to malignant were demonstrable in a number of microscopic fields of the neck cyst. These microscopic features are frequently cited as proof of malignant transformation in casesof BCCA.J-X,lo When casesof BCCA and cystically metastasizing tonsillar carcinoma from the literature are compared, a number of similarities are noted. In 18 cases reported as BCCA, the average patient age was 58 years and the sex ratio (M/F) was 14:4.3-” Corresponding figures for 19 casesof cystically metastasizing tonsillar carcinoma are a mean age of 53 years and a sex ratio (M/F) of 13:6.‘2-‘6 The similarities are more pronounced in two Scandinavian series. In Granstrom and Edstrom’s nine cases of cystically metastasizing tonsillar carcinoma,i4 the average age was 60 years and the sex ratio (M/F) was 8: 1, whereas for Krogdahl’s sevencasesof BCCA the figures were 62 years and 6:1.6 Additionally, in those cases in which a histologic pattern was noted all of eight cystic metastasesand all of six BCCA showed pseudopapillary or polypoid epithelium.3%‘5*. ‘O-l3The similarities of these studies and the histopathologic characteristics of the present caselead to speculation that a portion of the casesreported as BCCA may actually have represented cystically metastasizing tonsillar carcinoma. The immunocytochemical findings disclosed an absence of detectable type IV collagen in this case, whereas the benign branchial cleft cyst exhibited foci of basement membrane zone reactivity. This method may prove valuable for excluding malignant transformation of an existing lesion and for limiting the differential diagnosis in future cases. CONCLUSION
The current caseillustrates the difficulties of diagnosing malignant transformation of lateral neck cysts.
Malignant lateral neck cyst 2 I 7
Volume 71 Number 2
It also demonstrates the features of cystically metastasizing tonsillar carcinoma that have been observed with some consistency. These include a clinically inapparent primary tumor,12-15poor correlation with risk factor history,i5 a single, freely movable subdigastric node,’ *-’ 5 and a lesion clinically suggestive of a branchial cleft cyst. Furthermore, equivocal findings are noted on FNA,14 a pseudopapillary histologic pattern is seen,‘**l 3 true cystic growth of the metastasis occurs with effacement of lymph node architecture, and the prognosis for what are clinically stage IV tonsillar carcinomas is apparently improved, with survival approaching 50% at 10 years. Because of these unique and characteristic features, cystically metastasizing tonsillar carcinoma should be recognized by clinicians and surgical pathologists as a distinctive clinical variant of oropharyngeal carcinoma. REFERENCES
1. Von Volkmann R. Das tiefe branchiogene Halskarcinom. Zentralbl Chir 1882;9:49-63. 2. Martin H, Morfit HM, Ehrlich H. The case for branchiogenic cancer (malignant branchioma). Ann Surg 1950;132:867-87. 3. Benisch BM, Som ML. Branchial cleft carcinoma. Arch Otolaryngol 1973;98:208-9. 4. Bernstein A, Scardino PT, Tomaszewski M, Cohen MH. Carcinoma arising in a branchial cleft cyst. Cancer 1976;37: 2417-22. 5. Honore LH, Blackwood HJ, O’Hara KE. Primary branchiogenie carcinoma. ENT J 1979;58:1l-4.
6. Krogdahl AS. Carcinoma occuring in branchial cleft cysts.
Acta Otolaryngol 1979;88:289-95. 7. Jablokow VR, Kathuria S, Wang T. Squamouscell carcinoma
arising in branchiogenic cyst branchial cleft carcinoma. J Surg Oncol 1982;20:201-4. 8. Artese L, Piattelli A, Piattelli M. Branchiogenic carcinoma: report of a case. Acta Stomatol Belg 1986;83:21-4. 9. Carrick DG, Jones WI, el Sharkawi A. Branchiogenic carcinoma-or cystic lymph node metastasis. J Laryngol Otol 1986;100:1089-90. 10. Soderstrom KO. In situ carcinoma in branchial cysts. ORL J Otorhinolaryngol Relat Spec 1987;49:149-51. 11. Sandiford JA, Chun BK, Patter JF. Branchiogenic carcinoma. J R Co11Surg Edin 1987;32:148-51. 12. Micheau C, Cachin Y, Caillou B. Cystic metastasesin the neck revealing occult carcinoma of the tonsil: a report of six cases. Cancer 1974;33:228-33. 13. Compagno J, Hyams VJ, Safavian M. Does branchiogenic carcinoma really exist? Arch Path01 Lab Med 1976;lOO: 311-4. 14. Granstrom G, Edstrom S. The relationship between cervical cvsts and tonsillar carcinoma in adults. J Oral Maxillofac Sura 1989;46:16-20. 15. Marlowe FI, Goodman RS, Mobini J, Dave U. Cystic metastasis from occult tonsillar primary simulating branchiogenie carcinoma: the case for tonsillectomy as a “grand biopsy.” Laryngoscope 1984;94:833-5. 16. Bataini JP, Rodriguez J, Brugere J, et al. Treatment of metastatic neck nodes secondary to an occult epidermoid carcinoma of the head and neck. Laryngoscope 1987;97:1080-4. Reprint requests to:
G. R. Warnock, CAPT, DC, USN Oral Pathology Department Naval Dental School National Naval Dental Center Bethesda, MD 20814-5077
C
ysts of the lateral aspect of the neck lined by malignant epithelium have long been an unusual diagnostic challenge for both the clinician and the pathologist. Almost without exception, these lesions represent a cystic metastasisfrom an undetected carcinoma. However, the possibility, albeit an unlikely one, remains that these lesions result from malignant Presented in part at the meeting of the American Academy of Oral
Pathology, April 26, 1989, Savannah, Ga. The opinions or assertationscontained in this article are the private onesof the writers and are not to be construed as official or as reflecting the views of the Department of the Navy, Department of Defense, or the U.S. Government. BResident,Oral Pathology Department, Naval Dental School, National Naval Dental Center. bHead, Oral Pathology Department, Naval Dental School, National Naval Dental Center. CFormerly, Resident, Otolaryngology/Head and Neck Surgery; currently, Staff, OtolaryngoIogy/Head and Neck Surgery, Naval Hospital, Orlando, Fla. dResident, Anatomic Pathology, National Naval Medical Center. %taff, Otolaryngology/Head and Neck Surgery, National Naval Medical Center. ‘Head Anatomic Pathology, National Naval Medical Center. 7/14/;453a 214
Fig. 1. Segment of cystic lesion showing pseudopapillary or polypoid projections, lymphoid tissue, and thin connective tissue capsule. (Original magnification, X20.)
transformation of branchial cleft cysts. The theory that malignant lesionsof the lateral aspectof the neck might arise from remnants of the branch&l clefts was provided by Von Volkmann’ in 1882. This premise
Malignant lateral neck cyst 215
Volume7I Number 2
Fig. 2. Portions of epithelial lining varying in appearancefrom benign (A) to dysplastic (B) to invasive (C). (Original magnification: A and B, X200; C, X100.)
received relatively wide acceptance during the first half of this century but was vigorously disputed by Martin et al.* in 1950. Martin and his colleagues proposed the following Memorial Hospital criteria for the tentative diagnosis of branchiogenic or branchial cleft carcinoma (BCCA): 1. The tumor must have occurred along the anterior margin of the sternocleidomastoid. 2. Histologic findings must be consistent with a known branchial cleft component. 3. The patient must survive 5 years without detection of a possible primary tumor. 4. The best criterion of all is the histologic demonstration of cancer developing in the wall of an epithelial-lined cyst in the lateral aspect of the neck.* Martin conceded that malignant transformation of a branchial cleft cyst was possible but that the diagnosis should be made only with considerable caution. Despite this skepticism, sporadic reports of purported BCCA continue to appear as small seriesand individual case reports.3V” During the past 15 years, the concept of BCCA has been questioned further by Micheau et al., I2 Compagno et a1.,13and most recently by Granstrom and Edstrom.14 These authors and othersI note that sometonsillar carcinomas have
an unusual propensity for the formation of a single cystic metastasiswhile remaining clinically undetectable. Our case is exemplary of a tonsillar carcinoma presenting in such a manner and illustrates a number of potential pitfalls in the diagnosis of BCCA. CASE REPORT
In May 1988 a 58-year-old white man was seenwith a 3 cm, nontender, firm, freely movable left jugulodigastric cervical mass, which had been present for 4 months. The patient was a nonsmoker and nondrinker with a medical history significant for tonsillectomy as a child. Complete head and neck examination was unremarkable except for the mass. Fine needle aspiration (FNA) was suggestive of salivary gland elements.At a follow-up examination in July, the masswas unchanged, as were the remainder of the head and neck findings. A computed tomographic scan revealed the mass to be cystic, and repeated FNA showed atypical squamouscells. The surgical plan was panendoscopy,with selective biopsies and excision of the cervical cyst. Additionally, a radical neck dissection was to be performed if frozen sections revealed carcinoma. The patient underwent panendoscopy,with unremarkable findings, followed by excision of the cyst. The cyst “shelled out” easily from its site adjacent to the anterior border of the sternocleidomastoid muscle. Visually, the neck contents were within normal limits. Intraoperative frozen sections revealed dysplastic epithelium, but the diagnosis of malignancy could not be made and the incision was closed. Grossly, the neck mass
216
Foss et al. DISCUSSION
Fig. 3. Squamous cell carcinoma excised from left tonsillar bed. (Original magnification, X40.) consisted of a thin-walled cyst filled with clear yellow fluid. Several small polypoid or pseudopapillary intraluminal projections were seen on the internal surface (Fig. 1). Histologic examination revealed a cystic lesion lined by a layer of epithelium that varied in appearance from relatively benign or bland, to dysplastic, to areas of malignant change with frank invasion (Fig. 2). Keratin formation was not observed. Subjacent to the epithelium was a prominent rim of lymphoid tissue with germinal center formation. The entire lesion was surrounded by a thin connective tissue capsule. Because of areas of apparent transition from benign to malignant epithelium, malignant transformation of a branchial cleft cyst was included in the differential diagnosis, A lymph node metastasis from an occult primary tumor of Waldeyer’s ring, probably tonsillar, was considered more likely. On this basis, and despite the history of childhood tonsillectomy, excision of the clinically normal mucosa covering the tonsillar fossae, and standard selective biopsies of the upper aerodigestive tract, were performed. A 1 cm focus of squamous cell carcinoma was identified in tissue excised from the left tonsillar bed. The histologic characteristics of this lesion were comparable to those of the cystic neck carcinoma (Fig. 3). The mucosa overlying this focus appeared normal. After removal of the presumed primary tumor, the patient received a course of radiation therapy to tonsillar and neck fields. The patient continues follow-up monthly and has no evidence of disease. Retrospectively, immunohistochemical staining of the cystic metastasis with a monoclonal antibody against basement membrane collagen type IV (BioGenex, Dublin, Calif.) was performed. For purposes of comparison, a branchial cleft cyst was stained simultaneously. The staining was done with a 1:200 antibody dilution after digestion of the tissues with pepsin. No reactivity was identified in any area of the cystic metastasis, regardless of the degree of apparent benignancy, dysplasia, or invasion present. Conversely, the branchial cleft cyst was irregularly positive for type IV collagen.
It is evident that several features of this case have the potential to support a misdiagnosis of BCCA, particularly in view of the criteria of Martin et al.,” which are generally well accepted. First, on the basis of location and clinical presentation, the neck mass was indistinguishable from a branchial cleft cyst (benign cervical lymphoepithelial cyst). Second, the primary tumor was clinically undetectable and potentially controllable within standard radiation fields for occult upper aerodigestive tract carcinoma.‘6 Radiation therapy is often cited in reports of BCCA and in the current case would likely have precluded the eventual discovery of the primary tumor.“, ‘, ‘). ’ ’ Finally and most significantly, areas of benign-appearing epithelium and apparent transition of this epithelium from benign to malignant were demonstrable in a number of microscopic fields of the neck cyst. These microscopic features are frequently cited as proof of malignant transformation in casesof BCCA.J-X,lo When casesof BCCA and cystically metastasizing tonsillar carcinoma from the literature are compared, a number of similarities are noted. In 18 cases reported as BCCA, the average patient age was 58 years and the sex ratio (M/F) was 14:4.3-” Corresponding figures for 19 casesof cystically metastasizing tonsillar carcinoma are a mean age of 53 years and a sex ratio (M/F) of 13:6.‘2-‘6 The similarities are more pronounced in two Scandinavian series. In Granstrom and Edstrom’s nine cases of cystically metastasizing tonsillar carcinoma,i4 the average age was 60 years and the sex ratio (M/F) was 8: 1, whereas for Krogdahl’s sevencasesof BCCA the figures were 62 years and 6:1.6 Additionally, in those cases in which a histologic pattern was noted all of eight cystic metastasesand all of six BCCA showed pseudopapillary or polypoid epithelium.3%‘5*. ‘O-l3The similarities of these studies and the histopathologic characteristics of the present caselead to speculation that a portion of the casesreported as BCCA may actually have represented cystically metastasizing tonsillar carcinoma. The immunocytochemical findings disclosed an absence of detectable type IV collagen in this case, whereas the benign branchial cleft cyst exhibited foci of basement membrane zone reactivity. This method may prove valuable for excluding malignant transformation of an existing lesion and for limiting the differential diagnosis in future cases. CONCLUSION
The current caseillustrates the difficulties of diagnosing malignant transformation of lateral neck cysts.
Malignant lateral neck cyst 2 I 7
Volume 71 Number 2
It also demonstrates the features of cystically metastasizing tonsillar carcinoma that have been observed with some consistency. These include a clinically inapparent primary tumor,12-15poor correlation with risk factor history,i5 a single, freely movable subdigastric node,’ *-’ 5 and a lesion clinically suggestive of a branchial cleft cyst. Furthermore, equivocal findings are noted on FNA,14 a pseudopapillary histologic pattern is seen,‘**l 3 true cystic growth of the metastasis occurs with effacement of lymph node architecture, and the prognosis for what are clinically stage IV tonsillar carcinomas is apparently improved, with survival approaching 50% at 10 years. Because of these unique and characteristic features, cystically metastasizing tonsillar carcinoma should be recognized by clinicians and surgical pathologists as a distinctive clinical variant of oropharyngeal carcinoma. REFERENCES
1. Von Volkmann R. Das tiefe branchiogene Halskarcinom. Zentralbl Chir 1882;9:49-63. 2. Martin H, Morfit HM, Ehrlich H. The case for branchiogenic cancer (malignant branchioma). Ann Surg 1950;132:867-87. 3. Benisch BM, Som ML. Branchial cleft carcinoma. Arch Otolaryngol 1973;98:208-9. 4. Bernstein A, Scardino PT, Tomaszewski M, Cohen MH. Carcinoma arising in a branchial cleft cyst. Cancer 1976;37: 2417-22. 5. Honore LH, Blackwood HJ, O’Hara KE. Primary branchiogenie carcinoma. ENT J 1979;58:1l-4.
6. Krogdahl AS. Carcinoma occuring in branchial cleft cysts.
Acta Otolaryngol 1979;88:289-95. 7. Jablokow VR, Kathuria S, Wang T. Squamouscell carcinoma
arising in branchiogenic cyst branchial cleft carcinoma. J Surg Oncol 1982;20:201-4. 8. Artese L, Piattelli A, Piattelli M. Branchiogenic carcinoma: report of a case. Acta Stomatol Belg 1986;83:21-4. 9. Carrick DG, Jones WI, el Sharkawi A. Branchiogenic carcinoma-or cystic lymph node metastasis. J Laryngol Otol 1986;100:1089-90. 10. Soderstrom KO. In situ carcinoma in branchial cysts. ORL J Otorhinolaryngol Relat Spec 1987;49:149-51. 11. Sandiford JA, Chun BK, Patter JF. Branchiogenic carcinoma. J R Co11Surg Edin 1987;32:148-51. 12. Micheau C, Cachin Y, Caillou B. Cystic metastasesin the neck revealing occult carcinoma of the tonsil: a report of six cases. Cancer 1974;33:228-33. 13. Compagno J, Hyams VJ, Safavian M. Does branchiogenic carcinoma really exist? Arch Path01 Lab Med 1976;lOO: 311-4. 14. Granstrom G, Edstrom S. The relationship between cervical cvsts and tonsillar carcinoma in adults. J Oral Maxillofac Sura 1989;46:16-20. 15. Marlowe FI, Goodman RS, Mobini J, Dave U. Cystic metastasis from occult tonsillar primary simulating branchiogenie carcinoma: the case for tonsillectomy as a “grand biopsy.” Laryngoscope 1984;94:833-5. 16. Bataini JP, Rodriguez J, Brugere J, et al. Treatment of metastatic neck nodes secondary to an occult epidermoid carcinoma of the head and neck. Laryngoscope 1987;97:1080-4. Reprint requests to:
G. R. Warnock, CAPT, DC, USN Oral Pathology Department Naval Dental School National Naval Dental Center Bethesda, MD 20814-5077
![[Clinical relevance of malignant lateral branchial cyst].](/assets/img/hold.png)
