1. 세포 월례집담회 KCP-811 전남대병원 전공의 나종인

2. Patient history CNUH 12642-2013 60/M C/C: 우측 경부 종물 (6-7 개월 전 ) 2 년 전 심장판막 수술 간경변 치료 중

3. Fine needle aspiration Right neck 20131016

6. Microscopic finding Tumor cell cluster; sheet pattern Small mature lymphocytes; infiltration into tumor sheet Tumor cell; often crowded or overlapping sometimes chromatin-rich than vesicular vesicular nuclei with prominent nucleoli indistinctive cell border

7. Differential diagnosis 1.Nasopharyngeal nonkeratinizing carcinoma, undifferentiated type 2.Lymphoepithelial carcinoma 3.Follicular dendritic cell tumor 4.Ectopic cervical thymoma

8. Diagnosis Right neck, Fine needle aspiration: Metastatic carcinoma, poorly differentiated Note: Primary focus evaluation 시행 바랍니다.

9. Neck CT 20131018 Level II-III LAPBoth retropharyngeal LAP Rt. lateral nasopharyngeal wall: soft tissue thickening and enhancement

10. Lateral wall of nasopharynx, Incision biopsy

13. CKP63 EBV

14. Diagnosis Lateral wall of nasopharynx, incision biopsy : Nasopharyngeal nonkeratinizing carcinoma, undifferentiated type

15. Clinical course 1 st cisplatin CCRT (2013.11.04) 2 nd cisplatin CCRT (2013.11.26) RT inac-IMRT, 200 cGy/fx, 주 5 회 총 33 회 (2013.12.2 – 2013. 12.18) PNS MRI (2014.01.03) 1.Complete remission of nasopharyngeal malignancy in right lateral nasopharyngeal wall 2.Decreased size and number of multiple small to enlarged lymph nodes in both retropharyngeal spaces, both level II-III and right level V: No significantly enlarged lymph node in scanned both lateral necks: => Suggesting improved metastatic LAPs

16. Nasopharyngeal nonkeratinizing carcinoma, undifferentiated type Age : 40-60 yrs, M≥F Association with EBV Signs and symptoms Painless enlargement of upper cervical lymph node- most common first presenting feature Nasal Sx. (blood stained post-nasal drip) Sx. related to eustachian tube obstruction (serous otitis media) Sx. related to cranial nerve involvement (headache) 10% asymptomatic

17. FNA of metastatic NPC to the lymph node Parameter Number of cases (%) CellularityHigh40 (74.1%) Moderate10 (18.5%) Low4 (7.4%) Architectural pattern Mixed25 (46.3%) Dissociated18 (33.3%) Carcinoma-like11 (20.4%) Naked nucleiAbundant23 (42.6%) Moderate16 (29.6%) Scarce15 (27.8%) AtypiaMarked9 (16.7%) Moderate43 (79.6%) Minimal2 (3.7%) Nucleoli number06 (11.1%) 113 (24.1%) >135 (64.8%) Nucleoli sizeSmall10 (18.5%) Medium35 (64.8%) Large9 (16.7%) Lymphoid cellsAbundant12 (22.2%) Moderate28 (51.9%) Minimal/absent14 (25.9%) Parameter Number of cases (%) Hodgkin’s-like cells Present4 (7.4%) Absent50 (92.6%) Squamous differentiation Present3 (5.6%) Absent51 (94.4%) GranulomasPresent3 (5.6%) Absent51 (94.4%) EosinophilsProminent4 (7.4%) Minimal/absent50 (92.6%) Suppurative changes Present5 (9.3%) Absent49 (90.7%) Diagn Cytopathol. 2005; 32:233-237

18. FNA of metastatic NPC, UD to the lymph node Diagn Cytopathol. 2005; 32:233-237 NPC, UD A great lymphoid component in tumor sheet Lymphoepithelial structure Dual population (large neoplastic cells & small lymphocytes) D/D Metastatic ca. from head & neck tumors (squamous cell ca., thyroid ca., salivary gland ca.), lung ca. & breast ca. Rare event in meta ca D/D Lymphoepithelial ca. from salivary gland, thyroid, larynx, lung, thymus Difficult to distinguish Very rare D/D Follicular dendritic cell tumor Ectopic cervical thymoma Difficult to distinguish

19. Dual cell population: large neoplastic cells and abundant reactive lymphoid cells NPC, UDFollicular dendritic cell tumorThymoma Dual (Biphasic) cellular pattern: Large neoplastic cells with small mature lymphocyte Syncytial pattern, ill-defined cell border, round to oval nucleus Vesicular nuclei with prominent nucleoli Fine granular chromatin, nucleoli (o), nuclear groove, nuclear pseudoinclusion (rare) Minimal nuclear pleomorphism, inconspicuous nucleoli Diagn Cytopathol. 2005; 32:233-237 Diagn Cytopathol. 2000; 22:238-242 Diagn Pathol. 2007; 2:13