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 Table of Contents  
ORIGINAL STUDY
Year : 2013  |  Volume : 27  |  Issue : 2  |  Page : 147-150

Tonsillar malignancy - Review of clinico-pathological presentation, diagnosis, and current treatment modalities: A case series


Department of Otorhinolaryngology, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Web Publication19-Nov-2013

Correspondence Address:
Pradip Mallik
Department of Otorhinolaryngology, Regional Institute of Medical Sciences, Lamphel, Imphal - 795 004, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-4958.121598

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  Abstract 

Oropharyngeal malignancy is the second most common malignancy of the head and neck surpassed only by carcinomas of the alveo-buccal complex in India (excluding thyroid malignancy). More than 75% of these oropharyngeal carcinomas occur in the tonsillar area. Two-thirds of the patients with tonsillar carcinomas present at advanced stages because early lesions are generally asymptomatic when small. A total of 5 cases of tonsillar malignancy (2 undifferentiated carcinomas, 2 non- Hodgkin's lymphomas, and 1 squamous cell carcinoma were reported and treated in the last 1 year. Four out of 5 cases presented with advanced disease (stage 4) at the time of their first visit to the hospital. A good response was seen in majority with primary radiotherapy or combined chemoradiation. This case series is an attempt to define the presentation, diagnosis, currently available treatment, and prognosis of these tumors.

Keywords: Chemotherapy, Malignancy, Radiotherapy, Tonsil


How to cite this article:
Babu AP, Mallik P, Pradhan S, Sobita P, Sudhiranjan T H, Bhutia NN. Tonsillar malignancy - Review of clinico-pathological presentation, diagnosis, and current treatment modalities: A case series. J Med Soc 2013;27:147-50

How to cite this URL:
Babu AP, Mallik P, Pradhan S, Sobita P, Sudhiranjan T H, Bhutia NN. Tonsillar malignancy - Review of clinico-pathological presentation, diagnosis, and current treatment modalities: A case series. J Med Soc [serial online] 2013 [cited 2019 Dec 14];27:147-50. Available from: http://www.jmedsoc.org/text.asp?2013/27/2/147/121598


  Introduction Top


The oropharynx consists of the tonsillar region (pillars and fossae), base of tongue, soft palate, and posterior and lateral oropharyngeal walls. The most distinguishing anatomical characteristic is the location for most of Waldeyer's lymphatic ring, including the palatine and lingual tonsils. Tonsillar malignancy is the second most common malignancy of the head and neck. Carcinoma arising from these sites usually is squamous in origin and is related strongly to smoking, HPV infection and, to a lesser degree, alcohol ingestion. [1] Most commonly, carcinoma affects patients in the fifth to seventh decade in life. The incidence in men is 2 to 5 times greater than the incidence observed in women. Squamous cell carcinoma (SCC) is the most common malignancy and forms 90% of the tumors in this region. Non-Hodgkin's lymphomas account for 8% and minor salivary gland tumors for 2%. With regard to the SCC, the frequency of affected sites is tonsil/lateral wall (60%), tongue base (25%), soft palate (10%), and posterior wall (5%). [2]

Oropharyngeal SCC tends to present in one of the three ways:

  1. Symptoms from primary disease with or without lymph node metastases;
  2. Lymph node metastasis with clinically detectable Oropharyngeal SCC primary;
  3. Lymph node metastasis with unknown primary.


Many patients with tonsillar malignancy present with advanced disease because early lesions are generally asymptomatic when small. The lack of symptoms is responsible for 67-77% patients presenting with tumors larger than 2 cm and often with regional node metastasis. At presentation, 45% of anterior tonsillar pillar lesions and 76% of tonsillar fossa lesions have clinically positive neck nodes. [2] The lymphatic drainage from the oropharynx is mainly to levels 2, 3, and 4 of neck nodes in the frequency of 55%, 33%, and 19%, respectively. [3],[4]


  Case Reports Top


Case 1

A 53-year-old female presented with a grey-white ulcero-proliferative growth arising from the left tonsillar fossa with left cervical lymphadenopathy involving the level 2 and 3 neck nodes for more than 1 year [Figure 1]. A biopsy was taken from the tonsillar growth, which showed malignant monomorphic population of cells with abnormal mitoses and pleomorphic vesicular nuclei suggesting undifferentiated carcinoma of the oropharynx. CT oropharynx revealed tumor mass >4 cm in diameter crossing the midline to involve the base of the tongue and soft palate with ipsilateral level 2 and 3 neck nodes involvement. Based on these findings, the tumor was in stage 4A with T 4a N 2b M 0 . This patient was treated primarily with external irradiation utilizing a 60Co unit using 2 parallel opposed lateral fields and an anterior field to cover the tumor in the tonsillar fossa and its extension in the base of the tongue, soft palate, and the involved level 2 and 3 neck nodes. Follow up done for 6 months post radiotherapy and there was no known complication from radiotherapy.
Figure 1 : Tonsillar carcinoma presenting as growth from tonsillar fossa in another patient

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Case 2

A 59-year-old male presented with a grey-white ulcero-proliferative growth arising from the right tonsillar fossa with right cervical lymphadenopathy involving the level 2 and 3 neck nodes for 8 months. A biopsy was taken from the tonsillar growth, which showed sheets of malignant monomorphic population of cells suggesting squamous cell carcinoma - well differentiated type [Figure 2]. CT oropharynx revealed tumor mass >4 cm in diameter confined to tonsillar fossa with ipsilateral level 2 and 3 neck nodes involvement. Based on these findings, the tumor was in stage 4A with T 3 N 2a M 0 . This patient was treated primarily with external irradiation utilizing a 60Co unit using 2 parallel opposed lateral fields; a greater dose was given to the affected side and an adequate prophylactic dose to the contra-lateral nodes. Patient was followed up for 6 months post radiotherapy and no known complication from radiotherapy was found.
Figure 2 : Histopathology picture of squamous cell carcinoma: Well differentiated

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Case 3

A 47-year-old female presented with a grey-white ulcero-proliferative growth arising from the left tonsillar fossa with left cervical lymphadenopathy involving the level 1b and 2 neck nodes for around a year [Figure 3]. A biopsy was taken from the tonsillar growth, which showed malignant cells with scanty cytoplasm, abnormal mitoses, pleomorphic vesicular nuclei, and a note is made of many tangible body macrophages suggesting non-Hodgkin's lymphoma- diffuse large cell variant of the tonsil. CT oropharynx revealed tumor mass >2 cm in diameter with ipsilateral level 2 and 3 neck nodes involvement. Based on these findings, the tumor was in stage 4A with T 2 N 2a M 0 . This patient was treated primarily with combined chemo-radiotherapy.
Figure 3 : Tonsillar carcinoma presenting as growth from tonsillar fossa

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Case 4

A 56-year-old female presented with a growth arising from the right tonsillar fossa with right tender palpable jugulodigastic lymphadenopathy for around 5 months. A biopsy was done, but the findings were inconclusive. The patient underwent tonsillectomy. Histopathological examination of the tonsillar growth showed malignant cells with scanty cytoplasm, abnormal mitoses, pleomorphic vesicular nuclei with many tangible body macrophages suggesting non-Hodgkin's lymphoma- diffuse large cell variant of the tonsil [Figure 4]. Post-operative CT oropharynx revealed single ipsilateral level 2 neck node involvement. Based on these findings, the tumor was in stage 3 with T 2 N 1 M 0 . This patient was treated post-surgically with combined chemo-radiotherapy.
Figure 4: Histopathology picture of non-Hodgkin's lymphoma

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Case 5

A 52-year-old male from Toben, Manipur presented with a grey-white proliferative growth arising from the left tonsillar fossa without any palpable neck nodes [Figure 5]. A biopsy was taken from the tonsillar growth, which showed malignant monomorphic population of cells with abnormal mitoses and pleomorphic vesicular nuclei suggesting undifferentiated carcinoma of the oropharynx [Figure 6]. CT oropharynx revealed tumor mass >4 cm in diameter crossing the midline to involve the base of the tongue and soft palate without any neck node involvement. Based on these findings, the tumor was in stage 4A with T 4a N 0 M 0 . This patient was treated primarily with external irradiation utilizing a 60Co unit using two parallel opposed lateral fields and an anterior field to cover the tumor in the tonsillar fossa and its extension in the base of the tongue, soft palate.
Figure 5 : CT image showing tonsillar growth extending into base of tongue without anterior nodal involvement

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Figure 6 : Histopathology picture of undifferentiated tonsillar carcinoma

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  Discussion Top


Several variables are considered when prescribing treatment for patients with oropharyngeal malignancy: The extent of the primary tumor; the tumor grade; the extent of nodal metastases; and the patient's age, general health, occupation, and personal preferences. Classification of carcinoma of tonsil is done prior to treatment modalities. According to UICC 2002, the classification is based on primary tumor (T), presence, size, numbers and localization of regional disease metastasis (N) and distant metastasis or not (M). [5]

Treatment and Prognosis of Squamous Cell Carcinoma of Tonsil

In stage I-II and some stage III (T1-2, N1) squamous cell carcinoma, external beam irradiation is given to local and regional site to good effect. According to the Liverpool series, it was concluded that tonsillar carcinoma with lymph nodes can be treated by radiotherapy to the tonsillar region and with radical neck dissection if the disease is more than N1. [6] Radiotherapy as a primary treatment modality in early tonsillar carcinoma and concurrent chemotherapy and radiation therapy is currently standard of care in advanced tonsillar carcinoma. [7] If the tumor is not considered resectable, then radiotherapy with or without chemotherapy is given as the only treatment. The expected 5 year survival rate in early squamous cell carcinoma is 50-90 per cent, whereas in advance stage, it is 20-55 percent. [7]

Treatment and Prognosis of Lymphomas of Tonsils

Among the non-Hodgkin lymphomas (NHL) found in Waldeyerxs ring, the tonsils are the primary location for the disease in 80% of the cases. Endo et al., who analyzed 38 cases of primary tonsillar NHL, concluded that in patients with stage I or II tonsillar lymphomas with bulky tumor mass, chemotherapy followed by radiotherapy might be the choice of treatment. [8] In the last few years, there have been many reports that favor aggressive systemic treatment with chemotherapy and radiotherapy, even for such well-localized lymphomas, avoiding the need for tonsillectomy of the normal tonsil. [9],[10] Number of risk factors present in aggressive NHL, compared with probability of complete remission (CR) and five-year survival (SV). [10]


  Conclusion Top


With increasing incidence of tonsillar malignancy in the recent years, early identification of tonsillar growth as malignancy followed by chemo-radiotherapy with dose and field size adjusted to the extent of the disease combined with surgery in advanced cases provides improved results.

 
  References Top

1.Johansen LV, Overgaard J, Overgaard M, Birkler N, Fisker A. Squamous cell carcinoma of the oropharynx: An analysis of 213 patients. Laryngoscope 1990;100:985-90.  Back to cited text no. 1
[PUBMED]    
2.Guay ME, Lavertu P. Tonsillar carcinoma. Eur Arch Otorhinolaryngol 1995;252:259-64.  Back to cited text no. 2
[PUBMED]    
3.Buckley JG, Feber T. Surgical treatment of cervical node metastasis from squamous carcinoma of upper aerodigestive tract: Evaluation of the evidence for modifications of neck dissection. Head Neck 2001;23:907-15.  Back to cited text no. 3
[PUBMED]    
4.Shimizu K, Inoue H, Saitoh M, Ohtsuki N, Ishida H, Makino K, et al. Distribution and impact of lymphnode metastasis in oropharyngeal cancer. Acta Otolaryngol 2006;126:872-7.  Back to cited text no. 4
[PUBMED]    
5.Sobin LH, Wittekind CH. UICC TNM classification of malignant tumors. 6 th ed. New York: Wiley 2002;23:239  Back to cited text no. 5
    
6.Jones AS, Beasley NJ, Houghton DJ, Williams S, Husband DG. Treatment of oropharyngeal carcinoma by irradiation or by surgery. Clin Otolaryngol Allied Sci 1998;23:172-6.  Back to cited text no. 6
[PUBMED]    
7.Charbonneau N, Gélinas M, del Vecchio P, Guertin L, Larochelle D, Tabet JC, et al. Primary radiotherapy for tonsillar carcinoma: A good alternative to a surgical approach. J Otolaryngol 2006;35:227-34.  Back to cited text no. 7
    
8.Endo S, Kida A, Sawada U, Sugitani M, Furusaka T, Yamada Y, et al. Clinical analysis of malignant lymphomas of tonsil. Acta Otolaryngol Suppl 1996;523:263-6.  Back to cited text no. 8
[PUBMED]    
9.Barton JH, Osborne BM, Butler JJ, Meoz RT, Kong J, Fuller LM, et al. Non-Hodgkin's lymphoma of the tonsil: A clinicopathological study of 65 cases. Cancer 1984;53:86-95.  Back to cited text no. 9
[PUBMED]    
10.Fujitani T, Takahara T, Hattori H, Imajo Y, Ogasawara H. Radiochemotherapy for non-Hodgkin's lymphoma in palatine tonsil. Cancer 1984;54:1288-92.  Back to cited text no. 10
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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Abstract
Introduction
Case Reports
Discussion
Conclusion
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