Malignant Tonsil Tumor Surgery Workup

Updated: Aug 06, 2018
  • Author: Niels Kokot, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Workup

Laboratory Studies

See the list below:

  • Liver function tests: Knowledge of hepatic function is necessary because (1) the patient's dietary and ethanol histories frequently lead to poor function, (2) hepatically metabolized chemotherapeutic agents or other medications (eg, pain medication) may be used, and (3) liver metastases are always possible.

  • Pulmonary function tests:

    • Any head and neck surgery carries additional risks of perioperative and postoperative respiratory complications.

    • Respiratory reserve is a necessary bit of knowledge before such surgery is performed.

  • Renal function tests: When certain chemotherapeutic agents are considered, renal function tests are necessary to ascertain whether the patient can eliminate agents that are handled by the kidneys.

  • Clotting and coagulation studies (including platelet count, typing, cross-matching)

    • The head and neck is one of the richest areas of vascularity in the human body.

    • Hemorrhage is one of the biggest problems in tonsillar surgery.

    • Having transfusion material available is wise.

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Imaging Studies

See the list below:

  • CT scanning of the neck, with and without contrast, is necessary to evaluate for metastases and to assess the extent of the tumor. In addition, if extended upward to include the bony areas, bone invasion is part of the new knowledge base. This is essential in staging tonsillar tumors.

  • MRI is also extremely useful for assessing tumor size and soft tissue invasion.

  • CT scan of the chest is the single most sensitive imaging study used to reveal lung metastasis and, therefore, should be the modality of choice, at least in high-risk patients (stage 4 disease, T4 tumor, N2 or N3 nodal disease, tumors that arise from the oropharynx, larynx, hypopharynx, or supraglottis). [8]

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Diagnostic Procedures

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  • Biopsy is the only tool for obtaining diagnostic tissue.

    • Tonsillar malignancies may be lymphoma; therefore, the pathologist and team should be immediately ready to handle the tissue properly.

    • Special fixatives must be prepared. Some tissue may be needed for fresh studies, which are time dependent and require immediate handling. Some tissue should be frozen in liquid nitrogen. Given the nature of frozen sections and the type of unexpected events in a pathologist's day, alerting the pathologist 24 hours in advance of a possible lymphoma biopsy is wise.

    • Another very important consideration is the fact that squamous cell carcinomas commonly arise deep in the crypts. This necessitates the surgeon taking a deep biopsy so that the true neoplasm is not missed. Given the propensity for these lesions to bleed, this is a tricky procedure, and the surgeon should be ready for the unexpected.

  • Panendoscopy

    • Operative endoscopy allows the surgeon to assess the full extent of the tumor. This can be very helpful when choosing between open and endoscopic surgical approaches. It also allows for a biopsy if it cannot be performed in the office.

    • Bronchoscopy and esophagoscopy are utilized to assess for second primary tumors that may be present at the time of diagnosis.

  • HPV testing

    • NCCN guidelines recommend HPV testing for prognostic factors.

    • Quantitative reverse transcriptase PCR (QRT-PCR) allows calculation of relative amounts of mRNA present in the sample.

      • Able to calculate copy number

      • Susceptible to false positives

    • Type-specific HPV DNA in situ hybridization

      • HPV-16 is most commonly used to examine oropharyngeal carcinomas.

      • It is both sensitive and specific.

    • P16 can be tested as a biomarker for HPV E7 activity.

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Histologic Findings

Squamous cell carcinoma

Most palatine tonsil squamous cell carcinomas are moderately to poorly differentiated.

The following variants, although essentially squamous cell carcinomas, in this area have been described with some frequency:

  • Basosquamous carcinoma Nonkeratinizing carcinoma (transitional cell or sinonasal type)

  • Undifferentiated or lymphoepithelioma type

Lymphomas

Lymphoma type determination is crucial and can be achieved only with the help of special studies obtained by the pathologist. The cell and tissue markers used to type lymphomas are quite sensitive. These require fresh frozen tissue and unusual fixatives, in addition to immunohistochemical stains.

All of these studies help in the crucial determination of lymphoma type. Many require fresh or frozen tissue for immunohistochemical studies.

Most tonsillar carcinomas are diffuse non-Hodgkin large B-cell lymphomas.

Mucosa-associated lymphoid tissue (MALT) low-grade B-cell lymphomas composed of small cells are uncommon in the tonsil. This is surprising because the tonsil consists of a very intimate intermingled arrangement of epithelium and lymphocytes, which, in theory, would make an ideal environment for the development of MALT lymphomas. In reality, they are so uncommon in this region that they are case reportable.

Minor salivary gland malignancies

Minor salivary gland malignancies are the third most common lesion of the tonsil. These lesions include mucoepidermoid carcinoma, adenoid cystic carcinoma, acinic cell carcinoma, and adenocarcinoma.

Metastatic lesions to the tonsil

Although the palatine tonsils are a rich source of lymphatics and lymphoid tissue, metastases to the palatine tonsils are rare. Case reports have described an extraordinarily wide spectrum of malignancies metastatic to this area. Breast, various lung primaries, renal carcinomas, and pancreatic and colorectal malignancies have been reported. Documented cases of Wilms tumor and choriocarcinoma metastasizing to this distant site also exist.

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Staging

Staging of tonsil carcinoma is according to the 6th edition of the AJCC Cancer Staging Manual. Clinical information is taken from all sources, including physical examination and any available imaging studies.

AJCC tumor staging of tonsil carcinoma is as follows:

  • Tx: Primary tumor cannot be assessed

  • T0: No evidence of primary tumor

  • Tis: Carcinoma in situ

  • T1: Tumor ≤ 2 cm in greatest dimension

  • T2: Tumor >2 cm but < 4 cm in greatest dimension

  • T3: Tumor >4 cm in greatest dimension

  • T4a: Tumor invades the larynx, deep or extrinsic muscles of the tongue, medial pterygoid muscle, hard palate, or mandible

  • T4b: Tumor invades the lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, skull base, or encases carotid artery

AJCC nodal categories (except thyroid and nasopharyngeal carcinoma):

  • Nx: Regional lymph nodes that cannot be assessed

  • N0: No regional node metastasis

  • N1: Metastasis in a single ipsilateral lymph node, 3 cm or smaller

  • N2: Metastasis in a single ipsilateral lymph node, larger than 3 cm but not larger than 6 cm in greatest dimension is found; multiple ipsilateral lymph nodes, none larger than 6 cm; bilateral or contralateral lymph nodes, none larger than 6 cm

  • N2a: Metastasis in a single ipsilateral lymph node larger than 3 cm but not larger than 6 cm

  • N2b: Metastasis in multiple ipsilateral lymph nodes, none larger than 6 cm

  • N2c: Metastasis in bilateral or contralateral lymph nodes, none larger than 6 cm

  • N3: Metastasis in a lymph node larger than 6 cm

Distant metastasis:

  • Mx: Distant metastasis cannot be assessed

  • M0: No distant metastasis

  • M1: Distant metastasis

The combination of the primary tumor, nodal status, and presence or absence of distant metastasis is used as a part of the overall staging of the patient’s disease according to AJCC guidelines:

  • Stage I: T1 N0 M0

  • Stage II: T2 N0 M0

  • Stage III: T3 N0 M0 T1 N1 M0 T2 N1 M0 T3 N1 M0

  • Stage IVa: T4a N0 M0 T4a N1 M0 T1 N2 M0 T2 N2 M0 T3 N2 M0 T4a N2 M0

  • Stage IVb: Any T N3 M0 T4b Any N M0

  • Stage IVc: Any T Any N M1

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