Clinical
Presentation:Patient is a 58-year-old man with odynophagia,
trismus and weight loss.
Radiological Findings:
Contrast CT: shows a large soft tissue mass in the region of right tonsil.
The lesion extends superiorly into the lateral right nasopharyngeal wall.
Laterally, the lesion erodes into the right medial pterygoid muscle. There are few small lymph nodes in the right neck level II area. The largest one measures 1.3 cm.
Figure 1: There is a soft tissue mass (star) in the region of right tonsil extending into the oropharynx.
Figure 2: Superiorly, the lesion extends into the right nasopharynx (arrow).
Figure 3: There is an enlarged lymph node located at level II (arrow). The lesion invades into medial pterygoid muscle (star).
Diagnosis: Invasive squamous cell carcinoma of the right tonsil
Clinical Discussion: Tonsillar cancer is a relative rare. It accounts less than 0.5% of all cancer in men in the US. Incidence is about 1.5 per 100,000 white men and 3.2 per 100,000 black men. It is more frequent in men than in women (3-4:1). Excessive consumption of alcohol and tobacco increases the risk of developing tonsillar tumors [1].
A triangular region contains the lymphoid tonsillar tissue. The limit includes anterior and posterior tonsillar pillars (palatoglossal and palatopharyngeal muscles respectively). Inferiorly, it is the glossopalatinin sulcus. Lymphatics from the tonsillar region drain into the jugulodiagastric basin and the submandibular triangle [2,3].
Squamous cell carcinoma accounts for near all of the lesions. Malignant lymphomas accounts about 5% of tonsillar cancers. Lymphoepitheliomas and minor salivary gland cancer are rare and may also occur in the tonsillar region [1,2,3].
Staging of tonsillar cancer as part of oropharyngeal cancer by TMN classification is based on The American Joint Committee on Cancer (AJCC) designation [4]. The extend of the primary disease and nodal status need to be evaluated by physical exam, complete endoscope exams and imaging studies [3, 4, 5]. MRI is preferred the modality for delineating the primary disease extent because of its superior soft tissue sensitivity. CT may be better at evaluating nodal status, often based on the size criteria. PET has been investigated in the setting of borderline enlarged cervical lymph nodes and its role is still evolving [3,6]. Tonsillar pillar cancers tend to be more superficial and less frequently metastasize to the cervical lymph nodes. In contrast, tumors in the tonsillar fossa often present in advanced stage with frequent nodal involvement. About 75% of patients present with stage III or IV disease at diagnosis; about 55% of patients with N2 or N3 disease. Contralateral metastasis is about 20% for tonsillar fossa tumors [7]. Prognosis ranges from 93% for stage 1 to 17% for stage IV [7,8]. Treatment options depend on cancer stage [1,2,9,10]. There are no randomized control trials for tonsillar cancer specifically to guide the therapy. Individual based treatment decision often requires multidisciplinary input in order to provide the optimal therapeutic benefit with minimal morbidity. Either surgery or radiation alone may be used to treat early stage I/II disease. Radiation may achieve similar if not better result of local disease control and overall survival and is usually preferred as it produces a potentially better functional outcome [11]. For advanced stage disease, combined modality therapy is often required. The option includes surgery and post-operative radiation with or without chemotherapy. It may also be treated with radiation alone or followed by neck dissection if there is residual disease. If the disease involves larynx, combined chemoradiation may be offered for the purpose of organ preservation.
DeVita VT, Hellman S, Rosenberg SA. Cancer: Principles Practice of Oncology, 7th ed. Section 2: Treatment of head and neck cancers. Lippincott Williams and Wilkins, 2005.
Bragg D, Rubin P, Hricak H.Oncologic Imaging, 2nd ed. Chapter 13. Malignancies of the oral cavity, oropharynx, and hypopharynx. WB Saunders Co, 2002.
Stenson K. Diagnosis and staging of head and neck cancer. UptoDate Online.
Ankenbrandt WJ, Brockstein. Imaging of head and neck cancer, UptoDate Online.
Lindberg R. Distribution of cervical lymph node metastases from squamous cell carcinoma of the upper respiratory and digestive tracts. Cancer. 1972 Jun;29(6):1446-9. [Medline]
Givens CD Jr, Johns ME, Cantrell RW. Carcinoma of the tonsil. Analysis of 162 cases. Arch Otolaryngol. 1981 Dec;107(12):730-4. [Medline]
