[Analysis of cases of cervical cystic lymph node metastasis with an unknown primary misdiagnosed as branchial cleft carcinoma].

Objectives: To analyze the location, discovery time and possible causes of cases of cervical cystic lymph node metastasis with an unknown primary misdiagnosed as branchial cleft carcinoma. Methods: A retrospective analysis was performed on clinical and pathological data of 15 patients misdiagnosed as branchiogenic carcinoma at Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College between January 2000 and December 2020. Results: Among the 15 patients, 6 were nasopharyngeal squamous cell carcinoma, 4 tonsil squamous cell carcinoma, 2 tongue root squamous cell carcinoma, 2 hypopharyngeal squamous cell carcinoma and 1 thyroid papillary carcinoma. The median time from the diagnosis of branchial cleft carcinoma to the discovery of primary lesions was 3.58 months (0-76 months). The causes of misdiagnosis might be the lack of experience in the diagnosis and treatment of branchial cleft carcinoma, and not enough attention to comprehensive examination and close follow-up. Conclusions: Different from oropharyngeal cancer reported internationally, the proportion of misdiagnosed cases with nasopharyngeal carcinoma as the primary site in the current article is higher. As a country with a high incidence of nasopharyngeal carcinoma, the examination of nasopharynx should not be taken lightly. Most hidden cases can be found in the comprehensive examination in a short time, while a few cases need long-term follow-up. Finding the primary sites should not rely too much on imaging examination, and we cannot ignore the importance of clinical physical examination.

A two-centre experience of tonsil biopsies in the investigation of patients with tonsillar asymmetry.

INTRODUCTION: We aim to evaluate our experience of tonsil biopsies in the investigation of patients presenting with asymmetrical tonsils. METHODS: A two-centre retrospective analysis of all patients who underwent histology sampling of the palatine tonsils between 1 January 2013 and 31 December 2018 was completed. Data collected included patient demographics, method of obtaining tonsil tissue, histological diagnosis and need for repeat tissue sampling. A follow-up period of 36 months was allowed to establish whether any patients re-presented with missed diagnoses. RESULTS: In total, 937 patients were included for analysis: 375 (40.0%) had a biopsy, of which 191 (50.9%) were performed in clinic. The mean duration from initial appointment with the ear, nose and throat clinic to tissue sample collection was 17.6 days (range 0-327 days) for all biopsies, reducing to 0.2 days (range 0-17 days) for biopsies performed in clinic. This was significantly shorter than for tonsillectomies (mean 38.9 days, range 0-444 days; p<0.05). Of the patients who underwent tonsil biopsy, six (1.6%) had malignancy that was not unequivocally diagnosed on initial biopsy. In all six patients, prior clinical suspicion was high, and repeat tissue sampling was undertaken on receipt of negative histology results. CONCLUSIONS: Tonsil biopsy is a viable alternative to tonsillectomy for histology in the assessment of tonsil asymmetry. Tonsil biopsy in the outpatient setting has reduced surgical morbidity, significantly less delay in diagnosis, less inconvenience for patients and lower healthcare costs compared with formal tonsillectomy. Although tonsil biopsies should not be used in isolation, they can be useful in the investigation of patients presenting with tonsillar asymmetry.

A Diagnostic Challenge: Toxoplasmosis Masquerading as Tonsillar Neoplasm.

This case report elucidates an uncommon manifestation of toxoplasmosis characterized by an ulcerative oropharyngeal lesion and cervical lymphadenopathy, which intriguingly simulated a tonsillar neoplasm. The patient, a 28-year-old immunocompetent woman, reported symptoms such as a persistent sore throat, unilateral neck pain, and otalgia. Despite the initial clinical impressions, a diagnostic left subtotal tonsillectomy revealed no malignancy but marked acute and chronic inflammation. A comprehensive investigation subsequently indicated a recent primary infection with Toxoplasma gondii, as evidenced by the presence of high IgM antibodies and low IgG avidity. This unique case underlines the significance of incorporating toxoplasmosis into the differential diagnosis of oropharyngeal lesions, thereby necessitating a meticulous approach to laboratory testing. Laryngoscope, 134:1741-1743, 2024.

Leiomyoma of the palatine tonsil - report of a rare and unusual tumor at this site.

A leiomyoma is a remarkably rare cause of a benign, one-side tonsillar enlargement. The diagnosis is essentially histologic and will not normally be suspected clinically. Immunohistochemistry is needed for substantiation of the morphology and confirmation. We submit this illustrative case report.

The isolated symptom of unilateral tonsillar enlargement has limited value in adults with a suspected head and neck cancer pathway.

OBJECTIVE: Given the uncertainty regarding the predictive value of unilateral tonsillar enlargement and/or lesion in malignancies, this study aimed to evaluate the efficacy of unilateral tonsillar enlargement and/or lesion referral criterion in the adult suspected head and neck cancer pathway. METHODS: All two-week wait referrals received in 2018-2019 were reviewed. All patients referred with unilateral tonsillar enlargement and/or lesion were included and analysed for patient demographic data, presenting symptoms, initial clinic outcomes and final diagnoses. RESULTS: A total of 4934 urgent head and neck cancer referrals were analysed, and 1.9 per cent of these had unilateral tonsillar enlargement and/or lesion. Only 10 patients were diagnosed with tonsil cancer. All the positive tonsil cancer cases had at least one additional head and neck red flag symptom. CONCLUSION: The referral criterion for unilateral tonsillar enlargement and/or lesion may be of limited benefit in an already economically challenged National Health Service. Further multicentre studies should be undertaken to refine conclusions on the value of unilateral tonsillar enlargement and/or lesion alone as a criterion for the head and neck cancer two-week wait pathway.

[Tonsillar asymmetry in adults: review of the literature and management algorithm]. / Asymétrie amygdalienne chez l'adulte: revue de littérature et proposition de prise en charge.

Tonsillar asymmetry is both a common clinical finding and a potential sign of cancer. The diagnosis of the latter requires tonsillectomy, which is associated with two weeks off work and post-operative risk of bleeding, which ranges between 1.5 and 15% of the cases. Thus, it is crucial to determine which patients can be followed clinically and which ones will need a diagnostic tonsillectomy. This article provides a review of the literature on tonsillar asymmetry in the adult population and an algorithm for its management.

L'asymétrie amygdalienne est à la fois une découverte clinique fréquente et un potentiel signe de cancer. Le diagnostic de ce dernier se pose par une amygdalectomie. Celle-ci est associée à un arrêt de travail d'environ deux semaines, ainsi qu'à des risques postopératoires de saignement qui varient de 1,5 à 15% des cas. Il est donc crucial de déterminer quels patients peuvent être suivis cliniquement et quels sont ceux qui doivent bénéficier d'une amygdalectomie diagnostique. Cet article propose une revue de la littérature sur l'asymétrie amygdalienne dans la population adulte ainsi qu'un algorithme de prise en charge.

Synchronous tonsillar tumors with differing histopathology: A case report and review of the literature.

BACKGROUND: Tonsillar squamous cell carcinoma (TSCC) due to human papillomavirus (HPV) infection has seen a dramatic increase in recent years. Bilateral tonsillar squamous cell carcinoma (biTSCC) has a much lower incidence than unilateral TSCC and three main hypotheses of biTSCC pathogenesis prevail: field carcinogenesis, single-clone, and multiple HPV infections. CASE: A 49-year-old Male with a remote history of chewing tobacco presented with symptoms of spitting up tissue and occasional hemoptysis. Physical exam showed a sole left tonsillar mass which was confirmed to be TSCC on biopsy. The patient's computed tomographic (CT) scan was consistent with this finding; however, positron emission tomography (PET) scan indicated a second tumor in the contralateral right tonsil. Surgical resection of both masses and selective neck dissection was performed, and the specimens were sent for further pathological analysis. No complications of surgery were noted and the final diagnosis of synchronous biTSCC was made. The tumors were a T2N0M0 left poorly differentiated TSCC (p16+, EGFR+, bcl2+) with basaloid features, and a T1N0M0 right well to moderately differentiated TSCC (p16+, EGFR+, bcl2-). CONCLUSION: Our present case was notable for differing tumor pathology and karyotype analysis between the right and left masses, directly supporting the multiple HPV infections hypothesis of biTSCC pathogenesis. Further genetic characterization of tonsillar tumors is needed to better characterize TSCC and best guide medical/surgical therapy.

Rectal Cancer With Synchronous Tonsillar Metastasis: A Case Report and Literature Review.

Colorectal cancer is the third most common cancer globally and nearly one fourth of distant metastases are found at the time of the primary diagnosis. Synchronous metastasis of colorectal cancer to the palatine tonsil is rare. To date, only 5 cases have been published in the English literature. In such cases, the prognosis is worse than in other common metastatic sites. Herein, we report a case of rectal adenocarcinoma who presented with a tonsillar mass initially.

Fibroepithelial polyp of palatine tonsil: a case report.

Fibroepithelial polyps represent a frequent cutaneous lesion of mesodermal origin, with a prevalence of 1.2% and are rarely located at palatine tonsils. We present a rare clinical report of a 70-year-old female patient with fibroepithelial polyp of palatine tonsil. This entity represents the eighth case of palatine tonsil fibroepithelial polyp in the English literature. She presented with a polypoid mass at the right tonsil and unspecified throat symptoms. Physicians should pay attention to such lesions because of the residual risk of malignant transformation, along with non-specific symptoms. Differential diagnosis was among neurofibroma, lipoma, squamous papilloma and fibroepithelial polyp. Histopathological examination following tonsillectomy showed a structure rich in vesicles inside lamina propria and surrounding inflammation, establishing the diagnosis of a fibroepithelial polyp. It requires vigilance during complete clinical examination, in order to detect masses at patients with throat symptoms that could have remained undiagnosed until they become even life threatening.

CT texture analysis of tonsil cancer: Discrimination from normal palatine tonsils.

The purposes of the study were to determine whether there are differences in texture analysis parameters between tonsil cancers and normal tonsils, and to correlate texture analysis with 18F-FDG PET/CT to investigate the relationship between texture analysis and metabolic parameters. Sixty-four patients with squamous cell carcinoma of the palatine tonsil were included. A ROI was drawn, including all slices, to involve the entire tumor. The contralateral normal tonsil was used for comparison with the tumors. Texture analysis parameters, mean, standard deviation (SD), entropy, mean positive pixels, skewness, and kurtosis were obtained using commercially available software. Parameters were compared between the tumor and the normal palatine tonsils. Comparisons were also performed among early tonsil cancer, advanced tonsil cancer, and normal tonsils. An ROC curve analysis was performed to assess discrimination of tumor from normal tonsils. Correlation between texture analysis and 18F-FDG PET/CT was performed. Compared to normal tonsils, the tumors showed a significantly lower mean, higher SD, higher entropy, lower skewness, and higher kurtosis on most filters (p<0.001). On comparisons among normal tonsils, early cancers, and advanced tonsil cancers, SD and entropy showed significantly higher values on all filters (p<0.001) between early cancers and normal tonsils. The AUC from the ROC analysis was 0.91, obtained from the entropy. A mild correlation was shown between texture parameters and metabolic parameters. The texture analysis parameters, especially entropy, showed significant differences in contrast-enhanced CT results between tumor and normal tonsils, and between early tonsil cancers and normal tonsils. Texture analysis can be useful as an adjunctive tool for the diagnosis of tonsil cancers.

[Palatine tonsil lymphoma: a pediatric case report]. / Linfoma de amígdala: reporte de un caso pediátrico.

Lymphoma is the most common childhood malignancy in the head and neck. The most common clinical manifestations of lymphoma in palatine tonsil are the tonsils asymmetry, alteration in the appearance of the mucous and cervical lymphadenopathy. The unilateral tonsillar hypertrophy must be differentiated with infectious processes, with chronic processes, other tumors or benign tonsillar hyperplasia. The monitoring of tonsillar hypertrophy is strict, because early diagnosis and treatment are of great importance in the prognosis of tonsillar lymphoma patients. A 14 year-old girl presents unilateral tonsillar enlargement and odynophagia. After 21 days of antibiotic treatment, she has not clinical improvement. The diagnosis is Burkitt's lymphoma. One year after diagnosis, she presents complete remission of the disease.

El linfoma es la neoplasia maligna de cabeza y cuello más común en la población pediátrica. Las manifestaciones clínicas de linfoma en amígdala palatina son generalmente asimetría amigdalina, alteración en la apariencia de la mucosa y adenopatías cervicales. Ante una hipertrofia amigdalina unilateral, se debe diferenciar de cuadros infecciosos, procesos crónicos, otros tumores o simplemente una hiperplasia amigdalina benigna. El seguimiento estricto de la asimetría amigdalina es un pilar importante a la hora del diagnóstico de los pacientes con linfoma amigdalino, debido a que un tratamiento temprano es fundamental para el pronóstico. Se presenta una niña de 14 años con hipertrofia amigdalina unilateral y odinofagia, de aproximadamente 21 días de evolución sin respuesta al tratamiento antibiótico, con diagnóstico de linfoma de Burkitt. Presenta remisión completa de la enfermedad al año del diagnóstico.

Prognostic Markers and Driver Genes and Options for Targeted Therapy in Human-Papillomavirus-Positive Tonsillar and Base-of-Tongue Squamous Cell Carcinoma.

The incidence of Human-papillomavirus-positive (HPV+) tonsillar and base-of-tongue squamous cell carcinoma (TSCC and BOTSCC, respectively) is increasing epidemically, but they have better prognosis than equivalent HPV-negative (HPV-) cancers, with roughly 80% vs. 50% 3-year disease-free survival, respectively. The majority of HPV+ TSCC and BOTSCC patients therefore most likely do not require the intensified chemoradiotherapy given today to head and neck cancer patients and would with de-escalated therapy avoid several severe side effects. Moreover, for those with poor prognosis, survival has not improved, so better-tailored alternatives are urgently needed. In line with refined personalized medicine, recent studies have focused on identifying predictive markers and driver cancer genes useful for better stratifying patient treatment as well as for targeted therapy. This review presents some of these endeavors and briefly describes some recent experimental progress and some clinical trials with targeted therapy.

Tonsillar p16-Positive Follicular Dendritic Cell Sarcoma Mimicking HPV-Related Oropharyngeal Squamous Cell Carcinoma: A Case Report and Review of Reported Cases.

Follicular dendritic cell sarcoma (FDCS) is a rare entity which can share morphologic features with non-keratinizing squamous cell carcinoma. Recent reports suggest that up to half of FDCSs show immunohistochemical positivity for p16 (Zhang et al., in Hum Pathol 66:40-47, 2017), a stain that is conventionally used in the risk stratification of oropharyngeal squamous cell carcinoma (OPSCC). Herein, we report a case of p16-positive FDCS with clinical and histomorphologic overlap with human papilloma virus (HPV)-related OPSCC.

Occult Malignancy in Adult Tonsillectomy for Benign Indication.

OBJECTIVE: National pathology guidelines recommend full pathologic analysis for all adult tonsillectomy specimens. We evaluated the available data on occult malignancy in adult tonsillectomy for benign indication, and created a screening system to reduce the risk of missed malignancies if routine histopathologic examination were to be discontinued. STUDY DESIGN: Retrospective chart review and systematic review of the literature. SETTING: Tertiary care academic hospital and multi-hospital private healthcare system. SUBJECTS AND METHODS: A systematic literature review identified case series of adult tonsillectomy. Retrospective chart review at our institutions from 2000 to 2016 produced an additional case series. The pooled rate of occult malignancy was determined, and re-analyzed using criteria based on preoperative risk factors designed to identify patients requiring full pathologic analysis. The predicted effects of prospective application of the proposed criteria were calculated. Pooled occult malignancy prevalence was estimated. RESULTS: Literature review and our own case series yielded 12,094 total cases. Occult malignancy prevalence in the combined data was 0.033%, representing four occult malignancies. Three out of the four would have been selected for full pathology preoperatively with use of the proposed criteria. Statistical analysis indicates that the predicted frequency of occult malignancy incidence in cases negative for the criteria is 0.01%, or 1/10,000. CONCLUSION: Application of the proposed criteria to adults undergoing tonsillectomy for benign indication identifies a subset of patients with an estimated incidence of occult malignancy similar to that reported for pediatric tonsillectomy, and potentially may permit safe elimination of pathologic analysis of their tonsil specimens. LEVEL OF EVIDENCE: Pooled analysis of case series from the literature and a single institution, level 4.

Primary tonsillar tuberculosis masquerading as carcinoma of the tonsil.

Primary tuberculosis (TB) of tonsil is a rare form of extra-pulmonary tuberculosis. Most tonsillar TB cases present with coexistent pulmonary tuberculosis. It can simulate tonsillar malignancy and poses a diagnostic challenge. Histopathological examination is often needed for confirmation. Herein, we report a case of primary tonsillar tuberculosis in a 55-year-old gentleman mimicking carcinoma of the tonsil.

Human papillomavirus (HPV) in Chinese oropharyngeal squamous cell carcinoma (OPSCC): A strong predilection for the tonsil.

OBJECTIVE: Compared with Occident's data, the incidence of Human papillomavirus (HPV)-driven oropharyngeal squamous cell carcinomas (OPSCCs) had been reported as relatively low in Mainland China. The objective of this study was to report the integrated prevalence of HPV and Epstein-Barr virus (EBV), and further evaluate the different behaviors of HPV-positive and -negative OPSCCs in eastern China. METHODS: In a cohort of 170 nonmetastatic OPSCCs treated from January 2007 to July 2019, p16 protein expression, HPV genotypes, and Epstein-Barr virus-encoded RNA (EBER) were determined by immunohistochemistry (IHC) and in situ hybridization (ISH). The clinical and pathologic findings were further collected and analyzed to comprehensively reveal the behaviors of Chinese OPSCCs. RESULTS: Out of the 170 tumor tissues evaluated, 57.6% (98) samples had positive p16 expressions. A total of 65.1% (99/152) samples had positive HPV genotypes, besides HPV16 (92/152), HPV11, 18, 33, 53, and 58 were also detected. The positive rate of EBER was 7.2% (9/124), and the co-infection rate of EBV/HPV was 4.0%. Related to the unequal distributions of p16 expression, HPV-related tumors arisen from tonsillar and non-tonsillar accounted for 68.8% (75/109) and 37.7% (23/61) of their cases, respectively (P < .001). With a median follow-up time of 13.1 months, significant survival advantages of HPV-related OSPCC were observed; 1-year OS, PFS, RFS, and MFS were 83.2% vs 96.7% (P < .001), 71.6% vs 96.2% (P < .001), 77.7% vs 96.2% (P = .002), and 90.4% vs 100.0% (P = .024) in p16-negative and -positive cases, respectively. CONCLUSIONS: The relative percent of HPV-positive OPSCCs in this study is close to the positive rate in many Western countries and a strong predilection was discovered for the tonsillar. The EBV infection and co-infection of HPV/EBV were largely low. The prognosis of HPV-positive OSPCCs was more favorable than its negative counterpart.

Unexpected occult malignancy diagnosed during tonsillectomy surgery for obstructive sleep apnea: A case report.

RATIONALE: Many previous studies have investigated the necessity of routine histopathological analysis of tonsillectomy specimen, and most recent studies have suggested that such an analysis is not justified in asymptomatic patients or those with no risk factors for malignancy. PATIENT CONCERNS: A 59-year-old man diagnosed with obstructive sleep apnea underwent surgery, including tonsillectomy; a tonsil specimen was sent to the department of pathology. DIAGNOSIS: Although the patient did not exhibit any tonsil-related signs or symptoms, nor did the appearance of the tonsil appear to be pathological, the right tonsil specimen was diagnosed with squamous cell carcinoma, with detection of human papilloma virus 16. INTERVENTIONS: Chemotherapy and radiotherapy were used to treat the tonsil cancer. OUTCOMES: No recurrence was observed during the 4-year follow-up. LESSONS: In the future, it may be necessary to reinvestigate the necessity of routine histopathological analysis of tonsillectomy specimens in asymptomatic patients, considering the drastically increased rate of detection of human papilloma virus-related oropharyngeal squamous cell carcinomas in these patients.

Rare case of tonsillar and subcutaneous metastasis from neuroendocrine cervical cancer.

Neuroendocrine cervical carcinoma (NECC) is a rare type of cervical cancer, with high tendency of lymphatic and distant metastasis and poor prognosis. Herein, we reported a rare case of relapsed NECC metastasizing to palatine tonsil and subcutaneous adipose tissue in multiple regions, which reflects the aggressive biological behavior of NECC.

Clinical parameters predicting tonsillar malignancy.

PURPOSE: Tonsillectomy is indicated in unilateral tonsillar enlargement (UTE) to rule out malignancy, which eventually is found in about 1.4% of the patients. The aim of this study was to evaluate the presenting symptoms of patients who underwent tonsillectomy for UTE and identify parameters that are associated with an increased risk for malignancy, for better assessment and refinement of current management protocols. METHODS: A retrospective chart review of adult patients with UTE who underwent tonsillectomy between 1/1/2006 and 31/12/2016 was conducted. RESULTS: Forty-one patients with a median age of 53 years were included. There were 20 (49%) females and 21 (51%) males. Sixteen (39%) patients were diagnosed as having tonsillar malignancy. Patients with malignancy were older than those in the benign group (p = 0.001), had a previous malignancy (p = 0.006), and were less likely to present as an incidental finding (p < 0.001). Lymphadenopathy, throat pain, suspicious appearance of tonsillar mucosa, and hard consistency were also found to be statistically significant findings in the malignancy group (p = 0.017, p = 0.001, p = 0.01 and p = 0.018, respectively). Multivariable regression showed age, appearance and adjacent tissue involvement to be independently with malignancy. CONCLUSIONS: UTE alone, as an incidental finding, should not be regarded as an indication for tonsillectomy, as the risk for malignancy is low and the morbidity is significant. We suggest integrating the above-mentioned clinical parameters in the decision-making process, which were found to be significantly more frequent in the malignant group.