Tonsil cancer

Tonsil cancer

Overview

Tonsil cancer is the most frequent kind of oropharyngeal cancer, and its prevalence is rapidly growing as the frequency of human papillomavirus (HPV)-induced tumors rises.

Tonsils are a component of the immune system. They protect the body from germs and viruses that enter the mouth and throat. Tonsil cancer, like other cancers, is more likely to respond to early treatment. Getting a diagnosis early enhances the likelihood of effective treatment and recovery.

 

Tonsil cancer definition

oropharyngeal cancer

Tonsil cancer is a kind of oropharyngeal cancer, sometimes known as oral cancer. Tonsil cancer develops when malignant cells proliferate in the tonsils. It can happen to persons who have had their tonsils removed since some tonsil tissue is commonly left behind following surgery.

Tonsil cancer is classified into two types: squamous cell carcinoma and lymphoma. Many persons with tonsil cancer might have favorable outcomes if they are discovered early. Bacteria and viruses are caught and destroyed by the tonsils. They can vary size and frequently expand with blood to capture viruses, such as when a person has a cold.

 

Epidemiology

Tonsils are the most common site of oropharyngeal cancer, accounting for 23.1 percent of all malignancies in this anatomical region, with an overall incidence rate of 8.4 cases per 100,000 people, according to large epidemiological studies. Concerningly, the incidence of tonsil and oropharyngeal cancer has risen considerably in the previous 40 years. This considerable increase has been ascribed to the HPV "viral pandemic," with western nations experiencing an increase in the proportion of HPV-associated malignancies from 42.5 percent before 2000 to 72.2 percent between 2005 and 2009. In contrast, there was no substantial rise in the rate of non-HPV oropharyngeal malignancies during the same time period.

 

HPV tonsil cancer

Oropharyngeal and tonsil malignancies have traditionally been linked to smoking and alcohol abuse, with the former maintaining an independent predictor of poor prognosis. However, in recent years, there has been a significant increase in the number of cases caused by HPV, with up to 93 percent of new oropharyngeal malignancies in Western Europe exhibiting HPV positive. Furthermore, there is a growing body of data that having a partner with HPV-related cancer increases the risk of acquiring oropharyngeal and anogenital malignancies.

 

Tonsil cancer symptoms

Tonsil cancer symptoms

Tonsillar malignancies can have a wide range of clinical manifestations. Patients may complain of a painful throat, unilateral otalgia, or a sense of a mass in the throat, with trismus being an alarming indicator of local invasion. Others may be asymptomatic and are referred to as an asymmetrical tonsil finding. Because of the tonsil's abundant lymphatic supply, many cancers show as an occult lesion with swollen cervical nodes, particularly in the jugulodigastric area.

It is critical to inquire about red flag symptoms such as weight loss, odynophagia, dysphagia, and chronic hoarseness. A thorough previous medical history and discussion of etiological variables such as smoking, increasing alcohol use, and risk behaviors (e.g., intravenous drug use) may assist in eliciting an underlying cause.

HPV-positive cancers often occur in younger nonsmoking individuals of either gender, but HPV-negative tumors typically present in older male smokers with more co-morbidities, and so have a worse overall prognosis.

An expert otolaryngologist should do a thorough examination of the ears, nose, and throat, including palpation of the neck for cervical lymphadenopathy and detailed observation of the oropharynx. Primary malignancies might be overlooked within the tonsil crypts, thus pay close attention to the tonsil beds. Flexible nasal endoscopy should be conducted on all patients to undertake a complete examination of the oropharynx, including an examination of the tonsils, tongue base, vallecula, and lateral pharyngeal wall for evidence of local invasion.

 

Diagnosis

Diagnosis of Tonsil cancer

Imaging 

Pre-treatment cross-sectional imaging will be required in all cases of tonsillar carcinoma, with contrast-enhanced MRI giving the finest quality soft tissue delineation of the main illness and local dissemination. CT can also be used to evaluate the main illness, albeit artifacts from surrounding dental procedures frequently restrict this.

 CT is the imaging modality of choice for staging all head and neck malignancies, and it should be conducted from the base of the skull to the diaphragm to search for concomitant nodal and pulmonary disease.

PET-CT can also be utilized in tonsil cancer to aid in diagnosis and staging of difficult-to-detect tumors, as well as post-treatment monitoring. Its limitations include false-positive results, which typically indicate uptake in contralateral tonsils, tongue base, and Waldeyer's ring in the absence of cancer.

 

Endoscopy 

It is strongly advised that all suspected tonsillar malignancies have an anesthetic examination and panendoscopy. This allows for a more thorough examination and biopsy of the illness, as well as the planning of surgical procedures and the exclusion of subsequent cancers in the upper airway and esophagus. FNA biopsies have been employed in people who are unable to undergo surgery; however, the accuracy of HPV detection in cytology samples has been called into doubt.

 

Tonsil cancer treatment

Tonsil cancer treatment

  • Surgical Management  

Early tonsil cancer is best treated with a single modality, with oncological results equivalent to transoral robotic surgery (TORS) and transoral laser microsurgery (TLM). TORs are becoming more common since they have been demonstrated to shorten operating time, hospital stay, and enhance swallowing recovery when compared to open procedures; nonetheless, chronic severe dysphagia can develop post-operatively.

TLM is less extensively used since it entails removing the tumor in numerous parts, making histological assessment of margins challenging. Due to the low incidence of bilateral synchronous tonsillar malignancies, it is recommended that both tonsils be removed at the moment of surgery, regardless of the technique of surgical intervention.

TLM or TORS can still be administered for early T3 tumors in advanced illness; however, this is frequently not practicable for T4 malignancies. The majority of these instances will instead be treated with chemoradiotherapy, as surgery would normally necessitate a mandibulotomy and significant surgical reconstruction, resulting in poor post-operative functional results.

Given the high likelihood of nodal disease in both early and late tonsillar carcinoma, it is suggested that the majority of cases seeking surgical intervention also have an elective level II to IV neck dissection.

Because of the necessity for reconstruction, a transoral resection may not be acceptable when the tumor has considerable involvement of nearby locations such as the soft palate, tongue base, or nasopharynx. When more than half of the soft palate or tongue base is removed, patients may benefit from flap repair, and an open surgical technique may be preferable. The majority of these characteristics may be adequately identified before bringing the patient to the operating room for final treatment. The extent of the tumor can be reliably determined by physical examination in the office or through surgical endoscopy. Preoperative imaging can be carefully examined to evaluate the carotid artery's closeness to the tumor.

 

  • Oncological Management

Primary radiation has been proven to improve oncological outcomes and overall survival in patients with early tonsillar carcinoma. Unilateral radiotherapy at levels II to IV can be utilized in non-lateralized tumors with a low risk of contralateral nodal recurrence and lower radiation toxicity. Bilateral radiation is recommended for patients with contralateral nodes.

Chemoradiotherapy was previously identified as the treatment of choice for advanced tonsil and oropharyngeal cancers in a Cochrane review. This eliminates the need for invasive surgery, which has a considerable long-term morbidity and frequently necessitates post-operative chemoradiotherapy. The most often utilized regimen combines radiotherapy with concurrent platinum-based cisplatin chemotherapy, with the monoclonal antibody cetuximab serving as an equally effective option in circumstances where cisplatin is contraindicated (renal impairment and hearing loss).

 

Tonsil cancer vs tonsillitis

tonsillitis

Tonsillitis is a tonsillitis infection. Tonsils are tissue lumps on both sides of the back of the throat that aid the immune system in protecting the body from infections. Tonsils that are inflamed become red and swollen, causing a painful throat. Tonsils that are inflamed appear red and swollen, with a yellow or white coating or patches. A kid suffering from tonsillitis may exhibit the following symptoms:

If a child's tonsils are frequently infected or are so large that it is difficult to breathe at night, a health care professional may prescribe a tonsillectomy . Tonsillectomy was once a frequent procedure. Tonsillectomy may be considered if a kid has seven sore throat episodes in one year, five episodes in two years, or three episodes in three years.

 

Staging

According to the AJCC TNM classification of malignant tumors, tonsil cancer is staged as oropharyngeal carcinoma. To reflect current understanding of the effect of HPV and p16 on prognosis and therapy, the 2016 eighth edition divides oropharyngeal cancer into p16 positive and negative tumors. This is a substantial departure from earlier versions of the handbook, and it has the potential to drastically affect the ultimate stage of the cancer.

T Classification Oropharyngeal Cancers

    • T1: Tumor 2 cm or less 
    • T2: Tumor more than 2 cm but less than 4 cm
    • T3: Tumor greater than 4 cm or extension into the lingual surface of epiglottis
  • p16 negative tumors
      • T4a: Tumor invades larynx, deep/extrinsic muscle of tongue, medial pterygoid, hard palate, or mandible
      • T4b: Tumor invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, skull base; or encases carotid artery
  • p16 positive tumors 
    • T4: Larynx, deep/extrinsic muscle of tongue, medial pterygoid, hard palate, mandible, lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, skull base; or encases carotid artery

N Classification p16 Negative

    • N0: No regional lymph node metastasis
    • N1: Single ipsilateral node less than 3 cm 
  • N2
      • N2a: Single ipsilateral node greater than 3 cm but less than 6cm 
      • N2b: Multiple ipsilateral nodes less than 6 cm
      • N2c: Bilateral and contralateral nodes less than 6cm
  • N3
    • N3a: Single node greater than 6 cm
    • N3b: Single or multiple nodes with extra-capsular spread

N Classification p16 Positive

  • N0: No regional lymph node metastasis
  • N1: Unilateral nodes all less than 6 cm
  • N2: Contralateral or bilateral nodes all less than 6 cm
  • N3: Metastasis greater than 6 cm

M Classification

  • M0: No distant metastasis
  • M1: Distant metastasis

 

Postoperative follow up

Patients who have tonsillar carcinoma surgery must be closely watched in the postoperative term. Airway control, the possibility of bleeding, and food are all significant considerations. The method utilized and the degree of resection determine airway management. When a transoral technique is used, patients may be kept intubated after surgery, depending on the degree of resection, the likelihood for bleeding, or the surgeon's discretion. Transoral resection patients, on average, do not require a tracheostomy because edema is lower than in open resections.

Edema is common in open resections, especially with flap repair, and most patients will require a tracheostomy. In most circumstances, the tracheostomy is just temporary. Bleeding after tonsillar cancer excision can be severe and life-threatening. In most cases of transoral excision, the wound heals on its own. As a result, external carotid artery branches that have been ligated during surgery are at danger of bleeding. Because of the close closeness to the airway, aspiration of blood can be a severe hazard. In a large series of oropharyngeal carcinomas treated with TLM, Rich et al observed a 3.6 percent bleeding rate.

Following surgical treatment for tonsillar cancer, it is also vital to resume an oral diet. Almost all patients will have some degree of dysphagia, which can make it difficult to resume a normal diet. Transoral resections are less likely to cause dysphagia, although many patients will require a temporary feeding tube. A clinical examination, with or without a modified barium swallow, helps determine the timing of feeding tube removal. With transoral resections, the need for a long-term percutaneous gastrostomy (PEG) tube is uncommon. In their preliminary investigation of TORS radical tonsillectomy, Weinstein et al found a 3.7 percent PEG tube rate. This is comparable to the rate (4%) reported by Moore et colleagues in their study of transoral tonsil cancer excision.

Following surgery, adjuvant radiation therapy or chemoradiation is commonly necessary and is determined by the final pathology. Perineural or lymphovascular invasion, multiple positive nodes, near margins, and T4 disease are all indications for postoperative radiation. Positive margins and extracapsular dissemination in the lymph nodes are indications for postoperative chemoradiation.

 

Prognosis

The HPV status of the tumor influences the prognosis of tonsil cancer, with HPV positive tumors having a 5-year overall survival rate of 71% compared to 46% in HPV negative illness in one research. However, the presence of smoking might reverse this survival benefit, with death rates considerably greater among HPV-positive smokers compared to non-smokers.

Other characteristics such as modest tumor volume, lack of nodal disease, young age, low comorbid status, and the presence of tumor infiltrating lymphocytes are considered to positively affect prognosis in oropharyngeal cancers. There have been no studies that directly compare survival results in tonsil tumors treated with a single surgical or oncological approach.

The authors analyzed 31 patients with negative-margin TORS who had selective neck dissection and adjuvant treatment to identify the rates of regional recurrence, and they identified just one regional recurrence. Pathological examination of the neck specimens revealed that 33% and 43% of the clinical N0 and N1 patients, respectively, were pathologically upstaged, whereas 4 of the 14 clinical N1 patients had negative pathological necks. The authors were able to selectively give adjuvant therapy and deintensify therapy in some patients due to pathological staging of the necks.

 

Complications

Untreated tonsillar carcinoma will develop and invade local structures gradually. In p16 negative tumors, invasion of the lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, skull base, and encasement around the carotid is indicative of unresectable T4b disease. Furthermore, invasion of the skull base and spinal tissues might interfere with developing nerves, resulting in Horner's syndrome and brachial plexus and phrenic nerve palsies. A carotid artery encasement can result in a potentially fatal carotid blow-out.

Tonsil cancer treatment choices might potentially be fraught with problems. TORS can cause severe postoperative discomfort and dysphagia, especially in advanced illness. Mucositis, xerostomia, and skin responses are common side effects of radiotherapy, and they can have a major influence on swallowing. These effects can be amplified in patients who have TORS resection combined with post-operative chemo-radiotherapy, who have significantly worse swallowing and quality of life outcomes than those who have single modality treatments.

 

Conclusion 

Tonsil cancer is becoming more prevalent in the United States. It is frequently caused by a previous infection with the human papillomavirus (HPV). The good news regarding HPV-positive tonsil cancer is that it usually has a very excellent prognosis.

Given their etiological and prognostic importance, all patients should be counseled on alcohol and smoking cessation. Although multiple studies have demonstrated their usefulness in the prevention of gynecological malignancies, there is minimal evidence supporting their usage in tonsillar tumors.

 

Furthermore, the lack of a pre-malignant stage (as seen in cervical CIS) and differences in HPV epidemiology between cancers may pose barriers to its efficacy. Nonetheless, vaccination of men and females in various nations, including the United Kingdom, the United States, Canada, and Australia, is hoped to lower oropharyngeal cancer rates in the long run.