Tonsil cancer

Most patients present with locally advanced, intermediate stage cancers stage II-IVa.

Accounts for little more than 0.5% of new malignancies in the United States every year.

More than 8,000 oropharyngeal carcinomas are diagnosed in the United States each year.

Squamous cell carcinomas are about 3-4 times more common in men than in women, and they are largely tumors that develop in the fifth decade of life or later.

Tonsil carcinoma

A type of squamous cell carcinoma.

Tonsil cancer is considered a form of oropharyngeal cancer.

It is the most common site of squamous cell carcinoma in the oropharynx.

Frequently presents at advanced stage, and around 70% of patients present with metastases to the cervical lymph nodes.

Most common site for the incidence of the tumor is the lateral wall of oropharynx 45%, base of the tongue 40%, posterior wall 10% and soft palate 5%.

The most frequent complaints include.: sore throat, otalgia or dysphagia.

About 20% patients present with a node in the neck as the only symptom.

Risk factors include: tobacco smoking and intake of high amounts of alcohol.

It has also been linked to Human Papilloma Virus, particularly HPV type HPV16).

Other risk factors include: poor oral hygiene, genetic predisposition, immunocompromised states and chronic exposure to agents such as asbestos and certain occupations, radiation therapy and dietary factors.

Early lesions are usually asymptomatic.

The patients with advanced stage disease comprises around 66-77% of the cases.

Advanced disease associated with a lump in the neck when palpated and weight loss, and fatigue.

On examination of the tonsil there may be only slight enlargement or the development of firmness around the area.

The carcinoma may grow into the oropharyngeal space and appear in the form of a neck mass mostly in the jugulodiagastric region.

Because the tonsil consists of a rich network of lymphatics, it may metastasise to the neck lymph nodes.

The tumor may invade the skull or mediastinum.

Additional symptoms include a painful throat, dysphagia, otalgia, bleeding, fixation of tongue and trismus.

Rarely, the tumor may also present as a fungating wound growing outwards, breaking the skin surface with a central ulceration, that is non-healing, with bleeding and pain.

Cervical lyphydenopathy can be ipsilateral 70% of the time, or bilateral in 30% patients.

The carcinoma of tonsil usually spreads through the cervical lymph node levels II, III, IV, V, and retropharyngeal lymph nodes.

The cancer cells may spread to adjacent structures, to lymphatics or to distant locations in the body producing secondary tumors.

The tumor may spread to soft palate and pillars, base of tongue, pharyngeal wall, hypopharynx, pterygoid muscles and mandible, resulting in pain and trismus, and the parapharyngeal space.

50% of patients have initial cervical node involvement at the time of presentation, with the jugulardigastric nodes first to be involved.

Distant metastases occur between 4%-31% in clinical studies.

Factors altering the incidence of distant metastasis are:

Location of primary tumor.

Initial staging

Histological differentiation

Loco-regional control of the primary tumor.

Diagnoses tonsil requires an accurate history and physical examination, followed by fine needle aspiration, blood tests, MRI, x-rays and PET scan.

The staging of a tumor mass is based on TNM staging.

T Stage Tumor Dimension Tx Primary tumor cannot be assessed T0 Primary tumor cannot be located Tis Carcinoma in situ T1 ≤ 2 cm in dimension T2 > 2 cm but ≤ 4 cm in dimension T3 > 4 cm and has grown till the epiglottis T4a Moderately advanced, tumor has grown into larynx, beyond muscles of tongue, hard palate, lower jawbone and/or medial pterygoid muscles T4b Extremely advanced, invasion of lateral pterygoin muscle, pterygoid plates, nasopharynx, into skull base or is encasing the carotid artery. N staging Edit This stage is decided through the assessment of the lymph nodes.

N Stage Lymph node dimension Nx No assessment of neck lymph nodes N0 No evidence of spread N1 Ipsilateral, Single lymph node, ≤ 3 cm in size N2a cancer cells have metastasised to a single lymph node, ipsilateral to main tumor, > 3 cm but ≤ 6 cm in size N2b Cancer cells have metastasised to multiple lymph nodes, ipsilateral to mail tumor, > 6 cm in size N2c Detection of lymph nodes in the neck, contralateral or bilateral to the main tumor, >6 cm in size N3 Metastasis of cancer cells to one or more lymph nodes, >6 cm in size M staging Edit Based on the examination of the entire body.

M Stage Metastasis beyond Head and neck M0 No evidence M1 Evidence of metastasis to structures outside head and neck present, commonly involved organs are: Lungs, bones, brain FInally, the stage is decided by concluding the above results and ref2242ing the following chart:

Stage T Stage N Stage M Stage 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 T4b Any N M0 Any T N3 M0 Stage IVC Any T Any N M1

The treatment for tonsil carcinoma includes the following methods:

Early radio-sensitive tumors are treated by radiotherapy along with irradiation of cervical nodes. The radiation uses high-energy X-rays, electron beams, or radioactive isotopes to destroy cancer cells.

Induction chemotherapy is the treatment adapted for shrinking the tonsil. Then the patient is given chemo-radiation therapy (a combination of chemotherapy and radiation) to completely destroy the tumor cells.[19]

If radiation and chemotherapy are unable to destroy the tumor, surgical intervention is considered.

Excision of the tonsil can be done for early superficial lesions.

Large lesions and those which invade bone require wide surgical excision with hemimandibulectomy and neck dissection.

Surgery may be combined with pre- or post operative radiation.

Chemotherapy may be given as an adjunct to surgery or radiation.

Prognosis is determined by stage, Human Papilloma Virus (HPV) status, lymph infiltration of cancer cells, spread of cancer cells beyond the lymph node capsule, margins of the tumor and the extent of metastasis.

It is shown that cases which are HPV positive have a better prognosis than those with HPV negative oropharyngeal cancer.

The stages of oropharyngeal cancer are as follows: Stage 0 (carcinoma in situ): This stage indicates a good prognosis as most patients with stage 0 survive for a long period without the requirement of an intensive treatment.

Stage I and II: Most patients presenting at this stage receive successful treatment, showing a good prognosis. The modes of treatment for this stage include chemotherapy, surgery, radiation therapy or chemoradiation.

The main treatment at this stage is radiation, targeting the tumor and the cervical lymph nodes.

Surgical removal of the tumor and lymphadenectomy of the cervical lymph nodes can also be taken up at the main treatment method instead of radiation.

Any remaining cancer cells post surgery are treated with chemoradiation.

Stage III and IVA: In this stage the cancer cells metastasize into the local tissues and cervical lymph nodes.

The treatment used in these cases is chemo radiation.

Any remaining cancer cells post chemoradiation are surgically removed.

Lymphadenectomy may also be done after treatment with chemoradiation if the cancer cells have infiltrated the cervical lymph nodes.

Another method of treatment includes, first, surgical removal of tumor as well as cervical lymph nodes followed by chemoradiation or radiation to decrease the chances of recurrence.

Stage IVB: In this stage the cancer has already undergone distant metastasis, hence showing poor prognosis. The treatment includes chemotherapy, cetuximab, or PD-L1 inhibitors.

Radiation may be used to aid in relieving symptoms arising from the cancer and also to prevent further development of complications.

Metastasis of cancer cells to cervical lymph nodes diminishes the chance of cure.

Metastasis of cancer cells outside the lymph node capsule is a bad prognosis especially for HPV-unrelated oropharynx cancer than it is for HPV-related oropharynx.

Tumor margin affects the extent of complete surgical excision of the tumor hence, affecting the chances of cure.

Spread to local structures like tissues, vessels, large nerves and lymphatics worsens prognosis.

The survival rate in HPV-related oropharynx carcinoma to that in HPV-unrelated oropharynx carcinoma, reveals that for STAGE III and STAGE IV oropharynx carcinoma, there was a discrepancy in survival after three years:The survival was 82% in HPV positive and 57% in HPV negative cancers.

There are two types of cancer that affect the palatine tonsils: squamous cell carcinoma and lymphoma.

In general, three types of treatments are used:

Surgery-Some individuals who have stage I or II cancer may not need any more treatment than this, although radiation may be recommended.

Radiation – After surgery, many patients undergo radiation.

Chemotherapy -for stage III or IV tonsil cancer.

Induction chemotherapy is being used to shrink tumors.

Most doctors will recommend a minimum of surgical treatment followed by localized radiation and chemotherapy.

There has been an increase in head and neck cancer due to HPV (human papilloma virus) infection.

It is believed that the virus is usually transmitted through unprotected oral sex.

HPV-positive malignancies are much more responsive to treatment than other head and neck cancers.

HPV has replaced tobacco as the leading cause of the tonsil cancers.

Radiosensitive with T1 and T2 treated with radiation, even if nodal disease is present.

HPV related tonsil cancers respond more favorably to treatment than do tobacco or alcohol related tonsil cancers.

Spreads locally to the tongue, soft palate, or nasopharynx.

Often spread to lymph nodes in the neck, and manifested as cystic masses.

May interfere with swallowing and breathing.

Stage II-IVa are classified as T1 N1-2 M0 or T2-4a N0-2 M0.

Approximately 80% of patients with locally advanced tonsil cancer present with T1-2 disease and 20% with T3-4a disease.

Stage is not a very helpful determinant of treatment choice.

Radiation therapy with concurrent Cisplatinum based chemotherapy is the standard initial treatment for patients with locoregionally advanced , nonmetastatic tonsil cancer who have large primaries T3-four.

Radiation and concurrent chemotherapy is pref2242ed for most patients with tonsil cancer because radiation therapy is associated with less morbidity, disfigurement, and loss of function then older standard surgical procedures, a transcervical partial pharyngectomy often including a partial mandibulectomy as well as tracheostomy.

Presently, the role of surgery is an adjuvant ond for remaining or recurrent tumor when needed.

For selected patients minimally invasive surgery with a transoral lateral oropharyngectomy is the primary treatment.

A transoral lateral oropharyngectomy can achieve rates of local control equivalent to those of radiation therapy for unilateral anterior T1-2 squamous cell carcinomas of the tonsil without posterior spread.

Induction chemotherapy is reserved for patients with more advanced neck disease with multiple lymph nodes, retropharyngeal lymph nodes, or lymph nodes in the lower deck that might herald a risk for distant metastases.

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