Oncologic Rationale For Bilateral Tonsillectomy In Head And Neck Squamous Cell Carcinoma Of Unknown Primary Source

Abstract

OBJECTIVE: To demonstrate on oncologic basis for the recommendation to perform bilateral tonsillectomy as a routine measure in the search for a primary mucosal lesion in patients presenting with cervical nodal metastasis of squamous cell carcinoma (SCC). STUDY DESIGN: A case series of individuals selected from a 3-year period is reported. SETTING: Masina Hospital, Bombay -Academic medical center. RESULTS: Each individual presented with metastatic squamous cell carcinoma in a cervical lymph node from an unknown primary source. In each case, the primary, either located contralateral to the node, or in both tonsils. CONCLUSIONS: The rate of contralateral spread of metastatic cancer from occult tonsil lesions appears to approach 10%. For this reason, bilateral tonsillectomy is recommended as a routine step in the search for the occult primary in patients presenting with cervical metastasis of SCC and palatine tonsils intact. The presentation of cervical metastatic head and neck squamous cell carcinoma (HNSCC) from a clinically occult primary is an unusual event, classically estimated as accounting for less than 5% of all HNSCC.1 The actual rate of “unknown primary” cancer in any series of HNSCC depends on the definition applied when a case is assigned that designation. The recommended work-up for individuals presenting with metastatic SCC without an obvious mucosal primary site currently includes computerized radiographic evaluation and examination under anesthesia with biopsies taken from specified sites that may commonly harbor occult mucosal lesions. There is growing support for the practice of tonsillectomy as a part of the screening directed biopsies used in the work-up of these patients. Several clinical series including our own have been published in the last decade indicating that an occult primary mucosal lesion can be identified in a tonsillectomy specimen in upwards of 30% of cases.2,3,4,5,6 Our rationale for bilateral tonsillectomy was to create a symmetric faucial arch to avoid confusion during the clinical post treatment surveillance for recurrence and second primary cancer and to capture the rare case of bilateral disease. Subsequently, we have identified 3 individuals who present with unilateral metastatic SCC in a cervical node and were found to have a primary lesion only in the contralateral tonsil. Finally, there were 2 individuals with bilateral nodal metastases & found to have an invasive carcinoma in one tonsil and an in situ lesion in the other. These cases prompted a renewed evaluation and repeated emphasis of the oncologic value of bilateral tonsillectomy.