Palatine tonsillar metastasis of rectal adenocarcinoma: a case report and literature review
© Wang and Chen; licensee BioMed Central Ltd. 2013
Received: 20 December 2012
Accepted: 12 May 2013
Published: 25 May 2013
Cases of primary colorectal adenocarcinoma metastasized to the palatine tonsil are extremely rare. To the best of our knowledge, only 10 cases have thus far been previously documented in the English literature. A 37-year-old Chinese woman presented with a right palatine tonsil swelling and odynophagia 5 months after a surgical resection of rectal adenocarcinoma was performed. The patient underwent a tonsillectomy, and a metastatic poorly differentiated adenocarcinoma from a colorectal origin was revealed by immunohistochemical analysis. The manner in which tonsillar metastases are involved remains unknown and should be further studied. Here, we report a new case, briefly summarize these 10 cases and review the literature.
KeywordsTonsil neoplasm Metastasis Rectal neoplasm Adenocarcinoma Immunohistochemistry
The most common sites of distant metastases from primary colorectal carcinoma are in the liver, lung, and brain, and less commonly in the bone, ovary, and adrenal gland. Metastasis to palatine tonsil from a primary colorectal carcinoma is an extremely rare event. Only 10 cases have thus far been previously documented in the English literature. Hematogenous dissemination is a probable explanation for the mechanism of metastasis to the palatine tonsils , as well as the suggestion of a retrograde cervical lymphatic spread through the thoracic duct .
A metastatic tumor in an unusual site may sometimes be troublesome to distinguish between a synchronous or metachronous primary cancer and a metastatic disease, especially when it is asymptomatic. In this paper, we report the case of a 37-year-old Chinese woman with a metastasis to the right palatine tonsil from a rectal adenocarcinoma and review the literature.
A 37-year-old Chinese woman was evaluated for right tonsil swelling and a sore throat in our hospital. She was diagnosed in September 2011 with rectal cancer revealed by generalized peritonitis evoked by tumor perforation. At diagnosis, the preoperative evaluation did not show distant metastasis (M0). The patient underwent an urgent exploratory laparotomy. The tumor measuring 10.0 cm×4.0 cm×3.5 cm was identified at the anterior rectal wall under the peritoneal reflection intraoperatively. A low anterior resection using a total mesorectal excision technique was performed, with a colostomy using noninflamed descending colon, and the divided end of the rectum was closed. The excised specimen contained a poorly differentiated adenocarcinoma invading into nonperitonealized perirectal fat with negative surgical margins (T3). Nine regional lymph nodes were positive for tumor extension (N2b). The tumor was classified as stage IIIc disease based on the American Joint Committee on Cancer TNM staging system.
Immunohistochemical analysis results of palatine tonsillar tumor cells
Metastases to tonsils from nonhematological malignant neoplasms are rare events , accounting for only 0.8% of all tonsillar malignancies . Malignant melanoma , renal cell carcinoma , breast carcinoma , and lung carcinoma  have been described as the most common primaries of tonsillar metastases. Adenocarcinoma of the stomach  and carcinoma of the pancreas  and seminomas  are less common primary sites. Sporadic cases of tonsillar metastasis have been reported from prostate carcinoma , gall bladder carcinoma , anaplastic thyroid carcinoma , Merkel cell carcinoma , choriocarcinoma , and malignant mesothelioma .
Clinicopathological features of reported cases of metastatic palatine tonsil tumor of colorectal primary
Para-aortic LN, bone, scalp
Lung, liver, bone
Brain, right axilla
In the metastatic process, tonsillar involvement could either be the first station or a part of widespread systematic distant metastases. Although the pathway by which malignancies metastasized to the tonsil remains controversial and difficult to determine, some hypotheses have been built. Brownson and colleagues suggested that retrograde cervical lymphatic spread through the thoracic duct may be a potential mechanism, since the palatine tonsil does not have afferent lymphatic vessels . On the other hand, hematogenous spread to the tonsil may occur through the systematic arterial blood flow passing through the lungs. Or tumor cells can reach the brain or head and neck region bypassing the lungs via venous blood flow through Batson’s plexus . In the present case, evidence of metastases to the liver, lungs, brain, and bone were not observed and no cervical lymphadenopathy was palpated –metastasis to the unilateral palatine tonsil through Batson’s plexus may therefore be a more reasonable explanation.
Metastatic palatine tonsil cancer from a primary colorectal adenocarcinoma is an extremely rare malignancy with a poor prognosis, and may lay a pitfall for clinicians. Immunohistochemical examination should therefore be performed. Immunomarkers including CK20, CK7, CDX-2, and villin are facilities in immunohistochemistry examination. The route of metastasis to the tonsil remains unclear and should been studied further.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
- H & E:
Hematoxylin and eosin.
- Park KK, Park YW: Tonsillar metastasis of signet-ring cell adenocarcinoma of the colon. Ear Nose Throat J. 2010, 89: 376-377.PubMed
- Brownson RJ, Laques WE, LaMonte SE, Zollinger WK: Hypernephroma metastatic to the palatine tonsils. Ann Otol Rhinol Laryngol. 1979, 88: 235-240.View ArticlePubMed
- Kleinschmidt HJ: Tonsillen Metastasen bei primaren Bronchial und Magenkarzinom. Z Laryngol Rhinol Otol Zhre Grenzgeb. 1966, 45: 389-394.
- Crawford BE, Callihan MD, Corio RL, Hyams VJ, Karnei RF: Oral pathology. Otolaryngol Clin North Am. 1979, 12: 29-43.PubMed
- Aydogan LB, Myers JN, Myers EN, Kirkwood J: Malignant melanoma metastatic to the tonsil. Laryngoscope. 1996, 106: 313-316. 10.1097/00005537-199603000-00013.View ArticlePubMed
- Tueche SG, Nguyen H, Larsimont D, Andry G: Late onset of tonsillar metastasis from breast cancer. Eur J Surg Oncol. 1999, 25: 439-440. 10.1053/ejso.1999.0672.View ArticlePubMed
- Seddon DJ: Tonsillar metastasis at presentation of small cell carcinoma of the lung. J R Soc Med. 1989, 82: 688-PubMed CentralPubMed
- Benito I, Alvarez-Gago T, Morais D: Tonsillar metastasis from adenocarcinoma of the stomach. J Laryngol Otol. 1996, 110: 291-293.View ArticlePubMed
- Maor E, Tovi F, Sacks M: Carcinoma of the pancreas presenting with bilateral tonsillar metastasis. Ann Otol Rhinol Laryngol. 1983, 92: 192-195.View ArticlePubMed
- Siniakov BS: A case of metastasis of seminoma to the palatine tonsil. Vestn Otorinolaringol. 1963, 25: 99-101.PubMed
- Millar EK, Jones RV, Lang S: Prostatic adenocarcinoma metastatic to the palatine tonsil: a case report. J Laryngol Otol. 1994, 108: 178-180.View ArticlePubMed
- Asami K, Yokoi H, Hattori T, Rao AJ, Yanagita N: Metastatic gall bladder carcinoma of the palatine tonsil. J Laryngol Otol. 1989, 103: 211-213. 10.1017/S0022215100108485.View ArticlePubMed
- Hadar T, Mor C, Har-El G, Sidi J: Anaplastic thyroid carcinoma metastatic to the tonsil. J Laryngol Otol. 1987, 101: 953-956. 10.1017/S0022215100103044.View ArticlePubMed
- Tesei F, Farneti G, Gavicchi O, Antonelli P, Zanetti G, Leone O: A case report of Merkel-cell carcinoma metastatic to the tonsil. J Laryngol Otol. 1992, 106: 1100-1102. 10.1017/S0022215100121899.View ArticlePubMed
- Kutty MK, Shenoy AV: Metastatic choriocarcinoma of the tonsil following hysterectomy for invasive mole and a period of ‘inactivity’ of trophoblastic tissue: case report. Oral Surg Oral Med Oral Pathol. 1971, 32: 248-252. 10.1016/0030-4220(71)90227-1.View ArticlePubMed
- Hefer T, Danino J, Joachims HZ, Groisman GM: Metastatic malignant mesothelioma to the tonsil. Otolaryngol Head Neck Surg. 1997, 116: 684-688. 10.1016/S0194-5998(97)70250-X.View ArticlePubMed
- Sellars SL: Metastatic tumours of the tonsil. J Laryngol Otol. 1971, 85: 289-292. 10.1017/S002221510007345X.View ArticlePubMed
- Low WK, Sng I, Balakrishnan A: Palatine tonsillar metastasis from carcinoma of the colon. J Laryngol Otol. 1994, 108: 449-451.View ArticlePubMed
- Wang WS, Chiou TJ, Pan CC, Chen WY, Chen PM: Signetring cell carcinoma of the rectum with tonsillar metastasis: a case report. Zhonghua Yixue Zazhi (Taipei). 1996, 58: 209-212.
- Vasilevsky CA, Abou-Khalil S, Rochon L, Frenkiel S, Black MJ: Carcinoma of the colon presenting as tonsillar metastasis. J Otolaryngol. 1997, 26: 325-326.PubMed
- Goldenberg D, Golz A, Arie YB, Joachims HZ: Adenocarcinoma of the rectum with metastasis to the palatine tonsil. Otolaryngol Head Neck Surg. 1999, 121: 653-654. 10.1016/S0194-5998(99)70076-8.View ArticlePubMed
- Vauléon E, De Lajarte-Thirouard AS, Le Prisé E, Guihaire P, Raoul JL: Tonsillar metastasis revealing signet-ring cell carcinoma of the rectum. Gastroenterol Clin Biol. 2005, 29: 70-72. 10.1016/S0399-8320(05)80696-7.View ArticlePubMed
- Güvenç MG, Ada M, Acioğlu E, Pamukçu M: Tonsillar metastasis of primary signet-ring cell carcinoma of the cecum. Auris Nasus Larynx. 2006, 33: 85-88. 10.1016/j.anl.2005.07.009.View ArticlePubMed
- Sheng LM, Zhang LZ, Xu HM, Zhu Y: Ascending colon adenocarcinoma with tonsillar metastasis: a case report and review of the literature. World J Gastroenterol. 2008, 14: 7138-7140. 10.3748/wjg.14.7138.PubMed CentralView ArticlePubMed
- Lemay F, Cervera P, de Gramont A: A man with colon cancer and tonsil swelling. Tonsillar metastasis from colon cancer. Gastroenterology. 2012, 142: 1423-1625. 10.1053/j.gastro.2012.01.002.View ArticlePubMed
- Kende AI, Carr NJ, Sobin LH: Expression of cytokeratins 7 and 20 in carcinomas of the gastrointestinal tract. Histopathology. 2003, 42: 137-140. 10.1046/j.1365-2559.2003.01545.x.View ArticlePubMed
- Chu P, Wu E, Weiss LM: Cytokeratin 7 and cytokeratin 20 expression in epithelial neoplasms: a survey of 435 cases. Mod Pathol. 2000, 13: 962-972. 10.1038/modpathol.3880175.View ArticlePubMed
- Poizat F, Gonzalez AM, Raynaud P, Baldet P, Garrel R, Crampette L, Costes V: Adenocarcinomas of nasal cavities and paranasal sinuses: diagnostic pitfalls in sinonasal glandular lesions. Ann Pathol. 2009, 29: 286-295. 10.1016/j.annpat.2009.07.007.View ArticlePubMed
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.