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.
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