Dr. T. Balasubramanian M.S.
Tonsils are common site for various neoplastic lesions.
These lesions could be benign and malignant. In this write up we
will attempt to describe the various neoplastic lesions of the
tonsil both benign and malignant.
This is the commonest benign tumor of this region. It
commonly arises from the tonsillar pillar, sometimes it may arise
from the surface of the tonsil itself. These lesions do not become
keratinised. The stratified squamous lining layer in this area gives
rise to this lesion. This lesion is purely a incidental finding
usually, and rarely requires treatment.
This is next common lesion in frequency. This is less
common than papilloma. This mass is generally presents itself as
pedunculated lesion attached to the surface of the tonsil. It
contains dilated and distorted lymphatics. It can even be considered
to be a hamartoma. Some authors tend to describe them as a acquired
Is one of the commonest cancers of head & neck. The
highest incidence is seen during the 7th decade of life. Lymphomas
present a decade earlier. Males are commonly affected. Squamous cell
carcinoma is the commonest histological type arising from the lining
layer of the tonsillar epithelium, while lymphomas arise from the
substance of the tonsil itself. Squamous cell carcinoma of the
tonsil is ulceroproliferative in nature, whereas lymphomas are
Etiology: Alcoholism, smoking, betelnut chewing, Human
papilloma virus infections have been attributed. A diet deficient in
fruits and vegetables have also been attributed in susceptible
The squamous cell carcinoma of the tonsil appear as an
ulcer / tumor mass / mucosal discoloration. The ulcer looks like a
crater with rolled and elevated borders. Infiltration is also
Tonsillar carcinomas spread to involve the soft palate,
tongue, anterior and posterior pillars, retropharyngeal space and
parapharyngeal space. Fatal bleeding from the ulcerated area of the
primary lesion occur in 10% of cases.
showing growth involving
growth tonsil involving the palate
Stage I : Carcinoma confined to the tonsil
Stage II : Carcinoma that has spread to the soft palate,
tonsillar pillars or tongue, without palpable
Stage III : Carcinoma with local extension beyond the
area specified in stage II or with palpable mobile
Stage IV : Carcinoma with involvement of the skin,
fixation of nodes and distant metastasis.
Irradiation has been recommended for stages I & II
and a combination of irradiation and resection of the mass for
stages III & IV.
Prognosis is determined by a 5 year survival rate after
For stage I it is 80%
Stage II - 70%
Stage III - 40%
Stage IV - 30%
TNM staging of carcinoma
T1 - Tumor less than 2 cm in
T2 - Tumor between 2 - 4 cm in diameter with
no invasion of surrounding tissues
T3 - Tumor greater than 4 cms / or with
limited extension to adjoining structures
T4 - Massive tumor / bone
No - No clinically palpable
N1 - Clinically palpable homolateral
cervical nodes that are not fixed, (suspected
N2 - Clinically palpable contralateral /
bilateral mobile nodes: (suspected metastasis)
N3 - Clincially palpable fixed nodes
Fig showing secondary node in
proliferation of well differentiated keratinising squamous
epithelial cells, which penetrate into the underlying lymphoid
tissue, appearing as sheets, groups or
of squamous cell carcinoma of tonsil
Carcinoma in situ - Also
include dysplasias: The squamous epithelial lining of the tonsils
and the surrounding oropharyngeal area may show dysplastic changes,
associated with hyperplasia.
These are difficult to distinguish from large cell
lymphomas. It is also associated with pseudocarcinomatous
hyperplasia of the epithelium overlying the tonsil. This tumor is
highly responsive to irradiation. Hence RT is the main modality of
treatment in these cases.
The large cell lymphoma (formerly reticulin cell sarcoma)
is the commonest lymphoma involving the tonsil. These constitute 60%
of all lymphomas involving the tonsil. Diffuse lymphocytic lymphoma
comes next with 30%, and Hodgekin's lymphoma constitute
The large cell lymphoma occur mainly during childhood,
while fully differentiated lymphocytic lymphomas are common in
adults. These well differentiated lymphomas may pose diagnostic
difficulties when inadequate material is provided. The vital pointer
to this disease is the loss of normal follicular pattern seen in the
tonsil. These patients may also have gastrointestinal lymphomas.
Since there is no direct lymphatic connection between the tonsil and
gut associated lymphoid tissue, various hypothesis have been
propounded to explain their occurance.
1. Gastrointestinal lymphoma is a concomittant primary
malignancy in addition to the tonsillar malignancy.
2. Implantation of tumor cells in the gut associated
lymphoid tissue due to swallowing.
3. Homing tendency of lymphoma of the tonsil to the gut
associated lymphoid tissue.
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