An Atypical Presentation of a Left-Sided Tonsil Carcinoma

Abstract

Background: This case report includes some atypical clinical features and presentations that are usually different from some typical features of tonsillar carcinoma. At the same time, some common characteristics are also absent in the described case.

Case Presentation: This patient, 58 years old, was admitted to the hospital with complaints of mild pain in the ear and mouth, vomiting, abdominal pain, pain during micturition, hardening of stool, postmenopausal bleeding, and feeling bad while tasting food. After detailed examination and lab investigations, this patient was found hypothyroid. CT- scan was performed and it revealed septal thickening along with bilateral pleural thickening and fibrosis. CT- scan of the maxilla-facial region revealed an infiltrative lesion in the left sulcus. This patient was sent to perform the biopsy and histopathological examination and this revealed invasive squamous cell carcinoma (Grade II) of the tonsil (Left side) as the sections showed tonsillar tissue on the left side. There was no associated visible weight loss. This patient got radiotherapy and chemotherapy with cisplatin (60mg) as a treatment for illness.

Conclusion: This case history shows that any carcinoma can present without its common features and symptoms even if it is an invasive malignant carcinoma. Sometimes, malignant and infiltrative carcinomas like tonsil carcinomas may present without common characteristics. In this case, some important and typical features may be absent (eg. Weight loss feature, hypothyroidism). So, diagnosis may be made carefully after detailed examination, lab investigations, and treatment.

Keywords: Tonsil Carcinoma; CT-scan; Biopsy; Histopathology

Background

An article related to tonsil carcinoma depicts that usually, the metastasis of the lymph nodes may be the first indicator of developing carcinoma. About sixty percent presented with enlarged lymph nodes and a significant amount presented with a lump in the neck during their first observation by medical persons [1].

A published article shows occult tonsillar carcinomas usually differ from primary carcinomas. The survival rate in the case of any primary carcinoma is about 38-55% [2].

Another article depicts that squamous cell carcinoma of the tonsil comprises a large amount of carcinoma of the larynx and upper respiratory tract. This article also depicts some stages of carcinoma (Stages 1, 2, 3 and 4). The treatment modalities discussed in this article were surgery alone, radiotherapy, and a combination of these two treatment modalities. This article also depicts the suitability of the treatment modalities according to the stages of cancer (Surgery only applies to Stages 1 & 2 whereas radiotherapy or a combination of both surgery and radiotherapy applies to Stages 3 &4) [1].

This article describes the possible relationship between tonsillar carcinoma and cervical cysts. Fine needle aspiration cytology (FNAC) revealed malignancy in three cases, whereas the other six cases were identified as malignancy after histopathological examinations after surgical removal. One-sided tonsillar carcinoma was found in six of the cases. Prevalence of the malignancy was found among those who were in the age of forty or above [3].

An article discusses the relationship between human papillomavirus (HPV) and tonsillar carcinoma. This article differentiates between tonsillar carcinoma and tonsillitis, where all tonsillar carcinoma appeared HPV-positive, and all tonsillitis appeared HPV-negative. This article defines the role of certain types of HPV virus in the pathogenesis of tonsillar carcinoma [4].

This study was performed to find out the relationship between Human papillomavirus and tonsillar carcinoma. It is noted that p16 immunochemistry was used to define HPV-related carcinoma. About eighty percent of the total p16-positive patients were found as patients of early-stage tonsillar carcinoma. So, this study depicts that there is a strong relationship between p16-positive patients with tonsillar carcinoma [5].

A study was performed to evaluate the effect of tonsillar carcinoma between young age and older age. This study significantly depicts that the incidence of this type of carcinoma spreads at a faster speed in the younger generation comparatively than the older generation but young age is associated with an excellent prognosis and better tumor sensitivity to radiation as well [6].

So, from these studies and perceptions, it is clearly understood that the present case report is somewhat different from any typical tonsillar carcinoma. There are some atypical features in this case (thyroid dysfunction, gum swelling, hardening of stool, pain during micturition, absence of human papillomavirus, bilateral pleural thickening) which indicates that a tonsil carcinoma may express itself with some atypical features too.

Case Presentation

This patient was admitted with complaints of mild pain in both ears and mouth, vomiting, anorexia, and pain during deglutition. The physicians found this patient slightly normal on general inspection and physical examinations. Some minor abnormality was found while taking the detailed history of the patient and these were sore throat, abdominal pain, post-menopausal bleeding, a feeling of an irregular surface while tasting any food, hardening of stool, headache, pain during micturition, and jaw pain. This patient was found to have hypothyroidism after screening of a routine blood test. Other tests revealed quite normal.

After this, the patient was sent to the Radiology department for a CT scan of the whole body, which revealed some abnormalities. Some of these were bilateral COPD, fibrosis, and an inflammatory change of the lower aspect of both lungs with septal thickening and bilateral pleural thickening. Another CT scan, especially performed in the maxilla-facial region, revealed some abnormalities such asinfiltrative soft tissue lesion at the posterior aspect of the left lower jaw involving the medial aspect of the left lower jaw with focal extension into the posterior part of the left gingiva-lingual sulcus and lower part of left gingiva-buccal sulcus However, there was no evidence of weight loss or cachexia and lymphadenopathy. Upon consideration of the CT scan, this patient was selected for biopsy and histopathology examination, and this examination depicted that it was a moderately invasive squamous cell carcinoma (Grade II) of the tonsil (Left side) as the sections showed tonsillar tissue of the left side.

This patient got radiotherapy and chemotherapy with cisplatin (60mg) as a treatment for illness.

Conclusion

This case history shows that any carcinoma can present without its common features and symptoms even if it is an invasive malignant carcinoma even if the tonsil carcinoma is sporadic. Occasionally some typical features related to that particular carcinoma may be absent. On the other hand, some atypical features may be present in that case. If the above case report is scrutinized it can be seen that there was the presence of some atypical features such as hypothyroidism, pain during micturition, and constipation were atypical presentation in this particular case. On the other hand, weight loss which is a common feature in the case of many carcinomas was absent in this specific case. Any case should be treated carefully and with attention by noting the atypical or uncommon features with natural features. Diagnosis should be confirmed and treatment should be made as early as possible for better life support for this kind of patient.

Declarations

Ethical Approval and Consent to Participate

Informed consent was taken from the respondent before enrolling in the study.

Confidentiality was maintained strictly.

During Data collection, the respondent was explained about the aim and objectives of the study.

Informed consent was taken from the respondent before data collection.

Respondent’s dignity and respect were maintained and interviews were taken with strict privacy.

This study did not cost additional expenses for the study subjects.

The respondent was allowed to withdraw at any stage of the study.

There was no potential harm to the respondent or the environment.

Funding

The researchers took the responsibility of funding while performing their research as they found no funding organization while conducting the study. The authors carried out all the issues related to funding by themselves.

References

1. Connal JG. Carcinoma of the tonsil. Br Med J. 1899; 1: 724.
2. McQuone SJ, Eisele DW, Lee DJ, Westra WH, Koch WM. Occult tonsillar carcinoma in the unknown primary. Laryngoscope. 1998; 108: 1605–1610.
3. Granström G, Edström S. The relationship between cervical cysts and tonsillar carcinoma in adults. J Oral Maxillofac Surg. 1989; 47: 16–20.
4. Snijders PJF, Cromme FV, Van Brule AJCD, Schrijnemakers HFJ, Snow GB, Meijer CJLM, et al. Prevalence and expression of human papillomavirus in tonsillar carcinomas, indicating a possible viral etiology. Int J Cancer. 1992; 51: 845–850.
5. Psychogios G, Alexiou C, Agaimy A, Brunner K, Koch M, Mantsopoulos K, et al. Epidemiology and survival of HPV-related tonsillar carcinoma. Cancer Med. 2014; 3: 652–659.
6. Nguyen NP, Ly BH, Betz M, Vinh-Hung V. Importance of age as a prognostic factor for tonsillar carcinoma. Ann Surg Oncol. 2010; 17: 2570–2577.