Table 3: Utility of tonsillectomy in HNSCCUP cancer unknown origin. IL: ipsilateral. BL: bilateral. PE: panendoscopy. Ix: Investigation. Ex: examination. BOT: base of tongue, PT: palentine tonsillectomy, Bx: biopsy.
Contralateral and synchronous tonsil tumours
There is considerable heterogeneity between papers regarding the practice of unilateral or bilateral palatine tonsillectomy; variations on the theme included ipsilateral tonsillectomy only, ipsilateral tonsillectomy with contralateral tonsil biopsies, and bilateral tonsillectomy. Nine studies reported synchronous and/or contralateral cancer identification rates5,12,11,14,19,23-26. Four small retrospective studies specifically addressed the role of bilateral palatine tonsillectomy 23-26. Rokkajer et al23 and Saber et al24 reported rates of synchronous primaries in tonsil SCC, not solely HNSCCUP.
Di Maio et al’s8 meta-analysis reported rates of 1% contralateral and 10% bilateral synchronous tonsil primaries. The synchronous tonsil primary rates amongst these studies varied from 3.3%23 up to 22.7%25. Contralateral rates ranged from 2%12 to 12.5%26. Saber et al24 found the majority of bilateral tonsil tumours were in patients with HPV positive disease (75%).
Given the possibility of contralateral tonsil cancers and rate of synchronous tonsil primaries there is a case for performing bilateral tonsillectomy in the workup of HNSCCUP. As a minimum, ipsilateral tonsillectomy should be performed and bilateral tonsillectomy should be considered.