Primary and salvage surgery for cancer of the tonsillar region: a retrospective study of 120 patients

Current management of tonsillar cancer

Traditionally, risk factors for the development of tonsil cancer include the use of alcohol and/or tobacco, however a significant proportion of new cases develop in young patients without these risk factors. Recent investigation suggests that human papilloma virus (HPV) may serve as an etiology in such cases and represent a unique risk factor in a sub-set of patients. Irrespective of the etiology, in the majority of cases early carcinoma of the tonsil can effectively be treated using single modality therapy. While local-regional control and survival are similar following surgery or radiotherapy, primary surgery can be accomplished with minimal functional morbidity while reserving radiation for recurrent disease. In contrast, surgical salvage following external beam radiotherapy can be technically challenging and is often associated with a significant increase in surgical complications and functional morbidity. In contrast to early tonsillar disease, advanced tonsil cancer represents a clinical challenge that requires multimodality therapy. While advanced lesions are often treated with a combination of radiation, chemotherapy, and surgical ablation, management of the neck and distant metastases continues to present a therapeutic dilemma.

Primary surgery as treatment for early squamous cell carcinoma of the tonsil

BACKGROUND

The management of tonsil carcinoma has gradually evolved such that the literature is replete with outcome summaries of this disease treated with primary RT and chemotherapy. Recently there have been no reports of patient outcomes with primary surgical therapy. Nonsurgical treatment is warranted when tumors are unresectable or if the patient refuses surgery. Our policy has been to treat operable squamous cell carcinoma (SCCA) of the tonsil with surgery. The decision to use adjuvant therapy is based on the surgical and histologic findings. We herein report our results with this treatment protocol.

METHODS

A retrospective review of 162 patients with SCCA of the tonsil was performed. Eighty-four patients were treated with surgery, which was followed by RT and/or chemotherapy if histologic signs of aggressive behavior were identified. Patients were followed 2 to 15 years after treatment.

RESULTS

Of the 9 patients with stage I disease, 89% are without evidence of recurrent disease and 91% of patients with stage II tonsil cancers are also disease free. The survival rates for stage III and stage IV cancer patients are 79 and 52%, respectively.

CONCLUSION

Our data suggest that patients with early tonsil cancer can be effectively treated with surgery. Surgery allows pathologic staging so that patients with advanced tumors can be treated with adjuvant therapy.