Surgeon Preference on Sending Routine Tonsillectomy Specimens for Pathological Evaluation

INTRODUCTION

Despite the presence of a growing body of literature suggesting cost-ineffectiveness of routine pathologic analysis of tonsillectomy specimens, little is known about common institutional policies and practice patterns of pediatric otolaryngologists. The objectives of this study were to determine the prevalence of routine pathological evaluation of tonsillectomy specimens for uncomplicated pediatric adenotonsillectomy procedures and to evaluate opinions regarding this controversy among board-certified pediatric otolaryngologists.

METHODS

This was a cross-sectional survey study sent to board-certified pediatric otolaryngologists currently practicing and registered with the American Society of Pediatric Otolaryngology (ASPO) assessing their institutions' or practices' current policies on sending routine tonsillectomy specimens for pathology, their experience with this practice, and their opinions on whether routine pathologic analysis should be employed. Basic statistical analysis was then conducted.

RESULTS

Respondents mostly practiced in an academic setting (68.4%), with the next most common being academically affiliated private practice (21.8%), and private practice was the least common (9.8%). Most respondents (85.1%) did not agree with routine pathologic analysis of otherwise uncomplicated pediatric tonsillectomy specimens.

CONCLUSION

Most pediatric otolaryngologists who responded to this survey do not support routine pathological analysis of otherwise uncomplicated pediatric tonsillectomy specimens. However, the results are likely biased and should be interpreted carefully, since only a small percentage of pediatric otolaryngologists responded to the survey. Potential cost savings could be seen by patients, payers, and hospital systems with judicious use of surgical pathology, specifically in cases with concurrent signs or symptoms suspicious for malignancy.

Routine evaluation of tonsillectomy specimens: a cross-sectional survey of Canadian Otolaryngology: Head and Neck Surgeons

Background

Tonsillectomy is a commonly performed procedure in Canada. The rate of occult malignancy is rare in adult and pediatric populations. At present, no guidelines exist surrounding the need for routine histopathological evaluation of tonsil specimens when no malignancy is suspected.

Methods

We sent a confidential online survey to active members of the Canadian Society of Otolaryngology – Head and Neck Surgery (CSO-HNS) about their current tonsillectomy practice and beliefs surrounding the need for routine histopathological evaluation of tonsillectomy specimens when no malignancy is suspected. We used Opinio survey software for data collection and descriptive statistics.

Results

95 participants completed our survey (response rate 19.3%). Most participants reported performing both adult and pediatric tonsillectomies. When no malignancy is suspected, participant responses were split between whether they send tonsil specimens in pediatrics only (4.2%), in adults only (31.6%), or not sending specimens (29.5%). Half of the participants reported that routinely sending specimens to rule out occult malignancy is an institutional policy. Approximately 75% of participants were in favour of removing this practice in both the pediatric and adult populations.

Conclusion

Eliminating the practice of automatically sending tonsil specimens for histopathological evaluation when no malignancy is suspected was supported by the majority of study participants. This is in keeping with Choosing Wisely, a campaign designed to facilitate conversations about unnecessary medical tests and procedures. Institutional change is likely required in order to alter this practice.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40463-022-00569-7.

Tonsillectomy and hematologic malignancy: Should routine pediatric tonsillectomy specimens be sent to pathology?

OBJECTIVES

Routine pediatric tonsillectomy ± adenoidectomy (T ± A) is one of the most common procedures for children worldwide, accounting for approximately 2000 procedures per year at our institution. To determine the utility of pathologic analysis of routine, nonsuspicious pediatric tonsil specimens, we investigated the incidence of hematologic and lymphoid malignancy diagnosed at the time of or following T ± A.

METHODS

Retrospective review of patients 0-18 years undergoing T ± A between 2012 and 2020 with or without pathologic analysis.

RESULTS

Included were 14,141 patients who underwent routine T ± A (mean age 11 ± 4.6 years, 48% female). Of these, tonsils of 2464 patients were sent to pathology, where zero were found to harbor malignancy. Seven patients (0.050%) developed malignancy after T ± A. Of these, 4 had unremarkable tonsils per pathology, and 3 did not have tonsils analyzed. There were 5 cases of Acute Lymphocytic Leukemia (ALL, 0.035%), 1 case of Acute Myeloid Leukemia (0.007%), and 1 case of Lymphoma (0.007%). The average length of time from T ± A to diagnosis was 2.4 ± 1.8 years.

CONCLUSION

No cases of occult malignancy were identified in specimens from routine T ± A with pathologic analysis, even among patients who later developed malignancy. This study suggests that sending routine pediatric T ± A specimens for formal pathologic analysis is an inefficient use of resources without appreciably improving the quality and safety of patient care.

Occult Malignancy in Adult Tonsillectomy for Benign Indication

OBJECTIVE

National pathology guidelines recommend full pathologic analysis for all adult tonsillectomy specimens. We evaluated the available data on occult malignancy in adult tonsillectomy for benign indication, and created a screening system to reduce the risk of missed malignancies if routine histopathologic examination were to be discontinued.

STUDY DESIGN

Retrospective chart review and systematic review of the literature.

SETTING

Tertiary care academic hospital and multi-hospital private healthcare system.

SUBJECTS AND METHODS

A systematic literature review identified case series of adult tonsillectomy. Retrospective chart review at our institutions from 2000 to 2016 produced an additional case series. The pooled rate of occult malignancy was determined, and re-analyzed using criteria based on preoperative risk factors designed to identify patients requiring full pathologic analysis. The predicted effects of prospective application of the proposed criteria were calculated. Pooled occult malignancy prevalence was estimated.

RESULTS

Literature review and our own case series yielded 12,094 total cases. Occult malignancy prevalence in the combined data was 0.033%, representing four occult malignancies. Three out of the four would have been selected for full pathology preoperatively with use of the proposed criteria. Statistical analysis indicates that the predicted frequency of occult malignancy incidence in cases negative for the criteria is 0.01%, or 1/10,000.

CONCLUSION

Application of the proposed criteria to adults undergoing tonsillectomy for benign indication identifies a subset of patients with an estimated incidence of occult malignancy similar to that reported for pediatric tonsillectomy, and potentially may permit safe elimination of pathologic analysis of their tonsil specimens.

LEVEL OF EVIDENCE

Pooled analysis of case series from the literature and a single institution, level 4.

Tonsil histopathology in HIV-infected versus HIV-uninfected adults

BACKGROUND

The relationship between HIV and tonsil malignancy has not been fully investigated and established. Both of these diseases prominently feature in the Otorhinolaryngology clinics.

OBJECTIVE

There is minimal data available on the histopathology of tonsillectomy specimens in the HIV-infected population. This retrospective review compared tonsil histopathology between HIV-infected and HIV-uninfected patients.

METHODS

Of the 319 adult patients undergoing tonsillectomy (01 July 2005 to 30 June 2015), HIV results were available for 160. The histological findings were compared in the HIV-infected and HIV-uninfected subgroups. The effects of age, HIV status and CD4 count on the risk of malignancy were determined.

RESULTS

There were 86 patients who were HIV-infected and 74 were uninfected. Reactive lymphoid hyperplasia was the most common diagnosis in both groups (77%). Malignancies were diagnosed in eight HIV-infected and six HIV-uninfected patients, an insignificant difference.

CONCLUSION

The majority of patients undergoing tonsillectomy had benign conditions. HIV status does not appear to be a specific risk factor for tonsil malignancies, but advanced age may be.

Is Routine Histopathologic Examination Necessary Following Tonsillectomy and/or Adenoidectomy Procedures in Pediatric Patients?

Tonsillectomy and/or adenoidectomy is the most common surgical procedure in ENT practice and the malignancy rate of tonsillar tissue is very rare. The purpose of the present study is to investigate the necessity of routine histopathologic examinations following tonsillectomy and/or adenoidectomy surgeries. A total of 385 patients between the age of 5 and 16 years who were admitted to our ENT clinic and underwent adenoidectomy and/or tonsillectomy between October 2008 and July 2015 participated in the study. Patient data such as age, sex, indication for surgery, and histopathologic findings were recorded prospectively. Histopathologic findings were analyzed for hyperplastic lymphoid parenchyma and malignancy. No malignancies were detected in the studied patients and all had hyperplastic lymphoid parenchyma. Unilateral tonsillar swelling, significant lesions on the tonsil or adenoid tissue, malignancy history in the head and neck region, or a mass in the neck region with weight loss must be examined histopathologically; however, we conclude that there is no need to perform histopathologic examination for patients for whom there is no clinical suspicion. A meta-analysis is needed in this regard.

Utility of Flow Cytometry in Diagnosing Hematologic Malignancy in Tonsillar Tissue

OBJECTIVE

Tonsil surgical biopsy or excision is a very common procedure. However, there exist no consensus guidelines for the pathologic handling of tonsil specimens; gross and/or microscopic evaluation may be used. Diagnosis of tonsillar hematologic malignancy requires histology, immunohistochemistry and/or flow cytometry. Data regarding the utility of flow cytometry in tonsillar tissues are limited. We assessed our experience with flow cytometry for tonsil diagnosis with regard to accuracy and use patterns at a tertiary academic medical center.

METHODS

We retrospectively analyzed all surgically biopsied or excised tonsil specimens that underwent flow cytometry evaluation from August 2011 to March 2014. Patient clinical information, intraoperative frozen section, histology, immunohistochemistry, and flow cytometry diagnoses were recorded.

RESULTS

The study included 154 tonsil specimens from 89 females and 65 males. Patients averaged 27.4 years old (range 2-87 years); 73 were pediatric. Both histology and flow cytometry were benign for 148 patients (96.1%). Hematolymphoid malignancy was diagnosed in 6 adults by histology/immunohistochemistry: diffuse large B-cell lymphoma (2), small B-cell lymphoma (2), concomitant follicular lymphoma and histiocytic sarcoma (1), and extraosseous plasmacytoma (1). Flow cytometry identified abnormal populations in 5 of 6 cases, and detected clonal populations in 2 reactive follicular hyperplasia cases.

CONCLUSION

Tonsillar hematolymphoid malignancy is uncommon, and flow cytometry was less accurate than histology/immunohistochemistry for its diagnosis. Despite the rarity of tonsillar lymphoma in children, nearly half of study patients were pediatric. Intraoperative frozen section diagnosis showed excellent sensitivity for malignancy, and could be used to effectively triage cases for flow cytometry evaluation.