Document Detail

Palatine tonsillar metastasis of rectal adenocarcinoma: a case report and literature review.
Jump to Full Text
MedLine Citation:
PMID:  23705669     Owner:  NLM     Status:  Publisher    
Cases of primary colorectal adenocarcinoma metastasized to the palatine tonsil are extremely rare. To the best of our knowledge, only 10 cases have thus far been previously documented in the English literature. A 37-year-old Chinese woman presented with a right palatine tonsil swelling and odynophagia 5 months after a surgical resection of rectal adenocarcinoma was performed. The patient underwent a tonsillectomy, and a metastatic poorly differentiated adenocarcinoma from a colorectal origin was revealed by immunohistochemical analysis. The manner in which tonsillar metastases are involved remains unknown and should be further studied. Here, we report a new case, briefly summarize these 10 cases and review the literature.
Hao Wang; Ping Chen
Related Documents :
23160549 - Hamate hook nonunion treated with a hook plate: case report and surgical technique.
22919869 - Ewing sarcoma/primitive neuroectodermal tumor (pnet) of the vulva. case report and revi...
24597779 - Meta-analysis of the efficacy of cold coagulation as a treatment method for cervical in...
2273029 - Civil litigation and the child psychiatrist.
23398849 - Metastatic paraganglioma of the spine: case report and review of the literature.
23618339 - Aetiology of auditory dysfunction in amusia: a systematic review.
2511589 - Sexually transmitted diseases and native americans: trends in reported gonorrhea and sy...
10648319 - Factors influencing the reporting of adverse perioperative outcomes to a quality manage...
22996719 - Osseous metaplasia in a nasal polyp: report of a rare case and review of the literature.
Publication Detail:
Type:  JOURNAL ARTICLE     Date:  2013-5-25
Journal Detail:
Title:  World journal of surgical oncology     Volume:  11     ISSN:  1477-7819     ISO Abbreviation:  World J Surg Oncol     Publication Date:  2013 May 
Date Detail:
Created Date:  2013-5-27     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  101170544     Medline TA:  World J Surg Oncol     Country:  -    
Other Details:
Languages:  ENG     Pagination:  114     Citation Subset:  -    
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): World J Surg Oncol
Journal ID (iso-abbrev): World J Surg Oncol
ISSN: 1477-7819
Publisher: BioMed Central
Article Information
Download PDF
Copyright ©2013 Wang and Chen; licensee BioMed Central Ltd.
Received Day: 20 Month: 12 Year: 2012
Accepted Day: 12 Month: 5 Year: 2013
collection publication date: Year: 2013
Electronic publication date: Day: 25 Month: 5 Year: 2013
Volume: 11First Page: 114 Last Page: 114
PubMed Id: 23705669
ID: 3669029
Publisher Id: 1477-7819-11-114
DOI: 10.1186/1477-7819-11-114

Palatine tonsillar metastasis of rectal adenocarcinoma: a case report and literature review
Hao Wang1 Email:
Ping Chen1 Email:
1Department of Gastrointestinal Surgery, Northern Jiangsu People’s Hospital, Yangzhou University, Yangzhou, Jiangsu Province, 225001, PR China


The most common sites of distant metastases from primary colorectal carcinoma are in the liver, lung, and brain, and less commonly in the bone, ovary, and adrenal gland. Metastasis to palatine tonsil from a primary colorectal carcinoma is an extremely rare event. Only 10 cases have thus far been previously documented in the English literature. Hematogenous dissemination is a probable explanation for the mechanism of metastasis to the palatine tonsils [1], as well as the suggestion of a retrograde cervical lymphatic spread through the thoracic duct [2].

A metastatic tumor in an unusual site may sometimes be troublesome to distinguish between a synchronous or metachronous primary cancer and a metastatic disease, especially when it is asymptomatic. In this paper, we report the case of a 37-year-old Chinese woman with a metastasis to the right palatine tonsil from a rectal adenocarcinoma and review the literature.

Case presentation

A 37-year-old Chinese woman was evaluated for right tonsil swelling and a sore throat in our hospital. She was diagnosed in September 2011 with rectal cancer revealed by generalized peritonitis evoked by tumor perforation. At diagnosis, the preoperative evaluation did not show distant metastasis (M0). The patient underwent an urgent exploratory laparotomy. The tumor measuring 10.0 cm×4.0 cm×3.5 cm was identified at the anterior rectal wall under the peritoneal reflection intraoperatively. A low anterior resection using a total mesorectal excision technique was performed, with a colostomy using noninflamed descending colon, and the divided end of the rectum was closed. The excised specimen contained a poorly differentiated adenocarcinoma invading into nonperitonealized perirectal fat with negative surgical margins (T3). Nine regional lymph nodes were positive for tumor extension (N2b). The tumor was classified as stage IIIc disease based on the American Joint Committee on Cancer TNM staging system.

The patient did not receive any adjuvant radiotherapy and chemotherapy postoperatively. In March 2012 the patient was admitted to our department on account of abdominal pain and distension triggered by small bowel obstruction. A nonenhanced abdominal computed tomography scan revealed enlarged para-aortic lymph nodes measuring approximately 4 cm in diameter (Figure 1), which compressed the left upper ureter (Figure 2). No evidence of cerebral and visceral metastasis or mediastinal lymph nodes was identified by computed tomography scan of the brain, chest, and abdomen.

In the following days, the patient complained of swelling of her right tonsil and odynophagia. She did not report symptoms of dysphagia or tonsillitis. Physical examination revealed an ulcerated mass measuring about 1 cm in maximum diameter, on the upper part of her right palatine tonsil. There were no palpable cervical lymph nodes. The rest of the physical examination was unremarkable. Routine laboratory parameters including the complete blood count, erythrocyte sedimentation rate, C-reactive protein level, liver and pancreas enzymes, and tumor markers (carcinoembryonic antigen, carcinoma antigen 125, carcinoma antigen 199, and α-fetoprotein) were all within normal limits. A punch biopsy was taken for histological examination, which showed a poorly differentiated adenocarcinoma (Figure 3). The patient underwent a palliative right tonsillectomy without neck dissection. Microscopic examination of the resected specimen disclosed surface squamous epithelium with extensive infiltration of the tonsillar lamina propria by abundant malignant small glandular cells (Figures 4 and 5). Immunohistochemical analysis results of tumor cells are presented in Table 1. These features confirmed the diagnosis of metastatic poorly differentiated adenocarcinoma of the right palatine tonsil identical to the colorectal primary. At the time of submission of the present manuscript the patient was still alive, 9 months after the diagnosis of metastatic disease.


Metastases to tonsils from nonhematological malignant neoplasms are rare events [3], accounting for only 0.8% of all tonsillar malignancies [4]. Malignant melanoma [5], renal cell carcinoma [2], breast carcinoma [6], and lung carcinoma [7] have been described as the most common primaries of tonsillar metastases. Adenocarcinoma of the stomach [8] and carcinoma of the pancreas [9] and seminomas [10] are less common primary sites. Sporadic cases of tonsillar metastasis have been reported from prostate carcinoma [11], gall bladder carcinoma [12], anaplastic thyroid carcinoma [13], Merkel cell carcinoma [14], choriocarcinoma [15], and malignant mesothelioma [16].

Metastasis from a primary colorectal adenocarcinoma to the palatine tonsil is an extremely rare event. We searched PubMed, MEDLINE, and Google Scholar, from inception to December 2012, using the terms ‘colorectal/colon/colonic/rectum/rectal’; ‘cancer/ carcinoma/adenocarcinoma’; ‘palatine tonsil/tonsil’; and ‘metastasis’. The literature was limited to English-language case reports. References of included articles were also searched. Only 10 cases have been documented previously. We present a summary of all these 10 cases, as well as the present case, to highlight their clinicopathological profiles (Table 2). In a total of 11 patients, the age ranged from 36 to 81 years (mean: 53.5 years; median: 53 years), having a male-to-female ratio of 1.75:1 (7 vs. 4). In our case, the patient was a 37-year-old woman with a primary rectal adenocarcinoma that had metastasized to the right palatine tonsil. This is the youngest female patient to be reported. The metastases to palatine tonsils have a tendency to manifest unilaterally, while the left side (7/11) was more commonly involved than the right (4/11). Involvement of both sides was not observed. Contradictorily, it had been reported that malignant melanoma metastatic to the tonsil usually manifests bilaterally [2,8]. Of the 11 cases, seven patients had enlarged cervical lymph nodes when the palatine tonsil mass was found, while seven patients had primary lesions with metastatic regional lymph nodes, and one patient had metastatic evidence in the liver, two patients in the lung, three patients in the brain, three patients in bone, two patients in the mediastinum, two patients in the subcutis, and one patient in the axilla. Metastatic palatine tonsillar adenocarcinoma is a systematic malignancy that harbors a poor prognosis irrespective of the differentiation of the primary tumor and stage of the disease. Even though only 10 cases have been reported, the life expectancy ranged from 6 to 15 months, no matter whether the patient is treated by palliative chemoradiotherapy or tonsillectomy.

In the metastatic process, tonsillar involvement could either be the first station or a part of widespread systematic distant metastases. Although the pathway by which malignancies metastasized to the tonsil remains controversial and difficult to determine, some hypotheses have been built. Brownson and colleagues suggested that retrograde cervical lymphatic spread through the thoracic duct may be a potential mechanism, since the palatine tonsil does not have afferent lymphatic vessels [2]. On the other hand, hematogenous spread to the tonsil may occur through the systematic arterial blood flow passing through the lungs. Or tumor cells can reach the brain or head and neck region bypassing the lungs via venous blood flow through Batson’s plexus [1]. In the present case, evidence of metastases to the liver, lungs, brain, and bone were not observed and no cervical lymphadenopathy was palpated –metastasis to the unilateral palatine tonsil through Batson’s plexus may therefore be a more reasonable explanation.

Malignancies of the palatine tonsil are unusual. Squamous epithelial carcinomas and lymphomas are generally observed in this area. In the present case, the palatine tonsillar tumor cells shown a glandular epithelial phenotype histologically (Figure 5), and were negative for both squamous epithelial carcinoma markers [cytokeratin (CK) 34βE12, CK5/6, and p63] and lymphoma markers [bcl-6, CD1a, CD10, CD20, CD3, CD45-LCA, CD45Ro, CD56, CD79a, granzyme B, melanoma-associated antigen (mutated) 1, perforin, and terminal deoxynucleotidyl transferase] immunohistochemically (Table 1). Since there is no glandular epithelium in the palatine tonsil, a metastatic adenocarcinoma should be incorporated into the differential diagnosis. Adenocarcinoma of unknown primary often occurs in clinical practice. Even in the era of advanced imaging techniques and molecular tests, identification of the site of origin for metastatic adenocarcinoma frequently poses a challenge to clinicians and pathologists, and may lead to different therapeutic consequences. Immunohistochemical analysis remains a mainstay choice in identifying the histological origin of palatine tonsillar tumor with an occult primary. Although only few of tumor markers are very specific and have high sensitivity, several markers with moderate specificity are available, and when used in panels the discriminating capacity of these markers may be sufficient. The different expression patterns of CK20, CK7, CDX-2 and villin can be useful [26,27]. Given that 78% of adenocarcinomas of the upper gastrointestinal tract express both CK20 and CK7, most colorectal adenocarcinomas are positive for CK20 but negative for CK7 [26,27]. Further, metastatic lung adenocarcinoma shows a respiratory-type phenotype (CK20–/CK7+/ CDX-2–/villin–), while metastatic colorectal adenocarcinoma shows an intestinal-type phenotype (CK20+/CK7–/CDX-2+/villin+, as in our case; Figures 6, 7, 8 and 9) [28].


Metastatic palatine tonsil cancer from a primary colorectal adenocarcinoma is an extremely rare malignancy with a poor prognosis, and may lay a pitfall for clinicians. Immunohistochemical examination should therefore be performed. Immunomarkers including CK20, CK7, CDX-2, and villin are facilities in immunohistochemistry examination. The route of metastasis to the tonsil remains unclear and should been studied further.


Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


CK: Cytokeratin; H & E: Hematoxylin and eosin.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

HW performed the majority of this study and drafted the manuscript. PC provided the collection of material from the database. All authors read and approved the final manuscript.

Park KK,Park YW,Tonsillar metastasis of signet-ring cell adenocarcinoma of the colonEar Nose Throat JYear: 20101137637720737376
Brownson RJ,Laques WE,LaMonte SE,Zollinger WK,Hypernephroma metastatic to the palatine tonsilsAnn Otol Rhinol LaryngolYear: 197911235240443718
Kleinschmidt HJ,Tonsillen Metastasen bei primaren Bronchial und MagenkarzinomZ Laryngol Rhinol Otol Zhre GrenzgebYear: 196611389394
Crawford BE,Callihan MD,Corio RL,Hyams VJ,Karnei RF,Oral pathologyOtolaryngol Clin North AmYear: 1979112943220581
Aydogan LB,Myers JN,Myers EN,Kirkwood J,Malignant melanoma metastatic to the tonsilLaryngoscopeYear: 19961131331610.1097/00005537-199603000-000138614195
Tueche SG,Nguyen H,Larsimont D,Andry G,Late onset of tonsillar metastasis from breast cancerEur J Surg OncolYear: 19991143944010.1053/ejso.1999.067210419718
Seddon DJ,Tonsillar metastasis at presentation of small cell carcinoma of the lungJ R Soc MedYear: 1989116882556580
Benito I,Alvarez-Gago T,Morais D,Tonsillar metastasis from adenocarcinoma of the stomachJ Laryngol OtolYear: 1996112912938730375
Maor E,Tovi F,Sacks M,Carcinoma of the pancreas presenting with bilateral tonsillar metastasisAnn Otol Rhinol LaryngolYear: 1983111921956838111
Siniakov BS,A case of metastasis of seminoma to the palatine tonsilVestn OtorinolaringolYear: 1963119910113977688
Millar EK,Jones RV,Lang S,Prostatic adenocarcinoma metastatic to the palatine tonsil: a case reportJ Laryngol OtolYear: 1994111781807513007
Asami K,Yokoi H,Hattori T,Rao AJ,Yanagita N,Metastatic gall bladder carcinoma of the palatine tonsilJ Laryngol OtolYear: 19891121121310.1017/S00222151001084852647880
Hadar T,Mor C,Har-El G,Sidi J,Anaplastic thyroid carcinoma metastatic to the tonsilJ Laryngol OtolYear: 19871195395610.1017/S00222151001030443668379
Tesei F,Farneti G,Gavicchi O,Antonelli P,Zanetti G,Leone O,A case report of Merkel-cell carcinoma metastatic to the tonsilJ Laryngol OtolYear: 1992111100110210.1017/S00222151001218991487674
Kutty MK,Shenoy AV,Metastatic choriocarcinoma of the tonsil following hysterectomy for invasive mole and a period of ‘inactivity’ of trophoblastic tissue: case reportOral Surg Oral Med Oral PatholYear: 19711124825210.1016/0030-4220(71)90227-15284108
Hefer T,Danino J,Joachims HZ,Groisman GM,Metastatic malignant mesothelioma to the tonsilOtolaryngol Head Neck SurgYear: 19971168468810.1016/S0194-5998(97)70250-X9215385
Sellars SL,Metastatic tumours of the tonsilJ Laryngol OtolYear: 19711128929210.1017/S002221510007345X5576091
Low WK,Sng I,Balakrishnan A,Palatine tonsillar metastasis from carcinoma of the colonJ Laryngol OtolYear: 1994114494518035134
Wang WS,Chiou TJ,Pan CC,Chen WY,Chen PM,Signetring cell carcinoma of the rectum with tonsillar metastasis: a case reportZhonghua Yixue Zazhi (Taipei)Year: 199611209212
Vasilevsky CA,Abou-Khalil S,Rochon L,Frenkiel S,Black MJ,Carcinoma of the colon presenting as tonsillar metastasisJ OtolaryngolYear: 1997113253269343772
Goldenberg D,Golz A,Arie YB,Joachims HZ,Adenocarcinoma of the rectum with metastasis to the palatine tonsilOtolaryngol Head Neck SurgYear: 19991165365410.1016/S0194-5998(99)70076-810547490
Vauléon E,De Lajarte-Thirouard AS,Le Prisé E,Guihaire P,Raoul JL,Tonsillar metastasis revealing signet-ring cell carcinoma of the rectumGastroenterol Clin BiolYear: 200511707210.1016/S0399-8320(05)80696-715738898
Güvenç MG,Ada M,Acioğlu E,Pamukçu M,Tonsillar metastasis of primary signet-ring cell carcinoma of the cecumAuris Nasus LarynxYear: 200611858810.1016/j.anl.2005.07.00916169179
Sheng LM,Zhang LZ,Xu HM,Zhu Y,Ascending colon adenocarcinoma with tonsillar metastasis: a case report and review of the literatureWorld J GastroenterolYear: 2008117138714010.3748/wjg.14.713819084924
Lemay F,Cervera P,de Gramont A,A man with colon cancer and tonsil swelling. Tonsillar metastasis from colon cancerGastroenterologyYear: 2012111423162510.1053/j.gastro.2012.01.00222543111
Kende AI,Carr NJ,Sobin LH,Expression of cytokeratins 7 and 20 in carcinomas of the gastrointestinal tractHistopathologyYear: 20031113714010.1046/j.1365-2559.2003.01545.x12558745
Chu P,Wu E,Weiss LM,Cytokeratin 7 and cytokeratin 20 expression in epithelial neoplasms: a survey of 435 casesMod PatholYear: 20001196297210.1038/modpathol.388017511007036
Poizat F,Gonzalez AM,Raynaud P,Baldet P,Garrel R,Crampette L,Costes V,Adenocarcinomas of nasal cavities and paranasal sinuses: diagnostic pitfalls in sinonasal glandular lesionsAnn PatholYear: 20091128629510.1016/j.annpat.2009.07.00719900634


[Figure ID: F1]
Figure 1 

Nonenhanced abdominal computed tomography scan. The scan revealed para-aortic lymph node enlargement measuring approximately 4 cm in diameter (arrows).

[Figure ID: F2]
Figure 2 

Enlarged para-aortic lymph nodes compressed the left upper ureter causing left ureteral obstruction and hydronephrosis. Arrow, left ureteral obstruction.

[Figure ID: F3]
Figure 3 

Microscopic section of the biopsy tissue showed abundant heterogenic cells with a neoplastic gland formation. H & E, magnification ×200.

[Figure ID: F4]
Figure 4 

Histopathological examination of the resected tonsillar specimen. Histopathology showed surface squamous epithelium with extensive infiltration of the tonsillar lamina propria by abundant malignant small glandular cells. H & E, magnification ×100.

[Figure ID: F5]
Figure 5 

Histopathological feature of the tonsillar tumor: abundant malignant small glandular cells. H & E, magnification ×200.

[Figure ID: F6]
Figure 6 

Tumor cytoplasm was cytokeratin 20-positive. 3,3′-Diaminobenzidine, magnification ×100.

[Figure ID: F7]
Figure 7 

Tumor cell nucleus was positive for CDX-2. 3,3′-Diaminobenzidine, magnification ×100.

[Figure ID: F8]
Figure 8 

Homogeneous diffuse membrane and cytoplasm uptake of anti-villin antibodies in tumor cells. 3,3′-Diaminobenzidine, magnification ×100.

[Figure ID: F9]
Figure 9 

Tumor cells were negative for cytokeratin 7. 3,3′-Diaminobenzidine, magnification ×100.

[TableWrap ID: T1] Table 1 

Immunohistochemical analysis results of palatine tonsillar tumor cells

Antibody P/N Antibody P/N Antibody P/N




Granzyme B













CD45Ro CKpan ++ villin +++

P/N positive/negative, CK cytokeratin, EMA epithelial membrane antigen, mum-1, melanoma-associated antigen (mutated) 1 TdT terminal deoxynucleotidyl transferase, –, no cells positive by immunohistochemistry (IHC); ±, sometimes weak positive, sometimes negative by IHC; +, <25% of cells positive by IHC; ++, 25 to 50% of cells positive by IHC; +++, >50% of cells positive by IHC.

[TableWrap ID: T2] Table 2 

Clinicopathological features of reported cases of metastatic palatine tonsil tumor of colorectal primary

Case (reference) Sex/age (years) Side Primary site Differentiation Stage Interval (months) Other metastases Follow-up (months)
1 [17]
2 [18]
Transverse colon
Para-aortic LN, bone, scalp
3 [19]
Signet-ring cell
Dukes C
15 alive
4 [20]
Hepatic flexure
Lung, liver, bone
5 [21]
Dukes C2
6 alive
6 [22]
Signet-ring cell
Subcutaneous, bone
7 [23]
Signet-ring cell
8 [24]
Ascending colon
13 alive
9 [1]
Splenic flexure
Signet-ring cell
Brain, right axilla
10 [25]
Left colon
Lung, mediastinum
Present case F/37 Right Rectum Poorly T3N2bM0 5 Para-aortic LN 9 alive

F female, M male, Well, well differentiated adenocarcinoma; moderately, moderately differentiated adenocarcinoma; poorly, poorly differentiated adenocarcinoma; Signet-ring cell, signet-ring cell carcinoma; interval, time between the diagnosis of colorectal carcinoma and the development of metastasis to the palatine tonsil; LN lymph nodes, NA not available.

Article Categories:
  • Case Report

Keywords: Tonsil neoplasm, Metastasis, Rectal neoplasm, Adenocarcinoma, Immunohistochemistry.

Previous Document:  Assessment of knowledge, attitude and practice towards post exposure prophylaxis for HIV among healt...
Next Document:  Hypotriglyceridemic Potential of Fermented Mixed Tea Made with Third-crop Green Tea leaves and Camel...