Bekir Hakan Bakkal  ( Department of Radiation Oncology, Faculty of Medicine, Bulent Ecevit University, Zonguldak, Turkey. )
Mehmet Birol Ugur  ( Department of Otorhinolaryngology, Faculty of Medicine, Bulent Ecevit University, Zonguldak, Turkey. )
Burak Bahadir  ( Department of Pathology, Faculty of Medicine, Bulent Ecevit University, Zonguldak, Turkey. )

The incidence of numerous head and neck tumours is a known issue though bilateral synchronous tonsillar carcinoma reports are so uncommon that only 20 cases were found in a literature review. Most of these patients were treated with bilateral tonsillectomy followed by adjuvant radiotherapy. We report, to our knowledge, the first case of bilateral synchronous tonsillar squamous cell carcinoma treated only with chemoradiotherapy without tonsillectomy.
Keywords: Bilateral tonsil carcinoma, Chemoradiotherapy.

Squamous cell carcinoma (SCC) of the tonsil is the third most common malignant tumour in the head and neck area after thyroid and laryngeal carcinoma.¹ Men are affected 3-4 times more than women, and the occurrence increases after the 4th decade.²
Alcohol consumption and tobacco use are the most significant risk factors in maturing of tonsillar cancer.³ Other risk factors include poor oral hygiene, mechanical irritation, chewing of betel quid preparations, lack of vegetables and fruits in diets and seropositivity of human papilloma virus (HPV) subtype 16.^3-7
Presentations of the disease is usually with a throat soreness, dysphagia, tonsillar asymmetry, bleeding, or non-healing ulcer. Neck mass may be the first symptom as lymphatic spread is common, affecting 50% of patients at presentation.⁸
It is not uncommon for head and neck cancer patients to develop a second primary as there is about a 4% incidence of synchronous secondary tumours.⁹ A secondary tumour is characterized as synchronous if it is diagnosed simultaneously or within 6 months of the primary tumour. If it is diagnosed after a period of 6 months it is called a metachronous tumour. The common sites involved with synchronous and metachronous cancers are the hypopharynx, oropharynx, oral cavity and larynx.¹¹ In a period of 5 years after the treatment of tonsillar carcinoma a metachronous tumour occurs in approximately 15% of the patients.¹¹
Current practice of tonsillar carcinoma is to perform tonsillectomy with or without radiotherapy. We present here what to our knowledge is the first case of bilateral synchronous tonsillar carcinoma without lymph node metastases treated with only chemoradiation.

A 62-year-old man was referred to the Ear, Nose and Throat (ENT) Department with a 3-month history of odynophagia with solid food and soreness of the throat. He was a 30 package-year smoker and consumed alcohol. Physical examination showed a mass 3cm in diametre on the right tonsil extended and combined with the ulcerated mass 2cm in diametre on the left tonsil. The neck was clear of lymphadenopathy on palpation. Magnetic Resonance Imaging (MRI) of the neck revealed bilateral tonsillar mass which extended to hypopharynx and invaded pterygoid muscles on the left side (Figure-1).

Bilateral tonsillar biopsy was done and histology confirmed both tonsils contained SCC (Figures-2 and 3).


Thorax computerised tomography (CT) and abdomen ultrasound were clear of metastatic disease. Patients\' unwillingness for surgery, extended tumour borders, and poor medical condition made him a poor candidate for surgery. Therefore, tonsillectomy was not performed. Subsequently, he presented in Radiation Oncology Department for therapy.
The patient was treated with chemoradiotherapy. Tonsils were irradiated to 70 Gy in 35 fractions and bilateral neck to 50 Gy in 25 fractions with 3-D conformal radiotherapy. Concomitant cisplatinum (100 mg/m2 on days 1, 22, and 43) and amifostine (200 mg/m2/day) were also applied. During chemoradiotherapy the patients suffered from grade 2 mucositis and grade 2 xerostomia, but completed the radiotherapy course without any break. He was free of disease after 58-month follow-up.

Head and neck cancer patients have a high risk of developing a second primary head and neck malignancy. This has been quantified as up to 3.6% per year and leads to excess mortality of 5.2% per year.¹² Synchronous cancers occur in 4% of head and neck cancers.⁹
A metachronous malignancy occurs in about 15% of tonsillar cancer patients.11 About 4% of cases with Head and Neck (H&N) malignancy develop a subsequent tumour in tonsil. The most common localisation for an occult primary H&N malignancy is tonsillar fossa.¹³
Bilateral synchronous tonsillar carcinoma is such an uncommon circumstance that only 20 cases have been described as yet. Synchronous tonsillar cancer in literature is usually mentioned with lymph node metastases.¹⁴ Most of the patients were presented with cervical lymph node metastases from unknown primary.
Radiotherapy with or without chemotherapy plays an important role in tonsil carcinoma. Use of radiation therapy without surgery is becoming more common with increasingly complicated radiotherapy techniques and organ preservation approach. Especially in head and neck cancer patients, intensity modulated radiotherapy (IMRT) considerably decreases the toxicity on the nearby organs at risk. Locoregional control and cause-specific survival may be up to 91% and 75% with chemoradiation, respectively, even in locally advanced patients.¹⁵

In literature, only 20 cases with bilateral synchronous tonsillar carcinoma have been reported. Therefore, the real incidence is unknown. Bilateral tonsillectomy is frequently preferred in eligible cases, but chemoradiation is also an acceptable option in treatment strategy.

1. Guay ME, Lavertu P. Tonsillar carcinoma. Eur Arch Otorhinolaryngol 1995; 252: 259-64.
2. Golas S. Trends in palatine tonsil cancer incidence and mortality rates in the United States. Community Dentist Oral Epidemiol 2007; 35: 98-108.
3. Talamini R, Bosetti C, La Vecchia C, Dal Maso L, Levi F, Bidoli E, et al. Combined effect of tobacco and alcohol on laryngeal cancer risk: a case-control study. Cancer Causes Control 2002; 13: 957-64.
4. Spitz MR. Epidemiology and risk factors forhead and neck cancer. Semin Oncol 1994; 21: 281-8.
5. Uzcudun AE, Retolaza IR, Fernandez FB, Sanchez Hernandez JJ, Grande AG, Garcia AG, et al. Nutrition and pharyngeal cancer: results from a case- control study in Spain. Head Neck 2002; 24: 830-40.
6. Mork J, Lie K, Glattre E, Clark S, Hallmans G, Jellum E, et al. Human papillomavirus infection as a risk factor for squamous-cell carcinoma of the head and neck. N Engl J Med 2001; 344: 1125-31.
7. D\'souza G, Kreimer AR, Viscidi R, Pawlita M, Fakhry C, Koch W, et al. Case-control study of human papillomavirus and oropharyngeal cancer. N Engl J Med 2007; 356: 1944-56.
8. Bradley P. Management of squamous cell carcinoma of the oropharynx. Curr Opin Otolaryngol Head Neck Surgery 2000; 8: 80-6.
9. Hsairi M, Luce D, Point D, Rodriguez J, Brugere J, Leclerc A. Risk factors for simultaneous carcinoma of the head and neck. Head Neck 1989; 11: 426-30.
10. Panosetti E, Luboinski B, Marnelle G, Richard JM. Multiple synchronous and metachronous cancers of the upper aerodigestive tract: a nine year study. Laryngoscope 1989; 99: 1267-73.
11. Scwartz LH, Ozsahin M, Zhang GN, Touboul E, De Vataire F, Andolenko P, et al. Synchronous and metachronous head and neck carcinomas. Cancer 1994; 74: 1933-8.
12. Teppermann BS, Fitzpatrick PJ. Second respiratory and upper digestive tract cancer after oral cancer. Lancet 1981; 2: 547-9.
13. Cianchetti M, Mancuso AA, Amdur RJ, Werning JW, Kirwan J, Morris JG, et al. Diagnostic evaluation of squamous cell carcinoma metastatic to cervical lymph nodes from an unknown head and neck primary site. Laryngoscope 2009; 119: 2348-54.
14. Moualed D, Qayyum A, Price T, Sharma A, Mahendran S. Bilateral synchronous tonsillar carcinoma: a case series and review of the literature. Eur Arch Otorhinolarygol 2012; 269: 255-9.
15. Prestwich RJ, Kancherla K, Oksuz DC, Williamson D, Dyker KE, Coyle C, et al. A single centre experience with sequential and concomitant chemoradiotherapy in locally advanced stage IV tonsillar cancer. Radiat Oncol 2010; 21: 121.