Boston Children’s Hospital, Department of Otolaryngology Summer 2016 Genevieve Medina ‘18 Boston Children’s Hospital, Department of Otolaryngology Summer 2016

Inflamed tonsils [Drawing] Inflamed tonsils [Drawing]. Mayo Foundation for Medical Education and Research Grading of palatine tonsils hypertrophy proposed by L. Brodsky [Drawing]. Dell’Aringa AR, Antonio JCJ, de Melo, C, Nardi, JC, Kobari K, Perches Filho RM. Histological analysis of tonsillectomy and adenoidectomy specimens -January 2001 to May 2003. Brazilian Journal of Otorhinolaryngology. 2005;71:2-113.

Current Literature Year Author Patient Population Number UTE Patients Number of Malignant Cases % 1999 Berkowitz et al. 1 Pediatric 46 2000 Syms et al.2 Non- pediatric 48 2 4.1 2002 Spinou et al.3 47 Harley et al.4 57 2004 Cinar et al.5 Non- Pediatric 53 2006 Oluwasanmi et al.6 87 2.3 2007 Van Lierop et al.7 13 Total   351 4 1.1%

Methods Literature Review National Data: Institutional Data Surveillance, Epidemiology and End Results Program, 1973-2013 data collection Institutional Data Comprehensive Retrospective Chart Review, case series.

National Results Cancer Type Subtype n % Bilateral Non-Hodgkin Lymphoma   Burkitt lymphoma/leukemia 43 31.2 4 Diffuse Large B-cell Lymphoma, NOS 37 26.8 Follicular lymphoma 14 10.1 5 Non-Hodgkin lymphoma, NOS, unknown lineage 8 5.8 Lymphoid neoplasm, NOS 3.6 3 Precursor Non-Hodgkin lymphoma, T-cell 2.9 1 Chronic/Small lymphocytic leukemia/lymphoma 2 1.4 Extranodal MZL, MALT type Non-Hodgkin lymphoma, B-cell, NOS Lymphoplasmacytic lymphoma 0.7 NK/T-cell lymph, nasal-type/aggressive NK leukemia Non-Hodgkin lymphoma, NOS, T-cell Sarcoma Rhabdomyosarcoma Synovial sarcoma Liposarcoma Kaposi's sarcoma Plasma Cell Neoplasms Plasmacytoma 2.2 Hodgkin Lymphoma Nodular Sclerosis Unclassified Carcinomas  Total 138 100 22

Instutional Data Case Age Gender Chief Complaint Other Signs/Symptoms Preoperative Suspicion for Malignancy Duration of Symptoms Time Before Office Visit Final Pathology Laterality Left Tonsil Size (Brodsky) Right Tonsil Size (Brodsky) 1 3 Male Obstructive Sleep Disordered Breathing Bilateral cervical lymphadenopathy, abnormal labs Yes 8+ weeks 6 weeks Acute Lymphoblastic Leukemia (ALL), T-cell Bilateral 4+ 2 4 Obstructive sleep disordered breathing, tonsillitis, enlarged right tonsil Bilateral cervical lymphadenopathy 3 weeks Burkitt lymphoma Right 1+ 7 Neck pain, enlarged right tonsil 12 weeks “barely detectable” (0) 9 Recurrent tonsillitis, enlarged right tonsil No 4 weeks 2+

Conclusions Limitations: Conclusions SEER reach: 28% US Population Retrospective chart review for institutional data Conclusions Marked tonsillar asymmetry and rapid enlargement, especially in a unilateral fashion, are harbingers of malignanacy. Pediatric tonsillar malignancies: primarily non-Hodgkin lymphomas, less frequently sarcomas, plasma cell neoplasms and Hodgkin lymphomas.

References 1. Berkowitz RG, Mahadevan M. Unilateral tonsillar enlargement and tonsillar lymphoma in children. The Annals of otology, rhinology, and laryngology. Sep 1999;108(9):876-879. 2. Syms MJ, Birkmire-Peters DP, Holtel MR. Incidence of carcinoma in incidental tonsil asymmetry. The Laryngoscope. Nov 2000;110(11):1807- 1810. 3. Spinou E, Kubba H, Konstantinidis I, Johnston A. Tonsillectomy for biopsy in children with unilateral tonsillar enlargement. International journal of pediatric otorhinolaryngology. Mar 15 2002;63(1):15-17. 4. Harley EH. Asymmetric tonsil size in children. Archives of otolaryngology--head & neck surgery. Jul 2002;128(7):767-769. 5. Cinar F. Significance of asymptomatic tonsil asymmetry. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. Jul 2004;131(1):101-103. 6. Oluwasanmi AF, Wood SJ, Baldwin DL, Sipaul F. Malignancy in asymmetrical but otherwise normal palatine tonsils. Ear, nose, & throat journal. Oct 2006;85(10):661-663. 7. van Lierop A, AJ. PC, Fagan J, Sinclair-Smith C. Is diagnostic tonsillectomy indicated in all children with asymetrically enlarged tonsils? South African Medical Journal. 2007;97(5).