Cancer pathologist tonsils oral
Usually, due to superinfection, the colour of the lesion is dirty grey or necrotic.
Tonsil cancer is one of the most common types of cancer in the ear, nose and throat area in Vietnam. Includes tonsil wall tumors, as well as the anterior, posterior abutment. In many cases, it is difficult to determine the starting point, whether from the tonsils or from the pit walls of the tonsils because they are closely related.
Ammonia has epithelial organization and connective tissue so its malignant tumor structure also divides into two groups of carcinoma and connective cancer. The first type of cancer is common in Vietnam (90%), while the second type is rare (10%).
Tonsil carcinoma: the common macroscopic form is a mixture of infiltrative ulcers, followed by proliferation, ulceration, infiltrates. Micro, often arising from the Malpighi epithelium, with different degrees of differentiation. In fact, differentiation is not a fixed feature of the tumor, it varies with the method and location of the biopsy.
Type of epithelial lymphoma: is described as a result of carcinogenesis at the same time the epithelial and lymphocytic structures of the tonsils mean both a carcinoma and a lymphoma. This type of cancer is usually in the arch tonsil and rarely develops in the female tonsil.
Lymph node metastasis: tonsillar carcinoma is very common with neck lymph node metastasis, while with epidermal type, metastasis is not directly related to differentiation. Lymphoma is also very common to spread to the lymph nodes. In fact, we often detect a metastatic lymph node in the neck, while the primary lesion in the tonsils is not apparent. In recent years, many reports of oncologists have commented that the cervical lymph nodes of tonsil cancer have some cases in the form of cocoons (kystique) because the tonsils come from the second gill sac.
Epidemiology and related factors of pathogenesis
Disease incidence: within the head and neck area, tonsil cancer ranks 7th and 8th. The disease is predominantly in men, at the age of 50-70 (Gustave Roussy Institute).
Pathogenetic factors: some authors have suggested that alcohol and tobacco are closely related factors such as most cancers of the food and airways. It is also important to mention other chronic irritants such as smoke, dust ... for mucosa. Many authors also believe that people with oropharyngeal carcinoma are usually those with a history of smoking, drinking a lot, but for sacoma, these factors are not relevant.
At the onset of symptoms, the symptoms are very discreet and in fact, very rarely seen patients at this stage. This phase progresses very quietly and lasts quite a long time in some cases. The first symptom to begin with is difficulty swallowing or a feeling of being caught on one side of the throat like a foreign object, especially when swallowing saliva, which is usually fixed in one place and one side of the throat, followed by a few weeks or so. Some months, it is difficult to swallow while eating and gradually swallow pain, especially pain in the ear. Some patients cough with sputum and little blood.
In addition, there are some patients who come to the examination, such as a subacute pharyngitis or as a tonsillitis and after taking antibiotics, the inflammation is reduced, some patients come to the examination because of the cervical lymph node or double when due to random periodic physical examination that found to palpate lymph nodes.
The first stage: need anesthesia of the pharyngeal mucosa to facilitate the examination and detection of lesions, a small or large ulcer can often be seen with the nature of a cancerous ulcer. hard, bleeding easily to the touch. We need to determine the location of the lesion. If damage is in the tail or back of the anterior abutment, use indirect mirror. In addition, we have to touch the tonsils to assess the penetration into depth or spread to the vicinity. In the case of lesions in the tongue tonsillar groove, in addition to scanning, it is also necessary to touch the base of the tongue.
Clear stage: patients often come to the examination at this stage, when clinical symptoms are quite obvious: continuous pain and especially when swallowing, pain in the ear, patients cannot tolerate, so often use drugs pain relief. In addition, this stage is often accompanied by superinfection, so it is very painful and breathing often smells of rotten, pronounced with a closed nose voice or swallowing a grain of something in the mouth, when examining, it is necessary to determine the lesions of the tonsils and lymph nodes.
Tonsilitis lesions are usually quite obvious, we need to assess the spread and infiltration into neighboring organizations. Cancer has many different forms:
Ulcerative form: ulcer can be shallow or deep, volcanic bottom, solid, often infiltrates into the pit walls of the tonsils.
The morphology: proliferation causes the volume of tonsils to enlarge very similar to a cancer of the association or sacoma, which is often sensitive to radiation.
Infiltration form: this body often spreads deep, so the touch is firm.
Mixed type: ulcerative, infiltrative. Usually due to superinfection, the color of the lesion is dirty gray or necrotic.
Examination and detection of cervical lymph nodes: lymph nodes are usually below jaw angle and scene sequence, must be examined meticulously to determine volume, number, position, mobility of lymph nodes. Usually, the lesions in the tonsils are small, but the lymph nodes are quite large. In some cases, the opposite is true. Currently, it is possible to rely on the lymph node (cytology) to also help diagnose and orient individual cases, it is necessary to do a nodule biopsy.
The clinical forms of tonsil carcinoma: based on the anatomical location of the tumor:
Polar cancer on the tonsils: the starting point is usually in the fovea of the female oropharynx, which begins with a red, burnt infiltrated nodule so Escat named it pseudo-gum. Diagnosis is difficult at first, but then the cancer spreads to the pharynx and nearby organs.
Polar cancer below the tonsils: need to use a mirror of the larynx to check and touch the tonsils, it often spreads to the anterior abutment and the edge of the tongue.
Cancer in the middle of the tonsils: often rare, only accounts for 5-6%. In fact it comes from the bottom of the slot and then spread outwards.
Cancer in the tonsillar groove: that is the junction at the base of the tongue and the bottom of the tonsils, because it is at the junction, the direction spreads to many sides, the prognosis is bad (this form accounts for about 5%).
Implementing the quadrants
Mainly based on microscopic results, in the case of biopsy difficult due to bleeding necrosis ulcers of the tonsils can also rely on the results of lymph node biopsy.
When making diagnosis, it is necessary to evaluate the spread of the tumor, so apart from direct examination, it is necessary to touch the tonsils and surrounding areas as well as evaluate the metastatic nodes.
It can be said that about 20% of patients at the first visit because of cervical lymphadenopathy and about 75% of patients who come to the examination due to tonsil cancer have easily palpable neck lymph nodes.
In general, because patients often come to a late stage, diagnosis is not very difficult, except in the early stages and especially with infiltrative, non-ulcerative forms, often to distinguish with the following diseases:
With an infiltrative ulcer: however rare but it should be avoided to avoid confusion with an ulcerative form of tuberculosis, TB lesions are generally less likely to be lumped in the tonsils and less deeply infiltrated, more common in patients with active pulmonary tuberculosis. Attention should be paid to a syphilis (either an erosive hypothyroidism or a period III syphilis ulcer). Differential diagnosis beyond microscopic results should be based on serum response and TB tests.
With ulcerative lesions of the tonsils: Vincent pharyngitis is common, but the disease is acute and has some features such as irregular ulcers, dirty ulcer base with blood pus or pseudo membrane covering, the ulcer is not solid and often accompanied by inflammatory lymph nodes in the neck, rapid development, resting mode and good oral hygiene. But it is also worth noting that Vincent sore throat develops on an tonsillar cancer lesion in the elderly that Le Maitre mentioned.
In the case that an infiltrated tonsil causes the tonsils to become enlarged, it is necessary to pay attention to differentiate the development of the tonsils itself and in cases where the tonsil is pushed out by a tumor in the neighboring area like a tumor in the throat, adenoma of the parotid., lymph node enlargement of the tonsils ... or tumors of the arch, the back of the pharynx, larynx junction ...
Mixed tumors and cylindromas of the pharyngeal region in the late stage can become ulcerated and spread to the tonsils, but these tumor organizations progress slowly, with a relatively long process or recurrence, making it easy to diagnose. In fact, the most important in differential diagnosis is the correct organizational of the lesion. It is difficult to evaluate the primary site of the tumor in the tonsils or pharynx in the late stage and it does not mean much for the treatment regimen. Particularly in cases that begin to manifest with cervical lymphadenopathy, it is necessary to distinguish between chronic lymphadenitis such as: tuberculosis, leukemia, lymphoma, Hodgkin and Non-Hodgkin.
If not treated, the patient only prolongs life for 12-16 months because tumors and lymph nodes develop along with superinfection causing bleeding and gradual deterioration.
Tonsillitis gradually makes the patient unable to eat or drink, the pain and tightness of the jaw make the disease worse.
Enlargement of the lymph nodes gradually compresses the nerves and infiltrates and large blood vessels in the neck leading to nerve paralysis or massive bleeding.
Superinfection, ingestion of the airways and metastasis to organs and organs are the last stage leading to death. Because the patient arrives at a late stage, if there is treatment, the recurrence rate is also quite high, adversely affecting treatment results.
In recent years, for female tonsil cancer, radiation treatment, including cervical lymph nodes, is mainly treated because in general this cancer is sensitive to radiation. Surgery is only to resolve cases that have already radiated but the tonsils or lymphoma are left. In addition, for cases of suspected tonsil cancer but still negative biopsies, surgery has two purposes: dissecting the tonsils and sending all biopsy specimens to find cancer.
Radiation therapy with tonsil tumors
Often used transcutaneous rays. Depending on the different energy sources (cobalt far telecobalt), bevatron (accelerated straight accelerator linearize) and the purpose of treatment, usually rays on the primary tumor and also the cervical lymph area.
The dose of rays: for tumors usually rays from 10Gy-12Gy / 1 week (average daily 2Gy). Total dose is about 70-75Gy over 7-8 weeks for tonsillar and lymphoma. When the amount of the beam reaches 45Gy, narrow the field of the posterior field rays to avoid and store the spinal cord there to no more than 45Gy for 4 and a half weeks. For lower cervical lymph nodes, the backup is about 45Gy in 4-5 weeks.
Method of inserting radioactive needles
Can apply to small tumors or tumors left behind. You can use either Radium or Ir192 needles, this type has the advantage of being soft, the dosage is accurate after checking, the number of rays usually used 70-80Gy in 7- 8 days. Can be combined with transdermal Co60 rays and high amounts of rays can be used in the 80-90 Gy tonsils.
Currently, many authors advocate that surgery only in cases where the tumor is left behind or relapsed after the rays but no longer able to use the rays. There are many surgeries available through the natural oral route or by bypassing the jawbone. Different from conventional tonsillectomy and dissection area easy to reach the cancer organization, so it must be cut wide, also known as extra-capsularis. Less surgical sequelae and postoperative mortality are also rare.
Treatment with chemicals: In recent years, some authors have conducted chemotherapy combined with radiation or surgery. There are many different opinions about the combination method and chemicals, in Vietnam this issue has not been used, so it is difficult to conclude and evaluate. The commonly used chemicals are Bleomycin, Cisplatin, 5FU ... that can be used before, after the rays and alternately, depending on the prescription of the physician on the specific patient.
Treatment for metastatic cervical lymph nodes
Mainly cut through the skin at the same time with tonsillar tumor, while Ir192 needle is only used for post-ray recurrent lymph node. Surgical treatment in small, mobile, and usually complete cervical lymphadenectomy involves resection of groups of lymph nodes under the chin, internal carotid veins, carotid lymph nodes, columns live and horizontal neck. If the cervical lymph nodes are both sides, then proceed to 2, then 15-20 days apart, but one side must retain the inner carotid vein.
Cervical lymphadenectomy can be performed under 2 different conditions, either in a patient with already palpable lymph nodes (dredging is necessary) or in a patient with no palpable lymph nodes (dredging according to principles).. In this case, we usually dredge the conserved lymph nodes, which means removing the lymph nodes and organizing the connective tissue of the neck, but retaining the sternum muscles, the inner carotid veins and the spinal nerve . And resection of the lymph nodes is only performed in some cases where the lymph nodes are left or recurrent after radiation.
Currently there are 3 main treatment methods:
Previously, the results of purely surgical treatment were very bad, but recently thanks to many improvements and progress, it has brought many encouraging results. Due to the different patient selection methods, it is difficult to accurately assess and compare between radiation and surgery alone (as reported by the Gustave-Roussy Cancer Institute, France, the above survival rate after 5 years is approximately). equal to 19-20%).
Many authors mentioned and commented that using Co60 rays has brought positive results, especially for young tumors that do not have cervical or mobile lymph nodes. According to Ennuyer and Bataini (France), living more than 5 years is 44% for T1, T2-No, N1 and 9% for T3, N3.
Coordinate radiation and surgery
Currently, although there are a number of different combinations: According to Pletcher and Ballantyne at Anderson Hospital (Houston) for T1, T2, using Co60 rays alone, including T3, T4 if it is friable and sensitive to rays. The patient must be closely monitored after the 50Gy ray has been obtained, if the lesions are infiltrated or the tumor remains, then after 6 weeks, the whole mass (monobloc) must be removed, if the lymph nodes are left after the ray is applied. lymph nodes must be dredged after 6 weeks. The survival result after 5 years is 36%. At Gustave-Roussy Institute (France), with T1, T2, and T3, the procedure is done 2 or 3, depending on whether the lymph nodes are palpable or not.
The most common are Non-Hodgkin’s malignant lymphomas within the Waldeyer region. According to some statistics, the rate of Non-Hodgkin's malignant lymphomas of the female tonsils usually occupy the entire Waldeyer ring is 59% (according to Ennuyer1970), 58% (Alseleem), 53% (Wang 1969), 40% (Banfi. 1970), 30% of the Gustave-Roussy Institute, 1970), ranked second after Hematosarcome in the nasal cavities and facial sinuses.
The first difficulty swallowing is a common symptom (2/3 of cases), very rarely hurts, if the tumor is too loud, the voice of the nose is very rare, there is very little symptom of jaw tightening, in one third of cases there is the alarming signal is cervical lymphadenopathy, so in front of a lymph node, a careful examination of the Waldeyer ring is required, especially paying attention to the palate tonsils.
The tonsils appear as an enlarged tonsil, pushing the pillars inward, the red mucosa is sometimes slightly dark, non-solid and non-infiltrating, sometimes on the surface of the tonsils there is a layer like pseudo membrane or necrosis ulcers, at first glance we can see clearly but there are some cases that are more discreet, such as a small tumor in the extremities of the tonsils, or the tonsils are slightly large, reddish but with normal density, or scattered under the mucosa. a small particle (micronodular). If in the late stage, the pillars, pharynx, sometimes the base of the tongue and lower throat will be spread because the tumor is too big to make it difficult to breathe. At this stage, there are usually three-quarters cervical lymph node, in some cases (Ennuyer 78%, Terz Farr 65%), in some cases, the cervical lymph node on both sides. The most common is the sub-jaw group,
Before a patient who is suspected of having tonsillar sarcoma, a biopsy of the tonsils is required to make lymph nodes (cytology) and a full body examination, especially the lymphatic areas, hematopoiesis, medulla, blood sedimentation rate, pulmonary scan is required., stomach...
Distinguishing between a carcinoma from a tonsillar sarcoma is usually not very difficult, mainly based on the biopsy results, but it is necessary to avoid the following confusion, do not assume that it is a normal enlarged tonsil. follow up, have a biopsy, or a tonsillar abscess then drain, given antibiotics without follow-up inspection, or before a swollen and red swollen cervical gang, hastily conclude that tuberculosis without examination tonsils. Radiotherapy to see if the biopsy is sensitive before the biopsy is also a mistake because biopsies are usually negative, no conclusions can be made.
Mainly skin radiation because this type of tumor is very sensitive to rays. Recently, many countries have combined chemotherapy before or after the rays, which also provide the best results for the highly malignant type of malignant lymphocytes.
Treatment with radiotherapy: if there are palpable cervical lymph nodes or even the lymph nodes are not palpable, the entire Waldeyer region and the entire region of the bilateral lymph nodes, including the epigastric ganglia, must be seen.
Treatment with chemicals: chemicals often used in combination are: prednisolon 40mg / day / 4 weeks. Vincristine (oncovin) intravenously injected 1.5mg / m2 / week.
Cyclophosphamide (Endoxan) 400mg / m2 / day intramuscularly or intravenously for 4 consecutive days, 15 days apart.
How to coordinate the following
Offensive treatment (according to Gustave-Roussy).
Prednisolon + Vincristine.
Vincristine (2ngày) + Cyclophosphamide (4 days).
V.M 26 + Cyclophosphamide (as above).
Consolidation therapy: Cyclophosphamide (600mg / m2 / 1 time for 15 days) is mainly used, with highly malignant lymphomas often used:
Vincristine intravenously injected 1.5mg / m2 / day for 4 weeks.
Vincarbazine (Velbe) intravenously 6mg / m2 / week.
Procarbazine (Natulan) 150mg / m2 / day for 20 days.
VM 26 and VP16.
Indications for treatment
If the body can be localized, the treatment is simple, the dose must be full, even if the baby's tumor goes away very quickly. Depending on the results of the biopsy of the tumor type of 40-60Gy malignant lymphoma or in the throat and cervical lymph nodes with low, medium or high malignancy, the dose of 50-60Gy is used. If the ganglion is too large or remains after the ray, an additional 10Gy ray must be applied in a limited field ray. In case there has been metastasis of the distant lymph node (abdomen, pelvis), first chemotherapy (attack) then radiation (rays of the anterior and posterior areas with rays below the diaphragm), then Chemical treatment with fortified therapeutic dosage. If in the late stage (the organs have metastasized M1), it is mainly symptomatic treatment with chemicals.
According to some foreign authors, living more than 5 years can reach 30-40% (Ennuyer 35%, El.saleem 40%, Terz and Farr 35%), but if the damage is localized. Results are 51% higher (Ennuyer), 79% (Wang). If the lesions spread to the vicinity, the results were gradually limited to 48% (Wang), 32% (Ennuyer). In the case of spreading, no cases live more than 5 years.
Progression of the disease after treatment
It is possible to recur cervical lymphoma or tumour, common in the first year (1/3 of cases according to Terz and Ferr), radiotherapy or lymphadenectomy can be used. May appear a sacoma far from the neck and face common in the first 6 months (Gustave-Roussy Institute 55%) such as stomach, bone ... this case has a bad prognosis and 75% of deaths due to this cause.