Disease Description (Causes and Symptoms)
- Definition: A malignant tumor occurring in the palatine tonsil, with the most common histologic type being squamous cell carcinoma.
- Main causes/risk factors:
- Smoking and excessive alcohol consumption (mutually synergistic effects).
- Human papillomavirus (HPV, especially HPV‑16) infection: Recently recognized as an important cause of tonsillar cancer; HPV-positive tumors have a relatively favorable prognosis in nonsmokers.
- Pathophysiology: Malignant cells arising in the tonsil invade local tissues, and cervical lymph node metastasis is common because of the abundant lymphatic vessels around the tonsil (cervical metastasis is observed in approximately 60–70% of cases at diagnosis). As the disease progresses, it can invade adjacent structures (the pharyngeal wall, mandible, and airway), causing dysphagia and dyspnea.
- Main symptoms:
- Throat (tonsil) pain, difficulty swallowing (dysphagia), a foreign-body sensation, oral bleeding, pain radiating to the ear (referred pain), a palpable lump in the neck (lymph node), and dyspnea (when the tumor obstructs the airway).
Treatment Methods
- Diagnostic procedures (required before treatment):
- Confirmation of the diagnosis by biopsy of the tonsillar area.
- Staging evaluation: CT/MRI, PET-CT, chest X-ray, abdominal ultrasonography, whole-body bone scan, and other tests to identify local and distant metastases.
- Local treatment:
- Surgery: Resection of the lesion (partial/total tonsillectomy) and, if necessary, neck dissection (removal of neck lymph nodes). Functional and aesthetic reconstruction of the defect (such as with a free flap) may be considered. Early lesions may be resected through the mouth with function-preserving techniques (transoral laser resection or TORS [transoral robotic surgery]).
- Radiation therapy (RT): May be used alone as initial local treatment; postoperative adjuvant radiation therapy is also performed.
- Systemic and combined treatment:
- Concurrent chemoradiation (CRT): Recommended for advanced stages or high-risk lesions (lymph node metastasis or residual lesions). The standard concurrent agent is cisplatin.
- Recurrent or metastatic disease: Chemotherapy, targeted therapy (e.g., EGFR-targeted agents), and immune checkpoint inhibitors (e.g., pembrolizumab and nivolumab) may be used depending on the indications and the patient’s condition.
- Rehabilitation and lifestyle management:
- Swallowing and voice rehabilitation (speech therapy), nutritional management (consider tube feeding in cases of weight loss), and oral hygiene care.
- Precautions:
- Do not smoke or drink alcohol during and after treatment (these reduce treatment response and increase complications).
- Monitoring and symptomatic treatment are needed for side effects of radiation and anticancer drugs (such as mucositis, dry mouth, dysphagia, skin reactions, and bone marrow suppression).
- Prognostic factors:
- HPV positivity (generally associated with a better prognosis), stage (presence or absence of local invasion, lymph node metastasis, or distant metastasis), and response to treatment.
Checkpoints Before an Outpatient Visit (Including Example Questions)
- Items to bring and test records:
- A list of current medications (including prescriptions, OTC medicines, and supplements) and a history of allergies (especially drug allergies).
- Copies of previous test results (biopsy reports, CT/MRI/PET results, etc.), if possible, and records of recent weight changes.
- Smoking and alcohol history (duration and amount), sexual history, and HPV vaccination status, if possible.
- The time symptoms began, factors that worsen or improve them, whether dysphagia, dyspnea, or bleeding is present and how often it occurs, and the nature and severity of pain.
- Items to show the doctor during the outpatient visit:
- A symptom diary (the types and frequency of food intake in cases of dysphagia) and photographs of the neck area (if there have been visible changes).
General Example Questions to Ask the Doctor
- "What is the detailed classification of my stage (how far has the disease spread)?"
- "What is the recommended first-line treatment option, and what are the advantages, disadvantages, and expected side effects of each option?"
- "What should I be careful about in daily life during treatment (diet, oral care, exercise, etc.)?"
- "What is the likelihood of long-term complications after treatment (such as dysphagia, voice changes, and dry mouth), and how can they be managed?"
- "Are there additional treatments that can be used if the disease recurs (such as medications or clinical trials)?"
Examples of Disease-Specific Questions
- "What are the results of the HPV (genetic) test for the tumor? If it is HPV-positive, how will that affect the treatment plan or prognosis?"
- "Cervical lymph node metastasis has been observed. Which combination of neck dissection and radiation therapy do you recommend? How likely is it that reconstruction after surgery (such as with a free flap) will be needed?"