This report presented the very rare case of a patient with a metastasis in the left palatine tonsil from hepatocellular carcinoma (HCC). A 69-year-old man suffered from an about 20-mm mass in the left palatine tonsil. The biopsy revealed that the mass in the palatine tonsil was a metastatic lesion from HCC. The patient underwent a left palatine tonsillectomy, and metastasis from HCC has not recurred after the operation. With the presentation of the present case, we looked through the so-far reported literature

Ikoma, Hisaaki

Matsuo, Satoshi

Nakahara, Kei

Takeuchi, Hiromi

Yonago Acta Medica

Tottori University Research Result Repository

217Yonago Acta medica 1999;42:217–220A Case of Hepatocellular Carcinoma Metastasizing to the Palatine TonsilKei Nakahara, Satoshi Matsuo, Hiromi Takeuchi and Hisaaki IkomaDepartment of Oto-Rhino-Laryngology, Faculty of Medicine, Tottori University, Yonago 683-0826, JapanThis report presents a very rare case of a patient with a metastasis in the left palatinetonsil from hepatocellular carcinoma (HCC).  A 69-year-old man suffered from a massof about 20 mm in the left palatine tonsil.  The biopsy revealed that the mass in thepalatine tonsil was a metastatic lesion from HCC.  The patient underwent a left palatinetonsillectomy, and metastasis from HCC has not recurred since the operation.  Withthe presentation of thist case, we have looked through the literature reported so far.Key words:  tonsillar metastasis; hepatocellular carcinoma; first manifestationAbbreviation: HCC, hepatocellular carcinomaMetastases from hepatocellular carcinoma(HCC) to the oral cavity are rare.  We have re-cently experienced the case of a patient withtonsillar metastases from HCC, which was  thefirst manifestation of the disease.  The presentarticle describs the case, with a thorough reviewof the literature.Patient ReportA 69-year-old man with a mass of about 20 mmin the left palatine tonsil visited the Departmentof Oto-Rhino-Laryngology Clinic, Tottori Uni-versity Hospital in March, 1999.  The patienthad noticed this mass for about 8 months.  Dur-ing this period, the patient removed it by him-self with no complication, but it recurred im-mediately.  The mass existed in the upper port-ion of the left palatine tonsil (Fig. 1), and its sur-face was necrotic.  Magnetic resonance imagingshowed that it was localized in the left palatinetonsil, without invasion to the ambient organs(Fig. 2).  Pathological findings were metastasesfrom HCC (Fig. 3).  Although he had sufferedfrom alcoholic liver disease with fatty liver for10 years, there had been no evidence of HCC upto that moment; the tonsillar mass was the firstdemonstration of the tumor.Clinical examinations revealed that a tumor70 × 80 mm in size existed in the right hepaticlobe, which invaded the portal vein.  There wereno other metastases other than the left palatinetonsil, the alpha-fetoprotein level was positive(1216.0 ng/mL) and hepatic disorders were notsevere (Child-A).  The disease was non-curable.The patient underwent a left palatine ton-sillectomy under general anesthesia for remov-ing the pharyngeal discomfort and for prevent-Fig. 1.  Oral cavity of the present patient.  There is atumor in the upper portion of the left palatine tonsil.K. Nakahara  et al.218ing dyspnea, dysphagia and severe bleeding.The tonsil had no adhesion to the surroundingtissue, and thre was no great loss of blood.  Noevident invasion could be found during the op-eration.  We could not find any evidence of re-currence up to 4 months after the operation.DiscussionMetastases to the tonsil are uncommon.  Theknown primary tumors are malignant melanoma,carcinomas of the breast, lung and stomach,hypernephromas and seminomas (Brownson etal., 1979).  Rarely observed cases are metasta-ses from renal carcinoma, pancreatic carci-noma, Wilms’ tumor, choriocarcinoma and mix-ed mesodermal tumor of the uterus (FernándezAceñero et al., 1996).  Tonsillar metastasis fromHCC is quite rare.  In Japan, at least 7 Japanesepatients were reported from 1981 to 1994.  Inthe West, we could find only 1 patient withHCC metastasizing to the palatine tonsil, re-ported from San Carlos University Hospital inSpain in 1996 (Llanes et al., 1996).The primary tumors of tonsillar metastasesreported in Japan (Table 1) are:  carcinomas ofFig. 2.  Magnetic resonance images (T2-weighted coronal views).  The tumor is localized in the left palatinetonsil.the lung, stomach, liver, colon, kidney, breast,pancreas, thyroid gland and gallbladder; malig-nant melanoma; choriocarcinoma; seminomaand mesothelioma (Funai et al., 1981; Mori et al.,1987; Kadowaki and Ikoma, 1990; Saiki et al.,1992; Kawai et al., 1993; Mochimatsu et al.,1993; Akiyama et al., 1995; Hando et al., 1995;Yamauchi et al., 1995).  On the other hand, thereported metastatic sites in the head and neck fromHCC are the orbit, paranasal sinus, gingivobuccalmucosa, palatine tonsil and lingual tonsil (Saiki etal., 1992; Kawai et al., 1993).Why are tonsillar metastases rare?  It hasbeen hypothesized that translymphangial meta-stasis is rare to occur because the tonsil has noafferent lymphoduct (Draizin et al., 1978).  Thetonsil has a high ability to eliminate cancer cellsby immunosurveillance (Funai et al., 1981), sotonsillar metastases are rarely searched for atgeneral postmortem examinations (Tanaka etal., 1981).The most common sites for extrahepaticmetastases from HCC are the lung, peritoneum,bone, intracelial organs and adrenal gland.  Thepatient’s tumor must have metastasized throughthe tonsillar hilus because HCC usually causestransvascular metastasis.FS 6.0 CORS# 4/10E# 1/1TR 3000TE 117FA 90HF/SH 220P –0.5A +2TNSA 8PRJ 192SML 512 RR LAFPH R–L219Tonsillar metastasis from HCCFig. 3.  Histological findings of the tumor (hematoxylin and eosin staining, × 100).  The surface tissue is thestratified flattened epithelium, but the inside tissue is of the hepatocellular carcinoma with sinusoidal pattern-ed cells.  Immunohistochemical staining of alpha-fetoprotein was negative, but that of carcinoembryonicantigen was positive.In patients with tonsillar metastases, thelesions are mostly unilateral, but several papersreported bilateral occurrences (Draizin et al.,1978; Kadowaki and Ikoma, 1990).The metastases usually appear within 1 yearafter the occurrence of the primary tumor.  Insome uncommon cases, however, lesions oc-curing before the existence of a primary tumorhas been noted, which allows for the definitediagnosis of the primary tumor (FernándezAceñero et al., 1996).  Similarly, both the pres-ent patient and the patient in San Carlos Univer-sity Hospital (Llanes et al., 1996) were diagnos-ed as HCC due on the metastasis to the unilater-al palatine tonsil.The common symptoms of metastatic tu-mors of the tonsil are pharyngeal discomfort,pain and bleeding.  Because the symptoms areweak in most cases, the metastases are general-ly found in the advanced stage.  Furthermore,they are usually a late event in the progressionof HCC, so that prognosis is generally pooronce its metastatic lesion is found.  Kanazawaand Sato (1989) explained that the mean surviv-Table 1.  The primary sites for tonsillar meta-stases reported in Japan     Primary site                     Number of patientsPulmonary cancer 24Gastric cancer   8Liver cancer   8*Colon cancer   3Malignant melanoma   3Choriocarcinoma   3Renal cancer   2Breast cancer   2Others   4*Including the present patient.al rate after the appearance of oral metastaseswas 21 weeks, ranging from 2 weeks to 2 years.The patient in San Carlos University Hospitaldied 8 months after the diagnosis of tonsillarmetastasis.Major treatment is resection of the tumor bypalatine tonsillectomy.  The operation is veryuseful for prevention of such complications aspharyngeal pain, dyspnea, dysphagia and se-vere bleeding (Hando et al., 1995; Yamauchi etK. Nakahara  et al.220(Received August 20, Accepted September 27, 1999)al., 1995).  And we should always respect thepatients’ quality of life during treatment be-cause of the poor prognosis.References 1 Akiyama Y, Yagi M, Murakami M, Yasuda N,Hisa Y.  Tonsillar metastasis from small cell lungcarcinoma:  report of a case.  Nisseki Igaku 1995;47:247–250 (in Japanese with English abstract). 2 Brownson RJ, Jaques WE, LaMonte SE, ZollingerWK.  Hypernephroma metastatic to the palatinetonsils.  Ann Otol Rhinol Laryngol 1979;88:235–240. 3 Draizin D, Matucci K, Royhfeld S.  Bilateralmetastatic tonsillar disease due to renal cell carci-noma.  Ear Nose Throat J 1978;57:14–18. 4 Fernández Aceñero MJ, Pascual Martin A,Martin Rodilla C, Blanco González J, IspizuaUribarri JI, Sanz Esponera J.  Tonsillar meta-stases:  report on two cases and review of litera-ture.  Gen Diagn Pathol 1996;141:269–272. 5 Funai H, et al.  Tonsillar metastasis of hepatoma:report of a case.  Jibiinkoka 1981;53:421–423 (inJapanese with English abstract). 6 Hando S, Sato Y, Hasegawa S, Nishiwaki C.Three cases of metastatic tonsillar tumor.Kenritsu Gan Senta Niigata Byoin Ishi 1995;34:61–64 (in Japanese with English abstract). 7 Kadowaki K, Ikoma H.  Metastatic carcinoma ofthe bilateral tonsils owing to gastric cancer:  acase report.  Jibi To Rinsho 1990;36:1144–1146(in Japanese with English abstract). 8 Kanazawa H, Sato K.  Gingival metastasis fromprimary hepatocellular carcinoma:  report of acase and review of literature.  J Oral MaxillofacSurg 1989;47:987–990. 9 Kawai A, Orita Y, Yamamoto H, Akisada T,Yamakawa J, Yoshihiro T.  Metastasis from pan-creatic carcinoma to palatine and lingual tonsil:  acase report.  Jibiinkoka Rinsho 1993;86:839–845(in Japanese with English abstract).10 Llanes F, Sanz-Ortega J, Suarez B, Sanz-Esponera J.  Hepatocellular carcinomas diag-nosed following metastasis to the oral cavity.  Re-port of 2 cases.  J Periodontol 1996;67:717–719.11 Mochimatsu I, Tsukada M, Furukawa S, SawakiS.  Tumors metastasizing to the head and neck:  areport of seven cases.  J Laryngol Otol 1993;107:1171–1173.12 Mori S, Sakurai K, Kuroyanagi H, Kishimoto A,Takatsu A, Iwata S.  Tonsillar metastasis fromlung cancer:  a case report.  Jibiinkoka Rinsho1987;80:1261–1265 (in Japanese with Englishabstract).13 Saiki T, et al.  Metastatic hepatocellular carcino-ma of tonsil:  report of a case.  Jibiinkoka TokeibuGeka 1992;64:747–751 (in Japanese with Englishabstract).14 Tanaka N, Toya M, Koyanagi Y.  Tonsillarmetastasis from carcinoma of the stomach:  reportof a case.  Jibi To Rinsho 1981;27:811–814 (inJapanese with English abstract).15 Yamauchi H, et al.  Tonsillar metastasis fromgastric cancer:  a case report.  Jibiinkoka TokeibuGeka 1995;67:650–654 (in Japanese with Englishabstract).

A Case of Hepatocellular Carcinoma Metastasizing to the Palatine Tonsil

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A Case of Hepatocellular Carcinoma Metastasizing to the Palatine Tonsil

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