Of Waldeyers Ring

ICD-0:8070/3

Carcinomas of Waldeyer's ring are typically squamous cell carcinomas (SCC) arising in the palatine tonsil and the base of the tongue. They are more common in men than in women and present during the 5th and 7th decades. Smoking, alcohol, poor hygiene, but also HPV infections, are risk factors [32, 51, 160]. Some SCC may be fungating and exophytic tumours, others present as deeply ulcerated infiltrative lesions. The majority of SCC of the palatine tonsil and base of the tongue typically grow undetected for some time as they arise from the crypt epithelium. At the time of clinical detection, extensive infiltration of the surrounding tissues and regional cervical lymph node metastases are typical. The metastases to cervical lymph nodes are often the presenting symptom of tonsillar carcinomas (Fig. 6.8). Histologically, primary carcinomas of the palatine tonsil and base of the tongue can be divided into ke-ratinising and non-keratinising subtypes. The solid non-keratinising carcinomas predominate. Tonsillar carcinomas may show a "transitional type" differentiation resembling lymphoepithelial carcinoma and EBV positivity [111, 132]. A basaloid-squamous carcinoma of Waldeyer's ring has also been described [7, 159]. The lymph node metastases can be quite large and are often cystic with multilocular complex lumina and papillary projections [165, 166, 189]. The majority of cystic metastases are lined with a stratified epithelium with cytological atypia and numerous mitoses. Foci of kera-tinisation can be appreciated. The cysts mostly contain necrotic tumour cells and debris. A minority of the cystic lymph node metastases is filled with clear fluid. Fluid-filled cystic metastases are more common in carcinomas of the base of the tongue than those arising from the palatine tonsils. It has been postulated that

Fig. 6.7. Lymphangiomatous tonsillar polyp. a Lymphangioma-tous polyps vary in size between several millimetres to several centimetres. The stalk may be composed of fibro-vascular stroma or adipose tissue. b The stroma may be fibrotic and contains numerous thin-walled vascular channels filled with proteinaceous

Fig. 6.7. Lymphangiomatous tonsillar polyp. a Lymphangioma-tous polyps vary in size between several millimetres to several centimetres. The stalk may be composed of fibro-vascular stroma or adipose tissue. b The stroma may be fibrotic and contains numerous thin-walled vascular channels filled with proteinaceous fluid and lymphocytes. c-d The surface is covered by either squamous epithelium with numerous intraepithelial lymphocytes or by respiratory epithelium with a dense lymphocytic infiltrate. e-f Markedly dilated lymphatic vessels accompanied by lymphocyt-ic infiltrate carcinomas that produce cystic metastases originate from the excretory ductal system of the submucosal minor salivary glands within the base of the tongue and the palatine tonsil [165].

A search for the primary carcinoma within the pharynx in patients with clinically occult tumours should include multiple blind biopsies of the base of the tongue and oro- and nasopharynx and/or ton-

Fig. 6.8. Tonsillar carcinoma. a Tonsillar squamous cell carcinomas frequently arise from the crypt epithelium. The carcinoma infiltrates deeply into the surrounding structures including skeletal muscles. b Cystic lymph node metastasis showing complex papil-lations which are lined by squamous epithelium; the cyst content is necrotic debris

Fig. 6.8. Tonsillar carcinoma. a Tonsillar squamous cell carcinomas frequently arise from the crypt epithelium. The carcinoma infiltrates deeply into the surrounding structures including skeletal muscles. b Cystic lymph node metastasis showing complex papil-lations which are lined by squamous epithelium; the cyst content is necrotic debris sillectomies. This practice has provided overwhelming evidence that isolated carcinomas in neck lymph nodes are metastases and not so-called primary "branchiogenic carcinomas" within a cervical lymph node. The evolution of in situ or invasive SCC from non-neoplastic squamous epithelium through dysplasia is viewed as the most important criterion for the histopathological diagnosis of a primary branchiogenic carcinoma. Primary cystic carcinoma arising in a lymph node or carcinoma arising in a branchiogenic cyst is probably a hypothetical entity. Reports of a supposed branchiogenic carcinoma included an extremely well-differentiated SCC arising in the background of longstanding chronic inflammation and scarring, one carcinoma arising from pre-auricular ectodermal remnants of the first pharyngeal/branchial cleft and another report of a well-differentiated mucoepider-moid branchiogenic carcinoma [16, 154, 178]. Treatment of SCC of Waldeyer's ring is surgical resection with a neck dissection.

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