Yonago Acta medica 1999;42:217–220

A Case of Hepatocellular Carcinoma Metastasizing to the Palatine Tonsil
Kei Nakahara, Satoshi Matsuo, Hiromi Takeuchi and Hisaaki Ikoma
Department of Oto-Rhino-Laryngology, Faculty of Medicine, Tottori University, Yonago 6830826, Japan
This report presents a 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 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 palatine
tonsillectomy, and metastasis from HCC has not recurred since the operation. With
the presentation of thist case, we have looked through the literature reported so far.
Key words: tonsillar metastasis; hepatocellular carcinoma; first manifestation

Metastases from hepatocellular carcinoma(HCC) to the oral cavity are rare. We have recently experienced the case of a patient withtonsillar metastases from HCC, which was thefirst manifestation of the disease. The present
article describs the case, with a thorough reviewof the literature.

70 × 80 mm in size existed in the right hepaticlobe, which invaded the portal vein. There wereno other metastases other than the left palatine
tonsil, 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 tonsillectomy under general anesthesia for removing the pharyngeal discomfort and for prevent-

Patient Report
A 69-year-old man with a mass of about 20 mmin the left palatine tonsil visited the Departmentof Oto-Rhino-Laryngology Clinic, Tottori University Hospital in March, 1999. The patient
had noticed this mass for about 8 months. During this period, the patient removed it by himself with no complication, but it recurred immediately. The mass existed in the upper portion of the left palatine tonsil (Fig. 1), and its surface was necrotic. Magnetic resonance imaging
showed that it was localized in the left palatine
tonsil, without invasion to the ambient organs(Fig. 2). Pathological findings were metastases
from HCC (Fig. 3). Although he had sufferedfrom alcoholic liver disease with fatty liver for10 years, there had been no evidence of HCC up
to that moment; the tonsillar mass was the first
demonstration of the tumor.
Clinical examinations revealed that a tumor

Fig. 1. Oral cavity of the present patient. There is atumor in the upper portion of the left palatine tonsil.

Abbreviation: HCC, hepatocellular carcinoma

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K. Nakahara et al.

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HF/S
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Fig. 2. Magnetic resonance images (T2-weighted coronal views). The tumor is localized in the left palatine
tonsil.

ing dyspnea, dysphagia and severe bleeding.
The tonsil had no adhesion to the surrounding
tissue, and thre was no great loss of blood. No
evident invasion could be found during the operation. We could not find any evidence of recurrence up to 4 months after the operation.

Discussion
Metastases to the tonsil are uncommon. The
known primary tumors are malignant melanoma,
carcinomas of the breast, lung and stomach,
hypernephromas and seminomas (Brownson etal., 1979). Rarely observed cases are metastases from renal carcinoma, pancreatic carcinoma, Wilms’ tumor, choriocarcinoma and mixed 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. In
the West, we could find only 1 patient with
HCC metastasizing to the palatine tonsil, reported from San Carlos University Hospital in
Spain in 1996 (Llanes et al., 1996).
The primary tumors of tonsillar metastases
reported in Japan (Table 1) are: carcinomas ofthe lung, stomach, liver, colon, kidney, breast,pancreas, thyroid gland and gallbladder; malignant melanoma; choriocarcinoma; seminoma
and 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 from
HCC are the orbit, paranasal sinus, gingivobuccal
mucosa, palatine tonsil and lingual tonsil (Saiki etal., 1992; Kawai et al., 1993).
Why are tonsillar metastases rare? It has
been hypothesized that translymphangial metastasis is rare to occur because the tonsil has noafferent lymphoduct (Draizin et al., 1978). The
tonsil has a high ability to eliminate cancer cells
by immunosurveillance (Funai et al., 1981), sotonsillar metastases are rarely searched for atgeneral postmortem examinations (Tanaka etal., 1981).
The most common sites for extrahepatic
metastases from HCC are the lung, peritoneum,bone, intracelial organs and adrenal gland. The
patient’s tumor must have metastasized throughthe tonsillar hilus because HCC usually causes
transvascular metastasis.

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