Incidence of Occult Malignancy Diagnosed on Histopathology in Routine Adult Tonsillectomies

To determine the contemporary prevalence of occult malignancy in adult tonsillectomy specimens, particularly in light of rising rates of human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC), and to evaluate the implications for current histopathological examination protocols.

A retrospective chart review was conducted of all patients aged ≥ 18 years who underwent tonsillectomy at a tertiary care hospital and affiliated centers from January 1, 2018, to December 31, 2022. Pathology reports, clinical indications, demographic data, smoking history, HPV vaccination status, and p16 immunohistochemistry were reviewed. Surgical indications were classified as either benign (e.g., tonsillitis, OSA, and tonsillolithiasis) or suspicious for malignancy (e.g., tonsillar asymmetry, tonsillar mass, or concern for cancer); malignancy rates were compared between these two groups.

Among 1580 adult tonsillectomy cases, 1529 (96.8%) underwent histopathological examination. Of these, 1328 were performed for benign indications. Two occult malignancies (0.15%) were detected in this group: one mantle cell lymphoma and one HPV-associated squamous cell carcinoma in a vaccinated 26-year-old female with no traditional risk factors. In contrast, malignancy was found in 32.8% (n = 66/201) of cases performed for suspicious indications, with squamous cell carcinoma predominating. p16 positivity was identified in 95.5% of HPV-associated OPSCCs. Smoking history and lack of HPV vaccination were significantly more common in patients with malignant pathology.

Although our findings align with previously reported incidence rates, they highlight the need for continued vigilance in histopathologic evaluation as HPV-related oropharyngeal cancer rates rise and patient risk profiles evolve.