Review of tonsillar lymphoma in pediatric patients from the pediatric oncology group: what can be learned about some indications for microscopic examination?

Financial considerations have led to suggestions that routine microscopic evaluation of tonsils and adenoids is neither cost effective nor clinically indicated. However, the possibility of tonsillar lymphoma must be carefully weighed when making institutional policy decisions. One way to find an appropriate algorithm for pathologic examination is to examine the characteristics of biopsy-proved tonsillar lymphomas. To investigate the clinicopathologic characteristics of tonsillar lymphoma, we performed a retrospective analysis of patients who had non-Hodgkin lymphoma (NHL) and large-cell or Burkitt lymphoma involving the tonsils and adenoids and were registered on Pediatric Oncology Group (POG) protocols. Seventy-seven (9%) of 832 POG cases of NHL involved the tonsils and adenoids. Review of the pathology reports available from 29 of these cases revealed that NHL was incidentally discovered by pathologic examination in only 5 cases, all of which had clinical evidence of unilateral tonsillar enlargement or size discrepancy by gross examination. The other 24 cases indicated a clinical suspicion of tonsillar cancer, as judged by a preoperative diagnosis or by a request for frozen-section examination. We conclude that in most cases there is a clinical suspicion of tonsillar NHL at the time of gross examination. With routine cases, we predict that the use of comparative organ weights, a clinical impression of tonsillar asymmetry, and review of clinical history will increase the recognition of tonsillar lymphoma when "gross-only" protocols are employed for specimen handling.