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Conn B, Pring M, Jones AV. Macroscopy of specimens from the head and neck. J Clin Pathol 2024; 77:185-189. [PMID: 38373780 DOI: 10.1136/jcp-2023-208834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/05/2023] [Indexed: 02/21/2024]
Abstract
Macroscopic examination of surgical resections from the head and neck may be difficult due to the complex anatomy of this area. Recognition of normal anatomical structures is essential for accurate assessment of the extent of a disease process. Communication with the surgical team, correct specimen orientation and sampling are critical for assessment and the importance of radiological and clinical correlation is emphasised. Tumour involvement at each subsite is highlighted with reference to where there are implications on pathological staging and the potential need for adjuvant therapy.
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Affiliation(s)
- Brendan Conn
- Pathology Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Miranda Pring
- School of Oral and Dental Sciences, University of Bristol, Bristol, UK
| | - Adam V Jones
- Cellular Pathology Department, University Hospital of Wales, Cardiff, Wales, UK
- Oral and Maxillofacial Pathology, University Dental Hospital, Cardiff, UK
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Shires CB, Sebelik M. Oropharynx cancer after sleep apnea surgery. Clin Case Rep 2022; 10:e05686. [PMID: 35425596 PMCID: PMC8991756 DOI: 10.1002/ccr3.5686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/30/2022] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
Surgery can treat sleep apnea. An elderly male underwent lingual/palatine tonsillectomy for OSA. He was then found to have T3N2 p16+ squamous cell carcinoma. He is receiving chemoradiation. Recognition of occult malignancy in tonsillectomy specimens may facilitate early diagnosis and treatment for patients following sleep apnea surgery.
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Kuhnow A, Al-Sayed AA, Taylor B. Routine evaluation of tonsillectomy specimens: a cross-sectional survey of Canadian Otolaryngology: Head and Neck Surgeons. J Otolaryngol Head Neck Surg 2022; 51:14. [PMID: 35387688 PMCID: PMC8985276 DOI: 10.1186/s40463-022-00569-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 03/01/2022] [Indexed: 11/24/2022] Open
Abstract
Background Tonsillectomy is a commonly performed procedure in Canada. The rate of occult malignancy is rare in adult and pediatric populations. At present, no guidelines exist surrounding the need for routine histopathological evaluation of tonsil specimens when no malignancy is suspected. Methods We sent a confidential online survey to active members of the Canadian Society of Otolaryngology – Head and Neck Surgery (CSO-HNS) about their current tonsillectomy practice and beliefs surrounding the need for routine histopathological evaluation of tonsillectomy specimens when no malignancy is suspected. We used Opinio survey software for data collection and descriptive statistics. Results 95 participants completed our survey (response rate 19.3%). Most participants reported performing both adult and pediatric tonsillectomies. When no malignancy is suspected, participant responses were split between whether they send tonsil specimens in pediatrics only (4.2%), in adults only (31.6%), or not sending specimens (29.5%). Half of the participants reported that routinely sending specimens to rule out occult malignancy is an institutional policy. Approximately 75% of participants were in favour of removing this practice in both the pediatric and adult populations. Conclusion Eliminating the practice of automatically sending tonsil specimens for histopathological evaluation when no malignancy is suspected was supported by the majority of study participants. This is in keeping with Choosing Wisely, a campaign designed to facilitate conversations about unnecessary medical tests and procedures. Institutional change is likely required in order to alter this practice. Graphical Abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s40463-022-00569-7.
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Affiliation(s)
- Alexi Kuhnow
- Faculty of Medicine, Dalhousie University, 1459 Oxford Street, Halifax, NS, B3H 4R2, Canada.
| | - Ahmed A Al-Sayed
- Division of Otolaryngology - Head and Neck Surgery, Nova Scotia Health Authority, 5820 University Ave, Halifax, NS, Canada
| | - Benjamin Taylor
- Division of Otolaryngology - Head and Neck Surgery, Nova Scotia Health Authority, 5820 University Ave, Halifax, NS, Canada
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AYDIN S, BOLDAZ E. Tonsillektomi spesmenlerinin Histopatolojik Retrospektif Analizi. MUSTAFA KEMAL ÜNIVERSITESI TIP DERGISI 2020. [DOI: 10.17944/mkutfd.521354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Syme N, Brettfeld S, Dorneden A, Samedi V, Bocklage T, Myers O, Herzon F, Meiklejohn DA. Occult Malignancy in Adult Tonsillectomy for Benign Indication. Ann Otol Rhinol Laryngol 2020; 130:356-362. [PMID: 32840127 DOI: 10.1177/0003489420952474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE National pathology guidelines recommend full pathologic analysis for all adult tonsillectomy specimens. We evaluated the available data on occult malignancy in adult tonsillectomy for benign indication, and created a screening system to reduce the risk of missed malignancies if routine histopathologic examination were to be discontinued. STUDY DESIGN Retrospective chart review and systematic review of the literature. SETTING Tertiary care academic hospital and multi-hospital private healthcare system. SUBJECTS AND METHODS A systematic literature review identified case series of adult tonsillectomy. Retrospective chart review at our institutions from 2000 to 2016 produced an additional case series. The pooled rate of occult malignancy was determined, and re-analyzed using criteria based on preoperative risk factors designed to identify patients requiring full pathologic analysis. The predicted effects of prospective application of the proposed criteria were calculated. Pooled occult malignancy prevalence was estimated. RESULTS Literature review and our own case series yielded 12,094 total cases. Occult malignancy prevalence in the combined data was 0.033%, representing four occult malignancies. Three out of the four would have been selected for full pathology preoperatively with use of the proposed criteria. Statistical analysis indicates that the predicted frequency of occult malignancy incidence in cases negative for the criteria is 0.01%, or 1/10,000. CONCLUSION Application of the proposed criteria to adults undergoing tonsillectomy for benign indication identifies a subset of patients with an estimated incidence of occult malignancy similar to that reported for pediatric tonsillectomy, and potentially may permit safe elimination of pathologic analysis of their tonsil specimens. LEVEL OF EVIDENCE Pooled analysis of case series from the literature and a single institution, level 4.
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Affiliation(s)
- Noah Syme
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Stefan Brettfeld
- Department of Pathology, University of Colorado, Denver, CO, USA
| | - Ashley Dorneden
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Von Samedi
- Department of Pathology, University of Colorado, Denver, CO, USA
| | - Therese Bocklage
- Department of Pathology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Orrin Myers
- Department of Family and Community Medicine, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Fred Herzon
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Duncan A Meiklejohn
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of New Mexico Hospital, Albuquerque, NM, USA
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Bant P, Szczygielski K, Cierniak S, Kosek J, Kania J, Sienicki R, Jurkiewicz D. Tonsillectomy in own material. Otolaryngol Pol 2020; 74:1-5. [PMID: 33028738 DOI: 10.5604/01.3001.0014.1612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
<b>Introduction:</b> Tonsillectomy belongs to the most frequently performed surgical treatments; however, the necessity of its performance is questioned. Therefore, there are many attempts to unify and define the indications for the procedure. <br><b>Aim:</b> The main objective of the current dissertation was an analysis of the clinical symptoms occurring in patients qualified for tonsillectomy, as well as a comparison of those with a histopathological image of the removed tonsils in a repeatedly carried out, unified pathomorphological examination. The secondary objective was the designation of the demographic profile, existing comorbidities, and complications in the form of postoperative bleeding in patients after tonsillectomy in own material. <br><b>Material and method:</b> A retrospective analysis of 301 procedures of palatine tonsil removal was performed, which were completed in the years 2017-2019 at the Department of Otolaryngology with Division of Cranio-Maxillo-Facial Surgery of the Military Institute of Medicine, Warsaw, Poland. The indications were defined on the grounds of data from the anamnesis. Based on unified criteria, the removed material was divided into 2 groups: with the signs of Chronic Tonsillitis (CT) as well as Tonsillar Hyperthrophy (TH). <br><b>Results:</b> The average size of tonsils was the greatest in a group of patients under 35 years of age, and smallest in the group over 51 years of age. As patients aged, the reduction in size of the palatal tonsils was observed. In the examined group, the histopathological diagnosis in the form of HT was found in 165 patients (54.8%), while CT in 136 (45.2%). It was proven that the larger the tonsils in the clinical picture, the more often the histopathological image responded to HT. Among clinical symptoms reported by patients qualified for tonsillectomy, the following were observed: recurring tonsil inflammation in 211 (70.1%), snoring and sleep apnea in 47 (15.6%), as well as sleep apnea in 33 (11%) patients. Primary bleeding occurred in 10 patients (3.34%), and secondary in 8 patients (2.66%). The most common comorbidities were cardiovascular burdens. <br><b>Conclusions:</b> For most cases, clinical symptoms were confirmed by adequate features of removed material in histopathological examination. The most common histopathological diagnosis was tonsillar hyperthrophy.
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Affiliation(s)
- Przemysław Bant
- Department of Otolaryngology and Laryngological Oncology with the Clinical Department of Cartilage-Maxillofacial Surgery, Central Clinical Hospital of the Ministry of National Defense, Military Medical Institute
| | - Kornel Szczygielski
- Department of Otolaryngology and Laryngological Oncology with the Clinical Department of Cartilage-Maxillofacial Surgery, Central Clinical Hospital of the Ministry of National Defense, Military Medical Institute
| | - Szczepan Cierniak
- Department of Pathomorphology, Central Clinical Hospital of the Ministry of National Defense, Military Institute of Medicine
| | - Jarosław Kosek
- Department of Otolaryngology and Laryngological Oncology with the Clinical Department of Cartilage-Maxillofacial Surgery, Central Clinical Hospital of the Ministry of National Defense, Military Medical Institute
| | - Joanna Kania
- Department of Pathomorphology, Central Clinical Hospital of the Ministry of National Defense, Military Institute of Medicine
| | - Rafał Sienicki
- Department of Otolaryngology and Laryngological Oncology with the Clinical Department of Cartilage-Maxillofacial Surgery, Central Clinical Hospital of the Ministry of National Defense, Military Medical Institute
| | - Dariusz Jurkiewicz
- Department of Otolaryngology and Laryngological Oncology with the Clinical Department of Cartilage-Maxillofacial Surgery, Central Clinical Hospital of the Ministry of National Defense, Military Medical Institute
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Park D, Lee BJ, Go M, Kim JS, Heo SJ. Unexpected occult malignancy diagnosed during tonsillectomy surgery for obstructive sleep apnea: A case report. Medicine (Baltimore) 2020; 99:e19793. [PMID: 32358351 PMCID: PMC7440168 DOI: 10.1097/md.0000000000019793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Many previous studies have investigated the necessity of routine histopathological analysis of tonsillectomy specimen, and most recent studies have suggested that such an analysis is not justified in asymptomatic patients or those with no risk factors for malignancy. PATIENT CONCERNS A 59-year-old man diagnosed with obstructive sleep apnea underwent surgery, including tonsillectomy; a tonsil specimen was sent to the department of pathology. DIAGNOSIS Although the patient did not exhibit any tonsil-related signs or symptoms, nor did the appearance of the tonsil appear to be pathological, the right tonsil specimen was diagnosed with squamous cell carcinoma, with detection of human papilloma virus 16. INTERVENTIONS Chemotherapy and radiotherapy were used to treat the tonsil cancer. OUTCOMES No recurrence was observed during the 4-year follow-up. LESSONS In the future, it may be necessary to reinvestigate the necessity of routine histopathological analysis of tonsillectomy specimens in asymptomatic patients, considering the drastically increased rate of detection of human papilloma virus-related oropharyngeal squamous cell carcinomas in these patients.
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Affiliation(s)
- Donghwi Park
- Department of Physical Medicine and Rehabilitation, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan
| | - Byung Joo Lee
- Department of Physical Medicine and Rehabilitation, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan
| | - Minchul Go
- Department of Otorhinolaryngology – Head and Neck Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital
| | - Jung-Soo Kim
- Department of Otorhinolaryngology – Head and Neck Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital
| | - Sung Jae Heo
- Department of Otorhinolaryngology – Head and Neck Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, South Korea
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Elghouche AN, Alwani MM, Matt BH. Indiscriminate Pathologic Examination of Pediatric Supraglottoplasty Specimens: An Evidence-Based Approach toward Exempt Status. Otolaryngol Head Neck Surg 2020; 163:194-197. [PMID: 31935163 DOI: 10.1177/0194599819900260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The primary aim of this study was to demonstrate that indiscriminate pathologic evaluation of supraglottoplasty specimens is unnecessary and does not influence postoperative management. The secondary objective was to determine the costs associated with pathologic evaluation of supraglottoplasty specimens. METHODS A planned chart review was conducted to evaluate data from consecutive patients undergoing supraglottoplasty. Demographic data were extracted and pathology reports were reviewed. Projected cost savings were estimated based on 2018 Centers for Medicare & Medicaid Services reimbursement rates for Current Procedural Terminology code 88304 (surgical pathology, gross and microscopic examination). RESULTS A total of 1417 consecutive patients were identified. All specimens underwent gross and microscopic examination. Pathologic outcomes were categorized into 3 major categories: no diagnostic abnormality (n = 1069), chronic inflammation (n = 346), and other (n = 2). Pathologic evaluation did not alter postoperative management in any patient. Projected yearly and 5-year cost- savings totaled $11,818.08 and $59,173.92, respectively. DISCUSSION These findings demonstrate that pathologic examination of supraglottoplasty specimens adds no value to patient management. A more selective approach to pathologic examination of certain surgical specimens is an improvement opportunity to enhance the value of patient care by eliminating direct financial costs and "hidden costs" associated with unnecessarily increased workload. IMPLICATIONS FOR PRACTICE Addressing inappropriate, indiscriminate pathologic examination of certain surgical specimens is a potential quality improvement opportunity that has a meaningful impact on the value of patient care and reduces strains on the workload of surgical and pathology department personnel.
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Affiliation(s)
- Alhasan N Elghouche
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mohamedkazim M Alwani
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Bruce H Matt
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Bizzell JG, Richter GT, Bower CM, Woods GL, Nolder AR. Routine pathologic examination of tonsillectomy specimens: A 10-year experience at a tertiary care children's hospital. Int J Pediatr Otorhinolaryngol 2017; 102:86-89. [PMID: 29106883 DOI: 10.1016/j.ijporl.2017.09.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/11/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To review histopathologic diagnoses from tonsillectomy specimens and determine whether routine pathologic exam is necessary. METHODS Pathology reports of patients undergoing tonsillectomy from 2005 to 2014 at our pediatric tertiary care hospital were reviewed. Histopathologic diagnoses were recorded with special attention to identification of malignancy. RESULTS A total of 8807 paired tonsil specimens were sent to pathology over a 10-year course. Gross analysis was performed on all. Microscopic histopathologic analysis was performed on 612 (6.95%) specimens with all but one demonstrating strictly reactive lymphoid hyperplasia. The single specimen (0.16%) demonstrated follicular hyperplasia with focal necrotizing granulomatous lymphadenitis without organisms identified on special staining. The surgeon requested pathologic diagnosis to rule out lymphoma in 4 of 8087 (0.05%) of the specimens. No malignancies were identified. The approximate charges for gross examination of a paired tonsillectomy specimen and microscopic examination were $136.10 and $294.54, respectively. Over the 10 year period of the study, total charges were estimated at $1,115,340 (gross) and $180,258 (microscopic). DISCUSSION Microscopic analysis of tonsil specimens is unlikely to identify abnormal pathology that changes patient management. This study suggests that neither gross nor microscopic pathologic examination of tonsillectomy specimens is necessary on a routine basis. Histologic analysis of tonsils should be requested only on a case by case basis when clinical suspicion for malignancy is high. Avoiding routine pathologic exam of tonsils may be cost effective and medically safe.
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Affiliation(s)
- Jamie Glancy Bizzell
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham, Slot 543, Little Rock, AR 72205, USA.
| | - Gresham T Richter
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham, Slot 543, Little Rock, AR 72205, USA; Arkansas Children's Hospital, Division of Pediatric Otolaryngology, 1 Children's Way, Slot 836, Little Rock, AR 72202, USA.
| | - Charles M Bower
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham, Slot 543, Little Rock, AR 72205, USA; Arkansas Children's Hospital, Division of Pediatric Otolaryngology, 1 Children's Way, Slot 836, Little Rock, AR 72202, USA.
| | - Gail L Woods
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham, Slot 543, Little Rock, AR 72205, USA; Arkansas Children's Hospital, Division of Pediatric Otolaryngology, 1 Children's Way, Slot 836, Little Rock, AR 72202, USA.
| | - Abby R Nolder
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham, Slot 543, Little Rock, AR 72205, USA; Arkansas Children's Hospital, Division of Pediatric Otolaryngology, 1 Children's Way, Slot 836, Little Rock, AR 72202, USA.
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Aisagbonhi O, DeLelys M, Hartford N, Preffer F, Ly A. Utility of Flow Cytometry in Diagnosing Hematologic Malignancy in Tonsillar Tissue. Int J Surg Pathol 2017; 25:406-413. [PMID: 28351195 DOI: 10.1177/1066896917700726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Tonsil surgical biopsy or excision is a very common procedure. However, there exist no consensus guidelines for the pathologic handling of tonsil specimens; gross and/or microscopic evaluation may be used. Diagnosis of tonsillar hematologic malignancy requires histology, immunohistochemistry and/or flow cytometry. Data regarding the utility of flow cytometry in tonsillar tissues are limited. We assessed our experience with flow cytometry for tonsil diagnosis with regard to accuracy and use patterns at a tertiary academic medical center. METHODS We retrospectively analyzed all surgically biopsied or excised tonsil specimens that underwent flow cytometry evaluation from August 2011 to March 2014. Patient clinical information, intraoperative frozen section, histology, immunohistochemistry, and flow cytometry diagnoses were recorded. RESULTS The study included 154 tonsil specimens from 89 females and 65 males. Patients averaged 27.4 years old (range 2-87 years); 73 were pediatric. Both histology and flow cytometry were benign for 148 patients (96.1%). Hematolymphoid malignancy was diagnosed in 6 adults by histology/immunohistochemistry: diffuse large B-cell lymphoma (2), small B-cell lymphoma (2), concomitant follicular lymphoma and histiocytic sarcoma (1), and extraosseous plasmacytoma (1). Flow cytometry identified abnormal populations in 5 of 6 cases, and detected clonal populations in 2 reactive follicular hyperplasia cases. CONCLUSION Tonsillar hematolymphoid malignancy is uncommon, and flow cytometry was less accurate than histology/immunohistochemistry for its diagnosis. Despite the rarity of tonsillar lymphoma in children, nearly half of study patients were pediatric. Intraoperative frozen section diagnosis showed excellent sensitivity for malignancy, and could be used to effectively triage cases for flow cytometry evaluation.
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Affiliation(s)
| | | | | | | | - Amy Ly
- 1 Massachusetts General Hospital, Boston, MA, USA
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