Evaluation of Tonsillectomy and Lymphoma Workup -Who Should Get a Lymphoma Workup? Is It Cost Effective?.

Intro: Tonsillectomy is a common surgery for both adults and children. In children (under 18 years) the most common diagnosis is follicular hyperplasia. In adults (18 years and older) the most common neoplastic diagnosis is squamous cell carcinoma. Although a common fear of lymphoma involving the tonsils persist, the literature indicates non-Hodgkin lymphoma as the least common diagnosis among tonsillectomy specimens. The purpose of this study was to provide indications and guidelines to delineate a cost effective approach for selection of tonsils for lymphoma workup. At UC Davis Medical Center, if lymphoma is considered in the differential, the tonsil is processed through a lymphoma workup protocol; touch preps, flow cytometry, cytogenetics, electron microscopy, B5-fixed, and formalin-fixed tissue in paraffin. Tissue is frozen in liquid nitrogen and stored for possible future studies. This approach diminishes the possibility of a missed lymphoma diagnosis, however it is costly and labor intensive. The initial phase of our investigation involved the identification of worrisome clinical findings for comparison with our patient population. Next, we address the incidence of tonsillar lymphoma in children versus adults in our hospital because the two populations historically exhibit drastically different diagnoses. In the final phase of our investigation we address the cost effectiveness of our approach.

Method: To define what clinical findings are worrisome, we performed a literature search of “tonsillectomy and lymphoma” on pubmed and revealed 60 articles dating back to 1980 with 22 articles selected for review. Next, we reviewed over 900 tonsillar specimens collected over five years at the Medical Center. This data was stratified with respect to age, diagnoses, and whether a lymphoma workup was performed.

Data: Prominent worrisome clinical findings included: unilateral enlargement, rapidly growing tonsillar mass, and grossly asymmetric tonsils. The results of our specimen (UC Davis) review is included in the chart below. In 5 years lymphoma workups were performed in19 children and 42 adults. The cost of each workup was $4063.00 and Medicare reimburses $1180.

Conclusion: The incidence of lymphoma in our pediatric population is 0 and in our adult population is less than 1%. The cost per lymphoma diagnosis in our pediatric population exceeds $77,197.00. In contrast, the cost per lymphoma diagnosis in our adult population is $21,330.00. This data in conjunction with our literature search leads us to recommend selecting specimens for lymphoma work up in both adults and pediatric patients with the clinical findings of unilateral growth, rapidly enlarging tonsillar mass, and grossly asymmetric tonsils as a criteria. Special consideration in the pediatric population should also include strong clinical suspicion for lymphoma prior to ordering a lymphoma workup due to an extremely low incidence.

Benign diagnoses include: follicular hyperplasia, benign mucosa and tonsillar tissue, amyloidosis, acute and chronic tonsillitis.Lymphoma diagnoses include: large B-cell , follicle center cell , and lymphoblastic lymphoma. Other Neoplasm diagnoses include: squamous cell and basal cell and metastatic adenocarcinoma, malignant spindle cell sarcoma.