Evaluation of the utility of histopathologic exam as a routine in tonsillectomies

Rev Bras Otorrinolaringol 2006;72(2):252-5 ORIGINAL ARTICLE Evaluation of the Utility of histopathologic exam as a routine in Tonsillectomies Felippe Felix1, Geraldo Augusto Gomes2, Bruno Peer de Souza3, Gustavo Azeredo Cardoso4, Shiro Tomita5 Key words: tonsillectomy, histopathologic, cost. Summary T onsillectomy is one of the most commonly performed procedures of the head and neck. It is performed for a wide variety of indications in both adults and children. It is common to send the material achieved in the surgery to routine histopathologic exam, as to analyze suspected material or for a medical-legal documentation. Objective: Analyze the utility and cost of routine histopathologic diagnosis for tonsillectomy. Methodology: retrospective study of the histopathologic result of all tonsillectomies between 1978 and 2004 in a university hospital and analyzed the files of the patients with cancer. Results: 2103 results of histopathologic exams were analyzed. Of these, only four cases presented any case of malignancy, being all of these non-Hodgkin lymphoma and already suspected before the surgery. Discussion: The world literature has encountered similar results and each time more the histopathologic analysis of all cases is questioned. The cost of the exam is high and your results, in the case of malignancy were already knew before the surgery. Conclusion: Histopathologic analysis of all tonsillectomies is not indicated. The risks factors established by Beaty should guide the solicitation of the exam, to try to low the costs with unnecessary exams. 3rd year resident of Otorhinolaryngology - Clementino Fraga Filho University Hospital - Federal University of Rio de Janeiro. MD, MS student - Otorhinolaryngology - Clementino Fraga Filho University Hospital - Federal University of Rio de Janeiro. 3 Medical Student - Federal University of Rio de Janeiro. 4 Medical Student - Federal University of Rio de Janeiro. 5 Full Professor and Head of Otorhinolaryngology - Clementino Fraga Filho University Hospital - Federal University of Rio de Janeiro. Hospital Universitário Clementino Fraga Filho da Universidade Federal do Rio de Janeiro. Mailing address:Rua Cel. Moreira Cesar 229/ 1815 Icaraí Niterói RJ 24220-120. Paper submitted to the ABORL-CCF SGP (Management Publications System) on August 25th, 2005 and accepted for publication on March 10th, 2006. 1 2 BRAZILIAN JOURNAL OF OTORHINOLARYNGOLOGY 72 (2) MARCH/APRIL 2006 HTTP://WWW.RBORL.ORG.BR / E-MAIL: 252 INTRODUCTION RESULTS Tonsillectomy is one of the most commonly performed surgeries in the world. It bears a variety of indications; both in adults and children, and the most common indications are upper airway obstruction and recurrent tonsillitis. It is common to send the specimen for histopathology exam, most of the times as standard procedure in many institutions, either to analyze suspicious material or for legal purposes as proof of its removal1. Besides, hidden malignancy, in other words, the finding of malignant neoplasia by chance in a surgical specimen without clinical suspicion before surgery, is an important factor that favors the fact that all physicians should send their surgical specimens to analysis. This debate about sending or not this material for exam is nothing recent. Starry2 and Yarington3, in 1939 and 1967, respectively, instructed physicians to request histopathology exam of all specimens. Weibel4, in 1965, was the first to speak against the microscopic exam in routine tonsillectomies. In this study, we retrospectively analyzed 2,103 charts from patients who underwent tonsillectomies regardless of surgical indication, gender and age, aiming at evaluating if the routine histopathology exam is indicated. A total of 2,103 histopathology analysis results were reviewed. Of this sample, only 4 cases presented some type of malignancy, and all of them were non-Hodgkin lymphomas, corresponding to 0.19% of the total. The four cases are reviewed on Table 1. 15 cases of squamous cell carcinoma were found in palatine tonsils. These cases were not included in this paper because they were found by lesion biopsy only, and not tonsillectomy, as all the other ones which were evaluated. Table 1. Evaluation of malignant cases related to Beaty risk factors. METHODS We reviewed the files from the Department of Pathology of the University Hospital Clementino Fraga Filho, and collected the histopathology analysis report from palatine tonsils of adult and pediatric patients operated in the last 25 years, from 1978 to 2004, regardless of patient age and surgical indication. Within the group of non-malignant pathologies we included the following cases: follicular hyperplasia, lymphoid hyperplasia, acute and chronic inflammation. We excluded the biopsy cases in which the entire tonsil was not removed. Patients that had malignancy in their exam had their charts pulled out and reviewed. Besides, there was a cost analysis for both the hospital and the public health system, and we consulted the literature from the last 20 years on the subject. The cost of each histopathology exam for palatine tonsils is of about R$ 13.89 per specimen, according to data supplied by the Hospital Financial Department and the rates from the Public Health System. Since in all the cases the tonsillectomy was bilateral, the cost ended up being of R$ 27.78. Data from the private sector vary according to insurance company and the type of insurance plan the patient had subscribed to, and they were not used in this study. Case 1 Case 2 Case 3 Case 4 Age of diagnosis 80 44 28 75 Neck lymphadenomegaly X X X - Palatine tonsil asymmetry X X X X Mucosal irregularities/alterations felt in the palpation ? X X X Body symptoms or unexplainable weight losing X X - - Past history of immune depression or malignancy ? ? - - Suspicion before surgery X X X X: present; -: absent; ?: undetermined or unavailable X DISCUSSION The pathological analysis of the surgical material serves to guide patient care and treatment. It also it helps guarantee for the health insurance plans that documented procedures are performed, for legal reasons as well as an educational tool, used to confirm presumed diagnosis. Recently, studies based on the histology of palatine tonsils have shown that in routine cases this exam may not be necessary5. These authors show that there is very little chance for a significant pathological finding in the specimens removed by routine indications. Unfortunately this risk is not zero, yet, that is why the need for routine histopathology is still controversial. In 1996, Dohar and Bonilla6, sent a survey to pediatric otolaryngologists in the United States. In this survey they found that 56% of the physicians sent all the removed material to microscopic analysis, 44% only sent them to macroscopic analysis or did not do it at all. Besides, these same authors reviewed 2,000 pediatric tonsillectomies from an American inst (...truncated)