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Journal of
Oncology Pharmacy Practice
Case Report
A case of rectal adenocarcinoma presented with palatine tonsil metastasis
J Oncol Pharm Practice 0(0) 1–4 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1078155214565124 opp.sagepub.com
Onder Tonyali1, Ahmet Taner Sumbul1, Mehmet Akif Ozturk2, Ali Koyuncuer3 and Fuat Ekiz4
Abstract The most common metastatic sites of colorectal cancer are liver, lung, peritoneum and lymph nodes. Metastasis of colorectal carcinoma to palatine tonsil is rarely seen. To our knowledge, only 11 patients were documented in English literature. Atypical metastases can sometimes lead to misdiagnosis. Precise diagnosis of atypical metastases requires a careful physical examination, good imaging method and comprehensive pathological evaluation. Here, we report a case of rectal adenocarcinoma presented with palatine tonsil metastasis.
Keywords Colorectal cancer, palatine tonsil, metastasis, adenocarcinoma
Introduction Metastatic malignancies of the palatine tonsil are rarely seen and the most common malignancies of palatine tonsil are lymphomas and squamous cell carcinomas.1 Metastatic tumors of tonsillar palatine account for only 0.8% of all tonsillar malignancies.1 The most common primary malignancies spread to palatine tonsil are lung, breast, renal cancers, and malign melanoma.2–5 In the English literature, metastases of colorectal cancer to palatine tonsil were reported only in 11 cases.6 Herein, we report a case of rectal adenocarcinoma who presented with palatine tonsil metastasis.
Case report A 45-year-old Syrian woman with complaints of constipation, suprapubic pain and a painful mass on the left palatine tonsil persisting for two months was admitted to our clinic. On physical examination, an ulceronecrotic mass of 4 cm diameter was observed on left palatine tonsil (Figure 1). At digital examination, there was a mass on the rectum located at 3 cm from the anal verge. There was no significant finding on family history. Her medical history was unremarkable. She was a non-smoker with had no history of alcohol abuse. A colonoscopy examination was performed and an ulcerated-vegetative and necrotic tumor located
at 3 cm from the anal verge was found. Tumor was almost occluding the lumen of the rectum and was 4 cm in length. Biopsy revealed poorly differentiated adenocarcinoma of the rectum. Diagnosis of rectum adenocarcinoma was established and examination of thorax computed tomography (CT) and abdomen magnetic resonance imaging (MRI) was requested for staging. Serum CA 19-9 level was normal as 25.37 U/ml (N < 37), and serum carcinoembryonic antigen (CEA) level was elevated as 69.67 ng/ml (N < 2.5). Thorax CT was normal. Abdomen MRI showed a 1.4 cm metastatic mass in the segment 2 of the liver, thickening of rectal wall and parailiac multiple lymph nodes in 1.5 cm diameter. A biopsy of tonsillar mass was made and showed metastasis of poorly differentiated 1
Division of Medical Oncology, Department of Internal Medicine, Mustafa Kemal University, Faculty of Medicine, Hatay, Turkey 2 Department of Medical Oncology, Hatay Antakya State Hospital, Hatay, Turkey 3 Department of Pathology, Hatay Antakya State Hospital, Hatay, Turkey 4 Department of Gastroenterology, Hatay Antakya State Hospital, Hatay, Turkey Corresponding author: Onder Tonyali, Division of Medical Oncology, Department of Internal Medicine, Mustafa Kemal University Faculty of Medicine, Antakya, Hatay 31000, Turkey. Email: [email protected]
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Journal of Oncology Pharmacy Practice 0(0) 30% reduction on the tonsillar tumor size was observed. Radiotherapy for pain palliation on the primary tumor site was applied and a colostomy was performed. After four cycles of XELOX the disease progressed and FOLFIRI regimen (irinotecan 180 mg/m2 IV over 90 min, leucovorin 400 mg/m2 IV over 2 h, 5 fluorouracil 400 mg/m2 IV bolus infusion and 5 fluorouracil 2400 mg/m2 IV 46-h infusion every two weeks) was started. After two cycles of FOLFIRI, multiple papulonodular lesions were observed on the perineal region. Biopsies of these lesions confirmed the metastasis of rectal adenocarcinoma. Decision of disease progression was made and chemotherapy was stopped. Performance status of the patient deteriorated rapidly. Eight months after diagnosis, the patient died due to disease progression.
Figure 1. Image of the ulcerated-vegetative mass on left palatine tonsil.
Figure 2. Microscopic appearance of the mass on left palatine tonsil showing solid, non-gland form, and atypical epithelial cells with necro-inflammatory exudate (Hematoxylin and Eosin, 40).
adenocarcinoma of colorectal origin (Figure 2). Immunohistochemical characteristics of the metastatic tumor were positive for cytokeratin 20 (CK 20) and intestinal specific transcription factor (CDX2) and negative for cytokeratin 7 (CK7). A positron emission tomography (PET/CT) scanning was planned. Enhanced [18F] fluoro-2-deoxy-D-glucose (18F-FDG) uptake in rectum wall, parailiac lymph nodes, hepatic mass and left palatine tonsil palatine was observed. Chemotherapy regimen of XELOX (oxaliplatine 130 mg/m2 bolus infusion on day 1 and capecitabine 1500 mg/m2/daily on days 1–14 every three weeks) was started. After the first cycle of XELOX, nearly
Discussion Metastasis of colorectal cancer to palatine tonsil is extremely rare.6 This is the 12th reported case of colorectal cancer with tonsillar metastasis in English Literature. The presented case was clearly defined with physical finding, proper imaging methods and pathological features. In our case, immunohistochemical staining of tonsillar metastasis was positive for pan-cytokeratin, CK 20 and CDX2 but negative for common leucocyte antigen (CLA) and CK 7. Generally, colorectal cancers are positive for CK20 and CDX2 and negative for CK7.7 Atypical metastases are interesting because the physiopathology of these rare coincidences cannot be explained clearly in the majority of cases. Some hypotheses were suggested to explain the metastatic spread of cancers to tonsils. Retrograde cervical lymphatic spread through the thoracic duct and hematogenous transmission through the systemic arterial vasculature or the paravertebral (Batson) plexus are the most prominent.6 Also, traumatic procedure seeding the tumor to tonsils has been reported.8 The clinocopathologic characteristics of reported patients with tonsillar metastasis from colorectal cancer are shown in Table 1. Tonsillar metastasis of colorectal cancer occurred in both genders and all ages. It arises from the rectum more commonly when compared with other parts of colon.6,13 Signet ring cell histology was reported in 4 of 11 cases up to now, although signet cell histology is identified in only a percent of all colorectal cancers.9,11,14,15,19 Involvement of both tonsils can be observed but left side involvement was reported as double the frequency.6 Tonsillar metastasis can be established seven years after the diagnosis of colorectal carcinoma.9 Reported follow-up time of patients with tonsillar metastasis from colorectal cancer vary from 3 and 15 months.11,17 Two patients have six
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Tonyali et al.
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Table 1. Clinocopathologic characteristics of patients with tonsillar metastasis from colorectal cancer. Diagnosis time
Side
Treatment
Follow-up/ OS (month)
Well differentiated
7 years later
Right
Radiotherapy
na
Poorly differentiated
Same time
Left
Radiotherapy
6 (OS)
Rectum
Signet ring
2 years later
Right
Surgery
15
Moderately differentiated Poorly differentiated
Same time
Left
Surgery
12 (OS)
Israelis
Ascending colon Rectum
2 years later
Riht
Local radiotherapy
6
Turkish
Cecum
Signet ring adenocarcinoma
Same time
Left
Radiotherapy and chemotherapy
na
Man
French
Rectum
Signet ring adenocarcinoma
Same time
Left
Chemotherapy and radiotherapy
6 (OS)
53
Man
Chinese
Ascending colon
Moderately differentiated
18 months later
Left
Radiotherapy and chemotherapy
13
201017
76
Woman
American
Descending colon
Signet ring
2 years later
Left
Chemotherapy
3
201218
43
Man
French
Descending colon
Moderately differentiated
12 months later
Left
Chemotherapy
na
Year
Age
Gender
19689
55
Woman
199410
65
Man
199611
36
Man
199712
81
199913 200514
Nation
Primary site
Histology
South Africa
Rectum
Malayan
Transverse
Chinese
Woman
Canadian
53
Man
44
Man
200515
45
200816
20136
37
Woman
Chinese
Rectum
Poorly differentiated
5 months later
Right
Surgery
9
This
45
Woman
Syrian
Rectum
Poorly differentiated
Same time
Left
Chemotherapy and radiotherapy
8 (OS)
OS: Overall survival; na: not available.
months of overall survival.10,15 Our patient had poor prognosis with eight months of overall survival. If a patient with colorectal cancer complains of a mass on palatine tonsil on physical examination, metastasis of colorectal cancer to tonsil should be kept in mind. In such conditions, a through physical examination, good imaging methods and pathologic examination are necessary for a precise diagnosis. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest None declared.
References 1. Hyams VJ. Differential diagnosis of neoplasia of the palatine tonsil. Clin Otolaryngol Allied Sci 1978; 3: 117–126. 2. Hong W, Wang X, Yu XM, et al. Palatine tonsillar metastasis of lung cancer during chemotherapy. Int J Clin Exp Pathol 2012; 5: 468–471. 3. Maruzzo M, Giorgi CA, Marioni G, et al. Late onset (22 years) of simultaneous tonsillar and cervical lymph node metastases from breast ductal carcinoma. Am J Otolaryngol 2012; 33: 627–630. 4. Massaccesi M, Morganti AG, Serafini G, et al. Late tonsil metastases from renal cell cancer: a case report. Tumori 2009; 95: 521–524.
5. Wakasugi S, Kageshita T and Ono T. Metastatic melanoma to the palatine tonsil with a favourable prognosis. Br J Dermatol 2001; 145: 327–329. 6. Wang H and Chen P. Palatine tonsillar metastasis of rectal adenocarcinoma: a case report and literature review. World J Surg Oncol 2013; 11: 114. 7. Greco FA and Hainsworth JD. Cancer of unknown primary site. In: DeVita VT, Lawrence TS and Rosenberg SA (eds) Cancer principles and practice of oncolology, 9th ed. Philadelphia: Lippincott Williams and Wilkins, 2011, pp.2033–2051. 8. Struijs B, de Bree R, vac Groeningen CJ, et al. Tonsillar metastasis of oesophageal adenocarcinoma. Eur Arch Otorhinolaryngol 2008; 265: 127–129. 9. Sellars SL. Metastatic tumours of the tonsil. J Laryngol Otol 1971; 85: 289–292. 10. Low WK, Sng I and Balakrishnan A. Palatine tonsillar metastasis from carcinoma of the colon. J Laryngol Otol 1999; 108: 449–451. 11. Wang WS, Chiou TJ, Pan CC, et al. Signet-ring cell carcinoma of the rectum with tonsillar metastasis: a case report. Zhonghua Yi Xue Za Zhi (Taipei) 1996; 58: 209–212. 12. Vasilevsky CA, Abou-Khalil S, Rochon L, et al. Carcinoma of the colon presenting as tonsillar metastasis. J Otolaryngol 1997; 26: 325–326. 13. Goldenberg D, Golz A, Arie YB, et al. Adenocarcinoma of the rectum with metastasis to the palatine tonsil. Otolaryngol Head Neck Surg 1999; 121: 653–654. 14. Gu¨venc¸ MG, Ada M, Aciog˘lu E, et al. Tonsillar metastasis of primary signet-ring cell carcinoma of the cecum. Auris Nasus Larynx 2006; 33: 85–88.
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15. Vaule´on E, De Lajarte-Thirouard AS, Boucher E, et al. Tonsillar metastasis revealing signet-ring cell carcinoma of the rectum. Gastroenterol Clin Biol 2005; 29: 70–72. 16. Sheng LM, Zhang LZ, Xu HM, et al. Ascending colon adenocarcinoma with tonsillar metastasis: a case report and review of the literature. World J Gastroenterol 2008; 14: 7138–7140. 17. Park KK and Park YW. Tonsillar metastasis of signetring cell adenocarcinoma of the colon. Ear Nose Throat J 2010; 89: 376–377.
18. Lemay F, Cervera P and de Gramont A. A man with colon cancer and tonsil swelling. Tonsillar metastasis from colon cancer. Gastroenterology 2012; 142: 1423. 19. Bittorf B, Merkel S, Matzel KE, et al. Primary signet-ring cell carcinoma of the colorectum. Langenbecks Arch Surg 2004; 389: 178–183.
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(OPP)
[1–5] [INVALID Stage]
Journal of
Oncology Pharmacy Practice
Case Report
A case of rectal adenocarcinoma presented with palatine tonsil metastasis
J Oncol Pharm Practice 0(0) 1–4 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1078155214565124 opp.sagepub.com
Onder Tonyali1, Ahmet Taner Sumbul1, Mehmet Akif Ozturk2, Ali Koyuncuer3 and Fuat Ekiz4
Abstract The most common metastatic sites of colorectal cancer are liver, lung, peritoneum and lymph nodes. Metastasis of colorectal carcinoma to palatine tonsil is rarely seen. To our knowledge, only 11 patients were documented in English literature. Atypical metastases can sometimes lead to misdiagnosis. Precise diagnosis of atypical metastases requires a careful physical examination, good imaging method and comprehensive pathological evaluation. Here, we report a case of rectal adenocarcinoma presented with palatine tonsil metastasis.
Keywords Colorectal cancer, palatine tonsil, metastasis, adenocarcinoma
Introduction Metastatic malignancies of the palatine tonsil are rarely seen and the most common malignancies of palatine tonsil are lymphomas and squamous cell carcinomas.1 Metastatic tumors of tonsillar palatine account for only 0.8% of all tonsillar malignancies.1 The most common primary malignancies spread to palatine tonsil are lung, breast, renal cancers, and malign melanoma.2–5 In the English literature, metastases of colorectal cancer to palatine tonsil were reported only in 11 cases.6 Herein, we report a case of rectal adenocarcinoma who presented with palatine tonsil metastasis.
Case report A 45-year-old Syrian woman with complaints of constipation, suprapubic pain and a painful mass on the left palatine tonsil persisting for two months was admitted to our clinic. On physical examination, an ulceronecrotic mass of 4 cm diameter was observed on left palatine tonsil (Figure 1). At digital examination, there was a mass on the rectum located at 3 cm from the anal verge. There was no significant finding on family history. Her medical history was unremarkable. She was a non-smoker with had no history of alcohol abuse. A colonoscopy examination was performed and an ulcerated-vegetative and necrotic tumor located
at 3 cm from the anal verge was found. Tumor was almost occluding the lumen of the rectum and was 4 cm in length. Biopsy revealed poorly differentiated adenocarcinoma of the rectum. Diagnosis of rectum adenocarcinoma was established and examination of thorax computed tomography (CT) and abdomen magnetic resonance imaging (MRI) was requested for staging. Serum CA 19-9 level was normal as 25.37 U/ml (N < 37), and serum carcinoembryonic antigen (CEA) level was elevated as 69.67 ng/ml (N < 2.5). Thorax CT was normal. Abdomen MRI showed a 1.4 cm metastatic mass in the segment 2 of the liver, thickening of rectal wall and parailiac multiple lymph nodes in 1.5 cm diameter. A biopsy of tonsillar mass was made and showed metastasis of poorly differentiated 1
Division of Medical Oncology, Department of Internal Medicine, Mustafa Kemal University, Faculty of Medicine, Hatay, Turkey 2 Department of Medical Oncology, Hatay Antakya State Hospital, Hatay, Turkey 3 Department of Pathology, Hatay Antakya State Hospital, Hatay, Turkey 4 Department of Gastroenterology, Hatay Antakya State Hospital, Hatay, Turkey Corresponding author: Onder Tonyali, Division of Medical Oncology, Department of Internal Medicine, Mustafa Kemal University Faculty of Medicine, Antakya, Hatay 31000, Turkey. Email: [email protected]
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Journal of Oncology Pharmacy Practice 0(0) 30% reduction on the tonsillar tumor size was observed. Radiotherapy for pain palliation on the primary tumor site was applied and a colostomy was performed. After four cycles of XELOX the disease progressed and FOLFIRI regimen (irinotecan 180 mg/m2 IV over 90 min, leucovorin 400 mg/m2 IV over 2 h, 5 fluorouracil 400 mg/m2 IV bolus infusion and 5 fluorouracil 2400 mg/m2 IV 46-h infusion every two weeks) was started. After two cycles of FOLFIRI, multiple papulonodular lesions were observed on the perineal region. Biopsies of these lesions confirmed the metastasis of rectal adenocarcinoma. Decision of disease progression was made and chemotherapy was stopped. Performance status of the patient deteriorated rapidly. Eight months after diagnosis, the patient died due to disease progression.
Figure 1. Image of the ulcerated-vegetative mass on left palatine tonsil.
Figure 2. Microscopic appearance of the mass on left palatine tonsil showing solid, non-gland form, and atypical epithelial cells with necro-inflammatory exudate (Hematoxylin and Eosin, 40).
adenocarcinoma of colorectal origin (Figure 2). Immunohistochemical characteristics of the metastatic tumor were positive for cytokeratin 20 (CK 20) and intestinal specific transcription factor (CDX2) and negative for cytokeratin 7 (CK7). A positron emission tomography (PET/CT) scanning was planned. Enhanced [18F] fluoro-2-deoxy-D-glucose (18F-FDG) uptake in rectum wall, parailiac lymph nodes, hepatic mass and left palatine tonsil palatine was observed. Chemotherapy regimen of XELOX (oxaliplatine 130 mg/m2 bolus infusion on day 1 and capecitabine 1500 mg/m2/daily on days 1–14 every three weeks) was started. After the first cycle of XELOX, nearly
Discussion Metastasis of colorectal cancer to palatine tonsil is extremely rare.6 This is the 12th reported case of colorectal cancer with tonsillar metastasis in English Literature. The presented case was clearly defined with physical finding, proper imaging methods and pathological features. In our case, immunohistochemical staining of tonsillar metastasis was positive for pan-cytokeratin, CK 20 and CDX2 but negative for common leucocyte antigen (CLA) and CK 7. Generally, colorectal cancers are positive for CK20 and CDX2 and negative for CK7.7 Atypical metastases are interesting because the physiopathology of these rare coincidences cannot be explained clearly in the majority of cases. Some hypotheses were suggested to explain the metastatic spread of cancers to tonsils. Retrograde cervical lymphatic spread through the thoracic duct and hematogenous transmission through the systemic arterial vasculature or the paravertebral (Batson) plexus are the most prominent.6 Also, traumatic procedure seeding the tumor to tonsils has been reported.8 The clinocopathologic characteristics of reported patients with tonsillar metastasis from colorectal cancer are shown in Table 1. Tonsillar metastasis of colorectal cancer occurred in both genders and all ages. It arises from the rectum more commonly when compared with other parts of colon.6,13 Signet ring cell histology was reported in 4 of 11 cases up to now, although signet cell histology is identified in only a percent of all colorectal cancers.9,11,14,15,19 Involvement of both tonsils can be observed but left side involvement was reported as double the frequency.6 Tonsillar metastasis can be established seven years after the diagnosis of colorectal carcinoma.9 Reported follow-up time of patients with tonsillar metastasis from colorectal cancer vary from 3 and 15 months.11,17 Two patients have six
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Table 1. Clinocopathologic characteristics of patients with tonsillar metastasis from colorectal cancer. Diagnosis time
Side
Treatment
Follow-up/ OS (month)
Well differentiated
7 years later
Right
Radiotherapy
na
Poorly differentiated
Same time
Left
Radiotherapy
6 (OS)
Rectum
Signet ring
2 years later
Right
Surgery
15
Moderately differentiated Poorly differentiated
Same time
Left
Surgery
12 (OS)
Israelis
Ascending colon Rectum
2 years later
Riht
Local radiotherapy
6
Turkish
Cecum
Signet ring adenocarcinoma
Same time
Left
Radiotherapy and chemotherapy
na
Man
French
Rectum
Signet ring adenocarcinoma
Same time
Left
Chemotherapy and radiotherapy
6 (OS)
53
Man
Chinese
Ascending colon
Moderately differentiated
18 months later
Left
Radiotherapy and chemotherapy
13
201017
76
Woman
American
Descending colon
Signet ring
2 years later
Left
Chemotherapy
3
201218
43
Man
French
Descending colon
Moderately differentiated
12 months later
Left
Chemotherapy
na
Year
Age
Gender
19689
55
Woman
199410
65
Man
199611
36
Man
199712
81
199913 200514
Nation
Primary site
Histology
South Africa
Rectum
Malayan
Transverse
Chinese
Woman
Canadian
53
Man
44
Man
200515
45
200816
20136
37
Woman
Chinese
Rectum
Poorly differentiated
5 months later
Right
Surgery
9
This
45
Woman
Syrian
Rectum
Poorly differentiated
Same time
Left
Chemotherapy and radiotherapy
8 (OS)
OS: Overall survival; na: not available.
months of overall survival.10,15 Our patient had poor prognosis with eight months of overall survival. If a patient with colorectal cancer complains of a mass on palatine tonsil on physical examination, metastasis of colorectal cancer to tonsil should be kept in mind. In such conditions, a through physical examination, good imaging methods and pathologic examination are necessary for a precise diagnosis. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest None declared.
References 1. Hyams VJ. Differential diagnosis of neoplasia of the palatine tonsil. Clin Otolaryngol Allied Sci 1978; 3: 117–126. 2. Hong W, Wang X, Yu XM, et al. Palatine tonsillar metastasis of lung cancer during chemotherapy. Int J Clin Exp Pathol 2012; 5: 468–471. 3. Maruzzo M, Giorgi CA, Marioni G, et al. Late onset (22 years) of simultaneous tonsillar and cervical lymph node metastases from breast ductal carcinoma. Am J Otolaryngol 2012; 33: 627–630. 4. Massaccesi M, Morganti AG, Serafini G, et al. Late tonsil metastases from renal cell cancer: a case report. Tumori 2009; 95: 521–524.
5. Wakasugi S, Kageshita T and Ono T. Metastatic melanoma to the palatine tonsil with a favourable prognosis. Br J Dermatol 2001; 145: 327–329. 6. Wang H and Chen P. Palatine tonsillar metastasis of rectal adenocarcinoma: a case report and literature review. World J Surg Oncol 2013; 11: 114. 7. Greco FA and Hainsworth JD. Cancer of unknown primary site. In: DeVita VT, Lawrence TS and Rosenberg SA (eds) Cancer principles and practice of oncolology, 9th ed. Philadelphia: Lippincott Williams and Wilkins, 2011, pp.2033–2051. 8. Struijs B, de Bree R, vac Groeningen CJ, et al. Tonsillar metastasis of oesophageal adenocarcinoma. Eur Arch Otorhinolaryngol 2008; 265: 127–129. 9. Sellars SL. Metastatic tumours of the tonsil. J Laryngol Otol 1971; 85: 289–292. 10. Low WK, Sng I and Balakrishnan A. Palatine tonsillar metastasis from carcinoma of the colon. J Laryngol Otol 1999; 108: 449–451. 11. Wang WS, Chiou TJ, Pan CC, et al. Signet-ring cell carcinoma of the rectum with tonsillar metastasis: a case report. Zhonghua Yi Xue Za Zhi (Taipei) 1996; 58: 209–212. 12. Vasilevsky CA, Abou-Khalil S, Rochon L, et al. Carcinoma of the colon presenting as tonsillar metastasis. J Otolaryngol 1997; 26: 325–326. 13. Goldenberg D, Golz A, Arie YB, et al. Adenocarcinoma of the rectum with metastasis to the palatine tonsil. Otolaryngol Head Neck Surg 1999; 121: 653–654. 14. Gu¨venc¸ MG, Ada M, Aciog˘lu E, et al. Tonsillar metastasis of primary signet-ring cell carcinoma of the cecum. Auris Nasus Larynx 2006; 33: 85–88.
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15. Vaule´on E, De Lajarte-Thirouard AS, Boucher E, et al. Tonsillar metastasis revealing signet-ring cell carcinoma of the rectum. Gastroenterol Clin Biol 2005; 29: 70–72. 16. Sheng LM, Zhang LZ, Xu HM, et al. Ascending colon adenocarcinoma with tonsillar metastasis: a case report and review of the literature. World J Gastroenterol 2008; 14: 7138–7140. 17. Park KK and Park YW. Tonsillar metastasis of signetring cell adenocarcinoma of the colon. Ear Nose Throat J 2010; 89: 376–377.
18. Lemay F, Cervera P and de Gramont A. A man with colon cancer and tonsil swelling. Tonsillar metastasis from colon cancer. Gastroenterology 2012; 142: 1423. 19. Bittorf B, Merkel S, Matzel KE, et al. Primary signet-ring cell carcinoma of the colorectum. Langenbecks Arch Surg 2004; 389: 178–183.
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