Tonsillar Metastasis as an Initial Manifestation of Non-Small Cell Lung Carcinoma

A 54-year-old male with hyperlipidemia presented with a 2-week history of throat discomfort and blood-tinged saliva. Biopsy of the ulcerative mass in the right palatine tonsil suggested pleomorphic sarcoma or poorly differentiated carcinoma. Imaging revealed a 1.8-cm tonsillar mass and systemic lesions in the left lung, left hilum, and small intestine. Endobronchial ultrasound- guided biopsy confirmed non-small cell lung carcinoma (NSCLC), and repeat tonsillar biopsy demonstrated poorly differentiated metastatic carcinoma consistent with the lung primary. The patient subsequently developed intussusception due to small bowel metastasis, which was resected and confirmed as showing identical histology. Given the disseminated disease, pembrolizumab immunotherapy and tonsillar radiotherapy were initiated. This case illustrates tonsillar metastasis as the initial manifestation of NSCLC and highlights the importance of considering distant metastasis in atypical tonsillar masses.