Inverted papilloma of the nasal cavity and paranasal sinuses: a Korean multicenter study

[Interdisciplinary Management of Orbital Diseases]

Diagnosis and therapy of orbital diseases is an interdisciplinary challenge, in which i.e. otorhinolaryngologists, ophthalmologists, radiologists, radiation therapists, maxillo-facial surgeons, endocrinologists, and pediatricians are involved. This review article describes frequent diseases which both, otolaryngologists and ophthalmologists are concerned with in interdisciplinary settings. In particular the inflammatory diseases of the orbit including orbital complications, autoimmunological diseases of the orbit including Grave´s orbitopathy, and primary and secondary tumors of the orbit are discussed. Beside describing the clinical characteristics and diagnostic steps the article focusses on the interdisciplinary therapy. The review is completed by the presentation of most important surgical approaches to the orbit, their indications and possible complications. The authors tried to highlight the relevant facts despite the shortness of the text.

Prelacrimal recess approach for maxillary sinus inverted papilloma: a 15-year experience from a single center

PURPOSE

This large retrospective, single-center, follow-up study investigated the endoscopic prelacrimal recess approach (PLRA) for treating maxillary sinus inverted papilloma (MSIP).

METHODS

Between January 2007 and November 2022, patients with MSIP treated with PLRA were enrolled. Data on clinical manifestations, imaging, and surgical procedures were collected. The visual analog scale (VAS) scores for maxillofacial numbness and nasal symptoms and the SNOT-22 nasal symptom scores were statistically analyzed.

RESULT

Of 122 patients (68 males and 54 females) enrolled in the study, with a mean age of 50.75 ± 12.84 years (26-80 years), 111 patients underwent PLRA, nine underwent modified PLRA, one converted to an endoscopic medial maxillectomy (EMM), and one to an endoscopic modified Denker's approach. The average follow-up was 86.60 (13-192) months, the recurrence rate was 3.28%, and 29 patients (23.77%) complained of maxillofacial numbness one month postoperatively, which disappeared in most cases one year after surgery. Five patients (4.10%) experienced mild numbness at the end of the follow-up period. Maxillary sinus ostium contracture or atresia occurred in two cases (1.64%). After surgery, the VAS nasal symptom scores improved significantly (P < 0.001). SNOT-22 indicated that the most common postoperative symptom was thick nasal discharge.

CONCLUSION

PLRA is a flexible first-choice surgical treatment for maxillary sinus inverted papilloma and can be modified according to the extent of the lesion, the surgeon's experience and technique, and surgical instruments. That can help achieve complete resection and reduce recurrence and surgical complications. Upper teeth numbness, the most common postoperative complication, tends to disappear after 1 year.

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.

METHODS

In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.

RESULTS

The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.

CONCLUSION

As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

Treatment outcome and prognostic factors of inverted papilloma involving the frontal sinus

Objectives

This study aimed to evaluate the characteristics and treatment outcomes of inverted papillomas involving the frontal sinus.

Methods

Patients treated for inverted papilloma involving the frontal sinus between 2003 and 2020 were reviewed. Tumors were classified based on their extent (Extent 1: partially encroaching on the frontal sinus; Extent 2: completely filling the frontal sinus; Extent 3: eroding bony borders beyond the frontal sinus) and site of origin (Origin 1: originating outside the frontal sinus and prolapsing into the frontal sinus; Origin 2: originating from the frontal sinus walls medial to the vertical plane of the lamina papyracea; Origin 3: originating from the frontal sinus walls lateral to the vertical plane of the lamina papyracea). Treatment outcomes including tumor recurrence and patency of the frontal recess were analyzed according to tumor characteristics and surgical treatment modalities.

Results

A total of 49 surgical cases were analyzed. Extent 1 were the most common type (n = 27), followed by Extent 2 (n = 15), and Extent 3 (n = 7). The most common sites of origin were Origin 1 (n = 23), followed by Origin 2 (n = 15), and Origin 3 (n = 11). Overall, there were nine recurrences (18.4%). Recurrence was not associated with tumor extent, whereas tumor origin, particularly Origin 3 was associated with higher recurrence; 1/23 (4.3%) for Origin 1, 3/15 (20.0%) for Origin 2, and 5/11 (45.5%) for Origin 3 (Log-rank p < .001). Draf III frontal sinusotomy was associated with in the highest patency rate (84.6%) during the follow-up.

Conclusion

The recurrence rate of frontal sinus inverted papilloma depends on tumor origin rather than the extent of the tumor. In particular, lesions originating from the frontal sinus lateral to the lamina papyracea recur frequently. Draf III frontal sinusotomy can achieve patent frontal recess allowing active surveillance.

Level of Evidence

IV.

Nasal Malignant Melanoma With an Inverted Papilloma in the Contralateral Nasal Cavity: A Case Report

Background: We describe a patient with sinonasal mucosal melanoma (SNMM) and an inverted papilloma, which existed independently in both nasal cavities. Case presentation: We describe an unusual case of a 74-year-old male patient with SNMM and an inverted papilloma. He presented with symptoms of coughing up blood and pain in the left forehead. The patient underwent surgical resection of the lesion, and the SNMM and inverted papilloma were confirmed by histopathology. The patient refused further treatment after surgery, but was re-admitted 7 months later with local recurrence of the left tumor and systemic metastases. Conclusions: Nasal malignant melanoma with an inverted papilloma in the contralateral nasal cavity is rare and can easily be misdiagnosed as the same tumor by imaging. Simultaneous histopathology of bilateral nasal masses is very necessary. The recommended treatment is surgery for the inverted papilloma. An SNMM is a devastating tumor with poor outcomes.

Evaluation of inverted papilloma recurrence rates and factors associated recurrence after endoscopic surgical resection: a retrospective review

BACKGROUND

Sinonasal inverted papillomas (IP) are benign tumours arising from the mucosal lining of the nasal cavity and paranasal sinuses with a high propensity for recurrence and malignant transformation. Advances in endoscopic surgery and improved radiologic navigation have increased the role of endoscopic surgical resection in the treatment of IPs. The current study aims to evaluate the rate of IP recurrence after endoscopic endonasal resection and to evaluate factors which impact recurrence.

METHODS

This was a single-centre retrospective chart review of all patients who underwent endoscopic sinus surgery for management of IP between January 2009 and February 2022. Primary outcomes were the rate of IP recurrence and time to IP recurrence. Secondary outcome measures were patient and tumour factors that contributed to IP recurrence.

RESULTS

Eighty-five patients were included. The mean age was 55.7 and 36.5% of patients were female. The mean follow-up time was 39.5 months. Of the 85 cases, 13 cases (15.3%) had recurrence of their IP and the median time to recurrence was 22.0 months. All recurrent tumours recurred at the attachment site of the primary tumour. The univariate analysis did not identify any significant demographic, clinical, or surgical predictors of IP recurrence. There were no significant changes in sinonasal symptoms at the time IP recurrence was detected.

CONCLUSION

Endoscopic endonasal resection of IPs represents an effective surgical approach, however, the relatively high rate of recurrence and lack of symptomatic changes at the time of recurrence necessitates long term follow up. Better delineation of risk factors for recurrence can help identify high-risk patients and inform postoperative follow up strategies.

Differentiation between atypical sinonasal non-Hodgkin's lymphoma and inverted papilloma

AIM

To seek additional magnetic resonance imaging (MRI) features to improve the accuracy of differentiation between atypical sinonasal non-Hodgkin's lymphoma (NHL) and inverted papilloma (IP) using conventional MRI and apparent diffusion coefficient (ADC) maps.

MATERIALS AND METHODS

MRI examinations from 44 atypical cases (21 NHLs and 23 IPs) in sinonasal regions were reviewed retrospectively. Imaging features included tumour laterality, extension, T1-weighted imaging (WI)/T2WI signal intensity homogeneity and ratios, enhancement homogeneity and ratios, and ADC_mean.

RESULTS

In cases of NHL, homogeneous signal intensity was often observed on T2WI, which was homogeneous and significantly less enhanced than the turbinate, with lower ADC_mean. Whereas in IPs, heterogeneous signal intensity was seen on T2WI, which was heterogeneous and of comparable enhancement to the turbinate, and higher ADC_mean values were commonly seen. An ADC_mean cut-off point of 1.10 × 10^-3 mm²/s achieved 100% sensitivity, 90% specificity, and 90% accuracy. In addition, special features were observed that support the distinction between the two tumours, including intestinal pattern enhancement in NHL and spot-like appearance on T2WI and enhancement in IP.

CONCLUSIONS

ADC_mean was the most valuable metric for differentiating between the atypical sinonasal NHLs and IPs.

Diagnostic strategy and therapeutic management of sinonasal inverted papilloma: our experience with review of literature

Background

The sinonasal inverted papilloma is a rare benign tumor, characterized by local aggressiveness, a high rate of recurrence after surgical resection, and the possibility of malignant transformation. The aims of this study are to analyze diagnostic strategy and therapeutic modalities and to evaluate results after surgery.

Methods

We report a retrospective study, including patients operated for inverted sinonasal papilloma in our department. Preoperatively, all patients were assessed by CT scan (computed tomography), 9 of them by MRI (magnetic resonance imaging).

Results

The average age of our patients was 52 years with a male predominance. The most common symptom was unilateral nasal obstruction. The endoscopic appearance was suggestive of inverted papilloma (IP) in 75% of cases. Thirty-two patients underwent an exclusive endonasal endoscopic surgery; one patient was operated with a combined approach. Two patients underwent external approaches. A recurrence was observed in 4 patients (11%).

Conclusion

Preoperative investigation for IP is essentially based on MRI, also required in case of recurrence. Histological examination of the entire tumor is crucial to rule out an associated carcinoma. The “all endoscopic” management is not always achievable for these tumors.

Sinonasal Papillomas: 10-Year Retrospective Analysis of Etiology, Epidemiology, and Recurrence

OBJECTIVES

To examine the epidemiology, subtypes, trends over time, and predictive factors for recurrence and malignant transformation of sinonasal papillomas.

METHODS

A retrospective chart review of 118 patients with sinonasal papillomas from 2009 to 2019 was conducted at the University of California, Los Angeles. This study is a follow-up to a previously published study from 2000 to 2009 at the same academic center.

RESULTS

The mean age was at presentation was 58.5 years, with a 2:1 male to female ratio, and average follow-up of 30.1 months. The rate of recurrence after complete resection was 19% with an average of 32.6 months to recurrence. The time to recurrence followed a bimodal distribution with 57% of cases recurring within 24 months (mean = 10) and 43% from 40 to 103 months (mean = 61). The proportion of the inverted papillomas rose from 38% in 2000-2004 to 89.6% in 2015-2019. Patients presenting at a younger age had a higher chance of recurrence (mean age 52 with recurrence vs. 61 without recurrence). Age did not correlate with histopathologic transformation in surgical pathology. Furthermore, histopathological transformation did not raise the chance of recurrence. Smoking, alcohol use, chronic rhinosinusitis, and allergic rhinitis were not associated with any of the outcome measures in this study. The most significant factor predicting recurrence, beside age at presentation, was the history of two or more prior sinus surgeries for papillomas or other reasons (OR = 3.52 and 5.81).

CONCLUSION

This study explored the features of sinonasal papillomas as well as the risk factors for recurrence and transformation. Younger age at presentation and two or more prior surgeries for papillomas were associated with recurrence. Time to recurrence followed a bimodal distribution, with late recurrences happenning from 40 to 103 months after surgery, emphasizing the importance of long-term follow-up for timely resection of tumors and prevention of malignancy.

Keeping in Mind Its Synchronous Features, Is Sinonasal Inverted Papilloma Always Benign?

Sinonasal inverted papilloma (SNIP) is a rare benign tumor of paranasal sinuses. SNIP is known to be locally aggressive, with high rates of recurrence and a high potential for malignant transformation. We present a patient who presented with right-sided cheek pain and swelling for two weeks. The initial biopsy revealed SNIP. However, postoperative histopathology examination results revealed synchronous squamous cell carcinoma (SCC) with sinonasal inverted papilloma. Although the initial biopsy result showed a benign lesion, the aggressive features such as bony destruction and orbital involvement in computed tomography scan should raise a suspicion of a malignant lesion. Imaging features of SNIP from synchronous SCC are discussed.

Synchronous sinonasal and respiratory papilloma: could long-term positive pressure ventilation be the cause? A rare case report

This case report describes a rare presentation of synchronous pathologies—sinonasal inverted papilloma (SIP) and recurrent respiratory papillomatosis (RRP)—in a 47-year-old man using continuous positive airway pressure (CPAP) ventilation for progressive obstructive sleep apnoea. As far as we know, this is the first case of concurrent SIP and RRP disease described in the literature. The patient initially presented for management of chronic rhinosinusitis symptoms. He was found to have an extensive nasal lesion on flexible nasendoscopy, for which surgical management was recommended. However, during anaesthetic induction, he obstructed unexpectedly and was found to have an occlusive supraglottic lesion that required expedient ENT airway management. Diagnosis was made clinically and was supported with histopathology of excised tissue. Management involved multiple staged procedures for excision of sinonasal and glottic lesions and regular follow-up and imaging.

Inverted Papilloma of the Maxillary Sinus: A Recurrence Analysis According to Surgical Approaches

(1) Background: Various surgical approaches have been introduced to resect inverted papillomas (IP) stemming from the maxillary sinus (MS). This study aimed to compare the recurrence rates of IPs originating from the MS according to various surgical modalities. (2) Methods: A total of 155 surgical cases of sinonasal IPs originating from the MS were categorized into three groups according to the surgical approach adopted: endoscopic resection via middle or inferior meatus antrostomy (ESS), ESS with Caldwell−Luc approach or canine fossa trephination (ESS with CL), and expanded endoscopic approaches (ExEA) including endoscopic medial maxillectomy or a prelacrimal recess approach. A Kaplan−Meier curve was generated to examine the recurrence rates. (3) Results: The overall recurrence rate was 5.8% (9/155) with a mean follow-up period of 24.2 months. The recurrence rates for the ESS, ESS with CL, and ExEA groups were 10.0% (7/70), 3.5% (2/57), and 0% (0/28), respectively. The ExEA group had a significantly lower recurrence rate than the ESS group (p = 0.024) and there was a tendency for lower recurrence compared to the ESS within the CL group (p = 0.145). The ExEA required a shorter postoperative hospitalization period than in ESS with CL (p < 0.001). (4) Conclusions: ExEAs to the maxillary sinus such as the PLR and EMM approaches are excellent surgical options for IPs originating from the MS.

Sinonasal Inverted Papilloma and Squamous Cell Carcinoma: Contemporary Management and Patient Outcomes

Simple Summary

Inverted papillomas are benign sinonasal tumors that can recur or become cancerous. The mainstay of treatment is surgical resection. We summarize the biology of inverted papillomas and review surgical outcomes in an effort to define the current treatment strategy.

Abstract

Inverted papillomas (IP) are the most common sinonasal tumor with a tendency for recurrence, potential attachment to the orbit and skull base, and risk of malignant degeneration into squamous cell carcinoma (SCC). While the overall rate of recurrence has decreased with the widespread adoption of high-definition endoscopic optics and advanced surgical tools, there remain challenges in managing tumors that are multiply recurrent or involve vital neurovascular structures. Here, we review the state-of-the-art diagnostic tools for IP and IP-degenerated SCC, contemporary surgical management, and propose a surveillance protocol.

Sinonasal Inverted Papilloma Associated with Adenoid Cystic Carcinoma

Inverted papilloma is the most common benign tumor of the paranasal sinuses with the possibility of malignant transformation. On the one hand, adenoid cystic carcinoma (ACC) is a rare malignant neoplasm that arises from the secretory glands. Sinonasal ACC accounts for 10%-25% of all head and neck ACC. This neoplasm is defined by its distinctive histologic appearance. Surgical resection, whenever possible, is the mainstay therapy. An association between inverted papilloma and malignancy is controversial. A synchronous carcinoma has been established at diagnosis in 3.3%-11% of cases, and the risk of metachronous carcinoma is <3%. We report a case of an 84-year-old female affected with sinonasal inverted papilloma associated with synchronous ACC. She had right nasal obstruction due to the rapid growth of the tumor. She was referred to our department for further workup. A frozen biopsy revealed part of the tumor as ACC. The tumor was consistent with preoperative imaging, and surgical findings also showed infiltration into the orbit. There was no consent for radical surgery with orbital exenteration and adjuvant chemoradiotherapy in consideration of her advanced age. This is the first case report of the association between sinonasal inverted papilloma and ACC within our retrieval capability.

HPV-Positive Status Is an Independent Factor Associated With Sinonasal Inverted Papilloma Recurrence

OBJECTIVES

The present study aimed to evaluate human papillomavirus (HPV) occurrence in sinonasal inverted papilloma (SNIP), and to assess factors associated with HPV positivity and SNIP recurrence.

STUDY DESIGN

Prospective study.

METHODS

We prospectively collected clinical data and fresh tissue specimens from 90 consecutive patients treated for SNIP at Helsinki University Hospital, between 2015 and 2019. Fourteen patients with recurrent SNIP underwent repeated tumor sampling. All tissue specimens were analyzed for the presence of HPV. Factors associated with SNIP recurrence and HPV positivity were assessed.

RESULTS

Among 107 SNIP specimens, 14 (13.1%) were positive for low-risk HPV and 6 (5.6%) were positive for high-risk HPV. HPV positivity was associated with an increased risk of recurrence (P = .004). Smoking was significantly associated with HPV positivity in SNIP (P = .01), but a history of HPV-related diseases or patient sexual habits did not correlate with HPV positivity. The recurrence rate was lower among patients with SNIP that underwent an attachment-oriented resection, compared to patients treated without attachment-oriented resections (78.6% vs 25.8%, P < .001).

CONCLUSIONS

The risk of SNIP recurrence was highly associated with 1) HPV positivity and 2) surgery without an attachment-oriented resection. Oncogenic HPV was rare in SNIP.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

A Systematic Review of Definitive Treatment for Inverted Papilloma Attachment Site and Associations With Recurrence

OBJECTIVE

Inverted papilloma (IP) is the most common benign neoplasm of the nasal cavity with known risk of recurrence. There is no standardized approach to definitive treatment for attachment sites. This systematic review aims to determine whether surgeon choice of technique differs by anatomic attachment site and whether different surgical techniques contribute to reduced rates of recurrence.

DATA SOURCES

PubMed and Ovid Medline.

REVIEW METHODS

A systematic review was conducted for studies reporting on IP. Those that included IP recurrence rates and primary tumor attachment site were reviewed.

RESULTS

Of 122 published studies, 14 met eligibility criteria, representing 585 patients and a recurrence rate of 5.8%. The maxillary sinus (50.9%) was the most common primary attachment site, and the sphenoid sinus was associated with the highest rate of recurrence (10.4%). The most utilized technique included debulking the tumor, removing mucosa over the attachment site, and drilling the underlying bone. The most common Krouse stage represented was T3 (53.3%). No single technique predicted a propensity for recurrence, but certain techniques are favored depending on IP attachment site. Finally, frozen sections to obtain evidence of clear margins intraoperatively significantly reduced rates of recurrence (3.4% vs 7.3%, P = .045).

CONCLUSION

Based on the current literature, the most common technique to address site of attachment involves resecting mucosa and drilling the tumor base. Choice of technique appears to differ for various sites of attachment. Use of intraoperative frozen section analysis appears to be associated with decreased recurrence overall.

LEVEL OF EVIDENCE

3.

A Short-Term Efficacy of Anlotinib in the Treatment of Refractory Nasopharyngeal Inverted Papilloma: A Case Report

To our knowledge, no studies have reported the use of anlotinib in the treatment of locally cancerous nasopharyngeal inverted papillomas that cannot be operated on or treated with radiotherapy. Here, we report a case of a 53-year-old woman diagnosed with recurrent local canceration of nasopharynx papilloma. Magnetic resonance imaging (MRI) showed that the right parapharyngeal space, nasopharynx, and ethmoid sinus were changed, and recurrence was considered. There was no indication for surgery or radiotherapy. Imaging showed that the tumor had obvious enhancement and abundant blood vessels. Immunohistochemistry showed that vascular endothelial growth factor receptor (VEGFR) 2 expression was positive in papilloma tissue and in local canceration tissue of the papilloma. After the patient’s consent was obtained, anlotinib treatment was started in May and ended in November 2019. Then, the patient was treated with intensity-modulated radiotherapy (IMRT) with planning gross tumor volume (PGTV) 66 Gy, planning clinical tumor volume 1 (PCTV1) 60 Gy, and planning clinical tumor volume 2 (PCTV2) 54 Gy in 33 fractions. No disease recurrence was reported at 4 months after radiotherapy.

Clinical characteristics of sinonasal inverted papilloma associated with recurrence and malignant transformation

OBJECTIVE

Sinonasal inverted papilloma is a benign tumor but has a potential for recurrence and malignant transformation. The aim of this article is to analyze the clinical characteristics of sinonasal inverted papilloma associated with recurrence and malignant transformation.

MATERIAL AND METHODS

A retrospective study was performed in all patients with sinonasal inverted papilloma diagnosed between in our hospital during May 2013 and May 2018.

RESULTS

A total of 151 patients were enrolled in this study. The average age of these patients was 52.24 years, with a male-to-female ratio of 2.775:1, and the most frequent clinical symptom was nasal obstruction. The recurrence rate was 39.07% (59/151), the mean time of recurrence was 35.8 months and most recurrences occur within the first three years after surgery. There was no significant difference in recurrence rate between all four stages and between after endoscopic surgery and a combined endoscopic and external approach. The malignant transformation rate was 5.96% (9/151) and the mean time of malignant transformation was 9.06 months.

CONCLUSIONS

Because of its high recurrence rate and the potential of malignant transformation, so it is important to determine the primary site of the tumor and to make a complete removal and a follow-up of at least five years after surgery is recommended.

MRI features of different types of sinonasan rhabdomyosarcomas: a series of eleven cases

OBJECTIVE

To retrospectively analyze magnetic resonance imaging (MRI) features of various pathological subtypes of sinonasal rhabdomyosarcoma (RMS) and explore correlations between imaging features and pathological subtypes.

METHODS

In total, 11 cases with embryonal, alveolar or pleomorphic sinonasal RMSs, confirmed by surgical pathology, were selected. Their characteristics and distinctive imaging features were analysed, and the correlation between pathology and imaging features was explored.

RESULTS

Bone destruction was observed in all 11 cases with RMS. Expansive growth was predominant in three alveolar and three embryonal RMS cases, and creeping growth was predominant in two alveolar, two embryonal and one pleomorphic RMS cases. Signs of residual mucosa were observed in all 11 cases, and 10 cases showed involvement of multiple sinus cavities and orbital cavities. All cases exhibited mild-to-intermediate enhancement.

CONCLUSION

Sinonasal RMSs have the following characteristic MRI features: ethmoid sinuses and middle nasal conchae are the prevalent sites; lesions are mainly of mild enhancement; tumours exhibit signs of residual mucosa, mild-to-intermediate enhancement and frequent orbital involvement; bone invasion and bone destruction are frequently observed; and haematogenous metastasis is not as common as lymphatic metastasis. RMSs of various pathological subtypes were not significantly distinct by imaging.

Frequent Recurrence of Sinonasal Inverted Papilloma With Carcinoma In Situ in a Multifocal Attachment Pattern: A Case Report and Review of the Literature

Sinonasal inverted papilloma (SIP) is a benign tumor originating from the nasal cavity and paranasal sinuses. Sinonasal inverted papilloma is characterized by local infiltration, high recurrence, and malignant transformation, and its associated dysplasia ranges from mild, moderate, severe, carcinoma in situ (CIS) to invasive squamous cell carcinoma. Sinonasal inverted papilloma with carcinoma in situ (IPwCIS) is the highest degree of dysplasia, which is a stage of malignant transformation of IP. Surgical excision and proper adjuvant therapy can help reduce recurrence rates and suppress further deterioration. In this study, we present a patient with IPwCIS who developed 3 recurrences with a multifocal attachment pattern in less than 18 months. We report the clinical manifestations, development, and treatment process in detail. We also performed a literature review to analyze the characteristics of the disease. Despite comprehensive treatment methods, tumor recurrence and further deterioration of IPwCIS persist.

[Follow-up care of sinonasal papillomas - risk factors for recurrence and malignant progression]

OBJECTIVE

Sinonasal papillomas are tumors of the nasal cavity and paranasal sinuses. They are treated through complete resection under oncologic conditions. Two characteristics complicate follow-up: 1) frequent tumor recurrences (even many years after initial diagnosis), 2) possibility for malignant progression. This review elucidates risk factors for these two characteristics to depict "high-risk patients" for whom a closer follow-up is mandatory.

MATERIALS AND METHODS

Literature was searched in Pubmed (NCBI).

RESULTS

The most important risk factor for recurrence is incomplete tumor resection. This comprises several more factors: inappropriate surgical procedure, large tumors, difficult surgical conditions due to tumor localization or to prior surgery. Young age and tobacco smoking are risk factors for frequent recurrences. In regard to malignant progression, extended tumors, smoking, senior age, female sex, bone invasion, and lack of inflammatory polyps have been identified as risk factors. Histopathological factors for both - recurrences and malignant progression - are epithelial dysplasia, hyperkeratosis, squamous hyperplasia, as well as (if known) increased proliferation, aneuploidy, and infection with human papillomaviruses.

CONCLUSIONS

Complete resection of sinunasal papillomas under oncologic conditions is of utmost importance. A careful postoperative follow-up is mandatory. Most authors suggest at least a five-year, some a lifelong follow-up. Patients with one or more risk factors should be monitored more closely.

Treatment outcome and pattern of recurrence of sinonasal squamous cell carcinoma with EGFR-mutation and human papillomavirus

The objective of our study was to clarify the clinical features of EGFR-mutated sinonasal squamous cell carcinoma (SNSCC) and human papilloma virus (HPV)-related SNSCC. Patients with SNSCC treated from April 2008 to June 2019 at our institution were retrospectively reviewed. We examined EGFR mutation and HPV status for all patients. Main outcomes were overall survival, recurrence, and outcome of each treatment modality. A total of 85 patients with SNSCC were enrolled in this study. EGFR mutations and HPV DNA were detected in 24 (28%) and 7 (8%) patients, respectively. Patients with EGFR-mutated SNSCC showed a worse overall survival (OS) than those with EGFR wild-type in the multivariate analysis (p = 0.037). No death was observed in HPV-positive SNSCC. The cumulative incidence of local recurrence was significantly higher in EGFR mutant than EGFR wild-type tumors (p = 0.03). In patients with EGFR mutations, treatment with induction chemotherapy significantly improved OS (p = 0.01). EGFR-mutated SNSCC have a high-risk feature for recurrence and requires intensive attention for treatment and observation. A new treatment approach, such as EGFR tyrosine kinase inhibitors, may be needed.

Sine Qua Non: Sinonasal Inverted Papilloma

Inverted papilloma (IP) is a common proliferation of squamous epithelial cells of the sinonasal tract. Although considered benign, IP is known to cause local destruction, has a high rate of recurrence, and a low, but significant rate of malignant transformation. Differentiating an IP from its histologic mimickers is essential for appropriate risk stratification and long-term surveillance. A classic case of sinonasal inverted papilloma is discussed.

Clinical Analysis of 382 Sinonasal Inverted Papilloma Cases Treated at A Single Tertiary Medical Center

Background and Objectives: Sinonasal inverted papilloma (IP) is a benign tumor with a locally aggressive nature and a propensity to recur. Many risk factors for recurrence have been reported, but they are still controversial. The aim of this study was to comprehensively assess the demographic data, clinical features, and potential risk factors for recurrence of IP.Subjects and Method: This work is a retrospective review of 382 patients diagnosed with and treated for sinonasal inverted papilloma between 1986 and 2017 at a single tertiary medical center. Demographic data, presence of associated malignancy, information about previous surgeries, tumor location, Krouse stage, surgical approach, follow-up duration, and data on recurrence were obtained.Results: In our study, 31 of 382 cases (8.1%) were associated with malignancy. Mean age was significantly higher in patients with associated malignancy compared to the benign IP group. Of the 351 benign cases, 263 (74.9%) were primary, and 88 (25.1%) were revision cases (residual or recurrent disease). Although the proportion of patients with high Krouse stage or multifocal involvement was high in the revision cases, there was no significant difference in recurrence rate. The 226 patients with a minimum follow-up of 1 year were included for recurrence analysis. Recurrence rate was significantly higher in the conventional surgery group (17.4%) compared to that of the endoscopic and combined surgery groups (8.1% and 3.6%, respectively). Also, the recurrence group showed significantly larger proportion of patients with high Krouse stage and multifocal involvement.Conclusion: Risk factors for recurrence of IP found in this study are comparable to those previously published. Generally, the factors associated with recurrence of IP were prior surgery, clinical stage, involved site, and surgical approach. Therefore, surgeons should always consider these risk factors to reduce the chance of recurrence.

Primary Heterotopic Meningioma of Nasal Cavity: Case Report and Literature Review

Primary heterotopic meningiomas are lesions that are not associated with a cranial nerve foramen, vertebral canal, or intracranial structure. The most common histopathological subtype is meningeal epithelioma. In clinical practice, primary heterotopic nasal meningioma occurs relatively rarely, and its most common pathological type is psammomatous meningioma, whereas nasal fibrous meningioma is infrequent. In our case, a 31-year-old male patient was admitted to the hospital with "progressive nasal obstruction on the right side for half a year." Computed tomography examination of the paranasal sinuses revealed a polyploid mass in the right nasal cavity. The patient underwent surgical resection of the mass under nasal endoscopy. Histopathological examination confirmed that the mass was an ectopic meningioma of the nasal cavity. The patient was regularly followed up for 2 years without recurrence of the tumor. Primary heterotopic fibrous meningioma of the nasal cavity is clinically rare but should be considered as a differential diagnosis for hemangioma of the nasal cavity, inverted papilloma, and nasal polyp. The final diagnosis is based on pathology and immunohistochemistry analysis results.

Need for long-term follow-up in sinonasal inverted papilloma: A Single-institution experience

BACKGROUND

Most studies on sinonasal inverted papillomas (SNIPs) regarding risk factors for recurrence, recurrence rates (RRs) and malignant transformation are biased by a significant proportion of revision cases.

METHODS

Retrospective study on patients with consecutive, treatment-naïve SNIPs at a tertiary referral center between 1999 and 2019.

RESULTS

Overall, RR was 9.8% (10 of 102 patients), with 2 of 10 recurrences (20%) occurring after more than 5 years. Histopathological workup revealed synchronous malignancy in 2 of 102 patients (2%). Subgroup analysis revealed a significantly higher RR for SNIPs involving the frontal sinus (26.3% vs 6.0%, P = .02). No SNIPs primarily originating from the frontal sinus were observed.

CONCLUSION

Overall, RR of treatment-naïve SNIPs is comparably low; however, long-term follow-up is mandatory due to late recurrences. Secondary involvement of the frontal sinus was identified as risk factor for recurrence. No SNIPs primarily originating from frontal sinus were observed.

Prelacrimal approach vs conventional surgery for inverted papilloma in the maxillary sinus

BACKGROUND

The prelacrimal approach, termed endoscopic modified medial maxillectomy (EMMM), has recently been applied for treatment of inverted papilloma (IP) in the maxillary sinus. EMMM provides wider access to the maxillary sinus while preserving the inferior turbinate and nasolacrimal duct.

METHODS

We reviewed patients with IP in the maxillary sinus to compare the surgical results obtained by conventional surgery (ie, endoscopic maxillary sinus antrostomy or in combination with the Caldwell-Luc approach) with those obtained by EMMM.

RESULTS

All patients had a T3 on the Krouse staging system, and the average follow-up time was 46.0 months. Of the 18 patients in the conventional group, recurrence was seen in 3 patients (16.6%). No recurrence was seen in the 27 patients who showed preservation of the inferior turbinate and nasolacrimal duct, and no complications occurred in the EMMM group.

CONCLUSIONS

EMMM is an effective surgical approach that reduces recurrence with fewer complications.

Comparison of Current Staging Systems for Sinonasal Inverted Papilloma

Background

A staging system is essential for determining the optimal surgical approach and predicting postoperative outcomes for inverted papilloma (IP). Although staging systems based on the extent to which the location is occupied by an IP have been widely used, an origin site-based classification of IP using unsupervised machine learning algorithms has recently been reported.

Objective

To determine the most appropriate of five staging systems for sinonasal IP by comparing recurrence rates for each stage according to each of those systems.

Methods

Eighty-seven patients with sinonasal IP were enrolled in the study. Their tumors were retrospectively categorized according to the Krouse, Oikawa, Cannady, and Han staging systems, which are based on the extent of IP, and the Meng system, which is based on the site of origin. The rates of recurrence for each stage of the five systems were compared.

Results

Seven of the 87 patients (8.0%) had recurrences during an average 45.5 months (12–138 months) of follow-up. There were significant differences in disease-free survival between the stages specified by Han and Meng (p = 0.027 and p < 0.001, respectively), but not between the stages specified by Krouse, Oikawa, and Cannady (p = 0.236, 0.062, and 0.130, respectively). Cox proportional hazard models revealed that Meng system (adjusted hazard ratio [aHR] 4.32, 95% confidence interval [CI] 1.10–17.04) and presence of dysplasia (aHR 7.42, 95% CI 1.15–47.85) were significantly associated with recurrence.

Conclusion

The staging systems proposed by Han and Meng were found to be accurate in terms of tumor recurrence. We recommend use of the Han staging system before surgery and the Meng system after intraoperative identification of the origin of the tumor.

Clinical evidence based review and systematic scientific review in the identification of malignant transformation of inverted papilloma

Background

Inverted papilloma (IP) is an unusual type of benign tumor that has high recurrence rates and the potential to transform into squamous cell carcinomas (SCC). The mechanism of the transformation process from IP to IP-SCC is uncertain and there is no consensus regarding the best practice for IP-SCC detection. The goal of this study is to identify the best clinical methods to detect for IP-SCC.

Methods

An evidence-based review was performed using Medline and Ovid to obtain all articles up to October 10th, 2019 pertaining to identification of IP malignant transformation. All manuscripts discussing clinical methods or biomarkers were included.

Results

Based on clinical research studies, convoluted cerebriform pattern and apparent diffusion coefficient values on Magnetic Resonance Imaging (MRI) can help differentiate benign IP from SCC and increased SUVmax on PET/CT is associated with higher probability of malignancy although not as specific. No consensus about the best biomarker for IP-SCC has been reached among researchers and continues to be exploratory.

Conclusion

Endoscopy with biopsy is the gold standard practice to identify IP-SCC; however, MRI is the preferred imaging modality to recognize malignant transformation in cases where biopsy is difficult. Multiple biomarkers have shown positive results, but no single indicator with clinical significance for monitoring malignant transformation process has been found.

Squamous cell carcinoma associated with inverted papilloma: Recurrence and prognostic factors

The purpose of the present study was to review the recurrence and prognostic factors of squamous cell carcinoma (SCC) associated with inverted papilloma (IP). A retrospective chart review was conducted on 21 patients with SCC associated with IP, in the nasal cavity and paranasal sinuses, between March 2007 to March 2017. All patients underwent surgical treatment: Surgery prior to or following adjuvant therapy was performed in 17 patients (81.0%). During a mean follow-up time of 47.4 months (range, 3-123 months), 9 patients (42.9%) experienced local recurrence, and the risk factors of T4 stage and invasive orbital cavity had a significant influence on recurrence. The 1-, 3-, and 5-year overall survival rates were 90.5, 75.4 and 68.5%, and the 1-, 3-, and 5-year disease-specific survival (DSS) rates were 90.5, 80.4 and 80.4%, respectively. The prognosis of patients with stage T4 was not satisfactory compared with those with stage T3 or less, and a positive surgical margin was also significantly associated with poor survival. Overall, SCC associated with IP has a favorable DSS, early diagnosis and complete resection of lesions is required for a good prognosis. Furthermore, aggressive surgical approaches combined with postoperative adjuvant therapy seem to be effective in tumors at stage T4.

Endoscopic Resection of Sinonasal Inverted Papilloma: A Multivariate Retrospective Analysis of Factors Affecting Recurrence and Persistence

Sinonasal inverted papilloma (IP) is the most common benign epithelial tumor in the nasal cavity and paranasal sinuses, with a worldwide incidence between 0.6 and 1.5/100 000 persons per year. However, only a few studies have investigated patient-dependent factors related to IP recurrence and persistence. According to available evidence, these factors are still debated, and results are contradictory. In this multicenter retrospective study, we analyzed the clinical records of 130 patients who were surgically treated for sinonasal IP to evaluate the factors affecting recurrence and persistence of IP and compared the curative rates of different surgical approaches. Our analysis showed that IP recurrence is strongly related to specific risk factors including incomplete surgical removal, stage of disease, site of the lesion, surgical technique, and malignancy rate. In conclusion, the recurrence of IP may be affected by several risk factors; these factors must be carefully considered during clinical evaluation and especially during the follow-up of patients with IP.

Surgical management of inverted papilloma involving the frontal sinus: a practical algorithm for treatment planning

Inverted papilloma of the frontal sinus is a challenging disease. Given its rarity, only small case series are present in the literature. The objectives of the present study are to review our experience in the surgical management of inverted papillomas involving the frontal sinus and to propose a practical algorithm for selecting the most appropriate approach. Data on patients affected by inverted papilloma involving the frontal sinus and surgically treated between 2002 and 2016 were collected. The type of involvement of frontal sinus and extent of surgery performed (endoscopic endonasal, external or combined approaches) were analysed. A brief review of consistent literature was also carried out. Forty-seven consecutive patients were treated using an exclusive endoscopic endonasal approach (EEA) in 18 cases, while a combined endonasal with external osteoplastic approach was required in 29 cases. Most patients (29/47, 62%) had been treated previously, mainly by an endoscopic approach. A single intraoperative complication occurred (1/47, 2%), i.e. cerebrospinal fluid (CSF) leak, that was successfully repaired intraoperatively without any consequences. Recurrences were observed in only 2/47 cases (4%) after a mean follow-up of 43 months (range, 12-137). The management of inverted papilloma involving the frontal sinus requires great expertise and the surgical technique should be tailored to the site of attachment of the tumour, its extension and the anatomical conformation of each frontal sinus. The encouraging results obtained in this case series support the use of this practical treatment algorithm.

Frontal inverted papillomas: A 25-year study

Objectives/Hypothesis

This study analyzes the treatment outcomes of frontal inverted papillomas (FIPs) in an attempt to provide guidelines for surgery selection.

Study Design

Retrospective case series.

Methods

The treatment results of 29 FIPs classified into five categories were retrospectively analyzed. The five categories are F1, tumor prolapsed into frontal sinus, tumor origin outside frontal sinus; F2, tumor origin inside frontal sinus, medial to the plane of lamina papyracea; F3, tumor origin inside frontal sinus, lateral to the plane of lamina papyracea; F4, bilateral; and F5, extrasinonasal.

Results

Of the 11 F1 cases, 73% had Draf I and 27% had Draf IIA procedures. There was one (9%) frontal recurrence and one (9%) frontal stenosis. Of the 10 F2 cases, 10% had Draf I, 40% had Draf IIA, 40% had Draf IIB, and 10% had Draf III surgery with a trephination. One patient (10%) had a frontal recurrence. Of the five F3 cases, 40% had Draf IIA surgery, 20% had external frontoethmoidectomy, and 40% had external frontal sinusotomy. The recurrence rate was 60%, and frontal stenosis rate was 60%. The two F4 cases had external frontal sinusotomies and Draf III surgery with no frontal recurrence or stenosis. The patient with the F5 had a frontal recurrence after Draf IIA surgery and external frontoethmoidectomy.

Conclusions

Draf I or IIA surgery is adequate for most F1 tumors, and Draf II surgery is adequate for most F2 tumors. F3 and F4 tumors can be managed initially by Draf III surgery with external frontal sinusotomy added when required. F5 tumors probably require combined surgical approaches.

Level of Evidence

4 Laryngoscope, 130:1622–1628, 2020

Morphologic, intraoperative, and histologic risk factors for sinonasal inverted papilloma recurrence

OBJECTIVE

Sinonasal inverted papillomas (IP) are benign neoplasms with a propensity for local recurrence. Many risk factors are reported, with little consistency between studies. This study aimed to comprehensively assess for demographic, imaging, histopathologic, and intraoperative risk factors for recurrence.

METHODS

We performed a single-center retrospective cohort study of patients with pathologically diagnosed IP without malignancy who underwent surgical resection between 1997 and 2018. Eligible patients were identified through a database maintained by the Department of Pathology. Logistic regression identified variables associated with recurrence, and conjunctive consolidation was performed to create a predictive model.

RESULTS

Of 76 subjects, 37% (n = 28) had recurrence. Median follow-up and time to recurrence were 2.9 (range 0.5-21.1) and 1.7 (range 0.2-13.0) years, respectively. Confirmed negative margins on histology were protective (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.08-0.85). Frontal sinus involvement (adjusted odds ratio [aOR] 5.83, 95% CI 1.20-28.37), incomplete resection (aOR 9.67, 95% CI 2.24-41.72), and presence of dysplasia (aOR 4.38, 95% CI 1.01-19.10) were significantly associated with recurrence on multivariable analysis. A three-level composite recurrence risk staging system was created by consolidating the above three variables. The recurrence risks of composite stage I, II, and III disease were 20%, 38%, and 100%, respectively. No demographic, imaging, staging, or surgical approach variables were associated with recurrence.

CONCLUSION

Frontal sinus involvement, incomplete resection, and dysplasia were significant risk factors for IP recurrence, whereas confirmed negative margins were protective. Creation of a composite staging system using the above variables may allow for risk stratification and a patient-specific approach to postoperative IP management.

LEVEL OF EVIDENCE

3 Laryngoscope, 130:590-596, 2020.

Surgical outcomes of sinonasal inverted papilloma: a 17 year review

Introduction

Inverted papillomas represent one of the most common benign neoplasic lesions located in the sinonasal tract. Owing to the local erosive behavior, tendency to recur and the potential for malignant transformation, surgical management of inverted papillomas is often challenging.

Objective

This study aimed to analyze the surgical outcomes of patients with inverted papillomas, according to the Krouse staging and the different surgical approaches.

Methods

Retrospective study of patients diagnosed with sinonasal inverted papillomas who underwent surgical treatment between 2000 and 2016 at a tertiary referral hospital. Cases with follow-up less than 12 months were excluded. The rate and the time of recurrence were the main outcomes. Values of p < 0.05 were considered statistically significant.

Results

Thirty-six cases with mean age of 60 years, predominantly male (72%), were included. The follow-up period ranged from 1 to 16 years, with an average of 4.5 years. Krouse T1 Stage corresponded to 11.1%; T2 occurred in 50% of cases; while T3 and T4 Stages accounted for 30.6% and 8.3% of patients, respectively. Most cases were approached by an endoscopic technique alone (83.3%), with a recurrence rate of 13.3%. Patients treated via a combined or open approach revealed a recurrence of 16.7%. No differences in the recurrence rate were reported when comparing endoscopic surgery with the open or combined techniques. Krouse Stage T3 had a significant association with inverted papillomas recurrence (p = 0.023). All inverted papilloma relapses occurred up to 2 years post-operatively. One case of malignant transformation was recorded (2.7%).

Conclusion

Endoscopic surgery did not increase the recurrence rates and can be a safe and efficient alternative to open or combined techniques. The recurrence of inverted papillomas seem to be related to the persistence of the disease and tend to occur early after primary surgery. Krouse T3 Stages may be associated with a higher recurrence of inverted papillomas.

Origin site-based staging system of sinonasal inverted papilloma for application to endoscopic sinus surgery

Background

We aimed to assess the recurrence risk of sinonasal inverted papillomas (SNIPs), based on a staging system developed according to the originating site of SNIP.

Methods

A total of 200 patients with SNIP were enrolled, and a staging system was developed based on the originating sites and corresponding recurrence rates of tumor in the patients. In the verification phase, 675 patients with SNIPs were enrolled as above, and the originating sites of the SNIPs were confirmed by an endoscopic sinus surgery. Cluster analysis was performed to determine the stage for each SNIP.

Results

Overall, 608 patients completed the study. SNIP recurrence rates for stages 1‐4 were 0 (n = 43), 4.0% (n = 420), 13.4% (n = 134), 36.4% (n = 11), respectively (total = 6.4%).

Conclusions

The origin site‐based classification of SNIP may aid surgeons in selecting appropriate endoscopic surgical approaches to minimize the risk of recurrence.

Sinonasal inverted papilloma associated with small cell neuroendocrine carcinoma: A case report and literature review of rare malignancies associated with inverted papilloma

We report a rare case of sinonasal inverted papilloma (IP) associated with small cell neuroendocrine carcinoma (SNEC). To our knowledge, this is the first report to describe SNEC found during the treatment of sinonasal IP. Surgery and five cycles of cisplatin plus etoposide with concurrent intensity modulated radiation therapy were performed. Neither local recurrence nor distant metastasis was noted during 6 years of post-diagnostic follow-up. The prognosis of SNEC is very poor. Treatment planning for sinonasal IP should consider a possible association with this rare but aggressive malignancy, whose treatment is completely different from that of squamous cell carcinoma, a malignancy which is commonly associated with IP. We also performed a PubMed review of the literature to identify the incidence and pathological diagnosis of associated malignancy. Among a total of 5286 cases of sinonasal IP (61 studies), the incidence of associated malignancy was 8.02% in squamous cell carcinoma, 0.19% in transitional cell carcinoma, 0.04% in mucoepidermoid carcinoma, 0.02% in verrucous cell carcinoma and 0.02% in adenocarcinoma. The incidence of associated malignancy was significantly higher in East and Southeast Asia (11.0%) and North America (10.4%) than in Europe (3.9%) (p=0.04 and p=0.03, respectively; T-test).

Endoscopic Resection of Sinonasal Inverted Papilloma: Systematic Review and Meta-Analysis

Background Pure endoscopic surgery (functional endoscopic sinus surgery) has been increasingly replacing external approaches in the management of sinonasal inverted papillomas. Objective To analyze and compare the effectiveness of pure endoscopic procedure with external or combined procedures to paranasal inverted papillomas, including the experience from two institutions in North Greece, over a 20-year period. Methods Systematic literature searches of MEDLINE (1952-2016), EMBASE (1974-2016), and the Cochrane Central Register of Controlled Trials. Review of all English-language studies comparing endoscopic and open techniques. Odds ratios (ORs), risk ratio, 95% confidence intervals (CIs), and tests for heterogeneity were reported. Recurrence rates according to initial tumor stage. Results In total, 2451 patients had been enrolled in the 23 studies, published between 1992 and 2014. All the included articles are graded as level IV evidence. Among the 1526 patients of the endoscopic group, 212 (13.8%) had recurrence, with the mean time of recurrence to range from 14 to 46.6 months. In the external approach group, 111 (18.7%) of the 592 patients had recurrence, with the time of recurrence to range from 7 to 92 months. The recurrence rate in the combined approach group was 12.9%. The occurrence rate of recurrence attributable to the surgical choice was significantly different between endoscopic and external group (OR: 0.61; 95% CI: 0.40-0.92; P = 0.02; 14.9% vs. 18.8% in endoscopic and external group, respectively). Conclusions The present systematic review and meta-analysis indicates that endoscopic approach seems a favorable treatment option of sinonasal inverted papillomas and confirms the global recommendation that is the gold standard in the treatment of such nose lesions, revealing a lower recurrence rate compared to external approaches.

Incidental Histopathologic Finding of Sinonasal Inverted Papilloma Among Surgically Excised Polyps Increases the Risk of Tumor Recurrence

Inverted papilloma (IP) is a benign tumor remarkable for its tendency toward recurrence. Local relapse implicates incomplete resection concerning the bone adjacent to tumor base. The high false negative rates on biopsies, mainly when nasal polyps coexist, may affect the surgical management and outcomes. Our objective was to study the impact of preoperative histologic diagnosis in IP recurrence, particularly in patients with pre-surgical diagnosis of inflammatory polyps. A retrospective analysis of 62 patients treated for IP was conducted. Demographic data and information about smoking status, alcohol intake, tumor location, histology, presence of nasal polyps, staging, malignancy, previous biopsies and surgical approach were evaluated to identify factors associated with recurrence. Prevalence of nasal polyps was higher in patients with recurrence. Smoking history, alcohol abuse, staging, histologic type, malignancy and surgical approach were not associated with recurrence. The presence of nasal polyps at endoscopy was inversely associated with the diagnosis of IP at incisional biopsy. Incidental histologic diagnosis of IP after surgery increased the risk of recurrence more than tenfold. Biopsy reporting the diagnosis of IP previous to surgery was inversely associated to recurrence. In patients with IP, coexistence of nasal polyps at initial endoscopy and lack of pathological IP diagnosis prior to surgery are strongly associated with a higher risk of recurrence. When excisional biopsy reports IP incidentally, an early revision surgery should be considered in order to avoid future aggressive surgeries because of tumor recurrence.

Surgical management of inverted papilloma; a single-center analysis of 247 patients with long follow-up

BACKGROUND

Our aim was to review our management of inverted papilloma (IP), perform a recurrence analysis, and review the literature.

METHODS

A retrospective analysis of 247 patients treated for an IP. Patients were grouped according to surgical approach, tumor presentation (primary, residual and recurrence) and Krouse-stage.

RESULTS

Recurrence was observed in 20.3%, 28.6% and 35.1% (p = 0.017) of the patients who underwent endoscopic, external and combined surgery, respectively. Recurrences occurred more often in residual than primary IP (36.9% vs. 22.3%, p = 0.021). Primary endoscopic surgery had a recurrence rate of 12.5%, which was comparable to the recent literature (11.2%, 161/1433).

CONCLUSIONS

The relatively high number of recurrences in this cohort is explained by the long follow-up and previous (incomplete) surgery in 61.5% of the cases. The inferior outcome of residual IP underscores the importance of having a low threshold for preoperative biopsy in unilateral and atypical sinonasal disease.

Association of Krouse Classification for Sinonasal Inverted Papilloma With Recurrence: A Systematic Review and Meta-analysis

Importance

The risk factors for the recurrence of sinonasal inverted papilloma are still unclear.

Objective

To investigate the potential association between the Krouse classification and the recurrence rates of sinonasal inverted papilloma.

Data Sources

The EMBASE and MEDLINE databases were searched for the period January 1, 1964, through September 30, 2016, using the following search strategy: (paranasal sinuses [Medical Subject Headings (MeSH) terms] OR sinonasal [all fields]) AND (inverted papilloma [MeSH terms] OR (inverted [all fields] AND papilloma [all fields]).

Study Selection

The inclusion criteria were (1) studies including sinonasal inverted papilloma only and no other forms of papillomas, such as oncocytic papilloma; (2) minimum follow-up of 1 year after the surgery; and (3) clear report of cases (recurrence) and controls according to the Krouse classification system or deducible from the full-text article. Literature search was performed by 2 reviewers. Of the 625 articles retrieved in the literature, 97 full-text articles were reviewed. Observational cohort studies or randomized controlled trials were included, and the following variables were extracted from full-text articles: authors of the study, publication year, follow-up data, and number of cases (recurrence) and controls (no recurrence) in each of the 4 stages of the Krouse classification system.

Data Extraction and Synthesis

The Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines were followed. Odds ratios (ORs) and 95% CIs were estimated, and data of included studies were pooled using a random-effects model.

Main Outcomes and Measures

The main outcome was recurrence after surgical removal of sinonasal inverted papilloma according to each stage of the Krouse classification system.

Results

Thirteen studies comprising 1787 patients were analyzed. A significant increased risk of recurrence (51%) was highlighted for Krouse stage T3 disease when compared with stage T2 (pooled OR, 1.51; 95% CI, 1.09-2.09). No significant difference in risk of recurrence was found between Krouse stages T1 and T2 disease (pooled OR, 1.14; 95% CI, 0.63-2.04) or between stages T3 and T4 (pooled OR, 1.27; 95% CI, 0.72-2.26).

Conclusions and Relevance

Inverted papillomas classified as stage T3 according to the Krouse classification system presented a 51% higher likelihood of recurrence. Head and neck surgeons must be aware of this higher likelihood of recurrence when planning and performing surgery for sinonasal inverted papilloma.

The clinical behavior of sinonasal inverted papilloma with cellular dysplasia: case series and review of the literature

The prognosis and recurrence rate of inverted papilloma (IP) with concomitant cellular dysplasia are not well-delineated. Demographic, clinical and imaging data of all patients who were surgically treated for sinonasal inverted papilloma (SNIP) in our center between 1996 and 2013 were reviewed. Data regarding the coexistence of dysplastic changes or malignancy within the resected tissues were also retrieved. After the exclusion of malignant cases and patients who were lost for follow-up, 92 patients were included in the study. Five patients had coexisting cellular dysplasia (4.7%), four of them had severe dysplasia and one had mild-to-moderate dysplasia. All four cases with severe dysplasia recurred, three were primarily treated endoscopically and one by external approach. Only the case with mild to moderate dysplasia which had been treated by subcranial approach did not recur. Patients with dysplasia had significantly higher recurrence rate than patients without dysplasia (80 vs. 14%, p = 0.019). This significant relation between histology and recurrence remained even after adjustment to tumor extent. The adjusted odd ratio of dysplasia (dysplasia vs. no dysplasia) is 9.7, p = 0.043. SNIP with dysplasia should be treated aggressively and followed closely. The histopathologic investigation of SNIP specimens should always note the presence of dysplasia and its severity. Further investigation on the clinical behavior of SNIP with dysplasia is needed. Multicenter studies are warranted due to the rarity of dysplastic SNIP.

Advances in recurrence and malignant transformation of sinonasal inverted papillomas

Sinonasal inverted papilloma (SIP) is a benign tumor of the nasal cavity and sinus. SIP is characterized by aggressive malignant transformation and a high rate of recurrence. Inadequate removal of the tumor during surgery is one of the most significant contributors to SIP recurrence. A growing body of evidence suggests that molecular alteration in SIP, including human papilloma virus infections, single nucleotide polymorphisms of key genes, deregulation of signaling pathways and immunological changes, may lead to SIP occurrence and malignant transformation. However, the extent to which these molecular mechanisms contribute to SIP pathology and transformation remains unclear due to limited research. Further studies are warranted to elucidate the primary dependent factors that contribute to SIP etiology. The present article reviewed risk factors of progression and recurrence of SIP, including outdoor and industrial occupational exposure, smoking, septal deviation, SIP location, recurrent cases, stage of SIP-associated squamous cell carcinoma and choice of surgical method.

The analysis of expression of p16 protein in group of 53 patients treated for sinonasal inverted papilloma

Introduction

Sinonasal inverted papilloma constitute relevant therapeutic problem due to destructive character of growth, tendency to recur and the possibility of malignant transformation. Therefore, many attempts to identify risk factors for inverted papilloma occurrence have been undertaken, as well as research to find markers that would allow for the earlier detection of tumors and the application of adequate therapy. A widely known risk factor of inverted papilloma is HPV infection. One of the markers of HPV infection and the ongoing effect of this change (although arousing some controversy) is the expression of the p16 protein.

Objective

The aim of the study was to analyze the correlation between the expression of p16 as a surrogate of HPV infection in analyzed histopathological material and epidemiological variables, recurrences or malignant transformation.

Methods

The retrospective study includes a group of 53 patients (18 women and 35 men) undergoing treatment for sinonasal inverted papilloma in the period of 2002–2012. The intensity of the p16 protein in histopathological material was scored as: 0 – no expression, 1 – diffuse expression (borderline) and 2 – positive expression; or 0 – no expression/diffuse expression (borderline); 1 – positive expression. The Ethics Committee agreement was obtained (1089/12; 245/13).

Results and conclusion

There was no statistically significant relationship between the expression of p16 and the age of patients, cigarette smoking, tumor location, tumor staging according to the Krouse and Cannady classification, the presence of dysplasia or the occurrence of relapse.

Sinonasal Inverted Papilloma: Risk Factors for Local Recurrence After Surgical Resection

Objectives:

Sinonasal inverted papillomas (SIP) present a potential for recurrence years after the surgery, but most studies report short-term follow-up, and risk factors for recurrence are still debated. Furthermore, several classifications are described, and no consensus exists regarding which one should be used. The aims of this study were to report our long-term results, investigate for potential risk factors for recurrence, and compare the existing 8 staging systems.

Methods:

Over a 28-year period, 110 patients with a diagnosis of SIP were enrolled. The median follow-up time was 55.6 months.

Results:

In multivariate Cox regression modeling, history of previous surgery was the only variable associated with recurrence (hazard ratio = 4.91, 95% CI, 1.80-13.39). Recurrences occurred up to 60 months after the surgery. Among the 8 staging systems, none proved to be associated with recurrence.

Conclusion:

The only factor associated with recurrence of SIP was prior surgery, probably corresponding to an incomplete initial resection. Due to late recurrences, an extended follow-up of at least 5 years is mandatory. In the absence of a classification predicting prognosis, Krouse’s staging system should be used to homogenize studies’ report since it is the most widely used.