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Sjöstedt S, von Buchwald C, Agander TK, Aanaes K. Impact of human papillomavirus in sinonasal cancer-a systematic review. Acta Oncol 2021; 60:1175-1191. [PMID: 34319844 DOI: 10.1080/0284186x.2021.1950922] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Human papillomavirus (HPV) is an established prognostic marker in oropharyngeal squamous cell carcinoma. Currently, the role of HPV in sinonasal carcinoma is being explored. OBJECTIVES This systematic review addresses the role of HPV in sinonasal cancer, establishing the occurrence of HPV-positive cancers and the influence of HPV-positivity on prognosis in sinonasal cancer as well as the utility of the putative surrogate marker of HPV (p16) in sinonasal cancer. MATERIAL AND METHODS Studies were identified with searches of Medline via PubMed and Embase via OVID (4 May 2020). Articles on original research concerning sinonasal cancer and HPV in humans written in English were included. Case reports with less than five cases were excluded. RESULTS Initially, 545 articles were identified; 190 duplicate articles were removed leaving 355 articles for title/abstract screening. Title/abstract screening excluded 243 articles, leaving 112 studies assessed for eligibility. After full-text screening, 57 studies were included. All articles investigated the significance of HPV in sinonasal carcinomas. HPV was reported in approximately 30% of sinonasal squamous cell carcinoma (SNSCC), where it was associated with a better prognosis. In sinonasal cancer, p16 is associated with diagnostic pitfalls and a putative utility of p16 in SNSCC has yet to be established. HPV was not frequently reported in other types of sinonasal carcinomas, besides the recently described subtype, HPV-dependent Multiphenotypic Sinonasal Carcinoma. In other types of sinonasal carcinoma, HPV is not frequently found. CONCLUSION Approximately 30% of SNSCC are HPV-positive. HPV-positivity in SNSCC is associated with improved survival. HPV occurs only rarely in other sinonasal cancers. There is currently not sufficient evidence for p16 as a surrogate marker of HPV in SNSCC.
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Affiliation(s)
- Sannia Sjöstedt
- Department of Otorhinolaryngology, Head and Neck Surgery, and Audiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian von Buchwald
- Department of Otorhinolaryngology, Head and Neck Surgery, and Audiology, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Kasper Aanaes
- Department of Otorhinolaryngology, Head and Neck Surgery, and Audiology, Copenhagen University Hospital, Copenhagen, Denmark
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McCormick JP, Suh JD, Lee JT, Wells C, Wang MB. Role of High-Risk HPV Detected by PCR in Malignant Sinonasal Inverted Papilloma: A Meta-Analysis. Laryngoscope 2021; 132:926-932. [PMID: 34232507 DOI: 10.1002/lary.29735] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/21/2021] [Accepted: 06/26/2021] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Prior studies suggest that there may be a link between human papillomavirus (HPV) infection and malignant sinonasal inverted papilloma (SNIP). This systematic review and meta-analysis was performed to further evaluate this potential association. STUDY DESIGN Systematic review with meta-analysis. METHODS The Medline and Embase databases were used to identify case-control studies reporting the risk of malignant SNIP in patients with high-risk HPV subtypes identified by polymerase chain reaction (PCR). Meta-analysis was performed to determine pooled odds ratios (ORs) and 95% confidence intervals (CI). RESULTS Twenty-one studies were identified, including a total of 841 subjects with SNIP. Seventeen studies were included in the final analysis, as four studies did not have any HPV-positive tumors in either group. A total of 56 malignant SNIP and 551 benign SNIP were ultimately identified. The pooled log-OR was 1.80 (95% CI: 1.03-2.57) for all high-risk HPV subtypes. Stratification by high-risk HPV subtype showed a log-OR of 1.67 (95% CI: 0.88-2.46) for HPV-16 and log-OR of 2.68 (95% CI: 1.30-4.05) for HPV-18. CONCLUSION Infection with high-risk HPV subtypes may be associated with an increased risk of malignant SNIP. HPV-18 showed the greatest overall average effect size of the common high-risk subtypes. LEVEL OF EVIDENCE n/a Laryngoscope, 2021.
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Affiliation(s)
- Justin P McCormick
- Department of Head and Neck Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, California, U.S.A
| | - Jeffrey D Suh
- Department of Head and Neck Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, California, U.S.A
| | - Jivianne T Lee
- Department of Head and Neck Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, California, U.S.A
| | - Christine Wells
- Office of Information Technology-Statistical Computing, University of California Los Angeles, Los Angeles, California, U.S.A
| | - Marilene B Wang
- Department of Head and Neck Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, California, U.S.A
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Stepp WH, Farzal Z, Kimple AJ, Ebert CS, Senior BA, Zanation AM, Thorp BD. HPV in the malignant transformation of sinonasal inverted papillomas: A meta-analysis. Int Forum Allergy Rhinol 2021; 11:1461-1471. [PMID: 33956402 DOI: 10.1002/alr.22810] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/10/2021] [Accepted: 04/12/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To date, there is still a significant debate on the role of human papilloma virus (HPV) infection in transformation of inverted papillomas (IPs) to squamous cell carcinoma (SCC). This study was designed to determine if the presence of HPV in a sinonasal IP increases the risk of malignant transformation to IPSCC. METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 19 high-quality case-control and cohort studies with tissue-diagnosed IP or IPSCC and HPV diagnosis were analyzed. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using the Mantel-Haenszel method with correction for random effects. Subgroup, publication bias and a sensitivity analyses were also performed. RESULTS Nineteen studies with minimal bias met the inclusion criteria for quality and identified HPV infection in an IP. The pooled data revealed a strong association with progression to malignancy with an unweighted, pooled OR of 2.38 (CI95 1.47 to 3.83) and a weighted OR of 2.80 (CI95 1.42 to 5.51). Sensitivity analysis revealed that no single study contributed significantly to our pooled OR calculations (ORs 2.52 to 3.57). Subgroup analyses stratified by publication date, nucleic acid target, HPV detection method and type, sample size, and region all demonstrated a positive association of HPV with IPSCC. CONCLUSIONS There appears to be a significant association between HPV infection and malignant transformation of IPs. While HPV testing is not currently the standard of care for IPs, these data suggest a link between the two and suggest further studies should be performed to identify a link between the virus and malignant transformation.
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Affiliation(s)
- Wesley H Stepp
- Department of Otolaryngology, School of Medicine, The University of North Carolina, Chapel Hill, North Carolina, USA
| | - Zainab Farzal
- Department of Otolaryngology, School of Medicine, The University of North Carolina, Chapel Hill, North Carolina, USA
| | - Adam J Kimple
- Department of Otolaryngology, School of Medicine, The University of North Carolina, Chapel Hill, North Carolina, USA.,Marsico Lung Institute, School of Medicine, At the University of North Carolina, Chapel Hill, North Carolina, USA
| | - Charles S Ebert
- Department of Otolaryngology, School of Medicine, The University of North Carolina, Chapel Hill, North Carolina, USA
| | - Brent A Senior
- Department of Otolaryngology, School of Medicine, The University of North Carolina, Chapel Hill, North Carolina, USA
| | - Adam M Zanation
- Department of Otolaryngology, School of Medicine, The University of North Carolina, Chapel Hill, North Carolina, USA
| | - Brian D Thorp
- Department of Otolaryngology, School of Medicine, The University of North Carolina, Chapel Hill, North Carolina, USA
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Ding R, Sun Q, Wang Y. Association Between Human Papilloma Virus Infection and Malignant Sinonasal Inverted Papilloma. Laryngoscope 2020; 131:1200-1205. [PMID: 33111993 DOI: 10.1002/lary.29125] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/11/2020] [Accepted: 09/09/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This systematic review and meta-analysis aimed to evaluate the risk of malignant sinonasal inverted papilloma (SNIP) according to the type of human papilloma virus (HPV) infection. METHODS The databases of PubMed, EmBase, and Web of Science were searched for studies that reported the risk of malignant SNIP in patients infected by specific types of HPV. The quantitative analyses for pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. RESULTS Twenty-six molecular epidemiological studies that recruited a total of 900 patients with SNIP were selected for the final meta-analysis. The summary ORs indicated that HPV-6 (OR: 2.02; 95% CI: 0.47-8.61; P = .343), HPV-11 (OR: 0.86; 95% CI: 0.26-2.89; P = .806), and HPV-6/11 (OR: 1.44; 95% CI: 0.59-3.53; P = .426) infections were not associated with the risk of malignant SNIP. However, the risk of malignant SNIP was increased in patients infected with HPV-16 (OR: 8.51; 95% CI: 3.36-21.59; P < .001), HPV-11/16 (OR: 7.95; 95% CI: 1.13-56.01; P = .038), HPV-18 (OR: 23.26; 95% CI: 5.27-102.73; P < .001), and HPV-16/18 (OR: 24.34; 95% CI: 5.74-103.18; P < .001). CONCLUSIONS This study found that patients infected with HPV types 16, 11/16, 18, and 16/18 were associated with an increased risk of malignant SNIP. However, patients infected with HPV types 6, 11, and 6/11 did not have a significant risk of malignant SNIP. Laryngoscope, 131:1200-1205, 2021.
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Affiliation(s)
- Ronghua Ding
- Department of Otorhinolaryngology, Taizhou Second People's Hospital of Jiangsu Province, Taizhou, China
| | - Qiaorong Sun
- Department of Otorhinolaryngology, Nanjing Hospital of Traditional Chinese Medicine, Nanjing, China
| | - Yong Wang
- Department of Otorhinolaryngology, Taizhou Second People's Hospital of Jiangsu Province, Taizhou, China
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Long C, Jabarin B, Harvey A, Ham J, Javer A, Janjua A, Thamboo A. Clinical evidence based review and systematic scientific review in the identification of malignant transformation of inverted papilloma. J Otolaryngol Head Neck Surg 2020; 49:25. [PMID: 32354352 PMCID: PMC7193386 DOI: 10.1186/s40463-020-00420-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 04/22/2020] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Cai Long
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Basel Jabarin
- St Paul's Sinus Centre, University of British Columbia, Vancouver, BC, Canada
| | - Alexandra Harvey
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Jennifer Ham
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Amin Javer
- St Paul's Sinus Centre, University of British Columbia, Vancouver, BC, Canada
| | - Arif Janjua
- St Paul's Sinus Centre, University of British Columbia, Vancouver, BC, Canada
| | - Andrew Thamboo
- St Paul's Sinus Centre, University of British Columbia, Vancouver, BC, Canada.
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Wang H, Zhai C, Liu J, Wang J, Sun X, Hu L, Wang D. Low prevalence of human papillomavirus infection in sinonasal inverted papilloma and oncocytic papilloma. Virchows Arch 2019; 476:577-583. [PMID: 31797088 DOI: 10.1007/s00428-019-02717-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/06/2019] [Accepted: 11/05/2019] [Indexed: 12/12/2022]
Abstract
The aim of this study was to investigate the role of human papillomavirus (HPV) in sinonasal inverted papilloma (SIP) and sinonasal oncocytic papilloma (SOP) from a single institution and whether p16 can serve as a surrogate marker for HPV infection. This study included 49 subjects with SIP and 36 subjects with SOP. Formalin-fixed paraffin-embedded tissues were used to extract genomic DNA, and HPV detection was performed by utilizing a valid nested polymerase chain reaction approach that can detect all known HPV subtypes. Immunohistochemistry was used to evaluate the expression of p16 in all tumor sections. The presence of HPV DNA was found in 6.1% (3/49) of the SIP patients and 11.1% (4/36) of the SOP patients. All identified HPV subtypes in SIP were high-risk HPV, including HPV-16 (two patients) and HPV-58 (one patient). Regarding SOP, there were three patients positive for HPV-16 and one with low-risk HPV (type 6). In total, 11/49 (22.4%) SIP lesions and 10/36 (27.8%) SOP lesions were considered p16 positive, with p16 staining in more than 70% of tumor cells. There was only one SIP and one SOP that were positive for both HPV (high-risk HPV type 16) and p16 staining. HPV does not play an etiologic role in inverted papilloma or oncocytic papilloma of the sinonasal region. p16 immunostaining should not be used as a surrogate marker to evaluate the HPV infection status in these lesions.
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Affiliation(s)
- Huan Wang
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Fudan University, 83 Fen Yang Road, Shanghai, 200031, China
| | - Changwen Zhai
- Department of Clinical Pathology, Eye, Ear, Nose and Throat Hospital, Fudan University, Shanghai, China
| | - Juan Liu
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Fudan University, 83 Fen Yang Road, Shanghai, 200031, China
| | - Jingjing Wang
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Fudan University, 83 Fen Yang Road, Shanghai, 200031, China
| | - Xicai Sun
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Fudan University, 83 Fen Yang Road, Shanghai, 200031, China.
| | - Li Hu
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Fudan University, 83 Fen Yang Road, Shanghai, 200031, China. .,Department of Clinical Laboratory, Eye, Ear, Nose and Throat Hospital, Fudan University, Shanghai, China. .,Department of Experimental Center, Eye, Ear, Nose and Throat Hospital, Fudan University, 83 Fen Yang Road, Shanghai, 200031, China.
| | - Dehui Wang
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Fudan University, 83 Fen Yang Road, Shanghai, 200031, China
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Yamashita Y, Hasegawa M, Deng Z, Maeda H, Kondo S, Kyuna A, Matayoshi S, Agena S, Uehara T, Kouzaki H, Shimizu T, Ikegami T, Ganaha A, Suzuki M. Human papillomavirus infection and immunohistochemical expression of cell cycle proteins pRb, p53, and p16(INK4a) in sinonasal diseases. Infect Agent Cancer 2015; 10:23. [PMID: 26244053 PMCID: PMC4524447 DOI: 10.1186/s13027-015-0019-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 07/08/2015] [Indexed: 11/19/2022] Open
Abstract
Background We aimed to clarify the possible role of human papillomavirus (HPV) infection in the malignant transformation of sinonasal inverted papilloma (IP). Methods Subjects comprised 32 patients with chronic rhinosinusitis (CRS), 17 with IP, 5 with IP and squamous cell carcinoma (IP + SCC), and 16 with primary sinonasal SCC. HPV presence, viral loads, and physical status were investigated using polymerase chain reaction. Retinoblastoma (pRb), p53, and p16INK4a gene products were investigated by immunohistochemistry. Results HPV DNA was detected in 6.3 % of cases with CRS, 29.4 % with IP, 40 % with IP + SCC, and 25 % with SCC. IP cases had significantly higher HPV presence than CRS cases (p = 0.04). High-risk HPV-16 was the most frequently encountered subtype (10/13, 76.9 %). HPV-16 viral loads varied from 2.5 to 7953 E6 copies/50 ng genomic DNA. Patients in the SCC and IP + SCC groups had significantly higher viral loads than those in the IP and CRS groups (p < 0.01). All SCC and IP + SCC patients with HPV-16 demonstrated mixed-type integration, whereas 4 of 5 HPV-16 patients in the IP and CRS groups showed episomal type infection (p = 0.04). Positivity to pRb was found in 78.1 % of CRS, 35.3 % of IP, and 68.8 % of SCC cases. The presence of HPV DNA negatively correlated with pRb expression in SCC (p = 0.029) and IP (P = 0.049) groups. Although 62.5 % of SCC cases exhibited p53 positivity, only 5.9 % of IP, and no CRS cases were positive. Regardless of HPV status, p16INK4a positivity was frequently detected in IP cases (82.4 %), less in SCC (12.5 %) cases, and was not detected in the CRS group. Neither the IP nor SCC cohorts showed any correlation between HPV presence and the expression of either p53 or p16INK4a. Conclusions HPV infection was more frequent in the IP, IP + SCC, and SCC groups than the CRS group. Higher viral loads and integration observed in the IP + SCC and SCC groups, and an inverse correlation between HPV presence and positive pRb indicated that persistent infection and integration play a part in tumorigenesis and malignant transformation in certain IP cases. However, p16INK4a is not a reliable surrogate marker for HPV infection in IP.
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Affiliation(s)
- Yukashi Yamashita
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, 903-0215 Japan
| | - Masahiro Hasegawa
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, 903-0215 Japan
| | - Zeyi Deng
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, 903-0215 Japan.,Department of Otorhinolaryngology, Head and Neck Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Hiroyuki Maeda
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, 903-0215 Japan
| | - Shunsuke Kondo
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, 903-0215 Japan
| | - Asanori Kyuna
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, 903-0215 Japan
| | - Sen Matayoshi
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, 903-0215 Japan
| | - Shinya Agena
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, 903-0215 Japan
| | - Takayuki Uehara
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, 903-0215 Japan
| | - Hideaki Kouzaki
- Department of Otolaryngology, Head and Neck Surgery, Shiga University of Medical Science, Otsu, 520-2192 Japan
| | - Takeshi Shimizu
- Department of Otolaryngology, Head and Neck Surgery, Shiga University of Medical Science, Otsu, 520-2192 Japan
| | - Taro Ikegami
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, 903-0215 Japan
| | - Akira Ganaha
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, 903-0215 Japan
| | - Mikio Suzuki
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, 903-0215 Japan
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Lin GC, Akkina S, Chinn S, Prince ME, McHugh JB, Carey T, Zacharek MA. Sinonasal inverted papilloma: prognostic factors with emphasis on resection margins. J Neurol Surg B Skull Base 2014; 75:140-6. [PMID: 24719801 DOI: 10.1055/s-0033-1363169] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Accepted: 10/23/2013] [Indexed: 10/25/2022] Open
Abstract
Objective We review our institution's experience with the treatment of inverted papilloma (IP) with emphasis on the implications of surgical margins for disease control. Design Retrospective chart review of patients with IP treated at the University of Michigan from 1996 to 2011. Setting Tertiary care center. Participants Patients undergoing surgical resection with curative intent for IP. Main Outcome Measures Overall survival, disease-specific survival, and locoregional control were used as main outcome measures. Results We studied 129 patients including 19 with carcinoma arising from IP. Disease-free rates at 2, 3, and 5 years were 79.7%, 77.9%, and 61%, respectively. Overall, 10 of 18 recurrences were detected > 2 years from follow-up, with recurrences detected up to 8 years from surgery. For benign disease, obtaining tissue margins outside of the primary specimen for margin control did not affect disease control rates. Conclusion IP is a disease that requires significant follow-up periods beyond 2 years. For IP without carcinogenesis, acquiring margins outside of the tumor specimen did not appear to affect disease control rates in this study. No clear predictors of malignancy were seen in this study, which highlights the need for further research to predict this phenomenon.
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Affiliation(s)
- Giant C Lin
- Department of Otolaryngology, University of Michigan Health Systems, Ann Arbor, Michigan, United States
| | - Sarah Akkina
- Department of Otolaryngology, University of Michigan Health Systems, Ann Arbor, Michigan, United States
| | - Steven Chinn
- Department of Otolaryngology, University of Michigan Health Systems, Ann Arbor, Michigan, United States
| | - Mark E Prince
- Department of Otolaryngology, University of Michigan Health Systems, Ann Arbor, Michigan, United States
| | - Jonathan B McHugh
- Department of Pathology, University of Michigan Health Systems, Ann Arbor, Michigan, United States
| | - Thomas Carey
- Department of Otolaryngology, University of Michigan Health Systems, Ann Arbor, Michigan, United States
| | - Mark A Zacharek
- Department of Otolaryngology, University of Michigan Health Systems, Ann Arbor, Michigan, United States
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