Immunohistochemistry of p53 in sinonasal inverted papilloma and associated squamous cell carcinoma

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.

Differentiation-Related p53 Protein Expression in Nondysplastic Sinonasal Inverted Papillomas

To clarify p53 protein expression in nondysplastic sinonasal inverted papillomas, archived surgical specimens from 19 patients were studied using immunohistochemistry. Staining results were compared between inverted papillomas and adjacent, nonpapillomatous nasal mucosa. Further, immunoreactivity was compared between columnar (respiratory), transitional (cuboidal), and squamous epithelium in inverted papillomas. Positive staining was found in 17 of 19 inverted papillomas (89%). Immunoreactivity involved predominantly basal and parabasal cells and was either comparable or higher in inverted papillomas compared with adjacent mucosa. In 65% of immunoreactive inverted papillomas comparable staining results were seen between columnar (respiratory), transitional (cuboidal), and squamous epithelium. In 35% of p53 protein-positive inverted papillomas, enhanced immunoreactivity was observed in transitional (cuboidal) and squamous epithelium compared with columnar (respiratory) epithelium. Within these cases, immunoreactivity was either comparable or higher in squamous compared with transitional (cuboidal) epithelium. Conclusively, the expression of p53 protein is present in 89% of nondysplastic sinonasal inverted papillomas and also involves the adjacent, nonpapillomatous nasal mucosa. A tendency toward increasing p53 protein expression from nonpapillomatous nasal mucosa to inverted papilloma as well as along the metaplastic process from columnar (respiratory) to transitional (cuboidal) and finally squamous epithelium within inverted papillomas can be postulated.

Squamous cell carcinoma antigen as a marker of sinonasal inverted papilloma

This prospective study aimed to evaluate the usefulness of squamous cell carcinoma antigen (SCCA) as a clinical marker of sinonasal inverted papilloma (IP). The potential benefit of SCCA in the diagnosis of unilateral nasal pathology and as a marker of hidden recurrence was evaluated as well. Blood samples from patients with sinonasal IP were examined to determine serum SCCA levels before surgery, the day after surgery, and every 6 months during follow-up. Preoperative and postoperative levels of SCCA were compared. Twenty consecutive patients with histologically confirmed IP were included in the study, conducted between 2000 and 2011. The mean age of the patients was 54.2 years (range 35-72). The mean serum SCCA level before surgery was 3.885 μg/l (range 0.7-7.6). A decrease of the SCCA level to 0.885 μg/l (range 0.1-1.9) was observed on the 1 day after a radical surgical procedure. A statistically significant difference between the preoperative and postoperative levels was observed (P < 0.001). Elevated levels of SCCA during long-term follow-up were observed in three patients. All of them had a recurrence of IP. We conclude that the serum level of SCCA is a useful clinical marker of the presence of sinonasal IP. The level of SCC antigen was significantly lower in patients after IP was completely removed. According to our results, SCCA level also appears to be useful for long-term follow-up (hidden recurrence diagnosis).

Skull base inverted papilloma: a comprehensive review

Skull base inverted papilloma (IP) is an unusual entity for many neurosurgeons. IP is renowned for its high rate of recurrence, its ability to cause local destruction, and its association with malignancy. This paper is a comprehensive review of the reports, studies, and reviews published in the current biomedical literature from 1947 to September 2010 and synthesize this information to focus on its potential invasion to the base of the skull and possible intradural extension. The objective is to familiarize the clinician with the different aspects of this unusual disease. The role of modern diagnostic tools in medical imaging in order to assess clearly the limits of the tumors and to enhance the efficiency and the safety in the choice of a surgical approach is pointed out. The treatment guidelines for IP have undergone a complex evolution that continues today. Radical excision of the tumour is technically difficult and often incomplete. Successful management of IP requires resection of the affected mucosa which could be achieved with open surgery, endoscopic, or combined approach. Radio and chemotherapy were used for certain indications. More optimally research would be a multicenter randomized trials with large size cohorts.

Pattern of Expression of Cell Cycle–related Proteins in Malignant Transformation of Sinonasal Inverted Papilloma

Background

It has been suggested that sinonasal inverted papilloma (IP) can progress to squamous cell carcinoma (SCC); however, mechanisms of malignant transformation are not fully understood. This study investigated alterations in the expression of cell cycle–related proteins in a multistep process of malignant transformation of IPs.

Methods

The expression of cell cycle–related proteins, including p53, p21, p16, and p63, was evaluated by immunohistochemistry in 21, 56, 7, and 18 cases of nasal polyps, IPs, IPs with dysplasia, and IPs with SCC, respectively. Furthermore, we determined the possible correlation between the expression of these proteins and clinicopathological variables in patients with IPs with SCC.

Results

Expression of p53 was found only in 8 of 18 IPs with SCC (44.4%). The frequency of p21 positivity was significantly higher in IPs with dysplasia (71.4%) and IPs with SCC (77.8%) compared with nasal polyps (0%) and IPs (12.5%). A p16 positivity was observed in 82.1% of IPs and 57.1% of IPs with dysplasia, whereas 83.3% of IPs with SCC showed an apparent loss of p16 protein expression. A p63 positivity was found in all specimens, but the percentage of positive cells was significantly increased in IPs with dysplasia and IPs with SCC compared with nasal polyps and IPs. There was no significant correlation between the expression of these proteins and clinicopathological variables, such as tumor stage, histological differentiation, and the proportion of malignant areas in patients with IPs with SCC.

Conclusion

Alteration of cell cycle–related proteins may contribute importantly to the malignant transformation from IP to SCC.

Do nasal polyps and inverted papilloma have similar disorders in cell cycle regulation?

BACKGROUND

The aim of this study was to determine the expression of cell cycle regulation genes in patients with inverted papilloma (IP) and compare this with expression in patients with nasal polyps (NPs).

METHODS

Tissue from 18 patients with IP and 5 patients with NPs were stained by immunohistochemistry techniques for p53 and p27. Measurement of the gene expression was performed by three assessors, who we blinded with respect to the specimens.

RESULTS

The mean score for p53 expression (3.33) was significantly higher in the IP group than the NP group (1.46). The mean difference between IP and NPs was 1.80 (CI, 1.15-2.46; p = 0.003). Additionally, we showed in a number of individuals variation in the p53 expression within the same specimen. There was no difference in the mean scores for p27, with the mean difference 0.79 (CI, 0.30-1.89; p = 0.147).

CONCLUSION

Our study established a significantly increased expression of p53 in IP when compared with NPs. Additionally, there appear to be two different cell populations identified within the same specimens, which exhibited variation in their p53 expression.

HPV infections in benign and malignant sinonasal lesions

This review updates the evidence that the human papillomavirus (HPV) is involved in the development of benign and malignant sinonasal lesions. Since the early 1980s, when evidence was provided on the possible involvement of HPV in the aetiology of both benign respiratory papillomas and squamous cell carcinomas, a substantial number of studies have explored this issue. To date, 33.3% of sinonasal papillomas and 21.7% of sinonasal carcinomas analysed have been shown to be positive for HPV. Many elements of the data parallel the observations made in HPV lesions at other mucosal sites, such as malignant transformation and frequent recurrence after radical treatment; the fact that low risk HPV types 6 and 11 are usually confined to benign lesions, whereas the reverse is true for the oncogenic HPV types 16 and 18; and the presence of squamo-columnar junctions and squamous cell metaplasia in the sinonasal system. The discrepancies reported by several studies might result in part from technical reasons, but it is also possible that sinonasal lesions have a heterogeneous aetiology (HPV related and non-related) and/or that some novel (yet unidentified) HPV types exist in these lesions, which are detected by some studies but not by others.

Schneiderian papillomas and nonsalivary glandular neoplasms of the head and neck

Schneiderian papillomas and nonsalivary glandular neoplasms of the head and neck continue to be a source of confusion for both the clinician and pathologist. An update on these lesions is provided.

Human papilloma virus and p53 expression in carcinomas associated with sinonasal papillomas: a Danish Epidemiological study 1980-1998

OBJECTIVES

To determine a putative role and relation between human papilloma virus (HPV) and p53 in the etiology of sinonasal carcinomas associated with papillomas.

STUDY DESIGN

The study group consists of all patients with sinonasal carcinomas associated with papillomas diagnosed in Denmark from 1980 to 1998. After reviewing our national pathological files, tumor tissues from 36 patients were collected, comprising 15% of the total cases of sinonasal carcinomas. In 35 cases a squamous cell carcinoma was demonstrated and in one case an adenocarcinoma was evident. Inverted papilloma was associated with carcinoma in 31 cases and exophytic papillomas in 5 cases. The material was investigated for HPV using polymerase chain reaction analyses with two sets of consensus primers (GP5+/GP6+ and MY09/MY11). The HPV-positive cases were submitted to dot-blot hybridization to establish the HPV type. Using immunohistochemistry, the p53 expression was determined. A p53 overexpression is defined as positive staining in 10% or more of the tumor cells.

RESULTS

Among 30 examined cases of carcinomas associated with inverted papillomas, 4 cases were HPV-positive (13%). P53 overexpression was not shown among the HPV-positive cases, whereas p53 overexpression was seen in 21 of the 24 (88%) examined HPV-negative cases. Among the 5 carcinomas associated with exophytic papillomas, HPV was demonstrated together with p53 overexpression in 3 cases (60%). In addition, one case more was with p53 overexpression.

CONCLUSION

An inverse relation between HPV and p53 overexpression in sinonasal carcinomas associated with inverted papillomas appears to have been demonstrated. HPV and p53 might also have an etiological role among the carcinomas associated with exophytic papillomas.

Coexpression of cytokeratins typical for columnar and squamous differentiation in sinonasal inverted papillomas

Cytokeratin (CK) expression was studied in 22 sinonasal inverted papillomas. Columnar (respiratory) epithelium in inverted papillomas abundantly expressed CK7, CK8, CK18, and CK19. Immunoreactivity for CK5/14 and CK17 was found in basal and parabasal/suprabasal cells. Transitional (cuboidal) and squamous epithelium in inverted papillomas comparably expressed CK7, CK8, CK18, and CK19. In addition CK13 was found in subluminal and surface cells. Immunoreactivity for CK5/14 and CK17 involved all layers of the epithelium. In nonpapillomatous nasal mucosa adjacent to inverted papillomas, CK expression in columnar (respiratory) epithelium exactly matched the findings in inverted papillomas. Transitional (cuboidal) and squamous epithelium in nonpaillomatous mucosa were negative for CK7, CK8, CK18, and CK19. CK13 was expressed in subluminal and surface cells. Immunoreactivity for CK5/14 and CK17 was restricted to basal and parabasal/suprabasal cells. Conclusively, transitional (cuboidal) and squamous epithelium in inverted papillomas but not in the adjacent mucosa coexpress CKs typical for columnar and squamous differentiation.