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

"TuNa-saving" endoscopic medial maxillectomy: a surgical technique for maxillary inverted papilloma

The maxillary sinus is the most common site of sinonasal inverted papilloma. Endoscopic sinus surgery, in particular endoscopic medial maxillectomy, is currently the gold standard for treatment of maxillary sinus papilloma. Although a common technique, complications such as stenosis of the lacrimal pathway and consequent development of epiphora are still possible. To avoid these problems, we propose a modification of this surgical technique that preserves the head of the inferior turbinate and the nasolacrimal duct. A retrospective analysis was performed on patients treated for maxillary inverted papilloma in three tertiary medical centres between 2006 and 2014. Pedicle-oriented endoscopic surgery principles were applied and, in select cases where the tumour pedicle was located on the anterior wall, a modified endoscopic medial maxillectomy was carried out as described in this paper. From 2006 to 2014 a total of 84 patients were treated. A standard endoscopic medial maxillectomy was performed in 55 patients (65.4%), while the remaining 29 (34.6%) had a modified technique performed. Three recurrences (3/84; 3.6%) were observed after a minimum follow-up of 24 months. A new surgical approach for select cases of maxillary sinus inverted papilloma is proposed in this paper. In this technique, the endoscopic medial maxillectomy was performed while preserving the head of the inferior turbinate and the nasolacrimal duct ("TuNa-saving"). This technique allowed for good visualization of the maxillary sinus, good oncological control and a reduction in the rate of complications.

Management of inverted papilloma: review

BACKGROUND

Inverted papilloma is the most common benign tumour affecting the nose. There is a high rate of recurrence and a potential of malignant transformation. This review article aimed to identify the best available management of this pathology today.

METHOD

A systematic review of the current English-language literature was performed. Only original articles with a minimum follow up of one year and an average follow up of two years were included.

RESULTS

A total of 1385 patients from 16 case series were identified. The total recurrence rate for all patients was 11.5 per cent. Significantly lower recurrence rates were found for procedures using an attachment-oriented excision (recurrence of 6.9 per cent; p = 0.0001) and utilising frozen sections (recurrence of 7.0 per cent; p = 0.0001).

CONCLUSION

There is a general trend towards endoscopic surgery. There may be some benefit to the use of attachment-oriented surgery and frozen sections. Multi-centred randomised controlled trials are required.

Postoperative value of serum squamous cell carcinoma antigen as a predictor of recurrence in sinonasal inverted papilloma

OBJECTIVES

Sinonasal inverted papilloma (IP) has several unfavourable characteristics and therefore requires careful monitoring. The goal of this study was to identify whether serum squamous cell carcinoma antigen (SCCa) could predict IP recurrence.

DESIGN

A retrospective cohort study.

SETTING

Department of otolaryngology/head and neck surgery, Erasmus Medical Centre, Rotterdam, the Netherlands.

PARTICIPANTS

One hundred and thirty patients with IP treated at our centre with SCCa measurements available were included.

MAIN OUTCOME MEASUREMENTS

Follow-up of patients with IP since 2005, recurrence was defined as new disease within primary localisation at least 3 months after adequate surgical removal. We analysed the association between IP recurrence and serum SCCa values measured preoperatively, postoperatively and during follow-up.

RESULTS

Preoperative SCCa values or values measured during follow-up were not associated with risk of recurrence. Postoperative SCCa was positively associated with the risk of recurrence (P < 0.001). Postoperative SCCa had a good discriminative ability for the identification of recurrence with an area under the curve of 80.9%.

CONCLUSION

Postoperative SCCa is strongly associated with risk of recurrence. This might help the surgeon in the postoperative setting by identifying high-risk patients and planning follow-up strategy tailored to the individual patient.

Sinonasal inverted papilloma: From diagnosis to treatment

Inverted papilloma is a rare sinonasal tumor that mainly occurs in adults during the 5th decade. Three characteristics make this tumor very different from other sinonasal tumors: a relatively strong potential for local destruction, high rate of recurrence, and a risk of carcinomatous evolution. Etiology remains little understood, but an association with human papilloma virus has been reported in up to 40% of cases, raising the suspicions of implication in the pathogenesis of inverted papilloma. Treatment of choice is surgery, by endonasal endoscopic or external approach, depending on extension and tumoral characteristics. Follow-up is critical, to diagnose local relapse, which is often early but may also be late. The seriousness of this pathology lies in its association with carcinoma, which may be diagnosed at the outset or at recurrence during follow-up. It is important to diagnose recurrence to enable early treatment, especially in case of associated carcinoma or malignancy. A comprehensive review of the international literature was performed on PubMed and Embase, using the following search-terms: "sinonasal" [All Fields] AND ("papilloma, inverted" [MeSH Terms] OR ("papilloma" [All Fields] AND "inverted" [All Fields]) OR "inverted papilloma" [All Fields] OR ("inverted" [All Fields] AND "papilloma" [All Fields])). We reviewed all articles referring to sinonasal inverted papilloma published up to January 2015. The present article updates the state of knowledge regarding sinonasal inverted papilloma.

Rate of recurrence and malignant transformation in 88 cases with inverted papilloma between 1998-2008

Conclusions The recurrence rate of IP in the current study is comparable to international and national studies. When the primary tumour was located in the frontal or the sphenoid sinus, the tumour seemed more likely to recur. Some recurrences were more than 2 years after primary surgery, suggesting continued need for long-term follow-up. The rate of malignant transformation in inverted papilloma cases has not changed in Denmark. Objectives Inverted papillomas are benign tumours located in the nasal cavity and paranasal sinuses. They are known for their tendency to recur after surgery and show invasive growth, causing bone remodulation and the association with malignant transformation. The introduction of endoscopic sinus surgery and computer aided sinus surgery over the last decades has made this tumour more approachable with less cosmetic and functional damage. The objective of this study is to establish whether the recurrence rate and the rate of malignant transformation of IP have changed with the application of these new techniques. Method A retrospective study between 1998-2008 including 88 cases with inverted papilloma. Results In total, 25.3% had recurrence. Combined surgical approach with endoscope/open approach had the lowest rate of recurrence. A malignant transformation in the postoperative histological examination was found in 8.9%.

Inverted Papilloma of the Maxillary Sinus: Surgical Approach and Long-term Results

Background

Inverted papillomas (IP) commonly develop in the maxillary sinus (MS). However, the MS is a complex structure, and all areas in the MS are not easily approachable.

Objective

This study reviewed our surgical outcome of patients with IPs that originated from the MS in long-term follow-up and suggests appropriate approaches according to the tumor origin.

Methods

Thirty-one patients who were diagnosed with IP that originated from the MS, underwent surgery by a single operator between 1999 and 2011, and had postoperative follow-up of >3 years were enrolled.

Results

In all the cases, the endoscopic endonasal approach (EEA) was attempted at first and then canine fossa puncture (CP), canine fossa opening via the Caldwell-Luc approach (CO), and Caldwell-Luc operation (CLO) were added in consecutive order as the occasion demands. Six patients (19.4%) were treated only with EEA, and they had IPs from the superior, posterior, or medial wall. Five (16.1%) were treated with EEA plus CP, which was added for removal of IPs that originated from the lateral wall. Sixteen (51.6%) were treated with EEA plus CO, which was for removal of tumors from the medial, anterior, or inferior wall. Four patients (12.5%) whose IP attached to the whole MS mucosa underwent CLO. Three (9.7%) experienced recurrences, and the mean period to recurrence was 20.7 months.

Conclusion

The overall recurrence rate was 9.7%. IPs that originated from the lateral wall of the MS can be removed by using CP. When IPs originate from the anterior, inferior, or medial wall of the MS, CO may be needed for the thorough removal of them.

Challenges in the Management of Inverted Papilloma: A Review of 72 Revision Cases

OBJECTIVES/HYPOTHESIS

We report on the treatment outcome of endoscopically managed sinonasal inverted papilloma, focusing on revision cases. Our aim was to identify the properties of revision cases that affect treatment outcome by comparing them to primary cases in a single center. We propose using 5-fluorouracil (5-FU) in the postoperative management of inverted papilloma.

STUDY DESIGN

A retrospective single-center case series. This study met the criteria for approval by the local medical ethics committee.

METHODS

We performed a retrospective chart review identifying patients operated on between January 2003 and September 2013. Data were collected about patient demographics, symptoms, tumor attachment site, imaging, intraoperative and pathological findings, surgical approaches, postoperative treatment, follow-up, and recurrence.

RESULTS

One hundred and twenty-one (72 revision and 49 primary) cases were retrieved with a minimum follow-up of 1 year. Revision cases have significantly higher Krouse staging (P = 0.003), different distribution of tumor attachment sites, and higher recurrence rates. The recurrence rate was 4.1% for primary cases (mean follow-up 35.5 months) and 18.1% for revision cases (mean follow-up 45 months). Eight of the recurrent cases recurred within the first year. 5-fluorouracil was applied postoperatively in 18 (5 primary and 13 revision) cases, which included one (5.6%) recurrence and one minor complication (transient periorbital swelling).

CONCLUSION

The most important factors in preventing the recurrence of inverted papilloma are the determination of the location of the attachment and the completeness of resection in the primary endoscopic surgery. Revision cases have a higher recurrence rate, and the attachment sites are surgically more challenging. The use of 5-FU might have a place in the postoperative treatment of surgically challenging inverted papilloma.

LEVEL OF EVIDENCE

4.

High-resolution microendoscope imaging of inverted papilloma and normal sinonasal mucosa: evaluation of interobserver concordance

BACKGROUND

High-resolution microendoscopy (HRME) enables real-time imaging of epithelial tissue. The utility of this novel imaging modality for inverted papilloma has not been previously described. This study examines the ability of otolaryngologists to differentiate between images of inverted papilloma and normal sinonasal mucosa obtained with a HRME.

METHODS

Inverted papilloma and normal sinonasal mucosa specimens were stained with a contrast agent, proflavine. HRME images were subsequently captured. Histopathological diagnosis was obtained for each sample. Quality-controlled images were used to assemble a training set. After reviewing the training images, 6 otolaryngologists without prior HRME experience reviewed and classified test images.

RESULTS

Five samples of inverted papilloma and 2 normal sinonasal mucosa samples were collected. Four representative images from each specimen were used for the 28-image test set. The mean accuracy among all reviewers was 89.9% (95% confidence interval [CI], 84.3% to 94.0%). The sensitivity to correctly identify inverted papilloma was 86.7% (95% CI, 79.2% to 92.2%), and the specificity was 92.9% (95% CI, 89.0% to 100.0%). The Fleiss kappa interrater reliability score was 0.80 (95% CI, 0.70 to 0.89).

CONCLUSION

Inverted papilloma and normal sinonasal mucosa have distinct HRME imaging characteristics. Otolaryngologists can be successfully trained to distinguish between inverted papilloma and normal sinonasal mucosa. HRME is a feasible tool for identification of inverted papilloma. By conducting future in vivo trials, HRME potentially may enable real-time surgical margin determination during surgical excision of inverted papilloma.

Inverted papilloma of the sphenoid sinus: risk factors for disease recurrence

OBJECTIVES/HYPOTHESIS

Surgical treatment of inverted papilloma (IP) of the sphenoid sinus is complicated by close proximity to vital structures of the skull base. Identifying the site of tumor attachment and achieving complete removal can be challenging compared to IP at other sites. The objective of this study is to illustrate the clinical presentation, management, and risk factors for tumor recurrence for sphenoid IP.

STUDY DESIGN

Retrospective study.

METHODS

A multi-institutional, retrospective review of endoscopic resections of IP based within the sphenoid sinus was performed from 1996 to 2014. Demographic and tumor data, operative notes, complications, and recurrence rates were collected. Statistical analysis was performed to identify risk factors for tumor recurrence.

RESULTS

Forty-eight patients (31 males, 17 females) were identified. Mean age was 57 years, with a median follow-up of 13.6 months (range 6.8-36). Rate of tumor recurrence was 14.6%, with median time to recurrence of 13.1 months. Patients with dysplasia/carcinoma in situ (CIS) had a 3.6 greater rate of recurrence (RR) compared to patients with no dysplasia, approaching significance (RR = 3.6; P = 0.08). Patients with IP attachment sites overlying the optic nerve or carotid artery had a 4.76 greater rate of recurrence compared to other sites (RR = 4.76; P = 0.073).

CONCLUSION

Sphenoid sinus IP is associated with a 14.6% rate of recurrence after surgery. Potential risk factors for tumor recurrence identified in this study include attachment sites over the optic nerve and carotid artery or evidence of dysplasia or CIS. Close follow-up in the postoperative period is essential for these patients to monitor for tumor recurrence.

Sinonasal inverted papilloma: prognostic factors with emphasis on resection margins

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.

Endoscopic skull base surgery practice patterns: survey of the North American Skull Base Society

BACKGROUND

The objective of this study was to evaluate the potential impact of advanced endoscopic techniques on the current practice patterns in skull base surgery.

METHODS

A 20-item written survey approved by the American Rhinologic Society (ARS) and North American Skull Base Society (NASBS) was conducted at the 22nd Annual NASBS meeting in Las Vegas, NV, from February 17 to 19, 2012. The target group included 212 practicing skull base surgeons.

RESULTS

Seventy-nine physicians (37.3%) completed the survey. The subspecialty composition was 42 (53%) otolaryngologists and 35 (44%) neurosurgeons. The respondents represented all regions of the country, with most common being the North Central (24%) and Mid-Atlantic (23%) states. Open and endoscopic skull base techniques were used by 91% and 80%, respectively. During a typical year, the number of endoscopic skull base cases ranged between 20 and 50 in 32%, 50 to 100 in 13%, and >100 in 8%. Endoscopic pituitary surgery was performed by 95%, while transcribriform, transplanum, and transclival approaches were performed by 70.5%, 66%, and 66%, respectively. Wide variation in coding philosophy was noted, including use of unlisted neurosurgical (28%), open skull base (28%), unlisted endoscopic (24%), and sinus surgery (20%) codes. Only 30% of physicians reported adequate reimbursement in ≥50% of the performed cases. Overall, 87% were supportive of the creation of dedicated endoscopic skull base codes.

CONCLUSION

The present survey attests to the widespread adaptation of endoscopic techniques in the management schema of skull base surgery. The wide variation in coding techniques and inadequate reimbursement suggests that future dialogue should also focus on developing consensus with respect to the coding and billing process.