Survival outcomes and prognostic factors of squamous cell carcinomas arising from sinonasal inverted papillomas: a retrospective analysis of 120 patients

Microvessel barrier dysfunction in sinonasal inverted papilloma-associated squamous cell carcinoma and its manifestation in dynamic contrast-enhanced MRI

BACKGROUND

To date, an effective means to preoperatively predict the malignant transformation of sinonasal inverted papilloma (SIP) remains lacking due to similarities in clinical appearance. This study aimed to retrospectively evaluate dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) parameters and microvessel structure in tumors with histologically confirmed SIP and inverted papilloma-associated squamous cell carcinoma (IP-SCC), as well as correlate DCE-MRI findings with angiogenesis biomarkers.

METHODS

Absolute quantitative DCE-MRI parameters (Ktrans, Kep, Ve) based on the Tofts model and model-free semi-quantitative indices (Tpeak, WR, MaxSlope) of SIP (n = 22) and IP-SCC (n = 20) were investigated. Regions of interest (ROIs) were oriented according to the tumor subsites in the surgical records. Micro-vessel density (MVD) counts and tight junction protein (claudin-5) expression were evaluated in tumor specimens obtained during surgery. Differences in the above data were compared between the two groups. Correlations between DCE-MRI parameters and angiogenic biomarkers were analyzed.

RESULTS

Compared with SIP specimens, IP-SCC specimens were characterized by a significantly higher MVD and a leakier microvessel barrier. The values of Tpeak and Ve were significantly higher for SIP than those for IP-SCC, whereas WR, MaxSlope, and Kep were significantly lower, indicating early enhancement and a faster dispersion model in IP-SCC. MVD was positively correlated with WR and Kep and negatively correlated with Tpeak. Tpeak was slightly positively correlated to claudin-5 expression.

CONCLUSION

DCE-MRI can serve as a noninvasive biomarker of angiogenesis in the malignant transformation from SIP to IP-SCC. DCE-MRI may assist in the differentiation of malignancies and treatment selection.

Preoperative Prediction of Sinonasal Inverted Papilloma-associated Squamous Cell Carcinoma (IP-SCC)

INTRODUCTION

Sinonasal inverted papillomas (IP) can undergo transformation into IP-squamous cell carcinomas (IP-SCC). More aggressive treatment plan should be established when IP-SCC is suspected. Nevertheless, inaccuracy of the preoperative punch biopsy results to detect IP-SCC from IP raises the need for an additional strategy. The present study aimed to investigate significant clinicoradiological remarks associated with IP-SCC than IP.

MATERIAL AND METHODS

Postoperative surgical specimens obtained from patients with confirmed IP or IP-SCC at a single tertiary medical center from 1997 to 2018 were retrospectively evaluated. Patients' demographic and clinical characteristics, preoperative in-office punch biopsy results, and preoperative computed tomography (CT) or magnetic resonance images were reviewed. Univariate and multivariate analyses were performed to assess the odds ratio (OR) associated with IP-SCC. The area under the curve (AUC) in the receiver Operating Characteristic (ROC) curve was calculated in the prediction model to discriminate IP-SCC from IP.

RESULTS

The study included 44 IP-SCC and 301 patients with IP. The diagnostic sensitivity of in-office punch biopsy to detect IP-SCC was 70.7%. Multivariate analysis showed that factors significantly associated with IP-SCC included tobacco smoking >10PY (adjusted-OR [aOR]: 4.1), epistaxis (aOR: 3.4), facial pain (aOR: 4.2), bony destruction (aOR: 37.6), bony remodeling (aOR: 36.3), and invasion of adjacent structures (aOR: 31.6) (all p < 0.05). Combining all significantly related clinicoradiological features, the ability to discriminate IP-SCC from IP reached an AUC of 0.974.

CONCLUSION

IP patients with a history of tobacco smoking, facial pain, epistaxis, and bony destruction, remodeling, or invasion of an adjacent structure on preoperative images may be at higher risk for IP-SCC.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2502-2510, 2023.

Automated Prediction of Early Recurrence in Advanced Sinonasal Squamous Cell Carcinoma With Deep Learning and Multi-parametric MRI-based Radiomics Nomogram

RATIONALE AND OBJECTIVES

Preoperative prediction of the recurrence risk in patients with advanced sinonasal squamous cell carcinoma (SNSCC) is critical for individualized treatment. To evaluate the predictive ability of radiomics signature (RS) based on deep learning and multiparametric MRI for the risk of 2-year recurrence in advanced SNSCC.

MATERIALS AND METHODS

Preoperative MRI datasets were retrospectively collected from 265 SNSCC patients (145 recurrences) who underwent preoperative MRI, including T2-weighted (T2W), contrast-enhanced T1-weighted (T1c) sequences and diffusion-weighted (DW). All patients were divided into 165 training cohort and 70 test cohort. A deep learning segmentation model based on VB-Net was used to segment regions of interest (ROIs) for preoperative MRI and radiomics features were extracted from automatically segmented ROIs. Least absolute shrinkage and selection operator (LASSO) and logistic regression (LR) were applied for feature selection and radiomics score construction. Combined with meaningful clinicopathological predictors, a nomogram was developed and its performance was evaluated. In addition, X-title software was used to divide patients into high-risk or low-risk early relapse (ER) subgroups. Recurrence-free survival probability (RFS) was assessed for each subgroup.

RESULTS

The radiomics score, T stage, histological grade and Ki-67 predictors were independent predictors. The segmentation models of T2WI, T1c, and apparent diffusion coefficient (ADC) sequences achieved Dice coefficients of 0.720, 0.727, and 0.756, respectively, in the test cohort. RS-T2, RS-T1c and RS-ADC were derived from single-parameter MRI. RS-Combined (combined with T2WI, T1c, and ADC features) was derived from multiparametric MRI and reached area under curve (AUC) and accuracy of 0.854 (0.749-0.927) and 74.3% (0.624-0.840), respectively, in the test cohort. The calibration curve and decision curve analysis (DCA) illustrate its value in clinical practice. Kaplan-Meier analysis showed that the 2-year RFS rate for low-risk patients was significantly greater than that for high-risk patients in both the training and testing cohorts (p < 0.001).

CONCLUSION

Automated nomograms based on multi-sequence MRI help to predict ER in SNSCC patients preoperatively.

Development and Validation of a Clinical Prediction Model to Diagnose Sinonasal Inverted Papilloma Based on Computed Tomography Features and Clinical Characteristics

Objectives: Sinonasal inverted papilloma (SNIP) is one of the most common benign tumors of the nasal cavity and sinuses and is at risk for recurrence and malignant transformation. It is crucial to precisely predict SNIP before surgery to determine the optimal surgical technique and prevent SNIP recurrence. This study aimed to evaluate the diagnostic value of computed tomography (CT) features and SNIP clinical characteristics and to develop and validate a clinically effective nomogram. Methods: Here, 267 patients with SNIP and 273 with unilateral chronic rhinosinusitis with/without nasal polyps were included. Patient's demographic and clinical characteristics (i.e., gender, age, nasal symptoms, history of sinus surgery, smoking, and alcohol dependence) and CT features (i.e., lobulated/wavy edge, air sign, focal hyperostosis, diffuse hyperostosis, focal osseous erosion, and CT values) were recorded. Independent risk factors were screened using logistic regression analysis. A nomogram model was developed and validated. Results: Logistic regression analysis showed that age, facial pain/headache, history of sinus surgery, lobulated/wavy edge, air sign, focal hyperostosis, focal osseous erosion, and CT values were independent predictors of SNIP. A nomogram comprising these 8 independent risk factors was established. The area under the curve (AUC) for the training set was .960 (95% CI, .942-.978) and the AUC for the validation set was .951 (95% CI, .929-.971). Conclusion: The obtained results suggested that the nomogram based on age, facial pain/headache symptoms, history of sinus surgery, and CT characteristics had an excellent diagnostic value for SNIP.

A Clinical-Radiomics Nomogram Based on the Apparent Diffusion Coefficient (ADC) for Individualized Prediction of the Risk of Early Relapse in Advanced Sinonasal Squamous Cell Carcinoma: A 2-Year Follow-Up Study

Purpose

To develop and validate a nomogram model combining radiomic features and clinical characteristics to preoperatively predict the risk of early relapse (ER) in advanced sinonasal squamous cell carcinomas (SNSCCs).

Methods

A total of 152 SNSCC patients (clinical stage III-IV) who underwent diffusion-weighted imaging (DWI) were included in this study. The training cohort included 106 patients assessed at the headquarters of our hospital using MR scanner 1. The testing cohort included 46 patients assessed at the branch of our hospital using MR scanner 2. Least absolute shrinkage and selection operator (LASSO) regression was applied for feature selection and radiomic signature (radscore) construction. Multivariable logistic regression analysis was applied to identify independent predictors. The performance of the model was evaluated using the area under the receiver operating characteristic curve (AUC), calibration curve and decision curve analysis (DCA). Furthermore, the patients were classified into high- or low-risk ER subgroups according to the optimal cutoff value of the nomogram using X-tile. The recurrence-free survival probability (RFS) of each subgroup was assessed.

Results

ER was noted in 69 patients. The radscore included 8 selected radiomic features. The radscore, T stage and surgical margin were independent predictors. The nomogram showed better performance (AUC = 0.92) than either the radscore or the clinical factors in the training cohort (P < 0.050). In the testing cohort, the nomogram showed better performance (AUC = 0.92) than the clinical factors (P = 0.016) and tended to show better performance than the radscore (P = 0.177). The nomogram demonstrated good calibration and clinical utility. Kaplan-Meier analysis showed that the 2-year RFS rate for low-risk patients was significantly greater than that for high-risk patients in both the training and testing cohorts (P < 0.001).

Conclusions

The ADC-based radiomic nomogram model is potentially useful in predicting the risk of ER in advanced SNSCCs.

Preoperative Prediction of Malignant Transformation of Sinonasal Inverted Papilloma Using MR Radiomics

Purpose

Accurate preoperative prediction of the malignant transformation of sinonasal inverted papilloma (IP) is essential for guiding biopsy, planning appropriate surgery and prognosis of patients. We aimed to investigate the value of MRI-based radiomics in discriminating IP from IP-transformed squamous cell carcinomas (IP-SCC).

Methods

A total of 236 patients with IP-SCC (n=92) or IP (n=144) were enrolled and divided into a training cohort and a testing cohort. Preoperative MR images including T1-weighted, T2-weighted, and contrast enhanced T1-weighted images were collected. Radiomic features were extracted from MR images and key features were merged into a radiomic model. A morphological features model was developed based on MR morphological features assessed by radiologists. A combined model combining radiomic features and morphological features was generated using multivariable logistic regression. For comparison, two head and neck radiologists were independently invited to distinguish IP-SCC from IP. The area under the receiver operating characteristics curve (AUC) was used to assess the performance of all models.

Results

A total of 3948 radiomic features were extracted from three MR sequences. After feature selection, we saved 15 key features for modeling. The AUC, sensitivity, specificity, and accuracy on the testing cohort of the combined model based on radiomic and morphological features were respectively 0.962, 0.828, 0.94, and 0.899. The diagnostic ability of the combined model outperformed the morphological features model and also outperformed the two head and neck radiologists.

Conclusions

A combined model based on MR radiomic and morphological features could serve as a potential tool to accurately predict IP-SCC, which might improve patient counseling and make more precise treatment planning.

Long-term outcomes in sinonasal squamous cell carcinoma arising from inverted papilloma: Systematic review

Long-term survival and recurrence patterns of squamous cell carcinoma arising from inverted papilloma (IP-SCC) have not been thoroughly investigated. Four electronic databases were searched and primary studies describing overall survival (OS), recurrence, and mean time to recurrence of patients with IP-SCC were included for review. Our search yielded 662 studies. The 28 studies selected for inclusion identified 663 patients with IP-SCC. In 596 patients with reported T classification, 439 (73.7%) were T3/T4 on presentation. Of the 650 participants with recurrence data (local, regional, and distant), 155 (23.8%) experienced a recurrence, with an aggregate mean time-to-recurrence of 24.3 months. In 565 patients with 5-year OS rates, the aggregate 5-year OS was 62%. Based on the literature to date, IP-SCC is associated with a 5-year OS rate of 62%. 23.8% of patients experienced recurrence at a mean time of 24.3 months, suggesting the need for long-term surveillance.

Down-regulating NEAT1 inhibited the viability and vasculogenic mimicry formation of sinonasal squamous cell carcinoma cells via miR-195-5p/VEGFA axis

The role of long non-coding RNA nuclear-enriched abundant transcript 1 (lncRNA NEAT1) in sinonasal squamous cell carcinoma (SNSCC) remained obscure. Target genes and potential binding sites of NEAT1, microRNA (miR)-195-5p and VEGFA were predicted using StarBase and TargetScan, and confirmed by dual-luciferase reporter assay. Quantitative real-time polymerase chain reaction (qRT-PCR) was performed to detect the expressions of NEAT1, vascular endothelial growth factor A (VEGFA) and miR-195-5p. Pearson's correlation analysis of NEAT1, miR-195-5p and VEGFA was conducted. Cell viability, apoptosis and tube formation capability were assessed by MTT assay, flow cytometry and capillary-like tube formation assay, respectively. Expressions of VEGFA and proteins related to the phosphatidylinositide 3-kinase/Protein Kinase B (PI3K/AKT) pathway were measured by Western blot. In SNSCC tissues and cells, the expressions of NEAT1 and VEGFA were up-regulated while the expression of miR-195-5p was down-regulated, and NEAT1 was negatively correlated with miR-195-5p yet positively correlated with VEGFA. Overexpressed VEGFA promoted the viability and capillary-like tube formation of SNSCC cells yet suppressed their apoptosis, while silencing VEGFA led to the opposite results. MiR-195-5p could bind to NEAT1, and down-regulating miR-195-5p reversed the effects of silencing NEAT1 on the expressions of NEAT1 and miR-195-5p, cell viability, apoptosis and capillary-like tube formation as well as PI3K/AKT pathway activation. VEGFA was the target of miR-195-5p, and overexpressed VEGFA reversed the effects of miR-195-5p. Down-regulating NEAT1 inhibited the viability and vasculogenic mimicry formation of SNSCC cells yet promoted their apoptosis via the miR-195-5p/VEGFA axis, providing a possible therapeutic target for SNSCC treatment.

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.

Prognostic Factors of Sinonasal Squamous Cell Carcinomas Arising De Novo and From Inverted Papilloma

BACKGROUND

The prognostic factors and survival difference between inverted papilloma (IP)-associated sinonasal squamous cell carcinoma (SCC) and de novo SCC are unclear.

OBJECTIVE

This study aimed to compare the clinical features and oncologic outcomes in patients with IP-associated SCC and de novo SCC; and additionally, to analyze the prognostic factors of the two types of SCCs.

METHODS

Data from 173 SCC patients treated for IP-associated SCC (n = 89) and de novo SCC (n = 84), were reviewed retrospectively for demographic features, tumor characteristics, treatment modality, and clinical outcomes. 5-year overall survival (OS) and disease free survival (DFS) was analyzed using the Kaplan-Meier method, and Cox proportional hazards model was used to analyze factors influencing prognosis.

RESULTS

A higher proportion of IP-associated SCC occurred in frontal and sphenoid sinus compared to de novo SCC. The two groups demonstrated similar 5-year OS and DFS (5-year OS: 63.3% and 55.4%, DFS: 45.4% and 50.1%, respectively). The metachronous tumor had a relatively better prognosis outcome than synchronous tumor and de novo SCC (5-year OS: 73.1%, 54.5% and 55.4%, respectively). Both groups showed similar loco-regional recurrence rates (p > 0.05); however, de novo SCC tumors demonstrated an increased incidence of distant metastasis. Multivariate analysis indicated that age >70 years, advanced tumor stage and surgical margin were independent predictive factors for the risk of mortality (HR 2.047, 1.581 and 1.931, respectively).

CONCLUSION

IP-associated SCCs have an aggressive loco-regional tendency, whereas de novo SCCs have a higher aggressive distant metastatic propensity. Age, tumor stage and surgical positive margin are key factors for poor prognosis and should be routinely taken into consideration during treatment planning and subsequent surveillance.