Recurrence of sinonasal inverted papilloma following surgical approach: A meta-analysis

Prospective Analysis of Squamous Cell Carcinoma Antigen-1 and -2 for Diagnosing Sinonasal Inverted Papilloma

Background: The goal of this research was to confirm whether preoperative serum squamous cell carcinoma antigen (SCCA)-1 and -2 levels are useful diagnostic markers for sinonasal inverted papilloma (IP) in a prospective study. Methods: Participants were 102 patients who underwent consecutive endoscopic sinus surgery: 18 with IP, two with other types of papilloma, 77 with chronic rhinosinusitis, four with sinonasal cancer, and one with hemangioma. SCCA-1 and SCCA-2 were measured preoperatively by an automatic chemiluminescence immunoassay and an enzyme-linked immunosorbent assay, respectively. Results: SCCA-1 and SCCA-2 values were significantly correlated (r = 0.603, p < 0.001). Receiver operating characteristic analysis for differentiating papilloma (IP and other types of papilloma) from other diseases yielded an area under the curve of 0.860, with a Youden index of 1.75. Combined with SCCA-2 analysis, the detection system had a sensitivity and specificity of 0.65 and 0.98, respectively. While our study did not find a strong link between SCCA levels and skin or lung diseases, smoking status may influence SCCA levels in IP patients (p = 0.035). We recommend a cutoff value of 1.8 ng/mL for SCCA-1 in IP diagnosis. Conclusions: SCCA-1 and SCCA-2 when combined with imaging and pathology hold promise for enhancing the preoperative detection of IP, which would be a valuable contribution to clinical practice.

Bilateral sinonasal inverted papillomas originating from both sides of the frontal sinus and the left lamina papyracea: A case report

RATIONALE

The present investigation documented a case of bilateral sinonasal inverted papilloma (SNIP) that arose from both sides of the frontal sinus and ethmoid sinus. The occurrence of bilateral involvement of the nasal cavities and frontal sinus is rather infrequent.

PATIENT CONCERNS

Informed consent was obtained from the patient.

DIAGNOSIS

Bilateral SNIP.

INTERVENTIONS

The tumor was completely removed by Draf III endoscopic resection complemented by an external eyebrow arch approach, and the postoperative recovery was uneventful.

OUTCOMES

The purpose of this paper is to present a comprehensive reference for the management of bilateral SNIP that affects the frontal sinuses.

LESSONS

This study addresses the staging and surgical management of bilateral SNIP, along with a review of the factors contributing to its recurrence. The recommended treatment method involves applying the Draf III technique combined with an external nasal approach.

Computed Tomography Imaging Patterns of Sinonasal Inverted Papillomas: Comparison of Primary and Recurrent Disease

OBJECTIVE

To analyze clinical and radiographic features that may impact the rate of focal hyperostosis (FH) on computed tomography (CT) for primary and recurrent sinonasal inverted papillomas (IPs) as well as highlight factors that may affect concordance between FH and IP true attachment point (TAP).

METHODS

All IPs resected between 2006 and 2022 were retrospectively reviewed. CTs were read by a neuroradiologist blinded to operative details. IP with malignancy was excluded. Operative reports and long-term follow-up data were evaluated.

RESULTS

Of 92 IPs, 60.1% had FH, 25% had no CT bony changes, and 20.7% were revision cases. The recurrence rate for rhinologists was 10.5% overall and 7.3% for primary IPs. Primary and revision IPs had a similar rate of FH (63% vs. 52.6%; p = 0.646) and FH-TAP agreement (71.7% vs. 90%; p = 0.664). Nasal cavity IPs, especially with septal attachment, were more likely to lack bony changes on CT (57.1%) compared to other subsites (p = 0.018). Recurrent tumors were 16 mm larger on average (55 mm vs. 39 mm; p = 0.008). FH (75.0% vs. 60.9%; p = 0.295), FH-TAP concordance (91.7% vs. 74.4%; p = 0.094), and secondary IP (18.8% vs. 20.3%; p = 0.889) rates were similar between recurrent and nonrecurrent tumors.

CONCLUSION

Primary and revision IPs have a similar rate of FH and FH-TAP agreement. Nasal cavity IPs are less likely to exhibit bony CT changes. Lower recurrence was associated with smaller size and fellowship training but not multiple TAPs, revision, FH absence, or FH-TAP discordance.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:1591-1596, 2024.

[Inverted papilloma of the nose and paranasal sinuses : Diagnosis, treatment, and malignant transformation]

Inverted papilloma (IP) are benign tumors that show a locally aggressive behavior, a high rate of recurrence, and a potential for malignant transformation. Specific radiological signs such as hyperostosis at the origin of the IP and convoluted cerebriform patterns, as well as the typical endoscopic aspect, can lead to diagnosis and enable preoperative planning of surgical access and the extent of surgery. Endonasal endoscopic techniques are considered the gold standard and the introduction of extended surgical techniques such as the prelacrimal approach, frontal drillout, or orbital transposition facilitate complete subperiosteal resection with preservation of important physiological structures. There is a risk of synchronous and metachronous squamous cell carcinomas (IP-SCC). Research focuses on radiological criteria to differentiate benign IP from IP-SCC, genetic and epigenetic factors in the process of malignant transformation, and estimation of the risk of IP progressing to IP-SCC.

Global research on sinonasal inverted papilloma over the past two decades: a bibliometric analysis

Objective

This study aimed to investigate the global research status, hot topics, and prospects in the field of sinonasal inverted papilloma (SNIP) through bibliometric analysis.

Methods

The literature on SNIP was retrieved and downloaded from the Web of Science Core Collection from 2002 to 2021. The bibliometric and visualisation networks of SNIP were constructed using VOSviewer 1.6.18, CiteSpace 6.1. R2, and a bibliometric online analysis platform.

Results

A total of 560 original articles about SNIP research were included, involving 2,457 authors from 610 institutions in 45 countries. The number of SNIP publications showed an overall rising trend, with an average annual output of 28 articles and almost 3 times as many articles published in 2020 as in 2002. The analysis of keyword burst detection indicated that EGFR mutation, malignant transformation and infection are emerging research hotspots. Moreover, EGFR mutation, KRAS mutation, malignant tumour, metallothionein 2a gene, pre-operative diagnosis, HPV-negative tumour, and expression were among the 11 key clusters of co-cited references.

Conclusions

This study provided a comprehensive, systematic, and objective analysis and visualised knowledge map of SNIP over the past 2 decades. In particular, current hotspots and prospective trends in the field of SNIP have been identified. These results highlight the future direction of SNIP research for rhinologists.

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.

Extended sphenoidotomy combined with transpterygoid approach for sphenoidal sinus inverted papilloma

PURPOSE

Inverted papilloma of the sphenoid sinus (IPSS) is a rare tumor with debated surgical management due to its proximity to vital structures. The aim of this manuscript is to highlight the role of a transpterygoid approach (TPA) and pedicle-orientated strategy in case of involvement of critical structures in IPSS and compare it with data from the literature.

METHODS

Patients with primary IPSS between January 2000 and June 2021 were included. Pre-operative CT/MRI were analyzed to classify the pneumatization of the SS and predict the insertion point of the inverted papilloma. All patients were treated with a trans-sphenoidal approach which was combined with a TPA in case of lateral insertion point. A systematic search was also performed to summarize the available literature.

RESULTS

Twenty-two patients were treated for IPSS. By CT, the SS was categorized with type III pneumatization in 72.8% of cases. Eleven patients (50%) were treated with a TPA with a statistical association with the insertion point on the SS lateral wall (p = 0.01), rather than a SS pneumatization (p = 0.63). The overall success was 95.5% after a mean follow-up of 35.9 months. For the literature, 26 publications were included on 97 patients and described a trans-sphenoidal approach with a success rate of 84.6% after a mean follow-up of 24.5 months.

CONCLUSION

IPSS is generally treated with a sphenoidotomy approach, although in selected cases, a TPA should be preferred to expose the whole SS lateral wall though allowing a complete pedicled oriented resection of the tumor.

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.

The choice of endoscopic surgical approach and four steps of operation of inverted papilloma of the maxillary sinus

OBJECTIVE

The aim of this study was to determine the long-term efficacy of four steps of operation on the treatment of maxillary sinus (MS) inverted papilloma (IP).

METHODS

83 patients who were diagnosed with IP that originated from the MS, underwent four step procedure of attachment sites, including mucosal stripping, periosteum ablation, bone drilling and bone ablation and had postoperative follow-up of 3 years were enrolled.

RESULTS

Of the 83 patients, 59 (71.1%) patients were primary surgery and revision surgery in 24 (28.9%), single attachment was in 31(37.3%) patients and multifocal attachments in 52 (62.7%).When the numbers were not mutually exclusive, the most common origin sites of IPs were the medial wall in 54 (37.2%), lateral wall in 29 (20.0%), anterior wall in 18 (12.4%), inferior wall in 22 (15.2%), posterior in 15 (10.3%), and superior wall in 7 (4.8%). Large MMA alone was performed in 5 (6.0%), MMA combined with medial maxillectomy 76 (91.6%), and MMA combined with Caldwell-Luc approach in 2 (2.4%). No major intra- or postoperative complications were observed. The average follow-up was 41 months (range, 37-61 months). CT and endoscope showed that tumor and symptom recurrence occurred in 2 patients (2.41%). In addition, although the opening of antrostomy was closed and CT revealed the uniform soft tissue shadow and hyperostosis of MS in 11(13.3%) patients, they didn't report any symptoms and showed well epithelization of middle meatus mucosa.

CONCLUSION

The four steps of operations of attachment sites of MS IP, including mucosal stripping, periosteum ablation, bone drilling and bone ablation, may effectively prevent the recurrence of MS IP.

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.

Recurrence rates of de-novo versus inverted papilloma-transformed sinonasal squamous cell carcinoma: a meta-analysis

Background: There is a paucity of reporting on recurrence patterns of de-novo sinonasal squamous cell carcinoma (DN-SCC) and inverted-papilloma-transformed sinonasal squamous cell carcinoma (IP-SCC). Method: A systematic literature review queried studies comparing recurrence patterns in patients with both DN-SCC and IP-SCC. Primary outcomes included local and regional recurrence and rates of distant metastasis. Of the 595 studies screened, eight were included. Results: Patients with DN-SCC had significantly higher rates of positive margins, advanced T classification (T3/T4), treatment with chemotherapy and radiotherapy. There were no significant differences in local recurrence or regional recurrence. Overall risk of distant metastasis was lower in IP-SCC. DN-SCC, compared to IP-SCC, is more likely to present with advanced TNM classification and have positive margins after surgical resection, which may affect rates of distant metastasis and recurrence. Conclusions: The findings in this study suggest IP-SCC may be a less aggressive malignancy compared to DN-SCC, with the possibility of a reduced role for adjuvant therapy in IP-SCC. Further studies are required to better understand differences in tumor biology and treatments strategies between IP-SCC and DN-SCC.

Sinonasal Symptom Outcomes following Endoscopic Anterior Cranial Base Surgery in the Pediatric Population

Objective This study aimed to evaluate the impact of endoscopic anterior cranial base (ACB) surgery on sinonasal symptoms in the pediatric population utilizing the Sino-Nasal Outcome Test (SNOT)-22 questionnaire.

Design This is a retrospective review.

Setting The study was conducted at a tertiary academic medical center.

Participants Thirty-four consecutive patients, age 6 to 17 years, M:F 14:20, who underwent endoscopic ACB surgery from July 2008 to August 2019. Ten patients had baseline and a minimum of two subsequent postoperative SNOT-22 questionnaires available for analysis.

Main Outcome Measures Baseline and postoperative SNOT-22 scores were compared. The mean change from baseline sinonasal symptom scores in the pediatric and historical adult cohorts was compared.

Results The mean baseline SNOT-22 score for our 10 patient cohort was 0.46 out of 5 for each of the first 10 sinonasal-specific questions. This worsened to 1.69 at 1 month and returned to near baseline, 0.7, at 3 months postoperatively. The mean quality-of-life score improved to 0.91 at 1 month and 0.6 at 3 months postoperatively. The mean change from baseline for the following items: need to blow nose, runny nose, postnasal discharge, thick nasal discharge, wake up at night, reduced concentration, and frustrated/restless/irritable were similar to those in our historical adult cohort at 3 months postoperatively.

Conclusion Endoscopic ACB surgery in the pediatric population results in increased sinonasal symptom morbidity in the early postoperative period; however, symptoms return to near baseline by ∼3 months, and quality-of-life scores progressively improve in the postoperative period. These trends were similar to those seen in our historic adult cohort.

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.

Effectiveness of the Endoscopic Prelacrimal Recess Approach for Maxillary Sinus Inverted Papilloma Removal: A Systematic Review and Meta-Analysis

BACKGROUND

Conventional minimally invasive surgery has a high recurrence rate, and nasal morbidity can occur if the scope of surgery is expanded to complete removal of maxillary sinus inverted papilloma.

OBJECTIVE

To analyze the efficacy of the endoscopic prelacrimal recess approach (EPLRA) for maxillary sinus inverted papilloma removal.

METHODS

Eighteen studies were included in this meta-analysis. Articles comparing the prelacrimal recess approach with conventional surgery (endoscopic surgery or the Caldwell-Luc operation) for inverted papilloma removal were included. Outcomes of interest included recurrence and postoperative morbidities. The methodological quality was assessed using the Newcastle-Ottawa scale.

RESULTS

The recurrence rates of inverted papilloma, postoperative facial or gingival numbness, and alar collapse were 3.13% (95% confidence interval [CI]: 1.32, 7.27), 9.02% (95% CI: 3.70, 20.39), and 3.39% (95% CI: 1.28, 8.68), respectively. The recurrence rate of inverted papilloma was significantly lower after the EPLRA than after conventional surgery (odds ratio [OR] = 0.2290; 95% CI: 0.0808, 0.6489). However, there were no significant differences between the procedures in the rates of facial or gingival numbness (OR = 0.4567; 95% CI: 0.1497, 1.3933), epistaxis (OR = 0.3150; 95% CI: 0.0471, 2.1044), or periorbital swelling (OR = 1.2405; 95% CI: 0.1205, 12.7731).

CONCLUSIONS

The EPLRA can preserve the lacrimal system and is useful for maxillary sinus inverted papilloma removal due to a lower recurrence rate compared with conventional surgeries.

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.

Attachment-Oriented Endoscopic Treatment of Inverted Papilloma Involving the Frontal Sinus/Recess

PURPOSE

Sinonasal inverted papilloma (IP) is a benign but locally aggressive tumor for which an endoscopic or external surgical approach is the treatment of choice. Complete resection of IP involving the frontal sinus/recess forms one of the most challenging procedures in the field of sinonasal surgery. This study aims to present our experience in the management of extensive frontal sinus IP based on the attachment sites of the tumor.

METHODS

Thirteen patients with IP involving the frontal sinus/recess between 2010 and 2018 were presented. The data collected include demographic data, tumor attachment sites, tumor extension, tumor staging according to Meng's staging system, surgical approach, recurrence, and follow-up.

RESULTS

The patients were successfully treated by endoscopic surgery without any additional external approaches. The attachment sites of the IP were multifocal in some patients. No recurrence was identified after an average follow-up period of 52.88 months. No major intra- or postoperative complications were observed.

CONCLUSION

The present study shows that attachment-oriented excision for IP involving the frontal sinus/recess is an acceptable approach. Surgeons should select the surgical approach based on the attachment sites of the tumor rather than the extension of the tumor. Even more importantly, the tumor attachment sites should include the sites of adhesion to the bone wall and the site of origin.

Dynamic Contrast-Enhanced MRI Can Quantitatively Discriminate the Original Site From Peripheral Portion of Sinonasal Inverted Papillomas

BACKGROUND

Identification of the original site of sinonasal inverted papillomas (SIPs) is difficult but essential for reducing the recurrence rate. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) may provide information about tissue perfusion and permeability to solve this problem.

PURPOSE

To investigate the accuracy of DCE-MRI parameters in discriminating between regions of interest (ROIs) in the original site and peripheral portion.

STUDY TYPE

Retrospective.

POPULATION

Ninety consecutive patients with pathologically proven SIP.

FIELD STRENGTH/SEQUENCE

3.0T/DCE-MRI using fast-spoiled gradient recalled (FSPGR) T₁ -weighted images with fat saturation.

ASSESSMENT

ROIs were placed in the original site and the peripheral portion of SIP by two radiologists according to surgical records. Maximum slope of increase (MaxSlope), contrast-enhancement ratio (CER), bolus arrival time (BAT), initial area under the signal intensity-time curve (IAUGC), volume transfer constant (K^trans ), volume of the extravascular extracellular space (v_e ), and rate constant (K_ep ) were calculated and repeated again with a month interval by a radiologist.

STATISTICAL TESTS

Univariate and multivariate analysis was used to determine the best diagnostic parameters, and their performances in discrimination were evaluated by receiver operating characteristic (ROC) curves. Reproducibility was estimated by the intraclass correlation coefficient (ICC).

RESULTS

MaxSlope, CER, IAUGC, K^trans , and v_e were significantly lower (P < 0.05) in the original site than the peripheral portion of SIPs. CER (odds ratio [OR] = 0.227, 95% confidence interval [95% CI] = 0.073-0.704) and v_e (OR = 0.048, 95% CI = 0.004-0.527) were the best indicators for identifying the original ROIs. The combination of CER and v_e had the best diagnostic performance in the discrimination between the ROIs (the area under the curve [AUC]: 0.937; 95% CI: 0.896-0.974).

DATA CONCLUSION

DCE-MRI derived parameter values differed between the original site and the peripheral portion of SIPs. The model combining CER and v_e appears to be able to accurately distinguish the original from peripheral ROIs.

LEVEL OF EVIDENCE

4 TECHNICAL EFFICACY STAGE: 2.

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.

The role of human papillomavirus in the pathogenesis of sinonasal inverted papilloma: a narrative review

Sinonasal inverted papillomas (IPs) are rare tumours arising from the nasal epithelial mucosa. Most lesions are benign, but a subset of IPs progress to dysplasia and squamous cell carcinoma. Although the epidemiology and clinical features of IPs are well known, the pathogenesis is still unclear. Given the established role of human papillomaviruses (HPVs) in the formation of other mucosal tumours including cervical and oropharyngeal cancer, some have suggested the virus may play a role in IP development. However, the association between HPV and IPs has not yet been proven, and the variable detection of HPV DNA in IPs has cast uncertainty on whether the virus plays a major role in pathogenesis. In this review, we summarize early clinical reports and synthesize recent studies that may elucidate the association between HPV and IPs. We also discuss the role HPV may have in the progression of benign IP to dysplasia and malignancy, as well as potential pathological mechanisms. We hope that synthesizing the initial and recent studies on this topic will not only lead to a better understanding of research in the role of HPV in IP development, but also help guide and contextualize future studies.

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.

Methodological Quality of Systematic Reviews and Meta-analyses Published in High-Impact Otolaryngology Journals

OBJECTIVE

To assess the methodological quality of intervention-focused systematic reviews (SRs) and meta-analyses (MAs) published in high-impact otolaryngology journals.

DATA SOURCES

Ovid Medline, Embase, and Cochrane Library.

REVIEW METHODS

A comprehensive search was performed for SR and MA citations from 2012 to 2017 in the 10 highest impact factor otolaryngology journals. Abstracts were screened to identify published manuscripts in which the authors indicated clearly that they were performing an SR or MA. Applying a modified typology of reviews, 4 reviewers characterized the review type as SR, MA, or another review type. A simplified version of the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2) tool was used to assess the reporting and methodological quality of the SRs and MAs that were focused on interventions.

RESULTS

Search and abstract screening generated 499 manuscripts that identified themselves as performing an SR or MA. A substantial number (85/499, 17%) were review types other than SRs or MAs, including 34 (7%) that were literature reviews. In total, 236 SRs and MAs focused on interventions. Over 50% of these SRs and MAs had weaknesses in at least 3 of the 16 items in the AMSTAR 2, and over 40% had weaknesses in at least 2 of the 7 critical domains. Ninety-nine percent of SRs and MAs provided critically low confidence in the results of the reviews.

CONCLUSION

Intervention-focused SRs and MAs published in high-impact otolaryngology journals have important methodological limitations that diminish confidence in the results of these reviews.

Roles of PI3K pan-inhibitors and PI3K-δ inhibitors in allergic lung inflammation: a systematic review and meta-analysis

Meta-analysis can be applied to study the effectiveness of the summary estimates for experimental papers, producing objective and unbiased results. We investigated the effects of phosphoinositide-3-kinase (PI3K) on the inflammatory profile in allergic mouse models, which are currently under development in signal transduction materials. PubMed, EMBASE and Web of Science databases were searched for relevant literature using the search terms “ PI3K inhibitor” and “allergy” or “asthma”. Cochrane Review Manager and R were used for handling continuous variables. The primary outcomes of the inflammatory profile were divided into cell counts and inflammatory cytokines. We used a random effects model to draw a forest plot. Through the database search and subsequent selection, 17 articles were identified. Regarding the cell counts, both the PI3K pan-inhibitors and PI3K-δ inhibitors effectively reduced the total cell counts, eosinophils, neutrophils and lymphocytes. In contrast to PI3K-δ inhibitors, PI3K pan-inhibitors effectively reduced macrophages. Regarding the inflammatory cytokines, PI3K pan-inhibitors and PI3K-δ inhibitors effectively reduced total IgE, IL-4, IL-5, IL-13, TNF-α, IL-1β, VEGF and had no effect on IL-6. Compared to the PI3K pan-inhibitors, which block all pathways, selective PI3K-δ inhibitors are expected to be relatively less toxic. Regarding the efficacy, PI3K-δ inhibitors have at least the same or better efficacy than PI3K pan-inhibitors in effector cells and inflammatory mediators.

Modified endoscopic Denker approach in management of inverted papilloma of the anterior maxillary sinus

BACKGROUND

Inverted papilloma (IP) is a benign epithelial tumor of the sinonasal cavity that is locally aggressive and has a propensity for recurrence. Tumors involving the anterior maxillary sinus can be challenging to reach endoscopically, and have historically been approached through a Caldwell-Luc or canine fossa trephination. We present a case series of 22 patients with maxillary IPs originating from the anterior wall, which were successfully resected using a modified endoscopic Denker (MED) procedure. This technique enables access to the entire maxillary sinus without the need for a separate transseptal or sublabial incision.

METHODS

A retrospective chart review was performed on patients who underwent the MED approach for management of maxillary IPs involving the anterior wall from 2012 to 2018. The demographic data, clinical presentation, radiographic findings, pathology, and surgical outcomes were reviewed.

RESULTS

Twenty-two patients were identified, including 13 males and 9 females. Eighteen of the 22 patients had prior surgery and all had Krouse stage 3 disease. After a mean follow-up of 24 (range, 4-63) months, only 1 patient (4.5%) developed a recurrence, which was treated successfully with endoscopic resection. Complications included 1 patient with preoperative epiphora who required dacryocystorhinostomy, epistaxis in another, and 1 patient with transient upper lip numbness. No patients developed alar notching or pyriform aperture stenosis.

CONCLUSION

The MED technique is highly effective for surgical resection of primary and recurrent maxillary IPs involving the anterior wall, providing complete access to the entire maxillary sinus. In many cases, the MED can obviate the need for an adjunctive sublabial or transseptal incision, while also providing excellent exposure for postoperative surveillance.

Computed Tomography as a Predictor of Sinonasal Inverted Papilloma Origin, Skull Base Involvement, and Stage

Objective  To investigate the diagnostic performance of computed tomography (CT) to determine the origin, skull base involvement, and stage of sinonasal inverted papilloma (IP). Design  This is a retrospective cohort study. Setting  This is set at a tertiary care medical center. Participants  Patients with preoperative CT imaging who underwent extirpative surgery for histologically confirmed sinonasal IP between January 2005 and October 2019. Main Outcome Measures  The likely sites of tumor origin, skull base involvement, and radiographic tumor stage were determined by two board-certified neuroradiologists after re-reviewing preoperative CT imaging. These radiologic findings were then compared with intraoperative and pathologic findings. Results  Of 86 patients, 74% (64/86) had IP lesions with correctly classified sites of origin on CT. CT was not sensitive for diagnosing ethmoid sinus origin (48%, 52%), frontal sinus origin (80%, 40%), and skull base origin (17%, 17%). CT was not sensitive (62%, 57%) but specific (86%, 98%) for identifying any skull base involvement. There was substantial-to-near perfect agreement between radiographic and pathologic Cannady stages (weighted κ = 0.61 for rater 1; weighted κ = 0.81 for rater 2). Interrater agreement was substantial for identifying tumor origin (κ = 0.75) and stage (weighted κ = 0.62) and moderate for identifying skull base involvement (κ = 0.43). Conclusion  Interrater agreement on CT findings was substantial except on skull base involvement. CT correctly predicted site of tumor origin in up to 74% of subjects. CT was not sensitive for diagnosing skull base involvement but had substantial-to-near perfect agreement with pathologic tumor staging. CT is a useful but albeit limited adjunct for tumor localization and surgical planning for sinonasal IP.

Surgery of Inverted Papilloma of the Maxillary Sinus via Translacrimal Approach-Long-Term Outcome and Literature Review

There are several differential diagnoses of unilateral sinus disease. One of these is inverted papilloma (IP) of the maxillary sinus, which is a common benign tumor with a substantial rate of malignant transformation. In general, endoscopic endonasal techniques for addressing the tumor are favored nowadays instead of classical external approaches. The aim of this retrospective study was to investigate the long-term outcome of inverted papilloma treated endoscopically via the prelacrimal approach. We reviewed 17 patients with primary or recurrent IP of the maxillary sinus that were treated via the prelacrimal endoscopic endonasal technique. After a median follow-up period of 45.9 months (3.8 years), none of the 17 included patients showed signs of recurrent disease and no serious complications were reported. Hypoesthesia of the incisors was reported by four patients and was resolved with time in one. All of the maxillary sinuses could be fully visualized with the flexible endoscope. IP is an important differential diagnosis in the clinical finding of unilateral nasal polypoid lesions. The prelacrimal approach is an effective and safe method in the treatment of IP with limited patient morbidity.

Inverted papilloma with multifocal attachment is associated with increased recurrence

BACKGROUND

Inverted papilloma (IP) is a benign sinonasal tumor with a well-known propensity to recur, especially at its bony attachment site. Anecdotal evidence suggests lower rate of recurrence in primary resection. We also aimed to evaluate the effect of multifocal vs single focus of attachment in disease control.

METHODS

This work is a retrospective review of 535 IP resections performed during the period from 2006 to 2016 at a tertiary-care center. Demographic data, tumor location and attachment sites, and follow-up duration data were obtained.

RESULTS

Two hundred ten patients were eligible for analysis. The mean age was 57 years, with an average postoperative surveillance of 36.4 months. Patients who had a previous procedure at an outside institution have a recurrence rate of 22.3%, compared with 12.4% for patients who had primary surgery at our institution. The most common site of attachment was maxillary sinus (47.6%), followed by ethmoid sinus (39%). Individual tumor review showed 50% of the patients to have multifocal attachment disease, of which there is a higher prevalence in secondary cases when compared with primary cases (53.7% vs 44.9%). Multiple tumor attachment sites had a significant effect on recurrence (odds ratio, 3.5; 95% confidence interval, 1.6-7.6; p = 0.002).

CONCLUSION

Primary resection and single-focus attachment of inverted papilloma are associated with lower recurrence rates at 3-year follow-up.

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.

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.

Whole-Exome Sequencing of Sinonasal Small Cell Carcinoma Arising within a Papillary Schneiderian Carcinoma In Situ

OBJECTIVE

The pathogenetic underpinnings of extrapulmonary small cell carcinomas (EPSCCs) of the head and neck are poorly understood. We sought to describe the clinical case and whole-exome DNA sequencing data of a patient with sinonasal Schneiderian carcinoma in situ whose tumor progressed to small cell carcinoma (SCC).

STUDY DESIGN

Case report and whole-exome sequencing of tumor DNA.

SETTING

Academic medical center.

SUBJECTS AND METHODS

A 52-year-old man with sinonasal Schneiderian carcinoma in situ whose tumor progressed to small cell carcinoma. We performed whole-exome genetic sequencing and copy-number variation (CNV) analysis of tumor and normal DNA extracted from flash-frozen, paraffin-embedded (FFPE) samples.

RESULTS

A total of 93 high-confidence, nonsynonymous somatic mutation events were identified in sinonasal SCC, including loss-of-function mutations in TP53, MAML3, a transcriptional coactivator of the Notch pathway, and GAS6, an activating ligand of the TAM family of tyrosine kinase receptors. Focal amplifications of chromosomal regions 6p25-11.1, containing SOX4 and VEGFA, and 14q32.1-32.3, containing AKT1 and the Notch inhibitory ligand DLK1, were also seen. Further CNV analysis revealed deletions in the critical cell cycle regulators CDKN2A, RB1, RBL1, and RBL2 and the chromatin modifier EP300.

CONCLUSIONS

Small cell carcinoma may rarely arise from sinonasal Schneiderian carcinoma in situ and exhibits similar genomic aberrations (eg, SOX amplification, Notch pathway inactivation) to pulmonary small cell carcinoma.

Use of intraoperative negative margins reduces inverted papilloma recurrence

BACKGROUND

Recurrence of inverted papilloma (IP) is a problem in 12-17% of tumors. Controversy exists regarding benefits of intraoperative frozen section histopathology (IFSH) for IP resection; however, to our knowledge, no study has specifically investigated this. IFSH for IP resection is the standard of care in our practice. We, therefore, reviewed our outcomes of using IFSH for IP resection. A secondary goal was to assess the reliability of IFSH.

METHODS

Patients with IP who underwent surgical resection (2010-2016) with minimum 9-month follow-up were included.

RESULTS

Twenty-two adults with IP met inclusion criteria. All underwent surgery via endoscopic techniques, supplemented by external ports in five patients. At the time of presentation, 36% IPs were recurrent tumors; 68% were graded as Krouse stage 3. Resection was conducted until "clear" (negative) mucosal margins were achieved on IFSH. In 6 (27%), a "positive" IFSH result dictated additional resection to clear margins. Final negative margins were achieved in all the patients. Both positive and negative predictive values for IFSH were 100% (concordance with final pathology results). Surveillance was performed every 1-6 months with nasal endoscopy by using imaging when necessary. No recurrences were noted (0%) at mean follow-up of 40 months (range, 10-73 months).

CONCLUSIONS

Positive IFSH results led to increased resection in 27% of the patients, with a 0% recurrence rate in this cohort. The reliability of IFSH for IP is very high. No recurrence of IP was noted in any patient at a mean follow-up of 3.3 years. IFSH may help reduce recurrence rates of IP, but additional studies with longer follow-up are warranted.

Different characteristics of a single sinonasal inverted papilloma from sequential PET-CT: A case report

RATIONALE

Inverted papilloma (IP) is a benign tumor that should be monitored carefully because it frequently recurs and has the potential to become malignant.

PATIENT CONCERNS

We report a case of a 59-year-old woman who presented with a mass which had been found incidentally on positron emission tomography computed tomography (PET CT).

DIAGNOSES

Using endoscopy and CT, the preoperative diagnosis was inverted papilloma. PET CT showed a mass with hot uptake in the left ethmoid and frontal sinus (maximum standardized uptake value (SUVmax) = 7.80).

INTERVENTIONS

We performed endoscopic sinus surgery (ESS) using 4 mm 0° and 70° endoscopes under general anesthesia. After 15 months of follow-up, remnant masses existed in the left frontal and supraorbital ethmoid cells. In the second PET CT taken at this time, a mass with lower SUV compared to the preoperative PET was observed in the lateral side of the left frontal sinus (SUVmax= 1.71). Revision ESS was performed using the "above and below" technique.

OUTCOMES

Two years after initial surgery, follow-up CT showed there was no tumor recurrence in the frontal sinus or supraorbital ethmoid cell. There were no complications such as numbness in the forehead area after the operations.

CONCLUSION

If the tumor is located at a site that is difficult to reach with an endoscope alone, it is faster and less painful to choose a more convenient approach for the patientand it can avoid unnecessary cost burden. It should also be noted that the SUV of PET is not a tool to distinguish IP from other inflammatory polyps or cancer.

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.

"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.