Factors affecting recurrence of sinonasal inverted papilloma

Fluorescence grid analysis for the evaluation of piecemeal surgery in sinonasal inverted papilloma: a proof-of-concept study

Purpose

Local recurrence occurs in ~ 19% of sinonasal inverted papilloma (SNIP) surgeries and is strongly associated with incomplete resection. During surgery, it is technically challenging to visualize and resect all SNIP tissue in this anatomically complex area. Proteins that are overexpressed in SNIP, such as vascular endothelial growth factor (VEGF), may serve as a target for fluorescence molecular imaging to guide surgical removal of SNIP. A proof-of-concept study was performed to investigate if the VEGF-targeted near-infrared fluorescent tracer bevacizumab-800CW specifically localizes in SNIP and whether it could be used as a clinical tool to guide SNIP surgery.

Methods

In five patients diagnosed with SNIP, 10 mg of bevacizumab-800CW was intravenously administered 3 days prior to surgery. Fluorescence molecular imaging was performed in vivo during surgery and ex vivo during the processing of the surgical specimen. Fluorescence signals were correlated with final histopathology and VEGF-A immunohistochemistry. We introduced a fluorescence grid analysis to assess the fluorescence signal in individual tissue fragments, due to the nature of the surgical procedure (i.e., piecemeal resection) allowing the detection of small SNIP residues and location of the tracer ex vivo.

Results

In all patients, fluorescence signal was detected in vivo during endoscopic SNIP surgery. Using ex vivo fluorescence grid analysis, we were able to correlate bevacizumab-800CW fluorescence of individual tissue fragments with final histopathology. Fluorescence grid analysis showed substantial variability in mean fluorescence intensity (FI_mean), with SNIP tissue showing a median FI_mean of 77.54 (IQR 50.47–112.30) compared to 35.99 (IQR 21.48–57.81) in uninvolved tissue (p < 0.0001), although the diagnostic ability was limited with an area under the curve of 0.78.

Conclusions

A fluorescence grid analysis could serve as a valid method to evaluate fluorescence molecular imaging in piecemeal surgeries. As such, although substantial differences were observed in fluorescence intensities, VEGF-A may not be the ideal target for SNIP surgery.

Trial registration

NCT03925285.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00259-021-05567-x.

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.

Clinical characteristics of sinonasal inverted papilloma associated with recurrence and malignant transformation

OBJECTIVE

Sinonasal inverted papilloma is a benign tumor but has a potential for recurrence and malignant transformation. The aim of this article is to analyze the clinical characteristics of sinonasal inverted papilloma associated with recurrence and malignant transformation.

MATERIAL AND METHODS

A retrospective study was performed in all patients with sinonasal inverted papilloma diagnosed between in our hospital during May 2013 and May 2018.

RESULTS

A total of 151 patients were enrolled in this study. The average age of these patients was 52.24 years, with a male-to-female ratio of 2.775:1, and the most frequent clinical symptom was nasal obstruction. The recurrence rate was 39.07% (59/151), the mean time of recurrence was 35.8 months and most recurrences occur within the first three years after surgery. There was no significant difference in recurrence rate between all four stages and between after endoscopic surgery and a combined endoscopic and external approach. The malignant transformation rate was 5.96% (9/151) and the mean time of malignant transformation was 9.06 months.

CONCLUSIONS

Because of its high recurrence rate and the potential of malignant transformation, so it is important to determine the primary site of the tumor and to make a complete removal and a follow-up of at least five years after surgery is recommended.

[Follow-up care of sinonasal papillomas - risk factors for recurrence and malignant progression]

OBJECTIVE

Sinonasal papillomas are tumors of the nasal cavity and paranasal sinuses. They are treated through complete resection under oncologic conditions. Two characteristics complicate follow-up: 1) frequent tumor recurrences (even many years after initial diagnosis), 2) possibility for malignant progression. This review elucidates risk factors for these two characteristics to depict "high-risk patients" for whom a closer follow-up is mandatory.

MATERIALS AND METHODS

Literature was searched in Pubmed (NCBI).

RESULTS

The most important risk factor for recurrence is incomplete tumor resection. This comprises several more factors: inappropriate surgical procedure, large tumors, difficult surgical conditions due to tumor localization or to prior surgery. Young age and tobacco smoking are risk factors for frequent recurrences. In regard to malignant progression, extended tumors, smoking, senior age, female sex, bone invasion, and lack of inflammatory polyps have been identified as risk factors. Histopathological factors for both - recurrences and malignant progression - are epithelial dysplasia, hyperkeratosis, squamous hyperplasia, as well as (if known) increased proliferation, aneuploidy, and infection with human papillomaviruses.

CONCLUSIONS

Complete resection of sinunasal papillomas under oncologic conditions is of utmost importance. A careful postoperative follow-up is mandatory. Most authors suggest at least a five-year, some a lifelong follow-up. Patients with one or more risk factors should be monitored more closely.

Sine Qua Non: Sinonasal Inverted Papilloma

Inverted papilloma (IP) is a common proliferation of squamous epithelial cells of the sinonasal tract. Although considered benign, IP is known to cause local destruction, has a high rate of recurrence, and a low, but significant rate of malignant transformation. Differentiating an IP from its histologic mimickers is essential for appropriate risk stratification and long-term surveillance. A classic case of sinonasal inverted papilloma is discussed.

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.

Can Computed Tomography Findings Predict the Recurrence of Sinonasal Inverted Papilloma?

OBJECTIVE

To evaluate the correlation between the ability to predict the attachment site of sinonasal inverted papilloma by computed tomography and the long-term surgical outcome.

STUDY DESIGN

Retrospective cohort study.

SETTING

Five tertiary medical centers.

METHODS

Study patients underwent attachment-oriented resection of inverted papilloma. The primary outcome was tumor recurrence.

RESULTS

Among 195 patients eligible for the study, focal hyperostosis was recognized on computed tomography in 65% (n = 127), in 71% of primary cases (n = 101), and in 50% of revision procedures (n = 26). There was a trend for a higher incidence of squamous cell carcinoma among the patients without detectable hyperostosis (P = .051). Location of hyperostosis coincided with the actual tumor attachment site in 114 patients (90%). Discordance between these parameters did not differ significantly (P = .463) between 11 primary and 2 revision cases. The overall rate of recurrence was 9.7% (n = 19), with a mean time to recurrence of 20 months (range, 7-96 months). The rate of recurrence did not correlate with any of the following: tumor stage, surgical approach, presence of squamous cell carcinoma, whether the surgery was primary or revision, and the presence or location of focal hyperostosis on computed tomography. Inverted papilloma recurred significantly more often (38.5%) when the intraoperative findings of the tumor attachment site did not match the location of hyperostosis observed on computed tomography (odds ratio, 6.5; 95% CI, 1.78-23.66).

CONCLUSION

Detectability of focal hyperostosis on preoperative computed tomography does not affect the long-term outcome of inverted papilloma resection.

How aggressive should resection of inverted papilloma be? Refinement of surgical planning based on the 25-year experience of a single tertiary center

BACKGROUND

The technique for transnasal endoscopic resection of inverted papilloma (IP) has evolved considerably during the last 20 years. The aim of the present study is to retrospectively analyze a single tertiary center series, with special emphasis on assessing the value of an "insertion-driven" technique on local control.

METHODS

Patients undergoing endoscopic resection for IP at the University of Brescia during the period 1991 to 2015 were enrolled. Site of origin and extension of IPs were assessed, together with presence of dysplasia and carcinoma in situ. Patients were divided in 3 cohorts: (1) historical cohort (treated before 2008), (2) contemporary "centripetal" cohort (treated with a traditional technique after 2008), and (3) contemporary "insertion-driven" cohort (treated with insertion-driven resection). Groups were compared considering outcomes and complications.

RESULTS

The series included 210 patients. Mean follow-up was 77.8 months. Thirty-eight (18.1%) patients showed precancerous changes. Maxillary involvement (p = 0.021) and presence of precancerous changes (p = 0.013) were significantly associated with a higher risk of recurrence. Five-year local control rate before and after 2008 was 95.1% and 90.5%, respectively. The insertion-driven cohort was associated with lower disease control when IPs involved the maxillary sinus. The rate of complications was 11.9%. The insertion-driven cohort was associated with a lower rate of major complications (p = 0.098).

CONCLUSION

Preoperative evidence of precancerous changes and/or involvement of maxillary sinus should prompt the surgeon to address the disease more aggressively (centripetal resection). Preoperative imaging and biopsy with abundant material may optimize the chance to stratify patients eligible for less or more conservative approaches.

Squamous cell carcinoma associated with inverted papilloma: Recurrence and prognostic factors

The purpose of the present study was to review the recurrence and prognostic factors of squamous cell carcinoma (SCC) associated with inverted papilloma (IP). A retrospective chart review was conducted on 21 patients with SCC associated with IP, in the nasal cavity and paranasal sinuses, between March 2007 to March 2017. All patients underwent surgical treatment: Surgery prior to or following adjuvant therapy was performed in 17 patients (81.0%). During a mean follow-up time of 47.4 months (range, 3-123 months), 9 patients (42.9%) experienced local recurrence, and the risk factors of T4 stage and invasive orbital cavity had a significant influence on recurrence. The 1-, 3-, and 5-year overall survival rates were 90.5, 75.4 and 68.5%, and the 1-, 3-, and 5-year disease-specific survival (DSS) rates were 90.5, 80.4 and 80.4%, respectively. The prognosis of patients with stage T4 was not satisfactory compared with those with stage T3 or less, and a positive surgical margin was also significantly associated with poor survival. Overall, SCC associated with IP has a favorable DSS, early diagnosis and complete resection of lesions is required for a good prognosis. Furthermore, aggressive surgical approaches combined with postoperative adjuvant therapy seem to be effective in tumors at stage T4.

Does evaluation of tumor volume or/both origination site better guide to optimal surgery for inverted papilloma?

INTRODUCTION

Sinonasal inverted papilloma is noted for its high rate of recurrence. Staging systems aid to reduce recurrence and avoid excessive surgeries by guiding the selection of the optimal surgical approach.

OBJECTIVE

To evaluate the effectiveness of different endoscopic approaches in inverted papilloma by assessing tumor origin site and tumor volume.

METHODS

Krouse classification system that is based on tumor volume was used for staging; furthermore, tumor origin sites were grouped as lateral nasal wall, medial wall and other walls of maxillary sinus. The main treatment method for all patients was endoscopic sinus surgery. Endoscopic extended middle meatal antrostomy, endoscopic Caldwell-Luc and endoscopic medial maxillectomy were the additional surgery types performed in different combinations.

RESULTS

Fifty-five patients (42 male) with a mean 54.9±14.4 years of age were included. 37 patients were diagnosed with advanced stage inverted papilloma (67.2 %). Recurrence was observed in 12 patients (21.8 %). In early stage lateral nasal wall origination, no recurrence was observed in the simple tumor resection group (0/10). In early stage medial wall origination, no recurrence was observed in the extended middle meatal antrostomy group (0/8). In advanced stage medial wall origination, the recurrence rates of extended middle meatal antrostomy, extended middle meatal antrostomy+endoscopic Caldwell- Luc and endoscopic medial maxillectomy were 100.0 %, 53.8 % and 13.6 %, respectively (p=0.002). In advanced stage other walls of maxillary sinus origination, recurrence rates of extended middle meatal antrostomy+endoscopic Caldwell-Luc and endoscopic medial maxillectomy were 20 % and 16.6 %, respectively (p=0.887).

CONCLUSION

Tumor origin site, tumor stage and surgery types show an impact on recurrence. Despite the fact that tumor origin site singly could lead to appropriate selection of the surgery type in most cases, tumor stage carries substantial importance in selection of surgery type for sinonasal-inverted papilloma. An operation plan regarding both tumor volume and tumor origin site may aid surgeons in selecting optimal endoscopic surgical method to avoid recurrence or excessive surgeries.

Sinonasal inverted papilloma: rate of recurrence and malignant transformation in 44 operated patients

Introduction

Although sinonasal inverted papillomas are benign lesions, they are locally aggressive and have a potential malignant transformation ranging from 5% to 15%, with a high recurrence rate.

Objective

The aim of this article is to describe the rate of recurrence and malignant transformation in patients with a diagnosis of inverted papilloma who underwent surgery in a tertiary hospital in São Paulo.

Methods

We performed a retrospective analysis of patients diagnosed with sinonasal papilloma who had undergone surgery in a tertiary hospital in São Paulo, between August 1998 and August 2017. A patient chart review was conducted to assess data of patients’ demographics, tumors characteristics, follow-up appointments, recurrence and malignancy. Inverted papillomas were analyzed and classified under the Krouse staging system.

Results

A total of 69 surgeries were performed in patients with diagnosis of sinonasal papilloma. Inverted papilloma was the most prevalent subtype (49 cases ‒ 80.33%), followed by exophytic papilloma (6 cases ‒ 9.84%) and by oncocytic papilloma (6 cases – 9.84%). The recurrence rate was 34.09% for inverted papilloma (15/44) and the mean time of recurrence was 24.6 months. Malignant transformation occurred in 6 patients (13.64%). Three of these patients presented carcinoma in the first surgery and three patients developed carcinoma during the follow-up.

Conclusion

The high recurrence rate and malignancy potential allow us to consider inverted papillomas as aggressive tumors. In a tertiary hospital in São Paulo the recurrence rate the mean time to recurrence is 24.6 months. The recurrence after 10 years implies was 34.09% and the need for long-term follow up. It is possible that the high recurrence rate and the high malignant transformation rate we found are due to the large number of tumors discovered at an advanced stage (most of them staged T3 and T4), secondary to poor access to health system, in developing countries.

Endoscopic Resection of Sinonasal Inverted Papilloma: Systematic Review and Meta-Analysis

Background Pure endoscopic surgery (functional endoscopic sinus surgery) has been increasingly replacing external approaches in the management of sinonasal inverted papillomas. Objective To analyze and compare the effectiveness of pure endoscopic procedure with external or combined procedures to paranasal inverted papillomas, including the experience from two institutions in North Greece, over a 20-year period. Methods Systematic literature searches of MEDLINE (1952-2016), EMBASE (1974-2016), and the Cochrane Central Register of Controlled Trials. Review of all English-language studies comparing endoscopic and open techniques. Odds ratios (ORs), risk ratio, 95% confidence intervals (CIs), and tests for heterogeneity were reported. Recurrence rates according to initial tumor stage. Results In total, 2451 patients had been enrolled in the 23 studies, published between 1992 and 2014. All the included articles are graded as level IV evidence. Among the 1526 patients of the endoscopic group, 212 (13.8%) had recurrence, with the mean time of recurrence to range from 14 to 46.6 months. In the external approach group, 111 (18.7%) of the 592 patients had recurrence, with the time of recurrence to range from 7 to 92 months. The recurrence rate in the combined approach group was 12.9%. The occurrence rate of recurrence attributable to the surgical choice was significantly different between endoscopic and external group (OR: 0.61; 95% CI: 0.40-0.92; P = 0.02; 14.9% vs. 18.8% in endoscopic and external group, respectively). Conclusions The present systematic review and meta-analysis indicates that endoscopic approach seems a favorable treatment option of sinonasal inverted papillomas and confirms the global recommendation that is the gold standard in the treatment of such nose lesions, revealing a lower recurrence rate compared to external approaches.

Endoscopic management of maxillary sinus inverted papilloma attachment sites to minimize disease recurrence

BACKGROUND

Inverted papillomas (IPs) are benign neoplasms, most commonly arising from the mucosal lining of the maxillary sinus. IPs can have single or multifocal sites of attachment. Although pedicle location is an important factor to consider in surgical planning, it is less clear whether the location or number of IP attachment sites hold any prognostic value. Herein, we aimed to determine the prognostic significance of the number and location of attachment sites of IPs originating from the maxillary sinus when managed by a pure endoscopic approach.

METHODS

This was a single-center, single-surgeon retrospective chart review. Patients with maxillary sinus IPs who were managed by endoscopic approaches only, from January 1, 2010 to June 30, 2016, were identified. Demographic data, operative technique, number and location of IP attachment sites, follow-up duration, recurrence, and presence of malignant transformation were captured.

RESULTS

Twenty-eight maxillary IP patients (61% males) were included, with a mean age of 54.9 (standard deviation (SD): 16.5) years. Approximately 36% of patients were referred from other institutions for management of recurrent IPs after failing previous surgical treatment. All patients were managed with an endoscopic approach, and all required an endoscopic medial maxillectomy to facilitate access to the maxillary sinus. At a mean follow-up of 31.1 (SD: 22.6) months, there were no recurrences identified. IPs with single (46%) and multifocal (54%) attachments were predominately to the medial and lateral walls. Maxillary IPs with multifocal attachments most frequently involved 2-3 walls of the sinus. Osteitis (36%) was commonly seen.

CONCLUSION

IPs originating from the maxillary sinus frequently had multifocal attachments, but this did not impact disease recurrence. Despite the surgical challenges of accessing all of the maxillary sinus walls, IPs originating from the maxillary sinus can be effectively managed via a pure endoscopic approach.

Risk Factors of Recurrence and Malignant Transformation of Sinonasal Inverted Papilloma

Sinonasal inverted papilloma is a relatively rare disease; however, it is prevalent enough for every ENT practitioner to encounter it several times throughout medical routines. Despite the developments in experimental and clinical medicine as well as surgical techniques, our knowledge of this disease is still inadequate. With improved imaging and better diagnostic techniques, proper diagnosis and qualification for surgical approaches leave no doubt. Although the endoscopic approach seems to be the gold standard for such condition, some cases may additionally require an external approach. Regardless of the type of surgery, postoperative management is crucial for both healing and long-term follow-up. Unfortunately, the procedures are still lacking in explicit and standardized postoperative management guidelines. Moreover, an important issue is still the need for a biomarker indicative of inverted papilloma and its malignant transformation. Several particles, within the spotlight of the researchers, have been SCCA, Ki-67, Bcl-2, Wnt proteins, and many more. Nevertheless, the topic requires further investigations.

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.

Advances in recurrence and malignant transformation of sinonasal inverted papillomas

Sinonasal inverted papilloma (SIP) is a benign tumor of the nasal cavity and sinus. SIP is characterized by aggressive malignant transformation and a high rate of recurrence. Inadequate removal of the tumor during surgery is one of the most significant contributors to SIP recurrence. A growing body of evidence suggests that molecular alteration in SIP, including human papilloma virus infections, single nucleotide polymorphisms of key genes, deregulation of signaling pathways and immunological changes, may lead to SIP occurrence and malignant transformation. However, the extent to which these molecular mechanisms contribute to SIP pathology and transformation remains unclear due to limited research. Further studies are warranted to elucidate the primary dependent factors that contribute to SIP etiology. The present article reviewed risk factors of progression and recurrence of SIP, including outdoor and industrial occupational exposure, smoking, septal deviation, SIP location, recurrent cases, stage of SIP-associated squamous cell carcinoma and choice of surgical method.

Sinonasal Inverted Papilloma: Risk Factors for Local Recurrence After Surgical Resection

Objectives:

Sinonasal inverted papillomas (SIP) present a potential for recurrence years after the surgery, but most studies report short-term follow-up, and risk factors for recurrence are still debated. Furthermore, several classifications are described, and no consensus exists regarding which one should be used. The aims of this study were to report our long-term results, investigate for potential risk factors for recurrence, and compare the existing 8 staging systems.

Methods:

Over a 28-year period, 110 patients with a diagnosis of SIP were enrolled. The median follow-up time was 55.6 months.

Results:

In multivariate Cox regression modeling, history of previous surgery was the only variable associated with recurrence (hazard ratio = 4.91, 95% CI, 1.80-13.39). Recurrences occurred up to 60 months after the surgery. Among the 8 staging systems, none proved to be associated with recurrence.

Conclusion:

The only factor associated with recurrence of SIP was prior surgery, probably corresponding to an incomplete initial resection. Due to late recurrences, an extended follow-up of at least 5 years is mandatory. In the absence of a classification predicting prognosis, Krouse’s staging system should be used to homogenize studies’ report since it is the most widely used.

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.

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

OBJECTIVES/HYPOTHESIS

Inverted papilloma (IP) is a rare benign tumor, which is found in the sinonasal area. It is characterized by recurrence, local destruction, and malignant change. Of these, recurrence is a challenging problem to many otolaryngologists. In this study, we evaluated recurrence based on the type of surgical approach using a meta-analysis.

STUDY DESIGN

MEDLINE, Embase, and Cochrane database.

METHODS

Relevant studies were identified by searching the following databases: MEDLINE, Embase, and Cochrane through February 2016. Random-effects models were used to estimate risk ratio (RR) and 95% confidence interval (CI). The Newcastle-Ottawa scale was used to assess the quality of cohort studies.

RESULTS

Our search yielded 14 retrospective cohort studies involving a total of 696 endoscopic approaches and 444 nonendoscopic approaches. The pooled RR for IP recurrence (endoscopic vs. external approach) was 0.56 [95% CI: 0.36-0.85, I² =48.3%]. A subgroup analysis was also performed.

CONCLUSIONS

Surgical management of IP via an endoscopic approach reduces the risk of recurrence compared to an external approach. Although further data are needed, early- stage IP requires endoscopic or endoscopic-assisted surgery to reduce the risk of tumor recurrence.

LEVEL OF EVIDENCE

NA Laryngoscope, 127:52-58, 2017.

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.

Nasal endoscope: an armamentarium in the management of sinonasal inverted papilloma

Sinonasal inverted papillomas (SIP) are unique group of locally aggressive benign neoplastic lesions arising from mucosa of sinonasal tract with potential for recurrences and known association with squamous cell carcinoma in 5-15 % of cases. This study was conducted was to assess the efficacy and usefulness of the nasal endoscope in treating SIP. We reviewed 28 biopsy proven cases of SIPs that were treated at our hospital between June 2009 and September 2013. Average patient age was 46 years. Fourteen were treated by transnasal endoscopic excision of tumor with noted recurrence of 21.43 %. Thirteen were treated by endoscopic assisted open surgery which had 23 % recurrence. Three patients had malignant inverted papillomas, of whom two (7 %) were found to have synchronous squamous cell carcinoma and one (3.6 %) had metachronous squamous cell carcinoma. No evidence of recurrence was found in rest during our follow up. The endoscopic approach is the preferred method for the treatment of the majority of inverted papillomas. Powered instrumentation is extremely useful to achieve good results. Although significant number of cases was done by external approach by lateral rhinotomy, the endoscopic assistance is required to ensure complete removal of the tumour to reduce the recurrence rates. Close follow up of the patient for a longer period of time is necessary for the early detection of recurrence and to allow for surgical salvage.