Markers of malignant transformation of sinonasal inverted papilloma

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.

METHODS

In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.

RESULTS

The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.

CONCLUSION

As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

Tumors of the Nose and Paranasal Sinuses: Promoting Factors and Molecular Mechanisms-A Systematic Review

Sinonasal neoplasms are uncommon diseases, characterized by heterogeneous biological behavior, which frequently results in challenges in differential diagnosis and treatment choice. The aim of this review was to examine the pathogenesis and molecular mechanisms underlying the regulation of tumor initiation and growth, in order to better define diagnostic and therapeutic strategies as well as the prognostic impact of these rare neoplasms. A systematic review according to Preferred Reporting Items for Systematic Review and Meta-Analysis criteria was conducted between September and November 2022. The authors considered the three main histological patterns of sinonasal tumors, namely Squamous Cell Carcinoma, Intestinal-Type Adenocarcinoma, and Olfactory Neuroblastoma. In total, 246 articles were eventually included in the analysis. The genetic and epigenetic changes underlying the oncogenic process were discussed, through a qualitative synthesis of the included studies. The identification of a comprehensive model of carcinogenesis for each sinonasal cancer subtype is needed, in order to pave the way toward tailored treatment approaches and improve survival for this rare and challenging group of cancers.

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

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

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.

Impact of human papillomavirus in sinonasal cancer-a systematic review

BACKGROUND

Human papillomavirus (HPV) is an established prognostic marker in oropharyngeal squamous cell carcinoma. Currently, the role of HPV in sinonasal carcinoma is being explored.

OBJECTIVES

This systematic review addresses the role of HPV in sinonasal cancer, establishing the occurrence of HPV-positive cancers and the influence of HPV-positivity on prognosis in sinonasal cancer as well as the utility of the putative surrogate marker of HPV (p16) in sinonasal cancer.

MATERIAL AND METHODS

Studies were identified with searches of Medline via PubMed and Embase via OVID (4 May 2020). Articles on original research concerning sinonasal cancer and HPV in humans written in English were included. Case reports with less than five cases were excluded.

RESULTS

Initially, 545 articles were identified; 190 duplicate articles were removed leaving 355 articles for title/abstract screening. Title/abstract screening excluded 243 articles, leaving 112 studies assessed for eligibility. After full-text screening, 57 studies were included. All articles investigated the significance of HPV in sinonasal carcinomas. HPV was reported in approximately 30% of sinonasal squamous cell carcinoma (SNSCC), where it was associated with a better prognosis. In sinonasal cancer, p16 is associated with diagnostic pitfalls and a putative utility of p16 in SNSCC has yet to be established. HPV was not frequently reported in other types of sinonasal carcinomas, besides the recently described subtype, HPV-dependent Multiphenotypic Sinonasal Carcinoma. In other types of sinonasal carcinoma, HPV is not frequently found.

CONCLUSION

Approximately 30% of SNSCC are HPV-positive. HPV-positivity in SNSCC is associated with improved survival. HPV occurs only rarely in other sinonasal cancers. There is currently not sufficient evidence for p16 as a surrogate marker of HPV in SNSCC.

HPV in the malignant transformation of sinonasal inverted papillomas: A meta-analysis

OBJECTIVES

To date, there is still a significant debate on the role of human papilloma virus (HPV) infection in transformation of inverted papillomas (IPs) to squamous cell carcinoma (SCC). This study was designed to determine if the presence of HPV in a sinonasal IP increases the risk of malignant transformation to IPSCC.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 19 high-quality case-control and cohort studies with tissue-diagnosed IP or IPSCC and HPV diagnosis were analyzed. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using the Mantel-Haenszel method with correction for random effects. Subgroup, publication bias and a sensitivity analyses were also performed.

RESULTS

Nineteen studies with minimal bias met the inclusion criteria for quality and identified HPV infection in an IP. The pooled data revealed a strong association with progression to malignancy with an unweighted, pooled OR of 2.38 (CI₉₅ 1.47 to 3.83) and a weighted OR of 2.80 (CI₉₅ 1.42 to 5.51). Sensitivity analysis revealed that no single study contributed significantly to our pooled OR calculations (ORs 2.52 to 3.57). Subgroup analyses stratified by publication date, nucleic acid target, HPV detection method and type, sample size, and region all demonstrated a positive association of HPV with IPSCC.

CONCLUSIONS

There appears to be a significant association between HPV infection and malignant transformation of IPs. While HPV testing is not currently the standard of care for IPs, these data suggest a link between the two and suggest further studies should be performed to identify a link between the virus and malignant transformation.

Expression of Sp100 Protein in Human Papillomavirus-Associated Sinonasal Inverted Papilloma

OBJECTIVE

Sinonasal inverted papilloma (SNIP) is a benign tumor characterized by an aggressive growth, a tendency to recur, and an association with malignancy. However, the precise etiology of SNIP is still unknown. The objective of this study was to identify the expression pattern of speckled protein 100 (Sp100) in the malignant transformation (MT) of SNIP and its correlation with human papillomavirus (HPV)-16 and HPV-18 infections and other clinical features. This would further help in understanding the possible mechanisms for the development of SNIP.

METHODS

Individual nasal mucosa specimens from 40 patients (25 males and 15 females) and 10 inferior turbinate specimens as controls were included in the present study. The samples were divided into several sections for histopathological examination, HPV DNA detection, and immunohistochemical staining.

RESULTS

We observed that as SNIP progressed, the Sp100 protein expression was gradually downregulated, and SP100 localization changed from nucleus to the cytoplasm. Positive rate of HPV infection in the SNIP with MT group was higher than that in the other groups, and Sp100 expression was correlated to HPV infections and SNIP with MT. However, no correlation was observed between Sp100 expression and clinical features, such as age, gender, and smoking.

CONCLUSION

Positive rate of HPV infection is high in the SNIP with MT and has a correlation with Sp100 expression. In addition, the expression of Sp100 is downregulated in SNIP with MT, and Sp100 may play a role in the progression of SNIP.

Human Papillomavirus in Sinonasal Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

Simple Summary

The causative role of human papillomavirus (HPV) in sinonasal squamous cell carcinoma (SNSCC) remains unclear and is hindered by small studies using variable HPV detection techniques. This meta-analysis aims to provide an updated overview of HPV prevalence in SNSCC stratified by detection method, anatomic subsite, and geographic region. From 60 eligible studies, an overall HPV prevalence was estimated at 26%. When stratified by detection method, HPV prevalence was lower when using multiple substrate testing compared to single substrate testing. Anatomic subsite HPV prevalence was higher in subsites with high exposure to secretion flow compared to low exposure subsites. HPV prevalence in SNSCC followed the global distribution of HPV+ oropharyngeal squamous cell carcinoma. Taken together, this meta-analysis further supports a role for HPV in a subset of SNSCCs.

Abstract

Human papillomavirus (HPV) drives tumorigenesis in a subset of oropharyngeal squamous cell carcinomas (OPSCC) and is increasing in prevalence across the world. Mounting evidence suggests HPV is also involved in a subset of sinonasal squamous cell carcinomas (SNSCC), yet small sample sizes and variability of HPV detection techniques in existing literature hinder definitive conclusions. A systematic review was performed by searching literature through March 29th 2020 using PubMed, Embase, and Web of Science Core Collection databases. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed by two authors independently. A meta-analysis was performed using the random-effects model. Sixty studies (n = 1449) were eligible for statistical analysis estimating an overall HPV prevalence of 25.5% (95% CI 20.7–31.0). When stratified by HPV detection method, prevalence with multiple substrate testing (20.5%, 95% CI 14.5–28.2) was lower than with single substrate testing (31.7%, 95% CI 23.6–41.1), highest in high-exposure anatomic subsites (nasal cavity and ethmoids) (37.6%, 95% CI 26.5–50.2) vs. low-exposure (15.1%, 95% CI 7.3–28.6) and highest in high HPV+ OPSCC prevalence geographic regions (North America) (30.9%, 95% CI 21.9–41.5) vs. low (Africa) (13.1, 95% CI 6.5–24.5)). While small sample sizes and variability in data cloud firm conclusions, here, we provide a new reference point prevalence for HPV in SNSCC along with orthogonal data supporting a causative role for virally driven tumorigenesis, including that HPV is more commonly found in sinonasal subsites with increased exposure to refluxed oropharyngeal secretions and in geographic regions where HPV+ OPSCC is more prevalent.

Primary Malignant Epithelial Tumors of the Lacrimal Drainage System: A Major Review

Purpose: To perform a literature review on the primary malignant epithelial tumors (PMET) involving the lacrimal drainage system (LDS).Methods: The authors performed a PubMed search of all articles published in English on primary malignant epithelial tumors of the lacrimal sac and the nasolacrimal duct. Data analyzed include prevalence, demographics, clinical presentation, histopathological subtypes, management modalities, outcomes, and recurrence rates.Results: Malignant epithelial tumors of the lacrimal sac are commonly diagnosed in the fifth to seventh decades of life (mean age: 58 years) and have no gender predilection. Typical clinical presentation includes epiphora (84%) and lacrimal fossa mass lesion (78%). Pain (9%) and blood-stained epiphora (4%) were inconsistent findings. Among the PMET, squamous cell carcinomas (SCCs) were the most common (61%) followed by transitional cell carcinomas (TCC; 15%), and mucoepidermoid carcinoma (MEC; 7%). Complete surgical excision followed by radiotherapy (59%) was the preferred modality of management, and only 18% required orbital exenteration. Of the 331 tumors with available treatment details, 85% survived at a mean follow-up of 33 months. The overall recurrence rate following treatment was 20% (65/331). MECs of the lacrimal sac had the best while adenoid cystic carcinoma had the worst prognosis.Conclusion: Blood-stained epiphora was not the classical presentation for primary epithelial malignancies of the LDS. No validated staging system exists for lacrimal drainage tumors. There is a need for consistent and detailed reporting in the literature, more so on the histological subtypes and their management.

ErbB1 and ErbB2 overexpression in patients with sinonasal inverted papilloma and inverted papilloma with squamous cell carcinoma in China

Background: Currently, the expression patterns of epidermal growth factor receptor (EGFR) family genes in sinonasal inverted papilloma (SNIP) and inverted papilloma with squamous cell carcinoma (IPwSCC) are not clear.Objective: This study aimed to investigate the expression of EGFR family members and their ligands in SNIP and IPwSCC and to analyze their correlations with SNIP histological grade and Krouse stage.Materials and methods: Data from 25 cases of inverted papilloma patients in China were collected and divided into 16 cases in the SNIP group and 9 in the IPwSCC group. In addition, eight cases of normal nasal mucosa (NNM) were collected and used as the control group. The expression levels of EGFR family members and their ligands in the NNM and SNIP groups and EGFR family members in the IPwSCC group were evaluated using immunohistochemistry and qRT-PCR. In addition, their correlations with the SNIP histological grade and Krouse stage were analyzed. The statistical analysis was performed using the GraphPad Prism 7.0 statistical software.Results: The ErbB1 and ErbB2 mRNA and protein expression levels were significantly higher in the SNIP group than in the NNM group (p < .01). The ErbB1 and ErbB2 protein expression levels were significantly higher in the IPwSCC group than those in the NNM and SNIP groups (p < .01). The ErbB1 and ErbB2 mRNA and protein expression levels in the SNIP group were positively correlated with the SNIP dysplasia grade.Conclusion: Upregulation of ErbB1 and ErbB2 expression may be associated with SNIP pathogenesis and carcinogenesis.

Clinical features of nasal and sinonasal inverted papilloma associated with malignancy

OBJECTIVE

Nasal and sinonasal inverted papilloma (IP) are rare benign tumors and have the potential to exhibit malignancy in approximately 10% of cases. This study aimed to analyze the clinical features of IP associated with malignancy. Furthermore, we reviewed our therapeutic strategy and the clinical course of malignant IP.

METHODS

Overall, 70 patients with IP at our institution were retrospectively analyzed from April 2006 to December 2015; of these, six (9%) had associated malignancy. Data was collected on sex, age, presenting symptoms (nasal bleeding, rhinorrhea, facial or cheek pain, and nasal obstruction), bone destruction, and extent of disease on CT and MRI. Categorical data of patients with and without malignancy were compared using the chi-square test. A p value of <0.05 was considered statistically significant. Our therapeutic strategy for IP with malignancy, particularly the surgical procedure, i.e., the external incision or the endoscopic nasal approach, varied based on when the carcinoma was detected. In addition, we considered postoperative radiation therapy depending on histological examination.

RESULTS

Nasal bleeding (p<0.001), pain (p=0.040), bone destruction (p<0.001), and extent of disease (p=0.026) on CT and MRI findings were significantly associated with malignancy. Carcinoma was diagnosed preoperatively in two (33%) and postoperatively in four patients (67%). We operated five patients (one case was not treated because of end-stage pancreatic cancer). Two patients underwent endoscopic sinus surgery (ESS) alone, two ESS plus Denker's method, and one ESS plus anterior craniotomy. Three patients underwent surgery only, and two patients received postoperative radiotherapy. The median follow-up period was 69.3 months. One patient died of the disease and the remaining patients are alive without recurrence.

CONCLUSION

For IP patients exhibiting these clinical findings preoperatively, we should suspect complication with malignancy and plan a treatment. Even if postoperative histology does not confirm malignancy, we should ensure careful observation because of metachronous malignant transformation or the possibility to overlook small malignant lesions. Our result suggests that our strategy for malignant IP could be a reasonable option.

The clinical behavior of sinonasal inverted papilloma with cellular dysplasia: case series and review of the literature

The prognosis and recurrence rate of inverted papilloma (IP) with concomitant cellular dysplasia are not well-delineated. Demographic, clinical and imaging data of all patients who were surgically treated for sinonasal inverted papilloma (SNIP) in our center between 1996 and 2013 were reviewed. Data regarding the coexistence of dysplastic changes or malignancy within the resected tissues were also retrieved. After the exclusion of malignant cases and patients who were lost for follow-up, 92 patients were included in the study. Five patients had coexisting cellular dysplasia (4.7%), four of them had severe dysplasia and one had mild-to-moderate dysplasia. All four cases with severe dysplasia recurred, three were primarily treated endoscopically and one by external approach. Only the case with mild to moderate dysplasia which had been treated by subcranial approach did not recur. Patients with dysplasia had significantly higher recurrence rate than patients without dysplasia (80 vs. 14%, p = 0.019). This significant relation between histology and recurrence remained even after adjustment to tumor extent. The adjusted odd ratio of dysplasia (dysplasia vs. no dysplasia) is 9.7, p = 0.043. SNIP with dysplasia should be treated aggressively and followed closely. The histopathologic investigation of SNIP specimens should always note the presence of dysplasia and its severity. Further investigation on the clinical behavior of SNIP with dysplasia is needed. Multicenter studies are warranted due to the rarity of dysplastic SNIP.

Smoking, not human papilloma virus infection, is a risk factor for recurrence of sinonasal inverted papilloma

BACKGROUND

The recurrence rate of sinonasal inverted papillomas (SNIP) is 15-20%. However, few studies have investigated patient-dependent factors related to recurrence of SNIPs.

OBJECTIVE

To analyze risk factors, including human papilloma virus (HPV) infection and smoking, as well as other factors, for recurrence of SNIPs.

METHODS

Fifty-four patients who were diagnosed with SNIP and underwent surgery were enrolled: 39 men and 15 women, with the mean age of 54.0 years. Their mean follow-up was 40.6 months. Demographics and information about the history of smoking, previous surgery, tumor extent, follow-up, and recurrence were reviewed retrospectively. Those patients whose tumors were associated with malignant transformation were excluded in this study. HPV detection and genotyping in the tumor specimens were performed with the HPV DNA chip, a polymerase chain reaction-based DNA microarray system.

RESULTS

Seven patients (13.0%) had recurrence, with a mean time to recurrence of 39.8 months. Recurrence rates in T1, T2, T3, and T4 of the Krouse staging system were 0% (0/4), 8.3% (2/24), 17.4% (4/23), and 33.3% (1/3), respectively (p > 0.5). Eight patients (14.8%) were positive for HPV DNA. All of these patients belonged to the group without recurrence (p > 0.5). However, recurrence rates according to HPV DNA positivity were not statistically different (0% versus 15.2%). Three (42.9%) in the group with recurrence and four (8.5%) in the group without recurrence were smokers (p < 0.5).

CONCLUSION

Smoking was associated with recurrence of SNIP. However, HPV infection is not a recurrence of SNIP risk factor.

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.

Human papillomavirus infection and biomarkers in sinonasal inverted papillomas: clinical significance and molecular mechanisms

BACKGROUND

The role of human papillomavirus (HPV) in sinonasal inverted papillomas (IPs) is controversial. Determining the prevalence of HPV infection and its impact on the molecular biology of these tumors is critical to characterizing its role in the pathogenesis of IPs.

METHODS

A total of 112 paraffin-embedded IPs from 90 patients were studied. A tissue microarray was constructed and stained for p16, p53, epidermal growth factor receptor (EGFR), and cyclin D1. HPV presence and types were determined using PGMY 09/11 primers and integration using HPV 11 detection of integrated papillomavirus sequences by ligation-mediated polymerase chain reaction (DIPS-PCR).

RESULTS

HPV was detected in 11 of 90 (12%) patients. HPV 11 was found in 9 samples. HPV 6 and HPV 27 were found in 1 sample each. EGFR staining proportion was higher in HPV-positive IPs vs HPV-negative specimens (56.2% vs 23.6%; p = 0.009). Differences in p16, p53, and cyclin D1 staining were not significant. HPV-positive lesions tend to progress to malignancy (p = 0.064). Three samples were analyzed for integration. Viral integration was found in both malignant tumors but not in the precursor IP.

CONCLUSION

Degradation of p53 and p16/cyclin D1 dysregulation are not important mechanisms in low-risk HPV-related IP. The low prevalence of HPV in this series indicates it is not a main etiological factor for IPs; however, when present, low-risk HPV may contribute to the biology of IPs through an increase of EGFR expression and a predisposition for malignant progression by integration into the cellular genome.

Carcinoma ex-Schneiderian papilloma (malignant transformation): a clinicopathologic and immunophenotypic study of 20 cases combined with a comprehensive review of the literature

Schneiderian papilloma (SP) are uncommon tumors with malignant transformation even less common. The histologic criteria to define malignant transformation are not well developed nor is the immunohistochemical profile reported in a large series of carcinomas. 20 cases of malignant transformation of SP included 7 females and 13 males, aged 38-86 years (mean 60.7 years). Patients presented most frequently with a mass (n = 11) and obstructive symptoms (n = 7), present for 38.7 months (mean). Most patients had no previous history of SP (n = 13); metachronous carcinoma was identified in 7 patients an average of 34.4 months after the first diagnosis of SP, with 1-4 recurrences of SP. With a mean size of 4.1 cm, the majority of tumors involved a combination of more than one anatomic site (n = 10), followed by the maxillary sinus only (n = 5) or nasal cavity only (n = 3). Histologically, 17 were inverted and 3 exophytic type SP. There were 17 squamous cell carcinomas, 2 mucoepidermoid carcinomas and 1 sinonasal undifferentiated carcinoma, comprising from 10 to 95 % of the tumor volume. Malignant histologic features included atypical mitoses, necrosis, bone invasion, lymphovascular invasion, decreased transmigrating neutrophils, paradoxical maturation, dyskeratosis and/or perineural invasion (n = 3). Patients tended to present with advanced stage (n = 14, Stage III and IV). Immunohistochemical studies showed positive reactions in the malignancies for CK5/6 (86 %), p63 (86 %), CK7 (luminal, 50 %), p53 (83 %), and p16 (25 %). In situ hybridization detected human papillomavirus in 26 %. Surgery was often accompanied by radiation therapy (n = 13), with a mean of 2.4 years of follow-up. Five patients developed a recurrence between 0.8 and 3.3 years. Carcinomas ex-SP are less common and are associated with better outcome than previously reported. Patients tend to present with a synchronous carcinoma, developing in an inverted type SP, with squamous cell carcinoma the most common malignancy. Development of metachronous carcinomas ex-SP was always preceded by SP recurrence in this series.

Chapter 9: Benign sinonasal neoplasms

Benign sinonasal neoplasms are a heterogeneous group of tumors that present with similar symptoms including nasal obstruction, anosmia, rhinorrhea, and epistaxis. The proper workup and accurate diagnosis is essential for these tumors so that the appropriate treatment plan can be established. In this article of benign sinonasal neoplasms, we discuss their typical clinical presentation, histological and radiographic findings, and treatment options.

Human papillomavirus is not an etiologic agent of urothelial inverted papillomas

Inverted papilloma of the urinary bladder is rare, accounting for <1% of all bladder neoplasms. Although there is general consensus that inverted papilloma is benign in nature, little is known about its pathogenesis. Some have suggested that human papillomavirus (HPV) plays an etiologic role in the development of this neoplasm. These claims have not been adequately substantiated, and there is controversy as to the role of HPV in other urinary bladder neoplasms as well. To further investigate a possible etiologic role of HPV in urothelial neoplasia, we evaluated 27 inverted papillomas of the urinary bladder for the presence of HPV. Both immunohistochemical and in situ hybridization (ISH) studies for HPV and immunohistochemical analysis for p16, a surrogate marker for HPV infection, were used to assess HPV infection status. In the urinary bladder inverted papillomas of these 27 patients (age range, 35 to 78 y; M:F ratio, 11:1), no HPV was detected by HPV immunohistochemistry or by ISH. Immunoreactivity to p16 was detected in 11/27 (41%) of the cases. Expression of p16 is seen inconsistently within these neoplasms and does not correlate with the presence of HPV antigens or genes by immunohistochemistry or ISH, respectively. Therefore, p16 is not a reliable surrogate marker for HPV infection in urothelial inverted papilloma. Our findings indicate the absence of HPV in urothelial inverted papillomas. HPV testing should not be used as a diagnostic adjunct for inverted papilloma cases.

Transitional neoplasms of the naso-lacrimal system: A review of the histopathology and histogenesis

Transitional papilloma (inverted papilloma, Schneiderian papilloma) is a relatively common, benign epithelial neoplasm of the sinonasal tract that also occurs in the lacrimal drainage system. The name transitional papilloma is recommended because it reflects the key histological features required for pathological diagnosis, as well as the histogenesis of the tumour. The histogenesis of the tumour is reviewed, together with its natural history, which is characterized by bone remodelling and destruction, a tendency to recur and to undergo malignant transformation. Biomarkers associated with these features have been identified in the sinonasal tumours and may also be of relevance to the lacrimal sac tumours, although the necessary studies have not yet been undertaken.

Smoking and malignancy in sinonasal inverted papilloma

OBJECTIVES/HYPOTHESIS

The authors investigated clinical features of squamous cell carcinomas (SCC) arising in sinonasal inverted papillomas (IP) and risk factors responsible for their malignant transformation.

STUDY DESIGN

Retrospective analysis.

METHODS

In total, 162 patients diagnosed with sinonasal IP and treated between 1998 and 2009 at Pusan National University Hospital were enrolled. Their demographic data, information about previous surgery, smoking history, treatment modalities, follow-up duration, recurrence, and presence of malignancy were reviewed retrospectively.

RESULTS

Seventeen patients (10.5%) were diagnosed with SCC arising in sinonasal IPs. Among them, nine (9/162, 5.6%; 9/17, 52.9%) were diagnosed with synchronous malignancies and three (3/162, 1.8%; 3/17, 17.6%) were diagnosed with metachronous malignancies. In five cases (5/162, 3.1%; 5/17, 29.4%), we could not determine whether their malignancies were synchronous or metachronous. Among 53 smokers, 14 (26.4%) had malignant transformation, while only three (2.8%) in 109 nonsmokers had malignant transformation (Odds ratio = 12.7; P < .001). The mean follow-up in the 17 patients with malignancy was 47.0 months. Three patients did not receive surgical treatment and died of progression of SCC. Among the other 14 patients who underwent curative surgeries, four (28.6%) had recurrences, and their mean period to cancer recurrence was 6.3 months. Two of them died of progression of the cancer. Mean survival of the five patients who died was 14.0 months. They all belonged to T4 stage.

CONCLUSIONS

Smoking history is associated with malignant transformation of sinonasal IP. It suggests that close follow-up be required in smokers with sinonasal IP in order not to overlook the malignant transformation.

LEVEL OF EVIDENCE

2b.

Skull base inverted papilloma: a comprehensive review

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

Detection of human papillomavirus in sinonasal carcinoma: systematic review and meta-analysis

Since first suggested (in 1983), the etiological role for human papillomavirus (HPV) in sinonasal carcinomas has been subject to constantly increasing interest. To perform systematic review and formal meta-analysis of the literature reporting on HPV detection in sinonasal squamous cell carcinomas (SCC), literature was searched through May 2012. The effect size was calculated as event rates (95% CI), with homogeneity testing using Cochran Q and I(2) statistics. Meta-regression was used to test the impact of study-level covariates (HPV detection method, geographic origin, papilloma type) on effect size, and potential publication bias was estimated using funnel plot symmetry. Thirty-five studies were eligible, covering 492 sinonasal SCCs from different geographic regions. Altogether, 133 (27.0%) cases tested HPV-positive; effect size 0.305 (95% CI, 0.260-0.355; fixed effects model), and 0.330 (95% CI, 0.249-0.423; random effects model. In meta-analysis stratified by (i) HPV detection technique and (ii) geographic study origin, the between-study heterogeneity was significant only for the latter; P = .526, and P = .0001, respectively. In maximum likelihood meta-regression, HPV detection method (P = .511) and geographic origin of the study (P = .812) were not significant study-level covariates. Some evidence for publication bias was found only among polymerase chain reaction-based studies and among studies from Europe and North America but with negligible effect on summary effect size estimates. In sensitivity analysis, all meta-analytic results were robust to all one-by-one study removals. In formal meta-regression, the variability in HPV detection rates reported in sinonasal SCCs was not explained by the HPV detection method or geographic origin of the study.

Detection of human papillomavirus in sinonasal papillomas: systematic review and meta-analysis

OBJECTIVES/HYPOTHESIS

To perform a systematic review and formal meta-analysis of the literature reporting on HPV detection in sinonasal papillomas. Since first reported in 1983, the etiological role for human papillomavirus (HPV) in sinonasal papillomas has been subject to increasing interest.

STUDY DESIGN

A systematic review, with meta-analysis and formal meta-regression.

METHODS

Literature was searched through April 2012. The effect size was calculated as event rates (95% confidence interval [CI]), with homogeneity testing using Cochran's Q and I(2) statistics. Meta-regression was used to test the impact of study-level covariates (HPV detection method, geographic origin, papilloma type) on effect size, and potential publication bias was estimated using funnel plot symmetry.

RESULTS

Seventy-six studies were eligible covering 1,956 sinonasal papillomas from different geographic regions. Altogether, 760 (38.8%) cases tested HPV-positive; effect size 0.421 (95% CI 0.359-0.485, random effects model). The summary HPV prevalence was highest (65.3%) in exophytic papillomas (EP), followed by inverted papillomas (37.8%) and cylindrical cell papillomas (22.5%). In meta-analysis stratified by 1) HPV detection technique, 2) geographic study origin, and 3) papilloma type, the between-study heterogeneity was significant only for the papilloma types (P = .001). In meta-regression, HPV detection method (P = .102), geographic origin (P = .149), or histological type (P = .240) were not significant study-level covariates. Some evidence for publication bias was found only for studies on EP. In sensitivity analysis, all meta-analytic results were robust to all one-by-one study removals.

CONCLUSIONS

Variability in HPV detection rates in sinonasal papillomas is explained by their histological types (not by HPV detection method or geographic origin of study), but none of the three were significant study-level covariates in formal meta-regression.

Pattern of expression of cyclooxygenase-2 in malignant transformation of sinonasal inverted papilloma

OBJECTIVE

Cyclooxygenases (COXs) are enzymes that catalyze the conversion of arachidonic acid to prostaglandins. Many studies have suggested that COX-2, the inducible form of COX, is important in carcinogenesis. However, little is known about the pattern of expression of COX-2 in a multistep process of malignant transformation of sinonasal inverted papilloma (IP). In this study, we investigated COX-2 expression in IPs, IPs with dysplasia, IPs with squamous cell carcinoma (SCC), and primary SCCs of sinonasal tract.

STUDY DESIGN

A retrospective study was conducted.

SETTING

The setting was a tertiary care referral center.

SUBJECTS AND METHODS

The expression of COX-2 was evaluated by immunohistochemistry in 56, 7, 18, and 17 cases of IPs, IPs with dysplasia, IPs with SCC, and primary SCCs, respectively. Furthermore, we investigated the possible correlation between the expression of COX-2 and clinicopathologic variables in patients with IPs with SCC and primary SCC patients.

RESULTS

Positive immunoreactivity for COX-2 was observed in 3 (5.4%) of 56 IPs, 7 (38.9%) of 18 IPs with SCC, and 7 (41.2%) of 17 primary SCCs, whereas it was not observed in IPs with dysplasia. The percentage of tumors with COX-2-positive immunostaining was significantly higher in IPs with SCC and primary SCCs compared with benign IPs. There was no significant correlation between the expression of COX-2 and clinicopathologic variables, such as tumor stage, histologic differentiation, and the proportion of malignant areas in patients with IPs with SCC.

CONCLUSION

Cyclooxygenase-2 may play an important role in the process of malignant transformation from IP to SCC.

Delineating an epigenetic continuum in head and neck cancer

A tissue field of somatic genetic alterations precedes the histopathological phenotypic changes of carcinoma. Genomic changes could be of potential use in the diagnosis and prognosis of pre-invasive squamous head and neck carcinoma (HNSCC) lesions and as markers for cancer risk assessment. Studies of sequential molecular alterations and genetic progression of pre-invasive HNSCC have not been clearly defined. Studies have shown recurring alterations at chromosome 9p21 (location of the CDKN2A) and TP53 mutations in the early stages of HNSCC. However, gene silencing via hypermethylation is still a relatively new idea in the development of HNSCC and little is known about the contribution of epigenetics to the development of neoplasia, its transformation, progression, and recurrence in HNSCC. This review examines the role of promoter hypermethylation of tumor suppressor genes in the progression continuum from benign papillomas to malignancy in HNSCC.

Promoter methylation in head and neck tumorigenesis

In addition to genetic alterations of gains and losses, epigenetic events of promoter methylation appear to further undermine a destabilized genomic repertoire in squamous head and neck carcinoma (HNSCC). This chapter provides an overview of frequently methylated tumor suppressor genes in benign head and neck papillomas, primary HNSCC tumors, and HNSCC cell lines and their relevance as epigenetic markers in head and neck tumorigenesis.

Sinonasal inverted papilloma associated with malignancy: the role of human papillomavirus infection and its implications for radiotherapy

Sinonasal inverted papilloma (IP) is a benign but destructive tumor originating from the ciliated respiratory mucosa of the sinonasal tract. It can be associated with malignancy (squamous cell histology, in particular) and human papillomavirus infection has been investigated as a potential etiological factor linked to malignant alterations of IP. Surgery is the treatment of choice for IP, however, radiotherapy as an adjunct to surgery is indicated for IP with associated malignancy.

Evaluation of p53, p63, p21, p27, ki-67 in paranasal sinus squamous cell carcinoma and inverted papilloma

Using a molecular genetic approach, we try to confirm the molecular alterations of inverted papilloma and clarify its status as a putative precursor lesion of sinonasal squamous cell carcinoma. To better understand its genetics, we investigated the immunohistochemical protein expression patterns of cell-cycle-regulators p53, p63, p21, p27 and proliferation marker Ki-67 in 22 inverted papilloma and 9 squamous cell carcinoma of the sinonasal tract. Significantly elevated levels of p53 and p63 in squamous cell carcinoma of sinonasal tract compared with inverted papilloma were revealed. Ki-67-stained neoplastic cell nuclei were found in a significantly higher percentage of squamous cell carcinoma of sinonasal tract than in inverted papilloma, whereas no variation of p21 and p27 expression was identified. This work first examined the immunohistochemical overexpression of p63 in sinonasal inverted papilloma and squamous cell carcinoma. In conclusion, this is a first study shedding light on the expression of p63 in tumors of paranasal sinuses.

Schneiderian Papillomas and Carcinomas: A Retrospective Study with Special Reference to p53 and p16 tumor suppressor gene expression and association with HPV

Schneiderian papillomas are uncommon benign tumors of the sinonasal area. They are prone to local aggressiveness and recurrence, and some undergo malignant progression. We analyzed specimens obtainedfrom 67 Chinese patients who had presented to the ENT department of a regional hospital with biopsy-proven schneiderian papilloma. Seven of these patients had either synchronous or metachronous carcinoma, 1 of whom had pure carcinoma in situ. For each case, we documentedthe morphology, immunohistochemical expression of tumor suppressor genes p53 and p16, and any association with human papillomavirus (HPV) infection as detected by either polymerase chain reaction or in situ hybridization techniques. We found that severe dysplasia andp53positivity were strongly associated with malignantprogression. Association with HPV was demonstrated in 22 of the 67patients (33%); the association was strongest among patients with exophytic papillomas and carcinomas. The effect of HPV in papilloma oncogenesis probably begins duringthe early phase, while other factors are responsible for progression to carcinoma. We conclude thatp53-positive, dysplastic schneiderian papillomas warrant aggressive surgical treatment.

Sinonasal inverted papilloma: narrative review

BACKGROUND

Sinonasal inverted papilloma is a benign condition with the potential for recurrence and malignant change. Over the past few decades, numerous studies and reviews have addressed different aspects of this condition.

OBJECTIVE

To amalgamate the current literature on inverted papilloma, in order to review the evidence and consider the gaps in current knowledge.

METHODS

Retrospective, narrative review.

RESULTS

The reported incidence of inverted papilloma varies between centres and is affected by selection bias. The exact aetiology of inverted papilloma is not fully understood. Currently, there is no reliable histological or biological marker to predict the probability of recurrence or malignant transformation. There is no universally accepted staging system available for sinonasal inverted papilloma. Complete surgical removal of the tumour is the mainstay of treatment, but the method of choice depends on the extent of the disease, the skill of the surgeon and the technology available.

CONCLUSION

In order to compare different studies and to enable meta-analysis of the literature, there should be a universally accepted staging and classification system for sinonasal inverted papilloma. Further research on the aetiology of sinonasal inverted papilloma, and on biological markers for its recurrence and malignant transformation, is required. To enable meaningful future research, we would encourage multicentre participation with a consensus on management.

Management of Sinonasal Inverted Papillomas and Comparison of Classification Staging Systems

Background

The aim of this study was to describe treatment results in patients with sinonasal inverted papilloma and to compare recent classification staging systems.

Methods

We performed a retrospective study of 79 patients with primary paranasal sinus inverted papilloma from 1978 to 2008.

Results

The median age at diagnosis was 59 years. There were 68 men (86%) and 11 women (14%). Sixty inverted papilloma (76%) were located in the ethmoidal sinus complex, 16 (20%) were in the maxillary sinus, 2 were in the sphenoid sinus (3%), and 1 was in the septum (1%). Malignancy was simultaneously associated in four cases (5%). Intracranial extension was found in five patients (6%) and we did not find orbital content involvement. The external approach was used in 22 cases (28%) and 57 patients were treated with endoscopic nasal resection (72%). The overall recurrence rate in the total population was 21%. Recurrences were observed in 7 cases (32%) in the group of patients who received external approach and in 10 (17%) patients in the endoscopic group. Recurrences according to the Krouse system were 0% in T1 stage, 16% in T2 stage, 25% in T3 stage, and 60% in T4 stage (p = 0.05). Recurrences for groups A, B, and C stages using the Cannady staging system were 12, 26, and 60%, respectively (p = 0.039). Recurrences according to Han's system were 19% in both T1 and T2, 20% in T3, and 60% in T4 (p > 0.05).

Conclusions

Our results support the endoscopic approach as the treatment of choice when feasible in patients with inverted papilloma, combined in selected cases with external approaches. The Krouse and Cannady systems provided a good distribution of patients according to local control.

Endoscopic medial maxillectomy as a procedure of choice to treat inverted papillomas

CONCLUSIONS

Endoscopic medial maxillectomy (EMM) is a safe, effective method for the treatment of inverted papillomas (IPs) of the paranasal sinuses.

OBJECTIVE

To evaluate the efficacy of EMM as a surgical technique in the treatment of IP compared with non-endoscopic techniques.

PATIENTS AND METHODS

This was a retrospective study of 52 patients with an IP diagnosed by biopsy from 1990 to 2004. EMM was performed in 34 patients (65.4%), whereas non-endoscopic techniques were used in 18 (34.6%). The mean duration of follow-up was 54.2 months.

RESULTS

Recurrence occurred in 4 of the 34 patients who underwent EMM (11.8%; 95% confidence intervals (CI) = 39 at 26%) and in 8 of the 18 patients treated using non-endoscopic techniques (44.4%; 95% CI = 23.2 at 67.3%). There was a statistically significant difference (p < 0.05) between treatments, assessed by Kaplan-Meier estimator and log-rank testing. Of the 12 patients who suffered a recurrence, 6 (50%) were treated with endoscopic surgery, 4 (33%) with mediofacial degloving and 2 (17%) were merely followed up; no malignant degeneration occurred.

Common head and neck cases in our consultation referrals: diagnostic dilemmas in inverted papilloma

Papillomas of the nose and paranasal sinuses comprise three morphologically distinct variants--everted papilloma, inverted papilloma and cylindric cell papilloma in descending order of frequency. Recurrence of everted papilloma is unusual and malignant change does not occur. However, inverted papilloma is associated with multiple recurrences and malignant change. The histology of low grade squamous cell carcinoma of the nose may mimic that of inverted papilloma and low grade squamous cell carcinoma may coexist with inverted papilloma and be present in the same biopsy material. There is a high index of suspicion of concomitant malignancy in the presence of severe atypia or hyperkeratosis. Columnar cell papillomas are also associated with an increased risk of malignancy but the rarity of these lesions makes accurate assessment of malignant potential difficult. The most common diagnostic dilemma for pathologists referring cases for second opinion is the recognition of low grade malignancy versus benign inverted papilloma at presentation and in lesions which recur. Recent studies have addressed the requirement for histological parameters to predict the clinical course of these lesions and new molecular markers are being applied to tissue diagnosis. The early recognition and treatment of malignancy associated with inverted papilloma is key to decreased morbidity and improved patient survival and forms the basis of this discussion.

Fascin over expression is associated with dysplastic changes in sinonasal inverted papillomas: a study of 47 cases

Sinonasal inverted papilloma (IP) is a primary benign lesion with a tendency for local recurrence. Malignant transformation may develop in up to 15% of cases. Fascin (Fascin 1) is an actin cross-link binding protein required for the formation of actin-based cell-surface protrusions and cell motility. Fascin up-regulation in lung, gastric, breast and hepatobiliary carcinomas correlates with aggressiveness and decreased survival. Here we evaluate immunohistochemical expression of fascin in 47 sinonasal IPs from 34 patients. Fascin over-expression is significantly more common in sinonasal IP with high-grade dysplasia than in those with no dysplastic or low-grade dysplastic epithelium (P = 0.0001). No significant change in fascin expression is seen with recurrence. Over expression of fascin in high-grade dysplastic epithelium in IP may be associated with tumor progression and malignant transformation.

[Clinico-histopathological characteristic of inverted papilloma of nasal cavity and paranasal sinuses cases treated in Department of Laryngological Oncology UM of Lodz between 2002-2006--review of latest literature]

Authors introduced diagnostic procedures, clinico-morphological features and treatment results of 16 cases of nasal cavity and paranasal sinuses inverted papillomas treated surgically on Department of Laryngological Oncology of Medical University of Lodz between 2002-2006. References review, definition, classification, clinico-hiostopathological criteria and treatment methods of Schneiderian papilloma were introduced in study.

Cyclooxygenase inhibitors induce apoptosis in sinonasal cancer cells by increased expression of nonsteroidal anti-inflammatory drug-activated gene

Nonsteroidal anti-inflammatory drug-activated gene-1 (NAG-1) has recently been shown to be induced by nonsteroidal anti-inflammatory drugs (NSAIDs) and to have proapoptotic and antitumorigenic activities. Although sulindac sulfide induced apoptosis in sinonasal cancer cells, the relationship between NAG-1 and NSAIDs has not been determined. In this study, we investigated the induction of apoptosis in sinonasal cancer cells treated by various NSAIDs and the role of NAG-1 expression in this induction. The effect of NSAIDs on normal human nasal epithelial (NHNE) cells was also examined to evaluate their safety on normal cells. Finally, the in vivo anti-tumorigenic activity of NSAIDs in mice was investigated. In AMC-HN5 human sinonasal carcinoma cells, indomethacin was the most potent NAG-1 inducer and caused NAG-1 expression in a time- and dose-dependent manner. The induction of NAG-1 expression preceded the induction of apoptosis. Conditioned medium from NAG-1-overexpressing Drosophila cells inhibited proliferation of sinonasal cancer cells and induced apoptosis. In addition, in NAG-1 small interfering RNA-transfected cells, apoptosis induced by indomethacin was suppressed. In contrast, NAG-1 expression and apoptosis were not induced by NSAIDs or conditioned medium in NHNE cells. Furthermore, indomethacin induced a dose-dependent in vivo increase in the expression of NAG-1 mRNA in the mice tumors and the volume of xenograft tumors of AMC-HN5 cells in indomethacin-treated nude mice was reduced compared to that in control mice. In conclusion, indomethacin exerts proapoptotic and antitumorigenic effects in sinonasal cancer cells through the induction of NAG-1 and can be considered a safe and effective chemopreventive agent against sinonasal cancer.

The prevalence of human papilloma virus infection in sinonasal inverted papilloma specimens classified by histological grade

BACKGROUND

Histological analysis suggests that inverted papilloma (IP) tumorigenesis may occur through a stepwise series of discrete events. The association between human papilloma virus (HPV) and IP has been described at varying incidences. The purpose of this study was to evaluate the prevalence of the HPV subtypes in a large series of IP specimens classified by histological grade.

METHODS

Fifty-seven paraffin-embedded specimens of Korean population were available for study. Each specimen was graded according to a four-stage histological grading system (stages I and II, benign IP; stage III, dysplastic IP; stage IV, carcinoma arising from IP). A representative section of IP specimen was isolated through laser capture microdissection (7.5- to 10-mum laser spot size). Subsequently, DNA extraction and HPV genotyping with the HPV DNA chip test (Biomed Lab Co., Seoul, Korea) was performed. The HPV DNA chip contained 22 type-specific probes that consisted of 15 high-risk subtypes and 7 low-risk subtypes.

RESULTS

Histological grading was as follows: 5, grade I; 23, grade II; 22, grade III; and 7, grade IV. Seven of 57 specimens (12.3%) showed HPV DNA. All of the HPV(+) cases showed HPV DNA in early grade (grades I and II) IP lesions. No higher grade (grades III and IV) IP tumors showed HPV DNA. Among the seven HPV(+) cases, five were high-risk subtypes and two were unspecified subtypes.

CONCLUSION

HPV infection, mainly high-risk subtypes, occurs in benign IP as an early event during the multistep tumorigenesis of IP. Cumulative other genetic insults may be required to progress from benign IP (grades I and II) to dysplastic IP (grade III) and carcinoma arising from IP (grade IV).

Expression of epidermal growth factor receptor, transforming growth factor-alpha and Ki-67 in relationship to malignant transformation of pleomorphic adenoma

CONCLUSION

Quantitative assessment is more sensitive as a measure of cellular protein content as compared with standard optical density measurements. The data support the hypothesis that increased epidermal growth factor receptor (EGFR) and transforming growth factor (TGF)-alpha expression is associated with early events in malignant transformation of pleomorphic adenoma (PA).

OBJECTIVE

In the present study, we attempted to identify EGFR and TGF-alpha expression and Ki-67 index in carcinoma ex-pleomorphic adenoma (Ca ex-PA) and PA. We also compared the presence of EGFR and TGF-alpha and Ki-67 index with clinical data.

MATERIALS AND METHODS

The tissues were stained with monoclonal antibodies to EGFR, TGF-alpha and Ki-67. The results were analysed using quantitative immunohistochemical analysis. We also analysed the association of patients' prognosis with clinical parameters and the histological classification of the carcinomatous component.

RESULTS

As regards the association of patients' prognosis with EGFR staining and Ki-67 index, a significant increase was observed in patients who died or had residual disease compared with patients who were alive without disease. In the immunohistochemical analysis of EGFR and TGF-alpha and Ki67 index, a significant increase was observed in Ca ex-PA, especially with adenocarcinoma, compared with PA and sialadenitis.

Epigenetic events underlie the pathogenesis of sinonasal papillomas

Benign inverted papillomas have been reported as monoclonal but lacking common genetic alterations identified in squamous cell carcinoma of the head and neck. Epigenetic changes alter the heritable state of gene expression and chromatin organization without change in DNA sequence. We investigated whether epigenetic events of aberrant promoter hypermethylation in genes known to be involved in squamous head and neck cancer underlie the pathogenesis of sinonasal papillomas. Ten formalin-fixed paraffin DNA samples from three inverted papilloma cases, two exophytic (everted) papilloma cases, and two cases with inverted and exophytic components were studied. DNA was obtained from microdissected areas of normal and papilloma areas and examined using a panel of 41 gene probes, designed to interrogate 35 unique genes for aberrant methylation status (22 genes) using the methylation-specific multiplex-ligation-specific polymerase assay. Methylation-specific PCR was employed to confirm aberrant methylation detected by the methylation-specific multiplex-ligation-specific polymerase assay. All seven cases indicated at least one epigenetic event of aberrant promoter hypermethylation. The CDKN2B gene was a consistent target of aberrant methylation in six of seven cases. Methylation-specific PCR confirmed hypermethylation of CDKN2B. Recurrent biopsies from two inverted papilloma cases had common epigenetic events. Promoter hypermethylation of CDKN2B was a consistent epigenetic event. Common epigenetic alterations in recurrent biopsies underscore a monoclonal origin for these lesions. Epigenetic events contribute to the underlying pathogenesis of benign inverted and exophytic papillomas. As a consistent target of aberrant promoter hypermethylation, CDKN2B may serve as an important epigenetic biomarker for gene reactivation studies.

Cell proliferation, apoptosis, and apoptosis inhibition in malignant transformation of sinonasal inverted papilloma

CONCLUSION

Increasing cell proliferation seems to be a very important factor in the development of inverted papilloma (IP). Apoptosis that was increased but weakly inhibited by Bcl-2 did not cause imbalance in the cell proliferation. Further increased cell proliferation in IP with dysplasia was an important mechanism of growth in dysplastic areas.

OBJECTIVES

The purpose of this study was to compare cell proliferation, apoptosis, and apoptosis inhibition by Bcl-2 in IP.

PATIENTS AND METHODS

Cell proliferation and apoptosis inhibition were detected by immunohistochemical staining with monoclonal antibodies to Ki-67 and Bcl-2. Apoptosis was detected by the transferase-mediated dUTP nick end-labeling (TUNEL) method.

RESULTS

As regards the Ki-67 index (KI), a significant increase was observed in IP with severe dysplasia, IP with carcinoma and invasive squamous cell carcinoma (SCC) compared with EP and IP with mild and moderate dysplasia. For the apoptosis index (AI), a significant increase was observed in IP with mild and moderate dysplasia compared with IP with carcinoma, invasive SCC and EP. For the Bcl-2 index (BI), a significant increase in expression was observed in IP with severe dysplasia and carcinoma and invasive SCC compared with control, EP and IP with mild dysplasia. Among IP, the KI (average 18.2%) was much higher than the AI (6.4%) and BI (4.1%).

Risks of malignancy in inverted papilloma of the nose and paranasal sinuses

PURPOSE OF REVIEW

The majority of inverted nasal papilloma are benign and treatment is by complete local surgical removal. There is an associated real, but small risk of malignancy, which may coexist at the time of presentation or develop at a later time. This article reviews some of the recent publications addressing the association of inverted papilloma with malignancy.

RECENT FINDINGS

Neither the etiology of inverted papilloma nor the factors responsible for malignant transformation are fully elucidated to date. Inverted papilloma is associated with squamous cell carcinoma in approximately 10% of the cases. Malignancy may occur synchronously or metachronously.

SUMMARY

Based on the literature, the rates of synchronous and metachronous carcinoma are 7.1 and 3.6%, respectively, although rates may be exaggerated due to a referral bias to tertiary centres. A thorough removal of all diseased mucosa is curative and a meticulous histological examination of the entire specimen is necessary. The working risk is approximately 10%. Recurrent disease and metachronous carcinoma can develop after a prolonged period of time. As most recurrences are due to incomplete resection, it is mandatory to perform a close follow-up, with biopsies performed when indicated. Life-long follow-up is recommended.

Inverted papilloma of paranasal sinuses

INTRODUCTION

Inverted papilloma (Schneiderian papilloma) is a primarily benign lesion that occurs in the nasal cavity and paranasal sinuses. Clinical problems include a tendency towards local destruction, recurrence and malignant transformation into squamous cell carcinoma. Hence, complete surgical removal is the therapy of choice and a meticulous follow-up is mandatory.

STUDY DESIGN

This is a review including a short introduction to the different histological types of nasal papilloma, their pathogenesis and the clinical and histopathological diagnosis. Staging systems, therapeutic approaches, and surgical concepts are discussed.

RESULT

The detection and definition of factors that allow a prognosis of recurrence or malignant transformation of inverted papilloma is an active field of research. The results of studies dealing with the definition of prognostic factors, that investigated immunohistochemical methods, virus detection, molecular genetics, and histomorphological studies are discussed including our own results on the prognostic value of histology. A concept for the diagnosis, management, therapy and follow-up of inverted papilloma is proposed.

Increased expression of cyclooxygenase-2 and Ki-67 are associated with malignant transformation of pleomorphic adenoma

OBJECTIVES

In the present study, we attempted to identify cyclooxygenase-2 (COX-2) expression and Ki-67 index in carcinoma ex-pleomorphic adenoma (Ca ex-PA) using quantitative immunohistochemical analysis and to compare the benign component of the neoplasia. We also aimed to relate the overexpression of COX-2 with the pathways of malignant transformation of Ca ex-PA as evidenced by distinct morphological features.

MATERIALS AND METHODS

Forty Ca ex-PA from patients treated at Department of Otolaryngology, Yokohama City University Medical Center, Yokohama, Japan, from 1999 to 2005, were selected. All Ca ex-PA showed only one malignant histological component: adenocarcinoma (23 cases), adenoid-cystic carcinoma (10), epithelial-myoepithelial carcinoma (7). The tissues were stained with monoclonal antibodies to COX-2 and Ki-67. The results were analyzed using quantitative immunohistochemical analysis. We also analyzed the association of the histological classification of the carcinomatous component.

RESULTS

In the immunohistochemical analysis of COX-2 and Ki-67 index, significant increase was observed in Ca ex-PA, especially with adenocarcinoma, compared to pleomorphic adenoma and sialadenitis. Quantitative assessment is more sensitive as a measure of cellular protein content as compared to standard optical density measurement.

CONCLUSIONS

The data support the hypothesis that increased COX-2 expression is associated with early events in malignant transformation of pleomorphic adenoma.

Relationship between p21 and p53 Expression, Human Papilloma Virus Infection and Malignant Transformation in Sinonasal-inverted Papilloma

AIMS

To identify the relationship between p21 and p53 expression, human papilloma virus (HPV) infection and malignant transformation in sinonasal-inverted papilloma.

MATERIAL AND METHODS

Nasal tissues, exophytic papilloma, inverted papilloma (IP) with dysplasia, IP with carcinoma and invasive squamous cell carcinoma (SCC) were stained with the monoclonal antibodies p21 and p53. In-situ hybridisation for HPV DNA was also carried out for types 6/11, 16/18 and 31/33.

RESULTS

Significant increased staining of p21 and p53 was observed in IP with severe dysplasia, IP with carcinoma and invasive carcinoma compared with control nasal mucosa. A significant increase of dysplasia was observed in IP in the HPV 6/11 and 16/18-positive group, compared with the HPV 6/11 and 16/18-negative group. Significant decrease in expression of p21 and p53 was observed in HPV 16/18-positive IP compared with HPV 16/18-negative IP.

CONCLUSIONS

Our data raise the possibility that testing for p21, p53 and HPV may help to screen out papilloma lesions with a potential for dysplasia or carcinoma.