Treatment outcomes in the management of inverted papilloma: an analysis of 160 cases

The Role of Positron Emission Tomography for the Management of Sinonasal Malignancies: A Systematic Review

BACKGROUND

Positron emission tomography (PET) scan is a valuable imaging modality widely used in the management of cancers. Its usage is well defined for most head and neck malignancies. However, there is a lack of consensus regarding the utility of PET scan for sinonasal malignancies. This is highlighted by the latest international consensus statement on endoscopic skull base surgery.

OBJECTIVE

This systematic review aims to clarify the role of PET scan in the management of sinonasal malignancies.

METHODS

We conducted a comprehensive literature search using PubMed, MEDLINE, EMBASE, Web of Science, CINAHL, and Cochrane databases for research studies of interest. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) updated statement was used to guide the review.

RESULTS

In total, 1807 articles were assessed for eligibility. Thirty-nine original papers, published between 2004 and 2021, met inclusion criteria. Seven articles focused on the role of PET scan for inverted papilloma, 23 for sinonasal carcinoma, 4 for melanoma, and 3 for lymphoma, and finally, 3 articles focused on the use of specific PET scan tracers for sinonasal malignancies. Qualitative summaries for each potential role of PET scans were provided. In general, included studies were retrospective in nature with low level of evidence.

CONCLUSIONS

In general, and across all types of sinonasal malignancies, PET scan yielded positive results regarding detection and initial staging. It was also considered as the modality of choice for detection of distant metastases, except in the case of sinonasal lymphoma. PET scan's main limit resides in its inability to detect lesions in or close to the metabolic activity of the brain.

Rare and unusual benign tumors of the sinonasal tract and pharynx: Case series and literature review

There are a number of benign tumors of the nose and pharynx that are seldomly reported in literature but that can sometimes prove difficult to treat and extremely important for differential diagnosis. The present study presents cases of rare benign tumors localized in the pharynx, nasal and sinus cavities, as well as reviews of literature and historical references for each type of tumor. Unilateral nasal hemangioma in a 72-year-old male which, although not a rare pathology, raised problems due to auto-resection of the tumor. The surgeon was able to pull it out with ease without bleeding; it is possible that the mass would have eventually fallen out. Pilomatrixoma is a relatively uncommon ectodermal benign tumor of the skin derived from hair matrix cells. Surgical resection is curative but recurrence is possible (≤5% risk). The presented case is of a 26-year-old female with a pilomatrixoma of the left cheek who, for aesthetic reasons, refused a classical external surgical approach. Trans-oral resection was performed, which proved feasible but laborious and prone to recurrence. Inverted Schneiderian papilloma is a rare benign tumor of the nasal and sinus cavities with increased potential for invasion, recurrence and malignant transformation compared with other types of papilloma and other benign tumors of the area. The tumor represents 0.5-4.0% of all nasal tumors and has been described under different names, such as villiform cancer and cylindrical/transitional papilloma. The present study reports a rare case of bilateral papilloma in a 68-year-old male. He presented with bilateral evolving nasal obstruction and hyposmia. Following surgery, the patient was treated by a multidisciplinary team and followed by a respiratory rehabilitation program.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

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

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

Surgical treatment of sinonasal inverted papilloma

PURPOSE OF REVIEW

To highlight how surgery of inverted papilloma has developed during the past year. Moreover, to give our own opinion on the state of research regarding inverted papilloma surgical management.

RECENT FINDINGS

Recent studies covering surgical treatment of inverted papilloma concentrated on the optimum surgical management aiming at complete resection, least morbidity and best outcome, with special interest regarding the maxillary and frontal sinuses. In maxillary sinus inverted papilloma, to avoid empty nose and/or epiphora, recent articles exerted all attempts to preserve the integrity of both the inferior turbinate and nasolacrimal duct, yet offer best exposure of all maxillary sinus walls specially the anterior and inferior ones. These included the new modifications of the prelacrimal and Denker approaches and lateral nasal wall transposition. In frontal sinus inverted papilloma, to avoid an external approach and insure postoperative patency of frontal sinus ostium, the periorbital suspension was introduced and orbital transposition approach was comprehensively utilized especially in far lateral located lesions and/or in supraorbital recess involvement. Associated malignancy is an important issue to identify as management plans significantly differ. Recurrence occurs early within the first 2 years but long-term follow-up is mandatory.

SUMMARY

Surgical procedures of sinonasal inverted papilloma are planned according to origin rather than the tumor extent. Origin targeted surgery and proper management of the site of attachment are the key to achieve complete surgical resection of sinonasal inverted papilloma. Recent trends advise the least destructive surgical techniques that offer best exposure, complete excision SNIP and least recurrence.

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.

Endoscopic Modified Danker's Approach for Management of Sinonasal Inverted Papilloma: Our Experience

Sinonasal inverted papilloma (SNIP), Inverting papilloma, Schneiderian papilloma etc. It is a benign tumor with incidence nearly 70% of all sinonasal papilloma and 0.5-4.0% of all sinonasal neoplasms. The most common site of origin is lateral nasal wall and common presenting symptom is nasal obstruction followed by epistaxis. On histopathology examination, it is characterized by invagination of neoplastic epithelium into underlying stroma. With the advent of technology, the endoscopic modified dankers approach became the surgical approach of choice. The present study was undertaken to study its role in management of SNIP with reference to rate of recurrence and malignancy. An observational study was conducted in a tertiary health center in which 40 biopsy proven cases of SNIP, operated by endoscopic assisted modified Danker's approach between September 2008 and January 2019 with minimum follow-up period of 6 months were analyzed. Male:Female ratio was 2.33:1. The most common symptom was nasal obstruction (97.5%) followed by rhinorrhoea (87.5%). Using various imaging and diagnostic measures, lateral nasal wall was found to be the most common site of origin. Out of total 40 cases, 9 (27.5%) patients had recurrence, of these, 6 were benign and remaining 3 had malignancy as confirmed by biopsy. Most of the cases of SNIP can be managed endoscopically, although extensive lesions or the lesions with malignant transformation, external approach may be needed so expertise in both endoscopic and conventional techniques is needed. Although most of the recurrences occurred in first 2 years, but life time follow-up is advisable.

Papillary Mucinous Adenocarcinoma of the Endolymphatic Sac: A Rare Middle Ear Neoplasm

Glandular neoplasms of the temporal-mastoid region and endolymphatic sac (ELS) are rare, and it is quite challenging to differentiate between an adenoma and an adenocarcinoma. ELS tumors (ELST) usually present with papillary, follicular, or solid patterns and can be further distinguished histologically and through immunohistochemistry. The microscopic features and clinical course of this neoplasm have been comprehensively explained by Heffner, who considered it "low-grade adenocarcinoma of likely ELS origin." The papillary form more commonly affects females, and it is a more aggressive form of ELST that is destructive and exhibits extensive local spread. The tumor usually has a close association with von Hippel-Lindau (VHL) disease, but 11%-30% of the ELST cases develop in individuals without a VHL mutation. ELSTs manifest with headaches, hearing loss, ear discharge, and cranial nerve palsies. Currently, the only available curative therapeutic intervention consists of wide local excision and long-term follow-up. Because of the sensitive location of this tumor, the adjuvant radiotherapy options are still questionable. In this case report, the author presents a 74-year-old woman with a past medical history of Schneiderian papilloma and was diagnosed with papillary mucinous adenocarcinoma of the ELS not associated with VHL disease.

MRI of Sinonasal Malignancies

ABSTRACT

Sinonasal cavity is an important subsite in head and neck tumors. There are a myriad of malignancies that present within this area. Adequate staging for treatment planning requires multimodality evaluation. Magnetic resonance imaging (MRI) forms an important component in the evaluation of sinonasal tumors. We sought to review the most common sinonasal tumors, including sinonasal anatomy, clinical features, and common imaging features. A literature review was performed to evaluate common sinonasal tumors. Owing to the different tissue types within the sinonasal cavity, there are multiple different tumor pathologies within the sinonasal compartment. Most present in adults although some present in the young. Many of these tumor types have imaging overlaps, although some have a characteristic appearance. MRI can aid in soft tissue delineation, evaluation of multicompartmental extension, intracranial spread, and perineural spread. Sinonasal tumors are a heterogeneous group for which soft tissue delineation via MRI forms an important role in ensuring adequate treatment planning to improve outcomes, decreasing morbidity, and improve functional outcomes.

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.

MRI Predictors of Malignant Transformation in Patients with Inverted Papilloma: A Decision Tree Analysis Using Conventional Imaging Features and Histogram Analysis of Apparent Diffusion Coefficients

OBJECTIVE

Preoperative differentiation between inverted papilloma (IP) and its malignant transformation to squamous cell carcinoma (IP-SCC) is critical for patient management. We aimed to determine the diagnostic accuracy of conventional imaging features and histogram parameters obtained from whole tumor apparent diffusion coefficient (ADC) values to predict IP-SCC in patients with IP, using decision tree analysis.

MATERIALS AND METHODS

In this retrospective study, we analyzed data generated from the records of 180 consecutive patients with histopathologically diagnosed IP or IP-SCC who underwent head and neck magnetic resonance imaging, including diffusion-weighted imaging and 62 patients were included in the study. To obtain whole tumor ADC values, the region of interest was placed to cover the entire volume of the tumor. Classification and regression tree analyses were performed to determine the most significant predictors of IP-SCC among multiple covariates. The final tree was selected by cross-validation pruning based on minimal error.

RESULTS

Of 62 patients with IP, 21 (34%) had IP-SCC. The decision tree analysis revealed that the loss of convoluted cerebriform pattern and the 20th percentile cutoff of ADC were the most significant predictors of IP-SCC. With these decision trees, the sensitivity, specificity, accuracy, and C-statistics were 86% (18 out of 21; 95% confidence interval [CI], 65-95%), 100% (41 out of 41; 95% CI, 91-100%), 95% (59 out of 61; 95% CI, 87-98%), and 0.966 (95% CI, 0.912-1.000), respectively.

CONCLUSION

Decision tree analysis using conventional imaging features and histogram analysis of whole volume ADC could predict IP-SCC in patients with IP with high diagnostic accuracy.

Need for long-term follow-up in sinonasal inverted papilloma: A Single-institution experience

BACKGROUND

Most studies on sinonasal inverted papillomas (SNIPs) regarding risk factors for recurrence, recurrence rates (RRs) and malignant transformation are biased by a significant proportion of revision cases.

METHODS

Retrospective study on patients with consecutive, treatment-naïve SNIPs at a tertiary referral center between 1999 and 2019.

RESULTS

Overall, RR was 9.8% (10 of 102 patients), with 2 of 10 recurrences (20%) occurring after more than 5 years. Histopathological workup revealed synchronous malignancy in 2 of 102 patients (2%). Subgroup analysis revealed a significantly higher RR for SNIPs involving the frontal sinus (26.3% vs 6.0%, P = .02). No SNIPs primarily originating from the frontal sinus were observed.

CONCLUSION

Overall, RR of treatment-naïve SNIPs is comparably low; however, long-term follow-up is mandatory due to late recurrences. Secondary involvement of the frontal sinus was identified as risk factor for recurrence. No SNIPs primarily originating from frontal sinus were observed.

The Nasal Cavity Mass with Oropharyngeal Extension Causing Progressive Dysphagia

Although dysphagia and lump sensation in the throat caused by intranasal benign tumors with oropharyngeal extension is a rare condition, we suggest that clinicians should thoroughly examine the presence of nasal pathologies using various endoscopes for the differential diagnosis.

A multimodal diagnostic approach to inverted papilloma: Proposal of a novel diagnostic flow-chart

PURPOSE

Inverted papilloma (IP) is a tumor usually arising from sinonasal cavities, with tendency for recurrence and possible malignant transformation. Along with endoscopy, computed tomography (CT) and magnetic resonance imaging (MRI) play a crucial role in defining preoperative staging, tumor origin, and possible differential diagnosis, with significant repercussions on therapeutic planning. However, at present no consensus has been reached concerning IP diagnostic workup. Aim of this study is to assess CT and MRI sensitivity and specificity in identifying IP imaging hallmarks, evaluating their global diagnostic accuracy in order to define a novel diagnostic flowchart.

METHODS

We retrospectively analyzed multimodal imaging of patients with histologically confirmed IP and mimics. Two neuroradiologists in consensus retrospectively rated the presence of typical imaging features of IP, both on CT and MRI scans. Sensitivity, specificity and diagnostic accuracy were assessed for both the techniques. Final results were expressed as ROC curves and relative areas under the curve (AUC).

RESULTS

The AUC considering CT parameters were 0.42, whereas the AUC considering MRI parameters were 0.54. Combining the 2 techniques and limiting the evaluation to the most distinctive features such as focal hyperostosis and CCP, the AUC was 0.79.

CONCLUSION

MRI can provide better tissue characterization and higher diagnostic accuracy in case of suspected IP, whereas CT is more useful in determining bony involvement. Here we propose a possible diagnostic flowchart for IP, based on the assumption that the combination of the imaging techniques allows to optimize the clinical assessment and the subsequent therapeutic planning.

Bilateral simultaneous sino-nasal inverted papilloma; A report of two cases and literature review

Introduction

Inverted Papilloma is a benign sinonasal tumor with a high recurrence rate and potential for malignant transformation, it typically presents as an obstructing unilateral nasal mass, atypical presentations include bilateral involvement which occurs in up to 5 % of cases.

Case presentation

Here we present two different cases of bilateral inverted papilloma, both presented complaining of bilateral nasal obstruction, the second case also had associated nasal polyposis and history of multiple previous endoscopic sinus surgeries, both cases were managed with endoscopic medial maxillectomy and tumor removal, with no signs of recurrence on follow up.

Conclusion

Bilateral involvement is an uncommon, atypical presentation of inverted papilloma, endoscopic surgery is a safe, reliable approach and it is the mainstay of treatment, regular endoscopic and clinical follow up is important for detection of recurrence.

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

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

[Inverted papilloma: a study of 13 cases in the Oto-Rhino-Laryngology at the National University Hospital of Fann]

Introduction

Inverted Papilloma (IP) is a rare benign tumour of the nose and paranasal sinuses histologically characterized by invagination of the outer layer of the epithelium in the underlying chorion. Its most distinctive feature is a strong local aggressiveness, a tendency to recur and an unpredictable risk of association with epidermoid carcinoma. The purpose of this study was to report the epidemiological, clinical, paraclinical data as well as to assess the outcomes of endoscopic endonasal surgery.

Methods

We conducted a retrospective study on a series of 13 patients whose data were collected in the Oto-Rhino-Laryngology at the National University Hospital Center of Fann, from 1^st January 2012 to 31^st December 2017. All patients followed up for inverted papilloma confirmed by anathomopathological examination were included in the study.

Results

The average age of patients was 44 years, the sex-ratio was 2.25. All patients had nasal obstruction; 53% of them had rhinorrhea followed by epistaxis in 30% of cases. Right-sided symptoms were reported by 69% of patients, left-sided symptoms by 23% and bilateral symptoms by 7% of patients. Anterior rhinoscopy showed endonasal mass in all patients. All patients underwent CT scan; the MRI was performed in a single patient. Endoscopic resection of IP was performed in 10 patients (76.9%) while external approach was used in 23% of cases. Surgery helped to clarify where the tumor had originated: in 46% of cases in the maxillary sinus, in 15% in the lower nasal turbinate, in 15% in the mid-turbinate, in 7% in the ethmoid bulla and in 7% in the lateral wall of the nasal fossa. One patient had recurrence after an average period of 26 months. Malignant transformation to squamous cell carcinoma occurred in one patient.

Conclusion

Inverted papilloma is a very aggressive tumor. CT scan is essential to highlight its spread, especially to bone. The advent of endoscopic surgery has revolutionised treatment, providing excellent results. But, there is nevertheless a risk of recurrence after surgery which motivates an indication for long term monitoring.

Combined Endoscopic and External Resection of an Inverted Papilloma of the Lacrimal Sac: A Case Report and Review of the Literature

Background

Inverted papillomas (IPs) are benign, locally aggressive neoplasms with a high recurrence rate that most commonly arise from the lateral nasal wall. Rarely, IP can originate from the lacrimal sac and/or nasolacrimal duct (NLD) system. A 58-year-old man presented with chronic epiphora and an enlarging mass inferior to his left medial canthal tendon (MCT) for 2 years.

Objective

The patients’ clinical presentation and surgical management are described. A literature review on IP of the lacrimal sac and NLD system was conducted.

Methods

Case report.

Results

We present a case of an IP that arose primarily from the lacrimal sac and grew below the MCT rather than extending above it. This is one of few published case reports detailing the use of a combined endoscopic and external approach for the resection of an IP of the lacrimal sac.

Conclusion

Combined endoscopic and external resection is a viable approach for complete removal of extensive IP of the lacrimal sac and NLD system. IP arising from the lacrimal sac may grow below the MCT or extend above it as previously reported.

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

BACKGROUND

This study aimed to analyze the prognostic factors and survival outcomes of squamous cell carcinoma (SCC) originating from sinonasal inverted papillomas (IPs), based on data from a single institution.

METHODS

The data from 120 patients treated at the affiliated Beijing Tongren Hospital, Capital Medical University, for SCC originating from sinonasal IPs between 2005 and 2018 were retrospectively reviewed. Data related to demographic features, tumor characteristics, treatment modality, and clinical outcomes were collected. Survival data were investigated using the Kaplan-Meier method, Cox regression analysis, and the nomogram model predictive of survival probabilities.

RESULTS

Among 1034 patients with sinonasal IPs, 120 patients (11.6%) with malignancy were identified. The overall survival (OS) and disease-free survival (DFS) rates at 5 years were 56.0% and 42.3%, respectively. Multivariate analysis showed that synchronous tumors and tumor stage were independent predictive factors for the risk of mortality (hazard ratio [HR], 1.954; 95% confidence interval [CI], 1.022-3.737, p = 0.043; HR, 1.737, 95% CI, 1.095-2.770, p = 0.020, respectively). The surgical margin was another important independent predictor, with patients with negative margins demonstrating a more than 2-fold improved survival compared to those with positive margins (HR, 2.095; 95% CI, 1.031-4.243; p = 0.041).

CONCLUSION

The main factors affecting the prognosis and outcomes were synchronous tumors, advanced tumor stage, and positive surgical margins. These findings highlight the importance of tumor biology and early detection in patient outcomes. In addition, risk factors should be taken into consideration during treatment planning and subsequent tumor surveillance.

A Case of Inverted Papilloma Originating from the Middle Ear and Review of the Literature

Inverted papilloma (IP) with malignant transformation is rarely seen in the middle ear. Up to now, there have been 16 primary middle ear IPs reported in the English literature. Even though it is very rare in the middle ear, this pathology should be kept in mind for the differential diagnosis of middle ear masses. In this case, we report a 77-year-old female who had recurrent IP with malignant transformation and complication.

Overexpression of FoxM1 in Sinonasal Inverted Papilloma and Associated Squamous Cell Carcinoma

Background

Sinonasal inverted papilloma (IP) is a rare tumor of nasal cavity and paranasal sinuses. Its etiology and factors associated with tumor progression remains unclear. Forkhead Box M1 (FoxM1) has also been suggested to serve as an oncogene due to its pivotal roles in cell proliferation and cell cycle regulation. The aim of this study was to characterize the expression pattern of FoxM1 in IP and IP with associated squamous cell carcinoma (IPwSCC).

Methods

The study included 8 subjects with IPwSCC, 17 subjects with sinonasal IP, and 8 normal uncinate tissue (UT) mucosa. Real-time polymerase chain reaction (PCR) and immunohistochemistry were used to assess the expression and distribution of FoxM1, polo-like kinase 1 (PLK1), cyclin B1, and cyclin D1 in IP tissues and normal control. The expression of FoxM1, PLK1, cyclin B1, and cyclin D1 in IPwSCC was evaluated using immunohistochemistry.

Results

The messenger RNA (mRNA) expression of FoxM1, PLK1, cyclin B1, and cyclin D1 was significantly upregulated in IP tissues versus normal UT by real-time PCR (all P values < .05). Using immunohistochemistry, the expression of FoxM1 was observed in the tumor cells of sinonasal IP and IPwSCC, but scarce positive cells in normal UT mucosa. The percentage of positive FoxM1-staining cells was statistically higher in IPwSCC than IP and normal UT mucosa (both P < .05). Both mRNA and protein expression of FoxM1 in IP with or without associated squamous cell carcinoma was correlated with tumor histological grades (both P < .05).

Conclusion

FoxM1, a proliferation specific transcription factor, was overexpressed in sinonasal IP and IPwSCC. FoxM1 might be a key molecule associated with growth of IP and malignant transformation of IP into IPwSCC.

Surgical outcomes of sinonasal inverted papilloma: a 17 year review

Introduction

Inverted papillomas represent one of the most common benign neoplasic lesions located in the sinonasal tract. Owing to the local erosive behavior, tendency to recur and the potential for malignant transformation, surgical management of inverted papillomas is often challenging.

Objective

This study aimed to analyze the surgical outcomes of patients with inverted papillomas, according to the Krouse staging and the different surgical approaches.

Methods

Retrospective study of patients diagnosed with sinonasal inverted papillomas who underwent surgical treatment between 2000 and 2016 at a tertiary referral hospital. Cases with follow-up less than 12 months were excluded. The rate and the time of recurrence were the main outcomes. Values of p < 0.05 were considered statistically significant.

Results

Thirty-six cases with mean age of 60 years, predominantly male (72%), were included. The follow-up period ranged from 1 to 16 years, with an average of 4.5 years. Krouse T1 Stage corresponded to 11.1%; T2 occurred in 50% of cases; while T3 and T4 Stages accounted for 30.6% and 8.3% of patients, respectively. Most cases were approached by an endoscopic technique alone (83.3%), with a recurrence rate of 13.3%. Patients treated via a combined or open approach revealed a recurrence of 16.7%. No differences in the recurrence rate were reported when comparing endoscopic surgery with the open or combined techniques. Krouse Stage T3 had a significant association with inverted papillomas recurrence (p = 0.023). All inverted papilloma relapses occurred up to 2 years post-operatively. One case of malignant transformation was recorded (2.7%).

Conclusion

Endoscopic surgery did not increase the recurrence rates and can be a safe and efficient alternative to open or combined techniques. The recurrence of inverted papillomas seem to be related to the persistence of the disease and tend to occur early after primary surgery. Krouse T3 Stages may be associated with a higher recurrence of inverted papillomas.

Sinonasal (Schneiderian) papilloma of the lacrimal sac

Sinonasal papillomas, also known as Schneiderian papillomas, are benign but infiltrative epithelial neoplasms that arise from ectodermally derived pseudostratified ciliated (or Schneiderian) epithelium that lines the sinonasal tract and nasal cavity. We describe a rare case of a sinonasal papilloma confined to the lacrimal duct and sac in a 45-year-old man who presented with 10 months of right-sided epiphora and swelling of his medial right lower eyelid. He was found to have a 10 × 10 mm area of distension near the right lacrimal sac and underwent an external dacryocystorhinostomy. A computed tomography scan revealed an expansile mass in the right nasolacrimal duct area. Right endoscopic sinus surgery and endoscopic dacryocystorhinostomy were performed. This case illustrates the importance of including sinonasal papilloma, a benign but invasive neoplasm, in the differential diagnosis of nasolacrimal duct obstruction.

Combination of serum squamous cell carcinoma antigens 1 and 2 as potential diagnostic marker for sinonasal squamous cell carcinoma and inverted papilloma

BACKGROUND

Differentiating inverted papilloma from squamous cell carcinoma (SCC) is sometimes difficult. We evaluated the clinical usefulness of serum SCCA1 and SCCA2 in the management of patients with inverted papilloma or SCC.

METHODS

Serum and tissue samples for the analysis of SCCA1, SCCA2, and SCC antigen were taken from 18 patients with sinonasal inverted papilloma and 23 cases with sinonasal SCC. The SCCA1, SCCA2, and SCC antigen levels were determined.

RESULTS

The serum SCCA1 concentration was significantly higher in the inverted papilloma group than in the SCC group, whereas the serum SCCA2 level was significantly higher in the SCC group than in the inverted papilloma group.

CONCLUSION

Patients with sinonasal inverted papilloma predominantly express SCCA1 protein, whereas those with SCC predominantly express SCCA2. This suggests that combined measurements of both serum SCCA1 and SCCA2 concentrations can be very useful for distinguishing sinonasal inverted papilloma from SCC.

Genetic mutation analysis of the malignant transformation of sinonasal inverted papilloma by targeted amplicon sequencing

BACKGROUND

The mechanism underlying the malignant transformation of inverted papilloma (IP) has not yet been elucidated.

METHODS

To clarify the genes responsible for the malignant transformation, we analyzed 10 cases of IP, 8 of IP with dysplasia, and 11 of squamous cell carcinoma (SCC) by targeted amplicon sequencing.

RESULTS

The number of mutant genes increased in the order of IP < dysplasia < SCC. Significant differences were observed in the mutation rates of three genes (KRAS, APC and STK11) in particular. TP53 was altered frequently in each group and might be involved in malignant transformation based on to the site of the mutation. A comparison of the genetic variants by region of IP tissue among patients with IP alone, and those with dysplasia or SCC revealed significant differences in the mutation rate of the KRAS gene.

CONCLUSION

Identification of genetic mutations in KRAS is effective for predicting the malignant transformation of IP.

Modified Endoscopic Medial Maxillectomy for Chronic Maxillary Sinusitis

Background

Recently, modified endoscopic medial maxillectomy (MEMM) has been described as an alternative technique to open maxillectomy for benign sinonasal neoplasms. However, few reports discuss the efficacy of MEMM for treatment of inflammatory disease of the maxillary sinus. We evaluate the efficacy of MEMM in treating chronic maxillary sinusitis.

Methods

A retrospective review of patients who underwent MEMM for refractory inflammatory disease between December 2002 and September 2004 was performed. All patients were treated with MEMM alone or as part of an endoscopic sinus surgery procedure. Standard demographic data, operative technique, and postoperative follow-up times were collected.

Results

Nineteen patients (average age, 57 years) underwent 24 EMMs for chronic maxillary sinusitis refractory to middle meatal antrostomy. All patients failed prior sinus surgery, including 14 Caldwell-Luc procedures. Average follow-up was 19.5 months (range, 10–27 months). One patient has persistent hyperplastic sinusitis that currently requires monthly follow-up and medical treatment. Our only complication was one nasolacrimal duct injury.

Conclusion

MEMM is both a safe and an effective treatment for chronic maxillary sinusitis refractory to standard medical and endoscopic surgical management.

Comparison of Open versus Endoscopic Resection of Inverted Papilloma

Background

Lateral rhinotomy with medial maxillectomy has served as the standard for surgical management of inverted papilloma (IP) in the pre–endoscopic era; since the late 1980s, endoscopic techniques have emerged as the minimally invasive alternative. The objective of this study was twofold: (1) to compare operative parameters, complications, and recurrence rates and (2) predictive factors for recurrence for open versus endoscopic cases of IP resection.

Methods

Retrospective data analysis was performed on 68 patients with histopathologically confirmed IP treated at a tertiary care medical center from January 1983 to May 2005. Parameters for comparison included operative time (OT), estimated blood loss (EBL), length of hospital stay (HS), complications, and recurrence rate. Predictive factors for recurrence including open versus endoscopic cases, primary versus secondary IP, and tumor by Krouse stage were analyzed.

Results

The average age at time of presentation was 57.4 years with a male/female ratio of 2.2:1. Forty-nine patients underwent endoscopic resection, 13 patients underwent open resection, and 6 patients underwent limited open resection. Average OT and EBL were statistically similar for the three groups, whereas the average HS was statistically shorter (p = 0.002) for the endoscopic group. Biopsy-proven recurrence was noted in 11 (22%) endoscopic cases, 5 (39%) open cases, and 3 (50%) limited open cases. After reresection, all patients were free of disease. Mean follow-up was 16 months, 56 months, and 69 months for the endoscopic, open, and limited open groups, respectively. Analysis of predictive factors indicated that the surgical approach and primary versus secondary IP, regardless of approach, did not statistically impact recurrence rate. Chi-square analysis illustrated that patients with advanced-stage IP had a higher risk of recurrence (p = 0.002), regardless of surgical technique.

Conclusion

In this series, endoscopic resection of IP was associated with shorter HS and equivalent EBL and OT compared with the open groups. The overall recurrence rate was lower in the endoscopic group with acceptable morbidity compared with the open and limited open groups. Thus, the endoscopic approach may serve as a superior alternative to the open approaches for successful extirpation of IP.

Inverted Papilloma: New Classification and Guidelines for Endoscopic Surgery

Background

Surgery is the gold standard in the management of inverted papilloma (IP); however, the approach and extent of the surgical procedure are still controversial. Moreover, there is still no universal staging system of IP to plan surgery and/or evaluate results. We performed a retrospective study.

Methods

A new classification depending on the origin of the lesion was used to plan surgery in 70 cases of IP. Conservative transnasal endoscopic excision was performed in lesions arising from the nasal septum and lateral nasal wall (type I IP, 42 cases) and radical transnasal endoscopic medial maxillectomy was performed in lesions arising from the maxillary sinus (type II IP, 28 cases).

Results

Excluding cases with a follow-up of <2 years, follow-up for periods ranging between 2 and 13.3 years with a median of 78 months showed recurrence in a single case of type I (3.2%) and 2 cases of type II (9.5%).

Conclusion

The new classification system, based on the origin of IP, is a simple tool for grading IP. It can be used to define cases suitable for conservative excision or radical medial maxillectomy. Both could be performed transnasally and endoscopically.

Better surgical outcome by image-guided navigation system in endoscopic removal of sinonasal inverted papilloma

PURPOSE

The purpose of this study was to validate and compare treatment outcomes for endoscopic resection of sinonasal inverted papilloma (IP) with or without the use of a navigation system.

MATERIALS AND METHODS

A total of 58 patients who underwent endoscopic resection of sinonasal inverted papilloma by a single surgeon from 2007 to 2016 at our institution were retrospectively reviewed. Depending on the use of the navigation system, subjects were divided into two groups: a conventional endoscopic resection group without navigation system (CER group) and a navigation-assisted endoscopic resection group (NER group).

RESULTS

There were 24 patients (41.4%) in the CER group and 34 patients (58.6%) in the NER group. Treatment outcomes showed that navigation-assisted endoscopic resection was a more beneficial surgical technique than conventional endoscopic resection for sinonasal IP. Post-surgical recurrence was noted in seven cases (29.2%) in the CER group and two cases (5.9%) in the NER group. Accordingly, the recurrence rate was significantly less in the NER group compared to the CER group (p = 0.026). There were two cases of complications (8.3%) in the CER group comprising cerebrospinal fluid leak and periorbital fat exposure, while no complications were noted for the NER group (p = 0.167).

CONCLUSION

This study demonstrated that navigation-assisted endoscopic removal of sinonasal IP is helpful for reducing recurrence and avoiding surgical complications. Therefore, navigation systems should be always considered when performing endoscopic removal of sinonasal IP.

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.

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.

Combined endonasal and eyelid approach for management of extensive frontal sinus inverting papilloma

OBJECTIVES

Sinonasal inverting papilloma (IP) is a benign but locally aggressive mucosal neoplasm with a high recurrence rate. Extension into the frontal sinus presents surgical challenges for endonasal resection. This study presents an orbitofrontal approach for managing extensive IP.

STUDY DESIGN

Case series.

METHODS

Four patients seen between 2012 and 2016 with biopsy-proven IP with lateral frontal sinus extension underwent a combined endonasal and transpalpebral approach for tumor resection. Patient demographic data, preoperative characteristics, imaging, and follow-up data were compiled through retrospective chart review. Patients were selected for this approach when the tumor extended to the posterior frontal sinus wall, lateral frontal sinus recess, and orbit. Tumors were first approached endonasally until the frontal recess was reached. A Draf IIB or Draf III procedure was then performed to gain better exposure. Orbitofrontal exposure was achieved through an upper eyelid incision. Miniorbitofrontal craniotomy window was designed based on tumor location. Resection of the frontal and orbital extension was enhanced by endoscopic-assisted dissection through the orbitofrontal window.

RESULTS

The transpalpebral approach provided access to all walls of the ipsilateral frontal sinus, the intersinus septum, and the medial aspect of the contralateral sinus. Complete tumor resection was achieved in all patients. There were no orbital complications, no visible eyelid asymmetry or scarring, and all patients had preserved forehead sensation. There were no recurrences on follow-up.

CONCLUSION

Combining a transpalpebral orbitofrontal craniotomy with the endonasal approach allows complete resection of invasive IP with extension into the frontal sinus. This is achieved with great cosmetic results.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:3-9, 2018.

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

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

Management of inverted papilloma: review

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Atypical presentations of sinonasal inverted papilloma: Surgical management and influence on the recurrence rate

BACKGROUND

Sinonasal inverted papilloma (SNIP), classically, is a unilateral benign tumor of the nasal lateral wall. Numerous variations have been observed, depending on location, bilateral presentation, or association with nasal polyposis.

OBJECTIVE

The aim of this work was to describe atypical presentations of SNIPs with their management specificities and to assess their influence on the recurrence rate in a large case series.

METHODS

A retrospective single center study of 110 patients treated for SNIP. Atypical inverted papillomas were identified according to the following criteria: (1) unusual location (frontal, posterior, anterior), (2) bilateral involvement, and (3) association with nasal polyposis. Surgical management was detailed, and the influence of each atypical group on recurrence was assessed by using Kaplan-Meier survival curves and the log-rank test.

RESULTS

Distribution of atypical presentations was as follows: frontal sinus localization (10.9%); posterior localization, including sphenoid sinus (9%); nasal anterior localization (3.6%); bilateral involvement (3.6%); and nasal polyposis association (10%). The surgical approach was endoscopic (74.5%), external (5.5%), or combined endoscopic and external (20%). Except for nasal anterior localization, all the groups were associated with a higher recurrence rate, without reaching statistical significance.

CONCLUSION

Recurrence rates for these atypical presentations arise from their specific surgical challenges. The choice of the surgical technique is guided by tumor location and extension, and by the surgeon's experience; the main objective is a complete resection. The endoscopic endonasal approach is the most frequent procedure.

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.

Preoperative Staging and Surgical Approaches for Sinonasal Inverted Papilloma

Objectives:

We sought to determine the value of preoperative staging by magnetic resonance imaging (MRI) assessment in the surgical management of sinonasal inverted papillomas (IPs).

Methods:

Preoperative MRI staging was used to assess 22 patients with IPs. In addition to the Krouse staging system, T3 cases were categorized as subgroup T3-B if tumors extended into the frontal sinus or the supraorbital recess; otherwise, they were categorized as T3-A. Standard endoscopic sinus surgery (ESS) was the first choice for T1 and T2 cases. Endoscopic approaches, including ESS combined with endoscope-assisted transantral approach and endoscopic medial maxillectomy, were considered in T3-A cases, and external approaches were considered in T3-B cases. Patients were followed for a minimum of 1 year after surgery.

Results:

Preoperative MRI staging and postoperative staging were coincident in 21 of the 22 patients (95%). All 8 T2 cases were treated by an endoscopic approach. Of 10 T3-A cases, 9 (90%) were treated by an endoscopic approach and 1 (residual case) was treated by an external approach. All 3 of the T3-B cases underwent an external approach. One T4 case with malignant transformation underwent an external approach followed by radiotherapy. After a median follow-up period of 22 months, none of the 22 patients had had a recurrence. No major complications were observed after endoscopic approaches, but epiphora or hemorrhage requiring transfusion occurred in 3 of the 5 patients (60%) who underwent external approaches.

Conclusions:

Preoperative staging of IP by MRI is useful for selecting cases that can be managed by endoscopic approaches, resulting in lower rates of tumor recurrence and morbidity.

Clinical management of squamous cell carcinoma associated with sinonasal inverted papilloma

OBJECTIVE

The aim of this study was to investigate the clinical features and prognosis of patients with squamous cell carcinoma (SCC) associated with sinonasal inverted papilloma (IP).

METHODS

The medical records of 95 patients who were diagnosed with IP or SCC associated with IP were retrospectively reviewed. Out of 95 patients, 15 were diagnosed with SCC associated with IP. The clinical characteristics, treatment modalities, and survival outcomes of the patients were analyzed.

RESULTS

The incidence of SCC associated with IP was 15.8%. Although differential diagnosis between IP and SCC associated with IP is difficult, epistaxis may be the specific symptom in SCC associated with IP cases. The 3-year disease-specific survival rate was higher in cases with T1, 2 and 3 than in cases with T4. There was no significant difference in survival rate between maxillary sinus and other primary sites. On the other hand, there was a significant difference in survival rate between the microscopic SCC with IP cases and the other cases. In addition, the patients with <70 years old better than those with >70 years old with a 3-year disease free survival of 80% versus 0%.

CONCLUSIONS

Some T4 patients were found to have a highly aggressive disease. Therefore, complete surgical resection followed by chemo-radiation therapy is the recommended treatment for patients with T4 disease to control of the primary tumor site.

Survival outcomes after endoscopic resection for sinonasal squamous cell carcinoma arising on inverted papilloma

BACKGROUND

Sinonasal inverted papillomas (IPs) can be associated synchronously or metachronously to invasive squamous cell carcinoma (SCC) in 5% to 10% of cases. The purposes of the present study were to analyze the outcomes of patients with sinonasal SCC arising from inverted papilloma (IP-SCC) treated through an endoscopic approach and review the pertinent literature.

METHODS

The medical records of all patients treated for IP-SCC between 1997 and 2014 at 2 referral centers following a uniform policy were retrospectively analyzed.

RESULTS

Thirty-four patients fulfilled the inclusion criteria. The 5-year overall survival (OS), disease-specific survival (DFS), and recurrence-free survival (RFS) rates were 66.8 ± 0.99%, 71.2 ± 0.96%, and 73.1 ± 0.82%, respectively. Multivariate analysis revealed that the advanced pT classification (pT3 or greater), the high-grade of tumoral differentiation, the cranioendoscopic approach, and the recurrence of disease impacted negatively on survival rates.

CONCLUSION

The endoscopic approach provides encouraging oncologic outcomes for sinonasal IP-SCC, comparable to those observed with traditional external approaches while minimizing morbidity for patients. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.

Survival Outcome of Squamous Cell Carcinoma Arising from Sinonasal Inverted Papilloma

Background:

Sinonasal inverted papilloma (IP) is a rare benign tumor of the nasal cavities and paranasal sinuses. It is destructive or bone-remodeling, tends to recur after surgical resection, and has a significant malignant potential. The present study aimed to perform a retrospective analysis of patients with squamous cell carcinoma (SCC) arising from IP, including characteristics, survival outcome, and predictors of associated malignancy.

Methods:

The medical records of 213 patients diagnosed with IP from January 1970 to January 2014 were retrospectively reviewed. Eighty-seven patients were diagnosed with SCC/IP; their clinical characteristics, treatments, and survival outcomes were analyzed.

Results:

Of the 87 patients with SCC/IP, the 5- and 10-year overall survival outcomes were 39.6% and 31.8%, respectively. Twenty-nine of these patients received surgery and 58 received combined surgery and radiation. Of the patients with stages III–IV, the 5-year survival rate was 30.7% for those treated with surgery only and 39.9% for those given the combination treatment (P = 0.849). Factors associated with significantly poor prognosis were advanced-stage, metachronous tumors, or with cranial base and orbit invasion. Age, synchronous or metachronous tumors, and pathological stage were independent risk factors for mortality, shown by multivariate analysis.

Conclusion:

Patients with SCC/IP had low overall survival outcomes. Advanced age, stage, and metachronous tumors are the main factors affecting prognosis. Treatment planning should consider high-risk factors to improve survival outcome.

Role of Wnt signaling pathway in progression of sinonasal inverted papilloma to squamous cell carcinoma

BACKGROUND

Sinonasal inverted papilloma (IP) is one of the most common benign tumors of the sinonasal area and malignant transformation has frequently been reported. However, the exact mechanism of the transition from benign lesion to malignancy is not known. The Wnt signaling pathway involves a network of multiple signaling glycoproteins that are known to play an important role in embryogenesis and carcinogenesis.

OBJECTIVE

The purpose of this study was to evaluate the role of the Wnt pathway and signaling proteins in malignant transformation of IP to dysplasia and squamous cell carcinoma.

METHODS

Expression of the Wnt signaling pathway proteins, including Wnt-1, beta-catenin, cyclin D1, and Dishevelled-1 (Dvl-1), were detected by immunohistochemistry by using 3-mm tissue core microarrays that consisted of 115 cores of IP tissue. Each of the IP cores was graded as I (prominent squamous metaplasia), II (inverted pattern), III (dysplasia), or IV (squamous cell carcinoma). The expression pattern of each protein and the correlation between the expression of each target protein and IP grade were evaluated.

RESULTS

Membranous staining of beta-catenin showed a significant positive correlation with IP grade (ρ = 0.247, p < 0.001), as did staining of cyclin D1 (ρ = 0.365, p < 0.001), which showed a nuclear pattern and staining of Dvl-1 (ρ = 0.380, p < 0.001), which showed a membranous, cytoplasmic, and nuclear pattern. For Dvl-1, a nuclear expression pattern was more frequently observed in grade III and IV IP (p = 0.036). In the case of Wnt-1, cytoplasmic expression was observed; however, it did not show a significant correlation with IP grade (ρ = 0.141, p = 0.130).

CONCLUSIONS

Wnt signaling proteins, including beta-catenin, cyclin D1, and Dvl-1, may play crucial roles in the malignant transformation of IP.

Primary inverted papilloma of the middle ear with intracranial invasion

BACKGROUND

Primary inverted papillomas of the middle ear are extremely rare tumors, with only few cases published in the literature. They have a characteristic epithelium surface inversion to the inside of the stroma. Inverted papillomas are benign lesions but have a high propensity of recurrence, local aggressiveness, and association with malignancy.

METHODS

We present a patient with an inverted papilloma originating in the middle ear producing chronic otorrhea and facial nerve palsy treated with a subtotal petrosectomy.

RESULTS

During the follow-up, the patient developed an intracranial invasion of the tumor causing his death.

CONCLUSION

Primary inverted papillomas of the middle ear can have an extremely aggressive behavior despite their benign characteristics; therefore, an aggressive treatment must be performed in order to minimize the possibility of recurrence.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

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

OBJECTIVES/HYPOTHESIS

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

STUDY DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

4.

Frequency, suppressive capacity, recruitment and induction mechanisms of regulatory T cells in sinonasal squamous cell carcinoma and nasal inverted papilloma

Background

Sinonasal squamous cell carcinoma (SSCC) and nasal inverted papilloma (NIP) represent the predominant type of malignant and benign tumors in sinonasal tract, respectively. CD4⁺CD25⁺Foxp3⁺ natural regulatory T (Treg) cells might play critical role(s) in the suppression of anti-tumor immune response and thus shed light on tumor progression from benign to malignant.

Objective

This study aimed to evaluate the frequency and suppressive capacity of Treg cells in SSCC compared to NIP and further to explore the underlying mechanisms.

Patients and Methods

Frequencies of Treg, Th1 and Th2 cells were evaluated by flow cytometry in tissue homogenate and peripheral blood from 31 SSCC patients, 32 NIP patients and 35 normal controls. Treg cells were tested for regulatory function by co-culture with effector T cells. CCR4 and its ligands, CCL22 and CCL17, were analyzed by flow cytometry and Luminex, respectively. The chemoattractant properties of CCR4/CCL22 and CCR4/CCL17 for Treg cells were assessed using the Boyden chamber technique, to elucidate the potential mechanisms of Treg recruitment in tumor microenvironment. Treg cells induction via TGF-β was assessed with transwells after local CD4⁺Foxp3⁺ T cells were assessed by immunohistochemistry and TGF-β concentration was measured by Luminex.

Results

Tumor-infiltrating Treg cells increased significantly from normal to NIP to SSCC (P ≤ 0.001 for normal vs. NIP and P = 0.004 for NIP vs. SSCC). Significantly elevated frequency and enhanced suppression capacity of circulating Treg cells in SSCC were detected compared to NIP and healthy controls, concomitant with Th1 decrease and Th2 increase. Apparently increased CCL22 attracted CCR4-expressing Treg cells to tumor microenvironment in SSCC, compared to NIP. SSCC produced significantly more TGF-β than NIP and thus possessed greater potential for Treg cell induction.

Conclusion

Frequency and suppressive capacity of Treg cells enhanced with progression of malignancy from NIP to SSCC. Circulating Treg cells were recruited to tumor tissue via CCR4/CCL22 signalling, whereas tumor-synthesised TGF-β contributed to induction of peripheral Treg cells.