Preoperative staging of sinonasal inverted papilloma by magnetic resonance imaging

Sinonasal Inverted Papilloma and Squamous Cell Carcinoma: Contemporary Management and Patient Outcomes

Simple Summary

Inverted papillomas are benign sinonasal tumors that can recur or become cancerous. The mainstay of treatment is surgical resection. We summarize the biology of inverted papillomas and review surgical outcomes in an effort to define the current treatment strategy.

Abstract

Inverted papillomas (IP) are the most common sinonasal tumor with a tendency for recurrence, potential attachment to the orbit and skull base, and risk of malignant degeneration into squamous cell carcinoma (SCC). While the overall rate of recurrence has decreased with the widespread adoption of high-definition endoscopic optics and advanced surgical tools, there remain challenges in managing tumors that are multiply recurrent or involve vital neurovascular structures. Here, we review the state-of-the-art diagnostic tools for IP and IP-degenerated SCC, contemporary surgical management, and propose a surveillance protocol.

Clinical evidence based review and systematic scientific review in the identification of malignant transformation of inverted papilloma

Background

Inverted papilloma (IP) is an unusual type of benign tumor that has high recurrence rates and the potential to transform into squamous cell carcinomas (SCC). The mechanism of the transformation process from IP to IP-SCC is uncertain and there is no consensus regarding the best practice for IP-SCC detection. The goal of this study is to identify the best clinical methods to detect for IP-SCC.

Methods

An evidence-based review was performed using Medline and Ovid to obtain all articles up to October 10th, 2019 pertaining to identification of IP malignant transformation. All manuscripts discussing clinical methods or biomarkers were included.

Results

Based on clinical research studies, convoluted cerebriform pattern and apparent diffusion coefficient values on Magnetic Resonance Imaging (MRI) can help differentiate benign IP from SCC and increased SUVmax on PET/CT is associated with higher probability of malignancy although not as specific. No consensus about the best biomarker for IP-SCC has been reached among researchers and continues to be exploratory.

Conclusion

Endoscopy with biopsy is the gold standard practice to identify IP-SCC; however, MRI is the preferred imaging modality to recognize malignant transformation in cases where biopsy is difficult. Multiple biomarkers have shown positive results, but no single indicator with clinical significance for monitoring malignant transformation process has been found.

Sinonasal papillomas in a private referral otorhinolaryngology centre: Review of 22 years experience

OBJECTIVES

To evaluate the clinical presentation, treatment outcome and follow-up of all patients managed with sinonasal papillomas (SP), at a tertiary private otorhinolaryngology centre in Caracas (Venezuela).

MATERIAL AND METHODS

We reviewed 94 patients with SP that were treated at our otolaryngology center, from July 1st 1993 to June 31st 2015. The demographic data, clinical features, radiological findings, anatomical origin, disease extension into the adjacent structures, surgical approaches performed, histopathology outcomes, recurrent risk, malignant transformation rate and coadjuvant therapies were assessed.

RESULTS

Sixty-five patients (69.1%) were male and 29 (30.9%) female with an average age of 44.5 years (range 9-80 years). All patients underwent endoscopic sinus surgery. The most commont histologic subtypes of SP were inverted papilloma (58 patients; 61.7%), fungiform papilloma (35 patients; 37.2%) and oncocytic papilloma (one patient; 1.1%). SP was associated in 2 patients with undifferentiated squamous cell carcinoma. Twelve patients (12.8%) had disease with extension beyond the sinus without associated malignancy. All these patients received adjuvant treatment with advanced techniques of radiotherapy. The mean duration of the follow-up period was 9 years and 2 months. Eighteen patients (19.1%) had recurrent disease during the entire course of follow-up.

CONCLUSIONS

Complete endoscopic surgical removal of SP is the treatment of choice. In less endoscopically accessible tumours, with peripheral extension or incompletely resected, Intensity Modulated Radiotherapy and Volumetric Modulated Arc Therapy may be indicated. Timely post-operative endoscopic follow-up with biopsy of suspected lesions is important for early detection of recurrences and associated malignancy.

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.

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.

Sinonasal inverted papilloma: From diagnosis to treatment

Inverted papilloma is a rare sinonasal tumor that mainly occurs in adults during the 5th decade. Three characteristics make this tumor very different from other sinonasal tumors: a relatively strong potential for local destruction, high rate of recurrence, and a risk of carcinomatous evolution. Etiology remains little understood, but an association with human papilloma virus has been reported in up to 40% of cases, raising the suspicions of implication in the pathogenesis of inverted papilloma. Treatment of choice is surgery, by endonasal endoscopic or external approach, depending on extension and tumoral characteristics. Follow-up is critical, to diagnose local relapse, which is often early but may also be late. The seriousness of this pathology lies in its association with carcinoma, which may be diagnosed at the outset or at recurrence during follow-up. It is important to diagnose recurrence to enable early treatment, especially in case of associated carcinoma or malignancy. A comprehensive review of the international literature was performed on PubMed and Embase, using the following search-terms: "sinonasal" [All Fields] AND ("papilloma, inverted" [MeSH Terms] OR ("papilloma" [All Fields] AND "inverted" [All Fields]) OR "inverted papilloma" [All Fields] OR ("inverted" [All Fields] AND "papilloma" [All Fields])). We reviewed all articles referring to sinonasal inverted papilloma published up to January 2015. The present article updates the state of knowledge regarding sinonasal inverted papilloma.

Endoscopic and combined external-transnasal endoscopic approach for the treatment of inverted papilloma: analysis of 110 cases

The aim of the study was to evaluate the effectiveness of the endoscopic approach for the management of inverted papilloma (IP) of the nose and paranasal sinuses and the possible factors associated with its recurrence. One hundred and forty-one patients affected by an IP originating at the level of the sinonasal tract were treated surgically using an endoscopic technique alone or a combined external-endoscopic approach at the ENT Department of the University of Bologna between January 1994 and December 2012. Of these patients, 110 were selected for the recurrence analysis. Univariate and multivariate analyses were performed to detect risk factors for IP recurrence. The patients had a mean follow-up of 56.7 months (24-167 months). Seven cases (6.3%) of recurrence were observed in patients treated with the endoscopic approach for the primary or recurrent tumor. Previous surgery (p = 0.005) and number of previous surgical procedures (p = 0.003) were associated with higher recurrence rate. The number of previous operations was associated to recurrence-free survival at Cox regression analysis. In our study, the endoscopic approach showed itself to be a useful tool for the radical resection of an IP. The endoscopic approach should be tailored for the different extensions of IP. Recurrent cases showed an increased risk of further recurrence. Therefore, these should be treated paying particular attention to the boundaries of the primary tumor.

Co-existing of sinonasal inverted papilloma and angiofibroma: case report and review of the literature

Sinonasal tumors may grow to considerable size before presentation and in view of their relation to the base of skull, orbit, cranial nerves and vital vessels; a precise diagnostic and therapeutic planning is needed to achieve the optimal results. We report a case who presented with unilateral nasal blockage, rhinorrhea and episodes of epistaxis which diagnosed as sinonasal inverted papilloma and angiofibroma.

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.

Advances in endoscopic resection of sinonasal neoplasms

Management of sinonasal diseases has undergone significant change with the advent of endoscopic techniques. A wide variety of pathology can now be surgically managed with the use of endoscopes both within and beyond the sinonasal tract. Endoscopic techniques allow for excellent visualization and complete tumor resection with low morbidity. As experience continues to grow, endonasal endoscopic techniques are becoming the surgical procedures of choice for the management of a wide variety of benign neoplasms.

[Endoscopic medial maxillectomy for maxillary sinus tumors: indications and clinical outcome]

Endoscopic sinus surgery (ESS) widely conducted in nasal and paranasal sinus surgery provides superior magnification, illumination, and angled visualization, enabling the surgeon to isolate the tumor base and accurately define disease extent. Endoscopic medial maxillectomy (EMM), an advanced ESS procedure, effectively treats benign sinonasal neoplasms such as inverted papilloma. We analyzed a series of EMM cases and their clinical outcomes, including 9 inverted papillomas, 1 solitary fibrous tumor, 1 hemangioma, 1 blood boil and 1 esthesioneuroblastoma. EMMs were conducted by an experienced surgeon. Removal of the medial wall and the wide maxillary sinus opening enabled by EMM allows easy access to the entire maxillary sinus with a generous work space. All tumors were treated endoscopically and the postoperative course was uneventful. No recurrence was observed in follow-up. We found EMM to be safe and efficacious in resecting maxillary sinus tumors thanks to its improved accessibility and visualization. In conclusion, EMM enables complete removal of benign tumors from the maxillary sinus, having the advantages of no external incision, decreased blood loss, low morbidity, shorter hospital stay, and the possibility of repetition in recurrence, compared to conventional approaches. EMM may thus become the treatment of choice for maxillary sinus tumors.

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.

Computed tomography and/or magnetic resonance imaging for pre-operative planning for inverted nasal papilloma: review of evidence

BACKGROUND

Inverted nasal papilloma is a benign tumour with variable biological behaviour. It is a unique neoplasm and is often difficult to manage, being characterised by a tendency to recur following excision, an association with malignancy and an ability to destroy bone. Radiological diagnosis has traditionally been based on computed tomography, but it is often impossible to differentiate between polyps with entrapped debris and inverted nasal papilloma. Magnetic resonance imaging, especially T2-weighted images, is perhaps a better tool in differentiating inverted nasal papilloma from other nasal lesions, and has recently been advocated as the imaging modality of choice.

AIMS

To review the evidence on the ideal imaging modality for pre-operative planning of surgery for patients with histologically proven inverted nasal papilloma.

MATERIALS AND METHODS

A systematic review of studies was undertaken, focusing on radiological assessment of inverted nasal papilloma (primary and recurrent). All English language articles were potentially included in the review. However, we excluded single case reports, case series, pictorial essays, 'teaching' reviews and reviews of inverted nasal papilloma not focusing on pre-operative imaging.

RESULTS

Sixteen studies were identified based on our search strategy. Only 10 fulfilled our criteria. Computed tomography scanning was the standard imaging modality of choice for assessing sinus involvement of inverted papilloma and for planning the extent of surgery. T2-weighted magnetic resonance imaging scans were able to distinguish tumour (intermediate signal) from inflammatory tissues (bright signal), but not post-operative scarring from recurrent tumour. No studies were found which compared the specificity and sensitivity of magnetic resonance imaging and computed tomography in the accurate pre-operative identification of the extent of inverted papilloma.

CONCLUSIONS

There is currently not enough evidence to suggest one sole modality as providing optimum imaging for inverted nasal papilloma. Computed tomography remains the imaging modality of first choice for inverted nasal papilloma, despite certain disadvantages. Magnetic resonance imaging is able to distinguish tumour from inflammation and is advocated as a better tool for recurrent tumour, but bone destruction of sinus walls is less easy to recognise, compared with computed tomography. Evaluation of sinus tumours usually involves both imaging modalities, and inverted nasal papilloma should be included within this pathological group. The cohort of patients is usually small, so cost-effectiveness should not generally be an issue when considering whether to use computed tomography, magnetic resonance imaging or both. A well structured, prospective study is needed to evaluate the efficacy of magnetic resonance imaging versus computed tomography for pre-operative planning of histologically proven inverted nasal papilloma.

Survival outcomes of squamous cell carcinoma arising from sinonasal inverted papilloma: report of 6 cases with systematic review and pooled analysis

BACKGROUND

Inverted papilloma (IP) is an uncommon sinonasal tumor. Squamous cell carcinoma (SCC) is associated with IP in about 7% of cases. To date, there has been no pooled analysis to formulate a survival outcome associated with this rare condition.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of patients with IP and SCC treated at our institution during 1999-2007. Including our series, a systematic review of literature on Medline database and pooled analysis were performed to establish a survival estimate.

RESULTS

Six patients were identified. Squamous cell carcinoma was metachronous to the initial diagnosis of IP in 1 case and synchronous in 5 cases. Of 5 patients who had completed therapy at the time of this report, only 1 remained disease-free at 74 months. The median overall survival in our series was 33 months. Three patients developed distant metastases in brain, lung, bone, and liver. Literature review and pooled survival analysis consisting of 76 cases indicated a median overall survival of 126 months with 3- and 5-year survival rates of 63% and 61%, respectively.

CONCLUSION

Although the survival outcome of SCC arising from IP seems comparable with sinonasal SCCs, some patients with this disease do have a highly aggressive disease, including hematogenous distant metastasis. Overall, about 40% of patients will die of the disease within the first 3 years.

Bilateral inverted papilloma: case report and literature review

The inverted papilloma is an uncommon unilateral nasosinusal benign tumor. The clinical picture presents nonspecific signs and symptoms, such as unilateral nasal obstruction, anosmia and headache. The diagnosis is established by anamnesis, physical exam, computed tomography and magnetic resonance imaging. Treatment is essentially surgical. This report has the objective of presenting an uncommon bilateral inverted nasal papilloma and making a literature review.

The roles and limitations of computed tomography in the preoperative assessment of sinonasal inverted papillomas

BACKGROUND

Preoperative radiological assessment of sinonasal inverted papilloma (SNIP) is important in the planning of surgical treatment. This study investigates the roles and limitations of preoperative plain computed tomography (CT) scan in the preoperative assessment of SNIP.

METHODS

Plain CT scans from 30 patients with SNIP were reviewed retrospectively by a radiologist who had no prior knowledge of the final surgical findings. Disease at each sinus was judged by the CT findings of opacity and additional signs. The overall disease was staged according to the staging system proposed by Krouse. All of the findings were compared with the final disease extent and staging confirmed by intraoperative and histological findings.

RESULTS

Using opacity with additional signs for diagnosis, the range of accuracy of CT diagnosis for each sinus involvement was 83-97%. Staging by plain CT was concordant with postoperative staging in 80% of patients. Among the additional signs, focal hyperostosis or "bony strut" had the highest positive predictive value (100%) of tumor origin.

CONCLUSION

Focal hyperostosis or bony strut is the most important CT sign predicting the origin of tumor. Although using multiple CT diagnostic signs provides a reasonable assessment of tumor origin and extent, accurate tumor mapping was still impossible because of inadequate differentiation of tumor from inflammatory pathologies. This drawback may be overcome by a complementary MRI scan. Since preoperative CT staging was inaccurate in 20% of cases, surgical planning should be flexible to provide for the need of the intraoperative findings.

Endoscopic treatment of sinonasal papilloma: a 12 year review

CONCLUSION

Endoscopic surgical management is recommended as a viable treatment option for sinonasal papilloma, with comparable results to those treated by an external approach. An external approach is still indicated in cases where the papilloma is not accessible endoscopically, or where there is extrasinus invasion. Long-term follow-up is essential for recurrence detection.

OBJECTIVES

The goal of this study was to highlight our experience with endoscopic surgery for the management of sinonasal papilloma.

PATIENTS AND METHODS

A retrospective study of all patients who underwent endoscopic surgery for the treatment of sinonasal papilloma over a 12 year period at the Gui de Chauliac Hospital, Montpellier, France.

RESULTS

A total of 55 patients were included in this study; 32 patients (58%) were treated exclusively by an endoscopic approach and 23 (42%) were treated by a combined approach. Minimal follow-up was 3 years. The overall recurrence rate was 7%. All recurrences occurred at the initial site and the average delay between surgery and recurrence was 30 months (14 months to 4 years).

Sinonasal inverted papilloma: value of convoluted cerebriform pattern on MR imaging

BACKGROUND AND PURPOSE

A convoluted cerebriform pattern (CCP) has been reported as a valuable MR imaging feature of inverted papilloma (IP). The purpose of this study was to validate the usefulness of CCP for distinguishing IP from various malignant sinonasal tumors in a relatively large number of patients.

MATERIALS AND METHODS

We retrospectively reviewed MR images of 30 patients with IP and 128 patients with various malignant sinonasal tumors proved on histologic examination and compared the prevalence of a CCP between the 2 groups. In 8 patients with IP concomitant with squamous cell carcinoma, we also tried to find the MR features to help suggest coexistent malignancy.

RESULTS

A CCP was demonstrated in all 30 (100%) of the IPs and 17 (13%) of the 128 malignant sinonasal tumors on MR imaging. There was a significant statistical difference in the prevalence of a CCP between IP and malignant sinonasal tumors with the overall sensitivity, specificity, positive predictive value, negative predictive value, and accuracy 100%, 87%, 64%, 100%, and 89%, respectively. Of 8 IPs concomitant with squamous cell carcinoma, a focal loss of a CCP was demonstrated in 4 tumors, 3 of which also showed aggressive bone destruction with extrasinonasal extension on MR images.

CONCLUSION

Although a CCP is a reliable MR imaging feature of sinonasal IPs, it can also be seen in various malignant sinonasal tumors. A focal loss of a CCP might be a clue to the diagnosis of IPs concomitant with malignancy.

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.

Endoscopic surgery of inverted papillomas under image guidance--a prospective study of 42 consecutive cases at a Danish university clinic

BACKGROUND

To evaluate the feasibility of endoscopic surgery with image guidance in the treatment of inverted papillomas.

STUDY DESIGN AND SETTING

This prospective cohort study comprised 42 consecutive patients with biopsy-confirmed inverted papillomas that were diagnosed between 1998 and 2003. All patients were treated by the first author (C.B.). Image guidance based on preacquired CT scans of the patients was used to assist the surgeon aiming at endoscopic resection of inverted papilloma. The success of the surgery was judged primarily by the recurrence rate and the treatment morbidity.

RESULTS

The study group consisted of 30 males and 12 females with a median age of 61 years. The follow-up period ranged from 9 months to 69 months (median, 37 months). The only additional procedure performed was the Caldwell-Luc procedure (8 cases). Recurrence was diagnosed in 10 cases (24%), all in the original tumor site. Eight of these had undergone previous surgery for inverted papilloma. The recurrences were predominantly located in the maxillary or in the frontal sinus (8 cases). In 2 cases, the recurrence was simply removed endoscopically while performing the biopsy procedure. All recurrences were identified within the first 9 months. Associated malignancy was not shown. No severe complications occurred.

CONCLUSIONS

A treatment based on endoscopic resection with image guidance appears to offer a safe treatment modality of inverted papilloma with insignificant morbidity. Predominantly cases with nonmedial involvement of the maxillary sinus still require a supplement with the Caldwell Luc procedure. Although all the recurrences were found within 9 months postoperatively, later recurrences cannot be excluded. Long-term follow-up is recommended.