Inverted Papilloma of the Orbit and Nasolacrimal System

Long-Term Outcome for Primary Papillomas of the Lacrimal Drainage System

AIMS

To report long-term outcomes after surgery for primary benign papillomas of the lacrimal drainage system.

METHODS

Retrospective review of patients with primary lacrimal drainage system papillomas, first seen between 1984 and 2021, but excluding lesions with sino-nasal origin or malignant histology. Patients were categorized by tumor histology (squamous, transitional, and mixed cell) and growth pattern (exophytic, endophytic, or mixed).

RESULTS

Thirty patients (18 female; 60%) presented at a mean age of 46.1 years (12-79 years). Over an average follow-up of 10.4 years, 30% of patients experienced recurrence, with rates differing slightly by growth pattern: 25% for exophytic tumors and 40% for endophytic and mixed-pattern tumors (p = 0.431). The overall 5-year recurrence-free survival was 67% (± 9% standard error), this being slightly higher for exophytic lesions (75% ± 10%) as compared to 48% (± 19%) for tumors with an endophytic component (p = 0.370). No cases of malignant transformation were observed, and the tumor type at recurrence matched the initial diagnosis.

CONCLUSION

Primary benign papillomas of the lacrimal drainage system have a long-term recurrence rate of about one-third, with a higher frequency in those exhibiting an endophytic growth pattern. The study highlights the importance of prolonged surveillance for recurrence, especially for endophytic and mixed growth pattern tumors, and for the potential to undergo malignant transformation. The results support the effectiveness of endoscopic surgical excision or laser thermos-ablation in managing recurrent lacrimal drainage system papillomas after dacryocystorhinostomy.

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Viral and Genomic Drivers of Squamous Cell Neoplasms Arising in the Lacrimal Drainage System

The pathogenesis of squamous cell neoplasms arising in the lacrimal drainage system is poorly understood, and the underlying genomic drivers for disease development remain unexplored. We aimed to investigate the genomic aberrations in carcinomas arising in the LDS and correlate the findings to human papillomavirus (HPV) status. The HPV analysis was performed using HPV DNA PCR, HPV E6/E7 mRNA in-situ hybridization, and p16 immunohistochemistry. The genomic characterization was performed by targeted DNA sequencing of 523 cancer-relevant genes. Patients with LDS papilloma (n = 17) and LDS carcinoma (n = 15) were included. There was a male predominance (68%) and a median age at diagnosis of 46.0 years (range 27.5-65.5 years) in patients with papilloma and 63.8 years (range 34.0-87.2 years) in patients with carcinoma. Transcriptional activity of the HPV E6/E7 oncogenes was detected in the whole tumor thickness in 12/15 (80%) papillomas (HPV6, 11, 16) and 10/15 (67%) squamous cell carcinomas (SCC) (HPV11: 3/15 (20%) and HPV16: 7/15 (47%)). Pathogenic variants in PIK3CA, FGFR3, AKT1, and PIK3R1, wildtype TP53, p16 overexpression, and deregulated high-risk E6/E7 transcription characterized the HPV16-positive SCC. The deregulated pattern of HPV E6/E7 expression, correlating with HPV DNA presence and p16 positivity, supports a causal role of HPV in a subset of LDS papillomas and carcinomas. The viral and molecular profile of LDS SCC resembles that of other HPV-driven SCC.

Quality of life in sinonasal tumors: an up-to-date review

PURPOSE OF REVIEW

To assess the impact of benign and malignant sinonasal tumors and their management on patients' Quality of Life (QOL) as measured by Patient Reported Outcome Measures (PROMS).

RECENT FINDINGS

Although there is a growing consensus that endoscopic surgical management in carefully selected patients with sinonasal tumors is at least as (and probably more) effective than open resection, it is not clear to what extent this translates to better QOL outcomes. Earlier studies reported better outcomes in the emotional and physical function domains after endoscopic resection, and it seems that postsurgical morbidity is less in endoscopic compared to open approaches. QoL after endoscopic surgery for sinonasal and anterior skull base tumors seems to improve within several months of surgery in both benign and malignant tumor groups. However, patients with benign sinonasal tumors have a higher QOL pre and post operatively compared to those with malignancy mainly due to absence of (neo) - adjuvant radiotherapy and/or chemotherapy. Factors that seem to be associated with worse QoL include > 60 years, less than 6 months from surgery, prior and adjuvant chemo and radiotherapy, smoking history, advanced staging and malignancy.

SUMMARY

There is not a universally accepted PROM for use in patients with sinonasal benign and malignant tumors: A variety of different PROMs have been used with different degrees of effectiveness. Most likely a combination of disease-specific (such as SNOT 22 and anterior skull base questionnaire) and generic (such as Short Form health survey questionnaire (SF-36) and Karnofsky Performance Status) health outcome measures provide the most insight into QOL of patients with sinonasal tumors. QOL of these patients appears to undergo a bimodal impact with patients experiencing an initial dip in QOL after surgical treatment followed by a slow improvement over time. However, while patients with benign tumors' return to their status quo ante QOL, this is not the case for patients with malignant tumors who stabilize at a lower than initially QOL. To a large extent this seems to be the effect of (neo) adjuvant chemo radiotherapy.

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.

Critical review of multidisciplinary approaches for managing sinonasal tumors with orbital involvement

Orbital invasion is frequently observed in tumors involving the maxillary, ethmoid and frontal sinuses given the proximity of the orbit to the sinonasal tract and ventral skull base. The main objective of the present review is to determine the existing evidences on the frequency, treatment, and outcomes of orbital invasion in benign and malignant sinonasal tumors. A systematic review of the literature published from 1995 to 2020 was performed and data sources included PubMed, Cochrane library, NCBI Bookshelf, National Guideline Clearinghouse. Orbital invasion was reported in 2-4% of inverted papillomas, 12-15% of fibro-osseous lesions, 27-32% of juvenile angiofibromas, 35-45% of low-grade malignancies, and 50-80% of high-grade cancers. Surgical resection with negative margins represents the cornerstone of management for benign and low-grade malignant tumors. Histology-specific induction chemotherapy can be used for high-grade sinonasal cancers in order to downstage the tumor and increase the possibility of orbital preservation. When a significant response to induction chemotherapy is observed, exclusive chemoradiation should be offered to improve overall survival rates. Appropriate reconstruction of any surgical defects is essential in order to minimize complications and optimize functional and aesthetic outcomes. Orbital apex invasion represents a negative prognostic factor. In conclusion, a multidisciplinary teamwork is mandatory to maximize local control, minimize morbidity and improve orbital preservation rates.