Endoscopic Resection of Sinonasal Inverted Papilloma: A Multivariate Retrospective Analysis of Factors Affecting Recurrence and Persistence

Sinonasal inverted papilloma (IP) is the most common benign epithelial tumor in the nasal cavity and paranasal sinuses, with a worldwide incidence between 0.6 and 1.5/100 000 persons per year. However, only a few studies have investigated patient-dependent factors related to IP recurrence and persistence. According to available evidence, these factors are still debated, and results are contradictory. In this multicenter retrospective study, we analyzed the clinical records of 130 patients who were surgically treated for sinonasal IP to evaluate the factors affecting recurrence and persistence of IP and compared the curative rates of different surgical approaches. Our analysis showed that IP recurrence is strongly related to specific risk factors including incomplete surgical removal, stage of disease, site of the lesion, surgical technique, and malignancy rate. In conclusion, the recurrence of IP may be affected by several risk factors; these factors must be carefully considered during clinical evaluation and especially during the follow-up of patients with IP.

Blood transfusion requirements for endoscopic sinonasal inverted papilloma resections

Background

Endoscopic resection of sinonasal Inverted Papilloma (SNIP) tumors has been shown to reduce intra-operative blood loss and recovery time compared to open approaches. The purpose of this study is to investigate the incidence and requirements of blood transfusion for endoscopic SNIP surgeries.

Methods

An individual retrospective cohort study of endoscopic SNIP surgeries over a 10-year period was performed. Age, sex, pre-existing co-morbidity, use of anti-coagulants, tumor type and stage, time of surgery, estimated blood loss and the requirement for blood transfusion were recorded.

Results

82 patients were included (57 males, 25 females). 4 (5%) Stage 1, 7 (8.5%) Stage 2, 62 (75.5%) Stage 3 and 9 (11%) Stage 4 SNIP tumors were identified according to the Krouse staging system. 3 (4%) patients required blood transfusion. 3 of the 9 (33%) Stage 4 tumors required blood transfusion. Stage 4 tumors were significantly associated with blood transfusion (p < 0.05). Higher staged tumors were associated with greater blood loss (p < 0.05) than lower staged cases. No other tumor stage required blood transfusion and no other pre-operative variable was associated with requirement for blood transfusion.

Conclusion

Endoscopic SNIP resections rarely require blood transfusions. No pre-operative factor other than tumor stage is associated with the requirement for blood transfusion. We would therefore suggest that only Stage 4 SNIP tumors require pre-operative type and screen.

Evolution of endoscopic surgery in the treatment of inverted papilloma

Inverted papilloma (IP) has several treatment avenues. The endoscopic approach in the last decade has proven to be a good option over the traditional approach.

Objective

Describe the epidemiological profile of patients with inverted Papilloma, describe our experience on managing this tumor and compare our data with the literature. Study Design: Cross-sectional, historical cohort.

Method

Retrospective study of medical records of 17 patients treated for histopathologically-confirmed inverted papilloma between 2005 and 2011. We assessed patients age, gender, tumor side, symptoms, diagnosis, comorbidities and habits, Krouse staging, surgical approach, intraoperative and postoperative, and malignant postoperative recurrence and also the correlation between recurrence with preoperative staging, the surgical approach used, and the presence of malignancy.

Results

Five (29.41%) patients were classified as Krouse stage T2, 9 (52.94%) as T3 and 3 (17.65%) as T4. Three (17.65%) patients had malignancy and the recurrence rate was 23.5% (4 pacients). Eleven patients (64.70%) underwent endoscopic approach, 3 (17.6%) the combined aprroach (endoscopic assisted) and 3 (17.6%) external approach.

Conclusion

The endoscopic approach is currently becoming a method not only effective but also safe for the treatment of more advanced stages of IP.

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.

Surgical treatment of inverted papilloma

Inverted papilloma (IP) is the most common benign tumor of the nose and the paranasal sinuses and constitutes almost 0.5% to 4% of the primary nasal tumors. In this study, our objective was to retrospectively review the results of surgical treatment of IP.Sixty-eight patients with a histopathologically proven diagnosis of IP were retrospectively evaluated. Two patients who had an associated squamous cell carcinoma were excluded from the study. Ten patients were operated on for revision surgery, and 56 eventually had a primary tumor. Patients operated on for primary tumor were included in this study. Nasal obstruction was the most frequent symptom observed in 50 patients (89%). The origin of the tumor was most common at the maxillary sinus, the lamina papyracea, and the ethmoid sinus. Endoscopic endonasal resection, endoscopic endonasal resection with the Caldwell-Luc procedure, medial maxillectomy after lateral rhinotomy (LR), and endoscope-assisted medial maxillectomy with LR approaches were used. The patients operated on only with medial maxillectomy after an LR procedure have a recurrence rate of 28% (2 patients). Endoscopic endonasal resection has a recurrence rate of 9% (2 patients). Recurrence observed after endoscopic endonasal resection with Caldwell-Luc procedures was 7% (1 patient). One recurrence (8%) was determined after an endoscope-assisted medial maxillectomy after LR. No major postoperative complications were observed after surgery.In conclusion, IP can be treated both with internal and external approaches. The type of surgery should be determined according to the tumor stage. Combined internal and external approaches have less recurrence rates in advanced cases. Endoscopic endonasal resection should be used in early-stage tumors.

The evolution of management for inverted papilloma: an analysis of 200 cases

OBJECTIVES

To assess the evolution of management within one institution with the largest case series and longest clinical follow-up of IP to date in the literature and to compare this management with what has been recently presented in publication.

METHOD

A case series was performed assessing sex, age, presenting symptoms, origin of lesion, staging, primary versus recurrence, radiographic findings, method of treatment, rate of recurrence, and associated malignancy.

RESULTS

Two hundred patients (average age, 57) underwent endoscopic or endoscopic-assisted resection of IP. The mean follow-up was 4.3 years (range, 9 months-19 years). Eighty percent of cases over the last decade had prior surgery before presentation. Sixty-three percent were Krouse stage T3, and 25 percent were T4. Combined approaches were used for 57 percent of the most recent 40 cases, including Caldwell-Luc, lateral rhinotomy, medial maxillectomy, trephine, or osteoplastic flap.

CONCLUSION

Inverted papilloma can be addressed endoscopically when possible, with data from this study and the current literature suggesting this is feasible in 43 percent to 66 percent of cases. This decision should be made for each individual case, and variables that will likely affect the decision to use adjuvant external approaches include significant scarring and anatomic distortion from previous surgery, high Krouse stage, and associated malignancy.

Bilateral aggressive inverted papillomas: A changing scenario

OBJECTIVES

The ideal management of bilateral, recurrent inverted papillomas is intriguing and often controversial. We describe the ideal management of such tumors.

DESIGN

Retrospective, case series

METHODS

The three patients in this series inspite of several surgical procedures in the past had recurrences and behaved in an aggressive fashion. The patients underwent surgical excision by either bilateral lateral rhinotomy, midfacial degloving or craniofacial approaches.

RESULTS

One patient who underwent excision by midfacial degloving approach had recurrence. This was removed by lateral rhinotomy approach. Two patients were subjected to radiotherapy due to the presence of mitotic figures on histopathology. All the patients are asymptomatic at 6 months follow-up.

CONCLUSION

Aggressive inverted papillomas may have varied presentation. They could have multiple recurrences, bilateral presentation or intracranial extension. They can be effectively managed with bilateral lateral rhinotomy or cranio-facial resection. Adjuvant radiotherapy has a role in controlling recurrences.

Endoscopic versus open surgical interventions for inverted nasal papilloma: a systematic review

Inverted nasal papilloma is a unique neoplasm characterised by a tendency to recur following excision, an association with malignancy and an ability to destroy bone. The coexistence with nasal polyps (not always sent for histology), the lack of a universally accepted staging system and the fact that most data on Inverted papilloma come from tertiary centres (selected cases probably the most aggressive) account for the difficulty in determining its true incidence. Treatment is surgical. The gold standard approach was an open radical procedure. The introduction of endoscopic surgery for primary or recurrent lesions has shown potential advantages. Lack of complications of open surgery together with improved access to specific nasal areas suggests that the endoscopic techniques in experienced hands and for selected lesions may be a good alternative. The aim of this review was to assess the effectiveness of the endoscopic versus open techniques for management of inverted papilloma. There is not enough evidence in the literature to support one or the other treatment option for management of inverted papilloma. There is a trend though towards endoscopic approach. Ideal management should aim at complete removal of all diseased mucosa with creation of wide cavities and long term follow-up to detect subsequent recurrence or malignant transformation.