Unique clinical and prognostic behavior of patients diagnosed with combined exophytic and inverted papilloma histologic subtype

Objectives

To evaluate the clinical and prognostic behaviors of sinonasal papillomas.

Methods

Patients diagnosed with sinonasal papilloma were reviewed between 2001 and 2016 at a tertiary rhinology practice. Using pathology-specific electronic medical record software, patients diagnosed with sinonasal papilloma were identified. Four subcategories of this lesion were identified: inverting (IP), exophytic (EP) oncocytic (OP) and inverting + exophytic (IP + EP) papillomas.

Results

A total of 107 patients were identified with unique sinonasal papilloma diagnoses. Of these, the majority were diagnosed with IP (87, 81.3%). The subpopulation of patients co-diagnosed with IP and EP (IP + EP) was unique with respect to clinical presentation and prognosis relative to both the IP and EP alone populations. IP + EP patients (5, 4.7%) were older with an average age of 75.25 years compared to 45 (EP) and 55.26 (IP), p < .0001. IP + EP patients more often presented with epistaxis (60%) compared to 33.3% (EP) and 4.6% (IP). Finally, all IP + EP patients had at least one recurrence of their disease, compared to 33.3% (EP) and 28.5% (IP).

Conclusions

Each histopathologic subtype of sinonasal papilloma has unique clinical characteristics and recurrence rates after surgical resection. The subpopulation of patients diagnosed with IP + EP tends to be older, more likely to present with epistaxis, and more likely to recur. Additional investigation and analysis of this subpopulation is warranted.

Level of Evidence

4.

The implications of concomitant mucosal inflammation on clinical manifestations and outcomes of sinonasal inverted papilloma

PURPOSE

This study examines the impact of concomitant mucosal inflammation on clinical manifestations and long-term outcomes of Inverted Papilloma (IP).

METHODS

This retrospective cohort study was conducted in five tertiary medical centers. The included patients underwent an attachment-oriented surgical resection for IP with a minimum follow-up of 3 years.

RESULTS

Of 185 patients with IP, 65 patients (35.1%) had synchronous mucosal inflammation with polypoid changes. The mean age was 56.7 years, and 69% were males. Most tumors originated from the maxillary sinus. Age, gender, Krouse stage, and tumor attachment site did not differ between the mucosal inflammation and IP-only groups. IP recurrence rate was twofold in the patients with mucosal inflammation (15.4% vs. 7.5%, p = 0.092). However, the difference was not significant, with a similar median time to recurrence between the two groups [15.5 (3-36) months vs. 16(6-96) months, p = 0.712]. In revision cases, IP recurred only in patients with mucosal inflammation (19% vs. 0%, p = 0.07). This group had a significantly worse 5-years recurrence-free survival than revision cases without mucosal inflammation (80.6% vs. 100%, p = 0.04).

CONCLUSIONS

IP in the setting of mucosal inflammation might be associated with a higher recurrence rate, predominantly after revision surgery. Otolaryngologists should consider this during these patients' diagnosis, surgical planning, and follow-up.

Etiology of sinonasal inverted papilloma: An update

Objective

Sinonasal inverted papilloma (IP) and its clinical features have been widely studied, but there are few studies delving into its etiology and risk factors. A narrative review was conducted to summarize a contemporary understanding of the potential etiologies of IP, including immunologic/inflammatory, viral, genetic, and environmental causes.

Study Design

Review.

Methods

A MEDLINE search was conducted through August 11, 2021, focusing on studies investigating the etiology and risk factors for sinonasal IP and its malignant transformation.

Results

High‐ and low‐risk human papillomavirus have been connected with the formation of IP, but conflicting evidence exists regarding their role. Occupational and industrial exposures may also contribute to IP formation, while smoking may increase the odds of malignant progression. Exon 20 mutations in EGFR are an active area of research in IP with mixed evidence. Finally, several cell cycle and angiogenic factors such as Ki67, VEGF, and Akt/mTOR have been implicated in the development and progression of IP.

Conclusion

There continues to be conflicting evidence around the development of IP, but significant progress has been made in recent years. Further study is needed for all these potential etiologies to elucidate risk factors and therapeutic strategies.

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.

Increased Neutrophil Infiltration and Epithelial Cell Proliferation in Sinonasal Inverted Papilloma Compared to Contralateral Nasal Polyps

BACKGROUND

Sinonasal inverted papilloma (IP) is a rare and benign epithelial tumor in the sinonasal tract. Recent study suggested the potential role of chronic inflammation in the pathogenesis of IP. This study aims to compare the inflammatory pattern, the capacity of epithelial cell proliferation and EGFR mutation status of unilateral IP with contralateral polyp tissue.

METHODS

Sixteen patients with unilateral IP and contralateral nasal polyps (NP) were identified through a retrospective chart review. The neutrophil and eosinophil infiltration in IP and NP were assessed by immunostaining for neutrophil elastase and major basic protein (MBP). Immunohistochemistry was also used to assess the expression of FoxM1, Ki67 and cyclin D1 in IP tissue and contralateral NP. Sanger sequencing was used to evaluate the EGFR mutations.

RESULTS

The neutrophil count in IP was significantly higher than contralateral NP and 68.8% patients presented with neutrophilic inflammation, whereas only 37.5% contralateral NP tissue showed neutrophilic inflammation. The percentage of positive FoxM1-staining cells was significantly increased in IP, and positively correlated with the percentage of cells with positive staining for cyclin D1 and ki67 as well as neutrophil counts. EGFR exon 20 insertions were detected in 14 (87.5%) IP samples and no EGFR mutations were found in contralateral NP sample.

CONCLUSION

Our study demonstrated distinct inflammatory pattern between IP and contralateral NP and implied the oncogenic role of neutrophils in the pathogenesis of IP. EGFR mutations may be the early event to initiate IP development by enhancing epithelial cell proliferation.

Abnormal Expression of YAP Is Associated With Proliferation, Differentiation, Neutrophil Infiltration, and Adverse Outcome in Patients With Nasal Inverted Papilloma

Background

Nasal inverted papilloma (NIP) is a common benign tumor. Yes-associated protein (YAP) is the core effector molecule of the Hippo pathway, which regulates the proliferation and differentiation of airway epithelium. While its role in proliferation may be connected to NIP formation, no definitive association has been made between them.

Methods

We compared the difference of YAP expression and proliferation level between the control inferior turbinate, NP (nasal polyps), and NIP groups. In addition, we further used PCR, immunofluorescence, and immunohistochemistry to investigate YAP's role in the proliferation and differentiation of the nasal epithelium and inflammatory cell infiltration, correlating them with different grades of epithelial remodeling. We further used an IL-13 remodeling condition to investigate YAP's role in differentiation in an in vitro air-liquid interface (ALI) human nasal epithelial cell (hNECs) model. Finally, we also explored the correlation between YAP expression and clinical indicators of NIP.

Results

The expression of YAP/active YAP in the NIP group was significantly higher than that in the NP group and control group. Moreover, within the NIP group, the higher grade of epithelial remodeling was associated with higher YAP induced proliferation, leading to reduced ciliated cells and goblet cells. The finding was further verified using an IL-13 remodeling condition in differentiating ALI hNECs. Furthermore, YAP expression was positively correlated with proliferation and neutrophil infiltration in NIP. YAP expression was also significantly increased in NIP patients with adverse outcomes.

Conclusion

Abnormal expression of YAP/active YAP is associated with proliferation, differentiation, neutrophil infiltration, and adverse outcome in NIP and may present a novel target for diagnosis and intervention in NIP.

Presence of Tertiary Lymphoid Organ in Nasal Inverted Papilloma Is Correlated with Eosinophil Infiltration and Local Immunoglobulin Production

INTRODUCTION

Nasal inverted papilloma (NIP) is a benign tumour with multiple inflammatory cell infiltration. Tertiary lymphoid organs (TLOs) support local antibody production and play important roles in airway inflammation. However, the evidence of TLOs and local immunoglobulins in NIP has not been reported yet. We investigated the presence of TLOs and immunoglobulins in NIP tissues and their association with the clinical-pathological characteristics of NIPs.

METHODS

We analyzed the occurrence and composition of TLOs and local immunoglobulins by immunohistochemistry and evaluated the lymph organogenesis associated genes and cytokines by quantitative qPCR and Luminex assays, respectively, in papilloma tissues from 84 NIP cases.

RESULTS

TLOs were present in 54% (45/84) of the NIP patients but not in control subjects. TLOs were composed of T cells, B cells, follicular dendritic cells, macrophages, and natural killer cells. Compared to NIP tissues without TLOs, tissues with TLOs showed significantly higher eosinophil infiltration levels (3.5-fold), elevation of lymphorganogenic genes (CXCL12, CXCL13, CCL20, CCL21, CD21L, and lymphotoxin alpha and beta), and increased Th17 (IL-21, IL-22, and GM-CSF) and Th2 (IL-5 and IL-13) cytokine production. Moreover, NIP with TLOs demonstrated a higher number of follicular T helper cells and immunoglobulin-producing plasma cells (CD138+ IgA+, CD138+ IgM+, CD138+ IgE+, and CD138+ IgG+) than those without TLOs, and these antibody-producing cells were positively correlated with the eosinophil number.

CONCLUSION

The high frequency of TLOs and excess local immunoglobulin production are associated with an eosinophilic and Th2 skew microenvironment in the NIP mucosa, which would contribute to an important immunopathogenic response during NIP pathogenesis.

Prevalence and association of Epstein-Barr virus infection with sinonasal inverted papilloma and sinonasal squamous cell carcinoma in the northeastern Thai population

Aims

Sinonasal inverted papillomas (SIP) and sinonasal squamous cell carcinomas (SNSCC) are sinonasal tumors with unclear etiology and pathogenesis. Epstein-Barr virus (EBV) has been detected in these tumors but information concerning their association is still limited. This study aimed to investigate the prevalence in, and association of EBV infection with SIP and SNSCC in northeastern Thailand.

Methods

DNA was extracted from 226 formalin-fixed, paraffin-embedded tissues including 80 nasal polyps (NP; the control group), 64 SIP and 82 SNSCC samples. Presence of EBV in these tissues was investigated using real-time PCR and their localization within tissues was confirmed using in situ hybridization (ISH). Characteristics of patients and the association of EBV prevalence with sinonasal tumors were analyzed.

Results

SIP and SNSCC were frequently found in people aged > 50 years and more often in males than in females (3:1 ratio). EBV infection was detected in 33.75, 64.06 and 37.80% of NP, SIP and SNSCC tissues, respectively, by real-time PCR. There was a statistically significant association between EBV infection and SIP (odds ratio [OR] = 3.52). This was not the case for SNSCC when compared to the NP group (OR = 1.83). Interestingly, EBV infection tended to be associated with inflammation and dysplasia in SIP. In SNSCC, EBV was mostly found in samples with undifferentiated or poorly differentiated cell types as well as in recurrent cases and lymph-node metastasis. Using ISH, EBV was detected only in infiltrating lymphocytes within the tumor stroma, not in the tumor epithelial cells.

Conclusions

Infiltrating lymphocytes containing EBV in the tumor microenvironment might enhance tumorigenesis of SIP and SNSCC. The mechanism by which EBV promotes development of SIP and SNSCC needs to be elucidated in the future.

Inverted papilloma is associated with greater radiographic inflammatory disease than other sinonasal malignancy

BACKGROUND

The pathogenesis of inverted papilloma (IP) has not been fully elucidated. However, chronic paranasal sinus inflammation has been anecdotally observed in sites distant from tumor obstruction in IP patients, suggesting an association between inflammation and IP tumorigenesis. This study assesses the association between sinonasal inflammation found in IP and compares this to the level of inflammation observed in other sinonasal tumors.

METHODS

A retrospective chart review was performed identifying patients with unilateral IP. Pertinent clinical data was obtained and comparative analysis of preoperative computed tomography (CT) imaging and histopathology was performed. A sample of unilateral, sinonasal, non-IP and non-squamous cell tumors was used as the control. The Lund-Mackay scoring system was used to assess radiologic sinonasal inflammation both ipsilateral and contralateral to the tumor.

RESULTS

Seventy-one patients were included; 58.9% of patients with IP had evidence of contralateral sinusitis at the time of presentation. In the control group, 26.7% had evidence of contralateral inflammation. When comparing contralateral sinus inflammation between the 2 study groups, the IP patients had significantly higher Lund-Mackay scores than the control group (1.9 vs 0.26, p < 0.001). When comparing ipsilateral sinus inflammation, no significant difference was found in Lund-Mackay scores (5.44 vs 4.00, p < 0.184).

CONCLUSION

In this study, unilateral IPs were associated with a higher level of contralateral sinonasal inflammation when compared to control. This suggests that IP may be associated with inflammation that is independent of obstruction by the tumor. Further studies are needed to better understand the temporal relationship between chronic inflammation and tumorigenesis.

Sinonasal Inverted Papilloma: Efficacy of Demucosation to Reduce Recurrence After Surgical Managements

To compare the outcomes of various surgical approaches to resect sinonasal inverted papilloma and to discuss their advantages and disadvantages. A retrospective chart review of 61 consecutive patients with sinonasal inverted papilloma was performed. Surgical treatment included non-demucosation endoscopic sinus surgery (ESS), demucosation ESS, endonasal medial maxillectomy (EMM), Draf type 3, Caldwell-Luc surgery, Denker, Killian, and lateral rhinotomy. Recurrence rates were compared between endonasal and external approaches and between demucosation and non-demucosation. After the first curative surgery, the non-demucosation ESS, endonasal demucosation (demucosation ESS, EMM, and Draf type 3), and external surgery showed recurrence rates of 61.5%, (8/13), 0.0% (0/21), and 7.4% (2/27), respectively. A significantly lower recurrence rate was observed in the endonasal demucosation (p < 0.001) and in the demucosation ESS group (p < 0.001) in comparison with the non-demucosation ESS. However, as for recurrence rate, no statistically significant difference was observed between endonasal surgery and external surgery (p = 0.162). Demucosation is a better strategy for the treatment of inverted papilloma than is non-demucosation. Demucosation is the key procedure for preventing recurrence.

Increase in IL-17-positive cells in sinonasal inverted papilloma

OBJECTIVE

Neutrophil infiltration in patients with sinonasal inverted papilloma (SNIP) is significantly high. Whether IL-17, which is a potent factor mediating neutrophilic inflammation, is involved in the neutrophilic phenotype of SNIP is investigated in the current study.

STUDY DESIGN

Laboratorial study.

PARTICIPANTS

Nasal papilloma and inferior turbinate were collected from patients with SNIP (n = 50) and control subjects with septal deviation (n = 15).

METHODS

IL-17 + cells were evaluated in tissues obtained from patients with SNIP and control subjects with septal deviation, by immunohistochemistry and flow cytometry.

MAIN OUTCOME MEASURES

The IL-17 + cells were mainly localised in mononuclear cells and neutrophils, and were up-regulated in the SNIP samples compared with those in the controls. The IL-17 + T-cell subsets mainly included CD4+ (Th17, 60.0%) and CD8+ (Tc17, 30.0%), and both subsets were enhanced in the SNIP samples than controls. The total level of IL-17 + cells was significantly correlated with neutrophil infiltration in the SNIP tissues. Furthermore, the SNIP homogenates could significantly promote IL-17 production in peripheral blood mononuclear cells.

CONCLUSIONS

An increase in IL-17 + cells is evident in SNIP and may be involved in neutrophil infiltration in local tissues. IL-17 could be a potential therapeutic target to relieve the neutrophilic pathological change in SNIP.

Endoscopic Resection of Inverted Papilloma: University of Miami Experience

Background

The aim of this study was to evaluate the efficacy and safety of endoscopically resecting paranasal sinus inverted papillomas at a tertiary medical center.

Methods

Over a 9-year period, 51 patients with a diagnosis of inverted papilloma underwent endoscopic resection at the University of Miami/Jackson Memorial Medical Center. The study group consisted of 14 women and 37 men with a mean age of 59 years (range, 20–88 years) enrolled in a clinical data base. All of the patients were followed endoscopically at regular intervals on an outpatient basis.

Results

Endoscopic evidence of extensive papillomas involving the anterior and posterior ethmoid sinuses and at least one (usually the maxillary) dependent sinus was found in 60% of the cases. Extensive radiological disease (varying degrees of mucoperiosteal thickening or opacification of all five cavities) was evident in 50% of the cases. All but two had unilateral disease. An association with chronic inflammatory polyps (clinically and pathologically) was observed in 25 of 51 patients (49%). Follow-up ranged from 6 to 99 months (mean, 30 months). There have been seven recurrences (14%). Four of these have been managed in the office under topical anesthesia. Three recurrences were managed surgically in the operating room. All of the patients have been free of disease. Complications included an intraoperative CSF leak (three patients); temporary infraorbital hypesthesia (three patients); periorbital ecchymosis, hematoma, or cheek edema (four patients); and orbital symptoms (two patients). Carcinoma was found in four patients (8%) who received postoperative radiotherapy and remain free of disease.

Conclusion

The endoscopic approach continues to provide at least equivalent short-term results as compared with external techniques for the removal of paranasal sinus inverted papilloma. The final cavity should allow for adequate postoperative surveillance and potential resection of recurrences in the office setting, without the need for a return to the operating room in most patients. The association of inverted papilloma with chronic inflammatory polyps and tobacco use warrants additional study.

Challenges in the Management of Sphenoid Inverted Papilloma

Background

Inverted papilloma (IP) arising in the sphenoid sinus is extremely rare. Management of sphenoid sinus IP is especially challenging because of the paucity of sinonasal symptoms on presentation and the inherent surgical risks associated with the anatomic location of the sphenoid sinus.

Methods

We performed a retrospective review of medical records of all patients with IP arising within the sphenoid sinus.

Results

A total of five patients were identified. All patients were managed with endoscopic resection. The most common presenting symptom was headache (three patients). The mean follow-up period was 37.6 months (range, 10–79 months). Two patients with erosive skull base lesions adjacent to the internal carotid artery were managed with a staged endoscopic resection. Only one patient developed a recurrence after 38 months and underwent revision endoscopic resection.

Conclusions

Endoscopic management of sphenoid IP allows maximal resection with minimal morbidity and facilitates endoscopic postoperative surveillance. Complete preoperative radiological assessment of tumor extent is essential. Preoperative medical therapy can help normalize inflamed mucosa and minimize intraoperative bleeding. For large erosive IP, surgical risks may be minimized by considering a staged resection and using computer-aided surgery.

Inflammation and the Pathogenesis of Inverted Papilloma

Background

Despite existing clinical and histopathological evidence, the role of inflammation in the pathogenesis of inverted papilloma (IP) is not well understood. The goal of this study was to describe the inflammatory cell component present in sinonasal papilloma (SP), with the intention of further defining the existence of inflammation in IP and perhaps gaining insight into IP pathophysiology.

Methods

Computerized database analysis was performed to identify all patients with SP who underwent surgery at the Cleveland Clinic Foundation between 1995 and 2001. Histopathological features of all SP were reviewed and semiquantitative analysis of the inflammatory cells present was performed. IP was histopathologically graded into four categories by the extent of inflammatory infiltrate and cellular atypia. Statistical analysis of the inflammatory cell component present in the epithelial layer of exophytic papilloma and IP was performed.

Results

SP was classified into three types: cylindrical papilloma (5% [2/41]), exophytic squamous papilloma (34% [14/41]), and IP (61% [25/41]). Twenty-eight instances of IP in 25 patients were identified. Altogether, 11% were grade I (3/28), 54% were grade II (15/28), 25% were grade III (7/28), and 11% were grade IV (3/28). The inflammatory cell population was significantly greater in IP compared with other SPs and greater in grades I and II IP when compared with grade III and IV IP.

Conclusion

Inflammatory cells were identified as a significant cell population in IP, whereas it was less commonly encountered in other forms of SP. The proposed IP staging system may serve as the foundation for improved understanding of IP and, ultimately, may help to predict recurrence or apparent malignant transformation.

Etiology of sinonasal inverted papilloma: A narrative review

Objective

Sinonasal inverted papilloma (IP) is a benign and uncommon tumor of the nasal cavity and paranasal sinuses with a tendency for recurrence and even malignant transformation. Though the morphology and clinical behavior of this lesion has been well described, its etiology remains controversial.

Methods

Computerized searches were performed in PubMed, Scopus, and Google scholar through May 2015. In this review, etiologic factors including human papilloma virus (HPV), Epstein–Barr virus (EBV), cell cycle related proteins and angiogenic factors, occupational and environmental exposures, and chronic inflammation, will be discussed.

Results

Many studies indicate that HPV has been detected in a significant percentage of IP, while EBV has not been shown to be significantly associated. Certain cell cycle regulatory factors and angiogenic proteins contribute to the dysregulation of proliferation and apoptosis, and facilitate migration and tumor invasion. Occupational exposures, such as welding and organic solvents, have been implicated, and smoking seems more critical to recurrence and dysplasia rather than initial IP occurrence. Chronic inflammation may also have a causative relationship with inverted papilloma, but the mechanism is unclear.

Conclusions

Though etiology of sinonasal IP remains controversial, the studies reviewed here indicate a role for viral infection, cell cycle and angiogenic factors, environmental and occupational exposure, and chronic inflammation. Further study on etiologic factors is necessary for clinical guidance and therapeutic targets.

Histopathological features of sinonasal inverted papillomas in chinese patients

OBJECTIVES/HYPOTHESIS

Nasal inverted papilloma (IP) is a benign tumor with high recurrence rates. Evidence of inflammation has been reported in IP in Caucasian studies. This study aimed to investigate the histopathological patterns and their associations with clinical characteristics in Chinese patients with IP.

STUDY DESIGN

Basic science study.

METHODS

IP tissues were obtained from 50 Chinese patients with unilateral IPs. Biopsies of inferior turbinate mucosa from 17 healthy subjects were used as controls. The histological patterns and severity of epithelial remodeling and inflammatory cell infiltration were evaluated and analyzed for associations with clinical characteristics.

RESULTS

Thirty-one percent of IP specimens were classified as grade I (mild remodeling) and 49% as grade II (moderate and severe remodeling). Concomitant inflammatory nasal polyps were found in 14 patients (28%). Recurrent IP was strongly associated with grade II (odds ratio: 5.81, 95% confidence interval: 1.34-25.18). Except CD4(+) T cells, quantities of neutrophils, macrophages, eosinophils, CD8(+) T cells, and FoxP3(+) T-reg cells were significantly elevated in IP. Of these, neutrophils were the predominant cell type in IP.

CONCLUSIONS

Inflammation may have potential roles in IPs and the higher grade of epithelial remodeling was associated with the recurrence of IPs.

LEVEL OF EVIDENCE

NA.

Comparison of radiographic and clinical characteristics of low-risk and high-risk cystic fibrosis genotypes

BACKGROUND

Patients with cystic fibrosis (CF) exhibit a wide range of disease severity, and can be broadly stratified into high-risk and low-risk groups based on cystic fibrosis transmembrane conductance regulator (CFTR) mutation class. Patients with a low-risk genotype are often diagnosed as adults, with milder disease and lower sweat chloride values. The aim of the current study was to better understand radiographic and clinical characteristics of sinus disease in adult CF patients within this risk category.

METHODS

Adult CF patients were retrospectively compared to a control group of patients with chronic rhinosinusitis. CF diagnostic testing and pulmonary characteristics were compared between high-risk and low-risk CF groups, and sinus CT findings were compared among all 3 groups.

RESULTS

When comparing CF cohorts (n = 25 and 30, respectively), earlier age at diagnosis (p < 0.001), higher sweat chloride values (p < 0.001), lower forced expiratory volume in 1 second (FEV1 ) values (p < 0.001), and a higher prevalence of pulmonary infection with Pseudomonas aeruginosa (p = 0.001) were found in the high-risk genotype group. A significantly increased incidence of sinus hypoplasia/aplasia and bony sclerosis was seen when comparing both CF groups to the control cohort (n = 30), as well as when comparing the high-risk and low-risk CF genotype cohorts.

CONCLUSION

The current study describes clinicopathologic findings of sinus disease in adult CF patients in the context of genotype severity. Our data demonstrate that while patients within a low-risk genotype cohort have generally milder lung disease, they retain classic radiographic findings of CF sinus disease that can help raise the index of suspicion for undiagnosed CF.

Chapter 9: Benign sinonasal neoplasms

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

Schneiderian papillomas: comparative review of exophytic, oncocytic, and inverted types

BACKGROUND

Sinonasal papillomas are benign epithelial neoplasms arising from Schneiderian mucosa. The three subtypes, exophytic, oncocytic, and inverted (inverted papilloma [IP]), should be distinguished from one another histopathologically. This study (1) highlights the histopathological and clinical differences between the Schneiderian papilloma subtypes and (2) identifies clinical features that potentially predict papilloma subtypes.

METHODS

A retrospective review was performed of patients with Schneiderian papillomas over an 11-year period.

RESULTS

Seventy patients with sinonasal papillomas who underwent sinus surgery were identified. There were 50 (71%) male and 20 (29%) female subjects diagnosed at an average age of 53 years (range, 13-80 years). Exophytic (n = 25), oncocytic (n = 9), and IP (n = 37) were identified. IP was associated with transformation into squamous cell carcinoma in three (8%) cases and dysplasia in three (8%) cases. Neither oncocytic nor exophytic subtypes were associated with dysplasia or malignancy. On multivariate analysis of potential predictors of papilloma subtype, history of chronic rhinosinusitis (CRS) and location of papilloma were significantly associated with papilloma subtype. Using classification and regression tree model, papilloma subtypes can be predicted based on presence or absence of CRS and papilloma location with nominal 82.4% accuracy.

CONCLUSION

The inverted and exophytic type are the most common sinonasal papillomas, with the inverted type having an 8% rate of malignant transformation in this study. In contrast, the oncocytic type was not associated with dysplasia or malignancy in our series despite reports in the literature indicating malignant potential. History of CRS and papilloma location can provide clues to the histological subtype, which is important for surgical planning and patient counseling.

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.

Radiological localization of Schneiderian papilloma

BACKGROUND

It has been recently reported that the site of attachment of Schneiderian papillomas can be predicted with high accuracy on preoperative computed tomography (CT) scans using bony osteitic changes as an indicator. The objective of this study is to evaluate, in a blinded fashion, the reliability of the osteitis sign at predicting the site of attachment of Schneiderian papillomas.

METHODS

A retrospective cohort study of patients who underwent endoscopic surgical resection for inverted papilloma (IP) or cylindrical papilloma between September 2002 and September 2009 in a tertiary care rhinology center was carried out. The preoperative sinus CT scans were collected and reviewed by a fellowship-trained and experienced head and neck radiologist who was blinded to the intraoperative findings. The radiologist attempted to identify and grade bony osteitic changes in the sinuses. The radiological findings were then correlated with the actual site of attachment reported by the surgeon in the operative report.

RESULTS

A total of 34 patients were evaluated. Six (18%) patients had a single site of osteitis and 28 (82%) were found to have multiple sites of osteitis. The sensitivity and specificity of the radiological prediction based on the degree of osteitis was found to be 74% (46.5-90.3%) and 0% (0-17%), respectively. The predictive value of the radiological localization was 41%.

CONCLUSION

Osteitic changes are very common nonspecific findings on CT scans of patients with Schneiderian papillomas. Their presence as well as the degree of osteitis did not allow preoperative localization of tumor attachment.

Pattern of Expression of Cell Cycle–related Proteins in Malignant Transformation of Sinonasal Inverted Papilloma

Background

It has been suggested that sinonasal inverted papilloma (IP) can progress to squamous cell carcinoma (SCC); however, mechanisms of malignant transformation are not fully understood. This study investigated alterations in the expression of cell cycle–related proteins in a multistep process of malignant transformation of IPs.

Methods

The expression of cell cycle–related proteins, including p53, p21, p16, and p63, was evaluated by immunohistochemistry in 21, 56, 7, and 18 cases of nasal polyps, IPs, IPs with dysplasia, and IPs with SCC, respectively. Furthermore, we determined the possible correlation between the expression of these proteins and clinicopathological variables in patients with IPs with SCC.

Results

Expression of p53 was found only in 8 of 18 IPs with SCC (44.4%). The frequency of p21 positivity was significantly higher in IPs with dysplasia (71.4%) and IPs with SCC (77.8%) compared with nasal polyps (0%) and IPs (12.5%). A p16 positivity was observed in 82.1% of IPs and 57.1% of IPs with dysplasia, whereas 83.3% of IPs with SCC showed an apparent loss of p16 protein expression. A p63 positivity was found in all specimens, but the percentage of positive cells was significantly increased in IPs with dysplasia and IPs with SCC compared with nasal polyps and IPs. There was no significant correlation between the expression of these proteins and clinicopathological variables, such as tumor stage, histological differentiation, and the proportion of malignant areas in patients with IPs with SCC.

Conclusion

Alteration of cell cycle–related proteins may contribute importantly to the malignant transformation from IP to SCC.

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.

A Case-Control Study of the Risk Factors Associated with Sinonasal Inverted Papilloma

Background

The etiology of sinonasal inverted papilloma (IP) is unknown. This study was designed to evaluate the possible risk factors associated with IP

Methods

This is a case-control epidemiology study in a tertiary referral center. Fifty patients with IP and 150 matched controls were interviewed using a questionnaire on suspected risk factors. Univariate analysis of the risk factors and calculation of the matched odds ratios, the corresponding 95% CIs, and p values was performed. Significant risk factors were further studied using conditional logistic regression analysis.

Results

Outdoor and industrial occupations were associated with IP. Tobacco smoking, drinking alcohol, history of allergic rhinitis, sinusitis, nasal polyp, non-sinonasal papilloma and non-sinonasal malignancy were not significant factors.

Conclusions

Outdoor and industrial occupations were associated with IP and may be potential risk factors. Future studies are warranted to further evaluate the individual type of occupation and chemical involved.

Radiological sinonasal findings in adults with cystic fibrosis

BACKGROUND

Care of cystic fibrosis (CF) patients has extended the expected survival far into adulthood. The morphological changes of adult CF patients' paranasal sinuses have not been thoroughly addressed.

METHODS

A retrospective review was performed of computed tomography imaging of adult CF patients at an academic medical center. Developmental changes, bone sclerosis, mucoceles, and degree of inflammation (using a modified Lund-Mackay scoring system) were assessed.

RESULTS

Forty-five patients were included in the study. The majority of frontal and sphenoid sinuses were either aplastic or hypoplastic. Maxillary hypoplasia was less commonly seen. Seven patients had mucoceles. Sclerosis of the sinuses was a common finding, affecting 84.4% of patients. Inflammation of the sinuses was also common, with a median modified Lund-Mackay score of 15.0 (out of a median 20 possible).

CONCLUSION

Poor development of the sinuses seen in pediatric CF patients persists into adulthood. Inflammation of the sinuses is a common finding. Bone sclerosis, likely caused by chronic inflammation, affects a large majority of these patients.

Clinical outcomes of endoscopic and endoscopic-assisted resection of inverted papillomas: a 15-year experience

BACKGROUND

The endoscopic resection of sinonasal inverted papillomas (IPs) has been well described. However, the majority of published reports in the literature are small case series with limited clinical follow-up. The aim of this retrospective study was to review the experience with the endoscopic and endoscopic-assisted resection of IPs at a major academic tertiary care facility and assess long-term outcomes.

METHODS

A retrospective review of endoscopic and endoscopic-assisted resections of IP was performed. Charts were reviewed for standard demographic data, operative technique, adjuvant approaches, complications, and postoperative follow-up times.

RESULTS

One hundred fourteen patients (average age, 56 years) underwent endoscopic or endoscopic-assisted resection for IPs with a mean disease-free follow-up of 40 months (7-135 months). Seventeen patients developed disease after endoscopic or endoscopic-assisted resection for a recurrence rate of 15%. Average time to recurrence was 23 months. Combined approaches were used when indicated in 34% (39/114) of patients, including adjuvant osteoplastic flap, midface degloving, trephine, or Caldwell-Luc approaches. Four patients (4%) had cerebrospinal fluid leaks that were successfully repaired endoscopically.

CONCLUSION

In this large series of endoscopically resected IPs with extensive clinical follow-up, recurrences occurred an average of 23 months after the procedure. This emphasizes the importance of long-term endoscopic follow-up to detect recurrences in all patients. Endoscopic or endoscopic-assisted resection of IPs is a valid technique in this series with recurrence rates comparable with open approaches.

Do nasal polyps and inverted papilloma have similar disorders in cell cycle regulation?

BACKGROUND

The aim of this study was to determine the expression of cell cycle regulation genes in patients with inverted papilloma (IP) and compare this with expression in patients with nasal polyps (NPs).

METHODS

Tissue from 18 patients with IP and 5 patients with NPs were stained by immunohistochemistry techniques for p53 and p27. Measurement of the gene expression was performed by three assessors, who we blinded with respect to the specimens.

RESULTS

The mean score for p53 expression (3.33) was significantly higher in the IP group than the NP group (1.46). The mean difference between IP and NPs was 1.80 (CI, 1.15-2.46; p = 0.003). Additionally, we showed in a number of individuals variation in the p53 expression within the same specimen. There was no difference in the mean scores for p27, with the mean difference 0.79 (CI, 0.30-1.89; p = 0.147).

CONCLUSION

Our study established a significantly increased expression of p53 in IP when compared with NPs. Additionally, there appear to be two different cell populations identified within the same specimens, which exhibited variation in their p53 expression.

Endoscopic sinus surgery: where we are-and where we're going

PURPOSE OF REVIEW

Improved understanding of sinonasal mucociliary function as well as technological advancements have led to a renaissance in the management of sinonasal disease. The current techniques, and adjunctive intraoperative technologies, have allowed for a more precise and safer surgical dissection, extending this surgical application to include the routine endoscopic management of skull base lesions and sinonasal malignancies. The anatomic boundaries of the nasal endoscope continue to be redefined. This paper will review the recent advances in the field of surgical rhinology as well as discuss directions for the future.

RECENT FINDINGS

Advancements in imaging technology including image acquisition, three-dimensional reconstruction, stereotactic navigation, and CT-MRI fusion have aided in more thorough preoperative planning, enabling safer and more precise endoscopic surgical dissection. Refinement of endonasal powered instrumentation including microdebriders and high-speed suction irrigation drills have minimized trauma to normal tissues and accelerated postoperative healing. Increased experience with the endoscope has broadened the endoscopic ventral skull base exposure from the odontoid process to foramen ovale to the olfactory bulb.

SUMMARY

Endoscopic sinus surgery is no longer exclusively for the management of chronic rhinosinusitis and nasal polyposis. Sinonasal malignancies, as well as anterior skull base lesions have become part of the rhinologist's responsibility. Furthermore, selective lesions managed through traditional craniotomies may now be accessed via trans-sinonasal transcranial endoscopic routes.