Surgical management of inverted papilloma; a single-center analysis of 247 patients with long follow-up

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Abstract

Background

Our aim was to review our management of inverted papilloma (IP), perform a recurrence analysis, and review the literature.

Methods

A retrospective analysis of 247 patients treated for an IP. Patients were grouped according to surgical approach, tumor presentation (primary, residual and recurrence) and Krouse-stage.

Results

Recurrence was observed in 20.3%, 28.6% and 35.1% ( p = 0.017) of the patients who underwent endoscopic, external and combined surgery, respectively. Recurrences occurred more often in residual than primary IP (36.9% vs. 22.3%, p = 0.021). Primary endoscopic surgery had a recurrence rate of 12.5%, which was comparable to the recent literature (11.2%, 161/1433).

Conclusions

The relatively high number of recurrences in this cohort is explained by the long follow-up and previous (incomplete) surgery in 61.5% of the cases. The inferior outcome of residual IP underscores the importance of having a low threshold for preoperative biopsy in unilateral and atypical sinonasal disease.

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Most cited references 40

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European position paper on endoscopic management of tumours of the nose, paranasal sinuses and skull base.

Paolo Castelnuovo, V Lund, Peter Tomazic … (2009)

Tumours affecting the nose, paranasal sinuses and adjacent skull base are fortunately rare. However, they pose significant problems of management due their late presentation and juxtaposition to important anatomical structures such eye and brain. The increasing application of endonasal endoscopic techniques to their excision offers potentially similar scales of resection but with reduced morbidity. The present document is intended to be a state-of-the art review for any specialist with an interest in this area 1. to update their knowledge of neoplasia affecting the nose, paranasal sinuses and adjacent skull base; 2. to provide an evidence-based review of the diagnostic methods; 3. to provide an evidence-based review of endoscopic techniques in the context of other available treatments; 4. to propose algorithms for the management of the disease; 5. to propose guidance for outcome measurements for research and encourage prospective collection of data. The importance of a multidisciplinary approach, adherence to oncologic principles with intent to cure and need for long-term follow-up is emphasised.

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Development of a staging system for inverted papilloma.

John Krouse (2000)

Inverted papillomas of the nose and sinuses are uncommon neoplasms. In the past decade there has been a trend toward the use of endoscopic surgical techniques in the management of these tumors, in contrast to the extensive open procedures recommended previously. This trend has not been without controversy, given the association of inverted papillomas with malignancy. It has been difficult to compare surgical approaches to these neoplasms, because of the absence of a uniformly applied staging system representing the extent of disease. It was the purpose of this study to develop such a system that could be easily applied in outcomes research. This study involved an integrated literature review and a synthesis of findings from a number of studies. Previous and current clinical studies examining the treatment of inverted papilloma were reviewed. Findings were organized, and a staging system was framed based on this review. A simple, easily applied staging system was developed based on the extent of tumor involvement noted on endoscopic examination of the nasal cavity and computed tomography (CT) scan evaluation. Stage I disease is limited to the nasal cavity alone. Stage II disease is limited to the ethmoid sinuses and medial and superior portions of the maxillary sinuses. Stage III disease involves the lateral or inferior aspects of the maxillary sinuses or extension into the frontal or sphenoid sinuses. Stage IV disease involves tumor spread outside the confines of the nose and sinuses, as well as any malignancy.

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Sinonasal inverted papillomas: recurrence, and synchronous and metachronous malignancy.

S S Mirza, M Stacey, Andrea N. Jones … (2007)

Inverted papillomas are relatively rare, benign epithelial tumours of the nasal cavity which generate considerable interest because they are locally aggressive, have a tendency to recur and are associated with malignancy. To review our experience of the management of inverted papillomas, and to review the literature in order to evaluate recurrence rates, rates of synchronous and metachronous carcinoma, and outcomes of treatment, both endoscopic and conventional. We retrospectively reviewed all cases of inverted papilloma that presented to our unit, a tertiary referral centre, over a 20-year period from 1985 to 2005. A Medline review of the literature was performed to identify published case series of inverted papillomas. We undertook a critical analysis of the literature. We treated 65 patients with inverted papilloma over the 20-year period, with a mean follow up of five years (range one to 20 years). Fifty-eight patients initially underwent nasal biopsy, often with polypectomy. Thirty-six had endoscopic surgery, with five (14 per cent) suffering recurrence, whilst 16 had a lateral rhinotomy and medial maxillectomy, of which four (25 per cent) suffered a recurrence. Seven septal inverted papillomas required local resection, with no subsequent recurrences. There were seven (11 per cent) synchronous and two metachronous malignancies.Sixty-three case series with adequate data were identified from the literature. There were 163 (7.1 per cent) cases of synchronous carcinoma, out of 2297 cases. Metachronous carcinomas were reported in 74 out of 2047 cases, representing a transformation rate of 3.6 per cent. However, the true population base for these figures is uncertain, given that many series were reported from tertiary centres, where recurrent and problematic cases are likely to be over-represented. The recurrence rates were 12.8 per cent for endoscopic procedures, 17.0 per cent for lateral rhinotomy with medial maxillectomy, and 34.2 per cent for limited resections such as nasal polypectomy and Caldwell-Luc approaches. No significant association between atypia or dysplasia and recurrence or malignant transformation was found. The mean time taken to develop a metachronous carcinoma was 52 months (range six to 180 months). The estimated malignant potential for recurrent disease was up to 11 per cent. Patients with inverted papilloma should undergo thorough surgery to remove all mucosal disease, most probably by the endoscopic, endonasal route when complete resection is possible. Cases demonstrating atypia or dysplasia may be treated by the endoscopic route. Recurrent disease and metachronous carcinoma can develop after a prolonged period of time. Long-term follow up is recommended to detect recurrence, as disease can become quite extensive before it becomes symptomatic.

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Author and article information

Contributors

Oisín Bugter:

ORCID: http://orcid.org/0000-0003-3584-0440

010 70 33 106 , o.bugter@erasmusmc.nl

Journal

Journal ID (nlm-ta): J Otolaryngol Head Neck Surg

Journal ID (iso-abbrev): J Otolaryngol Head Neck Surg

Title: Journal of Otolaryngology - Head & Neck Surgery

Publisher: BioMed Central (London )

ISSN (Print): 1916-0208

ISSN (Electronic): 1916-0216

Publication date (Electronic): 20 December 2017

Publication date PMC-release: 20 December 2017

Publication date Collection: 2017

Volume: 46

Electronic Location Identifier: 67

Affiliations

ISNI 000000040459992X, GRID grid.5645.2, Department of Otorhinolaryngology and Head and Neck Surgery, , Erasmus MC, ; ‘s-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands

Author information

Oisín Bugter http://orcid.org/0000-0003-3584-0440

Article

Publisher ID: 246

DOI: 10.1186/s40463-017-0246-7

PMC ID: 5738878

PubMed ID: 29262865

SO-VID: 295bbae8-d347-4508-b496-da1d5671b527

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 7 July 2017

Date accepted : 6 December 2017

Custom metadata

Keywords: inverted papilloma,endoscopic surgery,recurrence,retrospective study,follow-up

Data availability:

Keywords: inverted papilloma, endoscopic surgery, recurrence, retrospective study, follow-up

Surgical management of inverted papilloma; a single-center analysis of 247 patients with long follow-up

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Abstract

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Core Readings in Statistical Mediation Analysis

Most cited references 40

European position paper on endoscopic management of tumours of the nose, paranasal sinuses and skull base.

Development of a staging system for inverted papilloma.

Sinonasal inverted papillomas: recurrence, and synchronous and metachronous malignancy.

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