Comprehensive analysis of HPV infection, EGFR exon 20 mutations and LINE1 hypomethylation as risk factors for malignant transformation of sinonasal-inverted papilloma to squamous cell carcinoma.

Different risk factors are suspected to be involved in malignant transformation of sinonasal papillomas and include HPV infection, tobacco smoking, occupational exposure, EGFR/KRAS mutations and DNA methylation alterations. In our study, 25 inverted sinonasal papillomas (ISPs), 5 oncocytic sinonasal papillomas (OSP) and 35 squamous cell carcinomas (SCCs) from 54 patients were genotyped for 10 genes involved in EGFR signalling. HPV-DNA detection was performed by in-situ hybridisation and LINE-1 methylation was quantitatively determined by bisulphite-pyrosequencing. High-risk HPV was observed only in 13% of ISP-associated SCC and in 8% of de novo-SCC patients. EGFR mutations occurred in 72% of ISPs, 30% of ISP-associated SCCs and 17% of de novo-SCCs. At 5-year follow-up, SCC arose in only 30% (6/20) of patients with EGFR-mutated ISPs compared to 76% (13/17) of patients with EGFR-wild-type ISP (p = 0.0044). LINE-1 hypomethylation significantly increased from papilloma/early stage SCC to advanced stage SCC (p = 0.03) and was associated with occupational exposure (p = 0.01) and worse prognosis (p = 0.09). In conclusion, our results suggest that a small subset of these tumours could be related to HPV infection; EGFR mutations characterise those ISPs with a lower risk of developing into SCC; LINE-1 hypomethylation is associated with occupational exposure and could identify more aggressive nasal SCC.

Human papillomavirus (HPV) and somatic EGFR mutations are essential, mutually exclusive oncogenic mechanisms for inverted sinonasal papillomas and associated sinonasal squamous cell carcinomas.

Background: Inverted sinonasal (Schneiderian) papilloma (ISP) is a locally aggressive neoplasm often associated with sinonasal squamous cell carcinoma (SNSCC). While the etiology of ISP is not well understood, human papillomavirus (HPV) has been detected in a subset of cases. Our group recently identified activating somatic EGFR mutations in the majority of ISP and ISP-associated SNSCC. However, the relationship between EGFR mutations and HPV infection has not been explored. Patients and methods: We evaluated 58 ISP and 22 ISP-associated SNSCC (including 13 patients with matched ISP/SNSCC samples), as well as 14 SNSCC without clinical or pathologic evidence of an associated ISP. Formalin-fixed, paraffin-embedded samples were evaluated for EGFR mutations using Sanger sequencing and for HPV infection using GP5+/GP6+ PCR. HPV subtyping based on the L1 sequence was done for HPV positive cases including temporally distinct tumors for four patients. Clinicopathologic data including progression free survival was also analyzed. Results: All ISP and ISP-associated SNSCC demonstrated either an EGFR mutation or HPV infection. HPV and EGFR mutation were mutually exclusive in all cases of ISP-associated SNSCC and all but one ISP; this case was only weakly HPV positive, and analysis of a prior temporally distinct ISP specimen from this patient failed to show HPV infection, suggesting transient infection/incidental colonization. HPV subtypes in ISP and ISP-associated SNSCC were predominantly low-risk, in contrast with SNSCC without ISP association, which showed frequent high-risk HPV. All paired ISP and associated SNSCC samples demonstrated concordant HPV status and EGFR genotypes. ISP progression to SNSCC was significantly associated with the presence of HPV infection and the absence of an EGFR mutation (log-rank = 9.620, P = 0.002). Conclusions: Collectively our data show that EGFR mutations and HPV infection represent essential, alternative oncogenic mechanisms in ISP and ISP-associated SNSCC.

Role of the Akt/mTOR signaling pathway in human papillomavirus-associated nasal and sinonasal inverted papilloma.

Nasal and sinonasal inverted papilloma (NSIP) is a benign tumor in which surface epithelial cells grow downward into the underlying supportive tissue with varying degrees of metaplasia. Human papillomavirus (HPV) has been proposed as the causal agent in the pathogenesis of this disease. Many studies have shown that HPV can activate the Akt/mechanistic target of rapamycin (mTOR) signaling pathway, but the role of this pathway in HPV-associated NSIP is largely unknown. In this study, we enrolled 40 control tissue samples and 80 NSIP tissue samples. HPV genotyping showed that 47 of the 80 examined cases of NSIP were HPV-positive (58.8%), and the most common subtype was HPV11 (20/53, 37.7%). The immunohistochemistry showed statistically significant differences in phosphorylated Akt and phosphorylated S6 ribosomal protein staining among control samples, HPV-positive NSIP and HPV-negative NSIP. The HPV11 L1-L2 plasmid increased the proliferation of normal human nasopharyngeal epithelial NP69-SV40T cells and human nasopharyngeal cancer CNE1 cells. Meanwhile, rapamycin, an mTOR inhibitor, reversed the increased cell proliferation induced by the HPV11 L1-L2 plasmid. Western blot analysis showed that Akt/mTOR/S6 were overexpressed in NP69-SV40T cells and CNE1 cells infected with the HPV11 L1-L2 plasmid. These data demonstrate that HPV promotes cell proliferation through the Akt/mTOR signaling pathway in NSIP.

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.

Human papillomavirus infection and the malignant transformation of sinonasal inverted papilloma: A meta-analysis.

A growing number of molecular epidemiological studies have been conducted to evaluate the association between human papillomavirus (HPV) infection and the malignancy of sinonasal inverted papilloma (SNIP). However, the results remain inconclusive. Here, a meta-analysis was conducted to quantitatively assess this association. Case-control studies investigating SNIP tissues for presence of HPV DNA were identified. The odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by the Mantel-Haenszel method. An assessment of publication bias and sensitivity analysis were also performed. We calculated a pooled OR of 2.16 (95% CI=1.46-3.21, P<0.001) without statistically significant heterogeneity or publication bias. Stratification by HPV type showed a stronger association for patients with high-risk HPV (hrHPV) types, HPV-16, HPV-18, and HPV-16/18 infection (OR=8.8 [95% CI: 4.73-16.38], 8.04 [95% CI: 3.34-19.39], 18.57 [95% CI: 4.56-75.70], and 26.24 [4.35-158.47], respectively). When only using PCR studies, pooled ORs for patients with hrHPV, HPV-16, and HPV18 infection still reached statistical significance. However, Egger's test reflected significant publication bias in the HPV-16 sub-analysis (P=0.06), and the adjusted OR was no longer statistically significant (OR=1.65, 95%CI: 0.58-4.63). These results suggest that HPV infection, especially hrHPV (HPV-18), is significantly associated with malignant SNIP.

Smoking and malignancy in sinonasal inverted papilloma.

OBJECTIVES/HYPOTHESIS: The authors investigated clinical features of squamous cell carcinomas (SCC) arising in sinonasal inverted papillomas (IP) and risk factors responsible for their malignant transformation. STUDY DESIGN: Retrospective analysis. METHODS: In total, 162 patients diagnosed with sinonasal IP and treated between 1998 and 2009 at Pusan National University Hospital were enrolled. Their demographic data, information about previous surgery, smoking history, treatment modalities, follow-up duration, recurrence, and presence of malignancy were reviewed retrospectively. RESULTS: Seventeen patients (10.5%) were diagnosed with SCC arising in sinonasal IPs. Among them, nine (9/162, 5.6%; 9/17, 52.9%) were diagnosed with synchronous malignancies and three (3/162, 1.8%; 3/17, 17.6%) were diagnosed with metachronous malignancies. In five cases (5/162, 3.1%; 5/17, 29.4%), we could not determine whether their malignancies were synchronous or metachronous. Among 53 smokers, 14 (26.4%) had malignant transformation, while only three (2.8%) in 109 nonsmokers had malignant transformation (Odds ratio = 12.7; P < .001). The mean follow-up in the 17 patients with malignancy was 47.0 months. Three patients did not receive surgical treatment and died of progression of SCC. Among the other 14 patients who underwent curative surgeries, four (28.6%) had recurrences, and their mean period to cancer recurrence was 6.3 months. Two of them died of progression of the cancer. Mean survival of the five patients who died was 14.0 months. They all belonged to T4 stage. CONCLUSIONS: Smoking history is associated with malignant transformation of sinonasal IP. It suggests that close follow-up be required in smokers with sinonasal IP in order not to overlook the malignant transformation. LEVEL OF EVIDENCE: 2b.

In inverted papillomas HPV more likely represents incidental colonization than an etiological factor.

Inverted papillomas (IPs) are the most frequent type of sinonasal papillomas. These benign but destructive lesions are known for their high recurrence rate, probably due to incomplete excision. Our aim was to investigate the frequency of human papillomavirus (HPV) infection in patients with IPs and in IPs associated with squamous cell carcinoma (IPsSCC) and to compare it with the frequency of HPV infections in the control group. The influence of HPV infection on the malignant alteration and recurrence rate of IPs was also evaluated. Paraffin-embedded tissue samples from 68 patients with sinonasal IPs and 5 patients with IPsSCC were analyzed in this retrospective study. The control group consisted of 47 patients who had undergone septoplasty or mucotomy of the inferior turbinate. PCR amplification with consensus primer sets was performed to detect alpha-HPVs, and direct sequencing of the PCR products with the same primers was used to determine the HPV genotypes in the samples. We detected HPV DNA in 20 (30.3%) patients with IPs, in 3 (60%) patients with IPsSCC, and in 6 (13%) patients from the control group. The frequency of HPV infection in the study group was statistically significantly higher (p = 0.032) than in the control group. The presence of HPV DNA was not a statistically significant predictor of the recurrence of IPs (p = 0.745) nor was it a statistically significant risk factor for associated SCC (p = 0.32). Since HPV type 11 was the predominant genotype in the IPs, IPsSCC, and in the control cases, we presume that HPV infection may represent incidental colonization rather than being an important etiological factor of IPs.

The development of multiple cutaneous inverted papilloma following ovariohysterectomy in a dog.

CASE HISTORY: Ovariohysterectomy was performed on an adult Cavalier King Charles Spaniel. The skin that had been clipped for surgery was noticed to be erythematous 8 days later. CLINICAL AND PATHOLOGICAL FINDINGS: Poorly defined patches containing multiple papules were visible bilaterally within the clipped skin. These became larger over the following 2 weeks, and samples were collected for histology. Seven days later, the lesions were multiple raised masses, up to 5 cm in diameter. Histology revealed numerous cup-shaped epidermal proliferations extending into the dermis. The presence of keratinocytes with increased quantities of blue-grey cytoplasm, and koilocytosis suggested papillomaviral infection; Canis familiaris papillomavirus (CfPV-2) DNA was amplified from two separate samples. Complete regression was observed 8 weeks after the lesions had been initially observed. DIAGNOSIS: Multiple inverted papilloma confined to skin that had been clipped for surgery. CLINICAL RELEVANCE: This is the first time that the development of canine cutaneous papillomas has been associated with surgery. The nature of the association between surgery and development of the papillomas is uncertain. However, it is possible that damage to superficial skin could promote the formation of papillomas. This is the first identification of CfPV-2 in New Zealand.

Cigarette smoking increases risk of recurrence for sinonasal inverted papilloma.

BACKGROUND: Sinonasal inverted papilloma (IP) is a neoplasm in the nasal cavity, characterized by its local aggressiveness and tendency to cause malignancy. Despite the frequent recurrence of IP, few studies have reported the effects of situational parameters including smoking on the recurrence rate of IP. This study was performed to evaluate clinical and environmental factors including smoking that can predict neoplasm recurrence after surgery in patients with IP. METHODS: This study was conducted retrospectively on 132 patients who were diagnosed with IP between November 1985 and September 2007. The study focused on the risk factors of recurrence, such as smoking behaviors, diabetes mellitus (DM), hypertension (HTN), allergic rhinitis (AR), the sites of tumor origin and involvement, neoplasm staging, and the surgical method. The age of the patients ranged from 22 to 85 years, and among the 132 patients, 39 patients were smokers (29.5%), 17 (13.3%) with DM, 31 (24.4%) with HTN, and 11 (9.3%) with AR. RESULTS: The recurrence rate showed great disparity between the groups of smokers and nonsmokers: 28.2% of smokers suffered recurrence compared with 10.7% recurrence from the nonsmoker group. The Krouse stage IV group experienced more frequent recurrence than the stage I, II, and III groups. Some patients in Krouse stage III (5/72, 6.9%) and IV (3/3, 100%) groups underwent malignant transformation of IP. Histories of DM, HTN, and AR did not exert a statistically meaningful influence on the recurrence and malignant transformation. CONCLUSION: The smoking behavior and tumor with extranasal/sinus extension appear to be associated with recurrence of IP after surgical resection.

[Inverted papilloma of the nose in patient after skin face transplantation]. / Przypadek odwróconego brodawczaka blony sluzowej nosa u pacjenta po przeszczepie skóry twarzy z powodu naczyniaka.

INTRODUCTION: We discuss a case of 65 year old men with inverted papilloma of the right nose cavity. During childhood he had an operation of skin face transplantation prior to face haemangioma. He has no medical documentation from that time. For several months prior to hospitalisation he complained of right nasal cavity obstruction. METHOD: In endoscopic examination we found red, fragile tumor filing posterior part of right nasal cavity and nasopharynx. Because of skin transplantation and residual haemangioma we choose sublabial and transplant technique of operation to avoid external facial incision. RESULTS: We observed one recovery of the tumor after 3 months of observation which was sucessfully operated. Follow up for 10 months determine no recurrence in our patient. CONCLUSIONS: Authors discuss various operation methods of inverted papilloma of the nose.

Benign sinonasal neoplasms: a focus on inverting papilloma.

Benign sinonasal neoplasms are a pathologic and clinically varied group of tumors. Inverting papilloma is a notable member of this group, and it is renowned for its high rate of recurrence, its ability to cause local destruction, and its association with malignancy. This article aimed to familiarize the clinician with all the practical aspects of inverting papilloma and its management. The treatment algorithm for this tumor has undergone a complex evolution that continues today.

Inverted papilloma invading the orbit through the nasolacrimal duct: a case report.

PURPOSE: Inverted papillomas of the nose and paranasal sinuses are uncommon neoplasms, characterized by their tendency to recur and by their association with malignancy and invasive potential to the adjacent structures. The authors report a case of recurrent inverted papilloma of the nasal cavity and sinuses that eventually invaded the orbit through the nasolacrimal duct. METHOD: Assessment and management of a 47-year-old patient who presented with epiphora, left medial canthal area mass, proptosis and lateral displacement of his left eye associated with significant nasal obstruction. RESULTS: Computed tomography and magnetic resonance imaging studies revealed a mass filling the nasal cavities and sinuses, invading the left orbit without destruction of any orbital walls. During excision of the tumor, it was learned that the orbital component of the tumor was connected with the sinonasal tumor through the nasolacrimal duct without any bony defects of the orbit. Histopathology of tumor proved to be inverted papilloma with areas of malignant transformation. CONCLUSION: Athough a rare cause of proptosis, inverted papilloma with orbital invasion must be considered in the differential diagnosis of nasosinus tumors invading the orbit. The case presented demonstrates that these tumors may invade the orbit through the nasolacrimal duct in the absence of orbital wall defects.

[Sino-nasal inverted papillomas and occupational etiology]. / Papillomi invertiti naso-sinusali ed eziologia occupazionale.

The sino-nasal inverted papilloma is a rare benign tumour with certain aggressive features because of frequent relapses and the high probability of malignant degeneration. For these reasons, several studies have been made to evaluate the efficacy of the different courses of treatment, but only afew studies have been carried out to establish the etiology of this tumour, which is still uncertain. Although it is believed that viral infection, chronic inflammation and cigarette smoking can play an important etiological role, it has recently been suggested that occupational risk factors, such as those involved in malignant epithelial sino-nasal cancer (SNC), can also be involved in causing sino-nasal inverted papilloma. A group of 70 patients was examined who have been diagnosed with inverted papilloma from 1991 to 2003; the occupational history, collected via the standardized questionnaire, showed that risk factors like wood and leather dusts, chromium and nickel vapours or fumes and formaldehyde were associated with only 5% of all cases. This proportion is much lower than that established for SNC in several epidemiological studies. Although occupational environmental pollution can be a source of chronic sino-nasal mucosa irritation, on the basis of our results we believe that a causal relationship between exposure to occupational risk factors and inverted papilloma is not likely, differently from the suggestions made in other studies. Consequently, an epidemiological surveillance of inverted papilloma as a "sentinel" tumour, as has been proposed in Italy for SNC, is not considered necessary. Among the possible non-occupational risk factors we observed that 75% of the male patients were smokers and 40% of all patients suffered from chronic sinusitis and sino-nasal polyps. Lastly, among the 70 cases of inverted papilloma, we observed 5 with malignant degeneration.

[Viral assumption and inverted papilloma: role of human herpes viridae n 8]. / Hypothèse virale et papillome inversè: mise au point a propos du rôle de HHV 8.

INTRODUCTION: The aetiology of inverted papillomas is still not known. Current thinking favours a viral agent in particular OBJECTIVE: To widen viral research to "Human Herpes Viridae n 8" (HHV 8). MATERIAL AND METHOD: 14 patients were included in a prospective study over a 38 months period. The average age was 49.6 years. The technique used is the PCR. RESULTS: No samples revealed the presence of HHV n8. CONCLUSION: The virus "human herpes viridae" was found in no samples, but as long as the etiopathogeny of the inverted papilloma is unknown. Further viral research is needed.

[Ureteral inverted papilloma: a case report].

A 43-year-old man presented with left hydronephrosis, incidentally found by ultrasonography. He had undergone transurethral bladder tumor resection when he was 29 years old. Cystoscopy revealed a tumor protruding from the left ureteral orifice. Left partial ureterectomy was performed, and its histopathological diagnosis was ureteral inverted papilloma. He has remained free of disease for 18 months after the surgery.

The prognostic value of a primary inverted papilloma of the urinary tract.

PURPOSE: Ever since the recognition of the inverted papilloma as a distinct lesion of the urinary tract, there has been discussion about the possible (pre)malignant potential of this rare tumor, with subsequent uncertainty about followup. Hampering the discussion are the low frequency, the unknown etiology, the difficult histopathological diagnosis and the reported association with transitional cell carcinoma. We reviewed the literature and studied our patients, resulting in the largest series reported in the literature to date. MATERIALS AND METHODS: We selected 51 patients with an inverted papilloma without a history of or a concordant transitional cell carcinoma of the urinary tract. Histology of all patients was reviewed. RESULTS: After review, as many as 14 patients appeared to be misdiagnosed (transitional cell carcinoma in 11). In 37 patients, we could confirm the diagnosis of inverted papilloma, with characteristics that were highly comparable to those described in the literature. Only 1 patient had a superficial bladder tumor after 49 months. CONCLUSIONS: Reviewing these data and our own results, we conclude that an inverted papilloma does not seem to be a risk factor for transitional cell carcinoma, although inverted papillomas and transitional cell carcinoma appear to be related to some extent. Therefore, frequent and long-term followup does not seem to be necessary provided that there is no doubt about the difficult histological diagnosis.

Human papillomavirus and Epstein-Barr virus in sinonasal Schneiderian papillomas. An in situ hybridization and polymerase chain reaction study.

Using the polymerase chain reaction (PCR), it has been recently reported that the Epstein-Barr virus (EBV) is present in the majority of Schneiderian sinonasal papillomas (SNP) of the inverted type and may play a role in the pathogenesis of these lesions. The reported prevalence rates of human papillomavirus (HPV) in different types of SNP is also controversial and in need of clarification. Twenty-eight SNP from 27 patients were histologically classified and evaluated for evidence of EBV using PCR and 2 different sensitive and specific in situ hybridization (ISH) procedures for EBER1. Similarly, two methods of ISH were also used for the detection of HPV, using biotinylated DNA probes sensitive for 14 different HPV types as well as more sensitive and specific radioactive RNA probes for HPV types 6, 11, and 16. Polymerase chain reaction was successful in 19 papillomas, including 12 of 19 inverted SNP, 1 of 1 inverted SNP with squamous cell carcinoma, 4 of 5 fungiform SNP, and 2 of 3 oncocytic lesions. Southern blot hybridization of PCR products showed the presence of EBV DNA in two lesions, including one inverted SNP and the single inverted SNP with squamous cell carcinoma. By both DNA- and RNA-mRNA ISH, positivity for EBER was detected in rare stomal lymphocytes but not the overlying epithelium in the inverted SNP with SCC. The remaining cases, including the other inverted SNP positive for EBV by PCR, were completely negative by both ISH techniques. Human papillomavirus was detected by ISH in 1 of 19 (5%) inverted, 1 of 1 (100%) inverted with squamous cancer, 5 of 5 (100%) fungiform, and 0 of 3 (0%) oncocytic SNP. Three SNP contained HPV 6 (all fungiform), three SNP labeled for HPV 11 (two fungiform and the inverted SNP with squamous cancer), and one inverted SNP contained HPV 16. Of the five fungiform SNP, four showed foci of koilocytosis. The results indicate that EBV is not present in sinonasal papillomas. The presence of EBV positive stromal lymphocytes in these lesions may account for a proportion of PCR-positive cases. Oncocytic SNP are unassociated with HPV, whereas inverted SNP contain HPV in a minority of cases. In contrast, fungiform SNP are consistently associated with HPV types 6 and 11 and usually show histologic evidence of viral infection.

Is there an occupational etiology of inverted papilloma of the nose and sinuses?

The etiology of inverted papilloma is believed to be of viral origin, as viruses or viral material is found in these tumors of the nose and paranasal sinuses. As the nose is the first defense line of the respiratory tract, we suspected an etiology of airborne pollution as well, especially occupational pollution. We examined a group of 47 patients treated in our department for nasal inverted papilloma, asking about lifelong professional history and occupational exposure. A matched control group of patients with non-malignant diseases was included in the study. We found a significantly higher degree of occupational exposure to different smokes, dusts, and aerosols in the case group. No similar results have been published to our knowledge. To obtain better proof of the role of possible noxious agents, a study technically investigating exposure is mandatory.

Inverted papillomas that invade the orbit.

We describe 10 patients with inverted papillomas (IPs), uncommon endophytic epithelial tumors that arose in the nose, paranasal sinuses, and lacrimal sac, that invaded the orbit; review the world literature on IP; and discuss treatment options. Patients ranged in age from 49 to 72 years (mean age, 62 years; median age, 66 years). Six patients were men and four were women. Presenting symptoms and signs included a medial canthal mass (n = 5), epiphora/lacrimal drainage obstruction (n = 3), inability to wear eyeglasses (n = 2), diplopia (n = 1), and painful dentures (n = 1). Histopathologic examination was performed in each patient and revealed all patients to have areas with malignant transformation: six patients with IPs that contained areas of squamous cell carcinoma and four with areas of transitional cell carcinoma in the tumor within the orbit. Eight of the patients with IPs had a recurrence after initial resection. In two patients, the IPs were completely excised and did not recur; yet, follow-up was short. Eight patients required orbital exenteration for local control of disease. Nevertheless, local spread of tumor through bone to brain occurred in three patients with orbital involvement. Indeed, IPs that invade the orbit have a high incidence of malignancy and are locally aggressive tumors. Treatment is difficult, and the recurrence rate is high. Early, wide excision of this aggressive tumor provides the best chance of cure.