Recurrent Primary Inverted Papilloma of the Mastoid with Intracranial Invasion: A 7-Year Follow-Up.

A 55-year-old man presented to the otolaryngology department complaining of aural fullness in his left ear after an episode of probable otitis 3 months before. magnetic resonance imaging revealed a soft tissue mass within the mastoid cavity that had destroyed the posterior wall of the middle ear with no apparent middle ear or sinonasal origin. The patient underwent a left canal wall-up tympanomastoidectomy, and the pathology report confirmed an inverted papilloma. Inverted papillomas are uncommon benign epithelial tumors related to a high recurrence rate and high risk of secondary malignant transformation after multiple surgeries. The patient has undergone 2 additional surgical interventions involving the neurosurgery team due to recurrent inverted papilloma that exerted a mass effect over the left cerebellar hemisphere. Despite no signs of recurrence on magnetic resonance imaging 5 years after the last surgery, at least 1 radiologic study per year is granted. Clinical multidisciplinary follow-up including nasal endoscopy and head and neck examination as a part of a stringent follow-up is essential to rule out synchronous nasosinusal inverted papillomas.

Unique volatile metabolite signature of sinonasal inverted papilloma detectable in plasma and nasal secretions.

BACKGROUND: Sinonasal inverted papilloma (SNIP) is a benign neoplasm with aggressive features, including a high recurrence rate and a propensity for malignant transformation. Accurate diagnosis with complete resection and the need for close long-term surveillance is widely accepted as standard management. In this study, we investigate whether SNIP produces a unique volatile metabolite signature, which may ultimately lead to a novel approach to diagnose and monitor SNIP. METHODS: Whole blood and nasal secretions from patients with SNIP and healthy age-, sex-, and smoking-status-matched controls, were collected. There were 56 blood samples and 42 nasal secretion samples collected. The volatile metabolite signature of SNIP plasma and nasal secretion samples were compared with those of healthy controls using chromatography. RESULTS: Seventy-two volatiles were identified in plasma samples. Multivariate analysis of variance results, even when controlled for smoking status, indicated toluene as a significant univariate result with lower levels of toluene identified in SNIP plasma samples than healthy control plasma samples. A linear discriminant analysis (LDA) model for plasma volatiles correctly classified 23 of 24 SNIP patients and 26 of 27 control patients, with a cross-validation error rate of 6.02%. Sixty-nine volatiles were identified in nasal samples. For nasal secretion samples, no single univariate response was significant. The LDA model correctly classified 21 of 21 SNIP patients and 11 of 12 control patients, with a cross-validation error rate of 6.55%. CONCLUSION: This study suggests that SNIP produces a unique, detectable volatile metabolite signature. With further investigation, this can have dramatic clinical implications for diagnosis and monitoring. Although most volatile metabolite studies have investigated solid-organ malignancy, this novel study addresses a benign sinonasal neoplasm by using nasal secretions and plasma as an analysis medium, representing the first such study.

Does evaluation of tumor volume or/both origination site better guide to optimal surgery for inverted papilloma? / A avaliação do volume do tumor e/ou dos seus locais de origem fornece a melhor orientação para a técnica cirúrgica ideal do papiloma invertido?

Abstract Introduction Sinonasal inverted papilloma is noted for its high rate of recurrence. Staging systems aid to reduce recurrence and avoid excessive surgeries by guiding the selection of the optimal surgical approach. Objective To evaluate the effectiveness of different endoscopic approaches in inverted papilloma by assessing tumor origin site and tumor volume. Methods Krouse classification system that is based on tumor volume was used for staging; furthermore, tumor origin sites were grouped as lateral nasal wall, medial wall and other walls of maxillary sinus. The main treatment method for all patients was endoscopic sinus surgery. Endoscopic extended middle meatal antrostomy, endoscopic Caldwell-Luc and endoscopic medial maxillectomy were the additional surgery types performed in different combinations. Results Fifty-five patients (42 male) with a mean 54.9 ± 14.4 years of age were included. 37 patients were diagnosed with advanced stage inverted papilloma (67.2 %). Recurrence was observed in 12 patients (21.8 %). In early stage lateral nasal wall origination, no recurrence was observed in the simple tumor resection group (0/10). In early stage medial wall origination, no recurrence was observed in the extended middle meatal antrostomy group (0/8). In advanced stage medial wall origination, the recurrence rates of extended middle meatal antrostomy, extended middle meatal antrostomy + endoscopic Caldwell- Luc and endoscopic medial maxillectomy were 100.0 %, 53.8 % and 13.6 %, respectively (p = 0.002). In advanced stage other walls of maxillary sinus origination, recurrence rates of extended middle meatal antrostomy + endoscopic Caldwell-Luc and endoscopic medial maxillectomy were 20 % and 16.6 %, respectively (p = 0.887). Conclusion Tumor origin site, tumor stage and surgery types show an impact on recurrence. Despite the fact that tumor origin site singly could lead to appropriate selection of the surgery type in most cases, tumor stage carries substantial importance in selection of surgery type for sinonasal-inverted papilloma. An operation plan regarding both tumor volume and tumor origin site may aid surgeons in selecting optimal endoscopic surgical method to avoid recurrence or excessive surgeries.

Resumo Introdução O papiloma invertido nasossinusal é conhecido por sua alta taxa de recorrência. Os sistemas de estadiamento ajudam a reduzir a recorrência e evitar cirurgias excessivas e orientam a seleção da abordagem cirúrgica ideal. Objetivo Avaliar a eficácia de diferentes abordagens endoscópicas no papiloma invertido, de acordo com o local de origem e o volume do tumor. Método Para o estadiamento, usou-se o sistema de classificação de Krouse, baseado no volume do tumor; além disso, os tumores foram agrupados de acordo com seus locais de origem: parede nasal lateral, parede medial e outras paredes do seio maxilar. O principal método de tratamento para todos os pacientes foi a cirurgia endoscópica nasossinusal. Foram feitos, em diferentes combinações, os seguintes tipos de cirurgia: antrostomia estendida do meato médio, Caldwell-Luc endoscópica e maxilectomia medial endoscópica. Resultados Foram incluídos 55 pacientes (42 homens) com média de 54,9 ± 14,4 anos. Trinta e sete pacientes foram diagnosticados com papiloma invertido avançado (67,2%). Foi observada recorrência em 12 pacientes (21,8%). No estágio inicial com origem na parede nasal lateral, não foi observada recorrência no grupo de ressecção simples de tumor (0/10). No estágio inicial com origem na parede medial, não foi observada recorrência no grupo de antrostomia estendida do meato médio (0/8). Com tumor em estágio avançado com origem na parede medial, as taxas de recorrência na antrostomia estendida do meato médio, antrostomia estendida do meato médio + Caldwell-Luc endoscópica e maxilectomia medial endoscópica foram de 100,0%, 53,8% e 13,6%, respectivamente (p = 0,002). No tumor em estágio avançado em outras paredes do seio maxilar, as taxas de recorrência na antrostomia estendida do meato médio + Caldwell-Luc endoscópica e maxilectomia medial endoscópica foram de 20% e 16,6%, respectivamente (p = 0,887). Conclusão O local de origem do tumor, o estágio do tumor e os tipos de cirurgia mostram impacto na recorrência. Apesar da consideração de que na maioria dos casos o local de origem do tumor pode, de forma isolada, orientar a seleção apropriada do tipo de cirurgia, o estágio do tumor tem importância substancial na seleção do tipo de cirurgia para papiloma invertido nasossinusal. Um planejamento cirúrgico considerando tanto o volume quanto o local de origem do tumor pode ajudar os cirurgiões a selecionar o tipo ideal de cirurgia endoscópica para evitar recorrências ou remoções excessivas.

Bilateral Sinonasal Inverted Papilloma: Report of an Uncommon Case Involving Sinuses of the Face and Orbital Cavity.

BACKGROUND Nasosinusal papilloma is a benign aggressive tumor. It usually occurs unilaterally in the nasal cavity and can extend to the sinuses. The diagnosis is made by the correlation of findings observed in tomographic and histopathological exams. The recommended treatment is surgical excision with clinical monitoring. Orbital involvement occurs in about 9% of cases of advanced SIP. However, there is no report of cases of a benign tumor that invaded the adjacent soft tissues. Therefore, our objective is to report an unusual case of SIP that bilaterally involved the nasal cavity and maxillary sinuses, and extended to involve the ethmoidal cells and sphenoid and frontal sinuses. CASE REPORT In this article, we report an unusual presentation of sinonasal inverted papilloma (SIP) in a 60-year-old man. The tumor bilaterally involved the nasal cavity and maxillary sinuses and extended to involve the ethmoidal cells and the sphenoid and frontal sinuses, as well as the orbital cavity on the right side. An open surgical procedure was performed for complete removal of the lesion and follow-up with imaging exams. CONCLUSIONS The involvement of these structures is uncommon in SIP. This highlights the importance of this case report. Diagnosis and surgical treatment must be carefully planned. In this work, we describe all the steps that helped guide the choice of the best surgical technique to be performed and offer the best clinical follow-up.

Inverted Nasal Papilloma Affecting Ears and Pulmonary Parenchyma: Case Report.

Inverted papilloma is a rare sinonasal neoplasm. It can be locally invasive and potentially degenerate to a malignant tumor. We present a case report of a 36-year-old woman who was treated for nasal inverted papilloma for over 10 years and presented bilateral temporal bone, and pulmonary involvement. Several procedures were performed to completely remove the tumor. Even without evidence of malignant degeneration, the patient continued battling tumor recurrences. To the best of our knowledge, this report presents the first case of a multicentric inverted papilloma with nasal, bilateral temporal bone, and pulmonary metachronous localization. Laryngoscope, 131:E2640-E2642, 2021.

Sinonasal inverted papilloma: rate of recurrence and malignant transformation in 44 operated patients / Papiloma invertido nasossinusal: taxa de recorrência e transformação maligna em 44 pacientes operados

Abstract Introduction: Although sinonasal inverted papillomas are benign lesions, they are locally aggressive and have a potential malignant transformation ranging from 5% to 15%, with a high recurrence rate. Objective: The aim of this article is to describe the rate of recurrence and malignant transformation in patients with a diagnosis of inverted papilloma who underwent surgery in a tertiary hospital in São Paulo. Methods: We performed a retrospective analysis of patients diagnosed with sinonasal papilloma who had undergone surgery in a tertiary hospital in São Paulo, between August 1998 and August 2017. A patient chart review was conducted to assess data of patients' demographics, tumors characteristics, follow-up appointments, recurrence and malignancy. Inverted papillomas were analyzed and classified under the Krouse staging system. Results: A total of 69 surgeries were performed in patients with diagnosis of sinonasal papilloma. Inverted papilloma was the most prevalent subtype (49 cases ‒ 80.33%), followed by exophytic papilloma (6 cases ‒ 9.84%) and by oncocytic papilloma (6 cases - 9.84%). The recurrence rate was 34.09% for inverted papilloma (15/44) and the mean time of recurrence was 24.6 months. Malignant transformation occurred in 6 patients (13.64%). Three of these patients presented carcinoma in the first surgery and three patients developed carcinoma during the follow-up. Conclusion: The high recurrence rate and malignancy potential allow us to consider inverted papillomas as aggressive tumors. In a tertiary hospital in São Paulo the recurrence rate the mean time to recurrence is 24.6 months. The recurrence after 10 years implies was 34.09% and the need for long-term follow up. It is possible that the high recurrence rate and the high malignant transformation rate we found are due to the large number of tumors discovered at an advanced stage (most of them staged T3 and T4), secondary to poor access to health system, in developing countries.

Resumo Introdução: Embora os papilomas invertidos nasossinusais sejam lesões benignas, eles são localmente agressivos e apresentam uma potencial transformação maligna que varia de 5% a 15%, com alta taxa de recorrência. Objetivo: Descrever a taxa de recorrência e transformação maligna em pacientes com diagnóstico de papiloma invertido submetidos à cirurgia em um hospital terciário em São Paulo. Método: Análise retrospectiva dos pacientes diagnosticados com papiloma nasossinusal submetidos a cirurgia em um hospital terciário em São Paulo, entre agosto de 1998 e agosto de 2017. Uma revisão de prontuários dos pacientes foi realizada para avaliar dados demográficos, características dos tumores, consultas de seguimento, recorrência e malignidade. Os papilomas invertidos foram analisados e classificados de acordo com o sistema de estadiamento de Krouse. Resultados: Foram realizadas 69 cirurgias em pacientes com diagnóstico de papiloma nasossinusal. O papiloma invertido foi o subtipo mais prevalente (49 casos - 80,33%), seguido pelo papiloma exofítico (6 casos - 9,84%) e pelo papiloma oncocítico (6 casos - 9,84%). A taxa de recidiva foi de 34,09% para o papiloma invertido (15/44) e o tempo médio de recorrência foi de 24,6 meses. Transformação maligna ocorreu em seis pacientes (13,64%); três desses pacientes apresentaram carcinoma na primeira cirurgia e três pacientes desenvolveram carcinoma durante o seguimento. Conclusão: A alta taxa de recorrência e o potencial de malignidade nos permitem considerar os papilomas invertidos como tumores agressivos. Em um hospital terciário de São Paulo, a taxa de recorrência foi de 34,09% e o tempo médio de recorrência de 24,6 meses. A recorrência após 10 anos implica na necessidade de acompanhamento a longo prazo. É possível que a alta taxa de recorrência e a alta taxa de transformação maligna que encontramos sejam devidas à grande extensão dos tumores (a maioria deles nos estágios T3 e T4), decorrente do acesso precário ao sistema de saúde nos países em desenvolvimento.

[Inverted urothelial papilloma of the bladder in an adolescent]. / Papiloma urotelial invertido vesical en adolescente.

INTRODUCTION: Inverted urothelial papilloma is a very rare neoplasm in the pediatric population. Because of the low incidence of cases and the reports of atypical components, the management and follow-up plan is not standardized. OBJECTIVE: To report a case of inverted papilloma in a female adolescent and to review the diagnostic approach, management, and follow-up plan for this entity. CLINICAL CASE: We reported a case of inverted papilloma as an incidental finding of a polypoid lesion on bladder ultrasound in a 13-year-old adolescent. Endoscopic resection was performed, and the histopathological analysis was compatible with inverted urothelial papilloma. The patient remains asymptomatic, with no evidence of recurrence after 3 years of ultrasound follow-up. CONCLUSION: This case supports the benign beha vior of inverted papilloma, highlighting the importance of a correct histopathological diagnosis for the decision to carry out a non-invasive ultrasound follow-up.

Sinonasal inverted papilloma: rate of recurrence and malignant transformation in 44 operated patients.

INTRODUCTION: Although sinonasal inverted papillomas are benign lesions, they are locally aggressive and have a potential malignant transformation ranging from 5% to 15%, with a high recurrence rate. OBJECTIVE: The aim of this article is to describe the rate of recurrence and malignant transformation in patients with a diagnosis of inverted papilloma who underwent surgery in a tertiary hospital in São Paulo. METHODS: We performed a retrospective analysis of patients diagnosed with sinonasal papilloma who had undergone surgery in a tertiary hospital in São Paulo, between August 1998 and August 2017. A patient chart review was conducted to assess data of patients' demographics, tumors characteristics, follow-up appointments, recurrence and malignancy. Inverted papillomas were analyzed and classified under the Krouse staging system. RESULTS: A total of 69 surgeries were performed in patients with diagnosis of sinonasal papilloma. Inverted papilloma was the most prevalent subtype (49 cases ‒ 80.33%), followed by exophytic papilloma (6 cases ‒ 9.84%) and by oncocytic papilloma (6 cases - 9.84%). The recurrence rate was 34.09% for inverted papilloma (15/44) and the mean time of recurrence was 24.6 months. Malignant transformation occurred in 6 patients (13.64%). Three of these patients presented carcinoma in the first surgery and three patients developed carcinoma during the follow-up. CONCLUSION: The high recurrence rate and malignancy potential allow us to consider inverted papillomas as aggressive tumors. In a tertiary hospital in São Paulo the recurrence rate the mean time to recurrence is 24.6 months. The recurrence after 10 years implies was 34.09% and the need for long-term follow up. It is possible that the high recurrence rate and the high malignant transformation rate we found are due to the large number of tumors discovered at an advanced stage (most of them staged T3 and T4), secondary to poor access to health system, in developing countries.

Does evaluation of tumor volume or/both origination site better guide to optimal surgery for inverted papilloma?

INTRODUCTION: Sinonasal inverted papilloma is noted for its high rate of recurrence. Staging systems aid to reduce recurrence and avoid excessive surgeries by guiding the selection of the optimal surgical approach. OBJECTIVE: To evaluate the effectiveness of different endoscopic approaches in inverted papilloma by assessing tumor origin site and tumor volume. METHODS: Krouse classification system that is based on tumor volume was used for staging; furthermore, tumor origin sites were grouped as lateral nasal wall, medial wall and other walls of maxillary sinus. The main treatment method for all patients was endoscopic sinus surgery. Endoscopic extended middle meatal antrostomy, endoscopic Caldwell-Luc and endoscopic medial maxillectomy were the additional surgery types performed in different combinations. RESULTS: Fifty-five patients (42 male) with a mean 54.9±14.4 years of age were included. 37 patients were diagnosed with advanced stage inverted papilloma (67.2 %). Recurrence was observed in 12 patients (21.8 %). In early stage lateral nasal wall origination, no recurrence was observed in the simple tumor resection group (0/10). In early stage medial wall origination, no recurrence was observed in the extended middle meatal antrostomy group (0/8). In advanced stage medial wall origination, the recurrence rates of extended middle meatal antrostomy, extended middle meatal antrostomy+endoscopic Caldwell- Luc and endoscopic medial maxillectomy were 100.0 %, 53.8 % and 13.6 %, respectively (p=0.002). In advanced stage other walls of maxillary sinus origination, recurrence rates of extended middle meatal antrostomy+endoscopic Caldwell-Luc and endoscopic medial maxillectomy were 20 % and 16.6 %, respectively (p=0.887). CONCLUSION: Tumor origin site, tumor stage and surgery types show an impact on recurrence. Despite the fact that tumor origin site singly could lead to appropriate selection of the surgery type in most cases, tumor stage carries substantial importance in selection of surgery type for sinonasal-inverted papilloma. An operation plan regarding both tumor volume and tumor origin site may aid surgeons in selecting optimal endoscopic surgical method to avoid recurrence or excessive surgeries.

Surgical outcomes of sinonasal inverted papilloma: a 17 year review / Resultados cirúrgicos do papiloma invertido nasossinusal: uma revisão de 17 anos

Abstract Introduction: Inverted papillomas represent one of the most common benign neoplasic lesions located in the sinonasal tract. Owing to the local erosive behavior, tendency to recur and the potential for malignant transformation, surgical management of inverted papillomas is often challenging. Objective: This study aimed to analyze the surgical outcomes of patients with inverted papillomas, according to the Krouse staging and the different surgical approaches. Methods: Retrospective study of patients diagnosed with sinonasal inverted papillomas who underwent surgical treatment between 2000 and 2016 at a tertiary referral hospital. Cases with follow-up less than 12 months were excluded. The rate and the time of recurrence were the main outcomes. Values of p < 0.05 were considered statistically significant. Results: Thirty-six cases with mean age of 60 years, predominantly male (72%), were included. The follow-up period ranged from 1 to 16 years, with an average of 4.5 years. Krouse T1 Stage corresponded to 11.1%; T2 occurred in 50% of cases; while T3 and T4 Stages accounted for 30.6% and 8.3% of patients, respectively. Most cases were approached by an endoscopic technique alone (83.3%), with a recurrence rate of 13.3%. Patients treated via a combined or open approach revealed a recurrence of 16.7%. No differences in the recurrence rate were reported when comparing endoscopic surgery with the open or combined techniques. Krouse Stage T3 had a significant association with inverted papillomas recurrence (p = 0.023). All inverted papilloma relapses occurred up to 2 years post-operatively. One case of malignant transformation was recorded (2.7%). Conclusion: Endoscopic surgery did not increase the recurrence rates and can be a safe and efficient alternative to open or combined techniques. The recurrence of inverted papillomas seem to be related to the persistence of the disease and tend to occur early after primary surgery. Krouse T3 Stages may be associated with a higher recurrence of inverted papillomas.

Resumo Introdução: Os papilomas invertidos são uma das lesões neoplásicas benignas mais comuns no trato nasossinusal. Devido ao seu comportamento localmente agressivo, tendência para recidivar e potencial de malignização, o tratamento cirúrgico dos papilomas invertidos constitui frequentemente um desafio. Objetivo: Analisar os resultados cirúrgicos dos papilomas invertidos segundo o estadiamento de Krouse, bem como avaliar as diferentes abordagens cirúrgicas. Método: Estudo retrospectivo de pacientes com diagnóstico de papiloma invertido nasossinusal submetidos a tratamento cirúrgico entre 2000 e 2016 em hospital terciário. Casos com acompanhamento inferior a 12 meses foram excluídos. A taxa e o tempo de recidiva foram os principais resultados analisados desfechos avaliados. Valores p < 0,05 foram considerados estatisticamente significativos. Resultados: Foram incluídos 36 casos, com média de idade de 60 anos, predominantemente do sexo masculino (72%). O período de acompanhamento variou de 1 a 16 anos, em uma média de 4,5 anos. Relativamente ao estadiamento, 11,1% dos pacientes foram classificados como estadio Krouse T1, 50% como T2, 30,6% como T3 e 8,3% como T4. A maioria dos casos foi tratada exclusivamente por cirurgia endoscópica (83,3%), com taxa de recidiva de 13,3%. Pacientes tratados com uma técnica combinada ou aberta apresentaram recidiva de 16,7%. Não foram observadas diferenças quanto à taxa de recidiva entre os casos abordados por via endoscópica e os casos tratados com técnica aberta ou combinada. Verificou-se uma associação significativa entre o estadio T3 de Krouse e recidiva de papilomas invertidos (p = 0,023). Todas as recidivas de papilomas invertidos foram observadas até dois anos após a cirurgia. Um caso de transformação maligna foi registrado (2,7%). Conclusão: A cirurgia endoscópica não aumentou as taxas de recidiva e pode ser uma alternativa segura e eficiente às técnicas abertas ou combinadas. Os casos de recidiva do papiloma invertido parecem estar relacionados com a persistência da doença e tendem a ocorrer precocemente após a cirurgia primária. Os estadios T3 de Krouse podem estar associados a uma maior recidiva.

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.

Surgical outcomes of sinonasal inverted papilloma: a 17 year review.

INTRODUCTION: Inverted papillomas represent one of the most common benign neoplasic lesions located in the sinonasal tract. Owing to the local erosive behavior, tendency to recur and the potential for malignant transformation, surgical management of inverted papillomas is often challenging. OBJECTIVE: This study aimed to analyze the surgical outcomes of patients with inverted papillomas, according to the Krouse staging and the different surgical approaches. METHODS: Retrospective study of patients diagnosed with sinonasal inverted papillomas who underwent surgical treatment between 2000 and 2016 at a tertiary referral hospital. Cases with follow-up less than 12 months were excluded. The rate and the time of recurrence were the main outcomes. Values of p<0.05 were considered statistically significant. RESULTS: Thirty-six cases with mean age of 60 years, predominantly male (72%), were included. The follow-up period ranged from 1 to 16 years, with an average of 4.5 years. Krouse T1 Stage corresponded to 11.1%; T2 occurred in 50% of cases; while T3 and T4 Stages accounted for 30.6% and 8.3% of patients, respectively. Most cases were approached by an endoscopic technique alone (83.3%), with a recurrence rate of 13.3%. Patients treated via a combined or open approach revealed a recurrence of 16.7%. No differences in the recurrence rate were reported when comparing endoscopic surgery with the open or combined techniques. Krouse Stage T3 had a significant association with inverted papillomas recurrence (p=0.023). All inverted papilloma relapses occurred up to 2 years post-operatively. One case of malignant transformation was recorded (2.7%). CONCLUSION: Endoscopic surgery did not increase the recurrence rates and can be a safe and efficient alternative to open or combined techniques. The recurrence of inverted papillomas seem to be related to the persistence of the disease and tend to occur early after primary surgery. Krouse T3 Stages may be associated with a higher recurrence of inverted papillomas.

Inverted papilloma with multifocal attachment is associated with increased recurrence.

BACKGROUND: Inverted papilloma (IP) is a benign sinonasal tumor with a well-known propensity to recur, especially at its bony attachment site. Anecdotal evidence suggests lower rate of recurrence in primary resection. We also aimed to evaluate the effect of multifocal vs single focus of attachment in disease control. METHODS: This work is a retrospective review of 535 IP resections performed during the period from 2006 to 2016 at a tertiary-care center. Demographic data, tumor location and attachment sites, and follow-up duration data were obtained. RESULTS: Two hundred ten patients were eligible for analysis. The mean age was 57 years, with an average postoperative surveillance of 36.4 months. Patients who had a previous procedure at an outside institution have a recurrence rate of 22.3%, compared with 12.4% for patients who had primary surgery at our institution. The most common site of attachment was maxillary sinus (47.6%), followed by ethmoid sinus (39%). Individual tumor review showed 50% of the patients to have multifocal attachment disease, of which there is a higher prevalence in secondary cases when compared with primary cases (53.7% vs 44.9%). Multiple tumor attachment sites had a significant effect on recurrence (odds ratio, 3.5; 95% confidence interval, 1.6-7.6; p = 0.002). CONCLUSION: Primary resection and single-focus attachment of inverted papilloma are associated with lower recurrence rates at 3-year follow-up.

Abordaje multidisciplinario del papiloma invertido nasal asociado con mucopiocele frontoetmoidal orbitario: técnica endoscópica y abierta por otorrinolaringología, neurocirugía y oftalmología / Multidisciplinary approach of nasal inverted papilloma associated with frontoethmoidal orbitary mucopiocele: endoscopic and open technique by otorhinolaryngology, neurosurgery and ophthalmology

Introducción: el papiloma invertido nasal es un tumor nasosinusal primario de comportamiento intermedio, con potencial de malignización y capacidad de recidiva en asociación con mucocele. El manejo quirúrgico de ambas patologías se ha descrito de manera independiente. Caso clínico: paciente con diagnóstico de papiloma invertido nasal Krause III y mucopiocele frontoetmoidal orbitario derecho con destrucción de techo de órbita y pared posterior del seno frontal en quien se realizó el manejo multidisciplinario mediante abordaje endoscópico y abierto sin recidiva luego de un año de seguimiento. Discusión: a la luz de la evidencia actual, el tratamiento del papiloma nasal invertido es quirúrgico recomendando abordajes endoscópicos en estadios I, II y III, y técnicas combinadas en estadio IV. En nuestro caso se realizó una resección endoscópica completa del tumor con frontoetmoidoesfenoidotomía + maxilectomía medial y fresado de inserciones óseas. Para el mucocele frontal, el abordaje debe permitir la remoción de la mucosa sinusal y la secuestrectomía ósea. Teniendo en cuenta la localización lateral y el compromiso osteolítico del techo de la órbita y la pared posterior del seno frontal, se optó por un abordaje abierto mediante un colgajo osteoplástico con cranealización de seno frontal. El manejo de las secuelas orbitarias consistió en la reconstrucción del techo de la órbita y dacriocistorrinostomía endoscópica.

Introduction: Nasal inverted papilloma is a primary nasosinusal tumor of intermediate behavior, with potential for malignancy and relapse capacity in association with mucocele. The surgical management of both pathologies has been described independently. Case report: Patient with a diagnosis of Krause III nasal inverted papilloma and right frontoethmoidal orbitary mucopiocele with destruction of the orbital roof and posterior wall of the frontal sinus is performed using a multidisciplinary approach with an endoscopic and open approach without relapse after one year of follow-up. Discussion: The treatment of inverted nasal papilloma is surgical recommending endoscopic approaches in stages I, II and III, and combined techniques in stage IV. In our case, a complete endoscopic resection of the tumor was performed with frontoethmoidosphenoidotomy + medial maxillectomy and milling of osseous insertions. For the frontal mucocele, the approach should allow the removal of the sinus mucous membrane and the bone sequestractomy. Considering the lateral location, the osteolytic involvement of the orbital roof and the posterior frontal sinus wall, we opted for an open approach using an osteoplastic flap with frontal sinus cranialisation. The management of the orbital sequelae consisted of reconstruction of the orbital roof and endoscopic dacryocystorhinostomy.

The analysis of expression of p16 protein in group of 53 patients treated for sinonasal inverted papilloma / Análise da expressão da proteína p16 em um grupo de 53 pacientes tratados para papiloma invertido nasossinusal

Abstract Introduction: Sinonasal inverted papilloma constitute relevant therapeutic problem due to destructive character of growth, tendency to recur and the possibility of malignant transformation. Therefore, many attempts to identify risk factors for inverted papilloma occurrence have been undertaken, as well as research to find markers that would allow for the earlier detection of tumors and the application of adequate therapy. A widely known risk factor of inverted papilloma is HPV infection. One of the markers of HPV infection and the ongoing effect of this change (although arousing some controversy) is the expression of the p16 protein. Objective: The aim of the study was to analyze the correlation between the expression of p16 as a surrogate of HPV infection in analyzed histopathological material and epidemiological variables, recurrences or malignant transformation. Methods: The retrospective study includes a group of 53 patients (18 women and 35 men) undergoing treatment for sinonasal inverted papilloma in the period of 2002-2012. The intensity of the p16 protein in histopathological material was scored as: 0 - no expression, 1 - diffuse expression (borderline) and 2 - positive expression; or 0 - no expression/diffuse expression (borderline); 1 - positive expression. The Ethics Committee agreement was obtained (1089/12; 245/13). Results and conclusion: There was no statistically significant relationship between the expression of p16 and the age of patients, cigarette smoking, tumor location, tumor staging according to the Krouse and Cannady classification, the presence of dysplasia or the occurrence of relapse.

Resumo Introdução: Papiloma invertido nasossinusal constitui um problema terapêutico relevante devido ao caráter destrutivo do crescimento, a tendência à recorrência e a possibilidade de transformação maligna. Assim, muitas tentativas têm sido realizadas para identificar fatores de risco para ocorrência de papiloma invertido, bem como pesquisas para encontrar marcadores que permitam a detecção precoce de tumores e a utilização de terapia adequada. Um fator de risco amplamente conhecido de papiloma invertido é a infecção pelo HPV. Um dos marcadores da infecção por HPV e do efeito contínuo dessa alteração (embora suscite alguma controvérsia) é a expressão da proteína p16. Objetivo: Analisar a correlação entre a expressão de p16 como um substituto da infecção pelo HPV no material histopatológico analisado e as variáveis epidemiológicas, recorrências ou transformação maligna. Método: O estudo retrospectivo inclui um grupo de 53 pacientes (18 mulheres e 35 homens) submetidos a tratamento para papiloma invertido nasossinusal de 2002 a 2012. A intensidade da expressão da proteína p16 no material histopatológico foi pontuada como: 0 - sem expressão, 1 - expressão difusa (limite) e 2 - expressão positiva; ou 0 - sem expressão/expressão difusa (limite); 1 - expressão positiva. O Comitê de Ética aprovou o estudo (1.089/12; 245/13). Resultados e conclusão: Não houve relação estatisticamente significante entre a expressão de p16 e a idade dos pacientes, o tabagismo, a localização tumoral e o estadiamento tumoral de acordo com a classificação de Krouse e Cannady, presença de displasia ou ocorrência de recidiva.

Cirugía endoscópica nasal en el tratamiento de papiloma invertido: a propósito de 18 casos / Endoscopic sinus surgery in the management of inverted papilloma: an analysis of 18 cases

RESUMEN Introducción El papiloma invertido nasosinusal es un tumor benigno con tendencia a la recidiva, y con riesgo de malignización. El tratamiento habitual es la extirpación quirúrgica. Objetivo Describir y analizar las características clínicas, epidemiológicas, y resultados del tratamiento quirúrgico por vía endoscópica. Material y método Estudio retrospectivo, descriptivo, incluyendo pacientes con papiloma invertido nasosinusal sometidos a extirpación quirúrgica endoscópica entre los años 2012 y 2016. Se analizaron variables epidemiológicas, clínicas, complicaciones quirúrgicas, recurrencias y transformación maligna. El grado de extensión se evaluó con tomografia computarizada según la clasificación de Krouse. Resultados La serie está constituida por 18 pacientes, con una edad promedio de 57,4 años. La clínica se caracterizó por obstrucción nasal unilateral 72,2% (13/18 pacientes), rinorrea 33,3% (6/18 pacientes), hiposmia 27,8% (5/18 pacientes) y epistaxis 27,8% (5/18 pacientes). Según la clasificación de Krouse, las lesiones iniciales se describen como estadio T1 en 7/18, T2 en 5/18, T3 en 5/18 y T4 en 1/18 pacientes. En el período de seguimiento, se observa recurrencia en 4 pacientes en un período promedio de seguimiento de 5,6 meses, y un caso de transformación maligna. No hubo complicaciones quirúrgicas, excepto un caso de epífora por obstrucción de la vía nasolagrimal. Conclusiones El abordaje endoscópico fue efectivo para el tratamiento de papilomas invertidos nasosinusales.

ABSTRACT Introduction Sinonasal inverted papillomas are benign tumors with a tendency to recur and a potential for malignant transformation. Surgical resection is the treatment of choice. Aim To describe and analyze the clinical characteristics, epidemiology, and surgical results from an endoscopic endonasal approach. Material and method Retrospective and descriptive study of all patients who underwent endoscopic sinus surgery for the treatment of a sinonasal inverted papilloma between the years 2012 and 2016. Variables analyzed include demographics, signs and symptoms, surgical complications, recurrence rate and malignant transformation. Tumor extension was evaluated with the Krouse staging system on computed tomography imaging. Results This series includes 18 patients, with a mean age of 57.4 years. Clinically, patients presented with unilateral nasal obstruction 72.2% (13/18 patients), followed by rhinorrhea 33.3% (6/18 patients), hyposmia 27.8% (5/18 patients) and epistaxis 27.8% (5/18 patients). Based on the Krouse staging system, 7/18 were T1, 5/18 were T2, 5/18 were T3 and 1/18 was T4 on initial evaluation. On follow-up, 4 patients presented with a recurrence at a mean period of 5.6 months, and one patient exhibited malignant transformation. No surgical complications were observed except for one case of epyphora as a consequence of nasolacrimal obstruction. Conclusions The endoscopic approach was effective for the treatment of sinonasal inverted papillomas.

Abordaje endoscópico transeptal de tumores benignos de cavidades paranasales / Transseptal endoscopic approach of benign tumors of paranasal sinuses

RESUMEN La cirugía endoscópica nasosinusal es un procedimiento frecuente en la práctica otorrinolaringológica, y en la última década se han introducido nuevas técnicas para ayudar a la resección de tumores en regiones tradicionalmente consideradas de difícil acceso. Una de estas técnicas es el abordaje transeptal, que permite el abordaje de la pared anterior y lateral del seno maxilar, así como el trabajo a cuatro manos para el abordaje de estos tumores. El objetivo de esta revisión es describir el abordaje endoscópico transeptal, como técnica complementaria en la cirugía endoscópica de tumores nasales benignos, específicamente de papiloma invertido y angiofibroma nasofaríngeo juvenil.

ABSTRACT Endoscopic sinus surgery is a frequent procedure in Otorhinolaryngology practice, in the last decade new techniques have been introduced to help the resection of tumors in regions traditionally considered of difficult access. One of these techniques is the trans-septal approach, which allows the approach of the anterior and lateral wall of the maxillary sinus, as well as four-handed work for approach of these tumors. The aim of this review is to describe the transeptal endoscopic approach as a complementary technique in the endoscopic surgery of benign nasal tumors, specifically inverted papilloma and juvenile nasopharyngeal angiofibroma.

The analysis of expression of p16 protein in group of 53 patients treated for sinonasal inverted papilloma.

INTRODUCTION: Sinonasal inverted papilloma constitute relevant therapeutic problem due to destructive character of growth, tendency to recur and the possibility of malignant transformation. Therefore, many attempts to identify risk factors for inverted papilloma occurrence have been undertaken, as well as research to find markers that would allow for the earlier detection of tumors and the application of adequate therapy. A widely known risk factor of inverted papilloma is HPV infection. One of the markers of HPV infection and the ongoing effect of this change (although arousing some controversy) is the expression of the p16 protein. OBJECTIVE: The aim of the study was to analyze the correlation between the expression of p16 as a surrogate of HPV infection in analyzed histopathological material and epidemiological variables, recurrences or malignant transformation. METHODS: The retrospective study includes a group of 53 patients (18 women and 35 men) undergoing treatment for sinonasal inverted papilloma in the period of 2002-2012. The intensity of the p16 protein in histopathological material was scored as: 0 - no expression, 1 - diffuse expression (borderline) and 2 - positive expression; or 0 - no expression/diffuse expression (borderline); 1 - positive expression. The Ethics Committee agreement was obtained (1089/12; 245/13). RESULTS AND CONCLUSION: There was no statistically significant relationship between the expression of p16 and the age of patients, cigarette smoking, tumor location, tumor staging according to the Krouse and Cannady classification, the presence of dysplasia or the occurrence of relapse.