| Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Inverted Papilloma Inverted papillomas represent a difficult challenge to the otolaryngologist. Their etiology is unclear. They are known to have high recurrence rates. They are associated with malignancy and also have locally aggressive growth patterns, which makes them technically difficult to remove. There is also controversy over the appropriate surgical approach for tumor removal. There is a role for radiation therapy. Papillomas differ from inflammatory polyps, which are more common, in that inflammatory polyps are associated with allergic rhinitis and are actually reactive lesions, not a tumor. There is an accumulation of intracellular fluid in the cells, which causes the papilloma. There is a background of inflammatory cells, and as we all know it is associated with asthma and aspirin sensitivity in Sampter's triad. Nasal papillomas are true neoplasms and, while their etiology is unclear, they are known to arise from the nasal respiratory epithelium, which undergoes metaplastic change and proliferation. Dr. Ward first described nasal papillomas in 1854. A year later, Dr. Billroth published two cases, which he termed villiform cancer, which was later found to be inverted papilloma. In 1935, Dr. Cramerson classified papillomas as a true tumor, as opposed to a reactive lesion, which distinguished it from inflammatory nasal polyps. In 1938, Dr. Rings is given credit for coining the term "inverted papilloma" after describing the inversion of the epithelium into the underlying connective tissue. Because of its histological appearance, numerous pseudonyms have been given to inverted papillomas, such as transitional cell tumors, Schneiderian papillomas, papillary carcinoma, villous cancer and cylindrical cell carcinoma. Inverted papillomas arise from the Schneiderian membrane, which is an invagination of the olfactory ectoderm that occurs during the fourth week of embryonic development. The mucosa creates a transitional zone between the endodermally-derived respiratory epithelium of the nasopharynx and keratinizing squamous epithelium with the nasal vestibule. In 1971, Dr. Hyams reviewed 315 cases of nasal papillomas and described three distinct growth patterns: fungiform papillomas, cylindrical papillomas and inverted papillomas. All of these were thought to be derived from the Schneiderian membrane. Fungiform papillomas are clinically distinct from inverted papillomas or cylindrical papillomas. They typically arise in the nasal septum. They have an exophytic growth pattern and do not grow down into the underlying normal stroma. They are almost always associated with human papillomavirus, and unlike inverted papillomas, do not have a tendency to recur. Cylindrical cell papillomas look different from inverted papillomas both grossly and histologically. They have a ragged, beefy appearance and histologically they appear totally different. They are composed of columnar cells. They have a pink cytoplasm, their nuclei are oval or round, and they have many areas of mucin cysts. While they look totally different, both grossly and histologically, they actually act very similar to inverted papillomas. Cylindrical cell papillomas are often included in the literature with Inverted papillomas given their similar clinical behavior. It is important to understand the histology of inverted papillomas since this forms the basis for the problems that we see in their treatment. The specimen is a transverse section through the papilloma and there is a thick epithelium. It is starting to overtake the surrounding connective tissue stroma and you can see a crypt, which always maintains its connection to the nasal cavity. With a high-power view, there is a metaplastic change of the respiratory epithelium where it goes from the basal layer and then a clear or transitional layer, which is why they were termed transitional cell neoplasms. The base of the membrane remains intact. Grossly, inverted papillomas appear more opaque than inflammatory polyps, and this is because they have such a thick epithelial layer. They are commonly located in the nasal cavity and they typically involve an adjacent sinus. The most common location is the middle turbinate, but other common locations include the ethmoid sinus and maxillary sinus. They have even been found in the nasopharynx. Most common symptoms are unilateral and including nasal obstruction, nosebleed and nasal discharge. As in our patient, it was an incidental finding on examination. These tumors are rare. They occur about 0.6 cases per 100,000 per year and they occur approximately 1/25th as often as inflammatory polyps. The average age at diagnosis is 53, but can range anywhere from the pediatric age of 6 to the elderly age of 89. They are known to have a male predominance of approximately 1:3. They are not believed to be associated with smoking. The recurrence rates cited in the literature varies anywhere from 11% to 78%, and this depends a lot on the treatment modality used. They are associated with malignancy, as I mentioned, which was first reported by Dr. Helman in 1970, and later confirmed in several publications. In the literature, there is a range of associated malignancy from 2% to 56%, but 5% to 15% malignancy rates are most generally accepted. Inverted papillomas are more commonly associated with squamous cell carcinomas. There are five types of association. First there is a squamous cell carcinoma that occurs at the same time as the papilloma but in a different location, which is called metachronous squamous cell carcinoma. You can also have focal areas of carcinoma in situ within the inverted papillomas, or primary cancer with areas of inverted papilloma within the cancer. The two most important associations are synchronous lesions, where cancer occurs in the same location at the same time as when you diagnose the inverted papilloma, and malignant transformation. In 1975, Dr. Vrabec showed that malignant transformation can occur. He performed sequential biopsies in the same patient over a 3-year period, and showed a progressive atypia resulting in eventual squamous cell carcinoma. The rate of malignant transformation is much lower than the 5% to 15% overall association with squamous cell carcinoma, most likely in the 1% to 2% range. Because of all of these different associations with cancer, it is important to examine the entire specimen carefully. The symptoms of patients who have an associated cancer have been found to be different than those in patients who present with a benign inverted papilloma. In 1989, Dr. Benninger of Cleveland, Ohio did a retrospective review of 46 patients. Thirty-four of them had inverted papillomas and 12 had squamous cell carcinoma associated with their inverted papillomas. He found statistically significant differences between the two groups of patients. The patients with cancer presented more often with epistaxis, rather than unilateral obstruction, as their main complaint, and there was a shorter time between the time of symptom onset and the time of their diagnosis. He also noted a trend, although not statistically significant, that the patients with squamous cell carcinoma tended to be older, although he admits that older patients are more prone to have squamous cell carcinoma in the first place. In addition to an associated malignancy, inverted papillomas also display a locally aggressive behavior, due to their downward growth pattern into the stroma. This downward growth can cause pressure necrosis on adjacent bony structures. In 1996, Dr. Miller from the New York School of Medicine published a review of the literature from 1962 to 1992, and a case report. He looked for other cases where the inverted papillomas had involved the anterior cranial fossa with or without dural invasion, and did not include any lesions that had any associated malignancy. He reviewed 1469 cases and found 5 other cases, other than his own, in the literature, with the first case being recorded by Dr. Myers in 1981. Dr. Miller's case report was a 42-year-old female, who after treatment of the frontal sinus papilloma by external ethmoidectomy and placement of a nasal frontal duct stent, had followup CT scan six months later after complete resection that showed no evidence of disease. She came back one year after surgery and did not have any complaints. However, on a screening CT scan, she was noted to have erosion of the floor of the anterior cranial fossa. In an MRI you could see the tumor and it looked to be invading the dura of the brain and into the frontal lobe. This patient had bicoronal frontal craniotomy followed by radiation therapy, and was disease free after three years. The second example is by Dr. Jones, from Mount Sinai in New York. He presented a 35-year-old, African-American female who had a history of recurrent inverted papillomas. This patient was referred to him after undergoing three lateral rhinotomies and medial maxillectomy of sinonasal inverted papilloma, all of which occurred during one year. She subsequently developed complete ipsilateral facial nerve weakness and sensorineural hearing loss. While she did not have any recurrent disease at the initial site, she did have disease. On a CT scan there was erosion into the clivus and the carotid canal was gone. On magnetic resonance imaging, the tumor can been seen and had actually encased the carotid artery, involved the calvarium and there was either dura involvement or dural inflammation. This patient had a large resection involving combined infratemporal fossa and temporal craniotomy. Dr. Jones did not give any information on followup. The goal of any work-up is to determine the site of origin of disease and the assess the extent of involvement. This is done through careful history, thorough endoscopic examination and imaging. Computed tomography scan is an excellent diagnostic tool. It is what we use for most sinus pathology; however, you must be aware, that you cannot tell the difference between tumor and secretions on CT scan. On this scan it looks like the tumor involves the whole maxillary sinus, all the ethmoids and the middle turbinate area of the nasal cavity. However, on an MRI you can see that most of the maxillary sinus is actually filled with secretions, as well as part of the ethmoid sinus. So some authors recommend a routine magnetic resonance imaging, at least for more aggressive lesions, to evaluate patients with inverted papilloma. Dr. Sukenik and Casiano at University of Miami published an interesting prospective study that looked at computed tomography scan versus intraoperative endoscopic examination. They found that while CT scan and intraoperative exam had the same sensitivity, intraoperative examination actually had a much higher specificity, basically pointing out that physical examination is a better tool than imaging. The mainstay of treatment is surgery, although radiation therapy can be involved. Traditionally procedures have been either a transnasal procedure with polypectomy or confined transnasal polypectomy with additional sinus procedure, such as Caldwell-Luc. The gold standard was lateral rhinotomy with medial maxillectomy. As understanding of inverted papilloma characteristics emerged, there was a trend toward more aggressive initial surgery. Dr. Phillips best demonstrates this in a study at the Mayo Clinic where he reviewed his own experience from 1944 to 1987, 112 cases. Then DeGreene analyzed his experiences from 1944 to 1974, a 30-year period, which showed the percentage of time that he performed each one of these procedures. He then compared that with a 12-year period from 1975 and 1987, where there was an increase in lateral rhinotomies from about 50% to 75%. His recurrence rates were reported to be 13% for lateral rhinotomy, 35% for transnasal and Caldwell-Luc procedures, and 58% if only a transnasal procedure was performed. Dr. Calcaterra and Dr. Myers reported on their own recurrence rates using lateral rhinotomy approach. Dr. Calcaterra had recurrences in 1 in 19 patients, while Dr. Myers had recurrences in 0 of 13 patients when using the lateral rhinotomy approach with en-bloc excision via medial maxillectomy. He recommended this as the standard of care for patients with inverted papilloma. In fact, Dr. Myers wrote “tumor recurrence is the fault of the surgeon and not due to tumor characteristics.” Dr. Krouse recently did a literature review of 33 studies, including over 1400 patients. He broke down surgical options as aggressive, conservative, and non-endoscopic intranasal. His recurrence rate agreed with those in the previous studies, with 18% for lateral rhinotomy, going up to 67% for a simple intranasal excision. Now we all know that we are always looking to improve surgery, and one way to do that is by improving cosmesis. Some surgeons have looked at replacing the lateral rhinotomy with a mid face degloving procedure. Dr. Dolgin at Case Western reported his results using a mid face degloving procedure versus a lateral rhinotomy. He looked at 23 patients and 14 had a lateral rhinotomy and 9 had a mid facial degloving procedure. His patients who underwent the mid facial degloving procedure actually tended to have more extensive disease than those who underwent a lateral rhinotomy and medial maxillectomy. He also included two patients in the mid facial degloving who had associated squamous cell carcinoma and had similar recurrence rates of 29 and 22%, respectively. Kind of going along the same lines of trying to improve cosmetic results and decrease morbidity, in the early 90’s there was a move toward using endoscopic excision for treatment of these tumors. This came along with improvements not only in endoscopic equipment but also in the resolution of computed tomography scans and MRI. It was thought that endoscopic surgery would provide a cosmetically better result and, in addition, they hoped to avoid the complications associated with a lateral rhinotomy and medial maxillectomy including epiphora, diplopia, lid edema, dacrycystitis and atrophic rhinitis, which can give a patient persistent malodorous discharge, nasal crusting, pain and stenosis. It was thought that patients who undergo endoscopic surgery could be followed closely in the clinic using endoscopy there. The first English literature reporting use of endoscopic surgery for inverted papillomas was done by Dr. Comal out of Cairo University in Egypt. While he was not the first person to do it, he was the first person to publish his results of three cases in the English literature. His patients had unilateral localized disease with limited extension to the sinonasal region, and he noted no recurrence with an average followup anywhere from 12 to 39 months. His study was followed shortly thereafter by Dr. Weitz and Wigen out of Germany where they looked at 51 of their patients; 35 of them underwent an endoscopic Sinus surgery case plus or minus an additional external transoral antrostomy depending upon tumor location. Basically they did endoscopic Sinus surgery on any patient who they thought they could visualize the tumor appropriately with endoscopic technique. This also included revision cases. He compared them to 16 cases, which he did extranasally, and he admits that in general the patients who underwent extranasal approach had larger, more extensive disease, but he noted a similar recurrence rate between the two procedures, 17 versus 19%, with a mean followup of about 4 years. On a recent study by Dr. Han at the Medical College of Wisconsin this year, he reported his experience over the past 15 years of 31 patients, again there were 19 patients treated endoscopically with or without a transoral antrostomy and there were 12 patients to underwent the traditional lateral rhinotomy or mid face degloving procedure and he showed similar recurrence rates of, basically, two patients in th endoscopic Group and one patient in the external group. Finally, Dr. Krause in his review of 1400 cases this year reported a recurrence rate of lateral rhinotomy of 18% and a recurrence of 12% in the endoscopic sinus surgery group. Now the problems with doing a literature review is that there is obviously a selection bias for the endoscopic cases. These cases are usually more localized, are not as extensive and any tumor that was associated with malignancy was usually done through an external approach. He also noted that really there was no standardized staging procedure for inverted papillomas and he suggested his own, which includes, based on the T&M system. The T1 and T2 involves intranasal sites, T3 has extension into the paranasal sinus and T4 would be any tumor that extended beyond the paranasal sinus. When doing an endoscopic technique it is recommended that first you undergo general debulking of the tumor and then you proceed with meticulous sterilization of the tumor margins because, as you can see here, the normal mucosa is here and the inverted papilloma is right next door. We also recommend that you burn the underlying bone with a diamond burr in order to get rid of deep-reaching tumor infiltration. In the case of endoscopic excision, it depends upon how comfortable the surgeon is with their skills and, therefore, there is a lot of controversy as to what extent of tumor can be excised using endoscopic excision. In addition, you want to use an external approach for disease that is not accessible endoscopically, such as Caldwell-Luc for maxillary sinus involvement, and some authors are getting more aggressive with endoscopic technique. Dr. Sukenik and Cassiano reported performing endoscopic medial maxillectomies on their patients. So endoscopic surgery is becoming more widespread for inverted papilloma. However, no author is currently using endoscopic technique if there is an associated malignancy. Now a few words concerning radiation therapy. Radiation therapy can be used as the sole therapy for inverted papilloma or it can be used postoperatively. The absolute indication for radiation therapy is when an inverted papilloma is associated with squamous cell carcinoma. However, the relative indications occur when you are treating just a benign papilloma. There had been anecdotal reports of malignant transformation of inverted papillomas into squamous cell carcinoma, but there had been no proven cases and it is hard to prove that this occurs, given the background setting that there is already a 5 to 15% association with squamous cell carcinoma in inverted papilloma. The patients who should get radiation therapy are those who had advanced incompletely resected or unresectable lesions that are biologically aggressive, or patients where morbidity in resection would be more pronounced that morbidity of tumor radiation. I could not find many papers speaking solely about radiation therapy. Radiation therapy is usually thrown in with other larger case reports; however, Dr. Mendenhall at the University of Florida has two papers; one from 1984 and one from 1990, treating a total of 12 patients. Five of these patients were considered inoperable and seven patients underwent initial debulking procedure with postoperative radiation. Of the five patients who had inoperable disease, four of them have no evidence of disease anywhere from three to eight years with one patient dying from locally recurrent disease. Of the seven patients underwent debulking procedure, all seven patients are now free of disease, at least at the time of the paper, anywhere from 3 to 20 years after treatment. We talked about the pathogenesis being understood. We do not believe it is associated with chronic sinusitis or allergic rhinitis because these conditions are bilateral conditions typically and inverted papilloma usually are unilateral. In addition, a lot of patients who have inverted papillomas do not have allergic rhinitis or chronic sinusitis. I had mentioned that the role of smoking is not associated, but you can find papers that show an association, but I think more papers show that there is not an association then show that there is. Ever since the discovery of inverted papillomas, they have always wondered if there was a viral etiology to these things. We know that papillomas in the larynx, such as RRP is associated with HPV, cervical papillomas of the uterus are associated with HPV, so the question has always been “is human papillomavirus associated with inverted papillomas of the nose?”. More specifically, what role if any does human papillomavirus have in the initial formation of the papilloma, does it cause the papilloma to have more aggressive behavior, or does it induce malignant transformation of benign inverted papilloma into a squamous cell carcinoma. Just a couple of slides in review of human papillomavirus. We all know it is a not envelope DNA virus. There are over 80 types, I think we all know about 6 of them. Human papillomavirus infects squamous epithelial cells and produces a characteristic cytoplasmic vacuole on a process called koilocytosisand here is a koilocyte here just for example. In benign lesions, the viral DNA exists in its circular form and does not get incorporated into the host DNA, but in malignant lesions that viral DNA gets incorporated into the host cell DNA near the site of the cellular proto-oncogenes. The two genes are thought to be involved in malignant degeneration are E6 and E7. The gene E6 encodes a protein, which binds to the P53 tumor suppressor gene, and E7 encodes a protein that binds to the retinal blastoma gene. It is thought through this action that the human papillomavirus can induce malignant transformation of the cells. We all know that type 16, 18, 31, 33 and 35 are associated with malignant type transformation, whereas type 6 and 11 are usually associated with benign lesions. Interferon alpha can be used as a treatment modality for lesions caused by human papillomavirus in other areas anyway. Dr. Respler, Patar and Patar in 1987 published the first study that showed definitive association of human papillomavirus in an inverted papilloma by examining the total DNA from two specimens. They found DNA to HPV type 11 in one of the two specimens. This was followed up by Dr. Randy Weber and Dr. Donovan in 1988. They looked at 21 specimens through M.D. Anderson and found that 16 of the 21 specimens through in situ hybridization techniques stained positive for type 6 or 11. However, if you review the literature, and I have looked at several studies, at how often HPV is found in inverted papillomas, you find mixed results. In these six studies here, totally a 168 specimens, only 18 specimens were found to have HPV associated with them, or 11%. This is contrasted by a publication by Dr. Beck at the University of Michigan in 1985. They looked at 32 inverted papillomas and they used multiple techniques; in situ hybridization, polymerase chain reaction, etc. They were able to detect 20 cases of infection, or 63% of lesions being positive for a type of human papillomavirus. Whether or not there is association there is still unclear. If HPV is present does it induce a malignant degeneration? If you look at the same studies that we looked at before; looking at total number of cancers found were 25 and 168, which goes along with published incidence of cancer with inverted papilloma and 20%, or 5 of these lesions, were found to have human papillomavirus associated with them. They are typically type 16 and 18, but there was incidence of type 11 being found with a cancer. There are no predictors of aggressive behavior for inverted papillomas and that is one of the problems. Even histologic features such as severe atypia do not preclude the inverted papilloma will undergo malignant degeneration. So elucidation of a marker could help in screening surgical planning or postoperative surveillance. The question then remains is does human papillomavirus cause more aggressive behavior. I found this to be a very interesting study, it was the only one I could find like it. Dr. Beck did a followup study to the original 32 patients. What they did is they followed up on these 32 patients who were diagnosed with inverted papilloma to find out if they had recurrence of their disease after treatment. These patients were actually followed up at the University of Michigan. They were able to track down 25 patients. They found that 13, or 52% of the patients had recurrences and all 13 patients had tested positive previously for the presence of human papillomavirus. In addition, three patients that later developed squamous cell carcinoma all contained human papillomavirus DNA. The 12 patients who did not have recurrence, all of them had originally tested negative for human papillomavirus. So this is just one study, but I think it is one study that shows a possible correlation between inverted papilloma behavior and infection with human papillomavirus. Why is there a discrepancy between how much human papillomavirus is found in different studies, with; some studies showing 60% and other studies showing 10%. This has basically been written off to be a technical problem. Either differences in what type of mobilization technique, such as PCR or in situ hybridization and also which kind of probe is used, because DNA probes are less sensitive than RNA probes. In addition, some people use probes that are specific for just one type of HPV, where as other people are using consensus primers, which can detect 30 or 40 different types of HPV. In summary, inverted papillomas cause a problem because of a downward growth into the stroma and this causes locally invasive disease. They can display locally aggressive behavior and they have high recurrence rates depending on treatment modality. There is a known 5 to 15% association with malignancy and I still feel that medial maxillectomy via lateral rhinotomy or mid face degloving approach is still the gold standard of treatment, but that endoscopic excision is becoming more common for selective cases. Case Presentation: J.G. is a 65-year-old male who was initially noted to have an asymptomatic nasal mass on exam. A CT showed the mass arising from the inferior turbinate and a biopsy showed inverted papilloma. An endoscopic medial maxillectomy was originally planned for 12/26/01, but was delayed due to the patient's worsening cardiac status. Bibliography: Bawa R, Allen GC, Ramadan HH. Cylindrical cell papilloma of the nasal septum. Ear Nose Throat J 1995;74:179-181. Beck JC, McClatchey KD, Lesperance MM, Esclamado RM, Carey TE, Bradford CR. 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Arch Otolaryngol Head Neck Surg 1988;114:23-26. Weiner JS, Sherris D, Kasperbauer J, Lewis J, Li H, Persing D. Relationship of human papillomavirus to Schneiderian papillomas. Laryngoscope 1999;109:21-26. Weissler MC, Montgomery MW, Turner PA, Montgomery SK, Joseph MP. Inverted papilloma. Ann Otol Rhinol Laryngol 1986;95:215-221. Winter M, Rauer RA, Gode U, Waitz G, Wigand ME. Inverted papilloma of the nose and paranasal sinuses. Long-term outcome of endoscopic endonasal resection. HNO2000;48:568-572. Grand Rounds Archive | Department Home page BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2005 Baylor College of Medicine
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