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PubMed2000

Development of a staging system for inverted papilloma.

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

Endoscopy↗

PubMed1999

The endoscopic management of sinonasal inverted papillomas.

Sinonasal inverted papillomas are well known for high recurrence rates after surgery and the risk of malignant change. Recurrent disease occurs because of inadequate excision as a result of poor exposure and visualization. For these reasons, aggressive surgery has been advocated-classically a lateral rhinotomy and en bloc medial maxillectomy. Endoscopic techniques have provided excellent visualization and a less invasive approach to these tumours. We describe 18 patients with inverted papillomas treated endoscopically at the Singapore General Hospital since 1993. The presentation, sites of involvement and diagnostic imaging are presented. All the patients had a minimum follow-up of 18 months with a mean of 32.8 months. One case of recurrence at the frontal recess is reported. Endoscopic management is appropriate for the diagnosis, follow-up and treatment of circumscribed primary and recurrent inverted papillomas.

Endoscopy↗

PubMedDate not supplied

[Four new cases of urothelial inverted papilloma].

Urothelial inverted papilloma account for 2.2% of all urothelial tumours. The preferred location is the bladder; they occur singly and are generally benign, although the majority of authors agrees in treating this entity as a tumour of low aggressiveness. The report contributes four cases of inverted papilloma, three in male patients and the fourth in a female. One was located in the renal pelvis. A revision is made of the etiology, clinical signs and symptoms, diagnosis and treatment, as well as their relationship to surface carcinoma, as it occurs asynchronously in one of the cases described.

Adult↗

PubMed2000

Inverted papilloma.

BACKGROUND: Inverted papilloma, a benign sinonasal lesion, constitutes 0.5% to 4% of all nasal tumors. Its local aggressiveness, high recurrence rate, association with malignancy or malignant transformation, and tendency toward multicentricity lead most physicians to advocate radical surgery. Nonetheless, conservative surgery is effective for selected patients with limited disease. This study was done to reassess the efficacy of both radical and conservative surgery. METHODS: The records of all patients with the diagnosis of inverted papilloma treated at the Taipei Veterans General Hospital between January 1986 and October 1998 were collected. A minimal follow-up period of 12 months was required for inclusion in the study. Clinical manifestations, radiologic findings, methods of treatment, pathology reports and recurrence rates were all retrospectively reviewed. RESULTS: Sixty patients with an average age at diagnosis of 58 years were studied. The follow-up period ranged from 12 to 195 months, with a mean of 43 months. The most common presenting symptom was unilateral nasal obstruction. The duration of symptoms ranged from one month to 30 years, with a mean of 36 months. The lateral wall and middle meatus were the most commonly involved sites. Bone erosion and intracranial or intraorbital extension were observed in some patients. Medial maxillectomy was the most common surgical treatment, followed by functional endoscopic sinus surgery and the Caldwell-Luc operation. The overall recurrence rate was 23%, with an average interval from initial treatment to recurrence of 42 months (range, 2-93 months). The recurrence rates for the two groups undergoing medial maxillectomy and conservative surgery were 16% and 27%, respectively. CONCLUSIONS: Early diagnosis relies on high suspicion and biopsy. The treatment modality is related to the location and extent of the disease, which is assessed by preoperative imaging studies. Any tumor with extensive involvement of the sinuses or inaccessibility to the endoscope should be treated with traditional medial maxillectomy for best control. The endoscopic technique is good for preoperative biopsy and follow-up.

Adult↗

PubMed2006

Radiographic and histologic analysis of the bone underlying inverted papillomas.

INTRODUCTION: Inverted papilloma (IP) is a benign but locally aggressive sinonasal tumor. Those localized to the maxillary sinus or medial maxillary wall have classically been removed through an external approach. In recent years, endoscopic removal has been advocated as an effective, minimally invasive approach. Successful endoscopic management is based on accurate intraoperative identification and complete resection of the tumor. The surgical management of the bone underlying the surface of an IP is less clearcut. Controversy exists as to whether the bony undersurface of an IP should be removed. In this article, histopathologic specimens and preoperative radiologic studies are prospectively examined to better understand the involvement of the bone underlying an inverted papilloma. MATERIALS AND METHODS: A prospective study of patients with maxillary sinus IP treated with endoscopic or endoscopic-assisted resection over a 12-month period was conducted. Intraoperatively, the site of tumor attachment was identified, and a 1- to 2-cm wedge of bone with overlying tumor was removed en bloc and analyzed under light microscopy. Preoperative radiographic studies were analyzed with respect to bony changes in the area of the tumor pedicle. RESULTS: On histopathologic analysis, the bony surface underlying the IP was irregular with multiple bony crevices in all nine cases. In two cases (22% of specimens), an isolated rest of normal-appearingsalivary gland and/or mucosal tissue was seen embedded in the underlying bone. Radiographic osteitic bony changes were seen at site of tumor attachment in 100% of cases. CONCLUSION: The irregularity of the bony surface may hinder complete tumor removal because microscopic rests of mucosa can be hidden within the bony crevices. Intraoperative removal of the bony surface at the site of tumor attachment may ensure a more complete removal.

Adult↗

PubMed1985

Inverted papillomas of the urinary tract. A case of multiple, recurring inverted papillomas of the renal pelvis, ureter and bladder associated with malignant change.

A case of multiple, recurring urothelial inverted papillomas is reported with localization in the bladder, ureter and renal pelvis. Association of several of these with areas of transitional cell tumours and final occurrence of pure transitional cell tumour of papillary and non-papillary type grade II, causes us to question the original concept of inverted papillomas as benign tumours and lean to the more recent concept of inverted papillomas representing precancerous lesions.

Humans↗

PubMed2006

Natural history of urothelial inverted papilloma.

BACKGROUND: Inverted urothelial papilloma is an uncommon urothelial neoplasm. Although it is traditionally regarded as a benign tumor, conflicting data on multiplicity, recurrence rate, and association with urothelial carcinoma have left uncertainties concerning its biologic behavior. METHODS: The authors analyzed the clinicopathological characteristics of 75 cases of inverted papilloma in the urinary tract without prior or concurrent urothelial carcinoma to determine its biologic behavior and prognosis, and to correlate these findings with surveillance strategies. RESULTS: These patients ranged in age from 26 to 85 years (mean, 60 years). Of the 46 patients for whom tobacco use history was available, 28 gave a history of smoking. Inverted papillomas were located in the urinary bladder (67 cases), prostatic urethra (4 cases), and ureter (4 cases). The majority of vesical tumors arose from the trigone or near the bladder neck. Common presenting complaints included hematuria, dysuria, and irritative voiding symptoms. In 1 case of vesical inverted papilloma, there was a recurrence. All other patients were free of tumor recurrence or progression during a mean follow-up of 68 months (range, 2-240 months). CONCLUSIONS: Both the extremely low incidence of tumor recurrence (1%) and strikingly favorable prognosis suggest that inverted urothelial papilloma, when diagnosed according to strictly defined criteria, is a benign urothelial neoplasm not related to urothelial carcinoma. Therefore, complete transurethral resection of inverted papilloma is adequate surgical therapy, and surveillance protocols as rigorous as those employed in the management of urothelial carcinoma seem unnecessary.

Adult↗

PubMed1993

[The histogenesis and malignant transformation of inverted papilloma on the sino-nasal cavity--in comparison with inverted papilloma on the urinary bladder].

Inverted papilloma on the sino-nasal cavity (IP on SN) is a rare benign tumor. However, local recurrence and distant metastasis do occasionally occur. The histogenesis and histological prospects for the biological behavior of this tumor are still unknown. To clarify these issues, we histologically studied 25 cases of IP on SN and 10 cases of IP on the urinary bladder (IP on UB), which were biopsied or resected in the National Shikoku Cancer Center Hospital. Since, with regard to aspects of histogenesis such as metaplasia, dysplasia and malignant transformation, there were some similarities and differences between these two benign tumors. Biopsied or resected specimens were microscopically examined with hematoxylin-eosin (HE), periodic acid-Shiff (PAS), and Azan stains. Sixteen of 25 IP on SN presented a typical inward growth Pattern and 9 cases were simultaneously associated with an exophilic proliferation pattern. In cases of IP on UB, a typical inverted growth Pattern was observed in 3 cases. Seven of 10 IP on UB showed a complex of inward and exophilic patterns. Subsequently, we focused on metaplasia of IP, probably caused by certain physiological, chemical and inflammatory stimuli. All IP on SN bore squamous metaplasia and 5 cases simultaneously showed features of transitional metaplasia. Often, these two types of metaplasia were observed in the submucosal glands. In IP on UB, 7 of 10 cases showed squamous metaplasia and 9 cases presented intestinal metaplasia. These metaplastic changes were also found in Brunn's nest. Furthermore, the metaplastic epithelium in 24 IP on SN demonstrated stratified proliferation, atypical nuclei and/or mitosis which were considered to be evidence of malignancy. In fact, 9 of 25 IP on SN partially contained a component of squamous cell carcinoma and 7 cases out of 10 IP on UB showed features of transitional carcinoma in a portion of the papilloma lesion. This evidence suggests that both IP on SN and IP on UB originate in submucosal glands, specifically exocrine glands in the sino-nasal region and Brunn's nest in the urinary bladder. Also, in these glands, metaplastic change was commonly seen, and occasionally revealed malignant features such as squamous cell carcinoma in the sino-nasal cavity and transitional carcinoma in the urinary bladder. We finally concluded that the process of growth and the mechanism of malignant transformation might be similar between IP on SN and IP on UB and metaplastic change might play an important role in the malignant transformation of IP on SN and IP on UB.

Adult↗

PubMedDate not supplied

Challenges in the management of sphenoid inverted papilloma.

BACKGROUND: Inverted papilloma (IP) arising in the sphenoid sinus is extremely rare. Management of sphenoid sinus IP is especially challenging because of the paucity of sinonasal symptoms on presentation and the inherent surgical risks associated with the anatomic location of the sphenoid sinus. METHODS: We performed a retrospective review of medical records of all patients with IP arising within the sphenoid sinus. RESULTS: A total of five patients were identified. All patients were managed with endoscopic resection. The most common presenting symptom was headache (three patients). The mean follow-up period was 37.6 months (range, 10-79 months). Two patients with erosive skull base lesions adjacent to the internal carotid artery were managed with a staged endoscopic resection. Only one patient developed a recurrence after 38 months and underwent revision endoscopic resection. CONCLUSION: Endoscopic management of sphenoid IP allows maximal resection with minimal morbidity and facilitates endoscopic postoperative surveillance. Complete preoperative radiological assessment of tumor extent is essential. Preoperative medical therapy can help normalize inflamed mucosa and minimize intraoperative bleeding. For large erosive IP, surgical risks may be minimized by considering a staged resection and using computer-aided surgery.

Adult↗

PubMed1992

[Inverted papilloma of the nose. Apropos of a case associating polyps and an inverted papilloma of the nose].

In this article is presented a case report of a 59 years old woman with a medical history of recurrent nasal polyps (from 20 years ago). This woman presented an inverted papilloma in the middle meatus of the lateral wall of the nasal cavity simultaneously with the nasal polyps, and she was faced with surgical intranasal removal. The patient, two years later, presented again nasal polyps, but without any indication of the recurrence of the inverted papilloma. It is noticed the value of the local surgical removal of the inverted papilloma in patients who do not present extensive tumors.

Female↗

PubMed1989

Multiple simultaneous inverted papillomas of the upper urinary tract. A case report with a review of ureteral and renal pelvic inverted papillomas.

An asymptomatic 73-year-old woman was found to have multiple, simultaneous, inverted papillomas of the renal pelvis and ureter. A review of the world literature yielded 34 cases of inverted papillomas in the upper urinary tract: 13 in the renal pelvis, and 21 in the ureter. Among these 34 cases, there were 26 male and five female patients, with gender not given for three others. Patients ranged in age from 19 to 89 years (mean, 64.1 years). Many cases lacked complete clinical details but, among the others, gross painless hematuria was the presenting symptom in seven; hematuria with flank pain or colic in six; and pain without hematuria in six. Only six patients lacked urinary tract symptoms, and three of these had microscopic hematuria. Only two patients had more than one inverted papilloma, and these were not multicentric. Adequate pathologic documentation and follow-up data were, unfortunately, absent in many of the cases. Although inverted papillomas are curable with surgical resection, with a low rate of local recurrence, they appear to be associated with synchronous or asynchronous carcinomas, especially other transitional cell tumors in the urinary tract.

Aged↗

PubMed1978

Inverted papilloma and papillary transitional cell carcinoma of urinary bladder: report of four cases of inverted papilloma, one showing papillary malignant transformation and review of the literature.

Four new cases of inverted urothelial papillomas are described and added to the 47 cases previously reported in the literature. Three papillomas present benign gross and microscopic characteristics. The fourth case, however, demonstrates inverted papilloma and papillary transitional cell carcinoma in a single polypoid lesion. This papillary malignant transformation, not previously observed in inverted papillomas, cautions against overconfidence in benign nature of inverted papilloma.

Aged↗

PubMed2006

Endoscopic management of inverted papilloma.

PURPOSE OF REVIEW: Inverted papillomas are uncommon benign tumors that may occur in the sinonasal tract. Because of their tendency towards recurrence and their potential for malignant transformation, complete en bloc resection has been the standard treatment modality. With the application of minimally invasive surgical techniques in the management of sinonasal disease processes, transnasal endoscopic removal of inverted papillomas is gaining in acceptance. The following represents a review of the current literature regarding sinonasal inverted papilloma and its clinical management. RECENT FINDINGS: The recent literature has further refined the technique of endoscopic resection of inverted papillomas by delineating essential principles and applying new technologies, such as image guidance and angled endoscopic drills. Modified approaches and methodology have been described to address tumors originating in particular anatomic locations. At the same time, new information relevant to the diagnosis and surveillance of inverted papillomas has been published, regarding the role of imaging, serum tumor markers, and human papillomavirus. SUMMARY: Growth in experience with the endoscopic management of inverted papillomas has led to evolving technical improvements and innovations. In most tumor locations, the completeness of resection achieved by a skilled endoscopic surgeon is equivalent, if not superior, to that attained with an open approach. In some instances, an endoscopic exploration with tumor resection may help define the site of tumor attachment and direct adjunctive open procedures when indicated. Long-term outcomes studies with sizeable patient cohorts will be needed to define the role of various surgical strategies in the optimal management of inverted papilloma.

Antigens, Neoplasm↗

PubMed1992

Conservative endoscopic surgery in inverted papilloma. Preliminary report.

Inverted papilloma is noted for recurrence and occasional association with malignancy, leading most authors to recommend lateral rhinotomy as the initial surgical approach in all cases; however, conservative surgery has been reported to be effective in selective cases. Endoscopic control was used in the surgical treatment of three cases of inverted papilloma. In all three cases, the lesions were unilateral and localized, with limited extension into the sinonasal region, and they were not associated with malignancy or recurrent (as proved by endoscopy, computed tomography, and histopathologic examination). Total removal of the mass was achieved through a conservative intranasal approach. Endoscopic follow-up for periods ranging between 12 and 39 months, with an average of 23 months, failed to identify any recurrence. These findings point to the feasibility of applying this conservative endoscopic approach for total excision of limited lesions of inverted papilloma.

Adult↗

PubMed2005

Markers of malignant transformation of sinonasal inverted papilloma.

AIM: To measure HPV status, epidermal growth factor receptor (EGFR) and transforming growth factor-alpha (TGF-alpha) expression and Ki-67 index in exophytic papilloma (EP), inverted papilloma (IP) with dysplasia, IP with carcinoma and invasive squamous cell carcinoma (SCC). METHODS: Forty-four patients with sinonasal papilloma and invasive SCC were selected. The nasal tissues were stained with monoclonal antibodies to EGFR, TGF-alpha and Ki-67. The results were analysed using quantitative immunohistochemical analysis. In situ hybridization studies for HPV DNA for 6/11, 16/18 and 31/33 were also performed on the tissue. RESULTS: Significant increase of EGFR and TGF-alpha was observed in IP with severe dysplasia, IP with carcinoma and invasive SCC compared to IP with mild dysplasia and control nasal mucosa. And a serial upreguration in terms of Ki-67 index in IP with dysplasia was observed. Among IP, HPV 6/11-positive was present in 42% tumour and HPV 16/18-positive was present in 31% of tumours. Among HPV 6/11 and 16/18-positive IP, significant increase of EGFR and Ki-67 index were observed. CONCLUSION: Pre-cancerous lesions of IP exhibited elevated levels of EGFR and TGF-alpha and these expression may be associated with early events in IP carcinogenesis. HPV infection may be an early event in a multistep process of malignant formation of IP.

Antibodies, Monoclonal↗

PubMed1993

[Cytokeratins in inverted papillomas of the urinary bladder. (Part 1.)].

Inverted papilloma (transitional cell papilloma, inverted type) is a rare, benign urothelial tumor. The distribution of cytokeratin (CK) expression in 22 cases was investigated and compared with normal urothelium and urothelial carcinomas: CK7/8, basal increased positivity; CK13, diffuse positivity; CK18, loss of intensity and loss of umbrella cell staining; CK19, reduction of positivity; CK20, reduction of umbrella cell staining. The data indicate that the inverted papilloma is a basal cell urothelioma.

Biomarkers, Tumor↗

PubMed1988

Cutaneous inverted papillomas in dogs.

Inverted papillomas of the skin occurred in five dogs. Lesions were 1-2 cm, circumscribed, flask-like structures below the level of the surrounding normal skin. Walls of the structures consisted of hyperplastic epidermis, forming thin papillary projections on thin fibrovascular stalks. Cells in the stratum granulosum had clear cytoplasm, numerous keratohyalin-like granules of various sizes, and poorly defined intranuclear inclusions. These cells stained positively for papillomavirus group-specific antigens by both the peroxidase-antiperoxidase and avidin-biotin methods. Virions with a mean diameter of 35.7 nm were present within nuclei in cells of the stratum granulosum when examined by electron microscopy. In situ DNA hybridization, using a canine oral papillomavirus probe, localized papillomavirus DNA in canine oral papillomas, but not in canine cutaneous squamous or inverted papillomas, suggesting that a different papillomavirus type was present in the latter lesions. Although these lesions resembled intracutaneous cornifying epitheliomas (keratoacanthomas), they appear to be a distinct lesion, probably with a different etiology.

Animals↗

PubMed2006

Inverted papillomas of the prostatic urethra.

Inverted papillomas of the genitourinary tract are uncommon benign neoplasms usually occurring in the urinary bladder and less frequently in the upper urinary tract. To date, there are scant data and no comprehensive studies of inverted papilloma originating in the prostatic urethra. We identified 21 cases and evaluated their demographic, clinical, and histopathologic features. Patients had a mean age of 65.1 years (range: 30 to 89 y), with 10/21 (47.6%) presenting with gross hematuria (n = 8) or irritative symptoms (n = 2) related to the inverted papilloma and 11/21 (52.4%) detected incidentally during work-up/treatment of prostate cancer (n = 6) or benign prostatic hypertrophy (BPH) (n = 5). Fourteen cystoscopically evaluated lesions measured 0.1 to 2.0 cm, and were described as polypoid (n = 9), papillary (n = 4), or an enlarged median lobe (n = 1). Lesions were diagnosed on transurethral resection (n = 8), biopsy/polypectomy targeted to the lesion (n = 6), radical prostatectomy for prostate cancer (n = 4), or biopsy unrelated to the lesion (n = 3). Histologically, 14/21 cases (67%) displayed classic inverted papilloma architecture. The remaining cases showed foci of squamous metaplasia with moderate atypia (n = 4), rare true papillary fronds in a classic inverted papilloma background (n = 2), or both (n = 1). Eleven cases with prostatic tissue revealed adenocarcinoma of the prostate [n = 6; Gleason score 6 (n = 3) or 7 (n = 3)], high-grade prostatic intraepithelial neoplasia (n = 1), benign prostatic hypertrophy (n = 3), or adenosis (n = 1). No patients had a prior history of either inverted papilloma or urothelial carcinoma, whereas 2 patients were diagnosed with high-grade urothelial carcinoma of the bladder synchronous with their inverted papilloma diagnosis. Only 1 of the 18 patients with available follow-up had a recurrence of inverted papilloma in the prostatic urethra. None of the other patients had local recurrences or recurrences at other locations in the urinary tract (mean follow-up 39.9 mo; range: 3 to 120 mo). Inverted papillomas of the prostatic urethra are benign lesions that are commonly detected incidentally and are not associated with a history of urothelial malignancy. Although urothelial carcinoma elsewhere in the genitourinary tract may occur simultaneously, malignant transformation or recurrence as a malignant lesion has not been identified in inverted papilloma of the prostatic urethra.

Adenocarcinoma↗