Inverted papilloma

Inverted papilloma

1. Inverted papilloma Dr Mohammed Nishad N

2. Papilloma of the nose Definition Benign locally aggressive neoplasm originating from the schneiderian membrane of nasal cavity Male : female 3:1 Age group –30-50

3. Most common site – lateral wall (70%) ethmoid complex septum

4. Papilloma are of three types Fungiform / papillary/ exophytic / everted papilloma Inverted papilloma Cylindrical papilloma

5. Inverted papilloma Schneiderian papillomas Ringertz tumour Transitional cell papilloma Polyp with inverting metaplasia Epithelial papilloma Soft papilloma Papillary fibroma Squamous papillary epithelioma

6. DEFINITION A Benign epithelial neoplasm arising from Schneiderian membrane of nose and paranasal sinuses. The mucosal lining of nose and paranasal sinuses is known as Schneiderian membrane . Papillomas arising from this membrane is very unique in that they are found to be growing inwardly and hence the term inverted papilloma .

7. Inverted papillomas behave like neoplasms , arising from reserve / replacement cells located at the basement membrane of the mucosa due to UNKNOWN stimulus . The resulting thickening of the epithelium assumes an inverting, fungiform or combination growth pattern

8. Depending on the degree of metaplasia varying amounts of respiratory / cylindrical cells may be seen in Schneiderian papillomas . Rarely the papilloma may be composed entirely of cylindrical cells, and hence the term cylindrical cell papillomas is used to describe this subtype.

9. ANATOMIC CLASSIFICATION OF SCHNEIDERIAN PAPILLOMA Inverted papilloma can be classified according to its site of occurrence i.e. Lateral wall and septal papillomas . Septal papillomas remain confined to the nasal septum and may very rarely involve the roof and floor of the nasal cavity. Carcinomatous transformation is rare in septal papillomas & Vice versa in lateral wall papillomas

10. INCIDENCE M > F, 20 to 70 yrs . Mean age is 50 yrs . ETIOLOGY HPV (with mutation of genes) 6,11,16,57b

11. GROSS APPREARANCE 1. Papillary and exophytic . 2. Inverted with inwardly invaginating epithelial growth into underlying stroma . A combination of both patterns also can occur The papillary form/ fungiform papilloma tends to commonly occur in the nasal septum, while the inverted form often occurs in the lateral wall of the nose and sinuses

12. MICROSCOPY Papillary form : epithelial proliferation over a thin core of connective tissue. Inversion of epithelial masses is usually not present . In inverted papilloma of lateral wall – Proliferation of the covering epithelium & extensive finger like inversion in to the underlying stroma of the epithelium When they undergo malignant transformation the stroma is found to be breached . The predominant cell type in these papillomas is epidermoid in nature .

13. Intercellular bridges can be clearly demonstrated. Microscopic mucous cysts can also be identified in both these types. It shows complex , arborescent exoendophytic growth pattern with primary ,secondary & tertiary ramifications in to underlying stroma Keratinisation is very minimal. Excessive keratinisation is very rare, and should prompt the pathologist to other diagnosis like malignant transformation

14. Clinical features Unilateral nasal mass . Commonly fleshy in nature . Sometimes it may occur behind a sentinel nasal polyp It commonly involves the nasal cavity, erodes the medial wall of maxilla and may present inside the maxillary sinus

15. Symptoms: Unilateral nasal obstruction . Nasal bleeding . Nasal discharge . Hyposmia / anosmia Proptosis , diplopia ,if lamina papyracea is breached Reddish ,firm , solitary,friable and granular mulberry /knobby type

16. KROUSE STAGING SYSTEM (1) Tumour confined to nasal cavity with no evidence of malignancy. (2) Tumour involving the ostiomeatal complex, ethmoid sinuses, and/or medial portion of maxillary sinus ,with no evidence of malignancy . (3) Tumour involving the lateral, inferior, superior, anterior, or posterior walls of maxillary sinus, the sphenoid sinus, and/or the frontal sinus with or without involvement of the nasal cavity. (4) All malignant tumours and those tumours with extra nasal and extra sinus extension.

17. Schwals staging T1 –Confined to nasal cavity T2 &T3– Progressive involvement of PNS T4– Tumour extended in to orbit or intra cranial cavity

18. Skolnick et al T1 – Tumour confined to one anatomical site with in the nose T2 – Tumour involves two sites with in the nose T3– Involvement of sinuses T4—Extension outside the nose and sinuses

19. Can get transformed to Transitional cell carcinoma Squamous cell carcinoma Inverted papilloma can coexist with squamous cell carcinoma in 27% (synchronous)

20. Endoscopic view

21. Differential diagnosis Antrochoanal polyp AFRS Esthesionueroblastoma Malignancy

22. Investigation Biopsy –For definite diagnosis CT Scan with contrast –hyper dense areas and calcification (linear). Bony destruction & Erosion of the lateral wall MRI .. Intracranial & extra cranial extension . Enhancing mass with heterogeneous conveluted cerebriform appearance -- characteristic

23. TREATMENT Medial maxillectomy – TOC Approches by 1)endoscopic 2) lateral rhinotomy 3) sublabial midfacial degloving

24. Treatment Choice –surgery with marginal clearance Endoscopic medial maxillectomy Recurrance ..Lateral rhinotomy ( moure”s incision) & Medial maxillectomy + with spheno ethmoidal clearance (en-bloc dissection) depending on extent of tumour

25. Endoscopic medial maxillectomy Indications Inverted Papilloma ( Schneiderian Papilloma ) Benign sinonasal neoplasms arising from the lateral nasal wall or maxillary sinus Highlights: Sinonasal landmarks are identified, including the maxillary sinus ostium , middle & inferior turbinates , and ethmoid roof Attachment of the tumor (stalk) is identified and transected Bulk of the tumor is excised

26. Bone at the base of the tumor (stalk attachment site) is drilled and/or resected in order to clear microscopic disease The entire lateral nasal wall, including the inferior turbinate, is resected At the completion of surgery the maxillary sinus and nose should be a common cavity, enhancing postoperative surveillance for tumor recurrence

27. Keep in mind: If the nasolacrimal duct is transected during surgery, a lacrimal stent is placed to decrease the likelihood of postoperative epiphora . This stent is removed one week after surgery. Postoperative nasal saline irrigations are helpful to clear crusts which commonly form after this surgery

28. Sub cranial approach Lateral rhinotomy is generally reserved if exenteration of the orbit is needed simultaneously BEST Endoscopic Resection Caldwell-Luc or the “limited open approach” was initially used but has fallen out of favour , given the poor visualization and higher rates of recurrence associated with this technique

29. Bone removed & tumor exposed

30. Tumour removed & inicision closed

31. Midfacial degloving approach

32. Thank you