European Annals of Otorhinolaryngology, Head and Neck diseases 133 (2016) 337–341

Available online at
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Review

Sinonasal inverted papilloma: From diagnosis to treatment

∗
Q. Lisan , O. Laccourreye , P. Bonfils
Service d’ORL et de Chirurgie Cervico-Faciale, Hôpital Européen Georges Pompidou, Faculté de Médecine Paris Descartes, Université Paris V, 20 Rue Leblanc,
75015 Paris, France

A R T I C L E I N F O A B S T R A C T

Keywords:
Inverted papilloma is a rare sinonasal tumor that mainly occurs in adults during the 5th decade. Three
Inverted papilloma
characteristics make this tumor very different from other sinonasal tumors: a relatively strong
Sinonasal tumor
HPV
potential for local destruction, high rate of recurrence, and a risk of carcinomatous evolution. Etiology
Endonasal endoscopic surgery remains little understood, but an association with human papilloma virus has been reported in up to 40%
Squamous cell carcinoma of cases, raising the suspicions of implication in the pathogenesis of inverted papilloma. Treatment of
choice is surgery, by endonasal endoscopic or external approach, depending on extension and tumoral
charac- teristics. Follow-up is critical, to diagnose local relapse, which is often early but may also be
late. The seriousness of this pathology lies in its association with carcinoma, which may be diagnosed
at the out- set or at recurrence during follow-up. It is important to diagnose recurrence to enable early
treatment, especially in case of associated carcinoma or malignancy. A comprehensive review of the
international lit- erature was performed on PubMed and Embase, using the following search-terms:
“sinonasal” [All Fields] AND (“papilloma, inverted” [MeSH Terms] OR (“papilloma” [All Fields] AND
“inverted” [All Fields]) OR “inverted papilloma” [All Fields] OR (“inverted” [All Fields] AND “papilloma”
[All Fields])). We reviewed all articles referring to sinonasal inverted papilloma published up to
January 2015. The present article updates the state of knowledge regarding sinonasal inverted
papilloma.
© 2016 Elsevier Masson SAS. All rights reserved.

1. Introduction
up to January 2015 were read and analyzed; relevant articles were
identified and read in full.
Inverted papilloma (IP) was first described in 1854. It is a
tumor of the nasal cavities and paranasal sinuses, with 3 main
charac- teristics that distinguish it from other sinonasal tumors: 3. Epidemiology – etiology
relative local aggression, high rates of recurrence, whether early
or late, and possible association with carcinoma, diagnosed IP is a benign sinonasal epithelial tumor categorized under
initially or at recur- rence. The present study updates the state of sinonasal Schneiderian papilloma. On the World Health Organiza-
knowledge, focusing on epidemiology, diagnosis and assessment. tion (WHO) 2005 classification, Schneiderian papilloma comprises
inverted, oncocytic and exophytic papilloma, with rates of 62%,
6% and 32%, respectively, among sinonasal papillomas [1].
2. Methods
IP rates in sinonasal cavity tumor range between 0.4% and 7%
[ 1 ] . Incidence ranges between 0.2 and 1.5/100,000 per year [2–
An exhaustive review was conducted on the international
4]. Sex ratio ranges between 2 and 5 males to 1 female [1]. The vast
literature on PubMed and Embase, using the following search-
majority of IPs occur in adults, with a mean age at diagnosis of 55
terms: “sinonasal” [All Fields] AND (“papilloma, inverted” [MeSH
years [2,5].
Terms] OR (“papilloma” [All Fields] AND “inverted” [All Fields])
IP etiology is as yet unknown. Certain hypotheses have been
OR “inverted papilloma” [All Fields] OR (“inverted” [All Fields]
suggested, but causality has never been established for the sus-
AND “papilloma” [All Fields])). The only restriction was to articles
pected factors: smoking, allergy or certain occupational exposures
pub- lished in English or in French. Abstracts of all articles
[3]. Recurrence and carcinomatous potential have for many years
published
suggested viral origin. An implication of Epstein–Barr Virus (EBV)
has been studied, but inconclusively [1]. For more than 30 years,
∗ Corresponding author. Tel.: +33 01 56 39 34 72.
human papilloma virus (HPV) has been suspected of playing a
major role in the pathophysiology of IP, but the literature data
E-mail address: pierre.bonfils@aphp.fr (P. Bonfils).
remain

http://dx.doi.org/10.1016/j.anorl.2016.03.006
1879-7296/© 2016 Elsevier Masson SAS. All rights reserved.
 Q. Lisan et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 133 (2016) 337–341
33
contradictory. The main studies and meta-analyses of recent years
show HPV rates varying between 17% and 38%, with ranges from
0% to 70% in individual series [6–8]. This great variability
between reports can be attributed neither to differences in
detection method nor to differences in the geographical origin of
the series, but rather to histologic differences (dysplasia grades)
between series [6,8]: HPV seems significantly more frequent in IP
showing severe dys- plasia or associated carcinoma than in IP with
no or mild dysplasia: 55% versus 22%, respectively; p < 0.02 [8].
HPV integration in the cell genome induces overexpression of
oncoproteins E6 and E7, which deactivate cell-cycle regulators
such as p16, p21, p27, p53, cyclin D1 or retinoblastoma gene (Rb)
pro- tein [9,10], of which p53 and p21 have been most widely
studied. According to several reports, p53 is found in IP associated
with carcinoma and not in benign IP or healthy mucosa [7,9].
Differ- ent mechanisms are thought to be associated: p53 gene
mutation or increased degradation of normal p53 protein, both
reducing the tumor-suppression action of p53. p21 mediates cell-
cycle arrest in phase G1, and is induced by p53. A recent meta-
Fig. 1. Histologic cross-section of sinonasal inverted papilloma. Invagination of
analysis found p21 overexpression in 67% of IPs associated with
superficial epithelium into underlying stroma (black asterisks).
carcinoma and almost never in healthy mucosa; but it was also
found in 63% of benign IPs [7]. Relations between HPV, p53 and
p21 and their involve- ment in the oncogenesis of malignant
factors for synchronous carcinoma have not been identified;
tumors associated with IP are strongly suspected but yet to be
smoking is suspected: there was a single study reporting a sig-
fully elucidated [7].
nificant correlation between smoking and synchronous carcinoma
The HPV 6 and 11 serotypes are more frequently found in
benign (OR = 12.7; p < 0.001) [20].
IP, and the 16 and 18 serotypes (associated with high oncogenic Radiologic assessment has two main objectives: precise deter-
risk) in IP with associated high-grade dysplasia or carcinoma [7,8]. mination of tumor extension, and location of the tumor site. Sinus
However, many studies are contradictory, and levels of evidence CT is systematic. The aspect on CT is non-specific, with an iso-
are generally insufficient to establish a clear line of causality dense unilateral homogeneous lesion generally centered on the
[1,6,8]. Thus, HPV is very probably involved in IP pathogenesis, but meatus nasi medius. Microcalcifications within the lesion are
present data provide no certainty as to its precise role [1]. found in about 20% of cases, and guide diagnosis [21]. Bone
erosion is fre- quent. IP may be associated with CT images, such as
bone lysis, suggestive of malignancy, but biopsy is essential to
4. IP diagnosis and assessment guiding treat- ment [1,5]. In case of synchronous carcinoma, the
destruction of the osseous infrastructure is greater than in benign
IP is generally diagnosed at a late stage, 1–4 years after first IP [22]. There may be focal hyperostosis, which several authors
onset of sinonasal symptoms [11,12]. Functional signs are non- take as predict- ing the IP implantation site, with a positive
specific, nasal obstruction, anterior and/or posterior rhinorrhea, predictive value (PPV) of 89–95%, depending on reports [23,24].
headache, hyposmia or anosmia, epistaxis, or facial pain. In 4– CT, however, fails to dif- ferentiate the lesion from the surrounding
23% of cases, the lesion is asymptomatic and discovered inflammation or from retention phenomena, and thus is not
serendipitously [11,13]. Clinical examination by endoscopic sufficient in itself, over- estimating lesion size and not allowing
exploration of the nasal cavities finds a reddish-gray lobulated adequate preoperative planning.
tumor, more firm than an inflammatory polyp, with a fairly MRI is now systematic as a complement to CT. On T1-weighted
characteristic “raspberry” aspect sequences, the lesion shows in hyposignal. After contrast-medium
[1]. On palpation, IPs are classically friable and bleed on contact. injection, there is intense and often homogeneous uptake. The
Pathologic examination is essential to diagnosis [10,14,15]. IP tumor shows an aspect of cerebriform circumvolutions, typical of
may coexist with an inflammatory process showing inflamma- IP; the same aspect is found on T2-weighted images, strongly ori-
tory polyps. This accounts for the false negative rates of up to enting diagnosis (Fig. 2) [25,26]. The cerebriform aspect is related
17% on biopsy reported in the literature, diagnosing inflamma- to the invagination found on pathologic examination; its focal or
tory polyp [12,16], due to insufficient sampling, restricted to the total disappearance suggests synchronous carcinoma [25]. On T2-
polyps and not the papilloma. In case of unilateral polyp, sinonasal weighted sequences, the tumor is generally iso- or hypo-intense
tumor, and IP in particular, should always be suspected; one study compared to the normal mucosa [21,26]. In one study, the PPV
reported 16% incidence of IP in patients with a unilateral polyp of MRI in diagnosing IP was estimated at 70–90%, with negative
[17]. One objective of pathologic examination is to rule out associ- predictive value (NPV) of 93–100% according to location [27].
ated carcinoma, which affects treatment strategy. Microscopy finds Several IP classifications have been published. In 2000, Krouse
invagination of the superficial IP epithelium into the underlying developed a classification based on tumor extension assessed on
stroma, whence the term “inverted” in this type of papilloma. The radiology [28] (Table 1). Although this classification has not been
epithelium may be of the keratinized squamous, respiratory or proved superior to others in terms of prognosis or therapeutic
transitional types (Fig. 1), which may coexist in varying propor- decision-making, it has the advantage of being simple to imple-
tions [1]. The basal membrane is intact, separating the ment and reproducible, and is therefore the most widely used in
hyperplastic inverted epithelium from the underlying stroma, the international literature, facilitating comparison between the
which is also nor- mal [11]. Exo- and/or endophytic components results of different studies. Other less widely used classifications
may be sometimes found within the IP. Various degrees of are those of Han (2001), Kamel (2005), Cannady (2007) and Drag-
hyperplasia are observed, in up to 10% of IPs [1]. These signs do onetti (2011). Associated carcinomas are staged according to the
not necessarily indicate carcinoma, but alert the pathologist to TNM system of the American Joint Committee on Cancer.
closer examination. Syn- chronous carcinoma is found in a mean
7% of cases [18,19]. The most frequent histologic type is
squamous cell carcinoma. Risk

Fig. 2. T2-weighted MRI, coronal slice. Inverted papilloma involving maxillary sinus,
ethmoid and right nasal cavity, with aspect of cerebriform circumvolutions.
Table 1
Krouse classification, from [28].
Krouse staging system for inverted papilloma
T1 Tumor totally confined to the nasal cavity, without
extension into the sinuses. There must be no concurrent
malignancy.
T2 Tumor involving the ostiomeatal complex, and ethmoid
sinuses, and/or the medial portion of the maxillary sinus,
with or without involvement of the nasal cavity. There must
be no concurrent malignancy.
T3 Tumor involving the lateral, inferior, superior, anterior, or
posterior walls of the maxillary sinus, the sphenoid sinus,
and/or the frontal sinus, with or without involvement of the
medial portion of the maxillary sinus, the ethmoid sinuses,
or the nasal cavity. There must be no concurrent malignancy.
T4 All tumors with any extranasal/extrasinus extension to involve
adjacent, contiguous structures such as the orbit, the
intracranial compartment or the pterygomaxillary space. All
tumors associated with malignancy.
5. Treatment of sinonasal inverted papilloma
IP treatment is surgical, with the main aims of relieving symp-
toms and enabling pathologic examination of a complete specimen,
notably to check for carcinoma.
Preoperative medical treatment associating antibiotic therapy
and corticosteroids is often prescribed, to reduce existing inflam-
mation and intraoperative bleeding so as to improve conditions for
surgery, although no conclusive data are available on this point.
Until the mid-1990s, the gold-standard was surgery on
an external approach: usually paralateronasal with associated
medial maxillectomy [2,10]. Endoscopic treatment for IP was
first described in 1992 by Waitz and Wigand, and by Kamel
in the same year [29,30], and is now for many authors the
new gold-standard [15,31,32]. However, endonasal endoscopic
approaches are indicated only for tumors of limited extension, and
an external or combined external/endoscopic approach remains
indicated for certain locations. These comprise, firstly, large
frontal sinus involvement, especially when lateral [4,13–15,31–
33]. Most authors use an external approach with frontal
osteoplas- tic flap; some begin with a Draf type-III procedure,
completed by frontal osteoplastic flap if control seems
insufficient with the
Table 2
Surgical approach according to tumor extension, following [4,12–15,29,31–
34,36]. Involvement Suggested surgical approach
Septum Endonasal endoscopic
Lateral wall of nasal cavity
Anterior or posterior
ethmoid
Sphenoethmoid and sphenoid spaces
Maxillary sinus (medial, superior or
posterior wall)
Frontal space and frontal sinus
(limited medial involvement)
Lateral wall of frontal sinus Endonasal endoscopic + frontal
osteoplastic flap (e.g.,
bicoronal approach)
Maxillary sinus (anterior, inferior
Endonasal
or lateral wall)
endoscopic + Caldwell-Luc
approach
Extrasinus extension
External (e.g., paralateronasal
Associated carcinoma
approach)
endoscopic approach [34]. The frontal sinus should never be
filled during surgery, as this prevents follow-up and recurrence
is diagnosed at a later stage. Secondly, in most cases of lateral,
inferior or anterior maxillary sinus wall involvement [4,13,31–34],
a combined endoscopic/Caldwell-Luc approach is used [4,32–34],
although some authors consider that endoscopic medial maxil-
lectomy allows control of any kind of maxillary sinus lesion [35].
Thirdly, an external or combined external/endoscopic approach is
indicated in case of extrasinus involvement [ 1 2 , 3 2 ] and,
fourthly, in case of associated carcinoma [29,36]. Table 2 presents
these indications. Overall, an external or combined
external/endoscopic approach should be considered whenever
total endoscopic con- trol of the IP appears impossible. When an
external approach is required, it is most commonly
paralateronasal, frontal superciliary or bicoronal with frontal
osteoplastic flap [4,31–33].
Success depends on complete exposure of the tumor insertion
point, allowing total resection, as most recurrences occur early,
within 2 years of surgery, usually in the site of the primary lesion
[4,14,15]. Monoblock resection is rarely feasible endoscopically;
debulking is usually required, extended until the insertion point is
identified. Ideally, release of the tumor implantation point is
subpe- riosteal, followed by reaming of the underlying bone
[14,15,29,33]. As much tumoral tissue as possible should be sent
to pathol- ogy, to limit the risk of overlooking a small carcinoma
site. Many authors recommend frozen section biopsy of the
mucosal resection edges, to ensure complete resection, repeating
the examination into healthy tissue [4,27,34,35].
Radiation therapy (RT) may be considered in IP in two circum-
stances: associated carcinoma, and impossibility of surgery. There
are few reports, and all concerned small samples; moreover, the
RT procedure was rarely described. A recent review of the litera-
ture on RT in IP retrieved only 6 articles with sufficient data for
analysis, for a total 16 patients [37]. There is no consensus as to
indications for RT in IP, but associated carcinoma and
impossibility of surgery are widely recognized [3,10,18,22,36]. For
postoperative RT, the dose averages 56 Grays, whether resection
was microscop- ically complete or not. For exclusive RT (in non-
operable patients), the mean dose in 61 Grays. In case of
carcinoma, surgery followed by RT seems more effective than
exclusive surgery or RT in terms of 5-year survival, which is 84% for
associated versus 41% for exclusive treatment (p = 0.006) [38].
6. Surveillance in sinonasal inverted papilloma
IP follow-up duration and modalities are not codified; many
authors recommend a minimum 3–5 years [5,14,15], others for
lifetime follow-up [13]. There are several arguments for the latter
attitude. Firstly, recurrence may be late: a study of recurrence
rates according to follow-up duration in 578 patients [39] reported
a sig- nificant difference, with 8.5% recurrence at less than and
26.1% at more than 3 years’ follow-up (p < 0.001), illustrating the
importance of follow-up beyond 3 years. Likewise, another study,
compar- ing patients with less than versus more than 5 years’
follow-up, reported a recurrence rate of 11% in the former versus
44% in the latter [40]. Other articles also reported late recurrence
beyond 5 and up to 15 years after primary treatment [15,41]. The
second rationale for prolonged follow-up is the risk of
metachronous car- cinoma, with onset often several years after
primary diagnosis [18]. All this argues for close prolonged, ideally
life-long, follow-up. Most authors follow patients up every 3 or 4
months during the first year, every 4–6 months during the second
year, and then every 6–12 months [13,33].
Follow-up comprises clinical examination and systematic flexi-
ble endoscopy. In case of doubt regarding recurrence, biopsies can
be performed. MRI is performed regularly during follow-up, except
in particular cases: e.g., totally resected septal IP, in which clini-
cal surveillance is straightforward and sufficient. In case of doubt
regarding recurrence or of poor sinus cavity visualization on
flexible endoscopy, CT and MRI are performed more frequently. In
case of synchronous squamous cell carcinoma, some authors
recommend MRI every 4 months for 1 year then every 6 months
for 4 years [15]. Some authors consider only 30% of recurrences
to be symp- tomatic, and 70% are thus detected only on clinical
and radiological follow-up [12].
Recurrence, for most authors, implicates incomplete resection
[4,5,15,39], and indeed very often occurs at the initial IP site, usually
within 2 years of surgery [3,4,33,34]. According to some authors,
incomplete resection usually concerns the bone, with pathological
mucosal fragments left within anfractuosities [42]; they
therefore stress the importance of reaming the underlying bone
during pri- mary surgery, or else performing bone resection,
especially in the lamina papyracea [42]. Late recurrence, on the
other hand, is con- sidered as a second location, more suggestive
of viral etiology [33]. Recurrence rates vary widely, from 0 to
50%, between reports.
In Busquets’s meta-analysis, the mean recurrence rate, taking all
stages together, was 15% at a mean 44 months’ follow-up [19].
Numerous studies have focused on risk factors for relapse. In
Busquets’s meta-analysis, endoscopic management seemed to pro-
cure better results than an external approach [19]: for the period
since the advent of endonasal endoscopic surgery, recurrence
rates were 12% for endoscopic treatment, versus 20% for external
surgery (p = 0.001) [19]. Another study, analyzing recurrence-free
survival, found a similar difference, with higher recurrence rate for
an exter- nal (44%) than endoscopic approach (12%; p = 0.009) [43].
Other reports found no such difference [32,39]. The largest
published series, in a multicenter study of more than 500
patients, found less recurrence in Krouse stage-4 cases managed
by an exter- nal rather than endoscopic approach (8.3% vs. 25%
respectively), although the difference was not significant, due to
lack of power according to the authors [39]. It should be borne in
mind that patients operated on by an external approach were
often from older series, and that anatomic knowledge and surgical
technique have since improved. Krouse stage seems unrelated
to risk of recur- rence [15,39,44]. Tumor location correlated
with recurrence risk in several studies; in the largest published
series, recurrence was significantly less in IP originating in the
nasal cavity (OR = 0.485; p = 0.005), probably because more
flagrant symptoms led to ear- lier diagnosis and because this
location is more easily accessible to surgery [39]. In the same
study, frontal sinus involvement was an important risk factor for
recurrence (OR = 2.522, p = 0.001) [39]; other studies confirmed this
finding [44,45]. Other locations are not generally associated with
elevated recurrence [15,39,44,45];
nor are age, gender, smoking status or ethnicity [44]. Histologi-
cally, certain factors (hyperkeratosis, elevated mitosis index,
severe epidermal hyperplasia) were reported by some authors to
be signif- icantly associated with elevated recurrence [45], but not
by others [46]. An association between recurrence and presence of
HPV has not been formally established: results from the main
studies were contradictory. Lawson et al., in a meta-analysis, found
a clear asso- ciation, with a 58% HPV-positive rate in recurrent IP,
versus 10% in non-recurrent IP (OR = 10.2; 95% CI: 3.2–32.8) [8].
Some reports likewise found a clear association [47,48], while
others found no significant correlation [7,49]. Finally, only frontal
sinus involve- ment is agreed by several authors to be an
important risk factor for IP recurrence.
Onset of carcinoma associated with recurrence in patients ini-
tially treated for benign IP has been well described. In some cases,
however, it cannot be ruled out that carcinoma was concomitant at
initial diagnosis and that incomplete resection and non-diagnosis,
leading to insufficient primary surgery, account for the secondary
finding. The main reviews of the literature found metachronous
carcinoma rates of 2.3–11% [5,18]. Time to onset did not differ
from that of recurrence without carcinoma. Mortality in IP with
associated carcinoma, whether synchronous or metachronous, is
non-negligible: a meta-analysis found 126 months’ median sur-
vival [50]; 1-year survival was 80%, 2-year survival 71% and 3-
year survival 63% on Kaplan–Meier analysis. These figures agree
with those for sinus squamous cell carcinoma without IP [50].
7. Conclusion
Inverted papilloma is a benign sinonasal tumor, the precise eti-
ology of which is unknown. High risk of recurrence and the risk of
carcinomatous progression warrant wide surgical resection,
ideally based on the tumor insertion point as found on radiologic
exami- nation. Endonasal endoscopic surgery seems to provide
equivalent or better results than surgery on an external approach.
The present state of knowledge favors prolonged follow-up.
Disclosure of interest
The authors declare that they have no competing interest.
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