Inverted papilloma Staging, Recurrence, Surgery

Papillomas are benign tumors of epithelial layers that have finger-like projections that grow outwards. But inverted papillomas grow inward, towards the bone. Papillomas are locally aggressive but tend to metastasis; chances of recurring are very high, about 40-75%. Squamous cell carcinoma is associated with inverted papillomas. The tumor can be observed through MRI images. Mucosal secretion and inflammatory, infective polyp are the characteristics of inverted papilloma. It may be or may not be invaded by fungus. It can develop into carcinoma and melanoma. 

Inverted papilloma Staging, Recurrence, Surgery

What is Inverted papilloma?

Inverted papillomas are rare benign tumors developed in a sinonasal cavity’s mucosal lining. The majority are non-cancerous, occasionally undergo a malignant transformation, and become a carcinoma but not metastasize to other areas of the body.  It is more common in males of middle-aged age as compared to females. Inverted papillomas are irregular masses with a tendency to bleed and in pink color. Many patients are asymptomatic and are diagnosed accidentally. Symptoms are similar to sinonasal masses, nasal obstruction or congestion usually on one side only, nasal discharge or postnasal drip due to excessive mucosal production, sinus infection, loss of sense of smell, facial pain, headaches, bleeding, and sinus pain may occur. It grows inward and can expand to adjacent areas of the nasal cavity into the paranasal sinuses with cysts and aggression. It may expand and surround the nasal cavity’s bone, which is the most common area for its growth. It covers the bone around the eyes and brain if it remains untreated. Sign of increase in size showed by facial swelling and bulging of eyes. Its mass increases in size and can cause the nasal bone remodelling and may affect the nose’s drainage system.

Location, the tumour’s extent, and the cancer shape are useful in the diagnosis and suggest better treatment plans. The exact cause of inverted papilloma is unknown. Some records indicate that human papillomavirus may cause it. Inverted papilloma has a characteristic appearance. Diagnosis is made through nasal endoscopy by inserting a flexible tube with a camera into the nose. A biopsy is performed via sample of the tumor which is extracted to determine the nature of the cell. To determine the extent of cancer and the degree of bone destruction, CT scans, MRI imaging techniques are helpful. If a patient is diagnosed with inverted papilloma, MRI differentiates between inverted papillomas and other types of nasal lesions. Radio imaging can’t differentiate between malignant inverted papilloma and only inverted papillomas. 

Inverted papilloma Staging

There are different staging systems for inverted papilloma. According to the Krouse system, it is divided into four stages, T1, in which the tumor is confined to one wall of the nasal cavity only. T2 tumor begins to complex still no metastasis yet begins. T3 no concurrence of malignancy, but tumor expands to other walls, and different sinus regions get involved in it. T4 tumors become carcinoma now and extend till intracranial region. Hans’ system categorizes its stages into four groups, which says somehow according to Krouse systems. The Cannady system gives three groups, which stated that group A confined to the nasal cavity. In contrast, group B involves sinus cavities, and in the C group, papilloma extends beyond the sinuses cavities.

Inverted papilloma Surgery

Otolaryngologists are often concerned about treating this inverted papilloma of the nasal cavity safely and effectively by removing the tumor. Inverted papilloma is malignant and can rapidly grow in numbers. The treatment purpose is to stop the size of cancer and localize it to the tumor site. Surgery is the primary treatment because of its high rate of recurring. Surgery of early-stage papilloma shows better results, and it is recommended. It was also performed to remove the tumor via an external incision named Endoscopic endonasal approach (EEA). EEA decreases the chances of recurrence and gives satisfied cosmetic outcomes. It is considered because of other advantages that are not associated with any disfigurement. Different types of functional endoscopic sinus surgery are performed to minimize the invasion of the tumor. Extended tumors to intracranial regions are removed through the advanced techniques, which may be associated with neurosurgery with otolaryngology because the papilloma may surround the brain or eye region. Surgeries are made without skin incisions to heal, and recovery is very rapid. 

Inverted papilloma Recurrence

There are chances of tumor recurrence because of the metastasis of the benign tumor. The surgical procedure is essential because the recurrence rate depends on how efficiently the surgery is performed. It is recommended to go to an experienced surgeon because recurrence increases if the papilloma is not eradicated. The cases of recurrence range from 15 to 75%, totally depending on the surgical procedure. This rate increases much more if inverted papilloma is associated with squamous cell carcinoma. Sometimes, malignant tumors recur after surgery, so in this case, patients need to go for another surgery with chemotherapy or radiotherapy. For the prevention of potential recurrence, patients asked for follow-up checkups for proper evaluation by physicians.

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