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Abstract
In the vestibule and nostril, papillomas are usually stratified squamous arising on the skin surface. Rarely do they recur after simple removal, and malignant transformation is seldom a problem. Abnormal hyperplastic changes of the epithelium are frequent, but if similar criteria of assessment for possible cancerous or precancerous change are used to those applied in other stratified squamous epithelia (see Chapter 34), a diagnosis of malignancy will be unusual.
Fungiform papillomas are benign mucosal neoplasms presenting as a unilateral exophytic mass involving the anterior portion of the nasal septum. In this study, we present an exceptional case of a bilateral fungiform papilloma with a synchronous verrucous carcinoma of the nasal septum.
A case study with a review of the literature concerning malignant changes in fungiform papilloma.
The general consensus in most of the literature is that malignant change in fungiform papilloma is exceptional. Our patient is probably the third reported case of verrucous carcinoma of the nasal septum, and the first report of a bilateral fungiform papilloma with a synchronous verrucous carcinoma. The tumour was subjected to complete surgical removal in the first instance. There was no recurrence at follow up seven months after surgery.
Although fungiform papillomas are generally not premalignant, occasional malignant transformation may occur. Thus, they must be managed with the utmost cautiousness.
Die in der Literatur der letzten 15 Jahre mitgeteilten Berichte über das invertierte Papillom (IP) der Nase und ihrer Nebenhöhlen sind vorwiegend Fallberichte oder Studien, in welchen das klinische Verhalten dieser Geschwulst diskutiert und die heute gültigen Richtlinien für ihre Behandlung erarbeitet wurden. Der vorliegende Beitrag beschäftigt sich mit der ätiologischen und morphologischen Genese des IP, dem Vorkommen des IP's ausschließlich in einem Areal, dessen Schleimhaut entwicklungsgeschichtlich von den Riechfeldern abstammt, also ektodermalen Ursprungs ist (im Gegensatz zur entodermalen Abstammung der Schleimhäute der übrigen Luftwege).
Vergleiche zwischen dem Wachstumsverhalten des IP's und dem Verhalten der Schleimhaut aus beiden Riechfeldern während der Embryogenese ergeben teilweise frappierende Übereinstimmungen. Die prospektive Bedeutung dieses Schleimhautareals - der sog. „Schneiderschen Membran” - dürfte daher eine entscheidende gestaltprägende und wachstumsbestimmende Determinante für das IP sein, lassen sich doch die gleichen Bau- und Wachstumsmerkmale sowohl im IP als auch in der Schneiderschen Membran während der Ausbildung der inneren Nase und ihrer Nebenhöhlen nachweisen. Vor allem ist das Wachstums- und Aufteilungsprinzip der „asymmetrischen Dichotomie” und der „Adventiv-Knospung” ein bestimmender Faktor.
Summary
In the last 15 years papers dealing with the inverting papilloma (IP) of the nose and the paranasal sinuses mainly described the clinical appearance and behaviour and/or discussed treatment modalities. Little is known about the aetiology of the IP.
Comparisons between the histological appearance of the IP and the different stages of the embryonic development of Schneider's membrane, i.e. the lamina mucosa nasi derived from the ectoderm, show strikingly similar growth patterns. The main task of Schneider's membrane is to actively form the inner nose and the paranasal sinuses during development of the foetus. Hence, it emplays the system of „asymmetric dichotomy” when growing into the embryonic tissue of the viscerocranium.
As the IP originates exclusively in the area equivalent to Schneider's membrane and moreover presents some unique features which are histologically and morphologically identical with this membrane, the author believes that the embryonic determination to build up the sinuses and the meatus of the nose is responsible for the histological appearance of the inverting papilloma.
Presence of human papillomavirus (HPV) as the etiologic agent in nearly all upper respiratory tract recurrent papillomas is well-established. The technique of nucleic acid hybridization now allows specific typing of HPV with a high degree of accuracy. This article reports a series of nine consecutive patients treated for nasal papillomas over the past 9 years. Eight of these patients had a personal history of genital papillomas (seven patients) or exposure (one patient). With the use of in situ hybridization and autoradiographic technique on paraffin-embedded tissue sections, HPV RNA type 6/11 was expressed in eight of nine nasal papillomas, and corresponding HPV types were also found in the two cases with which concurrent anogenital papilloma tissue was also available for analysis. Human papillomavirus RNA types 16 and 18 were not detected in any of the specimens. Signals of HPV messenger RNA type 6/11 were stronger in the fungiform areas than in the inverted areas of papillomas.
A series of 19 paraffin-embedded sinonasal papillomas (four squamous papillomas, three fungiform papillomas, nine inverted papillomas, and three cylindrical cell papillomas) were investigated for evidence of human papillomavirus (HPV) infection using immunohistochemistry (polyclonal antibody to HPV capsid antigen), in situ hybridization (DNA probes for HPV 6/11, 16/18, and 31/33/35), and the polymerase chain reaction (primers and probes for HPV 6, 11, 16, 18, and 33). All three fungiform papillomas were positive by all three techniques: immunohistochemistry, in situ hybridization for HPV 6/11, and the polymerase chain reaction for HPV 11. None of the other lesions contained detectable HPV using the specific probes included in this study. These results support the continued classification of fungiform papilloma as a distinctive variant of schneiderian papilloma characterized by a predominantly exophytic growth pattern and an association with HPV 11.
Nasal inverted papilloma is a rare benign tumor occasionally associated with squamous cell carcinoma. To determine the etiological role of human papillomavirus in inverted papilloma, and to clarify the relationship between human papillomavirus and malignant transformation of this benign tumor, we retrospectively analyzed inverted papillomas from 26 patients, 7 of whom had squamous cell carcinoma.
We used an immunohistochemical method and molecular pathologic techniques, or dot‐blot hybridization of DNA extracted from paraffin‐embedded tissues, in situ hybridization, and polymerase chain reaction. Human papillomavirus was detected in 5 of 26 patients (19%), 3 patients with human papillomavirus 11 and 2 patients with human papillomavirus 16. The latter 2 patients had inverted papillomas associated with squamous cell carcinoma. We speculate that human papillomavirus may be related to the malignant transformation of inverted papillomas.
Between 1944 and 1987, 112 patients with inverting papilloma of the nasal cavity were treated. The average duration of follow-up for this population was 6.2 years. The most common symptoms were nasal obstruction and history of previous surgery for nasal "polyps". Recurrence rates were lower when treatment consisted of lateral rhinotomy with medial maxillectomy (14%) vs. transnasal operation with a sinus procedure (35%) or transnasal operation alone (58%). Recurrence rates between men and women were not significantly different when treatment methods were analyzed; however, a higher-than-expected association with tobacco usage was noted. Eight (7%) of the 112 patients had associated nasal carcinoma. Current treatment is lateral rhinotomy with medial maxillectomy to prevent troublesome and potentially malignant recurrent disease.
Two men aged 54 and 73 years, respectively, had oncocytic Schneiderian papilloma (OSP) containing synchronous carcinoma at the time of first biopsy. In both cases, invasive carcinoma involved a small proportion of excised tissue and was in continuity with dysplastic surface epithelium. Our cases document that the epithelial component of OSP can undergo malignant transformation. The focal involvement of OSP with carcinoma underscores the need to examine all excised tissue microscopically.
• Human papillomaviruses (HPVs) have been associated with both benign and malignant neoplasms of the head and neck. To determine the prevalence and types of HPVs in this neoplasm, we examined fixed tissue from 21 patients by in situ hybridization. Human papillomavirus types 6b and 11 probes were used, and hybridization was positive to both types in lesions from 16 (76%) of 21 patients. Hybridization to the HPV-11 probe resulted in the most intense nuclear staining throughout the epithelium, probably indicating a high copy number. The high incidence of viral DNA sequences found in this tumor suggests a potential etiologic role. Therapeutic implications are briefly discussed.
(Arch Otolaryngol Head Neck Surg 1988;114:23-26)
Inverted papilloma is notorious 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 effective in selected cases. To assess the role of conservative procedures, 90 cases of inverted papilloma were retrospectively reviewed. Associated malignancy was rare. Conservative surgery was successful in controlling some cases, but often required two or three operations. All patients with clear sinus films were cured by a single procedure. Abnormal mitotic activity was seen in some aggressive lesions and some associated with malignancy. The surgical exposure in inverted papilloma should be adequate to ensure complete excision. Selected patients with localized disease can be satisfactorily managed by conservative procedures if they are carefully followed. All tissue should be inspected for possible malignancy.
Fifteen inverted papillomas were examined by the peroxidase-antiperoxidase method for their ability to synthesize secretory component (SC) and to take up IgA and IgM. In each case, SC and IgA could be localized to the apical cytoplasm of some tumor cells. In addition, secretory component, IgA, and IgM were observed as the main constituents of hyaline globules lying in the intracytoplasmic lumina of one columnar cell variant of inverted papilloma, suggesting an intact transepithelial transport mechanism of polymeric immunoglobulins. Goblet cells, found only in the transitional cell variant of inverted papilloma, did not react with anti-SC, anti-IgA, or anti-IgM. Since SC can be utilized as a marker to differentiate columnar cells from goblet cells, transitional cell papillomas may originate from undifferentiated reserve cells, which retain their capacity to differentiate into both columnar cells and goblet cells. In contrast, in columnar cell papillomas only differentiated columnar cells are integrated into the neoplastic process.
To determine by review of their histogenesis whether papillomas of the nose and paranasal sinuses are three distinct entities or, as has been favored in the literature, three variations of a single entity.
We examined biopsy sections from 191 patients with sinonasal papillomas. Biopsy sections included all types of sinonasal papillomas stained using routine methods and, in some cases, using immunohistochemistry for macrophages (PG-M1) and proliferation antigen (MIB-1). Two cases of inverted papilloma were also examined using transmission electron microscopy.
Everted and cylindric cell papillomas are true papillomas, lined by stratified squamous and microcystladen, columnar, oncocytic epithelium, respectively. Inverted papillomas are polyps with marked, patchy squamous metaplasia and numerous microcysts containing macrophages in ductal and surface epithelium. There are no intermediate forms from any one of the three types to another.
Some differences between the three types are already established with regard to sites of origin, tendency to recur, and association with malignancy. It is likely that their etiologies--eg, concerning human papillomavirus infection--will be found to differ, if their distinct histogeneses are considered.
To determine the role of human papillomavirus (HPV) in the etiology of sinonasal papillomas, 57 inverted papillomas including 5 cases associated with carcinomas, 16 exophytic papillomas, and 5 cases of columnar cell papillomas were examined for the presence of HPV DNA by in situ hybridization and polymerase chain reaction (PCR). The genetic studies were performed on the formalin-fixed, paraffin-embedded material.
In only 6% of the 52 benign inverted papillomas was HPV DNA identified, whereas 69% of the exophytic papillomas were infected by HPV DNA. In none of the 5 cases with columnar cell papillomas could HPV be demonstrated. HPV 6/11 was identified in all of these HPV-positive cases. In the carcinoma area, HPV was detected in 2 (1 HPV 6/11 and 1 HPV 18) of the 5 inverted papillomas associated with carcinomas. The findings confirm the presence of HPV DNA in sinonasal papillomas. The results also indicate that HPV 6/11 may be involved in the pathogenesis of, solely, exophytic papillomas. We found that in situ hybridization and PCR seem equally sensitive in detecting HPV in sinonasal papillomas.
Tumors of the upper respiratory tract and ear. Atlas of tumor pathology, 2nd series, Fascicle 25. Armed Forces Institute of Pathology
- V J Hyams
- J G Batsakis
- L Michaels
- VJ Hyams
Intranasal verrucous carcinoma: relationship to inverting papilloma and human papillomavirus
- L J Orvidas
- J E Lewis
- K D Olsen
- LJ Orvidas