Investigation Of Clinical, Paraclinical Symptoms And Converted Prevalence To Carcinoma Of Sinonasal Inverted Papilloma Patients – Nguyen Ba Khoa

Journal of military pharmaco-medicine n o 7-2018 113 INVESTIGATION OF CLINICAL, PARACLINICAL SYMPTOMS AND CONVERTED PREVALENCE TO CARCINOMA OF SINONASAL INVERTED PAPILLOMA PATIENTS Nguyen Ba Khoa*; Ho Anh Son**; Do Tram Anh*** Nguyen Thi Ngoc Dung*; Nguyen Linh Toan** SUMMARY Objectives: To investigate the sinonasal inverted papilloma clinical, paraclinical symtoms and prevalence of inverted papilloma conveted to carcinoma. Subjects and method: A cross- sectional study was carried on 81 subjects with sinonasal inverted papilloma. Data of main clinical, paraclinical symptoms (endoscopy and histopathology data) were collected and analyzed by independent - sample t-test or Pearson’s χ2 test or Fisher’s exact test. Results: The main symptoms of inverted papilloma patient were nose obstruction (96.5%); runny nose (42%); headache occurred in 38.3% of patients. Nose bleeding occurred in 13.6% of patients with statistically significant differences between male and female (p < 0.05). In 81 inverted papilloma patients, 16%; 17.3% and 8.6% of them had a history of smoking; alcohol consumption and allergy, respectively. Stage T3 was predominant in inverted papilloma patients (37%). Other stages, T2, T4 and T1 were 28.4; 24.7 and 9.9%, respectively. The recurrent rate of inverted papilloma was 28.4%; malignant transformation rate was 10.5%. Conclusion: Inverted papilloma is poor in symptom but rich in recurrence and malignant transformation rate. * Keywords: Sinonasal inverted papilloma; Clinical, paraclinical symptoms. INTRODUCTION Sinonasal inverted papilloma (IP) is a benign and relatively rare tumor of the nasal cavity and paranasal sinuses, that usually originates in the nasal mucosa and nasal sinus wall. This disease has been documented in the literature for more than a century, but so far, IP is still a matter of debate due to the complex nature of the disease, the high prevalence of recurrence. and the coordination with the cancer. With an incidence between 0.2 and 1.5 cases per 100,000 persons per year, IPs account for 0.5 - 4% of all sinonasal neoplasms [1, 2]. IP tumors usually occur on one side of the nose and the incidence of papillary sinus reversal is more common in men than in women. The disease is more common among whites than blacks and is most common in the 50s and 60s of ages. In Vietnam, IPs is a rare disease that has not been studied yet, even in the ear, nose and throat specialist. We conducted this study: To investigate the IP clinical, paraclinical symtoms and prevalence of IPs converted to carcinoma. * Ear, Nose, Throat Hospital, Hochiminh City ** Vietnam Military Medical University *** 103 Military Hospital Corresponding author: Nguyen Linh Toan (toannl@vmmu.edu.vn) Date received: 01/07/2018 Date accepted: 20/08/2018 Journal of military pharmaco-medicine n o 7-2018 114 SUBJECTS AND METHODS 1. Subjects. The study was conducted on 81 cases of sinonasal inverted papilloma. 2.Methods. A cross-sectional study and analysis were carried on 81 subjects with IPs. * Data collection: - Clinical: Stuffy nose, runny nose, nose bleeds, loss of smell, headache... - Sinonasal endoscopy: The surface was classified to grape-like, strawberry- like or polyp-like tumor. - CT-scan: All patients underwent CT- scan to assess the location and extent of tumor invasion in the nasal cavity with the surrounding organism. It was useful for appropriate surgery. - Histopathology: All IP tumors were sliced and histo-staining before and after surgery. All slices were checked in Histopathology Department, Hochiminh Medical Phamaceutical University. * Data analysis: Data was collected and analyzed by STATA software for Pearson’s χ2 test or Fisher’s exact test, student t-test to compare continuous variables. RESULTS AND DISCUSTION IPs patients were more concentrated in the age group 50 - 59 (33.3%), followed by the age group 40 - 49 (23.5%). Mean age of the group was 50.9. Men with sinonasal inverted papilloma accounted for 63% and female was 37% (male:female ratio was 1.7:1.0). Table 1: Some characters of IPs symptom. Signs of nose obstruction appeared quite common in IPs patients (96.5%). There were no statistically significant differences between the male and female group. Runny nose and headache occurred in 42% and 38.3% of patients, respectively. There were no statistically significant differences between the male and female group. Nose bleeding occurred in 13.6% of patients with statistically significant differences between male and female (p < 0.05). Male (n = 51) Female (n = 30) Total (n = 81) Sex Characters n % n % n % Nose obstruction 48 94.1 30 100.0 78 96.3 Runny nose 21 41.2 13 43.3 34 42.0 Nose bleeding 10 19.6 1 3,3 11 13.6 Headache 22 43.1 9 30.0 31 38.3 Journal of military pharmaco-medicine n o 7-2018 115 Table 2: Historical disease of IPs patients. In patients with IPs disease, 16%; 17.3% and 8.6% of them had a history of smoking; alcohol consumption and allergy, respectively. The difference between male and female groups was not statistically significant. Similar to other head and neck tumors, smoking has been identified as a risk factor of IPs recurrence. Outdoor and industrial occupations may be another potential environmental risk factors, particularly exposure to organic solvents, including diethylnitrosamine. Other risks such as alcohol consumption, allergy history are controversy in mechanism of IPs [6]. Table 3: IPs tumor stage. Stage T3 was predominant in IPs patients (37%). Other stages, T2, T4 and T1 were 28.4; 24.7 and 9.9%, respectively. The clinical stage of IPs has been defined using the Krouse staging system [3]. Many authors have emphasized the role of stage system on IP recurrence. Table 4: Location of IPs tumor. Male (n = 51) Female (n = 30) Total (n = 81) Sex Characters n % n % n % Smoking 13 25.5 0 0 13 16.0 Alcohol 14 27.5 0 0 14 17.3 Allergy 4 7.8 3 10.0 7 8.6 Male (n = 51) Female (n = 30) Total (n = 81) Sex Stage n % n % n % T1 3 5.9 5 16.7 8 9.9 T2 14 27.5 9 30.0 23 28.4 T3 20 39.2 10 33.3 30 37.0 T4 14 27.5 6 20.0 20 24.7 Male (n = 51) Female (n = 30) Total (n = 81) Sex Site n % n % n % Right 22 43.1 11 36.7 33 40.7 Left 29 56.9 19 63.3 48 59.3 Both sites 0 0 0 0 0 0 Location of IPs tumor was 40.7% on right site. In opposite site, IPs tumor was 59.3%. None of patient tumor was located on both sites. Other study also found that, tumor site distribution was not predominant factor to estimate the recurrence or dysplasia of the cell in IP patients. Journal of military pharmaco-medicine n o 7-2018 116 Table 5: Recurrent rate among subjects. The recurrence rate of IPs was very high, 28.4% of patients undergoing surgery had a history of IPs. Of the 23 patients with IPs recurrence, the average number of recurrences was 1.8 times and there was a patient had recurrence in 6 times. IP is a benign tumor which originates from the sinonasal Schneiderian mucosa. Unlike other benign tumors, IPs exhibit remarkable aggressive behaviors, including invasiveness, recurrence and malignant transformation (~10%) [6]. Table 6: Sinonasal endoscopy of IPs tumor. Under endoscopy, we found that IPs showed 44.2% of mulberry shape. Grape shape accounted for the second most popular category with 32.5% of cases. In addition, polyp-like images were also common in IPs with 23.4% of cases. Pre-surgery IPs tumor histology After surgery IPs tumor histology Figure 1: Pre-surgery and after surgery tumor histology. Male (n = 51) Female (n = 30) Total (n = 81) Sex Characters n % n % n % Number of recurrent patients 15 29.4 8 26.7 23 28.4 Number of IPs recurrence 1.5 ± 0.8 2.3 ± 1.8 1.8 ± 1.2 First surgery 36 70.6 22 73.3 58 71.6 Male Female Total Sex Characters n % n n n % Grape 14 29.2 11 37.9 25 32.5 Strawberry 23 47.9 11 37.9 34 44.2 Polyp-like 11 22.9 7 24.1 18 23.4 Total 48 100 29 100 77 100 Journal of military pharmaco-medicine n o 7-2018 117 In preoperative IPs patients, the prevalence of polyps was 4.2%. After the surgery, tissue fragments were checked by histologist, three preoperative polyps were diagnosed as IPs. There were 8 cases (10.5%) diagnosed as carcinoma after operation, meanwhile they were diagnosed as IPs preoperation. Figure 2: Preoperative IPs histology. (Huynh Van P; left: 40X, right 200X) (Huynh Van P was biopsy before surgery through endoscopy, was diagnosed as IP, including Malpighi epidermis, papillae and deep invasion into the connective tissue and leukocyte infiltration) Figure 3: Histology of Aenoid-cystic carcinoma. (Huynh Van P after surgery: left: 40X, right 200X) However, histopathological findings of postoperative tumors revealed small, round, dark, cytoplasmic small cells, arranged in a variety of tubular, hollow, and small rounded structures. The lining was lined with one or two rows of adenoid cells. The cushion has a mucosal area. This was a histology of Aenoid cystic carcinoma. The mechanisms leading to the recurrence and malignant transformation of IP remain unclear. Malignant transformation of IP may be associated with the following factors: HPV genotype 16 and 18 chronic infections, the epidermal growth factor receptor mutations, abnormal cell cycle proteins [6]. Journal of military pharmaco-medicine n o 7-2018 118 CONCLUSION The main symptom of IP patient were nose obstruction (96.5%); runny nose (42%); headache occurred in 38.3% of patients. Nose bleeding occurred in 13.6% of patients with statistically significant differences between male and female (p < 0.05). In 81 IP patients, 16%; 17.3% and 8.6% of them had a history of smoking; alcohol consumption and allergy, respectively. Stage T3 was predominant in IPs patients (37%). Other stages, T2, T4 and T1 were 28.4; 24.7 and 9.9%, respectively. The recurrent rate of IPs was 28.4%; malignant transformation rate was 10.5%. REFERENCES 1. Scheel A, Lin G.C, McHugh J.B et al. Human papillomavirus infection and biomarkers in sinonasal inverted papillomas: Clinical significance and molecular mechanisms. Forum Allergy Rhinol. 2015, 5, 701e-707. 2. Pajor AM, Danilewicz M, Stasikowska- Kanicka O, Jo´zefowicz-Korczynska M. The immunoexpression of CD34, Bcl-2, and Ki-67 antigens in sinonasal inverted papillomas. Am J Rhinol Allergy. 2014, 28, e31-e34. 3. Krouse J.H. Development of a staging system for inverted papilloma. Laryngoscope. 2000, 110, pp.965-968. 4. Moon I.J, Lee D.Y, Suh M.W, Han D.H, Kim S.T, Min Y.G, Lee C.H, Rhee C.S. Cigarette smoking increases risk of recurrence for sinonasal inverted papilloma. Am J Rhinol Allergy. 2010, 24, pp.325-329. 5. Hong S.L, Kim B.H, Lee J.H, Cho K.S, Roh H.J. Smoking and malignancy in sinonasal inverted papilloma. Laryngoscope. 2013, 123, pp.1087-1091. 6. Sun Q, An L, Zheng J, Zhu D. Advances in recurrence and malignant transformation of sinonasal inverted papillomas. Oncol Lett. 2017, 13 (6), pp.4585-4592.