IP Archives of Cytology and Histopathology Research

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Online ISSN: 2456-9267

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IP Archives of Cytology and Histopathology Research (ACHR) open access, peer-reviewed quarterly journal publishing since 2016 and is published under the Khyati Education and Research Foundation (KERF), is registered as a non-profit society (under the society registration act, 1860), Government of India with the vision of various accredited vocational courses in healthcare, education, paramedical, yoga, publication, teaching and research activity, with the aim of faster and better dissemination more...


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Barman and Priyadharisini J: Bilateral Schneiderian (sinonasal) papilloma: An uncommon rare entity


Introduction

Sinonasal papilloma (SNP) is a benign surface mucosal neoplasm with an incidence rate of 0.6 cases/100,000 people/year.1 It comprises 0.5–4% of all primary nasal tumors.2, 3 and is more common in males around a 5-6th decade. It is a rare benign tumor with the tendency to recur and even malignant transformation. Its etiology remains still controversial. Sinonasal papilloma can develop from any part of the Schneiderian membrane in the nose and paranasal sinuses, however, the most common sites include the lateral nasal wall and middle meatus. WHO classifies SNP into 3 histological subtypes based on the growth pattern and cytology, which includes Inverted sinonasal papilloma(ISP), Exophytic sinonasal papilloma(ESP), and oncocytic sinonasal papilloma(OSP). An Inverted sinonasal papilloma (ISP) is a distinctive growth pattern of sinonasal papilloma which usually presents as a unilateral nasal polyp, and therefore bilateral involvement of the nose and paranasal sinuses is a rare entity.

Case Report

A 60-year-old male patient presented with a chief complaint of nasal blockage more on the right side and nasal discharge for 5 years. It was slowly progressive since onset. The patient also gave past history of similar complaints at 10 and 25 years back, for which he was operated upon in a private clinic and the mass was removed, however, the histopathology reports are not available. On anterior rhinoscopy, a multiple, pinkish, pedunculated, irregular, firm mass was located in the right nasal cavity. X-ray reveals bilateral nasal mass with associated opacification of the adjacent maxillary antrum. A provisional clinical diagnosis of recurrent nasal polyposis was given. The mass was surgically excised by transnasal endoscopic approach and the excised tissue was sent for histopathological examination. On histological examination, the hematoxylin and eosin-stained section showed polypoid tissue covered with non-keratinized stratified squamous epithelium with focal area pseudostratified columnar ciliated epithelium with admixed mucocytes (goblet cells) and intraepithelial neutrophils, which showed inversion into the underlying connective tissue stroma to form nests and islands. The epithelium shows prominent mitosis involving the basal layer of epithelium, however no evidence of atypia/malignancy. Stroma shows edema and congested vessels along with chronic inflammatory infiltrate composed of lymphocytes, plasma cells, and eosinophils (Figure 1, Figure 2, Figure 3). The clinicopathologic correlation was suggestive of a final diagnosis of Inverted Sinonasal papilloma (Schneiderian Papilloma).

Figure 1

HPE shows polypoidal structure lining by thickened non-keratinizing squamous epithelium with down growth of epithelium into stroma showing edema.(H&E,X100 )

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/10e1e2c6-217f-48d2-9350-2706eff45ab2image1.png
Figure 2

Transition of ciliated columnar and squamous epithelium with down growth into underlying stroma.(H&E,X100 )

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/10e1e2c6-217f-48d2-9350-2706eff45ab2image2.png
Figure 3

Shows intraepithelialpseudocysts and neutrophilic abscess. (H&E,X400)

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/10e1e2c6-217f-48d2-9350-2706eff45ab2image3.png

Discussion

Inverted papilloma (also known as Transitional cell papilloma, Schneiderian cell papilloma, sinonasal-type papilloma) can be defined as a group of benign neoplasm arising from the sinonasal (Schneiderian) mucosa and is composed of squamous or columnar epithelial proliferation with associated mucous cells.4

Sinonasal papilloma usually presents as a unilateral nasal polyp and obstruction, however bilateral involvement is a rare entity. However, in the case of bilateral disease, appropriate clinical evaluation is necessary to exclude the possibility of extension from unilateral disease. Bilateral involvement is considered only if a lesion certainly crosses through a solid midline structure (e.g., nasal septum). Inverted sinonasal Papilloma with bilateral involvement is rare, with a reported rate of up to 5 %.5 It has been suggested that bilateral and multicentric presentations could be the result of the extension of the lesion through metaplasia of the adjacent mucosa.6, 7

Sinonasal papilloma shows variable growth patterns and cytology features on histopathology. WHO classification shows 3 histological subtypes of SNP, which include inverted, exophytic, and oncocytic sinonasal papilloma. Of which Inverted variant shows association with EGFR mutation. Histologically, inverted papillomas have an endophytic/ inverted growth of markedly thickened non-keratinizing squamous epithelial proliferation growing into the underlying connective tissue stroma to form large islands. The epithelium can show variable cellularity composed of squamous, transitional or columnar cells) with admixed mucocytes (goblet cells) and intraepithelial microcysts /neutrophil collection. A mixed chronic inflammatory cell infiltrate is characteristically seen within all layers of the surface epithelium. The cells are relatively bland, however, may show mild pleomorphism and atypia. The stromal components vary from myxoid to fibrous, with admixed chronic inflammatory cells and variable vascularity.

A series published from the UK had a reported rate of just under 7% for bilateral involvement8 whilst other series report rates typically between 2%,4%, and 5%.5, 9, 10 It is mandatory to resect not only the tumor but also to remove the mucoperiosteum, which is the site of origin, in order to avoid recurrences. Intraoperatively histologic control by frozen section is strongly recommended, however not performed regularly.

The recurrence rate of sinonasal papilloma is 5-25%, most commonly within 24 months in many cases as per kinds of literature. The malignant transformation from the sinonasal papilloma is about 2-10%. Malignant transformation and concurrent malignant disease are well recognized in this benign sinonasal tumor with rates in the literature ranging from 6 to 14.5%11 No histological features predict later malignant transformation, rather increased mitosis and atypia are common in recurrent lesions. Inverted and oncocytic variant shows more propensity for malignant transformation than exophytic sinonasal papilloma. The most common form of malignant transformation is squamous cell carcinoma.12

Differential diagnosis includes Inflammatory polyp with squamous metaplasia, Rhinosporidiosis, REAH (Respiratory epithelial adenomatoid hamartoma), and sinonasal epithelial malignancies such as Non-keratinising squamous cell carcinoma. Inflammatory polyp with squamous metaplasia shows absent thick non keratinized stratified squamous epithelium or downward growth which is seen in inverted sinonasal papilloma. Rhinosporidiosis imitates intraepithelial pseudocysts of ISP, however, doesn't show a significant degree of inflammation seen in rhinosporidiosis. REAH also shows downward epithelial growth from ciliated columnar surface however lacks epithelial thickening, mucous cells, and microcysts of ISP. Non-keratinizing squamous cell carcinoma mimics the architecture of ISP, however, the cytology of Nonkeratinizing SCC shows high-grade atypia, mitosis, and necrosis. 13

Conclusion

Bilateral inverted papillomas are rare and can present with bilateral nasal obstruction. The treatment of choice is based on the extent of the lesion and should be aimed at avoiding recurrence. Thorough histological examination of sinonasal papilloma is recommended to rule out the possibility of malignant transformation. Patients with bilateral disease should have long-term surveillance for recurrence and/or malignancy

Source of Funding

No financial support was received for the work within this manuscript.

Conflict of Interest

The authors declare that they have no conflict of interest.

References

1 

C. Buchwald L.H. Nielsen PL. Nielsen P Ahlgren M Tos Inverted papilloma: A follow-up study including primarily unacknowledged casesAm J Otolaryngol19891042738110.1016/0196-0709(89)90008-2

2 

DP Vrabec The inverted schneiderian papilloma: A 25-year studyLaryngoscope1994104558260510.1002/lary.5541040513

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N Upadhyaya S Khandekar A Dive R Mishra Sinonasal inverted papilloma: A case report and mini review of histopathological featuresJ Oral and Maxillofacl Pathol201519340510.4103/0973-029x.174644

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W Lawson J Le Benger P Som PJ Bernard HF Biller Inverted papilloma: An analysis of 87 casesLaryngoscope198999111724

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JT Murphy A Chandran DR Strachan S Sood Bilateral inverted papilloma: A report of two cases and review of the current literatureIndian J Otolaryngol Head Neck Surg2010623313610.1007/s12070-010-0079-4

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W Ming-Jie JE Noel Etiology of sinonasal inverted papilloma: A narrative reviewWorld J Otorhinolaryngol - Head Neck Surg20173154810.1016/j.wjorl.2016.11.004

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S Hosal JL Freeman Bilateral lateral rhinotomy for resection of bilateral inverted papillomaOtolaryngol - Head Neck Surg19961141103510.1016/s0194-5998(96)70292-9

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S Mirza P J Bradley A Acharya M Stacey N S Jones Sinonasal inverted papillomas: recurrence, and synchronous and metachronous malignancyJ Laryngol Otol200712198576410.1017/s002221510700624x

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W Lawson MR Kaufman HF Biller Treatment Outcomes in the Management of Inverted Papilloma: An Analysis of 160 CasesLaryngoscope2003113915485610.1097/00005537-200309000-00026

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VJ Hyams Papillomas of the Nasal Cavity and Paranasal SinusesAnn Otol, Rhinol Laryngol197180219220610.1177/000348947108000205

11 

T Tanvetyanon D Qin T Padhya R Kapoor J Mccaffrey A TrottiSurvival outcomes of squamous cell carcinoma arising from sinonasal inverted papilloma: report of 6 cases with systematic review and pooled analysisAm J Otolaryngol20093013843

12 

Q Sun L An J Zheng D Zhu Advances in recurrence and malignant transformation of sinonasal inverted papillomasOncol Letters201713645859210.3892/ol.2017.6089

13 

D Gnepp J Bishop Gnepp's Diagnostic Surgical Pathology of the Head and Neck3rd Edn.Elsevier2020



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© This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Article type

Case Report


Article page

132-134


Authors Details

Partho Protim Barman, Priyadharisini J


Article History

Received : 08-05-2021

Accepted : 15-05-2021

Available online : 29-05-2021


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