xRead - Nasal Obstruction (September 2024) Full Articles

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KUANetal.

Treatment of the site of attachment in inverted papilloma

duration and modalities should include routine endo scopic evaluation or MRI in lesions not easily seen endoscopically for a minimum of 5 years postoperatively, followed by recommended lifetime follow-up. 736,740 Postoperative follow-up appears to primarily consist of clinical history, endoscopy, and interval CT/MRI scans. Some recurrences are subclinical in up to 70% of cases, so radiographic follow-up is imperative in those lesions that cannot be adequately evaluated endoscopically. 701 One study elucidating the role of radiographic follow-up for IP determined that MRI visualized recurrent lesions and permitted precise evaluation of extension where CT remained equivocal in 40% of recurrent lesions. 741 There are also published small case series indicating a possible role for 18 FDG-PET/CT whereby patients who had sus pected recurrences had avid lesions on PET and those without recurrence did not, yet the use of nuclear medicine surveillance is not established for IP (Table XVI.9). 742,743 Recurrence risk and surveillance in inverted papilloma

Aggregate grade of evidence

C (Level 4: seven studies)

Benefit

Lower recurrence rates with reduced morbidity. Baseline risk of epistaxis and postoperative pain.

Harm

Cost

Associated costs with surgery.

Benefits–harm assessment

Preponderance of benefits over harms.

Value

The surgeon must attempt to identify the attachment site in order to properly resect this region to minimize risk of recurrence.

judgments

Policy level Recommendation. Intervention Perform pedicle-oriented resection via any

surgical approach in order to definitively address primary site and reduce recurrence risk. Definitive treatment may entail cauterization or drilling of the pedicle following mucosal resection.

Aggregate grade of evidence

Recurrence: B (Level 2: three studies, Level 3: two study, Level 4: 14 studies) Surveillance: C (Level 4: six studies) Prognosis for recurrence can be determined by identification of risk factors (multifocal attachment, prior surgery, high-risk HPV, STR such as disease overlying carotid, etc.). Prolonged surveillance allows for prompt identification of IP recurrence. Potential for under- or oversurveillance and early discharge from surveillance that would preclude detection of later recurrences. Clinical charges associated with assessment of risk factors including clinic visits for history and physical, imaging, endoscopy, and operative cost for intra/postoperative risk factor assessment. Preponderance of benefits over harms. Risk factors for recurrence are wide ranging and need to be assessed on a patient-specific basis. Determining presence of recurrence as soon as evident will allow for more timely intervention of a less extensive tumor and potential mitigation of malignant transformation risk. Though endoscopy may be utilized for most surveillance visits, imaging may be considered for specific cases (e.g., maxillary sinus following prelacrimal approach, lateral frontal sinus).

H Recurrence and surveillance Predilection for recurrence is one of the most significant clinical features of IP, with published recurrence rates as high as 78%. 410,644,727 As such, there are several published reports who aim to define the most important risk factors that portend recurrence. One multivariate retrospective analysis indicates the presence of moderate to severe dys plasia, Dragonetti–Minni classification, anatomic location of lesion, and history of prior sinonasal surgery as the key factors associated with recurrence. 728 Other notable studies identified detection of HPV, 67 young age at initial diagnosis, 68 smoking history, 64,66,69 multiple IP attach ment sites, 54,63 Krouse stage T3 or T4, 70 and postoperative elevation of serum SCC antigen levels 71 as risk factors for recurrence. 138,644,726,728–733 Endoscopic resection of IP, as compared with tradi tional open techniques, afforded obvious reduction in morbidity of resection, yet endoscopic techniques were only widely accepted once recurrence rates were at least as good as open approaches. 409,734–736 One of the largest meta analyses of outcomes of IP resection by surgical approach documented recurrence rates of 12.8%, 16.58%, and 12.60% for endoscopic, open, and combined surgical approaches, respectively (Table XVI.8). 737,738 The majority of recurrent IP lesions arise within the first year following resection and often occur in the same anatomic location as the primary lesion; however, 20% of recurrences will occur after 5 years postoperatively. 739 Given this potential for late recurrence and potential metachronous malignant transformation, IP follow-up

Benefit

Harm

Cost

Benefits–harm assessment

Value

judgments

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