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A case report of inverted papilloma associated with esthesioneuroblastoma treated by endoscopic sinus surgery
A Case Report of Inverted Papilloma Associated With Esthesioneuroblastoma Treated by Endoscopic Sinus Surgery Ernesto Pasquini, MD, Vittorio Sciarretta, MD, Giacomo Ceroni Compadretti, MD, and Cosetta Cantaroni, MD The inverted papilloma is a benign tumor arising more frequently at the level of the paranasal sinuses and at the level of the lateral nasal wall. Generally, the presenting symptom is characterized by nasal obstruction. These tumors, although benign in nature, can be locally aggressive and destroy the bone by pressure erosion. They also tend to recur if not excised completely. This neoplasm can also be associated with malignant lesions like squamous cell carcinoma, with an incidence ranging from 8% to 50% (average, 9%; if we consider most series reports) or more rarely with adenocarcinoma.1,2 The aim of this study was to report the synchronous association of an inverted papilloma with an esthesioneuroblastoma. At the moment, we know of no other case reported in the existing literature describing a patient simultaneously affected by these 2 tumors. CASE REPORT A 72-year-old man with the diagnosis of inverted papilloma was referred to our hospital in Bologna in October 1997 for the surgical treatment. This patient had symptoms of nasal obstruction and hyposmia for 3 years. A computed tomography (CT) scan of the facial skeleton was performed in another institution 3 months before together with a nasal biopsy. The histopathological report showed an in-
From the Ear, Nose, and Throat Department, Sant’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy. Address correspondence to: Ernesto Pasquini, MD, University of Bologna, ENT Department, Sant’OrsolaMalpighi Hospital, Via Massarenti 9, 40131, Bologna, Italy. Email: [email protected]. © 2003 Elsevier Inc. All rights reserved. 0196-0709/03/2403-0010$30.00/0 10.1016/S0196-0709(03)00003-6
verted papilloma of the left nasal fossa, whereas the CT scan pointed out a mass involving the posterior portion of the ethmoid sinus and the ipsilateral sphenoid and reaching also the rhynopharynx (Fig 1A and B). The endoscopic examination performed in our hospital the day of admission indicated a pinkish gray– colored mass of the posterior left nasal fossa that obstructed the superior and middle meatus and extended within the left rhynopharynx. Thereafter, a left sphenoethmoidectomy and a middle turbinectomy were performed through an endoscopic transnasal approach, and the lesion was dissected en bloc with the mucoperiosteum. The definitive histological report of the surgical specimens showed the coexistence of 2 tumors: an inverted papilloma (composing the largest portion of the specimen) and an olfactory neuroblastoma or esthesioneuroblastoma (Fig 2A and B). In this case, because of the apparent radicality of the surgery performed, the small size of the malignant lesion, the age of the patient, and the refusal of the patient to receive further treatments, we performed only a close follow-up of the patient. In fact, an endoscopic examination was performed every 2 months in the first year (several examinations were completed by a biopsy taken from the site of surgery) and every 3 months after the first year. Moreover, enhanced CT scans and magnetic resonance imaging with gadolinium of the facial skeleton were also taken yearly to complete this follow-up (Fig 1B). After 53 months from the time of the surgery, the patient is free of any disease recurrence. DISCUSSION Some authors have reported in selected cases the use of endoscopic transnasal ap-
American Journal of Otolaryngology, Vol 24, No 3 (May-June), 2003: pp 181-182
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proaches for the surgical treatment of inverted papilloma.1,3-5 This surgical technique is associated with less morbidity, less discomfort, and shorter hospital stay compared with the more invasive traditional external approaches like ethmoidectomy and/or medial maxillectomy through a lateral rhinotomy or midfacial degloving. The esthesioneuroblastoma is a rare malignant tumor arising from neuroectodermal cells of the olfactory mucous membrane. This tumor can invade the orbit, the skull base, and the paranasal sinuses and can also give cervical metastases in 10% to 50% of patients in less differentiated histologic grades. Generally, the management for esthesioneuroblastoma consists of an anterior craniofacial resection alone or in combination with a radio/ chemotherapy.6 In this case, because of the apparent radicality of the endoscopic endonasal approach, the small size of malignant lesion, the patient’s age, and the refusal of the patient to receive further treatments, we offered this patient only a close posttherapeutic surveillance. To our knowledge, this is the only case reported in the existing literature of synchronous association between an inverted papilloma and an esthesioneuroblastoma.
Fig 1. scan.
(A) Preoperative and (B) postoperative CT
Fig 2. Definitive histological report showed the coexistence of 2 tumors: (A) an esthesioneuroblastoma and (B) an inverted papilloma.
Furthermore, in agreement with recent literature, we also wanted to point out that endoscopic surgery compared with more traditional approaches, if correctly planned and performed, can achieve a radical resection of benign and, in selected cases, also of malignant lesions.7,8 For this reason, we advocate the use of minimally invasive approaches like endoscopic sinus surgery in selected cases. REFERENCES 1. Krouse JH: Endoscopic treatment of inverted papilloma: Safety and efficacy. Am J Otolaryngol 22:87-99, 2001 2. Kerschner JE, Futran ND, Chaney V: Inverted papilloma associated with squamous cell carcinoma and adenocarcinoma: Case report and review of the literature. Am J Otolaryngol 17:257-259, 1996 3. Tufano RP, Thaler ER, Lanza DC, et al: Endoscopic management of sinonasal inverted papilloma. Am J Rhinol 13:423-426, 1999 4. Chee LWJ, Sethi DS: The endoscopic management of sinonasal inverted papillomas. Clin Otolaryngol 24:6166, 1999 5. McCary WS, Gross CW, Reibel JF, et al: Preliminary report: Endocopic versus external surgery in the management of inverting papilloma. Laryngoscope 104:415-419, 1994 6. Koka VN, Julieron M, Bourhis J, et al: Aesthesioneuroblastoma. J Laryngol Otol 112:628-633, 1998 7. Stammberger H, Anderhuber W, Walch C, et al: Possibilities and limitations of endoscopic management of nasal and paranasal malignancies. Acta Otorhinolaryngol Belg 53:199-205, 1999 8. Casiano RR, Numa WA, Falquez AM: Endoscopic resection of esthesioneuroblastoma. Am J Rhinol 15:271279, 2001
From the Ear, Nose, and Throat Department, Sant’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy. Address correspondence to: Ernesto Pasquini, MD, University of Bologna, ENT Department, Sant’OrsolaMalpighi Hospital, Via Massarenti 9, 40131, Bologna, Italy. Email: [email protected]. © 2003 Elsevier Inc. All rights reserved. 0196-0709/03/2403-0010$30.00/0 10.1016/S0196-0709(03)00003-6
verted papilloma of the left nasal fossa, whereas the CT scan pointed out a mass involving the posterior portion of the ethmoid sinus and the ipsilateral sphenoid and reaching also the rhynopharynx (Fig 1A and B). The endoscopic examination performed in our hospital the day of admission indicated a pinkish gray– colored mass of the posterior left nasal fossa that obstructed the superior and middle meatus and extended within the left rhynopharynx. Thereafter, a left sphenoethmoidectomy and a middle turbinectomy were performed through an endoscopic transnasal approach, and the lesion was dissected en bloc with the mucoperiosteum. The definitive histological report of the surgical specimens showed the coexistence of 2 tumors: an inverted papilloma (composing the largest portion of the specimen) and an olfactory neuroblastoma or esthesioneuroblastoma (Fig 2A and B). In this case, because of the apparent radicality of the surgery performed, the small size of the malignant lesion, the age of the patient, and the refusal of the patient to receive further treatments, we performed only a close follow-up of the patient. In fact, an endoscopic examination was performed every 2 months in the first year (several examinations were completed by a biopsy taken from the site of surgery) and every 3 months after the first year. Moreover, enhanced CT scans and magnetic resonance imaging with gadolinium of the facial skeleton were also taken yearly to complete this follow-up (Fig 1B). After 53 months from the time of the surgery, the patient is free of any disease recurrence. DISCUSSION Some authors have reported in selected cases the use of endoscopic transnasal ap-
American Journal of Otolaryngology, Vol 24, No 3 (May-June), 2003: pp 181-182
181
182
PASQUINI ET AL
proaches for the surgical treatment of inverted papilloma.1,3-5 This surgical technique is associated with less morbidity, less discomfort, and shorter hospital stay compared with the more invasive traditional external approaches like ethmoidectomy and/or medial maxillectomy through a lateral rhinotomy or midfacial degloving. The esthesioneuroblastoma is a rare malignant tumor arising from neuroectodermal cells of the olfactory mucous membrane. This tumor can invade the orbit, the skull base, and the paranasal sinuses and can also give cervical metastases in 10% to 50% of patients in less differentiated histologic grades. Generally, the management for esthesioneuroblastoma consists of an anterior craniofacial resection alone or in combination with a radio/ chemotherapy.6 In this case, because of the apparent radicality of the endoscopic endonasal approach, the small size of malignant lesion, the patient’s age, and the refusal of the patient to receive further treatments, we offered this patient only a close posttherapeutic surveillance. To our knowledge, this is the only case reported in the existing literature of synchronous association between an inverted papilloma and an esthesioneuroblastoma.
Fig 1. scan.
(A) Preoperative and (B) postoperative CT
Fig 2. Definitive histological report showed the coexistence of 2 tumors: (A) an esthesioneuroblastoma and (B) an inverted papilloma.
Furthermore, in agreement with recent literature, we also wanted to point out that endoscopic surgery compared with more traditional approaches, if correctly planned and performed, can achieve a radical resection of benign and, in selected cases, also of malignant lesions.7,8 For this reason, we advocate the use of minimally invasive approaches like endoscopic sinus surgery in selected cases. REFERENCES 1. Krouse JH: Endoscopic treatment of inverted papilloma: Safety and efficacy. Am J Otolaryngol 22:87-99, 2001 2. Kerschner JE, Futran ND, Chaney V: Inverted papilloma associated with squamous cell carcinoma and adenocarcinoma: Case report and review of the literature. Am J Otolaryngol 17:257-259, 1996 3. Tufano RP, Thaler ER, Lanza DC, et al: Endoscopic management of sinonasal inverted papilloma. Am J Rhinol 13:423-426, 1999 4. Chee LWJ, Sethi DS: The endoscopic management of sinonasal inverted papillomas. Clin Otolaryngol 24:6166, 1999 5. McCary WS, Gross CW, Reibel JF, et al: Preliminary report: Endocopic versus external surgery in the management of inverting papilloma. Laryngoscope 104:415-419, 1994 6. Koka VN, Julieron M, Bourhis J, et al: Aesthesioneuroblastoma. J Laryngol Otol 112:628-633, 1998 7. Stammberger H, Anderhuber W, Walch C, et al: Possibilities and limitations of endoscopic management of nasal and paranasal malignancies. Acta Otorhinolaryngol Belg 53:199-205, 1999 8. Casiano RR, Numa WA, Falquez AM: Endoscopic resection of esthesioneuroblastoma. Am J Rhinol 15:271279, 2001