Outcomes of sinonasal inverted papilloma resection by surgical approach: an updated systematic review and meta‐analysis

Abstract

BackgroundSelecting the optimal surgical approach for resection of sinonasal inverted papilloma (SIP) remains a challenge, with endoscopic, external, and combined approaches being utilized. This systematic review was conducted as an update to a 2006 systematic review to determine the preferred surgical approach for tumor control.MethodsThe study protocol was developed a priori following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) process. Data were collected and outcomes were analyzed according to surgical approach and sites of tumor involvement.ResultsA total of 96 papers and 4134 SIP patients were included. The overall recurrence rate was 12.80% (322/2515) for the endoscopic approach group, 16.58% (182/1098) for the external approach group, and 12.60% (65/516) for the combined approach group. Meta‐analysis by random effects model showed that the summarized risk ratio (RR) of recurrence was 0.61 (95% confidence interval [CI], 0.44 to 0.85, p = 0.003), I2 = 37.95% for the endoscopic vs external approach; 0.98 (95% CI, 0.69 to 1.39, p = 0.901), I2 = 9.06% for the endoscopic vs combined approach; 1.61 (95% CI, 1.06 to 2.43, p = 0.025), I2 = 0.00% for the external vs combined approach. After adjusting for publication bias, the adjusted RRs were 0.66 (p = 0.014) for endoscopic vs external; 0.99 (p = 0.955) for endoscopic vs combined; and 1.33 (p = 0.224) for external vs combined.ConclusionAn enlarging and maturing body of literature continues to indicate that endoscopic approaches result in significantly lower recurrence rates than open approaches for surgical resection of SIP.

Comparison of Current Staging Systems for Sinonasal Inverted Papilloma

“…A recent meta-analysis showed that the recurrence rate after endoscopic surgery is lower than it was after external surgery before the introduction of endoscopic approaches. 10 In addition, the newly introduced surgical techniques of EMLP and prelacrimal approach have enabled further extension of the indications for endoscopic surgery for IP. The EMLP approach has made it possible to approach the lateral wall of the frontal sinus, and the prelacrimal approach has enabled approaching the anterior and medial walls of the maxillary sinus.…”

“…4–7 An endoscopic approach reportedly achieves equal or superior recurrence rates compared with a conventional external approach. 8–10 However, in some cases, it is impossible to achieve complete resection endoscopically and an external incision is still needed.…”

Clinical evidence based review and systematic scientific review in the identification of malignant transformation of inverted papilloma

“…Inverting papilloma (IP) is a challenging condition to manage in the sinonasal cavity. A recent literature review has shown that the best surgical approach to the management of IP is endoscopic [1]. However, the challenge remains on how to best surveillance these patients postoperatively, especially if the recurrence converts to malignant transformation.…”

“…However, the challenge remains on how to best surveillance these patients postoperatively, especially if the recurrence converts to malignant transformation. To our knowledge, the most up to date IP recurrence rate is 13.72% with a malignant transformation potential of 7.6% [1][2][3]. Given that the recurrence and malignant transformation can happen more than 8 years after the preliminary surgery, followup of 3 years or greater is recommended [4,5].…”

“…While the most common surveillance technique is endoscopy [1] followed by a biopsy if there is a concerning finding, surgeons struggle to check areas in the nose that cannot be easily visualized such as the lateral frontal sinus, the anterior medial maxillary sinus and sinus cavities that have stenosed due to post-surgical healing. Therefore, surgeons require other surveillance techniques to best identify incidents of IP recurrence but more importantly the transformation to SCC.…”