文献摘要

鼻部倒生性乳突瘤復發相關的型態學、術中以及組織學因素
Morphologic, intraoperative, and histologic risk factors for sinonasal inverted papilloma recurrence

Volume 4, Issue 4

關鍵字 :
倒生性乳突瘤,鼻竇,復發,分化不良,額竇, Inverted papilloma, paranasal sinus, recurrence, dysplasia, frontal sinus

作者 :
Jake J. Lee, MD ; Lauren T. Roland, MD, MS; Jordan J. Licata, DO; Hilary L.P. Orlowski, MD; Pawina Jiramongkolchai, MD ; Jay F. Piccirillo, MD; Dorina Kallogjeri, MD, MPH; Cristine N. Klatt-Cromwell, MD; Rebecca D. Chernock, MD; John S. Schneider, MD, MA

譯者 :
林口長庚醫院 耳鼻喉部 傅嘉祥 醫師

摘要:


Objective: Sinonasal inverted papillomas (IP) are benign neoplasms with a propensity for local recurrence. Many risk factors are reported, with little consistency between studies. This study aimed to comprehensively assess for demographic, imaging, histopathologic, and intraoperative risk factors for recurrence.


Methods: We performed a single-center retrospective cohort study of patients with pathologically diagnosed IP without malignancy who underwent surgical resection between 1997 and 2018. Eligible patients were identified through a database maintained by the Department of Pathology. Logistic regression identified variables associated with recurrence, and conjunctive consolidation was performed to create a predictive model.


Results: Of 76 subjects, 37% (n = 28) had recurrence. Median follow-up and time to recurrence were 2.9 (range 0.5–21.1) and 1.7 (range 0.2–13.0) years, respectively. Confirmed negative margins on histology were protective (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.08–0.85). Frontal sinus involvement (adjusted odds ratio [aOR] 5.83, 95% CI 1.20–28.37), incomplete resection (aOR 9.67, 95% CI 2.24–41.72), and presence of dysplasia (aOR 4.38, 95% CI 1.01–19.10) were significantly associated with recurrence on multivariable analysis. A three-level composite recurrence risk staging system was created by consolidating the above three variables. The recurrence risks of composite stage I, II, and III disease were 20%, 38%, and 100%, respectively. No demographic, imaging, staging, or surgical approach variables were associated with recurrence.


Conclusion: Frontal sinus involvement, incomplete resection, and dysplasia were significant risk factors for IP recurrence, whereas confirmed negative margins were protective. Creation of a composite staging system using the above variables may allow for risk stratification and a patient-specific approach to postoperative IP management

專家評論:


鼻部倒生性乳突瘤復發相關的型態學、術中以及組織學因素


林口長庚醫院 耳鼻喉部 傅嘉祥醫師


倒生性乳突瘤 (inverted papilloma, IP) 佔鼻部腫瘤約 4%,約有 7-11% 合併或轉變為惡性的機會;另具有 14-33% 復發的機率。先前的文獻提出了許多可能與復發相關的因素,但多數仍存在著爭議與不可確定性:例如抽菸、先前鼻部手術史等;以及型態學因素:如腫瘤位置、骨質侵犯 (osseous invasion)、腫瘤分期;組織學 (histopathologic) 因素:如無分化 (atypia)、分化不良 (dysplasia)、核分裂數 (mitotic index)、生長型態;手術方法:如經鼻內視鏡、外部開放式、合併內視鏡及開放式等。臨床常用的 IP 腫瘤分期如 KrouseCannady stage,與復發率常被提出無明顯關聯。目前無單一研究分析所有臨床 (clinical)、臨床外 (paraclinical)、統計學上 (demographic)、手術方法 (surgical technique) IP 腫瘤復發相關的因素,以及合併症 (comorbidity) 嚴重度與手術結果的相關性。本研究將分析所有上述相關因素與腫瘤復發之關係,並且發展一套以手術中發現與病理學上三類 IP 腫瘤分期 (three-category staging system) 來預測術後復發率。


本研究以回顧方式收集美國亞特蘭大 Emory Medicine 醫學中心自 1998 2018 年以手術治療、經病理證實為 IP 的個案,排除了到院初表現為復發型 IP、追蹤小於 6 個月、與已合併惡性腫瘤 (carcinoma) 者。於他處先行接受鼻息肉內視鏡手術,但發現為 IP 因而轉介而來的患者也被納入研究;而在他院以 IP 診斷接受內視鏡切除手術後,因復發而轉介來的患者則被排除在外。最後共收納 76 例,追蹤時間的中位數為 2.9 年(0.5-21.1 年),共 28 例復發 (37%),平均復發時間為術後 1.7 年(0.2-13.0 年)。初始症狀最多為鼻塞 (67%, 51 / 76);而 16% 的患者一開始是以無相關的症狀求醫(如聽力下降、喉嚨痛、噁心感、手部顫抖等)。經單變項分析後,不完整的切除 (incomplete resection)、廣基無柄型腫瘤底部 (sessile tumor base)、額竇侵犯 (frontal sinus involvement)、分化不良 (presence of dysplasia) 等因素與腫瘤復發相關;而組織病理學確認標本邊緣為陰性 (confirmed negative margins) 與腫瘤未復發有關。額竇侵犯者復發率達 64% (9 / 14),其中 12 例經鼻內視鏡手術治療(7 例復發),另外 2 例合併內視鏡手術及外部切除(2 例皆復發)。於多變項分析中,與腫瘤復發相關各因素之調整後的勝算比 (adjusted odds ratio, aOR)為:不完整的切除 (aOR = 9.67, 95% CI 2.24-41.72)、額竇侵犯 (aOR = 5.83, 95% CI 1.20-28.37)、分化不良 (aOR = 4.38, 95% CI 1.01-19.10)。廣基型底部在多變項分析未達統計意義;而「確認標本邊緣陰性」因與完整切除的項目意義重複、以及 66% (50 / 76) 案例未送冰凍切片確認標本邊緣,而排除於多變項分析中。接下來作者以 conjunctive consolidation 叢集分析將切除狀態(完整/不完整)、額竇侵犯(有/無) 與腫瘤復發與否做分析,建立了一套新式三類 (three-category) 的術中分期系統 (intraoperative staging system),可將復發率初分成三個族群。作者進一步將此系統與分化不良與否(有/無)做結合,形成六類 (six conjoined categories) 的複合分期系統 (composite staging system),可將術後復發率最終分成三族群(復發率分別約為 20%38%100%)。利用此術中發現所建立的新型分期系統分析,可得知該患者預期復發率落在哪一族群;而落在第三群復發率最高者,則需更密集的追蹤。


本研究為回溯性收集,很多資料來自單純依賴臨床醫師的紀錄、IP 有限的個案數及復發個數、位於轉介之醫學中心與收案的納入排除條款、以及收案僅排除追蹤不到 6 個月之個案等,均可能造成分析的選擇性誤差。然而本篇作者提供單一醫學中心案例的系列分析與結果,透過術中發現而研發的新式分期系統,可有效將患者的預期復發率做有效率的分期,而非僅仰賴影像學的分期做預後分析,能更進一步提供臨床醫師一套客觀的參考與佐證。


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