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Malignant Transformation of NasalPolyposis: Case Report andReview of the LiteratureGuillaume Michel 1*, Florent Espitalier 1 , Elisabeth Cassagnau 2 andOlivier Malard 3

1Department of Otolaryngology, University Hospital of Nantes, Nantes, France2 Department of Anatomopathology, University Hospital of Nantes, Nantes, France3Department of Otolaryngology, University Hospital of Nantes, Nantes, France*Corresponding author: Guillaume Michel, Service d'ORL et de chirurgie cervico-faciale, CHU Hôtel Dieu, 1, Place A. Ricordeau, BP 1005, 44093 Nantes Cedex01, Tel: 0240083475; FAX: 0240083477 ; E-mail: guillaumemichel@live.fr

Rec date : Jun 19, 2014, Acc date: Aug 08, 2014, Pub date: Aug 18, 2014

Abstract

Nasal polyposis is a chronic inflammatory disease of the nasalmucosa. Nasal polyps are bilateral and benign, andcharacterized in histopathological terms by epithelial andvascular remodelling as well as the presence of aninflammatory infiltration of the stroma.

We review the literature after reporting a case of evolved nasalpolyposis, with multiple in situ epidermoid carcinomas insidethe inflammatory polyps.

After surgical treatment, the histopathological examinationrevealed complete squamous metaplasia over large territorieson both sides, without inverted papilloma. This was a multifocaldegeneration of evolved nasal polyposis.

A systematic histopathological examination after a surgicalintervention for nasal polyposis is recommended, because of the possibility of incidentally discovered benign or malignanttumours. However, this malignant progression of nasalpolyposis has not been reported in the literature.

The proliferation index of epithelial cells in nasal polyposis ishigher than in normal nasal mucosa, due to the presence of inflammatory mediators. Late in the natural history of nasalpolyposis, it can be assumed that cell proliferation becomes

deregulated, responsible for a malignant transformation.

Keywords: Nasal Polyps; Nasal Mucosa; Nasal Obstruction; EthmoidSinus

Introduction

Nasal polyposis is a chronic inflammatory disease of the nasalmucosa, characterized by bilateral polyps arising from the anteriorethmoid complex [1]. The presenting symptoms (nasal obstruction,rhinorrhea, hypo- or anosmia, facial pressure) had evolved for morethan 12 weeks and were associated with a suggestive nasofibroscopy [2].

The nasal polyps typically appear as pseudo-tumoural masses withnonspecific histological characteristics: these polyps are benign, withno degenerative potential. As a consequence, surgical treatment is only indicated if medical treatment fails [3].

We review the literature after a case report on substantial nasalpolyposis, with histopathological examination revealing multiple insitu epidermoid carcinomas inside the inflammatory polyps.

Case Report

A 59-year-old patient consulted for an historical nasal polyposis; apolypectomy had been performed 10 years before, with effective buttemporary results.

He had no personal history, no allergy nor aspirin intolerance, noasthma; he had quit smoking 45 years before, with estimated tobaccosmoking at less than five pack-years. He worked as a technicalinspector, without wood dust or nickel exposure.

He was taking no local treatment or oral corticotherapy.

Clinical symptoms were anosmia and complete nasal obstruction,but no facial pressure. Clinical examination revealed a massive nasalpolyposis, deforming the nostrils with extra-nasal externalization(Figure 1).

The CT scan showed complete filling of all nasal cavities (Figure 2).

Figure : Clinical aspect of this deforming nasal polyposis, withextra-nasal externalization.

Figure 2: CT scan axial sequence. Left and right ehmoidal sinusesare completely filled by the nasal polyposis.

Michel et al., J Otol Rhinol 2014, 3:4http://dx.doi.org/10.4172/2324-8785.1000176 Journal of Otology &

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Because of this advanced and disabling nasal polyposis, surgicaltreatment was performed, complementary to medical treatment. Thesurgery consisted of a bilateral ethmoidectomy of the meatus with

bilateral sphenoidotomy. The nasal polyps were sent for routinehistopathological examination.

The histopathological examination revealed inflammatory polyps ascommonly described in nasal polyposis (Figure 3a); the chorion wasoedematous, highly vascularized, with moderate inflammatory infiltration of mononuclear cells and eosinophils.

The surface was covered with a respiratory pseudostratifiedepithelium; this epithelium presented squamous metaplasia in variousdegrees. It was a complete squamous metaplasia over large territories

(Figure 3b), characterized with loss of maturation, cytonuclear atypiaand mitosis over the entire epithelium height. On both sides, multipleepidermoid carcinomas in situ were found.

Figure 3: Histological sections a) Normal respiratory epithelium; b) In situ epidermoid carcinoma, with loss of maturation, cytonuclear atypiaand mitosis over the entire epithelium height.

There was no inverted papilloma, meaning this histological analysiswas a multifocal degeneration of an evolved nasal polyposis. There wasno bacteria on the direct examination, but rare colonies of Escherichiacoli, Citrobacter koseri and Streptococcus agalactiae were found afterculture.

The case was presented in a multidisciplinary staff meeting. Clinicalsurveillance was decided, because the resection seemed to be distantfrom the multiple carcinomas. Resection limits were difficult toevaluate, however.

Discussion

Nasal polyposis is a chronic disease of the nasal mucosa, and theetiology of the primitive form is still unknown. The Bernstein model

considers nasal polyposis a multifactorial disease [4], with animportant role played by mediators such as cell adhesion moleculesand cytokines, causing an inflammatory reaction.

Nasal polyps are bilateral and benign, and characterized inhistopathological terms by epithelial and vascular remodelling as wellas the presence of an inflammatory infiltration of the stroma [5].

The development of nasal polyps is bilateral and symmetric. Thepresence of unilateral nasal polyps must challenge the nasal polyposisdiagnosis and points to benign or malignant tumours.

However, a number of authors have described the presence of benign or malignant tumours incidentally discovered after surgery forbilateral nasal polyps. This warrants systematic histopathological

examination after a surgical intervention for nasal polyposis.The most common diagnose is an inverted papilloma [6].

The rate of unsuspected diagnoses during nasal polyposis surgery varies from 0% [7] to 0.92% [6]. Garavello et al. [8] analysed 2147patients presenting bilateral nasal polyposis and found 0.37%unsuspected diagnoses: seven cases of inverted papilloma and one caseof adenocarcinoma.

These findings are considered an incidental pathologicalassociation, distinct from nasal polyposis and masked by nasal polyps.These tumours evolve at the same time with no epidemiologicalrelation with nasal polyposis, which is not considered at risk of malignant transformation.

We have presented a case that appears to be different, becausemultifocal transformations were developing into an advanced nasalpolyposis; this course of nasal polyposis has not been reported in theliterature.

The histopathological examination found extensive and multipleterritories of in situ carcinoma on both sides, with various degrees of epithelium metaplasia. In situ epidermoid carcinomas evolve intoinflammatory polyps, with histological features compatible with nasalpolyposis.

Histopathological examination found no inverted papilloma: thiswas not a transformation of a benign tumour, as is commonly found,but actual carcinoma, suggesting a malignant transformation of nasalpolyposis.

Primitive epidermoid carcinoma occurring in nasal cavities isfrequently seen, but nasal polyposis turning into epidermoidcarcinoma is uncommon.

The proliferation index of epithelial cells in nasal polyposis is higherthan in normal nasal mucosa, due to the presence of inflammatory

Citation: Michel G, Espitalier F, Cassagnau E, Malard O (2014) Malignant Transformation of Nasal Polyposis: Case Report and Review of the Literature. J Otol Rhinol 3:4.

doi: http://dx.doi.org/10.4172/2324-8785.1000176

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mediators. Epithelial lesions caused by inflammatory mediators induceincreased cell proliferation, via processes of epithelial repair andsecretion of growth factors [9]. A recent study [10] showed that

STAT3 (signal transducer and activator of transcription 3) was over-expressed in a phosphorylated form in nasal polyps, compared tocontrol subjects, indicating an activation of STAT3 in polyps. Theauthors conclude that pSTAT3, which can promote oncogenesis by being constitutively active [11], plays a crucial role in the proliferativedevelopment of nasal polyps.

Late in the natural history of nasal polyposis, it can be assumed thatcell proliferation becomes deregulated, responsible for a malignanttransformation.

Conclusion

We report a case of a patient presenting a classic but extensive nasalpolyposis. Histopathological examination after surgery revealedmultiple epidermoid carcinomas in the nasal polyposis, with noprimary tumour such as an inverted papilloma.

Potential long-term transformation has not been reported in theliterature, although a higher proliferation index in nasal polyposis hasalready been demonstrated.

Conflict of Interest

There is no conflict of interest among authors.

References

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3. Bonfils P (2007) Evaluation of the combined medical and surgicaltreatment in nasal polyposis. I: functional results. ActaOtolaryngol 127: 436-446.

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8. Garavello W, Gaini RM (2005) Histopathology of routine nasalpolypectomy specimens: a review of 2,147 cases. Laryngoscope115: 1866-1868.

9. Coste A, Rateau JG, Roudot-Thoraval F, Chapelin C, Gilain L, etal. (1996) Increased epithelial cell proliferation in nasal polyps.Arch Otolaryngol Head Neck Surg 122: 432-436.

10. Linke R, Pries R, Könnecke M, Bruchhage KL, Böscke R, et al.(2013) Increased activation and differentiated localization of native and phosphorylated STAT3 in nasal polyps. Int ArchAllergy Immunol 162: 290-298.

11. Bowman T, Garcia R, Turkson J, Jove R (2000) STATs inoncogenesis. Oncogene 19: 2474-2488.

Citation: Michel G, Espitalier F, Cassagnau E, Malard O (2014) Malignant Transformation of Nasal Polyposis: Case Report and Review of the Literature. J Otol Rhinol 3:4.

doi: http://dx.doi.org/10.4172/2324-8785.1000176

Volume 3 • Issue 4 • 1000176 • Page 3 of 3 •

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