Michel et al.

, J Otol Rhinol 2014, 3:4

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

Journal of Otology &

Rhinology

Case Report

A SCITECHNOL JOURNAL

Malignant Transformation of Nasal

Polyposis: Case Report and
Review of the Literature
Guillaume Michel1*, Florent Espitalier1, Elisabeth Cassagnau2 and
Olivier Malard3
1Department

of Otolaryngology, University Hospital of Nantes, Nantes, France

2Department

of Anatomopathology, University Hospital of Nantes, Nantes, France

3Department

of Otolaryngology, University Hospital of Nantes, Nantes, France

*Corresponding

author: Guillaume Michel, Service d'ORL et de chirurgie cervicofaciale, CHU Htel Dieu, 1, Place A. Ricordeau, BP 1005, 44093 Nantes Cedex
01, 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

The nasal polyps typically appear as pseudo-tumoural masses with

nonspecific histological characteristics: these polyps are benign, with
no 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 nasal
polyposis, with histopathological examination revealing multiple in
situ epidermoid carcinomas inside the inflammatory polyps.

Case Report
A 59-year-old patient consulted for an historical nasal polyposis; a
polypectomy had been performed 10 years before, with effective but
temporary results.
He had no personal history, no allergy nor aspirin intolerance, no
asthma; he had quit smoking 45 years before, with estimated tobacco
smoking at less than five pack-years. He worked as a technical
inspector, without wood dust or nickel exposure.
He was taking no local treatment or oral corticotherapy.

Nasal polyposis is a chronic inflammatory disease of the nasal

mucosa. Nasal polyps are bilateral and benign, and
characterized in histopathological terms by epithelial and
vascular remodelling as well as the presence of an
inflammatory infiltration of the stroma.

Clinical symptoms were anosmia and complete nasal obstruction,

but no facial pressure. Clinical examination revealed a massive nasal
polyposis, deforming the nostrils with extra-nasal externalization
(Figure 1).
The CT scan showed complete filling of all nasal cavities (Figure 2).

We review the literature after reporting a case of evolved nasal

polyposis, with multiple in situ epidermoid carcinomas inside
the inflammatory polyps.
After surgical treatment, the histopathological examination
revealed complete squamous metaplasia over large territories
on both sides, without inverted papilloma. This was a multifocal
degeneration of evolved nasal polyposis.
A systematic histopathological examination after a surgical
intervention for nasal polyposis is recommended, because of
the possibility of incidentally discovered benign or malignant
tumours. However, this malignant progression of nasal
polyposis has not been reported in the literature.
The proliferation index of epithelial cells in nasal polyposis is
higher than in normal nasal mucosa, due to the presence of
inflammatory mediators. Late in the natural history of nasal
polyposis, it can be assumed that cell proliferation becomes
deregulated, responsible for a malignant transformation.

Figure 1: Clinical aspect of this deforming nasal polyposis, with

extra-nasal externalization.

Keywords: Nasal Polyps; Nasal Mucosa; Nasal Obstruction; Ethmoid

Sinus

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

Figure 2: CT scan axial sequence. Left and right ehmoidal sinuses

are completely filled by the nasal polyposis.

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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
Because of this advanced and disabling nasal polyposis, surgical
treatment was performed, complementary to medical treatment. The
surgery consisted of a bilateral ethmoidectomy of the meatus with
bilateral sphenoidotomy. The nasal polyps were sent for routine
histopathological examination.
The histopathological examination revealed inflammatory polyps as
commonly described in nasal polyposis (Figure 3a); the chorion was
oedematous, highly vascularized, with moderate inflammatory
infiltration of mononuclear cells and eosinophils.

The surface was covered with a respiratory pseudostratified

epithelium; this epithelium presented squamous metaplasia in various
degrees. It was a complete squamous metaplasia over large territories
(Figure 3b), characterized with loss of maturation, cytonuclear atypia
and mitosis over the entire epithelium height. On both sides, multiple
epidermoid carcinomas in situ were found.

Figure 3: Histological sections a) Normal respiratory epithelium; b) In situ epidermoid carcinoma, with loss of maturation, cytonuclear atypia
and mitosis over the entire epithelium height.
There was no inverted papilloma, meaning this histological analysis
was a multifocal degeneration of an evolved nasal polyposis. There was
no bacteria on the direct examination, but rare colonies of Escherichia
coli, Citrobacter koseri and Streptococcus agalactiae were found after
culture.

The rate of unsuspected diagnoses during nasal polyposis surgery

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

The case was presented in a multidisciplinary staff meeting. Clinical

surveillance was decided, because the resection seemed to be distant
from the multiple carcinomas. Resection limits were difficult to
evaluate, however.

These findings are considered an incidental pathological

association, distinct from nasal polyposis and masked by nasal polyps.
These tumours evolve at the same time with no epidemiological
relation with nasal polyposis, which is not considered at risk of
malignant transformation.

Discussion
Nasal polyposis is a chronic disease of the nasal mucosa, and the
etiology of the primitive form is still unknown. The Bernstein model
considers nasal polyposis a multifactorial disease [4], with an
important role played by mediators such as cell adhesion molecules
and cytokines, causing an inflammatory reaction.
Nasal polyps are bilateral and benign, and characterized in
histopathological terms by epithelial and vascular remodelling as well
as the presence of an inflammatory infiltration of the stroma [5].
The development of nasal polyps is bilateral and symmetric. The
presence of unilateral nasal polyps must challenge the nasal polyposis
diagnosis 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 for
bilateral nasal polyps. This warrants systematic histopathological
examination after a surgical intervention for nasal polyposis.
The most common diagnose is an inverted papilloma [6].

Volume 3 Issue 4 1000176

We have presented a case that appears to be different, because

multifocal transformations were developing into an advanced nasal
polyposis; this course of nasal polyposis has not been reported in the
literature.
The histopathological examination found extensive and multiple
territories of in situ carcinoma on both sides, with various degrees of
epithelium metaplasia. In situ epidermoid carcinomas evolve into
inflammatory polyps, with histological features compatible with nasal
polyposis.
Histopathological examination found no inverted papilloma: this
was not a transformation of a benign tumour, as is commonly found,
but actual carcinoma, suggesting a malignant transformation of nasal
polyposis.
Primitive epidermoid carcinoma occurring in nasal cavities is
frequently seen, but nasal polyposis turning into epidermoid
carcinoma is uncommon.
The proliferation index of epithelial cells in nasal polyposis is higher
than in normal nasal mucosa, due to the presence of inflammatory

Page 2 of 3

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
mediators. Epithelial lesions caused by inflammatory mediators induce
increased cell proliferation, via processes of epithelial repair and
secretion of growth factors [9]. A recent study [10] showed that
STAT3 (signal transducer and activator of transcription 3) was overexpressed in a phosphorylated form in nasal polyps, compared to
control subjects, indicating an activation of STAT3 in polyps. The
authors conclude that pSTAT3, which can promote oncogenesis by
being constitutively active [11], plays a crucial role in the proliferative
development of nasal polyps.
Late in the natural history of nasal polyposis, it can be assumed that
cell proliferation becomes deregulated, responsible for a malignant
transformation.

Conclusion
We report a case of a patient presenting a classic but extensive nasal
polyposis. Histopathological examination after surgery revealed
multiple epidermoid carcinomas in the nasal polyposis, with no
primary tumour such as an inverted papilloma.
Potential long-term transformation has not been reported in the
literature, although a higher proliferation index in nasal polyposis has
already been demonstrated.

Conflict of Interest
There is no conflict of interest among authors.

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