Is routine histopathological examination of FESS material useful?

Cindy van den Boer 0 1 Guy Brutel 0 1 Nico de Vries 0 1 0 G. Brutel Department of Pathology, Sint Lucas Andreas Hospital , P.O. Box 9243, 1006AE Amsterdam, The Netherlands 1 C. van den Boer N. de Vries (&) Department of Otolaryngology/Head Neck Surgery, Sint Lucas Andreas Hospital , P.O. Box 9243, 1006AE Amsterdam, The Netherlands Analysis of the clinical value of histopathological examination of material collected during functional endoscopic sinus surgery. Retrospective analysis of collected data of patients undergoing functional endoscopic sinus surgery over a 7-year period. Data were collected from a pathology database of the Sint Lucas Andreas Hospital, Amsterdam, The Netherlands. All material collected from 1,944 functional endoscopic sinus surgery cases in 1,695 patients (some patients underwent revision surgery) operated between 2000 and 2007 was examined histologically. Patients with a histological outcome diVerent from chronic inXammation or polyposis nasi, were checked on indication of surgery, type of surgery and preoperative clinical suspicion for (pre)malignancy. The impact of the histological diagnosis on the clinical course was evaluated. Thirty-seven unusual diagnoses were reported: 18 cases of inverted papilloma, one squamous cell carcinoma, two malignant lymphomas, one leiomyosarcoma, eight squamous cell papillomas, one Churg Strauss syndrome, one Schneiderian papilloma, two cases of Wegener's granulomatosis and three cases of sarcoidosis. All other specimens were identiWed as chronic inXammation and/or nasal polyposis. Only two clinically signiWcant, unexpected diagnoses, both inverted papilloma, have resulted from the histological investigation. We conclude that the close correlation between histopathology outcome and examination on clinical grounds or gross inspection indicates that routine histopathological examination of functional endoscopic sinus surgery material has little clinical value and it is questionable if this should be performed. In patients in whom there is a high degree of suspicion for (pre)malignancy, histopathological examination of functional endoscopic sinsus surgery material remains indicated. - Chronic rhinosinusitis (CRS) with/without nasal polyposis (NP) is a common disease, which aVects annually approximately 16% of the population in the United States [1, 2]. Functional endoscopic sinus surgery (FESS) is indicated in patients with CRS when conservative treatment has (partially) failed or when massive polyposis is present. Other indications for FESS might be suspicion of (pre)malignancy and/or an increased risk of orbital, endocranial and/ or septic complications. [36] In most of the institutes in the US and Europe, it is routine clinical practice to have FESS material investigated histologically to conWrm the clinical diagnosis. The adagium is if it is important enough to have it removed, it is important enough to have it investigated. However, it is a clinical reality that the clinical diagnosis of CRS with/without NP in patients undergoing FESS, is conWrmed by histological investigation in almost all cases. In only a very small number of patients other unexpected diagnoses such as premalignant (e.g., inverted papilloma), or malignant tumours are found. We were interested to examine how often histological examination identiWed pathology not expected preoperatively on clinical grounds and how far such a Wnding would alter the subsequent treatment and follow-up. Is routine histological investigation of all FESS material necessary or not? Materials and methods Between 2000 and 2007, 1,944 specimens collected from FESS from 1,695 patients (some patients underwent revision surgery) were histological examined in the Sint Lucas Andreas Hospital (SLAZ) in Amsterdam, The Netherlands. All collected FESS material was found by making use of a database (PALGA) with the search term upper airways. Further selection was done by making use of information given about the surgeon, diagnosis, and origin of the material (nose or paranasal sinuses). Data collected about the patients included name, gender, patient registration number, date of birth, material, diagnosis with linked codes, surgeon and date of material collection. The average age of patient population was 48 years. 46% was female. As the site of removal and the procedure were coded from the clinical information, topography and procedure were not always certain. All FESS material was investigated at the department of pathology at the SLAZ. The histological diagnosis was reported and Wled in the database. Standard histological examination consisted of macroscopic investigation, Wxation in formalin, often decalciWcation and microscopic examination of slides prepared with HE-staining on glass slide. No systematic slide review was done. Preparations were only reviewed if indicated. Patient Wles were studied only in case of diagnosis other than chronic inXammation with/without NP. PALGA did not provide information about the indication for surgery. Therefore, we were not able to distinguish between routine and diagnostic indications of histopathological examination. SigniWcant nose bleeds, unilateral pathology, diVerent aspect with nasendoscopy than normally seen with CRS with/without NP, palpable cervical lymph nodes, unexplained weight loss or unexplained constitutional symptoms (fever, fatigue) were regarded as warning signs for potential pathology other than CRS with/without NP, particularly (pre)malignant disease. In case of pathology other than CRS with/without NP, without preoperative clinical suspicion and with potential consequences for further treatment, the diagnosis was regarded as clinical signiWcant. Costs of histological examination were calculated by making use of COTG (Central Organ of Rates in Health System). The costs were 47.10 euro per patient, independent of how many slides were prepared. Between 2000 and 2007, 1,944 diVerent FESS specimens from 1,695 patients (some patients underwent revision surgery) were investigated microscopically. Most diagnoses were chronic inXammation and polyposis with/without eosinophilia. The histopathological diagnosis was NP with/ without inXammation in 1,101 patients (65%) and chronic inXammation in 557 patients (33%). In 37 (2.1%) of the 1,695 patients, the histopathological diagnosis was diVerent (Table 1). There were 18 inverted papillomas, 7 squamous cell papillomas, 2 malignant lymphomas, 1 Churg Strauss syndrome, 1 leiomyosarcoma, 1 Schneiderian papilloma, 2 cases of Wegeners granulomatosis, 3 cases of sarcoidosis, 1 papilloma with metaplastic changes and 1 squamous cell carcinoma (Table 2). The clinical Wles of these 37 patients were analysed, and the indication for surgery and risk factors were noted (Table 3). 27 patients were seen with unilateral pathology and were therefore suspicious for pathology other than CRS with/without NP, e.g., premalignancy, malignancy or other divergent diagnoses. In these cases FESS (...truncated)