Is surgery for severe type 2 nasal polyps safe under the treatment with biologics?

Abstract

In approximately 85% of US and European patients with uncontrolled severe chronic rhinosinusitis with nasal polyps (CRSwNP), the sinonasal mucosal tissues express increased concentrations of type 2 inflammatory interleukins (IL)-4, IL-5, and polyclonal immunoglobulin E (IgE). 1 Bachert C Marple B Schlosser RJ et al. Adult chronic rhinosinusitis. Nat Rev Dis Primers. 2020; 6: 86 Crossref PubMed Scopus (44) Google Scholar Well-designed phase 3 multicenter trials with type 2 targeted monoclonal antibodies have proved that biologic therapy may offer new treatment strategies for patients with severe type 2 CRSwNP who were not controlled by a standard of care. 2 Gevaert P Omachi TA Corren J et al. Efficacy and safety of omalizumab in nasal polyposis: 2 randomized phase 3 trials. J Allergy Clin Immunol. 2020; 146: 595-605 Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar ,3 Han JK Bachert C Fokkens W et al. Mepolizumab for chronic rhinosinusitis with nasal polyps (SYNAPSE): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Respir Med. 2021; 9: 1141-1153 Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar However, as biologics will not lead to a response in all patients, 2 Gevaert P Omachi TA Corren J et al. Efficacy and safety of omalizumab in nasal polyposis: 2 randomized phase 3 trials. J Allergy Clin Immunol. 2020; 146: 595-605 Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar , 3 Han JK Bachert C Fokkens W et al. Mepolizumab for chronic rhinosinusitis with nasal polyps (SYNAPSE): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Respir Med. 2021; 9: 1141-1153 Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar , 4 Bachert C Han JK Desrosiers M et al. Efficacy and safety of dupilumab in patients with severe chronic rhinosinusitis with nasal polyps (Liberty NP SINUS-24 and Liberty NP SINUS-52): results from two multicentre, randomised, double-blind, placebo-controlled, parallel-group phase 3 trials. Lancet. 2019; 394: 1638-1650 Abstract Full Text Full Text PDF PubMed Scopus (443) Google Scholar there still were patients with remaining polyp mass who needed to undergo surgery. The patient information leaflet of these biologics does not describe the consequences of performing sinus surgery in a patient on biologic treatment. Recently, a European expert opinion indicated that when the controlling level of the disease was not satisfied among patients after 6 months of biologics treatment, a “salvage surgery under biologic protection” might be considered to remove the remaining polyps. 5 Bachert C Han JK Wagenmann M et al. EUFOREA expert board meeting on uncontrolled severe chronic rhinosinusitis with nasal polyps (CRSwNP) and biologics: definitions and management. J Allergy Clin Immunol. 2021; 147: 29-36 Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar However, the benefit and the safety of surgery in this situation have not been found clearly. Furthermore, type 2 targeted biologics could decrease the expression of vascular endothelial growth factor and its receptor in nasal tissue, 6 Cavaliere C Masieri S Greco A Lambiase A Segatto M. Nasal expression of the vascular endothelial growth factor and its receptors is reduced by mepolizumab in chronic rhinosinusitis with nasal polyposis. Ann Allergy Asthma Immunol. 2021; 126: 442-443 Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar which might increase the potential of hemorrhage. Therefore, it is necessary to investigate the safety of performing sinus surgery in patients currently treated with type 2 biologics, and exclude increased risks associated with sinus surgery or disturbed postoperative wound healing, to develop optimized care pathways. 7 Bachert C Zhang N Cavaliere C Weiping W Gevaert E Krysko O. Biologics for chronic rhinosinusitis with nasal polyps. J Allergy Clin Immunol. 2020; 145: 725-739 Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar