Current use of intralesional cidofovir for recurrent respiratory papillomatosis

Unachieved antiviral strategies with acyclic nucleoside phosphonates: Dedicated to the memory of dr. Salvatore "Sam" Joseph Enna

Many acyclic nucleoside phosphonates such as cidofovir, adefovir dipivoxil, tenofovir disoproxil fumarate, and tenofovir alafenamide have been marketed for the treatment or prophylaxis of infectious diseases. Here, this review highlights potent acyclic nucleoside phosphonates for their potential in the treatment of retrovirus (e.g., human immunodeficiency virus) and DNA virus (e.g., adeno-, papilloma-, herpes- and poxvirus) infections. If properly assessed and/or optimized, some potent acyclic nucleoside phosphonates can be possibly applied in the control of current and emerging infectious diseases.

Clinical Biomarkers in Otolaryngology-Head and Neck Surgery

OBJECTIVE

The purpose of this paper is to review the literature and compile promising and clinically relevant biomarkers in otolaryngology-head & neck surgery not related to autoimmune disorders.

STUDY DESIGN

Narrative review.

METHODS

PubMed and Google Scholar were queried using combined key words such as "biomarkers" and "otolaryngology." Additional queries were made with combined key words such as "biomarkers" and a particular subspecialty such as "rhinology" or "otology" to maximize yield of relevant titles. Subsequently, specific biomarkers identified, such as "beta-2 transferrin," were used as key words. Relevant titles were reviewed and selected for abstract review. Applicable abstracts were then selected for review of the full text.

RESULTS

Biomarkers currently in clinical use within the field of otolaryngology were included in this review. The compiled biomarkers were then detailed individually regarding their molecular characteristics, function, and clinical significance.

CONCLUSIONS

The number of biomarkers in use in otolaryngology is rapidly expanding representing a new diagnostic modality for our field. This review defines the key biomarkers that are currently or likely to be soon translated into clinical use within the field of otolaryngology. The majority of these biomarkers are in the form of proteins such as beta-2 transferrin, thyroglobulin, and P16. Given their growing impact on diagnosis, management and surveillance of otolaryngologic disorders periodic surveys are needed for education and to guide further advances and applications of otolaryngologic biomarkers.

Surgery and Adjuvant Therapy Improve Derkay Scores in Adult and Pediatric Respiratory Papillomatosis

OBJECTIVES/HYPOTHESIS

Comparing Derkay anatomical score at time of procedure, disease characteristics, and mean treatment interval among adult and pediatric patients with recurrent respiratory papillomatosis (RRP).

STUDY DESIGN

Restrospective study.

METHODS

Retrospective review of juvenile-onset (JO) and adult-onset (AO) RRP patients treated longitudinally at pediatric and adult institutions from 1999 to 2019. Patients were included if they had a tissue diagnosis of papilloma and had at least a 12-month follow-up.

RESULTS

One hundred and twelve patients met inclusion criteria (68 JO-RRP and 44 AO-RRP). All patients were stratified into either potassium titanyl phosphate (KTP) (n = 42), CO₂ (n = 21), or microdebrider (n = 49) treatment groups. The Derkay score improved between first and last procedure in the KTP group (mean difference, 3.5; P < .001), CO₂ group (mean difference, 4.4; P < .001), and microdebrider group (mean difference, 4.1; P < .001), but overall improvement did not differ across groups (P = .73). Baseline mean to last mean Derkay score improved for nine patients during bevacizumab treatments (mean difference, 3.0; P = .01) but did not improve for these same patients during an interval prior to receiving bevacizumab treatments. Baseline mean to last mean Derkay score improved for 19 patients during cidofovir treatments (mean difference, 3.84; P < .001) but did not improve for these same patients during the interval prior to receiving cidofovir treatments. The AO-RRP population had more patients with dysplasia (50%) compared to JO-RRP population (10%) (P < .001).

CONCLUSION

Various surgical modalities appear to be equally effective treatments for RRP. Adult and pediatric patients have decreased recurrent disease burden when receiving bevacizumab or cidofovir. AO-RRP patients have more concomitant dysplasia.

LEVEL OF EVIDENCE

3 Laryngoscope, 132:2420-2426, 2022.

Systemic and Intralesional Bevacizumab in Juvenile Onset Recurrent Respiratory Papillomatosis: A Report of Two Cases

Recurrent respiratory papillomatosis (RRP) is a stubborn disease. Despite volumes of researches done for a definite cause and management, the scientific community offers only theories for causation and options for treatments. Bevacizumab has emerged as a promising solution to the fear of sufferers of RRP of undergoing repeated surgeries. The patients who received bevacizumab, either systemically or intralesionally, show decreased need for surgeries mostly and even remission in a few. Till date there are limited studies of use of bevacizumab, in adults, but only reports of its use in pediatric population. This is a report of two cases of juvenile onset RRP with use of systemic bevacizumab infusion in a child and intralesional injection in an adult.

Juvenile Larynxpapillomatose

Hintergrund

Trotz multipler Therapieoptionen ist heutzutage eine Heilung der juvenilen rezidivierenden respiratorischen Larynxpapillomatose (JORRP, „juvenile onset recurrent respiratory laryngeal papillomatosis“) nicht möglich. Außerdem weisen viele Medikamente nicht zu unterschätzende Nebenwirkungen auf.

Fragestellung

Darstellung aktueller und früherer Therapieoptionen der JORRP mit Diskussion von Wirkstoff, Darreichungsart und Dosierungen.

Materialien und Methoden

Literaturrecherche und -zusammenfassung. Analyse der Therapieoptionen anhand von Wirkstoff, Darreichungsart, Dosierungen und Nebenwirkungen.

Ergebnisse

Die chirurgische Therapie bleibt weiterhin Grundlage der Therapie. Multiple Therapieoptionen werden beschrieben, jedoch keine mit der Aussicht auf eine vollständige Remission. Der Funktionserhalt der Stimme sowie die Verlängerung des Zeitintervalls zwischen den Eingriffen bzw. die Verminderung der Papillommasse im Rezidivfall bleiben oberstes Gebot. Neue immunmodulatorische Therapieoptionen werden aktuell näher untersucht.

Schlussfolgerungen

Einige der mannigfaltigen Therapieoptionen scheinen zwar vielversprechend zu sein und ein sicheres Nebenwirkungsprofil aufzuweisen, jedoch reicht die aktuelle Datenlage, die überwiegend auf Fallserien basiert, nicht für eine generelle Therapieempfehlung aus. Weitere prospektive Studien mit einer größeren Patientenzahl sind nötig.

The serum and tissue expression of vascular endothelial growth factor-in recurrent respiratory papillomatosis

OBJECTIVE

Recurrent respiratory papillomatosis (RRP) is known for its recurrent relapse despite various surgical and non-surgical treatments. Vascular Endothelial growth factor (VEGF) receptor expression on tissue is reported to be raised in RRP, and anti-VEGF targeted treatment is being explored to decrease recurrences. This study aims to identify the patients most suitable for systemic anti-VEGF therapy.

METHODS

The study design was a prospective cohort evaluation. The study group included all consecutive cases of RP treated surgically from November 2016-June 2019. Tissue receptor expression and serum levels of VEGF were assessed by immunohistochemistry and ELISA assay. Control samples for normal levels obtained by serum samples of healthy individuals and tissue samples obtained from healthy non-inflamed peripheral tissue of laryngectomy specimens. The tissue expression and serum levels of VEGF were compared with various disease-related factors of RP.

RESULTS

32 cases of RRPs were included in the study with a median age of 20.85 years (range: 3-60 years). The glottis was involved in all patients and tracheobronchial involvement was seen among 6 patients (18.75%). The systemic and tissue expression of VEGF-A was significantly higher among cases than controls (p= <0.001). The serum level of VEGF-A was significantly higher among cases with higher Derkay's score (>20) (p = 0.02) and tissue expression of VEGF-A was significantly higher in tracheobronchial RRP (p = 0.04).

CONCLUSION

Patients of RP with tracheobronchial involvement and high Derkay's score with strong tissue receptor expression & high serum level of VEGF can be identified as the patients wherein anti-VEGF monoclonal antibody treatment is more likely to be effective and merits further investigation to prove this.

An updated review of the epidemiological factors associated with recurrent respiratory papillomatosis

OBJECTIVES

To identify studies evaluating the epidemiology of recurrent respiratory papillomatosis (RRP), including patient demographics, human papillomavirus (HPV) immunology, clinical course, surgical and medical treatments, and psychosocial factors.

METHODS

A systematic literature search through PubMed was performed to identify studies evaluating the epidemiological factors associated with RRP. All studies were screened through a priori selection criteria using the titles and abstracts.

RESULTS

A total of 208 studies were identified, of which 54 met eligibility criteria and were included in the review.

CONCLUSIONS

RRP is a rare disease most commonly caused by HPV 6 and 11. It is characterized by recurring benign papillomatous lesions in the respiratory tract, particularly the larynx. Existing evidence about disease risk factors is limited but includes both maternal HPV infection and patient smoking and sexual behaviors. Disease management involves a combination of routine surgical and medical treatment. Surgical techniques include CO2-laser, sharp dissection, coblation, microdebridement, and photoangiolytic laser. Medical treatments which have been found to facilitate disease control off-label include interferon-alpha (IFN-α), indole-3-carbinol, acyclovir, bevacizumab, retinoids, and the Gardasil and mumps vaccines. Many patients suffer from additional psychosocial challenges related to their diagnosis. Current disease knowledge remains limited, and more robust controlled trials about risk factors, medical therapies, and surgical options are needed.

LEVEL OF EVIDENCE

5.

The Tale of Stridor and Wheezing in an Infant

Recurrent respiratory papillomatosis is a respiratory disease caused by human papillomavirus and can infect any part of the aerodigestive tract, but the larynx is most involved (Derkay et al. 2010). This report is a discussion about a 7-month-old male that presented to our institution for respiratory distress. He was admitted to the Pediatric Intensive Care Unit (PICU) for stabilization, observation, and further treatment and management due to an acute RSV infection. Initial efforts failed to improve his respiratory failure. A bronchoscopy was performed and showed various flesh-colored lesions throughout the larynx, vocal cords, and tracheal tree just above the carina. Pediatric otolaryngology performed an emergent debulking surgery to alleviate his respiratory failure. He has had multiple exacerbations of his condition since then and has required frequent debulking procedures with a few trials of intralesional bevacizumab therapies.

Evaluation of Safety of Intralesional Cidofovir for Adjuvant Treatment of Recurrent Respiratory Papillomatosis

Importance

The use of intralesional cidofovir injections for recurrent respiratory papillomatosis (RRP) remains controversial owing to concern regarding the risks of its use, including increased risk of dysplasia or carcinogenesis.

Objective

To describe the rates of dysplasia, development of malignant lesions, and adverse events associated with use of intralesional cidofovir injections as adjuvant treatment for RRP compared with patients treated without adjuvant cidofovir.

Design, Setting, and Participants

In this case series performed at a tertiary care referral center, review of electronic medical records on all adult and pediatric patients (N = 154) treated for RRP with adequate follow-up from January 1, 2000, to December 31, 2016, was performed. Data were collected on the use of cidofovir, development and presence of dysplasia or malignant lesions, complications, and intersurgical interval.

Exposures

Adjuvant intralesional cidofovir or surgical excision only.

Main Outcomes and Measures

The main outcomes measured were the development of dysplasia, malignant lesions, and complications from treatment. These outcomes were determined before collection of data.

Results

Of the 154 patients included in the analysis, 83 patients (53.9%) received adjuvant intralesional cidofovir and 71 patients (46.1%) underwent surgical excision only. One hundred patients (64.9%) were male; mean age was 27.7 (95% CI, 24.3-31.2) years. Patients were followed up for a median (interquartile range) of 70 (24-118) months in the noncidofovir group and 91 (47-152) months in the cidofovir group. There were no statistically significant differences in the rates of development of dysplasia (2.8%; 95% CI, -8.3% to 13.2%) or malignant lesions (2.2%; 95% CI, -5.3% to 11.2%) between the groups. No nephrotoxic effects were observed in the treated cohort, and only 5 minor complications that occurred in 628 injections were noted in the cidofovir group; 3 were related to direct laryngoscopy and 2 were related to needle malfunction.

Conclusions and Relevance

In this cohort of patients with RRP, adjuvant intralesional cidofovir injections did not appear to cause major complications or an increased rate of development of dysplasia and cancer.

Parenteral Bevacizumab for the Treatment of Severe Respiratory Papillomatosis in an Adult Population

OBJECTIVES/HYPOTHESIS

Recurrent respiratory papillomatosis (RRP) is a rare, potentially life-threatening, disease that impacts the voice, breathing, and quality of life of patients. Frequent surgical interventions may be needed to control symptoms. We examined the safety and efficacy of utilizing parenteral bevacizumab in the management of severe RRP in adults.

STUDY DESIGN

This is a retrospective review of clinical management approaches in a group of patients with severe RRP defined as having a high disease burden, frequent need for debridement, and/or tracheobronchial disease. Patients were initially treated with 15 mg/kg of bevacizumab at 3-week intervals. Bevacizumab dosing and frequency was then individually titrated down.

RESULTS

Fourteen adults received a median of 8.5 (range 2-17) bevacizumab infusions over approximately 24 months. All had a history of laryngeal RRP with 6/14 having additional tracheobronchial lesions. Patients required a median of 4 (range 2-11) procedures in the year prior to treatment. Only 3/10 (30%) patients who continued therapy required any additional procedures. Bevacizumab administration was generally well tolerated, with four patients discontinuing therapy. Medical reasons included severe epistaxis and hypertension and thrombocytopenia in an individual with systemic lupus erythematosus. Common side effects included hypertension (grade 2), headache (grades 1-2), elevated creatinine (grades 1-2), and epistaxis (grade 3).

CONCLUSIONS

Intravenous bevacizumab for the primary treatment of severe RRP in adults appears clinically effective and safe. Expected and typically mild side effects related to bevacizumab were observed. Continued investigation of bevacizumab through a prospective clinical trial is warranted.

LEVEL OF EVIDENCE

4. Laryngoscope, 131:E921-E928, 2021.

Spontaneous Regression of Recurrent Respiratory Papillomatosis with HPV Vaccination: A Case Study

OBJECTIVES

Recurrent respiratory papillomatosis (RRP) is characterized by recurrent laryngeal papillomas and treated with repeated surgical excision. The human papillomavirus (HPV) vaccine prevents infection with strains of HPV unrelated to RRP, and has recently been shown to increase the interval between surgeries when used as an adjuvant. The objective of this study was to report one case from our institution in which HPV vaccination was found to induce spontaneous regression of disease, absent of surgical intervention or use of other adjuvants.

STUDY DESIGN

Retrospective case study.

METHODS

Records of one patient with RRP receiving partial HPV vaccination was reviewed with attention to videolaryngostroboscopic findings, Derkay score, need for surgical intervention, and voice quality.

RESULTS

Spontaneous regression of disease after vaccination was seen in this patient, as evidenced by reduced tumor burden and decreased voice handicap index. The patient was a 30-year old female, who had improved disease burden and voice quality after one dose and total resolution of disease following the second dose. Vaccine administration was the sole therapeutic mechanism.

CONCLUSIONS

These findings suggest that HPV vaccination can treat RRP without surgical intervention. Further studies are needed to investigate the underlying mechanism of disease regression and which patients may benefit most. We believe that HPV vaccination for all patients with RRP, even over the age of 45 years, may decrease treatment costs for individuals and the healthcare system overall.

Bronchoscopic intratumoural therapies for non-small cell lung cancer

The past decade has brought remarkable improvements in the treatment of non-small cell lung cancer (NSCLC) with novel therapies, such as immune checkpoint inhibitors, although response rates remain suboptimal. Direct intratumoural injection of therapeutic agents via bronchoscopic approaches poses the unique ability to directly target the tumour microenvironment and offers several theoretical advantages over systemic delivery including decreased toxicity. Increases in understanding of the tumour microenvironment and cancer immunology have identified many potential options for intratumoural therapy, especially combination immunotherapies. Herein, we review advances in the development of novel bronchoscopic treatments for NSCLC over the past decade with a focus on the potential of intratumoural immunotherapy alone or in combination with systemic treatments.

Laryngeal sequelae secondary to surgical treatment for recurrent respiratory papillomatosis in children

OBJECTIVE

to describe the frequency and predictive factors associated with laryngeal scarring caused by surgical treatment of recurrent respiratory papillomatosis (RRP) in children.

INTRODUCTION

RRP is an important cause of hoarseness and respiratory obstruction in children. The current standard of care for RRP is the systematic and repetitive surgical interventions. The repetitive surgeries may increase the risk of sequelae. A larger number of surgeries, the surgical technique used, and disease severity are related to an increased risk of scarring.

MATERIAL AND METHODS

A retrospective, descriptive review of the medical charts of patients with RRP younger than 18 years was conducted. Between 2014 and 2017, 79 patients were identified; five patients were excluded. Demographic and clinical data were recorded and analyzed. The patients were divided into two groups, one with and the other without surgical sequelae, for comparison to identify sequela-associated factors.

RESULTS

75 patients, 40 (53.3%) male, were analyzed. Age at symptom onset ranged from 2 months to 13 years. Median age at the time of diagnosis was 42 months. Overall, 44% presented with disseminated disease. A median of nine (range, 1 to 86) surgeries were performed in each patient with a median of two (range, 0.6 to 10) of the average number of surgeries per year per patient. 29 patients (38.7%) had laryngeal sequelae. When comparing the patients with and without sequelae, statistically significant differences were found in the variables of dissemination during the course of the disease, overall number of surgeries and mean number of surgeries per year, history and number of previous surgeries at an outside institution, urgent surgeries, and CO2 laser use. Patients who underwent more than 10 surgeries or who had a history of previous surgeries at an outside institution had a higher frequency of laryngeal scarring in multivariate analysis.

CONCLUSION

Scarring secondary to surgical treatment for RRP is common. Surgery-related variables seem to be predisposing factors. A greater number of surgeries and surgeries performed at less specialized centers are strongly related to this complication. Future studies with a larger sample size are necessary to determine whether other factors are involved.

International Pediatric Otolaryngology Group (IPOG): Juvenile-onset recurrent respiratory papillomatosis consensus recommendations

OBJECTIVES

To develop consensus recommendations for the evaluation and management of juvenile-onset recurrent respiratory papillomatosis (JORRP) in pediatric patients.

METHODS

Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). The mission of the IPOG is to develop expertise-based consensus recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. The consensus recommendations herein represent the first publication by the group.

RESULTS

Consensus recommendations including diagnostic considerations, surgical management, systemic adjuvant therapies, postoperative management, surveillance, and voice evaluation. These recommendations are based on the collective opinion of the IPOG members and are targeted for otolaryngologists, primary care providers, pulmonologists, infectious disease specialists, and any other health care providers that manage patients with JORRP.

CONCLUSIONS

Pediatric JORRP consensus recommendations are aimed at improving care and outcomes in this patient population.

Paediatric virology and human papillomaviruses: An update

Almost 10 years ago, in October, 2008, the scientist who reported for the first time the association between human papillomaviruses (HPV) and cervical cancer, was awarded with the Nobel prize. In the years that followed, Professor Harald zur Hausen actively supported the value of the HPV vaccination in the prevention of different types of cancer and highlighted the necessity of its introduction in both girls and boys. However, to date, in the majority of countries, HPV vaccination among male adolescents has not been implemented into the national vaccination schemes, while in several countries, including Greece, the participation rate to HPV vaccination among female adolescents still remains low. Recent data indicate that catch-up HPV vaccination among young women has been extremely useful and has exhibited a significant effect in decreasing the prevalence of HPV. While the marketed current HPV vaccines prevent anogenital HPV infection, their impact on the natural history of oral HPV and their efficacy in preventing HPV-related head and neck carcinomas need to be further investigated. Juvenile onset recurrent respiratory papillomatosis, as well as HPV-associated conjunctival papillomas continue to be observed in childhood and their clinical management involves different therapeutic approaches with controversial outcomes. This review article provides an overview of recent views and advances on HPV infections and prevention in childhood that were presented at the '4th Workshop on Paediatric Virology' on Saturday September 22, 2018 in Athens, Greece.

Update on Recurrent Respiratory Papillomatosis

Recurrent respiratory papillomatosis (RRP) remains a challenging disease afflicting children and adults, resulting in an estimated $120 million per year in United States healthcare-related costs, with annual costs per patient approaching $60,000. Although the prevalence of RRP has declined, RRP remains the most common benign laryngeal neoplasm in children. RRP is unique in its high rate of multisite recurrence, its high burden on patient quality of life, and its high associated healthcare costs. This article summarizes current understanding of the natural history and quality of life burden of RRP, and basic science advancements in prevention and treatment.

Implementation of Routine HPV Vaccination in the Management of Recurrent Respiratory Papillomatosis

OBJECTIVES:

To investigate vaccine compliance and clinical outcomes after implementation of an initiative to provide the human papillomavirus (HPV) vaccine to all patients with recurrent respiratory papillomatosis (RRP).

METHODS:

A retrospective review was performed of all adult patients treated for RRP from 2012 to 2017. Rates of HPV vaccination were evaluated before and after December 2015, when a program was established to increase compliance by educating patients and providing financial assistance toward vaccine administration. Paired sample analyses were conducted to compare intersurgical intervals (ISIs) and number of procedures per year pre- and post-vaccination.

RESULTS:

Fourteen patients with RRP completed the HPV vaccine series, with 11 patients undergoing vaccination after the initiative began. The pre-initiative vaccination rate of all patients with RRP was 9.7%; post-initiative rates improved to 43.8% ( P = .004; odds ratio, 7.26). Of vaccinated patients, there were significant differences between mean pre-vaccine ISI (3.5 months) and post-vaccine ISI (12.8 months; P = .0021), as well as between number of surgical procedures performed per year before and after vaccination (2.7 vs 0.81; P = .014). After vaccination, 5 patients demonstrated no evidence of papilloma regrowth for >12 months.

CONCLUSIONS:

Initiatives focused on patient education and financial support can successfully boost HPV vaccination rates in an RRP patient cohort. Our research mirrors prior findings that HPV vaccination is correlated with an increase in time between procedures and a decrease in number of procedures needed per year-factors that can dramatically reduce the disease burden on patients coping with RRP.

Advances in Designing and Developing Vaccines, Drugs and Therapeutic Approaches to Counter Human Papilloma Virus

Human papillomavirus (HPV) is a viral infection with skin-to-skin based transmission mode. HPV annually caused over 500,000 cancer cases including cervical, anogenital and oropharyngeal cancer among others. HPV vaccination has become a public-health concern, worldwide, to prevent the cases of HPV infections including precancerous lesions, cervical cancers, and genital warts especially in adolescent female and male population by launching national programs with international alliances. Currently, available prophylactic and therapeutic vaccines are expensive to be used in developing countries for vaccination programs. The recent progress in immunotherapy, biotechnology, recombinant DNA technology and molecular biology along with alternative and complementary medicinal systems have paved novel ways and valuable opportunities to design and develop effective prophylactic and therapeutic vaccines, drugs and treatment approach to counter HPV effectively. Exploration and more researches on such advances could result in the gradual reduction in the incidences of HPV cases across the world. The present review presents a current global scenario and futuristic prospects of the advanced prophylactic and therapeutic approaches against HPV along with recent patents coverage of the progress and advances in drugs, vaccines and therapeutic regimens to effectively combat HPV infections and its cancerous conditions.

Current and future management of recurrent respiratory papillomatosis

Objectives

Recurrent respiratory papillomatosis (RRP) is a chronic disease of the respiratory tract that occurs in both children and adults. It is caused by the human papillomavirus (HPV), in particular low‐risk HPV6 and HPV11, and aggressiveness varies among patients. RRP remains a chronic disease that is difficult to manage. This review provides perspectives on current and future management of RRP.

Results

The current standard of care is surgical excision, with adjuvant therapies as needed. Surgical management of RRP has evolved with the introduction of microdebriders and photoangiolytic lasers; the latter can now be used in the office setting. Numerous adjuvant pharmacologic therapies have been utilized with some success. Also, exciting preliminary data show that HPV vaccines may prolong the time to recurrence in the RRP population. There is also optimism that wide‐spread HPV vaccination could reduce RRP incidence indirectly by preventing vertical HPV transmission to newborns.

Conclusion

To date, the biology of RRP is not well understood, although it has been noted to become more aggressive in the setting of immune suppression. Additional research is needed to better understand immune system dysfunction in RRP such that immunomodulatory approaches may be developed for RRP management.

Level of Evidence

4

Comparison of cidofovir and the measles, mumps, and rubella vaccine in the treatment of recurrent respiratory papillomatosis

We conducted a retrospective study of the use of cidofovir and the measles, mumps, and rubella (MMR) vaccineas adjunctive treatments to lesion debridement in patients with recurrent respiratory papillomatosis (RRP). Our study population was made up of 15 children-7 boys and 8 girls, aged 1 to 16 years at diagnosis (mean: 6.2)-with pathologically confirmed RRP who had been followed for at least 1 year. In addition to demographic data, we compiled information on disease severity, the type of adjunctive treatment administered to each patient, the frequency of debridements, the length of observation, and remission rates. Of the 15 patients, 5 had been treated with cidofovirafter debridement (cidofovir-only group), 6 were treated with MMR vaccine after debridement (MMR-only group), 3 were treated with one and later switched to the other based on parental preference, and 1 received neither treatment, only debridement. The initial mean Derkay disease severity scores were 12.6 for the cidofovir-only group and 11.0 for the MMR-only group (p = 0.61). The cidofovir-only patients underwent an average of 11.8 adjunctive treatments and the MMR-only patients an average of 17.7 (p = 0.33). The average duration of observation was 44.0 months in the cidofovir-only group and 64.7 months in the MMR-only group (p = 0.29). Remission rates were 20% in the cidofovir-only group and 50% in the MMR-only group (p = 0.54). Our study found insufficient evidence of any significant differences between cidofovir and the MMR vaccinein terms of the number and frequency of adjunctive treatments and the rates of remission.

Economic impact of recurrent respiratory papillomas in a UK adult population

Objective:

To calculate the financial burden of recurrent respiratory papilloma. This study is UK-based, where up until now no financial estimates have been calculated for this group of patients.

Background:

Recurrent respiratory papilloma is caused by the human papilloma virus (subtypes 6 and 11). The burden for the patient and the healthcare system is significant given the recurrent nature of the disease.

Methods:

Data were collected, using a questionnaire completed during routine clinical follow up, from a single centre managing recurrent respiratory papilloma in Glasgow, Scotland. Cost information was sourced from the Scottish Government's Information Services Division.

Results:

Fourteen patients with active recurrent respiratory papilloma between 2013 and 2014 were identified. The direct measurable cost to NHS Greater Glasgow and Clyde amounted to £107 478.

Conclusion:

Recurrent respiratory papilloma is a benign condition, but the financial implications of diagnosis are significant. Recurrent respiratory papilloma has a natural history of relapse and remission, and patients may require healthcare input over a period of several years.

Recurrent respiratory papillomatosis in northern Sweden: clinical characteristics and practical guidance

CONCLUSION

Recurrent respiratory papillomatosis (RRP) patients with high surgical treatment frequency (≥ 1/year, HF) were significantly younger and had a more widespread laryngeal disease compared to a low frequency treated group (< 1 treatment/year, LF). This study confirms the existence of a clinical RRP group, not primarily related to HPV sub-type, but more care-intensive and in need of more vigilant follow-up.

OBJECTIVES

RRP is associated with high morbidity due to its influence on breathing and voice. The purpose of this study was to characterize RRP patients in northern Sweden and investigate possible predictor factors affecting therapeutic needs.

METHOD

Patients from the regional referral area (northern Sweden) were categorized for age, disease duration, juvenile or adult onset, profile of disease development, number of surgical sessions in relation to disease duration, laryngeal deposition of papilloma, gender, and HPV sub-types, in order to identify patients with increased need for frequent surgical treatment.

RESULTS

The median age of the RRP patients (n = 48) was 44.5 years; 34 (71%) were males and 14 (29%) females, most were infected with HPV 6. Patients with high surgical treatment frequency/year were significantly younger and showed more widespread papillomatous vegetation in the larynx, compared to the low frequency treated group.

Recurrent respiratory papillomatosis: current and future perspectives

Although recurrent respiratory papillomatosis is a benign disease of the upper aerodigestive tract caused by infection with human papillomavirus, the disease process is unpredictable, ranging from mild disease and spontaneous remission to an aggressive disease with pulmonary spread and requirement for frequent surgical debulking procedures. It can present a protracted clinical course and cause potentially life-threatening compromise of the airways. Over recent decades, a number of alternative medical therapies to standard surgical treatment have been investigated, with modest outcomes overall. Currently, some additional therapies are being explored, together with novel surgical instrumentation that can help to avoid inevitable long-term stenotic complications, ultimately affecting quality of life. Hopefully, clinicians might soon be able to significantly improve the quality of treatment and outcomes for patients affected with recurrent respiratory papillomatosis, with human papillomavirus vaccination having a potentially important role.

Recurrent respiratory papillomatosis of the airway: The experience of an endoscopic unit

INTRODUCTION

Recurrent respiratory papillomatosis (RPP) is a rare benign neoplasm caused by human papillomavirus (HPV). RPP is characterized by recurrent proliferation of the papillomata in the respiratory tract.

OBJECTIVES AND METHODS

Retrospective analysis of all adult patients with diagnosis of recurrent respiratory papillomatosis admitted to our endoscopic unit between 2000 and 2013 with histological proved papillomatosis.

RESULTS

Four patients were included (3 women) with an average age of 53±19 years (27-72). Before endoscopy unit admission, all the patients have been previously submitted to surgical removal of the papillomas with a median number of surgeries per patient of 6.5. These patients were submitted to therapeutic endoscopy and the most frequent endoscopic treatments were Laser YAG and local injection of cidofovir. All the patients treated with cidofovir presented complete remission of the disease. The median follow-up was 6 years: 2 presented malignant transformation to epidermoid carcinoma and 1 had severe dysplasia on the histological examination. We describe the four cases due to different forms of presentation.

CONCLUSION

Papillomatosis of the airway is a rare condition predisposing to malignant transformation. RRP tends to recur and repeated surgeries are needed to remove papillomatas. Endoscopic treatment is important for the removal of the papillomas that are not accessible via laryngoscopy (YAG Laser, cryotherapy, etc.) and for resistant moderate/severe cases of RPP because it allows intralesional administration of adjuvant therapy like cidofovir.

Pathologies of the larynx and trachea in childhood

Pathologies in the larynx and trachea in the pediatric age can be characterized in 4 main groups: airway stenosis, acute infections, benign neoplasia and foreign body aspiration. In this review main diagnostic strategies and therapeutic options are presented. Laryngomalazia is the most frequent condition of supraglottic stenosis. The term supraglottoplasty summarizes all different techniques used for it's repair using an endoscopic approach. Glottic stenosis is rare in children. Usually a compromise between voice preservation and airway restoration has to be sought. Type of reconstruction and timing are varying considerably in individual cases, endoscopic approaches should be preferred. Subglottic stenosis remains the largest group in paediatric airway pathology, with cicatrial stenosis being predominant. Today, cricotracheal resection is the most successful treatment option, followed by the classical laryngotracheal reconstruction with autologous cartilage. In early infancy subglottic stenosis is particularly demanding. Endoscopic treatment is possible in selected patients, but open reconstruction is superior in more severe cases. Tracheostomy is not a safe airway in early infancy, it's indication should be strict. Foreign body aspiration needs to be managed according to a clear algorhythm. Recurrent respiratory papillomatosis should be treated with emphasis on function preservation. The role of adjuvant medication remains unclear. Infectious diseases can be managed conservatively by a pediatrician in the majority of cases.

Clinical efficiency of quadrivalent HPV (types 6/11/16/18) vaccine in patients with recurrent respiratory papillomatosis

The aim of the study was to assess the clinical efficiency of quadrivalent HPV (types 6/11/16/18) vaccine in patients with recurrent respiratory papillomatosis (RRP). This was a prospective study of patients with RRP treated from January 2009 to July 2012 at the Ear, Nose and Throat Department of the Emergency County Hospital of Cluj-Napoca, Romania. Demographic characteristics, onset of RRP, HPV typing, use and number of cidofovir injections, number of surgeries for RRP per year, and use of human papillomavirus vaccine (types 6, 11, 16, 18) (recombinant, adsorbed)/Silgard® were considered from all the patients included in the study. Charts were reviewed for follow-up after diagnosis, after cidofovir, and after Silgard; all the statistical tests were applied at a significance level of 5%. The recurrences were observed within 27.53 ± 11.24 days after intralesional cidofovir injection. Thirteen patients with recurrence after cidofovir agreed and received Silgard® vaccine. 85% [54.44–99.41] of patients had no recurrences during 1-year follow-up. The recurrence of papillomas was observed in two patients (15%, 95% CI [0.59–45.56]), one with adult-onset RRP and one with juvenile-onset RRP. Both recurrences appeared after the first Silgard dose; one month after the third vaccine dose each patient underwent a new surgery for remaining papillomas with no recurrences at 1-year follow-up visit. Silgard® vaccination had a good effect and proved to be efficient in the treatment of our patients with RRR without appearance of recurrence in 85% of the patients during 1-year follow-up.

Trends in the management of recurrent respiratory papillomatosis in Japan

OBJECTIVE

Recurrent respiratory papillomatosis (RRP) has historically been and still continues to be a difficult disease to treat. The present study aimed to characterize current practices in the treatment of RRP in Japan.

METHODS

A questionnaire was posted to the Department of Otolaryngology of all 80 central university hospitals in Japan.

RESULTS

A total of 56 universities responded to the survey. Regarding the use of surgical instruments, a trend toward a preference for lasers (50 hospitals) rather than a microdebrider (16 hospitals) or cold instruments (20 hospitals) was observed. Among the 50 hospitals frequently performing laser surgery, a carbon dioxide (CO2) laser was most commonly used, followed by a potassium-titanyl-phosphate (KTP) laser. The most favored adjuvant therapy was traditional Chinese medicine. Eight of the 56 university hospitals had an experience of using cidofovir, involving a total of 28 patients.

CONCLUSION

The present study demonstrated the current trends in the management of RRP based on a questionnaire survey in a geographical area other than the US and UK for the first time. Treatment trends were generally similar in all three areas except for the least popular use of cidofovir in Japan.

Insights into the mechanism of action of cidofovir and other acyclic nucleoside phosphonates against polyoma- and papillomaviruses and non-viral induced neoplasia

Acyclic nucleoside phosphonates (ANPs) are well-known for their antiviral properties, three of them being approved for the treatment of human immunodeficiency virus infection (tenofovir), chronic hepatitis B (tenofovir and adefovir) or human cytomegalovirus retinitis (cidofovir). In addition, cidofovir is mostly used off-label for the treatment of infections caused by several DNA viruses other than cytomegalovirus, including papilloma- and polyomaviruses, which do not encode their own DNA polymerases. There is considerable interest in understanding why cidofovir is effective against these small DNA tumor viruses. Considering that papilloma- and polyomaviruses cause diseases associated either with productive infection (characterized by high production of infectious virus) or transformation (where only a limited number of viral proteins are expressed without synthesis of viral particles), it can be envisaged that cidofovir may act as antiviral and/or antiproliferative agent. The aim of this review is to discuss the advances in recent years in understanding the mode of action of ANPs as antiproliferative agents, given the fact that current data suggest that their use can be extended to the treatment of non-viral related malignancies.

High-dose sublesional bevacizumab (avastin) for pediatric recurrent respiratory papillomatosis

OBJECTIVES

We review and report the use of high-dose bevacizumab for the treatment of recurrent respiratory papillomatosis (RRP) in pediatric patients.

METHODS

We included all patients with pediatric-onset RRP who underwent bevacizumab (25 mg/mL) injections by a single practitioner. A series of 5 consecutive subepithelial injections were administered at 4- to 6-week intervals with concomitant 532 nm KTP laser ablation. The lesions were staged according to the Derkay staging system. The outcomes included pretreatment and posttreatment Derkay scores, the time interval between procedures, and voice outcomes. The demographic data extracted included sex, age at diagnosis, and current age.

RESULTS

Nine patients were included in this study, with 1 patient lost to follow-up; their median age was 8 years (range, 3 to 21 years). The mean bevacizumab dose was 14.25 mg (range, 5 to 45 mg). There was a median Derkay score of 11.5 (range, 4 to 23) at the time of diagnosis and a median 58% improvement following therapy. All patients demonstrated an increased time interval between injections, for a median improvement of 2.05× (range, 1.6× to 3.25×).

CONCLUSIONS

Evidence exists in support of vascular endothelial growth factor as an important factor in the development of RRP. Although some variability in response is demonstrated by this study, high-dose bevacizumab appears to yield promising results for pediatric patients with RRP.

Intralesional cidofovir as adjuvant for the successful management of aggressive respiratory papillomatosis in an infant

Recurrent respiratory papillomatosis (RRP) in young children is frequently characterized by a recalcitrant course and need for multiple surgeries. Periodic surgical debulking and ablation is the mainstay of therapy as a cure for RRP rarely occurs. Benefits of adjuvant treatment with local injection of cidofovir in aggressive cases of RRP have been reported in both children and adults. However, a consensus on initiation, dosage, or scheduling of this drug has not been established in the very young patient. Literature on successful remission in children less than 1 year of age is not available. One such case of an infant with aggressive RRP treated with local adjuvant cidofovir is described herein.

Prevalence of diabetes mellitus and its impact on disease severity in adult recurrent respiratory papillomatosis

OBJECTIVES

Following human papilloma virus (HPV) infection, recurrent respiratory papillomatosis (RRP) develops secondary to dysfunction of innate and adaptive immune responses. Diabetes mellitus (DM) is a common medical disorder; these patients are considered to be relatively immunocompromised. It is hypothesized that comorbid DM occurs more frequently than expected in a cohort of adult RRP patients and that RRP patients with DM have more severe disease than those without DM.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care laryngology practice, 5-year period.

SUBJECTS AND METHODS

Adult-onset RRP patients from 2007 to 2012 at the University of Washington were reviewed. The gender, age of onset of RRP, number of interventions, pathology, presence or absence of DM, and calculated anatomic Derkay severity score were recorded.

RESULTS

Eighty-four adult RRP patients were characterized; 64 male (76%) and 20 female (24%). Six of 84 patients (7.1%) had DM; this prevalence was not higher than an age-matched general population. The number of interventions required for disease control did not significantly differ (P = .13) between adult RRP patients with DM (avg 2.6/yr, median 2.3/year) and those without DM (avg 1.9/yr, median 1.3/yr). There was no significant difference in anatomic Derkay score at the time of intervention (P = .26) or presence of dysplasia in biopsy specimens (P = .49) between RRP patients with and without DM.

CONCLUSIONS

In this large series of adult RRP patients, DM does not appear to have a higher prevalence than that seen in age-matched controls, nor do RRP patients with DM appear to have more severe disease.

Epidermal growth factor receptor inhibitor therapy for recurrent respiratory papillomatosis

The epidermal growth factor pathway has been implicated in various tumors, including human papillomavirus (HPV) lesions such as recurrent respiratory papillomatosis (RRP). Due to the presence of epidermal growth factor receptors in RRP, epidermal growth factor receptor (EGFR) inhibitors have been utilized as adjuvant therapy. This case series examines the response to EGFR inhibitors in RRP. Four patients with life-threatening RRP were treated with EGFR inhibitors. Operative frequency and anatomical Derkay scores were calculated prior to, and following EGFR inhibitor treatment via retrospective chart review. The anatomical Derkay score decreased for all four patients after initiation of EGFR inhibitor therapy. In one patient, the operative frequency increased after switching to an intravenous inhibitor after loss of control with an oral inhibitor. In the other patients there was a greater than 20% decrease in operative frequency in one and a more than doubling in the time between procedures in two.  This study suggests that EGFR inhibitors are a potential adjuvant therapy in RRP and deserve further study in a larger number of patients.