Recurrent respiratory papillomatosis: the role of cidofovir

"A systematic literature review of the epidemiology, clinical, economic and humanistic burden in recurrent respiratory papillomatosis"

INTRODUCTION

Recurrent respiratory papillomatosis (RRP) is a chronic disease caused by human papillomavirus (HPV), characterized by recurrent papillomas in the respiratory tract. Presenting as either juvenile-onset RRP (JoRRP) or adult-onset RRP (AoRRP), the severity of the disease is subjective and unpredictable. Lack of curative therapies necessitates disease management involving repeated surgical removal of lesions. The review aimed to assess the clinical, humanistic and economic burden associated with RRP.

METHODS

Systematic literature reviews of Embase®, MEDLINE® and Cochrane databases were conducted for epidemiology, clinical, humanistic, and economic burden, from database inception to November 30, 2022. Conference abstracts were also searched (2019-2022). Key inclusion criteria consisted of juveniles or adults with RRP/laryngeal papillomatosis, with no restriction on study country, interventions, or comparators. Outcomes of interest included incidence, prevalence, risk factors, symptomatic presentation, HPV genotype, cost burden, resource use and health related quality of life (HRQoL).

RESULTS

In JoRRP, the incidence rate ranged from 0.2-2.1 per 100,000 and the prevalence rate ranged from 0.8-4.3 per 100,000. Incidence and prevalence of AoRRP were 0.2-3.9 and 0.4-8.4 per 100,000, respectively. Limited studies reported the subsequent impact of introducing national prophylactic HPV immunisation programs on JoRRP epidemiology, but where available, they were associated with significantly reduced incidence rates. Symptomatic presentations were diverse, with voice impact and breathing difficulties commonly reported. More aggressive disease was linked to earlier age of onset and HPV11 genotype. Healthcare utilisation was largely driven by surgical interventions, due to lack of curative treatments. Cost burden was substantial, with JoRRP associated with triple the costs of AoRRP in the US. Patients with JoRRP and AoRRP experienced considerable HRQoL impairment, particularly relating to voice disorder.

CONCLUSION

Extensive clinical, humanistic and economic disease burden was reported for both JoRRP and AoRRP, as it is a chronic condition, with propensity to recur and spread. Feasibility of improving HPV prophylactic vaccination coverage against HPV6/HPV11 should be explored to reduce incidence, alongside efforts to improve treatment of JoRRP and AoRRP patients. Despite the existing literature, RRP remains a poorly understood disease, and future research on risk factors and medical options are needed.

Evaluating the efficacy and safety of intralesional bevacizumab in the treatment of recurrent respiratory papillomatosis: A systematic review

PURPOSE

Recurrent respiratory papillomatosis (RRP) represents a clinical challenge, often necessitating multiple interventions to help mitigate against disease recurrence or airway obstruction. Multiple management strategies have been advocated by specialists regarding the management of RRP. However, the success rates and disease progression still vary widely. One promising treatment is bevacizumab, a vascular endothelial growth factor (VEGF) monoclonal antibody, which had been initially introduced systemically. More recently, intralesional bevacizumab has become one of the newest arms in dealing with RRP. The aim of this study is to systematically review the literature on the effectiveness, applicability and usage of intralesional bevacizumab in the treatment of RRP.

METHODS

A systematic search was carried out on MEDLINE, Embase, Journals@Ovid and PubMed. PRISMA guidelines were adhered to in the reporting of this study. Study quality and bias risk was assessed using the Newcastle-Ottawa Scale (NOS).

RESULTS

6 studies have met our inclusion and exclusion criteria, one randomised doubled blinded placebo-controlled pilot study, one case series, three prospective and one retrospective study, encompassing a total of 108 patients. Anatomical, functional and objective outcomes are presented and scrutinised. Where reported, complete remission or minimal recurrence was identified in 34/38 (89 %) patients following treatment with intralesional bevacizumab. However, outcome measures were not consistent across all studies making it difficult to draw direct comparisons. Of the 6 studies, 2 (33 %) were deemed poor quality and 4 (66 %) fair quality. No adverse effects of intralesional bevacizumab were reported.

CONCLUSIONS

This study's findings suggest a potential role for intralesional bevacizumab in the management of RRP objectively and functionally. Further research is required to necessitate a stronger evidence base, paying close attention to dose optimisation, assessment of long-term side effects and management of less severe disease phenotypes.

Results of CO2 laser surgery in laryngeal papillomatosis

Recurrent respiratory papillomatosis is medical condition strictly connected with HPV infection of the epithelium of the upper respiratory track. The main treatment of lesions located in larynx or lower pharynx includes microsurgical excision by using CO2 laser. A thorough preoperative assessment of patients is extremely important, which should not only be based on traditional laryngological examination, but also on endoscopy of the larynx and the use of the NBI (narrow band imaging) technique to assess the vascularization of lesions. In patients with recurrent papillomas, neoadjuvant therapy with antiviral agents or agents that inhibit angiogenesis is also often used. Among our group of 31 patients with laryngeal papillomas, 15 people (48%) required repeated surgical intervention and additional antiviral therapy while 10 (33%) people had to undergo the procedure three or more times due to disease recurrence. In this article we will discuss that laryngeal microsurgery with a CO2 laser is an effective method of treating patients with laryngeal papillomatosis and we will present the possibilities of adjuvant therapy.

Juvenile onset recurrent respiratory papillomatosis: What do we know in 2024 ?

Juvenile onset recurrent respiratory papillomatosis is a lifelong benign squamous lesion associated with HPV infection, particularly HPV6 and HPV11 genotypes. These lesions are rare, but can lead to laryngeal obturations, which can cause disabling dyspnea, or transform into squamous cell carcinoma. The aim here is to provide an epidemiological, biological and clinical overview of this pathology, particularly in children, in order to understand the issues at stake in terms of research and the development of medical and therapeutic management tools.

Surgical outcome of different surgical modalities for adult recurrent respiratory papillomatosis

BACKGROUND

Surgical debulking remains the mainstay of treatment of adult-onset recurrent respiratory papillomatosis (AO-RRP). But there are no guidelines for decision-making of surgical modality.

OBJECTIVES

This retrospective study aims to obtain a better understanding of AO-RRP, and select the best surgical modality for RRP among microdebrider, CO₂ laser, and KTP laser.

MATERIAL AND METHODS

Medical records of 72 AO-RRP patients were reviewed, with at least a 6-month follow-up. We focused on demographic data, the median treatment intervals (MTI) (Days), the survival curves, and treatment-related complications.

RESULTS

Seventy-two AO-RRP and a total of 172 surgical procedures were included, with either the microdebrider (n = 46), CO₂ laser (n = 102), or KTP laser (n = 24). The MTI of all patients was 230.0[132.0, 455.0] (median[P25-P75]), with microdebrider group (267.50[152.5, 449.5]), CO₂ laser group (247.5[145.5, 474.7]), and KTP laser group (107.5[68.3, 330.5]), and there were no significant differences among three surgical modalities on MTI or survival curves (p > .05). The duration of surgery was 44.9[25.6] in the microdebriders group, 48.4 [29.5] in the CO2 laser group, and 51.3[18.4] in the KTP laser group, but there was no significant difference in the operation duration among the three groups (p > .05). Postoperative glottic webs and scar formations were found in 4.3% of patients in microdebrider group, 16.7% of patients in CO₂ laser group, and 8.3% of patients in KTP group.

CONCLUSION AND SIGNIFICANCE

Microdebrider surgery for RRP took the shortest time and had the lowest rate of postoperative complications. However, different surgical modalities are equally effective in controlling recurrence after RRP surgery.

Safety of different surgical modalities for recurrent respiratory papillomatosis resection: A systematic review and meta-analysis

BACKGROUND

Currently, the most common surgical modalities used for recurrent respiratory papillomatosis (RRP) resection are microdebrider, carbon dioxide (CO₂ ) laser and potassium-titanyl-phosphate (KTP) laser. However, complication rates vary among different surgical modalities and have been controversial in different studies.

OBJECTIVE OF REVIEW

This study systematically reviews the available studies which reported intra-operative and post-operative complications, aiming to compare the safety of microdebrider, CO₂ laser and KTP laser.

TYPE OF REVIEW

Meta-analysis.

SEARCH STRATEGY

Seven electronic databases (PubMed/MEDLINE, EMBASE[Ovid], Scopus, Cochrane Library and Web of Science) were searched from inception through 28 April 2022. Randomised controlled, prospective or retrospective observational studies that recorded the complications of three different surgical modalities for RRP resection were included in the meta-analysis.

EVALUATION METHOD

Outcomes of interest were intra-operative and post-operative complications, and complication rate was calculated to evaluate the safety of surgical methods.

RESULTS

Twenty different studies were included in quantitative synthesis. Only one study compared outcomes of those three kinds of treatment modalities simultaneously, two studies compared microdebrider and CO₂ laser, and the remaining studies focussed on only one of three treatments. The weighted average complication rate for microdebrider was 0.03 (95% confidence interval [CI] 0.00-0.21), n = 6, for CO₂ laser treatment was 0.16 (95% CI 0.09-0.25), n = 14 and for KTP laser treatment was 0.04 (95% CI 0.00-0.14), n = 4.

CONCLUSION

The limited evidence demonstrated that CO₂ lasers in the surgical treatment of RRP may lead to more surgical complications, and microdebrider and KTP lasers may be safer. However, the heterogeneous data limit any strong comparison of outcomes of different treatment of laryngeal papillomas. Future randomised controlled trials that directly compare the safety of different surgical modalities are needed.

HPV and Recurrent Respiratory Papillomatosis: A Brief Review

Recurrent Respiratory Papillomatosis (RRP) is a rare but severe manifestation of human papillomavirus (HPV). As our knowledge about HPV infections has expanded, it has become possible to understand the course of RRP disease and unravel plausible efficient methods to manage the disease. However, the surge in reports on HPV has not been accompanied by a similar increase in research about RRP specifically. In this paper, we review the clinical manifestation and typical presentation of the illness. In addition, the pathogenesis and progression of the disease are described. On the other hand, we discuss the types of treatments currently available and future treatment strategies. The role of vaccination in both the prevention and treatment of RRP will also be reviewed. We believe this review is essential to update the general knowledge on RRP with the latest information available to date to enhance our understanding of RRP and its management.

[Research progress in the adjunct therapy of recurrent respiratory papillomatosis]

Recurrent respiratory papillomatosis （RRP） is a benign tumor of the respiratory tract caused by human papillomavirus （HPV） infection. At present, there is no cure for this disease, and mainly depends on surgical resection to relieve symptoms but cannot prevent recurrence. Multiple surgeries will bring heavy mental and economic burdens to patients and their families. Therefore, researchers are constantly seeking new treatments to reduce the number of operations and prevent recurrence. Hence, research on adjuvant therapy drugs has also been widely carried out, including bevacizumab, cidofovir, HPV vaccine, and Chinese medicine as an adjuvant drug according some reports. This article reviews the adjuvant treatment of RRP in recent years.

Vocal cord surgery and pharmacological treatment of a patient with HPV and recurrent respiratory papillomatosis

Recurrent respiratory papillomatosis (RRP) is caused by persistent infection of the respiratory epithelium by human papillomavirus (HPV), especially HPV 6 and 11. We present a case of surgically treated RRP. The main purpose of our protocol is to remove the lesions with a non-aggressive surgical technique and prevent recurrences with the use of cidofovir for local infiltrations in multiple sessions. We use low-power energy CO₂ laser, directed towards the upper part of the vocal cord, to determine a retraction of the mucosa with consequent coverage of the epithelium of the free edge. The aim of this technique is to treat and stop the formation of synechia of the anterior commissure and the free margin of the vocal cords in the anterior commissure. After 8 years follow-up, there are no signs of recurrence of the disease. The voice had a net improvement confirming the effectiveness of the protocol.