Experience of 11 years use of cidofovir in recurrent respiratory papillomatosis

Intralesional cidofovir vs. bevacizumab for recurrent respiratory papillomatosis: a systematic review and indirect meta-analysis

BACKGROUND

Specific HPV types cause recurrent respiratory papillomatosis (R.R.P.). When administered intralesionally, cidofovir, an antiviral agent, has shown favorable outcomes in reducing papilloma. Bevacizumab, an angiogenesis inhibitor, has demonstrated improved R.R.P. However, both treatments lack FDA approval for R.R.P. Our study aims to evaluate the efficacy and safety of intralesional Cidofovir and Bevacizumab for R.R.P. and compare the two interventions.

METHODS

We searched five electronic databases to find relevant studies. After the screening, data were extracted from the included studies. Pooled ratios with 95% confidence intervals (CIs) were used for categorical outcomes, and mean difference (MD) was used for continuous outcomes. Statistical heterogeneity was evaluated using the chi-squared test for I2 statistics. The Cochrane Risk of Bias assessment tool was used to assess the methodological quality of randomized controlled trials (RCTs), while the National Institutes of Health's tool was used for observational studies. Analysis was done by Review Manager software.

RESULTS

In our comprehensive meta-analysis of 35 articles involving 836 patients, cidofovir demonstrated an overall remission ratio of (0.90 [95% CI: 0.83, 0.98], p = 0.01), while bevacizumab (0.92 [95% CI: 0.79, 1.07]), p = 0.3). The complete remission ratio for cidofovir was (0.66 [95% CI: 0.57, 0.75], p > 0.0001), while bevacizumab was (0.29 [95% CI: 0.12, 0.71], p = 0.07). In partial remission, Bevacizumab showed a higher ratio than Cidofovir 0.74 [0.55, 0.99] vs. 0.40 [0.30, 0.54]. Bevacizumab had a pooled ratio of 0.07 [95% CI: 0.02, 0.30] in terms of no remission, indicating better outcomes compared to Cidofovir with a ratio of 0.28 [95% CI: 0.16, 0.51]. Additionally, Cidofovir showed a favorable decrease in the Derkay Severity Score (DSS) with a mean difference (MD) of 1.98 [95% CI: 1.44, 2.52].

CONCLUSION

Cidofovir had a higher impact on complete remission compared to Bevacizumab. Both showed partial remission, with Bevacizumab having a higher ratio. Moreover, Cidofovir showed a significant decrease in DSS. Bevacizumab had lower rates of no remission and recurrence and fewer adverse events compared to Cidofovir. However, the difference between the two treatments was not significant, except for partial remission.

Intralesional Cidofovir: A Systematic Review of Administration Protocols and Long-term Recurrence Rates in Adult and Juvenile Recurrent Respiratory Papillomatosis

OBJECTIVE

This is a systematic review aimed to explore Cidofovir administration protocols, recurrence rates, and long-term effectiveness for severe cases of recurrent respiratory papillomatosis (RRP). The primary goal was to identify current practices, determine the preferred protocol, and assess the adjuvant therapy's ability to prevent long-term papilloma recurrence in juvenile and adult-onset disease.

METHODS

The following databases were searched: Pubmed, Google Scholar (pages 1-10), EMBASE, Scopus, ISI (clarivate), Cochrane Library, and Journal Storage from 1996 to June 2022. Articles that reported the use of intralesional Cidofovir in RRP and reported remission/recurrence rates with follow-up were included in the review. The systematic review was registered through PROSPERO and contains the detailed protocol for the conduction of the review.

RESULTS

A total of 389 records were identified, 126 titles and abstracts screened, 45 studies fully read, and 30 studies met the inclusion criteria. Two hundred and fourteen adult-onset RRP (AORRP) and 126 juvenile-onset RRP (JORRP) cases were treated with Cidofovir across the included studies. There was no universal protocol for administering Cidofovir, with variations in concentration, treatment period, number and interval of injections, and follow-up duration. Most lesions showed human papilloma virus types 6 and 11. Recurrence rates varied, and other outcomes reported included remission rates, lesion reduction, surgical intervals, and side effects. Some studies demonstrated significant improvements in disease severity and extended intervals between recurrences after Cidofovir administration.

CONCLUSIONS

The analysis of 30 studies reveals the need for greater consistency in reporting treatment parameters and outcomes. The use of recurrence-free period as an outcome measure and the potential benefits of a concentration of 7.5 mg/mL are identified. Additionally, the importance of viral typing within papilloma lesions is emphasized. To further enhance understanding and establish optimal protocols, future research should focus on uniform reporting, including severity, dosage, interval, treatment duration, functional outcome, and related procedures.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022299549.

Aggressive recurrent respiratory papillomatosis: A series of five consecutive patients successfully treated with adjuvant intravenous bevacizumab. A single Belgian academic center experience

BACKGROUND

Recurrent respiratory papillomatosis (RRP) is a currently incurable benign neoplasm caused by human papilloma virus (HPV) infection. It usually reduces voice, respiratory, and general quality of life, and is sometimes life-threatening. Patients usually need repeated operations. The use of adjuvant bevacizumab, a monoclonal antibody targeting vascular endothelial growth factor A, has been described in several case reports, with a good efficacy and safety profile.

METHODS

We report the cases of five patients with aggressive RRP who were treated with adjuvant systemic bevacizumab in a single Belgian tertiary center.

RESULTS

A complete response was achieved in four patients after a median of 4.5 months, and a partial response in one. In all cases, the number of surgeries was drastically reduced, and quality of life improved. Toxicity was easily managed.

CONCLUSIONS

Systemic bevacizumab seems to be an effective and safe adjuvant treatment for aggressive RRP.

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.

Juvenile-Onset Recurrent Respiratory Papillomatosis Diagnosis and Management - A Developing Country Review

Recurrent respiratory papillomatosis (RRP) is a condition caused by human papillomavirus (HPV), usually HPV types 6 and 11, which is characterized by recurrent papillomas of the respiratory tract, mainly the larynx. Patients usually present between the ages of 2 and 6 years. The initial presenting symptom is progressive dysphonia, followed by stridor and respiratory distress. Treatment consists of repeated microlaryngoscopic procedures to remove the papillomas as there is no cure. The poor availability and accessibility of appropriate healthcare services in developing countries are barriers to the early diagnosis and appropriate management of patients with juvenile-onset recurrent respiratory papillomatosis (JoRRP), requiring many patients to have a tracheostomy. The introduction of prophylactic vaccines that include HPV6 and HPV11 is necessary in order to reduce the incidence of JoRRP.

Treatment With Quadrivalent Human Papillomavirus Vaccine for Juvenile-Onset Recurrent Respiratory Papillomatosis: Case Report and Review of the Literature

Although juvenile-onset recurrent respiratory papillomatosis (JoRRP) generally involves a benign tumor on the larynx and other respiratory tract areas, almost all patients with this disease require repeated surgical intervention (to prevent airway obstruction during the course of illness) and various adjuvant therapies such as interferon, cidofovir, acyclovir, ribavirin, indole-3-carbinol, HspE7, mumps vaccine, photodynamic therapy, propranolol, cimetidine, and bevacizumab. Some case reports recently described the effectiveness of the quadrivalent human papillomavirus vaccine (HPV4) as an adjuvant therapy. On the basis of these reports, we administered HPV4 to a 2-year-old boy with JoRRP. However, no therapeutic effect was found. A review of the available literature revealed that current evidence for the effectiveness of therapeutic HPV4 and other adjuvant therapies for JoRRP is inconsistent. Therefore, the prophylactic use of currently available HPV vaccine for adolescents is the most effective strategy for preventing not only anogenital cancers but also genital warts, which might be a risk factor for JoRRP among their children in the future.

The use of the quadrivalent human papillomavirus vaccine (gardasil) as adjuvant therapy in the treatment of recurrent respiratory papilloma

OBJECTIVE

To examine the effect of the quadrivalent human papillomavirus vaccine, Gardasil, on the disease course of patients with recurrent respiratory papillomatosis (RRP).

METHODS

A retrospective chart review of patients with RRP was conducted and 20 patients were selected who had received the Gardasil vaccine as part of their treatment. Efficacy was assessed by calculating the intersurgical interval (ISI) before and after receiving the vaccine, as well as number of complete and partial remissions.

RESULTS

Analysis of all patients found a significant increase in the ISI of 3.1 months (95% confidence interval [CI]: 1.02-5.19, P=0.0061). Male patients experienced an increase in the ISI of 4.2 months (95% CI: 1.6-6.7, P=0.0048). Female patients had a nonsignificant increase in ISI of 1.2 months (95% CI: 3.1-5.4, P=0.51). Eight patients (40%; six male and two female) experienced complete remission. Five patients (25%) overall (three male and two female) experienced partial remission. In total, complete or partial remission was achieved in a total of 13 (65%) patients (nine male and four female).

CONCLUSIONS

The Gardasil vaccine can modulate the severity of RRP and induce remission in some patients. The effect was much greater in males and in females in low estrogen states.

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.

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.

HPV associated with recurrent respiratory papillomatosis

Papillomaviruses are members of the Papillomaviridae family. Over 150 HPV types have been identified. Recurrent respiratory papillomatosis (RRP) is a chronic condition caused by HPV characterized by recurrent papillomas of the respiratory tract, mainly the larynx. During the early stages, the condition presents with hoarseness, while more advanced disease presents with stridor and respiratory distress. There is no specific cure and treatment consists of repeated surgical procedures to remove the papillomas. Most patients eventually go into remission, but some suffer for many years with this condition, which may be fatal. HPV-6 and HPV-11 are the HPV types most commonly associated with RRP. Although most studies have found RRP due to HPV-11 to be more aggressive than disease due to HPV-6, the variability in disease aggressiveness is probably multifactorial. Information regarding the current epidemiology, molecular diversity and host immune responses is important for strategizing ways to reduce disease. Data on HPV genotypes associated with RRP would provide valuable information for vaccination programs to reduce the incidence of these genotypes in mothers and, in the long term, reduce the incidence of RRP in children. This review focuses on HPV-6 and HPV-11 as the HPV types that cause RRP, and discusses the viral genome and replication, clinical presentation of RRP, current techniques of diagnosis and genotyping, and the molecular diversity of HPV-6 and HPV-11.