Juvenile Laryngeal Papillomatosis in a Pediatric Population: A Clinicopathologic Study

Effectiveness of combined approach to recurrent respiratory papillomatosis (RRP)

PURPOSE

Recent approaches for recurrent respiratory papillomatosis including local injection of bevacizumab and HPV vaccination show promise in reducing the need for frequent surgeries. In this study we propose a new combined approach of surgery, intralesional injection of 25 mg bevacizumab and HPV vaccine that can lead to resolution of RRP.

MATERIAL AND METHODS

Our study involved 5 patients treated with a combination of transoral microsurgery, intralesional injection of 25 mg bevacizumab, and HPV vaccination with Gardasil 9 between April 2020 and May 2023. Standard video laryngoscopy was performed to assess the presence of papilloma and Derkay score was used to assess the severity of disease.

RESULTS

All 5 patients completed the study successfully and a complete response was achieved by all. The follow-up ranged from 8 to 45 months. The mean total Derkay score before treatment was 41 (range 25 to 52) and after the combined approach was 0 both anatomically and clinically in all patients.

CONCLUSIONS

This study demonstrates the effectiveness of a combined treatment approach for RRP involving surgical intervention, intralesional injection of bevacizumab, and HPV vaccination.

[Papillomatosis of the larynx in children: the current state of the problem]

There is the authors have considered variants of modern methods of medical and surgical treatment of laryngeal papillomatosis in children in the review, based on the etiology of the disease. The analysis of the effectiveness of new methods of combined treatment with the use of modern technologies, taking into account their advantages and disadvantages. The possible prospects for further study problems and develop new methods of adjuvant therapy.

On surmounting the barriers to HPV vaccination: we can do better

The major impediment to increased human papillomavirus (HPV) vaccination coverage in young males and females is lack of health care provider recommendation. Despite its efficacy in preventing cervical cancer, HPV vaccination in females (49.5%) and males (37.5%) ages 13 through 17 falls well below the Centers for Disease Control and Prevention's (CDC) Healthy People 2020 target of 80% coverage. Parents' willingness to vaccinate their child has been shown to be much higher when physicians share personal vaccination decisions for their own children as well as what other parents have done at that particular clinic. Furthermore, the vaccine must be presented presumptively as a "bundle" along with the rest of the standard adolescent vaccine panel. Multiple exemplars presented including in several European countries, low-income countries and Rwanda, demonstrate that school-based health care systems dramatically increase vaccination coverage. Finally, acceptability for vaccination of males must improve by increasing provider recommendation and by presenting the HPV vaccine as a penile, anal and oropharyngeal cancer prevention therapy in males and not merely a vaccine to prevent cervical cancers in females. Paediatricians, obstetrician/gynaecologists and primary care physicians should consider these data as a call-to-action. Key messages   • Despite recent efforts in the US, only 49.5% of females and only 37.5% of males ages 13 through 17 have received all recommended HPV vaccine doses. These numbers fall well below the 80% target set forth by the Healthy People 2020 initiative.   • According to the CDC, if health care providers increase HPV vaccination rates in eligible recipients to 80%, it is estimated that an additional 53,000 cases of cervical cancer could be prevented during the lifetime of those younger than 12 years. Furthermore, for every year that the vaccination rate does not increase, an additional 4400 women will develop cervical cancer.   • First and foremost, healthcare providers (HCPs) must make a strong recommendation to vaccinate patients and these recommendations must become routine, including for males.   • It is clear that HPV vaccination rates improve significantly when vaccine administration occurs at designated, well-organized sites such as school-based vaccination programmes. Furthermore, HPV vaccination should be a high school requirement and offered in the standard adolescent vaccine panel as a bundle with Tdap and MenACWY vaccines in order to promote maximum adherence.   • Finally, research on immunogenicity and antibody titre longevity needs to be done in newborns. The HPV vaccine may be recommended in the newborn panel of vaccines to avoid any issues of sexualization and misplaced fears of sexual disinhibition, akin to the success of the Hepatitis B vaccine in the 1980s.   • The HPV vaccine is a vaccine against cancer and should be aggressively marketed as such. As healthcare providers, we need to make every effort to overcome barriers, real or perceived, to protecting our population from potential morbidity and mortality associated with this virus.

Human papillomavirus type 6 and 11 genetic variants found in 71 oral and anogenital epithelial samples from Australia

Genetic variation of 49 human papillomavirus (HPV) 6 and 22 HPV11 isolates from recurrent respiratory papillomatosis (RRP) (n = 17), genital warts (n = 43), anal cancer (n = 6) and cervical neoplasia cells (n = 5), was determined by sequencing the long control region (LCR) and the E6 and E7 genes. Comparative analysis of genetic variability was examined to determine whether different disease states resulting from HPV6 or HPV11 infection cluster into distinct variant groups. Sequence variation analysis of HPV6 revealed that isolates cluster into variants within previously described HPV6 lineages, with the majority (65%) clustering to HPV6 sublineage B1 across the three genomic regions examined. Overall 72 HPV6 and 25 HPV11 single nucleotide variations, insertions and deletions were observed within samples examined. In addition, missense alterations were observed in the E6/E7 genes for 6 HPV6 and 5 HPV11 variants. No nucleotide variations were identified in any isolates at the four E2 binding sites for HPV6 or HPV11, nor were any isolates found to be identical to the HPV6 lineage A or HPV11 sublineage A1 reference genomes. Overall, a high degree of sequence conservation was observed between isolates across each of the regions investigated for both HPV6 and HPV11. Genetic variants identified a slight association with HPV6 and anogenital lesions (p = 0.04). This study provides important information on the genetic diversity of circulating HPV 6 and HPV11 variants within the Australian population and supports the observation that the majority of HPV6 isolates cluster to the HPV6 sublineage B1 with anogenital lesions demonstrating an association with this sublineage (p = 0.02). Comparative analysis of Australian isolates for both HPV6 and HPV11 to those from other geographical regions based on the LCR revealed a high degree of sequence similarity throughout the world, confirming previous observations that there are no geographically specific variants for these HPV types.

Women's knowledge of Pap smear test and human papillomavirus: acceptance of HPV vaccination to themselves and their daughters in an Islamic society

OBJECTIVE

Cancer of cervix uteri is the second most common cancer among women, and it has been shown to be caused by human papillomavirus (HPV) infection in more than 99% of cases. We surveyed Muslim Turkish women, who mostly accept talking about sex as a taboo, to examine their knowledge about Papanicolaou (Pap) smear test, HPV, HPV vaccine, and their attitude toward vaccination to themselves and their daughters.

METHODS

We surveyed 525 women aged between 19 and 53 years to examine their knowledge about cervical cancer screening Pap smear test, HPV, HPV vaccine, and their attitude toward vaccination to themselves and their daughters with a questionnaire that is consisted of 5 parts with a total of 31 items.

RESULTS

The knowledge of cervical screening was high (70%), and 51% of the subjects were at least once had a Pap smear test, but most respondents (56%) had never heard of HPV. For most women, recommendations from health workers (67%) were the major influences in deciding to get vaccinated.

CONCLUSIONS

The importance of successful introduction on the vaccine by the drug providers and health care professionals in Turkey was shown in this present study with a high rate of awareness of cervical cancer vaccine. "Early-age vaccination knowledge" before any sexual contact is probably due to the correct education of mothers by health care professionals. The professionals should be educated and trained about HPV, vaccination, and its relation with cervical cancer to increase the knowledge about it.

Human papillomavirus vaccines: current status and future prospects

Worldwide, cervical cancer is the second most common cancer of women. Less-developed countries bear the greatest burden in terms of morbidity and mortality, largely due to the lack of organized screening programmes. Cervical cancer is the first cancer shown to be caused solely by virological agents: oncogenic genotypes of human papillomavirus (HPV). Two recently developed prophylactic cervical cancer vaccines, which are based on viral-like particle (VLP) technology of HPV, have the capacity to diminish a large proportion of cervical cancer cases worldwide. However, to be successful public health tools, they need to be widely implemented to the appropriate target population, preferably prior to first sexual intercourse. To increase vaccination coverage, national programmes in some countries have also included catch-up vaccination, for a limited time period, to young adult women aged up to 26 years. Despite the excellent efficacy for high-grade dysplasia due to vaccine-related HPV types (near to 100%) and immunogenicity induced against the HPV types 16 and 18 in females naive to those HPV types pre-vaccination, some form of cervical precancer screening will still be necessary. Immunity to HPV is primarily type specific, and thus protection induced by the current generation of vaccines, based on a limited number of HPV VLP types, cannot provide complete protection against all oncogenic HPV types. Both these vaccines translate to protection of cervical cancer in the order of 70-75%, which represents the percentage of invasive cancers attributable to HPV-16 and -18. Challenges to ensuring the successful control of this largely preventable disease include endorsement by governments and policy makers, affordable prices, education at all levels, overcoming barriers to vaccination and continued adherence to screening programmes.

Estimating the prevalence of and treatment patterns for juvenile onset recurrent respiratory papillomatosis in Australia pre-vaccination: a pilot study

Background: Recurrent respiratory papillomatosis (RRP) causes serious morbidity. RRP in Australia may be eliminated in the near future following the implementation of a national vaccination program using a human papillomavirus (HPV) vaccine that protects against infection with HPV types 6 and 11, those responsible for RRP. Baseline data on RRP prevalence and disease burden in Australia are lacking. Methods: Three study methods were used to estimate the burden of juvenile onset RRP in Australia. We conducted a retrospective chart review of RRP cases treated at The Children’s Hospital at Westmead over 10 years, examined the coding of these cases, and then calculated and applied the positive predictive value of the codes to national data to estimate the prevalence of RRP in Australia. We also conducted an online survey of otolaryngologists in Australia who manage RRP. Results: Nineteen patients were treated at the hospital over 10 years, involving 359 admissions. We estimate that between 33 and 56 RRP cases aged <20 are being treated nationally per year (0.6–1.1 per 100 000 persons), with children 5–9 years having a higher estimated rate of 1.2–1.8 per 100 000. Among 39 otolaryngologists treating juvenile onset RRP, the majority (73%) treated RRP in a paediatric tertiary hospital, and used the microdebrider for ablation of lesions. Conclusions: Our estimates of RRP disease burden agree with international estimates. As a small number of clinicians treat RRP nationally, we believe that establishment of a national RRP register is both feasible and necessary to monitor the impact of vaccination.

Human papilloma virus in hyperplastic tonsillar and adenoid tissues in children

BACKGROUND

Human papillomavirus (HPV) in childhood causes skin and anogenital warts as well as the recurrent respiratory papillomatosis, a life-threatening cause of upper airway obstruction in children. To date, the information on HPV infection in tonsillar and adenoid hyperplasia in children is limited.

PURPOSE

The purpose of this study was to investigate the presence of HPV DNA in children with benign tonsillar and/or adenoid hyperplasia.

METHODS

One hundred six samples of paraffin-embedded adenoid and/or tonsillar tissues from 102 children, 57 girls and 45 boys (age range, 2-14 years), were tested for the presence of HPV DNA using polymerase chain reaction (PCR) with general primers GP5+/GP6+. HPV typing was performed by PCR with specific primers for HPV-16, -18, -33 and -11.

RESULTS

HPV DNA was detected in 9 (8.5%) of the 106 collected specimens. The frequencies of HPV typing were 6 of 9 (66.7%) for HPV-16, 2 of 9 (22.2%) for HPV-11, zero of 9 (0%) for HPV-33 and HPV-18, whereas one HPV-positive sample remained untyped. No multiple HPV infection was detected. HPV was detected in 6 (9.4%) children with tonsillar hyperplasia and in 3 (7.1%) with adenoid hyperplasia. The mean age of children with HPV-positive specimens was lower than that of HPV-negative children (P = 0.006). No statistical correlation in the prevalence of HPV infection was observed according to children's sex, origin or residence (urban or rural).

CONCLUSION

Although the significance of the presence of HPV DNA in tonsillar and adenoid hyperplasias remains obscure, the PCR detection of high-risk HPV DNA should be evaluated cautiously.

High sustained efficacy of a prophylactic quadrivalent human papillomavirus types 6/11/16/18 L1 virus-like particle vaccine through 5 years of follow-up

Human papillomavirus (HPV) causes cervical, vulvar, and vaginal cancers, precancerous dysplasia, and genital warts. We report data for the longest efficacy evaluation to date of a prophylactic HPV vaccine. In total, 552 women (16–23 years) were enrolled in a randomised, placebo-controlled study of a quadrivalent HPV 6/11/16/18 L1 virus-like-particle vaccine with vaccination at months 0, 2, and 6. At regular intervals through 3 years, subjects underwent gynaecologic examination, cervicovaginal sampling for HPV DNA, serum anti-HPV testing, and Pap testing, with follow-up biopsy as indicated. A subset of 241 subjects underwent two further years of follow-up. At 5 years post enrolment, the combined incidence of HPV 6/11/16/18-related persistent infection or disease was reduced in vaccine-recipients by 96% (two cases vaccine versus 46 placebo). There were no cases of HPV 6/11/16/18-related precancerous cervical dysplasia or genital warts in vaccine recipients, and six cases in placebo recipients (efficacy=100%; 95% CI:12–100%). Through 5 years, vaccine-induced anti-HPV geometric mean titres remained at or above those following natural infection. In conclusion, a prophylactic quadrivalent HPV vaccine was effective through 5 years for prevention of persistent infection and disease caused by HPV 6/11/16/18. This duration supports vaccination of adolescents and young adults, which is expected to greatly reduce the burden of cervical and genital cancers, precancerous dysplasia, and genital warts.

Recurrent respiratory papillomatosis: Cytopathological findings in an unusual case

Recurrent respiratory papillomatosis (RRP) primarily is a disease of children and adolescents. Most patients experience spontaneous regression at a later age, while others continue to be affected throughout their lives. Here, we present the case of a 26-yr-old man who presented with persistent cough, worsening dyspnea, and development of pneumothorax. Eight years prior, he had presented with similar complaints and an evaluation at that time had showed RRP. Follow-up since that time showed recurrent disease managed by multiple surgical procedures. At the most current admission, an ultrasound-guided fine-needle aspiration (FNA) of the lung showed numerous papillary tissue fragments and single atypical squamous cells consistent with recurrent RPR. To our knowledge, morphological findings of RRP have been reported rarely.

Molecular Events in the Progression of Recurrent Respiratory Papillomatosis to Carcinoma

Context.—Identification of the type of human papillomavirus (HPV) by polymerase chain reaction and sequencing to determine coinfection or superinfection (by more than 1 HPV type) and other molecular events have not been reported in a series of patients exhibiting the morphologic spectrum of recurrent respiratory papillomatosis progressing to carcinoma.

Design.—Four cases of juvenile-onset recurrent respiratory papillomatosis progressing to carcinoma (no history of smoking or irradiation in 2 cases) were studied. Morphologically distinct foci (squamous papilloma, pulmonary papillomatosis, squamous dysplasia subjacent to carcinoma, and squamous carcinoma) were subjected to laser capture microdissection and polymerase chain reaction amplification using general primers in addition to type-specific primers for HPV types 16 and 18. Direct sequencing of polymerase chain reaction products identified the type of HPV. The tissue sections were immunostained using antibodies to p53, pRb, p21WAF1, and p16 proteins with a semiquantitative assessment.

Results.—Human papillomavirus 11 was the only type of HPV identified in all lesions of all cases associated with recurrent respiratory papillomatosis. There was a marked increase in p53 protein expression in foci of dysplasia and carcinoma as compared to squamous papilloma and pulmonary papillomatosis. An inverse correlation between p53 and p21WAF1 protein expression was noted in all lesions. pRb protein expression increased from the benign to the malignant end of the spectrum. p16 protein was expressed in all lesions.

Conclusions.—Infection by HPV-11 may be an early event associated with progression of recurrent respiratory papillomatosis to carcinoma. Increased expression of p53 and pRb proteins and a reduced expression of p21WAF1 protein appear to be significant subsequent events.

Human papillomavirus update with a particular focus on cervical disease

Human papillomavirus (HPV) is a common viral infection of squamous epithelial tissues, but its importance has only recently been recognised by the medical community. HPVs are now realised to consist of many genotypes and are associated with a diverse spectrum of clinical manifestations. Within the genital tract, some diseases have been recognised since antiquity; for example, genital warts which are caused by HPV types distinct from those causing genital cancer. However, others (such as cervical cancer), although recognised centuries ago as linked to sexual activity, have only been associated with oncogenic HPVs relatively recently, with the tools of molecular biology. We now understand that genital HPV infections are the most common sexually transmitted viral infections, are largely transient, asymptomatic and of no consequence. This virus manifests as more than just benign warts. Chronic carriage of with oncogenic genotypes (over years and in a minority of patients), together with other cofactors (host and/or exogenous) in complex pathways not totally understood, result in severe dysplasia or, ultimately, carcinogenesis. As it takes time for precursor lesions to develop and there are effective screening programmes for their detection and treatment, HPV-related neoplastic disease of the cervix is largely a preventable reproductive health issue of women. Yet, on a global scale, cervical cancer is the second most common cancer of women, with the majority of cases occurring in developing countries. Although HPV is noncultivatable by traditional diagnostic virological methods, successfully applied molecular biology techniques have underpinned development of vaccines which are now in phase II/III clinical trials. Successful vaccination ultimately has the greatest potential to impact upon the global burden of disease from genital HPV infection. However, the outcome from reduction in incidence of dysplasia and neoplasia will take years to eventuate; consequently, various cervical cancer prevention strategies still need to be endorsed and maintained in the meantime.

Successful ribavirin therapy for life-threatening laryngeal papillomatosis post liver transplantation

A 3-yr-old girl developed severe progressive juvenile laryngeal papillomatosis (JLP) 2 yr after liver transplantation (Tx) for biliary atresia. The papillomata were resistant to withdrawal of immunosuppression, to laser surgery, and to subcutaneous interferon (3 MU/m2, three times weekly), necessitating tracheostomy. Oral ribavirin therapy (25 mg/kg/day) in combination with no immunosuppression effectively prevented the rapid recurrence of JLP over 5 yr. Hence, oral ribavirin is a potentially useful therapy in this life-threatening situation and may also be of benefit in other children with severe JLP.