Local injection of bevacizumab (Avastin) and angiolytic KTP laser treatment of recurrent respiratory papillomatosis of the vocal folds: a prospective study

Recurrent Laryngeal Papillomatosis in Denmark from 1994 to 2021: A Nationwide Register Study

OBJECTIVES

The aim of this study is to describe the incidence and demographics of laryngeal papillomatosis (LP) in Denmark, including sex and age distribution, recurrence rates, and HPV subtypes, using a new method of register identification.

METHODS

The data were extracted from the Danish Pathology Data Bank using SNOMED codes instead of the usual method using ICD codes from the Danish National Health Register. The derived pathology records were manually verified by three medical doctors. The study period was 1994-2021. Patients were categorized according to age as either juvenile-onset RRP (JoRRP) if <18 years or adult-onset RRP (AoRRP) if 18 years or older.

RESULTS

We identified 1819 RRP patients (JoRRP: 56; AoRRP:1763). The overall incidence per 100,000 inhabitants were 0.17 for JoRRP and 1.45 for AoRRP. The vast majority (72%) of the patients were male, but there was no significant difference in age at onset of RRP or recurrence rates between the sexes. Children below 3 years of age had the highest recurrence probability. Extracting data using SNOMED codes resulted in a positive predictive value of 99% regarding total number of biopsies and 98% regarding individuals. The incidence decreased throughout the study period.

CONCLUSION

Comparable incidence and recurrence rates of RRP were found between Denmark and Norway. In this study, the Danish Pathology Register was found to be a highly valuable method for identifying LP patients. The effect of the nationwide HPV vaccination program can be evaluated using this method as the vaccinated cohort is starting to grow older and reproduce.

LEVEL OF EVIDENCE

Retrospective registry-based national cohort study, level of evidence 3 Laryngoscope, 2024.

Adjuvant Intralesional Bevacizumab in Pediatric and Adult Populations With Recurrent Respiratory Papillomatosis: A Systematic Review

OBJECTIVE

Recurrent respiratory papillomatosis (RRP) is a rare disease of the airway for which there is no known cure. Treatment involves the surgical removal or destruction of these lesions. There has been a long-standing debate over the effectiveness of the adjuvant intralesional injection of the immune modifying agent bevacizumab. This study is a systematic review investigating the effect of adjuvant intralesional bevacizumab on patients with laryngeal papillomatosis. The main objective was to assess functional outcomes and efficacy.

DATA SOURCES

Pubmed, Google Scholar, and Web of Science.

REVIEW METHODS

Search words were "intralesional bevacizumab" AND "recurrent respiratory papillomatosis." Sources were systematically identified using inclusion and exclusion criteria (ie, study publication must post-date 2000, must be peer-reviewed, investigate patients with RRP, apply bevacizumab intralesionally, not systemically). Findings were then collected and analyzed.

RESULTS

Ten studies were included for analysis. The majority of these studies found an increase in the surgical interval, voice outcomes, and a decrease in tumor burden in most patients. No studies reported side effects or lasting complications related to the bevacizumab injection.

CONCLUSION

This systematic review provides further evidence for the safety of intralesional bevacizumab injections and their likely positive effect on disease control. Future research would benefit from the implementation of standardized documentation of RRP outcomes.

Recurrent respiratory papillomatosis disease course in immunosuppressed populations

OBJECTIVE

Recurrent respiratory papillomatosis is a benign manifestation of human papillomavirus types 6 and 11 in the respiratory tract. Disease is recurrent, and factors predicting these recurrences and severity of disease are incompletely characterised. This retrospective cohort study examined the relationship of immunosuppression with recurrent respiratory papillomatosis morbidity.

METHODS

A retrospective cohort of 97 adult patients with recurrent respiratory papillomatosis treated at a tertiary referral centre from 2005 to 2020 was conducted. Measures assessed included inter-surgical interval, Voice Handicap Index ('VHI-10') and anatomical Derkay scores.

RESULTS

Bivariate analyses comparing average inter-surgical interval, Voice Handicap Index and Derkay scores in immunosuppressed and healthy patients were insignificant. When controlling for diabetes mellitus and comparing immunosuppressed to healthy patients, inter-surgical interval and Voice Handicap Index change were insignificant (p = 0.458 and p = 0.465, respectively).

CONCLUSION

Recurrent respiratory papillomatosis morbidity for immunosuppressed patients did not significantly differ from that of immunocompetent patients.

Usefulness of Intraoperative Narrow-Band Imaging in the Site Diagnosis of Respiratory Papillomatosis

OBJECTIVE

Narrow-band imaging (NBI) is considered useful for detecting respiratory papillomatosis. However, the choice between preoperative and intraoperative NBI depends on the facility. We investigated the usefulness of NBI and determined whether preoperative NBI can replace intraoperative NBI with a comparable detection rate.

METHODS

In this retrospective cohort study conducted at single a tertiary care center, patients with respiratory papillomatosis treated between 2017 and 2022 were enrolled. We systematically compared preoperative white light imaging (WLI) with preoperative and intraoperative NBI. The primary endpoints were the papilloma detection rate and lesion site assessed by the Derkay scoring system. The secondary endpoints were the risk factors for increased Derkay scores.

RESULTS

The study included 127 patients with papilloma. Intraoperative NBI yielded significantly higher Derkay scores than preoperative WLI (p < 0.001) and preoperative NBI (p = 0.004). The papilloma detection rates of preoperative WLI and preoperative NBI were not significantly different. Intraoperative NBI detected more lesions than preoperative NBI in 37 of 127 (29%) patients; the overall number of additional lesions was 47 of 279 (17%). Compared with preoperative NBI, intraoperative NBI yielded significantly higher scores for the vocal cords (p = 0.005), false vocal cords (p = 0.010), and ventricle of the larynx (p < 0.001). Elevated Derkay scores were significantly associated with male sex (p = 0.012) and alcohol consumption (p = 0.007).

CONCLUSION

Intraoperative NBI is more accurate in detecting papillomatous lesions, and preoperative NBI cannot replace intraoperative NBI.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1820-1824, 2024.

Off-label drugs in otolaryngological practice against the background of legal conditions of Polish legislation

<b><br>Introduction:</b> 'Off-label drug use' refers to the administration of drugs for unapproved indications or age groups, a different dosage or other form of administration. Considering the legal issues, there clearly exists a need to implement rules that would regulate the use of pharmaceuticals outside the scope of a marketing authorisation. The brevity and diversity of Polish laws in the field of health care leads to many interpretative doubts associated with particular legal acts.</br> <b><br>Aim:</b> We aimed to present clinical examples from everyday practice of off-label drug use from the medical and legal perspectives, and to support it with relevant legal acts.</br> <b><br>Material and method:</b> Off-label drug use in various otolaryngology subspecialties - otology (mesna), laryngology (bevacizumab, cidofovir and botulinum toxin) and head and neck surgery (botulinum toxin) - are presented and discussed in detail.</br> <b><br>Results:</b> Fourteen Polish legal acts regarding off-label drug use and 4 from EU legislation are commented on. The algorithm of cascade of decision-making processes in off-label drug use is shown.</br> <b><br>Conclusions:</b> Off-label use of medicinal products is not prohibited in Poland or the EU; nevertheless, it is undeniable that the unclear legal situation regarding the use of medicinal products for nonregistered indications creates difficulties. To minimise a doctor's liability risk, obtaining the informed consent from the patient for such treatment is advisable.</br>.

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.

Human Papillomavirus Vaccination as an Adjuvant Therapy for Recurrent Respiratory Papillomatosis: Additional Case Series

Prevention of the recurrence of recurrent respiratory papillomatosis (RRP), a neoplasm of the respiratory tract, is a challenge. Human papillomavirus (HPV) vaccine has been expected to suppress the aggressiveness of RRP. However, there has been insufficient data to verify whether HPV vaccination can serve as an adjuvant therapy option for RRP. The aim of this study was to add our data on the efficacy of HPV vaccination for RRP to the academic discipline. Twenty-four RRP patients were treated with a combination therapy of surgery and three sessions of quadrivalent HPV vaccine. The patients' clinical courses, which were HPV infection status changes, intersurgical interval, and disease severity score (Derkay's site score), were statistically analyzed before and after combination therapy. Twelve of the 24 (52.5%) RRP patients who were HPV-DNA positive turned negative after the combination therapy. The mean of intersurgical interval was significantly extended from 6.85 ± 4.49 months to 30.5 ± 27.6 months after the therapy (P <0.01). The median of Derkay's score of the participants also significantly decreased from 7.5 (interquartile range, 5-12) to 1 (interquartile range, 0-4.25) after the therapy (P <0.01). Thus, combination therapy comprising of surgery and HPV vaccination can postpone the recurrence and lessen the severity of RRP.

Intralesional Bevacizumab as Adjuvant Therapy for Juvenile Onset Recurrent Respiratory Papillomatosis: A Systematic Review

Background: Respiratory papillomatosis is one of the common benign lesions of the airway that is often difficult to treat and carries significant morbidity. Bevacizumab is a monoclonal antibody that acts upon vascular endothelial growth factor receptor and is known to have an effect in respiratory papillomatosis. This study aims to systematically review the literature on efficacy of intralesional Bevacizumab in juvenile onset respiratory papillomatosis. Materials and methods. A systematic search of literature in various databases was conducted. The search was restricted to the English language, however, no restrictions were made regarding the date of publication keeping December 31st, 2020 as the last date of publication. We strictly complied with the PRISMA guidelines. Results. Of 145 articles analyzed, only 3 were selected as eligible and a total of twenty-one cases were evaluated. There was improvement in anatomic Derkay score after initiating intralesional Bevacizumb with reduction in the number of surgeries. Where reported, voice related functional outcomes also were also improved. No adverse effect related to the drug was reported. Conclusion: Intralesional Bevacizumab can be a promising efficacious, and safe adjuvant in the management of JORRP. Well-designed studies are further required in the future to prove its efficacy and safety over other adjuvants available.

Recurrent laryngeal papillomatosis: multimodal therapeutic strategies. Literature review and multicentre retrospective study

Objectives

Recurrent respiratory papillomatosis (RRP) is a benign, rare disease caused by Human Papilloma Virus (HPV) that can be divided into juvenile and adult forms. The course of the disease is variable, but is usually more aggressive in the juvenile form. The standard surgical treatment is represented by CO2 laser resection, although photoangiolytic lasers represent a valid alternative. Adjuvant therapies have been proposed for disease control in case of frequent surgical resections or spreading into the lower airways. In recent years, the development of immunotherapy led to the use of bevacizumab either intratumorally or intravenously, but the most promising therapeutic development is represented by HPV vaccination. This paper aims to present a narrative review of the literature and the experience of three different University Centres in the treatment of RRP.

Methods

A retrospective analysis of the clinical charts of all patients affected by laryngeal papillomatosis and treated in three different University Centres between 2002 and 2022 was performed. The following parameters were collected: sex, age at first evaluation, sites of larynx involved, HPV type, type of first surgical treatment, presence and number of recurrences, surgical treatment of recurrences, adjuvant therapies, side effects and status at last follow-up.

Results

Seventy-eight patients were available for evaluation. Of these, 88% had adult onset RRP (Ao-RRP) and 12% juvenile onset RRP (Jo-RRP). The glottis was the most frequently involved subsite; all patients were submitted to surgical resection with CO2 laser under general anaesthesia. Recurrences appeared in 79% of the patients, the patients who did not recur were all adults. The mean number of recurrences was 9 (range 1-110). Recurrences were more frequent in children (M = 20; range 2-110) than adults (M = 5; range 1-21). Thirty-two (52%) of the 62 patients who recurred were re-treated with CO2 laser under general anaesthesia, while office-based treatment with a photoangiolytic laser was preferred in the remaining 30 (48%) patients. Adjuvant treatments were applied in 26 patients. The analysis of the course of the disease showed that in the 9 patients with Jo-RRP, 6 (67%) were free of lesions at the last follow-up, while the other 3 (33%) had papillomas. Of the 69 patients with Ao-RRP, 53 (77%) were alive and free of disease at the last visit, 14 (21%) were alive with disease, 1 (1%) was lost at follow-up and 1 (1%) died for other disease. Severe side effects were not observed except for 2 patients, who developed posterior glottic stenosis.

Conclusions

Our results confirmed the literature review. RRP is a potentially aggressive disease, especially in juvenile onset. Surgical resection is still first-line treatment, but in case of multiple recurrences the use of adjuvant therapies must be taken into consideration.

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.

Systemic bevacizumab for pediatric patients with aggressive recurrent respiratory papillomatosis: One single‐center experience of eight patients

Recurrent respiratory papillomatosis (RRP) is a human papilloma virus (HPV)-driven benign neoplasm, affecting larynx, trachea, and even lung, leading to voice disorders, airway obstruction, and postobstructive pneumonia. Several case reports have documented the promising efficacy of intravenous bevacizumab in reducing the need for surgical intervention among RRP patients. Herein, we present our experience on systemic bevacizumab for pediatric patients with aggressive RRP.

Methods

We retrospectively analyzed clinical, laboratory, radiological, and bronchoscopy findings of pediatric patients with aggressive RRP treated with systemic bevacizumab from July 26, 2021 to March 1, 2022.

Results

Eight consecutive patients were included. Median age at treatment initiation was 5.5 (range 2.5-8) years old. Twenty-five percentage (2/8) of patients experienced tracheotomy. Pulmonary papilloma was present in 62.5% (5/8) patients. Patients received median 10 cycles of bevacizumab (range 5-12). Patients received initial dosing of 4-7.5 mg/kg every 2-10 weeks of bevacizumab and subsequently extended after achieving the maximum response. None of the patients required surgical intervention during a median 10 (range 8.2-15.4) months follow-up after initiating bevacizumab treatment. Both patients with evaluable lung lesions showed objective response. Only Grade 1 abdominal pain and Grade 1 hyperuricemia were recorded.

Conclusion

Systemic bevacizumab seems to be a well-tolerated and effective treatment option for pediatric patients with aggressive RRP.

Molecular Mechanisms of Carcinogenesis in Pediatric Airways Tumors

Primary tumors of the airways in the pediatric population are very rare entities. For this reason, little is known about the pathogenesis of these neoplasms. Understanding the biology has different practical implications: for example, it could help in the differential diagnosis, have a prognostic significance, or may lead to the development of a targeted therapy. The aim of this article is to present the current knowledge about pediatric airways tumors, focusing on the molecular mechanisms that cause the onset and progression of these neoplasms. After a brief introduction of epidemiology and clinical presentation, the tumorigenesis of the most frequent pediatric airways tumors will be described: Juvenile-onset recurrent respiratory papillomatosis (JORRP), Subglottic Hemangiona (SH), Rhabdomyosarcoma (RMS), and Mucoepidermoid carcinoma (MEC).

[Recurrent laryngeal papillomatosis]

Human papillomaviruses (HPV) 6 and 11 cause 90% of recurrent laryngeal papillomatosis (RLP). It is unclear whether recurrences are caused by new infections or the spread of infected cells. Symptomatic and sometimes curative treatment is laser surgery or conventional microsurgical removal. RLP surgery aims to relieve shortness of breath and improve the voice. Patients (especially children) are affected by voice problems, repetitive surgeries, pulmonary manifestations, and psychological trauma. Vaccination with Gardasil 9 (Merck & Co., Rahway, NJ, USA) prevents new infections with HPV 6, 11, 16, 18, 31, 33, 45, 52, and 58 and induces vaccine antigen-specific antibodies and CD4+ T helper cells. According to current studies, RLP can be avoided with prophylactic vaccination. The treatment is associated with a general vaccination risk (European Medicines Agency approval: girls and boys from 9 years). Studies also show that the vaccine after removal of HPV-associated neoplasia/papilloma prevents recurrences. Extension of the vaccination recommendation to prevent recurrences of HPV-associated diseases in men may promote applicability and herd immunity. For rare and treatment-refractory cases with laryngotracheal involvement, systemic therapy with bevacizumab (e.g. Avastin; Genentech, San Francisco, CA, USA), a VEGF antibody, is a promising adjuvant treatment option.

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.

Efficacy of cidofovir versus bevacizumab in recurrent respiratory papillomatosis: A randomized, double-blind, placebo-controlled pilot study

OBJECTIVES

After surgical resection of papilloma, adjuvant therapy may be recommended for the control of recurrent respiratory papillomatosis (RRP). As the efficacy of adjuvant therapy remains unproven, the aim of this study was to compare the efficacy of cidofovir versus bevacizumab used as adjuvant therapies for the control of RRP.

METHODS

This randomized, double-blind, placebo-controlled pilot study was performed in a national respiratory disease referral centre. Patients with RRP were recruited prospectively and were divided into juvenile or adult RRP. Participants were randomly assigned to receive adjuvant therapy with cidofovir, bevacizumab or placebo. The study drug or placebo was administered after direct microlaryngoscopy with papilloma resection using cold instruments. The Derkay severity score and the Voice Handicap Index (VHI) were assessed at 3-6-week intervals, for a total of 3 visits. Follow-up included VHI and Derkay score assessments at 2-month intervals over the course of one year. Annual rates before and after surgical treatment were compared.

RESULTS

Five children and 11 adults were enrolled in the study. After one year, the group treated with cidofovir had a significant decrease in Derkay score (p=.027). No difference between treatment arms was observed in the annual surgery rate. There was a significant decrease in the VHI score in all treatment groups (p<.001), and no significant difference was observed between groups (p=.32).

CONCLUSION

While we observed a significant decrease in RRP severity with intralesional cidofovir, we were unable to provide proof of efficacy of intralesional bevacizumab.

CLINICALTRIALS

gov Identifier: NCT02555800.

Multifunctional Gold Nanoparticles for Improved Diagnostic and Therapeutic Applications: A Review

The medical properties of metals have been explored for centuries in traditional medicine for the treatment of infections and diseases and still practiced to date. Platinum-based drugs are the first class of metal-based drugs to be clinically used as anticancer agents following the approval of cisplatin by the United States Food and Drug Administration (FDA) over 40 years ago. Since then, more metals with health benefits have been approved for clinical trials. Interestingly, when these metals are reduced to metallic nanoparticles, they displayed unique and novel properties that were superior to their bulk counterparts. Gold nanoparticles (AuNPs) are among the FDA-approved metallic nanoparticles and have shown great promise in a variety of roles in medicine. They were used as drug delivery, photothermal (PT), contrast, therapeutic, radiosensitizing, and gene transfection agents. Their biomedical applications are reviewed herein, covering their potential use in disease diagnosis and therapy. Some of the AuNP-based systems that are approved for clinical trials are also discussed, as well as the potential health threats of AuNPs and some strategies that can be used to improve their biocompatibility. The reviewed studies offer proof of principle that AuNP-based systems could potentially be used alone or in combination with the conventional systems to improve their efficacy.

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.

Systemic bevacizumab as adjuvant therapy for recurrent respiratory papillomatosis in children: A series of three pediatric cases and literature review

Recurrent respiratory papillomatosis (RRP), a viral disease caused by human papillomavirus (HPV), is the most common benign neoplasm of the larynx among children and the second most frequent cause of infantile hoarseness. The course of the disease is variable; some patients experience spontaneous remission, while others may develop an aggressive respiratory compromise. Especially juvenile-onset RRP cases experience shorter intervals between surgical interventions and thus more surgeries overall, causing high rates of depression and voice-related quality of life. Various local adjuvant therapies have been studied with mixed efficacy and some early potential but have failed to show consistent effect across large cohorts of patients. Bevacizumab, a recombinant monoclonal antibody that inhibits VEGF, has shown efficacy in patients with rapid regrowth of papillomas with severe airway compromise, and/or distal multisite spread of disease. We present three juvenile-onset RRP cases successfully managed with systemically administered bevacizumab.

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.

Efficacy of cidofovir versus bevacizumab in recurrent respiratory papillomatosis: A randomized, double-blind, placebo-controlled pilot study

OBJECTIVES

After surgical resection of papilloma, adjuvant therapy may be recommended for the control of recurrent respiratory papillomatosis (RRP). As the efficacy of adjuvant therapy remains unproven, the aim of this study was to compare the efficacy of cidofovir versus bevacizumab used as adjuvant therapies for the control of RRP.

METHODS

This randomized, double-blind, placebo-controlled pilot study was performed in a national respiratory disease referral centre. Patients with RRP were recruited prospectively and were divided into juvenile or adult RRP. Participants were randomly assigned to receive adjuvant therapy with cidofovir, bevacizumab or placebo. The study drug or placebo was administered after direct microlaryngoscopy with papilloma resection using cold instruments. The Derkay severity score and the Voice Handicap Index (VHI) were assessed at 3-6-week intervals, for a total of 3 visits. Follow-up included VHI and Derkay score assessments at 2-month intervals over the course of one year. Annual rates before and after surgical treatment were compared.

RESULTS

Five children and 11 adults were enrolled in the study. After one year, the group treated with cidofovir had a significant decrease in Derkay score (p=.027). No difference between treatment arms was observed in the annual surgery rate. There was a significant decrease in the VHI score in all treatment groups (p<.001), and no significant difference was observed between groups (p=.32).

CONCLUSION

While we observed a significant decrease in RRP severity with intralesional cidofovir, we were unable to provide proof of efficacy of intralesional bevacizumab. Clinicaltrials.gov Identifier: NCT02555800.

Biologics for the Treatment of Recurrent Respiratory Papillomatosis

This article aims to educate readers on adjuvant therapies for recurrent respiratory papillomatosis (RRP). Although antivirals are injected locally into papillomas as an adjuvant treatment, new biologics targeting vascular endothelial growth factor or induction of human papillomavirus (HPV)-specific immunity are gaining traction with demonstration of clinical benefit and mechanism of action in retrospective case series and prospective clinical trials. The future of RRP treatment, alone or in combination with surgery, lies in the careful clinical study of vascular and immune targeting agents that balance the risk of adverse events with the chance for elimination of HPV-infected cells.

Treatment of Recurrent Respiratory Papillomatosis: Case Series and Review of Technique

Adult Recurrent Respiratory Papillomatosis (RRP) is a rare disease caused by the human papilloma virus in which papilloma grows from the respiratory epithelium. Patients can suffer from significant respiratory distress secondary to tracheal or bronchial obstruction by papilloma and the mainstay of treatment is bronchoscopic debridement. There are a variety of techniques to resect the endoluminal tumor, including CO2 or YAG laser, argon plasma coagulation, microdebrider and cold forceps. There have been documented cases of healthcare workers contracting HPV after exposure to surgical smoke during ablation of papilloma and measures should be taken to avoid inhalation of the smoke plume. For proximal lesions that are accessible to a microdebrider, this appears to be a safe and effective technique that does not generate heat or surgical smoke. The rate of recurrence of adult-onset respiratory papilloma after initial debulking varies and adjuvant medical therapy including intralesional cidofovir, interferon, or oral indole-3-carbinol has been used to slow recurrence. Malignant transformation of adult-onset RRP to squamous cell carcinoma has been reported to occur in 3-7% of cases. Therefore, ongoing surveillance is needed to monitor for disease progression and malignant transformation. Here we describe three patients whose tracheal disease was managed with an Nd-YAG laser and microdebrider. One patient was treated with adjuvant systemic indole-3 carbinol and another was maintained with serial debridement only. The third patient presented with obstructing squamous cell carcinoma of the trachea and was treated with definitive chemoradiation. She presented with a new left mainstem lesion 6 months later which was diagnosed as RRP. She was started on indole-3 carbinol, but unfortunately it transformed to squamous cell carcinoma 8 months later.

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.

Recurrent respiratory papillomatosis: A 2020 perspective

OBJECTIVE

Despite recent advancement recurrent respiratory papillomatosis (RRP) remains a rare but challenging benign airway neoplasm. In recent years there has been significant shifts in incidence of this disease due to changes in vaccination and prevention for human papilloma virus (HPV) and its related pathology. This review will highlight the epidemiology, prevention and treatment of RRP.

METHODS

The PubMed database was searched using relevant MeSH terms including "recurrent respiratory papillomatosis." The titles and abstracts were reviewed to assess relevance and unrelated articles were excluded. A full-text review for select articles was performed, the data and discussions were interpreted and synthesized to create a concise update on the management of RRP.

RESULTS

With the increasing utilization of the 9-valent and quadrivalent HPV vaccine in Australia, we have seen a significant decrease in the incidence of RRP. Preliminary data in the US shows a similar trend of decreased incidence after implementation of vaccination. Single dose Gardasil in developing countries has shown sustained immunization for at least 7 years. Preliminary clinical trials and retrospective studies have shown the HPV vaccine may have benefit as a treatment method in addition to prevention for HPV related diseases. Bevacizumab (Avastin), a VEGF monoclonal antibody, has shown promise as a systemic treatment for RRP. The Corona Virus Disease 2019 (COVID-19) pandemic has affected perioperative management of RRP.

CONCLUSION

RRP continues to decline in incidence since the implementation of HPV vaccination. Advancement in the medical management including Bevacizumab show promise as an additional option for the management of RRP.

Interventional bronchoscopy for HPV 16 and 66 with the use of spraying interferon-α (2b) plus bevacizumab and anti-reflux agent

A fifty year old male was diagnosed with bronchial HPV. He was treated with local interventional treatment argon plasma coagulation and subcutaneous injections bevacizumab. Spraying of the regions followed with a specially designed catheter with interferon-α (2b). Systematic treatment of esomeprazole was also administered. After six months the patient is disease free and on close follow-up.

How Enhancing Immunity to Low-Risk HPV Could Cure Recurrent Respiratory Papillomatosis

Recurrent respiratory papillomatosis (RRP) is currently treated with repeat surgical resection of papillomatous disease that does not address the fundamental underlying issue of chronic infection with low-risk human papillomavirus. Here, we review the biology and immunology of low-risk human papillomavirus (HPV) infections. Antiviral or antiangiogenic adjuvant treatments similarly address the papillomatous disease itself but do not activate HPV immunity. It is likely that only through immune-mediated clearance of low-risk HPV infection can patients with RRP be cured. In some patients, this occurs spontaneously. In others with more aggressive disease, adjuvant immunotherapy to activate immunity may be needed. Based on current understanding of antiviral immune responses, the only rational strategy to clear HPV-infected epithelial cells is through activation of the T-lymphocyte arm of the adaptive immune response. Translation of immunotherapies that are Food and Drug Administration-approved or under clinical study for cancer, such as immune checkpoint blockade or engineered therapeutic vaccines, may provide a path toward tolerable and efficacious adjuvant immunotherapy for RRP. LEVEL OF EVIDENCE: NA Laryngoscope, 131:2041-2047, 2021.

Sublesional Bevacizumab Injection for Recurrent Respiratory Papillomatosis: Evaluation of Utility in a Typical Clinical Practice

OBJECTIVES

The goal of this study was to evaluate the benefit of sublesional bevacizumab injection for recurrent respiratory papillomatosis (RRP) as used in a typical clinical practice.

METHODS

A retrospective review of patients with RRP treated between 2011 and 2016 was undertaken. All patients were treated with in-office potassium titanyl phosphate (KTP) laser photoablation. Sublesional bevacizumab injection was used based on joint patient-physician decision making. Papilloma burden was objectively measured on prior recordings by 2 blinded reviewers and described as vocal fold segments affected (VFSA) by papilloma. Each patient served as their own control by comparing times when bevacizumab was or was not used. Mixed model for longitudinal data was used to determine if the previous use of bevacizumab decreased the disease burden.

RESULTS

A total of 19 patients met inclusion criteria and all prior laryngoscopic exams were reviewed for VFSA as described above. The mean (SD) number of VFSA when bevacizumab was not used at the prior procedure was 15 (14) as compared to 8 (11) when bevacizumab was used. When adjusted for age, time from initial presentation and baseline disease burden, mixed model showed a decrease of 11 VFSA (95% CI 6.5, 15.5, P < .0001) when bevacizumab was used as compared to when bevacizumab was not used at the prior procedure. In mixed model analysis, there was not a significant association between bevacizumab dose used and VFSA at the subsequent visit (P = .8).

CONCLUSION

Using sublesional bevacizumab intermittently based on clinical findings appears to be effective in improving disease control. Papilloma burden is significantly decreased at the subsequent clinical follow-up following injection of sublesional bevacizumab. The beneficial effect of sublesional bevacizumab may be not be dose-dependent.

Systemic Bevacizumab for Treatment of Respiratory Papillomatosis: International Consensus Statement

OBJECTIVES/HYPOTHESIS

The purpose of this study is to develop consensus on key points that would support the use of systemic bevacizumab for the treatment of recurrent respiratory papillomatosis (RRP), and to provide preliminary guidance surrounding the use of this treatment modality.

STUDY DESIGN

Delphi method-based survey series.

METHODS

A multidisciplinary, multi-institutional panel of physicians with experience using systemic bevacizumab for the treatment of RRP was established. The Delphi method was used to identify and obtain consensus on characteristics associated with systemic bevacizumab use across five domains: 1) patient characteristics; 2) disease characteristics; 3) treating center characteristics; 4) prior treatment characteristics; and 5) prior work-up.

RESULTS

The international panel was composed of 70 experts from 12 countries, representing pediatric and adult otolaryngology, hematology/oncology, infectious diseases, pediatric surgery, family medicine, and epidemiology. A total of 189 items were identified, of which consensus was achieved on Patient Characteristics (9), Disease Characteristics (10), Treatment Center Characteristics (22), and Prior Workup Characteristics (18).

CONCLUSION

This consensus statement provides a useful starting point for clinicians and centers hoping to offer systemic bevacizumab for RRP and may serve as a framework to assess the components of practices and centers currently using this therapy. We hope to provide a strategy to offer the treatment and also to provide a springboard for bevacizumab's use in combination with other RRP treatment protocols. Standardized delivery systems may facilitate research efforts and provide dosing regimens to help shape best-practice applications of systemic bevacizumab for patients with early-onset or less-severe disease phenotypes.

LEVEL OF EVIDENCE

5 Laryngoscope, 131:E1941-E1949, 2021.

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.

High Radiofrequency Surgery and Chromoendoscopy: A Novel Surgical Technique for the Treatment of Respiratory Papillomatosis

Recurrent Respiratory Papillomatosis is a highly recurrent and residual disease. The use of indigo-carmine chromoendoscopy increases the early detection of nonvisible disease and reduces the possibility of leaving residual lesions. The best chances of papillomatosis being eradicated depend upon a surgical shallow epitheliolysis approach applied to patients who have never been surgically damaged before. We developed a novel surgical technique based upon the use of a time controlled High Radiofrequency (HRF) energy output. We applied a three-step bloodless HRF-surgical technique, that is, epitheliolysis, angiolysis and peeling without the aid of adjunct therapies. It acts according to differences in the water density of the tissues. We use it to remove the epithelial viral reservoir thus preserving subepithelial layers. For this purpose, we designed and manufactured a custom-made HRF electrodes set for office and O.R. use. From 2005 to 2018, 39 patients (100%) with recurrent respiratory papillomatosis participated in the present prospective work. Twenty-five (64,10%) achieved complete postsurgical remission, 6 (15,38%) were lost to follow up, and 8 (20,51%) present partial remissions. Thirty-six patients had laryngeal papillomatosis. Follow-up was possible in 30 of the 36 patients with laryngeal papillomatosis with a success remission rate of 83,33% (25 of 30). Eleven of those 36 (30,55%) entered this study without previous surgical treatment and 9 of 11 (81,81%) were cured. Indigo-carmine chromoendoscopy, a visualization solution for papillomatosis detection, together with a bloodless HRF-surgical technique proved to be effective tools to eradicate papillomatosis. Voice restoration to normal or near normal levels was achieved in all patients.

Trends in recurrent respiratory papillomatosis treatment

Recurrent respiratory papillomatosis (RRP) consist of benign tumours along the airway caused by human papillomavirus infection. Papillomas may cause changes in phonation and obstruct the airway. The purpose of this study was to evaluate the different surgical and adjuvant therapies available for the treatment of this condition reported between 2014-2018. A PubMed search was performed for RRP treatment articles published between 2014 -2018. Forty articles that encompassed 1425 patients with RRP met the criteria. Of these, 24 articles evaluate the use of adjuvant therapies such as bevacizumab, human papillomavirus vaccine and cidofovir. There has been an increase in adjuvant therapy options for RRP in the literature in recent years. An awareness of these options highlights gaps and opportunities in the care of these patients, opens the door to new protocols to control disease and increase intersurgical intervals, and guides us towards new management paradigms in the future.

Angiolytische Laserverfahren am Kehlkopf

Durch transorale Lasermikrochirurgie wurden bei der Larynxkarzinomtherapie temporäre Tracheotomien reduziert, die Organerhaltraten erhöht und funktionelle Resultate verbessert. Goldstandard für die laserbasierte transorale Resektion eines Larynxkarzinoms ist der Einsatz des CO2-Laser, dabei sind onkologische Radikalität und postoperative Stimmfunktion individuell abzuwägen. Angiolytische Lasereffekte ermöglichen eine Beeinflussung des Tumormikromilieus durch zielgerichtete Gefäßobliteration und Blockierung der Angiogenese mit Schonung von schwingungsfähigem Gewebe für eine gute Stimmfunktion. Mit der Verabschiedung der S3-Leitlinie zur Diagnostik, Therapie und Nachsorge des Larynxkarzinoms wird eine nationale evidenzbasierte Standardisierung gefördert. International nimmt die Evidenz zur Kalium-Titanyl-Phosphat-Laser-Therapie laryngealer Schleimhautdysplasien und von T1a-Larynxkarzinomen zu. Auch bei juveniler Papillomatose und der Stützlaryngoskopie unter Narkose sowie für ausgewählte Patienten in Lokalanästhesie werden angiolytische Laser eingesetzt.

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.

Implication and Management of Incidental Oropharyngeal Papillomas-A Retrospective Case Series Review

INTRODUCTION

Incidental papillomas of the pharynx can be found while examining the nasopharynx, oropharynx, and hypopharynx for other disorders of the head and neck. Purpose of the study is to explore the location, biopsy protocol, and decision to perform office-based versus operative management via potassium titanyl phosphate (KTP) laser when an oropharyngeal papilloma is discovered incidentally.

METHODS

A retrospective review of the senior author's patient population was performed using Current Procedural Terminology and/or International Classification of Diseases codes to identify patients who had KTP laser removal of incidental oropharyngeal papillomas. Patients were included based on the incidental nature of the papilloma and confirmed pathology report of squamous papilloma. Demographics, presenting complaint, lesion location, pathological analysis, type of intervention, and outcomes were recorded. When available, human papillomavirus (HPV) subtype was noted.

RESULTS

A total of 26 cases were identified, 13 females and 13 males. The median age at time of surgery was 58 years (range: 21-77). The most common presenting symptoms were difficulty swallowing and throat pain. The most common locations were the base of tongue, uvula, tonsils, and the soft palate. Of the 26 patients, 23 patients received KTP laser ablation therapy as an office-based procedure, while the remaining 3 were performed under general anesthesia in the operating room. Only 5 patients had a recorded recurrence that required reoperation. There were no operative or postoperative complications. There were 16 biopsy samples tested for HPV, where 12 were negative for HPV and 4 were positive for HPV.

CONCLUSION

Oropharyngeal papillomas, when present, can be found incidentally during examination of the oropharynx for other symptoms. Office-based biopsy and KTP laser is a safe and efficient means of identifying and removing most oropharyngeal papillomas.

Laryngeal distribution of adult-onset recurrent respiratory papillomatosis: A longitudinal study

OBJECTIVES/HYPOTHESIS

To describe recurrence patterns in patients with recurrent respiratory papillomatosis (RRP) following surgical intervention.

STUDY DESIGN

Single-center, retrospective, longitudinal case series.

METHODS

Initial and follow-up laryngoscopic examinations of seven previously untreated adult-onset RRP patients were reviewed. Patients were followed longitudinally for periods ranging from 3 months to 7 years. Lesion locations were recorded using a twenty-one region laryngeal schematic, and maps were generated to illustrate the distribution of disease before and after cold-knife or potassium-titanyl-phosphate laser intervention. Univariate and multivariate analyses were employed to examine variables affecting recurrence patterns.

RESULTS

Across all patients, a statistically significant correlation between initial distribution and primary recurrence was observed. Seventy-five percent of new lesions were adjacent to regions with preexisting disease; 83% of new glottic lesions were adjacent to preexisting glottic lesions, and 66% of supraglottic lesions were adjacent to preexisting supraglottic regions. No statistically significant differences in recurrence rate were observed across sites.

CONCLUSIONS

In previously untreated patients with adult-onset recurrent respiratory papillomatosis, lesions tended to recur either in the same regions or regions adjacent to those affected at the time of initial surgery.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:1993-1997, 2019.

Multi-Year Effect of Human Papillomavirus Vaccination on Recurrent Respiratory Papillomatosis

OBJECTIVE

To examine whether human papilloma virus (HPV) vaccination in combination with surgical resection could suppress recurrence for an extended period of time in patients with recurrent respiratory papillomatosis (RRP).

METHODS

In a prospective case series, data of patients who received combination therapy comprising surgery and quadrivalent HPV vaccination (Gardasil; Merck & Co., West Point, PA) were collected. Patients were followed up for RRP from March 2012 to July 2018 in an academic tertiary care center. The patients comprised 16 adults with RRP who were observed for >12 months after HPV vaccination, and whose HPV-DNA status was tested before and for >12 months after completion of combination therapy. The outcomes of this study were the severity score of larynx disease, tumor incidence rate, and relationship between this rate and HPV-DNA negative conversion after therapy.

RESULTS

The severity score of laryngeal disease significantly decreased from before combination therapy to the time of final examination (P = 0.00045). The tumor incidence rate decreased to approximately 20% during the period from 12 to 47 months after HPV vaccination. Regarding HPV-DNA status in the final test results of each patient, 12 of 16 (75%) patients showed negative conversion; these 12 were significantly less likely to experience recurrence than patients who persistently tested positive for HPV-DNA during the period between 12 and 47 months after vaccination.

CONCLUSION

HPV vaccination prevented recurrence associated with RRP surgery for 4 years in 80% of patients. This may be an effective adjuvant therapy, and HPV-DNA negative conversion after HPV vaccination might predict prevention of recurrence.

LEVEL OF EVIDENCE

2 Laryngoscope, 130:442-447, 2020.

Office-Based 532-Nanometer Pulsed Potassium-Titanyl-Phosphate Laser Procedures in Laryngology

With fiber-based lasers that may be passed via the working channel of a flexible laryngoscope, in-office laser laryngeal surgery has become possible. The potassium-titanyl-phosphate laser has several features that make it ideal for laryngeal surgery, and it is now the laser of choice for in-office management of a variety of laryngeal lesions. Its applications have expanded significantly since its introduction, with reports of new indications continuing to appear in the literature. This article provides a comprehensive review of the indications and technical details of in-office potassium-titanyl-phosphate laser laryngeal surgery, and a summary of the existing literature regarding outcomes of these procedures.

A Method for Reconstruction of Anterior Commissure Glottal Webs With Endoscopic Fibro-Mucosal Flaps

Background:

Anterior-commissure (AC) cicatrization and web formation is a difficult problem that can result from a variety of clinical scenarios. An advancement-rotation flap utilizing papillomatous epithelium and subepithelial fibrous tissue has been previously described. For patients in whom there was not excessive redundant papillomatosis covering the AC web, including other clinical scenarios, a microlaryngoscopic procedure was designed to lengthen the glottal/subglottal aperture using substantial local fibro-mucosal tissue. Although it has been done for over a decade, this approach is not widely known and to our knowledge not photo-documented.

Study Design:

Retrospective.

Material and Methods:

An analysis was done with Institutional Review Board approval that identified 42 patients who underwent 53 procedures to treat AC webs, which were reconstructed with local soft-tissue flaps and without any device/stent to maintain the glottal aperture. The microlaryngoscopic method and technical nuances for this approach with and without diseased epithelium are described and photo-documented. Tactical mucosal incisions were made to facilitate advancement and/or rotation of fibro-mucosal flaps with enough length to resurface the medial aspect of 1 vocal fold. The scarred submucosal soft tissue in the AC region was separated with cold instruments, and the flaps were sutured in position. Variations of this method are demonstrated mobilizing fibro-mucosal soft tissue from different locations, including the web itself, contralateral vocal fold, infrapetiole region, and/or the inner aspect of the thyroid lamina below the anterior-commissure tendon.

Results:

Of the 53 cases in which anterior commissure glottal webs were reconstructed with endoscopic fibro-mucosal flaps, 31 of 53 had recurrent respiratory papillomatosis (RRP). Redundant RRP comprised the majority of the flap in 14 of 31 RRP cases. Fibro-mucosal tissue without a substantial amount of disease occurred in 17 of 31 RRP cases. Of the remaining 22 AC web cases, the primary diagnoses observed were: glottic cancer = 7 of 22, intraepithelial dysplasia = 10 of 22, glottic trauma = 3 of 22, congenital = 1 of 22, and radiotherapy = 1 of 22.

Conclusion:

Endolaryngeal utilization of local fibro-mucosal tissue to lengthen the glottal/subglottal aperture for AC webs is an effective strategy. It can be done without using devices or keels for webs that are congenital or from nonsurgical trauma, idiopathic disease, or postsurgical traumatic cicatrization of the anterior commissure subsequent to treatment of epithelial disease (eg, cancer, dysplasia, and RRP). Normalizing the architecture of the anterior commissure was a valuable asset in patients who require future treatment of epithelial diseases, especially in an office-based setting.

Pharyngeal Papilloma: a Rare Non-Pulmonary Cause of Hemoptysis

The most common benign neoplasm of the pharynx is papilloma. It is characterized by bulging brittle lesions, which are pedicled or sessile, whitish-grey or pinkish colour. Progressive hoarseness is the main clinical feature. When the papillomata spread throughout the tracheobronchial tree symptoms such as chronic cough, stridor, dyspnea or acute respiratory distress are mostly present. Hemoptysis as a presenting symptom is exceptionally rare in patients with pharyngeal papillomatosis. Herein, we report a case of pharyngeal papillomatosis in which hemoptysis was the primary clinical manifestation. The clinical and therapeutic aspects of the disease are briefly discussed.

Airway Papillomatosis: New Treatments for an Old Challenge

Recurrent respiratory papillomatosis (RRP) is the recurrent growth of small, benign tumors, or papillomas, in the respiratory tract, caused by human papillomavirus (HPV). Currently, there is no cure. Palliative treatments seek to prevent airway obstruction, keep underlying tissues healthy, and maintain voice quality. The most common intervention, the local surgical removal of papillomas, may be inadequate as a standalone treatment for pediatric populations that experience rapid papilloma regrowth, as repeated surgeries cause increased damage to the surrounding tissues and impose significant emotional and economic burden on families. Interferon α and Cidofovir have been shown to lengthen the time between surgical interventions and/or decrease the total number of procedures needed, although the evidence of their efficacy and safety is controversial. Novel therapies, including photodynamic therapy, indole-3-carbinol, anti-reflux medication, heat shock protein, and Mumps and HPV vaccination, may provide potential avenues for treatment, but require further research. Among all the novel therapies investigated, systemic bevacizumab seems to offer the most promising alternative to surgery. Randomized control trials to investigate its impact, especially in a pediatric population, should be conducted before implementing it as a standard form of care. This review will summarize the latest literature on medical care for aggressive RRP disease.

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.

[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.

Exophytic sinonasal papillomas and nasal florid papillomatosis: A retrospective study

BACKGROUND

Sinonasal exophytic papillomas are rare. The multifocal form, florid papillomatosis, has not been yet described in literature. We report on the clinical features and the management of the different forms of exophytic papilloma.

METHODS

A retrospective study was conducted that included all patients with exophytic papilloma treated in our center over the past 12 years. We recorded clinical presentation, treatments, recurrences, pathology (p16 expression and human papillomavirus [HPV] status).

RESULTS

We included 13 patients with a mean follow-up of 5 years. The main location of exophytic papilloma was the anterior part of the septum. Lesions were multifocal in 3 patients corresponding to florid papillomatosis. The main treatment was surgery. Cases of HPV-11 or HPV-6 were present in all forms of exophytic papilloma (dysplasia in 4 cases). Late recurrences occurred in 3 patients (2 patients with florid papillomatosis) over a period of 3 years.

CONCLUSION

Exophytic papilloma has 2 clinical presentations: localized and diffuse. Patients with florid papillomatosis should be monitored closely as recurrence seems to be frequent.

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

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.

Photothermal enhancement of chemotherapy in breast cancer by visible irradiation of Gold Nanoparticles

Photothermal Therapy (PTT) impact in cancer therapy has been increasing due to the enhanced photothermal capabilities of a new generation of nanoscale photothermal agents. Among these nanoscale agents, gold nanoshells and nanorods have demonstrated optimal properties for translation of near infra-red radiation into heat at the site of interest. However, smaller spherical gold nanoparticles (AuNPs) are easier to produce, less toxic and show improved photoconversion capability that may profit from the irradiation in the visible via standard surgical green lasers. Here we show the efficient light-to-heat conversion of spherical 14 nm AuNPs irradiated in the visible region (at the surface plasmons resonance peak) and its application to selectively obliterate cancer cells. Using breast cancer as model, we show a synergistic interaction between heat (photoconversion at 530 nm) and cytotoxic action by doxorubicin with clear advantages to those of the individual therapy approaches.