Safety and dosing of bevacizumab (avastin) for the treatment of recurrent respiratory papillomatosis

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.

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.

Systemic Bevacizumab for Recurrent Respiratory Papillomatosis: A Single Institution's Experience

OBJECTIVES

Medical therapies to limit disease recurrence are critically needed for recurrent respiratory papillomatosis (RRP). Systemic bevacizumab is emerging as an exciting adjuvant therapy toward this end, but uptake has been poor due to the lack of experience and awareness of best prescribing practices. The objective of this study was to describe a single tertiary care academic medical center's experience using systemic bevacizumab for the treatment of RRP.

METHODS

A retrospective review was performed to identify patients with RRP on systemic bevacizumab. Demographic and clinical characteristics, findings on imaging reports, and disease response at all anatomic subsites involved in papilloma were documented.

RESULTS

Of the 17 RRP patients on systemic bevacizumab, 9 (52.9%) were male, and 12 (70.6%) were diagnosed with juvenile-onset RRP. The total lifetime number of surgeries was high, with more than half (n = 9; 52.9%) undergoing more than 50 surgeries. Following induction of systemic bevacizumab, a significant reduction in patients with laryngeal (n = 15; 94.1% vs. n = 7; 41.2%, p < 0.001) and tracheal (n = 11; 64.7% vs. n = 5; 29.4%, p = 0.04) RRP was noted. Surgical frequency was significantly lower following systemic bevacizumab (2.5 vs. 0.5 surgeries per year; p < 0.001). The most common complications were new-onset hypertension (n = 4; 23.5%) and proteinuria (n = 5; 29.4%).

CONCLUSION

Systemic bevacizumab is effective in reducing the number of surgeries needed for RRP while exhibiting a relatively safe complication profile. Papillomas in the larynx and trachea are most responsive to systemic bevacizumab, while pulmonary RRP is most likely to exhibit a partial-to-stable response.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:3253-3259, 2024.

VEGF as a Key Actor in Recurrent Respiratory Papillomatosis: A Narrative Review

Recurrent respiratory papillomatosis (RRP) is a benign disease of the upper aerodigestive tract caused by human papillomavirus (HPV) types 6 and 11. The clinical course is unpredictable and some patients, especially younger children, experience a high rate of recurrence with a significant impact on their quality of life. The molecular mechanisms of HPV infection in keratinocytes have been extensively studied throughout the years, with particular regard to its role in causing malignant tumors, like cervical cancer and head and neck carcinomas. A minor but not negligible amount of the literature has investigated the molecular landscape of RRP patients, and some papers have studied the role of angiogenesis (the growth of blood vessels from pre-existing vasculature) in this disease. A central role in this process is played by vascular endothelial growth factor (VEGF), which activates different signaling cascades on multiple levels. The increased knowledge has led to the introduction of the VEGF inhibitor bevacizumab in recent years as an adjuvant treatment in some patients, with good results. This review summarizes the current evidence about the role of VEGF in the pathophysiology of RRP, the molecular pathways activated by binding with its receptors, and the current and future roles of anti-angiogenic treatment.

Profiling of VEGF Receptors and Immune Checkpoints in Recurrent Respiratory Papillomatosis

OBJECTIVES

Recurrent respiratory papillomatosis (RRP) is caused by human papilloma virus (HPV) infection of the aerodigestive tract that significantly impacts quality-of-life including the ability to communicate and breathe. Treatment was traditionally limited to serial ablative procedures in the O.R. with possible local adjuvant therapy, but new systemic therapies, such as Vascular endothelial growth factor (VEGF) inhibitors, are showing significant promise. This study aims to determine whether rationale exists for combination therapeutic approaches using VEGF inhibitors and/or immune checkpoint blockade.

METHODS

Using fresh specimens from the O.R., we performed flow cytometry on papilloma, normal adjacent tissue, and blood. Papilloma and surrounding tissue were examined for expression of PD-L1, PD-L2, Galectin-9, VEGFR2, and VEGFR3. CD8+ and CD4+ T cells were assayed for expression of PD-1, TIGIT, LAG3, and TIM3.

RESULTS

Our data shows that papilloma tissue exhibits significantly higher levels of PD-L1 and PD-L2 compared to adjacent tissue. Elevated levels of the VEGF receptor VEGFR3 were also observed in papilloma tissue. When examining T cells within the papilloma, elevated PD-1 and TIGIT expression was observed on CD8+ T cells, while levels of PD-1, TIGIT, and TIM3 were elevated on CD4+ T cells compared to PBMCs. Heterogenous marker expression was observed between individuals.

CONCLUSIONS

Our analysis shows that RRP tissue shows elevated levels of multiple immune check point targets and VEGFR3, with varied patterns unique to each papilloma patient. Some of these immune checkpoint markers already have novel immunotherapies available or in development, providing molecular rationale to offer these systemic treatments to selected patients affected by RRP alongside VEGF inhibitors. Laryngoscope, 134:2819-2825, 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.

[Epidemiological features of laryngeal papillomatosis in adults in Moscow]

OBJECTIVE

To evaluate the incidence of laryngeal papillomatosis (LP) and LP recurrence in adults and to determine the risk factors for the development of LP recurrence in adults in Moscow. To solve the tasks set, a survey of patients carried out, including the collection of complaints and anamnesis, a standard examination of the ENT organs, an assessment of the condition of the larynx, and a histological examination.

MATERIAL AND METHODS

We conducted a retrospective analysis of the case histories of 299 patients with LP observed and treated at the Sverzhevsky Research and Clinical Institute of Otorhinolaryngology in the period 2010-2020.

RESULTS

On average, over the entire study period, the prevalence of PG was 17.80%. It was found that out of 299 patients, 69.6% (n=208) had a relapse of LP. Papilloma of the larynx were more often localized in the glottis. 275 (92%) patients had a widespread form of LP. LP recurrences were significantly more common in women and in patients with an existing cicatricle process in the larynx. The relapse rate was higher in non-smokers (73.5% vs 47.8%; p<0.001). Although the recurrence rate was higher in patients with non-voice occupations (70.6% vs. 52.9%), there was no statistically significant association between relapses and the vocal professions (p=0.125).

CONCLUSION

As a result of the study, a number of risk factors for laryngeal papillomatosis recurrent have been identified, and their study should be continued.

Long-Term Follow-up of Parenteral Bevacizumab In Patients with Recurrent Respiratory Papillomatosis

OBJECTIVE

The clinical course of recurrent respiratory papillomatosis (RRP) varies from spontaneous remission to severe airway obstruction with wide variability in recurrence. Standard treatment involves debulking to improve voice and/or breathing. Non-surgical therapies are emerging in hopes of non-operative disease control. This retrospective review analyzes long-term safety, efficacy, and durability of clinical control in the largest reported series of parenteral bevacizumab in adults with RRP.

METHODS

Twenty-three patients with known RRP who have been receiving off-label systemic bevacizumab were included. Dosage, infusion interval, number of cycles, debulking requirements, subjective outcomes, adverse events, and reasons for treatment termination were investigated.

RESULTS

Patients have been followed for an average of 791.43 (21-1468) days. The most common starting dosing regimen was 15 mg/kg at 3 weeks in 11 followed by 10 mg/kg at 6 weeks intervals in 6 individuals. Long-term maintenance dosage varied with the least intensive regimen being 10 mg/kg at 14-week intervals. Subjective improvement of voice and/or breathing was reported in 18/23 subjects. The median time for patients that needed a procedure after treatment was 634 days. Procedures after infusions decreased from 3.08 ± 2.48 procedures in the year prior to 0.52 ± 1.12 during systemic Bevacizumab, and to 0.86 ± 2.05 after stopping bevacizumab. Therapy termination occurred in 8 subjects where only 3 were due to adverse events.

CONCLUSION

Parenteral bevacizumab remains a well-tolerated treatment for patients with recalcitrant RRP. There appears to be a durable reduction in the frequency of debulking surgery requirements although on a maintenance regimen. Laryngoscope, 133:2725-2733, 2023.

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.

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.

Stridor in the Infant Patient

Stridor is a high-pitched extrathoracic noise associated with turbulent airflow, commonly associated with respiratory distress in infants. Workup for stridor requires evaluation of the upper-respiratory airway, with severe distress requiring evaluation under anesthesia. The differential diagnosis of stridor depends on location of the obstruction, age of the patient, and acuity of the symptoms. The most common reason is laryngomalacia; most patients can be managed conservatively with resolution of symptoms by 2 years of age. In children who do not improve or have severe disease, supraglottoplasty is the treatment of choice, and the majority will have resolution of stridor postoperatively.

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.

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.

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.

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.

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.

Long-Term Follow-Up on Systemic Bevacizumab Treatment in Recurrent Respiratory Papillomatosis

OBJECTIVES/HYPOTHESIS

Recurrent respiratory papillomatosis (RRP) is a primarily benign disease affecting the entire respiratory tract. Treatment is challenging and usually involves surgical interventions and adjuvant medications. Previously, promising results on systemic administration of bevacizumab have been reported. However, experience on long-term systemic use in patients with RRP is not yet available. Here, we present our long-term follow-up on RRP patients undergoing systemic bevacizumab treatment.

STUDY DESIGN

Case series.

METHODS

To describe experience on long-term systemic bevacizumab administration, we performed the underlying investigation. Clinical, radiological, and bronchoscopy data were collected.

RESULTS

To date, a total of n = 5 patients has been treated with systemic bevacizumab at Muenster University Hospital. With a median follow-up since first systemic bevacizumab administration of 95.5 months long-term follow-up is illustrated. Following bevacizumab treatment partial remission or very good partial remission were achieved in all patients. After papilloma recurrence/progression due to bevacizumab discontinuation, further response was documented in all patients in whom bevacizumab was started again. In one patient, bevacizumab was discontinued due to loss of efficacy. Lung cancer developed in one patient with pulmonary papillomatosis prior to bevacizumab administration whereas three patients suffered from malignant transformation during bevacizumab treatment. Systemic bevacizumab led to long-term reduction in surgical interventions in all patients. Except from mild proteinuria and hypertension in two patients therapy was well tolerated.

CONCLUSIONS

Systemic bevacizumab represents a promising long-term treatment option for aggressive forms of papillomatosis. Rate of malignant transformation under bevacizumab treatment, optimal treatment schedule, and influence on survival should be further evaluated in clinical trials.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1926-E1933, 2021.

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.

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

OBJECTIVE

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

[Treatment outcomes of recurrent respiratory papillomatosis : Retrospective analysis of juvenile and adult cases. German version]

BACKGROUND

Recurrent respiratory papillomatosis (RRP) is a rare, chronic disease of viral etiology which is characterized by multiple, recurrent growth of papillomas in the aerodigestive tract.

MATERIALS AND METHODS

The surgical outcomes and the recurrence rates of 106 patients with RRP of the larynx were analyzed. The patients were treated at the University of Magdeburg between 1983 and 2014. The surgical outcomes of conventional and laser surgery regarding time to relapse and complications were compared. In addition, the influence of the quadrivalent vaccine Gardasil® on the disease was analyzed in 10 patients.

RESULTS

Children with RRP had a statistically significant greater number of surgeries throughout their lifetimes compared to adult patients. There were no differences between the adult (n = 79) and juvenile (n = 27) groups in the time to relapse and the number of surgeries/year. The time to relapse and number of procedures/year were not influenced by the various surgical methods. Complications after conventional and laser surgery were not statistically different between the two groups. Serious complications and the need for a tracheotomy were only reported after conventional surgery. In the 10 patients who were immunized with Gardasil®, a statistically significant lower number of surgeries/year after vaccination was achieved.

CONCLUSION

RRP is a rare disease. Treatment requires experience and may be very difficult. The analysis of the course of the disease has shown that the treatment of choice is surgical excision with the CO₂ laser combined with the quadrivalent or polyvalent vaccine. Consequent vaccination of both boys and girls has the potential to reduce the occurrence of RRP.

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.

Systemic Bevacizumab for Recurrent Respiratory Papillomatosis: A Single Center Experience of Two Cases

BACKGROUND Recurrent respiratory papillomatosis (RRP), caused by human papillomavirus (HPV), is the most common benign neoplasm of the larynx and central airways. RRP has a significant impact on quality life and high annual costs to healthcare. Currently, there is no cure for RRP, leading to repeated debulking operations for symptomatic palliation. Various local adjuvant therapies have also been studied with mixed efficacy. HPV oncogene products increase expression of vascular endothelial growth factor (VEGF) providing a potential target for treatment of RRP. Bevacizumab, a recombinant monoclonal antibody that inhibits VEGF, has shown efficacy in patients with localized disease. CASE REPORT We present two cases of extensive airway and parenchymal RRP successfully managed with systemically administered bevacizumab, a recombinant monoclonal antibody that inhibits VEGF. CONCLUSIONS Bevacizumab has shown efficacy in patients with localized disease, but here we illustrate the potential of bevacizumab for patients with extensive parenchymal burden as well as provide a brief review of the literature.

Systemic bevacizumab for recurrent respiratory papillomatosis: A national survey

OBJECTIVES/HYPOTHESIS

Aggressive laryngeal, tracheal, and pulmonary papilloma is an extremely challenging clinical problem without proven treatment options. A recent German report documented promising results with systemic bevacizumab. The objective of this study is to report the initial experience of this novel treatment in the United States for recurrent respiratory papillomatosis (RRP).

STUDY DESIGN

Cases series.

METHODS

Electronic survey of the RRP Task Force of the American Society of Pediatric Otolaryngology, American Broncho-Esophagological Association, and physicians known to the authors to have used systemic bevacizumab for RRP.

RESULTS

Eleven completed surveys were obtained. In three cases, systemic bevacizumab was considered clinically but not administered. Eight patients were treated with systemic bevacizumab, all for aggressive papillomatosis uncontrolled by surgical and adjuvant therapy, including seven of eight with pulmonary disease. Treatment dosing ranged from 5 to 10 mg/kg every 2 to 4 weeks, with all patients responding (7/8 partial response, 1/8 complete response). In four patients who had postbevacizumab chest imaging, three demonstrated improvement of disease and one stabilization. Treatment interval could be lengthened in seven patients and clinical response maintained. One patient with long-standing pulmonary disease (>10 years) was diagnosed with malignant transformation while on treatment, and bevacizumab was discontinued in lieu of other chemotherapeutic agents. All other patients continue on systemic bevacizumab with minimal complications (hemoptysis n = 1, proteinuria n = 1).

CONCLUSIONS

Systemic bevacizumab appears to have significant promise in the most treatment-resistant and aggressive forms of papillomatosis with a low complication profile. These results suggest bevacizumab should be studied in a formal clinical trial for RRP.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2225-2229, 2017.

Intersurgical interval increased with use of quadrivalent human papillomavirus vaccine (Gardasil) in a pediatric patient with recurrent respiratory papillomatosis: A case report

This is a case of a 4 year old female with recalcitrant recurrent respiratory papillomatosis with decreasing intersurgical interval that had improvement in clinical course after administration of the quadrivalent HPV vaccine.

Case Report: Pulmonary Papillomatosis in a Patient Presenting with Cough and Hemoptysis

A previously healthy patient was seen in the Emergency Department for evaluation of a one-month history of cough and one-day history of hemoptysis. A computed tomography scan of the thorax found a mass on the right lower pulmonary lobe and a mass on the left upper lobe. A biopsy specimen of the right lobe lung mass, obtained during bronchoscopy, demonstrated papilloma. This case report, from a pulmonologist's perspective, includes a comprehensive review of the patient's clinical presentation and outcome, as well as a discussion of recurrent respiratory papillomatosis.

Office-based Management of Recurrent Respiratory Papilloma

This review will highlight the indications and benefits of office-based therapy for recurrent respiratory papillomatosis (RRP) and discuss the utilization of photo-dynamic lasers and adjuvant medical therapy in office-based settings. Office-based management of RRP allows for more timely interventions, is preferred by the majority of patients, and negates the risk of general anesthesia. Current literature argues for the utilization of KTP laser over CO₂ laser for office-based treatment of RRP. Medical therapies for RRP are limited, but agents such as bevacizumab are promising and have been shown to reduce disease burden. Medical therapies that can induce disease remission are still needed. Office-based procedures save time and healthcare expenses compared to like procedures in the operating room. However, the increased frequency for office-based procedures predicts similar overall healthcare costs for office-based and OR laser excision of RRP. Office-based management of RRP is a feasible and well-tolerated strategy in appropriately selected patients with adequate local anesthesia.

Recurrent respiratory papillomatosis: current and future perspectives

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Xenograft model for therapeutic drug testing in recurrent respiratory papillomatosis

OBJECTIVE

Identifying effective treatment for papillomatosis is limited by a lack of animal models, and there is currently no preclinical model for testing potential therapeutic agents. We hypothesized that xenografting of papilloma may facilitate in vivo drug testing to identify novel treatment options.

METHODS

A biopsy of fresh tracheal papilloma was xenografted into a NOD-scid-IL2Rgamma(null) (NSG) mouse.

RESULTS

The xenograft began growing after 5 weeks and was serially passaged over multiple generations. Each generation showed a consistent log-growth pattern, and in all xenografts, the presence of the human papillomavirus (HPV) genome was confirmed by polymerase chain reaction (PCR). Histopathologic analysis demonstrated that the squamous architecture of the original papilloma was maintained in each generation. In vivo drug testing with bevacizumab (5 mg/kg i.p. twice weekly for 3 weeks) showed a dramatic therapeutic response compared to saline control.

CONCLUSION

We report here the first successful case of serial xenografting of a tracheal papilloma in vivo with a therapeutic response observed with drug testing. In severely immunocompromised mice, the HPV genome and squamous differentiation of the papilloma can be maintained for multiple generations. This is a feasible approach to identify therapeutic agents in the treatment of recurrent respiratory papillomatosis.

HPV associated with recurrent respiratory papillomatosis

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