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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Recurrent respiratory papillomatosis: comparing in-office and operating room treatments

Objective

We report the management of recurrent respiratory papillomatosis (RRP) employing a protocol that includes both office-based (OB) and general anaesthesia (GA) procedures. Quality of life (QoL) outcomes in the OB cohort were compared to those obtained from an historical cohort treated only under GA.

Methods

Patients affected by RRP from 2019 until 2023 ("new protocol") and from 2012 to 2019 ("historical protocol") were enrolled. In both groups the Derkay site score (DSS) was calculated. In patients adhering to the new protocol, questionnaires measuring QoL were prospectively administered (voice handicap hindex-10 [VHI-10] along with a specific questionnaire to measure the tolerance to the OB procedures). A cost analysis was also performed.

Results

In all, 35 patients composed the new protocol cohort and 13 the historical. In the first group, patients underwent a median of 4 treatments. At 2 years, 68% of patients were treated exclusively in the office. Overall, for the new protocol, median DSS and VHI-10 after one year were both significantly lower than those at baseline [2 vs 4 and 3 vs 14, respectively; p < 0.001]. No differences were found between the new and the historical protocol cohorts considering DSS over time.

Conclusions

Treatment of RRP may be conducted successfully in an office-based setting reducing healthcare costs.

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.

Human Papillomavirus Infections and the Role Played by Cervical and Cervico-Vaginal Microbiota-Evidence from Next-Generation Sequencing Studies

This comprehensive review encompasses studies examining changes in the cervical and cervico-vaginal microbiota (CM and CVM) in relation to human papillomavirus (HPV) using next-generation sequencing (NGS) technology. HPV infection remains a prominent global health concern, with a spectrum of manifestations, from benign lesions to life-threatening cervical cancers. The CM and CVM, a unique collection of microorganisms inhabiting the cervix/vagina, has emerged as a critical player in cervical health. Recent research has indicated that disruptions in the CM and CVM, characterized by a decrease in Lactobacillus and the overgrowth of other bacteria, might increase the risk of HPV persistence and the progression of cervical abnormalities. This alteration in the CM or CVM has been linked to a higher likelihood of HPV infection and cervical dysplasia. NGS technology has revolutionized the study of the cervical microbiome, providing insights into microbial diversity, dynamics, and taxonomic classifications. Bacterial 16S rRNA gene sequencing, has proven invaluable in characterizing the cervical microbiome, shedding light on its role in HPV infections and paving the way for more tailored strategies to combat cervical diseases. NGS-based studies offer personalized insights into an individual's cervical microbiome. This knowledge holds promise for the development of novel diagnostic tools, targeted therapies, and preventive interventions for cervix-related conditions, including cervical cancer.