Estudo do efeito do Cidofovir na papilomatose laríngea recorrente em crianças: relato preliminar

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.

Surgical treatment and adjuvant therapies of recurrent respiratory papillomatosis

Objective

Method

Results

Conclusion

Systematic review of intralesional cidofovir dosing regimens in the treatment of recurrent respiratory papillomatosis

OBJECTIVE

Surgical management of recurrent respiratory papillomatosis (RRP) usually involves resection via microlaryngoscopy. Intralesional injection of cidofovir has been shown to be an effective adjuvant treatment, but remains unlicensed. United Kingdom General Medical Council guidelines recommend the prescribing doctor should "be satisfied that there is a sufficient evidence base and/or experience of using the medicine to demonstrate its safety and efficacy". This study reviews the published dosing regimens of intralesional cidofovir in the treatment of RRP in order to provide a precedent for those that wish to prescribe it.

METHODS

A systematic review of the literature was undertaken using Medline, EMBASE and CINAHL. Articles describing the use of intralesional cidofovir for RRP were reviewed. Information regarding cidofovir concentration, volume, total dose, number of treatments, interval between treatments, overall treatment period and follow up was extracted.

RESULTS

Fifty-one articles were identified. Concentration of cidofovir injected ranged from 0.0001mg/ml to 37.5mg/ml, with 5 to 7.5mg/ml being the most common. The volume of cidofovir solution injection ranged from 0.1 to 20ml. The total dose per injection ranged from 0.15 to 105mg. There was wide variation in dosing regimens with different intervals between endoscopies, number of injections and total doses delivered.

CONCLUSIONS

Based on this published literature, the precedent for prescribing intralesional cidofovir supports a concentration of 5 to 7.5mg/ml. Volumes up to 5ml per injection are routinely used. Total dose and frequency of cidofovir administration is highly variable. The need for repeat doses of cidofovir should be judged on an individual basis.

Side-effects of cidofovir in the treatment of recurrent respiratory papillomatosis

Recurrent respiratory papillomatosis (RRP) is a chronic and difficult to treat disease of the larynx. In 1998, the first article was published that described the use of the antiviral substance cidofovir to treat this disease. Although the results are promising, there remains some concern about the potential carcinogenicity of cidofovir. There is a demand for a qualitative review of the side-effects of this medicine. In this review, the side-effects of cidofovir are investigated. Special attention was given to the potential carcinogenicity of cidofovir. For this review a search is performed in PubMed and EMBASE for relevant articles in which the use of intralesional cidofovir for patients with RRP is described. Eventually, 31 articles could be included for this review. In these articles a total of 188 patients with RRP were described who underwent therapy with intralesional cidofovir. Five of these patients have developed dysplasia of the larynx during the treatment with cidofovir. This is a percentage of 2.7. This percentage is concurrent with the incidence of spontaneous malignant degeneration of RRP (2–3%). Based on this review, it can be concluded that the use of intralesional cidofovir does not increase the risk of laryngeal dysplasia. Apart from the articles that describe the intralesional administration of cidofovir, some articles have been published in which the use of intravenous cidofovir is described as a therapy for RRP. Therefore, a summary is given on the side-effects of intralesional cidofovir as well as a summary on the reported side-effects of the intravenous administration of cidofovir. Based on the outcomes of this review, recommendations are given for a safe use of cidofovir for treatment of recurrent respiratory papillomatosis in the future.