Recurrent respiratory papillomatosis: A 2020 perspective

Strategically striving to be more inclusive: A recommendation for gender-neutral human-papillomavirus vaccine policies

The World Health Organization (WHO) has shifted from a multiple-dose human papillomavirus (HPV) vaccine schedule to a one-dose schedule prioritizing females aged 9-14 y. Given the burden of HPV-associated disease aside from cervical cancer and affecting both sexes, a shift toward emphasizing gender-neutral HPV vaccination strategies may improve vaccination coverage and more comprehensively address HPV-driven disease across both sexes, particularly for low- and middle-income countries.

Off-label drugs in laryngology- what should the doctor and the patient know about such therapies? A consensus statement of the European Laryngological Society

PURPOSE

Off-label drugs are being used in laryngology. Prescribing of a medicinal product is a decision taken within the relationship between a patient and his/her treating health care provider (HCP). The purpose of this article is to discuss the medicolegal aspects of off-label drug use, to provide recommendations for obtaining informed patient consent for off-label treatment and to propose the place and role of scientific societies and specialist boards in shaping good practices in this area. The final aim is to present recommendations concerning off-label usage and propose special clauses in informed patients consent.

METHODS

The literature was reviewed regarding off-label applications in laryngology. Practical information on off-label use in various EU countries was collected.

RESULTS

Registration data and pharmacokinetics of cidofovir, bevacizumab, Gardasil®, hyaluronic acid and mitomycin are provided. Off-label prescribing is not prohibited by EU law. Informed consent to treatment with an off-label drug exists in all EU countries. The risk that a court will accept liability of a HCP in case of off-label prescribing is higher than in case of on-label prescribing. If a HCP is held liable for the outcome of a medical treatment, the approval by the competent authorities and professional guideline is a strong defense.

CONCLUSION

A patient's precise, explicit consent for the procedures including off-label drugs administration is mandatory. The second prerequisite is defining a need for creating based on recommendations by national or international scientific societies.

Nonlinear relationship between operational frequency and age in respiratory papillomatosis patients

BACKGROUND

Respiratory papillomatosis (RP) is a benign tumor that primarily affects the respiratory tract and is often caused by human papillomavirus (HPV). Patients typically require multiple surgeries. Recent studies suggest that age may significantly influence the frequency of surgeries, although specific research on this correlation remains limited.

METHODS

This study retrospectively analyzed data from 676 RP patients who underwent surgery between 2000 and 2022 at a specific hospital. Patients were divided into two groups: those over 18 years old and those 18 years old or younger. This study examined the impact of factors such as age, weight, length of hospital stay, and HPV infection on the number of operations. Smooth curve fitting and threshold effect analysis were employed to explore the nonlinear relationship between age and surgery frequency. Univariate and multivariate regression analyses, along with a generalized additive model, were used to investigate the associations between age and the number of surgeries.

RESULTS

This study analyzed data from 676 patients with respiratory papillomatosis and revealed a significant nonlinear relationship between age and the number of operations. The results revealed that younger patients, especially those under 18 years of age, needed more surgeries, with an average of 5.5 surgeries per year, whereas adult patients had an average of only 1.7 surgeries. Through generalized additive modeling, we established that 8.2 years is a critical inflection point; below this age, each additional year is associated with a decrease of 0.7 surgeries (95% CI [-0.8, -0.6], P < 0.001), whereas the frequency stabilizes above this age. Multivariable regression analysis further confirmed the significant impact of age on surgical frequency, maintaining this association even when adjusting for other variables (β= -2.16, 95% CI [-2.97, -1.36], P < 0.001).

CONCLUSION

Age is a crucial factor influencing the frequency of surgeries in RRP patients, with this effect being particularly pronounced in younger patients. Notably, below the critical age of 8.2 years, the number of surgeries increases significantly. This finding provides important insights for clinical practice, aiding in the development of more precise treatment strategies and prognostic assessments.

Recurrent respiratory papillomatosis: Immunological mechanisms involved in recurrence

Recurrent respiratory papillomatosis is a benign neoplastic pathology in children, young people, and adults. It causes a significant deterioration in the quality of life, with symptoms typically referred to as dysphonia and hoarseness. This disease, with variable clinical courses ranging from spontaneous resolution to dissemination of the lower airway or airway obstruction that puts the individual's life at risk, characteristically requires multiple surgical interventions. Therapy with adjuvant drugs does not yet prove the effectiveness necessary to limit the recurrence and need for surgical reoperation in this condition. The review aimed to synthesize the immunopathogenic mechanisms of relapse in recurrent respiratory papillomatosis published in the current literature and the immunological implication of risk factors and treatment.

Laryngeal Papillomatosis

Laryngeal papillomatosis and recurrent respiratory papillomatosis are caused by the human papillomavirus. It is characterized by papillomatous growths and is the most common benign disease of the larynx. Juvenile-onset RRP is characterized by more aggressive disease compared with adult-onset RRP. Patients often require frequent surgical procedures, with an increasing shift toward office-based treatment. A variety of surgical and adjuvant medical therapies are available with mixed responses. New targeted therapies and vaccines are currently under investigation as potential adjuncts in the management.

Therapeutic Impact of Gardasil® in Recurrent Respiratory Papillomatosis: A Retrospective Study on RRP Patients

Background: Recurrent respiratory papillomatosis (RRP) is a rare, non-malignant disease caused by human papillomavirus (HPV) types 6 and 11. The condition primarily affects the larynx, potentially leading to life-threatening airway obstruction. It is more aggressive in younger patients, necessitating frequent surgical interventions. This study investigates the therapeutic potential of the prophylactic HPV vaccine Gardasil® in RRP patients, focusing on its impact on lesion size and the frequency of surgical interventions. Furthermore, a literature review was conducted to analyze the factors influencing the decision to vaccinate. Methods: A retrospective analysis was conducted on 63 RRP patients treated from 2008 to 2021. Disease burden was assessed using the Derkay score and the annual frequency of laser-surgical ablations. Comparisons were made between pre- and post-vaccination periods in vaccinated patients (n = 18), and between first and second halves of the disease's course in unvaccinated patients (n = 14). Results: A reduction in the frequency of surgical interventions post-vaccination (p < 0.05) could be seen. The cumulated Derkay score per year decreased after second and third vaccination (p < 0.05). The decision to be vaccinated is influenced by multiple factors (e.g., potential side-effects, sociocultural factors, impact of social media, pre-existing conditions and the wider context of the recent pandemic). Conclusions: Gardasil® appears to reduce the frequency of surgery and lessen disease severity in RRP patients, supporting the potential role of HPV vaccination as a therapeutic option for RRP. Moreover, it is crucial to overcome skepticism towards vaccinations to prevent the development of HPV-associated diseases in the first place.

Quantifying Bevacizumab Efficacy in Recurrent Respiratory Papillomatosis

OBJECTIVES

To develop and validate a novel method for quantifying the efficacy of Bevacizumab (Bev) in treating Recurrent Respiratory Papillomatosis (RRP), and to evaluate the clinical outcomes of a three-dose Bev induction therapy followed by surgical intervention.

METHODS

Twenty-one RRP patients treated with a three-dose Bev regimen were included. A novel efficacy evaluation method using ImageJ software was developed to calculate the standardized lesion volume from laryngoscopic images. This was compared with the Derkay score. Clinical outcomes, including reduction rate, cumulative reduction rate, efficacy grading, recurrence, and adverse reactions, were analyzed.

RESULTS

In the study cohort, the reduction rate was significantly higher after the first treatment compared with subsequent treatments. The overall response rate increased from 75% after the first treatment to 100% after the third. Among patients with localized lesions who underwent surgery, 76% experienced recurrence with a mean recurrence time of 114.23 days. Most recurrent lesions were smaller than at baseline. Adverse reactions included increased blood pressure in seven patients, which resolved without intervention. The new method showed a significant positive correlation with the Derkay score.

CONCLUSION

In conclusion, based on the above findings, systemic Bev treatment for RRP is a safe and effective therapeutic approach, though further research is needed. Moreover, the new efficacy evaluation method we developed can significantly aid in studying the effectiveness of Bev treatment for RRP.

LEVEL OF EVIDENCE

2 Laryngoscope, 135:257-262, 2025.

Genomic diversity of HPV6 and HPV11 in recurrent respiratory papillomatosis: Association with malignant transformation in the lungs and clinical outcomes

Recurrent respiratory papillomatosis (RRP) is a rare, proliferative disease caused by human papillomavirus 6 (HPV6) and HPV11. RRP can occasionally spread and undergo malignant transformation. We analysed samples across time for five RRP patients with malignant transformation and four with highly recurrent, non-malignant RRP by applying high-throughput sequencing. Patients with malignant transformation were infected by HPV11_A1/A2, while most non-malignant cases were associated with HPV6. Transient multiple infections with HPV6 and HPV11 were found in two patients, and resolved later to single infections. Viral genome loads were homogeneous across groups (median = 78 viral genomes per human genome). Within-patient, we did not observe differences between the viral sequences in the papillomatous lesions and in the malignant tissue. Genetic analysis of the NLRP1 gene revealed no known mutations linked to idiopathic RRP, though some novel variants merit to be explored in larger cohorts. HPV11 infections appear associated with RRP malignant transformation in young patients. Multiple infections can occur in RRP, but within-patient viral diversity is minimal for a given genotype. Our results confirm the importance of viral genotype in disease prognosis and are consistent with growing evidence of HPV11 infections to be differentially associated with RRP malignant transformation in young patients.

The Recurrence of Tracheobronchial Papillomatosis Following Prostate Cancer Diagnosis

Recurrent respiratory papillomatosis (RRP) is a challenging disease to manage, due to its highly recurring nature and the lack of a definitive treatment. It is characterized by the presence of benign papillomatous lesions caused by the human papillomavirus (HPV), which can pose a threat to the patient's airway patency and restrict their breathing ability. We present the case of a 64-year-old patient with a history of papillomas in the trachea and bronchi, treated with endobronchial cryotherapy. However, tracheal and bronchial papillomas recurred 10 years after the initial treatment and two years after the diagnosis of prostate cancer and hormonal therapy. We also engage in a discussion of the clinical and radiological features of RRP.

Advances in Recurrent Respiratory Papillomatosis Treatment: Adjuvant Intralesional Bevacizumab's Impact, Potential and Insights from a Case Series Study

Recurrent respiratory papillomatosis is an aggressive benign disease characterised by the repeated growth of multiple warts involving the larynx as well as other parts of the respiratory tract. Recurrent respiratory papillomatosis is most commonly caused by human papillomaviruses 6 and 11. It requires multiple surgical procedures for tumour debulking.Our study aims to evaluate the impact and potential of adjuvant intralesional bevacizumab in the treatment of recurrent respiratory papillomatosis while providing valuable insights based on a case series analysis.A prospective study of a total of 13 patients with Recurrent respiratory papillomatosis attending a tertiary care hospital with ages ranging from 3 to 30 years was conducted from February 2018 to February 2023 by intralesional bevacizumab 1 ml with a concentration of 2.5 mg/ml per dose, 3 injections, each once every 4 weeks by calculating the number of operative procedures per year, duration of time between procedures, calculating the Derkay score before 1 year of the first injection and after 1 year of the last dose injection of bevacizumab treatment. Inclusion criteria are ages between 3 and 30 years with recurrent respiratory papillomatosis who underwent at least 4 or more surgical procedures with no adjuvant therapies. In all our cases, the affected area was the larynx.Adjuvant therapy with intralesional bevacizumab increases the duration of time between surgical procedures and reduces the number of operative procedures each year with an overall improvement in the Derkay score. No adverse drug effects have been reported in our study.Intralesional Bevacizumab is an effective and safe adjuvant treatment option for recurrent respiratory papillomatosis. It increases the duration of time between surgical procedures and decreases the number of procedures per year with an overall improvement in the Derkay score.

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.

Quality of Life in Recurrent Respiratory Papillomatosis Patients after Vocal Fold Surgery: An In-Depth Exploration

INTRODUCTION

This study explores the quality of life among patients with recurrent respiratory papillomatosis (RRP) after vocal fold surgery as measured by the outcome scores of the Voice Handicap Index (VHI) and the Distress Thermometer and Problem List in Patients with Recurrent Respiratory Papillomatosis (DT&PL). Differences in quality of life were explored within the independent variables age, surgical frequency, weeks since last vocal fold operation, gender, HPV type, surgical location, vaccination with Gardasil©, and a patient's request to speak with a speech-language pathologist.

METHODS

A single-center, observational cohort study was conducted using VHI and DT&PL scores and demographic and clinical data obtained from patient files. Inclusion criteria were a confirmed HPV type, age 18 years or older, the ability to fill in both questionnaires in Dutch, and having undergone at least one surgical procedure to remove laryngeal papilloma. Relationships of the independent variables with VHI and Distress Thermometer (DT) scores were explored using univariable and multivariable regressions and linear regression models.

RESULTS

Of 271 RRP patients, 100 met the inclusion criteria and responded to requests to fill in both questionnaires with a minimum of 12 weeks after their last operation. Our study showed a statistically significant negative relationship between age and VHI scores (p = 0.02) in the univariable, and multiple linear regressions (p = 0.01), indicating that patients experienced fewer self-perceived functional voice disabilities with each increase in age. A parallel negative relationship is seen between the variables age (p = 0.03) and DT scores. Our results showed a statistically significant positive relationship between the number of vocal fold surgeries and DT scores (p = 0.03).

CONCLUSION

The results of this study show a significant relationship between age, surgical frequency, and quality of life in patients with RRP. Older patients have lower Voice Handicap Index (VHI) and Distress Thermometer (DT) scores, indicating fewer self-perceived voice and disease-related quality of life problems. Conversely, a rise in surgical frequency is significantly associated with higher DT scores, reflecting greater disease-related distress.

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.

Adjuvant Human Papillomavirus Vaccination in Recurrent Respiratory Papilloma Patients Older than 45

OBJECTIVES

The primary objective was to examine the intersurgical interval (ISI) of recurrent respiratory papillomatosis (RRP) in patients older than 45 years before and after a Gardasil vaccination series.

METHODS

We conducted a retrospective chart review of adult patients >45 years of age diagnosed with RRP from 2012 to 2022. Patients were excluded if they did not receive at least two doses of the Gardasil vaccine series or if they underwent two or fewer surgeries during the study period.

RESULTS

Thirteen patients met the inclusion criteria, 11 males and two females. The age at initial diagnosis ranged from 46 to 80 years, with a mean of 59 years. There was a significant increase in the average ISI, from 126 ± 87 days pre-vaccination compared to 494 ± 588 days post-vaccination (p < 0.01). The average number of surgeries per patient was 6.8 ± 2.4 over an average follow-up of 49.7 ± 30.3 months.

CONCLUSION

Adjuvant Gardasil use in RRP patients older than 45 years significantly increases the ISI. Current CDC recommendations include only patients ages 9 to 45, but this study provides evidence that RRP patients outside this age range may benefit from adjuvant HPV vaccination.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:3226-3229, 2024.

Juvenile onset recurrent respiratory papillomatosis: What do we know in 2024 ?

Juvenile onset recurrent respiratory papillomatosis is a lifelong benign squamous lesion associated with HPV infection, particularly HPV6 and HPV11 genotypes. These lesions are rare, but can lead to laryngeal obturations, which can cause disabling dyspnea, or transform into squamous cell carcinoma. The aim here is to provide an epidemiological, biological and clinical overview of this pathology, particularly in children, in order to understand the issues at stake in terms of research and the development of medical and therapeutic management tools.

The Larynx is Protected from Secondary and Vertical Papillomavirus Infection in Immunocompetent Mice

OBJECTIVE

Mouse papillomavirus MmuPV1 causes both primary and secondary infections of the larynx in immunocompromised mice. Understanding lateral and vertical transmission of papillomavirus to the larynx would benefit patients with recurrent respiratory papillomatosis (RRP). To test the hypothesis that the larynx is uniquely vulnerable to papillomavirus infection, and to further develop a mouse model of RRP, we assessed whether immunocompetent mice were vulnerable to secondary or vertical laryngeal infection with MmuPV1.

METHODS

Larynges were collected from 405 immunocompetent adult mice that were infected with MmuPV1 in the oropharynx, oral cavity, or anus, and 31 mouse pups born to immunocompetent females infected in the cervicovaginal tract. Larynges were analyzed via polymerase chain reaction (PCR) of lavage fluid or whole tissues for viral DNA, histopathology, and/or in situ hybridization for MmuPV1 transcripts.

RESULTS

Despite some positive laryngeal lavage PCR screens, all laryngeal tissue PCR and histopathology results were negative for MmuPV1 DNA, transcripts, and disease. There was no evidence for lateral spread of MmuPV1 to the larynges of immunocompetent mice that were infected in the oral cavity, oropharynx, or anus. Pups born to infected mothers were negative for laryngeal MmuPV1 infection from birth through weaning age.

CONCLUSION

Secondary and vertical laryngeal MmuPV1 infections were not found in immunocompetent mice. Further work is necessary to explore immunologic control of laryngeal papillomavirus infection in a mouse model and to improve preclinical models of RRP.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:2322-2330, 2024.

Systemic bevacizumab for treatment of recurrent respiratory papillomatosis

OBJECTIVES

To characterize treatment response of recurrent respiratory papillomatosis (RRP) including adult-onset RRP (AORRP) and juvenile-onset RRP (JORRP) to systemic bevacizumab (bev), and share our treatment regimen experience.

METHODS

Patients were enrolled in bev treatment based on a pathologically confirmed diagnosis of squamous papilloma. According to lesion characteristics and medical history, systemic bev was used as preoperative adjuvant therapy, postoperative adjuvant therapy, or primary therapy. The assessment of treatment response relied on the morphological changes of lesions. Vocalization and voice-related quality of life were evaluated using the voice handicap index-30 (VHI-30) for adults and the pediatric VHI (pVHI) for children. Adverse effect was monitored through patient self-reported symptoms and regular follow-ups.

RESULTS

This study included 24 patients, comprising nine AORRP and 15 JORRP cases. In AORRP, all patients (100%) exhibited various degrees of response to systemic bev, with 5 (55.56%) achieving complete response (CR). Among JORRP patients, 14 (93.33%) showed a response to systemic bev, with 8 (53.33%) achieving CR and currently being followed up. No instances of aggravation were observed during systemic bev treatment. A total of 21 patients (21/24, 87.50%) reported voice improvement, accompanied by reduced VHI-30 or pVHI scores across all aspects, including total, functional, physical, and emotional dimensions. No grade 3 or higher adverse events occurred. The most common adverse events were grade 1 gum bleeding (n = 4, 16.67%) and grade 1 proteinuria (n = 4, 16.67%).

CONCLUSIONS

Systemic bev can be used as a powerful therapy for both AORRP and JORRP. The findings provide a reference to the systemic bev treatment for RRP.

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>.

Pulmonary Involvement in Recurrent Respiratory Papillomatosis: A Systematic Review

Recurrent respiratory papillomatosis (RRP) is a non-malignant disease, characterized by the production of wart-like growths in the respiratory tract, affecting both young people and adults (juvenile-onset recurrent respiratory papillomatosis, JORRP, and adult-onset recurrent respiratory papillomatosis, AORRP, respectively). Infection caused by human papillomavirus (HPV) is known as the main factor involved in RRP development. Complications of RRP may rarely occur, including lung involvement and malignant transformation. The present systematic review aimed to evaluate the prevalence of severe complications, such as lung involvement and lung tumor in JORRP and AORRP patients, and assess the role of HPV genotypes in the progression of disease severity following the guideline for reporting systematic reviews and meta-analysis (PRISMA Statement). A total of 378 studies were found on PubMed and Scopus using the following MESH terms: "recurrent respiratory papillomatosis and lung tumor" and "pulmonary tumor and recurrent respiratory papillomatosis". Basing on inclusion and exclusion criteria, a total of 11 studies were included in the systematic review. We found a pooled prevalence of 8% (95% CI: 4-14%; I2: 87.5%) for lung involvement in RRP patients. In addition, we found a pooled risk difference of 5% in lung involvement between JORRP and AORRP (95% CI: -7-18%; I2: 85.6%, p-value: 0.41). Among patients with lung involvement, we observed a pooled prevalence of lung tumor of 4% (95% CI:1-7%; I2: 67.1%) and a pooled prevalence mortality for this group of 4% (95% CI:2-6%; I2: 0%). Overall, the positivity rate for HPV-6 and -11 in patients with RRP was 91%. Considering only cases with pulmonary involvement, the pooled prevalence for HPV-11 was 21% (95% CI: 5-45%; I2: 77.2%). Our results evidenced a low/middle risk of pulmonary involvement and lung tumor in JORRP and AORRP patients, with an increased risk for HPV-11-positive patients. Further studies should be performed to improve knowledge and adopt preventive measures to contrast the progression to severe diseases in RRP patients.

HPV-related diseases in male patients: an underestimated conundrum

PURPOSE

Human papillomavirus (HPV) infection is the most common sexually transmitted disease, in males and females worldwide. While the role of HPV in female diseases is well known and largely studied, males have negligibly been included in these programs, also because the proportion of women suffering and dying from HPV-related diseases is much larger than men. The aim of this review is to focus on HPV-related diseases in male patients.

METHODS

We performed a literature analysis on the electronic database PubMed. We considered randomized trials, observational and retrospective studies, original articles having as topic the relationship between HPV male infection and the following items: oral, anal penile cancers, warts, condylomas, male infertility, altered sperm parameters, anti-sperm antibodies (ASA). We also included experimental in vitro studies focused on the effects of HPV infection on oocyte fertilization, blastocyst development, and trophoblastic cell invasiveness. In addition, studies describing the adjuvant administration of the HPV vaccination as a possible strategy to promote HPV clearance from semen in infected males were included.

RESULTS

Regarding head and neck HPV-related diseases, the most important non-neoplastic disease is recurrent respiratory papillomatosis (RRP). Regarding neoplastic diseases, the proportion of head and neck cancers attributable to HPV has increased dramatically worldwide. In addition, nowadays, it is thought that half of head and neck squamous cell carcinomas (HNSCCs) cases in the United States are caused by infection with high-risk HPV. HPV is noteworthy in andrological practice too. It was described as having a high HPV prevalence, ranging between 50 and 70%, in male penile shaft, glans penis/coronal sulcus, semen as well as in scrotal, perianal, and anal regions. Moreover, in male patients, HPV infection has been associated, among other diseases, with penile cancers. HPV semen infection has been reported in about 10% in men from the general population and about 16% in men with unexplained infertility, although these data seem widely underestimated according to clinical experience. In particular, HPV semen infection seems to be most related to asthenozoospermia and to anti-sperm antibodies (ASAs).

CONCLUSIONS

HPV infection represents a health problem with a detrimental social and public impact. Despite this evidence, little has been done to date to widely promote vaccination among young males.

Preclinical Models of Laryngeal Papillomavirus Infection: A Scoping Review

OBJECTIVE

Laryngeal human papillomavirus (HPV) infection causes recurrent respiratory papillomatosis (RRP) and accounts for up to 25% of laryngeal cancers. Lack of satisfactory preclinical models is one reason that treatments for these diseases are limited. We sought to assess the literature describing preclinical models of laryngeal papillomavirus infection.

DATA SOURCES

PubMed, Web of Science, and Scopus were searched from the inception of database through October 2022.

REVIEW METHODS

Studies searched were screened by two investigators. Eligible studies were peer-reviewed, published in English, presented original data, and described attempted models of laryngeal papillomavirus infection. Data examined included type of papillomavirus, infection model, and results including success rate, disease phenotype, and viral retention.

RESULTS

After screening 440 citations and 138 full-text studies, 77 studies published between 1923 and 2022 were included. Models used low-risk HPV or RRP (n = 51 studies), high-risk HPV or laryngeal cancer (n = 16), both low- and high-risk HPV (n = 1), and animal papillomaviruses (n = 9). For RRP, 2D and 3D cell culture models and xenografts retained disease phenotypes and HPV DNA in the short term. Two laryngeal cancer cell lines were consistently HPV-positive in multiple studies. Animal laryngeal infections with animal papillomaviruses resulted in disease and long-term retention of viral DNA.

CONCLUSIONS

Laryngeal papillomavirus infection models have been researched for 100 years and primarily involve low-risk HPV. Most models lose viral DNA after a short duration. Future work is needed to model persistent and recurrent diseases, consistent with RRP and HPV-positive laryngeal cancer.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:3256-3268, 2023.

Transnasal Humidified Rapid Insufflation Ventilatory Exchange Augments Oxygenation in Children With Juvenile Onset Recurrent Respiratory Papillomatosis During Surgery: A Prospective Randomized Crossover Controlled Trial

BACKGROUND

Evidence is lacking regarding the efficacy of transnasal humidified rapid insufflation ventilatory exchange (THRIVE) in tubeless anesthesia, especially in pediatric patients. This study aimed to evaluate the use of THRIVE for juvenile onset recurrent respiratory papillomatosis (JORRP) patients.

METHODS

Twenty-eight children aged 2 to 12 years with JORRP, abnormal airways, and ASA physical status II-III that presented for surgical treatment under general anesthesia were included in this study. Each patient received 2 interventions in random order, with a 5-minute washout period between treatments: apnea without oxygen supplementation and apnea with THRIVE intervention. The primary outcome apnea time was defined as the duration from withdrawal of intubation to reintubation and resumption of controlled ventilation. The secondary outcomes were the mean transcutaneous carbon dioxide (tc co2 ) increase rate, the minimum pulse oxygen saturation (Sp o2 ) during apnea, and the occurrence of unexpected adverse effects.

RESULTS

The median apnea time in the THRIVE period was significantly longer than that in the control period (8.9 [8.6-9.4] vs 3.8 [3.4-4.3] minutes; mean difference [95% confidence interval (CI)], 5.0 [4.4-5.6]; P < .001) for all patients. The rate of CO 2 change in the control period was higher than that in the THRIVE period both for patients aged 2 to 5 years old (6.29 [5.19-7.4] vs 3.22 [2.92-3.76] mm Hg min -1 ; mean difference [95% CI], 3.09 [2.27-3.67]; P < .001) and for patients aged 6 to 12 years old (4.76 [3.7-6.2] vs 3.38 [2.64-4.0] mm Hg min -1 ; mean difference [95% CI], 1.63 [0.75-2.56]; P < .001). The minimum Sp o2 was significantly higher in the THRIVE period than in the control period (mean difference [95% CI], 19.7 [14.8-22.6]; P < .001).

CONCLUSIONS

Our findings demonstrate that THRIVE safely increased the apnea time among children with JORRP undergoing surgery and decreased the rate of carbon dioxide increase. THRIVE is clinically recommended as an airway management technique for tubeless anesthesia in apneic children.

Intralesional Cidofovir: A Systematic Review of Administration Protocols and Long-term Recurrence Rates in Adult and Juvenile Recurrent Respiratory Papillomatosis

OBJECTIVE

This is a systematic review aimed to explore Cidofovir administration protocols, recurrence rates, and long-term effectiveness for severe cases of recurrent respiratory papillomatosis (RRP). The primary goal was to identify current practices, determine the preferred protocol, and assess the adjuvant therapy's ability to prevent long-term papilloma recurrence in juvenile and adult-onset disease.

METHODS

The following databases were searched: Pubmed, Google Scholar (pages 1-10), EMBASE, Scopus, ISI (clarivate), Cochrane Library, and Journal Storage from 1996 to June 2022. Articles that reported the use of intralesional Cidofovir in RRP and reported remission/recurrence rates with follow-up were included in the review. The systematic review was registered through PROSPERO and contains the detailed protocol for the conduction of the review.

RESULTS

A total of 389 records were identified, 126 titles and abstracts screened, 45 studies fully read, and 30 studies met the inclusion criteria. Two hundred and fourteen adult-onset RRP (AORRP) and 126 juvenile-onset RRP (JORRP) cases were treated with Cidofovir across the included studies. There was no universal protocol for administering Cidofovir, with variations in concentration, treatment period, number and interval of injections, and follow-up duration. Most lesions showed human papilloma virus types 6 and 11. Recurrence rates varied, and other outcomes reported included remission rates, lesion reduction, surgical intervals, and side effects. Some studies demonstrated significant improvements in disease severity and extended intervals between recurrences after Cidofovir administration.

CONCLUSIONS

The analysis of 30 studies reveals the need for greater consistency in reporting treatment parameters and outcomes. The use of recurrence-free period as an outcome measure and the potential benefits of a concentration of 7.5 mg/mL are identified. Additionally, the importance of viral typing within papilloma lesions is emphasized. To further enhance understanding and establish optimal protocols, future research should focus on uniform reporting, including severity, dosage, interval, treatment duration, functional outcome, and related procedures.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022299549.

Recurrent respiratory papillomatosis (RRP) of tracheobronchial tree presenting as lung collapse with malignant transformation after a decade

Recurrent respiratory papillomatosis is a rare disease caused by HPV infection. We hereby report a patient with recurrent respiratory papillomatosis of the tracheobronchial tree with no laryngeal involvement who remained clinically stable for more than 10 years but then developed malignant transformation with metastases. A 61-year-old lady with good past health presented to our department in 2010 because of chronic cough for years. Chest X-ray showed reduced left lung volume. Bronchoscopy showed multiple nodules over left main bronchus and left upper lobe progressing to involve the posterior trachea and left lower lobe. Biopsy revealed squamous papilloma with mild dysplasia. She refused surgical intervention. She remained relatively stable until November 2022 when she developed left chest pain. CT showed features of malignant transformation with local invasion and metastases. Fine needle aspiration suggested squamous cell carcinoma. She succumbed in December 2022. Bronchoscopy should be considered in the investigation of unexplained chronic cough so that this rare disease can be detected at an early stage. The disease may not require intervention if uncomplicated. Despite clinical stability for a prolonged period, close monitoring for malignant transformation is warranted indefinitely.

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.

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.

Human papillomavirus vaccination in Africa: An airway perspective

INTRODUCTION

Recurrent respiratory papillomatosis (RRP) is a chronic condition caused by Human papillomavirus six (HPV-6) and HPV-11 that involves the respiratory tract. Disease severity ranges from mild (hoarseness), through to severe (stridor, respiratory distress and airway emergencies). Africa has the fastest growing and youngest population of all the continents. It also has the greatest burden of cervical cancer. There is an association with infection of the oncogenic HPV strains and the strains responsible for RRP. It is reasonable to conclude that although RRP may be underestimated in low-to-middle-income countries, it poses a considerable health risk to Africa. The primary aim of this project was to assess the suitability of HPV vaccination coverage on the African continent.

METHODS

A prospective study was designed to consist of an online survey. It was distributed to 135 African otolaryngologists. Questions focussed on HPV vaccination programmes; whether they were government directed; and their rollout. Information from countries that had multiple otolaryngologists respond to the survey were compared. Additionally, data review and corroboration were performed.

RESULTS

There were 58 (43%) participants from 19 countries. Nine countries reported a national vaccination programme (NVP), five used Cervarix; four used quadrivalent Gardasil. Collateral data revealed 18 of 54 countries had NVP in Africa and 26 countries had completed HPV vaccine pilot or demonstration projects.

CONCLUSIONS

HPV vaccination in Africa should be urgently re-evaluated to include the HPV-6 and HPV-11 strains that cause JORRP, which have not been recognised during national vaccination programme planning.

Analysis of lesion location and disease characteristics of pharyngeal and laryngeal papilloma in adult

OBJECTIVES

Papilloma is a common benign epithelial tumor of the respiratory tract in adults. Its histological structure and immune environment vary from site to site. This study investigated the disease characteristics and prognostic differences of papillomas at various primary locations.

METHODS

Clinical data was collected from patients with adult glossal root and hypopharyngeal papilloma admitted to our tertiary referral center between January 2010 and December 2020, and compared with patients with laryngeal papilloma. Differences in age, sex, smoking, alcohol consumption, single or multiple lesions, surgical methods, immunohistochemical indexes, Ki-67 and p16, were analyzed in patients with different primary papilloma sites.

RESULTS

A total of 84 cases of glossal root papilloma, 51 cases of hypopharyngeal papilloma, and 51 cases of laryngeal papilloma were included. Differential analysis between groups showed that there were statistically significant differences in age, sex, smoking, single and multiple lesions, and surgical methods in the different primary sites. Ki-67 expression in laryngeal papilloma was higher than that in glossal root and hypopharyngeal papilloma. There was no significant difference in p16 expression in the three groups. In terms of prognosis, laryngeal papilloma is more likely to relapse than glossal root or hypopharyngeal papilloma, and the recurrence time is shorter.

CONCLUSIONS

As the largest clinical study of papilloma in different primary locations, this study found that the clinical characteristics and postoperative recurrence of papilloma of the glossal root and hypopharynx differ from those of papilloma of the larynx. This finding supports the current clinical experience in treating papillomas in different locations and facilitates the development of clinical treatment plans.

Systemic Bevacizumab for Severe Recurrent Respiratory Papillomatosis

Recurrent respiratory papillomatosis (RRP) is the most common benign pediatric laryngeal neoplasm. Various adjuvant medical therapies have failed to reliably decrease surgical frequency in this challenging airway disease. Recently, systemic bevacizumab has shown promise in advanced, treatment-resistant papillomatosis. We describe the use of systemic bevacizumab in two children with severe RRP unresponsive to other therapies. Voice and breathing improved dramatically in both patients with minimal side effects. Both patients have not required surgery in 24 months and 16 months, respectively. Systemic bevacizumab is a promising long-term treatment for severe RRP, with oncology playing an important role in patient care.

Use of cryotherapy to treat obstructing papilloma of an accessory tracheal bronchus: case report

BACKGROUND

Tracheal papillomatosis is a relatively rare condition with limited data on successful treatment modalities. To our knowledge, this is the first report to describe a papilloma arising from an accessory bronchus. Furthermore, this case report demonstrates successful treatment with clinical and patient-centered improvements after use of Spray Cryotherapy.

CASE PRESENTATION

A 71-year-old woman presented with one year history of recurrent fevers and intermittent hemoptysis. Imaging and video bronchoscopy revealed an obstructing papilloma of an accessory tracheal bronchus to the right upper lobe. She was treated with debridement followed by multiple cryotherapy treatments resulting in complete clinical and radiographic resolution of her post-obstructive pneumonia.

CONCLUSIONS

This case report not only supports existing literature on the use of cryotherapy for airway diseases but also presents a unique form of obstructing papilloma confined to an accessory bronchus, the only report of its kind based on extensive literature review.

Papillomaviral skin diseases of humans, dogs, cats and horses: A comparative review. Part 1: Papillomavirus biology and hyperplastic lesions

Papillomaviruses (PVs) cause disease in humans, dogs, cats, and horses. While there are some differences, many aspects of the pathogenesis, presentation, and treatment of these diseases are similar between the four species. In this review, the PV-induced diseases of humans are compared to the similar diseases that develop in the companion animal species. By comparing with the human diseases, it is possible to make assumptions about some of the less common and less well-studied diseases in the veterinary species. In the first part of this review, the PV lifecycle is discussed along with the classification of PVs and the immune response to PV infection. The hyperplastic diseases caused by PVs are then discussed; including PV-induced cutaneous, anogenital, and oral warts within the four species.

Pulmonary manifestations of chronic HPV infection in patients with recurrent respiratory papillomatosis

Human papillomavirus (HPV) types 6 and 11 can infect the squamous epithelium of the respiratory tract. Up to 8·9% of patients with HPV-associated recurrent respiratory papillomatosis (RRP) have pulmonary involvement. Pulmonary manifestations of HPV infection are associated with considerable morbidity, in part because treatment options and management guidelines are lacking. Patients with pulmonary RRP have a 32-times increased lifetime risk of malignant transformation compared with the overall RRP population. We review the clinical and radiographic presentation, pathological features, and genetics of pulmonary RRP, and we provide management algorithms based on our clinical experience with this complex patient population. In patients with suspected pulmonary involvement, tissue-sparing procedures to address growing lesions might be warranted given the chronicity and multifocality of the disease over a patient's lifetime. However, malignant transformation of pulmonary lesion(s) warrants standard-of-care treatment for primary lung squamous cell carcinoma. Large cohort studies are needed to understand the clinical course of pulmonary RRP and to identify molecular markers of increased risk of malignant transformation in order to develop guidelines for optimal and standardised surveillance and treatment.

The i-gel supraglottic airway device improves airway management during endobronchial ablative therapy under general anesthesia: a case report

Endobronchial ablative therapy (EAT) in patients with preexisting obstructive airway disease can cause hypoxemia because bronchoscope insertion interferes with ventilation and a low fraction of inspired oxygen (FiO₂) is essential to avoid airway fire. A man in his early 50s with moderately severe obstructive airway disease was scheduled for EAT for treatment of tracheal papillomatosis. Ventilation and oxygenation would have been difficult because of narrowing of the endotracheal tube by bronchoscopic insertion and a low FiO₂; therefore, an i-gel supraglottic airway device with a larger inner diameter was inserted. All visible intratracheal papillomas were ablated by a potassium titanyl phosphate laser through the bronchoscopic port that passed through the lumen of the i-gel at an FiO₂ of 0.3. During anesthesia for EAT, the i-gel supraglottic airway device provided a wider lumen for ventilation. We were thus able to provide stable ventilation at an FiO₂ of 0.3 during EAT in this patient with obstructive airway disease, avoiding airway fire and hypoxemia.

Expanded Basal Compartment and Disrupted Barrier in Vocal Fold Epithelium Infected with Mouse Papillomavirus MmuPV1

Laryngeal infection with low-risk human papillomaviruses can cause recurrent respiratory papillomatosis (RRP), a disease with severe effects on vocal fold epithelium resulting in impaired voice function and communication. RRP research has been stymied by limited preclinical models. We recently reported a murine model of laryngeal MmuPV1 infection and disease in immunodeficient mice. In the current study, we compare quantitative and qualitative measures of epithelial proliferation, apoptosis, differentiation, and barrier between mice with MmuPV1-induced disease of the larynx and surrounding tissues and equal numbers of uninfected controls. Findings supported our hypothesis that laryngeal MmuPV1 infection recapitulates many features of RRP. Like RRP, MmuPV1 increased proliferation in infected vocal fold epithelium, expanded the basal compartment of cells, decreased differentiated cells, and altered cell–cell junctions and basement membrane. Effects of MmuPV1 on apoptosis were equivocal, as with RRP. Barrier markers resembled human neoplastic disease in severe MmuPV1-induced disease. We conclude that MmuPV1 infection of the mouse larynx provides a useful, if imperfect, preclinical model for RRP that will facilitate further study and treatment development for this intractable and devastating disease.

A Novel In Vivo Model of Laryngeal Papillomavirus-Associated Disease Using Mus musculus Papillomavirus

Recurrent respiratory papillomatosis (RRP), caused by laryngeal infection with low-risk human papillomaviruses, has devastating effects on vocal communication and quality of life. Factors in RRP onset, other than viral presence in the airway, are poorly understood. RRP research has been stalled by limited preclinical models. The only known papillomavirus able to infect laboratory mice, Mus musculus papillomavirus (MmuPV1), induces disease in a variety of tissues. We hypothesized that MmuPV1 could infect the larynx as a foundation for a preclinical model of RRP. We further hypothesized that epithelial injury would enhance the ability of MmuPV1 to cause laryngeal disease, because injury is a potential factor in RRP and promotes MmuPV1 infection in other tissues. In this report, we infected larynges of NOD scid gamma mice with MmuPV1 with and without vocal fold abrasion and measured infection and disease pathogenesis over 12 weeks. Laryngeal disease incidence and severity increased earlier in mice that underwent injury in addition to infection. However, laryngeal disease emerged in all infected mice by week 12, with or without injury. Secondary laryngeal infections and disease arose in nude mice after MmuPV1 skin infections, confirming that experimentally induced injury is dispensable for laryngeal MmuPV1 infection and disease in immunocompromised mice. Unlike RRP, lesions were relatively flat dysplasias and they could progress to cancer. Similar to RRP, MmuPV1 transcript was detected in all laryngeal disease and in clinically normal larynges. MmuPV1 capsid protein was largely absent from the larynx, but productive infection arose in a case of squamous metaplasia at the level of the cricoid cartilage. Similar to RRP, disease spread beyond the larynx to the trachea and bronchi. This first report of laryngeal MmuPV1 infection provides a foundation for a preclinical model of RRP.

A Case of Recurrent Respiratory Papillomatosis With Lung Involvement and Malignant Transformation

Recurrent respiratory papillomatosis is a rare and complex progression of the disease due to the human papillomavirus (HPV). In this case report, we present the findings of a 53-year-old male who was diagnosed with obstructing respiratory papillomatosis of the trachea and underwent several procedures until the disease progressed to squamous cell carcinoma. Our objective with this case report is to contribute to a broader understanding of this disease by reporting a clinical case.

Comprehensive multiomic characterization of human papillomavirus-driven recurrent respiratory papillomatosis reveals distinct molecular subtypes

Recurrent respiratory papillomatosis (RRP) is a debilitating neoplastic disorder of the upper aerodigestive tract caused by chronic infection with low-risk human papillomavirus types 6 or 11. Patients with severe RRP can require hundreds of lifetime surgeries to control their disease and pulmonary papillomatosis can be fatal. Here we report the comprehensive genomic and transcriptomic characterization of respiratory papillomas. We discovered and characterized distinct subtypes with transcriptional resemblance to either a basal or differentiated cell state that associate with disease aggressiveness and differ in key molecular, immune and APOBEC mutagenesis profiles. Through integrated comparison with high-risk HPV-associated head and neck squamous cell carcinoma, our analysis revealed divergent molecular and immune papilloma subtypes that form independent of underlying genomic alterations. Cumulatively our results support the development of dysregulated cellular proliferation and suppressed anti-viral immunity through distinct programs of squamous cell differentiation and associated expression of low-risk HPV genes. These analyses provide insight into the pathogenesis of respiratory papillomas and provide a foundation for the development of therapeutic strategies.

Cem Sievers et al. performed genomic and transcriptomic analysis in human recurrent respiratory papillomatosis (RRP). They found that RRP harbors few genomic alterations, but that distinct transcriptional subtypes correlate with HPV gene expression and frequency of clinically-indicated interventions.

Relevance of Human Papillomaviruses in Head and Neck Cancer-What Remains in 2021 from a Clinician's Point of View?

Human papillomaviruses (HPV) cause a subset of head and neck cancers (HNSCC). HPV16 predominantly signs responsible for approximately 10% of all HNSCC and over 50% of tonsillar (T)SCCs. Prevalence rates depend on several factors, such as the geographical region where patients live, possibly due to different social and sexual habits. Smoking plays an important role, with non-smoking patients being mostly HPV-positive and smokers being mostly HPV-negative. This is of unparalleled clinical relevance, as the outcome of (non-smoking) HPV-positive patients is significantly better, albeit with standard and not with de-escalated therapies. The results of the first prospective de-escalation studies have dampened hopes that similar superior survival can be achieved with de-escalated therapy. In this context, it is important to note that the inclusion of p16^INK4A (a surrogate marker for HPV-positivity) in the 8th TMN-classification has only prognostic, not therapeutic, intent. To avoid misclassification, highest precision in determining HPV-status is of utmost importance. Whenever possible, PCR-based methods, still referred to as the "gold standard”, should be used. New diagnostic antibodies represent some hope, e.g., to detect primaries and recurrences early. Prophylactic HPV vaccination should lead to a decline in HPV-driven HNSCC as well. This review discusses the above aspects in detail.