Bevacizumab as adjuvant therapy for recurrent respiratory papillomatosis in an infant

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.

Aggressive recurrent respiratory papillomatosis: A series of five consecutive patients successfully treated with adjuvant intravenous bevacizumab. A single Belgian academic center experience

BACKGROUND

Recurrent respiratory papillomatosis (RRP) is a currently incurable benign neoplasm caused by human papilloma virus (HPV) infection. It usually reduces voice, respiratory, and general quality of life, and is sometimes life-threatening. Patients usually need repeated operations. The use of adjuvant bevacizumab, a monoclonal antibody targeting vascular endothelial growth factor A, has been described in several case reports, with a good efficacy and safety profile.

METHODS

We report the cases of five patients with aggressive RRP who were treated with adjuvant systemic bevacizumab in a single Belgian tertiary center.

RESULTS

A complete response was achieved in four patients after a median of 4.5 months, and a partial response in one. In all cases, the number of surgeries was drastically reduced, and quality of life improved. Toxicity was easily managed.

CONCLUSIONS

Systemic bevacizumab seems to be an effective and safe adjuvant treatment for aggressive RRP.

Systemic Bevacizumab for Recurrent Respiratory Papillomatosis: A Scoping Review from 2009 to 2022

BACKGROUND

Respiratory recurrent papillomatosis (RRP) is a fatal disease with no known cure. In severe RRP cases, systemic bevacizumab (SB) could be used as adjuvant therapy.

OBJECTIVE

This study aims to determine the extent and type of evidence in relation to the clinical outcomes of RRP after SB treatment.

METHODS

Participants with RRP of all genders are included in this scoping review. There were no exclusion criteria (country, language, or document type). The information sources included experimental, quasi-experimental, and analytical observational studies. Unpublished data will not be covered, but gray literature was covered. Screening, paper selection, and data extraction were all done by two independent reviewers. This procedure was performed blindly.

RESULTS

Of the 175 unique records found, 15 were eligible for inclusion. Fourteen studies were included after applying inclusion and exclusion criteria. Thirty-four patients in these studies came from the United States, India, Germany, Colombia, Argentina, Chile, and Spain. In total, 17 and 34 patients were below 18 years old and were adults respectively. The most commonly reported dose was 10 mg/kg, which was received by 25 (73.5%) patients. According to reports, 58.8% of patients completed the questionnaire. Twelve (35%) patients did not require a repeat surgery. The time interval between surgical procedures has increased for patients who require them.

CONCLUSION

SB may be a promissory treatment and control option for RRP. More research is needed to evaluate the efficiency and adverse effects in various populations.

Bevacizumab as treatment option for recurrent respiratory papillomatosis: a systematic review

Purpose

To this day, there is no cure for recurrent respiratory papillomatosis (RRP). Multiple surgical procedures are performed to achieve symptom relief and prevention of airway obstruction. A promising drug for RRP is the vascular endothelial growth factor (VEGF) binding antibody bevacizumab. This chemotherapeutic agent has an angiogenesis-inhibiting effect which inhibits tumor growth. The objective of this review was to investigate the efficacy of bevacizumab as treatment option for RRP, and to explore the difference of its effects between intralesional and systemic treatment.

Methods

A systematic search was conducted in Cochrane, PubMed, and Embase. Articles were included if bevacizumab treatment was given intralesionally and/or systemically. The methodological quality of the studies was assessed using the CAse REport (CARE) guidelines.

Results

Of 585 unique articles screened by title and abstract, 15 studies were included, yielding a total of 64 patients. In 95% of the patients treated with systemic bevacizumab, the post-bevacizumab surgical interval was considerably prolonged. More than half of them did not need any surgical intervention during mean follow-up of 21.6 months. Treatment with intralesional bevacizumab showed a lower efficacy: in 62% of the patients, the post-bevacizumab surgical interval (mean, 1.8 months follow-up) was extended when compared to the interval before the treatment.

Conclusion

Systemically and intralesionally administered bevacizumab are effective treatment options for severe RRP. A systemic administration might be the treatment of first choice. Further prospective research with long term follow-up is advocated to elucidate this important topic.

Systemic Bevacizumab Treatment for Recurrent Respiratory Papillomatosis: Long-Term Follow-Up

OBJECTIVES/HYPOTHESIS

Systemic bevacizumab is a new adjuvant therapy for recurrent respiratory papillomatosis (RRP) that has shown promising preliminary results in children. The objective of this study was to report the largest series to date that includes long-term follow-up data on bevacizumab treatment.

STUDY DESIGN

Retrospective chart review.

METHODS

Retrospective review of seven pediatric patients treated within the past 6 years with systemic bevacizumab for RRP refractory to traditional debridement.

RESULTS

All seven patients had a significant reduction in disease burden after initiation of systemic bevacizumab. There have been no major complications associated with systemic therapy so far. Median duration of bevacizumab treatment was 2.13 years. Three of the seven patients have been on treatment for over 3 years with the longest duration of treatment in our first patient now at 5.5 years. One patient experienced significant disease recurrence on two occasions when therapy was temporarily discontinued and was recently diagnosed with squamous cell carcinoma of the lung.

CONCLUSION

Systemic bevacizumab is an effective therapy for cases of severe RRP with promising results both in short-term and long-term follow-up. Side effects are minimal. Patients must be followed closely to determine appropriate dosing intervals to control disease and to screen for disease progression.

LEVEL OF EVIDENCE

IV Laryngoscope, 2022.

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

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

Pharmacotherapy for recurrent respiratory papillomatosis (RRP): a treatment update

Introduction: Recurrent respiratory papillomatosis is a rare human papillomavirus (HPV)-induced condition where warts grow within the airway and especially the larynx to effect voice and restrict breathing.Areas covered: A PubMed search using the following search terms was performed: respiratory papillomatosis and cidofovir, alpha-interferon, bevacizumab, PD1, and HPV vaccines. Surgery remains the mainstay of treatment. There has been a change in options available for adjuvant therapies with systemic bevacizumab and the potential benefits of prophylactic HPV vaccine. Despite efforts to identify a drug therapy to control RRP, no therapy yet remains which is predictable and effective in all. The current status of therapeutic vaccines and immunotherapy is discussed.Expert opinion: The current adjuvant therapies do offer a reasonable expectation of control but the effect for the individual is unpredictable despite the therapies being based on good science. The current therapies would allow an escalating treatment strategy to be formulated, however a single therapy is unlikely to be curative. Multi-center trials are required such that adequate numbers to show an effect are achieved.

The Tale of Stridor and Wheezing in an Infant

Recurrent respiratory papillomatosis is a respiratory disease caused by human papillomavirus and can infect any part of the aerodigestive tract, but the larynx is most involved (Derkay et al. 2010). This report is a discussion about a 7-month-old male that presented to our institution for respiratory distress. He was admitted to the Pediatric Intensive Care Unit (PICU) for stabilization, observation, and further treatment and management due to an acute RSV infection. Initial efforts failed to improve his respiratory failure. A bronchoscopy was performed and showed various flesh-colored lesions throughout the larynx, vocal cords, and tracheal tree just above the carina. Pediatric otolaryngology performed an emergent debulking surgery to alleviate his respiratory failure. He has had multiple exacerbations of his condition since then and has required frequent debulking procedures with a few trials of intralesional bevacizumab therapies.

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.

Systemic Bevacizumab (Avastin) for Juvenile-Onset Recurrent Respiratory Papillomatosis: A Systematic Review

OBJECTIVES

Juvenile onset recurrent respiratory papillomatosis (JORRP) can cause severe or disseminated disease. Surgical treatment may be inadequate. Systemic bevacizumab has shown initial success for severe JORRP. The objective of this systematic review was to assess usage, effectiveness, and safety of this treatment.

METHODS

We searched PubMed, Embase, and Web of Science for studies of humans with JORRP treated with systemic bevacizumab. Two researchers independently reviewed the studies to determine inclusion and aggregate data on patient characteristics, dosing protocols, treatment response, adverse events, and level of evidence.

RESULTS

Of 80 identified articles, 12 studies were included detailing 20 distinct cases. At a mean age of 12.8 years (range = 1-43 years) patients received initial dosing of 5 to 10 mg/kg of bevacizumab followed by ongoing doses at a mean 3-week intervals (range = 2-5 weeks). All patients had clinically significant disease reduction with reduced need for surgery. Six patients (30%) had complete response in at least one involved anatomic site. Eleven (55%) required no surgery after initiating treatment. There was recurrence in all four patients whose treatment was stopped, but had rapid improvement with treatment resumption. Six (30%) experienced mild or moderate adverse events.

CONCLUSIONS

Marked improvement in severe JORRP has been reported from systemic bevacizumab. Treatment protocols vary, and treatment discontinuation was not feasible in any reported patient. Based on currently available data, systemic bevacizumab can be considered for severe JORRP as it appears to be well tolerated and effective. A clinical trial could enhance the understanding of its safety and efficacy for this indication. Laryngoscope, 131:1138-1146, 2021.