Recurrent respiratory papillomatosis

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.

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.

A review of the risk factors associated with juvenile-onset recurrent respiratory papillomatosis: genetic, immune and clinical aspects

BACKGROUND

Juvenile-onset recurrent respiratory papillomatosis (JoRRP) is one of the most common benign lesions of hyperplastic respiratory epithelial tissue in children and is predominantly caused by human papillomaviruses (HPVs) 6 and 11. The clinical course of the disease is variable, and some patients even develop a malignancy. The purpose of this review was to summarize the related factors affecting the disease course in patients with JoRRP.

DATA SOURCES

We used databases, including PubMed and Google Scholar, to search for publications on factors associated with the genetic, immune, and clinical aspects of JoRRP. The most relevant articles to the scope of this review were chosen for analysis.

RESULTS

Mother-to-child transmission is the most important mode of disease transmission; other factors, such as immune condition or genetic susceptibility, may be important determinants of JoRRP occurrence. Genetically, the presence of DRB1*0301 and HPV 6/11 E6/E7 is associated with a more severe disease. Immunewise, patients have an enhanced T helper 2-like response. In addition, regulatory T cells are enriched in tumors and may become one of the effective prognostic indicators. For clinical characteristics, patients infected with HPV-11 have more aggressive disease. However, compared with HPV type, age at first onset is a more important factor related to the aggressiveness of JoRRP. Furthermore, socioeconomic status may also affect the course.

CONCLUSIONS

Genetic, immune, and some clinical factors have been noted to play an important role in the course of JoRRP. Exploring definite influencing factors will be an important direction of research in the future.

Presenting Symptom as a Predictor of Clinical course in Juvenile Onset Recurrent Respiratory Papillomatosis

OBJECTIVE/HYPOTHESIS

Determine if the presentation of voice versus airway symptoms at the time of diagnosis of juvenile recurrent respiratory papillomatosis (JORRP) correlates with treatment and outcomes.

STUDY DESIGN

Original report, Retrospective review.

METHODS

Twenty year retrospective review of all patients with JORRP presenting at any time in treatment to a single tertiary children's hospital between 1997 and 2017.

RESULTS

Fifty-four patients presented with a diagnosis of JORRP during the 20 year study period. Of these, 32 were female and 22 were male. African American children made up the majority of the patients (65%), with 19% identifying as Caucasian, 9% Hispanic, and 7% Asian. Fifteen of the children presented initially to the ENT clinic (87% with hoarseness), 12 to the emergency department (92% with airway concerns), 11 to the voice clinic, and the remaining 12 at outside hospitals or clinics and care were transferred. Voice symptoms, namely hoarseness, was the presenting symptom in 31 (57%), airway symptoms, namely respiratory distress or stridor was predominate in 17 (32%), and the presenting symptom was unknown in six cases (11%). Children presenting with airway symptoms were younger at presentation (median 2.1 years, range 0.38-8.77 years) than those presenting with voice symptoms (median 6.7 years, range 0.98-15.13 years), and after adjusting for age underwent a greater number of surgeries in the first year to control disease.

CONCLUSIONS

Patients who present with airway symptoms present younger and have an increased number of surgeries in the first year compared to those presenting with voice complaints.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1670-1675, 2021.

Parenteral Bevacizumab for the Treatment of Severe Respiratory Papillomatosis in an Adult Population

OBJECTIVES/HYPOTHESIS

Recurrent respiratory papillomatosis (RRP) is a rare, potentially life-threatening, disease that impacts the voice, breathing, and quality of life of patients. Frequent surgical interventions may be needed to control symptoms. We examined the safety and efficacy of utilizing parenteral bevacizumab in the management of severe RRP in adults.

STUDY DESIGN

This is a retrospective review of clinical management approaches in a group of patients with severe RRP defined as having a high disease burden, frequent need for debridement, and/or tracheobronchial disease. Patients were initially treated with 15 mg/kg of bevacizumab at 3-week intervals. Bevacizumab dosing and frequency was then individually titrated down.

RESULTS

Fourteen adults received a median of 8.5 (range 2-17) bevacizumab infusions over approximately 24 months. All had a history of laryngeal RRP with 6/14 having additional tracheobronchial lesions. Patients required a median of 4 (range 2-11) procedures in the year prior to treatment. Only 3/10 (30%) patients who continued therapy required any additional procedures. Bevacizumab administration was generally well tolerated, with four patients discontinuing therapy. Medical reasons included severe epistaxis and hypertension and thrombocytopenia in an individual with systemic lupus erythematosus. Common side effects included hypertension (grade 2), headache (grades 1-2), elevated creatinine (grades 1-2), and epistaxis (grade 3).

CONCLUSIONS

Intravenous bevacizumab for the primary treatment of severe RRP in adults appears clinically effective and safe. Expected and typically mild side effects related to bevacizumab were observed. Continued investigation of bevacizumab through a prospective clinical trial is warranted.

LEVEL OF EVIDENCE

4. Laryngoscope, 131:E921-E928, 2021.

International Pediatric Otolaryngology Group (IPOG): Juvenile-onset recurrent respiratory papillomatosis consensus recommendations

OBJECTIVES

To develop consensus recommendations for the evaluation and management of juvenile-onset recurrent respiratory papillomatosis (JORRP) in pediatric patients.

METHODS

Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). The mission of the IPOG is to develop expertise-based consensus recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. The consensus recommendations herein represent the first publication by the group.

RESULTS

Consensus recommendations including diagnostic considerations, surgical management, systemic adjuvant therapies, postoperative management, surveillance, and voice evaluation. These recommendations are based on the collective opinion of the IPOG members and are targeted for otolaryngologists, primary care providers, pulmonologists, infectious disease specialists, and any other health care providers that manage patients with JORRP.

CONCLUSIONS

Pediatric JORRP consensus recommendations are aimed at improving care and outcomes in this patient population.

Efficacy of microsurgery in combined with topical-PDT in treating recurrent respiratory papillomatosis: compare JORRP with AORRP

Background: Recurrent respiratory papillomatosis (RRP) remains a challenging and frustrating disease to treat.Objective: To explore the efficacy of microsurgery in combined with Topical-PDT in treating recurrent respiratory papillomatosis.Materials and methods: Fifty patients with RRP were treated with microsurgery in combined with Topical-PDT. Medical document of each patient was retrospectively reviewed. Detailed clinical information, metrics of clinical course, and current results were evaluated.Results: Juvenile onset RRP (JORRP) might experience a more aggressive course than AORRP (adult onset RRP) with higher Derkay score (p < .01) and higher operation frequency per year (p < .01). Microsurgical excision combined with Topical-PDT every 25 days achieved "remission" of disease in 78% of patients, "clearance" of disease in 52%, and "Cured" in two patients. Each patient who achieved "remission" of disease, performed 6.82 ± 3.39 operations, and continued 8.93 ± 7.03 months of treatment duration. No statistically differences were found in these two aspects between JORRP and AORRP. A negative correlation between tracheotomy and the efficacy of microsurgery in combined with Topical-PDT was found (p = .025, Pearson's r = -0.3).Conclusions and significance: Microsurgery in combined with Topical-PDT might be a powerful method to treat RRP. Tracheotomy is a negative factor for this therapy.

Safety and clinical activity of PD-L1 blockade in patients with aggressive recurrent respiratory papillomatosis

Background

Recurrent respiratory papillomatosis (RRP) is a human papillomavirus (HPV)-driven disorder that causes substantial morbidity and can lead to fatal distal airway obstruction and post-obstructive pneumonias. Patients require frequent surgical debridement of disease, and no approved systemic adjuvant therapies exist.

Methods

A phase II study was conducted to investigate the clinical activity and safety of programmed death-ligand 1 (PD-L1) blockade with avelumab in patients with RRP.

Results

Twelve patients were treated. All patients with laryngeal RRP displayed improvement in disease burden, and 5 of 9 (56%) displayed partial responses. None of 4 patients with pulmonary RRP displayed a response. Using each patient’s surgical history as their own control, patients required fewer surgical interventions after avelumab treatment (p = 0.008). A subset of partial responders developed HPV-specific reactivity in papilloma-infiltrating T-cells that correlated with reduced HPV viral load and an increased Tissue Inflammation Signature.

Conclusions

Avelumab demonstrated safety and clinical activity in patients with laryngeal RRP. Further study of immune checkpoint blockade for RRP, possibly with longer treatment duration or in combination with other immunotherapies aimed at activating antiviral immunity, is warranted.

Trial registration

NCT, number NCT02859454, registered August 9, 2016.

Electronic supplementary material

The online version of this article (10.1186/s40425-019-0603-3) contains supplementary material, which is available to authorized users.

Histopathological features of juvenile-onset laryngeal papillomatosis related to severity

BACKGROUND

Laryngeal papillomatosis (LP) is a disease that presents in both juvenile (JLP) and adult patients (ALP). This study correlated papillomatosis characteristics with the Derkay score.

METHODS

Retrospective data and biopsies of 36 patients with JLP and 56 with ALP were collected and separated into groups according to their scores.

RESULTS

The mean of the Derkay score, in the JLP group was 10.97 and in Group ALP was 8.26. The JLP group presented a more aggressive result than in the adult group (P = .02). In the JLP group, the respiratory difficulty (P = .01) and tracheostomy were correlated to a higher Derkay score (P < .05). Microscopically, the JLP samples presented a higher incidence of atypical mitosis and mitosis above the basal cells layer of the epithelium (P < .05) and these characteristics were correlated with a higher Derkay index (P = .03).

CONCLUSION

Findings suggest that ALP and JLP can present different clinical courses and histopathological features. There was a higher degree of LP severity in JLP.

Ten years of HPV vaccination in the Netherlands: current evidence and future challenges in HPV-related disease prevention

INTRODUCTION

Girls-only vaccination against human papillomavirus (HPV) type 16 and 18 was implemented in the Netherlands in 2009. Despite the evidence of the efficacy against precancerous lesions, cross-protection induced by the vaccine and a greater potential for cancer prevention than cervical cancer only, vaccine coverage in the girls-only program has remained below target levels.

AREAS COVERED

In this paper, we review the literature from the Netherlands on the effectiveness and cost-effectiveness of HPV vaccination since vaccine introduction, give an account of the coverage, safety and effectiveness of HPV vaccination as has been reported in the Dutch surveillance program and discuss challenges of the current HPV vaccination program.

EXPERT COMMENTARY

Girls-only HPV vaccination may confer a substantial health gain in HPV-related disease prevention. However, vaccine coverage declined remarkably recently possibly related to safety concerns, limiting the benefits from girls' vaccination and increasing the potential additional benefit of sex-neutral HPV vaccination. Considering the emergence of novel vaccination and screening options and the change from cytology- to HPV-based screening in 2017, further research is required to inform decisions on the optimization of an integrated vaccination and screening program.

HPV vaccination as preventive approach for recurrent respiratory papillomatosis - a 22-year retrospective clinical analysis

BACKGROUND

Recurrent respiratory papillomatosis (RRP) is a rare, benign disease of the aerodigestive tract, especially the larynx, caused by infection with the human papillomavirus (HPV) types 6 or 11. Current management focuses on surgical debulking with microdebrider of papillomatous lesions with or without concurrent adjuvant therapy, e.g. Cidofovir®. This retrospective study evaluates the results of patients treated at a department of the university clinic between 1990 and 2012 and compares the results of the conventional treatment with a new treatment approach using adjuvant vaccination with Gardasil®.

METHODS

A retrospective Kaplan Maier analysis of n = 24 patients diagnosed and treated with RPR was performed. The records were reviewed for gender, age at the time of first manifestation of disease and time to recurrence.

RESULTS

Only n = 2 (15.4%) of the n = 13 vaccinated patients developed a recurrence of the disease after a mean time of 54.9 months (SD: 9.5 months). All patients who were not vaccinated (n = 11; 100%) developed a relapse after a mean time of 12.3 months (SD: 9.72 months).

CONCLUSION

We propose that adjuvant HPV vaccination with Gardasil® might have a preventive effect in RRP by occluding new papilloma formation.

A Young Adult with Cough and Wheezing Since Infancy

A 20-year-old man presented for outpatient evaluation of treatment options for recurrent respiratory papillomas. He was born with vocal cord paralysis. At 4 weeks of life, he underwent tracheostomy. In childhood his tracheostomy was closed, and he was found to have occasional, small papillomas in the trachea. During puberty, he experienced a dramatic increase in the number and size of the papillomas.

Histologic Review of Cidofovir-Treated Recurrent Respiratory Papillomatosis

Objectives

Recurrent respiratory papillomatosis is currently the most common lesion of the larynx in children. The course of the disease is variable and often requires repetitive surgical interventions to maintain the airway. The predominant concern for disease progression is the possibility of spread to the tracheobronchial tree, as this increases the rates of morbidity and mortality. Cidofovir is an antiviral drug with activity against members of the DNA virus family. Development of local malignant change secondary to use of cidofovir has been a concern. The histopathologic findings from biopsy specimens from children treated with cidofovir have not been previously reported.

Methods

We performed a retrospective review of pediatric operative histologic biopsies and charts of patients treated with intralesional cidofovir and untreated study controls from January 1, 1995, through November 1, 2001.

Results

Ninety-six specimens were evaluated by 2 blinded pathologists. No cases of dysplasia were identified. The most commonly identified finding was an increased nucleus-to-cytoplasm ratio in 8 of 95 cases (8.4%). No cases of abnormal mitoses, prominent nucleoli, or cellular or nuclear enlargement were found.

Conclusions

This is the first report of pathologically evaluated recurrent respiratory papillomatosis specimens taken before and after treatment with intralesional cidofovir. No dysplasia was identified, and there were no significant dysplastic changes in the specimens analyzed.

Pediatric laryngeal carcinoma in a heterozygous carrier of Fanconi anemia

A case of invasive, keratinizing squamous cell carcinoma of the larynx in an 8-year-old female treated with laryngectomy is presented. Perinatal exposure to human papilloma virus and constitutional heterozygosity for a FANCC mutation were identified, though FANCC heterozygosity is not known to be cancer predisposing. An additional tumor-associated mutation in NOTCH1 was also identified potentially contributing to oncogenesis. This case illustrates an exceedingly rare type of cancer in the pediatric population and discusses diagnostic workup, evaluation of risk factors for head and neck cancer, and treatment options.

Quality and readability assessment of websites related to recurrent respiratory papillomatosis

Objective

Recurrent respiratory papillomatosis (RRP) is a rare disease for which a limited number of information sources for patients exist. The role of the Internet in the patient–physician relationship is increasing. More and more patients search for online health information, which should be of good quality and easy readable. The study aim was to investigate the quality and readability of English online health information about RRP.

Study Design

Quality and readability assessment of online information.

Methods

Relevant information was collected using three different search engines and seven different search terms. Quality was assessed with the DISCERN instrument. The Flesch Reading Ease Score (FRES) and average grade level (AGL) were determined to measure readability of the English websites.

Results

Fifty‐one English websites were included. The mean DISCERN score of the websites is 28.1 ± 9.7 (poor quality); the mean FRES is 41.3 ± 14.9 (difficult to read); and the mean AGL is 12.6 ± 2.3.

Conclusion

The quality and readability of English websites about RRP is alarmingly poor.

Level of Evidence

NA. Laryngoscope, 127:2293–2297, 2017

Quality of life of young patients with recurrent respiratory papillomatosis

OBJECTIVE

To assess quality of life of children and teenagers with recurrent respiratory papillomatosis, according to the evidence of infection by human papillomavirus types 6 and 11, compared with healthy volunteers and patients with chronic otitis media.

METHOD

Participants and their parents completed the Pediatric Quality of Life Inventory 4.0.

RESULTS

Patients with recurrent respiratory papillomatosis and their parents reported lower quality of life than healthy subjects (p < 0.01), but similar quality of life to patients with chronic otitis media. Those with human papillomavirus type 11 showed the lowest scores among all participants (p < 0.05).

CONCLUSION

Young Mexican patients with recurrent respiratory papillomatosis and their parents perceive a poor quality of life, and they may experience limitations in interactions with their peers. Infection by human papillomavirus type 11 may increase the impact of the disease on quality of life.

Use of the Pediatric Quality of Life Inventory to Assess the Health-Related Quality of Life in Children with Recurrent Respiratory Papillomatosis

Objectives:

The objective of this study was to use the Pediatric Quality of Life Inventory (PedsQL), a 23-question modular instrument designed to measure the health-related quality of life (HRQOL) in children and adolescents, to compare the HRQOL in children with recurrent respiratory papillomatosis (RRP) with the HRQOLs reported for healthy children and children with other chronic medical conditions.

Methods:

The PedsQL version 4.0 Generic Core Scales consist of 23 questions in 4 subscales (Physical, Emotional, Social, and School Functioning) for parent-proxy reporting on the HRQOL in children ages 2 to 4 years, parent reporting for children 5 to 18 years, and child self-reporting for ages 5 to 7 years (age-adjusted questions and rating scales) and 8 to 18 years. The questionnaires were administered in person or by telephone to 22 children with RRP and (or, for children 2 to 4 years of age) one parent recruited from a tertiary pediatric otolaryngology practice. The results were compared with validated norms for healthy children and scores for children whose parents reported a chronic medical condition.

Results:

Compared with healthy controls, the children 5 to 18 years of age with RRP self-reported a significantly (p < .05) worse HRQOL as measured by the PedsQL Total Score, Psychosocial Health score (a combination of Emotional, Social, and School Functioning Scores), and Social Functioning and School Functioning scores. Self-reported scores for the children 5 to 18 years of age with RRP compared with children with other chronic illnesses followed the same trend, and the difference approached statistical significance (p = .05) for the School Functioning Subscale scores. The parent-proxy report (for children 2 to 18 years of age) scores for children with RRP were significantly lower (p < .0001) on every scale and in total compared with scores for healthy children. Compared with scores of children with other chronic medical conditions, the parent-proxy report scores were significantly lower for psychosocial health (p = .005) and school functioning (p<.0001).

Conclusions:

Children with RRP report a lower quality of life than do those who are healthy, and a quality of life similar to that of those who have other chronic medical problems. The parent reports also reflect a lower quality of life for children affected by this disease, as compared with healthy children. The PedsQL demonstrated a statistically significant low HRQOL in children with RRP; however, the clinical implications of this finding appear trivial. A distinct, disease-specific survey for RRP, if developed, would have enhanced responsiveness and sensitivity to change (due to the natural course of the disease and/or surgical treatments).

Role of Vascular Endothelial Growth Factor–A in Recurrent Respiratory Papillomatosis

Vascular endothelial growth factor–A (VEGF-A) is known to play an important role in the angiogenic response essential for tumor growth in a variety of human and experimental tumors. This study was designed to investigate whether VEGF-A may play a role in the pathogenesis of recurrent respiratory papillomatosis (RRP). A retrospective study with institutional review board approval was performed at a tertiary care medical center on 12 patients with a history of laryngeal RRP. Their ages at the time of initial diagnosis ranged from 19 to 96 months (mean, 56 months). All patients had involvement of right and left true vocal cords. All patients required multiple endoscopic procedures (range, 4 to 66; mean, 12). Normal pediatric larynx samples from 5 autopsy patients were used as controls. Formalin-fixed, paraffin-embedded sections of laryngeal squamous papillomas from the 12 patients with a diagnosis of RRP and the 5 control patients were examined by in situ hybridization for the presence of messenger RNA (mRNA) for VEGF-A and vascular endothelial growth factor receptor 1 (VEGFR-1) and vascular endothelial growth factor receptor 2 (VEGFR-2). The biopsy specimens were from the true vocal cord (N = 10) or subglottis (N = 2) in the patients with RRP and consisted of large sections of larynx including the true vocal cord in the control patients (N = 5). Strong expression of VEGF-A mRNA was noted in the squamous epithelium of papillomas of all 12 patients. Strong expression of VEGFR-1 and VEGFR-2 was noted in the endothelial cells of the underlying vessels in all 12 patients. Neither strong labeling of VEGF-A mRNA nor labeling of its receptors was noted in the control patients. We conclude that the angiogenic growth factor VEGF-A is strongly expressed in the epithelium of squamous papillomas in RRP. Also, VEGFR-1 and VEGFR-2 mRNAs are strongly expressed by underlying vascular endothelial cells, suggesting an important role in the pathogenesis of RRP.

Rational Design of Peptide Vaccines Against Multiple Types of Human Papillomavirus

Human papillomavirus (HPV) occurs in many types, some of which cause cervical, genital, and other cancers. While vaccination is available against the major cancer-causing HPV types, many others are not covered by these preventive measures. Herein, we present a bioinformatics study for the designing of multivalent peptide vaccines against multiple HPV types as an alternative strategy to the virus-like particle vaccines being used now. Our technique of rational design of peptide vaccines is expected to ensure stability of the vaccine against many cycles of mutational changes, elicit immune response, and negate autoimmune possibilities. Using the L1 capsid protein sequences, we identified several peptides for potential vaccine design for HPV 16, 18, 33, 35, 45, and 11 types. Although there are concerns about the epitope-binding affinities for the peptides identified in this process, the technique indicates possibilities of multivalent, adjuvanted, peptide vaccines against a wider range of HPV types, and tailor-made different combinations of the peptides to address frequency variations of types over different population groups as required for prophylaxis and at lower cost than are in use at the present time.

Preliminary Report Of Endolaryngeal And Endotracheal Laser Surgery Of Juvenile-Onset Recurrent Respiratory Papillomatosis By Nd:Yag Laser and a New Fiber Guidance Instrument

OBJECTIVES: Recurrent respiratory papillomatosis (RRP) caused by human papilloma virus (type 6 and 11) is the most common benign neoplasm of the larynx in children. Despite being a benign disease, treatment is very difficult and is characterized by frequent recurrence, spread throughout the respiratory tract, and malignant degeneration. Besides surgical resection and the established CO2 laser treatment, laser surgery by fiber-guided Nd:YAG laser light promises to be a bloodless and effective treatment procedure. To improve this new method, a novel fiber guidance instrument has been developed to aid in endolaryneal laser surgery of RRP.

STUDY DESIGN AND SETTING: The method described uses a specially designed instrument for fiber guidance that is equipped with a bendable distal tip to move the fiber end precisely. Moreover, the instrument includes an additional channel for the suction of smoke and pyrolysis products. Up to now, 5 patients (aged 4 to 8 years) with RRP were treated by Nd:YAG laser light (λ = 1064 nm; power, 10W; irradiance, 3.5 kW/cm 2 , continuous wave) with a prototype version of the new instrument and were followed up for 12 months each. RESULTS: Because of the adequate length and the bendable distal tip with a range of −5° up to 45° to the optical axis of the fiber and less than 10% light loss at maximal deflection, RRP can be treated by Nd:YAG laser light easily and precisely. The continuous suctioning ensured an optimum view of the operating field and a minimal load of potential infectious laser plume and toxic pyrolysis products for the patient as well as for the physician. The laser treatment of RRP with the new fiber guidance instrument was only minimally traumatic. During 1-year follow-up visits, all Nd:YAG laser light-treated patients, showed a regression of the disease.

CONCLUSIONS: The new fiber guidance instrument enables a precise and easy treatment of the RRP with fiber-guided laser systems (eg, Nd:YAG-, diode-, and KTP-lasers) and an effective removal of infectious laser plume as well as toxic pyrolysis products. A follow-up period of 1 year revealed that Nd:YAG laser surgery seems to prevent a rapid recurrence of juvenile respiratory papillomatosis in the treated patients.

HPV Type 6 and 18 Coinfection in a Case of Adult-Onset Laryngeal Papillomatosis: Immunization with Gardasil

Laryngeal papillomatosis (LP) is a rare human papillomavirus (HPV) related disease that often requires multiple surgical interventions and residual impairment of voice is almost inevitable. We report the case of a patient with adult onset recurrent LP, showing moderate dysplasia and coinfection with HPV types 6 and 18. The tetravalent HPV vaccine Gardasil was prescribed off label, with the aim of triggering an immunogenic response and consequently reducing the probability of further recurrences. The patient was followed for 9 months with no sign of relapse of his LP. The postexposure use of the anti-HPV vaccine could represent a promising therapeutic agent in established LP. Unfortunately, the potential efficacy of this new therapeutic option in this situation has been suggested only by isolated case reports. Further controlled studies, with a longer follow-up and a larger sample size, are needed to assess efficacy of Gardasil in LP.

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.

Pathologies of the larynx and trachea in childhood

Pathologies in the larynx and trachea in the pediatric age can be characterized in 4 main groups: airway stenosis, acute infections, benign neoplasia and foreign body aspiration. In this review main diagnostic strategies and therapeutic options are presented. Laryngomalazia is the most frequent condition of supraglottic stenosis. The term supraglottoplasty summarizes all different techniques used for it's repair using an endoscopic approach. Glottic stenosis is rare in children. Usually a compromise between voice preservation and airway restoration has to be sought. Type of reconstruction and timing are varying considerably in individual cases, endoscopic approaches should be preferred. Subglottic stenosis remains the largest group in paediatric airway pathology, with cicatrial stenosis being predominant. Today, cricotracheal resection is the most successful treatment option, followed by the classical laryngotracheal reconstruction with autologous cartilage. In early infancy subglottic stenosis is particularly demanding. Endoscopic treatment is possible in selected patients, but open reconstruction is superior in more severe cases. Tracheostomy is not a safe airway in early infancy, it's indication should be strict. Foreign body aspiration needs to be managed according to a clear algorhythm. Recurrent respiratory papillomatosis should be treated with emphasis on function preservation. The role of adjuvant medication remains unclear. Infectious diseases can be managed conservatively by a pediatrician in the majority of cases.

Photodynamic therapy for recurrent respiratory papillomatosis

BACKGROUND

Recurrent respiratory papillomatosis (RRP) is a benign condition of the mucosa of the upper aerodigestive tract. It is characterised by recurrent papillomatous lesions and is associated with human papillomavirus (HPV). Frequent recurrence and rapid papilloma growth are common and in part responsible for the onset of potentially life-threatening symptoms. Most patients afflicted by the condition will require repeated surgical treatments to maintain their airway, and these may result in scarring and voice problems. Photodynamic therapy introduces a light-sensitising agent, which is administered either orally or by injection. This substance (called a photo-sensitiser) is selectively retained in hyperplastic and neoplastic tissue, including papilloma. It is then activated by light of a specific wavelength and may be used as a sole or adjuvant treatment for RRP.

OBJECTIVES

To assess the effects of photodynamic therapy in the management of recurrent respiratory papillomatosis (RRP) in children and adults.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 27 January 2014.

SELECTION CRITERIA

Randomised controlled trials utilising photodynamic therapy as sole or adjuvant therapy in participants of any age with proven RRP versus control intervention. Primary outcome measures were symptom improvement (respiratory distress/dyspnoea and voice quality), quality of life improvement and recurrence-free interval. Secondary outcomes included reduction in the frequency of surgical intervention, reduction in disease volume and adverse effects of treatment.  

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration. Meta-analysis was not possible and results are presented descriptively.

MAIN RESULTS

We included one trial with a total of 23 participants. This study was at high risk of bias. None of our primary outcomes and only one of our secondary outcomes (reduction in volume of disease, assessed endoscopically) was measured in the study. There was no significant difference between the groups (very low-quality evidence). Adverse effects reported included airway swelling requiring intubation in a child with severe RRP a few hours after photodynamic therapy.

AUTHORS' CONCLUSIONS

There is insufficient evidence from high-quality randomised controlled trials to determine whether photodynamic therapy alters the course of disease or provides an added benefit to surgery in patients with recurrent respiratory papillomatosis. Multicentre randomised controlled trials with appropriate sample sizes and long-term follow-up are required to evaluate whether photodynamic therapy is of benefit. Outcomes such as improvement in symptoms (respiratory function and voice quality) and quality of life should be measured in future trials.

Risk factors for the development and severity of juvenile-onset recurrent respiratory papillomatosis: a systematic review

OBJECTIVES

Juvenile-onset recurrent respiratory papillomatosis (JoRRP) is a rare yet aggressive disease caused by human papillomavirus (HPV). Although many newborns are likely exposed to HPV, few develop JoRRP and the clinical course of the disease varies from one child to another. This systematic review seeks to provide an up-to-date understanding of the risk factors for acquisition and severity.

METHODS

We conducted a comprehensive literature search in EMBASE, MEDLINE and EBMR databases using various combinations of keywords related to JoRRP etiology, risk factors and severity. We also searched Google Scholar and the reference lists of eligible studies. Our search was limited to original studies published in French or English between 1995 and July 2012 and to patients under 20 years of age.

RESULTS

Of 1362 citations, we retrieved 102 articles and found 14 additional studies. We retained 32 studies meeting inclusion criteria. All were observational and together included 2296 JoRRP cases. Risk factors could be classified mainly as maternal and birth history, viral genotype, and host factors. A history of genital warts during pregnancy and delivery was strongly linked to the development of JoRRP. Depending on ethnicity, specific human leukocyte antigen class II alleles and immune response factors were important determinants of JoRRP acquisition and severity. HPV-11 genotype and younger age at onset of JoRRP were important predictors of severity.

CONCLUSIONS

Genetic and immunological profiles underlying the acquisition and clinical course are not readily modifiable. Thus, preventing condylomas in women of childbearing age could reduce the burden of this life-threatening disease.

Juvenile respiratory papillomatosis: risk factors for severity

Juvenile recurrent respiratory papillomatosis is caused mainly by human papillomavirus genotypes 6 or 11, acquired at birth or during pregnancy from an infected mother. Recurrent respiratory papillomatosis is characterized by recurring warts growing most commonly in the larynx. Multiple surgical procedures and the risk of airway obstruction contribute to the devastating impact of this disease. Some children will go into remission after a few surgeries whereas others will require repeated interventions over several years. Further understanding of the risk factors associated with severity may contribute to tailored treatments. A retrospective study of cases diagnosed between January 1995 and December 2008 was conducted to study determinants of severe forms of juvenile recurrent respiratory papillomatosis. Demographic and clinical variables were abstracted from children's medical charts and mothers' delivery charts. Viral factors (HPV genotyping and viral load) were studied from archived biopsies. Specific HLA class II alleles and killer-cell immunoglobulin-like receptors genes were tested from saliva samples. Logistic regression was performed to identify risk factors for severity. Overall, 31 pediatric cases of recurrent respiratory papillomatosis were identified. The only significant factor associated with severe forms of recurrent respiratory papillomatosis was the maternal history of condylomas during pregnancy (OR: 12.05 [P=0.05]). The analysis failed to identify risk factors that could be used clinically to identify recurrent respiratory papillomatosis cases likely to take a severe course. Although too early to determine, vaccination against the HPV types involved most commonly in recurrent respiratory papillomatosis may provide the best hope to prevent severe forms of this disease.

Surgical treatment and adjuvant therapies of recurrent respiratory papillomatosis

Objective

Method

Results

Conclusion

Whole genome analysis of human papillomavirus genotype 11 from cervix, larynx and lung

The prevalence of human papillomavirus genotypes differs in various target organs. HPV16 is the most prevalent genotype in the cervix while genotypes 6 and 11 are highly prevalent in skin and aero-digestive tract infections. In this study HPV11 positive specimens were selected from cervix, larynx and lung biopsy tissue to analyze the whole genome by PCR and direct sequencing. Five HPV11 whole genomes were characterized, consisting of two cervical specimens, two laryngeal specimens and one lung specimen. The results showed high homology of HPV11 in these organs. Phylogenetic analysis showed that all HPV11 derived from various organs belonged to the same lineage. Molecular characterization and functional studies can further our understanding of virulence, expression or transmission. Additional studies on functional protein expression at different organ sites will also contribute to our knowledge of HPV infection in various organs.

Adjuvant antiviral therapy for recurrent respiratory papillomatosis

BACKGROUND

This is an update of a Cochrane Review originally published in Issue 4, 2005 of The Cochrane Library and previously updated in 2010.Recurrent respiratory papillomatosis is a condition characterised by benign papillomatous (wart-like) growths in the upper airway. It can affect both adults and children causing airway obstruction and voice change. Treatment usually involves repeated surgical debulking of the papillomata. Several agents have been proposed as adjuvants to surgical debulking, including antivirals, administered systemically or injected into the lesions.

OBJECTIVES

To assess the effectiveness of antiviral agents as adjuvant therapy in the management of recurrent respiratory papillomatosis in children and adults.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 24 February 2012.

SELECTION CRITERIA

Randomised controlled trials.

DATA COLLECTION AND ANALYSIS

We identified 143 references from the searches. Forty-three were appropriate for retrieval and assessed for eligibility by the authors. One randomised controlled trial met the inclusion criteria, involving 19 participants. We contacted the authors to obtain additional data to facilitate the review.

MAIN RESULTS

The included study was a single-institution, randomised, double-blind, placebo-controlled trial of intralesional cidofovir administered at the time of surgical debulking. Adults (n = 15) and children (n = 4) were included. We judged the study to have a reasonably low risk of bias. After a 12-month trial period, no difference was found between the cidofovir and placebo groups. Both groups showed a significant reduction in disease extent (as assessed at the time of surgery using the Derkay Scoring System), but no significant change in health-related quality of life.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support the efficacy of antiviral agents as adjuvant therapy in the management of recurrent respiratory papillomatosis in children or adults. The included randomised controlled trial showed no advantage of intralesional cidofovir over placebo at 12 months. The study was limited by a small sample size and a change in the cidofovir concentration midway through the trial, from 0.3 mg/ml in children and 0.75 mg/ml in adults, to 5 mg/ml in both adults and children. An adequately powered randomised controlled trial of intra-lesional cidofovir, consistently using higher concentrations of cidofovir in comparison with injected placebo, would be required to determine effectiveness convincingly. Future studies must include health-related quality of life and symptom-based outcome measures.

Increased expression of the prolactin receptor is associated with malignant laryngeal tumors

The altered expression of the prolactin receptor (PRLR) has been associated with the development of various types of cancer, particularly breast, prostate and endometrial cancer. However, in laryngeal tumors, the expression of PRLR has not yet been documented. The aim of this study was to determine the expression and localization of PRLR in laryngeal cancer (LC) in comparison with recurrent respiratory papillomatosis (RRP). PRLR expression was analyzed in 48 paraffin-embedded tissues (18 RRP and 30 laryngeal cancer tissues) by immunoperoxidase staining. Furthermore, PRLR expression was evaluated in ten samples from each group by Western blot analysis and quantitative real-time PCR. PRLR was observed in all laryngeal tumors at different intensities. PRLR overexpression was significantly associated (P<0.005) with LC. The staining pattern was homogeneous, mainly cytoplasmic, and confined to the tumor area. We found increased expression of different isoforms in LC in comparison with RRP. Our results suggest a possible role of PRL/PRLR in the development of LC. PRLR may be useful as a target for further investigations in laryngeal tissues.

[Respiratory papillomatosis--new methods of treatment]

BACKGROUND

Respiratory papillomatosis is caused by HPV. The most common location in head and neck is larynx, palatine tonsils and arches of palate, uvula and mucosa oral and nasal cavity. The disease is benign but recurrent. The aim of this study was to estimate new methods of treatment respiratory papillomatosis based on intralesional injection of cidofovir into sites where papillomas had just been excised.

METHODS

The purpose of the study were 59 patients treating in Otolaryngology Clinic Stomatology Department Medical University of Warsaw. The treatment was based on surgical excision of papilloma and after it intralesional injection of cidofovir in after 4-5 weeks.

RESULTS

We observed the patients during 28 months. 41 patients had 4 times intralesional injection of cidofovir. 18 patients had increased number of injection of ciodofovir because of recurrent papilloma. Rest of this group of the patients clinical studies showed remission disease.

CONCLUSION

Surgery with intralesional cidofovir injection in the place after removal of papilloma is very effective methods. We observed that this treatment caused long lasting remission of papilloma recurrence.

Human papillomavirus-related disease in men: not just a women's issue

The most common cause of mortality related to human papillomavirus (HPV) infection is cervical cancer. However, male HPV infection is also an important concern, both for the disease burden in men and for the risk of transmission to women. HPV is associated with a variety of cancers in men, including anal cancer and a subset of penile and oral cancers. The incidence of anal and oral cancers related to HPV is increasing in the general population and is growing even faster among individuals who are immunocompromised because of human immunodeficiency virus (HIV) infection. Penile HPV infection is very common among heterosexual men and remains high throughout a wide range of ages. Likewise, anal HPV infection and anal intraepithelial neoplasia are very common throughout a wide range of ages in both HIV-negative and HIV-positive men who have sex with men. Other HPV-related diseases of clinical importance in men include condylomata acuminata (genital warts) and recurrent respiratory papillomatosis. The quadrivalent HPV vaccine has been shown to be highly efficacious in the prevention of genital warts in women and precancerous lesions of the cervix, vulva, and vagina. In addition, recent interim data have shown that the quadrivalent HPV vaccine is highly effective in reducing external genital lesions in young men. Although the protective efficacy of HPV vaccination in men has not yet been fully established-pending the outcome of public policy discussions and cost-efficacy studies-there may be a strong rationale for vaccinating boys, similar to girls, at an early age when they have had limited or no prior sexual activity.

ProEx C Stain Analysis in Recurrent Respiratory Papillomatosis

Objectives:

We evaluated the presence and pattern of ProEx C stain, a marker for the proliferative capacity of cells, in laryngeal tissues, including benign, malignant, and recurrent respiratory papilloma (RRP) specimens, and compared it to hematoxylin and eosin staining for the presence of dysplasia.

Methods:

We performed a retrospective study with chart review.

Results:

A total of 26 specimens (9 benign, 7 malignant, 10 RRP) representing 21 patients were stained. ProEx C stained positive in the nuclei of laryngeal tissue, consistent with its localization in cervical cytology specimens. Seven of 9 benign and 7 of 10 RRP specimens stained positive. The benign specimens were mostly polyps. The malignant specimens were either well or moderately differentiated squamous cell carcinoma, and they stained strongly and diffusely. In benign and RRP specimens, the basal layer typically stained positive. Other areas of epithelium stained weakly in benign specimens and variably in RRP specimens. Current analysis of hematoxylin and eosin—stained RRP specimens revealed that 30% of specimens had at least moderate dysplasia and 80% exhibited viral changes (koilocytosis).

Conclusions:

ProEx C is a clean and reliable stain in laryngeal tissue, and stains positive in RRP. This study could not definitively correlate positive ProEx C staining in areas of greater dysplasia, although a trend was observed. Further studies are necessary to determine whether ProEx C can be used in triage of cases of clinically aggressive RRP for closer follow-up or frequent operative intervention.

Comparison of intravenous general anaesthesia vs endotracheal intubation in the surgical management of juvenile onset recurrent respiratory papillomatosis

CONCLUSIONS

Both intravenous general anaesthesia (IVGA) and general anaesthesia with endotracheal intubation (GA with ET) are applicable for the procedure of juvenile onset recurrent respiratory papillomatosis (JO-RRP). GA with ET was found to be better for JO-RRP patients with dyspnoea, as it provided better stabilization of the vital signs with fewer postoperative complications.

OBJECTIVES

To evaluate the safety and efficacy of two different anaesthetic techniques in the removal of JO-RRP.

METHODS

A total of 52 JO-RRP patients with mild dyspnoea were included in the study. Each case underwent two procedures, one by IVGA and the other by GA with ET. A total of 104 procedures were performed. The effectiveness and safety of the two anaesthetic techniques were pairwise compared.

RESULTS

There were no significant differences in anaesthetic recovery time, operative time or postoperative voice quality between the two anaesthetic groups. However, significant differences in heart rate, oxygen saturation and carbon dioxide saturation were observed. Some patients who underwent IVGA developed apnoea (28.8%) and laryngeal spasm (19.2%). These complications were not observed in the GA with ET group.

Adjuvant antiviral therapy for recurrent respiratory papillomatosis

BACKGROUND

This is an update of a Cochrane Review originally published in Issue 4, 2005 of The Cochrane Library.Recurrent respiratory papillomatosis is a condition characterised by benign papillomatous (wart-like) growths in the upper airway. It can affect both adults and children causing airway obstruction and voice change. Treatment usually involves repeated surgical debulking of the papillomata. Several agents have been proposed as adjuvants to surgical debulking, including antivirals, administered systemically or injected into the lesions.

OBJECTIVES

To assess the effectiveness of antiviral agents as adjuvant therapy in the management of recurrent respiratory papillomatosis in children and adults.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources for published and unpublished trials. The date of the most recent search was 30 September 2009.

SELECTION CRITERIA

Randomised controlled trials.

DATA COLLECTION AND ANALYSIS

We identified 143 references from the searches. Forty-three were appropriate for retrieval and assessed for eligibility by the authors. One randomised controlled trial met the inclusion criteria, involving 19 participants. We contacted the authors to obtain additional data to facilitate the review.

MAIN RESULTS

The included study was a single-institution, randomised, double-blind, placebo-controlled trial of intralesional cidofovir administered at the time of surgical debulking. Adults (n = 15) and children (n = 4) were included. After a 12-month trial period, no difference was found between the cidofovir and placebo groups. Both groups showed a significant reduction in disease extent (as assessed at the time of surgery using the Derkay Scoring System), but no significant change in health-related quality of life.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support the efficacy of antiviral agents as adjuvant therapy in the management of recurrent respiratory papillomatosis in children or adults. The included randomised controlled trial showed no advantage of intralesional cidofovir over placebo at 12 months. The study was limited by a small sample size and a change in the cidofovir concentration midway through the trial, from 0.3 mg/ml in children and 0.75 mg/ml in adults, to 5 mg/ml in both adults and children. An adequately powered randomised controlled trial of intra-lesional cidofovir, consistently using higher concentrations of cidofovir in comparison with injected placebo, would be required to determine effectiveness convincingly. Future studies must include health-related quality of life and symptom-based outcome measures.

Estimating the prevalence of and treatment patterns for juvenile onset recurrent respiratory papillomatosis in Australia pre-vaccination: a pilot study

Background: Recurrent respiratory papillomatosis (RRP) causes serious morbidity. RRP in Australia may be eliminated in the near future following the implementation of a national vaccination program using a human papillomavirus (HPV) vaccine that protects against infection with HPV types 6 and 11, those responsible for RRP. Baseline data on RRP prevalence and disease burden in Australia are lacking. Methods: Three study methods were used to estimate the burden of juvenile onset RRP in Australia. We conducted a retrospective chart review of RRP cases treated at The Children’s Hospital at Westmead over 10 years, examined the coding of these cases, and then calculated and applied the positive predictive value of the codes to national data to estimate the prevalence of RRP in Australia. We also conducted an online survey of otolaryngologists in Australia who manage RRP. Results: Nineteen patients were treated at the hospital over 10 years, involving 359 admissions. We estimate that between 33 and 56 RRP cases aged <20 are being treated nationally per year (0.6–1.1 per 100 000 persons), with children 5–9 years having a higher estimated rate of 1.2–1.8 per 100 000. Among 39 otolaryngologists treating juvenile onset RRP, the majority (73%) treated RRP in a paediatric tertiary hospital, and used the microdebrider for ablation of lesions. Conclusions: Our estimates of RRP disease burden agree with international estimates. As a small number of clinicians treat RRP nationally, we believe that establishment of a national RRP register is both feasible and necessary to monitor the impact of vaccination.

Sensitive HPV detection in oropharyngeal cancers

Background

Human papillomaviruses (HPV) are the aetiological agents of certain benign and malignant tumours of skin and mucosae; the most important of which is cervical cancer. Also, the incidence of ano-genital warts, HPV-anal cancer and oropharyngeal cancers are rising. To help ascertain a useful PCR detection protocol for oropharyngeal cancers, we directly compared three commonly used primer sets in detection of HPV from different clinical samples.

Methods

We compared PGMY09/11, MY09/11 and GP5+/6+ primers sets in PCRs of 34 clinically diagnosed samples of genital warts, cervical brushings (with associated histological diagnosis) and vulval biopsies. All negative samples were subsequently tested using the previously reported PGMY/GP PCR method and amplicons directly sequenced for confirmation and typing. An optimised PCR protocol was then compared to a line blot assay for detection of HPV in 15 oropharyngeal cancer samples.

Results

PGMY09/11 primers detected HPV presence in more cervical brushing (100%) and genital wart (92.9%) samples compared to MY09/11 (90% and 64.3%) and GP5+/6+ (80% and 64.3%) primer sets, respectively. From vulval biopsies, HPV detection rates were: MY09/11 (63.6%), GP5+/6+ (54.5%) and PGMY09/11 (54.5%). PGMY/GP nested PCR demonstrated that HPV was present, and direct sequencing confirmed genotypes. This nested PCR protocol showed detection of HPV in 10/15 (66.7%) of oropharyngeal cancer samples.

Conclusions

PGMY09/11 primers are the preferred primer set among these three for primary PCR screening with different clinical samples. MY09/11 and GP5+/6+ may be used (particularly for cervical samples) but demonstrate lower detection rates. A nested PCR approach (i.e. a PGMY-GP system) may be required to confirm negativity or to detect low levels of HPV, undetectable using current primary PCR methods, as demonstrated using oropharyngeal cancer samples.

Recurrent respiratory papillomatosis presenting to an emergency department

Recurrent respiratory papillomatosis is a rare but important cause of stridor in children presenting to the emergency department. Delayed diagnosis makes treatment more difficult and can lead to critical upper-airway obstruction. This case report illustrates the typical presenting features of the disease in a 3-year-old child.

Squamous cell carcinoma associated with intralesional injection of cidofovir for recurrent respiratory papillomatosis

Recurrent respiratory papillomatosis is a common neoplasm of the larynx that may lead to severe, recurrent lesions. Intralesional injection of cidofovir has shown promise as an adjuvant therapy. There is concern for possible malignant transformation with its use but, to our knowledge, this has not been documented in the literature. We report a case of invasive squamous cell cancer arising from squamous papilloma in a patient treated with multiple injections of cidofovir. Although causation is not shown, we believe the association presented is a valuable addition to the literature and an important consideration in the use of cidofovir.

[Laryngeal papillomatosis: etiology, diagnostics and therapy]

Papillomas are rare tumors that originate from the mucosa. They may appear in the nose, paranasal sinuses, oral cavity, larynx, trachea, or the skin. Papillomas are mainly asymptomatic and are therefore mostly diagnosed coincidentally. In contrast, laryngeal papillomatosis may cause stridor, dyspnoea, and hoarseness. A viral cause of the disease seems likely, especially human papilloma virus. Mechanical irritation is also a possible reason when the nose, oral cavity, or oropharynx is affected. All papillomas, independent of their origin, may recur, and have the possibility of malignant degeneration in common. The therapy of choice is complete surgical excision. Regarding laryngeal papillomatosis, laser vaporisation or excision using the CO(2)laser is recommended. Because retreatments using conventional modalities are frequently necessary, especially in the case of laryngeal papillomatosis, adjuvant therapies are applied with the aim of reducing the recurrence rate and prolonging the interval between treatments.

Distribution and density of CD1a+ and CD83+ dendritic cells in HPV-associated laryngeal papillomas

BACKGROUND

Respiratory papillomatosis associated with human papilloma virus (HPV) infection is the most common benign laryngeal neoplasm. The age of patients at disease onset, HPV type, number of surgeries are well known prognostic factors of the disease course. The correlation between dendritic cell (DC) density in tumor tissue and clinical prognosis was established.

AIM

The aim of our study was to estimate the density of DC in laryngeal papillomas associated with HPV types 6/11 infection and to evaluate the relationship between the number of DC and the disease severity.

MATERIALS AND METHODS

Our study included 40 randomly selected biopsy specimens from patients with HPV-positive laryngeal papillomatosis aged from 1.7 to 20 year. DC were immunohistochemically labelled with anti-CD1a antibodies and anti-CD83 antibodies. The density of DC was analysed in epithelial layer and lamina propria.

RESULTS

In the epithelial layer of papillomas the number of CD1a+ and CD83+ DC was 86.2 (47.5-119.9) cells/mm(2) and 2.6 (0.6-7.9) cells/mm(2), respectively. In lamina propria - 15.3 (5.1-27.9) and 16.0 (6.7-33.2) cells/mm(2). For subgroups of patients with high number of operations (more than 3), early disease onset (children under 3 years of age) and lingering duration of disease (more than 1 year) we detected an increase of CD83+ DC in the epithelial layer. However, our data did not demonstrate a statistically significant difference in CD1a+ DC count neither in the epithelium nor in the lamina propria. Probably, the increase of CD83+ DC density in epithelial layer of patients with severe course of disease can be an evidence of impaired migration of matured DC.