Recurrent respiratory papillomatosis

Mesenchymal stem cells-derived exosomal miR-653-5p suppresses laryngeal papilloma progression by inhibiting BZW2

OBJECTIVES

Although miR-653-5p has been validated to participate in the progression of multiple types of cancer, the functional role of exosomal miR-653-5p derived from Mesenchymal Stem Cells (MSCs) in Laryngeal Papilloma (LP) has still remained elusive. Hence, this study aimed to investigate the role of MSCs-derived exosomal miR-653-5p in LP.

METHODS

LP tissues (n = 15) and adjacent normal tissues (n = 10) were collected to examine the expression level of miR-653-5p. The expression level of miR-653-5p in LP cells and normal cells was also detected. Then, miR-653-5p was overexpressed or silenced to explore its effects on the proliferation, migration, invasion, and apoptosis of LP cells. Thereafter, the effects of exosomal miR-653-5p derived from MSCs on LP cell progression and the potential regulatory mechanism of miR-653-5p were assessed.

RESULTS

It was revealed that the expression level of miR-653-5p was downregulated in LP tissues and cells. In addition, miR-653-5p suppressed the proliferation, migration, invasion, and apoptosis of LP cells. Exosomes derived from MSCs played a suppressive role in LP development and mediated the transmission of miR-653-5p to LP cells. Further exploration identified Basic leucine Zipper and W2 domains 2 (BZW2) as the target of miR-653-5p. More importantly, the rescue experiments revealed that MSCs-secreted exosomal miR-653-5p efficiently inhibited the aggressive phenotypes of LP cells, which could be significantly reversed by BZW2 overexpression in LP cells.

CONCLUSION

MSCs-derived exosomal miR-653-5p exerted inhibitory effects on LP progression through targeting BZW2, which provided a novel idea for the therapy of LP.

CLINICAL TRIAL REGISTRATION NUMBER

chictr-ior-17011021.

Human Papillomavirus Infection and Oropharyngeal and Gastrointestinal Cancers: A Causal Relationship?

The human papillomavirus (HPV) is one of the most common sexually transmitted infections worldwide. The risk of being infected at least once in a lifetime among both men and women is estimated to be 50%. Although the majority of HPV infections are asymptomatic and improve within 2 years, approximately 10% of individuals develop a persistent infection and have an increased risk of developing carcinomas. The association of HPV and genital cancer is well established. However, there is evidence that HPV may also be associated with other cancers, including those of the gastrointestinal system. The aim of this review is to organize the current evidence of associations between HPV infections and oropharyngeal and gastrointestinal cancers, including the following: oropharyngeal, esophageal, gastric, colorectal, and anal cancers. A comprehensive review of the most up-to-date medical literature concluded that an HPV infection might have a role in the oncogenesis of gastrointestinal tract cancers. HPV may have a causal relationship with oropharyngeal and esophageal squamous cell cancers. However, the association between HPV and gastric and colorectal cancers is weaker. The development of cancer in the oropharyngeal and gastrointestinal tract is usually multifactorial, with HPV having a role in at least a subset of these cancers. HPV infections pose a big challenge due to their burden of infection and their oncogenic potential.

The impact of HPV vaccination beyond cancer prevention: effect on pregnancy outcomes

While the benefits of human papillomavirus (HPV) vaccination relating to cervical cancer prevention have been widely documented, recent published evidence is suggestive of an impact on adverse pregnancy outcomes (APOs) in vaccinated mothers and their infants, including a reduction in rates of preterm births and small for gestational age infants. In this review, we examine this evidence and the possible mechanisms by which HPV vaccination may prevent these APOs. Large-scale studies linking HPV vaccination status with birth registries are needed to confirm these results. Potential confounding factors to consider in future analyses include other risk factors for APOs, and historical changes in both the management of cervical precancerous lesions and prevention of APOs. If confirmed, these additional benefits of HPV vaccination in reducing APO rates will be of global significance, due to the substantial health, social and economic costs associated with APOs, strengthening the case for worldwide HPV immunization.

Spontaneous Regression of Recurrent Respiratory Papillomatosis with HPV Vaccination: A Case Study

OBJECTIVES

Recurrent respiratory papillomatosis (RRP) is characterized by recurrent laryngeal papillomas and treated with repeated surgical excision. The human papillomavirus (HPV) vaccine prevents infection with strains of HPV unrelated to RRP, and has recently been shown to increase the interval between surgeries when used as an adjuvant. The objective of this study was to report one case from our institution in which HPV vaccination was found to induce spontaneous regression of disease, absent of surgical intervention or use of other adjuvants.

STUDY DESIGN

Retrospective case study.

METHODS

Records of one patient with RRP receiving partial HPV vaccination was reviewed with attention to videolaryngostroboscopic findings, Derkay score, need for surgical intervention, and voice quality.

RESULTS

Spontaneous regression of disease after vaccination was seen in this patient, as evidenced by reduced tumor burden and decreased voice handicap index. The patient was a 30-year old female, who had improved disease burden and voice quality after one dose and total resolution of disease following the second dose. Vaccine administration was the sole therapeutic mechanism.

CONCLUSIONS

These findings suggest that HPV vaccination can treat RRP without surgical intervention. Further studies are needed to investigate the underlying mechanism of disease regression and which patients may benefit most. We believe that HPV vaccination for all patients with RRP, even over the age of 45 years, may decrease treatment costs for individuals and the healthcare system overall.

Low-temperature radiofrequency coblation reduces treatment interval and post-operative pain of laryngotracheal recurrent respiratory papillomatosis

Laryngeal papillomatosis is a benign disease in the larynx but with the potential to develop into significant complications as a result of its high recurrence rate. CO₂ laser and radiofrequency controlled ablation (coblation) have been used to treat recurrent respiratory papillomatosis, but detailed comparisons of their respective treatment outcomes are not fully investigated. This retrospective study examines the procedure time, time interval between interventions, blood loss during operation, post-operative complications and pain scores among patients who received either CO₂ laser or radiofrequency coblation interventions for laryngotracheal recurrent respiratory papillomatosis. Compared with CO₂ laser intervention, radiofrequency coblation significantly reduced operation time, time interval between interventions, blood loss during operation and number of times bipolar electrocoagulation needed in each procedure. Post-operatively, pain scores after radiofrequency coblation were significantly lower than those after CO₂ laser intervention. Incidence rates of post-operative complications, in terms of palate pharyngeal mucosa damage, bleeding and subcutaneous emphysema, were also significantly reduced after radiofrequency coblation. Low-temperature radiofrequency coblation is a superior intervention compared with CO₂ laser against laryngotracheal recurrent respiratory papillomatosis.

The Use of Both Therapeutic and Prophylactic Vaccines in the Therapy of Papillomavirus Disease

Human papillomavirus (HPV) is the most common sexually transmitted virus. The high-risk HPV types (i.e., HPV16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59) are considered to be the main etiological agents of genital tract cancers, such as cervical, vulvar, vaginal, penile, and anal cancers, and of a subset of head and neck cancers. Three prophylactic HPV vaccines are available that are bivalent (vs. HPV16, 18), tetravalent (vs. HPV6, 11, 16, 18), and non-avalent (vs. HPV6, 11, 16, 18, 31, 33,45, 52, 58). All of these vaccines are based on recombinant DNA technology, and they are prepared from the purified L1 protein that self-assembles to form the HPV type-specific empty shells (i.e., virus-like particles). These vaccines are highly immunogenic and induce specific antibodies. Therapeutic vaccines differ from prophylactic vaccines, as they are designed to generate cell-mediated immunity against transformed cells, rather than neutralizing antibodies. Among the HPV proteins, the E6 and E7 oncoproteins are considered almost ideal as targets for immunotherapy of cervical cancer, as they are essential for the onset and evolution of malignancy and are constitutively expressed in both premalignant and invasive lesions. Several strategies have been investigated for HPV therapeutic vaccines designed to enhance CD4⁺ and CD8⁺ T-cell responses, including genetic vaccines (i.e., DNA/ RNA/virus/ bacterial), and protein-based, peptide-based or dendritic-cell-based vaccines. However, no vaccine has yet been licensed for therapeutic use. Several studies have suggested that administration of prophylactic vaccines immediately after surgical treatment of CIN2 cervical lesions can be considered as an adjuvant to prevent reactivation or reinfection, and other studies have described the relevance of prophylactic vaccines in the management of genital warts. This review summarizes the leading features of therapeutic vaccines, which mainly target the early oncoproteins E6 and E7, and prophylactic vaccines, which are based on the L1 capsid protein. Through an analysis of the specific immunogenic properties of these two types of vaccines, we discuss why and how prophylactic vaccines can be effective in the treatment of HPV-related lesions and relapse.

Successful Treatment of Adult-Onset Recurrent Respiratory Papillomatosis with CO2 Laser and Photodynamic Therapy

Recurrent respiratory papillomatosis is a noninvasive benign epithelial tumor caused by human papillomavirus. Clinically, it featured rapid growth, multifocus, and frequent recurrence. Though a number of therapies have been investigated, the recurrence after treatment is always a challenge. In this report, we describe a 27-year-old male patient with recurrent respiratory papillomatosis who was treated with CO₂ laser therapy followed by 5-aminolevulinic acid photodynamic therapy (ALA-PDT). There was no adverse reaction after treatment and no recurrence during the follow-up time.

Voice Outcomes Following Multiple Surgeries for Recurrent Respiratory Papillomatosis

OBJECTIVES

Recurrent Respiratory Papillomatosis (RRP) is a rare disease caused by the human papilloma virus that presents as warty, exophytic growths in the upper airway. RRP in the larynx can lead to severe airway obstruction and voice changes. It is clinically known that patients with RRP frequently experience dysphonia. The purpose of this study was to assess the impact of multiple surgical treatments on RRP patients' voice outcomes, and to determine whether a higher number of repeated surgeries lead to decreased voice quality.

METHODS

A retrospective cohort study was conducted of adult RRP patients (n = 23) who underwent multiple surgeries. Group 1 included patients (n = 11) who had <5 surgeries (range 2-4 surgeries) and Group 2 included patients (n = 12) who had ≥5 surgeries (range 5-50+ surgeries). Voice recordings were selected from the following clinic visits: initial office visit (initial presurgery), first postsurgery, and the last clinic encounter(s) with no immediate planned surgery. Blinded auditory-perceptual ratings along with cepstral and spectral acoustic measures assessed voice severity.

RESULTS

There was significant improvement from the initial presurgery visit compared to each postoperative visit over time for all voice outcome measures for both Group 1 and Group 2. The results of the study indicated that the number of surgeries did not significantly affect mean postoperative voice outcomes, and there were no significant differences between patient groups for voice quality over time.

CONCLUSIONS

The results of this study suggest that RRP patients' voice quality may not suffer cumulative negative effects when using modern tissue-sparing surgical techniques.

Implementation of Routine HPV Vaccination in the Management of Recurrent Respiratory Papillomatosis

OBJECTIVES:

To investigate vaccine compliance and clinical outcomes after implementation of an initiative to provide the human papillomavirus (HPV) vaccine to all patients with recurrent respiratory papillomatosis (RRP).

METHODS:

A retrospective review was performed of all adult patients treated for RRP from 2012 to 2017. Rates of HPV vaccination were evaluated before and after December 2015, when a program was established to increase compliance by educating patients and providing financial assistance toward vaccine administration. Paired sample analyses were conducted to compare intersurgical intervals (ISIs) and number of procedures per year pre- and post-vaccination.

RESULTS:

Fourteen patients with RRP completed the HPV vaccine series, with 11 patients undergoing vaccination after the initiative began. The pre-initiative vaccination rate of all patients with RRP was 9.7%; post-initiative rates improved to 43.8% ( P = .004; odds ratio, 7.26). Of vaccinated patients, there were significant differences between mean pre-vaccine ISI (3.5 months) and post-vaccine ISI (12.8 months; P = .0021), as well as between number of surgical procedures performed per year before and after vaccination (2.7 vs 0.81; P = .014). After vaccination, 5 patients demonstrated no evidence of papilloma regrowth for >12 months.

CONCLUSIONS:

Initiatives focused on patient education and financial support can successfully boost HPV vaccination rates in an RRP patient cohort. Our research mirrors prior findings that HPV vaccination is correlated with an increase in time between procedures and a decrease in number of procedures needed per year-factors that can dramatically reduce the disease burden on patients coping with RRP.

Recurrent respiratory papillomatosis with lung involvement

Recurrent respiratory papillomatosis (RRP) is a rare disease caused by human papillomavirus. Aggressive forms of RRP require repeated cytoreductive surgery to restore airway patency. Tracheal disease is even less common and lung parenchyma is involved in less than 1% of patients. We present reports of three cases of RRP with progressive lung disease in adult patients.

Prevalence, clinical presentations, associated risk factors and recurrence of laryngeal papillomatosis among inpatients attended at a Tertiary Hospital in Northern zone Tanzania

Introduction

Although Laryngeal papillomatosis is a rare disease and can be conventionally managed through surgical excision as well as adjuvant therapy yet Laryngeal papillomatosis has high tendency to recur raising its prevalence in the community, airway involvement warrants dangerous complications requiring emergency tracheostomy, especially if clinical course is poorly understood and misdiagnosis is common. The study aims to determine the prevalence, clinical features, risk factors and recurrence of Laryngeal Papillomatosis among patients attending ENT department at KCMC from 2005 to 2015.

Methods

This was a 10 year experience/ Descriptive hospital based cross-sectional study conducted based on patients' medical record at KCMC. Information was recorded into data collection sheets, entered and analyzed through SPSS version 20, summarized and presented in tables and charts, proportions and percentage used to compare groups.

Results

51 patients were identified over the 10 years study period corresponding to a prevalence of 0.09%. 26 were males and 25 females, ages ranging from 1 to 67 years. The median age of onset was 6 years. Children less than 5 years accounted for 19 (37.3%) and 58.8% had repeated surgeries. Clinical presentation ranged from hoarseness in 43 (84.3%) patients to weight loss 3 (5.9%) and 96.1% showed complete or partial presence of the clinical triad of risk factors.

Conclusion

Laryngeal papillomatosis is a rare disease that carries severe morbidity due to its highly recurring nature. It is primarily a paediatric disease, generally affecting more males; its clinical features highly resemble other airway obstructive diseases and therefore a careful thorough clinical evaluation is required in order to correctly diagnose Laryngeal papillomatosis.

NO ASSOCIATION OF RECURRENT RESPIRATORY PAPILLOMATOSIS AGGRESSIVENESS AND HUMAN PAPILLOMAVIRUS TYPE 6 AND 11

Recurrent Respiratory Papillomatosis (RRP) is the most common benign neoplasm of the larynx among children as a result of HPV infection mainly type 6 and 11. RRP is still considered as serious problem since papilloma in the airway can cause hoarseness and obstruction which later described as aggressive and non aggressive types. Patients underwent multiple surgeries to keep airway patency and in order to communicate vocally. Previous studies reported that HPV-11 was associated with a more aggressive disease course. This study aim is to determine the association of RRP aggressiveness with HPV-6 and 11. Papilloma specimens were taken from patients who underwent surgical treatment of RRP patients and subjected HPV typing. All 17 patients with completed data and epidemiologic questionaires were defined for their staging to disease severity. Informations in the database were analyzed to identity statistically significant relationship with HPV type and knowing the HPV type is to predict the disease course. 17 patients RRP (12 males and 5 females) with age at onset 3,15 + 2,28 years and age at diagnosis 3,81 + 2,51 years. Surgery was performed 2,71 ± 1,16 times per year and 9 patients treated more than 3 surgeries per year. 10 patients had distal papilloma and 11 patients had tracheotomy. Agrressive disease was show found in 14 patients among 17 patients. HPV-11 was detected in 10 patients, HPV-6 was detected in 7 patients. According to the statisitcal analysis (Chi square test), there is no relationship between HPV type and disease aggressiveness. HPV-6 and 11 are not the only cause that affect the aggressiveness of Recurrent Respiratory Papillomatosis.

Methylation of CpG sites in the upstream regulatory region, physical status and mRNA expression of HPV-6 in adult-onset laryngeal papilloma

The methylation status of HPV-6 upstream regulatory region (URR) in adult-onset laryngeal papillomatosis (AO-LP) remains unclear. The purpose of this study was to investigate the methylation status of URR and the physical status of HPV-6, as well as the dynamic variations of viral load and mRNA expression in AO-LP. We examined 18 specimens from 11 patients with AO-LP by real-time polymerase chain reaction (PCR), bisulfite-sequencing PCR, and amplification of papilloma oncogene transcripts. HPV-6 was identified in 9 of 11 patients (81.8%), and all the 15 specimens derived from 9 HPV-6-positive cases contained only episomal HPV-6 transcripts with intact E2. Three HPV-6-positive patients developed recurrent lesions, and HPV-6 copy numbers and mRNA expression decreased after surgical treatment. Among the 96 CpG sites (16/case), 67 (69.8%) were unmethylated, while 23 (30.2%) were heterogeneous (≥ 1 methylated CpG clone). High viral loads and episomal status of HPV-6 were frequently observed in AO-LP; thus, persistent E6/E7 mRNA expression of LR-HPV-6 may be associated with AO-LP recurrences. Hypomethylation and scattered patterns of methylated CpGs at the URR of HPV-6 were identified in AO-LP.

Multidimensional vocal assessment after laser treatment for recurrent respiratory papillomatosis

OBJECTIVES/HYPOTHESIS

Recurrent respiratory papillomatosis (RRP) is a benign epithelial tumor that exhibits a high frequency of recurrence. This study assesses the vocal function after laser treatment for RRP, particularly in relation to the frequency of surgery.

STUDY DESIGN

Retrospective study.

METHODS

Thirty RRP patients who underwent laser surgery that controlled the tumor were included. Preoperative and postoperative Grade, Roughness, Breathiness, Asthenia, and Strain Scale, videostroboscopic findings, aerodynamic and acoustic parameters, and self-assessment questionnaires were measured and compared with an age- and sex-matched control group. Subsequently, to evaluate the association between postoperative voice quality and the number of surgeries, the patients were divided into three groups (group 1: single surgery, group 2: 2-5 surgeries, group3: >6 surgeries), and comparative multidimensional vocal assessments were performed.

RESULTS

The mean number of surgeries was 3.4 (range, 1-8). Although all patients exhibited poorer vocal function than the control group preoperatively, they showed improvement in postoperative subjective and objective parameters. However, four patients who underwent one surgery with relatively aggressive ablation exhibited vocal cord scarring and deteriorated objective parameters. All remaining patients showed voice quality that was on par with the control group. Subgroup analysis proved no association between post-therapeutic voice quality and the patient characteristics, including preoperative staging and the number of surgical treatments performed.

CONCLUSIONS

RRP patients can achieve a close to normal voice with high satisfaction even after recurrent surgical treatment when ablation of a subepithelial lesion using sufficient laser energy is adequate.

LEVEL OF EVIDENCE

3b Laryngoscope, 127:679-684, 2017.

Identification of the murine H-2D(b) and human HLA-A*0201 MHC class I-restricted HPV6 E7-specific cytotoxic T lymphocyte epitopes

Recurrent respiratory papillomatosis is caused by human papillomavirus (HPV) infection, most commonly types 6 (HPV-6) and 11 (HPV-11). Due to failed host immune responses, HPV is unable to be cleared from the host, resulting in recurrent growth of HPV-related lesions that can obstruct the lumen of the airway within the upper aerodigestive tract. In our murine model, the HPV-6b and HPV-11 E7 antigens are not innately immunogenic. In order to enhance the host immune responses against the HPV E7 antigen, we linked calreticulin (CRT) to HPV-6b E7 and found that vaccinating C57BL/6 mice with the HPV-6b CRT/E7 DNA vaccine is able to induce a CD8+ T cell response that recognizes an H-2D(b)-restricted E7aa21-29 epitope. Additionally, vaccination of HLA-A*0201 transgenic mice with HPV-6b CRT/E7 DNA generated a CD8+ T cell response against the E7aa82-90 epitope that was not observed in the wild-type C57BL/6 mice, indicating this T cell response is restricted to HLA-A*0201. In vivo cytotoxic T cell killing assays demonstrated that the vaccine-induced CD8+ T cells are able to efficiently kill target cells. Interestingly, the H-2D(b)-restricted E7aa21-29 sequence and the HLA-A*0201-restricted E7aa82-90 sequence are conserved between HPV-6b and HPV-11 and may represent shared immunogenic epitopes. The identification of the HPV-6b/HPV-11 CD8+ T cell epitopes facilitates the evaluation of various immunomodulatory strategies in preclinical models. More importantly, the identified HLA-A*0201-restricted T cell epitope may serve as a peptide vaccination strategy, as well as facilitate the monitoring of vaccine-induced HPV-specific immunologic responses in future human clinical trials.

Viral load and mRNA expression of HPV type 6 among cases with recurrent respiratory papillomatosis

OBJECTIVES/HYPOTHESIS

To determine viral load of human papillomavirus type 6 (HPV6), physical state of HPV6-DNA, and transcription level of HPV6 E7-mRNA in laryngeal papilloma and in adjacent healthy mucosa.

STUDY DESIGN

Case series.

METHODS

A papilloma biopsy was collected from each of 25 adult patients with respiratory recurrent papillomatosis. From 14 of the 25 patients, we first collected a biopsy from healthy mucosa of the false vocal fold and another from the papilloma. Quantity of HPV6 and E7-mRNA was measured by polymerase chain reaction.

RESULTS

For the papilloma, the median load of HPV6 was 41 copies/cell, and the lowest amount was 5.4 copies/cell. Human papillomavirus type 6 was detected in 50% (7/14) of the healthy mucosa, with a median of 1.1 copies/cell, and the highest amount was 6.6 copies/cell. Overall, viral load was higher in papilloma than in healthy mucosa (P < 0.05). The average HPV6 E2/E7-DNA ratio was 1.3, indicating an episomal state. Human papillomavirus type 6-mRNA was detected in all HPV6-DNA-positive samples. The transcription median ratio of HPV6-mRNA/HPV6-DNA was 1.5 in papilloma and 3.8 in healthy mucosa.

CONCLUSION

The amount of HPV6-DNA was consistently higher in the papilloma than in healthy mucosa. The transcription level of HPV6 E7 mRNA was similar in the papilloma and in normal mucosa. We suggest that interfering with replication of HPV6 and suppression of HPV6 to fewer than five copies/cell may be curative.

The Use of Cryotherapy for Papilloma and Early Laryngeal Cancers: Long-term Results

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

To determine the efficacy of adjuvant cryotherapy in the treatment of early glottic cancer and laryngeal papillomatosis.

SUMMARY OF BACKGROUND DATA

The use of cryotherapy in conjunction with traditional modalities has recently been proposed to improve voice outcomes in patients with early laryngeal cancer as compared to pretreatment conditions. This study investigates its utility in improving oncological outcomes and decreasing recurrences of laryngeal papillomatosis.

METHODS

Patients with either early glottic cancer or laryngeal papillomatosis that received cryotherapy as part of their surgical regimen were investigated. All patients were seen at a large tertiary care center within a 10-year window. Demographic data were collected and all postoperative notes were reviewed. Recurrences of the laryngeal cancer were noted, as was the duration of time between successive papillomatosis operations.

RESULTS

The charts of 54 glottic cancer and 29 papillomatosis patients that received cryotherapy were reviewed. One patient from the papillomatosis cohort was excluded from statistical analysis due to lack of follow-up. Overall, 16 (30%) of the laryngeal cancer patient experienced a malignant recurrence. The overall 5-year survival of these patients was 98% and the 5-year disease-free survival was 74%. The use of adjuvant cryotherapy in the treatment of laryngeal papillomatosis extended the duration of time between surgeries by an average of 79 days (P=.23).

CONCLUSION

The use of adjuvant cryotherapy in the treatment of early glottic cancer does not improve the rate of carcinoma recurrences. Additionally, cryotherapy does not result in a statistically significant increase in the duration of disease-free period for laryngeal papillomatosis patients, although the observed increase may be clinically important.

Genetic dysregulation in recurrent respiratory papillomatosis

OBJECTIVES/HYPOTHESIS

Recurrent respiratory papillomatosis (RRP) is a devastating disease, caused by infection of the upper aerodigestive tract with human papillomavirus types 6 and 11. There is no cure for RRP, and surgical removal is the mainstay of treatment. The purpose of this project was to compare genes of cell cycle, apoptosis, and inflammatory cytokines in laryngeal papilloma versus normal tissue for a better understanding of the molecular mechanisms of the disease to discover novel therapies.

STUDY DESIGN

Basic science research study.

METHODS

Papilloma tissue was obtained from patients requiring surgical debridement. For comparison, normal mucosa was obtained from the excised uvula of patients undergoing uvulopalatopharyngoplasty. Total RNA was extracted from both groups and then probed using customized reverse transcriptase real time polymerase chain reaction gene arrays.

RESULTS

The custom arrays examine expression of 84 separate genes within the cell cycle, apoptosis, and inflammatory cytokine pathways. Our findings based on 11 papilloma samples run in comparison to normal mucosa shows that the MCL-1 gene of the apoptosis pathway is significantly downregulated. cytokine genes IL1-A, IL-8, IL-18, and IL-31 are also significantly dysregulated.

CONCLUSIONS

Genes of cell cycle and apoptosis are generally upregulated and downregulated, respectively, as expected in papilloma tissue, with MCL-1 achieving significance when compared to normal tissue. The finding of particular interest is that inflammatory cytokine genes were significantly downregulated, including IL1-A, IL-18, and IL-31. This finding may explain why patients infected with the virus are unable to mediate a T-cell immune clearance of their disease.

Tumors and tumorlike conditions of the large airways

OBJECTIVE

Large-airway tumors and tumorlike conditions are uncommon, but a systematic approach aids in narrowing the differential diagnosis. In this article, we describe an approach to dealing with large-airway lesions and discuss their imaging characteristics and clinical presentations.

CONCLUSION

We have found it useful to separate these entities into groups on the basis of the distribution pattern (focal vs diffuse) and location (trachea vs bronchi).

Adult recurrent respirator papillomatosis: a new therapeutic approach with pegylated interferon alpha 2a (Peg-IFNα-2a) and GM-CSF

OBJECTIVE

To determine a new therapeutic approach using granulocyte monocyte-colony-stimulating factor (GM-CSF) and pegylated interferon alpha 2a (Peg-IFNα-2a) as adjuvant therapy in patients with adult recurrent respiratory papillomatosis.

STUDY DESIGN

Descriptive observational clinical trial.

SETTING

Departments of Otolaryngology and Immunology.

METHODS

Fourteen patients with adult recurrent respiratory papillomatosis were examined regarding medical history and number of operations before and after treatment. Voice disorder and glottal stop were evaluated using the Voice-Related Quality-of-Life instrument. Papilloma staging was determined using the Coltera/Derkay diagram. The patients received Peg-IFNα-2a at 180 mcg weekly for 6 months. In the third month, the patients began GM-CSF treatment at 400 mcg weekly for 2 months. The patients were observed for 12 months after treatment ended.

RESULTS

Eleven patients met the study criteria; 3 patients had tracheotomies before treatment, and they were decannulated after treatment. Before treatment, the scale of voice quality ranged from 34 to 45 points (mean, 38.31). After treatment, the range was 12 to 35 points (mean, 21.09; P < .001). Prior to therapy, the glottal stop ranged from 50% to 90% (average, 62.27%). After therapy, the range decreased to 0% to 15% (mean, 4.63%; P < .001). The number of surgical interventions decreased. Two patients each had 1 surgical intervention after treatment began.

CONCLUSION

A new adjuvant treatment based on immunogenetic mechanisms against human laryngeal papilloma virus, with expectations of reducing disease aggressiveness and the number of operations, avoids the risks of surgery.

IMPLICATION FOR PRACTICE

Peg-IFNα-2a and GM-CSF is an adjuvant therapy for treating adult recurrent respiratory papillomatosis.

Recurrent respiratory papillomatosis

Recurrent respiratory papillomatosis (RRP) is a rare, benign disease with no known cure. RRP is caused by infection of the upper aerodigestive tract with the human papillomavirus (HPV). Passage through the birth canal is thought to be the initial transmission event, but infection may occur in utero. HPV vaccines have helped to provide protection from cervical cancer; however, their role in the prevention of RRP is undetermined. Clinical presentation of initial symptoms of RRP may be subtle. RRP course varies, and current management focuses on surgical debulking of papillomatous lesions with or without concurrent adjuvant therapy.

Effects of conjugated linoleic acid and high oleic acid safflower oil in the treatment of children with HPV-induced laryngeal papillomatosis: a randomized, double-blinded and crossover preliminary study

BACKGROUND

Surgery is the mainstay therapy for HPV-induced laryngeal papillomatosis (LP) and adjuvant therapies are palliative at best. Research revealed that conjugated-linoleic acid (CLA) may improve the outcome of virally-induced diseases. The effects of Clarinol™ G-80 (CLA) and high oleic safflower oil (HOSF) on children with LP (concomitant with surgery) were evaluated.

DESIGN

A randomized, double-blinded, crossover and reference-oil controlled trial was conducted at a South African medical university. Study components included clinical, HPV type/load and lymphocyte/cytokine analyses, according to routine laboratory methods.

PARTICIPANTS

Overall: ten children enrolled; eight completed the trial; five remained randomized; seven received CLA first; all treatments remained double-blinded.

INTERVENTION

Children (4 to 12 years) received 2.5 ml p/d CLA (8 weeks) and 2.5 ml p/d HOSF (8 weeks) with a washout period (6 weeks) in-between. The one-year trial included a post-treatment period (30 weeks) and afterwards was a one-year follow-up period.

MAIN OUTCOME MEASURES

Changes in numbers of surgical procedures for improved disease outcome, total/anatomical scores (staging system) for papillomatosis prevention/viral inhibition, and lymphocyte/cytokine counts for immune responses between baselines and each treatment/end of trial were measured.

FINDINGS

After each treatment all the children were in remission (no surgical procedures); after the trial two had recurrence (surgical procedures in post-treatment period); after the follow-up period three had recurrence (several surgical procedures) and five recovered (four had no surgical procedures). Effects of CLA (and HOSF to a lesser extent) were restricted to mildly/moderately aggressive papillomatosis. Children with low total scores (seven/less) and reduced infections (three/less laryngeal sub-sites) recovered after the trial. No harmful effects were observed. The number of surgical procedures during the trial (n6/available records) was significantly lower [(p 0.03) (95% CI 1.1; 0)]. Changes in scores between baselines and CLA treatments (n8) were significantly lower: total scores [(p 0.02) (95% CI -30.00; 0.00)]; anatomical scores [(p 0.008) (95% CI -33.00: -2.00)]. Immune enhancement could not be demonstrated.

CONCLUSIONS

These preliminary case and group findings pave the way for further research on the therapeutic potential of adjuvant CLA in the treatment of HPV-induced LP.

The cost effectiveness of human papillomavirus vaccines: a systematic review

INTRODUCTION

Human papillomavirus (HPV) is one of the world's most common sexually transmitted infections, and has been associated with a number of cervical and non-cervical diseases, including cancer. HPV vaccines have been licensed for use in females for some time, but the quadrivalent vaccine has only recently become licensed for use in males. Many countries have adopted a vaccination programme for adolescent females based on results of cost-effectiveness analyses. However, given the new indications for use of the vaccine in males, decision makers require information on the cost effectiveness of vaccinating males in order to make policy decisions on whether or not to fund such programmes.

OBJECTIVE

Our objective was to conduct a qualitative systematic review to update a previously conducted review of HPV vaccine studies.

METHODS

Articles were obtained from an extensive literature search to determine the cost effectiveness of implementing an HPV vaccination programme with routine cervical cancer screening. A total of 29 studies were included in this review. Seventeen of the included articles looked only at cervical disease outcomes, and 12 studies also included non-cervical disease outcomes. Four studies explored the economic impact of vaccinating both boys and girls. One study focused on a population of men who have sex with men (MSM).

RESULTS

While different model structures, input parameters and baseline assumptions were used, the consistent message in studies that focused on female-only vaccination programmes was that routine vaccination of females is cost effective compared with cervical cancer screening alone.

DISCUSSION

Based on the currently available literature, it appears that the addition of boys to a vaccination programme generally exceeds traditional cost-effectiveness thresholds. The MSM population represents a potential additional target for routine HPV vaccination; however, more cost-effectiveness studies are required before making such a policy change.

In situ hybridization signal patterns in recurrent laryngeal squamous papillomas indicate that HPV integration occurs at an early stage

Laryngeal papillomas are benign tumors that frequently recur and can compromise airways. We investigated HPV genotype, physical status, and protein expression in juveniles versus adults. Thirty-five laryngeal papilloma specimens were obtained from ten juveniles (1-16 years) and eleven adults (24-67 years). In cases of recurrent papillomatosis (7 juveniles, 7 adults), the first and last papillomas were assayed. HPV type was determined by GP5+/6+ PCR and dot blot hybridization. In situ hybridization (ISH) was performed on 34 specimens; the data were recorded in terms of diffuse (episomal HPV) and punctate (integrated HPV) signal patterns. Immunohistochemistry for the HPV L1 capsid protein, a marker of HPV productive status, was performed on 32 samples. All samples tested HPV positive: HPV 11 in 2/10 (20.0%) juveniles and 5/11 (45.5%) adults; HPV 6 in 7/10 (70%) juveniles and 5/11 (45.5%) adults; and HPV 6/11 double infection was noted in one juvenile and one adult. ISH signals (punctate ± diffuse) were detected among 7/10 (70.0%) juveniles and 7/11 (63.6%) adults. L1 staining was detected in 1/9 (11.1%) juveniles and 6/10 (60.0%) adults (P = 0.06). These data support the idea that integration of low-risk HPV types into the cell genome is an early and common event in the etiology of juvenile and adult recurrent laryngeal papillomas. Productive HPV infections may be more common in adults; accordingly, constant laryngeal re-infection by HPV shed from a productive lesion may contribute to adult recurrent lesions, whereas the mechanism of papilloma recurrence in juveniles may be more attributable to HPV integration.

Novel human papilloma virus (HPV) genotypes in children with recurrent respiratory papillomatosis

INTRODUCTION

Recurrent respiratory papillomatosis (RRP) is characterized by the presence of benign virally induced tumors of the larynx and respiratory epithelium that may obstruct the airway and tend to recur frequently. RRP is caused by the human papilloma virus (HPV), most frequently by HPV types 6 and 11. In this study, we present four cases of children with RRP in whom HPVs other than HPV-6 or HPV-11 were found.

MATERIAL AND METHODS

In all four cases, HPV typing was performed by polymerase chain reaction (PCR) followed by restriction digestion (RFLP) in biopsy samples collected during surgery.

RESULTS

In the first case, simultaneous HPV infection with types 13 and 39 was detected, while in the second case HPV-40 and HPV-56 were found. In cases 3 and 4, the biopsy samples were positive for unidentified 'low-risk' HPVs.

CONCLUSIONS

The presence of novel HPV genotypes in children with RRP emphasizes the need for further investigation of the implication of these genotypes in the disease.

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.

Radiofrequency coblation for treatment of advanced laryngotracheal recurrent respiratory papillomatosis

Background:

A variety of treatment modalities are currently used to treat recurrent respiratory papillomatosis. We aimed to study the efficacy of radiofrequency cold ablation (coblation) for the treatment of laryngotracheal recurrent respiratory papillomatosis, by comparing treatment intervals for coblation and CO2 laser vaporisation.

Method:

Retrospective case series of adult patients with advanced laryngotracheal recurrent respiratory papillomatosis.

Results:

Six patients were treated for at least two years by CO2 laser vaporisation with or without intralesional cidofovir. All six subsequently underwent treatment with radiofrequency coblation with or without intralesional cidofovir. Coblation resulted in longer periods between interventions, compared with CO2 laser (p = 0.03).

Conclusion:

Radiofrequency coblation appears to be an attractive alternative technique to CO2 laser for the surgical treatment of advanced laryngotracheal papillomata.

Pharmacotherapy of recurrent respiratory papillomatosis: an expert opinion

BACKGROUND

Recurrent respiratory papillomatosis is caused by the human papillomavirus types (HPV) 6 and 11. It affects both children and adults. In a small number of cases, the disease can be very aggressive causing significant morbidity and possibly death. Surgical therapy is the primary treatment but in patients with aggressive disease, adjunctive therapy is initiated. The majority of these adjuncts center on immunomodulation, disruption of molecular signaling cascades or interruption of viral replication to help decrease the severity of the disease. Recently, a preventative vaccine has become available but data on its effectiveness will be at least a decade away. In the mean time, researchers are examining other vaccination strategies in the fight against HPV disease.

OBJECTIVE

We will review the following pharmacotherapies used in the adjunct treatment of RRP: interferon, acyclovir, ribivirin, cidofovir, COX-2 inhibitors, retinoids, anti-reflux medications, zinc, indole-3-carbinol, therapeutic/preventative vaccines.

METHODS

This is a review paper. Utilizing Medline and Pubmed from 1966 to present, the key words as well as the above listed adjunct treatments were searched for relevant papers.

CONCLUSION

The evidence supporting each of these adjuncts varies with a majority having only case reports or cases-series to support their use. However, there is hope on the horizon with regard to the HPV vaccine and its potential to prevent future transmission of this disease.

Recurrent respiratory papillomatosis with pulmonary involvement: a case report and review of the literature

Recurrent respiratory papillomatosis (RRP) is a viral infection that usually affects the upper airways. Although it can spread throughout the respiratory tract, involvement of the lung parenchyma is quite rare. Radiographic images of RRP with lung involvement have been mainly presented in case reports of paediatric patients. We present the case of an adult patient with RRP and lung involvement, and detail the serial radiographic manifestations. CT and reconstructed images were obtained. The literature was also reviewed and radiographic features of RRP with lung involvement are summarized.

Epidemiology of human papillomavirus infection in men, cancers other than cervical and benign conditions

Human papillomavirus (HPV) infection is commonly found in the genital tract of men and women with or without any clinical lesion. The association of HPV DNA with several different ano-genital cancers other than cervical has been reported for the vulva, vagina, anus and penis. HPV DNA has also been identified in head and neck cancers in the oral cavity, the oropharynx and the larynx in both sexes. In men, 80-85% of anal cancers and close to 50% of penile cancers are associated with HPV infection. In women, HPV DNA is prevalent in 36-40% vulvar cancer cases and close to 90% of vaginal cancers. There is limited data available on the natural history and HPV-related diseases in the genital tract in men, although studies are ongoing. Efficacy of HPV vaccines in the prevention of HPV infection and disease among men also remains unknown. Among HPV DNA positive ano-genital cancer cases, HPV-16 is the most frequently found followed distantly by HPV-18. In benign HPV-related diseases such as genital warts or recurrent respiratory papillomatosis HPV-6 and 11, the two most frequent non-oncogenic types, are the predominant types detected. Oncogenic types are rarely detected. In this article we summarize and review studies describing the natural history of HPV infections among men and its impact on HPV related disease in women. We summarize the evidence linking HPV in the epidemiology and etiology of cancers of the vulva, vagina, anus and oropharynx and present recent estimates of the burden of and HPV type distribution in genital warts and in cases of HPV infection of the airways.

Human papillomavirus infection and the development of cervical cancer and related genital neoplasias

BACKGROUND

The human papillomaviruses (HPV) are simple, nonenveloped, double-stranded DNA viruses, which are responsible for an enormous global burden of genital disease. HPV is associated with 500,000 new cases of cervical cancer and 250,000 cervical cancer deaths worldwide each year. Oncogenic HPV types 16 and 18 are responsible for a majority of cervical cancers and can also cause low- and high-grade cervical lesions (CIN 1, 2, 3) as well as high-grade vulvar or vaginal intraepithelial neoplasia (VIN or VaIN 2/3). Nononcogenic types HPV 6 and 11 also contribute to the overall burden of HPV disease, giving rise to CIN 1, anogenital warts, cutaneous lesions, and respiratory papillomatosis.

PERSPECTIVES

A substantial body of clinical evidence demonstrates the effectiveness of cytological screening in preventing cervical cancer, but these techniques have not eradicated the disease and are not widely available in most developing countries. Furthermore, evaluation and management of HPV-associated cytologic abnormalities is costly, drains health care resources, and increases the risk for adverse pregnancy outcome.

CONCLUSIONS

Targeting cervical cancer through universal immunization with a quadrivalent HPV 6, 11, 16, 18 vaccine may herald the beginning of the end of this deadly disease and substantially reduce the overall global burden of HPV-related genital diseases.

Antiviral agents for the treatment of recurrent respiratory papillomatosis: a systematic review of the English-language literature

OBJECTIVE

To determine the efficacy of antiviral agents for recurrent respiratory papillomatosis (RRP) in children and adults.

STUDY DESIGN

Systematic review to include randomized controlled trials (RCTs), comparative studies (historical and/or nonrandomized), case series, and case reports.

RESULTS

Twenty-six original studies were included (one case-control series, 21 noncomparative trials, four case reports, and no RCTs). Meta-analysis was not possible. The antiviral modalities included acyclovir, ribavirin, intravenous cidofovir, and intralesional cidofovir injections. The strongest evidence was for intralesional cidofovir, with 17 studies including 158 patients. Of these, 90 patients (57%) demonstrated complete resolution, 55 patients (35%) a partial response, and 13 patients (8%) showed no improvement.

CONCLUSIONS

Insufficient evidence from controlled trials exists for reliable conclusions, but several series indicate intralesional cidofovir may have some efficacy. A well-designed placebo-controlled, double-blinded, randomized controlled trial is needed.

SIGNIFICANCE

This study provides the background for future study design and a comprehensive review of the available evidence.

Longstanding recurrent laryngeal papillomatosis: impact on voice quality

Human papilloma virus (HPV) infection in the larynx often requires frequent surgical procedures in order to keep voice quality reasonable. The purpose of this study was to evaluate the speaking voice quality of patients with longstanding recurrent laryngeal papillomatosis (RLP). The patients were seven males with adult-onset RLP whose disease had lasted over 5 years, and who were free of papilloma at the time of examination. Each patient had an age- and gender-matched control with similar smoking habits. Voice samples were recorded and acoustic analysis as well as perceptual listening test were performed. In our series a perceptual test discriminates between normal and pathological voice quality more precisely than acoustical voice analysis. It appears that the voice of the papilloma patient, even after frequent phonosurgical operations, is not deviant from the normal when analyzed acoustically, but perceptual assessment shows that overall quality is less than optimal, and roughness and breathiness are increased.