Low-Dose Cisplatin-Based Radiation Therapy for Refractory Recurrent Respiratory Papillomatosis

Recurrent respiratory papilloma (RRP) often presents multiple lesions in the respiratory tract and sometimes becomes fatal because of severe airway obstruction. We report the case of a 69-year-old woman who had juvenile-onset RRP in the trachea that was refractory to surgical treatment, and complete remission was achieved by low-dose cisplatin combined with de-escalated radiotherapy without any side effects. This case report is the first to illustrate the data on low-dose cisplatin for refractory benign RRP, and our experience reinforces the opinion that low-dose cisplatin combined with de-escalated radiotherapy can be an effective and safe treatment alternative for uncontrollable and lethal RRP. Laryngoscope, 134:2335-2337, 2024.

Factors Associated with Iatrogenic Laryngeal Injury in Recurrent Respiratory Papillomatosis

OBJECTIVE

To describe iatrogenic laryngeal injury and identify its risk factors in recurrent respiratory papillomatosis (RRP) patients receiving surgical care.

STUDY DESIGN

Case-control.

SETTING

Tertiary care academic hospital in a metropolitan area.

METHODS

Charts of patients with RRP seen at our institution from January 2002 to December 2022 were reviewed. Patients were separated into 2 cohorts based upon whether they experienced any form of iatrogenic laryngeal injury-including anterior commissure synechiae, vocal cord scar, reduced vocal fold pliability, vocal fold motion impairment, and glottic and/or subglottic stenosis. Adjusted logistic regressions were performed to identify factors associated with iatrogenic laryngeal injury.

RESULTS

Of 199 RRP patients, 133 (66.8%) had identifiable iatrogenic laryngeal injury. The most common injuries were anterior commissure synechiae (n = 67; 50.4%) and reduced vocal fold pliability (n = 54; 40.6%). On a multivariate logistic regression, patients with diabetes mellitus (adjusted odds ratio [aOR] [95% confidence interval [CI]]: 2.99 [1.02, 8.79]; P = .04) and who received at least 10 surgeries lifetime (aOR [95% CI]: 14.47 [1.70, 123.19]; P = .01) were at increased risk for iatrogenic laryngeal injury, whereas receiving less than 5 surgeries (aOR [95% CI]: 0.21 [0.09, 0.51]; P < .001) was found to be protective. When treating the lifetime number of surgeries as a continuous variable, a greater number of surgeries was a significant risk factor for iatrogenic laryngeal injury (aOR [95% CI]: 1.32 [1.14, 1.53]; P < .001).

CONCLUSION

These results suggest the importance of strict glucose control for diabetic patients receiving RRP surgical care, and emphasize the clinical need to identify medical therapies to decrease RRP surgical frequency for patients.

Systemic Bevacizumab for Recurrent Respiratory Papillomatosis: A Single Institution's Experience

OBJECTIVES

Medical therapies to limit disease recurrence are critically needed for recurrent respiratory papillomatosis (RRP). Systemic bevacizumab is emerging as an exciting adjuvant therapy toward this end, but uptake has been poor due to the lack of experience and awareness of best prescribing practices. The objective of this study was to describe a single tertiary care academic medical center's experience using systemic bevacizumab for the treatment of RRP.

METHODS

A retrospective review was performed to identify patients with RRP on systemic bevacizumab. Demographic and clinical characteristics, findings on imaging reports, and disease response at all anatomic subsites involved in papilloma were documented.

RESULTS

Of the 17 RRP patients on systemic bevacizumab, 9 (52.9%) were male, and 12 (70.6%) were diagnosed with juvenile-onset RRP. The total lifetime number of surgeries was high, with more than half (n = 9; 52.9%) undergoing more than 50 surgeries. Following induction of systemic bevacizumab, a significant reduction in patients with laryngeal (n = 15; 94.1% vs. n = 7; 41.2%, p < 0.001) and tracheal (n = 11; 64.7% vs. n = 5; 29.4%, p = 0.04) RRP was noted. Surgical frequency was significantly lower following systemic bevacizumab (2.5 vs. 0.5 surgeries per year; p < 0.001). The most common complications were new-onset hypertension (n = 4; 23.5%) and proteinuria (n = 5; 29.4%).

CONCLUSION

Systemic bevacizumab is effective in reducing the number of surgeries needed for RRP while exhibiting a relatively safe complication profile. Papillomas in the larynx and trachea are most responsive to systemic bevacizumab, while pulmonary RRP is most likely to exhibit a partial-to-stable response.

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

Quantification and Functional Studies of Neutrophilic Cells Identifies Distinct Papilloma Phenotypes

OBJECTIVES

To characterize the distribution of immune cell subsets within laryngeal papillomas and to study the function of potentially immunosuppressive neutrophilic and regulatory T cells (Tregs).

METHODS

Fresh clinical papilloma specimens were collected at the time of surgery and studied with multiparameter flow cytometry. Papilloma infiltrating neutrophilic cells and Tregs were sorted and studied functionally with ex vivo T cell suppression assays.

RESULTS

Flow cytometric analysis of fresh laryngeal papillomas samples from 18 adult patients with recurrent respiratory papillomatosis revealed patterns in immune constituency between patients. Clearly divergent phenotypes based primarily on the degree of neutrophilic and T cell infiltration were identified. Relative neutrophilic cell enrichment and T cell depletion were observed in 50% of samples and neutrophilic cell depletion and T cell enrichment were observed in the others. Greater papilloma neutrophilic cell enrichment was positively associated with the number of clinically indicated interventions required in the 12 months prior to sample collection, linking papilloma neutrophil inflammation to disease severity. Functional assays revealed the ability of both papilloma infiltrating neutrophilic and Tregs to suppress T cell function at roughly equal magnitudes, but substantially increased infiltration of neutrophilic cells compared to Tregs across samples.

CONCLUSION

Neutrophilic cells are an important contributor to immunosuppression within the respiratory papilloma microenvironment. Given these data and the association between greater neutrophilic cell infiltration and lack of clinical response to therapeutic vaccination, additional study of strategies aimed at limiting neutrophilic cell infiltration or function within papillomas is warranted.

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

Off-label drugs in otolaryngological practice against the background of legal conditions of Polish legislation

<b><br>Introduction:</b> 'Off-label drug use' refers to the administration of drugs for unapproved indications or age groups, a different dosage or other form of administration. Considering the legal issues, there clearly exists a need to implement rules that would regulate the use of pharmaceuticals outside the scope of a marketing authorisation. The brevity and diversity of Polish laws in the field of health care leads to many interpretative doubts associated with particular legal acts.</br> <b><br>Aim:</b> We aimed to present clinical examples from everyday practice of off-label drug use from the medical and legal perspectives, and to support it with relevant legal acts.</br> <b><br>Material and method:</b> Off-label drug use in various otolaryngology subspecialties - otology (mesna), laryngology (bevacizumab, cidofovir and botulinum toxin) and head and neck surgery (botulinum toxin) - are presented and discussed in detail.</br> <b><br>Results:</b> Fourteen Polish legal acts regarding off-label drug use and 4 from EU legislation are commented on. The algorithm of cascade of decision-making processes in off-label drug use is shown.</br> <b><br>Conclusions:</b> Off-label use of medicinal products is not prohibited in Poland or the EU; nevertheless, it is undeniable that the unclear legal situation regarding the use of medicinal products for nonregistered indications creates difficulties. To minimise a doctor's liability risk, obtaining the informed consent from the patient for such treatment is advisable.</br>.

Pulmonary Involvement in Recurrent Respiratory Papillomatosis: A Systematic Review

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

Environmental Sustainability: Waste Audit Comparison Operating Roomand In-Office Laryngeal Surgery

INTRODUCTION

With vast improvements in imaging and endoscopic technology, there has been a massive shift towards in office procedures for various laryngeal disorders with significant health system and patient benefits. Another benefit which has yet to be investigated is the potential environmental effects and waste reduction of in-office laryngeal procedures over traditional operating room surgery.

OBJECTIVES

The purpose of this study is to perform a waste audit and compare the results between operating room and in-office laser laryngeal surgery.

METHODS

Ten cases of in-office and operating room laser laryngeal surgery, performed for recurrent respiratory papillomatosis, were subjected to a waste audit with four waste streams identified. Recyclable, general waste, anesthesia source and sharps. All waste was included from the time of case preparation to termination.

RESULTS

The cases were extremely homogeneous in the waste produced. The mean waste total produced for the operating room laser surgery was 2972 g of which 18% was recoverable/recyclable. Contamination rate was very low. Recycling was performed very well by nursing/prep staff; however, anesthesia was not recovering 13% of potential materials. The in-office waste produced was approximately one tenth of the operating room waste with almost all delegated into general waste. Potentially divertible/recyclable materials accounted for 38% of the waste in-office procedures.

CONCLUSIONS

In-office laryngeal procedures produce 13% of waste compared to surgery performed for similar pathology. These procedures are cost effective, safe and have been demonstrated to enhance environmental sustainability.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:803-806, 2024.

Clinical evaluation of pediatric patients with recurrent respiratory papillomatosis.: A longitudinal study at a Saudi Arabian tertiary care center

OBJECTIVES

To study the clinical evaluation of recurrent respiratory papillomatosis (RRP) patients and the factors associated with the improvement in the Derkay's score as a measure of disease severity.

METHODS

A retrospective cohort that included all juvenile RRP patients who were admitted to King Abdulaziz University Hospital, Riyadh, Saudi Arabia, between September 2015 and June 2022 and underwent surgical debulking.

RESULTS

A total of 16 patients were eligible to join our study. Among them, 7 patients were males. Hoarseness of voice was the most frequent symptom. The median period of the follow-up was 56 months. Complete remission was achieved in 31.3%. The univariate linear regression model revealed that the cidofovir-treated patients had a significant reduction in the change value of Derkay's score compared to those without treatment (regression coefficient= -5.83, 95% confidence interval [CI]: [-11.5 to -0.143], p=0.045). Also, the increased first Derkay's score decreased the change value and subsequently increased the improvement chance of the disease (regression coefficient= -0.424, 95% CI: [-0.764 to -0.083], p=0.018). However, in the multivariate regression model, both variables showed non-significant results.

CONCLUSION

cidofovir treatment and higher Derkay's scores affected the disease improvement.

Efficacy of Systemic Bevacizumab for Recurrent Respiratory Papillomatosis with Pulmonary Involvement

OBJECTIVES

Pulmonary papillomatosis is a rare but severe manifestation of recurrent respiratory papillomatosis (RRP). Efficacy data of systemic bevacizumab for pulmonary RRP are limited. This study's objective was to characterize disease response of pulmonary RRP to systemic bevacizumab.

METHODS

A retrospective review was performed to identify patients with pulmonary RRP seen at three medical institutions. Clinical symptoms, CT findings, and disease response were compared before and after initiation of systemic bevacizumab therapy. Disease response was categorized as complete response, partial response, stabilization, or progression for each subsite involved by papilloma.

RESULTS

Of the 12 pulmonary RRP patients treated with systemic bevacizumab, 4 (33.3%) were male, and 11 (91.7%) were juvenile-onset RRP patients. All presented with laryngeal, tracheal, and pulmonary RRP. The median (range) age at first bevacizumab infusion was 48.1 (19.5-70.2) years. Progression to pulmonary malignancy was identified in 3 (25.0%) patients, 2 before initiation of and 1 after complete cessation of bevacizumab therapy. Clinical symptoms such as dyspnea (75.0% vs. 25.0%; p = 0.01) and dysphagia and/or odynophagia (33.3 vs. 0.0%; p = 0.03) were significantly decreased following bevacizumab therapy. Compared with pre-treatment baseline, 9 (75.0%) patients experienced a stable-to-partial response in the lungs to systemic bevacizumab, and 10 (83.3%) experienced partial-to-complete responses in the larynx and trachea.

CONCLUSION

Systemic bevacizumab is effective in stabilizing progression in even the most severe cases of RRP, with both a dramatic reduction in laryngeal and tracheal disease as well as a stable-to-partial response of pulmonary involvement in a majority of patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:577-581, 2024.

Profiling of VEGF Receptors and Immune Checkpoints in Recurrent Respiratory Papillomatosis

OBJECTIVES

Recurrent respiratory papillomatosis (RRP) is caused by human papilloma virus (HPV) infection of the aerodigestive tract that significantly impacts quality-of-life including the ability to communicate and breathe. Treatment was traditionally limited to serial ablative procedures in the O.R. with possible local adjuvant therapy, but new systemic therapies, such as Vascular endothelial growth factor (VEGF) inhibitors, are showing significant promise. This study aims to determine whether rationale exists for combination therapeutic approaches using VEGF inhibitors and/or immune checkpoint blockade.

METHODS

Using fresh specimens from the O.R., we performed flow cytometry on papilloma, normal adjacent tissue, and blood. Papilloma and surrounding tissue were examined for expression of PD-L1, PD-L2, Galectin-9, VEGFR2, and VEGFR3. CD8+ and CD4+ T cells were assayed for expression of PD-1, TIGIT, LAG3, and TIM3.

RESULTS

Our data shows that papilloma tissue exhibits significantly higher levels of PD-L1 and PD-L2 compared to adjacent tissue. Elevated levels of the VEGF receptor VEGFR3 were also observed in papilloma tissue. When examining T cells within the papilloma, elevated PD-1 and TIGIT expression was observed on CD8+ T cells, while levels of PD-1, TIGIT, and TIM3 were elevated on CD4+ T cells compared to PBMCs. Heterogenous marker expression was observed between individuals.

CONCLUSIONS

Our analysis shows that RRP tissue shows elevated levels of multiple immune check point targets and VEGFR3, with varied patterns unique to each papilloma patient. Some of these immune checkpoint markers already have novel immunotherapies available or in development, providing molecular rationale to offer these systemic treatments to selected patients affected by RRP alongside VEGF inhibitors. Laryngoscope, 2024.

Renal Implications of Long-Term Systemic Bevacizumab for Recurrent Respiratory Papillomatosis

BACKGROUND

Bevacizumab is a vascular endothelial growth factor (VEGF) inhibitor that is used off-label for select cases of recurrent respiratory papillomatosis (RRP) that are severe, involve the distal airway or lung parenchyma, and refractory to other forms of adjuvant therapy. However, there is limited safety data for the use of bevacizumab in children and VEGF inhibitors are reported to have a range of adverse renal effects, including hypertension, proteinuria, and thrombotic microangiopathy (TMA).

CASE-DIAGNOSIS/TREATMENT

This report describes a case of severe juvenile-onset RRP that had an exceptionally high operative burden that was refractory to several adjuvant treatment strategies (including intralesional cidofovir and subcutaneous pegylated interferon). Bevacizumab treatment resulted in a dramatic and sustained improvement in disease control over a 5-year period. However, after 3 years of treatment, the patient developed hypertension and proteinuria and was found to have evidence of a glomerular TMA on kidney biopsy. These complications were successfully managed with a reduction in bevacizumab frequency and angiotensin-converting enzyme inhibitor initiation.

CONCLUSIONS

Clinicians caring for children treated with VEGF inhibitors should be aware of the potential renal complications and their management.

A case report describing the use of systemic bevacizumab in the treatment of recurrent respiratory papillomatosis with pulmonary involvement

Recurrent respiratory papillomatosis (RRP) is a rare disease characterized by recurrent papilloma along the aerodigestive tract. In this case, we describe a 16-year-old with longstanding laryngeal RRP secondary to vertical transmission of human papillomavirus (HPV) who presented with symptomatic pulmonary involvement and was successfully treated with systemic bevacizumab. The case describes the clinical and radiological improvement with therapy as well as the adverse effects that occurred and resolved with dose adjustments.

Interim Results of a Phase 1/2 Open-Label Study of INO-3107 for HPV-6 and/or HPV-11-Associated Recurrent Respiratory Papillomatosis

OBJECTIVE

To evaluate the safety, immunogenicity, and efficacy of INO-3107, a DNA immunotherapy designed to elicit targeted T-cell responses against human papillomavirus (HPV) types 6 and 11, in adult patients with recurrent respiratory papillomatosis (RRP; NCT04398433).

METHODS

Eligible patients required ≥2 surgical interventions for RRP in the year preceding dosing. INO-3107 was administered by intramuscular (IM) injection followed by electroporation (EP) on weeks 0, 3, 6, and 9. Patients underwent surgical debulking within 14 days prior to first dose, with office laryngoscopy and staging at screening and weeks 6, 11, 26, and 52. Primary endpoint was safety and tolerability, as assessed by treatment-emergent adverse events (TEAEs). Secondary endpoints included frequency of surgical interventions post-INO-3107 and cellular immune responses.

RESULTS

An initial cohort of 21 patients was enrolled between October 2020 and August 2021. Fifteen (71.4%) patients had ≥1 TEAE; 11 (52.4%) were Grade 1, and 3 (14.3%) were Grade 3 (none treatment related). The most frequently reported TEAE was injection site or procedural pain (n = 8; 38.1%). Sixteen (76.2%) patients had fewer surgical interventions in the year following INO-3107 administration, with a median decrease of 3 interventions versus the preceding year. The RRP severity score, modified by Pransky, showed improvement from baseline to week 52. INO-3107 induced durable cellular responses against HPV-6 and HPV-11, with an increase in activated CD4 and CD8 T cells and CD8 cells with lytic potential.

CONCLUSION

The data suggest that INO-3107 administered by IM/EP is tolerable and immunogenic and provides clinical benefit to adults with RRP.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:3087-3093, 2023.

The Efficacy of Human Papillomavirus Vaccination as an Adjuvant Therapy in Recurrent Respiratory Papillomatosis

OBJECTIVE

To characterize the efficacy of human papillomavirus (HPV) vaccination as an adjuvant therapy in recurrent respiratory papillomatosis (RRP).

DATA SOURCES

PubMed, Embase, Cochrane, Google Scholar, ClinicalTrials.gov, and Web of Science databases were queried for articles published before April 2021.

REVIEW METHODS

All retrieved studies (n = 870) were independently analyzed by two reviewers according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement using predefined inclusion and exclusion criteria. 13 studies met inclusion criteria. A random-effects meta-analysis was performed to study intersurgical interval (ISI) and number of surgical procedures per year before and after vaccination.

RESULTS

The systematic review included 13 studies, comprising 243 patients. All studies utilized the Gardasil® quadrivalent vaccine, and one study (Yiu et al. 2019) utilized both the quadrivalent and Gardasil® 9-valent vaccines. Our meta-analysis included 62 patients with ISI data across 4 studies, and 111 patients with data on the number of surgical procedures per month across 7 studies. The mean number of surgical procedures decreased by 4.43 per year after vaccination (95% CI, -7.48 to -1.37). Mean ISI increased after vaccination, with a mean difference of 15.73 months (95% CI, 1.46-29.99). Two studies reported on HPV sero-conversion, with HPV seropositivity of 100% prior to vaccination and 25.93% after vaccination.

CONCLUSION

The addition of HPV vaccination was associated with an increase in time between surgeries and reduction in the number of surgical procedures required. HPV vaccination may be a beneficial adjuvant treatment for RRP.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:2046-2054, 2023.

Placental and Breast Metastasis of Squamous Cell Carcinoma in a Patient With Recurrent Respiratory Papillomatosis

Recurrent respiratory papillomatosis (RRP), which is usually benign, is an intractable disease characterized by recurrent papillomas (wart-like lesions). Although it most commonly involves the mucosal epithelial lining of the upper respiratory tract, on rare occasions, it can also involve lung parenchyma. RRP carries the risk of malignant transformation, most often to non-small-cell squamous lung cancer. Here, we present the case of a 32-year-old pregnant female with a past medical history of RRP who developed mild respiratory distress during her immediate postpartum period. This prompted imaging of the chest which revealed right lower lobe hypodensities with extensive hilar and perihilar lymphadenopathy. Histopathology of the bronchial specimen showed squamous cell carcinoma with 100% programmed death-ligand 1 (PD-L1) expression. Gross examination of the patient's placenta showed multiple tan-colored nodules which was confirmed on histopathological examination as multifocal regions of squamous cell carcinoma metastatic from the lung. The patient underwent a staging positron emission tomography (PET) scan which showed hypermetabolic regions in the right middle and lower lobes of the lung, with avidity in the right paratracheal region and an enhancing lesion in the left breast. Biopsy from the breast lesion was also positive for squamous cell carcinoma and PD-L1. She was diagnosed with Stage IVB (T1c, N3, M1c) non-small-cell squamous lung cancer and was started on pembrolizumab. Carboplatin and paclitaxel were added after an initial mixed response to therapy. The patient was non-compliant with her updated treatment regimen as well as with outpatient follow-up visits. A restaging PET scan demonstrated an inadequate response to the amended immunotherapy/chemotherapy regimen. Ultimately, she passed away within one and a half years of her initial diagnosis. Malignant transformation of papillomatous lesions into squamous cell cancer is infrequent, and the occurrence of metastasis to the breast and/or placenta is exceptionally rare. To our knowledge, this is the first reported case of placental and breast metastasis of squamous cell lung cancer in a patient with RRP.

Benralizumab as an Adjuvant Therapy for Recurrent Laryngeal Papillomatosis

Recurrent respiratory (RRP) or laryngeal papillomatosis is the result of human papillomavirus-mediated benign tumor growth on the larynx and is challenging to manage. Benralizumab is a monoclonal antibody targeted against the alpha subunit of the IL-5 receptor on eosinophils. A 61-year-old male patient presented with refractory RRP following multiple surgical excisions. His disease course improved substantially when benralizumab was added to his asthma regimen. There is no clear mechanistic role suggested for benralizumab directly treating RRP. This case may represent a novel application of benralizumab as an adjuvant treatment for patients with RRP and comorbid asthma. Laryngoscope, 133:863-865, 2023.

Recurrent laryngeal papillomatosis: multimodal therapeutic strategies. Literature review and multicentre retrospective study

Objectives

Recurrent respiratory papillomatosis (RRP) is a benign, rare disease caused by Human Papilloma Virus (HPV) that can be divided into juvenile and adult forms. The course of the disease is variable, but is usually more aggressive in the juvenile form. The standard surgical treatment is represented by CO2 laser resection, although photoangiolytic lasers represent a valid alternative. Adjuvant therapies have been proposed for disease control in case of frequent surgical resections or spreading into the lower airways. In recent years, the development of immunotherapy led to the use of bevacizumab either intratumorally or intravenously, but the most promising therapeutic development is represented by HPV vaccination. This paper aims to present a narrative review of the literature and the experience of three different University Centres in the treatment of RRP.

Methods

A retrospective analysis of the clinical charts of all patients affected by laryngeal papillomatosis and treated in three different University Centres between 2002 and 2022 was performed. The following parameters were collected: sex, age at first evaluation, sites of larynx involved, HPV type, type of first surgical treatment, presence and number of recurrences, surgical treatment of recurrences, adjuvant therapies, side effects and status at last follow-up.

Results

Seventy-eight patients were available for evaluation. Of these, 88% had adult onset RRP (Ao-RRP) and 12% juvenile onset RRP (Jo-RRP). The glottis was the most frequently involved subsite; all patients were submitted to surgical resection with CO2 laser under general anaesthesia. Recurrences appeared in 79% of the patients, the patients who did not recur were all adults. The mean number of recurrences was 9 (range 1-110). Recurrences were more frequent in children (M = 20; range 2-110) than adults (M = 5; range 1-21). Thirty-two (52%) of the 62 patients who recurred were re-treated with CO2 laser under general anaesthesia, while office-based treatment with a photoangiolytic laser was preferred in the remaining 30 (48%) patients. Adjuvant treatments were applied in 26 patients. The analysis of the course of the disease showed that in the 9 patients with Jo-RRP, 6 (67%) were free of lesions at the last follow-up, while the other 3 (33%) had papillomas. Of the 69 patients with Ao-RRP, 53 (77%) were alive and free of disease at the last visit, 14 (21%) were alive with disease, 1 (1%) was lost at follow-up and 1 (1%) died for other disease. Severe side effects were not observed except for 2 patients, who developed posterior glottic stenosis.

Conclusions

Our results confirmed the literature review. RRP is a potentially aggressive disease, especially in juvenile onset. Surgical resection is still first-line treatment, but in case of multiple recurrences the use of adjuvant therapies must be taken into consideration.

A single Belgian academic center experience

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Molecular Mechanisms of Carcinogenesis in Pediatric Airways Tumors

Primary tumors of the airways in the pediatric population are very rare entities. For this reason, little is known about the pathogenesis of these neoplasms. Understanding the biology has different practical implications: for example, it could help in the differential diagnosis, have a prognostic significance, or may lead to the development of a targeted therapy. The aim of this article is to present the current knowledge about pediatric airways tumors, focusing on the molecular mechanisms that cause the onset and progression of these neoplasms. After a brief introduction of epidemiology and clinical presentation, the tumorigenesis of the most frequent pediatric airways tumors will be described: Juvenile-onset recurrent respiratory papillomatosis (JORRP), Subglottic Hemangiona (SH), Rhabdomyosarcoma (RMS), and Mucoepidermoid carcinoma (MEC).

Public health impact and cost-effectiveness of switching from bivalent to nonavalent vaccine for human papillomavirus in Norway: incorporating the full health impact of all HPV-related diseases

AIM

The objective of this study was to estimate and compare the cost-effectiveness of switching from a bivalent to a nonavalent human papillomavirus (HPV) vaccination program in Norway, incorporating all nonavalent vaccine-preventable HPV-related diseases and in the context of the latest cervical cancer screening program.

METHODS

A well-established dynamic transmission model of the natural history of HPV infection and disease was adapted to the Norwegian population. We determined the number of cases of HPV-related diseases and subsequent number of deaths, and the economic burden of HPV-related disease under the current standard of care conditions of bivalent and nonavalent vaccinations of girls and boys aged 12 years.

RESULTS

Compared to bivalent vaccination, nonavalent vaccination averted an additional 4,357 cases of HPV-related cancers, 421,925 cases of genital warts, and 543 cases of recurrent respiratory papillomatosis (RRP) over a 100-year time horizon. Nonavalent vaccination also averted an additional 1,044 deaths over the 100-year time horizon when compared with bivalent vaccination. Total costs were higher for the nonavalent strategy (10.5 billion NOK [€1.03 billion] vs. 9.3-9.4 billion NOK [€915-925 million] for bivalent vaccination). A switch to nonavalent vaccination had a higher vaccination cost (4.4 billion NOK [€433 million] vs. 2.7 billion NOK [€266 million] for bivalent vaccination) but resulted in a savings of 627-694 million NOK [€62-68 million] in treatment costs. A switch to nonavalent vaccination demonstrated an incremental cost-effectiveness ratio of 102,500 NOK (€10,086) per QALY versus bivalent vaccination.

CONCLUSIONS

Using a model that incorporated the full range of HPV-related diseases, and the latest cervical cancer screening practices, we found that switching from bivalent to nonavalent vaccination would be considered cost-effective in Norway.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Safety of different surgical modalities for recurrent respiratory papillomatosis resection: A systematic review and meta-analysis

BACKGROUND

Currently, the most common surgical modalities used for recurrent respiratory papillomatosis (RRP) resection are microdebrider, carbon dioxide (CO₂ ) laser and potassium-titanyl-phosphate (KTP) laser. However, complication rates vary among different surgical modalities and have been controversial in different studies.

OBJECTIVE OF REVIEW

This study systematically reviews the available studies which reported intra-operative and post-operative complications, aiming to compare the safety of microdebrider, CO₂ laser and KTP laser.

TYPE OF REVIEW

Meta-analysis.

SEARCH STRATEGY

Seven electronic databases (PubMed/MEDLINE, EMBASE[Ovid], Scopus, Cochrane Library and Web of Science) were searched from inception through 28 April 2022. Randomised controlled, prospective or retrospective observational studies that recorded the complications of three different surgical modalities for RRP resection were included in the meta-analysis.

EVALUATION METHOD

Outcomes of interest were intra-operative and post-operative complications, and complication rate was calculated to evaluate the safety of surgical methods.

RESULTS

Twenty different studies were included in quantitative synthesis. Only one study compared outcomes of those three kinds of treatment modalities simultaneously, two studies compared microdebrider and CO₂ laser, and the remaining studies focussed on only one of three treatments. The weighted average complication rate for microdebrider was 0.03 (95% confidence interval [CI] 0.00-0.21), n = 6, for CO₂ laser treatment was 0.16 (95% CI 0.09-0.25), n = 14 and for KTP laser treatment was 0.04 (95% CI 0.00-0.14), n = 4.

CONCLUSION

The limited evidence demonstrated that CO₂ lasers in the surgical treatment of RRP may lead to more surgical complications, and microdebrider and KTP lasers may be safer. However, the heterogeneous data limit any strong comparison of outcomes of different treatment of laryngeal papillomas. Future randomised controlled trials that directly compare the safety of different surgical modalities are needed.

Recurrent Respiratory Papillomatosis Presenting as Worsening Dyspnea in an HIV-infected Patient

Recurrent respiratory papillomatosis (RRP) is a rare manifestation of human papillomavirus (HPV) infection. It is characterized by relapsing bulky papillomas in the respiratory tract, which are usually benign in nature. We describe a challenging case of RRP in an HIV-infected patient with extensive pulmonary disease, presenting with worsening dyspnea. The interaction between HPV with HIV as a coinfection is still not completely understood, particularly the role of HIV-associated immunosuppression in RRP. Our main goal is to raise awareness of this clinical entity and to promote further studies on its management, particularly in specific populations such as HIV-infected individuals. A brief review of the theme is also presented.

Durable response in a patient with recurrent respiratory papillomatosis treated with immune checkpoint blockade

BACKGROUND

Immune checkpoint blockade can provide clinical benefit for patients with advanced cancer. Here, we report durable disease control over many years following PD-L1 blockade through induction of a viral antigen-specific T cell response in an adult patient with recurrent respiratory papillomatosis.

METHODS

Antigen-specific T cell response assays, single cell RNA-sequencing, and RNA-scope was used to study clinical tissues.

RESULTS

An HPV6 E2-specific T cell clone restricted to HLA-B*55, present at low frequency in the pre-treatment papilloma, significantly expanded after six doses of PD-L1 blockade and remained present and functional at the site of initial response in the larynx as a tissue resident memory T cell for 4 years. An associated reduction in E2 target gene was observed following treatment.

CONCLUSIONS

Although demonstrated in a single exceptional responder, these results highlight that immune checkpoint blockade may induce durable, viral antigen-specific immunity of sufficient magnitude to control disease in patients with nonmalignant disorders.

Recurrent Respiratory Papillomatosis: Quality of Life Data from an International Patient Registry

OBJECTIVES

Quality of life studies in recurrent respiratory papillomatosis (RRP) have traditionally relied upon clinician-designed survey instruments. This study's objective is to report quality of life outcomes from a patient-designed questionnaire.

METHODS

Patients who provided health information and completed a quality of life questionnaire were identified from the RRPF-CoRDS patient registry. Demographic, clinical, and quality of life measures were collected. Means and standard deviations were calculated for continuous data, and frequencies and percentages were calculated for categorical data. Outcomes for patients with juvenile-onset RRP (JORRP) and adult-onset RRP (AORRP) were compared using Student's t-tests for continuous data and χ² analyses for categorical data.

RESULTS

Seventy-three patients with RRP were identified (JORRP: 32; AORRP: 41). Common clinical symptoms included raspy voice (78.1%) and dyspnea (61.6%). The majority (97.3%) of patients reported feeling debilitated by their diagnosis, and 94.5% of patients reported avoiding participation in career and/or social activities due to their voice quality. Due to their RRP, 65.7% reported missing at least five work days each month. Social anxiety was reported in 79.5% of patients, though only 28.8% of the cohort reported utilizing mental health services. The median (range) lifetime number of surgeries received was 20 (1 - 3). Most patients (57.5%) reported paying at least 5% of their annual income towards RRP-related medical care.

CONCLUSION

RRP presents high mental and fiscal burden. Our results highlight data from a quality of life questionnaire designed by RRP patients, and may help to elucidate potential disconnects between what clinicians and RRP patients consider most impactful.

LEVEL OF EVIDENCE

4 Laryngoscope, 2022.

Metformin for the Treatment of Recurrent Respiratory Papillomatosis

OBJECTIVES

Metformin is an oral agent used for the management of type 2 diabetes. As a result of its ability to alter cellular metabolic requirements, metformin also possesses antiproliferative properties. Metformin has been shown to reduce mutagenesis in several malignancies, however has never been described as a treatment option for recurrent respiratory papillomatosis (RRP). The aim of this study is to present a case series of non-diabetic patients with adult-onset RRP who were treated with metformin.

METHODS

Case series.

RESULTS

Five patients (age 48 ± 17.82, range 35-68, 4 males, 1 female) were identified with a history of laryngeal RRP who were treated with 500 mg of metformin twice daily. Follow-up time ranged from 11 to 105 months. Two patients had spontaneous regression of RRP lesions within months of starting metformin. Four patients had reduced time intervals between surgical procedures after starting metformin. All patients tolerated metformin well with only minor side effects of self-limiting light-headedness, facial flushing or gastrointestinal upset.

CONCLUSION

Metformin is a low-risk medication that was used to reduce progression and burden of disease in 5 patients with RRP. Further studies should investigate the sole or adjunct use of metformin for treatment of RRP.

Comparing KTP and CO2 laser excision for recurrent respiratory papillomatosis: A systematic review

Objective

The CO2 laser and 532 nm potassium titanyl phosphate (KTP) laser have been applied to treat recurrent respiratory papillomatosis (RRP). This systematic review sought to compare outcome differences between these two methods.

Data Sources

Embase, Web of Science, PubMed, and the Cochrane Library.

Review Methods

CO2 laser and KTP laser studies were obtained by keyword searches of four authoritative medical databases. Articles were screened and retained when conforming to inclusion criteria. The primary outcome was cure rate; the secondary outcomes were recurrence, death, remission, clearance, and human papillomavirus (HPV)-detected rates, as well as laser effectiveness rates. Postoperative complications rate was the safety outcome measure. All outcomes were summarized within the CO2 and KTP groups, with results statistically compared (p < .05).

Results

Overall, the cure rates were 87.25% (KTP group) and 75.98% (CO2 group; p < .05). Complication rates significantly differed between the KTP (2.32%) and CO2 (17.71%) groups (p < .0001). There was a relatively higher but not significant difference in the recurrence rates between the CO2 (18.6%) and KTP (10.87%) groups (p = .1595). The CO2 group remission rate was considerably lower (38.9%) than the KTP group (88.46%, p < .0001). HPV-detected and clearance rates were only reported for the CO2 group. The bias risks were 13.1 ± 1.45 (CO2) and 13.6 ± 1.52 (KTP) for the two groups, indicating evidence was of fair quality.

Conclusion

Overall, KTP laser excision showed significantly better postoperative clinical outcomes than the CO2 laser, with a lower failure rate. Available fair-quality evidence suggests KTP laser excision might be better for treating RRP. Nevertheless, more high-quality randomized controlled studies are needed to compare these two surgical techniques, particularly in terms of reporting functional data such as vocal outcomes.

HPV and Recurrent Respiratory Papillomatosis: A Brief Review

Recurrent Respiratory Papillomatosis (RRP) is a rare but severe manifestation of human papillomavirus (HPV). As our knowledge about HPV infections has expanded, it has become possible to understand the course of RRP disease and unravel plausible efficient methods to manage the disease. However, the surge in reports on HPV has not been accompanied by a similar increase in research about RRP specifically. In this paper, we review the clinical manifestation and typical presentation of the illness. In addition, the pathogenesis and progression of the disease are described. On the other hand, we discuss the types of treatments currently available and future treatment strategies. The role of vaccination in both the prevention and treatment of RRP will also be reviewed. We believe this review is essential to update the general knowledge on RRP with the latest information available to date to enhance our understanding of RRP and its management.

Significant Declines in Juvenile-onset Recurrent Respiratory Papillomatosis Following Human Papillomavirus (HPV) Vaccine Introduction in the United States

BACKGROUND

Juvenile-onset recurrent respiratory papillomatosis (JORRP) is a rare and serious disease caused by human papillomavirus (HPV) presumably acquired during vaginal delivery. HPV vaccination of females through age 26 years, recommended in the United States since 2006, can prevent HPV transmission. We assessed trends in JORRP cases before and after HPV vaccine introduction in the United States.

METHODS

Case-patients were identified from 26 pediatric otolaryngology centers in 23 U.S. states. Demographics and clinical history were abstracted from medical records. Case-patients were grouped by year of birth, and birth-cohort incidences were calculated using number of births from either national or state-level natality data from the 23 states. We calculated incidence rate ratios (IRR) and 95% confidence intervals (CI) in 2-year intervals.

RESULTS

We identified 576 U.S. JORRP case-patients born in 2004-2013. Median age at diagnosis was 3.4 years (interquartile range: 1.9, 5.5). Number of identified JORRP case-patients declined from a baseline of 165 born in 2004-2005 to 36 born in 2012-2013. Incidence of JORRP per 100 000 births using national data declined from 2.0 cases in 2004-2005 to 0.5 cases in 2012-2013 (IRR = 0.2, 95% CI = .1-.4); incidence using state-level data declined from 2.9 cases in 2004-2005 to 0.7 cases in 2012-2013 (IRR = 0.2, 95% CI = .1-.4).

CONCLUSIONS

Over a decade, numbers of JORRP case-patients and incidences declined significantly. Incidences calculated using national denominator data are likely underestimates; those calculated using state-level denominator data could be overestimates. These declines are most likely due to HPV vaccination. Increasing vaccination uptake could lead to elimination of this HPV-related disease.

Evaluating the Effect of Recurrent Respiratory Papillomatosis on Work Productivity

OBJECTIVE

Patients with recurrent respiratory papillomatosis (RRP) have significant vocal dysfunction which affects their performance at work. This study aimed to evaluate voice-related work productivity before and after ablative treatment for RRP.

METHODS

This is a prospective case series conducted at 2 academic laryngology outpatient clinics. Adult employed patients with RRP completed the Work Productivity & Activity Impairment instrument (WPAI), Voice Handicap Index (VHI-10), WorkHoarse, Hospital Anxiety and Depression Scale (HADS), and a demographics questionnaire immediately before and 1 month after ablative treatment of papilloma. The primary outcome measure was the change in work productivity impairment domain of the WPAI, and changes in ratings before and after ablation were compared using a Wilcoxon Signed-Rank test.

RESULTS

The 32 participants (mean age 45, 84% male) had a median (interquartile range) voice-related work productivity impairment score of 48.8% (30.0) at baseline which was improved to 5.0% (10.0) at 1 month after surgical ablation of papillomata (difference 30.0% (30.0) improvement). For the secondary outcome measures, there were significant improvements in VHI-10 (P < .001), self-reported voice quality (P = .002), and Workhoarse (P = .001), but no significant change in HADS.

CONCLUSION

Patients with RRP experience significant voice-related work productivity impairment, and ablation of papillomata significantly improves work productivity.

Juvenile-Onset Recurrent Respiratory Papillomatosis in the United States, Epidemiology and HPV Types-2015-2020

BACKGROUND

Juvenile-onset recurrent respiratory papillomatosis (JORRP) is a rare disease characterized by the growth of papillomas in the respiratory tract. In the United States, JORRP is not a nationally notifiable condition and current data are limited.

METHODS

Children with JORRP aged <18 years were enrolled from 26 pediatric otolaryngology centers in 23 US states from January 2015 through August 2020. Demographic, birth information, and maternal vaccination history were collected from a parent/guardian. Clinical history was abstracted from medical records. Papilloma biopsies were tested for 28 human papillomavirus (HPV) types. Mothers who delivered in 2006 or later were considered age-eligible for HPV vaccination if aged ≤26 years in 2006. We described characteristics of enrolled children and their birth mothers and analyzed disease severity by diagnosis age and HPV type using multiple logistic regression.

RESULTS

Among 215 children with JORRP, 88.8% were delivered vaginally; 64.2% were firstborn. Among 190 mothers, the median delivery age was 22 years. Among 114 (60.0%) age-eligible for HPV vaccination, 16 (14.0%) were vaccinated, 1 (0.9%) before delivery. Among 162 specimens tested, 157 (96.9%) had detectable HPV; all 157 had a vaccine-preventable type. Disease severity was associated with younger diagnosis age and HPV 11; adjusted analyses found only younger diagnosis age significant (adjusted odds ratio: 6.1; 95% confidence interval: 2.9, 12.8).

CONCLUSIONS

Children with JORRP were commonly firstborn and delivered vaginally to young mothers; most of the mothers reported no HPV vaccination before delivery. Vaccine-preventable HPV was identified in all specimens with detectable HPV. Increasing preexposure HPV vaccination could substantially reduce or eliminate JORRP in the United States.

Prevalence of human papillomavirus 6 and 11 variants in recurrent respiratory papillomatosis

Human papillomavirus (HPV) types 6 and 11 are the etiological agents of recurrent respiratory papillomatosis (RRP). We examined the prevalence and distribution of HPVs 6 and 11 genetic variants in juvenile onset (JORRP) and adult onset (AORRP) laryngeal papillomas. Cases of JORRP and AORRP were collected, retrospectively. HPV detection and genotyping were accessed by polymerase chain reaction-sequencing in 67 RRP samples. Overall, the most prevalent HPV-6 variants were from B1 (55.8%) and B3 (27.9%) sublineages, whereas among HPV-11 positive samples A2 (62.5%) variants were predominant. A higher prevalence of HPV-6 B1 was observed in JORRP (83.3% B1 and 16.7% B3), compared with AORRP cases (58.3% B1 and 41.7% B3). HPV-11 A2 variants were more prevalent both in JORRP (57.2%) and in AORRP cases (70.0%). Nevertheless, with the exception that HPV-6 B1 were significantly less likely to recur, there was a lack of association between any particular HPVs 6 or 11 variant and clinicopathological features. Our data do not support an association between HPVs 6 and 11 variability and RRP.

Virus-Associated Biomarkers in Oropharyngeal and Nasopharyngeal Cancers and Recurrent Respiratory Papillomatosis

Nasopharyngeal cancer (NPC) is known to be associated with Epstein–Barr virus (EBV). Pre-treatment and post-treatment detection of plasma cell-free EBV DNA has been shown to be useful as a diagnostic as well as a prognostic factor in NPC. On the other hand, the incidence of human papillomavirus (HPV)-associated oropharyngeal cancer (OPC) is increasing. In contrast to cervical cancer, which is classically known to be an HPV-associated malignancy, HPV testing is not clinically applied for OPC, except for p16 immunostaining as a surrogate marker of HPV infection. One of the major characteristics of HPV-associated OPC is its association with a good prognosis compared with non-HPV-associated OPC. However, some patients still have a poor prognosis. Another characteristic of HPV-associated OPC is the distinct risk factor of high sexual activity. Establishing a biomarker for the prediction of the prognosis before and/or after initial treatment, as well as for diagnosis in populations at high risk, is of marked interest. With this background, HPV DNA detection in plasma and oral rinses has become an area of focus. In this review, the current significance of HPV DNA detection in plasma and oral rinse samples, as well as serum HPV antibody levels, is evaluated.

Initial Experience Treating HPV-Related Laryngeal Diseases with Oral Brincidofovir: A Pilot Study

OBJECTIVE

To determine if brincidofovir, an oral analog of cidofovir that achieves high tissue levels of the active metabolite with low systemic toxicity, has an observable effect on HPV-related disease of the larynx.

METHODS

Two patients with laryngeal recurrent respiratory papillomatosis (one each of genotypes 6 and 11) and 1 with recurring aryepiglottic fold carcinoma in situ (genotype 16) received oral brincidofovir according to protocol. Close-range videoendoscopic examinations were done during and after the study period to observe disease behavior in the absence of other interventions, and after subsequent surgical intervention. Disease character and magnitude of recurrence for each patient were compared to their patterns prior to brincidofovir.

RESULTS

Brincidofovir reduced papilloma burden in 1 patient and markedly attenuated the rate and magnitude of recurrence in both. After surgical intervention, Patient 1 remains disease-free at 10 years (7 years from last intervention) and Patient 2 has no symptoms at 8 years. Patient 3 with recurring carcinoma in situ has required less frequent resections and specimens show reduced degrees of dysplasia present only in islands amid normal mucosa at 8 years (currently no evidence of disease at 21 months from last intervention).

CONCLUSION

Brincidofovir appears to attenuate HPV disease of the larynx in this small pilot study, though further investigation is required because of the highly variable nature of the disease and potential confounding factors.

An updated review of the epidemiological factors associated with recurrent respiratory papillomatosis

OBJECTIVES

To identify studies evaluating the epidemiology of recurrent respiratory papillomatosis (RRP), including patient demographics, human papillomavirus (HPV) immunology, clinical course, surgical and medical treatments, and psychosocial factors.

METHODS

A systematic literature search through PubMed was performed to identify studies evaluating the epidemiological factors associated with RRP. All studies were screened through a priori selection criteria using the titles and abstracts.

RESULTS

A total of 208 studies were identified, of which 54 met eligibility criteria and were included in the review.

CONCLUSIONS

RRP is a rare disease most commonly caused by HPV 6 and 11. It is characterized by recurring benign papillomatous lesions in the respiratory tract, particularly the larynx. Existing evidence about disease risk factors is limited but includes both maternal HPV infection and patient smoking and sexual behaviors. Disease management involves a combination of routine surgical and medical treatment. Surgical techniques include CO2-laser, sharp dissection, coblation, microdebridement, and photoangiolytic laser. Medical treatments which have been found to facilitate disease control off-label include interferon-alpha (IFN-α), indole-3-carbinol, acyclovir, bevacizumab, retinoids, and the Gardasil and mumps vaccines. Many patients suffer from additional psychosocial challenges related to their diagnosis. Current disease knowledge remains limited, and more robust controlled trials about risk factors, medical therapies, and surgical options are needed.

LEVEL OF EVIDENCE

5.

Recurrent respiratory papillomatosis: A 2020 perspective

OBJECTIVE

Despite recent advancement recurrent respiratory papillomatosis (RRP) remains a rare but challenging benign airway neoplasm. In recent years there has been significant shifts in incidence of this disease due to changes in vaccination and prevention for human papilloma virus (HPV) and its related pathology. This review will highlight the epidemiology, prevention and treatment of RRP.

METHODS

The PubMed database was searched using relevant MeSH terms including "recurrent respiratory papillomatosis." The titles and abstracts were reviewed to assess relevance and unrelated articles were excluded. A full-text review for select articles was performed, the data and discussions were interpreted and synthesized to create a concise update on the management of RRP.

RESULTS

With the increasing utilization of the 9-valent and quadrivalent HPV vaccine in Australia, we have seen a significant decrease in the incidence of RRP. Preliminary data in the US shows a similar trend of decreased incidence after implementation of vaccination. Single dose Gardasil in developing countries has shown sustained immunization for at least 7 years. Preliminary clinical trials and retrospective studies have shown the HPV vaccine may have benefit as a treatment method in addition to prevention for HPV related diseases. Bevacizumab (Avastin), a VEGF monoclonal antibody, has shown promise as a systemic treatment for RRP. The Corona Virus Disease 2019 (COVID-19) pandemic has affected perioperative management of RRP.

CONCLUSION

RRP continues to decline in incidence since the implementation of HPV vaccination. Advancement in the medical management including Bevacizumab show promise as an additional option for the management of RRP.

How Enhancing Immunity to Low-Risk HPV Could Cure Recurrent Respiratory Papillomatosis

Recurrent respiratory papillomatosis (RRP) is currently treated with repeat surgical resection of papillomatous disease that does not address the fundamental underlying issue of chronic infection with low-risk human papillomavirus. Here, we review the biology and immunology of low-risk human papillomavirus (HPV) infections. Antiviral or antiangiogenic adjuvant treatments similarly address the papillomatous disease itself but do not activate HPV immunity. It is likely that only through immune-mediated clearance of low-risk HPV infection can patients with RRP be cured. In some patients, this occurs spontaneously. In others with more aggressive disease, adjuvant immunotherapy to activate immunity may be needed. Based on current understanding of antiviral immune responses, the only rational strategy to clear HPV-infected epithelial cells is through activation of the T-lymphocyte arm of the adaptive immune response. Translation of immunotherapies that are Food and Drug Administration-approved or under clinical study for cancer, such as immune checkpoint blockade or engineered therapeutic vaccines, may provide a path toward tolerable and efficacious adjuvant immunotherapy for RRP. LEVEL OF EVIDENCE: NA Laryngoscope, 131:2041-2047, 2021.

Sublesional Bevacizumab Injection for Recurrent Respiratory Papillomatosis: Evaluation of Utility in a Typical Clinical Practice

OBJECTIVES

The goal of this study was to evaluate the benefit of sublesional bevacizumab injection for recurrent respiratory papillomatosis (RRP) as used in a typical clinical practice.

METHODS

A retrospective review of patients with RRP treated between 2011 and 2016 was undertaken. All patients were treated with in-office potassium titanyl phosphate (KTP) laser photoablation. Sublesional bevacizumab injection was used based on joint patient-physician decision making. Papilloma burden was objectively measured on prior recordings by 2 blinded reviewers and described as vocal fold segments affected (VFSA) by papilloma. Each patient served as their own control by comparing times when bevacizumab was or was not used. Mixed model for longitudinal data was used to determine if the previous use of bevacizumab decreased the disease burden.

RESULTS

A total of 19 patients met inclusion criteria and all prior laryngoscopic exams were reviewed for VFSA as described above. The mean (SD) number of VFSA when bevacizumab was not used at the prior procedure was 15 (14) as compared to 8 (11) when bevacizumab was used. When adjusted for age, time from initial presentation and baseline disease burden, mixed model showed a decrease of 11 VFSA (95% CI 6.5, 15.5, P < .0001) when bevacizumab was used as compared to when bevacizumab was not used at the prior procedure. In mixed model analysis, there was not a significant association between bevacizumab dose used and VFSA at the subsequent visit (P = .8).

CONCLUSION

Using sublesional bevacizumab intermittently based on clinical findings appears to be effective in improving disease control. Papilloma burden is significantly decreased at the subsequent clinical follow-up following injection of sublesional bevacizumab. The beneficial effect of sublesional bevacizumab may be not be dose-dependent.

Association between the TAP1 gene polymorphisms and recurrent respiratory papillomatosis in patients from Western Mexico: A pilot study

Background

Recurrent respiratory papillomatosis (RRP) is a respiratory tract disease that affects children and adults and is characterized by the recurrent proliferation of multiple papillomas. The etiologic agent is the human papillomavirus, mainly genotypes 6 and 11. Furthermore, polymorphisms in TAP1 appear to influence the selection of antigenic peptides and the transport process to the rough endoplasmic reticulum, for their subsequent presentation to T lymphocytes, an essential process against viral diseases and tumor processes. Previous studies have shown that individuals with those polymorphisms are susceptible to immune, infectious, and tumor‐related diseases. The present study aimed to determine the association between the TAP1 rs1057141 (c.1177A>G) and rs1135216 (c.2090A>G) single nucleotide polymorphisms (SNPs) and RRP.

Methods

A case–control study was carried out on a group of 70 individuals (35 controls and 35 patients). RRP diagnosis, HPV genotyping, and viral load were determined through histology and PCR. SNPs rs1057141 and rs1135216 were identified through allelic discrimination, using real‐time PCR. The haplotypic analyses were performed using the Arlequin 3.5 program.

Results

HPV‐6 and HPV‐11 were the genotypes found in the samples. In the polymorphism analysis, rs1057141 showed no significant differences (p = 0.049, CI = 0.994–7.331). In contrast, a significant difference was found in rs1135216 (p = 0.039, OR = 2.4) in the allelic analysis, as well as in the dominant (p = 0.027, OR = 3.06), codominant (p = 0.033, OR = 3.06), and additive model (p = 0.043, OR = 2.505) in subjects with the G allele.

Conclusion

The G allele in rs1135216 was associated with a genetic risk of susceptibility for RRP in a population in Western Mexico.

Long-Term Follow-Up on Systemic Bevacizumab Treatment in Recurrent Respiratory Papillomatosis

OBJECTIVES/HYPOTHESIS

Recurrent respiratory papillomatosis (RRP) is a primarily benign disease affecting the entire respiratory tract. Treatment is challenging and usually involves surgical interventions and adjuvant medications. Previously, promising results on systemic administration of bevacizumab have been reported. However, experience on long-term systemic use in patients with RRP is not yet available. Here, we present our long-term follow-up on RRP patients undergoing systemic bevacizumab treatment.

STUDY DESIGN

Case series.

METHODS

To describe experience on long-term systemic bevacizumab administration, we performed the underlying investigation. Clinical, radiological, and bronchoscopy data were collected.

RESULTS

To date, a total of n = 5 patients has been treated with systemic bevacizumab at Muenster University Hospital. With a median follow-up since first systemic bevacizumab administration of 95.5 months long-term follow-up is illustrated. Following bevacizumab treatment partial remission or very good partial remission were achieved in all patients. After papilloma recurrence/progression due to bevacizumab discontinuation, further response was documented in all patients in whom bevacizumab was started again. In one patient, bevacizumab was discontinued due to loss of efficacy. Lung cancer developed in one patient with pulmonary papillomatosis prior to bevacizumab administration whereas three patients suffered from malignant transformation during bevacizumab treatment. Systemic bevacizumab led to long-term reduction in surgical interventions in all patients. Except from mild proteinuria and hypertension in two patients therapy was well tolerated.

CONCLUSIONS

Systemic bevacizumab represents a promising long-term treatment option for aggressive forms of papillomatosis. Rate of malignant transformation under bevacizumab treatment, optimal treatment schedule, and influence on survival should be further evaluated in clinical trials.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1926-E1933, 2021.

Office-based procedures in laryngology

Objective

Development of transnasal fiberoptic laryngoscopy, integration of an operative channel (OC), the advent of high-definition television imaging, with improvements in laser technology, cleared the way for office-based laryngology. Three treatment categories can be identified: bioendoscopy-guided biopsy; laryngeal injection; laser-assisted surgery.

Methods

26 patients underwent OBPs at the Otolaryngology Clinic of IRCCS Policlinico San Martino, Genoa, Italy. Sixty-eight procedures were performed: 60 for recurrent respiratory papillomatosis (RRP), 5 for unilateral vocal fold paralysis (UVFP) and 3 for glottic leukoplakias. Neoblucaine 5% was administrated through the operative channel, for local anaesthesia. All procedures were carried out with the physician standing behind the patient. Narrow band imaging (NBI – Olympus Medical) or i-scan (Pentax Medical) were used to enhance the accuracy of the biopsy thanks to identification of atypical vascular patterns. Laryngeal injections were made using a 25G flexible needle. Opera Evo (Quanta system IEC/EN 60825-1:2007) is a hybrid fibre laser that is used for “blanching” and vaporisation of RRP lesions and to treat selected leukoplakias that were previously biopsied.

Conclusions

No major complications occurred during the procedures.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

HPV genotype is a prognosticator for recurrence of respiratory papillomatosis in children

OBJECTIVES

This study aimed to compare the prognosis according to age, genotype or human papillomavirus (HPV) variant in patients with recurrent respiratory papillomatosis (RRP).

DESIGN

Non-concurrent cohort.

PARTICIPANTS

Forty one patients with RRP.

SETTING

Tertiary referral hospital.

MAIN OUTCOME MEASURES

Disease severity was defined by the number of surgeries performed, and Derkay score at surgeries, obtained from medical records. HPV was detected and genotyped, and HPV-6 variants were also assessed.

RESULTS

Fifteen (36.58%) individuals belonged to the juvenile RRP group (JoRRP, less than 18 years), while 26 patients (63.41%) were allocated at the adult group (AoRRP, equal or more than 18 years). JoRRP patients needed, in average, a higher number of surgeries to control the disease than AoRRP patients (mean difference: 3.36). Also, JoRRP patients showed a higher Derkay score at each surgery (mean difference: 3.76). There was no significant difference in the number of surgeries when we compared patients infected with HPV-6 or HPV-11, neither in accordance to HPV-6 variants. Patients with HPV-11 presented a higher mean Derkay score at surgery than those with HPV-6 (mean difference: 4.39); when co-variated by age, we observed that this difference occurred only among JoRRP patients (mean difference: 6.15).

CONCLUSIONS

Age of onset of RRP has an important impact on number of surgeries to control disease. Patients with JoRRP and HPV-11 tend to present worse Derkay score at each surgery. HPV genotype among adults and HPV-6 variants had no impact on the outcome of the disease.

Recurrent Respiratory Papillomatosis Office versus Operating Room: Systematic Review and Meta-Analysis

OBJECTIVES

Recurrent respiratory papillomatosis can be treated in the office or operating room (OR). The choice of treatment is based on several factors, including patient and surgeon preference. However, there is little data to guide the decision-making. This study examines the available literature comparing operative treatment in-office versus OR.

METHODS

A systematic review was performed following Preferred Reporting Items for Systematic Reviews guidelines. Of 2,864 articles identified, 78 were reviewed full-length and 18 were included. Outcomes of interest were recurrence and complication rates, number of procedures, time interval between procedures, and cost.

RESULTS

Only one study compared outcomes of operative in-office to OR treatments. The weighted average complication rate for OR procedures was 0.02 (95% confidence interval [CI] 0.00-0.32), n = 8, and for office procedures, 0.17 (95% CI 0.08-0.33), n = 6. The weighted average time interval between OR procedures was 10.59 months (5.83, 15.35) and for office procedures 5.40 months (3.26-7.54), n = 1. The weighted average cost of OR procedures was $10,105.22 ($5,622.51-14,587.83), n = 2 versus $2,081.00 ($1,987.64-$2,174.36), n = 1 for office procedures.

CONCLUSION

Only one study compares office to OR treatment. The overall data indicate no differences aside from cost and imply that office procedures may be more cost-effective than OR procedures. However, the heterogeneous data limits any strong comparison of outcomes between office and OR-based treatment of laryngeal papillomas. More studies to compare the two treatment settings are warranted.

Identification of 11 Different HPV Subtypes in Adult Patients With Recurrent Respiratory Papillomatosis

OBJECTIVE

To define the human papillomavirus (HPV) subtypes seen in a large adult population with traditionally defined recurrent respiratory papillomatosis.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary care laryngology practice.

SUBJECTS AND METHODS

All patients had a firm diagnosis of recurrent respiratory papillomatosis defined by (1) visually obvious papillomas, (2) recurrence requiring multiple surgeries, and (3) pathology diagnosis of "papilloma." Each patient had also undergone HPV subtyping. Age, sex, presence of malignancy, and HPV subtypes were tabulated and correlated with long-term patient outcomes.

RESULTS

A total of 184 patients were identified who fulfilled the above criteria. In total, 87.0% (160) had a low risk subtype; 9.2% had an alternative subtype. These consisted of subtypes 16, 18, 31, 44, 45, 55, and 70. Four patients (2.2%) had combinations of subtypes, with 1 patient with HPV 11 and 16, 1 patient with HPV 11 and 76, 1 patient with 11 and 84, and 1 patient with 18 and 45. Finally, 3.8% of patients were HPV negative, despite fulfilling all 3 criteria listed above.

CONCLUSION

In the patient population above, almost 10% of patients had an HPV subtype other than 6 and 11. This suggests that traditionally defined recurrent respiratory papillomatosis (RRP) can be caused by HPV subtypes other than 6 and/or 11. In addition, the clinical course of persons with this definition of RRP appears to vary by subtype, and this information may offer the ability to nuance follow-up instructions, reducing in particular the burden placed upon patients who have RRP caused by subtypes 6 and 11.

Recurrent respiratory papillomatosis with lower airway involvement in a young woman

Radiological presentation of bronchiectasis should prompt the respiratory physician to investigate various differential diagnosis leading to this condition. This case report describes a young non-smoking woman with HPV11 induced laryngeal Recurrent Respiratory Papillomatosis (RRP) since early childhood, who developed progressive exertional dyspnea. A thorough diagnostic process revealed HPV11 infection in the lung parenchyma consistent with RRP in the lower airways, an HPV infection that was most likely obtained from the patient´s mother during vaginal birth.

This case report illustrates that also respiratory physicians should keep RRP in mind in persons with the radiological presentation of bronchiectasis previously diagnosed RRP in the upper airways.

Altered Monocyte and Langerhans Cell Innate Immunity in Patients With Recurrent Respiratory Papillomatosis (RRP)

The micromilieu within respiratory papillomas supports persistent human papillomavirus (HPV) infection and disease recurrence in patients with recurrent respiratory papillomatosis (RRP). These patients show polarized (T_H2-/Treg) adaptive immunity in papillomas and blood, enriched immature Langerhans cell (iLC) numbers, and overexpression of cyclooxygenase-2/prostaglandin E₂ (PGE₂) in the upper airway. Blood monocyte-derived, and tissue-derived iLCs from RRP patients and controls were now studied to more fully understand innate immune dysregulation in RRP. Patients' monocytes generated fewer iLCs than controls, due to a reduced fraction of classical monocytes that generated most but not all the iLCs. Prostaglandin E₂, which was elevated in RRP plasma, reduced monocyte-iLC differentiation from controls to the levels of RRP patients, but had no effect on subsequent iLC maturation. Cytokine/chemokine responses by iLCs from papillomas, foreskin, and abdominal skin differed significantly. Freshly derived tissue iLCs expressed low CCL-1 and high CCL-20 mRNAs and were unresponsive to IL-36γ stimulation. Papilloma iLCs uniquely expressed IL-36γ at baseline and expressed CCL1 when cultured overnight outside their immunosuppressive microenvironment without additional stimulation. We conclude that monocyte/iLC innate immunity is impaired in RRP, in part due to increased PGE₂ exposure in vivo. The immunosuppressive papilloma microenvironment likely alters iLC responses, and vice versa, supporting T_H2-like/Treg HPV-specific adaptive immunity in RRP.

Juvenile-Onset Recurrent Respiratory Papillomatosis Diagnosis and Management - A Developing Country Review

Recurrent respiratory papillomatosis (RRP) is a condition caused by human papillomavirus (HPV), usually HPV types 6 and 11, which is characterized by recurrent papillomas of the respiratory tract, mainly the larynx. Patients usually present between the ages of 2 and 6 years. The initial presenting symptom is progressive dysphonia, followed by stridor and respiratory distress. Treatment consists of repeated microlaryngoscopic procedures to remove the papillomas as there is no cure. The poor availability and accessibility of appropriate healthcare services in developing countries are barriers to the early diagnosis and appropriate management of patients with juvenile-onset recurrent respiratory papillomatosis (JoRRP), requiring many patients to have a tracheostomy. The introduction of prophylactic vaccines that include HPV6 and HPV11 is necessary in order to reduce the incidence of JoRRP.

Therapeutic Use of the Human Papillomavirus Vaccine on Recurrent Respiratory Papillomatosis: A Systematic Review and Meta-Analysis

BACKGROUND

Recurrent respiratory papillomatosis is a benign condition caused by human papillomavirus (HPV). Surgery is the mainstay of treatment, but numerous adjuvant therapies have been applied to improve surgical outcome. Recently, HPV vaccination has been introduced, but only smaller studies of its effect have been published. The present meta-analysis is intended as a possible substitute for a proposed but not yet realized multicenter randomized controlled trial.

METHODS

A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. PubMed, Embase, and Cochrane were systematically searched. All retrieved studies (n = 593) were reviewed and qualitatively assessed. In addition, 2 previously unpublished data sets were included. The systematic review included 11 studies, comprising 133 patients, of whom 63 patients from 5 studies were eligible for meta-analysis. A random-effects meta-analysis was conducted for the mean difference in number of surgical procedures per month before and after vaccination.

RESULTS

The number of surgical procedures per month was significantly reduced after HPV vaccination compared with before vaccination (estimated mean, 0.06 vs 0.35). The mean intersurgical interval increased from 7.02 months (range, 0.30-45 months) before to 34.45 months (2.71-82 months) after HPV vaccination.

CONCLUSION

The present study supports the continued use of the HPV vaccine as an adjuvant treatment for recurrent respiratory papillomatosis.