Adjuvant Therapies May Increase Time Between Surgeries for Recurrent Respiratory Papillomatosis

What are the most current perspectives on management of recurrent respiratory papillomatosis (RRP)?

Bottom line: RRP is incurable with current treatment modalities, but adjuvant therapies should be used when surgery cannot control the disease, with their efficacy limited to increasing the time interval between surgical procedures.

Background: RRP is a rare chronic disease caused by low-risk human papillomavirus (HPV) types 6 and 11, characterized by recurrent exophytic papillomas of the epithelial mucosa in the respiratory tract. RRP is difficult to manage, and there is currently no cure. Treatment is primarily focused on maintaining airway patency and voice quality. Patients often require multiple surgeries in a short amount of time and occasionally adjuvant therapy.

Study design: Literature review.

Synopsis: The authors found several current and future recommendations for management: The current standard of care for RRP management is surgical excision. Complete eradication is not necessarily the goal, as aggressive resection has been associated with increased HPV expression in nearby HPV-infected cells. A complication rate increase and a voice quality decrease have been reported for cold instruments versus lasers; for lasers, the shortest possible pulse and lowest possible power required are recommended. Microdebriders are often used in combination with lasers to first remove the bulk of the papilloma. Although office laser procedures are well tolerated in adult patients, patients with bulky or extensive papillomas or inadequate tolerance of the scope, and pediatric patients, are poor candidates.

Approximately 20% of RRP patients require adjuvant therapy. Current adjuvants include interferon therapy, rarely used due to side effect concerns; cidofovir, which may be initiated when surgical debulking is required every two to three months; bevacizumab, which has been shown to be relatively safe; celecoxib, a COX-2-selective non-steroidal anti-inflammatory drug; programmed cell death protein-1 inhibitors, which have shown clinical efficacy in HPV-associated HNSCC; gefitinib, an EGFR tyrosine kinase inhibitor; and the HPV vaccine Gardasil, which shows encouraging therapeutic results but requires more testing.

Citation: Ivancic R, Iqbal H, deSilva B, Pan Q, Matrka L. Current and future management of recurrent respiratory papillomatosis. Laryngoscope Inv Otol. 2018;3:22–34