Recurrent Respiratory Papillomatosis: Much Has Been Done, but a Long Road Lies Ahead

It is not surprising that one of the biggest debates over the vaccine approval by the FDA was the age to initiate therapy. Convincing parents of pre-pubertal children that they should receive the vaccine might be difficult. Critics of early administration argue that explaining the vaccine’s purpose necessitates teaching recipients about sex and that such a discussion may encourage inappropriately young sexual activity. In support of early vaccination, however, is the finding that antibody levels to HPV-16 and -18 are two times higher in girls vaccinated between 10 and 14 years of age compared with women vaccinated between 20 and 25 years of age. The CDC’s Advisory Committee on Immunization Practices (ACIP) voted unanimously to urge all females between 11 and 26 years of age to be vaccinated and that girls as young as 9 receive the vaccine at the discretion of their physician. Hopefully Phase IV studies will confirm the long-term safety of the vaccine in children, unlike other vaccines, such as that for rotavirus, which was found to increase the risk of intussception.

Approval of Cervarix, the bivalent vaccine for HPV manufactured by GlaxoSmithKline, is expected in 2007. Because this vaccine does not confer direct resistance to HPV-6 and -11, it is incumbent upon us to push for use of the quadrivalent vaccine. We must convince pediatricians, family practitioners. and gynecologists of the importance of preventing HPV-6 and HPV-11-related disease. These viral subtypes are often termed low risk because of their low likelihood of inducing malignant disease. They are considered anything but low risk to us and to our patients with RRP.

Other Research Moves More Slowly

Research advancements for a vaccine to treat existent RRP are moving far more slowly. Pilot data from the HSPE7 vaccine, manufactured by Stressgen, showed a significant increase in the time interval between surgical interventions for patients receiving the vaccine. While I was concerned about the subjectivity of the outcome measure for patients that I enrolled in the study, I was thrilled to observe that two of my three severely affected patients entered remission in the year after the study was concluded-hinting at potentially promising long-term results. Nventa recently purchased the financially struggling Stressgen company and has announced plans to continue HSPE7 research.

Surgical therapy remains the mainstay for treatment of existent disease. Although we all have our personal preferences for instrumentation to remove papillomata, the equipment options do not vary the interval length between treatments. I believe that the use of the microdebrider will surpass the use of the CO₂ and KTP lasers in the next decade. Having been an advocate for CO₂ laser therapy for many years, I converted to microdebrider use several years ago as I find it better able to define the delicate plane between normal and abnormal tissue. Dr. Steven Zeitels continues his exploration of the pulsed dye laser (PDL) to eradicate papillomas by destroying their central feeding vessel. The PDL energy is delivered through a flexible cable and can be used in an office based setting under local anesthesia. It may carry a lower risk of causing web formation when treating lesions at the anterior commissure.