Comment: Recurrent respiratory papillomatosis (RRP) is a surgical disease for the majority of patients. When there is extensive tracheal and pulmonary spread, this benign disease process becomes very difficult to manage and can be fatal, and no standard systemic therapy has been shown to be consistently effective in the management of this disease process. This article reports the results of a national survey of the use of systemic bevacizumab for aggressive RRP. Eight patients were treated and all responded positively to the treatment. There were few reported complications. This study suggests that bevacizumab should be studied in a formal clinical trial for RRP. —Tanya K. Meyer, MD
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March 2018What has been the initial experience of the use of systemic bevacizumab in the U.S. for recurrent RRP?
Bottom line: Systemic bevacizumab appears to have significant promise and a low complication profile for the most treatment-resistant and aggressive forms of papillomatosis.
Background: Complex laryngotracheal and pulmonary papillomatosis management has proven unsatisfying as there is no uniformity in responses to surgical and adjuvant therapies and, to date, no systemic therapy has been consistently effective. Responses to sublesional bevacizumab injections have been dramatic, but there are no clinical trials utilizing bevacizumab for RRP or standardized protocols for its dosing.
Study design: Case series performed through an electronic survey of the RRP Task Force of the American Society of Pediatric Otolaryngology, American Broncho-Esophagological Association, and physicians known to the authors to have used systemic bevacizumab for RRP. Eight completed surveys representing seven medical centers were available for analysis.
Setting: Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University, Baltimore, Md.
Synopsis: For the most part, patients had a long clinical history of juvenile onset RRP, with aggressive clinical courses requiring very frequent surgical interventions, in many cases at least once a month. Numerous adjuvant treatments had been previously administered, including intralesional cidofovir, systemic interferon, and celecoxib. The two adult-onset patients had primary pulmonary papilloma without an antecedent history of laryngeal papilloma. Dosing was initiated in all patients in the range of 5 to 10 mg/kg per dose, most frequently at three-week intervals. Seven of the eight patients were characterized by their physicians as having a partial response to treatment, with one complete response. In all patients, the surgical interval between excisions for papilloma was significantly lengthened after systemic bevacizumab, and in some cases surgical debridement was no longer necessary. The treatment appears to have been very well-tolerated in most patients, with only two reported minor complications (hemoptysis and proteinuria). Limitations included a selection bias, poor recall of patient or medication details, and incomplete data.
Citation: Best SR, Mohr M, Zur KB. Systemic bevacizumab for recurrent respiratory papillomatosis: a national survey. Laryngoscope. 2017;127:2225–2229.