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Prognostic factors of recurrent respiratory papillomatosis spread to lower airway passages
International Journal of Pediatric Otorhinolaryngology (2004) 68, 1589—1590
www.elsevier.com/locate/ijporl
LETTER TO THE EDITOR
Prognostic factors of recurrent respiratory papillomatosis spread to lower airway passages Recurrent respiratory papillomatosis (RRP) remains an unsolved therapeutical problem in pediatrics. This makes physicians search for new methods of diagnostics and therapy, and also to critically reanalyze the existing ones. In this context, we would like to comment on the article by L. Zawadzka-Glos et al. ‘‘Lower airway papillomatosis in children’’ published in your journal [2]. In this publication the authors reported on the incidence of RRP spread to lower airway passages in a significant group of patients and suggested the necessity of early diagnostic of pulmonary involvement in RRP patients by chest X-ray. Taking into consideration the conclusions and suggestions made by the authors, we would like to draw attention to the role of tracheotomy, HPV typing, and timing of prospective observation of RRP patients in the process of RRP spread to lower airway passages [1]. Forty-two patients were recruited in our prospective study in 1983—1990 after a third relapse of laryngeal papillomatosis with surgery-free interval <3 months, and treated with adjuvant alfa-IFN (3 MU/m2 3 times a week) with a mean therapy duration of 32.4 21.6 months. As a result of the therapy, 24 patients achieved macroscopic remission at the end of IFN-therapy, other 14 patients required further surgical removal of lesions. In some cases, IFN-therapy was repeated and/or cidofovir injections were used. Analysis of 38 RRP patients followed up for a maximum of 242 months from the start of the study revealed that pulmonary spread (6/38 patients) occurred a mean of 149.3 97.3.6 months after RRP onset. We should mention that the incidence of pulmonary involvement is significantly higher in patients who did not respond to IFN-therapy.
Aggressive disease valued by initial extralaryngeal spread of papillomatosis and the number of surgeries >10 indicate a statistically significant probability of RRP spread to lungs. Age at RRP onset, gender, smoking and tracheotomy did not influence the incidence of pulmonary spread of the disease in our study, however, association with HPV type was statistically significant. In all the patients with pulmonary involvement of RRP HPV type 11 was detected. Four from these six patients underwent malignant transformation in lungs with development of squamous cell carcinoma (3/4 died within 2 years). The results obtained during long-term follow-up in our study justify the importance of HPV typing and analyzing of individual characteristics of the RRP course. Taking into consideration the high association between presence of HPV 11, extralaryngeal RRP involvement, number of surgeries >10 and incidence of RRP spread to lower airway passages, it is obviously advisable to recommend limitation of chest X-ray examination to patients with such clinico-pathological data. The increased incidence of pulmonary involvement in RRP patients from our study may be associated with initial selection of more severe cases of the disease course. Extremely unfavorable prognosis of such patients indicates the necessity of more frequent control of RRP spread as well as aggressive surgical sanation of local state before involvement of lower airway passages.
References [1] Gerein V, Zapf B, Zenner H, Schlo ¨ndorf G, et al., Humana Papilloma Virus (HPV)-Nachweis im Verlauf der Alpha-Interferon (IFN)-Therapie der juvenilen Larynxpapillomatose und dessen Bedeutung fu ¨r die Prognose. In: Kurzreferate der 60. Jahresversammlung der Deutschen Gesellschaft fu ¨r Hals-
0165-5876/$ — see front matter # 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2004.07.026
1590
Letter to the Editor
Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Kiel, 1989. p. 96—97. [2] L. Zawadzka-Glos, A. Jakubowska, M. Chmielik, A. Bielicka, M. Brzewski, Lower airway papillomatosis in children, Int. J. Pediatr. Otorhinolaryngol. 67 (2003) 1117—1121.
Gerein Valentina,b, Department of Pediatric Pathology Johannes Gutenberg University of Mainz Langenbeckstrasse 1, 55101 Mainz, Germany
b
Pediatric Clinic of Johann Wolfgang Goethe University, Frankfurt am Main Germany Tel.: +49 613 1175193 fax: +49 613 1175604 E-mail address: [email protected]
a
2 July 2004
www.elsevier.com/locate/ijporl
LETTER TO THE EDITOR
Prognostic factors of recurrent respiratory papillomatosis spread to lower airway passages Recurrent respiratory papillomatosis (RRP) remains an unsolved therapeutical problem in pediatrics. This makes physicians search for new methods of diagnostics and therapy, and also to critically reanalyze the existing ones. In this context, we would like to comment on the article by L. Zawadzka-Glos et al. ‘‘Lower airway papillomatosis in children’’ published in your journal [2]. In this publication the authors reported on the incidence of RRP spread to lower airway passages in a significant group of patients and suggested the necessity of early diagnostic of pulmonary involvement in RRP patients by chest X-ray. Taking into consideration the conclusions and suggestions made by the authors, we would like to draw attention to the role of tracheotomy, HPV typing, and timing of prospective observation of RRP patients in the process of RRP spread to lower airway passages [1]. Forty-two patients were recruited in our prospective study in 1983—1990 after a third relapse of laryngeal papillomatosis with surgery-free interval <3 months, and treated with adjuvant alfa-IFN (3 MU/m2 3 times a week) with a mean therapy duration of 32.4 21.6 months. As a result of the therapy, 24 patients achieved macroscopic remission at the end of IFN-therapy, other 14 patients required further surgical removal of lesions. In some cases, IFN-therapy was repeated and/or cidofovir injections were used. Analysis of 38 RRP patients followed up for a maximum of 242 months from the start of the study revealed that pulmonary spread (6/38 patients) occurred a mean of 149.3 97.3.6 months after RRP onset. We should mention that the incidence of pulmonary involvement is significantly higher in patients who did not respond to IFN-therapy.
Aggressive disease valued by initial extralaryngeal spread of papillomatosis and the number of surgeries >10 indicate a statistically significant probability of RRP spread to lungs. Age at RRP onset, gender, smoking and tracheotomy did not influence the incidence of pulmonary spread of the disease in our study, however, association with HPV type was statistically significant. In all the patients with pulmonary involvement of RRP HPV type 11 was detected. Four from these six patients underwent malignant transformation in lungs with development of squamous cell carcinoma (3/4 died within 2 years). The results obtained during long-term follow-up in our study justify the importance of HPV typing and analyzing of individual characteristics of the RRP course. Taking into consideration the high association between presence of HPV 11, extralaryngeal RRP involvement, number of surgeries >10 and incidence of RRP spread to lower airway passages, it is obviously advisable to recommend limitation of chest X-ray examination to patients with such clinico-pathological data. The increased incidence of pulmonary involvement in RRP patients from our study may be associated with initial selection of more severe cases of the disease course. Extremely unfavorable prognosis of such patients indicates the necessity of more frequent control of RRP spread as well as aggressive surgical sanation of local state before involvement of lower airway passages.
References [1] Gerein V, Zapf B, Zenner H, Schlo ¨ndorf G, et al., Humana Papilloma Virus (HPV)-Nachweis im Verlauf der Alpha-Interferon (IFN)-Therapie der juvenilen Larynxpapillomatose und dessen Bedeutung fu ¨r die Prognose. In: Kurzreferate der 60. Jahresversammlung der Deutschen Gesellschaft fu ¨r Hals-
0165-5876/$ — see front matter # 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2004.07.026
1590
Letter to the Editor
Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Kiel, 1989. p. 96—97. [2] L. Zawadzka-Glos, A. Jakubowska, M. Chmielik, A. Bielicka, M. Brzewski, Lower airway papillomatosis in children, Int. J. Pediatr. Otorhinolaryngol. 67 (2003) 1117—1121.
Gerein Valentina,b, Department of Pediatric Pathology Johannes Gutenberg University of Mainz Langenbeckstrasse 1, 55101 Mainz, Germany
b
Pediatric Clinic of Johann Wolfgang Goethe University, Frankfurt am Main Germany Tel.: +49 613 1175193 fax: +49 613 1175604 E-mail address: [email protected]
a
2 July 2004