Recurrent respiratory papillomas (RRP) pose a challenging management problem. In up to 20% of cases papillomas extend below the vocal cords to involve the lower respiratory tract causing cough, dyspnea and other symptoms on occasion. Permanent and complete eradication of RRP is still not considered possible at this time but remission of disease can occur in a few cases.
A 56 year old male presented with increasing shortness of breath and paroxysmal cough. Bronchoscopy revealed upper and lower respiratory papillomas in 1995. Human Papilloma Virus serotypes 16 and 18 were confirmed on tissue biopsy. The patient underwent 43 CO2 laser treatments between 1995-2004 via rigid bronchoscopy and direct laryngoscopy to treat his lesions. CO2 laser controlled lesions as far as the distal trachea but could not reach the distal trachea and right main bronchus where residual papillomas were noted. He had also received methotrexate therapy for approximately 1 year but this was discontinued for lack of any improvement. He continued to have cough and shortness of breath due to distal airway disease (Figure 1) and was referred to the Pulmonary Critical Care Division in May 2004. At bronchoscopy the right main bronchus was extensively involved with 40% narrowing by papillomas which also involved the lateral wall of the right mainstem bronchus continuously down to the level of the right upper lobe which was almost completely obstructed. Due to extensive disease he received multimodal therapy with argon plasma coagulation (APC) to ablate papillomas and Interferon 2 alpha starting in June and July 2004, respectively. Control of disease was significant after three APC treatments (Figure 2). The bronchoscopic approach used the side fire probe on two occasions and straight fire probes at other times. The latest bronchoscopy in April 2005 showed complete resolution of disease in the distal trachea and orifice to right main bronchus (Figure 2). The right upper lobe was fully patent with minimal residual disease proximal to the lobar orifice which was treated with APC. Interferon 2 Alpha dosing started in July 2004 initially on 9 million units three times a week. This was later reduced to 4.5 million units three times a week and subsequently to 4.5 million units twice a week. The dosage reduction was elected due to clinical control of RRP as assessed by bronchoscopy and to reduce systemic symptoms of fever, malaise, fatigue and myalgias following Interferon 2 Alpha injections.
There have been earlier case reports of APC being used to treat lower respiratory disease with good results. Presumably APC would also be effective in the upper respiratory tract. A comparison between the two methods may be warranted. The use of Interferon 2 Alpha also needs to be assessed independently of APC and CO2 Laser.
The combination of argon plasma coagulation with Interferon 2 Alpha injections has produced substantial improvement in a relatively short interval of 10 months of treatment. A declining dose of Interferon 2 Alpha has been used and appears adequate to control disease.
Mudusar Raza, None.