Preliminary report of endolaryngeal and endotracheal laser surgery of juvenile-onset recurrent respiratory papillomatosis by Nd:YAG laser and a new fiber guidance instrument.

OBJECTIVES: Recurrent respiratory papillomatosis (RRP) caused by human papilloma virus (type 6 and 11) is the most common benign neoplasm of the larynx in children. Despite being a benign disease, treatment is very difficult and is characterized by frequent recurrence, spread throughout the respiratory tract, and malignant degeneration. Besides surgical resection and the established CO(2) laser treatment, laser surgery by fiber-guided Nd:YAG laser light promises to be a bloodless and effective treatment procedure. To improve this new method, a novel fiber guidance instrument has been developed to aid in endolaryngal laser surgery of RRP.Study design and setting The method described uses a specially designed instrument for fiber guidance that is equipped with a bendable distal tip to move the fiber end precisely. Moreover, the instrument includes an additional channel for the suction of smoke and pyrolysis products. Up to now, 5 patients (aged 4 to 8 years) with RRP were treated by Nd:YAG laser light (lambda = 1064 nm; power, 10 W; irradiance, 3.5 kW/cm(2), continuous wave) with a prototype version of the new instrument and were followed up for 12 months each. RESULTS: Because of the adequate length and the bendable distal tip with a range of -5 degrees up to 45 degrees to the optical axis of the fiber and less than 10% light loss at maximal deflection, RRP can be treated by Nd:YAG laser light easily and precisely. The continuous suctioning ensured an optimum view of the operating field and a minimal load of potential infectious laser plume and toxic pyrolysis products for the patient as well as for the physician. The laser treatment of RRP with the new fiber guidance instrument was only minimally traumatic. During 1-year follow-up visits, all Nd:YAG laser light-treated patients, showed a regression of the disease. CONCLUSIONS: The new fiber guidance instrument enables a precise and easy treatment of the RRP with fiber-guided laser systems (eg, Nd:YAG-, diode-, and KTP-lasers) and an effective removal of infectious laser plume as well as toxic pyrolysis products. A follow-up period of 1 year revealed that Nd:YAG laser surgery seems to prevent a rapid recurrence of juvenile respiratory papillomatosis in the treated patients.     

Incidence, age at onset, and potential reasons of malignant transformation in recurrent respiratory papillomatosis patients: 20 years experience.

Forty-two patients with recurrent respiratory papillomatosis (RRP) were accepted into a multicenter prospective study in 1983 to 1990, treated with alfa-IFN 3 MU/m 2 3 times a week and then followed-up until August 1, 2003. All the patients who had disease progression with pulmonary spread were characterized by insufficient response to IFN-therapy and detection of HPV type 11. Five patients (4/5 smokers) presented malignant transformation in lungs or nasopharynx (mean RRP duration was 27.2 +/- 8 years from RRP onset and 14.6 +/- 6.3 years from pulmonary spread until malignant transformation) with persistent RRP in larynx. The results of long-term follow-up in RRP patients with HPV 11 underline the necessity of reanalyzing the current therapy.     

Recurrent respiratory papillomatosis

A 6-year-review of patients who presented with recurrent respiratory papillomatosis (RRP) to our hospital from January 1996 to December 2001 was carried out. Ten cases were identified, of which six were juvenile-onset RRP. Hoarseness was the most common symptom, noted in nine (90%) patients. Other clinical presentations included cough, stridor and aphonia. All patients had glottic papillomas; two had multiple sites of involvement. One patient underwent a tracheostomy that revealed papillomas over the trachea, bronchus and lung parenchyma. Half of the patients were Chinese. Of the six cases of juvenile-onset RRP, three patients were Malay, two Chinese and one Indian. Three Chinese and one German patient had adult-onset RRP. Among the juvenile-onset RRP cases, the mean age at presentation was 2 years, while for adult-onset RRP, it was 42 years. Juvenile-onset RRP was more common in females. There were more papillomas over more sites in patients with juvenile-onset RRP than with adult-onset disease. Subglottic involvement was noted in the juvenile-onset RRP cases. All patients were treated with CO2 laser therapy, but there was complete remission of the papillomas in only two cases.     

北京地区妇产科门诊患者人类乳头瘤状病毒的感染率、亚型分布及其与年龄的相关性分析

目的:研究北京地区妇产科门诊患者人类乳头瘤状病毒(HPV)感染现状及与年龄的相关性,为HPV疫苗的临床应用提供流行病学资料。方法:采集2013年4月至2014年5月于首都医科大学宣武医院妇产科门诊就诊患者的宫颈细胞标本1 999例,利用凯普电导流核酸分子杂交技术对HPV-DNA进行基因分型,对不同年龄段的HPV感染率进行年龄分层分析,结合年龄信息进行统计分析。结果:在1 999例标本中,HPV感染率为25.2%(502/1 999),其中16型的感染率为21.2%(69/326)最为常见,其次为52型19.3%(63/326)和58型16.0%(52/326)。与年龄的相关性分析结果显示不同年龄阶段HPV感染率不同,其中41~50岁患者感染率最高,60岁患者感染率最低。结论:北京地区妇产科门诊患者HPV感染具有明显的亚型分布异质性,提示HPV预防性疫苗的使用应同时考虑分型和年龄的因素。     

Laryngeal Kaposi sarcoma: case report and literature review

PROBLEM/OBJECTIVE: Kaposi sarcoma is the most frequently-occurring neoplasm in AIDS patients. Laryngeal localization is infrequent. We discuss the management options for laryngeal Kaposi sarcoma based on a literature review. CASE REPORT: A 42 year old, HIV-positive male receiving HAART therapy presented with mild hoarseness and sore throat. Fiberoptic laryngeal examination identified a small purple lesion in the right ventricular fold. He underwent biopsy under general anaesthesia. The lesion was histologically diagnosed as a Kaposi sarcoma. Systemic treatment was pursued, but 6 weeks later the patient developed severe dysphagia and acute airway obstruction when the lesion became glotto-supraglottic and obstruced the airway. Transoral tumour vaporization with a CO2 laser was performed in the emergency department. Post-operative chemotherapy was administered. Three months later, the patient was completely asymptomatic and the laryngeal examination was normal. CONCLUSION: Transoral CO2 laser vaporization combined with chemotherapy is a valid option for managing obstructive laryngeal Kaposi sarcoma.     

High-risk human papillomavirus in mammary gland carcinomas and non-neoplastic tissues of Mexican women: no evidence supporting a cause and effect relationship

Human papillomavirus (HPV) has been implicated in breast carcinogenesis. Consecutive and non-selected mastectomy specimens from Mexican patients harboring breast carcinomas were sampled in order to look for the presence of HPV DNA.HPV-16 was detected in 6 (10%) of 60 breast carcinomas. Two of these also had HPV genome in adjacent non-neoplastic mammary-tissues. Seven cases had HPV DNA only in non-neoplastic tissue specimens. HPV DNA was also detected in 4 (25%) of 10 tumor-bed specimens without residual neoplastic lesions that were obtained from patients who underwent neoadjuvant chemotherapy or neoadjuvant chemotherapy/radiotherapy. HPV-positive tumors tended to be smaller in size, than HPV-negative tumors (p = 0.047). Histological distributions of HPV-positive and -negative cases showed no significant difference.Although all the HPV-16 DNA were found integrated, its low viral load rendered it difficult to incriminate this virus in breast carcinogenesis. However, the possibility that HPV infection occurred during carcinoma development cannot be ruled out.     

A new laser treatment for vocal cord papilloma--585-nm pulsed dye.

OBJECTIVES: Microvascular targeting with the 585- nm pulsed dye laser (PDL) may provide a new form of therapy to control symptoms caused by recurrent respiratory papillomatosis (RRP). METHODS: Ten patients with RRP underwent 13 procedures under general anesthesia with the 585-nm PDL. A micromanipulator (11 procedures) and a flexible nasolaryngoscope (2 procedures) were used to deliver the laser pulses. Patients were followed postoperatively according to protocol. RESULTS: Clinical examination revealed regression of papillomas in all patients. Seven patients had complete regression after PDL surgery, and 2 patients had partial response to treatment. One patient was lost to follow-up. No complications were present during this prospective nonrandomized pilot study. CONCLUSION: Patients treated with PDL experienced regression of their papillomas. PDL may provide patients with RRP with an alternative treatment without the risks associated with CO(2) laser surgery. This procedure also has potential to be delivered on an outpatient basis with flexible fiberoptic laryngoscopes.     

Possible hazards from irradiation with the carbon dioxide laser

Previous investigators, using relatively high irradiance levels, have been unable to demonstrate viable tissue in the plume during carbon dioxide laser vaporization. Our study was undertaken to reinvestigate this possibility, particularly at the lower irradiance levels that are currently in clinical use. Fresh post-mortem skin was injected with a known quantity of bacterial spores and vaporized at different levels of irradiance and energy fluence. The plume and splatter were collected and cultured. Spores were found following the vaporization of five of 13 specimens treated at an irradiance of less than 500 W/cm2, while there were none in the 20 specimens treated at an irradiance of greater than 997 W/cm2. These results show that the widely accepted assumption that the carbon dioxide laser produces a sterile field may be false and that viable particles may be disseminated during vaporization at low irradiance. This may be important when considering the treatment of potentially infectious lesions.     

Clinical analysis of genital human papillomavirus infection in pregnancy

Objective: To determine the clinical characteristics, diagnosis and treatment of genital human papillomavirus (HPV) infection in the pregnant women and whether a woman with persistent HPV infection may get pregnant or not.Methods: Forty-five patients with genital HPV infection during pregnancy attending this hospital were analyzed retrospectively.Results: Among forty-five patients with genital HPV infection, 26 (58%) had genital warts, 18 (38%) had pathological changes but no symptoms and 1 (4%) was in a latent infection checked by HPV-DNA without symptom and pathological changes. 10 (22%) patients had other genital infections simultaneously. Only 16 (36%) of the patients had undergone the treatment of drug, laser, cryosurgery or surgery. 39 patients, including 3 patients with persistent HPV infection, had a full-term pregnancy. No respiratory papillomatosis cases were identified in any infants. In follow-up, 3 patients still had genital warts. 13 patients had thinprep cytologic test again and the results of 4 patients were abnormal. 5 patients had hybrid capture (HC2) again and 2 were positive.Conclusion: Respiratory papillomatosis cases were rare in the children with a maternal history of genital HPV infection during pregnancy. Pregnant women with genital HPV infection often had other genital infections. The patients with persistent HPV infection may try to get pregnant when virus burden is low.     

Human papillomavirus hpv-16 DNA as an epitheliotropic virus that induces hyperproliferation in squamous penile tissue

The prevalence of human papillomavirus HPV-16DNA sequences in 57 penile carcinoma biopsies was examined using the polymerase chain reaction (PCR) with type specific internal probes, employing HPV consensus primers from the L1 region. The cases comprised 39 typical squamous cell carcinoma and 18 specimens with different subtype. PCR products were analyzed and HPV-16DNA was detected in a high percentage of specimens. Thirty-eight biopsies were HPV-16DNA positive. This determination was correlated with cellular differentiation and growth pattern. Our data corroborates that squamous cell carcinoma was invariably associated with HPV-16DNA.     

Selective embolization for control of gastrointestinal hemorrhage.

Transcatheter embolization using Gelfoam plugs or autologous clot is an alternative or adjunct to the conventional management of gastrointestinal hemorrhage. During a 12 month period we successfully treated 10 patients who had massive gastrointestinal hemorrhage with selective embolization; 6 patients had upper gastrointestinal hemorrhage and 4 had bleeding from the colon. Most of these patients were critically ill and were poor surgical candidates. Hemorrhage was controlled by selective catheterization of the bleeding vessel, followed by injection of Gelfoam pledgets. Since the procedure was accomplished with ease and prolonged hemostasis obtained, we recommend it for gastrointestinal hemorrhage, especially in patients who are poor surgical risks or are unresponsive to vasopressin infusion, or both. Operative intervention for the primary disease could subsequently be performed electively, if necessary, days or weeks after transcatheter embolization.     

Detection of human papillomavirus in formalin-fixed, invasive squamous carcinomas using the polymerase chain reaction

We analyzed 88 formalin-fixed, paraffin-embedded invasive squamous carcinomas for human papillomavirus-related DNA sequences (HPV types 16 and 18) following in vitro gene amplification using the polymerase chain reaction. HPV DNA sequences were found in 35 of 50 (70%) carcinomas of the anogenital region, including four of four (100%) anal, six of eight (75%) vulvar, nine of 14 (64%) vaginal, two of five (40%) penile, and 14 of 19 (74%) cervical tumors. Nine of 25 (36%) oropharyngeal squamous carcinomas contained HPV DNA sequences, including four of 10 (40%) laryngeal, three of eight (38%) buccal, and two of seven (29%) glossal tumors. HPV DNA sequences were not found in 13 esophageal carcinomas. Of the 44 cases that contained viral DNA, HPV-16 was detected in 41 cases (93%) and HPV-18 in five cases (11%), while both types were found in two cases (one anal and one vulvar). HPV DNA sequences were found in 43 of 83 (52%) nonverrucous and in one of five (20%) verrucous carcinomas, but this difference was not significant. These findings demonstrate that HPV DNA sequences are more frequently associated with anogenital than oropharyngeal squamous carcinomas and can be readily detected in routinely processed tissues using the polymerase chain reaction.     

Biology of genital tract human papillomaviruses.

A large number of HPV types infect humans. They infect squamous epithelia of the skin and mucous membranes. Infections are widespread in sexually active populations. Some HPV types have oncogenic potential. Infections with HPV-16, HPV-18, and some additional types are risk factors for cervical cancer. The HPV-6 and HPV-11 types are responsible for most of the genital condylomas and nearly all respiratory papillomas. The immunologic responses to HPVs are not well understood.     

Inguinal hernia repair with the mesh plug method is safe after radical retropubic prostatectomy

Purpose

We evaluated the safety and efficiency of using the mesh plug method (MP) to repair inguinal hernias in patients with a history of radical retropubic prostatectomy (RRP). We also investigated how RRP influences the development of inguinal hernias and impacts their repair.

Methods

Among 488 adult male patients who underwent inguinal hernia repair during a recent 5-year period, 37 had a history of RRP. We compared the characteristics and surgical outcomes of the patients who had undergone RRP (post-RRP group) with those who had not (non-RRP group).

Results

All post-RRP hernias were treated by MP. The 37 post-RRP patients had a collective 41 hernias, 40 of which were of the indirect type. The side affected by the hernia did not differ significantly between the groups. We compared the short-term surgical outcomes of the indirect post-RRP hernias vs. the indirect non-RPP hernias without recurrence and incarceration. The operation times, postoperative hospital stay, and mobility rates did not differ significantly between the two groups. The blood loss was almost equal in both groups.

Conclusion

Inguinal hernia repair after RRP may be difficult because of inflammatory changes in the preperitoneal cavity, but the surgical outcomes of MP were equivalent in patients with or without a history of RPP in this study. MP is a safe and effective method for post-RPP hernia repair.     

Feasibility of skin deepithelialization using the contact neodymium-yttrium-aluminum-garnet laser.

In a manner similar to laserbrasion, the carbon dioxide (CO2) laser has a proven role for expediting skin deepithelialization, which is an essential component of many reconstructive procedures. However, the contact Neodymium-Yttrium-Aluminum-Garnet (Nd:YAG) laser has many additional attributes such as tactile feedback and less plume that theoretically offer an advantage over the CO2 laser for this adjunctive maneuver. In rat experimental models and clinical applications, removal of the epidermis necessary for skin deepithelialization may indeed be achieved using a rounded probe for vaporization with the contact Nd:YAG laser. Unfortunately, the length of time necessary for skin deepithelialization with the Nd:YAG laser exceeded even conventional methods, such that this role with the present technology, although possible, is inefficient and impractical.     

Superpulsed CO2 laser treatment of basal cell carcinoma with intraoperatory histopathologic and cytologic examination.

BACKGROUND: CO2 laser is currently one of the most versatile and useful laser devices in dermatologic practice in the fields of both cosmetology and oncology. The CO2 laser in a superpulsed mode enables the operator to effect precise and adequate vaporization of the affected area, with the possibility to appreciate visually the depth achieved, and, when necessary, to perform histologic and cytologic examination of the surrounding skin. OBJECTIVE: To show superpulsed CO2 laser treatment of basal cell carcinoma. METHODS: One hundred forty patients presenting single, multiple, superficial, or nodular basal cell carcinoma (BCC) have been treated with the superpulsed CO2 laser. Before the laser treatment the lesion was subjected to cytologic examination by scraping; this examination was then repeated when the papillary dermis was clinically detectable, and again when the operator considered the BCC completely vaporized. In selected subjects, histopathologic examination was done three times (biopsies were obtained at the same time as the samples for the cytologic examination). RESULTS: Recovery time was fast, with good healing outcomes. After 3 years follow-up no recurrences were seen. The cytologic and histopathologic examinations showed BCC in the specimens obtained prior to and during laser therapy, but not in those obtained after laser therapy. CONCLUSION: This technique causes minimal thermal cellular damage and no severe morphologic cellular alterations. Thus it permits an intraoperatory cytologic and histopathologic examination. Finally, this technique enables the operator to recognize the different skin levels removed by vaporization and to stop the vaporization as soon as unaffected dermis has been reached, as shown by intraoperatory cytologic and histopathologic examination.     

Correlation between HPV sperm infection and male infertility

Human papillomavirus (HPV) is one of the most common sexually transmitted diseases which comprises a group of small DNA viruses that infect both cutaneous and mucous squamous epithelia. Liquid bead microarray technology (LBMA) were used to evaluate 24 HPV genotypes in confirmed fertile and infertile males of North China so that the effects of HPV infection on semen parameters and relationship with male infertility could be discussed. A total of 1138 subjects were recruited in this study; 142 were HPV-positive (12.48%). Among 523 confirmed fertile males, only 35 were HPV-positive (6.70%), and two of them had multiple infections. Among 615 infertile males, 107 were HPV-positive (17.4%), and 29 of them had multiple infections. Infertile males had a relatively high HPV infection rate compared with confirmed fertile males. Sperm progressive motility (PR) and the normal morphology rate were significantly decreased in HPV-positive subjects. HPV-45, HPV-52, HPV-18, HPV-59 and HPV-16 infections were more frequently in infertile males. Hence, HPV infection is closely related to male infertility which will decrease sperm PR and morphology. HPV-45, HPV-52, HPV-18, HPV-59 and HPV-16 infection seems to be major risk factors.     

Human papilloma virus in melanoma biopsy specimens and its relation to melanoma progression

OBJECTIVES: To evaluate melanoma biopsy specimens for human papilloma virus (HPV) and determine the relation between the presence of HPV, in vitro growth, and clinical progression of melanoma in the patients from whom the biopsy specimens were derived. SUMMARY BACKGROUND DATA: Ultraviolet radiation from sun exposure appears to be the primary causal agent in the development of cutaneous melanoma. However, other agents, including HPV, as observed in different epithelial carcinomas, may also play a role in melanoma development and progression. METHODS: Twelve melanoma biopsy specimens obtained from 12 patients with AJCC stage III and IV melanoma were stained with antibodies against gp-100 (HMB-45) and S-100 protein to confirm melanoma diagnosis and with a polyclonal HPV antibody. After mechanical dissociation, the melanoma specimen cells' ability to grow in vitro was assessed. Patients were evaluated for melanoma progression with physical examination, complete blood count, and liver function tests every 3 months and a chest radiograph every 6 months. RESULTS: All biopsy specimens were positive for S-100, and nine (75%) were positive for gp-100. Seven of 12 (58%) were positive for HPV by immunohistochemistry. In vitro, none of the HPV-negative tumor cells grew from the tumor biopsies, whereas five of seven (71%) of the HPV-positive melanoma tumor cells grew very well. All patients with HPV-positive tumor cells had recurrences and died of melanoma progression, whereas four of five (80%) patients with HPV-negative tumor cells remained alive and without melanoma recurrence. CONCLUSIONS: The presence of HPV was found in 58% of the biopsy specimens obtained from patients with stage III and IV melanoma and correlated with rapid melanoma progression. HPV may serve as a cofactor in the development of melanoma and may modulate a more aggressive phenotype in HPV-containing melanoma cells.     

Prevalence of human papillomavirus type 16 DNA in squamous cell carcinoma of the palatine tonsil, and not the oral cavity, in young patients: a distinct clinicopathologic and molecular disease entity

Squamous cell carcinoma of the head and neck commonly affects patients in their sixth decade and older, particularly those with a prolonged history of alcohol and tobacco abuse. Less frequently, carcinomas occur in young individuals even in the absence of known risk factors. The purpose of this study is to investigate a possible relationship between these tumors and human papilloma virus (HPV). Thirty-three cases of squamous cell carcinoma of the head and neck in young patients under the age of 40 years were studied: 15 oral, 11 tonsillar, and 7 laryngeal. HPV DNA was detected by polymerase chain reaction in 10 tonsillar and 2 laryngeal carcinomas and in none of the oral tumors. Of the 12 HPV-positive tumors, 11 were HPV16 and 1 was HPV31. HPV-positive tumors had a distinct nonkeratinizing basal cell morphology, they stained diffusely and strongly with p16 antibodies, had higher Ki-67 and lower p53 staining scores as compared with the conventional keratinizing HPV negative carcinomas. It is concluded that in young patients high-risk HPV, particularly HPV16, is strongly associated with tonsillar squamous cell carcinoma and some cases of laryngeal, but not oral, tumors. The HPV-positive carcinomas have a distinct histopathologic and immunophenotypic features.     

Anesthetic management for laser excision of recurrent respiratory papillomatosis in a third trimester parturient

Recurrent respiratory papillomatosis (RRP) is characterized by the development of laryngeal papillomas, which can produce partial to complete upper airway obstruction. Patients with RRP often require intermittent surgical excision to treat symptoms such as hoarseness and stridor, and to control progression of the lesions. The anesthetic management of such patients is challenging, and it requires carefully coordinated care between an anesthesiologist and otolaryngologist.

We present 2 cases of general anesthesia administration during surgical excision of laryngeal papillomas, both occurring during the third trimester of separate pregnancies in the same parturient. The complexity of management was amplified in these cases because of the physiological and anatomical changes associated with pregnancy, along with the need to monitor fetal well-being. Possible complications included complete airway obstruction, pulmonary aspiration of gastric contents, hypoxemia, fetal distress, and preterm labor. Because pregnancy may lead to activation of human papillomavirus, the causative organism of RRP, management guidelines are provided for anesthesiologists who may care for patients with RRP during pregnancy.