Key Points:
  1. The onset age of RRP showed a bimodal distribution (2-6 and 26-30 years old).
  2. Men are more likely to develop AO-RRP.
  3. JO-RRP patients had higher Derkay score, higher surgical frequency and shorter surgical interval. AO-RRP showed a higher proportion of dysplasia (72.4%) and the risk of cancer (2.8%).
  4. The surgical intervals lengthened with age and shortened with higher Derkay scores.
  5. Microdebrider is most commonly used, and CO2 laser surgery has the longest surgical interval for JO-RRP patients.
Introduction
Recurrent respiratory papillomatosis (RRP) is a benign tumor that occurs in the respiratory tract[1] .At present, patients are usually divided into juvenile-onset recurrent respiratory papillomatosis (JO-RRP) and adult-onset recurrent respiratory papillomatosis (AO-RRP) according to whether they are over 18 years old, and RRP has a higher incidence in children and men [2-4]. However, a third peak of incidence around 64 years was discovered by cross-sectional study[5]. In general, JO-RRP grows rapidly, and the lesions are often multifocal, and they are prone to recurrence after surgery[6]. Patients with AO-RRP are mostly localized, relatively slow-growing, and according to the available evidence, about 1-7% of cases will develop into squamous cell carcinoma[7-10]. Pulmonary involvement occurs in approximately 3.3% of patients with juvenile laryngeal papilloma, and papilloma formation in the lungs and airways can lead to fatal obstructive pneumonia. In 16% of patients with lung involvement, it may progress to pulmonary malignancy[11].
Previous research found that endotracheal intubation aggravated distal spread, and the longer the tube carrying time, the longer the disease time, affecting the remission rate and mortality of patients[12, 13]. A study in Argentina of 82 patients with RRP under 16 years of age comparing the characteristics of RRP patients with or without extralaryngeal spread found that age younger than 5 years or history of tracheostomy at the time of diagnosis of RRP were factors associated with extralaryngeal spread, and the occurrence of extralaryngeal spread was also associated with HPV subtype 11 infection[14].
RRP is still mainly based on surgical treatment, the most commonly used is microdebrider [15], CO2 laser[16] or 532nm Potassium-Titanyl-Phosphate laser (KTP laser) [17-24]. However, surgery does not seem to completely prevent the recurrence of the disease, and the efficacy of a variety of existing adjuvant treatments is not clear, and some patients often require repeated surgery. The correlation between age of onset, lesion size, surgical mode and interval between operations has not been fully studied. In the current studies, the lack of uniform evaluation criteria for the description of lesion size hinders the systematic analysis of various studies.
Materials and methods
All subjects in this study were from cases diagnosed with RRP and underwent surgery in our hospital between January 2016 and December 2021, and eligible case demographic information, treatment-related information and postoperative follow-up data were collected. We have followed STROBE Statement (strobe-statement.org) as the reporting guideline.
The inclusion and exclusion criteria are as follows: Part I inclusion criteria: (1) cases with a preliminary preoperative diagnosis of ”laryngeal mass” or ”RRP” or ”benign laryngeal tumor”; (2) Have a complete laryngoscopy report within one month before surgery, or check the extent of lesions during surgery and have detailed records; (3) the patient consents to surgical treatment; (4) Postoperative specimens were sent for examination, and pathology report RRP. Exclusion criteria: (1) postoperative loss to follow-up; (2) Those who have not operated again after surgery and cannot calculate the interval between operations; (3) History of surgery or radiotherapy for other pharyngeal and laryngeal diseases during the course of RRP.
Part II Based on the first part of the study, obtain information about each operation of JO-RRP patients, and treat each operation as a surgical case, and screen eligible surgical cases among the study subjects included in the first part according to the following criteria as the study subjects of the second part. Inclusion criteria: Only a single surgical modality, such as a microdebrider or CO2 laser or KTP laser, was used intraoperatively. Exclusion criteria: (1) Use in combination with adjuvant therapy; (2) Postoperative pathology suggests malignant RRP transformation; (3) Previous history of tracheostomy surgery; (4) Papilloma lung involvement. The study was approved by the Ethics Committee of our institution.
Collect medical records of all included cases and record the following information: demographic information, including sex, age at first diagnosis (age at first diagnosis), age at onset (age at each onset); Clinical manifestations of the first episode: dysphonia, dyspnea, laryngeal obstruction division, dysphagia, Derkay score[25] calculated according to the site and size of the first lesion; Information related to surgical treatment: including operation time, operation method, operation interval (days), postoperative pathology report.
In the second part, the patients are treated with surgery, which is performed by senior doctors in the Department of Nose and Throat of our hospital. According to the surgical method, the surgical cases included in the study were divided into three groups, namely microdebrider group, CO2 laser group and KTP laser group. Since in the second part, each patient undergoes at least two surgeries, and each procedure may be different, each patient who undergoes surgery will be treated as one surgical case, that is, each surgery will be analyzed as a study subject. The demographic information, surgical records and postoperative follow-up information of patients in the three treatment groups were collected, and the operation interval (days) of the three treatment groups was counted.
Statistics are performed using IBM SPSS Statistics26. Continuous normal data are described by means ± standard deviation, and the difference is tested by independent sample T. Categorical data are represented using n(%), and differences between groups are represented using chi-square tests or Fisher analysis. The chi-square goodness-of-fit test was used to compare the proportion of dichotomous variables such as sex proportion and whether dysplasia was present. The correlation between two continuous variables was analyzed using linear correlation (the closer the absolute value of r to 1, the stronger the correlation, <0.3 very weak correlation, 0.3-0.5 weak correlation, 0.5-0.7 medium correlation, >0.7 strong correlation).Graph visualization in GraphPadPrism.P<0.05 is statistically significant.