Case Discussion

This patient has a long history of recurrent respiratory papillomatosis (RRP), starting at age 7. She presented for this imaging study after experiencing shortness of breath, dysphonia, dysphagia, increased vocal effort and voice changes, which are commonly associated symptoms of respiratory papillomatosis. Imaging demonstrates multiple papillomatous nodules throughout the upper airway, as well as a new cavitary lung lesion, which can be an associated feature.  

Patient diagnosis is consistently confirmed by pathology of lesional biopsies demonstrating squamous papilloma with HPV cytopathic effect and low-grade dysplasia, and on staining is noted to have patchy p16 positivity and slightly elevated Ki-67 index. Due to juvenile onset, the patient had yet to receive HPV vaccination, but other risk factors related to vertical transmission were not available in the chart.

This patient underwent more than 100 excision procedures previously using carbon dioxide laser, potassium titanyl phosphate (KTP) laser, and microdebridement. For the last few years, adjunctive treatment with local injection of bevacizumab seemed to decrease the frequency of procedures from once every few weeks to 2 to 3 times per year. As symptoms continued to progress, the patient recently opted to undergo systemic treatment with a series of bevacizumab infusions. This imaging was obtained as a baseline before beginning infusions.

With regular treatment, as with this patient, RRP can be manageable. In severe cases and untreated patients, airway obstruction can occur and may require undergoing a tracheotomy. Patients like this one who had juvenile-onset RRP have a <1% chance of malignant transformation, but regular cytopathology is recommended.

Case co-authors:

• Dr. Lara Aboud Syriani, Temple University Hospital, USA

• Dr. Bhishak Kamat, Temple University Hospital, USA