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Leclerc E, Jacomet C, Siproudhis L, Abramowitz L, Pereira B, Buisson A. Impact of screening programme to prevent anal cancer in high-risk patients with HIV. HIV Med 2024; 25:454-461. [PMID: 38031816 DOI: 10.1111/hiv.13594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 11/18/2023] [Indexed: 12/01/2023]
Abstract
INTRODUCTION We assessed the impact of a nationwide screening programme to reduce the risk of anal cancer in a large cohort of high-risk patients with HIV. METHODS From a large database from one referral centre, all high-risk patients with HIV (men who have sex with men, history of anal or genital warts, or previous cervix human papillomavirus-related lesions) who were eligible to enter the French anal cancer screening programme (2011-2020) were retrospectively included. Adherence to the screening programme was defined as no interval >18 months between two visits. Standardized management included perianal visualization and standard anoscopy with biopsies of macroscopic abnormalities. RESULTS Overall, 700 patients with HIV were included (median follow-up 8.4 years [interquartile range 4.3-9.2] and 1491.6 patient-years), and 336 had one or more proctology visit. A total of 13 patients were diagnosed with anal squamous cell carcinomas. The risk of anal cancer was higher with anal intra-epithelial neoplasia grade 3 (AIN3; hazard ratio [HR] 44.5 [95% confidence interval {CI} 11.2-176.6], p < 0.001), AIN2 (HR 11.9 [95% CI 2.1-66.9], p = 0.005), or high-grade dysplasia (HR 23.4 [95% CI 7.9-69.1], p < 0.001) than with low-grade dysplasia or no lesion. Among the patients who were strictly adherent to the screening programme (4.6% [32/700]), we did not report any AIN or anal cancer, but we also did not observe any significant reduction in the risk of anal cancer (p = 0.51), AIN3 (p = 0.28), high-grade dysplasia (p = 0.19), or any AIN lesions (p = 0.10) compared with non-adherent patients. In contrast, screened patients were more likely to be diagnosed with anal warts (HR 3.71 [95% CI 2.14-6.42], p < 0.001). CONCLUSION Macroscopic high-grade dysplasia lesions are associated with a higher risk of developing anal cancer. Despite finding no cases of cancer during the screening programme, we also did not demonstrate a clear benefit from our screening programme for the prevention of anal cancer in high-risk patients with HIV.
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Affiliation(s)
- Eloïse Leclerc
- Université Clermont Auvergne, Inserm, 3iHP, CHU Clermont-Ferrand, Service d'Hépato-Gastroentérologie, Clermont-Ferrand, France
| | - Christine Jacomet
- Université Clermont Auvergne, CHU Clermont-Ferrand, Service de Maladies infectieuses et tropicales, Clermont-Ferrand, France
| | - Laurent Siproudhis
- CHU Rennes, Univ Rennes, INSERM, CIC1414, Institut NUMECAN (Nutrition Metabolisms and Cancer), Rennes, France
| | | | - Bruno Pereira
- Université Clermont Auvergne, CHU Clermont-Ferrand, DRCI, Unité de Biostatistiques, Clermont-Ferrand, France
| | - Anthony Buisson
- Université Clermont Auvergne, Inserm, 3iHP, CHU Clermont-Ferrand, Service d'Hépato-Gastroentérologie, Clermont-Ferrand, France
- Université Clermont Auvergne, Inserm U1071, M2iSH, USC-INRA 2018, Clermont-Ferrand, France
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Loughrey MB, Shepherd NA. Anal and Perianal Preneoplastic Lesions. Gastroenterol Clin North Am 2024; 53:201-220. [PMID: 38280748 DOI: 10.1016/j.gtc.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Anal cancer, mainly squamous cell carcinoma, is rare but increasing in prevalence, as is its precursor lesion, anal squamous dysplasia. They are both strongly associated with human papillomavirus infection. The 2-tiered Lower Anogenital Squamous Terminology classification, low-grade SIL and high-grade SIL, is preferred to the 3-tiered anal intraepithelial neoplasia classification because of better interobserver agreement and clearer management implications. Immunohistochemistry with p16 is helpful to corroborate the diagnosis of squamous dysplasia. Similarly, immunohistochemistry is helpful to differentiate primary Paget disease from secondary Paget disease, which is usually due to anal squamous mucosal/epidermal involvement by primary rectal adenocarcinoma.
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Affiliation(s)
- Maurice B Loughrey
- Department of Cellular Pathology, Royal Victoria Hospital, Grosvenor Road, Belfast, Northern Ireland BT12 6BA, United Kingdom.
| | - Neil A Shepherd
- Gloucestershire Cellular Pathology Laboratory, Cheltenham General Hospital, Sandford Road, Cheltenham GL53 7AN, United Kingdom
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Yadav R, El Kossi M, Belal D, Sharma A, Halawa A. Post-transplant malignancy: Focusing on virus-associated etiologies, pathogenesis, evidence-based management algorithms, present status of adoptive immunotherapy and future directions. World J Meta-Anal 2023; 11:317-339. [DOI: 10.13105/wjma.v11.i7.317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/23/2023] [Accepted: 10/08/2023] [Indexed: 12/14/2023] Open
Abstract
Modern immunosuppression has led to a decrease in rejection rates and improved survival rates after solid organ transplantation. Increasing the potency of immunosuppression promotes post-transplant viral infections and associated cancers by impairing immune response against viruses and cancer immunoediting. This review reflects the magnitude, etiology and immunological characteristics of various virus-related post-transplant malignancies, emphasizing the need for future research. A multidisciplinary and strategic approach may serve best but overall literature evidence targeting it is sparse. However, the authors attempted to provide a more detailed update of the literature consensus for the prevention, diagnosis, management and surveillance of post-transplant viral infections and associated malignancies, with a focus on the current role of adoptive immunotherapy and the way forward. In order to achieve long-term patient and graft survival as well as superior post-transplant outcomes, collaborative research on holistic care of organ recipients is imperative.
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Affiliation(s)
- Rahul Yadav
- Department of Urology, Kidney Transplant and Robotic Uro-oncology, Tender Palm Super Speciality Hospital, Lucknow 226010, Uttar Pradesh, India
- Department of Urology and Kidney Transplant, Charak Hospital and Research Centre, Lucknow 226003, Uttar Pradesh, India
| | - Mohsen El Kossi
- Department of Nephrology, Doncaster Royal Infirmary, Doncaster DN2 5LT, United Kingdom
| | - Dawlat Belal
- Department of Nephrology and Medicine, Kasr El-Ainy School of Medicine, Cairo University, Cairo 11562, Egypt
| | - Ajay Sharma
- Department of Transplant Surgery, Royal Liverpool University Hospitals, Liverpool L7 8XP, United Kingdom
| | - Ahmed Halawa
- Department of Transplantation, Sheffield Teaching Hospitals, Sheffield S57AU, United Kingdom
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Squeo GC, Geba MC, Kane WJ, Thomas TA, Newberry Y, Wang XQ, Hedrick TL, Friel CM, Hoang SC. Impact of a High-Resolution Anoscopy Clinic on Management of Anal Dysplasia in Women Living With HIV. Am Surg 2023; 89:4689-4695. [PMID: 36154713 PMCID: PMC10036262 DOI: 10.1177/00031348221129508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The rate of anal squamous cell cancer (aSCC) is increasing among women living with HIV. Treatment of precursor high grade squamous intraepithelial lesions (HSIL) may reduce the risk of progression to aSCC. The objective of this study was to examine effects of a dedicated high-resolution anoscopy (HRA) clinic on management of HSIL in women with HIV. METHODS Women living with HIV who underwent anal dysplasia screening at a single institution between 2006 and 2020 were reviewed. Those who underwent screening before (Group A) and after (Group B) the implementation of an HRA program in 2017 were compared. The primary outcome of interest was the successful detection and treatment of HSIL. RESULTS A total of 201 women living with HIV underwent anal dysplasia screening between 2006 and 2020. Seventy-seven patients were found to have abnormal anal cytology requiring further treatment: 43 (55.8%) in Group A and 34 (44.2%) patients in Group B. Of the patients with abnormal anal cytology, 76.7% of patients in Group A received further biopsy and treatment, whereas 79.4% of Group B patients underwent subsequent biopsy and treatment. In propensity score weighting logistic regression analysis, the Group B was 4.6 times as likely to diagnosis HSIL on biopsy compared to Group A (OR = 4.60, 95% CI: 1.15 to 18.38, P = .03). CONCLUSIONS Anal dysplasia is common among women living with HIV. The establishment of a HRA program was associated with increased identification and treatment of HSIL among women living with HIV, which may prevent the progression to aSCC.
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Affiliation(s)
- Gabriella C. Squeo
- University of Virginia Health System, Department of Surgery, Division of Colon and Rectal Surgery, Charlottesville, VA, USA
| | - Maria C. Geba
- University of Virginia Heath System, Department of Medicine, Division of Infectious Diseases and International Health, Charlottesville, VA, USA
| | - William J. Kane
- University of Virginia Health System, Department of Surgery, Division of Colon and Rectal Surgery, Charlottesville, VA, USA
| | - Tania A. Thomas
- University of Virginia Heath System, Department of Medicine, Division of Infectious Diseases and International Health, Charlottesville, VA, USA
| | - Yvonne Newberry
- University of Virginia Health System, Department of Obstetrics and Gynecology, Charlottesville, VA, USA
| | - Xin-Qun Wang
- University of Virginia Health System, Department of Public Health Sciences, Division of Biostatistics, Charlottesville, VA, USA
| | - Traci L. Hedrick
- University of Virginia Health System, Department of Surgery, Division of Colon and Rectal Surgery, Charlottesville, VA, USA
| | - Charles M. Friel
- University of Virginia Health System, Department of Surgery, Division of Colon and Rectal Surgery, Charlottesville, VA, USA
| | - Sook C. Hoang
- University of Virginia Health System, Department of Surgery, Division of Colon and Rectal Surgery, Charlottesville, VA, USA
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Goldstone SE, Terlizzi JP, Levine RA, Moshier E, Pereira Vera B. A Prospective, Dual-Center Trial of Circumferential Radiofrequency Ablation of Anal High-Grade Squamous Intraepithelial Lesions Demonstrate Improved Long-term Efficacy Over Historical Controls of Targeted Ablation. Dis Colon Rectum 2023; 66:764-773. [PMID: 35522783 DOI: 10.1097/dcr.0000000000002365] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Targeted ablation of anal canal high-grade dysplasia results in high recurrence over time. Circumferential radiofrequency ablation might decrease recurrence. OBJECTIVE This study aimed to determine the safety and efficacy of circumferential radiofrequency ablation for anal high-grade dysplasia. DESIGN This was a dual-center, prospective trial of circumferential radiofrequency ablation with a 1-year follow-up with longer follow-up data abstracted from medical records of study patients returning after trial for surveillance. Ten participants from the identically conducted pilot circumferential radiofrequency ablation trial were included to improve sample size for longer-term analysis. SETTINGS This study included 3 surgeons at 2 sites. PATIENTS The study included 51 patients undergoing circumferential radiofrequency ablation for anal canal high-grade dysplasia. INTERVENTION Circumferential radiofrequency ablation of anal canal high-grade dysplasia and targeted radiofrequency ablation of recurrence. MAIN OUTCOME MEASURES The primary outcome measures were circumferential radiofrequency ablation efficacy and associated morbidity. RESULTS Fifty-one participants underwent circumferential radiofrequency ablation but 48 participants returned for 1 or more postprocedure high-resolution anoscopy and were evaluable. The mean age of participants was 43 years, most were male (94%), 33% were living with HIV, and 58% had 3 or more high-grade dysplasias treated. Sixty percent had no recurrence, whereas 19% had 1 recurrence, 15% had 2 recurrences, and 6% had 3 recurrences. Most recurrences (66%) developed within the first 6 months. Kaplan-Meier probability of recurrence combining both series was 19% at 3 months, 30% at 6 months, and approximately 40% after 6 months out to 30 months. Most common morbidities were pain (85.4%) lasting for a median of 21 (range, 4-91) days and bleeding (91%) lasting for a median of 21 (range, 5-87) days. Of those with pain and bleeding, 65% and 85%, respectively, described it as mild. No patients developed fistulas, stricture, or incontinence. No serious adverse events related to circumferential radiofrequency ablation occurred. Having a previous recurrence was the only significant predictor of a subsequent recurrence (HR, 28.53) for recurrence at 9 months or before. LIMITATIONS Enrollment ended prematurely, 10 participants from the pilot study were combined to increase the sample size, and longer-term follow-up was collected retrospectively were the limitations of this study. CONCLUSIONS Circumferential radiofrequency ablation has improved efficacy over targeted ablation but with increased pain and bleeding. See Video Abstract at http://links.lww.com/DCR/B973 . ESTUDIO PROSPECTIVO BICNTRICO SOBRE LA ABLACIN POR RADIOFRECUENCIA CIRCUNFERENCIAL DE LESIONES ANALES INTRAEPITELIALES ESCAMOSAS DE ALTO GRADO DEMOSTRANDO MAYOR EFICACIA A LARGO PLAZO CON RELACIN A CONTROLES HISTRICOS DE ABLACIN DIRIGIDA ANTECEDENTES:La ablación dirigida de la displasia de alto grado en el canal anal proporciona como resultados una alta recidiva a largo plazo. La ablación por radiofrecuencia circunferencial podría disminuir la reincidencia.OBJETIVO:Determinar la seguridad y eficacia de la ablación por radiofrecuencia circunferencial para la displasia anal de alto grado.DISEÑO:Estudio prospectivo bicéntrico de ablación por radiofrecuencia circunferencial con un seguimiento de 1 año, en base al monitoreo prolongado de datos, obtenidos de los registros medicos, de todos los pacientes incluidos en el estudio y que fueron controlados clinicamente. Diez participantes del estudio piloto de ablación por radiofrecuencia circunferencial realizada de manera idéntica, se combinaron para mejorar el análisis del tamaño de la muestra a largo plazo.PACIENTES:Se incluyeron 51 pacientes sometidos a la ablación por radiofrecuencia circunferencial de una lesion displásica de alto grado en el canal anal.AJUSTES:Tres cirujanos en 2 centros.INTERVENCIÓN:Ablación por radiofrecuencia circunferencial de la displasia de alto grado en el canal anal y ablación por radiofrecuencia dirigida de la recidiva.PRINCIPALES MEDIDAS DE RESULTADOS:Las medidas primarias fueron la eficacia de la ablación por radiofrecuencia circunferencial y la morbilidad asociada.RESULTADOS:Cincuenta y un participantes se sometieron a la ablación por radiofrecuencia circunferencial, de los cuales, 48 regresaron para ser evaluados con ≥1 anuscopias de alta resolución, después del procedimiento. La edad media de los participantes fue de 43 años, en su mayoría hombres (94%), el 33% eran portadores de VIH y el 58% tenía ≥3 lesiones displásicas de alto grado tratadas. El sesenta por ciento no tuvo recidiva, mientras que el 19%, 15% y 6% tuvieron 1, 2 o 3 recidivas. La mayoría de las recaídas (66%) se desarrollaron dentro de los primeros 6 meses. La probabilidad de recurrencia de Kaplan-Meier combinando ambas series fue del 19 % a los 3 meses, del 30 % a los 6 meses y aproximadamente del 40 % entre los 6 y 30 meses. Los indicadores de morbilidad más frecuentes fueron, el dolor (85,4%) con una mediana de duración de 21 días (rango, 4-91) y sangrado (91%) con una mediana de duración de 21días (rango, 5-87). Aquellos pacientes con dolor (65%) y sangrado (85%) respectivamente, los describieron como leves. Ningún paciente desarrolló fístula, estenosis o incontinencia. No se produjeron eventos adversos graves relacionados con la ablación por radiofrecuencia circunferencial. Tener una recurrencia previa fue el único factor predictivo importante de una recidiva ulterior (RH 28,53) en casos de recaída a los 9 meses o antes.LIMITACIONES:Como el registro finalizó prematuramente, se agregaron 10 participantes del estudio piloto para aumentar el tamaño de la muestra. El seguimiento a largo plazo fué recopilado retrospectivamente.CONCLUSIONES:La ablación por radiofrecuencia circunferencial ha mejorado la eficacia sobre la ablación dirigida pero con dolor y sangrado mas importantes. Consulte Video Resumen en http://links.lww.com/DCR/B973 . ( Traducción-Dr. Xavier Delgadillo ).
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Affiliation(s)
- Stephen E Goldstone
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joseph P Terlizzi
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rebecca A Levine
- Department of Surgery, Montefiore Medical Center, The Bronx, New York
| | - Erin Moshier
- Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Barbara Pereira Vera
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
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Anal Cancer in High-Risk Women: The Lost Tribe. Cancers (Basel) 2022; 15:cancers15010060. [PMID: 36612055 PMCID: PMC9817901 DOI: 10.3390/cancers15010060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
In developed countries the incidence of anal squamous cell carcinoma (SCC) has been rising; especially in women over the age of 60 years who present with more advanced disease stage than men. Historically, anal SCC screening has focused on people living with Human Immunodeficiency Virus (HIV) (PLWH) who are considered to be at the highest risk of anal SCC, and its precancerous lesion, anal squamous intraepithelial lesion (SIL). Despite this, women with vulval high-grade squamous epithelial lesions (HSIL) and SCCs have been shown to be as affected by anal HSIL and SCC as some PLWH. Nevertheless, there are no guidelines for the management of anal HSIL in this patient group. The ANCHOR trial demonstrated that treating anal HSIL significantly reduces the risk of anal SCC in PLWH, there is therefore an unmet requirement to clarify whether the screening and treatment of HSIL in women with a prior genital HSIL is also beneficial. This review presents the current evidence supporting the screening, treatment, and surveillance of anal HSIL in high-risk women with a previous history of genital HSIL and/or SCC.
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Faber MT, Frederiksen K, Palefsky JM, Kjaer SK. A nationwide longitudinal study on risk factors for progression of anal intraepithelial neoplasia grade 3 to anal cancer. Int J Cancer 2022; 151:1240-1247. [PMID: 35657350 PMCID: PMC9545245 DOI: 10.1002/ijc.34143] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 11/13/2022]
Abstract
Little is known about risk factors for progression of high‐grade anal intraepithelial neoplasia (AIN) to anal squamous cell carcinoma (ASCC). In this large, population‐based study, we assess the role of factors related to immune status for the risk of ASCC among individuals from the general population with a diagnosis of AIN3. Individuals diagnosed with AIN3 during 1985‐2016 were identified in the Danish Pathology Registry and followed for subsequent development of ASCC. The study population was linked to the National Patient Registry, the Danish Prescription Registry and the Danish HIV Cohort Study for information on autoimmune disease, genital warts and HIV status. To study the progression rate, Cox regression models with hazard ratios (HR) and 95% confidence intervals (CI) were applied with time since AIN3 as the underlying time scale and with adjustment for age at AIN3 diagnosis, year of AIN3 diagnosis and sex. The study population comprised 1222 individuals with AIN3 contributing 12 824 person‐years of follow‐up. Ninety‐seven individuals (7.9%) developed ASCC. Individuals registered with an autoimmune disease or genital warts before and/or after the AIN3 diagnosis had an increased rate of progression to ASCC compared to individuals without these conditions. People living with HIV had a higher progression rate than HIV‐negative individuals (HR = 4.25; 95% CI: 1.87‐9.65) with the highest progression rate among those with CD4 count ≤200 cells/μL. These associations may be caused by an interplay between HPV infection and immunosuppression.
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Affiliation(s)
- Mette T Faber
- Danish Cancer Society Research Center, Virus, Lifestyle and Genes, Strandboulevarden 49, DK-2100, Copenhagen, Denmark
| | - Kirsten Frederiksen
- Danish Cancer Society Research Center, Statistics and Data Analysis, Strandboulevarden 49, DK-2100, Copenhagen, Denmark
| | - Joel M Palefsky
- Department of Medicine, University of California, 513 Parnassus Ave, San Francisco, CA, USA
| | - Susanne K Kjaer
- Danish Cancer Society Research Center, Virus, Lifestyle and Genes, Strandboulevarden 49, DK-2100, Copenhagen, Denmark.,Department of Gynecology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK2100, Copenhagen, Denmark
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Barroso LF, Stier EA, Hillman R, Palefsky J. Anal Cancer Screening and Prevention: Summary of Evidence Reviewed for the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infection Guidelines. Clin Infect Dis 2022; 74:S179-S192. [PMID: 35416975 DOI: 10.1093/cid/ciac044] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In June 2019 the Centers for Disease Control and Prevention (CDC) convened an advisory group to assist in development of the 2021 CDC sexually transmitted infections (STI) guidelines. The advisory group on anal cancer screening and prevention met to formulate key questions in this field. The group examined published literature and abstracts to assess evidence and give recommendations for development of the CDC guidelines. This article summarizes key questions, evidence, recommendations, and areas for further research for the screening, diagnosis, and prevention of anal cancer.
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Affiliation(s)
- Luis F Barroso
- Internal Medicine/Infectious Diseases, Wake Forest University Health Sciences, Winston-Salem, North CarolinaUSA
| | - Elizabeth A Stier
- Obstetrics and Gynecology, Boston University School of Medicine, Boston Medical Center, Boston, MassachusettsUSA
| | - Richard Hillman
- Dysplasia and Anal Cancer Services, St Vincent's Hospital, Darlinghurst, Sydney, Australia
| | - Joel Palefsky
- Infectious Diseases, University of California, San Francisco, CaliforniaUSA
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Silvera R, Martinson T, Gaisa MM, Liu Y, Deshmukh AA, Sigel K. The other side of screening: predictors of treatment and follow-up for anal precancers in a large health system. AIDS 2021; 35:2157-2162. [PMID: 34014851 PMCID: PMC8808754 DOI: 10.1097/qad.0000000000002948] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anal cancer disproportionately affects people with HIV (PWH). High-grade squamous intraepithelial lesions (HSIL) are cancer precursors and treating them might prevent anal cancer. Data on adherence to HSIL treatment and surveillance is limited but needed to identify deficiencies of screening strategies. METHODS We collected data on high-resolution anoscopy (HRA) attendance and outcomes from 2009 to 2019 in a large urban anal cancer-screening program. Patients with an initial HSIL diagnosis were followed for return for HSIL electrocautery ablation within 6 months of index HSIL diagnosis, and follow-up HRA within 18 months of index HSIL diagnosis. We also evaluated predictors of these outcomes in univariable and multivariable analyses. RESULTS One thousand one hundred and seventy-nine unique patients with an anal HSIL diagnosis were identified and 684 (58%) returned for electrocautery ablation. Of those treated, only 174 (25%) and only 9% of untreated HSIL patients (47 of 495) underwent surveillance HRA within 18 months of index HSIL diagnosis. In multivariable analyses, black patients and PWH regardless of virologic control were less likely to undergo HSIL ablation within 6 months of HSIL diagnosis whereas patients with commercial insurance were more likely to be treated within 6 months of diagnosis. Among treated HSIL patients, PWH with viremia had a lower likelihood of engaging in post-treatment surveillance within 18 months of HSIL diagnosis. DISCUSSION Even in large specialized anal cancer screening programs adherence to HSIL treatment and surveillance is low. Psychosocial and economic determinants of health may impact retention in care. Addressing both personal and structural barriers to patient engagement may improve the effectiveness of anal cancer screening.
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Affiliation(s)
- Richard Silvera
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Tyler Martinson
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael M. Gaisa
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yuxin Liu
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ashish A. Deshmukh
- Department of Management, Policy and Community Health, University of Texas School of Public Health, Houston, TX, USA
| | - Keith Sigel
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, and
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Abstract
Viral venereal diseases remain difficult to treat. Human papilloma virus (HPV) and herpes simplex virus (HSV) are two common viral venereal diseases. HPV infections are characterized by anogenital warts and less commonly by premalignant or malignant lesions. HSV infections classically present as grouped vesicles on an erythematous base with associated burning or pain; however, immunosuppressed patients may have atypical presentations with nodular or ulcerative lesions. This review discusses the epidemiology, diagnosis, and management of anogenital HPV and HSV infections with an emphasis on treatment modalities for the practicing dermatologist. Diagnosis of these diseases typically relies on clinical assessment, although multiple diagnostic techniques can be utilized and are recommended when diagnosis is uncertain or evaluating an individual with increased risk of malignancy. Management of HPV and HSV infections involves appropriate counseling, screening, and multiple treatment techniques. Particularly for HPV infections, a practitioner may need to use a combination of techniques to achieve the desired outcome.
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Vergara-Fernandez O, Solórzano-Vicuña D, Coss-Adame E, Trejo-Avila M. Outcomes of radiofrequency ablation for anal high-grade squamous intraepithelial lesions. Tech Coloproctol 2021; 25:701-707. [PMID: 33590436 DOI: 10.1007/s10151-020-02379-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 11/20/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Radiofrequency ablation (RFA) of high-grade squamous intraepithelial lesions (HSIL) is a promising minimally invasive technique but its oncologic and functional outcomes are not well studied. The primary outcome was the efficacy of RFA, and the secondary outcomes were the functional and anatomical anal changes related to RFA. METHODS This was a retrospective analysis of our prospectively collected database of patients who had RFA for HSIL at our institution, between August 2018 and March 2020. To be eligible for RFA, all patients had impairment of their immune function. Targeted ablation was applied in all cases, with 5 overlapping pulsations at the targeted HSILs (delivering 12 J/cm2 per application) followed by circumferential, 2-pulsation (12 J/cm2) overlapping anal ablation, to cover the entire anal transition zone. Patients were assessed for recurrence or metachronous disease at 3-month intervals by means of high-resolution anoscopy (HRA) and targeted biopsies. Anorectal manometry, endoanal ultrasound, the 36-Item Short Form and Massachusetts General Hospital-Sexual Functioning Questionnaire (MGH-SFQ) were assessed at baseline and 12 months after intervention. RESULTS We included a total of 12 patients with anal HSILs. The mean age was 38.6 (± 7.68) years, and 7 (58.3%) were males. Six were HIV positive, 2 had a primary immunodeficiency disease, and 4 were receiving immunosuppressive therapy. A mean of 2.1 anal HSILs per patient were treated. At 12 months, high-resolution anoscopy showed that 7/12 (58.3%) patients had normal high-resolution anoscopy, 3/12 patients had recurrent HSILs, and 2/12 had a persistent lesion. Those lesions were treated with electrocautery, and reached complete response in the following the 6 months (total of 18 months). In particular, there were no metachronous lesions detected. Patients reported moderate to severe pain during the first 24 h after RFA, but only mild discomfort was present at 30 days. Patients were asymptomatic at their 6- and 12-month visits. RFA was not associated with changes in anorectal manometry or ultrasound examination. The 36-SF survey reported improvement in the general health domain (p = 0.038), while the MGH-SFQ showed improvements in sexual function. CONCLUSIONS In this study, targeted plus circumferential RFA had a 58.3% efficacy rate for the treatment of anal HSIL in immunocompromised patients, achieving 100% eradication after adding electrocautery ablation. No metachronous lesions were detected. Patients presented relatively mild symptoms after the procedure, no changes in anorectal anatomy or function, and some improvements in their sexual function. These results seem promising in light of the high recurrence reported after HSIL treatment. Larger studies are needed to validate our results.
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Affiliation(s)
- O Vergara-Fernandez
- Department of Colon and Rectal Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Tlalpan, 14000, Mexico City, Mexico.
| | - D Solórzano-Vicuña
- Department of Colon and Rectal Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Tlalpan, 14000, Mexico City, Mexico
| | - E Coss-Adame
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - M Trejo-Avila
- Department of Colon and Rectal Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Tlalpan, 14000, Mexico City, Mexico
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Corral J, Parés D, García-Cuyás F, Revollo B, Chamorro A, Lecumberri C, Tarrats A, Castella E, Piñol M, Clotet B, Videla S, Sirera G. Incidence of Recurrent High-Grade Anal Dysplasia in HIV-1-Infected Men and Women Following Infrared Coagulation Ablation: A Retrospective Cohort Study. Pathogens 2021; 10:pathogens10020208. [PMID: 33672969 PMCID: PMC7918241 DOI: 10.3390/pathogens10020208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/10/2021] [Accepted: 02/12/2021] [Indexed: 11/18/2022] Open
Abstract
This single-center, retrospective cohort study sought to estimate the cumulative incidence in HIV-1-infected patients of biopsy-proven high-grade anal intraepithelial neoplasia (HGAIN) recurrence after infrared coagulation (IRC) treatment. The study was based on data from a prospectively compiled database of 665 HIV-1-infected outpatients who attended a hospital Clinical Proctology/HIV Unit between January 2012 and December 2015. Patient records were checked to see which ones had received IRC treatment but later experienced a recurrence of HGAIN. Cytology samples were also checked for the presence of human papilloma virus (HPV). A total of 81 of the 665 patients (12%, 95%CI: 10–15%), of whom 65 were men and 16 women, were diagnosed with HGAIN and again treated with IRC. Of these 81, 20 (25%) experienced recurrent HGAIN, this incidence being true of both men (16/65, 95%CI: 19–57%) and women (4/16, 95%CI: 10–50%). The median time to recurrence was 6 (2–19) months overall, 6 (2–19) months in men, and 4 (2–6) months in women. HPV infection was detected in all patients except two, with HPV-16 being the most common genotype. This rate of incidence of recurrent HGAIN following IRC treatment is consistent with other reports and highlights the importance of continued post-treatment surveillance, particularly in the first year.
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Affiliation(s)
- Javier Corral
- Department of General Surgery, Hospital Germans Trias i Pujol, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain; (D.P.); (F.G.-C.); (M.P.)
- Lluita contra la Sida Foundation, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain; (B.R.); (A.C.); (C.L.); (A.T.); (B.C.); (G.S.)
- School of Medicine, Universitat Autónoma de Barcelona (UAB), Edifici M, Av. de Can Domènech, Bellaterra, 08193 Barcelona, Spain
- Correspondence: (J.C.); (S.V.)
| | - David Parés
- Department of General Surgery, Hospital Germans Trias i Pujol, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain; (D.P.); (F.G.-C.); (M.P.)
- Lluita contra la Sida Foundation, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain; (B.R.); (A.C.); (C.L.); (A.T.); (B.C.); (G.S.)
- School of Medicine, Universitat Autónoma de Barcelona (UAB), Edifici M, Av. de Can Domènech, Bellaterra, 08193 Barcelona, Spain
| | - Francesc García-Cuyás
- Department of General Surgery, Hospital Germans Trias i Pujol, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain; (D.P.); (F.G.-C.); (M.P.)
- Lluita contra la Sida Foundation, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain; (B.R.); (A.C.); (C.L.); (A.T.); (B.C.); (G.S.)
| | - Boris Revollo
- Lluita contra la Sida Foundation, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain; (B.R.); (A.C.); (C.L.); (A.T.); (B.C.); (G.S.)
- HIV Clinical Unit, Department of Medicine, University Hospital Germans Trias i Pujol, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain
| | - Ana Chamorro
- Lluita contra la Sida Foundation, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain; (B.R.); (A.C.); (C.L.); (A.T.); (B.C.); (G.S.)
- HIV Clinical Unit, Department of Medicine, University Hospital Germans Trias i Pujol, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain
| | - Carla Lecumberri
- Lluita contra la Sida Foundation, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain; (B.R.); (A.C.); (C.L.); (A.T.); (B.C.); (G.S.)
- Department of Obstetrics and Gynaecology, Hospital Germans Trias i Pujol, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain
| | - Antoni Tarrats
- Lluita contra la Sida Foundation, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain; (B.R.); (A.C.); (C.L.); (A.T.); (B.C.); (G.S.)
- Department of Obstetrics and Gynaecology, Hospital Germans Trias i Pujol, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain
| | - Eva Castella
- Department of Pathology, Hospital Germans Trias i Pujol, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain;
| | - Marta Piñol
- Department of General Surgery, Hospital Germans Trias i Pujol, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain; (D.P.); (F.G.-C.); (M.P.)
- Lluita contra la Sida Foundation, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain; (B.R.); (A.C.); (C.L.); (A.T.); (B.C.); (G.S.)
| | - Bonaventura Clotet
- Lluita contra la Sida Foundation, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain; (B.R.); (A.C.); (C.L.); (A.T.); (B.C.); (G.S.)
- School of Medicine, Universitat Autónoma de Barcelona (UAB), Edifici M, Av. de Can Domènech, Bellaterra, 08193 Barcelona, Spain
- Retrovirology Laboratory IrsiCaixa Foundation, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain
| | - Sebastià Videla
- Lluita contra la Sida Foundation, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain; (B.R.); (A.C.); (C.L.); (A.T.); (B.C.); (G.S.)
- Department of Clinical Pharmacology, Bellvitge University Hospital/IDIBELL/University of Barcelona, Hospitalet de Llobregat, Gran Via de les Corts Catalanes 199–203, 08907 Barcelona, Spain
- Correspondence: (J.C.); (S.V.)
| | - Guillem Sirera
- Lluita contra la Sida Foundation, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain; (B.R.); (A.C.); (C.L.); (A.T.); (B.C.); (G.S.)
- HIV Clinical Unit, Department of Medicine, University Hospital Germans Trias i Pujol, Carretera de Canyet, s/n, Badalona, 08916 Barcelona, Spain
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Feasibility and safety study of a high resolution wide field-of-view scanning endoscope for circumferential intraluminal intestinal imaging. Sci Rep 2021; 11:3544. [PMID: 33574405 PMCID: PMC7878729 DOI: 10.1038/s41598-021-82962-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 01/21/2021] [Indexed: 12/05/2022] Open
Abstract
Global anal cancer incidence is increasing. High resolution anoscopy (HRA) currently screens for anal cancer, although the definitive test remains unknown. To improve on intraluminal imaging of the anal canal, we conducted a first-in-human study to determine feasibility and safety of a high-resolution, wide field-of-view scanning endoscope. Fourteen patients, under an IRB-approved clinical study, underwent exam under anesthesia, HRA, and imaging with the experimental device. HRA findings were photographed using an in-line camera attached to the colposcope and compared with the scanning endoscope images. Patients were followed up within 2 weeks of the procedure. The imaging device is inserted into the anal canal and the intraluminal surface is digitally photographed in 10 s and uploaded to a computer monitor for review. Ten patients completed imaging with the device. Three patients were not imaged due to severe anal stenosis. One patient was not imaged due to technical device malfunction. The device images were compared to the HRA images. No adverse event attributable to the device was reported. The intraluminal scanning endoscope can be used for circumferential anal canal imaging and is safe for clinical use. Future clinical studies are needed to evaluate the performance of this device.
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15
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Moeckli B, Canner J, Najafian A, Carbunaru S, Cowell N, Atallah C, Paredes E, Chudnovets A, Fang SH. High-resolution anoscopy, is there a benefit in proceeding directly to the operating room? Tech Coloproctol 2021; 25:461-466. [PMID: 33569753 PMCID: PMC8016767 DOI: 10.1007/s10151-021-02416-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 01/22/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND The development of high-resolution anoscopy (HRA) has advanced our ability to detect anal dysplasia. Historically, HRA is performed in a clinical setting and subsequent ablation is performed in the clinical setting or operating room. The aim of this study was to determine the most effective venue for the performance of HRA. METHODS Following institutional review board (IRB) approval, the correlation between anal cytology and HRA performed in the clinic versus in the operating room was evaluated. Data were extracted from our IRB-approved prospective HRA database over the time period of 2013-2017. RESULTS One hundred twenty-eight HRAs were compared (101 in the clinical setting, 27 in the operating room). There was a statistically significant difference in the correlation between anal cytology and HRA pathology for procedures performed in the clinical setting (55% [56/101]) versus those performed in the operating room (82% [22/27]) (p = 0.014). More biopsies were obtained in the operating room than in the clinic setting (3 vs. 1, p < 0.0001). The majority of patients who had HRA in a clinical setting with subsequent HRA in the operating room stated that they preferred to have their HRAs performed in the operating room due to discomfort from the HRA procedure. CONCLUSIONS Detection rates for anal dysplasia on HRA, are significantly higher when performed in the operating room. To prevent discomfort in the clinical setting, patients with high-grade dysplasia on anal pap testing may benefit from proceeding directly to the operating room for concurrent HRA and ablation.
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Affiliation(s)
- B Moeckli
- Department of Surgery, Ravitch Division of Colon and Rectal Surgery, High Resolution Anoscopy Clinic, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21287, USA.,Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - J Canner
- Department of Surgery, Ravitch Division of Colon and Rectal Surgery, High Resolution Anoscopy Clinic, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21287, USA
| | - A Najafian
- Department of Plastic Surgery, Oregon Health Sciences University, Portland, OR, USA
| | - S Carbunaru
- Northwestern University School of Medicine, Chicago, IL, USA
| | - N Cowell
- Department of Surgery, Ravitch Division of Colon and Rectal Surgery, High Resolution Anoscopy Clinic, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21287, USA
| | - C Atallah
- Department of Surgery, Ravitch Division of Colon and Rectal Surgery, High Resolution Anoscopy Clinic, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21287, USA
| | - E Paredes
- Department of Surgery, Ravitch Division of Colon and Rectal Surgery, High Resolution Anoscopy Clinic, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21287, USA
| | - A Chudnovets
- Department of Surgery, Ravitch Division of Colon and Rectal Surgery, High Resolution Anoscopy Clinic, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21287, USA
| | - S H Fang
- Department of Surgery, Ravitch Division of Colon and Rectal Surgery, High Resolution Anoscopy Clinic, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21287, USA.
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Esser S, Sammet S. HIV‐Medizin in der Dermatologie und Venerologie. J Dtsch Dermatol Ges 2021; 19:82-97. [PMID: 33491891 DOI: 10.1111/ddg.14373_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/04/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Stefan Esser
- HPSTD-Ambulanz, Klinik für Dermatologie und Venerologie, Universitätsklinikum Essen
| | - Stefanie Sammet
- HPSTD-Ambulanz, Klinik für Dermatologie und Venerologie, Universitätsklinikum Essen
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17
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Brogden DRL, Walsh U, Pellino G, Kontovounisios C, Tekkis P, Mills SC. Evaluating the efficacy of treatment options for anal intraepithelial neoplasia: a systematic review. Int J Colorectal Dis 2021; 36:213-226. [PMID: 32979069 PMCID: PMC7801290 DOI: 10.1007/s00384-020-03740-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Anal intraepithelial neoplasia (AIN) is the accepted precursor of anal squamous cell carcinoma (ASCC). There has long been a hypothesis that treating AIN may prevent ASCC. Many different treatment modalities have been suggested and studied. We conducted this systematic review to evaluate their efficacy and the evidence as to whether we can prevent ASCC by treating AIN. METHODS MEDLINE and EMBASE were electronically searched using relevant search terms. All studies investigating the use of a single treatment for AIN that reported at least one end outcome such as partial or complete response to treatment, recurrence after treatment and/or ASCC diagnosis after treatment were included. RESULTS Thirty studies were included in the systematic review investigating 10 treatment modalities: 5% imiquimod, 5-fluorouracil, cidofovir, trichloroacetic acid, electrocautery, surgical excision, infrared coagulation, radiofrequency ablation, photodynamic therapy and HPV vaccination. All treatment modalities demonstrated some initial regression of AIN after treatment; however, recurrence rates were high especially in HIV-positive patients. Many of the studies suffered from significant bias which prevented direct comparison. CONCLUSIONS Although the theory persists that by inducing the regression of AIN, we may be able to reduce the risk of ASCC, there was no clinical evidence within the literature advocating that treating AIN does prevent ASCC.
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Affiliation(s)
- Danielle R. L. Brogden
- Chelsea and Westminster Hospitals, NHS Foundation Trust and Imperial College, London, UK
| | - Una Walsh
- Chelsea and Westminster Hospitals, NHS Foundation Trust and Imperial College, London, UK
| | - Gianluca Pellino
- Colorectal Surgery, Vall d’Hebron University Hospital, Barcelona, Spain ,Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania Luigi Vanvitelli, Naples, Italy
| | | | - Paris Tekkis
- Chelsea and Westminster Hospitals, NHS Foundation Trust and Imperial College, London, UK
| | - Sarah C. Mills
- Chelsea and Westminster Hospitals, NHS Foundation Trust and Imperial College, London, UK
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18
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Esser S, Sammet S. HIV medicine for dermatologists and venereologists. J Dtsch Dermatol Ges 2020; 19:82-96. [PMID: 33377314 DOI: 10.1111/ddg.14373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/04/2020] [Indexed: 11/29/2022]
Abstract
Broad administration of combined antiretroviral therapy (ART) has dramatically reduced the morbidity and mortality of the HIV-infection and substantially improved the life expectancy of people living with HIV (PLWH). PLWH, who are effectively treated with an ART, are considered to be unable to transmit HIV. The standard of care is usually an antiretroviral single tablet regimen. Since 2015 the Robert Koch Institute has reported a slight decrease in the rate of recently diagnosed HIV-infections in Germany, but the proportion of late presenters (initial diagnosis in advanced stages of infection) has remained consistently high at around 32 % since 2005. HIV-infections have not been diagnosed in 10,800 PLWH so far. In comparison to the general population PLWH suffer more frequently from skin diseases. Depending on the stage of immunodeficiency, untreated PLWH develop HIV indicator diseases of the skin and the mucocutaneous membranes. Knowledge of these diseases facilitates the selection of individuals who should be offered HIV testing. Early diagnosis of HIV-infections allows early introduction of the ART, prevents the spread of HIV and reduces the mortality rates and treatment costs associated with late diagnosis. HIV is a predominantly sexually transmitted infection. Through focused sexual anamnesis and the diagnosis of HIV indicator diseases and other sexually transmitted infections, dermatovenereologists in particular may be able to identify previously undiagnosed PLWH and persons with an increased risk of HIV infection, enabling initiation of ART in the former and pre-exposure prophylaxis counseling in the latter.
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Affiliation(s)
- Stefan Esser
- HPSTD clinic, Department of Dermatology and Venereology, University Hospital Essen, Germany
| | - Stefanie Sammet
- HPSTD clinic, Department of Dermatology and Venereology, University Hospital Essen, Germany
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Sánchez-Corredor CD, Guerrero-Machado M, Rubio-Romero JA, Ángel-Müller E, Rey-Serrano G, Díaz-Cruz LA. Prevalence of high-risk human papilloma virus infection and abnormal cytology of the anal transformation zone in women with cervical dysplasia. Bogotá, Colombia, 2017-2019. ACTA ACUST UNITED AC 2020; 71:345-355. [PMID: 33515441 DOI: 10.18597/rcog.3558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 11/03/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine the prevalence of anal infection caused by high risk human papilloma virus (HR-HPV) and of abnormal anal cytology in women with confirmed cervical dysplasia. METHODS Cross sectional study that included patients between 30 and 65 years of age with a new diagnosis of cervical dysplasia by histopathology attended in two lower genital tract colposcopy and pathology units (one public and one private institution), conducted between December 2017 and April 2019. Women with human immunodeficiency virus (HIV) infection, immune compromise (use of steroids, transplant, chemo therapy), pregnancy or anorectal malformations were excluded. Consecutive sampling. Socio demographic variables, intercourse type, degree of cervical dysplasia, positive results of HR HPV Polymerase Chain Reaction test in anal canal and HR - HPV type indentified (16-18 or others) were evaluated. Descriptive statistics were used. RESULTS Of 188 candidates, 100 were included in the analysis. A 32 % prevalence of high-risk HPV infection and a 2.8 % prevalence of abnormal cytology in the anal canal (ASCUS) were found. Of the HR-HPV infections in the anal canal, 68.8 % corresponded to HR-HPV genotypes different from 16 or 18. CONCLUSIONS Prevalence of HR HPV infection in women with lower genital tract dysplasia was 32%. It is important to determine the usefulness of screening for anal mucosa compromise by HPV virus associated with a high risk of cancer in women with cervical dysplasia. Studies are needed on the prognosis of anal HR-HPV infection in women with cervical dysplasia.
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Affiliation(s)
| | - Mónica Guerrero-Machado
- Especialista en Obstetricia y Ginecología Universidad Nacional de Colombia; especialista en Cirugía Endoscópica Ginecológica, Fundación Universitaria de Ciencias de la SaludBogotáColombia
| | - Jorge Andrés Rubio-Romero
- Especialista en Ginecología y Obstetricia; magíster en Epidemiología Clínica. Profesor titular, Departamento de Obstetricia y GinecologíaUniversidad Nacional de Colombia, Bogotá (Colombia)
| | - Edith Ángel-Müller
- Especialista en Ginecología y Obstetricia. Profesora titular, Departamento de Obstetricia y GinecologíaUniversidad Nacional de Colombia, Bogotá(Colombia)
| | - Gustavo Rey-Serrano
- Especialista en Obstetricia y GinecologíaUniversidad Nacional de Colombia; magíster en Salud Sexual y Reproductiva, Universidad El Bosque, Bogotá (Colombia)
| | - Luz Amparo Díaz-Cruz
- Especialista en Ginecología y Obstetricia. Profesora asociada, Departamento de Obstetricia y GinecologíaUniversidad Nacional de Colombia, Bogotá (Colombia)
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Early Detection of Anal High-Grade Squamous Intraepithelial Lesion: Do We Have an Impact on Progression to Invasive Anal Carcinoma? J Low Genit Tract Dis 2020; 24:82-86. [PMID: 31860581 DOI: 10.1097/lgt.0000000000000505] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Anal high-grade squamous intraepithelial lesion (HSIL) may precede invasive cancer and can be detected clinically or during high-resolution anoscopy (HRA). The aims of this study were to compare the characteristics of HSIL discovered by HRA or in a surgical specimen without clinically visible lesion when diagnosed versus macroscopic HSIL when first diagnosed and then to compare their progression to invasive cancer. PATIENTS AND METHODS Clinical records of all patients with at least one HSIL lesion confirmed by histology and evaluated by HRA in a single center between September 1, 2009, and April 30, 2017, were retrospectively reviewed. The center's histological anal cancer data base was questioned in December 2017 to identify all cases. RESULTS During a median (interquartile range) follow-up of 19.1 (5.6-40.2) months, 12 (2.9%) anal cancers were diagnosed in patients with a diagnosis of HSIL. Period of time between the first diagnosis of anal lesion and the cancer was 28.8 months (interquartile range = 15.4-65.6), and 11 (92%) of 12 were diagnosed as superficially invasive squamous cell carcinoma or T1N0M0. The rate of progression to anal cancer differed significantly between patients with macroscopic HSIL at diagnosis (5.4%) and patients with microscopic HSIL diagnosed during HRA (0.9%) (p = .01). CONCLUSIONS Patients with macroscopic histologically proven HSIL at first diagnosis of anal intraepithelial lesion have a significantly higher risk of anal cancer compared with patients with microscopic lesions diagnosed during HRA, but the duration between the first diagnosis of HSIL and cancer does not differ between the 2 groups.
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21
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Goldstone SE. Anal cancer prevention: Solving the puzzle piece by piece. Cancer 2020; 126:1376-1378. [PMID: 31977083 DOI: 10.1002/cncr.32726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 12/24/2019] [Accepted: 12/31/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Stephen E Goldstone
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
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Gaisa MM, Liu Y, Deshmukh AA, Stone KL, Sigel KM. Electrocautery ablation of anal high-grade squamous intraepithelial lesions: Effectiveness and key factors associated with outcomes. Cancer 2020; 126:1470-1479. [PMID: 31977082 DOI: 10.1002/cncr.32581] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 05/06/2019] [Accepted: 05/16/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Electrocautery ablation (EA) is a common treatment modality for patients with anal high-grade squamous intraepithelial lesions (HSILs), but to the authors' knowledge its effectiveness has been understudied. The objective of the current study was to determine ablation outcomes and to identify clinicopathological factors associated with postablation disease recurrence. METHODS A total of 330 people living with HIV with de novo intra-anal HSIL who were treated with EA from 2009 to 2016 were studied retrospectively. Using long-term, surveillance high-resolution anoscopy biopsy data, treatment failures were classified as local recurrence (HSIL noted at the treated site at the time of surveillance) or overall recurrence (HSIL noted at treated or untreated sites). The associations between these outcomes and clinical factors were analyzed using Cox proportional hazards models. RESULTS Approximately 88% of participants were men who have sex with men. The median age of study participants was 45.5 years (range, 35-51 years) and approximately 49% had multiple index HSILs (range, 2-6 index HSILs). At a median of 12.2 months postablation (range, 6.3-20.9 months postablation), approximately 45% of participants had developed local recurrence whereas 60% had developed overall recurrence. Current cigarette smoking, HIV viremia (HIV-1 RNA ≥100 copies/mL), and multiple index HSILs were found to be predictive of local recurrence. Overall recurrence was more common in current smokers and those with multiple index lesions. In multivariable models that included human papillomavirus (HPV) genotypes, baseline and persistent infections with HPV-16 and/or HPV-18 were found to be significantly associated with both local and overall recurrence. CONCLUSIONS EA is an effective treatment modality for anal HSIL in people living with HIV, but rates of disease recurrence are substantial. Multiple index HSILs, HIV viremia, current cigarette smoking, and both baseline and persistent infection with HPV-16 and/or HPV-18 appear to negatively impact treatment success. Ongoing surveillance is imperative to capture recurrence early and improve long-term treatment outcomes.
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Affiliation(s)
- Michael M Gaisa
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Yuxin Liu
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ashish A Deshmukh
- Department of Management, Policy and Community Health, University of Texas School of Public Health, Houston, Texas
| | - Kimberly L Stone
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Keith M Sigel
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Clinical results of infrared coagulation as a treatment of high-grade anal dysplasia: a systematic review. Tech Coloproctol 2019; 23:707-712. [DOI: 10.1007/s10151-019-02041-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
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Koskan AM, Brennhofer SA, Helitzer DL. Screening for anal cancer precursors among patients living with HIV in the absence of national guidelines: practitioners' perspectives. Cancer Causes Control 2019; 30:989-996. [PMID: 31302838 DOI: 10.1007/s10552-019-01209-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 07/05/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE Immunocompromised populations including people living with HIV (PLWH) suffer disproportionate burden from anal cancer, a rare cancer caused by persistent infection of the anal canal with oncogenic strains of human papillomavirus. In the US, there are no nationally adopted screening guidelines for anal cancer. In the absence of such guidelines, this study explores healthcare practitioners' screening practices for early signs of anal cancer among PLWH. METHODS Between November 2017 and June 2018, the research team completed 25 interviews among a diverse sample of healthcare practitioners who provide care for PLWH. RESULTS Providers expressed frustration that screening and treatment guidelines for anal cancer were scant, and they varied in their screening practices. The majority of providers screened PLWH for anal dysplasia via the anal Pap smear; few providers were trained and had the medical equipment to conduct high-resolution anoscopy-guided biopsies, a more sensitive and specific screening method. Others screened through digital ano-rectal examinations (DARE) and both visually and with a DARE. Participants discussed how providers may be over-treating their patients who have high-grade anal intraepithelial neoplasia (AIN) and the role of biomarkers to determine whether the lesion is carcinogenic. CONCLUSIONS Practitioners who provide care for PLWH are proactive in screening to help prevent and control anal cancer, a rare and slow-growing disease. Continuing to regularly surveil high-risk populations, particularly PLWH previously diagnosed with high-grade lesions, is critical to prevent and control anal cancer.
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Affiliation(s)
- Alexis M Koskan
- College of Health Solutions, Arizona State University, 425 N. 5th Street, Phoenix, AZ, 85004, USA.
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Binda GA, Gagliardi G, Dal Conte I, Verra M, Cassoni P, Cavazzoni E, Stocco E, Delmonte S, De Nardi P, Sticchi L, Mistrangelo M. Practice parameters for the diagnosis and treatment of anal intraepithelial neoplasia (AIN) on behalf of the Italian Society of Colorectal Surgery (SICCR). Tech Coloproctol 2019; 23:513-528. [PMID: 31243606 DOI: 10.1007/s10151-019-02019-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 06/17/2019] [Indexed: 12/15/2022]
Abstract
Squamous cell carcinoma (SCC) of the anus is a human papilloma virus (HPV) related malignancy that is preceded by anal intraepithelial neoplasia (AIN) making this cancer, at least theoretically, a preventable disease. In the past 10 years the diagnosis, management and nomenclature of AIN has dramatically changed. Increased life expectancy in human immunodeficiency virus (HIV) positive patients due to highly active antiretroviral therapy (HAART) has caused an increase in the incidence of SCC of the anus. While many experts recommend screening and treatment of anal high-grade squamous intraepithelial lesion (HSIL), there is no consensus on the optimal management these lesions. Therefore, there is a need to review the current evidence on diagnosis and treatment of AIN and formulate recommendations to guide management. Surgeons who are members of the Italian Society of Colorectal Surgery (SICCR) with a recognized interest in AIN were invited to contribute on various topics after a comprehensive literature search. Levels of evidence were classified using the Oxford Centre for Evidence-based Medicine of 2009 and the strength of recommendation was graded according to the United States (US) preventive services task force. These recommendations are among the few entirely dedicated only to the precursors of SCC of the anus and provide an evidence-based summary of the current knowledge about the management of AIN that will serve as a reference for clinicians involved in the treatment of patients at risk for anal cancer.
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Affiliation(s)
- G A Binda
- Coloproctological Surgery, Biomedical Institute, Via Prà 1/b, 16157, Genoa, Italy.
| | - G Gagliardi
- Department of Surgery, University of Illinois at Chicago, Chicago, USA
| | - I Dal Conte
- Sexually Transmitted Infection Clinic, ASL Città di Torino, Turin, Italy
| | - M Verra
- Surgical Science Department, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - P Cassoni
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - E Cavazzoni
- Department of Surgery, University of Perugia School of Medicine, Perugia, Italy
| | - E Stocco
- Department of Surgery, ASS-5 Friuli Venezia Giulia, 33078, San Vito al Tagliamento, Italy
| | - S Delmonte
- Medical Science Department, Dermatologic Clinic, University of Turin, Turin, Italy
| | - P De Nardi
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - L Sticchi
- Hygiene Unit, Department of Health Sciences (DISSAL), IRCCS Policlinico San Martino Hospital, University of Genoa, Genoa, Italy
| | - M Mistrangelo
- Surgical Science Department, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
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Chin-Hong PV, Reid GE. Human papillomavirus infection in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13590. [PMID: 31077438 DOI: 10.1111/ctr.13590] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 05/06/2019] [Indexed: 02/06/2023]
Abstract
These guidelines from the American Society of Transplantation Infectious Diseases Community of Practice update the epidemiology and management of human papillomavirus (HPV) infections in organ transplant recipients. HPV is one of the most common sexually transmitted infections and is associated with cancers of the anogenital region. Increasing evidence suggests an association with head and neck cancers as well. Solid organ transplant recipients have a higher risk of HPV infection than the general population. Infection manifests as premalignant lesions, warts, or cancer of the cervix, penis, vulva, scrotum, and anal canal. Most are asymptomatic initially, so diagnosis can be difficult without screening. A vaccine is available though not effective in preventing all cancer-causing strains. Organ transplant recipients should be screened for HPV-associated cancers and appropriate therapy initiated in a timely manner. Further studies are warranted to delineate the most effective screening methods and therapeutic modalities, including whether changes in immunosuppression are effective in attenuating disease.
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Affiliation(s)
- Peter V Chin-Hong
- Division of Infectious Diseases, University of California at San Francisco, San Francisco, California
| | - Gail E Reid
- Division of Infectious Diseases, Loyola University Medical Center, Maywood, Illinois
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Goldstone SE, Hillman R, Jay N. What's wrong with the status quo? Plenty. Int J Colorectal Dis 2019; 34:941-942. [PMID: 30680450 DOI: 10.1007/s00384-019-03246-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2019] [Indexed: 02/04/2023]
Affiliation(s)
| | - Richard Hillman
- Dysplasia and Anal Cancer Services, St. Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Naomi Jay
- UCSF ANCRE Center, Mount Zion Hospital, San Fracisco, California, USA
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Anal Cancer Precursor Lesions in HIV-Infected Persons: Tissue Human Papillomavirus Type Distribution and Impact on Treatment Response. Dis Colon Rectum 2019; 62:579-585. [PMID: 30570548 DOI: 10.1097/dcr.0000000000001307] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Data on tissue distribution of human papillomavirus types in anal high-grade squamous intraepithelial lesions are limited and the impact on treatment outcomes poorly understood. OBJECTIVE We aimed to investigate potential predictors of treatment failure after electrocautery ablation, including human papillomavirus type(s) isolated from index lesions. DESIGN This was a retrospective cohort study. SETTINGS The study was conducted at a tertiary academic referral center in New York City. PATIENTS Seventy-nine HIV-infected patients with a diagnosis of anal high-grade squamous intraepithelial lesions between January 2009 and December 2012 were included, and genomic DNA was extracted from biopsy tissue. MAIN OUTCOME MEASURES The prevalence of human papillomavirus types in index lesions and surveillance biopsies after electrocautery ablation were analyzed to evaluate treatment response. RESULTS Of 79 anal high-grade squamous intraepithelial lesions, 71 (90%) tested positive for ≥1 human papillomavirus type; 8 (10%) had no human papillomavirus detected. The most common type was 16 (39%), followed by 33 (15%). Human papillomavirus type 18 was seen in 3%. Sixty-one patients (77%) underwent electrocautery ablation and had subsequent surveillance biopsies. Surveillance biopsies yielded benign findings or low-grade squamous intraepithelial lesions in 31 (51%) of 61 and recurrent high-grade squamous intraepithelial lesions in 30 (49%) of 61 patients (mean follow-up: 35 mo). Ablation response did not differ significantly based on baseline demographics, smoking history, history of anogenital warts, mean CD4 T-cell count, antiretroviral-therapy use, and HIV viral load (<50 copies/mL). The recurrence of high-grade lesions was not significantly associated with high-risk human papillomavirus types detected in index lesions. LIMITATIONS Human papillomavirus genotyping in surveillance biopsies was not performed. CONCLUSIONS Anal high-grade squamous intraepithelial lesions in HIV-infected patients contain a wide range of human papillomavirus types, and individual lesions commonly harbor multiple types concomitantly. Recurrence of anal high-grade squamous intraepithelial lesions after electrocautery ablation occurs frequently and is not affected by high-risk human papillomavirus types. See Video Abstract at http://links.lww.com/DCR/A833.
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Stankiewicz Karita HC, Hauge K, Magaret A, Mao C, Schouten J, Grieco V, Xi LF, Galloway DA, Madeleine MM, Wald A. Effect of Human Papillomavirus Vaccine to Interrupt Recurrence of Vulvar and Anal Neoplasia (VIVA): A Trial Protocol. JAMA Netw Open 2019; 2:e190819. [PMID: 30977845 PMCID: PMC6481452 DOI: 10.1001/jamanetworkopen.2019.0819] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
IMPORTANCE Human papillomavirus (HPV), particularly HPV type 16, causes most anal and vulvar high-grade squamous intraepithelial lesions (HSIL), which are precursors to cancer. After initial treatment of HSIL, more than 30% of patients will have disease recurrence, with even higher recurrence among HIV-positive individuals and men who have sex with men. Recurrences can be debilitating and lead to significant morbidity and medical expense. Observational studies suggest a possible therapeutic benefit of the licensed HPV vaccines in reducing recurrent lesions in previously infected persons. OBJECTIVE To test whether the licensed prophylactic HPV vaccine (Gardasil-9) can reduce the risk of HSIL recurrence by 50% in previously unvaccinated individuals recently treated for anal or vulvar HSIL. DESIGN, SETTING, AND PARTICIPANTS This is a trial protocol for a randomized, double-blind, placebo-controlled, proof-of-concept clinical trial. Eligible participants are aged 27 to 69 at study start and have not received prior HPV vaccination, have had anal or vulvar HSIL diagnosed on or after January 1, 2014, and have no evidence of HSIL recurrence at screening. Persons infected with HIV are eligible for the study provided they are receiving antiretroviral therapy. Target enrollment is 345 individuals. The primary outcome is time to histopathologically confirmed recurrence of HSIL. Differences in the risk for recurrence of HSIL will be evaluated using Cox proportional hazard models. Additional analyses include (1) frequency of HSIL recurrence; (2) role of HPV antibodies in deterring recurrence; (3) role of HPV persistence in recurrence, as measured by HPV genotype or HPV-16 variant lineage determined using swab samples collected at months 0, 18, and 36; and (4) incidence of adverse events. The study will be conducted at the University of Washington Virology Research Clinic from 2017 through 2022. Participants will be followed up for up to 36 months in the clinic, and up to 42 months by telephone. DISCUSSION Management of persistent or rapidly recurring anogenital HSIL remains challenging. Results from this study will provide evidence on whether incorporating the nonavalent HPV vaccine into routine care can decrease recurrence of anal and vulvar HSIL. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03051516.
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Affiliation(s)
| | - Kirsten Hauge
- Department of Medicine, University of Washington, Seattle
| | - Amalia Magaret
- Department of Biostatistics, University of Washington, Seattle
- Division of Vaccine and Infectious Diseases, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Laboratory Medicine, University of Washington, Seattle
| | - Constance Mao
- Department of Obstetrics and Gynecology, University of Washington, Seattle
| | - Jeffrey Schouten
- Department of Medicine, University of Washington, Seattle
- Division of Vaccine and Infectious Diseases, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Surgery, University of Washington, Seattle
| | - Verena Grieco
- Department of Pathology, University of Washington, Seattle
| | - Long Fu Xi
- Department of Epidemiology, University of Washington, Seattle
| | - Denise A Galloway
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Margaret M Madeleine
- Department of Epidemiology, University of Washington, Seattle
- Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Anna Wald
- Department of Medicine, University of Washington, Seattle
- Division of Vaccine and Infectious Diseases, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Laboratory Medicine, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
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Affiliation(s)
- Daniel L Feingold
- 1 Department of Surgery, Columbia University Irving Medical Center, New York, New York 2 Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
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Fokom Domgue J, Messick C, Milbourne A, Guo M, Salcedo MP, Dahlstrom KR, Chiao EY, Deshmukh AA, Sturgis EM, Schmeler KM. Prevalence of high-grade anal dysplasia among women with high-grade lower genital tract dysplasia or cancer: Results of a pilot study. Gynecol Oncol 2019; 153:266-270. [PMID: 30827725 DOI: 10.1016/j.ygyno.2019.02.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 02/20/2019] [Accepted: 02/23/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To estimate the prevalence of high-grade anal dysplasia in women with high-grade dysplasia or carcinoma of the cervix, vagina or vulva. METHODS In this cross-sectional study, participants underwent anal cytology, anal HPV testing with Cervista HPV16/18 and high-resolution anoscopy (HRA). Patients with HSIL (high-grade squamous cell intraepithelial lesion) or greater on anal cytology or anal biopsy were referred to a colorectal surgery specialist for further evaluation. RESULTS Seventy-five women were enrolled in the study, including 47 with cervical (cervix group), 10 with vaginal (vagina group), 15 with vulvar (vulva group), 1 with cervical and vaginal, and 2 with vulvar and vaginal disease. The median age in the cervix group (40 years (range 26-69)) was substantially younger than in the vagina (60 years (38-69)) and the vulva (59 years (36-75)) groups. Anal HSIL based on composite endpoints of the most severe cytology or histology result was diagnosed in 6 patients (8.0%). Anal cytology revealed HSIL in 2 (2.7%), atypical squamous cells of undetermined significance (ASCUS) in 12 (16.0%), low-grade squamous cell intraepithelial lesion (LSIL) in 2 (2.7%), and was normal in 59 (78.7%) patients. Anal HPV16/18 test was positive in 15 (20.0%), negative in 48 (64.0%) and insufficient in 12 (16.0%) patients. Of the 6 women with high-grade anal dysplasia, three (50%) had a positive anal HPV16/18 test. No case of anal cancer was observed. CONCLUSION Our results suggest that the prevalence of anal HSIL is elevated among women with HPV-related lower genital tract dysplasia or cancer. To further support the inclusion of this high-risk group into screening guidelines for anal dysplasia, further studies are necessary to determine what screening strategy is suited to this population.
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Affiliation(s)
- Joël Fokom Domgue
- The Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; The Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; The Department of Gynecology and Obstetrics, Faculty of Medicine and Biomedical Sciences, University of Yaoundé, Cameroon
| | - Craig Messick
- The Department of Colorectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrea Milbourne
- The Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ming Guo
- The Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mila P Salcedo
- The Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; The Department of Obstetrics & Gynecology, Federal University of Health Sciences/Irmandade Santa Casa de Misericordia, Porto Alegre, Brazil
| | - Kristina R Dahlstrom
- The Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elizabeth Y Chiao
- Department of Medicine - Infectious Disease, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Ashish A Deshmukh
- Department of Management, Policy and Community Health, UTHealth School of Public Health, Houston, TX, USA
| | - Erich M Sturgis
- The Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathleen M Schmeler
- The Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Siddharthan RV, Lanciault C, Tsikitis VL. Anal intraepithelial neoplasia: diagnosis, screening, and treatment. Ann Gastroenterol 2019; 32:257-263. [PMID: 31040622 PMCID: PMC6479653 DOI: 10.20524/aog.2019.0364] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 01/24/2019] [Indexed: 12/11/2022] Open
Abstract
Anal intraepithelial neoplasia (AIN) is a premalignant lesion for anal cancer. It is more commonly found in high-risk patients (e.g., human papilloma virus (HPV)/human immunodeficiency virus infections, post-organ transplantation patients, and men who have sex with men) and development is driven by HPV infection. The incidence of AIN is difficult to estimate, but is heavily skewed by preexisting conditions, particularly in high-risk populations. The diagnosis is made from cytology or biopsy during routine examinations, and can be performed at a primary care provider’s office. A pathologist can then review and classify cells, based on nucleus-to-cytoplasm ratios. The classification of low or high grade can better predict progression from AIN to anal cancer. There is little debate that AIN can develop into anal cancer, and the main rationale for treatment is to delay the progression. Significant controversy remains regarding screening, surveillance, and treatment for AIN. Management options are separated into surveillance (watchful waiting) and interventional strategies. Emerging data suggest that close patient follow up with a combination of ablative and topical treatments may offer the greatest benefit. HPV vaccination offers a unique treatment prior to HPV infection and the subsequent development of AIN, but its use after the development of AIN is limited. Ablative treatment includes excision, fulguration, and laser therapy.
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Affiliation(s)
- Ragavan V Siddharthan
- Department of Surgery, Division of Gastrointestinal and General Surgery (Ragavan V. Siddharthan, V. Liana Tsikitis), Oregon Health and Science University, Portland, OR, USA
| | - Christian Lanciault
- Department of Pathology (Christian Lanciault), Oregon Health and Science University, Portland, OR, USA
| | - Vassiliki Liana Tsikitis
- Department of Surgery, Division of Gastrointestinal and General Surgery (Ragavan V. Siddharthan, V. Liana Tsikitis), Oregon Health and Science University, Portland, OR, USA
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Tomassi MJ, Abbas MA, Klaristenfeld DD. Expectant management surveillance for patients at risk for invasive squamous cell carcinoma of the anus: a large US healthcare system experience. Int J Colorectal Dis 2019; 34:47-54. [PMID: 30244347 DOI: 10.1007/s00384-018-3167-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE To determine the impact of expectant management surveillance for patients at risk for squamous cell carcinoma of the anus (SCCA). METHODS Adult patients at risk for anal cancer, specifically those with human immunodeficiency virus (HIV) or known human papilloma virus (HPV) infections (anal dysplasia, anogenital warts, cervical dysplasia, or cervical cancer), underwent expectant management surveillance with targeted therapy of only grossly abnormal or symptomatic anoderm lesions. A retrospective analysis investigated the SCCA incidence in these surveilled populations and in the general population patients without known HIV or HPV infection. RESULTS There were 452 incident SCCA in a population of 5,978,510 patients (mean follow-up per patient of 5.4 years). Four hundred ten cancers (90.7%) developed in 5,750,501 HIV-negative patients without documented history of HPV infection (cumulative incidence 0.007%). In at-risk patient populations, the cumulative incidence was 0.69% in patients with anal dysplasia (6 out of 872 patients), 0.14% in HIV+ patients (8 out of 5626 patients), and less than 0.1% in the remaining at-risk groups: cervical cancer (1 out of 1168 patients), cervical dysplasia (14 out of 125,604 patients), and genital warts (14 out of 94,739 patients). CONCLUSIONS Expectant management surveillance, with targeted treatment for symptomatic or abnormal lesions, is an effective strategy for the diagnosis of anal cancer in at-risk patient populations. In this study, most patients who developed anal cancer had no known risk factors. A screening strategy for the general population needs to be further delineated.
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Affiliation(s)
- Marco J Tomassi
- Department of General and Colorectal Surgery, Kaiser Permanente San Diego, 4405 Vandever Avenue, Fourth Floor, San Diego, CA, 92120, USA.
| | | | - Daniel D Klaristenfeld
- Department of General and Colorectal Surgery, Kaiser Permanente San Diego, 4405 Vandever Avenue, Fourth Floor, San Diego, CA, 92120, USA
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Vassiliu P, Bartsokas C. Infrared Coagulation: A Treatment Option for Cervical Intraepithelial Neoplasia. J Glob Oncol 2018; 4:1-2. [PMID: 30241161 PMCID: PMC6180760 DOI: 10.1200/jgo.17.00038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
BACKGROUND The risk of anal carcinoma after previous diagnosis of anal intraepithelial neoplasia III is unclear. OBJECTIVE The purpose of this study was to estimate the risk of anal carcinoma in patients with anal intraepithelial neoplasia III and to identify predictors for subsequent malignancy. DESIGN This was a retrospective review using the Surveillance, Epidemiology, and End Results registry (1973-2014). SETTING The study was composed of population-based cancer registries from the United States. PATIENTS Patients who were diagnosed with anal intraepithelial neoplasia III were included. MAIN OUTCOME MEASURES The primary outcome was rate of subsequent anal squamous cell carcinoma. Predictors for anal cancer were identified using logistic regression and Cox proportional hazard models. RESULTS A total of 2074 patients with anal intraepithelial neoplasia III were identified and followed for a median time of 4.0 years (interquartile range, 1.8-6.7 y). Of the cohort, 171 patients (8.2%) subsequently developed anal cancer. Median time from anal intraepithelial neoplasia III diagnosis to anal cancer diagnosis was 2.7 years (interquartile range, 1.1-4.5 y). Fifty-two patients (30.4%) who developed anal carcinoma were staged T2 or higher. Ablative therapies for initial anal intraepithelial neoplasia III were associated with a reduction in the risk of anal cancer (OR = 0.3 (95% CI, 0.1-0.7); p = 0.004). Time-to-event analysis revealed that the 5-year incidence of anal carcinoma after anal intraepithelial neoplasia III was 9.5% or ≈1.9% per year. LIMITATIONS The registry did not record HIV status, surveillance schedule, use of high-resolution anoscopy, or provider specialty. CONCLUSIONS In the largest published cohort of patients with anal intraepithelial neoplasia III, ≈10% of patients were projected to develop anal cancer within 5 years. Nearly one third of anal cancers were diagnosed at stage T2 or higher despite a previous diagnosis of anal intraepithelial neoplasia III. Ablative procedures were associated with a decreased risk of cancer. This study highlights the considerable rate of malignancy in patients with anal intraepithelial neoplasia III and the need for effective therapies and surveillance. See Video Abstract at http://links.lww.com/DCR/A764.
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Douaiher J, Langenfeld SJ. Multidisciplinary Approach to the Management and Treatment of Anal Dysplasia. Clin Colon Rectal Surg 2018; 31:361-367. [PMID: 30397395 DOI: 10.1055/s-0038-1668106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The incidence of anal intraepithelial neoplasia (AIN) has been increasing over the years. AIN acts as a precursor lesion for anal squamous cell cancer. Factors leading to progression of AIN into malignancy are complex and involve grade of the lesion, human papillomavirus and HIV coinfection, as well as patient-related risk factors such as immunocompromised state and men who have sex with men. The multifaced aspects of this disease make its management challenging, as it involves several disciplines including pathology, primary care, infectious disease, and colorectal specialties. Each of these fields brings its own expertize to the management of AIN, and their collaborative, coordinated work culminates into best practice and optimized outcomes in the care of the AIN patient.
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Affiliation(s)
- Jeffrey Douaiher
- Kaiser Permanente Medical Center, Walnut Creek, CA; Division of General Surgery, Kaiser Permanente Northern California, Oakland, CA
| | - Sean J Langenfeld
- Kaiser Permanente Medical Center, Walnut Creek, CA; Division of General Surgery, Kaiser Permanente Northern California, Oakland, CA
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Abstract
High-resolution anoscopy (HRA) is a form of low-resolution anal microscopy currently utilized in the screening and management of anal squamous dysplasia. No randomized controlled trials, national or international guidelines exist on the use of HRA for this purpose. Much of our understanding of this entity has been adapted from the literature on cervical squamous dysplasia, including the technique of HRA itself. Epidemiologic evidence has shown that the prevalence and incidence of anal dysplasia is highest in HIV-positive populations. The history of this technique parallels the evolution of our understanding of anal dysplasia. To understand the history of the use of HRA and its place in the screening and management of anal squamous dysplasia, we discuss key advances in the understanding of human papillomavirus-related squamous dysplasia. We begin with early reports in the field establishing the link between this virus and squamous dysplasia, through the marked increase in anal cancer seen with the onset of the HIV epidemic, the identification of relevant populations at risk, the performance of the test itself, to its use today.
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Affiliation(s)
- S David Cho
- Department of Surgery, Kaiser Permanente, Portland, Oregon
| | - Emily Groves
- Department of General Surgery, Oregon Health and Science University, Portland, Oregon
| | - Victoria V Lao
- Department of General Surgery, University of Washington, Seattle, Washington
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Abstract
Anal intraepithelial neoplasia (AIN) is the premalignant condition of the anal squamous tissue. It is associated with the human papilloma virus and is considered the transition prior to the invasive anal squamous cell carcinoma. It is typically asymptomatic and can be either an incidental finding after anorectal surgery or identified when high-risk patient populations are screened. Once AIN is diagnosed, the optimal management remains controversial, partly because the natural history of the disease is unclear. Surgical management of the disease has essentially been replaced by more conservative treatment options and can range from expectant management to topical therapy to photodynamic therapy. The aim of this article is to review the varied treatment options and to briefly review prevention strategies.
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Affiliation(s)
- Rebecca E. Hoedema
- Department of Colorectal Surgery, Michigan State University College of Human Medicine, Grand Rapids, Michigan
- Department of Colorectal Surgery, Spectrum Health Medical Group/Ferguson Clinic, Grand Rapids, Michigan
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for Anal Squamous Cell Cancers (Revised 2018). Dis Colon Rectum 2018; 61:755-774. [PMID: 29878949 DOI: 10.1097/dcr.0000000000001114] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Clarke MA, Wentzensen N. Strategies for screening and early detection of anal cancers: A narrative and systematic review and meta-analysis of cytology, HPV testing, and other biomarkers. Cancer Cytopathol 2018; 126:447-460. [PMID: 29797691 DOI: 10.1002/cncy.22018] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 03/26/2018] [Accepted: 04/18/2018] [Indexed: 12/14/2022]
Abstract
Anal cancer incidence and mortality have been increasing over the past decade. Although the incidence in the general population remains low, it is much higher in certain subgroups, including those living with human immunodeficiency virus and men who have sex with men. Approximately 90% of anal squamous cell cancers are caused by infection with carcinogenic human papillomavirus (HPV). Given the common etiology between anal and cervical carcinogenesis, screening for anal cancer has been proposed in certain high-risk populations using strategies adapted from cervical cancer prevention. In this review, the authors discuss important differences in anal and cervical cancer regarding the populations at risk, disease natural history, and clinical procedures and outcomes that need to be considered when evaluating strategies for anal cancer screening. They also performed a systematic review and meta-analysis of the performance of anal cytology, anal HPV testing, and various biomarkers for the detection of anal precancers and cancers. The implications of these performance estimates are summarized in the context of risk-based screening and management of anal precancers, and important research gaps are highlighted that need to be addressed to fully understand the benefits and harms of anal cancer screening. Cancer Cytopathol 2018. Published 2018. This article is a U.S. Government work and is in the public domain in the USA.
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Affiliation(s)
- Megan A Clarke
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
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Brief Report: Radiofrequency Ablation Therapy for Anal Intraepithelial Neoplasia: Results From a Single-Center Prospective Pilot Study in HIV+ Participants. J Acquir Immune Defic Syndr 2018; 76:e93-e97. [PMID: 28857936 DOI: 10.1097/qai.0000000000001535] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND HIV-positive individuals have high incidence of anal high-grade squamous intraepithelial lesions (HSIL) at the squamocolumnar junction (SCJ), which can progress to cancer. Focal radiofrequency ablation (RFA) treats HSIL, but metachronous recurrence remains high and may be improved with circumferential treatment. SETTING The study was performed at a single center. METHODS This was a prospective trial of circumferential anal RFA using Barrx 60 RFA focal catheters in participants with ≥1 anal SCJ HSIL. The entire SCJ was ablated by RFA. Adverse events (AEs), symptoms, including pain, and quality of life were assessed. High-resolution anoscopy assessed recurrences at 3, 6, 9, and 12 months. Lesion site biopsies occurred at month 12. Recurrences were retreated with focal RFA. RESULTS Ten male participants (9 HIV+), with a median 2 HSILs (range 2-8) each, enrolled. Median T-cell count and viral load were 730 cells/mcL and 38 copies/mL. Median duration of RFA treatment was 6.5 (5-13) minutes. Lesion persistence occurred in 4 participants (3 at 3 months, 1 at 6 months). Recurrence at a new site occurred in 1 participant at 3 months. No lesion persisted after retreatment. All participants were HSIL free and completely healed by 12 months. Two device-related mild AEs occurred in 1 participant each (thrombosed external hemorrhoid and soft anal scar; both resolved). No serious AEs occurred. CONCLUSION Circumferential anal SCJ RFA produced total HSIL eradication with no more than 2 treatments. Circumferential RFA seems to be well tolerated with minimal pain and no serious AEs in HIV+ participants. CLINICALTRIALS.GOV:: NCT02189161.
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Abstract
Human papillomavirus (HPV) is a common infection in kidney transplant recipients. HPV causes cervical, anal, vulvar, vaginal, penile and head and neck cancers. Kidney transplant recipients have a disproportionate burden of disease given prolonged immunosuppression. Given the long pre-invasive state of precancer lesions such as cervical intraepithelial neoplasia (CIN) and anal intraepithelial neoplasia (AIN) most HPV-cancers are preventable with screening and targeted treatment of disease. Pre-transplant vaccination of age-eligible kidney transplant recipients is otherwise ideal.
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Affiliation(s)
- Peter V Chin-Hong
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, CA.
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Deshmukh AA, Chiao EY, Cantor SB, Stier EA, Goldstone SE, Nyitray AG, Wilkin T, Wang X, Chhatwal J. Management of precancerous anal intraepithelial lesions in human immunodeficiency virus-positive men who have sex with men: Clinical effectiveness and cost-effectiveness. Cancer 2017; 123:4709-4719. [PMID: 28950043 DOI: 10.1002/cncr.31035] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 04/05/2017] [Accepted: 05/15/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-positive men who have sex with men (MSM) are at disproportionately high risk for anal cancer. There is no definitive approach to the management of high-grade squamous intraepithelial lesions (HSIL), which are precursors of anal cancer, and evidence suggests that posttreatment adjuvant quadrivalent human papillomavirus (qHPV) vaccination improves HSIL treatment effectiveness. The objectives of this study were to evaluate the optimal HSIL management strategy with respect to clinical effectiveness and cost-effectiveness and to identify the optimal age for initiating HSIL management. METHODS A decision analytic model of the natural history of anal carcinoma and HSIL management strategies was constructed for HIV-positive MSM who were 27 years old or older. The model was informed by the Surveillance, Epidemiology, and End Results-Medicare database and published studies. Outcomes included the lifetime cost, life expectancy, quality-adjusted life expectancy, cumulative risk of cancer and cancer-related deaths, and cost-effectiveness from a societal perspective. RESULTS Active monitoring was the most effective approach in patients 29 years or younger; thereafter, HSIL treatment plus adjuvant qHPV vaccination became most effective. When cost-effectiveness was considered (ie, an incremental cost-effectiveness ratio [ICER] < $100,000/quality-adjusted life-year), do nothing was cost-effective until the age of 38 years, and HSIL treatment plus adjuvant qHPV vaccination was cost-effective beyond the age of 38 years (95% confidence interval, 34-43 years). The ICER decreased as the age at HSIL management increased. Outcomes were sensitive to the rate of HSIL regression or progression and the cost of high-resolution anoscopy and biopsy. CONCLUSIONS The management of HSIL in HIV-positive MSM who are 38 years old or older with treatment plus adjuvant qHPV vaccination is likely to be cost-effective. The conservative approach of no treatment is likely to be cost-effective in younger patients. Cancer 2017;123:4709-4719. © 2017 American Cancer Society.
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Affiliation(s)
- Ashish A Deshmukh
- College of Public Health and Health Professions, Department of Health Services Research, Management, and Policy, University of Florida, Gainesville, Florida
| | - Elizabeth Y Chiao
- Section of Infectious Disease, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Scott B Cantor
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elizabeth A Stier
- Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, Massachusetts
| | | | - Alan G Nyitray
- Division of Epidemiology, Human Genetics, and Environmental Sciences, The University of Texas Health Science Center at Houston School of Public Health, Houston, Texas
| | - Timothy Wilkin
- Division of Infectious Diseases, Weil Cornell Medicine, New York, New York
| | - Xiaojie Wang
- Department of Industrial and Systems Engineering, University of Florida, Gainesville, Florida
| | - Jagpreet Chhatwal
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston, Massachusetts
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Deshmukh AA, Cantor SB, Fenwick E, Chiao EY, Nyitray AG, Stier EA, Goldstone SE, Wilkin T, Chhatwal J. Adjuvant HPV vaccination for anal cancer prevention in HIV-positive men who have sex with men: The time is now. Vaccine 2017; 35:5102-5109. [PMID: 28807605 PMCID: PMC5581672 DOI: 10.1016/j.vaccine.2017.08.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 08/02/2017] [Accepted: 08/03/2017] [Indexed: 01/29/2023]
Abstract
IMPORTANCE Outcomes of treating high-grade squamous intraepithelial lesions (HSIL), a precursor to anal cancer, remain uncertain. Emerging evidence shows that post HSIL treatment adjuvant quadrivalent human papillomavirus (qHPV) vaccination improves the effectiveness of treatment. However, no recommendations exist regarding the use of qHPV vaccine as an adjuvant form of therapy. Our objective was to determine whether post-treatment adjuvant vaccination should be adopted in HIV-infected MSM (individuals at highest risk for anal cancer) on the basis of cost-effectiveness determined using existing evidence or whether future research is needed. METHODS We developed a Markov (state-transition) cohort model to assess the cost-effectiveness of post-treatment adjuvant HPV vaccination of 27years or older HIV-infected MSM. We first estimated cost-effectiveness and then performed value-of-information (VOI) analysis to determine whether future research is required by estimating the expected value of perfect information (EVPI). We also estimated expected value of partial perfect information (EVPPI) to determine what new evidences should have highest priority. RESULTS With the incremental cost-effectiveness ratio (ICER) of $71,937/QALY, "treatment plus vaccination" was the most cost-effective HSIL management strategy using the willingness-to-pay threshold of 100,000/QALY. We found that population-level EVPI for conducting future clinical research evaluating HSIL management approaches was US$12 million (range $6-$20 million). The EVPPI associated with adjuvant qHPV vaccination efficacy estimated in terms of hazards of decreasing HSIL recurrence was $0 implying that additional data from a future study evaluating efficacy of adjuvant qHPV vaccination will not change our policy conclusion that "treatment plus vaccination" was cost-effective. Both the ICER and EVPI were sensitive to HSIL treatment compliance. CONCLUSION Post-treatment adjuvant qHPV vaccination in HIV-infected MSM aged 27 or above is likely to be cost-effective. Use of adjuvant qHPV vaccination could be considered as a potential strategy to reduce rising anal cancer burden among these high-risk individuals.
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Affiliation(s)
- Ashish A Deshmukh
- Department of Health Services Research, Management and Policy, College of Public Health & Health Professions, University of Florida, Gainesville, FL, USA.
| | - Scott B Cantor
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Elizabeth Y Chiao
- Department of Medicine, Section of Infectious Disease, Baylor College of Medicine, Houston, TX, USA
| | - Alan G Nyitray
- Division of Epidemiology, Human Genetics, and Environmental Sciences, The University of Texas Health Science Center School of Public Health, Houston, TX, USA
| | - Elizabeth A Stier
- Department of Obstetrics and Gynecology, Boston University Medical Center, Boston, MA, USA
| | | | - Timothy Wilkin
- Division of Infectious Diseases, Weill Cornell Medical College, New York, NY, USA
| | - Jagpreet Chhatwal
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Allan-Blitz LT, Klausner JD. The Need for Outcome Studies Prior to Large-Scale Implementation of Screening for Anal Cancer. Clin Infect Dis 2017; 65:179-180. [PMID: 28419196 DOI: 10.1093/cid/cix328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Lao-Tzu Allan-Blitz
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine
| | - Jeffrey D Klausner
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine.,Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles
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Welton ML, Oberhelman HA, Lightner AL. Incorporating anal dysplasia screening and management into a surgical practice. SEMINARS IN COLON AND RECTAL SURGERY 2017. [DOI: 10.1053/j.scrs.2017.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Berry-Lawhorn JM, Palefsky JM. Progression of anal high-grade squamous intraepithelial lesions to anal squamous cell carcinoma and clinical management of anal superficially invasive squamous cell carcinoma. SEMINARS IN COLON AND RECTAL SURGERY 2017. [DOI: 10.1053/j.scrs.2017.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Brady JT, Ko B, Stein SL. High-resolution anoscopy: Is it necessary in the management of anal epithelial neoplasia. SEMINARS IN COLON AND RECTAL SURGERY 2017. [DOI: 10.1053/j.scrs.2017.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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