Length of human immunodeficiency virus disease and not immune status is a risk factor for development of anal carcinoma

Anal Dysplasia Screening and Treatment in a Southern Human Immunodeficiency Virus Clinic

BACKGROUND

Persistent human papillomavirus infection in human immunodeficiency virus (HIV)-infected individuals has been strongly associated with anal squamous cell carcinoma. The incidence of anal squamous cell carcinoma continues to increase in this population despite advances in HIV therapy. There are few studies describing the prevalence of anal cancer precursors, treatment outcomes, and associated factors among HIV-infected populations in the southern United States.

METHODS

A retrospective chart review was performed on 355 HIV-infected patients from a Southern HIV clinic who were 18 years or older and had received at least one anal Pap smear. Demographic and clinical variables were collected. Descriptive statistics, single variable, and multivariate logistic regression analysis were performed to evaluate for predictors of high-grade squamous intraepithelial lesion (HSIL). Odds ratios and 95% confidence intervals were constructed for independent measures.

RESULTS

After the first anal Pap smear, 38.3% (70/183) of patients with abnormal results were lost to follow-up. Comparing patients with biopsy proven HSIL versus low-grade squamous intraepithelial lesions, patients were less likely to have HSIL if they had a higher CD4 count (odds ratio, 0.81; 95% confidence interval, 0.72-0.93; P = 0.0022). Treatment success after the first round of treatment for topical and infrared coagulation therapy was 36.7% (18/49, all therapy types), and of those who achieved biopsy proven treatment success at follow-up screening, 94.4% (17/18) required subsequent therapy.

CONCLUSIONS

Patients with a higher CD4 count were less likely to have HSIL. CD4 nadir, number of sexual partners, and race/ethnicity were not significantly associated with the presence of HSIL.

Anal-rectal cytology as a screening tool for the detection of anal intraepithelial neoplasia in HIV-positive men

INTRODUCTION

Use of anal-rectal cytology is on the rise as a screening tool for the detection of anal squamous lesions in human immunodeficiency virus (HIV)-positive individuals. The purpose of this 5-year retrospective study was to determine the utility of routine anal-rectal screening for the detection of squamous lesions in HIV-positive patients with histology correlation.

MATERIALS AND METHODS

From January 1, 2008 through December 31, 2012, 448 anal-rectal Papanicolaou tests were performed on HIV-positive men, of which 133 were referred for high-resolution anoscopy.

RESULTS

Of the 448 cases, 184 (41%) were classified as atypical squamous cells of undetermined significance or above, of which 133 (72%) had histologic correlation. Nine (7%) were negative, 64 (48%) were anal intraepithelial neoplasia (AIN) 1, 36 (27%) were AIN 2, 21 (16%) were AIN 3, and 3 (2%) were squamous cell carcinoma.

CONCLUSIONS

The results of this study support the use of anal-rectal cytology as a screening tool in the detection of anal intraepithelial neoplasia, particularly in high-risk populations.

[Early detection of anal intraepithelial neoplasia in high-risk patients]

The incidence of anal squamous cell carcinoma has increased alarmingly, particularly in high-risk groups such as men who have sex with men and immunosuppressed patients. Infection with an oncogenic strain of the human papillomavirus in the anal canal or perianal skin leads to anal intraepithelial neoplasias (AIN), progressive dysplastic intraepithelial lesions that are the precursors of anal squamous cell carcinoma. AIN can be diagnosed through cytological screening and biopsy guided by high-resolution anoscopy and can be treated using a range of procedures in an effort to prevent progression to invasive anal carcinoma. Given the recent advances in the understanding of this disease, and the increasing calls from experts for the establishment of screening programs to identify AIN, we review current knowledge on the condition, its diagnosis, and treatment from the point of view of dermatology.

Anal cancers among HIV-infected persons: HAART is not slowing rising incidence

OBJECTIVE

To evaluate the incidence rates of anal cancer over the HIV epidemic and assess the impact of HAART use on anal cancer events.

METHODS

We evaluated the incidence of and factors associated with anal cancer using longitudinal data from the prospective U.S. Military Natural History Study (1985-2008). Poisson regression and Cox proportional hazard models were utilized.

RESULTS

Among 4506 HIV-infected men with 37 806 person-years of follow-up, anal cancer rates (per 100 000 person-years) increased five-fold, from 11 in the pre-HAART to 55 in the HAART era (P = 0.02). Rates continued to increase, reaching 128 in 2006-2008. Persons with HIV infection for more than 15 years had a 12-fold higher rate than those with less than 5 years (348 vs. 28, P < 0.01). At cancer diagnosis (n = 19), median age was 42 years, median CD4 cell count was 432 cells/microl, 74% had a CD4 nadir cell count less than 200 cells/microl, 42% had a prior AIDS event, and 74% had received HAART. From separate models, prior AIDS event (hazard ratio 3.88, P = 0.01) and lower CD4 nadir (hazard ratio 0.85 per 50 cell, P = 0.03) were associated with anal cancer, with a trend for a history of gonorrhea (hazard ratio 2.43, P = 0.07). Duration of HAART use was not associated with a reduced risk of anal cancer (hazard ratio 0.94, P = 0.42).

CONCLUSION

Incidence rates of anal cancer have progressively increased during the HIV epidemic. Persons with a longer duration of HIV infection have a substantially higher rate of anal cancer. As HIV-infected persons are experiencing longer life expectancies and HAART does not appear protective of anal cancer, studies on preventive strategies are needed.

Sensibilidade e especificidade da citologia anal com escova no diagnóstico das lesões clínicas provocadas pelo papilomavírus humano, comparando uma com duas coletas

OBJETIVO: comparar os resultados da coleta única com duas amostras para avaliar se haverá melhora da sensibilidade e especificidade do exame. MÉTODO: Foram 112 doentes masculinos HIV-positivo com doença anal pregressa ou atual pelo Papilomavírus humano (HPV). As lesões HPV induzidas foram observadas em 58 deles. Colhemos material do canal anal utilizando duas escovas (cytobrush) Comparamos estatisticamente os resultados da primeira amostra com a soma das duas coletas. RESULTADOS: dos 58 doentes com lesões clínicas, a primeira amostra confirmou a doença em 40 (69%) e a soma das duas coletas revelou lesões em 51 (88%). Os resultados mostraram sensibilidade de 69% com a primeira coleta e 88% quando somadas as duas amostras. Essa diferença foi confirmada estatisticamente. A especificidade foi menor para as duas amostras, porém sem diferença estatística. CONCLUSÃO: Concluímos que a sensibilidade foi maior e a especificidade foi semelhante quando os resultados foram obtidos com a somação das duas amostras da citologia anal.

Current understanding and potential immunotherapy for HIV-associated squamous cell carcinoma of the anus (SCCA)

Squamous cell carcinoma of the anus (SCCA) is a rare disease in the average population but is an increasing concern among immunocompromised individuals, such as the HIV-seropositive. Coinfection with human papillomavirus (HPV) in this population is common. HPV infection is difficult to clear with a compromised immune system, which results in a greater risk of tumor development and a more aggressive progression of the disease. The recent approval of a prophylactic HPV vaccine for cervical cancer has sparked an interest in a search for improved immunotherapeutic multimodality therapies to combat anogenital tumors associated with the virus. In this review, we discuss the known mechanisms of action of HIV-associated SCCA, examine the current treatments for the disease, and focus on the potential of an immunotherapeutic vaccine approach for both prophylactic and therapeutic application.

Invasive anal squamous-cell carcinoma in the HIV-positive patient: outcome in the era of highly active antiretroviral therapy

INTRODUCTION

The incidence of invasive anal squamous-cell carcinoma in patients with HIV is increasing. We report the outcome after combined chemoradiotherapy for anal squamous-cell carcinoma in HIV-infected individuals.

METHODS

Thirty-two HIV-positive patients treated at the St. Vincent's Cancer Care Center for anal squamous-cell carcinoma from 1997 through mid 2005 were reviewed retrospectively. All patients also received highly active antiretroviral therapy. Treatment consisted of radiotherapy concurrent with 5-fluorouracil and mitomycin C in most patients. Overall survival, anal cancer-specific survival, local recurrence, and toxicity were assessed.

RESULTS

Median time from completion of radiotherapy to last follow-up of surviving patients was 35 months. Five-year locoregional relapse, anal cancer-specific survival, and overall survival were 16 , 75, and 65 percent, respectively. In multivariate analysis, locoregional recurrence, cancer-specific survival, and overall survival were all significantly associated with tumor size. Overall survival was independently associated with high viral load and low CD4 count. Acute toxicity included: Grade 3 skin in 25 percent of patients, Grade 3 diarrhea: 28 percent, and Grade 3 or 4 hematologic toxicity in 21 and 48 percent, respectively. More than two-thirds of patients required radiotherapy interruption. There was no negative impact of chemoradiotherapy on viral load.

CONCLUSIONS

Outcome after chemoradiotherapy for HIV-related anal squamous-cell carcinoma in the era of highly active antiretroviral therapy is comparable to outcome in patients without HIV. However, significant toxicity is seen with standard treatment regimens. Earlier diagnosis and risk-adapted therapy could lead to improved survival and decreased treatment-related morbidity.

Human papillomavirus vaccines in HIV-positive men and women

PURPOSE OF REVIEW

Individuals with HIV are at greater risk of human papillomavirus-related cancers. This report will assess the potential and limitations of vaccines against human papillomavirus in HIV-positive individuals.

RECENT FINDINGS

A worldwide meta-analysis of published data established the under-representation of HPV16, and increased prevalence of multiple-type human papillomavirus infections in HIV-positive women. Associations between HIV-related immunodepression, the progression of human papillomavirus infection to cervical lesions, and an increased risk of cervical cancer in women with HIV have also been shown. An increased incidence of human papillomavirus infection in anal and vulvar/vaginal neoplasia has been reported in individuals with HIV. A prophylactic vaccine against HPV6, 11, 16 and 18 has been licensed, and one against HPV16 and 18 is under evaluation. Both have shown efficacy against persistent infection, as well as related human papillomavirus cervical lesions for up to 5 years. Preliminary results have also been reported on therapeutic vaccines, notably for the treatment of cervical intraepithelial neoplasia grades 2 and 3.

SUMMARY

The safety and efficacy of human papillomavirus vaccines in individuals with HIV need to be assessed to prevent cervical cancer in current and future generations. Screening for human papillomavirus-related cancer among HIV patients should be undertaken.

The growing problem of non-AIDS-defining malignancies in HIV

PURPOSE OF REVIEW

The incidence and spectrum of non-AIDS-defining cancers has continued to grow. As HIV-infected individuals live longer due to highly active antiretroviral therapy, their risk of dying from one of these cancers is increased. The recent literature pertaining to non-AIDS-defining cancers is reviewed.

RECENT FINDINGS

Recent epidemiological studies have identified higher rates of carcinoma of the anus, lung, breast, skin, conjunctiva, liver and prostate; hematopoietic malignancies such as Hodgkin's lymphoma, plasma-cell neoplasia and leukemia; and other neoplasms like melanoma and leiomyosarcoma in HIV-positive patients. The role of HIV-induced immunosuppression in the development of these non-AIDS-defining cancers appears less important than lifestyle habits like smoking and sun exposure, as well as coinfection with human papilloma, hepatitis B, hepatitis C and Epstein-Barr viruses.

SUMMARY

It is unclear whether the growing number of reports on non-AIDS-defining cancers reflects a true increased incidence or merely the product of increased surveillance, detection and reporting. Highly active antiretroviral therapy not only promotes longevity in the HIV-positive population, but may increase their risk of developing cancer like Hodgkin's lymphoma. Assertive prevention strategies are needed to adequately deal with non-AIDS-defining cancers in an aging and growing HIV-positive population.

Human papillomavirus-related tumors in HIV

PURPOSE OF REVIEW

Human papillomavirus-related anogenital cancers are theoretically preventable. Many HIV-infected women do not undergo routine cervical cytology screening, however, and there are currently no routine anal cytology screening programs. This review focuses on recent developments that may impact on the future incidence of these cancers: the effect of highly active antiretroviral therapy and the imminent approval of vaccines to prevent initial human papillomavirus infection.

RECENT FINDINGS

Highly active antiretroviral therapy has limited benefit to reduce the incidence of cervical intraepithelial neoplasia 3 and no benefit to reduce the incidence of anal intraepithelial neoplasia 3. Consistent with these findings, there has been no reduction in the incidence of cervical and anal cancer since the introduction of highly active antiretroviral therapy. More encouraging is the development of highly effective preventive human papillomavirus vaccines that are projected to reduce the incidence of cervical cancer by up to 70% among vaccinated women.

SUMMARY

HIV-positive men and women remain at risk for human papillomavirus-associated cancers, even in the highly active antiretroviral therapy era. Conversely, the incidence of anogenital cancers may decline in the future among HIV-positive individuals if they received the human papillomavirus vaccine before they acquired HIV infection, and studies should be done to assess the safety and efficacy of the vaccines in individuals already infected with HIV.

Increasing incidence of squamous cell carcinoma of the anus in Scotland, 1975-2002

In Scotland, since 1975–1979 (world) age-standardised incidence of squamous cell carcinoma of the anus has more than doubled, reaching 0.37 per 100 000 in males and 0.55 in females during 1998–2002, being somewhat higher in socioeconomically deprived areas.