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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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Plotzker RE, Vaidya A, Pokharel U, Stier EA. Sexually Transmitted Human Papillomavirus: Update in Epidemiology, Prevention, and Management. Infect Dis Clin North Am 2023; 37:289-310. [PMID: 37105644 DOI: 10.1016/j.idc.2023.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
This review presents the epidemiology, pathophysiology, prevention, and management of sexually transmitted human papillomavirus (HPV) and its associated diseases. HPV is the most common sexually transmitted infection worldwide. Prevalence varies regionally. Low-risk strains cause anogenital warts, which can be managed with patient- or provider-applied therapies. High-risk strains cause lower anogenital cancers. Primary and secondary prevention strategies include vaccination and screening for precancerous lesions, respectively. Management of abnormal screening results vary by test result, anatomic site, and individual cancer risk. Approaches include close rescreening, high-resolution visualization with biopsy, and-when biopsy-proven precancer is identified-removal or destruction of the lesion.
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Affiliation(s)
- Rosalyn E Plotzker
- California Prevention Training Center, University of California San Francisco, Bixby Center for Global Reproductive Health 490 Illinois Street, 10th Floor, San Francisco, CA 94143, USA; Department of Epidemiology and Biostatistics, University of California San Francisco, Mission Hall: Global Health and Clinical Sciences, Box 0560 550 16th Street, San Francisco, CA 94143, USA.
| | - Akanksha Vaidya
- California Prevention Training Center, University of California San Francisco, Bixby Center for Global Reproductive Health 490 Illinois Street, 10th Floor, San Francisco, CA 94143, USA
| | - Utsav Pokharel
- California Emerging Infections Program, HPV Impact, 360 22nd Street #750, Oakland, CA 94612, USA
| | - Elizabeth A Stier
- Boston University School of Medicine, Boston Medical Center, 771 Albany Street, Dowling 4, Boston, MA 02118, USA
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Gunder LC, Moyer TH, Johnson HR, Auyeung AS, Leverson GE, Zhang W, Matkowskyj KA, Carchman EH. Anal Cancer Prevention Through the Topical Use of Single or Dual PI3K/mTOR Inhibitors. J Surg Res 2023; 282:137-146. [PMID: 36274448 DOI: 10.1016/j.jss.2022.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 08/29/2022] [Accepted: 09/26/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Anal dysplasia and anal cancer are major health problems. This study seeks to determine if inhibition of mTOR and/or PI3K pathways is effective at anal cancer prevention in mice with/without established precancerous lesions of the anus (anal dysplasia). METHODS K14E6/E7 mice were entered into the study at 5 wk, 15 wk, or 25 wk of age. Mice were treated with a topical carcinogen, 7,12-Dimethylbenz[a]anthracene (DMBA), which ensures carcinoma development within 20 wk. Treatment groups included: no treatment, DMBA only, topical Pictilisib (PI3K inhibitor) with/without DMBA, topical Sapanisertib (mTOR inhibitor) with/without DMBA, and topical Samotolisib (dual PI3K/mTOR inhibitor) with/without DMBA. Mice underwent weekly observations for anal tumor development (tumor-free survival). After 20 wk of treatment, anal tissue was harvested and evaluated histologically for squamous cell carcinoma (SqCC). RESULTS All topical treatments in conjunction with DMBA increased tumor-free survival in mice that started treatment at 15 wk of age when compared to DMBA-only treatment, except for Pictilisib + DMBA in males. Topical Sapanisertib increased tumor-free survival in mice regardless of starting treatment age. When examining tissue for microscopic evidence of SqCC, only topical Samotolisib in males decreased SqCC in the 15 wk starting mice. CONCLUSIONS Sapanisertib, the mTOR inhibitor, had the greatest effect, in terms of increasing tumor-free survival, regardless of starting time point or sex. Unlike the other treatments, Samotolisib, the dual PI3K/mTOR inhibitor, decreased microscopic evidence of SqCC when starting treatment at 15 wk of age but only in male mice.
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Affiliation(s)
- Laura C Gunder
- University of Wisconsin-Madison, School of Medicine and Public Health, Department of Surgery, 5148 Wisconsin Institute for Medical Research (WIMR), Madison, Wisconsin
| | - Tyra H Moyer
- University of Wisconsin-Madison, School of Medicine and Public Health, Department of Surgery, 5148 Wisconsin Institute for Medical Research (WIMR), Madison, Wisconsin
| | - Hillary R Johnson
- University of Wisconsin-Madison, School of Medicine and Public Health, Department of Surgery, 5148 Wisconsin Institute for Medical Research (WIMR), Madison, Wisconsin
| | - Andrew S Auyeung
- University of Wisconsin-Madison, School of Medicine and Public Health, Department of Surgery, 5148 Wisconsin Institute for Medical Research (WIMR), Madison, Wisconsin
| | - Glen E Leverson
- University of Wisconsin-Madison, School of Medicine and Public Health, Department of Surgery, 5148 Wisconsin Institute for Medical Research (WIMR), Madison, Wisconsin
| | - Wei Zhang
- University of Wisconsin-Madison, Department of Pathology and Laboratory Medicine, 3170 UW Medical Foundation Centennial Building (MFCB), Madison, Wisconsin; University of Wisconsin-Madison, Carbone Cancer Center, Madison, Wisconsin
| | - Kristina A Matkowskyj
- University of Wisconsin-Madison, Department of Pathology and Laboratory Medicine, 3170 UW Medical Foundation Centennial Building (MFCB), Madison, Wisconsin; William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin; University of Wisconsin-Madison, Carbone Cancer Center, Madison, Wisconsin
| | - Evie H Carchman
- University of Wisconsin-Madison, School of Medicine and Public Health, Department of Surgery, 5148 Wisconsin Institute for Medical Research (WIMR), Madison, Wisconsin; William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin; University of Wisconsin-Madison, Carbone Cancer Center, Madison, Wisconsin.
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Gunder LC, Johnson HR, Green HA, Bilger A, Moyer TH, Zhang W, Ziolkowski MR, Bertrang PA, Carchman EH. The use of a topical protease inhibitor, Saquinavir, to alleviate mouse papillomavirus-mediated anal disease. Virology 2022; 576:96-104. [PMID: 36206607 DOI: 10.1016/j.virol.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/26/2022] [Accepted: 09/26/2022] [Indexed: 02/06/2023]
Abstract
Select protease inhibitors (PI) have been found to be effective in decreasing human papillomavirus oncoprotein expression. This study evaluated whether the topical PI, Saquinavir (SQV), promotes viral clearance in an infectious mouse model with Mus musculus papillomavirus 1 (MmuPV1). NOD scid gamma (NSG) mice were anally infected with ∼4 × 108 viral genome equivalents of MmuPV1 and 120 days post-infection (when majority have high-grade anal dysplasia), began topical treatments: control (mock), 7,12-dimethylbenz(a)anthracene (DMBA) only, once weekly to promote carcinogenesis, 1% SQV only, daily (Monday - Friday), and SQV + DMBA. Viral MmuPV1 load was analyzed from anal lavages pre and post-treatment. Anal tissue was harvested, processed, and evaluated for drug absorption, grade of anal disease, and anal viral RNA. Results suggest that topical SQV promotes decreased viral shedding in female mice treated with SQV.
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Affiliation(s)
- Laura C Gunder
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI, 53792, USA.
| | - Hillary R Johnson
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI, 53792, USA.
| | - Heather A Green
- University of Wisconsin Carbone Cancer Center, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI, 53705, USA.
| | - Andrea Bilger
- McArdle Laboratory for Cancer Research, Department of Oncology, School of Medicine and Public Health, University of Wisconsin-Madison, Wisconsin Institutes for Medical Research, 1111 Highland Ave, Madison, WI, 53705, USA.
| | - Tyra H Moyer
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI, 53792, USA.
| | - Wei Zhang
- Department of Pathology and Laboratory Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, 3170 UW Medical Foundation Centennial Building (MFCB),1685 Highland Avenue, Madison, WI, 53705, USA.
| | - Marissa R Ziolkowski
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI, 53792, USA.
| | - Payton A Bertrang
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI, 53792, USA.
| | - Evie H Carchman
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI, 53792, USA; University of Wisconsin Carbone Cancer Center, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI, 53705, USA; William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, WI, 53705, USA.
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5
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Hawkins AT, Fang SH. Anal Squamous Intraepithelial Lesions and Anal Cancer Management in Low Resource Settings. Clin Colon Rectal Surg 2022; 35:396-401. [PMID: 36111083 PMCID: PMC9470285 DOI: 10.1055/s-0042-1746188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A low resource setting (LRS) is defined as a health care system which does not meet the criteria defined by the World Health Organization (WHO) or other national/international organizations in the following areas: infrastructure, materials, and human resources. 1 Patients encounter barriers which limit their access to care and services that are considered standard of care. While LRS is most commonly associated with developing countries, it is easy to overlook communities in developed countries which lack the financial resources to afford basic health care. This article describes the societal implications and barriers to care for both squamous intraepithelial lesions (SILs) and anal cancer in LRS, the existing screening/surveillance approaches, available treatment approaches to anal cancer, and it also discusses potential evidence-based approaches to bridge the gap for these disparities in anal cancer care.
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Affiliation(s)
- Alexander T. Hawkins
- Department of Surgery, Section of Colon and Rectal Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Sandy H. Fang
- Department of Surgery, Oregon Health and Science University, Portland, Oregon
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Fuertes I, Chivite I, Cranston RD, Sánchez E, Cordón E, Rodríguez-Carunchio L, Blanco JL. Short-term effectiveness and tolerability of carbon dioxide laser for anal high-grade squamous intraepithelial lesions in individuals living with HIV. Int J STD AIDS 2022; 33:709-717. [PMID: 35611790 DOI: 10.1177/09564624221100069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ablative treatment of intra-anal high-grade squamous intraepithelial lesions (HSIL) reduces the risk of progression to anal squamous cell carcinoma. Our objective was to assess the short-term effectiveness and tolerability of the carbon dioxide laser for treating intra-anal HSIL in patients at high risk of anal cancer. METHODS This is an exploratory, pilot, single-arm, clinical trial of treatment response for anal HSIL in people living with HIV diagnosed with ≤3 not previously treated HSILs. Individuals were treated with one carbon dioxide laser treatment session. Clinical assessment by high resolution anoscopy and systematic recording of adverse events was performed. RESULTS Fifty-two patients with 72 HSILs were included. Response to treatment was assessed in 48 (92.3%) patients; in the per-protocol population analysis, complete, partial, and no response was seen in 50% (n = 24), 20.8% (n = 10) and 29.1% (n = 14), respectively. Being older than 40 years and having a CD4 T-cell count lower than 200 cells/μL at diagnosis of HSIL were significantly associated with a poor response to treatment. Data on adverse events was recorded for 49 patients and 69.4% (n=34) reported no symptoms after the procedure. CONCLUSIONS Carbon dioxide laser ablation is a promising and well tolerated treatment for intra-anal HSIL.
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Affiliation(s)
- Irene Fuertes
- Department of Dermatology, 16493Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Iván Chivite
- Department of Infectious Diseases, 16493Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Ross D Cranston
- Department of Infectious Diseases, 16493Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Emilia Sánchez
- Blanquerna School of Health Science, 82995Universitat Ramón Llull, Barcelona, Spain
| | - Encarna Cordón
- Department of Infectious Diseases, 16493Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | | | - José L Blanco
- Department of Infectious Diseases, 16493Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
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Gunder LC, Moyer TH, Ziolkowski MR, Keating MK, Leverson GE, Zhang W, Carchman EH. Systemic Delivery of a Dual PI3K/mTOR Inhibitor More Effective than Topical Delivery in Preventing Anal Carcinogenesis in an HPV Transgenic Mouse Model. JOURNAL OF CANCER SCIENCE AND CLINICAL THERAPEUTICS 2022; 6:157-173. [PMID: 36683775 PMCID: PMC9851170 DOI: 10.26502/jcsct.5079153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction Anal dysplasia is a growing health concern that over time can result in squamous cell carcinoma (SqCC) of the anus. In this study, we compare a topical versus systemic (oral) administration of LY3023414, a dual PI3K/mTOR inhibitor, to prevent anal carcinogenesis in a Human Papillomavirus (HPV) mouse model of anal cancer. Materials and Methods K14E6/E7 transgenic mice were used to model HPV-induced anal carcinogenesis. Mice with varying starting anal histologies (normal histology, low-grade, and high-grade anal dysplasia) were treated topically at the anus or systemically via oral gavage with LY3023414 with or without topical carcinogen for 20 weeks. Mice were monitored for overt anal tumor development and anal tissue was assessed for histology and markers of PI3K and mTOR activity (pAKT and pS6, respectively). Results LY3023414 treatment, regardless of the mode of delivery, significantly decreased overt tumor development in mice starting with normal histology and low-grade anal dysplasia. Systemic LY3023414 treatment was more effective in delaying tumor onset than topical treatment. Mice treated with systemic LY3023414 had significantly reduced rates of anal SqCC when starting with normal and low-grade anal dysplasia compared to topical treatment. Topical treatment was only effective in reducing SqCC in the setting of low-grade dysplasia. LY3023414 inhibition of pAKT and pS6 expression varied with starting histology. Neither treatment mode was effective in the setting of high-grade anal dysplasia. Conclusion Systemic LY3023414 treatment was more effective than topical application in delaying the progression of normal anal histology and low-grade dysplasia to anal cancer in HPV-associated mice.
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Affiliation(s)
- Laura C Gunder
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Tyra H Moyer
- Waisman Center, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | | | - Margaret K Keating
- Department of Cell and Regenerative Biology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Glen E Leverson
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Wei Zhang
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
| | - Evie H Carchman
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
- University of Wisconsin Carbone Cancer Center, UW Health University Hospital, Madison, Wisconsin, USA
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8
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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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Lee JY, Lensing SY, Berry-Lawhorn JM, Jay N, Darragh TM, Goldstone SE, Wilkin TJ, Stier EA, Einstein M, Pugliese JC, Palefsky JM. Design of the ANal Cancer/HSIL Outcomes Research study (ANCHOR study): A randomized study to prevent anal cancer among persons living with HIV. Contemp Clin Trials 2022; 113:106679. [PMID: 35017115 PMCID: PMC8844243 DOI: 10.1016/j.cct.2022.106679] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 01/06/2022] [Accepted: 01/07/2022] [Indexed: 02/03/2023]
Abstract
It is well established that persons living with HIV (PLWH) have highly elevated rates of anal HSIL and anal cancer compared with those who are not living with HIV. The 5-year risk of anal cancer following anal HSIL has been reported to be as high as 14.1% among PLWH compared with 3.2% among those who are not living with HIV. To address these concerns, the AIDS Malignancy Consortium completed a large-scale, randomized trial to compare strategies for the prevention of anal cancer among PLWH with anal HSIL. The objective of the study was to determine whether treating anal HSIL was effective in reducing the incidence of anal cancer in PLWH compared with active monitoring. This paper describes the design of the ANal Cancer/HSIL Outcomes Research Study (ANCHOR) with respect to estimating the anal cancer event rate in this high risk population.
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Affiliation(s)
- Jeannette Y Lee
- University of Arkansas for Medical Sciences, 4301 West Markham, Slot #781, Little Rock, AR 72205, USA.
| | - Shelly Y Lensing
- University of Arkansas for Medical Sciences, 4301 West Markham, Slot #781, Little Rock, AR 72205, USA.
| | - J Michael Berry-Lawhorn
- University of California, San Francisco, Hematology Oncology, 1600 Divisadero Street, Room A641, Box 1699, San Francisco, CA 94143, USA.
| | - Naomi Jay
- University of California, San Francisco, Mt. Zion Medical Center, 1701 Divisadero Street, Suite 480, Box 1217, San Francisco, CA 94143, USA.
| | - Teresa M Darragh
- University of California, San Francisco, Mt. Zion Medical Center Depts. of Pathology, OB/Gyn Box 1785, 1600 Divisadero Street, Room B618, San Francisco, CA 94143, USA.
| | - Stephen E Goldstone
- Laser Surgery Care Center, 420 West 23rd Street, Suite PB, New York, NY 10011, USA
| | - Timothy J Wilkin
- Weill Medical College of Cornell University, Cornell Clinical Trials Unit, 53 West 23rd Street, 6th Floor, New York, NY 10010, USA.
| | - Elizabeth A Stier
- Boston Medical Center, Department of Obstetrics and Gynecology, 85 E. Concord Street, 6th Floor, Boston, MA 02118, USA.
| | - Mark Einstein
- Rutgers New Jersey Medical School, Medical Science Building (MSB), 185 South Orange Avenue, Room E-506, Newark, NJ 07101, USA.
| | - Julia C Pugliese
- Emmes Company, LLC, 401 N. Washington Street, Rockville, MD 20850, USA.
| | - Joel M Palefsky
- University of California, San Francisco, 513 Parnassus Ave, Room S420, Box 0654, San Francisco, CA 94143, USA.
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Fuertes I, Cranston R, de Lazzari E, Rodriguez-Carunchio L, Blanco JL. Response factors associated with electrocautery treatment of intra-anal high-grade squamous intraepithelial lesions in a population of HIV-positive men who have sex with men. Int J STD AIDS 2021; 32:1052-1059. [PMID: 33978536 DOI: 10.1177/09564624211017005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ablative treatment of anal high-grade squamous intraepithelial lesions (HSIL) reduces the risk of progression to anal squamous cell carcinoma. OBJECTIVES To identify factors that influence the response to treatment of anal HSIL by electrocautery ablation (ECA) in a population of HIV-positive men who have sex with men (MSM). DESIGN Retrospective study of ECA treatment response in a prospectively followed anal dysplasia cohort. HIV-positive MSM diagnosed with anal HSIL were included. Demographic and HIV data were recorded. Response to treatment was assessed by biopsy after at least 18 months of follow-up. RESULTS One hundred and twenty-eight HSILs in 91 men were included in this study. The overall response rate at 18 months was 70.3%. The number of electrocautery sessions required (2 ECA sessions vs 1: adjusted odds ratio [aOR] = 0.36 (95%CI 0.13-1.01); >=3 sessions vs 1: aOR = 0.10 (95%CI 0.04-0.29); p < 0.001]) and the history of previous HPV-related anal pathology (previous anal lesions vs no previous lesions AOR = 2.83 (95%CI 1.14-7.02), p = 0.024) were independently associated with response at 18 months. No serious adverse events were reported. CONCLUSIONS Consideration should be given to alternative therapies in patients with unresolved HSIL after 1 ECA treatment.
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Affiliation(s)
- Irene Fuertes
- Department of Dermatology, 16493Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Ross Cranston
- Department of Infectious Diseases, 16493Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Elisa de Lazzari
- Department of Infectious Diseases, 16493Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | | | - José L Blanco
- Department of Infectious Diseases, 16493Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
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11
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The importance of anal cancer screening and high-resolution anoscopy to gastroenterology practice. Curr Opin Gastroenterol 2020; 36:393-401. [PMID: 32701604 DOI: 10.1097/mog.0000000000000661] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW Although human papillomavirus (HPV)-related anal squamous cell cancer (ASCC) is rare, its incidence has been rising and in high-risk populations exceeds the incidence of cancers for which screening programs are implemented. Therefore, targeted screening techniques are being evaluated with high-resolution anoscopy (HRA) as the current gold standard because of its ability to detect anal intraepithelial dysplasia (AIN) and premalignant high-grade squamous intraepithelial lesions (HSILs). However, a scarcity of trained providers presents a barrier to screening. RECENT FINDINGS ASCC incidence is rising especially in elderly women and young black men. Premalignant HSIL may not only progress to ASCC but also regress. Biomarkers such as HPV type, p16 immunostaining and DNA methylation markers may emerge as predictors of disease progression.HRA with acetic acid and Lugol's iodine staining can be used to detect HSIL and ASCC. Recent studies suggest that anal cancer screening may have an impact on the stage of ASCC at diagnosis and the incidence of anal cancer.The Anal Cancer HSIL Outcomes Research (ANCHOR) study is underway to determine whether treating HSIL effects ASCC incidence. SUMMARY Although there are no consensus screening guidelines for anal cancer, it is reasonable to screen high-risk populations with physical examination, anal cytology and HRA. Gastroenterologists can support anal cancer screening programmes through identifying patients at risk, performing noninvasive screening and considering to incorporate endoscopic techniques to examine the anal canal. VIDEO ABSTRACT: http://links.lww.com/COG/A32.
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Lum C, Prenen H, Body A, Lam M, Segelov E. A 2020 update of anal cancer: the increasing problem in women and expanding treatment landscape. Expert Rev Gastroenterol Hepatol 2020; 14:665-680. [PMID: 32458709 DOI: 10.1080/17474124.2020.1775583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Anal cancer is a rare malignancy with increasing incidence, notably in women. This disease is highly associated with HPV infection and its incidence and mortality are currently rising. Most patients present with localized disease which has a high survival after definitive treatment with chemoradiation. For patients who develop metastatic disease or present with this de novo, survival is poor. AREAS COVERED This review provides a summary of current literature on anal cancer. With a focus on women, this includes current epidemiological trends, role of HPV, and the current and future treatment landscape, including HPV vaccination and immunotherapy. Screening currently focusses on HIV-positive men, missing most female cases. In curative disease, trials are investigating treatment de-intensification in good prognostic groups. Immunotherapy is showing early promise in the advanced disease setting. EXPERT OPINION Similar to cervical cancer, anal cancer is strongly associated with HPV, and therefore, broader implementation of screening programs may reduce its incidence. HPV vaccination is expected to reduce the development of (pre)malignant anal lesions. The emergence of biomarkers will assist patient treatment selection, allowing optimal balance of treatment efficacy and morbidity. It is hoped that new treatment approaches, including immunotherapy, will improve outcomes. International collaboration is needed.
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Affiliation(s)
- Caroline Lum
- Medical Oncology, Monash Medical Centre , Clayton, Australia
| | - Hans Prenen
- Medical Oncology, Monash Medical Centre , Clayton, Australia.,Oncology Department, University Hospital Antwerp , Antwerp, Belgium
| | - Amy Body
- Medical Oncology, Monash Medical Centre , Clayton, Australia
| | - Marissa Lam
- Medical Oncology, Monash Medical Centre , Clayton, Australia
| | - Eva Segelov
- Medical Oncology, Monash Medical Centre , Clayton, Australia.,School of Clinical Sciences, Monash University , Clayton, Australia
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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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14
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Fuertes I, Bastida C, Lopez-Cabezas C, Rodríguez-Carunchio L, Ordi J, Mallolas J, Cranston RD, Blanco JL. The effectiveness and tolerability of imiquimod suppositories to treat extensive intra-anal high-grade squamous intraepithelial lesions/warts in HIV-infected individuals. Int J STD AIDS 2019; 30:1194-1200. [PMID: 31558130 DOI: 10.1177/0956462419864506] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Topical imiquimod is a potential treatment for intra-anal condyloma and squamous intraepithelial lesions caused by human papillomavirus (HPV). We aimed to assess the effectiveness and tolerability of imiquimod suppositories for the treatment of anal high-grade intraepithelial lesions (HSIL) and condylomas in HIV-infected patients. We conducted a retrospective analysis in a prospectively followed cohort. High-resolution anoscopy was used for diagnosis and assessment following treatment. Patients’ tolerability was assessed with a self-administered survey. Ninety-five patients (94.7% men) were analyzed. All were on combination antiretroviral therapy. Median CD4 T-cell count was 690 cells/µL, 89% had undetectable plasma viral load. Response to imiquimod was seen in 46.3% (complete: 12.5%, partial: 33.8%) in the intent-to-treat analysis, and in 55.2% (complete: 14.9%, partial: 40.3%) in the on-treatment analysis. Higher response rates were observed for anal condyloma compared with HSIL. A significantly poorer response rate was observed in smokers and in individuals with lower nadir CD4 T-cell counts. Imiquimod tolerability was “good” in 57.1% (n = 36), “acceptable” in 33.3% (n = 21), and “poor” in 9.5% (n = 6). Systemic side effects were reported in 20.7% (n = 13). There was no association between treatment effect and tolerability. In conclusion, imiquimod stands as a well-tolerated option for the treatment of HPV-associated intra-anal pathology in HIV-infected individuals.
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Affiliation(s)
- Irene Fuertes
- Department of Dermatology, Hospital Clinic of Barcelona, University of Barcelona, Spain
| | - Carla Bastida
- Department of Pharmacy, Hospital Clinic of Barcelona, University of Barcelona, Spain
| | - Carmen Lopez-Cabezas
- Department of Pharmacy, Hospital Clinic of Barcelona, University of Barcelona, Spain
| | | | - Jaume Ordi
- Department of Pathology, Hospital Clinic of Barcelona, University of Barcelona, Spain.,Institut de Salut Global de Barcelona (ISGlobal), Barcelona, Spain
| | - Josep Mallolas
- Department of Infectious Diseases, Hospital Clinic of Barcelona, University of Barcelona, Spain
| | - Ross D Cranston
- Department of Infectious Diseases, Hospital Clinic of Barcelona, University of Barcelona, Spain
| | - Jose Luís Blanco
- Department of Infectious Diseases, Hospital Clinic of Barcelona, University of Barcelona, Spain
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15
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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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