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Vyas M, Gonzalez RS. Anal intraepithelial neoplasia: a review of terminology, differential diagnoses, and patient management. Hum Pathol 2023; 132:56-64. [PMID: 35843339 DOI: 10.1016/j.humpath.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/08/2022] [Indexed: 02/07/2023]
Abstract
Despite the knowledge of etiological association with high-risk human papilloma viruses and high-risk patient cohorts, the incidence of anal squamous cell carcinoma has continued to rise. The known precursor lesion (in particular, high-grade squamous intraepithelial lesion) makes it amenable to screening and surveillance strategies. However, the diagnosis of anal intraepithelial neoplasia suffers from interpretation challenges leading to high interobserver variability, along with numerous differential diagnoses and lingering terminology issues. Proper treatment of anal lesions requires accurate diagnosis, and while a variety of modalities are available for treatment, the rate of recurrence remains high and each modality has its own set of side effects and complications. The aim of this review article is to outline the diagnostic considerations and provide practical tips for diagnosing anal squamous intraepithelial lesions.
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Affiliation(s)
- Monika Vyas
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - Raul S Gonzalez
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, 30322, USA.
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Bushara O, Krogh K, Weinberg SE, Finkelman BS, Sun L, Liao J, Yang GY. Human Immunodeficiency Virus Infection Promotes Human Papillomavirus-Mediated Anal Squamous Carcinogenesis: An Immunologic and Pathobiologic Review. Pathobiology 2021; 89:1-12. [PMID: 34535611 DOI: 10.1159/000518758] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/28/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Anal squamous cell carcinoma (SCC) is a rare gastrointestinal malignancy with rising incidence, both in the United States and internationally. The primary risk factor for anal SCC is human papillomavirus (HPV) infection. However, there is a growing burden of disease in patients with human immunodeficiency virus (HIV) and HPV coinfection, with the incidence of anal SCC significantly increasing in this population. This is particularly true in HIV-infected men. The epidemiologic correlation between HIV-HPV coinfection and anal SCC is established; however, the immunologic mechanisms underlying this relationship are not well understood. SUMMARY HIV-related immunosuppression due to low circulating CD4+ T cells is one component of increased risk, but other mechanisms, such as the effect of HIV on CD8+ T lymphocyte tumor infiltration and the PD-1/PD-L1 axis in antitumor and antiviral response, is emerging as significant contributors. The goal of this article is to review existing research on HIV-HPV coinfected anal SCC and precancerous lesions, propose explanations for the detrimental synergy of HIV and HPV on the pathogenesis and immunologic response to HPV-associated cancers, and discuss implications for future treatments and immunotherapies in HIV-positive patients with HPV-mediated anal SCC. Key Messages: The incidence of anal squamous cell carcinoma is increased in human immunodeficiency virus (HIV)-infected patients, even in patients on highly active antiretroviral therapy. Locoregional HIV infection may enhance human papillomavirus oncogenicity. Chronic inflammation due to HIV infection may contribute to CD8+ T lymphocyte exhaustion by upregulating PD-1 expression, thereby blunting cytotoxic antitumor response.
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Affiliation(s)
- Omar Bushara
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Katrina Krogh
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Samuel Edward Weinberg
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Brian Steven Finkelman
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Leyu Sun
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jie Liao
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Jochum SB, Tian W, Goczalk MG, Ritz EM, Favuzza J, Govekar HR, Bhama AR, Saclarides TJ, Jakate S, Hayden DM. Exophytic condyloma: are they as benign as we think? Colorectal Dis 2020; 22:1577-1584. [PMID: 32538546 DOI: 10.1111/codi.15187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 05/19/2020] [Indexed: 02/08/2023]
Abstract
AIM As the understanding of anal dysplasia continues to develop, controversy remains regarding treatment of these lesions. The purpose of this study was to evaluate lesion type (flat vs exophytic) and the association between morphology and dysplasia. METHODS This was a single-centre retrospective analysis of a prospectively collected pathological database of patients > 17 years old who underwent operative excision/biopsies for presumed anal condyloma or dysplasia from 2009 to 2018. The analysis includes comparisons between patient factors, phenotype and grade of dysplasia. RESULTS Sixty-nine patients had 423 lesions. The mean age of the study population was 48.2 years. 62.3% were men and 46.4% of patients were black. 47.8% of patients were human immunodeficiency virus (HIV) positive and 39.1% were men who have sex with men (MSM). There were 176 (41.6%) flat lesions and 234 (55.3%) exophytic lesions. Exophytic lesions were 2.5-fold more likely to be associated with a higher grade of dysplasia than flat lesions (OR 2.63, 95% CI 1.09-6.32). Neither lesion type nor dysplasia severity was associated with human papillomavirus, lesion location or patient characteristics, including race, MSM or HIV status. DISCUSSION Exophytic lesions were more than twice as likely to have advanced dysplasia compared with flat lesions. A clearer understanding of the association between gross lesion appearance and dysplasia will allow more appropriate counselling of patients and the development of better screening and treatment guidelines for anal condylomata and dysplasia.
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Affiliation(s)
- S B Jochum
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - W Tian
- Rush Medical College, Chicago, IL, USA
| | | | - E M Ritz
- Rush Bioinformatics and Biostatistics Core, Chicago, IL, USA
| | - J Favuzza
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - H R Govekar
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - A R Bhama
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - T J Saclarides
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - S Jakate
- Department of Pathology, Rush University Medical Center, Chicago, IL, USA
| | - D M Hayden
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
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Nadal LR, Saad SS, Lopes Filho GJ, Joaquim HPG, Manzione TDAS, Manzione CR, Nadal SR. Comparison between anal cytology, high-resolution anoscopy and HPV DNA genotyping by polymerase chain reaction in the post-treatment follow-up of condylomata acuminata. ACTA ACUST UNITED AC 2020; 47:e20202543. [PMID: 32638910 DOI: 10.1590/0100-6991e-20202543] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/15/2020] [Indexed: 12/31/2022]
Abstract
AIM to evaluate the presence of subclinical HPV-induced anal lesions with anal cytology, High-Resolution Anoscopy (HRA) and HPV genotyping by polymerase chain reaction (PCR) in the follow-up of treated condylomata acuminata (CA). METHODS seventy-nine male patients were included. One month after anal CA eradication, the patients underwent brush samples collection for anal cytology and PCR, and HRA with biopsy of acetowhite lesions. These methods were compared within all patients and between groups, according to Human Immunodeficiency Virus (HIV) infection status: HIV-negative; HIV-positive with TCD4 count above and below 350 cells/mm3. RESULTS the most frequent HPV types were 6 and 16. HPV DNA was isolated in 92%. HIV infection was associated with a higher number of oncogenic HPV types (p=0.038). All patients with negative PCR had negative HRA and cytology. There were no differences in cytological, HRA or histopathological findings between groups. CONCLUSION the association of the findings of cytopathology, HRA and genotyping of HPV refined the diagnosis of HPV-induced lesions. The degree of immunodeficiency was not associated with increase in remnant HPV-induced anal lesions.
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Abstract
Where does cancer come from? Although the cell-of-origin is difficult to pinpoint, cancer clones harbor information about their clonal ancestries. In an effort to find cells before they evolve into a life-threatening cancer, physicians currently diagnose premalignant diseases at frequencies that substantially exceed those of clinical cancers. Cancer risk prediction relies on our ability to distinguish between which premalignant features will lead to cancer mortality and which are characteristic of inconsequential disease. Here, we review the evolution of cancer from premalignant disease, and discuss the concept that even phenotypically normal cell progenies inherently gain more malignant potential with age. We describe the hurdles of prognosticating cancer risk in premalignant disease by making reference to the underlying continuous and multivariate natures of genotypes and phenotypes and the particular challenge inherent in defining a cell lineage as "cancerized."
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Affiliation(s)
- Kit Curtius
- Centre for Tumor Biology, Barts Cancer Institute, EC1M 6BQ London, United Kingdom
| | - Nicholas A Wright
- Centre for Tumor Biology, Barts Cancer Institute, EC1M 6BQ London, United Kingdom
| | - Trevor A Graham
- Centre for Tumor Biology, Barts Cancer Institute, EC1M 6BQ London, United Kingdom
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Abstract
Anal squamous cell cancer (SCC) is a relatively uncommon cancer in the United States. Anal SCC has long been associated with human immunodeficiency virus (HIV) positivity and/or men who have sex with men. The incidence of anal SCC has been increasing in both genders regardless of HIV status. Few clinicians are aware that white women, when not controlling for gender and sexual preference together, have the highest incidence of anal SCC. Anal intraepithelial neoplasia (AIN), dysplastic cells of the anal canal due to human papilloma virus infection, is believed to be the precursor to anal SCC. A vaccination has been approved by the Federal Drug Administration (FDA) for the prevention of high-risk human papilloma virus infections in presexually active girls and boys. Currently, there are no consensus guidelines for AIN screening, treatment or follow-up. Although anal SCC is treatable when caught early, treatment is often associated with significant morbidity. The purpose of this paper is to raise awareness of anal SCC and its precursor, AIN, in the non-HIV+ and non-MSM populations, and discuss means by which to decrease the incidence of anal SCC in all populations.
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Willems N, Libois A, Nkuize M, Feoli F, Delforge M, DeWit S. Treatment of anal dysplasia in HIV-positive men who have sex with men in a large AIDS reference centre. Acta Clin Belg 2017; 72:29-35. [PMID: 27320416 DOI: 10.1080/17843286.2015.1116725] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Over the last few decades, incidence of anal cancer among HIV-positive men has been on the rise. In this context, programmes of screening and treatment of anal dysplasia which is a precursor of anal cancer have been developed. The aim of our study was to describe the efficiency, side effects and outcome of anal dysplasia treatment in a population of HIV-positive men who have sex with men (MSM). METHODS We performed a retrospective study of HIV-positive MSM who received treatment for anal dysplasia between May 2010 and February 2014 in the Saint-Pierre University Hospital, Brussels. The different treatments used were electrocautery (ECA), infrared coagulation (IRC), surgical treatment and imiquimod. RESULTS Seventy-three HIV-infected MSM were included in the study, counting 62% of HGAIN. Median age was 41 years. Eighty-one per cent were on HAART. Median CD4 cell count was 525 cell/mm³, and 65% had undetectable viral loads. A total of 139 therapeutic interventions were recorded during the study period, and two-thirds of the enrolled patients received more than one treatment. At 540 days of follow-up, the rate of treatment response was 62%. Fifty per cent of the persistent HGAIN were metachronous lesions. No severe adverse events were recorded but frequent treatment-associated discomfort was reported, such as pain, self-limited bleeding, infection and anal irritation. CONCLUSION Treatment of anal dysplasia appears to be safe and to offer short-term efficiency. However, its long-term efficiency remains unknown, especially in the HIV-positive population in which spontaneous clearance is lower and rate of recurrence higher.
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Affiliation(s)
- Nathalie Willems
- Department of Infectious Disease and AIDS Reference centre, Brussels, Belgium
| | - Agnès Libois
- Department of Infectious Disease and AIDS Reference centre, Brussels, Belgium
| | - Marcel Nkuize
- Department of Gastroenterology, Saint-Pierre University Hospital, Brussels, Belgium
| | - Francesco Feoli
- Department of Pathology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Marc Delforge
- Department of Infectious Disease and AIDS Reference centre, Brussels, Belgium
| | - Stéphane DeWit
- Department of Infectious Disease and AIDS Reference centre, Brussels, Belgium
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Ntombela X, Sartorius B, Madiba T, Govender P. The clinicopathologic spectrum of anal cancer in KwaZulu-Natal Province, South Africa. Cancer Epidemiol 2015; 39:528-33. [DOI: 10.1016/j.canep.2015.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 05/15/2015] [Accepted: 05/18/2015] [Indexed: 10/23/2022]
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Azzolini F, Cecinato P, Iori V, De Marco L, Zecchini R, Fodero C, Tioli C, Sassatelli R. Endoscopic submucosal dissection of an unusual flat rectal neoplasm. Gut 2015; 64:180, 183. [PMID: 25320106 DOI: 10.1136/gutjnl-2014-308298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Francesco Azzolini
- Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Paolo Cecinato
- Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Veronica Iori
- Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Loredana De Marco
- Unit of Pathology, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Ramona Zecchini
- Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Cristina Fodero
- Cervical Cancer Screening Centre, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Cristiana Tioli
- Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Romano Sassatelli
- Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
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