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Krankowska D, Mazzitelli M, Ucak HA, Orviz E, Karakoc HN, Mortimer H, Aebi-Popp K, Gilleece Y. Screening and prevention of HPV-related anogenital cancers in women living with HIV in Europe: Results from a systematic review. HIV Med 2024; 25:769-793. [PMID: 38238990 DOI: 10.1111/hiv.13602] [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] [Received: 07/25/2023] [Accepted: 12/02/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND Women living with HIV (WLWH) are at increased risk of human papillomavirus (HPV)-related cancers. Throughout Europe, there is great heterogeneity among guidelines for screening programmes, access to HPV testing and HPV vaccination. The aim of this systematic review is to summarize available data on screening and prevention measures for HPV-related anogenital cancers in WLWH across the WHO European Region (WER). METHODS The systematic review followed the PRISMA guidelines and was registered on Prospero. PubMed, Embase and Web of Science databases were searched to identify available studies, written in English and published between 2011 and 2022. A metanalysis was conducted using random-effects models to calculate pooled prevalence of HPV. Subgroup analyses were conducted according to country and HPV testing. RESULTS Thirty-four articles involving 10 336 WLWH met the inclusion criteria. Studies were heterogenous in their methodology and presentation of results: 73.5% of studies focused on cervical cancer prevention, and only 4.4% on anal cancer; 76.5% of studies conducted HPV testing as a routine part of screening. The prevalence of high-risk HPV was 30.5-33.9% depending on the detection method used. A total of 77% of WLWH had cervical cytology results reported. Six studies reported the positive association of CD4 cell count <200 cells/μL with HPV prevalence and cervical abnormalities. Anal HPV testing was conducted in <8% of participants. HPV vaccination was completed in 5.6% of women (106/1902) with known vaccination status. There was no information about the vaccination status of the majority of women in the analysed studies (8434/10336). CONCLUSION Data about screening of HPV-related anogenital cancer in WLWH in Europe are heterogenous and lacking, especially in relation to anal cancer. HPV DNA testing is not routinely done as part of screening for HPV-related cancer; guidelines should include indications for when to use this test. Low CD4 count is a risk factor for HPV infection and cytological abnormalities. HPV vaccination data are poor and, when available, vaccination rates are very low among WLWH in Europe. This review concludes that significant improvements are required for data and also consistency on guidelines for HPV screening, prevention and vaccination in WLWH.
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Affiliation(s)
- Dagny Krankowska
- Department of Infectious and Tropical Diseases and Hepatology, Medical University of Warsaw, Warszawa, Poland
- Hospital for Infectious Diseases in Warsaw, Warsaw, Poland
| | - Maria Mazzitelli
- Infectious and Tropical Diseases Unit, Padua University Hospital, Padua, Italy
| | | | - Eva Orviz
- Centro Sanitario Sandoval, Hospital Clinico San Carlos, IdlSSC, Madrid, Spain
| | | | - Harriet Mortimer
- Brighton & Sussex Medical School and University Hospitals Sussex NHS Foundation Trust, Brighton, United Kingdom
| | - Karoline Aebi-Popp
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Obstetrics and Gynecology, Lindenhofspital, Bern, Switzerland
| | - Yvonne Gilleece
- Brighton & Sussex Medical School and University Hospitals Sussex NHS Foundation Trust, Brighton, United Kingdom
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Chromy D, Silling S, Wieland U, Kreuter A. [Anogenital warts-An update]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2024; 75:30-39. [PMID: 38108864 DOI: 10.1007/s00105-023-05282-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 12/19/2023]
Abstract
With a prevalence of around 1% in the sexually active population anogenital warts are the most frequent human papillomavirus (HPV)-related disease. In the vast majority of cases the underlying cause of the infection is due to HPV types 6 and 11. The diagnosis can usually be clinically established but in certain cases a histopathological work-up can be useful. Buschke-Lowenstein tumors represent such a scenario. The current therapeutic armamentarium for anogenital warts ranges from surgical ablative procedures up to local immunomodulatory treatment. All procedures have different advantages and disadvantages and are relatively time-consuming and sometimes also unpleasant for the patient. Anogenital warts are also a possible expression of an incomplete immunological control of HPV. Therefore, it should be emphasized that for certain affected individuals, especially immunosuppressed patients, special attention should be given to ensuring that screening investigations for HPV-associated dysplasia is carried out according to the respective valid guidelines. The primary prophylaxis by vaccination of girls and boys prior to first HPV exposure represents a very effective option to drastically reduce the prevalence of anogenital warts and other HPV-related diseases.
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Affiliation(s)
- David Chromy
- Universitätsklinik für Dermatologie, Medizinische Universität Wien, Wien, Österreich.
- Klinik für Dermatologie und Venerologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland.
| | - Steffi Silling
- Institut für Virologie, Nationales Referenzzentrum für Papillom- und Polyomaviren, Universitätsklinikum Köln und Universität zu Köln, Köln, Deutschland
| | - Ulrike Wieland
- Institut für Virologie, Nationales Referenzzentrum für Papillom- und Polyomaviren, Universitätsklinikum Köln und Universität zu Köln, Köln, Deutschland
| | - Alexander Kreuter
- Klinik für Dermatologie, Venerologie und Allergologie, Helios St. Elisabeth Klinik Oberhausen, Universität Witten-Herdecke, Oberhausen, Deutschland
- Klinik für Dermatologie, Venerologie und Allergologie, Helios St. Johannes Klinik Duisburg, Duisburg, Deutschland
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Sternjakob-Marthaler A, Berkó-Göttel B, Rissland J, Schöpe J, Taurian E, Müller H, Weber G, Lohse S, Lamberty T, Holleczek B, Stoffel H, Hauptmann G, Giesen M, Firk C, Schanzenbach A, Brandt F, Hohmann H, Werthner Q, Selzer D, Lehr T, Wagenpfeil S, Smola S. Human papillomavirus vaccination of girls in the German model region Saarland: Insurance data-based analysis and identification of starting points for improving vaccination rates. PLoS One 2022; 17:e0273332. [PMID: 36054196 PMCID: PMC9439211 DOI: 10.1371/journal.pone.0273332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 08/07/2022] [Indexed: 11/18/2022] Open
Abstract
In Germany, the incidence of cervical cancer, a disease caused by human papillomaviruses (HPV), is higher than in neighboring European countries. HPV vaccination has been recommended for girls since 2007. However, it continues to be significantly less well received than other childhood vaccines, so its potential for cancer prevention is not fully realized. To find new starting points for improving vaccination rates, we analyzed pseudonymized routine billing data from statutory health insurers in the PRÄZIS study (prevention of cervical carcinoma and its precursors in women in Saarland) in the federal state Saarland serving as a model region. We show that lowering the HPV vaccination age to 9 years led to more completed HPV vaccinations already in 2015. Since then, HPV vaccination rates and the proportion of 9- to 11-year-old girls among HPV-vaccinated females have steadily increased. However, HPV vaccination rates among 15-year-old girls in Saarland remained well below 50% in 2019. Pediatricians vaccinated the most girls overall, with a particularly high proportion at the recommended vaccination age of 9–14 years, while gynecologists provided more HPV catch-up vaccinations among 15-17-year-old girls, and general practitioners compensated for HPV vaccination in Saarland communities with fewer pediatricians or gynecologists. We also provide evidence for a significant association between attendance at the children´s medical check-ups “U11” or “J1” and HPV vaccination. In particular, participation in HPV vaccination is high on the day of U11. However, obstacles are that U11 is currently not financed by all statutory health insurers and there is a lack of invitation procedures for both U11 and J1, resulting in significantly lower participation rates than for the earlier U8 or U9 screenings, which are conducted exclusively with invitations and reminders. Based on our data, we propose to restructure U11 and J1 screening in Germany, with mandatory funding for U11 and organized invitations for HPV vaccination at U11 or J1 for both boys and girls.
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Affiliation(s)
| | | | - Jürgen Rissland
- Institute of Virology, Saarland University Medical Center, Homburg, Germany
| | - Jakob Schöpe
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University Medical Center, Homburg, Germany
| | - Emeline Taurian
- Institute of Virology, Saarland University Medical Center, Homburg, Germany
| | - Hanna Müller
- Institute of Virology, Saarland University Medical Center, Homburg, Germany
| | - Gero Weber
- Physical Geography and Environmental Research, Saarland University, Saarbrücken, Germany
| | - Stefan Lohse
- Institute of Virology, Saarland University Medical Center, Homburg, Germany
| | - Thomas Lamberty
- Ministry of Health, Social Affairs, Women and the Family, Saarbrücken, Germany
| | - Bernd Holleczek
- Ministry of Health, Social Affairs, Women and the Family, Saarbrücken, Germany
- Saarland Cancer Registry, Saarbrücken, Germany
| | - Harry Stoffel
- Kassenärztliche Vereinigung Saarland, Saarbrücken, Germany
| | | | | | | | | | | | | | - Quirin Werthner
- Clinical Pharmacy, Saarland University, Saarbrücken, Germany
| | - Dominik Selzer
- Clinical Pharmacy, Saarland University, Saarbrücken, Germany
| | - Thorsten Lehr
- Clinical Pharmacy, Saarland University, Saarbrücken, Germany
| | - Stefan Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University Medical Center, Homburg, Germany
| | - Sigrun Smola
- Institute of Virology, Saarland University Medical Center, Homburg, Germany
- Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), Helmholtz Centre for Infection Research, Saarbrücken, Germany
- * E-mail:
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4
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Ecke S, Huber A, Hilfrich R, French L, Reinholz M. HPV16 L1 serological test shows high concordance with anal cytology in people living with HIV. JID INNOVATIONS 2022; 2:100124. [PMID: 35620706 PMCID: PMC9127411 DOI: 10.1016/j.xjidi.2022.100124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Sara Ecke
- Department of Dermatology and Allergy, University Hospital, Ludwig Maxmilian University of Munich, Munich, Germany
| | - Anna Huber
- Abviris Deutschland GmbH, Ahrensburg, Germany
| | | | - Lars French
- Department of Dermatology and Allergy, University Hospital, Ludwig Maxmilian University of Munich, Munich, Germany
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Markus Reinholz
- Department of Dermatology and Allergy, University Hospital, Ludwig Maxmilian University of Munich, Munich, Germany
- Corresponding author
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5
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Albuquerque A, Stockdale CK, Heller D, Bornstein J, Roberts JM, Preti M, Poynten IM, Vieira-Baptista P. Vulvar High-Grade Squamous Intraepithelial Lesions and Cancer as a Risk Factor for Anal Cancer: A Review. J Low Genit Tract Dis 2022; 26:32-37. [PMID: 34670242 DOI: 10.1097/lgt.0000000000000631] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Anal squamous cell carcinoma (ASCC) has a higher incidence described in certain groups, namely, in women with vulvar high-grade squamous intraepithelial lesions (vHSILs) and/or human papillomavirus squamous cell carcinoma (VSCC). This review describes terminology, vHSIL, and VSCC in their association with ASCC and the published recommendations for early detection of this cancer in these women. MATERIALS AND METHODS A narrative review was conducted by the authors on vHSIL and VSCC as risk factors for ASCC. RESULTS The ASCC and VSCC incidence are increasing. Women with vHSIL and/or VSCC can present with ASCC at diagnosis, being one of the highest-risk groups. Suspicious symptoms include rectal bleeding, pain, and a sensation of an anal mass. Digital anorectal examination can help detect early ASCC. Sensitivity of anal cytology in women with vHSIL and VSCC seems low, with the exception of immunosuppressed women with genital neoplasia (cervix, vagina, and vulva). There are still insufficient data on high-resolution anoscopy in women with vHSIL and/or VSCC as a screening method. CONCLUSIONS Clinicians need be aware that women with vHSIL and VSCC comprise one of the highest-risk groups for ASCC. Inquiring suggestive symptoms of ASCC and a digital anorectal examination can help in the early detection of this type of cancer.
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Affiliation(s)
- Andreia Albuquerque
- CINTESIS-Center for Health Technology and Services Research, Medical Research Center, University of Porto, Porto, Portugal
| | | | | | - Jacob Bornstein
- Bar Ilan University and Galilee Medical Center, Nahariya, Israel
| | | | - Mario Preti
- Department of Surgical Science University of Torino, Torino, Italy
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Comparing and contrasting clinical consensus and guidelines for anal intraepithelial neoplasia in different geographical regions. Updates Surg 2021; 73:2047-2058. [PMID: 34482519 PMCID: PMC8606379 DOI: 10.1007/s13304-021-01156-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 08/23/2021] [Indexed: 12/03/2022]
Abstract
Anal Squamous Cell Carcinoma (ASCC) is an uncommon cancer with a recognised precursor Anal Intraepithelial Neoplasia (AIN). Although there are consistent evidence-based guidelines for the management of ASCC, historically this has not been the case for AIN and as a result there have been geographical variations in the recommendations for the treatment of AIN. More recently there have been updates in the literature to the recommendations for the management of AIN. To assess whether we are now closer to achieving an international consensus, we have completed a systematic scoping review of available guidelines for the screening, treatment and follow-up of AIN as a precursor to ASCC. MEDLINE and EMBASE were systematically searched for available clinical guidelines endorsed by a recognised clinical society that included recommendations on either the screening, treatment or follow-up of AIN. Nine clinical guidelines from three geographical areas were included. The most recent guidelines agreed that screening for AIN in high-risk patients and follow-up after treatment was necessary but there was less consensus on the modality of screening. Six Guidelines recommended the treatment of high-grade AIN and four guidelines describe a follow-up protocol of patients diagnosed with AIN. There appears to be increasing consensus on the treatment and follow-up of patients despite a poor evidence base. There is still significant discrepancy in guidance on the method to identify patients at risk of ASCC and AIN despite consensus between geographical regions on which patient subgroups are at the highest risk.
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8
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Brogden DRL, Kontovounisios C, Chong I, Tait D, Warren OJ, Bower M, Tekkis P, Mills SC. Local excision and treatment of early node-negative anal squamous cell carcinomas in a highly HIV prevalent population. Tech Coloproctol 2021; 25:1027-1036. [PMID: 34117969 PMCID: PMC8370967 DOI: 10.1007/s10151-021-02473-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/30/2021] [Indexed: 11/25/2022]
Abstract
Background Anal squamous cell carcinoma (ASCC) is an uncommon cancer associated with human immunodeficiency virus (HIV) infection. There has been increasing interest in providing organ-sparing treatment in small node-negative ASCC’s, however, there is a paucity of evidence about the use of local excision alone in people living with HIV (PLWH). The aim of this study was to evaluate the efficacy of local excision alone in this patient population. Methods We present a case series of stage 1 and stage 2 ASCC in PLWH and HIV negative patients. Data were extracted from a 20-year retrospective cohort study analysing the treatment and outcomes of patients with primary ASCC in a cohort with a high prevalence of HIV. Results Ninety-four patients were included in the analysis. Fifty-seven (61%) were PLWH. Thirty-five (37%) patients received local excision alone as treatment for ASCC, they were more likely to be younger (p = 0.037, ANOVA) and have either foci of malignancy or well-differentiated tumours on histology (p = 0.002, Fisher’s exact test). There was no statistically significant difference in 5-year disease-free survival and recurrence between treatment groups, however, patients who had local excision alone and PLWH were both more likely to recur later compared to patients who received other treatments for ASCC. (72.3 months vs 27.3 months, p = 0.06, ANOVA, and 72.3 months vs 31.8 months, p = 0.035, ANOVA, respectively). Conclusions We recommend that local excision be considered the sole treatment for stage 1 node-negative tumours that have clear margins and advantageous histology regardless of HIV status. However, PLWH who have local excision alone must have access to an expert long-term surveillance programme after treatment to identify late recurrences.
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Affiliation(s)
- D R L Brogden
- Chelsea and Westminster Hospitals NHS Foundation Trust, London, UK.,Imperial College London, London, UK
| | - C Kontovounisios
- Chelsea and Westminster Hospitals NHS Foundation Trust, London, UK. .,Imperial College London, London, UK.
| | - I Chong
- Royal Marsden NHS Foundation Trust, London, UK.,Institute of Cancer Research, London, UK
| | - D Tait
- Royal Marsden NHS Foundation Trust, London, UK.,Institute of Cancer Research, London, UK
| | - O J Warren
- Chelsea and Westminster Hospitals NHS Foundation Trust, London, UK.,Imperial College London, London, UK
| | - M Bower
- Chelsea and Westminster Hospitals NHS Foundation Trust, London, UK.,Imperial College London, London, UK
| | - P Tekkis
- Chelsea and Westminster Hospitals NHS Foundation Trust, London, UK.,Imperial College London, London, UK.,Royal Marsden NHS Foundation Trust, London, UK
| | - S C Mills
- Chelsea and Westminster Hospitals NHS Foundation Trust, London, UK.,Imperial College London, London, UK
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9
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Siegel R, Werner RN, Koswig S, Gaskins M, Rödel C, Aigner F. Clinical Practice Guideline: Anal Cancer—Diagnosis, Treatment and Follow-up. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:217-24. [PMID: 33531112 DOI: 10.3238/arztebl.m2021.0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The number of anal cancer diagnoses has been rising steadily, so that the incidence has doubled in the past 20 years. Almost all anal cancers are induced by persistent infection with human papillomaviruses. Hitherto the care of patients with anal cancer has been heterogeneous and little experience exists with the primary management of anal cancer. METHODS The guideline was developed in accordance with the requirements of the German Guideline Program in Oncology. In line with the GRADE approach, the certainty of the evidence was assessed on the outcome level following a systematic literature search. Interdisciplinary working groups were set up to compile suggestions for recommendations, which were discussed and agreed upon in a formal consensus conference. RESULTS Ninety-three recommendations and statements were developed. No high-quality evidence was available to support recommendations for or against the treatment of stage I anal cancer with local excision alone as an alternative to chemoradiotherapy. Chemoradiotherapy is the gold standard in the treatment of stages II–III. Among other aspects regarding the timing and extent of response evaluation after chemoradiotherapy, the guideline panel recommended against obtaining a biopsy in the event of complete clinical response. Owing to lack of confidence in the available evidence, only open recommendations were given for treatment of stage IV. CONCLUSION This evidence-based clinical practice guideline provides a sound basis for optimizing the interdisciplinary, cross-sector care of anal cancer patients. Among other areas, gaps in research were identified with respect to the care of patients with early-stage or metastatic anal cancer. Approaches such as chemoradiotherapy combined with regional deep hyperthermia require further investigation. The role for immunotherapy in the management of metastasized anal cancer has also been insufficiently explored to date.
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10
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Screening Women for Anal Cancers: Guidance for Health Care Professionals. Am J Gastroenterol 2021; 116:509-516. [PMID: 33606380 DOI: 10.14309/ajg.0000000000001186] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/11/2021] [Indexed: 12/11/2022]
Abstract
Anal cancer is rare in the general population but is steadily increasing in incidence over the past decade especially in women. Identification and screening of women with high risk facilitates detection of anal precancer and early-stage cancer, improves survival, and potentially uses less invasive therapies compared with the conventional chemoradiation treatments used for advanced cancers. No recently published guidelines currently describe details about screening women for anal squamous cell cancer (ASCC). The available evidence supports the existence of groups of women with higher prevalence of ASCC (e.g., women with human immunodeficiency virus, immune suppression, or previous lower-genital high-grade lesion or cancer) who would likely benefit from screening with some combination of anal cytology and human papillomavirus testing. Additional research is needed to establish the cost-effectiveness and the influence of screening on ASCC mortality rates.
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11
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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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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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13
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Albuquerque A, Stirrup O, Nathan M, Clifford GM. Burden of anal squamous cell carcinoma, squamous intraepithelial lesions and HPV16 infection in solid organ transplant recipients: A systematic review and meta-analysis. Am J Transplant 2020; 20:3520-3528. [PMID: 32343489 DOI: 10.1111/ajt.15942] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/30/2020] [Accepted: 04/10/2020] [Indexed: 01/25/2023]
Abstract
The number of solid organ transplant recipients (SOTR), and their life expectancy, is increasing, with higher risk for long-term complications from immunosuppression. We carried out a systematic review describing the burden of anal squamous cell carcinoma (SCC), and its surrogates, in SOTR. We conducted mixed effect model-based meta-analyses evaluating incidence of anal SCC (standardized incidence ratio [SIR] vs general population, and absolute incidence rate [IR]), prevalence of anal squamous abnormalities, and human papillomavirus (HPV) 16. Generalized I2 statistics were calculated, quantifying heterogeneity. Anal SCC incidence in SOTR was elevated vs the general population (pooled SIR = 6.8, 95% confidence interval [CI], 4.3-10.9; 6 studies including 241 106 SOTR; I2 = 82.3%), with an absolute IR of 12.3 (95% CI, 10.4-14.7) per 100 000 person-years (5 studies including 1 079 489 person-years; I2 = 0%). Prevalence of abnormal anal cytology was 12.9% (95% CI, 9.2%-17.7%; 6 studies including 328 SOTR; I2 = 17.4%). For histology, the pooled prevalence estimate of anal squamous intraepithelial lesions was 22.4% (95% CI, 17.3%-28.5%; 3 studies including 214 SOTR; I2 = 0%), with 4.7% (95% CI, 2.5%-8.5%; I2 = 0%) high-grade squamous intraepithelial lesions. Pooled anal HPV16 prevalence was 3.6% (95% CI, 1.6%-7.8%; 4 studies including 254 SOTR; I2 = 17.6%). There was substantial and consistent evidence of elevated anal SCC incidence in SOTR.
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Affiliation(s)
- Andreia Albuquerque
- Faculty of Medicine of the University of Porto, Porto, Portugal
- St. James's University Hospital, Leeds, UK
| | - Oliver Stirrup
- Centre for Clinical Research in Infection and Sexual Heath, Institute for Global Health, University College London, London, UK
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14
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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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15
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Kaufman E, de Castro C, Williamson T, Lessard B, Munoz M, Mayrand MH, Burchell AN, Klein MB, Charest L, Auger M, Marcus V, Coutlée F, de Pokomandy A. Acceptability of anal cancer screening tests for women living with HIV in the EVVA study. ACTA ACUST UNITED AC 2020; 27:19-26. [PMID: 32218656 DOI: 10.3747/co.27.5401] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Anal cancer is potentially preventable through screening. For screening to be implemented, the screening procedures must be acceptable to the affected population. The objective of the present study was to measure the acceptability of currently available anal cancer screening tests in a population of women living with hiv who had experienced the tests. Methods The evva study ("Evaluation of Human Immunodeficiency Virus, Human Papillomavirus, and Anal Intraepithelial Neoplasia in Women") is a prospective cohort study of adult women living with hiv in Montreal, Quebec. Participants were screened with cervical or anal hpv testing and cervical or anal cytology every 6 months for 2 years. High-resolution anoscopy (hra) and digital anal rectal examination (dare) were also performed systematically, with biopsies, at baseline and at 2 years. An acceptability questionnaire was administered at the final visit or at study withdrawal. Results Of 124 women who completed the acceptability questionnaire, most considered screening "an absolute necessity" in routine care for all women living with hiv [77%; 95% confidence interval (ci): 69% to 84%]. Yearly anal cytology or anal hpv testing was considered very acceptable by 81% (95% ci: 73% to 88%); hra every 2 years was considered very acceptable by 84% (95% ci: 77% to 90%); and yearly dare was considered very acceptable by 87% (95% ci: 79% to 92%). Acceptability increased to more than 95% with a longer proposed time interval. Pain was the main reason for lower acceptability. Conclusions Most participating women considered anal cancer screening necessary and very acceptable. Longer screening intervals and adequate pain management could further increase the acceptability of repeated screening.
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Affiliation(s)
- E Kaufman
- Department of Family Medicine, McGill University, Montreal, QC.,Cumming School of Medicine, University of Calgary, Calgary, AB
| | - C de Castro
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC
| | - T Williamson
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB
| | - B Lessard
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC
| | - M Munoz
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC
| | - M H Mayrand
- Départements d'obstétrique-gynécologie et de médecine sociale et préventive, Centre hospitalier de l'Université de Montréal and Université de Montréal, Montreal, QC
| | - A N Burchell
- Department of Family and Community Medicine and Centre for Urban Health Solutions, St. Michael's Hospital, and Department of Family and Community Medicine and Dalla Lana School of Public Health, University of Toronto, Toronto, ON.,Canadian Institutes of Health Research, Canadian HIV Trials Network, Vancouver, BC
| | - M B Klein
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC.,Canadian Institutes of Health Research, Canadian HIV Trials Network, Vancouver, BC
| | - L Charest
- Clinique médicale l'Actuel, Montreal, QC
| | - M Auger
- Department of Pathology, McGill University, and McGill University Health Centre, Montreal, QC
| | - V Marcus
- Department of Pathology, McGill University, and McGill University Health Centre, Montreal, QC
| | - F Coutlée
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC.,Département de microbiologie, infectiologie, et immunologie, Centre hospitalier de l'Université de Montréal and Université de Montréal, Montreal, QC
| | - A de Pokomandy
- Department of Family Medicine, McGill University, Montreal, QC.,Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC.,Canadian Institutes of Health Research, Canadian HIV Trials Network, Vancouver, BC
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16
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Recommendations Favoring Anal Cytology as a Method for Anal Cancer Screening: A Systematic Review. Cancers (Basel) 2019; 11:cancers11121942. [PMID: 31817212 PMCID: PMC6966611 DOI: 10.3390/cancers11121942] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 11/22/2019] [Accepted: 11/29/2019] [Indexed: 12/14/2022] Open
Abstract
Clinicians are increasingly facing the decision of performing anal cancer screening in high-risk groups. Anal cytology is commonly the first approach. We systematically reviewed recommendations favoring anal cytology for anal cancer screening. Three databases were searched: PubMed, Scopus, and Embase, from January 2007 to 12 September 2019. The references cited by the retrieved articles and the websites of relevant organizations were also searched without language restrictions. Studies reporting guidelines from regional or national societies, institutes, or groups were included. Eight papers met the inclusion criteria and were selected, five were from the United States of America (USA) and three from Europe. There were no national recommendations published. There was one guideline specifically for solid-organ transplant recipients. The other seven targeted HIV-positive patients, with HIV-positive men who have sex with men (MSM) included as a screening group in all of these. Two recommendations favored screening in all HIV-positive patients. Five recommendations targeting HIV-positive patients made considerations about the cytology follow-up, recommending at least annual cytology in case of a normal result, and in case of squamous cytological abnormalities, a referral for anoscopy/high-resolution anoscopy. There were no recommendations for upper and lower age limits for screening. In conclusion, several societies recommend anal cancer screening using anal cytology in HIV-positive MSM patients. There is a lack of screening recommendations for other high-risk groups, with only one society recommending screening in transplant recipients.
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17
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Sunderkötter C, Becker K, Kutzner H, Meyer T, Blödorn-Schlicht N, Reischl U, Nenoff P, Geißdörfer W, Gräser Y, Herrmann M, Kühn J, Bogdan C. Molecular diagnosis of skin infections using paraffin-embedded tissue - review and interdisciplinary consensus. J Dtsch Dermatol Ges 2019; 16:139-147. [PMID: 29418086 DOI: 10.1111/ddg.13438] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 08/21/2017] [Indexed: 01/18/2023]
Abstract
Nucleic acid amplification techniques (NATs), such as PCR, are highly sensitive and specific methods that have become valuable supplements to culture and serology in the diagnosis of infectious disorders. However, especially when using formalin-fixed and paraffin-embedded tissue, these techniques are associated with both false-negative and false-positive results, a pitfall that is frequently misjudged. Representatives of the German Society of Hygiene and Microbiology (DGHM) and the German Society of Dermatology (DDG) therefore set out to develop a consensus - in the form of a review article - on the appropriate indications for NATs using paraffin-embedded tissue, its contraindications, and the key points to be considered in the pre- and post-analytical phase. Given that fresh, naive tissue is preferably to be used in the workup of a suspected infection, PCR analysis on paraffin sections represents an exception. The latter may be considered if an infection is suspected at a later point in time and fresh tissue has not been preserved or can no longer be obtained. Potential indications include confirmation of histologically suspected infections with Leishmania spp., Bartonella spp., Rickettsia spp., or in case of ecthyma contagiosum. Infections with, for example, mycobacteria or RNA viruses, on the other hand, are not considered useful indications for NATs using paraffin sections. In order to avoid misinterpretation of test results, it is essential that laboratory reports on NATs using paraffin-embedded tissue contain information on the indication/diagnostic circumstances, the required and chosen pre-analytical steps, the limitations of the method, and on diagnostic alternatives.
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Affiliation(s)
- Cord Sunderkötter
- Department of Translational Dermatoinfectiology, Westphalian Wilhelms University, Münster, Germany, and Department of Dermatology and Venereology, University Medical Center, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Karsten Becker
- Institute of Medical Microbiology, University Medical Center, Münster, Germany
| | | | - Thomas Meyer
- Institute for Medical Microbiology, Virology, and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Udo Reischl
- Institute of Clinical Microbiology and Hygiene, University Medical Center, Regensburg, Germany
| | - Pietro Nenoff
- Laboratory of Medical Microbiology, Rötha OT Mölbis, Germany
| | - Walter Geißdörfer
- Microbiology Institute - Clinical Microbiology, Immunology, and Hygiene, University Medical Center, Erlangen, Germany
| | - Yvonne Gräser
- Institute of Microbiology and Hygiene, University Medicine Berlin - Charite, Berlin, Germany
| | - Mathias Herrmann
- Institute of Medical Microbiology and Hygiene Institute for Infectious Diseases, Saarland University Medical Center, now: Dean of the Medical Faculty, Westphalian Wilhelms University, Münster, Germany
| | - Joachim Kühn
- Institute of Virology, University Medical Center, Münster, Germany
| | - Christian Bogdan
- Institute of Microbiology - Clinical Microbiology, Immunology, and Hygiene, University Medical Center and Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
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18
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Hildebrand JA, Fischbeck AJ, Hundsdoerfer B, Clanner-Engelshofen BM, Marsela E, Wollenberg A, Flaig M, French LE, Reinholz M. Retrospective analysis of alpha-human papillomavirus (HPV) types in tissue samples from anogenital dysplasias - introduction of the RICH (Risk of HPV-related Carcinoma in HIV +/- patients) score. J Eur Acad Dermatol Venereol 2019; 34:377-384. [PMID: 31494974 DOI: 10.1111/jdv.15932] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 08/14/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Chronic viral infections caused by highly contagious human papillomaviruses (HPVs) from the alpha genus are a substantial risk factor for tumour diseases. OBJECTIVES The goal of this study was to compare the HPV infection pattern with histology in a patient group of immunocompromised HIV+ and non-immunocompromised patients with anal intraepithelial neoplasia. MATERIALS AND METHODS Tissue samples (n = 210) from the anogenital area of 121 patients underwent retrospective histological and molecular examination for HPV DNA prevalence by chip analysis. The study was part of a cancer screening from the Dermatology Department of the LMU Munich, Germany. All data were collected and processed anonymously. RESULTS HPV 6 or 11 are more abundant in tissue samples from histologically diagnosed condylomata acuminata (47.7%) compared to grade 1, 2, and 3 intraepithelial neoplasias (IN 1-3). Detection of high-risk (hr) alpha-HPV DNA was significantly higher in tissue samples from IN 3 (67.5%) compared to IN 1 and 2 (12.9%), and compared to condylomata acuminata (29.5%). No HPV types were detected in histologically unremarkable tissue samples. There was a significant association between the prevalence of HPV 16 and the classifications IN 1 to IN 3 (χ2 (2) = 13.62, P = 0.001). We identified a significant correlation between the prevalence of high-risk and low-risk (lr) HPV types and HIV, especially mixed infections of different HPV types correlated with high-grade IN. Based on the present data, we suggest the risk of carcinoma in HIV+/- patients (RICH) score and test it in the 121 patients. CONCLUSIONS hr alpha-HPVs, mainly HPV 16, are associated with increased oncogenic potential of premalignant lesions (IN 1-3), especially in HIV+ patients. Based on the combination of HIV/HPV-testing and histological analysis, we identified correlations that could potentially forecast the risk of malignant transformation and summarized them in the form of RICH score.
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Affiliation(s)
- J A Hildebrand
- Department of Dermatology and Allergology, University Hospital of Munich (LMU), Munich, Germany
| | - A J Fischbeck
- Department of Dermatology and Allergology, University Hospital of Munich (LMU), Munich, Germany
| | - B Hundsdoerfer
- Department of Dermatology and Allergology, University Hospital of Munich (LMU), Munich, Germany
| | - B M Clanner-Engelshofen
- Department of Dermatology and Allergology, University Hospital of Munich (LMU), Munich, Germany
| | - E Marsela
- Department of Dermatology and Allergology, University Hospital of Munich (LMU), Munich, Germany
| | - A Wollenberg
- Department of Dermatology and Allergology, University Hospital of Munich (LMU), Munich, Germany
| | - M Flaig
- Department of Dermatology and Allergology, University Hospital of Munich (LMU), Munich, Germany
| | - L E French
- Department of Dermatology and Allergology, University Hospital of Munich (LMU), Munich, Germany
| | - M Reinholz
- Department of Dermatology and Allergology, University Hospital of Munich (LMU), Munich, Germany
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19
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Sunderkötter C, Becker K, Kutzner H, Meyer T, Blödorn-Schlicht N, Reischl U, Nenoff P, Geißdörfer W, Gräser Y, Herrmann M, Kühn J, Bogdan C. Molekulare Diagnostik von Hautinfektionen am Paraffinmaterial - Übersicht und interdisziplinärer Konsensus. J Dtsch Dermatol Ges 2019; 16:139-148. [PMID: 29418100 DOI: 10.1111/ddg.13438_g] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 08/21/2017] [Indexed: 12/20/2022]
Abstract
Nukleinsäure-Amplifikations-Techniken (NAT), wie die PCR, sind hochsensitiv sowie selektiv und stellen in der mikrobiologischen Diagnostik wertvolle Ergänzungen zur kulturellen Anzucht und Serologie dar. Sie bergen aber gerade bei formalinfixiertem und in Paraffin eingebettetem Gewebe ein Risiko für sowohl falsch negative als auch falsch positive Resultate, welches nicht immer richtig eingeschätzt wird. Daher haben Vertreter der Deutschen Gesellschaft für Hygiene und Mikrobiologie (DGHM) und der Deutschen Dermatologischen Gesellschaft (DDG) einen Konsensus in Form einer Übersichtsarbeit erarbeitet, wann eine NAT am Paraffinschnitt angezeigt und sinnvoll ist und welche Punkte dabei in der Präanalytik und Befundinterpretation beachtet werden müssen. Da bei Verdacht auf eine Infektion grundsätzlich Nativgewebe genutzt werden soll, ist die PCR am Paraffinschnitt ein Sonderfall, wenn beispielsweise bei erst nachträglichaufgekommenem Verdacht auf eine Infektion kein Nativmaterial zur Verfügung steht und nicht mehr gewonnen werden kann. Mögliche Indikationen sind der histologisch erhobene Verdacht auf eine Leishmaniose, eine Infektion durch Bartonellen oder Rickettsien, oder ein Ecthyma contagiosum. Nicht sinnvoll ist oder kritisch gesehen wird eine NAT am Paraffinschnitt zum Beispiel bei Infektionen mit Mykobakterien oder RNA-Viren. Die Konstellation für eine NAT aus Paraffingewebe sollte jeweils benannt werden, die erforderliche Prä-Analytik, die jeweiligen Grenzen des Verfahrens und die diagnostischen Alternativen bekannt sein. Der PCR-Befund sollte entsprechend kommentiert werden, um Fehleinschätzungen zu vermeiden.
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Affiliation(s)
- Cord Sunderkötter
- Abteilung für translationale Dermatoinfektiologie, Westfälische Wilhelms-Universität Münster und Universitätsklinik für Dermatologie und Venerologie, Martin-Luther-Universität Halle-Wittenberg
| | - Karsten Becker
- Institut für Medizinische Mikrobiologie, Universitätsklinikum Münster
| | | | - Thomas Meyer
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf
| | | | - Udo Reischl
- Institut für Klinische Mikrobiologie und Hygiene, Universitätsklinik Regensburg
| | - Pietro Nenoff
- Labor für medizinische Mikrobiologie, Rötha OT Mölbis
| | - Walter Geißdörfer
- Mikrobiologisches Institut - Klinische Mikrobiologie, Immunologie und Hygiene, Universitätsklinikum Erlangen
| | - Yvonne Gräser
- Institut für Mikrobiologie und Hygiene, Universitätsmedizin Berlin - Charité
| | - Mathias Herrmann
- Institut für Medizinische Mikrobiologie und Hygiene Institute für Infektionsmedizin, Universitätsklinikum des Saarlandes, jetzt Dekanat der Medizinischen Fakultät, Westfälische Wilhelms-Universität Münster
| | - Joachim Kühn
- Institut für Virologie, Universitätsklinikum Münster
| | - Christian Bogdan
- Mikrobiologisches Institut - Klinische Mikrobiologie, Immunologie und Hygiene, Universitätsklinikum Erlangen und Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg
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20
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Albuquerque A. Cytology in Anal Cancer Screening: Practical Review for Clinicians. Acta Cytol 2019; 64:281-287. [PMID: 31533094 DOI: 10.1159/000502881] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 08/21/2019] [Indexed: 12/12/2022]
Abstract
The incidence and mortality of anal squamous cell carcinoma (SCC) are expected to continue to increase in the next 20 years. High-risk groups for anal SCC, i.e., human immunodeficiency virus (HIV)-positive patients, men who have sex with men (MSM), women with previous genital neoplasia, and solid-organ transplant recipients, have been identified. HIV-positive MSM have the highest risk, and some societies have advocated for anal cancer screening to be done in this population. Screening for anal SCC follows the same principles as that for cervical cancer since there are similarities between the two types of cancers. Anal cytology has been recommended as an initial screening method for high-risk groups, e.g., HIV-positive MSM. Normally, the cytology is liquid based and collected blindly by a clinician using a Dacron swab and it is especially used for internal lesions detection. The sensitivity to predict anal high-grade squamous intraepithelial lesions is higher in immunosuppressed patients with a high burden of the disease. The report should include the classification, normally according to the Bethesda terminology and the sample adequacy, in a manner similar to that for cervical cytology. In cases involving unsatisfactory samples, it is important to repeat the procedure given the prevalence of anal squamous cytological abnormalities in follow-up cytology procedures. The absence of transformation zone cells in anal cytology seems to increase the risk of false-negative results.
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21
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Todorova A, Schwierzeck V, Turek D, Zink A, Schwerdtfeger C, Kaliebe K, Spinner CD, Traidl-Hoffmann C. Evaluation of anal carcinoma screening in male and female HIV patients at an interdisciplinary HIV therapy centre. J Eur Acad Dermatol Venereol 2019; 33:1595-1601. [PMID: 30883929 DOI: 10.1111/jdv.15575] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 03/01/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Incidence of anal carcinoma is increased in people living with HIV (PLWH). Due to the improved life expectancy in PLWH, identifying appropriate prevention strategies for non-AIDS-defining cancer types such as anal carcinoma has become a priority in managing PLWH today. OBJECTIVE We aimed to evaluate anal cytology assessment as screening tool for anal dysplasia and/or carcinoma in PLWH, regardless of gender or sexual orientation. Additionally, we investigated the correlation between cancer risk factors and abnormal screening results in our patient cohort. METHODS People living with HIV from the Interdisciplinary HIV Centre of the University Hospital rechts der Isar in Munich, Germany (IZAR), were screened for anal carcinoma by single cytobrush examination and anal Papanicolaou (PAP) smear assessment from 2013 to 2015. Patients with abnormal PAP smear result were offered a follow-up examination after 12 months. Differences between two groups were tested for statistical significance using Student's t-test and Mann-Whitney U-test, as appropriate. RESULTS In total, 101 PLWH were included. 26.7% of subjects (n = 27) were PAP IIID, and 9.9% (n = 10) were PAP IVa. Seven female subjects had an abnormal finding at screening. Smoking was significantly associated with abnormal findings at screening (P = 0.005). In addition, our study found an association between sexually transmitted infections (STI) and anal dysplasia. Condylomata acuminata were increased in subjects with PAP IIID/PAP IVa (P = 0.045). Reactive syphilis serology was found to be significantly associated with abnormal screening results (P = 0.016), respectively. CONCLUSION Our results demonstrate that smoking and two common STIs, condylomata acuminata and syphilis, are risk factors associated with advanced anal intraepithelial neoplasia (AIN) stages in our PLWH cohort. While further analysis is needed to determine diagnostic guidelines concerning AIN in PLWH, these results suggest that interdisciplinary lifestyle prevention strategies are required to reduce the risk factors for AIN in PLWH in an outpatient setting.
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Affiliation(s)
- A Todorova
- Interdisciplinary HIV Center (IZAR), University Hospital rechts der Isar, Technical University of Munich, Munich, Germany.,Institute of Environmental Medicine, UNIKA-T, Technical University of Munich and Helmholtz Zentrum Munich - German Research Center for Environmental Health (GmbH), Munich, Germany
| | - V Schwierzeck
- Institute of Environmental Medicine, UNIKA-T, Technical University of Munich and Helmholtz Zentrum Munich - German Research Center for Environmental Health (GmbH), Munich, Germany
| | - D Turek
- Interdisciplinary HIV Center (IZAR), University Hospital rechts der Isar, Technical University of Munich, Munich, Germany.,Institute of Environmental Medicine, UNIKA-T, Technical University of Munich and Helmholtz Zentrum Munich - German Research Center for Environmental Health (GmbH), Munich, Germany
| | - A Zink
- Interdisciplinary HIV Center (IZAR), University Hospital rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Dermatology and Allergy, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - C Schwerdtfeger
- Interdisciplinary HIV Center (IZAR), University Hospital rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Medicine II, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - K Kaliebe
- Interdisciplinary HIV Center (IZAR), University Hospital rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Dermatology and Allergy, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - C D Spinner
- Interdisciplinary HIV Center (IZAR), University Hospital rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Medicine II, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - C Traidl-Hoffmann
- Interdisciplinary HIV Center (IZAR), University Hospital rechts der Isar, Technical University of Munich, Munich, Germany.,Institute of Environmental Medicine, UNIKA-T, Technical University of Munich and Helmholtz Zentrum Munich - German Research Center for Environmental Health (GmbH), Munich, Germany
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Abstract
PURPOSE OF REVIEW Adults living with HIV have an increased risk of malignancy yet there is little data for adolescents and young adults. We reviewed recently published cancer epidemiology, treatment, and outcome data for adolescents and young adults living with HIV (AYALHIV) aged 10 to less than 25 years between 2016 and 2017. RECENT FINDINGS AYALHIV are at increased risk of developing cancer compared to their uninfected peers. Kaposi sarcoma and non-Hodgkin lymphoma occur most frequently with variation by geographical region. Increased cancer risk is associated with HIV-related immunosuppression and coinfection with oncogenic viruses. Published data, particularly on posttreatment outcomes, remain limited and analyses are hampered by lack of data disaggregation by age and route of HIV transmission. SUMMARY Although data are sparse, the increased cancer risk for AYALHIV is the cause for concern and must be modified by improving global access and uptake of antiretroviral therapy, human papilloma virus (HPV) and hepatitis B virus (HBV) vaccination, screening for hepatitis B and C infection, and optimized cancer screening programs. Education aimed at reducing traditional modifiable cancer risk factors should be embedded within multidisciplinary services for AYALHIV.
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23
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[Vaccines for people living with HIV/AIDS]. MMW Fortschr Med 2018; 159:23-27. [PMID: 28597270 DOI: 10.1007/s15006-017-9730-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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A Pilot Study of the Immunologic, Virologic, and Pathologic Consequences of Intra-anal 5% Imiquimod in HIV-1-Infected Men With High-Grade Squamous Intraepithelial Lesions. Dis Colon Rectum 2018; 61:298-305. [PMID: 29360679 DOI: 10.1097/dcr.0000000000000991] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Imiquimod can be used to treat internal anal high-grade squamous intraepithelial lesions. In HIV-1-infected individuals there is a theoretical concern for increased HIV replication in anorectal tissue secondary to imiquimod-induced mucosal inflammation. OBJECTIVE The purpose of this study was to assess local virologic, immunologic, and pathologic effects of imiquimod treatment in HIV-infected individuals. DESIGN This was a pilot study at a single academic center. SETTINGS The study was conducted at the University of Pittsburgh Anal Dysplasia Clinic. PATIENTS HIV-1-infected individuals with biopsy-confirmed internal anal high-grade squamous intraepithelial lesions were included. INTERVENTION Imiquimod cream was prescribed for intra-anal use 3 times per week for 9 weeks. MAIN OUTCOME MEASURES Anal human papillomavirus typing, anal and rectal tissue HIV-1 RNA and DNA quantification, cytokine gene expression, and anal histology were measured. RESULTS Nine evaluable participants (1 participant was lost to follow-up) were all white men with a median age of 46 years (interquartile range = 12 y) and a median CD4 T-cell count of 480 cells per cubic millimeter (interquartile range = 835). All were taking antiretroviral therapy, and 7 of 9 had HIV-1 RNA <50 copies per milliliter. The median dose of imiquimod used was 27.0 (interquartile range = 3.5), and there was a median of 11 days (interquartile range = 10 d) from last dose to assessment. There was no progression to cancer, no significant change in the number of human papillomavirus types detected, and no significant change in quantifiable cytokines/HIV-1 RNA or DNA levels in anal or rectal tissue. Seven (35%) of 20 high-grade lesions resolved to low-grade squamous intraepithelial lesions. LIMITATIONS The study was limited by the small number of participants and variable time to final assessment. CONCLUSIONS Intra-anal imiquimod showed no evidence of immune activation or increase in HIV-1 viral replication in anal and rectal tissue and confirmed efficacy for intra-anal high-grade squamous intraepithelial lesion treatment morbidity. See Video Abstract at http://links.lww.com/DCR/A498.
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25
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The importance of HPV16 in anal cancer prevention. THE LANCET. INFECTIOUS DISEASES 2018; 18:131-132. [DOI: 10.1016/s1473-3099(17)30683-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 10/17/2017] [Indexed: 11/20/2022]
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26
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Abstract
Anogenital warts (condylomata acuminata) are much more frequent in human immunodeficiency (HIV)-positive patients compared to HIV-negative individuals. Anogenital warts of HIV-infected patients differ from those of HIV-negative individuals with respect to their spread, occurrence on more unusual anatomical sites, human papillomavirus (HPV)-type spectrum, tendency to recur, and risk of malignant transformation. Between 18 and 56% of anogenital warts of HIV-positive patients harbor high-grade dysplasia. Therefore, anogenital warts of HIV-infected patients should be preferentially treated with ablative methods and should be evaluated histopathologically. Gender-neutral prophylactic HPV vaccination of HPV-naive boys and girls could also lead to a significant reduction of anogenital warts in this patient group in the future.
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Affiliation(s)
- U Wieland
- Institut für Virologie, Nationales Referenzzentrum für Papillom- und Polyomaviren, Universität zu Köln, 50935, Köln, Deutschland.
| | - A Kreuter
- Klinik für Dermatologie, Venerologie und Allergologie, HELIOS St. Elisabeth Klinik Oberhausen, Universität Witten-Herdecke, 46045, Oberhausen, Deutschland
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27
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Kreuter A, Wieland U. Condylomata acuminata of HIV-positive men may harbour focal areas of dysplasia: relevant implications for the management of human papillomavirus-induced disease in high-risk patients. Br J Dermatol 2017; 175:672-3. [PMID: 27650742 DOI: 10.1111/bjd.14855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- A Kreuter
- Department of Dermatology, Venereology, and Allergology, HELIOS St. Elisabeth Hospital, Oberhausen, University Witten/Herdecke, Germany.
| | - U Wieland
- National Reference Center for Papilloma- and Polyomaviruses, Institute of Virology, Uniklinik Köln, University of Cologne, Cologne, Germany
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Spornraft-Ragaller P, Beissert S. Human papillomavirus is a risk factor for asymptomatic bacterial sexually transmitted infections in HIV-infected men who have sex with men. Br J Dermatol 2017; 174:717-8. [PMID: 27115585 DOI: 10.1111/bjd.14432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- P Spornraft-Ragaller
- Department of Dermatology, University Hospital Carl Gustav Carus at the Technical University of Dresden, Fetscherstr. 74, Dresden, 01307, Germany.
| | - S Beissert
- Department of Dermatology, University Hospital Carl Gustav Carus at the Technical University of Dresden, Fetscherstr. 74, Dresden, 01307, Germany
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Cuming T, Nathan M. Anal cancer screening: Techniques and guidelines. SEMINARS IN COLON AND RECTAL SURGERY 2017. [DOI: 10.1053/j.scrs.2017.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Esser S, Krotzek J, Dirks H, Scherbaum N, Schadendorf D. Sexualverhalten, STIs und HIV-Übertragungsrisiken bei HIV-positiven MSM - Ansätze für die ärztliche Präventionsarbeit. J Dtsch Dermatol Ges 2017; 15:421-429. [PMID: 28378480 DOI: 10.1111/ddg.13217_g] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 11/14/2016] [Indexed: 12/01/2022]
Abstract
HINTERGRUND Steigende Inzidenzen von HIV-Infektionen und STIs (sexually transmitted infections) bei MSM (men having sex with men) seit 2001 in Deutschland erfordern neue Ansätze in der ärztlichen Präventionsarbeit. Diese Studie befasst sich mit geeigneten Parametern für gezielte ärztliche Angebote an HIV-positive MSM mit hohem Risiko für die Übertragung von HIV und STIs. METHODIK UND PATIENTEN In einem zweijährigen Beobachtungszeitraum wurden 233 HIV-positive MSM in der HIV-Ambulanz des Universitätsklinikums Essen zu ihrem Sexualverhalten, Suchtmittelkonsum und psychischem Befinden im vorhergehenden Jahr systematisch befragt. Die dokumentierten Labordaten und klinische Verläufe wurden von der Erstdiagnose der HIV-Infektion bis zum Januar 2014 ausgewertet. ERGEBNISSE Drogengebrauch, Promiskuität, jüngeres Lebensalter und bekannte STIs in der Vorgeschichte waren bei HIV-positiven MSM mit häufigerem ungeschützten Geschlechtsverkehr und einer höheren STI-Inzidenz assoziiert. Zusätzliche HIV-spezifische Parameter für ein erhöhtes HIV-Transmissionsrisiko waren neben einer nachweisbaren HIViruslast unbehandelte HIV-Infektionen, Therapieadhärenzprobleme, Wechsel der antiretroviralen Therapie in den letzten zwölf Monaten, bekannte HIV-Multiresistenz und ein höherer CD4-Zell-Nadir. Obwohl die HIViruslast in der Routineversorgung quartalsweise bestimmt und anschließend vom Arzt mitgeteilt wird, schätzten nur 60 % der HIV-positiven MSM ihr HIV-Transmissionsrisiko korrekt ein. SCHLUSSFOLGERUNGEN Aus Routineuntersuchungen ergeben sich bei HIV-positiven MSM Profile, die auf ein Sexualverhalten mit hohem Risiko für die Übertragung von HIV und STIs hinweisen und Ansätze für die ärztliche Präventionsarbeit bieten.
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Affiliation(s)
- Stefan Esser
- Universitätsklinikum Essen, HPSTD-Ambulanz, Klinik für Dermatologie und Venerologie, Essen
| | - Judith Krotzek
- Universität Witten/Herdecke, Vestische Kinder- und Jugendklinik, Datteln
| | - Henrike Dirks
- Klinik für Abhängiges Verhalten und Suchtmedizin, LVR-Klinikum Essen, Kliniken der Universität Duisburg-Essen, Essen
| | - Norbert Scherbaum
- Klinik für Abhängiges Verhalten und Suchtmedizin, LVR-Klinikum Essen, Kliniken der Universität Duisburg-Essen, Essen
| | - Dirk Schadendorf
- Universitätsklinikum Essen, HPSTD-Ambulanz, Klinik für Dermatologie und Venerologie, Essen
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Esser S, Krotzek J, Dirks H, Scherbaum N, Schadendorf D. Sexual risk behavior, sexually transmitted infections, and HIV transmission risks in HIV-positive men who have sex with men (MSM) - approaches for medical prevention. J Dtsch Dermatol Ges 2017; 15:421-428. [PMID: 28294529 DOI: 10.1111/ddg.13217] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 11/14/2016] [Indexed: 01/12/2023]
Abstract
BACKGROUND Rising incidence rates of HIV and STIs (sexually transmitted infections) among MSM (men who have sex with men) in Germany since 2001 call for new approaches in medical prevention. The present study addresses appropriate parameters to identify those HIV-positive MSM who are at high risk for transmitting HIV and STIs. PATIENTS AND METHODS Over a two-year period, 223 HIV-positive MSM attending the HIV outpatient clinic at the University Medical Center Essen (Germany) were systematically surveyed with respect to their sexual behavior, substance abuse, and psychological well-being in the preceding year. Data analyzed included laboratory and clinical data from the time of the initial HIV diagnosis until January 2014. RESULTS In HIV-positive MSM, a history of substance abuse, promiscuity, younger age, and known STIs was associated with a greater incidence of unprotected sexual intercourse and STIs. Apart from a detectable viral load, additional HIV-specific parameters associated with an increased HIV transmission risk included untreated HIV infection, adherence problems, changes in antiretroviral treatment over the preceding twelve months, known multiresistant HIV infection, and a higher CD 4 nadir. Despite routine quarterly monitoring of viral loads - the result thereof was communicated to patients - only 60 % of individuals assessed their HIV transmission risk correctly. CONCLUSIONS In HIV-positive MSM, patient history and routine laboratory tests allow for the establishment of patient profiles that suggest sexual behavior associated with a high risk of HIV and STI transmission, thus offering new approaches for medical prevention.
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Affiliation(s)
- Stefan Esser
- Department of Dermatology and Venereology, Outpatient Clinic for HIV and STIs, University Medical Center Duisburg-Essen, Essen, Germany
| | - Judith Krotzek
- Children's Hospital Datteln, University Witten/Herdecke, Germany
| | - Henrike Dirks
- Addiction Research Group at the Department of Psychiatry and Psychotherapy, University Medical Center Duisburg-Essen, LVR Hospital Essen, Essen, Germany
| | - Norbert Scherbaum
- Addiction Research Group at the Department of Psychiatry and Psychotherapy, University Medical Center Duisburg-Essen, LVR Hospital Essen, Essen, Germany
| | - Dirk Schadendorf
- Department of Dermatology and Venereology, Outpatient Clinic for HIV and STIs, University Medical Center Duisburg-Essen, Essen, Germany
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Repiso-Jiménez J, Padilla-Espana L, Fernández-Morano T, de Troya-Martín M. Screening for Anal Intraepithelial Neoplasia: High-Resolution Anoscopy-Guided Biopsy of the Anal Canal. ACTAS DERMO-SIFILIOGRAFICAS 2017. [DOI: 10.1016/j.adengl.2016.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Abstract
Proctology is a medical subspecialty that encompasses diseases of the perianal region, anal canal, and rectum. Dermatologists play a pivotal role in this realm, as inflammatory perianal disorders, infectious and sexually transmitted diseases, as well as perianal tumors and their precursor lesions fall within the core competency of dermatology. In a concise manner, the present article highlights all relevant disease groups in the field of proctology. With a particular focus on aspects pertinent to dermatologists, this includes inflammatory disorders, "classic" proctologic diseases, sexually transmitted diseases, malignancies of the anal region, as well as pathogen-induced diseases. Despite the wide variety of disorders, there are only five key symptoms prompting patients to consult a proctologist, including anal pruritus and burning, discharge, bleeding, pain, and foreign body sensation. A simple algorithm, which incorporates these symptoms as well as key clinical features, may assist in quickly establishing the correct diagnosis in everyday clinical practice.
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Affiliation(s)
- Alexander Kreuter
- Department of Dermatology, Venereology, and Allergology, HELIOS St. Elisabeth Hospital, Oberhausen, Germany
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Repiso Jiménez JB, Padilla España L, Fernández Morano T, de Troya Martín M. Screening for Anal Intraepithelial Neoplasia: High-Resolution Anoscopy-Guided Biopsy of the Anal Canal. ACTAS DERMO-SIFILIOGRAFICAS 2016; 108:65-66. [PMID: 27600328 DOI: 10.1016/j.ad.2016.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 07/19/2016] [Accepted: 07/28/2016] [Indexed: 11/17/2022] Open
Affiliation(s)
| | - L Padilla España
- Área de Dermatología, Hospital Costa del Sol, Marbella, Málaga, España
| | | | - M de Troya Martín
- Área de Dermatología, Hospital Costa del Sol, Marbella, Málaga, España
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Siegenbeek van Heukelom ML, Richel O, de Vries HJC, van de Sandt MM, Beck S, van den Munckhof HAM, Pirog EC, de Koning MNC, Prins JM, Quint KD. Low- and high-risk human papillomavirus genotype infections in intra-anal warts in HIV-positive men who have sex with men. Br J Dermatol 2016; 175:735-43. [PMID: 26994411 DOI: 10.1111/bjd.14567] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Anogenital warts are often presumed to represent nondysplastic or low-grade anal intraepithelial neoplasia (LGAIN). We previously demonstrated that up to 20% of intra-anal warts in HIV-positive men who have sex with men (MSM) contain regions of high-grade AIN (HGAIN). OBJECTIVES To determine the causative human papillomavirus (HPV) types of low- and high- grade dysplastic areas in warts from HIV-positive MSM. METHODS A total of 42 intra-anal warts from 41 HIV-positive MSM were graded as nondysplastic, LGAIN or HGAIN. Whole-tissue sections (WTS) were analysed with the SPF10 polymerase chain reaction/LiPA25 HPV genotyping system. If the WTS contained multiple HPV types, dysplastic regions were isolated by laser capture microdissection (LCM) for HPV genotyping. RESULTS Overall, 38 of 42 (91%) WTS tested positive for HPV DNA. Of these, 23 (61%) contained a single HPV type and 15 (39%) contained multiple HPV types. All LCM-selected regions contained no more than one HPV type. Ten of 42 (24%) WTS contained HGAIN disease, of which six (60%) were associated with a high-risk HPV (hrHPV) genotype. Twenty-three of 42 WTS contained LGAIN disease, of which two (9%) were associated with hrHPV. AIN lesions containing hrHPV types were identified using p16 staining. CONCLUSIONS LGAIN lesions can be caused by high-risk HPV genotypes and vice versa. We therefore recommend routine follow-up and treatment of all dysplastic intra-anal warts for HIV-positive MSM.
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Affiliation(s)
- M L Siegenbeek van Heukelom
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, 1105AZ, Amsterdam, the Netherlands. .,Center for Infection and Immunology Amsterdam (CINIMA), Academic Medical Center, 1105AZ, Amsterdam, the Netherlands. .,Department of Dermatology, Academic Medical Center, 1105AZ, Amsterdam, the Netherlands.
| | - O Richel
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, 1105AZ, Amsterdam, the Netherlands.,Center for Infection and Immunology Amsterdam (CINIMA), Academic Medical Center, 1105AZ, Amsterdam, the Netherlands
| | - H J C de Vries
- Center for Infection and Immunology Amsterdam (CINIMA), Academic Medical Center, 1105AZ, Amsterdam, the Netherlands.,Department of Dermatology, Academic Medical Center, 1105AZ, Amsterdam, the Netherlands.,STI Outpatient Clinic, Public Health Service of Amsterdam (GGD Amsterdam), 1018 WT, Amsterdam, the Netherlands
| | | | - S Beck
- DDL Diagnostic Laboratory, 2288 ER, Rijswijk, the Netherlands
| | | | - E C Pirog
- Department of Pathology, Weill Medical College of Cornell University, New York, NY, 10065, U.S.A
| | - M N C de Koning
- DDL Diagnostic Laboratory, 2288 ER, Rijswijk, the Netherlands
| | - J M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, 1105AZ, Amsterdam, the Netherlands.,Center for Infection and Immunology Amsterdam (CINIMA), Academic Medical Center, 1105AZ, Amsterdam, the Netherlands
| | - K D Quint
- DDL Diagnostic Laboratory, 2288 ER, Rijswijk, the Netherlands.,Department of Dermatology, The Leiden University Medical Center, 2300 RC, Leiden, the Netherlands.,Department of Dermatology, Roosevelt Clinics, 2321 BL, Leiden, the Netherlands
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Kreuter A. Proktologie - Erkrankungen der Analregion. J Dtsch Dermatol Ges 2016. [DOI: 10.1111/ddg.12986_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Alexander Kreuter
- Klinik für Dermatologie, Venerologie und Allergologie; HELIOS St. Elisabeth Klinik; Oberhausen
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