The pathology and molecular biology of anal intraepithelial neoplasia: comparisons with cervical and vulvar intraepithelial carcinoma

Detecting Ureaplasma urealyticum among HIV-infected women with or without human papillomavirus using real-time PCR with the ANYPLEX™ II STI-7 assay system

Objectives

Human immunodeficiency virus (HIV) infections increase the chances of women contracting human papillomavirus (HPV), the prime causative agent of cervical cancer. Additionally, Ureaplasma urealyticum is the most frequent pathogen prevailing in sexually transmitted diseases in HIV-infected women. The aim of this study was to determine the presence of U. urealyticum among HIV-infected women with or without HPV in Ghana.

Methods

DNA samples were extracted from cervico-vaginal swabs obtained from 96 HIV-infected women attending the Kumasi South Hospital. U. urealyticum in the DNA samples was detected by real-time PCR with the Anyplex™ II STI-7 detection assay. Microsoft Excel was used to analyze the data, and the Chi-square test was used to determine associations and dependence among the variables.

Results

Among the study population, 93.75% (90/96) were positive for at least one pathogen.In total, 36.5% (35/96) of the women were infected by U. urealyticum, with 30.21% (29/96) being co-infected with HPV. There was no significant association (95% CI, p > 0.05) between U. urealyticum and HPV status among the HIV-infected women.

Conclusion

U. urealyticum and HPV are highly pathogenic, and their prevalence in this study reiterates the need for their routine screening in HIV-infected patients.

Anal Cancer Precursor Lesions in HIV-Infected Persons: Tissue Human Papillomavirus Type Distribution and Impact on Treatment Response

BACKGROUND

Data on tissue distribution of human papillomavirus types in anal high-grade squamous intraepithelial lesions are limited and the impact on treatment outcomes poorly understood.

OBJECTIVE

We aimed to investigate potential predictors of treatment failure after electrocautery ablation, including human papillomavirus type(s) isolated from index lesions.

DESIGN

This was a retrospective cohort study.

SETTINGS

The study was conducted at a tertiary academic referral center in New York City.

PATIENTS

Seventy-nine HIV-infected patients with a diagnosis of anal high-grade squamous intraepithelial lesions between January 2009 and December 2012 were included, and genomic DNA was extracted from biopsy tissue.

MAIN OUTCOME MEASURES

The prevalence of human papillomavirus types in index lesions and surveillance biopsies after electrocautery ablation were analyzed to evaluate treatment response.

RESULTS

Of 79 anal high-grade squamous intraepithelial lesions, 71 (90%) tested positive for ≥1 human papillomavirus type; 8 (10%) had no human papillomavirus detected. The most common type was 16 (39%), followed by 33 (15%). Human papillomavirus type 18 was seen in 3%. Sixty-one patients (77%) underwent electrocautery ablation and had subsequent surveillance biopsies. Surveillance biopsies yielded benign findings or low-grade squamous intraepithelial lesions in 31 (51%) of 61 and recurrent high-grade squamous intraepithelial lesions in 30 (49%) of 61 patients (mean follow-up: 35 mo). Ablation response did not differ significantly based on baseline demographics, smoking history, history of anogenital warts, mean CD4 T-cell count, antiretroviral-therapy use, and HIV viral load (<50 copies/mL). The recurrence of high-grade lesions was not significantly associated with high-risk human papillomavirus types detected in index lesions.

LIMITATIONS

Human papillomavirus genotyping in surveillance biopsies was not performed.

CONCLUSIONS

Anal high-grade squamous intraepithelial lesions in HIV-infected patients contain a wide range of human papillomavirus types, and individual lesions commonly harbor multiple types concomitantly. Recurrence of anal high-grade squamous intraepithelial lesions after electrocautery ablation occurs frequently and is not affected by high-risk human papillomavirus types. See Video Abstract at http://links.lww.com/DCR/A833.

Presence or Absence of Significant HPVE4 Expression in High-grade Anal Intraepithelial Neoplasia With p16/Ki-67 Positivity Indicates Distinct Patterns of Neoplasia: A Study Combining Immunohistochemistry and Laser Capture Microdissection PCR

Progression of anal intraepithelial neoplasia (AIN) involves transition from productive to transforming human papillomavirus (HPV) infection. Grading aims to distinguish productive low-grade AIN from high-grade anal intraepithelial neoplasia (HGAIN) with risk of cancer. We describe immunohistochemical patterns in AIN adding a novel marker for initiation of the productive phase of the HPV life cycle (panHPVE4) to those for cell cycle activity (Ki-67) and transforming activity of HPVE7 gene (p16). We studied 67 anal biopsies for suspected anal neoplasia (17 normal, 15 AIN1, 20 AIN2, 15 AIN3) from 54 men who have sex with men at New York Presbyterian Hospital, USA. Two pathologists generated consensus AIN and immunogrades. Whole tissue and laser capture microdissection samples from multiple HPV-infected biopsies were tested for HPV with SPF10-PCR-DEIA-LiPA25, version 1. (Para)basal Ki-67 expression distinguished normal from AIN (≥lower-third Ki-67) with sensitivity 0.92 and specificity 1.0. Ki-67 did not distinguish grades of AIN. Null/patchy p16 versus diffuse ≥lower-third patterns discriminated HGAIN (sensitivity, 1.0; specificity, 0.84). There was marked heterogeneity in E4 expression within HGAIN. Most AIN2 (14/20) was E4 versus 0/15 AIN3 (sensitivity, 0.70; specificity 1.0). HPV was detected in 63 (94%) biopsies, with 49 (77.8%) high-risk HPV. HPV16 was the most frequent (13%). Multiple HPV genotypes were found in 15 (24%) biopsies and laser capture microdissection -polymerase chain reaction confirmed specific HPV types in E4 +/- AIN. Although Ki-67 discriminated AIN and p16 HGAIN, E4/p16 staining shows that most AIN2 is different from transformed AIN3 in showing both entry into productive HPV infection and transforming activity.

Alterations in the expression and activity of extracellular matrix components in HPV-associated infections and diseases

Infection with human papillomaviruses is associated with a series of benign and malignant hyperproliferative diseases that impose a heavy burden on human populations. A subgroup of mucosal human papillomavirus types are associated with the majority of cervical cancers and a relevant fraction of vulvar, vaginal, anal, penile and head and neck carcinomas. Human papillomaviruses mediate cell transformation by the expression of two pleiotropic oncoproteins that alter major cellular regulatory pathways. However, these viruses are not complete carcinogens, and further alterations within the infected cells and in their microenvironment are necessary for tumor establishment and progression. Alterations in components of the extracellular matrix for instance, matrix metalloproteinases and some of their regulators such as tissue inhibitors of metalloproteinases, have been consistently reported in human papillomaviruses-associated diseases. Matrix metalloproteinases function by remodeling the extracellular matrix and alterations in their expression levels and/or activity are associated with pathological processes and clinical variables including local tumor invasion, metastasis, tumor relapse and overall patient prognosis and survival. In this review we present a summarized discussion on the current data concerning the impact of human papillomavirus infection on the activity and expression of extracellular matrix components. We further comment on the possibility of targeting extracellular matrix molecules in experimental treatment protocols.

Endoscopic submucosal dissection (ESD) for anal high-grade intraepithelial neoplasia: a case report

Anal intraepithelial neoplasia (AIN) is a precursor of anal carcinoma. Conventional therapy is based on topical and local ablative approaches. However, the recurrence rates are very high, leading to repetitive treatment sessions and need for long-term surveillance. Endoscopic submucosal dissection (ESD) is an established treatment for malignant early neoplasias of the gastrointestinal tract, especially in the esophagus, stomach, and colorectum. Japanese centers have reported few cases of ESD for early anal carcinoma. We report a case of high-grade AIN diagnosed with magnifying narrow-band imaging and chromoendoscopy that was resected R0 with ESD en bloc.

A trial of radiofrequency ablation for anal intraepithelial neoplasia

PURPOSE

Radiofrequency ablation (RFA) effectively treats esophageal high-grade dysplasia, but its efficacy in treating anal canal high-grade squamous intraepithelial lesions (HSILs) is unsubstantiated. This prospective study assessed the safety and efficacy of applying hemi-circumferential RFA to anal canal HSIL.

METHODS

Twenty-one HIV-negative participants with HSIL occupying ≤ half the anal canal circumference were treated with hemi-circumferential anal canal RFA. Participants were assessed every 3 months for 12 months with high-resolution anoscopy; recurrence in the treatment zone was re-treated with focal RFA.

RESULTS

Twenty-one participants with a mean of 1.7 lesions (range 1-4) enrolled and completed the trial. Six (29 %) participants had recurrent HSIL within the treated hemi-circumference within 1 year. Four participants (19 %) had persistence of an index lesion at 3 months. One (2.9 %) index HSIL persisted again at 12 months. No participants had more than two RFA treatments. KM curve-predicted HSIL-free survival within the treatment zone at 1 year was 76 % (95 % CI 52-89 %). Comparing the first 7 and last 14 participants, the predicted 1-year HSIL-free survivals are 43 % (95 % CI 10-73 %) and 93 % (95 % CI 59-99 %), respectively (p = 0.008), suggesting a learning curve with the treating physician. Multivariable analysis showed decreased recurrence in the last 14 participants (HR 0.02; 95 % CI 0.001-0.63) while increasing BMI increased recurrence (HR 1.43, 95 % CI 1.01-2.01). No participants had device or procedure-related serious adverse events, anal stricture, or heavy bleeding.

CONCLUSIONS

Hemi-circumferential RFA yielded a high rate of anal HSIL eradication in HIV-negative patients at 1 year with minimal adverse events. Lesion persistence was probably related to incomplete initial ablation.

Background and Current Treatment of Squamous Cell Carcinoma of the Anus

In this review, a summary of our current understanding of squamous cell carcinoma of the anus (SCCA) and the advances in our knowledge of SCCA regarding screening, prevention, the role of the immune system, current treatment and the potential for novel targets are discussed. The present standard of care in terms of treatment is 5-fluorouracil (5-FU) and mitomycin C (MMC) concurrently with radiation, which results in a high level of disease control for small early cancers. Preservation of the anal sphincter is achieved in the majority, although anorectal function is often impaired. Although evidence from prospective studies to support a change in the treatment strategy is lacking, patients with HPV-negative SCCA appear to be less responsive to chemoradiation (CRT) and relapse more frequently. In contrast, HPV-positive tumours usually fare better, but oncological outcomes are modified by smoking and immune incompetence. There is current interest in escalating the radiotherapy dose for larger, more advanced tumours, and de-escalating treatment for HPV-positive tumours. The use of novel immunological treatments to target the underlying different molecular pathways of HPV-positive cancers is exciting.

Screening, Surveillance, and Treatment of Anal Intraepithelial Neoplasia

The prevalence of anal intraepithelial neoplasia has been increasing, especially in high-risk patients, including men who have sex with men, human immunodeficiency virus positive patients, and those who are immunosuppressed. Several studies with long-term follow-up have suggested that rate of progression from high-grade squamous intraepithelial lesions to invasive anal cancer is ∼ 5%. This number is considerably higher for those at high risk. Anal cytology has been used to attempt to screen high-risk patients for disease; however, it has been shown to have very little correlation to actual histology. Patients with lesions should undergo history and physical exam including digital rectal exam and standard anoscopy. High-resolution anoscopy can be considered as well, although it is of questionable time and cost-effectiveness. Nonoperative treatments include expectant surveillance and topical imiquimod or 5-fluorouracil. Operative therapies include wide local excision and targeted ablation with electrocautery, infrared coagulation, or cryotherapy. Recurrence rates remain high regardless of treatment delivered and surveillance is paramount, although optimal surveillance regimens have yet to be established.

Systematic review of guidelines for the assessment and management of high-grade anal intraepithelial neoplasia (AIN II/III)

AIM

There is ambiguity with regard to the optimal management of anal intraepithelial neoplasia (AIN) III. The aim of this review was to assess and compare international/national society guidelines currently available in the literature on the management, treatment and surveillance of AIN III. We also aimed to assess the quality of the studies used to compile the guidelines and to clarify the terminology used in histological assessment.

METHOD

An electronic search of PubMed and Embase was performed using the search terms 'anal intraepithelial neoplasia', 'AIN', 'anal cancer', 'guidelines', 'surveillance' and 'management'. Literature reviews and guidelines or practice guidelines in peer reviewed journals from 1 January 2000 to 31 December 2014 assessing the treatment, surveillance or management of patients with AIN related to human papilloma virus were included. The guidelines identified by the search were assessed for the quality of evidence behind them using the Oxford Centre for Evidence-based Medicine 2011 Levels of Evidence.

RESULTS

The database search identified 5159 articles and two further guidelines were sourced from official body guidelines. After inclusion criteria were applied, 28 full-text papers were reviewed. Twenty-five of these were excluded, leaving three guidelines for inclusion in the systematic review: those published by the Association of Coloproctology of Great Britain and Ireland, the American Society of Colon and Rectal Surgeons and the Italian Society of Colorectal Surgery. No guidelines were identified on the management of AIN III from human papilloma virus associations and societies. All three guidelines agree that a high index of clinical suspicion is essential for diagnosing AIN with a disease-specific history, physical examination, digital rectal examination and anal cytology. There is interchange of terminology from high-grade AIN (HGAIN) (which incorporates AIN II/III) and AIN III in the literature leading to confusion in therapy use. Treatment varies from immunomodulation and photodynamic therapy to targeted destruction of areas of HGAIN/AIN II/III using infrared coagulation, electrocautery, cryotherapy or surgical excision but with little consensus between the guidelines. Recommendations on surveillance strategies are similarly discordant, ranging from 6-monthly physical examination to annual anoscopy ± biopsy. Over 50% of the recommendations are based on Level 3 or Level 4 evidence and many were compiled using studies that were more than 10 years old.

CONCLUSION

Despite concordance regarding diagnosis, there is significant variation in the guidelines over recommendations on the treatment and surveillance of patients with HGAIN/AIN II/III. All three sets of guidelines are based on low level, outdated evidence originating from the 1980s and 1990s.

Anal human papillomavirus (HPV) prevalences and factors associated with abnormal anal cytology in HIV-infected women in an urban cohort from Rio de Janeiro, Brazil

Identifying factors, including human papillomavirus (HPV) genotypes, associated with abnormal anal cytology in HIV-infected women have implications for anal squamous cell cancer (SCC) prevention in HIV-infected women. Anal and cervical samples were collected for cytology, and tested for high-(HR-HPV) and low-risk HPV (LR-HPV) genotypes in a cross-sectional analysis of the IPEC Women's HIV Cohort (Rio de Janeiro, Brazil). Multivariate log-binomial regression models estimated prevalence ratios for factors associated with abnormal anal cytology [≥ atypical squamous cells of undetermined significance, (ASC-US)]. Characteristics of the 863 participants included: median age 42 years, 57% non-white, 79% current CD4+ T-cell count >350 cells/mm(3), 53% HIV-1 viral load <50 copies/mL, median ART duration 5.8 years. Fifty-one percent of anal specimens contained ≥ 1 HR-HPV genotype; 31% had abnormal anal cytology [14% ASC-US, 11% low-grade squamous intra-epithelial lesion, (LSIL); 2% atypical squamous cells-cannot exclude high-grade SIL (ASC-H); 4% high-grade SIL/cancer (HSIL+)]. In multivariate analysis, cervical LSIL+, nadir CD4+ T-cell count ≤ 50 cells/mm(3), HIV-1 viral load ≥ 50 copies/mL, and anal HPV 6, 11, 16, 18, 33, 45, 52, 56, and 58 were associated with ≥ anal ASC-US (p<0.05). Abnormal anal cytology and HR-HPV prevalences were high. HIV-infected women with cervical LSIL+, low nadir CD4+ counts, or detectable HIV-1 viral loads should be a particular focus for enhanced anal SCC screening efforts.

Oncogenic human papillomavirus is not helpful for cytology screening of the precursor lesions of anal cancers in Taiwanese men who are infected with human immunodeficiency virus

BACKGROUND

Homosexual men infected with human immunodeficiency virus (HIV) are at increased risk of developing anal cancer. The aim of this study was to assess the clinical sensitivity of anal cytology analysis and oncogenic human papillomavirus (HPV) detection for predicting histological anal intraepithelial neoplasia.

METHODS

Between March 2011 and December 2013, we enrolled 196 HIV-positive men in Taoyuan General Hospital, Taiwan. We analyzed the results of thin-preparation anal Pap smears, HPV genotyping, and histology of anoscopic biopsy samples.

RESULTS

The mean age (±standard deviation) was 31.43 (±8.74) years. The proportion (95 % confidence interval) with abnormal thin-preparation anal cytology was 36.2 % (29.8-43.2 %): 16.8 % (12.2-22.7 %) atypical squamous cells of undetermined significance, 14.8 % (10.5-20.4 %) low-grade squamous intraepithelial lesions, and 4.6 % (2.4-8.5 %) high-grade squamous intraepithelial lesions. At least one HPV genotype was detected in 90.8 % of subjects, and the mean number of HPV infection types was 4.41 (±3.24).The frequency of histological high-grade anal intraepithelial lesions was 7.14 % (95 % confidence interval 4.3-11.6 %). Anal cytology yielding atypical squamous cells of undetermined significance or higher grades resulted in a sensitivity of 64.3 %, specificity of 65.9 %, positive predictive value of 12.7 %, and negative predictive value of 96 %. Using both oncogenic HPV and cytology did not provide better performance.

CONCLUSIONS

Anal cytology yielding atypical squamous cells of undetermined significance or higher grades could detect two-thirds of high-grade anal intraepithelial neoplasias in HIV-infected men and should be promoted for anal cancer prevention.

Anal squamous intraepithelial neoplasia

Diagnosis, follow up, and treatment of anal intraepithelial neoplasia are complex and not standardized. This may be partly caused by poor communication of biopsy and cytology findings between pathologists and clinicians as a result of a disparate and confusing terminology used to classify these lesions. This article focuses on general aspects of epidemiology and on clarifying the current terminology of intraepithelial squamous neoplasia, its relationship with human papilloma virus infection, and the current methods that exist to diagnose and treat this condition.

Anal human papillomavirus infection among HIV-infected and uninfected men who have sex with men in Beijing, China

BACKGROUND

In light of China's unique ethnic and sociocultural context, and a marked rise in HIV prevalence among MSM, it is important to determine prevalence, genotypes and predictors of anal human papillomavirus (HPV) among HIV-infected and uninfected men who have sex with men (MSM) in Beijing, China.

METHODS

In 2010-2011, we recruited MSM (age range 18-61; median 28 years) through peer volunteers, and collected demographic/behavioral information via interviewer-administrated questionnaires. Trained health workers collected anal swabs for HPV genotyping by PCR and blood samples for HIV/syphilis serologies.

RESULTS

We obtained anal specimens from 212 HIV-infected and 459 HIV-uninfected participants. Among HIV-infected MSM, 82.1% were HPV-infected vs. 57.5% in HIV-uninfected (p<0.01). HIV-infected men had the greatest likelihood of multiple types: 17.9% uninfected; 36.3% with one type; 36.8% with 2-3; 9.0% with ≥4. Oncogenic HPV prevalence was higher among HIV- infected (61.3%) than uninfected participants (39.7%; p<0.01). HIV-uninfected MSM reporting always using condoms during insertive anal intercourse (past 6 months) were less likely to be HPV-infected (OR=0.49, 95%CI: 0.31-0.77). Among HIV-uninfected MSM, HPV infection was associated with unprotected receptive anal intercourse (past 6 months; OR=1.92, 95%CI: 1.19-3.11) and being forced to have sex (previous year; OR=3.32, 95%CI: 1.10-10.0). Multivariable logistic analysis among HIV infected MSM suggested that unprotected oral intercourse (past 6 months) was associated with HPV (adjusted OR=2.12, 95%CI: 1.00-4.48). Syphilis occurred in 55.8% of HIV-infected/HPV-infected, 50.0% of HIV-infected/HPV-uninfected, 19.6% of HIV-uninfected/HPV-infected, and 13.0% of HIV-uninfected/HPV-uninfected MSM.

CONCLUSIONS

HPV anal infections were more common among HIV-infected than uninfected MSM in China, including oncogenic and multiple types. Unprotected oral and receptive anal sex were was independently associated with HPV infection. Promotion of safer sex and HPV vaccination is strongly recommended among MSM.

Concomitant anal and cervical human papillomavirusV infections and intraepithelial neoplasia in HIV-infected and uninfected women

OBJECTIVE

To assess factors associated with concomitant anal and cervical human papillomavirus (HPV) infections in HIV-infected and at-risk women.

DESIGN

A study nested within the Women's Interagency HIV Study (WIHS), a multicenter longitudinal study of HIV-1 infection in women conducted in six centers within the United States.

METHODS

Four hundred and seventy HIV-infected and 185 HIV-uninfected WIHS participants were interviewed and examined with anal and cervical cytology testing. Exfoliated cervical and anal specimens were assessed for HPV using PCR and type-specific HPV testing. Women with abnormal cytologic results had colposcopy or anoscopy-guided biopsy of visible lesions. Logistic regression analyses were performed and odds ratios (ORs) measured the association for concomitant anal and cervical HPV infection.

RESULTS

One hundred and sixty-three (42%) HIV-infected women had detectable anal and cervical HPV infection compared with 12 (8%) of the HIV-uninfected women (P  <  0.001). HIV-infected women were more likely to have the same human papillomavirus (HPV) genotype in the anus and cervix than HIV-uninfected women (18 vs. 3%, P  < 0.001). This was true for both oncogenic (9 vs. 2%, P  =  0.003) and nononcogenic (12 vs. 1%, P < 0.001) HPV types. In multivariable analysis, the strongest factor associated with both oncogenic and nononcogenic concomitant HPV infection was being HIV-infected (OR = 4.6 and OR  = 16.9, respectively). In multivariable analysis of HIV-infected women, CD4 cell count of less than 200 was the strongest factor associated with concomitant oncogenic (OR  = 4.2) and nononcogenic (OR  =  16.5) HPV infection.

CONCLUSION

HIV-infected women, particularly those women with low CD4 cell counts, may be good candidates for HPV screening and monitoring for both cervical and anal disease.

Current treatment options for management of anal intraepithelial neoplasia

Anal squamous cell cancer is an uncommon malignancy caused by infection with oncogenic strains of Human papilloma virus. Anal cancer is much more common in immunocompromised persons, including those infected with Human immunodeficiency virus. High-grade anal intraepithelial neoplasia (HGAIN), the precursor of anal cancer, is identified by clinicians providing care for patients with anorectal disease, and is increasingly being identified during screening of immunosuppressed patients for anal dysplasia. The traditional treatment for HGAIN has been excision of macroscopic disease with margins. This approach is effective for patients with small unifocal HGAIN lesions. Patients with extensive multifocal HGAIN frequently have recurrence of HGAIN after excision, and may have postoperative complications of anal stenosis or fecal incontinence. This led to the suggestion by some that treatment for HGAIN should be delayed until patients developed anal cancer. Alternative approaches in identification and treatment have been developed to treat patients with multifocal or extensive HGAIN lesions. High-resolution anoscopy combines magnification with anoscopy and is being used to identify HGAIN and determine treatment margins. HGAIN can then be ablated with a number of modalities, including infrared coagulation, CO2 laser, and electrocautery. These methods for HGAIN ablation can be performed with local anesthesia on outpatients and are relatively well tolerated. High-resolution anoscopy-directed HGAIN ablation is evolving into a standard approach for initial treatment and then subsequent monitoring of a disease which should be expected to be recurrent. Another treatment approach for HGAIN is topical treatment, principally with 5-fluorouracil or imiquimod. Topical therapies have the advantage of being nonsurgical and are well suited for treating widespread multifocal disease. Topical treatments have the disadvantage of requiring extended treatment courses and causing a symptomatic inflammatory response. Successful treatment requires adherence to a regime that is uncomfortable at best and at worst painful. Topical treatments can be successful in motivated adherent patients willing to accept these side effects.

Anal squamous carcinoma: a new AIDS-defining cancer? Case report and literature review

Squamous anal cell carcinoma is a rare malignancy that represents the 1.5% to 2% of all the lower digestive tract cancers. However, an increased incidence of invasive anal carcinoma is observed in HIV-seropositive population since the widespread of highly active antiretroviral therapy. Human papillomavirus is strongly associated with the pathogenesis of anal cancer. Anal intercourse and a high number of sexual partners appear to be risk factors to develop anal cancer in both sexes. Anal pain, bleeding and a palpable lesion in the anal canal are the most common clinical features. Endo-anal ultrasound is the best diagnosis method to evaluate the tumor size, the tumor extension and the infiltration of the sphincter muscle complex. Chemoradiotherapy plus antiretroviral therapy are the recommended treatments for all stages of localized squamous cell carcinoma of the anal canal in HIV-seropositive patients because of its high rate of cure. Here we present an HIV patient who developed a carcinoma of the anal canal after a long time of HIV infection under highly active antiretroviral therapy with a good virological and immunological response.

Epidemiology, natural history and risk factors for anal intraepithelial neoplasia

Studies conducted in HIV-seropositive individuals have enhanced our understanding of the natural history of anal intraepithelial neoplasia (AIN) and of factors predictive of progression to high-grade AIN, the immediate precursor to anal cancer. AIN is frequently detected in HIV-seropositive individuals. Factors that increase the risk for AIN include HIV infection, low current or nadir blood CD4+ cell counts, receptive anal intercourse, oncogenic human papillomavirus (HPV) infection, persistent anal HPV infection, multiple HPV type infections and high anal HPV viral load. This review confirms the importance of high-grade AIN in HIV-seropositive individuals and HIV-seronegative men having sex with men.

Anal intraepithelial lesions in women with human papillomavirus-related disease

OBJECTIVE

This study aimed to determine the prevalence of anal intraepithelial lesions in women with histologic diagnosis of intraepithelial lesions of the lower genital tract.

MATERIALS AND METHODS

This was a cross-sectional study conducted at the Lower Genital Tract and Colposcopy Unit of Hospital de Clínicas "José de San Martín," University of Buenos Aires, Argentina. A total of 481 women with histologically confirmed low-grade and high-grade cervical, vaginal, or vulvar intraepithelial lesions were evaluated between 2005 and 2011. They were referred for cytologic samples and examination with high-resolution anoscopy. We obtained biopsy specimens of any suspicious colposcopic images.

RESULTS

Of a total of 481 patients, 404 (84%) were immunocompetent, 31 (6.4%) were HIV+, and 46 (9.6%) had other causes of immunosuppression. Moreover, of the 481 patients, 134 (27.86%) had anal intraepithelial neoplasia (AIN); 28 (5.82%) had high-grade AIN and 106 (22%) had low-grade AIN. Women with high-grade cervical intraepithelial neoplasia (CIN 2, 3) had 2 times the odds of developing AIN compared with women with low-grade CIN (CIN 1) (odds ratio = 1.91, 95% confidence interval = 1.1-3.6). Regarding localization, we found statistically significant difference between the frequency of vulvar and anal lesions. Women with vulvar condylomata and vulvar intraepithelial neoplasia (VIN) may be more likely to develop AIN.

CONCLUSIONS

Immunocompetent women with CIN, vaginal intraepithelial neoplasia, or VIN may also present high-grade or low-grade anal intraepithelial lesions so we should consider AIN as part of multicentric disease of the lower genital tract. Cervical intraepithelial neoplasia, VIN, condyloma accuminatta, and vaginal intraepithelial neoplasia could be warning signs of anal intraepithelial lesions.

Treatment of high-grade anal intraepithelial neoplasia with infrared coagulation in a primary care population of HIV-infected men and women

BACKGROUND

High-grade anal intraepithelial neoplasia, the putative anal carcinoma precursor, is more common in HIV-infected persons. The ideal treatment for these lesions has not been established.

OBJECTIVE

The aim of this study was to evaluate the effectiveness of infrared coagulation treatment for high-grade anal intraepithelial neoplasia.

DESIGN

This is a prospective cohort study. Patients with high-grade anal intraepithelial neoplasia either received infrared coagulation treatment or voluntarily did not receive treatment and were reevaluated at a subsequent time point.

SETTING

This investigation was performed at a Ryan White-funded clinic located in the United States.

PATIENTS

HIV-infected men and women with biopsy-confirmed high-grade anal intraepithelial neoplasia were included.

MAIN OUTCOME MEASURES

The primary outcome measured was the histology collected by high-resolution anoscopy-directed biopsy.

RESULTS

The study included 124 patients. Of 42 patients who either delayed treatment or were not treated, 37 (88%; 95% CI = 74%-96%) still had high-grade anal intraepithelial neoplasia on reevaluation and 2 (5%; 95%CI = 1%-16%) had squamous-cell carcinoma. Of 98 patients who received infrared coagulation treatment, 73 (74%; 95% CI = 65%-83%) patients had no evidence of high-grade anal intraepithelial neoplasia on their first posttreatment evaluation, and none had progressed to squamous-cell carcinoma (p < 0.0001 in comparison with untreated). Upon completing all initial and, if necessary, follow-up treatment, 85 (87%; 95% CI = 78%-93%) patients treated by infrared coagulation had no evidence of high-grade anal intraepithelial neoplasia and none had progressed to squamous-cell carcinoma.

LIMITATIONS

The study population may not be representative of the general population, the study environment was uncontrolled, and patients were not randomly assigned to treatment.

CONCLUSIONS

Infrared coagulation is an effective treatment for high-grade anal intraepithelial neoplasia.

Premalignant lesions of the anal canal and squamous cell carcinoma of the anal canal

Squamous cell carcinoma of the anus (SCCA) is a rare tumor. However, its incidence has been increasing in men and women over the past 25 years worldwide. Risk factors associated with this cancer are those behaviors that predispose individuals to human papillomavirus (HPV) infection and immunosuppression. Anal cancer is generally preceded by high-grade anal intraepithelial neoplasia (HGAIN), which is most prevalent in human immunodeficiency virus-positive men who have sex with men. High-risk patients may benefit from screening. The most common presentation is rectal bleeding, which is present in nearly 50% of patients. Twenty percent of patients have no symptoms at the time of presentation. Clinical staging of anal cancer requires a digital rectal exam and a positron emission tomography/computed tomography scan of the chest, abdomen, and pelvis. Endorectal/endoanal ultrasound appears to add more-specific staging information when compared with digital rectal examination alone. Treatment of anal cancer prior to the 1970s involved an abdominoperineal resection. However, the current standard of care for localized anal cancer is concurrent chemoradiation therapy, primarily because of its sphincter-saving and colostomy-sparing potential. Studies have addressed alternative chemoradiation regimens to improve the standard protocol of fluorouracil, misogynic, and radiation, but no alternative regimen has proven superior. Surgery is reserved for those patients with residual disease or recurrence.

Electrocautery ablation of high-grade anal squamous intraepithelial lesions in HIV-negative and HIV-positive men who have sex with men

BACKGROUND

Anal squamous cell carcinoma (ASCC) incidence has been rising over the past decade, most dramatically in HIV-positive men who have sex with men (MSM). We aimed to identify a novel in-office approach for ablating high-grade anal intraepithelial neoplasia (HGAIN), the believed precursor lesion to ASCC.

MATERIALS AND METHODS

We performed a retrospective analysis of medical records from a New York City surgical practice, identifying patients with HGAIN treated with electrocautery ablation (ECA) and followed for at least 5 months with high-resolution anoscopy, biopsies, and/or cytology. We sought to determine HGAIN recurrence and progression to ASCC after ECA.

RESULTS

Two hundred thirty-two MSM, 132 HIV positive and 100 HIV negative, with median follow-up of 19.0 and 17.5 months, respectively, met inclusion criterion. In HIV-negative and HIV-positive MSM, the probability of curing a lesion after first ECA was 85% and 75%, respectively. Over follow-up, 53% of HIV-negative and 61% of HIV-positive patients recurred. After first and second ECA, HIV-positive MSM were 1.28 times (P = 0.16) and 2.34 times (P = 0.009) more likely to recur than HIV-negative MSM. The majority of recurrence was due to development of additional lesions at untreated sites (metachronous recurrence). One patient (0.4%) developed ASCC. At last visit, 83% of HIV-negative and 69% of HIV-positive patients were HGAIN free.

CONCLUSIONS

ECA is an effective treatment for HGAIN, with fewer patients progressing to ASCC than predicted with expectant management. HIV-positive patients are significantly more likely to recur than HIV-negative patients.

Long-term follow-up of infrared coagulator ablation of anal high-grade dysplasia in men who have sex with men

BACKGROUND

We previously reported on infrared coagulator ablation of anal high-grade intraepithelial squamous lesions in HIV-positive and HIV-negative men who have sex with men (MSM) with a median follow-up of 1.5 years.

OBJECTIVE

We sought to determine high-grade intraepithelial squamous lesion recurrence rates after long-term follow-up for infrared coagulator ablation, and whether patients progressed to invasive cancer.

DESIGN

: This study investigated a retrospective cohort.

SETTING

This study was set in an office-based practice.

PATIENTS

The patients evaluated were MSM who underwent at least 1 infrared coagulator anal high-grade intraepithelial squamous lesion ablation between 1999 and 2005 with at least 1-year additional follow-up.

INTERVENTION

Infrared coagulator ablation had been performed.

MAIN OUTCOME MEASUREMENT

The primary outcomes measured were high-grade intraepithelial squamous lesion recurrence and progression to anal squamous-cell carcinoma.

RESULTS

Ninety-six MSM were included (44 HIV-positive) with a median follow-up of 48 and 69 months in HIV-negative and HIV-positive MSM. Thiry-five percent of HIV-positive and 31% of HIV-negative subjects from the original cohort were lost to follow-up. In HIV-negative MSM, 32 (62%) had a recurrence in a mean of 14 months. Recurrence rates after the second and third treatments were 48% and 57%. In HIV-positive MSM, 40 (91%) had a recurrence in a mean of 17 months. Recurrence rates after the second, third, and fourth infrared coagulator ablations were 63%, 85%, and 47%. After the first ablation, HIV-positive MSM were 1.9 times more likely to have a recurrence than HIV-negative MSM (P = .009). One year after the first ablation, 61% of HIV-positive MSM had recurrent high-grade intraepithelial squamous lesions in comparison with 38% of HIV-negative MSM. One year after the second ablation, 49% of HIV-positive MSM had recurrent high-grade intraepithelial squamous lesions in comparison with 28% of HIV-negative MSM. In HIV-negative and HIV-positive MSM, the probability of curing an individual lesion after first ablation was 80% and 67%. Most recurrence was due to the development of metachronous lesions occurring in 82% and 52% of HIV-positive and HIV-negative subjects after their first infrared coagulator treatment. The mean number of recurrent lesions for both HIV-positive and HIV-negative MSM was never >2. No MSM developed squamous-cell carcinoma, and there were no serious adverse events. At last visit, 82% of HIV-positive MSM and 90% of HIV-negative MSM were high-grade intraepithelial squamous lesion free.

LIMITATIONS

This was a retrospective, observational study with significant loss to follow-up.

CONCLUSIONS

Infrared coagulator ablation is an effective treatment for high-grade intraepithelial squamous lesions, and no patients progressed to cancer. HIV-positive patients are significantly more likely to have a recurrence, and recurrence occurred more rapidly in these patients. Continued follow-up is important.

Multifocal intraepithelial neoplasia and the psychological consequence of vulvectomy

A 41-year-old female with significant psychiatric history presented with persistent vulvar lesions that were refractory to common clinic and home based wart therapies. Vulvoscopy directed biopsies confirmed invasive vulvar squamous cell carcinoma and further investigation revealed cervical and anal intraepithelial neoplasia in a patient who remained HIV negative with no other cause of immunosuppression detected other than smoking. Vulvectomy following cancer diagnosis lead to a relapse of her psychiatric illness and excessive alcohol intake. Her psychiatric illness in turn affected her further management and follow-up. This case highlights the need for the case based, medical, surgical, psychological and social considerations when managing persistent anogenital warts and anogenital neoplasia as well as the psychological impact of vulvectomy.

Prevalence of anal intraepithelial neoplasia defined by anal cytology screening and high-resolution anoscopy in a primary care population of HIV-infected men and women

BACKGROUND

Prevalence of high-grade anal intraepithelial neoplasia, the human papillomavirus-associated putative anal cancer precursor, is high in HIV-infected men who have sex with men, but less is known about its prevalence in other HIV-infected subgroups. Similarly, the prevalence of abnormal cytology, used as a screen, is not well-defined in these subgroups.

OBJECTIVE

This study aimed to estimate the prevalence of abnormal cytology and anal intraepithelial neoplasia in a primary care HIV-infected population.

DESIGN

This investigation was designed as a cross-sectional study.

SETTING

This study took place at a Ryan White-funded clinic.

PATIENTS

Included in the study were all (n = 779) HIV-infected patients receiving primary care services between March 2006 and March 2008.

MAIN OUTCOME MEASURES

The main outcome measures were anal cytology and high-resolution anoscopy results.

RESULTS

The prevalence of abnormal cytology was 43%: 62% in men who reported receptive anal intercourse, 39% in women who reported receptive anal intercourse, and 25% in all others (P trend <.0001). High-grade anal intraepithelial neoplasia prevalence was 27%: 44% in men who reported receptive anal intercourse, 26% in women who reported receptive anal intercourse, and 10% in all others (P trend <.0001). Two patients had squamous-cell cancer. Independent predictors of dysplasia were CD4 at screening, receptive anal intercourse, sexual orientation, and history of human papillomavirus disease. Anal cytology and histology findings were not well correlated.

LIMITATIONS

The study population may not be representative of the general HIV-infected population, there were differences between screened and unscreened patients and between patients with abnormal cytology who had high-resolution anoscopy and those who did not, only patients with abnormal cytology had high-resolution anoscopy, and there were possible misclassification errors and uncontrolled possible confounders.

CONCLUSIONS

High-grade anal intraepithelial neoplasia is relatively common in HIV-infected patients regardless of sexual practice. Although risk increases with receptive anal intercourse, patient-provided information on this sexual practice should not be used as a determining factor for screening. Strategies to prevent anal cancer are necessary for all HIV-infected patients.

HAART and progression to high-grade anal intraepithelial neoplasia in men who have sex with men and are infected with HIV

BACKGROUND

Human immunodeficiency virus (HIV)-seropositive men who have sex with men (MSM) are at risk for anal intraepithelial neoplasia (AIN) and cancer. The goal of this study was to identify risk factors associated with high-grade AIN (AIN-2,3) in HIV-positive MSM, including the receipt of highly active antiretroviral therapy (HAART).

METHODS

A cohort study involving 247 HIV-seropositive MSM receiving HAART or initiating HAART was followed up every 6 months for 3 years with human papillomavirus (HPV) testing and high-resolution anoscopy to identify predictors of AIN-2,3 by Cox regression analysis and period prevalence logistic regression.

RESULTS

AIN-2,3 was observed during the study in 132 (53%) of 247 participants. The progression rate to AIN-2,3 from a lesser abnormality at baseline was 12.8 cases per 1000 person-months (95% confidence interval [CI], 9.8-16.5 cases per 1000 person-months). The risk of AIN-2,3 increased with age (odds ratio [OR], 3.09 [95% CI, 1.12-8.52] for men 40-49 years of age and 4.78 [95% CI, 1.29-17.73] for men >50 years of age, compared with men <40 years of age) and for men whose CD4+ cell counts were <50 cells/mm(3) before starting HAART (OR, 14.40 [95% CI, 1.45-143.58]). Men who had been receiving their current HAART regimen for >4 years had a marginally significant lower risk of AIN-2,3 after adjustment for HPV (OR, 0.28 [95% CI, 0.07-1.06]) compared with those treated for <4 years. Anal HPV type 16 (HPV16) or type 18 (HPV18) infections (OR, 14.18; [95% CI, 3.51-57.32]) and HPV16 and HPV18 co-infection (OR, 31.03 [ 95% CI, 5.68-169.60]) were strongly associated with progression to AIN-2,3.

CONCLUSION

HPV16 and HPV18 infections and a low nadir CD4+ cell count increase the risk of AIN-2,3. Receiving the same HAART regimen for >4 years may contribute some benefit against AIN-2,3.

Episomal and integrated human papillomavirus type 16 loads and anal intraepithelial neoplasia in HIV-seropositive men

OBJECTIVES

To assess levels of episomal and integrated human papillomavirus type 16 (HPV-16) loads in HIV-seropositive men who have sex with men (MSM) in anal infection and to study the association between episomal and integrated HPV-16 loads and anal intraepithelial neoplasia (AIN).

STUDY DESIGN

A cohort study of 247 HIV-positive MSM followed each 6 months for 3 years. Overall, 135 (54.7%) men provided 665 HPV-16-positive anal samples.

METHODS

Episomal and integrated HPV-16 loads were measured with quantitative real-time PCR assays. HPV-16 integration was confirmed in samples with a HPV-16 E6/E2 of 1.5 or more with PCR sequencing to demonstrate the presence of viral-cellular junctions.

RESULTS

The HPV-16 DNA forms in anal samples were characterized as episomal only in 627 samples (94.3%), mixed in 22 samples (3.3%) and integrated only in nine samples (1.4%). HPV-16 episomal load [odds ratio (OR) = 1.5, 95% confidence interval (CI) 1.1-2.1], number of HPV types (OR = 1.4, 95% CI 1.1-1.8) and current smoking (OR = 4.8, 95% CI 1.3-18.6) were associated with high-grade AIN (AIN-2,3) after adjusting for age and CD4 cell counts. Integrated HPV-16 load was not associated with AIN-2,3 (OR = 0.7, 95% CI 0.4-1.1). Considering men with AIN-1 at baseline, four (16.7%) of the 24 men who progressed to AIN-2,3 had at least one sample with integrated HPV-16 DNA compared with three (23.1%) of 13 men who did not progress (OR = 0.7, 95% CI 0.2-3.8; P = 0.64). Integration was detected in similar proportions in samples from men without AIN, with AIN-1 or AIN-2,3.

CONCLUSION

High episomal HPV-16 load but not HPV-16 integration load measured by real-time PCR was associated with AIN-2,3.

[Anal intraepithelial neoplasia and anal carcinoma: an increasing problem in HIV patients]

Anal dysplasia is common in HIV patients, especially in HIV-positive men having sex with men (MSM). High-grade anal dysplasia can progress to invasive anal cancer. As in cervical carcinoma, there is a cause and effect relationship between anal cancer and human papillomavirus (HPV) infection, especially with high-risk types such as HPV16. Several experts have recommended screening programs for anal cancer, including anal cytology along the lines of the Pap smear in women. Such screenings should only be performed if pathological findings result in further diagnostic steps and, if necessary, appropriate treatment. Clinical inspection, lesion biopsy, and treatment of anal dysplasia are performed under high-resolution anoscopy. Anal cancer is divided into cancer of the anal margin and cancer of the anal canal. This classification is important because of the difference in treatment regimens. Early cancer of the anal margin is excised akin to squamous cell cancer of the exposed skin, whereas cancer of the anal canal is treated by radiochemotherapy. HIV-positive and HIV-negative patients have similar response rates to combined radiochemotherapy. However, side effects, especially acute post-irradiation skin toxicity, early local recurrences, and abdominoperineal rectal excision are more common in HIV-positive patients. Physicians working in the field of HIV/AIDS should regularly screen their patients for the presence of anal dysplasia and anal cancer. Basic diagnostic workup includes clinical inspection of the perianal area, digital rectal examination, and anal cytology.

Human papillomavirus genotypes in anal intraepithelial neoplasia and anal carcinoma as detected in tissue biopsies

Human papillomavirus (HPV) infection strongly correlates with the development of anal intraepithelial neoplasias and carcinomas; however, few studies have characterized the distribution of the specific subtypes of the virus in the varying grades of dysplasia. This report characterizes the distribution of HPV 16/18 in surgical specimens with anal intraepithelial neoplasia (AIN) I-III and histological variants of anal carcinoma. A total of 111 anal surgical specimens with no dysplasia (10), AIN I-III (53), and anal carcinomas (48) were evaluated for the presence of high-risk HPV infection and subtyped by nested PCR or the Invader Assay. High-risk virus types were detected in progressively greater number of anal intraepithelial lesions from 56% in low grade to 88% in high grade. Type 16 was the prevalent subtype and was noted in 28% of low grade and 68% of high-grade lesions. Moderate dysplasias showed type 16 in 20%, a prevalence similar to that in low-grade lesions. The non-16/18 subtypes of the virus predominated and were present in 50% of the cases. Most (89%) squamous carcinomas were associated with high-risk viruses, 68% with type 16, a prevalence similar to that noted in high-grade dysplasia. Non-16/18 subtypes were encountered more frequently in squamous carcinomas from immunodeficient individuals (57% cases) as compared with immunocompetent individuals (18% cases). The similarity in the prevalence of type 16 in high-grade dysplasia and squamous carcinomas suggests that anal intraepithelial lesion III is the true precursor of squamous carcinoma and warrants aggressive management. Anal intraepithelial lesions II showed a virus distribution that was similar to low-grade dysplasia. In addition, a subset of these that were associated with type 16 or 18 showed progression, whereas those associated with non-16/18 subtypes regressed, thereby raising the possibility of conservative management for these lesions.

Genotyping of human papillomavirus DNA in anal biopsies and anal swabs collected from HIV-seropositive men with anal dysplasia

BACKGROUND

Human papillomavirus (HPV) causes anal intraepithelial neoplasia (AIN) in HIV-seropositive men. The detection of HPV genotypes in anal biopsies and swabs was compared.

METHODS

HPV DNA was detected in anal swabs and biopsies obtained concurrently from 154 HIV-seropositive men [31 without AIN, 60 low-grade AIN (AIN-1), 62 high-grade AIN (AIN-2,3), and 1 indeterminate AIN] under or eligible to highly active antiretroviral therapy.

RESULTS

HPV DNA was detected in 24.2% of normal biopsies compared with 93.5% with AIN-2,3 (P < 0.001) and 88.3% with AIN-1 (P < 0.001). The proportion of biopsies containing multiple genotypes was greater in AIN-1 (n = 21, 35.0%; P = 0.002) and AIN-2,3 (n = 38, 58%; P < 0.001) than in normal biopsies (n = 2, 6.5%). The most frequent genotypes in order of frequency were in AIN-2,3 biopsies HPV-16, 18, 58, and 45 and were in AIN-1 biopsies HPV-6, 11, 16, and 39. Controlling for age, CD4 count, and smoking, the presence of high-risk HPV DNA in biopsies [odds ratio (OR) = 50.8, 95% confidence interval (CI): 13.0 to 199.5] but not in swabs (OR = 2.0, 95% CI: 0.6 to 7.0) was associated with AIN-2,3.

CONCLUSIONS

AIN-2,3 was associated with high-risk HPV infection detected in biopsies but not in swabs in men under or starting highly active antiretroviral therapy, possibly due to the presence of HPV foci outside of the neoplastic lesion.

Anal intraepithelial neoplasia in HIV infection

Human papillomavirus (HPV) infections belong to the most common sexually transmitted infections worldwide. While the immune system eliminates most HPV infections over time in immunocompetent individuals, HPV infections tend to persist in immunodeficient individuals. In HIV-infected men who have sex with men (MSM), anal HPV prevalence is more than 90% and infections with multiple HPV types are common. Consequently, HPV-associated anogenital malignancies occur with high frequency in patients with HIV infection. Anal intraepithelial neoplasia (AIN) is a potential precursor lesion of squamous cell carcinoma of the anus. Like its cervical counterpart, cervical intraepithelial neoplasia (CIN), AIN is causally linked to persistent infections with high-risk HPV types such as HPV16 or HPV18. As AIN and CIN share distinct biological similar-ities, AIN screenings analogous to Pap smear programs for CIN have been recommended in high-risk populations to reduce the incidence of anal carcinoma. These screenings include cytological analysis followed by high resolution anoscopy in case of anal dysplasia. Treatment guidelines for AIN are not yet available. Therapeutic strategies can be divided into topical (e.g. trichloroacetic acid, podophyllotoxin, imiquimod, photodynamic therapy) and ablative (e. g. surgical excision, laser ablation, infrared coagulation, electrocautery) measures. However, controlled studies on AIN treatment have not been performed. The impact of HPV vaccination on AIN development will also need to be assessed. Long-term follow-up of these patients is essential to gain more insight into the natural history of anogenital HPV infection in HIV-positive MSM.

Anal intraepithelial neoplasia and other neoplastic precursor lesions of the anal canal and perianal region

Anal cancer is rare and this helps to explain why anal pre-neoplastic conditions are poorly understood, especially with regard to their natural history and management. Anal intraepithelial neoplasia is closely linked to human papillomavirus infection and is particularly common in homosexuals and in immunosuppressed patients, especially those with HIV/AIDS. The high regression rates of low-grade anal intraepithelial neoplasia may simply reflect inconsistent pathologic reporting. Higher grades of anal intraepithelial neoplasia may remain static for long periods of time in immunocompetent patients, but those with HIV/AIDS show early and rapid malignant transformation. In general, most anal pre-neoplastic conditions are best diagnosed by biopsy and treated by surgical excision, although local recurrence is a problem. In anal Paget's disease, it is important to ascertain, at the time of diagnosis, whether it is due to a primary in-situ apocrine-type of neoplasia of the anus or if the disease is secondary to an invasive primary carcinoma of the rectum.

Early impact and performance characteristics of an established anal dysplasia screening program: program evaluation considerations

BACKGROUND

Screening for invasive anal cancer and its precursors is being increasingly advocated as a response to increasing incidence among HIV-infected persons. We implemented a comprehensive screening program in 2001 and report our early experience to inform monitoring and evaluation of such programs. Our research aims were: (1) to estimate incidence of and mortality from invasive anal cancer (IAC) before (1995-2000) and after (2001-2005) screening program implementation and (2) to examine potential screening program quality indicators.

METHODS

The study cohort included all patients under care for HIV infection at UCSD Owen Clinic between 1995-2005. Person-time incidence rates (IR) and case survival of IAC were estimated for the pre-screening (1995-2000) and post-screening (2001-2005) periods. High resolution anoscopy (HRA) operator accuracy was estimated by kappa agreement between cyto-histologic comparisons. Program quality indicators included: (1) screening coverage; (2) percent technically unsatisfactory cytology smears; (3) time between 1st abnormal cytology and 1st HRA; and (4) time between last clinic visit and last cytology.

RESULTS

28 cases of IAC and 13,411 person-years were observed between 1995-2005. IRs (95% CI) pre-screening and post-screening were 199 and 216 per 100,000 person-years, respectively. There was no routine treatment of high grade squamous intraepithelial lesions (HSIL) during the study period. The percent of patients with IAC requiring chemoradiation decreased from 90.9% to 70.6% (p=0.36). There was a significant improvement in cyto-histologic agreement at HRA with increasing operator experience (r=0.92, p=0.025). Screening coverage was 73% of the target population. Among 14 providers, the percent unsatisfactory cytology smears averaged 27% but varied from 0 - 62%. The median time from 1st abnormal cytology to 1st HRA was 258 days. The median interval between the last cytology and the last clinic visit was 207 days.

CONCLUSION

(1) The overall IR of IAC did not decline in the screening era and was higher than previous estimates for HIV cohorts; (2) stage shift to IAC of more favorable prognosis is a reasonable screening goal; (3) HRA accuracy varied by provider experience; (4) because of delay in access to HRA, digital rectal exam should be combined with cytology screening to detect palpable disease.

Anal cancer: an overview

Anal cancer is a rare tumor with an incidence that has been rising over the last 25 years. The disease was once thought to develop as a result of chronic irritation, but it is now known that this is not the case. Multiple risk factors, including human papillomavirus (HPV) infection, anoreceptive intercourse, cigarette smoking, and immunosuppression, have been identified. HIV infection is also associated with anal cancer; there is a higher incidence in HIV-positive patients but the direct relationship between HIV and anal cancer has been difficult to separate from the prevalence of HPV in this population. HIV infection is also associated with anal cancer; there are increasing numbers of HIV-positive patients being diagnosed with the disease. Treatment of anal cancer prior to the 1970s involved abdominoperineal resection, but the standard of care is now concurrent chemoradiation therapy, with surgery reserved for those patients with residual disease. We present a case of anal cancer followed by a general discussion of both risk factors and treatment.

Gastrointestinal malignancies in HIV-infected or immunosuppressed patients: pathologic features and review of the literature

The gastrointestinal (GI) tract is a common internal organ to be involved by human immunodeficiency virus (HIV)-related malignancies. It is the second most common site for Kaposi sarcoma after skin, and the commonest visceral site, for Kaposi sarcoma in AIDS patients. GI lymphomas have been documented in approximately 25% of AIDS patients with systemic lymphomas. Moreover, GI involvement of AIDS-lymphoma has been associated with poor prognosis and short survival. Several other malignancies that occur in the GI tract are also closely related to HIV-infected or immunosuppressed individuals; these include posttransplant lymphoproliferative disorder, Epstein-Barr virus-associated smooth muscle tumors, anal precancerous lesions, and squamous cell carcinoma. As a result of active antiretroviral therapy, patients infected with HIV are living longer and are consequently at increased risk for development of cancer. Therefore, it is possible that the number of AIDS-associated malignancies will rise and the pattern of tumors may change in the future. In this paper, the clinicopathologic features of GI malignancies associated with AIDS patients are reviewed and the differential diagnosis with other mimic lesions is discussed.

Infrared coagulator ablation of high-grade anal squamous intraepithelial lesions in HIV-negative males who have sex with males

PURPOSE

The incidence of anal squamous carcinoma in males who have sex with males is rising. We reported that infrared coagulation of high-grade squamous intraepithelial lesions in HIV-positive males who have sex with males yielded a recurrence rate after the first ablation of 65 percent and 58 percent after a second ablation. The cure rate of an individual lesion was 72 percent. We endeavored to determine whether this technique demonstrates improved results in HIV-negative males who have sex with males.

METHODS

We performed a retrospective review of medical records on HIV-negative males who have sex with males who had infrared coagulation ablation of anal high-grade squamous intraepithelial lesions. Patients had at least six months' follow-up with cytology, high-resolution anoscopy, and biopsy. Recurrent high-grade squamous intraepithelial lesions were retreated.

RESULTS

Seventy-five patients were enrolled, with a median age of 36 years, and 113 lesions were treated. Forty patients (53 percent) developed a recurrence in a median time of 238 days and 35 patients (47 percent) were disease free for a median of 516 days. When patients were treated a second or third time, recurrence rates dropped to 28 and 0 percent, respectively. The probability of successfully treating an individual lesion at first infrared coagulation was 81 percent and 93 percent when retreated. HIV-positive patients were twice as likely to have lesions persist and 1.7 times more likely to develop a recurrent high-grade squamous intraepithelial lesion. No patient developed squamous-cell carcinoma, anal stenosis, or had a serious complication.

CONCLUSIONS

Infrared coagulation is a safe and effective office-based procedure for treating anal high-grade squamous intraepithelial lesions. Although recurrence was high after the first infrared coagulation, repeated treatment led to resolution of high-grade squamous intraepithelial lesions. Treatment success with infrared coagulation is significantly superior in HIV-negative patients compared with HIV-positive patients.

Immunohistochemical Expression of p16 and Ki-67 Correlates With Degree of Anal Intraepithelial Neoplasia

Anal intraepithelial neoplasia (AIN) is a human papilloma virus related lesion. It has been shown that infection with high-risk human papilloma virus results in up-regulation of p16 and increased cellular proliferation. The objective of this study is to correlate p16 expression and cellular proliferation measured by Ki-67 staining with the degree of dysplasia in the anal canal and to determine the efficacy of these markers in diagnosing high-grade AIN. Seventy-five anal specimens from 55 patients (37 men; 18 women; mean age: 48 y; median: 44 y; range 25 to 96 y) were studied including 35 normal/reactive lesions, 23 low-grade AIN (AIN I and condyloma), and 17 high-grade AIN (AIN II and III). Immunostaining for p16 and Ki-67 was performed. Expression of p16 in AIN correlated with that of Ki-67 (P<0.001). High-grade AIN often demonstrated p16 staining in more than one-third of the thickness of the epithelium in a diffuse/continuous fashion. p16 expression in low-grade AIN was often restricted to the lower 1/3 of the epithelium and/or was focal and discontinuous. The expression of both p16 and Ki-67 correlated with the degree of dysplasia (P<0.01). When positive p16 staining was defined as the presence of diffuse/continuous staining in more than one-third of the thickness of epithelium, the sensitivity, specificity, and accuracy of p16 as a marker for diagnosing high-grade AIN were 76%, 86%, and 84%, respectively. When positive Ki-67 staining was defined as the presence of nuclear staining in more than 25% of the cells in more than one-third of the thickness of epithelium, the sensitivity, specificity, and accuracy of Ki-67 as a marker for diagnosing high-grade AIN were 71%, 84%, and 83% respectively. Both p16 and Ki-67 are reliable markers for diagnosing high-grade AIN.

Bilan préthérapeutique initial du carcinome épidermoïde invasif de l’anus

Anal epidermoid carcinoma is a rare malignant tumor, comprising less than 5% of all carcinomas of the colon, rectum, and anus. The primary therapy now includes radiotherapy, often in combination with chemotherapy. Radical surgery is now rarely indicated. Therapeutic indications are based on locoregional staging, the presence of visceral metastases and an evaluation of the medical history. Anorectal endosonography is helpful in evaluating locoregional extension. In addition, magnetic resonance imaging, positron emission tomography scanning and inguinal sentinel lymph node procedure should play a role in a more selective approach in patients with anal carcinoma.

Trends in the incidence of invasive and in situ vulvar carcinoma

OBJECTIVE

To characterize the incidence of vulvar carcinoma in situ and vulvar cancer over time.

METHODS

We used the Surveillance Epidemiology and End Results database to assess trends in the incidence of vulvar cancer over a 28-year period (1973 through 2000) and determined whether there had been a change in incidence over time. Information collected included patient characteristics, primary tumor site, tumor grade, and follow-up for vital status. We calculated the incidence rates by decade of age, used chi(2) tests to compare demographic characteristics, and tested for trends in incidence over time.

RESULTS

A total of 13,176 in situ and invasive vulvar carcinomas were identified; 57% of the women were diagnosed with in situ, 44% with invasive disease. Vulvar carcinoma in situ increased 411% from 1973 to 2000. Invasive vulvar cancer increased 20% during the same period. The incidence rates for in situ and invasive vulvar carcinomas are distributed differently across the age groups. In situ carcinoma incidence increases until the age of 40-49 years and then decreases, whereas invasive vulvar cancer risk increases as a woman ages, increasing more quickly after 50 years of age.

CONCLUSION

The incidence of in situ vulvar carcinoma is increasing. The incidence of invasive vulvar cancer is also increasing but at a much lower rate.

Molecular biology of squamous cell carcinoma of the anus

BACKGROUND

Squamous cell carcinoma of the anal canal provides a model for studying the contribution of human papillomavirus (HPV) and human immunodeficiency virus (HIV) infection to the development of neoplasia. This paper reviews the existing literature relating to the molecular biology of anal squamous cell carcinoma and proposes a theory of pathogenesis.

METHODS

A Medline literature search was performed to identify English articles on the pathogenesis of squamous cell carcinoma of the anus; further articles were obtained from the references quoted in the literature initially reviewed.

RESULTS

HPV infection and subsequent HPV DNA integration are necessary, but not sufficient, to cause cancer progression. Loss of heterozygosity at 11q23 is the most consistent genomic change observed. Loss of heterozygosity at 17p, 18q and 5q is frequently observed in tumours of HIV-negative patients, but not in those of HIV-positive patients. Current data suggest that mutations in p53, DCC and APC tumour suppressor genes contribute to the stepwise progression of anal squamous cell carcinoma in immunocompetent individuals.

CONCLUSION

In comparison with immunocompetent individuals, HIV-positive patients have persistent HPV infection in the anal canal. In this population, microsatellite instability, rather than chromosomal instability, appears to be a preferred pathway for rapid progression towards invasive carcinoma.

Clinical spectrum and virologic characteristics of anal intraepithelial neoplasia in HIV infection

BACKGROUND

Anal intraepithelial neoplasia (AIN) represents a precursor lesion of invasive squamous cell carcinoma with a clear association to high-risk human papillomavirus (HPV) types. HIV infection is strongly associated with a higher prevalence of genital HPV infection, a higher incidence of AIN, and, consecutively, an increased risk for anal cancer.

OBJECTIVE

The aim of this study was to determine the clinical spectrum of AIN and lesional HPV colonization in a cohort of homosexual men who were HIV positive and had a history of receptive anal intercourse.

METHODS

In all, 103 men who were HIV-1 positive were screened by using clinical, proctologic, cytologic, histologic, and HPV DNA testing.

RESULTS

Of all patients, 86% had anal HPV infection at their first visit. HPV-16 (53%), HPV-18 (27%), HPV-58 (22%), and HPV-83 (22%) were the most frequently found HPV types. AIN was diagnosed in 20 of the 103 patients (19.4%). High-risk HPV types were present in all AIN cases with up to 7 different high-risk and up to 5 different low-risk types per lesion. Histologically, 7 (35%), 7 (35%), and 6 (30%) of the patients had AIN grade I, II, or III, respectively. Four different types of clinical presentation could be distinguished in the 20 patients with AIN: bowenoid (1 case, 5%); erythroplakic (2 cases, 10%); verrucous (6 cases, 30%); and leukoplakic (11 cases, 55%). All verrucous lesions were graded as high-grade intraepithelial lesions in cytology, whereas 6 of the 11 leukoplakic lesions (55%) were low grade. All verrucous AIN carried at least 4 different HPV types, always including HPV-16, and the mean number of HPV types was higher in verrucous lesions than in leukoplakic lesions (5.5 vs 3.8, respectively).

CONCLUSION

These data confirm the high incidence and prevalence of AIN in patients who are HPV positive with HIV infection. Four different clinical types of AIN can be distinguished that might have prognostic implications. Standardized screening programs for anal cancer prevention and treatment protocols for AIN in patients infected with HIV must be implemented.