Anal dysplasia in homosexual men: role of anoscopy and biopsy

Human papillomavirus-associated anal squamous intraepithelial lesions in men who have sex with men and transgender women living with and without HIV in Karachi Pakistan: implications for screening and prevention

BACKGROUND

Anal squamous intraepithelial lesions (ASIL), strongly related to human papilloma virus (HPV) infection, is more prevalent among men who have sex with men (MSM). However, no such data are available for Pakistan yet, and neither HPV vaccination nor anal-cytology screening is implemented in Pakistan. The purpose of this first ever study was to assess the prevalence of HPV-related anal cytological abnormalities among MSM and transgender women living with and without HIV infection in Pakistan.

METHODS

We conducted a cross-sectional study from March 2016 to November 2017 at sexual health centers run by the Perwaaz Trust and the National AIDS Control Program in Karachi. The study enrolled MSM and transgender women aged greater-than-and-equal-to-18-years who reported anal sex in the preceding 6 months. We collected two anal samples for liquid-based cytology and HPV type testing by PCR, and socio-demographic and behavioral data were collected through face-to face interviews. ASIL and its associations with biological and behavioral risk factors were analyzed through Cox regression for prevalence ratios (PR) and corresponding 95% confidence intervals (CIs).

RESULTS

Out of 271 qualifying participants, 79% were MSM and 21% transgender women. The mean age was 28.8 (± 8) years. Almost 35% (93/271) of the study population had ASIL detected, ASIL was significantly more common among participants living with HIV than in HIV negative ((50/118) 42.4%; vs. (43/153) 28.1%) (p ≤ 0.001). Among ASIL, 66% (61/93) had low-grade squamous intraepithelial lesions (LSIL), and 3.6% (3/93) had high-grade squamous intraepithelial lesions (HSIL). The overall, HPV16 positivity was 35.5% (33/93) among all abnormal anal lesions and all 3 HSIL were HPV16 positive, however, HPV16 positivity could show its association with ASIL detection in univariate model only (PR_crude: 2.11(1.39-3.18)). Moreover, any HR-HPV type (PR 3.04; 95% CI 1.75-5.26), concurrent sexually transmitted infection (STI) (2.13; (1.28-3.55)) and HIV + /HPV + coinfection (1.75; (1.07-2.88)) remained independently associated with ASIL in the multivariate model.

CONCLUSIONS

Abnormal anal cytology among MSM and transgender is prevalent enough to consider optimal screening regimens. Further studies are required to see if periodic anal cytology can be made part of HIV care and treatment programs among MSM in Pakistan.

Prevalence and Association of Perianal and Intra-Anal Warts with Composite High-Grade Squamous Intraepithelial Lesions Among Gay and Bisexual Men: Baseline Data from the Study of the Prevention of Anal Cancer

Human papillomavirus (HPV) causes anal warts and anal squamous cell carcinoma (SCC). A higher incidence of anal cancer has been found among individuals previously diagnosed with anogenital warts. We aimed to investigate the association between anal warts and the presumed anal SCC precursor high-grade squamous intraepithelial lesion (HSIL), among participants in the Study of the Prevention of Anal Cancer (SPANC). SPANC was a longitudinal study of anal HPV infections and related lesions among gay and bisexual men (GBM) age 35 years and older, in Sydney, Australia. Anal cytology and high-resolution anoscopy were performed. Logistic regression was used to investigate the association between clinically diagnosed anal warts and intra-anal composite-HSIL (cytology and/or histology) at the baseline visit. The prevalence of HSIL within biopsies from intra-anal warts was calculated. Laser capture microdissection (LCM) and HPV-genotyping was performed on HSIL lesions. Among 616 participants at study entry, 165 (26.8%) and 51 (8.3%) had intra-anal and perianal warts, respectively. Warts were associated with composite-HSIL, even after adjustment for HIV status, age, lifetime receptive anal intercourse partner number, and smoking (perianal: aOR 2.13, 95% CI 1.17-3.87, p = 0.013; intra-anal: aOR 1.69, 95% CI 1.16-2.46, p = 0.006). HSIL was detected in 24 (14.5%) of 165 biopsies from intra-anal warts. Of 17 HSIL lesions, 16 (94.1%) had high-risk HPV detected by LCM. Anal warts were common. Prevalent anal warts were associated with composite-HSIL. HSIL may be detected within biopsies of intra-anal warts. Anal warts may be a useful addition to risk stratification for HSIL among GBM.

The Sentinel Node in Anal Carcinoma

Aims and Background

Anal cancer is a rare condition. The inguinal lymph nodes are the most common site of metastasis in this neoplasm. The inguinal lymph node status is an important prognostic indicator and the presence of metastases is an independent prognostic factor for local failure and overall mortality. Depending on the primary tumor size and histological differentiation, metastasis to superficial inguinal lymph nodes occurs in 15-25% of cases.

Methods and Study Design

To evaluate the inguinal lymph node status we performed a search for the sentinel node in a female patient affected by squamous anal carcinoma.

Results

Identification and examination of the sentinel node was positive and postoperative histology showed the presence of bilateral lymph node metastases.

Conclusions

We suggest that examination of the sentinel node in anal cancer could be an efficient way to establish the inguinal lymph node status, which would help the clinician to plan and perform adequate treatment.

Colposcopic Characteristics and Lugol's Staining Differentiate Anal High-Grade and Low-Grade Squamous Intraepithelial Lesions During High Resolution Anoscopy

Background

Methods

Results

Conclusions

High-resolution anoscopy: clinical features of anal intraepithelial neoplasia in HIV-positive men

BACKGROUND

High-resolution anoscopy is increasingly advocated to screen HIV+ men who have sex with men for anal cancer and its precursor lesions, anal intraepithelial neoplasia. A systematic comparison between clinical features and the histopathology of suspect lesions is lacking.

OBJECTIVE

This study aims to analyze interobserver agreement in classifying features of intra-anal lesions suspect for anal intraepithelial neoplasia and to compare these features with their histopathological outcome.

DESIGN

This study is a cross-sectional survey regarding high-resolution anoscopy with images and biopsies of suspect lesions. Two dermatologists experienced in high-resolution anoscopy, blinded for histopathological outcome, independently classified the lesions on clinical features.

SETTING

This investigation was conducted at the Dermatology outpatient clinic of the Academic Medical Center in Amsterdam, The Netherlands.

PATIENTS

Included in the study were 163 HIV+ men who have sex with men, older than 18 years, with no history of anal cancer.

MAIN OUTCOME MEASURES

The primary outcomes measured were the κ-coefficient for interobserver agreement and the proportions of anal intraepithelial neoplasia per clinical feature.

RESULTS

Three hundred four biopsies were taken from 163 patients. One hundred sixty-eight biopsies (55%) showed anal intraepithelial neoplasia, and 67/304 (22%) showed high-grade anal intraepithelial neoplasia. The κ-coefficient was 0.65 for condylomatous lesions, 0.14 for surface configuration, 0.54 for punctation, 0.08 for mosaicism, and 0.43 for atypical vessels. Condylomatous lesions showed high-grade anal intraepithelial neoplasia in 18% (95% CI, 11%-27%). In lesions with flat leukoplakia, punctation, and atypical vessels, high-grade anal intraepithelial neoplasia was seen in 25%, 30%, and 23%. In lesions with the combination punctation/atypical vessels and punctation/flat leukoplakia/atypical vessels, high-grade anal intraepithelial neoplasia was found in 38% and 40%.

LIMITATIONS

We did not take biopsies of healthy-looking mucosa. Furthermore, the real-time description of features during high-resolution anoscopy, instead of the use of images, would improve the recognition of subtle mucosal abnormalities.

CONCLUSIONS

A moderate to substantial interobserver agreement was demonstrated in recognizing condylomas, punctation, and atypical vessels. Furthermore, high-grade anal intraepithelial neoplasia is present in a high proportion of intra-anal condylomata. A combination of punctation, flat leukoplakia, and atypical vessels is the best predictor for high-grade anal intraepithelial neoplasia.

Anal cytology in patients with AIDS

The objective of the present study was to study the prevalence of abnormal anal cytology in patients with AIDS. Anal smears, obtained with a cytobrush, of 102 HIV-positive patients of the Emilio Ribas Institute (Sao Paulo, Brazil) were collected, and only after that, the patients were submitted to anoscopy. Thirty-two patients had LSIL and 14 others had HSIL. Squamous intra-epithelial lesions were also observed in 38% of the patients without condyloma (18/47): in 9 of the 33 patients without history of condyloma (27%) and in 9 of the 14 patients who had previously treated condyloma (64%). An invasive squamous cell carcinoma was observed in one patient without history of condyloma. In all 13 patients with HSIL, biopsies guided by high resolution anoscopy confirmed high grade dysplasia. Our findings suggest that anal cytology is mandatory in AIDS even in patients without macroscopic anal lesions or without previous history of anal condyloma.

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.

Management of internal genital warts: do we all agree? A postal survey

A postal survey was undertaken to determine whether there was any consensus of opinion regarding the management of internal genital warts in genitourinary medicine clinics in the UK. Overall, 110 forms were returned (57% response). The majority of clinics would refer patients with cervical warts for colposcopy especially if the patient was over the age of 25 or HIV-positive. Proctoscopy or anoscopy was performed in 60% of clinics for patients with perianal warts to determine the presence of warts within the anal canal or rectum. Only 24% of patients with intra-anal warts are referred directly to surgery for biopsy, increasing to 61% if the patient has HIV infection. Cryotherapy is the main treatment for all types of internal warts. Our findings suggest there is no consensus and we recommend that all HIV-positive patients with anal or cervical condyloma should be investigated for evidence of intraepithelial neoplasia.

High-resolution anoscopy in the diagnosis of anal cancer precursor lesions in renal graft recipients

BACKGROUND

Renal graft recipients are one of the population groups known to be at high risk of developing anal cancer. This study investigated the presence of subclinical anal squamous intraepithelial lesions and the diagnostic ability of high-resolution anoscopy in detecting these lesions in renal graft recipients followed-up in Manaus.

METHODS

In a cross-sectional study, 50 renal graft recipients were interviewed and submitted to high-resolution anoscopy with biopsies of acetowhite lesions or of the anal transition zone mucosa when acetowhitening was absent. Considering the histopathological reports of the examined anal specimens as the gold standard, the diagnostic validation and precision measures of high-resolution anoscopy were calculated as well as the prevalence of anal squamous intraepithelial lesions in the studied population.

RESULTS

In 42 renal graft recipients with satisfactory histopathological readings, prevalence of anal squamous intraepithelial lesions or condyloma acuminatum (ASIL-ACU) was 23.81%. Sensitivity of high-resolution anoscopy was 100%; specificity, 65.63%; positive predictive value, 47.62%; negative predictive value, 100%; and kappa coefficient, 0.48.

CONCLUSIONS

With a prevalence of 23.81% of subclinical ASIL-ACU lesions, the studied renal graft recipients had all these lesions detected by high-resolution anoscopy, notwithstanding most anal transition zone acetowhitened biopsied areas did not reveal histopathological aspects of anal cancer precursor lesions or condyloma acuminatum. Therefore, greater experience with the diagnostic tool was felt necessary to enhance its positive predictive value, specificity and diagnostic precision.

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.

Anal intraepithelial neoplasia and anal cancer in dermatological practice

Anal intraepithelial neoplasia is considered to be a precursor lesion of invasive anal cancer. It is now increasingly recognized in high-risk groups, such as men who have sex with men and HIV-infected patients. Human papillomaviruses are considered to be an important aetiological agent in both anal intraepithelial neoplasia and anal cancer. Dermatologists are likely to encounter these conditions among the differential diagnoses to be considered in high-risk patients presenting with perianal and anal lesions. Anal cancer rates are also increasing among the HIV-infected and HIV-non-infected population. The successful treatment of anal intraepithelial neoplasia may reduce the risk of subsequent development of anal cancer. However, current therapies for anal intraepithelial neoplasia may be associated with treatment-related morbidity and are not well validated. It is currently not proven that they reduce the likelihood of the development of anal cancer. Nevertheless, screening for anal intraepithelial neoplasia is being advocated for high-risk groups and may become standard dermatological care for these patients. In view of recent developments in the understanding of this condition, this article reviews the current understanding of anal intraepithelial neoplasia and its treatment from a dermatological perspective.

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.

Blind sampling is superior to anoscope guided sampling for screening for anal intraepithelial neoplasia

OBJECTIVES

Anal cytology smears are either collected "blind" (swab inserted 4 cm into anal canal and rotated) or guided through an anoscope (transformation zone visualised and then sampled). We compared these smear techniques with respect to sample quality and patient acceptability.

METHODS

Using a paired, random sequence clinical trial, 151 homosexual men (n = 95 HIV positive) underwent both smear techniques at a single visit; smear order was randomised and specimens were read blind. Both techniques utilised a Dacron swab, with water lubrication. Cytological specimens were prepared using a liquid based collection method (ThinPrep). The outcome measures were cytological specimen adequacy, cytological classification, presence of rectal columnar, squamous and metaplastic cells, contamination, patient comfort and acceptability, and volume of fluid that remained after the ThinPrep procedure.

RESULTS

Regardless of smear order, guided smears were less likely to detect higher grade abnormalities than blind smears (15 v 27 cases, p = 0.001). Controlling for smear order, guided smears were more likely to be assessed as "unsatisfactory" for cytological assessment (OR 6.93, 95% CI 1.92 to 24.94), and contain fewer squamous (OR 0.20, 95% CI 0.04 to 0.94) and metaplastic cells (OR 0.12, 95% CI 0.03 to 0.54) than blind smears; there were no other statistically significant differences between techniques. Regardless of smear technique, first performed smears were more likely to detect a higher grade abnormality than second performed smears (23 v eight cases, p < 0.001).

CONCLUSIONS

Blind cytology smears are superior to anoscope guided smears for screening for anal neoplasia in homosexual men.

Age-related prevalence of anal cancer precursors in homosexual men: the EXPLORE study

BACKGROUND

Infection with human papillomavirus (HPV) is causally linked to the development of anal and cervical cancer. In the United States, the incidence of anal cancer among men who have sex with men (MSM) is higher than the incidence of cervical cancer among women. Anal squamous intraepithelial lesions (ASILs) are anal cancer precursors comprising low-grade squamous intraepithelial lesions (LSILs) and high-grade squamous intraepithelial lesions (HSILs). The prevalence of cervical cancer precursor lesions peaks at around 30 years of age. The age-related prevalence of ASILs in HIV-negative MSM is unknown.

METHODS

We conducted a cross-sectional analysis of the prevalence and determinants of ASILs in 1262 HIV-negative MSM aged 18-89 years recruited from four U.S. cities. Anal cytology and behavioral data were obtained. Anal HPV infection status was assessed by polymerase chain reaction. Independent predictors of ASILs were identified using logistic regression. All statistical tests were two-sided.

RESULTS

The prevalences of LSILs and HSILs were 15% and 5%, respectively, and did not change with age. In a multivariable analysis, the risk of LSILs was associated with having more than five male receptive anal sex partners (P = .03), any use of poppers (alkyl nitrites) in the previous 6 months [odds ratio (OR) = 1.6, 95% confidence interval (CI) = 1.1 to 2.5; P = .03] or use of injection drugs two or more times per month during the previous 6 months [OR = 19, 95% CI = 1.3 to 277; P = .03], older age at first receptive anal intercourse (P = .004), and infection with a greater number of HPV types (P < .001 for linear trend). The risk of HSILs was associated with any anal HPV infection (OR = 3.2, 95% CI = 1.1 to 9.4; P = .039) and infection with an increasing number of HPV types (P < .001 for linear trend).

CONCLUSIONS

Sexually active HIV-negative MSM in all age groups have a high prevalence of ASILs, possibly reflecting their ongoing sexual exposure to HPV.

Malignant melanoma in an HIV-infected man: a case report and literature review

Although it is not proven by causative association, several studies indicate that patients with acquired immune deficiency syndrome (AIDS) have a high risk for developing cutaneous malignancies, especially lymphoma and Kaposi's sarcoma. Other malignant cutaneous lesions seen in this patient population include basal-cell carcinoma, squamous-cell cancer, Bowen's disease, and rarely, malignant melanoma. We review the clinical course of a human immunodeficiency virus (HIV)-infected man with a superficial spreading melanoma of the scapula treated with wide local excision. Ten years later, he was diagnosed as having metastatic and widespread disease. By placing our patient's experience in context with other case reports, we sought to determine whether malignant melanoma in the HIV-infected population presents atypically or has a more aggressive natural history. The appearance of malignant melanoma in homosexual men may be coincidental or reflective of the expanding spectrum of HIV-associated diseases. Of the 22 patients reported to have malignant melanoma and HIV, approximately one-third had metastatic disease at the time of initial examination, and those with a decreased CD4+ cell count were most likely to have systemic symptoms. Melanomas among patients with HIV infection were often atypical in appearance, being multiple or metastatic, as is the case in other well-defined immunosuppressed groups. Further epidemiological and clinical studies are required to determine whether melanoma occurs more frequently or is more likely to metastasize in persons with HIV disease. Laboratory investigators must also concentrate on those factors in the setting of HIV disease that may contribute to melanocyte activation. Our patient's fulminant clinical course should alert clinicians to carefully evaluate patients with HIV infection and unusual pigmented cutaneous lesions, or who have a prior history of malignant melanoma.

Colposcopic appearance of anal squamous intraepithelial lesions: relationship to histopathology

PURPOSE

The incidence of anal cancer is increased in men with a history of anal receptive intercourse. Analogous to cervical cancer, whose precursor is cervical high-grade squamous intraepithelial lesion (HSIL), anal cancer may be preceded by anal HSIL. Although not yet proven, detection, follow-up, and treatment of HSIL may prevent development of anal cancer. Cervical colposcopic methodology was used to describe anal lesions and to determine if HSIL could be distinguished from low-grade squamous intraepithelial lesion (LSIL).

METHODS

The colposcopic characteristics of 385 biopsied anal lesions were described and correlated with results of histopathology in a cohort of 121 human immunodeficiency virus-positive and 31 human immunodeficiency-negative homosexual/bisexual men with anal lesions followed as part of a longitudinal study of anal squamous intraepithelial lesions. Color, contour, surface, and vascular patterns of anal lesions were analyzed and correlated with histologic diagnosis.

RESULTS

Sixty-seven percent of biopsies showed LSIL and 26 percent showed HSIL. The positive predictive value for anal HSIL in lesions with characteristics typical of cervical LSIL was 7.7 percent (95 percent confidence interval, 1.8-14), whereas the positive predictive value for anal HSIL in lesions with characteristics typical of cervical HSIL was 49 percent (95 percent confidence interval, 40-58).

CONCLUSIONS

The colposcopic appearance of different grades of anal squamous intraepithelial lesions was similar to those described for the cervix. Incorporation of colposcopy into assessment of anal disease could aid in distinguishing anal LSIL from HSIL.

Anal neoplasia. Pathogenesis, diagnosis, and management

Prolonged, severe immunodeficiency provides the necessary milieu for the emergence of anogenital neoplasia caused by human papillomaviruses. Anal neoplasia is likely to become a more common manifestation of HIV disease as patients with profound immunodeficiency, who would have succumbed to opportunistic infections earlier in the epidemic, are now surviving for extended periods of time because of increasingly effective antiretroviral, prophylactic, and antimicrobial therapies. The screening and treatment strategies described for use in HIV-infected patients with anal neoplasia are currently being investigated and refined.

Primary care of the HIV patient: standard practice and new developments in the era of managed care

It is easy when taking care of the patient with AIDS to lose sight of the whole person and become focused on the details of micromanagement, distracted by the array of new therapies, and overwhelmed by the financial risks of the disease. It is therefore critical that a healing and respectful relationship is developed with patients and they are engaged in the decisions regarding their care. Physicians must also continue the search for new therapies and struggle to ensure that patients have access to state-of-the-art treatment. In this, the primary care physician plays a critical role, through identifying study centers, becoming an investigator in expanded access programs, and using referrals to clinical trials to provide new therapies to patients and improve understanding of HIV treatment. Finally, quality of life must be at the forefront of physicians' medical conscience. Ultimately, the physician must know when the best treatment he of she can offer is the assurance of a dignified and comfortable death.

High prevalence of human papillomavirus in squamous cell carcinoma and matched normal esophageal mucosa: assessment by polymerase chain reaction

BACKGROUND

Studies using DNA technology have reported the presence of human papillomavirus (HPV) DNA in esophageal carcinomas, suggesting that it could play a role in the pathogenesis of this tumor. In the present study, in addition to DNA from neoplasms, normal mucosa was screened for viral DNA, assuming that this would increase HPV detection substantially.

METHODS

Seventeen patients with esophageal carcinoma and 10 control subjects were studied. In 8 of the patients, normal mucosa was also available. Polymerase chain reaction (PCR) was performed using primers for the E6 region of HPV-16 and HPV-18. Koilocytosis, a commonly accepted histopathologic marker of viral infection, was studied, and results were correlated with PCR findings.

RESULTS

DNA from neoplastic lesions was positive for HPV-16 and HPV-18 in 8 of 16 (50%) and in 3 of 16 (18.8%), respectively. When tumor tissue and normal mucosa were available, PCR results were 3 of 8 (37.5%), 5 of 8 (62.5%), and 8 of 8 (100%) for HPV-16, in tumor, normal mucosa, and both. For HPV-18, results were 0 of 8 (0%), 5 of 8 (62.5%), and 5 of 8 (62.5%), respectively. In comparison with tumor samples, positivity in normal mucosa was increased for HPV-18 and for both viral genotypes (P = 0.01). No amplification was obtained in the control group. Koilocytosis was present in 33% of the cases.

CONCLUSIONS

These results suggested a high prevalence of HPV in esophageal carcinoma. The detection rate is significantly higher in normal mucosa specimens, suggesting that infection probably antedates tumor development. Koilocytosis was substantially less sensitive than PCR.

Skin cancers associated with acquired immunodeficiency syndrome

OBJECTIVE

To describe the types of skin cancer associated with the acquired immunodeficiency syndrome (AIDS).

DESIGN

A literature review of AIDS-related mucocutaneous neoplasms, including basal cell carcinoma, squamous cell carcinoma, bowenoid papulosis and Bowen's disease, squamous cell carcinoma, cloacogenic carcinoma, and malignant melanoma, is presented, and the incidence, etiopathogenesis, clinicopathologic features, treatment, and prognosis are discussed.

RESULTS

The association between cutaneous neoplasms and AIDS is well known. Neoplasms seem to grow more rapidly and be more invasive in patients with AIDS than in other groups of patients. Several oncogenic factors--for example, sunlight exposure or human papillomavirus infection--have been associated with the development of skin cancer in these patients. The morbidity and mortality rates of skin cancer are higher in patients infected with the human immunodeficiency virus (HIV) than in the general population. Early and complete excision of the neoplasm is especially important.

CONCLUSION

A link exists between AIDS and the development of skin cancer. HIV-infected patients should be followed up vigilantly for early diagnosis of skin cancer. Because these patients are less able to suppress common cutaneous malignant disease due to their immunocompromised status, biopsy specimens should be obtained from all suspicious lesions, and histopathologic assessment should be done.