Prevalence of high-grade dysplasia and cancer in the anal canal in human papillomavirus-infected individuals

Giant anogenital tumor of Buschke-Löwenstein in a patient living with human immunodeficiency virus/acquired immunodeficiency syndrome: a case report

Background

Buschke–Löwenstein tumor is a giant condyloma acuminata infection that is characterized by degeneration, invasion, and recurrence. It is associated with human papilloma virus infection. It develops around the genital and perineal area, sometimes causing a large budding ulcerated lesion. Although human immunodeficiency virus infection is frequent in Africa, there are few descriptions of Buschke–Löwenstein tumor diagnosis and its management. Screening for other sexually transmitted infections must be systematic among these patients.

Case presentation

We report herein the case of a 21-year-old African origin male patient who developed a perineal swelling. Physical examination showed evidence of a huge exophytic tumor made up of budding pinkish vegetations, with serrated crests, a ‘’butterfly wing’’ structure, and a cauliflower-like appearance crowned with centrifugal circinate lesions. Multiple condylomatous lesions of the anal margin were also present. The patient tested positive for human immunodeficiency virus (cluster of differentiation 4 count of 119 cells/mm³) and hepatitis B infections. Real-time polymerase chain reaction revealed human papilloma virus-16 and other high-risk human papilloma virus deoxyribonucleic acid. The diagnosis of Buschke–Löwenstein tumor was made on mass biopsy, and the patient underwent multidisciplinary intervention (surgery, podophyllin application, and antiretroviral therapy). Medium-term evolution was, however, fatal due to opportunistic infection.

Conclusion

Buschke–Löwenstein tumor is a rare tumor associated with human immunodeficiency virus infection. It is more frequent in male human immunodeficiency virus-positive patients. There is a need to screen for other sexually transmitted infections. In most cases, the treatment is surgical, in association with local therapies. However, recurrences are common.

High-risk human papilloma virus, precancerous lesions and cancer in anal condylomas

INTRODUCTION

Anal condylomas are associated with human papillomavirus (HPV) infection and are a risk factor for anal squamous cell carcinoma (SCC).

OBJECTIVE

To conduct a meta-analysis evaluating the prevalence of anal high-risk HPV, high-grade squamous intraepithelial lesions (HSIL) and SCC in patients with condylomas. The standardized incidence ratio (SIR) and the incidence rate of anal SCC were also calculated.

METHODS

Three electronic databases were searched until April 2020. Meta-analyses were performed using random effects models.

RESULTS

Pooled prevalence estimate of high-risk HPV (HR-HPV) in anal condylomas was 40.2% (21.0-63.1) in immunocompromised and 16.4% (10.7-24.3) in nonimmunocompromised patients, with an odds ratio (OR) of 3.79 (1.51-9.52, P = 0.005) for immunocompromised patients. HR-HPV in condylomas with HSIL was 73.8% (39.1-92.5) and in non-HSIL cases was 17.7% (9.6-30.2), corresponding to an OR of 12.33 (2.97-51.21, P = 0.001) for those with HSIL. The prevalence of HSIL in condylomas was 24.0% (16.4-33.7) in immunocompromised and 11.8% (7.2-18.8) in nonimmunocompromised patients, with an OR of 2.51 (1.72-3.65, P < 0.001) for immunocompromised patients. The overall prevalence of anal SCC in anal condylomas was 0.3% (0.0-1.7). The SIR of anal SCC was 10.7 (8.5-13.5), 20.1 (14.4-28.2) in men and 7.7 (5.6-10.5) in women. The overall incidence rate of anal SCC was 6.5 per 100 000 person-years (3.6-11.7), 12.7 (9.1-17.8) in men and 4.7 (1.7-13) in women.

CONCLUSION

Patients with a history of anal condylomas have a high risk of anal SCC, especially men. The prevalence of HR-HPV and HSIL in condylomas from immunocompromised patients is high. This information can change patient follow-up and treatment.

Human papilloma virus: A review study of epidemiology, carcinogenesis, diagnostic methods, and treatment of all HPV-related cancers

Background: Human papillomavirus (HPV) infection is considered as the most common viral sexually transmitted infection worldwide. This poses an increasingly interdisciplinary medical challenge. Since there is vast scattered information in databases about HPV and the correlated diseases, we decided to collect useful data so that the experts can get a more comprehensive view of HPV. Methods: In this article, HPV-associated diseases, prevalence, prevention, and new treatments are discussed. The retrieved articles reporting the latest data about the required information for our review were selected through searching in Web of Science, Scopus, Medline (PubMed), EMBASE, Cochrane Library, Ovid, and CINHAL with language limitations of English and German. Results: There are 2 groups of HPVs: (1) low-risk HPV types that can lead to genital warts, and (2) high-risk HPV types that are involved in HPV-associated oncogenesis. About 70% of all sexually active women are infected and most of these infections heal within many weeks or months. In the case of HPV-persistence, a risk of preneoplasia or carcinoma exists. These types of viruses are responsible for the existence of genitoanal, gastrointestinal, urinary tract, and head and neck tumors. There is still no definite successful treatment. The detection of HPV-related condylomata occurs macroscopically in women and men, and the diagnosis of the precursors of cervical carcinoma in women is possible by Pap smear. Conclusion: For extragenital manifestations, there is no structured early detection program. Meanwhile, studies on HPV vaccines confirm that they should be used for the primary prevention of HPV-dependent diseases. However, we need more research to find out the real advantages and disadvantages of vaccines.

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.

Interest of cytology combined with Xpert® HPV and Anyplex® II HPV28 Detection human papillomavirus (HPV) typing: differential profiles of anal and cervical HPV lesions in HIV-infected patients on antiretroviral therapy

OBJECTIVES

The aim of the study was to assess the interest to combine cytological examination and human papillomavirus (HPV) typing of anal and cervical Papanicolaou (Pap) smears of HIV-infected patients on combination antiretroviral therapy (cART), to evaluate whether differences in prevalence exist between anal and cervical squamous intraepithelial lesions in patients with high-risk oncogenic HPV infection.

METHODS

Anal and/or cervical Pap smears were obtained by anoscopy and/or colposcopy in 238 subjects recruited consecutively in 2015: anal smears were obtained from 48 male and female patients [42 men; 35 men who have sex with men (MSM)] and cervical smears from 190 female patients. Cytological Bethesda classification was coupled with HPV typing. HPV typing was performed, on the same smears, using the Xpert^® HPV Assay, which detects only high-risk HPV (hrHPV), and the Anyplex^® II HPV28 Detection assay, which detects hrHPV and low-risk (lr) HPV.

RESULTS

Our data showed clear-cut differences between the anal and cervical samples. Compared with the cervical samples, the anal samples exhibited (1) more numerous cytological lesions, which were histologically proven; (2) a higher hrHPV infection prevalence; (3) a higher prevalence of multiple hrHPV coinfections whatever HPV typing kit was used; (4) a predominance of HPV16 and HPV18/45 types. Overall, there was an almost perfect agreement between the two HPV typing assays (absolute agreement = 90.3%).

CONCLUSIONS

Co-testing consisting of cytology and HPV typing is a useful screening tool in the HIV-infected population on cART. It allows detection of prevalence differences between anal and cervical HPV-related lesions. As recently recommended, anal examination should be regularly performed especially in HIV-infected MSM but also in HIV-infected women with genital hrHPV lesions.

Social determinants of stage IV anal cancer and the impact of pelvic radiotherapy in the metastatic setting

Anal cancer is a relatively rare malignancy, and a minority of patients present with metastatic disease in the United States. The National Cancer Database (NCDB) was used to identify factors associated with metastatic disease at presentation and evaluate the role of pelvic radiotherapy in these patients. The NCDB was queried for patients with squamous cell cancer of the anus diagnosed between 2004 and 2013. Patients were stratified by clinical stage at diagnosis, and a binary logistic regression model was created to identify factors associated with metastatic disease at diagnosis. A secondary metastatic cohort was generated and a multivariable Cox proportional hazards model was created to identify factors associated with improved survival. To validate findings, propensity-score matching was performed to generate a 1:1 paired dataset stratified by receipt of pelvic radiotherapy. The primary analysis cohort consisted of 28,500 patients. Facility location, male gender, and lack of insurance were confirmed as independent risk factors for metastatic disease. The metastatic cohort consisted of 1264 patients. Multivariable analysis confirmed female sex, possession of a private or Medicare insurance plan, pelvic radiotherapy, and chemotherapy as independent predictors of improved survival. A propensity-score matched cohort of 730 patients was generated. The median survival was 17.6 months in patients who received radiotherapy versus 14.5 months in those who did not (P < 0.01). In this cohort, male gender and lack of insurance were associated with metastatic disease at presentation. Furthermore, a significant benefit was associated with the use of pelvic radiotherapy. Future prospective research is warranted to confirm these findings.

Management of precancerous anal intraepithelial lesions in human immunodeficiency virus-positive men who have sex with men: Clinical effectiveness and cost-effectiveness

BACKGROUND

Human immunodeficiency virus (HIV)-positive men who have sex with men (MSM) are at disproportionately high risk for anal cancer. There is no definitive approach to the management of high-grade squamous intraepithelial lesions (HSIL), which are precursors of anal cancer, and evidence suggests that posttreatment adjuvant quadrivalent human papillomavirus (qHPV) vaccination improves HSIL treatment effectiveness. The objectives of this study were to evaluate the optimal HSIL management strategy with respect to clinical effectiveness and cost-effectiveness and to identify the optimal age for initiating HSIL management.

METHODS

A decision analytic model of the natural history of anal carcinoma and HSIL management strategies was constructed for HIV-positive MSM who were 27 years old or older. The model was informed by the Surveillance, Epidemiology, and End Results-Medicare database and published studies. Outcomes included the lifetime cost, life expectancy, quality-adjusted life expectancy, cumulative risk of cancer and cancer-related deaths, and cost-effectiveness from a societal perspective.

RESULTS

Active monitoring was the most effective approach in patients 29 years or younger; thereafter, HSIL treatment plus adjuvant qHPV vaccination became most effective. When cost-effectiveness was considered (ie, an incremental cost-effectiveness ratio [ICER] < $100,000/quality-adjusted life-year), do nothing was cost-effective until the age of 38 years, and HSIL treatment plus adjuvant qHPV vaccination was cost-effective beyond the age of 38 years (95% confidence interval, 34-43 years). The ICER decreased as the age at HSIL management increased. Outcomes were sensitive to the rate of HSIL regression or progression and the cost of high-resolution anoscopy and biopsy.

CONCLUSIONS

The management of HSIL in HIV-positive MSM who are 38 years old or older with treatment plus adjuvant qHPV vaccination is likely to be cost-effective. The conservative approach of no treatment is likely to be cost-effective in younger patients. Cancer 2017;123:4709-4719. © 2017 American Cancer Society.

Determinants of macroscopic anal cancer and precancerous lesions in 1206 HIV-infected screened patients

AIM

Anal screening is recommended in HIV-positive patients, especially men who have sex with men (MSM), due to an increased incidence of anal cancer. The optimal screening methods are not generally agreed.

METHOD

Screening for anal lesions by anorectal examination, including anoscopy, was offered to HIV-positive outpatients in a tertiary care university hospital regardless of gender or sexual orientation.

RESULTS

Among the 1206 screened patients (701 MSM, 247 heterosexual men, 258 women), 311 (26%) had histologically proven lesions related to human papilloma virus (HPV) (34% MSM, 14% heterosexual men, 14% women); 123 (10%) had low-grade dysplasia and 70 (6%) high-grade dysplasia. Seven anal cancers were also diagnosed. Determinants of any lesion were age < 45 years [OR = 1.56 (95% CI, 1.16-2.11)], a CD4 count of < 200/mm³ [OR = 2.54 (1.71-3.78)], receptive anal intercourse [OR =3.03 (2.06-4.47)], sub-Saharan African origin [OR = 0.53 (0.33-0.85)], and history of HPV-related lesion [OR = 1.84 (1.35-2.51)]. These determinants were similar for all different grades of dysplasia. In patient subgroup analysis, receptive anal intercourse, the CD4 cell count and a history of HPV lesions were determinants of HPV-positivity in all patients, whereas age was only a determinant in men.

CONCLUSION

Anoscopy is an alternative method for anal screening in an HIV-positive population. This screening has to be compared with other tools in populations at high risk of anal cancer.

Prevalence of Anal Dysplasia in Patients With Inflammatory Bowel Disease

BACKGROUND & AIMS

Although the prevalence of anal dysplasia is higher in some immunosuppressed populations, the prevalence in patients with inflammatory bowel disease (IBD) is unknown. We examined the prevalence of abnormal anal cytology among IBD patients, and its relation to the human papilloma virus (HPV).

METHODS

Adults with IBD and age-matched healthy controls (HC) were recruited. IBD patients were categorized as nonimmunosuppressed (IBD-N) or immunosuppressed (IBD-I). Anal Papanicolaou tests were performed for HPV testing and classification by a cytopathologist as follows: negative, atypical squamous cells of undetermined significance (ASC-US), low-grade squamous intraepithelial lesion, high-grade squamous intraepithelial lesion, cancer, or unsatisfactory.

RESULTS

A total of 270 subjects (100 IBD-I, 94 IBD-N, and 76 HC) were recruited. ASC-US were detected in 19 subjects, with a trend toward a higher prevalence among IBD subjects compared with HC (8.8% vs 2.6%; P = .10). The prevalence did not differ with respect to immunosuppression. Crohn's disease (CD) subjects had a higher prevalence of ASC-US compared with others with IBD (P = .02). Among those with CD, female sex and disease duration longer than 10 years were risk factors. There were no cases of low-grade squamous intraepithelial lesion, high-grade squamous intraepithelial lesion, or anal cancer in the cohort. HPV was present in 5.3% and 1.5% of subjects with and without ASC-US, respectively (P = .26).

CONCLUSIONS

Although there was a trend toward abnormal anal Papanicolaou tests in IBD subjects compared with HC, there was no difference based on immunosuppression. The presence of HPV did not correlate with abnormal anal cytology. Risk factors associated with this increased trend include female CD subjects and those with a longer duration of CD. ClinicalTrials.gov number: NCT01860963; https://clinicaltrials.gov/ct2/show/NCT01860963.

The prevalence of proctological symptoms amongst patients who see general practitioners in France

Background

Patients do not often discuss anal symptoms, resulting in late diagnosis of proctological disorders and impacting health. Poor epidemiological knowledge is a contributing factor to this, which can be a significant problem in general medicine. Authors evaluated the role of family doctors in proctological disorders by assessing how many of these are spontaneously diagnosed and how many are diagnosed after questioning the patient.

Methods

Thirty-nine general practitioners completed a targeted questionnaire to assess all patients seen prospectively over 2.5 days of consultations.

Results

A total of 1079 questionnaires were completed, 621 (58%) for females and 458 (42%) for males with a median age of 54. Twenty-two patients (2%) were seen primarily for anal symptoms. Following questioning, an anal symptom was found in 153 patients (14%). Symptoms reported were: bleeding (32%), pain (31%), pruritus ani (22%), swelling (22%), oozing (14%), and anal discharge (14%). Physicians’ diagnoses were: haemorrhoids, anal fissure, anal discharge, dermatology disease, and functional disorder. In 35% of patients, questioning alone was used to make these diagnoses. Anal incontinence was the only factor associated with referral to a specialist (OR = 5; 95% CI: 1.4–17.8).

Conclusion

The role of proctology in the general population appears to be significant. In five out of six cases, patients conceal anal symptoms. The high proportion of unexamined patients with anal symptoms is probably multifactorial. Further studies are needed to identify these and put in place the improvement of diagnosis and treatment of anal disorder.

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.

Evaluation of Langerhans cells counts comparing HIV-positive and negative anal squamous cell-carcinoma patients

PURPOSE

To investigate the differences in Langerhans cells (LCs) populations between HIV-positive and negative anal squamous cell carcinomas patients.

METHODS

Twenty five patients (14 HIV-positive and 11 HIV-negative) were evaluated. Paraffin-block transversal thin sections from biopsies of anal squamous cell carcinomas (ASCC) were stained using the anti-CD1A antibody that identifies activated LCs. LCs counts were performed using histometry at 20 different sites, at baseline in the ASCC cases. These were then compared with LCs counts in anal canal specimens from HIV-negative and positive patients without ASCC (controls groups).

RESULTS

In patients with ASCC, the LC count was greater among HIV-negative individuals than among HIV-positive individuals (p<0.05). The LC count was greater in the control HIV-negative group than in HIV-positive patients with ASCC (p<0.05).

CONCLUSION

There was a lower amount of activated LCs in HIV-positive patients with anal squamous cell carcinomas than in HIV-negative patients, thereby suggesting worsening of the immune 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 warts and anal intradermal neoplasia

For the last five millennia we have been dealing with the annoyance of verrucas. Anogenital human papillomavirus (HPV) infection is the most common sexually transmitted disease in the United States and is increasing in incidence. As in other gastrointestinal conditions, HPV infection can lead to a stepwise transition from normal cells to dysplastic cells and then to invasive anal cancer. Knowledge of the natural history of HPV infection, risk factors, diagnostic tools, and therapeutic methods gives us the tools to adequately prevent, evaluate, treat, and counsel our patients. In this review, the authors detail the diagnosis, management, and treatment of anal condyloma and anal intraepithelial neoplasia with a focus on prevention, early detection, and treatment using current data and technology.

Giant disseminated condylomatosis in SLE

Introduction: Females with systemic lupus erythematosus (SLE) have higher prevalence of human papillomavirus (HPV) infection, which can lead to the development of warts. Herein we report the first case of giant disseminated condylomatosis (GDC) in a SLE female on mycophenolate mofetil (MMF). Case report: The patient, a 33-year-old, Black female, was diagnosed with SLE during her first pregnancy in 2003 based on the features of arthritis, skin rash, seizures, nephritis and presence of antinuclear antibodies. Her pregnancy resulted in preterm delivery of a stillborn fetus at 28 weeks. Since that time she has been treated with steroids and different regimens of immunosuppressive drugs such as cyclophosphamide, azathioprine and lately MMF. In the last few years she presented GDC involving the genital area in addition to skin on the lower abdomen. Topical therapy with trichloroacetic acid, imiquimod and podophyllin was only partially effective. Different types of HPV were identified in the lesions, being HPV-11 in abdomen, HPV 6, 11, 42 in vulva, HPV-6, 11 in vagina and HPV-6, 11 in endocervix. Conclusions: GDC may be a complication of SLE, secondary to the disease itself, its treatment or other factors not yet identified.

Four decades of anal cancer in Tasmania, Australia: what do the case data tell us?

Background Anal cancer is a rare cancer analogous to cervical cancer, largely caused by exposure to oncogenic human papillomavirus. We have sought to study this disease in the epidemiologically distinct population of Tasmania. Methods: Medical records at all tertiary and secondary referral centres in Tasmania were audited for records with corresponding International Classification of Diseases (ICD)-10 codes. Statistical significances of trends were evaluated using Fisher’s exact test, logistic regression or linear regression. Results: Of ~1350 screening records, 170 cases of anal cancer were found with patient presentation during 1973–2010, corresponding to 132 patients. This cohort was mostly female (66.7%), with squamous cell histology (81.8%) and anal canal primaries (72.0%). Most cases were detected at Stage II or below and the majority remained disease-free after treatment. Relatively few cases had documentation of typical risk factors for anal cancer, such as HIV seropositivity, a history of cancer or smoking. After 2000, there was a trend towards a lower stage at presentation, correlating with an increased 5-year survival. After 2000, no anal margin tumours presented beyond Stage II; nearly half were detected in situ and none were fatal. For anal canal tumours, there was virtually no change in the mean stage at detection or in survival. Conclusion: This is the first case series of anal cancer in Tasmania. We find that in many ways, including symptoms and pathology at presentation, epidemiology is typical. However, our cohort is distinct in its paucity of known risk groups, including HIV-positive people, those with a history of cancer and smokers.

FoxP3 overexpression and CD1a+ and CD3+ depletion in anal tissue as possible mechanisms for increased risk of human papillomavirus-related anal carcinoma in HIV infection

AIM

We analysed local cellular and humoral immunity factors in the anal mucosa in an attempt to explain how HIV infection increases the risk of anal cancer in HPV-infected patients.

METHOD

HIV-positive cases and matched HIV-negative controls with more than one recurrence of condylomas were included in a prospective study following treatment of the initial lesions. Patients were followed every 3 to 6 months for the development of anal intraepithelial neoplasia (AIN3) and cancer for up to 60 months. Tissue CD1a(+), CD3(+), CD4(+), CD8(+) cells and mRNAs of selected cytokines and chemokines were quantified and compared in patients with or without AIN3 or cancer using morphometric or immunohistochemistry analysis and qRT-PCR.

RESULTS

Sixty-six individuals (22 patients and 44 controls) were included. In the case group, CD1a(+) and CD3(+) cell counts were significantly lower in biopsies from AIN3 and cancer specimens compared with those from AIN 1-2 or normal biopsies (P < 0.0001). A CD1a(+) count of < 10/mm was predictive of AIN3 and cancer (Odds ratio = 9.4, 95% CI: 5.4-18.3, P < 0.0001). IL-8 and IL23 levels were significantly higher in cancer than in non-cancer tissues regardless of HIV status (P = 0.02). FoxP3 expression was significantly higher in HIV-infected cases than in controls with AIN3/cancer (P < 0.04).

CONCLUSION

Depletion of CD1a(+) and CD3(+) cells and overexpression of FoxP3 in the anal mucosa appear likely to contribute to the risk of HPV-related anal cancer in HIV-infected patients. Furthermore, overexpression of IL-8 and IL-23 in the anal mucosa might be responsible for the development of this cancer regardless of HIV status.

Emerging issues in management of sexually transmitted diseases in HIV infection

Sexually transmitted diseases (STDs) occur often among sexually active persons with HIV infection. Incident STDs may complicate the course of HIV infection and potentiate HIV transmission in the coinfected individual by mucosal disruption and an increase in HIV concentration in ulcers and involved mucous membranes. Conducting ongoing periodic sexual risk assessments in HIV-positive patients in routine medical care is critical to identifying asymptomatic infections. HIV clinicians should be familiar with updated recommendations for screening, diagnosis, and treatment of bacterial and viral STDs, including those specific to HIV infection. This article addresses emerging issues in the management of STDs in HIV-infected persons and summarizes the latest evidence that can be applied to clinical decision-making in this population.

Epidermal growth factor receptor and K-RAS status in two cohorts of squamous cell carcinomas

Background

With the availability of effective anti-EGFR therapies for various solid malignancies, such as non-cell small lung cancer, colorectal cancer and squamous cell carcinoma of the head and neck, the knowledge of EGFR and K-RAS status becomes clinically important. The aim of this study was to analyse EGFR expression, EGFR gene copy number and EGFR and K-RAS mutations in two cohorts of squamous cell carcinomas, specifically anal canal and tonsil carcinomas.

Methods

Formalin fixed, paraffin-embedded tissues from anal and tonsil carcinoma were used. EGFR protein expression and EGFR gene copy number were analysed by means of immunohistochemistry and fluorescence in situ hybridisation. The somatic status of the EGFR gene was investigated by PCR using primers specific for exons 18 through 21. For the K-RAS gene, PCR was performed using exon 2 specific primers.

Results

EGFR immunoreactivity was present in 36/43 (83.7%) of anal canal and in 20/24 (83.3%) of tonsil squamous cell carcinomas. EGFR amplification was absent in anal canal tumours (0/23), but could be identified in 4 of 24 tonsil tumours.

From 38 anal canal specimens, 26 specimens were successfully analysed for exon 18, 30 for exon 19, 34 for exon 20 and 30 for exon 21. No EGFR mutations were found in the investigated samples. Thirty samples were sequenced for K-RAS exon 2 and no mutation was identified. From 24 tonsil specimens, 22 were successfully analysed for exon 18 and all 24 specimens for exon 19, 20 and 21. No EGFR mutations were found. Twenty-two samples were sequenced for K-RAS exon 2 and one mutation c.53C > A was identified.

Conclusion

EGFR mutations were absent from squamous cell carcinoma of the anus and tonsils, but EGFR protein expression was detected in the majority of the cases. EGFR amplification was seen in tonsil but not in anal canal carcinomas. In our investigated panel, only one mutation in the K-RAS gene of a tonsil squamous cell carcinoma was identified. This indicates that EGFR and K-RAS mutation analysis is not useful as a screening test for sensitivity to anti-EGFR therapy in anal canal and tonsil squamous cell carcinoma.

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.

Growth factor receptor expression in anal squamous lesions: modifications associated with oncogenic human papillomavirus and human immunodeficiency virus

High prevalence of squamous anal lesions is linked to oncogenic human papillomavirus (HPV). Human immunodeficiency virus (HIV) promotes anal carcinogenesis. Epidermal growth factor receptor (EGFR), HER2/neu, c-Met, and vascular endothelial growth factor receptor-1 (VEGFR1) (tyrosine kinase growth factor receptors) are implicated in tumor progression, but little is known about their role in anal lesions. We investigated their expression and distribution in normal, dysplastic, and carcinomatous anal epithelium and then tried to analyze the effects on these variables of HPV and the HIV-positive status. Seventy-one HIV-positive and 47 HIV-negative patients were selected. We studied growth factor receptors, p16 and Ki67 expression, by in situ hybridization, fluorescent in situ hybridization (FISH) and chromogen in situ hybridization (CISH), immunocytochemistry, and morphological quantification in 226 lesions, either infected by HPV6 and 11 (31 condylomas acuminata) or infected with oncogenic HPVs (48 invasive cancers, 147 anal intraepithelial neoplasias). No HER2/neu was detected. Strong EGFR immunolabeling was not accompanied by gene amplification. The number and intensity of EGFR- and c-Met-immunoreactive cells increased significantly during lesion progression, highlighting the effects of oncogenic HPVs. EGFR, c-Met, VEGFR1, and p16 were coexpressed in 96% of invasive cancers. HIV-modified c-Met expression in condyloma acuminata (P < .008) and invasive cancers (P < .02). Strong HIV-related immunodeficiency and an absence of antiretroviral therapy increased c-Met and/or EGFR expression. HIV-positive anal cancers showed correlated c-Met and VEGFR1 (P < .003), strong p16 labeling, and an increased Ki67 proliferation. The finding that EGFR, c-Met, and VEGFR1 involved in carcinogenesis are well-represented and coexpressed in anal cancers, especially in HIV-positive population, suggests possible novel targeted treatments for anal diseases.

Epidermoid anal cancer prognosis comparison among HIV+ and HIV- patients

BACKGROUND

Previous studies suggest a poor prognosis of epidermoid anal cancer in HIV+ patients.

AIM

To investigate the long-term outcome of epidermoid anal cancer in HIV+ and HIV- patients in the highly active antiretroviral treatment (HAART) era.

METHODS

We included all patients with epidermoid anal cancer referred to six hospitals from 1998 to 2004.

RESULTS

In all, 151 patients (44 HIV+, 107 HIV-) were reviewed retrospectively for 27 (median of 16-44) months. HIV+ patients were male (100% vs. 27%, P < 0.001) and younger (45 vs. 62 years old, P < 0.001) than HIV- patients. No significant differences were observed in the tumour stage, pelvic radiotherapy dose or concomitant chemotherapy, according to the HIV status. After chemoradiotherapy, similar numbers of HIV+ and HIV- patients had grade III-IV toxicity. A complete response was obtained in 82% and 75% (N.S.) of cases, respectively. The disease-free survival rates were 77% and 67% (N.S.) and the overall survival rates were 85% and 84% (N.S.), respectively, after 3 years of follow-up. Duration of HIV infection, viral load and CD4 count had no effect on the survival rate of HIV+ patients with EAC.

CONCLUSIONS

The clinical outcome of HIV+ patients with epidermoid anal cancer is similar to that of HIV- patients. Therefore, the same therapeutic guidelines should be applied to both populations.

Prevalence of anal squamous intra-epithelial lesion in women presenting genital squamous intra-epithelial lesion

OBJECTIVE

To determine the frequency of anal squamous intra-epithelial lesions (ASIL) in women with genital squamous intra-epithelial lesions (GSIL).

STUDY DESIGN

In a cross sectional study, 184 patients with histopathological diagnosis of GSIL and 76 controls without GSIL, were submitted to anuscopy in order to determine the presence of ASIL. All the women were HIV-negative with anal aceto-white lesions were biopsed for histological diagnosis.

RESULTS

The frequency of ASIL was 17.4% in the GSIL group (3.2% high grade ASIL) and only 2.6% in the control group (0% high grade ASIL) (p<0.001). All the high grade ASIL diagnoses were found in women with cervical SIL.

CONCLUSION

Women presenting GSIL have high prevalence of ASIL.

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.

Diagnostic problems in anal pathology

Anal squamous cell carcinoma and its precursor lesions are increasing in incidence in the United States and Europe. This trend predates human immunodeficiency virus/acquired immune deficiency syndrome and has been associated with persistent high-risk human papilloma virus (HPV) genotype infection, previous lower genital tract dysplasia/carcinoma, high frequency anoreceptive intercourse, heavy cigarette smoking, immunosuppression in solid organ transplant and immune disorders, and human immunodeficiency virus seropositivity. Screening protocols for at-risk patients are under active investigation and pathologists are often asked to assess anal canal and perianal biopsies for the presence of dysplasia and/or invasive carcinoma. Because underdiagnosis and overdiagnosis of anal cancer and precancer may lead to inappropriate treatment, it is important for the pathologist to be aware of current screening strategies, specific risk lesions, and the role of pathology in initial diagnosis and evaluation of anal biopsy and/or resection specimens. Standardized histologic criteria and uniform terminology should be used for reporting all anal canal and perianal squamous intraepithelial lesions. HPV subtyping, anal cytology, and recently identified biomarkers, such as p16 and Becton Dickinson ProEx C may provide additional information in problematic cases, but it is important to be aware of the limitations of these assays. HPV has been linked to all the major histologic subtypes of anal carcinoma (eg, basaloid, cloacogenic, transitional, etc.) and this association is strongest for anal canal lesions. With the possible exception of the microcystic pattern, histologic subtype does not seem to predict prognosis; and anal squamous cell carcinomas should be classified as either keratinizing or nonkeratinizing. Poorly differentiated squamous cell carcinomas have a worse prognosis and should be distinguished from poorly differentiated adenocarcinoma, melanoma, and neuroendocrine tumors. Very well differentiated squamous cell carcinoma with pushing margins (so-called giant condyloma of Buschke and Lowenstein) should be classified as verrucous carcinoma; this tumor shows aggressive local infiltration but does not metastasize. As all anal condylomata may harbor foci of high-grade dysplasia or invasive carcinoma, careful sectioning and complete histologic examination is required.

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.

Earlier eradication of intra-anal warts with argon plasma coagulator combined with imiquimod cream compared with argon plasma coagulator alone: a prospective, randomized trial

PURPOSE

Despite the increasing incidence of condylomata acuminate, optimal treatment of anal warts is still undecided. This prospective, randomized study was designed to compare the efficacy of combined argon plasma coagulation and imiquimod cream vs. argon plasma coagulation alone in the management of intra-anal warts.

METHODS

From October 2002 to March 2005, 49 patients with intra-anal warts were randomly assigned to argon plasma coagulation plus imiquimod cream (n = 24) vs. argon plasma coagulation alone (n = 25). Therapeutic sessions were repeated until the elimination of the warts. Efficacy of therapy was defined as the time needed for eradication. All patients were followed up for a mean period of 12 months for signs of recurrence.

RESULTS

Elimination of warts was achieved earlier in patients receiving combination therapy compared with those receiving monotherapy with argon plasma coagulation (62.5 +/- 5.4 days vs. 91.2 +/- 6.4 days; P = 0.0016). A subgroup analysis performed in HIV-positive patients showed similar results (combination therapy 95 +/- 22.6 days; monotherapy 124.3 +/- 20.7 days; P = 0.033); however, in HIV-positive patients warts were eradicated later compared with HIV-negative patients (110.8 +/- 25.7 days vs. 65 +/- 25.4 days; P < 0.0001). No major complications were observed in our study population. After the follow-up period, recurrence of warts was evident in 22.7 percent of patients in the combination group compared with 34.7 percent of patients in the monotherapy group (P = 0.51). Recurrence was significantly higher in HIV-positive patients compared with HIV-negative patients (P = 0.0039).

CONCLUSIONS

Combination therapy with argon plasma coagulator plus imiquimod cream results in earlier clearance of intra-anal warts in both immunocompetent and immunocompromised patients; however, it does not affect the rate of recurrence.

Anogenital Warts Knowledge and Counseling Practices of US Clinicians: Results From a National Survey

OBJECTIVES

To examine messages US clinicians use when counseling patients diagnosed with anogenital warts.

STUDY DESIGN

In mid-2004, we conducted a confidential mail survey of nationally representative samples of physicians practicing internal and adolescent medicine, family/general practice, obstetrics/gynecology, urology, or dermatology; nurse midwives; physician assistants; and nurse practitioners. The survey assessed knowledge and counseling practices of clinicians who had diagnosed anogenital warts.

RESULTS

After adjusting for survey eligibility, 81% responded. Most (89%) were aware that human papillomavirus (HPV) causes anogenital warts, but only 48% were aware that oncogenic and wart-related HPV genotypes usually differ. Most (>95%) clinicians reported telling patients with warts that warts are an STD, are caused by a virus, or that their sex partners may have or may acquire warts. Many clinicians (>/=85%) also reported discussing STD prevention or assessing STD risk with such patients. Most reported addressing ways to prevent HPV (89%), including using condoms; limiting sex partners or practicing monogamy; or abstinence. Many also reported recommending prompt (82%) or more frequent (52%) Pap testing to female patients with anogenital warts. Potential barriers to counseling included providing definitive answers on how HPV infection was acquired, dealing with patients' psychosocial issues, and inadequate reimbursement.

CONCLUSIONS

Most surveyed clinicians appropriately counseled patients about the cause and prevention of anogenital warts. However, many clinicians were unaware that oncogenic and wart-related HPV types usually differ, and this may explain why many reported recommending more aggressive cervical cancer screening for female patients with warts.

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.

Anal squamous intraepithelial lesions and condyloma in HIV-infected heterosexual men, homosexual men and women: prevalence and associated factors

OBJECTIVE

To assess the prevalence of and factors associated with squamous intraepithelial lesions and condyloma [human papillomavirus (HPV)-related lesions) in HIV-infected patients.

DESIGN

A cross-sectional study in a tertiary-care university hospital conducted in 516 consecutive outpatients.

INTERVENTION

A systematic examination for macroscopic HPV-related lesions through anoscopy with histological confirmation, evaluation of dysplasia and HPV typing. Sexual behaviours were assessed using a semi-directive questionnaire.

RESULTS

Of 473 patients examined, (200 homosexual men, 123 heterosexual men, 150 women), 108 (23%) had histologically confirmed anal HPV-related lesions (36, 15 and 11% of the respective populations), including 51 (47%) with only endoanal localization. Among these 108 patients, histological dysplasia of grades I or II and grade III were noted in 59 and two patients, respectively, invasive endoanal cancer in one; three patients also had high-risk oncogenicity HPV without dysplasia. Independent identified associated factors of HPV-related condyloma were the number of incidents of sexual intercourse per month [odds ratio (OR) 1.04; 95% confidence interval (CI) 1.01-1.06], CD4 cell count below 200 x 10 cells/l (OR 3.22; 95% CI 1.37-7.60), history of anal HPV lesion (OR 4.57; 95% CI 2.13-9.81), and receptive anal intercourse (OR 2.30; 95% CI 1.11-4.77). The two latter factors remained associated with histological dysplasia (OR 2.82; 95% CI 1.38-5.76 for history of anal condyloma, and OR 4.29; 95% CI 2.18-8.44 for receptive anal intercourse).

CONCLUSION

The high rate of condyloma and histological dysplasia seen argues for a systematic screening for these lesions in HIV-infected individuals.

Langerhans cell density and high-grade vulvar intraepithelial neoplasia in women with human immunodeficiency virus infection

BACKGROUND

Decreased numbers of Langerhans cells (LCs) in the cervix of human immunodeficiency virus (HIV)-infected women are believed to contribute to the progression of human papilloma virus (HPV)-related squamous intraepithelial lesions. However, this impairment of local immunity has not been well studied in the vulva. The objective of this study was to compare the S100+ LC density in high-grade vulvar intraepithelial neoplasia (VIN) in HIV-positive and HIV-negative women.

METHODS

HIV-positive and HIV-negative patients with high-grade VIN, 48 (55%) and 40 (45%), respectively, were identified by retrospective chart review. Smoking status of patients was noted. The mean LC count per high-power field (HPF) was determined using S100 immunohistochemical staining. In situ hybridization was performed to detect HPV DNA types 16 and 18.

RESULTS

Mean S100+ LC counts for HIV-positive and HIV-negative patients were 5.82 and 9.86 per HPF, respectively (p = 0.0026). LC counts in HIV-positive and HIV-negative patients were compared between smoking and nonsmoking groups (HIV-positive p = 0.4812, HIV-negative p = 0.2821).

CONCLUSIONS

HIV-positive patients with high-grade VIN had significantly lower LC counts compared with HIV-negative patients. This suggests that local vulvar immunity as evaluated by S100+ LCs is impaired in HIV-positive women, possibly contributing to the progression of HPV-related vulvar lesions.

[Frequent and rare dermatological diseases in HIV patients]

HIV patients develop a variety of infectious and non-infectious diseases of the skin and mucous membranes. Some of these serve as indicator diseases for a weakening immune system. While none of the dermatological complications is pathognomonic, conditions such as oral hairy leukoplakia, herpes zoster, thrush, and eosinophilic folliculitis should make physicians consider the possibility of underlying HIV disease. Moreover, one has to consider HIV if these skin diseases take an atypical or severe course, or if they do not respond properly to appropriate medication. Frequent and rare dermatoses occurring in HIV infection are discussed.

Immunoreactivity of p16 in anal cytology specimens: histologic correlation

BACKGROUND

Cytology has been proposed as a potential screening tool in the evaluation of squamous anorectal disease in view of the morphologic similarities between anal and cervical squamous lesions. Previous studies have demonstrated that p16 overexpression correlates with the degree of dysplasia in the uterine cervix with promising results. Due to potential diagnostic pitfalls in anal cytology, p16 overexpression in these specimens was studied.

METHODS

Patients with anorectal cytology who underwent follow-up biopsy within 1 year were selected. Forty-three anorectal cytologic specimens from 29 patients were selected. One slide of each case was destained. Avidin-biotin immunocytochemical studies with the monoclonal antibody CINtec p16(INK4a) were performed. The results of the p16 immunostaining were correlated with the histologic findings.

RESULTS

Twenty-eight of the 43 cases demonstrated the presence of squamous cells immunoreactive for p16 in cytology specimens. The p16-positive cells were identified in cases of low-grade squamous intraepithelial lesion (LSIL) (n = 3 cases), high-grade squamous intraepithelial lesion (HSIL) (n = 22 cases), and invasive squamous carcinoma (n = 1 case), and in 2 cases with negative follow-up biopsies. No cell immunoreactive for p16 was found in 15 cases (5 benign cases and 10 cases with either LSIL or HSIL). The sensitivity and specificity of p16 immunoreactivity in the detection of anal intraepithelial neoplasia or carcinoma were 72% and 71%, respectively. The positive and negative predictive values were 93% and 33%, respectively.

CONCLUSIONS

The presence of p16 immunoreactivity is a good predictor of dysplasia in anal specimens. However, the sensitivity and specificity of this marker are not high.

Avaliação dos resultados do tratamento de 14 doentes de carcinoma espinocelular anal

A radioquimioterapia (RT/QT) tornou-se o tratamento de escolha para o carcinoma espinocelular anal (CEC). Na recidiva local ou na persistência da doença, deve-se instituir o tratamento cirúrgico. OBJETIVO: O objetivo deste estudo retrospectivo foi analisar os resultados do tratamento de doentes de CEC anal. MÉTODO: Acompanhamos 17 pacientes com diagnóstico anátomo-patológico de carcinoma espinocelular anal. Eram 14 (82,3%) do sexo feminino e três (17,8%) do masculino. A idade variou de 36 a 78 anos, com média de idade de 59,1 anos. Utilizando a classificação TNM, tivemos quatro (23,6%) no estádio I, seis (35,2%) no II, quatro (23,6%) no IIIa e três (17,6%) no IIIb. Todos foram submetidos a tratamento inicial com RT/QT, exceto um submetido a ressecção local. Definimos que a biópsia negativa, realizada entre 12 e 16 semanas após esse tratamento, determinaria o controle local da doença. RESULTADOS: Perdemos seguimento de três doentes (17,6%). Seguimos os 14 restantes (82,3%) entre um e cinco anos. Todos os doentes nos estádios I e II (10) apresentaram regressão total da doença, enquanto que três (75%) nos estádios IIIa e IIIb tiveram remissão completa. Realizamos a amputação abdomino-perineal de resgate em dois doentes e ressecção local em outros dois. A recidiva local ocorreu em dois (20%) nos estádios I e II e em dois (75%) nos estádios mais avançados (IIIa e IIIb). A sobrevivência em 3 anos foi de 100% nos que se encontravam nos estádios I e II, embora o controle da doença fosse atingido em oito (80%). Nos quatro doentes que estavam nos estádios IIIa e IIIb, a sobrevivência em um ano foi de 75% e em três anos foi de 25%. Esse último permanece livre da doença. Complicações do tratamento radioterápico ocorreram em oito doentes (57,1%). Nenhum óbito foi constatado durante o tratamento RT/QT. Os dois doentes, (14,3%) com sorologia positiva para HIV, apresentavam infecção anal pelo Papilomavírus humano (HPV). CONCLUSÃO: A análise dos nossos resultados evidenciou que o esquema de tratamento empregado foi efetivo para o controle local e preservação da função esfincteriana do ânus e que, na falha do tratamento radioquimioterápico, a operação de resgate controlou localmente a doença.

Length of human immunodeficiency virus disease and not immune status is a risk factor for development of anal carcinoma

BACKGROUND

The anal epithelium is subject to dysplastic change in patients with human immunodeficiency virus (HIV). We sought to determine if the duration of HIV disease or the patient's immune status were associated with the development of anal carcinoma.

METHODS

HIV-positive patients diagnosed with anal neoplasms were reviewed. Statistical analysis was performed via an unpaired Student t test and the Fisher exact test.

RESULTS

Fourteen patients were identified, 7 with anal intraepithelial neoplasms (group 1) and 7 with anal carcinoma (group 2). Human papillomavirus was detected in 100% of patients in group 1 and in 67% of patients in group 2. There was no significant difference in the level of immunosuppression as assessed by the CD4 counts (266.9 +/- 48.5 vs. 274.7 +/- 92.0 cell/c microl; P = .94) and viral loads (19,243 +/- 18,034 vs. 67,140 +/- 39,570 RNA/mL; P = .29) between groups 1 and 2, respectively. Group 2 had been HIV positive for a significantly longer period of time (12.6 +/- 2.3 y) compared with group 1 (5.9 +/- 2.0 y, P = .05).

CONCLUSIONS

The most significant factor for the development of invasive anal carcinoma in patients with HIV is duration of disease. As a result of improved long-term survival secondary to new HIV therapy, anal invasive carcinoma will become an increasing problem.

Increased apoptosis in cervical intraepithelial neoplasia associated with HIV infection: implication of oncogenic human papillomavirus, caspases, and Langerhans cells

PURPOSE

Increasing risk of squamous cervical intraepithelial neoplasia (CIN) exits in HIV-infected women. However, the relatively low incidence of invasive carcinoma in the untreated HIV-infected population suggests an imbalance between cell proliferation and apoptosis. We investigated apoptosis and caspases in cervical samples from this population comparatively to non-HIV-infected and control subjects.

EXPERIMENTAL DESIGN

Apoptotic terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling method, immunohistochemistry for caspase-2, caspase-3, caspase-8, caspase-9, and other apoptosis markers were done on 12 normal cervical samples and 103 low- and high-grade cervical lesions, containing human papillomavirus(es) from 35 HIV-negative and 33 HIV-positive women before tritherapy advent.

RESULTS

(a) The apoptotic index (AI) in epithelial cells did not vary between normal mucosa and condyloma acuminata infected or not with HIV. (b) AI augmented with the CIN severity in HIV-positive and HIV-negative women. (c) AI dramatically increased in oncogenic human papillomavirus-infected CIN of HIV-positive population compared with the CIN of similar grade in HIV-negative one. This was associated with a greater expression of caspase-8, active caspase-9, and active caspase-3 in those samples. Moreover, densities of Langerhans' cells, involved in apoptotic bodies engulfment, were greatly reduced in CIN of HIV-positive women. In samples, these densities were highly inversely correlated with AI (r = -0.88, P < 0.002).

CONCLUSIONS

This study provides the first evidence for the strongly enhanced apoptosis levels and caspase expression in CIN of untreated HIV-infected women. We suggest that the reduction in Langerhans' cell number could contribute at least partly to apoptotic cell accumulation.

Screening Methods for High-Grade Dysplasia in Patients with Anal Condyloma1

Human papilloma virus (HPV) is one of the most common sexually transmitted diseases in the United States. HPV infection can cause anal condylomas and is a risk factor for dysplasia. High-grade dysplasia may progress to squamous cell carcinoma. Currently, biopsy and histological examination are required to grade dysplasia. The purpose of this study is to determine whether anal cytology, morphological characteristics, and/or the presence of high-risk oncogenic HPV-types are effective noninvasive methods to detect high-risk anal condylomas.

PATIENTS AND METHODS

From November 2003 to June 2004, all patients with anal condyloma were prospectively evaluated for anal cytology, high-risk oncogenic HPV-types, and tissue biopsies. The Bethesda classification system was used to classify cytologic findings and histological examination, which were grouped as high-risk (HRL) and low-risk (LRL) lesions. Histology results served as true disease for all comparisons.

RESULTS

Forty-seven patients with anal condyloma were studied; 43 (91.5%) were men, and the mean age was 39 +/- 11 years. Histology showed 19 (40.5%) patients with HRL, and 28 (59.5%) patients with LRL. Cytology correctly identified 8 patients with HRL and 27 patients with LRL (sensitivity 42% and specificity 96%). High-risk oncogenic HPV-types were found in 84.2% of HRL and 39.3% of LRL (P = 0.0029). Combining cytology with oncogenic HPV-testing, the sensitivity of detecting HRL increased to 89%, and specificity decreased to 42%.

CONCLUSION

Anal cytology alone is not accurate for detecting HRL in patients with anal condylomas. Combining oncogenic HPV-testing with cytology is more sensitive in detecting HRL in patients with anal condyloma, and therefore, a more effective screening tool.

Prévalence des condylomes anaux chez les patients infectés par le VIH

BACKGROUND

In the general HIV-infected population, there are few data on the prevalence and risk factors for anal condyloma, precursor lesions for anal cancer.

METHODS

Screening for perianal and endoanal condyloma with an anoscopy was systematically proposed to 516 consecutive outpatients, followed in a university hospital in Paris. For each point, HIV characteristics and sexual behaviors assessed through semi-directive questionnaire were collected.

FINDINGS

The 473 (92%) examined patients, consisted of 200 homosexual men, 123 heterosexual men, 150 women; 76% were receiving HAART, HIV-RNA was<50 copies/ml in 60%, mean (+/-SD) CD4 cell count were 484 (+/-274)/mm(3). Overall, 108 (23%) pts had histologically-confirmed anal condyloma (36, 15 and 11% of the respective populations), including 51 (47%) pts with only endoanal localisation. Intraepithelial neoplasia of grade I was noted in 59 patients, of grade II in 10 and of grade III in 2 and an invasive endoanal cancer in 1. In multivariate regression analysis, condyloma independent risk factor were history of gonococcia or syphilis (OR=0.54 (0.29-0.99)), and history of previous anal condyloma (OR=2.05 (1.07-3.92) in homosexual men, history of previous penis condyloma (OR=26.8 (2.3-309.6), and unprotected sexual intercourse (OR=7.5 (2.1-26.3)) in heterosexual men and CD4 cell count below 200/mm(3), (OR=8.9 (1.5-51.6)), receptive anal intercourse (OR=6.7 (1.7-25.8)) and history of previous anal condyloma (OR=25.4 (3.4-188.2)) in women.

INTERPRETATION

In the HAART era, systematic screening revealed a high rate of anal condyloma in all HIV positive pts (not only in homosexual men). Anal examination should be proposed systematically to all HIV-infected patients.

Anal Condyloma: A Comparison between HIV Positive and Negative Patients

HIV positive and negative patients with anal condylomata were compared to determine an association with squamous cell neoplasia, its disease progression, and response to treatment. From 1992 to 2003, 61 patients were diagnosed with anal condylomata by anal biopsy. Thirty-four patients were HIV+ and 27 patients were considered HIV-. Upon retrospective chart review, details on disease progression, development of malignancy, and subsequent treatment were collected. Sixty-one per cent of HIV+ patients had a neoplastic process in contrast to 25 per cent of HIV- patients ( P = 0.005). Five patients demonstrated disease progression, of which four were HIV+. Three HIV+ patients were treated for invasive carcinoma with excision and standard chemoradiation therapy. Two patients with T3 lesions developed recurrence and died. Eighteen HIV+ patients had noninvasive carcinoma and were treated with local excision without recurrence at mean follow-up of 28 months. HIV+ patients were shown to have more condylomata harboring squamous cell neoplasia than HIV- patients. Noninvasive carcinoma can be treated effectively with local excision, independent of HIV status; however, long-term follow-up is needed. Chemoradiation therapy in patients who are relatively healthy and have stage I disease may be successful. The role for chemoradiation in AIDS patients with stage III disease remains unclear.

Human papillomavirus, condylomata acuminata, and anal neoplasia

Genital human papillomavirus (HPV) infection is an increasingly common sexually transmitted disease. This virus causes condylomata acuminata and is associated with anal neoplasia. Management options are discussed.

Anal carcinoma: incidence and effect of cumulative infections

INTRODUCTION

Human papilloma virus (HPV) causes anal condyloma that is a risk factor for anal carcinoma. The incidence and mechanism of invasive anal carcinoma in patients with anal condyloma are prospectively determined.

PATIENTS AND METHODS

From 1993 to 2002, 228 consecutive patients (164 HIV positive) with anal canal condylomas were included in the study, after curing of their lesions. They were asked to attend follow-up visits at 3- or 6-month intervals. We checked for anal co-infection with syphilis, gonococci, viruses (Epstein-Barr virus, cytomegalovirus, herpes simplex, HPV types), and quantified Langerhans' cells (LC) in anal mucosa at baseline and during follow up. We cured and analysed relapsed condylomas during follow up (3-112 months; median 26). Serum HIV loads and CD4 T-lymphocyte counts were determined at each visit and the densities of LC in consecutive specimens from patients with cancers were compared with that for a matched control group (n = 23).

RESULTS

Analysis of 199 patients showed high-grade dysplasia (HGD) in 13.6% of patients, more in HIV-positive (16%) than in HIV-negative (6%) patients at baseline. During follow up, 3.5% (7/199; six HIV positive) patients developed invasive carcinoma after 13-108 months and 112 (56%) patients relapsed condylomas. HIV and anal co-infection were identified as independent risk factors (P < 0.01) for HGD and cancer: odd ratio (95% confidence interval) of 9.4 (2.4-37.4) and 3.67 (0.95-14.2), respectively. LC densities in anal mucosa were lower in patients with invasive carcinoma than in controls.

CONCLUSION

The risk of invasive carcinoma in HPV-infected patients is increased by HIV and anal co-infection. Decreases in LC numbers in anal mucosa may favour this outcome.

The etiology and epidemiology of anal cancer

The anatomic definitions for anal cancer (canal versus margin) are made based on the relationship of the tumor to the anal verge. This method had led to confusion for some providers. A modification in the terminology is proposed that includes intra-anal, perianal, and skin as categories. The cause of anal carcinoma remains to be fully elucidated, and HPV seems to play a central role in this process. The incidence of anal cancers has increased, which is related to the evolution of HIV and AIDS, and their treatment. The accurate pathologic analysis of anal tumors is complex and is significantly aided by close communication between clinician and pathologist.

Anorectal cytology as a screening tool for anal squamous lesions: cytologic, anoscopic, and histologic correlation

BACKGROUND

Anorectal cytology has been increasingly used as a screening method for anal squamous lesions, particularly in high-risk, homosexual, patients with human immunodeficiency virus infection. The diagnostic cytologic, anoscopic, and histologic criteria bear some resemblance to the criteria used in cervicovaginal samples with few differences. It is important to recognize these differences because they can lead to an erroneous diagnosis of dysplasia and unnecessary procedures.

METHODS

Seventy-eight anorectal cytology specimens from 51 patients were reviewed blindly. Of the 51 patients, 33 were HIV positive. The cytology specimens consisted of 75 ThinPrep (Cytyc, Boxborough, MA) and 3 conventional Papanicolaou-stained smear specimens. The revised diagnosis was compared with the original diagnosis, corresponding histology specimens, and anoscopic results, when available.

RESULTS

Six specimens were unsatisfactory for review. The revised diagnosis was negative in 15 patients, atypical squamous cells of undetermined significance in 3 patients, low-grade squamous intraepithelial lesions in 24 patients, high-grade squamous intraepithelial lesions in 28 patients, and squamous cell carcinoma (SQC) in 2 patients. Five patients with an original diagnosis of SQC had the diagnosis revised upon review of their specimens. It is noteworthy that these five specimens showed the presence of atypical parakeratotic cells. Thirty-two patients had anoscopic evaluation and 30 patients had histologic correlation. Twenty-seven patients with abnormal anoscopic findings had confirmed abnormal histologic findings. Twenty- five of the 32 (78%) patients had abnormal cytology that correlated with abnormal anoscopic findings.

CONCLUSIONS

Anorectal cytology is an accurate method for screening patients for anal squamous lesions. Atypical parakeratotic cells represent a potential pitfall. Anoscopy is important in confirming the presence of a lesion, but only a biopsy can accurately determine the grade of a lesion.

Incidence of anal cancer in California: increased incidence among men in San Francisco, 1973-1999

BACKGROUND

Incidence of anal cancer has increased in the United States during the past 30 years. This report describes the incidence of this rare cancer in the diverse California population.

METHODS

Age-adjusted incidence rates (AAIR) were calculated by gender, race/ethnicity, county, and year of diagnosis for over 2100 cases of cancer of the anus diagnosed between 1995 and 1999. Age-adjusted incidence rates by time period 1973-1999 were calculated for San Francisco County.

RESULTS

Age-adjusted incidence was higher for women than for men (AAIR 1.5 vs 1.2) in California, but men under age 40 and those classified as non-Hispanic Black had higher rates than women, and men had higher rates in San Francisco County (AAIR=8.7). Rates were higher among non-Hispanic Blacks and Whites than among Hispanics and Asian/Pacific Islanders. For all of California, there was an average 2% annual increase among non-Hispanic White men between 1988 and 1999. Incidence of this cancer among White males residing in San Francisco County more than doubled between the 1984-1990 and 1996-1999 time periods. Rates rose especially dramatically for San Francisco men ages 40 to 64, from 3.7 cases per 100,000 in 1973-1978 to 8.6 cases per 100,000 in 1984-1990 and to 20.6 cases per 100,000 in 1996-1999.

CONCLUSIONS

Elevated incidence of anal cancer among White men residing in San Francisco County is likely to be related to the high proportion of men who have sex with men. Rates of anal cancer in this high-risk population increased during the past decade.