Initial prevalence of anal human papilloma virus infection in liver transplant recipients

Anal dysplasia and anal cancer screening practices among liver transplant centers in the United States: Results of an online survey

BACKGROUND

Solid organ transplant recipients are at an increased risk for anogenital Human Papillomavirus (HPV)-related disease, including anal high-grade squamous intraepithelial lesions (HSIL) and anal squamous cell cancer (ASCC). Guidelines for ASCC screening in transplant recipients are limited. Our aim was to understand current practice of ASCC screening in adult liver transplant (LT) candidates and recipients at transplant centers across the United States.

METHODS

We surveyed medical directors of 113 LT centers across the United States which had publicly available contact information. The survey evaluated center perceptions on cancer and HPV disease risk in transplant populations, ASCC screening, barriers and facilitators for ASCC screening and HPV vaccination practices.

RESULTS

We received 26/113 (23%) responses, of which 24 were complete and included in the analysis. Eleven of 24 (46%) centers reported screening for ASCC and 3/24 (12.5%) centers reported having formal guidelines. Centers who perform ASCC screening were more likely to perform transplants in people living with HIV and were more aware of the burden of HPV disease in transplant populations. All respondents believed that additional data on the impact of screening on ASCC incidence would support screening decisions. Increased access to specialists for screening/high-resolution anoscopy was also perceived as a facilitator. Only 7/24 (29%) centers regularly evaluated HPV vaccination status of their patients.

CONCLUSION

This national survey of LT centers reveals non-standardized ASCC screening practices, and identified data, educational and resource needs to improve prevention of ASCC in this population.

Carcinogenesis and Cancer Progression in De Novo Anal Squamous Cell Carcinoma After Organ Transplantation: A Systematic Review

Our aim was to perform a comprehensive literature review on the pathogenesis of squamous anal cancerin patients after solid-organ transplant. Medical databases were consulted until June 1, 2020, for potentially relevant publications.All studies on pathogenesis of de novo anal squamous cell carcinoma in solid-organ transplant recipients were included. Two researchers independently performed study selection, quality assessment, and data extraction and analysis. Twenty-one studies were included.None ofthe selected papers had been solely focused on carcinogenesis. Most ofthe studies identified human papillomavirus infection and immunosuppression to be significantly correlated with the development of de novo anal cancer in adult solid organ transplant recipients. CD4+ T-cell depletion and inactivation oftumor suppressor pathways were mainly implicated. All solid-organ transplant recipients, especially those who were human papillomavirus positive, were shown to be at increased risk for the development of posttransplant anal cancer. Further studies are needed to determine the specific mechanisms of pathogenesis according to different solid-organ transplant populations.

Construction and validation of a prognostic nomogram for anal squamous cell carcinoma

Background

Anal squamous cell carcinoma (ASCC) is the main subtype of anal cancer and has great heterogeneity in prognosis. We aimed to construct a nomogram for predicting their 1‐, 3‐, and 5‐year overall survival (OS) rates.

Methods

Patients with ASCC, enrolled between January 1, 2010 and December 31, 2017, were identified from the SEER database. They were divided into a training group and a validation group in a ratio of 7:3. Univariate and multivariate Cox analyses were used to identify the prognostic factors for OS. Then a prognostic nomogram was established and validated by Harrell consistency index (C‐index), area under the curve (AUC) of the receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA).

Results

We identified 761 patients in training group and 326 patients in validation group. Four prognostic factors including age, sex, AJCC stage, and radiotherapy were identified and integrated to construct a prognostic nomogram. The C‐index and AUC values proved the model's effectiveness and calibration plots manifested its excellent discrimination. Furthermore, in comparison to the AJCC stage, the C‐index, AUC, and DCA proved the nomogram to be of good predictive value. Finally, we constructed a risk stratification model for dividing patients into low‐risk, medium‐risk, and high‐risk groups, and there were obvious differences in OS.

Conclusions

A prognostic nomogram was firstly established for predicting the survival probability of ASCC patients and helping clinicians improve their risk management.

Anal squamous cell carcinoma: standards of care, new data and ongoing clinical trials

PURPOSE OF REVIEW

To summarize current standards of care, discuss results of recent studies and present ongoing clinical trials for anal squamous cell carcinoma (ASCC).

RECENT FINDINGS

Over the last year, no practice changing studies have been reported in the setting of localised ASCC. A number of retrospective analyses, however, have provided practice-informing data, such as those confirming the negative impact of low compliance to chemoradiotherapy (CRT) on patient outcomes. In contrast, and for the first time, randomized evidence has become available to inform the management of advanced tumours. The InterAACT trial represents a key milestone in the evidence-building process for this disease, establishing carboplatin plus paclitaxel as a new standard of care for treatment-naïve advanced ASCC patients. Furthermore, more data have accumulated about the value of triplet chemotherapy in the first-line setting and of immune checkpoint inhibitors (either as single agents or in combination with other agents) in the refractory setting.

SUMMARY

Recent findings have the potential to improve the treatment quality standards and overall outcome of patients with either localised or advanced ASCC. Results from ongoing clinical trials will hopefully provide useful insights into the management of this disease and further shape current treatment paradigms.

Burden of anal squamous cell carcinoma, squamous intraepithelial lesions and HPV16 infection in solid organ transplant recipients: A systematic review and meta-analysis

The number of solid organ transplant recipients (SOTR), and their life expectancy, is increasing, with higher risk for long-term complications from immunosuppression. We carried out a systematic review describing the burden of anal squamous cell carcinoma (SCC), and its surrogates, in SOTR. We conducted mixed effect model-based meta-analyses evaluating incidence of anal SCC (standardized incidence ratio [SIR] vs general population, and absolute incidence rate [IR]), prevalence of anal squamous abnormalities, and human papillomavirus (HPV) 16. Generalized I2 statistics were calculated, quantifying heterogeneity. Anal SCC incidence in SOTR was elevated vs the general population (pooled SIR = 6.8, 95% confidence interval [CI], 4.3-10.9; 6 studies including 241 106 SOTR; I2  = 82.3%), with an absolute IR of 12.3 (95% CI, 10.4-14.7) per 100 000 person-years (5 studies including 1 079 489 person-years; I2  = 0%). Prevalence of abnormal anal cytology was 12.9% (95% CI, 9.2%-17.7%; 6 studies including 328 SOTR; I2  = 17.4%). For histology, the pooled prevalence estimate of anal squamous intraepithelial lesions was 22.4% (95% CI, 17.3%-28.5%; 3 studies including 214 SOTR; I2  = 0%), with 4.7% (95% CI, 2.5%-8.5%; I2  = 0%) high-grade squamous intraepithelial lesions. Pooled anal HPV16 prevalence was 3.6% (95% CI, 1.6%-7.8%; 4 studies including 254 SOTR; I2  = 17.6%). There was substantial and consistent evidence of elevated anal SCC incidence in SOTR.

Human papillomavirus infection in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These guidelines from the American Society of Transplantation Infectious Diseases Community of Practice update the epidemiology and management of human papillomavirus (HPV) infections in organ transplant recipients. HPV is one of the most common sexually transmitted infections and is associated with cancers of the anogenital region. Increasing evidence suggests an association with head and neck cancers as well. Solid organ transplant recipients have a higher risk of HPV infection than the general population. Infection manifests as premalignant lesions, warts, or cancer of the cervix, penis, vulva, scrotum, and anal canal. Most are asymptomatic initially, so diagnosis can be difficult without screening. A vaccine is available though not effective in preventing all cancer-causing strains. Organ transplant recipients should be screened for HPV-associated cancers and appropriate therapy initiated in a timely manner. Further studies are warranted to delineate the most effective screening methods and therapeutic modalities, including whether changes in immunosuppression are effective in attenuating disease.

Sexual aspects of liver transplant candidates and recipients: evidence available in the literature1

OBJECTIVE

to analyze the evidence available in the literature on the alterations in the sexuality of candidates and recipients of liver transplantation.

METHOD

integrative review of the literature with search for primary studies in the databases MEDLINE (via PUBMED), CINAHL e LILACS, published in English, Portuguese and Spanish.

RESULTS

the 16 primary studies included were grouped into three categories: 1) female sexuality (n=5), 2) male sexuality (n=5) and 3) male and female sexuality (n=6). In category 1, the subjects investigated were contraception, pregnancy, sexual dysfunction, presence of gynecological symptoms and sexually transmitted infections. In category 2, the main focus of the studies was erectile dysfunction, sexual desire and satisfaction, and consequences of the immunosuppressive regimen with mycophenolic acid in men. In category 3, the evaluation of sexual function was the main topic.

CONCLUSION

the scientific evidence generated provides support to encourage health professionals to incorporate the topic of sexuality in the routine of care. Knowledge gaps were identified and new studies should be conducted in order to implement interventions to prevent, minimize and/or control changes related to the patient's sexuality.

Liver transplant recipients have a higher prevalence of anal squamous intraepithelial lesions

BACKGROUND

Anal squamous intraepithelial lesions (ASIL) are precancerous lesions of anal squamous cell carcinoma, with a higher prevalence in immunosuppressed patients. There are some studies in kidney transplant recipients, but there is no information regarding prevalence in liver transplantation. Our aim was to evaluate the prevalence of ASIL in this setting.

METHODS

Prospective case-control study involving liver transplant recipients without any other known risk factor for ASIL (n=59), which were compared with a healthy control group (n=57). All were submitted to anal cytology and high-resolution anoscopy was performed in those with abnormal results.

RESULTS

Ten (17%) of liver transplant recipients had abnormal cytological results, seven patients had atypical squamous cells of undetermined significance (ASC-US), one patient had atypical squamous cells that cannot exclude high-grade (ASC-H) and two patients had high-grade squamous intraepithelial lesions (HSIL). In the control group, one patient (2%) had an ASC-US result (P=0.005). Anal squamous intraepithelial lesions were confirmed in 7 out of 10 of liver transplant patients and 0 out of 1 in the controls (P=0.013) by high-resolution anoscopy with biopsies. Current smoking was the only risk factor for abnormal cytology (odds ratio=5.87, 95% confidence intervals=1.22-28.12, P=0.027).

CONCLUSIONS

Liver transplant patients have a higher risk of ASIL. Screening should be considered, especially in smokers.

Cervical human papillomavirus infection in the early postoperative period after liver transplantation: Prevalence, risk factors, and concordance with anal infections

Solid organ transplant recipients are at increased risk of developing several human papillomavirus (HPV)-related malignancies, including cervical and anal cancers. The purpose of this prospective study was to assess the initial prevalence and risk factors for high-risk HPV (HR-HPV) cervical infections in liver transplant recipients, as well as their concordance with anal infections. A total of 50 female patients were enrolled in the Department of General, Transplant and Liver Surgery at the Medical University of Warsaw (center with >1600 liver transplantations). The initial prevalence of cervical HR-HPV infection was 10.0% (5/50). The only significant risk factor for cervical HR-HPV infection was ≥4 lifetime sexual partners (P=.037). Statistical tendencies toward higher prevalence of cervical HR-HPV infections were found for patients with hepatitis B virus (HBV, P=.082) and with model for end-stage liver disease (MELD) score ≤8 (P=.064). Cervical cytology was abnormal in 10 patients, including three with HR-HPV. Out of 12 patients with available data on anal HR-HPV, one had concordant HPV 16 infection. In conclusion, the initial prevalence of high-risk HPV infection is relatively low, except for patients with ≥4 previous sexual partners and potentially in those with HBV and/or low MELD score.

Human papillomavirus vaccine trials and tribulations: Clinical perspectives

Human papillomavirus (HPV) affects hundreds of millions of people worldwide and is associated with both benign and malignant neoplasms in men and women. It is a double-stranded DNA virus with an icosahedral capsid. Forty HPV types are known to infect mucosal keratinocytes. If not cured by the immune system, the infection can lead to genital warts, mucosal dysplasia, or cancer. The most common oncogenic types are 16 and 18. The vaccine to prevent HPV and its associated morbidity and mortality has existed since 2006. Several variations protect against an increasing number of HPV types. The recommended vaccination age is before sexual exposure; administration of the vaccine to children has been controversial. This continuing medical education review evaluates the current HPV vaccines available to clinicians. Part I focuses on the debate over who should be vaccinated, at what age, and in which populations.

Anal cancer: current standards in care and recent changes in practice

Answer questions and earn CME/CNE The management of squamous cell carcinomas of the anal canal has evolved from surgery as first-line treatment to curative chemoradiation, with surgery reserved for salvage. Significant progress has been made in understanding how to most effectively deliver chemotherapy and reduce toxicity through advancements in radiation delivery. The purpose of this article is to review the multimodality approach to the diagnosis and management of anal cancer based on a review of the published data and in light of available guidelines.