Anal Pap smears and anal cancer: what dermatologists should know

Depo Medroxyprogesterone (DMPA) Promotes Papillomavirus Infections but Does Not Accelerate Disease Progression in the Anogenital Tract of a Mouse Model

Contraceptives such as Depo-medroxyprogesterone (DMPA) are used by an estimated 34 million women worldwide. DMPA has been associated with increased risk of several viral infections including Herpes simplex virus-2 (HSV-2) and Human immunodeficiency virus (HIV). In the current study, we used the mouse papillomavirus (MmuPV1) anogenital infection model to test two hypotheses: (1) contraceptives such as DMPA increase the susceptibility of the anogenital tract to viral infection and (2) long-term contraceptive administration induces more advanced disease at the anogenital tract. DMPA treatments of both athymic nude mice and heterozygous NU/J (Foxn1nu/+) but ovariectomized mice led to a significantly increased viral load at the anogenital tract, suggesting that endogenous sex hormones were involved in increased viral susceptibility by DMPA treatment. Consistent with previous reports, DMPA treatment suppressed host anti-viral activities at the lower genital tract. To test the impact of long-term contraceptive treatment on the MmuPV1-infected lower genital tract, we included two other treatments in addition to DMPA: 17β-estradiol and a non-hormone based contraceptive Cilostazol (CLZ, Pletal). Viral infections were monitored monthly up to nine months post infection by qPCR. The infected vaginal and anal tissues were harvested and further examined by histological, virological, and immunological analyses. Surprisingly, we did not detect a significantly higher grade of histology in animals in the long-term DMPA and 17β-estradiol treated groups when compared to the control groups in the athymic mice we tested. Therefore, although DMPA promotes initial papillomavirus infections in the lower genital tract, the chronic administration of DMPA does not promote cancer development in the infected tissues in our mouse model.

Liquid-based Anal Cytology as a Screening Tool for Prevention of Anal Cancer in at-risk Populations: A Single-Center Retrospective Analysis on 111 Patients

Objective Squamous cell carcinoma of the anus (SCCA) is associated with human papillomavirus (HPV) infection in almost 90% of the cases. Its incidence is alarmingly high among men who have sex with men (MSM) and continues to increase at an average rate of 2% per year. The objective of the present study is to evaluate the usefulness and performance of liquid-based anal cytology as a screening tool for prevention and early detection of SCCA in a cohort of at-risk men.

Method We conducted a retrospective study including 111 MSM, aged between 22 and 62 years old, who underwent anal cytological screening with a liquid-based Pap test at our sexually transmitted diseases (STDs) clinic from January 2015 to March 2017.

Results Out of 111 anal smears, 57 (51,4%) resulted negative, 42 (37,8%) abnormal, and 12 (10,8%) unsatisfactory for the cytological evaluation. Only patients with an abnormal cytology underwent anoscopy and subsequent biopsy. The histological results were as follows: negative for squamous intraepithelial lesion (SIL) in 5 cases, low-grade SIL (L-SIL) in 21, high-grade SIL (H-SIL) in 5, SCCA in 1. Five patients had a normal anoscopy and biopsy was not taken.

Conclusion Liquid-based cytology, reducing the “darkening factors” typical for the conventional smears, has a higher positive predictive value than the traditional technique. Moreover, a cytological diagnosis of atypical squamous cells of undetermined significance (ASC-US) or L-SIL may hide a severe dysplasia or even a carcinoma. Thus, all patients with an abnormal anal cytology at any grade should be considered for anoscopy.

Clinical characteristics and prognosis of anal squamous cell carcinoma: a retrospective audit of 144 patients from 11 cancer hospitals in southern China

Background

The incidence of anal squamous cell carcinoma (SCC) has been steadily growing globally in the past decade. Clinical data on anal SCC from China are rare. We conducted this study to describe the clinical and epidemiological characteristics of anal SCC in China and explore prognostic factors of outcomes among patients with anal SCC.

Methods

We audited demographic characteristics, relevant symptoms, risk factors, treatment modalities and outcomes for patients diagnosed with anal SCC at 11 medical institutions in China between January 2007 and July 2018.

Results

A total of 144 patients (109 females) were diagnosed with SCC during this period. Median age at initial diagnosis was 52.0 (interquartile range: 46.0–61.8) years. The most common symptoms were bleeding (n = 93, 64.6%), noticing a lump (n = 49, 34.0%), and pain (n = 47, 32.6%). The proportion of patients at the American Joint Committee on Cancer (AJCC) stages I-IV were 10 (6.9%), 22 (15.3%), 61 (42.4%) and 8 (5.6%), respectively, and AJCC stages in 43 (29.9%) patients were unknown. Thirty-six patients (25.0%) underwent abdominoperineal resection initially. Univariable analysis showed that T stage predicted recurrence-free survival (RFS) (Hazard ratio [HR] = 3.03, 95% Confidence interval [CI]: 1.10–8.37, p = 0.032), and age group (HR = 2.90, 95% CI: 1.12–7.49, p = 0.028), AJCC stage (HR = 4.56, 95% CI: 1.02–20.35, p = 0.046), and N stage (HR = 3.05, 95% CI: 1.07–8.74, p = 0.038) predicted overall survival (OS).

Conclusions

T stage was identified as prognostic factor of RFS, and age, AJCC stage, and N stage were identified as prognostic factors of OS. Improving symptom awareness and earlier presentation among patients potentially at risk for anal SCC should be encouraged. Familiarity with the standard treatment among health care providers in China should be further improved.

Dermatologic care of sexual and gender minority/LGBTQIA youth, Part 2: Recognition and management of the unique dermatologic needs of SGM adolescents

Sexual and gender minority (SGM) individuals, including lesbian, gay, bisexual, transgender/gender diverse, questioning/queer, intersex, and asexual (LGBTQIA) persons, represent a historically underserved population within the field of medicine, though their unique health needs are increasingly recognized. Part 2 of this two-part review will address unique concerns regarding acne, tanning behavior, sexually transmitted infections, and other health disparities among SGM adolescents. A more comprehensive understanding of the dermatologic needs of SGM youth will better allow pediatric dermatologists to actively and compassionately care for this health disparity population.

Anal Intraepithelial Neoplasia from a Pathologists Point of View

Anal squamous cell carcinoma is a relatively rare diagnosis, but its incidence has continued to rise. Anal squamous cell carcinoma and its precursor lesion, anal intraepithelial neoplasia (AIN), are human papillomavirus (HPV)-associated squamous neoplasias. High-risk HPV subtypes cause cellular proliferation in the anal transformation zone mucosa leading to similar dysplastic changes as seen in the cervix. Unified cytologic and histologic classification systems have emerged for all HPV-associated squamous lesions of the lower anogenital tract due to recent advancements in the understanding of these lesions. P16 immunohistochemical stain, a biomarker for HPV, is recommended in the diagnosis of HPV-associated lesions. The unity of terminology will aid in communication between pathologists and clinicians, ultimately leading to improved patient care.

Medical dermatologic conditions in transgender women

Many previous reviews and studies on transgender dermatology have highlighted the expected dermatologic manifestations of hormone affirmation therapy in transgender patients. Others have highlighted attitudes and practices of both transgender patients and medical professionals taking care of these patients. This review compiles data from other, lesser known aspects of transgender dermatology, including neovaginal concerns, neoplastic concerns (both neovaginal and cutaneous), autoimmune conditions, and the sequelae of injectable substances that have not been approved by the U.S. Food and Drug Administration. This review, like others, will be a stepping-stone and serve as an impetus for future research in transgender dermatology.

Survival rate variation with different histological subtypes of poor prognostic male anal squamous cell carcinoma: a population-based study

Background and objective

The prognosis of male anal squamous cell carcinoma (MASCC) and female anal squamous cell carcinoma (FASCC) is variable. The influence of tumor subtype on the survival rate and gender is poorly known. Our study is the largest population-based study and aims to outline the difference in survival between MASCC and FASCC patients.

Methods

A retrospective population-based study was performed to compare the disease-specific mortalities (DSMs) between genders related to the tumor subtypes. The Surveillance, Epidemiology, and End Results (SEER) program database was employed to obtain the data from January 1988 to December 2014.

Results

A total of 4,516, (3,249 males and 1,267 females), patients with anal squamous cell carcinomas (ASCC) were investigated. The 5-year DSMs were 24.18% and 18.08% for men and women, respectively. The univariate analysis of the male basaloid squamous cell carcinoma (BSCC) and cloacogenic carcinoma (CC) patients demonstrated higher DSMs (P <0.001). Moreover, in the multivariate analysis, BSCC and CC were associated with soaring DSMs in male patients (P < 0.05).

Conclusions

In the cohort of BSCC and CC patients, male patients demonstrated a considerable decrease in survival rate compared to females. A more precise classification of ASCC and individualized management for MASCC are warranted.

International trends in anal cancer incidence rates

Background

Previous studies have reported rapid increases in anal cancer incidence rates in seven high-income countries in North America, Europe and Oceania. There is very limited information on whether this pattern is replicated in other parts of the world. In this study, we examine recent trends in anal cancer incidence in 18 countries worldwide.

Methods

We calculated age-standardized incidence rates for anal squamous cell carcinoma (ASCC) and anal adenocarcinoma (AAC) for a minimum of 13 years through to 2007, using data from the International Agency for Research on Cancer's Cancer Incidence in Five Continents series, and applied joinpoint regression models to assess changes in incidence rates. We also conducted an extended analysis of the data from the USA through to 2012.

Results

ASCC was the main histological subtype in most of the countries considered in this analysis. The incidence of ASCC increased in both men and women in several high-income countries, including Australia, Canada, Denmark, France, Italy, Netherlands, the UK and the USA, whereas it increased only in women in Colombia, Estonia, the Russian Federation, Slovakia and Switzerland. Conversely, there was little change in the incidence of ASCC in either men or women in India, Israel, Japan, Singapore and Spain. The incidence rates of AAC decreased or were stable in most populations.

Conclusions

The ASCC incidence rates increased in both men and women or in women in all countries included in this study, except Asian countries and Spain, where the rates remained unchanged. Population-based preventive measures, including human papillomavirus vaccination and advocacy for safe sexual behaviours, may contribute to curbing the surging burden of the disease.

Risk of second primary cancer after a first potentially-human papillomavirus-related cancer: A population-based study

Human papillomaviruses (HPV) are involved in the development of anogenital and head and neck cancers. The purpose of this study was to assess the risk of developing a second primary cancer (SPC) after a first potentially-HPV-related cancer, and to analyze the sites where SPCs most frequently occurred in these patients. All patients with a first cancer diagnosed between 1989 and 2004, as recorded by 10 French cancer registries, were followed up until December 31, 2007. Only invasive potentially-HPV-related cancers (namely, cervical, vagina, vulva, anal canal, penile, oropharynx, tongue and tonsil) were included. Standardized Incidence Ratios (SIRs) were calculated to assess the risk of SPC. A multivariate Poisson regression model was used to model SIRs separately by gender, adjusted for the characteristics of the first cancer. 10,127 patients presented a first potentially-HPV-related cancer. The overall SIR was 2.48 (95% CI, 2.34-2.63). The SIR was 3.59 (95% CI, 3.33-3.86) and 1.61 (95% CI, 1.46-1.78) in men and women respectively. The relative risk of potentially-HPV-related SPC was high among these patients (SIR=13.74; 95% CI, 8.80-20.45 and 6.78; 95% CI, 4.61-9.63 for men and women, respectively). Women diagnosed in the most recent period (2000-2004) showed a 40% increase of their relative risk of SPC as compared with women diagnosed between 1989 and 1994 (ratio of SIRs=1.40; 95% CI, 1.06-1.85). HPV cancer survivors face an increased risk of SPC, especially second cancer. Clinicians may consider this increased risk of developing HPV-related SPC during follow-up to improve subsequent cancer prevention in these patients.

Background and Current Treatment of Squamous Cell Carcinoma of the Anus

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

Tracking vaginal, anal and oral infection in a mouse papillomavirus infection model

Noninvasive and practical techniques to longitudinally track viral infection are sought after in clinical practice. We report a proof-of-principle study to monitor the viral DNA copy number using a newly established mouse papillomavirus (MmuPV1) mucosal infection model. We hypothesized that viral presence could be identified and quantified by collecting lavage samples from cervicovaginal, anal and oral sites. Nude mice infected at these sites with infectious MmuPV1 were tracked for up to 23 weeks starting at 6 weeks post-infection. Viral DNA copy number was determined by SYBR Green Q-PCR analysis. In addition, we tracked viral DNA load through three complete oestrous cycles to pinpoint whether there was a correlation between the DNA load and the four stages of the oestrous cycle. Our results showed that high viral DNA copy number was reproducibly detected from both anal and cervicovaginal lavage samples. The infection and disease progression were further confirmed by histology, cytology, in situ hybridization, immunohistochemistry and transmission electron microscopy. Interestingly, the viral copy number fluctuated over the oestrous cycle, with the highest level at the oestrus stage, implying that multiple sampling might be necessary to provide a reliable diagnosis. Virus DNA was detected in oral lavage samples at a later time after infection. Lower viral DNA load was found in oral samples when compared with those in anal and vaginal tracts. To our knowledge, our study is the first in vivo study to sequentially monitor papillomavirus infection from mucosal anal, oral and vaginal tracts in a preclinical model.

Human papillomavirus vaccine trials and tribulations: Vaccine efficacy

As of December 2014, there were 3 approved vaccines for human papillomavirus (HPV): bivalent Cervarix (GlaxoSmithKline, New York, NY), quadrivalent Gardasil (Merck and Co, Kenilworth, NJ), and 9-valent Gardasil-9 (Merck and Co). The average cost per dose is $120, with a recommended 3-dose course. The quadrivalent vaccine is the most widely administered worldwide. As with the bivalent and 9-valent vaccines, the vaccine is considered safe, although concerns have been raised. In addition to immunization against the targeted HPV types, there is evidence that there is cross protection against other types of HPV. This continuing medical education review evaluates the differences in vaccines that are currently on the market; part II focuses on the cost-effectiveness of vaccination, the HPV vaccination programs currently instituted around the globe, efficacy, and safety.

Asymptomatic anal sexually transmitted infections in HIV-positive men attending anal cancer screening

BACKGROUND

HIV-positive men who have sex with men (HIV+MSM) have an increased risk for anal dysplasia and for sexually transmitted infections (STIs).

OBJECTIVES

We determined the positivity rates of Chlamydia trachomatis (CT), Neisseria gonorrhoea (NG), Mycoplasma genitalium (MG) and syphilis in HIV+MSM participating in an anal cancer screening programme.

METHODS

In total, 852 intra-anal swabs were collected from 503 HIV+MSM between 2012 and 2014. Anal cytology and polymerase chain reaction assays for human papillomavirus (HPV), CT, NG and MG detection were performed. The syphilis status was determined serologically. Risk factors for STIs were explored by multiple logistic regression analysis.

RESULTS

In total 20·7% (104 of 503) of the patients had an STI other than HPV within the study period. The most common was CT, found in 10·9%, followed by NG (8·9%) and MG (4·2%). Early syphilis was detected in 4·6% and past syphilis in 44·5% of the HIV+MSM. Eighteen patients (3·6%) had more than one STI episode, and 90·6% of the 127 cases of STIs were asymptomatic. Age, anal HPV infection, abnormal anal cytology and previous syphilis were risk factors for STI.

CONCLUSIONS

Anal STIs are frequent and mostly asymptomatic in HIV+MSM participating in anal cancer screening. STI screening should be incorporated into anal cancer screening programmes for HIV+MSM.