Using High-Resolution Anoscopy to Detect Anal Dysplasia Due to Papillomavirus in Patients with Inflammatory Bowel Disease

Introduction: Anal squamous cell carcinoma is rare, but its incidence and mortality have been increasing globally; 90% of cases are related to human papillomavirus (HPV) infection(1,2). Patients with inflammatory bowel disease (IBD) have a higher risk of infection with this virus; an incidence of 5.5 per 100,000 patients has been identified in the IBD group compared to 1.8 in the non-IBD group(3). Materials and methods: A descriptive case series study was conducted with 21 patients with IBD and no perianal symptoms between January and July 2022 at the Institute of Coloproctology in Medellín. They underwent anal cytology, HPV genotyping, and high-resolution anoscopy after explanation and acceptance of the procedure. If lesions were found, ablative treatment was performed. Results: 23% of this cohort had low-grade squamous lesions, while 14.2% had high-grade lesions with dysplasia changes during anoscopy. Besides, 90.4% had positive HPV genotyping, of which 76.1% were high-grade. Conclusions: Our study suggests that this series of patients with IBD behaves as a high-risk group for developing premalignant lesions in association with HPV. High-resolution anoscopy is a cost-effective, painless, and affordable method that, in expert hands, may impact the diagnosis and management of premalignant lesions and decrease the incidence of anal cancer in patients with IBD.

Introducción: El carcinoma anal de células escamosas es raro, pero su incidencia y mortalidad han ido en aumento globalmente. El 90% de los casos están relacionados con la infección por el virus del papiloma humano (VPH)1,2 y los pacientes con enfermedad inflamatoria intestinal (EII) tienen un mayor riesgo de infección por este virus; se ha identificado una incidencia de 5,5 por 100.000 pacientes en el grupo de EII frente a 1,8 en el grupo sin EII3. Metodología: Se realizó un estudio descriptivo de serie de casos en el que se incluyó a 21 pacientes con EII, sin síntomas perianales, entre enero y julio de 2022 en el Instituto de Coloproctología de Medellín, a quienes se les realizó citología anal, genotipificación del VPH y anoscopia de alta resolución, previa explicación y aceptación del procedimiento. Si se encontraban lesiones, se realizaba tratamiento ablativo. Resultados: El 23% de esta cohorte tenía lesiones escamosas de bajo grado, mientras que el 14,2% presentaba lesiones de alto grado con cambios de displasia al momento de la anoscopia. El 90,4% tenían genotipificación positiva para VPH, de los cuales el 76,1% eran de alto grado. Conclusiones: Nuestro estudio sugiere que esta serie de pacientes con EII se comporta como un grupo de alto riesgo para desarrollar lesiones premalignas en asociación con el VPH. La anoscopia de alta resolución es un método rentable, indoloro y asequible que, en manos expertas, puede impactar el diagnóstico y manejo de lesiones premalignas y disminuir la incidencia de cáncer anal en pacientes con EII.

Anal dysplasia among solid organ transplant recipients; a cross sectional study / Displasia anal entre receptores de transplantes de órgãos sólidos - um estudo transversal

ABSTRACT Introduction: The incidence of anal cancer in United States has increased over of the last few decades impacting immunosuppressed populations like solid organ transplant recipients, in particular. The aim of this study was to evaluate the prevalence of anal dysplasia among solid organ transplant patients. We also attempted to identify factors that predispose solid organ transplant recipients to developing anal dysplasia. Methods and materials: Patients presenting to transplant office for routine care were recruited to participate in the study. All anal cytology specimens were collected using standard anal pap technique. The results were assessed using Bethesda classification. Information on perceived risk factors for development of anal dysplasia among our subjects was obtained. Results: Among 80 patients approached, 47 agreed to participate in the study. Of all the samples 19.1% had an inadequate amount of specimen to perform any analysis. Dysplastic cells were found in 10.5% of the specimens available for analysis. We were not able to identify any risk factors including age, gender distribution, smoking, and duration of immunosuppression that were statistically significant different between patients with anal dysplasia versus those without anal dysplasia. Conclusions: The rate of anal dysplasia detectable on cytology is high enough to warrant anal dysplasia screening in transplant recipients, which can then be followed up with high-resolution anoscopy with biopsy. Defining a cohort of patients among solid organ transplant recipients who are at an increased risk for the development of anal dysplasia mandating screening continues to be a challenge.

RESUMO Introdução: A incidência de câncer anal nos Estados Unidos aumentou nas últimas décadas, afetando populações imunossuprimidas, especialmente receptores de órgãos sólidos. O objetivo deste estudo foi avaliar a prevalência de displasia anal entre pacientes que receberam transplante de órgãos sólidos. Os autores buscaram identificar fatores que predispõem os receptores de transplante de órgãos sólidos a desenvolverem displasia anal. Métodos e materiais: Pacientes que se apresentaram ao consultório de transplante para acompanhamento de rotina foram recrutados para participar do estudo. Todos os espécimes de citologia foram coletados usando a técnica padrão de Papanicolau anal. Os resultados foram avaliados usando a classificação de Bethesda. Foram coletados dados sobre os fatores de risco percebidos para o desenvolvimento de displasia anal entre os participantes. Resultados: Dos 80 pacientes abordados, 47 concordaram em participar do estudo. Do total de amostras, 19,1% tinham uma quantidade inadequada para realizar qualquer análise. Células displásicas foram encontradas em 10,5% dos espécimes disponíveis para análise. Não foi possível identificar quaisquer fatores de risco, incluindo idade, distribuição de gênero, tabagismo e duração da imunossupressão, que foram estatisticamente diferentes entre pacientes com displasia anal e aqueles sem displasia anal. Conclusões: A taxa de displasia anal detectável na citologia é alta o suficiente para justificar a triagem em receptores de transplante, que pode então ser acompanhada com anuscopia de alta resolução com biópsia. A definição de triagem para uma coorte de pacientes entre os receptores de transplantes de órgãos sólidos que apresentam risco aumentado para o desenvolvimento displasia anal continua a ser um desafio.

Protocolo para la pesquisa de la displasia anal mediante citología y anoscopía de alta resolución / Protocol for the investigation of anal dysplasia by cytology and high resolution anoscopy

Introducción: El carcinoma anal escamoso (CAE) representa el 2% de todas las neoplasiascolorrectoanales. Afecta a 2/100.000 habitantes por año en la población general. Se incrementa en lospacientes con serología positiva para el virus de la inmunodeficiencia humana (VIH-positivos), 60/100.000habitantes por año y asciende a 92-144/100.000 habitantes por año en los hombres que tienen sexocon hombres (HSH) VIH-positivos. Al igual que en el carcinoma escamoso del cuello uterino, el virus delpapiloma humano (VPH) está implicado en su génesis, y se encuentra presente en el 92% de los casos.El cáncer cervical y anal comparten el mismo origen embriológico, formando la zona de transformación,sitio donde se desarrollan las lesiones intraepiteliales escamosas (SIL) como resultado de la infección ypersistencia del VPH, en especial de los genotipos de alto riesgo que pueden progresar a CAE invasor. Elaumento significativo de CAE en las últimas décadas ha llevado a desarrollar la pesquisa de SIL anal (ASIL)mediante citología (PAP) y anoscopía de alta resolución (AAR) con técnica colposcópica, emulando losprotocolos de detección temprana para prevención el cáncer de cuello uterino.Objetivo: Conocer prevalencia de lesiones precursoras del CAE. Determinar sensibilidad (S), especificidad (E),valor predictivo positivo (VPP) y negativo (VPN) del PAP para la detección de displasias en población de riesgo.Material y Método: Diseño: Prospectivo, transversal, observacional, analítico. Se incluyeron individuos dealto riesgo (VIH-positivos, HSH, individuos con historia de VPH anogenital, mujeres con antecedentes decáncer o neoplasia intraepitelial genital inferior) estudiados en forma consecutiva, entre abril 2012 y febrero2014, en Consultorio de Detección Temprana del Cáncer Ana...

Introduction: Anal squamous cell carcinoma (SCC) represents 2% of all colo-recto-anal malignancies. It is confirmed a higher rate of anal cancer among HIV-infected population in comparison with the HIVuninfected population (60/100,000 person-years, versus 2/100,000 person-years). Among HIV-infected men who have sex with men (MSM), the incidence of anal cancer is as high as 92-144/100,000 population. Like cervical cancer, squamous-cell canal cancer is caused predominantly by high-risk, oncogenic strains of human papillomaviruses (HPV) detected in 92% of HIV-positive MSM. The cervical and anal cancer share the same embryological origin, and occurs at a squamo-columnar transition zone, site of squamous intraepithelial lesions (SIL) as a result of the persistence HPV infection, especially the high-risk genotypes that may progress to invasive cancer. In the last decades, the incidence of squamous-cell anal carcinoma is increasing rapidly forcing the research of anal SIL (ASIL) cytology (PAP) and high-resolution anoscopy (HRA) colposcopic technique, emulating protocols for early detection of cervical cancer as a primary prevention. Objective: This study aimed to determine the prevalence of SCC precursor lesions. Determine sensitivity (S), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) for the detection of anal dysplasia in the risk population. Material and Methods: Design prospective, cross-sectional, observational, analytical study. High-risk patients (HIV-positive MSM, patients with history of anogenital HPV, women with history of cancer or lower genital intraepithelial neoplasia) were included consecutively between April 2012 and February 2014 in Anal Early Detection Cancer Clinic...

Detección temprana de la displasia anal con citología (PAP) y anoscopía de alta resolución (AAR) en la población de riesgo: experiencia inicial / Early detection of anal dysplasia with cytology (PAP) and high resolution anoscopy (AAR) in the population at risk: initial experience

Antecedentes: La incidencia del carcinoma de células escamosas anal (CCE) aumentó drásticamente, es de 35/100.000 habitantes en los hombres que tienen sexo con hombres (HSH), similar a la del cáncer del cuello uterino antes del Papanicolaou (PAP). En forma análoga a la pesquisa del cáncer cervical, el PAP anal y la anoscopía de alta resolución (AAR), se utilizan para la detección temprana de las lesiones precursoras del CCE. Objetivo: Evaluar los hallazgos de la citología anal y la AAR en una población de alto riesgo para desarrollar displasia y CCE. Diseño: Observacional, descriptivo, transversal, prospectivo. Población: Pacientes de alto riesgo (individuos HIV positivos, hombres que tienen sexo con hombres (HSH), mujeres con antecedentes de cáncer o displasia del tracto genital inferior, individuos con antecedentes de HPV anal o genital) que concurrieron al Consultorio de Detección Temprana de la Displasia Anal, entre 1 abril y 30 junio 2012. Método: Tacto rectal, anoscopía convencional, PAP anal y AAR, con biopsia dirigida de lesiones sospechosas. Comparación de la citología con la histología...

Background: The incidence of anal squamous cell carcinoma (SCC) has increased dramatically, with an incidence of 35/100.000 inhabitants in men who have sex with men (MSM), similar to that of cervical cancer before the Papanicolaou (PAP). In analogy form to screening of cervical cancer, anal PAP and high resolution anoscopy (HRA) are used for early detection of SSC precursor lesions. Objective: To assess the findings of anal cytology and HRA in a high risk population for developing dysplasia and SCC. Design: Cross-sectional, descriptive, prospective, study. Population: High-risk patients (HIV- positive individuals, men who have sex with men, women with previous cancer or dysplasia of the lower genital tract, individuals with previous anal or genital condylomata) who attended the Anal Dysplasia Early Detection Clinic between April 1-June 30, 2012, were included. Methods: Digital rectal examination, conventional anoscopy, anal PAP and HRA, with biopsies of suspected areas was performed...

Recidiva de lesões associadas ao HPV em pacientes HIV positivos após tratamento cirúrgico / Recurrence of HPV lesions after surgical treatment in HIV-positive patients

O HPV é a doença anal sexualmente transmissível mais diagnosticada em pacientes HIV positivos. Neste estudo investigamos a taxa de recidiva após tratamento cirúrgico do HPV em pacientes HIV positivos. Foi realizado um estudo retrospectivo em 74 pacientes que foram submetidos a tratamento cirúrgico de lesões remanescentes após tratamento clínico do HPV, no Hospital Heliópolis, São Paulo, Brasil, de julho de 2004 até junho de 2007. A maioria dos pacientes eram homens (91,9 por cento), idade variando de 22 a 57 anos (média de 36 anos). Carga viral variou de indetectável até 488.000 cópias/mm³, células T CD4 de 19 a 900 céls/mm³. Observamos neoplasia intraepitelial de alto grau em 12,2 por cento e recorrência das lesões em 58,1 por cento dos pacientes. A recorrência foi significantemente menor em pacientes com células T CD4 =200 cells/mm³ e carga viral indetectável.

HPV is the commonest anal disease in HIV-infected patients. In the present study we investigated the recurrence rates after surgical treatment of HPV in HIV-positive patients. A retrospective review was performed on 74 patients who underwent surgical intervention for medically intractable anal condyloma at Hospital Heliópolis, São Paulo, Brazil, from July 2004 to June 2007. The majority of the patients were male (91,9 percent), ranged in age from 22 to 57 years (mean 36 years). Viral load ranged from undetectable to 488.000 copies/mm³, T CD4 cells counts from 19 to 900 cells/mm³. We observed high grade anal squamous intraepithelial lesions in 12,2 percent and anal condyloma recurred in 58,1 percent. A significantly lower recurrence was observed in patients with T CD4 cells counts =200 cells/mm³ and viral load undetectable.