Skip to main content

Advertisement

SpringerLink
Log in

High Resolution Anoscopy in the Planned Staged Treatment of Anal Squamous Intraepithelial Lesions in HIV-Negative Patients

  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Anal dysplasia (low-grade squamous intraepithelial lesions, LSIL; high-grade squamous intraepithelial lesions, HSIL) is a challenging disease for the surgeon. We reviewed 42 patients that underwent high-resolution anoscopy (HRA)-targeted surgical therapy of anal dysplasia in the past 10 years. Patients were followed up in the Anal Neoplasia Clinic with physical examination, cytology, HRA, and biopsy if indicated. Patients with disease amenable to local therapy were treated with office-based HRA-directed therapies. There were 30 men (mean age 39 years, range 21–63) and 12 women (mean age 50 years, range 31–71) included in the study. HSIL was present in 33, with four undergoing planned staged treatment due to circumferential disease. HSIL recurred in 45%, and most were re-treated successfully in-office. Progression to HSIL was seen in one patient with LSIL and to squamous cell carcinoma in one patient with HSIL despite therapy. No patients with LSIL had dysplasia at last follow-up. Minor complications occurred in three patients. HRA-targeted surgical therapy coupled with surveillance and re-treatment with office-based therapies offered an effective method in controlling anal dysplasia in the immunocompetent patient. Morbidity is minimal, and our progression to cancer rate is low (2.4%).

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1

Similar content being viewed by others

References

  1. Berry JM, Palefsky JM, Welton ML. Anal cancer and its precursors in HIV-positive patients: perspectives and management. Surg Oncol Clin N Am 2004;13(2):355–373.

    Article  PubMed  Google Scholar 

  2. Marchesa P, Fazio VW, Oliart S, Goldblum JR, Lavery IC. Perianal Bowen’s disease: a clinicopathologic study of 47 patients. Dis Colon Rectum 1997;40(11):1286–1293.

    Article  PubMed  CAS  Google Scholar 

  3. Margenthaler JA, Dietz DW, Mutch MG, Birnbaum EH, Kodner IJ, Fleshman JW. Outcomes, risk of other malignancies, and need for formal mapping procedures in patients with perianal Bowen’s disease. Dis Colon Rectum 2004;47(10):1655–1660; discussion 60–61.

    Article  PubMed  Google Scholar 

  4. Brown SR, Skinner P, Tidy J, Smith JH, Sharp F, Hosie KB. Outcome after surgical resection for high-grade anal intraepithelial neoplasia (Bowen’s disease). Br J Surg 1999;86(8):1063–1066.

    Article  PubMed  CAS  Google Scholar 

  5. Wieland U, Brockmeyer NH, Weissenborn SJ, Hochdorfer B, Stücker M, Swoboda J, Altmeyer P, Pfister H, Kreuter A. Imiquimod treatment of anal intraepithelial neoplasia in HIV-positive men. Arch Dermatol 2006;142(11):1438–1444.

    Article  PubMed  CAS  Google Scholar 

  6. Webber J, Fromm D. Photodynamic therapy for carcinoma in situ of the anus. Arch Surg 2004;139(3):259–261.

    Article  PubMed  CAS  Google Scholar 

  7. Watson AJ, Smith BB, Whitehead MR, Sykes PH, Frizelle FA. Malignant progression of anal intra-epithelial neoplasia. ANZ J Surg 2006;76(8):715–717.

    Article  PubMed  Google Scholar 

  8. Jay N, Berry JM, Hogeboom CJ, Holly EA, Darragh TM, Palefsky JM. Colposcopic appearance of anal squamous intraepithelial lesions: relationship to histopathology. Dis Colon Rectum 1997;40(8):919–928.

    Article  PubMed  CAS  Google Scholar 

  9. Chang GJ, Berry JM, Jay N, Palefsky JM, Welton ML. Surgical treatment of high-grade anal squamous intraepithelial lesions: a prospective study. Dis Colon Rectum 2002;45(4):453–458.

    Article  PubMed  Google Scholar 

  10. Pineda CE, Berry JM, Welton ML. High resolution anoscopy and targeted treatment of high-grade squamous intraepithelial lesions. Dis Colon Rectum 2006;49(1):126.

    Article  PubMed  Google Scholar 

  11. Goldstone SE, Hundert JS, Huyett JW. Infrared coagulator ablation of high-grade anal squamous intraepithelial lesions in HIV-negative males who have sex with males. Dis Colon Rectum 2007;50:565–575.

    Article  PubMed  Google Scholar 

  12. Goldstone SE, Kawalek AZ, Huyett JW. Infrared coagulator: a useful tool for treating anal squamous intraepithelial lesions. Dis Colon Rectum 2005;48(5):1042–1054.

    Article  PubMed  Google Scholar 

  13. Devaraj B, Cosman BC. Expectant management of anal squamous dysplasia in patients with HIV. Dis Colon Rectum 2006;49(1):36–40.

    Article  PubMed  Google Scholar 

  14. Marfing TE, Abel ME, Gallagher DM. Perianal Bowen’s disease and associated malignancies. Results of a survey. Dis Colon Rectum 1987;30(10):782–785.

    Article  PubMed  CAS  Google Scholar 

  15. Scholefield JH, Castle MT, Watson NF. Malignant transformation of high-grade anal intraepithelial neoplasia. Br J Surg 2005;92(9):1133–1136.

    Article  PubMed  CAS  Google Scholar 

  16. Sarmiento JM, Wolff BG, Burgart LJ, Frizelle FA, Ilstrup DM. Perianal Bowen’s disease: associated tumors, human papillomavirus, surgery, and other controversies. Dis Colon Rectum 1997;40(8):912–918.

    Article  PubMed  CAS  Google Scholar 

  17. Goldstone SE, Winkler B, Ufford LJ, Alt E, Palefsky JM. High prevalence of anal squamous intraepithelial lesions and squamous-cell carcinoma in men who have sex with men as seen in a surgical practice. Dis Colon Rectum 2001;44(5):690–698.

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgment

No grant support was received.

Author information

Authors and Affiliations

  1. Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, H3680F, Stanford, CA, 94305-5655, USA

    Carlos E. Pineda & Mark L. Welton

  2. Department of Medicine, University of California San Francisco, California, 1600 Divisadero St, MZ Building A A641, San Francisco, CA, 94143-1699, USA

    J. Michael Berry, Naomi Jay & Joel M. Palefsky

Authors
  1. Carlos E. Pineda
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J. Michael Berry
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Naomi Jay
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Joel M. Palefsky
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Mark L. Welton
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Carlos E. Pineda.

Additional information

Discussion

John H. Pemberton, M.D. (Rochester, MN): The authors must be congratulated for trying to sort out this particularly difficult neoplastic lesion. It seems like it has been confusing for just about forever. Historically, at least in the Midwest, we have seen patients with large areas of erythematous perianal skin, which, when biopsied, was positive for in situ squamous cell cancer. This was termed Bowen’s disease, and these areas were widely excised. Clearly, this approach does not seem appropriate for patients with discontinuous disease such as those described by you today. This problem is so rare that few people, with the exception of these authors, have extensive experience with it. It is indeed difficult to characterize and categorize.

Perhaps we should think of factors that might influence approaches to treatment, such as HIV positive or negative; HPV positive or negative; location (perianal or anal canal); and distribution of the process (continuous or discontinuous). Therefore, I wish to ask four questions.

First, would it be useful to include distribution of disease, the location, and its distribution as an additional way of categorizing patients in order to determine an accurate and acceptable treatment plan? Second, is it reasonable to assume, for those of us who are a little older, that Bowen’s disease and AIN2 and 3 are the same? Third, what is the role of HPV testing in these patients? And finally, you did not mention it, but I would be interested to know your take on the role of Aldara in the management of either discontinuous or continuous disease in order to prevent our patients from having to have those complicated flaps that you illustrated.

I wish to thank you again for sending the manuscript and for a great presentation.

Carlos E. Pineda, M.D. (Stanford, CA): Regarding the distribution and categorization of disease, we think it is very important that clinicians try to specify where the lesions are located. Our group encourages the use of standardized, simple terminology in order to facilitate communication among clinicians, using intra anal, perianal and skin to define disease location. When planning therapy, it is important to note that disease can occur above the dentate line. Disease in this location is not evaluated with the standard mapping procedures for “Bowen’s disease” using punch biopsies.

Anal squamous high-grade intraepithelial lesions (HSIL), anal intraepithelial neoplasia II/III (AIN), Bowen’s disease, and squamous cell carcinoma in situ are different names for the same disease. Training in histopathology, cytopathology, or dermatopathology lead to the different word choices, but all refer to the same pathologic process.

The role of HPV testing at this moment is unclear. In the future, microarray technology may allow us to analyze which subsets of HPV 16 and 18 will progress to invasive disease.

We have seen mixed results with the use of Aldara. Some patients respond dramatically and clear all disease. However, the majority of patients do not respond as well and require further therapy.

Dr. Pemberton: Is there anything to characterize those that don’t respond? How do they differ from those that do?

Dr. Pineda: We have not had personal experience that allows us to predict treatment success. Some feel that the more keratinized lesions are slower to respond and the clinician should persist in their treatment despite apparent lack of response.

Michael J. Stamos, M.D. (Orange, CA): I really enjoyed your talk today and think this is a great addition to the literature, particularly in that group of immunocompetent patients who we are faced with on a regular basis that have this problem. A few questions.

First question is, how many of your patients had visible disease? I mean, these are not patients you are screening because they are not high risk. So if these are patients with visible disease, I think the idea that anybody recommends watchful waiting is a little bit off, because most people who recommend watchful waiting do so in patients who have no visible disease. So the first question is, how many patients had visible disease versus no apparent disease?

The second question is, do you have any information on progression in those two groups, because I think that is another separate sub categorization that is very important for us to have to know whether we need to have this kind of procedure done on patients who have no visible disease, i.e., they underwent a hemorrhoidectomy and in the specimen they found some AIN.

And then finally, you had one patient who you said progressed to squamous cell carcinoma. Are you certain that she progressed and/or was she just delayed in diagnosis because she had this complicating factor and you didn’t biopsy the correct area early on but only after subsequent staged procedures?

Thank you.

Dr. Pineda: We did not track which patients had visible disease at initial evaluation, as it predominantly represents condylomatous disease caused by HPV 6 and 11. We can say that the vast majority of HSIL were not visible without the use of an operating microscope and acetic acid.

The woman who progressed to anal squamous cell carcinoma had undergone four operations over a 53 month period for recurrent HSIL in the posterior midline. During each of these procedures she was evaluated by an experienced colorectal surgeon (senior author) with a digital rectal exam, as well as high resolution anoscopy. During the fifth procedure she was noted to have an indurated lesion in the same location, we therefore conclude that this represents progression.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Pineda, C.E., Berry, J.M., Jay, N. et al. High Resolution Anoscopy in the Planned Staged Treatment of Anal Squamous Intraepithelial Lesions in HIV-Negative Patients. J Gastrointest Surg 11, 1410–1416 (2007). https://doi.org/10.1007/s11605-007-0262-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-007-0262-4

Keywords

Search

Navigation