High-resolution Anoscopy Research Articles

Provider preferences for anal cancer prevention screening: Results of the International Anal Neoplasia Society survey

ObjectiveThis study explores provider preferences regarding anal cancer screening indications, initiation age, tools, and referral threshold to high resolution anoscopy (HRA). MethodsInternational Anal Neoplasia Society affiliates were invited to complete an online survey. Options for initiation age and tools were delineated by sub-groups. HRA referral thresholds separately queried recommendations by patient immune status. ResultsOne hundred forty respondents participated. Although consensus was lacking with regard to specific screening initiation age, more respondents recommended younger initiation ages for men who have sex with men (MSM) living with HIV (LWH) compared with MSM not LWH (p < 0.01). “No age threshold” ranged 44-55% among sub-groups with lower genital tract disease. Cytology and digital anorectal exam (DARE) were the most frequently selected tools for all sub-groups (ranges 77-90% and 74-86%, respectively). HRA was recommended significantly more frequently for MSM LWH (58%) and patients with vulvar cancer (52%) compared to others (p < 0.01). “Any [test] abnormality” was more often selected as indication for HRA for immunocompromised (56%) and immunocompetent (46%) patients than a specific cytology test result (29%, 36% respectively). ConclusionCytology and DARE were preferred screening tools; screening initiation age and HRA referral threshold showed less consensus. Evidence-based guidelines are needed and may lead to more consistent screening practices.

Anal High-risk HPV and Liquid-based Cytology of Immunocompetent Brazilian Women with Genital High-risk HPV.

The purpose of this study was to compare the frequency of the occurrence of high-risk human papillomavirus (HPV) and abnormal anal cytology in immunocompetent women with and without HPV-induced genital lesions. This analytical cross-sectional, observational study was conducted between July 2017 and December 2018 in a specialized outpatient clinic of a tertiary hospital in Fortaleza, CE. Fifty-seven immunocompetent women with and without genital intraepithelial lesions were assessed; they were divided into two groups: group 1 was comprised of women with HPV-associated genital lesions (n = 26), and group 2 was comprised of those without HPV-associated genital lesions (n = 31). Samples for liquid-based cytology and high-risk DNA-HPV polymerase chain reaction real-time tests were collected from the cervix and anus. All cases were evaluated using high-resolution anoscopy; biopsies were performed when required. The Fisher exact and chi-squared tests were applied for consolidated data in the contingency table, and the Student t-test and Mann-Whitney U-test for independent variables. Anal high-risk HPV infections were more frequent in group 1 (odds ratio [OR], 4.95; 95% confidence interval [CI], 1.34-18.3; p = 0.012), along with concomitant high-risk HPV infections in the uterine cervix and the anus (OR 18.8; 95% CI, 2.20-160; p < 0.001). The incidence of high-risk cervical HPV infection was associated with high-risk anal HPV infection (OR, 4.95; 95% CI, 1.34-18.3; p = 0.012). There was no statistical difference concerning abnormal anal cytology or anoscopy between the groups, and no anal intraepithelial lesion was found in either group. Immunocompetent women with HPV-associated genital lesions and high-risk cervical HPV were more likely to have high-risk anal HPV.

Abstract PO-254: Assessment of the performance of anal cytology as a screening tool for anal high-grade squamous intraepithelial lesions by extent of disease in a clinic-based sample in Puerto Rico

Abstract Introduction: Anal cancer is increasing in the general population of Puerto Rico. Anal cytology is currently the standardized method for screening among populations at higher risk for developing anal high-grade squamous intraepithelial lesions (HSIL), the precursor lesion of anal cancer. However, studies have shown that anal cytology alone underestimates the anal lesion grade compared to the gold standard test, high-resolution anoscopy (HRA). While studies with both anal histology and cytology confirmed results are limited, the validity of cytology as a screening test seems to improve with more extensive HSILs. We evaluated the validity of anal cytology in detecting HSIL overall and by anal HSIL extension in a clinic-based Hispanic population. Methods: Data from baseline visits and examination from October 2014 to April 2021 of the Anal Neoplasia Clinic at the University of Puerto Rico Comprehensive Cancer Center were analyzed. Individuals who attended the clinic were eligible if they had completed anal cytology testing, HR-HPV typing, and HRA with biopsy. During the baseline visit basic demographic and clinical characteristics were collected. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were estimated by comparing anal cytology results with biopsy results from HRA, overall and by extent of histologically confirmed HSIL, defined as number of octants in the anal canal affected by HSIL (1 vs 2+). Results: Among 431 patients, 67.5% were male and the mean age was 43.57 +/- 13.27 years. Overall, 75.2% were living with HIV and 76.8% tested positive for HR-HPV. Persons diagnosed with any type of squamous intraepithelial lesion (SIL) via anal cytology and histology were 71.46% and 84.22%, respectively. In contrast, while anal HSIL was detected in only 2.09% of individuals through anal cytology, it was detected in 40.37% through biopsy-confirmed histology samples. The overall sensitivity of anal cytology compared to histology was 83.9% (95% CI: 77.6%-89%), whereas the specificity was 37% (95% CI: 31%-43.2%). Among persons with biopsy-confirmed HSIL, when comparing anal cytology to histology by HSIL extension (1 vs. 2+ octants affected) the sensitivity remained similar for both groups (83.7% vs. 84.1%), while specificity was the same with 37%. While the PPV decreased with HSIL extension (32.2% vs. 29.9%) and the NPV increased (86.4% vs. 88.0%), these indicators act as poor predictors of disease status in both groups. Conclusion: In this Hispanic population, anal cytology underestimates biopsy-confirmed HSIL and its performance in detected anal HSIL did not improve with HSIL extension. While future studies with larger sample sizes are needed to further validate research findings, this study emphasizes the need to continue to optimize anal cancer screening methods in high-risk populations. Determining the best way to detect and treat cellular abnormalities will help prevent further disease progression and anal cancer development. AMC-NCI Grant #'s: UM1CA121947, 2U54CA096297-17, R25CA240120. Citation Format: Kandyce G. Keller, Jeslie M. Ramos-Cartagena, MS, Humberto M. Guiot, Cristina Munoz, Yolanda Rodriguez, Vivian Colon-Lopez, Ashish A. Deshmukh, Maribel Tirado-Gomez, Ana Patricia Ortiz. Assessment of the performance of anal cytology as a screening tool for anal high-grade squamous intraepithelial lesions by extent of disease in a clinic-based sample in Puerto Rico [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-254.

Vulvar High-Grade Squamous Intraepithelial Lesions and Cancer as a Risk Factor for Anal Cancer: A Review.

Anal squamous cell carcinoma (ASCC) has a higher incidence described in certain groups, namely, in women with vulvar high-grade squamous intraepithelial lesions (vHSILs) and/or human papillomavirus squamous cell carcinoma (VSCC). This review describes terminology, vHSIL, and VSCC in their association with ASCC and the published recommendations for early detection of this cancer in these women. A narrative review was conducted by the authors on vHSIL and VSCC as risk factors for ASCC. The ASCC and VSCC incidence are increasing. Women with vHSIL and/or VSCC can present with ASCC at diagnosis, being one of the highest-risk groups. Suspicious symptoms include rectal bleeding, pain, and a sensation of an anal mass. Digital anorectal examination can help detect early ASCC. Sensitivity of anal cytology in women with vHSIL and VSCC seems low, with the exception of immunosuppressed women with genital neoplasia (cervix, vagina, and vulva). There are still insufficient data on high-resolution anoscopy in women with vHSIL and/or VSCC as a screening method. Clinicians need be aware that women with vHSIL and VSCC comprise one of the highest-risk groups for ASCC. Inquiring suggestive symptoms of ASCC and a digital anorectal examination can help in the early detection of this type of cancer.

Association of smoking with anal high-risk HPV infection and histologically confirmed anal high-grade squamous intraepithelial lesions among a clinic-based population in Puerto Rico

IntroductionCurrent smoking is a risk factor for anal cancer. Yet, its association with anal human papillomavirus infection (HPV) and anal high-grade squamous intraepithelial lesions (HSIL) remains unclear. We assessed the association of smoking with 1) anal high-risk HPV (HR-HPV) infection and 2) anal HSIL. MethodsData from the baseline visit of patients from the Anal Neoplasia Clinic of the University of Puerto Rico Comprehensive Cancer Center (May 2015- June 2021) was analyzed. Patients were eligible if they had information on smoking status, complete high-resolution anoscopy (HRA) with biopsy, and HR-HPV testing (n = 427). Logistic regression models estimated the odds ratio (OR) with 95% confidence intervals (CIs) adjusting for covariates. ResultsMean age was 44 ± 13 years, 69% were men, 74% were HIV-infected, and 25% reported being current smokers. 74% had anal HR-HPV infection. HSIL was diagnosed in 40% of patients. Current smokers had significantly higher odds (OR: 1.71, 95% CI: 1.04–2.82) of having HSIL compared to non-smokers after adjusting for age, sexual risk group, lifetime number of sexual partners, HIV status, and HR-HPV infection. Smoking was not associated with HR-HPV infection (OR: 1.56, 95% CI: 0.83–2.95) after adjusting for age, sexual risk group, lifetime number of sexual partners, and HIV status. ConclusionsCurrent smoking was associated with histologically confirmed HSIL but not with HR-HPV infection among this high-risk Hispanic population. Results highlight the need to explore targeted smoking cessation campaigns among populations at higher risk of developing HSIL, as an anal cancer prevention strategy.

Clinical Effects of Oral Bacteriotherapy on Anal HPV Infection and Related Dysplasia in HIV-Positive MSM: Results from the "HPVinHIV" Trial.

Background. Anal HPV infection, anal dysplasia and, ultimately, anal cancer are particularly common in HIV-infected men who have sex with men. Treatment of anal dysplasia, aiming to prevent evolution to squamous cell carcinoma of the anus, is currently limited to direct ablation and/or application of topical therapy. The aim of the present study is to investigate the effect of oral bacteriotherapy (Vivomixx® in EU, Visbiome® in USA) on anal HPV infection and HPV-related dysplasia of the anal canal in HIV-infected men who have sex with men. Methods. In this randomized, placebo-controlled, quadruple-blinded trial (NCT04099433), HIV-positive men who have sex with men with anal HPV infection and HPV-related dysplasia were randomized to receive oral bacteriotherapy or placebo for 6 months. Anal HPV test, anal cytology and high resolution anoscopy with biopsies of anal lesions were performed at baseline and at the end of the study. Safety and tolerability of oral bacteriotherapy were also evaluated. Interim analysis results were presented. Results. 20 participants concluded the study procedures to date. No serious adverse events were reported. In respect to participants randomized to placebo, individuals in the experimental arm showed higher rate of anal dysplasia regression (p = 0.002), lower rate of onset of new anal dysplasia (p = 0.023) and lower rates of worsening of persistent lesions (p = 0.004). Clearance of anal HPV infection was more frequently observed in the bacteriotherapy group (p = 0.067). Conclusion. Being an interim analysis, we limit ourselves to report the preliminary results of the current study. We refer the conclusions relating to the possible effectiveness of the intervention to the analysis of the definitive data.

Vroegtijdige opsporing van voorstadia van een anaal carcinoom bij hiv-seropositieve patiënten

Early detection of precursor lesions of anal cancer in HIV-seropositive patients Although anal cancer is rare in the overall population, its incidence is increasing in the last decades. Especially HIV-seropositive patients have an increased risk of developing anal squamous cell carcinoma (SCC), mainly because of the high prevalence of high-grade anal intraepithelial neoplasia (AIN) among these patients. High-grade AIN is a precursor lesion for anal SCC associated with human papillomavirus (HPV) infection. Despite the lack of direct evidence demonstrating that AIN identification reduces the risk of anal cancer, experts think that screening and treatment of high-risk patients will prevent the disease. This article aims to review the current literature about AIN and discusses the screening options, including digital rectal examination, anal cytology and high-resolution anoscopy.

Xpert HPV as a Screening Tool for Anal Histologic High-Grade Squamous Intraepithelial Lesions in Women Living With HIV.

Women living with HIV (WLWH) experience high rates of anal cancer. Screening using anal cytology, high-resolution anoscopy (HRA) with biopsies, can histologically diagnose anal cancer precursors called high-grade squamous intraepithelial lesions (HSIL). The low specificity of screening using anal cytology results in HRA referral for many WLWH without HSIL. Screening using high-risk human papillomavirus (HR-HPV) may improve specificity. Two hundred seven WLWH (63% non-Hispanic black) were screened for anal histologic HSIL (hHSIL) using cytology, HRA-guided biopsies, and Xpert HPV. Xpert performance for predicting anal hHSIL was compared with that of cytology. Usng Xpert 5 HPV genotypic results and accompanying cycle thresholds, receiver operator characteristic curve and recursive partitioning analyses were used to create predictive models for hHSIL. The performance of Xpert to predict hHSIL was not different from that of cytology with a sensitivity (Sn) of 89% and specificity (Sp) of 49%. Interpretation of Xpert was modified using genotypic results and receiver operator characteristic curve analysis, which produced a screen with an Sn and Sp of 75% and 84% for hHSIL, respectively. Another reinterpretation of Xpert was created using recursive partitioning and cycle thresholds, which predicted hHSIL with an Sn and Sp of 75% and 86%, respectively. The detection of HPV-16 was highly predictive of hHSIL in all analyses. These modified screening tests would reduce HRA referral in this population by almost half compared with anal cytology. Xpert HPV is an alternative to anal cytology to screen for anal HSIL and can be optimized to reduce the number of unnecessary HRAs performed in WLWH.

Screening with Anal Cytology in Colombia: Initial Experience and Need for High-Resolution Anoscopy

BackgroundMen who have sex with men (MSM) living with human immunodeficiency virus (HIV) are at increased risk of anal cancer. Anal cytology can be used to screen for dysplasia, with high-resolution anoscopy (HRA) required for diagnostic confirmation. We describe the impact lack of HRA had on management of abnormal screening results in Bogotá, Colombia. Material and MethodsThis retrospective cohort study includes MSM with HIV who underwent anal cytology screening between January 2019February 2020, with colorectal surgery (CRS) follow-up through July 2020. Cytology results included atypical squamous cells of undetermined significance (ASC-US), low-grade squamous intraepithelial lesion (LSIL), and high-grade squamous intraepithelial lesion (HSIL). Categorical and continuous variables were compared via Fisher's exact test and Wilcoxon rank-sum, respectively. ResultsOf 211 MSM screened, 68 had abnormal cytology: ASC-US (n = 23), LSIL (n = 41), HSIL (n = 4). Sixty (88.2%) were referred to CRS, and 51 (75.0%) attended ≥ 1 appointment. At initial assessment, 17 were referred for anal exam under anesthesia (EUA) for tissue resection, and 21 for rectosigmoidoscopy. Having perianal condyloma was associated with recommendation for EUA (P < 0.001), while cytology grade of dysplasia was not (P = 0.308). Eleven (16.2%) underwent EUA for condyloma resection. ConclusionsFew studies have described anal cancer screening in settings without HRA. We found lack of HRA limited management of abnormal cytology in Colombia. Those with condyloma underwent resection, but HRA remains necessary to localize and treat microscopic disease. Next steps include implementation of HRA in order to further develop the anal cancer screening program for MSM with HIV in Bogotá.

Anální intraepitelie a HD anoskopie

Anal intraepithelial neoplasia (AIN) is a precursor lesion of anal squamous cell cancer (aSCC). aSCC is considered a rare cancer, but its incidence is on the rise and in certain high-risk populations it approaches the incidence of colorectal cancer. Although controlled randomized trials are lacking, expert opinions support screening and therapy of this anal neoplasia in the high-risk groups. AIN/aSCC belongs among neoplasia associated with HPV infection. Individuals with a higher AIN/aSCC risk can be examined by rectal smear for cytology or more sensitive HPV DNA, not unlike the cervical cancer screening. In the case of a positive result, high-resolution anoscopy is recommended. However, this is not a common practice. The goal of this study is to acquaint the gastroenterology community with the not so well known AIN diagnosis and offer a new active approach to its detection and therapy. We retrospectively analyzed a cohort of 18 patients indicated for flexible anal endoscopy because of their higher risk of anal neoplasia or to explain rectorrhagia after normal colonoscopic finding. We named the anal examination with the use of flexible high-definition endoscope by the new term, high definition (HD) anoscopy. The detected lesions were removed by endoscopic mucosal resection (EMR) or biopsied and the samples sent for histopathological evaluation by one pathologist. Among 18 examined patients, AIN was diagnosed in 12 and the riskier AIN II/III was found in 7. In most cases the lesions were type IIa or Is according to Paris classifications. In all AIN cases irregularities of the mucosal IPCL vessels (intrapapillary capillary loops) were present. Based on our results we recommend active examination of the often neglected anorectal region by the flexible HD endoscope. High resolution and digital chromoendoscopic technology of modern endoscopes offers an easy way to detect and treat AIN without a risk of anal dysfunction.

Comparison of two sample collection devices for anal cytology in HIV-positive men who have sex with men: Cytology brush and Dacron swab.

HIV-positive men who have sex with men (MSM) are a vulnerable group for anal cancer (AC), a cancer with a well-described precursor lesion, which can be detected early in screening programs using anal liquid-based cytology (aLBC). We aim to compare two aLBC sample collection devices: cytology brush (CB) and Dacron swab (DS). Retrospective analysis of two consecutive study periods, the first using CB and the second DS. Participants underwent an aLBC, a human papillomavirus (HPV) DNA test and a high-resolution anoscopy (HRA), and a biopsy was performed for suspicious lesions. The sensitivity and specificity of aLBC, area under the receiver operating characteristic (ROC) curve (AUC), and concordance between cytology and HRA were assessed using Cohen's kappa coefficient. A total of 239 participants were enrolled (CB group, 120; DS group, 119). aLBC was benign in 46% of samples, and high-grade squamous intraepithelial lesion (HSIL) was detected in 11.7%. Prevalence of biopsy-proven HSIL was 15.3%. No differences in cytological and histological results were observed between the groups. aLBC-HRA concordance was weak for benign results (CB group, k=0.309; DS group, k=0.350) as well as for HSIL (k=0.321 and 0.387, respectively). Sensitivity and specificity were 100% and 51.4%, respectively, in the CB group and 88% and 54.3% in the DS group (AUC=0.711 and 0.759, respectively, P-value=.514). Representation of the transformation zone (TZ) was adequate in 83.3% of samples in the CB group and 50.4% in the DS group (P-value <.001). Our data suggest that both devices had similar accuracy to detect anal HSIL, although samples collected with CB are more likely to have an adequate TZ representation, the presence of which could be an indicator of sample quality.

Anal cancer screening and prevention: a review for dermatologists.

The incidence of and mortality from anal cancer, predominantly squamous cell carcinoma (SCC), have been increasing since the 1980s, during an era when many common malignancies have seen decreases in mortality. Dermatologists may be more likely to see patients at an increased risk for anal SCC, such as those living with HIV, MSM and those presenting for management of anogenital warts, yet there is little guidance in the field on how to manage these patients. We underwent a project to review the evidence surrounding screening and prevention of anal SCC. HPV vaccination, the main preventative measure for anal SCC, is often underutilized and may not be effective for those most at risk. Screening methods currently include high-risk HPV and anal cytology testing, with high-resolution anoscopy (HRA) reserved for biopsy and confirmatory testing. High-risk HPV testing has been associated with high sensitivity for intraepithelial neoplasia, but low specificity in high-risk groups. Recent meta-analyses examining AIN detection using anal cytology estimate a similarly high sensitivity of 74-87%, with a relatively higher specificity (44-66%) for identifying high-grade AIN. HRA is the gold standard for diagnosis, but its accessibility and cost are deterrents from its use as a screening tool. Cervical cancer screening, initially adopted without significant evidence of its impact, has significantly decreased cervical cancer rates. The argument can be made that rates of anal SCC may also benefit from appropriate screening methods, particularly anal cytology. It is prudent for dermatologists to be aware of the methods available to them in the management of at-risk patients, the data supporting them, and the potential benefits of screening in order to counsel patients appropriately and address the increasing burden of disease.

State of the Science: Screening, Surveillance, and Epidemiology of HPV-Related Malignancies.

Oropharyngeal, cervical, vulvar, and anal cancers share a common risk factor of HPV infection. HPV vaccination is currently recommended at age 11 or 12 to prevent new HPV infections for all genders with catch-up vaccination recommened up to age 26. Despite the known effectiveness of HPV vaccination to prevent HPV-related cancer, there is continued low uptake in the United States; only 40% of eligible persons were vaccinated in 2018, though rates are 70% among teenagers. Current American Cancer Society cancer screening guidelines recommend cervical cancer screening, but do not have specific recommendations for screening for other HPV-related cancers. Oropharyngeal cancer precursors have yet to be identified, and there are currently no routine screening tests for oropharyngeal cancer recommended by the U.S. Preventive Services Task Force. The U.S. Preventive Services Task Force and American Cancer Society recommend cervical cancer screening for women at average risk up to age 65, and screening guidelines do not currently differ by HPV vaccination status. Primary HPV DNA testing was first approved for cervical cancer screening in 2016 and was shown to be superior for cervical cancer prevention. Vulvar and anal cancer precursors have been identified, but optimal screening remains unclear. Examination of the anal canal and perianus is best performed by trained clinicians using high-resolution anoscopy, and effectiveness of using high-resolution anoscopy to detect and treat anal high-grade squamous intraepithelial lesions to prevent cancer is actively being researched. Current multistep approaches to control HPV-related malignancies include HPV vaccination coupled with cervical cancer screening or surveillance for oropharyngeal, vulvar, and anal cancers.

The other side of screening: predictors of treatment and follow-up for anal precancers in a large health system.

Anal cancer disproportionately affects people with HIV (PWH). High-grade squamous intraepithelial lesions (HSIL) are cancer precursors and treating them might prevent anal cancer. Data on adherence to HSIL treatment and surveillance is limited but needed to identify deficiencies of screening strategies. We collected data on high-resolution anoscopy (HRA) attendance and outcomes from 2009 to 2019 in a large urban anal cancer-screening program. Patients with an initial HSIL diagnosis were followed for return for HSIL electrocautery ablation within 6 months of index HSIL diagnosis, and follow-up HRA within 18 months of index HSIL diagnosis. We also evaluated predictors of these outcomes in univariable and multivariable analyses. One thousand one hundred and seventy-nine unique patients with an anal HSIL diagnosis were identified and 684 (58%) returned for electrocautery ablation. Of those treated, only 174 (25%) and only 9% of untreated HSIL patients (47 of 495) underwent surveillance HRA within 18 months of index HSIL diagnosis. In multivariable analyses, black patients and PWH regardless of virologic control were less likely to undergo HSIL ablation within 6 months of HSIL diagnosis whereas patients with commercial insurance were more likely to be treated within 6 months of diagnosis. Among treated HSIL patients, PWH with viremia had a lower likelihood of engaging in post-treatment surveillance within 18 months of HSIL diagnosis. Even in large specialized anal cancer screening programs adherence to HSIL treatment and surveillance is low. Psychosocial and economic determinants of health may impact retention in care. Addressing both personal and structural barriers to patient engagement may improve the effectiveness of anal cancer screening.

High Prevalence of Anal High-Grade Squamous Intraepithelial Lesions, and Prevention Through Human Papillomavirus Vaccination, in Young Men Who Have Sex With Men Living With Human Immunodeficiency Virus

BackgroundMen who have sex with men (MSM) are at high risk for human papillomavirus (HPV)–related anal cancer. Little is known about the prevalence of low-grade squamous intraepithelial lesions (LSILs) and the anal cancer precursor, high-grade squamous intraepithelial lesions (HSILs), among young MSM with HIV (MSMLWH). HPV vaccination is recommended in this group, but its safety, immunogenicity, and protection against vaccine-type HPV infection and associated LSILs/HSILs have not been studied.MethodsTwo hundred and sixty MSMLWH aged 18–26 years were screened at 17 US sites for a clinical trial of the quadrivalent (HPV6,11,16,18) HPV (qHPV) vaccine. Those without HSILs were vaccinated at 0, 2, and 6 months. Cytology, high-resolution anoscopy with biopsies of lesions, serology, and HPV testing of the mouth/penis/scrotum/anus/perianus were performed at screening/month 0 and months 7, 12, and 24.ResultsAmong 260 MSMLWH screened, the most common reason for exclusion was detection of HSILs in 88/260 (34%). 144 MSMLWH were enrolled. 47% of enrollees were previously exposed to HPV16. No incident qHPV type–associated anal LSILs/HSILs were detected among men naive to that type, compared with 11.1, 2.2, 4.5, and 2.8 cases/100 person-years for HPV6,11,16,18–associated LSILs/HSILs, respectively, among those previously exposed to that type. qHPV was immunogenic and safe with no vaccine-associated serious adverse events.Conclusions18–26-year-old MSMLWH naive to qHPV vaccine types were protected against incident qHPV type–associated LSILs/HSILs. Given their high prevalence of HSILs, there is an urgent need to vaccinate young MSMLWH before exposure to vaccine HPV types, before initiating sexual activity, and to perform catch-up vaccination.

HPV vaccination to prevent recurrence of anal intraepithelial neoplasia in HIV+ MSM.

Objective:Anal cancer precursor lesions high-grade anal intraepithelial neoplasia (HGAIN) are highly prevalent among HIV+ MSM. Treatment of HGAIN is frustrated by high recurrence rates. We investigated the efficacy of the quadrivalent human papillomavirus (qHPV) vaccine as posttreatment adjuvant in preventing HGAIN recurrence in HIV+ MSM.Design:Randomized, double-blind, placebo-controlled, multicentre trial.Setting:Three HIV outpatient clinics in Amsterdam, the Netherlands.Subjects:HIV+ MSM with CD4+ cell count more than 350 cells/μl, biopsy-proven intra-anal HGAIN successfully treated in the past year, and lesions still in remission at enrolment, as assessed by high-resolution anoscopy (HRA).Intervention:Participants were randomized to three doses of qHPV (Gardasil-4, MSD) or placebo with vaccinations at 0, 2, and 6 months. HRA was repeated at 6, 12, and 18 months.Main outcome measure:The primary outcome was cumulative, biopsy-proven HGAIN recurrence rate at 18 months, evaluated in an intention-to-treat (ITT) (received all vaccinations) and per-protocol analysis (all vaccinations and complete follow-up).Results:We randomized 126 participants of which 64 (50.8%) received qHPV and 62 (49.2%) placebo. All participants received three vaccinations, and in both groups for two participants follow-up was incomplete. We found no difference (P = 0.38) in cumulative HGAIN recurrence rates between the qHPV (44/64, 68.8%) and placebo group (38/62, 61.3%) in the ITT analysis [absolute risk reduction −7.5 (95% confidence interval (CI) −24.1 to 9.2)]. This was similar in the per-protocol analysis.Conclusion:Despite adequate serological responses to qHPV vaccination, short-term recurrence of HGAIN was not prevented. These findings do not support qHPV vaccination as a treatment adjuvant to prevent HGAIN recurrence in HIV+ MSM.

Results of the use of intranodal laser coagulation in patients with chronic internal hemorrhoids stage III

Aim: to assess the efficacy of intranodal laser coagulation for hemorrhoids stage III.Patients and methods: the study included 62 patients with chronic internal hemorrhoids stage III without external hemorrhoids, who were informed of the INLC technology, its advantages and disadvantages. The selection for this procedure was done due to the high-resolution anoscopy, in the presence of type 1 and type 2 severity of inflammatory changes in the nodes.Results: on the 3rd day, no pain occurred in 52 (83.9%) patients. After 12 months, a complete disappearance of hemorrhoid symptoms was observed in 51 (82.3%) patients, while 7 (11.3%) patients had a recurrence. In 8 (12.9%) patients, symptoms of discomfort and itching were noted.Conclusions: intranodal laser coagulation allowed in 61 (98.4%) cases to perform this procedure on an outpatient basis, and did not affect the anal sphincter function. Good long-term results were obtained in 82.3% of cases. Intranodal laser coagulation is an effective method for chronic hemorrhoids.

Self-reported anal symptoms and their association with anal pathology among gay and bisexual men: a cross-sectional observational analysis.

The Study of the Prevention of Anal Cancer was a longitudinal study of anal human papillomavirus and related lesions in Sydney, Australia. GBM aged ≥35 years were recruited from community settings between September 2010 and August 2015. Information about anal symptoms (discharge, itch, pain defecating, lump, bleeding, 'sores', tearing, tenesmus), STIs and sexual behaviours was collected. High-resolution anoscopy (HRA) and STI testing were performed. Logistic regression analyses on baseline data were performed to assess associations with each symptom. Among 616 participants (median age 49 years, 35.9% HIV positive), 35.3% reported at least one anal symptom within the past week and 65.3% were diagnosed with fistula, fissure, ulcer, warts, haemorrhoids and/or perianal dermatoses at HRA. Anal symptoms were not associated with anal chlamydia, gonorrhoea, warts or syphilis. Self-reported 'sores' were associated with previous anal herpes simplex virus (HSV; P < 0.001). 'Sores' (P < 0.001), itch (P = 0.019), discharge (P = 0.032) and lump (P = 0.028) were independently associated with ulceration. Among participants diagnosed with fissure, fistulae, haemorrhoids and perianal dermatoses, 61.9%, 100%, 62.0% and 63.9% respectively were asymptomatic. Only self-reported anal tear was independently associated with recent RAI. Previous anal HSV was the only STI associated with any symptom. Anal pathology was highly prevalent, but often asymptomatic. Anal symptoms do not appear to be useful markers of most anal pathology in GBM.

Knowledge, Attitudes, and Experiences of Anal Cancer and Anal Cancer Screening Among a Clinical Sample of Hispanic Women.

Anal cancer screening has been recommended for women with lower genital tract neoplasia, lupus, Crohn disease, HIV, and/or organ transplantation recipients. This study described and compared knowledge, attitudes, and experiences related to anal cancer and anal cancer screening between women at high risk for anal cancer and their counterparts. This is a cross-sectional study within colposcopy and gynecology oncology clinics in Puerto Rico; 278 women 21 years or older and with prior diagnosis of gynecological neoplasia completed an interviewer-administered questionnaire. Women were categorized according to their medical history as being high risk or non-high risk for anal cancer. The high-risk group included women with a history of lower genital tract neoplasia, lupus, Crohn disease, HIV, and/or organ transplantation. Overall, 40.7% of the study population were at high risk for developing anal cancer. History of anal cancer screening was low among high-risk and non-high-risk women (11.5% vs 5.6%, p > .05). Less than 1% of all women reported to have had a high-resolution anoscopy. Most women (87.6%) had little knowledge about anal Pap test but were willing to have one if their doctors recommended it (96.5%). No major differences in knowledge, attitudes, or screening history were observed between high-risk and non-high-risk women. Although experts do not recommend routine anal cancer screening for the general population, they do recommend it for women within certain high-risk groups. Study findings highlight the importance of increasing education and awareness of anal cancer among high-risk patients and physicians, to promote better preventive methods, achieve early detection, and improve disease outcomes.

Quality of life in women with HPV and accurary of direct visual anal inspection with acetic acid and lugol compared to high-resolution anoscopy to diagnose intraepithelial anal lesion

Abstract Objectives: to describe life quality of women with HPV and analyze the accuracy of anal visual inspection with acetic acid and lugol compared to high-resolution anoscopy in the detection of anal intraepithelial lesions. Methods: diagnostic evaluation study conducted with adult solid-organ transplant recipients and/or diagnosed with HIV and/or with a history of anogenital neoplasia, attended at the High Resolution Anoscopy outpatient clinic between April and December 2018. To calculate the accuracy parameters, 87 women participated: 44 with lesions and 43 without them. The 44 women with lesions were also subjected to a descriptive study to assess their life quality using the SF-36 questionnaire. Results: it was observed that almost half of the women in the study practiced vaginal, anal and oral intercourse without condom. History of HPV infection and anogenital neoplasia were the most prevailing with percentages of 81% and 72.7%, respectively. In five out of the eight domains of SF-36 they did not perform well in regard to life quality. Visual inspection with acetic acid and lugol presented sensitivity of 22.7% and specificity of 100%. Conclusion: unsatisfactory life quality was evidenced. Direct visual inspection with acetic acid and lugol should not be used in trials to spot intraepithelial HPV lesions, for it presents low sensitivity.