OncologyHigh-grade anal intraepithelial neoplasia: Progression to invasive cancer is not a certainty
Introduction
The incidences of anal cancer and its putative precursor (high-grade squamous intraepithelial lesions: HSIL) have greatly increased in recent decades [1], [2], [3] particularly in special population subgroups: men who have sex with men (MSM), those infected with human immunodeficiency virus (HIV), and women with previous cervical human papillomavirus (HPV)-related disease [4].
Anal carcinoma increased from 0.2 to 0.5/100 000 person-years among men and from 0.7 to 1.3/100 000 person-years among women from 1982 to 2012 [3].
Regarding cervical cancer, it is widely recognized that HSIL and superficially invasive squamous cell carcinoma (SISCCA) can preclude invasive cancer. The latter is defined as a nearly stage tumours ≤10 mm, corresponding to HSIL which has an invasive depth of ≤3 mm from the basement membrane of the point of origin, with horizontal spread of ≤7 mm at its maximal extent [5]. Both types of lesions are induced by persistent infections of carcinogenic HPV [6], [7]. Conventionally, they are likely to progress to an invasive cancer [5]. Little is known about the natural history of anal HPV infections and HSIL. One study estimated a HSIL regression rate of 23.5% per year [8].
The lack of data about the natural progression of HSIL and SISCCA to invasive cancers has led to unclear and controversial therapeutic strategies. Management of HSIL varies according to the doctor's expertise, ranging from expectant management with close surveillance [9], [10] to surgical treatment [11], topical application of chemotherapeutic agents [12] or photodynamic therapy [13]. To date, the recommended treatment for SISCCA is radiotherapy, but it has been associated with anatomical and functional side effects unless effective [14], [15], [16]. After we collected the data of consecutive patients with histologically proven HSIL, the aim of this study was to assess the clinical outcome with a special focus on the healing rate.
Section snippets
Patients
This cross-sectional study was conducted in a single tertiary gastroenterology unit (Rennes University Hospital, France) using the records of a central database. All patients with histories of HSIL (only AIN3 in the former classification) or SISCCA proven on anal biopsy, from March 2002 to May 2014, were invited to participate in a new evaluation. Medical records, using both retrospective (2002–2006) and prospective (2007–2014) databases, were extracted with special emphases on MSM and women
Population
From March 2002 to June 2014, 59 patients with HSIL or SISCCA on biopsy were referred to the Rennes University Hospital, France. We excluded 8 patients due to misdiagnoses: they had a true invasive anal squamous carcinoma at the time of initial diagnosis with a discrepancy between histological consideration and macroscopically ulcerative and infiltrative aspects. As a result, 51 patients with histologically confirmed HSIL or SISCCA were available for follow-up. Five patients (9.8%) (4 patients
Discussion
This study, analysing the clinical outcome of anal dysplasia, was the first to define the factors and to quantify the healing of HSIL in a cohort of HIV-infected and uninfected-patients.
The data of the present study emphasize some aspects of the clinical outcome of HSIL.
HSIL is not only an HIV+ related disease. Our data emphasized that a large proportion of HSIL and SISCCA lesions were found in HIV-uninfected, heterosexual, immunocompetent patients (11 patients, 21.5%) (including 4 active
Conclusion
Progression to cancer was a rare event after a three-year follow-up. Clinical regression and healing occurred far more commonly in the clinical outcome of HSIL. This finding suggested that patients might not require treatment in the initial phase of the diagnosis. Tobacco, sexually active lifestyles, homosexual sex, a number of high risk viruses at baseline and a past history of condyloma seemed to be predictive factors for more difficult healing. Future larger-scale studies are necessary to
Conflict of interest
None declared.
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2021, European Journal of Surgical OncologyCitation Excerpt :However, evidence of effective interventions to prevent progression of AIN to ASCC from randomised trials is lacking [6–8]. Furthermore, the natural history of AIN remains unclear, with reports of the risk of progression to cancer ranging from 2 to 26% [9–26]. In our institution, patients with biopsy-proven anal, cervical, vulval or vaginal intra-epithelial neoplasia are followed in a dedicated multifocal intraepithelial neoplasia (MuFIN) clinic.
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2017, Seminars in Colon and Rectal SurgeryCitation Excerpt :However, treatment of HSIL has evolved since that time and only 3 of the 13 were treated using current standards of therapy including 2 in which SISCCA was able to be excised.11 Risk factors for progression of HSIL to anal cancer have been reported in small, retrospective case series, and include smoking history, immunosuppression, and no history of treatment for anal HSIL.12–16 The rate of progression of HSIL to cancer is not clear, but has been estimated to be <1% per year.17–19
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