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.

Resultados de la aplicación del consenso cubano de prevención del cáncer anal / Results of the Application of the Cuban Consensus for Anal Cancer Prevention

Introducción: El incremento del cáncer anal en poblaciones de alto riesgo induce a la implementación de protocolos para efectuar diagnóstico precoz y seguimiento de neoplasia anal intraepitelial. Objetivo: Evaluar los resultados de la aplicación del consenso nacional de prevención del cáncer anal en Cuba. Métodos: Se realizó un estudio longitudinal prospectivo con 43 pacientes de alto riesgo de neoplasia anal intraepitelial atendidos en la consulta de Coloproctología del Hospital Universitario Clínico Quirúrgico "Comandante Manuel Fajardo", desde 2018 hasta 2019. Se evaluaron en el momento del diagnóstico y a los 6 meses. Se hicieron estudios de citología anal (normales, lesiones de bajo y alto grado, y células epidermoides atípicas de significado incierto), examen digital anorrectal y anoscopia de alta resolución (normal, tipos I-II y III). Resultados: El 53,5 por ciento de los resultados fueron normales. En los hallazgos anormales por citología anal, la lesión de bajo grado fue la de mayor porcentaje (50 por ciento). La neoplasia anal intraepitelial tipo I fue la de mayor frecuencia (52,9 por ciento). De los pacientes evolucionados a los 6 meses, la mayoría tuvo resultados anormales de citología anal (55,6 por ciento), se presentó el 70 por ciento con lesiones de bajo grado. El examen digital anorrectal fue normal en todos los casos. Los factores de riesgos predominantes fueron: sexo con penetración anal y sexo de hombres con otros hombres, incluyendo que todos habían padecido el virus del papiloma humano. Conclusiones: El protocolo permitió identificar fundamentalmente lesiones de bajo grado. Los factores de riesgo influyen en la aparición de esta neoplasia(AU)

Introduction: The increase of anal cancer in high-risk populations leads to the implementation of protocols to perform early diagnosis and follow-up of anal intraepithelial neoplasia. Objective: To evaluate the results of the application of the national consensus for anal cancer prevention in Cuba. Methods: A prospective longitudinal study was conducted with 43 patients at high risk of intraepithelial anal neoplasia cared for in the coloproctology consultation at Comandante Manuel Fajardo Clinical Surgical University Hospital, from 2018 to 2019. They were evaluated at the time of diagnosis and at six months. Anal cytology studies (normal, low- and high-degree lesions, and atypical epidermoid cells of uncertain significance), anorectal digital examination and high resolution anoscopy (normal, types I-II and III) were performed. Results: 53.5 percent of the results were normal. In abnormal anal cytology findings, low-degree lesion had the highest percentage (50 percent). Anal intraepithelial neoplasia type I was the most frequent (52.9 percent). Of the patients followed up at six months, the majority had abnormal anal cytology results (55.6 percent); 70 percent had low-degree lesions. The anorectal digital examination was normal in all cases. The predominant risk factors were anal penetrative sex and male-to-male sex, including that all had had human papillomavirus. Conclusions: The protocol allowed the identification of primarily low-degree lesions. Risk factors influence the appearance of this neoplasm(AU)

Comparative analysis of anal colposcopy with histology in the follow-up of patients under treatment for anal condyloma

Objectives: To compare morphological abnormalities on anal colposcopy against histology to determine anal high-grade squamous intraepithelial lesions (HSILs). Methods: This is a retrospective data assessment of HIV-negative and HIV-positive patients undergoing outpatient follow-up. The sample comprised 54 patients presenting acetowhite lesions on anal colposcopy. Acetowhite lesions were classified according to their morphology into punctation, verrucous, mosaic, ulcerated, or hypervascularized, and biopsies of these specimens were classified as anal HSIL, low-grade squamous intraepithelial lesion (LSIL), or normal. The data were analyzed using SPSS forWindows version 13.0 (SPSS Inc., Chicago, IL, USA). The results were analyzed using the nonparametric Mann-Whitney test, the Fisher exact test and the chi-squared parametric test. A 95% confidence interval (CI) was used and a level of significance <5% was adopted for all statistical tests. Results Fifty-four patients (50 males, 80% HIV+) with biopsied acetowhite lesions were assessed. There were 31 punctation lesions, 1 classified as HSIL (3.2%; 95%CI: 0- 40.0), 17 verrucous lesions, 3 HSIL (17.7%; 95%CI: 0-10.7), and 1 ulcerated, classified as HSIL (100%), and 4 mosaic and 1 atypical vessel lesion, all classified as LSIL. The results showed no association of presence of anal HSIL with positivity for HIV infection or with counts above or below 500/µl in HIV+patients. Statistical analysis was performed using the Mann-Whitney nonparametric test, the Fisher exact test, and the chi-squared parametric test. Conclusion: The comparison of morphological findings on anal colposcopy against histology revealed no morphological pattern suggesting anal HSIL. (AU)

Comparison between anal cytology, high-resolution anoscopy and HPV DNA genotyping by polymerase chain reaction in the post-treatment follow-up of condylomata acuminata / Comparação entre citologia anal, colposcopia anal e genotipagem do HPV por reação em cadeia da polimerase no seguimento pós-operatório de condiloma acuminado

ABSTRACT Aim: to evaluate the presence of subclinical HPV-induced anal lesions with anal cytology, High-Resolution Anoscopy (HRA) and HPV genotyping by polymerase chain reaction (PCR) in the follow-up of treated condylomata acuminata (CA). Methods: seventy-nine male patients were included. One month after anal CA eradication, the patients underwent brush samples collection for anal cytology and PCR, and HRA with biopsy of acetowhite lesions. These methods were compared within all patients and between groups, according to Human Immunodeficiency Virus (HIV) infection status: HIV-negative; HIV-positive with TCD4 count above and below 350 cells/mm3. Results: the most frequent HPV types were 6 and 16. HPV DNA was isolated in 92%. HIV infection was associated with a higher number of oncogenic HPV types (p=0.038). All patients with negative PCR had negative HRA and cytology. There were no differences in cytological, HRA or histopathological findings between groups. Conclusion: the association of the findings of cytopathology, HRA and genotyping of HPV refined the diagnosis of HPV-induced lesions. The degree of immunodeficiency was not associated with increase in remnant HPV-induced anal lesions.

RESUMO Objetivo: avaliar a presença de lesões anais subclínicas HPV-induzidas com citologia anal, colposcopia anal e genotipagem de HPV por reação em cadeia da polimerase (PCR) no seguimento de condilomas anais tratados. Método: foram incluídos 79 pacientes do sexo masculino. Após um mês da erradicação de lesões condilomatosas anais, os participantes voltaram em consulta para coleta de amostras com escova para citologia anal e PCR, e colposcopia anal com biópsia de lesões acetobrancas. Os métodos de detecção das lesões foram comparados entre os pacientes e entre grupos, de acordo com o status de infecção pelo vírus da imunodeficiência humana (HIV): HIV-negativo; HIV-positivo com TCD4 acima ou abaixo de 350 células/mm3. Resultados: os tipos de HPV mais frequentes foram 6 e 16. Infecção pelo HIV foi associada a maior número de tipos de HPV oncogênicos (p=0,038). Todos os pacientes com PCR negativo apresentaram colposcopia e citologia negativos. Não houve diferença nos achados citológico, colposcópico ou histopatológico entre grupos. Conclusão: a associação dos achados citopatológico, colposcópico e PCR melhorou a acurácia do diagnóstico de lesões anais HPV-induzidas. O grau de imunodeficiência não foi associado a maior frequência de lesões anais HPV-induzidas remanescentes.

Manifestaciones clínicas y anoscópicas de las lesiones ecamosas intraepiteliales de alto grado anales / Clinical and anoscopic manifestations of high-grade anal squamous intraepithelial lesions

Introducción: Las lesiones escamosas intraepiteliales de alto grado anales (H-ASIL) son consideradas el precursor del carcinoma escamoso anal. Es por esto que distintas Sociedades recomiendan su pesquisa y tratamiento en poblaciones de alto riesgo. El objetivo del trabajo es describir las manifestaciones de H-ASIL en la anoscopía de alta resolución (AAR) en nuestros pacientes. Diseño: Retrospectivo, descriptivo. Pacientes y métodos: Revisión de historias clínicas e imágenes de AAR de pacientes con diagnóstico de H-ASIL entre enero de 2016 y julio de 2017. La evaluación anoscópica incluyó la unión escamocolumnar, el conducto anal distal y el área perianal. Frente al hallazgo de una lesión sospechosa de ASIL, se tomaron biopsias. Resultados: Entre enero de 2016 y julio de 2017 se realizaron 184 AAR. Se biopsiaron 143 lesiones sospechosas de ASIL. Veintiséis de ellas, presentes en 13 pacientes fueron H-ASIL. Once hombres (diez hombres que tienen sexo con hombre (HSH) con infección por VIH). Todas las lesiones eran subclínicas y se encontraron a nivel endoanal; eran en su totalidad acetoblancas. Se buscaron áreas con puntillado y/o mosaico sugestivas de ASIL. El uso de Lugol nos permitió aumentar el grado de sospecha y delimitar las lesiones. Se tomaron biopsias para anatomía patológica bajo visión directa. Conclusiones: Las H-ASIL son consideradas en la actualidad las precursoras del carcinoma escamoso anal; su detección y tratamiento prevendrían su desarrollo. En nuestra casuística, todos los pacientes se encontraban en al menos un grupo de riesgo. Las lesiones fueron subclínicas y requirieron de la anoscopía de alta resolución para su hallazgo, lo que permitió realizar un tratamiento dirigido. Es importante que los profesionales de la salud consideren la pesquisa de H-ASIL en población de riesgo. (AU)

Introduction: The high-grade anal intraepithelial lesions (H-ASIL) are considered the precursor of the anal squamous cell carcinoma. This is why different societies recommend the screening and treatment in high-risk populations. The objective of this paper is to describe H-ASIL manifestations in the high resolution anoscopy (HRA) in our patients. Design: Retrospective, Descriptive Patients and Methods: Review of clinical histories and pictures of HRA of patients with H-ASIL diagnosis between January 2016 and July 2017. The anoscopic evaluation included the squamocolumnar junction, the distal anal duct and the perianal area. In case of the finding of a suspicious lesion of ASIL, biopsies were taken. Results: Between January 2016 and July 2017 184 HRA were performed. 143 ASIL suspicious lesion were biopsied. Twentysix of them, in 13 patients, were H-ASIL. Eleven were men (10 men who have sex with men with HIV infection). All lesions were subclinical and found at endoanal level. The totality of them were acetowhite. Areas with coarse punctation and a mosaic pattern were suggestive of ASIL. The use of lugol´s iodine allows us to increase the grade of suspect and delimit the lesions. Biopsies were taken for pathology under direct vision. Conclusion: The H-ASIL are considered at the present the precursors of the anal squamous carcinoma. Its development could be prevented with de proper detection and treatment of the H-ASIL. In our casuistic, all patients are in at least one risk group. The lesions were subclinical and required of the high resolution anoscopy for their finding, which allows to perform a directed treatment. It is important that health professionals consider the H-ASIL screening in risk population. (AU)

¿Permiten la citología, el genotipado y la anoscopia de alta resolución establecer un protocolo para la detección precoz del carcinoma epidermoide de canal anal en población de riesgo? / Do cytology, genotyping, and high resolution anoscopy allow to establish a protocol for early detection of squamous cell carcinoma of the anal canal in risk population?

Introducción: El cáncer anal ha experimentado un aumento de incidencia en los últimos años. Está mediado por el VPH y precedido de cambios precancerosos planteando la posibilidad de dirigir los esfuerzos preventivos hacia los grupos de alto riesgo. Sigue siendo controvertida la indicación de cribado y los métodos de detección ideales. Objetivo: Validar las pruebas de cribado implementadas en la actualidad comparadas con la biopsia como "gold standard". Material y Métodos: Estudio transversal con recogida de datos prospectiva, en una cohorte de hombres VIH+ que tienen sexo con hombres, pertenecientes al Hospital Gregorio Marañón e Infanta Leonor en un periodo de 2 años. Resultados: Se seleccionaron 179 pacientes con 286 visitas a la consulta de screening en las que se llevaron a cabo 3 pruebas de cribado en paralelo (citología anal, genotipado del VPH y anoscopia de alta resolución (AAR) con toma de biopsia dirigida sobre zona sospechosa o aleatoria). La sensibilidad y especificidad para la detección de displasia de alto grado y cáncer y su grado de concordancia con la biopsia fue la siguiente: citología 3,23%/94,43% (k: 0,03), genotipado de VPH de alto riesgo 90,32%/27,45% (k: 0,05), AAR 32,26%/87,45 (k: 0, 17) siendo el rendimiento diagnóstico de las tres pruebas muy bajo. Conclusión: La citología presenta un rendimiento diagnóstico muy bajo comparado con el genotipado que representa el mayor. A la luz de nuestros resultados, los protocolos clínicos tal y como vienen desarrollándose en la actualidad deberían de ser abandonados.

Introduction: The incidence of anal cancer has increased in recent years. It is mediated by HPV and preceded by precancerous changes, raising the possibility of directing preventive efforts towards high-risk groups. The indication of screening remains controversial and which methods would be the ideal ones. Objective: To validate the screening tests established actually, comparing it with the biopsy considered as the "gold standard". Materials and Methods: A cross-sectional study was performed, with prospective data collection in a cohort of VIH+ patients, who have male homosexual anal relations, belonging to Gregorio Marañón and Infanta Leonor Hospitals in a period of 2 years. Results: A total of 179 patients were selected with 286 visits to the screening Outpatient Clinic in which 3 parallel screening tests were performed (anal cytology, HPV genotyping and high resolution anoscopy (AAR) with a biopsy directed on a suspicious or random area). The sensitivity and specificity for the detection of high-grade dysplasia and cancer and their degree of agreement with the biopsy was as follows: cytology 3.23%/94.43% (k: 0.03), high HPV genotyping. risk 90.32%/27.45% (k: 0.05), AAR 32.26%/87.45 (k: 0, 17), the diagnostic accuracy of the three tests being very low. Conclusion: Cytology shows a very low diagnostic accuracy compared to the genotype that represents the highest one. In light of our results, clinical protocols as they are currently being developed should be abandoned.

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...