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6–2 | Clinical Manual for Management of the HIV-Infected Adult/2006
O: Objective
Examine the perianal and anal region, and perform
digital anorectal examination. Look for lesions, masses,
condylomata, and other abnormalities. In women, also
examine the vulva, vagina, and cervix. Simple anoscopic
examination with the naked-eye may not reveal any
abnormality because dysplastic tissue tends to be flat
and difficult to differentiate from normal anal tissue;
application of 3% acetic acid is required (see below).
A: Assessment
HIV-infected individuals with anal dysplasia have
an increased risk of progression to anal cancer. If the
history or physical examination reveals abnormalities
suggestive of anal dysplasia or anal cancer, an
appropriate evaluation should be undertaken. Because
most patients with anal dysplasia have no symptoms,
anal cancer screening should be considered if follow-up
evaluation of abnormal cytologic results is available.
P: Plan
Screening
No national or international guidelines for anal cytology
screening in people with HIV infection. However,
some experts recommend annual or biannual screening
regardless of sex or sexual practices. Anal cytologic
screening is performed using Papanicolaou (Pap) smears
(for technique, see the study by Berry and Palefsky
referenced below). Papanicolaou smear testing is
sensitive for the detection of dysplastic anal cells, but
does not reliably distinguish the grade of abnormality.
Like cervical cytology, anal cytology is graded using
the Bethesda 2001 system, which categorizes disease in
increasing order of severity as follows:
♦
♦
♦
♦
♦
♦
Negative for intraepithelial lesion or malignancy
Atypical squamous cells of undetermined
significance (ASCUS)
Atypical squamous cells suggestive of high-grade
(ASC-H)
Low-grade squamous intraepithelial lesion (LSIL)
High-grade squamous intraepithelial lesion (HSIL)
Squamous cell carcinoma (SCC)
All individuals with abnormal anal cytology should
be referred for high-resolution anoscopy (HRA) and
biopsy to grade the lesion. If available, refer to an anal
dysplasia specialty center.
Evaluation of Cytologic Abnormalities
HRA of the anal canal should be performed using a
colposcope for magnification (x16) and the application
of 3% acetic acid with or without Lugol’s Iodine
solution to aid in visualization of dysplastic lesions.
Abnormal areas should be biopsied. Anoscopic features
of high-grade disease are similar to those seen in the
cervix; these include coarse punctation, mosaicism, and
the presence of ring glands.
Treatment
The goal of treatment is to prevent progression to
anal cancer. Treatment of high-grade anal dysplasia to
prevent anal cancer is biologically plausible, following
the model of cervical dysplasia treatment. However, the
indications for treatment for anal dysplasia, the efficacy
of treatment, and the optimal treatments have not been
defined clearly.
The focus of treatment is high-grade, premalignant
dysplasia. For patients with HSIL, refer to an anal
dysplasia specialty clinic, if possible. If treatment is not
available, or is not pursued, patients diagnosed with
high-grade anal disease should be informed about the
initial symptoms of anal cancer and asked to follow up
promptly should these symptoms develop.
The optimal treatment for high-grade dysplasia is not
known. Specific treatment may vary depending on the
size, location, and extent of the lesions and the available
treatment modalities. In some cases, treatment of small
intra-anal lesions with 80% trichloroacetic acid or liquid
nitrogen has been successful. More promising, infrared
coagulation has shown 70% efficacy at 3 months
in clinical cohorts. This office procedure involves
identifying the lesion by HRA and applying an infrared
energy source to destroy the lesion.
For perianal lesions, topical therapy with
podophyllotoxin or imiquimod may be considered.
For large or extensive lesions, surgical treatments such
as cold-scalpel excision and electrofulguration are
typically required. Unfortunately, postoperative pain
and other complications may occur, and recurrence of
dysplastic lesions is common. Low-grade dysplasia is
not considered premalignant, but frequently progresses
to high-grade dysplasia. Some specialists do not treat
LSIL but monitor regularly instead with HRA, whereas
others choose to treat LSIL to prevent progression.