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Evolving Concepts in the Management of Anal Dysplasia
1. The UC San Diego AntiViral Research Center sponsors weekly
presentations by infectious disease clinicians, physicians and
researchers. The goal of these presentations is to provide the most
current research, clinical practices and trends in HIV, HBV, HCV, TB
and other infectious diseases of global significance.
The slides from the AIDS Clinical Rounds presentation that you are
about to view are intended for the educational purposes of our
audience. They may not be used for other purposes without the
presenter’s express permission.
AIDS CLINICAL ROUNDS
6. Federico is 24yo male and is studying to become a
fashion designer. He came complaining of anal pain.
• Following diagnosis of HIV infection in
January 2014 he started Epzicom +
dolutegravir. Recent CD4: 490 and VL
was undetectable.
• You performed a rectal GC/CT PCR and
tested positive for chlamydia spp. His
concurrent intake anal pap collected:
ASCUS
• He completed proper treatment for his
proctitis but did not show for his
recommended high resolution
anoscopy (HRA) last month.
8/14/2014 5
29. The one lesion, one virus concept
8/14/2014 28
1 clinical dysplastic lesion
Contains 1 specific HPV Type
in whole tissue analysis
The same HPV type is found using
in LCM in the dysplastic area
within whole tissue section
Most cervical cancers are caused for HPV type 16/18.
Cervical swabs correlates ≥ 94% cases with isolated
specific HPV type in dysplastic lesion.
43. Challenges of ablative therapy
8/14/2014 42
Treatment is imperfect
- No categorical proof of effectiveness:
Ongoing randomized trials
- Recurrence rate is high
- Associate to personal discomfort
46. What is the risk of progression to invasive anal cancer
(IAC)
8/14/2014 45
HSIL IAC
Cachay et al . HIV Medicine 2014. In press
Historical surgical cohorts 9 -15% of patientsCumulative incidence 1.65 (95% CI 0.59 – 4.52)
47. Why is the rate of progression to invasive
anal cancer lower than initially reported?
8/14/2014 46
49. The Australian SPANC study
8/14/2014 48
0 6m 1y 2y 3y
3 years
- Anal PAP
- HPVDNA
- HRA
HSIL = Cytology and/or
Histology
1a
Outcome
50. 450 MSM by June 2014. 31% were HIV+, all were age ≥
35yo, with a median age of 49 years.
8/14/2014 49
- Most observations consistent with literature
Description of their HSIL clearance rate *
164 MSM
HSIL
HIV+
64 (38%)
HIV –
105 (62%)
20 HIV+
41 HIV -
112 MSM
HSIL
Nº analyzed
Nº patients
downgrade
Grulich AE, et al. 20th IAC. 2014. Melbourne. Abstract WEAB0102
41.7
41.8
Clearance of
HSIL per 100PY
54. Owen clinic contribution
8/14/2014 53
2804 patients with at least 1 anal cytology followed
between 2001-2012 for median of ~ 5 years in a
universal inception cohort.
At baseline:
- Median age:40yo, 62% white,78% MSM
- 55% CD4 ≥ 350
- Three quarters were on ART 75% and 64% had HIV
viral load undetectable
58. Similar trends for anal dysplasia regression base
on severity of HSIL lesions:
AIN-2: 61 per 100 PY
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AIN-3: 36.9 per 100 PYVS
P = 0.037
AIN-2 has greater chances of regression than AIN-3
61. Effect of IRC
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< HSIL HSIL IAC
HR 4.2 (2.0–8.5)
HR 2.2 (0.6–7.9)
2.7 (0.6–11.7)
Eight percent (n= 218) underwent one or more IRC ablations for HSIL lesions
between 2007–2012.
62. Conclusion
Given the:
A. The low short term (2-year) probabilities of progression to IAC
B. Moderate to high probabilities of regression of HSIL to less
than HSIL cytology
C. Morbidity of HSIL ablative treatment
D. High recurrence rates among HIV-infected patients
61
63. Conclusion
• After careful initial HRA evaluation and biopsy:
“ It may be reasonable to defer routine immediate
treatment for HSIL provided that close monitoring
with HRA and DRE is available”
62