Squamous Intraepithelial Lesion of the Anus in a Man With HIV Infection

Susan C. Ball, MD, MPH


AIDS Read. 2004;14(9) 

In This Article

Anal Dysplasia in MSM

MSM have high rates of SILs. In a study by Goldstone and colleagues,[12] 93% of MSM referred for treatment of anal warts or benign rectal conditions were found by rectal PAP test to have abnormal cytology. Biopsy results for 120 (60%) of 200 MSM revealed high-grade SIL. Five patients had invasive squamous cell cancer.

Treatment of HPV in the anal canal is more difficult than treatment in the cervix because of the attendant morbidity associated with ablative surgical procedures in the anus. Cytodestruction through surgical excision is one of the main forms of treatment for lesions of the cervix and anus. Cytodestruction also includes excision by the loop excision electrocautery procedure (LEEP), cryotherapy, laser therapy, infrared photocoagulation, and bichloroacetic acid/trichloroacetic acid and podophyllotoxin. Treatments with interferon, cidofovir, 5-fluorouracil (5-FU), and imiquimod have also been tried.[9] No method is as yet a gold standard, because recurrence is a major problem, even with ablative procedures.

Often, recurrence occurs in adjacent tissue where HPV remains. In a study of residual virus after laser excision of anal condyloma, Ferenczy and colleagues[13] found 45% of patients still harbored HPV in normal-appearing tissue. For cervical lesions, LEEP allows assessment of the margins, something that laser or cryotherapy does not allow. Recurrence of cervical SILs after LEEP occurred in more than 30% of patients in a recent study and in nearly 50% of those with positive margins.[14]

With anal lesions, excision methods have potentially more morbidity, including pain, infection, bleeding, and problems with continence. Until recently, most anal procedures needed to be performed in the operating room with the patient under general anesthesia. The use of the infrared coagulator (IRC) has allowed anal lesions to be treated with the patient under local anesthesia. A recent presentation by Goldstone and associates[15] reviewed the IRC treatment of 165 lesions in 68 MSM in an office-based practice. This procedure was well tolerated and yielded a "per individual lesion cure rate" of 72%. Although 65% of the patients required re-treatment of either a persistent or a new SIL, the results and tolerability of this method are nonetheless encouraging.


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