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Expectant Management of High-Grade Anal Dysplasia in People with HIV

Long-term Data

Cajas-Monson, Luis C., M.D., M.P.H.; Ramamoorthy, Sonia L., M.D.; Cosman, Bard C., M.D., M.P.H., C.T.R.(Ret.)

doi: 10.1097/DCR.0000000000001180
Original Contributions: Colorectal Cancer
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BACKGROUND: Both ablation and expectant management of high-grade squamous intraepithelial lesions have been proposed. Expectant management would be reasonable if 1) the rate of high-grade squamous epithelial lesion progression to anal squamous cell carcinoma were low, and 2) anal squamous cell carcinoma arising under surveillance had a better prognosis than anal squamous cell carcinoma presenting without an identified precursor.

OBJECTIVE: This study aims to quantify aspects of high-grade squamous epithelial lesion/anal squamous cell carcinoma clinical evolution in a surgical practice.

DESIGN: This is a retrospective cohort study.

SETTINGS: This study was performed in 1 colorectal surgeon’s practice over a 20-year period.

PATIENTS: Consecutive patients with high-grade squamous intraepithelial lesion and anal squamous cell carcinoma were included.

MAIN OUTCOME MEASURES: We looked at the rate and timing of progression to anal squamous cell carcinoma, and the stage, treatment, and outcome of anal squamous cell carcinoma. We reviewed a comparison group of HIV-positive patients presenting de novo with anal squamous cell carcinoma (no prior history of high-grade squamous intraepithelial lesion).

RESULTS: With consideration of only HIV-positive patients, 341 patients had a mean 5.6 years follow-up from high-grade squamous intraepithelial lesion diagnosis to the most recent documented anal examination. Twenty-four of these surveillance patients developed anal squamous cell carcinoma, yielding a progression rate of 1.3% per patient-year. Mean follow-up was 7.3 years from the initial cancer diagnosis to the most recent contact. Forty-seven patients who presented de novo with anal squamous cell carcinoma developed 74 lesions, with a mean follow-up of 5.7 years after initial diagnosis. This de novo group had higher anal squamous cell carcinoma-specific mortality (3% per patient-year vs 0.05%). Our study did not show a significantly higher rate of high stage (stage III or IV) at anal squamous cell carcinoma diagnosis in the de novo group in comparison with the surveillance group (25.5% vs 8.3% (p = 0.09)).

LIMITATIONS: This study was retrospective in nature and had a predominately male population.

CONCLUSIONS: The progression of untreated high-grade squamous intraepithelial lesion to anal squamous cell carcinoma approximates 1% per patient-year. Anal squamous cell carcinoma developing under surveillance tends to be of an earlier stage and to require fewer major interventions than anal squamous cell carcinoma presenting de novo. Cancer-specific mortality was lower for malignancies that developed under surveillance. We suggest that expectant management of patients with high-grade squamous intraepithelial lesion is a rational strategy for preventing anal cancer morbidity. See Video Abstract at

Surgical Service, VA San Diego Healthcare System, and Department of Surgery, University of California, San Diego

Funding/Support: This article is in part the result of work supported with resources and the use of facilities at the VA San Diego Healthcare System.

Financial Disclosures: None reported.

Disclaimer: The contents of this report do not represent the views of the US Department of Veterans Affairs or the US Government.

Correspondence: Bard C. Cosman, M.D., M.P.H., C.T.R.(Ret.), 3350 La Jolla Village Dr, #112E, San Diego, CA 92161-0002. E-mail:

© 2018 The American Society of Colon and Rectal Surgeons