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HIV-Associated Anal Squamous Cell Cancer: An Otherwise Preventable Disease
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Journal of Clinical Oncology, Vol 24, No 27 (September 20), 2006: pp. 4516-4517
Panagiotis A. Konstantinopoulos, Hans P. Schlecht, Bradley Bryan
Divisions of Hematology/Oncology and Infectious Diseases, and Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
Liron Pantanowitz
Department of Pathology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA
Bruce J. Dezube
Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
"....Screening of HIV-positive patients for anorectal dysplasia and/or malignancy by means of an anal Pap test could save lives..."
A 49-year-old homosexual male with HIV disease (CD4+ T-lymphocyte count: 300 cells/μL, undetectable HIV-1 viral load) who was being treated with protease inhibitor-based highly active antiretroviral therapy regimen (HAART), presented with a 2 x 2 cm rock-hard, well-circumscribed anal lesion on rectal examination. Biopsy demonstrated a moderately differentiated invasive squamous cell carcinoma of the anus (Fig 1, hematoxylin and eosin stain; magnification x 40). Despite concomitant radiation and chemotherapy (fluorouracil plus mitomycin-C), his tumor recurred 10 months after biopsy. Computed tomography at the time of recurrence showed a large, heterogeneous, soft-tissue mass encircling the high rectum, measuring 8 x 7 cm at its greatest transverse diameter and extending to the anterior margin of the sacrum (Fig 2). At exploratory laparotomy, the tumor was invading the sacrum, and the patient underwent a palliative diversion colostomy. Despite treatment with carboplatin and paclitaxel, he developed metastatic disease in the liver. He received salvage gemcitabine without response and died shortly thereafter.
HIV and human papillomavirus (HPV) coinfected patients are at high risk of developing precancerous anal lesions (anal intraepithelial neoplasia) and anal malignancies.1 The natural history (that is, progression and persistence) of HPV-associated lesions is accelerated by HIV-related immunosuppression, which may result in the reactivation of previously acquired HPV infection and loss of control of HPV viral replication.2 The longer life expectancy of these coinfected patients in the era of HAART provides an opportunity for invasive anal carcinoma to develop from its dysplastic precursor. The prognosis of anal squamous cell carcinoma is poor in HIV-positive patients, who often present with advanced tumors.3 The appropriate treatment of patients with advanced anal cancer and HIV infection is uncertain.4 Concomitant radiation therapy and chemotherapy (fluorouracil and mitomycin-C) is the current standard of care for HIV-negative patients with invasive anal carcinoma, and that approach has been investigated and applied successfully in HIV-positive patients with similar anal cancers, particularly those with CD4+ T-lymphocyte counts greater than 200 cells/μL.5,6 HIV-positive patients with anal cancer treated with HAART tend to fare better than those patients who are not receiving HAART.7 It is prudent to point out that our patient never had an anal Papanicolaou (Pap) test (Fig 3, high-grade dysplastic squamous cells; ThinPrep, Cytyc Corporation, Marlborough, MA). HIV-associated anal carcinoma appears to mirror cervical carcinoma in unscreened women, presenting late in the course of the disease and having a protracted, ultimately fatal, course.8 Screening of HIV-positive patients for anorectal dysplasia and/or malignancy by means of an anal Pap test could save lives.9
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