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High Resolution Anoscopy in the Planned Staged Treatment of Anal High-Grade Squamous Intraepithelial Lesions (Hsil) in HIV Negative Patients
Carlos E. Pineda*1, J. Michael Berry2, Naomi Jay2, Joel M. Palefsky2, Mark L. Welton1
1Department of Surgery, Stanford University, Stanford, CA; 2Department of Medicine, University of California San Francisco, San Francisco, CA

Background: Anal HSIL (Bowen’s disease) is potentially pre-cancerous, but uncommon in immunocompetent patients. Traditional management is punch biopsy mapping and wide local excision of involved tissue with flap reconstruction. Morbidity is significant, a diverting stoma may be required, and the recurrence rate is 23%. High resolution anoscopy (HRA) allows direct visualization of HSIL using an operative microscope after application of acetic acid to the anorectal mucosa and perianal skin. HRA-directed targeted destruction of HSIL allows preservation of normal tissues, while potentially minimizing the risk of progression to anal cancer. We utilize HRA guided surgical destruction in the operating room followed with HRA-directed office-based therapies as a planned staged approach in the treatment of patients with large-volume HSIL.
Methods: We reviewed the medical records of 47 HIV-negative patients referred for surgical treatment of anal dysplasia from 1996 to 2006. All patients were evaluated prior to surgery with HRA, cytology, or biopsy and had a minimum postoperative follow-up of 3 months (mean=36, range=3-118).
Results: Of these patients, 32 were male (68%), age range was 20-71 years (mean=43), and none were immunocompromised. Preoperatively, 35 patients (74.5%) had HSIL, 12 (25.5%) had low-grade SIL (LSIL) and none had squamous cell carcinoma (SCC). In 30 (63%) patients lesions involved >25% of the anal circumference. Biopsies, taken at surgery when indicated, revealed LSIL in 11 (30%), HSIL in 19 (51%), superficially invasive SCC in 1 (3%), and SCC in 1 (3%). Staged procedures were required in 21 patients (44%). 17 patients were retreated in-office with trichloroacetic acid and/or infrared coagulation. Additional surgery was planned as the second stage in 4 patients, secondary to circumferential disease. Postoperative complications occurred in 2 patients (4.3%): fissure (1), and bleeding requiring reoperation (1). At an average follow-up of 36 months (3-118), 42 patients had no further evidence of high-grade disease or cancer (89.4%) and 5 (10.6%) had persistent HSIL.
Conclusions: In the immunocompetent patient, staged management with HRA targeted surgical treatment of large volume disease combined with office-based therapies with HRA-directed treatment of focal disease is a safe and effective technique for the management of HSIL. This approach compares favorably to reports of treatment for anal Bowen’s disease with anal mapping with punch biopsies and wide local excision, in terms of recurrence rates (23% vs 10%), complication rates and morbidity. No patients treated for HSIL in this series progressed to cancer.

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