Case of the Month
Case of the Month General Surgical Pathology Uropathology Gynecological Pathology Clinical Pathology

This is a 36 year old HIV+ male who presents for anal pap smear screen ing. A follow up anoscopy is done with biopsy.

Anal Cytology Screening

Diagnosis:

Anal Pap Smear: Low grade squamous intraepithelial lesion encompassing mild dysplasia and HPV cytopathic changes. Occasional cells suspicious for a high grade lesion are also seen.

Anal Biopsy: Moderate Anal Intraepithelial Neoplasia (AIN II) with associated HPV effect

The following information can be found on the web at: The Anal Pap Smear

The terminology used to describe the epithelial changes observed with HPV associated anal disease are very similar to those used for cervical cytology. Anal cytologies are read as either normal or abnormal. In the abnormal group there are three possible subgroupings: atypical squamous cells of undetermined significance (ASCUS), low-grade squamous intraepithelial lesions (LSIL), and high-grade squamous intraepithelial lesions (HSIL). On histology, HSIL is diagnosed when abnormal cells with increased nuclear to cytoplasmic ratio replace 50% or more of the epithelial thickness. LSIL is diagnosed when 20-25% is replaced or koilocytes are present. As in cervical cytology, ASCUS refers to cells found on cytology that are difficult to categorize as either normal or abnormal [1]. LSIL and ASCUS frequently regress, while HSIL rarely regresses and is considered a pre-cancerous lesion. In one study of homosexual/bisexual men, 62% of LSIL lesions in HIV positive men progressed to HSIL compared to 36 % in HIV negative men [3]. Though anal cytology may be as sensitive as a cervical PAP smear, biopsy remains the gold standard since cytologic grade often does not correlate with final histological grade [9].

Comments:

BIBLIOGRAPHY

[1]Palefsky JM, Cranston RD. Anal squamous intraepithelial lesions (ASIL): Diagnosis, screening and treatment. UpToDate, online version 9.2.

[2]Daling JR, Weiss NS, Hislop TG, et al. Sexual practices, sexually transmitted disease, and the incidence of anal cancer. N Engl J Med 1987; 317: 973-7.

[3]Palefsky JM, Holly EA, Hogeboom CJ, et al. Virologic, immunologic, and clinical parameters in the incidence and progression of anal squamous intraepithelial lesions in HIV-positive and HIV-negative homosexual men. J Acquir Immune Defic Syndr Hum Retrovirol 1998; 17: 314-319.

[4] Palefsky JM, Cranston RD. Virology of human papillomavirus infections and the link to cancer. UpToDate, online version 9.2.

[5] Vernon SD, Hart CE, Reeves WC, Icenogle JP. The HIV-1 tat protein enhances E-2 dependent human papillomavirus 16 transcription. Virus Res 1993; 27:133.

[6] Palefsky JM, Berry JM. Pathogenesis and clinical manifestations of HIV-associated anogenital neoplasia. Web Site: The AIDS Knowledge Base. November 1998.

[7] Palefsky JM, Holly EA, Ralston ML, et al. High incidence of anal high-grade squamous intraepithelial lesions among HIV-positive and HIV-negative homosexual and bisexual men. AIDS 1998; 12:495-503.

[8] Frisch M, Bengt G, et al. Sexually transmitted infection as cause of anal cancer. N Engl J Med 1997; 337:19:1350-1358.

[9] Holly EA, Ralston ML, Darragh TM et al. Prevalence and risk factors for anal squamous intraepithelial lesions in women. Journal of Nat Cancer Inst 2001:93:11:843-849.

[10]Friis S, Kjaer SK, Frisch M et al. Cervical intraepithelial neoplasia, anogenital cancer, and other cancer types in women after hospitalization for Condyloma Acuminata. Journal Infect Disease 1997; 175:743-8.

[11]Ryan DP, Compton CC, Mayer RJ. Carcinoma of the anal canal. N Engl J Med 2000; 342:11:792-800.

[12]Penn, I. Cancer of the anogenital region in renal transplant recipients. Cancer 1986; 58: 611-616.

[13]Martins, CR. HPV-induced anal dysplasia: What do we know and what can we do about it? The Hopkins HIV Report. May 2001.

[14]Darragh TM, Jay N, et al. Comparison of conventional cytologic smears and ThinPrep preparations from the anal canal. Acta Cytologica 1997; 41:4:1167-1170.

[15]Palefsky JM, Holly EA, Hogeboom CJ, et al. Anal cytology as a screening tool for anal squamous intraepithelial lesions. J Acquir Immune Defic Syndr Hum Retrovirol 1997: 14: 415-422.

[16]Goldie SJ, Kuntz KM, Weinstein MC, et al. The clinical effectiveness and cost-effectiveness of screening for anal squamous intraepithelial lesions in homosexual and bisexual HIV-positive men. JAMA 1999: 281: 1822-1829.

[17]Goldie SJ, Kuntz KM, Weinstein MC, et al. The cost-effectiveness of screening for anal squamous intraepithelial lesions in HIV-negative homosexual and bisexual men. Am J Med 2000; 108:634-641.

 

 

 
Archived Cases
 
 

 

© Webmaster@Got Path?
Read the Medical Disclaimer		 The Doctors Doctor• DermpathMD • Pathologist Mentor•