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Journal of Clinical Oncology, Vol 24, No 27 (September 20), 2006: pp. 4516-4517 © 2006 American Society of Clinical Oncology. DOI: 10.1200/JCO.2006.06.2224
HIV-Associated Anal Squamous Cell Cancer: An Otherwise Preventable DiseaseDivisions of Hematology/Oncology and Infectious Diseases, and Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
Department of Pathology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA
Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 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
Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
REFERENCES
1. Frisch M, Biggar RJ, Goedert JJ: Human papillomavirus-associated cancers in patients with human immunodeficiency virus infection and acquired immunodeficiency syndrome. J Natl Cancer Inst 92:1500-1510, 2000 2. Holly EA, Ralston ML, Darragh TM, et al: Prevalence and risk factors for anal squamous intraepithelial lesions in women. J Natl Cancer Inst 93:843-849, 2001 3. Vatra B, Sobhani I, Aparicio T, et al: Anal canal squamous-cell carcinomas in HIV positive patients: Clinical features, treatments and prognosis. Gastroenterol Clin Biol 26:150-156, 2002[Medline] 4. Chadha M, Rosenblatt EA, Malamud S, et al: Squamous-cell carcinoma of the anus in HIV-positive patients. Dis Colon Rectum 37:861-865, 1994[CrossRef][Medline] 5. Bartelink H, Roelofsen F, Eschwege F, et al: Concomitant radiotherapy and chemotherapy is superior to radiotherapy alone in the treatment of locally advanced anal cancer: Results of a phase III randomized trial of the European Organisation for Research and Treatment of Cancer Radiotherapy and Gastrointestinal Cooperative Groups. J Clin Oncol 15:2040-2049, 1997 6. Flam M, John M, Pajak TF, et al: Role of mitomycin in combination with fluorouracil and radiotherapy, and of salvage chemoradiation in the definitive nonsurgical treatment of epidermoid carcinoma of the anal canal: Results of a phase III randomized intergroup study. J Clin Oncol 14:2527-2539, 1996[Abstract] 7. Kim JH, Sarani B, Orkin BA, et al: HIV-positive patients with anal carcinoma have poorer treatment tolerance and outcome than HIV-negative patients. Dis Colon Rectum 44:1496-1502, 2001[CrossRef][Medline] 8. Leiman G: Anal screening cytology. Cytojournal 2:5, 2005[CrossRef][Medline] 9. Panther LA, Schlecht HP, Dezube BJ: Spectrum of human papillomavirus-related dysplasia and carcinoma of the anus in HIV-infected patients. AIDS Read 15:79-82, 2005[Medline]
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Copyright © 2006 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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