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especially individuals infected by HIV in whom the risk increases to 60 cases for every 100&#44;000 patients&#46; This represents an incidence between 10 and 50 times higher than in the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The group at greatest risk are homosexual men in whom the prevalence has increased to figures approaching 92&#8211;144 cases per 100&#44;000 patients&#47;year&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Etiology and risk factors&#58; anogenital infection by HR-HPV</span><p id="par0010" class="elsevierStylePara elsevierViewall">Anogenital infection by HPV is one of the most common sexually transmitted infections &#40;STIs&#41; worldwide&#44; especially in the young sexually active population&#46; Persistent infection by high-risk HPV &#40;HR-HPV&#41; genotypes is considered the fundamental etiological factor for the onset of the majority of genital carcinomas&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6</span></a> The spectrum of HR-HPV genotypes involved in anal carcinoma and its precursor lesions is similar to that reported for cervical carcinoma&#46; The most frequently isolated type is HPV-16&#44; present in 65&#8211;75&#37; of cases&#44; followed by type 18&#46; Alone or in combination&#44; both types are found in 78&#37; of all anal carcinomas&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> It has also been suggested that the number of HR-HPV isolates in an anal cytology is an additional risk factor&#59; the presence of more than 5 genotypes multiplies the risk of anal dysplasia by 7&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The practice of receptive anal sex is the principal risk behavior for developing anal carcinoma &#40;relative risk &#91;RR&#93; 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Both have an anatomical area of transformation where physiological metaplasia regions are located&#46; In these regions&#44; the glandular epithelium is replaced by squamous epithelium &#40;of the ectocervix or of the anal canal&#44; respectively&#41;&#46; This area gives rise to dysplastic intraepithelial lesions&#44; which are classified according to their severity as low-grade dysplasia &#40;cervical and anal intraepithelial neoplasia &#91;CIN&#47;AIN-1&#93; or low grade &#91;LG&#93;&#41;&#44; or high grade &#40;CIN&#47;AIN-2 and 3 or high grade &#91;HG&#93;&#41;&#46; The epithelial dysplasia is more extensive in these lesions&#44; and these lesions constitute the true precursors of both anal and cervical squamous cell carcinoma&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a> This dynamic scenario has been widely demonstrated in the case of uterine cervical carcinoma in which spontaneous regression&#44; persistence without changes or progression to invasive malignant lesions are all possible&#46; There is a general consensus to apply this same model to anal canal lesions&#44; while acknowledging that the clinical evidence that supports this approach is not definitive&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In the case of anal lesions&#44; the risk of progression of incipient AIN &#40;basal epithelial atypia&#41; to invasive carcinoma is not known&#46; It is believed that&#44; once HG-AIN develops in the anal epithelium&#44; spontaneous regression is highly unlikely&#44; even in individuals not infected by HIV&#46; Therefore&#44; the theoretical risk of progression of HG-AIN to carcinoma in immunosuppressed patients&#44; in whom HPV infection is more prevalent and harder to control&#44; should be even higher&#46; However&#44; the available epidemiological information is optimistic and suggests that the risk of transformation of HG-AIN to invasive squamous cell carcinoma is lower than that attributed to cervical dysplasia&#46; The prevalence rates for high-grade anal dysplasia published in the literature vary greatly depending on the series&#44; but data from a recent meta-analysis<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> indicate that it is approximately 29&#37; in homosexual men infected by HIV&#46; If this high prevalence of HG-AIN is compared with the much lower rate of anal carcinoma&#44; it seems very likely that only a minority of the cases progress will progress and will require significant time &#40;years to even decades&#41; to complete&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Anal dysplasia and HIV infection</span><p id="par0040" class="elsevierStylePara elsevierViewall">The progressive increase in the number of cases has made anal carcinoma one of the most common non-AIDS-defining cancers in the Western world&#46; Since 1986&#44; a marked increase has been confirmed in the incidence of anal dysplasia in homosexual men infected by HIV when compared with non-infected men &#40;RR of 5&#46;7 and 3&#46;7&#44; respectively&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> as well as a growing risk of progression to invasive lesions as the immunosuppression by HIV intensifies&#46; These data appear once again in the association among advanced infection HIV&#44; the increase in the incidence of HR-HPV infection and the onset of pre-neoplastic lesions or associated invasive tumors&#46; In patients infected by HIV&#44; the risk of anal carcinoma has been related to CD4 nadir figures below 200<span class="elsevierStyleHsp" style=""></span>cells&#47;mm<span class="elsevierStyleSup">3</span>&#44; as well as with the extended duration of HIV infection &#40;12 times greater risk in patients with more than 15 years of evolution compared with those with less than 5 years&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Unfortunately&#44; the incidence of anal cancer has not declined after the widespread use of highly active antiretroviral therapy &#40;HAART&#41;&#46; On the contrary&#44; the incidence of invasive carcinoma and its precursor lesions has multiplied since the introduction of HAART&#46; In the follow-up of the series by Crum-Cianfore et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> which included 4901 individuals infected by HIV&#44; the rate of anal carcinoma increased progressively from 11 cases per 100 patients&#47;year in the pre-HAART era to 128 cases in the period 2006&#8211;2008&#46; If we consider the long latency in the progression of dysplastic lesions caused by HPV&#44; the increase in the incidence of anal cancer could be due in part to the current increase in the survival of patients infected by HIV&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> It has been suggested that HIV infection could play a facilitator role <span class="elsevierStyleItalic">per se</span> in the progression of these tumors&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> a situation that is reflected in the faster progression and earlier incidence &#40;two decades sooner&#41; than in seronegative patients&#46; If these hypotheses are correct&#44; it is likely that the incidence of neoplasia will continue to increase in the coming years in patients with access to antiretroviral therapy&#46; According to estimates by Palefsky et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> 32&#37; of homosexual patients infected by HIV with normal anal cytology and 52&#37; of those with low-grade dysplasia could develop high grade intraepithelial lesions in 4 years&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Other patient populations at increased risk</span><p id="par0050" class="elsevierStylePara elsevierViewall">There is less experience in other immunocompromised populations&#44; but any patient who presents cell immunity dysfunction as a consequence of a disease or treatment has a greater risk of anal cancer&#46; In the Swedish national registry&#44; the risk of anal carcinoma is 10 times higher in patients with solid organ transplants compared to the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Solid organ transplant patients or those who have autoimmune diseases such as systemic lupus erythematosus or rheumatoid arthritis and are receiving immunosuppressive therapy require special monitoring&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Impact of early diagnosis and treatment on anal carcinoma morbidity</span><p id="par0055" class="elsevierStylePara elsevierViewall">The treatment of AIN and anal carcinoma in immunosuppressed patients&#44; especially those infected by HIV&#44; is especially difficult because the results of conventional therapies are inferior than those of the seronegative population&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Even in the HAART era&#44; anal carcinoma survival is lower in patients infected by HIV than in the uninfected population&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Furthermore&#44; patients infected with HIV have a lower tolerance to chemotherapy and radiation therapy&#44; with up to 50&#37; of cases presenting difficulties in properly complying with the oncology protocols&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> This data reinforces the need for early diagnosis of precursor lesions of anal carcinoma and already invasive lesions before their regional or general dissemination&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Diagnosis of anal carcinoma</span><p id="par0060" class="elsevierStylePara elsevierViewall">Given that anal squamous cell carcinoma develops in precursor lesions &#40;HG-AIN&#41;&#44; which can be diagnosed and treated&#44; it is a theoretically preventable type of tumor&#46; The clinical diagnosis of advanced anal carcinoma is simple&#59; however&#44; 20&#37; of locally advanced carcinomas are asymptomatic&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> It may therefore be reasonable to apply active search protocols in certain risk groups&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The clinical presentation of invasive anal carcinoma frequently seems anodyne&#59; many of the initial symptoms of the disease &#40;pain&#44; bleeding or onset of rectal masses&#41; can be similar to those of other processes common in homosexual men&#44; such as some STIs&#44; diarrheatic syndromes of diverse origin or even cracks&#44; fistulae and anal abscesses&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> The first diagnostic stage of anal cancer consists of the visual inspection and rectal examination&#44; which should be performed annually for all at-risk populations&#46; Patients should be instructed to actively participate in the process of early diagnosis&#44; performing periodic self-examinations and consulting in the event of any unusual finding or symptom&#46; The perianal examination is simple and detects tumors in the early stage&#46; The clinical appearance of intraepithelial dysplasia or <span class="elsevierStyleItalic">in situ</span> carcinoma is very non-specific and is often confused with benign anal diseases&#46; The diagnosis of incipient intraanal neoplasia is much more difficult&#44; and usually goes unnoticed during the digital exploration and is not diagnosed without the help of high resolution anoscopy &#40;HRA&#41;&#44; a term coined to describe the colposcopy of the anal canal and the perianal region&#46; HRA helps guide biopsies for the definitive diagnosis of anal canal dysplasia&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">History and justification for screening using cytology and anoscopy</span><p id="par0070" class="elsevierStylePara elsevierViewall">Cervical carcinoma cytology screening programs in the general population started in the United States 50 years ago&#44; and the incidence of invasive carcinoma has declined since then from 35 to 40 cases&#47;100&#44;000 inhabitants before its widespread use to 8&#47;100&#44;000 inhabitants afterwards&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Based on the similarities between cervical and anal tumors&#44; early detection programs for anal carcinoma have been established in the last 10 years&#44; which&#44; hoping to achieve similar positive effects&#44; follow performance protocols and clinical guidelines similar to those established for the cervical carcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Anal cytology as a screening test</span><p id="par0075" class="elsevierStylePara elsevierViewall">This is a simple and comfortable technique to perform and it obtains cells for cytopathological analysis&#46; It also allows for the qualitative determination of HPV when performed in a liquid medium&#46; The Bethesda classification&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> employed to interpret the results of the technique&#44; differentiates the lesions into the following categories&#58; &#40;a&#41; normal lesions&#44; &#40;b&#41; low-grade squamous intraepithelial lesions or LSIL &#40;dysplasia in the basal third of the epithelium&#41;&#44; &#40;c&#41; high-grade intraepithelial squamous lesions or HSIL &#40;dysplasia in the middle third or throughout the epithelium thickness&#41;&#44; &#40;d&#41; atypical squamous cells of undetermined significance &#40;ASCUS&#41; and &#40;e&#41; atypical squamous cells-cannot exclude HSIL &#40;ASC-H&#41;&#46; The performance of anal cytology is similar to that of cervical cytology and biopsy&#46; Its total sensitivity for the diagnosis of AIN is 69&#8211;93&#37;&#44; with a specificity of 32&#8211;59&#37;&#46; Unfortunately&#44; the specificity of the cytology in the detection of HG-AIN is limited&#59; therefore&#44; its practical usefulness is limited because many patients are unnecessarily subjected to HRA and biopsy&#46; Therefore&#44; there is a justifiable need for additional tests that&#44; in combination or isolation&#44; improve the current results&#46; The study of various biomarkers in anal cytology samples&#44; such as the messenger RNA of certain viral genotypes or the use of cytological staining of the proteins P16ink4a and Ki67&#44; are of considerable interest&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">High-resolution anoscopy</span><p id="par0080" class="elsevierStylePara elsevierViewall">This is the technique of choice for the targeted diagnosis of AIN lesions&#46; It requires the use of a colposcope equipped with a light and a magnifying lens&#44; which enables study of the transitional epithelium of the anal canal&#46; As with cervical colposcopy&#44; this examination uses gauze soaked with a 3&#37; acetic acid solution and Lugol&#39;s stain&#46; The presence of AIN should be suspected in the presence of acetowhite plaques&#44; which do not trap Lugol&#39;s stain&#44; and areas of the mucosa that present an abnormal vascular pattern of mosaicism&#44; patterns similar to those described in cervical displasia&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The biopsy of suspicious areas helps detect the presence of dysplasia and determine its depth in the studied epithelium&#46; Therefore&#44; taking into account the division of the epithelium in three parts&#44; the AIN is classified as grade 1 &#40;LG-AIN&#41;&#44; 2 and 3 &#40;HG-AIN&#44; both&#41;&#44; depending on the onset of morphological changes that affect the epithelium from lesser to greater depth&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Correlation between cytology and biopsy of the anal canal</span><p id="par0090" class="elsevierStylePara elsevierViewall">Due to the lack of correlation between its findings and those of the subsequent biopsies in a measurable proportion of cases&#44; the interpretation of anal cytology raises a number of controversies&#46; While the presence of high-grade cytology adequately predicts the presence of severe dysplasia in the biopsy&#44; this correlation is lost in low-grade cytologies &#40;ASCUS and LSIL&#41;&#44; which tend to underestimate the actual histological severity&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> For this reason&#44; it is recommended that HRA and biopsies be performed for any patient with risk factors and abnormal cytology&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> In cases with a normal biopsy after an abnormal cytology&#44; a high index of suspicion should be maintained because it is likely that the biopsy has not identified the dysplastic areas&#46; Repeating the HRA is advisable&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The combined search for HR-HPV in cytology samples does not offer advantages in most patients&#44; given that practically all homosexual men infected with HIV are coinfected by oncogenic HPV&#46; It has been proposed that the determination of HR-HPV would be helpful in differentiating 2 groups within the cytologies of undetermined significance &#40;ASCUS&#41;&#58; &#40;a&#41; those associated with HR-HPV &#40;&#43;&#41;&#44; which require anoscopy and biopsy and &#40;b&#41; the uncommon cases in which HR-HPV is not isolated&#44; in which clinical follow-up and repeated cytologies would be sufficient&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Practical development&#58; how to conduct the screening&#63;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Visual inspection and rectal examination constitute the basic diagnostic procedures to be performed for all individuals&#44; followed by sampling for anal cytology&#46; Regarding screening using cytology&#44; there is no universal scheme and most algorithms are based on the initial algorithm proposed by Palefsky &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> For patients with risk factors&#44; an anal cytology is performed using the previously mentioned technique&#46; If the result is negative and if the patient is immunocompromised&#44; the cytology is repeated in a year&#46; Conversely&#44; any abnormality in the cytology will be an indication for examination using high-resolution anoscopy and biopsy&#46; If a grade 1 AIN is detected in the biopsy&#44; repeating the anoscopy in 6 months is indicated&#46; If an HG-AIN is found&#44; the indication will be to treat&#46; If there are no findings in the anoscopy after an abnormal cytology&#44; the proposed approach depends on the authors&#44; although the more prudent option is to repeat the anoscopy in 6 months&#46; In specific situations&#44; it might be advisable to proceed directly with an anoscopy and biopsy&#44; without the need for a prior cytology&#46; This is the case for patients with positive findings in the initial rectal examination and for those who have histories of genital dysplasia&#44; as well as the follow-up of already treated patients&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Who should be offered the screening&#63;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Considering the practical impossibility of conducting an anal carcinoma screening of all patients who might require it &#40;individuals with anal infection by HR-HPV&#41;&#44; it is advisable to prioritize the attention to individuals at highest risk&#58; immunosuppressed patients&#44; especially those infected by HIV&#46; In this population&#44; the screening protocols for anal carcinoma should form part of the routine clinical follow-up protocols&#44; with the periodicity that is deemed appropriate&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">It has already been stated that HR-HPV infection affects seropositive patients of both sexes&#46; However&#44; the published guidelines prioritize the care of homosexual men because this group has the highest rates of infection by HR-HPV&#44; followed by heterosexual men and women with histories of anal warts or dysplasia in the anogenital region&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Patients with more severe immunological impairment and those infected by HIV for longer periods would theoretically have a greater risk of presenting anal dysplasia<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#59; however&#44; currently almost all patients receive antiretroviral therapy and remain in good immune condition&#44; and these differences might not be significant&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Treatment of AIN</span><p id="par0115" class="elsevierStylePara elsevierViewall">This represents a therapeutic challenge&#44; both because of the risk of recurrence and metachronous lesions and because none of the existing treatments is capable of definitely eradicating the anal infection by oncogenic HPV&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> Consequently&#44; long-term clinical follow-up of treated patients is required&#46; Given that none of the available techniques has demonstrated a greater efficacy&#44; the choice of technique should consider factors such as the location and extent of the disease&#44; the availability of technical means and the experience of the responsible medical team&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The treatment of AIN can be approached through topical treatments&#44; ablative treatments and surgical procedures&#46; For localized forms&#44; the treatment is relatively simple and the possibilities are numerous&#58; cryotherapy&#44; trichloroacetic acid&#44; treatment by infrared coagulation&#44; electrocautery&#44; CO<span class="elsevierStyleInf">2</span> laser and conventional surgery&#46; The approach for extensive forms is more complex&#44; and of these approaches&#44; the topical application of imiquimod&#44; 5-fluorouracil or cidofovir is preferable&#46; In any case&#44; treatment with infrared coagulation should be assessed&#46; This treatment uses thermal coagulation and has the advantage of treating extensive areas during a consultation&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> Several retrospective studies have indicated that this is a safe procedure&#44; with an effectiveness in the treatment of localized AIN lesions of 60&#8211;70&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Lastly&#44; the actual effectiveness of HPV vaccination programs in the prevention of anal dysplasia&#44; both in the general population and in patients infected by HIV&#44; represents a hopeful possibility that needs to be confirmed in the medium to long term&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">The upside and downside of screening&#58; areas of uncertainty</span><p id="par0130" class="elsevierStylePara elsevierViewall">The diagnostic tests used in anal cancer screening protocols have not been validated by any official body&#44; and their use in anal disease is based on the analogy with its usefulness in the screening of cervical carcinoma&#46; Although numerous studies have documented the onset of infiltrating squamous cell carcinoma in HG-AIN lesions&#44; we lack accurate data on the natural history of anal neoplasia and of the actual risk of progression of HG-AIN to anal carcinoma&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Others issues remain to be resolved&#46; The most important of these is the current lack of randomized studies that demonstrate a decrease in the incidence of invasive anal carcinoma after the implementation of screening and early diagnosis programs <span class="elsevierStyleItalic">versus</span> the expected behavior with results similar to those already demonstrated for cervical carcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> The results recently published in a study of patients with anal cancer and HIV infection were not very encouraging&#46; Seven of the 74 patients diagnosed with anal cancer had followed previous screening protocols&#44; and the found tumors were not in earlier stages&#44; and they did not have longer survival&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">A number of authors have warned that indiscriminate use of cytology&#44; HRA and biopsy might not be cost-effective and could even have a negative effect on the follow-up of these patients&#46; In addition&#44; most healthcare settings do not have the appropriate conditions for the generalized implementation of these guidelines&#44; either because of the increased burden of care and financial costs they entail or due to the lack of materials and training of health workers&#46; Screening techniques&#44; although simple and not too invasive&#44; can also entail iatrogenic risks and can increase the psychological discomfort of patients in the face of uncertain results and the need for long-term follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Recommendations and conclusion</span><p id="par0145" class="elsevierStylePara elsevierViewall">Anal carcinoma is a preventable cancer of known etiology and constitutes a public health problem of growing importance in specific&#44; clearly identified subpopulations&#46; We also know that it develops from identifiable and treatable precursor lesions&#44; which progress slowly over long periods before becoming invasive&#44; representing an opportunity for preventive clinical intervention&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">While acknowledging the pending issues of its cost-effectiveness and future repercussions&#44; the implementation of screening programs adapted to the characteristics of each healthcare setting offers a considerable opportunity to positively affect the morbidity and mortality associated with this cancer&#46; We will not know for some years the true repercussion of these proposals&#44; but in practice the protocols of early diagnosis of anal carcinoma are already a reality in many institutions in the United States and Europe&#44; which routinely include the protocols in the clinical follow-up of patients infected by HIV&#46;</p></span></span>"
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          "titulo" => "The clinical problem&#58; anal carcinoma"
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          "titulo" => "Etiology and risk factors&#58; anogenital infection by HR-HPV"
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          "titulo" => "Natural history of the anal carcinoma"
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          "titulo" => "Anal dysplasia and HIV infection"
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              "titulo" => "Other patient populations at increased risk"
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          "titulo" => "Impact of early diagnosis and treatment on anal carcinoma morbidity"
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          "titulo" => "Diagnosis of anal carcinoma"
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              "titulo" => "High-resolution anoscopy"
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              "titulo" => "Correlation between cytology and biopsy of the anal canal"
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          "titulo" => "Practical development&#58; how to conduct the screening&#63;"
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              "titulo" => "Who should be offered the screening&#63;"
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          "titulo" => "Treatment of AIN"
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          "titulo" => "The upside and downside of screening&#58; areas of uncertainty"
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    "fechaRecibido" => "2013-05-22"
    "fechaAceptado" => "2013-08-06"
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            0 => "Anal carcinoma"
            1 => "Human immunodeficiency virus"
            2 => "Human papilloma virus"
            3 => "Intraepithelial neoplasia"
            4 => "Screening"
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            0 => "Carcinoma anal"
            1 => "Virus de la inmunodeficiencia humana"
            2 => "Virus del papiloma humano"
            3 => "Neoplasia intraepitelial"
            4 => "Cribado"
            5 => "Diagn&#243;stico"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A 38-year-old white man had a 10-year history of human immunodeficiency virus &#40;HIV&#41; infection &#40;A3&#41;&#44; with no episodes of opportunistic diseases and in good immunologic recovery &#40;CD4 cell count&#58; 450 and indetectable HIV viral load&#41; while on HAART&#46; He presented with a two-month history of mild anal symptoms&#44; including pruritus and episodic bleeding&#46; He referred past episodes of anal warts&#44; self-treated with several topical compounds&#44; all proven unsuccessful&#46; Perianal examination showed erythema and scratching&#46; A 0&#46;5<span class="elsevierStyleHsp" style=""></span>cm sized tumor&#44; with infiltration at the base was detected on digital exam&#44; located at 15<span class="elsevierStyleHsp" style=""></span>mm from the anal margin&#46; Local biopsy driven by high-resolution anuscopy &#40;AAR&#41; yielded a final diagnosis of infiltrative epidermoid carcinoma&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Might that neoplasia have been prevented&#63;</p>"
      ]
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Herranz-Pinto P&#44; Sendagorta-Cud&#243;s E&#44; Bernardino-de la Serna JI&#44; Pe&#241;a-S&#225;nchez de Rivera JM&#46; Carcinoma anal e infecci&#243;n por el virus de la inmunodeficiencia humana&#58; &#191;es la hora del cribado&#63;&#46; Rev Clin Esp&#46; 2014&#59;214&#58;87&#8211;93&#46;</p>"
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Journal Information
Vol. 214. Issue 2.
Pages 87-93 (March 2014)
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Vol. 214. Issue 2.
Pages 87-93 (March 2014)
Clinical up-date
Anal carcinoma and HIV infection: Is it time for screening?
Carcinoma anal e infección por el virus de la inmunodeficiencia humana: ¿es la hora del cribado?
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P. Herranz-Pintoa,
Corresponding author
, E. Sendagorta-Cudósa, J.I. Bernardino-de la Sernab, J.M. Peña-Sánchez de Riverab
a Servicio de Dermatología, Hospital Universitario La Paz, Madrid, Spain
b Unidad VIH, Hospital Universitario La Paz, Madrid, Spain
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Abstract

A 38-year-old white man had a 10-year history of human immunodeficiency virus (HIV) infection (A3), with no episodes of opportunistic diseases and in good immunologic recovery (CD4 cell count: 450 and indetectable HIV viral load) while on HAART. He presented with a two-month history of mild anal symptoms, including pruritus and episodic bleeding. He referred past episodes of anal warts, self-treated with several topical compounds, all proven unsuccessful. Perianal examination showed erythema and scratching. A 0.5cm sized tumor, with infiltration at the base was detected on digital exam, located at 15mm from the anal margin. Local biopsy driven by high-resolution anuscopy (AAR) yielded a final diagnosis of infiltrative epidermoid carcinoma.

Might that neoplasia have been prevented?

Keywords:
Anal carcinoma
Human immunodeficiency virus
Human papilloma virus
Intraepithelial neoplasia
Screening
Diagnosis
Anoscopy
Cytology
Resumen

Varón de 38 años, diagnosticado de infección por el virus de la inmunodeficiencia humana (VIH) hace 10 años, y que seguía desde entonces terapia antirretroviral. Nunca había presentado enfermedades oportunistas y se encontraba en buena situación inmunológica, con recuento de CD4 de 450 células/mm3 y carga viral de VIH indetectable. Consultaba por presentar molestias anales persistentes desde hacía 2 meses, con prurito y leve sangrado ocasional. Al haber presentado varios episodios previos de verrugas anales, el paciente se había autoadministrado diversos tratamientos tópicos, sin eficacia y con empeoramiento de los síntomas. La exploración de la región perianal evidenció eritema inespecífico y signos de rascado. En el tacto rectal se detectaba una pequeña tumoración de 0,5cm y base infiltrada, dolorosa a la palpación y localizada a 15mm del orificio anal. Se realizó una anoscopia de alta resolución con biopsia de la lesión descrita, que confirmó la presencia de un carcinoma epidermoide infiltrante.

¿Habría podido prevenirse el desarrollo de esta neoplasia?

Palabras clave:
Carcinoma anal
Virus de la inmunodeficiencia humana
Virus del papiloma humano
Neoplasia intraepitelial
Cribado
Diagnóstico
Anoscopia
Citología

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