Electrocautery ablation effective for anal high-grade squamous intraepithelial lesions, but recurrence common
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Electrocautery ablation appeared effective for treatment of anal high-grade squamous intraepithelial lesions among people living with HIV, according to results of a retrospective study published in Cancer.
However, researchers observed substantial rates of disease recurrence. Multiple index high-grade squamous intraepithelial lesions (HSIL), HIV viremia, current cigarette smoking, and baseline and persistent HPV-16 or HPV-18 infection appeared to negatively affect treatment success.
“Treatment options for anal HSIL include topical immune modulators, chemotherapeutics, surgical excision, and targeted ablation using cryotherapy or thermocoagulation,” Michael M. Gaisa, MD, PhD, associate professor of medicine and infectious diseases at Icahn School of Medicine at Mount Sinai Hospital, and colleagues wrote. “Among these options, high-resolution anoscopy-guided electrocautery ablation has gained popularity as a fast, office-based procedure that produces favorable results with a low rate of complications.”
Electrocautery ablation eliminates lesions by inducing localized tissue necrosis to the depth of the submucosa while also sparing adjacent benign-appearing tissue, according to study background.
Gaisa and colleagues sought to determine the effectiveness of this treatment modality and identify factors associated with HSIL recurrence after ablation.
The researchers retrospectively analyzed 330 patients (median age, 45.5 years; interquartile range [IQR], 35-51) with HIV and de novo intra-anal HSIL treated with electrocautery ablation between 2009 and 2016. About 88% of patients were men who have sex with men, 49% had two to six index HSILs and 28% were current smokers.
Researchers analyzed associations of local recurrence (HSIL at the ablated site at the time of surveillance) and overall recurrence (HSIL at treated or untreated sites) with clinical factors using Cox proportional hazards models.
Results showed that, at median follow-up of 12.2 months (IQR, 6.3-20.9) after ablation, 148 patients (45%) developed local recurrence and 142 (43%) developed metachronous lesions. Overall, 198 patients (60%) had recurrent HSIL.
No patients progressed to invasive cancer during the study period.
Among those who experienced HSIL recurrence, surveillance high-resolution anoscopy showed 67% had a solitary lesion, 28% had two lesions and 5% had three or more lesions.
Unadjusted analyses showed significant associations of postablation overall recurrence with HIV RNA above 100 copies/mL (P = .03), more than one index lesion at baseline (P = .03) and infection by high-risk HPV types (P < .001). Additionally, researchers observed an association between HSIL recurrence and being a current smoker (P = .02).
HSIL recurrence appeared most common among patients infected with HPV-16 or HPV-18, followed by those infected with other high-risk HPV types. Those with undetectable high-risk HPV types had the lowest recurrence rates.
Researchers found no significant differences in postablation disease recurrence by age, race, AIDS diagnosis and CD4-positive T-cell count.
“The results of the current study corroborate that electrocautery ablation is an effective treatment for anal HSIL [among people living with HIV] and achieves high index HSIL clearance rates,” Gaisa and colleagues wrote. “Careful, ongoing surveillance using high-resolution anoscopy and biopsy is imperative to capture disease recurrence early and to improve long-term treatment outcomes.”
Although one study is not enough to change the standard of care, these results are part of growing evidence that treatment of HSIL prevents anal squamous cell cancer, Stephen E. Goldstone, MD, assistant clinical professor of surgery at Icahn School of Medicine at Mount Sinai, wrote in an accompanying editorial.
“[This study] showed us who needs to be followed closely for posttreatment disease recurrence, and that we must work harder to keep our patients compliant and engaged in care,” Goldstone wrote. “We cannot prevent all anal cancers through screening and HSIL treatment. But we can and must do better.” – by John DeRosier
Disclosures: Gaisa reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Goldstone reports grants from and a speaker role with Merck, a consultant role with THD America, and grants from Antiva, Inovio and Medtronic Inc.
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