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Z Gastroenterol 2017; 55(01): 23-31
DOI: 10.1055/s-0042-117646
Originalarbeit
© Georg Thieme Verlag KG Stuttgart · New York

Anal chromoendoscopy using gastroenterological video-endoscopes: A new method to perform high resolution anoscopy for diagnosing intraepithelial neoplasia and anal carcinoma in HIV-infected patients

Anale Chromoendoskopie mittels gastroenterologischer Video-Endoskopie: Eine neue Methode zur Durchführung der hochauflösenden Anoskopie in der Diagnostik der intraepithelialen Neoplasie und des Analkarzinoms bei HIV-infizierten Patienten
Mark Oette
1   Clinic for General Medicine, Gastroenterology, and Infectious Diseases, Augustinerinnen Hospital, Cologne, Germany
,
Ulrike Wieland
2   Institute of Virology, National Reference Center for Papilloma- and Polyomaviruses, University Clinic of Cologne, Cologne, Germany
,
Marko Schünemann
1   Clinic for General Medicine, Gastroenterology, and Infectious Diseases, Augustinerinnen Hospital, Cologne, Germany
,
Johannes Haes
1   Clinic for General Medicine, Gastroenterology, and Infectious Diseases, Augustinerinnen Hospital, Cologne, Germany
,
Stefan Reuter
3   Clinic for General Medicine 4, Leverkusen Hospital, Leverkusen, Germany
,
Björn Erik Ole Jensen
4   Clinic for Gastroenterology, Hepatology, and Infectious Diseases, University Clinic of Düsseldorf, Düsseldorf, Germany
,
Abdurrahman Sagir
5   Clinic for General Medicine 2, Bethesda Hospital, Duisburg, Germany
,
Herbert Pfister
2   Institute of Virology, National Reference Center for Papilloma- and Polyomaviruses, University Clinic of Cologne, Cologne, Germany
,
Dieter Häussinger
4   Clinic for Gastroenterology, Hepatology, and Infectious Diseases, University Clinic of Düsseldorf, Düsseldorf, Germany
› Author Affiliations
Further Information

Publication History

17 April 2016

13 September 2016

Publication Date:
02 November 2016 (online)

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Abstract

Introduction Anal carcinoma represents an increasing problem in HIV-infected patients. Anal intraepithelial neoplasia (AIN), the precursor lesion, is currently diagnosed by high-resolution anoscopy (HRA) using optical magnification derived from gynecological colposcopy. This prospective study evaluates anal chromoendoscopy (ACE) using standard gastroenterological video-endoscopes in diagnosing AIN.

Methods After clinical examination, proctoscopy and surface staining with acetic acid followed by Lugol’s solution, ACE was performed with a mucosectomy cap on the tip of the endoscope. Biopsy specimens were collected from areas with a pathological staining pattern and from areas with normal appearance; combined results were considered as reference.

Results Two hundred eleven HIV-positive patients seen between 2007 and 2013 were evaluated. Of these, 95.7 % were males, and the median age was 45 years. In 86.7 %, the mode of HIV transmission was sex among males. Combination antiretroviral treatment was applied in 75.8 %. The sensitivity of ACE in diagnosing AIN was 0.85, the specificity was 0.55, the positive predictive value was 0.50, and the negative predictive value (NPV) was 0.87. Diagnostic performance increased in individuals with high-grade lesions (NPV: 0.99) and in the second study period from 2011 to 2013. Side effects were rare and of minor clinical relevance.

Conclusions Anal chromoendoscopy is safe and effective in diagnosing AIN in a population of HIV-infected patients. It is particularly useful for the exclusion of high-grade lesions that have the strongest risk of progression to anal carcinoma. Therefore, ACE may become a valuable new tool to manage AIN and to prevent anal malignancy in HIV-positive patients.

Zusammenfassung

Einleitung Das Analkarzinom stellt ein zunehmendes Problem bei HIV-infizierten Patienten dar. Seine Vorläuferläsion, die anale intraepitheliale Neoplasie (AIN), wird gegenwärtig durch die hochauflösende Anoskopie (HRA) diagnostiziert, bei der eine gynäkologische Vergrößerungsoptik eingesetzt wird (Kolposkopie). Die vorliegende prospektive Studie untersucht die anale Chromoendoskopie (ACE) mit gastroenterologischen Video-Endoskopen in der Diagnostik der AIN.

Methoden Nach rektal-digitaler Austastung, einer Proktoskopie sowie der Oberflächenfärbung mit Essigsäure und Lugol’scher Lösung wurde die ACE mithilfe einer auf die Endoskopspitze aufgesetzten Mukosektomiekappe durchgeführt. Biopsien wurden von Arealen mit pathologischem Färbeverhalten und von unauffälligen Bezirken entnommen, als Referenz diente die kombinierte Analyse der Biopsiebefunde.

Ergebnisse Von 2007 bis 2013 wurden 211 Patienten eingeschlossen. 95,7 % waren männlich, das mediane Alter betrug 45 Jahre, bei 86,7 % war die HIV-Infektion durch Sex unter Männern erworben, eine kombinierte antiretrovirale Therapie wurde bei 75,8 % angewandt. Die Sensitivität der ACE für die Diagnose der AIN betrug 0,85, die Spezifität 0,55, der positive prädiktive Wert lag bei 0,50 und der negative prädiktive Wert (NPV) bei 0,87. Die diagnostische Ausbeute nahm für Patienten mit hochgradiger Neoplasie (NPV: 0,99) und in der zweiten Studienperiode von 2011 bis 2013 zu. Nebenwirkungen waren selten und von geringer klinischer Relevanz.

Schlussfolgerung Die ACE ist sicher und nützlich in der Diagnostik der AIN bei HIV-Infizierten. Sie ist insbesondere geeignet, um hochgradige anale Läsionen auszuschließen, die mit dem höchsten Risiko eines Progresses zum Karzinom einhergehen. Die ACE hat das Potenzial, zu einer wertvollen Methode des Managements der AIN und der Prävention des Analkarzinoms bei HIV-Positiven zu werden.

Schlüsselwörter

Anale Dysplasien - AIN - AIDS - Proktoskopie

Key words

anal dysplasia - AIN - AIDS - proctoscopy
 

  • References

  • 1 Simard EP. Pfeiffer RM. Engels EA. Cumulative incidence of cancer among individuals with acquired immunodeficiency syndrome in the United States. Cancer 2011; 117: 1089-1096
    CrossrefPubMedGoogle Scholar
  • 2 Park IU. Palefsky JM. Evaluation and management of anal intraepithelial neoplasia in HIV-negative and HIV-positive men who have sex with men. Curr Infect Dis Rep 2010; 12: 126-133
    CrossrefPubMedGoogle Scholar
  • 3 Abramowitz L. Benabderrahmane D. Ravaud P. et al. Anal squamous intraepithelial lesions and condyloma in HIV-infected heterosexual men, homosexual men and women: prevalence and associated factors. AIDS 2007; 21: 1457-1465
    CrossrefPubMedGoogle Scholar
  • 4 Kreuter A. Potthoff A. Brockmeyer NH. et al. Anal carcinoma in human immunodeficiency virus-positive men: results of a prospective study from Germany. Br J Dermatol 2010; 162: 1269-1277
    CrossrefPubMedGoogle Scholar
  • 5 Weis SE. Vecino I. Pogoda JM. et al. Prevalence of anal intraepithelial neoplasia defined by anal cytology screening and high-resolution anoscopy in a primary care population of HIV-infected men and women. Dis Colon Rectum 2011; 54: 433-441
    PubMedGoogle Scholar
  • 6 Swedish KA. Lee EQ. Goldstone SE. The changing picture of high-grade anal intraepithelial neoplasia in men who have sex with men: the effects of 10 years of experience performing high-resolution anoscopy. Dis Colon Rectum 2011; 54: 1003-1007
    CrossrefPubMedGoogle Scholar
  • 7 Palefsky JM. Holly EA. Efirdc JT. et al. Anal intraepithelial neoplasia in the highly active antiretroviral therapy era among HIV-positive men who have sex with men. AIDS 2005; 19: 1407-1414
    CrossrefPubMedGoogle Scholar
  • 8 Kreuter A. Brockmeyer NH. Hochdorfer B. et al. Clinical spectrum and virologic characteristics of anal intraepithelial neoplasia in HIV infection. J Am Acad Dermatol 2005; 52: 603-608
    CrossrefPubMedGoogle Scholar
  • 9 de Pokomandy A. Rouleau D. Ghattas G. et al. Prevalence, clearance, and incidence of anal human papillomavirus infection in HIV-infected men: the HIPVIRG cohort study. J Infect Dis 2009; 199: 965-973
    CrossrefPubMedGoogle Scholar
  • 10 Bouvard V. Baan R. Straif K. et al. A review of human carcinogens--Part B: Biological agents. Lancet Oncol 2009; 10: 321-322
    CrossrefPubMedGoogle Scholar
  • 11 Hoots BE. Palefsky JM. Pimenta JM. et al. Human papillomavirus type distribution in anal cancer and anal intraepithelial lesions. Int J Cancer 2009; 124: 2375-2383
    CrossrefPubMedGoogle Scholar
  • 12 Gervaz P. Hirschel B. Morel P. Molecular biology of squamous cell carcinoma of the anus. Br J Surg 2006; 93: 531-538
    CrossrefPubMedGoogle Scholar
  • 13 Simard EP. Watson M. Saraiva M. et al. Trends in the occurrence of high-grade anal intraepithelial neoplasia in San Francisco: 2000–2009. Cancer 2013; 119: 3539-3545
    CrossrefPubMedGoogle Scholar
  • 14 Berry JM. Jay N. Cranston RD. et al. Progression of anal high-grade squamous intraepithelial lesions to invasive anal cancer among HIV-infected men who have sex with men. Int J Cancer 2014; 134: 1147-1155
    CrossrefPubMedGoogle Scholar
  • 15 Dalla Pria A. Alfa-Wali M. Fox P. et al. High-resolution anoscopy screening of HIV-positive MSM: longitudinal results from a pilot study. AIDS 2014; 28: 861-867
    CrossrefPubMedGoogle Scholar
  • 16 Palefsky JM. Practising high-resolution anoscopy. Sex Health 2012; 9: 580-586
    CrossrefPubMedGoogle Scholar
  • 17 Mathews WC. Cachay ER. Caperna J. et al. Estimating the accuracy of anal cytology in the presence of an imperfect reference standard. PLoS One 2010; 5: e12284
    CrossrefPubMedGoogle Scholar
  • 18 Gimenez F. da Costa-e-Silva IT. Daumas A. et al. The value of high-resolution anoscopy in the diagnosis of anal cancer precursor lesions in HIV-positive patients. Arq Gastroenterol 2011; 48: 136-145
    CrossrefPubMedGoogle Scholar
  • 19 Esser S. Kreuter A. Oette M. et al. German-Austrian guidelines on anal dysplasia and anal cancer in HIV-positive individuals: prevention, diagnosis, and treatment. J Dtsch Dermatol Ges 2015; 13: 1302-1319
    CrossrefPubMedGoogle Scholar
  • 20 Silvera R. Gaisa MM. Goldstone SE. Random biopsy during high-resolution anoscopy increases diagnosis of anal high-grade squamous intraepithelial lesions. J Acquir Immune Defic Syndr 2014; 65: 65-71
    PubMedGoogle Scholar
  • 21 Pohl J. Pech O. May A. et al. Incidence of macroscopically occult neoplasias in Barrett’s esophagus: are random biopsies dispensable in the era of advanced endoscopic imaging?. Am J Gastroenterol 2010; 105: 2350-2356
    CrossrefPubMedGoogle Scholar
  • 22 Davis-Yadley AH. Neill KG. Malafa MP. et al. Advances in the endoscopic diagnosis of Barrett esophagus. Cancer Control 2016; 23: 67-77
    PubMedGoogle Scholar
  • 23 Wilkin T. Lee JY. Lensing SY. et al. High-grade anal intraepithelial neoplasia among HIV-1-infected men screening for a multicenter clinical trial of a human papillomavirus vaccine. HIV Clin Trials 2013; 14: 75-79
    CrossrefPubMedGoogle Scholar