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9.2 Notebook-Annotated Joel Palefsky, md, frcp(c) Diagnosis and Management of Professor of Medicine University of California San Francisco HPV-Associated Anogenital Dysplasia San Francisco, California Summary by Tim Horn Edited by in HIV-Infected Men and Women Stephen E. Goldstone, md, facs, Reprinted from The prn Notebook® | june 2004 | Dr. James F. Braun, Editor-in-Chief | Tim Horn, Executive Editor. and Antonio Urbina, md Published in New York City by the Physicians’ Research Network, Inc.® | John Graham Brown, Executive Director For further information and other articles available online, visit http://www.prn.org | All rights reserved. ©june 2004 antiretroviral therapy continues to have a positive impact on Infection of the Cervix and Anus both the incidence and prevalence of many aids-related diseases. At the hpv infection initially takes place at the basal cell layer of the same time, the life-extending benefits of antiretroviral therapy have paved anogenital epithelium. “This is the replicating cell layer,” Dr. Palefsky said. the way for infections with long latency periods to fulfill their pathogen- “When the cells divide they carry copies of the virus with them. One of the ic potential and fulminate into life-threatening complications. A prime ex- clinical consequences of this is the potential to generate a permanent or ample of this is human papillomavirus (hpv) and its sinister sequelae: semi-permanent infection, given that these cells are basically immortal and squamous intraepithelial lesions and invasive cervical or anal carcinoma. end up maintaining a permanent reservoir for hpv in the epithelium.” For clinicians involved in the management of hiv-infected individ- In the cervix, hpv infection usually occurs in the transformation uals, hpv infection is proving to be a significant challenge. This article zone or squamocolumnar junction, where the columnar epithelium of the reviews the epidemiology, pathogenesis, diagnosis, monitoring, and endocervix meets the squamous epithelium of the exocervix. In the anal management of cervical and anal dysplasia in the setting of hiv. “Data canal, hpv infection also occurs in the transformation zone, located at the continue to emerge, supporting the diagnosis and management of cer- junction of the stratified squamous epithelium of the anus with the vical and anal dysplasia in hiv-infected patients,” said Dr. Joel Palefsky, columnar epithelium of the rectum. Cervical and anal epithelia are his- who returned to prn in April 2004 to discuss recent advances in the tologically very similar and the transformation zone is typically the place study and clinical care of hiv/hpv coinfection. where most hpv-associated lesions, including invasive carcinoma, develop. Several classification systems have been used for the purpose of grad- ing the cellular atypia seen in hpv lesions, varying from relatively benign lesions to invasive malignant neoplasms. The Bethesda system is the ac- cepted standard for classifying and staging cytology for both cervical and I. HPV Primer anal precancerous lesions (asc, 2003). At one end of the hpv disease spectrum are anogenital warts (condy- Human Papillomavirus (HPV) loma acuminatum) and mild dysplasia: cervical intraepithelial neopla- human papillomavirus (hpv) is the most common sexually trans- sia grade 1 (cin i) and anal intraepithelial neoplasia grade 1 (ain i) (see mitted agent. It is more common than herpes and chlamydia and it has Figure 1). The Bethesda system combines cin i and ain i into one been estimated that more than 75% of sexually active adolescents and single category: low-grade squamous intraepithelial lesions (lsil). “The adults, between the ages of 15 and 49, acquire at least one type of hpv good news about lsil is that, while it’s very common, it regresses spon- infection during their lifetime. taneously most of the time,” Dr. Palefsky added. “It is not considered to “The way that patients know they have hpv infection is primarily be a cancer precursor.” through genital warts,” Dr. Palefsky explained. “Very often, it’s the pa- At the other end of the spectrum are cin/ain grades 2 and 3—also tient who brings these warts to the attention of his or her doctor. They known as moderate and severe dysplasia, respectively—and carcinoma can feel them. They burn and they itch. But these patients with warts rep- in situ. The Bethesda system groups all these changes as high-grade squa- resent the tip of the hpv iceberg. The majority of patients with hpv have mous intraepithelial lesions (hsil). Another cytological classification is subclinical infection that can only be found doing a Pap smear, a visual that of atypical squamous cells of undetermined significance (ascus), inspection, or have evidence of hpv-dna in their genital tract but no signs which refers to cells that cannot be classified as either completely nor- of disease.” mal or dysplastic. “The good news about hsil is that, since it takes a long More than 200 different hpv genotypes exist, approximately 30 of time for them to progress to invasive cancer, we have multiple oppor- which infect genital mucosal tissues. These include nononcogenic va- tunities to interfere with the process,” Dr. Palefsky said. “The whole ba- rieties—primarily types 6 and 11, as well as types 42, 43, and 44—that sis of the Pap smear screening system and cancer prevention screening are associated with the development of genital condylomas or mild system is to detect and treat this lesion before progression to cancer can dysplasia (along with plantar and palmar warts) and generally do not actually occur.” progress to either higher-grade lesions or cancer. Oncogenic varieties— types 16, 18, 31, and 35—are associated with more dysplastic lesions and account for the majority of invasive cervical or anal carcinoma cases. hpv type 16 accounts for approximately 50% of all cervical cancers; types 18, 31, and 35 account for an additional 20%; types 39, 45, 51, 52, 56, 58, 70, and others likely account for the rest. 24 THE PRN NOTEBOOK® | VOLUME 9, NUMBER 2 | JUNE 2004 | WWW.PRN.ORG Low-grade squamous High-grade squamous intraepithelial lesion (lsil) intraepithelial lesion (hsil) Condyloma cin/ain grade 1 cin/ain grade 2 cin/ain grade 3 Normal Very mild to mild dysplasia Moderate Severe In situ dysplasia dysplasia carcinoma Koilocytes Microinvasive carcinoma FIGURE 1. Schematic Representation of sil As shown in this illustration, with increasing severity of sil, of either the cervix or anus, the proportion of the epithelium replaced by immature cells with large nuclear-cytoplasmic ratios increases. Invasive cancer probably arises from one or more foci of high-grade sil (hsil), as depicted in the drawing by epithelial cells crossing the basement membrane below the region of hsil. Source: Joel Palefsky, md, frcp(c) II. Cervical Dysplasia and Carcinoma opportunity to biopsy sites of abnormality, and the results can be clin- ically correlated—by assessing characteristic color changes, vascular pat- General Screening Issues terns, and margins—with the results of the Pap smear. Colposcopy-di- since its clinical debut in the 1940s, papanicolaou (pap) smear rected biopsy usually provides enough clinical evidence for an accurate testing has been the gold standard for cytologic screening of the cervix. diagnosis. If colposcopic evaluation is unsatisfactory or inconclusive, a Although the false-negative rate of Pap smears in the general population cervical conization biopsy may be required, performed by a loop electrical has been reported to be as high as 20% to 45%—one-half of the false excision procedure (leep), laser, or cold knife. negatives are likely because of inadequate specimen sampling and the other half are attributed to failure to identify the abnormal cells or to in- terpret them accurately—its role in reducing the rates of cervical can- Risk Factors cer over the past 50 to 60 years is undisputed. Prior to the introduction although hpv infection is the most significant risk factor asso- of Pap smears, the incidence of cervical cancer was 40-50/100,000 ciated with the development of anogenital dysplasia and carcinoma, it is women. More recent data show that the incidence in the United States not the only one. Age is also of importance. “When women are pubertal, is approximately 8/100,000 women—a marked improvement—indi- the transformation zone is immature, bigger, and more exposed,” Dr. cating that cervical cancer is, by and large, completely avoidable. Palefsky commented. “Not only does this place them at a higher risk for “The fact is,” Dr. Palefsky said, “a single Pap smear is a very bad other sexually transmitted infections, like chlamydia, it also appears to in- screening test. Approximately half of the Pap smears from women crease their risk for getting hpv.” There is also cigarette smoking. “hpv with cervical abnormalities will come back normal. The good news is causes lesions, not so much through a direct effect, but rather through that its cumulative sensitivity is okay. The reason that it works as well chromosomal instability in cells,” he said. “You can imagine that in a as it does is because we tell women to come back. With repeated testing, woman who smokes, there is an increased risk of ongoing genetic dam- the chances that we’ll find an abnormality before it progresses to can- age. We’ve seen studies showing that women who smoke have higher lev- cer are good. Not all of the time, unfortunately, but most of the time.” els of tar and nicotine in their cervical mucus than in their serum.” Pap smears that suggest abnormal cells require further evaluation Immune suppression is a significant risk factor. “We know that by colposcopy, colposcopic-directed biopsy, and sometimes endocervi- many women are infected with hpv in their lifetimes but only a few cal curettage. Colposcopy offers direct visualization of the cervix with an of them experience dysplasia,” Dr.
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