Electrocautery ablation of anal high‐grade squamous intraepithelial lesions: Effectiveness and key factors associated with outcomes

Abstract

Background Electrocautery ablation (EA) is a common treatment modality for patients with anal high‐grade squamous intraepithelial lesions (HSILs), but to the authors' knowledge its effectiveness has been understudied. The objective of the current study was to determine ablation outcomes and to identify clinicopathological factors associated with postablation disease recurrence. Methods A total of 330 people living with HIV with de novo intra‐anal HSIL who were treated with EA from 2009 to 2016 were studied retrospectively. Using long‐term, surveillance high‐resolution anoscopy biopsy data, treatment failures were classified as local recurrence (HSIL noted at the treated site at the time of surveillance) or overall recurrence (HSIL noted at treated or untreated sites). The associations between these outcomes and clinical factors were analyzed using Cox proportional hazards models. Results Approximately 88% of participants were men who have sex with men. The median age of study participants was 45.5 years (range, 35‐51 years) and approximately 49% had multiple index HSILs (range, 2‐6 index HSILs). At a median of 12.2 months postablation (range, 6.3‐20.9 months postablation), approximately 45% of participants had developed local recurrence whereas 60% had developed overall recurrence. Current cigarette smoking, HIV viremia (HIV‐1 RNA ≥100 copies/mL), and multiple index HSILs were found to be predictive of local recurrence. Overall recurrence was more common in current smokers and those with multiple index lesions. In multivariable models that included human papillomavirus (HPV) genotypes, baseline and persistent infections with HPV‐16 and/or HPV‐18 were found to be significantly associated with both local and overall recurrence. Conclusions EA is an effective treatment modality for anal HSIL in people living with HIV, but rates of disease recurrence are substantial. Multiple index HSILs, HIV viremia, current cigarette smoking, and both baseline and persistent infection with HPV‐16 and/or HPV‐18 appear to negatively impact treatment success. Ongoing surveillance is imperative to capture recurrence early and improve long‐term treatment outcomes.

Anal cancer prevention: Solving the puzzle piece by piece

“…10 Based on the above recent series, Gaisa et al should have identified progression to ASCC in some of their patients. 4 And yet they did not. Granted, their study was not a prospective or randomized trial comparing HSIL treatment with observation to prevent cancer, and such a study currently is underway (Topical or Ablative Treatment in Preventing Anal Cancer in Patients With HIV and Anal High-Grade Squamous Intraepithelial Lesions [ANCHOR] trial; ClinicalTrials.gov identifier NCT02135419).…”

“…I am thrilled to report that in this issue of Cancer, Gaisa et al have presented data that point to the prevention of anal cancer by electrocautery ablation (EA). 4 In a large series of >300 people living with HIV (PLWH), the authors conducted a rigorous, albeit retrospective, study of their treatment results with EA from 2009 to 2016. 4 Not only did participants have a median follow-up of >1 year, but the study was rigorously conducted with thorough demographic data extracted, including smoking status and HIV-related parameters.…”

“…4 The calculated probability of any recurrence (local or metachronous at a site different from that of the primary HSIL) was 50% and 68%, respectively, at 12 months and 36 months. 4 Some argue against treating HSILs because recurrence rates after ablation are >50%. Although preventing recurrent HSIL would be wonderful, the primary goal of treatment always has been the prevention of ASCC.…”

“…Although the authors reported a high rate of HSIL recurrence after ablation, no patients in their relatively large treatment series developed ASCC. 4 More and more data continue to emerge demonstrating that untreated anal HSIL leads to ASCC. [3][4][5][6] Berry et al reported on 27 patients with untreated anal HSIL who progressed to ASCC at the HSIL site.…”

“…4 More and more data continue to emerge demonstrating that untreated anal HSIL leads to ASCC. [3][4][5][6] Berry et al reported on 27 patients with untreated anal HSIL who progressed to ASCC at the HSIL site. 7 A recent study by Arens et al of progression from HSIL to anal cancer (which included some of the authors from the study by Gaisa et al 4 ) merged the Surveillance, Epidemiology, and End Results database with Medicare claims to identify PLWH who were diagnosed with HSIL prior to ASCC.…”