BOSTONBenign anorectal disease should be treated as a possible
marker for precancerous anal lesions in men who have sex with men,
Stephen E. Goldstone, MD, said at the American Society of Colon and
Rectal Surgeons annual meeting.
More than 60% of 200 such men referred to his practice with presumed
benign anorectal conditions were found to have high-grade squamous
intraepithelial lesions (HSIL) or squamous carcinoma, he said. He
recommends aggressive screening of all men who have sex with men
referred for treatment of condyloma, hemorrhoids, and other benign
We must start taking anal warts seriously in men who have sex
with men. Anal warts should be viewed as a marker for a potentially
precancerous anal lesion, Dr. Goldstone told ONI. Treating
anal warts alone is not enough. You may miss the more serious
precancerous dysplasia inside the anal rectal canal.
Dr. Goldstone, assistant clinical professor, Mount Sinai School of
Medicine, New York, and medical director of gayhealth.com, said that
he sees many gay men in his general surgery practice. The appearance
of anal cancer in this population is a recent but growing phenomenon,
Dr. Goldstone said. He speculates that the disease is emerging now
because it develops slowly and HIV-positive people are living longer
as a result of new therapies.
Until recently, he saw almost no cases of anal cancer, he said. He
described the disease as extremely rare and more likely
to be found in elderly women. From 1997 to 1999, I saw five
cases. Before 97, I saw one in my whole career, he said.
Alarmed by the pathology reports he was seeing for gay men, he asked
Joel M. Palefsky, MD, of the Department of Laboratory Medicine,
University of California, San Francisco, to help design a study.
From 1997 to 1999, I collected 200 patients who were referred
to my practice for anal warts, hemorrhoids, fissures, anal
itchproblems you would never associate with precancerous
conditions, Dr. Goldstone said.
The majority157 patients (79%)came with a referral
diagnosis of condyloma. Four (2%) had anal squamous intraepithelial
lesions (ASIL), and 39 (19%) presented with other benign anorectal
disorders. The patients ranged from 22 to 59 years of age; 131 (66%)
were HIV positive. Standard Pap methods were used to report anal
cytology according to a modified Bethesda classification. Biopsy
specimens were obtained for everyone in the study.
Cytology showed that 105 patients (53%) had HSIL; only 14 (7%) had
benign anal cytology. The biopsy results were even more striking: 120
patients (60%) had HSIL and 5 (3%) showed invasive squamous
carcinoma. Only 11 patients (6%) had benign pathology.
Although prevalence of HSIL and squamous carcinoma was high for both
HIV-positive and HIV-negative men, the positive group was more likely
to have HSIL or squamous carcinoma. Prevalence of these conditions
was 71% in HIV-positive men vs 46% in HIV-negative men. Four of the
five patients with invasive squamous carcinoma were HIV positive.
Men without gross evidence of condyloma had a lower incidence (44%)
of HSIL or squamous carcinoma, but it was still high, he noted.
Dr. Goldstone stressed that cytology by itself should only be
considered a guide. On the one hand, it underpredicted the disease.
On the other hand, any abnormality that was found correlated with a
high incidence (64%) of biopsy-proven HSIL or squamous carcinoma.
Cytology is, at best, a predictor of abnormal cells, he said.