Treatment

Treatment of preinvasive disease
Cryotherapy, laser therapy, cone biopsy, and loop electrosurgical excision procedure have all been used to treat preinvasive disease in HIV-infected patients. Short-term recurrence rates of 40% to 60% have been reported.

Determinants of recurrence
Immune status of the patient seems to be the most important determining factor for recurrence. Close surveillance after initial therapy is critical, and repetitive treatment may be necessary to prevent progression to more invasive disease.

Treatment of cervical carcinoma
The same principles that guide oncologic management of the immunocompetent patient with cervical carcinoma (see chapter 17) are utilized in AIDS patients with this cancer.

Resection
Resection can be undertaken for the usual indications, and surgical decisions should be based on oncologic appropriateness and not on HIV status.

Radiation therapy
As most AIDS patients with cervical cancer present with advanced disease, radiation therapy is indicated more often than surgery. If the patient’s overall physical condition permits, treatment regimens are identical to those used for the same stage disease in uninfected individuals (see chapter 17). It is important to note that the standard of care for advanced carcinoma of the cervix (stages III–IV, without hematogeneous dissemination) now includes a combination of irradiation and concurrent cisplatin-based chemotherapy. At present, there is insufficient evidence to suggest that irradiation or other treatments for cervical carcinoma in AIDS patients is any less effective than in similar non–HIV-infected individuals.

Chemotherapy
Antineoplastic regimens, such as cisplatin (50 mg/m²) or carboplatin (200 mg/m²), bleomycin (20 U/m²; maximum, 30 U), and vincristine (1 mg/m²), have been used in patients with metastatic or recurrent disease. Vigorous management of side effects and complications of these treatments and of AIDS itself must be provided.

ANAL CARCINOMA

Although anal carcinoma is not currently an AIDS-defining illness, the incidence of this tumor is increasing in the population at risk for HIV infection. The incidence of anal carcinoma in homosexual men in a San Francisco study was estimated at between 25 and 87 cases per 100,000, compared with 0.7 case per 100,000 in the entire male population.

Etiology and risk factors

HPV
Precursor lesions of anal intraepithelial neoplasia (AIN), also known as anal SILs, have been found to be associated with HPV infection, typically with oncogenic serotypes, eg, types 16 and 18. Cytologic abnormalities occur in nearly 40% of patients, especially those with CD4 cell counts < 200 cells/μL. Abnormal cytology may predict the later development of invasive carcinoma.

Signs and symptoms

Rectal pain, bleeding, discharge, and symptoms of obstruction or a mass lesion are the most frequent presenting symptoms.

Screening and diagnosis

Studies to evaluate the usefulness of anoscopy with frequent anal cytology have been undertaken to determine whether early detection of AIN may result in interventions that would prevent the development of invasive tumors.

Work-up of patients with anal carcinoma
For patients with anal carcinoma, determination of the extent of local disease, as well as full staging for dissemination, should be undertaken (see chapter 13).

Pathology

Squamous cell carcinoma
The majority of anal carcinomas are of the squamous cell type.

Histologic grading
The grading for AIN is similar to that for CIN, with AIN-1 denoting low-grade dysplasia and AIN-2 and AIN-3 referring to higher grade dysplastic lesions. The gross appearance of lesions on anoscopy does not predict histologic grade. Higher grade dysplastic lesions are seen in patients with lower CD4 cell counts.