1. Anal Intra-epithelial Neoplasia A report of 2 cases Philipp Narciso, M.D. UAMS-AHEC South Arkansas

2. 60 y/o white female rectal bleeding – on and off x 6 mons vague lower abdominal pain s/p TAHBSO – “pre-cancerous” vaginal bleeding after colonoscopy – PAP smear – AGC – HPV negative 49 y/o white male anal mass – 6 mons – Imiquimod for 10 weeks slight decrease d/c - “RAW” FH of Colon CA HIV on HAART receptive anal intercourse

3. Colonoscopy Diverticulosis Hemorrhoids erythematous lesion – rectal mucosa biopsy – high grade AIN (2-3) – HPV high risk Diverticulosis Anal mass (3x2x1cm) incision biopsy – Squamous Cell CA in situ (at least) – HPV high risk

4. Colonoscopy

5. Referral Surgical Oncology HRA – no lesion seen Proctoscopy 10cm – no abnormality Repeat HRA – 3 months Oncology SCC (T2N0M0) Radiation Chemotherapy – Mitomycin C – 5 FU

6. Anal Intra-epithelial Neoplasia Female genital intra-epithelial neoplasia – CIN – pathology – VIN – natural history HPV infection Prevalence unknown – estimate <1% – Related to HIV status 52% HIV-positive men with AIN2 3-20% HIV-negative med with AIN2

7. Anal Intra-epithelial Neoplasia Progression to Anal CA: 10% at 5 years – High risk Immunocompromised Multifocal disease Progression to LG to HG in 2 years – 62% HIV-positive with MSM – 36% HIV-negative with MSM Regression – LG – spontaneous – HG – rarely regress (regardless of HIV status)

8. Risk Factors HPV infection Genital intra-epithelial neoplasia HIV infection Low CD4 count Anal receptive intercourse Immunosuppression

9. Screening No screening guidelines High index of suspicion – Risk factors (IV-B) Anal cytology (III-C) High Resolution Anoscopy (HRA) – with/out acetic acid or Lugol’s iodine – (+) anal cytology

10. Treatment Observation (IV-C) – AIN 1/2 Imiquimod (IV-C) 5-Fluorouracil (IV-C) Photodynamic therapy (V- D) Targeted destruction (III-C) – HRA-guided – High recurrence and morbidity

11. Treatment Others – TCA – Local excision – Cidofovir – anti-viral – HPV immunotherapy

12. Surveillance No standard protocol HRA (III-B) – dysplasia is present – Every 6 months Retreat recurrent/persistent Detection of invasive CA Close follow-up – HIV – High risk of persistence or recurrence of high-grade dysplasia

13. References National Guideline Clearinghouse Scholefield JH, Harris D, Radcliffe A. Guidelines for Management of Anal Intraepithelial Neoplasia. Colorectal Disease 2011: 13 (Suppl 1) Palefsky JM, Cranston RD. Anal Intraepithelial Neoplasia: Diagnosis, Screening, and Treatment. UpToDate

14. Thank you