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Anal Intra-Epithelial Neoplasia (AIN) Management in a 77-Year-Old Male

Explore the case study of a 77-year-old male with AIN, treatment options, pathology findings, and risk factors for anal cancer. Learn about screening methods, treatment considerations, and current research trials.

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Anal Intra-Epithelial Neoplasia (AIN) Management in a 77-Year-Old Male

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  1. Anal Intra-Epithelial Neoplasia(AIN) Dr Catherine Cheng Tuen Mun Hospital

  2. Case • Male, 77 years old • Chairbound, lives with family • Medical History • NPC completed RT in 2001 with bilateral vocal cord palsy and recurrent aspirations, on PEG feeding and has a tracheostomy • Laparoscopic Cholecystectomy for cholecystitis 2012

  3. Case • Bleeding anal polyp with excision done June 2017 • PathologyAIN 3 with areas of SCC, AIN extends to resected margin, invasive foci negative at margin • What would you do now?

  4. Options • 1) Discuss for re-excision of lesion • 2) Consult oncology for radiotherapy • 3) Observe, watchful waiting • 4) Upfront local treatment with 5-FU or Electrocautery

  5. Case • Multidisciplinary Meeting - Managed conservatively in view of poor premorbid • Admitted to medical end of November 2017 with pneumonia • Found to have persistent PR bleeding and anal mass. Hb 9.5

  6. Wide Local Excision with Advancement Skin Flap performed on 23rd January 2018

  7. Pathology • Moderately differentiated SCC • Invasive foci not present in margin • 12 o’clock margin showed AIN 3

  8. Definition https://www.cancer.org/cancer/anal-cancer/about/what-is-anal-cancer.html • Pre-malignant lesion of the anal mucosa • Anal canal 2 – 4cm in length • A precursor to Anal Cancer • Can progress to Anal Cancer (SCC) from AIN I/II/III Joseph R Roberts. World J GastrointestOncol. 2017; 9(2): 50–61

  9. Presentations • Anal/Pelvic Pain • Per Rectal Bleeding • Rectal Mass • Tissue Prolapse • Local soiling • Incontinence to flatus or stool • Constipation Common Less common

  10. Incidence • ~8600 cases of anal cancer per year in USA • Incidence on rising trend Siegel RL. et al. CA cancer J Clin. 2018; 68 (1): 7

  11. Risk factors • HIV • Men having sex with men (MSM) • HPV infection • History of Cervical CA/Gynaecological CA • Smoking • Post-transplant/Inflammatory Bowel Disease/Immunosuppressed individuals

  12. LAST Criteria • Low Anogenital Squamous Terminology - 2012 • LSIL – AIN 1, Condyloma, ASCUS • HSIL – AIN 2, AIN 3, Bowen’s disease, SCC in-situ • (CIN, VaIN, VIN, PeIN) • SISCCA (Superficial invasive squamous cell carcinoma) – Anus/Vulva/Vagina/Cervix/Penis Darragh TM. et. al. Arch Patho Lab Med. 2012; 136(10):1266-97

  13. HSIL to SCC up to 19.6% <=LSIL <=LSIL: low grade squamous intraepithelial lesion Berry J M. et al. Int J Cancer. 2014; 1;134(5):1147-55 William C. Mathews et. al. Plosone. 2014. 0104116

  14. Screening methods • PR examination • Anal cytology +/- DNA detection • Swab stick, Papanicolaou stain (Pap Smear), +/- PCR • High resolution anoscopy (HRA) +/- biopsy • Acetic acid, ‘acetowhite lesions’ (acetowhite epithelium - AWE), Lugol’s Iodine • Wolf forceps • 4 quadrant biopsy

  15. Siekas LL et. al, AIDS Read. 2009;19:178–186

  16. Recommendation - Palefsky and Rubin (2009) Palefsky JM et al. ObstetGynecolClin North Am. 2009;36:187–200

  17. How risky are high risk patients? • High risk AIN patients  Anal Cancer VS General population  Colon CA = x1.2 higher Joseph R Roberts. World J GastrointestOncol. 2017; 9(2): 50–61

  18. SPANC Trial • Study of the Prevention of Anal Cancer • Epidemiology of anal HPV in homosexual men aged 35 and older • Prospective longitudinal cohort study • Community based study • Sydney, Australia • Started in September 2010 and will concluded in mid-2015 • Follow-up continuing to 2018 • 5 study visits over 3 years • By July 2013, approximately 404 men had been assessed for inclusion and over 350 men have been recruited into the study

  19. Treatment Options • Trichloroacetic acid (TCA) • 5-flurouracil • Imiquimod Cream • RFA • Electrocautery (diathermy) • Infra red coagulation • Surgical treatment Topical therapy Ablative therapy Operative treatment

  20. Considerations • Size • Number • Location • Grade of lesions • Duration of treatment • Side effect profile • Patient compliance rate

  21. Stephen E Weis. OncoTargetesTher 2013. 6: 651–665.

  22. Stephen E Weis. OncoTargetesTher 2013. 6: 651–665.

  23. Stephen E Weis. OncoTargetesTher 2013. 6: 651–665.

  24. Role of Radiotherapy • No evidence to support to use of radiotherapy in AIN • ?Role in recurrent AIN Filip Troicki et. al. J Med Case Reports. 2010; 4: 67.

  25. Recommendation • LSIL: observation • Treatment only to reduce symptoms (not risk of CA) • HSIL: recommended for treatment • Periodic HRA for early detection of Anal SCC (earlier SCC staging  better prognosis) for those choosing not to have treatment • Exception – poor pre-morbid with short survival predicted (little benefit from treatment) Palefsky JM et al. ObstetGynecolClin North Am. 2009;36:187–200

  26. ANCHOR TRIAL • Anal Cancer HSIL Outcomes Research • 12 United States sites • Aims to determine whether screening and treatment of HSIL is effective in reducing subsequent anal cancer in high risk groups (i.e. HIV positive)

  27. Summary • Clinical case • Definition, risk factors, treatment options • Management recommendations • Upcoming trials

  28. References • AIN: a review of diagnosis and management - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5314201/ • Progression rates of AIN to anal cancer, HRA examples - World J Gastrointest Oncol. 2017 Feb 15; 9(2): 50–61. • Diagnosis / Treatment / Surveillance Algorithm - Palefsky JM, Rubin M. The epidemiology of anal human papillomavirus and related neoplasia. Obstet Gynecol Clin North Am. 2009;36:187–200 • HPV Vaccine against Anal HPV Infection and Anal Intraepithelial Neoplasia – NEJM Med 2011; 365:1576-85 • Comparison of imiquimod, topical fluorouracil, and electrocautery for the treatment of anal intraepithelial neoplasia in HIV-positive men who have sex with men: an open-label randomised controlled trial – The Lancet Oncology. April 2013, Volume 14, Issue 4: 346 – 353 • Evaluation and Management of Anal Intraepithelial Neoplasia in HIV-Negative and HIV-Positive Men Who Have Sex with Men – Current Infectious Disease Reports March 2010, Volume 12, Issue 2, p126-133 • LAST Criteria – Archives of Pathology Lab Med. 2012;136:1266–1297 • Onco Targets Ther. 2013; 6: 651–665. • Filip Troicki et. al. Radiation therapy of recurrent anal squamous cell carcinoma in-situ: a case report. J Med Case Reports. 2010; 4: 67.

  29. Questions

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