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Annual anal PAP smears; who should get them? atypia-- what does this mean
Aug 18, 2002

In the mid 1970s I had anal warts. They were treated topically and never reoccurred. I was infected with HIV in 1999. In 2000 I started to get yearly anal PAP smears.

In 2000 the lab report said scattered, poorly preserved atypical squamous cells with no evidence of dysplasia or malignancy.

In 2001 it said scattered atypical squamous cells suggestive of HPV effect.

My latest lab (July 2002) says rare koilocytic atypia and frequent binucleation, suggestive of HPV-related lesion. Mild atypia present in squamous cells, mild dysplasia cannot be ruled out. Unremakable columnar epithelium. Negative for malignancy.

What do these results indicate to you? Should I see a specialist? Should I have a biopsy done? I really dont want to unless its absolutely necessary.

Response from Dr. Dezube

I'm glad to hear that you are having a yearly anal PAP smear. For the readers of this forum, who are unfamiliar with anal PAP smears, let me explain. In a manner similar to the way women have been getting regular cervical PAP smears, anal PAP smears have recently arrived to the seen. A medical professional inserts a swab up one's butt and collects cells of the anal wall. These cells are then examined under the microscope for early changes of cancer. Treatment varies depending upon the results. It is recommended that all gay men, whether they are HIV+ or HIV- should have anal PAP smear testing. Woman with cervical HPV disease or who have been the recipients of anal intercourse should also have anal PAP smear testing.

Different labs report the results differently. A typical lab might report the following, listed from LEAST worrisome to MOST worrisome

1) normal cells

2) Atypical cells/HPV effect

3) Low grade dysplasia (AIN I)

4) High grade dysplasia (AIN II or AIN III)

5) Carcinoma-in-situ

6) Cancer

Human Papilloma Virus (HPV) infection is so common in gay men that most of my patients do not get a truly normal PAP smear (#1 above). Rather what they get is atypia/HPV infection (#2 above). This is not all that worrisome-- all it says is that you are infected by HPV (also known as the "wart" virus). It does not mean you have developed cancer. The next most common finding is low grade dyplasia (#3 above). These lesions tend NOT to progress to cancer and typically do NOT need to be treated. Rather patients with this finding can for the most part be safely watched. Any PAP smear with #4, #5, and #6 are more worrisome and require some form of treatment. Treatment of these more worrisome PAP findings is necessary to prevent cancers from forming. Your PAP smears do not seem too worrisome.

Most patients, however, with any abnormality of PAP smear should have anoscopy. This is a procedure whereby a medical professional looks up one's butt and actually takes a biopsy of the anal wall. This procedure is necessary since a biopsy is more accurate than a PAP test which is just a rubbing of the anal wall. Anoscopy (or more accurately high-resolution anaoscopy), however, may not be available in all geographic areas. Based on your PAP tests, I would recommend this procedure if you have access to it. The anoscopy will establish whether there are any higher grade lesions which the PAP smear has missed. If your PAP smear had shown absolutely nothing, then anoscopy would not be necessary.

This is a long-winded answer, but it's important to clarify many of the misunderstandings about PAP smears. As HIV-infected patients are living longer, many of these early HPV lesions will have time to progress to more serious/dangerous ones.

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