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High grade dysplasia (anal)
May 8, 2007

Hi Dr. Pierone:

This question is not about meds but I saw you answer other questions regarding this so I thought I'd give it a try (especially since there is no longer a category for this issue).

I was diagnosed HIV+ in Jan. '07. I went on HAART in May of '07 and after 6 weeks went to undetectable (at that time VL <500; since hi-sensitivity test always <50). My t-cells have gone from 28% to 43% (and have been in the 40%'s for years now). in 2003 I had my first rectal/anal pap and it came back high-grade dysplasia. However, after an exam I was told there was no dysplasia and the reading was probably not accurate. 2 subsequent paps in '04 and '05 came up clean. Then, in '06, when seeing a specialist for a thrombosed hemmroid, I had another pap and it came up high-grade dysplasia. I had an exam and subsequently underwent painful laser treatment to have the cells removed. Now, 6 months later I am once again getting results from a pap as high-grade dysplasia. Does being HIV+ mean I am going to have to keep going through this every 6 months? Is this a sign that I am eventually heading toward anal/rectal cancer? I don't think I can do this every 6 months with everything else that is going on with so many things to be concerned about. I do everything in my power to stay very healthy (i.e., eat right, don't smoke, get enough rest, get exercise, adhere to my meds, etc.) but this seems to be irrelevant when it comes to this issue. Is there any hope? I feel now like I'm just looking forward to the eventuality of cancer and wondering how much longer I have until I die from it or at best have colorectal cancer and end up with surgery, chemo or radiation, and a colostomy bag (something I will not do). What are your thoughts and experience regarding all of this?

Thank you.

Worried in NYC

Response from Dr. Pierone

Hello, and thanks for posting.

I am not an expert on anal dysplasia so I forwarded your question to Dr. Anthony Lee, an HIV specialist at the Orlando Immunology Center, who is an expert on this topic. I have paraphrased his comments:

Unfortunately we do not have the natural history data on the percentage of people with high grade squamous intraepithelial lesion (HGSIL) go on to develop cancer. Dysplasia is a moving target since we cannot eradicate HPV at this time. HGSIL will likely regress on it's own in most patients, but some patients will progress to cancer. With repeated treatment of HGSIL, the lesions will generally resolve, but this does not prevent the formation of new lesions in the anal canal.

The approach I take is to have patients use Aldara as a secondary prophylaxis in an attempt to prevent new lesions from forming following initial treatment with infra-red laser. And continual monitoring with biopsies can detect micro-invasive cancer in which case surgical excision alone is sufficient. Although there I don't have any long term mortality data, at the least this strategy avoids the morbidity of AP resection (colostomy), chemotherapy and radiation.

In my personal experience, I have only seen one patient with HIV end up with a colostomy because of anal squamous cell carcinoma. This occurred in a patient who been successfully treated for lymphoma of the prostate region 10 years prior. He had received pelvic radiation therapy as part of his treatment for lymphoma. So when he developed anal squamous cell carcinoma he was not able to receive standard combination chemotherapy and radiation therapy. Despite this, his cancer was cured with abdominal-perineal resection with permanent colostomy.

Back to your situation, anal dysplasia (HGSIL) rarely evolves into anal cancer as long as careful medical follow-up and treatment is maintained.

I hope that this information helps and best of luck!

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