High Resolution Anoscopy Overview. Naomi Jay, RN, NP, PhD University of California San Francisco

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1 High Resolution Anoscopy Overview Naomi Jay, RN, NP, PhD University of California San Francisco

2 Disclosures No Disclosures

3 Definition of HRA Examination of the anus, anal canal and perianus using a colposcope with 5% acetic acid and Lugol s solution.

4 Basic Principles Office-based procedure Adapted from gynecologic colposcopy. Validated for anal canal. Similar terminology and descriptors. may be unfamiliar to non-gyn providers. Comparable to vaginal and vulvar colposcopy. Clinicians familiar with cervical colposcopy may be surprised by the difficult transition.

10 Anal SCJ & AnTZ Original vs. current SCJ less relevant. TZ features less common, therefore more difficult to appreciate. SCJ more subtle, difficult to see in entirety requires more manipulation & acetic acid. Larger area of metaplastic changes overlying columnar epithelium compared to endocervix. Most lesions found in the AnTZ.

21 Atypical Metaplasia Atypical metaplasia may indicate the presence of HSIL. Radiate over distal rectum from SCJ. Thin, may wipe off. Features to look for indicating potential lesions: Atypical clustered glands (ACG) Lacy metaplastic borders (LM) Epithelial Honeycombing (EH)

28 Lugol s Staining. More utility in anus compared to cervix. Adjunctive to help define borders, distinguish between possible LSIL/HSIL. Most HSIL will be Lugol s negative LSIL may be Lugol s partial or negative Applied focally with small cotton swabs to better define an acetowhite lesion. NOT a short cut to determine presence or absence of lesions, acetic acid is used first and is applied frequently.

29 Anal vs. Cervical Characteristics Punctation & Mosaic rarely fine mostly coarse. Mosaic pattern mostly associated with HSIL. Atypical vessels may be HSIL or cancer Epithelial honeycombing & lacy metaplasia unique anal descriptors.

30 Typical LSIL Characteristics AWE, raised, papillary, warty vessels, Lugol s partialcomplete. AWE, shiny, Flat, punctation or none, Lugol s partialnegative. Indistinct AWE, micropapillary changes with Lugol s partial. Biopsy to establish diagnosis!

32 Typical HSIL Characteristics AWE, thickened, grey, flat tone. Smooth, sharp or indistinct border. Flat or slightly raised smooth thickening. Coarse punctation and mosaic pattern. Lugol s negative. Shallow ulcerations, friability. Example: AWE, grey, flat, distinct with CP and CM, LN. Biopsy to establish diagnosis!

34 HRA Signs of Invasive Cancer AWE may or may not be evident due to bleeding. Very coarse punctation and mosaic pattern. Atypical, non-branching, bizarre patterns, dilated vessels. Friable lesions. Denuded epithelium, fissures, or ulcerations. Coarse mosaic pattern appearing on keratinized mucosa.

39 Differences Higher magnification compared to cervical. Requires liberal application and re-application of acetic acid. Adjunctive use of Lugol s staining to highlight acetic acid findings. Physically more demanding. Requires adequate time ~ 15 minutes for experienced clinician.

40 Equipment If you can t see well, you can t find lesions. HRA requires higher magnification compared to cervical colposcopy and it needs to be used. Colposcope with better and higher magnification range. Non-ocular scopes do not work well

43 Got HRA? Field is relatively young with growing demand for services. Discuss with colleagues providing HRA. Rewarding, challenging sometimes a difficult transition. With practice, expertise is certainly possible. Consider taking the HRA Course July 2016 in Providence!

73 Understanding the Practice of HRA What Providers Need to Know About Managing Anal HSIL: Lessons Learned from Referrals J. Michael Berry-Lawhorn, MD Clinical Professor of Medicine University of California San Francisco Associate Director HPV-Related Clinical Studies

74 Disclosures I have no significant financial relationships to disclose that would pose a potential conflict of interest. Non-FDA-Approved There are NO FDA-approved treatments for anal HSIL.

75 Introduction Clinical scenarios faced frequently by providers who care for women Caveats about HRA Case-based demonstration of clinical points indicating importance, pitfalls, and challenges of HRA in managing anal neoplasia in women Conclusions

76 Now what do I do??? You don't perform HRA, but she insisted on having anal cytology and it shows HSIL Your patient over 50 just had her colonoscopy and was found to have anal condyloma You are treating a woman with extensive vulvar HSIL, you realize the lesions extend posteriorly and surround the anus Your patient has been diagnosed serendipitously with anal HSIL or SISCCA and is calling you for advice ALL of these women need high-resolution anoscopy or HRA!!!

77 Who Manages Anal HSIL? Typically referrals are made to general surgery, dermatology, oncology, gynecologic oncology, or colorectal surgery Currently very few of these providers have been trained in HRA A few providers have never heard of HRA Some have attended a 2-4 hour lecture and decided that HRA can be easily performed or they are very experienced colposcopists No matter what the experience level, there is no substitute for rigorous training and experience performing HRA

78 Why aren t there more HRA Providers Relatively new procedure, first public HRA course offered by ASCCP in 2005 Steep learning curve, even for those with colposcopy experience Getting good requires seeing high volume of patients at high-risk.. Minimum of 1-2 days per week No evidence yet that treating HSIL prevents cancer However, we and many others believe since HSIL is a precancerous lesion that it should be treated, when found

79 Initial HRA Results after Referral from Anal Surgeons Biopsy-proven HSIL 35 of 47 (74%) Squamous cell carcinoma 8 of 47 (17%) No lesions 4 of 47 ( 9%) (2 developed HSIL within 8 months) Presented at the 2012 ASCCP Biennial Meeting: Prevalence of High-Grade Anal Neoplasia after Referral from Anal Surgeons

80 Lessons Learned from Referrals

81 Case 1 54 YO woman with cervical HSIL diagnosed in 1994 treated with cryotherapy, subsequent normal cytology She works at a hospital clinical laboratory, learned about the association between HPV and anal cancer Requested anal cytology on 1/5/2007 which was negative but positive for HPV-16. Regular anoscopy normal and negative anal cytology until 3/30/3015 when anal cytology showed HSIL Referred for high resolution anoscopy (HRA).

84 Teaching Points Regular anoscopy has a limited role in managing positive HRHPV results Repeated cytology may be useful in following women serially Unlike cervical colposcopy, metaplasia should be biopsied in the anus to exclude HSIL HRA maximizes detection of HSIL

85 Case 2 60 YO woman s/p cryotherapy 40 years ago for abnormal Pap Diagnosed with Rheumatoid Arthritis at age 28 and has been maintained on etanercept (Enbrel) since 2000 In 2010 she had colonoscopy and condyloma biopsied: HSIL/AIN 3 Referred to colorectal surgeon for excision: normal hemorrhoid without dysplasia Referred for HRA

93 Teaching Points Well-trained colorectal surgeons who do not perform HRA may miss extensive HSIL Office-based treatment can successfully eradicate extensive HSIL

94 Case 3 29 YO HIV-negative woman, smoker c/o 2 year "vaginal rash", no relief with any OTC, resorted to using triamcinolone QID. Unable to have sex due to pain. Diagnosed with extensive vulvar HSIL/VIN 3. At UCSF lesions noted to extend to perineum. Anal cytology HSIL/severe dysplasia Referred for HRA, initial exam too painful

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101 Teaching Points Women with extensive vulvar lesions that extend to the perineum are highly likely to have anal canal and perianal HSIL. Once trained, an intra-anal block can easily be done when necessary. Extensive HSIL lesions can be subtle in appearance and require good light, lots of acetic acid, and high magnification.

102 Case 4 63 YO woman with no prior history of HPV-related LGTN referred for HRA because of persistent PA HSIL. Untreated hepatitis C, subsequently treated. Initially treated with 5FU (regimen not specified) with persistent HSIL followed by WLE with advancement flap for closure in September Recurrent PA HSIL in November Referred for HRA on February 13, 2015.

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109 Teaching Points You must excise lesions that are clinically suspicious for cancer, unless HRA-directed biopsies show cancer. WLE and flaps are ALMOST NEVER needed to treat extensive HSIL. Suturing should be minimized unless needed for hemostasis; anecdotally associated with progression to cancer.

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119 Teaching Points In order to successfully eradicate extensive HSIL, you must be persistent and appropriately aggressive. Patients need very close follow-up and must understand the process in order to be motivated. USE the colposcope when treating PA and possibly vulvar lesions to enhance identification of HSIL.

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123 Teaching Point You must define HSIL borders using high magnification and acetic acid to maximize treatment outcome and minimize recurrence.

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128 Teaching Points Although lesions are superficial, after initial burn, you must debride until you are sure that all abnormal vessels/epithelium have been ablated down to the submucosa. Then, burn the base of the lesion lightly.

129 Case 5 68 YO woman with a remote history of cryotherapy for cervical dysplasia +FOBT led to colonoscopy with anorectal mass Excised SCCA with 0.1 mm margin Referred to see if appropriate for conservative management, local tumor board thought CMT might be excessive and surgeon was confident that cancer had been removed

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134 Teaching Points You must learn how to perform careful, thorough DARE. ALWAYS biopsy abnormal appearing, subepithelial tissue and if worried about cancer, biopsy deep base of lesion after initial biopsy. Suturing should be minimized unless needed for hemostasis; anecdotally associated with progression to cancer.

135 Conclusions Learning HRA or identifying a colleague or nearby center where HRA is performed regularly is vital to the management of anal HSIL. Patients with SISCCA being considered for conservative management MUST HAVE HRA.

136 Conclusions If you are referring to a general, colorectal, or gynecologic oncologic surgeon; have a conversation with them about their specific training in HRA, if any. Standards of proficiency in HRA and possibly certification are desperately needed. Contact the International Anal Neoplasia Society for resources.

How might we implement screening for anal cancer in HIV-positive patients?

Objective How might we implement screening for anal cancer in HIV-positive patients? Identify the elements required to set up an anal cancer screening and prevention program J. Michael Berry, MD Associate