High-Resolution Anoscopy and the Treatment of Anal Dysplasia

High-Resolution Anoscopy and the Treatment of Anal Dysplasia

By Reza Rahbar, MD, FACS, FASCRS

Anal cancer is relatively uncommon, but for people at increased risk, there is an important opportunity to identify and treat precancerous changes before they become cancer.

At Carolina RHI, we offer high-resolution anoscopy (HRA) for the evaluation, diagnosis, surveillance, and treatment of anal dysplasia. Most evaluations and many treatments can be performed conveniently in our office.

What Is Anal Dysplasia?

Anal dysplasia refers to abnormal cells in the lining of the anal canal, most commonly caused by persistent infection with certain types of human papillomavirus (HPV).

These abnormalities are often described as:

• LSIL — low-grade squamous intraepithelial lesion

• HSIL — high-grade squamous intraepithelial lesion

HSIL is particularly important because it is considered a precursor to anal squamous cell cancer. Not every high-grade lesion will become cancer, but we now have strong evidence that identifying and treating HSIL can reduce the risk of anal cancer.

The ANCHOR Study Changed How We Treat Anal Dysplasia

For many years, physicians knew that HSIL could progress to anal cancer, but there was uncertainty about whether routinely treating these lesions actually prevented cancer.

That changed with the landmark ANCHOR trial — the Anal Cancer/HSIL Outcomes Research study.

I had the opportunity to participate in the ANCHOR study and have worked with physicians who helped establish this field, including Dr. Joel Palefsky, the study’s protocol chair, and Dr. Stephen Goldstone of Mount Sinai in New York.

The ANCHOR study demonstrated that treating biopsy-proven anal HSIL significantly reduced the subsequent development of anal cancer compared with active monitoring. The risk of progression to anal cancer was reduced by approximately 57% in patients whose HSIL was treated.

This was an important change in our understanding of anal dysplasia: high-grade anal dysplasia should be identified, treated, and followed rather than simply observed.

What Is High-Resolution Anoscopy?

High-resolution anoscopy is similar in concept to the colposcopy used to evaluate abnormal cervical Pap smears.

During HRA, the anal canal is carefully examined using magnification and special solutions that make abnormal areas easier to identify. This allows the physician to:

• Identify abnormalities that may not be visible during a routine examination

• Target suspicious areas for biopsy

• Determine whether LSIL or HSIL is present

• Precisely locate lesions for treatment

• Follow previously treated areas for recurrence

A standard digital examination or routine anoscopy alone may not identify small or subtle areas of dysplasia. HRA allows a much more detailed examination of the anal canal.

Who Should Consider Screening for Anal Dysplasia?

Screening may be appropriate for people with an increased risk of HPV-related anal disease, including certain patients with:

• HIV

• A history of anal or genital HPV

• Previous anal dysplasia

• Cervical, vaginal, or vulvar dysplasia or cancer

• Organ transplantation or chronic immunosuppression

• Abnormal anal cytology or an abnormal anal Pap test

• A history of anal condyloma or genital warts

Recommendations vary depending on age, immune status, previous HPV-related disease, and other individual risk factors.

Treating Anal Dysplasia in the Office

One advantage of specialized HRA care is that evaluation and treatment do not necessarily require an operating room.

At Carolina RHI, I diagnose, biopsy, monitor, and treat anal dysplasia in the office whenever appropriate.

Depending on the size, location, number, and pathology of the lesions, treatment may include targeted destruction or removal of abnormal tissue. The goal is to eliminate high-grade lesions while preserving as much normal anal tissue as possible.

Because HPV-related dysplasia can recur or develop in a different location, continued surveillance after treatment is important. Treatment is not necessarily a one-time event; it is often part of an ongoing prevention strategy.

Experience Matters With HRA

High-resolution anoscopy is a specialized procedure. Recognizing subtle abnormalities, deciding which areas require biopsy, interpreting the pattern of disease, and treating lesions while minimizing injury to normal tissue all require experience.

As a board-certified colon and rectal surgeon, my involvement in the landmark ANCHOR study and my experience evaluating and treating anal dysplasia allow Carolina RHI to provide this specialized care in an outpatient setting.

For many patients, that means being able to have the evaluation, biopsy, treatment, and follow-up performed in one specialized colorectal practice.

Treating Precancer Before It Becomes Cancer

The most important lesson from recent research is that we do not have to wait for high-grade dysplasia to progress to cancer before acting.

For patients at increased risk, an appropriate program of screening, high-resolution anoscopy, targeted biopsy, treatment of HSIL, and continued surveillance provides an opportunity to identify and treat disease at its precancerous stage.

That is an important part of the specialized colorectal care we provide at Carolina RHI.

Schedule an Evaluation

If you have an abnormal anal Pap test, a history of HPV or anal dysplasia, previous genital dysplasia, anal lesions, or have been told that you may benefit from high-resolution anoscopy, contact Carolina RHI to schedule an evaluation.

Carolina RHI: Specialized Colorectal Care

www.CarolinaRHI.com