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and the many therapeutic advances in this field have now provided numerous options for preventing progression to invasive anal SCC&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Although the utility of screening for AIN and treating it in high-risk patients is still a subject of debate&#44; screening and treatment programs are becoming increasingly common and will probably become widespread in dermatology practices in the future&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Epidemiology of Anal SCC</span><p id="par0025" class="elsevierStylePara elsevierViewall">Anal SCC is an uncommon cancer that accounts for less than 5&#37; of all gastrointestinal neoplasms&#46; Its incidence in healthy males in the United States is 0&#46;8 cases per 100&#160;000 population&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Unfortunately there are no reliable data on the incidence or prevalence of anal SCC in Spain as there are no official registers&#46; Nonetheless&#44; recent epidemiological studies conducted outside Spain &#40;mainly in Europe<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> and the United States<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#41; have revealed that the incidence of anal SCC is rising&#44; with estimates indicating a 2&#37; annual increase in the past 10 years&#59; the increase in high-risk groups has been particularly dramatic&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The incidence of anal SCC varies in different population subgroups&#46; In MSM&#44; for example&#44; an estimated 35 new cases per 100&#160;000 individuals are found each year&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> Although this figure is half that reported for patients infected with human immunodeficiency virus &#40;HIV&#41;&#44; it is similar to the incidence of cervical cancer in women before the introduction of widespread cytologic screening&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">More alarming&#44; however&#44; is the situation for MSM with HIV&#44; who have now become the group most at risk of developing this disease&#59; the incidence of anal SCC in this population is estimated at 70 to 128 cases per 100&#160;000 person-years&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;10</span></a> Several studies have analyzed changes in the incidence of anal SCC in relation to the AIDS epidemic of 1980 to 1990 and the introduction of highly active antiretroviral therapy &#40;HAART&#41; in 1996&#46; Practically all these studies concluded that HAART has not reduced the incidence of anal SCC as it reduced other AIDS-related tumors such as Kaposi sarcoma&#44; non-Hodgkin lymphoma&#44; and cytomegalovirus retinitis<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#59; in fact&#44; the incidence of anal SCC has increased markedly in the post-HAART era&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;10&#44;11</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Because HAART appears to have no effect on the natural history of anal SCC and considerably increases survival&#44; one would expect the incidence of anal SCC to continue to rise&#46; Anal SCC is now the most common non-AIDS-defining cancer<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> and has become one of the main health problems of HIV-positive individuals&#46;Other groups at risk of anal SCC are individuals with immunocompromised systems for reasons other than HIV infection&#44; such as those who have received immunosuppressive treatment following a solid-organ transplant&#46; Several studies have reported that patients who have undergone kidney transplantation&#44; for example&#44; are 10 times more likely than the general population to develop anal SCC&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The risk of anal SCC in women is associated with the presence of other tumors in the anogenital region&#59; this risk probably stems from the close proximity of the cervix and anal canal&#44; which both act as viral reservoirs&#44; favoring mutual reinfection regardless of which site was infected first&#46; Patients who have already had neoplasia in the anogenital region will thus be at considerably higher risk than the general population&#46; One recent study reported that 12&#46;2&#37; of patients with a history of cervical&#44; vulvar&#44; or vaginal intraepithelial neoplasia who underwent anal cytology and high-resolution anoscopy had AIN&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Obviously this risk will be much higher in immunosuppressed individuals&#44; and higher still if they are HIV-infected&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Etiopathogeny</span><p id="par0050" class="elsevierStylePara elsevierViewall">Long-term studies have yet to establish a definitive model that provides a compelling explanation of the natural history of anal neoplasia&#46; By analogy with cervical cancer&#44; and based on the results of recent studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;16&#8211;18</span></a> it is currently accepted that intraepithelial dysplastic lesions are precursors of invasive tumor lesions&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Evidence suggests that HPV plays a key role in the etiopathogenesis of up to 93&#37; of anal carcinomas&#46; Patients with anal SCC and its precursor&#44; high-grade AIN&#44; have been found to have a significantly higher prevalence of HPV-16 and HPV-18 infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#8211;21</span></a> In the cervix&#44; the virus infects the epithelium of the squamocolumnar junction &#40;the cervical transformation zone&#41;&#44; but in the anal canal it tends to infect the transformation zone between the columnar epithelium of the rectum and the stratified epithelium of the anoderm&#44; which is precisely where the dysplastic changes that characterize AIN occur&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">It is therefore easy to understand why AIN and anal SCC are so common in HIV-positive MSM&#46; On the one hand&#44; a prevalence of HPV infection as high as 60&#37; is well documented in MSM and rises to 93&#37; in MSM with HIV infection<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#8211;25</span></a>&#59; these higher rates are partly explained by longer survival and hence longer HPV exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">On the other hand&#44; AIN is also closely associated with different degrees of compromised immunity&#44; particularly in relation to HIV infection&#46; The interaction between HIV and HPV has been said to be related to various possible mechanisms&#44; including attenuation of cellular response to HPV antigens in HIV-positive patients&#44; aberrant expression of cytokines &#40;interleukin 6&#41; that regulate the expression of HPV genes&#44; increased expression of local growth factors&#44; and a direct effect of HIV on the expression of HPV oncogenes E6 and E7&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The Natural History of AIN</span><p id="par0070" class="elsevierStylePara elsevierViewall">AIN as the precursor of anal SCC was first described by Fenger and Nielsen<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> in 1981&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Anal biopsy is the gold standard for a diagnosis of AIN&#44; which is based on detection of dysplasia&#44; classified according to the depth of epithelial involvement&#46; A grade classification of 1 to 3 is assigned based on how many layers of the epithelium have dysplastic changes&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">AIN can also be detected by anal cytology&#44; just as dysplastic lesions of the uterine cervix can be detected by cervical cytology&#46; Accordingly&#44; the Bethesda<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> criteria can be used to distinguish between low-grade and high-grade lesions&#46; Cytologic findings&#44; however&#44; should always be confirmed histologically via anal biopsy&#44; which always provides the definitive diagnosis&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">While fewer studies have analyzed the natural history of AIN than are available for cervical dysplasia&#44; there is no doubt that high-grade AIN &#40;grades 2 and 3&#41; is a precursor of anal SCC&#46; Various authors have documented the progression of grade 3 dysplasia to carcinoma in situ&#44; using long-term histologic follow-up studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;16&#8211;18</span></a> Despite these observations&#44; however&#44; and despite evidence of progression of high-grade AIN to anal carcinoma&#44; more studies are required to clarify the clinical significance of these dysplastic lesions&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Untreated low-grade &#40;grade 1&#41; AIN can regress spontaneously or progress to higher-grade lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> Low-grade AIN may progress to high-grade AIN&#44; or even to anal SCC in approximately 10&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Scholefield et al<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> reported that 15&#46;6&#37; of patients &#40;5&#47;32&#41; with grade 3 AIN developed invasive anal SCC over a period of 18 months&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Logically&#44; those with the highest risk of AIN also have the highest risk of anal SCC&#46; The estimated prevalence of AIN in MSM&#44; for example&#44; is 35&#37;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> &#40;72&#37; to 81&#37; in HIV-positive individuals<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;23&#44;24&#44;30</span></a> and 20&#37; in patients with grade 3 cervical intraepithelial lesions or cervical cancer&#41;&#59; AIN is also more common in patients with immunosuppression for reasons other than HIV infection &#40;eg&#44; patients who have undergone kidney transplantation&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;15&#44;19</span></a> Furthermore&#44; approximately 10&#37; of patients with anal condyloma have AIN of varying grades&#44; demonstrating why histologic examination is important in the assessment of anal and perianal condyloma&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;31</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The increased risk of AIN in HIV-positive individuals was highlighted in 2 recent studies by the same group&#44; who showed that 81&#37; of HIV-positive MSM had AIN &#40;grades 1&#44; 2&#44; or 3&#41; and that 52&#37; had high-grade AIN&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> A study performed in Germany in 446 HIV-infected MSM found that 72&#37; had AIN of some degree of severity and 35&#37; had high-grade AIN&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">An association between CD4 expression and the risk of AIN has been shown in HIV-positive individuals&#44; in whom risk rises as CD4 cell counts fall&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;32</span></a> Duration of HIV infection &#40;ie&#44; of impaired immunity&#41; has also been proposed as a possible risk factor for anal SCC&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> A recent study in 4901 HIV-positive patients reported a 12-fold higher prevalence of anal SCC in those who had been infected for over 15 years compared to those who had been infected for less than 5 years &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Observations such as these are very interesting in terms of helping to identify appropriate candidates for screening &#40;ie&#44; individuals with a higher risk of developing anal carcinoma&#41;&#46; Based on the above observation&#44; the target population would be MSM with a longer duration of HIV infection&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The natural course of AIN &#40;progression or regression&#41; appears to be influenced by HIV infection&#44; the oncogenic potential of HPV infection&#44; HPV viral load&#44; multiple HPV infection&#44; and the host&#39;s immune status&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Several studies have shown that disease progresses more rapidly in HIV-positive patients&#44; who have lower rates of spontaneous regression and more frequent progression to more advanced stages of disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;35</span></a> Specifically&#44; these studies have shown that 32&#37; of HIV-positive MSM with normal cytology and 52&#37; of those with low-grade AIN develop high-grade lesions in just 4 years&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The incidence of anal SCC in immunocompetent MSM&#44; while still high&#44; is lower than would be expected considering the extremely high prevalence of AIN in these individuals<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> a pattern that stands in contrasts with that of HIV-infected MSM&#46; The probable explanation is that spontaneous regression of AIN is much more common in immunocompetent individuals&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Screening for AIN by Cytology and High-Resolution Anoscopy</span><p id="par0125" class="elsevierStylePara elsevierViewall">Anal cytology is the first screening test that should be performed in individuals at risk of AIN&#44; and those with abnormal findings should be referred for high-resolution anoscopy-guided biopsy &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Anal Cytology</span><p id="par0130" class="elsevierStylePara elsevierViewall">Anal cytology is a simple&#44; minimally invasive procedure used to collect cells for cytopathologic examination&#46; When collected in a liquid medium&#44; the sample can also be used for quantitative HPV testing&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The procedure involves introducing a cytobrush into the anal canal to a distance of 3<span class="elsevierStyleHsp" style=""></span>cm and rotating it to increase contact with the canal walls&#46; The brush is then submerged in a vial containing a preservative solution &#40;eg&#44; PreservCyt&#41; to release the cells for analysis&#46; Part of the sample is processed for HPV DNA testing by hybrid capture&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Anal cytology has improved considerably in recent years and now offers sensitivity and specificity rates that are at least comparable to those of cervical cytology&#46; When a liquid medium is used&#44; a sensitivity of 69&#37; to 92&#37; is possible&#44; with a specificity of 32&#37; to 59&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#8211;40</span></a> Nonetheless&#44; like cervical cytology&#44; it does not adequately predict the degree of histologic involvement&#46; High-grade dysplasia detected by anal cytology has a high predictive value for histologically confirmed high-grade dysplasia&#46; Low-grade cytologic abnormalities&#44; in contrast&#44; are not a reliable reflection of the true extent of disease&#46; Atypical squamous cells of undetermined significance &#40;ASCUS&#41; and low-grade dysplasia&#44; for example&#44; may be detected in histologically confirmed high-grade dysplasia&#46; Any abnormal cytology result&#44; therefore&#44; should be followed up with high-resolution anoscopy and biopsy of suspicious areas to confirm AIN and determine the level of dysplasia&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">High-Resolution Anoscopy-Guided Biopsy</span><p id="par0145" class="elsevierStylePara elsevierViewall">High-resolution anoscopy-guided biopsy is the gold standard for diagnosing AIN&#46; In this procedure&#44; the transformation zone of the anal canal is examined through a colposcope&#44; which lights and magnifies the surface&#46; A gauze pad soaked in 3&#37; acetic acid is inserted into the canal&#44; where it is left in contact with the mucosa for several minutes&#46; Intraepithelial lesions tend to acquire a whitish color when they come in contact with this solution&#44; thus helping to identify suspicious areas for biopsy&#46; Subsequent staining with Lugol solution can also be performed&#46; AIN should be suspected on detection of acetowhitening&#44; plaques that do not take up Lugol solution&#44; or areas of the mucosa with abnormal vascular patterns&#46; <a class="elsevierStyleCrossRef" href="#fig2">Figure 2</a> shows grades 1&#44; 2&#44; and 3 AIN as seen by high-resolution anoscopy &#40;<a class="elsevierStyleCrossRef" href="#fig2">Fig&#46; 2</a>A-I&#41;&#46; Histologic evaluation of samples obtained by punch biopsy is the method of choice for diagnosing and grading AIN&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><elsevierMultimedia ident="fig2"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Testing for HPV Infection</span><p id="par0150" class="elsevierStylePara elsevierViewall">Opinions are divided on the diagnostic value of HPV testing in AIN screening because of the extremely high prevalence of HPV in the highest risk groups such as HIV-positive MSM&#46; It is widely known that most HIV-positive MSM have multiple HPV infections&#44; and infection rates vary very little between those who have AIN and those who do not&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">HPV testing is used to determine the need for high-resolution anoscopy in women with a cervical cytologic diagnosis of ASCUS&#46; In HIV-positive MSM with anal ASCUS&#44; HPV testing is probably not useful as it does not increase the specificity for detecting AIN<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> as most of these patients will harbor an oncogenic HPV variant&#46; It has been suggested&#44; however&#44; that it might be a useful addition in HIV-negative MSM&#44; in whom the sensitivity of anal cytology is lower&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> HPV testing in other risk groups such as women with a history of cervical dysplasia might also be useful due to the lower prevalence of anal HPV infection in this group&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The inclusion of HPV testing as a routine part of AIN screening might also be of value because of its negative predictive value&#46; In other words&#44; because dysplasia is not found in patients who do not have oncogenic HPV infection&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> a negative result would indicate that high-resolution anoscopy could be avoided&#46; Unfortunately&#44; this occurs only in a very small percentage of at-risk patients&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Which At-Risk Patients Should Be Considered for Screening&#63;</span><p id="par0165" class="elsevierStylePara elsevierViewall">As mentioned previously&#44; a number of major groups have an increased risk of developing AIN in association with HIV infection&#46; Exactly which patients should be referred for screening&#44; however&#44; is a complicated decision in which cost-effectiveness is an important consideration&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a> shows which individuals are at risk&#44; although it should be noted that studies to date have only shown screening to be cost-effective when performed annually in HIV-positive patients and every 2 to 3 years in HIV-negative MSM&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#44;42</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">Several official HIV guidelines such as that published by the New York State Department of Health AIDS Institute<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> recommend systematically screening for AIN in patients with HIV infection&#46; Guidelines from the Centers for Disease Control and Prevention simply state that cytology is used by many experts to screen for AIN in HIV-positive patients but do not include any specific recommendations in this respect&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Screening Algorithms</span><p id="par0175" class="elsevierStylePara elsevierViewall">There are no universal screening algorithms for AIN and most authors use the protocol proposed by Chin-Hong and Palefsky<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; According to this protocol&#44; at-risk individuals should undergo anal cytology screening following the procedure described previously&#46; In the event of a negative result&#44; the test should be repeated after 1 year in HIV-positive individuals and after 2 to 3 years in HIV-negative individuals&#46; High-resolution anoscopy-guided biopsy is indicated in patients with abnormal anal cytology&#46; If the lesions are grade 1&#44; the anoscopy should be repeated in 6 months&#44; but if they are grade 2 or 3&#44; treatment is recommended&#46; Individuals with low-grade cytology but normal anoscopy findings should be scheduled for repeat cytology in 6 months&#46; In the rare situation where a patient has high-grade cytology but a normal anoscopy&#44; blind biopsy should be performed and cytologic examination repeated shortly afterwards&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Limitations and Future Prospects of AIN Screening</span><p id="par0180" class="elsevierStylePara elsevierViewall">As mentioned previously&#44; anal cytology has similar sensitivity and specificity to cervical cytology&#44; although higher rates have been reported in patients with disease in more than 1 quadrant of the anal mucosa and in HIV-positive patients&#44; particularly when their CD4 cell count is low&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Anal cytology&#44; like cervical cytology&#44; has its limitations for screening&#44; however&#44; because it does not detect all high-grade AIN&#46; Furthermore&#44; many healthy patients are unnecessarily referred for high-resolution anoscopy&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Because of these limitations&#44; molecular diagnostic techniques are being investigated in an effort to improve the sensitivity and specificity of AIN screening&#46; Recent proposals include the use of cytologic&#44; histologic&#44; and microbiologic markers to help identify candidates for high-resolution anoscopy&#46; Of note are proteins that can be used as surrogate markers of cell cycle deregulation&#44; biomarkers of DNA damage&#44; gamma tubulin and beta defensin levels&#44; HPV typing&#44; and the identification of integrated forms of HPV&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">46&#44;47</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Finally&#44; in view of the high incidence of AIN in certain risk groups&#44; some authors have even proposed that all high-risk individuals should go directly to high-resolution anoscopy screening&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Treating AIN</span><p id="par0200" class="elsevierStylePara elsevierViewall">AIN represents a therapeutic challenge for several reasons&#46; Firstly&#44; all current treatments are associated with a risk of recurrence and metachronous lesions&#46; Treatment&#44; unfortunately&#44; does not cure the viral infection&#44; meaning that patients need to be monitored for long periods of time because of the risks associated with persistent infection by oncogenic forms of HPV&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Secondly&#44; there is no treatment of choice for AIN&#46; Approaches vary according to the location and extent of disease and the availability of resources and local expertise&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">It is not considered necessary to treat low-grade AIN unless the patient has symptoms or feels particularly anxious about the disease&#46; High-grade AIN&#44; in contrast&#44; should be treated to prevent progression to invasive carcinoma&#44; except in cases in which treatment might result in more complications than the disease itself&#46; In such cases&#44; 3-monthly to 6-monthly follow-up with high-resolution anoscopy and digital rectal examination is recommended to ensure timely detection of progression to invasive carcinoma&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">AIN can be treated with topical agents&#44; ablative therapy&#44; or surgery<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0220" class="elsevierStylePara elsevierViewall">The treatment of local AIN is relatively simple and there are many options&#44; including cryotherapy&#44; trichloroacetic acid&#44; infrared coagulation&#44; electrocautery&#44; CO<span class="elsevierStyleInf">2</span> laser&#44; and surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Treatment is more complicated in the case of more extensive disease&#46; Options include patient-administered topical treatments with curative intent or to reduce the number of lesions for subsequent treatment with ablative techniques such as infrared coagulation&#46; The main topical treatments are imiquimod<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#8211;52</span></a> and 5-fluorouracil<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> creams&#44; which are associated with histologic regression rates of 74&#37; and 57&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#8211;53</span></a> Both treatments reduce the viral load of oncogenic HPV genotypes but are also associated with high recurrence rates&#58; 58&#37; in the case of imiquimod &#40;30 months post-treatment&#41;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> and 50&#37; in the case of 5-fluorouracil &#40;6 months post-treatment&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> Most recurrences&#44; however&#44; are detected at sites other the initial AIN site and are associated with high-risk HPV genotypes other than those detected in the initial examination&#46; In other words&#44; most recurrences are due to HPV reinfection&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">One particularly interesting recent study was a double-blind&#44; placebo-controlled&#44; randomized trial of imiquimod which included the option of a second 4-month treatment cycle for nonresponders&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> During this second phase&#44; which lasted at least 36 months&#44; 61&#37; of patients achieved complete remission&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Infrared coagulation&#44; which involves the delivery of heat to induce coagulation&#44; also holds much promise as a treatment for AIN&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54&#8211;56</span></a> This modality can be used to treat extensive disease in office-based settings &#40;with or without anesthesia depending on the site of the lesions&#41;&#44; and unlike treatment with CO<span class="elsevierStyleInf">2</span> lasers&#44; does not require the use of an extractor as it does not produce smoke&#46; Several retrospective studies have indicated that infrared coagulation is a safe procedure that achieves response rates of 60&#37; to 70&#37; when used on specific AIN lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> Higher response rates have been reported in HIV-negative patients and individuals who undergo several treatment sessions&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The Role of HPV Vaccines</span><p id="par0240" class="elsevierStylePara elsevierViewall">Considering that over 70&#37; of SCCs are caused by HVP-16&#44; vaccination is a promising primary preventive measure against AIN and anal SCC&#46; In October 2009&#44; the US Food and Drug Administration approved a quadrivalent HPV vaccine for the prevention of condylomas caused by HPV types 6&#44; 11&#44; 16&#44; and 18 in males aged between 9 and 26 years&#46; One of the main problems associated with the use of this vaccine to prevent anal carcinoma in high-risk groups of men is that it is most effective in men who have not yet been infected by HPV&#46; In other words&#44; it should ideally be administered prior to sexual debut&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Because it is impossible to identify at-risk individuals before they become sexually active&#44; it would be necessary&#44; at least hypothetically&#44; to vaccinate all preadolescent males in order to reduce the incidence of anal carcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> For this to be viable&#44; however&#44; it would first be necessary to determine whether universal vaccination would be cost-effective&#44; particularly given the high cost of the vaccine and the relatively low incidence of anal SCC&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">According to the results of a recent study by Kimm<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> designed to estimate the cost-effectiveness of the quadrivalent HPV vaccine administered at the ages of 12 years&#44; 20 years&#44; or 26 years in terms of preventing AIN and anal SCC in MSM&#44; the cost-benefit ratio was highest for vaccination at 12 years&#44; but the intervention was also cost-effective at 20 and 26 years&#44; ie&#44; at ages when individuals would be more likely to ask for the vaccination&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">The fact that multiple HPV infection&#8212;like infection by other sexually transmitted diseases&#8212;has been found to be independently associated with HIV acquisition in MSM<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> would be another argument in favor of vaccinating young males&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0260" class="elsevierStylePara elsevierViewall">The value of targeted and universal AIN screening has generated much debate in the past 10 years and none of the relevant national or international guidelines recommend routine AIN screening&#46; Nevertheless&#44; the results of population-based studies and the experience of dermatologists in the past decade bear witness to the fact that anal carcinoma is increasing at an alarming rate&#44; particularly in HIV-positive patients&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">We must offer patients the best preventive treatment possible based on the knowledge accumulated to date on the role of HPV in anal carcinoma and the natural history of AIN&#46; Anal cytology is a simple&#44; noninvasive technique&#44; but before extending its use to all at-risk populations&#44; we must first be able to provide a definitive diagnosis and offer treatment in the event of cytologic abnormalities&#46; In other words&#44; patients at centers that do not offer high-resolution anoscopy should be referred to centers that do&#46; When this is not possible&#44; high-risk patients should be followed closely and tests should include digital rectal examination to test for masses suggestive of anal carcinoma&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">In our opinion&#44; and in line with practices in other European countries&#44; AIN screening can and should be offered by dermatologists&#44; who are&#44; indeed&#44; specialists in sexually transmitted diseases&#44; with the aim of diagnosing and treating intraepithelial lesions associated with HPV&#46; That said&#44; the approach should be multidisciplinary and involve close collaboration with specialists from other departments such as internal medicine&#44; general surgery&#44; digestive surgery&#44; microbiology&#44; and pathology to offer patients the best possible care&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">Finally&#44; further studies are needed to develop an optimal AIN screening protocol and&#44; more importantly&#44; to establish appropriate guidelines and treatment&#46;</p></span></span>"
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        0 => array:2 [
          "identificador" => "xres95485"
          "titulo" => "Abstract"
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          "identificador" => "xpalclavsec82645"
          "titulo" => "Keywords"
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        2 => array:2 [
          "identificador" => "xres95486"
          "titulo" => "Resumen"
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          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Epidemiology of Anal SCC"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Etiopathogeny"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "The Natural History of AIN"
        ]
        8 => array:3 [
          "identificador" => "sec0025"
          "titulo" => "Screening for AIN by Cytology and High-Resolution Anoscopy"
          "secciones" => array:6 [
            0 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Anal Cytology"
            ]
            1 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "High-Resolution Anoscopy-Guided Biopsy"
            ]
            2 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Testing for HPV Infection"
            ]
            3 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Which At-Risk Patients Should Be Considered for Screening&#63;"
            ]
            4 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Screening Algorithms"
            ]
            5 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Limitations and Future Prospects of AIN Screening"
            ]
          ]
        ]
        9 => array:2 [
          "identificador" => "sec0060"
          "titulo" => "Treating AIN"
        ]
        10 => array:2 [
          "identificador" => "sec0065"
          "titulo" => "The Role of HPV Vaccines"
        ]
        11 => array:2 [
          "identificador" => "sec0070"
          "titulo" => "Conclusions"
        ]
        12 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
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    "fechaRecibido" => "2010-11-01"
    "fechaAceptado" => "2011-01-27"
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          "clase" => "keyword"
          "titulo" => "Keywords"
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          "palabras" => array:4 [
            0 => "Anal intraepithelial neoplasia"
            1 => "Anal squamous cell carcinoma"
            2 => "Screening"
            3 => "Human papillomavirus"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec82646"
          "palabras" => array:4 [
            0 => "Neoplasia intraepitelial anal"
            1 => "Carcinoma epidermoide anal"
            2 => "Cribado"
            3 => "Virus del papiloma humano"
          ]
        ]
      ]
    ]
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The incidence of anal squamous cell carcinoma has increased alarmingly&#44; particularly in high-risk groups such as men who have sex with men and immunosuppressed patients&#46; Infection with an oncogenic strain of the human papillomavirus in the anal canal or perianal skin leads to anal intraepithelial neoplasias &#40;AIN&#41;&#44; progressive dysplastic intraepithelial lesions that are the precursors of anal squamous cell carcinoma&#46; AIN can be diagnosed through cytological screening and biopsy guided by high-resolution anoscopy and can be treated using a range of procedures in an effort to prevent progression to invasive anal carcinoma&#46; Given the recent advances in the understanding of this disease&#44; and the increasing calls from experts for the establishment of screening programs to identify AIN&#44; we review current knowledge on the condition&#44; its diagnosis&#44; and treatment from the point of view of dermatology&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La incidencia de carcinoma epidermoide anal ha aumentado de forma alarmante&#44; especialmente en grupos de riesgo como son los pacientes homosexuales y los inmunosuprimidos&#46; La infecci&#243;n por un genotipo oncog&#233;nico del virus del papiloma humano &#40;VPH&#41; en el canal anal o en la piel perianal&#44; desencadena una progresi&#243;n de lesiones displ&#225;sicas intraepiteliales &#40;neoplasia intraepitelial anal o NIA&#41;&#44; que son las precursoras del carcinoma epidermoide anal&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La NIA puede diagnosticarse a trav&#233;s del cribado mediante citolog&#237;a y biopsia guiada por anoscopia de alta resoluci&#243;n&#44; y puede tratarse mediante diferentes procedimientos&#44; con el fin de evitar la progresi&#243;n a carcinoma anal invasivo&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">En vista de los recientes avances en el conocimiento de esta patolog&#237;a&#44; y de que cada vez son m&#225;s los expertos que recomiendan la puesta en marcha de programas de cribado de la NIA&#44; revisamos el concepto actual de la misma&#44; su diagn&#243;stico y tratamiento desde una perspectiva dermatol&#243;gica&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Sendagorta E&#44; et al&#46; Detecci&#243;n precoz de la neoplasia intraepitelial anal en pacientes de alto riesgo&#46; Actas Dermosifiliogr&#46;2011&#59;102&#58;757-765&#46;</p>"
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        "fuente" => "Algorithm adapted with permission from Dr&#46; JM&#46; Palefsky &#40;Chin-Hong PV&#44; Palefsky JM 9&#41;&#46;"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Screening algorithm adapted from Chin-Hong and Palefsky&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> AIN indicates anal intraepithelial neoplasia&#59; ASCUS&#44; atypical squamous cells of undetermined significance&#59; HG&#44; high-grade&#59; HIV&#44; human immunodeficiency virus&#59; HSIL&#44; high-grade squamous intraepithelial lesions&#59; LG&#44; low-grade&#59; LSIL&#44; low-grade squamous intraepithelial lesions&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A&#44; Condyloma in a patient with grade 1 anal intraepithelial neoplasia &#40;AIN&#41;&#46; B&#44; Grade 2 AIN showing a papillomatous pattern with vascular punctation&#46; C&#44; Acetowhite plaque with abnormal vascularization in the upper right and left quadrants in a patient diagnosed with grade 2 AIN&#46; D&#44; Extensive acetowhite plaque with a cobblestone appearance in lower right and left quadrants in a patient with grade 2 AIN&#46; E&#44; Circumscribed acetowhite plaque in the upper left quadrant&#44; corresponding to grade 2 AIN&#46; F&#44; Circumferential acetowhite plaques in a patient with grade 3 AIN&#46; G&#44; Acetowhite plaques and friable mucosa with hemorrhagic&#44; erosive areas in a patient with grade 3 AIN&#46; H&#44; Acetowhite plaque and thick&#44; tortuous vessels in upper quadrants&#46; I&#44; Exudative&#44; hemorrhagic mass in a patient with infiltrating squamous cell carcinoma&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Patients at risk of developing anal squamous cell carcinoma&#44; with lower-risk groups shown at the base of the pyramid and higher-risk groups at the top&#46; HIV indicates human immunodeficiency virus&#59; MSM&#44; men who have sex with men&#46;</p>"
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                  \t\t\t\t">85&#37; trichloroacetic acid&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Infrared coagulation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Liquid nitrogen&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Electrocautery&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">5&#37; imiquimod cream&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">CO<span class="elsevierStyleInf">2</span> laser&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5-Fluorouracil cream&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Surgery&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Documented Treatments for Anal Intraepithelial Neoplasia&#46;</p>"
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                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "L&#46;G&#46; Jhonson"
                            1 => "M&#46;M&#46; Madelein"
                            2 => "L&#46;M&#46; Newcomer"
                            3 => "S&#46;M&#46; Swchartz"
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                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
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                            "web" => "Medline"
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "HIV-associated anal cancer&#58; has highly active antiretroviral therapy reduced the incidence or improved the outcome&#63; J Acquir Immune Defic Syndr"
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            3 => array:3 [
              "identificador" => "bib0020"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Marked increase in the incidence of invasive anal cancer among HIV infected patients despite treatment with combination antiretroviral therapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Pikkety"
                            1 => "Selinger-Leneman"
                            2 => "S&#46; Grabar"
                            3 => "C&#46; Duvivier"
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
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                        "tituloSerie" => "AIDS"
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            4 => array:3 [
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Incidence of anal cancer in California&#58; increased incidence among men in San Francisco&#44; 1973&#8211;1999"
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                        0 => array:2 [
                          "etal" => false
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                            0 => "R&#46;D&#46; Cress"
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                          ]
                        ]
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                  ]
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                          "etal" => false
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                            1 => "E&#46; Smith"
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            6 => array:3 [
              "identificador" => "bib0035"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Age-related prevalence of anal cancer precursors in homosexual men"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                            0 => "P&#46;V&#46; Chin-Hong"
                            1 => "E&#46; Vittinghoff"
                            2 => "R&#46;D&#46; Cranston"
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                            4 => "S&#46; Buchbinder"
                            5 => "G&#46; Colfax"
                          ]
                        ]
                      ]
                    ]
                  ]
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Review
Early Detection of Anal Intraepithelial Neoplasia in High-Risk Patients
Detección precoz de la neoplasia intraepitelial anal en pacientes de alto riesgo
E. Sendagortaa,
Autor para correspondencia
elenasendagorta@hotmail.com

Corresponding author.
, P. Herranza, H. Guadalajarac, F.X. Zamorab
a Servicio de Dermatología, Hospital La Paz, Madrid, Spain
b Servicio de Medicina Interna, Hospital La Paz, Madrid, Spain
c Servicio de Cirugía General, Hospital La Paz, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The incidence of anal squamous cell carcinoma &#40;SCC&#41; has increased considerably in the past decade&#44; mainly due to the growing number of cases in high-risk groups such as men who have sex with men &#40;MSM&#41;&#44; immunosuppressed individuals&#44; and women with a history of cervical dysplasia&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">As is the case with cervical cancer&#44; anal SCC arises from intraepithelial dysplastic lesions &#40;anal intraepithelial neoplasia&#44; or AIN&#41; at the squamocolumnar junction of the epithelium of the anal canal&#46; These dysplastic lesions are caused by infection by the oncogenic human papillomavirus &#40;HPV&#41; and by HPV-16 in particular&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">AIN can be diagnosed by cytologic screening and high-resolution anoscopy&#44; and the many therapeutic advances in this field have now provided numerous options for preventing progression to invasive anal SCC&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Although the utility of screening for AIN and treating it in high-risk patients is still a subject of debate&#44; screening and treatment programs are becoming increasingly common and will probably become widespread in dermatology practices in the future&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Epidemiology of Anal SCC</span><p id="par0025" class="elsevierStylePara elsevierViewall">Anal SCC is an uncommon cancer that accounts for less than 5&#37; of all gastrointestinal neoplasms&#46; Its incidence in healthy males in the United States is 0&#46;8 cases per 100&#160;000 population&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Unfortunately there are no reliable data on the incidence or prevalence of anal SCC in Spain as there are no official registers&#46; Nonetheless&#44; recent epidemiological studies conducted outside Spain &#40;mainly in Europe<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> and the United States<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#41; have revealed that the incidence of anal SCC is rising&#44; with estimates indicating a 2&#37; annual increase in the past 10 years&#59; the increase in high-risk groups has been particularly dramatic&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The incidence of anal SCC varies in different population subgroups&#46; In MSM&#44; for example&#44; an estimated 35 new cases per 100&#160;000 individuals are found each year&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> Although this figure is half that reported for patients infected with human immunodeficiency virus &#40;HIV&#41;&#44; it is similar to the incidence of cervical cancer in women before the introduction of widespread cytologic screening&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">More alarming&#44; however&#44; is the situation for MSM with HIV&#44; who have now become the group most at risk of developing this disease&#59; the incidence of anal SCC in this population is estimated at 70 to 128 cases per 100&#160;000 person-years&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;10</span></a> Several studies have analyzed changes in the incidence of anal SCC in relation to the AIDS epidemic of 1980 to 1990 and the introduction of highly active antiretroviral therapy &#40;HAART&#41; in 1996&#46; Practically all these studies concluded that HAART has not reduced the incidence of anal SCC as it reduced other AIDS-related tumors such as Kaposi sarcoma&#44; non-Hodgkin lymphoma&#44; and cytomegalovirus retinitis<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#59; in fact&#44; the incidence of anal SCC has increased markedly in the post-HAART era&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;10&#44;11</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Because HAART appears to have no effect on the natural history of anal SCC and considerably increases survival&#44; one would expect the incidence of anal SCC to continue to rise&#46; Anal SCC is now the most common non-AIDS-defining cancer<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> and has become one of the main health problems of HIV-positive individuals&#46;Other groups at risk of anal SCC are individuals with immunocompromised systems for reasons other than HIV infection&#44; such as those who have received immunosuppressive treatment following a solid-organ transplant&#46; Several studies have reported that patients who have undergone kidney transplantation&#44; for example&#44; are 10 times more likely than the general population to develop anal SCC&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The risk of anal SCC in women is associated with the presence of other tumors in the anogenital region&#59; this risk probably stems from the close proximity of the cervix and anal canal&#44; which both act as viral reservoirs&#44; favoring mutual reinfection regardless of which site was infected first&#46; Patients who have already had neoplasia in the anogenital region will thus be at considerably higher risk than the general population&#46; One recent study reported that 12&#46;2&#37; of patients with a history of cervical&#44; vulvar&#44; or vaginal intraepithelial neoplasia who underwent anal cytology and high-resolution anoscopy had AIN&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Obviously this risk will be much higher in immunosuppressed individuals&#44; and higher still if they are HIV-infected&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Etiopathogeny</span><p id="par0050" class="elsevierStylePara elsevierViewall">Long-term studies have yet to establish a definitive model that provides a compelling explanation of the natural history of anal neoplasia&#46; By analogy with cervical cancer&#44; and based on the results of recent studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;16&#8211;18</span></a> it is currently accepted that intraepithelial dysplastic lesions are precursors of invasive tumor lesions&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Evidence suggests that HPV plays a key role in the etiopathogenesis of up to 93&#37; of anal carcinomas&#46; Patients with anal SCC and its precursor&#44; high-grade AIN&#44; have been found to have a significantly higher prevalence of HPV-16 and HPV-18 infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#8211;21</span></a> In the cervix&#44; the virus infects the epithelium of the squamocolumnar junction &#40;the cervical transformation zone&#41;&#44; but in the anal canal it tends to infect the transformation zone between the columnar epithelium of the rectum and the stratified epithelium of the anoderm&#44; which is precisely where the dysplastic changes that characterize AIN occur&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">It is therefore easy to understand why AIN and anal SCC are so common in HIV-positive MSM&#46; On the one hand&#44; a prevalence of HPV infection as high as 60&#37; is well documented in MSM and rises to 93&#37; in MSM with HIV infection<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#8211;25</span></a>&#59; these higher rates are partly explained by longer survival and hence longer HPV exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">On the other hand&#44; AIN is also closely associated with different degrees of compromised immunity&#44; particularly in relation to HIV infection&#46; The interaction between HIV and HPV has been said to be related to various possible mechanisms&#44; including attenuation of cellular response to HPV antigens in HIV-positive patients&#44; aberrant expression of cytokines &#40;interleukin 6&#41; that regulate the expression of HPV genes&#44; increased expression of local growth factors&#44; and a direct effect of HIV on the expression of HPV oncogenes E6 and E7&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The Natural History of AIN</span><p id="par0070" class="elsevierStylePara elsevierViewall">AIN as the precursor of anal SCC was first described by Fenger and Nielsen<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> in 1981&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Anal biopsy is the gold standard for a diagnosis of AIN&#44; which is based on detection of dysplasia&#44; classified according to the depth of epithelial involvement&#46; A grade classification of 1 to 3 is assigned based on how many layers of the epithelium have dysplastic changes&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">AIN can also be detected by anal cytology&#44; just as dysplastic lesions of the uterine cervix can be detected by cervical cytology&#46; Accordingly&#44; the Bethesda<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> criteria can be used to distinguish between low-grade and high-grade lesions&#46; Cytologic findings&#44; however&#44; should always be confirmed histologically via anal biopsy&#44; which always provides the definitive diagnosis&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">While fewer studies have analyzed the natural history of AIN than are available for cervical dysplasia&#44; there is no doubt that high-grade AIN &#40;grades 2 and 3&#41; is a precursor of anal SCC&#46; Various authors have documented the progression of grade 3 dysplasia to carcinoma in situ&#44; using long-term histologic follow-up studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;16&#8211;18</span></a> Despite these observations&#44; however&#44; and despite evidence of progression of high-grade AIN to anal carcinoma&#44; more studies are required to clarify the clinical significance of these dysplastic lesions&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Untreated low-grade &#40;grade 1&#41; AIN can regress spontaneously or progress to higher-grade lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> Low-grade AIN may progress to high-grade AIN&#44; or even to anal SCC in approximately 10&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Scholefield et al<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> reported that 15&#46;6&#37; of patients &#40;5&#47;32&#41; with grade 3 AIN developed invasive anal SCC over a period of 18 months&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Logically&#44; those with the highest risk of AIN also have the highest risk of anal SCC&#46; The estimated prevalence of AIN in MSM&#44; for example&#44; is 35&#37;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> &#40;72&#37; to 81&#37; in HIV-positive individuals<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;23&#44;24&#44;30</span></a> and 20&#37; in patients with grade 3 cervical intraepithelial lesions or cervical cancer&#41;&#59; AIN is also more common in patients with immunosuppression for reasons other than HIV infection &#40;eg&#44; patients who have undergone kidney transplantation&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;15&#44;19</span></a> Furthermore&#44; approximately 10&#37; of patients with anal condyloma have AIN of varying grades&#44; demonstrating why histologic examination is important in the assessment of anal and perianal condyloma&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;31</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The increased risk of AIN in HIV-positive individuals was highlighted in 2 recent studies by the same group&#44; who showed that 81&#37; of HIV-positive MSM had AIN &#40;grades 1&#44; 2&#44; or 3&#41; and that 52&#37; had high-grade AIN&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> A study performed in Germany in 446 HIV-infected MSM found that 72&#37; had AIN of some degree of severity and 35&#37; had high-grade AIN&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">An association between CD4 expression and the risk of AIN has been shown in HIV-positive individuals&#44; in whom risk rises as CD4 cell counts fall&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;32</span></a> Duration of HIV infection &#40;ie&#44; of impaired immunity&#41; has also been proposed as a possible risk factor for anal SCC&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> A recent study in 4901 HIV-positive patients reported a 12-fold higher prevalence of anal SCC in those who had been infected for over 15 years compared to those who had been infected for less than 5 years &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Observations such as these are very interesting in terms of helping to identify appropriate candidates for screening &#40;ie&#44; individuals with a higher risk of developing anal carcinoma&#41;&#46; Based on the above observation&#44; the target population would be MSM with a longer duration of HIV infection&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The natural course of AIN &#40;progression or regression&#41; appears to be influenced by HIV infection&#44; the oncogenic potential of HPV infection&#44; HPV viral load&#44; multiple HPV infection&#44; and the host&#39;s immune status&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Several studies have shown that disease progresses more rapidly in HIV-positive patients&#44; who have lower rates of spontaneous regression and more frequent progression to more advanced stages of disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;35</span></a> Specifically&#44; these studies have shown that 32&#37; of HIV-positive MSM with normal cytology and 52&#37; of those with low-grade AIN develop high-grade lesions in just 4 years&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The incidence of anal SCC in immunocompetent MSM&#44; while still high&#44; is lower than would be expected considering the extremely high prevalence of AIN in these individuals<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> a pattern that stands in contrasts with that of HIV-infected MSM&#46; The probable explanation is that spontaneous regression of AIN is much more common in immunocompetent individuals&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Screening for AIN by Cytology and High-Resolution Anoscopy</span><p id="par0125" class="elsevierStylePara elsevierViewall">Anal cytology is the first screening test that should be performed in individuals at risk of AIN&#44; and those with abnormal findings should be referred for high-resolution anoscopy-guided biopsy &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Anal Cytology</span><p id="par0130" class="elsevierStylePara elsevierViewall">Anal cytology is a simple&#44; minimally invasive procedure used to collect cells for cytopathologic examination&#46; When collected in a liquid medium&#44; the sample can also be used for quantitative HPV testing&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The procedure involves introducing a cytobrush into the anal canal to a distance of 3<span class="elsevierStyleHsp" style=""></span>cm and rotating it to increase contact with the canal walls&#46; The brush is then submerged in a vial containing a preservative solution &#40;eg&#44; PreservCyt&#41; to release the cells for analysis&#46; Part of the sample is processed for HPV DNA testing by hybrid capture&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Anal cytology has improved considerably in recent years and now offers sensitivity and specificity rates that are at least comparable to those of cervical cytology&#46; When a liquid medium is used&#44; a sensitivity of 69&#37; to 92&#37; is possible&#44; with a specificity of 32&#37; to 59&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#8211;40</span></a> Nonetheless&#44; like cervical cytology&#44; it does not adequately predict the degree of histologic involvement&#46; High-grade dysplasia detected by anal cytology has a high predictive value for histologically confirmed high-grade dysplasia&#46; Low-grade cytologic abnormalities&#44; in contrast&#44; are not a reliable reflection of the true extent of disease&#46; Atypical squamous cells of undetermined significance &#40;ASCUS&#41; and low-grade dysplasia&#44; for example&#44; may be detected in histologically confirmed high-grade dysplasia&#46; Any abnormal cytology result&#44; therefore&#44; should be followed up with high-resolution anoscopy and biopsy of suspicious areas to confirm AIN and determine the level of dysplasia&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">High-Resolution Anoscopy-Guided Biopsy</span><p id="par0145" class="elsevierStylePara elsevierViewall">High-resolution anoscopy-guided biopsy is the gold standard for diagnosing AIN&#46; In this procedure&#44; the transformation zone of the anal canal is examined through a colposcope&#44; which lights and magnifies the surface&#46; A gauze pad soaked in 3&#37; acetic acid is inserted into the canal&#44; where it is left in contact with the mucosa for several minutes&#46; Intraepithelial lesions tend to acquire a whitish color when they come in contact with this solution&#44; thus helping to identify suspicious areas for biopsy&#46; Subsequent staining with Lugol solution can also be performed&#46; AIN should be suspected on detection of acetowhitening&#44; plaques that do not take up Lugol solution&#44; or areas of the mucosa with abnormal vascular patterns&#46; <a class="elsevierStyleCrossRef" href="#fig2">Figure 2</a> shows grades 1&#44; 2&#44; and 3 AIN as seen by high-resolution anoscopy &#40;<a class="elsevierStyleCrossRef" href="#fig2">Fig&#46; 2</a>A-I&#41;&#46; Histologic evaluation of samples obtained by punch biopsy is the method of choice for diagnosing and grading AIN&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><elsevierMultimedia ident="fig2"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Testing for HPV Infection</span><p id="par0150" class="elsevierStylePara elsevierViewall">Opinions are divided on the diagnostic value of HPV testing in AIN screening because of the extremely high prevalence of HPV in the highest risk groups such as HIV-positive MSM&#46; It is widely known that most HIV-positive MSM have multiple HPV infections&#44; and infection rates vary very little between those who have AIN and those who do not&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">HPV testing is used to determine the need for high-resolution anoscopy in women with a cervical cytologic diagnosis of ASCUS&#46; In HIV-positive MSM with anal ASCUS&#44; HPV testing is probably not useful as it does not increase the specificity for detecting AIN<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> as most of these patients will harbor an oncogenic HPV variant&#46; It has been suggested&#44; however&#44; that it might be a useful addition in HIV-negative MSM&#44; in whom the sensitivity of anal cytology is lower&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> HPV testing in other risk groups such as women with a history of cervical dysplasia might also be useful due to the lower prevalence of anal HPV infection in this group&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The inclusion of HPV testing as a routine part of AIN screening might also be of value because of its negative predictive value&#46; In other words&#44; because dysplasia is not found in patients who do not have oncogenic HPV infection&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> a negative result would indicate that high-resolution anoscopy could be avoided&#46; Unfortunately&#44; this occurs only in a very small percentage of at-risk patients&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Which At-Risk Patients Should Be Considered for Screening&#63;</span><p id="par0165" class="elsevierStylePara elsevierViewall">As mentioned previously&#44; a number of major groups have an increased risk of developing AIN in association with HIV infection&#46; Exactly which patients should be referred for screening&#44; however&#44; is a complicated decision in which cost-effectiveness is an important consideration&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a> shows which individuals are at risk&#44; although it should be noted that studies to date have only shown screening to be cost-effective when performed annually in HIV-positive patients and every 2 to 3 years in HIV-negative MSM&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#44;42</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">Several official HIV guidelines such as that published by the New York State Department of Health AIDS Institute<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> recommend systematically screening for AIN in patients with HIV infection&#46; Guidelines from the Centers for Disease Control and Prevention simply state that cytology is used by many experts to screen for AIN in HIV-positive patients but do not include any specific recommendations in this respect&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Screening Algorithms</span><p id="par0175" class="elsevierStylePara elsevierViewall">There are no universal screening algorithms for AIN and most authors use the protocol proposed by Chin-Hong and Palefsky<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; According to this protocol&#44; at-risk individuals should undergo anal cytology screening following the procedure described previously&#46; In the event of a negative result&#44; the test should be repeated after 1 year in HIV-positive individuals and after 2 to 3 years in HIV-negative individuals&#46; High-resolution anoscopy-guided biopsy is indicated in patients with abnormal anal cytology&#46; If the lesions are grade 1&#44; the anoscopy should be repeated in 6 months&#44; but if they are grade 2 or 3&#44; treatment is recommended&#46; Individuals with low-grade cytology but normal anoscopy findings should be scheduled for repeat cytology in 6 months&#46; In the rare situation where a patient has high-grade cytology but a normal anoscopy&#44; blind biopsy should be performed and cytologic examination repeated shortly afterwards&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Limitations and Future Prospects of AIN Screening</span><p id="par0180" class="elsevierStylePara elsevierViewall">As mentioned previously&#44; anal cytology has similar sensitivity and specificity to cervical cytology&#44; although higher rates have been reported in patients with disease in more than 1 quadrant of the anal mucosa and in HIV-positive patients&#44; particularly when their CD4 cell count is low&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Anal cytology&#44; like cervical cytology&#44; has its limitations for screening&#44; however&#44; because it does not detect all high-grade AIN&#46; Furthermore&#44; many healthy patients are unnecessarily referred for high-resolution anoscopy&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Because of these limitations&#44; molecular diagnostic techniques are being investigated in an effort to improve the sensitivity and specificity of AIN screening&#46; Recent proposals include the use of cytologic&#44; histologic&#44; and microbiologic markers to help identify candidates for high-resolution anoscopy&#46; Of note are proteins that can be used as surrogate markers of cell cycle deregulation&#44; biomarkers of DNA damage&#44; gamma tubulin and beta defensin levels&#44; HPV typing&#44; and the identification of integrated forms of HPV&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">46&#44;47</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Finally&#44; in view of the high incidence of AIN in certain risk groups&#44; some authors have even proposed that all high-risk individuals should go directly to high-resolution anoscopy screening&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Treating AIN</span><p id="par0200" class="elsevierStylePara elsevierViewall">AIN represents a therapeutic challenge for several reasons&#46; Firstly&#44; all current treatments are associated with a risk of recurrence and metachronous lesions&#46; Treatment&#44; unfortunately&#44; does not cure the viral infection&#44; meaning that patients need to be monitored for long periods of time because of the risks associated with persistent infection by oncogenic forms of HPV&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Secondly&#44; there is no treatment of choice for AIN&#46; Approaches vary according to the location and extent of disease and the availability of resources and local expertise&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">It is not considered necessary to treat low-grade AIN unless the patient has symptoms or feels particularly anxious about the disease&#46; High-grade AIN&#44; in contrast&#44; should be treated to prevent progression to invasive carcinoma&#44; except in cases in which treatment might result in more complications than the disease itself&#46; In such cases&#44; 3-monthly to 6-monthly follow-up with high-resolution anoscopy and digital rectal examination is recommended to ensure timely detection of progression to invasive carcinoma&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">AIN can be treated with topical agents&#44; ablative therapy&#44; or surgery<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0220" class="elsevierStylePara elsevierViewall">The treatment of local AIN is relatively simple and there are many options&#44; including cryotherapy&#44; trichloroacetic acid&#44; infrared coagulation&#44; electrocautery&#44; CO<span class="elsevierStyleInf">2</span> laser&#44; and surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Treatment is more complicated in the case of more extensive disease&#46; Options include patient-administered topical treatments with curative intent or to reduce the number of lesions for subsequent treatment with ablative techniques such as infrared coagulation&#46; The main topical treatments are imiquimod<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#8211;52</span></a> and 5-fluorouracil<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> creams&#44; which are associated with histologic regression rates of 74&#37; and 57&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#8211;53</span></a> Both treatments reduce the viral load of oncogenic HPV genotypes but are also associated with high recurrence rates&#58; 58&#37; in the case of imiquimod &#40;30 months post-treatment&#41;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> and 50&#37; in the case of 5-fluorouracil &#40;6 months post-treatment&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> Most recurrences&#44; however&#44; are detected at sites other the initial AIN site and are associated with high-risk HPV genotypes other than those detected in the initial examination&#46; In other words&#44; most recurrences are due to HPV reinfection&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">One particularly interesting recent study was a double-blind&#44; placebo-controlled&#44; randomized trial of imiquimod which included the option of a second 4-month treatment cycle for nonresponders&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> During this second phase&#44; which lasted at least 36 months&#44; 61&#37; of patients achieved complete remission&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Infrared coagulation&#44; which involves the delivery of heat to induce coagulation&#44; also holds much promise as a treatment for AIN&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54&#8211;56</span></a> This modality can be used to treat extensive disease in office-based settings &#40;with or without anesthesia depending on the site of the lesions&#41;&#44; and unlike treatment with CO<span class="elsevierStyleInf">2</span> lasers&#44; does not require the use of an extractor as it does not produce smoke&#46; Several retrospective studies have indicated that infrared coagulation is a safe procedure that achieves response rates of 60&#37; to 70&#37; when used on specific AIN lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> Higher response rates have been reported in HIV-negative patients and individuals who undergo several treatment sessions&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The Role of HPV Vaccines</span><p id="par0240" class="elsevierStylePara elsevierViewall">Considering that over 70&#37; of SCCs are caused by HVP-16&#44; vaccination is a promising primary preventive measure against AIN and anal SCC&#46; In October 2009&#44; the US Food and Drug Administration approved a quadrivalent HPV vaccine for the prevention of condylomas caused by HPV types 6&#44; 11&#44; 16&#44; and 18 in males aged between 9 and 26 years&#46; One of the main problems associated with the use of this vaccine to prevent anal carcinoma in high-risk groups of men is that it is most effective in men who have not yet been infected by HPV&#46; In other words&#44; it should ideally be administered prior to sexual debut&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Because it is impossible to identify at-risk individuals before they become sexually active&#44; it would be necessary&#44; at least hypothetically&#44; to vaccinate all preadolescent males in order to reduce the incidence of anal carcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> For this to be viable&#44; however&#44; it would first be necessary to determine whether universal vaccination would be cost-effective&#44; particularly given the high cost of the vaccine and the relatively low incidence of anal SCC&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">According to the results of a recent study by Kimm<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> designed to estimate the cost-effectiveness of the quadrivalent HPV vaccine administered at the ages of 12 years&#44; 20 years&#44; or 26 years in terms of preventing AIN and anal SCC in MSM&#44; the cost-benefit ratio was highest for vaccination at 12 years&#44; but the intervention was also cost-effective at 20 and 26 years&#44; ie&#44; at ages when individuals would be more likely to ask for the vaccination&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">The fact that multiple HPV infection&#8212;like infection by other sexually transmitted diseases&#8212;has been found to be independently associated with HIV acquisition in MSM<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> would be another argument in favor of vaccinating young males&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0260" class="elsevierStylePara elsevierViewall">The value of targeted and universal AIN screening has generated much debate in the past 10 years and none of the relevant national or international guidelines recommend routine AIN screening&#46; Nevertheless&#44; the results of population-based studies and the experience of dermatologists in the past decade bear witness to the fact that anal carcinoma is increasing at an alarming rate&#44; particularly in HIV-positive patients&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">We must offer patients the best preventive treatment possible based on the knowledge accumulated to date on the role of HPV in anal carcinoma and the natural history of AIN&#46; Anal cytology is a simple&#44; noninvasive technique&#44; but before extending its use to all at-risk populations&#44; we must first be able to provide a definitive diagnosis and offer treatment in the event of cytologic abnormalities&#46; In other words&#44; patients at centers that do not offer high-resolution anoscopy should be referred to centers that do&#46; When this is not possible&#44; high-risk patients should be followed closely and tests should include digital rectal examination to test for masses suggestive of anal carcinoma&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">In our opinion&#44; and in line with practices in other European countries&#44; AIN screening can and should be offered by dermatologists&#44; who are&#44; indeed&#44; specialists in sexually transmitted diseases&#44; with the aim of diagnosing and treating intraepithelial lesions associated with HPV&#46; That said&#44; the approach should be multidisciplinary and involve close collaboration with specialists from other departments such as internal medicine&#44; general surgery&#44; digestive surgery&#44; microbiology&#44; and pathology to offer patients the best possible care&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">Finally&#44; further studies are needed to develop an optimal AIN screening protocol and&#44; more importantly&#44; to establish appropriate guidelines and treatment&#46;</p></span></span>"
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          "titulo" => "Abstract"
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          "identificador" => "xpalclavsec82645"
          "titulo" => "Keywords"
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          "identificador" => "xres95486"
          "titulo" => "Resumen"
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          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
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        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Epidemiology of Anal SCC"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Etiopathogeny"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "The Natural History of AIN"
        ]
        8 => array:3 [
          "identificador" => "sec0025"
          "titulo" => "Screening for AIN by Cytology and High-Resolution Anoscopy"
          "secciones" => array:6 [
            0 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Anal Cytology"
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            1 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "High-Resolution Anoscopy-Guided Biopsy"
            ]
            2 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Testing for HPV Infection"
            ]
            3 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Which At-Risk Patients Should Be Considered for Screening&#63;"
            ]
            4 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Screening Algorithms"
            ]
            5 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Limitations and Future Prospects of AIN Screening"
            ]
          ]
        ]
        9 => array:2 [
          "identificador" => "sec0060"
          "titulo" => "Treating AIN"
        ]
        10 => array:2 [
          "identificador" => "sec0065"
          "titulo" => "The Role of HPV Vaccines"
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        11 => array:2 [
          "identificador" => "sec0070"
          "titulo" => "Conclusions"
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          "titulo" => "References"
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    "tienePdf" => true
    "fechaRecibido" => "2010-11-01"
    "fechaAceptado" => "2011-01-27"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec82645"
          "palabras" => array:4 [
            0 => "Anal intraepithelial neoplasia"
            1 => "Anal squamous cell carcinoma"
            2 => "Screening"
            3 => "Human papillomavirus"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec82646"
          "palabras" => array:4 [
            0 => "Neoplasia intraepitelial anal"
            1 => "Carcinoma epidermoide anal"
            2 => "Cribado"
            3 => "Virus del papiloma humano"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The incidence of anal squamous cell carcinoma has increased alarmingly&#44; particularly in high-risk groups such as men who have sex with men and immunosuppressed patients&#46; Infection with an oncogenic strain of the human papillomavirus in the anal canal or perianal skin leads to anal intraepithelial neoplasias &#40;AIN&#41;&#44; progressive dysplastic intraepithelial lesions that are the precursors of anal squamous cell carcinoma&#46; AIN can be diagnosed through cytological screening and biopsy guided by high-resolution anoscopy and can be treated using a range of procedures in an effort to prevent progression to invasive anal carcinoma&#46; Given the recent advances in the understanding of this disease&#44; and the increasing calls from experts for the establishment of screening programs to identify AIN&#44; we review current knowledge on the condition&#44; its diagnosis&#44; and treatment from the point of view of dermatology&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La incidencia de carcinoma epidermoide anal ha aumentado de forma alarmante&#44; especialmente en grupos de riesgo como son los pacientes homosexuales y los inmunosuprimidos&#46; La infecci&#243;n por un genotipo oncog&#233;nico del virus del papiloma humano &#40;VPH&#41; en el canal anal o en la piel perianal&#44; desencadena una progresi&#243;n de lesiones displ&#225;sicas intraepiteliales &#40;neoplasia intraepitelial anal o NIA&#41;&#44; que son las precursoras del carcinoma epidermoide anal&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La NIA puede diagnosticarse a trav&#233;s del cribado mediante citolog&#237;a y biopsia guiada por anoscopia de alta resoluci&#243;n&#44; y puede tratarse mediante diferentes procedimientos&#44; con el fin de evitar la progresi&#243;n a carcinoma anal invasivo&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">En vista de los recientes avances en el conocimiento de esta patolog&#237;a&#44; y de que cada vez son m&#225;s los expertos que recomiendan la puesta en marcha de programas de cribado de la NIA&#44; revisamos el concepto actual de la misma&#44; su diagn&#243;stico y tratamiento desde una perspectiva dermatol&#243;gica&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Sendagorta E&#44; et al&#46; Detecci&#243;n precoz de la neoplasia intraepitelial anal en pacientes de alto riesgo&#46; Actas Dermosifiliogr&#46;2011&#59;102&#58;757-765&#46;</p>"
      ]
    ]
    "multimedia" => array:4 [
      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "fuente" => "Algorithm adapted with permission from Dr&#46; JM&#46; Palefsky &#40;Chin-Hong PV&#44; Palefsky JM 9&#41;&#46;"
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            "imagen" => "gr1.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Screening algorithm adapted from Chin-Hong and Palefsky&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> AIN indicates anal intraepithelial neoplasia&#59; ASCUS&#44; atypical squamous cells of undetermined significance&#59; HG&#44; high-grade&#59; HIV&#44; human immunodeficiency virus&#59; HSIL&#44; high-grade squamous intraepithelial lesions&#59; LG&#44; low-grade&#59; LSIL&#44; low-grade squamous intraepithelial lesions&#46;</p>"
        ]
      ]
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        "identificador" => "fig2"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A&#44; Condyloma in a patient with grade 1 anal intraepithelial neoplasia &#40;AIN&#41;&#46; B&#44; Grade 2 AIN showing a papillomatous pattern with vascular punctation&#46; C&#44; Acetowhite plaque with abnormal vascularization in the upper right and left quadrants in a patient diagnosed with grade 2 AIN&#46; D&#44; Extensive acetowhite plaque with a cobblestone appearance in lower right and left quadrants in a patient with grade 2 AIN&#46; E&#44; Circumscribed acetowhite plaque in the upper left quadrant&#44; corresponding to grade 2 AIN&#46; F&#44; Circumferential acetowhite plaques in a patient with grade 3 AIN&#46; G&#44; Acetowhite plaques and friable mucosa with hemorrhagic&#44; erosive areas in a patient with grade 3 AIN&#46; H&#44; Acetowhite plaque and thick&#44; tortuous vessels in upper quadrants&#46; I&#44; Exudative&#44; hemorrhagic mass in a patient with infiltrating squamous cell carcinoma&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Patients at risk of developing anal squamous cell carcinoma&#44; with lower-risk groups shown at the base of the pyramid and higher-risk groups at the top&#46; HIV indicates human immunodeficiency virus&#59; MSM&#44; men who have sex with men&#46;</p>"
        ]
      ]
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                  \t\t\t\t" style="border-bottom: 2px solid black">Topical Treatment&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Ablative Therapy&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">85&#37; trichloroacetic acid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Infrared coagulation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Liquid nitrogen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Electrocautery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#37; imiquimod cream&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">CO<span class="elsevierStyleInf">2</span> laser&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5-Fluorouracil cream&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Surgery&nbsp;\t\t\t\t\t\t\n
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              "imagenFichero" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Documented Treatments for Anal Intraepithelial Neoplasia&#46;</p>"
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      ]
    ]
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
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            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                            0 => "L&#46;G&#46; Jhonson"
                            1 => "M&#46;M&#46; Madelein"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
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                      "Revista" => array:6 [
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                            "web" => "Medline"
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                        ]
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                  ]
                  "host" => array:1 [
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            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
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                      "autores" => array:1 [
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "HIV-associated anal cancer&#58; has highly active antiretroviral therapy reduced the incidence or improved the outcome&#63; J Acquir Immune Defic Syndr"
                        "fecha" => "2004"
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                        "paginaInicial" => "1563"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15577408"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Marked increase in the incidence of invasive anal cancer among HIV infected patients despite treatment with combination antiretroviral therapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Pikkety"
                            1 => "Selinger-Leneman"
                            2 => "S&#46; Grabar"
                            3 => "C&#46; Duvivier"
                            4 => "M&#46; Bonmarchand"
                            5 => "L&#46; Abramowitz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "AIDS"
                        "fecha" => "2008"
                        "volumen" => "19"
                        "paginaInicial" => "1203"
                        "paginaFinal" => "1211"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Incidence of anal cancer in California&#58; increased incidence among men in San Francisco&#44; 1973&#8211;1999"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "R&#46;D&#46; Cress"
                            1 => "E&#46;A&#46; Holly"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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                        "fecha" => "2003"
                        "volumen" => "36"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12689800"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cancer in a population based cohort of men and women in registered homosexual partnerships"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46; Frisch"
                            1 => "E&#46; Smith"
                            2 => "A&#46; Grulich"
                            3 => "C&#46; Johansen"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:1 [
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                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46;V&#46; Chin-Hong"
                            1 => "E&#46; Vittinghoff"
                            2 => "R&#46;D&#46; Cranston"
                            3 => "L&#46; Browne"
                            4 => "S&#46; Buchbinder"
                            5 => "G&#46; Colfax"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/jnci/dji163"
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                        ]
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                    ]
                  ]
                ]
              ]
            ]
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sexual practices&#44; sexually transmitted diseases&#44; and the incidence of anal cancer"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;R&#46; Daling"
                            1 => "N&#46;S&#46; Weiss"
                            2 => "T&#46;G&#46; Hislop"
                            3 => "C&#46; Maden"
                            4 => "R&#46;J&#46; Coates"
                            5 => "K&#46;J&#46; Sherman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJM198710153171601"
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            ]
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                  "contribucion" => array:1 [
                    0 => array:2 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "P&#46;V&#46; Chin-Hong"
                            1 => "J&#46;M&#46; Palefsky"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
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                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0140673600036229"
                          "estado" => "S300"
                          "issn" => "01406736"
                        ]
                      ]
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                ]
              ]
            ]
            9 => array:3 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
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                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "Infectious Disease Clinical Research Program HIV Working Group"
                          "etal" => true
                          "autores" => array:6 [
                            0 => "N&#46;F&#46; Crum-Cianflone"
                            1 => "K&#46;H&#46; Hullsiek"
                            2 => "V&#46;C&#46; Marconi"
                            3 => "A&#46; Ganesan"
                            4 => "A&#46; Weintrob"
                            5 => "R&#46;V&#46; Barthel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
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                        "tituloSerie" => "AIDS"
                        "fecha" => "2010"
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