Websky Martin W von, Wesselmann Paul C, Schwarze-Zander Carolynne, Vilz Tim Oliver, Stoffels Burkhard, Boesecke Christoph, Rockstroh Jürgen, Kalff Jörg C, Pantelis Dimitrios
Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Deutschland.
Medizinische Klinik und Polikinik I, Universitätsklinikum Bonn, Deutschland.
Zentralbl Chir. 2019 Aug;144(4):349-354. doi: 10.1055/a-0632-2017. Epub 2018 Jul 3.
In HIV-patients, routine proctological assessment is warranted due to the high incidence of human papilloma virus (HPV) infection-related anogenital lesions, such as Condylomata acuminata (C. ac.), anal intraepithelial dysplasia (AIN) and anal cancer. For C. ac. and AIN, surgical resection and topical therapy with imiquimod have been discussed as treatment options.
In this study, we contrasted surgical resection and topical imiquimod therapy of HPV-associated anal lesions in HIV-patients, with a focus on healing rates and clinical outcome. We also analysed whether a synergistic treatment effect was detectable.
This was a retrospective analysis of 97 HIV patients who underwent proctological evaluation and treatment over a 10-year period (11/2004 - 11/2015) at our centre. Initial success of surgical treatment, topical imiquimod therapy and the combination of the two strategies were compared.
In 53/97 patients (54%), HPV-associated anal disease was diagnosed upon the first visit. In approx. 50% of the patients, the HIV infection was adequately controlled (52 patients with viral load < 40 copies [53.6%]) under cART. The mean age was 41.0 ± 11.6 years. In 7/53 patients with macroscopic C. ac., low-grade and in 18/53 patients high-grade AIN were additionally confirmed. Success rates of surgical resection, imiquimod treatment and the combination of the two were compared. Complete remission of C. ac. and AIN four weeks after treatment was considered a therapeutic success. For C. ac., success rates with imiquimod were 5/25 (20.0%) vs. surgery* 30/57 (52.6%, Mann-Whitney U test p < 0.05) vs. surgery+imiquimod 7/15 (46.7%). For AIN, success rates with imiquimod were 4/24 (16.7%) vs. surgery* 47/83 (56.7%, Mann-Whitney U test p < 0.05) vs. surgery+imiquimod 9/21 (42.8%). In 7/92 (13%) of surgical treatments, complications were reported: four minor and two significant bleeding episodes and one perianal thrombosis. No side effects of imiquimod were documented besides skin irritation.
Surgery is more effective than topical imiquimod as initial therapy of HPV-related anogenital disease in HIV-patients. A synergistic effect could not be demonstrated. On this basis, we recommend surgical treatment of C. ac. and AIN in HIV-patients as first line treatment.
在艾滋病患者中，由于人乳头瘤病毒（HPV）感染相关的肛门生殖器病变（如尖锐湿疣、肛门上皮内发育异常和肛门癌）的高发病率，进行常规直肠病学评估是必要的。对于尖锐湿疣和肛门上皮内发育异常，已讨论过手术切除和咪喹莫特局部治疗作为治疗选择。
在本研究中，我们对比了艾滋病患者HPV相关肛门病变的手术切除和咪喹莫特局部治疗，重点关注愈合率和临床结果。我们还分析了是否能检测到协同治疗效果。
这是一项对97例在我们中心10年期间（2004年11月 - 2015年11月）接受直肠病学评估和治疗的艾滋病患者的回顾性分析。比较了手术治疗、咪喹莫特局部治疗以及两种策略联合治疗的初始成功率。
在53/97例患者（54%）中，初诊时诊断出HPV相关肛门疾病。约50%的患者在抗逆转录病毒治疗（cART）下，HIV感染得到充分控制（52例病毒载量 < 40拷贝[53.6%]）。平均年龄为41.0 ± 11.6岁。在53例有肉眼可见尖锐湿疣的患者中，另外确诊7例低度和18例高度肛门上皮内发育异常。比较了手术切除、咪喹莫特治疗以及两者联合治疗的成功率。治疗四周后尖锐湿疣和肛门上皮内发育异常的完全缓解被视为治疗成功。对于尖锐湿疣，咪喹莫特治疗的成功率为5/25（20.0%），手术为30/57（52.6%，曼 - 惠特尼U检验p < 0.05），手术 + 咪喹莫特为7/15（46.7%）。对于肛门上皮内发育异常，咪喹莫特治疗的成功率为4/24（16.7%），手术为47/83（56.7%，曼 - 惠特尼U检验p < 0.05），手术 + 咪喹莫特为9/21（42.8%）。在92例手术治疗中有7例（13%）报告了并发症：4例轻微和2例严重出血事件以及1例肛周血栓形成。除皮肤刺激外，未记录到咪喹莫特的副作用。
在艾滋病患者中，手术作为HPV相关肛门生殖器疾病的初始治疗比咪喹莫特局部治疗更有效。未证明有协同作用。在此基础上，我们建议将艾滋病患者尖锐湿疣和肛门上皮内发育异常的手术治疗作为一线治疗。
