Surgical Service, VA San Diego Healthcare System, and Department of Surgery, University of California, San Diego.
Dis Colon Rectum. 2018 Dec;61(12):1357-1363. doi: 10.1097/DCR.0000000000001180.
Both ablation and expectant management of high-grade squamous intraepithelial lesions have been proposed. Expectant management would be reasonable if 1) the rate of high-grade squamous epithelial lesion progression to anal squamous cell carcinoma were low, and 2) anal squamous cell carcinoma arising under surveillance had a better prognosis than anal squamous cell carcinoma presenting without an identified precursor.
This study aims to quantify aspects of high-grade squamous epithelial lesion/anal squamous cell carcinoma clinical evolution in a surgical practice.
This is a retrospective cohort study.
This study was performed in 1 colorectal surgeon's practice over a 20-year period.
Consecutive patients with high-grade squamous intraepithelial lesion and anal squamous cell carcinoma were included.
We looked at the rate and timing of progression to anal squamous cell carcinoma, and the stage, treatment, and outcome of anal squamous cell carcinoma. We reviewed a comparison group of HIV-positive patients presenting de novo with anal squamous cell carcinoma (no prior history of high-grade squamous intraepithelial lesion).
With consideration of only HIV-positive patients, 341 patients had a mean 5.6 years follow-up from high-grade squamous intraepithelial lesion diagnosis to the most recent documented anal examination. Twenty-four of these surveillance patients developed anal squamous cell carcinoma, yielding a progression rate of 1.3% per patient-year. Mean follow-up was 7.3 years from the initial cancer diagnosis to the most recent contact. Forty-seven patients who presented de novo with anal squamous cell carcinoma developed 74 lesions, with a mean follow-up of 5.7 years after initial diagnosis. This de novo group had higher anal squamous cell carcinoma-specific mortality (3% per patient-year vs 0.05%). Our study did not show a significantly higher rate of high stage (stage III or IV) at anal squamous cell carcinoma diagnosis in the de novo group in comparison with the surveillance group (25.5% vs 8.3% (p = 0.09)).
This study was retrospective in nature and had a predominately male population.
The progression of untreated high-grade squamous intraepithelial lesion to anal squamous cell carcinoma approximates 1% per patient-year. Anal squamous cell carcinoma developing under surveillance tends to be of an earlier stage and to require fewer major interventions than anal squamous cell carcinoma presenting de novo. Cancer-specific mortality was lower for malignancies that developed under surveillance. We suggest that expectant management of patients with high-grade squamous intraepithelial lesion is a rational strategy for preventing anal cancer morbidity. See Video Abstract at http://links.lww.com/DCR/A699.
人们曾提出过对高级别鳞状上皮内病变（HSIL）进行消融治疗和观察等待治疗。如果 1）HSIL 进展为肛门鳞状细胞癌的风险较低，2）接受监测的肛门鳞状细胞癌的预后要好于没有明确前驱病变的肛门鳞状细胞癌，则观察等待治疗是合理的。
本研究旨在量化外科实践中 HSIL/肛门鳞状细胞癌临床演变的各个方面。
这是一项回顾性队列研究。
本研究在 20 年间于 1 位结直肠外科医生的诊室中进行。
连续纳入患有 HSIL 和肛门鳞状细胞癌的患者。
我们观察了进展为肛门鳞状细胞癌的速度和时间，以及肛门鳞状细胞癌的分期、治疗和结局。我们还回顾了一组首发肛门鳞状细胞癌（无 HSIL 病史）的 HIV 阳性患者作为比较组。
考虑到仅为 HIV 阳性患者，341 例患者从 HSIL 诊断到最近一次有记录的肛门检查的平均随访时间为 5.6 年。在这些接受监测的患者中，有 24 例发展为肛门鳞状细胞癌，患者年进展率为 1.3%。从首次癌症诊断到最近一次就诊的平均随访时间为 7.3 年。47 例首发肛门鳞状细胞癌患者共出现 74 个病灶，首次诊断后的平均随访时间为 5.7 年。新发组肛门鳞状细胞癌的特异性死亡率更高（3%/患者年，而 0.05%/患者年）。我们的研究并未显示新发组肛门鳞状细胞癌的分期（III 期或 IV 期）明显高于监测组（25.5%比 8.3%（p=0.09））。
本研究为回顾性研究，且主要为男性人群。
未经治疗的 HSIL 进展为肛门鳞状细胞癌的速度约为每年 1%/患者。接受监测的肛门鳞状细胞癌往往分期更早，需要的主要干预措施也更少，而新发的肛门鳞状细胞癌则需要更多的干预措施。在监测下发展的癌症的癌症特异性死亡率较低。我们建议，对 HSIL 患者进行观察等待治疗是预防肛门癌发病率的合理策略。
