Electrocautery ablation: safe and effective treatment of high-grade pre-cancerous anal lesions in gay men

A clinic-based intervention offers safe and effective treatment for high-grade pre-cancerous anal lesions, US investigators report in the online edition of the Journal of Acquired Immune Deficiency Syndromes.

Doctors at the Mount Sinai School of Medicine, New York, used a technique called electrocautery ablation to treat pre-cancerous anal lesions in 232 gay men, 132 of whom were HIV-positive.

Eighteen months after treatment, 83% of HIV-negative men and 69% of those with HIV were free of high-grade pre-cancerous anal lesions.

“Electrocautery ablation of high-grade anal squamous intraepithelial lesions is a safe and effective office-based procedure comparable to other available treatments,” comment the investigators.

Incidence of anal cancer has increased dramatically among gay men in recent years. HIV-positive gay men appear to be especially vulnerable to the disease, and its incidence is five-times higher in these patients compared to HIV-negative men.

Infection with high certain high-risk strains of human papillomavirus can cause cell changes in the anus, resulting in the formation of lesions. The severity of these changes is graded, and between 9% and 13% of high-grade lesions progress to anal cancer.

There are a number of treatments for these pre-cancerous lesions including infrared coagulation and topical creams such as imiquimod.

Another therapy is electrocautery ablation. The investigators described the procedure thus: “Using a gentle brushing technique the lesion was ablated [worn down] by moving [a] blade lightly across the surface like a paint-brush.” The therapy has a number of advantages and can be performed in clinics without the need for anaesthetic or sedation.

Investigators wished to assess the safety and effectiveness of this procedure. They therefore retrospectively analysed the notes of gay men who had the treatment between 2006 and 2010. The patients received an initial treatment and were then followed at intervals of three to six months and were provided with additional treatment if necessary.

At the first treatment session, a total of 375 lesions were treated in HIV-infected men compared to 226 lesions in the HIV-negative patients, a significant difference (p = 0.006).

Lesions recurred in 53% of HIV-negative men (mean number of lesions, 1.6) and in 61% of HIV-positive men (mean number of lesions, 1.9).

The number of lesions present at the time of the initial treatment session was associated with the risk of recurrence. Patients with only one lesion at this time were 55% and 73% less likely to experience a recurrence than individuals with two or three lesions (p = 0.008 and p < 0.001 respectively).

The persistence of individual lesions after the initial session of treatment was also examined by the researchers. They found a cure rate of 85% in HIV-negative individuals and 75% in HIV-positive patients.

The first treatment session appeared to offer the best chance of eradicating lesions. In HIV-negative patients the persistence rate after a second ablation treatment was 3.03 times greater than that observed after the first session.

Further analysis showed that lesions were a significant 2.34 times more likely to recur in HIV-positive men compared to HIV-negative men after a second treatment (p = 0.008).

“Extensive dysplastic tissue may indicate either infection with more oncogenic virus or a more immune compromised host,” suggest the investigators.

Nevertheless, at the last follow-up visit, 83% of HIV-negative individuals and 69% of men with HIV were free of high-grade anal lesions.

Such a level of efficacy is comparable to that achieved with alternative therapies.

“Given that infrared coagulation and electrocautery ablation have similar outcomes when treating high-grade anal squamous intraepithelial lesions, the choice of modality should be based on clinician comfort and preference,” comment the authors. “In our hands the overall impression was that electrocautery ablation seemed faster, more hemostatic and allowed more extensive disease to be treated in office.”

Pain after treatment was the most commonly reported side-effect. However, this was adequately controlled with mild painkillers. One HIV-positive patient progressed to anal cancer, despite multiple ablation treatments.

“While we documented a single progression (0.4%), rates were far lower tan series advocating a ‘watch and wait’ approach,” conclude the authors.