P47 – HPV associated anal lesions: a surgical infection?

Author(s):
Hugo Bonatti, B. Bruene, J. Wehnemann, Michael Oberwalder, Irmgard Kronberger, Friedrich Conrad, Felix Aigner, Easton Memorial Hospital

Background: Treatment concepts of human papilloma virus (HPV) associated anogenital infections include conservative treatment with local chemotherapy, immunomodulatory agents and antivirals but surgical management is still the most common approach.

Hypothesis: Anogenital HPV lesions are common and have a high recurrence rate.

Methods: Data of 433 patients (320 female, 73.9%) with a mean age of 30.1 ± 11.8 years treated at our proctology clinic for anogenital warts during a five year period were retrospectively analyzed. Patients were divided into three groups: predominant genital, anal, perianal lesions. 25 individuals had HIV infection; there were 32 pregnant women and 10 transplant recipients.

Results: A total of 410 patients (94.8%) presented with Condylomata accuminata. In 263 individuals (60.8%) both the genital and the anal region were involved, in 90% both areas were treated simultaneously using electrocautery. A total of 646 lesions (231 in the anal canal, 282 in the perianal region and 133 genital) were recorded and followed for an average of 10 (range 1-87) months. Of those having anal HPV infection, most lesions were found in the anal canal spreading to the perianal area (n=225, 52%). Isolated affection of the anal canal was seen in 26 patients (6%) and of the perianal region in 139 patients (32.1%). Anal intraepithelial neoplasia was diagnosed in 18 patients (4.1%) and anal squamous cancer in 19 patients (4.3%) including one giant condyloma (Buschke-Lowenstein). Primary non operative treatment of HPV associated lesions with imiquimod (n=11), trichloroacetic acid (n=1), podophyllotoxin (n=1) and the antiviral agent cidofovir (n=1) was exclusively used in the anal region for subsets of patients with either comorbidities precluding surgery and, in transplant recipients. Recurrence rates were 32% for genital, 28% for perianal and 23% for lesions in the anal canal. Recurrence rates for HIV infected individuals, pregnant women and transplant recipients exceeded 50%. Recurrent conylomata accuminata (n=176) were predominantly treated by repeat surgical intervention (66.8%).

Conclusions: Recurrence rates of anogenital HPV lesions remain high. Universal immunization against HPV may reduce incidence and prevalence of the disease, however, the available vaccines do not cover many HPV strains causing conylomata accuminata. Imiquimod and cidofovir represent promising new agents for subsets of patients.