Systematic Review of guidelines for the assessment and management of High Grade Anal Intraepithelial Neoplasia (AIN II/III)
Alam, Nasra N
White, D. A.
Narang, Sunil K.
Daniels, Ian R.
Smart, Neil J.
JournalColorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland
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AIM: There is ambiguity with regard to the optimal management of AIN III. The aim of this review was to assess and compare international/national society guidelines currently available in the literature on the management, treatment and surveillance of AIN III. We also aimed to assess the quality of the studies used to compile the guidelines and to clarify the terminology used in histological assessment. METHOD: An electronic search of PubMed and Embase was performed using the search terms 'anal intraepithelial neoplasia', 'AIN', 'anal cancer', 'guidelines', 'surveillance' and 'management'. Literature reviews and guidelines or practice guidelines in peer reviewed journals from 1st January 2000 to 31st December 2014, assessing the treatment, surveillance or management of patients with AIN related to HPV were included. The guidelines identified by the search were assessed for the quality of evidence behind them using the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence. RESULTS: The database search identified 5159 articles and two further guidelines were sourced from official body guidelines. After inclusion criteria were applied, 28 full text papers were reviewed. Twenty-five of these were excluded, leaving three guidelines for inclusion in the systematic review including those published by the Association of Coloproctology of Great Britain and Ireland (ACPGBI), the American Society of Colon and Rectal Surgeons (ASCRS) and the Italian Society of Colorectal Surgery (SICCR). There were no guidelines identified on the management of AIN III from HIV associations and societies. All three guidelines agree that a high index of clinical suspicion is essential for diagnosing AIN with a disease-specific history, physical examination, digital rectal examination and anal cytology. There is interchange of terminology from High Grade AIN (HGAIN) (which incorporates AIN II/III) and AIN III between the literature leading to confusion in therapy use. Treatment varies from immunomodulation and photodynamic therapy to targeted destruction of areas of HGAIN/AIN II/III using infrared coagulation, electrocautery, cryotherapy or surgical excision but with little consensus between the guidelines. Recommendations on surveillance strategies were similarly discordant, ranging from six-monthly physical examination to annual anoscopy +/- biopsy. Over 50% of the recommendations are based on Level 3 or Level 4 evidence and many were compiled using studies that were greater than 10 years old. CONCLUSION: Despite concordance regarding diagnosis, there is significant variation amongst the guidelines over recommendations on the treatment and surveillance of patients with HGAIN/AIN II/III. All three sets of guidelines are based on low level, out-dated evidence originating from the 1980s and 1990s. This article is protected by copyright. All rights reserved.