Screening Patients at High Risk.

As colorectal surgeons we read this important article with great interest (1). The authors correctly report that the incidence of anal cancer rises in HIV positive patients. The increased incidence in patients who are medically immunocompromised (for example, transplant patients) is not mentioned in the text in addition to other risk factors. The authors write: “There are no international, globally accepted, guidelines for screening in high-risk groups.” In September 2013 the Association of the Scientific Medical Societies in Germany (AWMF) published a “German-Austrian” guideline (2), in which screening in this high-risk group (HIV positive patients) was described. In our opinion, this guideline is the only German-language guideline that deals with human papillomaviruses (HPV), anal dysplasias, and anal carcinomas. We are not aware of any general German guideline for anal cancers. With regard to surgical treatment, the authors report that only T1 cancers of the anal margin should be excised. The guideline of the American Society of Colon and Rectal Surgeons (ASCRS), however, refers only to “small lesions,” without providing any information on tumor size or safety margin. In the AWMF guideline mentioned earlier, local excision of T1 and T2 tumors is an option in HIV patients. For dermatologists, R0 excision of squamous cell carcinomas measuring 3 cm (=T2) outside the 5 cm anal margin is entirely justified (3). For this reason it is confusing if the authors of the present article recommend automatic radiochemotherapy for such T2 tumors within the anal margin (3). The authors report that during follow-up care, incision biopsy is not permitted if relapse is suspected, “as the risk of incontinence or severely delayed wound healing is extremely high.” Radiochemotherapy has follow-on effects over time, and confirmation of a recurrence by means of a biopsy should be avoided in the first three months. In suspected superficial local recurrence, we think that a small superficial incision biopsy is possible without damaging the anal sphincter.