Resolving Clinically Indeterminate Findings During Anal Cancer Surveillance with TTMV-HPV DNA
by
, , , , , , , and
Rafi Kabarriti
1,†, 
Shane Lloyd
2,*,†,
James Jabalee
3,
Laurie M. Gay
3,
Tyler Slater
2,
Kayleen Guzman
2,
Corbin Jacobs
4,
Sean Inocencio
4,
Ray Lin
5,
Cammie Nguyen
5,
Iain MacEwan
6,
Alexandra H. Crawford
6,
Michael Rutenberg
7,
Jaswinder Singh
8,
Jennifer Ross
8,
Sophia Kim-Wang
9,
Chance Matthiesen
10,
Kasha Neff
10,
Gene-Fu Liu
11,
Tiffany M. Juarez
11 and
Stanley L. Liauw
9,*add
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1
Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY 10467, USA
2
Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT 84113, USA
3
Naveris, Inc., Waltham, MA 02451, USA
4
Cancer Care Northwest, Spokane Valley, WA 99216, USA
5
Scripps Health, San Diego, CA 92121, USA
6
California Protons Cancer Therapy Center, San Diego, CA 92121, USA
7
Mayo Clinic, Jacksonville, FL 32224, USA
8
MidAmerica Cancer Care, LLC, Kansas City, MO 64132, USA
9
Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL 60637, USA
10
Freeman Radiation Oncology, Joplin, MO 64804, USA
11
Providence Mission Hospital, Mission Viejo, CA 92691, USA
*
Authors to whom correspondence should be addressed.
†
These authors contributed equally to this work.
Cancers 2026, 18(1), 35; https://doi.org/10.3390/cancers18010035
Submission received: 22 November 2025
/
Revised: 13 December 2025
/
Accepted: 16 December 2025
/
Published: 22 December 2025
(This article belongs to the Special Issue Roles of the Tumor Microenvironment on Liquid Biopsy (2nd Edition))
Simple Summary
During post-treatment surveillance for anal squamous cell carcinoma (ASCC), clinical examination, anoscopy, and imaging frequently yield inconclusive findings that cannot be confidently classified as the presence or absence of disease. These clinically indeterminate findings (CIFs) delay care decisions and lead to additional procedures that carry financial, physical, and psychological burden. Circulating tumor tissue-modified viral (TTMV)-HPV DNA measured from plasma is accessible, repeatable, and independent of local post-treatment anatomic changes. In this multi-center retrospective cohort, TTMV-HPV DNA testing accurately resolved 92% of CIFs and positive tests often served as the earliest indicator of recurrence. These findings support the clinical utility of TTMV-HPV DNA to clarify indeterminate assessments post-treatment and help guide next steps in care.
Abstract
Background/Objectives: Surveillance for anal squamous cell carcinoma (ASCC) recurrence relies on clinical examination and imaging. Post-treatment edema, fibrosis, and inflammation can result in clinically indeterminate findings (CIFs) that delay diagnosis and increase patient and system burden. Circulating tumor tissue-modified viral (TTMV)-HPV DNA offers a biologically specific, noninvasive biomarker that may clarify equivocal assessments. Methods: In this multi-center retrospective study, 233 patients with HPV-associated ASCC were evaluated, including 185 with ≥1 post-treatment TTMV-HPV DNA test. CIFs were defined as exams or imaging results not definitively positive or negative for disease, and were paired with subsequent TTMV-HPV DNA tests. Concordance was defined by prespecified follow-up windows comparing TTMV-HPV DNA results with subsequent clinical outcomes. Results: Ninety patients (39%) experienced 214 CIFs, arising from exams (46%, 98) or imaging (54%, 116). Indeterminate rates by assessment were 7% for exams, 17% for imaging, and 1.3% for TTMV-HPV DNA testing. Overall, 52 CIF/TTMV-HPV DNA pairs were eligible for analysis, and TTMV-HPV DNA resolved disease status accurately for 48/52 (92%, 95% CI: 81.5–97.9). Negative tests predicted cancer-free status for 37/41 CIFs (90%), while 100% of positive tests (11/11) were concordant with clinically confirmed recurrence. In 73% of positive cases (8/11), TTMV-HPV DNA was the first indication of recurrence (median lead-time 29 days; IQR 25–147). Conclusions: TTMV-HPV DNA testing reliably clarifies clinically indeterminate findings during ASCC surveillance, demonstrating high accuracy (92%) and earlier detection of recurrence. These data support integration into post-treatment management to reduce diagnostic uncertainty and guide timely care.
Keywords:
TTMV-HPV DNA; HPV; ASCC; post-treatment; surveillance; anal cancer; ctDNA; circulating tumor DNA
