What are the treatment guidelines for High-grade Squamous Intraepithelial Lesions (HSIL)?

From the Guidelines

For the treatment of High-grade Squamous Intraepithelial Lesions (HSIL), an immediate loop electrosurgical excision or colposcopy with endocervical assessment is the recommended approach, except in special populations. This recommendation is based on the 2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests 1. The management of HSIL involves several key considerations, including:

• Immediate loop electrosurgical excision or colposcopy with endocervical assessment as an acceptable method for managing women with HSIL
• Observation for up to 24 months using both colposcopy and cytology at 6-month intervals if CIN 2,3 is not identified histologically, provided the colposcopic examination is satisfactory and endocervical sampling is negative
• A diagnostic excisional procedure in exceptional circumstances or if HSIL persists for 24 months without identification of CIN 2,3
• Management following the 2006 Consensus Guideline for the Management of Women with Cervical Intraepithelial Neoplasia if CIN 2,3 is identified histologically

The choice of treatment depends on various factors, including the patient's age, pregnancy status, and lesion characteristics. For adolescents and young women with HSIL, a diagnostic excisional procedure is recommended when colposcopy is unsatisfactory or CIN of any grade is identified on endocervical assessment 1. After treatment, follow-up is crucial, with repeat colposcopy and cytology recommended at regular intervals to monitor for any recurrence or progression of the disease. The goal of treatment is to remove the abnormal cells that could potentially progress to cervical cancer, thereby reducing the risk of morbidity and mortality associated with this disease.

From the Research

Treatment Guidelines for High-Grade Squamous Intraepithelial Lesions (HSIL)

• The treatment of choice for HSIL is Loop Electrosurgical Excision Procedure (LEEP) conization, especially in cases with negative surgical margins 2.
• LEEP is a therapeutic option following biopsy diagnosis of HSIL, and most LEEPs will confirm the HSIL biopsy diagnosis 3.
• Cold-knife conization (CKC) is also an effective treatment for HSIL, with a lower incidence of post-operative infection compared to LEEP 4.
• A "see and treat" management approach, where colposcopy and LLETZ are performed at the same visit, can be a cost-effective and convenient option for patients with HSIL Pap smears 5.
• Treatment of anal HSIL can prevent anal cancer, and office-based ablative procedures, ablation or excision under anesthesia, or topical fluorouracil or imiquimod can be effective treatment options 6.

Treatment Outcomes

• The recurrence rate for HSIL after LEEP treatment with negative surgical margins is very low, with 3.3% of patients developing abnormal Pap smears and 1.1% showing cervical dysplasia at biopsy 2.
• The frequency of negative LEEP findings following HSIL biopsies is 24%, and this does not portend a different clinical follow-up from a positive biopsy and positive LEEP result 3.
• The incidence of persistent cervical infection after CKC operation is lower than that of after LEEP surgery 4.
• Treatment of anal HSIL can reduce the risk of anal cancer by 57% compared to active monitoring 6.

Clinical Considerations

• Surveillance after LEEP treatment is necessary due to the potential for recurrence 2.
• Clinicians should pay attention to the pathogen isolated from cervical post-operative secretion to control subsequent surgical inflammation 4.
• High-resolution anoscopy and biopsy should be performed regularly to monitor for suspected ongoing HSIL or cancer 6.