What is the recommended management for a 42-year-old patient with Low-Grade Squamous Intraepithelial Lesions (LGSIL) and positive high-risk Human Papillomavirus (HPV) (excluding types 26 and 18), but with a negative HPV screening in 2023?

Management of LGSIL with Positive High-Risk HPV in a 42-Year-Old Patient

The recommended management for a 42-year-old patient with LGSIL and positive high-risk HPV (excluding types 16 and 18) who had a negative HPV screening in 2023 is colposcopy.

Rationale for Colposcopy

According to the National Comprehensive Cancer Network (NCCN) guidelines, colposcopy is the recommended management for adult women with LGSIL and positive high-risk HPV results 1. This approach is supported by multiple consensus guidelines:

• The American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines recommend colposcopy for women with LGSIL cytology, as HPV testing is not recommended for triage in these cases due to the high prevalence of HPV positivity 1
• For women over 30 years of age, LSIL requires colposcopy regardless of HPV status 1

Management Algorithm

1. Initial Management: Perform colposcopy with possible biopsy

   • Colposcopy should be performed by adequately trained health professionals 1
   • Biopsy any suspicious lesions identified during colposcopy

2. If Colposcopy is Satisfactory and Results Show CIN 1 or Negative:

   • Option A: Follow-up with HPV DNA testing at 12 months 1
   • Option B: Follow-up with repeat cytology at 6 and 12 months 1

3. Follow-up Management:

   • If HPV DNA test is negative or two consecutive cytology tests are negative: Return to routine screening 1
   • If HPV DNA test remains positive or cytology shows ASC-US or greater: Repeat colposcopy 1
   • If CIN 1 persists for at least 2 years: Either continued follow-up or treatment is acceptable 1

4. Return to Routine Screening:

   • After negative follow-up results, the patient can return to routine screening with co-testing (cytology and HPV) every 5 years (preferred) or cytology alone every 3 years 2

Important Considerations

Significance of Prior Negative HPV Test

The negative HPV test in 2023 followed by a positive test now indicates a new infection rather than persistent infection. However, this does not change the current management recommendation for colposcopy, as the current positive high-risk HPV with LGSIL requires evaluation 1.

Risk Assessment

The absence of HPV types 16 and 18 is somewhat reassuring, as these types carry higher oncogenic potential than other high-risk HPV types 2. However, colposcopy is still warranted due to the LGSIL finding with positive high-risk HPV.

Common Pitfalls to Avoid

1. Overtreatment: Avoid immediate excisional or ablative procedures for LGSIL/CIN 1 findings, as most of these lesions will regress spontaneously 1

2. Underestimation of Risk: Despite the absence of HPV 16/18, other high-risk HPV types can still lead to cervical neoplasia, so appropriate follow-up is essential 3

3. Inadequate Follow-up: Ensure proper documentation and tracking of results to prevent loss to follow-up, which is a major risk factor for progression to invasive disease 1

4. Misinterpreting Prior Negative HPV: The prior negative HPV test in 2023 does not negate the need for colposcopy with the current positive findings 1

By following this evidence-based approach, the risk of progression to higher-grade lesions can be minimized while avoiding unnecessary interventions for lesions that are likely to regress spontaneously.