What is the recommended treatment for a woman who develops High-grade Squamous Intraepithelial Lesions (HSIL)?

Management of High-Grade Squamous Intraepithelial Lesions (HSIL)

For women with HSIL cytology, an immediate loop electrosurgical excision procedure (LEEP) or colposcopy with endocervical assessment is recommended as the standard management approach due to the high risk of significant cervical disease. 1

Risk Assessment and Initial Management

• HSIL cytology carries a high risk for significant cervical disease, with 53-66% of women having CIN 2 or greater on colposcopy and 84-97% having CIN 2 or greater when evaluated using LEEP 1
• Approximately 2% of women with HSIL have invasive cancer 1
• Due to the considerable risk of CIN 2 or greater and high prevalence of HPV DNA positivity, intermediate triage using HPV testing or cytology is inappropriate for women with HSIL 1
• Colposcopy can miss a significant number of CIN 2,3 lesions, which can lead to serious consequences if not detected 1

Management Algorithm for Non-Pregnant Women

• First-line options (both acceptable): 1

  • Immediate LEEP (loop electrosurgical excision procedure)
  • Colposcopy with endocervical assessment

• If colposcopy is performed and CIN 2,3 is not identified histologically: 1

  • Observation for up to 24 months using both colposcopy and cytology at 6-month intervals is preferred (if colposcopic examination is satisfactory and endocervical sampling is negative)
  • In exceptional circumstances, a diagnostic excisional procedure is acceptable

• During follow-up: 1

  • If a high-grade colposcopic lesion is identified or HSIL cytology persists for 1 year, biopsy is recommended
  • If CIN 2,3 is identified histologically, management should follow the 2006 Consensus Guideline for the Management of Women with Cervical Intraepithelial Neoplasia
  • If HSIL persists for 24 months without identification of CIN 2,3, a diagnostic excisional procedure is recommended

Special Populations

Adolescents and Young Women

• After 2 consecutive "negative for intraepithelial lesion or malignancy" results, adolescents and young women without a high-grade colposcopic abnormality can return to routine cytological screening 1
• A diagnostic excisional procedure is recommended when colposcopy is unsatisfactory or CIN of any grade is identified on endocervical assessment 1

Pregnant Women

• Colposcopy is recommended for pregnant women with HSIL 1
• Colposcopic evaluation should be conducted by clinicians experienced in evaluating colposcopic changes induced by pregnancy 1
• Biopsy of lesions suspicious for CIN 2,3 or cancer is preferred; biopsy of other lesions is acceptable 1
• Endocervical curettage is unacceptable in pregnant women 1
• Diagnostic excision is unacceptable unless invasive cancer is suspected based on the referral cytology, colposcopic appearance, or cervical biopsy 1
• Re-evaluation with cytology and colposcopy is recommended no sooner than 6 weeks postpartum for pregnant women with HSIL in whom CIN 2,3 is not diagnosed 1

Post-Menopausal Women

• Post-menopausal women with HSIL have an increased risk of cervical cancer compared to pre-menopausal women (9.4% vs 3.8%) 2
• Post-menopausal women are more likely to have type III transformation zone (91.1% vs 59.1% in pre-menopausal women), making visualization more difficult 2
• The positive rate of endocervical margin after LEEP is significantly higher in post-menopausal women (20.5% vs 10.5%), requiring more careful follow-up 2

Efficacy and Outcomes

• The "see and treat" approach (immediate LEEP following colposcopy) for patients with HSIL has been shown to be effective with 84% of patients having either CIN 2 or CIN 3 on histology, resulting in an overtreatment rate of only 16% 3
• Progression from LSIL to HSIL is uncommon (approximately 3% when confirmed on review), suggesting that a diagnosis of HSIL following an LSIL should always be reviewed 4
• For women with biopsy-confirmed LSIL, regression occurs in 88.5% within 24 months, with persistence in 10.8% and progression to HSIL in only 0.7% 5

Important Considerations and Pitfalls

• Failure to detect CIN 2,3 at colposcopy can lead to serious consequences due to the high risk of significant disease 1
• The rate of HSIL varies with age: 0.6% in women 20-29 years, 0.2% in women 40-49 years, and 0.1% in women 50-59 years 1
• Women with current precancer risks of 60% or more, such as patients with HPV-16-positive HSIL, may proceed directly to excisional treatment, though performing colposcopy first to confirm the need for excisional treatment is acceptable 6
• Careful follow-up is essential as the risk for recurrence of squamous intraepithelial lesions and cervical cancer after conventional therapy is increased among HIV-infected women 1