Management of Prior HSIL on Pap Test: Colposcopy is Always Required
For any patient with a history of HSIL on Pap cytology, colposcopy is warranted regardless of current HPV test results, and HPV testing should be added to guide immediate management and long-term surveillance. 1
Immediate Management Algorithm
Colposcopy is Mandatory
- Colposcopy is always recommended for patients with a history of high-grade lesions (histologic or cytologic HSIL), even if current HPV testing is negative. 1
- Previous Pap test results do not modify this recommendation—colposcopy remains indicated. 1
- The rationale is that HSIL carries significant risk for CIN 2+ lesions (62.5-100% depending on HPV status), including invasive squamous cell carcinoma. 2, 3
Add HPV Testing for Risk Stratification
- HPV testing (preferably with HPV 16/18 genotyping) should be performed reflexively from the same specimen to determine next management steps. 1
- HPV 16 is the highest-risk type and warrants consideration of expedited treatment if HSIL cytology is present. 1
- HPV 18 has high association with adenocarcinoma, and endocervical sampling is acceptable at colposcopy when HPV 18 is detected. 1
Critical Caveat About HPV-Negative HSIL
- Even with negative HPV testing, 53.4% of patients with HSIL cytology have CIN 2+ lesions on biopsy, including invasive squamous cell carcinoma. 3
- Many HPV-negative HSIL cases have prior history of HPV positivity or positive p16 immunohistochemistry on follow-up biopsy. 2
- Negative HPV testing does NOT reduce the need for colposcopy in the setting of HSIL cytology. 1
Treatment Considerations at Colposcopy
For Confirmed CIN 2,3 on Biopsy
- Both excision and ablation are acceptable treatment modalities if colposcopy is satisfactory. 1
- For nonpregnant patients ≥25 years with HSIL cytology, expedited treatment (see-and-treat) is preferred, though colposcopy with biopsy is acceptable after shared decision-making. 1
- Diagnostic excisional procedure is required if colposcopy is unsatisfactory or for recurrent CIN 2,3. 1
For CIN 1 on Biopsy (Discordant with HSIL Cytology)
- Either diagnostic excisional procedure OR observation with colposcopy and cytology at 6-month intervals for 1 year is acceptable, provided colposcopy is satisfactory and endocervical sampling is negative. 1
- Review of cytologic, histologic, and colposcopic findings is acceptable; if revised interpretation occurs, follow guidelines for the revised diagnosis. 1
- Diagnostic excisional procedure is recommended if repeat HSIL cytology occurs at 6- or 12-month visit. 1
Long-Term Surveillance Protocol
Post-Treatment Surveillance Requirements
- After treatment for high-grade precancer, surveillance must continue for at least 25 years, even if this extends beyond age 65 years. 1
- Initial testing includes HPV test or cotest at 6,18, and 30 months post-treatment. 1
- If cytology alone is used, testing should occur at 6,12,18,24, and 30 months. 1
Long-Term Follow-Up Strategy
- After completing initial testing, perform testing at 3-year intervals if using HPV testing or cotesting. 1
- If using cytology alone, annual testing is required (more frequent than HPV-based surveillance). 1
- HPV testing or cotesting is preferred over cytology alone for follow-up, as negative HPV testing is less likely to miss disease than normal cytology alone. 1, 4
Common Pitfalls to Avoid
- Never defer colposcopy based on negative HPV results in patients with HSIL cytology—up to 53% still have CIN 2+ lesions. 3
- Do not use "return in 1 year" strategy for HSIL cytology; this is only appropriate for HPV-positive patients with normal cytology. 1, 4
- Do not discontinue surveillance at age 65 for patients with history of HSIL—25-year surveillance is mandatory regardless of age. 1
- Negative screening within the past 5 years does NOT reduce the need for colposcopy when HSIL cytology is present. 1
- If hysterectomy occurs during surveillance period, vaginal screening must continue. 1