Management of 59-Year-Old Woman with Normal Pap Smear and HPV-16 Positive Result
This patient requires immediate colposcopy with endocervical sampling due to HPV-16 positivity, regardless of the normal cytology result. 1, 2
Rationale for Immediate Colposcopy
HPV-16 infection carries a substantially elevated cancer risk that mandates immediate colposcopic evaluation, even when cytology is normal. 1
Women aged 30 and older with HPV-16 positivity and negative cytology have a 17-21% 10-year cumulative risk of developing CIN 3 or worse, which is dramatically higher than the 3% risk with other high-risk HPV types and the 1.5% risk with non-16/18 high-risk HPV types. 1
The American Society for Colposcopy and Cervical Pathology specifically recommends immediate colposcopy for HPV-16 or HPV-18 positivity regardless of cytology results, due to this significantly elevated risk of high-grade cervical intraepithelial neoplasia (CIN 3) and cervical cancer. 1
HPV-16 and HPV-18 are responsible for approximately two-thirds of all invasive cervical carcinomas. 3
Colposcopy Protocol
At the time of colposcopy, the following procedures should be performed: 1, 2
Endocervical sampling is preferred to evaluate for endocervical lesions that may not be visible on colposcopic examination. 1
Colposcopically-directed biopsies should be obtained from any visible lesions after application of 3-5% acetic acid solution. 1
A thorough examination of the transformation zone must be completed. 4
Management Based on Colposcopy Findings
If CIN 2 or CIN 3 is Identified
Treatment with excisional procedure (LEEP or cold-knife conization) or ablation is indicated. 1, 2
Post-treatment surveillance should continue for at least 25 years with HPV testing or co-testing at 6,18, and 30 months. 1, 2
Long-term surveillance includes testing at 3-year intervals if using HPV testing or cotesting, or annual testing if using cytology alone. 2
If CIN 1 or Less is Found
Repeat HPV testing with or without Pap test in 1 year is recommended. 2, 4
Colposcopy should be performed if HPV remains positive at follow-up. 4
If Colposcopy is Negative (No Lesions Identified)
HPV testing or cotesting at 12 months is recommended, with HPV testing or cotesting preferred over cytology alone for follow-up. 4
If HPV remains positive at 12 months, repeat colposcopy is warranted. 2
Critical Pitfalls to Avoid
Do not delay colposcopy based on negative cytology alone. 1
The combination of HPV-16 positivity significantly elevates risk regardless of cytology results. 1
Delaying colposcopy for HPV-16 positive results is inappropriate due to the high association with cancer. 4
At age 59, this patient is beyond the age where spontaneous clearance is likely, making immediate evaluation even more critical. 5, 6
Do not treat based on HPV result alone without histologic confirmation of disease. 2
- Histologic diagnosis through colposcopy-directed biopsy is required before initiating treatment. 2