Management of patients with high grade squamous intraepithelial lesions

The advent of modern electrosurgical equipment has allowed for outpatient excisional procedures rather than ablative therapy for patients with high grade squamous intraepithelial lesions (HGSILs).

The advantages and disadvantages of the commonly used ablative and excisional techniques for treatment of HGSILs were reviewed.

Electrofulguration or cryotherapy for HGSILs smaller than 2.5 cm results in a 90% cure rate after a single treatment, but the cure rate drops to 50% for treatment of large HGSILs. Carbon dioxide laser therapy has resulted in high cure rates, but the necessary equipment is expensive. Excisional techniques for HGSILs of any size and distribution provide for a greater than 90% cure rate after a single session. Complication rates arising from use of excisional techniques vary from 5% to 20%, depending on the method used; ablative techniques have a uniformly low complication rate (2%). The risk of inadvertently treating underdiagnosed invasive cancer is reduced with excisional but not with ablative methods. Of the excisional methods used to treat HGSILs, the loop electrosurgical excision procedure (LEEP) appears to be the most cost-effective.

The use of ablative techniques for small ectocervical HGSILs may be appropriate provided invasive cancer has been ruled out and the patient can be followed up long term. Loop electrosurgical excision procedure is the preferred excisional technique for lesions larger than 2.5 cm. The "see-and-treat" approach used with LEEP must be limited to only those lesions that are unequivocally verified by an expert in colposcopy and cytology. In questionable cases, the disease should be histologically ascertained by endocervical curettage and punch biopsies before therapy is undertaken.