Conservative Management of HSIL in Patients With Future Pregnancy Aspiration
Conservative Management of HSIL in Patients With Future Pregnancy Aspiration
Conservative management of high-grade squamous intraepithelial lesions (HSILs) seems safe and
 justified in young women (<30 years), but evidence is insufficient on whether it is also
 advisable for older women.

 This study will be conducted to analyze spontaneous HSIL regression rates in women of
 reproductive age and establish whether conservative HSIL management could be safely
 recommended to women of childbearing potential, irrespective of age.

 This is a single-center prospective observational study that will include consecutive women
 of reproductive age, referred to a tertiary hospital due to HSIL between March 2021 and
 December 2025, who prefer conservative management rather than immediate cervical conization.

 All patients will be followed-up regularly with colposcopy, cytology, human papillomavirus
 (HPV) testing and biopsies. In case their lesions progress or HSIL persists after 24 months
 of follow-up, conization will be indicated. Rates of spontaneous regression or resolution, as
 well as progression rates, will be assessed. Furthermore, the association between potential
 predictive factors and HSIL resolution will be analyzed.
In most developed countries, two main strategies are currently used for cervical cancer
 prevention: primary prevention with human papillomavirus (HPV) vaccination, and systematic
 screening with periodic cytology or HPV testing. Nevertheless, a significant number of women
 are still diagnosed with high-grade squamous intraepithelial lesions (HSIL), with higher
 prevalence rates among younger women (0.6% between ages 20 and 29; 0.2% between 40 and 49).
 Since the average age at first pregnancy in Catalonia is 32.2 years, many patients have not
 yet fulfilled their reproductive intentions when they are diagnosed with HSIL.

 Most HSIL cases are treated surgically with cervical conization, although previous studies
 have indicated that this may increase the incidence of preterm labor in future pregnancies.
 Therefore, many women diagnosed with HSIL will undergo treatment that may affect their future
 reproductive life.

 In patients diagnosed with HSIL, conservative management with periodic evaluations would be
 an efficient alternative to surgery, with the expectation of spontaneous resolution. Recent
 studies have shown that 40-88% of HSIL lesions can regress spontaneously within two years,
 especially in women under 25. Furthermore, a meta-analysis of 36 studies involving 3160
 patients concluded that active surveillance of patients diagnosed with cervical
 intraepitelial neoplasia (CIN) grade 2, rather than immediate surgical treatment, is
 justified, especially in young women (<30 years). Recent clinical guidelines include active
 surveillance as a valid option for management of HSIL in fertile women, with no age
 restrictions.

 Although the biological behavior of CIN2 without surgical treatment has been described in
 numerous studies, few included lesions classified as CIN3. Since the latest anatomical and
 pathological classification of the World Health Organization does not make any distinction
 between CIN2 and CIN3, classifying both as HSIL, treatment guidelines should be uniform for
 all HSILs, without discriminating between CIN2 or CIN3.

 Furthermore, although several studies have demonstrated the safety of conservative management
 for HSIL in women younger than 25-30 years, there is insufficient information in women aged
 30-40 years. Therefore, further evidence is still needed on the rate of spontaneous
 regression of HSIL (both CIN2 and CIN3) and on the safety of active surveillance, so that
 conservative management may be considered in all women who wish to become pregnant in the
 future.

 The main goal of this study will be to analyze whether spontaneous HSIL (CIN2 and CIN3)
 regression rates in women of reproductive age are high enough to support conservative
 management without age restrictions. We aim to describe the rates of spontaneous HSIL
 regression, HSIL persistence and HSIL progression in women under conservative management.
 Furthermore, we aim to describe predictive factors associated with HSIL regression rates. If
 this study confirms the safety of conservative management of HSIL, it could be possible to
 reduce the number of cervical conizations in these patients.

 Aim This will be a prospective observational cohort study performed at a Lower Genital Tract
 (LGT) unit of a tertiary hospital (Hospital de la Santa Creu i Sant Pau, Barcelona, Spain)
 affiliated with a cytology-based cervical cancer screening program. In this center, all
 colposcopic examinations are performed by two senior colposcopists, accredited by the Spanish
 Association for Cervical Pathology and Colposcopy (AEPCC). Pathology samples are analyzed by
 specialist technicians from the Pathology department of the same hospital and reviewed by
 expert pathologists. HPV tests are performed for all patients in the same laboratory using
 Genómica's Clart Human Papillomavirus 4.

 Patients All women referred to our LGT unit with biopsy-confirmed histological diagnosis of
 HSIL (CIN2 or CIN3) are assessed with colposcopy and counseled by expert gynecologists.
 Patients considered suitable for conservative management (instead of immediate surgical
 treatment with cervical conization) are routinely informed of the potential risks and
 benefits of both cervical conization and active surveillance of HSIL. Then, a shared decision
 is made for either surveillance or immediate conization. To be considered suitable for
 conservative management, women must: be of reproductive age; have transformation zone type 1
 or 2 (fully visible squamous-columnar union) at colposcopy, with a fully visible lesion and
 no atypical glandular cells (AGC) at cytology; and commit to attend follow-up visits at
 regular intervals.

 This study will start in March 2021 and will be concluded in December 2027. Consecutive women
 of reproductive age referred to our center from March 2021 to December 2025 with a diagnosis
 of HSIL that are considered suitable for conservative management and freely chose active
 surveillance will be invited to participate in this study. Patients will be followed-up for a
 minimum of 2 years.

 Eligibility criteria include positive high-risk (hr) HPV cytology, reproductive age and a
 wish to pursue pregnancy in the future. Women who are pregnant at diagnosis, immunosuppressed
 or diagnosed with carcinoma in situ of the cervix or cervical cancer will be excluded.

 This study was approved by the institution's ethics committee. Written informed consent will
 be obtained from all patients. All follow-up visits and clinical tests will be performed
 according to standard patient care and no tests or visits will be conditioned to
 participation in the study, nor will any additional treatment be given to patients enrolled.
 Verbal informed consent to continue conservative treatment will be reviewed at each follow-up
 visit. At any time during follow-up, patients can choose to have conization.

 Follow-up visits will be performed every 4 months, including colposcopy and cytology at each
 visit. Biopsies will not performed routinely, but on a case-by-case basis according to
 changes observed in colposcopy. The follow-up interval will be extended to 6 months if
 cytology and biopsies indicated low-grade squamous intraepithelial lesion (LSIL) or atypical
 squamous cells of undetermined significance (ASCUS) and this result is consistent with
 colposcopy. HPV will be determined every 8 12 months. This follow-up protocol will be
 continued until resolution of HSIL. Patients will be referred back to primary care when no
 HSIL is detected by cytology, colposcopy or biopsies and if HPV is negative at two
 consecutive visits.

 Conservative management will be discontinued and conization will be indicated if HSIL
 persists after 24 months of follow-up, if the patient no longer meet criteria for
 surveillance, or under the patient's request.

 All information will be retrieved from electronic patient files. Demographic data, smoking
 status, parity, use of contraceptives and colposcopy will be recorded. Information from
 pathology reports of cytology, biopsies and conization specimens will be collected, and time
 to HSIL resolution, regression or progression will be recorded.

 Patients will be classified into two groups according to the outcome of active surveillance:
 spontaneous HSIL regression or conization (women who had cervical conization for any reason
 during follow-up). Patients with spontaneous HSIL regression will be further classified into
 3 subgroups: total resolution (no colposcopic lesion, normal pathology by biopsy and
 cytology, and negative HPV for the HPV type initially detected); partial resolution
 (regression of colposcopic lesion, negative cytology and biopsies, but persistence of the
 initial hrHPV detected); and lesion regression (HSIL no longer detected, but persistent LSIL
 in either cytology, histology or colposcopy). Patients who eventually have conization will be
 further classified according to indication criteria: failure to meet criteria for
 conservative management or persistence of HSIL after 24 months of follow-up.

 Data analysis Patient characteristics will be described according to whether their lesions
 regress spontaneously or conization is indicated throughout the follow-up period. Numbers and
 percentages will be provided for categorical variables, whereas means and standard deviations
 will be used for quantitative variables.

 The association between potential predictive variables and HSIL resolution will be analyzed
 with chi-square tests (or Fisher's exact test when appropriate) for categorical variables and
 t-tests for quantitative variables. Variables assessed will include: age and ethnicity,
 smoking status, number of sexual partners within the previous 6 months, HPV type, alternative
 therapies, HPV vaccination.

 The characteristics of patients who have conization will be summarized, comparing patients
 referred to surgery because they failed to meet surveillance criteria to those referred to
 surgery due to persistence of HSIL at end of follow-up. The statistical analysis will be
 performed with SPSS version 26.0 (SPSS Inc., Chicago, IL, USA). Differences between groups
 were considered statistically significant at p < 0.05.
Inclusion Criteria:

 -  Reproductive age and aspirations of future pregnancies

 -  Acceptance of conservative management

 -  Commitment to attend scheduled follow-up visits

 -  Colposcopy with transformation zone (ZT) type 1 or 2 (fully visible squamous-columnar
 union) with lesion with grade 2 changes visible in its entirety. No endocervical
 involvement

 -  Colposcopy with grade 2 changes that are not extensive: <50% of the cervical surface

 Exclusion Criteria:

 -  Pregnancy at first visit or during follow-up.

 -  Immunosuppression (either iatrogenic or due to human immunodeficiency virus (HIV))

 -  Suspected or diagnosed Atypical Glandular Cells (ACG), In Situ Adenocarcinoma (AIS) or
 Cervical Cancer (CC)