A 31-year-old woman comes to the office for follow-up of a high-grade squamous intraepithelial lesion found on a recent Pap test. A Pap test 6 years ago was normal, and the patient did not receive screening in the interim. Her last menstrual period was 2 weeks ago, with menses occurring every 28 days and lasting 4 days. The patient is sexually active with her husband and takes an oral contraceptive. She became sexually active at age 14 and has had 7 sexual partners. The patient had a full-term vaginal delivery at age 20. She has a history of genital herpes, and the last outbreak was several months ago. The patient has no other medical issues or previous surgeries. She does not use tobacco, alcohol, or illicit drugs. Blood pressure is 110/70 mm Hg and pulse is 72/min. BMI is 24 kg/m². A colposcopic examination is performed and a biopsy is taken. Pathology report of the biopsy shows cervical intraepithelial neoplasia grade 3. Which of the following is the best next step in management of this patient?

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11ec25c8_d260_aa9a_bc81_cfec7287ae8a_MD0003_00 This patient has multiple risk factors for cervical cancer, including early onset of sexual activity, oral contraceptive use, and multiple sexual partners. The patient had an abnormal Pap test with high-grade squamous intraepithelial lesions (HSILs) and underwent evaluation with colposcopy and cervical biopsy, which revealed a histologic diagnosis of cervical intraepithelial neoplasia 3 (CIN3), a high-grade dysplastic lesion of the squamous epithelium. All nonpregnant patients age >25 with CIN3 require excision of the transformation zone (eg, cone biopsy) due to the high risk of progression to invasive squamous cell cervical carcinoma. cone biopsy Cervical conization is both a diagnostic and therapeutic procedure, typically removing the entire lesion and allowing for examination of the full depth of invasion. Treatment for invasive carcinoma includes hysterectomy, radiation, and chemotherapy, depending on disease stage (Choice C). If the specimen margins are clear of disease and no evidence of invasion is found, Pap testing with HPV co-testing in 1 and 2 years postprocedure is required. (Choice B) Human papillomavirus (HPV) co-testing is performed to triage low-grade abnormalities on Pap testing, including atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesions (LSILs), which may or may not be due to HPV infection. However, HPV infection is the cause of the high-grade lesions on Pap tests; therefore, HPV co-testing is not performed. Further evaluation of HSIL results is required with colposcopy and biopsy - regardless of presence or absence of HPV - due to the risk of malignancy. (Choices D and E) Repeat colposcopy in 6 months and a repeat Pap test in 12 months are not appropriate as HSILs typically progress; delays in treatment lead to more invasive disease. Educational objective: Cervical intraepithelial neoplasia 3 is a high-grade, premalignant lesion that requires treatment with cervical conization, a type of excisional biopsy. References: Meta-analysis of cold-knife conization versus loop electrosurgical excision procedure for cervical intraepithelial neoplasia. (http://www.ncbi.nlm.nih.gov/pubmed/27418835)

A 31-Year-Old Woman Comes to the Office for Follow-Up of a High-Grade