Comment re: Detection of cervical precancer by HPV genotype.

We read with interest the article by Safaeian and colleagues (1). Using data from the Atypical Squamous Cells of Undetermined Significance/Low-Grade Squamous Intraepithelial Lesions Triage Study (ALTS), they show that diagnosis of cervical intraepithelial neoplasia grade 3 or worse (CIN3+) due to human papillomavirus (HPV)-18 is delayed compared with HPV16 lesions. It has been suggested that the cytologic changes detected after HPV18 infection, unlike those detected after a HPV16 infection, underestimate the severity of the underlying histologic abnormality and thus may explain their findings (2). Collins and colleagues (3) suggested that early integration of HPV18 might be an explanation for this observation. Another possible explanation for their findings may be that some acethowhite lesions could be located out of the reach of visual evaluation (endocervix). Moreover, conventional cytology often misses lesions that are located higher up in the endocervix. Therefore, the reduced accessibility of these lesions may also be an explanation of the findings of Safaeian and colleagues (4). The design of the ALTS has a unique opportunity to give more insight into this, as histologically confirmed high-grade lesions were treated by the loop electrosurgical excision procedure (LEEP; ref. 5). Furthermore, an endocervical curettage was done at the discretion of the clinician. Information about the extension of the precancerous lesion in the LEEP specimen and the status of the endocervical curettage for the HPV16 versus the HPV18/45 CIN3 + subgroups can be very informative for the readership of the journal.We appreciate the importance of the work, but for daily practice in a colposcopy unit, it may be of clinical value to know if a HPV18/45-positive cytology report should also alert the gynecologist for lesions with a substantial risk of a location higher up in the cervical canal, next to the awareness of the mild colposcopic impression that HPV18/45-positive CIN3+ may give during colposcopy. We hope that the authors would be able to share their data on the LEEP procedure and endocervical curettage to give more insight into this.