Clinical Significance of High-Risk HPV Positivity with Negative Cytology: Can Further Evaluation Be Safely Delayed?

Background and Objectives: Primary HPV screening has high sensitivity in detecting premalignant and malignant cervical lesions. However, due to its relatively low specificity, this screening approach requires triage tests. Owing to its high specificity, cytology is most commonly employed in the triage of HPV-positive results. Nevertheless, the question remains as to how reliable cytology is in triaging these cases, given its relatively low sensitivity. This study evaluates the clinical significance of high-risk HPV (hrHPV) positivity in women with negative or low-grade cytological findings and assesses whether further evaluation can be safely deferred using HPV genotyping, colposcopy, and p16/Ki-67 biomarkers. Materials and Methods: A prospective hospital-based observational study was conducted on 125 women with a positive hrHPV cervical test. All participants underwent conventional cytology, extended HPV genotyping, colposcopy, and histopathological evaluation via biopsy or loop excision. Immunohistochemical analysis of p16 and Ki-67 expressions was performed on histopathological tissue samples. Particular attention was focused on women with negative for intraepithelial lesion or malignancy (NILM) and low-grade cytological findings. Associations between cytology, HPV genotype distribution, colposcopic findings, histopathology, smoking status, and biomarker expression were analyzed. Results: Among HPV-positive patients with NILM cytology, CIN2+ lesions were histopathologically confirmed in 28.0% of cases. More than half (51.4%) of all CIN2+ lesions detected in HPV-positive women were identified in patients with low-grade or negative cytology. HPV16/18 positivity was highly prevalent among women with CIN2+ lesions and low-grade cytological findings (78.4%). Unsatisfactory colposcopy with a non-visible squamocolumnar junction (transformation zone type 3, TZ3) was identified in more than half of these patients. Immunohistochemical markers p16 and Ki-67 demonstrated high sensitivity (95.5%) and negative predictive value (93.3%) for detecting CIN2+ lesions in hrHPV-positive women with low-grade cytology (NILM, ASC-US, and LSIL). Smoking status was significantly associated with CIN2+ lesions in this patient group (p < 0.001). Conclusions: Deferring further evaluation of hrHPV-positive women solely based on negative cytology may be unsafe, particularly in older women, smokers, and those positive for HPV16/18. The strong association between p16/Ki-67 positivity and CIN2+ lesions suggests that dual-stain testing directly from cytological samples could significantly improve triage strategies and reduce the need for invasive procedures.