Cervix -

High grade squamous intraepithelial lesion (HSIL)

This article was last reviewed and updated on July 16, 2019
by Jason Wasserman, MD PhD FRCPC

Quick facts:

  • High grade squamous intraepithelial lesion (HSIL) is a pre-cancerous disease that develops in the cervix.

  • HSIL is caused by a virus called human papillomavirus (HPV).

  • If left untreated, patients with HSIL are at high risk for developing a cancer of the cervix called squamous carcinoma.


The normal cervix

The cervix is part of the female genital tract. It is found at the bottom of the uterus where it forms an opening into the endometrial cavity. The cervix is lined by special cells called squamous cells that form a barrier on the surface of the cervix called an epithelium. The tissue below the epithelium is called the stroma.

What is high grade squamous intraepithelial lesion (HSIL)?

High grade squamous intraepithelial lesion (HSIL) is pre-cancerous disease that develops in the cervix when the squamous cells become infected with a virus called human papillomavirus (HPV).


HSIL is called a pre-cancerous disease because it can turn into an invasive cancer called squamous cell carcinoma. The cells in HSIL are abnormal and look almost identical to cancer cells, however, they are only seen in the epithelium on the outer surface of the cervix. No abnormal cells are found in the stroma.

Almost all cases of HSIL and squamous cell carcinoma in the cervix are a result of the normal squamous cells becoming infected with a high risk type of human papillomavirus (HPV).

The diagnosis of HSIL is usually made on a pap smear and a larger surgical procedure is later performed to remove the disease and to look for abnormal cells in the stroma.​

​Extent of disease

Larger samples of tissue are usually sent for pathological examination as a single piece of tissue and the tissue is then divided into multiple sections before being examined under the microscope. Your pathologist will describe the number of pieces (or 'blocks' as they are often called) that show HSIL in your report.

For example, your report may say "3 out of 14 blocks are positive for high grade squamous intraepithelial lesion (HSIL)" which means that 3 out of the 14 pieces of tissue examined show the disease.


A margin is any tissue that has to be cut by the surgeon in order to remove the tumour from your body. Pap smears do not have margins.


If you underwent a surgical procedure to remove the entire tumour from your body, your pathologist will examine the margin closely to make sure there are no cancer cells at the cut edge of the tissue.

The number and type of margins will depend on the type of procedure performed to remove the tumour from your body. Typical margins include:


  • Endocervical margin - This is where the cervix meets the inside of the uterus.

  • Ectocervical margin - This is the bottom of the cervix, closest to the vagina.

  • Stromal margin - This is the tissue inside the wall of the cervix.

A margin is considered positive when HSIL is seen at the edge of the cut tissue.

Why is this important? Finding HSIL at the margin increases the risk that the tumour will grow back in that location.

p16 status

Cells infected with high risk types of human papillomavirus (HPV) produce large amounts of a protein called p16. Your pathologist may perform a test called immunohistochemistry to look for p16 inside the abnormal cells. This will confirm the diagnosis of HSIL and rule out other conditions that can look like HSIL under the microscope. 


Why is this important? Almost all cases of HSIL are positive or reactive for p16 which means your pathologist saw the p16 protein in the abnormal cells.

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