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This is mostly due to the lack of understanding of the natural history of the disease, specifically, the risk of developing invasive carcinoma when patients remain untreated and whether value exists in screening and intervention strategies. Patients may even undergo three-stage procedures with creation and takedown of an intestinal stoma. Patients with large-volume disease can be safely and successfully treated in a staged fashion in the operating room and in the office, minimizing the risk for anal stenosis and development of cancer. Anal Nov 1 80, views and likes. Expectant management is based on the premise that the malignant progression rate is unknown and thus most patients simply warrant careful observation. However, these all describe the same lesion, even when examined with histology 4 and immunohistochemistry, 5 so in the interest of standardization we only use the term HSIL.