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Bethesda System for Reporting Cervical Cytology

August 2005

Bethesda System.

Epithelial cell anomalies according to The Bethesda System

- Atypical squamous cells of undetermined significance ASCUS
- Atypical glandular cells of undetermined significance AGUS
- Low-grade squamous intraepithelial lesion LSIL or LGSIL / Encompasses HPV (koilocytosis), mild dysplasia, CIN-1
- High-grade squamous intraepithelial lesion HSIL or HGSIL / Encompasses moderate and severe dysplasia and carcinoma in situ, CIN2, CIN-3
- Squamous cell carcinoma  
- Endocervical adenocarcinoma  
- Endometrial adenocarcinoma  
- Extrauterine adenocarcinoma  
- Adenocarcinoma, not otherwise specified  
- Other malignant neoplasia  

Nota bene

HSIL or LSIL cytology is the usual trigger to initiate colposcopy and/or diagnostic conization.

The presence of atypical squamous cells of undetermined significance (ASCUS) or atypical glandular cells of undetermined significance (AGUS) cytology, in particular when associated with high-risk human papillomavirus (HPV) and no colposcopic anomaly, also may require the same approach.

Cytologic categories must be distinguished carefully from histologic diagnoses.

Cytology has a high sensitivity for CIN, in general, but a low specificity for its grade.

Regrettably, cytologic and histologic diagnostic terms often are used interchangeably. Cytology tends to underestimate the severity of CIN.

As an example, high-grade (grades 2 and 3) CIN was preceded by HSIL in only 31% of cases in data compiled from 6 publications.

Testing for human papillomavirus: Presence of high-risk HPV (types 16,18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59), usually detected by Hybrid Capture II test, reinforces the need for histologic diagnosis, even if cytology is reported normal or of undetermined significance.

Pap report

Classification of Pap test results, based on the Bethesda System for reporting cervical cytology, was first introduced in 1988 and revised in 2001 to define satisfactory samples and to standardize reporting.

Inadequate samples for evaluation include those tests that lack patient identifying information, broken slides, inadequate squamous component (defined as < 5000 squamous cells on liquid-based medium or < 8000 to 12,000 cells on conventional medium), or obscuring elements on over 75% of squamous cells (typically due to lubricant, inflammation, or blood).

The Bethesda System terminology for cytologic reporting classifies epithelial abnormalities as follows:

- Squamous cell abnormalities

  • Atypical squamous cells (ASC)
  • Atypical squamous cells of undetermined significance (ASC-US)
  • Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H)
  • Low-grade squamous intraepithelial lesion (LSIL), encompasses those previously classified as koilocytic atypia (HPV changes) or cervical intraepithelial neoplasia (CIN) 1
  • High-grade squamous intraepithelial lesion (HSIL), encompasses those formerly called CIN 2 or CIN 3
  • Squamous cell carcinoma.

- Glandular cell abnormalities

The Bethesda System classifies LSIL and HSIL as squamous cervical precursor lesions.

Although originally used as cytologic diagnoses, the squamous intraepithelial lesion terminology can be used for histologic classification as well.

Generally, CIN grades 1 to 3 are used to classify histologic diagnoses. More than two-thirds of smears showing cellular atypia do not meet diagnostic criteria for dysplasia and are classified as ASC-US or as ASC-H.

Studies have shown that up to 90% of lower-grade Pap tests (LSIL) will spontaneously regress.

However, some estimates suggest LSIL may carry up to a 33% risk of harboring a higher-grade lesion (CIN 2 or 3). HSIL carries a risk of >70%.


- https://online.epocrates.com/u/29111123/Abnormal+Pap+smear/Summary/Overview