The Bethesda System For Reporting Cervical Cytology Pdf

Commentary

• Bethesda System For Reporting Cervical Smear 2014
• Bethesda System For Reporting Pap Results
• Bethesda Cytology Classification System
• The Bethesda System For Reporting Cervical Cytology Pdf 2015

The Pap test and Bethesda 2014

This article is jointly published in Journal of the American Society of Cytopathology, Cancer Cytopathology, Journal of Lower Genital Tract Disease, and Acta Cytologica by the American Society of Cytopathology, the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the International Academy of Cytology.

Abstract

Home; I Adequacy. II Non-neoplastic. III Endometrial > 45. IV ASC-US/ASC-H. V Epithelial Abnormalities Squamous. VI Epithelial Abnormalities Glandular. VII Other Malignant Neoplasms. VIII Anal Cytology. IX Adjunctive Testing. -6597 Email: bjenkins@cytopathology.org Web site: cytopathology.org ©2015 Board of Regents of the.

The history of “The Bethesda System” for reporting cervical cytology goes back almost 3 decades. This terminology and the process that created it have had a profound impact on the practice of cervical cytology for laboratorians and clinicians alike. Herein, we summarize the process and rationale by which updates were made to the terminology in 2014 and outline the contents of the new, third edition of the Bethesda atlas and corresponding website. https://inundensi.tistory.com/3.

“The reports of my demise have been greatly exaggerated.” (after a quotation from Mark Twain)

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The history of “The Bethesda System” (TBS) for reporting cervical cytology goes back almost 3 decades. This terminology and the process that created it have had a profound impact on the practice of cervical cytology for laboratorians and clinicians alike. The Bethesda conferences and their ensuing output have also set the stage for standardization of terminology across multiple organs systems, including both cytology and histology; have initiated significant research in the biology and cost‐effective management for human papillomavirus (HPV)‐associated anogenital lesions; and, finally, have fostered worldwide unification of clinical management for these lesions.

One snowy weekend in December 1988, a small group of individuals with expertise in cytopathology, histopathology, and patient management met at the National Institutes of Health in Bethesda, Maryland.1 This meeting, which became the first Bethesda workshop, was chaired by Robert Kurman and focused on addressing the issues related to the wide variability in reporting results of cervical cytology when cytologists used either the numeric “Pap Class” system or the “dysplasia” terminology. The objective was to establish terminology that would provide clear‐cut thresholds for management and decrease interobserver variability. During the 2 days of that historic workshop, 3 fundamental principles emerged that have guided TBS to this day:

1. Terminology must communicate clinically relevant information from the laboratory to the patient's health care provider;
2. Terminology should be uniform and reasonably reproducible across different pathologists and laboratories and also flexible enough to be adapted in a wide variety of laboratory settings and geographic locations; and
3. Terminology must reflect the most current understanding of cervical neoplasia.

On the basis of these principles, in 1988, the first iteration of TBS recommended a 2‐tiered reporting system for squamous intraepithelial lesions (SILs): low‐grade SIL (LSIL) and high‐grade SIL (HSIL). This terminology reflected the up‐to‐date understanding of HPV biology—squamous epithelium is affected by the virus in essentially 2 ways: either as viral infection or as viral‐associated precancer. In addition to the SIL terminology, TBS‐1988 also incorporated a “statement of adequacy” as an integral component of the report and, by extension, an important quality‐assurance element.2

After experience using TBS in clinical practice and further advances in scientific knowledge, subsequent Bethesda workshops were convened in 1991 and 2001. A major recommendation from the 1991 workshop was to develop criteria for TBS interpretive categories and diagnostic terms and for the determination of specimen adequacy. These deliberations and the codification of criteria led to the production of the first Bethesda atlas in 1994.3 After its publication, this monograph quickly became a worldwide reference for the practice of cervical cytology.

The next Bethesda workshop, held in 2001, was the first to use the Internet to provide the international cytopathology community an opportunity to offer input to the refinements proposed by the forum work groups. Over 2000 Internet comments were considered before the meeting, which then brought together over 400 participants, including representatives from more than 2 dozen countries, to finalize the 2001 Bethesda System Terminology.4

Noteworthy points from the 2001 Bethesda update included the following:

1. The terms “interpretation” or “result” were recommended instead of “diagnosis” in the heading of the cervical cytology report, because it was believed that cervical cytology should be viewed primarily as a “screening test, which in some instances may serve as a medical consultation by providing an interpretation that contributes to a diagnosis. The final diagnosis and management plan should integrate the cervical cytology with patient history, clinical findings, and results of other laboratory tests such as cervical biopsy.”2, 4
2. Although TBS was developed primarily for cervical cytology, specimens from other sites in the lower anogenital tract, such as the vagina and anus, could also be reported using this terminology.
3. Between 1991 and 2001, liquid‐based cytology, automation, computer‐assisted imaging, and HPV testing were introduced and increasingly utilized in laboratories that offered cervical cytology testing. The 2004 Bethesda atlas addressed all of these considerations. In addition, to facilitate widespread implementation of TBS‐2001 and to improve reproducibility, more detailed interpretive criteria, ample illustrations depicting mimics and pitfalls, histologic correlation, and sample reports were added.5
4. After TBS‐2001, but before publication of the corresponding atlas, a subset of atlas images were used to develop the web‐based Bethesda Interobserver Reproducibility Study (BIRST), the objectives of which were: i) to evaluate concordance among participants with varied training and experience, and ii) to identify specific cytomorphologic features and cytologic categories that represent sources of poor interobserver agreement.6 The results of that study highlighted important issues about the reproducibility of the various Bethesda categories, which has led to further progress in education and to the introduction of ancillary studies to improve the predictive value of the screening process.
5. In conjunction with the print atlas, an educational Bethesda website7 was established that provides additional images beyond those available in the print atlas, images, histograms from the BIRST,6 and a self‐evaluation test. This site has been extensively used—over 60,000 unique individuals from all over the world have taken the self‐test alone.

By early 2003, 85.5% of laboratories in the United States had implemented Bethesda 2001 terminology, and the adoption of TBS in the international cytopathology community had produced a significant impact.8

Implementation of TBS initiated several downstream events that significantly influenced cervical cancer screening and management and also impacted terminology development for other areas in cytopathology and histopathology:

Initiation of Research and Clinical Trials

TBS played a vital role in facilitating research related to the biology of cervical cancer and exploring new approaches and strategies for patient management. The introduction of TBS terminology of “atypical squamous cells of undetermined significance” (ASCUS) highlighted the inherent limitations of morphologic interpretation. Because ASCUS is the most common cytologic abnormality reported on Papanicolaou (Pap) tests, it accounts for over a million results annually in the United States and previously posed a significant clinical management problem, leading to billions of dollars in colposcopic follow‐up and/or treatment of these women.1 To determine the best course of management (immediate colposcopy, HPV triage, or conservative management) for equivocal and low‐grade abnormalities, the US National Cancer Institute sponsored the ASCUS/LSIL Triage Study (ALTS), which began in 1997.9 The results from ALTS established high‐risk HPV (hrHPV) testing as the most cost‐effective triage test for ASCUS. This was endorsed as the preferred management option for the Bethesda category re‐named as ASC‐US, under the category of Atypical squamous cells (ASC) in 2001.10 Additional assessment of the ALTS database resulted in numerous publications, which have provided a great deal of information related to cervical cancer, including the characteristics of cytology, colposcopy, the role of HPV testing, and the biology/management of HPV‐related cervical lesions.

1 Alignment of Management With Terminology

TBS provided the framework necessary for the development of systematic, evidence‐based cervical cancer screening and management guidelines. After the 2001 Bethesda conference, the American Society for Colposcopy and Cervical Pathology (ASCCP) held a consensus conference to tailor management strategies that conformed to the Bethesda reporting categories. This meeting was also a significant historic event, because it was the first time that there was coordination of reporting terminology that correlated with both HPV biology and clinical management. The results of ALTS and other clinical research formed the basis for development of the 2001 clinical management algorithms—a process that involved dozens of organizations and professional societies, spearheaded by the ASCCP. With continued development of additional insight into HPV biology, results from subsequent clinical trials, and experience in the United States, these management guidelines were subsequently updated in 2006 and 2012.11, 12

2 TBS as a Prototype for Standardized Reporting Terminology in Pathology

On the basis of the key principles of TBS, standardized terminology systems have been developed for cytology of other body sites, including thyroid,13 pancreas,14 and, most recently, urine.15 The 2‐tiered terminology of LSIL and HSIL used in TBS is now also recommended by the World Health Organization, the ASCCP, and the College of American Pathologists for reporting histopathology of HPV‐associated squamous lesions of the lower anogenital tract.16-19

BETHESDA 2014: WHY?

The past decade has witnessed several changes in the realm of cervical cancer screening, prevention, and management. These include the increased use of liquid‐based preparations; the addition of cotesting (Pap and hrHPV testing) and, more recently, primary hrHPV testing as additional screening options; further insights into HPV biology; changes in histopathology terminology; approval and implementation of prophylactic HPV vaccines; and updated guidelines for cervical cancer screening and clinical management.

Over the past few years, evidence‐based consensus guideline processes have incorporated the fundamental principles of balancing harms and benefits and providing equal management for equal risk.20 Management guidelines for abnormal cervical cytology results were updated in 2006 and 2012, with increased incorporation of hrHPV and genotyping for triage and follow‐up. When HPV testing is used alone for primary screening, cervical cytology has been proposed as a “reflex” test or triage for non‐16/18 HPV‐positive screens. With increased uptake of HPV vaccination and its downstream effects of decreased prevalence of HPV16/18‐associated lesions, cervical cytology will become even more challenging with respect to locator and interpretation skills because of the inherent loss of sensitivity when prevalence of the disease is low. On the basis of all of these changes, 2014 was an appropriate time for a review and update of the 2001 Bethesda System terminology, refinements of morphologic criteria, and incorporation of revisions and additional new information into a third edition of the Bethesda atlas for cervical cytology.21

BETHESDA 2014: PROCESS

Dr. Ritu Nayar, President of the American Society of Cytopathology in 2014, appointed a task force* (see acknowledgments, below), chaired by Dr. David Wilbur (American Society of Cytopathology President in 2002), comprised of a relatively small group of cytopathologists, clinicians, and epidemiologists, to accomplish the 2014 update. Because minimal changes were anticipated to the terminology recommended by TBS‐2001, no formal consensus meeting was held in association with this update. The task force was divided into 12 groups, each of which was responsible for 1 of 12 atlas chapters. The groups performed a literature review and proposed new and expanded content. The draft recommendations were shared with the international cytopathology community during an open comment period from March to June of 2014 through a widely advertised, Internet‐based bulletin board. In total, 2454 responses were received from individuals in 59 countries and were compiled and reviewed by the chapter‐based task force working groups. This process culminated in the refinement of positions and content, which were then incorporated into TBS‐2014 (Table 1) and into the third edition of the Bethesda atlas.21

SPECIMEN TYPE
Indicate conventional smear (Pap smear),liquid‐based preparation (Pap test) vs other
SPECIMEN ADEQUACY
θ Satisfactory for evaluation (describe presence or absence of endocervical/transformation zone component and any other quality indicators, eg, partially obscuring blood, inflammation, etc)
θ Unsatisfactory for evaluation (specify reason)
θ Specimen rejected/not processed (specify reason)
θ Specimen processed and examined, but unsatisfactory for evaluation of epithelial abnormality because of (specify reason)
GENERAL CATEGORIZATION (optional)
θ Negative for intraepithelial lesion or malignancy
θ Other: see Interpretation/Result (eg, endometrial cells in a woman aged ≥45 years)
θ Epithelial cell abnormality: see Interpretation/Result (specify “squamous” or “glandular,” as appropriate)
INTERPRETATION/RESULT
Negative for Intraepithelial Lesion or Malignancy
(When there is no cellular evidence of neoplasia, state this in the General Categorization above and/or in the Interpretation/Result section of the report—whether or not there are organisms or other non‐neoplastic findings)
Non‐Neoplastic Findings (optional to report)
θ Non‐neoplastic cellular variations
○ Squamous metaplasia
○ Keratotic changes
○ Tubal metaplasia
○ Atrophy
○ Pregnancy‐associated changes
θ Reactive cellular changes associated with:
¬ Inflammation (includes typical repair)
○ Lymphocytic (follicular) cervicitis
¬ Radiation
¬ Intrauterine contraceptive device (IUD)
θ Glandular cells status posthysterectomy
Organisms
θ Trichomonas vaginalis
θ Fungal organisms morphologically consistent with Candida spp.
θ Shift in flora suggestive of bacterial vaginosis
θ Bacteria morphologically consistent with Actinomyces spp.
θ Cellular changes consistent with herpes simplex virus
θ Cellular changes consistent with cytomegalovirus
Other
¬ Endometrial cells (in a woman aged ≥45 years)
(Also specify if “negative for squamous intraepithelial lesion”)
Epithelial Cell Abnormalities
Squamous Cell
¬ Atypical squamous cells
• Of undetermined significance (ASC‐US)
• Cannot exclude HSIL (ASC‐H)
¬ Low‐grade squamous intraepithelial lesion (LSIL)
(Encompassing: HPV/mild dysplasia/CIN‐1)
¬ High‐grade squamous intraepithelial lesion (HSIL)
(Encompassing: moderate and severe dysplasia, CIS; CIN‐2 and CIN‐3)
• With features suspicious for invasion (if invasion is suspected)
¬ Squamous cell carcinoma
Glandular Cell
¬ Atypical
• Endocervical cells (NOS or specify in comments)
• Endometrial cells (NOS or specify in comments)
• Glandular cells (NOS or specify in comments)
¬ Atypical
• Endocervical cells, favor neoplastic
• Glandular cells, favor neoplastic
¬ Endocervical adenocarcinoma in situ
¬ Adenocarcinoma
• Endocervical
• Endometrial
• Extrauterine
• Not otherwise specified (NOS)
Other Malignant Neoplasms (specify)
ADJUNCTIVE TESTING
Provide a brief description of the test method(s) and report the result so that it is easily understood by the clinician
COMPUTER‐ASSISTED INTERPRETATION OF CERVICAL CYTOLOGY
If case examined by an automated device, specify the device and result
EDUCATIONAL NOTES AND COMMENTS APPENDED TO CYTOLOGY REPORTS (optional)
Suggestions should be concise and consistent with clinical follow‐up guidelines published by professional organizations (references to relevant publications may be included)

• Abbreviation: CIN, cervical intraepithelial neoplasia; CIS, carcinoma in situ; HPV, human papillomavirus; NOS, not otherwise specified; Pap, Papanicolaou.

BETHESDA 2014: WHAT HAS CHANGED?

Bethesda Terminology Changes

There were minimal changes relating to the terminology itself. The 2014 Bethesda terminology is summarized in Table 1. Of note:

Reporting of benign‐appearing endometrial cells is now recommended for women aged ≥45 years

Rationale:

Although exfoliated endometrial cells are a normal finding during menses and the proliferative phase of the menstrual cycle, in postmenopausal women, their presence is considered abnormal and raises the possibility of endometrial neoplasia (Fig. 1). Thus, TBS‐1988 recommended reporting “cytologically benign‐appearing” endometrial cells in postmenopausal women to alert clinicians to the possibility of an endometrial abnormality.2 In 2001, because menopausal status is often unclear, inaccurate, or unknown to the laboratory, it was suggested that this reporting should be done in women aged ≥40 years to maximize the likelihood of including all postmenopausal women and that clinical correlation should be left to the ordering physician's discretion.4 Evaluation of this TBS‐2001 recommendation in clinical practice indicated that, although endometrial investigation increased, the predictive value for endometrial hyperplasia/carcinoma decreased significantly compared with the pre–TBS‐2001 experience.21 In the 2012 management guidelines, the ASCCP advised using histologic endometrial assessment only in postmenopausal women.12

During the TBS‐2014 update, after literature review and public comment consensus, it was decided that, to increase the predictive value of this category, cytologically “benign‐appearing” endometrial cells should be reported in women aged ≥45 years, and the suggested educational note should specify that endometrial evaluation be done only in postmenopausal women (Table 1).21

No new category was created for squamous lesions with LSIL and few cells suggestive of concurrent HSIL

Rationale

Occasionally, a specimen is encountered with cytologic features that lie between LSIL and HSIL; however, attention to morphologic features usually supports classification as either LSIL or HSIL. In cases with unequivocal HSIL, the presence of concurrent LSIL is not necessary to make an interpretation of HSIL.

Since the publication of TBS‐2001, it has been suggested that these intermediate morphologic patterns might be better designated with a diagnostic term other than LSIL or HSIL. Terms such as “LSIL, cannot exclude HSIL” or “LSIL‐H” have been proposed. In preparation for the 2014 TBS update, opinions regarding this topic were openly solicited, and consensus was achieved that formal TBS nomenclature should be limited to the original LSIL and HSIL categories, maintaining the 2‐tiered classification scheme. Adding terminology such as “LSIL‐H” would lead to a de facto 3‐tiered system, essentially negating the beneficial aspects of the 2‐tiered TBS nomenclature. Furthermore, current management guidelines all use LSIL and HSIL nomenclature without an intermediate category, and recent histopathology reporting recommendations also encourage reporting as LSIL or HSIL. Poor reproducibility and overuse of any new indeterminate cytology terminology would likely lead to confusion among clinicians and, possibly, inappropriate management.

For occasional cases in which it is not possible to categorize an SIL as either low‐grade or high‐grade, a comment explaining the nature of the uncertainty may be appropriate. Alternatively, an interpretation of atypical squamous cells (ASC) cannot rule out HSIL (ASC‐H) may be made in addition to an LSIL interpretation. This would indicate that definite LSIL is present as well as some cells that suggest the possibility of HSIL. In general, follow‐up guidelines for these interpretations are for colposcopy and biopsy; however, in patients (such as young women) who have samples for which the guidelines differ between LSIL and ASC‐H, the addition of the ASC‐H interpretation should lead to colposcopic evaluation. Intermediate interpretations should comprise only a small minority of cases in any laboratory, because classification into either LSIL or HSIL is possible in most instances after a careful overall evaluation of the cellular morphology (Fig. 2).

Third Edition of the Bethesda Atlas

Providing an updated atlas with retention of the popular features of the 2004 edition and additional images and content, reflecting continued experience and changes in practice, was the main motivation for the 2014 update.21 The content, both text and illustrations, have been increased by approximately 66% compared with the second edition.5 Among the 12 chapters, 6 correspond to the major Bethesda interpretive categories, and the remaining chapters are dedicated to other malignant neoplasms, anal cytology, reporting of adjunctive testing, computer‐assisted screening, educational notes, and a new chapter on cervical cancer risk assessment.21

Each chapter has been extensively updated, and the format includes: 1) background and introduction, including basic cell biology; 2) description of definitions, cytologic criteria, explanatory notes covering difficult morphologic patterns, mimics of epithelial lesions, and current clinical management guidelines for reporting in the 6 interpretation category‐based chapters; 3) sample reports; and 4) selected key references. The cytomorphologic criteria are described in general terms, followed by any significant differences related to specific preparation types where relevant, and tables have been added to compare and contrast criteria. Note that TBS does not endorse any particular methodology or manufacturer(s) for specimen collection, computer-assisted screening, adjunctive HPV or other testing.

More than 1000 images were evaluated for the third edition of the Bethesda atlas, including all 186 images from the second edition. Final selections were made after a multistage review process: first by the dedicated chapter group and, second, by a subgroup of the Bethesda 2014 Task Force. The 370 atlas illustrations, complemented by robust legends, illustrate a spectrum of morphologic variations observed on both conventional smears and liquid‐based cytologic preparations; 58% of the images are new, and 42% are from the second edition; 40% are from conventional preparations, and 60% are from liquid‐based preparations. Some images represent classic examples of an entity, whereas others were selected to illustrate interpretive dilemmas or “borderline” morphologic features that may not be interpreted in the same way by all cytologists. Unique to this edition is the substantially larger number of composite images for a side‐by‐side illustration of mimics and cytologic‐histologic correlations (Figs. 3-6). A brief summary of chapter updates and their rationale is provided below.

Chapter 1: Adequacy

Evaluation of specimen adequacy is considered by many to be the single most important quality assurance component of the Bethesda system. Data and clinical experience regarding specimen adequacy since 2001 were reviewed, leading to the inclusion of additional guidance for special situations, such as assessing cellularity in specimens obtained from postradiation patients, interfering substances (eg, lubricant, blood), and the effects of adequacy on HPV testing.

Chapter 2: Non‐neoplastic changes

An expanded variety of “normal” findings as well as non‐neoplastic mimics of classic epithelial abnormalities are included, providing a more complete representation of the morphologic variations that can be encountered in cervical cytology preparations (Fig. Equalizer on spotify for mac. 3).

Chapter 3: Endometrial cells

Bethesda System For Reporting Cervical Smear 2014

The age for reporting of “cytologically benign appearing” endometrial cells has been increased to women aged ≥45 years (the rationale for this is presented above).

Chapter 4: Atypical squamous cells

The category of ASC is by far the most commonly reported abnormal cervical cytology interpretation. ASC continues to be defined as the general category with subcategorization as ASC‐US and ASC‐H. The dichotomous reporting for ASC mirrors that observed for LSIL and HSIL. It must be emphasized that the ASC category was developed to designate the interpretation of an entire specimen, not individual cells, because atypia in individual cells remains a highly subjective and, hence, variable interpretation. Common patterns interpreted as ASC‐US and ASC‐H are reviewed and guidance provided to enable laboratories to use this reporting category along with HPV test results to monitor quality and consistency among practitioners and laboratories (Fig. 4).

Chapter 5: Squamous epithelial cell abnormalities

The dichotomous reporting terminology for LSIL and HSIL is maintained and reflects our current understanding of the natural history of HPV‐related infections—low‐grade changes represent productive, largely transient HPV infection, and high‐grade morphology represents a precancerous lesion. On the basis of our understanding of HPV biology and the behavior of preinvasive, HPV‐associated squamous lesions, the focus of cervical cancer screening is primarily aimed at detection and treatment of HSIL. Thus, this chapter has been substantially expanded to include problematic patterns and mimics that may lead to locator and/or interpretation errors of non‐neoplastic changes as HSIL/ASC‐H and vice versa (Figs 3 and 5). A new category was not created for squamous lesions with LSIL that also contain a few cells suggestive of concurrent HSIL, the rationale for which is described above.

Chapter 6: Glandular epithelial cell abnormalities

The Pap test was not designed to screen for glandular lesions of the cervix, and these abnormalities are more difficult to sample and interpret compared to their squamous counterparts. However, because of improvement in sampling devices and the increase in endocervical adenocarcinoma relative to squamous cell carcinoma over the past 2 decades, cytologists currently encounter more challenging presentations of glandular lesions and their mimics in cervical cytology specimens. This update includes many more images of glandular lesions and differential diagnostic considerations. Tables illustrating differences in criteria are included for quick reference.

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Chapter 7: Other malignant neoplasms

New published literature since TBS‐2001 has described malignant neoplasms, other than the usual variants of primary squamous carcinomas and endocervical adenocarcinomas, that infrequently involve the uterine cervix but that nevertheless may be observed in cervical cytologic preparations (Fig. 6). These may create interpretation challenges and result in diagnostic pitfalls. Most often, these tumors are special variants of cervical carcinoma or uncommon primaries arising in the uterine corpus or adenexa that appear in the cervical cytology specimens either as exfoliated cells or through direct sampling of tumors. Increased numbers of such cases are now illustrated.

Chapter 8: Anal cytology

Although anal cancer is relatively uncommon in the general population, rates have been increasing over the last several decades, especially in high‐risk groups. Anal cytology was first included in the 2001 Bethesda atlas and has gained acceptance as a tool for anal cancer screening in conjunction with high‐resolution anoscopy and biopsy—in a role similar to that of the Pap test. This edition further elaborates on new epidemiologic literature and defines high‐risk populations. Sampling devices used to collect anal cytology specimens, criteria for adequacy, and the role of cytohistologic/high‐resolution anoscopy correlation data are reviewed. Additional images of carcinoma, organisms, and mimickers are included (Fig. 7).

Chapter 9: Adjunctive testing

Reporting of the results from ancillary studies has evolved since the second edition, and this chapter updates reporting schemes. Data concerning use and reporting for the current HPV testing schemes and adjunctive immunocytochemistry procedures (eg, p16) are included.

Chapter 10: Computer‐assisted interpretation

Several new US Food and Drug Administration approvals in the field of automated cervical cytology screening have occurred in the past decade. These have included the so‐called “location‐guided screening” devices that identify areas at highest risk for containing potential abnormalities—essentially providing a prescreened slide. The third edition provides an overview of the currently used systems and updates recommendations, which now include the reporting items for “location‐guided screening” devices in addition to those covered previously.

Chapter 11: Educational notes and comments

One of the guiding principles of TBS has always been to improve communication from the laboratory provider to the physician caring for the patient. It is the responsibility of both laboratorians and clinicians to stay current with recent developments and communicate these to each other. The use of written recommendations and/or comments in cervical cytology reports is optional; and, when included in the cytology report, they must be worded carefully and relay clear, concise, current, evidence‐based information. In the second edition of the Bethesda atlas, it was recommended that such comments be directed to the clinician and that the laboratorian/laboratory not communicate directly with the patient unless specifically instructed to do so. In the United States, as of 2014, there are changes to the rules regarding patient access to test reports. In addition, standardization of reports to facilitate widespread electronic health record implementation has been encouraged. These changes may have further implications for the use of recommendations in pathology reports, and a relevant discussion is now included.21

Chapter 12: Risk assessment in cervical cancer

This new chapter is an important addition to the third atlas, because it is key to understanding how the results of various screening and triage test combinations relate to the patient's risk for cervical cancer.20 The concept of “equal management for equal risk,” along with balancing benefits and harms of screening, formed the basis of the 2012 management guidelines for abnormal cervical cancer screening tests and cancer precursors.12

1 Bethesda Interobserver Reproducibilty Study (BIRST‐II)

Although knowledge of normal morphology, its variations, and epithelial abnormalities is essential, some degree of interobserver and interlaboratory variability in cervical cytology and histology interpretation will always remain a reality.6, 22 In an effort to build on the information gathered from our experience with the BIRST project in 2003,6 85 images from the third atlas were posted as “unknowns” on a website that was open to the international cytopathology community. Data from this effort, which is currently ongoing, will provide a realistic gauge of interpretive reproducibility across a wide (and defined) demographic. The results of this exercise will be posted during spring of 2015 on the American Society of Cytopathology website23 and will be discussed in a subsequent publication.

2 Bethesda 2014 Web Atlas

An accompanying Bethesda website resource is being developed under the direction of Drs. Daniel Kurtycz and Paul Staats and with the help of a Bethesda Website Task Force** (see acknowledgments, below). In addition to all of the images from the third edition of the atlas, this website will contain many other examples of presentations and entities that could not be provided in the print atlas. A variety of search options will be provided, and the results of the reproducibility study (BIRST‐II) and accompanying histograms will be posted on this site. The group will also explore new avenues for delivery of the content that has been assembled during this update process. For further information on the Bethesda web atlas, please visit the educational resources page on the American Society of Cytopathology website.23

Conclusions

Given all the recent press about new methods of cervical cancer screening and the lack of sensitivity of the Pap test, some may question the significance of a new edition of the Bethesda atlas. Before exaggerating the demise of the Pap test, it must be remembered that it still has significant utility worldwide. Because of its greater specificity compared with HPV testing, the Pap test will have importance as a diagnostic triage tool after a positive HPV screening test. In locales where HPV testing is not available or reimbursed, regular Pap testing will remain the screening method of choice. Fitbit.com app for mac. An updated and enhanced Bethesda atlas will continue to serve its current purpose—that of being an inexpensive, portable, single‐volume resource that will be widely available internationally. Compared with the second edition, the new atlas contains a greater discussion of HPV biology and pathogenesis, includes all current recommendations for management, and has a more comprehensive group of illustrations that contains, in addition to the prior version's classic examples, a robust content of look‐alikes and equivocal presentations. An increased number of recommended report formats and a comprehensive reference list have also been included. Overall, this makes the third edition a greatly enhanced resource.

As in previous editions, the current editors and authors have committed to making the third edition affordable and, hence, widely accessible to all, including practitioners in low‐resource environments. No honoraria or royalties will be accepted by the editors/authors, and the edition will remain a graphically high‐quality, paperbound monograph. The publisher, Springer, will also make the corresponding electronic version (ebook) available online.

ACKNOWLEDGMENTS

On behalf of the American Society of Cytopathology, we thank Drs. Diane Solomon and Robert Kurman for their pioneering vision in initiating and organizing the implementation of The Bethesda System, the 2014 Bethesda Task Force members, the contributors of the first and second editions of the Bethesda atlas, and all of the other dedicated cytopathologists, cytotechnologists, and clinical colleagues who have volunteered to contribute to this effort over the past quarter of a century.2-5, 21

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*The 2014 Bethesda System Task Force: David C. Wilbur, MD (Chair), Ritu Nayar, MD (Cochair), and Diane Solomon, MD (Advisor); Members: Fadi W. Abdul‐Karim, MD; George G. Birdsong, MD; David Chelmow, MD; David C. Chhieng, MD; Edmund S. Cibas, MD; Teresa M. Darragh, MD; Diane D. Davey, MD; Michael R. Henry, MD; Walid E. Khalbuss, MD, PhD; Daniel F. I. Kurtycz, MD; Dina R. Mody, MD; Ann T. Moriarty, MD; Joel M. Palefsky, MD; Celeste N. Powers, MD, PhD; Donna K. Russell, MEd, CT(ASCP), HT(ASCP); Mark Schiffman, MD, MPH; Mary K. Sidawy, MD; Paul N. Staats, MD; Mark H. Stoler, MD; Sana O. Tabbara, MD; Alan G.Waxman, MD; Nicolas Wentzensen, MD, PhD.

**The 2014 Bethesda Website Task Force: Daniel F. I. Kurtycz, MD and Paul N. Staats, MD (Cochairs); Ritu Nayar, MD and David C. Wilbur, MD (Advisors); Members: Deborah Chute, MD; Maria Freidlander, MPA, CT(ASCP); Sara Monaco, MD; Donna K. Russell, MEd, CT(ASCP).

FUNDING SUPPORT

None for The Bethesda 2014 Atlas Update Project.

CONFLICT OF INTEREST DISCLOSURES

Dr Nayar (Immediate Past President, American Society of Cytopathology in 2013‐14) Dr Wilbur (Past President, American Society of Cytopathology, 2002‐2003).

• 1. In: R Nayar, DC Wilbur, eds. The Bethesda System for Reporting Cervical Cytology. Definitions, Criteria, and Explanatory Notes. 3rd ed. Springer; 2015.
• 2The 1988 Bethesda System for reporting cervical/vaginal cytologic diagnoses. National Cancer Institute Workshop. JAMA. 1989; 262: 931‐ 934.
• 3RJ Kurman, D Solomon, eds. The Bethesda System for Reporting Cervical/Vaginal Cytologic Diagnoses. Definitions, Criteria, and Explanatory Notes for Terminology and Specimen Adequacy. New York, NY: Springer‐Verlag; 1994.
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(Redirected from AGUS)

The Bethesda system (TBS) is a system for reporting cervical or vaginal cytologic diagnoses,^[1] used for reporting Pap smear results. It was introduced in 1988^[2] and revised in 1991,^[3] 2001,^[1][4][5] and 2014.^[6] The name comes from the location (Bethesda, Maryland) of the conference that established the system.

Additionally, the Bethesda system is used for cytopathology of thyroid nodules.

• 1Cervix
  • 1.1Squamous cell abnormalities
  • 1.2Glandular cell abnormalities

Cervix[edit]

Abnormal results include:

• Atypical squamous cells
  • Atypical squamous cells of undetermined significance (ASC-US)
  • Atypical squamous cells – cannot exclude HSIL (ASC-H)
• Low-grade squamous intraepithelial lesion (LGSIL or LSIL)
• High grade squamous intraepithelial lesion (HGSIL or HSIL)
• Atypical Glandular Cells not otherwise specified (AGC-NOS)
• Atypical Glandular Cells, suspicious for AIS or cancer (AGC-neoplastic)
• Adenocarcinoma in situ (AIS)

The results are calculated differently following a Pap smear of the cervix.

Squamous cell abnormalities[edit]

LSIL: low-grade squamous intraepithelial lesion [edit]

LSIL. Pap stain

A low-grade squamous intraepithelial lesion (LSIL or LGSIL) indicates possible cervical dysplasia. LSIL usually indicates mild dysplasia (CIN 1), more than likely caused by a human papillomavirus infection. It is usually diagnosed following a Pap smear.

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CIN 1 is the most common and most benign form of cervical intraepithelial neoplasia and usually resolves spontaneously within two years. Because of this, LSIL results can be managed with a simple 'watch and wait' philosophy. However, because there is a 12–16% chance of progression to more severe dysplasia, the physician may want to follow the results more aggressively by performing a colposcopy with biopsy.^[7] If the dysplasia progresses, treatment may be necessary. Treatment involves removal of the affected tissue, which can be accomplished by LEEP, cryosurgery, cone biopsy, or laser ablation.

HSIL: high-grade squamous intraepithelial lesion [edit]

HSIL. Pap stain.

High-grade squamous intraepithelial lesion (HSIL or HGSIL) indicates moderate or severe cervical intraepithelial neoplasia or carcinoma in situ. It is usually diagnosed following a Pap test. In some cases these lesions can lead to invasive cervical cancer, if not followed appropriately.

HSIL does not mean that cancer is present. Of all women with HSIL results, 2%^[8] or less^[9] have invasive cervical cancer at that time, however about 20% would progress to having invasive cervical cancer without treatment.^[10] To combat this progression, HSIL is usually followed by an immediate colposcopy with biopsy to sample or remove the dysplastic tissue. This tissue is sent for pathology testing to assign a histologic classification that is more definitive than a Pap smear result (which is a cytologic finding). HSIL generally corresponds to the histological classification of CIN 2 or 3.

HSIL treatment involves the removal or destruction of the affected cells, usually by LEEP. Other methods include cryotherapy, cautery, or laser ablation, but none are performed on pregnant women for fear of disrupting the pregnancy.^[11] Any of these procedures is 85% likely to cure the problem.

Bethesda System For Reporting Pap Results

Glandular cell abnormalities[edit]

Adenocarcinoma[edit]

Adenocarcinoma. Pap stain.

Adenocarcinoma can arise from the endocervix, endometrium and extrauterine sites.

AGC[edit]

AGC, formerly AGUS, is an acronym for atypical glandular cells of undetermined significance.^[12] Renamed AGC to avoid confusion with ASCUS.^[1]

The management of AGC is colposcopy with or without an endometrialbiopsy.

Thyroid nodules[edit]

The Bethesda System for Reporting Thyroid Cytopathology is the system used to report whether the thyroid cytological specimen is benign or malignant on fine-needle aspiration cytology (FNAC). Android mac address. It can be divided into six categories:

Bethesda system

Category	Description	Risk of malignancy[13]	Recommendation[13]
I	Non diagnostic/unsatisfactory	-	Repeating FNAC with ultrasound-guidance in more than 3 months
II	Benign (colloid and follicular cells)	0 - 3%	Clinical follow-up
III	Atypia of undetermined significance/follicular lesion of undetermined significance (follicular or lymphoid cells with atypical features)	5 - 15%	Repeating FNAC
IV	Follicular nodule/suspicious follicular nodule (cell crowding, micro follicles, dispersed isolated cells, scant colloid)	15 - 30%	Surgical lobectomy
V	Suspicious for malignancy	60 - 75%	Surgical lobectomy or near-total thyroidectomy
VI	Malignant	97 - 99%	Near-total thyroidectomy

Repeated FNAC is recommended for Category I, followed by clinical follow-up in Category II, repeat FNAC for Category III, and lobectomy for Category IV, near total-thyroidectomy/lobectomy for Category V, and near total thyroidectomy for Category VI.^[14] The risk of malignancy in a malignant FNAC report is 93.7% while for a suspicious FNAC report, it is 18.9%.^[15]

See also[edit]

Bethesda Cytology Classification System

References[edit]

1. ^ ^abcApgar BS, Zoschnick L, Wright TC (November 2003). 'The 2001 Bethesda System terminology'. Am Fam Physician. 68 (10): 1992–8. PMID14655809.
2. ^Soloman, Diane (1989). 'The 1988 Bethesda System for reporting cerval/vaginal cytologic diagnoses: developed and approved at the National Cancer Institute workshop in Bethesda, MD, December 12–13, 1988'. Diagn. Cytopathol. 5 (3): 331–4. doi:10.1002/dc.2840050318. PMID2791840.
3. ^Broder S (1992). 'The Bethesda System for Reporting Cervical/Vaginal Cytologic Diagnoses—Report of the 1991 Bethesda Workshop'. JAMA. 267 (14): 1892. doi:10.1001/jama.1992.03480140014005.
4. ^Nayar R, Solomon D. Second edition of 'The Bethesda System for reporting cervical cytology' – Atlas, website, and Bethesda interobserver reproducibility project. CytoJournal [serial online] 2004 [cited 2011 Apr 17];1:4. Available from: http://www.cytojournal.com/text.asp?2004/1/1/4/41272
5. ^Solomon D, Davey D, Kurman R, et al. (April 2002). 'The 2001 Bethesda System: terminology for reporting results of cervical cytology'. JAMA. 287 (16): 2114–9. doi:10.1001/jama.287.16.2114. PMID11966386.
6. ^Nayar R, Wilbur D. The Bethesda System for Reporting Cervical Cytology, Definitions, Criteria, and Explanatory Notes. Springer; 2015.
7. ^Wright TC Jr, Massad LS, Dunton CJ, Spitzer M, Wilkinson EJ, Solomon D (Oct 2007). '2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests'. Am J Obstet Gynecol. 197 (4): 346–55. doi:10.1016/j.ajog.2007.07.047. PMID17904957.
8. ^Massad LS; Collins YC; Meyer PM. Biopsy correlates of abnormal cervical cytology classified using the Bethesda system. Gynecologic Oncology. 2001 Sep;82(3):516-22.
9. ^Melnikow J, Nuovo J, Willan AR, Chan BK, Howell LP. Natural history of cervical squamous intraepithelial lesions: a meta-analysis. Obstetric Gynecology. 1998 Oct;92(4 Pt 2):727-35.
10. ^McIndoe WA; McLean MR; Jones RW; Mullins PR. The invasive potential of carcinoma in situ of the cervix. Obstetric Gynecology. 1984 Oct;64(4):451-8.
11. ^Wright TC Jr; Massad LS; Dunton CJ; Spitzer M; Wilkinson EJ; Solomon D. 2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests. American Journal of Obstetric Gynecology. 2007 Oct;197(4):346-55.
12. ^AGUS at eMedicine Dictionary
13. ^ ^abRenuka, I. V.; Saila Bala, G.; Aparna, C.; Kumari, Ramana; Sumalatha, K. (December 2012). 'The Bethesda System for Reporting Thyroid Cytopathology: Interpretation and Guidelines in Surgical Treatment'. Indian Journal of Otolaryngology and Head & Neck Surgery. 64 (4): 305–311. doi:10.1007/s12070-011-0289-4. PMC3477437. PMID24294568.
14. ^Renuka, I.V; Saila Bala, G; Aparna, C; Kumari, R; Sumalatha, K (December 2012). 'The Bethesda System for Reporting Thyroid Cytopathology: Interpretation and Guidelines in Surgical Treatment'. Indian J Otolaryngol Head Neck Surg. 64 (4): 305–311. doi:10.1007/s12070-011-0289-4. PMC3477437. PMID24294568.
15. ^Tee, Yoon Y; Lowe, Adrain J; Brand, Caroline A (November 2007). 'Fine-Needle Aspiration May Miss a Third of All Malignancy in Palpable Thyroid Nodules'. Annals of Surgery. 246 (5): 714–720. doi:10.1097/SLA.0b013e3180f61adc. our study showed that the risk of malignancy of malignant FNA and suspicious FNA diagnosis is around 93.7% and 18.9%, respectively.

The Bethesda System For Reporting Cervical Cytology Pdf 2015

External links[edit]

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