Bethesda System Terminology Research Articles

The reasons for colposcopy and histopathological outcomes in referral patients to Ayatollah Mosavi Hospital of Zanjan (2012–2017)

Objectives: The present study aimed at assessing the prevalence of cervical cancer and premalignant lesions of the cervix in patient referred to colposcopy unit in Zanjan, and to determine what extent colposcopy is conducted based on the scientific indications. Materials and Methods: In this registry-based cross-sectional study, all women who were referred to the Colposcopy unit of Zanjan Ayatollah-Mousavi Hospital to undergo colposcopy during 2012–2017 were studied. The required data were collected from the registered medical records in the Pathology Department of the hospital. The Bethesda System Terminology was used for classifying premalignant cervical lesions. Results: In the present study, the most common abnormal clinical signs were abnormal vaginal bleeding, whereas atypical squamous cells of undetermined significance (39.5%) remained the most common abnormal Pap smear test result. The clinical appearance of the cervix in 104 patients (62.3%) showed cervical erosion. The results of colposcopy showed some signs of inflammation in all patients. Out of these patients, 5.4% were reported with acute inflammation, and 39.5% with chronic inflammation. Conclusions: It can be concluded that the patients' referral for a colposcopy must be based on the scientific indications and unnecessary colposcopy should be avoided.

Bethesda 2014: improving on a paradigm shift.

The third iteration of the Bethesda System terminology manual was recently published. This update included changes in the reporting of benign endometrial cells, and guidance for special adequacy situations and for cases in which low grade squamous intraepithelial lesions are accompanied by some cells suggesting that a high grade lesion might also be present. In addition, the manual was increased in size to include more illustrations with special studies and comparisons to histology, a greatly increased reference list, and a new chapter devoted to the modern practice of risk-based management. The third edition of the Bethesda manual is meant to serve as a primary reference for the practice of gynecologic cytology designed to provide a uniform system of reporting Worldwide for clinical, teaching, and research purposes.

Clinicopathologic significance of Papanicolaou smear study of postmenopausal women in a rural tertiary care center

Background: Cervical cancer is a preventable disease in the vast majority of women. Papanicolaou (Pap) smear is still the most effective screening tool available for preventing cervical cancer. Therefore, it is important to investigate the significance of screening in older women. Objective: To study the distribution of cervical cancer among postmenopausal women and to determine the significance of cervical cancer screening in symptomatic and asymptomatic postmenopausal women. Materials and Methods: A total of 590 Pap smears were obtained from postmenopausal women between September 2012 and March 2013. Prefixed conventional cervical smears were stained with Pap stain. The cytology results were reported using the Bethesda system terminology. Results: Among the 590 postmenopausal women studied, 38.9% of asymptomatic postmenopausal women had clinically significant lesion whereas only 33.1% of symptomatic women had clinically significant lesion. There was low-grade squamous intraepithelial lesion at percentage of 17.5. Asymptomatic and symptomatic were 11.5% and 6.5%, respectively. High-grade squamous intraepithelial lesion was 4.5%. Asymptomatic and symptomatic were 7.5% and 2.85%, respectively. Atypical squamous cells of undetermined significance were seen in 8.85%. Asymptomatic and symptomatic were 4.25% and 4.6% respectively. Atypical glandular cells of undetermined significance were 1.7%. Only 3.2% of significant lesion was squamous cell carcinoma, and all were symptomatic. Conclusion: Postmenopausal women especially from the rural area and low socioeconomic strata suffered disproportionately from precancerous and cancerous lesions of the cervix. To reduce this burden, it's mandatory to motivate and screen asymptomatic older women.

Role of HPV Testing in Anal Pap Tests

Introduction: The National Cancer Institute reports an annual anal cancer incidence of 1.6 per 100,000 in the general population. Men who have sex with men (MSM) have a much higher incidence ranging 35-100 per 100,000 with increased incidence in HIV-infected patients. The causal connection between HPV infection and squamous epithelial lesions has been well documented. Based on experience for cervical cancer screening, anal Pap tests (PT) are now used to screen for squamous intraepithelial lesions in high risk patients. Materials and Methods: We studied 241 anal PT obtained from 151 HIVpositive male patients (MSM) attending the Veterans Affairs Medical Center in Washington DC obtained between 2006 and 2012. PTs were reported using the 2001 Bethesda system terminology (NILM, ASC-US, ASC-H, LSIL, HSIL, SCC). Our institution has been among many others to use the LSIL-H (low grade squamous intraepithelial lesion, cannot exclude a high grade squamous lesion) as a diagnostic category. We evaluated the follow up of patients with abnormal cytology, including repeat cytology and biopsy. Results: Of the 241 anal PT performed, 184 (77%) of the smears were considered satisfactory for evaluation. 44 cases (18%) were negative, 140 (58%) were abnormal. Of these 140 abnormal PT, 79 (56.4%) had cytologic (repeat PT) or histologic (biopsy under anoscopy) follow up (see Table 1). Among these 79 patients, 43 (54%) had a biopsy-proven dysplasia (low grade, high grade and SCC). 19 (24%) had LSIL or higher on repeat Pap. Conclusions: The high number of patients with no follow-up may be a bias of the population targeted in this study (MSM, homelessness, other socioeconomic and educational factors). The high rate of abnormal results described in this study and in the literature reinforces the need for aggressive screening and clinical follow up, as well as national guidelines for screening and follow-up.

Anal cytology as a predictor of anal intraepithelial neoplasia in HIV‐positive men and women

Human immunodeficiency virus (HIV)-infected individuals have increased risk of anal intraepithelial neoplasia (AIN) and squamous cell carcinoma (SCC). Cytologic screening is invaluable in the detection of cervical neoplasia, therefore many clinicians have adopted anal cytology as part of anal cancer screening in patients at high-risk for anal neoplasia. The purpose of this study is to determine whether anal cytology is a valuable screening test for identifying AIN in HIV+ patients. The cohort included 228 HIV+ patients who underwent anal cancer screening with collection of 318 anal cytology specimens between January 2006 and December 2009. Of this group, 74 (32.5%) patients had associated anal biopsies within a 6-month period, with a total of 89 comparison cases. The anal cytology samples were classified using the 2001 Bethesda System terminology. The sensitivity of anal cytology in detecting ASC-US, AIN 1-3 or SCC was 93%. Cytology was 88% sensitive for detecting low-grade AIN (AIN 1), but only 20% sensitive for detecting high-grade AIN (AIN 2-3) or SCC. Atypical squamous cells of undetermined significance cases were distributed evenly between low- and high-grade AIN, with two cases having normal histology. Only six cases had negative cytology, all of which were associated with AIN on biopsy, for a false negative rate of 7%. Anal cytology is a good predictor of AIN, as confirmed by the high degree of sensitivity. However, there is poor correlation between the cytological and histological grade of AIN. Cytology underestimates the grade of dysplasia compared to the corresponding biopsy.

Anal human papillomavirus DNA in women at a colposcopy clinic

To describe the type-specific prevalence of anal and cervical human papillomavirus (HPV) infections and the cytology in HIV-negative women without a history of cervical cancer, attending a colposcopy clinic. To examine if an HPV positive anal smear is related to anal pathology and consequently indicative for further examinations (high resolution anoscopy, anal biopsy). From 149 consecutive women an anal swab and a cervical swab were taken, using the Cervex-Brush. The presence of 18 different HPV genotypes was determined using TaqMan-based real-time quantitative PCR targeting type-specific sequences of viral genes. From the fluid containing the cellular material, a liquid-based cytology sample was prepared of both collections with the robotic BD PrepStain Slide Processor. All slides were pre-screened by BD FocalPoint system and categorized from quintiles 1 to 5 and afterwards screened using targeted microscopic interpretation of selected suspicious fields using FocalPoint guided screening review stations. The 2001 Bethesda System Terminology was used for the anal slides. Ninety-six anal samples and all 149 cervical samples were adequate. Overall presence of HPV in the anus was 56.3% and in the cervix 53.7%. Overall, cytological abnormalities were found in 10.8% of anal smears and in 32.8% of cervical smears. HPV genotypes were identified in 47 samples on both sites: partial or complete concordance was found in 85.1%. HPV types 6, 16 and 18 were found in 27.9% and in 26.6% of the anal and cervical samples, respectively. The top three HPV types in the anus were 16, 51 and 39; in the cervix 16, 39, 51 and 56 (a shared 3(rd) place). HPV type 11 was not found. The presence of HPV genotypes is clearly multifocal in this study population of women attending a colposcopy clinic, with high concordance of genotypes. The number of anal HPV infections is high. Although cytological abnormalities are rare, the presence of HPV may lead to anal lesions later in life. From this perspective, complementary medical history and clinical examination of the anal region are advised.

Diagnosis of anal human papillomavirus infection: polymerase chain reaction or cytology?

To investigate the relationship between human immunodeficiency virus (HIV)-positive and HIV-negative patients engaging in promiscuous behaviors and anal human papillomavirus (HPV) infection diagnosed by polymerase chain reaction (PCR) and cytology. Fifty-six HIV-positive patients and 49 HIV-negative patients who engaged in sexually promiscuous behavior were enrolled in the study. We performed cytological exams using the Pap smear and PCR for HPV-DNA detection, with identification of oncogenic strains. The 2001 Bethesda System terminology was used for the cytological exams. We also evaluated the immunologic status of the HIV-infected patients. PCR positivity for HPV-DNA was higher in the group of HIV-positive patients than in the group of HIV-negative patients with a statistically significant difference. In contrast we did not find any statistically significant difference by cytological exam. Oncogenic strains were equally distributed in the two groups. Our results indicate the importance of the cytological exam for anal HPV screening in the population at high risk of sexually transmitted disease and that HPV-DNA PCR can be used only as adjunct test.

Concordância entre citologia, colposcopia e histopatologia cervical

to evaluate the agreement between conventional cytology using the Papanicolaou test, repeated at the time of colposcopy, with colposcopic and histopathological findings. the study was carried out at the central public health laboratory of the state of Pernambuco between January and July, 2008, involving 397 women referred for colposcopic evaluation following an abnormal cervical smear test. Cytology was repeated at the time of colposcopy using conventional method, with particular attention being paid to the presence of abnormal colposcopic findings. The nomenclature used for cytology was the 2001 Bethesda system terminology, while that used for histology was the World Health Organization 1994 classification. Cytology performed at the time of colposcopy was compared with colposcopy and with histopathology obtained by colposcopy-directed biopsy. The Kappa coefficient was used to evaluate the agreement between methods, as well as the χ2 test, with the level of significance set at 5%. poor agreement was found between cytology performed at the time of colposcopy and colposcopic findings (K=0.33; 95%CI=0.21-0.45) and between colposcopy and histopathology (K=0.35; 95%CI=0.39-0.51). Cytology performed at the time of colposcopy compared with histopathology revealed a Kappa of 0.41 (95%CI=0.29-0.530), which was considered to reflect moderate agreement. agreement was better between cytology and histopathology than between colposcopy and cytology or between colposcopy and histopathology.

Significance of subclassifying high‐grade squamous intraepithelial lesions into moderate dysplasia/CIN II versus severe dysplasia/CIN III/CIS in the Bethesda system terminology

Recent revisions of the Bethesda System (TBS III) did not modify the original two-tiered low-grade and high-grade squamous intraepithelial lesion (LSIL/HSIL) terminology and continued to offer the option of subclassifying HSIL into moderate dysplasia/cervical intraepithelial neoplasia (CIN II) and severe dysplasia/CIN III. The purpose of this study is to evaluate the significance of the HSIL moderate dysplasia/CIN II subclassification and the causes of Pap test-biopsy discordance for this subclassification. HSIL/moderate dysplasia/CIN II Pap tests were identified from the University of California Davis Medical Center laboratory file for a 5-yr period (1997-2001) and correlated with follow-up cervical biopsies. Cervical biopsies with CIN II diagnoses were identified from the laboratory file for the same time period, and correlated with their preceding Pap test. Discordant Pap test-biopsy pairs from either group were reviewed by two pathologists for the following causes for discordance: cytologic overcall or undercall, biopsy overcall or undercall, and sampling error or possible lesion regression. During the review period, 161 of 378 total HSIL Pap tests had a HSIL/CIN II result (42%), and 81/161 (50%) had a follow-up cervical biopsy. 38/81 (47%) were concordant, and 43 (53%) were discordant; 39/43 discordant cases had both Pap test and biopsy slides available for review. CIN I was the most common discordant biopsy diagnosis. Sampling error was the most common cause of discordance and was three times more common than the other causes; 536 CIN cervical biopsies with CIN were identified in the laboratory files during this review period, and 108/536 (20%) received a diagnosis of CIN II. Sixty-seven of 108 (62%) had a preceding Pap test result available; 32 of the 67 (48%) had a concordant preceding Pap test with a HSIL/CIN II result, and 35 (52%) were discordant; 32/35 discordant cases had both Pap test and biopsy slides available for review. LSIL was the most common discordant Pap test diagnosis. Sampling error was also the most common cause of discordance, and was also three time more frequent than any other cause for discordance. HSIL/CIN II is a meaningful subclassification in our laboratory. We support the TBS III recommendation for optional subclassification of HSIL and suggest that individual laboratories may wish to monitor use of this subclassification through internal correlation studies.

Book Review

The Cytopathology Review Guide by E Blair Holladay has been expanded in the second edition with three new chapters on liquid-based cytology, special stains and molecular techniques, and laboratory management and administration. The questions now total 1186, 30% of which have associated images. The guide is comprehensive in scope and focuses on the most common specimens and problems encountered by cytologists and cytopathologists in a practice with a mix of gynecologic, fluid, and fine needle specimens. Each question is referenced, with the majority of references taken from Richard M DeMay's The Art & Science of Cytopathology. With the exception of the three new chapters, the text is nearly identical to the first edition, with only minor changes in some of the questions. Although uncommon, there are occasional typographical errors in the questions or the discussion of the answers. Some factual errors appear in the discussions. For example, pseudoparakeratosis is not synonymous with microglandular hyperplasia, estrogen receptor immunoreactivity does not confirm breast origin of a metastatic tumor, neither S-100 protein nor HMB-45 are specific for melanocytes, intrinsic factor is not involved in folate metabolism, and only rarely are pheochromocytomas associated with a high serum cortisol. Occasional images do not seem to correspond to the question. Most distressing is the fact that many of these errors were present in the first edition and were not corrected for the second edition. The photographs are small and of variable quality. The image quality is, in fact, slightly inferior to that of the first edition. In some cases, it is difficult to answer the question due to the quality of the image, but the image questions are generally easier than those with written microscopic descriptions. Some dated material exists, such as the questions concerning procedures such as oil myelograms, Grimelius staining, and emphasis on the evaluation of endocrinopathies by cytology in Chapter 2. In some cases, older terminology is used without accompanying current terminology, such as arrhenoblastoma, adenocanthoma, adenoma malignum, granular cell myoblastoma, sarcoma botryoides, and histiocytoses X. Questions dealing specifically with 2001 Bethesda System terminology are generally lacking. Another disappointment is that the new chapter on liquid-based cytology has no images. Although the second edition would have benefited from updating and correcting some of the material, this book does provide comprehensive coverage of cytopathology in an approachable format. The discussion is concise and stresses the key features that are useful in the practice of cytopathology and that make good examination questions. The second edition will remain a useful tool for self-assessment and preparation for the cytopathology board examination and the cytology board of registry examination.

Atypical squamous cells of undetermined significance--rule out high-grade squamous intraepithelial lesion: cytopathologic characteristics and clinical correlates.

The significance and clinical management of atypical squamous cells of undetermined significance (ASCUS) on cervical cytologic smears has been an area of much controversy. This study compiled a list of criteria useful in identifying the subset of cases that would be categorized as atypical squamous cells of undetermined significance- rule out high-grade squamous intraepithelial lesion (ASC-H) in the new Bethesda System terminology, which eventuate in a diagnosis of cervical intraepithelial neoplasia (CIN). The cytopathology files at Johns Hopkins Hospital were searched for ASC-H cases from the 3-yr period 1996-1998, which had definitive clinicopathologic follow-up (colposcopy and cervical biopsies). The smears were reviewed, cytomorphologic features studied, and clinical correlations performed. ASC-H was diagnosed in 257 of 45,428 gynecologic smears (0.6%), 72 having had clinicopathologic follow-up. Of these 72 cases, 35 (49%) on follow-up had a negative/reactive diagnosis (NR), whereas 37 (51%) turned out to be CIN [CIN-I-18 (49%) and CIN II and III-19 (51%)]. The significant cytomorphologic differences in the ASC-H category with a CIN follow-up (compared with an NR follow-up) were fewer atypical cells, more often discohesive or seen singly, more monomorphic, a higher nuclear-to-cytoplasmic (N/C) ratio, greater nuclear hyperchromasia, more coarse, unevenly dispersed chromatin, more prominent nuclear membrane irregularities, lack of nucleoli, chromocenters or nuclear grooves, and lack of an inflammatory background. Careful attention to subtle cytomorphologic characteristics may be helpful for a more definitive subdivision of ASC-H terminology into a NR and a CIN diagnosis.

A large-scale investigator-sponsored field study of the test performance of the ThinPrep papanicolaou test in a low-risk routine outpatient setting

The performance of the ThinPrep Papanicolaou test (TP)(CYTYC Corp., Boxborough, MA) was evaluated in a low- risk outpatient population in order to assess its efficacy in routine clinical use. A total of 18,246 cervical cytology samples were prepared using TP during a 6-month evaluation period from January through June 1997. Results of TP interpretation, assessed for specimen quality and diagnostic information as reported according to the Bethesda system terminology, were reviewed and compared with corresponding results from 2 historical control series of 35,347 and 35,409 conventional cervical smears (Papanicolaou smears). Archived conventional smears obtained during the first 6 months of 1995 and 1996 from the same general patient population by the same group of gynecologists and general practitioners were selected for analysis. Positive cytologic diagnoses in the TP series were reviewed and cytologic-histologic correlations were analyzed when biopsy material was available. The results demonstrated that the proportion of cytologic examinations classified as “satisfactory” was significantly greater in the TP series as compared to conventional controls (88.8% vs 71.1%, P < .0001). There was a significant increase in the number of TP examinations with an adequate endocervical component as compared to conventional controls (90.2% vs 86.9%, P < .005) and a significant decrease in the number of TP examinations that were classified as “satisfactory but limited by” either poor fixation or obscuring factors, such as blood, neutrophils, and contaminants (1.1% TP vs 14.1% nonTP, P < .0001). The overall sensitivity of detection for abnormal cells as indicated by the number of positive diagnoses was increased in the TP series (5.7% vs 2.4%, P < .01). The cytologic diagnoses of ASCUS, LSIL, and HSIL were respectively 1.6, 3.6, and 3 times more frequent in the TP series than in controls. Cytologic-histologic correlations were available for 110 (27%) of the 403 cytologic diagnoses of LSIL and for 90 (83%) of the 121 cytologic diagnoses of HSIL. The presence of a histologic lesion (LSIL or HSIL) was confirmed in 71 (65%) biopsies for LSIL and in 81 (90%) biopsies for HSIL. In conclusion, both sample quality and diagnostic sensitivity were significantly improved using the ThinPrep Papanicolaou test under routine conditions in a low-risk population.

Detection of high-grade cervical dysplasia: impact of age and Bethesda system terminology.

Pap smear, colposcopy, and biopsy results were collected from 1988-1993 at a group of family planning clinics. Positive predictive values and likelihood ratios were calculated for diagnosis of high-grade lesions based on age and Pap smear results. One thousand and forty-seven colposcopies were logged; 771 had a biopsy or endocervical curettage. Seventy-nine (10%) were high-grade lesions. If only human papillomavirus (HPV) was reported on the Pap smear, the likelihood of a high-grade biopsy was lowest (positive predictive value, 4.5%; likelihood ratio, 0.4). Women under age 25 were less likely to have high-grade biopsies (positive predictive value, 7.3%; likelihood ratio 0.7). Repeat Pap smears for atypical cells of undetermined significance (ASCUS) and low grade squamous intra-epithelial lesion (LGSIL) showing only HPV in women under age 30 would have reduced the immediate colposcopy rate by 60% and delayed diagnosis by 23% of high-grade lesions. Consideration of patient age and whether HPV is the only Pap smear finding may reduce referral for immediate colposcopy.

Impact of the Bethesda System.

Although the Bethesda System provides concise, specific descriptions for classifying cervical cytology, its usefulness has been questioned in the United States and abroad. The author attempted to evaluate the impact of the Bethesda System on cervical screening and subsequent management decisions. A MedLine search provided statistical information for comparison of screening procedures and results before and since introduction of the Bethesda System. The effect of the Bethesda System was evaluated by specimen adequacy, inclusion of human papillomavirus changes in the squamous intraepithelial lesion (SIL) category, and effect on the number of abnormal Pap smears. By 1992, 85% of cytology laboratories were using Bethesda system terminology. Diagnosis and treatment of patients with atypical squamous cells of undetermined significance (ASCUS) and low grade squamous intraepithelial lesions were reviewed. In women with ASCUS smears, follow-up studies showed that between 5% and 13% actually had high grade cervical lesions. For patients with a cytologic diagnosis of low grade SIL, one study found an 18.6% incidence of high grade lesions demonstrated by colposcopically directed cervical biopsy. An estimated 2% increase has occurred in the number of women with abnormal Pap smear results who require additional evaluation costing more than $1 billion. The Bethesda System has improved the quality of Pap smear diagnosis in the United States, but the number of women with abnormal Pap smear results has increased. Although this increase is partly due to the terminology of the Bethesda System, other factors play a role. Whether this has improved cancer prevention is unknown.