Geisinger Medical Laboratories Cytopathology Specimen Collection Instructions

Bethesda Diagnosis Reporting

Bethesda 2001 is used for reporting cervical/vaginal cytologic specimens by GML Department of Cytology
(adapted June 2002).

This report consists of three main categories: Specimen Type, Specimen Adequacy Interpretation Other comments that may be noted on the report are: Organisms, Other Nonneoplastic Findings, Automated Review or Ancillary Testing,  and Recommendations or Notes, as applicable.

Format of the Report:

1. Specimen Type
2. Specimen Adequacy
3. Interpretation
4. Organisms*
5. Nonneoplastic Findings*
6. Automated Review or Ancillary Testing*
7. Recommendations/Notes

*If applicable

Specimen Type:

Indicates the specimen source (cervical or vaginal) and the methodology (thinlayer or conventional). (top)

Specimen Adequacy:

The "satisfactory" and "unsatisfactory" categories are maintained. The "satisfactory but limited by" category has been eliminated. Instead, the presence or absence of a transformation zone component will be indicated after the satisfactory term along with other quality indicators, e.g. partially obscuring blood, inflammation, etc. There was general agreement at the recent clinical management meeting of the American Society for Colposcopy and Cervical Pathology (ASCCP) that negative satisfactory Paps lacking transformation zone component or exhibiting partial obscuring factor do not need an early repeat cytology and that annual screening is adequate. Unsatisfactory Paps should be repeated early (2-4 months). Wording of unsatisfactory Paps will change slightly to document whether the specimen was completely processed and examined by the lab or rejected when received. (top)

Primary Interpretation:

• Negative for intraepithelial lesion or malignancy.
• Atypical epithelial cells, uncertain whether squamous or glandular in origin.
• Atypical squamous cells of undetermined significance. 1
• Atypical squamous cells, cannot exclude high grade squamous intraepithelial lesion (HSIL).
• Low grade squamous intraepithelial lesion (LSIL). 2
• A squamous intraepithelial lesion is present, possibly high grade.
• High-grade squamous intraepithelial lesion (HSIL). 2
• High-grade squamous intraepithelial lesion (HSIL) with features suspicious for invasion.
• Squamous cell carcinoma.
• Atypical glandular cells. 3
• Atypical glandular cells, favor neoplastic. 3
• Atypical endocervical cells, favor in situ adenocarcinoma of the endocervix. 3
• In situ adenocarcinoma of the endocervix.
• Endocervical adenocarcinoma.
• Endometrial adenocarcinoma.
• Adenocarcinoma.

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Organisms:

• Bacteria morphologically suggestive of Actinomyces species present, suggest clinical correlation
• Fungal organisms morphologically suggestive of Candida species present, suggest clinical correlation.
• Cytopathic changes suggestive of Cytomegalovirus infection are present, suggest clinical correlation.
• Shift in flora suggestive of bacterial vaginosis present, suggest clinical correlation.
• Cytopathic changes suggestive of Herpes simplex virus are present, suggest clinical correlation.
• Organisms morphologically suggestive of Trichomonas vaginalis are present, suggest clinical correlation.

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Other Nonneoplastic Findings:

• Atrophy with chronic inflammation.
• Atrophy.
• Atrophy associated with exogenous progestational agent.
• Chronic inflammatory cells, predominantly lymphocytes, are present.
• Glandular/metaplastic cells, status post hysterectomy.
• Hyperkeratosis.
• Reactive cellular changes associated with inflammation.
• Reactive cellular changes associated with intrauterine contraceptive device.
• Fragments of benign glandular epithelium originating from the lower uterine segment are present. This finding may indicate high endocervical sampling.
• Parakeratosis.
• Atrophy associated with postpartum state.
• Pseudoparakeratosis; this finding may be seen in association with use of exogenous progestational agents.
• Reactive cellular changes associated with radiation therapy.
• Endometrial cells present in a woman40 years or older.
• Benign glandular cells are present in a patient with history of DES exposure.
• Human Papillomavirus (HPV) DNA testing will be reported in an addendum.

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Ancillary Testing:

• Human Papillomavirus (HPV) DNA testing will be reported in an addendum.

Automated Review:

• Focal Point computerized screening device (No Further Review).
• Focal Point computerized screening device (quintile 1, review).
• Focal Point computerized screening device (quintile 2, review).
• Focal Point computerized screening device (quintile 3, review).
• Focal Point computerized screening device (quintile 4, review).
• Focal Point computerized screening device (quintile 5, review).

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Recommendations/Notes:

• Recommend colposcopy and biopsy, if clinically indicated.
• Recommend endometrial biopsy, if clinically indicated.
• Recommend colposcopy and biopsy with good endocervical sampling, if clinically indicated.
• Suggest repeat cervical screening in 3-6 months following estrogen stimulation, if clinically indicated.
• Recommend repeat cervical screening in 6 months, if clinically indicated.
• Cellular features of the atypical glandular cells suggest an endocervical origin. Recommend colposcopy and biopsy with good endocervical sampling, if clinically indicated.
• Cellular features of the atypical glandular cells suggest an endometrial origin. Recommend colposcopy and biopsy with good endocervical sampling and endometrial sampling, if clinically indicated.
• Recommend diagnostic cervical excisional procedure following colposcopy and biopsy with endocervical sampling, if clinically indicated.
• Cellular features of atypical glandular cells suggest origin other than cervix or endometrium. Recommend colposcopy and biopsy with endocervical sampling, if clinically indicated.
• Repeat cytologic cervical screening has been shown to be inadequate follow-up for specimens interpreted as having atypical glandular cells.
• Endometrial cells after age 40, particularly out of phase or after menopause, may be associated with benign endometrium, hormonal alteration and less commonly, endometrial/uterine abnormalities. Clinical correlation is recommended. 4
• Recommend Human Papillomavirus (HPV) DNA testing. Alternatively, colposcopy may be considered if clinically indicated.
• Chronic inflammation (follicular cervicitis) in a premenopausal female may be associated with Chlamydial infection. Recommend DNA probe testing, if clinically indicated.
• Studies have shown that no patients with benign glandular cells on vaginal cytology post-hysterectomy have developed recurrent or de novo neoplastic lesions regardless of prior malignancy.
• Specimen submitted as vaginal. Cellular morphology is consistent with cervical source. If specimen is cervical, comment on glandular cells is unnecessary. If specimen is vaginal, glandular cells may warrant investigation.
• Recommend repeat thinlayer cervical screening in 12 months.
• Benign glandular cells are present in a patient with prior diethylstilbesterol (DES) exposure.
• No transformation zone component is identified. Clinical history indicates prior hysterectomy, but specimen submitted as cervical. If specimen is from vaginal source, the comment regarding transformation zone does not apply.

1. There are modifications to the category "atypical squamous cells of undetermined significance (ASCUS)." The new general category is "atypical squamous cells (ASC)" with two subcategories: "ASC of undetermined significance (ASC-US)" and "ASC cannot exclude high grade squamous intraepithelial lesion (ASC-H)." The former is intended to encompass cases in which low grade squamous intraepithelial lesion cannot be excluded. "ASCUS, favor reactive" has been eliminated.
2. The terminology for low and high grade squamous intraepithelial lesions is unchanged (LSIL and HSIL).
3. The term "atypical glandular cells of undetermined significance" has been eliminated and replaced by terms such as "atypical endocervical cells" and "atypical glandular cells." Some cases will be subcategorized as "favor neoplastic" or "favor in situ adenocarcinoma of the endocervix" if appropriate. The "favor reactive" subcategory has been eliminated as it implies women may not need follow-up.
4. Endometrial cells. The presence of normal appearing endometrial glandular cells will be mentioned if the woman is age 40 or older, or in a woman less than 40 years of age status post hysterectomy.

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Revised 1/20/2011