Atlas on bethesda system for reporting cervical cytology

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The Bethesda system
for reporting cervical
cytology
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Systemic Pathology Notes
The Bethesda system for reporting cervical cytology (2001) *
Dr. Ashish V. Jawarkar (M.D.)
Consultant Pathologist
Vadodara
Overview:
1. General points
2. Reporting format
3. Causes of false negative pap tests
4. Description of each category of reporting
a. Satisfactory for evaluation
b. Unsatisfactory for evaluation
c. NILM
i. Cells present
1. Superficial and intermediate squamous cells
2. Benign endometrial cells
ii. Cellular changes
1. Reactive changes
2. Radiation induced changes
3. Hyperkeratosis
4. Parakeratosis
5. Cytolysis
6. atrophy
iii. organisms
1. T. Vaginalis
2. Leptrotrichia
3. Candida spp.
4. Bacterial vaginosis
5. Actinomyces israelli
6. H. simplex virus
d. Squamous cell abnormalities
i. Atypical squmous cells
1. ASC-US
2. ASC-H
3. LSIL
4. HSIL
ii. Invasive squamous cell carcinoma
e. Glandular cell abnormalities
i. Atypical Glandular cells
1. AGC-NOS
2. AGC-N
3. AEC-NOS
4. AEC-N
ii. Adenocarcinoma in situ
iii. Adenocarcinoma
1. Endocervical adenocarcinoma
2. Endometrial adenocarcinoma


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*

Based on: ( Bethesda atlas (Solomon D., Nayar R. (editors). The Bethesda System for Reporting Cervical Cytology, Second
Edition. New York: Springer-Verlag, 2004.

* General Points
1. The system was developed in 1988 for reporting cervical/vaginal cytology, to provide uniform
guidelines for reporting and reviewing gynaecologic Papaniculou smears.
2. It was subsequently modified in 1991 and 2001.
3. Most effective cancer prevention test available till date. It has become the index to which all
other cancer screening tests are compared.
4. Yearly screening is estimated to reduce a woman’s risk of getting carcinoma by 93%.
5. One of the numerous advances made in cervical cytology in the last decade has been
introduction of liquid based cytology. This has improved sensitivity of the technique, reduced
the number of specimen with obscuring blood and inflammation and increased LSIL:ASC ratio.
Also HPV testing can be directly performed on LBC specimen.
*The Bethesda system 2001 classification (reporting format)
1.Specimen type

2.General Categorization

3.Interpretation/result

4. Suggestions

1. Satisfactory for evaluation
*describe presence or absence of transformation zone component (*not required in
2001 system)
2.Unsatisfactory for evaluation
a.
Specimen rejected
b. Specimen not processed
c.
Specimen processed but unsatisfactory
1. NILM
2. Epithelial cell abnormality
3. Others
1. Negative for intraepithelial lesion/malignancy
Organisms
1.T. Vaginalis
2.Fungal organisms suggestive of candida spp.
3.Shift in bacterial flora s/o bacterial vaginosis
4.Bacterial morphology consistent with actinomyces
5.cellular changes c/w H. simplex
Other non neoplastic findings
1.Reactive cellular changes
2.Atrophy
3.Glandular status post hysterectomy
Other findings
Endometrial cells in women more than 40 years of age
2. Epithelial cell abnormalities
Squamous cells
Atypical squamous cells (ASC-US, ASC-H)
LSIL
HSIL
Invasive squamous cell carcinoma
Glandular cells
Atypical endocervical cells
1.Endocervical cells NOS
2.Endocervical cells favor neoplasia
Atypical endometrial cells
1.Endometrial cells NOS
Atypical glandular cells
1.glandular cells NOS
2.Glandular cells favor neoplasia
Adenocarcinoma in situ
Adenocarcinoma
3. Other malignant neoplasms (specify)
(if any)


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Satisfactory for evaluation
LBC smear
Adequate squamous cellularity
This image depicts the approximate cellular density of an adequate ThinPrep specimen which significantly exceeds the minimum criteria. It is to
be used as a guide in assessing squamous cellularity of ThinPrep specimens

Satisfactory for evaluation
LBC smear
Borderline adequate squamous cellularity
Slides with borderline or low cellularity should be assessed by estimation of average cell number in at least 10 fields. At 40X, there were
approximately 11 cells per field when 10 microscopic fields along a diameter were evaluated for squamous cellularity. This would give an
estimated total cell count between 5,000 - 10, 000. Laboratories may choose to append a quality indicator statement such as "borderline or low
squamous cellularity" when specimens meet minimal criteria, but have only 5,000-20,000 cells.

*Not satisfactory for evaluation
1. <8000 squamous cells on conventional smears, <5000 squamous cells on LBC
2. >75% cells are obscured by blood or inflammation
3. If a single cell is atypical, it should not be reported as unsatisfactory


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Unsatisfactory for evaluation
Conventional smear
75 cells in this field, smear should be reported as unsatisfactory if all fields have these many or less cells

Unsatisfactory for evaluation
Conventional smear
If 50 - 75% of the slide has this appearance, obscuring inflammation should be mentioned in the quality indicators section of the report


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Metaplastic squamous cells
LBC smear
Normal polygonal squamous metaplastic cells with round to oval nuclei and bland chromatin pattern. On liquid based preparations
cells may appear more rounded, and nuclei may appear smaller. This would be interpreted as "NILM”

*Negative for intraepithelial lesion or malignancy (NILM)
CELLS PRESENT:
1.

Superficial squamous cells

Predominate at the time of ovulation when
Estrogen is high

Intermediate squamous cells

Predominate in late luteal phase when
progesterone is high

2.

Benign endometrial cells
a. Can be seen during menses
b. Any time during 1st half of menstrual cycle
c. Benign appearing endometrial cells in a post menopausal patient should be looked
at carefully, may be associated with endometrial polyps/hyperplasia or hormonal
alterations.
3. Benign Glandular cells


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There are generally two types of squamous cells seen on Pap Tests – superficial and intermediate cell types.
The superficial cells are the largest of the three and have small pyknotic (degenerative) nuclei and cytoplasm that generally stains eosinophilic.
The intermediate squamous cells are similar in appearance but are slightly smaller in size and have larger, clearly structured, round nuclei with
cytoplasm that usually stains basophilic. Both cell types are polygonal in shape. The intermediate cell type is the most common cell type seen.

Endometrial cells
Conventional smear
Exodus pattern is characterized by a double contour pattern of external glandular epithelium with internal stromal cells. The stroma in this
group is slightly eccentric. Nuclear features are easily appreciated, despite this being a conventional Pap smear. The nuclei have delicate even
chromatin. Histiocytes are often seen in association with the double contour fragments of exodus.


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CELLULAR CHANGES:
1. Reactive/reparative changes –
a. Mild nuclear enlargement
b. Prominent nucleoli
c. Abundant cytoplasm
d. Mitoses

No increase in N:C ratio

May be associated with –
Inflammation (repair)

A case of uterine prolapse (inflammation/repair changes)
Conventional smear
Flat monolayer sheets with distinct cytoplasmic outlines, streaming nuclear polarity, prominent nucleolus in almost every cell.

2. Radiation induced changes –
a. Quite enlarged
b. Frequently multinucleated
c. Cytoplasmic vacuolation
d. Cellular degeneration


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Radiation therapy induced changes
Conventional smear
Enlarged nuclei with abundant polychromatic cytoplasm with vacuolization. Mild nuclear hyperchromasia without coarse
chromatin, prominent nucleoli (coexisting repair). Note multinucleation (upper right corner insert).

Reactive changes associated with radiation therapy
LBC smear
Abundant cytoplasm. Smudgy chromatin with mild nuclear enlargement

3. Hyperkeratosis –
a. Anucleated, orange staining squamous cells
b. Can be seen in women with uterine prolapsed


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T. Vaginalis
LBC smear
Good example of a flagella. Flagella are usually not seen in conventional Pap smears. Also seen in this image (left lower inset) is
a "kite shaped" trichomonad- another finding noted in liquid based preparations.

Reactive squamous cells associated with T. Vaginalis
Conventional smear
Minimal nuclear enlargement, cytoplasmic polychromasia


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a. Leptotrichia
1. Large filamentous bacteria that appear as gray hair like structures
2. They coexist with T. Vaginalis

Leptothrix with T. Vaginalis
LBC smear
The finding of Trichomonas and leptothrix together has been referred to as "spaghetti and meatballs" The leptothrix should be
distinguishable from Doderlein bacilli, that are normally seen. When leptothrix are seen, one should search for the possible presence
of trichomonads. In liquid based preparations, the leptothrix organisms may tend to clump (as seen in this image) as opposed to
conventional smears.

Leptothrix with T. Vaginalis
Conventional smear


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ASC-US
LBC smear

1. ATYPICAL SQUAMOUS CELLS – CANNOT EXCLUDE HSIL (ASC-H)
Cytologic changes are suggestive of but not enough for diagnosis of HSIL
Criteria:
1. Resemble parabasal/basal cells
2. Nuclei are hyperchromatic and have irregular margins

ASC-H
Conventional smears
Less mature squamous cells/metaplastic cells with polygonal shape, and slightly enlarged nuclei with occasional nuclear contour irregularities


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ASC-H
LBC smear
Metaplastic cells with increased N:C ratios and nuclear contour irregularities


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SQUAMOUS INTRAEPITHELIAL LESION (LOW GRADE (LSIL) AND HIGH GRADE (HSIL))
Bethesda
CIN
WHO
Cell type
Arrangement
No. of abnormal
cells
Nuclear size

Hyperchromasia
N:C ratio
Koilocytosis

LSIL
CIN I
Mild Dysplasia
Superficial or
intermediate
Singly or in
sheets
+
4-6 times nomal

+
+
+++

HSIL
CIN II
Moderate
dysplasia
Parabasal

Severe
dysplasia
Basal

CIN III
Carninoma in situ (CIS)*
Basal/spindle/pleomorphic

Singly or in
sheets
++

Singly or in
sheets
+++

Singly or in sheets or
syncitia
++++

++
+
+
Overall size of nucleus/cell is not as much as LSIL but N:C ratio is
greatly increased
++
+++
++++
++
+++
++++
++
+/+/-

*CIS consists of three types of cells
1. Small basal cell type – cells similar to severe dysplasia but demonstrate even lesser cytoplasm and higher N:C ratio
2. Large cell non keratinizing type – syncitial like cell sheets in which individual cell membranes are difficult to identify
3. Large cell keratinizing type – pleomorphic highly atypical tadpole like cells, thich orangophilic cytoplasm

LSIL
Conventional Smear
Nuclear enlargement and hyperchromasia is of sufficient degree for the interpretation of LSIL.
Demonstration of HPV cytopathic effect is not necessary for an interpretation of LSIL, if required nuclear changes are present.


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Endometrial adenocarcinoma
Conventional Smear
Cluster of small cells with enlarged round or oval nuclei, small nucleoli and vacuolated cytoplasm in a background of "watery" diathesis.

Endometrial adenocarcinoma
LBC smear
Papillary cluster with large cells and prominent nucleoli.


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