The document discusses the Bethesda system for reporting cervical cytology and Pap test results. It outlines categories for specimen adequacy, diagnostic categories including non-neoplastic and neoplastic findings, criteria for various diagnoses, and follow-up guidelines. Key aspects covered include definitions of satisfactory and unsatisfactory specimens, classification of squamous and glandular cell abnormalities, and management recommendations for different diagnoses.
3. The first workshop was held in 1988, to reduce widespread confusion among
laboratories and clinicians created by the use of multiple classification
systems and inconsistently defined numerical grading conventions.
Earlier versions of bethesda include 3 categories of adequacy:
Satisfactory
Unsatisfactory
Borderline.
The 2001 bethesda system eliminates the borderline category. To provide a
clearer indication of adequacy specimens are now designated as
“satisfactory” or “unsatisfactory”.
4.
5. Area of metaplastic epithelium proximal to the original squamocolumnar junction is referred to as
transformation zone since it is an area of epithelial instability.
7. Conventional pap smear Liquid based preparations
8. Minimum squamous cellularity criteria
Conventional smear-8000 to 12000 well preserved, well visualised squamous
cells.
Liquid based prep-min 5000.
Endocervical zone component
Atleast 10 well preserved endocervical or squamous metaplastic cells ,singly
or in clusters.
If high grade cancer is present,it is not necessary to report presence or
absence of transformation zone component.
9. SATISFACTORY:
1. Describes presence or absence of endocervical/transformation zone component and
any other quality indicators.
2. Any specimen with abnormal cells (ASC-US,AGC or worse)is by definition satisfactory
for evaluation.
UNSATISFACTORY:
1. Rejected specimen-not processed because(specimen not labelled,slide
broken, patient particulars not mentioned etc.)
2. Fully evaluated, unsatisfactory specimen-specimen processed and
examined, but unsatisfactory for evaluation of epithelial abnormality
because of-obscuring blood, inflammatory cells,etc.
3. Specimens with more than 75% of squamous cells obscured should be
termed unsatisfactory.
4. When 50-75% cells are obscured,a statement describing the specimen as
partially obscured should be made.
11. Interpretation af ASC requires that cells demonstrate 3 features-
Squamous differentiation
Increased N/C ratio
Minimal nuclear hyperchromasia,chromatin clumping,irregularity,smudging or multinucleation
12. Nuclei approx 2 and 2.5 times area of nucleus of intermediate cells
Slightly increased N/C ratio.
Minimal hyperchromasia,irregilarity in chromatin distribution or nuclear shape.
13. Include 2 categories
Small cells with high N/C ratio-atypical metaplasia
*cells occur singly or in small fragments of less than 10 cells.
*cells size of metaplastic cells,nuclei about 1.5 to 2.5 times larger than normal.
Crowded sheet pattern-
*crowded cells,nuclei show loss of polarity or difficult to visualize.
*dense cytoplasm, polygonal cells and fragments with sharp linear edges generally favor
squamous over glandular differentiation.
14.
15. Mature type cytoplasm
Large cell size,increased N/C ratio.
Nuclear enlargement more than 3 times the area of normal intermediate nuclei
Bi and multinucleation
Chromatin uniformly distributed.
Nucleoli generally absent
Nuclear membrane slightly irreguilar
distinct cytoplasmic borders.
Koilocytosis.
18. Less mature than cells in LSIL.
Nuclear hyperchromasia accompanied by variations in nuclear size and shape.
Degree of nuclear enlargement more variable
Nuclear membrane quite irregular with indentations and grooves
Nucleoli absent,occassionally present
cytoplasm immature,lacy,delicate or densely metaplastic
19.
20. KERATINISING
1. relatively few cells present.
2. Marked variation in cell size and shape,wiith caudate , spindle cells and tadpole cells
3. Marked variation in nuclear size, irregular nuclear membrane, numerous dense opaque nuclei.
4. Coarsely granular chromatin with parachromatin clearing .
5. Tumor diathesis may be present, less than non keratinizing.
21. NON KERATINISING-
1. Cells occur singly or in syncitial aggregate with poorly defined cell borders.
2. Smaller than HSIL.
3. Marked irregular distribution of coarsely clumped chromatin.
4. A tumour diathesis consisting of necrotic debris and old blood.
22. Cells in sheets and strips, cell crowding, nuclear overlap.
Nuclear enlargement upto 3 to 5 times area of normal endocervical nuclei.
Some variation in nuclear size and shape.
Mild hyperchromasia
Nucleoli may be present
Mitosis rare
Cytoplasm fairly abundant, N/C ratio increased
Distinct cell border
23. Cells occur in small groups ,usually 5-10 cells/group.
Nuclei slightly enlarged
Mild hyperchromasia
Small nucleoli
Scant cytoplasm,ocassionaly vacuolated
Ill defined cell borders.
24. Cells occur in sheets,clusters,strips and rosettes with nuclear crowding and overlap, loss of honeycomb
pattern.
palisading nuclear arrangement with feathering
Enlarged. Stratified nuclei.
Hyperchromasia
Nucleoli small, inconspicuous
Mitosis and apoptosis seen
N/C ratio increased,cytoplasm and mucin diminished
Abnormal squamous cells may be present
25. Abundant abnormal cells,typically with columnar configuration
Single cells,2dimensional sheets or 3 dimensional clusters and syncitial aggregates commonly
seen
Enlarged pleomorphic nuclei,parachromatin clearing,nuclear membrane irregularities.
Macronucleoli present
Cytoplasm finely vacuolated
Necrotic tumour diathesis may be seen
26. Pear shaped,oval,cyanophilic organisms,15-30μ
Pale vesicular eccentrically located nucleus.
Eosinophilic cytoplasm granules centrally.
Inflammatory changes.
28. Double contoured pale pink hyphae and pseudohyphae
Pseudohyphae appear septate
Spores are eosinophilic
Inflammatory changes variable
29. Swollen nuclei with multinucleation.
Ground glass chromatin with prominent nuclear membrane and nuclear
inclusions(tombstones).
Nuclear moulding.
30. Koilocytosis-superficial and intermediate cells
Multinucleation
Nuclear swelling and degeneration
Keratotic spikes,pearls and rafts
Single dyskeratotic cells.
31. CHANGES IN SQUAMOUS EPITHELIAL CELLS-
Cytoplasmic abnormalities
*vacuolation
*perinuclear halo
*altered staining
*abnormal keratinisation
Changes in nucleaus-
*wrinkling of nuclear membrane
*multinucleation
*chromatin degeneration
CHANGES IN ENDOCERVICAL CELLS-
Cytoplasmic degeneration
Nuclear variation
32. Cell size markedly increased without increase in N/C ratio.
Nuclei show degenerative changes
Bi or multinucleation
Prominent single or multiple nucleoli
Cytoplasmic vacuolation
33. Endometrial shedding at any stage.
Single and clustered enlarged vacuolated glandular cells.
Neutrophilic exudate
Actinomycotic colony
34. Flat monolayer sheets of parabasal cells with preserved nuclear polarity
Parabasal cells may have hyprechromaisa
Chromatin uniformly distributed
Autolysis result in naked nuclei.
Abundant inflammatory exudate.
35. ASC-US + ASC-H:
*no immediate cancer risk.
*most cases don’t progress to cancer.
*perform HPV testing +ve----colposcopy
-ve---repeat PAP smear in
12m
•LSIL:
*12-16% cases progress to cancer in 10years
*50% cases regress in 2years.
*HPV testing +ve-colposcopy LOOP
-ve—repeat PAP smear at 6 and 12m
•HSIL:
*20% progress to cancer in 10years. colposcopy