Special Contribution

The Pap Test and Bethesda 2014

Ritu Nayar, MD1 and David C. Wilbur, MD2

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

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,

Corresponding author: Ritu Nayar, MD, Northwestern University Feinberg School of Medicine, Chicago, IL 60611; Fax: 3129266037; E-mail: r-nayar@
northwestern.edu.
1
Department of Pathology, Northwestern University, Feinberg School of Medicine, Northwestern Medicine, Chicago, Illinois; 2Departments of Pathology,
Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts

Cancer Cytopathology May 2015 271

Special Contribution

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.

Received: December 27, 2014; Accepted: December 27, 2014

Published online May 1, 2015 in Wiley Online Library (wileyonlinelibrary.com)

DOI: 10.1002/cncy.21521, wileyonlinelibrary.com

TBS-1988 also incorporated a “statement of other laboratory tests such as cervical biopsy.”
2,4
adequacy” as an integral component of the report
and, by extension, an important quality-assurance 2. Although TBS was developed primarily for
element.2 cervicalcytology, specimens from other sites in
After experience using TBS in clinical the lower anogenital tract, such as the vagina
practice and further advances in scientific and anus, could also be reported using this
knowledge, subsequent Bethesda workshops were terminology.
convened in 1991 and 2001. A major 3. Between 1991 and 2001, liquid-based
recommendation from the 1991 workshop was to cytology, automation, computer-assisted
develop criteria for TBS interpretive categories imaging, and HPV testing were introduced and
and diagnostic terms and for the determination of increasingly utilized in laboratories that offered
specimen adequacy. These deliberations and the cervical cytology testing. The 2004 Bethesda
codification of criteria led to the production of the atlas addressed all of these considerations. In
first Bethesda atlas in 1994.3 After its publication, addition, to facilitate widespread
this monograph quickly became a worldwide implementation of TBS-2001 and to improve
reference for the practice of cervical cytology. reproducibility, more detailed interpretive
The next Bethesda workshop, held in 2001, criteria, ample illustrations depicting mimics
was the first to use the Internet to provide the and pitfalls, histologic correlation, and sample
international cytopathology community an reports were added.5
opportunity to offer input to the refinements 4. After TBS-2001, but before publication of the
proposed by the forum work groups. Over 2000 corresponding atlas, a subset of atlas images
Internet comments were considered before the were used to develop the web-based Bethesda
meeting, which then brought together over 400 Interobserver Reproducibility Study (BIRST),
participants, including representatives from more the objectives of which were: i) to evaluate
than 2 dozen countries, to finalize the 2001 concordance among participants with varied
Bethesda System Terminology.4 training and experience, and ii) to identify
specific cytomorphologic features and
cytologic categories that represent sources of
Noteworthy points from the 2001 Bethesda update poor interobserver agreement.6 The results of
included the following:
that study highlighted important issues about
1. The terms “interpretation” or “result” were the reproducibility of the various Bethesda
recommended instead of “diagnosis” in the categories, which has led to further progress in
heading of the cervical cytology report, education and to the introduction of ancillary
because it was believed that cervical cytology studies to improve the predictive value of the
should be viewed primarily as a “screening
screening process.
test, which in some instances may serve as a
5. In conjunction with the print atlas, an
medical consultation by providing an
interpretation that contributes to a diagnosis. educationalBethesda website7 was established
The final diagnosis and management plan that provides additional images beyond those
should integrate the cervical cytology with available in the print atlas, images, histograms
patient history, clinical findings, and results of from the BIRST,6 and a selfevaluation test.
This site has been extensively used— over

272 Cancer Cytopathology May 2015

 The Pap Test and Bethesda 2014/Nayar and Wilbur

60,000 unique individuals from all over the and the biology/management of HPV-related
world have taken the self-test alone. cervical lesions.
By early 2003, 85.5% of laboratories in the
2. Alignment of Management With
United States had implemented Bethesda 2001
TerminologyTBS provided the framework
terminology, and the adoption of TBS in the
necessary for the development of systematic,
international cytopathology community had
evidence-based cervical cancer screening and
produced a significant impact.8
management guidelines. After the 2001 Bethesda
conference, the American Society for Colposcopy
Implementation of TBS initiated several and Cervical Pathology (ASCCP) held a
downstream events that significantly influenced consensus conference to tailor management
cervical cancer screening and management and also strategies that conformed to the Bethesda
impacted terminology development for other areas reporting categories. This meeting was also a
in cytopathology and histopathology: significant historic event, because it was the first
1. Initiation of Research and Clinical Trials TBS time that there was coordination of reporting
played a vital role in facilitating research related terminology that correlated with both HPV
to the biology of cervical cancer and exploring biology and clinical management. The results of
new approaches and strategies for patient ALTS and other clinical research formed the basis
management. The introduction of TBS for development of the 2001 clinical management
terminology of “atypical squamous cells of algorithms—a process that involved dozens of
undetermined significance” (ASCUS) highlighted organizations and professional societies,
the inherent limitations of morphologic spearheaded by the ASCCP. With continued
interpretation. Because ASCUS is the most development of additional insight into HPV
common cytologic abnormality reported on biology, results from subsequent clinical trials,
Papanicolaou (Pap) tests, it accounts for over a and experience in the United States, these
million results annually in the United States and management guidelines were subsequently
previously posed a significant clinical updated in 2006 and 2012.11,12
management problem, leading to billions of
dollars in colposcopic followup and/or treatment 3. TBS as a Prototype for Standardized
of these women.1 To determine the best course of ReportingTerminology in Pathology
management (immediate colposcopy, HPV triage, On the basis of the key principles of TBS,
or conservative management) for equivocal and standardized terminology systems have been
low-grade abnormalities, the US National Cancer developed for cytology of other
Institute sponsored the ASCUS/LSIL Triage bodysites,includingthyroid, 13
pancreas,14
Study (ALTS), which began in 1997. 9 The results and,mostrecently, urine. 15
The 2-tiered
from ALTS established high-risk HPV (hrHPV) terminology of LSIL and HSIL used in TBS is
testing as the most cost-effective triage test for now also recommended by the World Health
ASCUS. This was endorsed as the preferred Organization, the ASCCP, and the College of
management option for the Bethesda category re- American Pathologists for reporting
named as ASC-US, under the category of histopathology of HPV-associated squamous
Atypical squamous cells (ASC) in 2001. 10 lesions of the lower anogenitaltract.16–19
Additional assessment of the ALTS database
resulted in numerous publications, which have
BETHESDA 2014: WHY?
provided a great deal of information related to
cervical cancer, including the characteristics of The past decade has witnessed several changes in
cytology, colposcopy, the role of HPV testing, the realm of cervical cancer screening, prevention,
and management. These include the increased use

Cancer Cytopathology May 2015 273

Special Contribution

of liquid-based preparations; the addition of in association with this update. The task force was
cotesting (Pap and hrHPV testing) and, more divided into 12 groups, each of which was
recently, primary hrHPV testing as additional responsible for 1 of 12 atlas chapters. The groups
screening options; further insights into HPV performed a literature review and proposed new
biology; changes in histopathology terminology; and expanded content. The draft
approval and implementation of prophylactic recommendations were shared with the
HPV vaccines; and updated guidelines for international cytopathology community during an
cervical cancer screening and clinical open comment period from March to June of
management. 2014 through a widely advertised, Internet-based
Over the past few years, evidence-based bulletin board. In total, 2454 responses were
consensus guideline processes have incorporated received from individuals in 59 countries and
the fundamental principles of balancing harms were compiled and reviewed by the chapter-based
and benefits and providing equal management for task force working groups. This process
equal risk.20 Management guidelines for abnormal culminated in the refinement of positions and
cervical cytology results were updated in 2006 content, which were then incorporated into TBS-
and 2012, with increased incorporation of hrHPV 2014 (Table 1) and into the third edition of the
and genotyping for triage and follow-up. When Bethesda atlas.21
HPV testing is used alone for primary screening,
cervical cytology has been proposed as a “reflex” BETHESDA 2014: WHAT HAS CHANGED?
test or triage for non-16/ 18 HPV-positive screens.
With increased uptake of HPV vaccination and its Bethesda Terminology Changes
downstream effects of decreased prevalence of There were minimal changes relating to the
HPV16/18-associated lesions, cervical cytology terminology itself. The 2014 Bethesda
will become even more challenging with respect terminology is summarized in Table 1. Of note:
to locator and interpretation skills because of the
inherent loss of sensitivity when prevalence of the Reporting of benign-appearing endometrial cells is now
recommended for women aged 45 years
disease is low. On the basis of all of these
changes, 2014 was an appropriate time for a Rationale: Although exfoliated endometrial cells are
review and update of the 2001 Bethesda System a normal finding during menses and the
terminology, refinements of morphologic criteria, proliferative phase of the menstrual cycle, in
and incorporation of revisions and additional new postmenopausal women, their presence is
information into a third edition of the Bethesda considered abnormal and raises the possibility of
atlas for cervical cytology.21 endometrial neoplasia (Fig. 1). Thus, TBS-1988
recommended reporting “cytologically benign-
appearing” endometrial cells in postmenopausal
BETHESDA 2014: PROCESS women to alert clinicians to the possibility of an
Dr. Ritu Nayar, President of the American Society endometrial abnormality.2 In 2001, because
of Cytopathology in 2014, appointed a task force* menopausal status is often unclear, inaccurate, or
(see acknowledgments, below), chaired by Dr. unknown to the laboratory, it was suggested that
David Wilbur (American Society of this reporting should be done in women aged 40
Cytopathology President in 2002), comprised of a years to maximize the likelihood of including all
relatively small group of cytopathologists, postmenopausal women and that clinical
clinicians, and epidemiologists, to accomplish the correlation should be left to the ordering
2014 update. Because minimal changes were physician’s discretion.4 Evaluation of this TBS-
anticipated to the terminology recommended by 2001 recommendationin clinical practice
TBS-2001, no formal consensus meeting was held indicated that, although endometrial investigation

274 Cancer Cytopathology May 2015

 The Pap Test and Bethesda 2014/Nayar and Wilbur

increased, the predictive value for endometrial nomenclature. Furthermore, current management
hyperplasia/carcinoma decreased significantly guidelines all use LSIL and HSIL nomenclature
compared with the pre–TBS-2001 experience.21 In without an intermediate category, and recent
the 2012 management guidelines, the ASCCP histopathology reporting recommendations also
advised using histologic endometrial assessment encourage reporting as LSIL or HSIL. Poor
only in postmenopausal women.12 reproducibility and overuse of any new
During the TBS-2014 update, after literature indeterminate cytology terminology would likely
review and public comment consensus, it was lead to confusion among clinicians and, possibly,
decided that, to increase the predictive value of inappropriate management.
this category, cytologically “benign-appearing” For occasional cases in which it is not
endometrial cells should be reported in women possible to categorize an SIL as either low-grade
aged 45 years, and the suggested educational note or high-grade, a comment explaining the nature of
should specify that endometrial evaluation be the uncertainty may be appropriate. Alternatively,
done only in postmenopausal women (Table 1).21 an interpretation of atypical squamous cells
(ASC) cannot rule out HSIL (ASC-H) may be
No new category was created for squamous lesions with made in addition to an LSIL interpretation. This
LSIL and few cells suggestive of concurrent HSIL would indicate that definite LSIL is present as
Occasionally, a specimen is encountered
Rationale : well as some cells that suggest the possibility of
with cytologic features that lie between LSIL and HSIL. In general, follow-up guidelines for these
HSIL; however, attention to morphologic features interpretations are for colposcopy and biopsy;
usually supports classification as either LSIL or however, in patients (such as young women) who
HSIL. In cases with unequivocal HSIL, the have samples for which the guidelines differ
presence of concurrent LSIL is not necessary to between LSIL and ASC-H, the addition of the
make an interpretation of HSIL. ASC-H interpretation should lead to colposcopic
Since the publication of TBS-2001, it has evaluation. Intermediate interpretations should
been suggested that these intermediate comprise only a small minority of cases in any
morphologic patterns might be better designated laboratory, because classification into either LSIL
with a diagnostic term other than LSIL or HSIL. or HSIL is possible in most instances after a
Terms such as “LSIL, cannot exclude HSIL” or careful overall evaluation of the cellular
“LSIL-H” have been proposed. In preparation for morphology (Fig. 2).
the 2014 TBS update, opinions regarding this
topic were openly solicited, and consensus was Third Edition of the Bethesda Atlas
achieved that formal TBS nomenclature should be Providing an updated atlas with retention of the
limited to the original LSIL and HSIL categories, popular features of the 2004 edition and
maintaining the 2-tiered classification scheme. additional images and content, reflecting
Adding terminology such as “LSIL-H” would continued experience and changes in practice, was
lead to a de facto 3-tiered system, essentially the main motivation for the 2014 update. 21 The
negating the beneficial aspects of the 2-tiered TBS content, both text and illustrations, have been
TABLE 1. THE 2014 BETHESDA SYSTEM

SPECIMEN TYPE
Indicate conventional smear (Pap smear), liquid-based preparation (Pap test) vs other
SPECIMEN ADEQUACY
u Satisfactory for evaluation (describe presence or absence of endocervical/transformation zone component and any other quality indicators, eg, partially
obscuring blood, inflammation, etc)
u Unsatisfactory for evaluation (specify reason)
u Specimen rejected/not processed (specify reason)
u Specimen processed and examined, but unsatisfactory for evaluation of epithelial abnormality because of (specify reason) GENERAL
CATEGORIZATION (optional)

Cancer Cytopathology May 2015 275

Special Contribution

u Negative for intraepithelial lesion or malignancy u Other: see

Interpretation/Result (eg, endometrial cells in a woman aged 45 years)
u 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) u Non-neoplastic cellular
variations
Squamous metaplasia
Keratotic changes
Tubal metaplasia
Atrophy
Pregnancy-associated changes u
Reactive cellular changes
associated with:
: Inflammation (includes
typical repair) Lymphocytic
(follicular) cervicitis
: Radiation
: Intrauterine contraceptive
device (IUD) u Glandular cells
status posthysterectomy
Organisms u Trichomonas vaginalis u Fungal organisms
morphologically consistent with Candida spp.
u Shift in flora suggestive of bacterial vaginosis u
Bacteria morphologically consistent with
Actinomyces spp.
u Cellular changes consistent with herpes
simplex virus u 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.

276 Cancer Cytopathology May 2015

 The Pap Test and Bethesda 2014/Nayar and Wilbur

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 varia-

Figure 1. Exfoliated endometrial cells (conventional preparation) are

shown. Cells are arranged in 3-dimensional clusters. Nuclei are small
and are similar in size to an intermediate squamous cell nucleus.
Nucleoli are inconspicuous. Cytoplasm is scant, and cell borders are
indistinct. (From: The Bethesda System for Reporting Cervical
Cytology. Nayar R, Wilbur DC, (Eds), 3rd Edition, Springer, 2015.)

increased by approximately 66% compared with

the sec-
ond edition.5 Among the 12 chapters, 6 correspond
to the major Bethesda interpretive categories, and
the remaining chapters are dedicated to other Figure 2. High-grade squamous intraepithelial lesion (HSIL) is shown
(liquid-based preparation, ThinPrep). In this specimen, diagnostic
malignant neoplasms, anal cytology, reporting of HSIL cells are present. Even if these cells are observed in the
adjunctive testing, computerassisted screening, background of a majority of low-grade squamous intraepithelial
lesion cells elsewhere on the slide, the final interpretation should be
educational notes, and a new chapter on cervical
HSIL. (From: The Bethesda System for Reporting Cervical Cytology.
cancer risk assessment.21 Nayar R, Wilbur DC,
(Eds), 3rd Edition, Springer, 2015.)
Each chapter has been extensively updated,
and the format includes: 1) background and
introduction, including basic cell biology; 2) tions observed on both conventional smears and
description of definitions, cytologic criteria, liquidbased cytologic preparations; 58% of the
explanatory notes covering difficult morphologic images are new, and 42% are from the second
patterns, mimics of epithelial lesions, and current edition; 40% are from conventional preparations,
clinical management guidelines for reporting in and 60% are from liquid-based preparations.
the 6 interpretation category-based chapters; 3) Some images represent classic examples of an
sample reports; and 4) selected key references. entity, whereas others were selected to illustrate
The cytomorphologic criteria are described in interpretive dilemmas or “borderline”
general terms, followed by any significant morphologic features that may not be interpreted
differences related to specific preparation types in the same way by all cytologists. Unique to this
where relevant, and tables have been added to edition is the substantially larger number of
compare and contrast criteria. Note that TBS does composite images for a side-by-side illustration of
not endorse any particular methodology or mimics and cytologic-histologic correlations
manufacturer(s) for specimen collection, (Figs. 3–6). A brief summary of chapter updates
computer-assisted screening, adjunctive HPV or and their rationale is provided below.
other testing.
Chapter 1: Adequacy

Cancer Cytopathology May 2015 277

Special Contribution

Evaluation of specimen adequacy is considered by Figure 4. Atypical cells of undetermined significance (ASCUS)-atypical
repair (conventional preparation). In this image, cells are arranged in
many to be the single most important quality a 2-dimensional sheet with abundant cytoplasm showing a “pulled-
assurance component of the Bethesda system. out” or streaming effect. Nuclei exhibit pleomorphism of size and
shape, and some cells have multiple nuclei. Most nuclei have
Data and clinical experience regarding specimen
prominent nucleoli. These changes, although indicative of a
adequacy since 2001 were reviewed, leading to reparative reaction, may be classified as ASC-US because of the
the inclusion of additional guidance for special nuclear pleomorphism noted. In favor of a reactive process is the
generally fine granularity of the chromatin pattern. (From: The
situations, such as assessing cellularity in Bethesda System for Reporting Cervical Cytology. Nayar R, Wilbur
specimens obtained from postradiation patients, DC,
(Eds), 3rd Edition, Springer, 2015.)
interfering substances (eg, lubricant, blood), and
the effects of adequacy on HPV testing.
included, providing a more complete
Chapter 2: Non-neoplastic changes representation of the morphologic variations that
An expanded variety of “normal” findings as well can be encountered in cervical cytology
as nonneoplastic mimics of classic epithelial preparations (Fig. 3).
abnormalities are
Chapter 3: Endometrial cells
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

Figure 3. This sample from a young woman in the late second trimester of pregnancy was interpreted as negative for intraepithelial lesion or malignancy
(NILM). (A,B) These single cells (liquid-based preparation, ThinPrep) with an increased nuclear to cytoplasmic ratio and nuclear hyperchromasia are worrisome
for high-grade squamous intraepithelial lesion. Features suggesting the true stromal decidual nature of the cells include the smudgy chromatin and the
presence of a nucleolus. (C) Similar cells are observed in a follow-up cervical biopsy (H&E stain). (From: The Bethesda System for Reporting Cervical Cytology.
Nayar R, Wilbur
DC, (Eds), 3rd Edition, Springer, 2015.)
278 Cancer Cytopathology May 2015
 The Pap Test and Bethesda 2014/Nayar and Wilbur

must be emphasized that the ASC category was Figure 6. These are images of lobular breast carcinoma (liquidbased
preparation, SurePath). Lobular breast cancer presenting in an
developed to designate the interpretation of an atrophic background pattern can be challenging. (A) Small clusters of
entire specimen, not individual cells, because cells and (B) individual cells with mucin vacuoles contrast with a
background of parabasal cells. Confirmation with immunostains can
atypia in individual cells remains a highly
be helpful, including (C) gross cystic disease fluid protein 15 and (D)
subjective and, hence, variable interpretation. estrogen receptor immunocytochemistry (From: The Bethesda
Common patterns interpreted as ASC-US and System for Reporting Cervical
Cytology. Nayar R,Wilbur DC, (Eds), 3rd Edition, Springer, 2015.)
ASCH 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 Chapter 5: Squamous epithelial cell abnormalities
(Fig. 4). 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-

Figure 5. This high-grade squamous intraepithelial lesion (HSIL) (liquid-based preparation, ThinPrep) is markedly hypochromatic, but a diligent search may
reveal more classic cells elsewhere on the same slide. (A) Note the syncytial arrangement and nuclear grooves. (B) Abnormal, naked nuclei and a single,
hyperchromatic HSIL cell with a high nuclear to cytoplasmic ratio are shown.
(From: The Bethesda System for Reporting Cervical Cytology. Nayar R, Wilbur DC, (Eds), 3rd Edition, Springer, 2015.)

neoplastic changes as HSIL/ASC-H and vice

Cancer Cytopathology May 2015 279

Special Contribution

versa (Figs 3 and 5). A new category was not nevertheless may be observed in cervical
created for squamous lesions with LSIL that also cytologic preparations (Fig. 6). These may create
contain a few cells suggestive of concurrent interpretation challenges and result in diagnostic
HSIL, the rationale for which is described above. pitfalls. Most often, these tumors are special
variants of cervical carcinoma or uncommon
primaries arising in the uterine corpus or adenexa
Chapter 6: Glandular epithelial cell abnormalities The
that appear in the cervical cytology specimens
Pap test was not designed to screen for glandular
either as exfoliated cells or through direct
lesions of the cervix, and these abnormalities are
sampling of tumors. Increased numbers of such
more difficult to sample and interpret compared to
cases are now illustrated.
their squamous counterparts. However, because of
improvement in sampling devices and the Chapter 8: Anal cytology
increase in endocervical adenocarcinoma relative Although anal cancer is relatively uncommon in
to squamous cell carcinoma over the past 2 the general population, rates have been increasing
decades, cytologists currently encounter more over the last several decades, especially in high-
challenging presentations of glandular lesions and risk groups. Anal cytology was first included in
their 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

Figure 7. Pinworm eggs are shown (anal cytology; liquidbased Reporting of the results from ancillary studies has
preparation, ThinPrep). (From: The Bethesda System for Reporting
Cervical Cytology. Nayar R, Wilbur DC, (Eds), evolved since the second edition, and this chapter
3rd Edition, Springer, 2015.) updates reporting schemes. Data concerning use
and reporting for the current HPV testing schemes
and adjunctive immunocytochemistry procedures
mimics in cervical cytology specimens. This (eg, p16) are included.
update includes many more images of glandular
Chapter 10: Computer-assisted interpretation Several
lesions and differential diagnostic considerations.
new US Food and Drug Administration approvals
Tables illustrating differences in criteria are
in the field of automated cervical cytology
included for quick reference.
screening have occurred in the past decade. These
Chapter 7: Other malignant neoplasms have included the socalled “location-guided
New published literature since TBS-2001 has screening” devices that identify areas at highest
described malignant neoplasms, other than the risk for containing potential abnormalities—
usual variants of primary squamous carcinomas essentially providing a prescreened slide. The
and endocervical adenocarcinomas, that third edition provides an overview of the currently
infrequently involve the uterine cervix but that used systems and updates recommendations,

280 Cancer Cytopathology May 2015

 The Pap Test and Bethesda 2014/Nayar and Wilbur

which now include the reporting items for interlaboratory variability in cervical cytology and
“location-guided screening” devices in addition to histology interpretation will always remain a
those covered previously. reality.6,22 In an effort to build on the information
gathered from our experience with the BIRST
Chapter 11: Educational notes and comments One of project in 2003,6 85 images from the third atlas
the guiding principles of TBS has always been to were posted as “unknowns” on a website that was
improve communication from the laboratory open to the international cytopathology
provider to the physician caring for the patient. It community. Data from this effort, which is
is the responsibility of both laboratorians and currently ongoing, will provide a realistic gauge
clinicians to stay current with recent of interpretive reproducibility across a wide (and
developments and communicate these to each defined) demographic. The results of this exercise
other. The use of written recommendations and/or will be posted during spring of 2015 on the
comments in cervical cytology reports is optional; American Society of Cytopathology website 23 and
and, when included in the cytology report, they will be discussed in a subsequent publication.
must be worded carefully and relay clear, concise,
current, evidence-based information. In the Bethesda 2014 Web Atlas
second edition of the Bethesda atlas, it was An accompanying Bethesda website resource is
recommended that such comments be directed to being developed under the direction of Drs.
the clinician and that the laboratorian/laboratory Daniel Kurtycz and Paul Staats and with the help
not communicate directly with the patient unless of a Bethesda Website Task Force** (see
specifically instructed to do so. In the United acknowledgments, below). In addition to all of the
States, as of 2014, there are changes to the rules images from the third edition of the atlas, this
regarding patient access to test reports. In website will contain many other examples of
addition, standardization of reports to facilitate presentations and entities that could not be
widespread electronic health record provided in the print atlas. A variety of search
implementation has been encouraged. These options will be provided, and the results of the
changes may have further implications for the use reproducibility study (BIRST-II) and
of recommendations in pathology reports, and a accompanying histograms will be posted on this
relevant discussion is now included.21 site. The group will also explore new avenues for
delivery of the content that has been assembled
Chapter 12: Risk assessment in cervical cancer This new during this update process. For further
chapter is an important addition to the third atlas, information on the Bethesda web atlas, please
because it is key to understanding how the results visit the educational resources page on the
of various screening and triage test combinations American Society of Cytopathology website.23
relate to the patient’s risk for cervical cancer.20
The concept of “equal management for equal Conclusions
risk,” along with balancing benefits and harms of
Given all the recent press about new methods of
screening, formed the basis of the 2012
cervical cancer screening and the lack of
management guidelines for abnormal cervical
sensitivity of the Pap test, some may question the
cancer screening tests and cancer precursors.12
significance of a new edition of the Bethesda
Bethesda Interobserver Reproducibilty Study atlas. Before exaggerating the demise of the Pap
(BIRST-II) test, it must be remembered that it still has
significant utility worldwide. Because of its
Although knowledge of normal morphology, its
greater specificity compared with HPV testing,
variations, and epithelial abnormalities is
the Pap test will have importance as a diagnostic
essential, some degree of interobserver and
triage tool after a positive HPV screening test. In

Cancer Cytopathology May 2015 281

Special Contribution

locales where HPV testing is not available or Fadi W. AbdulKarim, MD; George G. Birdsong,
reimbursed, regular Pap testing will remain the MD; David Chelmow, MD; David C. Chhieng,
screening method of choice. An updated and MD; Edmund S. Cibas, MD; Teresa M. Darragh,
enhanced Bethesda atlas will continue to serve its MD; Diane D. Davey, MD; Michael R. Henry,
current purpose—that of being an inexpensive, MD; Walid E. Khalbuss, MD, PhD; Daniel F. I.
portable, singlevolume resource that will be Kurtycz, MD; Dina R. Mody, MD; Ann T.
widely available internationally. Compared with Moriarty, MD; Joel M. Palefsky, MD; Celeste N.
the second edition, the new atlas contains a Powers, MD, PhD; Donna K. Russell, MEd,
greater discussion of HPV biology and CT(ASCP), HT(ASCP); Mark Schiffman, MD,
pathogenesis, includes all current MPH; Mary K. Sidawy, MD; Paul N. Staats, MD;
recommendations for management, and has a Mark H. Stoler, MD; Sana O. Tabbara, MD; Alan
more comprehensive group of illustrations that G.Waxman, MD; Nicolas Wentzensen, MD, PhD.
contains, in addition to the prior version’s classic
**The 2014 Bethesda Website Task Force: Daniel
examples, a robust content of look-alikes and F. I.
equivocal presentations. An increased number of Kurtycz, MD and Paul N. Staats, MD (Cochairs);
recommended report formats and a Ritu Nayar, MD and David C. Wilbur, MD
comprehensive reference list have also been (Advisors); Members: Deborah Chute, MD;
included. Overall, this makes the third edition a Maria Freidlander, MPA, CT(ASCP); Sara
greatly enhanced resource. Monaco, MD; Donna K. Russell, MEd,
As in previous editions, the current editors and CT(ASCP).
authors have committed to making the third
FUNDING SUPPORT
edition affordable and, hence, widely accessible
None for The Bethesda 2014 Atlas Update Project.
to all, including practitioners in low-resource
environments. No honoraria or royalties will be CONFLICT OF INTEREST DISCLOSURES
accepted by the editors/authors, and the edition Dr Nayar (Immediate Past President, American Society of
will remain a graphically high-quality, Cytopathology in 2013-14) Dr Wilbur (Past President,
paperbound monograph. The publisher, Springer, American Society of Cytopathology, 2002-2003).
will also make the corresponding electronic
REFERENCES
version (ebook) available online.
1. Solomon D. Foreword. In: Nayar R, Wilbur DC, eds. The
Bethesda System for Reporting Cervical Cytology.
ACKNOWLEDGMENTS Definitions, Criteria, and Explanatory Notes. 3rd ed.
Springer; 2015.
On behalf of the American Society of 2. The 1988 Bethesda System for reporting cervical/vaginal
Cytopathology, we thank Drs. Diane Solomon cytologic diagnoses. National Cancer Institute Workshop.
JAMA. 1989;262: 931-934.
and Robert Kurman for their pioneering vision in 3. Kurman RJ, Solomon D, eds. The Bethesda System for
initiating and organizing the implementation of Reporting Cervical/Vaginal Cytologic Diagnoses.
The Bethesda System, the 2014 Bethesda Task Definitions, Criteria, and Explanatory Notes for
Terminology and Specimen Adequacy. New York, NY:
Force members, the contributors of the first and Springer-Verlag; 1994.
second editions of the Bethesda atlas, and all of 4. Solomon D, Davey D, Kurman R, et al. The Bethesda
the other dedicated cytopathologists, System 2001: terminology for reporting the results of
cervical cytology. JAMA. 2002;287:2114-2119.
cytotechnologists, and clinical colleagues who 5. Solomon D, Nayar R, eds. The Bethesda System for
have volunteered to contribute to this effort over Reporting Cervical Cytology. Definitions, Criteria, and
Explanatory Notes. 2nd ed. New York, NY: Springer-
the past quarter of a century.2–5,21
Verlag; 2004.
6. Sherman ME, Dasgupta A, Schiffman M, Nayar R,
*The 2014 Bethesda System Task Force: David C. Solomon D.
Wilbur, MD (Chair), Ritu Nayar, MD (Cochair), The Bethesda Interobserver Reproducibility Study
(BIRST): a webbased assessment of the Bethesda 2001
and Diane Solomon, MD (Advisor); Members:

282 Cancer Cytopathology May 2015

 The Pap Test and Bethesda 2014/Nayar and Wilbur

System for classifying cervical cytology. Cancer 20. Castle PE, Sideri M, Jeronimo J, Solomon D, Schiffman M.
Cytopathol. 2007;111:15-25. Risk assessment to guide the prevention of cervical cancer
7. National Cancer Institute, American Society of [serial online]. Am J Obstet Gynecol. 2007;197:356.e1-e6.
Cytopathology. Bethesda System Website Atlas. Available 21. Nayar R, Wilbur DC, eds. The Bethesda System for
at: http://nih.techriver. net/. Accessed December 17, 2014. Reporting Cervical Cytology. Definitions, Criteria, and
8. Davey DD, Neal MH, Wilber DC, Colgan TJ, Styler PE, Explanatory Notes. 3rd ed. Springer; 2015.
Mody DR. Bethesda 2001 implementation and reporting 22. Stoler MH, Schiffman M. Interobserver variability of
rates: 2003 practices of participants in the College of cervical cytologic and histologic interpretations: realistic
American Pathologists Interlaboratory Comparison Program estimates from the ASCUS-LSIL Triage Study. JAMA.
in Cervicovaginal Cytology. Arch Pathol Lab Med. 2001;285:1500-1505.
2004;128:1224-1229. 23. American Society of Cytopathology. Cytopathology
9. Schiffman M, Adrianza ME. ASCUS-LSIL Triage Study. Education and Resources. Available at:
Design, methods and characteristics of trial participants. http://www.cytopathology.org/cytopathology-education-2/.
Acta Cytol. 2000;44:726-742. Accessed December 18, 2014.
10. Wright TC, Cox JT, Massad LS, Twiggs LB, Wilkinson EJ.
2001 Consensus guidelines for the management of women
with cervical cytological abnormalities. JAMA.
2002;287:2120-2129.
11. Wright TC Jr, Massad SL, Dunton CJ, et al. 2006
Consensus guidelines for the management of women with
abnormal cervical cancer screening tests. Am J Obstet
Gynecol. 2007;197:346-355.
12. Massad LS, Einstein MH, Huh WK, et al. 2012 Updated
consensus guidelines for the management of abnormal
cervical cancer screening tests and cancer precursors. J Low
Genit Tract Dis. 2013; 17(5 suppl 1):S1-S27.
13. Ali SZ, Cibas ES, eds. The Bethesda System for Reporting
Thyroid Cytopathology. New York, NY: Springer; 2010.
14. Layfield LJ, Pitman MB, DeMay RM, et al.
Pancreaticobiliary tract cytology: journey toward
“Bethesda” style guidelines from the Papanicolaou Society
of Cytopathology [serial online]. Cytojournal. 2014;11:18.
15. Rosenthal D, Wojcik E. The quest for standardization of
urine cytology reporting—the evolution of the Paris system.
J Am Soc
Cytopathol. 2014;3:II-III.
16. Darragh TM, Colgan TJ, Cox JT, et al. The Lower
Anogenital Squamous Terminology Standardization Project
for HPVAssociated Lesions: background and consensus
recommendations from the College of American
Pathologists and the American Society for Colposcopy and
Cervical Pathology. Arch Pathol Lab Med. 2012;136:1266-
1297.
17. Darragh TM, Colgan TJ, Cox JT, et al. The Lower
Anogenital Squamous Terminology Standardization Project
for HPVAssociated Lesions: background and consensus
recommendations from the College of American
Pathologists and the American Society for Colposcopy and
Cervical Pathology. J Low Genit Tract Dis. 2012;16:205-
242.
18. Darragh TM, Colgan TJ, Cox JT, et al. The Lower
Anogenital Squamous Terminology Standardization project
for HPVassociated lesions: background and consensus
recommendations from the College of American
Pathologists and the American Society for Colposcopy and
Cervical Pathology. Int J Gynecol Pathol. 2013;32:76-115.
19. Stoler M, Bergeron C, Colgan TJ, et al. Epithelial tumours.
In: Kurman RJ, Carcangiu ML, Herrington CS, Young RH,
eds. Chapter 7: Tumours of the Uterine Cervix. WHO
Classification of Tumours of Female Reproductive Organs.
4th ed. Lyon, France: IARC Press; 2014:172-198.

Cancer Cytopathology May 2015 283