Citologia

C E R V I C A L C A N C E R

Cervical Cytology Classification and the Bethesda System
Diane D. Davey, MD, Lexington, Kentucky
ABSTRACT
Cervical cancer screening represents one of the great success stories in cancer prevention. Cervical cytology results were repor ted by use of various terminologies during the first 40 years of widespread screening. These terms did not correspond to currentknowledge of cervical carcinogenesis. The Bethesda System for reporting cervical cytology was developed to provide a uniform system of terminology that would promote clear management guidelines. The Bethesda System has been widely adopted since the first workshop was convened by the National Cancer Institute in 1988. Two additional workshops were held in 1991 and 2001 in order to address scientificadvances and controversial areas. The 2001 workshop was attended by more than 400 par ticipants and was preceded by Internet discussion groups. Major changes include specimen adequacy designation and criteria, general categorization, and terminology for atypical epithelial cells. The ‘‘within normal limits’’ and ‘‘benign cellular changes’’ categories have been combined into a single categor ycalled ‘‘negative for intraepithelial lesion or malignancy.’’ The ‘‘favor reactive’’ descriptors have been removed from the atypical epithelial categories, and new terms correlate better with management guidelines. Other changes are discussed, and a brief update of cancer screening guidelines is also provided. (Cancer J 2003;9:327–334)

KEY WORDS
Cervix, dysplasia, carcinoma, cervicalcancer/intraepithelial neoplasia, cervical/Papanicolaou smear, cytology, cytological techniques, terminology, Bethesda

Cervical cytology screening represents one of the great

success stories in cancer prevention, with mortality decreasing by over 70% in the past five decades. Cervical cytology screening came into widespread use with publiFrom the Depar tment of Pathology and Laborator y Medicine,University of Kentucky Medical Center, Lexington, Kentucky. Received on March 10, 2003; accepted for publication August 20, 2003. No benefits in any form have been or will be received from a commercial par ty related directly or indirectly to the subject of this ar ticle. Correspondence: Diane D. Davey, MD, Depar tment of Pathology and Laborator y Medicine MS117, University of Kentucky Medical Center,800 Rose St., Lexington, KY 40536-0298. E-mail: ddavey@uky.edu Copyright q 2003 Jones and Bartlett Publishers, Inc.

cations by Papanicolaou and Traut1 and Ayre,2 and through joint efforts of Dr. Papanicolaou with Dr. Charles Cameron, first Medical and Scientific Director of the American Cancer Society.3 A variety of terminologies were used for the first 40 years. Many laboratories used thePapanicolaou class system: a specific ‘‘class’’ provided a level of concern about the presence of cancer cells.4 For example, a class I smear was negative and a class V smear was cancer. However, this class system had many variations and did not correspond to scientific advances in the knowledge of cervical carcinogenesis and precursor lesions.4 Reagan5 encouraged use of the term dysplasia to designateprecancerous lesions; dysplastic lesions were then subdivided by degree of abnormality as well as by cell type, severe keratinizing dysplasia being an example.6 Richart7 introduced cervical intraepithelial neoplasia (CIN) terminology in the 1960s to promote the idea of a continuum of precursor lesions. Many laboratories continued to use the class system for cytology reports, in addition to otherpoorly defined terms that were used variably in different regions. In recognition of the widespread confusion caused by the use of multiple classification systems, the National Cancer Institute held a workshop in 1988.4 The Bethesda System for reporting results of cervical cytology was developed to provide a uniform system of terminology that would lead to clear management guidelines. Two...