Results of Cervical Cytology the 2001 Bethesda System: Terminology For

The 2001 Bethesda System: Terminology for Reporting Results of Cervical Cytology

Diane Solomon; Diane Davey; Robert Kurman; et al. Online article and related content current as of February 17, 2009. JAMA. 2002;287(16):2114-2119 (doi:10.1001/jama.287.16.2114)

http://jama.ama-assn.org/cgi/content/full/287/16/2114

Correction Contact me if this article is corrected. Citations This article has been cited 529 times. Contact me when this article is cited. Related Articles published in 2001 Consensus Guidelines for the Management of Women With Cervical the same issue Cytological Abnormalities Thomas C. Wright, Jr et al. JAMA. 2002;287(16):2120.

New Bethesda Terminology and Evidence-Based Management Guidelines for Cervical Cytology Findings Mark H. Stoler. JAMA. 2002;287(16):2140.

April 24, 2002 JAMA. 2002;287(16):2153.

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The 2001 Bethesda System Terminology for Reporting Results of Cervical Cytology

Diane Solomon, MD Objectives The Bethesda 2001 Workshop was convened to evaluate and update Diane Davey, MD the 1991 Bethesda System terminology for reporting the results of cervical cytology. A primary objective was to develop a new approach to broaden participation in the Robert Kurman, MD consensus process. Ann Moriarty, MD Participants Forum groups composed of 6 to 10 individuals were responsible for Dennis O’Connor, MD developing recommendations for discussion at the workshop. Each forum group included at least 1 cytopathologist, cytotechnologist, clinician, and international repre- Marianne Prey, MD sentative to ensure a broad range of views and interests. More than 400 cytopatholo- Stephen Raab, MD gists, cytotechnologists, histopathologists, family practitioners, gynecologists, public health physicians, epidemiologists, patient advocates, and attorneys participated in the Mark Sherman, MD workshop, which was convened by the National Cancer Institute and cosponsored by David Wilbur, MD 44 professional societies. More than 20 countries were represented. Thomas Wright, Jr, MD Evidence Literature review, expert opinion, and input from an Internet bulletin board were all considered in developing recommendations. The strength of evidence of the Nancy Young, MD scientific data was considered of paramount importance. for the Forum Group Members and Consensus Process Bethesda 2001 was a year-long iterative review process. An the Bethesda 2001 Workshop Internet bulletin board was used for discussion of issues and drafts of recommenda- BACKGROUND tions. More than 1000 comments were posted to the bulletin board over the course of 6 months. The Bethesda Workshop, held April 30-May 2, 2001, was open to the The Bethesda System for reporting the public. Postworkshop recommendations were posted on the bulletin board for a last results of cervical cytology was devel- round of critical review prior to finalizing the terminology. oped as a uniform system of terminology that would provide clear guidance Conclusions Bethesda 2001 was developed with broad participation in the consen- 1 sus process. The 2001 Bethesda System terminology reflects important advances in for clinical management. The first biological understanding of cervical neoplasia and cervical screening technology. workshop was held in 1988, to reduce JAMA. 2002;287:2114-2119 www.jama.com widespread confusion among laboratories and clinicians created by the use tation.3 Currently, more than 90% of US considered an opportune time to re- of multiple classification systems and laboratories use some form of the 1991 evaluate the Bethesda System. inconsistently defined numerical grad- Bethesda System in reporting cervical cy- ing conventions. tology.4 With the increased utilization Bethesda 2001 Process The most important contribution of of new technologies and recent find- Eight months prior to the Bethesda the Bethesda System was the creation of ings from research studies, 2001 was 2001 Workshop, 9 forum groups (listed a standardized framework for laboratory reports that included a descriptive Author Affiliations: Division of Cancer Prevention, Na- Financial Disclosure: Dr Wright was the principal in- diagnosis and an evaluation of speci- tional Cancer Institute, Bethesda, Md (Dr Solomon); De- vestigator of the clinical trials investigating HPV DNA partment of Pathology and Laboratory Medicine, Uni- testing and liquid-based cytology funded by Digene men adequacy. While not everyone versity of Kentucky Medical Center, Lexington (Dr Corp and Cytyc Corp via formal grants to Columbia agreed with every detail of that initial ef- Davey); Departments of Gynecology and Obstetrics and University. Dr Wright has no financial or equity inter- fort, the recommendations of the 1988 Pathology, Johns Hopkins Hospital, Baltimore, Md (Dr est in, ongoing consultancy with, or membership on Kurman); AmeriPath Indiana, Indianapolis (Dr Mori- the scientific advisory board of Digene Corp, which workshop received widespread accep- arty); Clinical Pathology Associates, Louisville, Ky (Dr makes the only FDA-approved HPV DNA test in the tance in practice.2 A second workshop O’Connor); Quest Diagnostics Incorporated, St Louis, United States. Dr Wright currently serves on the speak- Mo (Dr Prey); Department of Pathology, Allegheny Hos- er’s bureau of Cytyc Corp and Tripath Inc, which make was held in 1991 to modify the Bethesda pital, Pittsburgh, Pa (Dr Raab); Division of Cancer Epi- liquid-based cytology test kits. System based on actual laboratory and demiology and Genetics, National Cancer Institute, Forum Group Members are listed at the end of this Bethesda, Md (Dr Sherman); Department of Pathol- article. clinical experience after its implemen- ogy, Massachusetts General Hospital, Boston (Dr Wilbur); Corresponding Author and Reprints: Diane Department of Pathology, Columbia University, New Solomon, MD, EPN Room 2130, 6130 Executive See also pp 2120 and 2140. York, NY (Dr Wright); and Department of Pathology, Blvd, Bethesda, MD 20892 (e-mail: ds87v@nih Fox Chase Cancer Center, Philadelphia, Pa (Dr Young). .gov).

Downloaded from www.jama.com at HSE: Health Service Executive (Ireland) on February 17, 2009 THE 2001 BETHESDA SYSTEM at the end of the article) were established to draft recommendations for BOX 1. Bethesda 2001 Workshop Cosponsors modifying the Bethesda System. A American Cancer Society* primary objective was to broaden American College Health Association* participation by using the Internet American College of Obstetricians and Gynecologists* in the premeeting development pro- American Social Health Association* cess. A dedicated Web site (http:// American Society of Cytopathology* * bethesda2001.cancer.gov) with an elec- American Society for Colposcopy and Cervical Pathology * tronic bulletin board was established to American Society of Clinical Pathologists American Society for Cytotechnology* seek input and critiques of draft rec- Asociacio´n Mexicana de Patologos ommendations. In total, more than Association of Reproductive Health Professionals 1000 individual comments were posted Association of Women’s Health, Obstetric and Neonatal Nurses to the bulletin board. Australian Society of Cytology The workshop was held April 30- British Society for Clinical Cytology May 2, 2001, with more than 400 par- Canadian Society of Cytology – Socie´te´ Canadienne de Cytologie* ticipants, including pathologists, cyto- Centers for Disease Control and Prevention technologists, clinicians, and patient Chinese Society of Cytopathology advocates. Forty-four professional so- College of American Pathologists* cieties, representing more than 20 coun- Deutsche Gesellschaft fu¨ r Zytologie Food and Drug Administration tries, were cosponsors (BOX 1). More Gynecologic Oncology Group, ACOG* than 20 national and international so- Health Care Financing Administration cieties have endorsed the 2001 Bethesda International Academy of Cytology System at this writing. The following International Society of Gynecological Pathologists summary highlights the most clinically Irish Association for Clinical Cytology* relevant changes to the Bethesda Sys- Japanese Society of Clinical Cytology tem (BOX 2); a more detailed text will Korean Society for Cytopathology be published in specialty journals. Magyar Onkolo´gusok Ta´rsasa´ga-Cytodiagnosztikai Sectio National Committee for Clinical Laboratory Standards THE 2001 BETHESDA SYSTEM Nurse Practitioners in Women’s Health Specimen Adequacy O¨ esterreichische Gesellschaft fuer Zytologie* Papanicolaou Society of Cytopathology* Evaluation of specimen adequacy is Planned Parenthood Federation considered by many to be the single Romanian Society of Cytology most important quality assurance com- Sociedad Argentina de Citologia ponent of the Bethesda System. Origi- Sociedad Chilena de Citologia nally, in 1988, specimen adequacy was Sociedad Espan˜ ola de Citologia* categorized as “satisfactory,” “less than Sociedad Peruana de Citologia optimal” (renamed “satisfactory but Sociedade Boliviana de Citologia limited by...”in1991), or “unsatis- Sociedade Brasileira de Citopatologia factory.” The middle category was used Societa` Italiana di Anatomia Patologica e Citopatologia Diagnostica most often for cases lacking endocer- Socie´te´ Belge de Cytologie Clinique—Belgische Vereniging voor Klinische Cytologie* vical or squamous metaplastic cells as Socie´te´ Franc¸aise de Cytologie Clinique* evidence of transformation zone sam- Society of Gynecologic Oncologists* pling, but which were otherwise “sat- Suid Afrikaanse Vereniging vir Kliniese Sitologie—South African Society of isfactory.” The 2001 Bethesda System Clinical Cytology* maintains the “satisfactory for evalua- *Indicates that the society has endorsed the 2001 Bethesda System. tion” and “unsatisfactory for evaluation” categories, but eliminates “satisfactory but limited by...”because the term was considered confusing to many Minimal squamous cellularity require- niques for evaluating cellularity will be clinicians and prompted unnecessary ments for a specimen to qualify as “sat- presented in future publications. repeat testing. Nevertheless, provid- isfactory” differ depending on speci- A notation is made regarding the ing information on transformation zone men type: an estimated 8000 to 12000 presence or absence of an endocervical/ sampling has value in improving over- well-visualized squamous cells for con- transformation zone component for all specimen quality and encourages ef- ventional smears and 5000 squamous specimens with adequate squamous cel- forts to optimize sample collection. cells for liquid-based preparations. Tech- lularity. The numeric criterion for a

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Comments on quality indicators such BOX 2. The 2001 Bethesda System (Abridged) as partially obscuring inflammation or SPECIMEN ADEQUACY blood may also be added to the “satisfactory” designation. A specimen is con- Satisfactory for evaluation (note presence/absence of endocervical/ transformation zone component) sidered “partially obscured” when 50% Unsatisfactory for evaluation...(specify reason) to 75% of the epithelial cells cannot be Specimen rejected/not processed (specify reason) visualized. Specimens with more than Specimen processed and examined, but unsatisfactory for evaluation of 75% of epithelial cells obscured are “un- epithelial abnormality because of (specify reason) satisfactory.” GENERAL CATEGORIZATION (Optional) Specimens that cannot be acces- Negative for intraepithelial lesion or malignancy sioned by the laboratory, if unlabelled Epithelial cell abnormality for example, are also designated as “un- Other satisfactory”; these are distinguished from specimens that have been pro- INTERPRETATION/RESULT cessed by the laboratory and deter- Negative for Intraepithelial Lesion or Malignancy mined to be unsatisfactory following Organisms Trichomonas vaginalis microscopic evaluation. Fungal oganisms morphologically consistent with Candida species Shift in flora suggestive of bacterial vaginosis General Categorization Bacteria morphologically consistent with Actinomyces species The “general categorization” is an op- Cellular changes consistent with herpes simplex virus tional component of the Bethesda Sys- Other non-neoplastic findings (Optional to report; list not comprehensive) tem, designed to allow clinicians and/or Reactive cellular changes associated with their staff to triage reports readily. The inflammation (includes typical repair) previous category headings of “within radiation normal limits” and “benign cellular intrauterine contraceptive device changes” have been combined into a Glandular cells status posthysterectomy Atrophy single category “negative for intraepi- Epithelial Cell Abnormalities thelial lesion or malignancy.”In this way, Squamous cell reactive changes are more clearly des- Atypical squamous cells (ASC) ignated as “negative.”“Other” has been of undetermined significance (ASC-US) added as a category for cases in which cannot exclude HSIL (ASC-H) there are no morphological abnormali- Low-grade squamous intraepithelial lesion (LSIL) ties in the cells per se; however, the find- encompassing: human papillomavirus/mild dysplasia/cervical ings may indicate some increased risk: intraepithelial neoplasia (CIN) 1 for example, benign-appearing “endo- High-grade squamous intraepithelial lesion (HSIL) metrial cells in a woman Ն40 years of encompassing: moderate and severe dysplasia, carcinoma in situ; age” (see below). CIN 2 and CIN 3 Squamous cell carcinoma These categories are mutually exclu- Glandular cell sive; therefore, if several findings Atypical glandular cells (AGC) (specify endocervical, endometrial, or not are present, the general categorization otherwise specified) is based on the most clinically sig- Atypical glandular cells, favor neoplastic (specify endocervical nificant result (eg, epithelial cell or not otherwise specified) abnormality). Endocervical adenocarcinoma in situ (AIS) Adenocarcinoma Interpretation/Result Other (List not comprehensive) Ն The workshop participants unani- Endometrial cells in a woman 40 years of age mously supported the view that cervi- AUTOMATED REVIEW AND ANCILLARY TESTING (Include as appropriate) cal cytology is primarily a screening test, EDUCATIONAL NOTES AND SUGGESTIONS (Optional) which in some instances may serve as a medical consultation by providing an interpretation that contributes to a diagnosis. However, a patient’s final di- transformation zone component is un- preserved endocervical or squamous agnosis, and therefore management, changed from the 1991 Bethesda Sys- metaplastic cells; however, clusters are must integrate clinical and laboratory tem—there should be at least 10 well- no longer required. results. Therefore, in the 2001 Bethesda

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System the term “diagnosis” has been gued for elimination of the ASCUS cat- Squamous Intraepithelial Lesions. The replaced by “interpretation” or “re- egory. However, the participants 1988 Bethesda System introduced a sult” to convey that cervical cytology decided that it was essential to main- 2-tiered terminology, LSIL and HSIL, for provides an interpretation of morpho- tain an equivocal category because of reporting the spectrum of noninvasive logical findings that must be inte- the large number of women with un- squamous cervical abnormalities. grated into a clinical context. derlying CIN 2 and 3 who are discov- After thorough consideration by the Negative for Intraepithelial Lesion ered through a workup for an equivo- Bethesda 2001 Workshop, the 2-tiered or Malignancy. Specimens for which no cal cytological reading. Estimates LSIL/HSIL terminology remains un- epithelial abnormality is identified are suggest that 10% to 20% of women with changed. reported as “negative for intraepithe- ASC have underlying CIN 2 or 3 and The dichotomous division of SIL re- lial lesion or malignancy.” Reporting that 1 in 1000 may have invasive can- flects the substantial virological, mo- non-neoplastic findings, other than the cer.6 The elimination of an equivocal lecular, and clinical evidence that LSIL listed organisms, is optional; Box 2 in- cytology category seemed imprudent is generally a transient infection with cludes a partial list of findings. given the high expectations for very sen- HPV, while HSIL is more often associ- Epithelial Cell Abnormalities. Atypi- sitive cervical cytological screening in ated with viral persistence and higher cal Squamous Cells. The 1988 Bethesda the United States. risk for progression.10-13 In addition, System included the term “atypical The 2001 Bethesda System differs in data from the ASCUS LSIL Triage Study squamous cells of undetermined sig- several fundamental ways with regard to demonstrate the following: (1) LSIL vs nificance” (ASCUS) to designate “cel- reporting equivocal results. First, “atypi- HSIL is a fairly reproducible diagnos- lular abnormalities that were more cal squamous cells” are now qualified tic breakpoint, (2) subdividing cyto- marked than those attributable to re- as “of undetermined significance logical HSIL into moderate and severe active changes but that quantitatively (ASC-US)” or “cannot exclude HSIL” dysplasia or CIN 2 and 3 is not very re- or qualitatively fell short of a defini- (ASC-H). The qualifier “undetermined producible, and (3) HPV cytopathic tive diagnosis of ‘squamous intraepi- significance” was retained to empha- effect cannot be reliably separated from thelial lesion’ (SIL).” Pathologists were size that some cases of ASC-US are as- mild dysplasia or CIN 1 (M. Schiff- encouraged to qualify ASCUS with re- sociated with underlying CIN 2 or 3. Sec- man, written communication, 2001). spect to whether a reactive process or ond, ASC is not a diagnosis of exclusion; However, the 3-tiered CIN 1-2-3 des- SIL was favored. In practice, patholo- all ASC is considered to be suggestive ignations may be helpful in managing gists reported a significant proportion of SIL. Accordingly, the category of some individual patients, in correlat- of smears as “ASCUS, not otherwise “ASCUS, favor reactive” was elimi- ing cytopathologic and histopatho- specified.” nated. Pathologists are encouraged to logic findings, or in reporting cytol- When the 1988 Bethesda System was judiciously downgrade to “negative for ogy results outside the United States. drafted, clinical management in the intraepithelial lesion or malignancy” a Some members of the European cyto- United States focused on identifying all portion of the cases previously termed pathology community in particular fa- SIL, including low-grade SIL (LSIL), “ASCUS favor reactive.” vor use of CIN terminology. As in pre- based on the view that all grades of SIL The new term “ASC-H” is thought to vious versions of the Bethesda System, represented closely linked precursors include approximately 5% to 10% of CIN or dysplasia terminology can be that required colposcopy and treat- ASC cases overall.7-9 This category re- used, either as a substitute for SIL or ment. However, there has been a shift flects a mixture of true HSIL and its as an additional descriptor. in the United States with regard to man- mimics. Although the interpretation is Atypical Glandular Cells.The classi- agement based on the recognition that not highly reproducible among patholo- fication of glandular abnormalities has most LSIL, especially in young women, gists, studies suggest that ASC-H has a been significantly revised in the 2001 represents a self-limited human papil- positive predictive value for histologi- Bethesda System, reflecting a reap- lomavirus (HPV) infection.5 Accord- cal CIN 2 or 3 that is intermediate be- praisal of the strengths and weak- ingly, the current emphasis is on de- tween ASC-US and HSIL. It is hoped nesses of cytology in assessing these tection and treatment of histologically that by highlighting such cases, ASC-H findings. confirmed high-grade disease (particu- will aid in more rapid detection and The term “atypical glandular cells of larly cervical intraepithelial neoplasia treatment of some cases of CIN 2 and undetermined significance” (AGUS) has [CIN] 3). Therefore, it is logical for the 3. However, the equivocal nature of the been eliminated to avoid confusion with ASC category qualifiers to emphasize ASC-H designation should encourage ASC-US. Glandular cell abnormalities the importance of detecting high- comprehensive review of all pathol- are classified as “atypical endocervi- grade SIL (HSIL), which has emerged ogy and colposcopic findings prior to cal, endometrial, or glandular cells.” as the central purpose of screening. performing a diagnostic loop electro- In the majority of cases, morpho- At the 2001 workshop, a small mi- surgical excision procedure in women logical features permit differentiation nority of workshop participants ar- with negative histology results. between atypical endometrial and en-

Downloaded from www.jama.com at HSE: Health Service Executive (Ireland) on February 17, 2009 THE 2001 BETHESDA SYSTEM docervical cells.14 The management of menstrual/menopausal status, exog- tive, consistent with clinical follow-up patients with glandular abnormalities enous hormone therapy, and other guidelines published by professional or- may vary significantly depending on cell clinical risk factors are often un- ganizations, and phrased in the form of type and justifies making this distinc- known or unclear. Although usually a suggestion. A qualifying phrase (eg, tion when possible. The term “atypi- benign in nature, identification of “as clinically indicated”) should gen- cal epithelial cells” may be used for endometrial cells, particularly if not as- erally be added since the pathologist cases where a squamous vs glandular sociated with menses or after meno- may be unaware of other pertinent clini- origin cannot be determined. pause, may indicate risk for an endo- cal information. One study has shown The finding of atypical glandular cells metrial abnormality.22-25 As noted above, that including suggestions for further (AGC) is important clinically because this finding is categorized as “other.” evaluation improves the likelihood that the percentage of cases associated with It is important to emphasize that cer- appropriate follow-up occurs.26 Pro- underlying high-grade disease is higher vical cytology is primarily a screening viding references for consensus clini- than for ASC-US. On follow-up, high- test for squamous epithelial lesions and cal follow-up guidelines for abnormal grade lesions (either squamous or glan- squamous cancer. It is unreliable for the cervical cytology results published by dular) may be seen in 10% to 39% of detection of endometrial lesions and medical organizations (eg, American such cases.15-17 Based on such data, the should not be used to evaluate sus- College of Obstetricians and Gynecolo- qualifier “favor reactive” was consid- pected endometrial abnormalities. gists, American Society for Colpos- ered misleading and it has been elimi- copy and Cervical Pathology) may also nated: such cases are now included in Automated Review be helpful.27 the AGC category. and Ancillary Testing In the 1991 terminology, adenocar- “Automated review and ancillary test- SUMMARY cinoma in situ (AIS) was included in ing” are elements of the report that are The goal of the Bethesda System is to “AGUS, probably neoplastic.” Since that included as appropriate. For slides promote more effective communica- time, studies have clearly documented scanned by automated computer sys- tion of cervical cytology results from the predictive value and reproducibility of tems, the instrumentation used and the laboratory to clinicians. The 2001 re- properly applied cytological criteria for automated review result should be in- vision of the terminology was devel- this interpretation.18-20 “Endocervical ad- cluded in the cervical cytology report. oped through a process designed to in- enocarcinoma in situ” is therefore now If an ancillary molecular test has been corporate new scientific data and a separate category. However, there is performed, the type of assay should be encourage input from a broad range of considerable morphological overlap be- specified in addition to the results. Ide- individuals involved in cervical can- tween AIS and well-differentiated inva- ally, cytology and ancillary testing re- cer screening. Management guide- sive endocervical adenocarcinoma; a per- sults should be reported concur- lines for women with abnormal cytol- centage of cases interpreted as AIS will rently; however, this may not always be ogy results, based on the 2001 Bethesda demonstrate invasion on histological possible. System, have been developed at a con- evaluation. sensus conference sponsored by the For cases showing some features sug- Educational Notes and Suggestions American Society for Colposcopy and gestive of, but not sufficient to reach an Written comments regarding the va- Cervical Pathology.28 Such collabora- interpretation of AIS, an intermediate lidity and significance of a cytology re- tive and integrated development of re- category of “atypical endocervical cells, sult are the responsibility of the pa- porting terminology and management favor neoplastic” conveys a significant thologist and are directed to the guidelines should provide more uni- level of concern. There is no basis for es- clinician who requested the test. The form, evidence-based care of women tablishing a category of “endocervical laboratory should avoid communi- with cervical abnormalities. glandular dysplasia” or “low grade glan- cating results directly to the patient, as dular intraepithelial lesion.”21 A mor- this may interfere with the patient- The Forum Group Members include the following: Specimen Adequacy: Diane D. Davey, MD, George phological spectrum of bona fide pre- clinician relationship. Direct contact be- Birdsong, MD, Henry W. Buck, MD, Teresa Darragh, cursors of AIS has not been identified for tween the patient and the laboratory MD, Paul Elgert, CT(ASCP), Michael Henry, MD, Heather Mitchell, MD, Suzanne Selvaggi, MD; Be- endocervical glandular lesions. may be acceptable, however, if specifi- nign Cellular Changes and Infections: Nancy Young, Other. In the previous version of the cally requested by the clinician. MD, Marluce Bibbo, MD, Sally-Beth Buckner, CT Bethesda System, the finding of endo- The use of educational notes or sug- (ASCP), Terence Colgan, MD, Dorothy Rosenthal, MD, Edward Wilkinson, MD; ASCUS: Mark Sherman, MD, metrial cells was reported only for post- gestions is optional. If used, the for- Fadi Abdul-Karim, MD, Jonathan Berek, MD, Patri- menopausal women. However, in the mat and style may vary depending on cia Braly, MD, Robert Gay, CT(ASCP), Celeste Pow- ers, MD, Mary Sidawy, MD, Sana Tabbara, MD; AGUS: 2001 Bethesda System, endometrial the preferences of the laboratory and its David Wilbur, MD, David Chhieng, MD, J. Thomas cells are noted if the woman is 40 years clinicians. Nevertheless, any com- Cox, MD, Jamie Covell, BS, CT(ASCP), Barbara Gui- dos, SCT(ASCP), Kenneth Lee, MD, Dina Mody, MD; of age or older, regardless of the date ments should be carefully and thought- HPV Triage: Stephen Raab, MD, Karen Allen, CT of the last menstrual period, because fully crafted, concise but not direc- (ASCP), Christine Bergeron, MD, PhD, Diane Harper,

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MD, Walter Kinney, MD, Alexander Meisels, MD; En- mined significance: baseline results from a random- nificance as defined by the Bethesda System. Am J Ob- dometrial Cells: Ann Moriarty, MD, Edmund Cibas, ized trial. J Natl Cancer Inst. 2001;93:293-299. stet Gynecol. 1997;177:1188-1195. MD, Gary Gill, CT(ASCP), Meg McLachlin, MD, Ellen 7. Sherman ME, Solomon D, Schiffman M, for the 18. Betsill WL, Clark AH. Early endocervical glandu- Sheets, MD, Theresa Somrak, CT(ASCP), Rosemary ALTS Group. Qualification of ASCUS: a comparison lar neoplasia, I: histomorphology and cytomorphol- Zuna, MD; LSIL /HSIL: Tom Wright, MD, Richard De- of equivocal LSIL and equivocal HSIL cervical cytology. Acta Cytol. 1986;30:115-126. May, MD, Rose Marie Gatscha, CT(ASCP), Lydia How- ogy in the ASCUS LSIL Triage Study. Am J Clin Pathol. 19. Lee KR, Manna EA, Jones MA. 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