Levine_Handbook for Principles and Practice of Gynecologic O

86 Handbook for Principles and Practice of Gynecologic Oncology evidence that LBC reduces the proportion of unsatisfactory slides nor that it has better performance than conventional cytology with respect to the identification of women with CIN 2,3. While there is no evidence that LBC is either more sensitive or more specific than conventional cytology, there are other advantages of LBC. The greatest of these appears to be the availability of residual fluid for “reflex” HPV testing in women with atypical squamous cells of undetermined sig nificance (ASC-US). Moreover, most cytologists agree that it is easier to evaluate LBC specimens than conventional cytology specimens. HPV Testing The use of HPV testing alone has demonstrated slightly better detection rates and associations with future development of CIN than Pap testing alone, but specificity may be lower. In April 2014, the FDA approved HPV testing alone as a screening method to determine which women require additional diagnos tic testing. Women infected with high-risk HPV 16 or 18 subtypes should be referred for immediate colposcopy, and women with other high-risk subtypes should have a Pap smear performed with those results indicating whether col poscopy is recommended. Women with negative HPV testing can have routine screening. As mentioned above, HPV testing alone is not recommended for screening women younger than 30 due to high rates of HPV infection. Cotesting with a Pap smear and HPV testing is the recommended approach to cervical cancer screening in women over the age of 30. Cotesting improves detection of CIN 2,3 and lowers the false-negative rate when compared to cytology alone. Cotesting also improves detection of glandular lesions. Terminology of Cytology Reports

The Bethesda system terminology is used for reporting cervical cytology results in the United States. The Bethesda system underwent significant modifications in 2001 (Table 4.4) and was most recently updated in 2014. The major features of the Bethesda system are that it requires (i) an esti mate of the adequacy of the specimen for diagnostic evaluation (i.e., is the transformation zone sampled); (ii) a general categorization of the specimen as being “negative for intraepithelial lesion or malignancy,” as having an “epithelial cell abnormality,” or as “other” (i.e., having endometrial cells in a woman 40 years of age and older); and (iii) a descriptive diagnosis that includes a description of epithelial cell abnormalities. The terms low grade squamous intraepithelial lesion (LSIL) and high-grade squamous intraepithelial lesion (HSIL) are used to designate cytologic changes that correlate with CIN 1 and CIN 2,3, respectively. In addition, the Bethesda system attempts to separate epithelial changes secondary to inflammation or repair from those associated with cervical cancer precursors whenever possible. Nondiagnostic squamous cell abnormalities are included in a cat egory of atypical squamous cells (ASC). ASC specimens have features sug gestive, but not diagnostic, of a SIL. This category is further subdivided into two subcategories: ASC-US (atypical squamous cells of undetermined significance) and ASC—cannot exclude HSIL (ASC-H). The risk of a woman with ASC-US having biopsy-confirmed CIN 2,3 is approximately 7% to 17%, and the risk for a woman with ASC-H is approximately 40%. Copyright © 2020 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.