# Bethesda system

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Reporting systems for pathology

**The Bethesda system** (**TBS**), officially called **The Bethesda System for Reporting Cervical Cytology**, is a system for reporting [cervical](/source/Cervix) or vaginal [cytologic](/source/Cytopathology) diagnoses,[1] used for reporting [Pap smear](/source/Pap_smear) results. It was introduced in 1988[2] and revised in 1991,[3] 2001,[1][4][5] and 2014.[6] The name comes from the location ([Bethesda, Maryland](/source/Bethesda%2C_Maryland)) of the conference, sponsored by the [National Institutes of Health](/source/National_Institutes_of_Health), that established the system.

Since 2010, the Bethesda system has been used for [cytopathology](/source/Cytopathology) of [thyroid nodules](/source/Thyroid_nodule), which is called **The Bethesda System for Reporting Thyroid Cytopathology** (TBSRTC or BSRTC). Like TBS, it was the result of a conference sponsored by the NIH and is published in book editions (currently by Springer). Mentions of "the Bethesda system" without further specification usually refer to the cervical system, unless the thyroid context of a discussion is implicit.

## Cervix

Abnormal results include:[*[citation needed](https://en.wikipedia.org/wiki/Wikipedia:Citation_needed)*]

- Atypical squamous cells - Atypical squamous cells of undetermined significance (ASC-US) - Atypical squamous cells – cannot exclude HSIL (ASC-H)

- Low-grade squamous intraepithelial lesion (LGSIL or LSIL)

- High-grade squamous intraepithelial lesion (HGSIL or HSIL)

- [Squamous cell carcinoma](/source/Squamous_cell_carcinoma)

- Atypical Glandular Cells not otherwise specified (AGC-NOS)

- Atypical Glandular Cells, suspicious for AIS or cancer (AGC-neoplastic)

- Adenocarcinoma *in situ* (AIS)

The results are calculated differently following a [Pap smear](/source/Pap_smear) of the [cervix](/source/Cervix).[*[citation needed](https://en.wikipedia.org/wiki/Wikipedia:Citation_needed)*]

### Squamous cell abnormalities

#### LSIL: low-grade squamous intraepithelial lesion

Cytopathology of low-grade squamous intraepithelial lesion (LSIL), with main features, as compared to an unremarkable intermediate squamous cell. [Pap stain](/source/Pap_stain).

A low-grade squamous intraepithelial lesion (LSIL or LGSIL) indicates possible [cervical dysplasia](/source/Cervical_intraepithelial_neoplasia). LSIL usually indicates mild dysplasia (CIN 1), more than likely caused by a [human papillomavirus](/source/Human_papillomavirus) infection. It is usually diagnosed following a [Pap smear](/source/Pap_smear).[*[citation needed](https://en.wikipedia.org/wiki/Wikipedia:Citation_needed)*]

CIN 1 is the most common and most benign form of cervical intraepithelial neoplasia and usually resolves spontaneously within two years. Because of this, LSIL results can be managed with a simple "watch and wait" philosophy. However, because there is a 12–16% chance of progression to more severe dysplasia, the physician may want to follow the results more aggressively by performing a [colposcopy](/source/Colposcopy) with [biopsy](/source/Biopsy).[7] If the dysplasia progresses, treatment may be necessary. Treatment involves removal of the affected tissue, which can be accomplished by [LEEP](/source/Loop_electrical_excision_procedure), [cryosurgery](/source/Cryosurgery), [cone biopsy](/source/Cone_biopsy), or laser ablation.[*[citation needed](https://en.wikipedia.org/wiki/Wikipedia:Citation_needed)*]

#### HSIL: high-grade squamous intraepithelial lesion

HSIL. [Pap stain](/source/Pap_stain).

High-grade squamous intraepithelial lesion (HSIL or HGSIL) indicates moderate or severe [cervical intraepithelial neoplasia](/source/Cervical_intraepithelial_neoplasia) or [carcinoma in situ](/source/Carcinoma_in_situ). It is usually diagnosed following a [Pap test](/source/Pap_test). In some cases, these lesions can lead to invasive [cervical cancer](/source/Cervical_cancer), if not followed appropriately.[*[citation needed](https://en.wikipedia.org/wiki/Wikipedia:Citation_needed)*]

HSIL does not mean that cancer is present. Of all women with HSIL results, 2%[8] or less[9] have invasive cervical cancer at that time; however, about 20% would progress to having invasive cervical cancer without treatment.[10][*[needs update](https://en.wikipedia.org/wiki/Wikipedia:Manual_of_Style/Dates_and_numbers#Chronological_items)*] To combat this progression, HSIL is usually followed by an immediate [colposcopy](/source/Colposcopy) with [biopsy](/source/Biopsy) to sample or remove the dysplastic tissue. This tissue is sent for [pathology](/source/Pathology) testing to assign a [histologic](/source/Histology) classification that is more definitive than a Pap smear result (which is a [cytologic](/source/Cytopathology) finding). HSIL generally corresponds to the histological classification of [CIN 2 or 3](/source/Cervical_intraepithelial_neoplasia).[*[citation needed](https://en.wikipedia.org/wiki/Wikipedia:Citation_needed)*]

HSIL treatment involves the removal or destruction of the affected cells, usually by [LEEP](/source/Loop_electrical_excision_procedure). Other methods include [cryotherapy](/source/Cryosurgery), cautery, or laser ablation, but none are performed on [pregnant](/source/Pregnancy) women for fear of disrupting the pregnancy—the indication per 2006 American Society for Colposcopy and Cervical Pathology consensus guidelines being only invasive cancer.[7]: 348 Any of these procedures is 85% likely to cure the problem.[*[citation needed](https://en.wikipedia.org/wiki/Wikipedia:Citation_needed)*]

### Glandular cell abnormalities

#### Adenocarcinoma

Adenocarcinoma. [Pap stain](/source/Pap_stain).

[Adenocarcinoma](/source/Adenocarcinoma) can arise from the endocervix, endometrium, and extrauterine sites.[*[citation needed](https://en.wikipedia.org/wiki/Wikipedia:Citation_needed)*]

#### AGC

AGC, formerly AGUS, is a term for *atypical glandular cells of undetermined significance*.[11] Renamed AGC to avoid confusion with ASCUS.[1]

The management of AGC is [colposcopy](/source/Colposcopy) with or without an [endometrial](/source/Endometrium) [biopsy](/source/Biopsy).[*[citation needed](https://en.wikipedia.org/wiki/Wikipedia:Citation_needed)*]

## Thyroid nodules

The *Bethesda System for Reporting Thyroid Cytopathology* is the system used to report whether the thyroid cytological specimen is benign or malignant on [fine-needle aspiration cytology](/source/Fine-needle_aspiration_cytology) (FNAC). It can be divided into six categories:

Bethesda system Category Description Risk of malignancy[12] Recommendation[12] I Non diagnostic/unsatisfactory - Repeating FNAC with ultrasound-guidance in more than 3 months II Benign (colloid and follicular cells) 0 – 3% Clinical follow-up III Atypia of undetermined significance/follicular lesion of undetermined significance (follicular or lymphoid cells with atypical features) 5 – 15% Repeating FNAC IV Follicular nodule/suspicious follicular nodule (cell crowding, micro follicles, dispersed isolated cells, scant colloid) 15 – 30% Surgical lobectomy V Suspicious for malignancy 60 – 75% Surgical lobectomy or near-total thyroidectomy VI Malignant 97 – 99% Near-total thyroidectomy

		- Thyroid cytopathology of Bethesda category III with clotting artifact

		- Category IV

		- Category V with intranuclear cytoplasmic inclusion

		- Category V with nuclear groove (arrow)

		- Cytopathology suspicious for [Hürthle cell neoplasm](/source/H%C3%BCrthle_cell_neoplasm) (Bethesda category IV, rather than Hürthle cell hyperplasia), Pap stain.[13]

Repeated FNAC is recommended for Category I, followed by clinical follow-up in Category II, repeat FNAC for Category III, and [lobectomy](/source/Lobectomy) for Category IV, near total-thyroidectomy/lobectomy for Category V, and near total thyroidectomy for Category VI.[14] The risk of malignancy in a malignant FNAC report is 93.7% while for a suspicious FNAC report, it is 18.9%.[15]

## See also

- [American Society for Clinical Pathology](/source/American_Society_for_Clinical_Pathology)

## References

1. ^ [***a***](#cite_ref-AFP-TBS2001_1-0) [***b***](#cite_ref-AFP-TBS2001_1-1) [***c***](#cite_ref-AFP-TBS2001_1-2) Apgar BS, Zoschnick L, Wright TC (November 2003). ["The 2001 Bethesda System terminology"](https://web.archive.org/web/20080905045527/http://www.aafp.org/afp/20031115/1992.html). *Am Fam Physician*. **68** (10): 1992–8. [PMID](/source/PMID_(identifier)) [14655809](https://pubmed.ncbi.nlm.nih.gov/14655809). Archived from [the original](http://www.aafp.org/afp/20031115/1992.html) on 2008-09-05. Retrieved 2009-01-03.

1. **[^](#cite_ref-pmid2791840_2-0)** Soloman, Diane (1989). "The 1988 Bethesda System for reporting cervical/vaginal cytologic diagnoses: developed and approved at the National Cancer Institute workshop in Bethesda, MD, December 12–13, 1988". *Diagn. Cytopathol*. **5** (3): 331–4. [doi](/source/Doi_(identifier)):[10.1002/dc.2840050318](https://doi.org/10.1002%2Fdc.2840050318). [PMID](/source/PMID_(identifier)) [2791840](https://pubmed.ncbi.nlm.nih.gov/2791840). [S2CID](/source/S2CID_(identifier)) [19684695](https://api.semanticscholar.org/CorpusID:19684695).

1. **[^](#cite_ref-3)** Broder S (1992). "The Bethesda System for Reporting Cervical/Vaginal Cytologic Diagnoses—Report of the 1991 Bethesda Workshop". *JAMA*. **267** (14): 1892. [doi](/source/Doi_(identifier)):[10.1001/jama.1992.03480140014005](https://doi.org/10.1001%2Fjama.1992.03480140014005).

1. **[^](#cite_ref-4)** Nayar R, Solomon D. Second edition of 'The Bethesda System for reporting cervical cytology' – Atlas, website, and Bethesda interobserver reproducibility project. CytoJournal [serial online] 2004 [cited 2011 Apr 17];1:4. Available from: [http://www.cytojournal.com/text.asp?2004/1/1/4/41272](http://www.cytojournal.com/text.asp?2004/1/1/4/41272) [Archived](https://web.archive.org/web/20181002174906/http://www.cytojournal.com/text.asp?2004%2F1%2F1%2F4%2F41272) 2018-10-02 at the [Wayback Machine](/source/Wayback_Machine)

1. **[^](#cite_ref-pmid11966386_5-0)** Solomon D, Davey D, Kurman R, et al. (April 2002). ["The 2001 Bethesda System: terminology for reporting results of cervical cytology"](http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11966386). *JAMA*. **287** (16): 2114–9. [doi](/source/Doi_(identifier)):[10.1001/jama.287.16.2114](https://doi.org/10.1001%2Fjama.287.16.2114). [PMID](/source/PMID_(identifier)) [11966386](https://pubmed.ncbi.nlm.nih.gov/11966386).

1. **[^](#cite_ref-6)** Nayar R, Wilbur D. The Bethesda System for Reporting Cervical Cytology, Definitions, Criteria, and Explanatory Notes. Springer; 2015.

1. ^ [***a***](#cite_ref-wrightjr2007_7-0) [***b***](#cite_ref-wrightjr2007_7-1) Wright TC Jr, Massad LS, Dunton CJ, Spitzer M, Wilkinson EJ, Solomon D, et al. (Oct 2007). "2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests". *Am J Obstet Gynecol*. **197** (4): 346–55. [doi](/source/Doi_(identifier)):[10.1016/j.ajog.2007.07.047](https://doi.org/10.1016%2Fj.ajog.2007.07.047). [PMID](/source/PMID_(identifier)) [17904957](https://pubmed.ncbi.nlm.nih.gov/17904957).

1. **[^](#cite_ref-8)** Massad LS, Collins YC, Meyer PM (Sep 2001). "Biopsy correlates of abnormal cervical cytology classified using the Bethesda system". *Gynecologic Oncology*. **82** (3): 516–522. [doi](/source/Doi_(identifier)):[10.1006/gyno.2001.6323](https://doi.org/10.1006%2Fgyno.2001.6323). [PMID](/source/PMID_(identifier)) [11520149](https://pubmed.ncbi.nlm.nih.gov/11520149).

1. **[^](#cite_ref-9)** Melnikow J, Nuovo J, Willan AR, Chan BK, Howell LP (Oct 1998). "Natural history of cervical squamous intraepithelial lesions: a meta-analysis". *Obstetric Gynecology*. **92** (4 Pt 2): 727–735. [doi](/source/Doi_(identifier)):[10.1016/s0029-7844(98)00245-2](https://doi.org/10.1016%2Fs0029-7844%2898%2900245-2). [PMID](/source/PMID_(identifier)) [9764690](https://pubmed.ncbi.nlm.nih.gov/9764690).

1. **[^](#cite_ref-10)** McIndoe WA, McLean MR, Jones RW, Mullins PR (Oct 1984). "The invasive potential of carcinoma in situ of the cervix". *Obstetric Gynecology*. **64** (4): 451–458. [PMID](/source/PMID_(identifier)) [6483293](https://pubmed.ncbi.nlm.nih.gov/6483293). [S2CID](/source/S2CID_(identifier)) [67962449](https://api.semanticscholar.org/CorpusID:67962449).

1. **[^](#cite_ref-11)** [AGUS](http://www.emedicinehealth.com/script/main/srchcont_dict.asp?src=AGUS) [Archived](https://web.archive.org/web/20160815060122/http://www.emedicinehealth.com/script/main/srchcont_dict.asp?src=agus) 2016-08-15 at the [Wayback Machine](/source/Wayback_Machine) at [eMedicine](/source/EMedicine) Dictionary

1. ^ [***a***](#cite_ref-Renuka2012_12-0) [***b***](#cite_ref-Renuka2012_12-1) Renuka, I. V.; Saila Bala, G.; Aparna, C.; Kumari, Ramana; Sumalatha, K. (December 2012). ["The Bethesda System for Reporting Thyroid Cytopathology: Interpretation and Guidelines in Surgical Treatment"](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3477437). *Indian Journal of Otolaryngology and Head & Neck Surgery*. **64** (4): 305–311. [doi](/source/Doi_(identifier)):[10.1007/s12070-011-0289-4](https://doi.org/10.1007%2Fs12070-011-0289-4). [PMC](/source/PMC_(identifier)) [3477437](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3477437). [PMID](/source/PMID_(identifier)) [24294568](https://pubmed.ncbi.nlm.nih.gov/24294568).

1. **[^](#cite_ref-13)** Image by Mikael Häggström, MD. References for findings: - Ayana Suzuki, C.T., Andrey Bychkov, M.D., Ph.D. ["Hürthle cell neoplasm"](https://www.pathologyoutlines.com/topic/thyroidhurthlecellneoplasm.html). *Pathology Outlines*.{{[cite web](https://en.wikipedia.org/wiki/Template:Cite_web)}}: CS1 maint: multiple names: authors list ([link](https://en.wikipedia.org/wiki/Category:CS1_maint:_multiple_names:_authors_list)) Last author update: 7 May 2020. Last staff update: 12 May 2022 - Shawky M, Sakr M (2016). ["Hurthle Cell Lesion: Controversies, Challenges, and Debates"](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4848220). *Indian J Surg*. **78** (1): 41–8. [doi](/source/Doi_(identifier)):[10.1007/s12262-015-1381-x](https://doi.org/10.1007%2Fs12262-015-1381-x). [PMC](/source/PMC_(identifier)) [4848220](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4848220). [PMID](/source/PMID_(identifier)) [27186039](https://pubmed.ncbi.nlm.nih.gov/27186039).

1. **[^](#cite_ref-14)** Renuka, I.V; Saila Bala, G; Aparna, C; Kumari, R; Sumalatha, K (December 2012). ["The Bethesda System for Reporting Thyroid Cytopathology: Interpretation and Guidelines in Surgical Treatment"](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3477437). *Indian J Otolaryngol Head Neck Surg*. **64** (4): 305–311. [doi](/source/Doi_(identifier)):[10.1007/s12070-011-0289-4](https://doi.org/10.1007%2Fs12070-011-0289-4). [PMC](/source/PMC_(identifier)) [3477437](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3477437). [PMID](/source/PMID_(identifier)) [24294568](https://pubmed.ncbi.nlm.nih.gov/24294568).

1. **[^](#cite_ref-15)** Tee, Yoon Y; Lowe, Adrain J; Brand, Caroline A (November 2007). "Fine-Needle Aspiration May Miss a Third of All Malignancy in Palpable Thyroid Nodules". *Annals of Surgery*. **246** (5): 714–720. [doi](/source/Doi_(identifier)):[10.1097/SLA.0b013e3180f61adc](https://doi.org/10.1097%2FSLA.0b013e3180f61adc). [PMID](/source/PMID_(identifier)) [17968160](https://pubmed.ncbi.nlm.nih.gov/17968160). [S2CID](/source/S2CID_(identifier)) [30354862](https://api.semanticscholar.org/CorpusID:30354862). our study showed that the risk of malignancy of malignant FNA and suspicious FNA diagnosis is around 93.7% and 18.9%, respectively.

## External links

- [ASCP: The Bethesda System Website Atlas](https://web.archive.org/web/20081223051738/http://nih.techriver.net/)

- [Bethesda 2001 Workshop](https://web.archive.org/web/20090114020353/http://www.bethesda2001.cancer.gov/)

- Bongiovanni, Massimo; Spitale, Alessandra; Faquin, William C.; Mazzucchelli, Luca; Baloch, Zubair W. (2012). ["The Bethesda System for Reporting Thyroid Cytopathology: A Meta-Analysis"](http://www.thyroid.org/professionals/ata-publications/clinical-thyroidology/january-2013-volume-25-issue-1/clin-thyroidol-20132516-17/). *Acta Cytologica*. **56** (4): 333–339. [doi](/source/Doi_(identifier)):[10.1159/000339959](https://doi.org/10.1159%2F000339959). [PMID](/source/PMID_(identifier)) [22846422](https://pubmed.ncbi.nlm.nih.gov/22846422). [S2CID](/source/S2CID_(identifier)) [14143335](https://api.semanticscholar.org/CorpusID:14143335). Retrieved 24 November 2022.

v t e Human papillomavirus Related diseases Cancers Cervical cancer cancers Anal Vaginal Vulvar Penile Head and neck cancer (HPV-positive oropharyngeal cancer) Warts genital plantar flat Laryngeal papillomatosis Epidermodysplasia verruciformis Focal epithelial hyperplasia Papilloma Others Acrochordon (skin tags) Vaccine HPV vaccines Cervarix Gardasil Screening Pap test: stain Bethesda system Cytopathology Cytotechnology Experimental techniques: Speculoscopy Cervicography Colposcopy Biopsy histology Cervical intraepithelial neoplasia (CIN) Koilocyte Vaginal intraepithelial neoplasia (VAIN) Vulvar intraepithelial neoplasia (VIN) Treatment Cervical conization Loop electrical excision procedure (LEEP) History Georgios Papanikolaou Harald zur Hausen

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Adapted from the Wikipedia article [Bethesda system](https://en.wikipedia.org/wiki/Bethesda_system) by Wikipedia contributors ([contributor history](https://en.wikipedia.org/wiki/Bethesda_system?action=history)). Available under [Creative Commons Attribution-ShareAlike 4.0 International](https://creativecommons.org/licenses/by-sa/4.0/). Changes may have been made.