Symposium part 1: Should the Bethesda System terminology be used in diagnostic surgical pathology?: Point

During the past 50 years, the histologic classification of cervical intraepithelial neoplasia (CIN) has evolved to incorporate the entire spectrum of genital papillomavirus infections, segregating those lesions with the higher risk of containing prototypic high-risk human papillomavirus types, and recently has meshed with treatment algorithms that include loop electrical excision procedures and follow-up alone. This review describes a classification system that divides CIN into categories of low-grade (CIN 1) and high-grade (CIN 2 and CIN 3). To successfully apply this system, the practitioner must efficiently exclude nonneoplastic entities and base the distinction of CIN 1 from CIN 2/3 on criteria that recognize the effects of viral oncogenes on replicating cells. This is achieved by basing the diagnosis of CIN 1 on uniform polarized epithelial growth, low mitotic index, low mitotic counts, and minimal parabasal cell anisokaryosis and coarse chromatin and CIN 2 on the presence of these features or abnormal mitoses. Simply put, the definition of CIN 2 (or higher) is the presence of atypical immature cells in the biopsy that if seen in a cytologic smear would merit a diagnosis of high-grade squamous intraepithelial lesion. In essence, a successful two-grade system requires careful application of cytologic criteria in a histologic milieu. This model is illustrated in a set of 25 images that underscore the importance of excluding benign changes (with the appropriate use of biomarkers), segregating unusual variants of low-grade squamous intraepithelial lesions, and identifying the morphologic transition to high-grade squamous intraepithelial lesions (CIN 2 or CIN 3) with an acceptable level of reproducibility.