AMERICAN JOURNAL OF CLINICAL PATHOLOGY
Editorial
Atypical Squamous Cells of Undetermined
Significance
Is Help on the Way?
Despite reams of literature detailing the cytologic char-
acteristics of the entity described and rigorously defined
as "atypical squamous cells of undetermined signifi-
cance" (ASCUS) in the Bethesda system, hot debate con-
tinues to rage in the cytology and gynecology communi-
ties regarding the diagnosis, clinical significance, and
proper management of patients labelled with ASCUS on
their cervical smears.
There has long been a morass of disparate opinions
regarding what actually should be called "atypical,"
along with vague and often confusing descriptions of the
criteria for diagnosis. In addition to diagnostic difficul-
ties, there was marked disparity between studies report-
ing on the followup of ASCUS cases. Numerous reports
stated that ASCUS could have follow-up of squamous
intraepithelial lesions (SIL) in as many as 60% of cases or
in as few as 10%.'~5 What was the thoughtful pathologist,
let alone the practicing gynecologist, to think? In my own
practice, I was beginning to believe that it didn't matter
what other workers in the field had found or believed.
The conclusion could only be that the various authors
were all correct in the settings of their own clinical ser-
vices. In laboratory A, a diagnosis of ASCUS portended
a high follow-up rate of SIL in that population. In labo-
ratory B, ASCUS exhibited a much lower level of risk
for development of SIL. As long as these rates were well
studied and reproducible in their individual settings, it
was irrelevant what was happening down the street.
Thus, individual clinicians could rely on the guidance
and education coming from laboratories with which they
had established relationships to assist them in providing
quality, cost-effective care of their ASCUS patients.
The newly arrived managed care environment has
changed this scenario dramatically. As Papanicolaou
smear business shifts from lab to lab with the rapidity
of the shifting sands of the Mohave, clinicians are being
thrust into a position that requires blanket management
of ASCUS with schema that must reflect the highest end
of perceived risk. This situation clearly will result in
overtreatment of many patients, increase cost at a time
of significantly diminishing resources, and may actually
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do harm to some patients who may have significant se-
quelae from treatment.
In their excellent monograph, which clearly states and
illustrates the cytologic criteria for ASCUS, Kurman and
Solomon, 6 along with the entire Bethesda criteria com-
mittee, have done the cytology community a great ser-
vice in codifying a standard of diagnostic practice. In the
final version of diagnostic nomenclature, the diagnosis
of ASCUS is to be subclassified into categories of "favor
reactive" and "favor neoplastic." This is clearly an at-
tempt to substratify the risk pool further and could,
therefore, aid in the guidance of therapy. Data from sev-
eral studies have shown this stratification of risk within
ASCUS to be of some utility, with cases in the "favor
reactive" category showing fewer cases of SIL on fol-
lowup than the category of "favor neoplastic."7"8 For the
daily practitioner of cytology, this subclassification is of
less utility. Although a subcategory of ASCUS may favor
an outcome in population studies, in an individual case,
it may be difficult to reliably predict the ultimate behav-
ior. However, studies such as these do hold some prom-
ise that more can be done with subcategorization of risk
based on subtle morphologic differential features.
In addition, and unfortunately, not all cytologic speci-
mens are amenable to optimal analysis using the
Bethesda system criteria. Smear quality based on prepa-
ration technique, fixation, and stain characteristics var-
ies between laboratories in virtually an infinite number
of combinations and appearances. Physiologic condi-
tions represented by blood, inflammation, microorgan-
isms, and debris make cells difficult to visualize, and can
induce artifacts closely mimicking changes considered
characteristic of ASCUS.
Therefore, one might consider that there are really, in
practice, two categories of ASCUS cases. One category is
represented by good examples of the process as defined
by the Bethesda system. Such ASCUS diagnoses might
well represent cells in the earliest phases of the neoplastic
spectrum (ie, pre-LSIL). The second is a "wastebasket"
group of cases that, although not meeting explicit
Bethesda criteria for ASCUS or SIL, are not completely
662 AMERICAN JOURNAL OF CLINICAL PATHOLOGY
normal either. Such cases may include poorly preserved
or presented cells derived from normal, reparative, and
benign reactive conditions, as well as true SIL, and even
carcinoma. Therefore, follow-up rates of SIL lesions
might be expected to be greater in laboratories plagued
by slides of suboptimal quality or with large numbers of
cases obscured by physiologic reactions.
In addition, inter- and intraobserver variability in cy-
tologic diagnosis is less than perfect.910 This fact would
argue that some differences in follow-up may likely be
due, at least in part, to differences in training, experience,
potential personal biases, as well as with inherent diffi-
culties with reproducibility of the diagnostic criteria for
ASCUS.
Given these drawbacks and the associated costs of ini-
tiating the highest level of treatment in all cases, the cy-
tology community is compelled to further clarify the is-
sue of what is the actual risk of an ASCUS diagnosis to
progress to, or be associated with, a more serious neo-
plastic lesion of the cervix. The goal of the Papanicolaou
testing program, after all, is the detection and eradication
of precursor lesions that may ultimately progress to can-
cer. Clearly, this program has already been dramatically
successful, reducing deaths from cervical cancer in de-
veloped countries by as much as 70%. Now, as a medical
community, we are in the fine-tuning stage, attempting
to wring the last bit of specificity out of the procedure, by
going after the most subtle, but also the most common,
diagnosis of ASCUS. How shall we attack this problem
and accomplish this goal when the evidence presented
previously suggests that the limits of the currently used
test may have already been reached?
As of September of 1995, a new era in the realm of
cervical cytology was ushered in when the U.S. Food and
Drug Administration approved two devices for the per-
formance of quality control and/or adjunctive testing.
Both devices were intended to evaluate only smears pre-
viously judged to be within normal limits and satisfac-
tory by routine methods in the cytology laboratory.
However, it was only a matter of time before new and
innovative applications for these instruments would be
identified and tested.
In the current issue of the Journal, Ryan and associ-
ates" demonstrate a newly conceived and potentially
useful triaging technique for cases diagnosed as ASCUS.
In this study, the authors used the PAPNET system
(Neuromedical, Suffern, NY) to review cases that had
been previously diagnosed as ASCUS by routine exami-
nation. The PAPNET system, an automated image anal-
ysis device, couples traditional algorithmic approaches
with neural network technology for the identification of
potentially abnormal cells. Upon detection of potentially
A.J.C.P.- lune 1996
abnormal cells, these can then be displayed on a video
monitor. This visual aspect makes possible the device's
potential use in the further classification of ASCUS
cases. The intent of the current study was to allow the
automated device to identify and display potentially ab-
normal cells in cases previously diagnosed as ASCUS, to
a group of six observers who were then to reanalyze each
case based on the presented images, a subsequent man-
ual review, and finally a correlation to biopsy results.
In 101 cases originally diagnosed as ASCUS, 35 cases
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(35%) were ultimately reclassified as SIL (22 LSIL and
13 HSIL) following manual rescreening prompted by the
video review. In biopsy-proven cases of SIL, the PAP-
NET review prompted a change in diagnosis from AS-
CUS to SIL in 65%. In addition, 21% of the original AS-
CUS cases were downgraded to negative by the PAPNET
video review. A control group of negative cases found
substantially lower rates of SIL when subjected to the
same analysis.
The authors state in their discussion that potential
problems do exist in the study. These reclassifications
represent the collective review efforts of six experienced
cytologists. The question remains as to how well a lone
observer would do in comparison. Does this increased
number and level of experience of observers in and of
itself account for a more accurate interpretation than
was rendered by the original screener or pathologist?
Two additional questions might also be raised regarding
the results. Were new cells identified by the device that
had been missed on original screening? If so, then auto-
mated screening would be of significant utility as it might
essentially decrease the "false-ASCUS" rate. If the cells
identified by PAPNET are the same ones that had been
previously interpreted, does the video presentation of
cells improve, in some way, the visualization and hence,
the interpretability of the case? These are questions that
need to be answered before one can reliably state whether
or not the use of this, or other, automated devices will
definitely improve our ability to more accurately stratify
cases originally diagnosed as ASCUS.
Cost/benefit issues always must be raised when evalu-
ating new procedures. In a recent analysis by Hutchin-
son,12 the automated cytology systems were found to be
significantly more expensive for the detection of false-
negative cervical smears, when used in a quality control
modality, than were other manual procedures such as
100% manual rescreening or rapid rescreening. Would
the same hold true for cases diagnosed as ASCUS?
Would a second manual rescreen in this series have pro-
vided the same efficiency for reclassifying these ASCUS
cases into the SIL or negative categories? In addition,
what resources are we, as a society, willing to commit to
 WILBUR
ndetermined Significance
Atypical Squamous Cells Oj
this endeavor, particularly when a strong argument
might alternatively be made that additional resources
might be more productively spent to increase the avail-
ability of the Pap screening procedure to the underserved
populations that are most at risk for the disease and that
are most likely to never be screened.
Potential criticisms such as those noted previously,
however, do not detract from the efforts of these authors.
Experimentation with and clinical use of these new tech-
nologies must continue to uncover and define new pro-
cedures that may ultimately prove to be useful. This con-
cept applies, as well, to the use of other technologies for
the triage of ASCUS. Testing for high-risk types of the
human papillomavirus (HPV) has been suggested as a
means of identifying ASCUS patients who might be at
significantly greater risk of harboring concomitant SIL,
or who are at higher risk of progression to SIL. In one
clinical study, the presence of high-risk HPV types in pa-
tients with ASCUS was associated with an 8-fold in-
creased likelihood of a cervical intraepithelial neoplastic
lesion on biopsy.13 In a study of ASCUS reclassification
by multiple reviewers, high-risk HPV types were identi-
fied significantly more frequently in cases reclassified as
SIL, rather than those reclassified as ASCUS or nega-
tive.14
Thin-layer slide methods for cervical cytology may
also show some utility in clarifying the ASCUS dilemma.
This automated method of slide preparation, from cellu-
lar material suspended in a liquid transport media, has
several potential advantages over conventionally pre-
pared smears. The smear is not subject to preparation
artifacts, such as air drying. The fluid suspension tends
to allow improved cell visualization despite physiologic
factors present such as blood and inflammatory exudate.
This enhanced smear quality should allow for improved
applicability of Bethesda system criteria, leading to more
appropriate categorization of the "wastebasket" form of
ASCUS derived from the conventional preparation
method. This phenomenon may well account for the re-
duced number of ASCUS cases (as compared to paired
conventional smears) that have been noted in several
clinical studies using thin-layer devices, despite increases
in SIL rates.1516 In addition, the capture of all cellular
material collected from the patient (rather than the ap-
proximately 35%, which is on average transferred to the
slide in the making of a conventional smear), may give
the thin-layer method a better chance at displaying cells
that are convincing for a diagnosis of SIL, in addition to
cells which may only be equivocal.17
Hopefully, cost/benefit analysis and not fear of litiga-
tion will be the driving force toward implementation of
new procedures potentially useful in cytology. Comput-
Vol. 11 •No. 6
663
erized instrumentation may aid in the elimination of
omission errors, and potentially, misinterpretations. Im-
proved preparation methods may provide the cytologist
with better specimens on which more accurate diagnoses
may be rendered. Molecular biologic and genetic tech-
niques may ultimately hold promise. Methods to reliably
identify the particular type(s) of HPV may predict for an
increased risk of the development of cervical carcinoma.
Other specific genetic abnormalities or profiles of abnor-
malities may be discovered in cervical carcinogenesis, as
they have been in other systems, which may permit spe-
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cific assignment of risk and provide more accurate meth-
ods of patient triage and management.
The past several years have been some of the most ex-
citing and fruitful for the field of cervical cytology since
this author entered the field. Work during the next few
years should unearth many of the answers to the ques-
tions and dilemmas noted above. In that light, the Na-
tional Cancer Institute has just initiated a major
multicenter clinical study designed to test many of the
new modalities previously mentioned, alongside tradi-
tional cytology, to determine the most efficient triaging
of patients presenting with diagnoses of ASCUS and
LSIL. Answers to many of the lingering questions in this
area should be forthcoming upon completion of this sort
of data collection and analysis. For those readers who,
like this author, consider themselves caught in the "abyss
of ASCUS," the following can be offered: "Help is on the
way!"
DAVID C. WILBUR, MD
Cytopathology Unit,
University ofRochester Medical Center,
Rochester, New York.
REFERENCES
1. Lindheim SR. Smith-Nguyen G. Aggressive evaluations for atypi-
cal squamous cells in Papanicolaou smears. J Repro Med
1990;35:971-973.
2. NoumofT JS. Atypia in cervical cytology as a risk factor for intra-
epithelial neoplasia. Am J Obslel Gynecol 1987:156:628-631.
3. Soutter WP, Wisdom S, Brough AK. Minaghan JM. Should pa-
tients with mild atypia in a cervical smear be referred for colpos-
copy? Br J Obslel Gynecol 1986;93:70-74.
4. Spitzer M, Krumholz BA, Chernys AE. Seltzer V, Lightman AR.
Comparative utility of repeat Papanicolaou smears, cervicogra-
phy, and colposcopy in the evaluation of atypical Papanicolaou
smears. Obslel Gynecol 1987;69:731-735.
5. Sheils LA, Wilbur DC. The significance of atypical cells of squa-
mous type on Papanicolaou smears with stratification of risk
based on morphologic type: A 5-year follow-up study. Acta Cy-
tol(\n press).
6. Kurman RJ, Solomon D. The Bethesda System For Reporting
Cervical/Vaginal Cytologic Diagnoses. New York: Springer-
Verlag, 1994, pp 30-43.
7. Magnan BJ, Steele CT, Powers CN. Atypical squamous cells: Is
subclassification worthwhile? Ada Cytol 1994:38:796 (Abstr).
8. Genest D, Dean B, Galvanek E, et al. Subclassification of atypical
Pap smears and the likelihood of squamous intraepithelial le-
664 AMERICAN JOURNAL OF CLINICAL PATHOLOGY
Editorial

sion (SIL) on subsequent biopsy. Mod Pathol 1996;9:34A
(Abstr).
9. YobsAR. Plott AE. Hicklin MD. etal. Retrospective evaluation of
gynecologic cytodiagnosis. II. Interlaboratory reproducibility as
shown in rescreening large consecutive samples of reported
cases. Acta Cylol 1987;31:900-910.
10. Kern WH, Zivolich MR. The accuracy and consistency of the cy-
tologic classification of squamous lesions of the uterine cervix.
ActaCytol 1977:21:519-523.
11. Ryan MR, Stastny JF, Remmers R, et al. PAPNET-directed re-
screening of cervicovaginal smears: A study of 101 cases of AS-
CUS (atypical squamous cells of undetermined significance).
Am J Clin Pathol 1996; 105:711 -718.
12. Hutchinson ML. Assessing the costs and benefits of alternative re-
with a cytologic diagnosis of atypical squamous cells of undeter-
mined significance. AmJObstet Gynecol 1995; 172:946-954.
14. Sherman ME, Schiffman MH, Lorincz AT, et al. Toward objective
quality assurance in cervical cytopathology: Correlation of cy-
topathologic diagnoses with detection of high-risk human papil-
lomavirus types. Am J Clin Pathol 1994; 102:182-187.
15. Wilbur DC, Cibas ES, Merritt S, et al. ThinPrep™ processor: Clin-
ical trials demonstrate an increased detection rate of abnormal
cervical cytologic specimens. Am J Clin Pathol 1994:101:209—
214.
16. Geyer J W, Hancock F. Carrico C, et al. Preliminary evaluation of
Cyto-Rich: An improved automated cytology preparation. Di-
agn Cytopathol 1993:9:417-422.
17. Hutchinson ML. Isenstein LM, Goodman A, et al. Homogeneous

Downloaded from https://academic.oup.com/ajcp/article/105/6/661/1756686 by guest on 04 August 2023

screening strategies. Acta Cytol 1996;40:4-8. sampling accounts for the increased diagnostic accuracy using
13. Cox JT, Lorincz AT, Schiffman MH.etal. Human papillomavirus the ThinPrep™ processor. Am J Clin Pathol 1994:101:215-
testing by hybrid capture appears to be useful in triaging women 219.

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