AJCP / Original Article
Effects of Implementing the Dual Papanicolaou Test
Interpretation of ASC-H and LSIL Following Bethesda
2014
A Retrospective Comparison With LSIL-H and ASC-H
Abha Goyal, MD, Ami P. Patel, MD, Thomas L. Dilcher, and Susan A. Alperstein, CT(ASCP)
From the Department of Pathology and Laboratory Medicine, Weill Cornell Medicine–New York Presbyterian Hospital, New York, NY.
Key Words: ASC-H and LSIL; LSIL-H; Cervical cytology
Am J Clin Pathol October 2020;154:553-558
DOI: 10.1093/AJCP/AQAA069
ABSTRACT
Objectives: To evaluate the impact of implementing the
dual interpretation of atypical squamous cells, cannot
exclude high-grade squamous intraepithelial lesion (ASC-
H) and low-grade squamous intraepithelial lesion (LSIL)
after the Bethesda System 2014 and to compare it with
other indeterminate interpretations.
Methods: Rates of high-risk human papillomavirus
(HPV) positivity and histologic follow-up and the
proportion of women with high-grade squamous
intraepithelial lesion on histologic follow-up were
compared for the combined interpretation of ASC-H and
LSIL (ASCHL) and the categories of LSIL, cannot
exclude high-grade squamous intraepithelial lesion
(LSIL-H) and ASC-H.
Results: The percentage of ASCHL HPV-positive cases
(86.0%) was similar to that of LSIL-H but significantly
higher in comparison to that of ASC-H. The rates of cervical
intraepithelial neoplasia grade 2 or higher (CIN 2+) and
CIN 3+ for ASCHL (29.6% and 3.6%, respectively) were
similar to those of LSIL-H and ASC-H. When stratified
by HPV test results, the proportions of patients with CIN
2+ and CIN 3+ remained statistically similar to those with
ASCHL and with LSIL-H and ASC-H.
Conclusions: Considering the similar risks of CIN 2+ and
CIN 3+ for ASCHL and ASC-H, having a separate
category of ASCHL for reporting cervical cytology
appears to be redundant.
© American Society for Clinical Pathology, 2020. All rights reserved.
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Key Points
• The study explores the impact of the implementation of the dual
interpretation of atypical squamous cells, cannot exclude high-grade
squamous intraepithelial lesion (ASC-H) and low-grade squamous
intraepithelial lesion (LSIL) after the Bethesda System 2014 and
compares it with other indeterminate interpretations of ASC-H and LSIL,
cannot exclude high-grade squamous intraepithelial lesion (LSIL-H).
• Considering the similar risks of cervical intraepithelial neoplasia grade
2 or higher (CIN 2+) and CIN 3+ for dual ASC-H and LSIL (ASCHL) and
ASC-H, having a separate category of ASCHL for reporting cervical
cytology appears to be redundant and should be studied further.
• The CIN 2+ and the CIN 3+ rates for ASCHL were statistically similar
to those of LSIL-H and ASC-H and remained so, even when stratified by
human papillomavirus test results.
The interpretation of low-grade squamous intraepithelial
lesion (LSIL), cannot exclude high-grade squamous
intraepithelial lesion (HSIL), or LSIL-H, was not strictly
regarded as a distinct category in the Bethesda System
2001 for reporting cervicovaginal cytology.1 However,
its use gained the support of multiple studies, and it has
been used as a Papanicolaou (Pap) test interpretation
by several laboratories. The reported rates of cervical
intraepithelial neoplasia grade 2 or higher (CIN 2+) with
LSIL-H have ranged from 24% to 61%, falling mostly in
between those associated with LSIL and HSIL and akin
to those observed with atypical squamous cells, cannot
exclude HSIL (ASC-H).2-15 These findings supported its
usage as a separate category and its clinical management
similar to that of ASC-H.9,11,14
The Bethesda System 2014 recommended that the
formal cervical cytology nomenclature should be 2-tiered,
Am J Clin Pathol 2020;154:553-558 553
DOI: 10.1093/ajcp/aqaa069
Goyal et al / Dual Interpretation of ASC-H and LSIL
comprising LSIL and HSIL. It discouraged the use of an
indeterminate category that could result in confusion re-
garding clinical management. In addition, a dichotomous
nomenclature was favored because it was in line with the
Lower Anogenital Squamous Terminology (LAST) pro-
ject recommendations.16 The Bethesda System 2014 re-
commended that when the squamous intraepithelial lesion
cannot be accurately graded, an explanatory comment re-
garding the uncertainty of the grade may be appropriate.
Alternatively, the interpretation of ASC-H in addition to
that of LSIL can be made. Such interpretations should be
used only in a minor proportion of cases.17
Our laboratory has used the category of LSIL-H for
more than a decade, but recently we transitioned to the use
of the dual interpretation of ASC-H and LSIL (ASCHL)
in lieu of LSIL-H. The aim of this study is to evaluate
the impact of this change in reporting terminology and
to compare it with the interpretations of LSIL-H and
ASC-H in terms of reporting frequency and rates of his-
tologic follow-up, positivity for high-risk human papil-
lomavirus (HPV), and associated CIN 2+ and cervical
intraepithelial neoplasia 3 or worse (CIN 3+).
Materials and Methods
This study was approved by our institutional
review board.
A database search was conducted for all cervical Pap
tests with a dual interpretation of ASCHL and inter-
pretations of ASC-H only or HSIL during the period of
January 1, 2017, through December 31, 2018. For com-
parison, the cervical Pap test results that were reported
as LSIL-H, ASC-H only, or HSIL during the prior
2-year period (ie, January 1, 2014, through December
31, 2015) were retrieved. The change from LSIL-H to
ASCHL was effectually implemented in 2016 in our lab-
oratory; therefore, we did not include the period between
January 1, 2016, and December 31, 2016, as it was a tran-
sition period. The terminology “SIL of indeterminate
grade” is rarely used in our gynecologic cytology reports;
therefore, we did not incorporate such categorization in
our study.
All Pap tests were prepared as ThinPrep during the
period of the study. High-risk HPV testing was performed
using the Aptima HPV assay (Hologic). The Aptima HPV
assay is an in vitro nucleic acid amplification test for the
qualitative detection of E6/E7 viral messenger RNA from
14 high-risk HPV types (16, 18, 31, 33, 35, 39, 45, 51, 52,
56, 58, 59, 66, and 68). It does not discriminate among the
14 high-risk types.
554 Am J Clin Pathol 2020;154:553-558
DOI: 10.1093/ajcp/aqaa069
For all cases retrieved, the patient’s age, the results of
concurrent HPV testing (if any), and the type and results of
any cervical histologic follow-up (including cervical biopsies,
endocervical curettages, loop electrosurgical excision pro-
cedures, cold knife cone biopsies, and hysterectomies) within
12 months subsequent to the Pap test were obtained. When
multiple biopsies or specimens were received, the most severe
diagnosis was recorded. The Pap tests were interpreted by
board-certified cytopathologists and the histology specimens
by gynecologic pathologists in our department.
The rate of HPV positivity; the percentage of women with
histologic follow-up; and, of those, the proportion with CIN
2+ and CIN 3+ for the different categories were compared
using the χ2 test and Fisher exact test. To compare the means, a
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t test was used. P < .05 was considered statistically significant.
Results
During the 2-year period from January 1, 2014,
through December 31, 2015, a total of 77,692 Pap tests
were processed at our laboratory. Of all the Pap test inter-
pretations for this duration, LSIL-H accounted for 0.43%
(n = 337), ASC-H for 0.39% (n = 309), and HSIL for
0.36% (n = 286). The number of LSIL-H interpretations
exceeded those of HSIL with an LSIL-H/HSIL ratio of
1.17. The period from January 1, 2017, through December
31, 2018, revealed a decline in the Pap test volume, with
a total of 63,134 Pap tests processed at our laboratory.
During this period, the Pap test interpretations encom-
passed 0.3% ASCHL (n = 209), 0.35% ASC-H (n = 223),
and 0.31% HSIL (n = 201). The frequency of ASC-H and
HSIL interpretations did not change significantly between
the 2 study periods (P = .16 and P = 0.11 respectively).
Age Group
During 2014-2015, the mean ages of the patient pop-
ulation were 42.3 years (range, 24-92 years) for those
with LSIL-H, 44.4 years (range, 26-80 years) for those
with ASC-H, and 42.7 years (range, 26-81 years) for those
with HSIL. In this population, 87.5% of LSIL-H inter-
pretations, 94.4% of ASC-H, and 93.7% of HSIL were
noted in women 30 years of age or older.
For the period 2017-2018, the mean ages of the pa-
tient population were 38.4 years (range, 21-83 years) for
those with ASCHL, 42.7 years (range, 23-88 years) for
those with ASC-H, and 40.8 years (range, 21-78 years) for
those with HSIL. Women 30 years of age or older consti-
tuted 74.1% of patients with ASCHL, 85.2% of patients
with ASC-H, and 86.5% of patients with HSIL.
© American Society for Clinical Pathology

The patients with an ASCHL interpretation were
younger than those with LSIL-H, ASC-H (for both
periods). and HSIL (for 2014-2015), with the differences
being statistically significant (P = .0005 for ASCHL vs
LSIL-H and P < .0001 for other comparisons). The age
of women with ASCHL was not statistically different
from those with HSIL for the period 2017-2018 (P = .06).
HPV Testing
A high percentage of women were tested for HPV
at our institution for the interpretations included in this
study. For 2014 and 2015, 75.0% of patients with LSIL-H,
84.0% of patients with ASC-H, and 69.5% of patients
with HSIL were tested for HPV. For 2017 and 2018, HPV
testing was performed for 91.1% of ASCHL interpret-
ations, 92.3% of ASC-H interpretations, and 84.2% of
HSIL interpretations. The increase in HPV testing in the
latter 2 years was due to increases in clinician requests.
In the 2014-2015 study period, of those tested for
HPV, 83.0% of those with LSIL-H, 58.0% of those with
ASC-H, and 91.3% of those with HSIL were HPV pos-
itive, whereas in the 2017-2018 period, 86.0% of those
with ASCHL, 65.5% of those with ASC-H, and 91.1% of
those with HSIL were HPV positive.
The percentage of patients with ASCHL who were
HPV positive was not statistically different from that of
LSIL-H or HSIL (for both periods); however, in com-
parison to the percentage of HPV-positive patients with
ASC-H (for both periods), it was significantly higher
(P < .0001) ❚Table 1❚.
Histologic Follow-up
For the patients diagnosed during 2014 and 2015, histo-
logic follow-up was available for 77.2% with LSIL-H, 79.0 %
with ASC-H, and 86.0% with HSIL. For the Pap tests during
2017 and 2018, histologic sampling was performed for 77.1%
❚Table 1❚
Comparison of HPV-Positive Rates for ASCHL and of Other
Cytologic Categories
Cytologic Interpretation HPV Positive, No. (%)
ASCHL 164/191 (86.0)
LSIL-H 207/249 (83.0)
ASC-H (2014-2015) 151/259 (58.0)
ASC-H (2017-2018) 136/207 (65.5)
HSIL (2014-2015) 178/195 (91.3)
HSIL (2017-2018) 154/169 (91.1)
ASC-H, atypical squamous cells, cannot exclude high-grade squamous
intraepithelial lesion; ASCHL, atypical squamous cells, cannot exclude high-grade
squamous intraepithelial lesion, and low-grade squamous intraepithelial lesion;
HPV, human papillomavirus; HSIL, high-grade squamous intraepithelial lesion;
LSIL, low-grade squamous intraepithelial lesion; LSIL-H, low-grade squamous
intraepithelial lesion, cannot exclude high-grade squamous intraepithelial lesion.
© American Society for Clinical Pathology
AJCP / Original Article
with ASCHL, 78.9% with ASC-H, and 89.4% with HSIL.
The percentage of patients with ASCHL who received histo-
logic follow-up within 1 year of the Pap test was not statisti-
cally different from that of LSIL-H, ASC-H, or HSIL.
Rate of CIN 2+
The rate of CIN 2+ for ASCHL interpretations
(29.6%) was not statistically different from that for
LSIL-H (25.7%) or ASC-H (22.8% and 31.1%). The rate
of CIN 2+ for HSIL interpretations was 60.1% and 68.8%
for the 2 study periods, respectively.
Rate of CIN 3+
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The rate of CIN 3+ for ASCHL interpretations
(3.6%) was not statistically different from that for LSIL-H
(2.4%) or ASC-H (3.6% and 6.7%). The rate of CIN 3+
for HSIL interpretations was 17.4% and 21.6% for the 2
study periods, respectively ❚Table 2❚.
HSIL on Histologic Follow-up, Stratified by HPV
Test Results
HPV-Positive Segment.—The rate of CIN 2+ for HPV-
positive ASCHL interpretations was 32.7%, which was
statistically similar to the rates for LSIL-H (28.5%)
and ASC-H (41.9% and 42.9%). The rate of CIN 3+
for ASCHL was 3.8%, which again was not statistically
different from rates for LSIL-H (1.9%) and ASC-H (6.4%
and 9.7%) ❚Table 3❚ and ❚Table 4❚.
HPV-Negative Segment.—The rate of CIN 2+ for HPV-
negative ASCHL interpretations was 6.2%, which was
statistically similar to rates for LSIL-H (6.6%) and ASC-H
(6.8% and 9.3%). No cases of HPV-negative ASCHL
or LSIL-H were associated with CIN 3+ on histologic
follow-up. A minimal amount of HPV-negative ASC-H
interpretations were associated with CIN 3+ (1.2% and
1.7% for the 2 study periods, respectively) and were not
statistically different (Tables 3 and 4).
P Value
— Discussion
1
<.0001 The category of LSIL-H in gynecologic cytology has
<.0001 received a lot of attention in the cytology literature. Many
.19
.23
investigators advocated its use as a distinct category be-
cause of its associated risk of CIN 2+, in between that
of LSIL and HSIL.2-15 Consequently, many laboratories
embraced the use of this indeterminate category. In fact,
a 2011 College of American Pathologists survey revealed
that LSIL-H was being used by 80.9% of laboratories to
Am J Clin Pathol 2020;154:553-558 555
DOI: 10.1093/ajcp/aqaa069
Goyal et al / Dual Interpretation of ASC-H and LSIL

❚Table 2❚
Comparison of HSIL Rates on Histologic Follow-up for ASCHL and Other Cytologic Categories
With CIN 2+ on Follow-up, P Value With CIN 3+ on Follow-up, P Value
Cytologic Interpretation No. (%) (for Rate of CIN 2+) No. (%) (for Rate of CIN 3+)
ASCHL 47/161 (29.1) — 6/161 (3.6) —
LSIL-H 67/262 (25.7) .41 6/262 (2.4) .55
ASC-H (2014-2015) 56/244 (22.8) .15 9/244 (3.6) 1
ASC-H (2017-2018) 56/177 (31.1) .75 12/177 (6.7) .23
HSIL (2014-2015) 148/246 (60.1) <.0001 43/246 (17.4) <.0001
HSIL (2017-2018) 124/180 (68.8) <.0001 39/180 (21.6) <.0001

ASC-H, atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion; ASCHL, atypical squamous cells, cannot exclude high-grade squamous
intraepithelial lesion, and low-grade squamous intraepithelial lesion; CIN 2+, cervical intraepithelial neoplasia grade 2 or higher; CIN 3+, cervical intraepithelial
neoplasia grade 3 or higher; HSIL, high-grade squamous intraepithelial lesion; LSIL, low-grade squamous intraepithelial lesion; LSIL-H, low-grade squamous
intraepithelial lesion, cannot exclude high-grade squamous intraepithelial lesion.

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❚Table 3❚
Comparison of HSIL Rates on Follow-up for ASCHL and LSIL-H Categories (HPV-Positive and -Negative Segments)
Histologic Follow-up Stratified by Cytologic Interpretation Cytologic Interpretation
HPV status of ASCHL (%) of LSIL-H (%) P Value
HPV positive with CIN 2+ 32.7 28.5 .45
HPV positive with CIN 3+ 3.8 6.4 .29
HPV negative with CIN 2+ 6.2 6.6 1
HPV negative with CIN 3+ 0 0 1

ASCHL, atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion, and low-grade squamous intraepithelial lesion; CIN 2+, cervical
intraepithelial neoplasia grade 2 or higher; CIN 3+, cervical intraepithelial neoplasia grade 3 or higher; HPV, human papillomavirus; HSIL, high-grade squamous
intraepithelial lesion; LSIL-H, low-grade squamous intraepithelial lesion, cannot exclude high-grade squamous intraepithelial lesion.

❚Table 4❚
Comparison of HSIL Rates on Follow-up for ASCHL and ASC-H Categories (HPV-Positive and-Negative Segments)
Cytologic In- Cytologic In- P Value
terpretation terpretation P Value (ASCHL vs
Histologic Follow-up Stratified by Cytologic Interpreta- of ASC-H for of ASC-H for (ASCHL vs ASC-H ASC-H for
HPV status tion of ASCHL (%) 2014-2015 (%) 2017-2018 (%) for 2014-2015) 2017-2018)
HPV positive with CIN 2+ 32.7 41.9 42.9 .19 .13
HPV positive with CIN 3+ 3.8 6.4 9.7 .40 .06
HPV negative with CIN 2+ 6.2 6.8 9.3 1 1
HPV negative with CIN 3+ 0 1.2 1.7 1 1

ASC-H, atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion; ASCHL, atypical squamous cells, cannot exclude high-grade squamous
intraepithelial lesion, and low-grade squamous intraepithelial lesion; CIN 2+, cervical intraepithelial neoplasia grade 2 or higher; CIN 3+, cervical intraepithelial ne-
oplasia grade 3 or higher; HPV, human papillomavirus; HSIL, high-grade squamous intraepithelial lesion; LSIL-H, low-grade squamous intraepithelial lesion, cannot
exclude high-grade squamous intraepithelial lesion.

report cases with features in between those of LSIL and
HSIL.18 Not only did the use of LSIL-H became widely
prevalent, but it also increased. Walavalkar et al8 showed
a statistically significant increase in the usage of this cat-
egory at their institution, from 0.28% of total Pap tests
in 2005 to 0.61% in 2010. Their analysis also revealed an
increase in the LSIL-H/HSIL ratio from earlier studies
incorporating data from 2001 to 2003 to the later ones that
discussed findings from 2009 and 2010. Alsharif and col-
leagues9 also noted in their study that LSIL-H accounted
for 0.41% of Pap tests in 2007, having increased from 0.2%
of Pap tests in 2004. Similarly, during 2014 and 2015,
LSIL-H accounted for 0.43% of all Pap tests at our insti-
tution, exceeding the numbers of HSIL, with an LSIL-H/
HSIL ratio of 1.17. In contrast, the dual interpretation
of ASC-H and LSIL accounted for 0.3% of all Pap tests
during the period of 2017 and 2018, with an ASCHL/HSIL
ratio of 0.84. Neither the ASC-H rate (0.39% vs 0.35%)
nor the HSIL rate (0.36% vs. 0.31%) showed a significant
change after the incorporation of the ASCHL interpreta-
tion. These findings indicate that at least in the initial years
of its implementation, the use of ASCHL has resulted in a
decrease in such indeterminate interpretations.
In terms of histologic follow-up, the average rate for
ASCHL (77.1%) was not significantly different from that
for ASC-H (78.9%), LSIL-H (77.2%), or HSIL (89.4%).
This result indicates that at our institution, patients with
ASCHL are being followed similarly to those with ASC-H

556 Am J Clin Pathol 2020;154:553-558 © American Society for Clinical Pathology

DOI: 10.1093/ajcp/aqaa069

and the previously used categorization of LSIL-H.
Other studies have reported varying rates of histologic
follow-up for ASC-H and LSIL-H. Nishino et al5 and
Owens et al13 reported high rates of histologic follow-up
for LSIL-H (82.6% over 1 year and 71.7% over 2 years,
respectively), similar to our study. In contrast, other au-
thors have found much lower rates of histologic follow-up
for these categories. For instance, Elsheikh et al7 reported
follow-up for 30.4% of LSIL-H interpretations; Thrall
et al6 reported follow-up for 31.9% of LSIL-H and 35.3%
of ASC-H interpretations; and Alsharif et al9 reported
follow-up for 49% of LSIL-H and 56.7% of ASC-H inter-
pretations. Such variations may be attributable, in part, to
differences in follow-up duration in the different studies
and to some patients being lost to follow-up or being fol-
lowed at another institution. In our study cohort, of the
patients with LSIL-H or ASC-H or ASCHL cytology
that did not receive histologic follow-up, only 2% had pro-
viders other than those from obstetrics and gynecology.
The HPV positivity rate of ASCHL (86.0%) was sim-
ilar to that of LSIL-H (83.0%) and HSIL (91.3% and 91.1%)
but was significantly higher compared with that of ASC-H
(58.0% and 65.5%). Even the age of the patient population
with ASCHL was significantly younger than the age of those
with ASC-H. This finding would correlate with the presence of
cytologic evidence of HPV infection in ASCHL and the higher
prevalence of HPV infection in younger women.19 It is inter-
esting to note that in our analysis, LSIL-H was seen in an older
age group than ASCHL. Perhaps this finding was related to
the ever increasing and indiscriminate use of LSIL-H.
The rate of CIN 2+ on histologic follow-up for
ASCHL (29.6%) in our study was slightly higher than the
rate associated with LSIL-H (25.7%); however, they were
not statistically different. The category of ASC-H also
showed statistically similar rates of CIN 2+ (31.1% and
22.8%) for the 2 study periods, respectively. Several studies
of LSIL-H have reported similar rates of high-grade dys-
plasia for LSIL-H and ASC-H.6,7,9,13 It is important to
note that the rate of CIN 3+ with ASCHL (3.6%) in our
analysis was not statistically different from that of ASC-H
(3.6% and 6.7%) or LSIL-H (2.4%) but was strikingly low
in comparison to that of HSIL (17.4% and 21.6%). On
further stratifying the groups based on HPV status, the
rates of CIN 2+ and CIN 3+ in the HPV-positive segment
of ASCHL interpretations (3.8%) were still statistically
similar to those of the HPV-positive segments of ASC-H
(6.4% and 9.7%) and LSIL-H (1.9%). Likewise, the rates
of CIN 2+ and CIN 3+ in the HPV-negative segment of
ASCHL interpretations were not different from those of
the HPV-negative segments of ASC-H and LSIL-H.
The 2019 American Society for Colposcopy and
Cervical Pathology guidelines for the management
© American Society for Clinical Pathology
AJCP / Original Article
of abnormal cervical cancer screening tests aim for a
simplified risk-based approach.20 Considering the similar
rates of CIN 2+ and CIN 3+ in patients with ASC-H and
ASCHL in 1 year of follow-up in our study, one could
argue that having a separate category of ASCHL appears
to be redundant. It creates confusion regarding the man-
agement of the patient, and such cases could be incor-
porated into ASC-H. However, we acknowledge that the
ASCHL category is HPV positive in a higher percentage
of cases than is ASC-H. Studies with larger cohorts and
longer follow-up duration can help elucidate whether
the risks of CIN 2+ and CIN 3+ significantly differ for
ASCHL (from those of ASC-H) for it to be regarded as a
distinctive cytologic category.
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Our study has several limitations. The cytopathologist
staffing of our laboratory underwent some changes during
the study period (to the extent of 40%), and that may have af-
fected the results of this study. The categorization of LSIL-H
in our laboratory has been used for cases that show unequiv-
ocal LSIL and cells suggestive but not diagnostic of HSIL
(ie, rare immature squamous metaplastic cells with nuclear
enlargement, hyperchromasia, and/or irregular nuclear con-
tours; few atypical keratinized squamous cells with nuclear
enlargement, hyperchromasia, and nuclear pleomorphism;
and rare syncytial groups of cells with nuclear overlap, high
nuclear-cytoplasmic ratio, and hyperchromasia). It is difficult
to say with certainty how the use of ASCHL may have af-
fected the diagnostic criteria applied by our cytopathologists.
However, from the cases that are reviewed at the multiheaded
scope during our consensus conferences, the threshold for
the ASCHL interpretation appears to have increased slightly
over that for LSIL-H, with the emphasis on the interpreta-
tion of ASC-H rather than that of LSIL. In addition, we
did not stratify our results based on patient age for compari-
sons because the majority of the patients in each category
were 30 years of age or older.
It is interesting to note that recent data indicate that
the use of ASCHL is not widespread across laboratories
in the United States. Davey et al21 reported the changes in
the practices of laboratories participating in the College
of American Pathologists PAP education program after
release of the Bethesda System 2014. The survey results
showed that in 2016, 51.3% of the laboratories continued
to use the categorization of LSIL-H for indeterminate
cases with clear LSIL and other cells approaching HSIL.
Only 21% of the laboratories had adopted the use of
ASC-H (with optional comment) or the reporting of both
LSIL and ASC-H for such cases.21
In conclusion, our study indicates that the use of
ASCHL, in comparison to LSIL-H, has resulted in a de-
crease in indefinite categorization of the Pap test, with a
similar clinical follow-up rate and without a significant
Am J Clin Pathol 2020;154:553-558 557
DOI: 10.1093/ajcp/aqaa069
Goyal et al / Dual Interpretation of ASC-H and LSIL
increase in CIN 2+ outcomes. Furthermore, our results
raise a question about whether ASCHL should be con-
sidered separate from the Bethesda category of ASC-H.
Further studies will be helpful regarding the effects of
this practice modification to understand the impact of
the Bethesda System 2014 recommendations and its risk
of precancer to define management.
Corresponding author: Abha Goyal, MD; abg9017@med.cornell.
edu.
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