College of American Pathologists
Printable Version

  PAP/NGC Program Review


cap today

Q and A

January 2004
Special Section

Q. We reviewed a slide for the CAP’s Pap program in which most of the cells were intermediate cells with extensive cytolysis. The number of intact cells did not meet the minimum numeric criteria recommended by Bethesda 2001 for conventional smears (8,000 to 12,000 cells). Should we label such a slide unsatisfactory? The reference interpretation was negative for intraepithelial lesion or malignancy. Furthermore, many of the vaginal specimens in our lab are from women with a history of radiation or chemotherapy for gynecologic carcinoma and exhibit less than the minimum number of squamous cells stated in Bethesda 2001 criteria.

A. The Bethesda atlas states, "Nuclear preservation and visualization are of key importance, and changes such as cytolysis and partial obscuring of cytoplasmic detail may not necessarily interfere with specimen evaluation." Abundant cytolysis (greater than 50 percent) may be mentioned as a quality indicator, but most such specimens do not qualify as unsatisfactory unless nearly all of the nuclei are devoid of cytoplasm. Cell numbers are also technically more difficult to estimate in slides with cell clustering, atrophy, or cytolysis. Laboratorians should use professional judgment and employ hierarchical review when evaluating these borderline slides.

The minimum cellularity criteria described were developed for use with cervical cytology specimens. In vaginal specimens (post total hysterectomy), laboratorians should exercise judgment in reporting cellularity based on clinical and screening history. Lower cellularity may be acceptable in certain circumstances. For example, clinicians are generally looking for recurrent lesions in women who have been treated for gynecologic malignancies, and chemotherapy and radiation may lead to atrophic mucosa and specimens with low cellularity. In such cases, cervical cytology is one part of the followup exam, not a primary screening modality.


Solomon D, Nayar R. The Bethesda System for Reporting Cervical Cytology: Definitions, Criteria and Explanatory Notes. New York, NY: Springer-Verlag. In press.

Diane D. Davey, MD
University of Kentucky Medical Center
Past-Chair, CAP
Cytopathology Committee
Bethesda Adequacy Forum Member

George Birdsong, MD
Emory University School of Medicine
Member, CAP
Cytopathology Committee
Bethesda Adequacy Forum Member