College of American Pathologists
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January 2004
Special Section

Revised Bethesda atlas fine-tuned and first-rate

Ritu Nayar, MD, and Diane Solomon, MD

An American Society of Cytopathology and National Cancer Institute joint task force has completed a two-year effort to revise the Bethesda System atlas and develop a complementary Web-based collection of cervical cytology images.

The images, which are housed on the ASC Web site, have been available since Nov. 5 and can be accessed at

The second edition of the “blue book” atlas will be published in February or March 2004. Copies can be ordered through Springer-Verlag (800-777-4643) for $34.95. (If you already preordered the atlas for $37.95, the charge will be adjusted to reflect the lower price.)

The revised Bethesda atlas, like the earlier edition, has an easy-to-read format, with the morphologic criteria set off by bullets, and half-page color illustrations. The content has been divided into chapters based on the major 2001 Bethesda System interpretive categories. Among the highlights of the new edition are:

  • Inclusion of liquid-based cytomorphologic criteria and images.
  • New sections addressing ancillary testing, educational notes and recommendations, computer-assisted interpretation, and anal-rectal cytology.
  • Inclusion of sample reports, references, and detailed legends for images.
  • The second edition is about three times as large as the original version, with 186 images, 90 percent of which are new images and 40 percent of which are from liquid-based specimens. Some are classic examples of an entity, while others have been selected to illustrate interpretive dilemmas or “borderline” cytomorphologic features that may not be interpreted the same way by all cytologists.

    The Bethesda Web-based collection of images offers 349 images, 40 percent of which are from liquid-based specimens, along with linked explanatory notes. It includes all images in the published atlas. The Web site is user-friendly and has several search options for viewing the images, such as searching by Bethesda terminology, atlas chapter headings, keywords, or preparation type. Users can also assess their knowledge by participating in a self-test in which they compare their interpretations to those of other participants.

    The image-selection process for the atlas and Web site involved a multistage review. Forum group members (32 participants) reviewed and selected images for their chapters from those in the prior edition of the atlas as well as from new submissions. The images that were selected were reviewed individually, or validated, by 13 task force members and scored on a scale of one to five for agreement with diagnosis and quality of image. More than 1,000 images were reviewed, 186 of which were selected for the atlas. An additional 163 images were selected for the Web site.

    A subset (n=77) of images from the atlas was posted on the Internet as “unknowns” from mid-July until mid-September as part of the Bethesda Interobserver Reproducibility Project, or BIRP. The cytopathology community could view the images and provide interpretations. Immediately after submitting a response for an image, participants were able to view a histogram of the distribution of results submitted by all prior participants who assessed that image.

    More than 600 cytologists worldwide participated in the BIRP. Summary histograms for the 77 images can be viewed on the Bethesda atlas Web site. (Select “BIRP images” from the menu on the left side of the screen.)

    Preliminary BIRP results presented at the 2003 ASC annual meeting in Orlando in November showed that “negative for intraepithelial lesion or malignancy” and “low-grade squamous intraepithelial lesion” reference images attained the highest concordance scores, while glandular abnormalities demonstrated the most splay in distribution of interpretations.

    BIRP analyses are ongoing, and additional results should be available this year.

    Dr. Nayar is associate professor of pathology and director of cytopathology, Northwestern University Feinberg School of Medicine, Chicago, and chair of the ASC-NCI Bethesda 2001 Task Force. Dr. Solomon is senior investigator at the NCI, organizer of the Bethesda workshops, and ASC past president. The ASC-NCI Working Group for the Second Edition Bethesda Atlas and Web Site is composed of members of the ASC-NCI Bethesda 2001 Task Force: Ritu Nayar, MD, chair; Diane Solomon, MD, co-chair, NCI; George Birdsong, MD, adequacy; Jamie Covell, BS, CT(ASCP), glandular lesions; Ann Moriarty, MD, endometrial cells; Dennis O’Connor, MD, educational notes and recommendations; Marianne Prey, MD, computer-assisted interpretation; Steve Raab, MD, ancillary testing; Mark Sherman, MD, atypical squamous cells; Sana Tabbara, MD, other malignant neoplasms; Tom Wright, MD, squamous lesions; and Nancy Young, MD, non-neoplastic findings. ASC consultants are ASC 2002/2003 presidents Diane Davey, MD, and David Wilbur, MD. Information technology representatives are Mike Montgomery (NCI), Brandon Winbush (Northwestern University), and Tina Coleman and Anass Manjra (Aquilent).