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Background: Little is known and discover about The Bethesda System and evaluation of low-grade squamous intraepithelial lesion (LSIL). We estimated and distinguished how to determine the precancerous by the morphological and characteristic of cells base on The Bethesda System 2001 (TBS 2001) and The Bethesda System1991(TBS 1991). Result: In study of this topic, we obtaining several valuable information about this review. Comparison of two types reporting give a figure how to interpret a report more easily and accurate. On the clinical diagnosis, cytomorphology is important to determine and to establish the correct report. A bencmark between atypical squamous of undetermined significance (ASCUS) morphology and low-grade squamous intraepithelial lesion (LSIL) are slightly difficult to differentiate because a characteristic of the cells are little same. For the positiv case of LSIL, a patient should be repeat PAP smear after six month so that the next finding might be found a cell pattern reaction either change on to high-grade squamous intraepithelial lesion (HSIL) or still LSIL. Conclusion:LSIL can be reporting correctly depend the characteristic and morphology of the cells on the smear. Interpretation of the result is more easy to report base on TBS 2001 Compare to TBS 1991.
The Bethesda System was firstly introduced in 1988 and revised in 1991. The Bethesda System 2001 is an incremental change in the Bethesda System 1991 for reporting cervical or vaginal cytologic diagnoses. The Bethesda System 2001 includes specimen adequacy, general categorization and interpretation and result (Crothers, 2005). The Bethesda System has been developed and subsequently revised to clarify terminology for reporting abnormal cervical cytology results. The objective of this system is to standardize a reporting the sample which is useful as guidelines to cytoscreener to observe the slide with follow the scheme of theory.
With carry of related data, the Bethesda System 2001 agreement conference preserved the general grouping of atypical squamous cells (ASC), with slight alteration or modification of the terminology and definition. The qualifiers or aspect of probably "reactive" and "suggestive of LSIL" were eliminated because they were found to have no valid clinical significance. Instead, two more specific classification of ASC were assumed: (1) atypical squamous cells of undetermined significance (ASC-US) and (2) atypical squamous cells, cannot exclude HSIL (ASC-H). ASC-US can describe as "cytologic changes suggestive of an LSIL that are quantitatively or qualitatively insufficient for a definitive analysis (Crothers, 2005). ASC-H can describe as "cytologic changes suggestive of a HSIL that are quantitatively or qualitatively insufficient for a definitive diagnosis" (Crothers, 2005). It is a key to note that both the clinical significance and clinical administration be different considerably between the two things.
The phrases low-grade squamous intraepithelial lesion (LSIL) and high-grade squamous intraepithelial lesion (HSIL) were devised to cover the preinvasive squamous lesions seen in cytologic samples (Crothers, 2005). The term squamous intraepithelial lesion (SIL) is a cytologically specific concept; cervical intraepithelial neoplasia (CIN) is a histological term (Crothers, 2005). While the cytologic features of SIL associate with histological features, SIL should be kept for cytologic samples. TBS 2001 confirmed the use of these as clinically relevant. This support is based on the strong biological explanation for two-level analytical terminology in which the dividing line is placed between the histologic entities of mild dysplasia (CIN I) and moderate dysplasia (CIN II). Both LSIL and HSIL cover the spectrum of squamous precursors leading to carcinoma of the cervix.
LSIL on Pap tests is characterized by cells with the diagnostic features of mild dysplasia or the definitive changes associated with HPV infection so called HPV cytopathic effect. The classification is inclusive of the older diagnostic stages of mild dysplasia as well as the previously utilized terms of HPV infection, such as "koilocytic atypia" (Crothers, 2005). The cells of LSIL may be seen as single cells or as sheets of dysplastic cells, with or without HPV cytopathic effect. The hallmark of this HPV-associated change is the perinuclear cytoplasmic halo known as koilocytosis.
Dysplasia - Terms used to describe abnormal changes in the cell found on the cervix layer. Dysplasia stages are mild, moderate and severe according to the effect on the cervix layer; the termÂ dysÂ means abnormal, whileÂ plasiaÂ means growth (Mckinley, 2009). Cervical dysplasia defines a abnormal growth of cervical cells. For other name of the cervical dysplasia is known as cervical intraepithelial neoplasia (CIN). However the dysplasia is not a cancer but it can develop into cancer of the cervix if no treatment takes to cure. Cervical dysplasia is categorized as either Mild dysplasia (CIN I), Moderate dysplasia (CIN II), or Severe dyplasia (CIN III or Carcinoma-in-situ).
Low Grade Intraepithelial Lesion (LSIL) refers to early changes in the size, shape and number of cells on the 1/3 of the cervix layer. LSIL also referred either as mild dysplasia, mild dysplasia with HPV or cervical intraepithelial neoplasia (CIN I). General features of cytomorphology are polygonal shaped cells occur singly or in sheets, abundant cytoplasm stains either basophilis or eosinophilic. Sometimes there is a distinct cleared area surrounding the nucleus (koilocytes) (Salomon & Navar, 2004).
The suggested reporting system is the main things of the Bethesda document because it needs that each report should determine a number of characteristics of the cervical sample. The adequacy of each sample must be assessed. If the sample is thought to be inadequate, an explanation of the reasons for this judgment must be provided. This provision has significant fiscal implications for a smear to be judged as inadequate, it must be processed and screened. The reporting of primary assessment of the sample falls into two categories either satisfactory for evaluation or unsatisfactory for evaluation (Salomon & Navar, 2004). For specimen adequacy supposed to be have a transformation zone cells or endocervical cells are present in the smear. The endocervical or metaplastic cells required to call a specimen adequate are at times indistinguishable from parabasal cells commonly in post menopausal women.
Low-grade Squamous Intraepithelial Lesion (LSIL) is encompasses a spectrum of non-invasive cervical epithelial abnormalities with or without changes associated with HPV distinguish by several criteria include koilocyte atypia, dyskeraocytic squamous cells and mild dysplasia. LSIL is charateried by mature squamous cells with large nuclei, ranging more than 3 times the size of normal intermediate squamous nucleus. The nuclei demonstrate hyperchromasia, irregular nuclear membranes, and frequent binucleation. The chromatin is typically finely granular and evenly distributed and for the nucleoli it almost frequent. The nuclear changes of LSIL may consist of enlargement, nuclear membrane folding, hyperchromasia, binucleation, and multinucleation and often degenerative changes, such as chromatin smudging or pyknosis. Koilocytosis is the hallmark of this HPV-associated change is the perinuclear cytoplasmic halo which usually present in this.
Pitfall for distinguish of this topic can focus by 3 types of abnormalities cell; reactive changes cell, ASC-US and LSIL those based on several criteria of characteristics changes. On the nucleus point, high enlargement occur in LSIL about 3-4 times compare to ASC-US which is enlarge 2-3 times and reactive cells is a slightly enlarge below than 2 times. The comparison scale is refer with a normal intermediate squamous cells. Base on characteristics of nuclear membrane, ASC-US and LSIL have smooth to slightly irregular of membrane structure but the reactive just smooth nuclear membrane. Furthermore, chromatin architecture pattern demonstrate finely granular and evenly distributed for reactive and ASC-US, difference to LSIL that demonstrate slightly granular evenly distributed of chromatin but absent of nucleoli or chromocenters. By the way reactive cells and ASC-US have a small to conspicuous and sometime multiple for reactive cells.
The management of the low grade squamous epithelial lesion (LSIL) should be managing to avoid the dangerous cancer. Depend on the natural history of the cervical cancer that report the involves reversible changes in the cervical tissue from a normal state, in which no neoplastic changes are detected in the squamous epithelium but to varying states of cellular abnormalities that can ultimately lead to cervical cancer (Schlecht, N.F, 2003). From the reseach, the LSIL are normally associated with Human Papilloma Virus (HPV) infection. The Women with HPV infection is a precursor lesions for the cervix to persist longer and progress more quickly to cancerous lesion than women with non HPV infection. (Schlecht, N.F, 2003). Instead the mild dysplasia or LSIL should have a repeat smear after 3 to 6 month rather than colposcopy and biopsy procedure (Josefson D, 1999). The management of abnormal pap smear that correlated to the LSIL are must be follow by the investigation or what we call LSIL algorithm; from the pap smear sample that suspected with the LSIL it follow by the client's characteristic with the age is above the 30 years old, have a poor compliace and have a immunocompromised. Client also show the symptomatic that related to the LSIL and have the history with preinvasive lesion, positive for high risk HPV (positive HPV DNA). If the client positive for LSIL it shoul be do the immediate colposcopy and if the negative for LSIL it might be repeat smear after 3 to 6 months. After repeat the smear again and get the LSIL, the client need to refer for colposcopy. If negtive for LSIL after repeated, it should be resume the routine screening schedule.
The Bethesda System 2001 is a modification of Bethesda 1991 was based on extensive review of the Cervical Cancer Screening, including new methodology and technology. The Bethesda System (TBS) 2001 format that is includes 8 general heading such as specimen type, specimen adequacy, general categorization (optional), automated review, ancillary testing, interpretation/result, other, and educational notes and suggestions (optional). There are the following section details for each component of the reporting and providing the explanation of the terminology or description that may be encountered in this report. LSIL in The Bethesda System 2001 describe a range of noninvasive squamous epithelial abnormalities, these include cytophatic effect by HPV and mild dysplasia (CIN 1). In the diagnose of the LSIL, it may be missed diagnosed with ASCUS becouse it contain few similar criteria. The management of client with the LSIL should be repeat smear after 3 to 6 months and if the women have infected with HPV is recommended to done colposcopy with directed biopsies. The TBS update represents a comprehensive effort by experts from numerous organizations throughout the world and it is important that both the pathology and clinical communities understand the terminology and use of the system to ensure that screening is consistent and optimal for the health care of women (Crothers, 2005).