The Bethesda System: Impact on reporting cervicovaginal specimens and reproducibility of criteria for assessing endocervical sampling

This study examined the impact of applying the Bethesda System guidelines for specimen adequacy on cytopathologic diagnosis at the Johns Hopkins Hospital laboratory of cytopathology during a one-year period. Application of the Bethesda guidelines resulted in a 1.3% unsatisfactory rate. In addition, 3.8% of specimens were satisfactory but contained an inadequate endocervical component (IEC). Smears obtained after a cone biopsy or an initial IEC smear were IEC in 16.5% and 18.7% of cases, respectively. The IEC rate following an initial smear lacking an endocervical component was 11.8% in repeat specimens obtained with an endocervical brush as compared to 29.4% in those obtained with a spatula alone. The reproducibility of the Bethesda criteria for assessing endocervical sampling was evaluated by comparing the level of agreement between three independent reviewers examining 40 test cases. Three- way agreement was achieved in 75% of cases. Two-way agreement ranged from 80.0% to 87.5%. We conclude that implementation of the Bethesda System guidelines for assessing specimen adequacy should produce a minimal impact on cytopathologic reporting and gynecologic practice. Repeat specimens lacking an endocervical component may be encountered relatively frequently in certain subsets of patients.