The 1988 Bethesda System for reporting cervical and vaginal cytologic diagnoses
dramatically altered the diagnostic categories at the lower end of the
cytologic spectrum. The primary impetus for this change was the
diagnostic variability and clinical confusion inherent in the class 2
Papanicolaou (Pap) group, which included a spectrum of cellular changes
that ranged from normal to definitive manifestations of human
papillomavirus (HPV). If clinical confusion were to be diminished, it
was clearly necessary to clarify the nature of each class 2 cellular
change more specifically. Unfortunately, some atypia remained ambiguous
and were designated atypical squamous cells of undetermined
significance (ASCUS). The designation "undetermined" highlights
the continuing dilemma regarding cells that have no distinguishing
characteristics to further clarify their nature. The category has been
a major clinical issue, with 2 to 3 million women given a diagnosis
that generates uncertainty each year.1,2 The magnitude of
the concern is highlighted by a major commitment by the National Cancer
Institute to evaluate the best triage option for women with equivocal
and low-grade Pap smears in a randomized trial that began in 1995 and
will end in 2001.3
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