- SPECIMEN TYPE
:
- Indicate conventional smear (Pap smear) vs. liquid-based vs.
other
- SPECIMEN ADEQUACY
- Satisfactory for evaluation (describe presence or absence of endocervical/transformation
zone
(component and any other quality indicators, e.g., partially obscuring
blood, inflammation, etc)
- Unsatisfactory for evaluation ... (specify reason)
- Specimen rejected/not processed (specify reason)
- Specimen processed and examined, but unsatisfactory for evaluation
of epithelial abnormality because of (specify reason).
- GENERAL CATEGORIZATION
(optional)
- Negative for Intraepithelial Lesion or Malignancy
- Epithelial Cell Abnormality: See Interpretation/Result (specify
"squamous" or "glandular" as
appropriate)
- Other : See Interpretation/Result (e.g. endometrial cells in a
woman > 40 years of age)
- AUTOMATED REVIEW
- If case examined by automated device, specify device and result.
- ANCILLARY TESTING
- Provide a brief description of the test methods and report the
result so that it is easily understood by the clinician.
- INTERPRETATION/RESULT
- NEGATIVE FOR INTRAEPITHELIAL LESION
OR MALIGNANCY
(when there is no cellular evidence of neoplasia, state this in
the General Categorization above and/or in the Interpretation/Result
section of the report, whether or not there are organisms or other
non-neoplastic findings).
- ORGANISMS :
- Trichomonas vaginalis
- Fungal organisms morphologically consistent with Candida
spp
- Shift in flora suggestive of bacterial vaginosis
- Bacteria morphologically consistent with Actinomyces
spp.
- Cellular changes consistent with Herpes simplex virus
- OTHER NON-NEOPLASTIC FINDINGS (Optional to report; list not
inclusive) :
- Reactive cellular changes associated with
- inflammation (includes typical repair)
- radiation
- intrauterine contraceptive device (IUD)
- Glandular cells status post hysterectomy
- Atrophy
- OTHER
- Endometrial cells (in a woman > 40 years of age)
(Specify if ‘negative for squamous intraepithelial lesion).
- EPITHELIAL CELL ABNORMALITIES
- SQUAMOUS CELL
- Atypical squamous cells
- of undetermined significance (ASC-US)
- cannot exclude HSIL (ASC-H)
- Low grade squamous intraepithelial lesion (LSIL)
encompassing: HPV/mild dysplasia/CIN 1
- High grade squamous intraepithelial lesion (HSIL)
encompassing: moderate and severe dysplasia, CIS/CIN 2 and CIN
3
- with features suspicious for invasion (if invasion is suspected)
- Squamous cell carcinoma
- GLANDULAR CELL
- Atypical
- endocervical cells (NOS or specify in comments)
- endometrial cells (NOS or specify in comments)
- glandular cells (NOS or specify in comments)
- Atypical
- endocervical cells, favor neoplastic
- glandular cells, favor neoplastic
- Endocervical adenocarcinoma in situ
- Adenocarcinoma
- endocervical
- endometrial
- extrauterine
- not otherwise specified (NOS)
- OTHER MALIGNANT NEOPLASMS:
(specify)
- EDUCATIONAL NOTES AND SUGGESTIONS
(optional)
- Suggestions should be concise and consistent with clinical
follow-up guidelines published by professional organizations (references
to relevant publications may be included).
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