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 ³ 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 ³ 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).

http://bethesda2001.cancer.gov/terminology.html