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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
- 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.
(i.e., Focal Point® TriPath Imaging™ Primary Screening
System)
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,
CIN 2 and CIN 3/CIS
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 favor neoplastic
- Endocervical cells, favor neoplastic
- Glandular cells, favor neoplastic
- Endocervical adenocarcinoma in situ (AIS)
Adenocarcinoma
- Endocervical
- Endometrial
- Extrauterine not otherwise specified (NOS)
OTHER MALIGNANT NEOPLASMS: (specify EDUCATIONAL
NOTES AND SUGGESTIONS (optional)
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smear reporting
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