| Specimen type |
| Indicate conventional smear (Pap smear), liquid-based preparation (Pap test), versus other |
| Specimen adequacy |
- Satisfactory for evaluation (describe presence or absence of endocervical/transformation zone component and any other quality indicators, eg, 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
- Other: see "Interpretation/results" (eg, endometrial cells in a woman older than 45 years)
- Epithelial cell abnormality: see "Interpretation/results" (specify "squamous" or "glandular," as appropriate)
|
| Interpretation/results |
| 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/results" section of the report—whether there are organisms or other non-neoplastic findings) |
| Non-neoplastic findings (optional to report) |
- Non-neoplastic cellular variations:
- Squamous metaplasia
- Keratotic changes
- Tubal metaplasia
- Atrophy
- Pregnancy-associated changes
- Reactive cellular changes associated with:
- Inflammation (includes typical repair)
- Lymphocytic (follicular) cervicitis
- Radiation
- Intrauterine contraceptive device (IUD)
- Glandular cells status posthysterectomy
|
| 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
- Cellular changes consistent with cytomegalovirus
|
| Other |
- Endometrial cells (in a woman older than 45 years)
(also 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) |
| Adjunctive testing |
| Provide a brief description of the test method(s) and report the result so that it is easily understood by the clinician |
| Computer-assisted interpretation of cervical cytology |
| If case examined by an automated device, specify the device and result |
| Educational notes and comments appended to cytology reports (optional) |
| Suggestions should be concise and consistent with clinical follow-up guidelines published by professional organizations (references to relevant publications may be included) |
