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 species

• Shift in flora suggestive of bacterial vaginosis

• Bacteria morphologically consistent with Actinomyces species.

• 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 (ASC)

• of undetermined significance (ASC-US)

• cannot exclude HSIL (ASC-H)

• Low grade squamous intraepithelial lesion (LSIL)
  encompassing: HPV/mild dysplasia/cervical intraepithelial neoplasia (CIN) 1

• High grade squamous intraepithelial lesion (HSIL)
  encompassing: moderate and severe dysplasia, carcinoma in situ (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 (AIS)

• 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).

1. Solomon D, Davey D, Kurman R, Moriarty A, O'Connor D, Prey M, Raab S, Sherman M, Wilbur D, Wright T Jr, Young N; Forum Group Members; Bethesda 2001 Workshop. The 2001 Bethesda System: terminology for reporting results of cervical cytology. JAMA. 2002 Apr 24;287(16):2114-9. [Medline]