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).
References:
- 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]
Created: May 20, 2007
